Examining the Role of Cartilage Transplantation in Foot and Ankle Surgery

Q: In what scenarios might foot and ankle surgeons find cartilage transplantation best applies?

David Yeager, DPM, FASPS comments that arthritis or joint disease impacts many throughout their lifetimes, and that particularly, hallux rigidus/limitus is quite common in his practice. In his experience, these cases can arise due to age, genetics, previous injuries, overuse, trauma and malalignment, among other reasons.
 
“Classic nonsurgical interventions include, RICE, NSAIDS, bracing, physical therapy, and injections,” he explains.
 
Early surgical options could include debridement, microfracture, and cheilectomy, he says. However, if any of these procedures go on to fail, they will require further and more significant surgical intervention such as, hemiarthroplasty, total joint arthroplasty, or arthrodesis, in the case of the first metatarsal. 
 
“As time passes, we as surgeons continuously push the envelope to develop new products and techniques that improve patient outcomes and patient satisfaction,” says Dr. Yeager. “In my observation, minimally invasive products and procedures have become a large focus over the last decade providing patients with fast pain relief, and early mobilization while maintaining full anatomic joint motion.”
 
He feels that surgeons will find that cartilage transplantation options could serve as an option that satisfies the tenets of innovation that he describes above.

Q: Are there any particular techniques or systems that make this procedure unique?

Dr. Yeager shares that in healthy patients with osteochondral lesions, bone marrow lesions, or cartilage lesions, a surgeon may have an option to utilize an OATS Technique (Osteochondral Allograft Transfer System).
 
“This is a technically challenging procedure, requires graft matching, is very expensive and requires specific patient qualifications to optimize outcomes,” he adds. “Even If the stars align and things go well, the patient would still be subject to a 9-12 month extensive rehabilitation and often require revision arthroscopy. I know of several techniques and devices coming onto the market that can make this procedure more accessible to surgeons with better outcomes for patients.”

Q: What challenges do you feel surgeons encounter when undertaking this procedure?

An OATS procedure is labor intensive, he says, and requires many steps. 
 
“Any time that you are entering the joint, you run the risk of increased chance of arthritis,” explains Dr. Yeager. “There is a definite learning curve associated with the OATS procedure.  Hopefully with the advent of new techniques and procedures, this curve is lowered.”

Q: What one thing do you most want the audience to know about cartilage transplantation?

Why do microfractures, or cartilage lesions fail? The answer, in Dr. Yeager’s clinical experience and research review, is that the problem exists in the bone.
 
“The subchondral bone is the foundation, with a complex integrated network of nerve endings and vascular channels that provide blood flow to the subchondral plate,” he explains. “This blood flow provides 50% of the nourishment to the basement layer of the cartilage, while the other 50% nourishment of the cartilage comes through the synovial fluid. Fixing the roof on a house with a bad foundation will not lead to favorable results. If you follow your patient with bone damage or microfracture on an MRI, you will see the progression and growth of these subchondral lesions. For the patient, these present as continued or frequently worsening symptoms (pain, stiffness, activity-related swelling, etc.) These lesions will fail faster in weight-bearing areas and depend on lesion size, location, depth etc.”  
 
Dr. Yeager discloses a relationship with Johnson & Johnson.