OLT IN THE ATHLETE: CURRENT RX CONCEPTSmedia-ns.mghcpd.org.s3.amazonaws.com/sports2018/2018...James AW et al. Stem Cells Transl Med 2012, Pierantozzi et al. Cell Tissue Res 2015 •

EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION

OLT IN THE ATHLETE:CURRENT RX CONCEPTS

Christopher W. DiGiovanni, MD

Assoc. Professor and Vice Chair (Acad Affairs)

Chief, Div. of Foot & Ankle Surgery

Depts. Of Orthopaedic Surgery

Mass General & Newton-Wellesley Hospitals

Harvard Medical School, Boston MA, USA

daVinci


DISCLOSURESIn AAOS & AOFAS database (N/A)◦ BMTI/WMT (2,3b,4,5)◦ Extremity Medical (1,3b,4)◦ Elsevier/Springer/Wolters (7)◦ AOFAS (9)◦ FAI, FAO (8)◦ Paragon 28 (1)◦ CreOsso (1)◦ OssVR (1)◦ Cartiva (3b)

In appreciation:

John Kennedy, MD

Mike Ehrlich, MD


OC Lesions of the Talus (OLT):More Common Than We Thought

27,000 ankle sprains/dayin the U.S. shear

Up to 50%

hyaline cartilage injury!

still our holy grail…

Baumhauer. AJSM. 1995; Junge. AJSM. 2009; Dvorak. BJSM. 2011Bonnaser, Silverberg. J Orthop Res. 2013


Cartilage Doesn’t Heal!

Reparative:

BMS (Microfx, Curettement)

ACI, MACI, AMIC, BMDSCT

Replacement:Autologous Osteochondral Transplantion

Allograft Osteochondral Transfer

Particulate cartilage, Biocartilage ECM

So how do we best Rx these today?

Itali Cohen, Mark Buckley, Lawrence Bonassar, Lena Bartell, Jessie Silver berg,Edward Bonnevie; Cornell University confocal Biomedical Engineering


75 experts, 25 countries

Work Group Questions◦ Literature review◦ Surveys◦ Discussion of Agreement/Recs◦ Final Voting by whole group

Level V Evidence (% Agreement) ◦ 100% = Unanimous◦ 75-99% = Strong Consensus◦ 51-74% = Consensus◦ ≤ 50% = No Consensus


DIAGNOSIS & WORK-UP of OLTDiagnosis: 94%

◦ HX: activity related pain, mech Sx

◦ PE: swelling, TTP

◦ Imaging: XRs WB ankle series

CT (best for dimensions/location)

MRI (sensitive, but overestimates lesion size)

Work-up: 96%◦ Alignment most important

◦ Happening to lesion (cysts, size/site, stability, DJD, edema)

◦ Happening @ lesion (assoc. path per, instab, kiss OLT)

Do diagnostic arthroscopy? 94%◦ Limited value: inaccurate ID size & seldom influences Rx

Elias I, FAI 2007


CONSERVATIVE RXWhen consider? 88%

◦ ASx lesion, very young/old, OA, acute non-displaced OLT

Optimal Rx for acute non-displaced OLT? 81%◦ 4-6 wks immobilization, TDWB, NSAIDS, then advance

◦ Repeat MRI @ 3 mos if no better

◦ No use for bone stim PEMF, even with bone edema

Inject bioproduct (BMAC, PRP, ADSCs…)? 61%◦ Consider cBMA or PRP if no Sx improvement after 4-6 wks

Biophys stim adjunct (electric, LIPUS, etc)? 83%

www.mayoclinic.org

www.healthcare-staffing.com


OPERATIVE RX (GENERAL)Use bioproduct as routine adjunct to cartilage surgery? 45%◦ PRP, cBMA, ADSC

Any optimal bioproduct, cell source/concentrate for OLT? 98%◦ Currently, NO

Risks to discuss prior to bioproduct use? 98%◦ Donor site pain, direct patient cost, hyper-inflamm response

Should we use cellular or acellular cartilage products? 95%◦ Not enough data to differentiate

Stem Cells

ScaffoldGrowth Factors

Kishk NA Cell Transplant 2015, Barry F et al Stem Cell Trans 2014, Caplan Al, J Pathology 2009


+ cBMA: marginal evidence for improved MRI, histo, scores in OLT

Fortier et al, JBJS Am 2010

• Equine model: Microfx + BMAC vs. Microfx

Saw et al, Arthroscopy 2009

• Goat model: MicroFx vs. MicroFx + HA vs.

