Autologous Chondrocyte Implantation ACI Autologous Chondrocyte Implantation - The Treatment Of Joint Cartilage Defects Ass. Prof. Milan HANDL, MD, PhD Prague, Czech Republic

Ass. Prof. Milan HANDL, MD, PhD 1985 Graduate at Charles University Prague, Czech Republic 1988 I-st Attestation (orthopaedics) 1993 II-nd Attestation (orthopaedics) 2006 PhD 2008 Associate Professor Member of ESSKA Member of ESSKA - AFAS Member of ISAKOS Ass. Prof. Milan HANDL, MD, PhD, Prague, CZ

Ass. Prof. Milan HANDL, MD, PhD, Prague, CZ Orthopaedic Surgery Current employment: University Hospital Motol Orthopaedic Clinic V uvalu 84 150 06 Prague 5, CZ deputy of chief of the clinic member of the teaching staff Private practice: Erpet Medical Centre Pstrossova 10 110 00Prague 1, CZ www.ortopedie-handl.cz Ass. Prof. Milan HANDL, MD, PhD, Prague, CZ

Autologous Chondrocyte Implantation The special interest in: Autologous Chondrocyte Implantation Ass. Prof. Milan HANDL, MD, PhD, Prague, CZ

Ass. Prof. Milan HANDL, MD, PhD, Prague, CZ Hyaline cartilage William Hunter (1718 – 1783) stated in 1743: „… articular cartilage, when it is injured or possesses pathology, does not heal“. Hunter W. Of the structure and diseases of articulating cartilage. Phil Trans 1743:42:514-521. Hyaline cartilage is an original congenital tissue, which when damaged is practically impossible to either fully restore or substitute with another tissue of similar quality. ACI – Autologous Chondrocyte Implantation belongs to most sofisticated and successful methods among the surgical orthopaedic procedures being utilized for the treatment. Ass. Prof. Milan HANDL, MD, PhD, Prague, CZ

How can we identify the cartilage derangement? We follow the symptoms in the joint as: pain swelling effusion instability limited range of motion The appearence of the symptoms can be slow at the very beginning Ass. Prof. Milan HANDL, MD, PhD, Prague, CZ

Ass. Prof. Milan HANDL, MD, PhD, Prague, CZ Follows This may cause that they cannot be early diagnosed and thus treated in an appropriate way, which can lead to secondary osteoarthritis (OA) Ass. Prof. Milan HANDL, MD, PhD, Prague, CZ

Pathoethiology of cartilage defects ISAKOS - ESSKA The main reasons for the cartilage defect are: recent joint cartilage injury posttraumatic follows severe chondropathies osteoarthritic cartilage degeneration osteochondriitis dissecans (OCD) postinflammatory etc. disorders Ass. Prof. Milan HANDL, MD, PhD, Prague, CZ

Arthroscopy for the evaluation of the cartilage surface derangements Outerbridge scale 1st Gr: softenning + oedema 2nd Gr: fragmentation of the surface 3rd Gr: fibrillation, rupture 4th Gr: erosion of the subchondral bone Ass. Prof. Milan HANDL, MD, PhD, Prague, CZ 9

Ass. Prof. Milan HANDL, MD, PhD, Prague, CZ What can we do??? Of course, it is necessary to scale the pathoethiology as well as to evaluate the cartilage defect properly. There are various kinds of surgical procedures as the option of the treatment… (from easy steps to the most sophisticated methods) Ass. Prof. Milan HANDL, MD, PhD, Prague, CZ

Ass. Prof. Milan HANDL, MD, PhD, Prague, CZ Surgical procedures shaving, debridement of the lesion arthroscopic drilling microfracturing autologous osteochondral grafting - mosaicplasty autologous chondrocyte implantation (ACI) Ass. Prof. Milan HANDL, MD, PhD, Prague, CZ

Ass. Prof. Milan HANDL, MD, PhD, Prague, CZ Autologous chondrocyte implantation in the form of a solid chondrograft (fixed by fibrin glue) as hyaline-like cartilage is considered as one of the most successful techniques developed to date used for reconstructing full-thickness chondral (cartilage) lesions. Ass. Prof. Milan HANDL, MD, PhD, Prague, CZ

Patients – Clinical Examination clinical pre-, intra- and postoperative evaluation: IKDC,Tegner, Lysholm, Mazur, Weber, AOFAS scores plain radiography: Anderson, Berndt and Harty scores MRI examination: pre- and postoperatively in 2m, and 1 to 10 yrs intervals Ass. Prof. Milan HANDL, MD, PhD, Prague, CZ

Ass. Prof. Milan HANDL, MD, PhD, Prague, CZ Indications for ACI ISAKOS - ESSKA arthroscopic classification – Outerbridge score grade III and IV focal deep cartilage defects more than 4 cm² well contoured cartilage in the surroundings age 10 – 60 years Additional indications for a concommitant surgery: laesion of LCA – the joint instability unicompartmental OA – genu varum Ass. Prof. Milan HANDL, MD, PhD, Prague, CZ

Ass. Prof. Milan HANDL, MD, PhD, Prague, CZ ACI surgery 1st surgery step: a diagnostic arthroscopy utilizing by the instrumentation set ACI BH (Beznoska – Handl) checking the cartilage defect measuring of the defect´s size harvesting a rice-seed size piece of cartilage for culturing at the Tissue Bank (delivery within 24 - 48 hours) Ass. Prof. Milan HANDL, MD, PhD, Prague, CZ

ACI surgery: 1-st surgery (arthroscopy) Ass. Prof. Milan HANDL, MD, PhD, Prague, CZ

