Is It Easy To Return To Pivoting Sports After Articular Cartilage Surgery?

Picture from Upswinghealth

My receptionist has been complaining of left ankle pain, especially after her netball training. While treating her, I found out that her ankle injury was sustained a year ago while playing competitive netball. She's been training very hard as she's hoping to represent Singapore one day. 

She saw 3 physiotherapists concurrently last year, but none really treated her. They all just gave her exercises to do. 

After assessing her, I told her she may have an osteochondral injury (or articular cartilage injury) in her ankle. I also shared with her a recent article (Toyooka et al, 2023) on how successful athletes are, at returning to pivoting sports after articular cartilage surgeries.

The scoping review evaluated the following articular cartilage procedures: microfracture, osteochondral autograft transplanation (OAT, or mosaicplasty,  harvested from one's own joint), osteochondral allograft (OCT, using a cadaveric graft) and autologous chondrocyte implantation (ACI, or autologous chondrocyte transplantation, ACT ). All of which have been written here previously.

16 studies fulfilled the ine inclusion criteria, of which 7 studies evaluated the microfracture technique alone. 44 to 83 percent managed to return to sport (RTS) after 6.2 to 10 months. 25-75 percent managed to return to their preinjury level. Average defect size was between 1.9-4.9 cm2. 

87-100 percent of athletes managed to RTS after their OAT or mosaicplasty surgery after 11.8 weeks to 6.5 months.. 67-93 percent managed to get back to their preinjury levels. Mean defect size varied from 1.34 to 2.9 cm2 (this is smaller than most OAT procedures that I've read previously).

For ACI, 33-96 percent managed to RTS 10.2 months after their surgery. 26-67 percent managed to return to their preinjury levels. Mean defect size ranged from 2.1 to 6.4 cm2. These athletes had also previously undergone an average up to 2.7 other surgeries.

The rate of RTS with the microfracture technique was not higher compared to other techniques in this review. This technique is usually the first-line treatment for articular cartilage injuries since it is relatively low cost and technical ease. Patients usually RTS within 9 months. The main disadvantage is that there is no restoration of hyaline cartilage. Fibrocartilage is formed after the procedure which may not tolerate pivoting sports. It is also not suitable for those with larger defect injuries. Defect sizes larger than 2 cm2 may not have good postoperative oucomes. 

Microfracture awls to puncture holes in the bone

The OAT or mosaicplasty techniques involve harvesting a bone plug with intact cartilage from the patient's joint in a non weight bearing area and transplanting that into the defect area. The main advantage of this technique is that it has high healing potential as a patient's own bone plug is used allowing the bone to integrate immediately. There may be some risk to donor site morbidity if too big bone plugs are taken (pictured below).

Harvesting the bone plugs in the knee

87-100 percent of athletes managed to return to pivoting sports after their OAT or mosaicplasty surgery after 11.8 weeks to 6.5 months in this review. 67-93 percent managed to get back to their preinjury levels. This suggest that the OAT  procedure may offer a good acceptable result for high demand athletes. Mean defect size varied from 1.34 to 2.9 cm2 (this is smaller than most OAT procedures that I've read previously) and smallest in this review.

ACI requires 2 surgeries to restore the damages done to the hyaline cartilage lining the joint, described in more detail in a previous post. For this review, 33-96 percent managed to RTS 10.2 months after their surgery. 26-67 percent managed to return to their preinjury levels in high demand pivoting athletes. Pivoting sports may have a lower RTS ate compared with other sports.

ACI

Mean defect size ranged from 2.1 to 6.4 cm2. These athletes had also previously undergone an average up to 2.7 other surgeries. This technique is used primarily with larger defects. However, it's limitations are requring 2 surgeries, high cost, open surgery and a very prolonged rehabilitation. 

Based on this review, the OAT procedure had the highest RTS rate in pivoting sports. They also returned to sport faster, especially when the defect size is small. For large defects, OCA and ACI may be considered with ACI preferred since OCA (caderveric) has many limitations like being expensive, limited in supply and restricted in many countries. Harvested bone plugs also need to be implanted within 14-21 days.

Most studies in this review reported high RTS rates although return to preinjury level was lower. RTS is a very critical variable and benchmark (to me) for patients who are athletes. These data can be used as a basis for selecting treatment options. 

Not only there are very few studies that only study athletes, the sports they compete in also vary. There was a tendency for RTS to be higher when the level the athletes were competing in were higher (especially professional), perhaps due to their access and compliance with rehab protocols, adaptibility to competition and for financial reasons.

Note that there was not enough data on the lesion size to decide between ACI and OAT. There were no significant difference in short term results between the two, although ACI outperformed the OAT in 10 year outcomes (in 2 studies).

Well, to my receptionist and other athletes reading this post, I hope this helps with your decision making should you need to consider the different options to return to your sport. It is definitely a long and winding road, with treacherous falls along the way while attempting your comeback, but it can be done.

Trust me, I've had 3 knee surgeries, a skull fracture and broke my back twice. You just need to be be persistent and never give up. Our team in our clinics have been patients before too and know how it feels like to be a patient and will be able to understand and do their utmost to help you.

References

Bentley G, Biant LC, Vijayan S et al (2012). Minimum ten-year Results Of A Prospective Randomised Study Of Autologous Chondrocyte Implantation Versus Mosaicplasty For Symptomatic Articular Cartilage Lesions Of The Knee. JBJS Br. 94: 504-509.

