1. 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.

2. Grading of cartilage lesions

3. 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

4. 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

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

6. 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

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

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

9. 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

10. 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

11. Evidence-Based Status of Microfracture Technique: A Systematic Review of Level I and II Studies Deepak Goyal et al (Arthroscopy: 29 (9) , , 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.

12. 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

13. 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

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

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

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

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

18. 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

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

22. 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.

23. 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.

24. 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. .

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

26. 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

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

28. 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.

29. Arthroscopic technique of ACIC

30. 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.

31. 1ST Stage cartilage repair of a patellar lesion (BMAC)

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

34. THANK YOU