Durability of regenerated articular cartilage produced by free autogenous periosteal grafts in major full-thickness defects in joint surfaces under the influence of continuous passive motion. A follow-up report at one year

An autogenous graft of tibial periosteum was sutured (with its cambium layer facing into the joint) to the base of a five by ten-millimeter full-thickness defect in the patellar groove of each of forty-five adolescent rabbits. The rabbits were randomly treated postoperatively by either four weeks of immobilization in a cast, intermittent active motion in a cage, or two weeks of continuous passive motion. One year postoperatively, the regenerated tissue from each rabbit was analyzed macroscopically, histologically, histochemically, and biochemically. Gross degenerative changes were seen in 57 per cent of the rabbits that had been immobilized in a cast, in 73 per cent of the rabbits that had been allowed intermittent active motion, and in 22 per cent of the rabbits that had been subjected to continuous passive motion (p less than 0.05). Out of a possible score of 7.0 points for the nature of the regenerated tissue, the scores for the three groups were: immobilization in a cast, 4.1 points; intermittent active motion, 4.0 points; and continuous passive motion, 5.9 points (p greater than 0.05). Out of a possible perfect combined score of 10.0 points for the structural characteristics of the regenerated tissue, the cast-immobilization group scored 3.8 points; the intermittent active-motion group, 2.5 points; and the continuous passive-motion group, 6.4 points (p less than 0.001). The total scores for freedom from cellular changes of degeneration, a perfect score being 5.0 points, were: immobilization in a cast, 2.4 points; intermittent active motion, 2.3 points; and continuous passive motion, 3.9 points (p less than 0.01). Degenerative changes in the adjacent cartilage, which were noted in 42 and 46 per cent of the knees in the immobilization and intermittent active-motion groups, respectively, were not found in the knees that had been subjected to continuous passive motion (p less than 0.05). The total indices, which were derived by combining the scores for all categories (maximum, 24.0 points), revealed that the index for the continuous passive-motion group was significantly better than the index for either of the other two groups: immobilization in a cast, 12.9 points; intermittent active motion, 11.2 points; and continuous passive motion, 19.2 points (p less than 0.0005).(ABSTRACT TRUNCATED AT 400 WORDS)     

Biological resurfacing of full-thickness defects in patellar articular cartilage of the rabbit. Investigation of autogenous periosteal grafts subjected to continuous passive motion.

We compared the effects of continuous passive motion with those of intermittent active motion on the results of the resurfacing with autogenous periosteal grafts of full-thickness defects on the articular surface of rabbit patellae. Of 45 rabbits with defects, 30 received grafts. Fifteen of these had continuous passive motion for two weeks and intermittent active motion for four weeks; the other 15 had intermittent active motion for six weeks. In 15 the defects were not grafted (control group) and they had intermittent active motion for six weeks. Ten more rabbits had a sham operation. Six weeks after surgery, the results were assessed by the gross appearance, histology, histochemistry, immunohistochemistry and electron microscopy. By all assessments the quality of neochondrogenesis produced by periosteal grafts was superior to that in ungrafted defects (p less than 0.05) and the results in continuous passive motion treated animals were superior to those in intermittent active motion treated animals (p less than 0.05). The periosteal grafts produced hyaline cartilage containing type II collagen but the organisation of its fibres was irregular.     

The repair of major osteochondral defects in joint surfaces by neochondrogenesis with autogenous osteoperiosteal grafts stimulated by continuous passive motion. An experimental investigation in the rabbit

The purpose of this investigation was to determine the effects of continuous passive motion (CPM) on the chondrogenic potential of autogenous osteoperiosteal grafts to repair major osteochondral defects. A 3.5-mm-wide circular full-thickness defect was drilled in one medial femoral condyle of 55 adolescent New Zealand rabbits. A graft of periosteum from the proximal tibia was wrapped around a disc of bone from the same area (cambium layer of the periosteum facing outward), then press-fitted into the defect. The rabbits were treated by either immobilization (Imm) or intermittent active motion (IAM) for five weeks, or by continuous passive motion (CPM) for two weeks followed by IAM for three weeks. A control group (no osteoperiosteal graft in the defect) was also treated by CPM for two weeks and IAM for three weeks. At five weeks, hyaline cartilage was the predominant tissue in only 10% of the defects in the Imm, IAM, and control groups, compared with 70% in the CPM group (p less than .025). Bonding of the newly formed tissue to the adjacent cartilage was significantly better in the CPM group.     

