THE HEALTH KNEE

CARTILAGE TISSUE

• Articular cartilage is the hyaline cartilage that lies on the surface of bones. Thiscartilage is often described in terms of four zones between the articular surfaceand the subchondral bone : is a low-friction, wear-resistant tissue present withinjoints that is designed to bear and distribute weight .

• It is a strong, rubbery, flexible tissue but has a poor regenerative capacity.

ARTICULAR CARTILAGE FUNCTIONS• Cartilage is a resilient and smooth elastic

tissue, rubber-like padding that covers and protects the ends of long bones at the joints

• Cartilage does not contain blood vessels (it isavascular) or nerves (it is aneural). Nutrition issupplied to the chondrocytes by diffusion. The

compression of the articular cartilage or flexion of the elastic cartilage generates fluid

flow, which assists diffusion of nutrients to the chondrocytes.

• Compared to other connective tissues, cartilage has a very slow turnover of its

extracellular matrix and does not repair.

• Osteoarthritis is a disease of the whole joint, however one of the most affected tissues isthe articular cartilage. The articular cartilage

covering bones is thinned, eventuallycompletely wearing away, resulting in a "bone

against bone" within the joint, leading to reduced motion, and pain.

• Osteoarthritis affects the joints exposed to high stress and is therefore considered the result of "wear and tear" rather than a true

disease.

ARTICULAR CARTILAGE FUNCTIONS

• Mechanical properties include the response of cartilage in frictional, compressive, shear and tensile loading. Cartilage is resilient and

displays viscoelastic properties.

• Frictional properties Lubricin, a glycoprotein abundant in cartilage and synovial fluid, plays a major role in bio-lubrication and wear protection of

cartilage.

• Repair Cartilage has limited repair capabilities: because chondrocytes are bound in lacunae, they cannot migrate to damaged areas. Therefore, cartilage

damage is difficult to heal. Also, because hyaline cartilage does not have a blood supply, the deposition of new matrix is slow.

• Damaged hyaline cartilage is usually replaced by fibrocartilage scar tissue with a very low resistance to stress and progressive and fast deteriorating .

• Over the last years, surgeons and scientists have elaborated a series of cartilage repair procedures that help to postpone the need for joint replacement.

• BIOENGINEERING TECHNIQUES ARE BEING DEVELOPED TO GENERATE NEW CARTILAGE, USING A CELLULAR "SCAFFOLDING" MATERIAL AND CULTURED or

SET TO RECONSTRUCT THE DEFECT

CARTILAGE DEFECT

CARTILAGE DEFECT

CARTILAGE DEFECT/OA: CLASSIFICATION

OA : CLINICAL AND NMR CLASSIFICATION

TOPOGRAPHIC PATTERNS OF CARTILAGE DEFECTS IN OA

TOPOGRAPHIC PATTERNS OF CARTILAGE DEFECTS IN OA

CARTILAGE DEFECT IN OSTEOARTHRITIS

TRADITIONAL ADVANCED APPROACH

OUR ADVANCED APPROACH: BIOLOGICAL RESURFACING WITH ADSCs COMBINED WITH BMSCs

ADSCcombined withBMSC

Onthebasis ofA.Caplan andJ.Purita studieswe started upapreliminary study onthecombination ofboth procedures (ADSCs +BMSCs)

inorder tofurther thegood results we justgotwiththesinglecohorts studies

but totry tofurther improve thequality oftherecontructed tissueandfinally theduration oftheoutcome

BoneMarrowisalsoaFormofAdiposeTissuewithPeculiarIdentityandTherapeuticImplications:

PerspectivesforSynergisticUseofWholeBoneMarrowandWhiteAdiposeTissueCarloVenturaandStefanoZanasi*

NationalInstituteofBiostructures andBiosystems (NIBB),Italy*SanDonato Group,Italy

INPRESS

SURGICAL TECHNIQUE

MAIN STEPS

1. MESENCHIMAL STEM CELLS HARVESTING1.MESENCHIMALSTEMCELLSHARVESTING

Alternativesiteofadiposetissue harvestingwhen abdominal liposuction inunavailable

Bonemarrow harvesting

Minilip foradiposetissueharvesting

2a. PROCESSING IN OPERATIVE THEATRE: THE MAGELLAN CENTRIFUGE FOR PRP AND BMAC

PROCESSING IN OPERATIVE THEATRE

3.

