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Benazzo F, Cadossi M, Cavani F, Fini M, Giavaresi G, Setti S, Cadossi R, Giardino R. Cartilage repair with osteochondral autografts in sheep: effect of biophysical stimulation with pulsed electromagnetic fields. J Orthop Res 2008; 26:631-42. [PMID: 18176941 DOI: 10.1002/jor.20530] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The effect of pulsed electromagnetic fields (PEMFs) on the integration of osteochondral autografts was evaluated in sheep. After osteochondral grafts were performed, the animals were treated with PEMFs for 6 h/day or sham-treated. Six animals were sacrificed at 1 month. Fourteen animals were treated for 2 months and sacrificed at 6 months. At 1 month, the osteogenic activity at the transplant-host subchondral bone interface was increased in PEMF-treated animals compared to controls. Articular cartilage was healthy in controls and stimulated animals. At 6 months, complete resorption was observed in four control grafts only. Cyst-like resorption areas were more frequent within the graft of sham-treated animals versus PEMF-treated. The average volume of the cysts was not significantly different between the two groups; nevertheless, analysis of the variance of the volumes demonstrated a significant difference. The histological score showed no significant differences between controls and stimulated animals, but the percentage of surface covered by fibrous tissue was higher in the control group than in the stimulated one. Interleukin-1 and tumor necrosis factor-alpha concentration in the synovial fluid was significantly lower, and transforming growth factor-beta1 was significantly higher, in PEMF-treated animals compared to controls. One month after osteochondral graft implantation, we observed larger bone formation in PEMF-treated grafts which favors early graft stabilization. In the long term, PEMF exposure limited the bone resorption in subchondral bone; furthermore, the cytokine profile in the synovial fluid was indicative of a more favorable articular environment for the graft.
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Affiliation(s)
- Franco Benazzo
- Orthopaedic and Traumatologic Clinic, University of Pavia, IRCCS Policlinico S. Matteo, Pavia, Italy
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YEN YIMENG, CASCIO BRETT, O'BRIEN LUKE, STALZER STEVE, MILLETT PETERJ, STEADMAN JRICHARD. Treatment of Osteoarthritis of the Knee with Microfracture and Rehabilitation. Med Sci Sports Exerc 2008; 40:200-5. [DOI: 10.1249/mss.0b013e31815cb212] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Philippon MJ, Schenker ML, Briggs KK, Maxwell RB. Can microfracture produce repair tissue in acetabular chondral defects? Arthroscopy 2008; 24:46-50. [PMID: 18182201 DOI: 10.1016/j.arthro.2007.07.027] [Citation(s) in RCA: 167] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2006] [Revised: 07/28/2007] [Accepted: 07/30/2007] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to investigate percent fill and repair grade of microfractured lesions of the acetabulum. METHODS Nine patients underwent revision hip arthroscopy for a variety of procedures after undergoing microfracture for treatment of a full-thickness chondral defect of the acetabulum at primary arthroscopy. The size of the chondral defect was measured during primary arthroscopy, and the percent fill of the defect and repair grade were noted at revision hip arthroscopy. RESULTS Mean time from primary arthroscopy to revision was 20 months (range, 10 to 36 months). The average percent fill of the acetabular chondral lesions at second-look was 91% (range, 25% to 100%). Eight of the patients had grade 1 or 2 repair product at second-look. The 1 patient with 25% fill and grade 4 repair product had diffuse osteoarthritis on the femur and acetabulum at primary microfracture. One patient required total hip arthroplasty 66 months after the index microfracture. CONCLUSIONS In this study, 8 of 9 patients had 95% to 100% coverage of an isolated acetabular chondral lesion or acetabular lesion associated with a femoral head lesion, with grade 1 or 2 appearance of the repair product at an average of 20 months follow-up. One patient who had diffuse osteoarthritis failed, with only 25% coverage with a grade IV appearance of the repair product 10 months after index arthroscopy. LEVEL OF EVIDENCE Level IV, therapeutic case series.
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Kang SW, Bada LP, Kang CS, Lee JS, Kim CH, Park JH, Kim BS. Articular cartilage regeneration with microfracture and hyaluronic acid. Biotechnol Lett 2007; 30:435-9. [DOI: 10.1007/s10529-007-9576-2] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2007] [Revised: 10/10/2007] [Accepted: 10/12/2007] [Indexed: 11/27/2022]
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Seedhom BB, Luo ZJ, Goldsmith AJ, Toyoda T, Lorrison JC, Guardamagna L. In-situ engineering of cartilage repair: a pre-clinical in-vivo exploration of a novel system. Proc Inst Mech Eng H 2007; 221:475-88. [PMID: 17822150 DOI: 10.1243/09544119jeim188] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
This investigation explores a new cartilage repair technique that uses a novel method to secure a non-woven multifilamentous scaffold in the defect site after microfracture. The hypothesis is that a scaffold provides a larger surface area for attachment and proliferation of the mesenchymal stem cells that migrate from the bone marrow. Two in-vivo studies were undertaken in an ovine model. The first study, which lasted for 8 weeks, aimed to compare the new technique with microfracture. Chondral defects, 7 mm in diameter, were created in both femoral medial condyles of five ewes. One defect was treated with the new technique while the contralateral knee was treated with microfracture alone. The results revealed that the quantity of repair tissue was significantly greater in the defects treated with the new system. The second study had two time points, 3 and 6 months, and used 13 ewes. In this study, both defects were treated with the new technique but one received additional subchondral drilling in order to stimulate extra tissue growth. The majority of the implants had good tissue induction, filling 50-100 per cent of the defect volume, while the compressive modulus of the repairs was in the range of 40-70 per cent of that for the surrounding cartilage. In addition, hyaline-like cartilage was seen in all the repairs which had the additional drilling of the subchondral bone.
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Affiliation(s)
- B B Seedhom
- Bioengineering Division, Academic Unit of Musculoskeletal Diseases, University of Leeds, Leeds, UK.
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Endres M, Neumann K, Häupl T, Erggelet C, Ringe J, Sittinger M, Kaps C. Synovial fluid recruits human mesenchymal progenitors from subchondral spongious bone marrow. J Orthop Res 2007; 25:1299-307. [PMID: 17549723 DOI: 10.1002/jor.20394] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Microfracture is a frequently used reparative technique that induces a healing response in articular cartilage defects. Penetration of the subchondral bone leads to blood clot formation, allows multipotent mesenchymal cells to access the defect and, subsequently, leads to cartilaginous repair tissue. The aim of our study was to analyze the chemotactic recruitment of human subchondral spongious bone marrow-derived cells by synovial fluid (SF) from normal donors (ND), patients with osteoarthritis (OA) and rheumatoid arthritis (RA). Subchondral spongious bone marrow-derived mesenchymal progenitors were isolated from bone cylinders after high tibial osteotomy and analyzed for the presence of stem cell-related cell surface antigens by flow cytometry. Recruitment of subchondral progenitors by normal SF and SF from donors with degenerated joint diseases was documented by using a modified Boyden chamber chemotaxis assay. The chemotaxis assay demonstrated that synovial fluid has the potential to recruit mesenchymal progenitors in vitro. SF from normal donors and patients with OA showed no difference in the potential to stimulate cell migration. SF obtained from RA donors showed significantly reduced cell recruitment compared to SF derived from OA patients (p = 0.0054) and normal donors (p < 0.0001). The chemotactic activity of SF obtained from normal donors and from patients with degenerative joint diseases suggests that SF may be actively involved in the migration of progenitors in cartilage defects after microfracture.
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Affiliation(s)
- Michaela Endres
- TransTissue Technologies GmbH, Tucholskystrasse 2, 10117 Berlin, Germany.
