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Surgical options for treating chondral or osteochondral defects
List of contents
Arthroscopic debridement
This procedure involves removing loose fragments of cartilage and smoothing the damaged area.
• Limited effectiveness & applicability: Arthroscopic debridement is most effective for mild osteoarthritis or meniscal tears. However, its effectiveness for treating osteochondral cartilage defects or degeneration is limited, especially for larger or more severe defects.
• Temporary relief: While debridement can provide temporary relief, it does not address the underlying cause of the defect, promote long-term cartilage repair, or stimulate the growth of new cartilage.
• Potential for complications: As with any surgical procedure, arthroscopic debridement carries risks of complications such as infection, blood clots, nerve or blood vessel damage, and adverse reactions to anesthesia. These risks are generally low but should be considered.
Supporting Literature:
“The small inconsequential benefit seen from interventions that include arthroscopy for the degenerative knee is limited in time and absent at one to two years after surgery.”
Arthroscopic surgery for degenerative knee: systematic review and meta-analysis of benefits and harms
“Arthroscopic surgery for osteoarthritis of the knee provides no additional benefit to optimized physical and medical therapy.”
A Randomized Trial of Arthroscopic Surgery for Osteoarthritis of the Knee
“In this controlled trial involving patients with osteoarthritis of the knee, the outcomes after arthroscopic lavage or arthroscopic debridement were no better than those after a placebo procedure.”
A Controlled Trial of Arthroscopic Surgery for Osteoarthritis of the Knee
“Unfortunately, these types of repair tissue do not exhibit the wear characteristics of hyaline cartilage. The repair tissue becomes unable to withstand the load demands of the knee and again breaks down, leading to recurrence of symptoms and progression of the size of the defect.”
Treatment of Articular Cartilage Defects of the Knee With Autologous Chondrocyte Implantation
Microfracture
The surgeon creates tiny fractures in the underlying bone to stimulate the formation of a new cartilage-like tissue to fill the defect.
• Limited durability & uniformity: The regenerated tissue is primarily fibrocartilage, which is not as durable or resistant to wear as native hyaline cartilage. Over time, this fibrocartilage may deteriorate, leading to a recurrence of symptoms and the need for further treatment.
• Subchondral bone changes: Microfracture alters the normal subchondral bone structure and may lead to the development of subchondral cysts or changes in bone density, potentially affecting long-term joint health.
Supporting Literature:
“The overall quality of cartilage regeneration was poor and did not achieve the characteristics of native hyaline cartilage.”
Microfracture Versus Drilling of Articular Cartilage Defects. A Systematic Review of the Basic Science Evidence
“There have been concerns regarding suboptimal repair with fibrocartilage infill, subchondral osseous overgrowth, questionable durability of fibrous cartilage, and deterioration of clinical improvement over long-term follow-up.”
Microfracture for cartilage repair in the knee: current concepts and limitations of systematic review
“The quality of cartilage repair following microfracture is variable and inconsistent due to unknown reasons.”
Microfracture for the treatment of cartilage defects in the knee joint – A golden standard?
“Shortcomings of the technique include limited hyaline repair tissue, variable repair cartilage volume, and possible functional deterioration.”
Clinical Efficacy of the Microfracture Technique for Articular Cartilage Repair in the Knee: An Evidence-Based Systematic Analysis
“Unfortunately, these types of repair tissue do not exhibit the wear characteristics of hyaline cartilage. The repair tissue becomes unable to withstand the load demands of the knee and again breaks down, leading to recurrence of symptoms and progression of the size of the defect.”
Treatment of Articular Cartilage Defects of the Knee With Autologous Chondrocyte Implantation
Autologous chondrocyte implantation (ACI) & Matrix-induced ACI (MACI)
Healthy cartilage cells (chondrocytes) are harvested from a patient's own knee, grown in a lab (or on a biodegradable scaffold), and then implanted into the defect to promote cartilage repair.
• Two-visit procedure: ACI and MACI require multiple surgical visits, including an initial arthroscopic procedure to harvest healthy cartilage from a non-weight-bearing area of the knee.
• Graft integration: The long-term success of ACI and MACI is dependent on the integration of the repaired tissue with the adjacent cartilage, and sometimes this integration may not be complete or ideal. In some cases, the implanted chondrocytes may lead to excessive cartilage growth, resulting in joint swelling, pain, and limited joint function.
• Limited availability and cost: ACI and MACI are complex procedures that require specialized facilities and expertise. As a result, they may not be widely available in all healthcare settings. Additionally, these procedures can be expensive, including the costs associated with cell culturing and laboratory processes.
Supporting Literature:
“The histologic appearance of the repair tissue of 3 different failed articular cartilage resurfacing procedures was similar and did not resemble normal articular cartilage.”
