Knee-deep in controversy Marketing of surgery on cartilage questioned

February 15, 1997|By Jonathan Bor | Jonathan Bor,SUN STAFF

A surgeon with the Helix Health System in Baltimore has begun using a controversial procedure to repair knees in which cartilage is removed, expanded in a laboratory and put back into the knee.

The technique has been hotly debated in the United States since its introduction two years ago, some surgeons praising it as a good alternative for some hobbled patients and others criticizing its commercialization.

Doctors with Helix say it is suitable for a small proportion -- perhaps 2 percent -- of patients with damaged knee cartilage who have exhausted conventional therapies and are too young for knee replacements.

Often, doctors repair cartilage tears by removing the damaged tissue so that the knee can move freely. But that leaves a patch of bone that is vulnerable to osteoarthritis, a painful and irreversible breakdown of the joint. Cartilage reduces friction and cushions the joint from the constant pounding of walking and running.

Dr. Michael Jacobs, a Baltimore surgeon who is a team orthopedist for the Orioles, performed his first cartilage transplant recently at Good Samaritan Hospital. The patient was a Washington policeman who had endured nine previous operations since stumbling into a pothole while chasing a rape suspect.

"The outcome of this is expected to be one where the normal cartilage re-forms in the joint," Jacobs said. He and a colleague, Dr. Leslie Matthews of Union Memorial Hospital, plan to treat eight other patients.

The policeman, 30-year-old Stephen Jiggetts, injured his knee in 1990. He was taken off street duty and assigned to less physically demanding work counseling high school students.

Jiggetts, a former amateur boxer who sparred with Riddick Bowe before Bowe became heavyweight champion, said he hopes to return to street duty and resume at least light athletics.

"I haven't jogged in two years," said Jiggetts, whose knee is covered with surgical scars.

The surgeons cautioned that the cartilage transplant is not an arthritis cure or a mainline therapy for the many thousands of people sidelined each year by torn knee cartilage.

The transplant is intended to repair articular surfaces -- the tough, smooth cartilage that coats the ends of the femur (thigh) and tibia (shin) that meet at the knee. It is not suitable for repairing meniscus cartilage, the fibrous rings that sit like washers between the bone ends.

A multistep procedure

The multistep procedure, which involves two operations several weeks apart, has been vigorously promoted by Genzyme Corp., a Cambridge, Mass., biotechnology company that cultures the extracted cartilage cells.

A surgeon harvests a small amount of healthy cartilage from an area of the knee where it is needed least. That is done in an outpatient procedure known as arthroscopy, which involves the insertion of narrow instruments and scopes through tiny incisions.

The tissue is shipped to Genzyme, which uses a proprietary process in which millions of new cells are grown in a laboratory. Several weeks later, the original cells and the ones generated from it are suspended in a liquid and returned to the hospital, ready for transplant.

The surgeon opens a 6- to 8-inch incision in the knee, sews a protective flap of tissue over the injured area and injects the cartilage cells beneath the flap.

Long rehabilitation

The cells eventually form a solid tissue similar to the original cartilage. The patient must stay off the leg for several weeks, then undergo months of rehabilitation.

The overall cost is $30,000 to $40,000, which includes a $10,000 fee charged by Genzyme. The procedure is not commonly covered by insurers, which generally regard it as experimental. Jiggetts and some other patients who were injured on the job have obtained coverage through worker's compensation.

The method was developed a decade ago by Dr. Lars Peterson, a Swedish doctor who has performed it about 400 times.

Genzyme brought the technique to the United States in 1995 and holds an exclusive license to apply the technology here. Since then, more than 250 U.S. physicians have been trained.

Genzyme has reported encouraging results with 53 patients who were followed for six months after surgery. Based on physical examinations, physicians reported that 73 percent of the patients improved and 12 percent worsened. When patients were asked how they felt, 84 percent said they felt better and 8 percent said they felt worse.

Preliminary results were similar for patients in Sweden who were followed for two years.

'Questions remain'

Peterson and a Boston doctor were scheduled to present longer-term results today during a symposium at a meeting of the American Academy of Orthopaedic Surgeons in San Francisco.

Members of the panel were to discuss articular cartilage regeneration and other new technologies. "Despite the apparent promise of these approaches," the academy said, "questions remain about their efficacy, long-term results and regulatory status."

The debate during last year's meeting of the academy was described as heated.

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