A pioneering operation is giving those with knee problems a chance to rapidly get back on their feet
CHERYL ADAMSON'S knee has caused her problems most of her life, eventually leaving the 29-year-old facing the prospect of arthritis in the future due to the extent of the damage she had suffered.
• Cheryl Adamson is on the road to recovery after being one of the first patients in the UK to have the pioneering surgery. Picture: Robert Perry
However, pioneering surgery which replaces the damaged tissue in the knee with a synthetic alternative has given the advertising account manager the chance of "getting back to normal".
The technique, now being performed in Scotland for the first time, uses a sponge-like material with a honeycomb structure to take on the role performed by the cartilage, helping protect joints and avoid wear and tear.
The technique, being performed in Scotland for the first time, uses a sponge-like material with a honeycomb structure to take on the role performed by the cartilage, helping protect the joints and avoid wear and tear.
Current treatments which involve removing the damaged tissue solve the problem of serious cartilage damage in the short-term, but can lead to osteoarthritis in the future.
Now, leading sports surgeon Gordon Mackay, based at Ross Hall Hospital in Glasgow, hopes more young, active patients with knee injuries could benefit from the implant technique, developed in Belgium.
The Scotsman was invited to the private hospital to see Cheryl become one of the first patients in Scotland to undergo the surgery. Speaking ahead of the operation, Professor Mackay explained that the synthetic implant was more than simply a replacement for the damaged cartilage – it also encouraged new tissue to grow in its place.
"The idea is that not only is it replacing the tissue, it also encourages regeneration of your own tissue. It is quite a clever idea. It has been piloted in Belgium. They have been doing controlled studies over the last two years. The results have been very promising in terms of tissue regeneration and its viability and use."
Prof Mackay said with cartilage problems so prevalent, the implant – known as Actifit and made by company Orteq – was worth exploring, though the procedure would not be suitable for everybody. "The idea that we can actually customise and replace a defect is an interesting step forward. In the past, cartilage loss would effectively guarantee arthritis," he said.
Prof Mackay said that, in some patients, damaged cartilage could be repaired and stitched back into place. But in more serious cases, it became so damaged that removal was the only option.
"It is in that situation that this technique offers considerable promise because, for the first time, we can actually replace the cartilage. The idea is not that it remains as a permanent synthetic replacement, but it is an immediate replacement that will protect the knee from wear and tear of impact. It will replace the cushion, but allow your own tissues, if not completely, at least in part, to infiltrate into the cartilage.
"The cartilage is designed a bit like a honeycomb, so there are gaps and spaces that cells can grow into."
The implant, which degrades over five years, is made from the same type of material used in vascular surgery, meaning experts are confident it has a good safety record.
Prof Mackay said: "There is a transition period where your natural cells regrow to provide a support and cushion for your knee. The combined effect will be to protect the knee from secondary damage."
According to Prof Mackay, studies by the developers in Belgium found tissue grew into the synthetic cartilage in 85 per cent of patients as early as three months after implantation. He said the tissue formed was very like cartilage.
The technique is at its early stages of use in the UK, with just a couple of centres in England taking it up so far. Prof Mackay went to Belgium to learn about the implant so it could be utilised to benefit patients in Scotland for the first time. One of those patients is Cheryl, from Saltcoats, Ayrshire. With her long history of knee problems, she was keen to try the procedure.
"I feel really lucky I am getting the opportunity," she said from her hospital bed ahead of the operation. "The thought of potentially getting osteoarthritis in my knee when I am not even 30 was not good.
"Prof Mackay explained that the material was the type they used for a heart bypass, almost acting like a junction. What it will do over about five years, it will break down in the body and restabilise everything in there and give me the cushion I don't have anymore. It sounds quite exciting."
Because of the high mobility in Cheryl's knee joint, Prof Mackay said, the cartilage had shredded itself and was unsuitable for repair.
