Hyaline cartilage has unique biomechanical qualities that enable it to withstand the shear forces of a moving joint. Consider this, every step you take, you are subjecting the knee joint to about 1.5-2.0x your body weight and factor in a 5km run which
average about 5000 steps and you’ll get the picture.
A survey showed that cartilage lesions affect up to 63% of
adults at the mean age of 43 years and more than half are
on the crucial stress areas of the knee. In addition, long
term follow-up has shown that 81% of people with damage
to the cartilage developed osteoarthritis, which can be
crippling. Furthermore, the onset of osteoarthritis is 10
years earlier.
How does Osteoarthritis feel like?
Osteoarthritis is a degenerative condition of the joints such as the knee. It can result from trauma or natural wear and tear. Whatever the cause, the condition manifests as pain, either acutely or chronic dull ache. The discomfort prevents you from engaging strenuous activities and is worse towards the end of activity. In addition, swelling may be associated with pain. The symptoms run an episodic course, waxing and waning although the underlying disease may not have improved.
Hunter once said in 1743 that “from Hippocrates to
the present age it is universally allowed that ulcerated
cartilage is a troublesome thing and that once destroyed,
is not repaired”. (Fig 2)
Hyaline cartilage has very little properties
to repair itself and when it does, it substitutes itself with
inferior quality cartilage, known as fibrocartilage. This
fibrocartilage lacks the biomechanical durability of
hyaline cartilage and often breaks down i.e., the repair do
not last. This has been very much the case till the late
1980s where tissue engineering coupled with cell culture
technology allows us to replace like for like, i.e. hyaline
cartilage for hyaline cartilage.
Osteoarthritis tends to run an unrelenting course. It usually starts from a particular area and spreads to the rest of the joint. As the disease progresses, the recurrent episodes of pain and swelling gets more frequent. Furthermore, the joint gets stiffer and restrictions of motion worsen. Towards the late stage of the disease, the leg may get deformed, developing a bow-legged deformity.
What is Autologous Cartilage Transplant (ACT)?
ACT is a surgical technique that combines state of the
art technology in cell cultures and tissue engineering for
the regeneration of hyaline cartilage. It requires the use of
the patient’s own cells, hence autologous, to grow in a cell
culture. The use of one’s own cells bypass ethical and
religious issues as well as completely avoiding concerns of
disease transmission. The cells are encouraged to grow in
certain cell lines and to a certain number of
multiplications to achieve the target populations of cells. (Fig 3)
The density of cells required is calculated based on the
size of the defect. The cells are subsequently transplanted
back into the defect in the patient’s joint.
Surgical Technique
This is essentially a 2 stage technique. The first stage
involves a key-hole surgery to harvest the cells to send to
the laboratory for culture. The procedure is minimal and
is done as a day surgery. (Fig 4)
After a period of 4 weeks to allow the cells to grow to
the desired quantity, the second stage takes place. This
involves a small incision in the affected joint and the cells
are implanted in. The patient can be discharged after 3-4
days stay in the hospital. Physiotherapy can be done as an
outpatient.
Results
The results have been encouraging. The longest
follow-up in the world is about 14 years and up to 90%
good to excellent results. Pain and swelling are
negligible after 6 months and most of our patients are able
to return to an active lifestyle.
Who is suitable?
ACT is applicable to anyone with cartilage problems, especially young people where conventional prosthetic resurfacing is not applicable. It is also applicable for older patients as age is not a limiting factor to successful outcome. The technique is most valuable in the sense that you are having a biological tissue, which is similar to the one that you have lost. It is not synthetic and therefore do not have the problem of shelf life. As the tissue is entirely from the patient, the issue of rejection is non-existent
This is an intra-operative video on cartilage transplant. This is the final stage of a 2-step procedure. In this stage, cells which are cultured in a laboratory are implanted into the defect. The first part of the video shows the exposure of the knee joint. This is done carefully to minimise damage to the surrounding tissues. The defect is exposed and scar tissue covering the floor of the defect is cleaned. The second part shows the harvesting of the periosteum to cover the defect. The periosteum is the normal covering of bones and we use it to provide a roof over the defect.
