Orthopaedics vs OrthoBiologics The next stage: new developments which may delay or avoid more invasive surgical

treatments. The future of orthopaedics: basically, less carpentry, more biology?

Prof. Vladimir Bobić, MD FRCS Ed Chester Knee Clinic www.kneeclinic.info office@kneeclinic.info @ChesterKnee

Nuffield Health, The Grosvenor Hospital Chester Seminars St. David’s Park Hotel, Ewloe, 7th October 2017

From Chondral Damage to Advanced OA

... to Advanced Medial OA?From Small MFC Chondral Lesion ...

Osteochondral Repair and OA: Surgical Options

ACI BioPoly

UKR & TKR

OATS

Microfracture

Chondroplasty

20172017

OrthoBiologics or BioOrthopaedics

Biotechnologies - Stem Cell Technologies already here and as important as Artificial Intelligence, Robotics, Micro and Nano satellites, Biofuels, Additive

manufacturing…

1st Orthopaedic Stem Cell Seminar in the UK

Regenerative Medicine - Stem Cell Technologies

Not so soon, but …

The Subchondral Unit: A New Frontier

re-drawn from Imhof et al. 1999

Henning Madry, Saarland University, Homburg/Saar, Germany

Imhof H, Breitenseher M, Kainberger F, Rand T, Trattnig S. (1999): Importance of subchondral bone to articular cartilage in health and disease. Top Magn Reson Imaging 10:180–192

The Structure of Subchondral Bone

Redrawn from: Imhof H, Breitenseher M, Kainberger F, Rand T, Trattnig S. (1999): Importance of subchondral bone to articular cartilage in health and disease. Top Magn Reson Imaging 10:180–192

A surprisingly high number of arterial and venous vessels, as well as nerves, can be seen in the subchondral region sending tiny

branches into the calcified cartilage …

CKC GNH Chester UK CKC GNH Chester UK

MR and Arthroscopic Cartilage Imaging

Microfracture13

14

Subchondral MR Imaging

Source: Carl Winalski, BWH, Boston 15

Intralesional Osteophyte after Microfracture

16

MFC Microfracture site after 5 years

17

OATS Indications:

• The “ideal” chondral lesion is relatively small, full-thickness defect (10 to 15 mm in diameter), without subchondral bone loss. • This lesion should be treated early, in an attempt to contain the defect and to repair the lost hyaline cartilage with hyaline cartilage.

Osteochondral Autograft Transplantation (OATS)

Autologous Osteochondral Grafting (OATS)

19

• Conclusions: Delivery of bone marrow concentrate can result in healing of acute full-thickness cartilage defects that is superior to that after microfracture alone in an equine model.

• If this is the case, looking at osteochondral defects, is this combination working better because microfracture (multiple perforations and tunnelling) of subchondral bone is making it less stiff but also allows “biologic fuel” (bone marrow, blood and who knows what else) to reach deeper areas, re-establish nutrition and facilitate local osteochondral repair?

ABMA: An Essential Ingredient for Octeochondral Repair?

JBJS A August 2010

Lateral Femoral Trochlea: a reliable source of good cancellous bone and bone marrow, even in advanced OA

CKC UK

MFC AVN

An alternative approach to the treatment of femoral and tibial Osteonecrosis, Chronic SONK and Secondary OA:

• The knee is often not too bad (all 3 compartments) or it is too early for a partial or a full knee replacement.

• Classic Microfracture and Core Decompression are probably not deep enough.

• Looking at most MRIs it seems that we need to reach at least 15 to 20 mm deep into subchondral bone, which is where any cylindrical osteochondral harvesters are very handy.

• Effectively, this is a combination of OAT and deep core (subchondral) decompression, with a hand driven K-wire, through the bottom of the recipient socket, with

• a mixture of autologous blood + bone marrow injected into the recipient socket,

• and capped with 10 mm OATS plug, which was soaked in the same mixture of bone marrow and blood.

• This “integrated” subchondral repair concept makes sense, it gives most people quick and durable pain relief and better knee function, but it is based on huge assumptions.

• The main question is weather unprocessed (and not concentrated) autologous bone marrow, is powerful enough biologically?

CKC UK

“Pre-TKR” option: OATS combined with autologous bone marrow aspirate

ACI (Autologous Cultured Chondrocyte Implantation)

periosteal cover

ACI is the very first tissue engineered orthopaedic (orthobiologic) surgical

procedure atlas

CCI Stage 1: Arthroscopic Chondral Biopsy

CKC Chester UK

CCI Stage 2: Open Implantation

Source: www.geistlich.com

Good ACI graft fill, a year after ACI

A game changer …

OsteoArthritis or OsteoArthrosis? or just wear and tear?

Regenerative Medicine - Stem Cell Technologies

What are Mesenchymal Stem Cells?

• Adult stem cells can help regenerate many tissues

• The best source is the autologous tissue

• Many different tissues can be used to process biologically powerful stem cells

• It seems that the best tissue to extract MSC is SVF (stromal vascular fraction) adipose tissue, which is the best source of cells and regenerative factors

Well, MSCs are NOT Stem Cells!

The MSC: an injury drugstore

MSCs and Blood Vessels

“The first great advancement in sports medicine was the arthroscope, the second is going to be this (stem cells).” James Andrews, MD, “The Athlete’s Surgeon”, Birmingham, Alabama, USA

OJSM 2017

In adults, stem cells act as a repair system for

the body. They allow replacement of ageing

and damaged cells in organs.

In adults, damaged tissue is usually replaced

with scar tissue which loses most of its original

function. Stem cell therapy has the potential to

restore the original structure and function of

the damaged tissue.

Researchers believe that stem cell therapy could

dramatically improve medical treatment, espe-

cially in the field of regenerative medicine.

Adult Stem Cells

KLSMC STEM CELLS

Stem Cells

KUALA LUMPUR SPORTS MEDICINE CENTRE

INFORMATION FOR PATIENTS

7th Floor, Wisma Perintis,

47 Jalan Dungun, Damansara Heights, 50490 Kuala Lumpur, Malaysia. Tel: +603 2096 1033

Fax: +603 2096 1500

Stem Cell Enquiry: +603 2089 5239 E-mail: enquiry@klsmc.com

Website: www.klsmc.com

Outpatient Clinic Hours Monday to Friday ( 9am to 5pm ) Saturday ( 9am to 1pm )

KUALA LUMPUR SPORTS MEDICINE CENTRE

Location Map

Parking is available in the basement P

Saw et al.: Arthroscopy 2013

Saw et al.: Arthroscopy 2011

Gradual Regeneration of Articular Surface

SVF Adipose Tissue MSCs

13th ICRS World Congress, Sorrento September 2016

Stem Cells No Better Than Placebo … So Far (Editor of Arthroscopy Journal re JBJSA September 2016 Article)

PRP Today

Arthroscopy Journal, article in press, 2015

PRP

Too old for stem cell therapy? Probably not!Cell apoptosis and senescence do exist but basic biological

healing principles persist.

“Youth would be an ideal state if it came much later in life.” Herbert Henry Asquith

Thank You. If you would like a copy of this presentation please email me: vbobic@me.com

The Future is Cellular!