Die Transplantation autogener Knorpelzellen in Gelenkflächendefekte des Kniegelenks

Objective Repair of articular cartilage defects of knee to restore a pain-free joint function. Indications Full-thickness chondral or osteochondral posttraumatic lesions and osteochondritis dissecans defects that have not been successfully repaired with methods such as debridement, drilling, and microfracturing. Contraindications Osteoarthritis. Rheumatoid arthritis. Sugical Technique During arthroscopy, the cartilage lesion is evaluated, and cartilage slices weighing 200–300 mg are harvested from the upper medial femoral condyle, a minor load bearing area. The chondrocytes are isolated enzymatically and grown in culture to increase the cell number during approximately 2 weeks. During the second operation, an arthrotomy is performed through a medial or lateral parapatellar approach. The defect is carefully debrided. A periosteal patch is obtained from proximal tibia, placed over the defect and sutured to the surrounding cartilage. The suture line is sealed with fibrin glue, and the chondrocytes are injected into the defect under the patch. Results Recently, Peterson has presented results in 213 patients with a follow-up between 2–10 years. He reported good to excellent results in 90% of 57 patients with single femoral condyle lesions, in 84% of 32 patients with osteochondritis dissecans and in 74% of 27 patients with femoral condyle lesions in combination with anterior cruciate ligament reconstruction. In 32 patients the patella was grafted and 22 improved, in twelve patients the trochlea was grafted and seven improved, and in 53 patients multiple lesions were grafted and 42 improved. Second-look arthroscopies were performed in 46 patients, 26 of them were biopsied; the transplanted tissues showed a hyaline-like appearance in 21 patients (80%).     

Treatment of chondral lesions in advanced osteochondritis dissecans: a comparative study of the efficacy of chondrocytes, mesenchymal stem cells, periosteal graft, and mosaicplasty (osteochondral autograft) in animal models

Management of chondral lesions in osteochondritis dissecans remains a challenge. This study investigated the efficacy of periosteal graft, osteochondroidal autograft, autologous chondrocyte and mesenchymal stem cell transplants in the treatment of chondral lesions in animal models. Full-thickness articular cartilage defects were created in the weight-bearing surface of the medial femoral condyle in 20-week-old NZW rabbits. A total of 56 knees were randomly divided into four groups as follows: group 1, transfer of cultured chondrocytes; group 2, transfer of cultured mesenchymal stem cells; group 3, repair by periosteal graft; and group 4, mosaicplasty. All of the contralateral knees served as control. Gross, histologic, and biomechanical examinations at 36 weeks after the operation showed that the cultured chondrocytes and mesenchymal stem cells had comparable enhancing effects on the repair of chondral defects in advanced osteochondritis dissecans, whereas mosaicplasty did well initially and periosteal graft did less favorably.     

Glued periosteal grafts in the knee

Periosteal grafting was performed in 4 patients with osteochondritis dissecans of the medial femoral condyle and 1 patient with osteonecrosis of the lateral femoral condyle following prednisone therapy. The lesions were drilled out deep into the cancellous bone. The periosteal graft was taken from the medial facet of the tibia and fixed to the excavated bony defect by the tissue glue Fibrinkleber Human Immuno® (Tisseel). The patients were followed clinically, by arthroscopic examination and by radiography at 3, 6, and 12 months. After 1 year the borderline between the new and surrounding cartilage was hardly visible.     

Glued periosteal grafts in the knee

Periosteal grafting was performed in 4 patients with osteochondritis dissecans of the medial femoral condyle and 1 patient with osteonecrosis of the lateral femoral condyle following prednisone therapy. The lesions were drilled out deep into the cancellous bone. The periosteal graft was taken from the medial facet of the tibia and fixed to the excavated bony defect by the tissue glue Fibrinkleber Human Immuno® (Tisseel). The patients were followed clinically, by arthroscopic examination and by radiography at 3, 6, and 12 months. After 1 year the borderline between the new and surrounding cartilage was hardly visible.     

