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ΠΛΗΡΩΣ ΑΡΘΡΟΣΚΟΠΙΚΗ ΑΠΟΚΑΤΑΣΤΑΣΗ ΧΟΝΔΡΙΝΩΝ ΚΑΙ ΟΣΤΕΟΧΟΝΔΡΙΝΩΝ ΒΛΑΒΩΝ ΓΟΝΑΤΟΣ
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ΠΛΗΡΩΣ ΑΡΘΡΟΣΚΟΠΙΚΗ ΑΠΟΚΑΤΑΣΤΑΣΗ ΧΟΝΔΡΙΝΩΝ ΚΑΙ ΟΣΤΕΟΧΟΝΔΡΙΝΩΝ ΒΛΑΒΩΝ ΓΟΝΑΤΟΣ

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ΠΛΗΡΩΣ ΑΡΘΡΟΣΚΟΠΙΚΗ ΑΠΟΚΑΤΑΣΤΑΣΗ ΧΟΝΔΡΙΝΩΝ ΚΑΙ ΟΣΤΕΟΧΟΝΔΡΙΝΩΝ ΒΛΑΒΩΝ ΓΟΝΑΤΟΣ ΜΕ ΕΜΦΥΤΕΥΣΗ ΚΑΛΛΙΕΡΓΗΜΕΝΩΝ ΧΟΝΔΡΟΣΦΑΙΡΙΔΙΩΝ ( ACT3D). ( Παρουσίαση περιστατικών στο Γερμανικό Ετήσιο Συνέδριο Χειρουργικής …

ΠΛΗΡΩΣ ΑΡΘΡΟΣΚΟΠΙΚΗ ΑΠΟΚΑΤΑΣΤΑΣΗ ΧΟΝΔΡΙΝΩΝ ΚΑΙ ΟΣΤΕΟΧΟΝΔΡΙΝΩΝ ΒΛΑΒΩΝ ΓΟΝΑΤΟΣ ΜΕ ΕΜΦΥΤΕΥΣΗ ΚΑΛΛΙΕΡΓΗΜΕΝΩΝ ΧΟΝΔΡΟΣΦΑΙΡΙΔΙΩΝ ( ACT3D). ( Παρουσίαση περιστατικών στο Γερμανικό Ετήσιο Συνέδριο Χειρουργικής Ορθοπαιδικής και Τραυματιολογίας, Βερολίνο, 2008).

FULLY ARTHROSCOPICALLY PERFORMED 3-DIMENSIONAL AUTOLOGOUS CARTILAGE TRANSPLANTATION (ACT3D) FOR MEDIUM TO LARGE FOCAL CHONDRAL DEFECTS AT THE KNEE

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  • Mr President, dear colleagues, thank you in advance for the invitation in this congress.
  • The purpose of this presentation is to show you our preliminary results in using the chondrospheres in treating arthroscopically, medium to large focal chondral defects at the knee.
  • What you can see in the present slide is not of course the 3-dimensional ACI, but is the method we successfully used, in order to treat cartilage defects up to about a year ago, when we first used the ACT 3D .
  • The ACT3D is an innovative technique in treating medium to large chondral defects, because in addition to previous operative methods, the surgeon can apply the cultivated spheroids fully arthroscopically, in most of the cases, without any scaffold, or membrane and without any fibrin glue, or other fixation mode. The product is strictly autologous, without any host reactive changes.
  • The spheroids are small balls, consisted of 3-dimensional conglomerats of chondrocytes, together with their matrix. Their diameter is no more than 1mm and we can detect about 200.000 chondrocytes in each one of them, after the cultivation.. We need about 10-70 spheroids per square centimeter for the defect. They are grown up in patients own serum, without any antibiotics . They can express hyaline like specific markers and chondrogenic growth factors and subsequently suppress the expression of collagen type I.
