Greetings From SCOI. Richard D. Ferkel, M.D

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2 Greetings From SCOI Richard D. Ferkel, M.D

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5 OLT In the Athlete Operative Treatment and Return to Play The Following relationships exist: Royalties and stock options Smith and Nephew Consulting income Smith and Nephew, Geistlich, Sanofi Research and educational support Ossur, Mitek, Don Joy, Smith & Nephew

6 Arthroscopic Treatment Thigh and Ankle Support Supine Ankle Distractor 2.7 mm Short Scope with Interchangeable Cannulae Use AM, AL, PL, TT,TM Portals,

7 Lift Lesion Lateral Inverted Osteochondral Fracture of the Talus Dunlap & Ferkel (2013) 10 Pts with Acute Injury All Lesions Involved Lateral Talus with Lateral Ligament Injury 8 Lesions Were Reattached and 2 Were Excised Arthroscopy 29: 1826, 2013

8 15 year old basketball player

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11 Operative Procedure

12 Absorbable Pins Made of Polydioxanon Takes 6 Months to Absorb Can Be Used Via Arthroscope or Open

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15 Operative Procedure And Results Mean Age = 17 Yrs Mean F/U 9.3 Yrs AOFAS Score Final Weber Score = 82 Berndt & Harty; E-G = 6, Fair = 3, Poor = 1 Arthroscopy 29: 1826, 2013

16 CHRONIC CHRONIC OSTEOCHONDRAL OSTEOCHONDRAL LESIONS LESIONS OF THE OFTHE TALUS TALUS

17 Indications for Surgery All CT or MRI Stage 1 & 2 Lesions That Fail Nonsurgical Rx All CT or MRI Stage 3 Lesions in Children Under 18 that Fail Nonsurgical Rx All CT or MRI Stage 3 Lesions in Adults & Children All CT or MRI Stage 4 Lesions in Adults & Children

18 Chronic OLT in Children Treat in Cast or Boot for 6 Weeks Physical Therapy Treat Conservatively Transtalar Drilling Without or With Bone Graft to Maintain Integrity of Articular Cartilage Bone Graft & Reattach Loose Chronic Lesions if Possible Excision, MicroFx Drilling Only If OLT Nonviable

19 Treatment Options for Cartilage Defects < 1 cm 2 Debridement Drilling MicroFracture cm 2 Debridement Drilling MicroFracture Osteochondral Transplants ACI Allografts Juvenile Allografts Micronized Cartilage Matrix cm 2 Drilling Osteochondral Transplants ACI Allografts Juvenile Allografts Micronized Cartilage Matrix

20 Factors Influencing Choice of OLT Surgical Procedure Size of Lesion Location of Lesion Containment of OLT Subchondral Cyst Status of Cartilage Cap Associated Pathology Patient Preference

21 Identify Lesion CT or MRI Verify that Lesion is Source of Pain Appropriate Conservative Treatment Chronic OLT In Adults T-M or T-T Drill if Not Loose Pin If Loose and Articular Cartilage Healthy Excise if Loose or Displaced, Then Drill/Microfracture Base Bone Graft Cyst if Large Via T-T or T-M

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23 Excision of P-M OLT Scope Thru P-L Portal Inflow Thru A-L Portal Instruments Through A-M Portal Via Notch of Harty

24 P-L View

25 Microfracture Place Holes 3-4 mm Apart and 4 mm Deep Avoid Collapsing Subchondral Plate Can Be Combined with Drilling J.J.

26 Use: Pick Assist Accessory to (Curved) Microfracture Picks Allows Surgeon to Use Mallet and Drive Tip of the Pick In the Intended Direction (Striking Plate on Handle) Hard Bone Minimize Skiving, Damage to Opposite Side Cartilage

27 MicroFx/Drilling How Deep is Enough? Steadman, R. et al. Do 3-4mm Deep Chen, H. et al. Drilling 6mm Depth Produced Better Fill and Quality of Cartilage Than 2mm Depth MicroFx Results Similar to Drilling at 2mm Depth At This Time, It is Not Clear Which Technique Gives a Better Cartilage Healing Response J Orthop Res. 29:

28 Drilling Options

29 P-L View

30 Crimson Duvet Leads To Fibrocartilage

31 Microfracture Augmentation Strategies Scaffold Augmentation Scaffold and Chondrocyte Augmentation Hyaluronic Acid Augment. Growth Factor Augment. Regenokine Modulation Bone Marrow Aspirate Platelet Rich Plasma

