TRATTAMENTO CON MSCS DELLE COIN LESIONS

DI GINOCCHIO DELLO SPORTIVO

STEFANO ZANASIVILLA ERBOSA HOSPITAL

GRUPPO SAN DONATOORTHOPAEDICS DEPARTMENT

IIIRD DIVISION – JOINT ARTHROPLASTY OPERATIVE CENTERCHIEF: STEFANO ZANASI M.D.

Ther’s high incidence of cartilage injuries in sport

sports at greatest risk are linked to sudden direction changes with knee or ankle sprain

Football/soccerRugby

VolleyballBasket

Skitennis

Cartilage injury is due to - single trauma (sprain) or to

- overuse for repetitive microtraumatism in athletic gesture

Cartilage has limited self-repair capabilites

articular cartilage defects will ultimately result in chronic tissue losses

To contrast this relentless outcome new reconstructive techniques have been developed such

as 1. ACT

long-term results are encouragingbut present limitations

2. MSCs able to differentiate into chondral

and osseous lineages, thus able to fill the whole thickness of a defect and secrete some trophic molecules, which contribute of regeneration of damaged tissue, the final result being

cartilage on the top and bone on the bottom

MSCs

Costituiscono una popolazione residente nel midollo osseo di cellule adulte non

differenziate capace di autorigenerarsi e differenziarsi in cellule del tessuto adiposo, del tessuto cartilagineo, del tessuto osseo e

nello stroma che supporta l’ematopoiesi

CELLULE STAMINALI DI MIDOLLO OSSEO AUTOLOGO

CONCENTRATO BMAC

Si ottengono in soli 15 minuti partendo da midollo osseo aspirato da cresta iliaca (60 o 120 ml)

attraverso ciclo di centrifugazione operato da una centrifuga di piccole dimensioni, da usare in sala operatoria

senza necessità di personale specializzato.

La procedura elimina i globuli rossi e il prodotto finale contiene• Cellule staminali emopoietiche • Cellule staminali mesenchimali

• Progenitori vascolari • Cellule immunitarie e piastrine

• Fattori di crescita (attivazione con trombina autologa) in un volume finale di 10 o 20 ml

La procedura di concentrazione richiede l’utilizzo della centrifuga e del kit BMAC composto di due confezioni

(A) contiene il materiale utilizzato nel campo operatorio sterile per il prelievo del midollo da paziente

(B) contiene il materiale per la procedura di concentrazione dell’aspirato midollare

AB

Procedura• nella fase 1, si procede al prelievo del midollo da paziente, che viene raccolto

in una apposita sacca di sangue e infine trasferito in una siringa per essere passato all’esterno del campo sterile

nella fase 2, il campione di midollo viene immesso nella provetta, centrifugato, concentrato nel volume desiderato e di nuovo trasferito al campo operatorio

per il definitivo utilizzo mediante connessione di 2 siringhe diverse

METODI E MATERIALI

Sono stati inclusi in questo studio 40 pazienti sportivi di medio-alto livello

Affetti da lesione a stampo (>3 <9cm2)), III-IV stadio di Outerbridge interessanti CFM,CFL,rotula

Trattatidal 2/2009 al 2/2012 con impianto one step di MSCs da aspirato midollare

L’età media è stata di 32a (+/-9a).

Tutti i pazienti sono stati ricontrollati ad follow-up medio di 18mesi (8-36ms) .

La valutazione clinica è stata effettuata utilizzando il protocollo ICRS-IKDC;

la valutazione dell’impianto cartilagineo è stato effettuata con RMN ad 1.5T applicando il MOCART scoring system.

L’EuroQol EQ-5D è stato utilizzato per valutare la la qualità della vita dei pazienti.

Exemplificative case MSCs: PATELLA simple

Defect: coin lesionLocation: centro- medial area of LEFT/RIGHT patella

Size: 1.5 x 2.5 cm Patient: C. V., male, 28 ys. football playerSymptoms: Severe pain, locking, giving-way, recurrent effusionHistory: bilateral ACL reconstruction on summer of 2009 grafted CONCURRENTLY BILATERALLY on 21/06/2009,

2nd look arthroscopy at 12 ms.