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Morisset S, Frisbie DD, Robbins PD, Nixon AJ, McIlwraith CW. IL-1ra/IGF-1 gene therapy modulates repair of microfractured chondral defects. Clin Orthop Relat Res 2007; 462:221-8. [PMID: 17534189 DOI: 10.1097/blo.0b013e3180dca05f] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Repair of cartilage defects involves sequential participation of specific hormones and growth factors with potential impairment by inflammatory cytokines. We explored an in vivo gene therapy treatment to supply adenoviral vectors carrying the genes of interleukin-1 receptor antagonist protein (IL-1ra) and insulinlike growth factor-1 (IGF-1), hoping to enhance repair of full-thickness equine chondral defects treated with microfracture. We asked whether our treatment could (1) increase proteoglycan and Type II collagen content in the repair tissue, (2) improve the macroscopic and histomorphometric aspect of the repair tissue, and (3) induce prolonged and increased IL-1ra and IGF-1 production in treated joints. Twelve horses had full-thickness chondral defects created in their carpus and stifle followed by microfracture. Joints were injected with either equine IL-1ra/IGF-1 adenoviral preparation or Gey's balanced salt solution. Sixteen weeks later, defect healing was evaluated macroscopically, histologically, histochemically, and biochemically. Production of IL-1ra and IGF-1 was measured by enzyme-linked immunosorbent assay and radioimmunoassay. We found increased proteoglycan content in treated defects along with augmented Type II collagen associated with substantial transgene expression of IL-1ra during the first 3 weeks. These data suggest in vivo gene therapy can improve biologic processes associated with chondral defect repair.
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Affiliation(s)
- Sophie Morisset
- Orthopaedic Research Center, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, CO 80524, USA
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160
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Chevrier A, Hoemann CD, Sun J, Buschmann MD. Chitosan-glycerol phosphate/blood implants increase cell recruitment, transient vascularization and subchondral bone remodeling in drilled cartilage defects. Osteoarthritis Cartilage 2007; 15:316-27. [PMID: 17008111 DOI: 10.1016/j.joca.2006.08.007] [Citation(s) in RCA: 136] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2005] [Accepted: 08/10/2006] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Marrow-stimulation techniques are used by surgeons to repair cartilage lesions although consistent regeneration of hyaline cartilage is rare. We have shown previously that autologous blood can be mixed with a polymer solution containing chitosan in a glycerol phosphate (GP) buffer (chitosan-GP), and that implantation of this polymer/blood composite onto marrow-stimulated chondral defects in rabbit and sheep leads to the synthesis of more chondral repair tissue with greater hyaline character compared to marrow-stimulation alone. In the current study, we examined the modulation of cell recruitment and repair tissue characteristics at early post-surgical time points (from day 1 to 56) in a rabbit model to elucidate potential mechanisms behind this improved repair outcome. DESIGN Thirty-three skeletally mature New Zealand White rabbits underwent bilateral arthrotomies, with each trochlea receiving a cartilage defect (3.5 mm x 4.5mm) bearing four microdrill holes (0.9 mm diameter, approximately 4 mm deep) into the subchondral bone. One defect per rabbit was treated with a chitosan-GP/blood implant, while the other defect was left as a microdrilled control. Repair tissues were stained by histochemistry, for collagen types I, II, and X by immunohistochemistry and analyzed using quantitative stereological tools. RESULTS Histological analyses demonstrated that control defects followed a typical healing sequence observed previously in marrow-stimulation animal models while chitosan-GP/blood implants led to three significant modifications in the healing sequence at early stages: (1) increased inflammatory and marrow-derived stromal cell recruitment to the microdrill holes, (2) increased vascularization of the provisional repair tissue in the microdrill holes, and (3) increased intramembranous bone formation and subchondral bone remodeling (BR). CONCLUSIONS These results suggest that the greater levels of provisional tissue vascularization and BR activity are main factors supporting improved cartilage repair when chitosan-GP/blood implants are applied to marrow-stimulated cartilage lesions.
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Affiliation(s)
- A Chevrier
- Chemical Engineering, Ecole Polytechnique, PO Box 6079, Station Centre-Ville, Montreal, Quebec, Canada
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Frisbie DD, Morisset S, Ho CP, Rodkey WG, Steadman JR, McIlwraith CW. Effects of calcified cartilage on healing of chondral defects treated with microfracture in horses. Am J Sports Med 2006; 34:1824-31. [PMID: 16832126 DOI: 10.1177/0363546506289882] [Citation(s) in RCA: 146] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Microfracture of full-thickness articular defects has been shown to significantly enhance the amount of repair tissue. However, there is a suggestion that leaving calcified cartilage inhibits this repair response. HYPOTHESIS Removal of the calcified cartilage with retention of subchondral bone enhances the amount of attachment of the repair tissue compared with retention of the calcified cartilage layer. STUDY DESIGN Controlled laboratory study. METHODS There were 1-cm(2) articular cartilage defects made in 12 skeletally mature horses on the axial weightbearing portion of both medial femoral condyles. Using a custom measuring device and direct arthroscopic observation of the subchondral bone beneath the calcified cartilage layer, the authors removed the calcified cartilage from 1 defect of each horse. The repair was assessed with arthroscopy, clinical examination, radiographic and magnetic resonance imaging examinations, biopsy at 4 months, gross and histopathologic examinations at 12 months, as well as mRNA and immunohistochemical evaluations. RESULTS Removal of calcified cartilage with retention of the subchondral bone plate increased the overall repair tissue as assessed by arthroscopic (4 months) and gross evaluation (12 months). An increase in the level of the subchondral bone was also observed with removal of the calcified cartilage layer. The clinical pain, radiographic examinations, magnetic resonance imaging evaluations, histologic character, matrix proteins, or mRNA expression do not appear to differ based on level of defect debridement. CLINICAL RELEVANCE Removal of the calcified cartilage layer appears to provide optimal amount and attachment of repair tissue. Therefore, close arthroscopic visualization is recommended for debridement of clinical lesions to ensure removal of the calcified cartilage layer.
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Affiliation(s)
- David D Frisbie
- Equine Orthopaedic Research Center, Colorado State University, 300 West Drake Road, Fort Collins, 80523, USA
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Results after microfracture of full-thickness chondral defects in different compartments in the knee. Osteoarthritis Cartilage 2006; 14:1119-25. [PMID: 16815714 DOI: 10.1016/j.joca.2006.05.003] [Citation(s) in RCA: 478] [Impact Index Per Article: 26.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2005] [Accepted: 05/09/2006] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine if the clinical results after microfracture of full-thickness cartilage lesions deteriorate over a period of 36 months. METHODS Between 1999 and 2002 85 patients (mean age 39.5 years) with full-thickness cartilage lesions underwent the microfracture procedure and were evaluated preoperatively and 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 and the International Cartilage Repair Society (ICRS)-score. The effects of the lesion localization and Magnetic resonance imaging (MRI) parameters were evaluated using the Pearson correlation and independent samples tests. RESULTS Both scores revealed significant improvement 18 months after microfracture (P<0.0001). Within the second 18 months after surgery there was a significant deterioration in the ICRS-score (P<0.0001). The best results could be observed in chondral lesions of the femoral condyles. Defects in other areas of the knee deteriorated between 18 and 36 months after microfracture. MRI 36 months after surgery revealed best defect filling in lesions on the femoral condyles with significant difference in the other areas (P<0.02). The Pearson coefficient of correlation between defect filling and ICRS-score was 0.84 and significant at the 0.01 level. CONCLUSIONS Microfracture is a minimal invasive method with good short-term results in the treatment of small cartilage defects. A deterioration of the results starts 18 months after surgery and is most evident in the ICRS-score. The best prognostic factors have young patients with defects on the femoral condyles.
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Microfracture and bone morphogenetic protein 7 (BMP-7) synergistically stimulate articular cartilage repair. Osteoarthritis Cartilage 2006; 14:1126-35. [PMID: 16765606 DOI: 10.1016/j.joca.2006.04.004] [Citation(s) in RCA: 91] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2005] [Accepted: 04/04/2006] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Microfracture is used to treat articular cartilage injuries, but leads to the formation of fibrocartilage rather than native hyaline articular cartilage. Since bone morphogenetic protein 7 (BMP-7) induces cartilage differentiation, we hypothesized that the addition of the morphogen would improve the repair tissue generated by microfracture. We determined the effects of these two treatments alone and in combination on the quality and quantity of repair tissue formed in a model of full-thickness articular cartilage injury in adolescent rabbits. DESIGN Full-thickness defects were made in the articular cartilage of the patellar grooves of forty, 15-week-old rabbits. Eight animals were then assigned to (1) no further treatment (control), (2) microfracture, (3) BMP-7, (4) microfracture with BMP-7 in a collagen sponge (combination treatment), and (5) microfracture with a collagen sponge. Animals were sacrificed after 24 weeks at 39 weeks of age. The extent of healing was quantitated by determining the thickness and the surface area of the repair tissue. The quality of the repair tissue was determined by grading specimens using the International Cartilage Repair Society Visual Histological Assessment Scale. RESULTS Compared to controls, BMP-7 alone increased the amount of repair tissue without affecting the quality of repair tissue. Microfracture improved both the quantity and surface smoothness of repair tissue. Compared to either single treatment, the combination of microfracture and BMP-7 increased both the quality and quantity of repair tissue. CONCLUSIONS Microfracture and BMP-7 act synergistically to stimulate cartilage repair, leading to larger amounts of repair tissue that more closely resembles native hyaline articular cartilage.
