Rimtautas Gudas

Ten-Year Follow-up of a Prospective, Randomized Clinical Study of Mosaic Osteochondral Autologous Transplantation Versus Microfracture for the Treatment of Osteochondral Defects in the Knee Joint of Athletes

Background: Various techniques have proven to be effective for treating articular cartilage defect (ACD) and osteochondral defect (OCD) of the knee joint, but knowledge regarding which method is best still remains uncertain. Purpose: To evaluate and compare the outcomes of mosaic-type osteochondral autologous transplantation (OAT) and microfracture (MF) procedures for the treatment of articular cartilage defects of the knee joint in young active athletes. This article represents an update of the clinical results at 10 years. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: Between 1998 and 2002, a total of 60 athletes with a mean age of 24.3 years (range, 15-40 years) and with a symptomatic ACD or OCD in the knee were randomized to undergo either OAT or MF. Patients were then evaluated postoperatively using the International Cartilage Repair Society (ICRS) score, Tegner activity score, radiographs, and magnetic resonance imaging. The mean follow-up time was 10.4 years (range, 9-11 years). Results: Three to 10 years after the OAT and MF procedures, patients had lower ICRS and Tegner scores (P < .05), but both groups still had significant clinical improvement over presurgery scores according to ICRS scores at 10-year follow-up. Statistically significantly better results were detected in patients in the OAT group compared with those in the MF group at 10 years (P < .005). At 10-year follow-up, there were 15 failures (26%), including 4 failures (14%) of the OAT and 11 failures (38%) of MF treatment (P < .05). Seven patients (25%) from the OAT group and 14 patients (48%) from the MF group had radiographic evidence of Kellgren-Lawrence grade I osteoarthritis at 10 years, but these differences were not significant (P = .083) or related to the clinical results. The ICRS and Tegner scores of younger athletes (<25 years at the time of primary surgery) remained significantly higher after 10 years compared with older patients (P < .05); 15 of 20 patients (75%) in the OAT group and 8 of 22 patients (37%) in the MF group maintained the same physical activity level. Conclusion: The OAT technique for ACD or OCD repair in the athletic population allows for a higher rate of return to and maintenance of sports at the preinjury level compared with MF.

A prospective, randomized clinical study of osteochondral autologous transplantation versus microfracture for the treatment of osteochondritis dissecans in the knee joint in children.

Purpose The aim of this study was to compare the outcomes of the arthroscopic mosaic-type osteochondral autologous transplantation (OAT) and microfracture (MF) procedures for the treatment of osteochondritis dissecans (OCD) defects of the femoral condyles of the knee joint in children under the age of 18 years. Type of Study Prospective, randomized clinical study. Methods Between 2001 and 2005, a total of 50 children with a mean age of 14.3 years (12 to 18) and with symptomatic lesions of the OCD in the femoral condyle of the knee were randomized to undergo either the OAT or the MF procedure. Only those children with grade 3 or 4 (OCD) in the medial or lateral femoral condyle (according to International Cartilage Repair Society, ICRS) were included in the study. Forty-seven patients (94%) were available for follow-up. There were 25 patients in the OAT group and 22 patients in the MF group. The mean duration of symptoms was 23.54±4.24 months and the mean follow-up was 4.2 years (range from 3 to 6 y), and none of the children had prior surgical interventions to the affected knee. Children were evaluated using ICRS score, x-rays, magnetic resonance imaging, and second-look arthroscopies. Results After 1 year, both groups had significant clinical improvement (P<0.05) and the ICRS functional and objective assessment showed that 23 of 25 (92%) patients had excellent or good results after OAT compared with 19 of 22 (86%) after MF (NS), but 19 of 23 (83%) after OAT and only 12 of 19 (63%) after MF procedure maintained excellent or good results after 4.2 years (range from 3 to 6 y). The MF group showed significant deterioration over the 4.2 years follow-up (P<0.05), but still had significant clinical improvement compared with pretreatment evaluation (P=0.004). There were 9 of 22 (41%) failures in the MF group, and none in the OAT group. Magnetic resonance imaging evaluation according to the ICRS evaluation system showed excellent or good repairs in 19 of 21 patients (91%) after OAT compared with 10 of 18 (56%) after MF. Conclusions At an average of 4.2 years follow-up, our prospective, randomized, clinical study in children under the age of 18 years has shown significant superiority of the mosaic-type OAT over MF for the treatment of osteochondritis dissecans defects in the knee. However, our study has shown that both MF and OAT give encouraging clinical results for children under the age of 18 years. Level of Evidence Level 1: randomized controlled trial, significant difference.

