Greetings From SCOI

Richard D. Ferkel, M.D

OLT In the Athlete Operative Treatment and Return to Play

The Following relationships exist:

Royalties and stock options – Smith and

Nephew

Consulting income – Smith and Nephew,

Geistlich, Sanofi

Research and educational support – Ossur,

Mitek, Don Joy, Smith & Nephew

Arthroscopic Treatment

Thigh and Ankle

Support – Supine

Ankle Distractor

2.7 mm Short

Scope with

Interchangeable

Cannulae

Use AM, AL, PL,

TT,TM Portals,

“Lift Lesion”Lateral Inverted Osteochondral

Fracture of the Talus

Dunlap & Ferkel (2013)

10 Pts with Acute Injury

All Lesions Involved

Lateral Talus with

Lateral Ligament Injury

8 Lesions Were

Reattached and 2 Were

Excised

Arthroscopy 29: 1826, 2013

15 year old basketball player

Operative Procedure

Absorbable Pins

Made of

Polydioxanon

Takes 6 Months to

Absorb

Can Be Used Via

Arthroscope or

Open

Mean Age = 17 Yrs

Mean F/U 9.3 Yrs

AOFAS Score 19 → 87

Final Weber Score = 82

Berndt & Harty; E-G = 6,

Fair = 3, Poor = 1

Operative Procedure And Results

Arthroscopy 29: 1826, 2013

CHRONICOSTEOCHONDRAL

LESIONSOF THE TALUS

CHRONICOSTEOCHONDRAL

LESIONSOF THE TALUS

Indications for Surgery

All CT or MRI Stage

1 & 2 Lesions That

Fail Nonsurgical Rx

All CT or MRI Stage

3 Lesions in

Children Under 18

that Fail

Nonsurgical Rx

All CT or MRI Stage

3 Lesions in Adults

& Children

All CT or MRI Stage

4 Lesions in Adults

& Children

Chronic OLT in ChildrenTreat in Cast or Boot for 6 Weeks

Physical Therapy

Treat Conservatively

Transtalar Drilling Without or With

Bone Graft to Maintain Integrity of

Articular Cartilage

Bone Graft & Reattach Loose

Chronic Lesions if Possible

Excision, MicroFx Drilling Only If

OLT Nonviable

Treatment Options for Cartilage Defects

< 1 cm2

Debridement

Drilling

MicroFracture

2.5 - 4 cm2

Drilling

Osteochondral

Transplants

ACI

Allografts

Juvenile

Allografts

Micronized

Cartilage Matrix

1 - 2.5 cm2

Debridement

Drilling

MicroFracture

Osteochondral

Transplants

ACI

Allografts

Juvenile

Allografts

Micronized

Cartilage Matrix

Factors Influencing Choice of OLT Surgical Procedure

Size of Lesion

Location of Lesion

Containment of OLT

Subchondral Cyst

Status of Cartilage Cap

Associated Pathology

Patient Preference

Identify Lesion

CT or MRI

Verify that Lesion

is Source of Pain

Appropriate

Conservative

Treatment

T-M or T-T Drill if

Not Loose

Chronic OLT In Adults

Pin If Loose and

Articular Cartilage

Healthy

Excise if Loose or

Displaced, Then

Drill/Microfracture

Base

Bone Graft Cyst if

Large Via T-T or T-M

Excision of P-M OLT

Scope Thru P-L Portal

Inflow Thru A-L Portal

Instruments Through A-M

Portal Via Notch of Harty

P-L View

Microfracture

Place Holes 3-4 mm

Apart and 4 mm

Deep

Avoid Collapsing

Subchondral Plate

Can Be Combined

with DrillingJ.J.

Use:

Accessory to (Curved)

Microfracture Picks

Allows Surgeon to Use

Mallet and Drive Tip of

the Pick In the Intended

Direction (Striking Plate

on Handle)

Hard Bone

Minimize Skiving,

Damage to Opposite Side

Cartilage

Pick Assist

MicroFx/Drilling – How Deep is Enough?

Steadman, R. et al. – Do 3-4mm Deep

Chen, H. et al. – Drilling 6mm Depth Produced Better

Fill and Quality of Cartilage Than 2mm Depth

MicroFx Results Similar to Drilling at 2mm Depth

At This Time, It is Not Clear Which Technique Gives a

Better Cartilage Healing Response

J Orthop Res. 29:1178 2011

Drilling Options

P-L View

“Crimson Duvet” Leads To Fibrocartilage

Microfracture Augmentation Strategies

Scaffold Augmentation

Scaffold and Chondrocyte

Augmentation

Hyaluronic Acid Augment.

Growth Factor Augment.

Regenokine Modulation

Bone Marrow Aspirate

Platelet Rich Plasma

Results – Ferkel et al (2008)

50 Pts. With OLT Treated Arthroscop.

Mean Age = 32 Yrs.