BONE MARROW CONCENTRATE CELL ANALYSYS :VIABLE QUOTE AT HARVESTING

THE TECHNOLOGY: THE MYSTEM DEVICE

• Single-use Medical Device

• One-step Procedure

• Process time 15 min

• 710.000 Nucleated Cells / ml

• Up to 10x Concentration

• International Patent

MYSTEM® PROCESS - STEP BY STEP -(Can be repeated several times for the same patient)

MYSTEM

®P

RO

CESS

-STEP

BY STEP

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e repeated

severaltimes

for th

e same

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t)

2b: PROCESSING IN OPERATIVE THEATRE - ADSC

MYSTEM® SVF isolation Process

(the process can be repeated several times for the same patient)

1. Tissue Harvesting 2. Fractioning

3. Cells Separation

4. Cells Concentration

Fat Fraction Liquid Fraction

7.1 millions cells / harvested ml

up to 10x volume reduction

ADIPOSE TISSUE CONCENTRATE CELL ANALYSYS :VIABLE QUOTE AT HARVESTING

LABORATORY STEP FOR TYPIZATIONS AND PATIENT IDENTITY CARD WITH ENZYMATIC DIGESTION OF THE BOTH PROCESSED TISSUES

A.BONEMARROWCONCENTRATECELLANALYSIS

FreshBMCaliquotsareanalyzedwithintheprocedure.

TheaverageTotalNucleatedCellconcentration,Cellviability,

ColonyFormingUnit-FibroblastandOsteogenic(CFU-FandCFU-O)and

CDmarkerphenotypicanalysesareevaluatedby

Clinicalgradingflowcytometry

Forphenotypeanalysis,fresh(noncultured)BMCcellswerestainedwithaseriesofrabbitanti-humanmonoclonalantibodiesforahematopoieticlineage-committed

(non-progenitor)panelofmarkersincludingCD2,3,8,and11b(APC-Cy7),CD34(PE),CD90(FITC),andCD105(APC),aswellasappropriateisotypecontrols.

MYSTEM® isolation Process

(the process can be repeated several times for the same patient)

LIQUID AND FAT FRACTION CAN BE ADDED FOR MAXIMUM REGENERATIVE POTENTIAL

1. Tissue Harvesting 2. Fractioning

3. Cells Separation

4. Cells Concentration

Fat Fraction Liquid Fraction

17.2 millions cells / harvested ml

up to 10x volume reduction

5. Nanofat Preparation

7.1 millions cells / harvested ml

CARTILAGE DEFECTS PREPARATION

HA-PGA SCAFFOLD: CHONDROTISSUE

• Features of chondrotissue®• 100% absorbable

• The carrier material gradually dissolvesin approx. 3-4 months. It leaves no

residue and is replaced by new tissue• 100% synthetic

• chondrotissue® does not containcomponents of animal or human origin.

It is therefore ideal for patients with animal protein allergy• 100% stable

• Thanks to its consistency, the scaffoldoffers maximum form stability and

mechanical resistance, in contrast to many other collagen or gel-like

implants.

The scaffold is reshaped according to the shape and size of the cartilage loss

BILAYER SCAFFOLD: MAIOREGEN

• MaioRegen is a multi-layered matrix, manufactured through a patented process.

• The product, composed by collagen and hydroxyapatite enriched with magnesium, mimics the chondraland osteochondral tissues, both in the chemical composition and in the micro- and nano-structure.

• MaioRegen is available in three different configurations: MaioRegen Prime, MaioRegenSlim and MaioRegen Chondro+ represent specific solutions for the treatment of the different phases of

early phases of arthritic pathology.

THE PROCESSED MATERIAL

AWAYR SYSTEM FOR SCAFFOLD BIOPERFUSION WITH BMACs AND ADSCs

• AWAYR is the most advanced perfusion device available on the market,

• Featuring a wealth of innovative solutions to the benefit of patients, surgeons and hospitals.

• AWAYR represents an advancement in hybrid engineered biomaterials science:

• permits to prepare an ideal graft that mimics autologous bone tissue and helps to improve the surgical and clinical outcome.

• AWAYR® homogeneously perfuses several types of porous tissue substitutes (e.g., osseous, cartilaginous, osteo-chondral, tendinous, ligamental, etc.) with biological fluids (e.g., bone marrow, bone marrow concentrate, whole blood, platelet-rich plasma) or physiological solutions with no cell components (e.g. saline solutions, antibiotic solutions, etc.) for use in orthopedics, neurosurgery, general surgery, plastic and oral-maxillofacial surgery.

