Satellite Symposium, Izmir Turkey

Chondral Defect Reconstruction with Hyaluronic Acid Scaffold (HyaloFast®) and Autologous Bone Marrow

Aspirate Concentrate

M. Spoliti M.D., F.R. Rossetti M.D.

San Camillo Hospital – Rome,ITALY

9/6/13 1

Articular Hyaline cartilage has a limited regeneration capacity

In 1743 W.Hunter Stated that :

“from Hippocrates to the present age, it is universally allowed that ulcerated cartilage is a troublesome thing and that when destroyed, it is not recovered”

Autonomous hyaline cartilage defect regeneration is due to infiltration of Mesenchimal Stem Cells (MSCs) from the bone marrow , through perforation/microfracturing the subchondral bone.

Unfortunately the reparative tissue consists of fibrocartilage.

This newly formed and less resistant tissue, could have a breakdown expecially in young active competitive patients.

Minas & Nehrer 1997, Shapiro 1993

To produce cartilage of BETTER QUALITY, as yet unidentified

FAVOURABLE CONDITIONS MUST BE CREATED.

REPAIR OF LARGE FULL-THICKNESS ARTICULAR CARTILAGE DEFECTS IN THE RABBITTHE EFFECTS OF JOINT DISTRACTION AND AUTOLOGOUS BONE-MARROW-DERIVED MESENCHYMAL CELL TRANSPLANTATIONT Yanai et Al , JBJS Br 2005

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Composed of:-Chondrocytes (1-10%)-Extra-Cellular matrix• Water (65-80%)• Collagen (90-95% of type II)• Proteoglycans• Other matrix proteins and lipids

It is avascular, alymphatic, and aneural, nutrition through diffusion from the synovial fluid.

Its lack of vascularity, high extracellular matrix to cell ratio, and lack of progenitor cells, leads to its limited capacity to self-repair injuries.

Articular Cartilage (Buckwalter et al. 1994)

P.Motta” La Sapienza” University Rome

Therapeutic Goals of Articular Cartilage

Repair • To resolve or at least alleviate the symptoms

• Ensure the functional recovery of the movement

• Restore the integrity of the articular surface

• Prevent further deterioration of the tissue

The final goal should be to produce a repair tissue that has the same

functional and mechanical properties of the original hyaline articular cartilage to prevent osteoarthritis.

(Jackson, Scheer et al., 2001)

Treatment procedures (Nehrer, et al. 2000; Felson, et al., 2000).

Symptomatic procedures

Repair procedures

Regenerative procedures

• Subchondral drilling

• Microfracture

• Osteochondral transplantation (OCT)

• Periosteal or perichondral grafting

• Autologous chondrocyte transplantation (ACT)

• One-step mesenchymal stem cells techniques (MSCs)

• Lavage, Shaving, Debridmen , Abrasion arthroplasty

Biological restoration: tissue repair/regeneration based on cells or living tissues

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Regenerative Techniques

The goal of these techniques is to restore the articular surface with a newly-formed hyaline-like tissue having physical, biomechanical and durability properties as similar as possible to the native cartilage.

• ACI and MACI (Auotologous Cultured Chondrocytes)

• New one-step techniques with scaffolds+MSC

ACI and MACI (Auotologous Cultured Chondrocytes )

Transplantation of cultured autologous chondrocytes into the cartilage defects to

regenerate hyaline articular cartilage.

Two-step technique:

1st surgery: arthroscopic biopsy collection

2nd surgery: arthroscopic graft implantation

ACI 1st generation MACI 2nd generation

Disavantages:• two surgeries•high costs•Graft not immediatly

available

Good clinical results at long term follow up, but…

The use of autologous bone marrow-derived MSCs in the treatment of

osteochondral lesions, represents an opportunity allowing, at the same time:

•the restoration of both cartilage and sub-chondral bone tissues

•AVOID A TWO-STEP surgical procedure (less invasive, lower cost)

One-step techniques with scaffolds + MSCs

The source of autologous MSCs can be:

1.bone marrow from subchondral bone at the lesion site (microfracture)

2.bone marrow aspirate, collected from the iliac crest, concentrated or not and then applied on the defect site.

A limitation is that MSCs are simply released (1) or applicated (2) into the joint,

rather then being contained at the site of the defect.

Free MSCs? Free MSCs?

Some papers found only a small number of MSCs in the implant site after 10 days

(5% of the implanted BM-MSCs).

