Case Study: Knee Arthroscopy: Abrasion Chondroplasty with
Measurements of the Osteochondral Defect and Arthrotomy
and Implantation of Cultured Autologous Chondrocytes on
Porcine Membrane (MACI) in a 47 year-old female

When the articular cartilage wears down to the point that the underlying bone is visible, an abrasion chondroplasty is done. A rotary burr is utilized in this treatment to scrape the bone tissue from the joint’s surface.

An orthopedic knee expert collects cartilage cells from the patient’s knee in order to execute a MACI operation. The surgeon transfers the cartilage cells that were collected to a lab, where the cells develop into new cartilage. The surgeon inserts the new cartilage into the knee’s injured area after it has recovered.

A 47 year-old patient presents with left knee pain that began one week ago. She works as a hemodialysis nurse at SBU and is out of work due to this pain. She is having pain, swelling, buckling and the swelling has decreased. She tried conservative management but had no benefit. The doctor advised her to do an MRI.

MRI was performed, reviewed and discussed by the doctor; the findings stated the Collateral Ligaments: The medial collateral ligament is intact. The lateral collateral ligament, biceps femoris tendon, iliotibial band, and popliteus tendon is intact.

Cruciate Ligaments: The anterior and posterior cruciate ligaments are intact. Menisci: The medial meniscus is intact. The lateral meniscus is intact. The Cartilage: There is a 9 x 6 mm full-thickness chondral defect in the midportion of the medial femoral condyle.

The chondral surfaces in the lateral compartment are intact. There is a focal area of chondral fissuring and partial-thickness cartilage loss in the central trochlea. Bones: The visualized osseous structures demonstrate normal bone marrow and cortical signal intensity without evidence of fracture, trabecular bone injury or dislocation.

No osseous lesions are identified. The Extensor Mechanism: The quadriceps and patellar tendons are normal. Joint: Large knee joint effusion. The soft tissues are otherwise normal. The neurovascular structures demonstrate normal course.

It has an impression of 9 x 6 mm full-thickness chondral defect in the midportion of the medial femoral condyle. Focal area of Chondral fissuring and partial-thickness cartilage loss in the central trochlea. Intact medial and lateral meniscus.

After discussing the options for treatment and the risks of injection, the patient wished to proceed with the injection to reduce pain and swelling. After a sterile prep, 7cc of 0.5% Marcaine and 80mg of depo-Medrol were injected into the left knee.

The patient tolerated the procedure well and there were no complications. Post injection pain, blood sugar elevation, skin discoloration, fatty atrophy and the signs of infection were discussed in detail.

MRI showed a focal osteochondral defect of the left femoral condyle. The rest of the knee looked good. We discussed treatment options and the patient opted for surgical management.

The patient was leaning towards possible repair and reconstruction of the osteochondral defects in an attempt to make it somewhat longer and avoid knee arthritis and early knee replacement. We discussed chondroplasty vs. osteochondral bone grafting vs. joint replacement surgery in the possible future.

The patient understood and agreed for arthroscopic chondroplasty and measurements. We discussed the risks and benefits including infection, bleeding, injury to the nerves and vessels, possible numbness, need for repeat surgery in case we need to do a repair or reconstruction, arthritis, rehabilitation, need in the surgery in the future, among others.

We also discussed the complications including blood clot, femoral artery complications or death. The patient understood and signed the informed consent.

MRI-3T Left knee non-contrast

MRI-3T Left knee non-contrast

The patient was taken to the operating room and she was placed on the right sided operating room table. The patient was sedated and a time out was called. 10 cc of 2% Lidocaine mixed with .5% Marcaine without epinephrine was injected into the mid portal.

A total injection of 30 cc was injected into the left knee. Sedation was given to the patient. The left knee was prepped and draped aseptically in the usual sterile fashion. Compression was applied. The knee was put in a clamp. A timeout was called. Preoperative consent was given already.

