Overview of Multiple Cartilage Sparing Techniques and Rehab - - PowerPoint PPT Presentation

Trent Rincon, PT, MPT, CSCS Brett Fischer PT, ATC, CSCS,CertDN

Overview of Multiple Cartilage Sparing Techniques and Rehab Principles For The Knee

Owner & Founder of the Fischer Institute www.fischerinstitute.com

The Knee Joint – 2 types of Cartilage

(A) Meniscus:

• Cushion between the femur & tibia
• Made up of fibrocartilage ( Type I & II Collagen)
• (FIG I)

(B) Articular: – hyaline cartilage

• Smooth layer that covers the articular bones
• Has a fractional coefficient 1/5 of ice on ice
• Large portion is fluid which helps with compressive forces
• Poor ability to heal itself
• Has only a single type of cell for renewal – the chondrocyte
• (FIG 2)

The Knee Joint – 2 types of Cartilage

FIG 1 FIG 2 Credit: Dr. Greg Portland

Osteoarthritis Of The Knee

Osteoarthritis Of The Knee

Credit: Dr. Greg Portland FIG 3 FIG 4

Osteoarthritis Of The Knee

1. Palliative Procedure 2. Intrinsic Repair Enhancement 3. Whole Tissue Transplantation of Hyaline Cartilage

• Autograft
• Allograft

4. Cell Based Repairs 5. Cell Based Repairs with Scaffold

• 6. Scaffold Based Repair

7. Minced Cartilage Repair Overview of Surgical Options For: Articular Cartilage Restoration

Palliative Procedure

• “Clean Out”
• Basically removed of loose fragments of cartilage or

meniscus

• Short term relief
• Doesn’t address the “true problem”
• 1. Palliative Procedure

• Drilling of subchondral bone causing the release of

mesenchymal stem cells from the bone marrow. This creates a fibrous tissue formation (not hyaline cartilage)

• The effectiveness depends on age, size & location of the

defect and post – op strategies

• Made popular by Vail, Co physician Dr. Richard Steadman
• 2. Intrinsic Repair Enhancement / Marrow Stimulation

Procedure aka “Microfracture”

• Positives
• Simple, inexpensive
• Negative
• The fibrous / clot formation is not as mechanically sound as

hyaline cartilage

• Need 6-8 weeks of NWB in some cases with 8 hours of CPM
• Muscle atrophy, compliance issues
• Research has shown only a 44% returns to sport (Mithoefer, et
• al. Am I Sports Med 2006, Sep)

Intrinsic Repair Enhancement / Marrow Stimulation Procedure

• (A) Autograft – Mosaicplasty / OATS
• (B) Allograft - AOT
• 3. Whole Tissue Transplantation of Hyaline

Cartilage

• Mosaicplasty – AOCG (Autologous Osteochondral Grafting)
• “OATS”-similar to Mosaicplasty but bigger plugs and less in

number

• Osteochondral plugs are taken from non-weight bearing

areas on both femoral condyles with insertion of these plugs into defect area.

• Usually 3-6 weeks NWB followed by 3 to 6 more weeks

PWB

Whole Tissue Transplantation of Hyaline Cartilage (Autograft)

• Positives
• Defect is filled with mature hyaline cartilage
• Better results than microFx ( Krych, Harnly, Williams, J Bone Joint

Surg AM, 2012)

• Negatives
• Only suitable for small defects
• Technically difficult
• Limited donor tissue available
• Donor site morbidly
• Non-impact activities until after 12 weeks
• Returns to sport 10 months & on

Autograft

• Similar procedure to mosaicplasty / OATS procedure except

the cartilage is obtained from another donor

• Usually used for larger type chondral defects
• Cryopreserved Chondral grafts such as
• “BioCartilage” or “Cartiform”
• –very popular brands used by Orthopods

Whole Tissue Transplanation of Hyaline Cartilage – Allograft (AOT)

• Positives
• Well documented success
• Viable, fresh cells & sustainable matrix
• 88% return to sports ( Krych, Robertson, Williams, AM Journal of

Sports Medicine 2012)

• Negatives
• Limited availability
• High Cost
• Disease Risk?
• Fresh allografts obtained 24-72 hours earlier provide higher

chondrocyte availability but carry a higher risk for disease transmission versus cryopreserved frozen allograft have reduced disease transmission but low chondrocyte availability.

Whole Tissue Transplantation of Hyaline Cartilage – Allograft (AOT)

• ACI (carticel)
• PRP
• Stem Cell
• Orthokine / Regenokine
• 4. Cell Based Repair Procedures

• Procedure performed in 3 major phases
• Phase I – Diagnostic arthroscopy with cartilage harvest
• Phase II – Chondrocyte Cultivation in lab for 6 weeks
• Phase III – Implantation surgery which consists of debridement
• f the defect, harvesting of the periosteal flap from the proximal

tibia to help create a patch followed by injection of harvested and cultured chondrocytes under the patch.

