全关节镜下基质诱导的自体软骨细胞移植修复膝软骨缺损

[目的]介绍全关节镜下自体软骨细胞移植修复膝软骨缺损的技术及疗效。[方法]选取2016年8月～2018年8月,共有22例膝软骨缺损患者,初次手术取患膝非负重区软骨体外培养、扩增并与胶原纤维支架复合,3周后接受自体软骨细胞移植,全程均在关节镜下进行。术后3、6、12个月随访。[结果]所有患者手术顺利,无严重并发症发生。与术前相比较,术后12个月VAS评分显著降低[(5.36±0.95) vs(0.32±0.48),P0.001],Lysholm评分显著增加[(59.18±4.92) vs(90.64±1.84),P0.001]。术后12个月T2 Mapping核磁Z值较术初显著改善[(0.42±0.06) vs(0.89±0.08),P0.001]。[结论]全关节镜下自体软骨细胞移植修复膝关节缺损可以迅速改善症状,无严重并发症。     

The treatment of cartilage defects in the knee joint: microfracture, mosaicplasty, and autologous chondrocyte implantation

The efficacy of microfracture (MF), mosaicplasty (MO), and autologous chondrocyte implantation (ACI) techniques are still a matter of debate. This review aims to analyze comparative studies of these techniques, review the results of no treatment, and the natural history of untreated articular cartilage lesions. A PubMed search on the topic was performed. The most important (14) articles, as judged by the author, were selected for this review. There is limited evidence that any intervention significantly alters the natural history of these lesions and there is no evidence of significant difference between ACI and MF and MO. Paramount for successful surgical cartilage repair is a stable knee with a well-aligned lower limb. There is insufficient evidence at present to say that ACI is cost-effective, compared with MF or MO.     

Surgical technique for articular cartilage transplantation to full-thickness cartilage defects in the knee joint

Focal arthritic defects in the knee lead to pain, swelling, and dysfunction. Treatment of the defects has includeddrilling, abrasion, and grafting. This report describes our surgical technique of autogenous articular cartilage grafting of arthritic and traumatic articular cartilage lesions. Articular cartilage grafting can be performed as a single arthroscopic outpatient procedure. The mixture of articular cartilage and cancellous bone appears to provide a supportive matrix for cartilage formation. Pain relief is excellent if careful surgical technique and a defined rehabilitation program is followed. Further collagen typing data and additional biopsies will reveal more about the durability of the newly formed cartilage.     

Treatment of full-thickness chondral defects in the knee with autologous chondrocyte implantation

Autologous chondrocyte implantation (ACI) has now been performed for over a decade in the United States. ACI has been demonstrated as a reproducible treatment option for large, full-thickness, symptomatic chondral injuries of the knee. As clinical experience has expanded and indications broadened to more complex cartilage defects, it has become evident that aggressive treatment of coexisting knee pathology is essential for optimal results. This includes management of malalignment, ligamentous, and/or meniscal deficiency, and subchondral bone loss to make the intra-articular environment as ideal as possible for successful cartilage restoration. Additionally, refinements in the rehabilitation necessary for biologic cartilage repair have been made, based on better understanding of the maturation process of the repair cartilage, allowing for earlier initiation of knee range of motion, strengthening exercises, and weight bearing. These changes have enhanced the recovery for the patient and decreased the risk of motion deficits. This article will discuss patient selection for ACI, review ACI surgical technique, including management of coexisting knee pathology, present postoperative ACI rehabilitation guidelines, and summarize clinical outcomes after ACI.     

Osteochondral autologous transplantation for the treatment of full-thickness articular cartilage defects of the shoulder

We performed eight osteochondral autologous transplantations from the knee joint to the shoulder. All patients (six men, two women; mean age 43.1 years) were documented prospectively. In each patient the stage of the osteochondral lesion was Outerbridge grade IV with a mean size of the affected area of 150 mm2. All patients were assessed by using the Constant score for the shoulder and the Lysholm score for the knee. Standard radiographs, magnetic resonance imaging and second-look arthroscopy were used to assess the presence of glenohumeral osteoarthritis and the integrity of the grafts. After a mean of 32.6 months (8 to 47), the mean Constant score increased significantly. Magnetic resonance imaging revealed good osseointegration of the osteochondral plugs and congruent articular cartilage at the transplantation site in all but one patient. Second-look arthroscopy performed in two cases revealed a macroscopically good integration of the autograft with an intact articular surface. Osteochondral autologous transplantation in the shoulder appears to offer good clinical results for treating full-thickness osteochondral lesions of the glenohumeral joint. However, our study suggests that the development of osteoarthritis and the progression of pre-existing osteoarthritic changes cannot be altered by this technique.     

