The Treatment of the Early Degenerative Knee and Use of Biologics

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1 The Treatment of the Early Degenerative Knee and Use of Biologics Presented to: Insert relevant presenter information Calibri 16pt Brian Chilelli, MD Presented on: Month day, Year Department Presented by: Insert of relevant Orthopaedic presenter information Surgery here

2 Disclosures I have no relevant financial disclosures to make.

3 The meniscus The meniscus is a critically important structure that functions to minimize joint contact stresses by providing maximum contact area.

4 The meniscus In a loaded knee the medial meniscus transmits 50% of the medial compartment load compared to the lateral meniscus, which transmits 70% of the lateral compartment load. Seedholm et al., JBJS Br 1974

5 The meniscus Biomechanical studies have proven that meniscectomy leads to higher contact forces and lower contact areas than when meniscus repair is performed. Baratz et al., AJSM 1986 Contact forces have been shown to increase by as much as 65% following partial meniscectomy and 235% following total meniscectomy. Baratz et al., AJSM 1986 These changes could lead to medial and/or lateral knee pain following meniscectomy as a result of compartment overload with the potential for progressive articular cartilage degeneration.

6 The meniscectomized knee Prospective 40-year follow up study 53 patients who underwent total meniscectomy as adolescents Conclusion - meniscectomy leads to symptomatic osteoarthritis of the knee later in life A 132-fold increase in the rate of total knee replacement when compared to age matched controls. Pengas et al., JBJS Br 2012

7 The meniscectomized knee Relative risk of developing advanced osteoarthritis following meniscectomy was 14.0 compared to matched controls. Roos et al., Osteoarthritis and Cartilage 2001 Many other authors have found a strong association between meniscectomy and the development of radiographic and symptomatic osteoarthritis. Englund et al., Arthritis Rheum 2003 McNicholas et al., JBJS 2000 Alford et al., AJSM 2005

8 Meniscectomized knee Sub-groups Pain without chondrosis Recent meniscectomy No damage yet to articular cartilage Pain usually only with higher impact activities Focal cartilage defect(s) Meniscectomy 1-5 years ago Focal damage to condyle, and occasionally tibia Pain with normal weightbearing activities Some swelling Advanced arthritic changes Remote meniscectomy Diffuse bipolar damage and radiographic changes (Fairbanks) Rest pain

9 Surgical Intervention Considered for symptomatic patients who fail nonoperative treatment, especially for young patients at high risk for rapid joint deterioration. Patient age, goals, activity level, and the extent of disease process should all be highly considered when deciding on a surgical plan.

10 Surgical Options Surgical options include cartilage repair/restoration Meniscus repair meniscal allograft transplantation (MAT) osteotomy unicompartmental knee arthroplasty total knee arthoplasty.

11 Meniscal Allograft Transplantation (MAT) For young patients with meniscal deficiency, meniscal allograft tranplantation can be considered The first human meniscal allograft transplantation was performed in 1984 Biomechanical studies demonstrate improved intraarticular contact area and pressures. Milachowski et al.,int Orthop 1989 Paletta et al., AJSM 1997

12 Meniscal Allograft Transplantation (MAT) The primary indication - symptomatic compartment of the knee in a patient with a history of total or subtotal meniscectomy. There is no consensus in regards to the upper age limit of the procedure is commonly used as a cut off Controversy exists in regards to how much chondral loss is acceptable cartilage defects greater than ICRS grade III articular should ideally be focal and small so that they can be addressed concurrently with cartilage repair

13 Meniscal Allograft Transplantation (MAT) Contraindications obesity ligamentous instability (unless it is addressed prior to or in conjunction with transplantation) previous joint infection squaring of the femoral condyles. Patients with greater than 3 degrees of varus or valgus malalignment should be considered for concurrent osteotomy (high tibial osteotomy vs distal femoral osteotomy).

14 MAT Outcomes McCormick et al., AJSM % survival rate in 172 patients at 5 years Vundelinckx et al., AJSM 2014 Followed 49 patients for and avg of 12 years and 8 months 90% of patients reported being very satisfied or satisfied and stated that they would undergo the procedure again. 6 (12.2%) failures requiring conversion to TKA Rosso et al., AJSM 2015 A systematic review of 55 studies concluded that meniscal allograft transplantation provides good clinical results at short-term and midterm follow up, with improvement in function and acceptable failure and complication rates.

