FULLY ARTHROSCOPICALLY PERFORMED ACI FORCHONDRAL & OSTEOCHONDRAL DEFECTS AT PFJ & TALUS.             PRELIMINARY RESULTS. ...
Treatment Options for Chondral Defects                                  Cell Therapy    Osteochondral Biomimetics Symptoma...
COMMON PROBLEMS IN TREATING        RETRO-PATELLAR & TALAR          CHONDRAL LESIONS              RETRO-PATELLAR LESION    ...
AUTOLOGOUS CHONDROCYTE          TRANSPLANTATION (ACT3D) WITH                  SPHEROIDSRELATIVELY NEW TECHNIQUE:• No scaff...
AUTOLOGOUS SPHEROIDS•   Small balls, consisted of 3-dimensional    conglomerats of chondrocytes together with    their mat...
Manufacturing of co.donchondrosphere®                                                   3-4 weeks    Biopsy removal       ...
Filling of the defect      Native                 Native      Native                     Native   20min after application ...
Autologous Chondrocyte TransplantationIndications:                   Ideal patient• Large stage III-IV defects   • Age 15-...
MATERIAL -METHOD•   5 pts, (3M/2F)-all recreational athletes•   Avg age 36(25-48)•   Avg size lesion 3.8cm2 (4R/1L knee)• ...
RETROPATELLAR LESIONS              ( 2 STAGE PROCEDURE) 1ST STAGE:• Arthroscopic inspection of chondral injury• Harvest c...
(2ND STAGE)    RETROPATELLAR AUTOLOGOUSCHONDROCYTE TRANSPLANTATION (ACT3D)      WITH CHONDROSPHERES
REHABILITATION PATELLAR AND     TROCHLEAR DEFECTS               WEEK 1               WEEK 2-7                  > WEEK 7MOB...
RESULTS• All the procedures progressed uneventfully.• Lysholm & Gillquist Score rose from 42.1 to 74.8  1 y.p.o• IKDC scor...
OSTEOCHONDRAL LESIONS OF        THE TALUS• Osteochondral lesions of the talus involve damage or separation of  the cartila...
Typical Sites of lesion
Staging•   Radiographic•   Computed Tomography•   Magnetic Resonance Imaging•   Arthroscopic
Radiographic Staging       Berndt and Harty
CT Staging Ferkel and Sgaglione
MRI Staging                      Hepple et al.• I: Superficial chondral lesion• II-a: Chondral lesion +  Subchondral compr...
Arthroscopic Staging     Pritsch et al. and Ferkel et al.A: Smooth, intact, but soft or ballotableB: Rough surfaceC: Fibri...
MRI Grading system with        arthroscopic correlation.        Mintz et al., Arthroscopy 2003•   Stage 0: Normal•   Stage...
SURGICAL TREATMENT              OPTIONS• Traditional treatment of choice in talar OCD is still MFx.• Concerns as compared ...
ACI TREATMENT OPTIONUnpopular in ankle joint despite ability to repair defects with hyaline-richcartilage, because of:•Art...
TALAR CHONDRAL DEFECTS-             LITERATURE REWIEW               – medial lesions are most often chronic and not necess...
MATERIAL AND METHOD•   7 patients (avg age 28 years) all recreational athletes•   R(5) and L(2) talus•   Between June 2008...
SURGICAL PROCEDURE
REHAB PROTOCOL•   Antibiotic and thrombosis prophylaxis are given for 48 hours and 3 weeks respectively.•   Hospitalizatio...
RESULTS• All the procedures progressed uneventfully.• We assessed the patient at 6m and 1 y.p.o• AOFAS score from 32.1 to ...
3D- Autologous Chondrocyte                     TransplantationAdvantages:                                    Disadvantages...
CONCLUSION•      ACT3D for treating talar and retropatellar chondral defects    preliminary results are very promising, ca...
