Case Report Open Access
3-Year Clinical Result of a Customized Metal Mini-Prosthesis for Focal Chondral Lesion in The Knee Of A Formerly Active 31-Year-Old Man.
Jens Ole Laursen*
Orthopedic and Emergency Department, Hospital of South Jutland, Denmark
*Corresponding author: Dr. Jens Ole Laursen, Orthopedic and Emergency Department, Hospital of South Jutland, Denmark; E-mail: @
Received: January 12, 2017; Accepted: February 16, 2017; Published: June 01, 2017
Citation: Jens Ole Laursen (2017) T3-Year Clinical Result of a Customized Metal Mini-Prosthesis for Focal Chondral Lesion in The Knee Of A Formerly Active 31-Year-Old Man. J Excer Sports Orthop 4(2):1-3.
Objective
The treatment of (osteo) Chondral lesions remains a clinical challenge. [1-3,6,7,8,16] A “gap” has been identified (9), where some patients with focal knee-lesions are considered too old for biological treatment or failed treatment, but too young for uni- or total arthroplasty (UKA/TKA). In order to fill this gap, an innovative, patient-specific metal implant (Episealer) has been designed from MRI-images and the lesion-size, and ongoing CPL (Controlled Product Launch) is taking Place, with almost 2-year follow-up. [11-14,15,17,18] the aim of this study is to present a case report of the first “Danish patient” with 3 year clinical and radiographic follow-up of this new resurfacing mini-prosthesis [18].
Methods
An innovative MR examination including a 3D-sequence and diagnostic sequences was obtained and analyzed into a “damage report” specifying the cartilage damage and bone marrow lesions (Fig. 1). Subsequently, individualized implants and guide instruments were manufactured. The mini-prostheses were inserted recessed 0.5 – 1 mm below the surrounding cartilage.
Figure 1: MRI scans of the lesion and 3-D marking – and orthroscopic verification.
Detail of the prosthesis
The mini-prosthesis (Episurf Medical) was manufactured from cobalt-chrome alloy. The articulating surfaces were individualized to the curvature of the affected condyle. (Fig.2&3) The bone facing part had an undercut peripheral edge and a flat underside designed to rest on the subchondral bone. Surfaces facing bone/cartilage were double coated with a layer of hydroxyapatite on top of a layer of titanium, both 60 μm thick. There was a 3 mm wide, 15 mm long peg inserted in an undersized drill hole to provide immediate interference fixation. Clinical results (VAS and KOOS scores), were obtained preoperatively and at 3 and 12 months and annually.
Figure 2: Episealer 20 mm femoral condyle.
Figure 3: Episealer in place postoperatively.
Patient case
31 year-old former fulltime carpenter, very active football- and handball-player. Knee injury in 2011 in handball with ACL – lesion and cartilage lesion on medial femur-condyle. Arthroscopic ACL-reconstruction and micro-fracturing of the 2 cm2, ICRS grade-3 cartilage lesion on the medial condyle. No effect on the medial knee-pain, and new arthroscopy 6 months later revealed a then grade-4 cartilage lesion. A new micro-fracturing procedure was carried out, but without effect. He had daily pain (VAS 7-8) in the knee – taking painkillers, paracetamol and NSAID regularly, and had been unable to work for almost 2 years. Two years after the index injury, he was operated with this new resurfacing mini-prosthesis (Episealer) (Fig. 2&5). He has not used any painkillers since the operation, followed according to the CLP – protocol with 3 months, 1, 2 and now 3-year clinical control. VAS declining from initial 7 – 8 until now, at 3 year control, at 2 (active) and KOOS rising from 40 until now 90. He returned to fulltime work as a carpenter 3 months after the operation, is still going strong without problems in his daily work, and has now even returned to playing soccer and handball. He was followed with radiographic controls at follow-up times. (Fig. 4) showing only slightly narrowing of the joint space - KL-grade [4] from 0 to 1 - and with fine cartilage on the tibial side adjacent to the miniprosthesis.
Figure 4: 3 years control – note no progression in cartilage wear.
Figure 5: Operating tools and operation
Conclusion
The early follow-up results after treatment with a customized metal mini-prosthesis in a challenging “older” patient with focal (osteo) Chondral lesions and a history of failed previous cartilage surgery demonstrated significant pain and subjective outcome improvements at 3 years. The patient had been out of work as a carpenter for almost 2 years and was at risk of losing his ability to work completely and becoming a heavy financial burden on society. We know from other studies [6,7,8,10] – that the loss of working ability can be fatal for such patients, who are still of working age, and the economic costs for society enormous, especially for these patients in the “Treatment Gap”. In the US, 3.6 million patients with symptomatic knee-pain fall into this group [10].
References
  1. Cicuttini F, Ding C, Wluka A, Davis S, Ebeling PR, Jones G.  Association with cartilage defects with loss of knee cartilage in healthy, middle-age adults: a prospective study. Arthritis Rheum. 2005;52(7):2033-2039.
  2. Dhollander AAM, Almquist KF, Moens K, Vandekerckhove P-J, Verdonk R, Verdonk P, et al. The use of a prosthetic inlay resurfacing as a salvage procedure for a failed cartilage repair. Knee Surg Sports Traumatol Arthrosc. 2015;23(8):2208-2212.
