15 Year old Catcher. Initial Presentation. Osteochondritis Dissecans 12/19/2017. Introduction, Nonoperative tx, Prognostic Factors.

Transcription

1 12/19/2017 Osteochondritis Dissecans Introduction, Nonoperative tx, Prognostic Factors Fixation Vu-Medi Webinar December 19 th, 2017 Theodore J, Ganley, MD Sports Medicine Director The Children s Hospital of Philadelphia Associate Professor of Orthopedic Surgery The University of Pennsylvania School of Medicine 15 Year old Catcher Initial Presentation 15 year-old female fell and hit her right knee Presented to the ED with mild swelling and pain. Xrays performed, then discharged with a knee immobilizer, crutches and recommended follow-up in orthopaedics clinic. 1

2 12/19/2017 Managing OCD of the Knee Questions Who, What, When, Where Why, How 1 What is it, Who gets it, Where does it occur 2 When does it heal, Why do you treat it 3 How do you treat it 2

3 12/19/ Osteochondritis Dissecans Definition: A focal idiopathic alteration of subchondral bone with risk for instability and disruption of adjacent articular cartilage 1 Osteochondritis Dissecans Definition: A focal idiopathic alteration of subchondral bone with risk for instability and disruption of adjacent articular cartilage that may result in premature osteoarthritis. Figure from Tothet al AJSM 3

4 12/19/2017 Figure from Ytrehuset al Bone Figure from Ytrehuset al Bone 4

5 12/19/2017 Images from Zbojniewicz et al 2015 AJR Roentgenol Images from Zbojniewicz et al 2015 AJR Roentgenol ACL Acute - Binary OCD Chronic - Continuum 5

6 12/19/2017 ACL Acute - Binary ACL 0 Intact 1 Not Intact Same Location Same Imaging Same Treatment OCD of the Knee Osteochondritis as a Spectrum Each OCD - a spectrum of varied Location/Size/Continuity/Features progeny and parent bone OCD of the Knee Osteochondritis Dissecans Location: lateral aspect of MFC > 70% Inferior-central lateral 15-20% Patellar 5-10% Trochlea <1% 6

7 12/19/2017 Boundary Boundary distinct higher or lower density line separating parent from progeny Juvenile OCD - Uniform Nomenclature Credit ROCK group Parent Bone Progeny Bone Fragmentation Fragmented >/= 2 pieces of bone 7

8 12/19/2017 Displacement Intact Partially Displaced Totally Dislpaced Shape / Contour Shape / Contour Concave Linear Convex 8

9 12/19/2017 Radiodensity More Less Same AJSM, Lesion Characteristics Described: 1. Parent vs. Progeny Bone Feb Lesion location (A-P; M-L) 3. Fragmentation and Boundary 4. Displacement 5. Shape/Contour 6. Radiodensity (compared to surrounding bone) 9

10 12/19/2017 Healing Potential Retrospective evaluation of 27 lesions in 24 patients Patients closer to skeletal maturity and those with MRI signs of instability less likely to heal Pill, Ganley et al JPO 2003 Healing Potential Skeletally immature patients 31/47 showed radiographic sign of progressive healing at 6 months Larger lesions and those causing mechanical symptoms less likely to heal Regression model predictors: Normalized width, Normalized length, and Symptoms Wall et al. JBJS

11 12/19/2017 OCD of the Knee Operative Treatment Nonoperatively Who s not going to heal? Length Width Symptoms Wall et al. JBJS 2008 OCD of the Knee Operative Treatment Nonoperatively Who s not going to heal? Length Width Symptoms Wall et al. JBJS 2008 Wall et al. JBJS 2008 OCD of the Knee Operative Treatment Nonoperatively treated JOCD pts Add Numbers Probability of healing 21% Wall et al. JBJS

12 12/19/2017 Juvenile OCD Articular Surface Intact -Not Marginated -Wide open growth plates Articular Surface Intact Marginated Not Intact A B C Arthroscopic Evaluation Stable, Salvageable Progeny Cue Ball Shadow Immobile ROCK Arthroscopic Evaluation Stable, Salvageable Progeny Locked Door mobile ROCK 12