Cellular origin and evolution of neochondrogenesis in major full-thickness defects of a joint surface treated by free autogenous periosteal grafts and subjected to continuous passive motion in rabbits

A graft of periosteum from the tibia of 27 rabbits was incubated in vitro with tritiated thymidine for 24 hours and then transplanted into a full-thickness defect in the patellar groove. The rabbits were managed after the operation on continuous passive motion (CPM), and the joints excised at intervals of two to 21 days. After one week the cells had begun to synthesize glycosaminoglycan and by two weeks the tissue resembled immature hyaline cartilage. Thymidine-labeled cells were seen throughout the entire regenerated tissue. The cellular origin of the hyaline-like tissue that filled the defects was the progenitor cells of the periosteal graft.     

Neochondrogenesis in repair of full-thickness articular cartilage defects using free autogenous periosteal grafts in the rabbit. A follow-up in six months

OBJECTIVE: To analyse the repair of lesions of articular cartilage with periosteum-free implants and follow-up at 6 months. DESIGN: Thirty-six New Zealand rabbits, 4-6 weeks old, were used. Full-thickness articular cartilage defects in the medial femoral condyle were created. Spontaneous evolution occurred in 18 animals; the other 18 animals were treated with a free autogenous periosteal tibial implant fixed with Tissucol. Animals were killed in groups of six at 8, 12 and 24 weeks. Macroscopic, histologic and histochemical results were evaluated and analysed statistically using the Mann-Whitney U-test. RESULTS: The spontaneous evolution of the lesion did not lead to complete repair in any case. The periosteum-free implant provided complete repair of the lesion and statistically significant restoration of the articular surface. CONCLUSIONS: In the rabbit, this study confirms the incomplete spontaneous repair of articular cartilage and the chondrogenic potential of tibial periosteum-free implants, with long-term maintenance of the macroscopic, histologic and histochemical characteristics of neo-cartilage. This raises the possibility of its use as an alternative method in the repair of circumscribed osteochondral lesions in young patients.     

Effects of hyaluronan on periosteal grafts for large full-thickness defects in rabbit articular cartilage

We studied the effects of hyaluronan (HA) on chondrogenesis in periosteal grafts in rabbit knees to elucidate the effects of this agent in the repair of articular cartilage. Large full-thickness defects of the articular cartilage were created in the anteromedial part of the femoral articular surface of bilateral knee joints. Periosteal grafts were then harvested and sutured onto the defects. HA was injected in the right knee immediately after the operation and then once a week for 4 weeks (HA group). The same volume of saline was injected in the left knee in the control group. The animals were killed 2, 5, 8, and 12 weeks after the operation. Macroscopic and histological findings of the regenerated tissue were evaluated with a semiquantitative histological grading system. The total histological scores of the HA group were better than those in the control group at each time examination point. At 12 weeks, in particular, the scores for surface regularity and integration to adjacent articular cartilage were significantly better in the HA group than in the control group (P < 0.05). No significant differences were observed between the two groups in regard to the area healed (%). HA may have beneficial effects on the repair of large full-thickness defects of the articular cartilage with autologous periosteal grafts. Received for publication on Feb. 18, 1998; accepted on Oct. 20, 1998     

Reconstruction of patellar cartilage defects with free periosteal grafts. An experimental study

The osteo-chondrogenic potential of free periosteal grafts was investigated within the knee joint in 26 rabbits aged four to six weeks. A total of 36 knee joints were operated on. The grafts were stripped from the medial side of the right tibia and sutured on the articular surface of the patella, from which the cartilage had been totally excised to the subchondral bone. In 16 knees the graft was sutured with the cambium layer towards the subchondral bone and in eight knees the fibrous layer faced the bone. In the control group of twelve knees the patellar articular cartilages were excised and no periosteal transplant was grafted to the patellar articular surface. In the transplantation group cartilage formation could be seen already one week after the operation. There were no marked differences between the series with the cambium layer facing the subchondral bone or the group with the fibrous layer facing the bone. At 20 weeks the hypertrophied cartilage had thinned and resembled normal joint cartilage. In the control group the histological picture resembled osteoarthritis.     

