STEFANO ZANASI
VILLA ERBOSA HOSPITAL
GRUPPO SAN DONATO
ORTHOPAEDICS DEPARTMENT
IIIRD DIVISION – JOINT ARTHROPLASTY OPERATIVE CENTER
CHIEF: 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/soccer
Rugby
Volleyball
Basket
Ski
tennis
Cartilage injury is due to
- single trauma (sprain) or to
- overuse for repetitive microtraumatism
in athletic gesture
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
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
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
Trattati
dal 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 lesion
Location:
centro- medial area of LEFT/RIGHT patella
Size:
1.5 x 2.5 cm
Patient:
C. V., male, 28 ys. football player
Symptoms:
Severe pain, locking, giving-way, recurrent effusion
History:
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
C.V., male, 28 years old - grafted on 11/04/2009
2nd look at 12ms.f.up
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
RMN AT 12 MS
C.V., male, 28 years old - grafted on 11/04/2009
2nd look at 12ms.f.up - HYSTOLOGY
LOW CONTENT
AND NOT-UNIFORM
DISTRIBUTION OF
TYPE II COLLAGEN
LIGHT STAINING
FOR GAGS
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 simple
C.D, male, 18 years old - grafted on 19/01/2002
Defect:
coin lesion
Location:
medial femoral condyle
Size:
2 x 2.5 cm
Patient:
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
C.D, male, 18 years old - grafted on 19/01/2002
ARTHROSCOPIC ACI TECHNIQUE
DEVELOPED
BY M. MARCACCI
C.D, male, 18 years old - grafted on 19/01/2002
2nd 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
C.D, male, 18 years old - grafted on 19/01/2002
2nd look artroscopy at 18 ms f.up
STRONG COLLAGEN TYPE II
DEPOSITION
WELL-MATURED NEOCARTILAGE, WITH
STRONG GLICOSAMINOGLYCANS
DEPOSITION.
COLUMNAR
CHONDROCYTE
REARRANGEMENT
INSIDE THE GRAFTED
TISSUE
In collaboration with: Prof. A. HOLLANDER, University of Bristol.
EuroQol (EQ-5D) (N=25 ACT VS 25 MSCs)
Pain/discomfort
85.0
100
% patients
74.2
60
40
20
8.0
18
16
21.1
15
60
40
20
0
0
Pre-operatively
MSCs
ACT
Reference
population*
89.1
86.0
80
4.7
0
0
% patients
76
80
Mobility
90.0
92
100
82.0
14
8.0
0
Pre-operatively
10
ACT
No pain or discomfort
No mobility problems
Moderate pain or discomfort
Some mobility problems
Extreme pain or discomfort
Confined to bed
Statistically significant improvement
similar for both groups (pain reduction)
(Wilcoxon signed rank test: p<0.0001)
0.2
0
0
MSCs
10.7
Reference
population*
Statistically significant improvement
in 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
PRELIMINARY CONCLUSIONS:
resurfacing by MSCs
• 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, 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
PRELIMINARY CONCLUSIONS:
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
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
MSCs
ACT
cartilage defect </= 4 cm2
simple
shouldered
cartilage defect> 4cm2
Good functional/clinical results
Good (?) % of hyaline tissue
Good functional/clinical results
Good % of hyaline tissue
duration?
14 yrs f.up
Short term Evaluating results
Long term Validated results
Simple wide, Shouldered
Complex-salvage
to delay implant arthroplasty
C.D, male, 18 years old - grafted on 19/01/2002
2nd look artroscopy at 18 ms f.up
EXCELLENT INTEGRATION OF THE NEOFORMED
TISSUE WITH THE SUBCHONDRAL BONE.
THE TYDE-MARK IS DEVELOPING
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 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 13/56
11 sportmen
shouldered, 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)