Osteochondritis dissecans

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  • Jason Lovett
  • First picture: One Herbert screw removed the second one slightly removed. Picture #2: After the screws were removed. Picture #3: The remaining OCD lesion. Picture #4: After the paste graft has been placed.
  • The procedure step by step.
  • ( Dulbecco/Vogt modified Eagle's minimal essential medium ), which contains approximately four times as much of the vitamins and amino acids present in the original formula and two to four times as much glucose .
  • Kevin R. Stone, Biological Knee Reconstruction Annual Joint Preserving Meeting, Johns Hopkins 2004

Transcript

  • 1. Salvage of Large OCD Lesions: Articular Cartilage Paste Grafting Kevin R. Stone, MD CPMC Grand Rounds 2/13/2009 Stone Research Foundation
  • 2. What to do when OCD fixation fails?
  • 3. Patient Example: JL
    • OCD Lesion: 35 x 40 x 30mm
    • Pain since 13 yrs old
    • 18 yrs old : Herbert screw fixation
    • 20 yrs old : Herbert screw tightening
    • 25 yrs old : Debridement and screw removal
    Pre-op Xray
  • 4. JL: Preoperative MRI Age 25: Pre-Hardware Removal
  • 5. Morselized Lesion Paste Graft to MFC Extraction of Herbert Screws OCD Lesion 35X 40 X 30 mm JL: Failed Herbert Screws
  • 6. Articular Cartilage Paste Graft Technique Step 1 Step 5 Step 4 Step 3 Step 2
  • 7. Biopsy of Paste Graft JL: 8 Mo Post-Paste Graft Histology
  • 8. A 6 X 6 mm central portion required a second Paste Graft. JL: 8 Mo Post Paste Graft
  • 9. Hypertrophy of the medial OCD lesion JL: 11 Mo Post Paste Graft Pre-Op 11 Mo Post-Op
  • 10. JL: 7 Years Post Paste Graft 7 Years Post Op
    • Chondrocalcinosis of MFC
    • Well- adhered base
    • Peripheral Flap
  • 11. JL: 7 Years Post Paste Graft
    • Chondroplasty of periphery
    • Well-adhered fibrous base
    • Microfracture of fibrous base
    A B C
  • 12. JL: 7 Year Post Op MRI
  • 13. JL: 8 Year Post Op Xray PA Flexion AP
  • 14. JL: 8 Year Post Op MRI
    • Age: 32
    • Tegner Score 6.5 Post-Op versus 3 Pre-Op
    • Improvement in Pain, Activity, Function (WOMAC, IKDC, Tegner Scores)
    • Ran a 10K race
  • 15. JL: 10 Year Post Op Xray
  • 16. JL: 10 Year Post Op MRI
  • 17. JL: 10 Year Post Op MRI
  • 18. JL: 10 Year Function
    • IKDC = 100
    • WOMAC = 0
    • Tegner Pre-Injury = 4
    • Tegner Current = 10
    • Competitive triathlete
    • Ran 28 miles in 2 days prior to follow-up
    • Reports no pain
  • 19. Patient Example: HV
    • Active 26 year old male
    • Medial knee pain
    • Symptomatic for 10 years
    • Re-injured in gymnastics
  • 20. HV 12/97 Art Cart Surgery
    • Full loss of articular cartilage on the medial femoral condyle (20 mm x 30 mm)
    • Removal of loose flap of dead articular cartilage
    • Removal of loose body
  • 21. HV 12/97 Art Cart Surgery
    • Articular Cartilage Paste Graft impacted into lesion
  • 22. HV 10 Month Post
  • 23. HV 10 Month Post Paste Graft
  • 24. HV 10 Month Post Paste Graft Biopsy
  • 25. HV 10 Month Post Histology
  • 26. HV 10 Month Post Histology
  • 27. HV 11 Year Post MRI
  • 28. HV 11 Year Post MRI
  • 29. HV 11 Year Post Function
    • IKDC = 94.25
    • WOMAC = 0
    • Tegner Pre-Injury = 8
    • Tegner Current = 8
    • Plays basketball 3 – 4 times per week without pain.
  • 30. Conclusions
    • Articular Cartilage Paste Grafting
    • Treatment option for large lesions
    • Low harvest morbidity
    • Arthroscopic procedure
    • The Articular Cartilage Paste Graft technique may be useful as primary treatment and for salvage of failed OCD repairs.
  • 31. Does the Paste Contain Live Cells?
  • 32.
    • Paste and intact core samples from Art Cart and Total Knee Arthroplasty patients shipped overnight to Anthony Ratcliffe, PhD
    • Samples cultured for 6 – 8 weeks -> cells harvested, seeded on scaffolds, and cultured additional 4 weeks in either static conditions or in chondrogenic media
    • Samples analyzed to determine biochemical content and gene expression
    Art Cart Paste Graft Characterization Study
  • 33. Preliminary Results
    • Paste and core tissue samples contain viable cells
    • Cells have the capacity to proliferate
    • Art Cart vs. TKA to be determined
    The cells have the ability to express collagen I, collagen II and aggrecan genes. Paste Core *DMEM: Dulbecco/Vogt modified Eagle's minimal essential medium DMEM Chondrogenic media DMEM Chondrogenic media
  • 34. Study Conclusions
    • The source of the cells: Unknown
      • Derived from cartilage, bone, or bone marrow
    • Cells have capacity to proliferate and deposit cartilaginous extracellular matrix when cultured in 3D environment
    • Cells respond to chondrogenic media.
  • 35. Thank You Stone Research Foundation