关节镜下自体镶嵌式骨软骨移植修复膝关节股骨髁软骨缺损

目的:评价自体镶嵌式骨软骨移植(osteochondral autograft transfer system,OATS)修复膝关节股骨髁软骨缺损的效果.方法:对12例股骨髁软骨缺损患者采用关节镜下OATS修复.缺损面积约2.0～4.0cm2,平均2.72 cm2.术后随访,对比手术前后的膝关节Lysholm评分、MRI表现以及术后并发症.结果:术后随访5～37个月,平均16.5个月.最终随访Lysholm评分优4例、良5例、中2例、差1例,优良率为75%.术前Lysholm评分(36.5±3.8)分,随访终末时(86.2±5.2)分,差异具有统计学意义(P＜0.05).术后3个月MRI T2加权像和脂肪抑制序列示移植骨软骨柱和周围软骨、软骨下骨间呈高信号,移植软骨和周围软骨基本平整.术后6个月高信号减少,软骨面平整.术后12个月移植软骨厚度与正常软骨相当.5例并发膝关节腔积血;2例患膝关节内有可以忍受的疼痛,其中1例偶有交锁.结论:OATS对膝关节股骨髁软骨损伤的修复效果满意,是一种实用的软骨修复技术.     

Cartilage repair techniques of the talus: An update

Symptomatic chondral or osteochondral defects of the talus reduce the quality of life of many patients. Although their pathomechanism is well understood, it is well known that different aetiologic factors play a role in their origin. Additionally, it is well recognised that the talar articular cartilage strongly differs from that in the knee. Despite this fact, many recommendations for the management of talar cartilage defects are based on approaches that were developed for the knee. Conservative treatment seems to work best in paediatric and adolescent patients with osteochondritis dissecans. However, depending on the size of the lesions, surgical approaches are necessary to treat many of these defects. Bone marrow stimulation techniques may achieve good results in small lesions. Large lesions may be treated by open procedures such as osteochondral autograft transfer or allograft transplantation. Autologous chondrocyte transplantation, as a restorative procedure, is well investigated in the knee and has been applied in the talus with increasing popularity and promising results but the evidence to date is poor. The goals of the current article are to summarise the different options for treating chondral and osteochondral defects of the talus and review the available literature.     

Managing Chondral Lesions: A Literature Review and Evidence-Based Clinical Guidelines

BackgroundArticular cartilage lesions are becoming increasingly common. Optimum diagnosis and management of chondral defects cause a lot of dilemma. A number of surgical methods have been reported in the literature for treating focal cartilage defects. There is a lack of consensus on the most effective management strategy, with newer surgical and cell-based treatments being advocated regularly.Study Design and MethodsA clinical review is constructed by appraising the published literature about clinical evaluation and diagnostic modalities for articular cartilage defects and subsequent surgical procedures, management strategies employed for such lesions. Prominent available databases (PUBMED, EMBASE, Cochrane) were also searched for trials comparing functional outcomes following cartilage procedures. Synthesis of a practical management guideline is then attempted based on the evidence assessed.ResultsSystematic examination and optimal use of diagnostic imaging are an important facet of cartilage defect management. Patient and lesion factors greatly influence the outcome of cartilage procedures and must be considered while planning management. Smaller lesions < 2 cm² respond well to all treatment modalities. Autologous osteochondral transplants (OATs) are effective in high activity individuals with intermediate lesions. For larger lesions > 4 cm², newer generation autologous chondrocyte implantation (ACI) has shown promising and durable results. Stem cells with scaffolds may provide an alternate option. Orthobiologics are a useful adjunct to the surgical procedures, but need further evaluation.ConclusionsMost treatment modalities have their role in appropriate cases and management needs to be individualized for patients. The search for the perfect cartilage restoration procedure continues.     