13 12/19/2017 Juvenile OCD Unstable, Salvageable progeny: Trap Door Crater with congruent flap Crater with incongruent loose flap That can be made congruent mobile ROCK Juvenile OCD Unstable, Unsalvageable progeny Crater with incongruent loose body that can not be made congruent Crater with fagmented loose body Crater without loose body ROCK OCD of the Knee Algorithm Nonoperative Protocol Phase 1 (4-6 weeks) Immobilization WBAT Phase 2 (6 weeks) No immobilization ADL s PT Phase 3 (Lesion healed - absence of symptoms) Gradual/Supervised return to sport 2010 AAOS Presentation Unloader > Casting or Restriction Kocher/Ganley/Micheli et al 13

14 12/19/2017 Juvenile OCD Articular Surface Intact Not Marginated Nonoperative Rx (crutches, activity) 6-9 months Healed Not Healed Arthroscopic Drilling Articular Surface Intact Not Marginated Nonoperative Rx (crutches, activity) 6-9 months Juvenile OCD Retroarticular Clinical Scenario Intact Transarticular Healed Not Healed Arthroscopic Drilling Articular Surface Intact Not Marginated Nonoperative Rx (crutches, activity) 6-9 months Juvenile OCD Retroarticular Clinical Scenario Intact Transarticular Healed Not Healed Notch Drilling Arthroscopic Drilling 14

15 12/19/2017 Reduction of Trap Door OCD of the Knee Detached OCD of the Knee Operative Management Defect - Small 1 cm Recruitment - mesenchymal cell stimulation 15

16 12/19/2017 OCD of the Knee Osteochondral Defect Osteochondral Allografts - Adult Patients 65 knees - age 28.6, f/u 7.7 yr (mean) All type 3 or 4 41 MFC lesions, 25 LFC lesions, 72% G/E, 11% Fair, 2% Poor. 15% underwent reoperation 3 cm Emmerson. AJSM OCD of the Knee Operative Treatment Defects - Large and Massive ACI Autologous Chondrocyte Implantation OCD of the Knee ACI Autologous Chondrocyte Implantation CHOP series (6 sq. cm) Kids > Adults Intl. Registry centers Selective King P, Ganley T; AAOS Annual Meeting 16

17 12/19/2017 OCD of the Knee Principles: Address Alignment Guided Growth OCD of the Knee Principles: Address Alignment Osteotomies Thank You 17

18 12/18/2017 Osteochondritis Dissecans (OCD) of the Knee Drilling Indications & Techniques Matthew D. Milewski MD Boston Children s Hospital Disclosures Elsevier, Inc. Editorial Work Operative Treatment Options Drilling Trans-articular Retro-articular Notch Fixation Metal vs Bioabsorbable Biologic Drilling Salvage Chondroplasty / Microfracture Osteochondral Autograft Transplantation (OATs) Osteochondral Allograft ACI / Bone Grafting 1

19 12/18/2017 Operative Treatment Options Drilling Trans-articular Retro-articular Notch Fixation Metal vs Bioabsorbable Biologic Drilling Salvage Chondroplasty / Microfracture Osteochondral Autograft Transplantation (OATs) Osteochondral Allograft ACI / Bone Grafting Pathoanatomy Subchondral bone drilling (not microfracture!) Lack of vascularity has been associated with OCD formation in human and animal studies Subchondral bone drilling with an intact lesion should help to restore vascularity ROCK Arthroscopy Classification Stable/Immobile Unstable/Mobile 2

20 12/18/2017 Isolated Drilling without additional procedures Isolated drilling for stable Lesions in those with significant growth remaining Stable/Immobile Lesions If closer to maturity, consider drilling + fixation, possible bone grafting For more advanced lesions, drilling in isolation is not enough Subchondral bone drilling options Trans-articular drilling Retro-articular drilling Drilling Trans-articular Visualize lesion / holes directly Ensures adequate coverage Retro-articular Doesn t violate articular cartilage Fluoroscopy ROCK RCT ongoing! Ben Heyworth CHB Trans vs retro MFC OCD lesions 3

21 12/18/2017 Drilling Subchondral bone drilling has demonstrated excellent outcomes in carefully selected patients, with 70-90% good results in multiple studies. Retro-articular drilling Trans-articular drilling OCD Subchondral Bone Drilling OCD lesion is clearly seen arthroscopically, subchondral bone drilling is straight forward region for drilling is clearly seen on the hyaline cartilage surface OCD lesion outline is not clear overlying hyaline cartilage is normal the use of MRI imaging and the C-Arm image intensifier is essential for pin placement OCD Drilling: Surgical Tips K wire Driver K-wires Inch for Trans-articular for Retro-articular C-Arm to get AP, Lateral, and Oblique Views If K-Wires are bent during drilling, remove them with a needle driver, to avoid having the wires shear at the bend site Use Driver with low torque/speed 4

