Surgical options for early arthritis in young persons and athletes: the role of meniscus transplants, microfracture, Osteoarticular Transplants (OATs), Autologous Chondrocyte Implantation (ACI) and osteotomy

Edited By: Christopher J. Wahl, M.D., Suzanne L. Slaney, PA-C, ATC, MMS
Last updated Friday, June 30, 2006

Considering surgery

Who should consider microfracture, meniscal transplantation, osteoarticular allograft/autograft transplants (oats), autologous chondrocyte implantation (aci) and ostotomy for arthritis in the athlete. for arthritis, osteochondral defects (ocd lesions), meniscus transplantation and cartilage loss in the knee. and in what cases?

WHO SHOULD CONSIDER SURGERY FOR KNEE ARTICULAR CARTILAGE DEFECTS OR A DEFICIENT MENISCUS?

Surgery should be considered as an option for a cartilage defect IMMEDIATELY when:

• the injury is traumatic, with a loose osteochondral fragment in the knee (repair may be possible if the surgery is done early enough)
• there are locking, catching, or grinding symptoms in the knee (even with a remote injury) and X-rays or an MRI demonstrates loose bodies or fragments in the joint (avoiding surgery can result in rapid joint deterioration)

Surgery should be considered as an option for a chronic focal cartilage lesion if:

• the defect is “global” (the symptoms are due to a generalized degeneration of the joint)
• conservative treatments (medication, therapy, orthotics, etc.) have failed to provide relief
• there are no untreated conditions (autoimmune or metabolic) that are responsible for the lesion
• the lesion may become irreparable if it is not addressed (e.g. avascular necrosis in danger of “collapsing” into a misshapen surface

What happens if nothing is done for arthritis, osteochondral defects (ocd lesions), meniscus transplantation and cartilage loss in the knee. (best case/worst case scenarios)?

Unlike bone, articular cartilage does not “regrow”. For this reason, few lesions are capable of healing without treatment.  One exception is osteochondritis dissecans (OCD).  In this instance some persons (particularly the young) have some ability to heal these lesions without surgery provided the lesion does not “collapse” before the bone repairs itself.

Early in their course, such lesions will cause discomfort, pain, swelling, and occasionally mechanical catching or grinding in the joint. This will prevent a person from enjoying her activities or will interfere with the normal functions of daily life.

Most other cartilage injuries (osteochondral defects, avascular necrosis (AVN), traumatic cartilage injuries) and severe meniscal injuries will not heal.  These lesions eventually affect the smoothness and structural integrity of the joints weight-bearing surface.  Eventually, an untreated lesion may lead to premature global deterioration of the joint, severe pain, deformity, and disability.

What options exist for surgery for arthritis, osteochondral defects (ocd lesions), meniscus transplantation and cartilage loss in the knee.?

Several options are available to the patient and the surgeon, depending on the nature of the lesion, the causes of the injury, and the age and activity level of the patient. Each procedure has an “ideal” indication, but the procedures can be used in conjunction to achieve the maximal benefit.  It is essential that the surgeon be familiar with the patient, the problem, and all the treatment options in order to achieve the optimal result.

Microfracture is a technique that was developed to “cover” small- to medium-sized bare regions of bone where the cartilage has been damaged but the bone beneath it is healthy.  The concept is to use the arthroscope to prepare the healthy cartilage surrounding the bare spot and to create tiny vascular channels which run from the underlying bone’s blood supply to the defect.  These vascular channels allow blood and the body’s reparative cells to enter the defect and create a fibrous scar (much like the way skin heals after a cut).  Over time, the reparative scar matures and resembles articular cartilage.  The mechanical properties of this reparative tissue do not equal that of native articular cartilage, but studies have shown that the majority of patients feel their pain is decreased and their function is improved after this procedure.  In most cases, this procedure can be performed as an outpatient, but it requires 6 to 12 weeks of rehabilitation.  The ultimate maturation of this tissue can take 4 to 6 months.