Biochemical, biomechanical and histological properties of osteoarthritic porcine knee cartilage: implications for osteochondral transplantation

Introduction Cartilage lesions of the knee joint are frequently observed during arthroscopy and when surgical intervention is required, osteochondral autograft procedures are an established method of treatment. Frequently lesions are located on the medial femoral condyle (MFC), and typical donor locations for osteochondral grafts include the medial and lateral patellar groove. This technique provides good results, even when the quality of cartilage transplanted from an osteoarthritic joint is doubtful. This study characterizes biological, biomechanical and histological properties of cartilage explants from the patellar groove harvested from osteoarthritic joints. Materials and methods Cylindrical cartilage explants were harvested from the arthritic areas of the MFC as well as normal appearing regions of the medial and lateral patellar groove from porcine joints revealing various grades of osteoarthritis. Matrix synthesis rates were determined, and explants were investigated by mechanical testing and histology. Results Articular cartilage obtained from the typical donor areas of the medial and lateral patellar groove provided constant enhanced material properties, matrix synthesis rates and histological appearance compared to samples from the arthritic lesions of the MFC, even in joints with end-stage osteoarthritis of the MFC. No significant difference was found between patellar groove cartilage samples harvested from joints with different stages of osteoarthritis. Conclusion Our findings demonstrate that healthy appearing cartilage from the patellar groove does not undergo significant alterations in material properties due to the arthritic milieu present in osteoarthritic joints. Accordingly these locations provide a source of functional tissue for transplant procedures even in joints with end-stage osteoarthritis.     

Arthroscopic autogenous osteochondral mosaicplasty for the treatment of femoral condylar articular defects A preliminary report

An arthroscopic technique for the use of mosaicplasty osteochondral grafting in the treatment of femoral condylar articular defects is described. During the procedure, small cylindrical grafts are harvested from the nonweightbearing periphery of the patellofemoral joint and implanted in mosaiclike fashion into the focal cartilage defect of the weightbearing condylar surface. This report describes the arthroscopic technique using newly designed instruments and the early results of 44 patients treated by this method. Good to excellent results have been obtained based on follow-up ranging from 1 to 5 years. The modified HSS scores are compared with a control group consisting of patients treated by abrasion arthroplasty. Evaluation was done clinically and, in some cases, by ultrasound, magnetic resonance imaging, 3-dimensional computed tomography. The results of 10 control arthroscopies and the histological evaluations of 6 biopsies demonstrated the hyalinelike cartilage surface at the recipient area and the fibrocartilage formation at the surface of the donor holes. Received: 6 February 1997 Accepted: 28 April 1997     

hIGF-I基因增强Mosaicplasty技术重建膝负重区大面积骨软骨复合缺损实验研究

目的研究hIGF-I基因增强组织工程提高Mosaicplasty修复大面积骨软骨缺损的修复质量，改善骨软骨的整合。 方法制造山羊膝关节股骨髁大面积骨软骨缺损模型，使用自制Mosaicplasty器械，植入2 mm直径骨软骨柱镶嵌充填缺损，以hIGF-I基因转染的骨髓基质干细胞复合可注射藻酸钙凝胶填充残余缺损。同时设立未转染hIGF-I基因的骨髓基质干细胞组、Mosaicplasty组和对照组。术后4 w、8 w、16 w处死动物，行大体观察、光镜、电镜观察，磁共振检查比较修复效果。 结果骨软骨缺损在16 w时IGF-I基因增强Mosaicplasty组移植物固定牢固，关节面平滑，移植物间界限消失，新生软骨组织类似于正常软骨，4~16 w修复效果逐渐改善，优于其他各组。光镜观察见移植的骨软骨生长良好，与新生软骨组织紧密相连，新生的软骨细胞排列规整，细胞外基质分布均一。对照组无明显修复。MRI观察类似大体观察结果。 结论使用转染hIGF-I基因的骨髓基质干细胞复合可注射藻酸钙凝胶可促进Mosaicplasty后骨软骨的整合，改善其修复效果。     

