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
Top Related