32 Results Ferkel et al (2008) 50 Pts. With OLT Treated Arthroscop. Mean Age = 32 Yrs. Mean F/U = 71 mos. Excellent Good 72%, Fair 20%, Poor 8% Sig. Correlation B/N Arthroscop. Stage and Result 17 Pts Previously Evaluated 5 Years Ago; 35% of Their Results Deteriorated One Grade AJSM 36: 1750, 2008

33 OLT With PRP or HA Mei-Dan et al (2012) Compared Use of PRP or Hyaluronic Acid to Treat OLT Group I = HA 15 Pts. Group 2 = PRP-14 Pts (15 OLTs) Men = 79% of Pts; F/U = 28 Weeks AOFAS: Group 1 = 66 78, Group 2 = Subjective Global Function Group I = 56 73, Group II = PRP + HA Rx Pain Scores Function PRP Signif. Better Outcome Than HA AJSM 40:534, 2012

34 OLT Is There A Critical Defect Size? Choi et al 120 Ankles with OLT Had Micro Fx; 26 Pts Ankle Lat. Lig. Stab. Clinical Failure = Osteochondral Transplantation or AOFAS Ankle Hindfoot Score <80 6.7% - Osteo Transplantation 18.4% - AOFAS Score <80 Failure Related to Defect Size 10.5% - Defect Area < 150 mm 2 80% - Defect Area > 150 mm 2 Size Calculated by MRI AJSM 37:1974, 2009

35 Containment of OLT Choi, et al. Looked at Prognostic Significance of Containment (Shoulder vs Non Shoulder) and Location of OLT Pts With Shoulder Type OLT Had Signif. Worse Clinical Outcome Than Non Shoulder Type No Signif. Difference Between Medial and Lateral OLT in Either Group AJSM 41: 126, 2013

36 Indications For Cartilage Replacement Failure of Previous Surgery With MSTs OLT > 1.5 mm 2 OLT That is Uncontained OLT With Large Underlying Cyst

37 Newer Treatment Options-2014 Osteochondral Grafts (Au/AI) Autol. Chondrocyte Implantation Juvenile Articular Cartilage Allograft Micronized Cartilage Matrix Focal Resurfacing Implant Osteochondral Progenitor Cell Transplantation Others

38 Arthroscopy if OATS - Talus Necessary Osteotomy or Release ATFL Laterally Core-Out or Drill Lesion to at Least 10mm Depth Compact Base and Measure Depth

39 Insert Donor Graft OATS Talus

40 OATS - Talus Scranton et al (2005) 50 Cases Two-Six Yr Follow up; 64% had Failed One or More Surgeries Prior to grafting 90% Excellent Good Results Concerns About: Cartilage Damage, Graft Fragmentation, Graft Position & Knee Pain

41 Allograft - Talus Reduce Donor Site Morbidity Match Contour and Cartilage Morphology Conventional OATS Or Box-Cut Technique

42 Allograft Talus Kelikian, et al Fresh Allografts Inserted 38 Pts: 22 Male, 16 Female Mean Age = 44 Years (19-74) Mean Size of Lesion = 1.5cm 2 Mean F/U = 38 Mos. (6-62) Graft Survival = 89% AOFAS Score JBJS 93:1634, 2011

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44 Indications for ACI in the Ankle Patients Aged Focal Defect > 2 cm 2 Unipolar (Only Talus) Contained Edge Loading Failed Previous Surgery Large Lesions with Subchondral Cystic Changes in Primary Cases

45 ACI - Osteotomy Correct Malleolar Osteotomy Allows for Exposure of Entire OLT Place Guide Pin Over Bone at Osteotomy Site and Mark with Methylene Blue Start Cut With Saw; Finish With Osteotome While Protecting Articular Cartilage

46 Bio-Gide Collagen Membrane Type I/III Bilayer Porcine Collagen Membrane Gomoll et al. Compared Subsequent Surgeries After ACI-P & ACI-C (Bio-Gide) in Knee Results Similar Except Hypertrophy Related Surgery ACI P = 52% ACI-C = 3.4% ICRS, May 2009

47 ACI Membrane Implantation Membrane is Implanted and Secured With 6-0 Vicryl to OLT Bed Fibrin Glue is Used to Seal the Membrane Water Tight Except a Hole is Left for Cell Insertion

48 ACI Cell Implantation Insert Catheter Through Opening in Membrane Slowly Inject Cells Suture Remaining Hole in Membrane Seal Hole With Fibrin Glue

