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Joint Preservation Overview for Shoulder, Hip and Knee Daniel C. Eby, DO
Joint Preservation Overview for Shoulder, Hip and Knee
Daniel C. Eby, DO
Daniel C. Eby, DO
Orthopedic Surgery
St. Thomas Medical Center
Jasper, IN
Disclosures
• Nothing to disclose
Our highly-trained medical staff hopes to serve you for your orthopedic needs!
Meet the Staff
Physical Therapy Front Office & Billing
Physical Therapy
Hydrotherapy Pool with Therasauna
Shoulder Preservation
Shoulder AnatomyOrigins and insertions of the muscles about the shoulder girdle. Left, Anterior view. Right, Posterior view. Miller Review of Orthopedics, 5th Edition, (From Jenkins DB: Hollinshead's Functional Anatomy of the Limbs and Back, 6th ed, Fig. 5–3. Philadelphia, WB Saunders, 1991.)
Glenohumeral Ligaments and Rotator Cuff Tendons
FIGURE 2–1 Glenohumeral ligaments and rotator cuff muscles.
Miller Review of Orthopedics, 5th Edition, (From Turkel SJ, Panio MW, Marshall JL, et al: Stabilizing mechanisms preventing anterior dislocation of the glenohumeral joint. J Bone Joint Surg [Am] 63:1209, 1981.)
Shoulder Exam
• Active and Passive ROM testing on Forward flexion, Abduction, Internal/External Rotation
• Impingement—Neer, Hawkins• Strength analysis
– Jobes Drop Shoulder—supraspinatus– Speed’s—long head of biceps– O’brien’s—biceps anchor, labrum
• Stability analysis– Apprehension test– Relocation test– Sulcus sign
Shoulder Exam
• Belly Press test, Lift off test—subscapularis
• AC joint
• Imaging in office with xray, ultrasound
• Consider MRI for evaluation of rotator cuff/labral tear
Impingement Testing
Diagnostic and Operative Arthroscopy, Andrews and Timmerman, pp. 78-79
Jobe’s Drop Shoulder Test
Diagnostic and Operative Arthroscopy, Andrews and Timmerman, pp. 78-79
JAAOS, Oct 2013, Vol. 21 (10), pg. 615
Clinical photograph of infraspinatus atrophy found on exam
Sleeper Stretch for Glenohumeral Internal Rotation Deficit
Surgical Techniques of Shoulder, Elbow, Knee in Sports Medicine, Cole, Sekiya, Pg. 91
Rotator Cuff
• Impingement Syndrome—Nonoperativetreatment
• Corticosteroid injections– Subacromial Injection test performed with steroid,
anesthetic, contrast dye and subsequently radiographed
– Best approach in Females• Anterior (84% accuracy)• Lateral (92% accuracy)• Posterior (56% accuracy)
– No statistical difference in injection accuracy in Males
Journal of American Academy of Ortho Surgeons, October 2013, Vol. 21 (10), page 642
• “Surgical techniques to enhance the biology of the repair site and improve mechanical stability should be used whenever possible.”
• “Recognizing the tear pattern and performing an anatomic, tension-free repair provides the best chance for success. Microfracture of the healing bed of the greater tuberosity and use of vented suture anchors allow marrow contents from the humerus to bathe the repair site and facilitate healing.”
Rotator Cuff Tear Fixation
Factors which affect cuff repair
• Decreased tendon vascularity with normal aging
• Increased collagen fragility
• Muscle atrophy
• Fatty infiltration of chronic cuff tendon tear
Atrophy and Degeneration
• Fatty degeneration and muscle atrophy associated with higher retear rates.
– Caused by mechanical unloading and denervation
• Mechanical unloading increases the pennationangle
– Allows fat, fibrosis to fill in the spaces between reoriented muscle fibers. Muscle fibers themselves did not regenerate.
