Osteochondral Defects of the Knee. Articular Cartilage Physiological role of articular cartilage...
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![Page 1: Osteochondral Defects of the Knee. Articular Cartilage Physiological role of articular cartilage –Minimizes stresses on secondary bone –Reduces friction.](https://reader036.fdocuments.net/reader036/viewer/2022081506/56649e665503460f94b61142/html5/thumbnails/1.jpg)
Osteochondral Defects of the Knee
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Articular Cartilage
• Physiological role of articular cartilage– Minimizes stresses on secondary bone– Reduces friction on weight bearing surface
• Critical in proper joint function
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The Problem
• Young active patients with articular cartilage defects!– Which defects progress to OA ?– Which defects are symptomatic ?– How do we most effectively treat these defects?
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Goals of Treatment
• Restore integrity of load bearing surface
• Obtain full range of motion
• Regain pain free motion
• Inhibit further cartilage degeneration
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Contributing Factors
• Age of the patient
• Defect size
• Knee stability
• Knee alignment
• Patient’s level of activity
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Partial Thickness Defects
• Articular cartilage lacks the capacity to repair structural damage
• Injuries/defects progress when exposed to mechanical wear
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Full Thickness Defects
• Do not heal with hyaline cartilage
• Progress to osteoarthritis
• Healing by secondary stimulation leads to the formation of fibrocartilage– Lacks physiological capabilities of hyaline
cartilage
– Poor wear characteristics
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Non-Surgical Options
• Activity modification (decrease load)
• Muscle strengthening (load absorption)
• Bracing (selective joint unloading)
• Aspiration (decrease painful joint distention)
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Non-Surgical Options• Pharmacological
– Oral• Non-steroidal anti-inflammatory medication
• Contrition sulfate
• Glucosamine
– Inject able• Corticosteroids - decrease the inflammatory response but have
no mechanical benefit
• Synvisc - may improve the status of the articular surface by improving chondrocyte “health”
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Surgical Options• Arthroscopic lavage - remove debris
• Arthroscopic debridement - smooth surface
• Thermal chondroplasty - “seal” the articular surface
• Drilling or microfracture - create fibrocartilage scar
• Abrasion arthroplasty
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Surgical Options
• Osteotomy - realignment to unload diseased compartment
• Osteochondral autograft - replace a damaged surface
• Autologous chondrocyte transplant - replace injured cartilage
• Allograft transplantation - use of human cadaveric osteochondral tissue for joint resurfacing
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Arthroscopic Lavage
• Arthroscopic removal of debris and inflammatory mediators
• Temporary relief
• Not a “curative” procedure
• Insufficient for athletic or active patients
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Arthroscopic Debridement
• Lavage and chondroplasty
• No sub-chondral stimulation
• May lead to improvement for up to 5 yrs.
• Pain improvement in 80-85%
• Debridement does nothing to promote repair
• Malaligned or unstable knees do poorly
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Thermal Chondroplasty
• New procedure• Requires bi-polar or ultrasonic device• “Seal” the articular surface with heat• Keplan L,M.D. reported no injury to the
chondrocytes of the involved or peripheral cartilage. “Radio-frequency energy appears to be safe for use on articular surface.” Arthroscopy, Jan-Feb. 2000, pp 2-5.
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Drilling or Microfracture• Debride the cartilage to a stable rim• Subchondral bone penetration (drill or pick) through
the calcified cartilage layer• 3 to 4 perforations per square centimeter• Results in fibrocartilage repair• Fibrocartilage lacks the durability and mechanical
properties of hyaline cartilage
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Drilling Results
Joseph Tippet,M.D.• 62 month follow up• 71% Excellent• 15% Good• 14% Fair / Poor
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Results :• Richard Steadman, M.D. reported
improvement in 364 of 485 patients (75%) at 7 years post-op– 90 - 100% of the defects were healed at 4
wks. with 30% hyaline cartilage– 12 mos. 42% hyaline cartilage
• Myron Spector, M.D. demonstrated complete filling of the lesions at 3 months in an animal model
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Abrasion Arthroplasty
• Debridement and stimulation of secondary bone
• 1 - 1.5mm deep
• Intracortical rather than cancellous
• Fibrocartilage stimulation/repair
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Results : Abrasion Arthroplasty
• Johnson 399 patients
• 66% with continued pain
• 99% with activity restriction
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Results : Abrasion Arthroplasty
• Unpredictable
• May not be better than debridement alone
• Rand noted 50% of patients who had an abrasion underwent TKR within 3 yrs.
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All “resurfacing procedures” “work better” or “last longer” when
proper alignment is restored
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Osteotomy
• Redistribution of joint load• Goal - to shift load away from the
degenerative area to a “normal” area• High tibial to correct varus alignment
– bow legged
• Distal femoral to correct valgus alignment– knocked kneed
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Osteochondral Grafting
• Autologous plugs of bone with hyaline cartilage cap
• Best done for small lesions (< 2cm.)