Repair of full-thickness cartilage defects in rabbit knees with free periosteal graft preincubated with transforming growth factor

This study compared different concentrations of transforming growth factor-beta 1 (TGF-beta1) used for short-term preincubation in vitro of large periosteal explants to determine the effect of chondrogenesis and the fate of repair cartilage over time. Eighty-two rabbits were divided into four groups: group A, non-grafted; group B, non-incubated grafted; group C, 100 ng/mL recombinant human (rh) TGF-beta1 preincubated grafted; and group D, 20 ng/mL rhTGF-beta1 preincubated grafted. Rabbits from each group were sacrificed at intervals between 2 and 24 weeks. Histologic slides were stained with safranin O and were scored based on a subjective scoring system. Group A healed with non-cartilaginous material. Group B healed with hyaline cartilage-like material with progressive thinning of this regenerated layer; at 24 weeks, this layer was fibrous tissue. Group C enhanced repair with hyaline cartilage-like material but accelerated early degeneration and osteophyte formation; the cartilage became fibrous tissue at 24 weeks. Group D did not enhance cartilaginous repair. At 24 weeks, all groups had the same result. The 100 ng/mL rhTGF-beta1 preincubation in vitro with periosteum enhanced early osteochondral repair but did not show prolonged durability. Clinical application of this growth factor necessitates further study.     

Autogenous osteoperiosteal grafts in the reconstruction of full-thickness joint surface defects

Summary Free, autogenous periosteal grafts from the medial metaphysis of the proximal tibia have been used to reconstruct full thickness cartilage defects of the articular surfaces of the knee joint. If there was a bone defect, it was initially filled with cancellous bone graft. The method is illustrated by six patients, three with acute traumatic patellar defects and three with local sclerotic osteochondritis of the medial femoral condyle. The latter had loose fragments unsuitable for fixation and single excision would have left a large and deep defect. The grafts have given satisfactory results, 14 to 59 months after the procedures. Clinical grading of the defects has been monitored by radiographs with arthroscopy of two knees and CT scan of one knee.

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Résumé On a eu recours, pour reconstruire toute l'apaisseur de pertes de substance cartilagineuses des surfaces articulaires du genou, à des greffes libres de périoste autologue, prélevées sur la face interne de la métaphyse supérieure du tibia. En cas de perte de substance osseuse on a commencé par la combler à l'aide de greffons d'os spongieux. Six cas illustrent cette technique, trois pertes de substance rotulienne d'origine traumatique et trois ostéochondrites du condyle fémoral interne. Le dernier cas présentait des corps étrangers dont la fixation était impossible et dont la résection simple aurait déterminé une vaste et profonde cavité. Les greffes ont donné des résultats satisfaisants, de 14 à 59 mois après l'opération. L'évolution locale a été suivie par des radiographies, par arthroscopie deux fois et par tomodensitométrie dans un cas.

     

The fate of free autogenous fascial grafts in the rabbit

Fascial grafts were taken from 34 New Zealand rabbits and implanted above and below the cranial periosteum in the same animal. They were placed as four-layered folded grafts and as single-layered grafts. When harvested from 6 to 14 months after transplantation, the multi-layered grafts and the single-layered grafts on bone had maintained their bulk but consisted histologically of only a retained collagen matrix with no viable cellular structure. The one-layered grafts on periosteum, however, retained their cellular make-up with normal vascularity and normal cellular structure when harvested at approximately the same intervals.     

Neochondrogenesis in free intraarticular periosteal autografts in an immobilized and paralyzed limb. An experimental investigation in the rabbit

The purpose of this investigation was to determine whether neochondrogenesis can be induced in free intraarticular autografts of periosteum in the complete absence of motion. In 17 adolescent rabbits, a rectangular graft of periosteum was elevated from the medial aspect of each proximal tibia and folded back on itself so that its deep (cambium) layer was facing outward on both sides. The grafts were transplanted into both ipsilateral knee joints that had been paralyzed by section of the femoral and sciatic nerves, and a cast was applied to one hind limb to provide immobilization. The opposite knee joint of each animal was then placed in the continuous passive motion (CPM) apparatus. At the time of death (21 days postoperatively), some degree of neochondrogenesis was evident in 69% of the grafts in the group with casts and in 100% of the grafts in the CPM group. Hyaline cartilage was the predominant tissue in 13% of the grafts in the group with casts compared to 63% of the grafts in the CPM group. Although this investigation has confirmed the chondrogenic potential of free periosteal grafts in a synovial fluid environment (and the significantly stimulating effect of CPM), the results have also demonstrated that at least some hyaline cartilage can be formed by periosteal grafts even with paralysis of the limb plus immobilization of the joint (presumably complete immobilization). Thus, other factors capable of stimulating neochondrogenesis warrant investigation.     

