Knee > Osteochondral Defect > Treatments

   Cartilage Transplantation

The decisions you make and the actions you take before your surgery can be every bit as important as the procedure itself in ensuring a healthy recovery.

   Make sure you have received any equipment you will need when you get home from the hospital. This may include a knee brace, crutches, ice packs or coolers, or a continuous passive motion (CPM) machine. You should receive prescriptions for any of these from your doctor when your surgery is scheduled.

   Understand the potential risks and benefits of the surgery, and ask your surgeon any questions that will help you better understand the procedure. It can also help to talk to someone else who has undergone the same surgery.

   Any physical problems, such as a fever or infection, should be reported to your surgeon, and you should notify your surgeon of any medication you are taking.

   Discontinue use of any anti-inflammatory medicine, especially aspirin, a week prior to surgery, to prevent excessive bleeding during the surgical procedure.

   To reduce the risk of infection, try to refrain from smoking for at least a week before surgery.

   If possible, practice walking with your crutches in case you need to use them after surgery.

   Most insurance companies require a second opinion before agreeing to reimburse a patient for a surgical procedure. Getting a second opinion from a surgeon who is as qualified as the surgeon who gave the initial diagnosis is advisable in any case.

   Make sure the orthopedist performing the surgery is board-certified, which can be determined by calling the American Board of Orthopaedic Surgery at 919-929-7103.

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At most medical centers, you will go to "patient admissions" to check in for your cartilage transplant surgery. If your surgery is going to be inpatient, there may be a separate department, so be sure to ask your doctor. After you have checked in to the hospital or clinic, you will go to a holding area where the final preparations are made. The paperwork is completed and your knee area may be shaved (this is not always necessary). You will wear a hospital gown and remove all of your jewelry. You will meet the anesthesiologist or anesthetist (a nurse who has done graduate training to provide anesthesia under the supervision of an anesthesiologist). Then, you will walk or ride on a stretcher to the operating room. Most patients are not sedated until they go into the operating room. Here are some important steps to remember for the day of your surgery:

   You will probably be told not to eat or drink anything after midnight on the night before your surgery. This will reduce the risk of vomiting while you are under general anesthesia.

   Since you will most likely be able to go home within a few hours of surgery, and because the anesthetic and pain medications may make you drowsy, arrange for someone to drive you home when you are released.

   Wear a loose pair of shorts or sweatpants with a zipper or buttons on the side that will fit comfortably over a knee brace when you leave the hospital.

   Take it easy. Keeping a good frame of mind can help ease any nerves or anxiety about undergoing surgery. Distractions such as reading, watching television, chatting with visitors, or talking on the telephone can also help.

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Cartilage transplant surgery for osteochondral defect usually takes one to two hours to perform. You are typically put under general anesthesia or numbed from the waist down with spinal anesthesia. Smaller osteochondral defect transplants can be done with an arthroscope, a tiny camera, and small surgical instruments that are inserted through three- to four-millimeter incisions. Larger defects require the knee to be opened with a larger, approximately four-inch incision. There are three types of surgeries:

OSTEOCHONDRAL AUTOGRAFT TRANSFER SURGERY (OATS)

   The osteochondral defect is cut away, including all damaged cartilage and the underlying subchondral bone, to make a recipient socket.

   Surgeons cut an intact, matching piece of cartilage and bone from a non-weight bearing area, typically the side of the thighbone's tip.

   OATS generally transfers a complete piece of hyaline cartilage attached to subchondral bone.

   Surgeons attach the bone into the recipient socket with small pins, screws, or sealant. The repaired cartilage generally blends seamlessly into the surrounding cartilage.

MOSAICPLASTY

   Surgeons generally do not transfer intact pieces of cartilage and bone that are bigger than two centimeters in diameter. For larger osteochondral defects, mosaicplasty may be prescribed.

   First, frayed cartilage and the underlying subchondral bone is cut away to make a recipient socket.

   Instead of one intact piece, surgeons take multiple small plugs of cartilage and bone from various non-weight bearing areas of your knee.

   The recipient socket is filled in like a mosaic painting with many plugs. The plugs are kept about one millimeter apart, leaving space that gets filled in over time with a different form of articular cartilage (fibrocartilage).

