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

Single Stage Biocartilage

(Micronized Articular Cartilage)

Kevin F. Bonner MD Jordan-Young Institute; Virginia Beach, VA Assistant Professor, Eastern Virginia Medical School Advanced Practitioners Course: Dec 7, 2017

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 cm2 ? Primary Tx? Secondary Tx? Low Demand? High Demand? Low/High Demand

• Arthrsocopic

Debridement

• Marrow

Stimulating Technique (Microfracture, Abrasion, Drilling)

• Arthrsocopic

Debridement

• Marrow

Stimulating Technique (Microfracture, Abrasion, Drilling)

• Osteochondral

Autograft

• Autologous

Chondrocyte Implantation

• Autologous

Chondrocyte Implantation

• Osteochondral

Autograft

Lesion > 2 cm2 ? Primary Tx? Secondary Tx? Low Demand? High Demand? Low/High Demand

• Autologous

Chondrocyte Implantation

• Arthrsocopic

Debridement

• Marrow

Stimulating Technique (Microfracture, Abrasion, Drilling)

• Osteochondral

Autograft

• Autologous

Chondrocyte Implantation

• Osteochondral

Autograft

• Autologous

Chondrocyte Implantation

• Osteochondral

Allograft

• Cole. Op Tech Orthopaedics 2001

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

• 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

Half empty

• r half full?

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

• f 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

Failures Osteoarthritis

MFX 32.5% 48% ACI 42.5% 57%

JBJS: 98-A;No.16: 2016 Level 1

• Differences not sig (p=0.356)

Why not just jump to more sexy options?

MFX Poor Prognostic Factors:

• Age > 35-40
• BMI > 30
• Size > 4cm2
• 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

• ther 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
• ptions

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

• MFX “plus” – augmentation
• Basic science support
• Off the shelf availability
• Awaiting clinical outcome

studies

Chitosan + Blood

IHC staining for type II collagen

• What is it?

– Allograft cartilage extracellular matrix (ECM) – Contains key components of cartilage: type II collagen, proteoglycans, and additional cartilaginous growth factors

• How is it intended to be used?

– 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 stimulation technique

BioCartilage

Cartilage Extracellular Matrix

Proteoglycan content evidenced by granular matrix (toluidine blue staining)

• Processing?

– Cartilage dehydrated then particulated – 100-300 microns – Aseptically packaged – Ambient temp storage – 5 year shelf-life

BioCartilage

Cartilage Extracellular Matrix

Cartilage Extracellular Matrix

In vivo supportive evidence

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.

Baboon model

Control Group Treatment Group

Rabbit Model

Micronized allograft articular cartilage and PRP improved cartilage repair in this model compared to MFX alone

Am J Sports Med 2016: 44(9)

MFX Defect BioCartilage 2 months

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

Courtesy: Tom Carter MD MFC

18 YO Basketball Player

• Micronized articular

cartilage allograft

• Repeat scope for

fibrosis

Courtesy: Tom Carter MD

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