Cartilage Repair: Microfracture, OATS and Autologous Chondrocyte Implantation

A thorough history of the mechanism of injury tells a doctor about 70% of what they need to know, since mild pain from ordinary walking is very different from a pop felt during sport followed by an immediate fall. Persistent pain despite conservative treatment should not be dismissed as non-compliance; something is usually being missed and warrants an MRI. Any significant mechanism of injury deserves a low threshold for imaging without delay, since ACL repair rather than reconstruction is possible if the patient is seen within two to three weeks of injury. Once an MRI is available and there is uncertainty about the findings, a second opinion through Jivo can confirm whether the patient needs conservative treatment, local surgery, or referral to Artemis.

A single ligament reconstruction, ACL or PCL, costs approximately $4,000 to $4,500, all-inclusive from admission to discharge. Meniscal debridement alone is $2,500 to $3,000, and meniscal repair ranges from $4,000 to $5,000 depending on the number of suture anchors used, at roughly $500 each. A simple Bankart repair for shoulder instability costs $4,000 to $5,000, with remplissage adding about $1,000. PRP injections without surgery run about $500 per injection, with 3 to 4 injections typically needed over roughly six weeks.

Ligament reconstruction, ACL or PCL, has a 98 to 99% success rate, with failures very rarely seen. Meniscal repair success depends on how much of the meniscus is torn and how early the patient presents, but even large tears repaired a year after injury succeed around 90 to 95% of the time. Shoulder stabilisation surgery, Bankart repair or Latarjet, is 95 to 98% successful when planned correctly, and rotator cuff repair succeeds 90 to 95% of the time.

Blood supply to the meniscus runs from outside to inside, dividing it into three zones. The outer red-red zone near the capsule has decent blood supply, which is why peripheral tears heal well. The middle red-white zone has moderate blood supply and can still be repaired if augmented with orthobiologics. The innermost white-white zone has very poor blood supply, and a peripheral rim tear there is better debrided than repaired with multiple anchors into non-vascular tissue.

The meniscus is the only shock absorber between the femur and the tibia, taking on all the compressive and shear stress of walking, running and sport, and preventing the two bones' cartilage from grinding directly against each other. Once it is removed, that cartilage-on-cartilage contact leads to arthritis within a few years. A patient can function without an ACL, but without a meniscus, arthritis is inevitable.

Microfracture creates small holes through the subchondral bone to stimulate fibrocartilage formation, and is used only for small defects up to 4 to 6 mm; it should not be used for larger defects.

OATS is a one-stage procedure that transfers a plug of the patient's own cartilage and bone into the defect, suitable for defects of 6 to 10 mm or more up to about 20 mm. ACI is a two-stage procedure for very large defects that grows the patient's own cartilage cells in a laboratory before implanting them, producing true hyaline cartilage rather than fibrocartilage.