M. Marcacci

Arthroscopic autologous condrocyte transplantation: technical note

Abstract.We describe an arthroscopic surgical technique for tissue engineered cartilage grafting. A three-dimensional hyaluronic acid support is used for autologous chondrocyte culturing. The technique reduces morbidity of classic autologous implant and avoids open surgery and the use of a periosteal flap. The procedure includes the advantages of arthroscopic osteochondral grafting without donor site morbidity. With this technique is possible to reduce the patient morbidity, time and cost of surgery.

Orderly osteochondral regeneration in a sheep model using a novel nano-composite multilayered biomaterial.

The objective of this article was to investigate the safety and regenerative potential of a newly developed biomimetic scaffold when applied to osteochondral defects in an animal model. A new multilayer gradient nano‐composite scaffold was obtained by nucleating collagen fibrils with hydroxyapatite nanoparticles. In the femoral condyles of 12 sheep, 24 osteochondral lesions were created. Animals were randomized into three treatment groups: scaffold alone, scaffold colonized in vitro with autologous chondrocytes and empty defects. Six months after surgery, the animals were sacrificed and the lesions were histologically evaluated. Histologic and gross evaluation of specimens showed good integration of the chondral surface in all groups except for the control group. Significantly better bone regeneration was observed both in the group receiving the scaffold alone and in the group with scaffold loaded with autologous chondrocytes. No difference in cartilage surface reconstruction and osteochondral defect filling was noted between cell‐seeded and cell‐free groups. In the control group, no bone or cartilage defect healing occurred, and the defects were filled with fibrous tissue. Quantitative macroscopic and histological score evaluations confirmed the qualitative trends observed. The results of the present study showed that this novel osteochondral scaffold is safe and easy to use, and may represent a suitable matrix to direct and coordinate the process of bone and hyaline‐like cartilage regeneration. The comparable regeneration process observed with or without autologous chondrocytes suggests that the main mode of action of the scaffold is based on the recruitment of local cells.

Surgical treatment for early osteoarthritis. Part I: cartilage repair procedures.

AbstractYoung patients with early osteoarthritis (OA) represent a challenging population due to a combination of high functional demands and limited treatment options. Conservative measures such as injection and physical therapy can provide short-term pain relief but are only palliative in nature. Joint replacement, a successful procedure in the older population, is controversial in younger patients, who are less satisfied and experience higher failure rates. Therefore, while traditionally not indicated for the treatment of OA, cartilage repair has become a focus of increased interest due to its potential to provide pain relief and alter the progression of degenerative disease, with the hope of delaying or obviating the need for joint replacement. This review of cartilage repair techniques will discuss currently available procedures, specifically pertaining to experiences in the setting of early OA. Level of evidence IV.

Platelet-rich plasma: why intra-articular? A systematic review of preclinical studies and clinical evidence on PRP for joint degeneration

PurposeThe aim of this review was to analyze the available evidence on the clinical application of this biological approach for the injective treatment of cartilage lesions and joint degeneration, together with preclinical studies to support the rationale for the use of platelet concentrates, to shed some light and give indications on what to treat and what to expect from intra-articular injections of platelet-rich plasma (PRP).MethodsAll in vitro, in vivo preclinical and clinical studies on PRP injective treatment in the English language concerning the effect of PRP on cartilage, synovial tissue, menisci, and mesenchymal stem cells were considered. A systematic review on the PubMed database was performed using the following words: (platelet-rich plasma or PRP or platelet concentrate or platelet lysate or platelet supernatant) and (cartilage or chondrocytes or synoviocytes or menisci or mesenchymal stem cells).ResultsFifty-nine articles met the inclusion criteria: 26 were in vitro, 9 were in vivo, 2 were both in vivo and in vitro, and 22 were clinical studies. The analysis showed an increasing number of published studies over time. Preclinical evidence supports the use of PRP injections that might promote a favourable environment for joint tissues healing. Only a few high-quality clinical trials have been published, which showed a clinical improvement limited over time and mainly documented in younger patients not affected by advanced knee degeneration.ConclusionsBesides the limits and sometimes controversial findings, the preclinical literature shows an overall support toward this PRP application. An intra-articular injection does not just target cartilage; instead, PRP might influence the entire joint environment, leading to a short-term clinical improvement. Many biological variables might influence the clinical outcome and have to be studied to optimize PRP injective treatment of cartilage degeneration and osteoarthritis.Level of evidenceIV.

