Stem cell ACL, cartilage repair India may be game changer

A young lady with combined anterior cruciate ligament and cartilage injury of her knee was treated with her own cells in Chennai through key-hole surgery. This is the first time that a patient’s own cells were used to repair a partial tear of the anterior cruciate ligament (ACL). A cartilage lesion under her knee cap was also simultaneously repaired using cells.

Case report– A 25-year-old AP housewife injured her right knee in a domestic fall two years ago. Following this, her knee would give way while descending stairs. She also felt pain on sitting. She sought treatment in Chennai from Dr.A.K.Venkatachalam. An MRI scan showed a partially torn anterior cruciate ligament (ACL) and cartilage damage underneath her knee cap. A key-hole surgery clearly identified the problem.  One of the two bundles of the ACL was partially torn. The other bundle was still attached. There was loss of cartilage under the knee cap. It was decided to repair the ligament and cartilage with her cells through key-hole surgery.  An intra-ligamentous injection of cells into the torn ligament was done and the cartilage lesion was treated with a cell gel technique in an one and half hour long key hole surgery procedure.
The patient is recovering with therapy and has been relieved of pain. The final result will be known by an MRI scan in future and its result too will be presented.

Discussion– The anterior cruciate ligament is the major internal ligament.  It stabilizes the knee joint in a front- back direction. Tears of this ligament occur in sports, road accidents and domestic falls. This injury invariably leads to degenerative changes in the knee and hence orthopedic surgeons advice surgical reconstruction.  Surgery for ACL tears involves taking down the torn ligament and replacing it with a ligament harvested from another part of the body. This is called an ACL reconstruction and it is the gold standard of ACL surgery.

Disadvantages of standard ACL reconstruction–

1. Recovery can take as long as one-year before return to sports is possible.
2. High risk of graft failure- A study published in the American Journal of sports medicine in 2014 showed that young patients had a risk of graft rupture².
3. Lack of stretch sense – Proprioceptive sense inherent in the native ligament is gone forever whatever the physical therapy input be.
4. Lack of full recovery in the donor tissue- The hamstring muscle from which the graft is harvested rarely regains its strength.
5. Risk of degenerative changes. This occurs invariably and more commonly in women.

So how does one avoid degenerative changes and additional morbidity associated with ACL reconstruction while retaining stability? This has sparked an interest in ACL repair with or without biologics.
A further development is the injection of biological cells into the torn ACL to make it heal. There is evidence that partial and in some early cases, even full thickness ACL tears can be healed with cell therapy. This is based on experimental evidence in both animals and humans.
A small case series in humans is available for treatment of ACL injuries with precisely targeted cell injections without key-hole surgery¹.

What are the benefits of cell repair of ACL tears over standard ACL reconstruction?

1. Morbidity associated with graft harvest from another body source is avoided. The risk of infection from a cadaveric allograft is also eliminated.
2. The recovery time with cell repair is much less than with a full ACL reconstruction. Recovery begins right away and takes about six to twelve weeks as against the six to nine months required for a full ACL reconstruction surgery. This is of great value to professional sports person as well as others. Everybody wants to recover faster from their ailments and lead normal lives.
3. The cost too is far less when you consider the surgical cost, rehab cost, time required off work and costs involved in inability to return to sports.

What is the benefit of key-hole surgery in this condition?

1. Key-hole surgery allows the surgeon to visualize the whole of the ligament including its bony attachments at both ends, tug at it to check its integrity and take the appropriate decision based on intra operative findings. This is what was done for this young lady. As the ligament was only partially torn, cells were injected into the torn portion to induce a biological healing response in accordance with evidence.
   Direct visualization of the other structures like cartilage and menisci is possible. In this case the MRI documented area of cartilage loss under the knee cap was reconfirmed. This too could be treated with cells.

Both the problems were treated with the patient’s own bone marrow derived cells in a one and half hour long procedure.

Who would benefit from cell treatment of ACL tears?

1. It would mainly benefit those patients with partial ACL tears in which part of the ligament is still attached to bone or there is a mid-substance partial tear.
2. Also it could contribute to patients who undergo surgical repair of un-retracted tears as opposed to reconstruction.
3. There is evidence that it also improves the healing of standard ACL reconstruction by improving the quality of ligament tissue and ligament-bone interfaces.

To benefit from cell mediated ACL repair, patients should seek medical help soon after a knee injury.
Not all patients with a knee injury seek help immediately. Case selection is very important. Delay in diagnosis and treatment leads to wide separation of the torn ends and results in additional damage to cartilage and menisci. These patients may well need an ACL reconstruction.
Patients with a partially torn ligament and minimal retraction of the ACL ends are most likely to benefit from this treatment. This would be possible only if patients sought medical attention soon after injury. Earlier MRI diagnosis would identify suitable cases for cell treatment. It would allow minimally invasive repair or stem cell treatment and avoid further damage to the menisci and articular cartilage.

To sum up, this novel key-hole cell mediated ACL; cartilage repair is likely to be a game changer. It will allow patients to retain their own ACL, preserve joint sensation, hasten recovery and lower costs. Biological treatments are finding an increasing role in orthopedic ailments.

References-

1. http://www.regenexx.com/wp-content/uploads/2015/08/anterior-cruciate-ligament-tears-treated-with-percutaneous-i_073115_26261.pdf
2. http://ajs.sagepub.com/content/42/3/641.abstract

See the video of the procedure Stem cell ACL,cartilage repair India .