Preclinical study of SZ2080 material 3D microstructured scaffolds for cartilage tissue engineering made by femtosecond direct laser writing lithography

Over the last decade DLW employing ultrafast pulsed lasers has become a well-established technique for the creation of custom-made free-form three-dimensional (3D) microscaffolds out of a variety of materials ranging from proteins to biocompatible glasses. Its potential applications for manufacturing a patients specific scaffold seem unlimited in terms of spatial resolution and geometry complexity. However, despite few exceptions in which live cells or primitive organisms were encapsulated into a polymer matrix, no demonstration of an in vivo study case of scaffolds generated with the use of such a method was performed. Here, we report a preclinical study of 3D artificial microstructured scaffolds out of hybrid organic-inorganic (HOI) material SZ2080 fabricated using the DLW technique. The created 2.1 × 2.1 × 0.21 mm(3) membrane constructs are tested both in vitro by growing isolated allogeneic rabbit chondrocytes (Cho) and in vivo by implanting them into rabbit organisms for one, three and six months. An ex vivo histological examination shows that certain pore geometry and the pre-growing of Cho prior to implantation significantly improves the performance of the created 3D scaffolds. The achieved biocompatibility is comparable to the commercially available collagen membranes. The successful outcome of this study supports the idea that hexagonal-pore-shaped HOI microstructured scaffolds in combination with Cho seeding may be successfully implemented for cartilage tissue engineering.

IS THAT POSSIBLE TO RESTORE PRE-INJURY PHYSICAL ACTIVITY LEVEL AFTER ONE-STAGE ARTICULAR CARTILAGE AND ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION PROCEDURE

Purpose to compare the concomitant treatment of the articular cartilage damage (ACD) in the knee with three different articular cartilage procedures at the time of anterior cruciate ligament (ACL) reconstruction. Methods between the 2006 and 2009, 102 patients with a mean age of 34.1 years and with an ACL rupture and the articular cartilage damage in the knee were randomized to undergo osteochondral autologous transplantation (OAT), microfractures (MF) or debridement (D) at the time of ACL reconstruction. Matched control group was included with 34 patients having intact articular cartilage (IAC) at the time of ACL reconstruction. There were 34 patients in OAT-ACL group, 34 patients in MF-ACL group, 34-D-ACL group and 34-control IAC-ACL group. The mean ACL injury-operation time was 19.32±3.43 months and the mean follow-up was 36.1 months (range from 34 to 37 months). Patients were evaluated using International Knee Documentation Committee (IKDC) score, Tegner activity score and clinical assessment. Results 97 of 102 (95 %) were available for the final follow-up. According to subjective IKDC score, all 4 groups did significantly better at the 3-year follow up than preoperatively (P<0.0000001). OAT–ACL group IKDC Subjective Knee evaluation was significantly better than MF-ACL (p=0.024) and D-ACL (p=0.018). However, IKDC subjective score of IAC-ACL group was significantly better, than OAT-ACL group IKDC evaluation (p=0.043). There was no significant difference between the MF-ACL and D-ACL IKDC subjective scores (p=0.058). Evaluation of manual pivot-shift knee laxity according to IKDC Knee Examination Form revealed similar evaluations for the four groups immediate postoperative and at 3 year follow-up and was normal or nearly normal (IKDC grade A and B) for 29 of 33 patients (88%) with OAT-ACL, 28 of 32 patients (88%) with MF-ACL, 27 of 32 patients (84%) with D-ACL and 31 of 34 patients (91%) with intact IAC-ACL. Conclusions Our study shows that intact articular cartilage during ACL reconstruction gives more favourable IKDC subjective scores compared to any other articular cartilage surgery types. However, if you have an articular defect, there are significantly better subjective IKDC scores for OAT versus microfracture or debridement after a mean period of 3 years. Anterior knee stability results were not significantly affected by the different articular cartilage treatment methods.

Characterization of tissue engineered cartilage products: Recent developments in advanced therapy.

Legislative requirements for the quality of pharmacological agents underwent certain evolution when new type of therapies emerged. This relates to cell based medicines, such as tissue engineered cartilage products (TECP) which are increasingly developed as new modalities for widely prevalent orthopaedic disorders. Although quality measures for TECP are subject to the same general regulatory quality requirements, combination of cellular and scaffold substances requires definition of specific characteristics in vitro that are highly relevant to potency and efficacy of the newly designed medicinal product. One of the specific issues in designing cell based medicines is the fact that the biological activity of active substance, or cells, usually is altered after seeding them on a three-dimensional scaffold. Newly acquired features of the TECP are influenced by chemical, physical and mechanical characteristics of the scaffolds. A vast array of analytical methods has been employed to measure efficacy and potency of TECP in cartilage regeneration studies in vitro. Designing specific physical characteristics of scaffolds may become essential part influencing pharmacological activity of cell based medicinal products, and discern TECP from typical pharmacological products. As an example, increasingly growing popularity of three-dimensional printing that utilizes direct laser writing technique provides an opportunity to improve efficacy of the final TECP. This review is intended to provide brief summary of current approaches used to characterize cells and scaffolds in vitro before and after combination into TECP. Validating TECP as pharmacological agents with unique biological and physical characteristics may broaden their clinical application.

