Clinical and MRI evaluation of medium- to long-term results after autologous osteochondral transplantation (OCT) in the knee joint.

PURPOSE: Autologous osteochondral transplantation (OCT) is one of the surgical options currently used to treat cartilage defects. It is the only cartilage repair method that leads to a transfer of hyaline cartilage repair tissue. The purpose of this study was to evaluate the magnetic resonance observation of cartilage repair tissue (MOCART) score, the 3D MOCART score and various clinical scores in patients after OCT in knee joints. METHODS: Two women and eight men were evaluated 6-9 years (median 7.2 years) after OCT on the femoral condyle of the knee joint. All patients were evaluated by magnetic resonance imaging (MRI) measurement, using a 3.0 T Scanner with different cartilage-specific sequences. Clinical assessment included the knee injury and osteoarthritis outcome score (KOOS), the international knee documentation committee (IKDC) subjective knee form, the Noyes sport activity rating scale and the Tegner activity score. For MRI evaluation, the MOCART score and 3D MOCART score were applied. RESULTS: Clinical long-term results after OCT showed median values of 77 (range 35.7-71.4) for the IKDC; 50 (6.3-100), 66.7 (30.6-97.2), 65 (0-75), 57.1 (35.7-71.4) and 80.9 (30.9-100) for the KOOS subscales (quality of life, pain sports, symptoms and activity of daily living); 61.4 (22.3-86.2) for the Noyes scale; and 3 (0-6) for the Tegner activity score. The median MOCART score was 75 (30-90) after both 1 and 2 years and 57.5 (35-90) after 7 years, as assessed by different cartilage-specific sequences. The 3D MOCART score showed values of 70 (50-85) and 60 (50-80) in the two different isotropic sequences after 7 years. CONCLUSION: The MOCART and 3D MOCART scores are applicable tools for patient follow-up after OCT. Post-operative follow-up assessments would also benefit from the inclusion of OCT-specific parameters. Long-term results after OCT reflect an impairment in clinical scores in the first 2 years with good results during follow-up. Stable conditions were observed between 2 and 7 years after surgery. The filling of the defects and the cartilage interface appeared good at MRI evaluation after the first 2 years, but cartilage loss was observed between the medium- and long-term follow-ups. Isotropic imaging with multiplanar reconstruction is useful for daily clinical use to assess bony cylinders in cartilage repair, especially in combination with the 3D MOCART. LEVEL OF EVIDENCE: Retrospective therapeutic study, Level IV.

Gender differences following computer-navigated single- and double-bundle anterior cruciate ligament reconstruction.

PURPOSE: Female patients not only demonstrate an increased risk for injury, but also a poorer response following anterior cruciate ligament (ACL) rupture. However, no study has investigated gender-related differences between computer-navigated single-bundle (SB) and double-bundle (DB) ACL reconstruction. The aim of this study was to evaluate the effects of gender on the outcome of computer-navigated SB and DB ACL reconstruction and to present reference values. METHODS: A retrospective review of 55 consecutive patients who underwent SB (15 males, 12 females) and DB (18 males, 10 females) ACL reconstruction with autogenous hamstring tendon grafts and showed a minimum follow-up of 24 months was conducted. Intraoperatively, the anteroposterior and rotational laxity were measured and the follow-up examination included pivot-shift testing, KT-1000 arthrometer testing, International Knee Documentation Committee (IKDC) form, the Lysholm score and Tegner score. RESULTS: Pre-operatively, female patients showed a significant higher internal rotation in (p < 0.001) both the SB and DB group. Regarding the post-operative reduction in internal rotation, females in the SB group revealed a greater reduction compared to males (p < 0.001), whereas females in the DB group revealed a significantly greater post-operative reduction in anterior-posterior translation (p = 0.04). Female patients following DB ACL reconstruction presented a significant worse IKDC score, Lysholm score and Tegner score compared to male patients. All score values of the female DB group were worse than in the female SB group. In contrast, male patients showed better results of all examined clinical scores following DB procedure compared to SB technique. CONCLUSION: Female patients who underwent computer-navigated DB ACL reconstruction exhibited significantly worse outcome scores than males who underwent DB ACL reconstruction. The gender-based relationship between joint function and outcome after ACL reconstruction remains unclear and requires further investigation. LEVEL OF EVIDENCE: Retrospective case-control series, Level III.

