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

Ortho Summit 2017 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

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 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

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 Intra-lesional • Perhaps not: osteophyte – Riff, Cole et al. AAOS Annual Meeting; Las Vegas, NV 2015

JBJS 96-A (10); 2014 4 yrs S/P Bilat ACI Pre-op TKA’s Survival: 78% @ 5 yrs 51% @ 10 yrs No difference: ACI-C/ACI-P or MACI

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 cm 2 – Address subchondral issues – Relatively high return to activity – Durable • Potential Donor site morbidity

Morbidity when graft transferred to other 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

• 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 cm 2 Arthroscopy. 2015 Apr;31(4)

Osteochondral Autografts • May be the best option for relatively small (< 2.0 cm 2) 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 cm 2 or 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 cm 2 – 46% concomitant procedures • 86% overall satisfaction rate Chahl J, Gross AE, Cole BJ. Arthroscopy. 2013

Return to athletic activity after osteochondral 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 osteochondral graft – Can be morbidity with donor sites

Thank you