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Osteochondral Injuries

WHAT IS IT?

These injuries affect the sub-chondral bone and sub-talar joint cartilage, and there are two types:

• Osteochondritis dissecans.
• Osteochondral fractures.

Osteochondritis dissecans is a term used to describe an osteochondral fracture of the talar dome. This type of fracture can be transchondral, intra-articular or in flakes, and can be classified into four stages:

• Stage I (intact): Compression fracture without displacement.
• Stage II (early separation): Incomplete avulsion of the osteochondral fragment.
• Stage III (detached): Complete avulsion of the osteochondral fragment.
• Stage IV (detached): Displaced osteocochondral fragment. It may be inverted in the crater or completely displaced.

CAUSES

The cause of osteochondritis dissecans is not clearly defined. This pathology probably arises due to repeated illnesses and traumas affecting the vascularisation of the bone.

In the case of fractures, it originates from trauma.

SYMPTOMS

In severe cases, there is usually pain, inflammation, ecchymosis and limitations to movement.

In chronic cases, it can cause joint stiffness, pain, crepitation and inflammation. There may occasionally be joint locking.

TREATMENT

• Immobilisation of the joint in cases of stage I and II fractures.
• Exercises to strengthen the muscles surrounding the joint.
• Adaptation of physical activity.
• When the injury reaches stage III or IV, surgical treatment is necessary. The technique most frequently applied at the Arthroscopic Surgery Unit is arthroscopy alongside treatment using platelet-rich plasma (PRP).
• Securing the osteocartilaginous fragment if it is visible.
• Extraction of the osteocartilaginous fragment if it is not “visible”, as is true for the majority of cases of osteochondritis dissecans.

PRGF®-Endoret® and osteochondritis dissecans

In the arthroscopic surgery used to treat this disorder, the wound bed is debrided, separating the osteocartilaginous fragment. Afterwards, the wound bed is spongialised to obtain a bloody wound bed, and activated PRP is injected into the wound bed.

If the fragment can be secured, a second PRP injection is administered in the space between the crater and the fragment. The objective is to fill and seal the area at all the edges of the secured fragment. If necessary, this is complemented with the use of pins or other usually biodegradable fixation systems.

When the fragment cannot be fixed, it will be extracted. Once extracted, and once the wound has been spongialised and the sub-chondral bone injected with PRP, a coagulum of PRP is deposited into the wound bed.

Finally, and in both cases, free intra-articular PRP is injected. This step is repeated on an outpatient basis in the Biological Therapy Unit on two or three further occasions, depending on the size of the injury.

The application of PRP induces the mobilisation of the mesenquimal cells and sends cell signals which initiate the process of joint cartilage repair. Furthermore, it forms a three-dimensional fibrin network which will be colonised by the cells, contributing to the synthesis of tissue which fulfils the mechanical functions of its predecessor.