Glued periosteal grafts in the knee

Periosteal grafting was performed in 4 patients with osteochondritis dissecans of the medial femoral condyle and 1 patient with osteonecrosis of the lateral femoral condyle following prednisone therapy. The lesions were drilled out deep into the cancellous bone. The periosteal graft was taken from the medial facet of the tibia and fixed to the excavated bony defect by the tissue glue Fibrinkleber Human Immuno (Tisseel). The patients were followed clinically, by arthroscopic examination and by radiography at 3, 6, and 12 months. After 1 year the borderline between the new and surrounding cartilage was hardly visible.     

Osteochondritis dissecans and other lesions of the femoral condyles

We reviewed lesions of the femoral condyles seen in 5,000 knee arthroscopies, recording the findings and the age and sex of the patients. We were able to distinguish the characteristics of developing and late osteochondritis dissecans, acute and old osteochondral fractures, chondral separations, chondral flaps and idiopathic osteonecrosis, and suggest that these are separate distinct conditions. Haemarthrosis was associated only with acute osteochondral fractures. The characteristic feature of osteochondritis dissecans was an expanding concentric lesion at the 'classical' site on the medial femoral condyle which appeared during the second decade of life and progressed to a concave steep-sided defect in the mature skeleton. Caffey's (1958) classification of epiphyseal dysplasias could not be applied to osteochondritis dissecans, which appeared to have a gradual onset without acute trauma. Much of the controversy about the cause of osteochondritis dissecans is the result of imprecise nomenclature.     

Osteochondritis dissecans of the femoral condyle treated with periosteal transplantation: Poor outcome in 14 patients followed for 6-9 years

We evaluated 14 consecutive periosteal transplantations to treat osteochondritis dissecans lesions of the femoral condyle. 1 year postoperatively, 9 knees were pain-free, but with 6-9 years follow-up, only 2 knees were pain-free. Formation of hyaline-like cartilage, assessed in 12 knees, was documented in 1 patient and assessed as possible in 1 more, but in 10 patients the tissue formed in the defects was not or probably not hyaline cartilage. 6 knees had developed arthrosis.     

Autogene osteochondrale Transplantation (AOT) bei Knorpeldefekten am Femurkondylus

Objective Healing of localized cartilaginous defects at the knee to maintain or to restore function. Indications Localized traumatic or degenerative cartilaginous defects or lesions caused by osteochondritis dissecans of a femoral condyle. Contraindications Coexisting advanced osteoarthritis, be it acute or chronic. Surgical Technique Removal of osteochondral cylinders from the defect area; they are discarded. Harvesting of osteochondral cylinders corresponding in size to the defect cylinders from the edge of the patellofemoral compartment and insertion by press-fitting into the defect bed. Twinned diamond-studded cylindric trephines that are cooled through their lumen are employed. Ligamentous instabilities or axial malalignments must be corrected. Results We operated 52 patients (23 men, 29 women, average age 36.4 [17–72] years). The mean duration of follow-up amounted to 56 (12–84) months. Original diagnosis: traumatic cartilage defects in 15, osteochondritis dissecans in eleven, and unicompartmental arthritis in 26 patients. The most impressive results were seen in instances of traumatic lesions and osteochondritis dissecans as documented by Lysholm Score (improvement from 56 to 85.5 points) and the Knee Society Score (KSS), recorded after an average of 24 months (91.2 points). These patients are completely symptom-free and could return to their occupational and sporting activities. From the 26 patients with, sometimes extensive, osteoarthritis, twelve became symptom-free, eight were markedly improved, and six were not satisfied. Two of these six patients had to undergo a joint replacement; their defects were > 9 cm². The Lysholm Score improved from 46 to 81 points, and the KSS reached 85 points at follow-up.     

