STEFANO ZANASIVILLA ERBOSA HOSPITAL
GRUPPO SAN DONATOORTHOPAEDICS DEPARTMENT
IIIRD DIVISION – JOINT ARTHROPLASTY OPERATIVE CENTERCHIEF: STEFANO ZANASI M.D.
RICOSTRUZIONE CON MSCs DELLE LESIONI CARTILAGINEE A STAMPO DEL GINOCCHIO E DELLA CAVIGLIA:
RISULTATI A 2 ANNI
SICOOP , MILANO 22 GIUGNO 2012
Cartilage has limited self-repair capabilites
articular cartilage defects will ultimately result in chronic tissue losses
To contrast this relentless outcome new reconstructive techniques have been developed such
as 1. ACT
long-term results are encouragingbut present limitations
2. MSCs able to differentiate into chondral
and osseous lineages, thus able to fill the whole thickness of a defect and secrete some trophic molecules, which contribute of regeneration of damaged tissue, the final result being
cartilage on the top and bone on the bottom
MSCsCostituiscono 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
CELLULE STAMINALI DI MIDOLLO OSSEO AUTOLOGO CONCENTRATO BMAC
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) 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
A B
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 sportmenshouldered 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 sportmenshouldered, limited kissing lesions not requiring realignment procedure
unshouldered kissing lesions and uni-compartmental OA concurrently with unloading/corrective osteotomy
39/67 sportmenaverage age 25 ys (range 19 - 50) - 47% F
average defect size 3.5 cm2 (range 2.5 – 12.5cm)
Exemplificative case: salvageD.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: salvageD.A.O.F., male, 44 years old - grafted on 11/10/2009
Exemplificative case: salvageD.A.O.F., male, 44 years old - grafted on 11/10/2009
Exemplificative case: salvageD.A.O.F., male, 44 years old - grafted on 11/10/2009
6 ms f.up
Exemplificative case: salvageD.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
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
INTACT SUBCHONDRAL LAMINA AND
SUBCHONDRAL BONE
SCORE 95
12 ms f.up
Exemplificative case: salvageD.A.O.F., male, 44 years old - grafted on 11/10/2009
WELL-MATURED NEOCARTILAGE, WITH STRONG
GLICOSAMINOGLYCANS DEPOSITION.
STRONG COLLAGEN TYPE II DEPOSITION
COLUMNAR CHONDROCYTE
REARRANGEMENT INSIDE THE
GRAFTED TISSUE
Exemplificative case: salvageD.A.O.F., male, 44 years old - grafted on 11/10/2009
2nd look at 18 ms. follow-up
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
CRFs analyzed: 56
Baseline Characteristics
34,3
79,3
0102030405060708090
100
IKDC
: me
an s
core
mean time 18ms
BasalFollow- up
IKDC: Subjective Knee Evaluation (n=67) (Score 0-100)
Improved patients: 84.0 %
36,6
94,0
41,2
72,4
28,9
72,4
0102030405060708090
100
IKDC
: me
an s
core
SIMPLE COMPLEX SALVAGE
BasalFollow- up
n= 30 n=23
Subjective IKDCin relation to lesion type
SIMPLE, COMPLEX, SALVAGE
Improved patients: 100.0% 66.7% 81.8%
n=14
Subjective IKDC in relation to lesion size
40,3
75,7
32,0
80,7
0102030405060708090
100
IKDC
: me
an s
core
2- 4 cm2 >=4 cm2
BasalFollow- up
Improved patients: 71.4% 88.9%
EuroQol (EQ-5D) (N=67)
Statistically significant improvement
(pain reduction)(Wilcoxon signed rank test:
p<0.0001)
Statistically significant improvementin 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, 1999
Pain/discomfort
76 74,280,0
8,021,1
124,7816
0
20
40
60
80
100
Pre-operatively Follow-up Referencepopulation*
No pain or discomfort
Moderate pain or discomfort
Extreme pain or discomfort
% p
atie
nts
Mobility
8,0
84,0 89,1
16 10,7
92
0 0 0,20
20
40
60
80
100
Pre-operatively Follow-up Referencepopulation*
No mobility problems
Some mobility problems
Confined to bed
% p
atie
nts
Normal/Nearly Normal: 95.3 %
90,5
23,8
57,1
4,8 4,819
020406080
100
Basal Follow- upNormal Nearly normal Abnormal
%
IKDC: Knee Examination
Statistically significant improvement(Wilcoxon signed rank test: p<0.0001)
MOCART SCORING SYSTEMHigh-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
100 %
Arthroscopic Evaluation (N=4)
Mean arthroscopic time from grafting: 17.3 months
Mean score: 11.4
55,644,4
0,0 0,00
20
40
60
80
100
% p
atie
nts
Normal Nearlynormal
Abnormal Severelyabnormal
Brittberg Score (1-12)
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
2 1 1
2nd-Look Biopsy Evaluation
Hyaline-like:Mixed tissue:Fibrocartilage:
Based on criteria of cellularity, cell distribution, matrix
composition and collagen type I and II immunolocalization
4 samples analyzed (mean time: 18 months)
Hyaline-like phenotypeH&E Safranin-O Polarized Light
• 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, giving-way) 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: resurfacing by MSCs
THE MATURATION OF IMPLANTED TISSUE ENGINEERED
CARTILAGE TO A CLEAR HYALINE-LIKE PHENOTYPE
WITH PECULIAR CELL ORGANIZATION
2nd look arthroscopy at 12 ms f. up: biopsy DEMONSTRATES
HIGH CONTENT AND UNIFORM
DISTRIBUTION OF TYPE II COLLAGEN
STRONG STAINING FOR GAGS
ABSENCE OF TYPE I COLLAGEN,
CELL CLUSTERING AND COLUMNAR ORGANIZATION
20x2.5x
THE MATURATION OF IMPLANTED MSCS
TO A CLEAR FIBRO-HYALINE-LIKE PHENOTYPE WITHOUT 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
Need to verify the results at 3 and 5 years to appreciate the
quality of the reconstructed tissueand the
Maintainance/IMPROVEMENT of the (FIBRO)cartilage quality (no degenerative changes?)
PRELIMINARY CONCLUSIONS: MSCs RECONSTRUCTION
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