Presentations

7/4/2019

30th Brucosport Football Medicine: What’s New 2017 Bruges, Belgium 11 March 2017 Aspetar Orthopaedic and Sports Medicine Hospital 1

Dr. Scott Gillogly Chief Medical Officer 26 February 2017

1 7/4/2019

Articular Cartilage Injuries in the Knee: Evaluation and Surgical Treatment Options based on Return to Play Scott D. Gillogly, MD 34th FIMS World Sports Medicine Congress Ljubljana, Slovenia 29 September - 2 October 2016

Aspetar Orthopaedic and Sports Medicine Hospital 3

ICRS Annual Meeting 29 September 2016 Aspetar Orthopaedics and Sorrento, Italy Sports Medicine Hospital

2 7/4/2019

Articular Cartilage Injuries in the Knee: Evaluation and Surgical Treatment Options based on Return to Play Scott D. Gillogly, MD

AFC Team Physiotherapist Sports Medicine Course Doha, Qatar 13-15 June 2016

Aspetar Orthopaedic and Sports Medicine Hospital 5

Cartilage Defects in Athletes: Return To Play (RTP)

Scott D. Gillogly, MD

1st GCC Sports Medicine Conference Doha, Qatar 23 April 2016

Aspetar Orthopaedic and Sports Medicine Hospital 6

3 7/4/2019

AAOS Articular Cartilage Restoration: The Modern Frontier 1 April 2016 Aspetar Orthopaedics and Sports Medicine Hospital Chicago, Illinois

AAOS Articular Cartilage Restoration: The Modern Frontier 2 April 2016 Aspetar Orthopaedics and Chicago, Illinois Sports Medicine Hospital

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8 April 2016 Aspetar Orthopaedics and Washington, D.C. Sports Medicine Hospital

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Return to Play (RTP) After Cartilage Repair of the Knee

Scott D. Gillogly, MD

Challenges in Football Injuries Doha, Qatar 11‐12 February, 2016

Aspetar Orthopaedic and Sports Medicine Hospital 11

Partial Osteochondral Fractures of the Condyles (Osteochondral Defects) Scott D. Gillogly, MD

3 February 2016 Val d’Isère, France

6 7/4/2019

Medial Fractures of the Patella (= Patellar Dislocation)

Scott D. Gillogly, MD

3 February 2016 Val d’Isère, France

ACL Reconstruction with Quadrupled Semitendinosus Hamstring and Tape Locking Screws (“The French Technique”) Integration into Clinical Practice in the U.S.

Scott D. Gillogly, M.D. Atlanta, Georgia Team Physician, Atlanta Braves Baseball Club

FH Orthopaedics The Original TLS Short Graft ACL Reconstruction Lyon, France 9 June 2015

7 7/4/2019

Return to Play (RTP) following Cartilage Procedures Scott D. Gillogly, M.D. Atlanta, Georgia Team Physician Atlanta Braves

AOSSM Partner Society Instructional Course ICL #09 Critical Issues in the Care of the Injured Athlete Lyon, France 9 June 2015

Return to Play (RTP) following Cartilage Procedures in the Knee

Scott D. Gillogly, M.D. Atlanta, Georgia Team Physician Atlanta Braves MLB

41st Annual Herodicus Society Lyon, France 3‐6 June 2015

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Dr. Scott Gillogly Chief Medical Officer 26 February 2017

Scott D. Gillogly, MD

• I have no relevant financial relationships with any commercial manufacturers or provider of commercial services

• I do not discuss an unapproved use a commercial product or device in this presentation

1 7/5/2019

OBJECTIVES: Review the relevant anatomy, injury mechanism, pathophysiology and key factors in treatment decision making of common sports injuries. Discuss the essential features of surgery contributing to excellent outcomes.

