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2. medicine
3. surgery

Biologic augmentation of
partial ruptured ACL
Eichhorn, Angele, Fehske
There is no natural healing of an ACL rupture
PDGF-AB
7 days after
injury
Steiner, 2009
Reasons?
• Insufficient repaircells and vessels in the defect
Amiel 1995, Chen 2002
• Regeneration possible, but lack of defect bridging
Murphy 2003, Murray 2007
Adding growth factors (TGF, FGF, PDGF, Tissue response technique)
Using scaffolds for defect bridging (LAD-Augmentation, Hyaluronic acid,
Kollagen-platelet Hydrogel…)
ACL healing possibelities
Steiner 2008
Criteria for partial ACL rupture
- MRI some fibres in direction
- KT1000 (0-4mm SSD)
- Only pivot glide
Prospective trial
Healing response + ACP
versus
Conservative treatment
(Control group)
Healing Response (Steadman)
Study presented at ACL Study
group in Nevis:
73% success
Prospective trial
07.2009 – 10.2013
Partial ACL rupture (specific criteria)
Follow-up: preOP, 6 wks, 3, 6, 12 months
Control group: n=41
Experimental group: n=163
Male / Female = 124 / 80
Grading of partial ACL rupture
Grade 1:
Grade 2:
Grade 3:
Grade 4:
Grade 5:
Partial ACL rupture
Grade 1: n=31
Grade 2: n=53
Grade 3: n=36
Grade 4: n=27
Grade 5: n=16
PCL
PL?
AM
AM
AM
AM
Products needed for the ACP - Therapy
ACP Double Syringe
and
Centrifuge
Rehabilitation protocol
(Prospective trial)
Week 0-2: 10kg body weight
20° immobilizer
Passive ROM 0-20-60°
Rehabilitation protocol
(Prospective trial)
After 2 weeks:
Repeated PRP injection
(office facility)
Rehabilitation protocol
(Prospective trial)
Week 3-6: Full body weight
ACL DJO brace 0-10-90°
Immobilizer 20° over night
Proprioceptive training
Release
Training therapy
Partial ACL rupture
Good results:
-KT1000: 1 – 2 mm
-No pivot shift
-Full ROM
-No subjective instability
Good results
(prospective trial)
Grade 1: 97%
Control group:
Grade 2: 94%
32%
Grade 3: 79%
(58% ACL-Recon)
Grade 4: 41%
Grade 5: 13% (n = 2)
Healing Response + ACP
- Age shows no differences
- Slightly worse results:
- Female
- smokers
Healing Response + ACP
Failures detected
within 6 months
Healing Response + ACP
Major advantage:
- Benefit of the preserved stump ?
- Don´t burn bridges
Healing Response + ACP
ACP seems to add benefit
to the healing response technique
Thank you for your attention !
Natürliche Heilung vorderes Kreuzband
PDGF-AB
7 Tage nach
Verletzung
Steiner, 2009
Keine natürliche Heilung des vorderen Kreuzbands
Gründe für fehlende Heilung vorderes Kreuzband
• ungeeignete Reparaturzellen und Gefäße im Defekt
Amiel 1995, Chen 2002
• Regeneration prinzipiell möglich, kein defect bridging
Murphy 2003, Murray 2007
Gabe von Wachstumsfaktoren (TGF, FGF, PDGF, Tissue response technique)
Scaffolds zum Defekt bridging (LAD-Augmentation, Hyaluronsäure,
Kollagen-platelet Hydrogel…)
Möglichkeit zur Heilung vorderes Kreuzband
Steiner 2008
Möglichkeit zur Heilung vorderes Kreuzband
Joshi 2009
ACL healing possibelities
Foster 2009
Is concentrating WBCs beneficial?
• Proposed theory:
– Concentrated WBCs will debride chronic tissue and jump start healing
– Potentiate an antibacterial response
• Concentrated WBCs at the site of injury may be detrimental
toward the healing progression
– When activated, neutrophils release non-specific, toxic agents1,2,3
• Matrix metalloproteinases (MMPs) and Serine proteinases
• The toxic agents will destroy everything in contact, injured or healthy
– Non-healing tissue with chronic inflammation is caused by overabundant neutrophil infiltration1
– Macrophages are NOT delivered in PRP
• PRP has been shown to inhibit macrophage proliferation (which is good in the short
term). PRP does promote cell infiltration at the later stage of healing (3-7 days)
(Type 1 Collagen formation) 4
– Are the WBC’s functional or simply activated packets of proteolytic
enzymes?
1.
2.
3.
4.
Diegelmann RF et al. Wound healing: an overview of acute, fibrotic and delayed healing. Front Biosci 2004; 9: 283-9.
Martin P et al. Inflammatory cells during wound repair: the good, the bad and the ugly. Trends Cell Biol 2005; 15(11): 599-607.
Scott A et al. What do we mean by the term “inflammation”? A contemporary basic science update for sports medicine. Br J Sports Med 2004; 38(3): 372-80.
Kajikawa et al. 2005
RBCs in PRP are not beneficial
• RBC’s can release free radicals
which will have the potential to
destroy surrounding tissue1
• RBC’s can inhibit platelet activation2
– RBCs decrease platelet proximity to
each other
– Positive correlation of PRP hematocrit
and PRP coagulation time
1.
2.
Why is
this PRP
RED?
Jiang N et al. Respiratory protein—generated reactive oxygen species as an antimicrobial strategy. Nat Immunol 2007; 8(10): 1114-22.
Andrade MG et al. Evaluation of factors that can modify platelet-rich plasma properties. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008; 105(1): e5-e12.
Why isn’t more better?
• There may be a threshold for max benefit from increased platelets
– Growth factors attach to cell receptor sites
– Once receptors are full, remaining GFs will degrade away
• Analogy: 1 Glass, 1 Pitcher of Water
– Once glass is full, remaining water wasted if continuing to pour
Die Healing Response Technik
Eine suffiziente Therapieoption bei Partialrupturen des
vorderen Kreuzbandes ?
Fehske K1, Ziai P², Eichhorn HJ³
1
Klinik und Poliklinik für Unfallchirurgie, Universitätsklinikum Würzburg
² AKH der Universität Wien
³ Sporthopaedicum, Straubing
Pilot Studie
Konservative, frühfunktionelle Therapie vs Anmeißelung
31 % vs 74 %
stabile Ergebnisse
Eichhorn, H-J, ACL-Study Group 2000
Subjektives Empfinden bei sportlicher Belastung
6%
7%
stabil
87 %
instabil
schm erzhaft
Revolutionary
• Tissue engineered ligament-replacement
• No donor site morbidity
BMW
Efficient
Dynamics
Studie
Vorsicht vor neuen
Industrie-Raketen:
• Kunststoffbänder (z.B. LARS)
• Xenograft (Centaurus)
• Neue Implantate
BIOLOGIC JOINTS
• Can biologic parts be superior?
Stone K.
XENOGRAFT ACL RECONSTRUCTION DEVICE
Porcine Bone-Patellar Tendon-Bone
• Harvested from closed herd bred
for high health initiative purposes
• Age at sacrifice and breed ensures
anatomic similarity to human BTB
constructs
• De-cellularization
• Treated with recombinant
-galactosidase
• Cross-linked with low-level
glutaraldehyde and inactivation by
end-capping
• Terminally sterilized with 17.8 kGy
irradiation
Evidence based
ist wichtiger als
rethorisches Geschick
Vielen Dank für Ihre Aufmerksamkeit !