Empfehlungen der AG Klinische Geweberegeneration zur Behandlung von Knorpelschäden am Kniegelenk. / Empfehlungen der AG Klinische Geweberegeneration zur Behandlung von Knorpelschäden am Kniegelenk.

The Working Group of the German Orthopedic and Trauma Society (DGOU) on Tissue Regeneration has published recommendations on the indication of different surgical approaches for treatment of full-thickness cartilage defects in the knee joint in 2004, 2013 and 2016. Based upon new scientific knowledge and new developments, this recommendation is an update based upon the best clinical evidence available. In addition to prospective randomised controlled clinical trials, this also includes studies with a lower level of evidence. In the absence of evidence, the decision is based on a consensus process within the members of the working group.The principle of making decision dependent on defect size has not been changed in the new recommendation either. The indication for arthroscopic microfracturing has been reduced up to a defect size of 2 cm2 maximum, while autologous chondrocyte implantation is the method of choice for larger cartilage defects. Additionally, matrix-augmented bone marrow stimulation (mBMS) has been included in the recommendation for defects ranging from 1 to 4.5 cm2. For the treatment of smaller osteochondral defects, in addition to osteochondral transplantation (OCT), mBMS is also recommended. For larger defects, matrix-augmented autologous chondrocyte implantation (mACI/mACT) in combination with augmentation of the subchondral bone is recommended.

Biological Reconstruction of Localized Full-Thickness Cartilage Defects of the Knee: A Systematic Review of Level 1 Studies with a Minimum Follow-Up of 5 Years.

OBJECTIVE: The objective of this study was to evaluate the best available mid- to long-term evidence of surgical procedures for the treatment of localized full-thickness cartilage defects of the knee. DESIGN: Systematic review using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines of Level 1 randomized clinical trials (RCTs), meta-analyses of RCTs and systematic reviews with a minimum follow-up of 5 years. Data extracted included patient demographics, defect characteristics, clinical and radiological outcomes, as well as treatment failures. RESULTS: Six RCTs and 3 Level 1 systematic reviews were included. Two RCTs compared microfracture (MFx) to periosteum-covered autologous chondrocyte implantation (ACI-P), 1 to matrix-associated ACI (M-ACI) and 2 to osteochondral autograft transplantation (OAT). One study compared OAT to collagen membrane covered ACI (ACI-C). The 3 Level 1 systematic reviews/meta-analyses assessed the outcome of MFx, OAT, and various ACI methods in RCTs. OAT showed significantly better outcomes compared with MFx. In the 2 RCTs comparing ACI-P and MFx, no significant differences in clinical outcomes were seen, whereas significantly better outcomes were reported for M-ACI versus MFx in 1 study including patients with larger defects (5 cm2), and for ACI-C versus OAT in terms of Cincinnati Score. Higher failure rates were reported for MFx compared with OAT and for OAT compared with ACI-C, while no significant differences in failure rates were observed for ACI-P compared to MFx. CONCLUSION: Restorative cartilage procedures (ACI-C or M-ACI and OAT) are associated with better long-term clinical outcomes including lower complication and failure rates when compared with reparative techniques (MFx). Among the restorative procedures, OAT seems to be inferior to ACI especially in larger defects after longer follow-up periods. LEVEL OF EVIDENCE: Level I: Systematic review of Level I studies.

Degenerative Cartilage Lesions of the Medial Knee Compartment. Associated Factors, Operative Options, and Preliminary Results from the CartilageRegistry DGOU. / Degenerativ bedingte Knorpelschäden im medialen Kniekompartiment. Assoziierte Faktoren, operative Optionen und präliminäre Ergebnisse aus dem KnorpelRegister (DGOU).