MicroFx + BMAC + HA

Saw et al, Arthroscopy 2014

• RCT 50 pts FU 2yrs: Microfx + BMAC + HA

vs HA

Kim et al, AJSM 2013

• Microfx vs. Microfx + BMAC

Hannon, Kennedy et al, Arthroscopy 2016Second Look

Arthroscopy - Control

Second Look

Arthroscopy – MSC

group


+ PRP: also “promise” but limited evidence for OLT

PRP MSc PDGFSmyth, Fortier, et al, Arthroscopy 2013

• Microfluidic device: PRP = anti-inflammatory, chondrogenic, & chemoattractive

Wang-Saegusa. Arch Orthop Trauma Surg. 2011.; Mei-Dan. AJSM. 2012.; Guney et al.

KSSTA. 2013 , Görmeli et. FAI 2015

JBJS 2017: 105 studies PRP prep protocols

highly inconsistent


Adipose-Derived Stem cells (ADSCs) in Cartilage Repair ?

Adipose pericytes (perivascular MSCs)

James AW et al. Stem Cells Transl Med 2012, Pierantozzi et al. Cell Tissue Res 2015

• Hurley et al, Syst Rev, KSSTA in press 2018

“Variability in type and use…have confounded any potential benefit of ADSCs on cartilage repair in clinical studies”


“Microfracture +” to improve Rx of OLT?

BioCartilage® (Arthrex)◦ EMCA (Extracellular matrix cartilage allograft)

DeNovo® NT (Zimmer Biomet)◦ PCA (Particulate cartilage allograft)

• Karnovsky et al, FAI 2018

• Dexter, Kennedy et al, Syst Rev, AJSM 2017

+/- favorable outcomes; available methodology/evidence = poor


Bone Marrow Stimulation (BMS) for OLT

When consider debridement/curettage (bleed) alone? 80%◦ Acute or partial thickness lesion (ex, pro athlete in season)

When consider BMS (microfx)? 93%◦ Full thickness lesions that have failed conserv Rx

Ideal lesion dimensions for BMS? 94%

◦ < 10 mm diameter (high fail ≥ 15 mm), <100mm2 area, < 5 mm deep

Lesion preparation for BMS: 95%◦ Debride loose cartilage to stable, vertical rim ◦ Stability more important than visual appearance◦ Hole diam ≤ 2mm; depth = bleeding or fat drops; distance = 3-5mm◦ Bone graft if depth > 5mm

A repeat BMS procedure? 86%◦ OK if prior incomplete debridement or improper technique 86%


BMS OUTCOME PREDICTOR: Lesion Size

o Lesion AREA & clinical outcome

Significant correlation 3 studies 107.43± 10.4 mm

No correlation 9 studies 85.52 ± 9.3 mm2

o Lesion DIAMETER & clinical outcome

Significant correlation 3 studies 10.42± 3.2 mm

No correlation 2 studies 8.80 ± 0.0 mm

Traditional < 15 mm, < 150 mm2 unreliable!

f

2009

2017


2nd look MRI, arthroscopy, scores @ 5-8 yrs show BMS deteriorates!Lee, AJSM 2009; Becher, KSSTA 2010,2014; Ferkel, AJSM 2008

The problem: we are collecting poor science in ankle cartilage repair !

AJSM 2013

Arthroscopic appearance,

2 years post

Microfractiure

Acute Lesion


Our current microfx technique also has biolog & mechan concerns…

@ 1 yr, biological & mechanical properties are different than nl hyaline cartilage !

• Breach SC plate fibrin clot recruit MSCs diff’ninto chondrocyte-like cells deposit type II collagen

HOWEVER

Furukawa, JBJS Am 1980; Shapiro, JBJS Am 1993; Michell, JBJS Am 1976; Duncan H, et al, JBJS 1987; Pugh et al, JBJS 1974


Our drilling/awls incur biology…but at what

mechanical cost?

