Carticel Repair: Advanced Techniques

Transcription

1 Carticel Repair: Advanced Techniques Complex Lesions and Combined Procedures JEFFREY HALBRECHT MD SAN FRANCISCO, CA

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3 Advanced Biological Resurfacing: Decisions Making Evaluate each case! Single/ multiple lesions Unipolar/Bipolar Chondral/Osteochodral? Deformity Allignment Meniscectomy Stability

4 Combined Procedures ACL Meniscal Allograft HTO Patella Realignment

5 Combined Procedures: Scott Gillogly -Atlanta 76 pts. ( 12 additional staged) At ACI: ACL reconstruction 13 (8 allograft) PF Realignment 39 (AMTT) HTO 14 (8 staged) Meniscal Transplant 5 Bone Graft (staged) 4 Osteochondral Autograft 1 76

6 Modified Cincinnati Rating Scale Minimum 2 year follow-up ACI Subgroup Clinical Results Subgroup # Pts MCRS Baseline MCRS 2 Yrs. Statistical Significance Comment ACI + Concomitant Procedure(s) no ACI only no Acute (< 1 yr from injury or symptoms) Chronic (> 1 yr from injury or symptoms p <.01 Knee Score p< yes Sport Score p<.001 Isolated defect no Multiple defects no Also Not Significant: Gender ( except Females on Sports Score p<.005), Age, Workers Comp, Size, Location ( except Patella on Sports Score p<.05)

7 Minas - BWH Complex Cases Total = 86 FC + HTO/TTO = 42% (36) FC + ACL = 7% (6) Trochlea = 30% (26) Patella = 19% (16) Tibia = 5% (4) Multiple = 44% (38) Knee Society Score n.b. patients may appear in multiple categories 0 BL N(86) 12M (26) 24M (16) 36M (7) 48M (5) p1=0.008 (12M compared to baseline) p2=0.038 (24M compared to baseline) p1=0.075 (36M compared to baseline) p1=0.105 (48M compared to baseline)

8 ACL /ACI Often two stage by default ACL + Bx ctlg If single stage: ACL first Be mindful of incisions/periosteum ACI after arthroscopy Modify rehab

9 Combine Procedure: ACI + Meniscus Allograft Indications: Chondral defect + absent meniscus (> 50%) Removal of meniscus can lead to a 350% increase in stress concentration Implantation peak stresses, approaches contact mechanics* *but does not return to normal Intact Meniscus Removed Allograft Paletta AJSM 1997, Alhalki AJSM 2000 Huang J Orthop Res 2003

10 ACI/ Men Allograft Technique Combined or stage Allograft first Extend incision for ACI

11 Case Example: ACI + MM Allograft 28 yo massage therapist s/p subtotal lateral meniscectomy 2.5 CM chondral defect

12 Bipolar Lesions Indications Large femoral defect Small tibial defect Normal (or corrected) alignment Technique ACI for femur microfracture for small tibial lesions Add meniscal allograft or HTO as necessary

13 Video Bipolar Lesion: 48 y.o.. female LFC + LTP defects Normal alignment

14 Bipolar Lesion: Follow Up

15 Multiple Lesions Multiple vials cells Sequential periosteal harvest Cells at conclusion of case Consider combined procedure (ACI / OCG)

16 Very Large Lesions Posterior access Alvarado Leg positioner Consider bone anchors posteriorly Avoid patch perforation Patch quilt 2 vials cells

17 Tibia Extensive exposure Medial : take down MCL, MM Lateral: take down LM (+/-LCL)

18 Complex lesions Internal osteophyte Skip lesions Ovalize irregular borders

19 Modify needle/anchors Posterior Condyle Lesions Hyperflex/Alvarado

20 ACI:Uncontained Defects Defect extending to intercondylar notch Defect extending to edge of condyle Courtesy of Scott Gillogly MD

21 ACI:Uncontained Defects Careful debridement to preserve margins Secure to periosteum, synovium, bone K-wire Needle through bone

