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SICOOP MSCS IN KNEE ANKLE DEFECTS
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 CHIEF: STEFANO ZANASI M.D. Costituiscono 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 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. 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 B (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 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 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 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 23/67 14 sportmen shouldered, limited kissing lesions not requiring realignment procedure unshouldered kissing lesions and uni-compartmental OA concurrently with unloading/corrective osteotomy 39/67 sportmen average age 25 ys (range 19 - 50) - 47% F average defect size 3.5 cm2 (range 2.5 – 12.5cm) Exemplificative case: salvage D.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 Exemplificative case: salvage D.A.O.F., male, 44 years old - grafted on 11/10/2009 Exemplificative case: salvage D.A.O.F., male, 44 years old - grafted on 11/10/2009 Exemplificative case: salvage D.A.O.F., male, 44 years old - grafted on 11/10/2009 6 ms f.up Exemplificative case: salvage D.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 Exemplificative case: salvage D.A.O.F., male, 44 years old - grafted on 11/10/2009 MOCART SCORING SYSTEM AT 12 MS F-UP A COMPLETE FILLING OF THE DEFECT 12 ms f.up A COMPLETE INTEGRATION OF THE BORDER ZONE TO THE ADJACENT CARTILAGE INTACT AND HOMOGENEOUS TISSUE REPAIR INTACT SUBCHONDRAL LAMINA AND SUBCHONDRAL BONE SCORE 95 Exemplificative case: salvage D.A.O.F., male, 44 years old - grafted on 11/10/2009 2nd look at 18 ms. follow-up STRONG COLLAGEN TYPE II DEPOSITION WELL-MATURED NEOCARTILAGE, WITH STRONG GLICOSAMINOGLYCANS DEPOSITION. COLUMNAR CHONDROCYTE REARRANGEMENT INSIDE THE GRAFTED TISSUE 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 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 Baseline Characteristics CRFs analyzed: 56 IKDC: Subjective Knee Evaluation (n=67) (Score 0-100) Improved patients: 84.0 % 100 IKDC: mean score 90 79,3 Follow-up 80 70 60 50 40 Basal 34,3 30 20 10 0 mean time 18ms Subjective IKDC in relation to lesion type SIMPLE, COMPLEX, SALVAGE Improved patients: 100.0% 66.7% Basal 94,0 100 90 IKDC: mean score 81.8% 72,4 80 72,4 70 60 50 40 36,6 41,2 28,9 30 20 10 0 SIMPLE n= 30 COMPLEX n=14 SALVAGE n=23 Follow-up Subjective IKDC in relation to lesion size Improved patients: 71.4% 88.9% 100 IKDC: mean score 90 80,7 75,7 80 Follow-up 70 60 50 40,3 32,0 40 30 20 10 0 2-4 cm2 Basal >=4 cm2 EuroQol (EQ-5D) (N=67) Pain/discomfort Mobility 76 80 92 100 80,0 60 40 80 60 40 21,1 20 8,0 16 12 8 4,7 0 20 0 Pre-operatively Follow-up 89,1 84,0 74,2 % patients % patients 100 Reference population* 16 8,0 0 Pre-operatively 10,7 0 0,2 Follow-up Reference population* No pain or discomfort No mobility problems Moderate pain or discomfort Some mobility problems Extreme pain or discomfort Confined to bed Statistically significant improvement (pain reduction) (Wilcoxon signed rank test: p<0.0001) Statistically significant improvement in 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, 1 IKDC: Knee Examination Normal/Nearly Normal: 95.3 % 90,5 100 80 % 57,1 60 40 20 23,8 19 4,8 4,8 0 Basal Normal Follow-up Nearly normal Abnormal Statistically significant improvement (Wilcoxon signed rank test: p<0.0001) High-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 Arthroscopic Evaluation (N=4) Brittberg Score (1-12) Mean score: 11.4 Mean arthroscopic time from grafting: 17.3 months 100 % Significantly improved appearance of the tissue 100 % patients 80 Total scaffold biodegradation 55,6 Complete and uniform fibrocartilagineous tissue 44,4 60 resurfacing 40 discrete mechanical 20 0 0,0 Normal Nearly normal Abnormal 0,0 Severely abnormal resistence to probe palpation Areas of uneven cartilage stiffness 2nd-Look Biopsy Evaluation 4 samples analyzed (mean time: 18 months) Hyaline-like: Mixed tissue: Fibrocartilage: H&E 2 1 1 Based on criteria of cellularity, cell distribution, matrix composition and collagen type I and II immunolocalization Hyaline-like phenotype Safranin-O Polarized Light PRELIMINARY CONCLUSIONS: resurfacing by MSCs • 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, givingway) 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 2nd look arthroscopy at 12 ms f. up: biopsy DEMONSTRATES 2.5x 20x STRONG STAINING FOR GAGS HIGH CONTENT AND UNIFORM DISTRIBUTION OF TYPE II COLLAGEN 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 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 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?) 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