Cartilage repair techniques -

actual changes in indication

Angele

Conflict of Interest

Company: Aesculap,Arthrex, Orteq

x consultant

x research activities

Patient selection

Ideal patient for cartilage repair

Focal defect

Isolated defect

Intact corresponding joint surface

Short duration of symptoms

No prior surgery

Stable defect edge

Individualised therapy

Patient selection

Cartilage injury in athletes „Prognostic parameter after cartilage treatment“

age (<40 years) (Microfracture, OCT, ACT)

[Mithoefer, 2005,2006; Gudas, 2006]

Interval of pain (<1 year) significant better outcome after Mfx (p=0,009) and ACT (p<0,01; 0,05)

[Mithoefer, 2005,2005,2006]

Number of previous knee surgeries none: 86% RTS; more than one: 67% no RTS [Mithoefer, 2005,2005,2006]

Professional (after Mfx and ACT)

[Kreuz, 2007; Blevins 1998]

Tissue Response

OCT

ACT

Footprint Cartilage injury Laterale Hypercompression syndrome Patella luxation

Patellofemoral shear stress

injury

osteoarthitis

Biologic cartilage-

reconstruction

Osteotomy

Ligament- reconstruction

Meniscus- therapy

Fracture repair

Moderne Joint therapy (early phase)

1) MACT 2) HTO D.E. 29.09.64

Treat the comorbidity /

underlying cause of cartilage defect

Treat the comorbidity /

underlying cause of cartilage defect

drugs Brace / insole Physiotherapy

Cartilage repair

Niemeyer et al, 2013, 2016

Defect size

Activity level

Therapy

low high

Subchondral defect

large small

Bone augmentation

Indication Microfracture

Cartilage defects (ICRS Grad 3): < 2-3cm2

[Mithoefer, 2006; Gudas, 2005; Asik, 2008; Kreuz, 2006]

BMI: <30kg/m2 [Mithoefer, 2005; Asik, 2008]

Femoral defects (Retropatellar and tibial reduced outcome) [Kreuz, 2006]

< 40 years [Steadman, 2003; Gudas, 2005; Asik, 2008; Knutsen, 2004; Kreuz, 2006]

[reviewed in Gomoll, 2012]

Not a first line treatment

for all cartilage lesion

Drilling better than Microfracture (Superclot) Microfracture: Compacted bone=sealing of canals Drilling: Removal of bone, access to marrow, 6mm more Superclot then 2mm

Microfracture / Drilling

[Chen, 2009, 2011, 2011]

• rectangular full-thickness chondral defect

• trochlea, adult sheep

• treated with 6 subchondral drillings (1.0 and 1.8 mm)

• osteochondral repair assessed after 6 months in vivo

Effect of hole size on repair Mona Eldracher Dietrich Pape/Henning Madry

1.0 mm holes...

Effect of hole size on cartilage repair

….significant enhancements at individual and overall histological

cartilage repair, reduced type-I collagen content

Eldracher, Madry et al. Am J Sports Med 2014

Smaller drill holes are better

AMIC: Initial pain reduction & functional improvement MRI variable defect filling AMIC vs. MACI: better results in MRI with MACI Stable clinical results over mid-term is inconclusive

Microfracture and Biomaterial

Benthien, 2010,2011; Dhollander, 2011; Gille, 2010; Bark,2014

Improvement over microfracture? Yes possible, but not proven yet

75

80

85

90

95

100

Lesio

n %

Fill

0 BST-CarGel MFX

70,46

85,04

30

50

70

90

BST-CarGel MFX

T2 R

ela

xation T

ime (

ms)

p=0.033

®

Reference control T2 ~50ms

Reference Literature T2 ~57ms

Quantitativ Qualitativ

Microfracture and Biomaterial (BST-CarGel, Smith Nephew)

Stanish, 2013

large arthrotomy

co-morbidity due to periost harvest

risk of leakage

long surgery

no periost harvest necessary

small arthrotomy

no sealing necessary as cells are immobilized in biomaterial

shorter surgery + b

iom

ate

ria

l c

las

sic

Chondrocyte transplantation

First to third generation

Gudas R, Kalesinskas RJ, Kimtys V, Stankevicius E, Toliusis V, Bernotavicius G, Smailys A. A prospectiverandomizedclinicalstudyofmosaicosteochondral

autologoustransplantation versus microfractureforthetreatmentof osteochondraldefects in thekneejoint in youngathletes. Arthroscopy. 2005

Sep;21(9):1066-75.

