Early osteoarthritis.

Everybody knows what osteoarthritis (OA) is and how to
manage it. Everybody knows (or thinks to know) what a
cartilage defect is and continues to discuss how to treat it.
But there is a ‘‘no man’s land’’ in between, where surgeons
prefer not to go: patients where cartilage repair is ‘‘not
enough’’, but prosthetic solution is ‘‘too much’’; something
like ‘‘wait till you are bad enough/old enough for a total/uni
knee replacement’’….
In reality, a lot of people are willing to conquer this no
man’s land: on the one hand cartilage surgeons (and don’t
forget about industry, please) advancing: ‘‘we will make
our implant bigger!’’, and on the other hand prosthetic
people proposing: ‘‘we will make our implant smaller!’’
But it’s not just a matter of size … rather, treatments
should be targeted according to the proper disease and
disease phase.
Until now, despite the growing interest in this category
of patients and new fashionable treatments continuously
coming up, still, nobody can clearly define where this
‘‘shadow zone’’ of early OA begins and ends. And once we
know, what should we do?
There is an increasing awareness on the importance in
identifying early phases of the degenerative processes,
when there might still be some regenerative ability of
cartilage, which is permanently lost in the advanced stages
of the disease. Nonetheless, surprisingly the definition of
OA has not changed since 1986 to capture OA and certainly
early OA [1].
The diagnosis of early knee OA is more complicated
than already established OA, where clear signs can be
detected simply through radiographs and more defined
history, signs, and symptoms [1]. In this early phase, signs
and symptoms may still be limited and sporadic, only
becoming manifest under certain conditions such as after
long-term loading. Moreover, even though early OA is
thought to display a number of tissue-related phenomena
leading to the loss of knee homeostasis and in most cases to
established OA [2, 3], such structural changes are not
detectable by radiographic evaluation [1]. Other than
arthroscopy, which is seldom used as a pure diagnostic
tool, new imaging techniques improving in quality over the
last years, in particular MRI, may detect the spectrum of
joint tissue changes to identify the pathological tissues and
the loss of joint homeostasis. With MRI available in the
daily clinical practice, early OA phase should be possible
to define in the majority of patients.
In view of the increasing knowledge on joint pathophysiology
and the availability of diagnostic tools, a
consensus of experts of different fields (orthopedics,
rheumatology, biology, sports medicine, and rehabilitation)
has been assembled in an ESSKA Cartilage Committee
Consensus Meeting held in Bologna at the Rizzoli Orthopaedic
Institute in March 2011, aiming to define ‘‘early
OA’’. For the first time, arthroscopic exam and MRI findings
have been taken into account, together with X-ray and
clinical evaluation
A clear definition of the early OA phase is important
from two points of view: it could allow one to identify
patients before advanced degenerative phases, which definitely
contraindicates the current regenerative treatments,
but it would also identify patients at risk for progression,
thus allowing one to better assess the potential of the
available procedures and patients who may better benefit
from their use. In fact, despite the literature showing
overall promising findings of novel approaches, the clinical Everybody knows what osteoarthritis (OA) is and how to
manage it. Everybody knows (or thinks to know) what a
cartilage defect is and continues to discuss how to treat it.
But there is a ‘‘no man’s land’’ in between, where