  3. Gobbi A, Karnatzikos G, Kumar A. Longterm results after micro fracture treatment for full-thickness knee chondral lesions in athletes. Knee Surg Sports Traumatol Arthrosc. 2014;22(9):1986-1996. Doi: 10.1007/s00167-013-2676-8
  4. Kellgren JH, Lawrence JS. Radiological assessment of osteo-arthrosis. Ann Rheum Dis. 1957;16(4):494-502.
  5. Kreuz PC, Steinwachs MR, Erggelet C, Krause SJ, Konrad G, Uhl M, et. al. Results after micro fracture of full-thickness chondral defects in different compartments in the knee. Osteoarthritis Cartilage. 2016;14(11):1119-1125.
  6. Laursen JO, Lind M. Treatment of full-thickness femoral cartilage lesions using condyle resurfacing prosthesis.  Knee Surg Sports Traumatol Arthrosc. 2017;25(3):746-751. Doi:1007/s00167-05-3726-1
  7. Laursen JO. Treatment of full-thickness cartilage lesions and early OA using large condyle resurfacing prosthesis: UniCAP.  Knee Surg Sports Traumatol Arthrosc. 2016;24(5):1695-1671. Doi: 10.1007/s00167-016-4000-x
  8. Laursen JO. High mid‑term revision rate after treatment of large, full‑ thickens cartilage lesions and OA in the patellofemoral joint using a large inlay resurfacing prosthesis: Hemi CAP‑ Wave®. Knee Surg Sports Traumatol Arthrosc. 2016. DOI 10.1007/s00167-016-4352-2        
  9. Li CS, Karlsson J, Winemaker M, Sancheti P, Bhandari M. Orthopedic surgeons feel that there is a treatment gap in management of early OA: international survey. Knee Surg Sports Traumatol Arthrosc. 2014;22(2):363-378. Doi: 10.1007/s00167-013-2529-5
  10. London NJ, Miller LE, Block JE. Clinical and economic consequences of the treatment gap in knee osteoarthritis management. Med Hypotheses. 2011;76(6):887-892. Doi: 10.1016/j.mehy.2011.02.044    
  11. Manda K, Eriksson A. Modeling of constrained articular cartilage               growth in an intact knee with focal knee resurfacing metal implant. Biomechanics and Modeling in Mechanobiology. 2014;13(3):599-613. Doi: 10.1007/s10237-013-0521-0       
  12. Manda K, Eriksson A. Time-dependent behavior of cartilage surrounding a metal implant for full-thickness cartilage defects of various sizes: a finite element study. Biomechanics and Modeling in Mechanobiology. 2011;11(5):731-742. Doi: 10.1007/s10237-011-0346-7
  13. Martinez-Carranza N, Ryd L, Hultenby K, Hedlund H, Nurmi-Sandh H, Berg HE, et al.  Treatment of full thickness focal cartilage lesions with a metallic resurfacing implant in a sheep animal model, 1 year evaluation. Osteoarthritis and Cartilage. 2016;24(3):484-493. Doi: 10.1016/j.joca.2015.09.009    
  14. Martinez-Carranza N, Berg HE, Ryd L, Nurmi-Sandh H, Schupbach P, Largerstedt AS. Fixation of a double-coated titanium-hydroxyapatite focal knee resurfacing implant: A 12-month study in sheep. Osteoarthritis and Cartilage. 2014;22(6):836-844. Doi: 10.1016/j.joca.2014.03.019           
  15. Martinez-Carranza N, Berg HE, Ryd L, Nurmi-Sandh H, Largerstedt AS,Hultenby K. Focal knee resurfacing and effects of surgical precision on opposing cartilage. A pilot study on 12 sheep. Osteoarthritis and Cartilage. 2013;21(5):739-745. Doi: 10.1016/j.joca.2013.02.004           
  16. Mithoefer K, Williams RJ, Warren RF, Potter HG, Spock CR, Jones EC, et al. The micro fracture technique for the treatment of articular cartilage lesions in the knee: a prospective cohort study. J Bone Joint Surg Am. 2005;87(9): 1911-1920. Doi: 10.2106/JBJS.D.02846             
  17. Ryd L, Brittberg M, Eriksson K, Jurvelin JS, Lindahl A, Marlovits S, et al. Pre-Osteoarthritis: Definition and Diagnosis of an Elusive Clinical Entity. Cartilage. 2015;6(3):156-165. Doi: 10.1177/1947603515586048  
  18. Sköldenberg O, Eisler T, Stark A, Muren O, Ryd L, Martinez-Carranza N. Measurement of the migration of a focal knee resurfacing implant with radiostereometry. Acta Orthopaedica. 2014;85(1):79-83. Doi: 10.3109/17453674.2013.869654  
  19. Steadman JR, Briggs KK, Rodrigo JJ, Kocher MS, Gill TJ, Rodkey WG. Outcomes of micro fracture for traumatic chondral defects of the knee: 11-year follow- up. J Arthroscopy. 2003;19(5):477–480. Doi: 10.1053/jars.2003.50112
 
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