ANKLE OSTEOCHONDRAL ALLOGRAFTS
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1 ANKLE OSTEOCHONDRAL ALLOGRAFTS UNIVERSITY OF CALIFORNIA, SAN DIEGO
2 CHOLL KIM, M.D., Ph.D. AMIR JAMALI, M.D. F. RICHARD CONVERY, M.D. WILLIAM BUGBEE, M.D.
3 ANKLE OSTEOCHONDRAL ALLOGRAFTS BACKGROUND - ORGAN COMPLEX FULL THICKNESS CARTILAGE WITH UNDERLYING BONE. FIRST DESCRIBED BY LEXER 1908.
4 ANKLE OSTEOCHONDRAL ALLOGRAFTS BACKGROUND - LARGE ALLOGRAFTS USED IN TUMOR SURGERY. SHELL OSTEOCHONDRAL ALLOGRAFTS USED IN OCD AND DJD.
5 ANKLE OSTEOCHONDRAL ALLOGRAFTS BACKGROUND - UNVERSITY OF TORONTO- 100 KNEES WITH 3.8 YEAR F/U. 75% OVERALL SUCCESS. MCDERMOTT ET AL., CORR 1984
6 ANKLE OSTEOCHONDRAL ALLOGRAFTS BACKGROUND - UCSD MEDICAL CENTER- 96 KNEES WITH 4.2 YEAR F/U. 74% OVERALL SUCCESS. BUGBEE AND CONVERY, IN PRESS.
7 ANKLE OSTEOCHONDRAL ALLOGRAFTS OBJECTIVE - CLINICAL OUTCOMES. POST-TRAUMATIC TIBIO-TALAR DJD.
8 ANKLE OSTEOCHONDRAL ALLOGRAFTS PROCEDURE - RECONSTRUCT TIBIO-TALAR JOINT. BIPOLAR, SHELL OTEOCHONDRAL ALLOGRAFTS.
9 MATERIALS AND METHODS DONOR TISSUE - UCSD and Miami Tissue Bank. Harvested within 24h of death. Transplanted fresh within 7 days.
10 INTRA-OP PHOTO
11 MATERIALS AND METHODS SURGICAL TECHNIQUE - Size-matched, orthotopic donors. POST-OPERATIVE MANAGEMENT - Non-weight bearing for 3 months. Early ROM program.
12 INTRA-OP PHOTO
13 PATIENT DISTRIBUTION 8 patients with post-traumatic DJD. 6 female and 2 male. One lost to follow-up. Avg. age at surgery 45 (range 34-67).
14 FOLLOW-UP Average 10.8 years (range months).
15 OUTCOMES ANALYSIS Olerud and Molander Ankle Score - Survey focusing on subjective ankle pain and function. Short Form-12 (SF-12) Health Survey - Survey to assess overall health
16 OUTCOMES ANALYSIS Patient satisfaction - Patients asked to rate result as excellent, good, fair, or poor. Would they undergo a similar operation on the other ankle?
17 ANKLE SCORE Parameter Level of Function Score Running Possible 5 Impossible 0 Pain None 25 While walking on uneven surfaces 20 While walking on even surfaces outdoors 10 While walking indoors 5 Constant and severe 0 StiffnessNone 10 Stiffness 0 Swelling None 10 Only on evenings 5 Constant 0 Stairclimbing No problems 10 Impaired 5 Unable 0
18 ANKLE SCORE Parameter Level of Function Score Jumping Possible 5 Impossible 0 Squatting No problems 10 Unable 0 Supports No supports 10 Taping/wrapping 5 Cane or crutch 0 Work, ADLs No limitations 20 Loss of tempo 15 Change to simpler job 10 Disabled, strongly impaired 0 Total Score 100 Olerud and Copyright Molander, UCSD Dept. CORR of 1986.
19 SF-12 SLIDE
20 SF-12 SLIDE
21 RESULTS ANKLE SCORE - All patients - Pre-op avg. 25 (0-50). Post-op avg. 43 (0-80).
22 RESULTS PATIENT SATISFACTION - How would you rate the result of your procedure? Excellent 2/7 Good 2/7 Fair 0/7 Poor 3/7 Would you do the same procedure on your other ankle? Yes 5/7 No 2/7
23 RESULTS SF-12 SCORE - PHYSICAL COMPONENT All patients - Pre-op avg. 30 (23-46). Post-op avg. 38 (21-53).
24 RESULTS SF-12 SCORE - MENTAL COMPONENT All patients - Pre-op avg. 46 (19-67). Post-op avg. 53 (28-62).
25 COMPLICATIONS J.M. - Graft fragmentation - 1 year post-op. Underwent 2nd allograft-failed. Successful arthrodesis.
26 CLINICAL PHOTO
27 COMPLICATIONS N.H. - Talar allograft subluxation.
28 CLINICAL PHOTO
29 COMPLICATIONS N.H. - Talus repositioned and fixed with Herbert screws.
30 CLINICAL PHOTO
31 COMPLICATIONS N.H. - Herbert screws backed out. Screws removed.
32 CLINICAL PHOTO
33 COMPLICATIONS V. R. - Medial malleolus fracture. HIV positive. Tibio-talar arthrodesis.
34 CLINICAL PHOTO
35 REPRESENTATIVE CASE History - M.H. movie stunt pilot and rancher. Tibial pilon fx. Ambulation tolerance less than one block. Unable to fly plane.