Anatomic double-bundle and over-the-top single-bundle with additional extra-articular tenodesis: an in vivo quantitative assessment of knee laxity in two different ACL reconstructions

PurposeCombinations of intra- and extra-articular procedures have been proposed for anterior cruciate ligament reconstruction with the aim of achieving an optimal control of translational and rotational knee laxities. Recently, the need for better reproducing the structural and functional behavior of the native anterior cruciate ligament led to the definition of anatomic double-bundle surgical approach. This study aimed to quantitatively verify whether the in vivo static and dynamic behavior obtained using over-the-top single-bundle with extra-articular tenodesis reconstruction was comparable to the results achieved by anatomic double-bundle approach.MethodsThirty-five consecutive patients, with an isolated anterior cruciate ligament injury, were included in the study. Standard clinical laxities and pivot-shift test were quantified before and after anterior cruciate ligament reconstruction by means of a surgical navigation system dedicated to kinematic assessment; displacements of medial and lateral compartment during stress tests were also analyzed.ResultsSingle-bundle with extra-articular tenodesis approach presented statistically better laxity reduction in varus/valgus stress test at full extension and in internal/external rotation at 90° of flexion; lateral plasty controlled better the lateral compartment during drawer test and varus/valgus stress test both at 0° and 30° of flexion and both the compartments during internal/external rotation at 90° of flexion. On the other hand, pivot-shift phenomenon was better controlled by anatomic double-bundle reconstruction.ConclusionsBoth the reconstructions worked similarly for static knee laxity. The extra-articular procedure played an important role in better constraining the displacement of lateral tibial compartment, whereas the anatomic double-bundle reconstruction better restored the dynamic behavior of knee joint highlighted under pivot-shift stress test.Study designCase series.

Surgical treatment for early osteoarthritis. Part II: allografts and concurrent procedures

Young patients with early osteoarthritis (OA) represent a challenging population due to a combination of high functional demands and limited treatment options. Conservative measures such as injection and physical therapy can provide short-term pain relief but are only palliative in nature. Joint replacement, a successful procedure in the older population, is controversial in younger patients, who are less satisfied and experience higher failure rates. Therefore, while traditionally not indicated for the treatment of OA, cartilage repair has become a focus of increased interest due to its potential to provide pain relief and alter the progression of degenerative disease, with the hope of delaying or obviating the need for joint replacement. The field of cartilage repair is seeing the rapid development of new technologies that promise greater ease of application, less demanding rehabilitation and better outcomes. Concurrent procedures such as meniscal transplantation and osteotomy, however, remain of crucial importance to provide a normalized biomechanical environment for these new technologies.Level of evidenceSystematic review, Level II.

ST/G ACL reconstruction: double strand plus extra-articular sling vs double bundle, randomized study at 3-year follow-up

Several investigators have reported the presence of biomechanical, kinematic, anatomic, fiber orientation patterns and biological differences between the anteromedial bundle and the posterolateral bundle of ACL. The purpose of this prospective randomized study was to compare the clinical, instrumental and X‐ray outcome of two ACL reconstruction techniques with hamstring tendons: one with a single intra‐articular bundle associated to an extra‐articular sling, the second with a more anatomic double‐bundle technique that reproduces better the native ACL function. From an initial group of 100 patients who underwent ACL reconstruction, 72 patients (35 single bundle plus lateral plasty and 37 double bundle) were evaluated with IKDC, Tegner score, KT2000 arthrometer, Activity Rating Scale, Psychovitality Questionnaire and Ahlback radiographic score at a mean 3 years follow‐up. Double‐bundle group showed significantly better results regarding IKDC, ROM, Activity Rating Scale and time to return to sport. Also KT 2000 showed significant differences in objective stability. The double‐bundle technique for ACL reconstruction described in this paper has demonstrated significantly better subjective, objective and functional results compared with a double‐stranded hamstrings plus extra‐articular sling at a minimum 3‐year follow‐up.

