autologous chondrocyte implantation - anzsom · autologous chondrocyte implantation is the harvest...
TRANSCRIPT
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Autologous Chondrocyte Implantation
Gerard Hardisty FRACS
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Disclosure
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Orthopaedic Surgeons
Strong as an OX and half as bright
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Orthopaedic Innovation
Arthroscopy
Joint replacement
Trauma management
MIS
Early mobilisation and discharge
ACI
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What is ACI Autologous Chondrocyte Implantation is the harvest of
autologous cartilage cells, grown in the lab and then reinserted in the donor’s damaged chondral surface.
Why? – because we cannot repair cartilage that is damaged with normal hyaline cartilage cells. Fibrocartilage repair results and is not durable. This leads to premature osteoarthritis
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Bone and Joint Decade 2000-2010
Osteoarthritis
Rheumatoid Arthritis
Osteoporosis
Back pain
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Osteoarthritis Disease burden increasing
TKR is cost effective in the long term
Obesity and Age two biggest factors in the increasing economic burden
Joint replacements are being done in younger patients
But how many revision joint replacements can one have?
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Challenging times ahead Longevity
Orthopaedic Tsunami
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The Active Aged Population
57,256 TKR’s in Australia last year
Stress fractures on the rise
Tendinitis and ruptures increasing
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How long can humans live?
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TKR’s TKR at 60
15yrs for primary
10yrs for revision
8yrs for second revision
5 years for third?
= 38yrs – only 30 or so years to go
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Total Knee Replacement Increasing revisions…
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Total Knee Replacement Eventually this… …or this
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Health Costs
Costs 2050 - 50%
30%
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Osteoarthritis Prevention is better than
cure?
Can we reduce the incidence of debilitating knee and ankle arthritis?
60% of Arthroscopies have chondral damage
ACI can heal cartilage defects
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Classification of Chondral Lesions
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History of ACI
1964(Smith) - isolated chondrocytes
1971(Bentley) - transplanted chondrocytes
1984(Peterson) - therapeutically credible
1994(Brittberg) - NEJM-23 patients ACI
In WA – since 2000 (Prof Zheng)
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ICRS treatment algorithm
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ACI Overview
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ACI technique 1st Stage - Biopsy
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ACI technique Serology
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ACI technique 2nd Stage Cartilage cells – Ortho-ACI(Orthocell)
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ACI technique 2nd Stage - Cells to porcine collagen scaffold
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ACI technique 2nd Stage – Debride lesion
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ACI technique 2nd Stage – Measure size
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ACI technique 2nd Stage – Cut template ACI graft
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ACI technique 2nd Stage – Cut template ACI graft
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ACI technique 2nd Stage – Tisseel glue(fibrin)
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ACI technique 2nd Stage – Implantation(open or arthroscopic)
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Case Study 28yo male fall from ladder
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Case Study 28yo male fall from ladder – MFC lesion
Debride lesion After ACI
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Case Study
3 months
12 months
MRI after ACI
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Case Study 28yo arthroscopy at 12 months
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ACI in the Ankle Osteochondral injury to talus
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Osteochondral talar defects Aetiology – Traumatic
~10% of ankle sprains
20-40yrs
Arthroscopic curettage
Results not always predictable
80% improve
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Treatment Options
Further debridement
Microfracture
Mosaicplasty(OATS)
ACI
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Microfracture
Marrow stimulation
Stem cells transform to chondral cells
Best for smaller lesion(<2cm)
Fibrocartilage
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OATS OsteoArticular Transport System
Good results reported(Hangody,Outerbridge)
Small grafts
Non specialised cartilage
Surface problems
Gaps(fibrocartilage grouting)
Donor site morbidity
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ACI results in Ankle
Functional Outcome of Matrix Associated Autologous Chondrocyte Implantation in the Ankle
Foot Ankle Int 2011 Apr;32(4) 368-74
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Treatment algorithm
Treatment
Algorithm
Presentation
MRI
Arthroscopy
Better
Followup @ 6m MACI
Return to sport YES
NO
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ACI Inclusion Criteria 15-55
No Hep/HIV
Single lesion
Small size
Contained
Stable ankle
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Surgical technique Malleolar osteotomy – 60%
Requires ORIF
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Surgical technique
Good access to lesion
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Surgical technique ACI graft
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Results
75% significantly improved
85% would undergo again
68% returned to full manual labour
50% able to run again without restriction
Younger do better
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Case report 18yo sprain playing AFL
Failed microfracture – ACI graft
Preop 6m Post op
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Case report 50yo oil and gas supervisor
Fall down steps and rolled ankle
Arthroscopy and microfracture 2006
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Case report Failed at 6m with symptoms
Underwent ACI as 2 stage with medial malleolar osteotomy
Rehabilitation for 3m
Returned to work restricted at 4m
MRI at 6m shows good infill
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Case report
Re arthroscopy at 2 years for further injury
Lateral dome injury – Chondroplasty
Medial fully healed
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Case report
Now 61yrs – increasing pain
MRI deterioration of medial graft
Has option now of TAR as well as arthrodesis
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Summary
ACI well proven technique
Alternatives less good science(stem cells, PrP)
Ortho-ACI now has ARTG registration and FDA(US) approval
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The future RCT’s necessary
Do in acute setting?
Who to select?
As techniques improve - ?Obviate replacement and arthrodesis surgery.
Not all but a few…
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Thankyou