The Tissue Bank - Material and Methods enzymatic isolation of chondrocytes in vitro culturing/ pimoculture/2-3 subcultures) nutrient medium at 37°C and 5% CO2 atmosphere Growth Quality Control The quality control viability of cells – the proliferation test - inverted light microscopy fibrin glue suspension of chondrocytes (8 - 10 million of cells per ml) forming a solid chondrograft soft, elastic and easy to handle transport to the operating room at room temperature up to 48 hours Primoculture of Chondrocytes Ass. Prof. Milan HANDL, MD, PhD, Prague, CZ 17

Ass. Prof. Milan HANDL, MD, PhD, Prague, CZ Patients Review 2003 - 2013 155 patients 135 knee (83M, 52F) 20 ankle (6M, 14F) 23 children (11M, 12F) mean age: knee 36,00 ankle 29,56 children 15,23 Women 3 9 5 10 7 2 15 8 Men 12 19 16 Total 18 22 34 24 Ass. Prof. Milan HANDL, MD, PhD, Prague, CZ

Ass. Prof. Milan HANDL, MD, PhD, Prague, CZ ACI surgery The procedure: ACI implantation Ass. Prof. Milan HANDL, MD, PhD, Prague, CZ

Ass. Prof. Milan HANDL, MD, PhD, Prague, CZ ACI surgery OCD - lateral femoral condyle 2m 8y pre University Hospital Motol, Prague, CZ Ass. Prof. Milan HANDL, MD, PhD, Prague, CZ

Ass. Prof. Milan HANDL, MD, PhD, Prague, CZ ACI surgery OCD - lateral femoral condyle pre post 5y 2m Ass. Prof. Milan HANDL, MD, PhD, Prague, CZ

Ass. Prof. Milan HANDL, MD, PhD, Prague, CZ ACI surgery Example of the surgery Ass. Prof. Milan HANDL, MD, PhD, Prague, CZ

Ass. Prof. Milan HANDL, MD, PhD, Prague, CZ ACI surgery the patellar defect pre post 2m 7y University Hospital Motol, Prague, CZ Ass. Prof. Milan HANDL, MD, PhD, Prague, CZ

Ass. Prof. Milan HANDL, MD, PhD, Prague, CZ ACI surgery – + opening wedge osteotomy medial femoral condyle defect + genu varum second look arthroscopy after 4 years Ass. Prof. Milan HANDL, MD, PhD, Prague, CZ

Ass. Prof. Milan HANDL, MD, PhD, Prague, CZ ACI surgery medial femoral condyle MRI before and after the surgery Ass. Prof. Milan HANDL, MD, PhD, Prague, CZ

Ass. Prof. Milan HANDL, MD, PhD, Prague, CZ ACI surgery medial femoral condyle MRI before and after the surgery Ass. Prof. Milan HANDL, MD, PhD, Prague, CZ

Ass. Prof. Milan HANDL, MD, PhD, Prague, CZ ACI in the ankle Postinflammatory cartilage necrosis of the talus MRI before and after the surgery Ass. Prof. Milan HANDL, MD, PhD, Prague, CZ

Second look arthroscopy and biopsy chondrograft before ACI ASC – biopsy SL histology – chondrogenic cells and collagen II-nd type Ass. Prof. Milan HANDL, MD, PhD, Prague, CZ

Post-operative rehabilitation care partial weight-bearing after 6 weeks full-weight-bearing at 8 weeks full exercise program at 3 months no limits of sports activity 6 months after surgery Ass. Prof. Milan HANDL, MD, PhD, Prague, CZ

Ass. Prof. Milan HANDL, MD, PhD, Prague, CZ Clinical evaluation Ass. Prof. Milan HANDL, MD, PhD, Prague, CZ

Ass. Prof. Milan HANDL, MD, PhD, Prague, CZ ACI – The Knee clinical evaluation after 10 years Meyers score The significant improvement of the mean clinical scoring 1 year after the surgery Ass. Prof. Milan HANDL, MD, PhD, Prague, CZ

ACI – The Knee clinical evaluation after 10 years Lysholm score The significant improvement of the mean clinical scoring 1 year after the surgery Ass. Prof. Milan HANDL, MD, PhD, Prague, CZ

ACI – The Ankle clinical evaluation after 10 years The significant improvement of the mean clinical scoring 1 year after the surgery Ass. Prof. Milan HANDL, MD, PhD, Prague, CZ 33

ACI – The Ankle clinical evaluation after 10 years The significant improvement of the mean clinical scoring 1 year after the surgery Ass. Prof. Milan HANDL, MD, PhD, Prague, CZ

Ass. Prof. Milan HANDL, MD, PhD, Prague, CZ Results very good to excellent evaluation results in 75 - 80% in all test scores MRI confirmation: a propper position and ingrowth of chondrograft second-look ASC: full integration of chondrografts histology: present chondrocytes and collagen 2nd type Ass. Prof. Milan HANDL, MD, PhD, Prague, CZ 35

Ass. Prof. Milan HANDL, MD, PhD, Prague, CZ Take home message If you suffer from any cartilage disease feel free to contact us so that we could help you to solve your problem !!! We can treat patients from all over the world !!! www.ortopedie-handl.cz e-mail: info@ortopedie-handl.cz Ass. Prof. Milan HANDL, MD, PhD, Prague, CZ

Intercontinental Hotel www.esska.org PRAGUE CZECH REPUBLIC APRIL 11-12, 2014 ESSKA – AFAS Welcome to Intercontinental Hotel www.esska.org 2nd International Congress on Cartilage Repair of the Ankle Joint Ass. Prof. Milan HANDL, MD, PhD, Prague, CZ

Ass. Prof. Milan HANDL, MD, PhD, Prague, CZ Thank you! Ass. Prof. Milan HANDL, MD, PhD, Prague, CZ