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The Illustrative Book
of Cartilage Repair
Deepak Rajkumar Goyal
Editor

123
The Illustrative Book of Cartilage Repair
Deepak Rajkumar Goyal
Editor

The Illustrative Book

of Cartilage Repair
Editor
Deepak Rajkumar Goyal
Saumya Arthroscopy and Sports Knee Clinic
Ahmedabad
India
Visiting Professor of Orthopaedics
Graduate School of Biomedical and Health Sciences
Hiroshima University
Hiroshima
Japan

ISBN 978-3-030-47153-8    ISBN 978-3-030-47154-5 (eBook)

https://doi.org/10.1007/978-3-030-47154-5

© Springer Nature Switzerland AG 2021

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or
part of the material is concerned, specifically the rights of translation, reprinting, reuse of
illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way,
and transmission or information storage and retrieval, electronic adaptation, computer software,
or by similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specific statement, that such names are
exempt from the relevant protective laws and regulations and therefore free for general use.
The publisher, the authors, and the editors are safe to assume that the advice and information in
this book are believed to be true and accurate at the date of publication. Neither the publisher nor
the authors or the editors give a warranty, expressed or implied, with respect to the material
contained herein or for any errors or omissions that may have been made. The publisher remains
neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
Foreword

Injury and degeneration of articular cartilage continue to present a therapeu-

tic conundrum that challenges the best minds in translational biology and
orthopedic surgery. In this one volume, Deepak Goyal and colleagues offer
the clinical specialist all the information needed to understand the nature of
cartilage lesions, historical and contemporary approaches to their treatment,
and a peek into what the future might hold. Dr. Goyal has assembled an out-
standing group of experts in the field to provide the reader with the most
authoritative information available on each relevant topic. The hallmark of
this book is the exhaustive collection of illustrations that augment the text and
thoroughly clarify each teaching point. Arthroscopic and gross photographs,
photomicrographs, computed tomograms, magnetic resonance images, and
original artwork all do their part to bring the text to life. The Illustrative Book
of Cartilage Repair provides every reader, from novice to expert, with the
knowledge needed to navigate this dynamic medical field.

Bruce Reider MD
Editor-in-Chief
American Journal of Sports Medicine
Orthopaedic Journal of Sports Medicine
Professor of Orthopaedic Surgery, Emeritus
University of Chicago
 Chicago, IL, USA

v
Foreword

Hunter’s observation in 1743 that cartilage “once destroyed, is not repaired,”

had a great impact on the attempts of cartilage repair for almost 250 years.
When young individuals suffer from articular cartilage defects of the knee
caused by trauma or osteochondritis dissecans, it is difficult to expect a spon-
taneous healing of the defects because articular cartilage has poor spontane-
ous healing capacity, due to its lack of blood vessels and nerve supply. They
will often result in osteoarthritis in the long run. Total knee replacement is a
last possible procedure left for severe OA of the knee.
In order to prevent such early progression to secondary osteoarthritis, vari-
ous techniques such as mosaicplasty and bone marrow stimulating technique
have been developed to repair articular defects.
In 1994, a milestone paper published by M. Brittberg and L. Peterson
came up with a new treatment procedure for cartilage repair. In their proce-
dure, a small amount of cartilage slices was harvested from non-weight-bear-
ing areas of the femur, which were expanded in a monolayer culture system,
and then implanted in suspension into a prepared recipient site in the region
of the chondral defect, which was covered with a periosteal flap. It was aston-
ishing that the repaired area was demonstrated to be hyaline-like cartilage.
However, I personally thought that their implantation method had several
probable weak points such as leakage and inhomogeneous distribution of
implanted chondrocytes. In 1996, we addressed these concerns for the first
time by implanting autologous chondrocytes, cultured in three-dimensional
atelocollagen gel, into the cartilage defect site, and reported the early results
in 2001 and 2002. This procedure has been listed as an item covered by the
National Health Insurance in Japan since 2013, and so far, more than 1000
cases have been performed there.
Since then, in order to overcome the statement made by Hunter about 250
years ago about cartilage—“once destroyed, is not repaired”—many treat-
ment methods and medical products using different types of autogenic or
allogenic stem cells have been developed, and such efforts are still being
made so as to achieve more optimal clinical outcomes in cartilage repair.
This book has comprehensibly outlined the chronological development of
surgical procedures for the cartilage repair. The editor of this book, Deepak
Rajkumar Goyal has had several appointments at domestic and international
associations such as ICS (Indian Cartilage Society), where he had served as

vii
viii Foreword

President for four years, ACRS (Asian Cartilage Repair Society), and ESSKA
(European Society of Sports Traumatology, Knee Surgery and Arthroscopy)
in the past; currently, he has been serving as President of Asian Cartilage
Repair Society (ACRS). Up until today, throughout his academic life, Dr.
Deepak has been passionately pursuing clinical practices and his research in
the field of cartilage repair. My first encounter with Dr. Deepak Rajkumar
Goyal goes back to an international conference held in September 2005 when
I was invited to deliver a lecture presentation in Budapest in Hungary. At that
time, Dr. Deepak was being trained under Prof. Dr. Berkes István. Since then,
more than 15 years have passed, and his zest for cartilage repair has not
shown any sign of cooling down.
I am certain that The Illustrative Book of Cartilage Repair will contribute
significantly to the continued evolution of cartilage repair procedures in
orthopedics. For that, I am truly grateful to Dr. Deepak Rajkumar Goyal for
having successfully compiled this book, while securing many world-famous
talented authors for their excellent contributions. Congratulations to the edi-
tor and the authors on this splendid accomplishment.

Mitsuo Ochi, MD, PhD.

President, Hiroshima University
Hiroshima, Japan

President, JOSKAS
(Japanese Orthopaedics Society of Knee,
Arthroscopy and Sports Medicine), 2009-2018
First President, APKAS (Asia-Pacific Knee,
Arthroscopy and Sports Medicine Society)
First President, ACRS (Asian Cartilage Repair Society)
Preface

From “no treatment” to 3-D bioprinting technologies in cartilage repair, the

science of cartilage repair has grown out of its infancy and is fast maturing
up. The illustrative book of cartilage repair is aimed to provide a visual and
first-hand impression of the different concepts behind cartilage repair to the
young aspiring as well as the established cartilage surgeons. Young surgeons,
who are inadvertently confused with this rapidly evolving science, can under-
stand the basics of cartilage repair along with a broad outlook of the various
commonly performed cartilage repair surgeries through a pictorial display of
the techniques. It is not uncommon for the established cartilage surgeons to
follow some of the cartilage repair procedures while remaining away from
the remaining spectrum of cartilage repair surgeries options. The established
cartilage surgeons can also have a quick deeper insight into the cartilage
repair techniques that they do not commonly perform due to either a lack of
availability or a lack of training or due to a disbelief towards a procedure.
Pioneers and masters in their respective fields have contributed to the book so
as to provide a major insight into the latest technology and the operative tech-
niques. Some of the authors are the basic researchers of their respective tech-
niques and have shared their rich experience in the form of a detailed case
presentation as well as step-by-step pictorial guide to the respective tech-
nique. I wish this book will find its place in the major libraries as well as on
the coffee table of the surgeon’s room across the globe.

“Let us preserve the joints”

Ahmedabad, Gujarat, India Deepak Rajkumar Goyal

President, Asian Cartilage
Repair Society (ACRS)
Founder and Past President,
Indian Cartilage Society (ICS)
Fellow Member and Past Committee
Chair, International Cartilage
Repair Society (ICRS)

ix
Acknowledgement

The patient does not care about your science; what he wants to know is, can you
cure him?—Martin H. Fischer

Let the young know they will never find a more interesting, more instructive book
than the patient himself.—Giorgio Baglivi

We, as medical professionals continue to learn, understand, and implement

the advances in medical science for the welfare of our patients. But we should
not forget that at the end, what patient wants is a cure. We learn from the
patients and patients expect a cure. Both the philosophies go parallel and will
continue to remain so.
While writing the acknowledgement, the first thing that comes to my mind
is my patients. The medical education and the professional training made me
an educated doctor but my patients made me a human doctor. Their pains and
disabilities had lots of human feelings that are not written in the medical
books. I learnt a lot treating them and implemented a lot that I learnt from
them. I am deeply thankful to my patients who have trusted me for the last
three decades and have allowed me to treat them. I have applied lots of infor-
mation in this book that I gathered while treating them.
It takes tremendous time while writing, editing, and reviewing a book. My
wife, Anjali, not only allowed me to utilize our personal time for the prepara-
tion of this book, but also served as a great helping hand. My kids, Aarju and
Saumya, helped me in managing the technical part of the images while in
fact, I was utilizing their quality time. I am thankful to my wife, children, and
my parents who had been a backbone of my professional and academic activ-
ities all these years.
The contributors of the book have also worked very hard to provide
sequential images for their respective chapters. While the surgeons do have
many images of a surgical technique, we discovered that it is very difficult to
have a complete series of one patient, from clinico-radiological preoperative
diagnosis to the sequential surgical steps and then the long-term follow-up
confirmation of the results. However, I am so glad that each corresponding
author of the book worked very hard to collect the required information and
transformed their respective cases into a chapter. The reviewers were also
very exemplary. They understood the concept behind the book very well and
then contributed immensely in giving their suggestions. I immensely thank
all the contributors and reviewers for this detailed and easy-to-understand
collection of the illustrated cartilage repair techniques.

xi
xii Acknowledgement

Lastly, I thank the editorial support team of Springer who put a deep trust
in me and supported me from the conceptualization to the publication of this
book.