• Anterior Cruciate Ligament (ACL) Tears

• Meniscus Tears

• Knee Cartilage Defects

• Ankle Syndesmosis Disruptions

• Shoulder Dislocation (Bankart Lesion)

• Anatomy: ACL / PCL • Cruciate: means cross • ACL/PCL cross • ACL Function . Limits anterior translation of tibia (86%) . Limits internal rotation of tibia

• Cause of Injury . Non-contact: Low-velocity, deceleration . Pivoting, Cutting or Landing - Flexion / internal rotation . Contact: . Side-on contact: knee valgus, hyperextension,(football tackle)

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. Signs / Symptoms . Knee popping- 75-90% . Knee swelling- rapid onset of swelling (blood in joint) . Knee pain and giving-way- Unable to continue play . Severity: Lachman and Anterior Drawer Tests . Grade I: 0-5 mm . Grade II: 6-10 mm . Grade III: >10 mm . Pivot Shift: 98% sensitive for tear

. Partial Tears: If any fiber disruption Lachman Test present, then ACL likely to be incompetent

• Radiographs: • Can appear normal • Bony involvement • MRI • ACL Tear • Additional Pathology

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• Meniscal tears • Acute injury: 40-60% • Chronic injury: >90% • Lateral meniscus tears most common

• Osteochondral and Chondral injuries • Acute: 12-23% • Chronic: > 50%

• Bone Edema (Bone Bruise) • Acute: 95%

. Conservative vs Surgical Treatment . Patient activity and functional instability . Adolescent / Child? . Concomitant pathology (meniscus, cartilage) . ACL is necessary for Athletic function . Unstable Knee leads to further meniscus and cartilage damage

. Goals for Surgical Reconstruction . Stability: allow cutting, deceleration . Full Range of Motion equal to opposite side . Symmetric Strength . Athletic Confidence . Return to prior level of competition . Restore natural history

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Pre-operative Essentials . Timing of Surgery . Obtain range of motion . Restore quad function . Decrease swelling . Restore tissue equilibrium . Less risk of Arthrofibrosis . Restore gait, Educate patient for rehab . No reason to hurry . Graft Selection for surgical reconstruction Graft Biomechanics Biologic

Patellar Stronger, stiffer, Bone healing, 3-4 Tendon  vs native ACL wks, faster

Hamstrings, Stronger, stiffer, Tendon-bone DST/G, QST  vs native ACL healing, 8-12 wks, slower

. Factors Influencing Selection . High demand athletes and younger patients . No significant pre-existing patellofemoral chondrosis or subluxation . Skeletally mature or nearly mature . Patients who are able to rehabilitate their quad function . Older players or those unable to rehabilitate quadriceps . Patellofemoral subluxation, anterior knee pain . Position requiring kneeling: Cultural as well . Previous anterior knee surgery . Small sized patellar tendon, patellar tendonitis . Surgeon preference, technique

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. Patellar Tendon (Bone-Tendon-Bone BTB)

. Hamstrings (Semitendinosus, Gracilis)

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•Intra-articularLM MM Pathologies: Chondral Defects

ACL Lateral Meniscus Medial Meniscus

Outcomes After ACL Reconstruction For any Graft Selection

What influences results long term ? • Stable reconstruction (negative pivot shift) • Full Extension and Flexion single most important factor after stability • Medial meniscectomy (secondary restraint) • Articular Cartilage Injury • Lateral Meniscectomy RTP when Rehab criterion met, Typically 9-12 months

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Meniscectomy vs Repair • Anatomy: Meniscus • Medial • Lateral • Peripheral blood supply, move during knee flexion, specialized collagen fibers • Meniscus Function . Load transmission . Peak stress by 235% . Stability: Static and dynamic . Laxity with ACL tear > 50% . Lubrication . Coefficient of Friction 20% . Joint Congruity . Contact area 75%

Tear Characteristics

Petersen and enstrom Fig 11.34

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Signs, Symptoms and Imaging

. Signs / Symptoms . Swelling, stiffness, locking . Pain with rotation . Difficulty straightening knee . Catching or Locking

. Fairbanks Changes (1948) . Osteophytes, Flattening, and Narrowing . Degenerative Changes

Meniscectomy vs Repair

• Tear Patterns . Longitudinal . Radial . Bucket Handle . Parrot Beak

. Factors leading to best treatment option: . Extent of tear . Type of tear . Patient expectations . Associated injuries . Repairable versus non-repairable . Age of patient

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Meniscectomy vs Repair Best for Repair: • Longitudinal (Vertical) Tear • Peripheral Third of Meniscus • Peripheral Detachment • With ACL Reconstruction • Acute Tear • Less than 40 years old

. All Inside Techniques: Needs blood supply

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Return To Play (RTP) . Surgical Options . Partial meniscectomy (85%) . Pros . Rapid Recovery from Surgery . RTP 2-6 weeks . Cons (Fate of knee may be sealed with Injury) . Secondary effects on Stability and Cartilage wear . Steady progression to osteoarthritis (long term) . Meniscus repair (15%) . Pros . Restores anatomy and function? . Slows onset of arthritis? . Cons . Likelihood of re-tear and additional surgery . Slower rehabilitation . RTP 4-6 months +