Autologous Chondrocyte Implantation (ACI) (Carticel)

• Positives
• Somewhat favorable outcomes (vol. 4 Genzyme tissue repair,

Cambridge, MA,1998) (891 Transplants – 86% good to excellent results)

• Negatives
• Hypertrophy of the patch – leads to another surgery
• Unreliable potential of re-implanted cartilage cells
• Less favorable at patellofemoral joint

Autologous Chondrocyte Implantation (ACI) (Carticel)

• PRP - Platelet-Rich Plasma
• Basically infuses the joint via injection with high concretion of

growth factors that promote healing and remolding.

• (In 2009, Drengk, et all in Cell Tissue Organ) reported that PRP

creates proliferation of autologous chondrocytes + mesenchymal cells. This also increases hyaluronic acid

• secretion. These chondrocytes demonstrate less interleukin - 1B

– induced inhibition of Collagen II

PRP

• Positives
• Easy
• Non surgical
• Good outcomes for early osteoarthritis
• Negatives
• Limited lasting effect
• No Change on MRI
• Relatively, new treatment frequency still being debated

PRP

• Use of stem cell found in humans to promote healing within

the joint by creating more chondrocyte cell

• Allogeneic mesochymal stem cells ( adult cells, not fetal, or

embryonic, usually harvested from bone marrow or adipose tissue)

• Embryonic Stem Cells (Medical News Today, 3/4/2015)

Univ of Manchester, U.K. – promising new results

Stem Cell Procedures for Osteoarthritis

• Positives
• Less Invasive
• Easier Recovery
• Outpatient Basis
• Negative
• Science in still not there yet
• Costly

Stem Cell Procedures for Osteoarthritis

Orthokine / Regenukine

• Experimental medical procedure in which the patients own

blood is extracted, manipulated and then re-introduced to the body as an anti-inflammatory drug.

• Around 60 ML of blood is removed from the patient
• Developed in Germany by Dr. Reinecke and Dr.Wehling
• Focuses on treating the inflammation as opposed to the

mechanical problem in the joint

• Different than PRP in that PRP, platelets are targeted

whereas the interleukin – 1 (an arthritic agent in one’s blood) is targeted

Orthokine / Regenokine

• Positives
• Non – Surgical
• Easy to administer
• Early results are good (accordantly to German studies 75%

success rate)

• Negatives
• Costly (around $10,000 cost per joint)
• Not FDA Approved

Orthokine / Regenokine

• Similar to ACI in that patients own cells are harvested but

these cells are then embedded into Type I collagen matrix and incubated in an unique processor that stimulates the cells to produce protein then implanted over the defect

• 5. Cell Based Repairs With Scaffold

(Neocart)

• Positives
• Results are promising (Crawford, et all ,J Bone Joint Surg 2012)
• Negatives
• Takes up to 9 weeks for final implantation
• Costly
• Long term studies not available

Cell Based Repairs With Scaffold (Neocart)

• Much like ACI procedure but collagen patch with cultured

harvested cells is secured with fibrin glue

• Positives
• Early studies are processing (mostly in Europe)
• Negatives
• Not FDA Approved
• Costly
• Long Rehab time

MACI – Matrix-Introduced Autologous Chondrocyte Implantation

• (“Trufit” :by Smith & Nephew)
• Synthetic osteochondral graft by use of polymers, ceramics and
• fibers. The material is designed to be a highly porous scaffold to

support issue incorporation and remodeling by absorbing biological fluids and nutrients, the material is biologically friendly.

• Positives
• Easily done arthroscopically
• Negatives
• Not available in US yet
• Mixed results so far
• Not FDA Approved
• 6. Scaffold Based Repairs

• DeNovo NT (Natural Tissue)
• Made out of minced cartilage from organ donors under the age of

13

• Uses fibrin to “stick” minced carriage onto defect area
• Positives
• Not harvesting of own cells
• 1 step procedure – immediate implantation
• Negatives
• Costly
• Limited availability, donors
• No long term studies / follow up
• 7. Minced Cartilage Repair

• Identify & treat the tissue and / or the cause
• Such as identity & treat ROM imbalances

Restore / improve / facilitate proper Movement via manual therapy, Neuromuscular re-education, etc

• Establish rapport/trust with patient!

Goals of Evaluation

• Basic understanding of the biomechanics of the lower chain,

then functionally isolate to find specific deficits.( not symptom based treatment )

Overall Goal of Evaluation

3 Planes Of Motion

Gary Gray

• Sagittal Plane Motion

3 Planes Of Motion

Gary Gray

• Frontal Plane Motion

3 Planes Of Motion

Gary Gray

• Transverse Plane Motion

3 Planes Of Motion

Gary Gray

Kinetic Chain

• “The body works synergistically with muscles, joints,

and proprioceptors, all working together.”

• “There is a cause effect relationship in movement

between force reduction and force production.”

