1 resorbable meniscus scaffold for the treatment of partial meniscal tear or meniscal loss p.djian,...
TRANSCRIPT
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Resorbable meniscus scaffold for the treatment of
partial meniscal tear or meniscal loss
P.Djian, P.Beaufils, J Bellemans, P.Colombet, R Cugat, H Laprell, P.Neyret, H Paessler, E.Servien,
R.Verdonk, P. Verdonk
JOFDOF Martinique les trois ilets 2010
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No potential financial disclosure
Presenters Financial Disclosure
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Introduction
• The potential detrimental outcome following partial meniscectomy has been well establish
• Symposium SFA 1995 : – 95 Partial meniscectomies – F.U : 11.5 ± 1.2 Y– 45 % arthrosis
• Symposium SFA 2008– 47 partial meniscectomies– FU : 22.5 Years– 100 % arthrosis 3
a b c d
(a): Intact meniscus (b): partial meniscectomy (c): scaffold implanted knee (d): fully meniscectomized knee
Tibial Plateau Load Transmission*
*Ovine Model (HSS)7
Current Standard of Care
Partial Meniscectomy
Mechanical imbalance
in the knee joint
Addresses symptoms only
Biomechanical Cadaver Study
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THE SPORT SURGEONS NEED:
• A means to replace lost tissue and to reinforce remaining tissue post meniscectomy
• Ideal Product Requirements:
– Biocompatible
– Timely biodegradation
– Promotes blood vessel and tissue ingrowth
– Provides chondroprotection
– Easy to insert and suture arthroscopically
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THE ORTEQ SOLUTION
The Optimum Material
+
An Optimized Design
Results in:A new vascularized and functional meniscus
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[i] Ghadially FN, Lalonde JM, Wedge JH (1983);136:773-791.[ii] King D. (1936) J Bone Joint Surg 18:1069-1076.
THE IRREPARABLE MENISCUS
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The Actifit™ concept
Partial meniscectomy Tissue regeneration through
vascular ingrowth and cellular
infiltration from the synovium and
the meniscal rim
Regenerated tissue next to
meniscal tissue
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Dimensions and shape based on human meniscus
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INDICATION• Irreparable medial or lateral partial meniscal tear
• Intact rim
• Anterior and posterior horn present
• Stable knee joint or stabilization procedure within 12 weeks
• (BMI) < 35 kg/m2
• Axial alignment
• ICRS classification ≤ 3
• Full understanding of importance to adhere to rehabilitation
program 8
SURGICAL TECHNIQUE:
• Debride the damage
• Measure defect
• Cut the scaffold
• Insert into defect
• Suture in place
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Safety and Efficacy Study
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Study CentersNAME• Prof R Verdonk• Dr P Beaufils• Prof P Neyret• Dr H Paessler• Dr R Cugat• Dr P Colombet• Dr H Laprell• Dr P Djian• Prof J Bellemans
AFFILIATION• University Hospital Gent• Centre Hospitalier de Versailles• Centre Livet de Lyon• Atos Praxisklinik Heidelberg• Hospital Quirón de Barcelona• Clinique de Merignac-Bordeaux• Lubinus Clinicum of Kiel• Institut Nollet Paris• University Hospital Pellenberg
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OBJECTIVES– Safety
o Adverse event profile (ongoing)o Gross examination at 12 months relooko Device stability and cartilage score on MRI (3, 6, and 12
months)– Performanceo Tissue ingrowth
• Dynamic Contrast Enhanced MRI (3 months)• Tissue Biopsy (12 months)
– Efficacyo Pain
• VAS (Baseline, 1 week, 3, 6,12 months)o Functionality
• IKDC, KOOS, Lysholm (Baseline, 3, 6, 12 months)
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Study Population
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Enrolment : March 2007- April 2008
Enrolled: 52 subjects (34 M / 18 L)
Withdrawn before 3 month follow-up:1 post-operative infection
Major protocol violations: 8 subjects (5 M / 3 L)of which 3 withdrawn (2 M / 1 L)
Baseline characteristics
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Medial Lateral
N = 34 N = 18
Age (years)
Mean ± SD: 33.4 ± 9.4 25.8 ± 8.5
Sex (n)
Male: 25 (73.5%) 14 (77.8%)
Female: 9 (26.5%) 4 (22.2%)
Longitudinal length (mm)
Mean ± SD: 48.8 ± 10.4 43.9 ±8.6
Previous surgeries on index knee*
No previous surgery on index knee 2 ( 3.8%)
One previous surgery on index meniscus 34 (65.4%)
Two previous surgeries on index meniscus 12 (23.1%)
* Missing data on 4 subjects
Baseline characteristics
Safety No Serious Adverse Device Events Six Serious Adverse Event:
Subject number Description of SAE
01‑002* Allograft transplantation / investigational device removal
01‑005* Medical device removal
01-013 Cartilage graft
01‑023* Knee arthroplasty / investigational device removal
06‑001 Myocardial infarction
07‑004 Post operative infection with investigational device removal
* Subjects 01-002, 01-005 and 01-023 did not fulfill the inclusion criteria and were considered protocol violators.
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Safety AE profile similar to that reported in the literature
for meniscal surgery and meniscal implants.
Overall, 29 (55.8%) subjects reported an AE (20 M / 9 L)
Majority of AEs were mild or moderate in intensity.
7 subjects experienced AEs considered probably or possibly related to the device.