Deepak Rajkumar Goyal MB, MS, DNB

Consultant Arthroscopy & Sports Knee Surgeon

Saumya Arthroscopy and Sports Knee Clinic,

Ahmedabad, India

Visiting Professor of Orthopaedics

Graduate School of Biomedical
and Health Sciences, Hiroshima
University, Hiroshima,
Japan
Contents

1 The Science of Illustrated Cartilage

Repair and Its Rationale ����������������������������������������������������������������   1
Deepak Rajkumar Goyal
2 The Illustrative Anatomy and the Histology
of the Healthy Hyaline Cartilage����������������������������������������������������   5
Tamás Oláh, Tunku Kamarul, Henning Madry, and Malliga
Raman Murali
3 The Illustrative Anatomy and the Histology
of the Degenerative Hyaline Cartilage ������������������������������������������ 11
Tamás Oláh, Deepak Rajkumar Goyal, and Henning Madry
4 The Illustrative Role of the Subchondral Bone
and the Overlying Cartilage������������������������������������������������������������ 21
Tomoyuki Nakasa and Nobuo Adachi
5 The Illustrative Biomechanics of a Chondral Injury�������������������� 33
Deepak Rajkumar Goyal
6 The Classifications of the Chondral Lesions �������������������������������� 43
Deepak Rajkumar Goyal
7 The Illustrative Magnetic Resonance Imaging
of the Chondral and the Osteochondral Lesions�������������������������� 57
Drushi Patel, Ankur Shah, and Deepak Rajkumar Goyal
8 The Illustrative Role of Cells in Cartilage Repair������������������������ 77
Byoung-Hyun Min
9 The Illustrative Chondral and Osteochondral Scaffolds
in Cartilage Repair�������������������������������������������������������������������������� 87
Alberto Poggi, Luca Andriolo, Angelo Boffa,
Sante Alessandro Altamura, Iacopo Romandini,
Alessandro Di Martino, Stefano Zaffagnini,
and Giuseppe Filardo
10 The Illustrative Marrow Stimulation Techniques
for Cartilage Repair: The Microfracture Technique�������������������� 97
Katarzyna Herman, Eleonora Irlandini, Ignacio Dallo,
Ezequiel Santa Coloma, and Alberto Gobbi

xiii
xiv Contents

11 The Illustrative Osteochondral Cylinder Transfer Techniques

for Cartilage Repair: The Mosaicplasty Technique���������������������� 105
Laszlo Hangody
12 The Illustrative Osteochondral Cylinder Transfer Techniques
for Cartilage Repair: The OATS Technique���������������������������������� 123
Sachin Ramchandra Tapasvi, Anshu Shekhar,
and Shantanu Sudhakar Patil
13 The Illustrative First and Second Generation Autologous
Chondrocyte Implantation (ACI) for Cartilage Repair �������������� 137
Mats Brittberg
14 The Illustrative Membrane Based Autologous Chondrocyte
Implantation for Cartilage Repair ������������������������������������������������ 147
Nicholas Ramos, Bert Mandelbaum, and Michael Banffy
15 The Illustrative Third Generation Autologous
Chondrocyte Implantation for Cartilage Repair:
The Gel Based ACI Technique�������������������������������������������������������� 157
Deepak Rajkumar Goyal
16 The Illustrative Single-Stage Cartilage Repair Technique
with Chitosan-Based Bioscaffold (BST-CarGel) �������������������������� 167
Ivan Wong and Anjaneyulu Purnachandra Tejaswi Ravipati
17 The Illustrative Multilayer Scaffolds for the Single-Stage
Cartilage Repair in the Osteochondral Lesions���������������������������� 181
Elizaveta Kon and Alessandra Nannini
18 The Illustrative Bone Marrow Aspirate Concentrate
and Hyaluronan-Based Scaffold Technique for Single-Stage
Cartilage Repair������������������������������������������������������������������������������ 191
Alberto Gobbi, Ignacio Dallo, Katarzyna Herman,
and Eleonora Irlandini
19 The Illustrative Overlay Autologous Chondrocyte Implantation
(Overlay ACI) Technique for Repair of the Extra-­Large
Osteochondral Defects �������������������������������������������������������������������� 203
Deepak Rajkumar Goyal
20 The Illustrative Osteochondral Allograft-Based
Cartilage Repair������������������������������������������������������������������������������ 219
Martyn Snow
21 The Illustrative 3D Bioprinting in Cartilage Repair�������������������� 241
Timothy F. Reed, Pooja N. Swami, Taylor L. Mustapich,
and Daniel A. Grande
22 The Illustrative Magnetic Resonance Image (MRI)
Assessment of Cartilage Repair������������������������������������������������������ 259
Dinshaw N. Pardiwala, Kushalappa Subbiah,
and Pradeep Mandapalli
Contributors

Nobuo Adachi Department of Orthopaedic Surgery, Biomedical & Health

Sciences, Hiroshima University, Hiroshima, Japan
Sante Alessandro Altamura Clinic IRCCS Istituto Ortopedico Rizzoli,
Bologna, Italy
Luca Andriolo Clinic IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
Michael Banffy Kerlan Jobe Institute, Los Angeles, CA, USA
Angelo Boffa Clinic IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
Mats Brittberg Cartilage Research Unit, University of Gothenburg, Region
Halland Orthopaedics, Kungsbacka Hospital, Kungsbacka, Sweden
Ezequiel Santa Coloma Orthopaedic Arthroscopic Surgery International
(O.A.S.I.) Bioresearch Foundation, Gobbi N.P.O., Milan, Italy
Ignacio Dallo Orthopaedic Arthroscopic Surgery International (O.A.S.I.)
Bioresearch Foundation, Gobbi N.P.O., Milan, Italy
Alessandro Di Martino Clinic IRCCS Istituto Ortopedico Rizzoli, Bologna,
Italy
Giuseppe Filardo Applied and Translational Research center (ATRc),
IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
Alberto Gobbi Orthopaedic Arthroscopic Surgery International (O.A.S.I.)
Bioresearch Foundation, Gobbi N.P.O., Milan, Italy
Deepak Rajkumar Goyal Saumya Arthroscopy and Sports Knee Clinic,
Ahmedabad, Gujarat, India
Visiting Professor of Orthopaedics, Graduate School of Biomedical and
Health Sciences, Hiroshima University, Hiroshima, Japan
Daniel A. Grande Donald and Barbara Zucker School of Medicine at
Hofstra/Northwell, Hempstead, NY, USA
Orthopaedic Research Laboratory at Feinstein Institute for Medical Research,
Northwell Health, Manhasset, NY, USA
Department of Orthopaedic Surgery, Northwell Health, Great Neck, NY,
USA

xv
xvi Contributors

Laszlo Hangody Hungarian Academy of Sciences, Budapest, Hungary

Department of Traumatology, Semmelweis University, Budapest, Hungary
Department of Orthopaedics, Uzsoki Hospital, Budapest, Hungary
Katarzyna Herman Orthopaedic Arthroscopic Surgery International
(O.A.S.I.) Bioresearch Foundation, Gobbi N.P.O., Milan, Italy
Eleonora Irlandini Orthopaedic Arthroscopic Surgery International
(O.A.S.I.) Bioresearch Foundation, Gobbi N.P.O., Milan, Italy
Tunku Kamarul Tissue Engineering Group, Department of Orthopedics
Surgery, NOCERAL, Faculty of Medicine, University of Malaya, Kuala
Lumpur, Malaysia
Elizaveta Kon Department of Biomedical Sciences, Humanitas, University,
Milan, Italy
Humanitas Clinical and Research Center, Milan, Italy
Henning Madry Center of Experimental Orthopaedics, Saarland University,
Homburg, Germany
Department of Orthopaedic Surgery, Saarland University Medical Center,
Homburg, Germany
Pradeep Mandapalli Arthroscopy Service, Kokilaben Dhirubhai Ambani
Hospital, Mumbai, India
Bert Mandelbaum Kerlan Jobe Institute, Los Angeles, CA, USA
Byoung-Hyun Min Department of Orthopedic Surgery, Ajou University
School of Medicine, Suwon, Korea
Department of Molecular Science and Technology, Ajou University, Suwon,
Korea
Cell Therapy Center, Ajou University Hospital, Suwon, Korea
Malliga Raman Murali Tissue Engineering Group, Department of
Orthopedics Surgery, NOCERAL, Faculty of Medicine, University of
Malaya, Kuala Lumpur, Malaysia
Taylor L. Mustapich Orthopaedic Research Laboratory at Feinstein
Institute for Medical Research, Northwell Health, Manhasset, NY, USA
Tomoyuki Nakasa Department of Orthopaedic Surgery, Biomedical &
Health Sciences, Hiroshima University, Hiroshima, Japan
Alessandra Nannini Department of Biomedical Sciences, Humanitas,
University, Milan, Italy
Humanitas Clinical and Research Center, Milan, Italy
Tamás Oláh Center of Experimental Orthopaedics, Saarland University,
Homburg, Germany
Dinshaw N. Pardiwala Arthroscopy Service, Kokilaben Dhirubhai Ambani
Hospital, Mumbai, India
Contributors xvii

Drushi Patel Gujarat Imaging Centre, Samved Hospital, Ahmedabad,

Gujarat, India
Shantanu Sudhakar Patil SRM Medical College and Hospitals, SRM
University, Kattankulathur, Tamil Nadu, India
Alberto Poggi Clinic IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
Nicholas Ramos Kerlan Jobe Institute, Los Angeles, CA, USA
Anjaneyulu Purnachandra Tejaswi Ravipati Division of Orthoapedics,
Dalhousie University, Halifax, NS, Canada
Timothy F. Reed Donald and Barbara Zucker School of Medicine at Hofstra/
Northwell, Hempstead, NY, USA
Orthopaedic Research Laboratory at Feinstein Institute for Medical Research,
Northwell Health, Manhasset, NY, USA
Iacopo Romandini Clinic IRCCS Istituto Ortopedico Rizzoli, Bologna,
Italy
Ankur Shah Sadbhav Imaging Centre, Ahmedabad, Gujarat, India
Anshu Shekhar The Orthopaedic Speciality Clinic, Pune, India
Martyn Snow The Royal Orthopaedic Hospital, Birmingham, UK
Department of Chemical Engineering, University of Birmingham,
Birmingham, UK
Kushalappa Subbiah Arthroscopy Service, Kokilaben Dhirubhai Ambani
Hospital, Mumbai, India
Pooja N. Swami Orthopaedic Research Laboratory at Feinstein Institute for
Medical Research, Northwell Health, Manhasset, NY, USA
Sachin Ramchandra Tapasvi The Orthopaedic Speciality Clinic, Pune,
India
Ivan Wong Division of Orthopaedic Surgery, Dalhousie University, Halifax,
NS, Canada
Stefano Zaffagnini Clinic IRCCS Istituto Ortopedico Rizzoli, Bologna,
Italy
 The Science of Illustrated Cartilage
Repair and Its Rationale 1
Deepak Rajkumar Goyal

A historic statement by Hunter [1], “Ulcerated car- is making us more equipped to better understand
tilage is a troublesome thing, once destroyed…. is the science behind the cartilage repair. Young
not repaired” had a great impact on the attempts of surgeons are very keen to learn and understand
cartilage repair for almost 250 years. The obser- this emerging field of cartilage repair. However,
vation came when he was studying inflammation, as the cartilage science is yet to reach a consen-
suppuration, or lymph collection around a wound sus plateau, they are unable to have a clear and a
and found none appearing around the cartilage long-lasting message about the cartilage repair.
and the corneal lesions. Though true in a research Diversities of the opinions also make it nearly
context, the statement was not true in the context impossible for young surgeons to have a first-hand
of a surgical intervention. Hunter brother’s find- experience of all the existing technologies.
ings were questioned by many authors [2–4] but The basic science of cartilage repair, diagnosis
still, no attempts were made to repair the cartilage and classifications of cartilage lesions, understand-
until the latter half of the last century [5]. ing concepts behind each cartilage repair technique
Cartilage repair is presently a fast-changing and its step-by-step execution, postoperative reha-
science with a very fast evolution process. The last bilitation and long term results etc are the impor-
two decades have seen a plethora of surgical tech- tant fundamentals that must be understood properly
niques and products that can keep even a veteran before any cartilage repair is attempted. Illustrated
cartilage surgeon guessing. Many products have portray of various concepts with a step-by-step
come and have vanished. There are huge contro- description is a unique way to understand the major
versies and concurrences for each and every car- concepts of cartilage repair. Oláh et al. [6, 7] have
tilage repair technique; be it a marrow stimulation produced many gross and histological sections in
technique, an osteochondral cylinder transfer tech- the laboratory and have described the anatomy and
nique, a cell-based technique or a scaffold-­based histology of the healthy and the degenerative car-
technique. But then, every change in the technique tilage in a step wise manner. Their chapters also
include a basic information about the special stains
and the immunohistochemical stains. The sub-
D. R. Goyal (*) chondral (SC) bone plays many important roles,
Saumya Arthroscopy and Sports Knee Clinic,
Ahmedabad, India
like cartilage nourishment, support to the overlying
cartilage and a supplier of cells and growth factors
Visiting Professor of Orthopaedics,
Graduate School of Biomedical and Health Sciences,
[8]. SC bone also behaves differently in response
Hiroshima University, Hiroshima, Japan to injury, necrosis, arthritis, and to a surgical pro-
e-mail: deepak@knee.in cedure. The role of SC bone and its response to

