EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Tom Minas MD MS
Director, CRC, Paley Orthopedic Institute,
West Palm Beach Florida
Professor Emeritus,
Harvard Medical School
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Disclosures
Vericel ( formerly Genzyme Biosurgery)
Consultant
Elesevier
Book royalties
ConforMIS Inc., SAB member-stocks and royalties
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
ACI - 2 Stage TechniqueGeneration 1
Arthroscopic
biopsy
2nd stage open ACI
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Landmark Paper-The Beginning
BRIT TBERG M, L INDAHL A, NILSSON A, OHLSSON C, ISAKSSON O, PETERSON L . TREATMENT OF DEEP CARTILAGE DEFECTS IN THE KNEE WITH AUTOLOGOUS CHONDROCYTE TRANSPLANTATION. N ENGL J MED. 1994;331(14) :889 -895.
FEMORAL CONDYLES 14/16 G/E OUTCOMES – 2 REVISED
PATELLA 2/7 G/E, 3 FAIR , 2 POOR
WHY??
FDA BLA1233- AUGUST-1997 AFTER REVIEW OF 153 PATIENTS IN GOTHENBERG, SW.
INDICATIONS-FC OR TROCHLEA, FAILED PRIOR TREATMENT, 18 -65 YRS.
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Correction of the “Background Factors”Cause/contributing to chondral loss‘Biological Reconstructions’
Malalignment
Status of meniscus
Ligament stability
Staged/simultaneous reconstruction
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Tasks ahead – to expand care to our patientsTechnical improvements and Clinical OutcomesPatella
Adolescents
Multiple defects-OA
Insurance industry age restrictions, 18-45, 15-55 ?
Complex reconstructions, ACL, HTO, DFO,meniscal transplant
Prior cartilage surgery- marrow stimulation, OCA
Bony deficiency, uncontained defects
Kissing defects – PF, TF
PERIOSTEAL COMPLICATIONS-Hypertrophy 5-65 % in different studies
Hypertrophy
(Morphologic appearance)Superficial Fibrillation
Edge Overlapping
Onion layering
Focal thickening (mounding)
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Periosteal Substitute with Porcine Collagen MembraneUSA 5-2007
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
ACI to MFC+LFC-Disease progression
MM
5 Yr ACI-
Trochlea+Patella
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
MFC+LFC- CACIType I-III Collagen Porcine membrane- Biogide
MM
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
25.7% P- 5% C hypertrophy requiring scope (p<0.0001)
2.3% P vs 4%C failed (p=0.2)
1. Gomoll AH, Probst C, Farr J, Cole BJ, Minas T. Use of a type I/III bilayer collagen membrane
decreases reoperation rates for symptomatic hypertrophy after autologous chondrocyte implantation.
Am J Sports Med. 2009 Nov;37 Suppl 1:20S-23S. Epub 2009 Oct 19. PubMed PMID: 19841142.
Multi-center study, 3 centers
300P-ACI vs 101 C-ACI
Compared 1 yr hypertrophy and failure rates
Similar age
#defects C>P 1.8 to 1.5 (P=0.001)
overall SA C>P, 8.6 to 6.7cm2 (p=0.003)
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Based Cartilage Products NeoCart®, NOVOCART®, and MACI
12
BM: bone marrow; NA: not applicable; P1: passage 1: PEG, polyethylene glycol.
Huang BJ, et al. Biomaterials. 2016;98:1-22.
Autologous chondrocytes are seeded in a
bovine-derived three-dimensional type I
collagen honeycomb matrix
The chondrocyte-embedded matrix is then
cultured in a bioreactor, which creates an
environment of variable hydrostatic pressure
and low oxygen tension, to simulate intra-
articular conditions
NOVOCART™3D is a combination of
autologous chondrocytes and a biphasic,
three-dimensional collagen-chondroitin
sulphate scaffold
Cultured Cells embedded into the scaffold
Matrix: three-dimensional, biphasic collagen-
chondroitin sulphate scaffold.
Cultivation time: 2-3 weeks from cartilage
harvest
MACI, autologous cultured chondrocytes on
porcine collagen membrane, is a cellular
sheet that consists of autologous
chondrocytes seeded on a 3 x 5 cm,
resorbable porcine Type I/III collagen
membrane, for implantation into cartilage
defects of the knee. The active ingredients
of MACI are the autologous cultured
chondrocytes and porcine Type I/III
collagen.
Cartilage Tissue Implant Cells Embedded in Membrane Cells on the Surface of Membrane
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
MACI
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
MACI- Vericel,Inc., FDA approved Dec. 13, 2016
28 YO Male ,failed MFX VMO adv+lat release
Jan 31-2017
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
17 YO goalie hockey playerMACI Sandwich to MFC
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
35 YO male with prior MFX, disabling pain with any exercise and large effusions
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
MACI + TTO
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Reconstruction Summary• Background factors critical-
• Alignment, tracking, stability, meniscus
• MACI technically much easier to perform, less invasive, more uniform cell ditribution
• Realistic patient Informed consent –risks and recovery
• Surgeon knowledge of outcomes and skill factor
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