Recent updates in the management of cartilage lesions in young adults Dr (Prof.) Raju Vaishya MS Orth, MCh (L’pool), FRCS (Eng) Sr Consultant Orthopaedics & Joint Replacement Surgery Indraprastha Apollo Hospital, New Delhi.

Grading of cartilage lesions

Imaging Radiographs *Standing anteroposterior (AP) *45° flexion posteroanterior (PA “Rosenberg”) *Flexion lateral *Shallow angle axial (Merchant) *Long leg axial True lateral radiograph useful in assessing trochlear dysplasia Patellar tilt not always appreciated on Merchant view

Imaging Magnetic resonance imaging Arthroscopy - gold standard for - 100%sensitivity and 81.5% specificity - Allows staging of chondral lesions - May detect very early intra cartilaginous lesions - PD and T2 images are useful Arthroscopy - gold standard for assessing articular injury

Treatment of Cartilage Lesions Objectives :- Pain relief Reduce inflammation Restore function Reduce disability Postpone/alleviate need of prosthetic replacement

Surgical Treatment of Articular Cartilage Defects ) Palliative Treatment: Debridement & lavage Radio frequency Energy ) Reparative Treatment: Marrow stimulating techniques Drilling Abrasion arthroplasty Micro fracture C) Restorative techniques : Autologous Chondrocyte Implantation(ACI) Osteochondral grafting Autogenous - Mosaicoplasty Fresh Allografts

Palliative Techniques (Debridement & Lavage) Smaller Lesions (< 3 cm2) Low demand patients Mechanical symptoms Recurrent effusion

Marrow Stimulating Techniques Expose the chondral defect to pluripotential stem cells to form fibro cartilage Indicated for smaller lesions (< 2cm2) in lower demand pts

Microfracture Induce a reparative response by perforation of the subchondral bone Perforation of the subchondral bone Extravasation of blood & marrow Formation of a blood clot The mesenchymal cells within differentiate into fibrocartilaginous repair tissue

Microfracture - disadvantages May also form bone, resulting in an intra-lesional osteophyte Unlike hyaline cartilage, fibro-cartilage predominantly is type I collagen and exhibits inferior wear characteristics Not suitable for larger defects

Evidence-Based Status of Microfracture Technique: A Systematic Review of Level I and II Studies Deepak Goyal et al (Arthroscopy: 29 (9) , 1579-1588, 2013) The use of microfracture for the treatment of small lesions in patients with low postoperative demands was observed to result in good clinical outcomes at short-term follow-up. Beyond 5 years postoperatively, treatment failure after microfracture could be expected regardless of lesion size. Younger patients showed better clinical outcomes.

There was insufficient evidence for long-term results for OCT Evidence-Based Status of OATS Techniques: A Systematic Review of Level I and II Studies (Deepak Goyal et al: Arthroscopy 2014) OCT had an advantage over MF in younger patients with small chondral lesions. Comparison of outcomes between OCT and ACI showed no significant difference in 2 studies and contrasting results in another 2 studies. There was insufficient evidence for long-term results for OCT

Restorative Treatment Re-estabilish normal congruity with mechanically stable hyaline cartilage Best reserved for higher demand pts with significant symptoms & failed prior palliative preparative procedure Complex & expensive

Cartilage : An ideal tissue for transplantation! Avascular Aneural Immunoprivileged Amenable to storage Can be fashioned to fit recipient

A C I Resurfaces focal chondral defects with “hyaline -hike” cartilage Which is bio-mechanically superior to fibro cartilage

A C I Indications :- High demand patients Symptomatic Gr III/IV lesion of femur (2 - 10 cm2) Prior failed palliative/ reparative treatment

Techniques of ACI 1st generation: Periosteum-based ACI (P-ACI). 2nd generation: Collagen membrane based ACI (C-ACI/MACI) 3rd generation: Scaffold based

1st generation ACI Medium to large size chondral defects Cartilage biopsy obtained arthroscopically Expanded in a monolayer culture Defect debrided to create stable, vertical shoulders & non bleeding bed of subchondral bone Patch of periosteum is harvested from the prox tibia Sewn to cover defect, cambium layer facing inwards. Fibrin glue is added to the suture line to achieve a watertight seal after injection of the chondrocyte suspension

Disadvantages of 1st generation ACI Havesting and donor site problems Hypertrophy Ossification of periosteum Complex technique (suturing)

2nd Generation ACI - Came up to circumvent these problems -Bio-engineered bilayer collagen (C-ACI) or synthetic membranes (MACI) used – to avoid spill over and asymmetric distribution.

3rd Generation ACI Biopsy Isolation Replace Repair Restore Regenerate Cells ± Scaffold ± Signas Cytokines GF Propagation Chondrocytes embedded in three dimensionally constructed scaffolds/gel Do not need periosteal cover or stitches Can be trimmed to exactly fit into defect with fibrin glue.

Weak evidence showing : - C-ACI is better than P-ACI Evidence-Based Status of 2nd & 3rd generation ACI Over 1st generation: A Systematic Review of Level I and II Studies (Deepak Goyal et al)Arthroscopy 2013: pp 1-7 1 Weak evidence showing : - C-ACI is better than P-ACI - MACI is comparable with both P-ACI and C-ACI No evidence to support scaffold-based ACI or arthroscopic implantation over first-generation ACI. .

Biomaterials in ACT Biomaterial instead of periosteum cover Scaffold for cell transplantation Pre cultured cell -augmented matrix for implantation Preserving the chondrocytic phenotype

Cellular Joint Repair (Prof George Bentley, London) No difference between ACI and MACI Higher the age of the pt, higher in the failure rate 5 times failure rates with h/o previous procedures Results tend to deteriorate over 10 years ACI is significantly better as 1st line Rx

Newer techniques of cartilage repair Autologus Collagen Induced Chondrogenesis (ACIC) Bone Marrow Aspirate Concentrate (BMAC)

CO2 facilitates the application of gel in dry conditions. Autologous Collagen induced chondrogensis (ACIC): Single-stage arthroscopic cartilage repair technique (Prof AA Shetty, London) Arthroscopic microdrilling and atelocollagen of fibrin gel application under CO2 insufflation. Atelocollagen mixed with fibrinogen and thrombin in a 2way syringe can maintain the shape of the articular surface CO2 facilitates the application of gel in dry conditions.

Arthroscopic technique of ACIC

MSCs for cartilage healing (Prof Alberto Gobbi, Italy) MSCs can be harvested from bone marrow, adipose tissue, synovium etc Spin the aspirate from the bone marrow (Bone marrow aspirate concentrated cells: BMAC) Put the clot on a scaffold membrane and suture to the defect.

1ST Stage cartilage repair of a patellar lesion (BMAC)

CARTILAGE REPAIR Interest expanding at a rapid rate Treat only symptomatic lesions Correct any malalignment, prior

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