22 12/18/2017 Subchondral Bone Drilling For OCD Hyaline Cartilage surface is normal Medial Femoral Condyle The C-arm is used to identify the OCD lesion. A guide pin is placed in the most inferior region of the lesion, to be used as a marking point for additional drilling File name Picture - Start of subchondral bone drilling video - Medial Femoral Condyle Notch Drilling Technique for OCD This K-wire defines the Medial and posterior edge of the OCD lesion. This is placed with Guidance from the mini C-arm. PCL Origin and Fibers File name Picture - Notch Drilling Technique for OCD Video - OCD Notch drilling Video - OCD Notch drilling with Marker Pin 5

23 12/18/2017 Case 12 yo female AAU Basketball Vague knee pain for a month No mechanical symptoms No obvious effusion Case MRI Small cystlike foci Rimlike hyperintense signal No thickening of the cartilage No articular cartilage fissuring normal articular cartilage contour Case Sudden increased pain with weight bearing after 8 weeks of non-weightbearing Decision was made at that time to proceed with arthroscopy and possible drilling vs fixation 6

24 12/18/2017 Genetics. Retro-articular drilling after confirming stability of the lesion Case Went on to heal with return to activities at 3 months post operatively Returned to clinic with her brother at 7 months post operatively Genetics 12 yo younger brother 4 month history of vague knee pain Baseball / Basketball No currently available commercial genetic OCD testing 7

25 12/18/2017 Conclusion Subchondral bone drilling is a surgical option in the treatment of OCD lesions of the knee. Best used for stable lesions in skeletally immature patients Can supplement other techniques such as fixation in older patients Trans-articular, retro-articular techniques are available, can be supplemented with notch drilling 70-90% good / excellent results but patient selection is key. 8

26 Treatment of Unstable OCD Stephanie W. Mayer, MD Children s Hospital Colorado University of Colorado Sports Medicine

27 Disclosures Arthrex Consultant

28 Unstable OCD at initial presentation

29 Progression to unstable lesion despite treatment

30 Surgical Options Fixation (arthroscopic or open) Bioabsorbable screw Metal screw Headless Headed Drilling and Fixation Debridement of base of lesion with fixation Bone grafting with fixation Osteochondral allograft Osteochondral autograft Autologous chondrocyte implantation Microfracture

31 Fixation Unstable lesions with salvageable cartilage Often combined with drilling Ensure countersunk below cartilage surface Multiple, (unconventional) c-arm views Nepple et al., J Knee Surg, 2016 Courtesy, Kevin Shea, MD

32 Fixation Unstable lesions with salvageable cartilage Metal vs bioabsorbable screws

33 Bioabsorbable screws Generally 2.9mm diameter Advantages No need for removal Disadvantages Cyst formation? Can break during insertion Deeper drill tract and tap

34 Metal screws 2-3mm mini frag or headless compression Courtesy, Kevin Shea, MD Advantages Sturdier during insertion and rehab Disadvantages Need for second scope for removal, 3-6 months Also considered an advantage!

35 Bioabsorbable vs Metal screws Adachi et al /33 healing at 2 years with no cyst/synovitis Kocher et al No difference in healing, outcomes scores, cyst/synovitis Millington et al Lower healing rate and higher complications in nonthreaded bioabsorbable screws Webb et al /13 bioabsorbable implants failed

36 Fixation Unstable lesions with salvageable cartilage Metal vs bioabsorbable screws Debridement of base of lesion?

37 Debridement of base of lesion with fixation If already a hinged lesion If fibrous tissue is preventing reduction Carey et al., AJSM, 2016 Courtesy, John Polousky, MD

38 Fixation Unstable lesions with salvageable cartilage Metal vs bioabsorbable screws Debridement of base of lesion? Bone grafting of base?

39 Bone grafting If significant bone loss or cystic changes at base of lesion Cancellous chips, DBM, autogenous local grafting Courtesy, John Polousky, MD

40 Fixation Unstable lesions with salvageable cartilage Metal vs bioabsorbable screws Debridement of base of lesion? Bone grafting of base? Autograft/allograft fixation?

