Justus Gille

A cell-seeded biocomposite for cartilage repair*

Chondrocytes in monolayer cultures lose their phenotype and capability to express type-II collagen, they dedifferentiate into a fibroblastic cell type. Using three-dimensional culture systems a redifferentiation of these cells may occur. In the present study we investigated the morphology and biosynthetic activity of human articular chondrocytes seeded on porous matrices of type I/III collagen (Chondrogide, Geistlich Biomaterials, Wolhusen, Switzerland). Microscopical examinations showed that chondrocytes adhere firmly to a collagen-I/III-membrane exhibiting their characteristic spherical cell shape. Cell numbers after enzymatic digestion of the membrane showed a 93% recovery of seeded cells. Immunohistological examination revealed positive staining for type-II collagen in some areas. The generated biocomposite withstands mechanical stress, keeps its size and design and does not shrink in culture. It is therefore easy to handle, can be sutured, glued or fixed with pins. This study shows, that in vitro production of autologous cartilage-like tissue could be established using a bilayer collagen type I/III fleece. This biocomposite carries active chondrocytes and is currently being evaluated in vivo in a sheep model as well as in a clinical trial for the repair of localized cartilage defects in the knee.

Cell-Laden and Cell-Free Matrix-Induced Chondrogenesis versus Microfracture for the Treatment of Articular Cartilage Defects: A Histological and Biomechanical Study in Sheep.

Objective: The aim of this study was to evaluate the regenerative potential of cell-laden and cell-free collagen matrices in comparison to microfracture treatment applied to full-thickness chondral defects in an ovine model. Methods: Animals (n = 30) were randomized into 5 treatment groups, and 7-mm full-cartilage-thickness defects were set at the trochlea and medial condyle of both knee joints and treated as follows: 2 scaffolds in comparison (collagen I/III, Chondro-Gide®; collagen II, Chondrocell®) for covering microfractured defects (autologous matrix-induced chondrogenesis), both scaffolds colonized in vitro with autologous chondrocytes (matrix-associated chondrocyte transplantation), or scaffold-free microfracture technique. One year after surgery, cartilage lesions were biomechanically (indentation test), histologically (O’Driscoll score), and immunohistochemically (collagen type I and II staining) evaluated. Results: All treatment groups of the animal model induced more repair tissue and showed better histological scores and biomechanical properties compared to controls. The average thickness of the repair tissue was significantly greater when a scaffold was used, especially the collagen I/III membrane. However, none of the index procedures surpassed the others from a biomechanical point of view or based on the histological scoring. Collagen type II expression was better in condylar defects compared to the trochlea, especially in those treated with collagen I/III membranes. Conclusion: Covering of defects with suitable matrices promotes repair tissue formation and is suggested to be a promising treatment option for cartilage defects. However, it failed to improve the biomechanical and histological properties of regenerated articular cartilage compared to microfracture alone in an ovine model under the given circumstances.

Apoptotic chondrocyte death in cell-matrix biocomposites used in autologous chondrocyte transplantation

Tissue engineering may be a promising approach for the treatment of focal articular cartilage defects. Programmed cell death (apoptosis) plays an important role in multiple degenerative processes of cartilage (e.g. osteoarthritis). It is known that matrix provides a trophic signal for the cells and an altered matrix may influence the availability of factors that regulate apoptosis. In this study we investigate the viability of chondrocytes seeded on a Chondrogide scaffold (Geistlich Biomaterials, CH), which we use in matrix-induced autologous chondrocyte transplantation (MACT). By now, we have studied material from 29 patients treated for localized articular cartilage defects in the knee. Our results indicate that light microscopy (Mayers hematoxylin-eosin, Masson-Goldner, Trypan-blue and TUNEL method) and electron microscopy can be used to investigate for apoptotic cells grown on a Chondrogide resorbable scaffold. Neither the handling of the cell-matrix biocomposite nor the procedures for fixation could destroy the scaffold or the cell sheet adhering firmly to the matrix. Apoptotic cells were revealed in all samples and with all techniques used. Mayers hematoxylin-eosin and Masson-Goldner staining show cells with a condensed, pycnotic nucleus and shrunken cytoplasm. In electron microscopy we observed cells with chromatin condensation and volume shrinkage consistent with apoptosis. The results of the Trypan-blue staining show a mean viability of 92.1 +/- 9.8% (range 57-100%). The TUNEL method revealed 44.6 +/- 20.4% positive cells. Our results indicate that apoptosis plays an important role in chondrocytes grown on a scaffold. An optimal scaffold will determine the growth, morphology and phenotype of the chondrocytes by its physical and chemical characteristics.

