Running Healthy: Running Healthy: Protecting, Preserving and Protecting, Preserving and

Restoring CartilageRestoring Cartilage

Matthew Busam, MDMatthew Busam, MD

Cincinnati SportsMedicineCincinnati SportsMedicine

Team Physician: Elder HSTeam Physician: Elder HS

““If you have a body, you’re an If you have a body, you’re an athlete.”athlete.”

-Bill Bowerman-Bill Bowerman

GoalsGoalsReview evidence concerning running Review evidence concerning running and arthritisand arthritisReview supplementsReview supplementsReview “cortisone” injectionsReview “cortisone” injectionsReview signs and symptoms of when Review signs and symptoms of when we ask our patients to stop running we ask our patients to stop running and consider further evaluationand consider further evaluationSurgical advances in articular Surgical advances in articular cartilage injuriescartilage injuries

Benefits of runningBenefits of running

PhysicalPhysical– CardiovascularCardiovascular– Weight managementWeight management– Intellectual? – regular exercise can Intellectual? – regular exercise can

improve cognition (at least in mice)improve cognition (at least in mice)– Maintenance of bone mineral densityMaintenance of bone mineral density– Protective effect for joints?Protective effect for joints?

PsychologicalPsychological

Adverse effectsAdverse effects

InjuriesInjuries– 30% of “serious distance runners”30% of “serious distance runners”

– >25 miles per week>25 miles per week– will be injured in a given yearwill be injured in a given year– 30% of these injuries involve the knee30% of these injuries involve the knee

Running & ArthritisRunning & Arthritis

Does running cause arthritis?Does running cause arthritis?

–NO!NO!

But what about…?But what about…?

Anecdotal evidence for just about Anecdotal evidence for just about anything.anything.

No proven relationship implicating No proven relationship implicating running with development or running with development or progression of osteoarthritisprogression of osteoarthritis

ExamplesExamplesJAMA. 1986 Mar 7;255(9):1147-51. JAMA. 1986 Mar 7;255(9):1147-51. Lane NE, , Bloch DA, , Jones HH, , Marshall WH Jr, , Wood PD, , Fries JFLong-distance running, bone density, and Long-distance running, bone density, and osteoarthritis.osteoarthritis.

Running is associated with Running is associated with increased bone mineral but increased bone mineral but not, not, in this cross-sectional study, with in this cross-sectional study, with clinical osteoarthritisclinical osteoarthritis

EvidenceEvidence

J Rheumatol. 1993 Mar;20(3):461-8J Rheumatol. 1993 Mar;20(3):461-8. . – Lane NE, , Michel B, , Bjorkengren A, , Oehlert J, , Shi H, , Bloch DA, , Fries JF..– The risk of osteoarthritis with The risk of osteoarthritis with

running and aging: a 5-year running and aging: a 5-year longitudinal study.longitudinal study.

– Running did not accelerate the Running did not accelerate the development of radiographic or development of radiographic or clinical OA of the kneesclinical OA of the knees

Curr Opin Rheumatol. 1999 Sep;11(5):413-6. Curr Opin Rheumatol. 1999 Sep;11(5):413-6. Exercise and osteoarthritis.Exercise and osteoarthritis.Lane NE, , Buckwalter JA..

Recreational jogging in Recreational jogging in individuals 60 or more years of individuals 60 or more years of age with normal knee and hip age with normal knee and hip joints does not increase the joints does not increase the risk for the development of risk for the development of osteoarthritis. osteoarthritis.

Who hurts more?Who hurts more?

Arthritis Res Ther. 2005;7(6):R1263-70. Epub 2005 Sep 19.Arthritis Res Ther. 2005;7(6):R1263-70. Epub 2005 Sep 19. – Bruce B, , Fries JF, , Lubeck DP..– Aerobic exercise and its impact on Aerobic exercise and its impact on

musculoskeletal pain in older adults: a 14 year musculoskeletal pain in older adults: a 14 year prospective, longitudinal study.prospective, longitudinal study.