Gary Gray

• Pronation – the collapsing or eccentric loading phase
• Supination – the propulsion or concentric loading phase

Definitions

• The basis for understanding the biomechanics of the Lower

Extremity

Gait

• Movement Analysis
• You will only see what you are looking for…be unbiased
• Gather data before you analyze, be systematic
• View each motion at 90 degrees to the plane observed
• Video when possible and freeze key motions & phases
• Mark calcaneal bisector, tibial tuberosity, lumbo-pelvic

markers

• Choose appropriate speeds to cover all training speeds &
• ver speed
• ( From Matthew Walsh, BSc., PT, Level III)

Gait Evaluation Tips

• Movement Analysis
• Mimic movements in your head, try to assemble all the

factors together

• Allow speed changes, inclination & fatigue to be part of

your evaluation

• Get a second opinion (often from a non PT!)
• Change as many variables as possible & analyze the

effects (arms, vision, strike, shoes, speed, surface, camber)

• ( From Matthew Walsh, BSc.,PT, Level III )

Gait Evaluation Tips

• Foot/Ankle/Knee
• Metatarsal Phalangeal Extension – 60-70 deg – terminal stance
• Forefoot Abduction/Adduction – sign of the toes – early midstance
• Longitudinal Arch – navicular drop, early midstance
• Subtalar/Calcaneal Position – 12-15 deg total ROM
• Heel Rise – 10 deg ROM during gait, view from side – different timing in Running
• Pivoting (Terminal St.) – in-toe or out toe, is it associated with foot or hip motion
• Knee Control (Initial Contact) – is there excessive trunk flexion also, has the quad

absorbed initial load

• Knee Alignment (Medial-Lateral) – marker on the knee, view anterior
• Knee Flexion & swing line, Stance & swing
• Knee Extension (Initial Contact)
• Knee Extension (Single Limb Support or Initial Swing In Running)
• (From Mathew Walsh, BSc., PT, Level III )

Gait Evaluation - Checklist

• Hip/Pelvis/Lumbar Spine
• Pelvic Tilt (Trendelenburg) – place markers or tape on iliac crest
• Pelvic Rotation – that is, Lumbar spine rotation
• Hip Extension & Lumbar Extension – best viewed side-on and from

both sides

• Hip Flexion – especially in the swing phase, 45 deg to the ground
• Femoral Rotation – view anterior
• Hip abd/add – 5-7 deg acceptable as normal
• Lumbar Side Flexion – mark the skin or use tape, should be

symmetrical to the hip abd/add

• ( From Matthew Walsh, BSc.,PT,Level III )

Gait Evaluation - Checklist

• Trunk & Arms
• Thoracic Flexion / Extension
• Scapular Posture
• Arm Swing – compare the swing to the thoracic rotation, forearm position
• Breathing Pattern
• Head Movement
• Vertical – look for the timing of the rise, should be midstance
• Lateral – may indicate Trendelenburg or poor counter rotation (e.g. instability or

structural scoliosis)

• Rotation – usually indicates cervical or upper thoracic dysfunction, possibly

scoliosis

• Center of Mass – should follow a smooth curve of motion
• Cranial-Vertebral Posture - eyes level?
• (From Matthew Walsh, BSc., PT, Level III)

Gait Evaluation - Checklist

Ankle Dorsiflexion Passive / Standing

Standing MP Extension

Standing Calcaneal Eversion

Knee Flexion Single Leg Squat

Hip Rom IR/ER Supine

Hip Rom IR/ER Prone

Thomas Test Hip Flexor Psoas

Quad Bias Strength Test

Hamstring Bias Strength Test

Hip Abduction Bias Strength Test

Hip Rotation Strength Test

• Poor posture results in
• Altered Length-Tension Relationships
• Altered Force-Couple Relationships
• Altered joint Arthrokinetics

A Objective Evaluation - Posture

From Dr. Michael Clark, MS,PT,PES,CSCS

• Standard Posture Side View

A Objective Evaluation - Posture

From Dr. Michael A. Clark, MS,PT,PES,CSCS

• Standard Posture Back View

A Objective Evaluation - Posture

From Dr. Michael A. Clark, MS,PT,PES,CSCS

• Objective Evaluation – Posture
• Anterior View
• Head – Rotated? Ear to shoulder height
• Shoulder – ANT or POST rotated?
• Chest – ANT or POST
• Hand Position – Count “knuckles”
• Hip/Pelvis – Lateral Shift?
• Knee – Varus/Valgus? Extended/Flexed?
• Ankle – Navicular Height

Posture

Clark, Michael A., MS, PT, PES, CSCS. Integrated Kinetic Chain Assessment. National Academy of Sports Medicine: Integrated Training for the New Millenium, 8-10. Gambetta, V ., & Gray, G., PT. (n.d). Following the Functional Path. http://www.gambetta.com/a97004p.html Gray, Gary. (1996). Chain Reaction Festival, 8,10. Walsh, Matthew, BSc, PT, Level III. (May 2003) The Running Course: Biomechanical Analysis and

• Rehabilitation. North American Seminars, 33-35.

Webster’s Dictionary Online. www.dictionary.com.

References

Special Acknowledgement

• Dr. Riley J Williams, HSS, NYC

Thank You!