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Femoral trochlea chondral lesion- Chondrogide membrane(Geistlich pharma) for chondral regeneration

    Overview

    Learn the Femoral trochlea chondral lesion: Chondrogide membrane(Geistlich pharma) for chondral regeneration surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Femoral trochlea chondral lesion: Chondrogide membrane(Geistlich pharma) for chondral regeneration surgical procedure.
    Chondral regenerative techniques have been used for many years, but due to the problems in funding for autologous chondrocyte implantation techniques, the non-cell-based techniques using membranes are gaining popularity for the treatment of focal articular defects. In distinction to focal resurfacing there is a slower recovery and some post-operative restrictions are required, but the potential of biological reconstruction without removing any native joint is appealing in the younger population. These biological reconstruction techniques usually require a period of reduced weightbearing up to 2 months and often a restricted range of movement range using a brace. The chondral membrane techniques may be used as isolated chondral surface regenerates or they may be combined with stimulation techniques which breach the subchondral bone. Similarly the chondral membrane techniques may be combined with bone grafting (autologous or allograft which is my preference) or for some surgeons synthetic bone graft substitute to reconstruct a bone void beneath a chondral lesion.
    The classic patient for biological reconstruction is in the 18-50 age range with a focal chondral lesion which is symptomatic and has failed traditional non-operative treatments such as offloader bracing and injection therapies such as visco-supplementation. Steroid injection is controversial for these patients as there may be some symptomatic relief, but likely damage to the good native chondral surface and therefore this is not part of my standard practice for young chondral damage patients.
    Please remember to check alignment as osteotomy is an excellent proven treatment for the malaligned overloaded joint. Chondral regenerative techniques will not work in mechanically overloaded joints without osteotomy, which is a principle this applies in the tibiofemoral as well as the patella-femoral joints which are covered on OrthOracle at Patella stabilisation : Tibial tubercle osteotomy and Medial patellofemoral ligament reconstruction.
    Chondrogide is a Porcine Collagen type I/III matrix produced by Giestlich. It has been used clinically for over 15 years with a metanalysis from 2019 demonstrating its clinical efficacy in the knee with benefit maintained for at least 5 years in a population of 20-50 year old patients.
    Steinwachs MR, Gille J, Volz M, Anders S, Jakob R, De Girolamo L, Volpi P, Schiavone-Panni A, Scheffler S, Reiss E, Wittmann U. Systematic Review and Meta-Analysis of the Clinical Evidence on the Use of Autologous Matrix-Induced Chondrogenesis in the Knee. Cartilage. 2019 Sep 11:1947603519870846. doi: 10.1177/1947603519870846. Epub ahead of print. PMID: 31508990.
    The Chondrogide membranes are available in 3 sizes and are sold with a sterile aluminium foil template for ease of measuring the chondral defect.
    Readers will also find of interest the following OrthOracle techniques:
    Medial Femoral Condyle Focal Resurfacing with HemiCAP(Arthrosurface)
    Knee arthroscopy and microfracture of osteochondral defect
    Stem cell harvest and transplant for knee osteochondral defect (Synergy Medical technologies)
    HAMIC and Medial malleolar osteotomy for Osteochondral defect of talus, using Chondrotissue by Biofuse.



