關(guān)節(jié)軟骨損傷手術(shù)wolfe教授

1、The Athletic Knee,Shannon M. Wolfe,The Problem,Young active patients with articular cartilage defects!Which defects progress to OA ?Which defects are symptomatic ?How do we most effectively treat these defects?,The Bi

2、ology,Physiologic role of articular cartilageMinimize stresses on the subchondral boneReduces friction on the weight bearing surfaceCritical in proper joint function,Goals of Treatment,Restore integrity of load bearin

3、g surfaceObtain full range of motionObtain pain free motionInhibit further degeneration,Treatment Considerations,Age of the patientDefect sizeKnee stabilityKnee alignmentLevel of activity,Partial Thickness Defects

4、,Articular cartilage lacks the capacity to repair structural damageProgresses when exposed to mechanical wear,Full Thickness Defects,Do not heal with hyaline cartilageHealing by subchondral stimulation leads to the for

5、mation of fibrocartilageLacks physiological role of hyaline cartilagePoor wear characteristicsProgress to osteoarthritis,Non-Surgical Options,Activity modification (decrease load)Muscle strengthening (load absorption

6、)Bracing (selective joint unloading)Aspiration (decrease painful joint distention),Non-Surgical Options,PharmacologicalOralNon-steroidal anti-inflammatory medicationChondrotin sulfateGlucosamineInjectableCorticos

7、teroids - decrease the inflammatory response but have no mechanical benefitSynvisc - may improve the status of the articular surface by improving chondrocyte “health”,Surgical Options,Arthroscopic lavage - remove debr

8、isArthroscopic shaving - smooth surfaceDrilling or microfracture - create fibrocartilage scarOsteotomy - realignment to unload diseased compartmentOsteochondral autograft - replace a damaged surfaceAutologous chondr

9、ocyte transplant - replace injured cartilageAllograft osteochondral transplantation,Arthroscopic Lavage,Remove debris and inflammation mediatorsTemporary reliefNot a definitive procedure - not curativeNot normally su

10、fficient for athletic or active patients,Arthroscopic Debridement,Lavage and chondroplastyNo sub-chondral stimulationMay lead to improvement for up to 5 yrs.10-20% may become worseDebridement does nothing to promote

11、repairMalaligned or unstable knees do poorly,Thermal Chondroplasty,New procedureRequires bi-polar or ultrasonic device“Seal” the articular surface with heatKeplan L,M.D. reported no injury to the chondrocytes of the

12、involved or peripheral cartilage. “Radio-frequency energy appears to be safe for use on articular surface.” Arthroscopy, Jan-Feb. 2000, pp 2-5.,Abrasion Arthroplasty,Debridement and stimulation of subchondral bone 1 -

13、 1.5mm deep results in fibrocartilage repair intracortical rather than cancellous,Results : Abrasion Arthroplasty,Johnson 399 patients66% with continued pain99% with activity restriction,Results : Abrasion Arthroplast

14、y,UnpredictableMay not be better than debridement aloneRand noted 50% of patients who had an abrasion underwent TKR within 3 yrs.,Drilling or Microfracture,Debride lose cartilageSubchondral bone penetration drill or p

15、ick, 3/cm squaredResults in fibrocartilage repairLacks durabilityLacks the mechanical properties of hyaline cartilage,Drilling Results,Joseph Tippet,M.D.62 month follow up71% Excellent15% Good14% Fair / Poor,Resu

16、lts :,Richard Steadman, M.D. reported improvement in 364 of 485 patients (75%) at 7 years post-op90 - 100% of the defects were healed at 4 wks. with 30% hyaline cartilage12 mos. 42% hyaline cartilage Myron Spector, M.