PURPOSE: This study was aimed to determine the impact of bioregenerative operations in case of degenerative cartilage lesions within the media knee compartment. MATERIAL AND METHODS: The CartilageRegistry DGOU was founded in 2013. At the deadline August 2016 a total of 1847 patients were included. A total of 23.3% (n = 432) was suffering from a degenerative cartilage lesion in the medial compartment. Follow-up was performed after 6, 12, and 24 months (online evaluation). The patients were asked for their subject feeling as well as the KOOS (Knee injury and Osteoarthritis Outcome Score) was determined. RESULTS: Most of the patients (n = 358) suffered from a single femoral lesion. In 25 cases single tibial and in 49 cases combined defects ("kissing lesions") were addressed by different treatment options: 39.9% autologous chondrocyte transplantation, in 8.1% in combination with a spongiosa plasty. Other treatments were drilling, microfracturing with or without matrix. In 17.9% the surgeons had chosen combined methods. The bioregenerative treatment was combined with a concomitant operation in 39.7% in patients with medial, in 56.0% in patients with a tibial, and in 67.9% in patients with combined defects. The mostly performed additional operations were osteotomies. There were no gender differences at baseline or during follow-up. The history of patients with femoral defects was shorter than in the other groups. The patients with medial defects judged the subjective outcome significant more frequently better after 6, 12, or 24 months compared with the other groups. The KOOS raised from baseline (median 52 points) to a median of 75 after 6, to 78 points after 12, and to 80 points after 24 months. Patients with femoral defects had a better KOOS-outcome in tendency. Revision operations were required in 7.1%. CONCLUSIONS: The treatment of degenerative cartilage lesions (respective early OA) by bioregenerative procedures are well-established measures. These treatments are sufficient to produce high patients' satisfaction and acceptable short/midterm results.

Non-operative treatment of unicompartmental osteoarthritis of the knee: a prospective randomized trial with two different braces-ankle-foot orthosis versus knee unloader brace.

BACKGROUND: The use of an unloader brace is a non-surgical treatment option for patients with medial osteoarthritis (OA). However, many patients do not adhere to brace treatment, because of skin irritation due to the pads at the level of the joint space and bad fit. A new concept to unload the medial compartment of the knee is a foot ankle brace with a lever arm pressing the thigh in valgus. The aim of this prospective randomized trial was to examine the outcomes of patients with medial OA after treatment with a conventional knee unloader brace (Unloader One®) and the new foot ankle orthosis (Agilium FreeStep®). METHODS: For this multicenter trial, 160 patients (> 35 years) with medial OA were randomly allocated to treatment with a conventional knee unloader brace (Unloader One®) or treatment with the new knee OA ankle brace (Agilium FreeStep®). The primary outcome measure was pain (numerical analog scale) at baseline (T0), 8 weeks (T1), and 6 months (T2). Secondary outcome measures were knee function (Knee Injury and Osteoarthritis Outcome Score, KOOS), side effects, additional interventions, and compliance. RESULTS: In both groups, walking pain improved between T0 and T1 and also between T0 and T2 without a significant group difference. For pain at sports, both groups showed a significant improvement between T0 and T2 without a significant group difference. The KOOS subscales symptoms, pain, activity, sport, and quality of life increased significantly in both treatment groups without any significant group differences at T 0, T1, and T2. There was also no significant group difference in additional interventions and weekly or daily brace use. In the Agilium FreeStep® group (23.5%), significantly less patients reported bruises in contrast to the Unloader One® group (66.7%). DISCUSSION: The results of this clinical trial show that the foot ankle brace is as effective as a conventional knee unloader brace for the treatment of medial knee OA with regard to clinical outcome. The rate of side effects such as bruises was significantly lower in the Agilium FreeStep® group. TRIAL REGISTRATION: DRKS00009215, 13.8.2015.

[Biologic Reconstruction of Full Sized Cartilage Defects of the Hip: A Guideline from the DGOU Group "Clinical Tissue Regeneration" and the Hip Committee of the AGA]. / Biologische Rekonstruktion lokalisiert vollschichtiger Knorpelschäden des Hüftgelenks: Empfehlungen der Arbeitsgemeinschaft "Klinische Geweberegeneration" der DGOU und des Hüftkomitees der AGA.

