Tissue Repair Techniques of the Future: Options for Articular Cartilage Injury

Vladimir Bobic, MD

Disclosures

Medscape Orthopaedics & Sports Medicine eJourn. 2000;4(1) 

In This Article

Introduction

Robert Goddard was not a happy man when he read his copy of The New York Times on January 13, 1920. Not long before, Goddard, a physics professor at Clark University in Worcester, Mass, had published an arid little paper on an outrageous topic, rocket travel. He, unlike most of his colleagues, believed rocketry was a viable technology, and his paper, primly titled "A Method of Reaching Extreme Altitudes," was designed to prove it. If you used his technology to build a rocket big enough, he argued, and if you primed it with fuel that was powerful enough, you just might be able to reach the moon with it.

When The Times saw his article, it pounced. As anyone knew, the paper explained with an editorial eye roll, space travel was impossible, since without atmosphere to push against, a rocket could not move so much as an inch! Professor Goddard, it was clear, lacked "the knowledge ladled out daily in high schools."

After Apollo 11 lifted off en route to humanity's first moon landing, The New York Times took a bemused backward glance at a tart little editorial it had published 49 years before. "Further investigation and experimentation," said the paper in 1969, "have confirmed the findings of Isaac Newton in the 17th century, and it is now definitely established that a rocket can function in a vacuum as well as in atmosphere. The Times regrets the error" (Time. March 29, 1999:99-102).

In 1895, top-flight scientist Lord Kelvin allegedly insisted that "heavier-than-air flying machines are impossible." Thomas J. Watson, former CEO of IBM, supposedly said in 1943, "I think there is a world market for maybe five computers." However, Ken Olson, founder of Digital Equipment Corporation, reportedly said, "There is no reason anyone would want a computer in their home." In 1949, Popular Mechanics made the accurate but limited prediction that "computers in the future may weight no more than 1.5 tons (Scientific American. 1999; 10(3):100).

Today, I am in the air some 33,000 feet above the Atlantic Ocean, flying from Manchester to New York, while reading the Scientific American "Your Bionic Future" issue, and editing this article on my ultraportable notebook computer. And, by the way, in 1999 we have four computers at home.

Although there is no scientific evidence that current surgical techniques of repairing hyaline articular cartilage defects are useful in the long run, we should remember that what may seem impossible now will almost certainly become possible and available in the not too distant future. We should not be dismissive of present attempts to repair cartilage. It is true that we are not doing terribly well at the moment and that our results are not exactly perfect. However, we should keep trying, and we should be far more critical and methodical in diagnosing chondral injury. We should try to understand the real meaning of articular cartilage injury and accept the fact that even as a superficial injury, fissures and delamination do have profound effects on the integrity and durability of articulating surfaces.

In 1743, Hunter stated: "From Hippocrates to the present age it is universally allowed that ulcerated cartilage is a troublesome thing and that when destroyed, it is not recovered." The inability of cartilage to repair itself after traumatic injuries and the incapacity of the treatment to stop further degenerative process, leading to osteoarthrosis, has been described repeatedly for at least 250 years. Historically, many scientists and clinicians attempted to develop clinically useful procedures to repair damaged articular cartilage, but these have not yet proved entirely successful. Treatment options are limited and the long-term outcome is still uncertain.

The multidisciplinary challenge to restore damaged articular surface has generated tremendous interest among research scientists, clinicians, and patients. Many new articular cartilage repair techniques have emerged in the past four to six years, most of which appear to be promising. Current state of the art of articular cartilage repair is the result of the increased awareness of the significance of articular cartilage damage, the explosive interest, the intense research, and rapid development of clinical applications. The final product is still in its infancy and far from being finished, but it is this systemic, sequential progression that will lead to future developments. At this rapid pace, further advances in articular cartilage research, leading to clinical application with reliable long-term outcome, are not far away. However, orthopaedic surgeons have enormous responsibilities in diagnosing and treating articular cartilage injury, and we should critically examine the limitations of what is available to us at present.

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