Guest DJ, Smith MR, Allen WR. Equine embryonic stem-like cells and mesenchymal stromal cells have different survival rates and migration patterns following their injection into damaged superficial digital flexor tendon. Equine Vet J 2010

The goal is the appropriate scaffold The goal is the appropriate scaffold

MSCs NEED A SCAFFOLD FOR SUPPORT• To stay and grow at the defect site • To build a 3D structure of hyaline-like tissue

In order to stabilize the blood clot at the defect site, reasorbable

scaffolds are developed to enhance cartilage regeneration

One-step techniques with scaffolds + MSCs

The Ideal Scaffold

• Resistant (Arthroscopic implant)

• Tridimensional • Absorbing • Allowing good cellular adhesion• Enhancing MSCs proliferation• Biodegradable • Biocompatible • Promoting cell differentiation towards chondrogenetic and/or osteogenic

phenotype• Handful

HYAFF 3D-Scaffold

• Non woven felt, 2 mm thick, fiber diameter 10 microns.• Biocompatible• Bioresorbable • Main degradation product: Hyaluronic Acid

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AUTOLOGOUS CELLS IMPLANT

• 2-steps surgery

• High costs

• No bony defect regeneration

• Good results

• Hyaline like cartilage

• Single step surgery

• Less expensive procedure

• Bony regeneration

• Results (?)

MACI vs BM - derived MSCs

Knee chondral defects:

• III - IV degree (According to Outerbridge classification)

•area > 1-5 cm2

RESUMING

Our case series

• 163 chondral defect of the knee (III-IV degree)• Age range 15-51 y• mean age 36 y• Last 4 years

• 39 MACI• 17 MSCs• 43 microfractures + HialoFast • 51 microfractures• 13 OATs

Defect size• 64 < 1 cm2

• 99 >1 -5 cm2

>1 -5 cm2

< 1 cm2

Inclusion criteria:

• Defect: III° - IV° degree

• Width: 1- 5 cm 2

• Age range: 15-50 years old

Exclusion criteria:

• Arthritis

• Scheletrical malalignement

• ACL-PCL tear

• Patellar instability

• Kissing lesions

Comparison MACI vs MSCs Implant

Study

Comparison MACI vs MSCs Implant

Group 1 - 17 cases MACI (Two-step procedure ):Mean age: 35,8 years (range15-49)

Gender: 10 M + 7 F

Defect location: 2 patella ,1 tib.plateau ,5 lat. condyle, 9 med. condyle

Mean follow-up time: 30,5 months (range 3 months to 4 years)

Defect Size: 6 Pts >1/= 2 9 Pts >2 =3 2 Pts >3

Group 2 - 15 cases (BMAC)+ Hyalofast:Mean age: 31,9 anni (range19-42)

Gender: 11 M + 4 F

Defect location: 2 patella, 2 lateral condyle, 5 medial condyle, 2 troclea

Mean follow-up time: 10,1 months (range 5 to 26 months)

Defect Size: 3 Pts >1/= 2 7 Pts >2 =3 2 Pts >5

Study

MACI Implant Protocol

• 2nd surgical step: arthroscopic graft implantation

• 1st surgical step: cartilage biopsy collection

• Chondrocites in vitro expansion, seeding and culture on 3D HA matrix (Hyalograft C autograft).

Study

•Harvest the bone marrow from postero-superior iliac crest, with the patient in the lateral decubitus (60 mL of bone marow).

•Process the collected bone marrow directly in the operating room by removing erythrocytes and plasma by a cell separator-concentrator consisting of a centrifuge and a disposable double chamber.

•At the end of a 15 min centrifugation cycle, 7 mL of concentrate containing nucleated cells (stem cells, monocytes, lymphocytes, and other bone marrow resident cells) are retrieved in the anterior chamber.

•3ml/cm2 of BMAC can be loaded onto the scaffold together with the PRP gel and thrombin; the matrix, due to its hydrophilic properties, allows the homogeneous distribution of the concentrate fluid rapidly.