Background Symptomatic pre-arthritic deformities such as femoroacetabular impingement (FAI) or hip dysplasia often lead to localised cartilage defects and subsequently to osteoarthritis. The present review of the working group "Clinical Tissue Regeneration" of the German Society of Orthopaedics and Trauma (DGOU) and the hip committee of the AGA (German speaking Society for Arthroscopy and Joint Surgery) provides an overview of current knowledge of the diagnosis and surgical treatment of cartilage defects, in order to infer appropriate therapy recommendations for the hip. Methods Review of FAI and resultant cartilage damage in the hip as reported in published study findings in the literature and discussion of the advantages and disadvantages of different surgical procedures to preserve the joint. Results Most published studies on the surgical treatment of cartilage damage in the hip report defects caused by cam-type FAI at the acetabulum. Development of these defects can be prevented by timely elimination of the relevant deformities. At present, current full-thickness cartilage defects are mostly treated with bone marrow-stimulating techniques such as microfracture (MFx), with or without a biomaterial, and matrix-assisted autologous chondrocyte transplantation (MACT). Osteochondral autologous transplantation (OAT) is not the treatment of choice for isolated full-thickness chondral defects at the hip, because of the unfavourable risk-benefit profile. Due to the relatively short history of cartilage repair surgery on the hip, the studies available on these procedures have low levels of evidence. However, it is already becoming obvious that the experience gained with the same procedures on the knee can be applied to the hip as well. For example, limited healing and regeneration of chondral defects after MFx can also be observed at the hip joint. Conclusions The cartilage surface of the acetabulum, where FAI-related chondral lesions appear, is considerably smaller than the weight-bearing cartilage surface of the knee joint. However, as in the knee joint, MACT is the therapy of choice for full-thickness cartilage defects of more than 1.5 - 2 cm2. Minimally invasive types of MACT (e.g. injectable chondrocyte implants) should be preferred in the hip joint. In cases where a single-stage procedure is indicated or there are other compelling reasons for not performing a MACT, a bone marrow-stimulating technique in combination with a biomaterial covering is preferable to standard MFx. For treatment of lesions smaller than 1.5 - 2 cm2 the indication for a single-stage procedure is wider. As with defects in the knee, it is not possible to determine a definite upper age limit for joint-preserving surgery or MACT in the hip, as the chronological age of patients does not necessarily correlate with their biological age or the condition of their joints. Advanced osteoarthritis of the hip is a contraindication for any kind of hip-preserving surgery. Long-term observations and prospective randomised studies like those carried out for other joints are necessary.

[Coincidence and Therapy of Dysalignments and Degenerative Knee Cartilage Lesions. Results from the German CartilageRegistry DGOU]. / Koinzidenz und Therapie von Beinachsdeviationen bei degenerativen Knorpelschäden des Kniegelenks. Ergebnisse aus dem Deutschen KnorpelRegister DGOU.

Purpose This multicenter study was aimed to evaluate the coincidence of degenerative knee cartilage lesions with a varus or valgus dysalignment. Furthermore, the frequency of the combined surgery of cartilage treatments and corrective osteotomies are determined. Material and Methods A total of 1778 patients were included in the German CartilageRegistry (deadline 01.08.2016). In 90.6% of patients, the surgeon calculated the alignment by clinical observation. Varus or valgus conditions were measured radiologically in only 56.0%. This study describes patients who underwent treatment of degenerative cartilage lesions with a complete (clinical and radiological) determination of the alignment. Results The mean mechanical tibia-femur angle (Paley) (mTFA) in clinically neutral extremities was 0.2° (SD 0.6; 0 - 5), in varus cases 5,0° (SD 3.2; 0 - 15), and - 4.7° (SD - 4.0; - 15 - 0) in valgus cases. Varus dysalignment was significantly associated with cartilage lesions in the medial compartment. Valgus dysalignment more frequently occurred in knees with lateral cartilage lesions. Independently of the surgeon's choice of the method of cartilage surgery, in 72.4% of all valgus deformities a corrective osteotomy was performed. Valgus dysalignment was corrected in 50%. Conclusions In about a quarter of all cases, cartilage lesions are associated with a varus (18.9%) or valgus (4.2%) dysalignment. In a number of cases, the treatment of cartilage lesions should include the addressing of these axial deviations. Still the efficacy of this procedure regarding prognosis and clinical outcome is unclear.