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Nishimori M, Deie M, Kanaya A, Exham H, Adachi N, Ochi M. Repair of chronic osteochondral defects in the rat. A bone marrow-stimulating procedure enhanced by cultured allogenic bone marrow mesenchymal stromal cells. ACTA ACUST UNITED AC 2006; 88:1236-44. [PMID: 16943480 DOI: 10.1302/0301-620x.88b9.17810] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Bone marrow mesenchymal stromal cells were aspirated from immature male green fluorescent protein transgenic rats and cultured in a monolayer. Four weeks after the creation of the osteochondral defect, the rats were divided into three groups of 18: the control group, treated with an intra-articular injection of phosphate-buffered saline only; the drilling group, treated with an intra-articular injection of phosphate-buffered saline with a bone marrow-stimulating procedure; and the bone marrow mesenchymal stromal cells group, treated with an intra-articular injection of bone marrow mesenchymal stromal cells plus a bone marrow-stimulating procedure. The rats were then killed at 4, 8 and 12 weeks after treatment and examined. The histological scores were significantly better in the bone marrow mesenchymal stromal cells group than in the control and drilling groups at all time points (p < 0.05). The fluorescence of the green fluorescent protein-positive cells could be observed in specimens four weeks after treatment.
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Affiliation(s)
- M Nishimori
- Department of Orthopaedic Surgery, Graduate School of Biomedical Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan.
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Shive MS, Hoemann CD, Restrepo A, Hurtig MB, Duval N, Ranger P, Stanish W, Buschmann MD. BST-CarGel: In Situ ChondroInduction for Cartilage Repair. ACTA ACUST UNITED AC 2006. [DOI: 10.1053/j.oto.2006.08.001] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Gill TJ, Asnis PD, Berkson EM. The treatment of articular cartilage defects using the microfracture technique. J Orthop Sports Phys Ther 2006; 36:728-38. [PMID: 17063835 DOI: 10.2519/jospt.2006.2444] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Chondral defects of the articular surface pose a challenging problem to the orthopedic surgeon. The goal of surgery is to alleviate pain, maximize function, and prevent degenerative changes in the future. A number of techniques have been described to treat these lesions. When considering the treatment options for chondral defects, the surgeon must consider the size, depth, location, and chronicity of the lesion. In addition, the overall alignment of the joint must be evaluated. Prior to treating chondral defects, it is important to understand the indications and contraindications for the microfracture technique. When indicated, the microfracture technique has many advantages over other surgical options. This technique is relatively easy to perform, cost effective, and has low patient morbidity. In addition, the microfracture technique does not burn any long-term bridges, enabling the surgeon to choose a different procedure to revise the chondral defect if the microfracture fails. It is important to understand the mechanism of healing by microfracture, including the effects of the local environment. The postoperative protocol used after the procedure may be as important as the surgery itself. Understanding the science behind the microfracture procedure will lead to better surgical technique and improved outcomes.
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Mithoefer K, Williams RJ, Warren RF, Potter HG, Spock CR, Jones EC, Wickiewicz TL, Marx RG. Chondral resurfacing of articular cartilage defects in the knee with the microfracture technique. Surgical technique. J Bone Joint Surg Am 2006; 88 Suppl 1 Pt 2:294-304. [PMID: 16951101 DOI: 10.2106/jbjs.f.00292] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Microfracture is a frequently used technique for the repair of articular cartilage lesions of the knee. Despite the popularity of the technique, prospective information about the clinical results after microfracture is still limited. The purpose of our study was to identify the factors that affect the clinical outcome from this cartilage repair technique. METHODS Forty-eight symptomatic patients with isolated full-thickness articular cartilage defects of the femur in a stable knee were treated with the microfracture technique. Prospective evaluation of patient outcome was performed for a minimum follow-up of twenty-four months with a combination of validated outcome scores, subjective clinical rating, and cartilage-sensitive magnetic resonance imaging. RESULTS At the time of the latest follow-up, knee function was rated good to excellent for thirty-two patients (67%), fair for twelve patients (25%), and poor for four (8%). Significant increases in the activities of daily living scores, International Knee Documentation Committee scores, and the physical component score of the Short Form-36 were demonstrated after microfracture (p < 0.05). A lower body-mass index correlated with higher scores for the activities of daily living and SF-36 physical component, with the worst results for patients with a body-mass index of >30 kg/m(2). Significant improvement in the activities of daily living score was more frequent with a preoperative duration of symptoms of less than twelve months (p < 0.05). Magnetic resonance imaging in twenty-four knees demonstrated good repair-tissue fill in the defect in thirteen patients (54%), moderate fill in seven (29%), and poor fill in four patients (17%). The fill grade correlated with the knee function scores. All knees with good fill demonstrated improved knee function, whereas poor fill grade was associated with limited improvement and decreasing functional scores after twenty-four months. CONCLUSIONS Microfracture repair of articular cartilage lesions in the knee results in significant functional improvement at a minimum follow-up of two years. The best short-term results are observed with good fill grade, low body-mass index, and a short duration of preoperative symptoms. A high body-mass index adversely affects short-term outcome, and a poor fill grade is associated with limited short-term durability.
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Affiliation(s)
- Kai Mithoefer
- Harvard Vanguard Orthopaedics and Sports Medicine, Brigham and Women's Hospital, 291 Independence Drive, Chestnut Hill, MA 02467, USA.
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Mithoefer K, Williams RJ, Warren RF, Wickiewicz TL, Marx RG. High-impact athletics after knee articular cartilage repair: a prospective evaluation of the microfracture technique. Am J Sports Med 2006; 34:1413-8. [PMID: 16735588 DOI: 10.1177/0363546506288240] [Citation(s) in RCA: 234] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Knee articular cartilage injuries in athletes present a therapeutic challenge and have been identified as an important cause of permanent disability because of the high mechanical joint stresses in athletes. PURPOSE To determine whether microfracture treatment of knee articular cartilage injuries can return athletes to high-impact sports and to identify the factors that affect the ability to return to athletic activity. STUDY DESIGN Case series; Level of evidence, 4. METHODS Thirty-two athletes who regularly participated in high-impact, pivoting sports before articular cartilage injury were treated with microfracture for single articular cartilage lesions of the knee. Functional outcome was prospectively evaluated with a minimum 2-year follow-up by subjective rating, activity-based outcome scores, and the ability for postoperative participation in high-impact, pivoting sports. RESULTS At last follow-up, 66% of athletes reported good or excellent results. Activity of daily living, Marx activity rating scale, and Tegner activity scores increased significantly after microfracture. After an initial improvement, score decreases were observed in 47% of athletes. Forty-four percent of athletes were able to regularly participate in high-impact, pivoting sports, 57% of these at the preoperative level. Return to high-impact sports was significantly higher in athletes with age <40 years, lesion size <200 mm(2), preoperative symptoms <12 months, and no prior surgical intervention. CONCLUSION Microfracture is an effective first-line treatment to return young athletes with short symptomatic intervals and small articular cartilage lesions of the knee back to high-impact athletics.