Mean F/U = 71 mos.

Excellent – Good 72%, Fair 20%, Poor 8%

Sig. Correlation B/N Arthroscop. Stage and

Result

17 Pts Previously Evaluated 5 Years Ago;

35% of Their Results Deteriorated One

Grade AJSM 36: 1750, 2008

OLT With PRP or HAMei-Dan et al (2012) Compared Use of PRP or

Hyaluronic Acid to Treat OLT

Group I = HA – 15 Pts.

Group 2 = PRP-14 Pts (15 OLTs)

Men = 79% of Pts; F/U = 28 Weeks

AOFAS: Group 1 = 66 78, Group 2 = 68 92

Subjective Global Function Group I = 56 73,

Group II = 58 91

PRP + HA Rx Pain Scores Function

PRP Signif. Better Outcome Than HA

AJSM 40:534 , 2012

OLT – Is There A Critical Defect Size?

Choi et al – 120 Ankles with

OLT Had Micro Fx; 26 Pts

Ankle Lat. Lig. Stab.

Clinical Failure =

Osteochondral Transplantation

or AOFAS Ankle – Hindfoot

Score <80

6.7% - Osteo Transplantation

18.4% - AOFAS Score <80

Failure – Related to Defect Size

10.5% - Defect Area < 150 mm2

80% - Defect Area > 150 mm2

Size Calculated by MRI AJSM 37:1974, 2009

Containment of OLTChoi, et al. – Looked at

Prognostic Significance of

Containment (Shoulder vs

Non Shoulder) and Location

of OLT

Pts With Shoulder – Type

OLT Had Signif. Worse

Clinical Outcome Than Non

Shoulder Type

No Signif. Difference

Between Medial and Lateral

OLT in Either Group

AJSM 41: 126, 2013

Indications For Cartilage Replacement

Failure of Previous

Surgery With MSTs

OLT > 1.5 mm2

OLT That is Uncontained

OLT With Large

Underlying Cyst

Newer Treatment Options-2014

Osteochondral Grafts (Au/AI)

Autol. Chondrocyte Implantation

Juvenile Articular Cartilage Allograft

Micronized Cartilage Matrix

Focal Resurfacing Implant

Osteochondral Progenitor Cell

Transplantation

Others

OATS - TalusArthroscopy if

Necessary

Osteotomy or Release

ATFL Laterally

Core-Out or Drill

Lesion to at Least

10mm Depth

Compact Base and

Measure Depth

OATS – TalusInsert Donor Graft

OATS - Talus

Scranton et al (2005) – 50 Cases

Two-Six Yr Follow up; 64% had Failed

One or More Surgeries Prior to

grafting

90% Excellent – Good Results

Concerns About: Cartilage Damage,

Graft Fragmentation, Graft Position &

Knee Pain

Allograft - Talus

Reduce Donor Site

Morbidity

Match Contour and

Cartilage Morphology

Conventional OATS

Or Box-Cut Technique

Allograft – TalusKelikian, et al

Fresh Allografts Inserted

38 Pts: 22 Male, 16 Female

Mean Age = 44 Years (19-74)

Mean Size of Lesion = 1.5cm2

Mean F/U = 38 Mos. (6-62)

Graft Survival = 89%

AOFAS Score 52 → 79 JBJS 93:1634, 2011

Indications for ACI in the Ankle

Patients Aged 15 – 55

Focal Defect > 2 cm2

Unipolar (Only Talus)

Contained

Edge Loading

Failed Previous Surgery

Large Lesions with Subchondral

Cystic Changes in Primary Cases

ACI - Osteotomy

Correct Malleolar Osteotomy

Allows for Exposure of Entire

OLT

Place Guide Pin Over Bone at

Osteotomy Site and Mark with

Methylene Blue

Start Cut With Saw; Finish

With Osteotome While

Protecting Articular Cartilage

Bio-Gide Collagen MembraneType I/III Bilayer

Porcine Collagen

Membrane

Gomoll et al. Compared

Subsequent Surgeries

After ACI-P & ACI-C

(Bio-Gide) in Knee

Results Similar Except

Hypertrophy Related

Surgery

ACI –P = 52%

ACI-C = 3.4%ICRS, May 2009

ACI Membrane Implantation

Membrane is Implanted

and Secured With 6-0

Vicryl to OLT Bed

Fibrin Glue is Used to

Seal the Membrane

“Water Tight” Except a

Hole is Left for Cell

Insertion

ACI Cell Implantation

Insert Catheter

Through Opening in

Membrane

Slowly Inject Cells

Suture Remaining Hole

in Membrane

Seal Hole With Fibrin

Glue

ACI “Sandwich” Bone Grafting

CYST

ACI Results - Ferkel (2014)32 Patients Total

Male = 16; Female = 16

Medial = 24; Lateral = 8

32/32 = Previous Surgery

Current Study: F/U 29/32 = 91%

Ave. Age = 34 (18-54)