• New technique
• Limited data at follow-up
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Osteochondral Autografting
• Advantages– Potential for physiologic hyaline cartilage
– Single stage procedure
– Can be done all arthroscopically
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Osteochondral Autografting
• Disadvantages / Concerns– Damage to secondary plate
– Creates bleeding - fibrocartilage
– Donor site morbidity
– Incongruency of plugs
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Osteochondral Autografting Indications
– Full thickness (grade IV) lesions in the weight bearing surface of the femoral condyles
– Well circumscribed lesion - sharp transition zone
– <2 cm diameter lesion
– Young patient (< 45 yrs.)
– Normal alignment and stability
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Osteochondral Autografting Contraindications
• Axial malalignment (varus / valgus)• Arthritis : poor transition zone and or bicondylar lesions • Age : patients > 55 - 60 poor results despite other
inclusion criteria• Lesions > 2cm.• Osteochondritis dissecans without healed secondary bone• Large OCD usually exceed donor area limitations &
large bony defects w/ no secondary reference points
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Osteochondral Autografting : Results
• Bobic– 12 Cases
– Lesion 1 - 2.2cm.
– 10/12 excellent results at 2 yrs.
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Osteochondral Autografting : Results
• Morgan & Carter– 52 Cases
– IKDC evaluation
– Pain• 65% improved 2 grades• 31% improved 1 grade• 4% no change (failure)
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Osteochondral Autografting : Results
• Morgan & Carter– 52 Cases
– IKDC evaluation
– Activity• 27% 2 grade improvement• 50% 1 grade improvement• 23% no change
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Osteochondral AutograftBiopsy Proven Survival : Hyaline
Cartilage, Tidemark & Bone
• Wilson 10 years
• Outerbridge 9 years
• Hangody 5 years
• Bobic 3 years
• Morgan 1 year
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Donor Site Morbidity : Osteochondral Autografts
• Morgan, Carter & Bobic 104 cases - no donor morbidity
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Osteochondral Autograft• Post-op
• Early motion– Immediate active, active assisted, and passive
ROM
– NWB x 2 weeks
– Thigh muscle strengthening & stretching 3 months
– Avoidance of sports & running for 3 months
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Autologous Chondrocyte Implantation
• First procedure : biopsy– Arthroscopic chondrocyte harvest from femoral
intracondylar notch
• Cultivation of cells 14-21 days• Second procedure : implantation
– Arthrotomy & debridement of the degenerative lesion– Defect is covered with a periosteal flap– Cultured chondrocytes injected into the defect, under
the seal flap
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Autologous Chondrocyte Implantation : Indications
• Age 15-55
• Defect location femoral condyle
• Defect size 1-10cm.
• Defect type Grade IV
• Ligament stability
• “Normal” alignment
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Autologous Chondrocyte Implantation
• Post-op– CPM
– Active ROM
– Toe touch weight bearing for 6 months
– week 7-12 closed chair exercises
– Jogging at 9 months
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Autologous Chondrocyte Implantation
Swedish Results 1997
• 100 patients 2-9 year follow-up– 90% improvement with femoral condyle lesions– 74% with femoral condyle and ACL reconstruction– 58% for trochlear lesions– 75% for multiple defects
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Autologous Chondrocyte Implantation
US Clinical Experience
• 121 patients 6 month follow-up
• 42 patients 12 month follow-up
• 85% improved overall condition
• 80% improved pain scores at 12 months
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Autologous Chondrocyte Implantation: Advantages
• Less donor site morbidity• Larger and multiple defects can be
addressed• Good early results• No violation of host’s secondary plate• FDA approved
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Autologous Chondrocyte Implantation : Disadvantages
• Requires 2 procedures• Not arthroscopic• Expensive• No “long” term results
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Osteochondral Allograft Transplantation
• Joint resurfacing with fresh or fresh frozen cadeveric tissue
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Allograft Procedure
• Open procedure
• Expose the degenerative lesion
• Remove the defective articular cartilage and a “thin” bony base
• Utilize allograft tissue to replace and restore the articular surface
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Allograft Advantages
• Replaces articular hyaline cartilage with hyaline cartilage
• Single procedure
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Allograft Disadvantages
• Cost
• Risk of disease transmission from fresh allograft tissue
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Allograft Results
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Treatment Recommendations
• Low demand patients
• Small focal lesion (<2cm)
• Arthroscopic chondroplasty– 50% relief up to 5 years
• Autograft Osteochondral or chondrocyte if failed chondroplasty
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Treatment Recommendations
• High demand patient• Small focal lesion (<2cm)• Debridement plus drilling / fx
– 75% success with all– 50% success with sports
• Osteochondral grafting or chondrocyte transplant if failure
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Treatment Recommendations
• Low demand patient
• Large lesion (>2cm)
• Debridement or microfracture with chondrocyte harvest
• If persistent pain - osteochondral or chondrocyte transplant
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Treatment Recommendations
• High demand patients
• Large lesion (>2cm.)
• Chondrocyte transplant 1st line treatment yields 90% success
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Conclusions
• Articular cartilage does not repair itself• Numerous treatments with varying results• Most treatments fail in the long term due to
articular cartilage’s inability to reproduce hyaline cartilage
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Conclusions• Osteochondral auto grafts and chondrocyte
transplants show promising results
• Osteochondral auto grafts allow transplantation of bone capped with hyaline cartilage
• Autologous chondrocyte implantation allows near normal hyaline cartilage growth into defects