ΠΛΗΡΩΣ ΑΡΘΡΟΣΚΟΠΙΚΗ ΑΠΟΚΑΤΑΣΤΑΣΗ ΧΟΝΔΡΙΝΩΝ ΒΛΑΒΩΝ ΕΠΙΓΟΝΑΤΙΔΟΜΗΡΙΑΙΑΣ ΑΡΘΡΩΣΗΣ ΚΑΙ ΑΣΤΡΑΓΑΛΟΥ ΜΕ ΕΜΦΥΤΕΥΣΗ ΚΑΛΛΙΕΡΓΗΜΕΝΩΝ ΧΟΝΔΡΟΣΦΑΙΡΙΔΙΩΝ ( ACT3D). ( Παρουσίαση περιστατικών στο Ελληνικό Ετήσιο Συνέδριο Αρθροσκόπησης και Χειρουργικής Γόνατος, Ρέθυμνο 2011). FULLY ARTHROSCOPICALLY PERFORMED ACI FOR CHONDRAL & OSTEOCHONDRAL DEFECTS AT PFJ & TALUS. PRELIMINARY RESULTS. RETHYMNO 2011

1. FULLY ARTHROSCOPICALLY PERFORMED ACI FOR
CHONDRAL & OSTEOCHONDRAL DEFECTS AT PFJ & TALUS.
PRELIMINARY RESULTS.
S.ALEVROGIANNIS, MD, PhD.
CONSULTANT ORTHOPAEDIC SURGEON
2ND Orth. Dept.251 General Air Force Hospital, Athens/GR.

2. Treatment Options for Chondral Defects
Cell Therapy Osteochondral Biomimetics
Symptomatic Stem Cells
•Periosteal Grafting •TRUFIT
• Lavage • Drilling Grafting
• Autografts •Chondromi
• Debridement • Abrasion •Autologous metic
Arthroplasty Chondrocyte  OATS
Implantation
• MFx Mosaicplasty
•ACI (1st gen.)
• AMIC® •MACI(2nd gen)
• Allografts
•ACT 3D

3. COMMON PROBLEMS IN TREATING
RETRO-PATELLAR & TALAR
CHONDRAL LESIONS
RETRO-PATELLAR LESION POSTEROMEDIAL TALAR LESION
• Difficult surgical procedure
• Often open surgery required
• Major trauma
• Lower limb mal-alignment
• Removal of hardware (2nd operation specially talar chondral injuries)
OFTEN LEAD TO FAIR TO POOR SUBJECTIVE & OBJECTIVE RESULTS

4. AUTOLOGOUS CHONDROCYTE
TRANSPLANTATION (ACT3D) WITH
SPHEROIDS
RELATIVELY NEW TECHNIQUE:
• No scaffold, membrane, periosteum or
growth factors needed
• No fibrin glue or other fixation
• Strictly autologous, no viral transmission
• Minimally invasive technique
(mainly arthroscopically performed)

5. AUTOLOGOUS SPHEROIDS
• Small balls, consisted of 3-dimensional
conglomerats of chondrocytes together with
their matrix
• Diameter about 1mm
• About 2x105 chondrocytes in their de novo
matrix
• 10-70 spheroids/ cm2 of defect
• Grown in the patients own serum
• Cultivated without antibiotics
• Expression of hyaline specific markers:
proteoglycans
collagen type II
S-100, CEP-68
• Suppression of the expression of collagen
type I
• Expression of chondrogenic growth factors:
TGF-β, IGF-1,PDGF,FGF-2

6. Manufacturing of co.don
chondrosphere®
3-4 weeks
Biopsy removal Monolayer cell culture cultivation
2-3 weeks
co.don
3d-cell culture Preparation of Transplantat
chondrosphere®
Spheroid formation
 induced by 3D cell-cell-
contacts
 induced by matrix synthesis

7. Filling of the defect
Native Native Native Native
20min after application of appr. 30 Defect
spheroids/ cm2 Few days after transplantation
Native Native Native Native
Ddefect Defect
appr. 6 weeks after OP appr. 12 weeks after OP

8. Autologous Chondrocyte Transplantation
Indications: Ideal patient
• Large stage III-IV defects • Age 15-50 years old
• Extensive subchondral • No malalignment
cystic changes • No degenerative joint
• Failed previous surgery disease
• No instability
Grade I Grade II Grade III Grade IV
OUTERBRIDGE CLASSIFICATION