  • We have treated operatively in our Dept., 35 symptomatic patients between March 2007 and May 2008. All pts were recreational athletes and the mean age was 32 years old. The mean area of cartilage defect was 6.75cm2 and all the cases were classified as grade III and IV according to Outerbrigde scale. 34 of them were treated fully arthroscopically, in addition to one case with multiple defects, we had to operate through an open arthrotomy, and was excluded from our final results.
  • 22 out of 34 patients were male and 24 of them had the operation at the right knee.
  • Most of the cartilage lesions (18) were located in the weight-bearing surface of the medial femoral condyle, (8) in the lateral one ,(6) in the trochlea area and 2 in the lateral facet of the patella.
  • In most of the cases (19) the defect was due to trauma, .(8) of them were caused due to failed microfracturing technique.All of them had been performed elsewhere, more than 5 years ago. Of the remaining 7 cases, 2 were due to chondromalacia patella and 5 of them due to osteochondritis dissecans.
  • 2 of our pts had previous partial medial meniscectomy, 1 partial lateral one. 8 of them had previous MFx ,as I have mentioned in previous slide, 1 had an arthroscopic debridement and another one an arthroscopic lateral release.
  • We strictly procceded, keeping always in mind the indications and contra-indications of the method .
  • What is more important, whatever method the surgeon prefers to perform for a chondral injury, is alignment. Nothing will work if alignment is out.
  • Keeping that in mind ,we currently use this algorithm as a baseline philosophy for every patient we treat having a cartilage defect.
  • According to this we have performed 15 applications of ACT 3D as single procedure. In 5 cases we had to perform a medial open wedge high tibial osteotomy due to varus leg, concommitant with ACT3D application, as a two stage procedure. Apart from that, we have performed 11 ACL reconstructions combined with the spheres, 1 case with concommitant open wedge distal femoral valgus osteotomy and lateral meniscal transplantation , 1 case with medial open wedge high tibial osteotomy and ACL reconstruction and another one with revision ACL reconstruction and medial open wedge high tibial osteotomy as a biologic knee replacement procedure. In all cases the osteotomies were performed in the first stage of ACI and the second stage was performed when the osteotomy had features of callus formation (mostly 5-6 weeks later).All the osteotomies were performed with use of either TOMOFIX or PUDDU plate. In the later cases we used the wedge shaped plate in order to avoid patella baja. All cases with ACL reconstruction (9 with hamstrings tendon and 2 with BPTB) were performed at the 2 nd stage of ACI and the rehab protocol was modified. In the revision ACL case ,the removal of the ACL xenograft was accompanied with placement of bone allograft in the tunnels, accompanied by revision ACL (anterior tibialis allograft) in 2 nd stage, 3 monthes later.
  • I will show you some of our cases. The first one is a 44 year old gentleman, with a medial genu varum and a concomittant chondral defect ,grade IV, 6.5cm 2 ,in the weight-bearing surface of MFC. He underwent an open wedge high tibial osteotomy with a TOMOFIX plate and ACT3D application 5 weeks later. You can easily see the consolidation of the osteotomy and the remaining space in the medial compartment.
  • Regarding the MRI scans, all of our patients underwent an MRI scan 6 and 12 m.p.o as a standard protocol. In all but one case we found no persisting subchondral oedema 6-12m.p.o and no graft hypertrophy. In one case ,in which the clinical score was excellent and the patient had no complaint at all, we found evidence of persisting subchondral oedema and not good consolidation of the graft and so we had to scope him.
  • Transcript

    • 1. S.ALEVROGIANNIS, MD, PhD. CONSULTANT ORTHOPAEDIC SURGEON 2 ND Orth. Dept.251 General Air Force Hospital, Athens/GR.
    • 2. AIM OF THE STUDY
      • To present our preliminary results in fully arthroscopically performed 3-dimensional autologous cartilage transplantation (ACT 3D ) for medium to large focal chondral defects at the knee.
    • 3. MATRIX INDUCED AUTOLOGOUS CHONDROCYTE IMPLANTATION (MACI).
