Arthrex offers several different cartilage repair treatment options that treat a variety of cartilage indications. For indications that require a microfracturing type technique, traditional microfracture awls are available as well as newer options like the Arthrex PowerPick, which allows for microdrilling up to 4 mm deep into the subchondral bone. The PowerPick comes in 30 and 45 degree angles. 
 
The bioabsorbable PLLA Chondral Dart has a unique, double reversed barbed design to facilitate superior fixation and compression of osteochondral flap tears up to 2 cm in diameter. The 18 mm long, 1.3 mm diameter Chondral Dart provides secure fixation under the hyaline cartilage surface to eliminate contact with sensitive articulating surfaces. 
 
For larger lesions, the Bio-Compression Screw may be used to fixate OCD lesions securely while eliminating the challenges of metal screw removal, soft tissue impingement, and unwelcome image scatter. Produced from solid enhanced PLLA and designed for excellent thread-to-bone contact, the Bio-Compression Screw provides excellent strength during insertion and through healing.

Knee

Procedure

Microfracture surgery is an articular cartilage repair technique performed by creating small fractures in the underlying bone in order for new fibrocartilage to form. Arthrex provides products, including the PowerPick, allowing surgeons to effectively perform microfracture surgery safely and reproducibly.

Microfracture

Human

Child (D)

The bioabsorbable PLLA Chondral Dart has a unique, double reversed barbed design to facilitate superior fixation and compression of osteochondral flap tears up to 2 cm in diameter. The 18 mm long, 1.3 mm diameter Chondral Dart provides secure fixation under the hyaline cartilage surface to eliminate contact with sensitive articulating surfaces. 
 
For larger lesions, the Bio-Compression Screw may be used to fixate OCD lesions securely while eliminating the challenges of metal screw removal, soft tissue impingement, and unwelcome image scatter. Produced from solid enhanced PLLA and designed for excellent thread-to-bone contact, the Bio-Compression Screw provides excellent strength during insertion and through healing.

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The Arthrex Chondral Dart™

Osteochondral Flap Repair System Using the Chondral Dart™ Implant

Orthobiologics

Patrick Smith, MD, (Columbia, MO) gives an in-depth review of various technique options when treating cartilage defects. Dr. Smith explains the benefits of using the PowerPick™ to perform marrow stimulation, reviews some case examples utilizing the Arthrex® Bio-Compression Screws and Chondral Dart™, highlights research associated with the OATS® procedures, and details the potential of BioCartilage® Cartilage Extracellular Matrix. The principle of BioCartilage is to serve as a scaffold over a microfractured defect, providing a tissue network that can potentially signal autologous cellular interactions and improve the degree and quality of tissue healing within a properly prepared articular cartilage defect.

