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 ,
Disclosures • Consultant – Arthrex ( Royalties) – JRF – Johnson and Johnson and Depuy Mitek – Exactech – Geistlich – Regen Labs – Alter G
The Knee Joint is an Organ … we must consider alignment, meniscal , ligament deficiency, molecular, tissue and matrix issues
Mechano-Orthobiologic Paradigm 2017 Doherty 1994 Hunziker 1992 Hunziker 1992 Performance cell/ organ tissue Buckwalter 1986 matrix molecule m cm mm µm nm
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 Places mechanical stress on: – Meniscus – Hyaline cartilage “ Athletic Varus ” – Ligaments
MECHANICAL AXIS Midpoint of lateral plateau vs. Between the spines Mechanical Axis
Malalignment • Neutralize hostile environment • Unload a defect or arthritic compartment
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° of valgus, which favors cartilage repair
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
Factors affecting cartilage repair after medial opening-wedge high tibial osteotomy Kumagai et al 2017 HTO was performed in 131 knees of 100 • patients mean age 66 • 2 nd look at mean 20 months Incidence of cartilage regeneration significantly higher overcorrected knees and Lower BMI
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 • 2 nd look at mean 14 months. • 45 knees (63.4 %) showed no repair and 26 knees (36.6 %) showed repair. NO difference between overcorrected knees !
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
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
Cartilage Preservation Osteotomy Conclusions • Concept: Realign and unload involved compartment • Clinical EBM : minimal and limited • Practice: Selection is critical and Correct, not over-correct
ACL injury is Catabolic
Osteoarthritis OA… the Perfect Storm Articular Cartilage Injury ACL “Catabolic I njury” Alignment GAG Gender MMPs Level of play Growth Factors Age of Injury Present age Timing of RX Modulators Meniscus Injury
Prevalence of radiographic knee OA 0 Men & Women meniscus inj 15-20y f-u Women soccer ACL inj 12y f-u Men soccer ACL inj 14y f-u 10 % 20 30 Men 40 ¤ ¤ ¤ 50 ¤ Women 60 70 Age Class 15-24 25-34 35-44 45-54 55-64 65-74 75-84 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
Impact of ACL Knee injury Molecular Response ( Lohmander JOR ‘94 ) Bone Bruise • Matrix Metalloproteinase's • stromelysin MMP-3 • collagenase MMP-1 • TIMP (inhibitor) • COMP
Osteoarticular Cartilage Injury Acute Injury: ACL • “Bone Bruise” • Metalloproteinase release MMP-3, 1 • ↓ GAG Content (chronic) • ↓ Aggrecan Levels after 2 yrs • Chondrocyte Apoptosis Beynnon AJSM 2005 Tiderius, Arthritis Rheum 2005 • Traumatic Focal OC Defect • Incidence 9-60% • Shear Injury/Compression • Forces > 25-35 MPa • Subchondral Bone Fracture Chen AJSM 2008 Meyer AJSM 2008
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)
ACLR or not? The Effect of ACL Reconstruction on the Risk of Knee Re-injury: An Outcomes Study of 6,576 Cases 2004 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
ACL Catabolic Injury Chondropenia p< 0.001
ACL Catabolic Injury Chondropenia p< 0.001
ACL Catabolic Injury Chondropenia p< 0.001
Knee Osteoarthritis After Anterior Cruciate Ligament Injury: A Systematic Review 0lestad et al Oslo, Norway •isolated ACL injury (0%–13%) •combined injuries meniscal tears Stratification correlates with (21%–48%). OA prognosis
I OC Consensus ACL I njuries in Children ACL I njury in Nonoperative Treatment Children Meniscal tear rates 3-12X Lausanne October 2017 • Angel & Hall ( Arthroscopy 1989) BJSM 2018 » 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 Deficiency in Young Anderson et al 2014 Delay to ACLR meniscus or chondral incidence and severity >3X
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%
Conclusions ACL Injury,
Conclusions ACL Injury, Malalignment
Conclusions ACL Injury, Malalignment Meniscus deficiency,
Conclusions ACL Injury, Malalignment, Meniscus deficiency, with osteoarticular lesions
Conclusions 12/6/17 ACL Instability, Malalignment Meniscus deficiency, with Osteoarticular lesions NOT tolerated over time and will result in compromised cartilage repair, OA and progression
Thank You Allen Anderson ! 1949-2017
Results – Anterior Displacement Summary
Evolving Concept…. “Chondropenia” Normal Articular Cartilage The Journey • Loss of volume articular cartilage Osteoarthritis
• Systematic Review Analysis of Outcomes for High Tibial Osteotomies Performed With Cartilage Restoration Techniques • 839 knees Kahlenberg, Williams 2017 • 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 or avoid the need for Arthroplasty
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