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Frequently Asked Questions About Cartilage Repair

Are all cartilage problems the same?

What improvement can I expect following cartilage repair?

It will depend on the severity of your symptoms beforehand. Patients with severe and debilitating pain prior to treatment will most likely see a marked improvement in their quality of life that will allow them to return to activities that may have previously seemed impossible.

Those with only mild symptoms (for instance, pain only when running) may not see enough benefit from current procedures to warrant intervention. In these cases, more conservative physical therapy may be more appropriate.

Why aren’t all the cartilage repair options available to me?

There are a multitude of treatments available to either repair or replace damaged cartilage and joints. However, both the cartilage damage itself, and individual patient circumstances, means that some approaches are either unlikely to benefit the patient because they are are too risky or are not advanced enough to offer a solution at the present time.

Rest assured there are usually several options for most types of cartilage complaints, so speak to your physician for a tailored solution appropriate to you.

Autologous chondrocyte implantation (ACI)

How long will the treatment last?

Studies have shown that ACI lasts for at least 10–20 years, with good recovery both on an objective, scientific, level, and also in terms of how patients feel and manage activities of daily life.

How long do I need to stay away from sport or from work after ACI? How long before I can return to previous activity levels?

How long it takes to return to previous levels of activity depends on your level of activity before the operation. If you do not use your knee at work (for example, in an office job), you can regain your previous activity levels within a couple of days. If you work in a factory and have a job that requires heavy manual labour, or your job involves standing all day, it will take at least 6 months to return to previous activities. For jobs involving hard labour, such as mining or carpentry, the recovery period is 6–9 months.

It is important in all cases to resume your activities gradually, in a step-by-step process, as full healing takes between 12 and 15 months.

Cartilage injury and disease in children

Will the disease have possible consequences for the future?

If the treatment, rehabilitation and timing are as intended, the chances of any future consequences from a cartilage injury are minimal.

Will the surgery be painful?

Thanks to current pain management protocols, patients usually experience no or only mild pain after surgery.

Will my child return to their previous sporting activity?

The chances are very high. Only in very specific cases will a reduction to less demanding activity be required.

Cartilage repair

What are my options for treatment?

There are different surgical and non-surgical options, depending on the sex and age of the patient, and the nature of the injury. The decision of which technique is optimal should be made on an individual basis in collaboration with a surgeon specializing in articular cartilage repair that has broad experience with the entire spectrum of cartilage repair techniques.

What are the chances of an operation solving cartilage problems in the long-term?

Cartilage repair procedures are still relatively new field. There is little long-term data both on the natural history of untreated cartilage lesions or studies that can predict surgical results years and years into the future. That being said, encouraging mid-term results are hoped to carry on into the long-term.

Will they implant any foreign material into my joint that will cause allergic reaction or has to be removed later?

Normally the answer is no, unless the patient has another procedure, such as anterior cruciate ligament reconstruction or an osteotomy. For which, in rare cases the fixation device or plate may have to be removed at a later time if it begins to cause irritation.

Could the surgery be avoided or delayed?

Chondral/osteochondral lesions are not able to ‘self repair’. The condition could potentially get worse over time and may cause more pain and a variety of other problems. The patient may have to give up sporting activities, and conservative treatment such as non-steroidal anti-inflammatory drugs (NSAIDs) can only delay this progress.

How long will I be in hospital; how long before I can start weight bearing exercises; how long is the rehabilitation period; and when can I return to work/sport/daily activities? Or, most importantly: When can I drive?

The answer is that it depends on the type of cartilage repair technique used and whether or not another procedure, such as reconstruction of the anterior cruciate ligament or an osteotomy, was performed. It also depends on the daily activities of the patient. Therefore, the duration of treatment, hospital stay and expected rehab are usually individualized based on the patient’s exact pathology.

Cartilage repair – The next generation

Am I eligible to receive stem cell therapy?

As patients with damaged or diseased cartilage would generally prefer not to have total knee replacement, one of the most common questions they ask is whether they could have cartilage repair using stem cell therapy.

