Everyone has an opinion in regard to cartilage repair. Everyone has a preferred method. Just last November, Boffeli and colleagues published an algorithm in Podiatry Today on determining what procedure to do for cartilage lesions/cysts of the talus.1 The algorithm was well thought out and logical, but do we really need so many options? Should every surgeon be capable of performing every procedure? Boffeli and colleagues focused on older patients but our focus is the athlete and soldier, and once you start talking about athletes, discussions start to get heated and often unscientific.
First, no one is doing a lot of cartilage repairs in athletes. There are only a handful of surgeons who are actually skilled in performing cartilage repair in high numbers in athletes. The rest of us may do these procedures here and there. We all are guilty of boasting our successes and hiding our failures. My question to anyone who will listen: how do you know you are a success? Is it really proof of success when an X-ray or magnetic resonance imaging (MRI) indicates the athlete can return to play?
For the senior author, the only proof is a second look after surgery. We all do second looks on someone else’s patients but are you looking at your own? Though second looks are often reserved for additional arthroscopic procedures secondary to continued pain, a second look can also provide the opportunity for the surgeon to see how a cartilage repair should look after healing has taken place. On many occasions, I will gladly share my second looks with the original surgeon.
The issue with these repairs is that so many athletes struggle to get back to pain-free running after a cartilage repair or remain asymptomatic until they begin pursuing their full activity level. If you are not looking or educating your patient about the value of second looks, then patients will often go to other surgeons. Far too often, these athletes may be forced to endure a far more aggressive surgery.
Prior to presenting to the senior author, one soldier had five surgeries including two arthroscopic procedures, one osteochondral allograft transplantation surgery (OATS) with a medial malleolar osteotomy and one medial malleolar osteotomy with an allograft shoulder transplant. Additionally, the soldier’s previous doctor told him he needed an ankle fusion. After reviewing many of the soldier’s original scope pictures, the senior author notes it was clear he never needed these surgeries. His original chondroplasty healed perfectly but the second surgeon failed to recognize that he not only needed a simple scar resection but also failed to address his ankle valgus deformity, which was the whole reason for his continued pain.
Educating Surgeons On Acceptable Post-Op Outcomes
A report by Krych and coworkers in 2018 found the number of cartilage revision surgeries was increasing nationally and the primary failure point was not the repair but a failure to address deformities.2 Thus, our goal is to familiarize surgeons with how a cartilage repair should appear postoperatively and the use of different repair techniques to ensure proper resolution of the lesion. Everyone must be adept in dealing with a completely fibrotic ankle joint.
Often, athletes will seek the opinion of a second surgeon, assuming that the first surgery was a failure. Having rescoped at least 200 cartilage repairs performed by other surgeons, the senior author has rarely considered any of them true failures. The senior author has performed second looks on just about every technique imaginable including chondroplasties, microfractures, osteochondral allograft plugs, autograft plugs from the knee, procedures involving DeNovo NT (Zimmer Biomet) or ProChondrix CR (Stryker), autologous chondrocyte implantation (ACI), procedures involving BioCartilage (Arthrex) and allograft transplants.
Just as Gobbi and colleagues reported in their study in 2006, there is no difference between chondroplasty, microfracture and OATS with regard to ankle-hindfoot score (AHS) and Subjective Assessment Numeric Evaluation (SANE) ratings in patients with osteochondral lesions of the talus.3 Routinely, these cartilage repairs were not failing but rather it was that the patient had developed significant postoperative fibrosis. The simple fix was arthroscopic debridement. There is no doubt that a high percentage of athletes are having needless repeat cartilage repairs, resulting in more invasive procedures simply because surgeons are unfamiliar with how these procedures actually heal. In assessing the use of particulated juvenile cartilage allograft transplantation, Dekker and coworkers in 2018 noted a failure rate of 40 percent in their series of patients with osteochondral lesions of the talus at Duke University.4 The authors made no mention of second looks and just noted no resolution of symptoms or abnormal MRI findings.
The senior author has been at meetings where surgeons are shocked by the amount of scar tissue that these osteochondral lesions produce. Once you dig through all the fibrotic tissue and finally get down to the repair, it is often hard for surgeons to comprehend that cartilage repairs frankly never look like hyaline cartilage. Fibrocartilage is functional but are never pretty, especially early on. It may take two years for the fibrocartilage to mature and look normal. Unfortunately, there are a significant number of surgeons who have limited ideas of what a cartilage repair looks like postoperatively. Surgeons need to familiarize themselves with each and every technique while being able to support their techniques with second looks.
