SCOI
ACI/MACI Where Are We At? SCOI
ACI/MACI The following relations exists Royalties and stock options – Smith and Nephew, Wolters Kluwer Consulting income – Smith and Nephew, Geistlich, Ossur, Cannuflow Research and educational support – Mitek, Smith & Nephew & Arthrex SCOI
Treatment Options for Cartilage Defects 1 - 2.5 cm 2 < 1 cm 2 2.5 - 4 cm 2 Debridement Debridement Drilling Drilling Drilling Osteochondral MicroFracture Transplants MicroFracture Osteochondral ACI Transplants Allografts ACI Juvenile Allografts Allografts Micronized Cartilage Juvenile Allografts Matrix Micronized Focal Resurfacing Cartilage Replacement Focal Resurfacing Replacement SCOI
SCOI
Indications for ACI in the Ankle Patients Aged 15 – 55 Focal Defect > 1 cm 2 Unipolar (Only Talus) Contained Edge Loading Failed Previous Surgery Large Lesions with Subchondral Cystic Changes in Primary Cases SCOI
ACI – MM Osteotomy Incision Over Medial Malleolus and Expose Anterior & Posterior Avoid Injury to N-V Structures & Tendons Using Fluro, Place Guide Pin over Bone at Correct Osteotomy Site and Mark with Methylene Blue Predrill Two Oblique Cannulated Screw Holes Prior to Osteotomy SCOI
Technique for OFO Use Guide Pin & Fluro to Mark Osteotomy Osteotomy Plane Orientated to Allow Two Interfrag. Screws + Plate & Exits at Syndesmosis Pre-Drill Interfrag. Screw Holes SCOI
Chondro-Gide Chondro-Gide is a Porcine Type I/III Collagen Membrane (Matrix) Bilayer Matrix With One Compact (Smooth) and One Porous Surface Membrane Takes the Place of Periosteum Used for ACI-C (CACI) and AMIC as a Patch Sold in USA as Bio-Gide Currently Being Used Instead of Periosteum SCOI
Bio-Gide Collagen Membrane Type I/III Bilayer Porcine Collagen Membrane Gomoll et al. Compared Subsequent Surgeries After ACI-P & ACI-C (Bio-Gide) in Knee Results Similar Except Hypertrophy Related Surgery ACI –P = 26% ACI-C = 5.0% AJSM 37:20S, 2009 SCOI
ACI – Defect Preparation Incise Lesion Vertically and Remove All Damaged Cartilage From Subchondral Bone Make 90º, Sharp Walls B/N Defect and Healthy Cartilage SCOI
ACI Membrane Implantation Membrane is Implanted and Secured With 6-0 Vicryl to OLT Bed Fibrin Glue is Used to Seal the Membrane “Water Tight” Except a Hole is Left for Cell Insertion SCOI
ACI Cell Implantation Insert Catheter Through Opening in Membrane Slowly Inject Cells Suture Remaining Hole in Membrane Seal Hole With Fibrin Glue SCOI
ACI “Sandwich” Bone Grafting CYST SCOI
Rehabilitation Initially Short Leg Cast NWB At Two Weeks, Stitches Out and Start 30lbs WB In CAM Boot for 4 Weeks At Six Weeks, Progress to FWB and Start Phase I P.T. SCOI
ACI Results - Ferkel (2014) 32 Patients Total Male = 16; Female = 16 Medial = 24; Lateral = 8 32/32 = Previous Surgery Current Study: F/U 29/32 = 91% Ave. Age = 34 (18-54) Ave. F/U = 70 Mos (24-129) “Sandwich” Procedures = 9 2 nd Look = 90% (26/29) Excell. = 8, Good = 15, Fair = 5 Poor = 1 AJSM, 42:2156, 2014 SCOI
ACI Results in Ankle Giannini et al. (2014) Developed an Arthroscopic ACI Procedure 46 pts. Had the Procedure With Mean Age = 31 Mean Follow up: 7 + 1.2 yrs Pre-op AOFAS = 57, Post-op AOFAS = 92 Failures = 3 KSSTA 22:1311, 2014 SCOI
ACI - Pearls Adequate Osteotomy Excise All Diseased Tissue Bone Graft Deep Cysts When Suturing Periosteum/Membrane, Grasp 4-5 mm Into Normal Cartilage Seal Graft Completely Correct Associated Instability Rigid Fixation of Osteotomy SCOI
MACI Scaffold Matrix Induced ACI Biocomposite With Highly Purified Bioresorbable Type I-III Collagen Membrane Supporting ACI Launched in 2000 in Europe and Australia with 3200 Pts Treated Vericel Acquired Genzyme & is Developing MACI in US SCOI Courtesy of Eric Giza, MD
MACI Scaffold Remove Osteochondral Lesion Size Defect Apply MACI with Fibrin Glue SCOI Courtesy of Prof. Pedro Guillen Garcia
MACI Case Study 37 y/o Female Who Suffered FX- Disl. Left Ankle During Roller Derby Match on 9-1-14 She Had ORIF by PMD and Healed With Pain OLT Noted and Scope Debridement and MicroFX by PMD Without Help 8-2015 Pt Had Scope Knee & Ankle + ACI Biopsy MACI Was Done With Excision of OLT & Cyst. ICBG Insert With Sandwich Procedure = MACI SCOI
MACI Case Study – Pre op CT SCOI
MACI Case Study 1 2 4 3 5 6 SCOI
MACI Case Study 7 8 9 10 11 12 SCOI
MACI Case Study 13 14 15 18 17 16 19 21 20 SCOI
MACI Aurich et al (2011) – Studied 18 Pts With Scope MACI Used Arthrometrix Woven Tissue SCORES Pre Post FFI Pain 5.5 2.8 FFI Disability 5.0 2.6 AOFAS 59 80 Excellent – Good 64% 81% Returned to Sports AJSM 39:311, 2011 SCOI
OLT Ankle - Summary Newer Technology Shows Positive Early Results But More Cases With Longer F/U Needed Cartilage Max. Clinical & Histological Solution Results at 24 mos. Or Longer Future – Scaffolds, Stems Cells, Growth Factors, ? Solution is Within Our Grasp and Must Be Done Arthroscopically Stepwise Evolution of Concepts and Science SCOI
ACI/MACI Treatment International Consensus Meeting on Cartilage Repair of the Ankle Nov 17-18, 2017, Pittsburgh, PA Significant Recommendations for Treatment of OLTs Publications Coming Early 2018 SCOI
T Y H O A N U K SCOI
Recommend
More recommend
