5/18/2015
Return to Play (RTP) following
Cartilage Procedures
Scott D. Gillogly, M.D.
Atlanta Georgia
Atlanta,
Team Physician Atlanta Braves
AOSSM Partner Society Instructional Course
ICL #09 Critical Issues in the Care of the Injured Athlete Lyon, France
9 June 2015
Introduction: RTP after Cartilage Repair
• Multiple Factors influence selection of
Cartilage Repair technique
• Characteristics of Defect(s)
Characteristics of Defect(s) • Level of Sports Participation
Level of Sports Participation
• Age of patient
• Prior Treatment
• Concomitant Pathology • Goals and Expectations
• Cartilage repair is a physiologically slow
process
• Durability
D rabilit of repair depends on q
quality
alit of
repair tissue
• Rehabilitation is integral to maturation of
repair tissue and final outcome
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Factors
Influencing Cartilage Repair Outcomes
• Defect Characteristics
• Size
• Location(s)
• Containment
< 2 cm2
≥ 2 – 4 cm2
• Patient Characteristics
•
•
•
•
•
Duration of Symptoms
P i Treatment(s)
Prior
T t
t( )
Age
Activity Level
Expectations and Goals
Factors
Influencing Cartilage Repair Outcomes
• Concomitant Knee
Pathology
gy
• Tibio‐Femoral Malalignment
• Patellofemoral Maltracking
• Ligament Deficiency
• Meniscus Deficiency
Cartilage Defect(s)
Meniscal
Meniscal Deficiency
Instability
Malalignment
• Rehabilitation Compliance
• Mechanical Over-Loading and Under-Loading are
detrimental to cartilage restoration
• Avoidance of Preventable Complications
• Periosteum vs. Absorbable Collagen Membrane
• RTP before tissue healing
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Cartilage Treatment Concepts
Increaasing Time to Re
eturn to Play
• Palliative 
• Arthroscopic Debridement
• Reparative 
• Microfracture/Marrow
Stimulation
• Substitutive 
• Osteoarticular Transfers,
Autograft and Allograft
• Regenerative 
• ACI/MACI/Scaffold/MSC
Rehabilitation after Cartilage Repair
Advancing Understanding
• Mechanical forces affect proteoglycan turnover and synthesis
• Cyclic Loading enhances proteoglycan synthesis and stiffens cartilage
• Continuous trend to earlier weight bearing in cartilage repair 11‐12
cartilage repair 11
12 wks 5
wks
5‐6
6 wks
wks
• Rehabilitation provides conducive mechanical environment for cartilage maturation and remodeling
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Autologous Chondrocyte Implantation
Post-Operative Repair Process
Proliferation
Transition
Remodeling
•0‐6 weeks
•Cells attach to bone
•7‐12 weeks
•Repair tissue spongy, compressible
ibl
•12‐36 weeks
•More matrix, organization
Pre‐Op
Maturation
• Up to 1‐2 years
• Stiffness approaches native cartilage
native cartilage
1 year
5 months
3 year
Rehabilitation Comparison
Microfracture
Osteochondral
Grafting (Autograft)
Activity
Autologous
Chondrocyte
Implantation
Continuous Passive
Motion ((CPM))
Immediately post‐
p
operative
6‐8 hours per day
Up to 8 weeks
Immediately post‐
p
operative
6‐8 hours post‐operative
8‐12 hours per day
8‐12
hours per day
Up to 6 weeks (at least 2)
Non-Weight-Bearing
Not specified
Weeks 0‐2
Weeks 0‐2
Protected WeightBearing
Weeks 0‐8
Weeks 2‐8
Weeks 2‐7
Full Weight-Bearing
Weeks 6‐8
At week 8
By weeks 8‐9
Normal Daily
Activities
Weeks 6‐8
At 3 months
Gradually increased through weeks 6‐12
Low Impact
Activities
At 3 months
At 3‐4 months
At 6 months
High Impact
Activities
(running, aerobics)
Not Specified
At 4‐5 months (OATS)
At 6‐7 months (Mosaicplasty)
At 9‐12 months
Return to Sports
(high impact,
pivoting activities)
At 4‐6 months
At 5‐6 months (OATS)
At 9 months (Mosaicplasty)
At 12‐18 months
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Principles of Articular Cartilage Loading
Weight Bearing Loading
