Chondral Fissure: Understanding, Symptoms, Causes, Diagnosis, and Treatment

What is a Chondral Fissure?

A chondral fissure is a crack or split in the articular cartilage, the smooth, slippery tissue covering the ends of bones within a joint, most commonly affecting the knee, ankle, or shoulder.

Understanding Articular Cartilage

Articular cartilage is a specialized type of hyaline cartilage that lacks nerves, blood vessels, and lymphatic supply. Its primary functions are to reduce friction between bones during movement, absorb shock, and distribute loads evenly across the joint surface. This remarkable tissue allows for smooth, pain-free joint motion. Unlike bone, articular cartilage has a very limited capacity for self-repair due to its avascular nature.

What is a Chondral Fissure?

A chondral fissure represents an injury to this critical joint surface. It is essentially a crack or split within the cartilage matrix, ranging from superficial breaks to deeper lesions that may extend down to the subchondral bone (the bone directly beneath the cartilage). Unlike a full-thickness defect where a piece of cartilage might be missing, a fissure implies an intact, though damaged, surface. These injuries are distinct from meniscal tears, which involve the crescent-shaped cartilage structures within the knee, though both can occur simultaneously.

Causes of Chondral Fissures

Chondral fissures can arise from several mechanisms, often involving a combination of factors:

• Acute Trauma: A direct blow to the joint, a twisting injury, or a sudden, forceful impact (e.g., falls, sports injuries, car accidents) can cause the cartilage to crack.
• Repetitive Stress and Overuse: Chronic, repetitive loading or microtrauma to a joint, common in athletes or individuals with physically demanding occupations, can gradually wear down and damage the cartilage, leading to fissures.
• Degenerative Changes: As part of the aging process, cartilage can naturally thin and lose its elasticity, making it more susceptible to fissuring with less stress. This is often a precursor to osteoarthritis.
• Malalignment or Biomechanical Issues: Abnormal joint mechanics, such as genu varum (bow-leggedness) or genu valgum (knock-knees), patellar maltracking, or foot deformities, can lead to uneven loading of the cartilage, predisposing it to injury.
• Osteochondritis Dissecans (OCD): A condition where a segment of bone and its overlying cartilage loses blood supply, softens, and can eventually crack or separate from the surrounding bone, forming a fissure or loose body.

Common Symptoms

The symptoms of a chondral fissure can vary depending on the size, depth, and location of the lesion, as well as the individual's activity level. Common signs include:

• Joint Pain: Often described as a deep, aching pain, which may worsen with activity, weight-bearing, or after prolonged rest.
• Swelling: Fluid accumulation (effusion) in the joint can occur, especially after activity.
• Stiffness: The joint may feel stiff, particularly after periods of inactivity.
• Clicking, Popping, or Grinding (Crepitus): These sounds or sensations can occur as the damaged cartilage surfaces rub against each other.
• Catching or Locking: In some cases, a loose flap of cartilage or a displaced fragment can temporarily interfere with joint movement, causing a sensation of catching or locking.
• Reduced Range of Motion: Pain and swelling can limit the ability to fully bend or straighten the joint.

Diagnosis

Diagnosing a chondral fissure typically involves a multi-pronged approach:

• Clinical Examination: A thorough physical examination by a healthcare professional, including assessment of pain, swelling, range of motion, and stability of the joint.
• Medical History: Detailed questions about the onset of symptoms, previous injuries, activity levels, and any contributing factors.
• Imaging Studies:
  • X-rays: While X-rays cannot directly visualize cartilage (as it is radiolucent), they can rule out fractures, identify bone spurs, or show signs of advanced osteoarthritis (joint space narrowing).
  • Magnetic Resonance Imaging (MRI): MRI is the gold standard for diagnosing chondral lesions. It provides detailed images of soft tissues, allowing visualization of cartilage integrity, depth of fissures, and associated injuries to ligaments or menisci.
  • Arthroscopy: In some cases, a minimally invasive surgical procedure called arthroscopy may be performed. This allows the surgeon to directly visualize the cartilage, assess the extent of the damage, and often perform immediate repair or debridement.