    Indications

    INDICATIONS
    Unstable, painful chondral or osteochondral defects grade III or IV in any compartment of the knee, with either correct or corrected alignment. The size of the defect is still debated although in the largest metanalysis the mean size was 4.24 cm2 (0.8-22 cm2). Remember that with surface membrane techniques there may be a need to bone graft (auto / allograft or synthetic) to reconstruct any bone loss beneath the chondral lesion. Other membrane-based chondral regenerative techniques include, ChondroTissue, Synergy Medical or MaioReg to name 3 examples of which two (ChondroTissue and Synergy Medical are available to view on Orthoracle).
    In this case there was no bone loss and so there was no need for subchondral bone grafting.
    The defect should be unifocal, in other words it should only be on one side of the joint. Chondral regeneration is therefore not for ‘arthritis’ where there is joint failure on both sides of the joint.
    In the young patient I would always try a biological reconstruction first rather than a focal resurfacing. Historically microfracture or drilling has been performed although this is questioned now due to the risk of intra-lesional osteophytes and a poorer outcome with subsequent chondral regenerative techniques following microfracture. Microfracture is often combined with the use of a matrix or scaffold in the technique known as AMIC (autologous matrix induced chondrogenesis) In the metaanalysis listed above approximately 1% of patients with a symptomatic intra-lesional osteophyte following AMIC requiring further surgery.
    Consequently there has been a resurgence of drilling and abrasion techniques (using a burr) and a less invasive microfracture technique called nano-fracture which requires a very simple aiming device with a central cannula for a small bore wire which penetrates the subchondral bone; hopefully this will have less side effects than microfracture.
    The problem though with any regenerative technique is the more involved rehab process than with focal resurfacing and this needs to be balanced with preservation of the joint in the young patient. Perhaps in the middle-aged population, focal resurfacing Medial Femoral Condyle Focal Resurfacing with HemiCAP(Arthrosurface) allows a clearer and simpler recovery pathway. However in the young patient biological reconstruction should be the first step for symptomatic lesions, but remember that focal resurfacing can be used as the salvage should this not work.
    SYMPTOMS & EXAMINATION
    Symptoms:
    Localised pain over the affected compartment. Sometimes the patient is able to locate the site of pain with one finger eg for the medial side of the knee. However if the patient is experiencing lateral femoral condylar damage then this pain and tenderness will be on the lateral side. Remember that for patellofemoral cases the pain is located anteriorly.
    In this case symptoms of anterolateral pain were found
    Stiffness
    Examination:
    Tenderness in the superolateral knee around the lateral Patellofemoral joint line. Remember that for medial or lateral tibiofemoral disease the relevant compartment and not the superolateral knee will be tender; the rest of this examination is relevant to the superolateral chondral lesion present in this case
    Pain on loading the patella in valgus at 20 degrees of flexion.
    No pain in the medial or lateral tibiofemoral joints on varo-valgus loading. If there was tenderness in the medial & lateral tibiofemoral joints or pain on loading in varus/valgus then there must be a significant concern that there will be degenerative change in those joints too. Such a picture points to ‘arthritis’ or joint failure rather than an isolated chondral or osteochondral lesion amenable to ChondroGide or other chondral membrane technique. However in the very young patient it may be possible to combine treatments in multiple compartments, with a reserve procedure of TKA.
    Intact ACL – or reconstructed ACL. It is very reasonable to combine an ACLR with chondral membrane technique – in fact there may be biological benefits from the ACLR analogous to the improved healing of meniscal repair with concomitant ACLR.
    Normal patella height and tracking. If this is abnormal then a realignment is necessary. Please see the OO technique on TTO listed above.
    IMAGING
