Potholes are a problem, in both roads and shoulders.

by Dr. Joseph Guettler

We can all agree that the roads here in metro Detroit are a problem, and the damage to our wheels and rims can get old. I tip my hat to the road crews who work around the clock to fill potholes, but as a state with some of the worst roads in America, don’t we need a longer-term solution to the problem?

Like our roads, potholes can also develop in the human knee, but fortunately, there already are long-term solutions to this problem. 

As an orthopedic surgeon and cartilage specialist, I am going to take a couple of lessons from our roads here in Michigan, as well as our road services’ work to fill those potholes, and apply those concepts to potholes that can develop in the human knee. While potholes in roads, as well as knees, can be a perplexing problem, I can assure you we are developing some very cool ways to fill them, if they do happen to develop.

Before we go any further, let’s review some cartilage basics. Articular cartilage is a tough, resilient tissue that exists within the joints of the human body. It provides cushioning and allows joints to glide smoothly. However, when articular cartilage is damaged, it simply does not heal. Therefore, treatment often involves innovative techniques to replace or stimulate cartilage to grow. In the past, a significant cartilage injury in a young person has almost guaranteed that arthritis will develop as a result of that injury. But, we can now help prevent arthritis from developing with some of these techniques that help restore areas of injured cartilage. 

First, I want to be very clear about something: Cartilage restoration surgery is not for everyone. I tell my patients that the cartilage in your knee joint is like the pavement on a road. If the pavement is all bad (like wear-and-tear arthritis), you may need a surgery like a knee replacement, a partial knee replacement or a procedure called an osteotomy that realigns the leg to take the load off of the bad part of the knee. If the pavement is good but has a “pothole,” we may be able to fill the pothole using one of these cartilage restoration procedures. These “pothole-filling” procedures general apply to a “younger” patient population – and I use that term loosely.

If you have a defect, injury or “pothole” in your cartilage that hasn’t turned into arthritis yet, here are some of the techniques we are currently using to restore cartilage. These techniques include:

  • Microfracture: Small holes are placed in the bone where cartilage has worn away. Cells from the bone marrow leak into the area and transform into a protective layer of scar cartilage. This is often one of the first lines of defense and can easily be done at the time of knee arthroscopy. Newer procedures are being used that add a layer of fertilizer to the microfractured area so that, in theory, “better” cartilage grows. 
  • Osteochondral grafting: A plug of bone and healthy cartilage is harvested from one area in the knee and transplanted to the injury site. This procedure “robs Peter to pay Paul” and can only be used for small defects. For larger defects, we can actually use plugs taken from a cadaver, so you don’t have to rob your own knee. Another even newer procedure that has promise involves cartilage cells that are taken from a “young donor.” These cells come in the form of little cartilage chips that are then suspended in a gelatinous mold that fills the cartilage defect.
  • Cartilage transplantation: Healthy cartilage cells are harvested from the knee and then sent to a lab where they are grown in culture and incubated on an advanced biologic membrane. This is now considered the third generation of advanced cartilage restoration, and we are excited to offer it as a great option to fill your pothole with your own “stuff.” It still takes two procedures, but the reimplantation part can be done in a more minimally invasive way because we can simply cut and paste the cell/membrane construct into the pothole (the previous generation required us to sew a patch over the pothole and then inject the cells underneath the patch – necessitating a larger incision).
  • The future of cartilage restoration – we’re on it! We have been involved in some pretty cutting-edge research. One national research project that we were involved with uses a procedure that “does it all” in one step by mincing the cartilage cells, impregnating them on a scaffold and stapling the construct into a defect. Another study we were recently involved with uses yet another advanced bioengineered scaffold that incubates your own cartilage cells within the scaffold and is glued into the pothole. 
  • Other new horizons we are looking into involve modulating genes, using growth factors, and upregulating receptors so that stem cells are attracted to areas of the knee in need of repair – more to follow…
  • Stem cell therapy and platelet rich plasmaboth have a role in the grand scope of articular cartilage restoration and arthritis management – and we continue to work out the kinks.

Now you might ask: How do I know if I have a cartilage defect in my knee? Many times, these problems are diagnosed at the time of arthroscopic surgery, but our imaging techniques are advancing rapidly, and we are now able to pick up many cartilage problems with the use of MRI. Interestingly, in yet another research study, we used ultra-sensitive MRI technology to look at the knees of collegiate basketball players (high impact athletes) and compare them to the knees of collegiate swimmers (low impact athletes). We found that even though all of these young athletes’ knees were asymptomatic, the knees of the basketball players had significantly more early cartilage damage when compared to the swimmers. Thus, the take home message is that we might have to rethink how we train our young impact athletes, and that for the rest of us, you really can’t go wrong with a low impact exercise regimen.

Yet another study that we recently did involves the use of our “fancy” MRI technology, combined with bloodwork, to try to screen for patients who might be predisposed to the development of osteoarthritis later on in life. And that leads me to my final point – always remember the best treatment is prevention. We can’t control things like genetics, but there are some things we can. A healthy lifestyle is key to your cartilage health. A “cartilage friendly” workout routine includes aerobic activities that encourage smooth joint motion (ie – walking, cycling, swimming, cross country skiing) without the pounding. Keeping yourself “slim and trim” also takes a lot of the load off your knees, as well as your back, hips, ankles and feet. And yes, I’m also a fan of cartilage vitamins that include glucosamine and chondroiten.

The bottom line – if you have been diagnosed with “a pothole problem” in your knee, you might want to look into ways to have that pothole filled before “the whole road goes to pot.” As you can see, there are many exciting advances in cartilage restoration, and much of the research – as well as the most innovative procedures – are being done right down the road.

Dr. Joseph Guettler is an orthopedic surgeon who specializes in sports medicine, as well as surgery of the knee, shoulder and elbow. He is a proud member of the MOS team.