Knee Preservation and Articular Cartilage Restoration With Special Thanks to Aaron Krych, MD and Riley Willims, MD Zak Knutson, MD Articular Cartilage Layer of tissue covering the bone which are part of a synovial joint Contains cells called chondrocytes which make the cartilage and surround themselves with it Cartilage functions as both a slick surface for motion and a compression surface for weight bearing http://altunderground.com/wpcontent/uploads/2012/03/articular cartilagediagram.jpg Articular Cartilage Cartilage has 4 zones which each function separately These layers can wear down like the tread on a tire or be taken off in large chunks from trauma Articular Cartilage CARTILAGE HAS A POOR INTRINSIC CAPACITY FOR REPAIR Many people have heard that cartilage doesn t grow back If you figure out how to do it let me know. We will make millions Articular Cartilage Injuries CLINICAL FACT ARTICULAR CARTILAGE LESIONS ARE FREQUENTLY ENCOUNTERED AJSM 2003 Articular Cartilage Injury in ~50% of athletes undergoing ACL reconstruction Often incidental findings during arthroscopy for other reasons OFTEN INCIDENTALLY FOUND CLINCAL PROBLEM 1
CM CM 43 Y.O. MALE KNEE PAIN ACHE 5+ YRS STEADILY INCREASING NO MECHANICAL SYMPTOMS LABORER FAILED PT & VISCOSUPPLEMENTATION LIMITED WALKING TOLERANCE MEDIALLY BASED PAIN TENDER MED JOINT LINE PAIN WITH HYPERFLEXION NO INSTABILITY NO EFFUSION ROM FULL 6 2 195 LBS ALIGNMENT NEUTRAL CM CM WHAT IS THE BEST PROCEDURE FOR THIS PATIENT? HOW DOES ONE COME TO A DECISION? DILEMMA WHAT IS THE APPROPRIATE APPROACH TO ARTICULAR CARTILAGE SURGERY? CARTILAGE SURGERY WORKUP COMPONENTS What I need to make an Informed Decision HISTORY PHYSICAL EXAM RADIOGRAPHS MRI : CARTILAGE SENSITIVE PREVIOUS ARTHROSCOPY PHOTOS 2
CONSIDERATIONS THE LESION THE PATIENT THE KNEE THE SURGEON THE TIMING/REHAB THE EVIDENCE LESION ETIOLOGY TRAUMATIC CHRONIC DEGENERATIVE EARLY OA AVASCULAR NECROSIS OSTEOCHONDRITIS DISSECANS LESION CHARACTERISTICS LOCATION SIZE GRADE MORPHOLOGY CHARACTER CHONDRAL OSTEOCHONDRAL BONE LESION ONLY CONTAINMENT LESION CHARACTERISTICS Is there a critical size? 2 cm 2 lesions without degenerative changes at up to 4 years No difference in clinical outcome in ACL reconstructed knees with 2.1 cm 2 lesion vs control at 15 years Homminga et al JBJS 1990 Widuchowski et al AJSM 2009 MRI & Articular Cartilage Lesions Critical role Preoperative Planning Postoperative Assessment: Objective Previous MRI may not be good enough to see subtle changes in the cartilage PATIENT CHARACTERISTICS AGE DEMAND BODY MASS INDEX (BMI) / WEIGHT LOWER EXTREMITY ALIGNMENT FITNESS MENTAL STATE 3
PATIENT ISSUES: THE KNEE LEG ALIGNMENT MENISCI STABILITY MOTION PREVIOUS SURGERY OVERALL KNEE HEALTH UNDERSTANDING INDICATIONS SYMPTOMS PAIN RECURRENT EFFUSION MECHANICAL SYMPTOMS FOCAL CHONDRAL OR OSTEOCHONDRAL LESION OF THE KNEE INDICATIONS NORMAL OR CORRECTABLE KNEE ALIGNMENT NORMAL OR CORRECTABLE KNEE STABILITY MENISCI: FUNCTIONAL TISSUE KEYS TO SUCCESSFUL CARTILAGE REPAIR SURGERY LESION ETIOLOGY LESION CHARACTERISTICS PATIENT DEMAND PATIENT CHARACTERISTICS (BMI, ALIGNMENT) GOALS OF GIVEN SURGICAL REPAIR METHODS PHYSIOLOGY OF REPAIR METHODS AND ITS RELATION TO POSTOPERATIVE REHAB TECHNICAL ISSUES SURGEON RELATED ISSUES EXPERIENCE EXPERTISE KNOWN CARTILAGE REPAIR PROCEDURES OSTEOTOMY /Techniques PALLIATIVE INTRINSINC REPAIR ENHANCEMENT / MARROW STIM CELL BASED REPAIR WHOLE TISSUE TRANSPLANTATION SCAFFOLDS CELL + SCAFFOLDS PALLIATIVE The wash out REMOVAL MECHANICAL IRRITANTS STABILIZE CARTILAGE DEFECTS LESION FILL NOT ADDRESSED DEBRIDEMENT JOINT LAVAGE CHONDROPLASTY Temporary results, may not address primary issue 4