© Springer Nature Switzerland AG 2021 1

D. R. Goyal (ed.), The Illustrative Book of Cartilage Repair,
https://doi.org/10.1007/978-3-030-47154-5_1
2 D. R. Goyal

various pathologies and surgical procedures are dis- biggest challenge with the ACI procedures is two
cussed by Nakasa and Adachi [9]. Many traumatic stage surgeries that put lots of economic, social,
and degenerative chondral lesions have abnormal psychological and physical load on the patient, and
biomechanical forces working behind them, aptly the healthcare industry. To overcome these issues,
discussed by Goyal [10]. While arthroscopic clas- there are simultaneous efforts to evolve into the
sification is the gold standard as described by single stage cartilage repair procedures. To develop
Goyal [11], a magnetic resonance imaging (MRI) a single stage procedure, the major concentration is
classification and assessment is the first insight into on supplying an optimum scaffold while relying on
the cartilage lesion that has been discussed by Patel in vivo cells. BST-Cargel™, bone marrow aspirate
et al. [12]. Cells and scaffolds form the basis of concentrate (BMAC), and artificial single to multi-
any cartilage repair; and hence a basic knowledge layer scaffolds are the various single stage cartilage
about their sources, properties, and their construct repair techniques that have shown good midterm
is a must. While Min [13] has beautifully discussed results in various publications. Wong and Ravipati
the roles of the various cells that have a potential to [22] have described the basic concept behind the
repair the cartilage, Poggi et al. [14] have created BST-Cargel technique, where chitin-based scaffold
beautiful pictures to describe various scaffolds. uses cells coming from a microfracture technique
Microfracture technique is one of the simplest car- [15]. Multiphasic scaffolds like MaioRegen™ as
tilage repair technique that was once considered as described by Kon and Nannini [23] give specific
the first line of treatment by many. An insight into signals to the cells coming from the bone marrow
the detailed operative technique, along with a dis- to differentiate into either chondrocytes or osteo-
cussion about the guarded expectations, has been cytes depending on the properties of the scaffold
discussed by Herman et al. [15]. Two elaborative material. Gobbi et al. [24] have discussed the
chapters have been dedicated to the osteochondral application of bone marrow aspirate concentrate as
cylinder transfer techniques using two different a source of cells while using the hyaluronan mem-
surgical techniques: mosaicplasty by Hangody [16] brane as a scaffold.
and the osteoarticular autogenous transfer system Chondral lesions may not be purely chondral
by Tapasvi et al. [17]. The autologous chondrocytes but can also be combined osteochondral lesions.
implantation (ACI) technique was first published While chondral lesions with a small bony defect
by Brittberg et al. [18] in 1994. The technique was may be treated with an isolated cartilage repair-
revolutionary but had many challenges, leading to ing technique, large or extra-large osteochon-
its evolution to many generations. While the first- dral lesions require a combination of bone
generation technique used the periosteum to cover grafting in conjunction with the cartilage repair
the chondrogenic chamber, the second-generation surgery as described by Goyal [25] in the over-
ACI replaced the periosteum with a collagen mem- lay ACI technique. Alternatively, such lesions
brane. Both first and second-generations are now can be treated with an osteochondral allograft as
gradually being replaced by the third-generation discussed by Snow [26]. Cartilage science must
ACI techniques; still a basic insight into these grow out of the current scenario and find solu-
two techniques is a must which has been covered tions using the latest technology. A 3D bioprint-
by none another but the pioneer of the technique, ing is a promising technology that can ensure a
Brittberg [19] himself. In the third-generation near-perfect scaffold-cell construct and ensure a
ACI, instead of making a chondrogenic chamber hyaline repair. Reed et al. [27] have discussed
at the defect site, a scaffold loaded with the cul- the potential of 3D bioprinting technology in
tured chondrocytes is prepared. While membrane- cartilage repair while also discussing its advan-
based third-­ generation ACI is two dimensional tages and the limitations. Apart from the clinical
ACI as described by Ramos et al. [20], the three- analysis, MRI provides a first insight into the
dimensional third-generation scaffold-based ACI ongoing cartilage repair process after a cartilage
is also available as discussed by Goyal [21]. The repair surgery. Pardiwala et al. [28] have pro-
1 The Science of Illustrated Cartilage Repair and Its Rationale 3

vided a significant insight into the MRI analysis editor. The illustrative book of cartilage repair. Berlin:
Springer; 2021, In Press.
after an untreated lesion as well as after various 13. Min B-H. The illustrative role of cells in cartilage
cartilage repair procedures are carried out. repair. In: Goyal D, editor. The illustrative book of
This book is aimed to display the differ- cartilage repair. Berlin: Springer; 2021; In Press.
ent aspects of cartilage repair, from the basic 14. Poggi A, Andriolo L, Boffa A, Altamura SA,
Romandini I, Di Martino A, Zaffagnini S, Filardo G.
science to the clinical application, for a quick The illustrative chondral and osteochondral scaffolds
visual understanding along with a pictorial dis- in cartilage repair. In: Goyal D, editor. The illustrative
play of all the major cartilage repair techniques. book of cartilage repair. Berlin: Springer; 2021; In
While the aspiring cartilage surgeons can have a Press.
15. Herman K, Irlandini E, Dallo I, Coloma ES, Gobbi
quick perception of the cartilage repair science, A. The illustrative marrow stimulation techniques
existing cartilage surgeons can refresh their for cartilage repair: the microfracture technique. In:
observations about the various cartilage repair Goyal D, editor. The illustrative book of cartilage
technologies. repair. Berlin: Springer; 2021; In Press.
16. Hangody L. The illustrative osteochondral cylinder
transfer techniques for cartilage repair: the mosaic-
plasty technique. In: Goyal D, editor. The illustrative
References book of cartilage repair. Berlin: Springer; 2021; In
Press.
1. Hunter W. Of the structure and diseases of articulating 17. Tapasvi SR, Shekhar A, Patil SS. The illustrative
cartilages. Philos Trans. 1742;42:514–21. osteochondral cylinder transfer techniques for car-
2. Brodie BC. Pathological and surgical observations tilage repair: the OATS technique. In: Goyal D, edi-
on the diseases of the joints. 3rd ed. Washington: tor. The illustrative book of cartilage repair. Berlin:
D. Green; 1834. Chap. 4. p. 35. Springer; 2021, In Press.
3. Leidy J. On the intimate structure and history of the 18. Brittberg M, Lindahl A, Nilsson A, Ohlsson C,
articular cartilages. Am J Med Sci. 1849;34:277–294 Isaksson O, Peterson L. Treatment of deep cartilage
(a) 287; a 291. defects in the knee with autologous chondrocyte
4. Buckwalter JA. Were the Hunter brothers wrong? Can transplantation. N Engl J Med. 1994;331(14):889–95.
surgical treatment repair articular cartilage? The Iowa 19. Brittberg M. The illustrative 1st and 2nd generation
Orthopaedic Journal. 1997;17:1–13. autologous chondrocyte implantation (ACI) for the
5. Pridie K. A method of resurfacing osteoathritic knee cartilage repair. In: Goyal D, editor. The illustrative
joints. J Bone Joint Surg Br. 1959;41-B:618–9. book of cartilage repair. Berlin: Springer; 2021, In
6. Oláh T, Kamarul T, Madry H, Murali MR. The illus- Press.
trative anatomy and the histology of the healthy hya- 20. Ramos N, Mandelbaum B, Banffy M. The illustrative
line cartilage. In: Goyal D, editor. The illustrative membrane based autologous chondrocyte implanta-
book of cartilage repair. Berlin: Springer; 2021; In tion for the cartilage repair. In: Goyal D, editor. The
Press. illustrative book of cartilage repair. Berlin: Springer;
7. Oláh T, Goyal D, Madry H. The illustrative anatomy 2021, In Press.
and the histology of the degenerative hyaline carti- 21. Goyal D. The illustrative third generation autologous
lage. In: Goyal D, editor. The illustrative book of car- chondrocyte implantation for the cartilage repair-the
tilage repair. Berlin: Springer; 2021; In Press. gel based ACI technique. In: Goyal D, editor. The
8. Goyal D, Goyal A, Adachi N. Subchondral bone: illustrative book of cartilage repair. Berlin: Springer;
healthy soil for the healthy cartilage. In: Bio-­ 2021; In Press.
orthopaedics. Berlin: Springer; 2017. p. 479–86. 22. Wong I, Ravipati APT. The illustrative single stage
9. Nakasa T, Adachi N. The illustrative role of the sub- cartilage repair technique with chitosan-based
chondral bone and the overlying cartilage. In: Goyal bioscaffold (BST-cargel). In: Goyal D, editor. The
D, editor. The illustrative book of cartilage repair. illustrative book of cartilage repair. Berlin: Springer;
Berlin: Springer; 2021; In Press. 2021; In Press.
10. Goyal D. The illustrative biomechanics of a chondral 23. Kon E, Nannini A. The illustrative multilayer scaf-
injury. In: Goyal D, editor. The illustrative book of folds for the single stage cartilage repair in the osteo-
cartilage repair. Berlin: Springer; 2021, In Press. chondral lesions. In: Goyal D, editor. The illustrative
11. Goyal D. The classifications of the chondral lesions. book of cartilage repair. Berlin: Springer; 2021; In
In: Goyal D, editor. The illustrative book of cartilage Press.
repair. Berlin: Springer; 2021, In Press. 24. Gobbi A, Dallo I, Herman K, Irlandini E. The illustra-
12. Patel D, Shah A, Goyal D. The illustrative description tive bone marrow aspirate concentrate and hyaluro-
of the imaging of the damaged cartilage. In: Goyal D, nan-based scaffold technique for single stage cartilage
4 D. Goyal

repair. In: Goyal D, editor. The illustrative book of 27. Reed TF, Swami PN, Mustapich TL, Grande DA.
cartilage repair. Berlin: Springer; 2020. The illustrative 3-D bioprinting in cartilage repair.
25. Goyal D. The illustrative overlay autologous chondro- In: Goyal D, editor. The illustrative book of cartilage
cytes implantation (overlay ACI) technique for repair repair. Berlin: Springer; 2021; In Press.
of the extra-large osteochondral defects. In: Goyal D, 28. Pardiwala DN, Subbiah K, Mandapalli P. The illustra-
editor. The illustrative book of cartilage repair. Berlin: tive magnetic resonance image (MRI) assessment of
Springer; 2021; In Press. cartilage repair. In: Goyal D, editor. The illustrative
26. Snow M. The illustrative osteochondral allograft book of cartilage repair. Berlin: Springer; 2021; In
based cartilage repair. In: Goyal D, editor. The illus- Press.
trative book of cartilage repair. Berlin: Springer;
2021, In Press.
 The Illustrative Anatomy
and the Histology of the Healthy 2
Hyaline Cartilage