Fatty Infiltration of the Cuff
• Physical Exam Findings:
– Supraspinatus and/or Infraspinatus atrophy often found with severe cuff disease
– Stage 3, 4 Fatty infiltration of Infraspinatus, Teres Minor found with more severe cuff pathology
Shoulder
• Conservative treatment
• Arthroscopy
– DJD, loose bodies
– Labral tear, instability
– Rotator cuff tear, subacromial impingement
– Massive cuff tears that are irrepairable with arthroscope:
• Open augmentation with Graft Jacket
• Superior Capsular Reconstruction
Preoperative Ultrasound Guided Interscalene Nerve Block
Shoulder Arthroscopy
Shoulder Arthroscope
Arthroscopy Back Table Setup
Arthroscopy Burr and Shaver
Anterior Labral Repair with suture knots
Labral Tape
Tear prior to repair Fixation with Knotless Tape
Positive “Drive Through” Test for Shoulder Instability
Capsular Plication for Shoulder Instability
Bony Bankart/Glenoid Rim Fracture with labral repair
Acromioplasty for Impingement
Humeral Head Microfracture
Partial Articular-sided and Bursal Surface Rotator Cuff tear Debridement
Subscapularis Tubularization Repair
Coracoplasty with Subscapularis Repair
High Grade Partial Cuff Repair
Rotator Cuff Calcific Tendinitis
• Epidemiology
– 3-8% of population
– 10% require surgery
– 40-50% symptomatic
• 80% supraspinatus
• 15% infraspinatus
• 5% subscapularis
– Pathogenesis
• Formative, Resting, Resorptive (symptomatic)
Risk Factors for Calcific Tendinitis
• Subacromial Impingement
• Insulin Dependent Diabetes Mellitis
• Female > Males
• Age 40-60 years
• Indications:
– Severe disabling pain with ADL’s
– > 6 mos duration
– Failure of nonoperative treatment
Physical Exam
• +/- crepitus
• Limited ROM with pain at 70-110 degrees of active forward flexion/abduction
• Impingement
Excision Calcific Tendinitis with Cuff Repair
Small Bursal Surface Cuff Repair
Medium sized full thickness cuff tear with double row fixation
Massive cuff repair with Speedbridgetechnique
Open cuff repair with Patchgraftaugmentation
Biceps Long Head Release
Soft Tissue Biceps Tenodesis
Bony Biceps Tenodesis
Bony Biceps Tenodesis with Rotator Cuff Repair
Traditional Total Shoulder Replacement Arthroplasty
AP projection Lateral projection
Reverse Total Shoulder Replacement Arthroplasty
AP projection Lateral projection
The Journal of Bone & Joint Surgery, Volume 95, Issue 10Scientific Articles | May 15, 2013Comparison of Functional Outcomes of Reverse Shoulder Arthroplasty with Those of Hemiarthroplasty in the Treatment of Cuff-Tear Arthropathy: A Matched-Pair Analysis
Simon W. Young, FRACS1; Mark Zhu, MBChB1; Cameron G. Walker, PhD2; Peter C. Poon, FRACS1
J Bone Joint Surg Am, 2013 May 15;95(10):910-915. doi: 10.2106/JBJS.L.00302
Rotator cuff tears arthropathy has been a challenge to arthroplasty surgeon. Poor results of conventional TSA and cuff deficit shoulders due to glenoid component loosening have led to hemiarthroplasty being the preferred surgical option. This study showed that those with reverse shoulder arthroplasty resulted in a functional outcome superior to hemiarthroplasty.
Use of Orthobiologics
Use of Biologics
• Used in the treatment of rotator cuff disease
• Low Vitamin D levels slowed early cuff healing (Angeline et al)
• Mesenchymal stem cells augment cuff healing (Gulotta et al)
• Injection of adipose derived stem cells showed better healing, less atrophy/fatty infiltration and improved strength (Olt et al)
Biological Cuff Repair Augmentation
• Platelet Rich Fibrin Matrix (PRFM) added to the cuff repair found no beneficial effect (Rodeo et al)
– PRP remains highly controversial
• Acellular Human Dermal Matrix Graft augmentation being used on 2 tendon cuff tears
– Avg. 2 years f/u outcomes showed augmented group had superior outcomes and healing
– 85% healing with augment graft, 45% healing in unaugmented group
Shoulder Biologics
• Cole: Biopatch/Biocartilage
– Micronized Cartilage Scaffold
– Aseptically processed with 5 yr shelf life
– Mix into paste with PRP or BMC and spread over OCD lesion following microfrx
– Fixated with Fibrin glue patch
Adult Human Mesenchymal Stem Cells Delivered via Intra-Articular Injection to the Knee Following Partial Medial Meniscectomy: A Randomized, Double-Blind, Controlled Study
C. Thomas Vangsness, Jr., MD1; Jack Farr, II, MD2; Joel Boyd, MD3; David T. Dellaero, MD4; C. Randal Mills, PhD5; Michelle LeRoux-Williams, PhD5
Conclusions: There was evidence of meniscus regeneration and improvement in knee pain following treatment with allogeneic human mesenchymal stem cells. These results support the study of human mesenchymal stem cells for the apparent knee-tissue regeneration and protective effects.