One can make a convincing argument that as long as one properly debrides and prepares every osteochondral lesion, almost every technique will produce fibrocartilage. Numerous studies have questioned the cost-effectiveness of all of the newer cartilage grafting techniques based solely upon outcomes, especially with regard to first-line treatment.5 One of the newer trends is the use of stem cells, amniotic products and/or bone marrow aspirate in conjunction with cartilage grafts. It is safe to say that everything we can do as surgeons to improve the biology of the joint while reducing scarring will help improve outcomes. The main hurdle in non-athletes and non-military patients is cost. Conversely, in athletes and soldiers, cost is less important in comparison to their ability to restart their career.
Comparing Different Methods Of Cartilage Repair
We will look at three different methods for cartilage repair, including, chondroplasty/microfracture, DeNovo and ProChondrix. For each of these techniques, we will discuss typical second looks. While surgeons may see the development of significant post-op fibrosis with all three repair methods, these techniques can all be successful options, especially when surgeons use an arthroscopic technique.
The majority of surgeons have utilized chondroplasty, chondral picking, microfracture and/or curettage in some form.6-7 Many surgeons will utilize these techniques as first-line treatments as it is well-known that these have a proven track record in the majority of patients. I often wonder how many athletes who have had successful repairs were deemed failures due to chronic pain and received revision surgery with more advanced procedures like OATS, mosaicplasty or even autologous chondrocyte implantation. Lambers and colleagues in 2018 did a review of surgical failure papers, finding that surgeons were utilizing a wide range of surgical techniques for their second procedure for osteochondral defects of the talus.8 The authors found a very high rate of failure with far more advanced and open techniques, which the senior author has always advocated for arthroscopic-only repairs.
As with anything in medicine, we are always striving for better. DeNovo NT is a natural tissue allograft that consists of juvenile hyaline cartilage pieces with chondrocytes. Surgeons originally utilized this allograft in open procedures but there has been an evolution with surgeons now incorporating DeNovo NT in arthroscopic techniques with widespread use.9-18 Personally, the senior author has only performed this technique arthroscopically.
Prepare the lesion via curettage, microfracture and/or chondral picking. Apply a layer of fibrin glue to the lesion, layer the particles within the defect and then cover the particles with fibrin glue. Early reports focused on the development of hyaline cartilage but second looks and biopsies have proven that fibrocartilage is being produced. Just as Farr and coworkers reported in 2014, histologically, the repair tissue in biopsy samples was composed of a mixture of hyaline and fibrocartilage.9
As with any technique, processes and techniques evolve. AlloSource, the same company that procures and processes DeNovo NT for Zimmer, saw in its own research the same issues (exuberant scar tissue development) that surgeons were starting to see and that Tan and colleagues reported in 2018.18
The senior author has seen similar occurrences of hyperproliferation of the pellets above the level of the talar dome (see photo 1). As we continued to see similar cases and discuss among our peers, we started to wonder if donor age had anything to do with this. We were able to determine donor age via lot numbers and found that age had a significant role in determining the growth of the implanted particulates. The younger the donor, the more the pellets grew. In one case, the senior author performed a second look, a third look and scheduled a fourth look, noting the pellets continued to grow over a four-year period (see photo 2). The donor was five years old. The older the donor, the less growth of pellets. AlloSource saw this and developed its own product called ProChondrix, utilizing adult cartilage with the hope of seeing less growth of pellets.
The senior author has utilized ProChondrix in the same way as DeNovo. The senior author has not seen the exuberant growth of pellets he has seen with DeNovo but still sees a fair number of soldiers needing scar resection. The photos above show a second look of ProChondrix. This looks very similar to what we see with chondroplasty.
Many courses argue that all one needs is an arthroscope and curette to resolve these osteochondral lesions. The physiologic process of a blood clot transforming into fibrocartilage worked for years and will frankly continue to heal in 80 percent of cases.7 Vannini and colleagues concluded in their series in 2017 that traditional bone marrow stimulation was the most successful technique for athletes.7
It is the large and cystic lesions for which many feel a simple curettage is inadequate. For many surgeons, chondroplasty and microfracture will always be the standard of care with the opinion that surgeons should reserve biologic grafting techniques strictly for revision cases. Results with chondroplasty in the past have been successful but how do we justify not spending the money for biologics on a professional athlete when biologics have the potential to return athletes to activity more quickly?
Most, if not all, of the senior author’s failures with osteochondral lesion treatment occurred in smokers and patients who had sustained ankle injuries during the first six months of their recovery. Typically, the cartilage repair will often look elevated or detached or, worse, delaminated. After performing second looks in over 100 of his own patients and having performed hundreds of revision cases, the senior author has rarely had a need to perform revision surgery on lesions. Postoperative fibrosis, recurrent synovitis and inadequate tibial spur resection were the primary issues with a very high percentage of these athletes and soldiers returning to their desired level of activity.
