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Current techniques do not obtain quality cartilage repair

Expert discusses the current clinical status of cartilage repair and how to make decisions.

Issue: February 2006

ByDouglas W. Jackson, MD

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Lars Engebretsen, MD, has been a friend since we were young surgeons, and he is a well-known international contributor in orthopedics. He is professor and chairman of the Orthopaedic Center at the Ullevaal University Hospital in Oslo, Norway.

An increasing number of surgeries for articular cartilage defects in the knee are being done worldwide. I turned to Lars to share his insights on the current approaches and indications based on the published literature.

Douglas W. Jackson, MD
Chief Medical Editor

Douglas W. Jackson, MD: Is there any procedure orthopedic surgeons can perform in younger or older patients to reproducibly obtain quality cartilage repair?

Lars Engebretsen, MD: Unfortunately, the answer is no. None of the methods used so far have been able to show quality cartilage in the form of reproduction of hyaline cartilage with proper histology. In fact, most histology results show fibrous or some hyaline with large areas of fibrous cartilage in between. The few studies using electron microscopy show that the collagen fibers are different from Type II and are randomly dispersed. So far, we can fill most lesions with some substance and this may reduce the pain and lead to improved function for some years. We have no information on whether this will eventually lead to osteoarthritis or remain a substitute for normal cartilage.

Jackson: What indications can be drawn from the existing literature as a basis for the surgical treatment of articular cartilage lesions and/or degeneration?

Engebretsen: When it comes to cartilage degeneration, the new biological resurfacing techniques do not seem to lead to good results. In fact, very few studies are available in this field, which seems to be governed by surgeon-to-surgeon anecdotes. When it comes to traumatic lesions or osteochondritis dissecans, many studies have been published. Unfortunately, the quality of the studies are not good — in fact there are only four randomized controlled trials — and they suggest that there is minimal difference in outcome at two and five years between autologous cartilage cell transplantation, microfracture and mosaicplasty. Eight of 10 patients will have improvement from baseline, but keep in mind that many still have a rather low functional score and that the improvement may be marginal. One should be very critical when reading studies in this field.

Jackson: How does one determine if a patient with an articular cartilage lesion is symptomatic and can be helped by a surgical procedure?

Engebretsen: This is a big challenge! We scoped 1000 patients for chronic knee pain in the year 2000. Eleven percent had grade III and IV cartilage lesions and 6% had grade III and IV >2 cm² lesions. Some of these patients also had meniscal lesions, so it was difficult to be sure that the cartilage lesion was their main problem. If no other pathology can be seen and the patient with a lesion >2 cm² is pain free after an intraarticular anesthesia injection, then we say that the patient’s pain is coming from the cartilage lesion and will usually treat it. In acute cases it may be even more difficult since we really do not know the natural history of acute cartilage lesions except for smaller lesions in conjunction with an ACL tear.

Jackson: What do you do at the time of arthroscopic surgery for a degenerative meniscal tear in your patients older than 45 years when you see localized areas of exposed bone?

Engebretsen: Some of these patients will have a varus alignment. I tell them that I can do the meniscal debridement. If they do not show improvement at six months, I will suggest an osteotomy and will include microfracture. If they have normal alignment, I will give the patient the option of doing a microfracture on the femur. If kissing lesions exist or exposed bone is found in the patellofemoral joint, I will still do the meniscal work but will then talk to the patient about modifying the activity level.