治疗关节软骨缺损手术方法的比较

目的对比研究骨膜移植术,软骨细胞移植术和骨软骨钻孔术对关节软骨损伤的修复。方法 纯种青紫蓝兔４４只,随机分为Ａ、Ｂ、Ｃ、Ｄ４组,在膝关节作全层软骨缺损模型,Ａ、Ｂ、Ｃ组分别选择行上述一种操作,Ｄ组不作处理。术后４、８、１２周取材作大体,光镜和电镜观察。结果 各组缺损均有不同程度修复,但修复优势组织性质有所差别。结论 自体游离骨膜移植术的钻孔术修复关节节软骨缺损效果明显优于未处理组,其中以钻孔术为简     

Osteochondritis dissecans of the talus treated by the transplantation of tissue-engineered cartilage

Management of osteochondral lesions of the joint has been difficult, because articular cartilage has a poor healing capacity as a result of its lack of vessels, nerve supply, and its isolation of systemic regulation. Although a lot of basic research and surgical treatments for cartilage repair have focused on osteochondral lesions in the knee joint, orthopedic surgeons have recently diverted their attention to osteochondral lesions in the ankle joint, partly because of the widespread introduction of arthroscopy in ankle surgery. There have been many attempts to treat articular cartilage defects in the ankle joint as well as in the knee joint. However, no treatment has achieved efficient healing with hyaline cartilage. Recently, tissue engineering technique for cartilage repair has been gaining much attention in the orthopedic field. In this study, we reported on a patient with osteochondritis dissecans of the talar dome, successfully treated by transplantation of tissue-engineered cartilage made ex vivo using atelocollagen gel and low tibial osteotomy.     

保留钙化层结构的猪股骨滑车全厚软骨缺损模型建立

目的建立保留钙化层结构的猪股骨滑车全厚软骨缺损模型,为观察组织工程软骨在保留钙化层的膝关节软骨缺损模型中的修复效果提供良好的实验研究平台。方法选取6月龄清洁级贵州小香猪9只,体重40～50 kg,用标准的软骨缺损制作套件在其右后肢股骨滑车切迹旁制备直径6 mm、深0.2～0.5 mm、不伤及钙化层结构的圆柱形全厚软骨缺损模型。造模4周后行3.0T MRI观察,取材后进行大体、体视显微镜观察及固绿-番红O、阿利新蓝、天狼星红组织学染色观察缺损处软骨修复情况。结果造模后实验动物均存活,术后切口无感染,无髌骨脱位;术后即可下地行走并部分负重,1周后均能自由活动,无跛行。造模后4周,MRI检查可见滑车处有明显连续信号中断,异常信号深及软骨下骨,缺损周边深层未见明显信号异常。标本大体观察示缺损底部有少量填充物、出血点,与周围正常软骨界限清楚。体式显微镜观察示钙化层基本完整,缺损局部软骨下骨板有塌陷。普通显微镜下,固绿-番红O及阿利新蓝染色示缺损处无软骨细胞及染料着色;偏光显微镜下,天狼星红染色示缺损底部被连续、强折光性的纤维组织少量填充。结论通过该造模方法制作的不伤及钙化层结构的猪股骨滑车全厚软骨缺损模型,可用于骨关节炎早期软骨病变修复的研究及猪软骨钙化层结构作用研究的动物模型。     

High susceptibility of human articular cartilage glycosaminoglycan synthesis to changes in inorganic sulfate availability

The effect of sulfate concentration in the medium on glycosaminoglycan synthesis in articular cartilage of five different species was examined in relation to the physiological serum sulfate concentration in these species. Only the rate of sulfated glycosaminoglycan synthesis in human articular cartilage was sensitive to small deviations from the physiological sulfate concentration. A reduction in the sulfate concentration from 0.3 mM (physiological) to 0.2 mM resulted in a 33% reduction in glycosaminoglycan synthesis. In addition, we studied the effect of arthritic and "osteoarthritic" alterations in murine cartilage on the dependence of glycosaminoglycan synthesis on low sulfate concentrations. Arthritic and "osteoarthritic" cartilage had a similar dependence on the sulfate concentration in the medium as normal cartilage. Glycosaminoglycan synthesis in human articular cartilage appears to be very sensitive to the potential sulfate-depleting effects of drugs used in the treatment of rheumatoid arthritis and osteoarthritis.     

