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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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S.ALEVROGIANNIS, MD, PhD.CONSULTANT ORTHOPAEDIC SURGEON
2ND Orth. Dept.251 General Air Force Hospital, Athens/GR.
FULLY ARTHROSCOPICALLY PERFORMED ACI FOR CHONDRAL & OSTEOCHONDRAL DEFECTS AT PFJ &
TALUS. PRELIMINARY RESULTS.
Treatment Options for Chondral Defects
Symptomati
c
• Lavage
• Debridem
ent
Stem Cells
• Drilling
• Abrasion
Arthroplas
ty
• MFx
• AMIC®
Cell Therapy• Periosteal
Grafting• Autologous
Chondrocyte
Implantation • ACI (1st
gen.)• MACI(2nd
gen)• ACT 3D
Osteochond
ral Grafting
•
Autografts
OATS
Mosaicpla
sty
•
Allografts
Biomimetics• TRUFIT• Chondr
omimetic
COMMON PROBLEMS IN TREATING RETRO-PATELLAR &
TALAR CHONDRAL LESIONS
• 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
RETRO-PATELLAR LESION
POSTEROMEDIAL TALAR LESION
AUTOLOGOUS CHONDROCYTE TRANSPLANTATION (ACT3D) WITH
SPHEROIDS
RELATIVELY 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)
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
3d-cell culture
2-3 weeks
Preparation of Transplantatco.don chondrosphere®
Spheroid formation induced by 3D cell-cell-
contacts induced by matrix synthesis
Monolayer cell culture
3-4 weeks
cultivation
Manufacturing of co.don chondrosphere®
Biopsy removal
Filling of the defect
Native Native
20min after application of appr. 30 spheroids/ cm2
Defect Few days after transplantation
Native Native
Ddefectappr. 6 weeks after OP
Native Native
Defectappr. 12 weeks after OP
Native Native
Autologous Chondrocyte Transplantation
Indications:• Large stage III-IV
defects • Extensive
subchondral cystic changes
• Failed previous surgery
Ideal patient• Age 15-50 years old• No malalignment• No degenerative
joint disease• No instability
Grade I Grade II Grade III Grade IVOUTERBRIDGE CLASSIFICATION
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)
RETROPATELLAR LESIONS( 2 STAGE PROCEDURE)
1ST STAGE:• Arthroscopic inspection of chondral
injury• Harvest cells from NWB area of knee
joint• Cell cultivation2ND STAGE:• Arthroscopic debridement of patellar
lesion• Cells implantation FULLY ARTHROSCOPICALLY
PERFORMED
(2ND STAGE)RETROPATELLAR AUTOLOGOUS
CHONDROCYTE TRANSPLANTATION (ACT3D) WITH CHONDROSPHERES
REHABILITATION PATELLAR AND TROCHLEAR DEFECTS
WEEK 1 WEEK 2-7 > WEEK 7
MOBILIZATION
Brace in extension
CPM with restrictions :Week 2-3: 0/0/300
Week 4-5: 0/0/600
Week 6-7: 0/0/900
Free movement (restricted by pain)
0-14 DAYS WEEK 3 - 4 >WEEK 4
WEIGHT BEARING
Foot sole contact 3-point –walking with crutches
PWB (up to 50%) 3-point –walking with crutches
Building up FWB within 3-6 weeks
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).
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
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 compression fracture + Bone Edema
• II-b: Without bone edema• III: Separated but
nondisplaced fragment• IV: Displaced fragment• V: Subchondral cyst
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
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
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).
ACI TREATMENT OPTION
Unpopular in ankle joint despite ability to repair defects with hyaline-rich cartilage, because of:• Arthrotomy• Malleolar osteotomy• Source of morbidity
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, van Dijk 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,et al. Foot Ankle Int. 2010;31(9):747-53.3. Comparison of MRI and arthroscopy after autologous chondrocyte implantation in patients with osteochondral 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, Applegate GR. 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 of autologous chondrocyte transplantation: determination of interobserver variability and correlation to clinical outcome after 2 years. European Journal of Radiology 2006; 57(1): 16-23.
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.
SURGICAL PROCEDURE
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.
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).
3D- Autologous Chondrocyte Transplantation
Advantages:• Easy use/arthroscopic
procedure• Cell-matrix ratio similar to
that of the natural cartilage• Full coverage of the defect• Full integration of the newly
produced cartilage to the neighboring healthy tissue
• Hyaline like cartilage• Large surface area may be
repaired• Less hospitalization time• Less medication needed• Less pain experienced• Continuous improvement• No interruption of everyday
lifestyle• Return to sports without
limitations
Disadvantages:• Expensive• Needs cartilaginous rim• Cannot address cystic lesion
without an additional stage to procedure (bone grafting)
• Further investigation is necessary to determine if this theoretical advantage of superior repair tissue results in improved structural and biomechanical properties, and whether this translates into better long-term outcomes.
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.