Overview of Multiple Cartilage Sparing Techniques and Rehab Principles For The Knee

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1 Overview of Multiple Cartilage Sparing Techniques and Rehab Principles For The Knee Owner & Founder of the Fischer Institute Trent Rincon, PT, MPT, CSCS Brett Fischer PT, ATC, CSCS,CertDN

2 The Knee Joint 2 types of The Knee Joint 2 types of Cartilage Cartilage (A) Meniscus: Cushion between the femur & tibia Made up of fibrocartilage ( Type I & II Collagen) (FIG I) (B) Articular: hyaline cartilage Smooth layer that covers the articular bones Has a fractional coefficient 1/5 of ice on ice Large portion is fluid which helps with compressive forces Poor ability to heal itself Has only a single type of cell for renewal the chondrocyte (FIG 2)

3 Osteoarthritis Of The Knee FIG 1 FIG 2 Credit: Dr. Greg Portland

4 Osteoarthritis Of The Knee FIG 3 FIG 4 Credit: Dr. Greg Portland

5 Overview of Surgical Options For: Articular Cartilage Restoration 1. Palliative Procedure 2. Intrinsic Repair Enhancement 3. Whole Tissue Transplantation of Hyaline Cartilage Autograft Allograft 4. Cell Based Repairs 5. Cell Based Repairs with Scaffold 6. Scaffold Based Repair 7. Minced Cartilage Repair

6 1. Palliative Procedure Clean Out Basically removed of loose fragments of cartilage or meniscus Short term relief Doesn t address the true problem

7 2. Intrinsic Repair Enhancement / Marrow Stimulation Procedure aka Microfracture Drilling of subchondral bone causing the release of mesenchymal stem cells from the bone marrow. This creates a fibrous tissue formation (not hyaline cartilage) The effectiveness depends on age, size & location of the defect and post op strategies Made popular by Vail, Co physician Dr. Richard Steadman

8 Intrinsic Repair Enhancement / Marrow Stimulation Procedure Positives Simple, inexpensive Negative The fibrous / clot formation is not as mechanically sound as hyaline cartilage Need 6-8 weeks of NWB in some cases with 8 hours of CPM Muscle atrophy, compliance issues Research has shown only a 44% returns to sport (Mithoefer, et al. Am I Sports Med 2006, Sep)

9 3. Whole Tissue Transplantation of Hyaline Cartilage (A) Autograft Mosaicplasty / OATS (B) Allograft - AOT

10 Whole Tissue Transplantation of Hyaline Cartilage (Autograft) Mosaicplasty AOCG (Autologous Osteochondral Grafting) OATS -similar to Mosaicplasty but bigger plugs and less in number Osteochondral plugs are taken from non-weight bearing areas on both femoral condyles with insertion of these plugs into defect area. Usually 3-6 weeks NWB followed by 3 to 6 more weeks PWB

11 Autograft Positives Defect is filled with mature hyaline cartilage Better results than microfx ( Krych, Harnly, Williams, J Bone Joint Surg AM, 2012) Negatives Only suitable for small defects Technically difficult Limited donor tissue available Donor site morbidly Non-impact activities until after 12 weeks Returns to sport 10 months & on

12 Whole Tissue Transplanation of Hyaline Cartilage Allograft (AOT) Similar procedure to mosaicplasty / OATS procedure except the cartilage is obtained from another donor Usually used for larger type chondral defects Cryopreserved Chondral grafts such as BioCartilage or Cartiform very popular brands used by Orthopods

13 Whole Tissue Transplantation of Hyaline Cartilage Allograft (AOT) Positives Well documented success Viable, fresh cells & sustainable matrix 88% return to sports ( Krych, Robertson, Williams, AM Journal of Sports Medicine 2012) Negatives Limited availability High Cost Disease Risk? Fresh allografts obtained hours earlier provide higher chondrocyte availability but carry a higher risk for disease transmission versus cryopreserved frozen allograft have reduced disease transmission but low chondrocyte availability.

14 4. Cell Based Repair Procedures ACI (carticel) PRP Stem Cell Orthokine / Regenokine

15 Autologous Chondrocyte Implantation (ACI) (Carticel) Procedure performed in 3 major phases Phase I Diagnostic arthroscopy with cartilage harvest Phase II Chondrocyte Cultivation in lab for 6 weeks Phase III Implantation surgery which consists of debridement of the defect, harvesting of the periosteal flap from the proximal tibia to help create a patch followed by injection of harvested and cultured chondrocytes under the patch.