髋臼后壁重建后关节软骨修复的实验研究

目的 研究髋臼后壁重建区臼面软骨修复的组织学特点,初步探讨软骨柱播种在其修复中的作用。方法 选取12只家犬共24髋,随机分为3组,均采用后壁截骨法建立髋臼后壁60°弧1/2缺损的动物模型,两侧髋臼后壁缺损区分别选用不同的重建方法：A组：解剖重建+软骨柱播种,B组：解剖重建,C组：普通重建。术后12周取材进行大体形态、光镜观察,参照Pineda标准对新生组织进行评分。结果 A组中以成熟、新生类透明软骨修复缺损,B组为类纤维软骨修复,C组为纤维肉芽组织或板层骨修复。A、B、C组关节软骨修复Pineda总评分平均分别为(5.1±0.1)、(6.5±0.2)、(12.3±0.2)分,差异有统计学意义(F=3.157,P=0.000),3组间两两比较差异均有统计学意义(P＜0.05)。结论 解剖重建促使部分软骨柱集中在缺损区,其修复组织具备部分关节软骨的组织特性,能够较好地替代关节软骨。     

Minced cartilage without cell culture serves as an effective intraoperative cell source for cartilage repair.

Traumatic articular cartilage injuries heal poorly and may predispose patients to the early onset of osteoarthritis. One current treatment relies on surgical delivery of autologous chondrocytes that are prepared, prior to implantation, through ex vivo cell expansion of cartilage biopsy cells. The requirement for cell expansion, however, is both complex and expensive and has proven to be a major hurdle in achieving a widespread adoption of the treatment. This study presents evidence that autologous chondrocyte implantation can be delivered without requiring ex vivo cell expansion. The proposed improvement relies on mechanical fragmentation of cartilage tissue sufficient to mobilize embedded chondrocytes via increased tissue surface area. Our outgrowth study, which was used to demonstrate chondrocyte migration and growth, indicated that fragmented cartilage tissue is a rich source for chondrocyte redistribution. The chondrocytes outgrown into 3-D scaffolds also formed cartilage-like tissue when implanted in SCID mice. Direct treatment of full-thickness chondral defects in goats using cartilage fragments on a resorbable scaffold produced hyaline-like repair tissue at 6 months. Thus, delivery of chondrocytes in the form of cartilage tissue fragments in conjunction with appropriate polymeric scaffolds provides a novel intraoperative approach for cell-based cartilage repair.     

Basic science and surgical treatment options for articular cartilage injuries of the knee

The complex structure of articular cartilage allows for diverse knee function throughout range of motion and weight bearing. However, disruption to the structural integrity of the articular surface can cause significant morbidity. Due to an inherently poor regenerative capacity, articular cartilage defects present a treatment challenge for physicians and therapists. For many patients, a trial of nonsurgical treatment options is paramount prior to surgical intervention. In instances of failed conservative treatment, patients can undergo an array of palliative, restorative, or reparative surgical procedures to treat these lesions. Palliative methods include debridement and lavage, while restorative techniques include marrow stimulation. For larger lesions involving subchondral bone, reparative procedures such as osteochondral grafting or autologous chondrocyte implantation are considered. Clinical success not only depends on the surgical techniques but also requires strict adherence to rehabilitation guidelines. The purpose of this article is to review the basic science of articular cartilage and to provide an overview of the procedures currently performed at our institution for patients presenting with symptomatic cartilage lesions.     

