Articular Cartilage Injury in the Knee - David Menche, MD

Dr. Sechrest: Hello, I’m Dr. Randale Sechrest, your host for eOrthopod.TV. Today I’m back talking remotely with Dr. David Menche. Dr. Menche is an orthopaedic surgeon who practices in New York City. Dr. Menche did his medical school training at New York University. From there he completed a orthopaedic residency at the Hospital for Joint Diseases, and after that completed a fellowship in Gothenburg, Sweden with Dr. Lars Peterson. Thanks for joining us again, Dr. Menche.

Dr. Menche: Thank you, Dr. Sechrest. It’s good to be here.

Dr. Sechrest: Well, today what I thought we would cover is something that in the minds of patients, I think, is somewhat confused, and as we become more technically capable of beginning to do procedures on the articular surface of the knee, the articular cartilage as we would call it, I think that we’re beginning to get to the point where we need to distinguish for patients the difference in different types of cartilage tears. I think that you’ve mentioned in the past that patients will come to the office and will say, “I’ve injured a cartilage.” In the old days that normally meant to us and most patients that they had torn a meniscus or torn the little gasket type cartilages that are in the knee. Today more likely patients are coming in and talking about two different types of injuries. One is still that meniscal tear or the torn cartilage as it’s commonly called; but other patients are coming in and saying I’ve injured the articular surface of the joint, what’s called the articular cartilage – two very different substances, very different roles in the knee – and now, because we can begin to look at perhaps repairing or doing something to reduce the impact of an articular cartilage injury, we need to make sure what we’re really talking about. Sometimes those injuries can actually come together. You can tear a meniscus or tear one of the meniscal cartilages and at the same time, you can actually damage the joint surface of the knee or damage the articular surface. So I guess we ought to start this conversation out by talking a bit about the difference and defining for patients what we’re meaning as orthopaedic surgeons when we talk about the articular cartilage and when we’re talking about the old standby cartilage, the meniscal cartilage, so help us understand that.

Dr. Menche: So, yes, Dr. Sechrest. Basically there are two common cartilages within the knee which, as you very clearly stated, can be confused by patients. One is the meniscus cartilage, or the soft tissue shock absorbers that are within the knee, that’s a typical sort of sporting injury that patients get and typically when patients say they have a cartilage injury they are usually referring to this meniscus or shock absorber within the knee. On the other hand, there is also the articular cartilage or the joint surface which covers the bone. Normally, the bone is very rough. If that’s exposed there’s a lot of friction in the joint and the articular cartilage is the white surface that is actually covering the bone which lets the joint move without friction. The articular cartilage has no blood supply and therefore, once damaged, is relatively hard to treat. However, over the last two decades treatments have been formulated in order to treat this problem and get patients better. When a patient comes in it’s very important for the physician to be able to explain to the patient, if they have cartilage injury, is it a meniscus or shock absorber cartilage injury or is it an articular cartilage or joint surface injury? The prognosis and natural histories of these injuries are different as well as their treatment.

Dr. Sechrest: Let’s talk a little bit about the difference in terms of the injury itself. Is there a difference on how someone would injure their articular cartilage as opposed to how someone would perhaps tear a cartilage or injure a meniscus?

Dr. Menche: Well, you can injure the articular cartilage or the joint surface covering and the meniscus in similar types of injuries. It could be a sporting injury. Commonly, if one rips their anterior cruciate ligament they can have a meniscal injury and an articular cartilage injury. Articular cartilage injuries are also defined as traumatic but also you can get degenerative wearing down of the joint surface where the joint surface wears down to bone and that could be more of a wear and tear degenerative process rather than an acute traumatic process. So sometimes the injury mechanism could be the same but other times they could be different.

Dr. Sechrest: Now let’s talk a little bit about the symptoms and how a patient is going to present to you as an orthopaedic surgeon. What type of symptoms do both of these injuries cause? What’s the patient going to feel?

