S.ALEVROGIANNIS, MD, PhD.S.ALEVROGIANNIS, MD, PhD.CONSULTANT ORTHOPAEDIC SURGEON CONSULTANT ORTHOPAEDIC SURGEON

22NDND Orth. Dept.251 General Air Force Orth. Dept.251 General Air Force Hospital, Athens/GR.Hospital, Athens/GR.

AIM OF THE STUDYAIM OF THE STUDY

To present our To present our preliminary results in preliminary results in fully arthroscopically fully arthroscopically performed 3-performed 3-dimensional dimensional autologous cartilage autologous cartilage transplantation transplantation (ACT(ACT3D3D) for medium to ) for medium to large focal chondral large focal chondral defects at the knee.defects at the knee.

MATRIX INDUCED AUTOLOGOUS MATRIX INDUCED AUTOLOGOUS CHONDROCYTE IMPLANTATION (MACI).CHONDROCYTE IMPLANTATION (MACI).

AUTOLOGOUS CHONDROCYTE AUTOLOGOUS CHONDROCYTE TRANSPLANTATION (ACTTRANSPLANTATION (ACT3D3D) WITH ) WITH SPHEROIDSSPHEROIDS

A NEW TECHNIQUE:A NEW TECHNIQUE:

No scaffold, membrane, No scaffold, membrane, periosteum or growth factors periosteum or growth factors neededneeded

No fibrin glue or other fixationNo fibrin glue or other fixation Strictly autologous, no viral Strictly autologous, no viral

transmissiontransmission Minimally invasive techniqueMinimally invasive technique (mainly arthroscopically (mainly arthroscopically

performed)performed)

AUTOLOGOUS SPHEROIDSAUTOLOGOUS SPHEROIDS

Small balls, consisted of 3-dimensional Small balls, consisted of 3-dimensional conglomerats of chondrocytes together conglomerats of chondrocytes together with their matrixwith their matrix

Diameter about 1mmDiameter about 1mm About 2x10About 2x1055 chondrocytes in their chondrocytes in their de de

novonovo matrix matrix 10-70 spheroids/ cm10-70 spheroids/ cm22 of defect of defect Grown in the patients own serumGrown in the patients own serum Cultivated without antibioticsCultivated without antibiotics Expression of hyaline specific markers:Expression of hyaline specific markers: proteoglycansproteoglycans collagen type IIcollagen type II S-100, CEP-68S-100, CEP-68 Suppression of the expression of Suppression of the expression of

collagen type Icollagen type I Expression of chondrogenic growth Expression of chondrogenic growth

factors:factors: TGF-TGF-ββ, IGF-1,PDGF,FGF-2, IGF-1,PDGF,FGF-2

MATERIAL-METHODMATERIAL-METHOD

(Mar 2007-May 2008) (Mar 2007-May 2008) 3535 pts pts with chondral defect at the with chondral defect at the knee (recreational athletes-knee (recreational athletes-none elite athlete)none elite athlete)

Mean age Mean age 3232 (17-54) (17-54) Mean area of cartilage defect: Mean area of cartilage defect:

6.75cm6.75cm22 ( 2.2-10cm ( 2.2-10cm22)) Grade III Grade III ((1616)) & grade IV & grade IV ((1818))

lesionslesions 3434 cases were performed cases were performed

arthroscopically- arthroscopically- 11 case case (multiple injuries) mini-open (multiple injuries) mini-open arthrotomyarthrotomy

MATERIALMATERIAL30%

70%

RIGHT LEFT

65%

35%

SEXMEN

FEMALE

SITE OF DEFECTSSITE OF DEFECTS

MFC: 18; 53%Trochlea:6;

18%

LFC: 8; 23%

Patella:2; 6%

MFC

Patella

LFC

Trochlea

AETIOLOGY OF DEFECTSAETIOLOGY OF DEFECTS

5; 15%

2; 6%

8; 24%

19; 55%

Trauma

OCD

Chondr. Patella

Failed MFx

PREVIOUS OPERATIONSPREVIOUS OPERATIONS

NONE:21

ARTHR. PAT.L. RELEASE:1

DEBRIDEMENT:1

MFx:8

PART. L.MENISC.: 1

PART. M.MENISC.: 2

INDICATIONS ACTINDICATIONS ACT3D3D

Symptomatic chondral/osteochondral Symptomatic chondral/osteochondral defect without other correctable joint defect without other correctable joint pathologypathology

