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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
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
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
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
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
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
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
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
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
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
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
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
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
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
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
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
+ 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
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
+ 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
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
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”
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
“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
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
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%
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
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
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
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
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
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
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
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
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
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
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
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
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
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% !
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
OCAutl Basic Surgical Technique
Video Courtesy J Kennedy, MD, FRCS
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
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
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
• 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
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Gianakos et al, FAI 2015
◦ Anterolateral Chevron osteotomy
ALTERNATIVE (Lateral) OSTEOTOMIES
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
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
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
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*
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
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
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
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%
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
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
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
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
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
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
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
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!
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
THANK YOU
“The human foot is a masterpiece of engineering…and a work of art.”Leonardo da Vinci, The Notebooks (c. 1508-1518)