22 Osteochondritis Dissecans Deep Lesion Stage Bone Procedure > 8mm Bony Involvement Courtesy of T. Minas

23 Two Stage Bone Grafting Arthroscopic bone graft

24 Swedish Sandwich Technique Deep Bony Involvement 1. Bone Graft 2. Periosteum cambium up 3. Secure with fibrin glue 4. Periosteum cambium down 5. Implant cells 1 yr. Follow-up MRI Bone Reconstituted Full Repair Tissue Courtesy of M. Brittberg

25 Osteotomies for Cartilage Protections Jeffrey Halbrecht,, MD San Francisco, Ca

26 ACI/Osteotomy Osteotomy: Optimal Patient Selection Mechanical axis falls within involved compartment Mild joint space narrowing Or physiologic varus Opposite compartment intact Response to unloading trials Bracing, lateral heel wedges Not obese Compliance Nicotine use

27 Types of Osteotomies Unload femoral-tibial joint Varus HTO Opening wedge Closing wedge Valgus Distal femoral osteotomy Opening wedge Closing wedge Varus HTO Unload Patello-femoral joint Anteriorization Medialization Antero-medialization

28 VARUS KNEE Why Osteotomy for Chondral Protection? Medial Joint Loading: A Quick Biomechanical Review Normal wb loads Normal joint mechanics: external varus moment throughout stance phase of gait This results in normal increase med comp loads Medial 60 %, lat 40% ( Kettelkamp 1976) OA situation: Increased varus moment due to narrowing of joint space as mech allignment shifts towards varus Harrington IJ: 1983 Also, altered gait causes increased adductor moment, increased knee loading rate, and shift in load bearing contact location to less tolerant (thick) cartilage ( Andriacchi 2005, 2006)

29 Benefit of HTO on artic ctlg Decrease med comp loads results in med. loads of 50% or less (Kettelkamp Best results >5 deg anat valgus --- Allows regeneration of cartilage Kettelkamp 76) Fibrocartilage cover best with valgus > 5 (Koshino Knee 2003) Improves results of microfx Clinical scores (Steadman AJSM 2004)

30 HTO: Biomechanical Goals Goal for chondral protection different than with OA! OA: Coventry: anatomic valgus 10 deg Mechanical valgus 3-55 deg Noyes: 62% tibial width ( 3.5 deg valgus mech axis) Chondral Protection: Restore mech axis 0-22 degrees valgus mech. Axis 50-55% 55% tibial width OA Ctlg protection

31 Indications: When to add an HTO My indications Varus allignment > 5 always 3-55 sometimes Very large lesions 0-22 usually not Compare to other side! Less aggressive with bilateral tibia vara to your ACI

32 Pre op planning: All patients! Long leg bilateral WB x-rayx ray Measure mechanical axis 45 degree flexion WB x-rayx ray

33 Opening vs Closing Wedge Clinical results = but closing wedge slightly more accurate (Brouwer JBJS (B) 2006) Clinical results = (Hoell Arch Ortho Tr Surg 2005) BUT..

34 Opening Wedge Osteotomy Advantages no fib osteotomy no deformity prox tib Easier conv to TKR No added lateral laxity Same side incision Disadvantages Longer time to heal Prolonged non WB Need graft Risk non union Patella baja Change tib slope

35 Closing Wedge Osteotomy Advantages No bone graft Earlier WB Rare non union Disadvantages Fibular osteotomy Deformity prox tib More difficult conv to TKR Add l Lateral incision Added lat. laxity

36 Opening Wedge: Ex Fix Ex Fix Advantages Obtain exact correction every time Minimal incision Early WB (2-4 4 wks) No residual hardware Disadvantage Pin care Medial frame against opp leg Unsightly 2 nd procedure ROH Frame on wks

