FAQ Category: Ankle

Surgeons know a lot more about cartilage, its properties, and its injuries now that there are MRIs and arthroscopic examinations available. These diagnostic techniques make it possible to see the exact size, shape, and location of cartilage lesions. All of these tools are used to plan the most appropriate treatment.

Nonoperative (conservative) care might work okay for sedentary (inactive) adults with a small lesion. But active individuals and especially athletes eager to get back into action will need surgery to repair or restore the cartilage. Repair débridement is the first line of treatment for small lesions (less than 1 cm2 in size). The surgeon carefully removes any loose pieces and smoothes any frayed edges.

If that doesn’t work, then the débridement may be repeated. If further treatment is needed, restoration rather than repair is advised. Restoration means that normal hyaline cartilage is harvested from a donor site and transplanted to the defect or hole in the cartilage. Sometimes the donor material comes from the patient. That’s called an autograft. When the harvested healthy cartilage comes from another person, it’s referred to as an allograft.

In either case, essentially what happens is the surgeon takes a plug of cartilage and the bone underneath it from a healthy site (usually the nonweight-bearing portion of the knee) and transplants it into the defect or hole in the damaged cartilage. This is called an osteochondral autograft transplantation (OAT).

The patient stays off that leg for several weeks after surgery to avoid disrupting the healing process. Reports so far of short- to mid-term results are very favorable with this technique. The studies are small but the majority of patients report good-to-excellent results. They say they would have the same procedure done again if they had it to do all over.

That was the first method used to try and restore the cartilage. Now, the technique has advanced forward. A new method called autologous chondrocyte implantation (ACI) is available. Healthy cartilage cells are taken from the patient and grown in a lab until 200 to 300 cells becomes 12 million cells. It takes about six to eight weeks to accomplish the multiplication process.

Then the new cartilage cells are transferred back into the defect (hole). The advantage of this approach is that the new cells can be saved in a cold place for more than a year. The disadvantage is that the procedure requires two separate operations.

In the second operation, the lesion is smoothed and prepped for the new cells. A special patch of bone is layer over the top to protect the healing area. The patch is sealed with a special fibrin cement or glue. The new cartilage cells are injected under the patch. Again, small studies are reporting good-to-excellent results that last beyond 48 months (four years).

In a few patients, the surgeons are able to do a repeat arthroscopy exam and sample some of the healed tissue to see what’s really going on. They have been able to see that the defect doesn’t always fill in with good hyaline cartilage. Sometimes it’s just a fibrous filler, so there’s some concern about that.

One final restorative technique under investigation is the matrix-induced autologous chondrocyte implantation (MACI) that you mentioned. This is similar to the autologous chondrocyte implantation. But instead of growing the harvested cells in a culture and then injecting them into the defect, they are placed on a special membrane where they grow and multiply. The membrane is then used to fill and cover the defect. No extra bone patch or flap is needed. Cells can also be harvested right next to the damaged area, rather than finding another spot to gather them (e.g., from the knee).

There are numerous possible advantages of the MACI procedure over the others:

When joint cartilage is damaged and needs repair, surgeons can take a plug of cartilage and subchondral bone from a healthy joint and transfer it to the defect. A special tool called the Osteochondral Autograft Transfer System (OATS) is used to harvest the bone-cartilage plug. The graft is called autologous because it is taken from the patient. This technique has been used for several different sites such as the shoulder, elbow, and knee.

Results are fairly good. Younger patients seem to have better outcomes than older adults. There’s been some concern about the donor site and problems that might develop there later. It seems the hole left by removing a plug of bone and cartilage doesn’t fill back in with strong cartilage. Instead, the donor site is replenished with more of a fibrous tissue. This could leave the donor site at risk for future problems.

Some research has been done in this area. Surgeons have followed selected groups of patients for two to five years keeping track of pain, stiffness, and loss of function of the donor joint (usually the knee). Evidently, obesity is a negative risk factor for less than satisfactory results. The more overweight the person is, the worse their function afterwards. Pain, stiffness, and changes in gait (walking) patterns can occur.

But if you are a young, healthy adult, all should go well. The procedure is both safe and effective in restoring the damaged area with minimal effects on the donor site for most people.

Ankle sprains are very, very common in athletes of all kinds, but especially among dancers of all kinds. As with most soft tissue injuries, healing and recovery takes time. The amount of time depends on the severity of the injury. Partial tears of the ligaments may require less recovery time compared with complete ruptures.

