Paul R. Fleissner, Jr., MD: On the Cutting Edge of Cartilage Repair

Wednesday, December 20, 2017

When pediatric orthopedist Paul R. Fleissner isn’t seeing patients at Crystal Clinic Orthopaedic Center, he is looking for innovative ideas that will improve his treatments and results. So when he learned about a new device — the Reveille® Cartilage Processor — that enabled 1-stage, instead of the traditional 2-stage, surgical repair of articular cartilage with autologous tissue, he was intrigued.

Paul R. Fleissner, Jr., MD, is a board-certified pediatric orthopedic surgeon who has treated sports injuries in children and adolescents at Crystal Clinic Orthopaedic Center for 27 years. In February 2017, he became the first surgeon in the US to commercially use the Reveille® Cartilage Processor to perform autologous chondrocyte implantation in a single-stage, instead of the traditional two-stage, surgery.

“I am always looking for ways to improve and achieve better outcomes for my patients,” says Dr. Fleissner, who had been trying for years to develop a single-stage repair for cartilage defects. “Nothing that we do is ever perfect, so if we look at what we do critically and try to figure out how to do it better, sometimes we find answers that make a difference.”

The Reveille processor seemed to fit the bill. It creates autologous tissue grafts in the OR immediately after the cartilage is harvested, so it can be implanted within minutes.

It didn’t take long before Dr. Fleissner contacted the manufacturer (Exactech) –for more information and, subsequently, for training. In February 2017, he was the first in the United States to commercially use the Reveille.

The patient was a 16-year-old who had dislocated his kneecap and injured a weight-bearing area of the knee while playing basketball. An MRI revealed cartilage loss, but no bone loss.

“Cartilage loss in a child’s or adolescent’s weight-bearing area of the knee can cause osteoarthritis within five to ten years,” Dr. Fleissner explains. “So it’s important that it be repaired.”

In the past, this was done in a 2-stage procedure. Stage one involved harvesting the cartilage to send to a lab to grow in culture. Stage two occurred about six weeks later, after the lab returned the prepped cartilage for implantation.

Dr. Fleissner points out that this isn’t ideal — not only because the patient has to undergo two operations, but because lab-prepared cartilage cells lose their phenotype.

“That’s not good. We hope that the cells will return to their normal type/normal cartilage when they’re put back into the body, but we don’t know that for sure,” he says.

With the Reveille, that problem is avoided because the implantable tissue is created and implanted within minutes of harvesting. “There’s not a bunch of repeated generations in a culture dish, so we think (with the Reveille) it’s going to stay the same type, instead of losing that normal cartilage type,” says Dr. Fleissner.

The process begins with harvesting the cartilage in the usual way. (For Dr. Fleissner’s 16-year-old patient with the cartilage loss in the knee, the cartilage was obtained from the distal femur in a non-weight bearing area, called ‘the notch’.) The tissue is then placed in the Reveille Cartilage Processor, which is a cylindrical device consisting of two blades, a sieve, and removable tissue reservoir.

The Reveille Cartilage Processor creates autologous tissue grafts in the OR immediately after the cartilage is harvested, so it can be implanted within minutes.

“The blades spin very fast and process the cartilage into 1 mm pieces which are filtered through saline,” explains Dr. Fleissner. “After the tissue is processed — it only takes two minutes — we implant it right into the area where there’s cartilage loss and cover it with fibrin glue to seal it. We also add PRP, (platelet-rich plasma), because it has the growth factors that help cartilage heal and grow. So we give the graft a little nutrition to kind of jump start it.”

For the past several years, Dr. Fleissner has been conducting clinical research on biologic methods to improve graft healing. The use of PRP is one of those methods. And it’s showing promise.

The entire single-stage procedure only takes about one hour. According to Dr. Fleissner, the surgery is relatively painless if done arthroscopically.

“Most of the time cartilage repair in the knee is done with an arthroscope,” says Dr. Fleissner. “If the defect is on the back of the knee cap, then we do have to make a bigger incision, so that’s a little more painful.”

Afterwards, the patient must remain non weight-bearing on the repaired limb for six weeks to allow the graft to heal. “We want them to move the limb, because that’s good for the cartilage, but they’re not allowed to walk on it for six weeks. And then they do rehab. It’s usually six months before they can participate in sports,” he says.

In the past eight months, Dr. Fleissner has used the Reveille to perform 15 single-stage autologous chondrocyte implantations in the knee, two in the elbow and one in the shoulder. He points out that it’s indicated for use in any joint but primarily used in the knee.

“The patient has to have an isolated loss of cartilage in an area that is 4 cm2 or less, and everything else has to be normal. There can be no mal-alignment; the patient can’t be knock-kneed or bow-legged. If he or she is, that has to be corrected at the same time as the cartilage repair,” he explains.

“The patient can’t have an unstable knee. If he or she is ACL deficient, that has to be corrected at the same time, too,” he adds. “They have to have a fairly normal joint space, as well.”

As for age limitation, there doesn’t seem to be any. However, the single-stage procedure is not indicated for patients with total joint disease, degenerative arthritis or osteoarthritis.

“It’s usually for a sports injury or over-use injury,” Dr. Fleissner explains. “A lot of our patients are kids who have been injured playing sports, and they lose cartilage from their knee cap or end of their thigh bone.”

He points out that the single-stage procedure seems to be working very well so far. In addition to being less traumatic for the patient, it’s less expensive than the traditional 2-stage cartilage defect surgery.

“I am excited to offer this innovative procedure,” he says. “I hope it becomes more prevalent and the standard of care for cartilage defects.”

For more information, or to refer a patient, call Dr. Paul Fleissner at 330-668-4040.