Knee Cartilage surgery in India

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-often suffer from cartilage injuries. Cartilage surgery is available in India to cure cartilage problems and prevent them from developing knee osteoarthritis. Autologous cartilage cell implantation is being done by Madras Joint replacement center at an affordable cost. This biological intervention will hopefully avoid a knee replacement in young individuals.

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  • Knee Exercises for Effective Treatment of Osteoarthritis :
    http://www.kneesurgeon.in/knee_rehabilitation_excercise_demonstration.htm
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  • my left knee cartilage has been shaved off last year...is there any possibility to regenerate or implant?
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Knee Cartilage surgery in India

  1. 1. Fourth generation cartilage regeneration technique <ul><li>Dr. A. K. Venkatachalam </li></ul><ul><li>MS Orth, DNB Orth, FRCS, M.Ch Orth </li></ul><ul><li>Orthopedic Surgeon, </li></ul><ul><li>Chettinad health city </li></ul><ul><li>India. </li></ul><ul><li>www.kneeindia.com </li></ul>
  2. 2. Ubiquitous problem <ul><li>Cartilage loss is ubiquitous </li></ul><ul><li>Most common in Knee </li></ul><ul><li>Ankles less affected. </li></ul><ul><li>Suspected on basis of pain, crepitus. </li></ul><ul><li>confirmed by MRI, arthroscopy </li></ul><ul><li>Not seen on x rays early </li></ul>
  3. 3. <ul><li>Articular cartilage is a highly specialized, uniquely designed tissue forming smooth gliding surface for diarthrodial joints. </li></ul><ul><li>Cartilage once damaged, cannot regenerate itself </li></ul><ul><li>Requires surgical intervention to REGENERATE </li></ul><ul><li>Cartilage in knee joint is at Non Wt bearing & Wt bearing areas </li></ul><ul><li>No option in India till now to regenerate damaged cartilage </li></ul><ul><li>Surgeon shaves off damaged cartilage & removes loose bodies </li></ul><ul><li>5-10 years later Osteoarthritic changes set in </li></ul>
  4. 4. Articular cartilage structure <ul><li>3 zones- </li></ul><ul><li>Superficial or tangential zone </li></ul><ul><li>chondrocytes are flattened </li></ul><ul><li>Collagen fibres arranged parallel to surface. </li></ul><ul><li>Low water level </li></ul><ul><li>Intermediate zone- collagen fibres are oblique, chondrocytes are round </li></ul><ul><li>Deep or basal zone- Chondrocytes are round and in vertical columns </li></ul><ul><li>Collagen fibres are in vertical orientation. </li></ul>
  5. 5. Cartilage structure <ul><li>Chondrocytes constitute 5% of weight secrete matrix and collagen </li></ul><ul><li>Collagen- Type II- 90- 95 % of total collagen </li></ul><ul><li>Highly cross linked and inter connected. </li></ul><ul><li>Also type IX collagen and Type XI collagen </li></ul><ul><li>Proteoglycan matrix- 90% chondroitin & keratin sulphate. </li></ul>
  6. 6. <ul><li>OA is the most common form of arthritis </li></ul><ul><li>It is a disease of the joints wherein progressive degeneration of the articular cartilage </li></ul><ul><li>Most commonly affects the joints of knees, hips and spine. </li></ul><ul><li>Usually associated with ageing, causing pain, inflammation & loss of mobility, resulting in a significant reduction in the quality of life of those afflicted. </li></ul><ul><li>Significant financial burden on govt. healthcare system, predicted to increase as population continues to age </li></ul>
  7. 7. Magnitude of the problem <ul><li>Over 15 million people worldwide suffer from knee-joint failure each year due to the breakdown of surrounding cartilage in the joint. </li></ul><ul><li>Articular cartilage, most notably that which found in the knee joint, is generally characterized by very low friction, high wear resistance, and poor regenerative qualities . </li></ul>
  8. 8. Patient lifetime Overall quality of life Severity of the disease Lifestyle changes Pharmaceuticals IA – Steroids / HA Total Joint Replacement Revision joint Replacement PAIN RELIEF REPLACEMENT
