A review of orthopaedic and orthobiologic treatment options, with emphasis on the difference between osteoarthritis and osteoarthrosis (PTOA), the role of osteochondral unit, subchondral bone, etc.

1. 2019 Update on the
Management of Knee OA
Osteo-arthritis & Osteo-arthrosis
Orthopaedics & OrthoBiologics
New trends and developments which may delay or avoid surgical treatments
Vladimir Bobić, MD FRCS Ed
Chester Knee Clinic www.kneeclinic.info office@kneeclinic.info @ChesterKnee
Nuffield Health
The Grosvenor Hospital Chester Educational Seminars
St David’s Park Hotel, Ewloe, Wales, 18th May 2019

3. Less (orthopaedic) carpentry - more biology?

4. What are we going to talk about today?
Do not bother writing and taking pictures - just watch and listen!
The entire presentation will be available on:
www.slideshare.net/vbobic

5. Knee Osteoarthritis:
Overview and Treatment Options
Osteoarthritis is a degenerative joint disease that is
increasing in prevalence, and the knee is the most
commonly affected joint.
Factors such as increased incidence of obesity and
participation in sports, as well as the ageing of the
population, may contribute to this increased
prevalence.
The treatment options for osteoarthritis, which
range from conservative treatment options to
surgical intervention, have varying degrees of
success, but new therapies are on the horizon.
!5

6. Knee Injury and OA

7. Ageing and OA: An inevitable Encounter?
T Huegle et al.: Ageing and OA - An Inevitable Encounter? JAR 2012

8. OsteoArthritis vs. OsteoArthrosis vs. PTOA
CKC UK !8

10. Most patients in my practice do not have classic OA, as progressive, destructive
inflammatory disease of the entire knee joint and most of the time they do not have OA
of any other joint(s).
Most of my patients have one bad knee, usually the medial or PF side of it, because of
trauma, sports, work, etc. and they develop meniscal, chondral and ligament injuries
which in turn cause accelerated wear and tear (which is different from inflammatory
nature of classic OA and RA) and subsequent reactive synovitis and subchondral
degeneration resulting in stiff subchondral plate and further damage to articulating
surfaces.
Unsurprisingly most of those people respond well to arthroscopic surgery, including
deep subchondral drilling (which seems to re-establish osteochondral nutritional and
other communication channels, which is the same reason why microfracture works for
some people) and other arthroscopic treatments, which does not work well in OA and
RA knees.
So, there is a difference if we think (out of the box) about this as accelerated wear
and tear (known as gonarthrosis or osteoarthrosis in many European countries or
PTOA in the USA), which most people have, rather than OA (as inflammatory multi-
joint disease).
This is perhaps a bit too simplistic and even scientifically naive but that is my
impression, based on my clinical experience over the past 20+ years in the UK.
OsteoArthritis or OsteoArthrosis?
or just accelerated wear and tear?

13. Articular cartilage + Subchondral plate + Trabecualar bone are
biologically and functionally inseparable OsteoChondral unit
which absorbs and distributes loads across the joint.
CKC UK
We can not think and act in monolayer terms. Articular cartilage (surface)
repair is not good enough. We have to think and act in 3D terms!

14. The Structure of Subchondral Bone
Redrawn from: Imhof H, Breitenseher M, Kainberger F, Rand T, Trattnig S. (1999): Importance of subchondral bone to
articular cartilage in health and disease. Top Magn Reson Imaging 10:180–192
A surprisingly high number of arterial and venous vessels, as well
as nerves, can be seen in the subchondral region sending tiny
branches into the calcified cartilage …

15. The Structure of Subchondral Bone
The changes in the thickness of the subchondral bone plate depends on the
location and mechanical loads
Henning Madry, Saarland University, Homburg/Saar, Germany

16. From Minor Cartilage Damage to Advanced OA
... to Advanced Medial OA?From Small MFC Chondral Lesion ...

17. CKC GNH Chester UK CKC GNH Chester UK
MR and Arthroscopic Cartilage Imaging

18. Osteochondral Repair and OA: Surgical Options
ACI BioPoly
UKR & TKR
OATS
Microfracture
Chondroplasty

19. Microfracture
!19

20. !20
Nanofracture : deep drilling is better!

