Bandi score - Deutsche Kniegesellschaft

Experimental background and 21 years clinical
experiences of autologous osteochondral
mosaicplasty
Prof. László Hangody MD, PhD, DSc
Semmelweis University Department of Traumatology
Uzsoki Hospital Department of Orthopedics
Budapest, Hungary
2. Jahreskongress der Deutschen Kniegesellschaft
29-30. November 2013, Hamburg
BONE MARROW STIMULATION
drilling of the subchondral bone – K. H. Pridie
abrasion arthroplasty – L. L. Johnson
microfracture – R. J. Steadman
„NEW WAYS”
periosteal flapping
– Rubak, O’Driscoll, Lorentzon
perichondrial flapping
– Coutts, Homminga, Bruns
chondrocyte implantation
– Green, Brittberg, Petersen
„From Hippocrates
to the present age, it
is universally allowed
that ulcerated
cartilage is a
troublesome thing
and that once
destroyed it is not
repaired”
(Sir William Hunter, 1743)
allografts
– Lexer, Convery, Mankin, Gross, Reagan
autografts
– Krompecher, Pap, Fabricciani, Yamashita, Wagner
Osteochondral Autograft Transplantation
Pap, K. – Krompecher, I.: Arthroplasty of the knee – Experimental and clinical
experiences. J. Bone Joint Surg. 43-A:523-537, 1961
Lane, J., M. – Brighton, C., T. – Ottens, H., T. et al.: Joint resurfacing in the
rabbit using an autologous osteochondral graft. J Bone Joint Surg Am 59:218-222,
1977
Campanacci, M. – Cervellati, C. – Dontiti, U.: Autogenous patella as replacement
for a resected femoral or tibial condyle. A report of 19 cases. J Bone Joint Surg 67B:557-563, 1985
Yamashita, F. – Sakakida, K. – Suzu, F. – Takai, S.: The transplantation of an
autogenic osteochondral fragment for osteochondritis dissecans of the knee. Clin
Orthop 201:43-50, 1985
Outerbridge, H., K. – Outerbridge, A., R. – Outerbridge, R., E.: The use of a
lateral patellar autogenous graft for the repair of a large osteochondral defect in the
knee. J Bone Joint Surg 77-A:65-72, 1995
Basic problems of autologous
osteochondral grafting:
lack of the appropriate donor area
congruency problems
technical difficulties
AUTOLOGOUS
OSTEOCHONDRAL
MOSAICPLASTY
abrader
15
25
15
10
78.5 %
90 %
~ 100 %
Animal trials:
1991
German Shepherd dogs
1995-1996
different types of dogs
1997
horses
1999-2000
German Shepherd dogs and horses
2004-2006
horses
4 ws
6 ws
8 ws
Animal trials:
1991
1995-1996
1997
1999-2000
2004-2005
German Shepherd dogs
different types of dogs
horses
German Shepherd dogs and horses
horses
consistent survival of transplanted hyaline
cartilage
deep matrix integration of transplanted
tissue
cancellous bone filling and fibrocartilage
coverage of donor tunnels
Hangody, L. - Kárpáti, Z. - Tóth, J. et al.: Autogenous osteochondral grafting in the
knees of German Shepherd dogs: radiographic and histological analysis. Rev.
Sportsmed. 35:177-123, 1994
Hangody, L. - Kish, G. - Kárpáti, Z. et al.: Autogenous osteochondral graft technique
for replacing knee cartilage defects in dogs. Orthopaedics 5:175-181, 1997
Bodó, G. – Hangody, L. – Szabó, Zs. et al.: Arthroscopic autologous osteochondral
mosaicplasty for the treatment of subchondral cystic lesion in the medial femoral
condyle in a horse. Acta Vet. Hung. 48(3): 343-354, 2000
Bodó, G. – Kaposi, A., D. – Hangody, L. et al.: The surgical technique and the age of
the horse both influence the outcome of mosaicplasty in a cadaver equine stifle model.
