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Cartilage surgery

Surgical techniques adopted here are numerous and varied: some aim to stimulate the capacity of the residual cartilage tissue to repair itself through the production of fibrocartilage, while others are aimed at the ex-novo regeneration of damaged cartilage, and replacement with new hyaline cartilage. Obviously, which option is chosen depends on the severity of the injury, with worse cases requiring more radical intervention.

 

Chondral abrasion, or cartilage shaving: This is an intervention that simply regulates the surface of the damaged cartilage. In first degree lesions, cartilage starts to fray and form fibrils which are removed with a specific tool in an attempt to remove the flaps and loose edges that mechanically conflict with joint articulation. The long-term results of this strategy are poor. This technique by itself is not a final solution, because it has no reparative or regenerative capacity, it is merely used to alleviate symptoms.

Microfractures: this technique uses tiny needles to create numerous perforations at the sub-chondral level at a distance of 3-4 mm apart. This draws blood from the layer of bone beneath the cartilage, forming a new layer of qualitatively inferior cartilage (fibrous cartilage) when compared to the original (hyaline) cartilage, although this new layer is still biomechanically acceptable. This intervention is a reparative surgery. Load is generally acceptable one month after surgery, but high-impact sports should be avoided until around 6 months later.

Osteochondral autologous graft (OAT) or ‘plastic mosaic technique’: Core cartilage tissue is extracted together with a portion of sub-chondral bone from non-loading joints which is then inserted over the properly prepared, damaged cartilage. In this way the cartilage defect is filled with hyaline cartilage, giving good results even in the long term. This intervention includes a non-loading period of 30-45 days after surgery and allows return to high-impact sports after around 8 months.

Transplantation of autologous chondrocytes (ACI): This method involves two separate surgeries: First, chondrocytes are taken from the joint and are cultured for one month; after 30 days the chondrocytes are grafted on a three-dimensional matrix (hyaluronic acid, collagen and alginate) and are then re-inserted into the joint to fill the cartilage defect. The long-term results here are excellent, but post-surgical recovery times are very long. This intervention involves a non-loading period of 30-45 days after the surgery and allows return to high-impact sports after around 10 months.

Biomimetic Scaffolding (MaioRegen): One of the latest developments in surgery, this technique involves the implantation of synthetic support structures consisting of hydroxyapatite and collagen fibers. The technique involves a single surgery during which the scaffold is shaped over the cartilage defect. This part is then inserted after allowing the lesioned surface to bleed, so that totipotent cells contained in the blood can colonize the scaffold and produce chondrocytes. This intervention includes a non-loading period of 45-60 days after surgery and allows return to high-impact sports from 10 months onwards.

Transplantation of autologous mesenchymal cells: Stem cells are taken from the patient's bone marrow, extracted from the iliac crest. These cells are inserted on a support structure loaded with additional growth enzymes extracted from the patient's blood. Finally, this compound is implanted at the site of the lesion, filling the chondral defect. The results from these surgeries are comparable to those obtained from Biomimetic Scaffolding procedures, although the initial non-loading period is shorter at 30-45 days, high-impact sports must be avoided for at least 12 months, however.

 

Regardless of the severity of your injury, our Sports Medicine doctors all have a great deal of experience dealing with these injuries and can help you to decide which option is best.

Post-surgical rehabilitation will obviously vary widely depending on the surgical technique used. Times can vary significantly, but in all cases we proceed through our five phases of rehabilitation: starting with the reduction of post-operative pain and swelling, then recovering the range motion, before muscle strength and endurance are built back up, followed by the restoration of neuromotor co-ordination and finally, return to sport. The first phase of rehabilitation will be carried out by alternating time between the pool and gym. This moment is particularly delicate because the replaced cartilage is vulnerable to mechanical stimuli. If load is built up appropriately, it can stimulate the integration of new cartilage and its maturation; on the contrary, excessive loading can cause catastrophic failure of the implant.

Manual and physical therapies will be alternated in the gym, strengthening and proprioception exercises will be used according to the specific programme set out by the Case Manager. Aquatherapy aims to help recover correct gait and movements in the operated joint. If the patient is an athlete, specific exercises in deep water can also be introduced to begin restoring correct movements before loading the joint.

In the pool, as in the gym, strength and coordination exercises are tested using fins, life jackets and floats of various sizes. In the following months, the patient will begin to run on the treadmill and perform preparatory exercises for rehabilitation on the field. During the rehabilitation isokinetic training sessions are included which culminate in an isokinetic test to evaluate the differences in strength between the operated limb and the healthy one. When the operated limb is no longer significantly weaker than the un-operated one, introduction to the field begins, assuming the appropriate amount of time has passed to allow biological recovery of the cartilage. In this phase a threshold test is used to evaluate the state of the limb and give accurate information on your progress to your on-field rehab coach, so that they can carry out more personalised and effective work. This stage-by-stage progression will bring the patient back to their pre-injury fitness on the field and the restore their dexterity in the use of the specific sport movements.

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