Transcript Treating Injured Knees and Shoulders: Cartilage Restoration and Joint Resurfacing offering solutions for patients of all ages Philip A.

Treating Injured Knees and Shoulders:
Cartilage Restoration and
Joint Resurfacing
offering solutions for patients of all ages
Philip A. Davidson, MD
Heiden Davidson Orthopaedics
2012
Cartilage Restoration and Joint Resurfacing
A wide realm between…..
Arthroscopic debridement
Traditional TKA
The problem:
29 y.o. mother of 3
Former elite skier
Goals of Cartilage Restoration &
Joint Resurfacing
– Relieve pain
– Optimize function, sport
and activities
– Improve mechanics
– Long lasting
– Prevent or limit future
degenerative dhanges
– Retain future options
surgically
– Principles extend to many
joints
Cartilage Restoration and Joint Resurfacing Treatments:
…THE BIG PICTURE
• Debridement (clean up)
• Marrow stimulation
• Biological Restoration
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Biologic grafts
Biosynthetics
Scaffolds
Cellular therapy
• Prosthetic Resurfacing
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Metals and Plastics
Inlay Arthroplasty
Onlay Arthroplasty
Total Joint
Goal of Cartilage Restoration
Restore Specialized Articular Cartilage
Marrow Stimulation
• Techniques
- Drilling
- Picking
- Abrasion
- Microfracture
• Marrow stimulation results:
- Fibrocartilage
• Limited potential with
increased age, injury
chronicity
• Cheap, fast, easy
– Short term efficacy seductive.
Biological
Options
• Cell Therapy
• Osteochondral Grafts
– Autogenous
• Limited use
– Allograft
• Juvenile Cartilage Grafts
– Minced grafts
• Biologically Active
Scaffolds
Bone and Cartilage Grafts
• Autograft (self donor)
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No donor needed
Limited availability
Small lesions only
Repair Broken Cartilage
• Allograft (OCA)
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Human Donor
Very effective
Young patients
Handle Bone loss
Larger lesions
• Generally > 2 cm²
OCA– When is this done?
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Larger defects
Deeper defects
Bone loss
Patellofemoral
Younger Patients
Osteochondritis
Otherwise healthy joint
OCA donor tissue
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Fresh Stored ( < 30 days)
Germ Surveillance
Donor Testing/Screening
Limited Availability
Expensive
No game day decisions
No anti-rejection drugs
OCA- Procedure
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OCA- Procedure
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OCA- Procedure
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OCA- Procedure
OCA- Procedure
OCA- Procedure
What if biologics will not or cannot work?
…too large, no longer “young”, obese, smoking,
……..Or just plain worn out
Prosthetics - Joint Resurfacing
Biologic or Prosthetic Resurfacing ????
Key decision making point
• Multifactoral decision
– Lesion/Cartilage nearby
– Patient Factors
– Age (biological)
– Comorbidities
– Joint Status
– Resources
Decision Making – Bio vs. Prosthetic
Joint Shape
• Biologic Solutions are
less likely to work in
joint which has lost
shape or is “crooked”
Transitional thinking from biologics
to prosthetics
• Once planning
progresses to
resurfacing need
conceptual framework
1. Inlay
2. Onlay
3. Bone sacrificing
(
traditional)
Inlay Joint Resurfacing
Inlay Resurfacing
• Accommodates
different shapes and
sizes
• Intraoperative surface
mapping
• Preserves anatomy,
minimal bone resection
• Ways to think about
Inlay:
– “filling a cavity”
– “new tiles on the floor”
– “patching a tire”
Inlay Resurfacing:
Anatomical
Reconstruction
• Accommodate complicated
curvatures
• Minimally invasive procedure
allows for other
reconstructions at same time
• Inlay Arthroplasty is stable
• Accounts for different sizes
and shapes of persons and
joints
Inlay – Contoured Articular Prosthesis
• Geometry based on
patient’s native
anatomy
• Intraoperative joint
mapping
• Account for complex
asymmetrical geometry
• Extension of biological
resurfacing
InlayPlatform Technology
• Multiple Joints
• Multiple sizes and
shapes
• Metallic Inlay in
conjunction with stud
or set-screw
• Poly (special plastic)
Technology uses
cement in socket
Patellofemoral
(knee cap joint)
Inlay Resurfacing
• Trochlea alone or Bipolar
• Traditional prostheses
limited success and rarely
used
• Inlay device allows for
realignment easily, as no
overstuffing
• Inlay device can handle
very advanced PF DJD and
morphologic variability
Traditional PFA
Inlay PFA
Case # 1 – 42 year old female
Case #1
Case #1
Inlay Unicompartmental
resurfacing arthroplasty
aka….UniCAP™scope assisted Uni, AKR , etc..
Cementation
UniCAP case example –
medial knee resurfacing 46 year old cyclist
UniCAP – medial knee resurfacing
UniCAP – medial knee resurfacing
UniCAP – medial knee resurfacing
UniCAP – medial knee resurfacing
UniCAP – medial knee resurfacing
Minimum 5-year results of focal articular prosthetic resurfacing
for the treatment of full-thickness articular cartilage defects
in the knee.