Grading of Chondral Lesions

Chondral lesions are often graded to describe their severity, commonly using systems like the Outerbridge Classification or the International Cartilage Repair Society (ICRS) classification. A chondral fissure typically falls into the lower grades:

• Grade 0: Normal cartilage.
• Grade 1 (Fissure): Cartilage with softening (chondromalacia) or superficial fissures/blisters.
• Grade 2 (Fissure with Fragmentation): Partial-thickness defect with fissures and fragmentation less than 1.5 cm in diameter.
• Grade 3 (Deep Fissure/Full Thickness): Full-thickness defect extending to the subchondral bone, but without exposed bone, or lesions larger than 1.5 cm.
• Grade 4 (Osteochondral Lesion): Full-thickness defect with exposed subchondral bone.

Treatment Options

Treatment for a chondral fissure depends on several factors, including the size and depth of the fissure, the patient's age, activity level, and the presence of other joint injuries.

Conservative Management

Initial treatment often focuses on non-surgical approaches:

• Rest and Activity Modification: Reducing activities that aggravate the joint, possibly using crutches or braces to offload the affected area.
• Ice and Compression: To reduce pain and swelling.
• Non-Steroidal Anti-Inflammatory Drugs (NSAIDs): Over-the-counter or prescription medications to manage pain and inflammation.
• Physical Therapy: A structured rehabilitation program to restore joint mobility, strengthen surrounding muscles, improve balance, and optimize biomechanics. This is crucial for long-term joint health.
• Corticosteroid Injections: May provide temporary pain relief and reduce inflammation, but do not address the underlying cartilage damage.
• Viscosupplementation Injections: Injections of hyaluronic acid, a component of healthy joint fluid, can improve lubrication and shock absorption, potentially reducing symptoms.

Surgical Interventions

If conservative measures fail or in cases of larger, symptomatic fissures, surgical options may be considered:

• Arthroscopic Debridement/Chondroplasty: This involves smoothing out rough cartilage edges and removing loose fragments to prevent mechanical irritation. It provides symptomatic relief but does not regenerate cartilage.
• Microfracture: Small holes are drilled into the subchondral bone to stimulate bleeding and the formation of fibrocartilage, a less durable form of cartilage, to fill the defect.
• Autologous Chondrocyte Implantation (ACI): Healthy cartilage cells are harvested from the patient, cultured in a lab, and then implanted back into the defect. This is a two-stage procedure.
• Osteochondral Autograft Transfer System (OATS/Mosaicplasty): Healthy cartilage and bone plugs are harvested from a less weight-bearing area of the patient's joint and transferred to the damaged area.
• Allograft Transplantation: In severe cases, cartilage and bone from a deceased donor may be used.

Rehabilitation and Prognosis

Rehabilitation after a chondral fissure, whether treated conservatively or surgically, is critical for optimal outcomes. It typically involves:

• Pain and Swelling Management: Initial focus on reducing inflammation.
• Restoration of Range of Motion: Gentle exercises to regain full joint movement.
• Strengthening: Progressive strengthening of muscles surrounding the joint to improve stability and support.
• Proprioception and Balance Training: Exercises to improve the body's awareness of joint position and balance.
• Gradual Return to Activity: A carefully supervised progression back to daily activities and sports.

The prognosis for a chondral fissure varies. Superficial fissures may heal or remain asymptomatic. Deeper or larger fissures, especially those involving the subchondral bone, carry a higher risk of progressing to osteoarthritis due to the cartilage's limited healing capacity. Adherence to rehabilitation and long-term joint care strategies are key to managing symptoms and preserving joint function.

Prevention Strategies

While not all chondral fissures can be prevented, several strategies can reduce the risk:

• Maintain a Healthy Weight: Reduces stress on weight-bearing joints.
• Proper Exercise Technique: Ensures correct biomechanics during physical activity.
• Gradual Progression in Training: Avoids sudden increases in intensity or volume that can overload joints.
• Cross-Training: Incorporate a variety of activities to distribute stress across different joints and muscle groups.
• Strength Training: Build strong muscles around joints to provide support and stability.
• Adequate Warm-up and Cool-down: Prepares joints and muscles for activity and aids recovery.
• Appropriate Footwear: Provides cushioning and support, especially during high-impact activities.
• Listen to Your Body: Do not ignore persistent joint pain; seek professional advice early.

When to See a Doctor

If you experience persistent joint pain, swelling, stiffness, clicking, catching, or a feeling of instability, especially after an injury or if symptoms interfere with your daily activities, it is important to consult a healthcare professional. Early diagnosis and appropriate management of a chondral fissure can help mitigate symptoms, slow progression of cartilage damage, and preserve joint health.