Biant L, Vijayan S, Macmull S et al (2012). Autologous Chondrocyte Implantation Versus Mosaicplasty For Symptomatic Articular Cartilage Defects In The Young Adult Knee: Ten Year Results Of A Prospective Randomised Comparison Study. Orthop Proc. 94-B: 122-22

Toyooka S, Moatshe G, Persson A et al (2023). Return To Pivoting Sports After Cartilage Repair Surgery Of The Knee: A Scoping Review. Cartilage. Pub online. DOI: 10.1177/194760352211414

Still Can't Run 6 Months After An Ankle Sprain

R ankle

My last patient yesterday suffered an osteochondral injury in her right ankle last July after spraining her ankle while taking part in a trail running camp. Part of the reason may be wearing a new pair of shoes she wasn't used to.

Almost half a year later, she was still hoping to do a 50 km trail race earlier this month, but she definitely wasn't even ready to be running yet.

Many of her running friends and colleagues (she works in a hospital) can't believe an osteochondral injury can be that serious. In fact, some of the physiotherapists in her hospital don't even know what an osteochondral injury to her talus means. They definitely do not know how to treat her.

Hence, you have a runner who works in a hospital, yet comes to Sports Solutions to get treatment.  Just like the physiotherapist from another hospital who sees us after her microfracture surgery.

In the picture above, you can see where the talus is in the ankle. It is the bone that is below your tibial (shin bone). In the scenario where there is an injury to the articular cartilage (which lines the end of our bones to allow for load bearing and friction free movement), there will be both swelling and pain.

The main goal of non operative treatment is to allow the injured bone and articular cartilage to heal. Since articular cartilage has poor blood supply, this is not going to happen quickly.

Sometimes, crutches or a rocker boot may be necessary to take load off weight bearing. In severe cases, surgery is needed to ensure recovery. After three articles on the operative management on articular cartilage injuries, I think I've covered the topic enough. Just in case you're keen, drilling can be done like the picture you see below to stimulate healing.

Drilling is done

I've told my patient she can still volunteer at the race whether it's manning a water station, handing out medals or directing runners at checkpoints in the race. She can also lend support and cheer for her friends at the race. Meanwhile, she has also found "a distraction" or another way to motivate herself. She's been going to the gym regularly and her upper body is much more muscular than before.

I've told her to keep the long view in mind. If she wants to keep running for the rest of her life it's not worth risking it now. There will be other races for her in future definitely.

Have an osteochondral injury? Come see us in our clinics.

My Patient Had A Microfracture Done In The Knee

Articular cartilage is white, with the bone exposed

A fellow physiotherapist who works in a hospital came to see me after a microfracture procedure done on her knee. There was a grade 4 articular cartilage defect on her knee and this led to swelling and pain while climbing stairs and after weight training.

Outerbridge articular cartilage classification

All of us have a layer of articular cartilage covering the ends of  our bones, especially the joint surfaces. It is normally tough and resilient. This helps to protect the joint during load bearing and reduce friction during movement. Injury or damage to the articular cartilage can result from trauma (during sports) or from daily wear and tear. As articular cartilage has poor/ no blood supply, it does not heal well after injury.

There is no standard and uniform approach to managing articular cartilage injuries in the knee. Left untreated it can progress to significant joint destruction. The patient may then need a total knee replacement in the worse case scenario.

Treatment options include microfracture, arthoscopic drilling, mosaicplasty and chondrocyte transplantation to restore the joint surface.

A microfracture technique is where the surgeon performs key hole surgery to cause bleeding on the bone surface to promote healing (picture below). It is performed by the surgeon puncturing holes in the subchondral bone layer to allow bleeding to occur.  After the blood clots and heals, a layer of fibrocartilage is formed. This technique was first made popular more than 20 years ago by Dr Richard Steadman from Vail, Colorado who has since retired.

My patient had the microfracture procedure done (in the picture above) and as you can imagine, the rehabilitation to return to sport can be lengthy. There is usually a period of non weight bearing for the first six to eight weeks to allow healing while using continuous passive motion (CPM)  machine at night. Use of the CPM machine is to stimulate movement to enable nutrition in the articular cartilage since the patient is non weight bearing. Yes, correct movement and some loading forces are necessary for our articular cartilage to recuperate.

Most surgeons here do not usually suggest use of the CPM machine after performing the microfracture technique which I feel is critical in order for optimal healing to occur in the articular cartilage.

Lots of patience and consistency are required by the patient and physiotherapist to slowly regain functional range of movement and strength before any return to sport work can be done.

Fortunately, articular cartilage injuries are my area of interest having had them myself (and requiring 3 knee surgeries) and my postgraduate research was in this area.

I'll write more about mosaicplasty and and the chondrocyte transplantation procedure in the next post. Stay tuned.

References

Hurst JM, Steadman JR et al (2010). Rehabilitation Following Microfracture For Chondral Injury In The Knee. Clin Sports Med. 29(2): 257-265. DOI: 10.1016/j.csm.2009012.009.

Steadmann JR, Rodkey WG et al (1997). Microfracture Technique For Full-thickness Chondral Defects. Oper Tech Orthop. 7:300-304.

Here's what the surgeons use to cause bleeding in the bone