The severity of injury also determines the type of treatment. Most of the time, ankle sprains are handled nonoperatively. The foot and ankle are immobilized in an Ace wrap, cast, or airsplint. Compression from this type of immobilization helps keep the swelling down. The leg is elevated and ice is applied to the injured area.

Severe injuries may require the use of crutches when standing or walking. If placing weight on the foot is too painful, then walking (and dancing) is limited by partial or non-weightbearing status. The natural recovery of an ankle sprain is usually six to eight weeks.

Dancing on the leg too soon increases your risk of ankle sprain recurrence. If you are planning a career that involves dancing, then taking care of this injury now may help prevent future re-injuries. A fair number of athletes who sprain their ankles go on to develop chronic ankle instability, with repeated ankle sprains and strains.

That’s a good question. It has always been assumed that recovery from ankle sprains requires a certain approach with RICE to manage the acute phase and rehab to follow. But what if you did nothing? How long does it take to recover from an ankle sprain? Can you get back to normal in six or eight weeks?

When is ankle rehab needed? Here’s what a group of athletic trainers found out about the natural recovery of ankle sprains. They tested two groups of people in their biodynamics research lab at the University of North Carolina (Charlotte). One group had mild-to-moderate ankle sprains. The other group was the control — they were normal, healthy adults with no ankle sprain.

Measures of joint laxity (looseness) were taken using a special tool called an arthrometer. The arthrometer results showed more anterior (forward) motion of the ankle and more inversion rotation (foot turns inward) in the ankle sprain group compared to the control group. The amount of extra inversion motion available after injury gradually declined during the eight weeks following the injury. No change was observed in the amount of forward displacement between day three and week eight.

Future studies need to compare patients with an ankle sprain who do have rehab and those with an ankle sprain who do not. Since many people sprain their ankles without ever seeking help, knowing if rehab might help could place a higher premium on follow-up. Athletes interested in the fastest recovery time possible may be especially helped by this information.

In some areas of the country, there are specialty clinics that focus on dancers of all kinds from young children to adult professionals and from hip-hop to classical ballet. Usually these services are located in urban geographical areas like Los Angeles or New York City.

But not always — more and more former dancers are going into fields like physical therapy, sports medicine, and orthopedic surgery. They treat a wide range of patients but hold a special place in their hearts for dancers. Some even offer free screening clinics to help young dancers identify potential problems early on and to get help after minor injuries.

Overuse and repetitive motions comprise the bulk of the problems leading to dance injuries. The foot and ankle seem to be the number one area of problems. Tendonitis, ankle impingement, shin splints, and stress fractures head up the list of conditions encountered in the dance world. This makes sense when you realize that a dancer routinely puts 300 pounds of stress on the foot — and that’s before doing any moves that require jumping or leaping.

Poor technique and technical errors can often be corrected with coaching and/or some specific exercises. Adding a physical therapist to the team who has been a dancer or who has a special interest in dancers is essential. Most dancers will do anything they can to avoid surgery. And they are no strangers to exercise, so when it comes to doing remedial or rehab exercises, they make willing and compliant patients.

Education is the key to a successful, injury-free dancer. Start asking other parents what is available in your area. Check with the staff at the local dance studio (if you have one) to find out if there are any free clinics offered in your area for dancers.

If not, this might be a perfect time to start one! With a little help from local health care specialists, other parents, and dance instructors, this kind of idea could go a long way to improve the health and safety of many dancers, including your son.

Dancers are no strangers to foot and ankle injuries. Repetitive motion, long hours on the feet, and ignoring injuries when they first happen can lead to chronic problems such as you are describing. This may actually be an opportunity for you to help your young dancers learn how to get help early — before problems progress to the point that treatment becomes complex and lengthy.

When dancers are told that they are putting 300 pounds of weight on the bones and ligaments of the foot and ankle by standing on one foot and turning, for example, it can become an object lesson. Leaping and jumping increases that stress even more. Learning good technique and correcting technical errors right from the start head up the “To Do” list for any dancer. You can’t stress this enough.

Taking time to strengthen and stretch has always been a focal point of dance training. Now it’s time to add rehab and reconditioning after an injury. Dancers should be encouraged to report even the smallest, slightest injury. And instructors should be willing and able to accept and use that information to help formulate a plan to prevent a worse problem down the road.

Physical therapists and other sports specialists who have been dancers themselves or who have taken training in dance injuries can be very helpful. They can identify underlying problems and offer acceptable solutions for the athlete (dancer).

