1. Articular Cartilage Injury The “Knee Blowout” Jon D. Koman, MD

2. Tire Analogy Tread of a tire = articular cartilage

3. Degenerative

4. Traumatic

5. Focal Cartilage Defects Traumatic Traumatic o Concomitant ligament injury -- ex: ACL  Osteochondritis Dissecans lesion o Localized cartilage lesion due to unexplainable localized poor blood supply. o Most commonly seen on lateral part of medial femoral condyle.

6. Cartilage Lesion Classification Cartilage Lesion Classification

7. Bad to the Bone

8. Diagnosis History/Physical History/Physical X-rays X-rays MRI MRI Diagnostic arthroscopy Diagnostic arthroscopy

9. History/Physical Intermittent, vague, poorly localized pain. Intermittent, vague, poorly localized pain. Locking or catching if loose body present. Locking or catching if loose body present. May have associated secondary degenerative changes if bony incongruity present. May have associated secondary degenerative changes if bony incongruity present.

10. X-rays

11. MRI

12. Treatment Options Bone marrow stimulation (<5 mm).-- scar cartilage, not real weight bearing type of articular cartilage. Bone marrow stimulation (<5 mm).-- scar cartilage, not real weight bearing type of articular cartilage. Autologous Chondrocyte Implantation (> 2x2 cm lesions)--requires open arthrotomy and at least two surgeries but theoretically same type of weight bearing articular cartilage. Autologous Chondrocyte Implantation (> 2x2 cm lesions)--requires open arthrotomy and at least two surgeries but theoretically same type of weight bearing articular cartilage. Osteochondral Autograft Transplant Surgery (O.A.T.S.)( <2 x2 cm lesions ?) -- limited number of donor plugs but covers lesion with same type of weight bearing articular coverage. Osteochondral Autograft Transplant Surgery (O.A.T.S.)( <2 x2 cm lesions ?) -- limited number of donor plugs but covers lesion with same type of weight bearing articular coverage.

13. Bone Marrow Stimulation

14. Autologous Chondrocyte Implantation

15. O.A.T.S.

16. O.A.T.S.

17. O.A.T.S.

18. Rehabilitation Phases Protective (4 wks): NWB x 2 wks then 20-30lbs weight bearing. PROM exercises. Protective (4 wks): NWB x 2 wks then 20-30lbs weight bearing. PROM exercises. Transition (5th and 6th wks): 25% weight bearing, mini squats and aqua jogging. Transition (5th and 6th wks): 25% weight bearing, mini squats and aqua jogging. Maturation (7-12 wks): Full WB, full squats, walking swimming and stairmaster. Maturation (7-12 wks): Full WB, full squats, walking swimming and stairmaster. Functional (>12 wks): Full activity. Functional (>12 wks): Full activity.

19. Back to Work Issues No sooner than 3 mos. No sooner than 3 mos. ? Permanent work restrictions depending on size of lesion and concomitant injuries. ? Permanent work restrictions depending on size of lesion and concomitant injuries. Will more than likely have lifting restrictions depending on size of lesion and concomitant injuries. Will more than likely have lifting restrictions depending on size of lesion and concomitant injuries.

20. Case Study 25 year old male sustained a fall/twist on right knee. 25 year old male sustained a fall/twist on right knee. PE: 2+ effusion, ROM 0-130 deg, 2+ Lachman, pivot shift and anterior drawer. PE: 2+ effusion, ROM 0-130 deg, 2+ Lachman, pivot shift and anterior drawer. Xrays: wnl Xrays: wnl MRI: ACL tear, medial/lateral meniscus tears, full thickness cartilage defect of medial femoral condyle. MRI: ACL tear, medial/lateral meniscus tears, full thickness cartilage defect of medial femoral condyle.

21. MRI

22. Arthroscopic Findings ACL tear ACL tear MFC defect measuring 8mm x 16 mm. MFC defect measuring 8mm x 16 mm. Med/lat meniscus tears Med/lat meniscus tears

23. Arthroscopic Treatment Partial Med/lat menisectomies Partial Med/lat menisectomies O.A.T.S. of MFC O.A.T.S. of MFC ACL reconstruction ACL reconstruction

24. Conclusions O.A.T.S. procedure provides quick and near complete coverage of most focal full thickness cartilage lesions. O.A.T.S. procedure provides quick and near complete coverage of most focal full thickness cartilage lesions. Covers cartilage lesion with same type of weight bearing articular cartilage Covers cartilage lesion with same type of weight bearing articular cartilage Can be done at same surgery as other planned procedures. Can be done at same surgery as other planned procedures. Can be done arthroscopically providing faster rehabilitation and sooner return to work. Can be done arthroscopically providing faster rehabilitation and sooner return to work.