Transcript
Greetings From SCOI
Richard D. Ferkel, M.D
OLT In the Athlete Operative Treatment and Return to Play
The Following relationships exist:
Royalties and stock options – Smith and
Nephew
Consulting income – Smith and Nephew,
Geistlich, Sanofi
Research and educational support – Ossur,
Mitek, Don Joy, Smith & Nephew
Arthroscopic Treatment
Thigh and Ankle
Support – Supine
Ankle Distractor
2.7 mm Short
Scope with
Interchangeable
Cannulae
Use AM, AL, PL,
TT,TM Portals,
“Lift Lesion”Lateral Inverted Osteochondral
Fracture of the Talus
Dunlap & Ferkel (2013)
10 Pts with Acute Injury
All Lesions Involved
Lateral Talus with
Lateral Ligament Injury
8 Lesions Were
Reattached and 2 Were
Excised
Arthroscopy 29: 1826, 2013
15 year old basketball player
Operative Procedure
Absorbable Pins
Made of
Polydioxanon
Takes 6 Months to
Absorb
Can Be Used Via
Arthroscope or
Open
Mean Age = 17 Yrs
Mean F/U 9.3 Yrs
AOFAS Score 19 → 87
Final Weber Score = 82
Berndt & Harty; E-G = 6,
Fair = 3, Poor = 1
Operative Procedure And Results
Arthroscopy 29: 1826, 2013
CHRONICOSTEOCHONDRAL
LESIONSOF THE TALUS
CHRONICOSTEOCHONDRAL
LESIONSOF THE TALUS
Indications for Surgery
All CT or MRI Stage
1 & 2 Lesions That
Fail Nonsurgical Rx
All CT or MRI Stage
3 Lesions in
Children Under 18
that Fail
Nonsurgical Rx
All CT or MRI Stage
3 Lesions in Adults
& Children
All CT or MRI Stage
4 Lesions in Adults
& Children
Chronic OLT in ChildrenTreat in Cast or Boot for 6 Weeks
Physical Therapy
Treat Conservatively
Transtalar Drilling Without or With
Bone Graft to Maintain Integrity of
Articular Cartilage
Bone Graft & Reattach Loose
Chronic Lesions if Possible
Excision, MicroFx Drilling Only If
OLT Nonviable
Treatment Options for Cartilage Defects
< 1 cm2
Debridement
Drilling
MicroFracture
2.5 - 4 cm2
Drilling
Osteochondral
Transplants
ACI
Allografts
Juvenile
Allografts
Micronized
Cartilage Matrix
1 - 2.5 cm2
Debridement
Drilling
MicroFracture
Osteochondral
Transplants
ACI
Allografts
Juvenile
Allografts
Micronized
Cartilage Matrix
Factors Influencing Choice of OLT Surgical Procedure
Size of Lesion
Location of Lesion
Containment of OLT
Subchondral Cyst
Status of Cartilage Cap
Associated Pathology
Patient Preference
Identify Lesion
CT or MRI
Verify that Lesion
is Source of Pain
Appropriate
Conservative
Treatment
T-M or T-T Drill if
Not Loose
Chronic OLT In Adults
Pin If Loose and
Articular Cartilage
Healthy
Excise if Loose or
Displaced, Then
Drill/Microfracture
Base
Bone Graft Cyst if
Large Via T-T or T-M
Excision of P-M OLT
Scope Thru P-L Portal
Inflow Thru A-L Portal
Instruments Through A-M
Portal Via Notch of Harty
P-L View
Microfracture
Place Holes 3-4 mm
Apart and 4 mm
Deep
Avoid Collapsing
Subchondral Plate
Can Be Combined
with DrillingJ.J.
Use:
Accessory to (Curved)
Microfracture Picks
Allows Surgeon to Use
Mallet and Drive Tip of
the Pick In the Intended
Direction (Striking Plate
on Handle)
Hard Bone
Minimize Skiving,
Damage to Opposite Side
Cartilage
Pick Assist
MicroFx/Drilling – How Deep is Enough?
Steadman, R. et al. – Do 3-4mm Deep
Chen, H. et al. – Drilling 6mm Depth Produced Better
Fill and Quality of Cartilage Than 2mm Depth
MicroFx Results Similar to Drilling at 2mm Depth
At This Time, It is Not Clear Which Technique Gives a
Better Cartilage Healing Response
J Orthop Res. 29:1178 2011
Drilling Options
P-L View
“Crimson Duvet” Leads To Fibrocartilage
Microfracture Augmentation Strategies
Scaffold Augmentation
Scaffold and Chondrocyte
Augmentation
Hyaluronic Acid Augment.
Growth Factor Augment.
Regenokine Modulation
Bone Marrow Aspirate
Platelet Rich Plasma
Results – Ferkel et al (2008)
50 Pts. With OLT Treated Arthroscop.
Mean Age = 32 Yrs.