There is a much confusion regarding how stem cell therapy works and what can be expected in terms of outcomes. It is therefore important to discuss all treatment options extensively with your doctor and then decide on the best approach for you and your particular cartilage defects.

Debridement and microfracture

Should I try microfracture before autologous chondrocyte implantation (ACI)?

ACI can be less effective if the patient has already undergone microfracture. Speak to your orthopaedic surgeon to discuss an appropriate ongoing plan for your needs.

Will I get worse after having microfracture surgery?

There should be no additional pain following microfracture surgery. Generally, there will be some improvement in pain levels for all patients. However, it is important to remember that microfracture carries with it the usual risks associated with any surgery (infection, anaesthesia complications, etc.) although these complications are extremely rare.

What are my chances of improvement?

Two-thirds of patients are expected to improve when using basic rehabilitation techniques. However, this is based on your individual pathology that is causing you pain and discomfort.

Growth factors

Can I enrol in a trial using growth factors for cartilage repair?

Discuss with your Orthopaedic surgeon if there are any ongoing trials within your country.

Are growth factors available as a treatment for cartilage repair in humans?

Some growth factors, like PRP, are already available in many countries. However, well-defined clinical studies on large cohorts of patients and standardization of PRP production are necessary to validate these novel techniques and therapies. At the current time, further studies need to be completed before growth factors can be established as a standard treatment for cartilage repair. The ideal therapy in the future will most probably be multi-varied and will target multiple mechanisms. Growth factors might become an important part of the treatment mix.

Hyaluronic acid (HA)/Viscosupplementation

How does HA compare with other treatments?

In terms of adverse events, HA is a very well tolerated drug compared with non-steroidal anti-inflammatory drugs (NSAIDs) or steroids.

In particular, steroids may stop the inflammation, but they also stop all the regenerative capabilities of the cartilage. Furthermore, the effectiveness of steroids is reduced after two or three injections. Consequently, although steroids are effective at the time, they have the potential to make whatever problems are already present in the cartilage permanent and prevent any regeneration.

Will the HA cure my osteoarthrosis or osteoarthritis?

HA slows down the progression of a disease such as osteoarthritis, but the progression is not completely stopped. The patient cannot expect to be cured from osteoarthritis or osteoarthrosis, but perhaps can expect to have a slower course of degeneration.

One way of explaining it is that, with a treatment like HA, it can be expected that a potential total joint replacement, which might happen at some point, is delayed for some time. Depending on the individual, the delay can be between three and five years with HA, if the patient is considered a ‘responder’.

For patients who do not respond, the course of the osteoarthritis has become too inflamed and the activation of the anti-inflammatory components by HA cannot calm down the knee. HA should not be repeated if it has not worked the first time around. It makes no sense to do it over again, because the balance of the knee or joint cannot be altered by this treatment. If it doesn’t work, it doesn’t work.

How many injections will I need?

There are different methods of administering HA. Some formulations have a treatment schedule of five weeks, with one injection every week. While others require three injections over a three week period, while another only requires just one injection.

The number of injections required relates to the molecular weight of the drug, and how long the drug is estimated to remain in the joint after injection. We know that, the lower the molecular weight, the less time that it stays in the joint. However, the way in which the synovium reacts to the HA can be different with a higher molecular weight drug. These larger drugs stay longer in the synovium and can cause some reactions.

The number of injections should therefore be clarified, depending on whether the patient needs five injections in a row, three injections in a row or maybe just one injection. The clinical studies published so far have not been able to determine which number of injections achieves the best results.

One practice used by some people who use the product that recommends the 5 injections is to give three injections and then evaluate their success, or ‘efficacy’. Patients can then have two further injections three months later, if required, to prolong the efficacy of the HA, as there are five injections in a package.

The efficacy of the treatment should be assessed between six months and 12 months after the initial injection, and the symptoms should decrease during that timeframe. A patient can therefore expect to have one series of injections every year, if needed.

Joint resurfacing and joint replacement

How soon will it be before I can leave hospital after my surgery?

