Istituto Ortopedico Rizzoli

University of Bologna

head: Prof. Sandro Giannini

Evolution of ankle osteochondral

lesion surgery

S. Giannini, R. Buda, M. Cavallo, A. Ruffilli, F. Vannini

Evolution of ankle osteochondral

lesion surgery

Prof. Sandro Giannini

My disclosure is in the

Final AOFAS Mobile App.

I have no potential conflicts with

this presentation.

Autologous Chondrocyte Implantation (ACI)

• Open technique (I generation)

• Arthroscopic technique (II generation)

Bone Marrow Derived Cells Transplantation

(III generation)

OSTEOCHONDRAL LESIONS

Chronic type II-IIIA lesions of Giannini

classification (2005):

Indication for a regenerative procedure:

ANKLE HIND FOOT SCORE (100 POINTS)

(MEAN AOFAS SCORE, 10 PATIENTS)

PRE-OP : 41,2 ± 14.5 PTS

12 MONTHS : 79.4, ±12.6 (p<0,0005)

36 MONTHS : 85.3 ±11.0 (p<0,0005)

10 YEARS : 88.3 ±17.0 (p<0,0005)

OPEN FIELD ACI

MALE 40 yrs ACI open 8 yrs FU

AOFAS score 87

Excellent cartilage

regeneration hyaline-like

(45 msc) focus with no

signal both between 20

and 50 msc and between

50 and 80

Once the signal was

extend, it appeared as

a bony focus

biopsy site?

OPEN FIELD ACI:

CASE REPORT

ANKLE HIND FOOT SCORE (100 POINTS)

(MEAN AOFAS SCORE, 46 PATIENTS)

PRE-OP : 41,2 ± 14.5 POINTS

12 MONTHS : 79.4, ±12.6 (p<0,0005)

36 MONTHS : 85.3 ±11.0 (p<0,0005)

7 YEARS : 88.3 ±17.0 (p<0,0005)

ARTHROSCOPIC ACI

Chondrocytes expansion seed

onto the biomaterial

ARTHROSCOPIC ACI: CASE REPORT

Male 32 years : MRI T2 mapping at 5 yrs FU

High T2 area suggestive for hyaline cartilage in the

regenerated site

1) Platelet gel production

2) Bone marrow harvesting and concentration

3) Biomaterial preparation

4) Arthroscopic implantation

“ONE-STEP” TECHNIQUE

• 202 patients

• Mean age 28.3 yrs (min 15 yrs, max 46)

• Aofas pre-op: 64.4 (min 35- max 79)

• Mean f-u 29.8 months

(Min 6 months, max 57 months)

• All the patients received a completely arthroscopic treatment

• 3 biopses at 1 year of follow up with patients’ consent

CASE SERIES: ANKLE

AOFAS score: progressive significant

improvement over time.

Safranin-O staining of the biopsy specimen shows

a chondral tissue.

Proteoglicans are highly express (red) while

collagen component (green) is less represented

The presence of underlying bone is evident in

specimens

Hyaline regenerate in 80% of

regenerated area correlate

with higher clinical score (89

± 16 points) at 48 months FU

(p=0.06)

The presence of fibrocartilage

regenerate (T2 map<35 ms)

had a negative influence on the

clinical score at 48 months

(p=0.06)

MRI T2 MAPPING

CONCLUSIONS

The arthroscopic BMDC transplantation demonstrated to be able

to obtain good results under clinical, MRI and histological

aspects in osteochondral lesions of the ankle

Main advantages of this procedure are:

Less morbidity: only one step is required

Less invasivity: use of arthroscopy

Good results

Regeneration of both cartilage and subchondral bone

Lower costs

Brittberg M, Peterson L. Introduction to an articular cartilage classification. ICRS Newsletter. 1998;:1:8–8.

Mainil-Varlet P, Aigner T, Brittberg M, Bullough P, Hollander A, Hunziker E, et al. Histological assessment of cartilage repair: a report

by the Histology Endpoint Committee of the International Cartilage Repair Society (ICRS). The Journal of bone and joint surgery.