First successful autologous chondrocyte implantation in Pakistan

Osteochondritis dissecans entails a hyaline cartilage defect of the articular surface causing pain and functional restriction in young adults, sometimes resulting in early degenerative arthritis. Conventional treatment methods such as abrasion chondroplasty and mosaicplasty have limitations in terms of quality of the resultant cartilage and donor site morbidity. A more recent technique, autologous chondrocyte implantation (ACI) results in hyaline cartilage formation and gives good long-term outcome, but requires a high-level cell culture facility and two surgical procedures. The patient was a young female with knee pain, intermittent locking and feeling of "joint mouse". MRI scan and arthroscopy showed a 2 x 2 cm full thickness osteochondral defect in the medial femoral condyle. A free fragment of articular cartilage was found, which was extracted arthroscopically, and chondrocytes were cultured from it in the Juma laboratory. Subsequently, patient underwent surgery whereby the chondrocytes were injected under a periosteal patch sewn over the defect. Over six months, patient's symptoms completely resolved and she returned to full function. A repeat arthroscopy after one year revealed complete filling of the previous defect with normal appearing cartilage indicating success of the procedure. This technology can be utilized for treating patients with a variety of conditions affecting hyaline cartilage of joints.     

Osteochondral Autograft Transplantation for Osteochondritis Dissecans of the Capitellum in Nonthrowing Athletes

In this report, we present the cases of 3 nonthrowing athletes with osteochondritis dissecans of the capitellum. Preoperatively, they complained of elbow pain during rhythmic gymnastics, table tennis, and basketball, respectively. Magnetic resonance imaging showed a completely separated osteochondral fragment or a full-thickness cartilage defect. All 3 patients were treated with transplantation of an osteochondral autograft harvested from the lateral femoral condyle. They returned fully to their sports activities within 6 months of surgery. The continuity of the cartilage layer between the osteochondral graft and the capitellum was shown on magnetic resonance images taken at 12 months postoperatively. We believe that osteochondral autograft transplantation provides successful results for nonthrowing athletes with end-stage osteochondritis dissecans of the capitellum.     

Editorial Commentary: To Treat or Not to Treat? Are We Any Closer to Knowing What to Do With Cartilage Lesions of the Tibia?

The increasing interest and use of cartilage repair procedures in the knee has led to a better understanding of when and how chondral lesions should be treated. Nonetheless, there are still key areas where we lack understanding and need better data to guide clinical decision making. One of these areas is how to manage lesions of the tibia, particularly when they occur in conjunction with the more commonplace lesions of the femoral condyle. In this setting, a tibial chondral lesion may reflect a bigger clinical problem—a “bipolar defect” or more advanced joint disease—“established osteoarthritis.” My preferred treatment for these tibial lesions is to ignore the lesion (or perform a chondroplasty at most), except in cases of osteochondritis dissecans, focal defects in association with cysts, or tibial plateau fracture malunion.     

The treatment of osteochondral lesions using a combination of autologous chondrocyte implantation and autograft: three-year follow-up

In this study a combination of autologous chondrocyte implantation (ACI) and the osteochondral autograft transfer system (OATS) was used and evaluated as a treatment option for the repair of large areas of degenerative articular cartilage. We present the results at three years post-operatively. Osteochondral cores were used to restore the contour of articular cartilage in 13 patients with large lesions of the lateral femoral condyle (n = 5), medial femoral condyle (n = 7) and patella (n = 1). Autologous cultured chondrocytes were injected underneath a periosteal patch covering the cores. After one year, the patients had a significant improvement in their symptoms and after three years this level of improvement was maintained in ten of the 13 patients. Arthroscopic examination revealed that the osteochondral cores became well integrated with the surrounding cartilage. We conclude that the hybrid ACI/OATS technique provides a promising surgical approach for the treatment of patients with large degenerative osteochondral defects.     