Dye SF: Clin Orthop
325:10-18, 1996
• Load but don’t overload, Use but don’t
overuse
Principles of Articular Cartilage Loading
Resume Activity and RTP
• Return to sports activity criteria: all ≥ 90%
• Quad/Hamstringg Strength
g Index
• Single Leg Hop Tests
• KOS-ADL Scale
• On Field/Sport Assessment
• no pain or swelling
• Self Agility Full Speed
Unopposed
Practice
Opposed Practice Drills
Full Scrimmage (RTP)
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Cartilage Repair Procedures
Average Time to Return to Play
12‐18 months
Autologous Chondrocyte
Implantation
• Larger Lesions
• Slower Return
• Best Durability of Best Durability of
Repair 9‐12 months
OATS Allograft
6‐9 month
OATS Autograft
• Smaller Lesions
• Faster Return
• Less Durability of Repair
Microfracture
Chondroplasty
4‐6 months
3‐4 months
0
5
10
15
Months to Return to Play
Predictors of Outcomes
Articular Cartilage Defects
• Return to Play: Most ideal with
•
•
•
•
Younger Athletes, Higher skill level
Duration of Symptoms < 1 year
Smaller Lesions
Quicker RTP with MFx, OATS autograft but only
for smaller lesions (<2 cm2)
• Larger lesions better with ACI or OATS Allograft
• ACI has best durability and longest rehab
• Longer-term Preoperative Symptoms: creates
an adverse intra-articular environment for
cartilage repair
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Predictors of Outcomes
Articular Cartilage Defects
• RTP Decision Making:
Short Term:
• Higher probability for RTP w/OATS Auto vs.
MFx, but both work for small lesions
• Less RTP in NFL w/ MFx vs. Chondroplasty
• Mithoefer showed decline in sports participation and performance in MFx athletes after 18 mos
performance in MFx athletes after 18 mos.
• For focal lesions > 2 cm2. Microfracture and OATs showed significantly worse clinical outcomes and lower return to high level sports compared to smaller lesions < 2 cm2 Mithoefer AJSM 34, 2006; Mithoefer AJSM 33, 2005; Mithoefer AJSM 33, 1147, 2005; Predictors of Outcomes
Articular Cartilage Defects
• RTP Decision Making:
Long Term:
• 87% of ACI treated professional Soccer players remained at their previous sports level at average 52 mos. F/U
• For ACI, no influence on lesion size and clinical outcome or return to sport indicating that this is
outcome or return to sport indicating that this is clearly the better first option for larger lesions
• Higher Tegner scores after ACI than MicroFx as well as higher good to excellent treatment success in professional athletes and adolescent athletes 72‐95% Gudas Arthroscopy 21, 2005; Mithoefer AJSM 34, 2006; Marcacci Arthroscopy 21, 2005; 7
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RTP after Cartilage Procedures
Study
Patients
F/U os.
Time to RTP
RTP @
Comments
same or > level
52 pts.
70 mos.
8.2 mos.
67%
Chondroplasty
Scilia et al
Chondroplasty in p y
NFL Football
AJSM 2015
Microfracture
Gudas et al
OATS Auto vs OATS
Auto vs
MicroFracture, RCT
OATS
Autograft
60 pts. 37 mos
37 mos.
4‐6 mos. (ave 6.5 65
mos.RTP)
93% OAT • 15 (52%) MF patients returned 52%
52% to sports activities at the
to sports activities at the MFx preinjury level at an average of 6.5 mos. (4‐8 mos.) 60 pts. 4‐6 mos.
75% OATS 37% MFx
Arthroscopy 2005
Gudas et al
• Starting players more likely to RTP ((11.6 games/season)
• 4.4 % less likely to RTP with Microfracture
•No correlation with age, location of defect, position
OATS Auto vs
125 mos.
MicroFracture, RCT
AJSM 2012, 25% OATs and 48% MFx had mild DJD @ 10 yrs
•OATs technique allowed higher rate of return, longer maintenance at the preinjury level at 10 yr. F/U
RTP after Cartilage Procedures (Continued)
Study
Patients Time to F/U mos. RTP
RTP @
same or > level
Comments
32 pts. 4‐6 mos.
24 mos.