• Reilingh et al, KSSTA 2016; Dexter et al, Cartilage 2017 Syst Rev

• BMS techniques permanent abnl of SC 100% cases

• Gianakos et al, Arthroscopy 2016; Orth et al, AJSM 2016 Micro CT

• 1 mm awl best matched nl trabecular channels; less fxs/sclerosis; ↑ cartilage repair most effectively

1 mm awl 1 mm k-wire 2 mm awl


FIXATION RX TECHNIQUES

When consider fixation for Rx? 90%◦ If frag >10 mm diam and bone ≥ 3 mm thick◦ If fixable, fix ASAP◦ Fixing pure cartilage defect rarely works

An ideal fixation technique? 85%◦ Rec 2 point fixation◦ ≥ 1 bioresorb compression screw & 2nd

bioresorb antirot dart/pin◦ Can use 2.0 or 2.4 mm steel screw instead◦ Sealing of defect post-fixation unnecessary


OC AUTOGRAFTWhen consider OCAut? 81%

◦ 1° cystic or revision OLT > 1 cm diam; +/- contained

Technical Factors to consider: 92%◦ Graft must be congruent & perpendicular

◦ Optimal hole depth/graft length = 12-15 mm

◦ Rx “tweener” lesions w/ overlapping grafts

◦ Preferred donor LFC; ≥ 3 grafts may↑site morbidity

◦ Unnecessary to backfill

Osteotomy morbidity? 77%◦ Yes: non/malunion fixation technique critical

◦ Pre drill; use min 3 screws or plate for stability


A word about GRAFT PROUDNESS

Fansa A et al, AJSM 2011

Latt D & Easley M, AJSM 2011

Flushness restores contact pressures (R, 1mm↓ - 0.4mm↑)

1 mm proud graft = contact pressure ↑ to 675% !


OCAutl Basic Surgical Technique

Video Courtesy J Kennedy, MD, FRCS


General OUTCOMES

OCAuto similar to BMS…”gold standard”?

General: most with < 100 pts & @ 2 yr f/u…but results are G E (varied outcomes)

Scranton et al, JBJS Br 2006; Hangody et al, AJSM 2010; Kennedy et al, Cartilage 2011; Flynn et al, FAI 2016

Elite Athletes: 2/3 return to sport, avg time 23 wks (R15-52)

Paul et al, AJSM 2012; Hangody et al, AJSM 2010; Fraser et al, KSSTA 2016

Predictors: BMI, lesion size, prior microfxHaleem A et al, AJSM 2013, Ross AW, Arthroscopy 2016


• Post-op cyst formation @ 2/3 of cases at 1 yr– Ensure press fit, avoid drill heat, ?add biologic

Valderrabano et al, Arthroscopy 2009; Elliot et al, Arthroscopy 2016

Shimozono Y et al, submitted to Arthroscopy 2018

• 0-15% knee donor site morbidity (knee)– Rehab/ROM early, avoid tight capsular closure

– ? from hemarthrosis unclear if backfill helpsPaul, AJSM. 2012; Hangody, AJSM 2011; Mithoeffer, AJSM 2009; Murawski, Cartilage 2011; Fraser, AAOS 2015; Shimozono Y et al Syst Rev (in progress)

• MM osteotomy mal/nonunion– Rate high with only 2 lag screws

• Bull PE, FAI 2016; Lamb J, Kennedy JG et al. KSSTA 2013

• Ankle/knee cartilage not the same– Δ shear moduli, coefficient of friction, energy dissipation

• Henak CR et al, J Biomech 2016; Henak & Kennedy, JOR 2015

OCAuto CONCERNS


Gianakos et al, FAI 2015

◦ Anterolateral Chevron osteotomy

ALTERNATIVE (Lateral) OSTEOTOMIES


OC ALLOGRAFTWhen consider OCAllo instead? 85%

◦ Bulk graft for uncontained/shoulder lesions

◦ Plugs for contained lesions > 1.5 cm diam; knee OA/infection

Where source the plugs? 87%◦ From size/side matched fresh allo talus (best = cartilage anat)

◦ Non-frozen graft < 4 wks old preferred

◦ Insuff evidence to rec +/- HLA x-matching/T cell antigen resp

Best technique for talar dome bulk graft? 95%◦ Anterior approach in majority

◦ Excise lesion to healthy bleeding bone bed, but no more

◦ Bulk graft min bone depth = 10 mm

◦ Optimal fixation= headless compression screws


OCAllo TIPS

Surgical technique same as OCAuto

? Add BMAC

Outcomes ≈ OCAuto◦ with perhaps ↑ rate of nonunion, cysts, resorption

Ahmad J et al, FAI 2016;Elrashidy et al, JBJS 2011; Shimozono Y et al, JBJS in Submission 2018

Autograft Allograft P value

FAOS 81.9 70.1 0.006*

SF-12 74.7 66.1 0.021*

MOCART 87.1 75.5 0.005*

Pts w/ Cysts 43.5% 66.7% 0.162

Cyst location

Graft 7.7% 47.4% 0.017*

Inferior 30.8% 10.5% 0.150

Peripheral 61.5% 42.1% 0.280

Failure rate 0% 18.8% 0.025*


SCAFFOLD-BASED THERAPIES (?)