Acta Vet. Hung. 49:111-116, 2001
Hangody, L. - Feczkó, P. – Kemény, D. – Bodó, G. – Kish, G.: Autologous
osteochondral mosaicplasty for the treatment of full thickness cartilage defects of the
knee and ankle. Clin.Orthop. 391: October, Suppl. 328-337, 2001
Bodó, G. – Hangody, L. – Módis, L. – Hurtig, M.: Autologous osteochondral grafting
(mosaic arthroplasty) for the treatment of subchondral cystic lesions in the equine stifle
and fetlock. Veterinary Surgery 33: 588-596, 2004
Requirements at the indication:
symptomatic, focal chondral or osteochondral defects
1.0 – 4.0 cm2
age: under 50
paralel treatment of the underlying cause
no osteoarthritic changes
no kissing lesions
no tumor or synovial disease
treatment of the underlying
cause
- if it is possible -
in one step !!!
Rehabilitation:
immediately full range of motion
2-3 weeks non weight bearing
2 weeks partial loading (30-40 kg)
normal daily activity from 6-8. weeks
sports activity from 4 - 6. months !
(contained
uncontained)
Christel, P. et al.: Les greffes osteo-chondrales selon la technique de la mosaicplasty.Maitrise
Orthopedique, 76:1-13, 1998
Solheim, E.: Mosaikkplastikk ved leddbruskskader i kne. Tidsskr Nor Laegeforen, 27(119): 40224025, 1999
Marcacci, M. et al.: Use of autologous grafts for reconstruction of osteochondral defects of the
knee. Orthopedics 22(6):595-600, 1999
Traub, S. et al.: Die Technik der osteochondralen autologen Knorpeltransplantation (OATS) zum
Ersatz chondraler oder osteochondraler Defekte. Osteologie, 9: 46-55, 2000
Attmanspacher, W. et al.: Experiences with arthroscopic therapy of chondral and osteochondral
defects of the knee joint with OATS. Zentralbl Chir.125(6):494-499, 2000
Barber, F., A. – Chow, J., C.: Arthroscopic osteochondral transplantation: Histologic results.
Arthroscopy 17:832-835, 2001
Horas, U. et al.: Autologous chondrocyte implantation and osteochondral cylinder transplantation
in cartilage repair of the knee joint. J Bone Joint Surg 85-A:185-192, 2003
Simonian, P., T. – Sussmann, P., S. – Wiczkiewicz, T., L. et al.: Contact pressures at
osteochondral donor sites in the knee. Am J Sports Med, 26: 491-494, 1998
Duchow, J. – Hess, T. – Kohn, D.: Primary stability of press fit-implanted osteochondral
grafts: Influence of graft size, repeated insertion and harvesting technique. Am J Sports
Med 28:24-27, 2000
Ahmad, C., S. – Cohen, Z., A. – Levine, W., N. et al.: Biomechanical and topographical
considerations for autologous osteochondral grafting in the knee. Am J Sports Med
29:201-206, 2001
Pearce, S., P. – Hurtig, M., B. – Clarnette, R. et al.: An investigation of 2 techniques for
optimizing joint surface congruency using multiple cylindrical osteochondral autografts.
Arthroscopy 17:50-55, 2001
Kordás, G. – Szabó, J. – Hangody, L.: Primary stability of osteochondral grafts used in
mosaicplasty. Arthroscopy 22(4): 414-422, 2006
Kordás, G. – Szabó, J., S. – Hangody, L.: The effect of drill-hole length on the primary
stability of osteochondral grafts in mosaicplasty. Orthopedics 28: 401-404, 2005
Szerb, I. – Kárpáti, Z. – Hangody, L.:
In vivo arthroscopic cartilage stiffness
measurement in the knee.