Compared runners, who averaged about 26 miles a week, Compared runners, who averaged about 26 miles a week, to a matched set of controls, who averaged about two miles to a matched set of controls, who averaged about two miles a week. "If running creates damage through accumulated a week. "If running creates damage through accumulated trauma, then runners with about ten-fold the exposure to trauma, then runners with about ten-fold the exposure to such trauma should have increased pain over timesuch trauma should have increased pain over time." ."

The runners experienced "about 25 percent less The runners experienced "about 25 percent less musculoskeletal pain" than the controlsmusculoskeletal pain" than the controls..

Long-term study:Long-term study:

Percent Pain Increase Age 60-80Percent Pain Increase Age 60-80Female Female RunnersRunners:11.8%:11.8%Female Control: 70.6%Female Control: 70.6%Male Male Runners:Runners: 17.6% 17.6%Male Control: 41.4% Male Control: 41.4%

Imaging DataImaging Data

Objective FindingsObjective FindingsAm J Sports Med. 2004 Jan-Feb;32(1):55-9.Am J Sports Med. 2004 Jan-Feb;32(1):55-9.Hohmann E, , Wörtler K, , Imhoff ABMR imaging of the hip and knee before and after MR imaging of the hip and knee before and after

marathon marathon Results suggest that the high impact forces in long-distance Results suggest that the high impact forces in long-distance

running are well tolerated and subsequently do not running are well tolerated and subsequently do not demonstrate changes on MR images. demonstrate changes on MR images.

Eur Radiol. 2006 Oct;16(10):2179-85. Epub 2006 Mar 10.Eur Radiol. 2006 Oct;16(10):2179-85. Epub 2006 Mar 10. Schueller-Weidekamm C, , Schueller G, , Uffmann M, , Bader TR..Does marathon running cause acute lesions of the knee? Does marathon running cause acute lesions of the knee?

Evaluation with magnetic resonance imaging.Evaluation with magnetic resonance imaging.The evaluation of lesions of the knee with MRI shows that The evaluation of lesions of the knee with MRI shows that

marathon running does not cause severe, acute lesions of marathon running does not cause severe, acute lesions of cartilage, ligaments, or bone marrow of the knee in well-cartilage, ligaments, or bone marrow of the knee in well-trained runners trained runners

Objective FindingsObjective Findings

Am J Sports Med. 2008 May;36(5):966-70. Epub 2008 Feb Am J Sports Med. 2008 May;36(5):966-70. Epub 2008 Feb 20.20.

Kessler MA, , Glaser C, , Tittel S, , Reiser M, , Imhoff AB..

Recovery of the menisci and articular cartilage of Recovery of the menisci and articular cartilage of runners after cessation of exercise: additional runners after cessation of exercise: additional aspects of in vivo investigation based on 3-aspects of in vivo investigation based on 3-dimensional magnetic resonance imaging.dimensional magnetic resonance imaging.Recovery period of 1 hour, articular structures returned to normal

Objective findingsObjective findingsSkeletal Radiol. 2008 Jul;37(7):619-26. Epub 2008 May 16. Skeletal Radiol. 2008 Jul;37(7):619-26. Epub 2008 May 16. Krampla WW, , Newrkla SP, , Kroener AH, , Hruby WFHruby WF

Changes on magnetic resonance tomography in the Changes on magnetic resonance tomography in the knee joints of marathon runners: a 10-year knee joints of marathon runners: a 10-year longitudinal studylongitudinal studyLoads experienced in marathon running do not cause permanent damage in the internal structures of the knee. A disposition for premature arthrosis was not registered in the population investigated.

Causes of knee pain in runnersCauses of knee pain in runnersAnterior knee painAnterior knee pain– Lateral pressure Lateral pressure

syndromesyndrome– Patella instabilityPatella instability– Extensor Extensor

mechanism mechanism tendinopathytendinopathy

OthersOthers– MeniscusMeniscus– Focal chondral defectsFocal chondral defects– OAOA– BursitisBursitis– Stress fractureStress fracture– ITBITB– Popliteal tenosynovitisPopliteal tenosynovitis– Ligamentous instabilityLigamentous instability

Treatment: Where to interveneTreatment: Where to intervene

Training programsTraining programs

Anatomy, biomechanicsAnatomy, biomechanics

Shoes, orthoticsShoes, orthotics

Muscles: weakness, imbalanceMuscles: weakness, imbalance

Physical therapyPhysical therapy

MedicationMedication

SurgerySurgery

Rehab Rehab

Where to Start?Where to Start?