Again, this will depend on factors such as the type of implant, country of residence and your unique circumstances. You should be able to walk early after joint resurfacing, noting that partial or total knee arthroplasty may result in a short hospital stay, depending on the healthcare system in which you are cared for.

How long will my implant last?

This will depend on both the type of implant, and the circumstances after your operation that are unique to you. Many implants will be able to last for decades, that is the metal will not typically wear and the plastic will wear slowly. The major reason for implants failing is from “loosening from bone”. This has many reasons, but commonly include: over-stress or debris from plastic wear causing the body to “attack” the bone cement interface.

I have heard I will need to take antibiotics when visiting the dentist. Is this true?

Because you now have an artificial joint, care must be taken to prevent it getting infected. Dental work such as teeth cleaning, fillings or extractions (for example) can carry some low risk of infection, as can many other procedures (such as colonoscopies or other invasive procedures), which will need to be managed properly.

Depending on your unique circumstances, and your immune status (i.e. other health issues), enough time may have passed to no longer need prophylactic courses of antibiotics. Speak to your surgeon to find out what measures you need to take.

What practical considerations are there?

You surgeon will discuss all important considerations. In addition, there are many day-to-day practicalities that may need additional consideration. A common example is the question: do you need to provide proof of your implant in order to pass through metal scanners at airports. The answer is “No” as terrorists could get “arthroplasty cards” and thus these cards/proof are no not needed/honoured. Speak to your healthcare provider if you have any specific questions or concerns.

What limitations will I have following surgery?

It is essential to manage expectations, talk to your surgeon and keep activity after your operation to a safe level. To ensure the implants do not loosen or fracture, you should obey the surgeon’s activity recommendations.

Meniscus transplant

What will happen if I don’t have a transplant?

The decision as to whether or not to have a meniscus transplant comes down to quality of life and pain. If you do not have a transplant, pain may persist.

If you do not have pain and do not have any swelling, and you want to do very low or no-impact activities such as biking and swimming, you might do okay without having a meniscus transplant. On the other hand, if you are constantly on your feet, or you’re young and want to be active, then a meniscus transplant is probably a good thing for you to consider.

Should I have a meniscus transplant?

The ideal patient for a meniscus transplant is someone who has injured/lost a significant amount of his or her meniscus, and has pain. A transplant may also be indicated to protect a cartilage repair/restoration procedure.

There is some debate as to whether someone who is very young – for example, in their teenage years – should have a transplant before developing pain, if they lose their meniscus. This is particularly important on the lateral side in females as the rate of development of osteoarthritis can be fairly quick. There is some debate as to whether to treat those before symptoms develop, because if an individual starts to develop symptoms, the assumption is that they have already started developing some wear in their joint.

Mosaicplasty

When can I return to work/sport/daily activities?

The final goal of rehabilitation is to allow the patients’ return to all daily and sporting activities. It takes approximately 4–5 months to form a composite hyaline-like surface over the transplanted area that is able to tolerate shear forces.

Returning to sports activities depends on the depth and extent of the defect, and the state of the neuromuscular system. If the patients’ strength, power, endurance, balance and flexibility are not sufficient, sports activity should be postponed.

It should be noted that mosaicplasty is usually combined with the treatment of other joint problems, such as reconstruction of a ligament, corrective bone removal (osteotomy), meniscus removal (meniscectomy), or suture/replacement of a torn meniscus. Treatment of accompanying pathologies requires a special adaption of the rehabilitation protocol in most cases, and can change and extend the time periods indicated above.

How long before I can start walking again?

Walking with two crutches without weight-bearing can be started immediately. Walking with two crutches and partial loading (typically starting with 25% of your body weight) can usually start after 2–4 weeks, and full weight-bearing without crutches can resume after 3–5 weeks. However, your surgeon will decide on your weight bearing status based on your pathology and treatment.

How long will I be in hospital?

This is typically an outpatient procedure and you will go home the same day.

What will happen to the holes in my knee where the grafts were taken from?

The donor holes will go through the body’s natural healing processes: eventually the tunnels will be filled with bone and the surface will be covered by fibrocartilage tissue.

