John Campbell, MD, Orthopedic Surgeon who specializes in foot and ankle surgery at the Institute for Foot and Ankle Reconstruction at Mercy, Baltimore talks about using cartilage from cadavers and combining it with patient cells to treat patients with cartilage lesions in the ankle or knee.
Interview conducted by Ivanhoe Broadcast News in January 2018.
Can you tell me about the Arthrex, the BioCartilage? Can you tell me a little bit about it, what it’s used for, and what kind of injury especially in the ankle?
Dr. Campbell: Cartilage is the smooth surface on the ends of our bones that lets our joints move smoothly with very low friction. A lot of people, athletes in particular, can get injuries at the cartilage so they have a lot of joint pain, swelling and difficulty. There are some standard surgical techniques that sometimes people have heard of on public media and the sport page called the microfracture where you clean out that area or defect in the cartilage. It almost looks like a small pothole. You clean that out and then drill holes in the bone. The idea is the bleeding that will then fill that little hole can turn into sort of a scar tissue version of cartilage. That’s a pretty standard surgery that’s been around for a while and it works pretty well in a lot of patients. There are some people that it doesn’t work as well in and that tends to be people who have a much larger size pothole. The bigger the defect, the harder it is for that surgery to work. BioCartilage is taking it up a notch by trying to assist the healing with that type of surgery to patch a bigger hole. It’s a form of cartilage from cadavers that is processed and ground into a dust. It’s combined with cells from the patient, either from their peripheral blood or from their bone marrow. We can take some of their cells, concentrate it and mix it with this cartilage material and use that to patch the hole. That might give better odds for one of these larger lesions, or potholes, to fill in better while not having to go to a much larger surgery which is a lot more involved and invasive.
How long does it take to process this and can you also walk me through the steps that the patient would have to take to have this procedure done?
Dr. Campbell: The patient typically would present to us to find out why their ankle is bothering them. Things like: “I have trouble or pain when I’m running or playing sports.” “My ankle sometimes feels like it catches or locks, it may even buckle.” Many of our patients have been seen elsewhere and have tried physical therapy or a brace when they play sports, but they still have problems. When they’re evaluated, we typically get x-rays because we want to look at the state of the bones in the ankle. Many of them will even get either a CT scan or an MRI scan to get a better three dimensional view of what we’re dealing with. How big it is, where it’s located, is there anything else that’s injured at the same time that we need to address as well. When we get to a point where the patient is not progressing and they haven’t responded to a lot of these nonsurgical treatments, then we would start to entertain the possibility of surgery. This kind of surgery is typically outpatient or ambulatory, people don’t stay in the hospital afterward. The main technique or basis is arthroscopy with miniature cameras and video equipment to look in the joints to try to keep small incisions and minimally invasive because it makes it easier for the patient to heal. We start out by looking around; we get the lay of the land so to speak. We look for any other issues and we typically find this cartilage damage and then we start working on that. The surgery varies; it usually takes most people about an hour or two to get this done. Since it’s outpatient, they would be seen periodically back in the office a few weeks later to get stitches out. We try to get things moving relatively quickly, so after about two weeks they go into one of those removable boot braces, it looks like a removable cast. Then they can start doing some exercise to get things loosened up, try to get things moving so the ankle is not as stiff and weak. Then they slowly progress with putting weight. Usually most people recommend having the patient stay off the foot for about six weeks to allow that patch to start taking and healing and then slowly progressing.
You mentioned it’s a combination of donated cadaver cells plus the patient’s own cells. Can you talk to me a little bit about how that mix comes together? Is that something that’s done in the lab ahead of time?
Dr. Campbell: That’s a very good question. The answer is no, it’s done right during surgery. The material is like a dry powder and it encompasses all of the specialized proteins and things that are naturally in cartilage but it doesn’t have any cells in it. So we’re using the patient’s own cells to mix it together and it makes a pasty kind of material, so we can shape it and mold it. Think of it like patching a hole in your drywall while the material is liquid and soft. You can fit it in and then it hardens and dries, so it stays in the spot. This material is the same thing, we do it during surgery. We mix the two together and then we can use it, manipulate it, work it and smooth it out to get that nice smooth cartilage surface back by patching the hole.
