New Slide 1 © 2001 By Default! Custom and Patient-Matched Joint … · 2015. 11. 6. · Patient-Matched Resurfacing Outline • Cartilage Options - Overview ... • Former “hard

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Matthew T. Provencher, MD CDRMatthew T. Provencher, MD CDRAssociate Professor of OrthopaedicsAssociate Professor of OrthopaedicsDirector, Director, Shoulder, Knee Shoulder, Knee and Sports and Sports

SurgerySurgeryNaval Medical Center San DiegoNaval Medical Center San Diego

Custom and PatientCustom and Patient--Matched Matched Joint Resurfacing Joint Resurfacing –– Emerging Emerging Technologies Technologies -- ArthrosurfaceArthrosurface

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DisclosuresDisclosuresResearch Support:Research Support:

--AOSSM Young Investigator Grants (YIG) 2005AOSSM Young Investigator Grants (YIG) 2005--AANA Research Grants 2008; 2006AANA Research Grants 2008; 2006

--OREF Grants 2002;2004OREF Grants 2002;2004

--Editorial Boards/ReviewerEditorial Boards/Reviewer---- Elsevier (Arthroscopy; Associate Elsevier (Arthroscopy; Associate

Editor)Editor)--SLACK (Orthopaedics; JKS)SLACK (Orthopaedics; JKS)--Sage Publications (AJSM)Sage Publications (AJSM)

-- JBJS ReviewerJBJS Reviewer--JSES ReviewerJSES Reviewer

--No other ConflictsNo other Conflicts

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PatientPatient--Matched ResurfacingMatched ResurfacingOutlineOutline

•• Cartilage Options Cartilage Options --OverviewOverview

•• PatellofemoralPatellofemoralResurfacingResurfacing•• ArthrosurfaceArthrosurface PF ClassicPF Classic

•• ArthrosurfaceArthrosurface WAVEWAVE

•• Knee Knee CondyleCondyle and and Plateau ResurfacingPlateau Resurfacing

•• Shoulder ResurfacingShoulder Resurfacing•• ArthrosurfaceArthrosurface HemiCapHemiCap

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Young Young –– Moderately Young Moderately Young Active Duty Military Active Duty Military

PopulationPopulation•• Common Common diagnosisdiagnosis

•• Young, active Young, active populationpopulation

•• DemandingDemanding

•• Return to dutyReturn to dutySimilar to WCSimilar to WC

•• Large number of Large number of patients 35patients 35--55 55 years of age years of age with early OAwith early OA

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•• atellofemoralatellofemoralResurfacingResurfacing•• ArthrosurfaceArthrosurface PF ClassicPF Classic




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Cartilage OptionsCartilage OptionsNonNon--ArthroplastyArthroplasty

Cole & Provencher, 2007

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Emerging AlgorithmEmerging AlgorithmAnatomic Anatomic -- Limited Limited

ResurfacingResurfacing

LIMITED RESURFACING LIMITED RESURFACING

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Patellofemoral Arthritis…

•• At age 35: At age 35: •• 1111--35% incidence of 35% incidence of full thickness full thickness lesions (age 35)lesions (age 35)

AroenAroen A, et al. AJSM. A, et al. AJSM. 2004; 32: 2112004; 32: 211--1515Davies et al. Davies et al. ClinClinOrthop.2002Orthop.2002

•• Isolated PF chondral Isolated PF chondral injuries remain a injuries remain a problemproblem

•• Not all lesions Not all lesions symptomaticsymptomatic

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Challenges of PF AnatomyChallenges of PF AnatomyHighly VariableHighly Variable

•• Complex anatomyComplex anatomy•• 2 main facets 2 main facets ––medial and medial and laterallateral

•• 7 total facets 7 total facets •• Cartilage surface Cartilage surface = 2.5 to 6 mm = 2.5 to 6 mm depthdepth

•• PF joint is one of PF joint is one of the most the most challenging to challenging to dddd

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PF PathologyPF PathologyComplex DecisionComplex Decision--MakingMaking

•• Etiology of Etiology of defectsdefects

TraumaticTraumaticDegenerativeDegenerative

•• What else is What else is going on?going on?

Soft tissue Soft tissue injuriesinjuriesMalalignmentMalalignment

FemoralFemoralTibiaTibiaExtensor mechanismExtensor mechanism

•• Size of defectsSize of defects•• Location of Location of defectdefect

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PatellofemoralPatellofemoral ArthritisArthritisResurfacingResurfacing

•• Surgical indicationsSurgical indicationsYoung, active ptsYoung, active ptsIsolated Isolated patellofemoralpatellofemoralor two compartment or two compartment diseasediseaseAge < Age < 5555--65?65?