The best way to protect the knees of The best way to protect the knees of runners is with regular stretching and runners is with regular stretching and strengthening exercises…in addition strengthening exercises…in addition to running!to running!

Quads and HamstringsQuads and HamstringsPatellofemoral painPatellofemoral pain

Anterior knee painAnterior knee pain

““Runners Knee”Runners Knee”

Runners are tough, but weak!Runners are tough, but weak!

Running does Running does not produce not produce strengthstrength– It produces It produces

enduranceendurance

Weakness leads Weakness leads to imbalance to imbalance pain and injurypain and injury

Closed chain quad rehabClosed chain quad rehab

Iliotibial Band Iliotibial Band Streching/StrengtheningStreching/Strengthening

StretchingStretching

StrengthenStrengthen

ShoesShoesAm J Sports Med. 2006 Am J Sports Med. 2006 Dec;34(12):1998-2005. Dec;34(12):1998-2005. Butler RJButler RJ, , Davis ISDavis IS, , Hamill JHamill J..

Interaction of arch type Interaction of arch type and footwear on and footwear on running mechanics.running mechanics.

Running footwear Running footwear recommendations recommendations should be based on an should be based on an individual's running individual's running mechanics. If not mechanics. If not available, footwear available, footwear recommendations can recommendations can be based arch type. be based arch type.

ShoesShoesMidsoles wear out before outsolesMidsoles wear out before outsolesIf outsole is worn, midsole is likely worse!If outsole is worn, midsole is likely worse!Mileage estimates are really just guesses, but Mileage estimates are really just guesses, but usuallyusually– 300 miles300 miles is time for new footwear is time for new footwear– Unless pt is a very efficient, lightweight runnerUnless pt is a very efficient, lightweight runner

Running through InjuryRunning through Injury

Yes, No, and MaybeYes, No, and Maybe

Yes for shin splintsYes for shin splints

No for stress fracturesNo for stress fractures

No when swelling is presentNo when swelling is present

Return from InjuryReturn from Injury

Graduated return Graduated return to sport programto sport program

Prolonged processProlonged process

Start slowStart slow

Gradually increase Gradually increase time and distancetime and distance

Then focus on Then focus on speedspeed

What about regrowing What about regrowing cartilage?cartilage?

SupplementsSupplements““Patented ingredients help support, ease, Patented ingredients help support, ease, and rebuild joints….”and rebuild joints….”““Soothe away joint pain and watch as your Soothe away joint pain and watch as your skin regains a nourished, youthful skin regains a nourished, youthful appearance….”appearance….”““It’s like oil for your joints—it helps It’s like oil for your joints—it helps promote full range of motion and promote full range of motion and flexibility.”flexibility.”““New Miracle Relief Formula eliminates New Miracle Relief Formula eliminates even the worst pain...almost instantly!”even the worst pain...almost instantly!”

What is a Supplement?What is a Supplement?U.S. Food and Drug Administration (FDA) U.S. Food and Drug Administration (FDA) – dietary supplements: subcategory of “food,” providing dietary supplements: subcategory of “food,” providing

manufacturers with greater leeway and less oversight manufacturers with greater leeway and less oversight than products in the pharmaceutical categorythan products in the pharmaceutical category

– Asterisk syndrome: product is advertised to promote and Asterisk syndrome: product is advertised to promote and maintain “joint strength,* joint flexibility,* joint maintain “joint strength,* joint flexibility,* joint lubrication,* range of motion,* production of lubricating lubrication,* range of motion,* production of lubricating fluid,* and renewal of cartilage and connective tissue.*” fluid,* and renewal of cartilage and connective tissue.*” “*These statements have not been evaluated by “*These statements have not been evaluated by the Food and Drug Administration. This product is the Food and Drug Administration. This product is not intended to diagnose, treat, cure, or prevent not intended to diagnose, treat, cure, or prevent any disease.”any disease.”