Tape can be used to stabilize the foot and/or ankle while demonstrating important movements. Some dancers use a cosmetic sponge to smooth facial foundation over the tape to cover it up. In the meantime, a progressive rehab program is advised for retraining and retuning the ankle joint. The goal is to restore the ankle’s ability to sense and respond to even the tiniest movement. This is an essential step in preventing future ankle sprains.

Let your students see you diligently working to retrain after your own injury. If a picture is worth a thousand words, your actions will be a very powerful message.

Once you’ve sprained an ankle, there’s a good chance you’ll sprain it again. And each time the ankle is injured, the more likely it is that you’ll develop chronic ankle sprains. The orthopedic term for this condition is functional ankle instability (FAI). People with FAI report episodes where the foot and ankle just collapse, give way, or roll under them.

Lateral ankle sprains are the most common. Lateral refers to the outside ankle or the side away from the other leg. Physical therapists and athletic trainers help patients regain normal muscle activation and joint proprioception</i after ankle sprains. This type of rehab program is a strategy for preventing future (repeat) ankle sprains. Joint proprioception refers to the joint's sense of its own position.

But sometimes even after rehab, people end up spraining the ankle again. This is a puzzle. If rehab isn't effective, is it because it's the wrong rehab program? Or is there something else going on in the nervous system that can't be changed with rehab? Or maybe there's a need for a different approach altogether.

A recent study at the School of Kinesiology (University of Michigan-Ann Arbor) did some tests to help figure out where the problem was coming from. They specifically focused on muscle activation of the peroneal muscles. The peroneal muscles evert the foot and ankle. Evert means to move it away from the other foot. The idea was to check for a deficit of muscle activation called arthrogenic muscle inhibition (AMI).

AMI refers to the fact that the peroneal muscles are not being activated with sufficient force for a strong muscle contraction. Without this dynamic activation, the ankle is more likely to be unstable, giving way without warning. If the muscle isn’t getting the nerve messages needed to contract, why not? Is there a problem with local control of the nerve to muscle communication pathway? Or is the breakdown occurring more centrally in the spinal cord of the nervous system?

After conducting the experiment, it became clear that the problem was still in the peroneal muscles. It wasn’t a matter of neuromuscular inhibition or processing at the central nervous system interfering with ankle stability. That means we are back to the drawing board reviewing rehab protocols. Obviously current approaches are not restoring peroneal muscle function as needed to prevent reinjury.

If you are following what your trainer gave you, then you probably haven’t been doing anything wrong. And most likely, he or she gave you the most up-to-date program. This study helps point out the need to identify specific exercises, activities, or interventions that target and return peroneal muscle activation to normal. What’s being done traditionally may not be enough or just right for some patients like yourself.

Acute injuries with pain, swelling, and bruising are still treated conservatively with R.I.C.E. (Rest, Ice, Compression, Elevation). Acute refers to the first few days up to the first week. You can assess this by looking at the amount of tissue swelling (if any) is present after the first few days.

Once the initial swelling is gone, you may consider using mild heat for short periods of time. This is augmented with foot/ankle movement exercises. Usually just moving the foot and ankle up and down (called ankle pumps) is very helpful.

The goal of the heat is to draw blood supply to the area for healing. Too much heat and you can end up causing increased (rather than decreased) swelling and prolonged inflammation. The movement exercises help distribute the fluids and prevent any pooling and subsequent increased or return of swelling.

In many cases, damage to the soft tissues of the ankle is much more severe than the patient realizes. Recent evidence has shown that a short-leg cast may actually result in faster healing for moderate to severe ankle sprains than using a splint or elastic wrap to support the lower leg and ankle.

If you have more than a mild sprain and/or you have sprained the same ankle more than once, it might be a good idea to see an orthopedic surgeon who can evaluate what’s going on and the best treatment approach for optimal results.

Anyone who has sprained his or her ankle even once is at risk for a second or even third sprain of the same ankle. This is especially true when there’s been no treatment to restore the damaged ankle to normal. Chronic ankle sprains can lead to ankle instability. Unexpected and sudden ankle rolling is a sign of ankle instability.

There are many possible reasons for this type of problem. It’s likely you have damaged one or more of the ligaments, tendons, or muscles that help hold the ankle together. There may be an underlying anatomic reason as well. Sometimes variations in the normal anatomy set a person up for injury. For example, a narrow or shallow groove in the bone through which the tendons travel might not be able to hold the tendon in place like it should.