22 subjects experienced AEs considered related to the meniscus repair procedure.
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Results
• Clinical data :– KOOS Score– IKDC Score– VAS – Lysholm score
• Anatomic control– Relook at one year post-op
• Biopsie and histological control
– MRI 1 week, 3 MO, 6 MO, 12 MO• Special interest for vascularization 2
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Clinical Data : Efficacy
3 Months data available for 51 subjects
6 Months data available for 51 subjects
12 Months data available for 50 subjects
18 Months data available for 30 subjects
Parameters:
VAS
KOOS
IKDC
Lysholm score
*p=0.007
22.9 point change in mean VAS from baseline*
Efficacy at 12 Months
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Efficacy at 12 Months
24.8 point change in mean IKDC from baseline*
*p=0.0012
22.4 point change in mean Lysholm from baseline*
*p=0.0036
Efficacy at 12 Months
KOOS Symptoms
*p=0.0371
13.4 point change in mean KOOS Symptoms from baseline*
Efficacy at 12 Months
*p=0.0117
16.7 point change in mean KOOS Pain from baseline*
Efficacy at 12 Months
*p=0.0197
16.2 point change in mean KOOS Daily Living from baseline*
Efficacy at 12 Months
*p=0.0020
30.7 point change in mean KOOS sports from baseline*
Efficacy at 12 Months
*p=0.0143
21.9 point change in mean KOOS quality of life from baseline*
Efficacy at 12 Months
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Anatomical results
• Relook at 1 year FU– Biopsie and histological evaluation
– 27 biopsies samples• No signs of necrosis or cells death• Biocompatibility• Successful tissue ingrowth• No loose fragments of scaffold
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Relooks
L-M 8001
Photos courtesy of Dr Djian, Paris, France
Relooks
R-L 1016
Photos courtesy of Professor R Verdonk, Ghent, Belgium
Relooks
9003
Photos courtesy of Professor Bellemans, Leuven, Belgium
Histology Results
Biopsy from center of free inner edge
N= 27
Histology Results
Fibrous capsule (C)
layer 1: vascular, hyper cellular
layer 2: avascular, transition zone
layer 3: avascular, hypo cellular
Fibrous capsule
layer 1: vascular, hyper cellular
layer 2: avascular, transition zone
layer 3: avascular, hypo cellular
Histology Results
CD 34 IHC (200x) showing capsule, formation of vessel “sprouts” (arrows) in layer 1
Capsule and Layer 1
Histology Results
Histology Results
Sirius Red stain (400x) Layer 2 fibroblasts (short arrow) and fibrochondroblastic-like cells
(long arrow)
Layer 2
Histology Results
H&E staining : chondroblast like cells in layer 3
Layer 3
Histology Results
Immunohistochemistry (400x) with positive cartilage marker S100
Layer 3
Imaging Protocol Anatomic MR imaging at 1 week, 3, 12 and 24
months post-implantation
Dynamic Contrast Enhanced MRI (DCE-MRI) at
3 months Imaging in first 3 minutes after IV gadolinium injection
Influx of gadolinium causes increase in the signal Intensity
(SI) of a tissue
Signal enhancement is primarily determined by
vascularization, but also by perfusion rate and capillary
permeability[1, 2]
Increase in SI in the first 3 minutes can only be explained
by the presence of blood vessels
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Imaging Findings1 Week
No loosening of sutures or tears of the
scaffold were found.
All scaffolds had a normal position of
the posterior horn.
Some mild or moderate extrusion of
the body of the scaffold was observed.
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Imaging Findings3 Months
Increased enhancement observed in the peripheral half of the scaffold,
and thus evidence of tissue ingrowth into the scaffold in 36/42 (85.7%)
subjects with DCE-MRI at 3 months post-implantation.
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Imaging Findings3 Months
In 32 out of 48 subjects complete filling of the meniscal defect was observed.
17 subjects had slight (<33%) external displacement and 10 had moderate (>33%, <66%)) external displacement of the body of the scaffold meniscus.
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Imaging Findings12 Months In all subjects tissue gain was achieved with complete fill of the
meniscal lesion in 10 out of 33 subjects.
Complete filling of the meniscal defect at 12 months in subject with an autologous osteochondral plug transfer to repair a pre-study osteochondral defect overlying the scaffold.
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Imaging Findings12 Months
3/33 subjects had improved cartilage scores in the index compartment.
Filling of cartilage defect in the area overlying the tissue populated scaffold.
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Imaging Findings12 Months 3/33 subjects had a deteriorated cartilage scores in the index compartment.
Of these, two had generalized deterioration of the knee and one had developed a focal defect in an area not in direct contact with the scaffold.
Focal defect in area not adjacent to scaffold
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Discussion
• No comparative data
• Need to augmente the F.U.
• Cartilage status 15 years F.U
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Discussion
• Prospective study
• Clinical data and safety evaluation
• Anatomical evaluation with relook and biopsies
• MRI and vascularization 50
• Safe– No SADEs– Biocompatible
• Vital cell populations in all biopsies
• Promotes ingrowth of meniscus like tissue in 85.7% – Meniscus like morphology in biopsies– Positive staining for chondroblasts
• Effective– Significant improvements of pain and functionality
• Easy to use– Sizing, cutting, positioning, suturing
– Visible on MRI44
Conclusion
Actifit™ is a safe, novel solution
for the treatment of
irreparable, partial, meniscal
defects45