    AP weight bearing– ideally long leg alignment views to define alignment and to exclude ‘arthritis’ – in other words we do not want to try and reconstruct the joint surface in a joint that has failed, rather we want to treat isolated chondral or osteochondral trauma, or consider biological techniques on the failing joint surface with appropriate realignment.
    Weight-bearing lateral – is there full thickness joint space loss? If the answer is yes then that is beyond chondral grafting.
    Skyline patella view – is there full thickness joint space loss? If the answer is yes then that is beyond chondral grafting.
    Rosenburg (PA flexion at 45)– this really stresses the lateral tibio-femoral compartment. If there is any suggestion of lateral wear then a stress XR should be performed with values to check the state of the Lateral TF joint under increased load.
    If the patellofemoral joint has failed on both sides of the joint then chondral regeneration is probably not the correct strategy unless the patient is very young and the risk of salvage to PFJ arthroplasty is accepted. The Journey and Avon PFJ Arthroplasty techniques are also covered on OrthOracle:
    Patello-femoral replacement: Avon implant (Stryker)
    Patello-femoral replacement: Smith and Nephew Journey implant
    MRI
    All patients will have an MRI. Whilst MRI is the most objective modality of imaging the chondral surfaces (& excluding degenerative change of note), the sensitivity of this for chondral defects depends on the strength of the magnet and sequencing protocol; 1.5T is the current standard, but this is by no means perfect and all my cases are warned of the small chance of intra-operative conversion to a partial knee replacement with a PFJA if I find bifocal defects in an appropriately aged and consented patient.
    There is no widely accepted classification system for MRI grading of osteochondral lesions and the ones that are used vary according to the aetiology. Osteochondral defects are conventionally described using the International Cartilage Repair Society score, with a higher score correlating with worse prognosis. It was however designed for arthroscopic assessment and not MRI. Grade 0 is normal cartilage, grade 1 is soft (1a) or demonstrates superficial fissures and cracks (1b); grade 2 has defects less than 50% of the cartilage depth; grade 3 has defects greater than 50%, and this is further classified into a, b, c and d. Grade 4 is severely abnormal bone with penetration through the subchondral bone. More recently an AMADEUS (Area Measurement And DEpth & Underlying Structures) scoring system has been designed as an MRI score and classification system (Jungmann et al, Cartilage 2017) but it is not in common use.
    ALTERNATIVE OPERATIVE TREATMENT
    Arthroscopic Chondroplasty to remove unstable margins from the cartilage lesion. In full thickness disease, drilling and nano- or micro-fracture are still performed although there is debate regarding microfracture in particular.
    Autologous Chondrocyte Implantation – ACI or Matrix induced chondrocyte implantation – MACI. There is certainly evidence for this technology, but due to delays in approvals of ACI/MACI in the UK, many of the companies providing this technology have withdrawn from the UK. Spherox is the only commercially available MACI technique available in the UK and this is an injectable therapy relying on the chondrocytes being carried on biospheres.
    Focal resurfacing – generally in older populations.
    Osteotomy – if the Patellofemoral joint is not tracking appropriately then tubercle osteotomy surgery should be encouraged if alignment is abnormal.
    Joint Arthroplasty – Partial or Total Knee Replacement.
    NON-OPERATIVE MANAGEMENT
    Lifestyle modifications
    Analgesia
    Bracing – lateral PFJ offloader braces which push the patella medially.
    Injection therapy – steroid for inflammation, or viscosupplementation for stiffness and pain. Platelet Rich Plasma Injections such as N-Stride from Zimmer Biomet.
    CONTRAINDICATIONS
    Absolute
    Active infection
    Active inflammatory arthritis in the same joint
    Untreated and symptomatic ligament laxity – eg MPFL laxity and PFJ instability
    Relative
    Inflammatory arthritis in other joints
    ACL damage
    Significant loss of range of movement – restoring the joint surface will not improve range.

