chondral injuries - current concepts in management & cartilage regeneration
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10/01/2015 IASM Mumbai
Current Management Strategy for chondral injuries in athletes:
Square Pegs in Round Holes!
Dr Vaibhav Bagaria MBBS MS Dip SICOT CARE hospital & ORIGYN Clinic Nagpur, India
drbagaria.com
Ideal Cartilage restoration
✤ “Chasing the Holy Grail”
✤ Can we recreate what God created?
✤ ‘Dil Mange more’
✤ Question: Are we trying square pegs in round holes?
drbagaria.com
So...the ideal!!!
✤ Recreate Hyaline cartilage
✤ Reproduces zonal architecture
✤ Integrates with surrounding tissue
✤ Durable
✤ Cost Effective
✤ Single stage
✤ Minimally Invasivedrbagaria.com
Assessment - Clinical
✤ Knee Osteoarthritis& Outcome score (KOOS)
✤ IKDC
✤ Lysholm: too general & non specific
✤ Others: SF 36, Cincinatti rating, ICRS
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Assessment - Radio
✤ MRI ( Gad enhanced)
✤ MOCART Scores: 9 Parameters - Quantity, Integration, Surface, Structure, Signal intensity, Integrity of subchondral lamina
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Assessment - Arthroscopic
✤ Histological:
✤ Hyaline like
✤ Mixed Hyaline- Fibrocartilage
✤ Fibro-cartilage
✤ Fibrous tissue
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Modifier
✤ Anatomy: Size, Location & Depth (FT vs PT)
✤ Pathology: Traumatic vs Others
✤ Epidemiology: Age, Profession
✤ Confounders: Re surgery, Surgeon Skills, Associated lesion
✤ Expectations:
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Various Strategies
✤ Debridement & Lavage
✤ Abrasion Chondroplasty
✤ Microfracture & Pridie Drilling
✤ Soft tissue - periosteal grafts
✤ Osteochondral transfer
✤ ACI - Various Generations
✤ Newer Techniquesdrbagaria.com
Debridement & Lavage
✤ Chondral Lesions less than 2 Sq cm
✤ Remove Loose cartilage fragments & washout
✤ Good for low demand, older age pt who may not tolerate prolonged immobility
✤ Considered palliative, yet quick recovery with QOL improvement and fast mobility.
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Microfractures
✤ Less than 2 - 3 sq cm lesions
✤ Reparative strategy
✤ Drilling holes 0.5 -1mm dia thro articular cartilage into bone marrow cavity
✤ Allows access to bone marrow progenitor cells
✤ CPM with ltd activity required postop for healing
✤ Hyaline like cartilage that deteriorate over time.
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Abrasion Chondroplasty
✤ Abrading subchondral bone superficially
✤ Intraosseous space opens up with vessels n mesenchyme
✤ Stimulates reparative process.
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Osteochondral Transplantation
✤ Could be Allo or auto
✤ Commomest auto: Mosaicplaty ( S & N); OATS ( Arthrex)
✤ Good for Intermediate defects upto 5 sq cm
✤ Viability of harvested graft is the question
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Technique
✤ Harvesting from NWB areas
✤ Cylindrical osteochondral grafts
✤ Transferred to WB area
✤ 2-5 sq cm
✤ Non degenerate knees only
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Regeneration Strategy Triad
✤ Cells are required for de novo synthesis
✤ Scaffold provide the template to lay down the matrix
✤ Biological signalling molecule required to stimulate cell requirement, migration, differentiation as well as synthesis
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ACI - First Gen
✤ Cells isolated from NWB area
✤ Expanded in vito and transplanted to a defect
✤ Covered with periosteal flap
✤ Main drawback: two staged, time interval
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ACI - Gen 2
✤ Drawback of Gen 1: graft delamination, ectopic calcification, graft hypertrophy - mech symptoms “catching”
✤ 2nd gen - combines scaffold and cultured cells
✤ Scaffold provides structure for chondrocyte adhesion, expansion while maintaining the chondrocyte phenotype.
✤ Can be used to treat relatively large chondral defecrs
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ACI Gen 2✤ MACI - Porcine collagen I/ III matrix
✤ Hyalograft C- Hyaluronic acid scaffold
✤ Bioseed C - Polyglactin/poly - p - dioxan
✤ CaRes - 3D type 1 Collage
✤ Cartipatch hydrogel composed of alginate and agarose (inserted in mosaic fashion
✤ Novocart 3D – collagen-based biphasic scaffold (specific protective layer, collagen sponge)
BioCart IIBioCart II – freeze-dried homologous human fibrinogen and recombinant hyaluran – freeze-dried homologous human fibrinogen and recombinant hyalurandrbagaria.com
ACI - 3rd gen
✤ Avoid morbidity of auto harvest cartilage
✤ Uses allogenic or autogenic tissue
✤ Denovo ET: Allogenic fetal chondrocyte
✤ Cartistem: Umbilical Cord derived
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Bio Printing
✤ 3D Printing: Layered approach instead of suspension
✤ Create 3D multi-materials that mimic geometry of living tissue
✤ www.3dpost.in
drbagaria.com
Take home...
✤ Various strategies
✤ Numerous choices - superiority of one over another not established
✤ Customised Solution to your athletes
✤ Personal Choice: KISS: less than 2 sq cm: Micro fracture More than 2 sq cm: Offer 2nd gen ACI/ single stage BMAC repair
✤ Keep an eye for things on horizon
drbagaria.com
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