J Bone Joint Surg Am, 2014 Jan 15;96(2):90-98
Hip Preservation
Greater Trochanteric Pain Syndrome
• 10-25% population
• Most commonly affects women age 40-60
– Wide pelvic morphology
• Gluteus medius/minimus laterally with associated bursae and Iliotibial Band (peritrochanteric compartment)
• Piriformis, Obturator internis/externus medially
Peritrochanteric Hip Pain
• Trochanteric Bursitis viewed as secondary diagnosis
– Femoracetabular DJD
– CAM/Pincer Impingement
– Labral Tear
– Gluteus Medius/Minimus tears
– Lumbrosacral Radiculopathy
Peritrochanteric Pain Differential Dx
The Adult Hip/Hip Preservation Surgery, Clohisy pg. 328, Table 30.1
Peritrochanteric Bursae
• Subgluteus maximus Bursa– Most common– “trochanteric bursa”– Innervated by branches of obturator, femoral and
sciatic nerves
• Subgluteus minimus bursa– 3 separate bursa with largest at apical greater
trochanter
• Gluteus minimus bursa– Deepest, inserts onto anterior greater troch,
communicates with subgluteus medius
Iliotibial Band
• Tightest at hip during full extension of hip/knee with hip adduction
• “Snapping phenomenon”
– Taut band slides anterior over greater trochanter in hip flexion, slides back posterior in hip extension
Peritrochanteric Pain Exam
A: Palpation of Greater Trochanter
B: Resisted hip abduction with knee flexion
C: Resisted hip abduction with knee extension
D: FABER test—Troch pain with hip flexion, abduction, external rotation
The Adult Hip/Hip Preservation Surgery, Clohisy pg. 302, Fig 27.3
Snapping Hip
• ‘External Coxa Saltans’
• Symptomatic
– Late teens, early 20’s
– Active lifestyle
Snapping Hip
• Exam– Pt placed lateral recumbent, affected side up
– Palpate greater trochanter while patient actively flexes hip
– Diagnosis confirmed if pressure applied over proximal greater trochanter prevents snapping with repeated hip flexion
• Majority asymptomatic or can be treated with rest, activity modification, stretching, NSAIDs, PT or corticosteroid injections
Snapping Hip
• Conservative
• Surgical
– Bursectomy
– ITB Lengthening for bursitis and Snapping Hip syndromes
“Snapping Hip”
Endoscopic ITB Lengthening using the diamond shaped defect technique
The Adult Hip/Hip Preservation Surgery, Clohisy pg. 306, Fig 27.8
External Snapping Hip Syndrome
• Produced by posterior thickening of iliotibial band, anterior thickening of gluteus maximus
• Voluntary– “hip dislocates”– Asymptomatic: normal occurrence
– Symptomatic: Greater Trochanteric pain
– Frequently painless
– Tx with ITB stretching only
• If Trendelenberg gait found, consider associated abductor muscle tear– Single Leg stance in 10 sec intervals; (+) within 20 secs
Ober Test
The Adult Hip/Hip Preservation Surgery, Clohisy pg. 329, Fig 30.4
Iliotibial Band
Endoscopic ITB release
Diamond shaped window allows greater trochanter to move freely within defect
The Adult Hip/Hip Preservation Surgery, Clohisy pg. 346, Fig 31.9
Internal Snapping Hip Syndrome
• Produced by iliopsoas tendon snapping over iliopectineal eminence or femoral head
• Can occur without pain in up to 10% of population– Considered normal occurrence
• > 50% have associated intra-articular hip pathology
• Examined with patient supine, flex hip > 90 deg, then extending to neutral– May be accentuated with abduction/external rotation
in flexion and adduction/internal rotation in extension
Internal Snapping Hip Syndrome
Audible snap with maneuvers…cannot be seen through skin
Palpate snap with placement of hand directly over groin
The Adult Hip/Hip Preservation Surgery, Clohisy pg. 349, Fig 31.11-12
Gluteus Medius Tear
• Analogous to Shoulder Rotator Cuff Tear
• 25% female, 10% male; 4:1 female incidence
• Conservative– Rest, NSAIDs, PT for ROM/strengthening
• Surgical– Persistent pain, weakness adversely affecting ADLs
– Voos et al: 10/10 pts reported complete pain resolution, 9/10 regained full abduction strength following arthroscopic repair at average follow up of 25 months
Surgical Positioning for Open Gluteus Medius Repair
Gluteus Medius Repair Back Table Setup
Open Gluteus Medius Repair
Hip Impingement
• Pincer. This type of impingement occurs because extra bone extends out over the normal rim of the acetabulum. The labrum can be crushed under the prominent rim of the acetabulum.
