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Chicago – USA May 8 – 11, 2015 12 Th World Congress of the International Cartilage Repair Society

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Chicago – USA May 8 – 11, 2015 12 Th World Congress of the International Cartilage Repair Society 2 015 #ICRS15 Chicago – USA May 8 – 11, 2015 12 th World Congress of the International Cartilage Repair Society Main Programme & Extended Abstracts www.cartilage.org 21 AMA PRA Categorie 1 Credits Diamond Partner Platinum Sponsor Gold Sponsor Silver Sponsors 1 Invited Abstracts 1.1.2 in preshaped plugs 10 lengths in diameters of 7, 9, 11 and 15mm. Chondrofix® Osteochondral Allograft does not have the issue of a Allografts & Autogenous OsteoChondral Technologies waiting time as it is truly off-the-shelf. Chondrofix® is donated hu- J. Farr man tissue that is decellularized; that is, the hyaline cartilage and Greenwood/United States of America cancellous bone are delivered acellular but have mechanical proper- ties that are similar to unprocessed osteochondral tissue. The graft Introduction: Osteochondral grafts have been an important part undergoes a proprietary processing protocol, which includes lipid of the clinician’s armamentarium when treating cartilage lesion for removal, viral inactivation with methylene blue photoactivation and many years. The current issues are: identifying the best applications, terminal sterilization with low temperature low dose gamma irradia- refining the technique and optimizing the use of these tissues. While tion. Chondrofix® is currently available and being actively implanted the algorithm for cartilage restoration will continue to evolve, there in the US, noting there are no published clinical studies on this will remain overlap of the available applications with autograft and unique allograft application. Another acellular approach is frozen allograft continuing to play substantial roles. The amount of availa- osteochondral allograft. The cartilage chondrocytes are not reliably ble tissue for both autograft and allograft is limited, so creative solu- viable upon thawing and thus the matrix is not well-maintained over tions for optimizing tissue use are essential. The specific techniques time. After initial acceptable results, with longer term follow up the of harvest and insertion are increasingly refined. Thus, even these cartilage deteriorates to a variable degree as reported clinically and longstanding cartilage restoration techniques continue to evolve. confirmed most recently by Pallante et al using a goat model in 2012 (2). In an attempt to improve chondrocyte viability, cryopreservation Content: The optimal application for autograft has changed over the was tried in the past by CryoLife®, Inc. (Atlanta GA) as reported by years. Initially, the autograft option was popularized as osteochon- Davidson who was the lead investigator for the 2006 Multi-Center dral autograft transfer system by Bobic and Morgan and mosaicplas- Evaluation of Clinical and Radiographic Outcomes of Distal Femoral ty by Hangody. The orthopedic industry continues to offer instru- Resurfacing with Cryopreserved Osteoarticular Allografts. That stu- mentation to accomplish variations on a theme: OATS® osteochondral dy was subsequently cancelled without published reports. Continu- autograft transfer system (Arthrex, Naples FL) COR® chondral osse- ing the search for viable cryopreseved cartilage, Cartiform® (Osiris ous replacement (DePuySynthesMitek Sports Medicine Raynham, Therapeutics, Inc., Columbia, Maryland distributed by Arthrex, Nap- MA) Mosaicplasty® (Smith & Nephew plc London UK) Diamond les FL) has developed a new iteration of cryopreserved allograft car- TwInS® (Karl Storz GmbH & Co Tuttlingen, Germany) While the exqui- tilage. The cartilage is first prepared to approximately a 1.5 mm site technical prowess of Hangody demonstrated that the harvest thickness and is perforated, which may further aid in the cryopreser- and implantation of many small plugs was possible in the hands of vation process. The freezing sequences and the cryopreservatives some, when other techniques are readily available, most surgeons are unique and allow approximately a 70% survival of chondroctyes now limit the use of OC autograft plugs to treat lesions less than upon thawing. It has a shelf life of two years when stored between 2-2.5 cm² recognizing the potential morbity of the harvest site and –75° C and –85° C and thus is an “off the shelf (freezer) product. the technical difficulty of multiple plug insertions. The most common Additionally, the perforations (pores) allow outflow of cytokines and applications would be 1 or 2 plugs 6-10 mm in diameter. Laboratory potentially chondrocytes, both of which may influence local pluripo- studies have demonstrated the importance of avoiding a proud graft tential cells noting that in current clinical applications, approximate- that overloads the opposing joint