Dr. Menche: Many times in my experience the meniscal type of injury is more of a sharp pain and on the physical examination of that patient in the office, one could very commonly isolate joint line tenderness right where the meniscus anatomically lies and that is suggestive of a meniscus or shock absorber tear. Occasionally a patient can have sharp pain as well with articular cartilage injuries and pinpoint pain, but that’s going to be more again over the joint surface usually over the femoral condyles or the covering of the thigh bone in the knee joint. So locking, which I define as a mechanical situation where patients’ knees can get stuck usually with the inability to extend the knee, usually happens more with a displaced meniscus type of injury rather than an articular cartilage injury which will cause more of a patching where the patient feels that it’s getting stuck but they can still straighten out their knee.

Dr. Sechrest: I try to explain it to patients when we talk about locking because it’s such a core concept for us as orthopaedic surgeons but sometimes patients don’t really understand that. The way I try to explain it to them is it’s similar to when you’re closing a door, something gets caught in the door, in the hinge mechanism, you can see how you can’t completely close the door. For example, think of putting a pencil down where the door is closing where it attaches to the wall and then trying to close it. You just can’t close it. The pencil gets in the way and it stops that complete hinge movement. The same thing happens with the knee so that if the meniscus gets torn and then gets caught in that hinge mechanism it stops the knee from, like you say, normally going completely straight. But patients tend to know when that happens because it’s very difficult to straighten the knee and walk straight out on the knee; and normally, what I’ve found and if you agree, is that once that occurs they normally have some swelling in the knee, lots of pain when they try to put weight on it and it’s a pretty significant problem in the knee that brings them to the doctor pretty quickly.

Dr. Menche: Yes, in the acute situation then that’s absolutely true, but I’ve seen patients as well in a chronic situation and they’re walking on a bent knee, their knee could be swollen and they may not be in all that much pain. So when I ask that question of locking I’m basically asking that question and saying to them is the reason why you can’t straighten out your knee is because it hurts or just won’t go, and if the answer is that it just won’t go, that’s a great example with the doorstop, of something mechanically blocking it and not letting the knee fully straighten out. It just won’t go. Not necessarily because of pain because of the mechanical block.

Dr. Sechrest: Yes, I think that’s an important distinction. Now what about articular cartilage injuries. When we’re trying to really look at those patients and try to determine from a history a clinical examination whether they have had an articular cartilage injury or whether this is what’s causing their symptoms, what’s key for you? What are you looking for in that patient?

Dr. Menche: One, again, is their history and certainly their physical examination, but articular cartilage injuries can be tricky because sometimes you can’t pick up it on history and physical examination. MRIs are certainly getting a lot better but there are going to be occasions when one does an arthroscopy of the knee and was not fully expecting an articular cartilage injury and there is one that’s there. There are all different grades of articular cartilage injuries from very superficial injuries of this joint surface from injuries that go down to bone or into the bone; and depending upon the level of the injury, the diameter of the injury, and the patient’s symptoms, that’s going to dictate if treatments going to be instituted and what type of treatment that would be.

Dr. Sechrest: Well, let’s talk a little bit about when the patient does come into your office and you’re doing your examination, what types of studies are you going to order after you’ve gone through this history, gone through a physical examination, you’re suspicious – do you normally get x-rays at that point? Do you normally just go straight to an MRI scan? Are there any other imaging tests that you would recommend to use to try to distinguish whether the patient has an articular cartilage injury or has a meniscal tear or maybe something else going on in the knee?

Dr. Menche: I would routinely do x-rays and weight-bearing views to really see if there’s any joint space narrowing or arthritis in the knee. One of the general principles of treating articular cartilage injuries depends upon whether there is true arthritis in the knee or there is not. So getting a weight-bearing film is critical in the initial stages just for the physician’s knowledge and to be able to guide the patient as what is possible to do or not possible to do as far as treating that lesion. In addition, an MRI would be performed to look for a meniscus tear which, generally, an MRI is very good for meniscus tears and as I stated they are getting a lot better for articular cartilage injuries as well. If I knew that an articular cartilage lesion was to be treated, then we would also get full leg length films to look at the patient’s alignment to see if the knee alignment was in anatomical alignment or whether there was malalignment which may need to be treated at the same time as an articular cartilage injury. If there’s malalignment of the knee, and an articular cartilage lesion is to be treated, that malalignment may need to be addressed sooner rather than later.