• Cam. In cam impingement the femoral head is not round and cannot rotate smoothly inside the acetabulum. A bump forms on the edge of the femoral head that grinds the cartilage inside the acetabulum.
• Combined--both the pincer and cam types are present. – Orthoinfo.aaos.org
Pincer Impingement
Hip Injection Arthrogram
Flow chart outlining utilization guidelines for prearthritic hip disorders
The Adult Hip/Hip Preservation Surgery, Clohisy pg. 127, Fig 11-3
Hip Injection Arthrogram
The Adult Hip/Hip Preservation Surgery, Clohisy pg. 127, Fig 11-2
Labral Tear
The Adult Hip/Hip Preservation Surgery, Clohisy pg. 279, Fig 25-16
Hip Replacement--Anterior vs Posterior approach
• Anterior is more muscle sparing leading to quicker function and less need for hip precautions.
• Anterior requires use of intraoperative fluoroscopy. There is less visual exposure of the acetabulum.
• Marketing is really driving the Anterior approach in some areas.
Anterior approach for THA
Posterior approach for THA
Knee Preservation
Types of Knee Treatment
Conservative
• NSAIDs
• Steroid injections
• Viscosupplementation
• Bracing
• Topical trx
• Nutritional Supplements/Vitamins
• PRP, Stem cells
• Acupuncture
Surgical
• Prevention
• Debridement
• Marrow stimulation
• OATS
• Scaffolds
• Cell based therapies
• Osteotomy
• Osteochondral Allografts
• UKA
• TJA
J Am Acad Orthop Surg 2014; 22: 256-60
Management of Patellofemoral Pain Syndromes
• Quad, Hip, Core stretch/strengthening PT program most effective
• PT tried for 8 weeks
• If failed with PT, consider knee ATS with lateral release
Video of Lateral Retinacular Release
Percutaneous Ultrasound Tenotomy
• Macroscopic level- Removes scar tissue– U/S Ablation
– Suction
• 3-Year Level IV Data– Decreased Tendon Thickness
– Decreased Hypervascularity
– Clinical Outcome Scores• Sustained patient satisfaction, Improved Function with
Decreased pain scores» Seng and Morrey AJSM 2016
Tenex Patellar Tendon Knee
Video of Knee ATS with Medial/Lateral Menisectomy
Video of Knee Microfracture of Femoral Sulcus with Medial Patellar Facet OCD lesion drilling
Video of Medial Meniscus Repair
Video of ACL Reconstruction using Bone Tendon Bone Autograft
Unicompartment Knee Replacement
- Used for isolated single compartment degenerative joint disease with intact ACL.
- Biomet Oxford
- Can be done on outpatient or overnight stay with pain block
Unicompartment Arthroplasty
Total Knee Replacement- Dr. Eby uses the DePuy Rotating
Platform knee
- Used in tricompartmentaldegenerative knee disease
- ACL sacrificed
- Mobile polyethylene bearing moves in relation to tibia
- Polyethylene patellar component
- Performed with regional femoral nerve block, spinal anesthetic
- Ambulating on same day post-op, usually with walker, knee immobilizer
- 0-3 day hospital stay with frequent daily therapy
- We can now perform same-day joint replacement on outpatient basis with improving regional anesthetic techniques and ultrasonographic guidance.
Total Knee Arthroplasty
Cutting Edge Treatments for the Knee:
Subchondroplasty®
1. Synovium: Inflammation
2. Cartilage: Defects
3. Ligaments: Tears
4. Meniscus: Degeneration
5. Subchondral Bone: Edema / Lesions
Why Does My Knee Hurt?
1
23
45
What Is Subchondral Bone?
