Disclosures. How to approach cartilage repair. Articular Cartilage Problems: Surface Options

Transcription

1 Disclosures I have the following potential conflicts of interest: Consulting payments/royalties and research support directly related to products discussed: Vericel (ACI) [consultant] SLACK publishing [book royalties] FDA status of devices discussed: Many of the applications presented are considered off label Brigham and Women s Hospital Harvard Medical School Articular Cartilage Problems: Surface Options Andreas H. Gomoll, MD Associate Professor of Orthopaedic Surgery 850 Boylston Street Chestnut Hill, MA T: F: How to approach cartilage repair Be pragmatic, not dogmatic: Feel comfortable with most, if not all cartilage repair procedures Pick what works for the specific lesion 1

2 Cartilage Repair Options Surgical Options 1) Debridement 2) Microfracture (plus) 3) Osteochondral Autograft 4) Osteochondral Allograft 5) Juvenile particulated allograft cartilage (JPAC) 6) Perforated cartilage allograft (PCA) 7) ACI Cartilage Repair Options Surgical Options 1) Debridement 2) Microfracture (plus) 3) Osteochondral Autograft 4) Osteochondral Allograft 5) Juvenile particulated allograft cartilage (JPAC) 6) Perforated cartilage allograft (PCA) 7) ACI What is JPAC? Juvenile particulate allograft cartilage Hyaline cartilage Morcellized into <1 mm cubes Cell delivery vehicle Different from osteochondral allograft Cell based repair like MFx or ACI 2

3 Where do I use JPAC? Prime indications for JPAC: Focal contained defect 1 4cm 2 Adjuvant to OCA Anywhere Intact subchondral bone Results Bonner et al J Knee Surg 2010 Single patellar lesion at 2 y improved from baseline Farr et al Cartilage patients at 2 y post op improved from base line Tompkins Arthroscopy knees in 13 patients 73% normal or nearly normal ICRS MRI Tompkins et al Operative Techniques in Sports Med 2013 Technique review Farr et al AJSM patients with minimum 2 y post op; majority f/u Pros and Cons Pros and Cons: + Can address (almost) any size and shape + Can schedule surgery on specific date +Don t have to compromise healthy bone Need to consider bone Slow maturation and rehab (not fire + forget) Data still limited 3

4 JPAC Technique Outline defect; include all soft/fissured cartilage Create stable vertical shoulders Make foil template to prepare fibrin glue/jpac construct and fix in defect with additional fibrin glue; Or, place pieces in defect and cover with fibrin glue Biggest problems Limited data Long rehab as for all cell based Need for good bone What is PCA? Perforated cartilage allograft Hyaline cartilage layer with minimal bone Perforated to allow cell proliferation and subchondral integration Flexible can conform to complex PF anatomy Different from osteochondral allograft, but closer than JPAC Most of the graft remains structurally intact 4

5 Where do I use PCA? Prime indications for PCA: Not sure Focal contained defect up to 2cm diameter Anywhere Intact subchondral bone Results None clinical Pros and Cons Pros and Cons: + Can address complex PF geometry more easily than OCA + Can schedule surgery on specific date +Don t have to compromise healthy bone Need to consider bone slower rehab than OCA No data 5

6 PCA Technique Outline defect; include all soft/fissured cartilage Keep maximum graft size in mind Create stable vertical shoulders Make template and cut graft based on template Marrow stim defect base (abrasion arthroplasty) Secure in defect (sided graft!) with fibrin, suture, anchor Biggest problems No data Need for good bone Limited graft size and shape (2 cm diameter for now) What is ACI? Autologous chondrocyte implantation Autologous chondrocyte suspension Cell based repair > slow maturation process Implanted under periosteum (collagen) cover Approved almost 20 years ago 6

7 Where do I use ACI? Prime indications for ACI: Focal contained defect >2.5 cm 2 Multiple defects Femoral condyle, trochlea or patella (off label) Intact subchondral bone (OCD ok in young) Results against MFx Van Assche (RCT) No difference at 2 years (2.4cm 2 ) Kon (Cohort) similar at 2y, MACI better at 5y (2.4cm 2 ) Saris (RCT) histology, outcomes at 3y, at 5y only for more acute defects (<3y) (2.7cm 2 ) Basad (RCT) MACI better at 2y (>4cm 2 ) Saris (RCT) MACI better at 2y (4.8cm 2 ) Knutsen JBJS(2004) Saris AJSM(2008, 2009) Basad KSSTA (2010) Kon AJSM (2009) Van Assche KSSTA (2010) Saris AJSM (2014) Results Peterson, Farr, Cole, Zaslav, Minas, 210 patients with ACI, minimum 10 years (average 12 years) Ave age 36, ave defect size 8.4cm2 75% with intact grafts 25% revised (10% with arthroplasty, 15% with cartilage) Minas CORR

8 Pros and Cons Pros and Cons: + Can address any size and shape + Can schedule surgery on specific date +Don t have to compromise healthy bone +Tons of data Need to consider bone Slow maturation and rehab (not fire + forget) Classic ACI Technique Outline defect; include all soft/fissured cartilage Create stable vertical shoulders Secure patch with interrupted 6 0 sutures Waterproof suture line with fibrin glue Inject cells and close injection site Cell-seeding ACI Technique 8

9 Biggest problems Graft/patch hypertrophy Resolved with use of collagen membrane (40% > 5%) Two stage procedure Adds some morbidity, but also predictability Long rehab Has improved somewhat with accelerated rehab protocols Need for good bone Summary Surface treatments are viable options for cartilage repair Need largely intact bone ACI for larger defects JPAC for small to medium sized defects Share long rehabilitation due to slow tissue maturation PCA new, unclear indications How to approach cartilage repair Be pragmatic, not dogmatic: Feel comfortable with most, if not all cartilage repair procedures Pick what works for the specific lesion 9

10 Thanks very much! 10