KEYSTONE, Colo. A new
talar osteochondral defect repair technique using
stem cell-rich collagen paste produced excellent results in
maintaining ankle joint viability and mobility in patients, according to Stuart
D. Miller, MD, who presented the study results at the
2011 Annual Meeting of the American Orthopaedic Foot and Ankle
This is an extension of the
microfracture concept, Miller said. We are trying
to increase the number of stem cells and give it a more three-dimensional
scaffold so it can form
hyaline cartilage instead of
The stem cell-rich collagen paste was successful in returning many
patients to normal activity. Miller and his co-investigator Lew C. Schon, MD,
have performed the procedure on 25 patients thus far during a 3-year period.
We have a number of home runs where a patient has had complete
resumption of athletic activity including runners going back to running 12 to
15 miles per week, Miller said.
Hyaline cartilage more durable
The stem cell-rich paste, according to Miller, works better than
microfracture surgery alone because the hyaline cartilage created by the paste
is more durable than the fibrocartilage formed by microfractures.
Miller conceived the idea from another orthopedist at Rizzoli Insitute
in Italy, Francesca Vannini, MD. She used a matrix-induced autologous
chondrocyte implant (MACI, Genzyme Europe BV, Naarden, The Netherlands) as a
matrix for cartilage stem cells growth. These matrices are not available in the
United States, Miller explained, so he and his team used collagen from Integra
Life Sciences that is used for wound filling as the substrate.
How it is made
To create the paste, Miller and his team harvest the bone marrow from
patients at the time of surgery with a small needle aspiration of bone marrow
from the iliac crest. The marrow is spinned down and mixed with particulate
During the procedure, Miller and his team use an open
arthrotomy, such as a
plafondplasty, because it provides more exposure.
More often, I have been going through a more open procedure
because it is easier for me to obtain a nice contour to the collagen and there
is not as much morbidity to the patient to do a small arthrotomy, Miller
Next, the orthopedists add a drop of fibrin glue to the base of the
osteochondral defect and pour stem cell-rich paste into the defect, over which
they add two or three more drops of fibrin glue.
Usually, that involves releasing the attraction on the joint and
letting the corresponding tibial surface give you the appropriate contour to
the fibrin glue topping, Miller said.
The best candidates for stem cell-rich collagen paste are those with
deeper defects, Miller added. Other inclusion criteria in the study were repeat
microfractures or defects greater than 1 cm.
The researchers noted two patients who did not improve and needed DeNovo
juvenile cartilage allografts.
Miller and his colleagues continue to follow up on the patients who
undergo the procedure. Their next step is to collect outcomes of their MRI
findings to examine the regeneration of appropriate cartilage
signal, Miller said.
They also plan to conduct a study comparing patients undergoing DeNovo
vs. stem cell-rich collagen paste.
We are still waiting to determine outcomes, but it is yet another
option in treating osteochondral defects while preserving joint motion,
Miller said. We think it is better than microfracture alone for larger
defects. by Renee Blisard
- Miller SD, Schon LC. A new technique: Arthroscopic filling of
osteochondral defects with stem cell-rich collagen paste. Paper #7. Presented
at the 2011 Annual Meeting of the American Orthopaedic Foot and Ankle Society.
July 13-16. Keystone, Colo.
- Stuart D. Miller, MD, can be reached at Greater Chesapeake
Orthopaedic Associates, LLC, 3333 North Calvert St., Suite 400, Baltimore, MD
21201; 410-554-6530; email: firstname.lastname@example.org.
- Disclosure: Miller is a consultant for Integra and Biomet.
As our society is increasingly more active, osteochondral injuries to
the talus are becoming more commonly recognized causes of ankle pain and
disability. Yet, the treatment of these lesions remains challenging because of
the limited healing capacity of articular cartilage. The concern with
traditional reparative techniques, including arthroscopic debridement, drilling
and/or microfracture, is long-term fibrocartilage degradation. The use of stem
cells has been proposed to help form organized hyaline cartilage in the repair
of talar osteochondral lesions.
Drs. Miller and Schon present a novel technique of treating these
lesions. The authors attempt to create a hyaline cartilage repair utilizing a
paste of a concentrated stem cell-rich portion of autologous iliac crest bone
marrow aspirate mixed with a flowable particulate collagen/glycosaminoglycan.
Following debridement and microfracture through an arthroscopic or limited open
approach, the paste is then applied with a fibrin glue covering and molded to
the corresponding tibial surface.
As the authors note, patients with more defined and discrete articular
surface lesions fare better. Further studies utilizing MRI and cartilage
mapping should help to determine which lesions are most likely to benefit from
this novel treatment. While early reports are encouraging, longer term
follow-up is needed to confirm the durability and efficacy of this repair, and
to evaluate the relative benefit of this technique compared to microfracture
Craig S. Radnay, MD
Insall Scott Kelly
Institute for Orthopedics and Sports Medicine
New York City
Disclosure: Radnay is a consultant for Smith & Nephew and Wright
Medical, and is on the speakers panel for Ortho McNeil Janssen.