Name: autologous microfractured and purified adipose tissue for arthroscopic management of osteochondral lesions of the talus
Uploaded: 2018-01-23T13:00:00
Description: Watch this Scientific Journal Video about Autologous Microfractured and Purified Adipose Tissue for Arthroscopic Management of Osteochondral Lesions of the Talus at JoVE.com

The procedures are performed using the Lipogems System.

All procedures performed in the studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee, and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.
1. Medical History
<ol>
	<li>Start clinical examination with a detailed patient history. 
	NOTE: An OLT must always be suspected in case of instability of the ankle with repeated sprains associated with swelling, stiffness...

<ol>
	<li>D'Ambrosi, R., Maccario, C., Serra, N., Liuni, F., Usuelli, F. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Osteochondral+Lesions+of+the+Talus+and+Autologous+Matrix-Induced+Chondrogenesis:+Is+Age+a+Negative+Predictor+Outcome?.">Osteochondral Lesions of the Talus and Autologous Matrix-Induced Chondrogenesis: Is Age a Negative Predictor Outcome?.</a> Arthroscopy. 33 (2), 428-435 (2017).</li><li>Becher, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=T2-mapping+at+3+T+after+microfracture+in+the+treatment+of+osteochondral+defects+of+the+talus+at+an+average+follow-up+of+8+years.">T2-mapping at 3 T after microfracture in the treatment of osteochondral defects of the talus at an average follow-up of 8 years.</a> Knee Surg. SportsTraumatol. Arthrosc. 23 (8), 2406-2412 (2015).</li><li>Polat, G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Long-term+results+of+microfracture+in+the+treatment+of+talus+osteochondral+lesions.">Long-term results of microfracture in the treatment of talus osteochondral lesions.</a> Knee Surg. Sports Traumatol. Arthrosc. 24 (4), 1299-1303 (2016).</li><li>van Bergen, C. J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Arthroscopic+treatment+of+osteochondral+defects+of+the+talus:+outcomes+at+eight+to+twenty+years+of+follow-up.">Arthroscopic treatment of osteochondral defects of the talus: outcomes at eight to twenty years of follow-up.</a> J. Bone Joint Surg. Am. 95 (6), 519-525 (2013).</li><li>van Eekeren, I. C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Return+to+sports+after+arthroscopic+debridement+and+bone+marrow+stimulation+of+osteochondral+talar+defects:+a+5-+to+24-year+follow-up+study.">Return to sports after arthroscopic debridement and bone marrow stimulation of osteochondral talar defects: a 5- to 24-year follow-up study.</a> Knee Surg Sports Traumatol Arthrosc. 24 (4), 1311-1315 (2016).</li><li>D'Ambrosi, R., Maccario, C., Ursino, C., Serra, N., Usuelli, F. 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Arthrosc. 23 (5), 1308-1316 (2015).</li><li>Zuk, P. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Human+adipose+tissue+is+a+source+of+multipotent+stem+cells.">Human adipose tissue is a source of multipotent stem cells.</a> Mol. Biol. Cell. 13 (12), 4279-4295 (2002).</li><li>Tal&#233;ns-Visconti, R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Human+mesenchymal+stem+cells+from+adipose+tissue:+Differentiation+into+hepatic+lineage.">Human mesenchymal stem cells from adipose tissue: Differentiation into hepatic lineage.</a> Toxicol. In Vitro. 21 (2), 324-329 (2007).</li><li>Timper, K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Human+adipose+tissue-derived+mesenchymal+stem+cells+differentiate+into+insulin,+somatostatin,+and+glucagon+expressing+cells.">Human adipose tissue-derived mesenchymal stem cells differentiate into insulin, somatostatin, and glucagon expressing cells.</a> Biochem. Biophys. Res. Commun. 341 (4), 1135-1140 (2006).</li><li>Tremolada, C., Palmieri, G., Ricordi, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Adipocyte+transplantation+and+stem+cells:+plastic+surgery+meets+regenerative+medicine.">Adipocyte transplantation and stem cells: plastic surgery meets regenerative medicine.</a> Cell. Transplant. 19 (10), 1217-1223 (2010).</li><li>Keramaris, N. C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endothelial+progenitor+cells+(EPCs)+and+mesenchymal+stem+cells+(MSCs)+in+bone+healing.">Endothelial progenitor cells (EPCs) and mesenchymal stem cells (MSCs) in bone healing.</a> Curr. Stem Cell. Res. Ther. 7 (4), 293-301 (2012).</li><li>Leigheb, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Italian+translation,+cultural+adaptation+and+validation+of+the+American+Orthopaedic+Foot+and+Ankle+Society's+(AOFAS)+ankle-hindfoot+scale.">Italian translation, cultural adaptation and validation of the American Orthopaedic Foot and Ankle Society's (AOFAS) ankle-hindfoot scale.</a> Acta Biomed. 87 (1), 38-45 (2016).</li><li>Ware, J., Kosinski, M., Keller, S. 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M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Diagnosing,+planning+and+evaluating+osteochondral+ankle+defects+with+imaging+modalities.">Diagnosing, planning and evaluating osteochondral ankle defects with imaging modalities.