TRATTAMENTO CON MSCS DELLE COIN LESIONS DI GINOCCHIO DELLO SPORTIVO STEFANO ZANASI VILLA ERBOSA HOSPITAL GRUPPO SAN DONATO ORTHOPAEDICS DEPARTMENT IIIRD DIVISION – JOINT ARTHROPLASTY OPERATIVE CENTER CHIEF: STEFANO ZANASI M.D.

Ther’s high incidence of cartilage injuries in sport sports at greatest risk are linked to sudden direction changes with knee or ankle sprain Football/soccer Rugby Volleyball Basket Ski tennis Cartilage injury is due to - single trauma (sprain) or to - overuse for repetitive microtraumatism in athletic gesture

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 encouraging but 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

MSCs Costituiscono una popolazione residente nel midollo osseo di cellule adulte non differenziate capace di autorigenerarsi e differenziarsi in cellule del tessuto adiposo, del tessuto cartilagineo, del tessuto osseo 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.

Cellule staminali emopoietiche Cellule immunitarie e piastrine 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 B A (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

passato all’esterno del campo sterile 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

METODI E MATERIALI protocollo ICRS-IKDC; MOCART scoring system. Sono stati inclusi in questo studio 40 pazienti sportivi di medio-alto livello Affetti da lesione a stampo (>3 <9cm2)), III-IV stadio di Outerbridge interessanti CFM,CFL,rotula Trattati dal 2/2009 al 2/2012 con impianto one step di MSCs da aspirato midollare L’età media è stata di 32a (+/-9a). Tutti i pazienti sono stati ricontrollati ad follow-up medio di 18mesi (8-36ms) . La valutazione clinica è stata effettuata utilizzando il protocollo ICRS-IKDC; la valutazione dell’impianto cartilagineo è stato effettuata con RMN ad 1.5T applicando il MOCART scoring system. L’EuroQol EQ-5D è stato utilizzato per valutare la la qualità della vita dei pazienti.

Exemplificative case MSCs: PATELLA simple Defect: coin lesion Location: centro- medial area of LEFT/RIGHT patella Size: 1.5 x 2.5 cm Patient: C. V., male, 28 ys. football player Symptoms: Severe pain, locking, giving-way, recurrent effusion History: bilateral ACL reconstruction on summer of 2009 grafted CONCURRENTLY BILATERALLY on 21/06/2009, 2nd look arthroscopy at 12 ms.

C.V., male, 28 years old - grafted on 11/04/2009

C.V., male, 28 years old –grafted on 11/04/2009 : DX

C.V., male, 28 years old - grafted on 11/04/2009 : SN

95.5 12 C.V., male, 28 years old - grafted on 11/04/2009 2nd look at 12ms.f.up Patient: C.V. Male, 28 years old Arthroscopy Time: 12 months Follow-up time: IKDC Subjective Evaluation Score: 95.5 (improvement from baseline: 49.0) Knee functional grade: Normal ICRS Cartilage repair assessment: 12

C.V., male, 28 years old - grafted on 11/04/2009 2nd look at 12ms.f.up RMN AT 12 MS

C.V., male, 28 years old - grafted on 11/04/2009 2nd look at 12ms.f.up - HYSTOLOGY LOW CONTENT AND NOT-UNIFORM DISTRIBUTION OF TYPE II COLLAGEN LIGHT STAINING FOR GAGS PRESENCE OF TYPE I COLLAGEN, NOT CELL CLUSTERING AND COLUMNAR ORGANIZATION DEMONSTRATES THE MATURATION OF IMPLANTED MSCS TO A CLEAR FIBRO-HYALINE-LIKE PHENOTYPE WITHOUT PECULIAR CELL ORGANIZATION

** Exemplificative case: MFC simple C.D, male, 18 years old - grafted on 19/01/2002 Defect: coin lesion Location: medial femoral condyle Size: 2 x 2.5 cm Patient: C.D., male, 21 years old. A1 male Serie football athlete Juvenile National Italian football team History: grafted on 19/01/2002, NMR at 3, 6 and 9, 12 , 24 months post op arthroscopic 2nd look on 12/01/2003 **

C.D, male, 18 years old - grafted on 19/01/2002 ARTHROSCOPIC ACI TECHNIQUE DEVELOPED BY M. MARCACCI

