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De Novo Cartilage and Physical Therapy

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Adam Reece

on 18 February 2014

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Transcript of De Novo Cartilage and Physical Therapy

Rx of Patellofemoral & Tibiofemoral Osteochondral Defects
using PJACA

A review of current
concepts & best evidence

Condyle
Patellae
Decision Making

Procedure
Rehabilitation
Outcomes
Pascual-Garrido, Sept 2013
Tompkins, Oct 2013
Conclusion
Stevens, 2013
Adam Reece, SPT
Bonnie Bylund, PT
References
Conservative
Surgical
Tolerable pain
Absent mechanical s/s
Amenable to NSAIDs, Corticosteriod injections and Physical Rehabilitation
Persistent limitations in function
Failed outcomes with conservative measures
Depth/Size/Location/Status of subchondral bone
<50yoa
Lesion > 0.5cm(sq)
Restorative Procedures
1-4cm(sq) full-thickness
<40yoa
Difficult to perform w/ patellar defect d/t angle of approach (needs to be perpendicular)
Full thickness
1st line - >4.0cm(sq)
2nd line - Secondary treament
Harvested from NWB knee cartilage
Mixed reviews for patellae
"Plug"
1-4cm(sq)
Knee must still possess ligamentous stability
Difficult with patellar defects d/t terrain of articulating surface

DeNovo (PJACAI)
1-5cm(sq)
Patella must demonstrate minimal to absent subchondral bone edema
1 - Diagnostic arthroscopy to confirm location/size of lesion
2 - Parapatellar medial arthrotomy to access patellae
3 - Shape foil template to lesion, measure depth





4 - Extract 3D graft from culture
5 - Cover lesion floor with fibrin glue and implant graft
6 - Assess stability with ROM
Strauss, 2013
Griffin, 2013
Tompkins, 2013
DeNovo Post-op
- 6wks TTWB (AMZ)
- WBAT with brace locked in Ext
CPM: 30 (3wks), 90 (6wks), 120 (8wks)
12-24wks: WBAT, gait training, balance, proprioception
12-18mo: Return to sport/activity
*6mo with microfracture
0-6wks: WBAT
Progress ROM, strengthening
3mo: Sport training
3-6mo: PLOF/activity
Partial WB x6wks
Advance PROM: 30'/2wks, 90' by 6wks, 120' by 8wks
Strength post-op: SLR, quad sets
SAQ at 6wks, PRE as tolerated
3mo: Jogging
4-5mo: Agility drills
6mo: Deep squatting, PLOF/sport
DeNovo Clinical Trial with 12mo F/U
15 Patients (11 patellae, 3 trochlae, 1 both)
Mean age: 30
Outcomes: KOOS, IKDC, MRI T1 & T2
Results:
- 2 cases of graft hypertrophy
- Mild subchondral edema in 90%
- Good to Very Good cartilage fill (54%)
-
Sign. improvement in KOOS and IKDC
Retrospective analysis of a DeNovo Clinical Trial with 2yr (28mo +/- 10) F/U
15 Knees (Grade 4 patellar defect)
Mean age: 26 (+/- 9)
Outcomes: KOOS, IKDC, Pain VAS, Tegner Activity scale, MRI
Results: (no pre- data recorded... only f/u data provided)
- mean fill 89% +/- 19%, 5 cases of graft hypertrophy
- Pt's returned to "a" recreational level but not PLOF
- Low VAS values
- Similar
KOOS and IKDC values as Pascual-Garrido
youngest donors = greater risk of implant hypertrophy