Ave. F/U = 70 Mos (24-129)

“Sandwich” Procedures = 9

2nd Look = 90% (26/29)

Excell. = 8, Good = 15, Fair = 5

Poor = 1 AJSM, 2014

Arthroscopic 2nd Looks

Grade I Soft & Ballotable

II Medium Firm

III Firm

Firmness of Articular Cartilage

Increased with Longer-Up

9 Months MC

SC

48 Months

17 Months

AK

Scaffold Materials For The Repair of Chondral and Osteochondral Defects in 2014

Calcium phosphates (CaP)

Hydroxyapatite (HAp)

Biological polymers

Collagen

Fibrin

Alginates

Hyluronan (HyA)

Chitosan

Collagen/glycosaminoglycan (GA)

Synthetic polymers

Polylactic acid (PLA)

Polyglycolic acid (PGA)

Polycaprolactone (PCL)

Other

Demineralized bone matrix

Devitalised cartilage

Periosteum

Bioactive glass

ACI Comparative StudyGiannini et al

3 Pt. Groups: Open ACI, Scope ACI, BMAC

81 Pts; Mean Age = 30 Yrs

Mean F/U = 60 Months

Mean Overall AOFAS Score:

Pre op = 57

Post op = 93

Injury, 2012

ACI Comparative StudyGiannini et al

Pre op 38 57 65

12 Months 89 87 89

36 Months 94 89 93

MRI Complete Integration in 76%

Histology – All 3 Groups Hyaline-Like

Cartilage

Open ACI-10 Scope ACI - 46 BMAC - 25

Injury, 2010

AOFAS SCORES

Particulated Juvenile Cartilage

Juvenile Cartilage Allograft

Tissue (Donors < 13 yrs Old)

Juvenile NT Graft Consists of

Scaffold-Free Living Articular

Cartilage, Displaying

Biochemical Properties

Similar to Those of Articular

Cartilage Found in Young,

Healthy Joints.Adult

400xJuvenile

400x

DeNovo NT Graft

Particulated Juvenile Cartilage Technique

Bone Graft Cystic

Lesion and Cover

With Fibrin Glue

Place Fibrin Glue

Over Osteochondral

Defect (If No Bone

Graft)

Particulated Juvenile CartilageTechnique

Juvenile NT

Allograft is Placed

Into the Defect

and Impacted With

a Freer Elevator

P-L View Lt Ankle

Place Another Layer

of Fibrin Glue Over

Graft

Wait 5 Mins

Check ROM to

Ensure That There is

No Instability of

Fragments

Particulated Juvenile Cartilage

P-L View Lt Ankle

Particulated Juvenile Cartilage

Coetzee et al (2013) Multicenter Study

Involving 24 Ankles

Ave Age = 35 Yrs; Ave. F/U = 16 Mos

14 Pts Failed At Least One Prior BMS

Ave Size = 125 mm2, Ave Depth = 7 mm

FAI 34:1205, 2013

Particulated Juvenile Cartilage

Results: AOFAS = 85 (78% G-E)

SF12 Physical Compos. = 46

SF 12 Mental Health = 55

FAAM AODL = 82

FAAM Sports = 63

100-mm Visual Analog Pain = 24

92% E-G Results With Lesions Smaller

Than 15mmFAI 34:1205, 2013

Bone Marrow

Stimulation

Ferkel 100%

Back to Sports

Ave F/U 6 Yrs.

Shuman 45%

Limited or No

Play

Ave F/U 5 Yrs

Van Bergen 88%

Resume Sports

Ave F/U 12 Yrs

OATS Scranton Pain

With Sports

Ave F/U 3 Yrs

Paul Returned

But Mostly

Modified Activity

Ave F/U 5 Yrs.

Hangody Long

Term 93% E-G,

No Sports

Results

ACI Baums All Back

to Sports If Done

Pre Op

Ave F/U 5 Yrs

Giannini 86%

Return to Sports

With Hyalgraft

Ave F/U 3 Yrs

Ferkel

Tegner 1.6 → 4.3

Ave F/U 6 Yrs

Particulated

Juvenile Cartilage

Coetzee FAAM -

Sports = 63

Ave F/U 16 mos

*Osteochondral

Allografts – No

Data

Return to Sports

OLT Ankle - Summary

Newer Technology Shows

Positive Early Results But

More Cases With Longer F/U

Needed

Max. Clinical & Histological

Results at 24 mos. Or Longer

Future – Scaffolds, Stems

Cells, Growth Factors, ?

Solution is Within Our Grasp

and Must Be Done

Arthroscopically

Stepwise Evolution of

Concepts and Science

Cartilage

Solution

Cartilage

Loss

T

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K

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