    Setup

    Two main operative setups are used for chondral grafting with a scaffold such as ChondroGide;
    Leg holder – the operative thigh is held on or in a leg holder such that the knee can flex freely and hang dependently under gravity. The surgeon may sit or stand. If a sitting style is chosen consider a surgical stool whose height may be altered with a foot pedal intra-operatively by the surgeon
    As a standard TKR position with side support and foot roll. Surgeon standing. This is my chosen set-up for this operation.
    Tourniquet
    Where a surgeon chooses to use a tourniquet this should be applied at the start of the operation high on the thigh before skin preparation.
    My personal choice is to avoid the tourniquet and so attention must be paid to haemostasis during the procedure. Simple techniques such as raising the feet off the operating table and instillation of local anaesthetic with adrenaline at the start of procedure are sensible. Avoid over-tightening drapes around the knee as this creates a venous tourniquet inadvertently.
    Drugs
    Intravenous prophylactic antibiotics should be administered early (30-45 minutes) to achieve adequate tissue concentrations at the time of ‘knife to skin’. We use Cetriaxone as a one-off dose.
    Intravenous tranexamic acid on induction – 1000mg.
    If the wound is oozing then this induction dose can be repeated on closure.

    Operation – 1

    Preoperative axial T2 MRI scan revealed a full thickness lesion in the lateral trochlea measuring 18mm x 11mm.
    1 = normal lateral trochlea chondral surface
    2 = full thickness loss of the more lateral trochlea chondral surface but there is some cartilage lateral to this lesion – in other words it is encircled by healthy chondral tissue.

    Saggital T2 MRI with a full thickness lesion in the lateral trochlea marked ‘1’.
    From the previous axial and this saggital the lesion measured 18 x 11mm.

    Setup and prepare as if performing an ACL Reconstruction, Tibial Tubercle Osteotomy, Medial Partial Knee or Patellofemoral Replacement.1 = Surgial marker pen highlighting the medial border of the patella and patella tendon
    2 = Surgial marker pen highlighting the lateral edge of the tibial tuberosity.
    The leg, and knee in particular, is freely accessible by preparing the whole lower limb. I have used a thigh and foot support. Alternatively a thigh holder may be used as I do for my partial knee arthroplasties (PKAs).
    The anteromedial incision ‘1’ and the standard incision for a Tibial tubercle osteotomy ‘2’ are marked on the image for teaching purposes.
    In this case due to the combination of surgery, a single incision was used combining lines ‘1’ and ‘2’ into a single oblique incision.
    The setup is as a TKR, but I have used an arthroscopic drape.
    I have documented my setup and preparation on multiple Orthoracle techniques such as:
    https://www.orthoracle.com/library/total-knee-repla…smith-and-nephew/

    Local Infiltration Anaesthesia using a long needle; a grey (16G) venflon needle with both screw cap and adaptor removed makes a good, cheap and long needle for this purpose. REMEMBER TO ASPIRATE AND TELL THE ANAESTHETIST BEFORE INFILTRATING.
    I use a cocktail of 150ml of 0.1% Marcain with 0.6mg Adrenaline, 30mg Ketorolac and 10mg Morphine.
    The Ketorolac and Morphine are placed in one of the three 50ml syringes.
    Syringe 1. Skin – infiltrated at the start of the procedure.
    Syringe 2. Periosteal and capsule – instilled after preparation
    Syringe 3 (Morphine and Ketorolac) – instilled deep into the posterior capsule – it is vital to aspirate and I suggest moving the needle 4 times to guard against intravascular infiltration.

    Now is the time to perform an arthroscopic assessment and treatment for any other lesions, depending on the case.
    The arthroscopic image from superolateral portal demonstrates the lateral full thickness chondral lesion. For orientation purposes I have annotated the image:
    1 = distal
    2 = medial – healthy, white choral surface of the trochlea
    3 = lateral – there is a small but healthy rim of chondral surface around this lesion.
    4 = proximal
    5 = residual damaged chondral surface over subchondral bone
    6 = subchondral bone.

    The incision is made, with caution in the distal end not to damage the patella tendon. By making an oblique incision an excellent view of the joint is established with a limited skin incision. In this case the incision is much longer than normal for a trochlea ChondroGide as a TTO is also being performed. I have incised from the superior medial border of the patella to the lateral edge of the tibial tubercle.
    For detailed instruction on this approach please view the following OrthOracle techniques:
    Medial Femoral Condyle Focal Resurfacing with HemiCAP(Arthrosurface)
    Patella stabilisation : Tibial tubercle osteotomy and Medial patellofemoral ligament reconstruction


    Thick skin flaps are developed from the patella (1) down to the tibial tuberosity (3). As an arthroscopy was performed in this particular case, I have highlighted the anterolateral portal (2) with a pair of forceps so that the arthrotomy includes the portal. The incision is made, with caution in the distal end not to damage the patella tendon. By making an oblique incision an excellent view of the joint is established with a limited skin incision.
    The thick skin flaps minimise the risk of wound necrosis.