Enhanced microfracture techniques in cartilage knee surgery: Fact or fiction?

The limited intrinsic healing potential of human articular cartilage is a well-known problem in orthopedic surgery. Thus a variety of surgical techniques have been developed to reduce joint pain, improve joint function and delay the onset of osteoarthritis. Microfractures as a bone marrow stimulation technique present the most common applied articular cartilage repair procedure today. Unfortunately the deficiencies of fibrocartilaginous repair tissue inevitably lead to breakdown under normal joint loading and clinical results deteriorate with time. To overcome the shortcomings of microfracture, an enhanced microfracture technique was developed with an additional collagen I/III membrane (Autologous, Matrix-Induced Chondrogenesis, AMIC(®)). This article reviews the pre-clinical rationale of microfractures and AMIC(®), presents clinical studies and shows the advantages and disadvantages of these widely used techniques. PubMed and the Cochrane database were searched to identify relevant studies. We used a comprehensive search strategy with no date or language restrictions to locate studies that examined the AMIC(®) technique and microfracture. Search keywords included cartilage, microfracture, AMIC(®), knee, Chondro-Gide(®). Besides this, we included our own experiences and study authors were contacted if more and non published data were needed. Both cartilage repair techniques represent an effective and safe method of treating full-thickness chondral defects of the knee in selected cases. While results after microfracture deteriorate with time, mid-term results after AMIC(®) seem to be enduring. Randomized studies with long-term follow-up are needed whether the grafted area will maintain functional improvement and structural integrity over time.

Matrix-Associated Autologous Chondrocyte Implantation A Clinical Follow-Up at 15 Years

Introduction A prospective clinical investigation was carried out in order to clarify whether Matrix-associated autologous chondrocyte implantation (MACI) results in clinical improvement at long-term follow-up. Hypothesis MACI will result in clinical improvement at long-term follow-up. Study Design Case series; level of evidence, 4. Methods Thirty-eight patients were treated with MACI. These patients were evaluated for up to a mean of 16 years (range 15-17 years) after the intervention. Three different scores (Lysholm-Gilquist score, International Cartilage Repair Society score, and Tegner score) formed the basis of this study. Overall, we were able to obtain valid preoperative and postoperative results from 18 (47%) of 38 patients. In 1 patient, both knees were treated. In 4 patients, an arthroplasty was implanted over the course of time; thus they were excluded from this case series. In conclusion, follow-up of 15 knees was performed in the recent series. Results In subjective rating, 12 out of 14 patients (86%) rated the function of their knee as much better or better than before the index procedure. All numerical outcome scores showed significant improvement compared to the preoperative value (preoperative/postoperative at 5 years/postoperative at 15 years): Lysholm score 59.6 (±24.6)/78.6 (±21.5)/82.7 (±11.3), International Knee Documentation Committee score 50.6 (±22.7)/64.7 (±21.6)/69.7 (±18.7), Tegner score 3.0 (±2.2)/3.6 (±1.5)/5.2 (±1.7). Conclusion The significantly improved results on 3 scores after 15 years suggest that MACI represents a suitable treatment of local cartilage defects in the knee.

