STEFANO ZANASI VILLA ERBOSA HOSPITAL GRUPPO SAN DONATO ORTHOPAEDICS DEPARTMENT IIIRD DIVISION –...

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STEFANO ZANASI VILLA ERBOSA HOSPITAL GRUPPO SAN DONATO ORTHOPAEDICS DEPARTMENT IIIRD DIVISION – JOINT ARTHROPLASTY OPERATIVE CENTER CHIEF: 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

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RICOSTRUZIONE CON MSCs DELLE LESIONI CARTILAGINEE A STAMPO DEL GINOCCHIO E DELLA CAVIGLIA: RISULTATI A 2 ANNI SICOOP , MILANO 22 GIUGNO 2012. STEFANO ZANASI VILLA ERBOSA HOSPITAL GRUPPO SAN DONATO ORTHOPAEDICS DEPARTMENT IIIRD DIVISION – JOINT ARTHROPLASTY OPERATIVE CENTER - PowerPoint PPT Presentation

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Page 1: STEFANO ZANASI VILLA ERBOSA HOSPITAL GRUPPO SAN DONATO ORTHOPAEDICS DEPARTMENT IIIRD DIVISION – JOINT ARTHROPLASTY OPERATIVE CENTER CHIEF: STEFANO ZANASI M.D.

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

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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

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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

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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.

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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

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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

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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)

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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

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Exemplificative case: salvageD.A.O.F., male, 44 years old - grafted on 11/10/2009

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Exemplificative case: salvageD.A.O.F., male, 44 years old - grafted on 11/10/2009

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Exemplificative case: salvageD.A.O.F., male, 44 years old - grafted on 11/10/2009

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6 ms f.up

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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

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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

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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

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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

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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

Page 21: STEFANO ZANASI VILLA ERBOSA HOSPITAL GRUPPO SAN DONATO ORTHOPAEDICS DEPARTMENT IIIRD DIVISION – JOINT ARTHROPLASTY OPERATIVE CENTER CHIEF: STEFANO ZANASI M.D.

CRFs analyzed: 56

Baseline Characteristics

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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 %

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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

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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%

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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

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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)

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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

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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

Page 29: STEFANO ZANASI VILLA ERBOSA HOSPITAL GRUPPO SAN DONATO ORTHOPAEDICS DEPARTMENT IIIRD DIVISION – JOINT ARTHROPLASTY OPERATIVE CENTER CHIEF: STEFANO ZANASI M.D.

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

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• 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

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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

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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

Page 33: STEFANO ZANASI VILLA ERBOSA HOSPITAL GRUPPO SAN DONATO ORTHOPAEDICS DEPARTMENT IIIRD DIVISION – JOINT ARTHROPLASTY OPERATIVE CENTER CHIEF: STEFANO ZANASI M.D.

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