The third part is the implantation of the cells into the defect. The cells come in a suspension and this is injected into the defect after calculating the volume of the defect. An alternative technique uses a collagen patch with the cells impregnated on it to resurface the defect and obliterate the need for the periosteal patch. This technique is useful to treat cartilage defects, which if left untreated can lead to early osteoarthritis. It is suitable for young active adults with cartilage injuries who are not suitable for knee replacement.
The video is of a patient who is in her mid-30s who presents with persistent knee pain and swelling of 1-year duration. Clinical & MRI examination shows a cartilage ulcer of the kneecap, which is not responding to physiotherapy. Post-operatively, she made a good recovery and has returned to her sports.
MACI represents a new technique in the evolution of cartilage transplantation. It is a 2-stage process, where the first stage is that of a cells harvest done through a keyhole surgery. The second stage involves an open surgery where the cells, which are cultured on a membrane, are implanted. The key difference is that in MACI the cultured cartilage cells are now implanted onto a membrane instead of being in a liquid form (see video on Cartilage Transplant). This leads to the elimination of periosteal patch harvest and its attendant donor site morbidity and pain. In MACI, the membrane is pasted onto the defect instead of being stitched, technically simplifying the process.
This is a video clip of a patient who had Autologous Cartilage Transplant (ACT) done 6 weeks ago. This is a procedure for the treatment of osteoarthritis and cartilage damage. It uses tissue engineering technique to culture the patient’s own cells for implantation. The recovery is quick with good range of motion.
This video clip shows a patient 1 year after cartilage transplant, indicating that the good outcome at 6 weeks seen in the earlier video (see Cartilage Transplant at 6 weeks)last. The patient is able to resume sports activities like running and cycling. The range of motion is full and he can squat and kneel, movements that knee replacement is unable to do.
This video captures arthroscopy of a patient who complains of knee pain after a fall. Since the fall, he has been experiencing pain and swelling in the knee.
The video shows a detached piece of cartilage from its bed. It is floating off its bed and can be easily peeled off. Also, notice how the surrounding cartilage is easily peeled off from the underlying bone.
This patient subsequently went for a cartilage transplant and has since returned to active sports.
This is the video of a patient who is 18 months after cartilage transplant. During a second look arthroscopy, the grafted area protrudes from the surrounding area, indicating that the cells implanted actually grow and multiply. This occurs in about 10% of cartilage transplant cases.
Chondromalacia describes a condition where the cartilage is softened. In this video clip, you can see the tip of the metal probe being sunken into the cartilage crevices due to softening and splitting of the cartilage. This softening of the cartilage may lead to further cartilage damage and eventually to osteoarthritis.
This is a video clip on a normal knee joint. In the medial compartment, notice the smooth shiny white surface of the knee cartilage. The bone at the top is the thigh bone and the flatter bone at the bottom of the screen is the leg bone. The tongue of tissue sandwiched in between is the meniscus. The meniscus functions like the shock absorber of the knee, preventing the cartilage from impacting each other. The meniscus is easily damaged in twisting injury and when injured, causes knee pain and swelling. Sometimes it gets caught and jammed the knee. (watch video clip on Meniscus Flap Tear)
In the notch examination, the structure that is being tugged at is the anterior cruciate ligament (ACL). This is a commonly injured ligament in soccer players. It plays a very important role in knee stability. (watch video on Torn Knee Ligament) In the lateral compartment, the structure is fairly similar to the medial compartment.