16 Autologous Chondrocyte Implantation (ACI) (Carticel) Positives Somewhat favorable outcomes (vol. 4 Genzyme tissue repair, Cambridge, MA,1998) (891 Transplants 86% good to excellent results) Negatives Hypertrophy of the patch leads to another surgery Unreliable potential of re-implanted cartilage cells Less favorable at patellofemoral joint

17 PRP PRP - Platelet-Rich Plasma Basically infuses the joint via injection with high concretion of growth factors that promote healing and remolding. (In 2009, Drengk, et all in Cell Tissue Organ) reported that PRP creates proliferation of autologous chondrocytes + mesenchymal cells. This also increases hyaluronic acid secretion. These chondrocytes demonstrate less interleukin - 1B induced inhibition of Collagen II

18 PRP Positives Easy Non surgical Good outcomes for early osteoarthritis Negatives Limited lasting effect No Change on MRI Relatively, new treatment frequency still being debated

19 Stem Cell Procedures for Osteoarthritis Use of stem cell found in humans to promote healing within the joint by creating more chondrocyte cell Allogeneic mesochymal stem cells ( adult cells, not fetal, or embryonic, usually harvested from bone marrow or adipose tissue) Embryonic Stem Cells (Medical News Today, 3/4/2015) Univ of Manchester, U.K. promising new results

20 Stem Cell Procedures for Osteoarthritis Positives Less Invasive Easier Recovery Outpatient Basis Negative Science in still not there yet Costly

21 Orthokine / Regenukine Orthokine / Regenokine Experimental medical procedure in which the patients own blood is extracted, manipulated and then re-introduced to the body as an anti-inflammatory drug. Around 60 ML of blood is removed from the patient Developed in Germany by Dr. Reinecke and Dr.Wehling Focuses on treating the inflammation as opposed to the mechanical problem in the joint Different than PRP in that PRP, platelets are targeted whereas the interleukin 1 (an arthritic agent in one s blood) is targeted

22 Orthokine / Regenokine Positives Non Surgical Easy to administer Early results are good (accordantly to German studies 75% success rate) Negatives Costly (around $10,000 cost per joint) Not FDA Approved

23 5. Cell Based Repairs With Scaffold (Neocart) Similar to ACI in that patients own cells are harvested but these cells are then embedded into Type I collagen matrix and incubated in an unique processor that stimulates the cells to produce protein then implanted over the defect

24 Cell Based Repairs With Scaffold (Neocart) Positives Results are promising (Crawford, et all,j Bone Joint Surg 2012) Negatives Takes up to 9 weeks for final implantation Costly Long term studies not available

25 MACI Matrix-Introduced Autologous Chondrocyte Implantation Much like ACI procedure but collagen patch with cultured harvested cells is secured with fibrin glue Positives Early studies are processing (mostly in Europe) Negatives Not FDA Approved Costly Long Rehab time

26 6. Scaffold Based Repairs ( Trufit :by Smith & Nephew) Synthetic osteochondral graft by use of polymers, ceramics and fibers. The material is designed to be a highly porous scaffold to support issue incorporation and remodeling by absorbing biological fluids and nutrients, the material is biologically friendly. Positives Easily done arthroscopically Negatives Not available in US yet Mixed results so far Not FDA Approved

27 7. Minced Cartilage Repair DeNovo NT (Natural Tissue) Made out of minced cartilage from organ donors under the age of 13 Uses fibrin to stick minced carriage onto defect area Positives Not harvesting of own cells 1 step procedure immediate implantation Negatives Costly Limited availability, donors No long term studies / follow up

28 Goals of Evaluation Identify & treat the tissue and / or the cause Such as identity & treat ROM imbalances Restore / improve / facilitate proper Movement via manual therapy, Neuromuscular re-education, etc Establish rapport/trust with patient!

29 Overall Goal of Evaluation Basic understanding of the biomechanics of the lower chain, then functionally isolate to find specific deficits.( not symptom based treatment )

30 3 Planes Of Motion Gary Gray

31 3 Planes Of Motion Sagittal Plane Motion Gary Gray

32 3 Planes Of Motion Frontal Plane Motion Gary Gray

33 Gary Gray 3 Planes Of Motion Transverse Plane Motion

34 Gary Gray Kinetic Chain The body works synergistically with muscles, joints, and proprioceptors, all working together. There is a cause effect relationship in movement between force reduction and force production.