Dr. Sechrest: You’ve mentioned the presence of arthritis in the knee and I think it’s probably time that we sit down and talk a little bit with patients about the difference between an articular injury, an acute articular injury or a relatively recent articular injury, maybe even in a relatively young person, and that elderly patient or maybe late middle-aged person that simply has wear and tear arthritis or what we might call arthrosis of the knee that is probably not amenable to some types of articular cartilage resurfacing. So I think we probably ought to distinguish that because I think that’s another commonplace where patients are sometimes about what their options are in terms of treatment and especially when they’re hearing about these new techniques for articular cartilage reconstruction, some of those techniques are not amenable to the common wear and tear osteoarthritis of the knee that’s been going on for years and years and years, so can you help clarify that a bit as well?

Dr. Menche: Yes, absolutely. Actually, the original research that was done on cartilage transplantation was performed by myself and our research team at the Hospital for Joint Diseases when I was a second year resident in 1982. At that point in time, and in rabid model, we created an articular cartilage injury. Articular cartilage being defined as a traumatic event to the joint surface where basically a piece of covering of the joint surface was damaged yet the rest of the joint was okay, and that can happen in real life as well. In distinction to arthritis where that’s an acute traumatic injury, but a process over a period of time where not only does it affect the articular cartilage surface, but also affects the bone and the rest of the joint where there are now x-ray changes showing joint space narrowing, sclerosis of the bone, osteophytes, which are spurs, so it is a different entity from a traumatic joint surface problem, that is arthritis is a different entity than a joint surface problem that can occur from acute traumatic event. The treatment of the articular cartilage injury has progressed to also treating some of these arthritic lesions as people are pushing the envelope in treating joint surface issues.

Dr. Sechrest: Yes, I think that clarifies it significantly. I think that a lot of folks were very excited, especially folks who were looking at artificial knee replacement and some of those type techniques, because of their arthritis or the osteoarthritis in their knee. Early on they felt like that this is what I’ve been waiting on. This is going to change my options, and I don’t have to consider having an artificial knee now. I can go in for a cartilage resurfacing type of procedure, and I think that’s just not the case. I think that most of these folks are still candidates for total knee replacement as the primary objective and not necessarily going to respond to some of these procedures that we were talking about right now, the articular cartilage procedures that are used for relatively young patients. Is that accurate? Is my understanding accurate?

Dr. Menche: Yes, your understanding is accurate. Most surgeons today who are treating articular cartilage injuries are not doing this in an arthritic patient. Again, there are some surgeons who are pushing the envelope and exploring the possibilities, but most surgeons are not treating arthritis with articular cartilage resurfacing and other types of procedures. It is more for the acute traumatic event or before the joint actually becomes arthritic. The hope is, in the future, that a biological resurfacing arthroplasty, which is a terminology that was put forth about 20-30 years ago, will be developed that even in arthritic patients, that a resurfacing of the joint could be obtained and could be long-lasting and ultimately replace the metal and plastic that we’re putting in today in total joint replacement.

Dr. Sechrest: Yes, I think that’s useful information, because I do think there is some degree of confusion out there and I think you’ve clarified it quite nicely. Let’s move on now and talk a little bit about once you’re pretty sure that you’re dealing with a patient that has a relatively fresh articular injury or something that you feel like is potentially amenable to some type of cartilage resurfacing or reconstruction for the articular surface, how do you advise that patient at that point? What are you going to do in your office in terms of having a discussion about where you go next? What are the patient’s options?

