Pothole Pitfalls

Cosmetic Surgery & Beauty magazine discovers why potholes in the joints need as much care as those found on roads.

Cosmetic Surgery & Beauty Magazine - December 1, 11:45 PM

Driving on roads riddled with potholes damage your car at best and cause morbid catastrophes at its worst. When left unfixed, street craters become larger and deeper, affecting in higher instances of fatal vehicular accidents. This simple analogy can also be applied to your joints where “potholes” in the articular cartilage can worsen over time. When left untreated, such destructions are continually aggravated, becoming bigger, deeper and ultimately, irreparable. 
Consultant Orthopaedic Surgeon, Dr. Mohd Rusdi Abdullah from the Subang Jaya Medical Centre
These “potholes” – according to Consultant Orthopaedic Surgeon, Dr. Mohd Rusdi Abdullah from the Subang Jaya Medical Centre – are damages to the joint lining, normally occurring at weight bearing joints including the knee, hip and ankle or other common locations like the shoulder and elbow. Routinely caused by single injuries or repetitive microtraumas, severities will depend on the lesion’s depth, size and location. 
 Unluckily, superficial or small “potholes” effect in mild, gradual symptoms. In certain instances, patients have no indications whatsoever. Mild lesions however, can fail to heal and be subjected to further impact. Due to the minimal signs of damage, patients only seek medical attention when pain and swelling is severe. By this time, it may just be too late for possibilities of therapeutic treatments or less invasive procedures with surgery the only route to optimal recoveries. In this article, the good doctor explains how articular cartilage becomes damaged, why it takes a longer time to heal and how these “potholes” are filled and treated. 
What is the articular cartilage and how can it become damaged?
Healthy articular cartilage in the knee (Pictures courtesy of Dr. Mohd Rusdi Abdullah)
Articular cartilage is a firm, smooth and rubbery white tissue. Its thickness averages from two to four millimeters and works by cushioning and providing a smooth lubricated surface for joints during motion. Unlike muscle or bone, cartilage doesn’t enjoy good blood supply and hence, receives nutrients through the joint’s fluid. This not only results in longer healing but also poorer recovery. 
 As revealed, damages to the cartilage are frequently caused by an isolated incident, recurrent overuse when lesions are present, illness and even lifestyle choices. Such include, direct impacts or hits during falls, accidents or sports, joint dislocations, repetitive microtrauma and degenerative processes from ageing. Likewise, inflammation, infection, obesity and unstable joints due to ligament injuries may too affect in higher instances of articular cartilage destruction.
What symptoms will patients commonly experience?
Once the cartilage is impaired, the affected joint can swell up, become painful and feel stiff. Furthermore, patients may also find strange noises where joints click or grind. 
 In severe circumstances, broken pieces of cartilage may even turn lose and lock joints. If remained untreated, injured joints may lose function altogether. Should patients experience any of these symptoms, the first line of care is to protect the joint from further impairment. In addition to icing, resting and elevating the afflicted region, patients can also wear a support brace or bandage the joint. Of course, immediate and prompt visits to your orthopaedic specialist is advisable in order for early diagnosis and accurate treatment pathways. 
How are “potholes” diagnosed and what are the many forms of treatment available?
Articular cartilage damage is diagnosed via combinations of present symptoms, specific physical examinations, X-rays, MRIs and arthroscopy. Treatments are very individualised and tailored to patient factors including age, skeletal maturity, his or her activity level, symptoms, underlying medical conditions and ability to comply with rehabilitative processes. Moreover, lesion indications like its location, size, depth and presence of associated injuries also come into play. 
Patients that undergo early detection and present with mild lesions may be treated with activity modification, rest, physiotherapy, healthy body weights and an unloader brace. If added treatment calls for it, viscosupplementation like glucosamine sulphate and hyaluronic acid injection may be advocated. 
In terms of severe injuries that are resistant to non-operative therapies, surgery may be the next possible solution. Such include:
· Debridement/chondroplasty on damaged, irreparable and loose cartilage tissue flaps.
· Marrow stimulation techniques through microfracture, abrasion chondroplasty and drilling, allowing marrow elements to access defects and stimulate repair. This technique is cost effective without needs for implants. It also produces good results on small lesions less than 2x2cm.
Cartilage injury treated with microfracture.
· Osteochondral autograft or mosaicplasty which replaces damaged cartilage from weight bearing regions to non-weight bearing areas of the joint.
· Osteochondral allograft transplantation which replaces damaged cartilage with donor tissue. This is applicable to large and deep lesions. The technique may be considered costly with risks of disease transmission.
· Autologous chondrocyte implantation (ACI) is a 2-stage procedure. At the first stage, normal cartilage tissue from less weight bearing areas are harvested. In the lab, cartilage cells are cultured and expanded. During the second stage, cartilage cells are implanted into the lesion. This technique provides better quality cartilage tissue than marrow stimulation methods and can address larger defects.
· Treatment with synthetic cartilage implantation utilising a biodegradable hyaluronic acid-based scaffold for cartilage regeneration. 
Synthetic cartilage implantation.
How can patients care for their joints and cartilage after treatment or surgery?
 It’s essential that patients comply with rehabilitation processes after surgery. Limitation of motion depends on procedural type but generally, downtime may persist for as long as six to 12 weeks. 
 Patients can take better care for their weight bearing joints and avoid possibilities of cartilage damage by following these steps:
1. Exercise! With healthy joint motion, your cartilage will enjoy better nutrient supply from the joint’s fluid.
2. Adequate nutrition and healthy diets through foods or supplements high in amino acids, lycine, omega 3 fatty acids and Vitamin C and D.
3. Applying correct shoe wear and protective gears during sports and exercise.
4. Strengthening the muscles and tendons around joints.
5. Correct posture to ensure balance and proper load distribution on joints. 
6. Cessation of smoking as low blood oxygen levels obstruct tissue repair and recovery.
7. Following safe sports by preparing the body well, using correct equipment, practicing on safe grounds, understanding the game and abiding by the rules.
8. Varying exercises with low impact sports like swimming and cycling.
9. Maintaining an ideal body weight. 

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