You said it takes about six to eight weeks to start to fill in?
Dr. Campbell: We think so and that’s when we usually let the patient start to put some weight on it and slowly progress and work with physical therapy to get stronger and get mobility, balance, and strength back. It’s a little unclear and controversial as to when exactly they can go back to sports. A lot of surgeons tend to be a little conservative, trying to make sure things are healing appropriately. I usually tell my patients to expect at least six months before they can get back to running and jumping and high impact sports.
We’re talking about a cadaver involved and we talk donation. Is there a concern of rejection or anything from the tissue?
Dr. Campbell: That’s a very good question that a lot of patients have and the honest answer is not really. This is not donating an entire organ, like a kidney or lungs or things that are commonly done for transplantation. Those organs in their entirety have living cells that can cause the body to react to it which is what rejection is. People are typically on very powerful anti-rejection medications life-long. These types of materials that we use in orthopedics don’t have a lot of cells in them which is one of the key triggers for the rejection reaction, so these are well tolerated. For years, orthopedic surgeons have been using bone grafts and tissue like tendons and ligaments. It’s incredibly safe in terms of passing on any diseases or viruses and they don’t truly get rejected. Now I tell patients it’s not that your body rejects it, it may be more proper to think of it like, it just didn’t heal well and it just didn’t work well. It’s not the same as having a kidney transplant that the body rejects and having to have surgery all over again, it’s different.
Is this considered a middle step between the physical therapy and a more extensive surgery?
Dr. Campbell: Yes. Some of the bigger surgeries that are done for these kinds of cartilage lesions in the ankle or in the knee, which is another common place that this occurs, are a bit more invasive, they’re more involved. They often require taking a graft from the patient, like a cylinder of bone with cartilage on the surface, and then drill a hole in the ankle where the pothole is and plug a new graft in. That’s much more invasive and for us to get to the bone sometimes it means we may actually have to crack the ankle to get there. It’s almost like breaking your ankle to fix your ankle which is intimidating. That can have issues and that lengthens the recovery and the healing time. So that’s a reason people are excited with some of these newer techniques, to see if they can hold up and work as well or maybe even better than the older style techniques because they’re a lot less invasive and a lot less destructive to the joint.
Who would be a good candidate for this surgery and who should not consider something like this and look for something else?
Dr. Campbell: I think people who don’t have this surgery would be somebody who has a very straight forward simple case that’s very small and may not need that. They may do fine with just the routine standard surgery that’s been around for a long time. At the other end of the spectrum, people who have a massive defect or collapse in the cartilage in the bone within the ankle or within the knee, it’s almost like patching it and this may just not be enough anyway. That gets back to those bigger more invasive surgeries where it’s a big graft from the patient. Or if it’s an even bigger defect, then you may have to take a big chunk of a cadaver graft, like almost half of an ankle, to plug it in. If people have very advanced arthritis, if it’s not just one spot but it’s more throughout the entire ankle, we can’t really patch the whole thing. Then that starts getting into bigger surgeries that people are probably more familiar with in terms of ankle arthritis, like a fusion or an ankle replacement.
We’ve done some stories on NeoCart for the knee, is this similar?
Dr. Campbell: It may be a little. This is just one approach. There are other grafts or other materials that are along the same lines just with different materials. All of these are common or united in the sense of trying to do similar surgery or similar technique with less invasive or destructive methods than we’ve had available to us previously.
The Arthrex can also be used in the knee?
Dr. Campbell: Yes. It’s been used in a lot of different places in the body, but the ankle is probably one of the more common places along with the knee.
Is there anything I didn’t ask you that you would want people to know about this?
Dr. Campbell: The main issue from our standpoint is that we’re eager to see more research to tell us exactly how well this works. We also want to know the long-term effects. It may work great for the first couple years, but we want to know how it holds up over time and how it compares to some of the other alternatives. We want to know if one is better than the other. We don’t have a lot of that data and we’re hoping to have more information as time goes by
If this doesn’t work for a patient can they go to a larger surgery?
Dr. Campbell: Yes.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
If you would like more information, please contact:
Dan Collins
410-332-9714
Sign up for a free weekly e-mail on Medical Breakthroughs called
First to Know byclicking here.
