At the European Society of Sports Traumatology, Knee Surgery and Arthroscopy Congress, Christiaan van Bergen, MD, PhD, discussed consensus statements on the revision and salvage management of a cartilage repair procedure that reached either strong agreement or unanimous support during the International Consensus Meeting on Cartilage Repair of the Ankle at the University of Pittsburg.
van Bergen noted one of the important outcomes of the consensus meeting was the definition of failure.
“Treatment failure can be considered in any of the following circumstances: 1 year after surgery in the absence of additional ankle injury that is persistent pain or symptoms that interfere with desired patient activities correlated to the lesion; persistent lesions on imaging in symptomatic patients; and three, no improvements or even decline of [patient-reported outcome measures] PROMs compared to the preoperative situation,” van Bergen said in his presentation. “In addition, treatment failure of cartilage repair is considered if a revision surgery is performed for the primary lesion.”
He noted a revision procedure can be considered when the source of the symptoms has been identified as a failed primary procedure without severe degenerative joint disease, as well as when the cause for failure is tangible and “conservative treatment is unlikely to improve patient outcomes.”
A salvage procedure, such as an ankle arthrodesis or ankle arthroplasty, should be considered “in a symptomatic patient with a failed cartilage procedure that cannot be realistically addressed with a revision procedure or a patient with progressive OA of the joint,” van Bergen said.
Several factors were identified in determining the choice of a recent revision procedure, according to van Bergen, including the appearance of the lesion on imaging, mechanical factors, patient age, presence of additional cartilage pathology, presence of a cyst, progression of the lesion, size of the lesion and type of the initial procedure.
“Also, how does a previous procedure impact the results of the subsequent revision procedure?” van Bergen said. “It was agreed that any previously performed cartilage repair procedure may negatively impact the results of the subsequent revision procedure.”
Joint infection, degenerative joint disease, inflammatory arthritis, severe stiffness of the joint, substantial discrepancy between the symptoms and imaging findings, unrealistic patient expectations and patient noncompliance should be considered contraindications to a revision procedure, van Bergen noted.
“What criteria can be utilized in developing an algorithm to assist clinicians in approaching treatment failure in a revision or salvage surgery?” van Bergen said. “Again, a lot of factors: bipolar lesion; condition of the subchondral bone; degree of osteoarthritis; imaging; joint alignment and instability; patient age; patient symptoms; previous treatment failure; signs, location and type of lesion; and, finally, BMI.” – by Casey Tingle
van Bergen C. Consensus on revision and salvage management. Presented at: European Society of Sports Traumatology, Knee Surgery and Arthroscopy Congress; May 9-12, 2018; Glasgow, United Kingdom.
Disclosure: van Bergen reports no relevant financial disclosures.