Alignment and Ligament Deficiency: Keys to Successful Cartilage - - PowerPoint PPT Presentation

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Alignment and Ligament Deficiency: Keys to Successful Cartilage - - PowerPoint PPT Presentation

Apr 07, 2024 300 likes •688 views

Alignment and Ligament Deficiency: Keys to Successful Cartilage Surgery Bert R. Mandelbaum MD DHL (hon) Co-Director of Clinical Affairs KJI at Cedars Sinai CONCACAF Chair Medical Committee Asst Medical Director MLS Team Physician US Soccer,

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Alignment and Ligament Deficiency: Keys to Successful Cartilage Surgery

Bert R. Mandelbaum MD DHL (hon) Co-Director of Clinical Affairs KJI at Cedars Sinai CONCACAF Chair Medical Committee Asst Medical Director MLS Team Physician US Soccer, LA Galaxy, Pepperdine University ,

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SLIDE 2

Disclosures

  • Consultant

– Arthrex ( Royalties) – JRF – Johnson and Johnson and Depuy Mitek – Exactech – Geistlich – Regen Labs – Alter G

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SLIDE 3

The Knee Joint is an Organ…

we must consider alignment, meniscal , ligament deficiency, molecular, tissue and matrix issues

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SLIDE 4

Hunziker 1992

tissue cell/ matrix molecule m µm cm mm

  • rgan

nm

Buckwalter 1986 Doherty 1994 Hunziker 1992

Performance Mechano-Orthobiologic Paradigm 2017

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SLIDE 5

Macroenvironment

Malalignment

  • Contact pressures are

exponentially exacerbated with varus alignment

– Guertller et al AOSSM 2002

  • Incidences of OA 4-5X >> in

those individuals with varus or valgus malalignment

– Sharma et al JAMA 286:188- 195; 2001

“Athletic Varus”

Places mechanical stress on: –Meniscus –Hyaline cartilage –Ligaments

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SLIDE 6

Mechanical Axis MECHANICAL AXIS Midpoint of lateral plateau vs. Between the spines

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SLIDE 7

Malalignment

  • Neutralize hostile

environment

  • Unload a defect or

arthritic compartment

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SLIDE 8

High Tibial Osteotomy for Unloading Osteochondral Defects in the Medial Compartment of the Knee

Mina, Garrett et al 2008

  • complete unloading of the

medial compartment at

between 6° and 10°

  • f valgus, which

favors cartilage repair

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SLIDE 9

Cartilage repair procedures associated with high tibial osteotomy in varus knees: Clinical results at 11 years' follow-up Ferruzzi 2014

  • 56 knees
  • 20 HTO/ 18 HTO ACI/ 20 HTO MFX
  • HSS and WOMAC

HTO or HTO/ ACI good results ….not for the HTO/ MFX group

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SLIDE 10

Factors affecting cartilage repair after medial opening-wedge high tibial

  • steotomy

Kumagai et al 2017

  • HTO was performed in 131 knees of 100

patients mean age 66

  • 2nd look at mean 20 months

Incidence of cartilage regeneration significantly higher overcorrected knees and Lower BMI

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SLIDE 11

Is overcorrection preferable for repair of degenerated articular cartilage after open- wedge high tibial osteotomy?

Tsukada and Waku 2017

Over correction better?

  • 71 knees that underwent arthroscopy to

evaluate the articular cartilage during open- wedge HTO and second-look arthroscopy

  • 2nd look at mean 14 months.
  • 45 knees (63.4 %) showed no repair and 26

knees (36.6 %) showed repair.

NO difference between

  • vercorrected knees !
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SLIDE 12

Opening Wedge DFO Outcome

Cameron, et al Bugbee 2015

  • 40 knees mean

age 37

  • Mean 5 year f/u

(2-12)

  • IKDC improved

from 36 to 62 74% survivorship for OA 92% survivorship in cartilage repair

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SLIDE 13

Autologous chondrocyte implantation (ACI) for trochlea chondral defects Mandelbaum, Andersen, Fu et al 2005

  • 41 patients in ACI

registry

  • Retrospective

TTO or not no difference

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SLIDE 14

Cartilage Preservation Osteotomy Conclusions

  • Concept: Realign and

unload involved compartment

  • Clinical EBM : minimal

and limited

  • Practice: Selection is

critical and Correct, not over-correct

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SLIDE 15

ACL injury is Catabolic

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OA… the Perfect Storm

Meniscus Injury Articular Cartilage Injury

GAG MMPs Growth Factors Alignment Gender Level of play Age of Injury Present age Timing of RX Modulators

Osteoarthritis ACL “Catabolic I njury”

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SLIDE 17

Prevalence of radiographic knee OA

10 20 30 40 50 60 70 15-24 25-34 35-44 45-54 55-64 65-74 75-84

¤ ¤ ¤

Age Class

Men Women

Men & Women meniscus inj 15-20y f-u Women soccer ACL inj 12y f-u

Roos H et al. 1995, Englund et al. 2003, Englund et al. 2004, von Porat et al. 2004, Lohmander et al. 2004, Englund & Lohmander 2005

%

¤

Men soccer ACL inj 14y f-u

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SLIDE 18

Impact of ACL Knee injury Molecular Response

(Lohmander JOR ‘94 )

