16 - krych cartilage cases

3/13/2018

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©2014 MFMER | slide-1

Cartilage Cases

Aaron J. Krych, MD

Professor, Orthopedic SurgerySports Medicine Fellowship DirectorSports Medicine Research Fellowship DirectorMayo Clinic


Case

• 19 yo F division I college volleyball player outside hitter

• 1 year lateral knee pain “OCD”• Failed conservative management

• MFX performed elsewhere

• 1 year rehabilitation

• Continued pain/swelling

• Unable to play volleyball x 2 years


Physical exam

• Previous portal incisions

• Quad atrophy

• Trace effusion

• Lateral jt line TTP

• Full ROM

• Stable

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Initial outside films


Initial outside films


Outside arthroscopy—”MFX performed”

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Continued pain, swelling after 1 year

• Plain x-rays unchanged (PA flexion included)


Repeat MRI at 1 year

Subchondral edema increased, lesion size 18 x 8 mm


Treatment options?

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Repeat knee arthroscopy

Some fibrocartilage fill, size of lesion increased, new tibial chondromalacia

17 x 16 mm


8

8

6

17 x 16 mm

About 2.5 cm2


Post-op

• 4 weeks PWB• ROM as tolerated• Early quad function• Alter-G

• 4-8 weeks• Normalize gait• Closed chain strength

• 3-4 months• Elliptical for cardio

• 6 months jogging*/progressive return to controlled sport activities

*delayed jogging due to 2 years sx’s

3 month accelerated rehab Gilmore OJSM 2014

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6 month MRI follow-up


How does the OC plug heal?

Allograft plug creeping substitution Autograft plug fully incorporated

6 months 6 months


5 year follow-up completed 4 years competitive eligibility

No donor site symptoms

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• MA of level I and II prospective studies

• 249 patients at 5.5 years

• OAT had higher activity levels and lower failure rate

• MFX results deteriorated after 1 year


Best return to sport data

• 44 studies, 2549 patients

• OAT 93% return to sport

• OAT fastest return to sport 5.2 months

• OAT highest KOOS score


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History29 year old MCC: L knee painHPI:

•Basketball game•Landed on opponent’s foot and twisted his left knee, heard a pop•Inability to bend his knee afterwards•Noticed some mild swelling


Physical Examination• Inability to bend knee past 10 deg flexion due to excruciating pain•TTP along patella, negative apprehension,+1 quadrant patellar glide•Tight lateral retinaculum•Negative Lachman and Pivot shift, Stable V/V at 0 deg extension


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MPFL OK, no subluxation/dislocation


Treatment options?

“Doc, I am getting married in 2 weeks and need to walk down the aisle”


Grade 4 patella defect 25x15 mm—cartilage fragmented

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Second stage surgery


Lateral retinacular lengthening


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Defect Defect prep

MACI


Postoperative Course

•Outpatient procedure•Good pain control post-op•PWB for 6 weeks, ROM as tolerated


6 month follow-up imaging

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After Before


After: Excellent fill Before


After: normal patellar tilt Before: Abnormal tilt

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• 110 patients including bipolar defects

• Minimum 4 year f/u, avg 7.5 years

• Avg defect 5.4 cm (72% Fulkerson IV)

• 69% AMZ, 41% lateral release

• 86% good and excellent

• Improved WOMAC, IKDC, Cincinnati (p<0.05)



Case

• 20 yo M college football player safety

• Underwent OCD excision elsewhere

• 9-12 months lateral knee pain following a twisting injury, no instability

• c/o painful snapping in deep flexion

• Failed exhaustive conservative management (injxns, PT, etc)

• Pain with ADL’s

• Continued symptoms

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Outside MRI prior to knee scope


Physical exam

• Asymmetric valgus

• Trace effusion

• Full ROM 0-140 degrees

• Palpable PL joint line “snap” in deep flexion

• Ligaments Stable


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7 degrees mal-alignment


Options?

• Stage?

• Approach?

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OC allograft and osteotomy


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9 month follow-up

• Pain-free

• No swelling

• Strength and functional testing look good

• MRI


How fast should we rehab/return to sport?

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Case: GT

• CC: 32 yo golfer w/ right knee pain x 4 years

• HPI:• Knee injury following snow mobile accident in 2010• Mar 2010: arthroscopy with microfracture• Dec 2010: arthroscopy with debridement• Feb 2011: Osteochondral allograft transplant w/ 4 plugs• Aug 2013: 3 of 4 plugs removed (delamination) and

repeat microfracture

• Continues to have pain daily with activities


GT

•

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Pre-op Imaging



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Plan?



Pre-Op Post-Op

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• 33 patients undergoing revision OCA b/t 1983 and 2012

• Mean f/u: 10 yrs

• Failure defined as conversion to arthroplasty

• 13 of 39 (39%) failed

• Mean graft survival of 10 yrs

• 10 yr survival: 61%



Case

• 12 yo M football player

• Medial knee pain x 9 months

• Activity modification

• Casting/crutches x 6 weeks

• Continued pain/effusion with activity

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Physical exam

• Normal gait and alignment

• Full ROM, no effusion

• TTP medial joint line

• Stable knee


Radiographs

Wide open physes


Radiographs

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Stable or unstable?


Plan?


Need to discuss multiple options with family

• Stable vs unstable• Possible drilling

• Salvageable vs unsalvageable• Cartilage status, bone status of progeny fragment• Fixation—metal vs biocompression

• Not salvageable• Size of lesion

• Osteochondral autograft transfer• Excision only

• Partially able to salvage• Hybrid technique

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Unstable


No bone on anterior progeny fragment

Reasonable bone posterior fragment

Unstable, partially able to salvage


Screw fixation posterior

OAT anterior

Hybrid technique advantage: reliable single stage surgery

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6 month MRI


Beware: Hardware complications

Screw track

Fixation performed elsewhere

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• 20 patients unstable OCD lesions

• 11 of 20 skeletally immature

• At 6 months, all MRIs demonstrated healing with integration

• At 18 months, all knees rated as normal


Symptomatic OCD take home points

• Salvage fragment best• Drilling in open growth plates• Fixation if unstable

• Controversy metal vs biocompression and ?staged removal

• One stage best—discuss all scenarios w/athlete• Try to salvage a portion of fragment• Try to cover with OAT• If too large an area, then excision


ThankYou

16 - krych cartilage cases

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