Treatment of cartilage defects with autologous osteochondral grafts in the knee joint

. The treatment of full-thickness cartilage defects still poses problems. One of the currently applied methods to cover defects in the knee joint is osteochondral autografting. The purpose of this prospective study was to assess the outcome of this surgical treatment. Between August 1996 and July 1999, osteochondral transplantation was performed in 38 patients (mean age 37 years). The size of the lesion varied from 1.5 cm² to 6.5 cm². Before the operation the patients had suffered symptoms for an average of 15 months. Osteochondral grafts were harvested from the non-weight-bearing area of the femoral condyle. Patients were evaluated at a mean follow-up of 36 (range 23-58) months. The review protocol included clinical examination, X-ray, and magnetic resonance imaging (MRI). For comparative evaluation the HSS (Hospital for Special Surgery), Lysholm and Tegner activity scores were used. In 86% of the patients studied results were rated good or excellent. There were no infection, thrombophlebitis, or evidence of graft loosening. We conclude autologous osteochondral transplantation is an efficacious and valid one-step repair of the localized damaged articular surface of the knee. Nevertheless, in the future, studies with longer follow-ups and comparison with other forms of biologic resurfacing will be necessary. Résumé. Le traitement des lésions du cartilage articulaire pose encore des problèmes thérapeutiques. Une des méthodes actuellement employées pour réparer des lésions dans l'articulation du genou est l'autogreffe ostéochondrale. Le but de cette étude est d'évaluer les résultats de ce traitement chirugical. Dans la période du ao?t 1996 jusqu'au juillet 1999, 38 patients (age moyen: 37 ans) ont éte traités par une autogreffe ostéochondrale. La taille de la lésion variait de 1.5 cm² à 6.5 cm². Avant d'être opérés, les patients montraient des sympt?mes pour une moyenne de 15 mois. Les greffons ostéochondraux avaient été prélevés dans une zone non portante du condyle fémoral. Les patients ont été surveillès pendant une periode moyenne de 36 mois (de 23 à 58 mois). Le protocole du contr?le incluait des examens cliniques, des radiographies et du MRI. L'évaluation comparative a été executée par les scores d'activités HSS (Hospitale for Special Surgery), Lysholm et Tegner. Dans les 86%, les résultats etaient bons ou excellents. Il n'y a pas eu d'infection ni de thrombophlébite ni de signe que les greffons se détachaient. Nous concluons donc que l'autogreffe ostéochondrale est un moyen efficace, qui peut être exécuté par une seule intervention, pour réparer les lésions localisées de la surface articulaire du genou. Néanmoins, dans l'avenir d'autres études assurant des suivis plus longs et des comparaisons avec d'autres formes de la reconstitution biologique de la surface seront nécessaires.     

Classification of graft hypertrophy after autologous chondrocyte implantation of full-thickness chondral defects in the knee

OBJECTIVE: Graft hypertrophy is a major complication seen in autologous chondrocyte implantation (ACI) with a periosteal flap. We present the first magnetic resonance imaging (MRI) classification for periosteal hypertrophy including a grading of clinical symptoms and the surgical consequences. METHODS: One hundred and two patients with isolated chondral defects underwent an ACI covered with periosteum and were evaluated preoperatively, 6, 18 and 36 months after surgery. Exclusion criteria were meniscal pathologies, axial malpositioning and ligament instabilities. Baseline clinical scores were compared with follow-up data by paired Wilcoxon-tests for the modified Cincinnati knee, the ICRS (International Cartilage Repair Society) and a new MRI score including the parameters defect filling, subchondral edema, effusion, cartilage signal and graft hypertrophy. Hypertrophic changes were graded from 1 (minimal) to 4 (severe). RESULTS: All scores showed significant improvement (P<0.001) over the entire study period. Patients with femoral lesions had significantly better results than patients with patella lesions after 18 and 36 months postoperative (P<0.03). Periosteal hypertrophy occurred in 28% of all patients. Fifty percent of all patella implants developed hypertrophic changes. No patient with grade 1, and all patients with grade 4 hypertrophy had to undergo revision surgery. The Pearson correlation between graft hypertrophy and ICRS score was 0.78 after 6 months, and 0.69 after 36 months (P<0.01). Inclusion of graft hypertrophy in the MRI score improves the correlation to clinical scores from 0.6 to 0.69. CONCLUSIONS: Grading graft hypertrophy helps to identify patients needing an early shaving of the graft. Its integration into an MRI score improves correlation with clinical scores. Re-operation depends on the grade of hypertrophy and clinical symptoms.     