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Affiliation(s)
- Kai Mithoefer
- Harvard Vanguard Orthopedics and Sports Medicine, Brigham and Women's Hospital, Boston, MA, USA
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Changoor A, Hurtig MB, Runciman RJ, Quesnel AJ, Dickey JP, Lowerison M. Mapping of donor and recipient site properties for osteochondral graft reconstruction of subchondral cystic lesions in the equine stifle joint. Equine Vet J 2006; 38:330-6. [PMID: 16866200 DOI: 10.2746/042516406777749254] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
REASONS FOR PERFORMING STUDY To improve osteochondral graft reconstruction of subchondral cystic lesions in the medial and lateral femoral condyles by matching the material properties of donor and recipient sites. OBJECTIVES To measure biomechanical and biochemical parameters that influence the function and healing of osteochondral grafts used to reconstruct subchondral cystic lesions. HYPOTHESIS Suitable donor sites are available within the stifle joint for reconstructing the femoral condyles, despite considerable regional property variation. METHODS Fifty-six osteochondral cores were harvested from 6 distal femurs for initial studies that determined subchondral bone modulus of elasticity and ultimate stress. In a second study, 28 osteochondral cores were harvested from 6 distal femurs to measure cartilage aggregate modulus, thickness and sulphated glycosaminoglycan (sGAG) content. Using micro-CT imaging, subchondral bone mineral density and bone volume fraction were also measured. In both studies 2-dimensional contour plots using a bicubic interpolation method and normalised data were generated to allow visual comparison of joint surface characteristics. Statistical comparisons between donor and recipient site raw data were made using an ANOVA for repeated measures with a post hoc Tukey test. RESULTS Material properties of cartilage and bone vary considerably over the surface of the stifle joint but the central region of the medial condyle, where subchondral cystic lesions freqdently occur, typically demonstrated bone strength and modulus values of the highest observed. Cartilage thickness and aggregate modulus were highest in the medial femoral condyle and axial aspect of the lateral condyle. CONCLUSIONS Material properties of the grafts from the trochlear groove and axial aspect of the lateral trochlear ridge were the closest match for those found in the medial condyle, whereas properties of the lateral condyle were most similar to those found in the trochlear groove and axial aspect of the medial trochlear ridge.
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Affiliation(s)
- A Changoor
- Comparative Orthopaedic Research Laboratory, Ontario Veterinary College, Canada
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171
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Walmsley JP. Diagnosis and Treatment of Ligamentous and Meniscal Injuries in the Equine Stifle. Vet Clin North Am Equine Pract 2005; 21:651-72, vii. [PMID: 16297726 DOI: 10.1016/j.cveq.2005.08.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
The accuracy of the diagnosis of ligamentous and meniscal injuries in the equine stifle has improved significantly in the last 20 years. There are, however, significant limitations in the diagnosis of stifle injuries because of the size and anatomy of the equine stifle. Treatment of soft tissue injuries to the equine stifle has been empirical,with only a few large case studies for specific conditions of stifle ligaments and menisci and only retrospective case studies of the outcome of treatment. This article describes the diagnosis and treatment of ligamentous and meniscal injuries in the equine stifle using information from the author's own experience and from reports in the scientific literature.
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Affiliation(s)
- John P Walmsley
- The Liphook Equine Hospital, Forest Mere, Liphook, Hampshire GU30 7JG, United Kingdom.
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172
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Frisbie DD. Future Directions in Treatment of Joint Disease in Horses. Vet Clin North Am Equine Pract 2005; 21:713-24, viii. [PMID: 16297729 DOI: 10.1016/j.cveq.2005.07.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Osteoarthritis is one of the most economically important diseases facing equine practitioners. The loss of use associated with joint disease is a leading problem in the equine industry. Although osteoarthritis in all species is believed to be a multifactorial disease that is not well understood, significant advances are being made. This article presents areas of research that are relatively well developed but have not made it to commercialization or routine clinical practice and looks at new applications being investigated for peo-ple that may have an equine application.
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Affiliation(s)
- David D Frisbie
- Department of Clinical Sciences, Colorado State University, 2503 Bay Farm Road, Delivery Code 0912, Fort Collins, CO 80523, USA.
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173
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Hoemann CD, Hurtig M, Rossomacha E, Sun J, Chevrier A, Shive MS, Buschmann MD. Chitosan-glycerol phosphate/blood implants improve hyaline cartilage repair in ovine microfracture defects. J Bone Joint Surg Am 2005; 87:2671-2686. [PMID: 16322617 DOI: 10.2106/jbjs.d.02536] [Citation(s) in RCA: 192] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Microfracture is a surgical procedure that is used to treat focal articular cartilage defects. Although joint function improves following microfracture, the procedure elicits incomplete repair. As blood clot formation in the microfracture defect is an essential initiating event in microfracture therapy, we hypothesized that the repair would be improved if the microfracture defect were filled with a blood clot that was stabilized by the incorporation of a thrombogenic and adhesive polymer, specifically, chitosan. The objectives of the present study were to evaluate (1) blood clot adhesion in fresh microfracture defects and (2) the quality of the repair, at six months postoperatively, of microfracture defects that had been treated with or without chitosan-glycerol phosphate/blood clot implants, using a sheep model. METHODS In eighteen sheep, two 1-cm2 full-thickness chondral defects were created in the distal part of the femur and treated with microfracture; one defect was made in the medial femoral condyle, and the other defect was made in the trochlea. In four sheep, microfracture defects were created bilaterally; the microfracture defects in one knee received no further treatment, and the microfracture defects in the contralateral knee were filled with chitosan-glycerol phosphate/autologous whole blood and the implants were allowed to solidify. Fresh defects in these four sheep were collected at one hour postoperatively to compare the retention of the chitosan-glycerol phosphate/blood clot with that of the normal clot and to define the histologic characteristics of these fresh defects. In the other fourteen sheep, microfracture defects were made in only one knee and either were left untreated (control group; six sheep) or were treated with chitosan-glycerol phosphate/blood implant (treatment group; eight sheep), and the quality of repair was assessed histologically, histomorphometrically, and biochemically at six months postoperatively. RESULTS In the defects that were examined one hour postoperatively, chitosan-glycerol phosphate/blood clots showed increased adhesion to the walls of the defects as compared with the blood clots in the untreated microfracture defects. After histological processing, all blood clots in the control microfracture defects had been lost, whereas chitosanglycerol phosphate/blood clot adhered to and was partly retained on the surfaces of the defect. At six months, defects that had been treated with chitosan-glycerol phosphate/blood were filled with significantly more hyaline repair tissue (p < 0.05) compared with control defects. Repair tissue from medial femoral condyle defects that had been treated with chitosan-glycerol phosphate/blood contained more cells and more collagen compared with control defects and showed complete restoration of glycosaminoglycan levels. CONCLUSIONS Solidification of a chitosan-glycerol phosphate/blood implant in microfracture defects improved cartilage repair compared with microfracture alone by increasing the amount of tissue and improving its biochemical composition and cellular organization.
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Affiliation(s)
- Caroline D Hoemann
- Department of Chemical Engineering and Institute of Biomedical Engineering, Ecole Polytechnique, P.O. Box 6079, Station Centre-Ville, Montréal, Quebec H3C 3A7, Canada.
| | - Mark Hurtig
- Comparative Orthopaedic Research Laboratory, Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, Ontario N1G 2W1, Canada
| | - Evgeny Rossomacha
- BioSyntech Inc., 475 Armand-Frappier Boulevard, Laval, Quebec H7V 4B3, Canada
| | - Jun Sun
- BioSyntech Inc., 475 Armand-Frappier Boulevard, Laval, Quebec H7V 4B3, Canada
| | - Anik Chevrier
- Department of Chemical Engineering and Institute of Biomedical Engineering, Ecole Polytechnique, P.O. Box 6079, Station Centre-Ville, Montréal, Quebec H3C 3A7, Canada.
| | - Matthew S Shive
- BioSyntech Inc., 475 Armand-Frappier Boulevard, Laval, Quebec H7V 4B3, Canada
| | - Michael D Buschmann
- Department of Chemical Engineering and Institute of Biomedical Engineering, Ecole Polytechnique, P.O. Box 6079, Station Centre-Ville, Montréal, Quebec H3C 3A7, Canada.
