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My Algorithm for Small Cartilage Lesions

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My Algorithm for Small Cartilage Lesions 2/2/2020 Disclosure My Algorithm for Small Please see AAOS Surgeons Disclosure Website Cartilage Lesions 2 12 Cartilage Lesion Algorithm Small Cartilage Lesion Options 1. Cartilage Lesion Algorithm Lesion Location 2. Microfracture Femoral Condyle Patellofemoral a)Traditional b)Microdrilling and Nanofractures Malalignment 3. Microfracture Plus Patellofemoral a)Biocartilage Meniscal Alignment Deficiency b)Cartiform Rehabilitation c)ProChondrix Ligament d)AMIC Insufficiency 4. OATS (Osteo - Chondral Autograft Transfer) Size Size 5. MACI (Cell Based Therapy) Small Large Small Large 6. Allografts <2‐3cm2 >2‐3cm2 <2‐3cm2 >2‐3cm2 a)DeNovo (Allograft) b)OCA (Allograft) Microfracture ++ +/‐ Low Demand Microfracture ++ OC Autograft ++ +/‐ MACI +/‐ ++ 7. Reveille (Autograft) 1° MACI + ++ OC Autograft +/‐ 1° OC Allograft ++ OC Allograft + 8. Future Technologies OC Autograft ++ MACI ++ ++ 1. Agili-C 2° MACI +/‐ ++ OC Autograft + 2° OC Allograft ++ High Demand OC Allograft + ++ 2. NeoCart John G. Lane, MD ISMF‐2020 3 3. BST CarGel 4 John G. Lane, MD ISMF‐2020 34 Traditional Microfracture (MFx) Subchondral Bone Pathologies Most commonly performed cartilage repair procedure Subchondral Bone Single‐step procedure, inexpensive • Bone becomes thickened, sclerotic, and polished (eburnation). Simple arthroscopy equipment and microfracture awls • Subchondral bone displays thickened Extensive history and follow‐up trabeculae and microfractures. Most effective for very small lesions with good shoulders of • Tidemark is disrupted by vessels from articular cartilage the subchondral layer. • Subchondral bone cysts (SBC) are formed. SBC formation is associated with 1 2 3 4 • Microfractures, likely secondary to subchondral bone plate disruption. • Increased synovial fluid pressure combined with inflammatory mediators SB C moving from the joint into the bone. Initial LesionDebridement & Stabilization Microfractures cover the lesion Microfractures deep enough to reach blood supply John G. Lane, MD ISMF‐2020 5 John G. Lane, MD ISMF‐2020 6 56 1 2/2/2020 Improving MFx Bone Marrow Stimulation Microdrilling and Nanofractures Microdrilling or Nanofracture: does it make a difference? MFx as we know it today Does drilling allow better access than MFx? The super clot formation contains 0.02% MSC Deeper channels ‐ does it access more pluripotential cells? phenotype cells. What effect does it have on the lacuna in the bone? The integrity of the subchondral bone surface is removed by 15%. Weakened trabecular bone structure can lead to subchondral bone pathology: upward migration of the subchondral bone plate and cyst formation. Possible Improvement Using smaller drill‐holes with a diameter close to the Micro‐computed tomographic (microCT) physiological subchondral trabecular distance may 3D illustrations of subchondral bone cyst formation in the femoral condyle of Traditional MFx Microdrilling & Nanofractures result in better repair tissue sheep, 26 weeks following MFx, with 3 to 4 mm depth 6 to 9 mm depth persistent communications with the Violation of the subchondral bone? More, Smaller, and Deeper Channels improve subchondral plate and subarticular MFx hole. No bone compaction spongiosa restoration No heat necrosis John G. Lane, MD ISMF‐2020 7 John G. Lane, MD ISMF‐2020 8 Illustrations from Arthrosurface Website 78 Nanofracture: Is it safer and more effective? Micronized Acellular Cartilage: BioCartilage MFx‐induced fracturing and compaction of bone surrounding the holes 24hrs after creation (animal). This sealed off the holes from the subchondral marrow and caused osteonecrosis. Debridement In contrast, deeper drilling caused bone repair and remodeling over a MFx greater region and restored the bone volume fraction. Mix into a paste with PRP or BMC Fill cavity Cover with Fibrin Glue The Goal is to provide an internal scaffold that will improve the quality of repair tissue after MFx John G. Lane, MD ISMF‐2020 9 10 Benthien, J P et al. International Orthopaedics (SICOT) (2013) 37:2139–2145 John G. Lane, MD ISMF‐2020 910 Micronized Acellular Cartilage: Features Allograft Surface Treatments Dehydrated, micronized allogeneic cartilage Particle size 100‐300 microns (For ease of use & ProChondrix® and Cartiform® are wafer‐thin increased surface area) allografts where the bony portion of the allograft is Porous cartilage ECM scaffold ‐ contains the reduced. The discs are ECM that is native to articular cartilage, such as type II collagen, PGs and additional cartilaginous GFs and peptides (TGF, FGF and BMP’s) Laser etched or porated – Slow dry freeze & does not destroy peptides Contain hyaline cartilage with – Stem cells exposed to ECM will differentiate Chondrocytes based upon factors with ECM Growth factors Extracellular matrix proteins. 