    • 4. AUTOLOGOUS CHONDROCYTE TRANSPLANTATION (ACT 3D ) WITH SPHEROIDS
      • A NEW TECHNIQUE:
      • No scaffold, membrane, periosteum or growth factors needed
      • No fibrin glue or other fixation
      • Strictly autologous, no viral transmission
      • Minimally invasive technique
      • (mainly arthroscopically performed)
    • 5. AUTOLOGOUS SPHEROIDS
      • Small balls, consisted of 3-dimensional conglomerats of chondrocytes together with their matrix
      • Diameter about 1mm
      • About 2x10 5 chondrocytes in their de novo matrix
      • 10-70 spheroids/ cm 2 of defect
      • Grown in the patients own serum
      • Cultivated without antibiotics
      • Expression of hyaline specific markers:
      • proteoglycans
      • collagen type II
      • S-100, CEP-68
      • Suppression of the expression of collagen type I
      • Expression of chondrogenic growth factors:
      • TGF- β , IGF-1,PDGF,FGF-2
    • 6. MATERIAL-METHOD
      • (Mar 2007-May 2008) 35 pts with chondral defect at the knee (recreational athletes-none elite athlete)
      • Mean age 32 (17-54)
      • Mean area of cartilage defect: 6.75cm 2 ( 2.2-10cm 2 )
      • Grade III ( 16 ) & grade IV ( 18 ) lesions
      • 34 cases were performed arthroscopically- 1 case (multiple injuries) mini-open arthrotomy
    • 7. MATERIAL
    • 8. SITE OF DEFECTS
    • 9. AETIOLOGY OF DEFECTS
    • 10. PREVIOUS OPERATIONS
    • 11. INDICATIONS ACT 3D
      • Symptomatic chondral/osteochondral defect without other correctable joint pathology
      • Inclusion Criteria
      • Single/multiple defects
      • Defects1-10cm 2 per defect
      • MFC,LFC, retropatellar, trochlea, tibial plateau
      • Age 15-55 years
      • Able to complete rehabilitation protocol
      • Exclusion Criteria
      • Advanced Osteoarthritis
      • Rheumatoid Arthritis
      • (Ligament instability)
      • (Malalignment)
      • (Patellofemoral Instability)
      • Acute infection
      • Autoimmunologic disease
    • 12. ALIGNMENT IS CRITICAL
      • Nothing will work if alignment is out
    • 13. ARTICULAR CARTILAGE MANAGEMENT IN THE ATHLETE. Algorithm 2005 10 “patient directed” categorical situations Based on: lesion size, depth, alignment, ligament and meniscal integrity progress over time
    • 14. ACT 3D PROCEDURES (15) 44% (1) 3% (2) 6% (1) 3% (9) 26% (5) 15% (1) 3% ACT 3D ACT3D+MOWHTO ACT3D+OWDFVO + L.M.TRANSPL.) ACT3D+h-ACL ACT3D+p-ACL ACT3D+h-ACL+ MOWHTO ACT3D+MOWHTO+ R-ACL
    • 15. ACT 3D + ACL PROCEDURE
    • 16. CASE 1 6m.p.o 1 y.p.o
    • 17. CASE 2: A.S (M) 37Y.O OWHTO+ 1 ST STAGE REVISION ACL+1 ST STAGE ACI
      • intra-op c-arm
      • 1 y.p.o
    • 18. CASE 3: LB (M). AGE 42. VALGUS LATERAL OA DFVO + MENISCAL TRANSPLANT Preop Post op Alignment
    • 19. CASE 4: B.S (F). AGE 42. PATELLAR MAL-ALIGNMENT AND CHONDRAL DEFECT OF LATERAL FACET.
