Brian J. Cole

Autologous Chondrocyte Implantation in the Knee

Overview The purpose of this document is to describe the guidelines Neighborhood Health Plan (NHP) utilizes to determine the medical appropriateness for autologous chondrocyte implantation (ACI) for repairing cartilage defects of the knee. NHP may also consider FDA-approved matrix-induced chondrocyte implantation (e.g., MACI®, Vericel) as an acceptable alternative to autologous cultured chondrocytes (e.g., Carticel®) under the conditions listed in the coverage guidelines below. The treating specialist must request prior authorization for this procedure.

Criteria for Return to Play After Anterior Cruciate Ligament Reconstruction

Anterior cruciate ligament reconstruction (ACLR) is a common orthopaedic procedure often sustained during sports-related trauma. Many patients desire to return to play (RTP) following surgery, and modern advances in rehabilitation and surgical techniques aim to facilitate this. Preoperative rehabilitation and postoperative accelerated rehabilitations programs have both demonstrated positive outcomes in facilitating RTP following ACLR. Many preoperative, intraoperative, and postoperative factors influence time to RTP and rate of re-injury, including patient demongraphics, graft choice, and postoperative rehabilitation program. To maximize safe RTP, these factors need to be considered. Work is underway to develop objective guidelines for the time to RTP, and current research suggests that a combination of kinematic, neuromuscular, and psychological factors need to be considered.

Procedure 16 – Distal Femoral Osteotomy

• Examination • Inspection • Alignment (Q-Angle) • Muscle bulk • Prior surgical incisions • Palpation • Tenderness • Crepitus (medial, lateral, patellofemoral) • Active and Passive Range of Motion • Hip • Knee • Strength • Core • Lower extremity • Flexibility • Ober test • Hamstring • Neurovascular Exam • Bilateral lower extremity • Patellar Exam • Tilt • Apprehension • J sign • Static and dynamic Q angle assessment • Crepitus • Knee tests of stability and special tests • Pivot shift, Lachman, anterior drawer • Posterior drawer • Varus and valgus stress (at full extension and at 30° of flexion) s0010 u0010 u0015 u0020 u0025 u0030 u0035

Procedure 15 – Opening Wedge High Tibial Osteotomy

Examination/Imaging • Examination includes: • observation of standing and ambulation alignment (varus thrust) • correctable varus deformity • range of motion • ligamentous stability • bilateral lower extremity neurovascular exam • patellar exam (tilt, J sign, Q angle) • Unloader braces may be a useful nonsurgical tool to determine if an osteotomy is a viable option. • Radiographs include four views: standing anteroposterior (AP), lateral, Merchant’s, and 45° flexion posteroanterior (PA). • The flexion PA view allows better analysis of the posterior weight-bearing portion of the articular surface that is more sensitive for detecting arthritis. • In addition, bilateral long cassette view standing films are taken to measure the mechanical axis and degree of correction needed. • Double-leg stance radiographs: to assess the bony deformity. • Single-leg stance radiographs: to assess any soft tissue deformity (i.e., posterolateral knee insufficiency). • Magnetic resonance imaging may be used to evaluate the soft tissues of the knee and the presence or absence of soft tissue fluid or joint effusion. • Articular cartilage, menisci, and ligaments should be closely evaluated. • Unicompartmental bone edema can be an indicator of chronic compartment overload. • Meniscal volume can be assessed using the coronal and sagittal sequences. Careful evaluation of the previously menisectomized knee should be performed to interpret new injury versus postmenisectomized appearance. • Gradient echo sequences are used to decipher articular cartilage from the surrounding joint fluid and subchondral bone; however, gradient echo sequences are not able to identify intrasubstance cartilage defects. s0010 u0010 u0015

Anteromedial Tibial Tubercle Osteotomy (Fulkerson Osteotomy)

Multiple case series have reported outcomes of the AMZ procedures. Despite the heterogeneity in outcome measurements, results demonstrate high percentages of excellent and good results and improvements in objective, subjective and functional measures. Attention to details related to surgical planning and properly managing patient expectations is most likely to lead to good or excellent results. Newer techniques (i.e., the T3 system) allow the surgeon to objectively determine the inclination of the osteotomy to properly restore patellofemoral mechanics based upon the preoperative planning.