Fibrin Matirix-Support Autologous Chondrocyte Transplantation (ACT) for the Osteochondritis Dissecans (OCD) of the Knee - A case report - Changhoon Jeong M.D. The Dept. of Orthopaedic Surg., Holy Family Hospital, The Catholic University of Korea 1

Introduction Osteochondritis Dissecans (OCD) of the knee is a rare disease of unknown origin. Osteochondritis Dissecans (OCD) of the knee is a rare disease of unknown origin. OCD is characterized by the presence of an area along the femoral articular surface consisting of cartilage and bone that may become loose and separated from the rest of femoral condyle. OCD is characterized by the presence of an area along the femoral articular surface consisting of cartilage and bone that may become loose and separated from the rest of femoral condyle. 2

Natural history Children and adolescents in whom the distal femoral growth plate is open, spontaneous healing is the usual outcome. Children and adolescents in whom the distal femoral growth plate is open, spontaneous healing is the usual outcome. When the disorder is diagnosed after epiphyseal closure, the long term prognosis is guarded. When the disorder is diagnosed after epiphyseal closure, the long term prognosis is guarded. 3

Arthroscopic Classification Stage 1 – Intact lesion Stage 1 – Intact lesion Stage 2 – Early separated lesion Stage 2 – Early separated lesion Stage 3 – Partially detached lesion Stage 3 – Partially detached lesion Stage 4 – Salvageable craters and loose body Stage 4 – Salvageable craters and loose body Stage 5 – Unsalvageable craters and loose body Stage 5 – Unsalvageable craters and loose body From Guhl J 4

Treatment Nonoperative treatment Nonoperative treatment Younger children, open growth plate Younger children, open growth plate Activity restriction Activity restriction Short period of immobilization Short period of immobilization Arthroscopy Arthroscopy Failure of nonoperative treatment Failure of nonoperative treatment Persistence of symptom Persistence of symptom Unstable lesion Unstable lesion 5

Arthroscopic treatment Stage 1: drilling Stage 1: drilling Stage 2: in situ pinning (two k-wires) Stage 2: in situ pinning (two k-wires) Stage 3, 4: curettage and fixation Stage 3, 4: curettage and fixation Stage 5: Stage 5: Spongialization: removing all fibrous tissue and subchondral bone down to bleeding cancellous bone Spongialization: removing all fibrous tissue and subchondral bone down to bleeding cancellous bone Trephining Trephining Periosteal implantation Periosteal implantation OATS (Osteochondral Autograft Transplanation System) OATS (Osteochondral Autograft Transplanation System) Chondrocyte culture and reimplantation Chondrocyte culture and reimplantation Fibrous cartilage Hyaline cartilage 6 Brittberg et al. NEJM 1994 Grande et al. JOR 1989

Case 13yrs/boy 13yrs/boy C/C: Rt. knee painful swelling C/C: Rt. knee painful swelling onset) 2 months ago onset) 2 months ago by) No trauma Hx by) No trauma Hx PEx: Swelling/Effusion(+/+) PEx: Swelling/Effusion(+/+) Td(-) Td(-) ROM 0°~120° ROM 0°~120° Lat McMurray(+) Lat McMurray(+) 7

Initial X-ray 8

T2 T1 T1 CE Initial MRI 9

Bone scan 10

: : Curettage & multiple drilling Curettage & multiple drilling I/F c K-wires(x2) & AIBG I/F c K-wires(x2) & AIBG 11

Postop X-ray 12

POD 16 months 13

14

: : A/S curettage and debridement (2.5cm X3.5cm) A/S curettage and debridement (2.5cm X3.5cm) Harvest the piece of cartilage for chondrocyte culture Harvest the piece of cartilage for chondrocyte culture 15

: : Autologous chondrocyte transplantation Autologous chondrocyte transplantation Chondron supplied by Cellontech Chondron supplied by Cellontech AFTER TX. CPM POD 3D NWB for 2 weeks PWB between 3-6 weeks FWB after 6 weeks 16

ACT Periosteoum Periosteoum Injectable Chondron Fibrin and cell (12X10 6 cells/0.4 ml/vial) Fibrin (fibrinogen + thrombin) 조직공학용 fibrin 생산 Bio-matrix 중 가장 효과적인 glue 세포와 여러 활성인자를 포함하기 좋은 구조 Pore size 및 polymerization time 을 조절하기가 용이 17 Chondron® by Cellontech

POD 9 months No pain Full ROM No effusion and swelling Lysholm score:

Discussion A prospective, randomised comparison of autologous chondrocyte implantation versus mosaicplasty for osteochondral defects in the knee. 19 ACT (N=58)Mosaicplasty (N=48) OATS Scoring*88% excellent or good69% A/S finding82% excellent or good34% Bentley and associates J Bone Joint Surg Br Mar;85(2):

Discussion ACT for OCD of the knee ACT for OCD of the knee Peterson et al.: periosteum Peterson et al.: periosteum 16/18 (89%) improved..CORR /18 (89%) improved..CORR 2000 N=58, 90% successful clinical results, 2003 JBJS N=58, 90% successful clinical results, 2003 JBJS Noth U et al : a case report - BG and fibrin matrix- supported ACT, good result, 2006 E. Musculoskeletal review Noth U et al : a case report - BG and fibrin matrix- supported ACT, good result, 2006 E. Musculoskeletal review Ochs BG : 22 type III, IV OCD : BG and fibrin matrix- support ACT – clinical improvement, J Orthop Unfall 2007 Ochs BG : 22 type III, IV OCD : BG and fibrin matrix- support ACT – clinical improvement, J Orthop Unfall

Discussion Sandwich technique Sandwich technique Other bio-matrix Other bio-matrix Fibrin matrix-supported ACT Fibrin matrix-supported ACT  Very simple  Small incision  No periosteum suture  Short operation time  Injectable gel type  Easily molded  Reduced rehabilitation period  Hyaline cartilage regeneration  Collagen type II synthesis  Glycosaminoglycan synthesis  Even-distribution like normal cartilage  Complete matrix biodegradablity  Good integration 21

Conclusion This case report shows that ACT is a valid method for the treatment of large osteochondral defects even after fixation failed. This case report shows that ACT is a valid method for the treatment of large osteochondral defects even after fixation failed. 22

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