RICOSTRUZIONE CON MSCs DELLE LESIONI CARTILAGINEE A STAMPO
DEL GINOCCHIO E DELLA CAVIGLIA:
RISULTATI A 2 ANNI
SICOOP , MILANO 22 GIUGNO 2012
STEFANO ZANASI
VILLA ERBOSA HOSPITAL
GRUPPO SAN DONATO
ORTHOPAEDICS DEPARTMENT
IIIRD DIVISION – JOINT ARTHROPLASTY OPERATIVE CENTER
CHIEF: STEFANO ZANASI M.D.
Costituiscono una popolazione residente nel
midollo osseo di cellule adulte non
differenziate capace di autorigenerarsi e
differenziarsi in cellule del tessuto
cartilagineo, del tessuto osseo, del tessuto
adiposo e nello stroma che supporta
l’ematopoiesi
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
B
(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
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
MSCs : 67 pts. from 05/09 to 05/10
for chondral knee defects
Outerbridge stage III/IV
according to Tom Minas’ classification
simple 30/67
16 sportmen
coin defect (troclea, patellar, condyle/s, emi-tibial plate)
complex 14/67
9 sportmen
shouldered 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 23/67
14 sportmen
shouldered, limited kissing lesions not requiring realignment procedure
unshouldered kissing lesions and uni-compartmental OA
concurrently with unloading/corrective osteotomy
39/67 sportmen
average age 25 ys (range 19 - 50) - 47% F
average defect size 3.5 cm2 (range 2.5 – 12.5cm)
Exemplificative case: salvage
D.A.O.F., male, 44 years old - grafted on 11/10/2009
Defect:
bilateral patello-femoral kissing lesion
Location:
massive involvement of the troclea and patella
Size:
TROCLEA 2.5X1.5cm and PATELLA 3X1.5 cm /right
TROCLEA 1.5X1.5cm and PATELLA 2X1.5 cm / left
Patient:
D.A. O.F., male, 44 years old.
History:
grafted concurrently on 11/10/2009,
using fibrin glue as sealing (2 patches to fill the defect).
NMR at 1, 3, 6 and 12months post op
arthroscopic 2nd look on 30/07/2011
Exemplificative case: salvage
D.A.O.F., male, 44 years old - grafted on 11/10/2009
Exemplificative case: salvage
D.A.O.F., male, 44 years old - grafted on 11/10/2009
Exemplificative case: salvage
D.A.O.F., male, 44 years old - grafted on 11/10/2009
6 ms f.up
Exemplificative case: salvage
D.A.O.F., male, 44 years old - grafted on 11/10/2009
Patient:
Arthroscopy Time:
18 months
Follow-up time:
18 months
Subjective Evaluation Score:
93.5
(improvement from baseline: 49.0)
Knee functional grade:
Normal
Cartilage repair assessment:
12
Exemplificative case: salvage
D.A.O.F., male, 44 years old - grafted on 11/10/2009
MOCART SCORING SYSTEM
AT 12 MS F-UP
A COMPLETE FILLING OF THE DEFECT
12 ms f.up
A COMPLETE INTEGRATION OF THE
BORDER ZONE TO THE ADJACENT
CARTILAGE
INTACT AND HOMOGENEOUS TISSUE
REPAIR
INTACT SUBCHONDRAL LAMINA AND
SUBCHONDRAL BONE
SCORE 95
Exemplificative case: salvage
D.A.O.F., male, 44 years old - grafted on 11/10/2009
2nd look at 18 ms. follow-up
STRONG COLLAGEN TYPE
II DEPOSITION
WELL-MATURED NEOCARTILAGE,
WITH STRONG
GLICOSAMINOGLYCANS DEPOSITION.
COLUMNAR
CHONDROCYTE
REARRANGEMENT
INSIDE THE
GRAFTED TISSUE
Exemplificative case: salvage
M.I., male, 23 years old - grafted on 11/1/2009
Defect:
postraumatic ankle OA
Location:
massive involvement of the talar dome and tibia
Size:
3x2/2.5 cm and 2.5x1.5 cm
Patient:
Malanga Ivano , male, 23 years old.
History:
grafted on 11/1/2009,
using fibrin glue as sealing
(2 patches to fill the defect).