Arthroscopy 22:682-683, 2006
between 6th February 1992 and
31st December 2011
1419 follow up cases in different joints
(knee, ankle, elbow, hip, shoulder)
Femoral condylar results:
modified HSS score
modified Cincinatti score
Lysholm score
92
89
95
(1002 cases, 13.1 /1-20/ years follow up)
Tibial condylar results:
modified HSS score
modified Cincinatti score
Lysholm score
87
85
94
(45 cases, 10.2 /1-17/ years follow up)
Patellar and trochlear results:
modified HSS score
79
modified Cincinatti score 72
Bandi score
76 %
(211 cases, 13.1 /1-20/ years follow up)
Talar results:
Hannover score
94%
Bandi score: no morbidity 96%
(161 cases, 12.5 /1-18/ years follow up)
Complications:
4 deep septic complications
8 deep venous thromboses
Donor site morbidity:
long term morbidity: 3 % (Bandi score)
early morbidity - postop. bleeding
7 % !!!
Hangody,
L.:
Autologous
osteochondral
mosaicplasty.
Actualités en biomatériaux, Volume
V.: 155-161,2000
Feczkó, P. – Hangody, L. – Varga, J. et
al: Experimental results of donor site
filling for autologous osteochondral
mosaicplasty. Arthroscopy 19(7): 755761, 2003
• polylactate, polygluconate-B, carbon rods,
polycaprolactone, hydroxilapatite, compressed collagen
• German Shepherd dogs, horses, 1 year follow up
ChondroMimetic - Composition
• three natural constituents
Chondral layer:
Collagen/GAG
Osseous layer:
Collagen/GAG/calcium
phosphate
1) Collagen
2) Glucoseaminoglycans
3) Calcium phosphate
Mode of implantation
Single step arthroscopic delivery
• Implant is available in 8mm, 10mm
& 12mm diameter sizes
Arthroscopic delivery device
• All in one single use procedure
pack comprising of site preparation
instruments & a pre loaded delivery
device
Procedure pack
47
Chondromimetic for Small
Osteochondral Defects
Technique
Histological evaluation – implant
degradation, bone formation:
DMMB4x - bone
DMMB4x – bone/fibrocartilage
Histological evaluation – fibrocartilage formation:
PS10x – bone/fibrocartilage
DMMB4x - fibrocartilage
Mosaicplasty in 354 athletes (3 institutes):
soccer
handball
waterpolo
wrestling
gymnast
others
MFC
Defect location:
LFC
LTC
PF
talus
capitellum
humeri
Male : female
Male
Female
MP results in 354 athletes:
* average defect size: 2.5 cm2 (1.0-5.5 cm2)
* age: 24.3 (14-49) years
* 185:169 male-female ratio
* two third osteochondral defects, one third cartilage lesions
* in 43% slight or moderate osteoarthritic changes praeoperatively !
Hangody, L. – Dobos, J. – Baló, E. – Pánics, G. – Hangody, L., R. – Berkes, I.: Clinical experiences with
autologous osteochondral mosaicplasty in athletic population – a 17-years prospective multicenter study.
American Journal of Sporstmedicine 38:1125-1133, 2010
MP results in 354 athletes:
* 9.6 ys. (2-17 ys.) follow up
* no septic or thromboembolic complications
* average 4.9 months rehabilitation period to return to the sports
* 64 % return to same level sports activity
* 19 % return to a lower level sports activity (incl. hobby sports)
* 17 % no more sports activity (8% worse than praeop.)
?
Viewpoints at different cartilage repair
techniques:
optimal indication of the actual procedure (size, type and
location of the defect; age; high or low demand patient; etc.)
combination with other procedures
length of rehabilitation
costs
experience of the surgeon
Case report No. 1.
26 ys. old gymnast
2 sqcm cartilage defect
on the MFC, torn ACL
arthroscopic MP and
BTB ACL MP 6 ys.
before
full recovery in 5ms.
Case report No. 2.
27 ys. old soccerplayer
3.5 sqcm cartilage
defect on the LFC
miniarthrotomy MP
2.5 ys. before
full recovery
Conclusions:
Autologous osteochondral mosaicplasty
may be an alternative in the treatment
of small and medium sized focal
chondral and osteochondral defects of
the weight bearing surfaces.
- Hyaline like resurfacement
- One step procedure
- Combination with other procedures
- Arthroscopic or minimal invasive
approach
- Short rehabilitation