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1、The Athletic KneeShannon M. WolfeThe ProblemYoung active patients with articular cartilage defects!Which defects progress to OA ?Which defects are symptomatic ?How do we most effectively treat these defects?The BiologyPhysiologic role of articular cartilageMinimize stresses on the subchondral boneRe
2、duces friction on the weight bearing surfaceCritical in proper joint functionGoals of TreatmentRestore integrity of load bearing surfaceObtain full range of motionObtain pain free motionInhibit further degenerationTreatment ConsiderationsAge of the patientDefect sizeKnee stabilityKnee alignmentLevel
3、 of activityPartial Thickness DefectsArticular cartilage lacks the capacity to repair structural damageProgresses when exposed to mechanical wearFull Thickness DefectsDo not heal with hyaline cartilageHealing by subchondral stimulation leads to the formation of fibrocartilageLacks physiological role
4、 of hyaline cartilagePoor wear characteristicsProgress to osteoarthritisNon-Surgical OptionsActivity modification (decrease load)Muscle strengthening (load absorption)Bracing (selective joint unloading)Aspiration (decrease painful joint distention)Non-Surgical OptionsPharmacologicalOralNon-steroidal
5、 anti-inflammatory medicationChondrotin sulfateGlucosamineInjectableCorticosteroids - decrease the inflammatory response but have no mechanical benefitSynvisc - may improve the status of the articular surface by improving chondrocyte “health”Surgical OptionsArthroscopic lavage - remove debrisArthros
6、copic shaving - smooth surfaceDrilling or microfracture - create fibrocartilage scarOsteotomy - realignment to unload diseased compartmentOsteochondral autograft - replace a damaged surfaceAutologous chondrocyte transplant - replace injured cartilageAllograft osteochondral transplantationArthroscopi
7、c LavageRemove debris and inflammation mediatorsTemporary reliefNot a definitive procedure - not curativeNot normally sufficient for athletic or active patientsArthroscopic DebridementLavage and chondroplastyNo sub-chondral stimulationMay lead to improvement for up to 5 yrs.10-20% may become worseDe
8、bridement does nothing to promote repairMalaligned or unstable knees do poorlyThermal ChondroplastyNew procedureRequires bi-polar or ultrasonic device“Seal” the articular surface with heatKeplan L,M.D. reported no injury to the chondrocytes of the involved or peripheral cartilage. “Radio-frequency e
9、nergy appears to be safe for use on articular surface.” Arthroscopy, Jan-Feb. 2000, pp 2-5.Abrasion ArthroplastyDebridement and stimulation of subchondral bone 1 - 1.5mm deep results in fibrocartilage repair intracortical rather than cancellousResults : Abrasion ArthroplastyJohnson 399 patients66% w
10、ith continued pain99% with activity restrictionResults : Abrasion ArthroplastyUnpredictableMay not be better than debridement aloneRand noted 50% of patients who had an abrasion underwent TKR within 3 yrs.Drilling or MicrofractureDebride lose cartilageSubchondral bone penetration drill or pick, 3/cm
11、 squaredResults in fibrocartilage repairLacks durabilityLacks the mechanical properties of hyaline cartilageDrilling ResultsJoseph Tippet,M.D.62 month follow up71% Excellent15% Good14% Fair / PoorResults :Richard Steadman, M.D. reported improvement in 364 of 485 patients (75%) at 7 years post-op90 -
12、 100% of the defects were healed at 4 wks. with 30% hyaline cartilage12 mos. 42% hyaline cartilage Myron Spector, M.D. demonstrated complete filling of the lesions at 3 months in an animal modelMicrofracture Results :Unpublished75% improvement50% returned to sportsSteadman / HawkinsOsteochondral Gra
13、ftingAutologous plugs of bone with hyaline cartilage capBest done for small lesions ( 2cm.)New techniqueLimited data at follow-upOsteochondral AutograftingIndicationsFull thickness (grade IV) lesions in the weight bearing surface of the femoral condylesWell circumscribed lesion - sharp transition zo
14、ne 2 cm diameter lesionYoung patient ( 55 - 60 poor results despite other inclusion criteriaOsteochondral Autografting ContraindicationsLesions 2cm. (rare)Osteochondritis dessicansLarge OCD usually exceed donor area limitations & large bony defects w/ no subchondral reference pointsOsteochondral Aut
15、ograftingAdvantagesPotential for physiologic hyaline cartilageSingle stage procedureCan be done all arthroscopicallyOsteochondral AutograftingDisadvantages / ConcernsDamage to the subchondral plateCreates bleeding and fibrocartilageDonor site morbidityIncongruence of the plugs / articular surfaceDon
16、or Site Morbidity : Osteochondral AutograftsMorgan, Carter & Bobic 104 cases - no donor morbidityOsteochondral AutograftBiopsy Proven Survival : Hyaline Cartilage, Tidemark & BoneWilson 10 yearsOuterbridge 9 yearsHangody 5 yearsBobic 3 yearsMorgan 1 yearOsteochondral Autografting : ResultsBobic12 Ca