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174
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Scopp JM, Mandelbaum BR. A treatment algorithm for the management of articular cartilage defects. Orthop Clin North Am 2005; 36:419-26. [PMID: 16164947 DOI: 10.1016/j.ocl.2005.05.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The clinical consequences of articular cartilage defects of the knee are pain, swelling, mechanical symptoms, athletic and functional disability, and osteoarthritis. Full thickness articular cartilage defects have a poor capacity to heal. The challenge to restore the articular cartilage surface is multidimensional, faced by basic scientists in the laboratory and orthopedic surgeons in the operating room. This article provides an overview of the contemporary treatment options available for the restoration of articular cartilage defects of the knee.
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Affiliation(s)
- Jason M Scopp
- Peninsula Orthopaedic Associates, 111 Davis Street, Salisbury, MD 21804, USA.
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175
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Lewis CW, Williamson AK, Chen AC, Bae WC, Temple MM, Wong WV, Nugent GE, James SP, Wheeler DL, Sah RL, Kawcak CE. Evaluation of subchondral bone mineral density associated with articular cartilage structure and integrity in healthy equine joints with different functional demands. Am J Vet Res 2005; 66:1823-9. [PMID: 16273917 DOI: 10.2460/ajvr.2005.66.1823] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To determine and correlate subchondral bone mineral density and overlying cartilage structure and tensile integrity in mature healthy equine stifle (low magnitude loading) and metacarpophalangeal (high magnitude loading) joints. ANIMALS 8 healthy horses, 2 to 3 years of age. PROCEDURE Osteochondral samples were acquired from the medial femoral condyle (FC) and medial trochlear ridge (TR) of the stifle joint and from the dorsal (MC3D) and palmar (MC3P) aspects of the distal medial third metacarpal condyles of the metacarpophalangeal joint. Articular cartilage surface fibrillation (evaluated via India ink staining) and tensile biomechanical properties were determined. The volumetric bone mineral density (vBMD) of the underlying subchondral plate was assessed via dual-energy x-ray absorptiometry. RESULTS Cartilage staining (fibrillation), tensile moduli, tensile strength, and vBMD were greater in the MC3D and MC3P locations, compared with the FC and TR locations, whereas tensile strain at failure was less in MC3D and MC3P locations than FC and TR locations. Cartilage tensile moduli correlated positively with vBMD, whereas cartilage staining and tensile strain at failure correlated negatively with vBMD. CONCLUSIONS AND CLINICAL RELEVANCE In areas of high joint loading, the subchondral bone had high vBMD and the articular cartilage surface layer had high tensile stiffness but signs of structural wear (fibrillation and low failure strain). The site-dependent variations and relationships in this study support the concept that articular cartilage and subchondral bone normally adapt to physiologic loading in a coordinated way.
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Affiliation(s)
- Chad W Lewis
- Department of Mechanical Engineering, College of Engineering, Colorado State University, Fort Collins, CO 80523, USA
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176
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MITHOEFER KAI, WILLIAMS RILEYJ, WARREN RUSSELLF, POTTER HOLLISG, SPOCK CHRISTOPHERR, JONES EDWARDC, WICKIEWICZ THOMASL, MARX ROBERTG. THE MICROFRACTURE TECHNIQUE FOR THE TREATMENT OF ARTICULAR CARTILAGE LESIONS IN THE KNEE. J Bone Joint Surg Am 2005. [DOI: 10.2106/00004623-200509000-00002] [Citation(s) in RCA: 188] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
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177
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Abstract
BACKGROUND The microfracture technique has been used successfully for the treatment of cartilage defects in the knee. The purpose of this study was to evaluate the microfracture technique in the treatment of osteochondral and degenerative chondral defects of the talus. METHODS In a prospective study, 30 ankles in 30 consecutive patients (17 men and 13 women; average age, 41 years; range 20 to 74 years were treated with arthroscopic microfracture. Twenty patients had osteochondral defects and 10 had degenerative chondral defects. Patients were evaluated with clinical examination and MRI preoperatively and at 3, 6, 12, and 24 months postoperatively. RESULTS At a mean followup of 2 years (range 22 to 27 months), 29 patients were available for follow-up. The results for all ankles according to the Hannover Scoring System were 45% excellent, 38% good, and 17% satisfactory. Results in patients older than 50 years were not inferior to those in younger patients. Visual Analog Score revealed an average of 8 +/- 2 for pain (preoperatively 3 +/- 2; p < or = 0.001), 8 +/- 2 for function (preoperatively 3 +/- 2; p < or = 0.001) and 8 +/- 2 for satisfaction (preoperatively 2 +/- 2; p < or = 0.001). MRI and arthroscopic assessment suggested the presence of cartilage in the microfractured area. CONCLUSIONS At short-term followup, the microfracture technique appeared to repair severe cartilage damage with a good functional outcome. Age was not shown to be a limiting factor.
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Affiliation(s)
- Christoph Becher
- Centre for Knee and Foot Surgery/Sports Trauma, ATOS Clinic Center Heidelberg, Germany
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178
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Dorotka R, Bindreiter U, Macfelda K, Windberger U, Nehrer S. Marrow stimulation and chondrocyte transplantation using a collagen matrix for cartilage repair. Osteoarthritis Cartilage 2005; 13:655-64. [PMID: 15905106 DOI: 10.1016/j.joca.2005.04.001] [Citation(s) in RCA: 121] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2004] [Accepted: 04/04/2005] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The purpose of the study was to determine whether the implantation of a scaffold would facilitate cartilage repair after microfracture in sheep over a period of 12 months. Furthermore, we investigated the effect of additional autologous cell augmentation of the implanted constructs. METHODS Two chondral defects were produced in the medial femoral condyle of sheep without penetrating the subchondral bone. Twenty-seven sheep were divided into the following groups: seven served as untreated controls (Group 1), microfracture was created in 20 animals, seven of them without further treatment (Group 2), in six sheep the defects were additionally covered with a porcine collagen matrix (Group 3), and in seven animals the matrix was augmented with cultured autologous chondrocytes (Group 4). After 4 (11 sheep) and 12 months (16 sheep), the filling of the defects, tissue types, and semiquantitative scores were determined. RESULTS The untreated defects revealed the least amount of defect fill. Defects treated with microfractures achieved better defect fill, while the additional use of the matrix did not increase the defect fill. The largest quantity of reparative tissue was found in the cell-augmented group. Semiquantitative scores were best in the cell-augmented group. CONCLUSION Microfracture treatment was observed to enhance the healing response. The implantation of a cell-seeded matrix further improved the outcome. The implantation of a collagen matrix alone did not enhance repair. Autologous cell implantation appears to be a very important aspect of the tissue engineering approach to cartilage defects.
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Affiliation(s)
- R Dorotka
- Medical University of Vienna, Department of Orthopedic Surgery, Waehringer Guertel 18-20, 1090 Vienna, Austria
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179
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180
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Wang DW, Fermor B, Gimble JM, Awad HA, Guilak F. Influence of oxygen on the proliferation and metabolism of adipose derived adult stem cells. J Cell Physiol 2005; 204:184-91. [PMID: 15754341 DOI: 10.1002/jcp.20324] [Citation(s) in RCA: 171] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Articular cartilage is an avascular connective tissue that exhibits little intrinsic capacity for repair. Articular cartilage exists in a reduced oxygen ( approximately 5%) environment in vivo; therefore, oxygen tension may be an important factor that regulates the metabolism of chondrocyte progenitors. A number of recent studies have developed tissue engineering approaches for promoting cartilage repair using undifferentiated progenitor cells seeded on biomaterial scaffolds, but little is known about how oxygen might influence these engineered tissues. Human adipose-derived adult stem (hADAS) cells isolated from the stroma of subcutaneous fat were suspended in alginate beads and cultured in control or chondrogenic media in either low oxygen (5%) or atmospheric oxygen tension (20%) for up to 14 days. Under chondrogenic conditions, low oxygen tension significantly inhibited the proliferation of hADAS cells, but induced a two-fold increase in the rate of protein synthesis and a three-fold increase in total collagen synthesis. Low oxygen tension also increased glycosaminoglycan synthesis at certain timepoints. Immunohistochemical analysis showed significant production of cartilage-associated matrix molecules, including collagen type II and chondroitin-4-sulfate. These findings suggest oxygen tension may play an important role in regulating the proliferation and metabolism of hADAS cells as they undergo chondrogenesis, and the exogenous control of oxygen tension may provide a means of increasing the overall accumulation of matrix macromolecules in tissue-engineered cartilage.