</a> World. J. Orthop. 6 (11), 944-953 (2015).</li><li>van Dijk, C. N., Reilingh, M. L., Zengerink, M., van Bergen, C. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Osteochondral+defects+in+the+ankle:+why+painful?.">Osteochondral defects in the ankle: why painful?.</a> Knee Surg. Sports Traumatol. Arthrosc. 18 (5), 570-580 (2010).</li><li>Madry, H., van Dijk, C. N., Mueller-Gerbl, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+basic+science+of+the+subchondral+bone.">The basic science of the subchondral bone.</a> Knee Surg. Sports Traumatol. Arthrosc. 18 (4), 419-433 (2010).</li><li>Mintz, D. N., Tashjian, G. S., Connell, D. A., Deland, J. T., O'Malley, M., Potter, H. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Osteochondral+lesions+of+the+talus:+a+new+magnetic+resonance+grading+system+with+arthroscopic+correlation.">Osteochondral lesions of the talus: a new magnetic resonance grading system with arthroscopic correlation.</a> Arthroscopy. 19 (4), 353-359 (2003).</li><li>Leumann, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+novel+imaging+method+for+osteochondral+lesions+of+the+talus--comparison+of+SPECT-CT+with+MRI.">A novel imaging method for osteochondral lesions of the talus--comparison of SPECT-CT with MRI.</a> Am. J. Sports Med. 39 (5), 1095-1101 (2011).</li><li>Kim, Y. S., Park, E. H., Kim, Y. C., Koh, Y. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Clinical+outcomes+of+mesenchymal+stem+cell+injection+with+arthroscopic+treatment+in+older+patients+with+osteochondral+lesions+of+the+talus.">Clinical outcomes of mesenchymal stem cell injection with arthroscopic treatment in older patients with osteochondral lesions of the talus.</a> Am. J. Sports Med. 41 (5), 1090-1099 (2013).</li><li>Kim, Y. S., Lee, H. J., Choi, Y. J., Kim, Y. I., Koh, Y. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Does+an+injection+of+a+stromal+vascular+fraction+containing+adipose-derived+mesenchymal+stem+cells+influence+the+outcomes+of+marrow+stimulation+in+osteochondral+lesions+of+the+talus?+A+clinical+and+magnetic+resonance+imaging+study.">Does an injection of a stromal vascular fraction containing adipose-derived mesenchymal stem cells influence the outcomes of marrow stimulation in osteochondral lesions of the talus? A clinical and magnetic resonance imaging study.</a> Am. J. Sports Med. 42 (10), 2424-2434 (2014).</li><li>Kim, Y. S., Koh, Y. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Injection+of+Mesenchymal+Stem+Cells+as+a+Supplementary+Strategy+of+Marrow+Stimulation+Improves+Cartilage+Regeneration+After+Lateral+Sliding+Calcaneal+Osteotomy+for+Varus+Ankle+Osteoarthritis:+Clinical+and+Second-Look+Arthroscopic+Results.">Injection of Mesenchymal Stem Cells as a Supplementary Strategy of Marrow Stimulation Improves Cartilage Regeneration After Lateral Sliding Calcaneal Osteotomy for Varus Ankle Osteoarthritis: Clinical and Second-Look Arthroscopic Results.</a> Arthroscopy. 32 (5), 878-889 (2016).</li><li>Kim, Y. S., Lee, M., Koh, Y. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Additional+mesenchymal+stem+cell+injection+improves+the+outcomes+of+marrow+stimulation+combined+with+supramalleolar+osteotomy+in+varus+ankle+osteoarthritis:+short-term+clinical+results+with+second-look+arthroscopic+evaluation.">Additional mesenchymal stem cell injection improves the outcomes of marrow stimulation combined with supramalleolar osteotomy in varus ankle osteoarthritis: short-term clinical results with second-look arthroscopic evaluation.</a> J. Exp. Orthop. 3 (1), 12 (2016).</li><li>Hanke, C. W., Bernstein, G., Bullock, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Safety+of+tumescent+liposuction+in+15,336+patients.+National+survey+results.">Safety of tumescent liposuction in 15,336 patients. National survey results.</a> Dermatol Surg. 21 (5), 459-462 (1995).</li><li>Illouz, Y. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Complications+of+liposuction.">Complications of liposuction.</a> Clin Plast Surg. 33 (1), 129-163 (2006).</li><li>Dixit, V. V., Wagh, M. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Unfavourable+outcomes+of+liposuction+and+their+management.">Unfavourable outcomes of liposuction and their management.</a> Indian J Plast Surg. 46 (2), 377-392 (2013).</li><li>Lehnhardt, M., Homann, H. H., Daigeler, A., Hauser, J., Palka, P., Steinau, H. 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In recent years, clinical and preclinical trials have focused their attention on the effect of ADSCs to treat different musculoskeletal pathologies. The aim of this article is to describe the protocol for the treatment of osteochondral lesions of the talus using microfractured and purified adipose tissue in association with arthroscopic microperforations. The protocol involves several critical steps with high risks of complications. During fat harvesting, complications can be divided into local or systemic complications....