•The pre-loaded scaffold can be implanted by arthroscopic technique

MSCs implant protocolStudy

MSCs Implantation: Arthoscopic Technique

Study

Study

MSCs Implantation: Large troclear defect

Immobilization: first 24 hours

Back to Sports: Low impact from 4th month (swimming, cycling)

High impact from 10th month (running, soccer, tennis, etc…)

Control Passive Motion (CPM): after 24 hours, for 4 weeks

Joint Loading: not allowed for about 6 weeks. 6th-10th week: gradual recovery of the joint loading and of the step

Post-operative Rehabilitation

KEY POINTS

Study

Follow up evaluations

Clinical evaluations: •IKDC subjective: pre-op, 5 months, 10 months•Tegner score: 10 months follow up

•MRI assesment: •all patients underwent MRI evaluation at 3- 6 -12 - 24 months

•Cartilage repair evaluations: 3 Pts group 1 and 3 Pts group 2 2° look arthroscopy with biopsy and histology

Clinical ResultsPatient . Age Follow-up IKDC (pre-op) IKDC (5 m) IKDC (10 m) Tegner score (10

m)B.B. 35 4 Y 32 90 88 7S.A. 48 9 M 53 95 90 7P.F. 46 3 Y 25 70 75 5P.M. 23 2 Y 35 84 84 9D.D. 15 2 Y 30 89 98 9V.M 42 10 M 27 85 80 7L.D. 34 1 Y 36 85 83 9P.M. 44 1 Y 35 76 80 7P.L. 49 4 Y 23 45 49 4C.E. 21 2 Y 41 90 95 8P.A. 47 4 Y 33 74 88 6G.R. 45 4 Y 31 51 74 5B.B. 37 4 Y 40 73 89 5M.S. 23 3 Y 25 80 85 7A.G. 24 2 Y 19 85 87 9M.G. 49 11M 17 80 77 6D.S. 28 1 Y 51 75 65 4

Summary of MACI case series – Group 1

IKDC pre - op: 32,5 Poor TEGNER post op 10 m: 6.7

IKDC post- op 5 m: 78,5 Excel.

IKDC post- op 10 m: 81,6 Excel.

Patient Age Follow-up IKDC (pre-op) IKDC (5 m) IKDC (10 m) Tegner score (10 m)

B.A. 28 2 Y 25 85 89 9B.B. 42 18 M 35 88 76 7C.M 22 1 Y 30 90 95 8S.L. 40 1 Y 27 45 55 4R.V. 35 2 Y 36 73 75 6P.M. 25 10 M 35 85 88 6T.G. 27 11 M 23 74 85 6M.D 33 18 M 41 72 83 7R.M 29 2 Y 33 90 90 9S.G. 41 10 M 31 85 80 7M.L 32 3 Y 40 93 87 8N.V. 19 1 Y 25 91 65 7G.O. 42 16 M 29 72 77 6F.O. 39 17 M 27 77 81 7M.N. 25 15 M 45 84 76 7

Summary of MSCs + scaffold case series - Group 2Clinical Results

IKDC pre - op: 32,1 Poor

TEGNER post op 10 m: 7IKDC post- op 5 m: 80,2 Excel.

IKDC post- op 10 m: 80,1 Excel.

MRI Results

Uniform post-operative NMR evolution :

•3 months: subchondral bone edema important

•6 months: substantial reduction in subchondral edema

•12 months: disappearance of edema

• In the following assessment, we have found the coverage of the areas of chondropathy with integrity and restoration of the articular surface of the joint lining

3 M

6 M

MSCs implant

MSCs implant

MRI Results

24 months: there is a slight remodeling of 'subchondral bone, that means a cartilage still in the remodeling process.(in agreement with the results of Marcacci 2005).

MSCs implantMACIMACI

A B C D

E F G H

3 M 12 M

24 M 3 Y

FMSCs implant MACI MSCs implant MACI

MSCs implant MACI MSCs implant MACI

MRI Results

MACI 2nd look

D

SECOND LOOK 24 MONTHS

MSCs 2nd look

SECOND LOOK 6 MONTHS

On the basis of the results of this ongoing study, MSCs implantation via one-step regeneration procedure at present is a viable and lower cost alternative compared to two step techniques.

With confirmed long-term results, one-step technique could eventually replace autologous chondrocyte implantation.

Furthermore, the use of MSCs implantation allows us to treat via a "one-step“ technique associated lesions, such as meniscal or ligament tears .

Conclusions

BEWARE!!!!!In order to be effective in joint tissue regeneration, MSCs seem to need a

scaffold for :•Improving bone marrow handling

•Favouring cells attachment and organization at the lesion site

•Stimulating MSCs differentiation into chondrocytes and proper reorganization of the osteochondral compartment

The lack of a guide and containment in situ (osteo-chondral defect) leads the potential of these cells to a "wild” regeneration pattern.

Some PRP gel can add a supplement of growth factors to stimulate cell

differentiation and optimize implant stability.

www.marcospoliti.com