Why do they fail?? TOM MINAS MD MS. The Management of Failed Cartilage Repair Procedures PALM BEACH FL

Transcription

1 The Management of Failed Cartilage Repair Procedures Why do they fail?? TOM MINAS MD MS DIRECTOR, CARTILAGE REPAIR CENTER, PALEY ORTHOPEDIC INSTITUTE, PALM BEACH FL PROFESSOR EMERITUS, HARVARD MEDICAL SCHOOL, BOSTON MA

2 Disclosures Vericel ( formerly Genzyme Biosurgery) Consultant Elesevier Book royalties ConforMIS Inc., SAB member-stocks and royalties

3 Goal of Cartilage Repair Restoration of the Osteochondral Functional Unit Organized visco-elastic tissue integrated to subchondral bone to permit load transmission

4 The Beginning BRIT TBERG M, LINDAHL A, NILSSON A, OHLSSON C, ISAKSSON O, PETERSON L. TREATMENT OF DEEP CARTILAGE DEFECTS IN THE KNEE WITH AUTOLOGOUS CHONDROCYTE TRANSPLANTATION. N ENGL J MED. 1994;331(14): FEMORAL CONDYLES 14/16 G/E OUTCOMES 2 REVISED PATELLA 2/7 G/E, 3 FAIR, 2 POOR WHY DO THEY FAIL?? FDA BLA1233- AUGUST-1997 AFTER REVIEW OF 153 PATIENTS IN GOTHENBERG, SW.

5 Correction of the Background Factors Cause/contributing to chondral loss Biological Reconstructions Malalignment Status of meniscus Ligament stability Staged/simultaneous reconstruction

6 Longterm MINAS T, BRYANT T. THE ROLE OF AUTOLOGOUS CHONDROCYTE IMPLANTATION IN THE PATELLOFEMORAL JOINT. CLIN ORTHOP RELAT RES JUL; 436: FULKERSON TYPE III, IVA,B LESIONS DO EXCELLENT WITH ACI VON KEUDELL A, HAN R, BRYANT T, MINAS T, AUTOLOGOUS CHONDROCYTE IMPLANTATION TO ISOLATED PATELLA CARTILAGE DEFECTS. TWO- TO 15-YEAR FOLLOW-UP. CARTILAGE, 1-9, 2016 JUL 30 PATIENTS 2-15 YEARS, 83% G/E, 13% FAIR, 1 POOR FULKERSON PATELLA CLASS 18 TYPE IV, 9 TYPE III,3 TYPE II, AV 4.7CM SQ

7 4 centers, 110 patients ( including bipolar) All scales, clinically & statistically sig improvements IKDC WOMAC Mod Cinc Activity % G/E 92% would do surgery again 8% (9) treatment failures 16% not improved Gomoll AH, Gillogly SD, Cole BJ, Farr J Minas T. Autologous chondrocyte implantation in the patella - a multicenter experience. Am J Sports Med May;42(5):

8 Isolated Bipolar PF kissing lesions Survival rate n= was 60 84% at 5 years and 81% at 10 years Minas, Ogura, Bryant CRC BWH 2017

9 PERIOSTEAL COMPLICATIONS- Hypertrophy 5-65 % in different studies Hypertrophy (Morphologic appearance) Superficial Fibrillation Edge Overlapping Onion layering Focal thickening (mounding)

10 Periosteal Substitute with Porcine Collagen Membrane USA

11 ACI to MFC+LFC-Disease progression 5 Yr ACI- Trochlea+Patella MM

12 MFC+LFC- CACI Type I-III Collagen Porcine membrane- Biogide MM

13 Multi-center study, 3 centers 300P-ACI vs 101 C-ACI Compared 1 yr hypertrophy and failure rates Similar age #defects C>P 1.8 to 1.5 (P=0.001) 25.7% P- 5% C hypertrophy requiring scope (p<0.0001) 2.3% P vs 4%C failed (p=0.2) overall SA C>P, 8.6 to 6.7cm2 (p=0.003) 1. Gomoll AH, Probst C, Farr J, Cole BJ, Minas T. Use of a type I/III bilayer collagen membrane decreases reoperation rates for symptomatic hypertrophy after autologous chondrocyte implantation. Am J Sports Med Nov;37 Suppl 1:20S-23S. Epub 2009 Oct 19. PubMed PMID:

