8/9/2017 1 Management of Patellofemoral Cartilage Lesions Jack Farr, MD OrthoIndy Cartilage Restoration Center Indianapolis, IN Financial Disclosures Royalties • Arthrex T3 AMZ guide • DePuy/Synthes Sigma HP PFA Consulting • Arthrex • Advanced Biosurfaces • DePuy (JNJ company) • DePuy/Mitek (JNJ company) • Eli Lilly • MedShape • Moximed • NuTech • Genzyme • Osiris • RTI • Regenerative Biologics • SBM • Sanofi (Prior Genzyme) • Regeneration Technologies • Zimmer Pain • Pain is the central perception of a peripheral noxious stimulation • Being subjective, it is often difficult to assign a single cause • Dehabilitation often is a major component: not an operative solution
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Management of Patellofemoral Cartilage Lesions Jack Farr, MD · 8/12/2017 · Table 1. Epidemiology of Patellofemoral Cartilage Lesions Patellofemoral chondral lesions were seen
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• Pain is the central perception of a peripheral noxious stimulation
• Being subjective, it is often difficult to assign a single cause
• Dehabilitation often is a major component: not an operative solution
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Majority of PF Pain Patients Respond to Nonoperative
Management
Treat with “Core to Floor” comprehensive therapy
Assigning “Pain” to Chondrosis:Diagnosis of Exclusion as Articular Cartilage is aneural
Pain therefore originates from:
• Bone (Local or Remote, subchondral BML, referred hip)
• Soft tissue (Synovium, Capsule, Tendons and Ligaments)
• Nerves (Local or Remote, e.g., saphenous, neuroma)
AAOS Let’s Discuss: Joint Preservation of the Knee Chapter 13: Issues Specific to Cartilage Restoration in the Patellofemoral Joint Sherman SL, Nuelle C, Farr J
Table 1. Epidemiology of Patellofemoral Cartilage Lesions
Patellofemoral chondral lesions were seen in 60% of more than 25,000 patients who underwent knee
arthroscopy.(Widuchowski Knee 2007)
High grade focal chondral defects are reported to occur between 11‐20% in patients undergoing routine
knee arthroscopy. (Aroen AJSM 2004)
11‐23% of these lesions involved the patella and 6‐15% involved the trochlea. (Bajaj)
In one series looking at professional athletes, the prevalence of patellofemoral defects was 37%, with 64%
of these lesions located in the patella.(FlaniganMed Sci Sports Exer 2010)
Two studies evaluating MRI of the knee joint in asymptomatic NBA players demonstrated abnormal
cartilage signal in 57%, with incidence of high grade patella and trochlea lesions reaching 35% and 25%,
Presence of Chondral Lesion Focal Cartilage Defect (cm2)
Effusion; Mechanical Symptoms; Pain with patella compression; MRI or CT arthrogram correlation of lesions size/location and assess bone marrow lesions
Size of Cartilage Lesion N/AMRI correlation of lesion size ; ICRS Classification; Modified Outerbridge Classification
Osteochondral Lesion/OCD Stable vs. Unstable LesionEffusion, Mechanical symptoms, Location of tenderness; MRI Classification Stable vs. Unstable ; Anderson Modification of the Berndt and Harry Classification
Patient/ Pathology Specific Treatment Plan
Treat patients with pain on the basis of;
1. Abnormal mechanical factors
2. “Treatable” chondral defects (size & grade as per standard technique recommendations)
Exclude ill‐defined pain, CRPS, debilitation and those exceeding their “Scott Dye Envelope of Function”
Table 4. Concomitant Procedures That Accompany Patellofemoral Cartilage Restoration
TTO Abnormal TT‐TG, Abnormal Caton‐Deschamps Ratio
MPFL repair/reconstruction Incompetence of the MPFL
Lateral release/lengthening Fixed patella tilt with lateral retinacular tightness