Osteochondritis dissecans of the lateral femoral condyle in the adult

In osteochondritis dissecans, 15% of the lesions occur in the lateral condyle. In order to understand the significance of these lesions, 27 were studied prospectively from 1983 to 1990 and compared with 20 consecutive cases of lesions of the medial femoral condyle. Lesions of the lateral femoral condyle were larger, and often comprised the entire width of a condyle and resulted in deformation of a significant segment of the femoral condyle. They lay further posteriorly and commonly were associated with mechanical symptoms including buckling or locking. A discernible clunk was unique to these lesions. In addition, lateral lesions were more fragile, often having multiple bony islands that were prone to fragmentation, making replacement difficult if not impossible. Lateral lesions occurred directly within the main force-bearing areas of the condyle, disrupting normal contact areas and possibly leading to more rapid joint deterioration once segments are lost. This has prompted concern for reinsertion of articular fragments or reconstruction with osteochondral allografts.     

Osteochondritis dissecans of the knee. A long-term study.

Twenty-two knees with osteochondritis dissecans diagnosed before skeletal maturity were followed prospectively into middle age: 32% had radiographic evidence of moderate or severe osteoarthritis at an average follow-up of 33.6 years; only half had a good or excellent functional result. We found that osteoarthritis was more likely to occur if the defect was large or affected the lateral femoral condyle.     

An unusual case of osteochondritis dissecans of the medial tibial plateau

We report the case of a 17-year-old boy with osteochondrosis of the medial tibial plateau treated with reasorbable screw. This is an unusual location for osteochondritis dissecans, a pathologic process resulting from ischemic necrosis and characterized by the detachment of a fragment of the cartilage together with the subchondral bone of the articular surface. The lesion may be located in many joints, most frequently in the knee, close to lateral side of the articular surface of the medial femoral condyle. Received: 22 May 2002, Accepted: 3 June 2002     

Internal fixation of undisplaced lesions of osteochondritis dissecans in the knee

A total of 11 patients (12 knees) with stable lesions of osteochondritis dissecans of the knee underwent arthroscopic fixation of the fragments using polylactide bioabsorbable pins. The site of the lesion was the medial femoral condyle in ten knees and the lateral femoral condyle in two. The mean age of the patients was 14.8 years (12 to 16). At a mean follow-up of 32.4 months (13 to 38 months) all fragments had MRI evidence of union. One patient developed early transient synovitis, which resolved with non-steroidal anti-inflammatory medication. All patients returned to sporting activities within eight months of operation and did not require a period of immobilisation.     

成年人股骨髁剥脱性骨软骨炎的外科治疗

目的 探讨成年人不同类型股骨髁剥脱性骨软骨炎（OCD）治疗方法.方法 采用回顾性研究方法.纳入标准：18岁以上成年人,股骨髁OCD,采用外科治疗,术后随访24个月以上.排除标准：青少年OCD,非手术治疗患者,术后失随访患者.回顾2007年1月～2011年7月治疗股骨髁OCD 32例,男23例,女9例,男∶女为2.6：1,平均年龄23.6岁（18～52岁）.关节镜下病灶清理、微骨折10例,关节镜下用可吸收软骨钉（SmartNail; ConMed Linvatec,Largo,FL）固定骨软骨片12例,切开复位、AO钛合金空心钉固定骨软骨片8例,外侧单髁置换2例.术前、术后用Lysholm评分和主观IKDC评分评定膝关节功能.结果 本组32例患者平均随访时间35.8个月（24～52个月）.术前Lysholm评分平均（53.77±4.48）分,术后平均（90.89±4.42）分（t=-266.01,P〈0.01）;主观IKDC评分术前平均（58.50±5.99）分,术后平均（92.15±4.16）分（t=-87.62,P〈0.01）.结论 不同类型、不同时期股骨髁OCD有不同治疗选择,选择适当的治疗方法可获得良好的临床疗效,晚期治疗医疗成本增加.     

