Knee surgeon
Treatment

Cartilage transplantation

Description

Dr. Gelber is the world reference surgeon for fresh osteochondral allograft transplantation, the so-called cartilage transplantation. He receives young patients from the 5 continents who are looking for the only preservation surgery alternative. Those patients have most frequently been offered knee prostheses in somewhere else. Many of these patients are referred by colleagues from other parts of the world who know that their patients need a very delicate and sophisticated technique available to few surgeons. What differentiates Dr. Gelber from other of the few places where cartilage transplantation is also performed (mainly the United States) is the global understanding of the knee, not limiting itself to treating the chondral defect, but correcting the underling cause through complex surgeries. Therefore, in many cases, fresh osteochondral transplantation must be performed in association with ligamentous and meniscal surgeries and bone realignments (osteotomies).

Chondral knee injuries have different manifestations and clinical symptoms. They highly depend on the size, the location, the functional requests, the presence of chondral loose bodies, the thickness of the lesion, the limb alignment, the time since clinical onset and the accompanying lesions. 

Classic treatment techniques such as debridement, abrasion or microperforations /microfractures are outdated techniques that not only offer moderate improvements for a short time, but also lead to worse results when subsequent salvage treatments have to be performed. Currently, more complex restoration techniques are used, in which an attempt is made to cover the defect with cartilaginous tissue or something close to its characteristics.

While the focus should be fully customized to each patient, the two techniques most frequently performed by Dr. Gelber differ depending on whether the injury is only of articular cartilage or, on the other hand, the injury also compromises the underlying bone layer (osteochondral injury).

Chondral injury

Chondral lesions involving the full thickness of the cartilage normally require treatment using some replacement or regeneration-like technique. Numerous treatments based on growth factors or supplements that promise regeneration are currently advocated. However, it has never been shown that this is a reality and instead their use in these cases has little basis in scientific knowledge. A recently developed technique that has shown favorable results is that associating the so-called nanofracture adding up a stabilizer of its product (AMIC Technique).

Microfracture consists of making small channels in the subchondral bone to allow progenitor cells from the patient’s bone marrow to access the area of the injury, and subsequently help generate fibrocartilage that fills the chondral defect. However, these cells are normally diluted in the area to regenerate due to their lack of containment. A refinement of the microfracture, which generated 3mm diameter channels, has been developed. The new technique, called nanofractures, makes channels of only 1mm in diameter, thereby allowing for increased accuracy and efficiency. To prevent progenitor cells being diluted, the technique is combined with the in-situ contribution of a monolayer mesh of hyaluronic acid (Hyalofast). Sometimes, instead of nanofractures, this mesh is embedded with a bone marrow concentrate obtained from the same patient. Together, they generate a clot with a microenvironment that is especially suitable for the progenitor cells to develop and generate a tissue with a certain similarity to cartilage. It is important to note that there is no technique that regenerates cartilage as such. That is, it perfectly restores the complex structure of the original cartilage. In this case, the generated tissue shows favorable histological and clinical results.

Osteochondral injury

When injuries affect not only the entire thickness of the cartilage but also the underlying bone, a technique that only regenerates the cartilaginous layer will fail in its attempt to recover normal knee function. Again, treatment depends on the size and location of the injury. In small lesions, less than 2cm2, the preference is to transfer osteochondral plugs from other part of the knee joint (autologous), a technique called mosaicplasty or OATs. It is in fact the chondral technique that provides faster return to sport among all used in the world. It also provides a success rate of 92%. This makes OATs the gold standard, whenever possible. In cases where the lesion to be treated is larger than 2cm2, this is when the fresh osteochondral transplant finds its ideal terrain.

FRESH Cartilage transplantation

It consists of obtaining cartilage and its underlying bone (subchondral bone) from a young donor. In general, tissues that are used to reconstruct ligaments, bone defects and others, are storaged in a tissue bank under extreme cold conditions for long periods (years). However, freezing techniques are not tolerated by cartilage, making it unviable. Therefore, cartilage must be preserved close to body temperature and in a very specific and complex culture medium. These particular conditions are available in few places in the world. The Blood and Teixits Bank of Barcelona (BST), and thanks to the close collaboration with Dr. Gelber, has achieved the highest international standards in the processing of fresh cartilage after many years of validations and scientific verifications carried out jointly. This cartilage is obtained from young donors in a similar way to obtaining organs such as kidneys, heart or lungs. Within a few weeks, the fresh cartilage graft must be transplanted into the patient so that it does not lose its viability. Cartilage transplant can be applied to injuries of the patella, femur, or tibia.

Dr. Gelber is the leading instructor in this technique worldwide. He has published numerous international articles and book chapters on the subject. Many of these techniques can be seen on his Instagram account @doctorgelber, his YouTube channel @doctorgelber, or his Vimeo channel @doctorgelber. Please note that such videos may cause sensitivity among viewers.

Patients from all over the world have come to Barcelona to undergo this technique, with amazing results. People who had their lives limited and highly conditioned by their injuries have seen how they have recovered a way of living that they had already forgotten. You can see some patient interviews in the video.

Let's be realistic and do the impossible

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