NMR at 3, 6 and 9, 12, 18 months post op
MOCART SCORING SYSTEM
AT 12 MS F-UP
A COMPLETE FILLING OF THE DEFECT
A COMPLETE INTEGRATION OF THE
BORDER ZONE TO THE ADJACENT
CARTILAGE
INTACT AND HOMOGENEOUS TISSUE
REPAIR
SUBCHONDRAL LAMINA
SUBCHONDRAL BONE ALMOST
INTEGRATED
SCORE 85
Baseline Characteristics
CRFs analyzed: 56
IKDC: Subjective Knee Evaluation (n=67)
(Score 0-100)
Improved patients: 84.0 %
100
IKDC: mean score
90
79,3
Follow-up
80
70
60
50
40
Basal
34,3
30
20
10
0
mean time 18ms
Subjective IKDC
in relation to lesion type
SIMPLE, COMPLEX, SALVAGE
Improved patients: 100.0%
66.7%
Basal
94,0
100
90
IKDC: mean score
81.8%
72,4
80
72,4
70
60
50
40
36,6
41,2
28,9
30
20
10
0
SIMPLE
n= 30
COMPLEX
n=14
SALVAGE
n=23
Follow-up
Subjective IKDC in relation to
lesion size
Improved patients:
71.4%
88.9%
100
IKDC: mean score
90
80,7
75,7
80
Follow-up
70
60
50
40,3
32,0
40
30
20
10
0
2-4 cm2
Basal
>=4 cm2
EuroQol (EQ-5D) (N=67)
Pain/discomfort
Mobility
76
80
92
100
80,0
60
40
80
60
40
21,1
20
8,0
16
12 8
4,7
0
20
0
Pre-operatively
Follow-up
89,1
84,0
74,2
% patients
% patients
100
Reference
population*
16
8,0
0
Pre-operatively
10,7
0
0,2
Follow-up
Reference
population*
No pain or discomfort
No mobility problems
Moderate pain or discomfort
Some mobility problems
Extreme pain or discomfort
Confined to bed
Statistically significant improvement
(pain reduction)
(Wilcoxon signed rank test: p<0.0001)
Statistically significant improvement
in mobility
(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, 1
IKDC: Knee Examination
Normal/Nearly Normal: 95.3 %
90,5
100
80
%
57,1
60
40
20
23,8
19
4,8
4,8
0
Basal
Normal
Follow-up
Nearly normal
Abnormal
Statistically significant improvement
(Wilcoxon signed rank test: p<0.0001)
High-resolution 1.5T MRI was used to analyze the repair tissue
with nine pertinent variables.
A COMPLETE FILLING OF THE DEFECT was found in 92.5%,
A COMPLETE INTEGRATION OF THE BORDER ZONE TO THE ADJACENT
CARTILAGE in 94.1%.
AN INTACT SUBCHONDRAL LAMINA was present in 84.6%
AN INTACT SUBCHONDRAL BONE was present in 76.5%.
Isointense signal intensities of the repair tissue compared to the adjacent
native cartilage were seen in 92.3%.
AVERAGE VALUE OF 78/100
Arthroscopic Evaluation (N=4)
Brittberg Score (1-12) Mean score: 11.4
Mean arthroscopic time from grafting: 17.3 months
100 %
Significantly improved
appearance of the tissue
100
% patients
80
Total scaffold biodegradation
55,6
Complete and uniform
fibrocartilagineous tissue
44,4
60
resurfacing
40
discrete mechanical
20
0
0,0
Normal
Nearly
normal
Abnormal
0,0
Severely
abnormal
resistence to probe palpation
Areas of uneven cartilage
stiffness
2nd-Look Biopsy Evaluation
4 samples analyzed (mean time: 18 months)
Hyaline-like:
Mixed tissue:
Fibrocartilage:
H&E
2
1
1
Based on criteria of cellularity,
cell distribution, matrix
composition and collagen type I
and II immunolocalization
Hyaline-like phenotype
Safranin-O
Polarized Light
PRELIMINARY CONCLUSIONS:
resurfacing by MSCs
• Normal post-op without serious adverse events
correlated to the graft
• 6/56 cases of increased temperature (<39°)
completely ceased within 7 days
• clinical sympthoms (pain, effusion, catching, givingway) 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
2nd look arthroscopy at 12 ms f. up: biopsy DEMONSTRATES
2.5x
20x
STRONG STAINING
FOR GAGS
HIGH CONTENT
AND UNIFORM
DISTRIBUTION OF
TYPE II COLLAGEN
ABSENCE
OF TYPE I COLLAGEN,
CELL CLUSTERING
AND COLUMNAR
ORGANIZATION
THE MATURATION
OF IMPLANTED TISSUE ENGINEERED
CARTILAGE
TO A CLEAR HYALINE-LIKE PHENOTYPE
WITH 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
THE MATURATION
OF IMPLANTED MSCS
TO A CLEAR FIBRO-HYALINE-LIKE PHENOTYPE
WITHOUT PECULIAR CELL ORGANIZATION
PRELIMINARY CONCLUSIONS:
MSCs RECONSTRUCTION
Need to verify the results at 3 and 5 years to
appreciate the
quality of the reconstructed tissue
and the
Maintainance/IMPROVEMENT
of the (FIBRO)cartilage quality
(no degenerative changes?)
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