Rothman Institute Cartilage Restoration Center of Excellence
This is a center where patients can go the have their disabled joint biological resurfaced, realigned, and stabilized without having the joint replaced by artificial materials such as metal and plastic. It is well known that the outcomes of patients under the age of 50 undergoing artificial joint replacement are not as good as we would like. Therefore we feel the future of Orthopaedics is to try to restore a joint back to its original anatomy by realignment, ligament reconstruction, and cartilage restoration.
Articular cartilage is a firm, smooth, and slippery covering on the ends of bones that protects and cushions the bones in your joint. This surface although tough, can be injured to different degrees and depths, causing pain and swelling. Sometimes if the cartilage is partially or fully detached (called loose body), it can cause mechanical symptoms such as the feeling like your knee is catching or gets locked up. Depending on the size and depth of the damage, there are many different ways the accomplish the cartilage restoration.
Some small, partial thickness cartilage injuries, that don’t cause mechanical symptoms, can be treated without surgery. Non-operative treatment initially focuses on RICE (Rest, Ice, Compression, and Elevation) for the first 72 hours to decrease pain and swelling. Then physical therapy is initiated to regain full motion and improve the strength and flexibility of the muscles that stabilize the knee joint. Sometimes a series of weekly injections can also be given into the knee joint to promote recovery. They are called Hyaluronates, and there is evidence that they may naturally decrease pain and inflammation and possibly nourish and protect the cartilage.
Surgery is indicated if non-operative treatment fails, if there is mechanical symptoms, or if the cartilage injury is of significant size and is partially or completely detached. Sometimes if a large piece of cartilage is detached which has bone attached to it, it can be put back in its place with small absorbable screws or nails. Otherwise there are 4 main types of surgery to treat cartilage injuries: Chondroplasty/Debridement, Microfracture/Marrow Stimulating Procedure, ACI (Autologous Chondrocyte Implantation), and Osteochondral Transplant.
This procedure is usually indicated for partially damaged cartilage. This is done arthroscopically, where special instruments are used to smooth out any rough areas and remove any loose pieces of damaged cartilage.
Microfracture/Marrow Stimulating Procedure:
Done arthroscopically, Microfracture is indicated for small full thickness areas of cartilage damage. All debris has to be removed from the area first, and then small holes are drilled through the bone at the base of the damaged area. This allows cells (Stem cells) from the bone marrow to fill in the damaged area and produce a reparative fibrous tissue.
ACI (Autologous Chondrocyte Implantation):
ACI is indicated for larger areas of full thickness cartilage loss, and requires two surgeries. First we arthroscopically harvest normal cartilage cells from one area of the knee not needed. The second surgery is an open surgery where we implant the cartilage cells back into knee to repair the damaged area. The cells are either injected under a water tight membrane or on a special patch.
We are currently working on a one step process, where the harvest and the implantation are performed during one surgery.
Cartilage and bone transplants are indicated when the damaged area is very large, if there is failure of one of the other techniques, or if bone is also injured along with the cartilage. This is when cartilage and bone plugs are harvested from either an uninjured non-weight bearing area of the knee, or from a donor (cadaver), and then transplanted to cover the injured area of bone and cartilage.