ΠΛΗΡΩΣ ΑΡΘΡΟΣΚΟΠΙΚΗ ΑΠΟΚΑΤΑΣΤΑΣΗ ΧΟΝΔΡΙΝΩΝ ΒΛΑΒΩΝ ΕΠΙΓΟΝΑΤΙΔΟΜΗΡΙΑΙΑΣ ΑΡΘΡΩΣΗΣ ΚΑΙ ΑΣΤΡΑΓΑΛΟΥ
ΠΛΗΡΩΣ ΑΡΘΡΟΣΚΟΠΙΚΗ ΑΠΟΚΑΤΑΣΤΑΣΗ ΧΟΝΔΡΙΝΩΝ ΒΛΑΒΩΝ ΕΠΙΓΟΝΑΤΙΔΟΜΗΡΙΑΙΑΣ ΑΡΘΡΩΣΗΣ ΚΑΙ ΑΣΤΡΑΓΑΛΟΥ
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ΠΛΗΡΩΣ ΑΡΘΡΟΣΚΟΠΙΚΗ ΑΠΟΚΑΤΑΣΤΑΣΗ ΧΟΝΔΡΙΝΩΝ ΒΛΑΒΩΝ ΕΠΙΓΟΝΑΤΙΔΟΜΗΡΙΑΙΑΣ ΑΡΘΡΩΣΗΣ ΚΑΙ ΑΣΤΡΑΓΑΛΟΥ

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ΠΛΗΡΩΣ ΑΡΘΡΟΣΚΟΠΙΚΗ ΑΠΟΚΑΤΑΣΤΑΣΗ ΧΟΝΔΡΙΝΩΝ ΒΛΑΒΩΝ ΕΠΙΓΟΝΑΤΙΔΟΜΗΡΙΑΙΑΣ ΑΡΘΡΩΣΗΣ ΚΑΙ ΑΣΤΡΑΓΑΛΟΥ ΜΕ ΕΜΦΥΤΕΥΣΗ ΚΑΛΛΙΕΡΓΗΜΕΝΩΝ ΧΟΝΔΡΟΣΦΑΙΡΙΔΙΩΝ ( ACT3D). ( Παρουσίαση περιστατικών στο Ελληνικό Ετήσιο Συνέδριο Αρθροσκόπησης και Χειρουργικής Γόνατος, Ρέθυμνο 2011).

FULLY ARTHROSCOPICALLY PERFORMED ACI FOR CHONDRAL & OSTEOCHONDRAL DEFECTS AT PFJ & TALUS. PRELIMINARY RESULTS. RETHYMNO 2011

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ΠΛΗΡΩΣ ΑΡΘΡΟΣΚΟΠΙΚΗ ΑΠΟΚΑΤΑΣΤΑΣΗ ΧΟΝΔΡΙΝΩΝ ΒΛΑΒΩΝ ΕΠΙΓΟΝΑΤΙΔΟΜΗΡΙΑΙΑΣ ΑΡΘΡΩΣΗΣ ΚΑΙ ΑΣΤΡΑΓΑΛΟΥ

  1. 1. FULLY ARTHROSCOPICALLY PERFORMED ACI FORCHONDRAL & OSTEOCHONDRAL DEFECTS AT PFJ & TALUS. PRELIMINARY RESULTS. S.ALEVROGIANNIS, MD, PhD. CONSULTANT ORTHOPAEDIC SURGEON 2ND Orth. Dept.251 General Air Force Hospital, Athens/GR.
  2. 2. Treatment Options for Chondral Defects Cell Therapy Osteochondral Biomimetics Symptomatic Stem Cells •Periosteal Grafting •TRUFIT• Lavage • Drilling Grafting • Autografts •Chondromi• Debridement • Abrasion •Autologous metic Arthroplasty Chondrocyte  OATS Implantation • MFx Mosaicplasty •ACI (1st gen.) • AMIC® •MACI(2nd gen) • Allografts •ACT 3D
  3. 3. COMMON PROBLEMS IN TREATING RETRO-PATELLAR & TALAR CHONDRAL LESIONS RETRO-PATELLAR LESION POSTEROMEDIAL TALAR LESION• Difficult surgical procedure• Often open surgery required• Major trauma• Lower limb mal-alignment• Removal of hardware (2nd operation specially talar chondral injuries)OFTEN LEAD TO FAIR TO POOR SUBJECTIVE & OBJECTIVE RESULTS
  4. 4. AUTOLOGOUS CHONDROCYTE TRANSPLANTATION (ACT3D) WITH SPHEROIDSRELATIVELY 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. 5. AUTOLOGOUS SPHEROIDS• Small balls, consisted of 3-dimensional conglomerats of chondrocytes together with their matrix• Diameter about 1mm• About 2x105 chondrocytes in their de novo matrix• 10-70 spheroids/ cm2 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. 6. Manufacturing of co.donchondrosphere® 3-4 weeks Biopsy removal Monolayer cell culture cultivation 2-3 weeks co.don 3d-cell culture Preparation of Transplantat chondrosphere® Spheroid formation  induced by 3D cell-cell- contacts  induced by matrix synthesis
  7. 7. Filling of the defect Native Native Native Native 20min after application of appr. 30 Defect spheroids/ cm2 Few days after transplantation Native Native Native Native Ddefect Defect appr. 6 weeks after OP appr. 12 weeks after OP
  8. 8. Autologous Chondrocyte TransplantationIndications: Ideal patient• Large stage III-IV defects • Age 15-50 years old• Extensive subchondral • No malalignment cystic changes • No degenerative joint• Failed previous surgery disease • No instability Grade I Grade II Grade III Grade IVOUTERBRIDGE CLASSIFICATION