Second-generation autologous chondrocyte transplantation: MRI findings and clinical correlations at a minimum 5-year follow-up

OBJECTIVE To evaluate the clinical outcome of hyaluronan-based arthroscopic autologous chondrocyte transplantation at a minimum of 5 years of follow-up and to correlate it with the MRI evaluation parameters. METHODS Fifty consecutive patients were included in the study and evaluated clinically using the Cartilage Standard Evaluation Form as proposed by ICRS and the Tegner score. Forty lesions underwent MRI evaluation at a minimum 5-year follow-up. For the description and evaluation of the graft, we employed the MOCART-scoring system. RESULTS A statistically significant improvement in all clinical scores was observed at 2 and over 5 years. The total MOCART score and the signal intensity (3D-GE-FS) of the repair tissue were statistically correlated to the IKDC subjective evaluation. Larger size of the treated cartilage lesions had a negative influence on the degree of defect repair and filling, the integration to the border zone and the subchondral lamina integrity, whereas more intensive sport activity had a positive influence on the signal intensity of the repair tissue, the repair tissue surface, and the clinical outcome. CONCLUSION Our findings confirm the durability of the clinical results obtained with Hyalograft C and the usefulness of MRI as a non-invasive method for the evaluation of the repaired tissue and the outcome after second-generation autologous transplantation over time.

Polyurethane scaffold in lateral meniscus segmental defects: Clinical outcomes at 24 months follow-up

BACKGROUND Segmental tissue loss in the lateral meniscus is associated with pain and increased risk of osteoarthritis even when indications have been carefully considered. HYPOTHESIS Repairing the defect using a novel biodegradable scaffold will reduce pain and restore the knee function. METHODS In this prospective multicenter study, a total of 54 patients (37 males/17 females; mean age: 28 years [16-50]) were enrolled. All patients presented with postmeniscectomy syndrome and segmental lateral meniscus loss, and were treated with a polyurethane biodegradable scaffold (Actifit(®), Orteq) implanted arthroscopically. Clinical outcomes were assessed at 6, 12 and 24 months using Visual Analogue Scale (VAS), International Knee Documentation Committee Score (IKDC) and Knee Injury and Osteoarthritis Outcome Score (KOOS). RESULTS VAS decreased from 5.5 at baseline to 3.6 at 6 months, 3.4 at 12 months and 2.9 at 24 months. IKDC improved from 47.0 at baseline to 60.2, 67.0 and 67.0 at 6, 12 and 24 months. All KOOS subscores improved between baseline and 24 months. DISCUSSION Clinical results of this study demonstrate clinically and statistically significant improvements of pain and function scores (VAS, IKDC, and all KOOS subscales except sport), at the 6 months follow-up and on all clinical outcomes at the 2-year follow-up. The Actifit(®) scaffold is safe and effective in treating lateral meniscus defects. LEVEL OF EVIDENCE IV continuous prospective multicenter study.

Matrix assisted autologous chondrocyte transplantation for cartilage treatment: A systematic review

Objectives Matrix-assisted autologous chondrocyte transplantation (MACT) has been developed and applied in the clinical practice in the last decade to overcome most of the disadvantages of the first generation procedures. The purpose of this systematic review is to document and analyse the available literature on the results of MACT in the treatment of chondral and osteochondral lesions of the knee. Methods All studies published in English addressing MACT procedures were identified, including those that fulfilled the following criteria: 1) level I-IV evidence, 2) measures of functional or clinical outcome, 3) outcome related to cartilage lesions of the knee cartilage. Results The literature analysis showed a progressively increasing number of articles per year. A total of 51 articles were selected: three randomised studies, ten comparative studies, 33 case series and five case reports. Several scaffolds have been developed and studied, with good results reported at short to medium follow-up. Conclusions MACT procedures are a therapeutic option for the treatment of chondral lesions that can offer a positive outcome over time for specific patient categories, but high-level studies are lacking. Systematic long-term evaluation of these techniques and randomised controlled trials are necessary to confirm the potential of this treatment approach, especially when comparing against less ambitious traditional treatments.