Some people have extra bony bumps, extra bones, or a slightly displaced muscle belly. Some people have an additional muscle such as the peroneus quartus, peroneus digiti quinti, or peronealcalcaneus. In others, the tendon is angled more than is considered within normal limits. Any of these added anatomical features change the dynamics of how the foot works and can contribute to problems.

But you don’t have to continue suffering. It may be possible to rehab the ankle and stop these episodes from occurring. A program of physical therapy may be advised. If, after three-to-six months of daily effort to restore normal motion, biomechanics, and strength, you still have problems, then surgery might be in order. Consulting with a surgeon might be a good idea to see what are your options.

Orthopedic surgery of any kind affecting the lower extremity carries with it the risk of a blood clot called deep venous thrombosis (DVT). An even greater concern is if that clot breaks off and travels to the lungs causing a pulmonary embolism (PE). It could also go to the brain, which is called a cerebral venous thrombosis.

Each of these possible problems must be avoided because of the potential final result: loss of blood to the leg requiring amputation, stroke, and even death. Taking blood thinners before or after surgery is preventive or prophylactic therapy.

Studies show the risk of clots is much higher for hip or knee replacement compared to an ankle fracture. Not everyone having ankle surgery needs prophylaxis for blood clots. But there are some individual patient risk factors that can tip the scales in favor of this valuable treatment approach.

For example, anyone with diabetes (especially diabetes with complications such as delayed wound healing or infections) or peripheral vascular disease (PVD; poor blood circulation) should be considered for prophylactic management of clots.

The potential consequences of a blood clot should always be taken into consideration. You may not even need this kind of preventive care, but it is a good question to ask your surgeon when you go in for your pre-operative work-up.

With any surgical procedure, there’s always a risk of infection, delayed wound healing, or blood clots. In the case of orthopedic surgery, patients have the additional risk of potential complications during or following each specific operation. With severe ankle fractures, there’s the added risk of malunion (fracture heals in poor alignment), nonunion (fracture doesn’t heal at all), or the need for revision surgery.

Patient risk factors that can affect the results of surgery for ankle fractures include age over 75, severe fracture (more than one bone is broken), and general health. Older adults with diabetes and/or peripheral vascular disease (poor circulation) have a greater chance of developing complications after surgery.

It’s the job of every physician to assess patients for risk factors that predict future outcomes. Doing so helps doctors guide patients in the direction of reducing those risks and preventing future problems. Studies comparing high-volume hospitals/surgeons versus low-volume don’t show a significant difference in results for the treatment of ankle fractures requiring surgery.

These kinds of hospital-related factors have been shown in other studies to affect outcomes of hip and knee replacement surgeries. But provider volume hasn’t been shown to be a factor in the success or failure of surgery for ankle fractures.

The biggest concern for your mother may be postoperative care. Having the support and assistance of family members is in her best interest for a positive outcome with the fewest problems possible.

Years ago, surgeons asked the question: joint replacement has worked for the hip, knee, shoulder, and hand — why not for the ankle? It could spare ankle motion and would certainly be better than a fusion with no motion. But early attempts failed. The ankle is just so much more complex in its biomechanical design than even the shoulder.

So it was back to the drawing board. And now there’s a second-generation of implants that seem to have better results. Second-generation refers to the new and improved designs that have replaced those first implants. The studies available are somewhat limited, but it looks like there are fewer problems and a lower rate of failures with the newer ankle prosthetics.

The modern implant design tries to reproduce sliding, gliding, and rotational movements present in the natural ankle. By experimenting with different coatings sprayed on the implant, researchers have found materials that preserve bone and foster improved bone growth around the implant. With better ingrowth, cement is no longer needed to hold the implant in place. That helps eliminate problems caused by the use of cement.

Improved polyethylene (plastic) parts have also improved movement between the parts and reduced overall wear on the implant. That means they are less likely to break or shift causing a partial or complete joint dislocation.

Implants are expected to last at least five years. Some studies show fair-to-good survival rates at 10 years. Slow healing and fracture of the ankle bone are the two main problems that develop. There’s evidence to suggest that these problems are less common as the surgeon’s level of experience increases.

Sometimes the implant migrates (moves) or sinks down into the bone (called subsidence). That doesn’t always mean the implant is a failure. Many patients still report great improvement over their pre-operative state of severe pain and loss of function. They can move their ankle through a greater arc of motion. And they can walk with a normal or near-normal gait pattern. Some even participate in sports.