  9. 9. MATERIAL -METHOD• 5 pts, (3M/2F)-all recreational athletes• Avg age 36(25-48)• Avg size lesion 3.8cm2 (4R/1L knee)• 3 (Grade III) & 2 (Grade IV)-Outerbridge scale• 4 cases due to trauma/1 pat.mal-alignment (arthroscopic release in 1st stage ACI)• Past MHx: 2 previous arthroscopic debridement 1 MFx 1 ACL recon.• Pre and post-op evaluation (6m & 1y.) using: -LYSHOLM & GILLQUIST (0-100) -IKDC Knee Examination Score -Visual Analogue Score (0-10) -Patient Rating (worse, same, better) -Patient Functional Outcome (0-10) and -MRI scan (radiological assessment)
  10. 10. RETROPATELLAR LESIONS ( 2 STAGE PROCEDURE) 1ST STAGE:• Arthroscopic inspection of chondral injury• Harvest cells from NWB area of knee joint• Cell cultivation 2ND STAGE:• Arthroscopic debridement of patellar lesion• Cells implantationFULLY ARTHROSCOPICALLY PERFORMED
  11. 11. (2ND STAGE) RETROPATELLAR AUTOLOGOUSCHONDROCYTE TRANSPLANTATION (ACT3D) WITH CHONDROSPHERES
  12. 12. REHABILITATION PATELLAR AND TROCHLEAR DEFECTS WEEK 1 WEEK 2-7 > WEEK 7MOBILIZATION Brace in extension CPM with restrictions : Free movement Week 2-3: 0/0/300 (restricted by pain) Week 4-5: 0/0/600 Week 6-7: 0/0/900 0-14 DAYS WEEK 3 - 4 >WEEK 4WEIGHT Foot sole contact PWB (up to 50%) Building up FWBBEARING 3-point –walking 3-point –walking with within 3-6 weeks with crutches crutches
  13. 13. RESULTS• All the procedures progressed uneventfully.• Lysholm & Gillquist Score rose from 42.1 to 74.8 1 y.p.o• IKDC score rose from 56 to 92• VAS pain significantly reduced from 6.8 to 1.8• Patient Outcome Function score showed significantly better performance.• All MRI scans showed adequate filling of the defect, with no delamination, no significant BMO and no hypertrophy of the newly-formed cartilage).
  14. 14. OSTEOCHONDRAL LESIONS OF THE TALUS• Osteochondral lesions of the talus involve damage or separation of the cartilage and underlying subchondral bone.• This lesion may range from a small defect in the talar articular surface, a subchondral cyst, or a large detached osteochondral fragment.• Transchondral fracture• Osteochondral fracture• Osteochondritis dissecans• Talar dome fracture• Flake fracture
  15. 15. Typical Sites of lesion
  16. 16. Staging• Radiographic• Computed Tomography• Magnetic Resonance Imaging• Arthroscopic
  17. 17. Radiographic Staging Berndt and Harty
  18. 18. CT Staging Ferkel and Sgaglione
  19. 19. MRI Staging Hepple et al.• I: Superficial chondral lesion• II-a: Chondral lesion + Subchondral compression fracture + Bone Edema• II-b: Without bone edema• III: Separated but nondisplaced fragment• IV: Displaced fragment• V: Subchondral cyst
  20. 20. Arthroscopic Staging Pritsch et al. and Ferkel et al.A: Smooth, intact, but soft or ballotableB: Rough surfaceC: Fibrillations/ fissuresD: Flap present or bone exposedE: Loose, nondisplaced fragementF: Displaced fragment
  21. 21. MRI Grading system with arthroscopic correlation. Mintz et al., Arthroscopy 2003• Stage 0: Normal• Stage I: Hiperintense but intact chondral surface• Stage II: Chondral fibrillation or fissur• Stage III: Chondral flap or visible bone• Stage IV: Nondisplaced fragment• Stage V: Displaced fragment
  22. 22. SURGICAL TREATMENT OPTIONS• Traditional treatment of choice in talar OCD is still MFx.• Concerns as compared to ACI (hyaline-like cartilage, superior outcomes nature of repair, long-term results).