Healthy Subchondral Bone:
• Provides support for cartilage
• Distributes joint loads vertically &
horizontally
108
Bone Marrow Lesion (BML)
Concentrated Stress
109
Healing
Stress
BML’s are a common occurrence, even in healthy knees, from over-exertion of subchondral bone
HEALTHY BONE: Heals BML’s during the natural healing process
PATIENTS WITH JOINT DEGENERATION (cartilage, etc.) or OTHER RISK FACTORS:
Prolonged, localized stress leads to chronic BML’S that lack the ability to heal naturally
How Does Subchondral Bone Become Damaged?
Everyday Stresses on Healthy Bone
What Are Bone Marrow Lesions (BML’s)?
BML Characteristics1:
• Micro-cracks / defects (like a stress fracture)
• Represent a healing response surrounding
insufficiency fractures
• Chronic inflammation associated with
structurally altered bone
• Often underlies cartilage defect
• Weakened bone at site of defect
110
** Above data represents published results from various clinical studies on BML’s (see “References” slide)
Are BML’s a Big Deal?
If Left Untreated, BML’s Are . . .
• Known to cause pain2 & decrease knee function3
• Strongly associated with cartilage loss4,5
• A potent risk factor for structural deterioration6
Impact on Other Knee Treatments:
• Untreated BML’s show reduced benefits from arthroscopy7
• ~9x as likely to progress rapidly to Total Knee Replacement8
**Above data represents published results from various clinical studies on BML’s (see “References” slide)
• Visible ONLY on T1 & T2 MRI’s – best observed on fat-suppressed T2
• Palpation of area above MRI-identified BML elicits pronounced pain response
• Clinical diagnoses may be in combination with mechanical symptoms
112
How Are BML’s Diagnosed?
Heal Bone
113
1 2 3Diagnose BML w/ MRI Treat Bone Defect w/ SCP®
Minimally Invasive Procedure that Fills & Repairs
Bone Defects Associated w/ BML’s
The Subchondroplasty® (SCP®) Procedure
Osteotomy
• Used to correct alignment
• Lasts up to 15 years
• Preserves native joint
• 6 month recovery time
What Are My Other Options? Treatment Alternatives – Surgical
Post-Op X-Ray
115
Advantages:
• Only Treatment Option that Specifically Treats Defects Associated w/ BML’s
• Minimally invasive procedure:
– Does not limit future care options
– Preserves natural joint
– Bone substitute is remodeled into new bone while healing
• Recovery Time: Most patients are back to work w/in 1 week9
• Proven Results: Pain relief & increased function as early as 2 weeks; shown to last over 5 years9
Treating BML’s with Subchondroplasty®
**Based on preliminary data from clinical study conducted on SCP® (see “References” slide)
Post-Op X-Ray
1. Gigena et al. Transient bone marrow edema of the talus: MR imaging findings in five patients. Skeletal Radiol. 2002; 31(4):202-7.
2. Felson et al. The Association of Bone Marrow lesions with Pain in Knee Osteoarthritis; Annals of Internal Medicine 2001; 134: 541-549.
3. Sowers et al. Associations of Anatomical Measures from MRI with Radiographically Defined Knee OA Score, Pain, and Function; JBJS Am. 2011; 93: 241-251.
4. Hunter et al. Increase in bone marrow lesions associated with cartilage loss: a longitudinal magnetic resonance imaging study of knee osteoarthritis. Arthritis Rheum. 2006; 54:1529-35.
5. Raynauld et al. Correlation between bone lesion changes and cartilage volume loss in patients with osteoarthritis of the knee as assessed by quantitative magnetic resonance imaging over a 24-month period. Ann Rheum Dis. 2008; 67: 683-8.
6. Felson et al. Bone marrow edema and its relation to progression of knee osteoarthritis. Ann Intern Med. 2003 Sep 2; 139 (5 Pt 1): 330-6.
7. Suter et al. Medical Decision Making in Patients With Knee Pain, Meniscal Tear, and Osteoarthritis. Arthritis & Rheumatism Vol. 61, No. 11, November 15, 2009, pp 1531-1538.
8. Scher et al. Bone marrow edema in the knee in osteoarthritis and association with total knee arthroplasty within a three-year follow-up. Skeletal Radiol. 2008; 37: 609-17.
9. Initial results from the review of 60 patients treated with Subchondroplasty® by Dr. Steven B. Cohen of the Rothman Institute (submitted as an abstract for AAOS 2013 and ISAKOS 2013).