There are a few studies comparing the long-term results of fusion versus joint replacement. It’s a little bit like comparing apples to oranges. Reasons for failure or the need for revision surgery differ. But the rate of amputation for a failed procedure has been less (one per cent) in patients with ankle replacement compared with five per cent of patients with ankle fusion. All other things being equal, it looks like the results are fairly equal between these two treatment options.

It sounds like you have a condition called osteochondritis or osteochondral lesion of the talus. A corner of the talus breaks off and becomes a loose fragment of bone in the ankle joint. Trauma is the main reason why a corner of the talus breaks off and enters the joint space.

Other causes may include heredity, hormones, and loss of blood supply to the area. A small number of people seem to develop this problem for no apparent reason. Scientists are still scratching their heads over that and trying to figure out what’s really going on.

To answer your question, we don’t have a lot of studies to go on. And those studies that have been done comparing various treatments before and after 12 months have a limited number of patients in them.

But early identification of the problem is helpful in avoiding long-term complications. If the patient with a mild, stable lesion can be placed in a cast or walking boot with protected weight-bearing, the lesion may be able to heal itself.

If the problem goes undetected and untreated, it can become a chronic issue and then a delay in treatment can occur. The results may not be as good as if it were caught early and treated conservatively.

In cases of chronic lesions, or large, unstable defects, surgery can no longer be put off. Here’s where the timing of the more advanced surgeries (bone grafting or chondrocyte implantation) doesn’t seem to make a difference in the final results.

Outcomes in terms of pain, stiffness, tenderness, and gait (walking) pattern are the same whether implantation occurs within the first year of injury or sometime after 12 months have gone by. That information gives the patient and surgeon time to try more conservative approaches. When all else fails, it’s not too late to try one of these more advanced procedures such as you are having.

Ankle replacements were first attempted in the 1970s with mixed results. The failure rate was high and interest declined. But improved designs and better ways to hold the implant in place have turned that around. New understanding of ankle biomechanics and motion has also helped scientists develop a more successful second-generation total ankle arthroplasty (replacement).

As you have discovered, not everyone is a good candidate for a total ankle replacement. Choosing the right patient is as important as selecting the best implant design. The patients most likely to benefit from this procedure are those with severe osteoarthritis, rheumatoid arthritis, and post-traumatic arthritis. They have tried and failed with conservative management. They are candidates for ankle fusion called arthrodesis but would like to save joint motion.

Most of the patients selected for ankle replacement are older and less active. They have severe pain from their ankle arthritis. Those with rheumatoid arthritis seem to have the best results so far. Using these implants for younger, more active adults remains a topic that is debated.

For sure, anyone with a large amount of bone loss, infection, or severe deformity won’t qualify as a candidate for ankle replacement. Surgeons may carefully screen patients who are obese, have severe ankle instability, engage in heavy-labor, or have poor skin or bone quality. These people may be more likely candidates in the future but right now, they aren’t considered good candidates for this procedure.

Surgeons are aware that ankle replacements have improved but still carry a high degree of risk and potential problems even when carried out by an experienced surgeon. Choosing patients carefully, being familiar with the various implants, and knowing how to do the surgery are essential for a successful outcome. The surgeon must plan carefully for individual patient variations in anatomy, alignment, and joint biomechanics.

Fragments of bone loose in a joint is a problem called osteochondritis. The talus is a bone in the ankle between the calcaneus (heel) and the two bones of the lower leg (tibia and fibula). Sometimes the talus is referred to as the anklebone but really there are many bones that work together to form ankle motion.

Chronic ankle pain and loss of ankle motion are the two main symptoms of this problem. Severe ankle pain after trauma (such as an ankle sprain) could be caused by problems other than osteochondritis. There could be a disruption of the blood supply, a fracture, infection, nerve damage, or even an unstable (dislocated) ankle.

If there has been a thorough diagnostic workup (and it sounds like there has been), it’s probably clear where is the exact location of the problem and the amount of damage done. If there is a significant amount of damage and/or the joint is unstable, then if it is left untreated, the condition could worsen to the point of needing an ankle replacement sometime down the road.

Sometimes it’s possible to save the joint by doing an ankle fusion called an arthrodesis. This just holds off the inevitable gradual joint destruction requiring a joint replacement anyway. All of that occurs much later but it’s clear that without proper treatment at the outset, the final result is less than satisfactory.

Sprained ankles are one of the most common musculoskeletal injuries – they make up about a quarter of all sports injuries. And, as you know, you don’t have to be in a sport to sprain your ankle.