Tamás Oláh, Tunku Kamarul, Henning Madry,

and Malliga Raman Murali

2.1 Introduction (radial) zones based on the general orientation of

the collagen fibrils, the morphology and arrange-
Hyaline articular cartilage is a 2–4 mm thick, ment of the chondrocytes, and the staining prop-
avascular and aneural tissue, consisting of chon- erties of the matrix [4–6]. Between the deep zone
drocytes (only 1–2% of the total cartilage vol- and the calcified cartilage layer, a radiologically
ume) embedded in an extracellular matrix [1, 2]. denser, 5 μm thin discrete band of mineralized
Its principal function is to provide a smooth, cartilage, called tidemark, can be found. Located
lubricated surface for articulation and to facilitate below the tidemark, the calcified cartilage is a
the transmission of loads with a low frictional 20–250 μm thick transitional zone, which reduces
coefficient [1]. The extracellular matrix contains the “stress riser” between the much stiffer bone
mainly water (>70%) and two major organic and cartilage. Its physiological function is to
components: type II collagen and the proteogly- form an interface between the cartilage and the
can aggrecan, which provide tensile strength and bone for the transmitting forces, attaching carti-
compressive resilience to the tissue [2–4]. lage to bone, and limiting diffusion from the bone
Histologically, the articular cartilage can be to the deeper layers of cartilage [4, 7]. Under the
divided into the superficial, transitional, and deep calcified cartilage lies the subchondral bone
which provides mechanical and metabolic sup-
port to the articular cartilage, absorbs shock, and
maintains the joint shape [4, 5]. The subchondral
T. Oláh bone consists of two parts with different macro-
Center of Experimental Orthopaedics, Saarland scopic structures: the subchondral bone plate and
University, Homburg, Germany the subarticular spongiosa [4]. The subchondral
e-mail: tamas.olah@uni-saarland.de
bone plate is a dense bony lamella, similar to the
T. Kamarul · M. R. Murali cortical bone of other bony structures, separating
Tissue Engineering Group, Department of Orthopedics
Surgery, NOCERAL, Faculty of Medicine, University the calcified cartilage from the marrow cavity.
of Malaya, Kuala Lumpur, Malaysia The subarticular spongiosa is a more porous and
e-mail: tkzrea@um.edu.my; drmurali@um.edu.my metabolically active network of trabecular bone
H. Madry (*) containing innervation and blood vessels [4].
Center of Experimental Orthopaedics, Saarland This chapter describes the normal gross anatomy
University, Homburg, Germany
and histological characteristics of the hyaline
Department of Orthopaedic Surgery, Saarland articular cartilage that give the tissue its extraor-
University Medical Center, Homburg, Germany
dinary load-bearing characteristics.
e-mail: henning.madry@uks.eu

© Springer Nature Switzerland AG 2021 5

D. R. Goyal (ed.), The Illustrative Book of Cartilage Repair,
https://doi.org/10.1007/978-3-030-47154-5_2
6 T. Oláh et al.

2.2 The Illustrations

Figure 2.2.1: The Healthy

Hyaline Cartilage: The Gross
Anatomy of the Femoral
Condyles. The gross anatomy of
the healthy hyaline cartilage of
the femoral condyles from a
cadaveric specimen. Macroscopic
image of a left (a) medial and (b)
lateral normal human femoral
condyle sample of a 96-year-old
woman. The medial femoral
condyle is larger and more oval
than the lateral femoral condyle.
The condyles and their radiuses
are larger in males than in
females, depending on the body
height [8]. Healthy hyaline
cartilage forms a smooth, shiny,
and glassy surface on the
diarthrodial joints, such as the
femoral condyles and the tibial
plateaus of the knee. (Picture
Courtesy—Henning Madry)

Figure 2.2.2: The Healthy Hyaline Cartilage: The Gross acterized by two prominences, the medial and lateral
Anatomy of the Tibial Plateau. The gross anatomy of the tubercles [9]. The macroscopic image of a left normal human
healthy hyaline cartilage of the tibial plateau from a cadav- tibial plateau shows largely smooth, intact articular cartilage
eric specimen of a 52-year-old man. The proximal tibia is surface and the remnants of the meniscal roots and ligaments
composed of the medial and lateral tibial condyles. The supe- which were removed in order to obtain better view of the
rior surface of these condyles (the tibial plateau) consists of cartilage. Since the articular cartilage and the underlying
the superior articular surfaces (facets) and the fossae. The subchondral bone forms a very tight functional unit, called
central portion of the superior articular surface is the inter- the osteochondral unit, studying them simultaneously is
condylar eminence (the spine of the tibia). The spine is char- desirable [4]. (Picture Courtesy—Henning Madry)
2 The Illustrative Anatomy and the Histology of the Healthy Hyaline Cartilage 7

a b

Figure 2.2.3: The Healthy Subchondral Bone: The was cut in the coronal plane to illustrate the microstruc-
Gross Anatomy. The gross anatomy of the healthy sub- ture of the subchondral bone. Below the thin subchondral
chondral bone of the left tibial plateau from a cadaveric bone plate, the intricate trabecular architecture of the sub-
specimen of a 52-year-old man shown in Figure 2.2.2. (a) articular spongiosa following the Wolff’s law is visible.
A superior view of the 3D reconstructed micro-CT (com- The datasets of the micro-CT images allow to retrieve the
puted tomography) image showing the subchondral bone detailed 3D characteristics (including bone volume frac-
plate of the articulating surface. Micro-CT allows to study tion, bone surface/volume ratio, bone surface density, tra-
the morphology of the bone, normally hidden by soft tis- becular number, trabecular separation, connectivity
sues at high resolution. Note the absence of osteophytes density, structure model index, degree of anisotropy) of
on the margins of this healthy specimen, which are gener- the bone microarchitecture using specific analyzing soft-
ally present in diseases like osteoarthritis. (b) The sample ware. (Picture Courtesy—Henning Madry)

Figure 2.2.4: The Healthy Hyaline Cartilage: medial femoral condyle (top) and medial tibial plateau
The Arthroscopic View. The gross anatomy of the (bottom) is seen from the anterolateral portal, without evi-
healthy hyaline cartilage of the tibial plateau and femoral dence of cartilage defects or osteoarthritis changes. A nor-
condyles from an arthroscopy surgery of a 17-year-old mal medial meniscus is seen on the right corner. (Picture
male. The smooth shiny articular cartilage surface of Courtesy—Henning Madry)
8 T. Oláh et al.

Figure 2.2.5: The Histology of the Healthy Hyaline lagen content in superficial zone is to resist the shear stress
Cartilage: The Routine Stains. All four zones of carti- applied on the cartilage tissue. Middle zone will have ran-
lage; the superficial zone (orange arrow), the middle zone domly oriented collagen fibers and proteoglycans to keep
(blue arrow), the deep zone (yellow arrow), and the calci- the tissue hydrated, and deep zone will have collagen fibers
fied zone (green arrow) is seen along with the tidemark aligned perpendicular to the surface. Chondrocytes are the
(black arrow) and the subchondral bone (red arrow) in the cellular components in the cartilage that are responsible for
hematoxylin-eosin stained sample of the healthy hyaline synthesizing and maintaining the extracellular matrix of the
cartilage. Superficial zone has the highest proportion of col- cartilage and are located in the matric cavities known as the
lagen, mainly collagen type II arranged in parallel direction lacunae. (Picture Courtesy—Tunku Kamarul)
to the surface of the tissue. The main function of high col-

a b

Figure 2.2.6: The Histology of the Healthy Hyaline that by controlling the quantity of stain to the adequate levels,
Cartilage: The Special Stains. The special stains for histo- the subchondral bone and the cortical bone regions can be
logical examination of the healthy hyaline cartilage. (a) The clearly differentiated (black arrow). (b) The IHC stains for
healthy cartilage and the healthy subchondral bone are histological examination of the healthy hyaline cartilage can
stained using a special staining technique, the safranin O include a number of staining types, for example, picrosirius
technique, where cartilage is stained orange to red (green red (to detect cartilage). Immunostaining using antibodies
arrow) and all other areas such as bone is stained blue (red against collagen type II (the predominant collagen of the car-
arrow). Safranin O is a basic stain which binds with the pro- tilage tissue) has been used in this image. Higher intensity of
teoglycans in the cartilage with a strong affinity, forming an brown color denotes a higher presence of collagen type II
orange to red complex, and the nuclei are stained black. Note (blue arrow). (Picture Courtesy—Tunku Kamarul)
2 The Illustrative Anatomy and the Histology of the Healthy Hyaline Cartilage 9

Figure 2.2.7: The Histology of the Healthy pinkish (blue arrow) color. Areas of high proteoglycan in
Subchondral Bone: The Routine Stains. Healthy carti- general appear bluish as seen in this picture. Black arrows
lage and the healthy subchondral bone sample is stained marks tidemark in the subchondral bone plate connecting
using hematoxylin and eosin staining method (H&E stain- the cartilage to the bone, and the green arrow shows the
ing). The cell nuclei were stained in blue-purple (red fenestrae connecting to the bone marrow. (Picture cour-
arrow) and the cartilage matrix was stained in purple- tesy—Tunku Kamarul)

a b

Figure 2.2.8: The Histology of the Healthy (indicated by the green arrow). The subchondral bone
Subchondral Bone: The Special Stains. Safranin O is a region shows only a light green counterstain indicating the
cationic dye that stains the proteoglycan as well as the absence of proteoglycans. (b) The IHC stains are also
glycosaminoglycan. The staining also provides a propor- used for the histological examination of the healthy sub-
tional dye intensity to the proteoglycan content, thereby chondral bone. An image of the cartilage to the subchon-
providing some form of indication of the proteoglycan dral bone can be observed in a smooth nice transition of
quantity. (a) A high intensity of orange-red staining is color intensity, as noted in the areas which are of high
observed in the cartilage tissue due to the presence of collagen type II from the surface region (green arrow) to
higher amount of proteoglycans (indicated by blue arrow) the area where the collagen type II is diminished at the
as compared to a lower intensity of staining in the carti- subchondral region (blue arrow). (Picture courtesy—
lage-bone interphase due to a poor glycoprotein content Tunku Kamarul)
10 T. Oláh et al.

