Philip A. Davidson, MD Heiden Davidson Orthopaedics 2012

1. Treating Injured Knees and Shoulders:Cartilage Restoration andJoint Resurfacing offering solutions for patients of all ages Philip A. Davidson, MD Heiden Davidson Orthopaedics 2012

2. Cartilage Restoration and Joint ResurfacingA wide realm between….. Arthroscopic debridement Traditional TKA

3. The problem: 29 y.o. mother of 3 Former elite skier

4. Goals of Cartilage Restoration &Joint Resurfacing • Relieve pain • Optimize function, sport and activities • Improve mechanics • Long lasting • Prevent or limit future degenerative dhanges • Retain future options surgically • Principles extend to many joints

5. Cartilage Restoration and Joint Resurfacing Treatments:…THE BIG PICTURE Debridement (clean up) Marrow stimulation BiologicalRestoration Biologic grafts Biosynthetics Scaffolds Cellular therapy Prosthetic Resurfacing Metals and Plastics Inlay Arthroplasty Onlay Arthroplasty Total Joint

6. Goal of Cartilage RestorationRestore Specialized Articular Cartilage

7. Marrow Stimulation • Techniques - Drilling - Picking - Abrasion - Microfracture • Marrow stimulation results: - Fibrocartilage • Limited potential with increased age, injury chronicity • Cheap, fast, easy • Short term efficacy seductive.

8. Biological Options • Cell Therapy • Osteochondral Grafts • Autogenous • Limited use • Allograft • Juvenile Cartilage Grafts • Minced grafts • Biologically Active Scaffolds

9. Bone and Cartilage Grafts • Autograft (self donor) • No donor needed • Limited availability • Small lesions only • Repair Broken Cartilage • Allograft (OCA) • Human Donor • Very effective • Young patients • Handle Bone loss • Larger lesions • Generally > 2 cm²

10. OCA– When is this done? • Larger defects • Deeper defects • Bone loss • Patellofemoral • Younger Patients • Osteochondritis • Otherwise healthy joint

11. OCA donor tissue • Fresh Stored ( < 30 days) • Germ Surveillance • Donor Testing/Screening • Limited Availability • Expensive • No game day decisions • No anti-rejection drugs

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26. What if biologics will not or cannot work? …too large, no longer “young”, obese, smoking, ……..Or just plain worn out Prosthetics - Joint Resurfacing

27. Biologic or Prosthetic Resurfacing ???? Key decision making point • Multifactoral decision • Lesion/Cartilage nearby • Patient Factors • Age (biological) • Comorbidities • Joint Status • Resources

28. Decision Making – Bio vs. ProstheticJoint Shape • Biologic Solutions are less likely to work in joint which has lost shape or is “crooked”

29. Transitional thinking from biologics to prosthetics • Once planning progresses to resurfacing need conceptual framework • Inlay • Onlay • Bone sacrificing( traditional)

30. Inlay Joint Resurfacing

31. Inlay Resurfacing • Accommodates different shapes and sizes • Intraoperative surface mapping • Preserves anatomy, minimal bone resection • Ways to think about Inlay: • “filling a cavity” • “new tiles on the floor” • “patching a tire”

32. Inlay Resurfacing: Anatomical Reconstruction • Accommodate complicated curvatures • Minimally invasive procedure allows for other reconstructions at same time • Inlay Arthroplasty is stable • Accounts for different sizes and shapes of persons and joints

33. Inlay – Contoured Articular Prosthesis • Geometry based on patient’s native anatomy • Intraoperative joint mapping • Account for complex asymmetrical geometry • Extension of biological resurfacing

34. Inlay- Platform Technology • Multiple Joints • Multiple sizes and shapes • Metallic Inlay in conjunction with stud or set-screw • Poly (special plastic) Technology uses cement in socket

35. Patellofemoral (knee cap joint)Inlay Resurfacing • Trochlea alone or Bipolar • Traditional prostheses limited success and rarely used • Inlay device allows for realignment easily, as no overstuffing • Inlay device can handle very advanced PF DJD and morphologic variability Traditional PFA Inlay PFA

36. Case # 1 – 42 year old female

37. Case #1

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39. Inlay Unicompartmental resurfacing arthroplasty aka….UniCAP™scope assisted Uni, AKR , etc..

40. Cementation

41. UniCAP case example – medial knee resurfacing 46 year old cyclist

42. UniCAP – medial knee resurfacing

43. UniCAP – medial knee resurfacing

44. UniCAP – medial knee resurfacing

45. UniCAP – medial knee resurfacing

46. UniCAP – medial knee resurfacing

47. Minimum 5-year results of focal articular prosthetic resurfacingfor the treatment of full-thickness articular cartilage defectsin the knee. Becher, C. et.al. Arch Orthop Trauma Surg . DOI 10.1007/s00402-011-1323-4. June, 2011. • 21 patients, mean age 54 yrs, minimum f-u 5 yrs, small focal unipolar lesions • KOOS scores improved significantly (P < 0.005) • pain (51.1 to 77.6), • symptoms (57.9 to 79.5), • ADL (58.8 to 82.4), • Sports (26.3 to 57.8) • Tegner activity level • improved significantly (P< 0.02) from 2.9 to 4. • SF-36(physical) increased by 15.2 to 46.9 compared to the preoperative value • 16/21 of the would have the operation again. • Radiographic results: • solid fixation, preservation of joint space and no change in the osteoarthritic stage.

48. Inlay Shoulder Resurfacing

49. ANATOMIC INLAY RESURFACING FOR GLENOHUMERAL OSTEOARTHRITISClinical Results in a Consecutive Case Series

50. Shoulder Resurfacing Study-Patient Population • N = 48 • Males – 29 • Female – 19 • Mean age at surgery • 61 years • Follow-up • 3 years