Dr. Menche: Well, if I know that the patient has an articular cartilage injury and that the symptoms are coming from that articular cartilage injury, then the discussion is relatively easier because I can explain the different options to them that we would most likely use in that situation. Again the problem can sometimes arise where we go into a knee joint and we’re not fully aware that there’s going to be an articular cartilage injury. Routinely before an arthroscopy, I will tell patients that sometimes I will need to do things, like a microfracture which I’ll explain to you in a second, where the patient need to be on crutches for several weeks because we may see something unexpected. But that is relatively unusual, probably less than 5% of the situations that we deal with. So, again, definite articular cartilage injury as a joint surface problem, if that lesion is down to bone and if I know that that’s the case going in, the first line treatment that I’m going to do for relatively small lesions, is either just to debride the lesion, meaning to clean up the edges so that there is no mechanical catching or even locking of the knee and just try to smooth the borders so that the lesion hopefully will not progress in the future; or to do what we call a microfracture which is to remove the calcium layer which is just above the bone, and then to get the bone to bleed which will create a new surface over the exposed rough bone, that surface is fibrocartilage, not articular cartilage, but it is a smooth surface covering the bone which is not as good as the articular cartilage but better than the bone being exposed. In those cases, many times, patients will need to be on crutches just for better healing not because of pain or anything like that, and we would also try to keep their knee moving in order to encourage healing. So, first line treatments for most of the patients that we see in outpatient population, are going to be relatively simple type of procedures and not transplants or anything like that and usually I’m going to do that for a second line procedure.

Dr. Sechrest: Now the procedure you’ve just described, either the debridement or the microfracture, I’m assuming that’s done at the time of the initial arthroscopy and it’s done as an outpatient so those patients can actually go home the same day?

Dr. Menche: Oh, absolutely. Yes, those patients go home the same day. It really doesn’t add much to the regular surgical procedure and is a relatively simple procedure to perform so it doesn’t really add much to the postoperative course except, again, for the microfracture where a patient would need to be on crutches for a period of time to encourage better healing.

Dr. Sechrest: Now how long is the rehabilitation for these two procedures? For the debridement, my understanding is it’s relatively short – weight-bearing fairly quickly – if you haven’t done a microfracture you can get back to normal routine pretty much based on symptoms and when the knee is felt to be relatively stable. From the microfracture technique, I’m assuming that you have to give it a little bit more time and the rehabilitation is a little more extended that simple debridement?

Dr. Menche: Yes, so with the debridement there’s rarely no holding back the patient. We progress them as they feel and there’s no limitations. We’re not really waiting for any biological response. In the microfracture, we’re waiting for this fibrocartilaginous repair process to cover the surface of the bone, so depending upon the size of the lesion, location of the lesion, and also what the patient’s goals are, that could take several months to really get that patient back to where they want to be. So typically they could be on crutches if we can persuade them to be on the crutches because the patients are usually feeling very well very quickly after a microfracture, and we really have to explain to the patients the biology of the situation that we really want them to be on crutches or partial weight-bearing or non-weight-bearing for a 4-6 week period depending upon the scenario of the pathology seen at the time of the surgery.

Dr. Sechrest: Let’s move on to more advanced techniques that might be required if either the microfracture is not appropriate or, for example, doesn’t seem to do the trick. Are there other options that you explain to patients or you would offer patients at that point? For example, if you don’t feel that the patient is going to benefit from a microfracture technique or you’re seeing a patient that perhaps has had a microfracture technique, and it was not enough, it did not get them where they wanted to be and you still feel that some type of cartilage reconstruction or resurfacing procedure is potentially available to them, how would you advise them at that point?

Dr. Menche: If a patient had a failed procedure with persistent symptoms, my next articular cartilage procedure would most likely be what we are calling now an ACI or autologous chondrocyte implantation procedure. Admittedly I’m biased as to that procedure because I was on the original team which developed that procedure here in the United States. I actually went, after my residency to Gothenburg, Sweden, and worked with Lars Peterson there for a year. Dr. Peterson is really the pioneer and my mentor with this technique and he did the first one in Sweden, I believe, in 1988 and those results published in the New England Journal of Medicine. I did the first procedure here in New York State in 1995. So having been associated with that procedure from a rabid model and somewhat in a clinical model, to me, that’s my bias and that’s what I would be doing. There are other options of whether we take osteochondral autografts which are almost, I guess, almost like a hair transplant where you take a piece of the articular cartilage and bone, a little core, and you take it from an area in the knee joint where you don’t really need it too much, and you take that core and then you can plug it into the area of the defect. That’s a good option, a relatively good option, for a very small lesion. There are also potentials of using allograft tissue or tissue from a cadaver to also replace articular cartilage injuries. But in my hands I’m probably going to be using an autologous chondrocyte implantation technique which is a technique where we take a sample of the articular cartilage from the patient’s knee joint. We then send it to a laboratory where it’s broken up into millions of cells and then we have to come back another day and transplant those cells into the defect where the cells will then replicate and then hopefully resurface the joint, not in a fibrocartilaginous way as with a microfracture, but hopefully getting it back to its normal articular cartilage status.