•• Treatment remains a Treatment remains a challenge challenge

high high pressures across pressures across the knee jointthe knee joint

33--5 5 xx body weightbody weightdifficulties in difficulties in achieving a congruent achieving a congruent resurfacing procedureresurfacing procedure

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ArthrosurfaceArthrosurface HemiCAPHemiCAPPP--F Inlay Prosthesis F Inlay Prosthesis

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TrochleaTrochlea PF Anatomic Implant PF Anatomic Implant Variety of GeometryVariety of Geometry

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Patellar ImplantsPatellar ImplantsVariety of Sizes/Shapes, Variety of Sizes/Shapes,

CementedCemented

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PurposePurpose

To determine To determine patellofemoralpatellofemoralkinematics after limited kinematics after limited

resurfacing with a resurfacing with a trochleartrochlearanatomicanatomic--specific implantspecific implant

JKS 2009*

*No funding was received for this study

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MethodsMethods

•• Eight fresh frozen Eight fresh frozen cadaveric knee cadaveric knee specimensspecimens

Mean age = 62.0 Mean age = 62.0

•• Custom Custom patellofemoralpatellofemoraltesting apparatus testing apparatus

•• Mini lateral Mini lateral arthrotomyarthrotomy centered centered proximal to the proximal to the patella patella

•• RealReal--time pressure time pressure sensor pad sensor pad

((TekscanTekscan Inc., South Inc., South Boston, MA), model KBoston, MA), model K--scan 4000scan 4000

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ResultsResultsPeak Force at 20 lbsPeak Force at 20 lbs

0

2

4

6

8

10

12

45 60 75

Ne

wto

ns

intactdefectimplant* *

*

* p< 0.05

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CaseCaseExample #1Example #1

•• 39 39 year oldyear old malemale•• 2 prior knee 2 prior knee surgeriessurgeries

•• Anterior knee Anterior knee painpain

•• Former Former ““hard hard corecore”” athlete athlete

•• Could not even Could not even walk with kids walk with kids

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CaseCase Example #1Example #1(healthy medial and lateral (healthy medial and lateral

))

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Surgical ExposureSurgical ExposureEither MIS medial incision Either MIS medial incision

(or midline)(or midline)

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Insert set screw Insert set screw

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Articular Mapping Articular Mapping

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Peripheral cutting Peripheral cutting --protect ambient cartilageprotect ambient cartilage

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Slide 25 Drilling for implant Drilling for implant

•• High speed drillHigh speed drill•• Do not use Do not use reamerreamer

•• Cooling Cooling irrigationirrigation

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Patella Patella Resurfacing Resurfacing Guide Guide

and Wireand Wire

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Slide 27Contact probe measures depth over Contact probe measures depth over centering shaftcentering shaft

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Drill to depth stop Drill to depth stop

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Patella Patella Trial Trial

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PatellaPatellacemented in cemented in place place

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Final Final TrochleaTrochleaImpactionImpaction

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Radiographs Radiographs

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RadiographsRadiographs

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Dr. Tibone case 7.26.06

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Radiographs after unilateralRadiographs after unilateral

If indicated: Consider distal realignment and/or lateral

releaseIn addition to resurfacing of the

joint

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•• PatellofemoralPatellofemoralResurfacingResurfacing•• ArthrosurfaceArthrosurface PFPF




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For Larger PF DefectsFor Larger PF DefectsLarger diameter prosthesisLarger diameter prosthesis

•• PF Classic = 20 PF Classic = 20 mm circular mm circular devicedevice

•• WAVE = WAVE = largerlarger37 mm medial37 mm medial--laterallateral35 mm superior35 mm superior--inferiorinferior

•• Prevents Prevents overstuffing overstuffing

•• Anatomical fit Anatomical fit preserved in preserved in designdesign

•• UniquelyUniquely

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Anatomic SizingAnatomic SizingMedMed--Lat Lat andand SupSup--InfInf

The depth (4 or 5 mm) of the preexisting trochlear groove is

determined.

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Read Contact Probe to obtain positive (+) superior and inferior offsets.

).