The Patello-Femoral Joint Degeneration and the Shape of the Patella in the Population Needing an Arthroscopic Procedure

Background: the main goal of the study was to investigate the prevalence of the articular cartilage defects (ACD) in the patellofemoral (PF) region of the knee joint based on the anatomical shapes of patella and its impact on the level of physical activity in the population needing arthroscopic procedures for all types of pathologies in the knee. Methods: The articular cartilage status of the PF region was obtained from 1098 arthroscopic procedures of the knee joint. The ACD were correlated to Wiberg’s shape of the patella and classified according to the degree, size and depth of the ACD in the PF region using the ICRS (International Cartilage Repair Society) system: group I consisting of patients with Wiberg type I shape (W1), group II—patients with Wiberg type II shape (W2) and group III—patients with Wiberg type III shape (W3). The Tegner physical activity scale was used to evaluate the physical activity of the patients. Results: The mean of ACD size (PF region) in the W3 group was 3.10 ± 0.99 cm2, which was a statistically significantly larger area in comparison with the W1 (1.90 ± 0.63 cm2; p < 0.0000) and W2 (1.95 ± 0.71 cm2; p < 0.0000). The patients from the W3 group (mean 3.10 ± 0.99) were less physically active (<4 Tegner) compared to the W2 group (mean of 4.48 ± 0.88; p = 0.004) and W1 group (mean of 4.55 ± 0.72; p = 0.002). Conclusions: The patients with the Wiberg type III patella shape had a higher incidence and larger size of ACD in the PF of the knee compared to the groups of Wiberg type I and II. Wiberg III patients with a lower level of physical activity had a larger size of ACD in the PF joint.

Quantitative Arthroscopic Assessment of Articular Cartilage Quality by Means of Cartilage Electromechanical Properties

Arthroscopic surgery has grown rapidly in recent decades. Despite accurately diagnosed clinical cases, the previous pain is retained in some patients after the operation, even though no visible chondral lesions are found during the procedure. A minimally invasive arthroscopic method of measuring articular cartilage electromechanical properties enables rapid and reliable intraoperative articular cartilage quality evaluation.

Knee Articular Cartilage Lesions Degree and Frequency Dependence on Gender, Age and Most Commonly Damaged Cartilage Areas

Santrauka Kelio sąnario kremzlės pažeidimai yra dažna ir aktuali problema. Pažeidimams įtakos turi lytis, amžius, rasė, genetiniai veiksniai, nutukimas, traumos, buvę uždegiminiai procesai. Šis tyrimas rodo kelio sąnario kremzlės pažeidimų priklausomybę nuo pagrindinių rizikos faktorių: amžiaus, lyties; dažniausiai pažeidžiamas kelio sąnario kremzlės sritis ir vyraujančius pažeidimo laipsnius, jų dažnį atskirose amžiaus grupėse. Rezultatai. Į tyrimą buvo įtraukti 1145 pacientai, kuriems kelio sąnario artroskopijos metu buvo vertinta kelio sąnario kremzlės pažeidimo laipsnis ir sritis. Vidutinis tiriamųjų pacientų amžius metais buvo 45,97 ± 16,71. Nustatyta, kad kelio sąnario kremzlės defektai bendrai buvo diagnozuoti 65,0% pacientų,o defektų nebuvo diagnozuota 35,0% pacientų. Palyginti vyrai ir moterys pagal tai, ar tarp jų pažeidimai įvyksta dažniau arba pažeidimų konkrečiam pacientui būna daugiau, apskaičiuota p reikšmė <0,05 ir Mann-Whitney vidutiniai rangai rodo, kad moterų grupėje pažeidimai pasitaikė dažniau. Kelio sąnario kremzlės I laipsnio pažeidimai bendrai buvo nustatyti 9,4% pacientų, II laipsnio – 43,9%, III laipsnio – 31,1%, IV laipsnio – 15,6%. I laipsnio pažeidimai statistiškai reikšmingai dažniau pasitaikė vyrams p<0,05, o II ir III moterims p<0,05, IV laipsnio pažeidimų skirtumų tarp lyčių nenustatyta, p>0,05. Operacijų metu buvo diagnozuota 3770 skirtingų sričių pažeidimų: vyrams 37,3%, moterims 62,7%. Spearmen‘o ranginės koreliacijos tarp pažeidimų kiekio konkrečiam pacientui ir paciento amžiaus gauta p reikšmė <0,05 rodo, kad koreliacija statistiškai reikšminga. Koreliacija 0,48 – stipri, teigiama, rodo, kad vyresniems pacientams pažeidimai pasitaikė dažniau. Išvados. Lytis ir amžius yra statistiškai reikšmingas faktorius kelio sąnario kremzlės pažeidimo laipsniui ir dažniui. Dažniausiai pažeidžiamos kelio sąnario kremzlės sritys yra F3-F4 šlaunikaulio vidinio krumplio kremzlė, P3-P4 girnelės kremzlė, T4-T5 blauzdikaulio vidinio krumplio kremzlė. Nuo 45-55 metų ženkliai didėja kelio sąnario kremzlės pažeidimų kiekis ir pažeidimo laipsnis.