ENHANCEMENT OF INTRINSIC REPAIR / MARROW STIMULATION RECRUITMENT OF PLURIPOTENT MARROW BASED CELLS FOR PURPOSE OF FORMING REPAIR TISSUE MICROFRACTURE DRILLING ABRASION ARTHROPLASTY Bone Marrow Stimulation: Microfracture Most frequently used technique for treating small symptomatic lesions of the articular cartilage in the knee. Technically straightforward. Costs are low compared with other modalities. Can be used for surprise lesions JBJS (Am). 2010;92:994-1009 Improvement of knee function scores was described in all studies during the first 24 months after microfracture. Decline of initial functional improvement after 2 years, although scores remain above preoperative levels. Repair Fill Excellent Fill Microfracture Magnetic Resonance Imaging Moderate Fill Poor Fill PRE-OPERATIVE 4 MONTHS POST MFX Micronized acellular cartilage Adjunct to microfracture Meant to form a scaffold and induce a more hyaline like repair Long term results pending In my current practice it is used in younger patients who heal better than adults 5
CELL BASED REPAIR IMPLANTATION OF EXPANDED or lab cultivated AUTOGENOUS CHONDROCYTES HYALINE LIKE CARTILAGE REQUIRES A COVER OR PATCH PERIOSTEUM or other absorbable matrix AUTOLOGOUS CHONDROCYTE IMPLANTATION (ACI) CARTICEL (GENZYME) CHONDROCELECT (TIGENIX) COLLAGEN COVERED AUTOLOGOUS CHONDROCYTE IMPLANTATION (CACI) MATRIX INDUCED AUTOLOGOUS CHONDROCYTE IMPLANTATION (MACI) ACI 1 Cartilage Harvest 2 Cartilage Growth 3 Excision of Bad Cartilage 4 Patch covering 5 Injection of good cells http://www.carticel.com/, and SCOI.com Autologous chondrocyte implantation Development of hyaline-like cartilage, rather than fibrocartilage better long-term outcomes and longevity. Minimum of 2 operations. Technically demanding. Used in my practice for patellofemoral lesions Outcomes Brittberg et al, 1994: -14/16 patients with femoral condylar lesions had good to excellent results. Zaslav et al, 2009: -126 patients with failed prior treatments, 76% good clinical result. JBJS (Am). 2010;92:994 1009 CELLS + SCAFFOLD This is the next step. Already in Europe IMPLANTATION OF AN MATRIX SCAFFOLD PRE SEEDED WITH AUTOGENOUS CHONDROCYTES TO INDUCE LESION FILL NEOCART (HISTOGENICS) MATRIX INDUCED AUTOLOGOUS CHONDROCYTE IMPLANTATION (MACI) GENZYME VERIGEN HYALOGRAFT C (FIDIA) WHOLE TISSUE TRANSPLANTATION IMPLANTATION OF A MATURE CARTILAGE plus BONE CONSTRUCT FOR PURPOSE OF RESURFACING A LESION WITH HYALINE CARTILAGE AUTOGRAFT MOSAICPLASTY OATS ALLOGRAFT FRESH FRESH FROZEN MINCED PEDIATRIC CARTILAGE Whole tissue transplantation: Osteochondral autografts or OATS Transplantation of viable hyaline cartilage from a different part of knee. Relatively brief rehabilitation period. Ability to perform in a single operation. Donor site morbidity. Limited availability of graft that can be harvested (patellofemoral joint or the zone adjacent to the intercondylar notch). Differences in orientation, thickness, and mechanical properties between donor and recipient cartilage. JBJS (Am). 2010;92:994-1009 6
MOSAICPLASTY or OATS TECHNIQUE MULTIPLE SMALL (< 10 mm) AUTOGRAFT OSTEOCHONDRAL PLUGS USED TO RESURFACE A CHONDRAL OR OSTEOCHONDRAL DEFECT ALLOGRAFT Cadaver or Donor Tissue Has been cleaned and prepared for implantation Can be bone, cartilage, or both Minced Cartilage DeNovo NT Natural Tissue Graft Juvenile donor cartilage Has ability to grow Single stage procedure with graft help in place by fibrin glue No long term results No filling of bony defects Whole tissue transplantation: Osteochondral allografts Precise surface architecture. Single-stage procedure. Potential to replace large defects. No donor site morbidity. Limited graft availability. High cost. Risk of immunological rejection. Possible incomplete incorporation. Potential for disease transmission. JBJS (Am). 2010;92:994-1009 7
