Surgical Cartilage Intervention

may be associated with an acute injury
acute: large knee effusion
insidious onset - no effusion
Progressive onset of joint line pain or patellofemoral pain
Occasional locking, catching

relief of symptoms
minimal morbidity
Cost effectiveness
Long term effectiveness

What does the clinician require?
defect fill
restoration of congruity
Durability
ultimate long term function

debridement/chondroplasty
microfracture
osteochondral autograft/allograft
autologous chondrocyte implantation
DeNovo Cartilage

no tissue repair or fill
Poor Durability
just cleans away calcium deposits

No Tissue repair or fill
poor durability
just removes damaged cartilage or bone

repair tissue - fibrocartilage
Fill - variable
Durability - 2+ years
tiny holes in the bone
stimulation of marrow progenitor cells, violate the calcified cartilage layer

Lower BMI
Small lesions, unipolar
Short pre-op intervals
Minimal Limb mal-alignment
symptomatic
Active, younger
reliable

"pick" holes in bone
create vertical walls so the underlying defect bears less load
3-5 mm depth, 2-3 mm apart (clot formation) - visualization of blood or fat droplets

Fibrocartilage (type 1) that is biomechanically inferior

75, 2
Good cartilage repair volume
poor defect fill frequently results in limited functional improvement and durability

Crutch and maybe bracing (patella/trochlea)
-if bracing, 6-8 weeks NWB, ROM 0-20 deg

WB
-Condylar -> TTWB vs
-Patella trochlea -> PWB to WBAT 2 weeks
CPM or Wall Slides
Strengthening

-Wk 0-8: SLR, wall slides, ankle pumps, core stability

WK 8-12: treadmill, elliptical, stationary bike

-WK 12-16: progressive resistive exercise, sidestepping, cardio program at 75%

-WK 16+: functional sport load, mod weight training, leg press/squats/lunges, light agility work

repair tissue - Hyaline Cartilage
Fill - near total
Durability - 5+ years
uses healthy cartilage to replaced damaged

single stage
autologous: gross/histologic
hyaline cartilage
no disease risk
low cost
long term function
increased healing potential

donor site morbidity
biomechanics
contour
limited donor tissue
small defects

first line treatment of focal defects
Durable hyaline cartilage repair
effective improvement in functional outcome has been demonstrated
recommend arthrotomy vs arthoscopy
close pack grafts - attention to detail in resurfacing is key to success

plugs of bone with cartilage caps taken from another area of the joint and implanted into defect

moving cartilage from NWB are to WB zone
-lateral to medial trochlea

1st or 2nd line treatment
higher demand
"small defects"
1-4cm^2

smaller femoral condyle lesions
failed microfracture
unipolar lesions
OATS>mosaicplasty - using a smaller number of larger plugs

early motion essential! (unless patella or trochlea)
Immediate Active, AA and passive ROM
NWB for 6 weeks vs NWB 1st 2 weeks
-variations based on size, # of plugs
-6 weeks sub-chondral integration
-even at 6 weeks there is still a 63% decrease in graft stiffness
CPM 4-6 hrs/day for 4-6 weeks (0-40 deg)
brace for 6 weeks
increase activity after week 8
RTP 4-6 months

allow 6 weeks for plug to heal
desk job RTW 1-2 weeks
Laborer RTW 3-4 months
Sports 4-6 months

repair tissue - Hyaline cartilage
Fill - near total
Durability - 10+ years
harvesting cartilage

Heat - used to ablate, sculpt, and weld tissue

Osteochondral drilling
Abrasion Arthroplasty
Microfracture

larger defects (>2.5cm^2)
OCD osteochondritis dissecans
AVN avascular necrosis
Post-traumatic (chronic)
intact meniscus, ACL without degenerative changes or malalignment
failure of other treatment modalities (microfracture, abrasion chondroplasty)

Mini arthrotomy
outpatient surgery
6-7mm of bone with healthy living cartilage
has to be implanted within 20-25 days

diffuse articular cartilage damage
OA
Ligamentous Instability
mechanical malalignment
bipolar

matched to patient's exact size and location
Pre op template by MRI, x ray
Transplanted within 25 days or procurement
Fresh or cold stored vs Fresh Frozen: cartilage cells and matrix are preserved

exact contour of defect is implanted into patient
same joint, hemicondyle + weight bearing portion
press fit
full articular cartilage and bone

No donor site morbidity
expensive
graft availability
chondrocyte viability
disease transmission
graft rejection

defects 2-10 cm
<6-8 mm bone loss
failed conservative care
focal, symptomatic, unipolar

cell based
repair damaged chondral tissue by replacing with autologous chondrocytes
harvesting!

Biopsy - superomedial trochlea or lateral notch
cellular expansion

chondrocyte re-implanted 6-8 weeks later
multicenter study: results out to 48 months - 76% survival rate

intermittent compression stimulates cell biosynthesis
immobilization causes cartilage atrophy
cartilage mechanically adapts to loads
activity level above certain threshold may be destructive

Labral repair
RTC Repair
ACL Repair
THR/TKR

trauma or throwing athlete
test of function - do the movement
P/A - intra articular
Selective tissue tests - + Instability, + crank, + biceps load
ROM limitations - depends on size + location
Motor Performance - Biceps painful, ST weakness (overactive upper trap), elbow

cartilage, bone, muscle, skin

Relax - 1st 2 weeks
Bone growth: 4-6 weeks immobilization
Gripping: activate RTC, compression to cartilage + bone

sleeping position
sling use
protocol restrictions
hand dominance! -> ADL's bad if dominant hand

truma or throwing athlete
test of function - motor performance limitations
P/A - contractile
Selective Tissue: + for Drop arm, Hawkins Kennedy, Yergason's, Speed's
ROM - loss of AROM
Motor Performance

Cartilage, bone, muscle, skin

4-6 weeka immobilization
need early activation: gripping, elbow movement
PROM 5-6 weeks start

Sleeping position
sling use
protocol restrictions
hand dominance!

Trauma or cutting athlete - MOI
test of function
selective tissue tests: positive Lachman's (no end feel with anterior translation), + pivot shift (tibial translation felt upon assessment of test)
ROM limitations
Motor Performance
Copers vs non copers

no significant difference in patient rated outcome, significantly higher rate of ACL revision found in allograft patients

autograft reconstruction leads to lower retear rates in younger individual, an important factor in the graft selection process for these patients

WB status
ROM restrictions
Hamstring utilization
CPM utilization

X ray findings consisent with OA or RA
ROM limitations
Motor function impairment
Functional Limitations - ambulation distance, stair climbing

walking immediately after surgery

better hip function at 1 year, less residual pain, fewer implant related complications, better long term hip survival rate

higher risk of cardiovascular disturbances/events

more significant pain at 1 year after surgery
more reoperations
higher incidence of preoperative iatrogenic fracture (internal fracture)
less cardiovascular disturbances

weight bearing status
ROM restrictions
THR - what type of approach, precautions
-avoid extension if anterior dislocation, avoid flex abd IR if post disloc
TKR - pain control and ROM