Single Stage Biocartilage (Micronized Articular Cartilage) Kevin F. - PowerPoint PPT Presentation

Advanced Practitioners Course: Dec 7, 2017 Single Stage Biocartilage (Micronized Articular Cartilage) Kevin F. Bonner MD Jordan-Young Institute; Virginia Beach, VA Assistant Professor, Eastern Virginia Medical School

Kevin F Bonner MD Disclosures 1.Royalties : Zimmer / Biomet 2.Consulting : Smith & Nephew LifeNet Health Abyrx 3.Research and educational support : Depuy / Johnson & Johnson Zimmer / Biomet LifeNet Health

Chondral Defects in the Knee: Surgical Options Lesion < 2 cm 2 ? Lesion > 2 cm 2 ? Primary Tx? Secondary Tx? Primary Tx? Secondary Tx? Low High Low/High Low High Low/High Demand? Demand? Demand Demand? Demand? Demand Cole. Op Tech Orthopaedics 2001  Arthrsocopic   Arthrsocopic Autologous  Debridement Autologous   Autologous Autologous Debridement Chondrocyte  Marrow Chondrocyte  Chondrocyte Chondrocyte Marrow Implantation Stimulating Implantation Implantation Implantation  Stimulating Arthrsocopic  Technique Osteochondral   Osteochondral Osteochondral Technique Debridement (Microfracture, Autograft Autograft Allograft  (Microfracture, Marrow Abrasion, Abrasion, Stimulating Drilling) Drilling) Technique  Osteochondral (Microfracture, Autograft Abrasion,  Autologous Drilling)  Chondrocyte Osteochondral Implantation Autograft Everyone develops their own personal, and likely ever-evolving, algorithm for cartilage defects

Relative frequency of Cartilage Procedures 2003-2014 55 Million private insured pts Truven Health Marketscan Research Database MFX to OAT 35:1 MFX to ACI 88:1 Khazai et al. AOSSM Toronto 2017

Debate: How best to perform marrow stimulation • Abrade vs perforate ? • Drill vs Impaction awls • Optimal Size & Depth? • Augmentation helpful? Mithoefer et al. AJSM 2009

Recent Reviews Half empty or half full? • Mithoefer K. Clinical efficacy of the microfracture technique for articular cartilage repair in the knee. An evidence-based systematic analysis. Am J Sports Med. 2009 • Mithoefer K. Clinical Outcome and Return to Competition after Microfracture in the Athlete's Knee: An Evidence-Based Systematic Review. Cartilage. 2010 • Chalmers. Activity-Related Outcomes of Articular Cartilage Surgery: A Systematic Review. Cartilage. 2013Goyal D. Evidence-based status of microfracture technique: systematic review of Level I and II studies. Arthroscopy. 2013 • Oussedik S. Treatment of Articular Cartilage Lesions of the Knee by MFX or ACI: A Systematic Review Arthroscopy. 2015

Return to Play in the NFL Mai et al. Am J Sports Med 2016: 44(9)

Return to Sport & Performance After Microfracture in the Knees of NBA Players 41 NBA Players Return to sport: 83% – Length of NBA career following microfracture (4.10 ± 3.91 years) was not sig different from controls. Harris et al. Orthop J Sports Med 2013: 1(6)

Prospective Clinical Outcomes Following MFX Surgery For Isolated and Multi-site Defects: Mid-term Follow-up Weber AE, Locker PL, Tilton A, Cvetanovich GL, Erickson BJ, Yanke AB, Cole BJ • 101 knees : 72 had isolated MFX – Ave age 36, Ave f/u 5.6 yrs • Significant and clinically meaningful improvements • Isolated defects and those < 3.6 cm may be optimal for MFX AOSSM Toronto 2017

Why not just jump to more sexy options? Failures Osteoarthritis MFX 32.5% 48% ACI 42.5% 57% • Differences not sig (p=0.356) Level 1 JBJS: 98-A;No.16: 2016

MFX Poor Prognostic Factors: • Age > 35-40 • BMI > 30 • Size > 4cm 2 • Other than Femoral condyle • Duration of symptoms > 12 months • Not primary procedure • S/P debridement degenerative shoulders • <66% fill on MRI • Pre-op Tegner <4

Results after microfracture in different compartments of the knee: • Patella the worst –Deteriorated between 18 and 36 months –Authors advocate other treatment methods Kreuz et al. Osteoarthritis and Cartilage 2006

In search of a single-stage solution What to do with acute traumatic lesions? -Not many single-stage options

Patella Defects >10 yr f/u J of Knee Surgery 2010: 23(2) Arthroscopy 2013 Oct 29(10)

Reality: Insurance Challenges

Microfracture procedure augmented with BioCartilage • Standard Microfracture • Prepare & apply Biocartilage • Apply Fibrin Glue over Biocartilage • Rehab similar to MFX But what is “BioCartilage”? And why do it?

Cartilage Extracellular Matrix: Biocartilage Chitosan + Blood • MFX “plus” – augmentation • Basic science support • Off the shelf availability • Awaiting clinical outcome studies

BioCartilage Cartilage Extracellular Matrix • What is it? – Allograft cartilage extracellular matrix (ECM) – Contains key components of cartilage: type II collagen, proteoglycans, and additional cartilaginous growth factors IHC staining for type II • How is it intended to be used? collagen – Provides a scaffold over microfractured defect – Signals autologous cellular interactions within the scaffold – Goal is to improve the tissue quality formed after utilizing a bone marrow Proteoglycan content stimulation technique evidenced by granular matrix (toluidine blue staining)

BioCartilage Cartilage Extracellular Matrix • Processing? – Cartilage dehydrated then particulated – 100-300 microns – Aseptically packaged – Ambient temp storage – 5 year shelf-life

Cartilage Extracellular Matrix In vivo supportive evidence Control Group Treatment Group Rabbit Model Baboon model Chadha N et al. Porous Cartilage-Derived Matrix Scaffolds for Repair of Articular Cartilage Defects. ORS 2012; Poster No. 0735. Malinin T et al. Induction of regeneration of articular cartilage defects by freeze dried particulate cartilage allografts. ICRS 2009 Meeting; poster presentation.

2 months BioCartilage MFX Defect Micronized allograft articular cartilage and PRP improved cartilage repair in this model compared to MFX alone Am J Sports Med 2016: 44(9)

Single stage option: BioCartilage 31 yo female -Patellar Defect

BioCartilage Cartilage Extracellular Matrix • Single stage MFX augmentation • Relatively inexpensive • No insurance issues thus far • Basic science support • Nearly 10,000 cases thus far • Awaiting clinical outcome studies

18 YO Basketball Player with activity related pain and swelling MFC Courtesy: Tom Carter MD

18 YO Basketball Player • Micronized articular cartilage allograft Courtesy: Tom Carter MD • Repeat scope for fibrosis

MST Rehabilitation • Dependent on location, size, containment • CPM, stationary bike • Limited WB for 6-8 weeks – NWB to TTWB • Return to sports 5-9 months

Marrow Stimulation ( + Biocartilage ) is a Viable Option • Consider patient & defect factors • Simple / Minimal morbidity / Low cost • Condylar lesions in young patients do best • > 30% Failure rates • Fibrocartilage not as durable but may be good enough for many • Risk/Benefit Analysis vs other options

Micronized Articular Cartilage (BioCartilage) Can augmentation “MFX plus” improve results? We hope But, we really don’t know yet…..

Thank you