Cartilage repair surgery for full-thickness defects of the knee in Germany: indications and epidemiological data from the German Cartilage Registry (KnorpelRegister DGOU).

PURPOSE: Treatment of cartilage defects of the knee remains an important issue with high relevance. In October 2013 the German Cartilage Registry (KnorpelRegister DGOU) was initiated in order to study indications, epidemiology and (clinical) outcome of different cartilage repair techniques. The present evaluation of the registry baseline data was initiated to report common practices of cartilage repair surgery in Germany. MATERIALS AND METHODS: 1065 consecutive patients who underwent surgical cartilage treatment of the knee have been included (complete data sets available in 1027 cases; FU rate 96.4 %) between October 1, 2013 and June 30, 2015. Data collection was performed using a web-based RDE System. All data were provided by the attending physician at the time of arthroscopic or open surgery of the affected knee. RESULTS: In 1027 cartilage repair procedures, single defects were treated in 80 % of the cases with the majority of the defects located on the medial femoral condyle, followed by the patella. Degenerative defects grade III or IV according to ICRS were treated in 60 % of the cases and therefore were found more frequently compared to traumatic or post-traumatic lesions. Autologous chondrocyte implantation (ACI) was the most common technique followed by bone marrow stimulation (BMS) and osteochondral transplantation (OCT). While ACI was performed in defects with a mean size of 4.11 cm(2) SD SD 2.16), BMS and OCT (1.51 cm(2), SD 1.19; p < 0.01) were applied in significantly smaller defects (both p < 0.01). Independent of defect size, the ratio of ACI versus BMS applications differed between different defect locations. ACI was used preferably in defects located on the patella. CONCLUSION: The present analysis of data from the German Cartilage Registry shows that the vast majority of cartilage repair procedures were applied in degenerative, non-traumatic cartilage defects. Experts in Germany seem to follow the national and international guidelines in terms that bone marrow stimulation is applied in smaller cartilage defects while cell-based therapies are used for the treatment of larger cartilage defects. In patellar cartilage defects a trend towards the use of cell-based therapies has been observed.

Characteristics and associated factors of Klee cartilage lesions: preliminary baseline-data of more than 1000 patients from the German cartilage registry (KnorpelRegister DGOU).

INTRODUCTION: Knee cartilage lesions are very frequent in arthroscopic surgery. This multi-center-study was aimed to evaluate the distribution and possible associated factors of these pathologies in more than 1000 patients. MATERIALS AND METHODS: The German cartilage registry (KnorpelRegister DGOU) started in 2013. In this paper, we present the baseline-data (distribution of knee cartilage lesions and the demographic data) of more than 1000 cases since the registries' start-up. RESULTS: A total number of 47 centers were involved into this multicenter study. A total of 1071 patients primary were registered. Degenerative knees 629 times (61.8 %) and injured knees 302 times (29.6 %) were involved. In the remaining 89 knees (8.7 %) the genesis of cartilage lesions was unclear. Single defects were observed in 792 cases (77.6 %). Most frequently the medial femoral condyle or the patella was affected. In 78 knees (7.6 %) the main-defect was associated with a defect of the corresponding joint surface. In the remaining cases complex cartilage damages were found. CONCLUSIONS: Our results are in confirmation with other multicenter studies. But these former studies did not differentiate into traumatic and degenerative lesions. Furthermore no characteristics were given regarding to single, kissing or complex lesions. Thus this database will be a sufficient instrument for the investigation of the "natural course" of cartilage lesions, but above all about the effectiveness of different treatment options.

