Cartilage Repair

Articular or hyaline cartilage is the tissue that covers the adjacent bone surfaces of the
knee and creates a smooth surface for motion. Articular cartilage often gets damaged
because of direct injury to the knee, and can result swelling, stiffness, locking and
limited movement. Articular cartilage has minimal capacity to repair itself. Generalised
wearing out of cartilage is termed osteoarthritis (OA), however any damage to cartilage
represents part of the osteoarthritis process.
Because cartilage does not heal itself well, surgical techniques have been developed to
stimulate the growth of new cartilage. Restoring articular cartilage can relieve pain and
allow better function. Most importantly, it can delay or prevent the onset of arthritis.
These surgical techniques to repair damaged cartilage are still evolving and the surgeons
at Sydney Knee Specialists are experienced in these operations. It is hoped that as more
is learned about cartilage and the healing response, surgeons will be better able to
restore an injured joint. At this stage, there are no treatments that restore the cartilage
to a completely normal structure. At best, the current techniques seem to stimulate a
mix of normal cartilage (hyaline cartilage) and a less resilient but still useful tissue called
fibrocartilage.
In many cases, patients who have joint injuries, such as meniscal or ligament tears, will
also have cartilage damage. This damage may be hard to diagnose because hyaline
cartilage does not contain calcium and cannot be seen on an X-ray. The diagnosis is
usually established by performing an MRI scan of the knee.

Articular cartilage in the knee damaged in a single, or focal, location.

Who Are Candidates for Cartilage Surgery?

Most candidates for cartilage repair are young adults with a single injury, or lesion. The
size of the lesion, site of the lesion and the status of other structures in the knee will
determine whether surgery is possible for you. Often, additional operations such as knee
re-alignment (osteotomy) and ligament reconstructions may also be required to improve
the chance of success. Older patients, or those with many lesions in one joint, are less
likely to benefit from the surgery, as this process is more representative of OA.

What Surgical Procedures Are Available?

Many procedures to restore articular cartilage are done arthroscopically. During
arthroscopy, the procedure is done through 2 small incisions (key-holes). Some
procedures require direct access to the affected area via an open incision (arthrotomy).
In general, recovery from an arthroscopic procedure is quicker and less painful than
traditional, open surgery. Your doctor will discuss the options with you to determine what
kind of procedure is right for you.
The most common procedures for damaged cartilage are:

Chondroplasty

Microfracture

Matrix-Induced Autologous Chondrocyte Implantation (MACI)

Osteochondral Autograft Transplantation

Chondroplasty
This term simply means smoothing out any unstable areas of cartilage and is performed
arthroscopically. The chondroplasty is performed using fine mechanical shavers and
thermal devices to stabilise loose areas of cartilage. The benefit of chondroplasty is that
it is not invasive and as such recovery is quicker than other techniques. However, unlike
the other procedures listed below, it does not allow the cartilage to regenerate.

Microfracture

Steps of the microfracture technique. Left: Damaged cartilage is removed. Center: Awl is used to make
holes in the subchondral bone. Right: Healing response brings new, healthy cartilage cells.
(Reproduced with permission from Mithoefer K, Williams RJ III, Warren RF, et al: Chondral resurfacing of
articular cartilage defects in the knee with the microfracture technique. J Bone Joint Surg Am
2006;88(suppl 1):294-304.

The goal of microfracture is to stimulate the growth of fibrocartilage by creating a new

blood supply. A sharp tool called an awl is used to make multiple holes in the joint
surface. The holes are made in the bone beneath the cartilage, called subchondral bone.
This creates a healing response. Your own stem cells (mesenchymal cells) from the
underlying bone marrow move in to the area and then cells differentiate into specific
cells that can create a fibrocartilage cover. The best candidates are young patients with
single lesions and healthy subchondral bone. Smaller lesions under 2cm respond best to
this treatment. The recovery is usually slower than a chondroplasty as specific
rehabilitation protocols are required to allow the new fibrocartilage to regenerate.

Normal healthy articular cartilage in the knee (left). A large cartilage defect in the knee
joint surface (center). During microfracture, an awl is used to penetrate the defect
(right).

Matrix-Induced Autologous Chondrocyte

Implantation (MACI)
MACI is a two-step procedure. New cartilage cells are grown and then implanted in the
cartilage defect. First, healthy cartilage tissue is removed from a non-weightbearing area
of the bone. This step is done as an arthroscopic procedure. The tissue which contains
healthy cartilage cells, or chondrocytes, is then sent to the laboratory. The cells are
cultured, and rapidly expanded in number from approximately 50,000 cells to up to 20

million cartilage cells over a period of 6 weeks. These cells are cultured on to a biologic
porcine membrane (Matrix).
An arthrotomy is then done to implant the matrix implant. The cartilage defect is
prepared and the matrix implant is glued in to position. Over time, the cells on this
matrix attempt to restore the normal structure of cartilage. The theoretical advantage of
this procedure is that it may regenerate more of the normal hyaline cartilage, as
opposed to a microfracture, which tends to produce fibrocartilage.
MACI is most useful for younger patients who have single defects larger than 2 cm in
diameter. MACI has the advantage of using the patients own cells, so there is no danger
of a patient rejecting the tissue. It does have the disadvantage of being a two-stage
procedure that requires an open incision. It also takes several weeks to complete.
Currently, the costs of treatment for a MACI procedure are very expensive, as the private
health industry no longer covers the costs of manufacturing the implant.

Rehabilitation
Post-operative physiotherapy will be required following cartilage repair surgery. The
amount and length of time undertaking this is dependent on the type of surgery as well
as other factors. It is important for the knee joint to be protected whilst the new
cartilage has time to regenerate. This often involves restricted weight bearing, using
crutches for up to 6 weeks so that the cartilage can heal. Often, your surgeon will also
recommend use of a knee-bending device called a Controlled Passive Motion (CPM)
machine. This needs to be used for between 4 and 6 hours per day to achieve the best
results in terms of smooth cartilage regeneration. Recent research also suggests that
injection of your own blood (PRP) in to the knee joint following this procedure may
benefit the quality of cartilage repair. As healing progresses, your therapy will focus on
strengthening the joint and the muscles that support it. It may be several months before
you can safely return to sports activity.

Results and Complications

Most patients who have cartilage repair notice a significant improvement in symptoms
and are able to return to most activities. However, as the knee joint cartilage has been
damaged, activities such as long distance running are not recommended as this can
result in rapid deterioration of the knee joint cartilage. The best way to keep your knee
joint healthy is to keep a low body weight and perform regular low impact exercises such
as bike riding, swimming, gym exercises and core exercises (eg pilates).
Some patients find no improvement in their symptoms following cartilage repair surgery.
The quality of the cartilage tissue that regenerates can vary between patients and affect

the result of surgery. Some times, the cartilage repair becomes too thick (hypertrophy)
and requires further surgery to perform a chondroplasty and reduce symptoms. Less
commonly, the cartilage repair can fail completely. Other symptoms that may arise
include swelling and clicking (crepitus)