9. MATERIAL -METHOD
• 5 pts, (3M/2F)-all recreational athletes
• Avg age 36(25-48)
• Avg size lesion 3.8cm2 (4R/1L knee)
• 3 (Grade III) & 2 (Grade IV)-Outerbridge scale
• 4 cases due to trauma/1 pat.mal-alignment (arthroscopic release in 1st stage ACI)
• Past MHx:
 2 previous arthroscopic debridement
 1 MFx
 1 ACL recon.
• Pre and post-op evaluation (6m & 1y.) using:
-LYSHOLM & GILLQUIST (0-100)
-IKDC Knee Examination Score
-Visual Analogue Score (0-10)
-Patient Rating (worse, same, better)
-Patient Functional Outcome (0-10) and
-MRI scan (radiological assessment)

10. RETROPATELLAR LESIONS
( 2 STAGE PROCEDURE)
 1ST STAGE:
• Arthroscopic inspection of chondral injury
• Harvest cells from NWB area of knee joint
• Cell cultivation
 2ND STAGE:
• Arthroscopic debridement of patellar lesion
• Cells implantation
FULLY ARTHROSCOPICALLY PERFORMED

11. (2ND STAGE)
RETROPATELLAR AUTOLOGOUS
CHONDROCYTE TRANSPLANTATION (ACT3D)
WITH CHONDROSPHERES

13. REHABILITATION PATELLAR AND
TROCHLEAR DEFECTS
WEEK 1 WEEK 2-7 > WEEK 7
MOBILIZATION Brace in extension CPM with restrictions : Free movement
Week 2-3: 0/0/300 (restricted by pain)
Week 4-5: 0/0/600
Week 6-7: 0/0/900
0-14 DAYS WEEK 3 - 4 >WEEK 4
WEIGHT Foot sole contact PWB (up to 50%) Building up FWB
BEARING 3-point –walking 3-point –walking with within 3-6 weeks
with crutches crutches

14. RESULTS
• All the procedures progressed uneventfully.
• Lysholm & Gillquist Score rose from 42.1 to 74.8
1 y.p.o
• IKDC score rose from 56 to 92
• VAS pain significantly reduced from 6.8 to 1.8
• Patient Outcome Function score showed
significantly better performance.
• All MRI scans showed adequate filling of the
defect, with no delamination, no significant BMO
and no hypertrophy of the newly-formed cartilage).

15. OSTEOCHONDRAL LESIONS OF
THE TALUS
• Osteochondral lesions of the talus involve damage or separation of
the cartilage and underlying subchondral bone.
• This lesion may range from a small defect in the talar articular
surface, a subchondral cyst, or a large detached osteochondral
fragment.
• Transchondral fracture
• Osteochondral fracture
• Osteochondritis dissecans
• Talar dome fracture
• Flake fracture

16. Typical Sites of lesion

17. Staging
• Radiographic
• Computed Tomography
• Magnetic Resonance Imaging
• Arthroscopic

18. Radiographic Staging
Berndt and Harty

19. CT Staging
Ferkel and Sgaglione

20. MRI Staging
Hepple et al.
• I: Superficial chondral lesion
• II-a: Chondral lesion +
Subchondral compression
fracture + Bone Edema
• II-b: Without bone edema
• III: Separated but nondisplaced
fragment
• IV: Displaced fragment
• V: Subchondral cyst

21. Arthroscopic Staging
Pritsch et al. and Ferkel et al.
A: Smooth, intact, but soft or ballotable
B: Rough surface
C: Fibrillations/ fissures
D: Flap present or bone exposed
E: Loose, nondisplaced fragement
F: Displaced fragment

22. MRI Grading system with
arthroscopic correlation.
Mintz et al., Arthroscopy 2003
• Stage 0: Normal
• Stage I: Hiperintense but intact chondral surface
• Stage II: Chondral fibrillation or fissur
• Stage III: Chondral flap or visible bone
• Stage IV: Nondisplaced fragment
• Stage V: Displaced fragment

23. SURGICAL TREATMENT
OPTIONS
• Traditional treatment of choice in talar OCD is still MFx.
• Concerns as compared to ACI (hyaline-like cartilage,
superior outcomes nature of repair, long-term results).

24. ACI TREATMENT OPTION
Unpopular in ankle joint despite ability to repair defects with hyaline-rich
cartilage, because of:
•Arthrotomy
•Malleolar osteotomy
•Source of morbidity