Mapping Joint S/I

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Select the Guide Block that corresponds with the offset from the

superior/inferior mapping point

Fixing the Guide Block

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Femoral Resurfacing Component: Cobalt-Chromium Alloy (Co-Cr-Mo)Undersurface Coating: Titanium (CP Ti)

Fixation Stud: Titanium Alloy (Ti-6Al-4V)

Implant In Situ

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Results of PF Resurfacing

ShortShort--term multicenter results: term multicenter results: •• 43 patients43 patients•• Average followAverage follow--up: 9 monthsup: 9 months•• Activity level at last followActivity level at last follow‐‐upup

70% of patients (N=30/43) achieved their pre70% of patients (N=30/43) achieved their pre‐‐injury injury levellevel21% of patients (N=9/43) improved by 1 level21% of patients (N=9/43) improved by 1 level9% of patients (N=4/43) decreased by 1 level at 9% of patients (N=4/43) decreased by 1 level at current followcurrent follow‐‐upup

•• Functional status at last followFunctional status at last follow‐‐upupUnrestricted (Level I): 30% of patients (N=13/43)Unrestricted (Level I): 30% of patients (N=13/43)Nearly Unrestricted (Level II): 56% of patients Nearly Unrestricted (Level II): 56% of patients (N=24/43)(N=24/43)Moderately Restricted (Level III): 14% of patients Moderately Restricted (Level III): 14% of patients (N=6/43)(N=6/43)

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•• PatellofemoralPatellofemoralResurfacingResurfacing•• ArthrosurfaceArthrosurface PFPF




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Unicompartmental Lesions & OA Medial OR Lateral

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Slide 50Set Pin Perpendicular &nline with Cam of Condyle

ap Superior/Inferior Curves

Map M/L curves

Ream Central Circle

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Slide 51Use Femoral Guide Block& Place I/S Pins

ace Trial & Insert Screw

Ream Inferior & Superior Circles

Final Bone Bed

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Place Tibial Implant

using wire shuttle & implant holder

Cement Implant in Place using “pressurized” cement

gun

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UniCAP™ CondyleFinal Implant

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39 y/o Male Navy Flight Doctor 1.5

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Where does the Where does the HemiCAPHemiCAP®® fit fit in?in?To provide a To provide a new option new option in the continuum of in the continuum of carecare after after conservative or conservative or biological treatments biological treatments have failed and either have failed and either before or, before or, hopefullyhopefully, , to avoid a traditional to avoid a traditional joint replacement.joint replacement.

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Treatment Options Treatment Options ARTHROSURFACE ARTHROSURFACE –– HemiCAPHemiCAP

Surface Surface hemiarthroplastyhemiarthroplasty

Bone sparingBone sparing

No compromise No compromise future TSAfuture TSA

FDA approved FDA approved Jan. Jan. ’’0404

Excellent Excellent earlyearlyresultsresults

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How does the How does the HemiCAPHemiCAP®® implant implant confer a congruent articular confer a congruent articular

surface in surface in two planes??two planes??

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Cartilage “Flow” over the Implant EdgeEmphasizes anatomic - fit

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AVNAVN--OperativeOperative

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Humeral Head DefectsHumeral Head DefectsReverse Hill SachsReverse Hill SachsLocked Posterior Locked Posterior

DislocationDislocation

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PostPost--Instability Instability Anchor ArthropathyAnchor Arthropathy

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ArthrosurfaceArthrosurface Clinical Clinical OutcomesOutcomes

62 patients62 patients36 male, 26 36 male, 26 femalefemaleMean age: 60 Mean age: 60 yrs yrs (range 25(range 25-- 84)84)Mean followMean follow--up: up: 8 mo (range 3 8 mo (range 3 --23)23)

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Simple Shoulder TestSimple Shoulder Test

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Slide 68 ConclusionsConclusionsLimitedLimited--Anatomic Anatomic

ResurfacingResurfacingArthrosurfaceArthrosurface SystemSystem

•• Joint preservation Joint preservation –– removal of minimal removal of minimal bone/cartilagebone/cartilage

•• Leaving functional tissues intactLeaving functional tissues intact

•• Retain future options Retain future options

•• The The patientpatient’’ss unique joint geometry guides unique joint geometry guides convexity mappingconvexity mapping

•• Avoids challenges withAvoids challenges withJoint heightJoint heightInclination angleInclination angleVersionVersionJoint volumeJoint volumeSoft tissue tensionSoft tissue tensionAnatomic resurfacing reduces risk of eccentric Anatomic resurfacing reduces risk of eccentric glenoid loadingglenoid loading

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Thank You!Thank You!Navy Orthopaedics San DiegoThank You!

Documents

New Slide 1 © 2001 By Default! Custom and Patient-Matched Joint … · 2015. 11. 6. · Patient-Matched Resurfacing Outline • Cartilage Options - Overview ... • Former “hard