Cartilage lesiosns - insight in management
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Cartilage lesiosns - insight in management
- 1. Lesion size, Etiology and algorithmic approaches to CHONDRAL LESIONS Dr.RAJAT JANGIR Professor Mahatma Gandhi Hospital, Jaipur
- 2. IDEAL CARTILAGE PROCEDURE CHASING THE HOLY GRAIL
- 3. DECISION MAKING IS NOT LINEAR SYMPTOMS CARTILAGE INJURY MENISCUS TEAR SUBCHONDRAL BONE LESIONS LIAGMENT INJURY MALALIGNMENT No reliable correlation between Clinical symptoms and Articular cartilage status
- 4. Etiology • Trauma – most common • OCD • Osteonecrosis Focal • Osteoarthritis – most common • Ligament instability • Meniscus deficiency Degenerative
- 5. Patient-centered Approach Patients Symptoms Concomitant knee pathology Correlation of Imaging findings Intraarticular and subchondral findings Goals and expectations
- 6. Patient-centered Evaluation • History • Risk factors Age Sex BMI • Alignment • Instability • Locking Symptoms will not always represent the degree of cartilage damage
- 7. Patient-centered Evaluation Performance demand Return to Sports Return to ADL Prophylactic treatment for the expectation of disease progression at the initial onset of symptoms is not recommended – unpredictable nature
- 8. Imaging • Xray Weight-bearing AP • Flexion PA view Tibiofemoral joint • Lateral View • Merchant view PF joint Standing full-length scanogram
- 9. MRI Cartilage Meniscus Ligament Subchondral Bone Identification, Sizing, Characterization, of focal chondral lesion 2D Fat Suppressant and 3D Fast Spin ECHO
- 10. DEPENDENCE ON MRI IS NOT JUSTIFIED 36 % Full thickness lesions
- 11. Arthroscopy – Gold Standard
- 12. Non Surgical Care The benefits of exercise overweighs and insufficient evidence that activity increases the progression Physical activity and dedicated rehab Symptoms relief Not Cartilage repair
- 13. USE ORTHOBIOLOGICS JUDICIOUSLY Paucity of high quality studies Preliminary results are encouraging Not enough to recommend routine use at this time
- 14. Criteria For Surgery Unacceptable Pain and dysfunction Concomitant Pathology Considered Nonsurgical treatment considered Risk-Benefit ratio for Patients Goals
- 15. SYMPTOMATIC TIBIOFEMORAL CHONDRAL LESION PF- TTO TF-DFO/HTO MALALIGNMENT REPAIR TRANSPLANT LIGAMANT RECONSTRUCTION MENISCUS INSTABILITY
- 16. Correct All comorbidities at Some Point along the treatment Continuum ALIGNMENT MENISCAL DEFICIENCY INSTABILITY SC SC
- 17. <2-3 CM2 LOW DEMAND DEBRIDEMENT MF +ADJUNCT* HIGH DEMAND DEBRIDEMENT MF +ADJUNCT* OCT OAG >2-3 CM2 LOW DEMAND DEBRIDEMENT MF +ADJUNCT* OCT OAG ACI * HIGH DEMAND OAG ACI* Size *Suchondral Bone Normal
- 18. Femoral MF OCT ACI OAG PF Joint Topographical Challenges for OCT Tibial Geometry Poor Access Little evidence Location
- 19. There is More Than One Right Answer FIBR0US EASIER HYALINE COMPLEX DBR MF OATS MACI OAG
- 20. DEBRIDEMENT IS AN ACCEPTABLE FORM OF TREATMENT 51.9 9.3 38.8 SYMPTOMATIC RELIEF INSURANCE DENIAL OTHERS
- 21. Microfracture and its adjuncts have evolved and remain a cost-effective first-line treatment strategy
- 22. OCT remains a durable and predictable graft option in smaller lesions (<2 cm2) in the young and active patient population.
- 23. • Large chondral lesions (≥3 cm2) • OAG, MACI • Both mid-term and long-term favourable results
- 24. Paucity of high quality studies Preliminary results are encouraging A lot of on going research
- 25. High-Grade Cartilage Defects in Young Active Patients Treatment Advantages Disadvantages MF Inexpensive works well on small defects relief tends to decline over time worse results with larger defects OCT Inexpensive excellent option for defects 2 cm2 in athletes Cannot be used on larger defects donor-site morbidity OAG Fast rehabilitation varying size and subchondral bone involvement athletes with large defects who cannot commit to long recovery Expensive availability limited options for revision ACI Durable symptom relief superior clinical improvement VS MF can treat large defects Expensive 2-stage operation long rehabilitation
- 26. Manage Expectations: Know the literature and know your own experience NON OPERATIVE SUCCESSFUL OUTCOME POOR OUTCOME CAREFUL PATIENT SELECTION IS THE KEY
- 27. Thank You