Optimal indication:  Patients of any age with small- to medium-sized lesions surrounded by normal cartilage.  Microfracture can frequently act as a temporizing measure to allow the athlete a faster return-to-play than OATs or ACI procedures. 

Results:  Long-term studies have demonstrated that even at up to 7 years follow-up, about 67% to 75% of patients have durable success with microfracture.

Another technique which has been developed to treat small- to large-sized defects in articular cartilage is osteoarticular grafts or osteoarticular autograft transplants (OATs).  The potential advantage of these techniques over microfracture is that they replace the injured articular cartilage with new articular-cartilage “plugs” which are taken from another region of the knee (autograft) or from a donated knee (allograft).  When an autograft is used, the size of defect that can be filled is limited by the number of plugs that can be taken from another region of the knee without causing symptoms (2 to 4cm² maximum).  For very large lesions of the femur or patella, massive plugs can be taken from a donor knee and used to restore normal mechanics to the knee.  While some OATs procedures can be done through minimal incisions with the use of an arthroscope, many OATs or donor graft procedures require an incision into the knee, and therefore a 1-to2-day hospital stay is required.  Weight bearing is limited for a short time post-operatively and a home-based rehabilitation period is required.

(see Figure 11a, Figure 11b)

Optimal Indication:  Patients aged 15 to 55 with small- to medium-sized lesions surrounded by normal cartilage.  Normal or nearly normal cartilage on the adjacent joint surface.

Results:  Studies over the long term have demonstrated excellent results in 86 to 90 percent of cases for selected lesions. 

AUTOLOGOUS CHONDROCYTE IMPLANTATION:

Autologous chondrocyte Implantation is a relatively new technique that takes advantage of the latest developments in biomedical engineering and orthopaedic science.  The concept behind ACI is to “harvest” a small sample of healthy cartilage cells from the injured knee and to “grow” them.  In actuality, the cells are cultured in such a way that they multiply into a population of “chondrocytes” (or cartilage “precursor cells”).  The grown chondrocytes are then introduced back into the defect in the knee, where they regenerate into mature cartilage-like tissue.  The advantages of ACI include:

• the ability to cover relatively large cartilage defects
• the regrown tissue is derived from the patient’s own cartilage cells (no donated tissue required)
• a very small amount of healthy cartilage can be grown to cover a large defect, unlike OATs (where an amount of cartilage equal to the defect size must be harvested from another healthy region of the knee)

One disadvantage of ACI is that the architecture of the “grown” tissue is not normal, and therefore its biomechanical properties are different.

Because it takes time to grow the precursor chondrocytes, ACI requires two separate surgical procedures.  The initial procedure is completed through the arthroscope and includes an evaluation and harvest of a very small amount of articular-cartilage tissue (about the size of 5 or 6 grains of rice).  Depending on the alignment of the knee, other surgical procedures may need to be performed at the initial surgery to maximize the benefit of the ACI procedure.  The second procedure requires an open surgery of the knee, in which a small flap of tissue called “periosteum” is sewn to the perimeter of the defect (like putting a manhole cover over a hole in the pavement).  The grown chondrocytes are then implanted beneath this cover.  The first procedure is usually performed on an outpatient basis.  The second procedure requires an open-knee incision, and usually requires a 1-to-2-day hospital stay.  The patient usually must limit weight bearing for a short time, and a home-based rehabilitation period is required.

Optimal indications:  Patients between 15 and 55 years with medium-to-large, full-thickness cartilage loss or osteochondritis dissecans, who have normal or nearly normal cartilage on the adjacent joint surface, healthy underlying bone, and a normal joint contour.

Results:  Depending on the nature of the cartilage lesions, studies have shown good to excellent results 75 to 90 percent of persons.  Recent studies have shown that in the short term, the cellular nature of tissue created by ACI may not be significantly different from that produced during microfracture.