Dozin B, Malpeli M, Cancedda R, Bruzzi P, Calcagno S, Molfetta L, Priano F, Kon E, Marcacci M. Comparativeevaluationofautologouschondrocyteimplantation

andmosaicplasty: a multicenteredrandomizedclinicaltrial. Clin J Sport Med. 2005 Jul;15(4):220-6.

Bartlett W, Skinner JA, Gooding CR, Carrington RW, Flanagan AM, Briggs TW,

Bentley G. Autologouschondrocyteimplantation versus matrix-inducedautologous chondrocyteimplantationforosteochondraldefectsoftheknee: a prospective,

randomisedstudy. J Bone Joint Surg Br. 2005 May;87(5):640-5.

Knutsen G, Engebretsen L, Ludvigsen TC, Drogset JO, Grøntvedt T, Solheim E, Strand T, Roberts S, Isaksen V, Johansen O. Autologouschondrocyteimplantation

comparedwithmicrofracture in theknee. A randomizedtrial. J Bone Joint Surg Am. 2004 Mar;86-A(3):455-64.

Bentley G, Biant LC, Carrington RW, Akmal M, Goldberg A, Williams AM, Skinner

JA, Pringle J. A prospective, randomisedcomparisonofautologouschondrocyte implantation versus mosaicplastyforosteochondraldefects in theknee. J Bone

Joint Surg Br. 2003 Mar;85(2):223-30.

Horas U, Pelinkovic D, Herr G, Aigner T, Schnettler R. Autologouschondrocyte implantationandosteochondralcylindertransplantation in cartilagerepairof thekneejoint. A prospective, comparativetrial. J Bone Joint Surg Am. 2003

Feb;85-A(2):185-92.

Wondrasch B, Zak L, Welsch GH, Marlovits S. Effectofaccelerated weightbearing after matrix-associatedautologouschondrocyteimplantation on the

femoralcondyle on radiographicandclinicaloutcome after 2 years: a prospective, randomizedcontrolledpilotstudy. Am J Sports Med. 2009 Nov;37

Suppl 1:88S-96S.

Vanlauwe J, Saris DB, Victor J, Almqvist KF, Bellemans J, Luyten FP; for the TIG/ACT/01/2000&EXT Study Group.Five-Year Outcome of Characterized Chondrocyte Implantation Versus

Microfracture for Symptomatic Cartilage Defects of the Knee: Early Treatment Matters. Am J Sports Med. 2011 Sep 9.

Gudas R, Simonaityte R, Cekanauskas E, Tamosiūnas R. A prospective, randomized clinicalstudyofosteochondralautologoustransplantation versus microfracture

forthetreatmentofosteochondritisdissecans in thekneejoint in children. J PediatrOrthop. 2009 Oct-Nov;29(7):741-8.

Zeifang F, Oberle D, Nierhoff C, Richter W, Moradi B, Schmitt H. Autologous

chondrocyteimplantationusingthe original periosteum-cover technique versus matrix-associatedautologouschondrocyteimplantation: a randomizedclinical

trial. Am J Sports Med. 2010 May;38(5):924-33.

Van Assche D, Van Caspel D, Vanlauwe J, Bellemans J, Saris DB, Luyten FP, Staes F. Physicalactivitylevels after characterizedchondrocyteimplantation versus microfracture in thekneeandtherelationshiptoobjectivefunctional

outcomewith 2-year follow-up. Am J Sports Med. 2009 Nov;37 Suppl 1:42S-49S.

Saris DB, Vanlauwe J, Victor J, Almqvist KF, Verdonk R, Bellemans J, Luyten FP; TIG/ACT/01/2000&EXT Study Group. Treatment ofsymptomaticcartilagedefects

oftheknee: characterizedchondrocyteimplantationresults in betterclinical outcomeat 36 months in a randomizedtrialcomparedtomicrofracture. Am J Sports

Med. 2009 Nov;37 Suppl 1:10S-19S.

Saris DB, Vanlauwe J, Victor J, Haspl M, Bohnsack M, Fortems Y, Vandekerckhove B, Almqvist KF, Claes T, Handelberg F, Lagae K, van der Bauwhede J, Vandenneucker

H, Yang KG, Jelic M, Verdonk R, Veulemans N, Bellemans J, Luyten FP. Characterizedchondrocyteimplantationresults in betterstructuralrepairwhen

treatingsymptomaticcartilagedefectsoftheknee in a randomizedcontrolled trial versus microfracture. Am J Sports Med. 2008 Feb;36(2):235-46.

