Cartilage Problems

Question 1

Osteochondritis dissecans
What is this?
Is there any inflammation?
What symptoms can is cause?

Answer 1

The separation of articular cartilage and subchondral bone fragment from a joint surface was misnamed as osteochondritis dissecans in the nineteenth century in the false belief that there was an underlying inflammatory pathology. We know now that this is not the case but the name has stuck. The separated fragment may become avascular and exist as a loose body within the joint. It is the most common cause of a loose body in the joint space of adolescent patients. The cause is unknown.
Can get effusions or some pain.

Question 2

Osteochondritis dissecans?
Which age group?
Does it heal or not?
Treatment?

Answer 2

Adolescents
Can heal or resolve spontaneously
If detaching on MRI can pin in place
it may be unlikely to heal so sometimes just take it out

Question 3

What is the saying about hyaline cartilage?

Answer 3

“Only god can make hyaline cartilage”

Question 4

How does surgery to hyaline cartilage heal?

Answer 4

ALWAYS with fibrocartilage

Question 5

What is mosaicplasty?

Answer 5

Take plugs out of patellofemoral joint and put them in the defect – can be autograft or allograft. Shown opposite.

Question 6

What is MACI?

Answer 6

Membrane induced autologous chondrocyte implantation (MACI) – basically cartilage cells are extracted, multiplied in the lab, and then re-inserted

Question 7

Give definitions of the following:
Tendinopathy
Tendonitis 
Tendonosis 
Tenosynovitis 
Enthesopathy

Answer 7

Tendinopathy – disease of a tendon.
Tendonitis – inflammation of a tendon.
Tendonosis – chronic tendon injury with damage to a tendon at cellular level.
Tenosynovitis – inflammation of the tendon sheath.
Enthesopathy – inflammation of the tendon origin or the insertion into bone.

Question 8

What is the predominant cell in tendons?

What are these cells responsible for?

Answer 8

The predominant cell in tendons is the fibroblast which are responsible for the production and maintenance of collagen and other proteins which confer the flexibility and tensile strength of tendons

Question 9

What are the three sources of blood supply to a tendon?

Answer 9

This comes from 3 sources: the perimyseum, the periosteal insertion of the tendon and the paratenon.

Question 10

What can the aetiology of tendon problems be divided into?

Give examples of each.

Answer 10

Intrinsic – anything do to with the body itself, including disease
- Age, gender
- Obesity
- Predisposing diseases e.g. Rheumatoid
- Anatomical factors e.g. limb malalignment, pes cavus, hyperpronation
Extrinsic factors typically relate to trauma and repetitive injury through sports or work related factors
- Trauma + repetitive injury
- Drugs e.g. steroids, ciprofloxacin
- Sports related factors

Question 11

In which conditions may steroid injections be tried?

Which conditions should this be avoided in?

Answer 11

Injections of local anaesthetic and cortisone around the tendon or the insertion can be considered for conditions such as rotator cuff pathology, tennis and golfer’s elbow but not Achilles tendon or knee extensor mechanism problems due to the risk of rupture.

Question 12

Tendinosis
What is this?
What is seen on histology?
What is it likely due to?
Where does it usually occur?

Answer 12

This is chronic tendon injury with damage to a tendon at cellular level.
Histology shows degeneration of collagen + extracellular matrix.
It is likely due to matrix metalloproteinases which increase with age and repetitive strain.
NB – it usually occurs at areas of poor blood supply.

Question 13

Symptoms and clinical findings of rotator cuff pathology?

Which tests will be positive?

Answer 13

Achy, dull pain which gradually increases over time
Pain tends to be present in 4 tendons of RC
Shoulder tenderness over the shoulder and gleno-humeral joint and the AC joint
Difficulty sleeping on affected side, reaching overhead & on lifting
Painful arc with RC weakness
Positive impingement tests e.g. Hawkins-Kennedy test, Jobe’s test, Scarf test

Question 14

What is the gold standard imaging used for rotator cuff pathology?

Answer 14

USS is the gold standard for imaging of the rotator cuff. A dynamic scan can detect impingement too.

Question 15

What is the aim of surgical repair of rotator cuff tear?

Answer 15

The aim of surgical rotator cuff repair is to promote power, not prevent formation of arthritis.

Question 16

Biceps brachii tendon rupture
Where are thee three sites that this can take place?
Which is most commonly affected and why?

Answer 16

• Long head
• Short head
• Distal end
  Predominantly the long head of biceps is affected where it passes through the bicipital groove located anteriorly on the proximal humerus. This is where most inflammation occurs which is usually friction related.

Question 17

Symptoms of biceps brachii tendon rupture?
Clinical signs?
There is weakness in which motion?
Treatment?