OSTEOTOMIES AND REALIGNMENT:

An osteotomy is a procedure designed to re-align joint surfaces to shift the body weight away from damaged regions of the joint to the surfaces that are in better condition.  A normal part of joint degeneration involves wear of the articular-cartilage surface, followed by “narrowing” of the joint space.  This causes the limb to change its alignment (that is, patients become “knock-kneed” or “bow-legged”), which further places stress on the injured cartilage and causes even more severe injury.  An osteotomy is a procedure in which the bone is cut, re-aligned, and re-fixed in a position that decreases the stress on injured cartilage.  These procedures are frequently done in conjunction with cartilage-salvage (microfracture) or cartilage-restoration (OATs, ACI) procedures to help protect the repaired joint surface.

Optimal indications:  Patients between 15 and 60 years of age who engage in “high-demand” or “high-impact” activities that would not be tolerated by prosthetic replacements.  Also patients who are candidates for cartilage salvage or cartilage reconstruction but have significant knee-alignment problems.

Results:  In the ideal patient population, successful results range between 80 and 93 percent.  The durability of these results is variable, and it is generally accepted that patients can expect reliable symptomatic relief for 6 to 10 years.

Meniscal transplantation is done to replace a completely degenerated or destroyed meniscus.  Transplants can be done for both the medial (inside) or lateral (outside) meniscal cartilages.  The meniscus is replaced with a size-matched donated (allograft) meniscus cartilage that retains its normal bony attachment.  When the meniscus is inserted, the bone is “grafted” into the patient; it will heal like a fracture would.  The edges of the meniscus are sewn to the edge of the joint so that they will heal with the normal soft-tissue attachments as well.  Once the allograft meniscus is healed, it assumes the functions of meniscal tissue and may prevent premature deterioration of the joint. 

Optimal indications:  In general, meniscus transplantation is performed in younger patients who have had severe meniscal injuries.  It is ideal to replace the meniscus when the patient has symptoms but HAS NOT YET DEVELOPED significant secondary arthritic changes to the joint.  Recent studies have shown some benefit using meniscal transplants to alleviate symptoms in knees in which arthritis HAS developed, but the long-term efficacy of this procedure is unknown.

Results:  The studies on meniscal transplantation are difficult to interpret, as many patients in these studies also undergo other procedures along with the transplant (ACL reconstruction, osteotomy, etc.).  In general, 75 to 89 percent good results are obtained at short- and medium-term follow-up.  Return to low-impact athletic is possible in the majority of persons.  Most studies have demonstrated that between 5 and 14 years after the procedure, the transplanted meniscus can deteriorate and symptoms recur.

The techniques of joint replacement or arthroplasty have undergone a remarkable evolution over the past 30 years.  All forms of arthroplasty involve the same concept:  the removal of severely diseased or arthritic cartilage and bone and the reconstruction of the joint with synthetic fitted components.  Because the new joint is man-made (it is usually metallic and plastic), it may wear out.  For this reason, joint replacement is a last-resort procedure to relieve joint pain, malalignment, and cartilage loss in individuals who have moderate or low demands on their knees.  There are three separate joints or “compartments” in the knee, and each can be replaced.  When only a portion of the joint surface is affected, partial replacements are possible.  “Unicompartmental” joint prostheses have been created to reconstruct only the medial (inside) or lateral (outside) bearing surfaces of the joint, and it is also possible to replace only the patellofemoral surface (between the kneecap and femur).

Optimal indications:  Patients older than 55 with severe osteoarthritis or joint collapse who engage in moderate- or low-demand activities.

When performed by an experienced surgeon, how effective is microfracture, meniscal transplantation, osteoarticular allograft/autograft transplants (oats), autologous chondrocyte implantation (aci) and ostotomy for arthritis in the athlete. for arthritis, osteochondral defects (ocd lesions), meniscus transplantation and cartilage loss in the knee. likely to be and how long will the benefit last?

In the hands of an experienced surgeon familiar with all the available reconstructive options, cartilage restoration is usually very effective at eliminating or markedly decreasing pain, restoring function to the joint, and allowing a return to activity in the motivated patient. Depending on the procedure, the surgeon may discourage a return to high-impact (cutting, jumping, running) activities to prolong the viability of the reconstruction.

The benefits of the above procedures may not be permanent, but in general their aim is to slow the progression of joint deterioration and preserve an active lifestyle for as long as possible.