GlucosamineGlucosamine “ “highly significant efficacy” for all outcomes, highly significant efficacy” for all outcomes, including joint space narrowing and Western Ontario including joint space narrowing and Western Ontario MacMaster University Osteoarthritis Index (WOMAC).MacMaster University Osteoarthritis Index (WOMAC). Structural and Symptomatic Efficacy of Glucosamine Structural and Symptomatic Efficacy of Glucosamine and Chondroitin in Knee Osteoarthritis A and Chondroitin in Knee Osteoarthritis A Comprehensive Meta-analysis Comprehensive Meta-analysis Florent Richy, MSc; Olivier Bruyere, MSc; Olivier Ethgen, Florent Richy, MSc; Olivier Bruyere, MSc; Olivier Ethgen, MSc; Michel Cucherat, MSc, PhD; Yves Henrotin, MSc, PhD; MSc; Michel Cucherat, MSc, PhD; Yves Henrotin, MSc, PhD; Jean-Yves Reginster, MD, PhD Jean-Yves Reginster, MD, PhD

Arch Intern Med.Arch Intern Med. 2003;163:1514-1522.  2003;163:1514-1522.

Glucosamine & ChondroitinGlucosamine & ChondroitinGA stimulates production of collagen and GA stimulates production of collagen and its precursors. It may also have an its precursors. It may also have an antiinflammatory role. antiinflammatory role.

CS inhibits enzymes that break down CS inhibits enzymes that break down cartilage. It also adds to the pool of cartilage. It also adds to the pool of molecules that form collagen. molecules that form collagen.

The combination of these compounds is The combination of these compounds is considered to enhance cartilage considered to enhance cartilage protectionprotection. .

GlucosamineGlucosamineAnother Another studystudy reported on 1,583 patients with reported on 1,583 patients with symptomatic knee osteoarthritis who were symptomatic knee osteoarthritis who were randomly assigned to take glucosamine, randomly assigned to take glucosamine, chondroitin, a combination of glucosamine and chondroitin, a combination of glucosamine and chondroitin, celecoxib, or placebo over 24 weeks. chondroitin, celecoxib, or placebo over 24 weeks. Overall rate of response to glucosamine, Overall rate of response to glucosamine, chondroitin, and the combination were not chondroitin, and the combination were not found to be significantly better than found to be significantly better than placeboplacebo, although patients with moderate to , although patients with moderate to severe pain at baseline were observed to respond severe pain at baseline were observed to respond significantly better with the combination. significantly better with the combination. N Engl J Med. 2006 Feb 23;354(8):795-808 N Engl J Med. 2006 Feb 23;354(8):795-808

Glucosamine: Side effectsGlucosamine: Side effectsPrimary side effects:Primary side effects:– mild gastrointestinal complaints such as constipation, mild gastrointestinal complaints such as constipation,

diarrhea, cramping, gas, heartburn, and nausea. diarrhea, cramping, gas, heartburn, and nausea. Glucosamine sulfate has been associated with Glucosamine sulfate has been associated with drowsiness and headache. The effects of glucosamine on drowsiness and headache. The effects of glucosamine on nursing or pregnant women have not been well-studied.nursing or pregnant women have not been well-studied.

– Glucosamine may increase blood sugar levels. Although Glucosamine may increase blood sugar levels. Although studies of glucosamine on patients with diabetes are studies of glucosamine on patients with diabetes are inconclusive, it is believed that higher doses may inconclusive, it is believed that higher doses may prompt the pancreas to produce less insulin, so caution prompt the pancreas to produce less insulin, so caution is advised.is advised.