AWAYR SYSTEM FOR SCAFFOLD BIOPERFUSION WITH BMACs AND ADSCs

AWAYR SYSTEM FOR SCAFFOLD BIOPERFUSION WITH BMACs AND ADSCs

CARTILAGE DEFECTS RECONSTRUCTION

Defect edges sealingwith fibrin glue transplantation

Graft set in situ

Stay sutures

After tourniquet release

preoperative

LABORATORY STEP FOR TYPIZATIONS AND PATIENT IDENTITY CARD (24HRS)

Positive markers: CD90, CD73, CD105, CD44, CD29

Negative markers: CD14, CD34, CD45, HLA-DR

By reference literature BD Stemflow™ hMSC Analysis Kit :

“….the Mesenchymal and Tissue Stem Cell Committee of the International

Society for Cellular Therapy proposes minimal criteria to define human MSC.

First, MSC must be plastic-adherent when maintained in standard culture

conditions. Second, MSC must express CD105, CD73 and CD90, and lack

expression of CD45, CD34, CD14 or CD11b, CD79alpha or CD19 and HLA-DR

surface molecules. Third, MSC must differentiate to osteoblasts, adipocytes

and chondroblasts in vitro.”

[Dominici M, et al. Minimal criteria for defining multipotent mesenchymal stromal cells. The

International Society for Cellular Therapy position statement. Cytotherapy. 2006;8(4):315-7

LABORATORY STEP FOR TYPIZATIONS AND PATIENT IDENTITY CARD (24HRS)

B.BONEMARROWCONCENTRATECELLSANALYSIS

Documentazioneesemplificativadelmaterialechevieneinfiltratonellaarticolazione

Partialexemplificative

sheet of the document

CLINICAL AND 1.5/3 T NMR AT 1,3,6,12,24 MS F.UP

MOCART SCORING SYSTEM

AT 6 MS F-UP

A COMPLETE FILLING OF THE

DEFECT

A COMPLETE INTEGRATION OF THE

BORDER ZONE TO THE ADJACENT

CARTILAGE

INTACT AND HOMOGENEOUS TISSUE

REPAIR

SCORE 93

REHABILITATION CUSTOMIZED PROTOCOL

1.REHABILITATIVE DEVICES

CPM - KINETEC I-ONE CEMP

REHABILITATIVE PROTOCOL

THERE ARE FOUR PHASES OF REHABILITATION BASED ON THE FOUR STAGES OF HEALING

• Phase 1: Weeks 0-6

• Phase 2: Weeks 7-12

• Phase 3: Weeks 12-26

• Phase 4: Weeks 26+

• THIS A STANDARDIZED PROTOCOL THATMUST BE CUSTOMIZED ACCORDING TO THETYPE OF RECONSTRUCTION

PHASE 1 : ACUTE (INPATIENT DAYS 0-4)

PHASE 1 : ACUTE (INPATIENT DAYS 0-4)

Physical therapy begins the day after surgery- Post-operative day 1 (POD1) Goals: ROM. Increase tibial-femoral and patellofemoral mobilityDecrease pain and swellingPrevent graft(s)over-loadEncourage muscle tone. Restore quadriceps control Independence with home exercise programI-ONEVIBRA only in patello femoral joint reconstruction

2.REHABILITATIVE DEVICES

VIBRA 3.0

TECAR THERAPY

PHASE 1 : ACUTE (INPATIENT DAYS 0-4)

• Immediately after surgery the patient will be placed in a knee immobilizer, which can be use whennot in the CPM or performing exercises.

• On POD 2 the patient will be fitted with a hinged knee brace (Bledsoe knee brace) to be wornduring ambulation until further notified by their doctor.

• Patients will begin standing/walking with bilateral upper extremity assistive devices on POD2 (afterthe epidural is stopped and full LE motor control has returned).

• Cryotherapy, Kendall foot pumps and compression stockings are used for swelling, pain control and prevention of DVT.Multi-directional patellar mobilization should begin immediately after surgery.

• The patient will be discharged home with a CPM machine as well as a home exercise program.Electrical stimulation for VMO/ quadriceps muscle re-education is encouraged early after surgery ifindicated.Weight bearing, CPM and ROM will depend on the graft site.

