OATS/MOSAICPLASTY/MEGA-OATS

Transcription

1 OATS/MOSAICPLASTY/MEGA-OATS JOÃO ESPREGUEIRA-MENDES, MD. PhD. Chairman of Clínica do Dragão - Espregueira-Mendes Sports Centre FIFA Medical Centre of Excellence Chairman and Professor of the Orthopaedic Department - Minho University President of the European Society of Knee Surgery, Sports Trauma and Arthroscopy Foundation Treasurer and Chairman of the Publication Committee of ISAKOS Board Member of the Patellofemoral Foundation Board Member of FIFA MCE PORTO, PORTUGAL

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3 DISCLOSURE STATEMENT Treasurer and Chairman of the Publication Committee of the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS) Board Member of the Patellofemoral Foundation Inventor and patent holder of PKTD (no royalties and no fees) KSSTA Journal Editorial Board Member President of the European Society of Sports Traumatology, Knee Surgery and Arthroscopy (ESSKA and ESSKA Foundation) Board Member of FIFA MCE

4 CARTILAGE LESIONS ARE THE MOST FREQUENT CAUSE OF KNEE PAIN CARTILAGE LESIONS WITHOUT PAIN? PAIN? PAINLESS PERIODS? PAIN WITHOUT CARTILAGE LESION?

5 CARTILAGE REPAIR: GOALS Diminish pain & swelling Improve function and unrestricted sports activities Prevent progression towards osteoarthritis Achieve goals with lowest co-morbidity and price Sports at the same level

6 Malalignment, loss of meniscal tissue, cartilage defects and joint instability, all seem to be strongly correlated to early osteoarthritis

7 PREVALENCE KOA IN SPORTS Increases with age Depends on the intensity, frequency, level of sport Symptomatic 10-38% >60y Former football players 16 80% (5-fold increased incidence than general population) Meniscal tears, ACL, cartilage or intra-articular fractures (5x)

8 ARE THE SPORTS THEMSELVES CAUSING CARTILAGE LESIONS? Competitive sports increase risk, specially with weight bearing Thelin,Scan. JMedSSports,2006 Spector, Arthritis Reu, 1996 Sandmark, Scan. JMedSSports,1999 Moderate exercise has a low risk Takeda, Engebretsen et al., Br.JSM, 2011 Repetitive impact & twisting (football) increases risk Buckwalter, AJSM, 1997 Kujala, Arthritis Reu, 1995 Appropriate exercise reduces disability of the knee Roddy, Rheumatology, 2005

9 NO CONSENSUS ON TREATMENT?? 2018 Debridement/Microfractures Periosteal or perichondral graft ACI / MACI Cartilage grafts Bone marrow Morselized graft Osteocartilaginous grafts Internal condyle Mosaicplasty/Porto GUT Allograft Gene therapy Growth factors & PRP Osteotomy Arthroplasty

10 No surgical technique showed superiority to others for the treatment of symptomatic, large, grade IV, WB, articular cartilage lesions. Mosaicplasty provided a good rate of return to competition - 87%, with 67% of the football players returning to the pre-injury level. Mosaicplasty provides a faster return to competition (av. 4,5 months) when compared to microfracture (av. 8 months) and ACI ( months).

11 Results No differences in re-op rates at 2 years At 5 and 10 years osteochondral autografts had lower re-op rate than micro# Second-generation ACI, OC Auto and MACI (in order) were the best treatments considering all outcome measures LOEvi I

12 OATS vs MF vs ACI 9 studies with 607patients OATS compared with another treatment modalities (MF and ACI) At least 12 months of follow-up OATS vs MF OATS had better clinical results and higher rate of return to sport at same level OATS vs ACI OATS clinical outcome improvement was not conclusive Better clinical results in lesions smaller than 2cm²

13 ACI & MOSAICPLASTY IN CARTILAGE REPAIR OF THE KNEE A PROSPECTIVE RANDOMIZED TRIAL 2Y F-Up 40 Patients > Fibrocartilage in ACI > Hyaline cartilage in OATS Slower recovery after ACI Superiority of mosaicplasty over ACI (P< 0,05)

14 SPORTS 60 patients at an average of 37.1 months (range, 36 to 38 months) follow-up, our prospective, randomized, clinical study in young active athletes under the age of 40 has shown significant superiority of mosaicplasty over MF. (P< 0,05)

