Fibrin Matirix-Support Autologous Fibrin Matirix-Support Autologous Chondrocyte Transplantation Chondrocyte Transplantation (ACT) for the Osteochondritis (ACT) for the Osteochondritis Dissecans (OCD) of the KneeDissecans (OCD) of the Knee

- A case report -- A case report -Changhoon Jeong M.D.Changhoon Jeong M.D.

The Dept. of Orthopaedic Surg., Holy Family The Dept. of Orthopaedic Surg., Holy Family Hospital, The Catholic University of Korea Hospital, The Catholic University of Korea

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Introduction Introduction

Osteochondritis Dissecans (OCD) of the Osteochondritis Dissecans (OCD) of the knee is a rare disease of unknown origin. knee is a rare disease of unknown origin.

OCD is characterized by the presence of OCD is characterized by the presence of an area along the femoral articular surface an area along the femoral articular surface consisting of cartilage and bone that may consisting of cartilage and bone that may become loose and separated from the rest become loose and separated from the rest of femoral condyle. of femoral condyle.

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Natural historyNatural history

Children and adolescents in whom the Children and adolescents in whom the distal femoral growth plate is open, distal femoral growth plate is open, spontaneous healing is the usual outcome. spontaneous healing is the usual outcome.

When the disorder is diagnosed after When the disorder is diagnosed after epiphyseal closure, the long term epiphyseal closure, the long term prognosis is guarded.prognosis is guarded.

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Arthroscopic Classification Arthroscopic Classification

Stage 1 – Intact lesion Stage 1 – Intact lesion Stage 2 – Early separated lesionStage 2 – Early separated lesion Stage 3 – Partially detached lesion Stage 3 – Partially detached lesion Stage 4 – Salvageable craters and loose bodyStage 4 – Salvageable craters and loose body Stage 5 – Unsalvageable craters and loose body Stage 5 – Unsalvageable craters and loose body

From Guhl J

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Treatment Treatment

Nonoperative treatmentNonoperative treatment Younger children, open growth plateYounger children, open growth plate Activity restriction Activity restriction Short period of immobilization Short period of immobilization

Arthroscopy Arthroscopy Failure of nonoperative treatmentFailure of nonoperative treatment Persistence of symptomPersistence of symptom Unstable lesion Unstable lesion

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Arthroscopic treatmentArthroscopic treatment Stage 1: drillingStage 1: drilling Stage 2: in situ pinning (two k-wires)Stage 2: in situ pinning (two k-wires) Stage 3, 4: curettage and fixation Stage 3, 4: curettage and fixation Stage 5:Stage 5:

Spongialization: removing all fibrous tissue and subchondral Spongialization: removing all fibrous tissue and subchondral bone down to bleeding cancellous bone bone down to bleeding cancellous bone

Trephining Trephining Periosteal implantation Periosteal implantation OATS (Osteochondral Autograft Transplanation System)OATS (Osteochondral Autograft Transplanation System) Chondrocyte culture and reimplantationChondrocyte culture and reimplantation

Fibrous cartilage

Hyaline cartilage

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Brittberg et al. NEJM 1994Grande et al. JOR 1989

CaseCase 13yrs/boy13yrs/boy

C/C: Rt. knee painful swellingC/C: Rt. knee painful swelling onset) 2 months agoonset) 2 months ago by) No trauma Hxby) No trauma Hx PEx: Swelling/Effusion(+/+)PEx: Swelling/Effusion(+/+) Td(-)Td(-) ROM 0°~120°ROM 0°~120° Lat McMurray(+)Lat McMurray(+)

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Initial X-rayInitial X-ray

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T2T1 T1 CE

Initial MRIInitial MRI

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Bone scanBone scan

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2005-04-20: 2005-04-20: Curettage & multiple drilling Curettage & multiple drilling I/F c K-wires(x2) & AIBG I/F c K-wires(x2) & AIBG

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Postop X-rayPostop X-ray

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POD 16 months

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2006-10-10: 2006-10-10: A/S curettage and debridement (2.5cm X3.5cm)A/S curettage and debridement (2.5cm X3.5cm) Harvest the piece of cartilage for chondrocyte culture Harvest the piece of cartilage for chondrocyte culture

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2006-11-29: 2006-11-29: Autologous chondrocyte transplantation Autologous chondrocyte transplantation Chondron supplied by Cellontech Chondron supplied by Cellontech

AFTER TX.•CPM POD 3D•NWB for 2 weeks •PWB between 3-6 weeks•FWB after 6 weeks 16

ACT Periosteoum Periosteoum Injectable Injectable

ChondronChondron

Fibrin and cell (12X106 cells/0.4 ml/vial)Fibrin (fibrinogen + thrombin) 조직공학용 fibrin 생산 Bio-matrix 중 가장 효과적인 glue 세포와 여러 활성인자를 포함하기 좋은 구조 Pore size 및 polymerization time 을 조절하기가 용이

17Chondron® by Cellontech

POD 9 monthsPOD 9 months

No pain Full ROM No effusion and swelling Lysholm score: 100 18

DiscussionDiscussion A prospective, randomised comparison of autologous

chondrocyte implantation versus mosaicplasty for osteochondral defects in the knee.

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ACT (N=58) Mosaicplasty (N=48)

OATS

Scoring* 88% excellent or good 69%

A/S finding 82% excellent or good 34%

Bentley and associatesJ Bone Joint Surg Br. 2003 Mar;85(2):223-

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Discussion Discussion

ACT for OCD of the kneeACT for OCD of the knee Peterson et al.Peterson et al.: periosteum : periosteum

16/18 (89%) improved ..16/18 (89%) improved ..CORR 2000CORR 2000 N=58 , 90% successful clinical results,N=58 , 90% successful clinical results, 2003 JBJS 2003 JBJS

Noth U et al Noth U et al : a case report - BG and fibrin : a case report - BG and fibrin matrix-supported ACT, good result, matrix-supported ACT, good result, 2006 E. 2006 E. Musculoskeletal review Musculoskeletal review

Ochs BG Ochs BG : 22 type III, IV OCD : BG and fibrin : 22 type III, IV OCD : BG and fibrin matrix-support ACT – clinical improvement , J matrix-support ACT – clinical improvement , J Orthop Unfall 2007 Orthop Unfall 2007

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DiscussionDiscussion Sandwich techniqueSandwich technique Other bio-matrix Other bio-matrix Fibrin matrix-supported ACTFibrin matrix-supported ACT

Very simple Small incision No periosteum suture Short operation time Injectable gel type Easily molded Reduced rehabilitation period

Hyaline cartilage regeneration

Collagen type II synthesis

Glycosaminoglycan synthesis

Even-distribution like normal cartilage

Complete matrix biodegradablity

Good integration

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Conclusion Conclusion This case report shows that ACT is a valid This case report shows that ACT is a valid

method for the treatment of large method for the treatment of large osteochondral defects even after fixation osteochondral defects even after fixation failed. failed.

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Thank you for attention 감사합니다 .