Jaime Lewis (Host): Step into the world of cutting-edge orthopedic innovation as we explore ankle cartilage restoration with Dr. Tara Moncman, orthopedic surgeon specializing in foot and ankle surgery at Holy Cross Health in Fort Lauderdale.

This is Thrive with Holy Cross Health, a production of Holy Cross Health in Fort Lauderdale. I'm Jamie Lewis. And Dr. Moncman, thank you so much for being here.

Tara Moncman, DO: Thank you so much for having me. I'm really excited to talk about this subject. I think it's something we don't know a lot about out in the community and even in the general medical world. It's just not something we see very often. So, yeah, let's get into it.

Host: All right. First question basically is what is cartilage restoration at the ankle and why is it important for patients experiencing any kind of joint pain or degeneration?

Tara Moncman, DO: Before I get into that, I think the biggest question is why would we need cartilage restoration, right? Why do patients require that? And that's typically because they have what's called an osteochondral defect of the ankle. That defect I like to think of as a pothole. So if you imagine a car driving over a pothole, the whole car shakes and jumbles, right? Your coffee spills. So now, imagine that that's your ankle joint, and your ankle joint has that defect. So as you're walking, running, cutting, you know, playing pickleball, everything is out of line. So, that can really disrupt the normal mechanics and the alignment of the ankle joint.

So, that pothole is basically where cartilage has elevated up. Sometimes we get this little flap, it can get stuck in the ankle and cause clicking, locking, instability. But what's worse is over time, the joint fluid can kind of seep under that defect and cause more of the cartilage to erode. And that's how we get progressive arthritis of the ankle.

So, I think to answer your question, that's the key. We need to diagnose these injuries early and allow patients to get the right treatment to avoid progressive arthritis of the ankle. So, my go-to, you know, when patients come in and they tell me they've had this vague, deep achy ankle pain after maybe a random ankle sprain a couple months ago, the first thing I think about is an osteochondral defect. So, we get that MRI because that's how you can see it better than on x-ray, and we evaluate for it because the worst thing is a missed defect because those are those patients I see when they're 50 or 60 years old that come in with really bad arthritis, and then we have to talk about a total ankle replacement or an ankle fusion.

Host: That's a lot. I'm wondering what are the common causes of cartilage damage in the ankle and how can they be prevented. Is it possible to prevent them?

Tara Moncman, DO: It's tough. So, we have a lot of studies now that show these actually go misdiagnosed or unseen for a really long time. And some studies show that up to 50% of ankle sprains and 75% of ankle fractures result in an osteochondral defect. But even as a physician, as a surgeon, you know, I wouldn't say that 50% of my patients with ankle sprains, I'm diagnosing these defects. So, they probably are asymptomatic for a while. And then over time, we're developing the effects of it, and that's arthritis. So while you can't really prevent it, because usually these traumas are not really preventable, right? We don't try to have an ankle sprain or an ankle fracture. I think the key is making sure, if you're having pain after one of these traumas and it just doesn't seem normal to you, that you're getting worked up so that we can make sure you don't have that there.

And aside from that, there's also something called osteochondritis dessicans, which is basically one of these defects that happens idiopathically. So, we don't really know why. It's usually in younger individuals. And it's usually because of the poor blood supply that the talus has. So, patients have these little defects and often they're asymptomatic. But it's definitely something we want to keep a close eye on to make sure when they're 30, all of a sudden they aren't missing all of the cartilage along their joint.

Host: Well, let's talk methodology. Can you explain some of the different techniques that are available for this kind of restoration of the ankle?

Tara Moncman, DO: Sure. There's a lot. There's three different categories. So, there's cartilage repair, cartilage replacement, and then cartilage regeneration.

So cartilage repair, that is like marrow stimulation or microfracture. This is the, I guess, the simplest technique. It's the least invasive. Basically, through arthroscopic portals or a camera, you go in there and you take this little surgical pick, which is like an ice pick, and you go into that defect and you make little holes. And you basically try to penetrate the subchondral bone and get to the marrow elements, right? Those good progenitor cells and healing factors. And then, that marrow is going to come up and you're going to get bleeding, and that's going to form this fibrocartilage cap. So, this cap, it's type I collagen, so it's not as strong as our normal hyaline cartilage, which is type II collagen. But it's going to form this little like scar cap, we like to think of it. So, that's option number one. It's really great because it's an easier procedure. It's a quicker procedure, quicker recovery. But you can only use it for smaller lesions. So, things that are less than 1.5 centimeters. They can't have an associated like cyst component along that lesion, so like a cyst in the bone. It's usually better for earlier injuries. So if I have a patient that comes to see me a year and a half out from an injury with a one and a half centimeter lesion, microfracture probably isn't the right choice for them. That's option number one.