17、D. demonstrated complete filling of the lesions at 3 months in an animal model,Microfracture Results :,Unpublished75% improvement50% returned to sportsSteadman / Hawkins,Osteochondral Grafting,Autologous plugs of bon

18、e with hyaline cartilage capBest done for small lesions (< 2cm.)New techniqueLimited data at follow-up,Osteochondral Autografting,IndicationsFull thickness (grade IV) lesions in the weight bearing surface of the

19、femoral condylesWell circumscribed lesion - sharp transition zone <2 cm diameter lesionYoung patient (< 45 yrs.)Normal alignment and stability,Osteochondral Autografting Contraindications,Axial malalignment (va

20、rus / valgus)Arthritis : poor transition zone and or bicondylar lesions Age : patients > 55 - 60 poor results despite other inclusion criteria,Osteochondral Autografting Contraindications,Lesions > 2cm. (rare)Os

21、teochondritis dessicansLarge OCD usually exceed donor area limitations & large bony defects w/ no subchondral reference points,Osteochondral Autografting,AdvantagesPotential for physiologic hyaline cartilageSingle

22、 stage procedureCan be done all arthroscopically,Osteochondral Autografting,Disadvantages / ConcernsDamage to the subchondral plateCreates bleeding and fibrocartilageDonor site morbidityIncongruence of the plugs / a

23、rticular surface,Donor Site Morbidity : Osteochondral Autografts,Morgan, Carter & Bobic 104 cases - no donor morbidity,Osteochondral AutograftBiopsy Proven Survival : Hyaline Cartilage, Tidemark & Bone,Wilson 10

24、 yearsOuterbridge 9 yearsHangody 5 yearsBobic 3 yearsMorgan 1 year,Osteochondral Autografting : Results,Bobic12 CasesLesion 1 - 2.2cm.10/12 excellent results at 2 yrs.,Osteochondral Autografting : Results,Morgan &

25、amp; Carter52 CasesIKDC evaluationPain65% improved 2 grades31% improved 1 grade4% no change (failure),LIMITATIONS OF OATS,Potential for DJD at donor site is realNo clinical support for repair of single or multiple

26、 plugsProphylactic surgeryDifficult to justify the procedure,ALL TEN SITES OF OSTEOCHONDRAL HARVEST,Articulated and demonstrated significant contact pressureRim stress concentration may lead to DJDOsteochondral donor

27、 sites do not heal normally,There is No Free Lunch!,Osteochondral Autograft,Post-opEarly motionImmediate active, active assisted, and passive ROMNWB x 2 weeksThigh muscle strengthening & stretching 3 monthsAvoid

28、ance of sports & running for 3 months,RECOVERY FROM OATS,Allow 6 weeks for plug to healDesk job RTW 1-2 weeksLaborer RTW 3-4 months,Autologous Chondrocyte Implantation,First procedure : biopsyArthroscopic chondroc

29、yte harvest from upper medial femoral condyleCultivation of cells 14-21 daysSecond procedure : implantationArthrotomy & debridement of lesionDefect covered with periosteal flapCultured chondrocytes injected into

30、 defect,First Surgery-Arthroscopy,,,Second Surgery-Arthrotomy,Inject $10,000 worth of cells!,Autologous Chondrocyte Implantation : Indications,Age 15-55Defect location femoral condyleDefect size 1-10cm.Defect type

31、 Grade IVLigament stabilityBiomechanical alignment,Autologous Chondrocyte Implantation,ContraindicationsKissing lesionsInflammitory arthritisTotal meniscectomyOver 50 (psychologic)Unstable kneeGeneralized degen

32、erative diseaseUnhealed lesion through subchondral bone,Dedifferentiation / Redifferentiation,Method of Restoration,Autologous Chondrocyte Implantation: Advantages,Less donor site morbidityLarger and multiple defects c

33、an be addressedGood results with longer follow-upNo violation of host’s subchondral plateFDA approved,Autologous Chondrocyte Implantation : Disadvantages,Requires 2 proceduresNot arthroscopicExpensiveNo long term r

34、esults,Autologous Chondrocyte Implantation,Post-opCPMActive ROMToe touch weight bearing for 6 weeksweek 7-12 closed chair exercisesJogging at 6 monthsSports at 1 year,Autologous Chondrocyte ImplantationUS Clinical

35、 Experience,121 patients 6 month follow-up42 patients 12 month follow-up85% improved overall condition80% improved pain scores at 12 months,Autologous Chondrocyte ImplantationSwedish Results NESM 1994,23 patients

