Alberto Ferruzzi

Autologous chondrocyte implantation in the knee joint: open compared with arthroscopic technique. Comparison at a minimum follow-up of five years.

Autologous chondrocyte implantation is a widely used technique for treating cartilage lesions1-10. The technique, first introduced and described by Brittberg et al. in 199411, required an arthrotomy of the joint, debridement of the lesions, and the suturing of a periosteal flap to create a pocket to host the chondrocytes. Autologous chondrocyte implantation in the knee joint has provided hyaline-like repair tissue11-16, with satisfactory clinical results in 80% to 90% of patients1,7,17. Moreover, autologous chondrocyte implantation has been shown to be a valid alternative to the mosaicplasty and microfracture repair techniques used in the treatment of osteochondral lesions of the knee1,6,13,17-20. In the recent past, to simplify the autologous chondrocyte implantation surgical technique, a three-dimensional hyaluronic acid scaffold was developed to support the autologous chondrocytes13. This scaffold enables an arthroscopic implantation technique to be used21. Furthermore, the chondrocytes embedded on the hyaluronic acid scaffold tend to maintain their original phenotype22 with respect to dedifferentiation induced by the fluid medium23. Despite initial encouraging results with the use of arthroscopic autologous chondrocyte implantation in the treatment of osteochondral lesions of the knee24-26, open and arthroscopic autologous chondrocyte implantation techniques have been compared in only a few studies23,25,26, and these have included only short-term follow-up and limited and nonhomogeneous case series. The aim of this study was to compare the long-term results in two groups of patients in whom osteochondral lesions in the knee joint were treated with the two aforementioned procedures. Patients were evaluated clinically, histologically, and with magnetic resonance imaging, with a minimum five-year follow-up. Between 1997 and 2002, …

Matrix-Assisted Autologous Chondrocyte Transplantation for Cartilage Regeneration in Osteoarthritic Knees Results and Failures at Midterm Follow-up

Background: Young patients with osteoarthritic knees are a challenging population because of a combination of high functional demands and limited indication for joint replacement. Purpose: To analyze the potential of the cartilage regenerative approach by documenting the results and failures of matrix-assisted autologous chondrocyte transplantation (MACT) at midterm follow-up. Study Design: Case series; Level of evidence, 4. Methods: Forty-four patients affected by cartilage lesions in osteoarthritic knees underwent MACT as a salvage procedure. The mean age at surgery was 42 years (range, 20-58 years), and the average defect size was 4 cm2 (range, 1.5-9 cm2). Patients were prospectively evaluated with the subjective International Knee Documentation Committee (IKDC), EuroQol visual analog scale (EQ-VAS), and Tegner scores preoperatively; at 1, 2, and 5 years; and at a final assessment at 9 years’ mean follow-up. Adverse events and failures were also reported. Results: A statistically significant improvement was observed in all scores from the initial evaluation to the final follow-up. The mean ± standard deviation IKDC subjective score improved from 38.0 ± 15.8 to 67.0 ± 18.3 at 2 years (P < .0005), with a subsequent decrease to 57.8 ± 20.6 at the final follow-up (P = .012). The same trend was confirmed by the EQ-VAS score. The activity level revealed by the Tegner score improved at all follow-ups but without achieving the preinjury level. The analysis of the influencing factors showed the importance of the meniscus condition, revealing a significantly inferior outcome in knees with previous or combined partial meniscectomy procedures. During the study period, 12 patients had failed results, producing a cumulative failure rate of 27.3%. At the last evaluation, half of the patients considered their condition not better than before the treatment, and 39% would not repeat the treatment considering the results obtained. Conclusion: Despite a statistically significant improvement, the clinical outcome was poor. A higher improvement could be obtained in patients who had not undergone previous or combined meniscectomies, but this was limited over time. The failure rate was also high, regardless of the degree of osteoarthritis. Tissue-engineered cartilage implantation is questionable for this indication, and the limits of this scaffold-based procedure have to be considered if it is used as a salvage procedure for young patients affected by knee osteoarthritis.

A prospective, randomised, controlled trial using a Mg-hydroxyapatite - demineralized bone matrix nanocomposite in tibial osteotomy.