Trochleoplasty Not currently indicated as adjunct to cartilage restoration
AAOS Let’s Discuss: Joint Preservation of the Knee Chapter 13: Issues Specific to Cartilage Restoration in the Patellofemoral Joint Sherman SL, Nuelle C, Farr J
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3 most common concomitant PF Procedures when treating
Cartilage Lesions
• Lateral Lengthening
• Tibial Tuberosity Osteotomy
• MPFL Reconstruction—only if RPI; not for pain or alignment
Lateral Trochlea with Pick
Drilling may be better than Microfracture• Characterization of Subchondral Bone Repair for Marrow-Stimulated Chondral Defects and Its Relationship to Articular Cartilage Resurfacing Hongmei (Buschmann and Hoemann Lab) AJSM 2011• Science and Animal Models of Marrrow Stimulation for Cartilage Repair. Fortier, et al J Knee Surg 2012
Patella with “Drilling”
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PF Microfracture LiteratureProcedure Study Design Defect Size
LocationFollow‐up
Results ConcludingComments
Kreuz, Arthroscopy 2006Kreuz, Osteoarthritis and Cartilage 2006
Case Series70 patients
Patella 3.ccm3 12 to 36 months
Results in the Patella deteriorated starting at 12 to 15 months in the patella
Kreuz, 2006 Osteo & Cartilage. Lowest score for ICRS fill and MCRS in the patella
MicrofractureNegrin et alInt Orthop 2012
Meta‐analysis, 5 studies,N 5 187Age 15–60 y
Range 1–10 cm2 2 to 5 yrs Decreased outcomes after 18–24 moIneffective for treatment of large chondral lesions<35 y improved outcomes LFC/MFC outcomes better than Patella
Mean standardizedtreatment increase of 22 overall KOOS pointsFC only not in the patella
MicrofractureSteadman et al,Arthroscopy 2003
33 PF chondral lesions in 71 patients, mean age 30.4
2.8 cm2 (range .2‐10 cm2)
11.3 (range 7‐17 yrs)
No statistical difference inresults based on site80% improved PRO
MicrofractureMithoefer et alJBJS 2005
Prospective cohort48 patients
4.82 cm2 (range .2‐20 cm)
41 Months 67% G/E resultsNo difference among knee regions
Best results with good fill grade, low BMI, and preopsymptom duration less than 12 months
• Easy to perform/ consider drilling options
• Inexpensive
• May be arthroscopic (Mini‐arthrotomy option for patellar lesions)
• “Easy to just Microfx” and ignore the need to optimization of force/contact area, stability and tracking
• Variable clinical results
• Patella is a sesamoid bone: the bone is harder & thicker
Blood supply different – possibly fewer stem‐cells
Fibrocartilage in high shear force environment
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Diego Costa Astur et al. J Bone Joint Surg Am 2014;96:816-823
Lysholm improved from 57.27 to 80.76Kujala improved from 54.76 to 75.18Fulkerson improved from 54.24 to 80.42
All G/E > 2 yrs
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• Consider drill techniques for dense subchondral plate of patella
• Recognize the difference in donor/recipient cartilage thickness
• Implications that harvest sites are often in/near the site of pathology
Courtesy Tony Schepsis
Trochlear OCA
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Bipolar PF Chondrosis
Bipolar OCA Shells
Bipolar PF Chondrosis with LFC extension
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Custom OCA Shells
PF + LFC OCA Shells
PF OC Allograft LiteratureProcedure Study Design Defect Size
LocationFollow‐up Results Concluding
Comments
Fresh osteochondral allografts Gross et al,CORR 2005
Prospective nonrandomized study ofgraft survivorship and clinical outcomes in 60 patients who had an OCA to the femoral condyle and 65 patients who had an OCA to the tibial plateau.