35 Definitions Pronation the collapsing or eccentric loading phase Supination the propulsion or concentric loading phase

36 Gait The basis for understanding the biomechanics of the Lower Extremity

37 Gait Evaluation Tips Movement Analysis You will only see what you are looking for be unbiased Gather data before you analyze, be systematic View each motion at 90 degrees to the plane observed Video when possible and freeze key motions & phases Mark calcaneal bisector, tibial tuberosity, lumbo-pelvic markers Choose appropriate speeds to cover all training speeds & over speed ( From Matthew Walsh, BSc., PT, Level III)

38 Gait Evaluation Tips Movement Analysis Mimic movements in your head, try to assemble all the factors together Allow speed changes, inclination & fatigue to be part of your evaluation Get a second opinion (often from a non PT!) Change as many variables as possible & analyze the effects (arms, vision, strike, shoes, speed, surface, camber) ( From Matthew Walsh, BSc.,PT, Level III )

39 Gait Evaluation - Checklist Foot/Ankle/Knee Metatarsal Phalangeal Extension deg terminal stance Forefoot Abduction/Adduction sign of the toes early midstance Longitudinal Arch navicular drop, early midstance Subtalar/Calcaneal Position deg total ROM Heel Rise 10 deg ROM during gait, view from side different timing in Running Pivoting (Terminal St.) in-toe or out toe, is it associated with foot or hip motion Knee Control (Initial Contact) is there excessive trunk flexion also, has the quad absorbed initial load Knee Alignment (Medial-Lateral) marker on the knee, view anterior Knee Flexion & swing line, Stance & swing Knee Extension (Initial Contact) Knee Extension (Single Limb Support or Initial Swing In Running) (From Mathew Walsh, BSc., PT, Level III )

40 Gait Evaluation - Checklist Hip/Pelvis/Lumbar Spine Pelvic Tilt (Trendelenburg) place markers or tape on iliac crest Pelvic Rotation that is, Lumbar spine rotation Hip Extension & Lumbar Extension best viewed side-on and from both sides Hip Flexion especially in the swing phase, 45 deg to the ground Femoral Rotation view anterior Hip abd/add 5-7 deg acceptable as normal Lumbar Side Flexion mark the skin or use tape, should be symmetrical to the hip abd/add ( From Matthew Walsh, BSc.,PT,Level III )

41 Gait Evaluation - Checklist Trunk & Arms Thoracic Flexion / Extension Scapular Posture Arm Swing compare the swing to the thoracic rotation, forearm position Breathing Pattern Head Movement Vertical look for the timing of the rise, should be midstance Lateral may indicate Trendelenburg or poor counter rotation (e.g. instability or structural scoliosis) Rotation usually indicates cervical or upper thoracic dysfunction, possibly scoliosis Center of Mass should follow a smooth curve of motion Cranial-Vertebral Posture - eyes level? (From Matthew Walsh, BSc., PT, Level III)

42 Ankle Dorsiflexion Passive / Standing

43 Standing MP Extension

44 Standing Calcaneal Eversion

45 Knee Flexion Single Leg Squat

46 Hip Rom IR/ER Supine

47 Hip Rom IR/ER Prone

48 Thomas Test Hip Flexor Psoas

49 Quad Bias Strength Test

50 Hamstring Bias Strength Test

51 Hip Abduction Bias Strength Test

52 Hip Rotation Strength Test

53 A Objective Evaluation - Posture Poor posture results in Altered Length-Tension Relationships Altered Force-Couple Relationships Altered joint Arthrokinetics From Dr. Michael Clark, MS,PT,PES,CSCS

54 From Dr. Michael A. Clark, MS,PT,PES,CSCS A Objective Evaluation - Posture Standard Posture Side View

55 From Dr. Michael A. Clark, MS,PT,PES,CSCS A Objective Evaluation - Posture Standard Posture Back View

56 Posture Objective Evaluation Posture Anterior View Head Rotated? Ear to shoulder height Shoulder ANT or POST rotated? Chest ANT or POST Hand Position Count knuckles Hip/Pelvis Lateral Shift? Knee Varus/Valgus? Extended/Flexed? Ankle Navicular Height

57 References Clark, Michael A., MS, PT, PES, CSCS. Integrated Kinetic Chain Assessment. National Academy of Sports Medicine: Integrated Training for the New Millenium, Gambetta, V., & Gray, G., PT. (n.d). Following the Functional Path. Gray, Gary. (1996). Chain Reaction Festival, 8,10. Walsh, Matthew, BSc, PT, Level III. (May 2003) The Running Course: Biomechanical Analysis and Rehabilitation. North American Seminars, Webster s Dictionary Online.

58 Special Acknowledgement Dr. Riley J Williams, HSS, NYC

59 Thank You!