References
The Knee Patient Contradiction
X-Rays Do Not Always Tell The Whole Story
Do You See This MRI Finding? How Do You Treat It?117
What do We Know?
• Articular cartilage has no pain fibers
• Synovium has some pain fibers, but more baroreceptors
• Ligaments have more proprioceptors
• Bone has pain fibers
What Does the Literature Say About Knee Pain?1
• Strongly related to large Bone Marrow Lesions (BMLs)
• Moderately related to synovitis & effusion
• Weakly related to cartilage volume / thickness
But Which Factor(s) Cause Pain?
1Hunter et al. Osteoarthritis Cartilage, Vol. 19, No. 5, May, 2011.
118
In 2011, BMLs were 1st Acknowledged in Mainstream Ortho Lit for their
Correlation with the Presence of Pain & Decreased Function
Sowers, et al; JBJS Am. 2011;93:241-251.
• “Large bone marrow lesions in the medial femoral condyle or the medial or lateral plateau were associated with substantially increased odds of reported pain”
• BML in medial compartments associated with “marked decreases in walking and stair-climbing performance (p<0.001)”
Associations of Anatomical Measures from
MRI with Radiographically Defined Knee
OA Score, Pain, & Function
How Do We Know?
119
Are BMLs Really a Big Deal?
120
The Overlooked Disease: Defining a Bone Marrow Lesion (BML)
BMLs are Micro-Trabecular Fractures1 in Subchondral Bone
Micro-cracks caused by acute impact or fatigue-related failure
Hard, sclerotic barrier forms inside soft cancellous bone as response to stress
Forces become concentrated at periphery
Not visible on X-ray
Seen on Fat-Suppressed MRI (T2, STIR, PD) as Hyperintense
Marrow Signal
Usually classified as “edema”, but minimal “true” edema
Lot of fibrosis & bone necrosis; reversal lines & remodeling
Change of architecture and cellular matrix
Chronic inflammation
Often below cartilage defect
Weakened load-bearing capacity
Recognized in up to 80% of TKR
1 Also commonly referred to as “micro-cracks”, “micro-
fractures”, “subchondral stress fracture” or “subchondral
defects”.
Gigena et al. Skeletal Radiol. Vol. 31, No. 4, 2002.
Felson et al. Annals Int Med. Vol. 134, 2001.
Felson et al. Ann Int Med. Vol. 139, No. 5, Sep 2, 2003.121
Sources: Millennium Research Group. Us Markets for Large-Joint Reconstructive Implants 2011
Severity of Procedure
Patients and/or Surgeons Delaying TKR
to Preserve Joint & Daily Activities
No Middle-Ground Treatment Available Before SCP®
Total Knee Replacement(~715,000 / Year)
SCP® Fills the Void in Current Treatment Options
Subchondroplasty®
Subchondroplasty® (SCP®) Overview
Minimally Invasive, Joint Preserving Procedure
Fills & Repairs Bone Defects (BMLs) – #1 Indicator of Pain
Treats Diseased Bone, Not Cartilage
WHEN: Conservative Treatments Fail Subchondroplasty® TKR
123
124
The Procedure
• Macro-Porous to Restore Bone Structure & Facilitate Fluid Transfer
• ONLY Bone Substitute Flowable within Cancellous Bone: Does Not Require Coring or Bone
Removal (Macro-Porous, Self-Setting)
• Non-Exothermic & Hardens at Body Temperature within 10 minutes
• Mimics Strength of Natural Bone (10 MPa) to Normalize Stress Distribution
• Osteoconductive to Stimulate Healing Response
• Crystalline Structure Interdigitates, Resorbs & Is Replaced w/ Natural Bone (1 – 2 yrs)
Knee Creations AccuFill™ Calcium Phosphate (CaP)
125
How Do We Know It’s Working? – Initial Results
0
1
2
3
4
5
6
7
8
9
0 1 wk 6 wks 3 mos 6 mos 1 yr 1.5 yrs 2 yrs
Pain Reduction – VAS ScoreSevere Pain
No Pain
Outcomes based on 60 patients from single-site analysis 2008-2012*Includes: 11 patients who went on to TKA / UKA
126
Outcomes based on 60 patients from single-site analysis 2008-2012*Includes: 11 patients who went on to TKA / UKA
0
10
20
30
40
50
60
70
80
0 1 wk 6 wks 3 mos 6 mos 1 yr 1.5 yrs 2 yrs
Function Improvement – IKDC Score
How Do We Know It’s Working? – Initial Results
127
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
0 10 20 30 40 50
SCP® Length of Benefit (Kaplan-Meier)
months
SCP® Kaplan-Meier curve based on outcomes from single-site analysis of 59 patients 2008-2012
How Do We Know It’s Working? – Initial Results
128
Advantages:
• Only Treatment Option for BMLs
• Minimally invasive procedure:
Does not limit future care options
BSM remodeled into new bone
Preserves natural joint
• Recovery Time: Most patients back to work in 1 week1
• Proven Results: Pain relief & increased function as early as 2 weeks; shown to last ~5 years1
• Additional Information:
www.subchondroplasty.com
http://www.youtube.com/user/KneeCreations/feed
Treating BMLs with Subchondroplasty®
1Initial results from the review of 60 patients treated with Subchondroplasty® by Dr. Steven B. Cohen of the Rothman Institute
(submitted as an abstract for AAOS 2013 & ISAKOS 2013).