Arthroscopy is the gold standard for the treatment of osteochondral lesions of the talus (OLTs) with the aim of pain relief, restoring functionality, and improving quality of life, especially in young and active patients.
Currently, arthroscopic techniques can be classified in three ways. The reparative technique stimulates cells derived from bone marrow through a debridement and microperforations at the level of lesion. The reconstructive technique replaces the lesion using an autologous or heterologous ostechondral graft. The regenerative technique exploits the ability of multipotent cells to differentiate and replicate to reconstruct the damaged tissue1,2,3,4,5,6.
In recent years , regenerative techniques have been the subject of numerous in vitro and in vivo studies for the treatment of OLTs, and particularly mesenchymal stem cells derived from adipose tissue (ADSCs)7,8,9. These mesenchymal stem cells exhibit morphological and functional characteristics similar to other multipotent cells, isolated from other tissues; they also have the ability to differentiate into several and different cellular lines both in vitro and in vivo10,11,12,13. The focus on research regarding these cells is mainly due to their localization, in fact they represent from 10% to 30% of normal body weight with a concentration of 5,000 cells per gram of tissue13,14. On the other hand, a factor that limits the use of these cells is related to their handling during laboratory procedures. The lipoaspirate containing aggregates of adipocytes, collagen fibers, and normal vascular components is enzymatically processed with collagen A type I, and subjected to hemolysis before culture. The aim here is to describe the protocol for the treatment of osteochondral lesions of the talus using microfractured and purified adipose tissue.

