Shuji Horibe

Autologous bone marrow stromal cell transplantation for repair of full-thickness articular cartilage defects in human patellae : two case reports

This study assessed the effectiveness of autologous bone marrow stromal cell transplantation for the repair of full-thickness articular cartilage defects in the patellae of a 26-year-old female and a 44-year-old male. These two patients presented in our clinic because their knee pain prevented them from walking normally. After thorough examination, we concluded that the knee pain was due to the injured articular cartilage and decided to repair the defect with bone marrow stromal cell transplantation. Three weeks before transplantation, bone marrow was aspirated from the iliac crest of each patient. After erythrocytes had been removed by use of dextran, the remaining nucleated cells were placed in culture. When the attached cells reached subconfluence, they were passaged to expand in culture. Adherent cells were subsequently collected, embedded in a collagen gel, transplanted into the articular cartilage defect in the patellae, and covered with autologous periosteum. Six months after transplantation, clinical symptoms (pain and walking ability) had improved significantly and the improvement has remained in effect (5 years and 9 months posttransplantation in one case, and 4 years in the other), and both patients have been satisfied with the outcome. As early as 2 months after transplantation, the defects were covered with tissue that showed slight metachromatic staining. Two years after the first and 1 year after the second transplantation, arthroscopy was performed and the defects were repaired with fibrocartilage. Results indicate autologous bone marrow stromal cell transplantation is an effective approach in promoting the repair of articular cartilage defects.

Single- versus bi-socket anterior cruciate ligament reconstruction using autogenous multiple-stranded hamstring tendons with EndoButton femoral fixation *: A prospective study

PURPOSEnThis prospective study was conducted to compare the single-socket and the bi-socket anterior cruciate ligament (ACL) reconstruction techniques in terms of outcome.nnnTYPE OF STUDYnNonrandomized control trial.nnnMETHODSnThere were 160 consecutive patients with unilateral chronic ACL insufficiency who underwent endoscopic single- or bi-socket ACL reconstruction alternately using multiple-stranded medial hamstring tendon and EndoButton (Smith & Nephew, Andover, MD) femoral fixation. All patients underwent the same postoperative rehabilitation protocol. Of them, 106 patients (57 single, 49 bi) were available for 2-year follow-up.nnnRESULTSnAccording to the IKDC Knee Ligament Evaluation Form, 23 patients (40%) of the single-socket group were subjectively graded as normal, 30 (53%) as nearly normal, and 4 (7%) as abnormal. Twenty-six patients (53%) of the bi-socket group were graded as normal, 21 (43%) as nearly normal, and 2 (4%) as abnormal (P =.19). The mean side-to-side anterior laxity difference (KT-1000 manual maximum force) was 0.9 +/- 1.8 mm for the single-socket group and 0.7 +/- 1.2 mm for the bi-socket group (P =.44). Fifty-three of 57 patients (93%) in the single-socket group and all patients in the bi-socket group showed anterior laxity differences of +/-3 mm or less (P =.12). There were no differences in thigh muscle strength between the groups.nnnCONCLUSIONSnBoth single- and bi-socket ACL reconstruction using autogenous multiple-stranded hamstring tendons with EndoButton fixation provided satisfactory anterior stability, and there were no statistically significant differences in subjective results or measured restored stability between the 2 groups.

Safety of autologous bone marrow-derived mesenchymal stem cell transplantation for cartilage repair in 41 patients with 45 joints followed for up to 11 years and 5 months.

Among autologous somatic stem cells, bone marrow‐derived mesenchymal stem cells (BMSCs) are the most widely used worldwide to repair not only mesenchymal tissues (bone, cartilage) but also many other kinds of tissues, including heart, skin, and liver. Autologous BMSCs are thought to be safe because of the absence of immunological reaction and disease transmission. However, it is possible that they will form tumours during long‐term follow‐up. In 1988, we transplanted autologous BMSCs to repair articular cartilage, which was the first such trial ever reported. Subsequently we performed this procedure in about 40 patients. Demonstration that neither partial infections nor tumours appeared in these patients provided strong evidence for the safety of autologous BMSC transplantation. Thus, in this study we checked these patients for tumour development and infections. Between January 1998 and November 2008, 41 patients received 45 transplantations. We checked their records until their last visit. We telephoned or mailed the patients who had not visited the clinics recently to establish whether there were any abnormalities in the operated joints. Neither tumours nor infections were observed between 5 and 137 (mean 75) months of follow‐up. Autologous BMSC transplantation is a safe procedure and will be widely used around the world. Copyright