– Because glucosamine is often made from shellfish and Because glucosamine is often made from shellfish and the source of the product is not required to be on the the source of the product is not required to be on the label, individuals who are allergic to seafood are advised label, individuals who are allergic to seafood are advised to exercise caution as wellto exercise caution as well

ChondroitinChondroitinStudy participants have generally reported a decrease Study participants have generally reported a decrease in pain and increases in joint movement when taking in pain and increases in joint movement when taking chondroitinchondroitin, although it is not uncommon for , although it is not uncommon for participants to take chondroitin in combination participants to take chondroitin in combination with aspirin or other conventional arthritis with aspirin or other conventional arthritis treatmentstreatments, so , so the true extent of the efficacy of the true extent of the efficacy of chondroitin remain unclear.chondroitin remain unclear.Some studies seem to show that chondroitin Some studies seem to show that chondroitin must be taken for up to 4 months before must be taken for up to 4 months before benefits are realizedbenefits are realized..A recent 24-week A recent 24-week trial of 279 patients found of 279 patients found no no significant difference between chondroitin and significant difference between chondroitin and placebo placebo as far as the study’s primary efficacy criteria as far as the study’s primary efficacy criteria (pain on daily activities and Lequesne’s index) were (pain on daily activities and Lequesne’s index) were concernedconcerned

ChondroitinChondroitinPrimary side effects:Primary side effects:– uncommon and include hair loss and minor uncommon and include hair loss and minor

gastrointestinal complaints. The effects of chondroitin on gastrointestinal complaints. The effects of chondroitin on nursing or pregnant women have not been well-studied.nursing or pregnant women have not been well-studied.

– Chondroitin can decrease the blood’s ability to clot, and Chondroitin can decrease the blood’s ability to clot, and it is not advisable to take it concurrently with aspirin, it is not advisable to take it concurrently with aspirin, antiplatelet, or anticoagulant drugs.antiplatelet, or anticoagulant drugs.

– Chondroitin products are also sometimes combined with Chondroitin products are also sometimes combined with manganese, which may assist in cartilage production, manganese, which may assist in cartilage production, but is toxic in large doses. The U.S. National Academy of but is toxic in large doses. The U.S. National Academy of Sciences has set the adult tolerable upper limit for Sciences has set the adult tolerable upper limit for manganese at 11 mg/day; patients should be advised manganese at 11 mg/day; patients should be advised not to exceed that level.not to exceed that level.

MSMMSMMethylsulfonylmethane (MSM) Methylsulfonylmethane (MSM) – Treatment for a variety of conditions from Treatment for a variety of conditions from

osteoarthritis to stress and snoring. osteoarthritis to stress and snoring. – Few clinical trials examine the supplement’s Few clinical trials examine the supplement’s

efficacy for osteoarthritis. efficacy for osteoarthritis. – Evidence for this is spotty at best Evidence for this is spotty at best

Omega-3Omega-3Little clinical evidence exists to support Little clinical evidence exists to support assertions that omega-3s are effective assertions that omega-3s are effective against arthritis.against arthritis.

Shark CartilageShark CartilageNo proof that taking a shark cartilage No proof that taking a shark cartilage supplement provides benefits. supplement provides benefits. No studies have been conducted to No studies have been conducted to determine whether shark cartilage has any determine whether shark cartilage has any serious or long-term side effects serious or long-term side effects

Supplements OverallSupplements OverallOf the commonly available supplements, Of the commonly available supplements, glucosamine, chondroitin, or a combination of the glucosamine, chondroitin, or a combination of the two appear to have the greatest efficacy based two appear to have the greatest efficacy based on clinical trials, but a number of researchers on clinical trials, but a number of researchers remain guarded even when recommending those remain guarded even when recommending those products products If less than 120 lbs: GA 1000mg + CS 800mg (1 If less than 120 lbs: GA 1000mg + CS 800mg (1 tab twice a day) tab twice a day) Between 120-200: GA 1500mg + CS 1200mg (2 Between 120-200: GA 1500mg + CS 1200mg (2 tabs in morning and 1 tab in afternoon) tabs in morning and 1 tab in afternoon) If greater than 200: GA 2000mg + CS 1600mg (2 If greater than 200: GA 2000mg + CS 1600mg (2 tabs twice a day) tabs twice a day)

InjectionsInjectionsClinical data supports Clinical data supports the uses of intra-the uses of intra-articular articular corticosteroids, even corticosteroids, even in repeated use (up to in repeated use (up to every 3 months for up every 3 months for up to 2 years) particularly to 2 years) particularly for patients with knee for patients with knee OA. OA.