Outcomes After Meniscus Injury Remove or Repair

What influences results long term ? • Preserve as much of native meniscus as possible • Aggressive Repair in younger athletes when possible • Natural history of injury may be sealed at the moment of injury • Meniscus provides load absorption and stability • Meniscus Repair can lead to Recurrence and additional surgery

RTP: Meniscectomy 2-6 weeks; Meniscus Repair 4-6 Months 22

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• Anatomy: Cartilage layers

• Cartilage Function . Low friction articulation

• Cause of Injury . Traumatic . Overuse

. Approximate Return to Train / Play Time . Depends upon type of surgical procedure – next slides

Anatomy

Femur Femoral Condyles

Tibia Tibial Plateau

Articular Cartilage is the smooth white surface on the ends of the bones in all joints, also called Chondral tissue

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Structure and Function of Articular Cartilage

• Minimizes friction (1/7th coefficient of friction of ice on ice) • Load Distribution (protects bone) • Enhances Range of motion • Cartilage composition: • 5% cells (Chondrocytes) • 95% Matrix made by the cells • Matrix gives the unique properties of Hyaline Cartilage

Signs, Symptoms and Severity . Mechanism of Injury . Traumatic vs. Repetitive . Acute vs. Chronic . Direct hit vs Indirect (Shear) . Signs / Symptoms . Knee popping and catching . Knee swelling . Knee pain and giving way . Severity (Outerbridge Classification) . Grade I: superficial fissures and cracks . Grade II: lesions < 50% of cartilage depth . Grade III: lesions > 50% of cartilage depth but not through the subchondral bone . Grade IV: exposed bone

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Cartilage Defects in Athletes “Ulcerated cartilage is a troublesome thing, once destroyed it is not repaired” John Hunter, 1743 • Lack of intrinsic repair • Presence in young active population • Inadequate traditional repair techniques

Normal Grades II-III Grade IV

Treatment Decision Making 2 – 4 cm2 • Size: Small lesions ≠ large lesions < 2 cm2 ≥

• Location: Femoral Condyles ≠ PatelloFemoroal Joint

• Condition: Chondral defect ≠ osteoarthritis

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Treatment Decision Making Patient Evaluation

• Known Cartilage • Review Op Notes, Video Lesion • Isolated vs • Standing Radiographs, Multiple, Size Alignment, Sunrise • Location Views • Alignment •MRI • Meniscal Status • Bone Status • Exam Correlation • Ligament Exam • Patellofemoral • Arthroscopy, Tracking Treatment, Chondral Bx

Cartilage Cellular Repair Can Lead to Several Different Tissue Types

Autologous Mesenchymal Stem Cells (Marrow Stimulation Techniques) Chondrocyte Implantation

*Availability of Stem Cells is Age Dependent Age 20: 1 per 200,000 Age 60: 1 per 2 Million Hyaline-like Cartilage

*Vasoactive mediators, TGFß, BMP, cytokines, Fibrous Tissue growth factors

Hypertrophic Cartilage

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Surgical Options . No perfect Repair available in 2017 . Chondroplasty

. Microfracture • BST Cargel •Hyalofast

. Osteochondral Autograft Transplantation (OATS – Autograft)

. Osteochondral Allograft Transfer (OATS – Allograft)

. Autologous Chondrocyte Implantation (ACI) or Matrix ACI

Cartilage Repair Procedures Average Time to Return to Play

• Larger Lesions • Slower Return • Best Durability of Repair

• Smaller Lesions • Faster Return • Less Durability of Repair Increasing Complexity Increasing Complexity Recovery and Months to Return to Play

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Outcomes After Articular Cartilage Injury Augmented Repair vs Regeneration

What influences results long term ? • No intrinsic or natural cartilage repair • No ideal surgical treatment, trade-offs are necessary • Natural history of injury may be sealed at the moment of injury (Can we change it?) • Symptoms and progression depend on other pathology or problems in the knee • Less invasive repairs heal quicker and are NOT durable; More complex regeneration heal slowly but remain durable RTP: Microfracture 4-6 months; OATS Allograft 9-12 months; ACI 12-18 months 33