15 FOOTBALL Methods: 1998 to patients (22 men and 9 women) with grade IV ICRS, W_B, prospectively evaluated by VAS, Lysholm score and MRI were operated and Mean size 3,3cm2 Mean follow-up months (+- 10y FU) Results: Vas and Lysholm score improvement P=0,00; MRI score improved (18-24 months after surgery); P= No morbidity on the donor site. Return to football: 78%

16 TIME ACI % returning to the same level in Microfracture % of athletes return competition in OATS/Mosaicplasty % of athletes in Osteochondral allograft 79% full activity at months 8-17 months months 9.6 months

17 ADVANTAGES 70-90% hyalin cartilage 10-30% fibrocartilage Less expensive One-step surgery Subchondral bone repair Faster recovery and return to activity Allows immediate full ROM Revision with bad subchondral bone

18 The future of cartilage repair lies in better diagnosis to properly recognize alterations in the subchondral bone that might isolated cartilage repair, as well as advanced treatment options that will allow to replace the entire osteochondral unit.

19 CLASSIC MOSAICPLASTY Size the defect Choose the donor site Harvest the LC or/& Troclea with 5mm to 10mm diameter Placement with a correct angle

20 MOSAICPLASTY: DONOR SITE Ahmad AJSM 2000 DO NOT PERFORM IN 10 minutes WHAT NATURE TAKES A LIFE TIME TO DO!!!

21 KNEE TO KNEE

22 KNEE TO ANKLE

23 ALTHOUGH CLINICAL EFFICACY OF MOSAICPLASTY HAS BEEN DEMONSTRATED, LARGE DONOR SITE MORBIDITY IS A DRAWBACK (AT LEAST 5% OF PATIENTS). HANGODY ET AL CAN WE AVOID IT? Donor site no radiographic or clinical complications

24 OSTEOCHONDRAL AUTOGRAFT UPPER TIBIO-FIBULAR JOINT - PORTO GUT

25 SHAPE AND SIZE OF ARTICULAR SURFACES 47 cases (cadaver & CT) FIBULA SURFACE AREA 2,57 cm2 TIBIAL SURFACE AREA 3,26 cm2 TOTAL AREA 5,83cm2

26 TIBIAL ARTICULAR SURFACE OF PTFJ ARTICULAR SURFACE OF EXTERNAL CONDYLE TIBIAL ARTICULAR SURFACE OF PTFJ ARTICULAR SURFACE OF EXTERNAL CONDYLE Mean thickness 1,9 mm (SD 0,5) Mean thickness 1,86 mm (SD 0,5) 20 cases 20 cases

27 SURGICAL TECHNIQUE OPEN HARVEST

28 OPEN HARVEST TRANSFORMATION IN MOSAICPLASTY

29 ARTROSCOPIC or OPEN Porto GUT PLACEMENT

30 CUSTOM MADE BLOCK

31 Conclusions: Sizing of the implanted osteochondral fragment plays an important role in preserving the histologic properties of cartilage.

32 Porto GUT with 10 to 14mm PLUGS

33 Porto GUT Methods: 1998 to patients (22 men and 9 women) with grade IV ICRS were operated and prospectively evaluated by VAS, Lysholm score and MRI before and after surgery Mean follow-up months Results: VAS and Lysholm score improvement P=0,00; MRI score improved (18-24 months after surgery); P=0.004

34 REHABILITATION & RETURN TO SPORTS CPM immediatly (8h / day difficult ) Non weight-bearing 4 to 8 weeks (size & treat) Partial weight-bearing (starting with 20% of the weight Alter G) Return to football within 6 to 12 months Anatomic location and size of the defect

35 Count Count A Pre Pos Mean VAS score improved from (S.D.=10.10) to (S.D.=11.53); B VAS Pre VAS Pos p value=0.00. Mean Lysholm score increased from (S.D.=4.52) to (S.D.=6.96); Lysholm Lysholm p value=0.00.

36 DONOR SITE EVALUATION TENDERNESS - Upper TFJ 2 (6,5%) SPONTANEUS FUSION 2 (6,5%) INFECTION - 0 STIFFNESS 0 LATERAL INSTABILITY - 0 PERONEAL NERVE LESION - 0 ANKLE COMPLAINTS - 0

37 MEGA OATS

38 AXIS CORRECTION Strong evidence that malalignment is an independent risk factor for progression of radiographic osteoarthritis 65 patients (90,9% sports) Improves pain and function Ok to downhill skiing and mountain biking No patient returned to competitive sports DO NOT OVERCORRECT!