Dr. Sechrest: Well, let’s talk a little bit about how you do that procedure. You mentioned that, really, it’s two procedures in one. One operation is really designed to harvest those cells, get a sample of the patient’s own cartilage, and then send that to a lab and then grow those cells over a period of days to weeks I’m assuming; and then come back at a second operation and actually re-implant those cells back into the knee into that lesion that you’re trying to fill with those cells. What are we talking about in terms of these two operations and what time frame are we talking about between the two operations?

Dr. Menche: Usually at the time of initial arthroscopy, this articular cartilage harvesting is going to be performed and then whatever other procedures need to be done would be done at the same time. That harvested tissue would then be set to the lab and typically 3 weeks later or so, if the patient’s knee is looking good and not a lot of swelling, pain, etc., those cells could be transplanted back in. The technique is actually an open surgical technique and that is a technique where we actually have to open up the knee, expose the articular cartilage injury. We then prepare that defect in a way that there’s no bleeding underneath to the bone because that will cause tissue to sort of grow in and potentially hamper the repair process. Then we take a piece of periosteum or sort of a thin filmy tissue that covers the bone, we suture that in place, so if you can imagine sort of a pocket that’s being developed where the exposed bone is underneath, a soft tissue is above it, and then we put the cells into that pocket, and then suture it up so that the cells are now between the bone and that periosteum or that thin covering, and then we seal the periphery of that defect so that the cells stay in place.

Dr. Sechrest: So you’re really creating, like you say, a pocket and injecting these cells. Now my understanding is that these cells tend to sort of fill that pocket and sort of ‘gel’, I guess, similar to what a blood clot would and sort of firm up there fairly quickly under that covering or that periosteum-the thin tissue that you put on top of it. Is that accurate?

Dr. Menche: That’s correct. Actually in the rabid model, which is, I don’t know if it’s obvious, but it’s relatively smaller, we can only put four sutures into that periosteal covering, so even injecting the cells, it was certainly my belief and I think the rest of the team’s, that not all the cells were able to be maintained in that pocket in a secure way. But now the technique is actually to do a water-sealed type of situation where we’re really trying to maintain the cells between the bone and that periosteal covering to keep as many of the cells in place in order to encourage this resurfacing of the joint with articular cartilage.

Dr. Sechrest: I think we ought to point out to patients that really what we’re doing is we’re seeding those cells, and those cells are cartilage cells. Once they’re there and living, they begin to produce what we see as cartilage, and the cartilage itself is really the matrix or the material that is not living necessarily, it’s not part of the cell, it’s the stuff that the cells secrete, and hopefully that will then turn into something that approaches normal articular cartilage and behaves like the normal articular surface because it’s been produced by the same cells that produce our normal native articular cartilage.

Dr. Menche: Yes, that’s correct. That’s exactly right.

Dr. Sechrest: Well, let’s talk a little bit about the rehabilitation after surgery. Now this, as you mentioned, an open procedure. So you’re going to have an incision in your knee. It’s a little bigger operation than simply an arthroscopy. How long do you stay in the hospital? What’s the regimen for rehabilitation after the surgery? What’s going to happen over the next weeks to months as this heals?