2.3 Take-Home Message ers for the early detection of OA are promising,
there is a considerable need to improve the scien-
The osteochondral unit is a mechanically, phys- tific knowledge, expand the technical capacities,
iologically, and biochemically interdependent, and advance the clinical practice through the
tight functional association of the articular car- acceleration of translational research and an
tilage, calcified cartilage, and the underlying identification of the areas of high-yield research
subchondral bone [4]. Together they are respon- topics in this field [10].
sible for transferring loads during weight-bear-
ing and a smooth joint motion [4]. Hyaline
articular cartilage is an important element of References
osteochondral unit ensuring smooth joint move-
ments and a proper load transmission. Due to 1. Sophia Fox AJ, Bedi A, Rodeo SA. The basic sci-
ence of articular cartilage: structure, composition, and
its avascular and aneural nature, it has limited function. Sports Health. 2009;1:461–8.
intrinsic repair capability which makes it vul- 2. Goldring SR, Goldring MB. Changes in the osteo-
nerable to traumatic and aging-related injuries chondral unit during osteoarthritis: structure, function
and degeneration. and cartilage-bone crosstalk. Nat Rev Rheumatol.
2016;12:632–44.
Musculoskeletal disorders and diseases are a 3. Imhof H, Breitenseher M, Kainberger F, Rand T,
leading cause of disability. Over half of the adults Trattnig S. Importance of subchondral bone to articu-
aged 50 years and older, in the western world, lar cartilage in health and disease. Top Magn Reson
have a chronic musculoskeletal condition [10]. In Imaging. 1999;10:180–92.
4. Oláh T, Madry H. The Osteochondral unit: the impor-
the USA, the economic burden is considerable; tance of the underlying subchondral bone. In: Farr J,
the cost of musculoskeletal conditions is Gomoll AH, editors. Cartilage restoration: practical
approaching $1 trillion annually, which repre- clinical applications. Cham: Springer International
sents over 7.4% of the gross domestic product. Publishing; 2018. p. 13–22.
5. Imhof H, Sulzbacher I, Grampp S, Czerny C,
The societal cost for the treatment for OA alone Youssefzadeh S, Kainberger F. Subchondral bone
has surpassed that of both cardiovascular disease and cartilage disease: a rediscovered functional unit.
and cancer [10]. Understanding the anatomy, Investig Radiol. 2000;35:581–8.
physiology, and the complex biomechanical and 6. Madry H, van Dijk CN, Mueller-Gerbl M. The basic
science of the subchondral bone. Knee Surg Sports
biochemical interactions of the articular cartilage Traumatol Arthrosc. 2010;18:419–33.
and the underlying subchondral bone and their 7. Oegema TR Jr, Carpenter RJ, Hofmeister F, Thompson
degeneration pattern in joint diseases, such as in RC Jr. The interaction of the zone of calcified carti-
osteoarthritis, is a major research question in lage and subchondral bone in osteoarthritis. Microsc
Res Tech. 1997;37:324–32.
order to be able to develop successful cartilage 8. Biscevic M, Hebibovic M, Smrke D. Variations of fem-
restoration strategies. Though still in its infancy, oral condyle shape. Coll Antropol. 2005;29:409–14.
the biological treatments for this burdensome 9. McLeod WD, Moschi A, Andrews JR, Hugston
disorder have been a focus of intense investiga- JC. Tibial plateau topography. Am J Sports Med.
1977;5:13–8.
tions. In spite of the recent advances, a significant 10. Madry H, Kon E, Condellao V, Peretti GM, Steinwachs
divergence of opinion on the future of early M, Seil R, Berruto M, Engebretsen L, Filardo G,
detection and biological treatments for orthope- Angele P. Early osteoarthritis of the knee. Knee Surg
dic injuries remains. Even though new biomark- Sports Traumatol Arthrosc. 2016;24:1753–62.
 The Illustrative Anatomy
and the Histology 3
of the Degenerative Hyaline
Cartilage

Tamás Oláh, Deepak Rajkumar Goyal,

and Henning Madry

3.1 Introduction Signs of osteoarthritic joint degeneration,

affecting the articular cartilage and the subchon-
Osteoarthritis is a degenerative disease of the dral bone, are well described on open surgeries,
entire joint, including the articular cartilage, the arthroscopy, and histological sections and on the
subchondral bone, muscles, ligaments, synovium, macroscopic and the micro-computed tomo-
capsules, and the menisci [1, 2]. It is the most graphic (microCT) images. In earlier, milder
prevalent debilitating joint disorder in the elderly, stages of the disease, the cartilage surface
and its occurrence is continuously increasing becomes slightly irregular, and the developing
with the increasing age and obesity of the global fissures and fibrillations do not reach the deeper
population [3]. Osteoarthritic degeneration is tissue layers. The loss of proteoglycans, reflected
also commonly initiated by previous injuries of in the safranin-O staining intensity on the histo-
the articular cartilage [4]. logical sections, is of a low degree, and the cell
clones are not frequent [5, 6]. In the subchondral
bone, a prominent degradation of the trabecular
structure is observed, including decreased tra-
becular volume, number, connectivity density,
T. Oláh
Center of Experimental Orthopaedics,
and degree of anisotropy, and an increased tra-
Saarland University, Homburg, Germany becular separation [7].
e-mail: tamas.olah@uni-saarland.de With the progression of the disease, clefts, and
D. R. Goyal fibrillations reach the deeper layers of the articu-
Saumya Arthroscopy and Sports Knee Clinic, lar cartilage and finally peak in the complete ero-
Ahmedabad, India sion down to the subchondral bone. The
Visiting Professor of Orthopaedics, chondrocytes in the remaining cartilage form
Graduate School of Biomedical and Health Sciences, doublets, triplets, or cell nests, or they are absent
Hiroshima University, Hiroshima, Japan
e-mail: deepak@knee.in
from the matrix, and the tidemark is duplicated or
triplicated. The loss of proteoglycans is signifi-
H. Madry (*)
Center of Experimental Orthopaedics, Saarland
cant [5, 6]. In this stage of the disease, the sub-
University, Homburg, Germany chondral bone is thought to undergo a
Department of Orthopaedic Surgery, Saarland
compensatory trabecular thickening and local
University Medical Center, Homburg, Germany stiffening, possibly contributing to the osteoar-
e-mail: henning.madry@uks.eu thritic cartilage degradation [8, 9].

© Springer Nature Switzerland AG 2021 11

D. R. Goyal (ed.), The Illustrative Book of Cartilage Repair,
https://doi.org/10.1007/978-3-030-47154-5_3
12 T. Oláh et al.

3.2 The Illustrations

a b c d

Figure 3.2.1: The Gross Anatomy of the Degenerated sion of the articular cartilage is visible only in a small
Hyaline Femoral Cartilage: Various Stages. The gross area on the surface of the medial condyle. A macroscopic
anatomy of the degenerated hyaline cartilage of the fem- image of the degenerated hyaline cartilage of the (c)
oral condyles from a cadaveric specimen, different medial and (d) lateral femoral condyle from the left knee
stages. Macroscopic image of the degenerated hyaline of a 75-year-old woman showing advanced osteoarthri-
cartilage of the (a) medial and the (b) lateral femoral tis. The surface of the articular cartilage is severely
condyle from the left knee of a 92-year-old woman with roughened in both the condyles. On the lateral condyle,
mild osteoarthritis. A diffuse thinning of the cartilage is the erosion reaches the subchondral bone. (Picture
visible throughout the condyles, while a localized ero- Courtesy—Henning Madry)

a b

Figure 3.2.2: The Gross Anatomy of the Degenerated the tibial plateau showing advanced osteoarthritis in (c)
Hyaline Tibial Cartilage: Various Stages. The gross cadaveric gross picture and (d) 3D reconstructed microCT
anatomy of the degenerated hyaline cartilage of the tibial image. On the internal and external margins of the medial
plateau retrieved post total knee arthroplasty showing late and the lateral tibial plateaus, a pronounced osteophyte
osteoarthritis in (a) cadaveric gross picture and (b) 3D formation is visible. Osteophyte development is a physi-
reconstructed microCT (micro-­ computed tomography) ological response of the bone thought to stabilize the
image. Note the complete erosion of the articular cartilage osteoarthritic joint [10]. An erosion of the subchondral
on the anterior and the intermediate peripheral regions of bone plate is prominent, and the subarticular spongiosa
the medial tibial plateau, originally protected by the containing bone marrow is exposed. (Picture Courtesy—
meniscus. The subchondral bone is only slightly affected. Henning Madry)
The gross anatomy of the degenerated hyaline cartilage of
3 The Illustrative Anatomy and the Histology of the Degenerative Hyaline Cartilage 13

c d

Figure 3.2.2: (continued)

a b

Figure 3.2.3: The Gross Anatomy of the Degenerated the trochlea, and the lateral femoral condyle show normal
Hyaline Femoral Cartilage During Open Surgery: hyaline cartilage in the form of a glistening white smooth
Various Stages. The degenerative process starts from one surface. (b) A peroperative image of a 68-year-old male
compartment of the knee joint and gradually spreads to all undergoing a right-side total knee arthroplasty, with the
the compartment of the knee joint. The extent of the knee flexed while viewing from the foot end. The articular
degenerative cartilage can easily be assessed during total surfaces of the medial and the lateral femoral condyles are
knee arthroplasty surgery, which also allows the inspec- nearly totally eroded with exposed subchondral (SC) bone
tion of the gross anatomy of the knee joint as well as its at multiple places. There is nearly total loss of cartilage in
articular surface. (a) A 63-year-old female underwent the surrounding areas. The exposed SC bone on the medial
total knee arthroplasty for left-side medial compartment femoral condyle is shiny indicative of a chronic erosion of
osteoarthritis and patellofemoral arthritis. Her knee was the affected area leading to a partial loss of the SC bone
examined for gross anatomic features while standing on plate. Also note the osteophytes all around the articular
the foot end of her left side. The medial femoral condyle surface of the femur. The patella is also showing similar
shows a completed eburnated cartilage with exposed sub- changes, while similar changes are seen on the medial half
chondral bone in its entire extent. Osteophyte formation of the medial tibial plateau. All these changes indicate a
on the medial tibial plateau is also seen. While there are severe osteoarthritis of the knee joint. (Picture Courtesy—
significant arthritic changes in the medial compartment, Manish Shah, Shah Hospital, Ahmedabad, India)
14 T. Oláh et al.

