The Failed Microfracture in a 41-Year-Old Weekend Warrior: What I - - PowerPoint PPT Presentation

The Failed Microfracture in a 41-Year-Old Weekend Warrior: What I Do Next

Kevin F. Bonner, M.D.

Jordan-Young Institute; Virginia Beach, VA Assistant Professor; Eastern Virginia Medical School

Ortho Summit 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

Careful in a 41 Year-Old “Isolated Lesions” often the initial phenotype of DJD

• Is it a train you cannot stop?

–Genetics

• Is it a truly isolated lesion?
• Need to address environment?

41 YO Ex college basketball player: Prior microfracture

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

Your Surgical Options for the Failed Microfracture

• Osteochondral Autograft

Transfer

• MACI
• Fresh Osteochondral

Allograft

• Newer options:

In what cartilage religion were you raised?

Have an open mind

Some may go to MACI next

• MFX may increase failure rate of subsequent ACI

?

– Minas, AJSM 2009 – Pestka, AJSM 2012

• Perhaps not:

– Riff, Cole et al. AAOS Annual Meeting; Las Vegas, NV 2015

Intra-lesional

• steophyte

JBJS 96-A (10); 2014

Survival: 78% @ 5 yrs 51% @ 10 yrs

No difference: ACI-C/ACI-P or MACI

4 yrs S/P Bilat ACI Pre-op TKA’s

MACI for the PF Compartment

• Good option for some

lesions not as amenable to OA grafts

• Supported by the

literature

• Insurance challenge

However: Nothing as reliable as a viable osteochondral graft

Trochlea MFC

41 YO Ex college basketball player

Osteochondral Autograft Transfer

• Good option for smaller

symptomatic lesions: < 2.0 cm2

–Address subchondral issues –Relatively high return to activity –Durable

• Potential Donor site morbidity

Morbidity when graft transferred to

• ther joints: Variable
• Iwasaki. Am J Sports Med. 2007

0% (11 pts)

• Reddy. Am J Sports Med. 2007

36% poor –Lysholm (11 pts)

• Paul. JBJS-Am. 2009

10% mod or very unsatisfied (112 pts)

• Kennedy. Cartilage. 2011

4% (72 pts)

• Kim. Am J Sports Med. 2012

0% (52 pts)

17-Year f/u in Athletic Population

• 354 pts (ave 9.6 yr f/u)
• 63% Mild / Mod arthritis

Good / Excellent Femoral 91% Tibial 86% Patellofemoral 74%

Harvest site pain: 5%

• Hangody. Am J Sports Med 2010

• Arthroscopy. 2015 Apr;31(4)
• 9 Level 1 & 2 studies (607 pts)
• Appropriate for < 2 cm
• Allows athletes to return at

high rate at 6 months

• Deterioration at 2-4 yrs ?

Bentley JBJS-Br 2003, 2012 Ave 4.66 cm2

Osteochondral Autografts

• May be the best option for relatively small (<

2.0 cm2) symptomatic lesions in athletes

– Higher level of activity Krych et al. JBJS-AM 2012

• Limited donor cartilage available
• Donor site morbidity?

Osteochondral Allografts

• Typically used for >2.0 cm2
• r subchondral pathology
• Restore cartilage-bone

architecture

• Results not effected by prior

MST

• Logistical & supply issues
• Cost / Infection /…..

Outcomes of osteochondral allograft transplantation in the knee.

• 19 studies - 644 knees (mean f/u 58

mos)

– Mean defect 6.3 cm2 – 46% concomitant procedures

• 86% overall satisfaction rate

Chahl J, Gross AE, Cole BJ. Arthroscopy. 2013

Return to athletic activity after

• steochondral allograft

transplantation in the knee.

• 43 athletes (2.5 yr ave f/u)
• 88% limited return to sport
• 79% full return to the

preinjury level

Krych AJ, et al. Am J Sports Med. 2012

Return to an athletic lifestyle after osteochondral allograft transplantation of the knee.

Shaha, Cook, Rowles, Bottoni, Shaha, Tokish

• 38 military pts
• 4.8 cm
• 42% unable to return to duty
• 7% able to return to sports

Am J Sports Med 2013; Sep 41(9)

Fresh Osteochondral Allografts: Patellofemoral (large grafts)

Trochlea: 89% extremely satisfied or satisfied (92% survival @ 10 yrs)

Cameron, Bugbee et al. Am J Sports Med. 2015

Patella: 29% considered failures

• Of the 71% (20) with grafts in-situ:
• 89% extremely satisfied or satisfied

Gracitelli, Bugbee et al. Am J Sports Med. 2015

Femoral Algorithm Autologous OAT

• Up to 2 plugs
• Large wide trochlea –donor site
• Younger athletes: Needs one operation

with RTP within 6 months

• Accepts risk of donor site morbidity

– “Robbing Peter to pay Paul”

• This would be maybe my second choice

Femoral Algorithm Viable OA Allograft

• Most reliable option in a 41 YO

– And probably for most

• My personal “go to procedure”
• Quicker recovery than MACI
• Accepts infection risk (minimal) & graft

failure

• Can do plugs arthroscopically

Personal thoughts & evolution on the treatment of articular cartilage lesions

• Often long office visits
• Reality is that they all don’t do well
• Risk / benefit analysis discussion
• Doing less than more initially OK
• Nothing more reliable than a viable
• steochondral graft

– Can be morbidity with donor sites

Thank you