21. MFC Microfracture site after 5 years
!21

22. !22

23. ACL injury + extensive BB
CKC MRI 110206
7 months later

24. SONK Before and After Subchondral Decompression
(… the road to hell is paved with good intentions …)
• 15/12/08: subarticular insufficiency
fracture and slight flattening of the
MFC and prominent subarticular
marrow oedema more marked on the
femoral side. Since 04/04/08,
significant deterioration in the medial
compartment with SONK-like
process, progressive degenerative
changes …
• 11/09/09: Comparison is made with
the previous scan 15/12/2008. In the
medial compartment, following the
subchondral decompression, there
is now evidence of articular
irregularity, deficiency and
thinning of articular cartilage,
slight increase in the subarticular
marrow oedema and early
subarticular cyst formation in the
outer aspect of the MFC …
• … however, if approached externally
(retrograde drilling) and injected
with autologous bone marrow
aspirate or PRP the outcome could
have been different (but we did not
know that in 2008)

25. The Subchondroplasty
Procedure

26. Frustration after a presentation at Sports Knee 2017
CKC UK 2018

28. The Subchondroplasty Procedure
Great idea, but it seems that this entirely new concept (as it is) is based on huge
assumptions.
Arguably, subchondroplasty is indicated mainly for the treatment of
subchondral cysts and cavities, rather than various bone marrow oedema
conditions.
Bone marrow oedema, as metabolic (vascular) “event” does not lack bone
(therefore injecting bone substitute is not the right ingredient). To the contrary,
injecting bone paste will clog many interconnected cellular spaces and will slow
down or prevent subchondral repair and remodelling. Not surprised to hear that
patients "should expect 3 days of severe pain" (!) as injected and cured bone paste
will increase intra-osseous pressure (which is already higher than normal and which
is why some SONK-like conditions are very painful to start with) and block
metabolic (vascular) pathways!
However, the real biologically desirable ingredient is autologous bone
marrow aspirate (or autologous stem cells or even PRP), delivered to the area
affected with bone marrow oedema.
This is where subchondroplasty becomes a bit more intelligent and gets entirely
new biological meaning and a lot more street cred.
Vladimir Bobic CKC: Articular Cartilage, Subchondral Bone and Osteochondral Unit. 4th BKS Meeting, Cardiff, UK 1-2 February 2018.

29. Frustration after a presentation at Sports Knee 2017
CKC UK 2018

30. OATS Indications:
• The “ideal” chondral lesion is relatively small, full-thickness
defect (10 to 15 mm in diameter), without subchondral bone loss.
• This lesion should be treated early, in an attempt to contain the
defect and to repair the lost hyaline cartilage with hyaline
cartilage.
Osteochondral Autograft Transplantation (OATS)

31. Autologous Osteochondral Grafting (OATS)
31

32. Lateral Femoral Trochlea:
a reliable source of good cancellous bone and bone marrow, even in advanced OA
CKC UK
MFC AVN

33. Autologous Osteochondral Grafting (OATS)

34. “Pre-TKR” option: OATS combined with autologous bone marrow aspirate

35. FU MRI: “In the medial
compartment, the graft over the
central weight-bearing portion of
the medial femoral condyle has
incorporated with adjacent
bone and the overlying
articular cartilage is flush
with adjacent native
cartilage. A small focus of
marrow oedema is noted directly
beneath the graft but overall
there has been a reduction in
marrow oedema around the
graft. A small trace of
subcortical fluid in the peripheral
portion of the medial femoral
condyle is similar to the pre-
operative scan - presumably not
included in the repair.”
Dr David Ritchie, Glasgow
CKC MRI 030307

