Focal resurfacing implants to treat articular cartilage damage in the knee

Evidence-based recommendations on focal resurfacing implants to treat articular cartilage damage in the knee in adults. This involves replacing the damaged area with an artificial implant.

# Recommendations
Evidence on the efficacy of focal resurfacing implants to treat articular cartilage damage in the knee is limited in quality and quantity. Short-term evidence shows no major safety concerns, but long-term evidence on safety is limited in quality and quantity. Therefore, this procedure should only be used with special arrangements for clinical governance, consent, and audit or research. Find out what special arrangements mean on the NICE interventional procedures guidance page.
Clinicians wanting to use focal resurfacing implants to treat articular cartilage damage in the knee should:
Inform the clinical governance leads in their healthcare organisation.
Give people (and their families and carers as appropriate) clear written information to support shared decision making, including NICE's information for the public.
Ensure that people (and their families and carers as appropriate) understand the procedure's safety and efficacy, and any uncertainties about these.
Audit and review clinical outcomes, including those in the long term, of everyone having the procedure. The main efficacy and safety outcomes identified in this guidance can be entered into NICE's interventional procedure outcomes audit tool (for use at local discretion).
Enter details about everyone having focal resurfacing implants to treat articular cartilage damage in the knee into a suitable registry and review local clinical outcomes.
Discuss the outcomes of the procedure during their annual appraisal to reflect, learn and improve.
Healthcare organisations should:
Ensure systems are in place that support clinicians to collect and report data on outcomes and safety for everyone having this procedure.
Regularly review data on outcomes and safety for this procedure.
Further research should report patient selection, including the site and size of the cartilage damage, and long-term outcomes, including the incidence of revision procedures and joint replacements.
Patient selection should be done by a multidisciplinary team experienced in managing the condition.
The procedure should only be done by surgeons experienced in focal articular cartilage resurfacing.
Report any problems with a medical device using the Medicines and Healthcare products Regulatory Agency's Yellow Card Scheme.# The condition, current treatments and procedure

# The condition
Cartilage covers the end of the bones comprising the knee joint. There are 2 types of cartilage in the knee  articular (or chondral) and meniscal. Damage because of injury or disease to a focal area of articular cartilage, particularly in the main weightbearing areas, can cause pain, stiffness and reduced mobility. Cartilage tissue has very limited self-healing potential and, if left untreated, cartilage damage can progress to osteoarthritis.

# Current treatments
Treatment for focal articular cartilage damage typically involves arthroplasty or biological treatment. Types of arthroplasty include total, bicompartmental, unicompartmental and patellofemoral. Types of biological treatment include microfracture, osteochondral autograft transfer system and autologous chondrocyte implantation.

# The procedure
Focal articular resurfacing is aimed at people for whom biological treatments and arthroplasty may not be suitable because of age or other factors.
Before surgery, the articular cartilage damage is assessed using a preplanned MRI, an arthroscopy or both. Then, either the implant is customised to fit the damaged area, or an implant is selected from a catalogue to closely match the damaged area. Various implant brands, designs and materials are used for the procedure. The procedure is done under regional (spinal) or general anaesthesia. An incision is made to access the damage site. The damaged area is prepared by removing the damaged bone and cartilage, and drilling a hole for the stem of the implant. The implant is then press-fitted into the damaged area with or without bone cement. The surface of the implant is slightly recessed below the surrounding articular cartilage.
Rehabilitation after surgery depends on the person and implant. It typically includes either an immediate (as tolerated) or gradual return to full weight bearing and range of motion.
The aim of this procedure is to alleviate pain, allow immediate weight bearing, preserve physiological joint function, slow progression to osteoarthritis, and reduce or delay the need for arthroplasty.