Mean F/U = 71 mos.
Excellent – Good 72%, Fair 20%, Poor 8%
Sig. Correlation B/N Arthroscop. Stage and
Result
17 Pts Previously Evaluated 5 Years Ago;
35% of Their Results Deteriorated One
Grade AJSM 36: 1750, 2008
OLT With PRP or HAMei-Dan et al (2012) Compared Use of PRP or
Hyaluronic Acid to Treat OLT
Group I = HA – 15 Pts.
Group 2 = PRP-14 Pts (15 OLTs)
Men = 79% of Pts; F/U = 28 Weeks
AOFAS: Group 1 = 66 78, Group 2 = 68 92
Subjective Global Function Group I = 56 73,
Group II = 58 91
PRP + HA Rx Pain Scores Function
PRP Signif. Better Outcome Than HA
AJSM 40:534 , 2012
OLT – Is There A Critical Defect Size?
Choi et al – 120 Ankles with
OLT Had Micro Fx; 26 Pts
Ankle Lat. Lig. Stab.
Clinical Failure =
Osteochondral Transplantation
or AOFAS Ankle – Hindfoot
Score <80
6.7% - Osteo Transplantation
18.4% - AOFAS Score <80
Failure – Related to Defect Size
10.5% - Defect Area < 150 mm2
80% - Defect Area > 150 mm2
Size Calculated by MRI AJSM 37:1974, 2009
Containment of OLTChoi, et al. – Looked at
Prognostic Significance of
Containment (Shoulder vs
Non Shoulder) and Location
of OLT
Pts With Shoulder – Type
OLT Had Signif. Worse
Clinical Outcome Than Non
Shoulder Type
No Signif. Difference
Between Medial and Lateral
OLT in Either Group
AJSM 41: 126, 2013
Indications For Cartilage Replacement
Failure of Previous
Surgery With MSTs
OLT > 1.5 mm2
OLT That is Uncontained
OLT With Large
Underlying Cyst
Newer Treatment Options-2014
Osteochondral Grafts (Au/AI)
Autol. Chondrocyte Implantation
Juvenile Articular Cartilage Allograft
Micronized Cartilage Matrix
Focal Resurfacing Implant
Osteochondral Progenitor Cell
Transplantation
Others
OATS - TalusArthroscopy if
Necessary
Osteotomy or Release
ATFL Laterally
Core-Out or Drill
Lesion to at Least
10mm Depth
Compact Base and
Measure Depth
OATS – TalusInsert Donor Graft
OATS - Talus
Scranton et al (2005) – 50 Cases
Two-Six Yr Follow up; 64% had Failed
One or More Surgeries Prior to
grafting
90% Excellent – Good Results
Concerns About: Cartilage Damage,
Graft Fragmentation, Graft Position &
Knee Pain
Allograft - Talus
Reduce Donor Site
Morbidity
Match Contour and
Cartilage Morphology
Conventional OATS
Or Box-Cut Technique
Allograft – TalusKelikian, et al
Fresh Allografts Inserted
38 Pts: 22 Male, 16 Female
Mean Age = 44 Years (19-74)
Mean Size of Lesion = 1.5cm2
Mean F/U = 38 Mos. (6-62)
Graft Survival = 89%
AOFAS Score 52 → 79 JBJS 93:1634, 2011
Indications for ACI in the Ankle
Patients Aged 15 – 55
Focal Defect > 2 cm2
Unipolar (Only Talus)
Contained
Edge Loading
Failed Previous Surgery
Large Lesions with Subchondral
Cystic Changes in Primary Cases
ACI - Osteotomy
Correct Malleolar Osteotomy
Allows for Exposure of Entire
OLT
Place Guide Pin Over Bone at
Osteotomy Site and Mark with
Methylene Blue
Start Cut With Saw; Finish
With Osteotome While
Protecting Articular Cartilage
Bio-Gide Collagen MembraneType I/III Bilayer
Porcine Collagen
Membrane
Gomoll et al. Compared
Subsequent Surgeries
After ACI-P & ACI-C
(Bio-Gide) in Knee
Results Similar Except
Hypertrophy Related
Surgery
ACI –P = 52%
ACI-C = 3.4%ICRS, May 2009
ACI Membrane Implantation
Membrane is Implanted
and Secured With 6-0
Vicryl to OLT Bed
Fibrin Glue is Used to
Seal the Membrane
“Water Tight” Except a
Hole is Left for Cell
Insertion
ACI Cell Implantation
Insert Catheter
Through Opening in
Membrane
Slowly Inject Cells
Suture Remaining Hole
in Membrane
Seal Hole With Fibrin
Glue
ACI “Sandwich” Bone Grafting
CYST
ACI Results - Ferkel (2014)32 Patients Total
