Inappropriate Use of New Technology
March 1, 2000 3 minutes read
Inappropriate Use of New Technology
Abstract & Commentary
Synopsis: In 96% of appealed cases, the criteria initially proposed by the developers of chondrocyte autotransplantation were not met.
Source: Mont MA, et al. Evidence of inappropriate application of autologous cartilage transplantation therapy in an uncontrolled environment. Am J Sports Med 1999;27(5): 617-620.
Autologous chondrocyte transplantation is a procedure that has been around for approximately seven years and was developed to treat articular defects in the knee, specifically involving the femoral condyles. Mont and colleagues attempted to examine the indications and contraindications for surgery in consecutive cases initially rejected for reimbursement for the surgical procedure and sent to them for a second opinion. There were 24 consecutive candidates reviewed for an opinion after the primary orthopedic surgeon appealed a rejection by the medical reviewer at the insurance company. Many factors were examined, including the size of the cartilage lesions, presence of tricompartmental arthritis, requests for transplantation for patellofemoral lesions, patient’s age, and deformity.
In 23 of the 24 cases (96%), the indications for the procedure were not met or there were specific contraindications present. In 63% of the cases, there were multiple contraindications. Mont et al state that the importance of a controlled, application-limited experience before releasing a new procedure for widespread clinical application is important. The uncontrolled use of this procedure may negatively skew the overall results for a technique that otherwise may be favorable.
COMMENT BY JAMES P. TASTO, MD
Traumatic articular cartilage defects are not uncommon in young patients, particularly in conjunction with meniscal or ACL pathology. Currently, there are a number of methods used by the orthopedic surgeon to attempt to resurface articular cartilage defects, including abrasion arthroplasty, microfracture, osteocartilagenous transfer techniques, and allografts. There appears to be a favorable clinical response in many of these cases and early results are promising; however, there is no well-orchestrated, double-blind, randomized study that is currently published or that has preliminary results available.
The most common clinically acceptable form of treatment for this today is merely a debridement with or without microfracture or abrasion as the primary method of treatment. When this fails and the patient remains symptomatic from a chondral defect, then consideration may be given to alternative forms of treatment as have been mentioned.
There are few data to support the concept that true hyaline type II collagen is produced with any of these techniques. At best, there is fibrocartilage with some component of type II collagen. We have few data to support the fact that the replacement tissue resembles normal articular cartilage in either biomechanical or biochemical characteristics. The chondrocyte autotransplantation technique made popular by Genzyme demonstrates the most promising results to date in terms of regenerating a true hyalin matrix. However, this article effectively demonstrates that enthusiasm to embrace a new technology can compromise our clinical judgment.
Although this is a challenging area in orthopedics that we may face on a daily basis, we cannot allow technology to run rampant when the original designers of the autologous chondrocyte transplantation technique have laid out some specific indications and contraindications. We stand the chance of perhaps eliminating a valuable procedure if it is going to be done on patients who are not appropriate candidates.
Additional Reading
1. Brittberg M, et al. Treatment of deep cartilage defects in the knee with autologous chondrocyte transplantation. N Engl J Med 1994;331:889-895.
2. Jackson DW, Simon TM. Chondrocyte transplantation. Arthroscopy 1996;12:732-738.
3. Minas T, Nehrer S. Current concepts in the treatment of articular cartilage defects. Orthopedics 1997;20: 525-538.
When Mont et al reviewed the appealed cases denied reimbursement for chondrocyte autotransplantation, they found:
a. most cases were inappropriately denied.
b. most cases did not meet stated indications for the procedure.
c. most cases could have been treated with another modality.
d. most cases had failed other treatment alternatives.
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