The tourniquet was elevated to 250 mmHg. After exsanguination an incision was made. The lateral portal anesthesia was given. A medial anterior portal incision was made with the use of a spinal needle. There was arthritis along the medial femoral condyle and medial tibial plateau. The meniscus was intact.

There was a Grade IV defect of the medial femoral condyle which was debrided with the use of curette and debrided and abrasion chondroplasty was performed with the use of a curette. The defect was measured and was 1.5 cm by 1.5 cm.

Examination revealed an intact ACL. Examination noted lateral tibial tendon patellofemoral compartment showed intact cartilage. Examination of the patellofemoral compartment showed intact cartilage over the patella but there was Grade III to Grade IV osteochondral lesion of the trochlea.

Debridement of this lesion was performed to stable margins. The defect was measured to be 1.5 cm x 1 cm. All of the measurements were taken. All of the pictures were taken and saved. The knee was drained. Closure was done with 3-0 nylon.

Dressing was done with the use of Xeroform, double 4 x 8, Ace wrap, the tourniquet was deflated. The patient was extubated and brought to the recovery room in stable condition.

Intraoperative images

Intraoperative images

The patient seen in the office for her postoperative visit, no x-rays were needed. The patient is doing well, she denies fever and chills. After discussing treatment options, we have decided to proceed with formal physical therapy as well as a home exercise program for rehabilitation of the knee.

We went over the arthroscopic pictures and removed the stitches during the visits. We will continue with ice and elevation of the knee to decrease swelling and pain. We will continue to utilize early mobilization and mechanical prophylaxis to reduce the chances of a deep vein thrombosis.

We will wean them off any narcotic medications and progress to anti-inflammatories and Tylenol as long as there are no contraindications to these medications. We also discussed the risk and benefits and common side effects of taking these medications. The patient agreed for a MACI procedure in future.

After a month the patient went to the office for her follow up checkup, no x-rays were needed. The patient is doing well, she denies fever, chills. She is not able to straighten her knee and bend completely. She is working now with her Physical Therapy.

After 2 months the patient is here for her monthly checkup, upon the follow up consultations the patient is doing well, she has no fever, chills and she is now able to straighten her knee and bend completely. She has no restriction of movement and no pain. She is scheduled for MACI.

The patient was taken to the operating room for MACI procedures, she was placed on a well-padded operating table. General anesthesia was induced in the form of LMA.

Left lower extremity was prepped and draped aseptically in a usual fashion with a bump under the head and a lateral post. A time-out was called. Preop antibiotic was given. Tourniquet was not inflated for the procedure.

Incision was planned along the midline anterior to the patella. It was extended from the distal quadriceps to the tibial tuberosity. Deep dissection and flap were raised above the patellar retinaculum as well as the patella.

A medial parapatellar arthrotomy was done with the use of a sharp blade taking precautions not to injure the cartilage as well as the meniscus. Once the arthrotomy was performed, a good exposure could be obtained for the medial femoral condyle and the patient’s knee was in 90-degree flexion and off the trochlea when the knee was in extension.

The lesions were again seen. In preparation for the transplant, oval template was used for the medial femoral condyle with the knee in 90-degree flexion. The cartilage along the oval template was cut with the use of a blade followed by curette to reach a stable subchondral region.

There was some extension of the loose cartilage posteriorly, which was also excised in line with the defect. Templating of the defect was done with the use of the cover of chromic catgut. Once a good templating was done, it was taken to the back table.

The MACI autologous cultured chondrocytes on the porcine membrane were opened and dropped on the operating field and the template was used to cut the MACI with the cells facing up. Once the template was cut, the medial femoral condyle was checked for any active bleeding.

Hemostasis was achieved well. Two drops of Vista seal were put on the floor and the graft MACI was put on it with the cells facing towards the bone. The Tegaderm was removed and the MACI membrane was patted well with the use of patty gently. Three minutes were given to dry.

