3/13/2018. Cartilage Cases. Case. Physical exam

Transcription

1 Cartilage Cases Aaron J. Krych, MD Professor, Orthopedic Surgery Sports Medicine Fellowship Director Sports Medicine Research Fellowship Director Mayo Clinic 2014 MFMER slide-1 Case 19 yo F division I college volleyball player outside hitter 1 year lateral knee pain OCD Failed conservative management MFX performed elsewhere 1 year rehabilitation Continued pain/swelling Unable to play volleyball x 2 years 2014 MFMER slide-2 Physical exam Previous portal incisions Quad atrophy Trace effusion Lateral jt line TTP Full ROM Stable 2014 MFMER slide-3 1

2 Initial outside films 2014 MFMER slide-4 Initial outside films 2014 MFMER slide-5 Outside arthroscopy MFX performed 2014 MFMER slide-6 2

3 Continued pain, swelling after 1 year Plain x-rays unchanged (PA flexion included) 2014 MFMER slide-7 Repeat MRI at 1 year Subchondral edema increased, lesion size 18 x 8 mm 2014 MFMER slide-8 Treatment options? 2014 MFMER slide-9 3

4 Repeat knee arthroscopy Some fibrocartilage fill, size of lesion increased, new tibial chondromalacia 17 x 16 mm 2014 MFMER slide x 16 mm About 2.5 cm MFMER slide-11 Post-op 4 weeks PWB ROM as tolerated Early quad function Alter-G 4-8 weeks Normalize gait Closed chain strength 3-4 months Elliptical for cardio 6 months jogging*/progressive return to controlled sport activities 3 month accelerated rehab Gilmore OJSM 2014 *delayed jogging due to 2 years sx s 2014 MFMER slide-12 4

5 6 month MRI follow-up 2014 MFMER slide-13 How does the OC plug heal? 6 months 6 months Allograft plug creeping substitution Autograft plug fully incorporated 2014 MFMER slide-14 5 year follow-up completed 4 years competitive eligibility No donor site symptoms 2014 MFMER slide-15 5

6 MA of level I and II prospective studies 249 patients at 5.5 years OAT had higher activity levels and lower failure rate MFX results deteriorated after 1 year 2014 MFMER slide-16 Best return to sport data 44 studies, 2549 patients OAT 93% return to sport OAT fastest return to sport 5.2 months OAT highest KOOS score 2014 MFMER slide MFMER slide-18 6

7 History 29 year old M CC: L knee pain HPI: Basketball game Landed on opponent s foot and twisted his left knee, heard a pop Inability to bend his knee afterwards Noticed some mild swelling 2014 MFMER slide-19 Physical Examination Inability to bend knee past 10 deg flexion due to excruciating pain TTP along patella, negative apprehension,+1 quadrant patellar glide Tight lateral retinaculum Negative Lachman and Pivot shift, Stable V/V at 0 deg extension 2014 MFMER slide MFMER slide-21 7

8 MPFL OK, no subluxation/dislocation 2014 MFMER slide-22 Treatment options? Doc, I am getting married in 2 weeks and need to walk down the aisle 2014 MFMER slide-23 Grade 4 patella defect 25x15 mm cartilage fragmented 2014 MFMER slide-24 8

9 Second stage surgery 2014 MFMER slide-25 Lateral retinacular lengthening 2014 MFMER slide MFMER slide-27 9

10 Defect Defect prep MACI 2014 MFMER slide-28 Postoperative Course Outpatient procedure Good pain control post-op PWB for 6 weeks, ROM as tolerated 2014 MFMER slide-29 6 month follow-up imaging 2014 MFMER slide-30 10

11 After Before 2014 MFMER slide-31 After: Excellent fill Before 2014 MFMER slide-32 After: normal patellar tilt Before: Abnormal tilt 2014 MFMER slide-33 11

