AMIC technique for cartilage regeneration

1. AMIC technique for cartilage regeneration Jacobi M, Jakob R.P Fribourg Switzerland

2. The problem Symptoms? Prognostic? Treatment?

3. Symptoms? 19 year old patient OCD right and left asympomatic symptomatic

4. Symptoms? Walking time 3h Walking time 30min

5. Prognostic? Hunter (1743) „From Hippocrates to the present age it is universally allowed that ulcerated cartilage is a troublesome thing and that when destroyed, it is not recovered.“ Hunter W. On the structure and diseases of articulating cartilages. Philos Trans Roy Soc. 42B:514-521, 1743

6. Treatment? • Analgetics • SADOA • Phytotherapeutics • Vitamin E • Cytokine antagonists • Growth factors • Orthokin • Physical therapie • Electrotherapie • Ortheses • Continous passiv motion • Lavage • Débridement • Pridie drilling • Laser smouthing • Abrasion arthroplasty • Spongialisation • Cartilage shaving • Microfracture technique • Mosaic plasty allogen • Mosaic plasty autologes • Mosaic plasty xenogen • Condyle transfer • MEGA-OATS • Outerbridge plasty • Screw fixation • Hemi-Arthroplasty • Total-Arthroplasty • Open wedge osteotomy • Closing wedge ostetomy • Arthrodeses • Autologes chondrocytes implantation (ACI) with periost flap • Autologes chondrocyte implantation with collagen membrane • AMIC • Autologous chondrocyte implantation 2nd generation with Scaffold of PGA, PLA, collagen, hyaloronic acid, fibrin etc. with or without chondrocytes or stem cells, autologes oder allogen with or without growth factors • Gore-Tex • Carbon fibre • Dacron • Silikon (Salucartilage) • Teflon implantation • Morselized autologous osteochondral mixture • Perichondrium flap • Periost flap • De novo catilage implant • And others...

8. Why AMIC • Analgetics • SADOA • Phytotherapeutics • Vitamin E • Cytokine antagonists • Growth factors • Orthokin • Physical therapie • Electrotherapie • Ortheses • Continous passiv motion • Lavage • Débridement • Pridie drilling • Laser smouthing • Abrasion arthroplasty • Spongialisation • Cartilage shaving • Microfracture technique • Mosaic plasty allogen • Mosaic plasty autologes • Mosaic plasty xenogen • Condyle transfer • MEGA-OATS • Outerbridge plasty • Screw fixation • Hemi-Arthroplasty • Total-Arthroplasty • Open wedge osteotomy • Closing wedge ostetomy • Arthrodeses • Autologes chondrocytes implantation (ACI) with periost flap • Autologes chondrocyte implantation with collagen membrane • AMIC • Autologous chondrocyte implantation 2nd generation with Scaffold of PGA, PLA, collagen, hyaloronic acid, fibrin etc. with or without chondrocytes or stem cells, autologes oder allogen with or without growth factors • Gore-Tex • Carbon fibre • Dacron • Silikon (Salucartilage) • Teflon implantation • Morselized autologous osteochondral mixture • Perichondrium flap • Periost flap • De novo catilage implant • And others...

9. What means AMIC Autologous Membrane Induced Chondrogenesis (Behrens 2001)

10. Case • 36 year old male • Status 17y after partial medial meniscectomy • 2y ago, hyperextension injury with full thickness medial condylar cartilage injury

13. Step 1: Osteotomy

14. Step 2: Abrasion Chondroplasty and Microfracture

15. Step 3: Covering the defect with Chondro-Gide® membrane Matrix cut to the size and sutured to the defect with 5-0 PDS

16. Step 4: Injection of Serum and opening of the tourniquet Meanwhile the serum of the patient is mixed with the thrombin of which half the thrombin has been discarded (Behrens, AMIC)

17. Step 5: Extension and Flexion of the knee Blood and fibrin glue have expanded the matrix

18. Postoperative Rx result

19. Rehabilitation • No motion of the knee for 7-10 days followed by Kinetec • Crutch walking for 10 weeks until osteotomy is healed and the defect is filled

20. Why AMIC? • Single stage procedure • Coasts are moderate • Chondro-Gide® provides a matrix to form fibrocartilage • it protects and stabilizes the blood clot • it prevents bleeding into the joint • No donor site morbidity • No cell culture

21. But... • We always check the mechanical alignement with full leg radiographs or a CT for femoropatellar problems • We are very generous to perform an additional osteotomy

22. Results

23. J. Orthop. Res. 2000;18:781 • HEALING OF CANINE ARTICULAR CARTILAGE DEFECTS TREATED WITH MICROFRACTURE, A TYPE II COLLAGEN MATRIX, OR CULTURED AUTOLOGOUS CHONDROCYTES • H.A. Breinan, Hu-Ping Hsu, • Scott Martin, and Myron Spector

24. Type II collagen-GAG scaffold Geistlich Biomaterials Trochlear Groove HA Breinan, et al. J . Orthop. Res. 2000;18:781

25. Hyaline Fibrocart. Fibrous Total fill 100 100 80 75 60 50 40 25 20 0 0 µfx µfx/II µfx µfx/II 15 Wks Post-op., n=8, Mean ± SEM % % HA Breinan, et al. JOR 2000;18:781

26. Microfracture-Treated Defects, 15 weeks post-op Adjacent articular cartilage Defect Microfracture alone Defect Adjacent articular cartilage Microfracture plus a type II collagen implant HA Breinan, et al. JOR 2000;18:781

27. Total 42 cases of AMIC procedures(2003-2006)

28. Indications • Femoropatellar joint 21 • Femoral lesion 6 • Femoral OCD lesion 9 • Talar OCD lesion 6 Total42

29. Histology

30. Failures • Femoropatellar joint 21 -> 0 • Femoral lesion 6 -> 1 • Femoral OCD lesion 9 -> 2 • Talar OCD lesion 6 -> 0 Total42 -> 3

31. Failures • 1 Femoral lesion III° not debrided to a IV° lesion • 2 OCD lesions without sufficient debridement • All other cases have a sactisfactory result (6-30 month follow-up)

32. Case 2 • 44y old female • Obesity 120kg • Femoropatellar pain • VAS (0-10) 9 • Walking time 15 min

36. Patella Trochlea

38. Debridement

39. Drilling

40. Abrasion

41. Covering Patella with Chondro-Gide®

42. Additional surgery • Coverage of trochlea with Periost Cambium down • Slight medialisation and ventralisation of tuberosity • Lateral release

43. Result 1 year 2 year Preoperative • VAS (0-10) 2-3 • Walking 2 hours possible

45. Case 3: OCDCangoroo method • 44 year old male • Large Osteochondral Defect on medial femoral condyle

48. First step: Unloading Osteotomy

49. 4 weeks later Abrasion and microfracturing

50. Preparation of Chondro-Gide Matrix