a b

c d

Figure 3.2.4: The Gross Anatomy of the Degenerated of a mild osteoarthritis of the medial compartment. (c) A
Hyaline Femoral Cartilage on Arthroscopy: Various 47-year-old female, who was suffering from osteoarthritis
Stages. The degenerative process of the articular cartilage of the left knee, was taken to operation theatre for a knee
is apparent very nicely on an arthroscopy. The normal glis- preservation surgery. The medial compartment showed ero-
tening, congruous, white, and the smooth surface of the sion and cartilage loss at the medial femoral condyle up to
cartilage gradually gets damaged as the degenerative pro- 50% thickness of the cartilage, along with multiple fissures
cess progresses. (a) A male aged 50 years suffered a left and fibrillations. The medial tibial articular surface also
lateral meniscus tear (not shown in the figure) and was shows roughened chondral surface. These changes are sug-
operated arthroscopically. Arthroscopic examination of his gestive of a moderate osteoarthritis. (d) A 56-year-old male
medial compartment revealed early roughening of the artic- patient suffering from medial compartment osteoarthritis
ular surface with loss of the normal glistening appearance. and tibia vara was taken for knee preservation surgery
Also apparent is a few early fibrillations, all suggesting the (arthroscopy and high tibial osteotomy). On examination of
beginning of an early osteoarthritis. (b) A 53-year-old male the medial compartment, there was a total cartilage loss
patient had a right-side complete anterior cruciate ligament covering the medial half of the medial femoral condyle and
(ACL) tear 5 weeks back and was operated for an ACL the posteromedial corner of the medial tibial plateau. The
reconstruction. Arthroscopic examination of the medial remaining cartilage also shows signs of degeneration in the
compartment showed degenerative changes in the body of form of extensive fibrillations and fissures. These changes
the medial meniscus along with more pronounced roughen- are indicative of a severe osteoarthritis of the knee. (Picture
ing of the medial femoral and the medial tibial cartilage. Courtesy—Deepak Rajkumar Goyal)
The chondral surface was lusterless, all changes indicative
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 After this, the atomic weight is always more than double the
atomic number. It will be seen that the above elements all have even
atomic numbers and have atomic weights which divide by 4. We may
therefore regard their nuclei as composed wholly of helium nuclei.
In the case of elements which have odd atomic numbers, there is
only one instance, nitrogen, in which the atomic weight (14) is just
double the atomic number (7). In this case, we may suppose that the
nucleus consists of three helium nuclei and two hydrogen nuclei. In
other cases, in the early part of the periodic table, the atomic weight is
greater by one than the double of the atomic number. Thus
phosphorus has the atomic number 15, and the atomic weight 31. The
same is true of the other early elements with odd atomic numbers,
except nitrogen. (From the element onward the atomic weight is
larger than it would be by this rule.) The inference is that the nuclei of
atoms which have odd atomic numbers usually consist of an
adequate number of helium nuclei together with three hydrogen
nuclei. The peculiarity of nitrogen is perhaps connected with the fact
that Rutherford found it the easiest element from which to detach
hydrogen nuclei.
The fact that the atomic weights are whole numbers, together with
the facts of radio-activity and of Rutherford’s bombardment, lead
irresistibly to the conclusion that the weight of an atom is due to
helium nuclei and hydrogen nuclei which exist together in its nucleus.
The overcrowding in the nucleus of a heavy atom must be something
fearful. Radium C, which emits the -particles that Rutherford used in
his experiments, has a nucleus whose radius is about three million-
millionths of a centimetre (about one million-millionth of an inch). Its
atomic number is 83 and its atomic weight is 214. This means that in
this tiny space it must contain 53 helium nuclei and 2 hydrogen nuclei;
it must also (as we shall see in a moment) contain 131 electrons. It is
no wonder that helium nuclei and electrons move fast when radio-
activity liberates them from this slum.
 The -rays show that the nucleus of an atom contains electrons.
This appears also from the fact that the atomic number (which
represents the net charge of the nucleus) is less than the atomic
weight which represents the gross positive charge. (Each hydrogen
nucleus contributes one unit of positive charge.) The difference
between the atomic weight and the atomic number represents the
number of electrons there must be in the nucleus, in order to bring its
net charge down to the atomic number. In this argument, however, we
have assumed that the helium nucleus itself consists of four hydrogen
nuclei and two electrons. We have still to examine the reasons in
favour of this view.
There is no experimental evidence that a helium nucleus can be
broken up into hydrogen nuclei and electrons. Radio activity and
Rutherford’s bombardments show that the helium nucleus is very
stable, and that no known process will disintegrate it. Nevertheless it
is believed by all students of the subject that the helium nucleus
consists of four hydrogen nuclei and two electrons. There is first of all
the argument from the atomic weight; the weight of the helium atom is
so nearly four times the weight of the hydrogen atom that we cannot
bring ourselves to attribute this fact to chance. But why is it not
exactly four times the weight of a hydrogen atom? If we take the
weight of a helium atom as 4, that of a hydrogen atom is not 1, but
1.008. According to every-day notions, this would be impossible if a
helium nucleus consisted of four hydrogen nuclei. (The electrons may
be ignored, as their contribution to the weight is negligible.) We are
used to thinking that if we place four pound weights in a scale, they
will weigh four pounds. This, however, is only approximately true. In
ordinary cases it is so nearly true that we could never discover the
error experimentally; but in extraordinary cases, such as the helium
nucleus, it may be sufficiently untrue for our measurements to be able
to detect the difference.
It used to be thought that the mass of a body (which is the
scientific conception that replaces the popular conception of weight)
could be defined as the “quantity of matter.” But Einstein has
revolutionized the conception of mass, as well as all the other
elementary conceptions of physics. Mass is now absorbed into
energy, and the mass of a body is not by any means always constant.
[10] A system of electrons and hydrogen nuclei may have different
amounts of energy in different arrangements; when the system
passes from an arrangement with more energy to one with less, the
energy it loses is radiated into the surrounding medium, in the sort of
way with which we became familiar when we were considering the
spectrum of hydrogen. When the system loses energy it also loses
mass. The loss of mass is very small compared to the loss of energy;
it is obtained by dividing the loss of energy by half the square of the
velocity of light, which is enormous. When the system has arranged
itself in a shape in which its energy is diminished, it can only go back
to its former shape if the lost energy is supplied from outside.
Therefore the shapes involving least intrinsic energy are the most
stable. This is what we must suppose to happen when four hydrogen
nuclei and two electrons come together to make a helium nucleus.
They arrange themselves in a configuration in which their energy is
less than when they were separated; the loss of energy can be
inferred from the loss of mass (or weight, to speak popularly), and is
got by multiplying this loss of mass by half the square of the velocity
of light. This represents an enormous amount of energy. Sommerfeld
calculated that it is about 10 million times greater than the amounts
involved in chemical combinations (for instance, in combustion). The
helium nucleus could only be disintegrated by supplying this amount
of energy from outside, which does not happen in any known natural
process. Thus the loss of weight in the helium atom is accounted for,
and by the same argument the extreme stability of the helium nucleus
is explained.
It is clear that, for the sake of unity and simplicity, it is desirable, if
possible, to regard the helium nucleus as consisting of hydrogen
nuclei and electrons. If we do not do so, we shall have to admit the
helium nucleus as a third ultimate constituent of matter, having, by a
strange coincidence, just twice the electric charge and four times the
amount of matter that exists in the hydrogen nucleus. It must be
admitted that this is a possible hypothesis; there are no known facts
that prove it to be false. But until we are forced to adopt it, we shall
prefer the simpler view that the helium nucleus is complex, like every
other except hydrogen, and that its relations of mass and charge to
the hydrogen atom are not a lucky fluke. Everything known about
nuclei is consistent with the hypothesis that they are composed of
hydrogen nuclei and electrons. The evidence that they consist of
hydrogen nuclei, electrons, and helium nuclei is overwhelming; the
further step, which dissolves the helium nucleus, is more or less
hypothetical, but it is a step which we may take with a reasonable
assurance that it will prove justified. The study of nuclei is still in its
infancy, but is likely to make rapid advances in the near future.
Meanwhile, we may assume, though not with complete certainty, that
all matter consists of hydrogen nuclei and electrons, which are
therefore the only “elements” in the strict sense of the word. Whether
these two will ultimately prove to be modifications of some one more
fundamental substance, it is quite impossible to say. For the present,
they represent the frontier of scientific knowledge, and what lies
beyond is as yet mere speculation.
As to the way in which the four hydrogen nuclei and the two
electrons are arranged in the helium atom, mathematical
considerations ought to be able to give us information, but so far they
have not given much. One model which is suggestive is the following:
Imagine a somewhat primitive wheel, with four spokes, and an axle
that sticks out some distance to either side. Place the two electrons at
the ends of the axle, and the four hydrogen nuclei at the ends of the
spokes, and imagine the wheel going round with suitable velocity.
(The wheel and spokes and axle are of course imaginary, and are
only intended to illustrate the relative positions of the nuclei and
electrons.) This gives a configuration which has a certain degree of
stability, and a fattish shape which is indicated by a certain amount of
experimental evidence. It seems, however, that the degree of stability
in this model is less than that required to account for the fact that no
known process will disintegrate a helium nucleus. There is also a
difficulty as regards the size of the helium nucleus. Taking our model
and applying the quantum theory to the revolutions of the hydrogen
nuclei, we can determine the radius of the circle in which they move
as we determined the minimum orbit in the hydrogen atom. The result
is that the size of the radius should be about 5 million-millionths of a
centimetre. This is about seventeen times too large, according to
Rutherford’s experimental evidence. It is possible, nevertheless, that
our model may be right, because the forces between electrons and
hydrogen nuclei may obey different laws, at such very tiny distances,
from those which they obey at ordinary distances. We may hope to
know more on this subject at no distant date, but for the present we
must remain in doubt.
[10] This subject of the variability of mass will be resumed in
chapter XIII.
 XII.
THE NEW PHYSICS AND THE WAVE
THEORY OF LIGHT
IN the physics of the atom, as it has become in modern times,
everything is atomic, and there are sudden jumps from one condition
to another. The electron and the hydrogen nucleus are the true
“atoms” both of electricity and of matter. According to the quantum
theory, there are also atomic quantities, not of energy as was
thought when the theory was first suggested, but of what is called
“action.” The word “action,” in physics, has a precise technical
meaning; it may be regarded as the result of energy operating for a
certain time. Thus if a given amount of energy operates for two
seconds, there is twice as much action as if it operated for one
second; if it operates for a minute, there is 60 times as much action,
and so on. If twice the amount of energy operates for a second,
there is again twice as much action, and so on. If the energy which is
operating is variable, and we wish to estimate its action during a
given time, we divide the time into a number of little bits, during each
of which the energy will vary so little that it may be regarded as
constant; we then multiply the energy during each little interval of
time by the length of the interval, and add up for all the intervals. As
we make the intervals smaller and more numerous, the result of our
addition approaches nearer and nearer to a certain limit; this limit we
define as the total action during the total period of time concerned.
Action is a very important conception in physics; from the point of
view of theory it is more important than energy, which has been
deposed from its eminence by the theory of relativity. Planck’s
quantum is of the nature of action; thus the quantum theory
amounts to saying that there are atoms of action.
 So long as we confine ourselves to what goes on in matter, this
theory is self-consistent and explains the facts, nor is it easy to
suppose that any theory which was not atomic would explain the
facts. But when we come to what goes on in “empty space,” or in the
“æther,” we find ourselves in difficulties if we adhere to the quantum
theory. Consider what happens when a wave of light is sent out by
an atom, with only one quantum of action in each period. The wave