Dr. Menche: Basically, many times, this can still be a same day surgical procedure depending upon the lesion, if there’s one lesion or multiple lesions? We usually do start CPM (Continuous Passive Motion) but usually wait a day or two just to let everything kind of get sticky. A lot of times we will keep patients non-weight-bearing for a couple of weeks. Again, this is a biological repair with sutures holding the covering in place so we don’t want to really put too many forces on the repair process until things really start to take place. The problem with the procedure is that, in a sense, it is a relatively long rehabilitation process and we don’t exactly know the exact extent of when we can push and we can’t so many surgeons are erring on being conservative. But typically patients will be on crutches for several weeks, and then they get into a program of functional training and getting back into their normal lifestyles. The maturity of the graft takes over a year to 18 months and even sometimes longer. As I said, the problem with the procedure, in a sense, is that there’s a long rehabilitation process in the beginning but the good news about the procedure is that if patients have success at the 2 year mark, there have been studies to show that that lasts a long time, up to 10 years, and probably now more as far as recovery is concerned, which is a different situation than with microfracture and some other techniques. So it’s really an indication for a patient who has persistent problems which are affecting their lifestyles, which many times have failed a primary procedure, but are looking back to get to an active lifestyle and are willing to put in the time and effort after their surgical procedure to get all this done.

Dr. Sechrest: I think you mentioned the CPM machine and probably for patients who don’t understand what that is we ought to explain what CPM is, and I’m assuming you’re referring to Constant Passive Motion which we’ve been using for many years now after lots of different procedures and lots of different joints, but can you just elaborate on what a Constant Passive Motion machine is and why we use it?

Dr. Menche: A Continuous Passive Motion machine is a machine that patients usually use while lying down. Your leg is in the machine and you can set the speed of the machine and the amount of motion that the knee has, but it basically moves the knee back and forth. We use it relatively slowly just to keep the joint moving. This was started, I believe, in the 80s maybe late 70s by Bob Salter up in Canada who also did rabid studies who showed healing of lesions in a rabid model using Continuous Passive Motion, and that is also used in a microfracture technique, and it’s also used for multiple different techniques. In the 80s, when we used to do anterior cruciate ligament reconstructions, we used to cast everybody and patients got stiff, swollen, muscle atrophy and all that, but as the concept of Continuous Passive Motion developed, we found out that moving knees is going to be a lot better than immobilizing knees for healing. Certainly that’s the case with microfracture and other techniques that we’re using.

Dr. Sechrest: Yes, I think we started using Constant Passive Motion in just literally anything and sometimes Constant Active Motion, so to speak, so that you actually have the patient begin that motion. But I think you’re right, that 30 years ago we thought that everything had to be protected in order to heal. Now we now that movement is key to nearly every operation as long as you’re not going to disrupt what you’ve gone in to fix, and if you can begin motion after any operation on any joint, you’re better off. I think Constant Passive Motion, really the whole research and the experience behind that really taught us that over the last 3 decades or so. Well, let’s talk a little bit about some things that sometimes we don’t like to talk about and that’s what can go wrong. What are the potential complications of all of these procedures that you worry about as an orthopaedic surgeon both around the time of the operation and then what you would consider complications down the road as healing continues or as the rehabilitation continues?

Dr. Menche: Complications around the surgery, the main potential complication that is potential with any surgical intervention is an infection. Obviously every surgeon takes every precaution that that doesn’t happen but, on rare occasion, maybe 1 in 500, 1 in 1000 cases, an infection can occur. As far as long-term complications with either the debridement or the microfracture, it’s not a complication, but it may just not work. Then, if it doesn’t work, what are the patient’s symptoms? Is it affecting their lifestyle? Does something else need to be done? With the ACI or autologous chondrocyte implantation, there is a relatively high re-operation rate that’s recorded in the literature. Some of it may be due to technical situations. Not a lot of these surgeries are being done by a lot of surgeons so, sometimes, there could be some technical errors. But sometimes it’s just a matter of overgrowth of the periosteum or failure of the articular cartilage to totally heal that an arthroscopic procedure may need to be done in order to trim down some overgrowth or potentiate some other healing, and that can happen in a percentage of cases. So again, autologous chondrocyte implantation is a salvage procedure at this point in time. There are other techniques that are being utilized in Europe. Second generation techniques using scalpels where periosteum is not being used so that these potential issues of overgrowth of the periosteum won’t need to be considered.