Oldest donors = greater risk of poor healing
1-5cm(sq) ~ Grade 4
Absent/mild subchondral edema
0-6wks post-op: TTWB - WBAT (with hinge brace), PROM with goal of 90 degree flexion
7wks - 2mo: WBAT, gait training, balance, proprioception
3mo: Initiate return to sport training
6mo: Return to sport/activity
Case report
44yo
Female c/o medial knee pain
PMHx: 2 partial medial meniscectomies
- poor reduction in s/s
Pre-op MRI: genu varus, full-thickness medial femoral condyle lesion (22mm x 33mm) -
7.6cm(sq)
Op #1: Denovo + tibial wedge osteotomy
- VAS pre 8/10, post 3/10
- 7mo MRI f/u: 8mm x 22mm lesion present
- 13mo: Pt c/o worsening knee s/s (VAS 5/10)
Op #2: Removed wedge hardware + OATs
- Area of residual lesion directly opposed previous partial meniscectomy
- Continued to have pain with activity
Op #3 @ 28mo: Medial unicompartmental Arthroplasty
Donor age, proprietary method used
Histological Assessment:
1. Good healing of DeNovo graft @ 7mo
2. DeNovo near OAT = hyaline like
3. DeNovo away from OAT = fibrocartilage
Future Research
1. McCormick F, Cole B, Nwachukwu B, Harris J, Adkisson D, Farr J. Treatment of focal cartilage defects with juvenile allogeneic 3-dimensional articular cartilage graft.
Oper Tech Sports Med
. 2013; 21: 95-9.
2. Tompkins M, Hamann J, Diduch D, et al. Preliminary results of a novel single-stage cartilage restoration technique: particulated juvenile articular cartilage allograft for chondral defects of the patella.
J Arthrosc Relat Surg
. 2013; 29: 1661-70.
3. Bonner J, Daner W. 2-year postoperative evaluation of a patient with a symptomatic full-thickness patellar cartilage repaired with particulated juvenile cartilage tissue. J Knee Surg. 2010; 23:109-14.
4. Strauss E, Galos D. The evaluation and management of cartilage lesions affecting the patellofemoral joint.
Curr Rev Musculoskelet Med
. 2013; published online.
5. Griffin J, Gilmore J, Miller M. Treatment of a patellar chondral defect using juvenile articular cartilage allograft implantation.
Arthroscop Tech
. 2013; 2: e351-54.
6. Pascual-Garrido C, Gold S, Snikeris J, Burge A, et al. Magnetic Resonance Imaging and clinical evaluation of chondral lesions treated with allografts juvenile cells.
Ortho J Sports Med
. 2013; XX: 1-2.
7. Stevens H, Shockley B, Willett N, Lin A, Raji Y, Guldberg R, Labib S. Particulated juvenile articular cartilage implantation in the knee: a 3-year EPIC-uCT and histological examination.
Cartilage
. 2013; XX: 1-4.
8. Farr J, Yao J. Chondral defect repair with particulated juvenile cartilage allograft. Cartilage. 2011; 2: 346-53.
Strauss E, Galos D. The evaluation and management of cartilage lesions affecting the patellofemoral joint.
Curr Rev Musculoskelet Med
. 2013; published online.
Strauss E, Galos D. The evaluation and management of cartilage lesions affecting the patellofemoral joint.
Curr Rev Musculoskelet Med
. 2013; published online.
Strauss E, Galos D. The evaluation and management of cartilage lesions affecting the patellofemoral joint.
Curr Rev Musculoskelet Med
. 2013; published online.
Strauss E, Galos D. The evaluation and management of cartilage lesions affecting the patellofemoral joint.
Curr Rev Musculoskelet Med
. 2013; published online.
Strauss E, Galos D. The evaluation and management of cartilage lesions affecting the patellofemoral joint.
Curr Rev Musculoskelet Med
. 2013; published online.
McCormick F, Cole B, Nwachukwu B, Harris J, Adkisson D, Farr J. Treatment of focal cartilage defects with juvenile allogeneic 3-dimensional articular cartilage graft.
Oper Tech Sports Med
. 2013; 21: 95-9.
Strauss E, Galos D. The evaluation and management of cartilage lesions affecting the patellofemoral joint.
Curr Rev Musculoskelet Med
. 2013; published online.
Griffin J, Gilmore J, Miller M. Treatment of a patellar chondral defect using juvenile articular cartilage allograft implantation.
Arthroscop Tech
. 2013; 2: e351-54.
Tompkins M, Hamann J, Diduch D, et al. Preliminary results of a novel single-stage cartilage restoration technique: particulated juvenile articular cartilage allograft for chondral defects of the patella.
J Arthrosc Relat Surg
. 2013; 29: 1661-70.
Pascual-Garrido C, Gold S, Snikeris J, Burge A, et al. Magnetic Resonance Imaging and clinical evaluation of chondral lesions treated with allografts juvenile cells.
Ortho J Sports Med
. 2013; XX: 1-2.
Stevens H, Shockley B, Willett N, Lin A, Raji Y, Guldberg R, Labib S. Particulated juvenile articular cartilage implantation in the knee: a 3-year EPIC-uCT and histological examination.
Cartilage
. 2013; XX: 1-4.
Tompkins M, Hamann J, Diduch D, et al. Preliminary results of a novel single-stage cartilage restoration technique: particulated juvenile articular cartilage allograft for chondral defects of the patella.
J Arthrosc Relat Surg
. 2013; 29: 1661-70.
Strauss E, Galos D. The evaluation and management of cartilage lesions affecting the patellofemoral joint.
Curr Rev Musculoskelet Med
. 2013; published online.
Case Report (Abstract only)
36-year-old male, full-thickness patellar defect
2yr f/u
Outcomes: IKDC, KOOS, MRI
Results:
- full defect fill
- "Substantial" changes in pain and function
- 1st case report of DeNovo with 2yr f/u

Bonner & Daner, Oct 2010
Bonner J, Daner W. 2-year postoperative evaluation of a patient with a symptomatic full-thickness patellar cartilage repaired with particulated juvenile cartilage tissue. J Knee Surg. 2010; 23:109-14.
Farr & Yao, 2013
Multi-center, prospective, single-arm,
25-patient study
Outcomes measured: IKDC, KOOS, MRI, & optional biopsy up to 5yrs
25 patients enrolled at time of publication but only
4 had met 24mo f/u
Pt 1: 38yo male w/
trochlear
groove lesion
Pt 2: 46yo female w/
medial femoral condyle
lesion
Pt 3: 39yo male w/
lateral femoral groove
lesion and
trochlear
lesion
PMHx: partial medial meniscectomy
Pt 4: 49yo male w/
trochlear
lesion
PMHx: cartilage debridement, partial medial meniscectomy
Detailed Results not provided
= authors are waiting for all 25 patients to reach 24mo f/u
General Results
- Good defect filling, improvements in IKDC, KOOS and pain VAS
most improvements were
reached by 12mo f/u
Farr J, Yao J. Chondral defect repair with particulated juvenile cartilage allograft. Cartilage. 2011; 2: 346-53.
Full transcript