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ORTHOPAEDIC MEDICINE CARTILAGE REGENERATION
CLINICAL RESULTS Patients need to be aware that the technique may not be successful in everyone for a variety of reasons. It is generally expected that 80–90% of patients undergoing either ACI or MACI will experience significant functional improvements. The relative effectiveness and durability of ACI compared with other cartilage repair techniques still remain somewhat inconsistent, which is due mainly to a lack of long-term follow-up studies (15,26). Poor preoperative function and a long history of symptoms with numerous previous surgical procedures have shown to be poor prognostic indicators. It is therefore of paramount importance that the clinician recognises these factors when providing the patient with treatment advice and prognosis. A limited number of long-term
studies with up to 9 years follow-up have, however, confirmed good or excellent results in 82–92% of patients (5,14,27). Complications included superficial wound infections, postoperative haematomas, intra-articular adhesions and periosteal hypertrophy, while complete graft failure was reported in up to 16% of cases. Minas reported on a group of 169 patients with large cartilage lesions of up to 12 cm2
treated with ACI. Overall,
87% of patients showed significant improvement after a minimum follow-up of 24 months, while 13% were considered failures (28). Similarly good results have also been reported by Behrens et al. (29) using the second-generation MACI technique (Figs. 4-6) (29,30).
References
1. Hunter W. On the structure and diseases of articulation cartilage. Philosophical Transactions. Royal Society (Great Britian) 1743;9:267–271 2. Bentley G. Repair of articular cartilage. In: Owen R, Goodfellow J, Bullough PG (eds) Scientific foundations of orthopaedics and traumatology. Heinemann 1980. ISBN 0433243201 3. Pridie KH. A method of resurfacing osteoarthritic knee joints. Journal of Bone and Joint Surgery 1959;41B:618–619 4. Bentley G, Greer RB III. Homotransplantation of isolated epiphyseal and articular cartilage chondrocytes into joint surfaces of rabbits. Nature 1971;230:385–388 5, National Institute of Health and Clinical Excellence. The use of autologous chondrocyte implantation for the treatment of cartilage defects in knee joints. Technology Appraisal 89. National Institute of Health and Clinical Excellence 2008. www.nice.org.uk 6. Schindler OS. Osteochondritis dissecans of the knee. Current Orthopaedics 2007;21:47– 58 7. Mankin HJ, Grodzinski AJ, Buckwalter JA.
Articular cartilage and osteoarthritis. In: Einhorn TA, Buckwalter, JA, O’Keefe RJ, American Academy of Orthopaedic Surgeons (eds) Orthopaedic basic science. American Academy of Orthopaedic Surgeons 2007. ISBN 9780892033577 8. Briggs TWR, Mahroof S, David LA, Flannelly J, et al. Histological evaluation of chondral defects after autologous chondrocyte implantation of the knee. Journal of Bone and Joint Surgery 2003;85–6:1077–1083 9. Armstrong CG, Mow VC. Friction, lubrication and wear of synovial joints. Owen R, Goodfellow J, Bullough PG (eds) Scientific foundations of orthopaedics and traumatology. Heinemann 1980. ISBN 0433243201 10. Teller P, König H, Weber U, Hertel P. MRI atlas of orthopedics and traumatology of the knee. Springer 2003. ISBN 3540440348
11. Steadman JR, Briggs KK, Rodrigo JJ, Kocher MS, et al. Outcomes of microfracture for traumatic chondral defects of the knee: average of 11 year follow-up. Arthroscopy 2003;19:477–484 12. Clarke HD, Scott WN. Alternatives in the treatment of knee arthritis: arthroscopy and cartilage restoration. In: Barrack RL, Hip Society, Knee Society, American Academy of Orthopaedic Surgeons, et al. (eds) Orthopaedic knowledge update: hip and knee reconstruction American Academy of Orthopaedic Surgeons 2006. ISBN 0892033487
