icl: chondral injury of the knee: current controversies in
TRANSCRIPT
ICL: Chondral Injury of the Knee: Current Controversies in 2021
Aaron Krych, MDJack Farr, MD
Andreas Gomoll, MD
Paul Caldwell, MD
Rachel Frank, MD
©2017 MFMER | slide-2
Get it Right the First Time!Aaron J. Krych, MD
Mayo Clinic Orthopedic Surgery and Sports Medicine
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Standard cartilage imaging: every patient!
• Good set of standard plain radiographs
• Standing AP, PA flexion
• Lateral
• Merchant
• Hip to ankle long-leg standing
• MRI (3T if possible)
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What am I looking for on imaging?
• Focal or diffuse process
• Cartilage lesion vs OA
• Background factors
• Why did lesion occur?
• Lesion factors: size, location, acuity, bone involvement
• Surgical planning
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What does imaging tell me?
• Focal or diffuse process
• Cartilage lesion vs OA
• Background factors
• Why did lesion occur?
• Lesion factors: size, location, acuity, bone involvement
• Surgical planning
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Which patients are candidates for cartilage
restoration?
Focal defects
Diffuse arthritis
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What does imaging tell me?
• Focal or diffuse process
• Cartilage lesion vs OA
• Background factors
• Why did lesion occur?
• Lesion factors: size, location, acuity, bone involvement
• Surgical planning
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Surgical Treatment Options for the Management of
Symptomatic Focal Cartilage Lesions of the Femur: U.S.
Femoral Condyle
< 2-4 cm2 > 2-4 cm2
Low Demand/
Older
High Demand/
Younger
High or Low Demand
1.Palliative
2. MFX
3. OAT
1. Osteochondral
Autograft
2. Cell Based Repair
1.Osteochondral Allograft
2.Cell Based Repair
Krych in Morrey Joint Replacement Arthroplasty 4th Ed
Correction of Background Factors
Patellofemoralvs
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Learning from Failure in Cartilage Repair Surgery:
An Analysis of Failure Mode of the Primary Procedure in Consecutive Cases at a Tertiary Referral Center
• Purpose:
• To determine common failure modes in primary cartilage restoration
• Goal: Improve surgical decision-making and patient outcomes
• Materials & Methods:
• Tertiary care center experience, single surgeon
• All revisions for failed cartilage surgery 2011 – 2017
Krych OJSM 2018
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• Study Population:
• 59 procedures in 53 patients
• Lesion Location:
• Medial femoral condyle most common failed location(54% of cases)
• Trochlea least common(15% of cases)
• Primary Procedure:
• Microfracture most commonindex procedure
• Various allograft forms more rare
• Failure Mode:
• Underlying malalignment predominant consensus reason for failure (56%)
Results
Krych OJSM 2018
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Patellofemoral background factors
• Trochlear dysplasia
• Patella alta
• Lateralized tubercle
• Tight lateral retinaculum
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19 year old male
• Pain and patella instability
• True J-sign tracking
• Patella cartilage defect
• Background factors
• 10 degrees valgus
• Trochlear dysplasia
• MPFL insufficiency
• Patella alta
• TT-TG 24 mm
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What does imaging tell me?
• Focal or diffuse process
• Cartilage lesion vs OA
• Background factors
• Why did lesion occur?
• Lesion factors: size, location, acuity, bone involvement
• Surgical planning
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What do we expect benchmarks to be?• Improved pain
• Improved function
• Long-term outcomes are durable
• Failures
• Osteoarthritis
• Total knee replacements
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What do we expect benchmarks to be?• Improved pain
• Improved function
• Long-term outcomes are durable
• No failures
• No osteoarthritis
• No total knee replacements
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Will I have improvement in pain?
Patient
• “I will be pain free”
Clinician
• “We can improve your pain during activities of daily living”
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• SUMMIT (MACI vs MFX) 5 year f/u
• 128 of 140 patients included
• Continued superior KOOS pain and function scores for MACI group
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• Lose 6.5 points on 9 questions (baseline: 23 points=mod-severe every category)
X 82
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Will I have improvement in pain?
Patient
• “I will be pain free”
Clinician
• “We can improve your pain during activities of daily living”
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Defect 2.8. + 1.4 cm2
Mean 2 year follow-up
100% simple lesions
0% combined procedures
Defect 8.4 + 5.5 cm2
Mean 12 year follow-up
8% simple lesions
62% combined procedures