25. TALAR CHONDRAL DEFECTS-
LITERATURE REWIEW
– medial lesions are most often chronic and not necessarily associated with
specific trauma whereas lateral lesions are almost always traumatic.
– Lateral lesions may be more amenable to internal fixation for acute
injuries
– Lateral lesions have a better prognosis than medial lesions.
– Studies which lump medial and lateral lesions together are difficult to
interpret.
1. Treatment of osteochondral lesions of the talus: a systematic review. Zengerink M, Struijs PA, Tol JL, van
Dijk CN. Knee Surg Sports Traumatol Arthrosc. 2010;18(2):2β8-4ό.
2. Matrix-induced autologous chondrocyte implantation of talus articular defects. Giza E, Sullivan M, Ocel D,et
al. Foot Ankle Int. 2010;31(9):747-53.
3. Comparison of MRI and arthroscopy after autologous chondrocyte implantation in patients with
osteochondral lesion of the talus. Lee KT, Choi YS, Lee YK, et al. Orthopedics. 2010:1-33(8).
4. Autologous chondrocyte implantation of the ankle: a 2- to 5-year follow-up. Nam EK, Ferkel RD, Applegate
GR. Am J Sports Med. 2009;7(2):274-84.
5. Marlovits S. et al. Magnetic resonance observation of cartilage repair tissue (MOCART) for the evaluation of
autologous chondrocyte transplantation: determination of interobserver variability and correlation to clinical
outcome after 2 years. European Journal of Radiology 2006; 57(1): 16-23.

26. MATERIAL AND METHOD
• 7 patients (avg age 28 years) all recreational athletes
• R(5) and L(2) talus
• Between June 2008 and Feb 2010.
• Lesions location :
 medial aspect of the talus (4)
 lateral aspect of the left talus (2)
 central aspect of the talus (1)
• Avg size measuring : 3.1 cm2 (2.4-3.8)
• All type III- IV (Outerbridge scale).
• All underwent arthroscopy ipsilateral knee (1st stage ACI)
• Avg. F/U 12 months
• Pre-op and post-op evaluation was done using the AOFAS
Score, LYSHOLM & GILLQUIST score, Patient Outcome
Function score and Visual Analogue Pain score.

27. SURGICAL PROCEDURE

29. REHAB PROTOCOL
• Antibiotic and thrombosis prophylaxis are given for 48 hours and 3 weeks respectively.
• Hospitalization 2-3 d.
• A gait as close to normal as possible is practiced, as well as stair walking is gained before the patient
is discharged from the hospital.
• CPM (s.d.p through whole hospitalization/6-8 h per day).
• Active ROM exercises post 3rd d.p.o.
• Calibrated brace to allow motion of 15° plantar flexion and 15° dorsal flexion (6 w.p.o).
• P.W.B (20Kgr) with crutches, for the first six weeks.
• Gradual increase is commenced every week until full weight bearing is achieved in week 8 to 10.
• The rehabilitation continues, under the supervision of a physical therapist, with motion and
strength training.
• Once the brace is removed pool exercises can commence.
• As full weight bearing is reached gait training is started along with long distance walking and
bicycling.
• Functional exercises in closed chain are also incorporated in the rehabilitation program.
• Motion and proprioceptive training is continued throughout the rehabilitation, running and
plyometric exercises have to wait for six months.

30. RESULTS
• All the procedures progressed uneventfully.
• We assessed the patient at 6m and 1 y.p.o
• AOFAS score from 32.1 to 91
• Lysholm & Gillquist Score rose from 45.5 to 72.5
• VAS pain significantly reduced from 6.3 to 1.7
• Patient Outcome Function score showed
significantly better performance.
• MRI showed adequate filling of the defect without
significant graft-associated complications for the
same period (no significant bone marrow oedema).

31. 3D- Autologous Chondrocyte
Transplantation
Advantages: Disadvantages:
• Easy use/arthroscopic procedure • Expensive
• Cell-matrix ratio similar to that of the • Needs cartilaginous rim
natural cartilage • Cannot address cystic lesion without an
• Full coverage of the defect additional stage to procedure (bone
• Full integration of the newly produced grafting)
cartilage to the neighboring healthy • Further investigation is necessary to
tissue determine if this theoretical advantage
• Hyaline like cartilage of superior repair tissue results in
improved structural and biomechanical
• Large surface area may be repaired properties, and whether this translates
• Less hospitalization time into better long-term outcomes.
• Less medication needed
• Less pain experienced
• Continuous improvement
• No interruption of everyday lifestyle
• Return to sports without limitations

32. CONCLUSION
• ACT3D for treating talar and retropatellar chondral defects
preliminary results are very promising, can be performed fully
arthroscopically, reduce operative time, avoid patient having multiple
operations
• The whole procedure requires surgeon’s experience and coordinative
team
• Rehabilitation protocol is quicker due to minimal trauma.
• Await medium and long term results
• A greater number of cases and further mid and long term follow-up
has to be studied in order to prove the efficacy of the method.
• As far as we know this is the first publication in the literature
regarding 3nd generation ACI technique fully arthroscopically
performed, concerning retro-patellar & talar chondral lesions, in our
country.