Anterior Cruciate Ligament Reconstruction with Multistranded Autogenous Semitendinosus Tendon

We evaluated 41 knees 24 to 48 months after anterior cruciate ligament reconstruction was performed using multiple autogenous semitendinosus tendons. The ip silateral free semitendinosus tendon was tripled or quadrupled to make a graft 7 to 10 mm in diameter and more than 60 mm long. When the diameter of the graft was less than 7 mm, an ipsilateral doubled gracilis tendon was also used (in seven cases). Twenty-three patients (56%) returned to their preinjury activity levels. According to the patients subjective assessment, 34 (83%) graded themselves as normal or nearly normal. No patient reported giving way of the knee or limitation of knee motion. The average anterior laxity difference between the involved knee and contralateral uninjured knee was 1.5 mm at 200 N. Twenty-nine patients (71 %) demonstrated an anterior laxity difference of 3 mm or less when the involved knee was compared with the contralateral uninjured knee. Quadriceps muscle strength was 90% compared with the contralateral healthy limb, and hamstring muscle strength was equivalent to the contralateral limb. In our study, tripled or quadrupled semitendinosus free tendons were ex cellent anterior cruciate ligament grafts for restoring knee stability, recovering thigh muscle power, and pre serving knee motion.

Reconstruction of the anterior cruciate ligament using allogeneic tendon Long-term followup

Eighty-four patients who underwent ACL reconstruc tion with fresh-frozen allogeneic tendon were reviewed and evaluated with subjective and functional rating scales, physical examinations, instrumented anterior drawer tests, isokinetic testing, and arthroscopy. The average followup was 57 months (range, 36 to 90 months) and the average age at operation was 22 years (range, 16 to 37 years). The subjective and functional results were rated as excellent in 48 patients (57%), good in 31 (37%), and fair in 2 (2%). Three patients (3%) experienced a retear of the ACL. Physical examinations and instrumented anterior drawer tests showed that satisfactory anterior stability was restored in 88% of the patients. Isokinetic evaluations demonstrated that the extension torque of the involved knee recovered to a slightly lower level than that of the controls, although the flexion torque recovered to a level equivalent to that of the controls. Arthroscopic evaluations revealed that the allografts were elaborately remodeled, viable, and taut. There was no sign of immunologic rejection at any time post operatively. Additional extraarticular procedures, con sisting of both pes anserinus transfer on the medial side and iliotibial band reinforcement on the lateral side, had no effect on the results.

Deterioration of patellofemoral articular surfaces after anterior cruciate ligament reconstruction

One hundred eighty-seven patients who had undergone intraarticular anterior cruciate ligament reconstruction using either a fresh-frozen allogeneic tendon or central third autogenous patellar tendon 3 to 89 months pre viously were arthroscopically evaluated. The focus was on secondary changes of the patellofemoral joint at the time of second-look arthroscopy. Overall, 93 knees deteriorated, 74 knees remained unchanged, and 14 improved. The deteriorative changes were predomi nantly located around the central ridge of the patellae, although all but two knees remained free from anterior knee pain. Statistical multivariate analysis showed sur gical approach by conventional medial parapatellar in cision and use of the central one-third of the autoge nous patellar tendon graft as possible risk factors for the deterioration, although chi-square analysis failed to demonstrate statistical significance for the latter.

Maturation of allograft tendons transplanted into the knee. An arthroscopic and histological study

We have performed an arthroscopic and histological study of the remodelling process of allogeneic tendons transplanted into the human knee as anterior cruciate ligament substitutes. Arthroscopic observations from six weeks to 55 months after operation showed that the grafts were viable, and that early surface hypervascularity subsided with time; moreover, these appearances remained unchanged from 11 months postoperatively onwards. Histological studies from three to 55 months after operation showed that all the grafts were infiltrated with fibroblasts, and that cellularity in their substance reduced with time, remaining unchanged from 18 months onwards; the collagen bundles were aligned as in a normal ligament from six months onwards. These findings suggest that the grafts reach maturity within the first 18 months and remain unchanged as viable ligaments thereafter.