Vista seal was applied along the margins also. The posterior margin of the membrane was sutured to the adjacent cartilage using 6-0 Vicryl. Once it was implanted well and dried, the knee was extended to focus attention on the trochlear lesion.

An oval cutting block was again taken, small size, and put on the defect and punched enough to make an abrasion along the cartilage. Knife and curette were used to create the defect. Subchondral bone was reached. Hemostasis was induced with the use of Gelfoam-soaked thrombins.

The MACI membrane was cut with the use of the same cutting block and hammer. The cut was made with a piece of tourniquet behind it. Now the cell surface facing the bone membrane was put onto the defect after application of Vista seal.

It was allowed to dry for 3 minutes followed by application of Vista seal on the edge and again allowed to dry for 3 minutes. Once it was dried, the knee was ranged gently and the grafts were checked on both sides and found to be stable.

Knee was gently irrigated with the use of normal saline. Hemostasis was achieved and closure was done in layers using PDS 4 and 2-0 Vicryl for the arthrotomy followed by 2-0 Vicryl for subcutaneous and 3-0 Monocryl for the skin.

Dressing was done with the use of Xeroform, 4 x 8’s, ABD, Webril, Ace wrap. Knee immobilizer was applied. The patient was given a post op femoral block. The patient was extubated and went to recovery in a stable condition.

With continued physical therapy and follow up checkup the patient did well after the surgery.

Disclaimer – Patient’s name, age, sex, dates, events have been changed or modified to protect patient privacy.