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Affiliation(s)
- David W Wang
- Department of Surgery, Division of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, USA
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181
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Uematsu K, Hattori K, Ishimoto Y, Yamauchi J, Habata T, Takakura Y, Ohgushi H, Fukuchi T, Sato M. Cartilage regeneration using mesenchymal stem cells and a three-dimensional poly-lactic-glycolic acid (PLGA) scaffold. Biomaterials 2005; 26:4273-9. [PMID: 15683651 DOI: 10.1016/j.biomaterials.2004.10.037] [Citation(s) in RCA: 242] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2004] [Accepted: 10/20/2004] [Indexed: 11/16/2022]
Abstract
Cartilage engineered from mesenchymal stem cells (MSCs) requires a scaffold to keep the cells in the cartilage defect and to act as a support for inducing hyaline cartilage formation. We developed a novel three-dimensional special poly-lactic-glycolic acid (PLGA) scaffold that provided structural support and stimulated repair. Three-dimensional PLGA scaffolds seeded with cultured MSCs were transplanted into large defects in rabbit knees and analyzed histologically at 4 and 12 weeks after the operation. Our findings showed that in the engineered cartilage with the PLGA scaffold, the defects were filled with smooth, shiny white tissue macroscopically and hyaline-like cartilage histologically at 12 weeks after the transplantation. The structure of the novel PLGA scaffolds provided architectural support for the differentiation of progenitor cells and demonstrated successful induction of in vivo chondrogenesis.
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Affiliation(s)
- Kota Uematsu
- Department of Orthopaedic Surgery, Nara Medical University, 840, Shijou-cho, Kashihara-city, Nara 634-8522, Japan.
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182
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183
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Akgun I, Kesmezacar H, Ogut T, Kebudi A, Kanberoglu K. Arthroscopic microfracture treatment for osteonecrosis of the knee. Arthroscopy 2005; 21:834-43. [PMID: 16012497 DOI: 10.1016/j.arthro.2005.04.106] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE This study evaluated the results of arthroscopic subchondral microfracture performed on patients with spontaneous osteonecrosis (ON) (group 1) or secondary ON (group 2) of the knee joint. TYPE OF STUDY Retrospective clinical study. METHODS Group 1 included 26 patients (mean age, 48 years) who had spontaneous ON. Group 2 included 15 patients (mean age, 32 years) with ON secondary to inflammatory disease or steroid therapy. Seventy-six percent of the chondral defects were located in the medial femoral condyle. The average defect sizes in group 1 was 162 mm2 and in group 2 was 362 mm2. After debridement of the necrotic tissues, multiple perforations were placed into the subchondral bone to obtain revascularization. RESULTS There was an increase in the average Lysholm scores from 57 to 90 in group 1 after 27 months of mean follow-up (P < .05); 71% of patients could participate in strenuous sports with no or minimal limitation. The mean activity level in group 1 according to Cincinnati Knee Rating System was 6 preoperatively and 13.54 postoperatively. For group 2, the average scores showed significant improvement and patient satisfaction after surgery (preoperative and postoperative average Lysholm scores were 41 and 75, respectively, with mean follow-up of 37 months). Average activity level in group 2 increased from 2.67 to 11.73. Control magnetic resonance imaging scans of the cases revealed the continuity of normal cartilage with cartilage-like tissue in the treated areas. However, an increase of the size of ON in the subchondral bone was detected in 27% of the knees. CONCLUSIONS The microfracture technique is safe, simple, and cost-effective, and may be an alternative procedure for treatment of ON of the knee, especially in young patients, before possible subsequent replacement surgery. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Isik Akgun
- Department of Orthopaedics and Traumatology, Cerrahpasa Faculty of Medicine, Istanbul University, Istanbul, Turkey
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184
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Dorotka R, Windberger U, Macfelda K, Bindreiter U, Toma C, Nehrer S. Repair of articular cartilage defects treated by microfracture and a three-dimensional collagen matrix. Biomaterials 2005; 26:3617-29. [PMID: 15621252 DOI: 10.1016/j.biomaterials.2004.09.034] [Citation(s) in RCA: 149] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2004] [Accepted: 09/21/2004] [Indexed: 12/19/2022]
Abstract
The objective of our study was to evaluate the behavior of ovine chondrocytes and bone marrow stromal cells (BMSC) on a matrix comprising type-I, -II, and -III collagen in vitro, and the healing of chondral defects in an ovine model treated with the matrix, either unseeded or seeded with autologous chondrocytes, combined with microfracture treatment. For in vitro investigation, ovine chondrocytes and BMSC were seeded on the matrix and cultured at different time points. Histological analysis, immunohistochemistry, biochemical assays for glycosaminoglycans, and real-time quantitative PCR for collagens were performed. The animal study described here included 22 chondral defects in 11 sheep, divided into four treatment groups. Group A: microfracture and collagen matrix seeded with chondrocytes; B: microfracture and unseeded matrices; C: microfracture; D: untreated defects. All animals were sacrificed 16 weeks after implantation, and a histomorphometrical and qualitative evaluation of the defects was performed. The in vitro investigation revealed viable cells up to 3 weeks; chondrocytes had a predominantly round morphology, produced glycosaminoglycans, and expressed both collagen markers, whereas BMSC stained positive for antibodies against type-II collagen; however, no mRNA for type-II collagen was amplified. All treatment groups of the animal model showed better defect filling compared to untreated knees. The cell-seeded group had the greatest quantity of repair tissue and the largest quantity of hyaline-like tissue. Although the collagen matrix is an adequate environment for BMSC in vitro, the additionally implanted unseeded collagen matrix did not increase the repair response after microfracture in chondral defects. Only the matrices seeded with autologous cells in combination with microfracture were able to facilitate the regeneration of hyaline-like cartilage.
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Affiliation(s)
- R Dorotka
- Department of Orthopaedic Surgery, Medical School, University of Vienna, Waehringer Guertel 18-20, A-1090 Wien, Austria
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185
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Gill TJ, McCulloch PC, Glasson SS, Blanchet T, Morris EA. Chondral defect repair after the microfracture procedure: a nonhuman primate model. Am J Sports Med 2005; 33:680-5. [PMID: 15722269 DOI: 10.1177/0363546504271744] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The extent and time course of chondral defect healing after microfracture in humans are not well described. Although most physicians recommend a period of activity and weightbearing restriction to protect the healing cartilage, there are limited data on which to base decisions regarding the duration of such restrictions. HYPOTHESIS Evaluation of the status of chondral defect repair at different time points after microfracture in a primate model may provide a rationale for postoperative activity recommendations. STUDY DESIGN Descriptive laboratory study. METHODS Full-thickness chondral defects created on the femoral condyles and trochlea of 12 cynomolgus macaques were treated with microfracture and evaluated by gross and histologic examination at 6 and 12 weeks. RESULTS At 6 weeks, there was limited chondral repair and ongoing resorption of subchondral bone. By 12 weeks, the defects were completely filled and showed more mature cartilage and bone repair. CONCLUSION In the primate animal model, significant improvements in the extent and quality of cartilage repair were observed from the 6- to 12-week time points after microfracture. CLINICAL RELEVANCE The poor status of the defect repair at 6 weeks and the ongoing healing observed from the 6- to 12-week time points may indicate that the repair is vulnerable during this initial postoperative period. Assuming the goal of postoperative weightbearing and activity restriction in patients after microfracture is to protect immature repair tissue, this study lends support to extending such recommendations longer than 6 weeks.
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Affiliation(s)
- Thomas J Gill
- Massachusetts General Hospital, WACC 508, 15 Parkman Street, Boston, MA 02114, USA.