  23. 23. ACI TREATMENT OPTIONUnpopular in ankle joint despite ability to repair defects with hyaline-richcartilage, because of:•Arthrotomy•Malleolar osteotomy•Source of morbidity
  24. 24. TALAR CHONDRAL DEFECTS- LITERATURE REWIEW – medial lesions are most often chronic and not necessarily associated with specific trauma whereas lateral lesions are almost always traumatic. – Lateral lesions may be more amenable to internal fixation for acute injuries – Lateral lesions have a better prognosis than medial lesions. – Studies which lump medial and lateral lesions together are difficult to interpret.1. Treatment of osteochondral lesions of the talus: a systematic review. Zengerink M, Struijs PA, Tol JL, vanDijk CN. Knee Surg Sports Traumatol Arthrosc. 2010;18(2):2β8-4ό.2. Matrix-induced autologous chondrocyte implantation of talus articular defects. Giza E, Sullivan M, Ocel D,etal. Foot Ankle Int. 2010;31(9):747-53.3. Comparison of MRI and arthroscopy after autologous chondrocyte implantation in patients withosteochondral lesion of the talus. Lee KT, Choi YS, Lee YK, et al. Orthopedics. 2010:1-33(8).4. Autologous chondrocyte implantation of the ankle: a 2- to 5-year follow-up. Nam EK, Ferkel RD, ApplegateGR. Am J Sports Med. 2009;7(2):274-84.5. Marlovits S. et al. Magnetic resonance observation of cartilage repair tissue (MOCART) for the evaluation ofautologous chondrocyte transplantation: determination of interobserver variability and correlation to clinicaloutcome after 2 years. European Journal of Radiology 2006; 57(1): 16-23.
  25. 25. MATERIAL AND METHOD• 7 patients (avg age 28 years) all recreational athletes• R(5) and L(2) talus• Between June 2008 and Feb 2010.• Lesions location : medial aspect of the talus (4) lateral aspect of the left talus (2) central aspect of the talus (1)• Avg size measuring : 3.1 cm2 (2.4-3.8)• All type III- IV (Outerbridge scale).• All underwent arthroscopy ipsilateral knee (1st stage ACI)• Avg. F/U 12 months• Pre-op and post-op evaluation was done using the AOFAS Score, LYSHOLM & GILLQUIST score, Patient Outcome Function score and Visual Analogue Pain score.
  26. 26. SURGICAL PROCEDURE
  27. 27. REHAB PROTOCOL• Antibiotic and thrombosis prophylaxis are given for 48 hours and 3 weeks respectively.• Hospitalization 2-3 d.• A gait as close to normal as possible is practiced, as well as stair walking is gained before the patient is discharged from the hospital.• CPM (s.d.p through whole hospitalization/6-8 h per day).• Active ROM exercises post 3rd d.p.o.• Calibrated brace to allow motion of 15° plantar flexion and 15° dorsal flexion (6 w.p.o).• P.W.B (20Kgr) with crutches, for the first six weeks.• Gradual increase is commenced every week until full weight bearing is achieved in week 8 to 10.• The rehabilitation continues, under the supervision of a physical therapist, with motion and strength training.• Once the brace is removed pool exercises can commence.• As full weight bearing is reached gait training is started along with long distance walking and bicycling.• Functional exercises in closed chain are also incorporated in the rehabilitation program.• Motion and proprioceptive training is continued throughout the rehabilitation, running and plyometric exercises have to wait for six months.
  28. 28. RESULTS• All the procedures progressed uneventfully.• We assessed the patient at 6m and 1 y.p.o• AOFAS score from 32.1 to 91• Lysholm & Gillquist Score rose from 45.5 to 72.5• VAS pain significantly reduced from 6.3 to 1.7• Patient Outcome Function score showed significantly better performance.• MRI showed adequate filling of the defect without significant graft-associated complications for the same period (no significant bone marrow oedema).
  29. 29. 3D- Autologous Chondrocyte TransplantationAdvantages: Disadvantages:• Easy use/arthroscopic procedure • Expensive• Cell-matrix ratio similar to that of the • Needs cartilaginous rim natural cartilage • Cannot address cystic lesion without an• Full coverage of the defect additional stage to procedure (bone• Full integration of the newly produced grafting) cartilage to the neighboring healthy • Further investigation is necessary to tissue determine if this theoretical advantage• Hyaline like cartilage of superior repair tissue results in improved structural and biomechanical• Large surface area may be repaired properties, and whether this translates• Less hospitalization time into better long-term outcomes.• Less medication needed• Less pain experienced• Continuous improvement• No interruption of everyday lifestyle• Return to sports without limitations
  30. 30. CONCLUSION• ACT3D for treating talar and retropatellar chondral defects preliminary results are 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• Rehabilitation protocol is quicker due to minimal trauma.• Await medium and long term results• A greater number of cases and further mid and long term follow-up has to be studied in order to prove the efficacy of the method.• As far as we know this is the first publication in the literature regarding 3nd generation ACI technique fully arthroscopically performed, concerning retro-patellar & talar chondral lesions, in our country.

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