15 Biologic Reconstruction with MAT Harris et al., Arthroscopy 2015 followed 18 patients who underwent meniscal transplantation, osteotomy, and cartilage repair statistically significant improvements in IKDC, Lysholm, and 4 KOOS subscores at a mean follow up of 6.5 years. 13 reoperations in 10 patients (55.5% reoperation rate) but only one patient was converted to total knee arthroplasty (5.6%)

16 Case 1 30yo female with left knee pain History of left meniscus repair 5-10 years ago. States her knee has never felt the same since then. Complains of mostly medial based pain but occasionally has anterior pain as well. Pain is daily with every day activities including walking to and from work.

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29 Case 2 24yo female with right knee pain Patient previously underwent partial lateral meniscectomy / subtotal lateral meniscectomy 6 years ago for a torn discoid lateral meniscus Localizes pain to lateral aspect of knee and reports pain with everyday walking

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38 Meniscal root tears / avulsions Posterior meniscal root tears lead to altered tibiofemoral contact pressures and contact areas, which have been reported to be functionally similar to a total meniscectomy. 2,16,21,25 (LaPrade paper) If left untreated can lead to progress degeneration of knee Several studies report delayed progression of degenerative changes seen on imaging following repair when compared to matched controls (6,11,12 from Laprade paper) Chung et al., Arthroscopy 2015 Kim JH et al., Arthroscopy 2011 Kim SB et al., Arthrosocpy 2011

39 Anatomic Transtibial Pull-Out Technique LaPade et al. 2016

40 Meniscal root repair outcomes LaPrade et al. AJSM knees in 49 patients, 45 for analysis 3 of 45 (6.7%) required revision surgery Significant improvements in postop Lysholm and WOMAC scores No difference in outcomes between patients <50 to those >50

41 Case 3 23yo male with right knee pain Reports wrestling with a friend and twisting his knee. Felt a pop followed by pain and swelling. Pain is located posteromedial and he has difficulty bearing weight.

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46 23yo female with right knee pain following recent PCL reconstruction 3 months prior Patient was 3 months post op from right PCL reconstruction. Was doing well with rehab but slipped and fell resulting in a twisting mechanism. This was followed by pain and swelling of the knee.

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55 Horizontal Cleavage Tears of the Meniscus Beamer et al., Arthroscopy 2016

56 Osteotomy Osteotomies (distal femoral vs proximal tibial) are joint-preserving procedures that can be used to treat early compartment osteoarthritis in young patients Varus-producing distal femoral osteotomy - lateral compartment disease Valgus-producing proximal tibia osteotomy - medial compartment disease Advantageous for young patients no long-term activity restrictions need for joint arthroplasty can be delayed or potentially prevented.

57 Osteotomy Opening and closing wedge osteotomies have been described but there is a lack of literature supporting one technique over another. Smith et al., The Knee 2011 Brouwer et al., JBJS Br 2006 With the advent of improved plating technology and various bone graft substitutes, opening wedge osteotomies have become the technique of choice. Lobenhoffer et al., Tech Knee Surg 2002 Stoffel et al., Clin Biomech Bristol Avon 2004

58 Osteotomy Outcomes LaPrade et al., Arthroscopy young adults (< 55 years) who underwent proximal tibia opening wedge osteotomies for medial compartment osteoarthritis and genu varus alignment. At a mean of 3.6 years of follow up Modified Cincinnati Knee Scores improved from 42.9 preoperatively to 65.1 Only 3 (6%) failures requiring revision osteotomy or conversion to total knee arthroplasty.

59 Osteotomy Systematic review of 21 studies concluded that valgus high tibial osteotomy reduces pain and improves knee function in patients with medial compartment osteoarthritis. Brouwer et al., The Cochrane Library 2014 While the use of varus-producing distal femoral osteotomies is less common, encouraging outcomes have been documented in patients with lateral compartment disease and genu valgus alignment. Wang et al. JBJS 2005 Saithna et al., The Knee 2014 Cameron et al., Clin Orthop Relat Res 205

60 Osteotomy My preference is to perform an osteotomy on patients younger than 55 with malalignment and isolated medial or lateral compartment disease. These patients tend to be more active and may not be willing to abide by the activity restrictions associated with unicompartmental knee arthroplasty. On the contrary, unicompartmental arthroplasty would be a good option for less active patients between the ages of with isolated unicompartmental disease.

