ΠΛΗΡΩΣ ΑΡΘΡΟΣΚΟΠΙΚΗ ΑΠΟΚΑΤΑΣΤΑΣΗ ΧΟΝΔΡΙΝΩΝ ΚΑΙ...
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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 KNEETRANSCRIPT
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