Male = 16; Female = 16
Medial = 24; Lateral = 8
32/32 = Previous Surgery
Current Study: F/U 29/32 = 91%
Ave. Age = 34 (18-54)
Ave. F/U = 70 Mos (24-129)
“Sandwich” Procedures = 9
2nd Look = 90% (26/29)
Excell. = 8, Good = 15, Fair = 5
Poor = 1 AJSM, 2014
Arthroscopic 2nd Looks
Grade I Soft & Ballotable
II Medium Firm
III Firm
Firmness of Articular Cartilage
Increased with Longer-Up
9 Months MC
SC
48 Months
17 Months
AK
Scaffold Materials For The Repair of Chondral and Osteochondral Defects in 2014
Calcium phosphates (CaP)
Hydroxyapatite (HAp)
Biological polymers
Collagen
Fibrin
Alginates
Hyluronan (HyA)
Chitosan
Collagen/glycosaminoglycan (GA)
Synthetic polymers
Polylactic acid (PLA)
Polyglycolic acid (PGA)
Polycaprolactone (PCL)
Other
Demineralized bone matrix
Devitalised cartilage
Periosteum
Bioactive glass
ACI Comparative StudyGiannini et al
3 Pt. Groups: Open ACI, Scope ACI, BMAC
81 Pts; Mean Age = 30 Yrs
Mean F/U = 60 Months
Mean Overall AOFAS Score:
Pre op = 57
Post op = 93
Injury, 2012
ACI Comparative StudyGiannini et al
Pre op 38 57 65
12 Months 89 87 89
36 Months 94 89 93
MRI Complete Integration in 76%
Histology – All 3 Groups Hyaline-Like
Cartilage
Open ACI-10 Scope ACI - 46 BMAC - 25
Injury, 2010
AOFAS SCORES
Particulated Juvenile Cartilage
Juvenile Cartilage Allograft
Tissue (Donors < 13 yrs Old)
Juvenile NT Graft Consists of
Scaffold-Free Living Articular
Cartilage, Displaying
Biochemical Properties
Similar to Those of Articular
Cartilage Found in Young,
Healthy Joints.Adult
400xJuvenile
400x
DeNovo NT Graft
Particulated Juvenile Cartilage Technique
Bone Graft Cystic
Lesion and Cover
With Fibrin Glue
Place Fibrin Glue
Over Osteochondral
Defect (If No Bone
Graft)
Particulated Juvenile CartilageTechnique
Juvenile NT
Allograft is Placed
Into the Defect
and Impacted With
a Freer Elevator
P-L View Lt Ankle
Place Another Layer
of Fibrin Glue Over
Graft
Wait 5 Mins
Check ROM to
Ensure That There is
No Instability of
Fragments
Particulated Juvenile Cartilage
P-L View Lt Ankle
Particulated Juvenile Cartilage
Coetzee et al (2013) Multicenter Study
Involving 24 Ankles
Ave Age = 35 Yrs; Ave. F/U = 16 Mos
14 Pts Failed At Least One Prior BMS
Ave Size = 125 mm2, Ave Depth = 7 mm
FAI 34:1205, 2013
Particulated Juvenile Cartilage
Results: AOFAS = 85 (78% G-E)
SF12 Physical Compos. = 46
SF 12 Mental Health = 55
FAAM AODL = 82
FAAM Sports = 63
100-mm Visual Analog Pain = 24
92% E-G Results With Lesions Smaller
Than 15mmFAI 34:1205, 2013
Bone Marrow
Stimulation
Ferkel 100%
Back to Sports
Ave F/U 6 Yrs.
Shuman 45%
Limited or No
Play
Ave F/U 5 Yrs
Van Bergen 88%
Resume Sports
Ave F/U 12 Yrs
OATS Scranton Pain
With Sports
Ave F/U 3 Yrs
Paul Returned
But Mostly
Modified Activity
Ave F/U 5 Yrs.
Hangody Long
Term 93% E-G,
No Sports
Results
ACI Baums All Back
to Sports If Done
Pre Op
Ave F/U 5 Yrs
Giannini 86%
Return to Sports
With Hyalgraft
Ave F/U 3 Yrs
Ferkel
Tegner 1.6 → 4.3
Ave F/U 6 Yrs
Particulated
Juvenile Cartilage
Coetzee FAAM -
Sports = 63
Ave F/U 16 mos
*Osteochondral
Allografts – No
Data
Return to Sports
OLT Ankle - Summary
Newer Technology Shows
Positive Early Results But
More Cases With Longer F/U
Needed
Max. Clinical & Histological
Results at 24 mos. Or Longer
Future – Scaffolds, Stems
Cells, Growth Factors, ?
Solution is Within Our Grasp
and Must Be Done
Arthroscopically
Stepwise Evolution of
Concepts and Science
Cartilage
Solution
Cartilage
Loss
T
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