Magnetic resonance imaging for diagnosis and assessment of cartilage defect repairs

Clinical magnetic resonance imaging (MRI) is the method of choice for the non-invasive evaluation of articular cartilage defects and the follow-up of cartilage repair procedures. The use of cartilage-sensitive sequences and a high spatial-resolution technique enables the evaluation of cartilage morphology even in the early stages of disease, as well as assessment of cartilage repair. Sequences that offer high contrast between articular cartilage and adjacent structures, such as the fat-suppressed, 3-dimensional, spoiled gradient-echo sequence and the fast spin-echo sequence, are accurate and reliable for evaluating intrachondral lesions and surface defects of articular cartilage. These sequences can also be performed together in reasonable examination times. In addition to morphology, new MRI techniques provide insight into the biochemical composition of articular cartilage and cartilage repair tissue. These techniques enable the diagnosis of early cartilage degeneration and help to monitor the effect and outcome of various surgical and non-surgical cartilage repair therapies.     

鼻翼软骨缝合与鼻中隔软骨移植并用纠正女性鼻头宽大低垂

目的：探讨鼻翼软骨缝合与自体鼻中隔软骨移植并用,纠正女性鼻头宽大低垂的整形手术方法。方法：设计鼻小柱开放式切口,自体鼻中隔软骨做鼻小柱支柱和盾形移植,同时进行鼻翼软骨内侧脚顶缝合。结果：本组就医者22例,术后随访3～24个月,全部就医者术后鼻部美学效果明显改善,形态自然。结论：自体鼻中隔软骨做鼻小柱支柱和盾形移植,同时进行鼻翼软骨内侧脚顶缝合,是纠正女性鼻头宽大低垂有效的手术方法。     

Repair of articular surfaces by allografts of articular and growth-plate cartilage

Allografts of intact cartilage, isolated chondrocytes and cultured chondrocytes taken from the epiphysial growth-plate and from the articular surface of immature rabbits were inserted into full thickness defects in the tibial articular surface of 160 mature rabbits. In the contralateral knees, which were used as controls, similar defects were made but no grafts were inserted. Grafts were followed up for periods of up to one year after transplantation. Both intact articular and intact growth-plate grafts produced significantly better repair than that seen in control ungrafted defects in normal joints (P less than 0.01 and P less than 0.05 respectively) and in arthritic joints (P less than 0.01). Cultured chondrocytes cut to a precise fit also produced significantly better repair than ungrafted defects in arthritic joints (P less than 0.05).     

The chondrogenic repair response of undifferentiated mesenchymal cells in rat full-thickness articular cartilage defects

OBJECTIVE: The aim of this study is to develop a rat model of full-thickness articular cartilage defects that is suitable for detailed molecular analyses of the regenerative repair of cartilage. MATERIALS AND METHODS: The V-shaped full-thickness defects (width: 0.7 mm; depth: 0.8 mm; and length: 4mm) were created in the femoral patellar groove of 6 weeks old male rats using a custom-built twin-blade device. Prior to starting the repair experiments, our device was examined for its accuracy and reliability in generating defects. Then, the time course of the repair response in these cartilage defects was examined using a semi-quantitative histological grading scale. The expression of chondrogenic differentiation markers in the reparative regions was examined with immunohistochemistry and in situ hybridization. RESULTS: Our device creates full-thickness articular cartilage defects uniformly. In these defects, undifferentiated mesenchymal cells filled the defect cavities (4 days) and initiated chondrogenic differentiation at the center of the defect (7 days). Cartilage formation was observed in the same region (2 weeks). Finally, hyaline-like articular cartilage and subchondral bone layers were reconstituted in their appropriate locations (4 weeks). CONCLUSIONS: We have successfully developed a rat model containing identically sized full-thickness defects of articular cartilage that can undergo chondrogenic repair in a reproducible fashion.     

In vitro model of full-thickness cartilage defect healing.