Then, there's cartilage replacement. In these terms, you might hear like OATS, like the osteochondral autograft or allograft transfer. And that's where you take a plug of cartilage and bone, and you basically transplant it into the patient's defect. Now, where do you get that plug from? It can be autograft, meaning we take it from the patient, so a non-weightbearing portion of the patient's knee or their talus, or you can use allograft, which would be a cadaver. It's nice because it's a single-stage procedure. You can fill really large defects, so ones that are greater than 1.5 centimeters. The downside is in order to insert these plugs, you have to be, like, perpendicular with the joint. So in order to do that, you usually have to do what's called an osteotomy. So, you have to break the tibia along the medial malleolus or along the fibula in order to have access to that defect and put the plug in. So, it's a little bit more invasive, a longer recovery, which is not always appealing to patients, that usually these are active patients that are trying to get back as fast as possible. But it's a good option when it's needed.

Another replacement option, which is my go-to choice, is particulated juvenile cartilage. So, what does that mean? We basically take cartilage from children cadavers less than 13 years old, usually less than two years old, and this is their actual cartilage that is sterilized and then we pack it into that defect. What I like to do is take some bone marrow aspirate from the patient's pelvis, so you get those good healing factors and progenitor cells, mix it with the cartilage. So, we pack it in there and then we stick some glue on top. This is a great procedure because it's single stage, so you can all do it all in one setting. You could do it all minimally invasive, so through two tiny little incisions, each requiring one suture to close, using your arthroscopic camera. And the studies show that patients do really well. Eighty percent are better at two years, which is great. But again, it's an earlier technique I would say. So, we're still waiting to see long-term results.

And then last, which is kind of the most innovative procedure we have so far, is the regenerative option. So, that's things like MACI or ACI, so autologous chondrocyte implantation, or when you use a matrix to lock all that in place, it's called MACI or matrix-induced autologous chondrocyte implantation. And basically, what that is, is you harvest the patient's cartilage. If you had the defect, we'd go in there, we'd take some of your cartilage from your talus or your knee, and then it is cultured and grown in the lab. Once we have enough cartilage grown in the lab, we can then transplant that into the defect and then lock it in place with like the special cap or the matrix, which is like a scaffold basically. It's innovative, it works. There's some studies that go back and look on MRI and arthroscopy and see that patients, it looks like they have normal cartilage as if they've never had an injury. So, it's pretty incredible.

There's always a downside though, right? So, the negatives with that procedure is that it's two-staged. So, patients who have this, you have to have two surgeries, one for the harvest, one for the transplant. It's expensive. Most insurances cover it now, but not all the time. And it's also facility-dependent. So, not all hospitals or surgical centers have the resources to grow and culture that cartilage.

So, those are the options. And I know it's a lot of information. But I think the things we see most are the microfracture, the OATS procedure, and the particulated juvenile cartilage. And that's kind of in my hands, those are the three main things that I do, depending on the patient and the size of their defect.

Host: Are there any non-surgical management strategies for managing ankle cartilage damage?

Tara Moncman, DO: Yeah, of course. In fact, for the most part, I almost always start with non-operative management. Even patients that say this has been going on for nine to 12 months, it's always worth a shot, right? Avoid the complications of surgery. The patient's been dealing with it for so long, what's a couple more months to give it a try? So if you have a cartilage defect, I put a patient in a boot. If they have pain when they walk in the boot, then I make them non-weightbearing. If they don't have pain when walking in the boot, then I let them keep walking in the boot. And that's for six weeks.