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I had an extremely friendly and personalized medical consult with Dr Karkare. Dr Karkare was very knowledgeable and very professional. His communication skills was extremely good and explained my medical condition in very simple words. The office visit was very helpful in understanding my medical condition. Thank you Dr Karkare
Padmanabhan Nagaraj
20:49 25 Sep 23
Dr. Karlkare and his staff were excellent. Dr. Karkare explained everything clearly and took his time getting to know my Dad.
Anna Acker
22:46 07 Sep 23
Dr Vedant Vaksha had done emergency surgery in 2020 after a traumatic injury.His office at Complete Orthopedics handled the continued care thereafter.Dr V and his staff had been Professional and friendly throughout the process, taking the time to explain all the questions on how to proceed and what to expect.Whenever I needed to speak with Dr V or the office they were a phone call away, without waiting or calling several numbers like in so many other medical offices.The office was accommodating to scheduling to my needs at all times. Dr Vedant Vaksha earned the following5 out of 5 stars, highly recommended.
John Kuey
20:58 05 Sep 23
Dr. Vaksha helped me recover from an injury. I am very thankful that he took the time to explain the best treatment for my injury. Also thankful for the wonderful office staff!
Joseph Castelli
22:30 02 Aug 23
The office is wonderful!… Dr Paresh was very helpful and attentive and made my sister in laws recovery so much better.. Thank you for everything
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17:48 14 Jul 23
The ladies are very welcoming, the service is great, the doctor is very professional and caring and the building is super clean. I really like to come here, the atmosphere is very friendly... Come and you will love it too.
Joan Carasco
14:41 30 Jun 23
Dr. Nakul Karkare is awesome! And patriotic! Thank you, Dr. Karkare for displaying the American Flag in your waiting room, honoring and mourning our military personnel, this Memorial Day, who died while serving in the United States Armed Forces.
Dave
00:52 30 May 23
Excellent and skilled orthopedic practice specializing in joint replacements. Dr Karkare was trained at the Hospital for Special Surgery and has excellent results, as do his associates!! Would gladly refer family members to the practice!!
Eclectic54
00:24 30 May 23
I had such a wonderful experience with Complete Orthopedics in Stony Brook. Not only did Dr. Kuo fix my broken wrist with such kindness and care, but the office staff, including Billing, Reception and the X-Ray Technician, was always so helpful, going out of their way to ensure that each patient felt welcome, answering any questions with a smile, and ensuring any issues with insurance/billing were handled with the utmost professionalism. I highly recommend their practice!
Victoria DeMatteo
19:49 10 May 23
I'm very happy St. Catherine's sent me to this office for treatment after I broke my collar bone! Unfortunately the break was too severe to repair on its own and I had to have it rebuilt a week after the injury. Dr. Vaksha did a great job fixing it. I'm three months out, and I have full use of the arm and shoulder. The whole office staff is very professional, accommodating, and welcoming. I hope to not need orthopedic services again, but Dr. Vaksha will be my number one choice if I or anyone in family suffers such am injury.
Tina Rivera
20:42 08 May 23
No one likes going to the doctor. But these people make it painless. I go for knees, hips and shoulders. At almost 70 Complete Orthopedics keeps my active life style running smoothly. Whether chasing my Grandson and even surfing again, I highly recommend them!!
Thomas Slavin
15:02 02 Mar 23
Dr. Kuo knowledgeable and competent surgeon- very good experience and more importantly great result.
Joseph McCoy
21:23 25 Feb 23
Dr Vaksha was so kind and helpful. He took extra time with us and explained things so thoroughly. Highly recommend. Office very clean.
Susan Bosinius
20:20 19 Feb 23
Dr Vaksha, is a great doctor very professional knows what he talking about. Treat patient with upmost respect. Thank You
Troy Spencer
16:46 19 Jan 23
Dr. Karkare is an amazing doctor, very caring and attentive, the girl at the front desk is very kind and helpful. .elizabeth .thank you so much .
blanca ventura
21:32 26 Oct 22
Been going to this place before my accident and after I had my knee surgery. So happy how I been treated and how well I am getting. Thank you all and specially Dr. VAKSHA for everything and getting back on track.
Ita Opico
19:01 25 Oct 22
Love this place From the minute I called I was treated kindly. When I arrived The Dr saw me right away he was compassionate and ordered the appropriate tests for me. I came back in for my follow up and had the same great experience.
Christine Rostock
21:28 23 May 22