Management of chronic recurrent osteitis pubis/pubic bone stress in a Premier League footballer: Evaluating the evidence base and application of a nine-point management strategy

BACKGROUND/AIM The aim of this paper was to use a clinical example to describe a treatment strategy for the management of recurrent chronic groin pain and evaluate the evidence of the interventions. METHODS A professional footballer presented with chronic recurrent OP/PBS. The injury was managed successfully with a nine-point programme - 1. Acute pharmacological management. 2. Tone reduction of over-active structures. 3. Improved ROM at hips, pelvis and thorax. 4. Adductor strength. 5. Functional movement assessment. 6. Core stability. 7. Lumbo-pelvic control. 8. Gym-based strengthening. 9. Field-based conditioning/rehabilitation. The evidence for these interventions is reviewed. RESULTS The player returned to full training and match play within 41 and 50 days, respectively, and experienced no recurrence of his symptoms in follow up at 13 months. CONCLUSION This case report displays a nine-point conservative management strategy for OP/PBS, with non-time dependent clinical objective markers as the progression criteria in a Premier League football player.

MID-TERM RESULTS OF AUTOLOGOUS MATRIX INDUCED CHONDROGENESIS (AMIC) IN CARTILAGE KNEE SURGERY

Introduction The regeneration capacity of articular cartilage is very limited. Therefore, cartilage defects heal poorly and are known as prearthrotic lesions. Autologous Matrix-Induced Chondrogenesis (AMIC) is an innovative treatment concept for localized full-thickness cartilage defects. This technique combines the well-established microfracturing with a collagen I/III scaffold fixated by fibrin glue. Methods Presented are medium-term results of two different prospective studies of patients treated with AMIC. Symptomatic full-thickness cartilage lesions (Outerbridge grade III or IV) were treated using AMIC (Chondro-Gide, Geistlich Pharma, Switzerland). Patients were initially evaluated by established knee scores (e.g. Lysholm score, IKDC score) and in selected cases by magnetic resonance imaging (MRI). Patients were re-evaluated up to 5 years after the initial procedure. Results In total 84 patients could be followed up. The average age of patients was in both groups 37 years (16–61 years). The mean defect size was 3.4 cm2 respectively 4.2 cm2. The majority of patients were satisfied with the postoperative outcome, reporting a significant decrease of pain level. Significant improvement of the mean Lysholm score was observed as early as 1 year after AMIC and further increased values were noted up to two years postoperatively. MRI analysis showed moderate to complete filling with a normal to incidentally hyperintense signal in most cases. Conclusion AMIC is an effective and safe method of treating symptomatic full-thickness chondral defects of the knee in appropriately selected cases. However, further studies with long-term follow-up are needed to determine whether the grafted area will maintain structural and functional integrity over time. Level of evidence: Prognostic study, Level IV.

Biomechanical evaluation of novel ultrasound-activated bioresorbable pins for the treatment of osteochondral fractures compared to established methods.

Abstract Background: Osteochondral injuries often lead to osteoarthritis of the affected joint. All established systems for refixation of osteochondral defects show certain disadvantages. To address the problem of reduced stability in resorbable implants, ultrasound-activated pins were developed. By ultrasound-activated melting of the tip of these implants, a more secure anchoring is assumed. Materials and methods: The aim of the study was to investigate if ultrasound-activated pins can provide secure fixation of osteochondral fragments compared to screws and conventional resorbable pins. In a biomechanical laboratory setting, osteochondral fragments of the medial femoral condyle of sheep were refixated with ultrasound-activated pins [US fused poly(L-lactide-co-D,L-lactide) (PLDLLA) pins], polydioxanone (PDA) pins and conventional titanium screws. Anchoring forces of the different fixation methods were examined, registered and compared concerning shear force and tensile force. Results: Concerning the pull out test, the US fused PLDLLA pins and titanium screws (~122 N and ~203 N) showed comparable good results, while the PDA pins showed significantly lower anchoring forces (~18 N). Examination of shear forces showed a significantly higher anchoring of the screws (~248 N) than the US fused PLDLLA pins (~218 N). Nevertheless, the US fused PLDLLA pins could significantly outperform the PDA pins (~68 N) concerning shear forces. Conclusion: The US fused PLDLLA pins demonstrated a comparable anchorage to the fixation with screws, but were free from the disadvantages of metal implants, i.e. the need for implant removal. The PDA pin application showed inferior biomechanical properties.