Stephen F. Brockmeier, MDAssociate Professor, Orthopaedic Surgery

University of VirginiaTeam Physician UVA Athletics

ACSM/AMSSM/AOSSM Advanced Team Physician Course

December 8-11, 2016San Diego, CA

Learning Objectives

1. To review prevalence of, presentation of, and management strategies for osteochondritisdissecans and focal chondral lesions in the knee.

2. To critically review the current literature and evidence and potential research avenues to improve team physicians’ abilities to appropriately and safely treat knee OCD.

University of Virginia Orthopaedic Surgery

Consultant – Zimmer Biomet, MicroAire Speaker – Zimmer Biomet, Depuy, Arthrex Clinical Trial (active) – Zimmer Biomet Publishing Agreement/Royalties – Springer Research Grant – Arthrex Fellowship Grant – DJO, Depuy Mitek, Arthrex, Editorial Board – TSES, OJSM Board/Committee Appointments – AOSSM

Disclosures

OCD Introduction

• Etiology—Trauma/Microtrauma• JOCD => AOCD• Symptoms—Pain, Swelling,

Mechanical• Diagnosis—PE, Radiographs,

MRI• Treatment—Individualized• Adult Chondral Injuries

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• 18 yo NCAA D1 baseball pitcher• Intermittent knee pain for several

years• Never previously evaluated• No acute injury• Currently rehabbing s/p UCL

reconstruction• Exam:Moderate effusion FROMMild, vague TTP

anteromedially Normal ligamentous exam

Case Example

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Imaging

University of Virginia Orthopaedic Surgery

Imaging

University of Virginia Orthopaedic Surgery

Imaging

KneeOsteochondritis Dissecans

Osteochondritis Dissecans• Juvenile form (open physes)-

Better prognosis– Initial management conservative

(Non-weight bearing 6-12 weeks)

• Most commonly affects Lateral aspect of MFC

• Pathological changes begin in subchondral bone Tria, et al Illustrated Guide to the Knee

Churchill-Livingstone 1992

KneeOsteochondritis DissecansCritical Treatment Considerations: Age / Skeletal Maturity***

Lesion Size Lesion Location Lesion Stability Lesion Viability

Other Factors (Aligment, Stability, etc.)

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Back to our case…

University of Virginia Orthopaedic Surgery

University of Virginia Orthopaedic Surgery

University of Virginia Orthopaedic Surgery

Probing lesion (Video)

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Extended portal….

University of Virginia Orthopaedic Surgery

University of Virginia Orthopaedic Surgery

University of Virginia Orthopaedic Surgery

University of Virginia Orthopaedic Surgery

Imaging

University of Virginia Orthopaedic Surgery

University of Virginia Orthopaedic Surgery

University of Virginia Orthopaedic Surgery

University of Virginia Orthopaedic Surgery

• 21yo NCAA D1 Women’s soccer player

• 18 months s/p ACLR• Insidious onset of lateral

knee pain and episodic swelling

Case Example

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Clinical Assessment

• History– Mechanism– Previous injuries– Previous symptoms– Previous surgeries– Instability?

• Symptoms– Pain, effusion, mechanical symptoms– Similar to meniscus tear

• Physical Exam– Joint effusion– Tenderness– Ligamentous exam– Alignment

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Radiographic Assessment

• Plain x-ray– Used to evaluate for alignment, bony defects

and presence/absence of arthritis– Include flexion PA view to evaluate for early

degenerative changes and merchant view to evaluate the patellofemoral joint

– Consider long limb standing films to evaluate alignment

• MRI– Most sensitive for evaluating focal cartilage

defects– Allows accurate assessment of chondral lesion,

edema, and any concomitant pathology including ligamentous or meniscal injury

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Description and Characterization

• Descriptive– Based on MRI (size, depth)

• Classification Systems

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Management

• Considerations– Duration and severity of symptoms– Concomitant injuries– Location of lesion– Depth of defect– Size (diameter) of defect– Patient age– History of trauma– Concomitant arthritis– Patient activity level/demands– Mechanical alignment/mal-alignment

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Management: Non-Surgical

• Potential option for small or asymptomatic lesions

• Includes rest, NSAIDs, therapy• +/- injections

– Corticosteroid injections, HA injections

• Goal is to reduce symptoms, not heal the lesion

• The lesion is unlikely to heal with conservative therapies

• Little data on natural history of such lesions in young individuals, but most suggest deterioration over time

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Management: Surgical

• Numerous options:– Arthroscopic Lavage and

Debridement– Abrasion Arthroplasty / Subchondral

Drilling/ Microfracture– Osteochondral Autograft /

Mosaicplasty– Osteochondral Allograft– ACI/MACI

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Debridement

• Early arthroscopic option for chondrallesions

• May remove loose flaps or edges that mechanically impinge in the joint

• Will not result in cartilage regeneration, but can improve symptoms

• Typically used more frequently for degenerative lesions

• Symptomatic improvement in 45% of patients, however only 68% of patients have prolonged improvement

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Microfracture, etc

• Marrow stimulation techniques include subchondral drilling and microfracture

• Technique includes debridement of lesion edges to create a contained crater

• Subchondral drilling involves use of a drill to perforate the bone and allow bleeding into the defect and clot formation

• Microfracture avoids the the thermal effects of a drill by using an arthroscopic awl to create several holes 3-4 mm apart

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• 22 yo WSOC– S/p slide tackle injury– Anterior knee pain– Mechanical catching– Effusion

Case Example

University of Virginia Orthopaedic Surgery

Case Example

University of Virginia Orthopaedic Surgery

Microfracture, etc

Outcomes• Steadman, et al 1997

– 75% with improvement at 5 years– 20% with stabilization of symptoms– 5% with deterioration

• Kreuz, et al 2006– All patients improved in first 18 months– Deterioration began at 18 months– More pronounced for age > 40

• Alparslan, et al 2007– Overall good improvement of function

and activitiy

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Microfracture, etc

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Osteochondral Autografting

• Indications:– Discrete, focal traumatic lesion– Weight bearing surface– Accessible– No diffuse arthritis– No “kissing” lesions

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Osteochondral Autografting

Like changing the pin location on the putting green!