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186
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Abstract
In part 1 of this 2-part Current Concepts article, the authors reviewed the basic science of normal articular and meniscal cartilage and its response to injury. They reviewed the historical perspectives and basic science behind these various methods and presented a rationale for patient evaluation, treatment selection, and timing. In part 2, the authors review the specific indications for the treatment of chondral injuries and describe the techniques and outcomes of the various treatment options, including palliative, reparative, and restorative procedures. In addition, they will examine specific complex clinical scenarios emphasizing treatment options of comorbid conditions including ligament instability, meniscal deficiency, and malalignment. A limited review of the application of these techniques in joints other than the knee will also be presented. A conceptual algorithm is developed to assist in clinical decision making.
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Affiliation(s)
- J Winslow Alford
- Shoulder and Sports Medicine Division, West Bay Orthopedics, Warwick, RI, USA
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187
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Hallux Rigidus Treatment With Cheilectomy, Extensive Plantar Release, and Additional Microfracture Technique. TECHNIQUES IN FOOT AND ANKLE SURGERY 2004. [DOI: 10.1097/00132587-200412000-00004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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188
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The Technique of Microfracture of Full-Thickness Chondral Lesions and Postoperative Rehabilitation. ACTA ACUST UNITED AC 2004. [DOI: 10.1097/01.btk.0000135867.35924.f3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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189
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Scott GSP, Crawford WH, Colahan PT. Arthroscopic findings in horses with subtle radiographic evidence of osteochondral lesions of the medial femoral condyle: 15 cases (1995–2002). J Am Vet Med Assoc 2004; 224:1821-6. [PMID: 15198269 DOI: 10.2460/javma.2004.224.1821] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To determine arthroscopic findings in lame horses with subtle radiographic lesions of the medial femoral condyle. DESIGN Retrospective study. ANIMALS 15 horses examined because of lameness that had subtle radiographic evidence of osteochondral lesions involving the medial femoral condyle in at least 1 joint. PROCEDURE Medical records were reviewed, and results of physical examination, radiography, and arthroscopy were recorded. Follow-up information was obtained through reexamination of the horses or telephone conversations with the referring veterinarians, owners, or trainers. RESULTS Lameness severity ranged from grade 1 to 3 on a scale from 0 to 5. Radiography and arthroscopy were performed on 28 stifle joints. The 4 unaffected joints in 4 horses with unilateral hind limb lameness that underwent bilateral arthroscopy had no radiographic lesions, but 2 of the 4 had arthroscopic lesions. Of the remaining 24 joints, 20 had radiographic evidence of flattening of the apex of the medial femoral condyle and 4 had minimal subchondral lucency. Lesions were identified arthroscopically in 18 of the 20 joints with flattening of the condyle and in all 4 joints with subchondral lucency. Treatment consisted of abrasion arthroplasty or microfracture. Seven of the 9 horses with focal cartilage lesions and 2 of the 6 horses with generalized cartilage lesions were reportedly sound without any evidence of joint effusion at the time of final follow-up. CONCLUSIONS AND CLINICAL RELEVANCE Results suggest that horses with hind limb lameness and subtle radiographic lesions of the medial femoral condyle are likely to have arthroscopically apparent cartilage lesions and subchondral bone defects.
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Affiliation(s)
- Grant S P Scott
- Department of Large Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Gainesville, FL 32610-0136, USA
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190
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Thermann H, Becher C. [Microfracture technique for treatment of osteochondral and degenerative chondral lesions of the talus. 2-year results of a prospective study]. Unfallchirurg 2004; 107:27-32. [PMID: 14749850 DOI: 10.1007/s00113-003-0713-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The microfracture technique has become an established method for the treatment of chondral lesions in the knee. The aim of this study was to determine its usefulness in the treatment of osteochondral (OCL) and degenerative chondral lesions (DCL) of the talus. In a prospective study, 32 patients with an osteochondral lesion (22 patients) or degenerative chondral lesion (10 patients) were operated arthroscopically and treated with the microfracture technique. All patients were evaluated preoperatively as well as 3, 6, 12, and 24 months postoperatively with the Hannover scoring system and a visual analog score (VAS). MRI scans were performed at all points. Statistical analyses were performed using the Wilcoxon sign rank-sum test with a level of significance of p < or = 0.05. At a mean follow-up of 2 years (range: 22-27 months), 23 patients (14 OCL, 9 DCL) were available for follow-up. The average age of the 17 male and 15 female patients at the time of operation was 39 years (range: 16-74 years). The results according to the Hannover scoring system were 43% excellent, 35% good, and 22% satisfactory with 93% excellent or good results for OCL. Older patients (>50 years, n=8) had slightly better results than younger patients. VAS revealed an average of 7.84 (preoperative: 3.53) for pain, 7.85 for function (preoperative; 3.38), and 7.78 for satisfaction (preoperative: 2.41). MRI and arthroscopic assessment showed a visible regeneration of the cartilage in the microfractured area. In a short-term follow-up, the microfracture technique has proven to restore severe cartilage damage with a good functional outcome. Age is not a limiting factor. However, longer-term results remain to be evaluated.
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Affiliation(s)
- H Thermann
- Zentrum für Knie- und Fusschirurgie/Sporttraumatologie, ATOS-Klinik, Heidelberg.
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191
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Williams RJ, Dreese JC, Chen CT. Chondrocyte survival and material properties of hypothermically stored cartilage: an evaluation of tissue used for osteochondral allograft transplantation. Am J Sports Med 2004; 32:132-9. [PMID: 14754736 DOI: 10.1177/0095399703258733] [Citation(s) in RCA: 133] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND There is little information available on the material properties of hypothermically stored allograft specimens used to repair osteochondral defects. PURPOSE To analyze the effect of hypothermic storage on the material properties of fresh knee specimens over a 60-day interval. STUDY DESIGN Controlled laboratory study. METHODS Twelve sheep knee condyles were isolated. The femoral and tibial condyles and the patella were stored in a nutritive medium containing Dulbecco's Modified Eagle's Medium for 1, 8, 15, 29, 45, or 60 days. Total chondrocyte density, chondrocyte viability, matrix proteoglycan content, matrix water content, and matrix dynamic modulus of elasticity were determined. RESULTS Mean chondrocyte viability decreased significantly over the storage interval: 100% (day 1), 98.2% (day 8), *80.2% (day 15), *80.6% (day 29), *64.6% (day 45), and *51.6% (day 60) (* P < 0.05). Qualitative analysis demonstrated a preponderance of nonviable chondrocytes in the superficial cartilage layer. Significant decreases in matrix proteoglycan were observed in day 15 through day 60 specimens (P < 0.05). The matrix dynamic modulus significantly decreased from day 1 through day 60 (P < 0.05). CONCLUSION The material properties of hypothermically stored knee condyles progressively decline over 60 days. CLINICAL RELEVANCE This observed decline may have significant ramifications on long-term graft survival following stored-allograft implantation.
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Affiliation(s)
- Riley J Williams
- Laboratory for Soft Tissue Research, Hospital for Special Surgery, New York, New York 10021, USA
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192
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193
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Affiliation(s)
- Brian J Cole
- Rush Cartilage Restoration Center, Department of Orthopedic Surgery and Anatomy (Conjoint), Rush University Medical Center, 1725 W. Harrison Street, Suite 1063, Chicago, IL 60612, USA.
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194
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Pearce SG, Hurtig MB, Boure LP, Radcliffe RM, Richardson DW. Cylindrical press-fit osteochondral allografts for resurfacing the equine metatarsophalangeal joint. Vet Surg 2003; 32:220-30. [PMID: 12784198 DOI: 10.1053/jvet.2003.50032] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To investigate the feasibility of resurfacing the equine fetlock joint using cylindrical, orthotopic, press-fit, osteochondral allografts. STUDY DESIGN Experimental study. ANIMALS Ten mature, mixed-breed horses. METHODS Cylindrical, osteochondral grafts (6.5-mm diameter) were harvested aseptically from cadaveric equine metatarsophalangeal joints. Allografts were transplanted into 6 horses; 4 horses were sham operated. The surgical approach involved creation of a bone block at the origin of the medial collateral ligament and luxation of the metatarsophalangeal joint. Grafts were placed into the medial and lateral metatarsal condyles. Radiographs were taken at 8 and 25 weeks, and lameness was evaluated at 25 weeks. Horses were killed at 25 weeks. Analyses included gross evaluation, microradiography, paravital staining, light microscopy, and cartilage biochemistry. RESULTS No complications occurred that could be attributed to the surgical procedure. Graft congruency with the surrounding articular cartilage was fair to excellent. Two horses were sound at 25 weeks. Most grafts had more than 90% articular cartilage coverage, and histologic and microradiographic analysis revealed good graft incorporation and articular cartilage survival. Sulphated glycosaminoglycan concentration was decreased in grafted tissue. CONCLUSIONS We attribute the viability of osteochondral allografts in the equine fetlock to adequate congruency, stable graft fixation, and the use of orthotopic tissue. Host response to the allograft bone tissue did not affect cartilage viability. CLINICAL RELEVANCE Before clinical use, improvements to instrumentation are required that would decrease damage to grafts and minimize technique-associated incongruencies of the articular surface at the time of grafting. Larger grafts would also likely be required to resurface a greater surface area.