We in vivo investigated the bone healing ability of a nanocomposite (DBSint®), constituted by biomimetic nano-structured Mg-hydroxyapatite (SINTlife®) and human demineralized bone matrix. Thirty-one subjects undergoing high tibial osteotomy for genu varus were randomly assigned to three groups: during surgery, DBSint® was inserted into nine patients, SINTlife® in thirteen patients and lyophilised bone chips, that is the routine surgery, in nine subjects. As outcome measures, clinical, radiographic and histomorphometry scores were calculated. The osseointegration was evaluated by imaging six weeks, three, six and twelve months after surgery. At six-week follow-up, DBSint® showed a significantly higher osseointegration rate in comparison with lyophilised bone chips (p = 0.008). At the same follow-up, CT-guided bone biopsies were obtained and analysed by histomorphometry: a good osteogenetic potential was demonstrated with DBSint®, as well as with SINTlife® and controls. Unresorbed material was evident with DBSint® and SINTlife®, with a significantly higher percentage in SINTlife® group. At 1-year follow-up, DBSint® was demonstrated as effective and safe as SINTlife® and lyophilized bone chips. More significant results could be obtained by continuing the clinical trial, by increasing the patient number and the study power. Eventually, the role of non-resorbed graft remnants is still unclear and requires further investigation.

Allograft Salvage Procedure in Multiple-Revision Anterior Cruciate Ligament Reconstruction

Background: Multiple-revision anterior cruciate ligament (ACL) reconstructions represent a surgical challenge due to the presence of previous tunnels, hardware, injuries to the secondary stabilizers, and difficulties in retrieving autologous tendons. An anatomic ACL reconstruction may therefore result in a demanding surgery, thus requiring 2 stages. Purpose: To analyze the efficacy of an over-the-top ACL reconstruction technique plus extra-articular plasty using Achilles or tibialis posterior tendon allograft in restoring knee stability in patients with at least 2 failed previous ACL reconstructions, as well as to evaluate the factors able to affect the final outcome. Study Design: Case series; Level of evidence, 4. Methods: From 2002 to 2008, 24 male athletes with a mean age of 30.8 years underwent surgery. Twenty patients had undergone 2, whereas 4 patients had undergone 3 previous reconstructions. The International Knee Documentation Committee (IKDC) score and KT-2000 arthrometric evaluation were used to measure outcomes at a mean follow-up period of 3.3 years (range, 2-7). Results: The mean ± SD IKDC subjective score at follow-up was 81.3 ± 14.0. The IKDC objective score was an A or B in 20 patients (83%). Arthrometer side-to-side difference averaged 3.1 ± 1.1 mm. Range of motion was normal or nearly normal in 23 patients and abnormal in 1. Of the 20 good results, 17 patients resumed sports activity at the preinjury level. Conclusion: A 2-stage revision is an accepted option in cases of excessive tunnel enlargement and bone loss, especially on the femoral side, to achieve anatomic reconstruction. Nonanatomic over-the-top ACL reconstruction and lateral extra-articular plasty technique allow one to overcome difficult anatomic situations on the femoral side, permitting a 1-step surgery. The overall results obtained in this series are comparable with those of other ACL revision series. The higher rate of mild instability observed in our series may not be attributable to the surgical technique but rather to the chronic instability suffered by these knees before last revision.

Arthroscopic Treatment of Ankle Anterior Bony Impingement The Long-term Clinical Outcome

Background: Arthroscopic treatment of anterior ankle bony impingement provides good results, with a tendency to decrease over time. The purpose of this study was to analyze the factors affecting long-term results. Methods: Eighty consecutive patients with a mean age of 37.3 years were treated between 2000 and 2004. Impingement lesions were identified according to Scranton-McDermott classification. Preoperative ankle osteoarthritis was documented by van Dijk scale upon the x-rays. Bone spurs were analyzed and classified according to location and size. The associated chondral lesions were classified following the International Cartilage Repair Society (ICRS) criteria. Patient data, foot morphology, and previous traumas were recorded. Patients were evaluated after a mean of 104.6 months follow-up with the American Orthopaedic Foot and Ankle Society (AOFAS) scale. The influence of different factors on outcomes was statistically analyzed. Results: The mean preoperative AOFAS score was 50.9, while at follow-up it was 70.7 (P < .05). The different grades of Scranton-McDermott impingement classification did not affect the results, but the different grades of van Dijk scale significantly affected the result but not the preoperative stage. Tibial localized spurs had better outcome at follow-up. The grade of the chondral lesions significantly affected the outcome. Other factors negatively affecting the results were age, cavus foot morphology, and history of previous ankle fracture. Conclusion: Arthroscopic treatment provides overall good results, but the long-term presence of associated conditions such as chondral lesions, advanced age, and previous trauma are relevant as prognostic factors. Based on these results, a new classification for bony impingement syndrome system is proposed. Level of Evidence: Level IV, case series.