Answer 17

Anterior shoulder pain radiating to elbow
Aggravated by shoulder flexion, forearm pronation and elbow flexion
Clicking or snapping sensation with shoulder movement
Popeye sign
Extensive bruising
Patients may complain of weakness of supination – screwdriver motion.
The mainstay of treatment is conservative with rest + physiotherapy.
Surgical repair can be carried out but runs a high risk of neurovascular complications especially the distal end

Question 18

Medial epicondylitis
Aka?
Symptoms?
Which test is positive?
Management?

Answer 18

Tennis elbow
Symptoms - pain and tenderness over the lateral epicondyle at the attachment of the forearm muscles. Pain is worse when stretching the muscles e.g. opening a jar.
Mill’s test is positive - this is where pain is reproduced by resisted wrist extension with palm pronated whilst moving the palm sideways in the direction of the thumb
Rest, physio, injection of LA and steroids, orthotics and surgical release for refractory cases.

Question 19

Lateral epicondylitis 
Aka?
What is this inflammation of?
Symptoms?
Peak incidence?
Natural history?
Management?

Answer 19

Golfer’s elbow
This is inflammation of the forearm flexor muscles.
It causes medial elbow pain with a tender point being located over origin of the flexors at the medial epicondyle. The pain is aggravated by wrist flexion and pronation which is the basis for testing on examination. It is also worse upon grasping e.g. opening a jar.
Peak incidence is 40-50 yo.
NB – this is a self-limiting condition.
Management is conservative with rest, physio, modification of activities, orthotics, or injection of LA and steroid. For refractory cases, surgical release may be required.

Question 20

Which structure does DeQuervians tenosynovitis affect?
How does it present?
Who is is most common in?
Which conditions is it associated with?
Which test is it diagnosed with?

Answer 20

It affects the first compartment which contains the extensor pollicis brevis and abductor pollicis longus.
It typically it presents as a repetitive strain injury with pain over the radial styloid process at the wrist.
It is most common in women aged between 30 and 50 and is associated with pregnancy and rheumatoid arthritis.
It can be diagnosed by Finklestein’s test whereby the patient makes a fist over the thumb and the hand is ulnar deviated to reproduce pain

Question 21

Investigation of DeQuervians tenosynovitis?

Management?

Answer 21

It is investigated with an USS and an X-ray to rule out CMC joint OA which can mimic DQ.
Management – splint, rest, physio, analgesics, injection, surgical decompression.

Question 22

If synovitis doesn’t respond to RA treatment, which can be done in order to prevent tendon ruptures?

Answer 22

Synovectomy

Question 23

Extensor pollicis longus rupture
What can this occur after?
What can it lead to?
What treatment does it require?

Answer 23

This can occur after Colles fracture, and leads to substantial loss of function.
It requires tendon transfer from the extensor indicus proprius (EIP) – the index finger has two tendons, so you can take this one and move it to the thumb, as shown opposite.

Question 24

Trigger finger
What causes this?
Management?

Answer 24

This is caused by stenosing tenosynovitis, which leads to fibrocartilaginous dysplasia and nodule formation on the flexor digitorum superficialis tendon.
The nodule attached to the A1 pulley, which causes the “triggering”.
Management – observe in kids; consider injection in adults, and surgical release in refractory cases.

Question 25

Knee extensor mechanism rupture
Who is it common in?
What is it associated with?
Management?

Answer 25

It is more common in the middle aged population who play running or jumping sports.
Tendon rupture is associated with blunt or penetrating trauma, steroid or antibiotic use, DM.
Management is predominantly by surgical repair with gradual increase in ROM post-operatively as part of the physiotherapy regime. However, small partial tears of the quadriceps may be amenable to immobilisation and physiotherapy.
Surgical repair of the quadriceps and patellar tendons is typically done using sutures with bony anchors through an open approach. It is difficult to attach tendon to bone so lots of stitches are required.

Question 26

Osgood-Schlatter's disease
What is this?
Who does it commonly occur in?
What does it tend to leave?
What other types of traction apophysitis can you get?

Answer 26

This is inflammation of the insertion of the patellar tendon into the anterior tibial tuberosity.
It most commonly occurs in adolescent active boys.
It tends to leave a prominent bony lump.
You get different types, e.g. Sever’s disease – traction apophysitis at the insertion of the tibialis anterior onto the os calcis.

Question 27

Tibialis posterior tendon dysfunction
Pathophysiology?
Symptoms?
Treatment?

Answer 27

Pathophysiology: tenosynovitis -> progressive elongation -> Rupture.
The cause is usually unclear.
Symptoms – progressive flat foot and valgus hindfoot.
Treatment – NSAIDs, orthotics/cast, injection, debridement.
May be helped by tendon transfer.