Disclosures. Reverse Engineer To Solve a Problem. Consider the big 6. Natural history vs. Surgical intervention. Which is better?

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1 Disclosures A la carte rebuilding of the knee: Stability, alignment and surface Jason M. Scopp, M.D. Director Joint Preservation Center Peninsula Orthopaedic Associates, P.A. Arthrex consultant Vericel consultant Cartilage Surgeons and Reverse Engineer To Solve a Problem Thought Process Consider the big 6 Natural history vs. Surgical intervention Which is better? 1. Mechanism of injury 2. Prevention of injury 3. Systematic details Fitness, fatigue, RTS 4. Biological Microenvironment, hormones 5. Knee joint as organ Alignment, stability, synovium, meniscal, bone 6. Regenerate, maintain and sustain: booster biologics 1

2 Functional Unit of the Knee Neutralize the hostile environment Booster Biologics to sustain: Catabolic Anabolic What is the answer? Considerations for organization Small Defects Large Defects OCD Alignment Meniscus Deficiency Courtesy of Brian J. Cole, MD Courtesy of Brian Cole, MD Functional Unit of the Knee Macroscopic Cartilage Microscopic Chondrocytes The obstacle to success Joint Stability Scaffold Functional Unit Imbalance Patient factors Right operation, wrong patient 2

3 New Technologies and Scaffolds Still must adhere to basic tenets of cartilage repair Team with industry Case Case Illustration 18 y old non contact, valgus rotational injury resulting in isolated ACL tear Case Case Reinjured knee Continued to play for 4 weeks before reporting to surgeon and athletic training staff Re tear Revised with Achilles 3

4 Medial compartment at time of revision #1 ACL Resorbed MFC Progression in 1 year Medial Compartment 2012 Medial Compartment 2013 Patient returned to sport 8M post revision Counseled, I am answer the coulds not the shoulds Non contact valgus rotational injury playing soccer 10/14 MRI DEC 2014 CT

5 Problem list 1. Recurrent ACL tear 2. Hyperextension 3. Bone loss 4. Varus 5. Chondral Defect MFC 6. Medial meniscus deficiency 7. Poor mechanics, biologic deficiency 8. (un)realistic expectations Do the patient goals match the surgeons goals and reality? Pressure sources: Coach Family Patient Problem 1 ACL deficient, hyperextension and bone loss Considerations 1 Problem 2 Tunnel widening: bone graft? Graft choice Anterolateral ligament reconstruction Correct mechanics Varus alignment 5

6 Considerations 2 Problem 3 High tibial osteotomy Unloader brace Role of meniscus deficiency Status of joint surface Medial meniscus deficiency Considerations 3 Problem 4 Role of secondary stabilizer for ACL Chondroprotective for chondral surface treatment Chondral defect MFC Considerations 4 Chondral or osteochondral treatment One stage or two stage biologic What does the BMF represent? Problem 5 Expectations 6

7 Consideration 5 Problem 6 Salvage situation Sports would be bonus not expectation Neuromusclar deficiencies and poor mechanics Consideration 6 Rational Rationale Is she willing to put in the work if I put in the work? Is she ready to commit to lifelong rehab? There are no absolutes. There is no dogma. Organize thoughts, understand options, outcomes. Functional Unit Macroscopic Cartilage Joint Stability Microscopic Chondrocytes Scaffold Stage 1 High tibial osteotmy Bone graft ACL tunnels OA graft to MFC (Cartiform vs OAG) Neuromuscular conditioning MRI at 6 months to evaluate BMF, OCG My Surgical Plan Stage 2 Revision ACL +/ ALL Medial meniscus transplant Neuromuscular conditioning 7

8 Rationale Surgery 3/15 Stage 1: Unloading medial compartment will assist OAG, bone marrow flare Complementary rehab between procedures Prepare knee for ACL Stage 2: ACL + ALL hyperextension and 2 time failure MAT: secondary stabilizer Allow for second look of surface treatment Subchondroplasty or fine tune as needed Surgery 3/15 MRI Follow up Pre op Post op #1 December 2015 Cartiform second look Pre op Post ACL/ALL 8

9 Post op X rays Post op #1 Post op #2 It is OK to profile PATIENT Do you want it? Surgeon Can I do it? Facility & Payor Can it be done? -N=18 undergoing meniscus, realignment and cartilage surgery /- 1 surgeries prior to enrollment -f/u 6.5 +/- 3.2 years Statistically significant and clinically meaningful improvements At long-term follow-up -55% reoperation (low revision rate) 9

10 Chondral Overload Syndrome A la carte rebuilding of the knee Individual Instability Injury BMI Compliance Activity level Gender Expectations Smoker Secondary injury Delayed reconstruction No reconstruction Chondropenia Macroenvironment Microenvironment The patients who do well are the patients who are selected well Daniel Saris ICRS 2015 Osteoarthritis Some advice: Avoid VOMIT: Victim Of Modern Imaging Technology BARF: Blind Application of Radiographic Findings Linear thinking A B 10