    • 20. REHABILITATION FEMORAL AND TIBIAL DEFECTS Aqua jogging, >8w:biking >6 m: jogging, skating >6-12m: skiing >12m: contact sports Aqua training, swimming mobilization WALKING, SPORT Free movement (restricted by pain) CPM with restrictions femoral condyle: Week 2-3:0/0/60 0 Week 4-6: 0/0/90 0 Brace in extension MOBILIZATION Building up FWB within 3-6 weeks PWB (up to 50%) 3-point –walking with crutches Foot sole contact 3-point –walking with crutches WEIGHT BEARING > WEEK 6 WEEK 2-6 WEEK 1
    • 21. REHABILITATION PATELLAR AND TROCHLEAR DEFECTS Building up FWB within 3-6 weeks PWB (up to 50%) 3-point –walking with crutches Foot sole contact 3-point –walking with crutches WEIGHT BEARING >WEEK 4 WEEK 3 - 4 0-14 DAYS Free movement (restricted by pain) CPM with restrictions : Week 2-3: 0/0/30 0 Week 4-5: 0/0/60 0 Week 6-7: 0/0/90 0 Brace in extension MOBILIZATION > WEEK 7 WEEK 2-7 WEEK 1
    • 22. CLINICAL SCORING SYSTEMS
      • Modified Cincinnati Rating System (0-100)
      • Visual Analogue Score (0-10)
      • Bentley Functional Rating System (0-5)
      • Patient Rating (worse, same, better)
      • Patient Functional Outcome (0-10)
      • Brittberg score (excellent-poor)
      • Lysholm & Gillquist (0-100)
      • Tegner & Lysholm (0-10)
      • Meyer (pain-function-ROM)
      • Functional Assessment following ACI (FAFA)
      • IKDC knee examination Score
    • 23. MODIFIED CINCINATTI SCORE (0-100) Excellent (>80), Good (55 to 79), Fair (30 to 54) or Poor (<30)
      • Pain
      • Swelling
      • Giving way
      • Overall activity level
      • Walking
      • Stairs
      • Running activity
      • Jumping or twisting activities
    • 24. VISUAL ANALOGUE SCORE (0 = good, 10= poor )
    • 25. PATIENT OUTCOME FUNCTION SCORE
    • 26. IKDC KNEE EXAMINATION SCORE
    • 27. MRI RESULTS
      • PRESENCE OF SUBCHONDRAL OEDEMA.
      • initial p.o phase: normal response
      • 9m-12m p.o phase: minimal oedema
      • if the amount of oedema persists or increases during the f.u period, this may be suggestive of failure of the ACI graft.
      • PRESENCE OF SUBCHONDRAL CYSTS WITH OEDEMA  fibrocartilage appearance rather than hyaline-like
      • GRAFT HYPERTROPHY ( commonly noted in pts with OCD within 6 month f.u period).
    • 28. CASE 5: S.S (M) 23Y.O 1Y.P.O O.C.D
    • 29. 2 nd LOOK ARTHROSCOPY
    • 30. CASE 6: T.G (M) 43Y.O
    • 31. CASE 6: T.G (M) 43Y.O 1 Y.P.O
    • 32. CASE 6: T.G (M) 43Y.O 1 Y.P.O
    • 33. COMPLICATIONS 1.Superficial wound inf : 0 2. Septic arthritis : 0 3. Lateral popliteal n. neuropraxia : 1 4.Knee stiffness requiring MUA : 0 5.Symptomatic graft hypertrophy : 0 6.Delamination :0 7.Unplanned arthroscopy : 0 8.Post op. DVT: 0 9. Graft failure : 1
    • 34.
      • Good short term clinical outcome using combined ACI and ACL reconstruction procedures
      • ACT 3D early results very promising, can be performed fully arthroscopically, reduce operative time, avoid patient having multiple operations
      • The whole procedure requires surgeon’s experience and coordinative team
      • Less medication needed
      • Less pain experienced
      • No disruption of everyday lifestyle
      • Sports activities without reduction in previous performance
      • Rehabilitation protocol is quicker due to minimal trauma and can be combined with other surgical procedures at the same op.procedure.
      • Await medium and long term results
      CONCLUSIONS
    • 35. Replacement/ Repair Regeneration THE ULTIMATE GOAL