CARTICEL - AUTOLOGOUS CULTURED CHONDROCYTE IMPLANTATION

   Carticel is a two-part surgical procedure that requires two hospital visits.

   The first step is an arthroscopic outpatient procedure, in which your surgeon makes small incisions, inserts a tiny instrument, and takes a sample of your healthy articular cartilage. You usually leave the hospital within a few hours after arthroscopy.

   Your physician sends the sample to a special laboratory, where the cartilage is cultured for about five weeks. Your cartilage cells multiply outside of your body. About 12 million new cartilage cells are sent back to your surgeon for use in the implant.

   In the second surgery, an incision is made down the front of the knee, about four to seven inches in length. The frayed cartilage is cut away, leaving the underlying bone intact.

   A layer of the skin that covers all your bones (periosteum) is sewn over the exposed bone, creating a pocket.

   The new cartilage cells are injected into the pocket between your bone and the layer of bone-skin. The Carticel cells continue to grow, eventually blending with the surrounding cartilage.

   After all cartilage transplant procedures, incisions are sewn up and the patient is taken to the recovery room.

After cartilage transplant surgery for osteochondral defect, you usually stay in the recovery room for at least two hours while the anesthetic wears off. General anesthesia wears off in about an hour and spinal anesthesia may take about two hours to wear off. You will be given adequate pain medicine, either orally or through an IV (intravenous) line, as well as instructions for what to do over the next couple of days. In addition, you will be given an appointment to return and a prescription for pain medicine. Your knee will be bandaged and may have ice on it. You may have significant pain early on and you should take the pain medicine as directed. Remember that it is easier to keep pain suppressed than it is to treat pain once it becomes present. When you feel the pain coming on, take another pill, as long as it is within the time limit on the bottle. You should try to move your feet while you are in the recovery room to improve circulation. Your temperature, blood pressure, and heartbeat will be monitored by a nurse, who, with the assistance of the doctor, will determine when you are ready to leave the hospital or, if necessary, be admitted for an overnight stay.

After cartilage transplant surgery, some patients remain in the hospital for as long as 24 hours. As soon as possible after surgery is completed, you will begin doing continuous passive motion exercises while in bed. Your leg will be flexed and extended to keep the knee joint from becoming stiff. This may be done using a continuous passive motion (CPM) machine. The CPM is attached to your bed and then your leg is placed in it. When turned on, it takes your leg through a continuous range of motion. There will likely be pain, and you can expect to be given pain medication as needed. Be sure to ask for medication as soon as you feel pain coming on, because pain medication works best on pain that is building rather than on pain that is already present. The nurses will not give you more than your doctor has prescribed and what is considered to be safe. Ice also helps control pain and swelling. Physicians generally suggest that you walk with crutches, keeping all weight off your injured leg, for about six to eight weeks. Your knee is usually immobilized in a stiff brace for a short period of time, which varies based on the size of the osteochondral defect. You will not be able to drive, so be sure to have arranged for a ride home.

Most people spend about seven to ten days at home after cartilage transplant surgery. Your knee may be partially immobilized in a removable, hinged brace, which may be locked to allow the knee to only bend and straighten a few degrees. This can make movement around the house difficult. Doctors strongly recommend that you avoid any movement that twists your knee. For example, getting your foot stuck under a table leg and twisting around can cause severe pain. Here is what you can expect and how you can cope after cartilage transplant surgery:

   You will likely feel pain or discomfort for the first few days, and you will be given a combination of pain medications as needed. Many patients may be given a narcotic painkiller and an anti-inflammatory.

   There may be some minor drainage since fluid may have accumulated during the surgery. Expect some blood to show through your bandage during the first 24 hours.

   As much as possible, you should keep your knee elevated above heart level to reduce swelling and pain. It often helps to sleep with pillows under your ankle. Icing your knee for 20 or 30 minutes a few times a day during the first two days after surgery also will reduce pain.

   Wait until you can stand comfortably for 10 or 15 minutes at a time before you take a shower. Once you can, put your leg in a plastic bag and tie the top around your leg above the knee bandage to keep the bandage dry. Ask your physician about the best place to buy plastic shower bags in your area.

   The dressing on your knee is usually removed the next day after cartilage transplant surgery.