spreads out in all directions, growing fainter as it goes on, like a
ripple when a stone is dropped into a pond. The evidence that light
consists of waves remains quite unshaken; it is derived from the
phenomena of interference and diffraction. As to interference, a few
words may be necessary. If two sets of waves are travelling more or
less in the same direction, if their crests come together they will grow
bigger, but if the crest of one comes in the same place as the trough
of the other, they will neutralize each other. Now it is possible to
arrange two sets of light-waves so that in some places their crests
come together, while in others the one covers the trough of the other.
When this is done, we get a lattice pattern of alternate light and
darkness, light where the waves reinforce each other, and darkness
where they neutralize each other. If light consisted of particles
travelling, and not of waves, this phenomenon, which is called
“interference,” could not take place.
The difficulties which arise for the quantum-theory out of the
phenomenon of interference have been forcibly stated by Jeans in
the following paragraphs:[11]
“If light occurred only in quanta, interference could only occur at a
point at which two or more quanta existed simultaneously. If the light
were sufficiently feeble the simultaneous occurrence of two or more
quanta at any point ought to be a very rare occurrence, so that all
phenomena, such as diffraction patterns, which depend on
interference, ought to disappear as the quantity of light present is
reduced. Taylor has shown that this is not the case; he reduced the
intensity of his light to such an extent that an exposure of 2,000
hours was necessary to obtain a photograph, and yet obtained
photographs of diffraction patterns in which the alternation of light
and dark appeared with undiminished sharpness. In Taylor’s
experiment the intensity of light was ... about one light-quantum per
10,000 cubic centimetres, so that if the quanta had been
concentrated nothing of the nature of a diffraction could possibly
have been observed.”
“Thus it appears that there is no hope of reconciling the
undulatory theory of light with the quantum-theory by regarding the
undulatory theory as being, so to speak, only statistically true when a
great number of quanta are present. One theory cannot be the limit
of the other in the sense in which the Newtonian mechanics is the
limit of the quantum-mechanics, and we are faced with the problem
of combining two apparently quite irreconcilable theories.”
Other similar difficulties might be mentioned, but the difficulty of
interference may suffice, since it is typical. It may be questioned
whether the difficulty still exists when the quantum theory is stated in
the form which it takes in Sommerfeld’s work. We no longer have
little parcels of energy; what we have is a property of periodic
processes. It would not be accurate to state this property in the form:
the total action throughout a complete period of any periodic process
is or an exact multiple of . But although this statement would not
be accurate, it gives, as nearly as is possible in non-mathematical
language, a general idea of the sort of thing that is affirmed by the
modern form of the quantum theory. In order to reconcile this
principle with the facts about the diffusion of light, it is only necessary
to avoid dividing the æther into imaginary particles. As the light-wave
travels outward, so long as it meets no obstruction its energy
remains constant, though it is more diffused, so that there is less of it
in any given area of the wave-front. But while we remain in empty
space, the wave must be treated as a whole, and the quantum-
theory must not be applied to separate little bits of it. The quantum
theory has to do, not with what is happening in a point at an instant,
but with what happens to a periodic process throughout its whole
period. Just as the period occupies a certain finite time, so the
process occupies a certain finite space; and in the case of a light-
wave travelling outward from a source of light, the finite space
occupied by the process grows larger as it travels away from the
source. For the purposes of stating the quantum principle, one
period of a periodic process has to be treated as an indivisible
whole. This was not evident at the time when Jean’s report was
written (1914), but has been made evident by subsequent
developments. While it makes the quantum principle more puzzling,
it also prevents it from being inconsistent with the known facts about
light.
It must be confessed that the quantum principle in its modern
form is far more astonishing and bewildering than is its older form. It
might have seemed odd that energy should exist in little indivisible
parcels, but at any rate it was an idea that could be grasped. But in
the modern form of the principle, nothing is said, in the first instance,
about what is going on at a given moment, or about atoms of energy
existing at all times, but only about the total result of a process that
takes time. Every periodic process arranges itself so as to have
achieved a certain amount by the time one period is completed. This
seems to show that nature has a kind of foresight, and also knows
the integral calculus, without which it is impossible to know how fast
to go at each instant so as to achieve a certain result in the end. All
this sounds incredible. No doubt the fact is that the principle has
assumed a complicated form because it has forced its way through,
owing to experimental evidence, in a science built upon totally
different notions. The revolution in physical notions introduced by
Einstein has as yet by no means produced its full effect. When it has,
it is probable that the quantum principle will take on some simple and
easily intelligible form. But it will only be easily intelligible to those
who have gone through the labour of learning to think in terms of
modern physical notions rather than in terms of the notions derived
from common sense and embodied in traditional physics. In the last
chapter of this book we shall try to indicate the sort of way in which
this may affect the quantum principle.
It is necessary, however, to utter a word of warning, in case
readers should accept as a dogmatic ultimate truth the atomic
structure of the world which we have been describing, and which
seems at present probable. It should not be forgotten that there is
another order of ideas, temporarily out of fashion, which may at any
moment come back into favour if it is found to afford the best
explanation of the phenomena. The charge on an electron, the equal
and opposite charge on a hydrogen atom, the mass of an electron,
the mass of a hydrogen nucleus, and Planck’s quantum, all appear
in modern physics as absolute constants, which are just brute facts
for which no reason can be imagined. The æther, which used to play
a great part in physics, has sunk into the background, and has
become as shadowy as Mrs. Harris. It may be found, however, as a
result of further research, that the æther is after all what is really
fundamental, and that electrons and hydrogen nuclei are merely
states of strain in the æther, or something of the sort. If so, the two
“elements” with which modern physics operates may be reduced to
one, and the atomic character of matter may turn out to be not the
ultimate truth. This suggestion is purely speculative; there is nothing
in the existing state of physics to justify it. But the past history of
science shows that it should be borne in mind as a possibility to be
tested hereafter. If the possibility should be realized, it would not
mean that the present theory is false; it would merely mean that a
new interpretation had been found for its results. Our imagination is
so incurably concrete and pictorial that we have to express scientific
laws, as soon as we depart from the language of mathematics, in
language which asserts much more than we mean to assert. We
speak of an electron as if it were a little hard lump of matter, but no
physicist really means to assert that it is. We speak of it as if it had a
certain size, but that also is more than we really mean. It may be
something more analogous to a noise, which is spread throughout a
certain region, but with diminishing intensity as we travel away from
the source of the noise. So it is possible that an electron is a certain
kind of disturbance in the æther, most intense at one spot, and
diminishing very rapidly in intensity as we move away from the spot.
If a disturbance of this sort could be discovered which would move
and change as the electron does, and have the same amount of
energy as the electron has, and have periodic changes of the same
frequency as those of the electron, physics could regard it as what
an electron really is without contradicting anything that present-day
physics means to assert. And of course it is equally possible that a
hydrogen nucleus may come to be explained in a similar way. All this
is however, merely a speculative possibility; there is not as yet any
evidence making it either probable or improbable. The only thing that
is probable is that there will be such evidence, one way or other,
before many years have passed.
[11] Report on Radiation and the Quantum Theory, p. 87.
 XIII.
THE NEW PHYSICS AND RELATIVITY
THE theory of quanta and the theory of relativity have been
derived from very different classes of phenomena. The theory of
quanta is concerned with the smallest quantities known to science,
the theory of relativity with the largest. Distances too small for the
microscope are concerned in the theory of quanta; distances too
large for the telescope are concerned in the theory of relativity.
Relativity came, in the first instance, from astronomy and the study
of the propagation of light in astronomical spaces, and its most
noteworthy triumphs have been in regard to astronomical
phenomena—the motion of the perihelion of Mercury, and the
bending of light from the stars when it passes near the sun. The
material of the quantum theory, on the contrary, is mainly derived
from small quantities of very rarefied gases in laboratories, and from
tiny particles running about in a vacuum as nearly perfect as we can
make it. In the theory of relativity, 300,000 kilometres counts as a
small distance; in the theory of quanta, a thousandth of a centimetre
counts as infinitely great. The result of this divergence is that two
theories have been pursued by different investigators, because they
required different apparatus and different methods. In this final
chapter, we shall consider what bearing the two theories have on
each other, and, in particular, whether there is anything in relativity
that makes the theory of quanta seem less odd and irrational.
The theory of relativity, as every one knows, was discovered by
Einstein in two stages, of which the first is called the special theory
and the second the general theory. The first dates from 1905, the
second from 1915. The first is not superseded by the second, but
absorbed into it as a part. We shall not attempt to explain the theory
of relativity, which has been done popularly (so far as is possible) in
a multitude of books and scientifically in two books which should be
read by all who have sufficient mathematical equipment: Hermann
Weyl’s Space, Time, Matter, and Eddington’s Mathematical Theory
of Relativity. We are only concerned with the points where this
theory touches the problem of atomic structure.
The special theory of relativity, as we have already seen, is
relevant to the problems we have been considering at several points.
It is relevant through its doctrine that mass, as measured by our
instruments, varies with velocity, and is, in fact, merely a part of the
energy of a body. It is part of the theory of relativity to show that the
results of measurement, in a great many cases do not yield physical
facts about the quantities intended to be measured, but are
dependent upon the relative motion of the observer and what is
observed. Since motion is a purely relative thing, we cannot say that
the observer is standing still while the object observed is moving; we
can only say that the two are moving relatively to each other. It
follows that any quantity which depends upon the motion of a body
relatively to the observer cannot be regarded as an intrinsic property
of the body. Mass, as commonly measured, is such a property; if the
body is moving with a velocity which approaches that of light, its
measured mass increases, and as the velocity gets nearer to that of
light, the measured mass increases without limit. But this increase of
mass is only apparent; it would not exist for an observer moving with
the body whose mass is being measured. The mass as measured by
an observer moving with the body is what counts as the true mass,
and it is easily inferred from the measured mass when we know how
the body concerned is moving relatively to ourselves. When we say
that any two electrons have the same mass, or that any two
hydrogen nuclei have the same mass, we are speaking of the true
mass. The apparent mass of an electron which is shot out in the
form of a -ray may be several times as great as the true mass.
There are two other points where the variability of apparent mass
is relevant in the theory of atoms. One concerns the “fine structure”
and the analogy between the electron in a hydrogen atom and the
planet Mercury; this was considered in Chapter VII. The other is the
explanation of the fact that the helium nucleus is less than four times
as heavy as the hydrogen nucleus, which concerned us in Chapter
XI. On both these points, as we have seen, the theory of relativity
provides admirably satisfactory explanations of facts which would
otherwise remain obscure. Both, however, raise the question of the
relativity of energy, which might be thought awkward for the quantum
theory, because this theory uses the conservation of energy, and
something merely relative to the observer cannot be expected to be
conserved.
In elementary dynamics, as every one knows, energy consists of
two parts, kinetic and potential. Ignoring the latter, let us consider the
former. The kinetic energy depends upon the mass and the velocity,