Injections (My philosophy)Injections (My philosophy)As an anti-As an anti-inflammatoryinflammatory– When pt has When pt has

effusioneffusion– When OA is knownWhen OA is known– Not given to “return Not given to “return

to sport”to sport”

As an adjunct to PTAs an adjunct to PT– Decrease acute Decrease acute

symptoms to allow symptoms to allow proper participation proper participation in physical therapyin physical therapy

– Not more than 3 per Not more than 3 per year.year.

Focal Chondral DefectsFocal Chondral Defects

OCDOCD– Osteochondritis dissicensOsteochondritis dissicens– Osteochondral defectOsteochondral defect

FCD: TreatmentFCD: Treatment

Is it symptomatic?Is it symptomatic?– Don’t make an asymptomatic finding a Don’t make an asymptomatic finding a

symptomatic problemsymptomatic problem– Don’t be surprised!Don’t be surprised!– Treatment and rehab is very differentTreatment and rehab is very different

Chondral repairChondral repair

OptionsOptionsObservationObservation

ChondroplastyChondroplasty

MicrofractureMicrofracture

OATS (AOT)OATS (AOT)

ACI (Carticel)ACI (Carticel)

Osteochondral Osteochondral allograft allograft

Meniscus Meniscus transplantstransplants

Ligament Ligament reconstructionreconstruction

Correction of Correction of alignmentalignment– OsteotomyOsteotomy

MicrofractureMicrofracture

Marrow stimulation techniqueMarrow stimulation technique– Body will produce repair tissue for a Body will produce repair tissue for a

chondral defect if undifferentiated chondral defect if undifferentiated mesenchymal cells are accessed.mesenchymal cells are accessed.

– Marrow cells, blood, platelets organize Marrow cells, blood, platelets organize into the defectinto the defect

– Differentiate into fibroblasts which Differentiate into fibroblasts which produce a fibrocartilage “healing” of the produce a fibrocartilage “healing” of the defectdefect

MicrofractureMicrofracture

Correct and incorrect methodsCorrect and incorrect methods

Correct:Correct:– Debride defect, leaving a sharp Debride defect, leaving a sharp

shouldered edge.shouldered edge.

MicrofractureMicrofracture

Microfracture is notMicrofracture is not

““poking some holes in the cartilage”poking some holes in the cartilage”

““the same rehab as a menisectomy”the same rehab as a menisectomy”

RehabRehab

TTWB for 6-8 weeks (modified based TTWB for 6-8 weeks (modified based on lesion location)on lesion location)

CPM at home for 6-8 weeks CPM at home for 6-8 weeks

After 6-8 weeks begin active ROM After 6-8 weeks begin active ROM and progress to full WBand progress to full WB

Cutting, twisting, pivoting 6 monthsCutting, twisting, pivoting 6 months

Success and cautionsSuccess and cautions

Return to impact sportsReturn to impact sports Maybe notMaybe not

DataData

HSS: 2006. HSS: 2006. – 66% G-E results66% G-E results

44% returned to sports44% returned to sports– 57% of those at same level57% of those at same level

Steadman: 2003Steadman: 200376% of NFL players returned to play next 76% of NFL players returned to play next

seasonseason

Steadman: 2003Steadman: 2003– 11.3 year f/u11.3 year f/u– Pts 45 and younger with no meniscal or Pts 45 and younger with no meniscal or

ligamentous pathologyligamentous pathology– Showed improvement in function and Showed improvement in function and

had less pain.had less pain.