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Affiliation(s)
- Simon G Pearce
- Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, Ontario, Canada
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195
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Steadman JR, Briggs KK, Rodrigo JJ, Kocher MS, Gill TJ, Rodkey WG. Outcomes of microfracture for traumatic chondral defects of the knee: average 11-year follow-up. Arthroscopy 2003; 19:477-84. [PMID: 12724676 DOI: 10.1053/jars.2003.50112] [Citation(s) in RCA: 790] [Impact Index Per Article: 37.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE In this study, we measured functional outcomes of patients treated arthroscopically with microfracture for full-thickness traumatic defects of the knee. TYPE OF STUDY A case series of patients with 7 to 17 years' follow-up. METHODS Between 1981 and 1991, a total of 72 patients (75 knees) met the following inclusion criteria: (1) traumatic full-thickness chondral defect, (2) no meniscus or ligament injury, and (3) age 45 years and younger (range, 13 to 45 years). Seventy-one knees (95%) were available for final follow-up (range, 7 to 17 years). All patients completed self-administered questionnaires preoperatively and postoperatively. RESULTS The following results were significant at the P <.05 level. Significant improvement was recorded for both Lysholm (scale 1 to 100; preoperative, 59; final follow-up, 89) and Tegner (1 to 10; preoperative, 3; final follow-up, 6) scores. At final follow-up, the SF-36 and WOMAC scores showed good to excellent results. At 7 years after surgery, 80% of the patients rated themselves as "improved." Multivariate analysis revealed that age was a predictor of functional improvement. CONCLUSIONS Over the 7- to 17-year follow-up period (average, 11.3 years), patients 45 years and younger who underwent the microfracture procedure for full-thickness chondral defects, without associated meniscus or ligament pathology, showed statistically significant improvement in function and indicated that they had less pain.
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196
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Changes in subchondral bone in cartilage resurfacing--an experimental study in sheep using different types of osteochondral grafts. Osteoarthritis Cartilage 2003; 11:265-77. [PMID: 12681953 DOI: 10.1016/s1063-4584(03)00006-2] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE This article addresses the subchondral bone integrity in cartilage resurfacing by comparing fresh, untreated auto-, xeno-, and photooxidized osteochondral allo- and xenografts. Photooxidation was expected to improve mechanical stability of the osteochondral grafts through an improved linkage of the collagen fibers within the bone matrix. DESIGN Untreated auto- and xenografts and with photooxidation pretreated allo- and xenografts were surgically implanted in femoral condyles of sheep (n=40). After 2, 6, 12 and 18 months results were evaluated histologically using non-decalcified bone embedded in acrylic resin. Qualitative evaluation was performed with emphasis on bone matrix, biomechanical stability of graft anchorage, formation of cystic lesions, and bone resorption and formation. Quantitative evaluation of the total subchondral bone area was conducted histomorphometrically. Statistical analysis (factorial ANOVA test) was used to compare differences between groups with respect to the percentage of bone matrix and fibrous tissue per section. RESULTS Subchondral bone resorption was fastest in untreated, fresh autografts, followed by photooxidized allografts, untreated, fresh xenografts and last pretreated photooxidized xenografts. Cystic lesions were seen in all types of grafts, but were most pronounced at 6 months in autografts and least in photooxidized grafts. Cyst-like lesions had subsided substantially in the untreated auto- and photooxidized xenografts, if no graft dislocation occurred during the healing period. Mononuclear cell infiltration and an increase in the presence of multinuclear cells were observed at 2 months, mostly in untreated autografts, followed by photooxidized allo- and untreated xenografts. They were much higher in numbers compared to photooxidized grafts, at least in the early specimens at 2 months. Graft stability was linked to the rate of bone resorption. CONCLUSION Substantial resorption of the subchondral bone, involving the development of cyst-like lesions, lead to dislocation and finally to cartilage matrix degradation of the grafts. The process of photooxidation decreased the speed of bone resorption in osteochondral grafts and, thus, improved graft stability and cartilage survival. These results suggest that the remodeling of the subchondral bone of the host and the graft within the first 6 months is an important factor in graft stability and overall results of cartilage resurfacing.
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197
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Recht M, White LM, Winalski CS, Miniaci A, Minas T, Parker RD. MR imaging of cartilage repair procedures. Skeletal Radiol 2003; 32:185-200. [PMID: 12652334 DOI: 10.1007/s00256-003-0631-3] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2002] [Accepted: 01/13/2003] [Indexed: 02/02/2023]
Abstract
It is becoming increasingly important for the radiologist to evaluate the appearance and outcome of cartilage repair procedures. MR imaging is currently the best method for such evaluation but it is necessary to use cartilage-specific sequences and to modify those sequences when necessary to minimize artifacts from retained metal within the joint. This article reviews the surgical technique of the more commonly performed cartilage repair procedures, currently recommended techniques for the MR imaging evaluation of articular cartilage and cartilage repair procedures, and the MR imaging appearance of cartilage repair procedures and of the most frequently encountered complications following such procedures.
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Affiliation(s)
- Michael Recht
- Department of Radiology, Cleveland Clinic Foundation, 9500 Euclid Avenue, A21, Cleveland, OH 44195, USA.
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Frisbie DD, Oxford JT, Southwood L, Trotter GW, Rodkey WG, Steadman JR, Goodnight JL, McIlwraith CW. Early events in cartilage repair after subchondral bone microfracture. Clin Orthop Relat Res 2003:215-27. [PMID: 12567150 DOI: 10.1097/00003086-200302000-00031] [Citation(s) in RCA: 237] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The current study investigated healing of large full-thickness articular cartilage defects during the first 8 weeks with and without penetration of the subchondral bone using microfracture in an established equine model of cartilage healing. Chondral defects in the weightbearing portion of the medial femoral condyle were made bilaterally; one defect in each horse was microfractured whereas the contralateral leg served as the control. The expression of cartilage extracellular matrix components (Types I and II collagen and aggrecan) was evaluated using histologic techniques, reverse transcription coupled polymerase chain reaction, in situ hybridization, and immunohistochemistry. This study confirms an increase in Type II collagen mRNA expression in repair tissue as early as 6 weeks after microfracture. Although other matrix mRNA and protein levels changed in concentration and tissue location over the course of the study, no significant differences were seen in microfractured defects. Although the microfracture techniques appear to improve clinical functionality, volume of repair tissue, and augment Type II collagen content, aggrecan content is less than ideal. Therefore, methods to enhance key matrix components such as aggrecan after microfracture may additionally improve repair tissue observed after the procedure.
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Affiliation(s)
- David D Frisbie
- Orthopaedic Research Center, Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, CO, USA.
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200
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Abstract
Many compounds are being investigated for the control of symptoms of osteoarthritis in people and animals. Ideally, treatment should include analgesia, inflammation control, and chondroprotection. With further progress in this area, combination therapies tailored to the needs of the individual animal should enable us to maximize efficacy and minimize side effects. Only a few of the newer therapies and pharmaceutic agents have been investigated in the horse, however. With more rigorous investigation, they may be determined to be ineffective or unsafe. Meanwhile, as much information should be gathered from manufacturers as possible so as to ensure that appropriate recommendations are made.
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Affiliation(s)
- Erin D Malone
- Department of Clinical and Population Sciences, 225K Veterinary Teaching Hospitals, 1365 Gortner Avenue, St. Paul, MN 55108, USA.
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