129
Subchondroplasty General Post-op Treatment Protocol
• TTWB/NWB x 2 weeks, then WBAT• Optional use of Unloader brace—If patient
already has, then encourage use of brace• Start PT immediately for ROM, strengthening per
usual knee scope protocol• Pain mgmt important for 1st 48 hours due to
increased pain compared with routine scope (i.e. Percocet)
• RTW 4-8 weeks depending on occupation• Return to normal activity at 3 months
Platelets and Plasma
Platelet Rich Plasma
• According to Dragoo, Level 1 evidence supporting PRP use in:
– Lateral Epicondylitis
– Patellar Tendinopathy
– OA
– ? Muscle Regeneration
Platelet Rich Plasma
• Leukocyte Rich>>> Increased Inflammation, cytokine response
• Leukocyte Poor>>> Increased normal Collagen Matrix (Neutrophil depletion/ Increased Platelets/Decreased Inflammation)
• Tendinopathy LR-PRP (inject tendons)• OA LP-PRP (inject joint)• Muscle Repair Platelet Poor Plasma
– 2nd spin centrifuge (PRP w/ Plt leads to myoblast differentiation/proliferation), still undergoing trials
» Dragoo
Role of Thrombocytes (Platelets)
• To initiate primary hemostasis (slowed bleeding) and participate in secondary hemostasis (platelet activation)
• To aide in tissue healing through release of cytokines
Musculoskeletal Injury: The basics
The repair response of MSK tissues:
Starts with the formation of a blood clot and degranulation of platelets
1. This releases GFs & cytokines at the site
2. This microenvironment results in chemotaxis of inflammatory cells
3. Activation & proliferation of local progenitor cells
Platelet Rich Therapies Introduction
Most musculoskeletal injuries involve anatomic areas with minimal blood flow & low cell
turnover rate
Joint spaces, ligaments & cartilage have a naturally limited blood supply
Muscle & tendons commonly experience decreased local blood flow following injury
This imbalance of GF supply & demand hinders the regenerative process
PLATELET GROWTH FACTORS
• PDGF and TGF-
• Activate Inflammation Pathways – summons healing cells
• Fibroblastic Growth Factor (FGF) and Vascular Endothelial Growth Factor (VEGF)
• Important for tissue granulation and collagen synthesis
• Epithelial Growth Factor
• Help to grow epithelial (covering) cells to heal the wound
Platelet effects confined to site of delivery, they are first to arrive at injury site to mediate healing response why platelets used as delivery tool forGrowth factors. Stem cells must migrate to area due to GF response
#2ACP in conjunction with local anesthetics (marcaine & lidocaine) or steroids have a harmful effect on tendon cells in cultureGiven the harmful effects on tenocytes & chondrocytes (Chu,C) should we reconsider our tx paradigm for knee DJD
What can you tell me aboutthis article?
Cross et al. AJSM 2015
BONE MARROW CONCENTRATE
#6
Platelets are present in bone marrow aspirates & have a beneficial effect on tendon cells
When to use PRP or BMC
• Stem cells thought more valuable in areas where tissue cells are compromised and cellular presence is lacking
• Platelet growth factors more successful with inducing regenerative effect and jump starting healing cascade
• Postulated that combo of two is best remedy?
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Daniel C. Eby Orthopedics and Sports Medicine
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