All right, good morning. So I'm going to concentrate today pretty much just on what's going on with cartilage transplants because it's a short period of time. Those are my disclosures. So what are the indications in 2019 for cartilage replacement? Failure of previous marrow-stimulating techniques, lesions about 1.7 or greater centimeters squared, ones that are uncontained, ones that have large underlying cysts. I'm going to concentrate on the ones in the yellow box and kind of discuss each of those individually and where they're at. So it's important to realize that with osteochondral lesion treatment, the size still makes a big difference. Laura Raponi at HSS, when she did her study, showed 1.07 centimeters squared was a critical size in making success versus failure of marrow-stimulating techniques. So MACI now is matrix-induced ACI. It's a highly purified type 1, 3 collagen membrane. FDA approved it in the United States for use in January of 2017, and it's replaced regular ACI. This is a case study, a 37-year-old actually roller derby lady who had multiple injuries and also had failed surgical treatment arthroscopy. She had a large cyst with osteochondral lesion. You'll see we do a sandwich procedure with the bone grafting of the cyst and inserting the MACI. So this is her pre-op CT scan, pretty good size defect in her medial tailor dome. This is the incision with a medium-lear osteotomy pre-drill. In this case, we used a hook plate to get a little better compression across the osteotomy postoperatively. We then excised the osteochondral lesion, excised the cyst, bone grafted it, and then we sealed the bone graft with fiber and glue and a membrane, the MACI membrane, and then put another membrane above it, the so-called sandwich procedure. So if you look here, this is where we're actually sizing the MACI. Remember the MACI comes impregnated with the patient's cells already on it, and then when you actually put the membrane on, this is what it looks like, it's self-adherent. You can put some sutures, but oftentimes you don't need to put much, and then you reduce the osteotomy. Now Kirillin and his group with Eric Giza studied a small group of these in Australia. They actually had seven-year follow-up, and nine out of the ten filled out the forms. They were significantly improved on the SF36, and their FAS scores also improved. The particulate juvenile cartilage is kids, unfortunately, who have passed away under the age of 13. Of course, they have a lot more healthy cartilage cells than adults in general, and that was the whole concept of using their tissue. So the allograft chips are placed into the defectant using a cannula arthroscopically through a mini-open procedure, and then you impact them with a free area, you put fiber and glue on first, and then after you distribute these evenly, then you conceal it with additional fiber and glue. That's what it looks like going in. Now Lushon was part of the original multicenter study, and he reported last year at two to seven-year follow-up on 77 patients, 90 percent had a 70 percent improvement, which is kind of an unusual way of reporting results, but that's what they did. And he felt it took up to three years for ultimate recovery. They revised 7 percent, and 7 percent failed in their group of 77. Everything was sevens. Now Karnosky actually studied 50 patients, 30 with microfracture and 30 with BMAC plus the juvenile cartilage, and he found no significant differences in outcomes, but it's interesting that the OLT size was significantly larger for the articulated juvenile cartilage, and I actually kind of interpret that data a little differently. I think that shows that the results were, I think, a little better. Now micronized cartilage matrix is also an allograft cartilage extracellular matrix that contains the key components of cartilage, but doesn't contain cartilage itself. It's nice because it's dehydrated and has a five-year shelf life. Now the problem with using this is that there's a few short-term studies, no long-term studies at all in using it yet. As mentioned, the shelf life is five years, so if you get into a situation, you can pick this off the shelf, which is nice, and also it's significantly cheaper than the articulated cartilage in ACI, but of course a lot more research is needed. This is a patient that I was able to do a second look at seven months after a micronized cartilage, softer but still has a fairly good covering. Now FANZA and the group with John Kennedy studied 31 patients with the micronized cartilage in BMAC. Their follow-ups were a little shorter, 16 months, and they had the lesions were a little smaller, 86 millimeters squared, so usually we're going to put these in a little bigger size, but the PROMIS scores improved and their MOCART scores were 69, which is not bad. That was presented last year, but much more research needs to be done. Now Tom Temple in Miami has studied the so-called Miami cell, which is a marrow-isolated adult multilineage inducible, he calls it. It's a primitive mesenchymal stem cell and expresses many of the genes expressed by embryonal cells but follows a defined script, the Miami cell. He's shared these slides with me. Under appropriate conditions, these can be induced to become either bone-forming or cartilage-forming cells. So you mix these groups together with cartilage microparticles and these so-called PAMs with TGB3 and then these Miami cells to create what they hope is a type two type of collagen-rich environment in highland cartilage. But much more study needs to be done on these to see how they're doing. Also not available in the United States, but the original research was done at the University of Iowa, is this metallic camp implant used for failed cases primarily in the medial tailor dome. And Nick Van Dyke and his group have reported results at a mean of five years at 38 patients and the score has improved on almost all the subscales as it did the SF36. Some did return back to sports and they had two fails, but 21 reoperations, which is a pretty high percentage. Now I want to call your attention to this. This was a study group that Dr. Stone and I and Dr. Kennedy led with 86 surgeons around the world. And if you have an interest in osteochondral lesions and studying all the various aspects of it, I would encourage you to get a copy of this from FAI. It's the proceedings of our consensus meeting that was done at the University of Pittsburgh in November 2017, where we tried to answer every question involved with osteochondral lesions through a Delphi method of consensus and I think it's very, very helpful. So in summary, we're still trying to find this Carter's solution. I think eventually we'll do it all arthroscopically, but we still have a long way to go. Thank you.

cartilage transplants

indications for cartilage replacement

matrix-induced ACI (MACI)

allograft options

research