Inclusion Criteria•Single/multiple defects

•Defects1-10cm2 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

ALIGNMENT IS CRITICALALIGNMENT IS CRITICAL

Nothing will work if Nothing will work if alignment is outalignment is out

ARTICULAR CARTILAGE MANAGEMENT IN THE ATHLETE.Algorithm 2005

10 “patient directed” categorical situationsBased on:

lesion size, depth, alignment, ligament and meniscal integrityprogress over time

ACTACT3D3D PROCEDURES 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

ACTACT3D3D + ACL PROCEDURE + ACL PROCEDURE

CASE 1 6m.p.o 1 y.p.oCASE 1 6m.p.o 1 y.p.o

CASE 2: CASE 2: A.S (M) 37Y.OA.S (M) 37Y.OOWHTO+ 1OWHTO+ 1STST STAGE REVISION ACL+1 STAGE REVISION ACL+1STST STAGE STAGE ACIACI intra-op c-armintra-op c-arm

1 y.p.o1 y.p.o

CASE 3:CASE 3: LB (M). AGE 42. VALGUS LATERAL OA LB (M). AGE 42. VALGUS LATERAL OADFVO + MENISCAL TRANSPLANTDFVO + MENISCAL TRANSPLANT

Preop Post op Alignment

CASE 4: B.S (F). AGE 42. PATELLAR MAL-CASE 4: B.S (F). AGE 42. PATELLAR MAL-ALIGNMENT AND CHONDRAL DEFECT OF ALIGNMENT AND CHONDRAL DEFECT OF LATERAL FACET.LATERAL FACET.

REHABILITATION FEMORAL AND REHABILITATION FEMORAL AND TIBIAL DEFECTSTIBIAL DEFECTS

WEEK 1WEEK 1 WEEK 2-6WEEK 2-6 > WEEK 6> WEEK 6

WEIGHT WEIGHT BEARINGBEARING

Foot sole contact Foot sole contact 3-point – 3-point –walking with walking with crutchescrutches

PWB (up to 50%) PWB (up to 50%)

3-point –walking with crutches3-point –walking with crutches

Building up FWB Building up FWB within 3-6 weekswithin 3-6 weeks

MOBILIZATIONMOBILIZATION Brace in extensionBrace in extension CPM with restrictions femoral CPM with restrictions femoral condyle:condyle:

Week 2-3:0/0/60Week 2-3:0/0/6000

Week 4-6: 0/0/90Week 4-6: 0/0/9000

Free movement Free movement (restricted by pain)(restricted by pain)

WALKING, WALKING, SPORTSPORT

mobilizationmobilization Aqua training, swimmingAqua training, swimming Aqua jogging, Aqua jogging, >8w:biking>8w:biking

>6 m: jogging, skating>6 m: jogging, skating

>6-12m: skiing>6-12m: skiing

>12m: contact sports>12m: contact sports

REHABILITATION PATELLAR AND REHABILITATION PATELLAR AND TROCHLEAR DEFECTSTROCHLEAR DEFECTS

WEEK 1WEEK 1 WEEK 2-7WEEK 2-7 > WEEK 7> WEEK 7

MOBILIZATIOMOBILIZATIONN

Brace in extensionBrace in extension CPM with restrictions :CPM with restrictions :

Week 2-3: 0/0/30Week 2-3: 0/0/3000

Week 4-5: 0/0/60Week 4-5: 0/0/6000

Week 6-7: 0/0/90Week 6-7: 0/0/9000

Free movement Free movement (restricted by pain)(restricted by pain)

0-14 DAYS0-14 DAYS WEEK 3 - 4WEEK 3 - 4 >WEEK 4>WEEK 4

WEIGHT WEIGHT BEARINGBEARING

Foot sole contact Foot sole contact 3-point –walking 3-point –walking with crutcheswith crutches

PWB (up to 50%) PWB (up to 50%)

3-point –walking with 3-point –walking with crutchescrutches

Building up FWB Building up FWB within 3-6 weekswithin 3-6 weeks

CLINICAL SCORING SYSTEMSCLINICAL SCORING SYSTEMS

Modified Cincinnati Rating System (0-100)Modified Cincinnati Rating System (0-100) Visual Analogue Score (0-10)Visual Analogue Score (0-10) Bentley Functional Rating System (0-5)Bentley Functional Rating System (0-5) Patient Rating (worse, same, better)Patient Rating (worse, same, better) Patient Functional Outcome (0-10)Patient Functional Outcome (0-10) Brittberg score (excellent-poor)Brittberg score (excellent-poor) LysholmLysholm & & GillquistGillquist (0-100) (0-100) Tegner & Lysholm (0-10)Tegner & Lysholm (0-10) Meyer (pain-function-ROM)Meyer (pain-function-ROM) Functional Assessment following ACI (FAFA)Functional Assessment following ACI (FAFA) IKDC knee examination ScoreIKDC knee examination Score