C.V., male, 28 years old - grafted on 11/04/2009

C.V., male, 28 years old –grafted on 11/04/2009 : DX

C.V., male, 28 years old - grafted on 11/04/2009 : SN

Patient: C.V. Male, 28 years old

Arthroscopy Time:

12 months

Follow-up time: 12 months

IKDC Subjective Evaluation Score:

95.5 (improvement from baseline: 49.0)

Knee functional grade: Normal

ICRS Cartilage repair assessment:

12

C.V., male, 28 years old - grafted on 11/04/2009 2nd look at 12ms.f.up

C.V., male, 28 years old - grafted on 11/04/2009 2nd look at 12ms.f.up

RMN AT 12 MS

C.V., male, 28 years old - grafted on 11/04/2009 2nd look at 12ms.f.up - HYSTOLOGY

LIGHT STAINING FOR GAGS

LOW CONTENT AND NOT-UNIFORM DISTRIBUTION OF

TYPE II COLLAGEN

PRESENCE OF TYPE I COLLAGEN,

NOT CELL CLUSTERING AND COLUMNAR ORGANIZATION

DEMONSTRATES THE MATURATION OF IMPLANTED MSCS

TO A CLEAR FIBRO-HYALINE-LIKE PHENOTYPE WITHOUT PECULIAR CELL ORGANIZATION

Exemplificative case: MFC simpleC.D, male, 18 years old - grafted on 19/01/2002

Defect: coin lesionLocation: medial femoral condyleSize: 2 x 2.5 cmPatient: C.D., male, 21 years old. A1 male Serie football athlete Juvenile National Italian football team

History: grafted on 19/01/2002, NMR at 3, 6 and 9, 12 , 24 months post op

arthroscopic 2nd look on 12/01/2003

**

ARTHROSCOPIC ACI TECHNIQUE DEVELOPED

BY M. MARCACCI

C.D, male, 18 years old - grafted on 19/01/2002

C.D, male, 18 years old - grafted on 19/01/20022nd look artroscopy at 18 ms f.up

19/01/2002

Follow-up time: 18 months

Subjective Evaluation Score:97.5

(improvement from baseline: 49.0

Knee functional grade: Normal

Cartilage repair assessment: 12

In collaboration with: Prof. A. HOLLANDER, University of Bristol.

WELL-MATURED NEOCARTILAGE, WITH STRONG GLICOSAMINOGLYCANS

DEPOSITION.

STRONG COLLAGEN TYPE II DEPOSITION

COLUMNAR CHONDROCYTE

REARRANGEMENT INSIDE THE GRAFTED

TISSUE

C.D, male, 18 years old - grafted on 19/01/20022nd look artroscopy at 18 ms f.up

ACT VS MSCs: RESULTS two cohorts of 25 cases at 18 ms f.up

EuroQol (EQ-5D) (N=25 ACT VS 25 MSCs)

Statistically significant improvementsimilar for both groups (pain reduction) (Wilcoxon signed rank test: p<0.0001)

Statistically significant improvementin mobility similar for both groups

(Wilcoxon signed rank test: p<0.0001)

* Roset M et al. Sample size calculations in studies using EuroQol EQ5D. Quality of Life Research 8: 539-549, 1999

Pain/discomfort

Pre-opera-tively

MSCs ACT Reference population*

0

20

40

60

80

100

8.0

82.085.0

74.276

18 15 21.116

0 0 4.7

No pain or discomfort

Moderate pain or discomfort

Extreme pain or discomfort

% p

atie

nts

Mobility

Pre-opera-tively

MSCs ACT Reference population*

0

20

40

60

80

100

8.0

86.0 90.0 89.192

14 10 10.70 0 0 0.2

No mobility problems Some mobility problems

Confined to bed

% p

atie

nts

• Normal post-op without serious adverse events correlated to the graft

• 6/28 cases of increased temperature (<39°) completely ceased within 7 days

• clinical sympthoms (pain, effusion, catching, giving-way) significantly decreased within the 2nd month, and completely ceased, in all cases, within 3 months WITH GOOD/EXCELLENT JOINT FUNCTIONAL RECOVERY

• Significative improvement of ROM (flex-ext >15%):

average pre-op. active ROM 120° (range 80° - 140°)

average post-op active ROM 135° (range 110° - 140°)