11 John G. Lane, MD ISMF‐2020 12 John G. Lane, MD ISMF‐2020 11 12 2 2/2/2020 Cartiform: Cryo‐Preserved Chondral Graft ProChondrix: Fresh Osteochondral Graft A living biospecific chondral scaffold in conjunction with autologous MSCs ProChondrix is a cellular 3D fresh osteochondral allograft that provides Intended to augment MFX, to access Live functional cells and other biological components for repair and Autologous MSCs regeneration of damaged cartilage tissues. “Best of both Worlds” ‐ Allogeneic living healthy chondrocytes and Internal scaffold promotes MSC migration. Cartiform Technique autologous MSC’s Induces chondrogenesis by signaling the host cells to differentiate Graft Fixation into chondrocytes. Anchors Fresh graft for up to 28 days 1mm‐ all suture ProChondrix Cartilage Restoration Matrix Sutures 5.0 or 6.0 vicryl Sew right through fenestration Fibrin glue‐ periphery only Goal: Secure sufficiently to allow for early ROM Biomechanically, holes allow a bit more moldability Living chondrocytes and better application of the cryoprotectant into the inner portions of the graft so all cells receive cryoprotection during the storage process. John G. Lane, MD ISMF‐2020 13 John G. Lane, MD ISMF‐2020 14 13 14 AMIC: Autologous Matrix‐Induced AMIC Combines MFx and Collagen Membrane Chondrogenesis Single Staged Procedure Type I/III Collagen Membrane Stabilizes MSC Clots AMIC Plus adds PRP to Augment Europe CE mark vs. US would need a BLA for a knee indication Case Series (Gill 2010 and Kusano 2012) – Increase quantity – Quality of tissue? Provides mechanical stability of the clot and – Effects on bone integration? is stimulus for chondrogenic differentiation. 15 16 John G. Lane, MD ISMF‐2020 John G. Lane, MD ISMF‐2020 15 16 OATS (Osteo ‐ Chondral Autograft Transfer) Good to excellent clinical results* • 92% of patients with femoral condyles • 87% of tibial resurfacings • 74% of patellar and/or trochlear mosaicplasties • 93%of talar procedures Disadvantages • Moderate and severe donor‐site disturbances were present in 3% of patients • Limited donor tissue availability in smaller joints *Hangody et. al. Autologous osteochondral grafting‐‐technique and long‐term results. Injury. 2008 Apr;39 Suppl 1:S32‐9 John G. Lane, MD ISMF‐2020 17 18 John G. Lane, MD ISMF‐2020 17 18 3 2/2/2020 Autologous Chondrocyte Implantation KOOS Pain/Function Subscales Two Years Δ baseline KOOS pain and function subscores are significantly higher for MACI vs MFX (P=0.001) KOOS Pain Subscale* KOOS Function Subscale* 90 MACI MFX 70 82.5 MACI MFX 80 60.9 70.9 60 70 48.7 50 60 50 40 40 37 35.5 30 30 Mean Score Mean Score 20 20 14.9 12.6 10 10 n=72 n=71 n=72 n=70 n=72n=72 n=71 n=69 n=72 n=70 0 0 Baseline Year 2 Baseline Year 2 John G. Lane, MD ISMF‐2020 19 John G. Lane, MD ISMF-2020 19 20 MACI Implantation MACI Implantation MACI is implanted through mini-arthrotomy MACI is implanted through mini-arthrotomy 1 Defect is assessed and debrided 1 Defect is assessed and debrided All damaged and underlying cartilage must be removed, All damaged and underlying cartilage must be removed, including the calcified cartilage layer, until vertical walls including the calcified cartilage layer, until vertical walls of healthy, stable cartilage surround the defect site of healthy, stable cartilage surround the defect site Hemostasis must be achieved prior to implantation Hemostasis must be achieved prior to implantation using hemostatic agents using hemostatic agents 2 Template is sized and shaped to match defect MACI implant is cut according to template MACI Surgical Manual. Cambridge, MA: Vericel Corporation; 2017. John G. Lane, MD ISMF‐2020 John G. Lane, MD ISMF‐2020 21 22 MACI Implantation DeNovo NT Particulated Juvenile Articular Cartilage MACI is implanted through mini-arthrotomy 1 Defect is assessed and debrided Fresh‐stored articular cartilage All damaged and underlying cartilage must be removed, including the calcified cartilage layer, until vertical walls Donors under 13 years old of healthy, stable cartilage surround the defect site Knee cartilage minced into 1 to 2 mm cubes Hemostasis must be achieved prior to implantation using hemostatic agents 2 Template is sized and shaped to match defect 1 MACI implant is cut according to template 3 Fibrin sealant is applied to empty defect MACI implant is placed on the defect, with the cells facing the bone bed 2 Fibrin is then added to the surrounding edge 4 Gentle pressure is applied until the MACI implant is secured After fibrin has set, knee is fully extended and 3 flexed several times Wound is closed in standard fashion 4 John G. Lane, MD ISMF‐2020 John G. Lane, MD ISMF‐2020 24 23 24 4 2/2/2020 Why Juvenile Articular Cartilage? Two‐Year Level IV Smaller Lesion Study: Results Lesion Characteristics 23 patients Clinical Outcomes: KOOS Juvenile cartilage is more cellular and the cells have more robust matrix 29 defects formation than adult chondrocytes (Fedder et al, 2004); Adkisson AJSM Defect Size 2.7cm2 2010 potential for cartilage restoration # of patients with 2 lesions 4 Defect Location Femoral Condyle 18 Trochlea 11 ICRS Grade 3A 2 3B 3 3C 16 3D 2 4A 6 MRI Outcomes: Fill rate persist for 2 years Cellular senescence, the loss of the ability of cells to divide, has been noted as the major factor contributing to age‐related changes in cartilage homeostasis, function, and response to injury.
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