The ACL is an important ligament in the human knee joint. It plays an important role in stabilizing the knee joint, particularly in pivoting, twisting, turning and cutting maneuvers. It is an often injured ligament and athletes who have injured their ACL often described their knees as “unstable”, “giving way” or “the knee buckles”. Once the ACL is torn, it is not capable of healing itself and the instability persists. The instability often leads to further damages to the surrounding knee structures such as the meniscus, cartilage etc.
Treatment is often in the form of surgical reconstruction especially in athletes who are involved with ball sports. The following video clips hopes to provide a glimpse of the surgical steps and techniques involved in the reconstruction of the ACL. It is not intended to be exhaustive and does not serve as an instructional video.
The ACL is an important ligament in the human knee joint. It plays an important role in stabilizing the knee joint, particularly in pivoting, twisting, turning and cutting maneuvers. It is an often injured ligament and athletes who have injured their ACL often described their knees as “unstable”, “giving way” or “the knee buckles”. Once the ACL is torn, it is not capable of healing itself and the instability persists. The instability often leads to further damages to the surrounding knee structures such as the meniscus, cartilage etc.
Treatment is often in the form of surgical reconstruction especially in athletes who are involved with ball sports. The following video clips hopes to provide a glimpse of the surgical steps and techniques involved in the reconstruction of the ACL. It is not intended to be exhaustive and does not serve as an instructional video.
The ACL is an important ligament in the human knee joint. It plays an important role in stabilizing the knee joint, particularly in pivoting, twisting, turning and cutting maneuvers. It is an often injured ligament and athletes who have injured their ACL often described their knees as “unstable”, “giving way” or “the knee buckles”. Once the ACL is torn, it is not capable of healing itself and the instability persists. The instability often leads to further damages to the surrounding knee structures such as the meniscus, cartilage etc.
Treatment is often in the form of surgical reconstruction especially in athletes who are involved with ball sports. The following video clips hopes to provide a glimpse of the surgical steps and techniques involved in the reconstruction of the ACL. It is not intended to be exhaustive and does not serve as an instructional video.
The ACL is an important ligament in the human knee joint. It plays an important role in stabilizing the knee joint, particularly in pivoting, twisting, turning and cutting maneuvers. It is an often injured ligament and athletes who have injured their ACL often described their knees as “unstable”, “giving way” or “the knee buckles”. Once the ACL is torn, it is not capable of healing itself and the instability persists. The instability often leads to further damages to the surrounding knee structures such as the meniscus, cartilage etc.
Treatment is often in the form of surgical reconstruction especially in athletes who are involved with ball sports. The following video clips hopes to provide a glimpse of the surgical steps and techniques involved in the reconstruction of the ACL. It is not intended to be exhaustive and does not serve as an instructional video.
The ACL is an important ligament in the human knee joint. It plays an important role in stabilizing the knee joint, particularly in pivoting, twisting, turning and cutting maneuvers. It is an often injured ligament and athletes who have injured their ACL often described their knees as “unstable”, “giving way” or “the knee buckles”. Once the ACL is torn, it is not capable of healing itself and the instability persists. The instability often leads to further damages to the surrounding knee structures such as the meniscus, cartilage etc.
Treatment is often in the form of surgical reconstruction especially in athletes who are involved with ball sports. The following video clips hopes to provide a glimpse of the surgical steps and techniques involved in the reconstruction of the ACL. It is not intended to be exhaustive and does not serve as an instructional video.
The ACL is an important ligament in the human knee joint. It plays an important role in stabilizing the knee joint, particularly in pivoting, twisting, turning and cutting maneuvers. It is an often injured ligament and athletes who have injured their ACL often described their knees as “unstable”, “giving way” or “the knee buckles”. Once the ACL is torn, it is not capable of healing itself and the instability persists. The instability often leads to further damages to the surrounding knee structures such as the meniscus, cartilage etc.
Treatment is often in the form of surgical reconstruction especially in athletes who are involved with ball sports. The following video clips hopes to provide a glimpse of the surgical steps and techniques involved in the reconstruction of the ACL. It is not intended to be exhaustive and does not serve as an instructional video.
