Inlay Resurfacing Arthroplasty - Davidson Orthopedics · UniCAP Limitations and Concerns •...
Transcript of Inlay Resurfacing Arthroplasty - Davidson Orthopedics · UniCAP Limitations and Concerns •...
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Inlay Resurfacing Arthroplasty
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OUTLINE• Perspective on resurfacing• Introduction of Inlay
Arthroplasty Concept– Biomechanical Basis
• Knee CAP– HemiCAP, UniCAP, PF – Indications– Technique– Cases
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Joint Resurfacing A wide realm between…..
Arthroscopic debridement
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Goals: Cartilage Restoration &
Joint Resurfacing
– Relieve pain– Restore functional– Improve Mechanics– Long lasting – Prevent or Limit Future
Degenerative Changes– Retain Options for
younger or more active individuals
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Theme of Minimally Invasive Joint Restoration
• Spectrum of Pathology• Individualize according to
the specific patient • Wide array of treatment
options• Biologic Restoration in
youth, when possible• Appropriate Minimally
Invasive Prostheses• Continually incorporating
new technologies
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Cartilage Restoration and Joint Resurfacing Treatments:…an evolving continuum of options• Marrow stimulation• Biological restoration
– Biologics– Bio-synthetics/scaffolds– Modulated therapy– Cellular therapy
• Joint Resurfacing– Prosthetic resurfacing– Micro-invasive– Bio-elements– Inlay Arthroplasty– Onlay Arthroplasty – Total Joint
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Biological Options
• Autologous Chondrocytes– ACI– MACI
• Osteochondral Grafts– Autogenous– Allogeneic
• Chondral grafts• Biologically Active
Scaffolds
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Transitional thinking from biologics to prosthetics
• Age, health• Pathology
– Kissing lesions– Joint “out of round”
• Comorbidities– Health– Same joint
• Stability, alignment, meniscus
Inverted patella 31 year old
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Mandates associated with Minimally Invasive Joint Resurfacing
• Minimize Perioperativemorbidity
• Retain future options – as possible
• Maximize Outcomes– Equal, or better than
traditional treatments
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Anatomical Reconstruction
• Concave and convex geometric surfaces –complicated curvatures
• Intraoperative articular mapping involves measuring/replicating complex surface configurations
• Inlay Arthroplasty allows for ideal anatomic reconstructions
• Accounts for morphologic variability
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ANATOMY- Alignment
• Must know alignment, potentially correct or accommodate with resurfacing
• Must have long leg standing films available
• Inlay minimaldeformity
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“Ideal” First Patient for CAP• 30-60 yrs• Nearly normal
alignment• Any comorbidity
mitigating against Biological solution
• Unicompartmentaldisease (III b,c or IV)
• “Staging” Scope
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Introduction of CAP
• Geometry based on patient’s native anatomy
• Intraoperative joint mapping
• Account for complex asymmetrical geometry
• Extension of biological resurfacing
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Knee Implants• HemiCAP ( small unipolar knee)
– Not currently FDA approved in US
• UniCAP– Developed Medial, used
Medial and Lateral– Includes Tibial Inlay
• PF HemiCAP– Regular & XLT(large FTG)
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untreated knee flush HemiCAP® 1mm proud HemiCAP®
Basic Science- Pressure Studies-reciprocal surface (tibial plateau)
Anterior
Posterior
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Finite Element - Analysis
Physiological With HemiCAP
Conclusion: • No stress shielding •Effective load transmission into underlying bone
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P-F XLT ”Wave” Inlay Prosthesis
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PF- PROSTHETIC RESURFACING
• Trochlea alone or Bipolar • Traditional prostheses
limited success and rarely used
• Inlay device allows for concurrent re-alignment easily, as no overstuffing
• Inlay device for younger patients
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Trochlear Implants Variety of Geometry
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Patellar ImplantsVariety of Sizes/Shapes, Cemented
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Case Report #1
• 41 year old female• 2 prior knee surgeries• Anterior knee pain• Former “hard core”
athlete • Could not even walk
with kids
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Case #1(healthy medial and lateral )
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Surgical Exposure 1st - Arthroscopic Lateral Release
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Surgical ExposureEither MIS medial incision (or midline)
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Technique –• Guidewire key to
cannulated system
• Perpendicular placement– Careful attention to
this!!