Long-term results 8 years after autologous osteochondral transplantation: 7 T gagCEST and sodium magnetic resonance imaging with morphological and clinical correlation.

OBJECTIVE: To correlate long-term clinical outcome and the results of morphological as well as advanced biochemical magnetic resonance imaging (MRI) techniques [T2-mapping, glycosaminoglycan chemical exchange saturation transfer (gagCEST), sodium-23-imaging] in patients after autologous osteochondral transplantation (AOT) in knee joints. METHOD: Nine AOT patients (two female and seven male; median age, 49) had clinical [International Knee Documentation Committee (IKDC), modified Lysholm, visual analog scale (VAS)] and radiological long-term follow-up examinations at a median of 7.9 years (inter-quartile range, 7.7-8.2). Standard morphological MRI and T2-mapping of cartilage were performed on a 3 T MR unit. Biochemical imaging further included sodium-23-imaging and chemical exchange saturation transfer (CEST) imaging at 7 T. The Magnetic resonance Observation of CArtilage Repair Tissue (MOCART) score was used for quantitative assessment of morphological MRI. RESULTS: Clinical outcome was good with a median modified Lysholm score of 90. Median VAS revealed 1.0 and median MOCART score 75 points. The difference between native and repair cartilage was statistically significant for all three biochemical imaging techniques. The strongest correlation was found between the results of the advanced biochemical imaging methods sodium-23 and CEST [ρ = 0.952, 95% confidence interval (CI): (0.753; 0.992)]. Comparing the results from morphological and biochemical imaging, a correlation was found between MOCART score and CEST ratio [ρ = -0.749, 95% CI: (-0.944; -0.169)]. Comparing the results from clinical scores with MRI, a correlation between modified Lysholm and T2-mapping [ρ = -0.667, 95% CI: (-0.992; -0.005)] was observed. CONCLUSION: Long-term clinical outcome in patients 7.9 years after AOT was good, but did not correlate with morphological and biochemical imaging results except for T2-mapping.

Refixation after lateral meniscus tear followed by complete luxation in an 11-year-old.

Isolated meniscus tears with consecutive complete luxation of the meniscus are an exceptional injury especially in children. We report a case of an 11-year-old girl with a complete luxation of the lateral meniscus, injured by a jump from low height. Following clinical examination and magnetic resonance imaging, a surgical refixation of the entire lateral meniscus was performed. Short-time clinical and radiological follow-up was conducted.

Gene expression and cell differentiation in matrix-associated chondrocyte transplantation grafts: a comparative study.

OBJECTIVE: Although scaffold composition and architecture are considered to be important parameters for tissue engineering, their influence on gene expression and cell differentiation is rarely investigated in scaffolds used for matrix-associated autologous chondrocyte transplantation (MACT). In this study we have therefore comparatively analyzed the gene expression of important chondrogenic markers in four clinical applied cell-graft systems with very different scaffold characteristics. METHODS: Residuals (n=165) of four different transplant types (MACI®, Hyalograft®C, CaReS® and Novocart®3D) were collected during surgery and analyzed for Col1, Col2, aggrecan, versican, melanoma inhibitory activity (MIA) and IL-1ß by real-time PCR. Scaffold and cell morphology were evaluated by histology and electron microscopy. RESULTS: Despite the cultivation on 3D scaffolds, the cell differentiation on all transplant types didn't reach the levels of native cartilage. Gene expression highly differed between the transplant types. The highest differentiation of cells (Col2/Col1 ratio) was found in CaReS®, followed by Novocart®3D, Hyalograft®C and MACI®. IL-1ß expression also exhibited high differences between the scaffolds showing low expression levels in Novocart®3D and CaReS® and higher expression levels in MACI® and Hyalograft®C. CONCLUSIONS: Our data indicate that scaffold characteristics as well as culture conditions highly influence gene expression in cartilage transplants and that these parameters may have profound impact on the tissue regeneration after MACT.

