Download Preservation Techniques for Shoulder and Hip

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 Anatomy
Origins 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
Clinical photograph of infraspinatus atrophy found on exam
JAAOS, Oct 2013, Vol. 21 (10), pg. 615
Sleeper Stretch for Glenohumeral
Internal Rotation Deficit
Surgical Techniques of Shoulder, Elbow, Knee in Sports Medicine, Cole, Sekiya, Pg. 91
Rotator Cuff
• Impingement Syndrome—Nonoperative
treatment
• 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
Rotator Cuff Tear Fixation
• “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.”
Journal of American Academy of Ortho Surgeons, October 2013, Vol. 21 (10), page 642
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 pennation
angle
– 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 Speedbridge
technique
Open cuff repair with Patchgraft
augmentation
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 10
Scientific Articles | May 15, 2013
Comparison 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
CAM impingement
www.hipandkneeadvice.com
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 tricompartmental
degenerative 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®
Why Does My Knee Hurt?
1. Synovium:
Inflammation
2. Cartilage:
Defects
3. Ligaments:
Tears
4. Meniscus:
Degeneration
5. Subchondral Bone:
Edema / Lesions
1
3
2
4
5
What Is Subchondral Bone?
Healthy Subchondral Bone:
• Provides support for cartilage
• Distributes joint loads vertically &
horizontally
 108 
How Does Subchondral Bone Become Damaged?
Everyday Stresses on Healthy Bone
Concentrated Stress
Stress
Healing
Bone Marrow Lesion (BML)
 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
 109 
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)
How Are BML’s Diagnosed?
• 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 
The Subchondroplasty® (SCP®) Procedure
1
Diagnose BML w/ MRI
2
Treat Bone Defect w/ SCP®
3
Heal Bone
Minimally Invasive Procedure that Fills & Repairs
Bone Defects Associated w/ BML’s
 113 
What Are My Other Options?
Treatment Alternatives – Surgical
Osteotomy
• Used to correct alignment
• Lasts up to 15 years
• Preserves native joint
• 6 month recovery time
Post-Op X-Ray
Treating BML’s with Subchondroplasty®
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
**Based on preliminary data from clinical study conducted on SCP® (see “References” slide)
 115 
Post-Op X-Ray
References
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 24month 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).
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
But Which Factor(s) Cause Pain?
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
1Hunter
et al. Osteoarthritis Cartilage, Vol. 19, No. 5, May, 2011.
118
How Do We Know?
In 2011, BMLs were 1st Acknowledged in Mainstream Ortho Lit for their
Correlation with the Presence of Pain & Decreased Function
Associations of Anatomical Measures from
MRI with Radiographically Defined Knee
OA Score, Pain, & Function
• “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)”
Sowers, et al; JBJS Am. 2011;93:241-251.
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”, “microfractures”, “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 et121
al. Ann Int Med. Vol. 139, No. 5, Sep 2, 2003.
SCP® Fills the Void in Current Treatment Options
Patients and/or Surgeons Delaying TKR
to Preserve Joint & Daily Activities
Total Knee Replacement
Subchondropla
sty®
Severity of Procedure
No Middle-Ground Treatment Available Before SCP®
Sources: Millennium Research Group. Us Markets for Large-Joint Reconstructive Implants 2011
(~715,000 / Year)
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
The Procedure
124
Knee Creations AccuFill™ Calcium Phosphate (CaP)
• 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)
125
How Do We Know It’s Working? – Initial Results
Severe
Pain
9
Pain Reduction – VAS Score
8
7
6
5
4
3
2
1
No Pain
0
0
1 wk
6 wks
3 mos
6 mos
Outcomes based on 60 patients from single-site analysis 2008-2012
*Includes: 11 patients who went on to TKA / UKA
126
1 yr
1.5 yrs
2 yrs
How Do We Know It’s Working? – Initial Results
80
Function Improvement – IKDC Score
70
60
50
40
30
20
10
0
0
1 wk
6 wks
3 mos
6 mos
Outcomes based on 60 patients from single-site analysis 2008-2012
*Includes: 11 patients who went on to TKA / UKA
127
1 yr
1.5 yrs
2 yrs
How Do We Know It’s Working? – Initial Results
SCP® Length of Benefit (Kaplan-Meier)
100.0%
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
0
10
20
30
40
50
months
SCP® Kaplan-Meier curve based on outcomes from single-site analysis of 59 patients 2008-2012
128
Treating BMLs with Subchondroplasty®
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
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 for
Growth factors. Stem cells must migrate to area due to GF response
#2
ACP in conjunction with local anesthetics
(marcaine & lidocaine) or steroids have a
harmful effect on tendon cells in culture
Given the harmful effects on tenocytes & chondrocytes (Chu,C) should we
reconsider our tx paradigm for knee DJD
What can you tell me about
this 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?
LipoGems
Daniel C. Eby Orthopedics and Sports Medicine
Located at 600 West 13th Street, Suite 200 in Jasper, Indiana!