藻酸钙复合自体软骨细胞修复羊膝关节负重区软骨缺损的实验研究

[目的]以中国山羊为动物模型,观察藻酸钙复合自体软骨细胞修复膝关节负重区软骨缺损的可行性。[方法]取羊肩关节软骨,分离、培养软骨细胞,蕃红"O"、 Giemsa及Ⅱ型胶原免疫组织化学染色对其进行鉴定。将自体软骨细胞与藻酸钙凝胶复合,修复山羊股骨髁负重区全层软骨缺损(直径6 mm),实验分为四组:(1)缺损旷置组:缺损内未植入任何组织;(2)骨膜覆盖组:自体骨膜覆盖缺损区;(3)藻酸钙+骨膜组:凝胶植入软骨缺损区,并用自体骨膜覆盖;(4)藻酸钙+细胞+骨膜组:藻酸钙复合自体软骨细胞植入软骨缺损区,自体骨膜覆盖;分别于手术后3、6个月取材,通过大体观察及组织学评分检测修复效果。[结果]软骨细胞复合物蕃红"O"、 Giemsa染色及Ⅱ型胶原免疫组化染色结果均为阳性,将藻酸钙凝胶-软骨细胞复合物用于羊负重区关节面软骨缺损修复,从大体观察和组织学评分进行比较,发现各组均有不同程度的组织修复,藻酸钙+细胞+骨膜组效果最好,与其他组差异有统计学意义(P<0.05)。[结论]藻酸钙凝胶-软骨细胞复合物结合自体骨膜覆盖,可较好修复山羊膝关节负重区软骨缺损。     

Treatment of full-thickness chondral defects with autologous chondrocyte implantation

Autologous chondrocyte implantation (ACI) is a reproducible treatment option for large full-thickness symptomatic chondral injuries with appropriate knowledge of technique and patient selection. It provides a cellular repair that offers a high percentage of good to excellent clinical results over a long follow-up period. It is applicable over a wide range of chondral injuries from simple to more complex lesions. It is essential that the intra-articular environment be as close to normal as possible for successful cartilage repair. Coexisting knee pathology must be aggressively treated. ACI does have a prolonged postoperative rehabilitation course necessitated by the biologic nature of the repair, and patients must be able to comply with the rehabilitation and temporary restrictions required for a successful outcome.     

The effectiveness of autologous chondrocyte implantation for treatment of full-thickness articular cartilage lesions in workers' compensation patients

This prospective longitudinal analysis evaluated the effectiveness of autologous chondrocyte implantation in 24 workers' compensation patients with articular cartilage injuries >2 cm2. Mean lesion size was 4.7 cm2, (range: 2-10 cm2). Nineteen lesions were on the distal femur and 5 were on the patella. Clinical assessment scores improved from a mean of 3.2 at baseline to 6.8 one year postoperatively, with 78% rated good or excellent. Among patients with > or = 1-year follow-up, 63% returned to unrestricted work status at a mean of 7 months; an additional 22% returned to modified work.     

基质诱导的自体软骨细胞移植术修复膝关节软骨缺损1O例术后2年的随访

目的应用基质诱导的自体软骨细胞移植技术（MACI,Genzyme,America）对膝关节软骨损伤的患者进行治疗,通过对患者进行术后2年的随访分析,评价MACI治疗的安全性和有效性。方法从2004年至2008年11月,对10例患者实施MACI手术。患者平均年龄34.9岁（14～57岁）,缺损的平均面积（3.69±2.62）cm2/处（0.4～8cm2,n=20）。MACI技术是从患者非负重区取自体关节软骨,进行体外消化并分离出软骨细胞,培养扩增后接种在Ⅰ/Ⅲ型双层胶原膜上。移植前按缺损的部位修剪成相应形状,用生物蛋白胶将胶原膜粘贴在关节软骨缺损处。分别于术前1周、术后3个月、6个月、1年和2年使用KOOS评分问卷进行临床康复效果的评估并进行术后核磁共振的检测（MRI）。此外,术后对2例患者进行了3次关节镜检查和2次组织学检测。结果 10例患者术后均未发生并发症及与手术相关的不良事件。患者术后3个月KOOS评分显示疼痛明显改善（P〈0.05）;术后6个月KOOS评分显示：疼痛、症状、日常生活、运动及娱乐和生活质量5项均明显升高,5项评分间有统计学差异（P〈0.05）。术后1年和2年患者的情况得到了持续的改善（P〈0.05）。患者术后3个月的MRI显示软骨缺损部位得到大部分填充和修复;6个月移植软骨基本与周围软骨完全整合;1年后修复组织呈等信号,软骨下骨髓水肿消失;2年后大部分患者软骨修复组织信号与周围组织信号强度一致,软骨下骨无骨髓水肿。术后15个月和2年的组织学检查显示新生的软骨组织以透明软骨为主。MACI手术一般都能在2h内完成,术中出血量小于100ml。结论 MACI技术是修复关节软骨缺损安全、可靠和有效的治疗措施,具有操作简单、手术时间短和术中出血量少等特点。     

