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Orthobiologics: A New Era for Articular Cartilage Surgery?

Bert R. Mandelbaum, MD, DHL (Hon)

Disclosures

March 18, 2016

Microfracture Augmentation Procedures

Treatments for articular cartilage problems have come a long way. As I outlined in my last column, not every knee with a cartilage injury should have surgery. And it's never the whole answer.

But for the right patient, surgery can make a huge difference, and the techniques we can offer are getting better, thanks to the availability of orthobiologics—cell-based therapies and biomaterials that promote healing, such as platelet-rich plasma, hyaluronic acid, and stem cells.

The choice of procedure depends a lot on the size of the lesion, the overall health of the knee meniscus, ligamentous integrity, and ligamentous alignment. For smaller cartilage lesions that don't extend to the bone, I have had good success with microfracture, a surgical technique used to repair damaged articular cartilage by making multiple small holes in the surface of the joint to stimulate a healing response.

This procedure has been around since the 1980s, and the short-term results can be very good. Over the years, it has allowed many athletes to return to sport. In the 2000s, we learned that the benefits wane after 2 years, perhaps because the newly generated fibrocartilaginous tissue has inferior biochemical and biomechanical properties compared with normal hyaline cartilage. As a result, the procedure has lost some of its allure.[1]

But in a modification, called microfracture augmentation procedures, or microfracture plus, we inject platelet-rich plasma, or scaffolds, into the microfractured defect. Scaffolds, which are thought to provide structural support and promote cell adhesion and migration during the repair process, include chitosan-glycerol phosphate blood implants or BioCartilage®, a cartilage extracellular matrix (Arthrex Inc; Naples, Florida). The platelet-rich plasma provides growth factors and other cytokines that stimulate healing of bone and cartilage. The scaffold helps the clot organize itself better and make a better, more hyaline surface.[1]

BioCartilage is cartilage from a young donor mixed with platelet-rich plasma. It becomes like putty, and you can use it to patch the cartilage defect. There have not been a lot of studies on the donor cartilage, but so far the results are good.[2]

I give platelet-rich plasma and other orthobiologics not just during the surgery but afterward as well. And this is a key point: We have to think of orthobiologics as something we use in preparation for surgery, during surgery, and then after surgery, all of which make them a supportive adjunct to improve regeneration of the cartilage. The outcomes reported by my patients have improved when I've used this approach.

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