1. Cartilage Restoration and Joint Resurfacing Procedures
Phil Davidson, MD
March 2017

2. Introduction Ortho Surgeon – Park City and Cottonwood Heights
New Office in Park City in collaboration with Mountain Land PT & Rehab
Dedicated Knee and Shoulder Surgeon with focus on Cartilage Restoration and Joint Resurfacing
Davidson Orthopedics
Utah Orthopedic Injury & Spine Center
Owner and Medical Director
Clinic treating patients injured in accidents
7 Specialists, multiple fields

3. Biological restoration
Cartilage Restoration and Joint Resurfacing: …an evolving continuum of options, biological thru prosthetic
Biological restoration
Stem Cell therapy Marrow stimulation
Biologic grafts
Scaffolds
Biosynthetics
Prosthetic Resurfacing
Inlay Arthroplasty
Onlay Arthroplasty
Combined Procedures
Total Joint

4. Focused on options between…..
Arthroscopic debridement
Traditional TKA

5. How do we systematically, scientifically and effectively get a handle on these challenging cases?
31 year old UPS worker
39 year old female ski guide

6. Comprehensive Knee Treatment
Biological and Prosthetic Joint Resurfacing not in isolation
Stability
Alignment
Meniscal status
Other compartments

7. Biologic or Prosthetic Resurfacing ???? Key decision making point
Multifactoral decision
Lesion/Cartilage nearby
Patient Factors
Age (biological)
Comorbidities
Joint Status
Expectations of patient
Radiographs, “bone spurs”
Resources

8. Biological Options Marrow stimulation Cell Therapy and scaffolds
MACI now in USA
Limited Efficacy vs. MFX
Biologically Active Scaffolds
Osteochondral Grafts
Autogenous
Allogeneic
Chondral grafts
Cryopreserved living
Minced (DeNovo)
Devitalized
( Biocartilage®)

9. No more microfx, now “Nanofracture”
1x10mm channel
Little risk of subchondral fx
No thermal necrosis
Optimal access for MSCs

10. Nanofracture case- 34 yr old LFC injury adding stem cell therapy in many pts

11. Osteochondral Allograft
Very successful, but somewhat limited
First described in 1908
30+ year reports of success
Using modern storage and implantation techniques multiple authors report success in the 75%+ range
Chondral grafts are a natural progression from our successful OCA history

12. Clinical, Histologic, and Radiographic Outcomes of Distal Femoral Resurfacing With Hypothermically Stored Osteoarticular Allografts P. A. Davidson, D. W. Rivenburgh, P.E. Dawson, and R. Rozin Am. J. Sports Med., Jul 2007; 35:

14. Results: IKDC Scores 0-100 point system Pre-op mean: 27 (range 9-55)
Post-op mean: 79 (range 56-99)

15. Cartiform, what is it. Cryopreserved Processed Chondral Graft …
Cartiform, what is it? Cryopreserved Processed Chondral Graft ….a living biospecific chondral scaffold in conjunction with autologous MSCs
Intended for use with marrow stim, to access autologous MSCs
“Best of both worlds”
Allogeneic living healthy chondrocytes AND autologous MSCs

16. Cartiform - Technique Graft fixation Anchors 1mm –all suture Sutures
5-0 or 6-0 vicryl
Sew right thru fenestration
Fibrin glue- periphery only
Goal: Secure to allow early ROM

17. Turning now to prosthetics…..
29 y.o. mother of 3

18. What is Joint Resurfacing?
An array of bone and soft tissue preserving procedures
Provide smooth articulating surfaces to minimize pain
Retain future options surgically
May be a “bridge”
Principles extend to many joints

19. Transitional thinking from biologics to prosthetics
Once progress in resurfacing algorithm from bio to prosthetic need conceptual framework
Inlay
Onlay
Combination
Bone sacrificing ( traditional)

20. Inlay Joint Resurfacing

21. Inlay Resurfacing Accommodates morphologic variability and size
Intraoperative Topographic mapping
Preserves anatomy, minimal bone resection
Truly an inset, therefore limited mechanical stress

22. Inlay Resurfacing: Anatomical Reconstruction
Accommodate complicated curvatures
Minimally invasive procedure allows for concurrent reconstructions
Inlay Arthroplasty is intrinsically stable as it is literally inset. No edge loading.
Accounts for morphologic variability