Dr Vaksha and Dr karkare are 2 of the best orthopedic doctors around my wife Susan had a very serious broken ankle in March of 2019 she didn't think she was going to walk again Dr vaksha did an excellent surgery on her ankle he said it was his toughest he ever did he put a lot of hardware in her ankle and told her she would be alright she made remarkable recovery thanks to his surgery as of now she regained 100 percent use of her ankle she would highly recommend him to anyone. My own experience with Dr karkare has been wonderful he takes his time with you listens to what you have to say and prescribes various treatments and is very caring I would highly recommend him to anyone I would give both doctors a 10 plus rating we are very happy with them the best.
Harry Jones
23:31 19 May 22
Complete orthopedics is a wonderful place to go when you hurt or injured a great staff and wonderful doctors very knowledgeable and helpful I would recommend this place to all of my family and friends that is in me of orthopedic care I give them 10 thumbs up
Wayne Pemberton
17:39 18 May 22
The staff is very professional and helpful. Dr. Vaksha is excellent. He takes time to listen and offer suggestions to help you get better. I’m very thankful and happy to be a patient here at Complete Orthopedics.
Phoenix Rising
19:54 16 May 22
Dr.Karkare is the best. He listens to everything and explains everything I recommend him to everyone. I am so happy he is my doctor.
Myrna James
00:48 13 May 22
Dr.Kuo is amazing very attentive,caring,and passionate and staff is awsome too.Thank you for everything Dr.kuo.
Erick Murillo
23:17 12 May 22
I was in a car accident November 1 I was referred to Dr. Vaksha For shoulder surgery . I he was amazing he made me feel very comfortable and explained everything that was going to happen from surgery all the way through my physical therapy highly recommend Dr. Vaksha
Yolanda Ojeda
19:37 09 May 22
My appointment with Dr. Vaksha was amazing. Dr. Vaksha was very thorough and kind. I would refer this office to anyone who needs a great orthopedic doctor.
John Senechal
19:54 05 May 22
Scheduling my appointment was quick and easy. The staff was super friendly and down to earth. I was seen on time. The appropriate test, “x-rays” were taken before the conversation with doctor, something I really liked, test for analysis and conversation was done upfront. Dr. V had a great personality and was no BS, straight forward diagnosis and a play on next steps. I am happy I found them and would refer them to friends and family.
Sam
00:46 03 May 22
I have seen Dr. Kuo two times already and he's awesome along with his staff. Very friendly office and I'm glad to be a patient here.
Camaris A
20:01 28 Apr 22
Amazing team!! Very caring, profesional, and friendly!! Dr. Kevin Kuo, you are the best, very passionate, caring, and helping thank you for getting me better and being so kind to me! Elizabeth you the best thank you for you help always and you big smile and positive actitud❤️🙏🏼
breidy valerio
19:01 22 Apr 22
The staff is truly exceptional, they make you feel comfortable and welcomed. The doctors are amazing,always professional, compassionate and great listeners.
Elizabeth Collado
03:25 09 Apr 22
What a great place! The place is clean and organized.The staff is wonderful. Setting up physical therapy is right there as well.I'm so glad I found this place.
Donna Anne
22:45 05 Apr 22
This was my 1st time breaking something in my 27 years on this planet. I was recommended here by a friend Dr. Vashka helped me from day 1 and still continues to check in on me and my healing ankle. Would highly recommend
tyron davis
16:06 01 Apr 22
Brand new office, same great doctors! Rooms are clean, plenty of parking, physical therapy attached, Dr. Karkare and his staff are awesome. Thank you!
Emily B
02:49 24 Mar 22
Dr.VAksha is the best, I love the way he treats me as his patient, he is caring,understanding and very attentive to my needs
Mirna Caballero
14:53 03 Mar 22
Great staff. Dr. Vaksha is awesome and takes the time to listen to his patients. He is very compassionate. I would highly recommend this office.
Bebe Doyle
01:24 23 Feb 22
After suffering from a severe ankle injury Dr. V was able to help me heal and return back to work completely to a job where I stand for 12 hours a day. The office is very clean and I appreciated the reminders of my appointments via phone call and through text. The patient portal made it easy for me to access all my documents including work notes. The office staff is wonderful and Rebecca was able to schedule me with a busy schedule and awesome at answering all of my questions including referring me to a great physical therapy office. I highly recommend this office to anyone who’s looking for knowledgeable and kind orthopedic office.
Elizabeth Birchwell
21:31 28 Jan 21
The staff here are great, I was seen at the time of my appointment and was well taken care of!
Shaun Berry
18:14 07 Jan 21
They are an excellent practice. The front and back office people are amazing and so helpful. Rebecca is such a kind and understanding person. I had an issue with paperwork and she cleared it right up. Dr. Karkare is very knowledgeable, helpful, and caring.
Matt S.
19:31 18 Nov 20
Rebecca K. - What a true burst of sunshine. Very friendly and definitely an asset to the practice!
Laura Aston
18:17 17 Nov 20
Great experience, the Doctor is nice but the staff is incredible. I worked with Linda, who was profession and assisted me beyond what any person has done at other practices. Complete Ortho should be complimented for having such a person on their staff.I highly recommend this place!!!