36. ACI/CCI Stage 1: Arthroscopic Chondral Biopsy
CKC Chester UK

37. ACI/CCI Stage 2: Open Implantation
Source: www.geistlich.com

38. Good ACI graft fill, a year after ACI

39. A game changer …

40. Grow your own knee …, well, not really …

41. Prof. Vladimir Bobić
MD FRCSEd, Consultant Orthopaedic Knee Surgeon
Chester Knee Clinic at Nuffield Health, The Grosvenor Hospital Chester, United Kingdom
www.kneeclinic.info office@kneeclinic.info @ChesterKnee
BioPoly®RS Knee System
The partial resurfacing implant
41

42. 42
Registry Study Results

43. 43

44. ConforMIS iTotal Customised Knee
Replacement Implants

45. Not so soon, but …

46. 1st Orthopaedic Stem Cell Seminar in the UK

47. “The first great advancement in sports medicine was the arthroscope, the second is going to be
this (stem cells).” James Andrews, MD, “The Athlete’s Surgeon”, Birmingham, Alabama, USA

48. 2017
2017
OrthoBiologics or BioOrthopaedics

52. CHONDROTOXICITY OF INTRA-ARTICULAR
INJECTIONS OF LOCAL ANAESTHETICS AND
STEROIDS - DO WE HAVE A PROBLEM?
(JUST ONE MORE THING TO WORRY ABOUT!)
Prof Vladimir Bobić, Consultant Orthopaedic Knee Surgeon
Chester Knee Clinic at Nuffield Health,The Grosvenor Hospital Chester
@ChesterKnee
11th Oswestry Cartilage Symposium
RJAH, Oswestry, 5th and 6th October 2017

53. CHONDROTOXICITY OF INTRA-ARTICULAR
INJECTIONS OF LOCAL ANAESTHETICS
VB CKC UK

54. CHONDROTOXICITY OF INTRA-ARTICULAR
INJECTIONS OF LOCAL ANAESTHETICS
VB CKC UK
… fast forward (2015):

55. CHONDROTOXICITY OF INTRA-ARTICULAR
INJECTIONS OF LOCAL ANAESTHETICS
VB CKC UK

56. CHONDROTOXICITY OF INTRA-ARTICULAR STEROID INJECTIONS
VB CKC UK

57. Physiotherapy Better Than Steroid injections!

58. Biological Treatment Options:
Oral Supplements (Glucosamine + CS)
Viscosupplement Injections
Shockwave Therapy (SWT)
PRP Injections
Autologous Stem Cell Injections
Arthroscopic Subchondral Drilling
Nanofracture with Intra-osseous Injections
AMIC (nanofracture site covered with membrane)
ChondroTissue (scaffold)
OATS with Autologous Bone Marrow Aspirate
ACI (Autologous Chondrocyte Implantation)
!58

59. Oral Supplements: Glucosamine and Chondroitin Sulphate

60. Hyaluronic Acid Injections

61. Hyaluronic Acid Injections

62. Regenerative Medicine - Stem Cell Technologies

63. What are Mesenchymal Stem Cells?
• Adult stem cells can help
regenerate many tissues
• The best source is the
autologous tissue
• Many different tissues can be
used to process biologically
powerful stem cells
• It seems that the best tissue to
extract MSC is SVF (stromal
vascular fraction) adipose
tissue, which is the best source of
cells and regenerative factors

64. Well, MSCs are NOT Stem Cells!

65. The MSC: an injury drugstore

66. MSCs and Blood Vessels

73. Stem Cells No Better Than Placebo … So Far
(Editor of Arthroscopy Journal re JBJSA September 2016 Article)

75. Too old for stem cell therapy? Probably not!
Cell apoptosis and senescence do exist but basic biological
healing principles persist.
“Youth would be an ideal state if it came much later in life.”
Herbert Henry Asquith

76. PRP Today

77. Arthroscopy Journal, article in press, 2015

78. PRP

83. THANKYOU FORYOUR ATTENTION
VB CKC UK
KEEP MOVING AND LOOK AFTERYOUR KNEES!