17、sesLesion 1 - 2.2cm.10/12 excellent results at 2 yrs.Osteochondral Autografting : ResultsMorgan & Carter52 CasesIKDC evaluationPain65% improved 2 grades31% improved 1 grade4% no change (failure)LIMITATIONS OF OATSPotential for DJD at donor site is realNo clinical support for repair of single or mult
18、iple plugsProphylactic surgeryDifficult to justify the procedureALL TEN SITES OF OSTEOCHONDRAL HARVESTArticulated and demonstrated significant contact pressureRim stress concentration may lead to DJDOsteochondral donor sites do not heal normallyOsteochondral AutograftPost-opEarly motionImmediate act
19、ive, active assisted, and passive ROMNWB x 2 weeksThigh muscle strengthening & stretching 3 monthsAvoidance of sports & running for 3 monthsRECOVERY FROM OATSAllow 6 weeks for plug to healDesk job RTW 1-2 weeksLaborer RTW 3-4 monthsAutologous Chondrocyte ImplantationFirst procedure : biopsyArthrosco
20、pic chondrocyte harvest from upper medial femoral condyleCultivation of cells 14-21 daysSecond procedure : implantationArthrotomy & debridement of lesionDefect covered with periosteal flapCultured chondrocytes injected into defectFirst Surgery-ArthroscopySecond Surgery-ArthrotomyInject $10,000 worth
21、 of cells!Autologous Chondrocyte Implantation : IndicationsAge 15-55Defect location femoral condyleDefect size 1-10cm.Defect type Grade IVLigament stabilityBiomechanical alignmentAutologous Chondrocyte ImplantationContraindicationsKissing lesionsInflammitory arthritisTotal meniscectomyOver 50 (psych
22、ologic)Unstable kneeGeneralized degenerative diseaseUnhealed lesion through subchondral boneDedifferentiation / RedifferentiationMethod of RestorationAutologous Chondrocyte Implantation: AdvantagesLess donor site morbidityLarger and multiple defects can be addressedGood results with longer follow-up
23、No violation of hosts subchondral plateFDA approvedAutologous Chondrocyte Implantation : DisadvantagesRequires 2 proceduresNot arthroscopicExpensiveNo long term resultsAutologous Chondrocyte ImplantationPost-opCPMActive ROMToe touch weight bearing for 6 weeksweek 7-12 closed chair exercisesJogging a
24、t 6 monthsSports at 1 yearAutologous Chondrocyte ImplantationUS Clinical Experience121 patients 6 month follow-up42 patients 12 month follow-up85% improved overall condition80% improved pain scores at 12 monthsAutologous Chondrocyte ImplantationSwedish Results NESM 199423 patients 14-4814/16 Good ex
25、cellent results with 2 year follow-upBiopsy has appearance of hyaline cartilageAutologous Chondrocyte ImplantationSwedish Results 1997100 patients 2-9 year follow-up90% improvement with femoral condyle lesions74% with femoral condyle and ACL reconstruction58% for trochlear lesions75% for multiple de
26、fectsLIMITATIONS OF ACILittle proof that $10,000 worth of cells do anythingCartilage that regrows is not normal Ideal patient is rareYoung, isolated lesion, no meniscal tear or instabilityDifficult to justify procedureOsteochondral Allograft TransplantationJoint resurfacing with fresh or fresh froze
27、n cadeveric tissueAllograft ProcedureOpen procedureExpose the degenerative lesionRemove the defective articular cartilage and a “thin” bony baseUtilize allograft tissue to replace and restore the articular surfaceAllograft AdvantagesReplaces articular hyaline cartilage with hyaline cartilageSingle p
28、rocedureAllograft DisadvantagesCostRisk of disease transmission from fresh allograft tissueAllograft ResultsWhat to do?Treatment RecommendationsLow demand patientsSmall focal lesion (2cm)Arthroscopic chondroplasty50% relief up to 5 yearsAutograft Osteochondral or chondrocyte if failed chondroplastyT
29、reatment RecommendationsHigh demand patientSmall focal lesion (2cm) Debridement or microfracture with chondrocyte harvestIf persistent pain - osteochondral or chondrocyte transplantTreatment RecommendationsHigh demand patientsLarge lesion (2cm.)Chondrocyte transplant 1st line treatment yields 90% su
30、ccessLong HistoryNo Acute SymptomsVarus KneeMarked DJDArthroscopic ResultsUnpredictableLittle ImprovementConclusionsArticular cartilage does not repair itselfNumerous treatments with varying resultsMost treatments fail in the long term due to articular cartilages inability to produce hyaline cartila
31、geConclusionsOsteochondral auto grafts and chondrocyte transplants show promising resultsOsteochondral auto grafts allow transplantation of bone capped with hyaline cartilageAutologous chondrocyte implantation allows near normal hyaline cartilage growth into defectsMeniscal Allograft IndicationsPati
32、ent age - young - 20-40Previous meniscectomyPainful compartmentMinimal Arthritic ChangesCorrect alignmentStable kneeSterilizationViral contamination risk 1:1.6 million to 1:1.2 billionRadiation 2.5 mrads destroys collagen 2 yr. follow-up11 (16%) failures70% of patients had subjective improvements with painCryo-Life 5 Year ResultsLateral (10)5 (5%) intact4 (40%) partial meniscectomy1 (10%) total meniscectomy