This is an intra-operative video clip of the new Anterior Cruciate Graft as it is put through its range of motion. There is no impingement of the graft against any bony structures, signaling a good graft location.
This is part of the rehabilitation for my patients who had Anterior Cruciate Ligament Reconstruction 3 months ago. The training emphasizes on range of motion, endurance, position sense and agility. It is part of the rehabilitation to return post-surgical patients back to sports.
This video clip captures a flap tear of a medial meniscus. The tear has been displaced from its bed and is lodged at the side of the knee. It is being crushed between the femur and tibia, causing the patient to have pain, swelling and a locked knee. Sometimes, patients may feel something moving inside the knee joint.
The video shows a large tear of the meniscus, a tissue that function as a shock absorber in the knee, in a national windsurfer. The torn meniscus has flipped forward, impeding full extension of the knee. The meniscus was subsequently replaced back in its original position and repaired (please refer to Meniscal Repair In-Out video)
This video illustrates one of the techniques that surgeons use to repair the meniscus. Menisci are important weight sharing structures in the knee joint and preservation is the key to prevention of arthritis. Removal of the meniscus results in increase in cartilage stress of >300x, often leading to arthritis in 5-10 years time.
This is an intra-operative keyhole surgery video of a torn meniscus. The meniscus is a tissue that functions as a shock absorber of the knee and part of it is torn here. Compare this to the bucket handle tear video clip and you will notice that the tear pattern is very different. In this instance, the tear is near complete and is hinging on the attached part. The patient feels “something moving in my knee” and may experiences locking of the knee. Treatment is keyhole surgery.
8.
Meniscus Transplant
The meniscus is an important tissue in the human knee joint. It has many functions, chief of which is shock absorption function. It helps to reduce the stress of weight bearing on the cartilage and extends the life of the cartilage.
Meniscal Injuries
Meniscal injuries are very common in active individuals, professional and amateurs alike. Symptoms of meniscal tears include exercise-induced pain and swelling, difficulty in bending the knee or squatting as well as a locked knee. Most meniscal tears can and should be repaired because of the important functions that they serve. However, there will be some who are not reparable and the torn menisci will have to be removed. In such cases, the risk of developing osteoarthritis is high and the onset will be in 5-10 years’ time eg a young athlete who lost his meniscus at 20 years of age runs a high risk of developing osteoarthritis at about 30 years of age, with its attendant crippling effects.
Meniscal Allograft Transplantation
Meniscal transplantation provides a solution to that problem. Using cadaveric allograft meniscus, we are able to restore the weight
bearing characteristics in knees who have lost their menisci. We did the first successful allograft meniscal transplantation in ASEAN and the patient has since returned to sports. In meniscal transplantation, unlike other organ transplants, there is no need for long term medications and risk of rejection is very low. The long term outcomes have been rewarding and lasting with patients feeling no pain in their knees and returning to an active life.
Sometimes the meniscus damage is so extensive that it has to be removed. In these patients, they develop post-meniscectomy syndrome where they experience pain and swelling in the knee especially after exertion. In these patients, the meniscus is replaced using allograft tissues and this video clip illustrates the sequence of events leading to the restoration of the meniscus. We have done numerous of this surgery with very good outcomes. There is no need for long term immunosuppressive medications and graft rejection is not a concern.
This video clip demonstrates the sequence of events leading to a shoulder dislocation. The humeral head rotates outwards to the point that it falls off the glenoid and the flat part (Hill Sach Lesion) perches on the torn glenoid and the shoulder is out.
This is an intra-operative video where the dislocated shoulder joint is reduced. Noticed that there is a flattened part of the humeral head, not unlike a dented table tennis ball. This happens after numerous dislocations where the humeral head impinges on the anterior edge of the glenoid resulting in a divot.