Evaluation of the Suitability of Miniature Pigs as an Animal Model of Juvenile Osteochondritis Dissecans

Juvenile osteochondritis dissecans (JOCD) is a developmental disease characterized by formation of intra‐articular (osteo)chondral flaps or fragments. Evidence‐based treatment guidelines for JOCD are currently lacking. An animal model would facilitate study of JOCD and evaluation of diagnostic and treatment approaches. The purpose of this study was to assess the suitability of miniature pigs as a model of JOCD at the distal femur. First, stifle (knee) joints harvested from three juvenile miniature pigs underwent magnetic resonance imaging (MRI) to establish the vascular architecture of the distal femoral epiphyseal cartilage. Second, vessels supplying the axial or abaxial aspects of the medial femoral condyle were surgically interrupted in four additional juvenile miniature pigs, and the developing epiphyseal cartilage lesions were monitored using three consecutive MRI examinations over nine weeks. The miniature pigs were then euthanized, and their distal femora were harvested for histological evaluation. Vascular architecture of the distal femoral epiphyseal cartilage in the miniature pigs was found to be nearly identical to that of juvenile human subjects, characterized by separate vascular beds supplying the axial and abaxial aspects of the condyles. Surgical interruption of the vascular supply to the abaxial aspect of the medial femoral condyle resulted in ischemic cartilage necrosis (a precursor lesion of JOCD) in 75% (3/4) of the miniature pigs. Cartilage lesions were identified during the first MRI performed 3 weeks post‐operatively. No clinically apparent JOCD‐like lesions developed. In conclusion, miniature pigs are suitable for modeling JOCD precursor lesions. Further investigation of the model is warranted to assess induction of clinically apparent JOCD lesions. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:2130–2137, 2019     

The transplantation of an autogeneic osteochondral fragment for osteochondritis dissecans of the knee

Osteochondritis dissecans in two adults with a large osteochondral defect on the weight-bearing surface was treated by transplantation of an autogeneic osteochondral fragment. The graft was transplanted from the normal portion of the medial femoral condyle, which in extension was in contact with neither patella nor meniscus. The donor site was repaired with an iliac bone fragment. After curettage of the crater, the osteochondral fragment was transfixed with AO mini-cancellous screw(s). Six months after the operation, the grafted cartilage of one patient looked the same as normal cartilage when macroscopically observed and showed no sign of histologic degeneration. At the follow-up examination, the patients were asymptomatic. One patient had a full range of motion two years and three months later; the other three years later. Roentgenographic examinations revealed slight irregularities at the grafted site. There was no significant change in the patellofemoral joint except the concavity of the donor site.     

Experiences with arthroscopic therapy of chondral and osteochondral defects of the knee joint with OATS (Osteochondral Autograft Transfer System)

Between 1.6.1997 and 31.12.1998 an osteochondral transplantation with the OATS (Osteochondral Autograft Transfer System) was performed in 18 patients. Indication for OATS was in 9 cases a chondral defect in ACL deficient knees. 3 times we found a fresh chondral defect, in 6 cases we found cartilage damage on the medial femoral condyle at the main weight-bearing area (Outerbridge, type III-IV) in chronic ACL deficient knees. The defect-size in these 9 patients (7 male and 2 female) ranged between 12 mm and 23 mm in diameter and had an average-size of 15 mm. There have been 3 cases with osteochondrosis dissecans, 4 patients had a osteonecrosis at the medial femoral condyle. In the 18 cases an average of 1.8 grafts was needed; more than 3 grafts were used only in exceptional cases, because in such cases the stability between the grafts is reduced. The short outcome in the Lysholm-score showed mainly good results. The average score value during follow-up was 89.5 (range 78-92). This outcome makes hopeful for likewise middle-term-results. The OATS can be recommended for the treatment of chondral and osteochondral defects in the main-weight-bearing area of the knee as a safe procedure for transplantation of hyaline cartilage.