Histologic and Immunohistochemical Characteristics of Failed Articular Cartilage Resurfacing Procedures for Osteochondritis of the Knee A Case Series
“The complex logistics of this approach, such as the necessity for two surgeries, and the associated high patient burden, delayed rehabilitation and high costs, are considerable drawbacks of this treatment.”
Failure of cartilage regeneration: emerging hypotheses and related therapeutic strategies
Osteochondral autograft transplantation
Healthy cartilage and bone plugs are taken from a non-weight-bearing area of the knee or from a donor site and transplanted into the defect.
• Mismatched graft size and contour: Finding a graft that matches the exact size and contour of the cartilage defect is challenging. Misalignment or size mismatch between the graft and the defect can potentially lead to suboptimal outcomes and incomplete integration.
• Donor site morbidity: The healthy cartilage plugs used as grafts are typically harvested from a non-weight-bearing area of the same knee. The donor site may experience pain, weakness, or potential complications, which can affect the overall function of the knee.
• Graft integration and longevity: The success of OAT relies on proper integration of the transplanted graft with the surrounding native cartilage. While good integration can be achieved, long-term studies have shown that patients may experience graft deterioration or failure over time..
Supporting Literature:
“In Patients 1 and 3, severe central wear developed in the transplants, with locking of the knee and pain, 14 and 11 months, respectively, after transplantation. Both patients required a second operation.”
Treatment of Deep Cartilage Defects in the Knee with Autologous Chondrocyte Transplantation
Osteochondral allograft transplantation
Donor cartilage and bone plugs are used to replace the damaged area. This procedure is typically reserved for larger defects.
• Graft availability: Osteochondral allografts are sourced from human donors, which means the availability of suitable grafts may be limited. There are instances where a suitable graft cannot be found.
• Graft viability and quality: The success of OAT relies on the viability and quality of the allograft. There is a risk of graft failure or deterioration over time due to inadequate integration, immune reactions, or disease transmission.
• Surgical complexity and longer recovery: OAT is a complex surgical procedure that may involve a longer recovery period compared to other treatment options.
• Cost and insurance coverage: Osteochondral allograft transplantation can be expensive, and insurance coverage may vary.
Supporting Literature:
“Limitations include cost, availability, and not ideal for small lesions.”
Fresh Osteochondral Allograft Transplantation for Treatment of Articular Cartilage Defects of the Knee
Autologous matrix-induced chondrogenesis (AMIC)
A biodegradable scaffold is placed in the defect to stimulate the growth of new cartilage cells from surrounding tissues.
• Variable and unpredictable outcomes: The quality and quantity of regenerated cartilage can vary, and not all patients achieve satisfactory pain relief, function improvement, or cartilage quality. AMIC may also have limited effectiveness for larger cartilage defects or degeneration.
• Longer recovery and rehabilitation: AMIC typically requires a longer recovery and rehabilitation period compared to some other treatment methods.
• Potential for complications: The scaffold used in AMIC can sometimes cause complications. These may include infection, inflammation, allergic reactions, or the formation of adhesions or fibrous tissue. There is a risk of graft delamination or detachment from the underlying tissue. This can occur due to inadequate integration or mechanical stresses on the repaired area.
• Cost: AMIC can be a relatively costly procedure compared to some other treatment options for cartilage defects, which impacts insurance coverage.
Supporting Literature:
“The outcome scores and MRI results are comparable to other cell-based cartilage methods. It should be pointed out that we still lack understanding on the ideal conditions for chondrogenesis.”, “Authors reported good outcomes in 72% to 87% of patients.”
Autologous Matrix-Induced Chondrogenesis in the Knee: A Review
Partial knee replacement
A partial knee replacement surgery involves replacing only the damaged compartment of the knee joint with an artificial implant while preserving the healthy portions of the knee.
• Potential for progression: Although partial knee replacement can alleviate symptoms and improve function, it does not address the underlying cause of cartilage degeneration. If the remaining compartments of the knee are affected over time, additional surgeries or conversions to total knee replacement may be required. Additionally, revision surgery can be more complex and may have poorer outcomes compared to the initial procedure.
• Technical challenges: Partial knee replacement surgery requires precise alignment and accurate implant positioning. The procedure can be technically demanding, and there is a learning curve for surgeons. In cases where the alignment is not achieved correctly, it can lead to implant wear, instability, or early failure.
• Potential for implant-related complications: Partial knee replacement carries risks associated with any joint replacement surgery, such as infection, blood clots, implant loosening, or implant wear over time. While these complications are relatively rare, they can occur and may require further intervention or revision surgery.
Supporting Literature:
“The progression of lateral OA is a common cause for failure of medial [partial knee replacement].”
Treatment of Unicompartmental Cartilage Defects of the Knee with Unicompartmental Knee Arthroplasty, Patellofemoral Partial Knee Arthroplasty or Focal Resurfacing
