1. An approach to cartilage surgery
Dr M.N. Basu Mallick
Consultant, Arthroscopy and Sports Surgery
Apollo Gleneagles Hospital, Kolkata

2. DEFINE?
The aim of an articular cartilage repair treatment is to restore the surface of an articular joints hyaline cartilage
To make the patient ‘painfree’ for now and the future.

3. Treatment options….. MEDICAL MANAGEMENT
Arthroscopic lavage and debridement
Marrow stimulation technique (Microfracture and Others)
Osteochondral Autografts and Allografts (OATS)
Cell based repairs (ACI)
Autologous Mesenchymal Stem Cell Transplant
KNEE REPLACEMENT

4. Prevalence of abnormal findings on knee MRI in asymptomatic NBA basketball players -Brian Cole et al, JKS, 2008

5. Avoid LINEAR REASONING !!!

6. The Symptomatic cartilage defect
Presentation
Options
Pain
Deformity
Instability
Debride / lavage
Microfracture
OATS/ Mosaicplasty
ACI / MACI

7. Arthroscopic lavage and debridement
A "cleaning up" procedure
Is not considered an articular cartilage repair procedure but rather a palliative treatment
Reduce pain, mechanical restriction and inflammation.
Removes degenerative cartilage flaps and fibrous tissue.
The main target group are patients
Very small defects of the articular cartilage.
Significant ‘painless’ defects , diagnosed incidentally

8. Marrow stimulation – Microfracture Dr Richard Steadman, 1980s
The subchondral bone  is perforated to generate a ‘blood clot’ within the defect ( drilling, microfracture, abrasion)
Blood clot contains pluripotent stem cells
The blood clot converts to ‘fibrous tissue’ about 8 weeks
Over 4 months fibrous tissue becomes ‘fibrocartilage’.

9. Does these work? Mixed results in atheletes Brian Cole et al
75-80% good results with proper pt selection and proper rehab
Poor outcomes
Poor shear resistance of fibrocartilage
Elderly, obese,
>2.5cm defects
Brian Cole et al
839 patients ( )
60% improved in 4-6 months
25% no improvement
15% improved immediately!!!
30% revised at 1yr
Best outcome in first 2yrs

10. Make them work? Achieve vertical walls Remove calcified cartilage
healthy cartilage at the rim better shoulder the load and makes the lesion less clinically relevant
Remove calcified cartilage
allows better fit and fill by fibrocartilage which is more tenacious and histologically superior.
Holes 2-3 mm apart
Correct malalignment/ instability
Compliance with rehab
SMALL defects in high demand patients (<2 sqcm)
Larger defects in low demand patients (<4-5 sqcm)

11. Marrow stimulation - Microfracture + AMIC
Evolvement of the microfracture technique - Implantation of a collagen membrane onto the site of the micro-fracture - Autologous Matrix Induced Chondrogenesis – AMIC (2003)
Collagen membrane provides an environment where cells can adhere, proliferate and produce repair tissue in a protected setting – improved ‘fibrocartilage’ quality.
Outcome studies:
Coming from propounders – significantly better/ longer lasting benefit/ large defects <8 sqcm
One RCT at 24 months – clinically no significant difference/ radiologically inferior surface and integration

12. Osteochondral Autografts (OATS)
OATS > Mosaicplasty
Few large plugs > Many small plugs
Transfer cartilage+bone from non wt bearing area to wt bearing dome.
Often 2nd line of Tx
High demand young pt
Defects 2-5 sqcm
LIMITATIONS
Defect size
Age/ osteoporosis
Arthrosis

13. Does Oats work? 2 yr/5yr/10yr FU study OATS vs MF
(RCT, level 1 evidence)
Better pain relief
Better histology
Better radiology
6wk OATS
Romanowski-Giemsa
Safranin O
Masson trichrome

14. Osteochondral Allografts
Cryopreserved < 14 days ( < 28 days)
Proteoglycan synthesis / cell viability <14 days
Long term retrieval study (Jamali, JBJS, 2007, 30yrs/ Maury, JBJS, 2007, 25yrs)
Donor chondrocytes survive, donor host margin indistinct – host chondrocytes do not re -populate the graft
Subchondral bone necrosis and stabilisation – behaves different to bone grafts, bone allografts and there is no creeping substitution.
6 month retrieval study

15. ACI
BIOPSY 200mgm of cartilage Culture Of isolated chondrocytes for 6 wk to upto 1 lakh cells TRANSPLANT Under periosteal or biomembrane cover

16. MACI ( Matrix Induced ACI)
2-10 sq.cm
<5-6mm deep
Failed primary treatment
Best results in PF articulation

17. ACI – Future? Arthrofibrosis Symptomatic hypertrophy Disturbed fusion
Delamination
Graft failure
Knutsen et al - FU results in patients randomized for ACI or microfracture.
At 2 yrs FU: "Both methods had acceptable short-term clinical results. There was no significant difference in macroscopic or histological results no association between the histological findings and the clinical outcome."
At 5 yrs : "Both methods provided satisfactory results in 77% of the patients at five years. There was no significant difference in the clinical and radiographic results between the two treatment groups and no correlation between the histological findings and the clinical outcome
Minas et al. - clinical outcome in a cohort study of 321 patients
Defects treated by ACI, which had a prior treatment with as microfracture, were three times more likely to fail than for defects treated by primary ACI
Marrow stimulating techniques should be employed judiciously in larger cartilage defects that may require future treatment with ACI.[5]

18. Does that make sense?

19. Co-morbidities
Malalignment PF jt / TF jt
Stability
Menisci

20. PF jt defects – REALIGN!!
Tibial tuberosity ANTERO- MEDIALISE or ANTERIORISE?
NOT medialise only!!

21. TF malalign – Do We Need‘HTO’/‘DFO’?
Age / Symptoms
Location of defect
Size / depth
Opposing surface
Correct to neutral – do not over correct

22. ALGORITHM Femoral condyle Patellofemoral Mal-alignment Lig Deficiency
Meniscal injury
Chondral defect
SIZE >2.5 cm
Mosaicplasty
Microfracture
SIZE > 2.5 cm
Allograft
ACI
Patellofemoral
Rehabilitation
Malalignment
Size < 2.5 cm
SIZE > 2.5cm
Autograft
ALGORITHM