Houston Methodist. Leading Medicine

Ankle FAQ

Question:

I don't know if you've ever seen the Bill Murray movie Lost in Translation but that describes me. I just came back from the orthopedic surgeon's office. I listened while they described three or four possible ways to treat the torn cartilage in my ankle. I have papers and pamphlets of all kinds. I can't remember half of what was said. Could you go over this with me again. I am lost in the translation. What's a debridement, OAT, ACI, and MACI? Which one should I go for?

Answer:

Surgeons know a lot more about cartilage, its properties, and its injuries now that there are MRIs and arthroscopic examinations available. These diagnostic techniques make it possible to see the exact size, shape, and location of cartilage lesions. All of these tools are used to plan the most appropriate treatment. Nonoperative (conservative) care might work okay for sedentary (inactive) adults with a small lesion. But active individuals and especially athletes eager to get back into action will need surgery to repair or restore the cartilage. Repair débridement is the first line of treatment for small lesions (less than 1 cm2 in size). The surgeon carefully removes any loose pieces and smoothes any frayed edges. If that doesn't work, then the débridement may be repeated. If further treatment is needed, restoration rather than repair is advised. Restoration means that normal hyaline cartilage is harvested from a donor site and transplanted to the defect or hole in the cartilage. Sometimes the donor material comes from the patient. That's called an autograft. When the harvested healthy cartilage comes from another person, it's referred to as an allograft. In either case, essentially what happens is the surgeon takes a plug of cartilage and the bone underneath it from a healthy site (usually the nonweight-bearing portion of the knee) and transplants it into the defect or hole in the damaged cartilage. This is called an osteochondral autograft transplantation (OAT). The patient stays off that leg for several weeks after surgery to avoid disrupting the healing process. Reports so far of short- to mid-term results are very favorable with this technique. The studies are small but the majority of patients report good-to-excellent results. They say they would have the same procedure done again if they had it to do all over. That was the first method used to try and restore the cartilage. Now, the technique has advanced forward. A new method called autologous chondrocyte implantation (ACI) is available. Healthy cartilage cells are taken from the patient and grown in a lab until 200 to 300 cells becomes 12 million cells. It takes about six to eight weeks to accomplish the multiplication process. Then the new cartilage cells are transferred back into the defect (hole). The advantage of this approach is that the new cells can be saved in a cold place for more than a year. The disadvantage is that the procedure requires two separate operations. In the second operation, the lesion is smoothed and prepped for the new cells. A special patch of bone is layer over the top to protect the healing area. The patch is sealed with a special fibrin cement or glue. The new cartilage cells are injected under the patch. Again, small studies are reporting good-to-excellent results that last beyond 48 months (four years). In a few patients, the surgeons are able to do a repeat arthroscopy exam and sample some of the healed tissue to see what's really going on. They have been able to see that the defect doesn't always fill in with good hyaline cartilage. Sometimes it's just a fibrous filler, so there's some concern about that. One final restorative technique under investigation is the matrix-induced autologous chondrocyte implantation (MACI) that you mentioned. This is similar to the autologous chondrocyte implantation. But instead of growing the harvested cells in a culture and then injecting them into the defect, they are placed on a special membrane where they grow and multiply. The membrane is then used to fill and cover the defect. No extra bone patch or flap is needed. Cells can also be harvested right next to the damaged area, rather than finding another spot to gather them (e.g., from the knee). There are numerous possible advantages of the MACI procedure over the others:
  • It can be done without cutting into the ankle bone, a procedure called malleolar osteotomy
  • Since cells are harvested from right next to the defect, there's no donor site and no donor site problems
  • Fibrin glue can be used without additional stitches required
  • Cells can be harvested and stored for use later when the initial debridement is done (the just-in-case approach); that way, if the debridement is not successful, the stored cells can be pulled out of the freezer without doing yet another surgical procedure.
  • With the MACI technique, there are more live cells transplanted compared with the ACI approach; that may translate into better results later on. Even with these more advanced restorative techniques, it's still advised to have débridement first to repair the initial damage before advancing to the more invasive restorative process. And not just once, but debridement may be done up to three times before considering a restorative procedure. If there are loose fragments of cartilage, these should be restitched to the joint surface whenever possible. But when all efforts fail to produce a satisfactory result, then the osteochondral autograft transplantation (OAT), autologous chondrocyte implantation (ACI), or matrix-induced autologous chondrocyte implantation (MACI) procedure can be used. These approaches are still considered a potential second-line treatment procedure. They are not the first effort made to repair or restore the problem. Matthew E. Mitchell, MD, et al. Cartilage Transplantation Techniques for Talar Cartilage Lesions. In Journal of the American Academy of Orthopaedic Surgeons. July 2009. Vol. 17. No. 7. Pp. 407-414.

    *Disclaimer:* The information contained herein is compiled from a variety of sources. It may not be complete or timely. It does not cover all diseases, physical conditions, ailments or treatments. The information should NOT be used in place of visit with your healthcare provider, nor should you disregard the advice of your health care provider because of any information you read in this topic.
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