The role of free periosteal grafts in improving the survival of autogenous onlay bone grafts to the facial bones in rabbits

Summary Comparison is made between the survival of two groups of autogenous onlay bone grafts with periosteum taken from the ilium and applied to the nasal bones, in rabbits. In one group the periosteum on the graft surface was left undisturbed, while in the other an overlay of free periosteum was applied to the de-periostealised bone graft at the recipient site.Using serial radiographic recording of the bone grafts for periods up to one year, together with terminal histological examination, it was found that the overlay group survived better at all stages. This is attributed to increased rapidity of vascularisation and osteogenic activity in the periosteal osteoblasts in those grafts having a superimposed free graft of periosteum, with increased production of periosteal new bone more rapidly replacing the underlying bone of the graft.It is suggested that clinical application of these findings might allow accurate contour sculpturing of onlay bone grafts, while in no way impairing graft survival.Presented to the Swiss Association of Plastic and Reconstructive Surgery, on 3rd October, 1975 at Murten, Switzerland     

The effect of continuous passive motion on knee ligament reconstruction with carbon fibre. An experimental investigation

Our purpose was to determine whether continuous passive motion enhanced the quality of knee ligament reconstruction using carbon fibre. In 46 rabbits the medial collateral ligaments were excised and replaced with carbon fibre prostheses. The animals were treated postoperatively by either continuous passive motion, cast immobilisation or cage activity, termed intermittent active motion. At six weeks, the ligaments were compared histologically and biomechanically with normal (control) medial collateral ligaments and with sham-operated controls. The ligaments treated with continuous passive motion were superior to those in the other two treatment groups. There were no ligament failures in any of the groups. This study suggests that continuous passive motion, initiated immediately postoperatively, enhances the biomechanical properties of carbon fibre ligament replacement of the medial collateral ligament while preventing the harmful effects of joint immobilisation.     

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.     

Active proliferation of mesenchymal cells prior to the chondrogenic repair response in rabbit full-thickness defects of articular cartilage

OBJECTIVES: In full-thickness articular defects, fibroblast growth factor-2 (FGF-2) participates in the chondrogenic repair response which occurs in a defect-size dependent manner. Here we demonstrate that FGF-2 plays a critical role in the proliferation of pre-chondrogenic mesenchymal cells during chondrogenic induction. METHODS: Three-millimeter- or 5-mm-diameter cylindrical defects were created in the femoral trochlea of the rabbit knee. The defects received sterile saline or FGF-2 (50 pg/h) via an osmotic pump for the initial 2 weeks. We assessed the proliferative capacity of undifferentiated mesenchymal cells in the reparative tissue with the anti-proliferating cell nuclear antigen (PCNA) monoclonal antibody. Using a total of 180 rabbits, we performed three sets of experiments. RESULTS: In the 3-mm-diameter defects, undifferentiated mesenchymal cells spontaneously initiated chondrogenic differentiation within 2 weeks, resulting in the regeneration of surfacing articular cartilage concomitantly with the repair of subchondral bone. No evidence of chondrogenesis was seen in the 5-mm-diameter defects, whereas application of FGF-2 promoted successful regeneration of articular cartilage. In the 3-mm-diameter defects and in the FGF-2-treated 5-mm defects, PCNA immunoreactivity was widely detected in undifferentiated cells in the reparative tissue at 1 and 2 weeks after creation of the defects. In contrast, in the 5-mm-diameter defects without FGF-2 treatment, the PCNA-positive cells were found at a significantly lower incidence. CONCLUSIONS: Active expansion of undifferentiated cell population mediated by FGF-2 is required to initiate and support a chondrogenic repair response in full-thickness defects of articular cartilage. Endogenous FGF-2 could not meet the requirements of growth signaling in the center of larger sized defects.     

自体骨膜游离移植的实验研究--不同龄动物大块关节软骨缺损修复的比较

目的研究比较自体骨膜移植软骨再生修复不同龄动物大块关节软骨缺损。方法用52只不同龄家兔自体骨膜游离移植修复大块关节软骨缺损,比较移植骨膜生发层朝向关节腔与松质骨时再生软骨的差别。结果经不同时期肉眼和组织学检查证实,幼年兔和成年兔的骨膜移植都能生成软骨,修复大块关节软骨缺损。在成年兔骨膜再生的软骨与成年兔本身周围正常软骨的厚度、组织结构一样。移植骨膜生发层朝向关节腔与松质骨二者间再生软骨结果无明显差别。结论骨膜具有再生软骨的能力,可用来移植修复关节软骨的缺损。骨膜移植生发层不同朝向对软骨再生无明显影响。成年后骨膜移植修复关节软骨缺损能够生成与自身相适应的软骨。