36 PRE-OP XRAYS
37 REPRESENTATIVE CASE Patient- What can you do about this bum ankle doc? I can t take it anymore!
38 REPRESENTATIVE CASE Treatment options- Orthoses/Walking aids. Tibio-talar arthrodesis. Total ankle arthroplasty. Tibio-talar osteochondral allograft.
39 POST-OP XRAYS
40 POST-OP XRAYS
41 POST-OP XRAYS-2YR
42 POST-OP XRAYS -2YR
43 POST-OP XRAYS -6YR
44 PHOTO WITH PLANE
45 CONCLUSIONS 1. Most patients have improved ankle function and overall health. 2. Most patients are satisfied.
46 CONCLUSIONS 3. Good results depend on proper graft fit and adequate fixation. 4. Ankle osteochondral allografts are a viable alternative to arthrodesis.
47 THANK YOU
48 Photo of UCSD
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50
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53 THANK
54 YOU
55 PRE-OP XRAYS
56 CASE PRESENTATION PE- Swelling and warmth. 0 dorsiflexion. 20 painful plantarflexion.
57 RESULTS SF-12 SCORE - MENTAL COMPONENT All patients - Pre-op avg. 46 (19-67). Post-op avg. 53 (28-62). 4/7 successful patients. Pre-op avg. 39 (19-61). Post-op avg. 55 (52-61).
58 RESULTS ANKLE SCORE - All patients - Pre-op avg. 25 (0-50). Post-op avg. 43 (0-80). 4/7 successful patients. Pre-op avg. 21 (0-50). Post-op avg. 57 (30-80).
59 MATERIALS AND METHODS Post-operative Management - Non-weight bearing for 3 months. Early ROM program.
60 MATERIALS AND METHODS Patient Selection - Consecutive patients, regardless of age, gender, race who failed non-surgical treatments for debilitating ankle pain.
61 COMPLICATIONS J.M. - 2nd allograft size mismatch. Tibio-talar arthrodesis.
62 ANKLE OSTEOCHONDRAL ALLOGRAFTS
63 CASE PRESENTATION History - M.H. 67 y/o movie stunt pilot and rancher. Tibial pilon fx 30 years ago. Ambulation tolerance less than one block. Unable to fly plane. PE- Swelling and warmth. 0 dorsiflex, 20 painful plantarflex
64 ANKLE OSTEOCHONDRAL ALLOGRAFTS Objective - Assess the efficacy and effectiveness of ankle osteochondral allografts in the treatment of post-traumatic DJD. Study Design - Reconstruct the tibio-talar joint using shell osteochondral allografts from fresh cadaveric donors.
65 MATERIALS AND METHODS Surgical Technique - Anterior approach to the tibio-talar joint. Transverse tibial and talar cuts using oscillating saw. Size-matched, orthotopic donors pressfit vs. Herbert screws vs. PDS absorbable pins. Post-operative Management - Non-weight bearing for 3 months. Early ROM program.
66 OUTCOMES ANALYSIS SF-12 - General health survey to assess effectiveness. Olerud and Molander Ankle Score - Survey focusing on ankle pain and function to assess efficacy. Patient satisfaction - Patients rate result as excellent, good, fair, or poor. Would they undergo a similar operation on the other ankle?
67 COMPLICATIONS Non-union 1/7 Fragmentation 2/7 Subluxation Fracture Poor graft fit Hardware failure Infections 1/7 (Talus) 1/7 (medial malleolus) 1/7 (Talus too small) 1/7 (Herbert screws backed out, removed). 1/7 HIV-pos (donor HIV-neg) 1/7 Hep C
68 MATERIALS AND METHODS Patient Selection - Consecutive patients, regardless of age, gender, race who failed non-surgical treatments for debilitating ankle pain. Donor Tissue - UCSD and Miami Tissue Bank. Harvested within 24h of death. Transplanted fresh within 7 days.
69 OUTCOMES ANALYSIS SF-12 - General health survey. Olerud and Molander Ankle Score - Survey focusing on subjective ankle pain and function.
70 CONCLUSIONS 1. Preliminary result - Small sample, long-term follow-up. 2. Failure rate 3/7 (42%). 3. Most patients satisfied with result. 4. Patient satisfaction correlates with Ankle Score improvement. 5. Additional patients needed to improve stats. 6. Focal defects vs. diffuse arthropathy.
71 CONCLUSIONS 5. Patient satisfaction correlates with improvements in the Ankle Score and SF-12 score. 6. Good results depend on proper graft size and adequate fixation. 7. Immune reaction? 8. Diffuse arthropathy vs. focal defects.
72 RESULTS SF-12 - Ankle Score - Preop avg. 25 vs. Post-op avg. 43.
73 RESULTS Patient Satisfaction - Excellent 2/7 Good 2/7 Fair 0/7 Poor 3/7 Would do same surgery on other ankle 5/7 Failure rate - Requiring fusion or ankle score worse than pre-op: 3/7 (42%).
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