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Technique- Drill for set screw (no plunge)
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Technique – Tap (undertap)
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Insert set screw (not too deep!)
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Height measuring cap
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Articular Mapping…if measured values NOT on chart, must
consider WHY
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Peripheral cutting -protect ambient cartilage
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Drilling for implant
• High speed drill• Do not use reamer• Cooling irrigation
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Device Trial
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Patellar guide and wire
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Starter drill over guidewire
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Insert centering shaft/depth limiter
This shoulder limits drill depth in next step
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Drill to depth stopbasically need patella “deep enough”
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Patellar Trial
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Insert Trochlea –Suction inserter with alignment
Alignment marker
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Radiographs pre and post
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Case # 2 – 42 year old female
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Case #2
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Case #2
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Case # 3 50 year old
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Case #3
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Patella-Trochlea alignment Key step- Patella directly over FTG
cannot have poly on cartilage/bone
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UniCAP™aka… inlay arthroplasty, scope assisted
Uni, AKR , etc..
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Cement and FDA
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UniCAP Advantages• UniCAP may prevent patello-femoral
complications/encroachment of conventional UKA through inlay resurfacing
• Revision to standard UKA may be possible due to shallow implant bed resurfacing technique• UniCAP avoids L-cut
• Ample room for ACL, osteotomy, soft tissue procedures
• Meniscal sparing technology for patients with healthy, functional meniscus
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UniCAP Limitations and Concerns• Limited/Little angular correction can be obtained with an
inlay resurfacing • Tibial surface:
• UniCAP only for central lesions• More common peripheral• Extensive tibial loss, need other option
• Patient selection remains critical:• Treat all pathology in the knee – homeostasis
• Be cautious and specific about referred pain and radiating pain patterns• Extending tibial pain is important to note! • Don’t want to undertreat tibia
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UniCAP case example –medial knee resurfacing 46 year old cyclist
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UniCAP – medial knee resurfacing
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UniCAP – medial knee resurfacing
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UniCAP – medial knee resurfacing
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UniCAP – medial knee resurfacing
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UniCAP – medial knee resurfacing
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Case Report –51 year old, failed Microfracture, unable to exercise
due to medial knee pain
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1 year post microfracture,no pain relief
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ACL graft – Medial UniCAP
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Case Report 63 year old business man, hiker
• Neutral alignment• Told he needed a TKA• Seen 6 doctors, essentially refusing to accept
TKA• Healthy, ideal body weight
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Combining Biologics with Inlay Arthroplasty29 year old firefighter
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•6 wks post op back at work light duty•12 wks post op full RTW as firefighter
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Technical Failure38 yr old 9 mos post op - no pain relief from unipolar UniCAP
synovitis, cartilage debris, UniCAPproud, tibial wear, FTG defect
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Failure“normal” fibrous overgrowth, asymetric, proud
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UniCAP removal- revision to UKA
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Indication Failure – complex revision53 yr old Navy MD, persistent medial/PF pain and instability
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Complex revisionretained medial UKA, new lat UKA, PFA and ACL