C.D, male, 18 years old - grafted on 19/01/2002 2nd look artroscopy at 18 ms f.up 19/01/2002 Follow-up time: 18 months Subjective Evaluation Score: 97.5 (improvement from baseline: 49.0 Knee functional grade: Normal Cartilage repair assessment: 12

C.D, male, 18 years old - grafted on 19/01/2002 2nd look artroscopy at 18 ms f.up STRONG COLLAGEN TYPE II DEPOSITION WELL-MATURED NEOCARTILAGE, WITH STRONG GLICOSAMINOGLYCANS DEPOSITION. COLUMNAR CHONDROCYTE REARRANGEMENT INSIDE THE GRAFTED TISSUE In collaboration with: Prof. A. HOLLANDER, University of Bristol.

ACT VS MSCs: RESULTS two cohorts of 25 cases at 18 ms f.up

EuroQol (EQ-5D) (N=25 ACT VS 25 MSCs) Pain/discomfort Mobility Statistically significant improvement similar for both groups (pain reduction) (Wilcoxon signed rank test: p<0.0001) Statistically significant improvement in mobility similar for both groups (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

PRELIMINARY CONCLUSIONS: resurfacing by MSCs Normal post-op without serious adverse events correlated to the graft 6/28 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 22

PRELIMINARY CONCLUSIONS: Second look arthroscopy at 12 mo.:9/28 PRELIMINARY CONCLUSIONS: 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 23

2nd look arthroscopy at 12 ms f. up: biopsy DEMONSTRATES 2.5x 20x LIGHT STAINING FOR GAGS STRONG STAINING FOR GAGS LOW CONTENT AND NOT-UNIFORM DISTRIBUTION OF TYPE II COLLAGEN HIGH CONTENT AND UNIFORM DISTRIBUTION OF TYPE II COLLAGEN PRESENCE OF TYPE I COLLAGEN, NOT CELL CLUSTERING AND COLUMNAR ORGANIZATION ABSENCE OF TYPE I COLLAGEN, CELL CLUSTERING AND COLUMNAR ORGANIZATION THE MATURATION OF IMPLANTED TISSUE ENGINEERED CARTILAGE TO A CLEAR HYALINE-LIKE PHENOTYPE WITH PECULIAR CELL ORGANIZATION THE MATURATION OF IMPLANTED MSCS TO A CLEAR FIBRO-HYALINE-LIKE PHENOTYPE WITHOUT PECULIAR CELL ORGANIZATION

PRELIMINARY CONCLUSIONS: MSCs RECONSTRUCTION Need to verify the results at 3 and 5 years to appreciate the quality of the reconstructed tissue and the Maintainance/IMPROVEMENT of the (FIBRO)cartilage quality (no degenerative changes?) 25

non si osserva alcuna complicanza locale nè sistemica 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

Short term Evaluating results Long term Validated results Although longer followup is needed to confirm the validity of the repair overtime, the arthroscopic one-step technique represents an advance in osteochondral regeneration, achieving high clinical scores with the formation of repair tissue and without the major disadvantages of previous techniques. MSCs cartilage defect </= 4 cm2 simple shouldered ACT cartilage defect> 4cm2 Simple wide, Shouldered Complex-salvage to delay implant arthroplasty Good functional/clinical results Good (?) % of hyaline tissue duration? Good functional/clinical results Good % of hyaline tissue 14 yrs f.up Short term Evaluating results Long term Validated results

THE TYDE-MARK IS DEVELOPING C.D, male, 18 years old - grafted on 19/01/2002 2nd look artroscopy at 18 ms f.up EXCELLENT INTEGRATION OF THE NEOFORMED TISSUE WITH THE SUBCHONDRAL BONE. THE TYDE-MARK IS DEVELOPING

MSCs : 56 pts. from 02/09 to 02/12 for chondral knee defects Outerbridge stage III/IV according to Tom Minas’ classification simple 32/56 26 sportmen coin defect (troclea, patellar, condyle/s, emi-tibial plate) complex 11/56 5 sportmen shouldered 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 13/56 11 sportmen shouldered, limited kissing lesions not requiring realignment procedure unshouldered kissing lesions and uni-compartmental OA concurrently with unloading/corrective osteotomy 32/56 sportmen average age 25 ys (range 19 - 50) - 47% F average defect size 3.5 cm2 (range 2.5 – 12.5cm)