Rotational and translational laxity after computer-navigated single- and double-bundle anterior cruciate ligament reconstruction.

Based on biomechanical cadaver studies, anatomic double-bundle reconstruction of the anterior cruciate ligament (ACL) was introduced to achieve better stability in the knee, particularly in respect of rotatory loads. Previously, the success of ACL reconstruction was believed to be mainly dependent on correct positioning of the graft, irrespective of the number of reconstructed bundles for which computer-assisted surgery was developed to avoid malpositioning of the tunnel. The aim of the present study is to compare rotational and translational stability after computer-navigated standard single-bundle, and anatomic double-bundle ACL reconstruction. The authors investigated 55 consecutive patients who had undergone the single-bundle or double-bundle ACL reconstruction procedure with the use of autogenous hamstring tendon grafts and EndoButton fixation, and the patients had been followed for a minimum period of 24 months. Intraoperative, anteroposterior and rotational laxity was measured with the computer navigation system, and compared between groups. Both surgical procedures significantly reduced anteroposterior displacement (AP) and internal rotation (IR) of the tibia compared to the pre-operative ACL-deficient knee (P < 0.05). No significant differences were registered between groups with regard to anteroposterior displacement of the tibia. A significantly greater reduction in internal rotation was noted in the double-bundle group (15.6 degrees) compared to the single-bundle group (7.1 degrees). The IKDC and Lysholm score were significantly higher in the double-bundle group. However, the results were excellent in both groups. The use of a computer-assisted ACL reconstruction, which is a highly accurate method of graft placement, could be useful for inexperienced surgeons to avoid malposition. Whether double-bundle ACL reconstruction, which was associated with improved rotational laxity and significantly better IKDC and Lysholm scores compared to the standard single-bundle ACL reconstruction procedure, provide an influence in terms of avoiding osteoarthritis or meniscus degeneration, long-term results of at least 5 years are needed.

[Biomaterial for autologous chondrocyte transplantation]. / Biomaterialien für die autologe Knorpelzelltransplantation.

Autologous chondrocyte transplantation (ACT) is a cell-based biological cartilage repair procedure for the regeneration of injured articular cartilage. The further modification of classical ACT to matrix-associated autologous chondrocyte transplantation (MACT) includes the use of biomaterials as cell carriers and has biological and surgical advantages. The use of biomaterials as cell carriers for chondrocytes requires the analysis of cell culture conditions, cell-cell and cell-matrix interactions and also the determination of chondrocytic differentiation. The biomaterials used preserve the specific cellular architecture of chondrocytes and the combination of cultivated cells with biomaterials leads to the formation of cartilage-specific extracellular matrix components.

Characteristics of polytrauma patients between 1992 and 2002: what is changing?

OBJECTIVE: To analyse the characteristics of polytrauma patients and the quality and progress of treatment regimens by an evaluation of a trauma population. METHODS: The study included all polytrauma patients treated between 1992 and 2002 at a level 1 trauma centre. Data of 501 cases were collected prospectively and analysed retrospectively. The analysis included the demographic data, injury severity, preclinical haemodynamics, intubation rates, incidences of multiorgan failure and adult respiratory distress syndrome, and mortality. RESULTS: Per year of the study, the average age of patients increased by 0.748 years. Preclinical intubation rates also increased and the number of cases of primary shock decreased. The Injury Severity Score fell on average by 0.59 points per year. There was a significant decrease in multiorgan failure and adult respiratory distress syndrome. The mortality rate remained constant. CONCLUSIONS: Protracted time of initial rescue, early intubation and good preclinical treatment lead to a reduction of complications during intensive care. The increasing number of elderly patients results in persistently high mortality even with decreasing injury severity.

[Long-term results in the treatment of foot injuries in polytraumatized patients]. / Langzeitergebnisse in der Behandlung von Fussverletzungen bei polytraumatisierten Patienten.