    Make your normal arthrotomy – medial paraptella, medial subvastus or lateral approaches are all reasonable, but it is sensible to stay with your normal approach
    I perform a mini-medial subvastus approach as documented in my PPK medial partial knee replacement technique on Orthoracle.
    Cut down to capsule straight away and then lift the skin off the capsule a little way to the medial and lateral.
    Caution needs to be excercised at the distal end in looking for infra-patella branches of the saphenous nerve. These are often not seen but being aware of them will reduce the risk of inadvertent dissection or suturing into the wound upon closure risking neuroma formation.
    Identify the vastus medalis obliquus (VMO) and perform an arthrotomy paramedially from the tibial tubercle to the superomedial corner of the patella and then continue in the manner of a mini-subvastus, incising approximately 2cm along the VMO / capsule junction.
    This achieves excellent visualisation of the medial condyle and reduces the chance of the lateral skin flap and patella tendon

    I have placed two retractors inside the skin and muscle/capsule layer to expose the knee. The first retractor is placed laterally under the extensor mechanism and resting on the lateral (non-articular) femoral condyle. The second retractor is placed medially resting on the medial (non-articular) Medial femoral condyle.
    The assistant stands at the head end proximally and retracts with two Hohman’s placed lateral (1) and medial (2) to the femoral condyles prior to exposing the trochlea fully.

    The trochlea (1) is now visible but not well exposed. I will release the fat pad, simply by incising down the medial side to allow the fat pad to travel laterally with the extensor mechanism which is subluxed. In knee arthroplasty exposure I resect the fat pad, but in joint preservation I prefer to preserve as much as possible!
    This exposes the trochlea and then move the Hohman’s laterally and use a Langenbeck medially to improve visualisation of the trochlea lesions in the next slide.

    The Trochlea lesions are identified (1 & 2) – as expected from the preoperative MRI. For orientation:
    3 = patella
    4 = patela tendon
    5 = fat pad
    At this stage once the decision is confirmed to proceed to Chondrogide patching then the Tisseal Glue should be defrosted and opened. Reasons to abandon would be too large an area (over 6 square centimetres) or wear on the chondral surface of the patella.
    If there is a bone cyst or subchondral collapse then bone grafting should be performed. This is usually known for the preoperative MRI however.


    The lateral trochlea chondral lesion (1) has been highlighted here. Check that the surrounding cartilage is stable and healthy. If there is healthy cartilage lifting up then a Tisseal glue can be used to secure this. Alternatively if the cartilage is not healthy it should be removed.

    The first template is in place (1) and the 2nd template (2) is on my finger prior to introduction onto the central trochlea lesion.
    The templates should fit inside the chondral lesions as when the proper ChodroGide is cut and then implanted, the membrane swells as little – approximately 10%.

    Prepare the margins of the defect to create square shoulders – at 90 degrees to the joint surface.It is important not to undercut of chamfer the edges as this damages the potential for support and nutrition of the adjacent articular cartilage. I use a fresh Number 15 knife blade for this step.

    Work around the whole lesion with the 15 blade – again being cautious not to undercut – keep at 90 degrees to the joint surface.

    The base of this lesion is cleaned to bare bone using a small currette (1).

    Options for Nano-fracture, burring, drilling or microfracture then exist. Notice how the chondral defect is ‘clean cut’ now and the base is clear from any debris – 1.
    In general my preference is for burring if the subchondral plate is thickened, or drilling with a small diameter drill 1.0 to 1.5mm. Where I have a Nano-fracture kit available this is a good alternative.
    The traditional microfracture technique has been criticised because of the formation of intra-lesional osteophytes and for short-lived results.

    Once the first lesion of the trochlea (1) is prepared the second (2) is exposed by the Langenbeck and the process of cleaning the margin and the base repeated.

