Department of Orthopaedics Polytechnic University of Marche Ancona - Italy A. Gigante The role of Regenerative Medicine
Department of Orthopaedics
Polytechnic University of Marche
Ancona - Italy
A. Gigante
The role of Regenerative Medicine
• Articular environment (patient – pathology – grade – side/size)
• Scaffolds
• Cells
TISSUE ENGINEERING
• Biological environment (patient – pathology – grade – side/size)
• Scaffolds
• Cells
TISSUE ENGINEERING
* Natural polymers
SCAFFOLDS FOR CARTILAGE
• Hydrogels (agarose - alginate) Wang et al., 2007
• Chitosans Muzzarelli et al., 1995
• Synthetic materials (PLA - PGA – PDS)
• Human cartilaginous matrix
• Hyaluronic acid* Pavesio et al., 2003
• Collagen types I and II* Gigante et al., 2003
• Collagen I* + Hydroxyapatite Roveri et al., 1998
• Polysaccharides* (CS photocrosslinkable) Li et al., 2004
• Fibrin gel* Homminga et al., 1993
Biomimicry
BIOMATERIALS PROPERTIES
CELLS SCAFFOLD
BIOMIMIC SCAFFOLDS
• Collagen I membranes for tendon repair: effect of collagen fiber orientation on cell behavior. Gigante A et al. J Orthop Res. 2009 Jun; 27(6):826-32.
• Adult mesenchymal stem cells for bone and cartilage engineering: effect of scaffold materials. Gigante A et al. Eur J Histochem. 2008; 52(3):169-74.
• Engineered articular cartilage: influence of the scaffold on cell phenotype and proliferation. Gigante A et al. J Mater Sci Mater Med. 2003 Aug;14(8):713-6.
CARTILAGE EXTRACELLULAR MATRIX
COLLAGEN
• Chondrocytes in suspension covered by a
membrane (II generation);
• Chondrocytes grown on biological or artificial
scaffolds (MACI – III generation);
• Microfracture covered by a membrane
(AMIC);
• MSCs or buffy coat seeded in a biological or
artificial scaffolds.
SCAFFOLDS
• invasiveness
(mini-open approach or
arthroscopic method)
• operative time
• patient discomfort
Chondrocytes – microfractures – MSCs
grown on biological or artificial scaffolds
COLLAGEN AS SCAFFOLD
CELLS
CELLS FROM MICROFRACTURES
MESENCHIMAL STEM CELLS (buffy coat)
DIFFERENTIATED CHONDROCYTES
TWO STEPS
ONE STEPS
MACI® & NOVOCART® 3D
MACI type I, III collagen (porcine)
Safranin O S-100
protein
Cell density 106
mln/cm2
Gigante et al., 2006
Not controlled, prospective study,
mono and multicentric data
Clinical experience
D’Anchise R., Manta N., Prospero E., Bevilacqua C., Gigante A.
Autologous implantation of chondrocytes on a solid collagen scaffold after two years of follow up.
J Orthopaed Traumatol 6: 36-43, 2005.
Cherubino P., Grassi F.A., Bulgheroni P., Ronga M.
Autologous chondrocyte implantation using a bilayer collagen membrane: a preliminary report.
J Orthop Surg., 11(1): 10-5, 2003
• 59 consecutive cases (10 ♂ - 5 ♀)
• Median age 31
• Follow up 3-5 years
• 51 isolated – 8 multiple lesions
• 33 trauma and microtrauma
• 9 OCD
• 8 degenerative
• 0 connective disease
Patients and methods
Indications
Knee
2 cm2 – max 8 cm2 - mean 4 cm2
Ankle
1 cm2 – max 4 cm2 - mean 2 cm2
33 trauma and microtrauma - 9 OCD
8 degenerative – 0 connective disease
Patients and methods
Associated treatment:
• 9 ACL reconstructions
• 7 valgus osteotomies
• 9 p.f. distal realignments
Patients and methods
Distal realignment and patellar ACI: mid term results in a
selected population.
Gigante A, Enea D, Greco F,
Bait C, Denti M, Schonhuber H, Volpi P
Knee Surg Sports Traum Arthr 2009 ; 17:2-10
Isolated lesions
Multiple lesions
Degenerative lesions: “unshouldered lesions”
• MACI + tissucol + polar sutures
Patients and methods
14 MACI:
Grading III-IV Outerbridge
Size > 2cm2
Causes:
» 7 malallineaments
» 5 trauma
» 2 doc
Patella and throclea
Glued + sutured membrane Patella
Glued + sutured membrane
Patella
Patella: Glued + sutured membrane + TTT
Distal realignment and patellar ACI: mid term results in a selected population.