It’s not really possible to compare a sprained ankle with a broken ankle because there are too many variables, things that can change. A simple fracture with one clean break may be fairly easy to heal, while a more complicated may need surgery. A simple sprain my heal quickly, but one that does more damage may end up taking longer to heal or, again, need surgery.

The average length of time for someone with a sprained ankle to feel recovered is about six to eight weeks, similar to that of a broken ankle.

Between 10 and 40 percent of patients with sprained ankles develop unstable ankles. The ankles no longer work as well to keep your body upright and keep your feet straight. When you have an unstable ankle, it is much easier to sprain it again because of its weakness.

How about all of the above? The rule of thumb when treating a sprained ankle (or wrist or knee, for that matter) is to follow R-I-C-E.
R = Rest the ankle
I = Ice the ankle
C = Compress the ankle (using a bandage, tape or even a brace)
E = Elevate the ankle

For most sprains, that’s all that is needed, in addition to some rehabilitation exercises to strengthen up the ankles again.

You may need a follow-up phone call or visit with your selected surgeon before making your final decision. It may be helpful to have the therapist evaluate your situation and offer his or her opinion as well. Here are some things to consider. Are there other leg, ankle, or foot soft tissue or bony structures that were damaged at the time of your injury?

Sometimes a tendon rupture pulls a small piece of bone away from the ankle. This type of injury may require a short period of immobilization to allow healing to occur without movements of the foot and ankle disrupting the damaged area. Another consideration is the extent of damage done to the tendon itself. A tear of less than half the tendon fibers can often be managed with conservative (nonoperative) care such as physical therapy.

The injury is given a fair chance to heal and recover. If symptoms have not improved, or the ankle remains unstable after three to six months of conservative care, then surgery may be the next step. If the surgeon gave you a choice between the two treatment options, then it’s likely you are a good candidate for nonoperative care.

If more than 50 per cent of the tendon was torn or you are a competitive athlete eager to get back into training and play, then early surgery may be your best option. Anyone involved in activities that stress the ankle may require the stability surgical reconstruction can offer to avoid repeated injuries.

Chronic ankle sprains can result in major scarring, soft tissue damage, and joint instability. The tendons along the outside of your ankle start up at the top of your lower leg and travel all the way down to the bones of your foot. If tendon repair or reconstruction is needed, an open incision is required to gain access to all the structures involved.

When knee surgery is performed arthroscopically, the damage is confined within the joint and can be seen with a scope. The surgeon may have to enter the knee joint at several different points to see from different angles, but an open incision is no longer needed. The foot and ankle is a much more complex anatomical structure. For simple procedures, a scope may be possible. In your case, it sounds like the damage is more extensive requiring open access to the area.

Scientists have found ways to get a healing response in joint cartilage, but nothing really restores the cartilage back to normal. One way to foster healing is to take normal, healthy cartilage cells from one area of the joint and transfer them to the damaged section. This has been done successfully in the knee and more recently, also in the ankle. The procedure is called an autologous chondrocyte implantation (ACI).

The sandwich procedure is used when the surgeon performs an ACI. Patients selected for this treatment have defects in the joint cartilage that go clear down to the bone. They have had extensive nonoperative treatment as well as at least one failed surgical procedure.

The sandwich procedure was recently developed by a group of surgeons to use along with an ACI in the ankle. They call it a modified ACI procedure. First, the ACI graft is done. Healthy cartilage is harvested from the knee and transplanted to the defect. Once that’s in place, then the surgeon sews a covering over the healing site. The covering is called a periosteal flap. This is the first piece of bread in the sandwich procedure. A special fibrin glue is injected between the flap and the bone graft. This is done to seal off the bone marrow cavity from the joint.

The surgeon puts the second piece of bread in the sandwich right on top of the first. This is done by placing one more layer of bone on top of the first periosteal flap. This layer consists of another periosteal flap, this time turned so the outer bone layer is facing the first periosteal flap. The second flap is also sewn in place, but the surgeon leaves a tiny opening at one end.

Once the second flap is sutured in place, then fibrin glue is used to form a tight seal around the sutures. They do a water test to make sure there are no areas of leakage. At this point, the filling is placed between the two pieces of bread. In other words, the harvested chondrocytes are injected between the two layers of bone graft (i.e., between the two periosteal flaps). The surgeon injects the transplanted chondrocytes into the tiny hole left open when the second periosteal flap was sutured.

It’s good to have an understanding of the different techniques used to repair deep cartilage defects. But this isn’t a commonly used procedure. It may not be one your surgeon performs. Having done your homework, you’ll have a better idea what to ask your surgeon when you do go in for your consult.