MODIFIED CINCINATTI SCOREMODIFIED CINCINATTI SCORE (0-100)(0-100)ExcellentExcellent (>80), (>80), GoodGood (55 to 79), (55 to 79), FairFair (30 to 54) or (30 to 54) or PoorPoor(<30)(<30)

PainPain

SwellingSwelling

Giving wayGiving way

Overall activity levelOverall activity level

WalkingWalking

StairsStairs

Running activityRunning activity

Jumping or twisting Jumping or twisting activities activities

41,5

68,2 72,5

0

10

20

30

40

50

60

70

80

PRE.OP

6M.P.O

1Y.P.O

VISUAL ANALOGUE SCOREVISUAL ANALOGUE SCORE (0 = (0 = good,good, 10= 10=poorpoor))

0

2

4

6

8

10

0 6 12

months

po

ints

81%

1%18%

BETTER SAME WORSE

PATIENT OUTCOME PATIENT OUTCOME FUNCTION SCOREFUNCTION SCORE

IKDC KNEE EXAMINATION SCOREIKDC KNEE EXAMINATION SCORE

MRI RESULTSMRI RESULTS

PRESENCE OF SUBCHONDRAL OEDEMA.PRESENCE OF SUBCHONDRAL OEDEMA. initial p.o phase: normal responseinitial p.o phase: normal response 9m-12m p.o phase: minimal oedema9m-12m p.o phase: minimal oedema if the amount of oedema persists or increases during if the amount of oedema persists or increases during

the f.u period, this may be suggestive of failure of the the f.u period, this may be suggestive of failure of the ACI graft.ACI graft.

PRESENCE OF SUBCHONDRAL CYSTS WITH PRESENCE OF SUBCHONDRAL CYSTS WITH OEDEMAOEDEMA fibrocartilage appearance rather than fibrocartilage appearance rather than hyaline-likehyaline-like

GRAFT HYPERTROPHYGRAFT HYPERTROPHY ( commonly noted in pts ( commonly noted in pts with OCD within 6 month f.u period).with OCD within 6 month f.u period).

CASE 5: S.S (M) 23Y.O 1Y.P.O CASE 5: S.S (M) 23Y.O 1Y.P.O O.C.DO.C.D

22ndnd LOOK ARTHROSCOPY LOOK ARTHROSCOPY

CASE 6: T.G (M) 43Y.OCASE 6: T.G (M) 43Y.O

CASE 6: T.G (M) 43Y.O 1 Y.P.OCASE 6: T.G (M) 43Y.O 1 Y.P.O

CASE 6: T.G (M) 43Y.O 1 Y.P.OCASE 6: T.G (M) 43Y.O 1 Y.P.O

COMPLICATIONSCOMPLICATIONS1.Superficial wound inf : 01.Superficial wound inf : 02. Septic arthritis : 02. Septic arthritis : 03.3.Lateral popliteal n. neuropraxia : 1Lateral popliteal n. neuropraxia : 14.Knee stiffness requiring MUA : 04.Knee stiffness requiring MUA : 05.Symptomatic graft hypertrophy : 05.Symptomatic graft hypertrophy : 06.Delamination :06.Delamination :07.Unplanned arthroscopy : 07.Unplanned arthroscopy : 08.Post op. DVT: 08.Post op. DVT: 09.9.Graft failure : 1Graft failure : 1

Good short term clinical outcome using combined ACI and ACL Good short term clinical outcome using combined ACI and ACL reconstruction proceduresreconstruction procedures

ACTACT3D3D early results very promising, can be performed fully early results very promising, can be performed fully arthroscopically, reduce operative time, avoid patient having arthroscopically, reduce operative time, avoid patient having multiple operationsmultiple operations

The whole procedure requires surgeon’s experience and The whole procedure requires surgeon’s experience and coordinative teamcoordinative team

Less medication neededLess medication needed Less pain experiencedLess pain experienced No disruption of everyday lifestyleNo disruption of everyday lifestyle Sports activities without reduction in previous performanceSports activities without reduction in previous performance Rehabilitation protocol is quicker due to minimal trauma and can Rehabilitation protocol is quicker due to minimal trauma and can

be combined with other surgical procedures at the same be combined with other surgical procedures at the same op.procedure.op.procedure.

Await medium and long term resultsAwait medium and long term results

CONCLUSIONSCONCLUSIONS

Replacement/ Repair Regeneration

THE ULTIMATE GOALTHE ULTIMATE GOAL