41 Osteochondral autograft/allograft Osteochondral autograft plugs or allograft bone sticks Press fit to create fixation of the OCD Miniaci et al. Courtesy, Ted Ganley, MD

42 Fixation Unstable lesions with salvageable cartilage Metal vs bioabsorbable screws Debridement of base of lesion? Bone grafting of base? Autograft/allograft fixation? Open or arthroscopic approach?

43 Open or arthroscopic considerations for fixation Where is the lesion? Do I need to debride the base? Is it already detached? How big and where is the piece? Is bone grafting needed?

44 THANK YOU! ROCK Kevin Shea, MD John Polousky, MD Ben Heyworth, MD Matt Milewski, MD Jim Carey, MD, MPH

45 12/11/2017 Treatment of Failed OCD- Cartilage Recovery and Salvage Options John D. Polousky, MD Surgical Director Chief of Pediatric Orthopedics Dallas, Texas Disclosures Consultant- Allosource/JRF. Dallas, Texas Why did it fail? Disease too severe. Cartilage in poor condition. Poor healing ability. [Skeletally mature]. Malalignment Varus Valgus Elevated TT-TG Dallas, Texas 1

46 12/11/2017 Assess Alignment-Long, standing X-rays. Dallas, Texas Correcting Alignment is prerequisite. Distal femoral osteotomy. Proximal tibial osteotomy. Tibial tuberosity osteotomy. Guided growth [skeletally immature]. Dallas, Texas Several options following realignment: Fix it. Cartilage is relatively good and skeletally immature. Open fixation with bone graft. Dallas, Texas 2

47 12/11/2017 Treatment-Operative 15 year-old female Dallas, Texas Treatment-Operative 15 year-old female Dallas, Texas Treatment-Operative 15 year-old female Dallas, Texas 3

48 12/11/2017 Treatment-Operative 15 year-old female Dallas, Texas Treatment-Operative 15 year-old female Dallas, Texas Treatment-Operative [salvage] Microfracture Technically easy. Inexpensive. Gudas [2009] Microfracture vs. OATS Prospective, randomized. 41% failure in microfx at 4.2 yrs. 0% failure for OATS. Dallas, Texas 4

49 12/11/2017 Treatment-Operative [salvage] Microfracture Technically easy. Inexpensive. Gudas [2009] Microfracture vs. OATS Prospective, randomized. 41% failure in microfx at 4.2 yrs. 0% failure for OATS. Dallas, Texas Treatment-Operative Autologous Chondrocyte Implantation [ACI, now MACI] Good results for large defects. Peterson [2003] 91% good to excellent at 5.6 yrs. Large lesions [mean 5.7cm 2 ]. Mithofer [2005] 96% good-excellent. Dallas, Texas Treatment-Operative MACI Good early results. Failure of 11% at 7 years. IKDC subjective from 39 to 77 at 24 months. Best groups- traumatic, OCD, male, young age, lack of prior surgery. Dallas, Texas 5

50 12/11/2017 Treatment-Operative Fresh Osteochondral Allograft Replaces bone and cartilage. Emmerson [2007] 72% good-excellent at 7.7 yrs. Mean size 7.5 cm 2. All had prior surgery. Murphy, Pennock, Bugbee [2014] 88% good-excellent at 10 years in adolescents. Dallas, Texas Treatment-Operative Fresh Osteochondral Allograft Replaces bone and cartilage. Emmerson [2007] 72% good-excellent at 7.7 yrs. Mean size 7.5 cm 2. All had prior surgery. Murphy, Pennock, Bugbee [2014] 88% good-excellent at 10 years in adolescents. Dallas, Texas Summary Always assess alignment. Microfracture/Marrow Stimulation/Debridement does not produce durable long-term results. Fixation with bone grafting is an option if cartilage is in good condition and patient has growth remaining. Osteochondral allograft and ACI/MACI are good options for large unsalvagable lesions. Dallas, Texas 6

51 12/18/2017 OCD of the Knee: Evidence-Based Techniques in Rehabilitation Mark V. Paterno PT, PhD, MBA, SCS Professor, Division of Sports Medicine Coordinator of Orthopaedic and Sports Physical Therapy Scientific Director Division of Occupational Therapy and Physical Therapy Cincinnati Children s Hospital Medical Center Cincinnati, OH I have nothing to disclose Objectives 1. Review rehabilitation for the patient pursuing non-operative management of OCD of the knee 2. Review algorithm for post-operative management for OCD lesions of the knee in skeletally immature patients 1

