Overview of Multiple Cartilage Sparing Techniques and Rehab Principles For The Knee Owner & Founder of the Fischer Institute www.fischerinstitute.com Trent Rincon, PT, MPT, CSCS Brett Fischer PT, ATC, CSCS,CertDN
The Knee Joint – 2 types of The Knee Joint – 2 types of Cartilage 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) •
Osteoarthritis Of The Knee FIG 1 FIG 2 Credit: Dr. Greg Portland
Osteoarthritis Of The Knee Osteoarthritis Of The Knee FIG 3 FIG 4 Credit: Dr. Greg Portland
Overview of Surgical Options For: Articular Cartilage Restoration 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
Palliative Procedure 1. Palliative Procedure “Clean Out” • • Basically removed of loose fragments of cartilage or meniscus Short term relief • • Doesn’t address the “true problem”
2. Intrinsic Repair Enhancement / Marrow Stimulation Procedure aka “ Microfracture ” 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 •
Intrinsic Repair Enhancement / Marrow Stimulation Procedure 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)
3. Whole Tissue Transplantation of Hyaline Cartilage (A) Autograft – Mosaicplasty / OATS • • (B) Allograft - AOT
Whole Tissue Transplantation of Hyaline Cartilage (Autograft) 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
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
Whole Tissue Transplanation of Hyaline Cartilage – Allograft (AOT) 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 ” o r “ Cartiform ” – very popular brands used by Orthopods •
Whole Tissue Transplantation 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.
4. Cell Based Repair Procedures ACI (carticel) • • PRP • Stem Cell Orthokine / Regenokine •
Autologous Chondrocyte Implantation (ACI) (Carticel) 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 • of 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
PRP 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
Stem Cell Procedures for Osteoarthritis 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
Orthokine / Regenukine Orthokine / Regenokine 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
5. Cell Based Repairs With Scaffold (Neocart) 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
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
MACI – Matrix-Introduced Autologous Chondrocyte Implantation 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
6. Scaffold Based Repairs • (“ 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
7. Minced Cartilage Repair 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 •
Goals of Evaluation • 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!
Overall Goal of Evaluation Basic understanding of the biomechanics of the lower chain, • then functionally isolate to find specific deficits.( not symptom based treatment )
3 Planes Of Motion Gary Gray
3 Planes Of Motion Sagittal Plane Motion • Gary Gray
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