<table>
	<tbody>
		<tr>
			<td>PROCESS KIT - PROCESSING KIT FOR FAT TISSUE</td>
			<td>LIPOGEMS</td>
			<td>LG PK 60</td>
			<td>Lipogems Kit to obtain microfractured and purified ADSCs</td>
		</tr>
		<tr>
			<td>HINTERMANN SPREADER</td>
			<td>INTEGRA</td>
			<td>119654</td>
			<td>The spreader allow to access most of the talar dome, in particular in case of posterior lesion</td>
		</tr>
		<tr>
			<td>CUP CURETTE</td>
			<td>ARTHREX</td>
			<td>AR-8655-02</td>
			<td>To remove the damaged cartilage and necrotic and sclerotic bone</td>
		</tr>
		<tr>
			<td>CHONDRAL PICK 30&#176; TIP / 60&#176; TIP</td>
			<td>ARTHREX</td>
			<td>AR-8655-05 
			AR-8655-06</td>
			<td>To perfrom microperforation at the level of the lesion, stimulating bleeding from the subchondral bone</td>
		</tr>
		<tr>
			<td>SHAVER</td>
			<td>ARTHREX</td>
			<td>AR-7300SR</td>
			<td>To clean the joint and aspirate water</td>
		</tr>
	</tbody>
</table>

autologous microfractured and purified adipose tissue for arthroscopic management of osteochondral lesions of the talus

In recent years, regenerative techniques have been increasingly studied and used to treat osteochondral lesions of the talus. In particular, several studies have focused their attention on mesenchymal stem cells derived from adipose tissue. Adipose-derived stem cells (ADSCs) exhibit morphological characteristics and properties similar to other mesenchymal cells, and are able to differentiate into several cellular lines. Moreover, these cells are also widely available in the subcutaneous tissue, representing 10 - 30% of the normal body weight, with a concentration of 5,000 cells per gram of tissue.
In the presented technique, the first step involves harvesting ADSCs from the abdomen and a process of microfracture and purification; next, the surgical procedure is performed entirely arthroscopically, with less soft tissue dissection, better joint visualization, and a faster recovery compared with standard open procedures. Arthroscopy is characterized by a first phase in which the lesion is identified, isolated, and prepared with microperforations; the second step, performed dry, involves injection of adipose tissue at the level of the lesion.
Between January 2016 and September 2016, four patients underwent arthroscopic treatment of osteochondral lesion of the talus with microfractured and purified adipose tissue. All patients reported clinical improvement six months after surgery with no reported complications. Functional scores at the latest follow-up are encouraging and confirm that the technique provides reliable pain relief and improvements in patients with osteochondral lesion of the talus.

Between January 2016 and September 2016, four patients underwent arthroscopic treatment of osteochondral lesion of the talus with microfractured and purified adipose tissue. All patients reported clinical improvement six months after surgery. Preliminary clinical results are reported in Table 1. No complications were reported.
In recent years, the use of ADSCs for the treatment of foot and ankle pathologies has ...

Watch this Scientific Journal Video about Autologous Microfractured and Purified Adipose Tissue for Arthroscopic Management of Osteochondral Lesions of the Talus at JoVE.com

Autologous Microfractured and Purified Adipose Tissue for Arthroscopic Management of Osteochondral Lesions of the Talus

The aim of this study is to report a protocol for the arthroscopic treatment of osteochondral lesions of the talus using microfractured and purified adipose-derived stem cells.

In recent years, regenerative techniques have been increasingly studied and used to treat osteochondral lesions of the talus. In particular, several ...