This is an intra-operative keyhole surgical video clip of the front of the shoulder joint. The shoulder is often described as a golf ball on a tee where the arm is the golf ball and the glenoid is the tee. In this video, part of the lip of the glenoid is knocked off resulting in loss of a door stopper effect and the golf ball keeps falling off the front, not unlike a shoulder dislocation. If you notice the lower part of the video, you can see how the humeral head (golf ball) is perched on the broken glenoid and prevent reduction.
This is part of a surgical reconstruction video clip series on the keyhole technique of repairing the glenoid. The torn part of the lip is mobilized so that the tissue can be re-tensioned and repaired.
These are bioabsorbable implants that we use to re-attach the torn labrum to the glenoid. In so doing, we retension the anterior labor-capsular complex and stop the humeral head from falling the glenoid.
This is the finale of the keyhole repair of the labrum. You will notice that the "new" labrum has been constructed serving like a curb to prevent the humeral head (golf ball) from rolling off the glenoid (tee).
This is a video clip of my patient 6 weeks after keyhole surgery to the right shoulder. He has achieved full range of motion, which is painless. Compared to the left side, there is no detectable difference in the range of motion. This is the key advantage of keyhole shoulder surgery, it allows quick recovery of good shoulder range of motion. (watch video on Keyhole Shoulder Surgery)
This video captures arthroscopic resection of the acromioclavicular joint. This joint is located over our shoulder and is responsible for the tip of the shoulder on either side. It can get arthritic and painful especially in athletes involved in overhead sports as well as weight-lifters. In the video, the location of the joint is first identified and resection is performed through keyhole surgical techniques. The rationale is to excise the 2 rough joint surfaces so that there is no more contact and hence no pain. Recovery is quick and patients can often return to their previous sports.
Keyhole shoulder surgery is a big advancement in the field of shoulder surgery. It minimises surgical trauma to the surrounding tissues, hence accounting for faster recovery and better range of motion. It utilises special instruments specially designed to perform the surgery under limited access.
This video shows the surgical scars from a keyhole shoulder surgery 6 weeks after surgery. (watch video on Arthroscopic Examination of the Shoulder)
This is an arthroscopic examination of the shoulder joint. The arthroscope is a specialized instrument that allows the surgeon, through very small incisions, make a thorough examination of the inside of the shoulder joint. (watch video on Keyhole Shoulder Surgery Scar) In this video, the patient suffers from instability of the shoulder with recurrent dislocations of the shoulder. The scope allows the surgeon to examine the various parts of the shoulder joint. The Hill Sach Lesion is a result of the repeated dislocations such that part of the back of the humeral head is flattened. In another scene, the video captured the dislocation seen from within the shoulder joint, where the Hill Sach lesion engages onto the anterior labrum of the shoulder and the joint is dislocated.
Arthroscopic Bankart Repair is the surgical procedure using keyhole technology to treat the instability. (watch the series on Mobilising Anterior Labrum, Suture Anchor & New Labrum)
Foot & Ankle
No
List of Services
1.
Ankle Stabilisation Surgery
2.
Bunion Surgery
3.
Correction of Hallux Rigidis (stiff Big Toe)
4.
General Foot and Ankle Surgery
5.
Keyhole Ankle Surgery
Hip
No
List of Services
1.
Keyhole Hip Surgery
2.
Hip Labral Injuries and Treatment
3.
Hip Ligament Injuries and Treatment
Wrist and Hand
No
List of Services
1.
General Wrist and Hand Surgery
2.
Ligament Injury and Treatment
3.
Nerve Injury and Treatment
4.
Tendon Injury and Treatment
5.
Wrist Keyhole Surgery
Others
No
List of Services
1.
Bursitis
2.
Muscle Strains
3.
Overuse Injuries
4.
Tendonitis (e.g.: Tennis Elbow)
JL Sports Medicine & Surgery #05-08 Gleneagles Medical Centre
6 Napier Road Singapore258499