  9. 9. Patient lifetime Before ACI Overall quality of life Severity of the disease Lifestyle changes Pharmaceuticals IA – Steroids / HA Total Joint Replacement Revision joint Replacement PAIN RELIEF REPLACEMENT GAP For many Patients relief is no longer effective but too young for replacement
  10. 10. Patient lifetime Overall quality of life Severity of the disease Lifestyle changes Pharmaceuticals IA – Steroids / HA Total Joint Replacement Revision joint Replacement PAIN RELIEF REPLACEMENT CELL THERAPY Biologics REGENERATION
  11. 11. <ul><li>The use of braces and drug therapies, such as anti-inflammatory drugs, COX-2 selective Inhibitors, Hydrocortisone. </li></ul><ul><li>Above treatments shown to alleviate the pain caused by cartilage deficiency. </li></ul><ul><li>They may slow down the degenerative process. </li></ul>
  12. 12. <ul><li>Arthroscopic Debridement </li></ul><ul><li>Mosaicplasty </li></ul><ul><li>Microfracture </li></ul><ul><li>1987 Autologous Chondrocyte Implantation in Sweden in animals </li></ul><ul><li>1 st Generation of ACI – Periosteum + Cells (sutured) ( 1994, Brittberg et al) </li></ul><ul><li>2 nd Generation of ACI – Porcine membrane + Cells (sutured) </li></ul><ul><li>3 rd Generation of ACI – MACI – Matrix( porcine membrane) + Cells ( glued) (1995) </li></ul><ul><li>4 th Generation of ACI – Cell Gel Type – INJECTABLE no suture, </li></ul><ul><li>Developed in S.Korea in 2001 by Dr. Chang & Dr. Kim </li></ul>
  13. 13. <ul><li>Assess defect using MRI / Arthroscopy </li></ul><ul><li>Perform 20-30 minute procedure of “Shaving off all loose & defective cartilage” </li></ul><ul><li>Pain relief , BUT, NO SURGICAL INTERVENTION PERFORMED </li></ul><ul><li>Leads to rapid degeneration of cartilage </li></ul><ul><li>Osteoarthritis very early </li></ul>
  14. 14. <ul><li>Creating tiny fractures in the underlying bone </li></ul><ul><li>Blood & bone marrow creates a super clot of mesenchymal stem cells producing fibro cartilage </li></ul><ul><li>Fibrous Cartilage + OA </li></ul><ul><li>Small defect size 1.5 cm </li></ul><ul><li>Low demand individuals </li></ul><ul><li>Pain returns in 1-2years </li></ul><ul><li>Arthroscopic technique, cost efficient. </li></ul>
  15. 15. <ul><li>Assess defect. Shave off loose cartilage & defective cartilage. Expose the defect clearly. </li></ul><ul><li>Measure the defect and decide number of osteochondral plugs to be used. </li></ul><ul><li>Harvest 1-4 osteochondral plugs from non wt bearing area and place same plugs into defect area </li></ul><ul><li>Formation of Fibrous Cartilage </li></ul><ul><li>Significant pain over time + Quality of Life hampered </li></ul>
  16. 16. Cell Isolation & Cultivation Cell implantation & rehabilitation Cell Collection & Growth Autologous Chondrocyte Implantation Arthroscopic view after ACI
  17. 17. Autologous cartilage implantation <ul><li>First described by Brittberg et all in 1994. </li></ul>
  18. 18. <ul><li>First clinical trial by Brittberg et al in 1994. </li></ul><ul><li>Small cartilage biopsy via arthroscopy 4mm osteochondral plug from the edge of the intercondylar notch </li></ul><ul><li>Send to lab for processing cells </li></ul><ul><li>Cells multiplied 10- 15 times in lab </li></ul><ul><li>Remove Periosteum from tibia; suture on defect </li></ul><ul><li>Inject cells. Suture. </li></ul>
  19. 19. Disadvantages of ACI <ul><li>Insufficient mechanical stability </li></ul><ul><li>Uncertain cell distribution within the defect </li></ul><ul><li>Fixation of periosteal flap with sutures penetrating healthy cartilage </li></ul><ul><li>Necessity of intact cartilage shoulder surrounding the defect. </li></ul><ul><li>Chance of periosteal hypertrophy </li></ul>
  20. 20. <ul><li>Small cartilage biopsy via arthroscopy </li></ul><ul><li>Send to lab for processing cells </li></ul><ul><li>Mix cells with porcine membrane / synthetic membrane </li></ul><ul><li>Suture. </li></ul><ul><li>Immunological problems + Cell leakage </li></ul>
