Chondral Injuries are one of the technically challenging cases for sports injury surgeons. There are various techniques described including lavage, abrasion chondroplasty, micro fracture, Mosaicplasty, ACI - various generations and newly developed Bioprinting

1. 10/01/2015 IASM Mumbai
Current Management Strategy for
chondral injuries in athletes:
Square Pegs in Round Holes!
Dr Vaibhav Bagaria
MBBS MS Dip SICOT
CARE hospital & ORIGYN Clinic
Nagpur, India
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2. Ideal Cartilage restoration
✤ “Chasing the Holy Grail”
✤ Can we recreate what God created?
✤ ‘Dil Mange more’
✤ Question: Are we trying square pegs in round holes?
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3. So...the ideal!!!
✤ Recreate Hyaline cartilage
✤ Reproduces zonal architecture
✤ Integrates with surrounding tissue
✤ Durable
✤ Cost Effective
✤ Single stage
✤ Minimally Invasive
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4. Structure of Cartilage
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5. Assessment - Clinical
✤ Knee Osteoarthritis& Outcome score (KOOS)
✤ IKDC
✤ Lysholm: too general & non specific
✤ Others: SF 36, Cincinatti rating, ICRS
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6. Assessment - Radio
✤ MRI ( Gad enhanced)
✤ MOCART Scores: 9 Parameters - Quantity, Integration, Surface,
Structure, Signal intensity, Integrity of subchondral lamina
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7. Assessment - Arthroscopic
✤ Histological:
✤ Hyaline like
✤ Mixed Hyaline- Fibrocartilage
✤ Fibro-cartilage
✤ Fibrous tissue
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8. ICRS
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9. Strategies
✤ Palliative
✤ Reparative
✤ Regenerative
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10. Modifier
✤ Anatomy: Size, Location & Depth (FT vs PT)
✤ Pathology: Traumatic vs Others
✤ Epidemiology: Age, Profession
✤ Confounders: Re surgery, Surgeon Skills, Associated lesion
✤ Expectations:
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11. That’s the concept!
✤ Ensuring the right match is the key!
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12. Various Strategies
✤ Debridement & Lavage
✤ Abrasion Chondroplasty
✤ Microfracture & Pridie Drilling
✤ Soft tissue - periosteal grafts
✤ Osteochondral transfer
✤ ACI - Various Generations
✤ Newer Techniques
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13. Debridement & Lavage
✤ Chondral Lesions less than 2 Sq cm
✤ Remove Loose cartilage fragments & washout
✤ Good for low demand, older age pt who may not tolerate prolonged
immobility
✤ Considered palliative, yet quick recovery with QOL improvement
and fast mobility.
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14. Microfractures
✤ Less than 2 - 3 sq cm lesions
✤ Reparative strategy
✤ Drilling holes 0.5 -1mm dia thro articular cartilage into bone marrow
cavity
✤ Allows access to bone marrow progenitor cells
✤ CPM with ltd activity required postop for healing
✤ Hyaline like cartilage that deteriorate over time.
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15. Microfractures
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16. Microfracture

17. Abrasion Chondroplasty
✤ Abrading subchondral bone superficially
✤ Intraosseous space opens up with vessels n mesenchyme
✤ Stimulates reparative process.
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18. Abrasion Chondroplasty
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19. Osteochondral Transplantation
✤ Could be Allo or auto
✤ Commomest auto: Mosaicplaty ( S & N); OATS ( Arthrex)
✤ Good for Intermediate defects upto 5 sq cm
✤ Viability of harvested graft is the question
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20. Technique
✤ Harvesting from NWB areas
✤ Cylindrical osteochondral grafts
✤ Transferred to WB area
✤ 2-5 sq cm
✤ Non degenerate knees only
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21. OATS/Mosaicplasty
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22. OATS/Mosaicplasty
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23. Regeneration Strategy Triad
✤ Cells are required for de novo synthesis
✤ Scaffold provide the template to lay down the matrix
✤ Biological signalling molecule required to stimulate cell requirement,
migration, differentiation as well as synthesis
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24. Trilogy of Biology
✤ The Cells
✤ The Matrix
✤ The growth Factors
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25. ACI - First Gen
✤ Cells isolated from NWB area
✤ Expanded in vito and transplanted to a defect
✤ Covered with periosteal flap
✤ Main drawback: two staged, time interval
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26. ACI - Gen 1
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27. ACI - Gen 2
✤ Drawback of Gen 1: graft delamination, ectopic calcification, graft
hypertrophy - mech symptoms “catching”
✤ 2nd gen - combines scaffold and cultured cells
✤ Scaffold provides structure for chondrocyte adhesion, expansion
while maintaining the chondrocyte phenotype.
✤ Can be used to treat relatively large chondral defecrs
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28. ACI Gen 2
✤ MACI - Porcine collagen I/ III matrix
✤ Hyalograft C- Hyaluronic acid scaffold
✤ Bioseed C - Polyglactin/poly - p - dioxan
✤ CaRes - 3D type 1 Collage
✤ Cartipatch hydrogel composed of alginate and agarose (inserted in
mosaic fashion
✤ Novocart 3D – collagen-based biphasic scaffold (specific protective
layer, collagen sponge)
BioCart IIBioCart II – freeze-dried homologous human fibrinogen and recombinant hyaluran– freeze-dried homologous human fibrinogen and recombinant hyaluran
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29. ACI 2
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30. MACI
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31. ACI - 3rd gen
✤ Avoid morbidity of auto harvest cartilage
✤ Uses allogenic or autogenic tissue
✤ Denovo ET: Allogenic fetal chondrocyte
✤ Cartistem: Umbilical Cord derived
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32. Various sources of MSC
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33. ACI - gen 3
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34. Bio-printing: RPBio-printing: RP
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35. Bio Printing
✤ 3D Printing: Layered approach instead of suspension
✤ Create 3D multi-materials that mimic geometry of living tissue
✤ www.3dpost.in
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36. Take home...
✤ Various strategies
✤ Numerous choices - superiority of one over another not established
✤ Customised Solution to your athletes
✤ Personal Choice: KISS: less than 2 sq cm: Micro fracture More than 2
sq cm: Offer 2nd gen ACI/ single stage BMAC repair
✤ Keep an eye for things on horizon
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