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OCD: Beyond Microfracture
Gregory C Berlet MD, FRCS(C), FAOA Orthopedic Foot and Ankle Center
Columbus Ohio
Disclosures
• Consultant/Speaker Bureau/Royalties/ Stock: Wright Medical, Stryker, ZimmerBiomet, DJO, Plasmology4, Amniox Medical, United Orthopedic Group, Paragon 28, CrossRoads, Ossio
OCD Talus: My Approach
Dictated by :
• Symptoms of the patient
• Mechanism of injury
• Size of the lesion
• Containment of the lesion
• Previous treatment of the lesion
• Corresponding damage to the tibia
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Outcomes: Microfracture OLT
Tol JL et al. 2000
–Meta‐analysis 32 studies; 1966‐1998
– Success of OLT surgeries:
• Excision, curettage, drilling: 85%
• Excision, curettage: 78%
• Excision alone: 38%
Tol … van Dijk: : FAI 21(2), 2000
Results: OFAC
• Retrospective review of 189 patients
• Arthroscopy + Microfracture
• MRI used to determine size
• Review of clinical outcomes ( 37 mo avg)
Cuttica, Berlet et al: FAI 32(11), 2011
Results: OFAC
• Direct correlation of size to outcome
• Linear relationship of size of lesion to outcome
• MRI changes may persist longer than expected
Size vs. Outcome
GoodFair
Poor
0 0.5 1 1.5 2 2.5 3 3.5
Size (mm2)
Ou
tcom
e
Cuttica, Berlet et al: FAI 32(11), 2011
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Results: OFAC vs Tol
• Average lesion size in Tol = 7 mm
• OFAC results deteriorated after > 1 cm
• Maybe size does matter
• Strategy has to be size dependent
• CRITICAL SIZE DEFECT
Critical Defect Size
Choi et al:
• 120 ankles with talus microfracture
• Failure defined as:
– Repeat surgery
– AOFAS < 80 ( fair or poor result )
• Defect size > 150 mm2 ( 7 mm )
– 80% failure rate ( p < .001)
Choi et al. AJSM 37(10) Oct 2009
They call it medical practice for a reason ….
1 year post microfracture of 1 x 1.5 cm OCD
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Scope, Drilling OCD Talus
• 1.0 X 1.2 cm OCD
• contained
10 x 15 mm lesion
One Year Later With our Patient … Disappointment
• Pain initially was better but now has come back
• Swelling
• Does not feel ‘right’
• Complication: Failure to achieve long term clinical success for our patient
Why did it fail ?
• Size of the lesion ‐ maybe
• Access to lesion
– Don’t think so
• Bone support
– Don’t think so but …
• Limitation of microfracture
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I Believe That …. Quality of Repair Matters:
Quality of the cartilage repair is at least part of the reason that size matters
I focus on critical size defects for my advanced cartilage restoration
Lesions between 1.0 – 2.0:
Particulated cartilage grafting
Lesions > 2.0
Osteoarticular reconstruction
Juvenile Cartilaginous Allograft Tissue
• Particulated cartilage with viable cells
• Secured into chondral defects with fibrinJuvenile Donor Joint
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DeNovo NT Graft Talus Study
Purpose:
• Evaluate mid‐term outcomes of DeNovo NT Graft for the treatment cartilage lesions in the talus
Hypothesis:
• DeNovo NT Graft provides good clinical outcomes in a challenging patient population
Coetzee et al FAI 34(9), 2013
Study Design
• Retrospective and prospective
–All cases of ankle DeNovo NT Graft included
• Single‐arm, multi‐center
• 5 study centers
• 24 patients
• FAAM, AOFAS, VAS Pain (100mm), SF‐12, Pt Satisfaction
Coetzee et al FAI 34(9), 2013
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Large Lesions
Containment Full75 to 99%50 to 74%
6 (27%)11 (50%)5 (23%)
Bone Removal NoneOsteotomy
Plafondplasty
4 (17%)12 (50%)8 (33%)
Lesion Size (mm2) 125 ± 75 (range, 50 to 300)
Lesion Depth (mm) 7 ± 5 (range, 3 to 20)
Coetzee et al FAI 34(9), 2013
Results at ≥ 12 months
Average Outcome Scores @ Final F/U
78% of ankles demonstrating good to excellent scores
(AOFAS ≥ 80)
Coetzee et al FAI 34(9), 2013
Results at ≥ 12 months
Re‐Operation Reason # Re‐Operations
Removal of symptomatic or failed osteotomy hardware
5