When consider ACI? 80%◦ Lesions > 1 cm2; 1° or revis, +/- contained, +/- cysts

Any optimal scaffold type or harvest location? 95%◦ Not yet…ideally self-adherent (vs fibrin)

◦ No ideal harvest location, but consider talus

When bone graft defect prior to scaffold use? 87%◦ If > 3mm of intra-op bone loss post debridement

◦ Volume needed = scaffold is flush when done

Openi.nlm.nih.gov

Fibrin glue scaffoldRibeiro N, Proc Engineering 2013


ONLY SUBCHONDRAL PATHOLOGYWhen consider retrograde drilling? 90%

◦ On arthroscopy: intact artic roof, isolated SC lesion, +/- cyst

Does BME alone require Rx? 96%◦ Asx or Sx: 4-6 wks NWB, NSAIDs

◦ ? retrograde drill if Sx >3 mos & repeat MRI still (+)

Shimozono Y et al, Subm AJSM 2018: BME prognosticST→ rxn from surg trauma…LT→ rel’d to worse outcome

Grade 0No BME

Grade 1< 25%

Grade 225-50%

Grade 3> 50%



REVISION & SALVAGE RXWhen consider revision? 98%

◦ When failed 1° cartilage proced = Sx source

What guides choice of procedure? 92%◦ Size/progression of lesion, extent of artic path

◦ Mechanical factors (instability, malalignment)

◦ Nature of initial procedure

Contraindications to revision? 99%◦ Extensive DJD or inflamm arthritis, infection, severe stiffness, Sx &

imaging incongruity

Salvage arthrodesis or TAA


REHAB/RETURN TO SPORTHow return pt to ADLs & recreational/elite sports? 92%

◦ Limit shear x 3 mos, then progress to sport-specific rehab/training◦ Return to competition @ 6-12 mos post surgery (individualized)

How predict level of sport return? 86%◦ Still no validated recommendations◦ Emphasize diligent rehab reduces pain/promotes function

Benefit to early vs. delayed WB/ROM post cartilage repair? 94%◦ Early AROM beneficial 1 wk post-op ◦ Early WB beneficial 4 wks post-op, but minimize shear

Any clinical criteria to clear athlete for return to play? 88%◦ Pain, swelling, strength◦ Lack of negative effects with impact loading◦ Physical function testing against contralateral limb◦ Sport specific tasks at 100% in an unopposed setting◦ NOTE that unnecessary to use imaging in this decision process


POST-Rx F/U & OUTCOME SCORESHow define Rx success? 91%◦ Return to ADLs/work/sports at pre-injury level, pre-post

Rx PRO improvement

Which aspects of the PE help define this? 98%◦ Painless FWB, restored FROM, lack of effusion/TTP

Does imaging help define this? 93%◦ XR: healed osteotomy/graft, jt/graft congruent◦ MRI: graft integrated, no cysts/BME, cartilage OK

For how long after cartilage repair can one expect post-op SC BME on imaging? 91%◦ In aSx pts, may be seen up to 2 yrs post Rx


CONCLUSIONSBMS

◦ ? Gold standard for small 1° lesions, but perhaps smaller (10mm) than historic benchmark (15mm); use 1 mm awls

◦ Alters microarchitecture of SCBP and deteriorates over time; must optimize BMS technique to ↓ SCB damage & ↑ outcomes

OCAuto

◦ Ideal for large 1° lesions > 10.4mm, 107.4mm2 …and revisions

◦ G to E mid-term outcomes; can be affected by prior BMS case

◦ Beware donor site & osteotomy morbidity (low)

OCAllo

◦ Have reasonable clinical outcomes but higher failure rates

◦ No donor site morbidity…but ? immunorejection

Minimal evidence for DeNovo, BioCartilage, ADSC formulations

•Mounting but marginal evidence for PRP & cBMA augmentation

•Need to improve LOE & QOE in ankle cartilage research!


THANK YOU

“The human foot is a masterpiece of engineering…and a work of art.”Leonardo da Vinci, The Notebooks (c. 1508-1518)

Documents

OLT IN THE ATHLETE: CURRENT RX CONCEPTSmedia-ns.mghcpd.org.s3.amazonaws.com/sports2018/2018...James AW et al. Stem Cells Transl Med 2012, Pierantozzi et al. Cell Tissue Res 2015 •