13. Brittberg M, Lindahl A, Nilsson A, Ohlsson C, et al. Treatment of deep cartilage defects in the knee with autologous chondrocyte implantation. New England Journal of Medicine 1994;331:889–895 14. Peterson L, Minas T, Brittberg M, Nilsson A, et al. Two-to nine-year outcome after autologous chondrocyte transplantation of the knee. Clinical Orthopaedics and Related Research 2000;374:212–234 15. Bentley G, Biant LC, Carrington RW, Akmal M, et al. A prospective, randomised comparison of autologous chondrocyte implantation versus mosaicplasty for osteochondral defects in the knee. Journal of Bone and Joint Surgery 2003;85- B:223–230 16. Haddo O, Mahroof S, Higgs D, David L, et al. The use of chondroguide membrane in autologous chondrocyte implantation. Knee 2004;11:51–55 17. Gillogly SD. Autologous chondrocyte implantation: complex defects and concomitant procedures. Operative Techniques in Sports Medicine 2002;10:120–128 18. Minas T, Peterson L. Advanced techniques in autologous chondrocyte transplantation. Clinical Sports Medicine 1999;18:13–44 19. Micheli LJ, Browne JE, Erggelet C, Fu F, et al. Autologous chondrocyte implantation of the knee: multicentre experience and minimum 3-year follow-up. Clinical Journal of Sport Medicine 2001;11:223–228 20. Ueno T, Kagawa T, Mizukawa N, Nakamura H, et al. Cellular origin of endochondral ossification from grafted periosteum. Anatomical Record 2001;264:348–357 21. Sohn DH, Lottman LM, Lum LY, Kim SG, et al. Effect of gravity on localization of chondrocytes implanted in cartilage defects.
Clinical Orthopaedics and Related Research 2002;394:254–262 22. Frankel SR, Toolan B, Menche D, et al. Chondrocyte using a collagen bilayer matrix for cartilage repair. Journal of Bone and Joint Surgery 1997;79B:831–836 23. Salter RB. The biological concept of continuous passive motion of synovial joints: the first 18 years of basic research and its clinical application. In: Ewing JW (ed.) Articular cartilage and knee joint function. Raven Press 1990. ISBN 0881675423 24. Rodrigo JJ, Steadman JR, Silliman JF, et al. Improvement of full thickness chondral defect healing in human the knee after debridement and microfracture using continuous passive motion. American Journal of Knee Surgery 1994;7:109–116 25. Kreuz PC, Steinwachs M, Erggelet C, Lahm A, et al. Importance of sports in cartilage regeneration after autologous chondrocyte implantation. American Journal of Sports Medicine 2007;35:1261–1268 26. Knutsen G, Engebretsen L, Ludvigsen T, Drogset JO, et al. Autologous chondrocyte implantation compared with microfracture in the knee. Journal of Bone and Joint Surgery 2004;860A:455–464 27. Brittberg M, Tallheden T, Sjögren- Jansson E, Lindahl A, Peterson L. Autologous chondrocytes used for articular cartilage repair. Clinical Orthopaedics and Related Research 2001;391S:S337–S348 28. Minas T. Autologous chondrocyte implantation for focal chondral defects of the knee. Clinical Orthopaedics and Related Research 2001;391(Suppl. 1):349–361 29. Behrens P, Bitter T, Kurz B, Russlies M. Matrix-associated autologous chondrocyte transplantation/implantation (MACT/MACI): 5-year follow-up. Knee 2006;13:194–202 30. Ronga M, Grassi FA, Manelli A, Bulgheroni P. Tissue engineering techniques for the treatment of a complex knee injury. Arthroscopy 2006;22:576
THE AUTHOR
Oliver Schindler is a consultant orthopaedic surgeon who joined the team at the
Droitwich Knee Clinic in 2001. He is one of
only a few surgeons who have embraced the state- of-the-art concept of biologic knee resurfacing which in conjunction with knee re-alignment (osteotomy) can prevent the need for joint replacement surgery especially in the young and active patient group. In 2002 he was awarded the Ilizarov Fellowship
in Russia and in 2006 he represented the British Orthopaedic Association as their ASG Travelling Fellow in Europe. The American Knee Society elected him for the 2007 Insall Travelling Fellowship, which allowed him to visit a number of renowned knee specialist units in North America. Since 1999 his orthopaedic practice has specialized exclusively in lower limb and knee surgery. He carries out well over 300 operations per annum most of which are either keyhole or minimally invasive procedures.
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