Could the surgery be avoided or delayed?

Cartilage repair is not an urgent surgery. It can certainly be delayed, and patients have the choice not to have any surgical treatment at all. It must be noted, however, that these lesions have a very poor ability to regenerate and, without surgery, the condition will get worse, causing more complaints.

Neutraceuticals

Will my doctor prescribe a neutraceuticals for me?

Current practice depends on your specific healthcare provider. It is important for you to have an open discussion with your physician about the potential risks and benefits of using any of these neutraceuticals.

Are all brand-name versions of neutraceuticals the same? Surely I can just buy the cheapest?

Absolutely not. Due to a lack of proper regulation, many neutraceuticals are marketed in extremely low, ineffective doses. Look for ‘USP’ grade supplements that recommend a dosage that is similar to the amounts used in the high level studies that have been published in peer-reviewed studies. As a quick guide the following doses (Glucosamine ?1500 mg; Chondroitin 800-1200 mg; SAMe 800–1200 mg; ASU 300-600 mg) have been used in some of the studies we have referenced for your further reading, however, it is essential that you discuss the use and dosage with you healthcare provider prior to starting any of these medications.

How long should I try neutraceuticals for?

Due to the slow mechanism of action of many neutraceuticals, it is imperative that they are given ample time to work. Speak to your physician about treatment duration. As a rough guide, a 3–6 month course should be long enough to evaluate the effects of the product on your symptoms.

New scaffolds

How long will the new cartilage take to grow inside the scaffold?

This varies from patient to patient. Please discuss with your doctor.

Osteochondral allograft transplantation

What can I expect to be able to do after the procedure?

This depends on many factors but, if your knee is otherwise healthy, we would expect you to return to your previous activities. High-demand sports always carry risks, however, and there is no guarantee that you will be able to participate at the highest level.

Does rejection occur?

Immunologic rejection like that seen with organ transplants is not seen with allografts for OCA. While antibodies to the graft have been detected in about half of patients undergoing OCA, the clinical relevance is unclear.

How is the donor matched to me?

Donors for OCA are matched by size and location

How long will I have to wait for a donor?

Patients typically have to wait between 1 and 4 months for an OCA donor.

Osteotomy

Will I have one leg shorter than the other after osteotomy?

The operated leg will be shorter by up to around 1 cm for closing wedge osteotomies and up to 1 cm longer in opening wedge osteotomies, but this is not usually noticeable after a few months.

Will osteotomy affect the success of a future total knee replacement?

While there was some previous thinking that this might be the case, newer systematic reviews of patients undergoing knee replacements after osteotomy have shown no significant impact on outcomes.

Patellofemoral pain

Which surgery is right for me?

Only you and your surgeon can answer this question.

PF pain is very common but it has several potential causes (see ‘What causes patellofemoral pain?’ above), which must be considered before deciding which surgery is best. Your surgeon will take these factors into consideration and answer any questions you may have.

Radiofrequency

Is it a well-established technique?

As before, we have seen that there is abundance of information to support the use of radiofrequency for removing diseased articular cartilage fragments from a damaged joint.

Is radiofrequency safe?

As discussed in the Advantages and Disadvantages sections above, data from more than 10 years of study in animals and humans have shown that radiofrequency is a safe technique, causing less collateral damage than, for example, a motorised shaver.

What is my activity level like after cartilage repair?

What will my rehabilitation involve?

As discussed above, the rehabilitation programme chosen for you depends on the nature of the injury and the type and number of procedures performed. Close cooperation of the cartilage surgeon and cartilage repair rehabilitation specialist will help to optimise postoperative care, shorten recovery time and will facilitate the ability to return to sports.

What are my options for treatment?

There are different surgical and non-surgical options, depending on the sex and age of the patient, and the nature of the injury. The decision of which technique is optimal should be made on an individual basis in collaboration with a surgeon specializing in articular cartilage repair that has broad experience with the entire spectrum of cartilage repair techniques.

How soon can I go back to my previous activities?

That depends on the nature of the injury and the most appropriate treatment, but recovery can take up to 1 year.

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