Matrix-associated stem cell transplantation (MAST) in chondral defects of foot and ankle is effective

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Abstract

Background

The aim of the study was to assess the feasibility and clinical results of matrix-associated stem cell transplantation (MAST) and 2-year-follow-up in chondral defects of foot and ankle.

Methods

In a prospective, consecutive, non-controlled clinical follow-up study, all patients with chondral defects, that were treated with MAST from April 1st to November 30th, 2009 were analyzed. The size and location of the chondral defects, method-associated problems and the Visual Analogue Scale Foot and Ankle (VAS FA) before treatment and at follow-up were registered and analyzed.

Results

Twenty-six chondral defects in 25 patients were included in the study. The mean age of the patients was 33 years (range, 16–48 years), 18 (72%) were male. The VAS FA before surgery was 49.2 on average (range, 24.3–68.4). The defects were located as follows: medial talar shoulder, n = 9; lateral talar shoulder, n = 13 (medial and lateral talar shoulder, n = 1); distal tibia, n = 1; posterior calcaneal facet, n = 1; head of 1st metatarsal, n = 2. The defect size was 1.1 cm2 on average (range, .5–6 cm2). All patients completed 2-year-followup. No complications or consecutive surgeries were registered. The mean VAS FA at follow-up was 94.5 (range, 73.4–100; t-test, p < .01).

Conclusions

MAST led to good clinical scores. No complications were registered. Even though a control group is missing, we conclude that MAST is a safe and effective method for the treatment of chondral defects. The main advantage of MAST in comparison with ACI and MACI is the single procedure methodology. The advantage in comparison with AMIC is the potential higher concentration of stem cells.

Introduction

The optimal treatment for chondral defects at foot and ankle is debatable. The current options are distraction, debridement, abrasion, microfracture, antegrade or retrograde drilling, mosaicplasty or osteochondral autograft transfer system (OATS), autologous chondrocyte implantation (ACI), matrix-induced autologous chondrocyte implantation (MACI), autologous matrix-induced chondrogenesis (AMIC), allologous stem cell transplantation, or allograft bone/cartilage transplantation [1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36], [37], [38], [39], [40], [41], [42], [43], [44], [45], [46], [47]. Methods like debridement, abrasion, microfracture and retrograde drilling have a limited complexity, expense and morbidity [32], [33], [42]. However, these methods do not create a normal cartilage but fibrous tissue, or at best fibrous cartilage [32], [38], [42]. Retrograde drillings might maintain the existing cartilage but cannot create any new cartilage [42]. The effect of distraction on the cartilage remains debatable [44], [45], [46], [47]. A positive effect on the cartilage texture could be shown in the animal experiment but not in humans so far [47]. Mosaicplasty or OATS have the advantage of transferring normal cartilage and showed good results [19], [21], [23], [31], [34], [35], [36]. Considerable disadvantages such as morbidity at the donor site (mostly the knee, up to 30%), mismatch of the cartilage thickness and shape between donor and recipient site, and cumbersome technical issues like often necessary malleolar osteotomies limited the indications and dissemination of these techniques [19], [21], [31]. Furthermore, OATS did not show better results than microfacture alone which is much easier and quicker to do, and without donor site morbidity [33]. Cartilage cell transplantation techniques (ACI, MACI) utilize autologous cultured chondrocytes that were harvested during an earlier surgical procedure [1], [8], [11], [12], [18], [20], [24], [30], [38]. The results of these techniques have also been favorable [1], [8], [11], [12], [18], [20], [24], [30], [38]. However, the disadvantages are enormous. First, an additional surgical procedure for harvesting the cells is needed, and second, the cultivating process is costly and not covered by the health insurances in most countries. ACI, using chondrocytes in fluid form alone, is extremely difficult to perform because the fluid has to be fixed within the cartilage defect which is for example done with periosteal flaps that are sutured above and/or below (sandwich technique) the chondrocyte-fluid [24], [30]. MACI, using a scaffold matrix, is a useful modification to keep the chondrocytes in the defect and made ACI obsolete in the opinion of most experts [1], [11], [20]. Still, the most significant disadvantages like two surgical procedures and high cost could not be justified by the results that were clinically not superior to debridement methods [1]. However, the potential of these methods, especially MACI, could be shown in MRI and histological studies in which more physiological cartilage than with debridement or microfracture has been verified [1]. This called into question if “cells” have to be harvested during an earlier surgery. AMIC is using local cells from the underlying bone marrow, cells from the peripherial blood [10], [13], [22]. The clear advantages in comparison with ACI and MACI are the single surgery and much lower cost [10], [13], [22]. The latest results of these single stage procedures are comparable to the “real” chondrocyte transplantations, and seem to be more promising overall [10], [13], [22]. Questionable are the type of cells used, and the techniques for the application and fixation. Some techniques do just inject centrifuged peripheral blood into joints whereas other techniques use centrifuged bone marrow content implanted on hyaluronic acid membranes [10], [13], [22]. One step further is the use of “real” stem cells (CD 34+) that are currently available as allograft [43]. The use of allograft has several disadvantages such as potential infection and incompatibility (host versus graft and graft versus host). Other unsolved problems are the dosage and control of the stem cell performance or function. Still, the potential of these pluripotent cells (especially when autologous) seems to be the future for cartilage repair (see below). This potential calls especially into question if allologous bone/cartilage transplantation is really an useful option for the further future, or just a temporary trend. The results of these allograft techniques are not convincing but they are mostly used for large cartilage and bone defects that are not comparable with just superficial defects limited to the cartilage [6], [9], [14], [17]. Based on these considerations, comparable techniques with bone plugs or hemiprosthesis seem also to be seminal developments [15].

Matrix-associated stem cell transplantation (MAST) is a modification of AMIC with a potentially higher concentration of stem cells in the implanted matrix. The aim of the study was to assess the feasibility and 2-year-follow-up of MAST in chondral defects of the ankle and additionally in other joints of the foot.

Section snippets

Technique

MAST was performed as single open procedure associated with other procedures (Table 1). Stem cell-rich blood was harvested during the procedure from the ipsilateral pelvic bone marrow with a Jamshidi needle (10 mm × 3 mm, Cardinal, Dublin, OH, USA) and a special syringe (Arthrex-ACP®, Arthrex, Naples, FL, USA) through a stab incision. The syringe was centrifuged (10 min, 1500 rotations per minute (RPM)). The supernatant was used to impregnate a collagen I/III matrix (Chondro-Guide®, Geistlich,

Results

Twenty-six chondral defects in 25 patients were included in the study. The age of the patients was 33 years on average (range, 16–48 years), 18 (72%) were male. 18 patients (72%) stated that they performed sports at least at recreational level before having symptoms, and 6 (24%) at the time at surgery. Table 2 shows cause and injury mechanism. The most common cause was sports-related trauma (n = 11, 42%), and the most common injury mechanism was multiple sprains at the ankle (n = 10, 38%). The VAS

Discussion

There are numerous treatment options for cartilage defects of the foot and ankle, of which the majority has been applied of the talus [1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36], [37], [38], [39], [40], [41], [42], [43], [44], [45], [46], [47]. This implies that none of the options described is optimal. Furthermore, the use of these

Conflict of interest

None of the authors or the authors’ institution received funding in relation to this study.

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