61 Case 5 60yo male with left knee pain Patient has several years of medial based pain. Previously underwent partial medial meniscectomy years ago.

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64 Case 6 32yo male with left knee pain Patient complains of medial based knee pain. He has pain with every day walking. Previously underwent partial medial meniscectomy twice with the most recent surgery being 9 months ago.

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69 Arthroplasty Unicompartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA) are treatment options for advanced degeneration of the knee. Preferred for patients older than 55 who are lower demand due to the limited life span of the implants. They can also be used as salvage options following failed cartilage surgery

70 Unicompartmental Arthroplasty Isolated unicompartmental disease can be successfully treated with UKA while more diffuse disease that involves more than one compartment is better treated with TKA. In a consecutive series of 54 lateral unicompartmental arthroplasties the survivorship was 94.4% at 10 years and 91.4% at 15 years. Lustig et al., The Knee 2014 Similarly, medial compartment arthroplasty survival rates have been documented as 94% - 100% at 10 years Murray et al., JBJS 1998 Keys et al., Knee 2004 Rajasekhar et al., JBJS Br 2004

71 Case 7 54yo male with left knee pain Patient reports medial based knee pain for several years. He previously underwent partial medial meniscectomy 8 years ago.

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77 Decision making osteotomy versus arthroplasty? Decision based on age and expectations Osteotomy: Younger (< 55? years) More active Don t like or can t have restrictions (sports, work) Unicompartmental disease Partial replacement: Middle aged to older (55-70 years) Unicompartmental disease Total knee replacement: Older (>70 years) Several compartments affected Low demand

78 What is new?...

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84 Bioscaffolds.just to name a few. MACI (Matrix-Induced Autologous Chondrocyte Implantation) BST-CarGel AMIC (Autologous Matrix-Induced Chondrogenesis) Gelrin C Chondrotissue ChonDux MaioRegen Chondromimetic Agili-C Aseed Scasffold CAIS (Cartilage Autograft Implant System) CRT (Cell Replacement Technology) Cartistem Revaflex CariGro NeoCart CaReS/CartiPlug Hyalograft C Bioseed C Cartipatch Novocart 3D

85 What about PRP?... Harris et al, Arthroscopy 2016 Systematic review of level 1 studies PRP to treat OA of the knee 6 studies with 739 patients and 817 knees Mean age: 59.9 years 38 week avg follow up Significant improvements in statistical and clinical outcomes (pain, function, stiffness) 5 out of 6 studies showed significant differences in outcomes between PRP and HA or PRP and placebo in pain and function

86 References Seedholm B, Dowson D, Wright V: Functions of the menisci: a preliminary study. J Bone Joint Surg Br 1974;56-B: Baratz ME, Fu FH, Mengato R. Meniscal tears: the effect of meniscectomy and of repair on intraarticularcontact areas and stress in the human knee: a preliminary report. Am J Sports Med 1986;14: Pengas IP, Assiotis A, Nash W, Hatcher J, Banks J, McNicholas MJ: Total meniscectomy in adolescents: a 40-year follow-up. J Bone Joint Surg Br 2012;94-B(12): Englund M, Roos EM, LohmanderLS: Impact of type of meniscal tear on radiographic and symptomatic knee osteoarthritis: a sixteen-year followup of meniscectomy with matched controls. Arthritis Rheum 2003;48: McNicholas MJ, Rowley DI, McGurty D, et al: Total meniscectomy in adoles- cence: a thirty-year follow-up. J Bone Joint Surg Br 2000;82-B: Alford JW, Cole BJ: Cartilage restoration, part 2: techniques, out- comes, and future directions. Am J Sports Med 2005;33(3): Milachowski KA, Weismeier K, Wirth CJ: Homologous meniscus transplantation. Experimental and clinical results. Int Orthop 1989;13:1 11. Paletta GA Jr, Manning T, Snell E, et al: The effect of allograft meniscal replacement on intraarticularcontact area and pressures in the human knee. A biomechanical study. Am J Sports Med 1997;25: Alhalki MM, Hull ML, Howell SM: Contact mechanics of the medial tibial plateau after implantation of a medial meniscal allograft: a human cadaveric study. Am J Sports Med 2000;28: Gomoll AH, Filardo G, Almqvist FK, Bugbee WD, Jelic M, Monllau JC, PudduG, Rodkey WG, Verdonk P, Verdonk R, ZaffagniniS, Maracci M: Surgical treatment for early osteoarthritis. Part II: allografts and concurrent procedures. Knee Surg Sports Traumatol Arthrosc 2012;20: Verdonk P, Van Laer M, ElAttarM, Almqvist KF, Verdonk R: Results and Indications. In: Beaufils P, Verdonk R (eds) The Meniscus. Springer, Berlin, 2010, pp Cole BJ, Carter TR, Rodeo SA: Allograft meniscal transplantation: Background, techniques, and results. Instr Course Lect 2003;52: Harris JD, Hussey K, Wilson H, Pilz K, Gupta AK, Gomoll A, Cole BJ: Biological reconstruction for combined malalignment, meniscal deficiency, and articular cartilage disease. Arthroscopy 2015;31(2): McCormick F, Harris JD, Abrams GD, Hussey KE, Wilson H, Frank R, Gupta AK, Bach Jr BR, Cole BJ: Survival and reoperation rates after meniscal allograft transplantation: analysis of failures for 172 consecutive transplants at a minimum 2-year follow-up. Am J Sports Med 2014;42(4):