Human meniscus cell: characterization of the primary culture and use for tissue engineering.

Human meniscus cells from 47 surgically excised menisci were grown in primary culture. Cell proliferation and morphologic features were evaluated in three different culture media. Human meniscus cells showed three distinguishable cell types in monolayer culture: elongated fibroblastlike cells, polygonal cells, and small round chondrocytelike cells. These cells proliferated in Dulbecco’s modified Eagle’s medium, but by Day 7, elongated fibroblastlike cells became predominant. Cells did not proliferate in Ham’s nutrient mixture-F-12. In a mixture of Ham’s nutrient mixture-F-12 and Dulbecco’s modified Eagle’s medium, cells proliferated, maintaining their morphologic features and their ability to express messenger ribonucleic acids for aggrecan and Types I, II, and III collagen. Hyaluronan enhanced cellular proliferation without altering morphologic features or chondroitin sulfate production. Cultured human meniscus cells attached to a porous collagen sponge after cell seeding. Gene transfer was successful and an introduced gene was expressed by the cells, indicating that human meniscus cells can undergo gene manipulation. The finding that cells collected from small surgical specimens of human meniscus could be cultured, propagated, and seeded onto a collagen scaffold holds promise for the development of a cell-based, tissue engineered collagen meniscus.

Quantitative evaluation after arthroscopic anterior cruciate ligament reconstruction Allograft versus autograft

We measured the anteroposterior ligamentous laxity and thigh muscle power in 92 subjects who were rated as successes after they had undergone arthroscopic anterior cruciate ligament reconstruction for unilateral anterior cruciate ligament insufficiency 18 to 36 months previously. The subjects were divided into 2 groups according to the type of graft: fresh-frozen allogenic tendon (N = 47) or central one third of the ipsilateral patellar tendon (N = 45). Instrumented drawer tests in the Lachman position were performed to measure an terior tibial displacement at 200 N (anterior laxity). Thigh muscle power was isokinetically measured with a Cy bex II dynamometer. Significantly more anterior laxity was found in the reconstructed knees than in the contralateral normal knees regardless of graft material (paired t-test, P < 0.01), except for the male allograft patients. Although the mean anterior laxity difference between sides for the allograft patients was less than that for the autogenous ones, analysis of variance failed to demonstrate a statistically significant difference be tween the 2 groups if the comparison was strictly made within the same sex. Thigh muscle tests revealed that extension torque in the reconstructed knees was sig nificantly less than that in the contralateral knees and analysis of variance showed that knee extension torque at 60 deg/sec for the allograft patients was significantly better than that of the autograft ones (P < 0.05). We concluded that the allograft procedure is advantageous over the patellar tendon autograft in terms of better restoration of anterior stability.

Subluxation of the patella. Computed tomography analysis of patellofemoral congruence.

Fifty patients who had patellar subluxation and thirty control subjects were examined using axial roentgenograms of the patellofemoral joint that were made with the knee in 30 and 45 degrees of flexion, as well as computed tomography scans that were made with the knee in full extension. The amount of lateral patellar tilt was quantitatively assessed using the lateral patellofemoral angle, as described by Laurin et al., and the congruence angle, as described by Merchant et al. In both the control subjects and the patients, the angle of Laurin et al. changed significantly when the knee was flexed from full extension to 30 degrees. The difference between the groups was statistically significant at each angle of flexion of the knee, and the difference between the groups was most prominent on the computed tomography scans that were made with the knee in full extension (p less than 0.001). In the patients, the average congruence angle (as described by Merchant et al.) was 5 degrees and in the control subjects, -10 degrees. This indicated that, in our patients, the extent of the patellar subluxation was less than that in previously reported series, and, as a result, the sensitivity of the congruence angle in diagnosing patellar subluxation was only 0.30. In contrast, the sensitivity and specificity of the computed tomography scans for diagnosing patellar subluxation were 0.96 and 0.90, respectively--that is, they were higher than the values that were obtained using any axial roentgenograms. Thus, our results indicated that patellar subluxation can be detected more accurately by using computed tomography with the knee in full extension than by using conventional axial roentgenograms.