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Complex Revision3 compartments, ACL
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Inlay Indications Contraindications
• Minimal angular deformity
• Large focal or limited degenerative lesions
• Limited, not diffuse disease
• ICRS Grade IIIB,C,D or IV • PF- can address severe
deformity
• Extensile T-F disease• Tricompartmental• Angular deformity• Large or Peripheral
Tibial defects• Crystalline arthropathy• Chondropenia - diffuse
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Managing Utilization
• Staging scope• Scope photos• MRI – 3T Fat Suppressed Fast Spin Echo,
cartilage sequences • Have multiple options available• Multiple cases in one day
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Shoulder Series
HemiCAPOsteoarthritis
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Traditional Surgical Alternativesfor G-H Osteoarthritis
• Total Shoulder Arthroplasty
• Hemiarthroplasty (stemmed)
• Hemiarthroplasty (non-stemmed)– “Copeland style”
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Traditional Treatment OptionsTotal Shoulder
• Potential Problems:– Tissue balance– Blood loss– Overstuffing– Humeral height and
version – Glenoid Loosening– Patient acceptance– Surgically difficult
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Traditional Treatment Options-Non-stemmed Hemiarthroplasty
• Humerus is “milled” to accommodate implant
• Problem: – non-native
convexity/geometry
• This is counter- intuitive
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Osteoarthritis – typical case
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Osteoarthritis- typical case
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HemiCAP for RCT and Osteoarthritis
• 73 y/o Male, Tennis player with a failed previous rotator cuff repair
• Previous surgical findings of articular disease
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• Open Rev. RCR with Augmentation, HemiCap for RCT and Osteoarthritis– Post-op marked pain relief– Improved ROM– Marked decrease in pain
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ANATOMIC INLAY RESURFACING FOR GLENOHUMERAL OSTEOARTHRITISClinical Results in a Consecutive Case Series
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Surgical Technique
• Anterior approach• Subscapularis take down• Capsular releases• Osteophyte resection on
both humerus and glenoid• NO glenoid resurfacing or
reaming
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Demographic Data• N = 48
– Males – 29– Female – 19
• Mean age at surgery– 61 years
• Follow-up– Mean – 28 mos.– Max – 36 mos.– Min – 13 mos.
• Side– Right – 19– Left - 14
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HemiCAP in OA • Concurrent Procedures– Rotator Cuff Repair
• 12– Subacromial Decompression
• 25– Distal Clavicle Resection
• 23– Biceps Tenodesis
• 2– Biceps Tenotomy
• 21– Capsulolabral Repair
• 5– Hardware Removal
• 1
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Simple Shoulder Test
3.2
7.58.7 9.4
10.3
0
2
4
6
8
10
12
Pre-Op 6 MoPost-
Op
1 YrPost-
Op
2 YrPost-
Op
3 YrPost-
Op
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VAS Pain
0123456789
10
Pre-Op 6 MoPost-Op
1 Yr Post-Op
2 Yr Post-Op
3 Yr Post-Op
At Rest
With Activity
Today
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NO reported loosening of implant in the shoulder
No signs of- Device disengagement- Progressive
periprosthetic radiolucency
- Implant subsidence
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Complications
One patient suffered a traumatic, high-energy injury 3 months postoperatively, subsequently
resulting in revision surgery
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Osteoarthritis- Perhaps a prime indication for the HemiCAP
• How much pain from glenoid??
• Surprisingly little!!!• Removal of
Osteophytes critically important
• Soft tissue releases• Treat concurrent
pathologies
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Expanding Indications Beyond “Focal Defects”
• Osteoarthritis• Rheumatoid arthritis• Post traumatic arthritis• Rotator Cuff Tears• Avascular Necrosis• Hill-Sachs (some)
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CONCLUSIONS Shoulder Resurfacing with HemiCAP for
Glenohumeral Osteoarthritis
• Short term (3 year) results very encouraging • Restoration of native anatomy• Comprehensive pathology treatment is key• Excellent option for primary OA of Shoulder
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Advantages of CAP• Immediate, excellent pain
relief• Simple, canulated,
reproducible, yet elegant surgery
• Very few soft tissue balancing challenges
• Minimally bone sacrificing • Minimal EBL, can be
outpatient• Can easily convert to
traditional or reverse arthroplasty
• Patient acceptance• Allows concurrent soft
tissue procedure • Maintain cartilage
restoration principles • Based on patient, or
ambient anatomy
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Thank You [email protected]