Dr. Sechrest: I think one of the things that we need to really clarify for patients, and I think this is true of a lot of orthopaedic procedures, but especially true of procedures where we’re going to an abnormal knee with an abnormal articular surface and we’re doing procedures that we hope to improve the situation. I think a lot of patients have this concept of surgery similar to an appendectomy. As long as you go in, you do it, you take the appendix out, the operation is a success. It’s over and you don’t have to worry about it. That’s not true for a lot of orthopaedic procedures, especially procedures where we’re dealing with an abnormal situation like an articular lesion. I would like your opinion and how you set expectations for patients because, as you said, these procedures don’t always work, sometimes they fail completely. Sometimes they work partially where we get maybe some improvement but we don’t give patients back a normal knee. It’s unlikely that, with any of these procedures, that we’re actually going to return a patient to a normal situation. So I would really like to hear how you try to talk to patients and set those expectations before they go down this path.

Dr. Menche: Well, I think one of the first things is really to understand from the patient what their issues are, what their problems are, and what their goals are. Specifically, in this conversation, is the problem that they’re having specifically related to the articular cartilage injury that they have or is it something else going on? So sometimes you can have an articular cartilage injury, let’s say on the medial femoral condyle, but maybe it’s a kneecap problem that they’re having or something else; and just going in there on the articular cartilage side may not treat the other issues that they may be having, and is the pain that they’re having significant enough from the articular cartilage injury to really warrant basically a two-stage operation if that’s what the surgeon’s going to be doing. What are they not doing now that they want to do and will the procedure get them there? As you stated clearly, there may not be total pain relief. In some cases, there may need to be other surgeries performed. So for these articular cartilage injuries, in most, I would say, Journal Surgeon Practices, there are not a lot of surgeons that are doing these secondary procedures because there are not a lot of patients whose symptoms are such that are going to warrant this type of procedure. There are going to be patients certainly on occasion, but not many, many times in my own personal experience. Meniscal tears and situations like that, you know that if they’re hurting from the meniscus that if you go in there arthroscopically, you’re going to get a satisfaction rate of 90-95% if there are no other situations going on like arthritis or ligament injuries and things like that. The same is not true with articular cartilage injury, again, specifically, depending upon the location and diameter of the lesion. So, you’re absolutely right. It’s very important for the physician to know what the issues are that the patients are having and what their goals are, and whether with the surgical procedure that the surgeon is contemplating, is he or she going to be able to give that patient what they want and really to be on the same page before going into that surgical intervention so that everybody understands what it’s all about, including the postoperative course that we spoke about.

Dr. Sechrest: Well, I think that’s well said and clarifies is for me, and I hope that clarifies it for the patients that are watching because I do think making sure expectations match, the surgeon’s expectations and what realistically the surgeon thinks he can accomplish matches what the patient really is expecting as an outcome. I think we will have a lot less dissatisfied patients if we take the time to really make sure that patients do understand exactly what the reality is with their knee, and what can be accomplished with these newer techniques. So thanks very much clarifying that to some degree. As we close this discussion, I think it has been useful information for patients in terms of these articular cartilage injuries and how we, as orthopaedic surgeons, approach those injuries, is there anything you would hope patients can take from this discussion or would understand when they’re dealing with a cartilage injury? First, how to distinguish that from a meniscal injury and then what they’re options are in terms of treatment for articular cartilage injuries down the road? Anything you would like patients to understand that we have not discussed?

Dr. Menche: No, I think we really hit it. But, in summary, there is a difference between meniscus cartilage which is your shock absorber, and the articular cartilage and I would state that most people, when they’re talking about cartilage injuries, you know like they’re just talking to their friends, are usually talking about meniscus injuries and not articular cartilage injuries. As far as prognosis in general concerned, whether a patient has arthritis in that knee or not, is going to be a critical factor in how we treat any of these injuries. Again, the key is to have that patient expectation in line with what the surgeon can do before undergoing any surgical procedure.

Dr. Sechrest: Well, thanks for that summary and thanks again for joining us today. I think this has been a wonderful discussion and will clearly serve patients well into the future. So thanks for joining us today and thanks for the information.