Integration of the host-graft interface is implicated as one of the significant reasons for lack of complete healing in osteochondral grafting procedures for the treatment of cartilage lesions. We developed an in vitro model of cartilage healing in an osteochondral setting to study the effect of developmental age and collagenase treatment. Circular full-thickness vertical surgical incisions were made in the cartilaginous portion of cylindrical bovine osteochondral specimens. Two age groups were selected: Young (1-2 months old) and Older (6-8 months old). Cartilage integration across the surgical incisions was assessed by histologic analysis and by mechanical push-out testing at 2 and 4 weeks in culture. Histologic integration as well as peak push-out shear stress was significantly higher in older calf cartilage than in the young calf. Collagenase pretreatment in the older calf samples increased push-out strength at 4 weeks. Histologic integration correlated well with the mechanical push-out strength. Developmental age and time after injury affected the response to collagenase pretreatment. This osteochondral cartilage integration model can be useful to study factors that modulate healing of surgical replacement procedures in vitro, which may aid the development of newer approaches to promote the healing of cartilage defects.     

The use of debrided human articular cartilage for autologous chondrocyte implantation: maintenance of chondrocyte differentiation and proliferation in type I collagen gels.

Autologous chondrocyte implantation (ACI) is the most promising surgical treatment for large full thickness knee joint articular cartilage (AC) defects where cells from healthy non-weight bearing area AC are multiplied in vitro and implanted into such defects. In the routine surgical procedure for symptomatic knee full thickness AC defects, damaged AC surrounding the edge and the base of such defects is usually debrided and discarded. The purpose of this study was to examine if chondrocytes from this 'debrided' AC can proliferate, synthesize a cartilage specific matrix and thus can be used for ACI. METHODS: Biopsies were retrieved from 12 patients (debrided articular cartilage: DAC, aged 35-61) and from two autopsies (normal articular cartilage: NAC, aged 21 and 25). Chondrocytes were isolated, seeded at low density in type I collagen gels and as monolayer cultures for 4 weeks without passage. RESULTS: After 4 weeks cultures in type I collagen gels, cell proliferation from DAC (18.34 +/- 1.95 fold) was similar to cells from NAC (11.24 +/- 1.02 fold). Syntheses of proteoglycan and collagen in DAC were also similar to NAC. Newly synthesized matrices in gel cultures consisted predominantly of type II collagen as shown by immuno-labelling and SDS-PAGE followed by fluorography. Chondrocytes from 'debrided human AC' cultured at low density in type I collagen gels may be used for the ACI procedure as they provide sufficient viable cell numbers for ACI and maintain their chondrocyte phenotype as they synthesize a cartilage-like matrix.     

Delayed gadolinium‐enhanced magnetic resonance imaging of cartilage (dGEMRIC) in Femoacetabular impingement

Femoroacetabular impingement is a well‐described pre‐arthritic condition with two main types; cam and pincer. Studies using the open treatment for impingement have described patterns of articular cartilage wear specific to cam and pincer impingement. Assessing articular damage in the hip joint is an important component of treatment. Intravenous gadolidium allows radiologists to perform an indirect assessment of articular cartilage glycosaminoglycan (GAG) content by using a technique called dGEMRIC. Using this indirect assessment of articular cartilage, we compared the dGEMRIC indices in a group of six cam and seven pincer patients to a control group (n = 12) of asymptomatic controls that had no plain MRI findings of osteoarthritis. The superior portion of the hip joint was divided into seven regions from 9 to 3 o'clock. These regions were then subdivided into peripheral and central regions. The cam and pincer groups both had statistically lower dGEMRIC values compared to the control group. The cam group demonstrated not only peripheral but also central involvement of the joint and this was concentrated in the anterior portion of the joint. The pincer group exhibited more global hip involvement with all areas of the hip averaging a dGEMRIC index 28% less than controls. With the use of dGEMRIC more specific patterns of cartilage wear can be elicited in patients with impingement, which may improve patient selection and help better understand the progression of osteoarthithis throughout the hip joint. © 2011 Orthopaedic Research Society Published by Wiley Periodicals, Inc. J Orthop Res 29: 1305–1311, 2011     

Formation of cartilage repair tissue in articular cartilage defects pretreated with microfracture and covered with cell‐free polymer‐based implants

