Autologous Chondrocyte Implantation. Gerard Hardisty FRACS

Transcription

1 Autologous Chondrocyte Implantation Gerard Hardisty FRACS

2 Disclosure

3 Orthopaedic Surgeons Strong as an OX and half as bright

4 Orthopaedic Innovation Arthroscopy Joint replacement Trauma management MIS Early mobilisation and discharge ACI

5 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

6 Bone and Joint Decade Osteoarthritis Rheumatoid Arthritis Osteoporosis Back pain

7 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?

8 Challenging times ahead Longevity Orthopaedic Tsunami

9 The Active Aged Population 57,256 TKR s in Australia last year Stress fractures on the rise Tendinitis and ruptures increasing

10 How long can humans live?

11 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

12 Total Knee Replacement Increasing revisions

13 Total Knee Replacement Eventually this or this

14 Health Costs Costs % 30%

15 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

16 Classification of Chondral Lesions

17 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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19 ICRS treatment algorithm

20 ACI Overview

21 1 st Stage - Biopsy ACI technique

22 Serology ACI technique

23 ACI technique 2 nd Stage Cartilage cells Ortho-ACI(Orthocell)

24 ACI technique 2 nd Stage - Cells to porcine collagen scaffold

25 ACI technique 2 nd Stage Debride lesion

26 ACI technique 2 nd Stage Measure size

27 ACI technique 2 nd Stage Cut template ACI graft

28 ACI technique 2 nd Stage Cut template ACI graft

29 ACI technique 2 nd Stage Tisseel glue(fibrin)

30 ACI technique 2 nd Stage Implantation(open or arthroscopic)

31 28yo male fall from ladder Case Study

32 Case Study 28yo male fall from ladder MFC lesion Debride lesion After ACI

33 Case Study MRI after ACI 3 months 12 months

34 Case Study 28yo arthroscopy at 12 months

35 ACI in the Ankle Osteochondral injury to talus

36 Osteochondral talar defects Aetiology Traumatic ~10% of ankle sprains 20-40yrs Arthroscopic curettage Results not always predictable 80% improve

37 Treatment Options Further debridement Microfracture Mosaicplasty(OATS) ACI

38 Microfracture Marrow stimulation Stem cells transform to chondral cells Best for smaller lesion(<2cm) Fibrocartilage

39 OATS OsteoArticular Transport System Good results reported(hangody,outerbridge) Small grafts Non specialised cartilage Surface problems Gaps(fibrocartilage grouting) Donor site morbidity

40 ACI results in Ankle Functional Outcome of Matrix Associated Autologous Chondrocyte Implantation in the Ankle Foot Ankle Int 2011 Apr;32(4)

41 Treatment algorithm Presentation Treatme MRI Better nt Algorith YES Return to sport NO Arthroscopy 6m m MACI

42 ACI Inclusion Criteria No Hep/HIV Single lesion Small size Contained Stable ankle

43 Surgical technique Malleolar osteotomy 60% Requires ORIF

44 Surgical technique Good access to lesion

45 ACI graft Surgical technique

46 Results 75% significantly improved 85% would undergo again 68% returned to full manual labour 50% able to run again without restriction Younger do better

47 Case report 18yo sprain playing AFL Failed microfracture ACI graft Preop 6m Post op

48 Case report 50yo oil and gas supervisor Fall down steps and rolled ankle Arthroscopy and microfracture 2006

49 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

50 Case report Re arthroscopy at 2 years for further injury Lateral dome injury Chondroplasty Medial fully healed

51 Case report Now 61yrs increasing pain MRI deterioration of medial graft Has option now of TAR as well as arthrodesis

52 Summary ACI well proven technique Alternatives less good science(stem cells, PrP) Ortho-ACI now has ARTG registration and FDA(US) approval

53 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

54 Thankyou