Gigante A, Enea D, Greco F, Bait C, Denti M, Schonhuber H, Volpi P
Knee Surg Sports Traum Arthr 2009 ; 17:2-10
Knee: maci by arthroscopy
Arthroscopic Delivery of Matrix-Induced Autologous Chondrocyte Implantation:
International Experience and Technique Recommendations
F. Cortese, M. McNicholas, G. Janes, S. Gillogly, S.P. Abelow, A. Gigante, N. Coletti
Cartilage, 2011, in press
6 ankle (talus) Gigante et al., JBJS, 2005
ANKLE Ankle: maci by arthroscopy
• Subjective knee function state
VAS (1,2,3,6,12 and 24 M)
• Objective finding:
1. ICRS-surgeon form part
(1: normal; 2: nearly normal;
3: abnormal; 4: severely abnormal)
2. Lysholm and Tegner scores at
baseline and after 6, 12 and 24 months
Materials and methods
“Modified ICRS score”
TIME
(MONTHS)
0 1 6 12 24 36
N PATIENT/
KNEE 5,42
±1,5
2,71
±1,4
1,03
±1,5
0,45
±0,8
0,21
±0,4
0,23
±0,4
VAS
FUNCTIONAL STATE
TIME
(MONTHS)
0 1 6 12 24 36
2.55±0.
51
* 1.12±0.
31
1.06±0.
27
1.00±0.
25
1.03±0.
25
00:00
01:12
02:24
03:36
04:48
06:00
preop. 6 months 24 months
VAS
Function
Clinical Results at 3 years
IKDC SCORE (from ICRS score)
TIME (MONTHS) 0 6 12 24 36
Functional
test
3.23
±0.45
1.04
±0.39
1.28
±0.37
1.00
±0.25
1.00
±0.02
Ligament
examination
1.17
±0.34
1.05
±0.27
1.07
±0.28
1.06
±0.28
1.06
±0.58
Passive
motion Deficit
1.06
±0.29
1.03
±0.23
1.00
±0.25
1.00
±0.25
1.00
±0.36
Effusion/
compartment
s findings
2.25
±0.49
1.26
±0.36
1.16
±0.33
1.04
±0.27
1.04
±0.17
Jamshidi needle mm. 3 Ø deep > 5 mm
2nd look and biopsy
• 12 - 24 months
• 22 cases fron multicentric national study
2nd look and biopsy at 12 months
MACI at medial condyle and ACL reconstruction
Feature/score 0 1 2 3
I. Surface Discontinuities/
irregularities
Smooth/
continuous
II. Matrix Fibrous tissue Fibrocartilage Misture:
hyaline/fibro
cartilage
Hyaline
III. Cell distribution Individual
cells/disorga
nized
Clusters Mixed/columnar-
clusters
Columnar
IV. Cell population
viability
<10% viable Partially viable Predominantly
viable
V. Subchondral Bone Detached/fractur
e/callus at
base
Bone
necrosis
Increased
remodelling
Normal
VI. Cartilage
mineralization
Abnormal/inappr
opriate
location
Normal
ICRS Visual Histological Assessment Scale
Membrane completely reabsorbed at 12 months
ICRS Visual Histological Assessment Scale
Feature/score 0 1 2 3
V. Subchondral Bone Detached/fractu
re/callus at base
Bone
necrosis
Increased
remodelling
Normal
VI. Cartilage
mineralization
Abnormal/inappr
opriate location
Normal
ICRS Visual Histological Assessment Scale
19/22
The histological data have confirmed that the regenerated cartilage is a typical hyaline cartilage, with a straight tide-mark with subchondral bone, well-organized cell-clusters and strong reactivity for hyaline markers.
MACI: conclusions
The cost efficiency
of this technique
remains to be evaluated
COLLAGEN AS SCAFFOLD
CELLS
CELLS FROM MICROFRACTURES
MESENCHIMAL STEM CELLS (buffy coat)
DIFFERENTIATED CHONDROCYTES
TWO STEPS
ONE STEPS
Cells from buffy coat + collagen membrane
ONE STEP
MERG
membrana per riparazione guidata
• autologous
• lower costs
• one step
• multi-potent?
ONE STEP
Buffy coat (marrow cells) + Collagen scaffold (MERG)
7 biopsies > 1 year
Gigante A. and Calcagno S.
MERG 7 biopsies > 1 year
Gigante A., Calcagno S., Cecconi S., Ramazzotti D., Manzotti S., Enea D.
Use of collagen scaffold and bone marow concentrate as a one step cartilage repair in the knee.
Int. J. Immunopathol. Pharmacol., 24 (suppl.2), 69-72, 2011
• Articular environment (patient – pathology – grade – side/size)
• Scaffolds
• Cells
TISSUE ENGINEERING
Thanks