The aim of our study was to evaluate the mid‐term outcome of a cell‐free polymer‐based cartilage repair approach in a sheep cartilage defect model in comparison to microfracture treatment. Cell‐free, freeze‐dried implants (chondrotissue®) made of a poly‐glycolic acid (PGA) scaffold and hyaluronan were immersed in autologous serum and used for covering microfractured full‐thickness articular cartilage defects of the sheep (n = 4). Defects treated with microfracture only served as controls (n = 4). Six months after implantation, cartilage implants and controls were analyzed by immunohistochemical staining of type II collagen, histological staining of proteoglycans, and histological scoring. Histological analysis showed the formation of a cartilaginous repair tissue rich in proteoglycans. Histological scoring documented significant improvement of repair tissue formation when the defects were covered with the cell‐free implant, compared to controls treated with microfracture. Immunohistochemistry showed that the cell‐free implant induced cartilaginous repair tissue and type II collagen. Controls treated with microfracture showed marginal formation of a mixed‐type repair tissue consisting of cartilaginous tissue and fibro‐cartilage. Covering of microfractured defects with the cell‐free polymer‐based cartilage implant is suggested to be a promising treatment option for cartilage defects and improves the regeneration of articular cartilage. © 2009 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 27:1353–1360, 2009     

Transplantation of free tibial periosteal grafts for the repair of articular cartilage defect: An experimental study

Background:

Articular chondrocytes have got a long lifespan but rarely divides after maturity. Thus, an articular cartilage has a limited capacity for repair. Periosteal grafts have chondrogenic potential and have been used to repair defects in the articular cartilage. The purpose of the present study is to investigate the differentiation of free periosteal grafts in the patellofemoral joint where the cambium layer faces the subchondral bone and to investigate the applicability of periosteal grafts in the reconstruction of articular surfaces.

Materials and Methods:

The study was carried out over a period of 1 year on 25 adult, male Indian rabbits after obtaining permission from the institutional animal ethical committee. A full-thickness osteochondral defect was created by shaving off the whole articular cartilage of the patella of the left knee. The defect thus created was grafted with free periosteal graft. The patella of the right knee was taken as a control where no grafting was done after shaving off the articular cartilage. The first animal was used to study the normal histology of the patellar articular cartilage and periosteum obtained from the medial surface of tibial condyle. Rest 24 animals were subjected to patellectomy, 4 each at serial intervals of 2, 4, 8, 16, 32 and 48 weeks and the patellar articular surfaces were examined macroscopically and histologically.

Results:

The grafts got adherent to the underlying patellar articular surface at the end of 4 weeks. Microscopically, graft incorporation could be appreciated at 4 weeks. Mesenchymal cells of the cambium layer were seen differentiating into chondrocytes by the end of 4 weeks in four grafts (100%) and they were arranged in a haphazard manner. Till the end of 8 weeks, the cellular arrangement was mostly wooly. At 16 weeks, one graft (25%) had wooly arrangement of chondrocytes and three grafts (75%) had columnar formation of cells. Same percentage was maintained at 32 weeks. Four grafts (100%) at 48 weeks showed columnar orientation. The control side showed no changes over the shaved off articular surface in all the rabbits. One rabbit at 4 weeks had a dislocation of the patella on the control side. None of the rabbits developed any infection or wound dehiscence.

Conclusion:

Autologous periosteal graft transplantation can be a promising substitute for articular cartilaginous defects.     

The role of mandibular condylar cartilage in articular cartilage repair.

