Autologous Chondrocyte Implantation Gerard Hardisty FRACS
Disclosure
Orthopaedic Surgeons Strong as an OX and half as bright
Orthopaedic Innovation Arthroscopy Joint replacement Trauma management MIS Early mobilisation and discharge ACI
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
Bone and Joint Decade 2000-2010 Osteoarthritis Rheumatoid Arthritis Osteoporosis Back pain
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?
Challenging times ahead Longevity Orthopaedic Tsunami
The Active Aged Population 57,256 TKR s in Australia last year Stress fractures on the rise Tendinitis and ruptures increasing
How long can humans live?
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
Total Knee Replacement Increasing revisions
Total Knee Replacement Eventually this or this
Health Costs Costs 2050-50% 30%
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
Classification of Chondral Lesions
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)
ICRS treatment algorithm
ACI Overview
1 st Stage - Biopsy ACI technique
Serology ACI technique
ACI technique 2 nd Stage Cartilage cells Ortho-ACI(Orthocell)
ACI technique 2 nd Stage - Cells to porcine collagen scaffold
ACI technique 2 nd Stage Debride lesion
ACI technique 2 nd Stage Measure size
ACI technique 2 nd Stage Cut template ACI graft
ACI technique 2 nd Stage Cut template ACI graft
ACI technique 2 nd Stage Tisseel glue(fibrin)
ACI technique 2 nd Stage Implantation(open or arthroscopic)
28yo male fall from ladder Case Study
Case Study 28yo male fall from ladder MFC lesion Debride lesion After ACI
Case Study MRI after ACI 3 months 12 months
Case Study 28yo arthroscopy at 12 months
ACI in the Ankle Osteochondral injury to talus
Osteochondral talar defects Aetiology Traumatic ~10% of ankle sprains 20-40yrs Arthroscopic curettage Results not always predictable 80% improve
Treatment Options Further debridement Microfracture Mosaicplasty(OATS) ACI
Microfracture Marrow stimulation Stem cells transform to chondral cells Best for smaller lesion(<2cm) Fibrocartilage
OATS OsteoArticular Transport System Good results reported(hangody,outerbridge) Small grafts Non specialised cartilage Surface problems Gaps(fibrocartilage grouting) Donor site morbidity
ACI results in Ankle Functional Outcome of Matrix Associated Autologous Chondrocyte Implantation in the Ankle Foot Ankle Int 2011 Apr;32(4) 368-74
Treatment algorithm Presentation Treatme MRI Better nt Algorith YES Return to sport NO Arthroscopy Followup @ 6m m MACI
ACI Inclusion Criteria 15-55 No Hep/HIV Single lesion Small size Contained Stable ankle
Surgical technique Malleolar osteotomy 60% Requires ORIF
Surgical technique Good access to lesion
ACI graft Surgical technique
Results 75% significantly improved 85% would undergo again 68% returned to full manual labour 50% able to run again without restriction Younger do better
Case report 18yo sprain playing AFL Failed microfracture ACI graft Preop 6m Post op
Case report 50yo oil and gas supervisor Fall down steps and rolled ankle Arthroscopy and microfracture 2006
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
Case report Re arthroscopy at 2 years for further injury Lateral dome injury Chondroplasty Medial fully healed
Case report Now 61yrs increasing pain MRI deterioration of medial graft Has option now of TAR as well as arthrodesis
Summary ACI well proven technique Alternatives less good science(stem cells, PrP) Ortho-ACI now has ARTG registration and FDA(US) approval
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
Thankyou