Anterior Impingement 1
Partial Graft Delamination (full revision)
1 (~ 25% of graft)
Coetzee et al FAI 34(9), 2013
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Juvenile Articular CartilageSaltzman et al (2017):
• Systematic review
– Total of 32 patients
– Level IV and V evidence
– Mean OCD size 117.8 mm2
• Substantial clinical improvement
• No implant related adverse events
• Only one conversion to bulk allograft
Saltzman et al, Cartilage 8(1), 2017
Autologous Chondrocyte Implantation (ACI)
• First clinical use 1994 ( knee)
• Implantation of In vitro cultured autologous chondrocytes
• Expansion of chondrocytes
• Re‐implanted using a periosteal tissue cover
Brittberg et al NEJM 331; 1994
Cell Preparation
• Scope or open harvest of donor chondrocytes
• Processed to remove interstitial matrix and expand chondrocytes in the millions
• Reimplantation
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Results ACI
Kwak et al (2014):
– 29 OCD talus treated with ACI
• 23 medial: 6 lateral failed micro#
• Mean size of 18 x 11 mm
• Average follow up 70 months
• 86% had second look scope
– Improvement in all parameters tested:
• Tegner, Finsen, AOFAS
Kwak et al AJSM;42(9):2014
ACI for Talus Defect
Case: 33 year old male
– Large lateral lesion
– Microfracture in 2007
– Repeat MRI in 2009
– Edema improved but still symptomatic
– Arthroscopy, biopsy and plan for ACI
Courtesy of Dr. Eric Giza MD
One Year: ACI for Talus OCD
Pre‐op ACI
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I Believe That ….
Subchondral Injury is Important :
We have not focused enough on this side of the problem
Micro# does not treat this part
Correlation of MRI Edema and Outcomes after Micro#
Cuttica, Berlet et al (2011):
• 30 patients at an avg of 9 mo post op
• Talus edema classified as none, mild, moderate or severe on MRI
Those with moderate or severe edema had poorer clinical outcome
Cuttica DJ… Berlet GC: FAS 4(5), 2011
Subchondral Bone and Micro#
Reilingh ML et al (2016):
• Dimensional changes and bony healing of talarOCD after microfracture
• 58 patients with OCD talus / micro#
• CT scans obtained at:
Baseline, 2weeks, 1 year
• 3 dimensional changes / bone healing
Reilingh et al Knee Sports Traumatol Arthrosc. 24(4) 2016
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Bone Healing is Poor
Reilingh ML et al (2016):
• OCD increased in size in all directions at 2 week evaluation
• Only dimension to decrease significantly at 1 year was depth
• 14/58 were ‘well’ healed
• No difference in AOFAS / NRS pain found between well and poorly healed
Can We Avoid Microfracture?Chu et al (2018):
• Hypothesis: BMC without microfracture improves cartilage repair compared to microfracture alone
• Equine model
• Paired chondral defects were randomly assigned:
BMC without microfracture
Microfracture alone
Chu CR, Fortier LA et al: JBJS 100‐A(2), 2018
BMA vs BMC
• Culture expanded cells from BMA underwent cartilage differentiation in vitro
• Freshly isolated cells from BMA did not undergo cartilage differentiation
This questions the role of BMA aspiration and immediate injection into articular environment
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1Year: BMA vs Microfracture
• Cartilage repairs in both groups were fibrous to fibrocartilaginous with no differences seen between groups
• Morphological MRI showed:
Detrimental subchondral bone changes with microfracture
Improved overall outcomes for BMA group without subchondral damage
Chu CR, Fortier LA et al: JBJS 100‐A(2), 2018
Unanswered Questions
Can we treat the cartilage deficiency without treating the bone ?
Does BME matter ?
Can we treat BME without treating the cartilage deficiency ?
Cartilage Resurfacing: 2018
• < 1.0 cm = Microfracture is still the gold standard
• Gap Strategy
1.0 – 2. 0 cm = Particulated cartilage
> 2.0 cm = Osteoarticular options
• Evolving evidence to watch: BMA and treatment without compromising subchondral plate
SUMMARY
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