Repair of human articular cartilage after implantation of autologous chondrocytes

Tissue engineering is an increasingly popular method of addressing pathological disorders of cartilage. Recent studies have demonstrated its clinical efficacy, but there is little information on the structural organisation and biochemical composition of the repair tissue and its relation to the adjacent normal tissue. We therefore analysed by polarised light microscopy and immunohistochemistry biopsies of repair tissue which had been taken 12 months after implantation of autologous chondrocytes in two patients with defects of articular cartilage. Our findings showed zonal heterogeneity throughout the repair tissue. The deeper zone resembled hyaline-like articular cartilage whereas the upper zone was more fibrocartilaginous. The results indicate that within 12 months autologous chondrocyte implantation successfully produces replacement cartilage tissue, a major part of which resembles normal hyaline cartilage.     

First-generation versus second-generation autologous chondrocyte implantation for treatment of cartilage defects of the knee: a matched-pair analysis on long-term clinical outcome

Purpose

Since the introduction of autologous chondrocyte implantation (ACI) for the treatment of cartilage defects, the initial technique has undergone several modifications. Whereas an autologous periosteum flap was used for defect coverage in first generation ACI, a standardized collagen membrane was utilized in second generation ACI. To date, however, no study has proven the superiority of this modification in terms of long-term clinical outcome. The purpose of this matched-pair analysis was therefore to compare the clinical long-term outcome of first and second generation ACI with a minimum follow-up of ten years.

Methods

A total of 23 patients treated with second generation ACI for isolated cartilage defects of the knee were evaluated after a minimum follow-up of ten years using Lysholm and IKDC scores. The results of these patients were compared to those of 23 matched patients treated with first generation ACI. Pair wise matching was performed by defect location, patient age, and defect size.

Results

While all patient characteristics such as age (31.7 years SD 6.9 vs. 31.4 years SD 7.8), defect size (5.1 cm² SD 2.3 vs. 4.9 cm² SD 1.5), and follow-up time (10.7 months SD 1.0 vs. 10.5 months SD 0.6) were distributed homogenously in both treatment groups, significant better Lysholm (82.7 SD 9.9 versus 75.6 SD 11.8; p?=?0.031) and IKDC scores (76.4 SD 12.8 versus 68.0 SD 12.0, p?=?0.023) were found in the group of patients treated with second generation ACI compared to those treated with first generation ACI. In both groups, four patients (17.4 %) received surgical reintervention during follow-up.

Conclusions

The use of a collagen membrane in combination with autologous chondrocytes (second generation ACI) leads to superior clinical long-term outcome compared to first generation ACI. Based on these results, second generation ACI should be preferred over first generation ACI.     

Autologous chondrocyte transplantation for treatment of cartilage defects of the knee joint. Clinical results

Cartilage defects in the knee joint are common and have a bad tendency for healing due to the limited regeneration of hyaline cartilage. Surgeons have an ample choice of various operative treatment measures. Especially for the treatment of larger lesions first results of autologous chondrocyte transplantation (ACT) were published in 1994 [3]. Autologous chondrocytes are isolated from an arthoscopically harvested cartilage biopsy, cultured in vitro and implanted in the defect under a periostal flap in a second procedure. In an international multicenter study 1,051 patients treated with ACT between 6/95 and 12/98 were documented with follow-up examinations after 12 months (588 patients), 24 months (220 patients) and 36 months (40 patients). The majority of the defects (61.2%) were localized on the medial femoral condyle, measuring 4.6 cm2 and mostly described as grade III/IV lesions. The clinical evaluation was performed using a modified Cincinnati knee rating system independently for clinician and patient. Evaluations showed an increase from 3.35 to 6.25 after 24 months and from 3.10 to 6.77 in a scale from 1 (bad) to 10 (excellent). ACT favours defects of the femur with an improvement rate of 85%. Adverse events possibly related to ACT were described in 4.8% of the patients. Diagnostic second-look arthroscopies are included in the reoperation rate of 5.1%. The presented data indicate autologous chondrocyte transplantation as an effective and safe option for the treatment of large full thickness cartilage defects in the knee joint.     