37 Opening Wedge: Ex Fix Initial compression Begin distraction 1 week 1mm /day Remove weeks

38 Dome Osteotomy Technically demanding Biplanar correction No bone graft No effect on tibial slope No patella baja

39 HTO : Avoiding Complications

40 Closing Wedge Use rigid fixation Intermedics-Sulzer Sulzer- Centerpulse-Zimmer Compression Avoid violation medial cortex Early wb No immobilization

41 Osteotomies: : Avoiding NV Injury Closing wedge: Peroneal nerve Assoc. proximal fib osteotomy Tight post op bandage Bleeding Use post retractor Prox tib fib joint disruption vs osteotomy Hemostasis No tight bandages No tourniquet ( my preference) Ant tib artery Stay sub periosteal Opening wedge no reports of per nerve injury Protect post tib artery with retractors!

42 Parameter Total Complications Patients HTO Complications Medial Opening Wedge Miller et al 17 (35.4%) Gillogly 16 (30.2) 48 (ave. age 38 yrs) 34 males, 14 females Hardware Failure 2: 4.2% 3: 5.6% 53 (ave. age 38.1 yrs) 31 males, 22 females Lateral Cortex Disruption 2: 4.2% 2: 3.7% Delayed Union 2: 4.2% 4: 7.4% DVT Wound Infection Loss of Correction/ Revision 2: 4.2% 0 0 1: 1.8% 7: 14.2% 6: 11.3% (5/6 had allograft or bone substitute)

43 Medial Opening HTO Incisions: Surgical Technique Separate incision 5-77 cm posterior to any anterior incision Exposure: Protection of neurovascular structures, Patellar tendon Courtesy of Scott Gillogly MD

44 Medial Opening HTO Osteotomy Cut Positioning Surgical Technique Coronal: aim at level of fibular head Sagittal: : parallel to tibial slope 2cm below joint 1 cm from Lat cortex 2 CM 1CM Courtesy of Scott Gillogly MD

45 Osteotomy Distraction Medial Opening Wedge Technique Cont. Courtesy of Scott Gillogly MD

46 Medial Opening HTO Sagittal Plane: Tibial Slope Important to maintain normal slope As posterior slope increases, lose extention! Increasing post. slope promotes anterior translation (worsens ACL deficiency, diminishes PCL deficiency) Courtesy of Scott Gillogly MD

47 Medial Opening HTO Plate Placement and Fixation Place fixation at or posterior to mid-line of tibia on lateral view Fixation: 1 st generation: Puddu Plate 2 nd generation: Locking Puddu 3 rd generation: Reinforced plates, stronger screws (EBI) (Synthes( Synthes) Courtesy of Scott Gillogly MD

48 Medial Opening HTO Bone Grafting: Allograft Surgical Technique >7.5 mm of opening Wedges, tricortical IC cancellous chips, Bone Paste, BMP Autograft Use for higher risk pts (smokers, obese) Iliac Crest Local Source: Distal Femur or Tibia? Courtesy of Scott Gillogly MD

49 OW HTO: Avoiding Complications Lateral cortical fx: Leave 10mm bone A/P drill hole? ( Kessler CORR 2002 CW med cortex) Intra-articular articular fx 2 cm below joint line Slow distraction Increased post slope Sagital cut parallel to post slope Angled wedge plate Plate midline or post! Post gap 2x ant (Noyes) Non union Stronger plate / screws for corections > 10mm ( EBI) Bi/tri cortical graft.autograft?

50 OW HTO: Dealing with Intraoperative Complications Lateral cortical fx Staple Intra-articular articular fx Stable non dislplaced- leave alone Unstable /displaced: perc cannulated screw Allignment: check with flouro/ / leg loaded Slope: check pop ROM! Check flouro Change plate position more post. if necessary 68 68% reduction in torsional stiffness Miller AJSM 2005

51 Medial Opening HTO Summary Careful Patient Selection: Cautious of BMI > 40, Smokers, Noncompliant Sound Surgical technique: Always protect neurovascular structures, gradual opening wedge If Lateral Cortex disrupted, fix it with Staple Use stronger 2 nd or 3rd generation fixation methods Protected weight bearing 8-12 weeks Reduce pitfalls and complications

52 Valgus Knee: Lateral Compartment Defect: Correct alignment to neutral! < 10 degrees Prox tibia varus osteotomy Closing wedge Opening wedge >10 degrees Distal femoral osteotomy Lateral opening wedge ( < 15 degree?) Medial closing wedge Lateral opening wedge osteotomy (Marti JBJS 2001)

53 Trochlea Re-establish establish contour Oversize periosteum Alternating sutures Avoid excess tension Alignment Re-align for lat lesions Post op rehab!