It is uncertain if the problem stems from the equipment, biologics or from other outside sources, but surgeons are confused in thinking that cartilage repair techniques other than autologous chondrocyte implantation (ACI) will ever produce true hyaline cartilage, let alone ever resemble perfectly smooth cartilage.19-20 There are numerous histologic papers that have confirmed that even juvenile particulated cartilage (DeNovo) biopsied at second looks does not produce hyaline cartilage. Fibrocartilage is often not aesthetically pleasing to the surgeon but will improve with time. Fibrocartilage is functional despite a surgeon’s conviction that anything short of perfectly smooth cartilage is a failure (see photo 4).
As some studies have demonstrated, as long as the ankle mechanics are restored and the ankle ligament remains stable, cartilage repairs will do well for the long-term. However, too many surgeons must face the reality that athletes and soldiers are prone to reinjury, which will ultimately lead to the failure of any repair. There is no way to prevent our patients from reinjury.
Far too often, surgeons attribute a “surgical failure” to a surgical technique while ignoring the possibility of re-njury or simply overuse. Whether it is a Special Forces soldier spending a year in Afghanistan wearing a 200-pound rucksack while walking and running on uneven ground, or the marathon runner completing multiple marathons post-cartilage repair, both scenarios will likely affect the long-term sustainability of any cartilage repair technique. The ability of fibrocartilage to withstand mechanical loading and protect the subchondral bone over time is a concern which many surgeons like Murawaski and Kennedy questioned in their article in 2013.21 Will any technique hold up to that abuse?
Dr. Spitalny is an adjunct faculty member with the Depaul Podiatric Surgical Residency Program in St. Louis.
Dr. Staples is a second-year resident with the Depaul Podiatric Surgical Residency Program in St. Louis.
Dr. Patel is a second-year resident with the Depaul Podiatric Surgical Residency Program in St. Louis.
1. Boffeli TJ, Schaefbauer HH. A proposed treatment algorithm for osteochondral lesions of the talus. Podiatry Today. 2018; 31(11):18–24.
2. Krych AJ, Hevesi M, Desai VS, et al. Learning from failure in cartilage repair surgery: an analysis of the mode of failure of primary procedures in consecutive cases at a tertiary referral center. Orthop J Sports Med. 2018;6(5):2325967118773041.
3. Gobbi A, Francisco RA, Lubowitz JH, et al. Osteochondral lesions of the talus: randomized controlled trial comparing chondroplasty, microfracture, and osteochondral autograft transplantation. Arthroscopy. 2006;22(10):1085-92.
4. Dekker TJ, Steele JR, Federer AE, et al. Efficacy of particulated juvenile cartilage allograft transplantation for osteochondral lesions of the talus. Foot Ankle Int. 2018;39(3):278-283.
5. Clar C, Cummins E, McIntyre L, et al. Clinical and cost-effectiveness of autologous chondrocyte implantation for cartilage defects in knee joints: systematic review and economic evaluation. Health Technol Assess. 2005;9(47):iii-iv, ix-x, 1-82.
6. Ramponi L, Yasui Y, Murawski CD, et al. Lesion size is a predictor of clinical outcomes after bone marrow stimulation for osteochondral lesions of the talus: a systematic review. Am J Sports Med. 2017;45(7):1698-1705.
7. Vannini F, Cavallo M, Ramponi L, et al. Return to sports after bone marrow-derived cell transplantation for osteochondral lesions of the talus. Cartilage. 2017;8(1):80-87.
8. Lambers KTA, Dahmen J, Reilingh ML, et al. No superior surgical treatment for secondary osteochondral defects of the talus. Knee Surg Sports Traumatol Arthrosc. 2018;26(7):2158-2170.
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15. DeSandis BA, Haleem AM, Sofka CM, et al. Arthroscopic treatment of osteochondral lesions of the talus using juvenile articular cartilage allograft and autologous bone marrow aspirate concentration. J Foot Ankle Surg. 2018;57(2):273-280.
16. Lanham NS, Carroll JJ, Cooper MT, et al. A comparison of outcomes of particulated juvenile articular cartilage and bone marrow aspirate concentrate for articular cartilage lesions of the talus. Foot Ankle Spec. 2017;10(4):315-321.
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18. Tan EW, Finney FT, Maccario C, et al. Histological and gross evaluation through second-look arthroscopy of osteochondral lesions of the talus after failed treatment with particulated juvenile cartilage: a case series. J Orthop Case Rep. 2018;8(2):69-73.
19. Dewan AK, Gibson MA, Elisseeff JH, Trice ME. Evolution of autologous chondrocyte repair and comparison to other cartilage repair techniques. Biomed Res Int. 2014;2014:272481.
20. Niemeyer P, Salzmann G, Schmal H, et al. Autologous chondrocyte implantation for the treatment of chondral and osteochondral defects of the talus: a meta-analysis of available evidence. Knee Surg Sports Traumatol Arthrosc. 2012;20(9):1696-703.
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