"If it was left that way, as would traditionally be the case, you could guarantee that she would have arthritis in currently what is quite a healthy knee within 15 to 20 years," he said. "When you take out a cartilage it massively increases the contact stresses between the joint surfaces, and the surface of the joint breaks down and that's the start of arthritis and, eventually, you end up with bare bone on bare bone. The idea here in an otherwise healthy knee is to restore the cushioning effect of the cartilage and hopefully prevent all these secondary worries we would normally be leaving her to expect."
When it is time for the surgery to start, Cheryl is taken down to be given a general anaesthetic. Wheeled unconscious into the operating theatre, she is oblivious to the disco beat emanating from a music system, currently playing Best of My Love by The Emotions. The operation is carried out using keyhole surgery, which means just two small incisions are needed, allowing a camera and operating tools to be inserted for the delicate procedure. The inside view of the knee is displayed on large screens above the surgical team's heads.
With surgical assistant Moira Brown at his side, Prof Mackay prepares the inside of the knee joint to receive the implant. The gap where the cartilage has been removed is measured with a tiny tape measure. Prof Mackay then cuts the implant – which resembles a small crescent of foam-like material – to size. This is then placed inside the knee to take the place of the old, damaged cartilage. As the final stitches fix it in place, the music system reassuringly plays Solid as a Rock, and the surgery is complete.
Prof Mackay said while the operation cost around 2,000, it could ultimately save money if it prevented the need for later knee replacements, which cost in the region of 6,000, thus making it a cost-effective option for the NHS.
"The only proviso is we don't really know how it will be in five or ten years, but since we don't have a good alternative for these patients I think we have a strong enough clinical case to press on. Even if, worse-case scenario, they benefit for five years, that's a very important period."
Prof Mackay, who has treated some of Scotland's leading rugby and football players, and once played for Rangers, said the procedure could also prove helpful to those in the sporting arena. "It would be ideally suited to those who are involved in sport because it will protect their joint. The frustration for the high-performance athlete is that the rehabilitation would have to be relatively slow and structured to allow this to integrate and for things to heal nicely.
"In my experience in the professional sporting world, they agree with the theory but they often go for the quick fix which means, 'Just take the cartilage out and let me get on with it'. You might find it is more suited to those who enjoy being active in a recreational sense, but don't mind being patient over six months to allow this to settle and heal properly instead of the sportsman who wants to be back in six weeks."
A week after her surgery, Cheryl is well on the road to recovery, though her leg remains in a brace to help with her rehabilitation. "There was a bit of pain in the first few days which was to be expected, but I am not even taking painkillers," she said. "I think it was worth doing. I'm now just looking forward to being able to get back to normal again."
ANATOMY OF AN OPERATION
• 7:20am: Cheryl Adamson arrives at Ross Hall Hospital in Glasgow for cartilage replacement surgery.
• 7:40am: Surgeon Gordon Mackay talks to Cheryl in her hospital room, making sure she is clear what is going to be done. He marks the knee to be operated on with a large arrow.
• 8:10am: Cheryl is wheeled down to the operating theatre.
• 8:15am: Cheryl is prepared for the surgery and given a general anaesthetic by consultant anaesthetist Duncan Allan.
• 8:22am: Cheryl is taken into the theatre and moved on to the operating table.
• 8:24am: Professor Gordon Mackay makes the first incision in the knee for the keyhole surgery to commence.
• 8:30am: Unwanted tissue is removed from inside the knee and the surface prepared for implant.
• 8:35am: A mini tape measure is put inside Cheryl's knee joint to measure the gap to be filled by the implant.
• 8:40am: The implant is prepared and cut to size on the trolley containing the sterile operating equipment.
• 8:45am: Gripped between surgical tweezers, the implant is placed in the gap in Cheryl's knee.
• 8:49am: The implant is stitched into place and final adjustments are made.
• 9:02am: The operation is complete. Operating tools are removed from knee and plasters put over the incisions.
• 9:07am: Knee is bandaged and splint put on to keep it straight.
• 9:09am: Cheryl is wheeled out of theatre into the recovery room.
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