Knutsen G, Drogset JO, Engebretsen L, Grøntvedt T, Isaksen V, Ludvigsen TC,

Roberts S, Solheim E, Strand T, Johansen O. A randomizedtrialcomparing autologouschondrocyteimplantationwithmicrofracture. Findingsatfiveyears. J

Bone Joint Surg Am. 2007 Oct;89(10):2105-12.

Gudas R, Stankevicius E, Monastyreckiene E, Pranys D, Kalesinskas RJ. Osteochondralautologoustransplantation versus microfractureforthetreatment

ofarticularcartilagedefects in thekneejoint in athletes. KneeSurg Sports TraumatolArthrosc. 2006 Sep;14(9):834-42.

Saris D(1), Price A(2), Widuchowski W(3), Bertrand-Marchand M(4), Caron J(5), Drogset JO(6), Emans P(7), Podskubka A(8), Tsuchida A(9), Kili S(10), Levine

D(11), Brittberg M(12); SUMMIT study group. Matrix-Applied Characterized Autologous Cultured Chondrocytes Versus Microfracture: Two-Year Follow-up of a Prospective Randomized Trial.

Am J Sports Med. 2014 Jun;42(6):1384-94. doi: 10.1177/0363546514528093. Epub 2014 Apr 8.

Prospective randomised trials for chondrocyte transplantation

Inclusion and exclusion criteria for prospective randomised studies (ACT / MACT)

The major 8 RCT for „cartilage regeneration“ include patients according to almost the same inclusion criteria

- Representation only 4 % patients in daily clinical routine

- No explanation of medical sensefulness of inclusion and exclusion criteria available

Engen et al., Cartilage 2010

106 centers

Patient follow up over 10 y

>2500 registered patients

Industry independent

Hip – Knee - Ankle

Initiative of Working group „Tissue Regeneration“ of DGOU

GCP conform data base

Stand: 1.3.2016

Degenerative genesis

Partial meniscectomy

Reduced cartilage height at defect edge

Beginning damage of corresponding joint surface

Changed joint homeostasis

„Every day“ Indication for cartilage repair

Patient selection for MACT

?

Consensus Meeting Verona 2015 Focal early OA

KSSTA June 2016

injury

gonarthrosis

Biologic cartilage-

reconstruction

Osteotomy

Ligament- reconstruction

Meniscus- therapy

Fracture repair

Modern Joint therapy (Late stage)

Joint replacement Conservative

therapy

Biologic cartilage-

reconstruction

?

Outcome Analysis (KOOS 12 months)

Defect ethiology

0%

20%

40%

60%

80%

100%

Trauma Degeneration OCD

Non-Responder

Resonder

Stand: 1.3.2016

2015

Significant improvement:

- Swelling

- Pain

- Function

p<0,0001

Complication – defect type

Angele, 2015

No indication for chondrocyte transplantation

Niemeyer et al, 2013, 2016

Defect size

Activity level

Therapy

low high

Subchondral defect

large small

Bone augmentation

Osteochondral transplantation - Small osteochondral Lesion

OCT

Z.n. OCT med. FC

1y postOP

PJ 28.11.76

Level IV Study 20% failure after 1 y (=3 of 20) Poor integration Scare tissue with Foreign body reaction

Dhollander, 2012

B.P.19.8.93

Osteochondritis dissecans Lat. FC Grad IV

Stöhr, Angele, 2013

Bone block Augmentation / MACT

50 patients

1-3 years follow-

up

IKDC Score:

50 points

improvement

Bone block augmentation / MACT

MRI correlates with good clinical outcome

• Indication and patient selection

• Degenerative focal cartilage defect:

•Improved clinical outcome to baseline

•Increase in failure rate (2 fold)

• Understand the trauma mechanism

• Treatment of underlying comorbidity

Summary – What has changed?

Summary Osteochondral lesions

•Treat the bone defect

•Small osteochondral lesions – osteochondral transfer

•Huge chondral and osteochondral defects:

- Significant improvement with MACT +/- Bone block

augments

- MRI and clinical evaluation show correlation

• Cell free implants – variable / questionable results,

no correlation between MRI and clinical evaluation

ACL-rupture–

40% cartilage damage in

athletes

Best treatment is

prevention !

Thank you for your attention

Early OA

25./26.11.2016