49 ACI Sandwich Bone Grafting CYST

50 ACI Results - Ferkel (2014) 32 Patients Total Male = 16; Female = 16 Medial = 24; Lateral = 8 32/32 = Previous Surgery Current Study: F/U 29/32 = 91% Ave. Age = 34 (18-54) Ave. F/U = 70 Mos (24-129) Sandwich Procedures = 9 2 nd Look = 90% (26/29) Excell. = 8, Good = 15, Fair = 5 Poor = 1 AJSM, 2014

51 Arthroscopic 2 nd Looks Grade I Soft & Ballotable II Medium Firm 9 Months MC III Firm 17 Months SC Firmness of Articular Cartilage Increased with Longer-Up 48 Months AK

52 Scaffold Materials For The Repair of Chondral and Osteochondral Defects in 2014 Calcium phosphates (CaP) Hydroxyapatite (HAp) Biological polymers Collagen Fibrin Alginates Hyluronan (HyA) Chitosan Collagen/glycosaminog lycan (GA) Synthetic polymers Polylactic acid (PLA) Polyglycolic acid (PGA) Polycaprolactone (PCL) Other Demineralized bone matrix Devitalised cartilage Periosteum Bioactive glass

53 ACI Comparative Study Giannini et al 3 Pt. Groups: Open ACI, Scope ACI, BMAC 81 Pts; Mean Age = 30 Yrs Mean F/U = 60 Months Mean Overall AOFAS Score: Pre op = 57 Post op = 93 Injury, 2012

54 ACI Comparative Study Giannini et al AOFAS SCORES Open ACI-10 Scope ACI - 46 BMAC - 25 Pre op Months Months MRI Complete Integration in 76% Histology All 3 Groups Hyaline-Like Cartilage Injury, 2010

55 Particulated Juvenile Cartilage Juvenile Cartilage Allograft Tissue (Donors < 13 yrs Old) DeNovo NT Graft Juvenile NT Graft Consists of Scaffold-Free Living Articular Cartilage, Displaying Biochemical Properties Similar to Those of Articular Cartilage Found in Young, Healthy Joints. Juvenile 400x Adult 400x

56 Particulated Juvenile Cartilage Technique Place Fibrin Glue Bone Graft Cystic Over Osteochondral Lesion and Cover Defect (If No Bone With Fibrin Glue Graft)

57 P-L View Lt Ankle Particulated Juvenile Cartilage Technique Juvenile NT Allograft is Placed Into the Defect and Impacted With a Freer Elevator

58 P-L View Lt Ankle Particulated Juvenile Cartilage Place Another Layer of Fibrin Glue Over Graft Wait 5 Mins Check ROM to Ensure That There is No Instability of Fragments

59 Particulated Juvenile Cartilage Coetzee et al (2013) Multicenter Study Involving 24 Ankles Ave Age = 35 Yrs; Ave. F/U = 16 Mos 14 Pts Failed At Least One Prior BMS Ave Size = 125 mm 2, Ave Depth = 7 mm FAI 34:1205, 2013

60 Particulated Juvenile Cartilage Results: AOFAS = 85 (78% G-E) SF12 Physical Compos. = 46 SF 12 Mental Health = 55 FAAM AODL = 82 FAAM Sports = mm Visual Analog Pain = 24 92% E-G Results With Lesions Smaller Than 15mm FAI 34:1205, 2013

61 Return to Sports Bone Marrow Stimulation Ferkel 100% Back to Sports Ave F/U 6 Yrs. Shuman 45% Limited or No Play Ave F/U 5 Yrs Van Bergen 88% Resume Sports Ave F/U 12 Yrs OATS Scranton Pain With Sports Ave F/U 3 Yrs Paul Returned But Mostly Modified Activity Ave F/U 5 Yrs. Hangody Long Term 93% E-G, No Sports Results ACI Baums All Back to Sports If Done Pre Op Ave F/U 5 Yrs Giannini 86% Return to Sports With Hyalgraft Ave F/U 3 Yrs Ferkel Tegner Ave F/U 6 Yrs Particulated Juvenile Cartilage Coetzee FAAM - Sports = 63 Ave F/U 16 mos *Osteochondral Allografts No Data

62 OLT Ankle - Summary Newer Technology Shows Positive Early Results But More Cases With Longer F/U Needed Cartilage Solution Max. Clinical & Histological Results at 24 mos. Or Longer Future Scaffolds, Stems Cells, Growth Factors,? Solution is Within Our Grasp and Must Be Done Arthroscopically Stepwise Evolution of Concepts and Science Cartilage Loss

63 T H A N Y O U K