SATISFACTORY CLINICAL RESULTS at 18 ms. average f. up

PRELIMINARY CONCLUSIONS: resurfacing by MSCs

Second look arthroscopy at 12 mo.:9/28

Significantly improved appearance of the tissue Total scaffold biodegradation

Complete and uniform fibrocartilagineous tissue resurfacing

discrete mechanical resistence to probe palpation Areas of uneven cartilage stiffness

PRELIMINARY CONCLUSIONS:

THE MATURATION OF IMPLANTED TISSUE ENGINEERED

CARTILAGE TO A CLEAR HYALINE-LIKE PHENOTYPE

WITH PECULIAR CELL ORGANIZATION

2nd look arthroscopy at 12 ms f. up: biopsy DEMONSTRATES

HIGH CONTENT AND UNIFORM

DISTRIBUTION OF TYPE II COLLAGEN

STRONG STAINING FOR GAGS

ABSENCE OF TYPE I COLLAGEN,

CELL CLUSTERING AND COLUMNAR ORGANIZATION

20x2.5x

THE MATURATION OF IMPLANTED MSCS

TO A CLEAR FIBRO-HYALINE-LIKE PHENOTYPE WITHOUT PECULIAR CELL ORGANIZATION

LIGHT STAINING FOR GAGS

LOW CONTENT AND NOT-UNIFORM DISTRIBUTION OF

TYPE II COLLAGEN

PRESENCE OF TYPE I COLLAGEN,

NOT CELL CLUSTERING AND COLUMNAR ORGANIZATION

Need to verify the results at 3 and 5 years to appreciate the

quality of the reconstructed tissueand the

Maintainance/IMPROVEMENT of the (FIBRO)cartilage quality (no degenerative changes?)

PRELIMINARY CONCLUSIONS: MSCs RECONSTRUCTION

In accordo con quanto scritto in Giannini S.,

“One-Step Bone Marrow-derived Cell Trasnsplantation in Talar Osteochondral Lesion”,

Clin. Orthop. Relat. Res. DOI 10.1007/s11999-009-0885-8 (Associaton of Bone and Joint Surgeons 2009).

Questo studio riporta che, in seguito a inoculo del concentrato di

midollo osseo su uno scaffold di acido ialuronico esterificato (HYAFF):

- non si osserva alcuna complicanza locale nè sistemica - si ha la riformazione di tessuto cartilagineo in modo del tutto sovrapponibile alla consolidata tecnica del trapianto di condrociti autologhi.- in un unico tempo operatorio, senza necessità di prelievo di

cartilagine e clonazione della stessa in centro di coltura specializzato con reimpianto successivo dopo circa 30 gg

- Significativo minor costo della procedura

Although longer followup is needed to confirm the validity of the repair overtime, the arthroscopic one-step technique represents an advance in osteochondral regeneration, achieving high clinical scores with the formation of repair tissue

and without the major disadvantages of previous techniques.

MSCs cartilage defect </= 4

cm2simple

shouldered

ACT

cartilage defect> 4cm2 Simple wide, Shouldered

Complex-salvageto delay implant arthroplasty

Long term Validated resultsShort term Evaluating results

Good functional/clinical resultsGood (?) % of hyaline tissue

duration?

Good functional/clinical resultsGood % of hyaline tissue

14 yrs f.up

EXCELLENT INTEGRATION OF THE NEOFORMED TISSUE WITH THE SUBCHONDRAL BONE.

THE TYDE-MARK IS DEVELOPING

C.D, male, 18 years old - grafted on 19/01/20022nd look artroscopy at 18 ms f.up

MSCs : 56 pts. from 02/09 to 02/12 for chondral knee defects Outerbridge stage III/IV

according to Tom Minas’ classification

simple 32/56 26 sportmen coin defect (troclea, patellar, condyle/s, emi-tibial plate)

complex 11/56 5 sportmenshouldered massive unipolar defect of the lateral/medial condyle

plurifocal not kissed and differently combined/spared coin defects (troclea, patellar, condyle/s, emi-tibial plate)

salvage 13/56 11 sportmenshouldered, limited kissing lesions not requiring realignment procedure

unshouldered kissing lesions and uni-compartmental OA concurrently with unloading/corrective osteotomy

32/56 sportmen

average age 25 ys (range 19 - 50) - 47% F

average defect size 3.5 cm2 (range 2.5 – 12.5cm)