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.