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Osteochondral Autografting

• Technique– Diagnostic arthroscopy– Debridement of edges– Plan geometry– Harvest plugs– Insert plugs

• Superolateral• Notch• Superomedial• Opposite Knee

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Back to our case: 21yo WSOC Player

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Osteochondral Autografting

Outcomes• Gudas et al (Arthroscopy, 2005):

– 96% good to excellent, 93% return to sports.

• Ma HL et al (Injury, 2004): – 89% good to excellent.

• Lahav et al (J Knee Surg, 2006): – 86% “would do again”

• Macacci et al (Arthroscopy, 2005): – 78.3% success

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Osteochondral ALLOgrafting

• Similar to autografting, but may be used for medium to large, full thickness defects

• Avoids donor site morbidity and size limitations of autograft

• Fresh allograft– Higher chondrocyte availability– Higher risk for disease transmission

• Cryopreserved frozen allografts– Reduced immunogenicity and disease– Lower chondrocyte availability

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ACI/MACI

• Multi-step procedure– Diagnostic arthroscopy and cartilage harvest– Chondryocyte cultivation in laboratory– Implantation surgery (6 weeks later)– ACI uses periosteal flap for injection of

chondrocytes– MACI uses collagen membrane and fibrin

glue

• Indications– Younger, active patients– Isolated traumatic femoral defect– Must correct ligamentous and meniscal

lesions, joint malalignment and patellofemoral instability

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ACI/MACI

Outcomes• 89% G/E results in focal femoral

condyle lesions, 75% in ACL reconstructed patients (1998)

• In a series of 891 patients, G/E results in 86%, with 12.6% complication rate

• Failure rate around 6% at 2 years

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Case Presentation

• 22 year old male collegiate basketball athlete presents with left knee pain

• Symptoms present for approximately one week

• He reports swelling, anterolateral tenderness and mechanical symptoms including catching with activity

• At time of injury, in pre-season practice, season starting in ~ 6 weeks

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Case Presentation

• PMH: none pertinent. denies previous left knee injury

• PSH: – right ankle lateral ligament

reconstruction 2 years earlier– left hip arthroscopy

• Exam:– 2+ effusion– Lateral joint line tenderness– No instability– Negative McMurray

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Case Presentation

University of Virginia Orthopaedic Surgery

Case Presentation

University of Virginia Orthopaedic Surgery

Case Presentation

PLAN?• 22 year old• D1 basketball player, starting

point guard, senior year• Full thickness lesion• 6 x 11 mm size• Plan? • Arthroscopy, OAT if possible,

microfracture if not

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Case Presentation

• After debridement, 8 x 15 mm• 2 plugs (one 8mm, one 6mm)• Returned to sport in 44 days

C. Jan Gilmore, MDChris T. Cosgrove, BS

Brian Werner, MDEric W. Carson, MDMark D. Miller, MD

Stephen F. Brockmeier, MDDavid R. Diduch, MD

University of Virginia Orthopaedic Surgery

Study Design

• Methods:• Retrospective chart review• Institutional cohort of 152 OAT procedures• All patients from 2000-present reviewed• 20 athletes identified in this cohort

• Athlete Cohort• Isolated OAT procedure for knee• Excluded if concomitant ligament or

meniscal procedure• All underwent physician-directed

accelerated progression and return to sports

• Evaluated for progression, time to return to sport and clinical outcomes

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Results

• Demographics• Average age 21.6 yrs• 70% male• Avg. lesion size: 134 mm2 [15 – 280 mm2]• Avg. # of plugs: 2.15 [1 – 4 plugs]

• Average plug size: 6.72 mm [4 – 10]• MFC lesions: 8• LFC lesions: 12

# of plugs # of patients

1 plug 5

2 plugs 9

3 plugs 4

4 plugs 2

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Results

• Outcomes• Average 4.4 years follow-up [1.3 - 6.9]• IKDC: 84.5 ± 9.5• Pre-Injury Tegner: 8.9 ± 1.7• Post-op Tegner: 7.7 ± 1.9• Satisfaction: 100% (satisfied

or very satisfied)

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Results

• Outcomes• Avg. time to release: 83.9 days [39 – 134 days]• # requiring reoperation: 0• # with pain @ release or later: 5 (25%)• # with effusions @ release or later: 4 (20%)• # requiring injection @ release or later: 4 (20%)• # with mechanical symptoms @ release: 0

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Return to Sports

University of Virginia Orthopaedic Surgery

Return to Sports

Systematic review of 1363 patients:• Microfracture: 8 ± 1 months• Osteochondral autograft: 7 ± 2 months• Osteochondral allograft: 10 months• ACI: 18 ± 4 months• OAT had highest RTS for athletes (91%) as

well as highest durability of pre-injury level of performance (96%)

Second review of 658 patients:• Microfracture: 59% RTS, 17 months• OAT: 93% RTS, 6.5 months• ACI: 78% RTS, 25 months