自体骨髓基质干细胞辅助Mosaicplasty技术促进骨软骨缺损修复整合

目的探讨以基于骨髓基质干细胞(BMSCs)的组织工程技术与自体骨软骨柱镶嵌移植术(Mosaicplasty)相结合的方法修复骨软骨及促进缺损间隙的整合效果。方法12只中国山羊于术前2周抽取骨髓,体外培养自体BMSCs。术中以自制器械分别制造山羊双后肢股骨内髁负重区直径5 mm、深3 mm的复合骨软骨缺损各一处。在Mosaicplasty技术填充缺损后,即以动物自体BMSCs与透明质酸凝胶相复合,注射填充于左后肢骨软骨柱之间及与周围组织的间隙内,右后肢单纯自体骨软骨柱移植作为对照组。术后第4、8、16周分别取材进行组织学、组织化学及蛋白聚糖含量等检测。比较16周时两组的缺损区惨复软骨组织与正常软骨的蛋白聚糖含量。结果两组自体骨软骨柱移植软骨均以透明软骨存活,与周围正常软骨间无明显差异。实验组骨软骨柱的间隙内可见新生软骨修复,组织学表现与周围正常软骨相同。交界区整合良好,间隙消失;对照组各时间点软骨间的间隙为纤维组织或纤维软骨填充,仍有间隙存留。移植软骨的基质、实验组骨软骨柱间隙内的新生软骨基质及Ⅱ型胶原免疫组化染色均为阳性。蛋白聚糖含量比较显示,对照组骨软骨柱间隙内新生组织的蛋白聚糖含量均低于正常软骨和实验组,差异有显著性意义(P< 0．05)。结论基于BMSCs的组织工程技术结合Mosaicplasty技术,可以有效地促进骨软骨缺损间隙的整合,改善修复效果好,有望成为一种理想的促进骨软骨缺损修复的方法。     

Mosaicplasty for the treatment of femoral head defect after incorrect resorbable screw insertion

Articular cartilage lesions and osteochondral defects remain a difficult problem for the patient and physician. A variety of procedures and treatments have been proposed to lessen symptoms and restore the articular surface. The knee joint has been the focus of the vast majority of these cartilage restoration procedures. Osteochondral defects of the proximal femur are significantly less common, and their management remains poorly defined. This article reports the case of a young man with a deep osteochondral defect of the femoral head caused by penetrated resorbable screw after internal fixation of a displaced large single fragment of the posterior acetabular rim and subsequent treatment using mosaicplasty.     

自体骨软骨马赛克移植成形术后膝关节供区部位发病率的系统评价

目的：对自体骨软骨马赛克移植成形术后膝关节供区部位发病率进行概述。方法：通过计算机检索2010年1月至2021年4月20日PubMed,EMbase,万方医学网和中国知网发表的评估马赛克成形术后膝关节供区发病率的相关研究文献,根据纳入与排除标准进行文献筛选,质量评价及数据提取,对移植的骨软骨柱个数和大小与供区发病率之间的相关性进行研究。结果：共纳入13篇文献,共661例患者。统计分析结果表明马赛克成形术后膝关节供体部位发病率为8.6%（57/661）,最常见的供区发病率主诉是膝关节疼痛感4.2%（28/661）。供体数目与术后供区发病率之间不存在相关性（P=0.424,N=10）;供体直径大小与术后供区发病率之间同样不存在相关性（P=0.699,N=7）。结论：自体骨软骨移植/马赛克成形术中的骨软骨柱采集通常会导致相当大的供区发病率8.6%（57/661）,最常见的供区发病率主诉是膝关节疼痛感,且供体部位发病率与骨软骨柱的数量和大小之间并没有明显的相关性,因此临床上对供体任何部位,数量和大小骨软骨骨柱的采集,都应该意识到其潜在的供体部位发病风险。     

The effect of surface incongruity of grafted plugs in osteochondral grafting: a report of five cases

Although grafted osteochondral plugs should ideally have a smooth surface for mosaicplasty, surface incongruity is sometimes evident at the time of surgery. There may be no problem if there is depression of the grafted plugs, but graft protuberance may have an adverse effect. We studied five knees in five patients who had incongruity (protuberance or depression) of grafted osteochondral plugs at the time of mosaicplasty. The mean age at surgery was 36.6 years (range, 15–65 years), and the mean follow-up period was 32.9 months (range, 24–49 months). All patients underwent second-look arthroscopy after a mean post-surgical period of 14.8 months (range, 3–18 months). We divided the cases so that there were two in the protuberant group (P) and three in the depressed group (D). In P, all patients had a catching sensation about 4 months after surgery, and sometimes pain in the knee joint. Second-look arthroscopy revealed fissuring of the plugs and fibrillation around the recipient site. In D, there were no symptoms due to the depressed plugs. Second-look arthroscopy showed that the depressed areas were covered with fibrocartilage-like tissue, and that the joint surface was smooth. In conclusion, our clinical results and second-look arthroscopic evaluation suggest that isolated osteochondral plug depressions of not greater than 1 mm could still promote acceptable cartilage healing leading to good clinical outcomes. However, plug protuberance at mosaicplasty should always be avoided.