video

Cartilage Treatment Options Update

I'd like to share with you some thoughts of some new techniques. Arthrex has to deal with common cartilage problems. I want to start with the basics, beginning with microfracture. We all do this for small lesions particularly, but we need to know that you do not get hyaline cartilage back, but you get fibrocartilage. The shortcomings, as well as the repaired cartilage volume is pretty unpredictable. And we know after two years, multiple studies have shown the results of microfracture clinically deteriorate. But what you might not think about is a different way to do it. The traditional all is used, but there's a new way with drilling. And Chen did a very elegant study in rabbits and looked at using micro drilling versus an awl. And what they looked at was either two millimeter drilled holes or six millimeter drill holes, and they found in the drilled specimens that they had better type two collagen, better cell types for cartilage repair, and a better fill. Importantly, when they used the drill, they did not see any heat necrosis. So these are sample. This is a post-op 14 day histologic study. The micro drilling here in the middle and the microfracturing here on the right. What you see in the microfracturing is just what you think you see. Compacted and fractured bone, where the micro drilling is more open and more cartilage. Early restoration of cartilage occurs with the micro drilling. They're free of debris. The problem with the micro fractures, you actually get a fracture response. And this is a patient of mine. I've seen this fairly often. This is six years out from a micro fracture I did to the trochlea. And you can see the hypertrophic bone. You actually get an internal osteophyte. Here's another case I saw recently. Same thing. This was five years out from a micro fracture. You can see that the osteophyte and this is the arthroscopic picture. So the knee does not work too well when you have this internal bone growth rubbing on the tibia. So micro fracture is problematic. The PowerPick that Arthrex has is great. There's less heat. And importantly you get less bone edema. If you do a post-operative MRI, you don't see bone edema from using the PowerPick it attaches to your shaver. There's two angles, either 30 or 45 degrees, and there's two lengths of the pin at either 2mm or 4mm to do your standard microfracture. Remove your zone of calcified cartilage. Here's the PowerPick space. Your holes usually 2 to 3mm. Very easy to use. So the PowerPick is a real advantage. And again it just attaches directly to your shaver. This is a case that I did recently that had 15 year old young man with bilateral patellar OCD lesions. You can see here on his x rays, his AP and his inflammatory view. Here's his MRI. And you can see that the abnormal medial facet. And again he had this on both sides. And what I chose to do was to internally fix both of these lesions. And for that Arthrex has the compression screws available made of PLA. They have a stepped pitch and taper for compression two diameters either three millimeters or 3.5. The 3.5 are cannulated, and we also have chondral darts available which have a double reversed barb design. They're 1.3mm in diameter and 18mm long. So here's the case. You can see the arthroscopic picture of this flap of the medial facet. I did this with a mini open. We tap first. And here's my screw fixation with the bio compression screw, which really gives you excellent compression as you tighten it down. And this particular case I wanted to control rotation. So I added a control dart. Here. You drill and pass the dart through the cannula system. And this is the completed repair with the dart there. And then the bio compression screw seen here recessed just slightly below the level of the articular cartilage. And you get great compression here. This is another lesion. This was a large lateral trochlear lesion. And a 14 year old that I chose to fixate as well. Utilizing four of the bio compression screws. It's important to prepare the defect. And you want to remove this fibrous tissue here before you insert. This is a case that I want to share with you. It's a large osteochondral lesion of the medial femoral condyle. You can see here OCD lesion on his MRI. This particular case I do have a second look that I'll show you. This is his preoperative MRI on the left. Here's his one year MRI here, and you can see how there's leftover signal from the bio compression screws that I used. But you see restoration of the tide mark in the articular surface. So this is the clinical case. This young man had had a prior procedure before I had got to him, but they thought it was a stable lesion. It was sent to me. And clearly there's a line of demarcation with this large OCD lesion of the femur, medial femoral condyle. I mobilized it first, used it, and I like to breed the bony bed. And I also like to breed a little bit of the bone that's attached to the articular cartilage. It's important you don't recess it, though. You just want to get that fibrous tissue cleaned up to enhance the healing process. The advantage with this system is we have a clear guide. So you place your guide, pin your tap over your guide pin. And so you can see this all done arthroscopically. And here's my first screw going into position. And I recess it just slightly below the articular surface to get the compression. So the first one has been positioned. Here's my second one. Again the guide allows us to see, as we're doing arthroscopically, pin, tap and then screw placement. So here's my second screw. And I prefer these over metal screws. You don't have to go back and take them out. I ended up putting three in this particular lesion here. You see the three. And then I actually came back at a year. This is a year follow up that I want to show you now in this same case. And you can see the appearance of his medial femoral condyle a year later. Nice and stable. You don't see the screws. There's been no problem with the overlying articular surface. And clinically he did very well. So the bio compression screws have been a very valuable adjunct for me. Also, we have available the Osteochondral Autograft transfer system or OATS. Now this is a transplant of a hyaline cartilage plug or multiple plugs. If you wish to fill condo defects do it Arthroscopically big advantage of using the patient's tissue. You can do multiple plugs, as I said, and it's a cost savings, particularly against ACI. These are the instruments seen here, an important