36、 14-48Defects 1.6 - 6.5cm14/16 Good excellent results with 2 year follow-upBiopsy has appearance of hyaline cartilage,Autologous Chondrocyte ImplantationSwedish Results 1997,100 patients 2-9 year follow-up90% impr

37、ovement with femoral condyle lesions74% with femoral condyle and ACL reconstruction58% for trochlear lesions75% for multiple defects,,,,,,LIMITATIONS OF ACI,Little proof that $10,000 worth of cells do anythingCartila

38、ge that regrows is not normal Ideal patient is rareYoung, isolated lesion, no meniscal tear or instabilityDifficult to justify procedure,Osteochondral Allograft Transplantation,Joint resurfacing with fresh or fresh fr

39、ozen cadeveric tissue,Allograft Procedure,Open procedureExpose the degenerative lesionRemove the defective articular cartilage and a “thin” bony baseUtilize allograft tissue to replace and restore the articular surfac

40、e,Allograft Advantages,Replaces articular hyaline cartilage with hyaline cartilageSingle procedure,Allograft Disadvantages,CostRisk of disease transmission from fresh allograft tissue,Allograft Results,,What to do??,Tr

41、eatment Recommendations,Low demand patientsSmall focal lesion (<2cm)Arthroscopic chondroplasty50% relief up to 5 yearsAutograft Osteochondral or chondrocyte if failed chondroplasty,Treatment Recommendations,High d

42、emand patientSmall focal lesion (<2cm)Debridement plus drilling / fx75% success with all50% success with sportsOsteochondral grafting or chondrocyte transplant if failure,Treatment Recommendations,Low demand pati

43、entLarge lesion (>2cm) Debridement or microfracture with chondrocyte harvestIf persistent pain - osteochondral or chondrocyte transplant,Treatment Recommendations,High demand patientsLarge lesion (>2cm.)Chondr

44、ocyte transplant 1st line treatment yields 90% success,Long HistoryNo Acute SymptomsVarus KneeMarked DJD,Arthroscopic ResultsUnpredictableLittle Improvement,,Conclusions,Articular cartilage does not repair itselfNu

45、merous treatments with varying resultsMost treatments fail in the long term due to articular cartilage’s inability to produce hyaline cartilage,Conclusions,Osteochondral auto grafts and chondrocyte transplants show prom

46、ising resultsOsteochondral auto grafts allow transplantation of bone capped with hyaline cartilageAutologous chondrocyte implantation allows near normal hyaline cartilage growth into defects,Meniscal Allograft Indicati

47、ons,Patient age - young - 20-40Previous meniscectomyPainful compartmentMinimal Arthritic ChangesCorrect alignmentStable knee,Sterilization,Viral contamination risk 1:1.6 million to 1:1.2 billionRadiation> 2.5 m

48、rads destroys collagen<2.5 mrads does not kill virusesSterile harvest and storage with donor screening,Meniscal Allograft Technique,Bone anchors for anterior and posterior hornsPlugs for medial meniscusSlot for la

49、teral meniscusIncreases the difficulty,Meniscal Allograft Technique,OpenEasierArthroscopicLess morbidityMore technically demandingCollateral ligament release if necessaryIncreases exposure & facilitates graft

50、passage under condyles,Allograft Meniscal Transplant,Postoperative protocolNot completely elucidatedReflect meniscal repair protocolsMost incorporate early full ROMRestricted weight bearing (6 weeks)CPM early in pos

51、t operative course,Allograft Meniscal Transplant: Results,5 year follow-up - cryolife 37 graftsMedial (27)20 (74%) intact4 (15%) partial meniscectomy2 (7%) Total meniscectomy1 (4%) non-removal failure,Allograft Meni

52、scal Transplant : Results,Goble - 69 allografts40 patients > 2 yr. follow-up11 (16%) failures70% of patients had subjective improvements with pain,Cryo-Life 5 Year Results,Lateral (10)5 (5%) intact4 (40%) partial