The articular hyaline cartilage of synovial joints has a very limited capacity for repair after injury. In contrast, the mandibular condylar cartilage of the temporomandibular joint possesses as intrinsic potential for regeneration. This study aimed to test the hypothesis that cultured allografts of mandibular condylar cartilage could be used to promote biological repair of injured orthotopic joint surfaces. Using a primate animal model, cultures of mandibular condylar cartilage cells were grafted into surgically created defects in a recipient hyaline cartilage joint surface. Articular wound healing was assessed macroscopically and histologically over a postoperative period of 52 weeks. Mandibular condylar cartilage cells scheduled for allogenous transplantation were initially characterised in vitro. Expansion of primary colonies in organ culture provided the allogenic cellular material for in vivo grafting. Grafting of osteochondral articular wounds with 5-week cultures of mandibular cartilage cells led to wound regeneration with complete reconstitution of articular surface continuity by 52 weeks. There was novel synthesis of cartilage collagens and sulphated glycosaminoglycans within the repair tissue and no evidence of immunological rejection. Healing of grafted defects was thought to occur by a combination of donor cell proliferation and ingress of host mesenchymal cells. In contrast, grafted control wounds underwent largely fibrous repair with incomplete articular regeneration. In conclusion, transplanted allografts of cultured mandibular condylar cartilage appeared to have the ability, in this primate model, to promote cartilaginous repair and regeneration of orthotopic articular wounds.     

残留软骨切下回植治疗手外伤后指间关节部分软骨缺损的临床疗效

目的 探讨残余软骨切下回植治疗指间关节部分软骨缺损的临床疗效。方法 自2012年6月至2019年8月共收治指间关节面部分软骨质缺损患者16例（16指）,近侧指间关节5例,远侧指间关节11例,切下残留软骨（残留达半面或以上）回植治疗重建指间关节,术后对指关节稳定性,外观、功能恢复等指标进行分析评估。结果 术后随访 12~60 个月,平均 36 个月,均未发现软骨坏死,指间关节侧弯畸形充分矫正,关节僵硬改善较好,侧弯面软组织挛缩得到有效改善,外观基本恢复。近侧指间关节屈曲达60°~90°,远侧指间关节屈曲达40°~80°。按照中华医学会手外科学会上肢部分功能评定试用标准进行评定,优 10例,良3例,可3例,优良率达到81.25%。结论 残留软骨回植治疗指间关节部分软骨缺损可部分重建关节功能,临床疗效满意。     

孔数不同的骨钻孔术对兔软骨缺损远期修复效果的实验比较

目的: 评价孔数不同的钻孔术对软骨缺损的远期修复效果。方法: 用中国白兔40只, 在股骨髁关节面制造6mm×8mm全层软骨缺损, 分别施行10孔及5孔钻孔术, 孔径1mm, 于术后13个月取材做组织学及电镜观察,并进行评估。结果: (1) 10孔、5孔和对照组中, 优势修复组织为透明软骨者分别占75%、70%、0%。(2) 修复组织厚度: 10孔与5孔无显著性差异, 已接近毗邻软骨厚度。(3) 修复组织覆盖缺损的面积: 10孔>5孔>对照组。结论: 软骨下骨钻孔对关节软骨缺损的远期修复效果良好, 能长期适应关节的运动和负重, 10孔比5孔的修复效果好。     

Hyaline cartilage degenerates after autologous osteochondral transplantation.

OBJECTIVES: Autologous osteochondral grafting is a well-established clinical procedure to treat focal cartilage defects in patients, although basic research on this topic remains sparse. The aim of the current study was to evaluate (1) histological changes of transplanted hyaline cartilage of osteochondral grafts and (2) the tissue that connects the transplanted cartilage with the adjacent cartilage in a sheep model. METHOD: Both knee joints of four sheep were opened surgically and osteochondral grafts were harvested and simultaneously transplanted to the contralateral femoral condyle. The animals were sacrificed after three months and the received knee joints were evaluated histologically. RESULTS: Histological evaluation showed a complete ingrowth of the osseous part of the osteochondral grafts. A healing or ingrowth at the level of the cartilage could not be observed. Histological evaluation of the transplanted grafts according to Mankin revealed significantly more and more severe signs of degeneration than the adjacent cartilage, such as cloning of chondrocytes and irregularities of the articular surface. CONCLUSION: We found no connecting tissue between the transplanted and the adjacent cartilage and histological signs of degeneration of the transplanted hyaline cartilage. In the light of these findings, long-term results of autologous osteochondral grafts in human beings have to be followed critically.