Becher, C. et.al. Arch Orthop Trauma Surg . DOI 10.1007/s00402-011-1323-4. June, 2011.
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21 patients, mean age 54 yrs, minimum f-u 5 yrs, small focal unipolar lesions
KOOS scores improved significantly (P < 0.005)
– pain (51.1 to 77.6),
– symptoms (57.9 to 79.5),
– ADL (58.8 to 82.4),
– Sports (26.3 to 57.8)
Tegner activity level
– improved significantly (P< 0.02) from 2.9 to 4.
SF-36(physical) increased by 15.2 to 46.9 compared to the preoperative value
16/21 of the would have the operation again.
Radiographic results:
– solid fixation, preservation of joint space and no change in the osteoarthritic
stage.
Inlay Shoulder Resurfacing
ANATOMIC INLAY RESURFACING FOR
GLENOHUMERAL OSTEOARTHRITIS
Clinical Results in a Consecutive Case Series
Shoulder Resurfacing StudyPatient Population
• N = 48
– Males – 29
– Female – 19
• Mean age at surgery
– 61 years
• Follow-up
– 3 years
• Concurrent Procedures
– Rotator Cuff Repair
• 12
– Subacromial Decompression
• 25
– Distal Clavicle Resection
• 23
– Biceps Tenodesis
• 2
– Biceps Tenotomy
• 21
– Capsulolabral Repair
• 5
– Hardware Removal
• 1
HemiCAP in OA
Simple Shoulder Test
12
10
8.7
8
9.4
10.3
7.5
6
4
3.2
2
0
Pre-Op 6 Mo
PostOp
1 Yr
PostOp
2 Yr
PostOp
3 Yr
PostOp
VAS Pain
10
9
8
7
6
5
4
3
2
1
0
At Rest
With Activity
Today
Pre-Op
6 Mo
1 Yr Post- 2 Yr Post- 3 Yr PostPost-Op
Op
Op
Op
NO reported loosening of implant in
the shoulder
No signs of
- Device disengagement
- Progressive
periprosthetic
radiolucency
- Implant subsidence
Osteoarthritis treatment: Resurfacing!
• Removal of bone
spurs
• Soft tissue releases
• Treat ALL conditions
of shoulder
CONCLUSIONS
Shoulder Resurfacing with
HemiCAP for Glenohumeral
Osteoarthritis
• Short term (3 year)
results very encouraging
• Restoration of native
anatomy
• Comprehensive
pathology treatment is
key
• Excellent option for
primary OA of Shoulder
Combining Inlay and Onlay
Technologies
Combining Inlay and Onlay
Technologies
Case #2
32 year old female rancher
• Neutral
alignment
• Told she
needed a TKA
• Healthy, ideal
body weight
PFJ
MFC
Radiographs
Resurfacing & Alignment
• Must know alignment,
potentially correct or
accommodate with
resurfacing
• Must have long leg
standing films
available
• Inlay does not restore
joint height
• Onlay can offer more
joint height restoration
Onlay Resurfacing Arthroplasty
A Uni or Partial by any other name???
• Onlay optimizes fit of
implant to bone
• Onlay minimizes bone
resection
• Onlay accounts for
alignment and patient
specific anatomy
using pre-op data
acquisition
Onlay Resurfacing
• Very little bone cut off
• Implants custom
made from CT scan
• More accurate fit may
increase longevity
• Accommodate
morphologic
variability, “odd sizes
and shapes”
Case #4
Onlay
Biologic Treatment - Injured Worker
Prosthetic Resurfacing Procedures
• Outpatient or one night
stay
• Full WB immediately
• Full ROM immediately
• Appropriate for
“younger” patients and
high demand boomers
Updating Traditional TKA
• Pre op limb imaging can yield data about bone shape , size
and alignment
• Alignment, sizing and intended corrections can be
precisely calculated preoperatively
• This digital information can be used to plan, create cutting
guides and manufacture implants
• Increases precision
• Increases efficiency by: decreasing OR time, instruments,
and inventory
• May lessen or obviate the need for intraoperative
navigation systems
• Saves time and money while potentially making
outcomes more predictable and ultimately better.
Updating Traditional TKA
• Pre-op templated
cutting guides/blocks
• Avoid/minimize
intraoperative intra and
extra medullary
alignment guides
• These traditional guides
can be used as “doublecheck”
Updating Traditional TKA
• Bicruciate preserving
resurfacing devices
• Onlay 3
compartments
• Pre-commercial
prototype
Closing thoughts…..Joint Resurfacing
• Excellent Option for many,
but not all, patients
• 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 to
Total Joint
Future Trends
– “Geographic” , biologic , or
large area contoured
resurfacing for DJD
– Combining biologics with
prosthetics
– Enhanced biomaterials for
resurfacing implants,
nanotechnology
– Decreasing the time and costs
associated with patient specific
implants and instruments
– Both patient demand and cost
containment will drive the
need for more precise, less
invasive joint resurfacing
Thank You
[email protected]
Office: 435-615-8822
www.orthoparkcity.com