12 110 patients including bipolar defects Minimum 4 year f/u, avg 7.5 years Avg defect 5.4 cm (72% Fulkerson IV) 69% AMZ, 41% lateral release 86% good and excellent Improved WOMAC, IKDC, Cincinnati (p<0.05) 2014 MFMER slide MFMER slide-35 Case 20 yo M college football player safety Underwent OCD excision elsewhere 9-12 months lateral knee pain following a twisting injury, no instability c/o painful snapping in deep flexion Failed exhaustive conservative management (injxns, PT, etc) Pain with ADL s Continued symptoms 2014 MFMER slide-36 12

13 Outside MRI prior to knee scope 2014 MFMER slide-37 Physical exam Asymmetric valgus Trace effusion Full ROM degrees Palpable PL joint line snap in deep flexion Ligaments Stable 2014 MFMER slide MFMER slide-39 13

14 2014 MFMER slide-40 7 degrees mal-alignment 2014 MFMER slide-41 Options? Stage? Approach? 2014 MFMER slide-42 14

15 2014 MFMER slide-43 OC allograft and osteotomy 2014 MFMER slide MFMER slide-45 15

16 2014 MFMER slide-46 9 month follow-up Pain-free No swelling Strength and functional testing look good MRI 2014 MFMER slide-47 How fast should we rehab/return to sport? 2014 MFMER slide-48 16

17 2014 MFMER slide-49 Case: GT CC: 32 yo golfer w/ right knee pain x 4 years HPI: Knee injury following snow mobile accident in 2010 Mar 2010: arthroscopy with microfracture Dec 2010: arthroscopy with debridement Feb 2011: Osteochondral allograft transplant w/ 4 plugs Aug 2013: 3 of 4 plugs removed (delamination) and repeat microfracture Continues to have pain daily with activities 2014 MFMER slide-50 GT 2014 MFMER slide-51 17

18 Pre-op Imaging 2014 MFMER slide MFMER slide MFMER slide-54 18

19 Plan? 2014 MFMER slide MFMER slide-56 Pre-Op Post-Op 2014 MFMER slide-57 19

20 33 patients undergoing revision OCA b/t 1983 and 2012 Mean f/u: 10 yrs Failure defined as conversion to arthroplasty 13 of 39 (39%) failed Mean graft survival of 10 yrs 10 yr survival: 61% 2014 MFMER slide MFMER slide-59 Case 12 yo M football player Medial knee pain x 9 months Activity modification Casting/crutches x 6 weeks Continued pain/effusion with activity 2014 MFMER slide-60 20

21 Physical exam Normal gait and alignment Full ROM, no effusion TTP medial joint line Stable knee 2014 MFMER slide-61 Radiographs Wide open physes 2014 MFMER slide-62 Radiographs 2014 MFMER slide-63 21

22 Stable or unstable? 2014 MFMER slide-64 Plan? 2014 MFMER slide-65 Need to discuss multiple options with family Stable vs unstable Possible drilling Salvageable vs unsalvageable Cartilage status, bone status of progeny fragment Fixation metal vs biocompression Not salvageable Size of lesion Osteochondral autograft transfer Excision only Partially able to salvage Hybrid technique 2014 MFMER slide-66 22

23 Unstable 2014 MFMER slide-67 Unstable, partially able to salvage No bone on anterior progeny fragment Reasonable bone posterior fragment 2014 MFMER slide-68 OAT anterior Screw fixation posterior Hybrid technique advantage: reliable single stage surgery 2014 MFMER slide-69 23

24 2014 MFMER slide-70 6 month MRI 2014 MFMER slide-71 Beware: Hardware complications Screw track Fixation performed elsewhere 2014 MFMER slide-72 24

25 20 patients unstable OCD lesions 11 of 20 skeletally immature At 6 months, all MRIs demonstrated healing with integration At 18 months, all knees rated as normal 2014 MFMER slide-73 Symptomatic OCD take home points Salvage fragment best Drilling in open growth plates Fixation if unstable Controversy metal vs biocompression and?staged removal One stage best discuss all scenarios w/athlete Try to salvage a portion of fragment Try to cover with OAT If too large an area, then excision 2014 MFMER slide-74 Thank You 2014 MFMER slide-75 25