    The base of the defect is burred with a 5mm high speed burr (1) to remove some of the thickened subchondral bone – I aim for punctate bleeding.
    The amount of bone to be removed is controversial, but I aim for restoring normal subchondral thickness – this can be appreciated on the MRI scans and comparing the lesion subchondral bone with the healthy surrounding areas’ subchondral bone plates.

    Notice how the base of the lateral trochlea lesion is now bleeding (1).

    The trochlea lesion is templated using the aluminium template, which comes as a separate sterile item in the ChondroGide packaging.
    Here I am cutting the template (1) to the shape of the lateral trochlea lesion.

    The cut template is placed into the lateral trochlea lesion (1) and any fine trimming adjustments made – removing any prominent Aluminium with scissors so that the template accurately matches the defect.
    There are no particular shapes that are required – simply match the defect with your template cutting.

    Both templates are now in place (1 and 2).

    Place the template onto the Chondrogide membrane. It is sensible to change gloves before this step – partly this minimises infection risk, but practically any moisture will reduce the handling ability of the Chondrogide – when the membrane is wet it becomes soft and like tissue, whereas when it is dry the membrane is much easier to cut.

    Cut the Chondrogide to match the template – remember that the Chondrogide will swell with fluid ingress to approximately 10% extra, so it is worth slightly undercutting the graft membrane to allow for this expansion; otherwise there may be some undulation in the Chondrogide rather than it sitting flat on the bone base.

    Operation – 2

    Now it is time to introduce the Chondrogide membrane. It is important to check for any prominences that need fine tuning as the graft may catch during cycling of the patellofemoral joint.
    I find introduction easiest using my finger. Here I have a clean (dry) pair of gloves on and the cut Chondrogide (1) is facing smooth side down to my finger and roughened surface away from my finger.
    Therefore when the ChondroGide is introduced the roughened surface

    The Chondrogide membrane is placed into the defect to ensure a good fit – ideal is 1-2mm smaller than the defect.Any adjustment should be made to the Membrane to achieve a good fit – any prominence from the membrane risks being caught during cycling of the patellofemoral joint.
    In this case the ChodroGide patches 1 and 2 are fitting well with no puckering suggesting that they are too big.

    The Tisseal Glue is then warmed in a bath of warm Saline.
    Some surgeons like to place the Tisseal underneath and above the graft membrane. I do this if the initial position check is not completely stable, but for most grafting I simply apply the Tisseal on the joint surface of the Chondrogide patch.

    The correctly shaped Chondrogide patches are laid down onto the bare bone defects.

    Here I have dry arthroscoped the knee to show the two ChodroGide patches in place (1 and 2) within the trochlea as I cycle the knee the membranes were stable.
    Had I not had an arthroscope available this step can simply be done ‘closed’. The patella is allowed to sit back into the trochlea by removing the Hohman retractors and then the knee is cycled 10-20 times. The patella is then subluxed by replacing the Hohman retractors to regain the view of the trochlea, to ensure that the ChondroGide patches (1 and 2) are still in place.


    The retractors are replaced and the ChondroGide membranes 1&2 exposed and ready for fixation with Tisseal Glue.

    The Tisseal Glue is then prepared. Remember that if the nozzle needle of the Tisseal blocks there are 3 spares supplied so a simple change of nozzle is all that is required. It is rare that this nozzle block on the first application with one patch, but if multiple patches are being applied this can be useful.

    The Tisseal Glue is then gently delivered to the end of the nozzle, by applying pressure on the red syringe, so that the Tisseal is ready for careful application.

    The Tisseal Glue is then placed around the edges of the Chondrogide overlapping the native cartilage by approximately 2mm. Remember that if the nozzle needle of the Tisseal blocks there are 3 spares supplied so a simple change of nozzle is all that is required. It is rare that this nozzle block on the first application with one patch, but if multiple patches are being applied this can be useful.