American volume. 2003 Jan;85-A Suppl:45–57.

Brittberg M, Winalski CS. Evaluation of cartilage injuries and repair. The Journal of bone and joint surgery. American volume. 2003

Jan;85-A Suppl:58–69.

Giannini S, Buda R, Faldini C, Vannini F, Bevoni R, Grandi G, et al. Surgical treatment of osteochondral lesions of the talus in young

active patients. The Journal of bone and joint surgery. American volume. 2005 Jan;87 Suppl 2:28–41.

Oreffo ROC, Cooper C, Mason C, Clements M. Mesenchymal stem cells: lineage, plasticity, and skeletal therapeutic potential. Stem cell

reviews. 2005 Jan;1(2):169–78.

Lucarelli E, Beccheroni A, Donati D, Sangiorgi L, Cenacchi A, Del Vento AM, et al. Platelet-derived growth factors enhance proliferation

of human stromal stem cells. Biomaterials. 2003 Aug;24(18):3095–100.

Dominici M, Pritchard C, Garlits JE, Hofmann TJ, Persons DA, Horwitz EM. Hematopoietic cells and osteoblasts are derived from a

common marrow progenitor after bone marrow transplantation. Proceedings of the National Academy of Sciences of the United States

of America. 2004 Aug 10;101(32):11761–6.

Kacena MA, Gundberg CM, Horowitz MC. A reciprocal regulatory interaction between megakaryocytes, bone cells, and hematopoietic

stem cells. Bone. 2006 Nov;39(5):978–84.

Olmsted-Davis EA, Gugala Z, Camargo F, Gannon FH, Jackson K, Kienstra KA, et al. Primitive adult hematopoietic stem cells can

function as osteoblast precursors. Proceedings of the National Academy of Sciences of the United States of America. 2003 Dec

23;100(26):15877–82.

Taichman RS. Blood and bone: two tissues whose fates are intertwined to create the hematopoietic stem-cell niche. Blood. 2005 Apr

1;105(7):2631–9.

Giannini S, Buda R, Cavallo M, Ruffilli A, Cenacchi A, Cavallo C, et al. Cartilage repair evolution in post-traumatic osteochondral

lesions of the talus: from open field autologous chondrocyte to bone-marrow-derived cells transplantation. Injury. 2010

Nov;41(11):1196–203.

Sánchez AR, Sheridan PJ, Kupp LI. Is platelet-rich plasma the perfect enhancement factor? A current review. The International journal

of oral & maxillofacial implants. 2012;18(1):93–103.

Nair MB, Varma HK, John A. Platelet-rich plasma and fibrin glue-coated bioactive ceramics enhance growth and differentiation of goat

bone marrow-derived stem cells. Tissue engineering. Part A. 2009 Jul;15(7):1619–31.

Giannini S, Buda R, Vannini F, Cavallo M, Grigolo B. One-step bone marrow-derived cell transplantation in talar osteochondral lesions.

Clinical orthopaedics and related research. 2009 Dec;467(12):3307–20.

Battaglia M, Rimondi E, Monti C, Guaraldi F, Sant’Andrea A, Buda R, et al. Validity of T2 mapping in characterization of the

regeneration tissue by bone marrow derived cell transplantation in osteochondral lesions of the ankle. European journal of radiology.

2011 Nov;80(2):e132–9.

Giannini S, Battaglia M, Buda R, Cavallo M, Ruffilli A, Vannini F. Surgical treatment of osteochondral lesions of the talus by open-field

autologous chondrocyte implantation: a 10-year follow-up clinical and magnetic resonance imaging T2-mapping evaluation. The

American journal of sports medicine. 2009 Nov;37 Suppl 1:112S-8S.

Battaglia M, Vannini F, Buda R, Cavallo M, Ruffilli A, Monti C, et al. Arthroscopic autologous chondrocyte implantation in

osteochondral lesions of the talus: mid-term T2-mapping MRI evaluation. Knee surgery, sports traumatology, arthroscopy : official

journal of the ESSKA. 2011 Aug;19(8):1376–84.