  21. 21. <ul><li>Chondro inductive or chondro conductive matrix, use of allogenic cells, </li></ul><ul><li>MACI- Matrix induced autologous cartilage regeneration </li></ul><ul><li>Small cartilage biopsy via arthroscopy </li></ul><ul><li>Send to lab for processing cells grown in culture later transferred to synthetic membrane PELA polymer sheet. </li></ul><ul><li>Grow cells on synthetic membrane Collagen I/III to form a bio-composite. </li></ul><ul><li>Patch is cut to exact size of defect. </li></ul><ul><li>This patch is glued with fibrin glue which takes only 1 minute. </li></ul><ul><li>No suture required, hence quicker </li></ul>
  22. 22. 4 TH GENERATION- cell gel implantation <ul><li>Biopsy </li></ul><ul><li>Cell Culture (<50million cells) </li></ul><ul><li>in lab in India 4 weeks </li></ul><ul><li>Transported back to surgeon </li></ul><ul><li>Each single use container has </li></ul><ul><li>12 million cells </li></ul><ul><li>Cell viability is 80% prior to final packing </li></ul><ul><li>Gel is outsourced( manufactured in US FDA </li></ul><ul><li>approved plant. </li></ul><ul><li>Mix Cells + Gel (5min) </li></ul><ul><li>Inject on defect </li></ul><ul><li>Wait 5 min </li></ul><ul><li>Regeneration process activated </li></ul>
  23. 23. <ul><li>The technology provides a convenient and effective photo-polymerization of a hydrogel that contains cells and growth factors necessary for the growth and integration of new cartilage in a damaged tissue. </li></ul><ul><li>It is conveniently injectable and flows to conform to the treated surface. </li></ul><ul><li>Can strongly attach to the surrounding tissue </li></ul><ul><li>Promotes cell growth and integration with the surrounding tissue </li></ul><ul><li>Degrades / adsorbs slowly enough to allow stable tissue regeneration. </li></ul>
  24. 24. Process isolated cells from the harvested tissue for approx. 4 weeks Debride damaged cartilage. The cartilage being regenerated . Implant Procedure Cell Culture Operation Rehabilitation Rehabilitation Tissue Harvest Obtain cartilage specimen from the superior aspect of the medial or lateral femoral condyle Diagnosis Chondral defect
  25. 25. Three stage procedure <ul><li>Arthroscopic biopsy </li></ul><ul><li>Cell culture in indigenous lab </li></ul><ul><li>Open implantation </li></ul><ul><li>Latest advance- arthroscopic procedure for ankle and working for same in knee also. </li></ul>
  26. 26. Follow up <ul><li>3 T MRI imaging- cartigram </li></ul><ul><li>Second look arthroscopy </li></ul>
  27. 27. Rehabilitation after ACI <ul><li>Non weight bearing- 6- 8 weeks </li></ul><ul><li>Range of movement exercises. </li></ul>
  28. 28. Indications for ACI <ul><li>Patients with one or more cartilage defects of size not exceeding 15 cm 2 for single defect and 20 cm 2 for multi defects. </li></ul><ul><li>Cartilage defects in knee, ankle, shoulder. </li></ul><ul><li>Has been tried in two cases of osteoarthritis in Korea with success. </li></ul>
  29. 29. Clinical results after ACI <ul><li>Objective- Clinical outcome in patients undergoing ACI. </li></ul><ul><li>Design- Prospective study </li></ul><ul><li>264 patients mean age- 36.47 years ( range- 13- 73) </li></ul><ul><li>Setting- 80 centers in Korea( multi center trial) </li></ul><ul><li>Mean chondral defect size was 4.91 cm 2 </li></ul><ul><li>All patients had 6 month post operative follow up. </li></ul><ul><li>Clinical evaluation based on Knee society scores A and B </li></ul><ul><li>Result- In KSS- A rating, 254 patients obtained more than ‘Fair’ grade results ( 97.3%) In the KSS-B evaluation, 171 patients obtained more than ‘Fair’ grade ( 89.3%) </li></ul><ul><li>Dr. Kim et al, Seoul, Korea </li></ul>
  30. 30. Supplemental treatment <ul><li>Osteotomies – Valgus or Varus osteotomies. </li></ul><ul><li>Closed wedge / Opening wedge </li></ul>
  31. 31. Thank you

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