Microfracture for the treatment of cartilage defects in the knee joint – A golden standard?

The evidence for the effectiveness of the microfracture procedure is largely derived from case series and few randomized trials. Clinical outcomes improve with microfracture for the most part, but in some studies these effects are not sustained. The quality of cartilage repair following microfracture is variable and inconsistent due to unknown reasons. Younger patients have better clinical outcomes and quality of cartilage repair than older patients. When lesion location was shown to affect microfracture outcome, patients with lesions of the femoral condyle have the best clinical improvements and quality of cartilage repair compared with patients who had lesions in other areas. Patients with smaller lesions have better clinical improvement than patients with larger lesions. The necessity of long postoperative CPM and restricted weight bearing is widely accepted but not completely supported by solid data. Maybe new developments like the scaffold augmented microfracture⁶ will show even more consistent clinical and biological results as well as faster rehabilitation for the treatment of small to medium sized cartilage defects in younger individuals.All in all there is limited evidence that micro fracture should be accepted as gold standard for the treatment of cartilage lesions in the knee joint. There is no study available which compares empty controls or non-surgical treatment/physiotherapy with microfracture. According to the literature there is even evidence for self regeneration of cartilage lesions. The natural history of damaged cartilage seems to be written e.g. by inflammatory processes, genetic predisposition and other factors. Possibly that explains the large variety of the clinical outcome after micro fracture and possibly the standard tools for evaluation of new technologies (randomized controlled trials, case series, etc.) are not sufficient (anymore).Future technologies will be evaluated by big data from international registries for earlier detection of safety issues, for detection of subtle but crucial co-factors for failure and osteoarthritis as well as for lower financial burdens affecting industry and healthcare systems likewise.     

Autologous chondrocyte implantation versus ACI using 3D-bioresorbable graft for the treatment of large full-thickness cartilage lesions of the knee

Background  

In autologous chondrocyte implantation (ACI), the periosteum patch which is sutured over the cartilage defect has been identified as a major source of complications such as periosteal hypertrophy. In the present retrospective study, we compared midterm results of first-generation ACI with a periosteal patch to second generation ACI using a biodegradable collagen fleece (BioSeed-C) in 82 patients suffering from chronic posttraumatic and degenerative cartilage lesions of the knee.     

微骨折术与自体骨填充治疗距骨软骨缺损的对比研究

目的评估关节镜下自体骨填充固定术与关节镜下微骨折术治疗距骨软骨缺损的临床疗效。 方法选取2012年1月至2016年6月因距骨软骨缺损就诊翼中能源峰峰集团有限公司总医院待行关节镜手术的患者，选择缺损直径大于10 mm可经手术修复的年龄为18～70岁的患者，排除合并类风湿性关节炎、踝关节疾病等病史者。共纳入26例患者，根据随机数字法分为观察组(n ＝11)和对照组(n＝15)，分别行关节镜下自体骨填充固定术和关节镜下微骨折术。使用t检验和卡方检验分析对比两组患者的美国矫形外科足踝协会(AOFAS)评分和疼痛数字评分(NRS)和影像学评价等。 结果两组患者术前一般资料差异无统计学意义(P>0.05)。两组均在术后1年完成随访及CT复查，部分完成MRI复查。术前和术后1年，观察组与对照组在休息和运动时，AOFAS评分和NRS评分无明显差异(P>0.05)。对比术前，同一组术后1年的NRS评分有明显改善(观察组t ＝14.65、7.99；对照组t ＝18.59、5.57；均为P <0.01)。两组MRI结果存在不同，两组患者软骨下骨的平整程度有显著差异(χ²＝7.23，P <0.01)。经关节镜下微骨折术后，12例患者见软骨面不平整，3例患者见软骨面平整，关节镜下自体骨填充固定后3例患者见软骨面不平整，8例患者见软骨面平整。 结论两组手术方法可以得到满意的临床疗效，均适合在临床上进一步推广。