Does Patient Sex Influence Cartilage Surgery Outcome? Analysis of Results at 5-Year Follow-up in a Large Cohort of Patients Treated With Matrix-Assisted Autologous Chondrocyte Transplantation

Background: Sexual dimorphism in humans has already been documented at different levels, and preliminary findings also suggest the importance of patient sex on clinical outcome in the treatment of cartilage lesions. Purpose: To document and analyze the influence of sex on clinical outcome in a large cohort of patients treated with a cartilage regenerative procedure for knee chondral lesions and prospectively followed at midterm follow-up. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 250 knees were treated with matrix-assisted autologous chondrocyte transplantation (MACT) and prospectively evaluated with International Knee Documentation Committee (IKDC), EuroQol visual analog scale (EQ-VAS), and Tegner scores at 1-, 2-, and minimum 5-year follow-ups to compare results obtained in men and women. The lesions were focal International Cartilage Repair Society grade III-IV chondral knee defects involving femoral condyles, trochleae, and patellae. Two homogeneous groups of 56 male patients and 56 female patients were then selected by a blinded statistician for a matched-pair analysis. Results: A statistically significant improvement in all the scores in both men and women was observed in the general population. The IKDC subjective score showed better results for men at all follow-up times: at 5 years, the mean IKDC subjective score was 79.5 ± 18.6 versus 64.3 ± 20.2 for men and women, respectively (P < .0005), and the same trend was confirmed with the EQ-VAS and Tegner scores. The matched-pair analysis confirmed the difference of final results achieved (74.1 ± 19.8 vs 63.7 ± 20.2, respectively; P = .006). However, men and women started with different preoperative levels, and the analysis of the improvement obtained was not significantly different. Finally, when scores were standardized for each patient, according to the mean score typical for the corresponding age and sex category in a healthy population, a sex-related difference was not confirmed at any of the follow-ups. Etiological factors, lesion site, and preinjury activity level differed in women and men of the general population and were the confounding factors responsible for the different outcome not confirmed by the analysis of homogeneous cohorts of patients. Conclusion: Women have a different knee chondral lesion pattern and more often have unfavorable conditions related to the cause of injury, site, and activity level, and they also have lower raw, not standardized, scores. However, a matched-pair analysis with data standardized for the specific patient categories showed that, on equal terms, women have the same possibilities for successful outcome as men after surgical treatment for knee cartilage regeneration.

Combined Arthroscopic Treatment of Tibial Plateau and Intercondylar Eminence Avulsion Fractures

Fractures of the tibial plateau represent 1% of all fractures and 8% of fractures in the elderly population1. These fractures represent a surgical challenge because of the variety of fracture patterns and the associated soft-tissue injuries. If not adequately treated, these fractures often cause persistent knee pain, arthritis, and angular deformity. In one study, posttraumatic knee arthritis following a tibial plateau fracture was reported, after a seven-year follow-up, in 74% of patients with an associated meniscal tear and in 34% of patients with intact menisci2. Intercondylar eminence avulsion fractures are relatively uncommon. First described by Poncet in 1875, this injury usually has been considered to be the childhood equivalent of anterior cruciate ligament rupture in adults3. As an isolated injury, these fractures are most frequent in pediatric patients between the ages of eight and fourteen years4-9. These lesions also can occur in adults in association with another periarticular injury or a tibial plateau fracture3,5. In our experience, 19.4% of tibial plateau fractures have been associated with an intercondylar eminence fracture whereas 84.3% of tibial spine fractures in adults have been associated with a tibial plateau fracture (unpublished data). Associated tibial plateau and intercondylar eminence avulsion fractures are complex articular lesions that vary widely from one patient to another, and therefore treatment requires personalized solutions. When determining the best treatment, anatomic joint reconstruction with minimally invasive techniques should be considered. Arthroscopic reduction and internal fixation have demonstrated various advantages over open reduction and internal fixation in terms of surgical morbidity, time of hospital stay, recovery, and complications such as infection and loss of knee motion10-12. The high prevalence of associated intra-articular lesions justifies the use of arthroscopy to evaluate and treat all of …

Age Is Not a Contraindication for Cartilage Surgery: A Critical Analysis of Standardized Outcomes at Long-term Follow-up