surface or subsided grafts that do ly 50% of defects, Cartiform® is used in conjunction with marrow not functionally participate in load sharing with the lesion shoul- stimulation. One published report of a patient at 9 months post ope- ders. Likewise, clinical observations of chondral delamination or de- ratively demonstrated good histology, clinical and MRI findings, gradation correlate with the laboratory studies showing chondro- which supports an earlier proprietary animal study (3). Cartilage Au- cyte death with moderate to high force impactions. The historical tograft Implant Sytem (CAIS, DePuy Synthes, Mitek) completed a harvest site was the lateral margin of the distal trochlea, which was successful pilot study and was reported by Cole, Farr et al in AJSM favored over intercondylar notch in light of the the smaller radius of 2011 (4). However, in light of pivotal trial slow enrollment, return on curvature at the notch. As stress studies have shown lower loads on investment considerations lead to the pivotal trial being stopped wi- the medial distal trochlea that region would be especially useful in thout plans to revive it. Fortunately, Danish researchers (personal patients with some degree of lateral facet patellar discomfort or if communication, Capser Foldager) have pursued the concept and will the lesion was on the medial femoral condyle. For allograft, the size be reporting their results in the minipig animal model as well as ear- is obviously not limited physically. Nevertheless, Bugbee has shown ly human trial data later this year. The concept continues to have the that the more graft material implanted, the more likely the patient promise of a cost efficient single stage cartilage treatment. Extrapo- will become antibody positive and that antibody positive patients lating from the success of the CAIS pilot study, Yao proposed a simi- have a higher probability of failure than antibody negative patients lar approach to juvenile cartilage (more cellular and metabolically (1). Related to this observation, is the trend to use less and less bone active that adult cartilage). Initial animal work demonstrated the on the OC constructs—both to lessen the bone marrow “load”, potential success of implanting particulated juvenile allograft carti- which is thought to contain the immunologically reactive componen- lage (PJAC) into defects. Applied in human cartilage lesions, fill was ts of the grafts and also to speed creeping substation as historically demonstrated per MRI by Bonner in a single patellar case and subse- bone collapse was the most common historical cause of OCA graft quently Farr et al in a multicenter case series with minimal 2 year failure (with thick bone). There are two main subcategories of OCA follow up (5-6). Over 10,000 implants have been performed since grafting: plug and shell. For plugs, each tissue bank who supplies introduction in 2007, but no randomized controlled trials are under- the graft also supplies a system to create a socket and form the plug. way or planned. While autograft and allograft may seem like mature The key in socket creation is to insert a guide pin perpendicular to restorative options, it is obvious that continued improvements are the local tangent of the defect with the goal to ream to a depth of underway. approximately 6 mm achieving similar wall depths north/south/east and west. If the bone is suboptimal/necrotic then that bone is remo- ved and replaced with impacted cancellous autograft. A dilator is References: useful to expand the socket just before insertion to assure seating of the plug without impaction. Interference fit is usually adequate, but 1. Bugbee W, Cavallo M, Giannini S. Osteochondral allograft in marginal or uncontained lesions may supplement the stability. For transplantation in the knee. J Knee Surg. 2012; 25(2):109-16 very large lesions of the patellar or trochlea, as well as very posterior condylar lesions, a shell graft may be used. The cuts are similar to 2. Pallante AL, Gortz S, Chen AC, Healey RM, Chase DC, Ball ST, Amiel unicondylar arthroplasty cuts and countersunk antegrade absorba- D, Sah RL, Bugbee WD. Treatment of articular cartilage defects in ble or metal retrograde screw fixation is necessary. While the use of the goat with frozen versus fresh osteochondral allografts: effects allograft is quite flexible, the amount of tissue is finite—and waiting on cartilage stiffness, zonal composition, and structure at 6 months. times for tissue can be lengthy. Thus, the search continues for ways J Bone Joint Surg Am. 2012;94(21):1984-95. to expand the number of grafts that can be obtained from a single donor and decrease the wait times. Four options are available as of 3. Hoffman JK, Geraghty S, Protzman NM. Articular cartilage repair this abstract: custom preshaped fresh stored, decellularized, frozen using marrow stimulation augmented with a viable chondral
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