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

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

3. Ass. Prof. Milan HANDL, MD, PhD, Prague, CZ
Orthopaedic Surgery
Current employment:
University Hospital Motol
Orthopaedic Clinic
V uvalu 84
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
Ass. Prof. Milan HANDL, MD, PhD, Prague, CZ

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

5. 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:
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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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 hours)
Ass. Prof. Milan HANDL, MD, PhD, Prague, CZ

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

17. 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 ( 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

18. Ass. Prof. Milan HANDL, MD, PhD, Prague, CZ
Patients Review
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

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

20. 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

21. 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

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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

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

31. 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

32. 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

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 33

34. 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

35. Ass. Prof. Milan HANDL, MD, PhD, Prague, CZ
Results
very good to excellent evaluation results
in % 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

36. 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 !!!
Ass. Prof. Milan HANDL, MD, PhD, Prague, CZ

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

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