Background: Age is commonly accepted as a negative prognostic factor in cartilage surgery, and cutoff values of 30 to 40 years have been previously suggested as treatment indication. However, the lower outcome scores documented in older patients do not take in consideration the decreasing requirements of an aging joint. Purpose: To analyze the real effect of age in terms of recovery with respect to the functional level expected for different age categories of patients treated for cartilage lesions. Study Design: Cohort study; Level of evidence, 3. Methods: Patients with International Cartilage Repair Society (ICRS) grade 3-4 defects, involving femoral condyles or trochlea without osteoarthritis, were treated with arthroscopic matrix-assisted autologous chondrocyte transplantation; 157 patients were evaluated with IKDC subjective and Tegner scores before surgery and then after 2 and 10 years. Results were first evaluated by dividing patients into 2 age groups according to the generally approved cutoff value of 40 years. The analysis was then repeated after the scores of each patient were standardized according to the score achievable per the normative data in healthy patients for the corresponding sex and age category. Results: A significant improvement in all scores was observed. IKDC subjective score improved from 38.9 ± 14.5 to 74.7 ± 21.8 at 10 years. When a cutoff value of 40 years was used, older patients reached a significantly worse IKDC subjective value at 10 years (65.8 ± 24.3 vs 77.2 ± 20.4, P = .007). However, different findings were obtained after the scores were standardized. Although optimal results were still found in younger patients (<30 years), patients older than 40 years also appeared to benefit from the treatment, and no significant differences were noted compared with the younger population. Conclusion: The benefit of cartilage treatments in patients with increasing age but without any sign of osteoarthritis was higher than previously reported in literature. In fact, when the decreasing functional level expected by an aging population was considered, standardized results showed an overall benefit after cartilage treatment in patients older than 40 years that was not significantly different from the outcome achieved in younger patients. Thus, age is not a strict contraindication as previously suggested, and future studies should consider standardization of data to prove the real age limit of cartilage treatments.

Tecnica artroscopica del trapianto di condrociti autologhi nella caviglia

Riassunto Il trattamento delle lesioni osteocondrali della superficie articolare della caviglia rappresenta un problema di estrema attualita per la chirurgia ortopedica. Il trapianto di condrociti autologhi (TCA) si e imposto, negli ultimi anni, come una delle metodiche di elezione nel trattamento di tali difetti. Questo e stato inizialmente impiegato a livello dell’articolazione del ginocchio e solo in un secondo tempo e stato applicato con successo anche a livello dell’articolazione tibiotarsica. Le tecniche descritte in letteratura prevedono un accesso chirurgico artrotomico alla caviglia e la fissazione di un lembo periostale al di sopra del difetto, con successivo riempimento di quest’ultimo con una soluzione liquida contenente condrociti. Con l’avvento di un nuovo scaffold (Hyalograft C), dotato di consistenza solida e proprieta adesive intrinseche, e stata sviluppata una tecnica di TCA per l’articolazione del ginocchio con accesso artroscopico. Gli Autori hanno sviluppato una tecnica di TCA artroscopico per l’articolazione tibiotarsica che si avvale dell’uso di uno scaffold contenente condrociti coltivati ed espansi e di uno strumentario appositamente ideato. Tale tecnica consente di evitare una chirurgia artrotomica riducendo quindi il tasso di morbilita e di complicanze di cui si grava la chirurgia invasiva. La durata dell’intervento e la degenza postoperatoria sono anch’esse ridotte, conducendo dunque a una diminuzione dei costi.

Trattamento artroscopico delle fratture del piatto tibiale

Riassunto Le fratture del piatto tibiale rappresentano i’1% di tutte le fratture. Il trattamento di queste fratture rappresenta una sfida chirurgica a causa della varieta e della complessita dei tipi di frattura e delle lesioni associate dei tessuti molli. Il trattamento incruento e riservato ai casi di frattura stabile con minima scomposizione o riduzione della congruita articolare, oppure in pazienti per i quali l’eta e le condizioni cliniche controindichino altri trattamenti. Il trattamento chirurgico tradizionale consiste nella riduzione artrotomica della frattura con osteosintesi interna. Attualmente pero questo tipo di trattamento e riservato alle fratture complesse pluriframmentarie, mentre in tutti gli altri casi si preferisce la riduzione artroscopica con sintesi percutanea. Il trattamento artroscopico, mini-invasivo, apre nuove frontiere nella riduzione chirurgica delle fratture del piatto tibiale.