   Within a week after surgery, patients typically are able to lift their leg without assistance while lying on their back. However, you should walk with crutches for up to eight weeks. Putting weight on your knee while it is healing may dislodge the transplanted cartilage.

   As soon as possible after surgery, you should begin doing exercises using a continuous passive motion (CPM) machine while in bed. Your doctor can arrange to get you a CPM machine for use at home, which helps flex and extend the leg and prevents the joint from becoming stiff due to inactivity.

   For two or three weeks after surgery, you may experience night sweats and a fever of up to 101. Your physician may suggest acetaminophen, coughing, and deep breathing to get over this. This is common and should not alarm you.

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After up to eight weeks on crutches, physicians generally suggest that you progress through rehabilitation slowly. The transplanted cartilage plug needs to stay intact. Too much movement after surgery may hinder the healing process. Your physical therapist can help you learn the proper combination of rest, gentle movement to stimulate blood flow and healing, and light exercises. It is important not to twist or bend in ways that may grind cartilage together until your physician is certain the osteochondral defect has healed. After the osteochondral defect has healed, physical therapy generally helps return healthy young athletes to sports at full strength. Arthritis may complicate the rehab process, especially for older athletes, but the physical therapy program generally recommended by physicians can be broken into three basic phases for everyone.

NON WEIGHT BEARING - SIX TO EIGHT WEEKS

Let the osteochondral defect heal. To restore movement and basic coordination, your physical therapist will help you begin moving your knee and teach you an exercise program to perform on your own.

RESTORING RANGE OF MOTION - TWO TO FIVE MONTHS

Rehab progresses into stretching and strengthening exercises that focus on the quadriceps and hamstrings - the main stabilizing muscles for your knee. Physicians suggest you gradually increase the amount of weight as your leg muscles get stronger. Strengthening exercises require dedication because results often take weeks and pain may recur.

RETURNING TO ACTIVITIES -SIX TO NINE MONTHS

The focus of rehab turns to increasing your coordination. After a few months of rehab, physical therapy can become activity oriented as you regain the ability to perform complicated movements, using stationary bikes, elliptical machines, and cross-country skiing machines. Once the muscles of your injured leg are about 90 percent as strong as the uninjured leg, you can usually return to activities.

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   Knee strengthening exercises: Cartilage injuries

Physicians generally suggests you continue strength training even after your knee has been rehabilitated. Adequate leg muscle strength is the best way to keep the bones in your knees from grinding into each other and prevent recurrence of osteochondral defect. Physicians usually suggest that you continue strength training even after your knee has been rehabilitated. Have your physician periodically check your knee. Weight control is also important. One extra pound of body weight translates into three or four pounds of weight across your knee every time you take a step. Lightening the load on your knees helps them to last longer. After an osteochondral defect, you may be at risk of suffering arthritis later in life. Depending on how well your knee heals, you may want to consider cutting back or avoiding repetitive-impact activities, like long-distance running, and contact sports, like football. Many of the exercises and activities that are popular for fitness put stress on your knees. To prevent osteochondral defects it is important to learn knee-sparing exercise techniques by dividing your activities into three components.

   Daily living - The average person takes between 12,000 and 15,000 steps a day, with each step exerting a force between two and five times your body weight on your knees. After a knee injury, take it easy on your knees during the day whenever possible to save them for activities and exercise. Avoid stairs when there is an elevator, take the shortest path when walking, and consider wearing athletic shoes designed to absorb shock rather than hard-soled shoes.

   Muscle strengthening and conditioning - Activities themselves are not a substitute for conditioning. Your need for special conditioning to prepare for activities increases with age. The best strengthening programs are low-impact and non-weight-bearing, like stationary bikes and certain weightlifting programs, so that the knees do not have to absorb shock.

   Recreation - Sports that require twisting and quick direction changes put great strain on your knee. To prevent injury, stick to light, non-impact activities for your recreation after arthroscopic fragment fixation. If you decide to return to sports like football and basketball, a physician should carefully examine your knee to make sure you have a proper coating of cartilage over your bones.

If pain recurs after rehab, physicians usually suggest you stop your activities and return for a check-up. Pain could be a sign that the fragment has not healed properly. Large osteochondral defects may make it difficult for some people to return to competitive athletic activity.