icl: chondral injury of the knee: current controversies in

ICL: Chondral Injury of the Knee: Current Controversies in 2021

Aaron Krych, MDJack Farr, MD

Andreas Gomoll, MD

Paul Caldwell, MD

Rachel Frank, MD

©2017 MFMER | slide-2

Get it Right the First Time!Aaron J. Krych, MD

Mayo Clinic Orthopedic Surgery and Sports Medicine


Standard cartilage imaging: every patient!

• Good set of standard plain radiographs

• Standing AP, PA flexion

• Lateral

• Merchant

• Hip to ankle long-leg standing

• MRI (3T if possible)


What am I looking for on imaging?

• Focal or diffuse process

• Cartilage lesion vs OA

• Background factors

• Why did lesion occur?

• Lesion factors: size, location, acuity, bone involvement

• Surgical planning


What does imaging tell me?








Which patients are candidates for cartilage

restoration?

Focal defects

Diffuse arthritis


44M steamfitter, adventure racing, heli-skiing


2 months post-op2 year post-op


Surgical Treatment Options for the Management of

Symptomatic Focal Cartilage Lesions of the Femur: U.S.

Femoral Condyle

< 2-4 cm2 > 2-4 cm2

Low Demand/

Older

High Demand/

Younger

High or Low Demand

1.Palliative

2. MFX

3. OAT

1. Osteochondral

Autograft

2. Cell Based Repair

1.Osteochondral Allograft

2.Cell Based Repair

Krych in Morrey Joint Replacement Arthroplasty 4th Ed

Correction of Background Factors

Patellofemoralvs


Learning from Failure in Cartilage Repair Surgery:

An Analysis of Failure Mode of the Primary Procedure in Consecutive Cases at a Tertiary Referral Center

• Purpose:

• To determine common failure modes in primary cartilage restoration

• Goal: Improve surgical decision-making and patient outcomes

• Materials & Methods:

• Tertiary care center experience, single surgeon

• All revisions for failed cartilage surgery 2011 – 2017

Krych OJSM 2018


• Study Population:

• 59 procedures in 53 patients

• Lesion Location:

• Medial femoral condyle most common failed location(54% of cases)

• Trochlea least common(15% of cases)

• Primary Procedure:

• Microfracture most commonindex procedure

• Various allograft forms more rare

• Failure Mode:

• Underlying malalignment predominant consensus reason for failure (56%)

Results

Krych OJSM 2018


Valgus Proximal Tibial Osteotomy


Varus Distal Femoral Osteotomy


Be careful of calculation

Same patient

Triple varus gait


Patellofemoral background factors

• Trochlear dysplasia

• Patella alta

• Lateralized tubercle

• Tight lateral retinaculum


19 year old male

• Pain and patella instability

• True J-sign tracking

• Patella cartilage defect


• 10 degrees valgus

• Trochlear dysplasia

• MPFL insufficiency

• Patella alta

• TT-TG 24 mm


First stage


Intra-op J-sign


Second stage: ACI implantation


Second stage


Correction of J-sign 3 months post-op


32M acute LFC lesion

Use axial MRI


MRI: Chondral or osteochondral

OCA

OAT


36F trochlear lesion


Trochlea chondral lesion


Delaminating lesion


Acute vs chronic


MRI: Location

OCA

OAT


Patella chondral defect s/p failed MFX

Inferomedial patellar lesion


What do we expect benchmarks to be?• Improved pain

• Improved function

• Long-term outcomes are durable

• Failures

• Osteoarthritis

• Total knee replacements


What do we expect benchmarks to be?• Improved pain

• Improved function

• Long-term outcomes are durable

• No failures

• No osteoarthritis

• No total knee replacements


Will I have improvement in pain?

Patient

• “I will be pain free”

Clinician

• “We can improve your pain during activities of daily living”


• SUMMIT (MACI vs MFX) 5 year f/u

• 128 of 140 patients included

• Continued superior KOOS pain and function scores for MACI group


• Lose 6.5 points on 9 questions (baseline: 23 points=mod-severe every category)

X 82


Will I have improvement in pain?

Patient

• “I will be pain free”

Clinician

• “We can improve your pain during activities of daily living”


How does my patient compare to literature?


Ideal lesionEarly OA in young patient


Defect 2.8. + 1.4 cm2

Mean 2 year follow-up

100% simple lesions

0% combined procedures

Defect 8.4 + 5.5 cm2

Mean 12 year follow-up

8% simple lesions

62% combined procedures


Get it Right the First Time!

• Develop standard approach for every patient

• X-rays can help determine focal vs diffuse

lesions, background factors

• Study MRIs to plan cartilage surgery: size,

location, acuity, bone involvement

• Manage patient expectations!

icl: chondral injury of the knee: current controversies in

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