Autologous Chondrocyte Implantation

Gerard Hardisty FRACS

Disclosure

Orthopaedic Surgeons

Strong as an OX and half as bright

Orthopaedic Innovation

Arthroscopy

Joint replacement

Trauma management

MIS

Early mobilisation and discharge

ACI

What is ACI Autologous Chondrocyte Implantation is the harvest of

autologous cartilage cells, grown in the lab and then reinserted in the donor’s damaged chondral surface.

Why? – because we cannot repair cartilage that is damaged with normal hyaline cartilage cells. Fibrocartilage repair results and is not durable. This leads to premature osteoarthritis

Bone and Joint Decade 2000-2010

Osteoarthritis

Rheumatoid Arthritis

Osteoporosis

Back pain

Osteoarthritis Disease burden increasing

TKR is cost effective in the long term

Obesity and Age two biggest factors in the increasing economic burden

Joint replacements are being done in younger patients

But how many revision joint replacements can one have?

Challenging times ahead Longevity

Orthopaedic Tsunami

The Active Aged Population

57,256 TKR’s in Australia last year

Stress fractures on the rise

Tendinitis and ruptures increasing

How long can humans live?

TKR’s TKR at 60

15yrs for primary

10yrs for revision

8yrs for second revision

5 years for third?

= 38yrs – only 30 or so years to go

Total Knee Replacement Increasing revisions…

Total Knee Replacement Eventually this… …or this

Health Costs

Costs 2050 - 50%

30%

Osteoarthritis Prevention is better than

cure?

Can we reduce the incidence of debilitating knee and ankle arthritis?

60% of Arthroscopies have chondral damage

ACI can heal cartilage defects

Classification of Chondral Lesions

History of ACI

1964(Smith) - isolated chondrocytes

1971(Bentley) - transplanted chondrocytes

1984(Peterson) - therapeutically credible

1994(Brittberg) - NEJM-23 patients ACI

In WA – since 2000 (Prof Zheng)

ICRS treatment algorithm

ACI Overview

ACI technique 1st Stage - Biopsy

ACI technique Serology

ACI technique 2nd Stage Cartilage cells – Ortho-ACI(Orthocell)

ACI technique 2nd Stage - Cells to porcine collagen scaffold

ACI technique 2nd Stage – Debride lesion

ACI technique 2nd Stage – Measure size

ACI technique 2nd Stage – Cut template ACI graft

ACI technique 2nd Stage – Cut template ACI graft

ACI technique 2nd Stage – Tisseel glue(fibrin)

ACI technique 2nd Stage – Implantation(open or arthroscopic)

Case Study 28yo male fall from ladder

Case Study 28yo male fall from ladder – MFC lesion

Debride lesion After ACI

Case Study

3 months

12 months

MRI after ACI

Case Study 28yo arthroscopy at 12 months

ACI in the Ankle Osteochondral injury to talus

Osteochondral talar defects Aetiology – Traumatic

~10% of ankle sprains

20-40yrs

Arthroscopic curettage

Results not always predictable

80% improve

Treatment Options

Further debridement

Microfracture

Mosaicplasty(OATS)

ACI

Microfracture

Marrow stimulation

Stem cells transform to chondral cells

Best for smaller lesion(<2cm)

Fibrocartilage

OATS OsteoArticular Transport System

Good results reported(Hangody,Outerbridge)

Small grafts

Non specialised cartilage

Surface problems

Gaps(fibrocartilage grouting)

Donor site morbidity

ACI results in Ankle

Functional Outcome of Matrix Associated Autologous Chondrocyte Implantation in the Ankle

Foot Ankle Int 2011 Apr;32(4) 368-74

Treatment algorithm

Treatment

Algorithm

Presentation

MRI

Arthroscopy

Better

Followup @ 6m MACI

Return to sport YES

NO

ACI Inclusion Criteria 15-55

No Hep/HIV

Single lesion

Small size

Contained

Stable ankle

Surgical technique Malleolar osteotomy – 60%

Requires ORIF

Surgical technique

Good access to lesion

Surgical technique ACI graft

Results

75% significantly improved

85% would undergo again

68% returned to full manual labour

50% able to run again without restriction

Younger do better

Case report 18yo sprain playing AFL

Failed microfracture – ACI graft

Preop 6m Post op

Case report 50yo oil and gas supervisor

Fall down steps and rolled ankle

Arthroscopy and microfracture 2006

Case report Failed at 6m with symptoms

Underwent ACI as 2 stage with medial malleolar osteotomy

Rehabilitation for 3m

Returned to work restricted at 4m

MRI at 6m shows good infill

Case report

Re arthroscopy at 2 years for further injury

Lateral dome injury – Chondroplasty

Medial fully healed

Case report

Now 61yrs – increasing pain

MRI deterioration of medial graft

Has option now of TAR as well as arthrodesis

Summary

ACI well proven technique

Alternatives less good science(stem cells, PrP)

Ortho-ACI now has ARTG registration and FDA(US) approval

The future RCT’s necessary

Do in acute setting?

Who to select?

As techniques improve - ?Obviate replacement and arthrodesis surgery.

Not all but a few…

Thankyou