    Allow the Tisseal to dry. This takes approximately 5 minutes. Then cycle the patellofemoral joint to ensure there is no catching or lifting of the ChondroGide patches (1&2).
    If this is the case then some more Tisseal should be used, or the proud edge of graft removed with a fresh 15mm blade, prior to adding further Tisseal to the margin between patch and native chondral surface.

    If more Tisseal Glue is required at this stage – remember to change the nozzle (1) as the tip of this (2) often becomes blocked with dried Tisseal.

    Additional Tisseal was placed over the central trochlea lesion, now covered with ChodroGide – marked 1 on this image. I will usually cover the whole ChodroGide with Tisseal.
    If the defect is very deep – such as in the patella cartilage – a double graft layer of ChondroGide may be used, but this was not required in this case in the Trochlea – even with the burring down to bleeding bone.

    A further cycling of the knee is then performed – this is the final check before closing and represents the last change for additional fixation should any margins be loose.

    I use a barbed number 1 monofilament absorbable suture to close the capsule.
    This suture has a double needle although there are alternative barbed sutures with single needle and a tab to pull against to save time in closure and avoid knots, thus minimising the amount of suture needing to absorb.
    I start centrally at the apex of the mini-subvastus approach – the superomedial part of the patella and travel distally with one needle and medially with the second needle. At the MPFL region I reverse the direction of travel and complete a 2nd layer capsular closure from proximal to distal.

    Deep dermis – interrupted 0-Vicryl then continuous 2-0 absorbable suture such as Vicryl.
    Wash the wound with 0.05% aqueous chlorhexidine.

    Please continue to wash with 0.05% Chlorhexidine solution but make sure this is AFTER the capsule has been closed – there is a risk of chondrotoxicity with Chlorhexidine which would be completely counter-productive for a chondral regenerative procedure.

    A continuous 2-0 suture is run in the deep dermis to create excellent opposition – I like to do this in flexion to minimise the risk of over constriction.

    Skin – subcuticular undyed absorbable barbed 2-0 monofilament is my personal preference – here I am using Stratafix 3-0 with a double needle starting in the centre of the wound and moving distal and proximally.

    Once the proximal and distal ends have been reached I return approximately 2-3 cm so that I ‘double close’ the subcuticular layer. With this double needle it allows the surgeon and assistant to be working together – notice the two forceps and two needle holders.


    Skin glue – application of this with the skin wet makes the glue cure much quicker.

    When the glue is dry…..the wound is ready for steristrips.

    Steristrips crossed so that they sit within the non-adherent part of the occlusive dressing and remove all together at the 2 week stage.

    Clear occlusive, showerproof dressing.
    Wool and Crepe initially, which is then reduced and a tubigrip applied before discharge.
    Alternatively Cryotherapy sleeves may be used at this stage.

    Post Operative

    Antibiotics: 24 hours prophylaxis – we use Ceftriaxone on induction so no further doses are required.
    Hospital Stay: day case or occasionally overnight surgery if there is a long travel time back to the patient’s home.
    Weight Bearing: reduced weight bearing – I suggest 1 month of touch weight bearing for tibiofemoral lesions, but for the PFJ the key is avoiding deep flexion. I therefore use partial weight bearing for 1 month with a range of movement brace restricting flexion 0-60 for 4 weeks and then 0-90 up to 8 weeks.
    Bloods: not required.
    Radiograph: not required.
    Dressing: Bulky wool compression bandage reduced at 6 hours and occlusive dressing left in situ for 2 weeks, ideally undisturbed from theatre, but changed on the rare occasions that the wound leaks.
    Venous thromboembolism prophylaxis: Aspirin 150mg for 6 weeks orally for standard risk. Patients with previous VTE receive 10 days of low molecular weight heparin (LMWH) in addition to their Aspirin. Patients on prophylactic long term anticoagulants including NOACs should simply return to their normal medication on day 2, using LMWH at prophylactic dose on day 1.
    Follow-up – depending on the patient’s functional ability we usually ask them to remove their own dressing at 2 weeks, but where this is impractical we review in our outpatient department at 2 weeks. Subsequent review is scheduled as: 6-8 weeks, 12 months, 2 years
    Variance – Any concerns with the wound should trigger a review by the treating surgical team and must not be managed in the community.