• Home discharge criteria:1) Safe transfers2) Safe ambulation with bilateral upper extremity assistive devices on level and stairs

• 3) Good understanding of precautions, weight bearing status, ROM, use of CPM, use of • brace and home exercise program• 4) Healthy appearing wound

5) Afebrile6) Good pain control

PHASE 1: SUB-ACUTE (OUTPATIENT): (WEEKS 1-6)

• The patient will be seen in an outpatient facility or by a home physical therapist after• being discharged from the hospital.• Impairments: • Edema • Pain• Impaired patellar mobility• Impaired knee ROM • Impaired muscle performance of hip and knee• Impaired function- ADL/IADL • Impaired gait• Goals: • Increase tibial-femoral and patella-femoral mobility• Decreased pain and swelling

Restore quadriceps control • Full knee extension• Week 3: at least 90 degrees of flexion• Week 6: at least 110 degrees of flexion• Independence with home exercise program • • No progression to stage 2 until MD clears patient at 6 weeks post- op

PHASE 1: SUB-ACUTE (OUTPATIENT): (WEEKS 1-6)

• Treatment Plan: • Begin use of CPM POD1 for 6-8 hours/day for 6weeks.• Begin 0-45/60 degrees POD1 then increase 10 degrees/day as tolerated.

• EXCEPT FOR PATELLA OR TROCHLEA GRAFT SITES- CPM is limited to 0-40 degrees only for first 2 weeks then increase to full as tolerated.

• Protective weight bearing with use of brace • Isometric exercises, ROM, Multi-directional patellar mobilization• E-Stim for VMO/ quadriceps muscle re-education (no in PFJ for kissing lesion• Reconstruction)• Soft tissue mobilization/deep friction to hamstring insertions, peripatellar region, • medial/lateral gutters and scar. • Cryotherapy for edema control • Compression stockings/TEDS for edema control and DVT prevention• TECAR THERAPY• VIBRA (ONLY FOR PATELLO-FEMORAL JOINT)

PHASE 2: (WEEKS 7-12):

• Impairments:

– Edema

– Pain

– Impaired patellar mobility

– Impaired knee ROM

– Impaired muscle performance of hip and knee

– Impaired gait

– Impaired balance reactions

– Impaired function- ADL/IADL

– Goals:

– Increase tibial-femoral and patella-femoral mobility

– Restore quadriceps control

– Full knee ROM by 12 weeks

– Treatment Plan:

• Discontinue CPM

• Continue with E-Stim for VMO/ quadriceps muscle re-education if indicated

• May begin gentle AROM extension for all graft sites if not previously allowed

• Multi-directional patellar mobilization

• Partial graduated weight bearing to full weight bearing by 12 weeks

• Progression of exercises per protocols

• Functional muscle usage, stationary bicycle, with progression to treadmill

• Cryotherapy for edema control

• No progression to stage 3 until MD clears patient at 12 weeks post- op

• ACQUATIC THERAPY

• VIBRA

ACQUATIC THERAPY

PHASE 3 (WEEKS 12-26)

• Impairments: • Edema • Pain• Impaired patellar mobility• Impaired knee ROM • Impaired muscle performance of hip and knee• Impaired gait• Impaired balance reactions• Impaired function-ADL/IADL • Goals• No assistive device. • Normal gait pattern • Improve muscular strength and endurance • Return to normal ADL’s/IADL’s• Independence with home exercise program• Treatment Plan: • Distance walking, resistance walking

PHASE 4 (WEEKS 26+)

• Impairments: • Impaired muscle performance of hip and knee• Impaired balance reactions• Impaired functional activities• Goals• • Gradual return to functional activities and sports• Functional activities (depending on graft site) • Skating, in-line skating, and cycling are permitted at 6 months• Running and aerobics may be performed at 12 month• Pivoting sports such as tennis, basketball, football, golf and baseball

may begin at 12-18 ms• months depending on graft site and once patient cleared by MD

CLINICAL AND 1.5/3 T NMR AT 1,3,6,12,24MS F.UP

MOCART SCORING SYSTEM

AT 6 MS F-UP

A COMPLETE FILLING OF THE

DEFECT

A COMPLETE INTEGRATION OF THE

BORDER ZONE TO THE ADJACENT

CARTILAGE

INTACT AND HOMOGENEOUS TISSUE

REPAIR

SCORE 93

2ba: PROCESSING IN OPERATIVE THEATRE – ADSCviscosupplementation in advanced prolotherapy2b.PROCESSINGinoperativetheatre

LIPOCELL LIPOGEMS