We should be making greater efforts to repair damaged cartilage and carry out more restorative surgery for meniscal tears, and patients should be made aware of the latest technology, says Simon Moyes
Consultant orthopaedic surgeon Simon Moyes sees many patients with damaged knee cartilage. “I think this is for a number of reasons,” says Moyes. “We’re all living longer, there are more of us. People are often bigger now, which adds increased loading on joints, causing strain.
“While more people are exercising to keep fit, if it’s not as regular or consistent as it could be, or people exercise without preparation, this can result in a lot more cartilage damage in joints. I see many patients with knee damage who have been pursuing an active lifestyle for longer than previous generations, and are naturally keen to continue doing so. For many of my patients, a sedentary life with no exercise is not an option.”
Moyes says: “The issue is that most meniscal tear surgery involves removing the damaged cartilage rather than repairing it. We should be doing far more in the way of restorative surgery.
“The problem with meniscal resection is that this can increase the chance of arthritis down the line. The latest cartilage repair and restorative technology is becoming more accessible, and patients should know that it exists – whether this be in the public or private sector.”
“Repairs to torn menisci can be carried out with a combination of stitching and adjuvant cell technology,” explains Moyes. “Damage to hyaline cartilage can be repaired with microfracture surgery – this uses tiny drill holes to expose bone marrow stem cells, which, in turn, generates neo-cartilage to cover the bone.
“For hyaline cartilage, surgeons can also use a range of stem cell treatments or cartilage grafting. A small amount of cartilage stem cells can be taken from the knee, multiplied in a laboratory and turned into a sheet of new cartilage, which, six weeks later, can be re-implanted into the knee. Other technologies available involve taking healthy knee cartilage from where it isn’t needed and moving it to an area where it is. Transplanted cartilage from a donor can also be effective. Companies are currently developing artificial cartilage substitutes.
“Viscosupplementation can reduce pain for people with arthritic and damaged knees, improve function and may help cartilage heal. Also, PRP (platelet-rich plasma) derived from your own blood can be injected into knees therapeutically, and is very popular in America.”
“Stem cell technology is moving at a fast and exciting pace,” says Moyes. “There are already systems where stem cells can be taken from your bone marrow, and used to augment cartilage repair techniques.”
According to Moyes, stem cells are the future; however, he admits that at the moment stem cell treatments are incredibly expensive, running to thousands of pounds. With time though, as with all new technologies, he’s confident that the cost will come down.
“Restorative and regenerative techniques are more involved than routine keyhole surgery, and the patient may be out of action for longer,” he admits. “However, ultimately, these techniques are more beneficial to the sufferer in the long term, as the damaged joint surfaces are restored and reconstructed rather than simply repaired. To improve patient care, it’s important that more is done in the way of restorative orthopaedics.”
Case study – Lucy Schwerdtfeger
Lucy Schwerdtfeger suffered a knee injury in March 2013 and a complication from the original injury manifested itself in June 2015. The first resulted in a full leg cast and she was unable to walk. The complication made it difficult for her to undertake everyday tasks or any sport.
In March 2013, Lucy was skiing in France when she fell and her boot bindings didn’t release. She sustained an unusual proximal tibial fracture with a displaced anterior tibial spine, which was essentially an avulsion injury of the anterior cruciate ligament with some cartilage issues.
Lucy was taken to a local hospital in France where she was X-rayed and put in a full leg cast to enable her to fly back to the UK, where she visited Simon Moyes to establish what her next stage of treatment would be.
During her visit to Moyes, he informed her that she had to wait 24 hours before undertaking any surgery due to the heparin injections she had been prescribed in France in order to safely fly home with the full leg cast. He confirmed that surgery was necessary in order to reset the section of bone that had come loose following her accident on the slopes, and would take place on the following day to avoid any further complications.
Moyes’ plan for the operation was to perform the surgery arthroscopically; however, the displacement of the bone fragment meant Lucy needed an open surgery to line up the broken bones. He placed a screw through the tibia to reattach the displaced bone, and tidied the cartilage tear.
Following the operation, Lucy was sent home with painkillers, and advised to start physiotherapy treatments within six weeks. Once the staples and stitches were removed, she noticed improvements in her knee and was able to move around more comfortably.
In June 2015, Lucy experienced discomfort in her knee, which became worse over the following month. It became painful to walk and she became concerned. “I’d injured my knee two years ago and had to have an operation so have always assumed my knee was never going to be 100 per cent again,” she comments. As the pain grew, Lucy visited her GP for a referral to see Moyes again, as she suspected the screw he had placed two years ago needed to be removed.
Moyes, suspecting the same, carried out an MRI scan but was unable to confirm the root of what was causing Lucy so much discomfort in her knee. She couldn’t lock her knee straight and it would sometimes lock out, which made Lucy feel that she was losing control over her knee. Her symptoms also stopped her from exercising.
Moyes suggested removing the screw that was placed during the initial operation, which would give him the opportunity to explore the rest of the knee tissue. He carried out a keyhole surgery but also had to make an additional small incision in order to take the screw out.
During the operation, he discovered that the head of the screw had become loose, which was part of the cause of Lucy’s discomfort. He also found a large Cyclops lesion, a further complication from the first surgery, and cleared out a floating bone fragment that had come loose.
After the operation, Lucy was later dismissed from the hospital and instructed to rest at home for a week with her leg elevated. She was able to get back to work the following week and was instructed to start physiotherapy treatments to help speed up her recovery period.
About Simon Moyes
Simon Moyes is a consultant orthopaedic surgeon with a special interest in the treatment of knee, shoulder, foot and ankle problems. He was one of the first to introduce arthroscopic/keyhole surgery to the foot and ankle into the UK.
He has been a consultant orthopaedic surgeon since 1994, previously being an orthopaedic lecturer at the Royal National Orthopaedic Hospital and having worked at University College Hospital in London. Moyes went into full-time private practice in 1997 and is currently based at the Wellington Hospital in Central London and also carries out clinics at 31 Old Broad Street in the City. He has a particular interest in developing cartilage regeneration and repair techniques and is one of the few international members of the Arthroscopy Association of North America.