54 Isolated Trochlea Lesions in Knees Treated with Autologous Chondrocyte Implantation >Two Year Swedish Pre 2.5 Post /15 Improved Avg. Size 4.5cm 2 U.S Pre 3.15 Post /33 Improved Avg. Size 5.2cm 2 2- Significant limitations w/adl, no sports 6- Some limitations with sports, but able to participate

55 Patella Lesions Keys to success Contained lesion Complete debridement Avoid bipolar Correct alignment

56 Swedish Experience: Patella Defects Treated with Autologous Chondrocyte Implantation % 43% Isolated Lesions Avg. 4.0cm 2 #7 (4/7) 67 Patient with 2 year follow-up 85% Good/Excellent 75% Fair/Poor 15% Isolated Lesions w/ reconstruction extensor mech Avg. 5.3cm 2 #20 (17/20) 25% Isolated Lesions w/ reconstruction extensor mech plus other lesion Avg. 4.0cm 2 #20 (15/20) 55% 45% Patella Trochlea Kissing Lesion w/ reconstruction extensor mech Avg. 6.8cm 2 #20 (11/20)

57 Patella Case Examples

58 Patella Case History 9 Months Lateral Facet Patella Ridge Restored 9 Months Medial Facet Courtesy T. Spalding

59 Bipolar Patella Defects Poor results Consider Microfx for smaller lesion Alignment Lateral trochlea Patella

60 Patella Malalignment and ACI Lateral facet defect minor malalignment (tight lat ret..normal Q angle, no subluxation or instability) Unload lateral facet Lateral release Lateral facet defect with true malalignment Unload lateral facet and realign Nl Q angle Lateral release w medial reefing HI Q angle Antero-medialization osteotomy (Fulkerson) Distal /central/lateral pole defect (no malalignment) Anteriorization only Unload proximal/ medial patella Unload proximal/ medial patella?

61 Distal Realignment Does not Work for Proximal Arthrosis! Anterior Displacement Shifts The Patella Distally And Rotates It On Its Horizontal Axis Increases proximal-medial medial loads Best for lesions in distal-lateral lateral locations

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63 Contraindications to Medialization Patient not skeletally mature Patient has normal q-angleq Kuroda, Andrish; AJSM, 2001 Medial tubercle transfer in presence of normal q-angleq increases pf contact pressures, Increase medial tibio-femoral compartment contact pressure Avoid in varus knee Avoid in menisectomized knee

64 Anteromedialization ANTERIORIZATION MEDIALIZATION

65 Case Example : Anteromedialization PREOP POSTOP Tubercle Malalignment, subluxation, tilt, lateral patella facet defect

66 Criteria for Straight Anteriorization No tilt or subluxation (No malalignment) symptomatic distal disease that has been unresponsive to more conservative measures Good medial restraints A rare subset of patients

67 Carticel Repair: Complex Restore Alignment, Stability, Meniscus for success! Consider bipolar if tibial lesion small Patella, trochlea successful with realignment Lesions Conclusions

68 THANK YOU

69 Case Study N.L. 45 yo male Injury during martial arts MFC defect 4.0 CM x 2.5 CM 5 5,, 255 lbs Hx PMM 30% G-2 2 Tibia

70 N.L. Non WB X-RAYX

71 N.L. Long Leg WB X-RayX Ray

72 N.L. MRI

73 N.L. Lateral Compartment

74 Our Plan ACI HTO opening wedge