Halogenated Dodecaborate Clusters as Agents to Trigger Release of Liposomal Contents.

Halogenated dodecaborates, and especially dodecaiodododecaborate(2-), are found to trigger effectively the release of the contents of phospholipid liposomes, including liposomes containing distearoylphosphatidylcholine and cholesterol, which are used clinically in cancer therapy. The basis of the release is studied through differential scanning calorimetry, cryo-transmission electron microscopy, and atomic force microscopy. Upon administration at high concentrations, drastic morphological changes are induced by the dodecaborates. Their possible use in triggered release is suggested.

Articular cartilage defects in the knee--basics, therapies and results.

Full-thickness defects of the articular cartilage in the knee joint have lower regenerative properties than chondral lesions of the ankle. In order to avoid early osteoarthritis, symptomatic articular cartilage defects in younger patients should undergo biological reconstruction as soon as possible. Various surgical procedures are available to biologically resurface the articular joint line. Numerous animal experiments and clinical studies have shown that early biological reconstruction of circumscribed cartilage defects in the knee is superior to conservative or delayed surgical treatment. This superiority refers not only to defect healing but also to the elimination of changes following secondary osteoarthritis. The various surgical procedures can be differentiated by the range of indications and the final outcome. Additional malalignment, meniscus tears and/or ligament instabilities should be treated simultaneously with the cartilage resurfacing. The mid- and long-term results of the various current techniques are promising, but further modifications and improvements are needed.

Navigation-guided transfer of cartilage defect geometry for arthroscopic autologous chondrocyte transplantation.

Cartilage repair with autologous chondrocyte transplantation shows intriguing results. Chondrogenic transplants generally must be inserted into cartilage defects via arthrotomy. The following study showed that arthroscopically-guided navigation could detect and precisely measure the cartilage defect sizes of different geometries. The new cartilage defect-managing module allowed for the precise transfer of navigated cartilage defect geometries for exact size preparation of the tissue engineering scaffolds. Therefore, navigation can help accomplish chondrocyte transplantation arthroscopically.

Reimplantation of extracorporeal irradiated bone segments in musculoskeletal tumor surgery: clinical experience in eight patients and review of the literature.

BACKGROUND: Two methods are available for extracorporeally devitalizing resected tumor-bearing bone specimens, the simpler of which, autoclaving, has substantial disadvantages. We present our experience with the alternative reconstruction technique of reimplantating extracorporeally irradiated specimens (IEIR) PATIENTS AND METHODS: Eight patients who had primary malignant bone tumors of the long bones were managed with wide en bloc resection and IEIR. The segments were fixed by either plate osteosynthesis, knee arthrodesis rod, or intramedullary nailing. All seven patients with high-grade tumors received chemotherapy. RESULTS: After a median follow-up of 66 months (40-76) five of eight patients were continuously free of disease. One man with a chondroblastic osteosarcoma developed pulmonary metastases which were resected. One woman with teleangiectatic osteosarcoma developed a local recurrence in the soft tissue without contact to the irradiated reimplant. At the latest follow-up, 58 months after resection of the pulmonary metastases and 28 months after resection of the locally recurrent tumor, there was no evidence of disease in either patient. Another woman 67 months after IEIR for an osteosarcoma of the distal femur developed a subcutaneous metastasis of the scalp and the thoracic wall and an ossifying pulmonary metastasis. At the time of writing she is receiving chemotherapy. After a median duration of 4.3 months (2.3-25.2) all graft-host junctions had healed. The functional result was good in four patients and excellent in the other four. CONCLUSIONS: Limb salvage using reimplantation of extracorporeally irradiated tumor-bearing bone segments for reconstruction offers an excellent reconstruction method in appropriately selected patients compared with other options of management.