Femoral Condyle: 10 y
Tibial Plateau:11.8 y
Femoral Condyle: Kaplan‐Meier survivorship showed 95% graft survival at 5 years, 85% at 10 years, and 74% survival at 15 years
Tibial plateau: Kaplan‐Meier survivorship showed 95% survival at 5 years, 80% at 10 years, and 65% at 15 years
Early bipolar lesions failed, not recommended
Long term outcomes confirm the value of fresh osteochondral allografts to reconstruct articular defects of the knee in the young active patient
Osteochondral allograft transplantationJamali et al,CORR 2005
( San Diego )
Retrospective cohort study, N 5 20 (18 patients)Age 42 y (range 19–64 y)patellar and 12 trochlea/ patella
Retrospective cohort study, N 5 14 knees(11 patients)Age 37 y (range 24–56 y)Mean previous operations, 4.42 patellar and 12 patellofemoral
Fresh Shell PF grafts
Mean, 10 y (range, 2.5–17.5 y)
6/14 revised to arthroplasty 10 of 11 successes wouldhave procedure again Knee Society Scores 46/82 Functional Scores 50/75 Lysholm 27/80Mean extension lag 12o/3oReoperation in 12 of 14 Complications in 4 patients(persistent anterior knee pain, skin rash)
Fresh osteochondralallografts for diffuse PF osteoarthritis can provide limited results, with a 42% failure ratePatients may benefit because of delay of arthroplasty
Osteochondral transplantation Chahal et al, Arthroscopy 2013
Systematic Reviews 9 studies; N 5 644 kneesAge 37 y (range 20–62 y)20 trochlear and 45 patellar lesions
Mean 6.3 cm2 58 mo(range 19–120 mo)
Overall OCA 86% in the FC, less in the Patella 18% failure rate overall
Patients have inferior results in the patellofemoral joint compared with tibiofemoral lesions
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Additional Bugbee OCA StudiesProcedure Study Design Defect Size
27 patients (28 knees) who underwent isolated OCA transplantation of the patella between 1983 and 2010
The mean allograft area was 10.1 cm(2) (range, 4.0‐18.0 cm(2)
Seventeen of the 28 knees (60.7%) had further surgery after the OCA transplantation; 8 of the 28 knees (28.6%) were considered OCA failures Patellar allografting survivorship was 78.1% at 5 and 10 years and 55.8% at 15 years
Pain and function improved from the preoperative visit to latest follow‐up, and 89% of patients were extremely satisfied or satisfied with the results of the OCA transplantation
Fresh osteochondral allograft transplantation for bipolar reciprocal osteochondral lesions of the knee.Meric et al, AJSM 2015
(San Diego)
Bipolar chondral lesions in 46 patients (48 knees) who underwent isolated OCA transplantation of the patella between 1983 and 2010.
The mean allograft area was 19.2 cm(2)
For OCAs still in situ, 7 years (range, 2.0‐19.7 years)
Survivorship of the bipolar OCA was 64.1% at 5 years.Thirty knees underwent further surgery; 22 knees (46%) were considered failures
Osteochondral allograft transplantation is a useful salvage treatment option for reciprocal bipolar cartilage lesions of the knee. High reoperation and failure rates were observed, but patients with surviving allografts showed significant clinical improvement.
Osteochondral allograft transplantation in the femoral trochleaCameron et al,AJSM 2016
( San Diego )
Graft survivorship and clinical outcomes in 28 patients (29 knees) who had an OCA limited to the femoral trochlea.
The mean allograft area was 6.1 cm(2), (range 2.3‐20.0)
7.0 years (range, 2.1‐19.9 years)
Graft survivorship was 100% at 5 years and 91.7% at 10 years. One patient was converted to a total knee arthroplasty 7.6 years after OCA surgery.89% of patients were extremely satisfied (63%) or very satisfied (26%) with their outcome at latest follow‐up.
Fresh OCA transplantation resulted in excellent clinical outcomes in this patient cohort with articular cartilage damage to the femoral trochlea. The procedure resulted in improved pain and function and high patient satisfaction.
• Availability
• Normalize environment
• Bipolar limitations
• Current stored tissue is NOT the same as historical fresh transplants
• Minimize bone thickness to shorten time for creeping substitution
• Patella and Bipolar are “off label” in US—see package insert
• Match facet curvature
• Depth of cartilage walls
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Review of the ACI Literature for the Patella
Key Findings:• Number of ACI Patella Publications: 15• Majority of Lesions were central, Panpatella• Average size lesion treated with ACI 4.4cm2
• Clinical Outcomes‐ 40‐84% Good to Excellent(TTO with ACI produced better outcomes 80 to 85%)( No TTO 40 to 55% )
IKDC scores +29 or greaterModified Cincinnati Score +3.5 or greater
• Range‐ 24 mths to 20 years• Patient Satisfaction‐ >90%• Failure Rate‐ 16 to 28% • Re‐operation rate‐ 10 to 30% ( Periosteum)• Well designed Rehab Protocol
37 mos. 5.4 80% Good to Exc ICRS Arthroscopic assessment 1.2 yrs11/12
MinasICRS 2013
30 73% w/ TTO
2‐10 years 5.5 83%‐ Good to Exc.13%‐ Fair4%‐ Poor
Best results seen with good fill rate and surface integrity
GilloglyAJSM 2014
27 Isolated All had AMTT
5‐11 years,Mean 7 years
6.4 83% Good to Exc.;IKDC 42 pre op improved to 75 post op (p<.0001)
Results for diffuselesions no different than facet lesions;91% satisfaction
GomollMulti‐CenterAJSM 2014
11069% AMZ27% Both
2‐4 yrs 5.26 4.5cmTrochlea Def.