14 2 Year 2 nd look ACI LFC+LTP+Lateral Meniscal Allograft HJ 141

15 18 knees, av age 31.8, 7.9 yr F/U (2-16 year) Defect av 7.9cm2 (2.3-21) 17 lat MAT, 1 med 75% 5+10 yr survival 1. Ogura T, Bryant T, Minas T, Biological Knee Reconstruction with Concomitant Autologous Chondrocyte Implantation and Meniscal Allograft Transplantation: Mid- to Long-term Outcomes. Orthop J Sports Med Oct 19;4(10):

16 23 YO Female 4 years post op LFC ACI (Prior partial lateral menisectomy)

17 Fresh LFC OCG +MAT

18 325 consecutive joints 111 MST vs 214 virgin chondral defects Failure rate 26% vs 8%, > 3x 5X failure rate after prior MFX Nawaz SZ, Bentley G, Briggs TWR, et al. Autologous Chondrocyte Implantation in the Knee.Mid-Term to Long- Term Results. JBJS (Am.)96:824-30, % failure rate at 10 years after prior cartilage repair Leela C. Biant, George Bentley, Sridhar Vijayan, John A. Skinner and Richard W.J. Carrington. Long-term Results of Autologous Chondrocyte Implantation in the Knee for Chronic Chondral and Osteochondral Defects. Am J Sports Med : Originally published online July 7, Failures 7/28 in ACI prior MFX versus 1/28 ACI = 6x failure rate Pestka JM,et al..clinical Outcome of Autologous Chondrocyte Implantation for Failed Microfracture Treatment for Articular Cartilage Defects in the Knee.Am J Sports Med.2012 Feb;40(2): Minas T, GomollAH, Rosenberger R, Royce RO, Bryant T. Increased failure rate of autologous chondrocyte implantation after previous treatment with marrow stimulation techniques. Am J Sports Med. 2009

19 Observations after Failed Marrow Stimulation- Treatment by ACI PRIOR ABRASION LT 056

20 Observations after Failed Marrow Stimulation- Treatment by ACI PRIOR MICROFRACTURE LA 117

21 Prior Microfracture Treated by ACI JJ 148

22 ACI has an increased failure rate after failed Marrow Stimulation Techniques ALTERATION IN THE SUBCHONDRAL BONE AFTER MARROW STIMULATION THICKENING, SCLEROSIS, INTRALESIONAL OSTEOPHYTE FORMATION

23 MST and Sub-Chondral Bone Changes ACI

24 Poor Integration - Delamination

25 Central Degeneration over Intralesional Osteophyte / Sclerotic Bone

26 Contained Osteochondral Defect Osteochondritis Dissecans Avascular Necrosis(Idiopathic) Bone cysts Failed Osteochondral allografts/autografts Failed Synthetic plugs

27 Sandwich ACI Defect Preparation

28 Sandwich ACI versus ABG alone 24 ACI Sandwich patients vs 17 ABG patients (Follow-up Avg = 7.8 yrs vs 15.7 yrs) Minas, Ogura, Hendrick, Bryant CRC BWH 2017

29 23 YO male MSU Football player HX Right knee injury OATS MFC MFX MFC allograft MFC arthroscopic debridement trochlea defect, extension of disease around allograft Presently, 8/10 pain with walking, biking, getting out of bed first steps Sports not possible

30 Standing Xrays

31 Extensile exposure TTO (+/- HTO)

32 Intraoperative Findings

33 Debridement and Cyst removed with hi speed Burr

34

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36 Post op xrays

37 6 month Post op MRI MFC ACI Sandwich LFC ACI

38 One Year Post operative

39 Failure = prosthetic arthroplasty 12 / 156 knees (8%) went on to arthroplasty 2 partials, 10 TKA Average time to prosthesis 38.2 mos (9-118 mos) Causes of failures; 3 Graft failure 1 inadequate pain relief 8 progression of OA beyond transplanted defects

40 Progression of Disease 10 years Post ACI - MFC, LFC, Trochlea, Patella 16.6 cm 2 DW 11

41 Patient Satisfaction for those who underwent TKA- Failed Compared to one year ago, how would you rate each operated joint now? 25% better,75% same Compared to before each surgery, how would you rate each operated joint now? Better 33%, same 33%,worse 33% What is your overall satisfaction level with each joint surgery? 58% satisfied, 25% neutral, 17% dissatisfied How would you rate the results of each joint surgery? 25% G / E, 50% fair, 25% poor Would you choose to have each joint surgery again? 92% yes, 8% uncertain

42 Summary Background factors critical- Alignment, tracking, stability, meniscus Realistic patient Informed consent risks and recovery Surgeon knowledge of outcomes and skill factor