10/01/2015 IASM Mumbai

Current Management Strategy for chondral injuries in athletes:

Square Pegs in Round Holes!

Dr Vaibhav Bagaria MBBS MS Dip SICOT CARE hospital & ORIGYN Clinic Nagpur, India

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Ideal Cartilage restoration

✤ “Chasing the Holy Grail”

✤ Can we recreate what God created?

✤ ‘Dil Mange more’

✤ Question: Are we trying square pegs in round holes?

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So...the ideal!!!

✤ Recreate Hyaline cartilage

✤ Reproduces zonal architecture

✤ Integrates with surrounding tissue

✤ Durable

✤ Cost Effective

✤ Single stage

✤ Minimally Invasivedrbagaria.com

Structure of Cartilage

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Assessment - Clinical

✤ Knee Osteoarthritis& Outcome score (KOOS)

✤ IKDC

✤ Lysholm: too general & non specific

✤ Others: SF 36, Cincinatti rating, ICRS

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Assessment - Radio

✤ MRI ( Gad enhanced)

✤ MOCART Scores: 9 Parameters - Quantity, Integration, Surface, Structure, Signal intensity, Integrity of subchondral lamina

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Assessment - Arthroscopic

✤ Histological:

✤ Hyaline like

✤ Mixed Hyaline- Fibrocartilage

✤ Fibro-cartilage

✤ Fibrous tissue

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ICRS

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Strategies

✤ Palliative

✤ Reparative

✤ Regenerative

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Modifier

✤ Anatomy: Size, Location & Depth (FT vs PT)

✤ Pathology: Traumatic vs Others

✤ Epidemiology: Age, Profession

✤ Confounders: Re surgery, Surgeon Skills, Associated lesion

✤ Expectations:

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That’s the concept!

✤ Ensuring the right match is the key!

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Various Strategies

✤ Debridement & Lavage

✤ Abrasion Chondroplasty

✤ Microfracture & Pridie Drilling

✤ Soft tissue - periosteal grafts

✤ Osteochondral transfer

✤ ACI - Various Generations

✤ Newer Techniquesdrbagaria.com

Debridement & Lavage

✤ Chondral Lesions less than 2 Sq cm

✤ Remove Loose cartilage fragments & washout

✤ Good for low demand, older age pt who may not tolerate prolonged immobility

✤ Considered palliative, yet quick recovery with QOL improvement and fast mobility.

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Microfractures

✤ Less than 2 - 3 sq cm lesions

✤ Reparative strategy

✤ Drilling holes 0.5 -1mm dia thro articular cartilage into bone marrow cavity

✤ Allows access to bone marrow progenitor cells

✤ CPM with ltd activity required postop for healing

✤ Hyaline like cartilage that deteriorate over time.

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Microfractures

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Microfracture

Abrasion Chondroplasty

✤ Abrading subchondral bone superficially

✤ Intraosseous space opens up with vessels n mesenchyme

✤ Stimulates reparative process.

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Abrasion Chondroplasty

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Osteochondral Transplantation

✤ Could be Allo or auto

✤ Commomest auto: Mosaicplaty ( S & N); OATS ( Arthrex)

✤ Good for Intermediate defects upto 5 sq cm

✤ Viability of harvested graft is the question

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Technique

✤ Harvesting from NWB areas

✤ Cylindrical osteochondral grafts

✤ Transferred to WB area

✤ 2-5 sq cm

✤ Non degenerate knees only

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OATS/Mosaicplasty

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OATS/Mosaicplasty

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Regeneration Strategy Triad

✤ Cells are required for de novo synthesis

✤ Scaffold provide the template to lay down the matrix

✤ Biological signalling molecule required to stimulate cell requirement, migration, differentiation as well as synthesis

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Trilogy of Biology

✤ The Cells

✤ The Matrix

✤ The growth Factors

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ACI - First Gen

✤ Cells isolated from NWB area

✤ Expanded in vito and transplanted to a defect

✤ Covered with periosteal flap

✤ Main drawback: two staged, time interval

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ACI - Gen 1

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ACI - Gen 2

✤ Drawback of Gen 1: graft delamination, ectopic calcification, graft hypertrophy - mech symptoms “catching”

✤ 2nd gen - combines scaffold and cultured cells

✤ Scaffold provides structure for chondrocyte adhesion, expansion while maintaining the chondrocyte phenotype.

✤ Can be used to treat relatively large chondral defecrs

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ACI Gen 2✤ MACI - Porcine collagen I/ III matrix

✤ Hyalograft C- Hyaluronic acid scaffold

✤ Bioseed C - Polyglactin/poly - p - dioxan

✤ CaRes - 3D type 1 Collage

✤ Cartipatch hydrogel composed of alginate and agarose (inserted in mosaic fashion

✤ Novocart 3D – collagen-based biphasic scaffold (specific protective layer, collagen sponge)

BioCart IIBioCart II – freeze-dried homologous human fibrinogen and recombinant hyaluran – freeze-dried homologous human fibrinogen and recombinant hyalurandrbagaria.com

ACI 2

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MACI

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ACI - 3rd gen

✤ Avoid morbidity of auto harvest cartilage

✤ Uses allogenic or autogenic tissue

✤ Denovo ET: Allogenic fetal chondrocyte

✤ Cartistem: Umbilical Cord derived

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Various sources of MSC

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ACI - gen 3

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Bio-printing: RPBio-printing: RP

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Bio Printing

✤ 3D Printing: Layered approach instead of suspension

✤ Create 3D multi-materials that mimic geometry of living tissue

✤ www.3dpost.in

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Take home...

✤ Various strategies

✤ Numerous choices - superiority of one over another not established

✤ Customised Solution to your athletes

✤ Personal Choice: KISS: less than 2 sq cm: Micro fracture More than 2 sq cm: Offer 2nd gen ACI/ single stage BMAC repair

✤ Keep an eye for things on horizon

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