level one study that was done about OATS versus microfracture. This was in 60 patients that were athletes. Their average age was 24 years. And the advantage of this study is they looked at a second look scope at a year. And they also looked at MRI at three years. And they found excellent good repair in the OATS group at 84% versus only 52% for the microfracture at second look and arthroscopically. The by way of MRI at three years, 94% were excellent in the OATS group versus only 49% for the microfracture. And finally, importantly, return to sport 93% for OATS versus only 52% for microfracture. Also, studies by Barber and Marr have shown that you have maintenance of both the hyaline cartilage and the subchondral bone with a transplanted OATS plugs, and a Cochrane review in 2011 showed that the outcome of OATS was equivalent to ACI autologous chondrocyte implantation. Now, I'd like to talk to you about new Arthrex product called BioCartilage. What is BioCartilage? It's allograft cartilage. Extracellular matrix has key components of cartilage type two collagen, proteoglycans, and growth factors. How is How is it processed? It's dehydrated and micronized 100 to 300 microns size. And it's packaged and it has importantly, it has a five year shelf life. How do we use it? It's a scaffold over microfracture. This is a microfracture plus type procedure. It signals the autologous cellular interactions within the scaffold. And the goal is to improve the quality of healing after a microfracture or bone stimulation technique. This is a study that was done by the University of Miami Tissue Bank in baboons. And they filled osteochondral defects with the micronized allograft, cartilage particulate and the gross appearance, as you see on the right of nice and articular surface. Also with saffron OATS staining, you can see good lacunae of the cartilage. How do we prepare it? This is the mixing and delivery system. You mix the powder of the allograft cartilage first and you add ACP. It's usually 1 to 1 ratio. You want to have a thick, almost like a slurry, and it snaps on a little device to mix it for you. So it all comes as a kit. Then you mix that up to create almost a putty scene here in five, and then you assemble your needle and you can deliver the product either arthroscopically or open. So why do we use PRP as a mixing liquid? Milano did a nice study looking at microfracture in one group. Microfracture only the other group they added five injections of ACP. And what they looked at is the histology, as you can see here on the right at 12 months. And when there was no ACP, there was a large defect. When the ACP was utilized, there was a better healing response. This is an equine study done by Lisa Fortier looking at five horses. There were two defects created in each knee, as seen here as the video is running. Proximal and distal in the trochlea BioCartilage was in one knee, microfracture in the other. This is the BioCartilage. You do your power picking, dry it. And here's the BioCartilage being delivered and you smooth it off. You don't want to overfill the defect and then we seal it with fibrin glue. In Lisa's study, they looked at arthroscopic scoring as well as MRI and histology. So here comes the fibrin glue to seal the defect with the articular surface now restored. Put the. This is again in the equine model in her study. So here's their data. At two months six months and 13 months. Second looks microfracture above BioCartilage below. And you can see the better fill with BioCartilage and the more normal appearing articular surface compared to the microfracture. Again, that's in the equine model. The cartilage scoring was the same microfracture here at 4.8 proximal defect 7.4 for the BioCartilage and also for the distal. So the BioCartilage scored better as well. The quality of the tissue. Here's a patient of mine, 17 year old who has these two very large defects of the lateral femoral condyle. You might think doing an osteochondral allograft but I chose not to. I felt that I could do the BioCartilage. I did a mini open. You can see that bridge of cartilage in between didn't really look that good and I took it all down. So it's a three by three centimeter defect. Here's the PowerPick. Here's the BioCartilage applied. You smooth it off again. You don't want it over the edge of the articular surface. Don't make it too proud. Here is sealed with the fibrin glue upon completion. So again this was a three by three lesion. And this is his preoperative MRI. On the left you can see the large defect of the articular surface. This is an MRI that I did recently at only ten months out. You can see the excellent restoration of the articular surface. And the tide mark is actually coming back as well. And again, that was a very large defect. Here's another one I had. This was a patient with patella instability who had a large three by three defect also of his lateral femoral condyle. There was the arthroscopic picture. I actually did the same thing. I did a mini open here. There's the sealed FiberLoop TissuGlu over the BioCartilage. And look at his MRI. His pre-operative MRI concerned me because he had this big cystic area of the of the femur, as you can see. But only nine months later you can see the bone edema is gone. The cystic area is gone. The tidemark is starting to restore. So I'm very encouraged about these results with the BioCartilage even in large defects. So in conclusion, I want to make the key point that the knee is an organ. I've showed you some new techniques that are great. We have to remember to think about the whole knee. We have to think about alignment number one in terms of many of these patients need an osteotomy in addition to the cartilage procedure. We have to think about the meniscus. They may need meniscal transplantation or they may need an ACL reconstruction. So we can't just take these procedures out of context. It all has to go together. But the advantages that I've showed you preservation, you have the bio compression screws or the candidates to preserve articular cartilage lesions. Powerpick is a great way to do an enhanced and a better microfracture for small lesions. Reconstruction wise OATS procedure is an old standby. Works great and I've showed you the new BioCartilage and that's very encouraging. But again, I want to emphasize the importance of assessing alignment, especially in Tom Diberardino is going to teach us more about the needs for osteotomy around the tibia. Thank you very much.

Cartilage Repair

Microfracture

OCD Fixation