Basketball is Alec's passion. In high school, he wasn't the tallest player on the court, but he was usually the fastest. Even when the ball wasn't in his hands, he never stopped moving. Alec lived for those games. So, it's easy to imagine his utter disappointment when his junior season was cut short by a knee injury.
On a Saturday afternoon, in the middle of that winter, he and some friends watered down a snow-covered driveway and froze it so that they could play ice hockey. "I always play to the fullest, so I was dropping to my knees a lot," Alec says.
When he woke the next morning, his right knee was sore, but not enough to keep him from playing basketball later in the day. By Monday morning, however, his knee had swollen quite a bit. "Eventually, it got to the point where I was in more pain than I was comfortable with," he says.
He underwent arthroscopic surgery on his knee and then, during a second procedure a few months later, he had three screws placed to repair a fracture of his lateral femoral condyle, the outer ball shape located at the end of the femur. It took him about six months to be able to run again, which felt like a lifetime to 18-year-old Alec, but he was back to normal just in time for the start of his senior season.
Alec played the entire season without any trouble from his knee. Over the months that followed, however, he grew increasingly uncomfortable. Most days, he felt a degree of pain with just about every step he took. Playing basketball was usually too much to bear for him. He even had to stop teaching a boxing class for people with Parkinson's disease.
Sensing that something was wrong, Alec met with Miltiadis H. Zgonis, MD, an orthopaedic sports medicine surgeon at Penn Orthopaedics and Co-Director of Penn's Human Tissue Laboratory. Dr. Zgonis diagnosed him with osteochondritis dissecans, or OCD, a condition in which the bone underneath the cartilage of a joint dies from lack of blood flow. In Alec's case, the affected bone and cartilage had detached and fragmented, breaking loose in the joint, which caused him pain and hindered his range of motion.
There was another layer to Alec's knee trouble, too. The screws that were placed during his surgery four years earlier had resorbed and fragmented and, Dr. Zgonis says, "caused a big cystic cavity to form behind the cartilage and bone defect."
A Difficult Procedure Made Even More Complicated
In November 2018, Dr. Zgonis performed arthroscopic surgery on Alec's right knee to alleviate some of the pain and stop it from locking, which it had become prone to doing without warning. Dr. Zgonis removed all of the cartilage, bone, and screw fragments that he could find. Afterward, Alec says it was the best his knee had felt since before his fracture. It felt so good, in fact, that he asked Dr. Zgonis whether the second surgery he planned for six months later was even necessary. It was. Left as is, Alec was likely to develop degenerative arthritis in his knee, even at his young age.
During that initial procedure, Dr. Zgonis also began laying the foundation for the next surgery. He took a cartilage biopsy from the healthy cartilage in Alec's knee. Those cartilage cells were then isolated and multiplied in a lab.
In May 2019, a couple weeks after graduating from Temple University, Alec underwent the second procedure, called autologous chondrocyte implantation. Basically, the "pothole" in the cartilage, as Dr. Zgonis refers to it, is cleared out, exposing the healthy bone underneath. Then patient's own cartilage cells that were multiplied in the lab are used to fill the hole and covered with a bovine collagen membrane to keep it in place while it absorbs into the patient's anatomy. Over time, the cells will mature into hyaline-like cartilage as if the hole was never even there.
"It's very similar to what you're born with," Dr. Zgonis says. "It's not exactly the same material because that is, at this time, not technically possible to replicate."
Before this procedure, which is now in its third generation, was developed, the only option to treat the "pothole" was to fill it with cartilage and bone from a compatible donor that would need to be transplanted almost as soon as they became available — whenever that may be.
The current iteration is a far more flexible surgery for all involved, but it's still quite complex and not widely-performed beyond Penn. "The Penn Cartilage Center is one of the busiest centers for autologous chondrocyte implantation in the world," says James L. Carey, MD, MPH, Director of the Penn Center of Advanced Cartilage Repair and Osteochondritis Dissecans Treatment.
"With Alec, we ended up having to essentially fill the cyst with a bone graft and then repeat the process for the original cartilage defect," Dr. Zgonis says. After that, Alec's multiplied cartilage cells were placed and given time to heal through.
"It's a lot to go through, but without it, Alec definitely would have developed degenerative arthritis down the line. And likely at a very early age because his injury was on a part of the knee that sees a lot of stress," he says. "Alec was really an ideal candidate for this intervention. He had such a positive attitude about all of this. He was unbelievably dedicated to his physical therapy, and he followed our instructions to a T."
"I Feel Really Good"
Alec's knee is expected to be back to normal around 18 months after his second surgery. But at the 10-month mark, he's already been playing basketball for several weeks. "I feel really good," Alec, now 22, says. "I'm able to shoot hoops without any pain or swelling, which is big."
The recovery process, particularly in its early phases, was tedious, Alec says. But he found the necessary patience to get through it and he committed to his physical therapy because he believed in Dr. Zgonis. When he told Alec to have faith, Alec did. And once he started jogging, it wasn't long before he was running at full-speed and jumping with his old explosiveness.
"I knew that Alec's knee was going to get better than it was. But, given the magnitude of his problem, I didn't know for sure that he'd be able to function at the level of what he's even doing now," Dr. Zgonis says. "With the remarkable progress he's made already, I don't see him having any functional limitations in the future."