The overall goal of this surgical procedure is to treat osteochondral lesions of the talus through the induced regeneration of talar cartilage using autologous microfractured and purified adipose tissue in conjunction with microperforations. This method can help answer key questions in the regenerative medicine field about how to improve the quality of neo-formed tissues. The main advantage of this technique is that it is completely arthroscopic, with little soft tissue dissection, better joint visualization, and a faster patient recovery.The implications of this technique extend beyond the ankle to the treatment of lesions on any another joint in the body. Visual demonstration of this method is critical, as the positioning of the Hintermann spreader is difficult to learn without observation of the open posterior lesion treatment position. To harvest the adipose tissue, first use a scalpel to make two 0.5-centimeter periumbilical incisions.Then, use a 60-milliliter syringe equipped with an 18-gauge needle to inject approximately 300 milliliters of Klein solution through the incisions into the subcutaneous fat tissue of the abdomen. When all of the solution has been delivered, use a 13-gauge blunt catheter attached to a 20-milliliter syringe to harvest 40 to 45 milliliters of adipose-derived stem cells, or ADSCs, from the periumbilical area, and apply a compression bandage onto the incision. Add the cell suspension into the large filter of a processing kit, and press 100 to 300 milliliters of the lipoaspirate through the filter into the kit device to obtain the first cluster reduction.A corresponding volume of saline solution will exit the kit into waste bag. Next, add stainless steel marbles to the kit to achieve a temporary emulsion between the oil, blood, and saline in the aspirate, and use a gravity counter-flow of saline solution to remove the contaminating oil residue and blood from the sample. When the eluate is clear and the lipoaspirate is yellow, stop the saline flux and reverse the device so that the gray cap is facing up.Then, connect a 10-milliliter syringe to the upper opening of the device, and use a second 10-milliliter syringe to push the floating adipose clusters from below through the second cutting hexagonal filter into the first syringe to achieve the second adipose cluster reduction. To prepare the lesion for adipose-derived stem cell injection, place the patient in the supine position under spinal anesthesia with a tourniquet at the thigh level to decrease the bleeding and to allow a better arthroscopic visualization. Using a dermographic pen, mark both the lateral and medial malleoli, the anterior joint line, the tibialis anterior and Achilles tendons, the great saphenous vein, and the superficial peroneal nerve.When all of the landmarks have been notated, use a scalpel to make a shallow skin incision just medial to the tibialis anterior tendon, and perforate the capsule by blunt dissection, taking care to avoid the saphenous nerve and the great saphenous vein. For arthroscopic treatment of the cartilage, place a wide-angle, 2.7-millimeter arthroscope with a 30-degree viewing angle into the anterior recess of the joint. After checking the joint line, create the anterolateral portal, medial to the lateral malleolus and lateral to the extensor digitorum tendon, as just demonstrated for the approach portal.Assess the size and position of the articular cartilage within the portal, using a palpator to evaluate the condition and the quality of the tissue. In the case of a posterior lesion, position one K-wire on the tibia and one K-wire on the talar bone, and percutaneously apply the opening level arm of a Hintermann spreader onto the K-wires to distract the joint and to allow exposure of the lesion. Use a standard arthroscopic curette to remove the damaged and unstable cartilage, the calcified layer, and any necrotic or sclerotic bone, resulting in a regular-shaped, contained lesion with shouldered borders.Next, use a chondral pick to create microperforations about three millimeters apart from the outside to the inside of the lesion to stimulate the bone marrow stem cells from the subchondral bone and to induce microfractures on the healthy subchondral bone beneath the defect. Then, use a shaver to remove any intraarticular water, followed by swabbing with a clean, cotton sponge. When the joint is completely dry, inject five to seven milliliters of adipose-derived stem cells into the ankle joint through either of the two portals, and release the tourniquet.Between January and September of 2016, four patients underwent arthroscopic treatment of osteochondral lesions of the talus with induced microfractures and purified adipose tissue, as just demonstrated. All patients reported clinical improvement six months after surgery, with no complications. Once mastered, this technique can be completed in 30 minutes if it is performed properly.Following this procedure, other surgical procedures such as lateral ligament reconstruction can be performed to improve ankle stability. After its development, this technique paved the way for researcher in the field of regenerative medicine to explore cartilage healing in orthopedics pathologies. After watching this video, you should have a good understanding of how to use arthroscopy to deliver autologous microfractured adipose-derived stem cell into the ankle joint.Although mesenchymal stem cell therapies are becoming more common in the clinic, it's important to remember to take extra safety precautions when using ADSCs in regenerative medicine methods/protocols.

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