24
mos
44% RTP and 25%
and 25% at same level
•After initial improvement, score decreases were observed in 47%
decreases were observed in 47% of athletes
• Best for < 40 yrs, < 2cm2, < 1 yr symptoms, no prior surgery
Microfracture
Mithoefer et al, Microfracture in Microfracture
in
High Impact Sports. AJSM 2006 Level 4 Case Series
OATS Allograft
Shaha et al; AJSM 2013
38 pts. 9‐12 mos.
47 mos.
29%
• 42% unable to return to duty, only 5.3% at preinjury level
Krych et al; AJSM
2012
43 pts.
30 mos.
79%
• Age > 25, pre‐op symptoms > 1 9‐12 mos.
yr negatively affected RTP
•75% Recreational, 23% Collegiate athletes
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RTP after Cartilage Procedures (Continued)
Study
Patients Time to F/U mos. RTP
RTP @
same or > level
ACI
Comments
Autologous Chondrocyte
Implantation
Mithofer et al; AJSM 2005, Soccer Players
45 pts.
45 pts.
50 mos.
12‐24 mos.,
14 mos. high level
80%
• Most successful in younger y
g
competitive athletes with less than 1 yr symptoms, of those RTP 87% maintained level > 4 yrs
Mithoefer et al;
AJSM 2005, Young Athletes
20 pts.
48 mos.
12‐18 mos.,
15 mos. Ave.
96%
•All with < I yr symptoms returned to pre‐injury level but only 33% with > I yr of symptoms
• Ave size 6.4 cm2 , 60 % with open growth plates
open growth plates MACI
Matrix Autologous
Chondrocyte Implantation
Zak et al: AJSM, 2012, Matrix ACI
70 pts
60 mos.
12‐18 mos. 74% RTP Pre‐injury level
•Third generation ACI with mid‐
term results very consistent with 10 ACI
Return to Play
Cartilage Procedures Meta-Analysis
STUDY
# PTS
F/U
1363 pts.
> 3yrs
RTP or
Full Duty
Comment
Combined M t A l i
Meta‐Analysis
Systematic Review,
20 studies, Mithofer et al, AJSM 2009
Varies by • Younger athletes, smaller defects, Technique shorter pre‐operative symptom duration, high skill level = HIGHEST RTP
• Highest Rate RTP: OATS Autograft
• Best Longevity: ACI
• Worst rates of RTP after long Worst rates of RTP after long
duration of pre‐op symptoms resulting from adverse environment for cartilage repair
• Age threshold about 30 years old
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Arthroscopic Debridement, Chondroplasty
Return to Play
Return to Play after Chondroplasty of the Knee in National Football
League Athletes. Scillia et al; AJSM 2015;43:663‐8. Level 4 Case Series
• 54
54 knees (52 patients) underwent knees (52 patients) underwent
arthroscopic chondroplasty
• 67% return to regular season NFL game play @ avg. of 8.2 months
• With Concomitant Microfracture players 4.4x
l
l
less likely to lik l
return to NFL than those who did not undergo procedure
Arthroscopic Debridement, Chondroplasty
Return to Play
Return to Play after Chondroplasty of the Knee in National Football
League Athletes. Scillia et al; AJSM 2015 Level 4 Case Series
• No
No significant correlation of RTP to age, significant correlation of RTP to age
lesion size, location, position played, draft round selection
* Age did not make difference
• Playing >11.6 games/season 4.7x more likely RTP
*Better players more able to return
• Athletes who RTP compared with player of Athletes who RTP compared with player of
similar level prior to surgery
– 56 fewer games
*Decreased Duration of Career
– 3.3 fewer seasons
– 3.2 fewer games/ season
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Arthroscopic Microfracture
Return to Play
High Impact Athletics after Knee Aricular Cartilage Repair: A
prospective evaluation of Microfracture Technique. Mithöfer, Williams , Warren, et al; AJSM 2006 Level 4 Case Series
• 32
32 pts with single lesions; F/U 2 years after pts with single lesions; F/U 2 years after
Microfracture (Steadman Technique)
• 44% able to regularly RTP in high impact, pivoting sport and 25% (8 pts) RTP at same level • Return to sport significantly hi h i
higher in patients:
ti t
•
•
•
•
< 40 years old Defect size < 2cm2
Pre‐op symptoms < 1 year No Prior Surgery
Osteoarticular Autograft Transfers
Return to Play
A Prospective Randomized Clinical Study of Mosaic Osteochondral
Autologous Transplantation Versus Microfracture for the Treatment
of Osteochondral Defects in the Knee Joint in Young Athletes.
