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Management and Myths of
Cartilage InjuryCharles J. Gatt, Jr., MD
Chair, Department of Orthopaedic SurgeryRutgers, Robert Wood Johnson Medical School
New Brunswick, NJ
• I have no disclosures.
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Clinical question
• Do current surgical techniques restore normal articular cartilage and prevent post traumatic arthritis of the knee?
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Healthy Cartilage
Articular Cartilage
Cancellous Bone
Calcified Zone
Subchondral Bone
Tidemark
Hyaline cartilage vs fibrocartilageHyaline cartilage consists of:• Proteoglycan aggregate, Collagen
Types: II, IX, XI• Organized collagen fiber
orientation
• Fibrocartilage consists of:• Proteoglycan, Collagen Type I• Unorganized collagen fiber
orientation
Knee Cartilage Pathologies
• Chondral Defects: Damage to otherwise healthy knee cartilage– Also OCD
• Chondral Degeneration: Wear damage to knee cartilage over time– Idiopathic, e.g. OA– Secondary
Natural History• Chondral injury → Osteoarthritis?
– Lack of sufficient scientific evidence– However, thought to be strongly correlated
• Natural history of asymptomatic lesions unknown– Typically only symptomatic lesions come to medical
attention
• Animal studies– Articular incongruity → Progressive chondral loss– Mimics OA
Incidental finding during meniscectomy
17 y/o soccer player with effusion
Diagnostic arthroscopy
Surgical repair
Microfracture
• Popularized by Steadman in late 1990s
• Perforation of subchondral bone for release of marrow elements and a vascular healing response
• Reserved for smaller, <2-3 cm2, defects in the absence of subchondral bone damage
• Creates a fibrocartilage scar– Less resistance to sheer stress– Less durable than hyaline
cartilage
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Best outcomes
good repair cartilage volume
lower body-mass index
shorter preoperative duration of symptoms
Microfracture§ Microfracture deterioration at 18 – 36 months
ú Blevins et al - Orthopaedics 2008ú Bachmann et al - Radiologe 2004ú Buckwalter - CORR 1999ú Gobbi et al - KSSTA 2005ú Kreuz et al - Arthroscopy 2006ú Kreuz et al - Osteoarthritis Cartilage 2006ú Mithoefer et al - JBJS 2005ú Mithoefer et al - AJSM 2006
DURABILITY???
Autologous Chondrocyte Implantation (ACI)
• Introduced in Sweden in 1987• First reported in 1994• 2-stage procedure
– Patient’s own cartilage harvested– Expanded in vitro– Reimplanted into cartilage defect
• Resurfaces with hyaline-like cartilage
• Can get overgrowth/hypertrophy of the graft– Reoperation rates as high as 50%*
*Gillogy SD, Wheeler KS. Autologous Chondrocyte Implantation with collagen membrane. Sports Med Arthrosc Rev.2015;23:118-124
Restorative Techniques§ ACI
ú 300 – 500 mg of cartilage obtained (biopsy)ú Sent to cell-culture lab
Cartilage minced Serial washes Re-suspended in culture medium Expanded 20 – 50 x original cell count Ready 2 – 3 weeks after biopsy
ú Re-implanted back into patientú Under periosteal flapú 3-8 weeks later
• JBJS 2003• At 5.6 year f/u
– 91 % G-E objective results– 93% G-E results subjectively– Repair tissue quality 11.2 on 12-point scale
• AJSM 2014• RCT (Level 1)• 144 patients (72 each), 95% completed treatment• Cartilage defect >3 cm2 on MFC/LFC/trochlea• MACI had better KOOS pain/function @ 2 yrs
• No major differences between ACI and microfracture• 30 of 80 were treatment failures• 50% of the remaining patients developed at least eary
osteoarthrits• raise serious concerns regarding the efficacy of these
procedures in delaying osteoarthritis and preventing further surgery in this patient group.
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Osteochondral Autograft Transplantation (OAT)
§ Osteochondral Transplantationú OATs or Mosaicplastyú First reported by Judet –
1908ú Transfer of osteochondral
bone plugs “Nonweightbearing” area Transplanted to defect
ú Instant fill with hyaline cartilage
ú Addresses subchondral bone issues
Restorative Techniques
§ JBJS 2003§ Prospective Cohort Study§ 92% good-excellent results at long-term f/u§ Femoral condyle > Plateau > Patellofemoral§ 2nd look arthroscopy
ú Maintenance of transplanted hyaline cartilage
ú Fibrocartilage in interstices
Osteochondral Allograft
• Osteochondral allograft– Requires size-matched donor
• Femoral hemicondyle
– Suitable for large defects– Process similar to OATS (press-
fit bone plug)– Also addresses subchondral
bone pathology– Can correct failed cartilage
restoration attempts
• AJSM 2017 • Systematic review (level 4)• 19 studies, 1036 patients, min 2 yr f/u• 5 year survival 86.7%• 10 year survival 78.6%
• Review of current literature– 80% return to play in professional athletes at 2.5 yrs.
(Krych)– 85% graft survival rate after 10 years– Outcomes positively correlated with young age, post-
traumatic lesions, short duration of symptoms
• Level of evidence - 4
Conclusions• Cartilage injuries are very common• The natural history is incompletely understood• Appropriate patient selection is key• No consensus exists on treatment• Reparative techniques may lack durability• Cell-based techniques show promise• More research is needed
Thank you