86 % Improved74% (20 point inc. on IKDC); 9% Failure
High Patient Satisfaction 92%
Autologous Chondrocyte Implantation for Patellar Chondral Defects: Results
ACI Annotated ReferencesProcedure Study
DesignDefect SizeLocation
Follow‐up
Results ConcludingComments
First‐generation ACI Pascual‐Garrido et al,AJSM‐ 2009
Prospective cohort study, N 62 (52 , 83% follow‐up) Age 31.8 y (range 15.8–49.4)
Mean 4.2 ± 1.6 cm2 Mean 4 y(range 2–7
Significant improvement in Lysholm, IKDC, KOOS Pain, KOOS Symptoms, KOOS Activities of Daily Living, KOOS Sport, KOOS Quality of Life, SF‐ 12 Physical, Cincinnati, and TegnerNo significant improvement in SF‐12 Mental44% reoperation rate7.7% failure rate
Outcome was not affected by previous cartilage proceduresPatients undergoing AMZ tended to have better outcomes
Second‐generation ACI Vanlauwe et al, AJSM 2012
Prospective cohort study, N 5 38Age 30.9 yLesions of patella (28), trochlea (7), or both (3)84% of patients had previous surgery
Mean 4.89 cm2
(range 1.5–11 cm2)Mean 37 mo(range 24–72 mo)
Significant improvements in KOOS and VAS at48 mo84% clinically relevantimprovement >10 patients at 3 y 13% failure . 24% reoperation rate
Second‐generation ACI yields promising outcomes in the patellofemoral joint at 3 y
First‐generation, second‐generation, and third‐generation ACINiemeyer et al,142008
Improved IKDC (61.6 ±21.5), Lysholm (73.0 ±22.4), and Cumulated Ambulation Score 61.5 ± 21.5Symptoms better 84%, same 2.9%, and worse 12.9%67% normal/nearly normal International Cartilage Repair Society81.4% would have
Patellar ACI yields good results in 70%–80% of patients
ACI Annotated References
Procedure Study Design
Defect SizeLocation
Follow‐up
Results ConcludingComments
First‐generation ACI ±AMZ (73.7%concomitant) Farr, ClinOrthop Relat Res 2007
Prospective study, N 5 39(38 knees)Age 31.2 ± 11.3 yPatella and trochlea
Trochlea: 4.3 ± 1.9 cm2(46% of cohort)Patella: 5.4 ± 1.9 cm2(36% of cohort)Bipolar: 8.8 ± 3.5 cm2(18% of cohort
Mean 1.2 y Modified Cincinnati OverallCondition score: median 3‐point improvementLysholm score: median 31‐point improvementVAS score resting: median 2‐point improvementVAS score maximum:3‐point improvement 25 patients had 32subsequent surgeriesThree patients failed
Overall condition improved regardless of concurrent AMZ or presence of >1 lesion
Comparison study, Total of 44 patients 22 per group, lesions of patella
Mean 2 y Osteotomy with greater increase in mean modified Cincinnati Knee Score (4.5 vs 1.7 points), better function (1.7 vs 2.5), better SF‐36 physical component scores (70.9 vs 55.4 points), higher IKDC scores (85.2 vs 60.6points
Patellar ACI with osteotomy has better outcomes than ACI alone, possibly in patient with normal PF biomechanics
MinasICRS 2013
30 patients 73% w/ TTO
5.5cm2 2‐10 years 83%‐ Good to Exc.13%‐ Fair4%‐ Poor
Best results seen with good fill rate and surface integrity
MacmullInt Orthop 2012
48 patients25 ACI23 MACI
4.73 40.3 mos 40% Good to Exc No TTOMajority of lesions were central, medial
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ACI Annotated ReferencesProcedure Study
DesignDefect SizeLocation
Follow‐up
Results ConcludingComments
Third‐generation ACI 1distal realignment Gigante et al, KSSTA 2009
Prospective cohort study, N 5 14 knees (12 patients)Age 31 y
Median 4 cm2(range 3–9 cm2)
Mean 3 y Improved Modified Cincinnati and median Lysholm, Tegner, and Kujala Score13/14 patients satisfied 50% excellent, 43% good 7% poor
93% of patients with third‐generation ACI and osteotomy have good/ excellent results