but the velocity depends upon the observer, and is not an intrinsic
property of a body. The result is that energy has to be defined in the
theory of relativity. It turns out that we can identify the energy of a
body with its mass as measured by the observer (or, in ordinary
units, with this mass multiplied by the square of the velocity of light).
Although, for a particular body, this mass varies with the observer, its
sum throughout the universe will be constant for a given observer,
however he may be moving.[12]
In the theory of relativity, there are two kinds of variation of mass
to be distinguished, of which so far we have only considered one.
We have considered the change of measured mass (as we have
called it) which is brought about by a change in the relative motion of
the observer and the body whose mass is being measured. This is
not a change in the body itself, but merely in its relation to the
observer. It is this change which has to be allowed for in deducing
from experimental data that all electrons have the same mass. We
allow for it by means of a formula, which enables us to infer what we
may call the “proper mass” of the body. This is the mass which it will
be found to have by an observer who shares its motion. In all
ordinary cases, in which we determine mass (or weight) by means of
a balance, we and the body which we are weighing share the same
motion, namely that of the earth in its rotation and revolution; thus
weighing with a balance gives the “proper mass.” But in the case of
swiftly-moving electrons and -particles we have to adopt other
ways of measuring their mass, because we cannot make ourselves
move as fast as they do; thus in these cases we only arrive at the
“proper mass” by a calculation. The “proper mass” is a genuine
property of a body, not relative to the observer. As a rule, the proper
mass is constant, or very nearly so, but it is not always strictly
constant. When a body absorbs radiant energy, its proper mass is
increased; when it radiates out energy, its proper mass is
diminished. When four hydrogen nuclei and two electrons combine
to form a helium nucleus, they radiate out energy. The loss of mass
involved is loss of proper mass, and is quite a different kind of
phenomenon from the variation of measured mass when an electron
changes its velocity.
There is another point, not easy to explain clearly, and as yet
amounting to no more than a suggestion, but capable of proving very
important in the future. We saw that Planck’s quantum is not a
certain amount of energy, but a certain amount of what is called
“action.” Now the theory of relativity would lead us to expect that
action would be more important than energy. The reason for this is
derived from the fact that relativity diminishes the gulf between
space and time which exists in popular thought and in traditional
physics. How this affects our question we must now try to
understand.
Consider two events, one of which happens at noon on one day
in London, while the other happens at noon the next day in
Edinburgh. Common sense would say that there are two kinds of
intervals between these two events, an interval of 24 hours in time,
and an interval of 400 miles in space. The theory of relativity says
that this is a mistake, and that there is only one kind of interval
between them, which may be analyzed into a space-part and a time-
part in a number of different ways. One way will be adopted by a
person who is not moving relatively to the events concerned, while
other ways will be adopted by persons moving in various ways. If a
comet were passing near the earth when our two events happened,
and were moving very fast relatively to the earth, an observer on the
comet would divide the interval of our two events differently between
space and time, although, if he knew the theory of relativity, he would
arrive at the same estimate of the total interval as would be made by
our relativity physicists. Thus the division of the interval into a space
portion and a time portion does not belong to the physical relation of
the two events, but is something subjective, contributed by the
observer. It cannot, therefore, enter into the correct statement of any
law of the physical world.
The importance of this principle (which is supported by a
multitude of empirical facts) is impossible to exaggerate. It means, in
the first place, that the ultimate facts in physics must be events,
rather than bodies in motion. A body is supposed to persist through a
certain length of time, and its motion is only definite when we have
fixed upon one way of dividing intervals between space and time.
Therefore any physical statement in terms of the motions of bodies is
in part conventional and subjective, and must contain an element not
belonging to the physical occurrence. We have therefore to deal with
events, whose relative positions, in the conventional space-time
system that we have adopted, are fixed by four quantities, three
giving their relations in space (e.g. east-and-west, north-and-south,
up-and-down), while the fourth gives their relation in time. The true
interval between them can be calculated from these, and is the same
whatever conventional system we adopt; just as the time-interval
between two historical events would be the same whether we dated
both by the Christian era or by the Mohammedan, only that the
calculation is not so simple.
It follows from these considerations that, when we wish to
consider what is happening in some very small region (as we have to
do whenever we apply the differential or integral calculus), we must
not take merely a small region of space, but a small region of space-
time, i.e. in conventional language, what is happening in a small
volume of space during a very short time. This leads us to consider,
not merely the energy at an instant, but the effect of energy
operating for a very short time; and this, as we saw, is of the nature
of action (in the technical sense). A quotation from Eddington[13] will
help to make the point clear:
“After mass and energy there is one physical quantity which plays
a very fundamental part in modern physics, known as Action. Action
here is a very technical term, and is not to be confused with
Newton’s ‘Action and Reaction.’ In the relativity theory in particular
this seems in many respects to be the most fundamental thing of all.
The reason is not difficult to see. If we wish to speak of the
continuous matter present at any particular point of space and time,
we must use the term density. Density multiplied by volume in space
gives us mass or, what appears to be the same thing, energy. But
from our space-time point of view, a far more important thing is
density multiplied by a four-dimensional volume of space and time;
this is action. The multiplication by three dimensions gives mass or
energy; and the fourth multiplication gives mass or energy multiplied
by time. Action is thus mass multiplied by time, or energy multiplied
by time, and is more fundamental than either.”
It is a fact which must be significant that action thus turns out to
be fundamental both in relativity theory and in the theory of quanta.
But as yet it is impossible to say what is the interpretation to be put
upon this fact; we shall probably have to wait for some new and
more fundamental way of stating the quantum theory.
There is one other respect in which some of the later
developments of relativity suggest the possibility of answers to
questions which have hitherto seemed quite unanswerable. Our
theory, so far, leads us to brute facts which have to be merely
accepted. We do not know why there are two kinds of electricity, or
why opposite kinds attract each other while similar kinds repel each
other. This dualism is one of the things which is intellectually
unsatisfying about the present condition of physics. Another thing is
the conflict between the discontinuous process by which energy is
radiated from the atom into the surrounding medium, and the
continuous process by which it is transmitted through the
surrounding medium. Relativity throws very little light on these
points, but there is another point upon which it throws at least a
glimmer. We find it hard to rest content with the existence of
unrelated absolute constants, such as Planck’s quantum and the
size of an electron, which, so far as we can see, might just as easily
have had any different magnitude. To the scientific mind, such facts
are a challenge, leading to a search for some way of inter-relating
them and making them seem less accidental. As regards the
quantum, no plausible suggestion has yet been made. But as
regards the size of an electron, Eddington makes some suggestive
observations, which, however, require some preliminary
explanations.
We saw that, according to the theory of relativity, the interval
between two events may be separated into a time-part and a space-
part in various ways, all of which are equally legitimate, and each of
which will seem natural to an observer who is moving suitably. The
first effect of this is to diminish the sharpness of the distinction
between space and time. But the distinction comes back in a new
form. It is found that the interval between two events can, in some
cases, be regarded as merely a space-interval; this will happen if an
observer who is moving suitably would regard them as simultaneous.
Whenever this does not happen, the interval can be regarded as
merely a time-interval; this will be the case when an observer could
travel so as to be present at both events. It takes eight minutes for
light to travel from the sun to the earth, and nothing can travel faster
than light; therefore if we consider some event which happens on the
earth at 12 noon, any event which happens on the sun between
11.52 a. m. and 12.8 p. m. could not have happened in the presence
of anything which was present at the event on earth at 12 noon.
Events happening on the sun during these 16 minutes have an
interval from the event on earth which will, for a suitable observer,
seem to be a spatial separation between simultaneous events; such
intervals are called space-like. Events happening earlier or later than
these 16 minutes will be separated from the event on earth at noon
by an interval which would appear to be purely temporal to an
observer who had spent the interval in travelling from the sun to the
earth, or vice versa as the case may be; such intervals are called
time-like. Two parts of one light-ray are on the borderland between
time-like and space-like intervals, and in fact the interval between
them is zero. But in all other cases there is a separation which is
either time-like or space-like, and in this way we find that there is still
a distinction between what is to be called temporal and what is to be
called spatial, though the distinction is different from that of every-
day life.
 For reasons which we cannot go into, Einstein and others have
suggested that the universe has a “curvature,” so that we could
theoretically go all round it and come back to our starting-point, in
the sort of way in which we go round the earth. All the way round the
universe, in that case, must be a certain length, fixed in nature.
Eddington suggests that some relation will probably be found
between this, the greatest length in nature, and the radius of the
electron, which is the least length in nature. As he humorously puts
it: “An electron could never decide how large it ought to be unless
there existed some length independent of itself for it to compare itself
with.”
He goes on to make another application of this principle, which is
suggestive, though perhaps not intended to be treated too solemnly.
The curvature of the universe, if it exists, is only in space, not in time.
This leads him to say:[14]
“By consideration of extension in time-like directions we obtain a
confirmation of these views which is, I think, not entirely fantastic.
We have said that an electron would not know how large it ought to
be unless there existed independent lengths in space for it to
measure itself against. Similarly it would not know how long it ought
to exist unless there existed a length in time for it to measure itself
against. But there is not radius of curvature in a time-like direction;
so the electron does not know how long it ought to exist. Therefore it
just goes on existing indefinitely.”
But even if the size of an electron should ultimately prove, in this
way, to be related to the size of the universe, that would leave a
number of unexplained brute facts, notably the quantum itself, which
has so far defied all attempts to make it seem anything but
accidental. It is possible that the desire for rational explanation may
be carried too far. This is suggested by some remarks, also by
Eddington, in his book, Space, Time and Gravitation (p. 200). The
theory of relativity has shown that most of traditional dynamics,
which was supposed to contain scientific laws, really consisted of
conventions as to measurement, and was strictly analogous to the
“great law” that there are always three feet to a yard. In particular,
this applies to the conservation of energy. This makes it plausible to
suppose that every apparent law of nature which strikes us as
reasonable is not really a law of nature, but a concealed convention,
plastered on to nature by our love of what we, in our arrogance,
choose to consider rational. Eddington hints that a real law of nature
is likely to stand out by the fact that it appears to us irrational, since
in that case it is less likely that we have invented it to satisfy our
intellectual taste. And from this point of view he inclines to the belief
that the quantum-principle is the first real law of nature that has been
discovered in physics.
This raises a somewhat important question: Is the world
“rational,” i.e., such as to conform to our intellectual habits? Or is it
“irrational,” i.e., not such as we should have made it if we had been
in the position of the Creator? I do not propose to suggest an answer
to this question.
[12] Eddington, op. cit., pp. 30-32.
[13] Space, Time and Gravitation, p. 147.
[14] The Mathematical Theory of Relativity, p. 155.
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