How urgent is microfracture, meniscal transplantation, osteoarticular allograft/autograft transplants (oats), autologous chondrocyte implantation (aci) and ostotomy for arthritis in the athlete. for arthritis, osteochondral defects (ocd lesions), meniscus transplantation and cartilage loss in the knee.?

Surgical procedures are rarely urgent unless the lesion was caused by trauma and discovered immediately. If this is the case, it is frequently possible to repair rather than restore the injured cartilage.  Saving the native cartilage is always the best option if it can be induced to heal. 

Once the lesion has become “chronic” or has been without a blood supply for an extended time, the surgical reconstruction is not an emergency.  However, in general the restoration of smaller lesions produces better results than large ones.  In the symptomatic patient, it is best to address a significant cartilage defect or meniscal injury before it leads to further deterioration of the joint.

• understand and accept the surgical alternatives, options, risks, and benefits
• have discussed and or attempted non-operative measures to treat the problem if it is not acute (i.e. rehabilitation/physical therapy)
• have undergone a comprehensive examination, X-ray and usually MRI work-up to define the factors contributing to the problem
• seek out a surgeon who is experienced in the treatment of complex cartilage injuries of the knee

What are the most frequent and most serious risks of microfracture, meniscal transplantation, osteoarticular allograft/autograft transplants (oats), autologous chondrocyte implantation (aci) and ostotomy for arthritis in the athlete. for arthritis, osteochondral defects (ocd lesions), meniscus transplantation and cartilage loss in the knee.? How common are they?

The risks of cartilage restoration procedures (microfracture, osteotomies, OATs, ACI, and mensical transplants) include but are not limited to the following:

• infection
• temporary or permanent injury to the nerves and blood vessels around the knee
• excessive joint stiffness
• pain
• scarring
• allergic reactions to the donor meniscus tissue or suture materials
• disease transmission from the donated meniscus
• failure of the meniscus transplant
• the need for additional surgeries
• anesthesia

If risks occur during or after microfracture, meniscal transplantation, osteoarticular allograft/autograft transplants (oats), autologous chondrocyte implantation (aci) and ostotomy for arthritis in the athlete. for arthritis, osteochondral defects (ocd lesions), meniscus transplantation and cartilage loss in the knee. how are they managed?

Many of the risks of surgery can be effectively managed if they are promptly identified and treated:

• Infections may require a wash-out of the joint, and rarely removal of the implanted tissue.
• Blood vessel or nerve injuries are rarely caused by the surgical procedure. Most of theses injuries resolve spontaneously overtime, but occasionally such an injury may require surgical repair.  It is common to have decreased sensation around the incision sites.  This numbness may or may not entirely resolve in time. 
• Excessive stiffness of the joint is rare in the person who is cooperative with the postoperative rehabilitation program, and most of the stiffness will respond to exercises.
• Pain is a likely response after a surgical procedure that can be treated with medications, rest, ice, and compliant rehabilitation.  As healing progresses overtime, the pain will diminish. 
• Individuals scar and heal differently, and it is inevitable that anyone undergoing a surgical procedure will have scars.  To allow for proper healing and therefore less scarring, the patient should follow post-operative instructions provided by their surgeon on how to care for their incisions. 
• The risk of disease transmission from donor tissue is very small, but cannot be disregarded.  All potential donors undergo strict screening that meets the guidelines of the American Association of Tissue Banks and the Food and Drug Administration.  The tissue is thoroughly tested for HIV (risk of contracting HIV through donor tissue is less than 1 in 1.67 million), hepatitis (risk of contracting hepatitis is less than 1 in 470,000), and other infectious diseases.  The transplant is then prepared and processed to prevent the transmission of bacteria and viruses according to United States Pharmacopeia guidelines.

If a patient has questions or concerns about the “normal” course after surgery, the surgeon should be informed as soon as possible so that they can explain the expected course and outcome.

Surgery for Arthritis, osteochondral defects (OCD lesions), meniscus transplantation and cartilage loss in the knee. at the University of Washington

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