Gudas R. et.al.: Arthroscopy 2005:21:1066. Level 1 RCT
• 60 athletes (24.3 yrs) with symptomatic cartilage lesions randomized to undergo OATs or MF. F/U 37 mos.; ICRS, Tegner, MRI.; same post‐op
post
op rehab protocol rehab protocol
• 26 (93%) OAT patients and 15 (52%) MF patients returned to sports activities at the preinjury level at an average of 6.5 mos. (4‐8 mos.) 11
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Osteoarticular Autograft Transfers
Return to Play
Ten-year follow-up of a prospective, randomized clinical study of
mosaic osteochondral autologous transplantation versus
microfracture for the treatment of osteochondral defects in the knee
joint of athletes. Gudas R. et.al.: AJSM 2012;40:2499-508. Level 1 RCT
• 60 athletes (24.3 yrs) with symptomatic cartilage lesions randomized to undergo OATs or MFx. F/U 10.4 yrs ICRS, Tegner, MR. • OATs
OAT vs. MFx
MF same postt op
rehab, NWB 4 wks, RTP 4‐6 mos.
• Over 50% failure by 36 mos.
in MFx group
Osteoarticular Autograft Transfers
Return to Play
Ten-year follow-up of a prospective, randomized clinical study of
mosaic osteochondral autologous transplantation versus
microfracture for the treatment of osteochondral defects in the knee
joint of athletes
athletes. Gudas R.
R et
et.al.:
al : AJSM 2012;40:2499-508
2012;40:2499-508. Level 1 RCT
Level 1 RCT
• OAT groups had 75% continued
RTP at same level vs 37% in MFx
group maintained @ 10 yrs (from prior evaluation at 3 yrs.)
• MRI and Radiographs showed 25% of OATS and 48% MFx groups had Mild DJD at 10 yrs. 12
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Osteochondral Allograft Transfer
Return to Activity & Play
Return to an Athletic Lifestyle After Osteochondral Allograft
Transplantation of the Knee. Shaha et al, AJSM 2013 Level 4 Case Series
• 38
38 pts with OATS Allograft; F/U 3.9 years, pts with OATS Allograft; F/U 3 9 years
Active Duty Military Personnel, Ave. Size 4.89cm2
• 29% (11/38) able to return to full duty • 5.3% returned to preinjury level • 42% separated from service with medical discharge
• All showed graft healing, No revisions, No effect of concomitant procedures
Osteochondral Allograft Transfer
Return to Play
Return to an Athletic Activity after Osteochondral Allograft
Transplantation in the Knee. Krych et al, AJSM 2012 Level 4 Case Series
• 43
43 athletes treated with OATS Allograft for thl t t t d ith OATS All
ft f
chondral defects, Ave. Size 7.25cm2, Ave F/U 2.5 years
• 75% Recreational, 23% Collegiate athletes
• 79% (34/43) able to return to 79% (34/43) able to return to
preinjury level of sport • Risk factors for not RTP:
• > 25 years old
• > 12 months duration of pre‐op symptoms
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Autologous Chondrocyte Implantation
Return to Play
Articular Cartilage Repair in Soccer Players with Autologous
Chondrocyte Implantation. Mithöfer, Peterson Mandelbaum, Minas, AJSM
2005 Level 4 Case Series
• 45
45 soccer athletes treated with ACI for chondral defects, soccer athletes treated with ACI for chondral defects
Ave. Size 5.7cm2, Ave F/U 3.5 years, 35% multiple defects
• 96% of adolescents reported good or excellent results by Tegner and Lysholm scores
• 96% RTP at high impact sports, 60% to an athletic level equal or higher than pre‐injury • RTP correlated with shorter pre‐op symptoms and a lower number of prior operations. • All adolescents with symptoms ≤12 months RTP pre‐
injury level whereas only 33% with preoperative symptom longer than 12 months returned to play
Autologous Chondrocyte Implantation
Return to Play
Functional Outcome of Knee Articular Cartilage Repair in
Adolescent Athletes. Mithöfer, Minas, Peterson, Yeon, Micheli; AJSM 2005
Level 4 Case Series
• 20
20 adolescent athletes treated with ACI for adolescent athletes treated with ACI for