87 References Cole BJ, Carter TR, Rodeo SA: Allograft meniscal transplantation: Background, techniques, and results. Instr Course Lect 2003;52: Rosso F, Bisicchia S, Bonasia DE, Amendola A: Meniscal Allograft Transplantation: a Systematic Review. Am J Sports Med 2015;43(4): Vundelinckx B, Vanlauwe J, Bellemans J: Long-term subjective, clinical, and radiographic outcome evaluation of meniscal allograft transplantation in the knee. Am J Sports Med 2014;42(7): Smith TO, Sexton D, Mitchell P, Hing CB: Opening- or closing-wedge high tibial osteotomy: A meta-analysis of clinical and radiological outcomes. The Knee 2011;18: Brouwer RW, Bierma-ZeinstraSM, Raaij van TM, VerhaarJ: Osteotomy for medial compartment arthritis of the knee using a closing wedge or an opening wedge controlled by a Puddu plate. A one-year randomized, controlled study. J Bone Joint Surg Br 2006;88: Lobenhoffer P, Simoni C, Staubli AE: Open-wedge high-tibial osteotomy with rigid plate fixation. Tech Knee Surg 2002;1: Stoffel K, Stachowiak G, Kuster M: Open-wedge high tibial osteotomy: Biomechanical investigation of the modified Ar- threx Osteotomy Plate (Puddu Plate) and the TomoFix Plate. Clin Biomech Bristol Avon 2004;19: LaPrade RF, Spiridonov SI, Nystrom LM, Jansson KS: Prospective outcomes of young and middle-aged adults with medial compartment osteoarthritis treated with a proximal tibial opening wedge osteotomy. Arthroscopy 2012;28(3): Brouwer RW, Bierma-ZeinstraMA, van Raaij TM, VerhaarJAN: Osteotomy for medial compartment arthritis of the knee using a closing wedge or an opening wedge controlled by a puddu plate: a one-year randomized, controlled study. The Cochrane Library 2014;12:1-80. Wang JW, Hsu CC: Distal femoral varus osteotomy for osteoarthritis of the knee. J Bone Joint Surg 2005; 87A: Saithna A, Kundra R, Getgood A, Spalding T: Opening wedge distal femoral varus osteotomy for lateral compartment osteoarthritis in the valgus knee. The Knee 2014; 21: Cameron JI, McCauley JC, Kermanshahi AY, Bugbee WD: Lateral opening-wedge distal femoral osteotomy: pain relief, functional improvement, and survivorship at 5 years. Clin Orthop Relat Res 2015; 473:

88 References Lustig S, Lording T, Frank F, Debette C, Servien E, Neyret P: Progression of medial osteoarthritis and long term results of lateral unicompartmental arthroplasty: 10 to 18 year follow-up of 54 consecutive implants. The Knee 2014;21(S1):S26-S32. Murray DW, Goodfellow JW, O Connor JJ: The Oxford medial unicompartmental arthroplasty: a ten-year survival study. J Bone Joint Surg Br 1998;80- B: Keys GW, Ul-Abiddin Z, Toh EM: Analysis of first forty Oxford medial unicompartmentalknee replacement from a small district hospital in UK. Knee 2004;11: Rajasekhar C, Das S, Smith A: Unicompartmental knee arthroplasty: 2- to 12-year results in a community hospital. J Bone Joint Surg Br 2004;86-B:983-5.