EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION

Tom Minas MD MS

Director, CRC, Paley Orthopedic Institute,

West Palm Beach Florida

Professor Emeritus,

Harvard Medical School

EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION

Disclosures

Vericel ( formerly Genzyme Biosurgery)

Consultant

Elesevier

Book royalties

ConforMIS Inc., SAB member-stocks and royalties

EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION

ACI - 2 Stage TechniqueGeneration 1

Arthroscopic

biopsy

2nd stage open ACI

EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION

Landmark Paper-The Beginning

BRIT TBERG M, L INDAHL A, NILSSON A, OHLSSON C, ISAKSSON O, PETERSON L . TREATMENT OF DEEP CARTILAGE DEFECTS IN THE KNEE WITH AUTOLOGOUS CHONDROCYTE TRANSPLANTATION. N ENGL J MED. 1994;331(14) :889 -895.

FEMORAL CONDYLES 14/16 G/E OUTCOMES – 2 REVISED

PATELLA 2/7 G/E, 3 FAIR , 2 POOR

WHY??

FDA BLA1233- AUGUST-1997 AFTER REVIEW OF 153 PATIENTS IN GOTHENBERG, SW.

INDICATIONS-FC OR TROCHLEA, FAILED PRIOR TREATMENT, 18 -65 YRS.

EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION

Correction of the “Background Factors”Cause/contributing to chondral loss‘Biological Reconstructions’

Malalignment

Status of meniscus

Ligament stability

Staged/simultaneous reconstruction

EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION

Tasks ahead – to expand care to our patientsTechnical improvements and Clinical OutcomesPatella

Adolescents

Multiple defects-OA

Insurance industry age restrictions, 18-45, 15-55 ?

Complex reconstructions, ACL, HTO, DFO,meniscal transplant

Prior cartilage surgery- marrow stimulation, OCA

Bony deficiency, uncontained defects

Kissing defects – PF, TF

PERIOSTEAL COMPLICATIONS-Hypertrophy 5-65 % in different studies

Hypertrophy

(Morphologic appearance)Superficial Fibrillation

Edge Overlapping

Onion layering

Focal thickening (mounding)

EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION

Periosteal Substitute with Porcine Collagen MembraneUSA 5-2007

EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION

ACI to MFC+LFC-Disease progression

MM

5 Yr ACI-

Trochlea+Patella

EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION

MFC+LFC- CACIType I-III Collagen Porcine membrane- Biogide

MM

EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION

25.7% P- 5% C hypertrophy requiring scope (p<0.0001)

2.3% P vs 4%C failed (p=0.2)

1. Gomoll AH, Probst C, Farr J, Cole BJ, Minas T. Use of a type I/III bilayer collagen membrane

decreases reoperation rates for symptomatic hypertrophy after autologous chondrocyte implantation.

Am J Sports Med. 2009 Nov;37 Suppl 1:20S-23S. Epub 2009 Oct 19. PubMed PMID: 19841142.

Multi-center study, 3 centers

300P-ACI vs 101 C-ACI

Compared 1 yr hypertrophy and failure rates

Similar age

#defects C>P 1.8 to 1.5 (P=0.001)

overall SA C>P, 8.6 to 6.7cm2 (p=0.003)

EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION

Based Cartilage Products NeoCart®, NOVOCART®, and MACI

12

BM: bone marrow; NA: not applicable; P1: passage 1: PEG, polyethylene glycol.

Huang BJ, et al. Biomaterials. 2016;98:1-22.

Autologous chondrocytes are seeded in a

bovine-derived three-dimensional type I

collagen honeycomb matrix

The chondrocyte-embedded matrix is then

cultured in a bioreactor, which creates an

environment of variable hydrostatic pressure

and low oxygen tension, to simulate intra-

articular conditions

NOVOCART™3D is a combination of

autologous chondrocytes and a biphasic,

three-dimensional collagen-chondroitin

sulphate scaffold

Cultured Cells embedded into the scaffold

Matrix: three-dimensional, biphasic collagen-

chondroitin sulphate scaffold.

Cultivation time: 2-3 weeks from cartilage

harvest

MACI, autologous cultured chondrocytes on

porcine collagen membrane, is a cellular

sheet that consists of autologous

chondrocytes seeded on a 3 x 5 cm,

resorbable porcine Type I/III collagen

membrane, for implantation into cartilage

defects of the knee. The active ingredients

of MACI are the autologous cultured

chondrocytes and porcine Type I/III

collagen.

Cartilage Tissue Implant Cells Embedded in Membrane Cells on the Surface of Membrane

EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION

MACI

EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION

MACI- Vericel,Inc., FDA approved Dec. 13, 2016

28 YO Male ,failed MFX VMO adv+lat release

Jan 31-2017

EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION

17 YO goalie hockey playerMACI Sandwich to MFC

EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION

35 YO male with prior MFX, disabling pain with any exercise and large effusions

EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION

MACI + TTO

EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION

Reconstruction Summary• Background factors critical-

• Alignment, tracking, stability, meniscus

• MACI technically much easier to perform, less invasive, more uniform cell ditribution

• Realistic patient Informed consent –risks and recovery

• Surgeon knowledge of outcomes and skill factor