Joe Allen
17:26 17 Nov 20
Linda and Becca they are so good ever time I come they are very nice I would tell everyone I no to come to this office..
Barbara Victor
16:45 17 Nov 20
I was rear ended in an auto accident , Dr Vashka was recommended by a friend of mine .I was experiencing Back , neck , and shoulder pain . After a thorough examination and given exercises to do at home , I am feeling much better , and I ended up avoiding surgery . The staff at Complete Ortho is extremely attentive and show great care when making an appointment and are very friendly and i never waited more than 5 minutes for my appointment . So I would strongly recommend Complete Orthopedics for any aches and pains that one might be experiencing.....
Bill Becht
04:44 17 Nov 20
It was the afternoon of Friday Sept. 24. We were in Pt. Jefferson and my wife, Mary Ann, broke her hip. We went to Mather Hospital and it was determined that she would have to have an operation to have it repaired. This would be her third time under the knife in the past year. It just so happened that we were very fortunate enough to have Dr. Karkare, who was on standby, perform the surgery. He put in a rod and two screws in her hip. She spent a few days in the hospital and then went to Gurwin rehabilitee for another few weeks.It has now been almost six weeks and we both worked the election the other day. If it wasn’t for Dr. Karkare’s expertise she never would have been able to work. She is able to walk with a walker and is doing physical therapy three times a week.We can not thank the doctor enough for the compassion and dedication that he puts into his work. It allows Mary Ann do the things that she likes to do, even on a limited basis for a while. I know that with her will, perseverance and the great work that the surgeon performed she will be back on her feet in no time.Sincerely:John V. PlumpEast Northport, NY 11731
Jack Harris
14:36 06 Nov 20
In the year of 2018 I was referred to Dr. Karkare because I was experiencing severe knee joint pain. After exhausting physical therapy and trying to labor through the pain, I had to make a quality of life decision. Total knee replacement was the only viable option. Dr. Karkare made my decision easy as he walked me through the whole process from surgery to recovery.On 12/13/19 ( Friday the 13th) I enter Lenox Hill Hospital in great hands. From the time I entered Dr. Karkare’s office for the first time until now, his staff has been amazing. Andrea the medical coordinator walked me through all the paper work and necessary preparations for the surgery. Courtesy and kind would be an understatement. Dr. Karkare went over and beyond from the wellness checks and phone calls all to assure me that I was important to him. This was the right decision no pain and no limp. Complete Orthopedics should be your choice!
Kenneth Randolph
22:18 25 Sep 20
Dr. Vadshka has a great bedside manner. He really takes his time and explains treatment options.
T Lee
12:33 09 Sep 20
I suffered with pain in both knees for years. My orthopedic doctor kept recommending knee replacement . I fought it for years, as I was just afraid. When I had no choice and could barely walk , it was recommended I see Dr. Karkare. We set up a consultation and my wife and I left his office feeling totally confident and comfortable with moving ahead with the surgery. He explained everything to us, and the office staff set everything up for us and made the process easy. So about one month after our initial meeting I had the first knee done. I was up walking mere hours after the surgery, and on the workout machines the next morning. I went home two days after the surgery, and yes walked my daughter down the aisle at her wedding only one week after the surgery without even a cane! Three months later I had the other knee done and went home the very next day. Dr. Karkare put my fears to rest . I would highly recommend him. His expertise gave me my life back. Thank you Dr. Karkare.SincerelyVito Congro
Ethel Congo
23:58 12 Aug 20
Dr Rhodin really cares for his patients. When I see him he makes sure to review my progress in detail.
Micki Cahill
15:03 08 Feb 20
My mom had a total hip replacement by dr karkare. He is the BEST orthopedic doctor.Her incision is almost invisable.She is going back for her other hip next week. The office staff is the best, love Andrea.You wont find a better doctor.
Ryan
21:06 13 Jul 18
There is no better Orthopedic doctor you will find. Broke my ankle three places on a Saturday. Called Dr. Karkare. He had is team ready at the hospital and operated on me within 6 hours after my injury. Now After 3 months of great care by him and his staff, I am walking to normalcy.
Spacecom Tel
04:13 23 Mar 18
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I am Vedant Vaksha, Fellowship trained Spine, Sports and Arthroscopic Surgeon at Complete Orthopedics. I take care of patients with ailments of the neck, back, shoulder, knee, elbow and ankle. I personally approve this content and have written most of it myself.

Please take a look at my profile page and don't hesitate to come in and talk.