A Unique Treatment For Knee Pain In A Master Athlete - Page #4
 

Working Diagnosis:
Osteochondral defect of medial patella

Treatment:
Via ultrasound-guidance, bone marrow aspiration was drawn from the patient’s iliac crest. This aspirate was then centrifuged to produce a concentrated solution of adult mesenchymal stem cells. These cells were then applied to a scaffold of dehydrated allogenic cartilage to produce a soft paste. Surgical exposure of the cartilaginous surface of the patella was achieved and the osteochondral defect was debrided. The stem cell paste was then applied to the prepared defect and secured with fibrin glue.
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Outcome:
At his six month follow-up he was running, biking and able to do high knees. He was also able to leg press up to 280 lbs without pain. At seven months, he began sprinting again which he has been unable to do for 2 years.

Author's Comments:
As the active, elderly population increases, they are demanding more options to maintain their fitness level. Some hope to achieve or return to a competitive level of sport. These types of master athletes are seeking regenerative medicine treatments and the science is starting to show promise. The patient in this study presented with an isolated patellar osteochondral defect that was greatly affecting his ability to participate in his track and field events. There are multiple treatment methods for defects of this type, however, have limitations and less than desirable outcomes for athletes. Many of these methods, including those that utilize cartilage replacement techniques, have been found to produce fibrocartilage and not the native hyaline cartilage. There are reports that fibrocartilage replacement in these articular surfaces leads to future breakdown. Newer methods are utilizing the patient’s own mesenschymal stem cells that are concentrated and applied to a scaffold. This collection is then applied to the prepared defect. This type of treatment may result in hyaline cartilage rather than fibrocartilage once it incorporates with the surrounding tissue. This technique was chosen to give this patient a chance at a stronger, longer-lasting cartilage repair so he can return to his previous activity level with less pain and more confidence. This case demonstrates the successful collaboration between sports medicine physicians, one specializing in regenerative medicine techniques and the other specializing in orthopedic surgery.

Editor's Comments:
The treatment of large full thickness chondral lesions with MSC scaffolds has been gaining traction. Gobbi et al. termed this “Biologic Arthroplasty” and published several studies showing functional improvements in treating grade 4 cartilage lesions. In ongoing studies, Gobbi purports that this technique may also be a viable option in treating symptomatic cartilage lesions in the active elderly. This case is an example of a successful outcome with this treatment, however optimism must be tempered due to the relatively short (7month) followup period.

References:
Anderson J, Little D, Toth AP, et al. Stem cell therapies for knee cartilage repair: the current status of preclinical and clinical studies. Am J Sports Med. 2014;42(9):2253-2261.

Anz AW, Hackel JG, Nilssen EC, Andrews J. Application of biologics in the treatment of the rotator cuff, meniscus, cartilage, and osteoarthritis. J Am Acad Orthop Surg. 22(2):68-79.

Fortier BL, Potter HG, Rickey EJ, et al. Full-Thickness Cartilage Repair Compared with Microfracture in the Equine Model. 2010:1927-1937.

Fortier BL, Barker JU, Strauss EJ, McCarrel TM, Cole BJ. The role of growth factors in cartilage repair. Clin Orthop Relat Res. 2011;469(10):2706-2715.

Gobbi A, Karnatzikos G, Scotti C et al.One-step Cartilage Repair with Bone Marrow Aspirate Concentrated cells and Collagen Matrix in Full-thickness Cartilage Lesions: Results at 2year follow up. Cartilage. July 2011;2 (3).

Gobbi A, Karnatzikos G. Biologic arthroplasty can be defined as the surgical reconstruction of the joint using biological solutions. ICRS Newsletter 2012.

Gobbi A, Karnatzikos G, Sankineani SR. Treatment of Full Thickness Chondral Defects of the Knee in One Step Surgery with Multipotent Stem Cells. Am J Sports Med 2014:42(3):648 – 657.

Gobbi A, Chaurasia S, KarnatikosG, Nakamura N. Matrix Induced Autologous Chondrocyte Implantation versus Multipotent Stem Cells for the Treatment of Large Patellofemoral Chondral Lesions: A nonrandomized Trial. Cartilage. Jan 2015

Koh YG, Choi YJ, Kwon OR, Kim YS. Second-Look Arthroscopic Evaluation of Cartilage Lesions After Mesenchymal Stem Cell Implantation in Osteoarthritic Knees. Am J Sports Med. 2014;42(7):1628-1637.

Koh Y-G, Jo S-B, Kwon O-R, et al. Mesenchymal stem cell injections improve symptoms of knee osteoarthritis. Arthroscopy. 2013;29(4):748-755

Nakamura N, Hui J, Koizumi Y, Nishii T, Lad D, Karnatzikos G, Gobbi A. Stem Cell Therapy in Cartilage Repair- Culture-free and Cell Culture-based Methods. Operative Techniques in Orthopaedics, Feb. 2014.

Nejadnik H, Hui JH, Feng Choong EP, Tai B-C, Lee EH. Autologous bone marrow-derived mesenchymal stem cells versus autologous chondrocyte implantation: an observational cohort study. Am J Sports Med. 2010;38(6):1110-1116.

Saw K-Y, Anz A, Siew-Yoke Jee C, et al. Articular cartilage regeneration with autologous peripheral blood stem cells versus hyaluronic acid: a randomized controlled trial. Arthroscopy. 2013;29(4):684-694.

Toh WS, Foldager CB, Pei M, Hui JHP. Advances in Mesenchymal Stem Cell-based Strategies for Cartilage Repair and Regeneration. Stem Cell Rev. 2014;10(5):686-696.

Vangsness, C. Thomas Jr, Ii JF, Boyd J, Dellaero DT, Mills CR, Leroux-williams M. Adult Human Mesenchymal Stem Cells Delivered Via Intra-articular Injection to the Knee Following Partial Medial Menisectomy.JBSJS. 2014:90-98.

Wakitani S, Nawata M, Tensho K, Okabe T, Machida H. Repair of articular cartilage defects in the patello-femoral joint with autologous bone marrow mesenchymal cell transplantation : three case reports involving nine defects in five knees. 2007:74-79.

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