ContraindicationsContraindications

MalalignmentMalalignment

Ligamentous instabilityLigamentous instability

Unshouldered lesionsUnshouldered lesions

Lesions > 10 mm deepLesions > 10 mm deep

Tibial lesions – less predictable Tibial lesions – less predictable resultsresults

ACIACI

Autologous chondrocyte implantationAutologous chondrocyte implantation

2 stage procedure2 stage procedure– Scope, biopsyScope, biopsy– Culture cellsCulture cells– Reimplant cells under patch Reimplant cells under patch

(periosteum)(periosteum)

Pre-implantPre-implant

Post implantPost implant

RehabRehab

Protected WBProtected WB

CPMCPM

No running or impact loading until 12 No running or impact loading until 12 monthsmonths

High level sports at 16 months if pain High level sports at 16 months if pain freefree

HypertrophyHypertrophyReported with need Reported with need for reoperation in for reoperation in up to 36% of up to 36% of patients…patients…

Reduced with non-Reduced with non-periosteal coversperiosteal covers– collagencollagen

After delaminationAfter delamination

ACI as a second line RxACI as a second line Rx

Unfortunately marrow stimulation Unfortunately marrow stimulation techniques increase failure rate from techniques increase failure rate from ACI by up to 3X!ACI by up to 3X!

Might not be best to mx then plan Might not be best to mx then plan ACI if no betterACI if no better

OATS/ AOTOATS/ AOT

Osteochondral autograft transferOsteochondral autograft transfer

Moves cartilage and its supporting Moves cartilage and its supporting bonebone

Successful provided defect is not too Successful provided defect is not too largelarge

Limited by sizeLimited by size– Supply of cartilageSupply of cartilage

OCAOCA

Transplantation of allograft Transplantation of allograft (cadaveric) cartilage and supporting (cadaveric) cartilage and supporting bone.bone.

Successful in many seriesSuccessful in many series

ConcernsConcerns– DiseaseDisease– MismatchMismatch– Non-healingNon-healing

Osteochdral allograft Osteochdral allograft

TechniqueTechnique

FinalFinal

Allograft meniscus Allograft meniscus transplantationtransplantation

Role of intact meniscus is Role of intact meniscus is unquestionedunquestioned

Does an allograft function like a Does an allograft function like a native meniscus?native meniscus?DiseaseDisease

MismatchMismatch

Non-healingNon-healing

Is it simply an “interposition arthroplasty”?Is it simply an “interposition arthroplasty”?

Meniscus TransplantMeniscus Transplant

Return to sports?Return to sports?MFX, ACI, OATS, OCA:MFX, ACI, OATS, OCA:

Durable enough to allow long-term cutting, Durable enough to allow long-term cutting, pivoting, impact sports?pivoting, impact sports?

Studies are limitedStudies are limited

If these heal and incorporate, can attempt return If these heal and incorporate, can attempt return to play if symptom freeto play if symptom free

Would not typically advise return to distance Would not typically advise return to distance running. running.

For ACI, sports participation meant better long-For ACI, sports participation meant better long-term results.term results.

DurabilityDurability

MAT and OCA have not been shown MAT and OCA have not been shown to have long-term superiority to to have long-term superiority to prosthetic replacements.prosthetic replacements.

These are often “bridge” procedures These are often “bridge” procedures that allow younger patients to avoid that allow younger patients to avoid metallic arthroplasty and thus avoid metallic arthroplasty and thus avoid revision. revision.

The FutureThe FutureResorbable matrix Resorbable matrix scaffoldsscaffolds

Off-label in US if Off-label in US if used for focal used for focal defectsdefects

Good results have Good results have been reported at been reported at short-term f/ushort-term f/u

The FutureThe Future

MACIMACI– Matrix-induced ACIMatrix-induced ACI

Culture chondrocytes implanted in collogen Culture chondrocytes implanted in collogen matrix prior to implantationmatrix prior to implantation

No periosteal flap neededNo periosteal flap needed

Cartilage “slurry”Cartilage “slurry”

Equine cartilageEquine cartilage

Genetic alterationsGenetic alterations

The FutureThe Future

Don’t be the last or first to do Don’t be the last or first to do something!something!

ThanksThanks