BioCartilage Update 2013
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Update on BioCartilage for the treatment of chondral lesions, performed arthroscopically for shoulder and knees
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BioCartilage Update 2013
- 1. BioCartilage Alan M. Hirahara, M.D., FRCS(C) Board Certified in Orthopaedic Surgery & Orthopaedic Sports Medicine Specializing in arthroscopic shoulder surgery Medical Director Team Physician Consultant Sacramento State Athletics Sacramento River Cats Oakland A’s MiLB - AAA
- 2. Micronized Cartilage ECM • Potential augment for Microfracture – Provides cartilage ECM scaffold – Allows for BM MSC attachment and growth – Stem Cells exposed to ECM will differentiate based on factors present within the matrix – Glycoproteins/Proteoglycans – Simple / inexpensive • Cheng et al (Tissue Engineering 2009) – Adult stem cells seeded onto the lyophilized cartilage scaffold – Chondrogenesis of ASCs evident by PCR & immunohistochemical examination – Resembled native articular cartilage Cheng N et al. Tissue Engineering 2009.
- 3. BioCartilage ECM Micronized Cartilage Matrix • Potential augment for microfracture? – Allograft cartilage ECM scaffold – Allows for BM MSC attachment and growth – Simplistic / inexpensive • In vitro evidence supporting this theory: – Adipose stem cells seeded onto lyophilized cartilage scaffold – Chondrogenesis of ASCs evident by PCR and immunohistochemistry • Abundant production of type II collagen – Cellular morphology resembled native articular cartilage – Cheng N et al. Chondrogenic differentiation of adipose- derived adult stem cells by a porous scaffold derived from native articular cartilage extracellular matrix. Tissue Engineering 2009; 15(2): 231-41.
- 4. BioCartilage ECM Micronized Cartilage Matrix • In vivo supportive evidence: – Same scaffolding material used within the previous mentioned in vitro study – Medial femoral condyle defects created within a rabbit model • Control group = microfracture performed • Treatment group = MFx plus lyophilized cartilage fagments formed into a scaffold Control Group – Treatment group had persistent upregulation of cartilage phenotypic markers: Type II Collagen and Aggrecan – Chadha N et al. Porous Cartilage-Derived Matrix Scaffolds for Repair of Articular Cartilage Defects. ORS 2012; Poster No. 0735. Treatment Group
- 5. Literature • Re: Tendon-to-bone healing. “Increase in the strength of the interface … [is] proportional to the amount of osseous ingrowth.” • Rodeo, Arnoczky et al., JBJS(A) 1993;75: 1795–1803 • Improving the osteoconductive/inductive environment improves tendon-bone healing • Shen H, et al. Int Orthop. 2010;34;(6)917-24. • Hioki S, et al. Am J Sports Med. 2012;40;(8)1772-80. • Kadonishi Y, et al. JBJS(B). 2012;94;(2)205-9.
- 6. BioCartilage ECM Micronized Cartilage Matrix • In vivo supportive evidence: – Baboon osteochondral defects filled with micronized cartilage particulate • 15 mm diameter, 10 mm depth – By 9 weeks had gross appearance of hyaline like cartilage – Histo: Newly formed cartilage cells, normal appearing proteoglycan content – Control group remained open or contained uneven patches of tissue – Malinin T et al. Induction of regeneration of articular cartilage defects by freeze dried particulate cartilage allografts. ICRS 2009 Meeting; poster presentation. 12 weeks
- 7. BioCartilage ECM Micronized Cartilage Matrix • Future In vivo support: – Full thickness cartilage defects – Microfracture vs. BioCartilage – Cole, Fortier, Cook • Future clinical support: – Post market release study for femoral condyle lesions – Post market release study for talar lesions
- 8. DeNovo NT (Zimmer) • DeNovo NT – Juvenile, allograft cartilage minced into 1 mm cubes – Priced around $4,500 • BioCartilage = $750 – Shelf life less than 1 month • BioCartilage = 4 years – Arthroscopic application is difficult • BioCartilage has paste like consistency when mixed with autologous blood , allowing for delivery through a needle
- 9. Microfracture “Plus” Sheep Pre-Clinical • BST CarGel Model – Piramal Healthcare – Chitosan based scaffold mixed with blood • Shrimp exoskeleton Microfractur Chitosan + e Blood – Received CE mark approval April 2012 – Conducting randomized pivotal trial in Canada Gross – 6 Histo – 6 month month
- 10. Relative Costs • ACI (Genzyme) • BioCartilage (Arthrex) – $10,000 – $750 • Cost for cultured cells – Morselized, dehydrated cartilage – Must add costs of two surgeries – Arthroscopic – Open Procedure • DoNovo NT (Zimmer) – $4,500 – Live cells – Juvenile, allograft cartilage minced into 1 mm cubes – Open procedure
- 14. Looks easy?
- 15. Deleted Scenes
- 16. How Should We Do It? Open Arthroscopy • Easy • Very challenging • Inexpensive • Clean margins • Quick – Curette / Burr • Instrumentation – Cannulas – Double lumen applicator for fibrin covering
- 17. Mixing and Delivery System
- 18. BioCartilage Mixing and Delivery System 3 1 2 4 5 6
- 19. Tips • Overlay fibrin glue (Evicel) to adhere to native cartilage – Use a double lumen syringe system – Don’t overuse fibrin, add slowly & carefully – Tisseel has own double lumen syringe avail. • Use cannula – Easier, more reliable instrument insertion – Not to disturb fibrin clot or sculpted biocartilage • Make good vertical margins – Prefer curette with microfracture – BEWARE making divots with burrs
- 20. Tips • Suction out fluid – Keep it DRY!!! • Do not overhydrate BioCartilage with ACP – 1.0 cc – Want a “tacky paste”
- 21. My Experience Shoulders – 6 Knees – 4 • All humeral head lesions • 2 Trochlear lesions • 1 LFC lesion • 1 MFC lesion All procedures performed arthroscopically
- 24. BioCartilage
- 25. BioCartilage