An Algorithm and Approach to Cartilage Failure: Revision Strategies - - PowerPoint PPT Presentation

An Algorithm and Approach to Cartilage Failure: Revision Strategies – Tips and Tricks

Brian Chilelli MD 12/6/17 SUMMIT

Disclosures

• Consultant - Vericel

Risk Factors for Failure

• Patient factors

− Age − Smoking − Obesity − Inflammatory joint disease

Risk Factors for Failure

• Concomitant injuries/abnormalities

− Malalgnment/Maltracking − Ligamentous instability − Meniscal deficiency

Risk Factors for Failure

• Defect Factors

− Prior surgery − Subchondral bone − Size − Location − Number of defects − Age of defect

Mechanisms of Failure (Early failure)

• Patient factors

− Non-compliant (WB, CPM usage, etc) − Traumatic injury

• Technical failure

− Improper technique

• Inadequate preparation of defect
• Implantation of MACI membrane
• Incongruent graft (OAT, OCA)
• Lack of press fit (OAT, OCA)

Mechanisms of Failure (Late failure)

• Progression of disease
• Mechanical failure

− Delamination of graft

• Biologic failure

− Inadequate fill / repair tissue − Incomplete integration − Subchondral cysts − Intralesional osteophyte − Lack of osseous incorporation − Membrane hypertrophy

Approach to the failed cartilage patient

• 4 questions to ask yourself……

Approach to Failed Cartilage Patient

• Is there malalignment or maltracking present?

− Obtain limb length x-rays to evaluate mechanical alignment − Scrutinize CT/MRI for TT-TG distance/TT-PCL distance

Approach to Failed Cartilage Patient

• What is the status of the subchondral bone?

− Is there subchondral bone deficiency present?

• Consider bone restoring procedure (OAT, OCA,

grafting) if > 6-10 mm of bone loss

− Subchondral cysts? − Subchondral bone marrow edema?

Approach to Failed Cartilage Patient

• Is there evidence of meniscal deficiency?

− Patient has history of prior meniscectomy − Evaluate MRI, previous operative reports, arthroscopy pictures

Approach to Failed Cartilage Patient

• Does the patient have ligamentous instability?

− ACL/PCL/MCL/PLC − History of subjective patient complaints − Evaluate MRI − Office examination − Evaluate previous operative reports − Dynamic stress x-rays

Correct Malalignment/Maltracking

• Osteotomy for malalignment

− High tibial osteotomy (HTO) for varus alignment and medial femoral condyle defect − Distal femoral osteotomy (DFO) for valgus alignment and lateral femoral condyle defect − Tibial tubercle osteotomy (TTO) for elevated TT-TG (> 16-20mm) and lateral patellar facet defect

Address Meniscal deficiency

• Medial meniscal allograft transplantation
• Lateral meniscal allograft transplantation

Treatment options

Marrow stimulation (Microfracture)

 Failed ACI (MACI) in setting of normal

subchondral bone and small lesion (<2cm2)

Particulated juvenile articular cartilage allograft (PJAC)

• Failed marrow stimulation (microfracture) or ACI

(MACI) in the setting of normal subchondral bone

Osteochondral Autograft Transfer (OAT)

• Failed marrow stimulation (microfracture) or ACI

(MACI)

• Ideally in small lesions (<2cm2)

Autologous Chondrocyte Implantation (MACI)

• Failed marrow stimulation (microfracture) in

setting of normal subchondral bone

Osteochondral Allograft Transplantation (OCA)

• Failed marrow stimulation (microfracture), ACI

(MACI), OAT, or previous OCA

• Effective in normal or abnormal subchondral

bone

ACI (MACI) with subchondral bone grafting (Sandwich technique)

• Femoral condyle or patellofemoral defect

with abnormal subchondral bone and

• steochondral allograft is not available

What about ACI (MACI) or OCA after marrow stimulation (microfracture) ……???

ACI following microfracture/marrow stimulation

• Peska et al. AJSM 2012
• Compared 28 patients treated with ACI after

microfracture had failed to 28 patients treated with ACI as a first line treatment

• Mean follow up of 48 months
• Significantly more failures associated with ACI after

microfracture (7 of 28) than with ACI as a first line treatment (1 of 28)

• Inferior clinical outcome was also associated with ACI

after microfracture.

ACI following microfracture/marrow stimulation

• Minas et al. CORR 2014
• Subgroup analysis of their long-term outcome

study

• Graft survival at 15 years was 79% in patients

without microfracture prior to ACI and only 44% in patients who underwent microfracture prior to ACI

Osteochondral allograft transplantation following microfracture/marrow stimulation

• Gracitelli et al. AJSM 2015
• 46 patients- OCA following failed marrow stimulation

− 20 of 46 knees (44%) reoperation − 7 of 46 knees (15%) failed − 10 year survivorship – 86%

• 46 patients- primary OCA

− 11 of 46 knees (24%) reoperation − 5 of 46 knees (11%) failed − 10 year survivorship – 87.4%

• No difference in functional outcomes or survivorship

My preference…

• Failed marrow stimulation (microfracture)

− Patellofemoral – ACI (MACI) or PJAC − Femoral condyle – OAT (small lesion, <2cm2), OCA (large lesion, >2cm2)

• Failed ACI (MACI)

− Patellofemoral – PJAC (normal subchondral bone) or OCA − Femoral condyle – PJAC (normal subchondral bone) or OAT (small lesion, <2cm2), OCA (large lesion, >2cm2)

• Failed OAT / OCA

− Patellofemoral – Revision OCA − Femoral condyle – Revision OCA

Final Pearls

• Ask yourself the 4 questions

− 1. Malalignment? − 2. Subchondral bone? − 3. Meniscal deficiency? − 4. Ligamentous insufficiency?

• Have a low threshold to consider diagnostic arthroscopy

prior to making definitive plan

• Each patient is different!...patient factors play a large

role in the decision process