And then, at six weeks, we transition out of the boot into a sneaker, and we start physical therapy. And it's a gradual return to activity, you know, a trial of life. And we see how the patient does. If they're doing well, we allow them to continue to progress as tolerated. I do like to keep an eye on it, so yearly x-rays. Even though we can't see cartilage on x-rays, we can at least make sure that the joint isn't progressively degenerating. And then, I always tell patients if there's any changes, like new pain, new swelling, locking, clicking, instability, anything that's different, then they should come back and see me earlier just to make sure, again, we're not setting them up for failure.

Host: Good. Well, what role do things like platelet-rich plasma and stem cell therapy play in this kind of procedure or in this kind of treatment, I should say?

Tara Moncman, DO: Yeah, it's a very hot topic. I almost always get asked this question by patients. In the right setting with the right patient, there's a place for it. So, things like PRP, bone marrow aspirate, stem cell therapy, you can do those injections, you know, in the office kind of as like a last resort before surgery. My counseling is usually if you are trying to avoid surgery, if you've tried everything and you're willing to spend the money because it's unfortunately out of pocket cost, then absolutely give it a try. But at the end of the day, there's just not literature to support that it will make a difference.

And, you know, some patients do well afterwards. Maybe it gives them a year, maybe a couple years. But I think if you're asking whether using that material or, you know, these augments Routinely, I would say probably not. I think they're nice as an adjuvant to surgery. So for example, I use PRP or more commonly bone marrow aspirate, which is basically, you know, blood taken from the pelvis that has all your progenitor cells and healing factors. And I mix it with that cartilage that we were talking about. Or if I'm doing an OATS procedure, I'll inject it along the area just to give it a little bit more healing potential. A lot of that's based on theory that it should help healing, not necessarily based on level one evidence. It's hard to get level one evidence on these adjuvants just because, as providers, we all use it so differently and we also use, you know, PRP and bone marrow aspirate in combination with something else. So if you were to go back and look at all of your patients you treated with microfracture and PRP, like is it the microfracture or is it the addition of the PRP that's making a difference? It's hard to know. So, there's just not that level one evidence that we would love to have.

Host: You have extensive research background, former Chief of Research at the Rothman Orthopaedic Institute. So with that being said, what kind of developments are you seeing that are getting you excited in this field?

Tara Moncman, DO: I think it is the use of allograft, actually, surprisingly. So for a while there, everything was about autograft, autograft, autograft, right? Taking from the patient. We figured that was the best source. It's just like we used to always take iliac crest from a chunk of the patient's pelvis bone, right? And use that in fusion surgery. And now what we're finding is that these allograft bones, things that are made in the lab, work just as well.

So, I actually had a patient once who had a very unusually sized defect. So, I couldn't take a plug from their knee or their talus just because it was going to be way too much bone, and it almost looked like a snowman. So, you were inevitably going to take some of the weightbearing portion. But you basically take a CT scan of the patient's contralateral talus. And then, they can give you a matched version of that, like a cadaver-matched version. And then, there's special instrumentation where you can take the exact plug that you need and then implant it into the patient's defect. So, it's pretty incredible. Like the CT guides that we have now that can basically like custom fit implants for patients.

Host: That is exciting. Well, is there any last note that you want to leave our listeners with about foot and ankle health and when to seek orthopedic care?

Tara Moncman, DO: Sure. I think everyone gets afraid of foot and ankle surgery, right? Everyone hears that you're going to be non-weightbearing for six months. You're going to be casted. There goes your life for years and years. And I don't think that's the way anymore. We're actually pretty progressive with our weight-bearing. And after a lot of these surgeries, it's true, you do have to be non-weight-bearing for six weeks. But we do try to get you moving quickly, early range of motion. So, I think it's always better to get evaluated and just be a good consumer of your own health. You never have to have the surgery, right? You can always go with non-operative treatment. But I think if anyone's ever experiencing pain in the ankle, it's always better to get it checked out just to avoid 20 years down the line coming in and now barely being able to walk just because the ankle is now full of arthritis, there's instability or malalignment. So, don't be scared.

Host: Good. That's a good note to leave people with. Thank you so much for all your insight and expertise today.

Tara Moncman, DO: Absolutely. Thank you so much for having me.

Host: That was Dr. Tara Moncman, orthopedic surgeon, specializing in foot and ankle surgery at Holy Cross Health in Fort Lauderdale. To learn more about orthopedic services and ankle cartilage restoration, visit holycrossorthopedics.com. And thank you for listening to Thrive with Holy Cross Health.