Third‐generation ACI Gobbi et al, AJSM 2009
Case series, N 5 34Age 31.2 y (range 15–55 y) Lesions of the patella (21), Trochlea 9 bipolar 4
Mean 4.45 cm2 5 y Significant improvement in IKDC, VAS, and Tegner at 2 and 5 y
Third‐generation ACI has good results in the patellofemoral joint at 5 y
Third‐generation ACI Kreuz et al, AJSM 2013
Comparison study (men vs women), N 5 25 men;27 womenAge, 35.6 y20 PF compartment lesions
Males: 7.00 ± 3.7 cm2Females: 4.33 ± 1.1 cm2
Follow‐up at 6, 12, and 48 mo
Female PF lesions: Lysholm/ IKDC improved at 6 mo, with continued IKDC improvementMale PF lesions: Lysholm/ IKDC improved at 6 mo with significant improvement at 12 mo
Male and female patients both improve after third‐generation ACI for patellar defects; however, men have greater improvement
85% (n = 40) of patients were satisfied with the results of their MACI surgery
MACI provides improved clinical and radiologic outcomes to 24 months in patients undergoing treatment specifically for articular cartilage defects on the patella
• Technically difficult
• Rehabilitation pre and post op extremely important
• Normalize environment
• 2nd and 3rd Generation ACI also report good results with patella (Steinwachs CACI, Gobi Hyalgraft‐C)
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MFC
8/2007
Particulated Juvenile Articular CartilageProcedure Study Design Defect Size
LocationFollow‐up Results Concluding
Comments
Particulated juvenile cartilage tissueBonner et al, JKS 2010
Case report, 2‐year postoperative evaluation36 YO M
1.68 cm2 2 yrs IKDC improved from 32 to 85All KOOS subdomainsimproved by at least 21 and as much as 70
21 month PO MRI showed defect filling with near‐complete resolution of subchondral edema
Particulated juvenilecartilage allograftFarr et al,Cartilage 2011
Case series of 4 patients with chondral lesions on the femoral condyle or trochleaAge 43 yrs (range 38‐49 yrs)(Subset of prospective 25 patient case series )
2 yrs Improvements in all scores across 24 month follow‐up period
Particulated juvenile cartilage allograft in the patellaTompkins et al, Arthroscopy 2013
Case series15 knees (13 patients)Age 26.4 yrs
2.4 cm2 28.8 months 73% normal or nearly normal ICRS MRI 80% showed at least 90% defect coverage
Viable option for patients with focal articular cartilage defects of the patella
Particulated juvenilearticular cartilageFarr et al,AJSM 2014
2‐year prospective study of symptomatic articular cartilage lesions of 25 patients with chondral lesions of the femoral condyle or trochleaAge 37 yrs (range yrs)
2.7 cm2 2 yrs IKDC improved from 45.7 to 73.6All KOOS subdomains improved by at least 16.8 and as much as 28.1
MRI suggests return to level approximating normal cartilage by 2 yrs
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• Technically straightforward
• Rehabilitation pre and post op extremely important
• Normalize environment as for ACI
• Less expensive than ACI or OCA
• Limited Clinical Reported Outcomes
PF CPAC
• 27 YO M who enjoys running, cycling, basketball and weight training
• Onset of pain Jan 2012, progressively increased and stopped cycling and running due to pain by June 2012
• 3/2013: DA, Subchondroplasty Patella• Retropatellar R knee pain; intermittent, sharp when loaded; crepitus; no instability
• ROM: 0/0/130; swelling and effusion proportional to activity
Initial Imaging: 2/2013
Caton-Deschamps: 1.0TT-TG: 9mmTT-PCL: 24mm
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Initial Imaging: 4/2013Post Patellar Chondroplasty and CaPhos to Patella