Clinician-to-Clinician Update Clinician-to-Clinician Update

Surgical Cartilage Restoration Gives New Life to Damaged Joints

March 2015 - Orthopaedics

Osteoarthritis is the most common chronic musculoskeletal disorder, affecting about 43 million patients in the United States.1 It is the leading cause of activity limitation and absenteeism among those of working age2 and is associated with a significant decline in function among older patients.3 Patients with osteoarthritis are at high risk of developing musculoskeletal comorbidities, neuropathic pain, depression, anxiety, and sleep disorders.4

Articular cartilage can be damaged by traumatic injury or degenerative disease. Once damaged, the healing of hyaline cartilage in the joint is limited by the absence of a vascular response and a relative lack of undifferentiated cells as a source of healing cells.5 Some cartilage defects when left untreated can result in radiographically detected signs of osteoarthritis after 10 years.6 Therefore, early diagnosis and treatment of articular cartilage defects are vital.

Coronal-view-of-knee-showing-OCD-443x294
— Coronal view of a knee showing signs of osteochondritis dissecans (OCD) of the lateral femoral condyle. A common cause of knee dysfunction, OCD primarily affects subchondral bone and its overlying articular cartilage.

At the University of Minnesota Health Orthopaedic Clinic, orthopaedic surgeons employ leading-edge techniques for the restoration of damaged and diseased articular cartilage, offering the experience that comes with handling a high volume of procedures (50 to 75 annually). Often, they can manage a patient’s articular cartilage damage or early-stage osteoarthritis with cartilage restoration procedures, delaying the need for joint replacement. Some of the procedures offered include osteochondral autograft transfer system (OATS®, Arthrex Inc.), autologous chondrocyte implantation (ACI), osteochondral allograft transplant, and limb realignment through an osteotomy.

Surgeons use osteochondral autografts from less weightbearing areas to fill focal articular defects, either as a single, large bone plug or multiple small plugs (mosaicplasty). OATS is generally indicated for patients under the age of 50 years and for those with small defects (1-4 cm2 ).

ACI is a 2-stage procedure. The first stage involves an arthroscopic evaluation of the damaged cartilage and harvesting of a small amount of cartilage from lesser weightbearing regions of the knee. Chondroyctes are then isolated from the harvested cartilage and are cultured (Carticel®, Genzyme). The second stage is performed about 6 weeks after the first stage and involves implantation of the cultured chondrocytes through a mini-arthrotomy. ACI is generally used for patients under 55 years of age who have medium to large defects (≥4 cm2).

An osteochondral allograft transplant is used for medium to large articular defects in patients of all ages. Because cadaver tissue is used, allografts may be taken from younger, healthier patients with better quality bone and cartilage, resulting in excellent outcomes.7

Osteotomy of the long bones of the leg is used when the load is being borne by one side of the joint and is associated with limb mal-alignment. In this procedure, the bone is cut and realigned to correct faulty joint alignment and to transfer weight from damaged to healthier cartilage, thereby prolonging the life span of the joint. An osteotomy can be used alone or in tandem with the above-mentioned techniques.

References

1. Lawrence RC, et al. Estimates of the prevalence of arthritis and other rheumatic conditions in the United States. Part II. Arthritis Rheum. 2008; 58(1):26-35.

2. Kotlarz H, et al. Osteoarthritis and absenteeism costs: evidence from US National Survey Data. J Occup Environ Med. 2010;52(3):263-268.

3. Adegoke BO, et al. Pain, balance, self-reported function and physical function in individuals with knee osteoarthritis. Physiother Theory Pract. 2012;28(1):32-40.

4. Gore M, et al. Clinical comorbidities, treatment patterns, and direct medical costs of patients with osteoarthritis in usual care: a retrospective claims database analysis. J Med Econ. 2011;14(4):497-507.

5. Man G, Mologhianu G. Osteoarthritis pathogenesis – a complex process that involves the entire joint. J Med Life. 2014;7(1):37-41.

6. Prakash D, Learmonth D. Natural progression of osteo-chondral defect in the femoral condyle. Knee. 2002;9(1):7-10.

7. Tompkins M, et al. Preliminary results of a novel single-stage cartilage restoration technique: particulated juvenile articular cartilage allograft for chondral defects of the patella. Arthroscopy. 2013;29(10):1661-1670.

When to Refer

The Orthopaedic Clinic subspecialists provide innovative care for problems of the ankle and foot, hand and upper extremity, shoulder and elbow, and spine. They also address scoliosis and musculoskeletal tumors. This multidisciplinary care team performs reconstruction and joint replacement and offers sports medicine and trauma care. Our physicians, nurses, rehabilitation specialists, and physical and hand therapists provide comprehensive, compassionate care with a cross-disciplinary approach that results in optimal treatment and outcomes.

To schedule a consultation, referral, or appointment: 612-672-7575

Patients with urgent medical or surgical needs are given priority. Appointments for nonurgent problems are scheduled several days to several weeks in advance. The Orthopaedic Clinic at University of Minnesota Medical Center will, to the fullest extent of its resources, accept emergency cases on the same or next day. Patients requiring hospitalization may be referred to an emergency room for evaluation

Collaborative Care

When you refer a patient to us, you are receiving the resources of a cohesive team of surgeons, physician assistants, nurses, and rehabilitation specialists who work with you to ensure that your patient receives the best possible orthopaedic care. We are committed to communicating our findings and recommendations with you promptly and to coordinating follow-up care with you and your patient so as to limit the time your patient needs to take off from work or school.

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