39 KNEE INSTABILITY ACLR + Meniscus repair.respect timeframe of each repair/reconstruction technique/tissue healing. Flexion may be limited to 90 degrees - 3/4 weeks - in repairs of the posterior medial meniscus horn Criteria based progress accept a delay on ROM, weightbearing, strengthening exercises, proprioception, neuromuscular reeducation if needed Residual instability (PA or Rot) causes cartilage damage PA & ROTATION INSTABILITY TO CARTILAGE DETERIORATION

40 PRESERVE THE CARTILAGE! REPAIR THE MENISCUS! Meniscal lesion (ML) is one of the most common pathologies leading to Orthopaedic Surgery throughout the world; Over arthroscopic procedures/ 4 billion USD per year for ML in USA (Cullen et al., NHS Rep, 2009) LOSS OF MENISCAL TISSUE SEEMS TO BE STRONGLY CORRELATED WITH CARTILAGE DETERIORATION

41 INNOVATIVE TECHNIQUE FOR THE PREPARATION OF POROUS HYDROXYAPATITE/CHITOSAN BILAYER SCAFFOLDS FOR BONE, CARTILAGE AND OSTEOCHONDRAL APPLICATIONS J.M. Oliveira 1,2, S.S. Silva 1,2, P.B. Malafaya 1,2, M.T. Rodrigues 1,2, M.E. Gomes 1,2, J.F. Mano 1,2 and R.L. Reis 1,2 1 3B's Research Group Biomaterials, Biodegradables and Biomimetics, Univ. Minho, Headquarters of the European Institute of Excellence on Tissue Engineering and Regenerative Medicine, AvePark, S. Cláudio de Barco, Taipas, Guimarães, Portugal. 2 IBB-Institute for Biotechnology and Bioengineering, 3B s Research Group - Biomaterials, Biodegradables and Biomimetics, University of Minho, AvePark, Zona Industrial da Gandra, S. Cláudio do Barco, Caldas das Taipas, Guimarães, Portugal European Centre of Excellence in TERM

42 PRODUCTION OF SCAFFOLDS FOR TE APLLICATIONS BONE Ceramic: Hydroxyapatite (HA) Composite: Carboxymethylchitosan/HA Polymer: Starch-polycaprolactone (SPCL) OSTEOCHONDRAL Grade 4 defects Bilayered: CHT/HA 16 mm 5 mm 5 mm INTERFACE CARTILAGE HA CHT 5 mm 2.00 mm Polymer: Chitosan (CHT) 5 mm

43 SCAFFOLDS ARCHITECTURE, POROSITY AND RBMSCs ADHESION (12 hrs) HA HA Scaffold HA+1x10 6 RBMSCs in MEM after 12 hrs HA Scaffold Mean porosity of 67.8 ± 5.1% Pore size m SPCL Scaffold SPCL+1x10 6 RBMSCs in MEM after 12 hrs SPCL Scaffold Mean porosity of 67.4 ± 1.3% Pore size m

44 TAKE HOME MESSAGE The choice of treatment is influenced by defect location, size & age (revision) No significant in results between MF/OATS/ACI-MACI/ALLOGRAFTS in large lesions, G IV, W-B Ready availability, low-cost and single-stage nature, make mosaicplasty (& Porto GUT) and microfracture first-line options Microfracture results deteriorate with time Factors affecting return to sports: age, preoperative duration of symptoms, level of play, number of games per season, lesion size, grade & location Time to return to sports > 2cm2 1st mosaicplasty, 2nd microfractures/allograft & 3rd ACI

45 TAKE HOME MESSAGE OUR INDICATIONS FOR SURGERY in 2018 Only symptomatic patients Correct axis, instability and meniscus Grade I and II: Do not touch! Grade III: Superficial regularization (?) or nothing CONDYLES NWB AND PATELLA Grade IV: Debridement/Microfractures

46 TAKE HOME MESSAGE CONDYLES, WB, Grade IV Small lesions (<1,5x2cm2): Debridement/Microfractures Large lesions (2 to 5cm2): Porto GUT Transfer of hyaline cartilage with subchondral bone graft Obtained out of the knee joint Custom made osteochondral block Normal joint mobility Low morbidity and low cost Very large lesions (>5cm2): ACI/MACI or Allograft

47 RESPECT THE PAST, UNDERSTAND THE PRESENT AND EMBRACE THE FUTURE