23. Inlay – Contoured Articular Prosthesis
Geometry based on patient’s native anatomy
Intraoperative joint mapping
Account for complex asymmetrical geometry
Extension of biological resurfacing

24. Inlay Advantages Able to restore mechanical “smoothness”
Alleviate pain
Avoid or limit propagation of chondral defects
Low volume, prevents encroachment on other parts of joint
Minimally invasive, low morbidity, outpatient procedure
Revision to subsequent arthroplasty is easy due to shallow implant bed with minimal bone resection
Ample room for ACL, osteotomy, soft tissue procedures
Relatively focal treatment preserving healthy adjacent anatomy

25. Inlay allows ample room for other procedures ( ACL reconstruction)

26. PF- Inlay Resurfacing Trochlea alone or Bipolar
Traditional, historic prostheses limited success and rarely used
Inlay device allows for concurrent re-alignment easily, as no overstuffing
Inlay device can handle very advanced PF DJD and morphologic variability
Hypoplastic, aplastic trochlea can be given concavity
Traditional PFA
Inlay PFA

27. 47 year old woman mainly anterior knee pain and swelling Synovitis

28. Loose Body (removal)

29. Normal, healthy medial knee

30. Lateral knee- cartilage damage

31. Patella Gr IV

32. Patella laterally subluxed

33. Patella before and after

34. Femoral Trochlea, Gr IV and dysplastic

35. Lateral Femur, before and after- Inlay

36. Preparing the Femoral Trochlea

37. Radiographs Now 4 years post op VAS pain:(with activity) Preop: 8
KOOS (sport):
Preop: 41
Postop: 84
IKDC:
Preop: 56
Postop: 91

38. Patellar-Trochlea alignment Key step- Patella directly over FTG cannot have poly on cartilage/bone – synovitis and debris

39. UniCAP case example – medial knee resurfacing 46 year old cyclist

40. UniCAP – medial knee resurfacing intact meniscus with central MTP DJD
MFC
MTP

41. UniCAP – medial femur resurfacing

42. UniCAP – medial tibia resurfacing

43. UniCAP – medial knee resurfacing

44. UniCAP – medial knee resurfacing

45. Technical Failure 38 yr old 9 mos post op - no pain relief from unipolar Inlay synovitis, cartilage debris, implant proud, tibial wear, FTG defect

46. Failure Note: “normal” fibrous overgrowth, Implant: asymmetric, proud

47. Inlay removal- revision to Onlay UKA with Inlay FTG

48. Resurfacing & Alignment
Must know alignment, potentially correct or accommodate with resurfacing
Must have long leg standing films available
Inlay conveys very minimal angular correction
Onlay can offer more joint height restoration

49. Onlay Resurfacing Arthroplasty A Uni or partial by any other name???
Onlay optimizes fit of implant to bone
Onlay minimizes bone resection, especially from distal femur
Onlay accounts for alignment and patient specific anatomy using pre-op data acquisition

50. Onlay Resurfacing Very little bone resection on distal femur
Implants custom made from CT scan
More accurate fit may increase longevity
Accommodate morphologic variability, “odd sizes and shapes”

51. Onlay Resurfacing

52. Residual cartilage subjacent to implant removed

53. Holes for implant pegs and cement interdigitation

55. Biologic Treatment - Injured Worker

56. Prosthetic Resurfacing Procedures
7/2/2019
Outpatient or one night stay
Many of these can be done in an ASC
Full WB immediately
Full ROM immediately
Appropriate for “younger” patients and high demand boomers

57. Closing thoughts…..Joint Resurfacing
Retain future options – as much as possible
Resurfacing may be a bridging procedure
Maximize Outcomes
Equal, or better than traditional treatments
Offering additional options to patients that may have had few alternatives

58. Regenerative Orthopedics

59. Evaluation of Patients Injured in Accidents

60. SHOULDER RESURFACING and RESTORATION
Focal Defects
AVN
Instability Defects
Post Traumatic Arthrosis
Osteoarthritis

61. Practical - Referrals UtahOSIC Davidson Ortho
Patients injured in accidents
Spine Surg, Pain Mgt, Knee, Shoulder, Hand/Wrist, Foot/Ankle, Neurology
Davidson Ortho
Knee and Shoulder
2nd Opinions, Evaluations, Treatments/Surgery
BCBS
Select
OON WC
Hybrid

62. Thank You phildavidsonmd@gmail.com www.davidsonorthopedics.com