chondral defects, Ave. Size 5.7cm2, Ave F/U 4.0 years
• 83% of high level players RTP and 16% recreational players RTP (33% of total players)
• 80 RTP at same or higher level and 87% maintained level of play for an ave. 4.4 years i t i dl l f l f
44
post‐op • Risk factors for not RTP:
• > 25 years old
• > 12 months duration of pre‐op symptoms
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RTP after Cartilage Repair 2015
Summary
• Cartilage lesions requiring treatment shorten high level athletic careers
• RTP most ideal with:
• Younger Athletes
• Higher skill level
• Duration of Symptoms < 1 year
• Smaller Lesions
• Faster RTP with Microfracture, OATS
autograft but only for smaller lesions (<2
cm2)
• ACI has best durability and longest
rehab
RTP after Cartilage Repair 2015
Summary
•Larger lesions better treated with ACI or
OATS Allograft and still have RTP
• Longer-term Preoperative Symptoms:
creates an adverse intra-articular
environment for cartilage repair with
diminished results
• Cartilage lesions requiring treatment
shorten high level athletic careers
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RTP after Cartilage Repair 2015
Summary
• Despite the often inadequate treatment
options for the all too frequent cartilage
injuries in athletes, RTP is still feasible in
the majority of cases.
• Understand what the literature
demonstrates (pros and cons) and don’t
put square pegs in round holes (it only
makes it worse). Manage Expectations.
• We need to continue to strive to do
better for our patient athletes
Thank
You !
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RTP after Cartilage Procedures: References
•
•
•
•
•
•
•
•
•
•
Mithöfer K1, Minas T, Peterson L, Yeon H, Micheli LJ. Functional outcome of knee articular cartilage repair in adolescent athletes. Am J Sports Med. 2005 Aug;33(8):1147‐53. Mithoefer K1, Hambly K, Della Villa S, Silvers H, Mandelbaum BR. Return to sports participation after articular cartilage repair in the knee: scientificevidence. Am J Sports Med. 2009 Nov;37 Suppl 1:167S‐76S
g JR1, Fleisigg GS1, Andrews JR1. Scillia AJ1, Aune KT2, Andrachuk JS1, Cain EL1, Dugas
Return to play after chondroplasty of the knee in national football league athletes. Am J Sports Med. 2015 Mar;43(3):663‐8
Krych AJ1, Robertson CM, Williams RJ 3rd; Cartilage Study Group. Return to athletic activity after osteochondral allograft transplantation in the knee. Am J Sports Med. 2012 May;40(5):1053‐9.
Shaha JS1, Cook JB, Rowles DJ, Bottoni CR, Shaha SH, Tokish JM. Return to an athletic lifestyle after osteochondral allograft transplantation of the knee. Am J Sports Med. 2013 Sep;41(9):2083‐9.
Mithoefer K1, Williams RJ 3rd, Warren RF, Wickiewicz TL, Marx RG. High‐
impact athletics after knee articular cartilage repair: a prospective evaluation of the microfracture technique. Am J Sports Med. 2006 Sep;34(9):1413‐8.
Gillogly, SD, Rienhold MM . Treatment of Full‐Thickness Chondral Defects in the Knee with Autologous Ch d
Chondrocyte Implantation. Journal of Orthopaedic & Sports Physical Therapy, 2006 Oct; 36(10):751‐764. t I l t ti
J
l f O th
di & S t Ph i l Th
2006 O t 36(10) 751 764
Mithöfer K1, Minas T, Peterson L, Yeon H, Micheli LJ. Functional outcome of knee articular cartilage repair in adolescent athletes. Am J Sports Med. 2005 Aug;33(8):1147‐53.
Mithöfer K1, Peterson L, Mandelbaum BR, Minas T. Articular cartilage repair in soccer players with autologous chondrocyte transplantation: functional outcome and return to competition. Am J Sports Med. 2005 Nov;33(11):1639‐46.
Zak L1, Aldrian S, Wondrasch B, Albrecht C, Marlovits S. Ability to return to sports 5 years after matrix‐
associated autologous chondrocytetransplantation in an average population of active patients. Am J Sports Med. 2012 Dec;40(12):2815‐21.
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