Anterior Inferior Tibia • Ankle Anatomy Posterior Inferior Tibia Fibular Ligament Fibular Ligament • Tibiofibular Ligaments • Talofibular Ligaments • Interosseous Membrane

Posterior Talo Anterior Talo Fib Ligament Fib Ligament

Syndesmosis Function Calcaneofibular Ligament • Fibrous union between two bones connected by interosseous ligaments • Maintains stability, micro‐motion but no gross translation • Prevents anterior ‐ posterior translation of distal fibula on tibia

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High Ankle Sprain

• Mechanism of Injury . External Rotation/ Dorsiflexion: typically contact injury (55%)

. Body Internal Rotation (catching foot causing ankle external rotation; Non-contact (35%)

Physical Exam Interosseous Palpation, Squeeze

Dynamic Tests: External Rotation Test, Shuck Test

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. May occur with or without fracture Imaging

Medial Clear Space (EF); ≤ 4mm.

Imaging

AITFL PITFL Interosseous Membrane

. MRI easily shows partial vs complete tears

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13 days post-op

Accelerated Rehab: Advance as tolerated

Surgical Options & Decision Making . Conservative vs non-conservative management . syndesmotic sprain (without fracture) with instability on stress radiographs . syndesmotic sprain refractory to conservative treatment . syndesmotic injury with associated fracture that remains unstable after fixation of fracture . Any Opening of the Tibio-Talar Medial Clear Space

• Surgical options: Syndesmosis Fixation • Suture button (Tight Rope) • Suture button and screw • Screw(s) one or two

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13 days post-op

Hardware Removal: • Screws 65% • Tight Rope 25% • Accept Broken Screws

Outcomes After Syndesmosis Injury Stabilization Repair What influences results long term ? • Do not miss diagnosis, much easier to treat acute than chronic injury • Surgical Stabilization is essential for complete disruptions • May occur with a fracture or “Just a Sprain” (Must distinguish from routine ankle sprain) • Dynamic “stress” testing often necessary for the diagnosis, physical exam is key • Multiple options for stabilization RTP: High Ankle Sprain with Surgery- 4-12 weeks; with Fracture 4 - 6 months

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Traumatic Unilateral Anterior Dislocation with Bankart Lesion requiring Surgery • Anatomy of glenohumeral joint • Glenohumeral joint stability relies entirely on soft-tissue balance • Glenoid labrum deepens socket • Ligamentous structures and muscle forces • Shoulder Exam • Apprehension, relocation test • Provocative testing • Mechanism of Anterior Dislocation . Forceful Abduction and External Rotation . Direct blow to posterior shoulder . Fall onto shoulder or with arm outstretched 43

Signs, Symptoms and Severity . Signs / Symptoms . Pain . Loss of strength & ROM . “Dead-Arm” Syndrome . Slipping Sensation . Recurrence 80-90% under age of 20 yrs.

. Dislocations / Subluxation . Dislocation: Humeral Head displaced from joint . Subluxation: partially displaced, often transient, slippage

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Imaging . Bankart Lesion: Anterior Glenoid Anterior . Soft tissue-MRI . Bony- Radiographs . Hill-Sachs Lesion: Posterior Humeral Head (black arrow)

Imaging . CT Scan for Glenoid Bone Deficiency . Evaluate Bone loss . Evaluate Hill Sachs Defect . Additional Injury

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Surgical Decision Making . Non-Operative Management: . Age > 30, first time dislocation . Able to do rehab program . No bony deformity . Surgical Reconstruction . Recurrence high <25 yrs. . High Demand Athletes . Soft Tissue Bankart, <10% Bony . Arthroscopic Stabilization . Bony Bankart 10-20% . Open Bankart, Capsular Shift . Bony Bankart >20-25 % . Bristow-Laterjet

Outcomes After Shoulder Dislocation Injury Stabilization Repair What influences results long term ? • Occurs in young athletes most commonly, traumatic • Surgical Stabilization is essential for yonger athletes and elite level athletes • High likelihood of recurrence after first time dislocation <25 years old • Soft tissue repair with Arthroscopic Stabilization repairing the Bankart Lesion (essential lesion) • Secondary bony involvement requires more invasive repairs and transfers (open surgery frequently)

RTP: Shoulder Stabilization: 6-8 months

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Thank You !

Aspetar Orthopaedics and Sports Medicine Hospital