    Recommended Reading

    There is undoubtedly improvement in function with AMIC and chondrogide as evidenced in this systematic review incorporating 12 studies of 375 patients with a mean age of 36. There was a statistical improvement from baseline to 1 or 2 years and this was maintained at >3years, when looking at visual analogue score (VAS) for pain, Lysholm or IKDC scores.
    Steinwachs MR, Gille J, Volz M, Anders S, Jakob R, De Girolamo L, Volpi P, Schiavone-Panni A, Scheffler S, Reiss E, Wittmann U. Systematic Review and Meta-Analysis of the Clinical Evidence on the Use of Autologous Matrix-Induced Chondrogenesis in the Knee. Cartilage. 2019 Sep 11:1947603519870846. doi: 10.1177/1947603519870846. Epub ahead of print. PMID: 31508990.
    Combination techniques with Chondrogide and cell-biology manipulation of bone-marrow derived stem cells shows promise:
    Mardones R, Giai Via A, Pipino G, Jofre CM, Muñoz S, Narvaez E, Maffulli N. BM-MSCs differentiated to chondrocytes for treatment of full-thickness cartilage defect of the knee. J Orthop Surg Res. 2020 Oct 6;15(1):455. doi: 10.1186/s13018-020-01852-x. PMID: 33023626; PMCID: PMC7539404.
    7 year results using AMIC with Chondrogide were reported by Justus Gille in a large series (131 patients) demonstrating good results
    Gille J, Reiss E, Freitag M, Schagemann J, Steinwachs M, Piontek T, Reiss E. Autologous Matrix-Induced Chondrogenesis for Treatment of Focal Cartilage Defects in the Knee: A Follow-up Study. Orthop J Sports Med. 2021 Feb 26;9(2):2325967120981872. doi: 10.1177/2325967120981872. PMID: 33738308; PMCID: PMC7934047.
    Long-term results with Bone-marrow stimulated HA membranes are positive. In this 2019 paper the mean 8 year (6-10y) follow up of large chondral defects (mean 6.5 cm2 range, 2-27 cm2) yielded significant improvement in Visual Analogue Pain (VAS) scores as well as improvement in Tegner Level and IKDC scores.
    Gobbi A, Whyte GP. Long-term Clinical Outcomes of One-Stage Cartilage Repair in the Knee With Hyaluronic Acid-Based Scaffold Embedded With Mesenchymal Stem Cells Sourced From Bone Marrow Aspirate Concentrate. Am J Sports Med. 2019 Jun;47(7):1621-1628. doi: 10.1177/0363546519845362. Epub 2019 May 16. PMID: 31095402.
    ChondroGide as a delivery for autologous chondrocytes dates back to 2004.
    Haddo O, Mahroof S, Higgs D, David L, Pringle J, Bayliss M, Cannon SR, Briggs TW. The use of chondrogide membrane in autologous chondrocyte implantation. Knee. 2004 Feb;11(1):51-5. doi: 10.1016/S0968-0160(03)00041-3. PMID: 14967329.
    One of the best summaries for the benefit for autologous cell implantation over microfracture comes from the Summit trial which is included as one of the 4 RCTs assessed in this review showing good cost effectiveness for ACI or MACI. These treatments however are still hard to access in the UK.
    Mistry H, Connock M, Pink J, Shyangdan D, Clar C, Royle P, Court R, Biant LC, Metcalfe A, Waugh N. Autologous chondrocyte implantation in the knee: systematic review and economic evaluation. Health Technol Assess. 2017 Feb;21(6):1-294. doi: 10.3310/hta21060. PMID: 28244303; PMCID: PMC5346885.

    Reference

    • orthoracle.com

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