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

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.