OSTECHONDRAL ALLOGRAFTS FRESH GRAFTS = VIABLE CELLS THEORY = LAST INDEFINITELY TREATMENT RATIONALE RESURFACE INCONGRUENT JOINT WITH SIZE MATCHED WHOLE TISSUE ALLOGRAFT CONTAINING VIABLE CELLS INDICATIONS LARGE LESIONS 2 10+ CM 2 BONE LOSS OR INVOLVEMENT NONCONSTRAINED LESIONS OCD, AVN PATELLA, TIBIA, FEMUR OK SALVAGE FOR FAILED FIRST LINE TXs Below the Bar Techniques Non cell based techniques Did not require the approval process of the viable cell implantation techniques Generally cheaper Can be stored on the shelf SCAFFOLD BASED REPAIR IMPLANTATION OF A SYNTHETIC SCAFFOLD MATRIX TO FACILITATE ARTICULAR CARTILAGE GROWTH & LESION RESURFACING SYNTHETIC BIPHASIC ABSORBABLE TRUFIT (SMITH & NEPHEW) OSSEOFIT (BIOMET) Chondrofix Osteochondral Allograft Acellular Donor Cartilage and Bone May serve to remove painful diseased subchondral bone How long does it last? TruFit CB Plug Maturation Has been PULLED FROM THE MARKET Longer follow-up ( 16 months) favorable 70% of plugs flush morphology 90% of plugs complete defect fill Excellent subchondral osseous incorporation 6 months 12 months 25 months 8
Current Treatment Options for Articular Cartilage Repair in the U.S. TREATMENT REPAIR TISSUE FILL DURABILITY CHONDROPLASTY None None Poor ENHANCEMENT INTRINSIC REPAIR Fibrocartilage Partial 2-11 Years AUTOLOGOUS OSTEOCHONDRAL TRANSPLANTATION CELL BASED Hyaline Cartilage Near Total 2-10 Years Hyaline Like Fibrocartilage Partial 2-11 Years SCAFFOLD BASED Hyaline Like Near Total 1-2 Years Cartilage Repair Methods Clinical Applications of Cartilage Repair Methodologies Osteochondral Allograft Autologous Chondrocyte Implantation Osteochondral Autograft Marrow Stimulating Technique 10 + 12 + CELL + SCAFFOLD Hyaline Like Near Total 2-3 Years ALLOGRAFT OSTEOCHONDRAL TRANSPLANTATION Hyaline Cartilage Near Total 5-15 Years Debridement / Lavage 0 2 4 6 8 10 12 2 Lesion Size (CM ) Surgical Treatment Options for the Management of Symptomatic Focal Cartilage Lesions of the Femur: U.S. LESION SIZE < 2 CM 2 Surgical Treatment Options for the Management of Symptomatic Focal Cartilage Lesions of the Femur: U.S. LESION SIZE >2 CM 2 PRIMARY TREATMENT SECONDARY TREATMENT PRIMARY TREATMENT SECONDARY TREATMENT LOW DEMAND HIGH DEMAND HIGH OR LOW DEMAND LOW DEMAND HIGH DEMAND HIGH OR LOW DEMAND 1.Palliative 2.Enhancement Intrinsic Repair 3. Scaffolds 1. Enhancement Intrinsic Repair 2.Osteochondral Autograft 3.Osteochondral Allograft 4.Cell Based Repair 5.Cell Based + Scaffold 1.Osteochondral Autograft 2.Osteochondral Allograft 3.Cell Based Repair 4.Scaffold Based Repair 5.Cell + Scaffold Repair 1.Palliative 2.Enhancement Intrinsic Repair 3.Osteochondral Autograft 4.Osteochondral Allograft 5.Cell Based Repair 1.Enhancement Intrinsic Repair 2.Osteochondral Autograft 3.Osteochondral Allograft 4.Cell Based Repair 5.Cell Based + Scaffold 1.Osteochondral Autograft 2.Osteochondral Allograft 3.Cell Based Repair 4.Cell Based + Scaffold Williams & Brophy Instr Course Lec 2008 57:553 562 Williams & Brophy Instr Course Lec 2008 57:553 562 KEYS TO SUCCESSFUL CARTILAGE REPAIR SURGERY LESION ETIOLOGY LESION CHARACTERISTICS PATIENT DEMAND PATIENT CHARACTERISTICS (BMI, ALIGNMENT) GOALS OF GIVEN SURGICAL REPAIR METHODS PHYSIOLOGY OF REPAIR METHODS AND ITS RELATION TO POSTOPERATIVE REHAB TECHNICAL ISSUES Rehab, Rehab,Rehab!!!!!!! Most repairs/implantations are 6 weeks of non or TTWB All will use CPM for that time Cartilage loves motion! Generally, low impact sports such as swimming, skating, in line skating, and cycling are permitted at about 6 months. High impact sports such as jogging, running, and aerobics may be performed at 8 9 months for small lesions 9 12 months for larger lesions. High impact pivoting sports such as tennis, basketball, football, and baseball may be allowed at 12 18 months. 9
Concomitant Procedures Improve success rate Osteotomy Distal Femur, DFO Proximal Tibia, HTO Tibial Tubercle Ligament Reconstruction Meniscal Transplant Prior meniscectomy Patient Expectations/Rehab One year recovery, rehab. May be 12 18 months before return to high impact sports Sooner for lower impact and smaller lesions Trying to get rid of daily pain not improve your marathon time Commitment on both of our parts NO! Arthritis Lesions in Multiple places Bone loss RA Gout/Pseudogou t A Lot to Ask Thank You 10
Zak Knutson, MD Please call or email me any time 405 834 9832 zknutson@osoi.com 11