  • Matrix

Metalloproteinase's

  • stromelysin MMP-3
  • collagenase MMP-1
  • TIMP (inhibitor)
  • COMP

Bone Bruise

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SLIDE 19

Osteoarticular Cartilage Injury

Acute Injury: ACL

  • “Bone Bruise”
  • Metalloproteinase release

MMP-3, 1

  • ↓ GAG Content (chronic)
  • ↓ Aggrecan Levels after 2 yrs
  • Chondrocyte Apoptosis
  • Traumatic Focal OC Defect
  • Incidence 9-60%
  • Shear Injury/Compression
  • Forces > 25-35 MPa
  • Subchondral Bone Fracture
Beynnon AJSM 2005 Tiderius, Arthritis Rheum 2005 Chen AJSM 2008 Meyer AJSM 2008
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SLIDE 20

Are Bone Bruise Characteristics and Articular Cartilage Pathology Associated with Inferior Outcomes 2 and 6 Years After Anterior Cruciate Ligament Reconstruction? Latterman et al 2016

  • No difference in overall outcome unless
  • 17 patients with Osteoarticular pathology were

3.4 times more likely to be symptomatic at 6-year (P = 0.04)

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SLIDE 21

The Effect of ACL Reconstruction

  • n the Risk of Knee Re-injury: An

Outcomes Study of 6,576 Cases

Warren R. Dunn, MD Stephen Lyman, PhD Andrew E. Lincoln, ScD, MS Paul J. Amoroso, MD, MPH Thomas Wickiewicz, MD Robert G. Marx, MD, MSc, FRCSC Aided by a grant from the Orthopaedic Research and Education Foundation

2004

ACLR or not?

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SLIDE 22

ACL Catabolic Injury Chondropenia

p< 0.001

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SLIDE 23

ACL Catabolic Injury Chondropenia

p< 0.001

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SLIDE 24

ACL Catabolic Injury Chondropenia

p< 0.001

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SLIDE 25

Knee Osteoarthritis After Anterior Cruciate Ligament Injury: A Systematic Review

0lestad et al Oslo, Norway

  • isolated ACL injury

(0%–13%)

  • combined injuries

meniscal tears (21%–48%).

Stratification correlates with OA prognosis

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SLIDE 26
  • Angel & Hall (Arthroscopy 1989)

» 5/7 failure (ACL reconstruction)

  • Graf et al (Arthroscopy 1992)

» 7/8 failure (ACL reconstruction, meniscal tears)

  • Janarv et al (J Pediatr Orthop 1996)

» 16/23 failure (ACL reconstruction)

  • Mizuta et al (JBJS-B 1985)

» 1/18 return to preinjury sport level, 6/18 meniscal tears

  • McCarroll et al (AJSM 1988)

» 3/16 return to preinjury sport, 4/16 meniscal tears

  • Millett et al (Arthroscopy 2002)

» ⇑ medial meniscus tears with delay in treatment

  • Moksnes H et al (KSSTA 2008)

» 20 children, 50% copers, 10% meniscal tear

  • Lawrence et al (AJSM 2011)

» 70 children: time (OR 4.1), instability (OR 11.4)

ACL I njuries in Children Nonoperative Treatment

Meniscal tear rates 3-12X

I OC Consensus ACL I njury in Children Lausanne October 2017 BJSM 2018

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SLIDE 27

ACL Deficiency in Young

Anderson et al 2014

Delay to ACLR meniscus or chondral incidence and severity >3X

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SLIDE 28

Association of Meniscal Status, Lower Extremity Alignment, and Body Mass Index With Chondrosis at Revision Anterior Cruciate Ligament Reconstruction

Brophy et al 2015

  • Multicenter ACL Revision Study (MARS) cohort
  • 246 patients age was 26.9
  • Medial compartment chondrosis associated

alignment (P = .002), and medial meniscal status (P = .001).

  • Lateral compartment chondrosis associated lateral

meniscal status (P < .001)

“intact” menisci decrease OR of OA 64% to 84%

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SLIDE 29

ACL Injury,

Conclusions

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SLIDE 30

ACL Injury, Malalignment

Conclusions

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SLIDE 31

ACL Injury, Malalignment Meniscus deficiency,

Conclusions

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SLIDE 32

ACL Injury, Malalignment, Meniscus deficiency, with

  • steoarticular lesions

Conclusions

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SLIDE 33

ACL Instability, Malalignment Meniscus deficiency, with Osteoarticular lesions NOT tolerated over time and will result in compromised cartilage repair, OA and progression

Conclusions 12/6/17

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SLIDE 34

Thank You Allen Anderson ! 1949-2017

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SLIDE 35

Results – Anterior Displacement Summary

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SLIDE 36

Evolving Concept…. “Chondropenia”

The Journey

  • Loss of volume

articular cartilage

Osteoarthritis Normal Articular Cartilage

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SLIDE 37
  • Systematic Review

Analysis of Outcomes for High Tibial Osteotomies Performed With Cartilage Restoration Techniques

Kahlenberg, Williams 2017

  • 839 knees
  • conversion to arthroplasty 6.8%
  • mean number of years to conversion was 4.9 to

13.0

  • complication rate was 10.3% .

reliable improvement to delay

  • r avoid the need for

Arthroplasty