INTRODUCTION: The aim of this study was to evaluate the long-term outcome of multiple injured patients with foot injuries. While severity and frequency of multiple injuries could be decreased in the last years, it was not possible to decrease the severity of injuries of the foot and ankle region. These injuries are often not detected and their severity is underestimated in primarily diagnostics what might lead to complaints in the longterm course. METHODS: The multiple trauma database of the Department of Traumatology of the University of Vienna includes 386 patients from September 1992 to April 2001. 40 (10.4 %) of these patients suffered a fracture or dislocation of foot or ankle. 33 (82.5 %) multiple injured patients with injuries of foot or ankle could be reexamined between April and September 2002 and the longterm outcome of the foot and ankle region could be evaluated objectively and subjectively. RESULTS: 22 (66.7 %) patients were male, 11 (33.3 %) female. The mean age was 34.5 years. 27 (81.8 %) patients still suffered from complaints related to their injured foot and ankle region. After calculation of the AOFAS these complaints were predominantly located in the ankle-hindfoot region. 22 (66.7 %) patients had to limit their sports activity. DISCUSSION: In our study period an increasing number and severity of injuries of foot or ankle can be shown. Furthermore multiple injured patients with concomitant injuries of foot or ankle show a lower ISS what suggests that these patients might have a higher survival rate and consecutively enter rehabilitation process.

[Polytrauma and air rescue. A retrospective analysis of trauma care in eastern Austria exemplified by an urban trauma center]. / Polytrauma und Luftrettung. Eine retrospektive Analyse der Versorgung im Osten Osterreichs am Beispiel eines urbanen Traumazentrums.

OBJECTIVE: The aim of this study was a retrospective analysis of polytraumatized patients who were treated by a helicopter emergency medical service (HEMS) crew. This study was performed to evaluate the level of prehospital care provided for severely injured patients. Special consideration was given to treatment strategies of specific injuries which led to multiple injuries, defined as "polytrauma." METHODS: From September 1992 to April 2001 data of 386 patients treated in the Department of Traumatology of the University of Vienna were collected. A total of 104 patients (26.9%) were transported by helicopter directly from the accident scene. This collective was analyzed demographically; relevant prehospital data such as therapeutic interventions and the early clinical course were examined. RESULTS: The mean Injury Severity Score (ISS) was 36.9: 70 (67.3%) patients were male and 34 (32.7%) female; the median age was 36.1 years. Traffic accidents were the most frequent trauma mechanism (78.9%) followed by falls from height (17.3%). The mean period between trauma and trauma emergency room was 0.73 h; 77 (74.0%) patients were intubated and mechanically ventilated at the scene and all patients received analgosedation. The mean preclinical fluid load was 1673 ml. The mean duration of treatment in the emergency room was 53 min. The mean length of intensive care was 8.6 days and the mortality rate was 19.2% within the first 24 h. CONCLUSION: Major trauma is an important cause for requesting a primary HEMS mission. As the results of this study show, immediate and invasive interventions at the scene lead to an improvement of vital functions at admission. For the patients' further course of treatment, the choice of a trauma center seems to be important, too.

[Autologous chondrocyte transplantation for the treatment of articular cartilage defects inf the knee joint. Techniques and results]. / Autologe Chondrozytentransplantation zur Behandlung von Knorpeldefekten des KniegelenksTechniken und Ergebnisse.

BACKGROUND: Currently the use of autologous chondrocytes as a cartilage-repair procedure for the repair of injured articular cartilage of the knee joint, is recommended. METHODS: This review presents the technique of autologous chondrocyte transplantation (ACT) and their modifications as matrix-associated autologous chondrocyte transplantation (MACT). Beside the surgical procedure the experimental and clinical results are discussed. Furthermore the major complications and the indication guidelines are presented. RESULTS: Articular cartilage in adults has a poor ability to self-repair after a substantial injury. Surgical therapeutic efforts in treating cartilage defects have focused on bringing new cells capable of chondrogenesis into the lesions. With ACT good to excellent clinical results are seen in isolated posttraumatic lesions of the knee joint in the younger patient with the formation of hyaline-like repair tissue. The major complications are periosteal hypertrophy, delamination of the transplant, arthrofibrosis and transplant failure. The current limitations include osteoarthritic defects and higher patient age. CONCLUSION: With the right indication and operative technique ACT is an effective and save option for the treatment of large full thickness cartilage defect of the knee joint.