52 12/18/2017 Management Stable Joint unloading Immobilization? Progressive physical therapy Unstable Operative management Progressive physical therapy OCD: Rehabilitation for Nonoperative management Rehabilitation Principles Education (client/family, coaches, teachers) Individualized program Criterion-based progression emphasizing Pain/effusion management Joint range of motion Progressive strengthening Progressive joint loading OCD: Rehabilitation for Nonoperative management Acute Phase Intermediate: - Protected WB - Progression of motion - Initiation of LE strengthening - Progression of WB/strength - Initiation of WB activity such as balance/prop., CKC activity Return to Sport: -Systematic progression back to activity 2

53 12/18/2017 OCD: Rehabilitation for Operative Management Post-Operative Management 1. OCD Drilling 2. Chondroplasty 3. Microfracture/Abrasion arthroplasty 4. OATS (Osteochondral autograft) 5. Mosaicplasty 6. ACI 7. Osteochondral allograft 8. Structural alignment procedure 9. Total knee arthroplasty Guiding Principles of Rehabilitation 1. Never overstress healing tissue 2. Allow progression of WB with goal of minimizing excessive compressive loads 3. Allow immediate ROM to facilitate healing 4. Progression of rehabilitation is dependent on size and location of lesion 3

54 12/18/2017 Guiding Principles of Rehabilitation 1. Location!: Tibiofemoral vs. Patellofemoral TF: Compressive forces with WB. too much vs. not enough PF: Compressive/shearing forces with quad contraction 2. Size of lesion Outcome dependent on lesion size: modifications based on size Guiding Principles: ROCK Group In the absence of evidence 1. Dichotomized treatment based on cell based intervention vs. structural intervention 2. Dichotomized by location (tibio-femoral joint vs. patellofemoral joint) Guiding Principles: ROCK Group Tibiofemoral Joint Patellofemoral Joint Cell-Based Intervention (ACI, microfracture) Structural Intervention (OATS, Osteochondral allograft, Fragment fixation,) 4

55 12/18/2017 Guiding Principles: ROCK Group 3. Focused in key variables: o WB guidelines o Bracing o CPM use o ROM limitations o Guidelines for strengthening o Return to Sport guidelines Guiding Principles: ROCK Group Weight Bearing: TF Joint Cell Based = 6 wk NWB, 2 wk PWB Structural = 4 wk NWB, 2 wk PWB PF Joint NWB 2 wk (in brace), PWB 2 wk Guiding Principles: ROCK Group Bracing: No bracing for TF lesion Post-op bracing in PF group (both cell based and structural interventions) locked in extension for WB CPM use: Moderate importance with cell based treatments 5

56 12/18/2017 Guiding Principles: ROCK Group ROM guidelines: Cell based treatment: No limits with TF joint lesion PF joint: 0-90 x 2 weeks with 10 degree weekly progression after 2 weeks Structural guideline: No limits with progression of ROM Guiding Principles: ROCK Group Return to Activity Guidelines: Structural Interventions: 3-6 months Cell based interventions: TF: MF=4-6 months; ACI=9-18 months PF: MF= 4-9 months; ACI=12-18 months Guiding Principles: ROCK Group Rehabilitation for Sub-chondral Drilling of OCD with intact Articular Cartilage (TF) NWB x 6 weeks Early ROM encouraged Strengthening aligned with WB status Transition to function ~3 months Return to sports (4-6 months) 6

57 12/18/2017 Functional Progression/Activity Restoration Restoration of normal limb symmetry with strength and functional movements Return to activity progression Limit return to activity until after successful completion of RTS program Set realistic goals for RTS/return to activity Future Needs: Objective criteria to determine readiness to RTS. Conclusion 1. Rehabilitation is a work in progress 2. Current focus should be to protect healing tissues and appropriately progress exercise to address impairments 3. Prior to return to activity, patients should complete a graded functional progression and demonstrate adequate level of function Thank You! Mark V. Paterno PT, PhD, MBA, SCS Professor, Division of Sports Medicine Coordinator of Orthopaedic and Sports Physical Therapy Scientific Director Division of Occupational Therapy and Physical Therapy Cincinnati Children s Hospital Medical Center Cincinnati, OH 7