[Evaluation of the Clinical Outcomes of Autologous Chondrocyte Implantation in the Management of Chondral Lesions of the Knee after 10+ Years]. / Vyhodnocení klinických výsledku metody implantace solidního chondrograftu v lécbe chondrálních lézí kolenního kloubu po více nez 10 letech.

PURPOSE OF THE STUDY: The authors present the outcomes of more than ten-year clinical follow-up of patients who underwent surgical treatment of deep chondral defect of the knee (medial or lateral condyle). The method of treatment was the implantation of autologous cultured chondrocytes in the form of a solid chondral graft. The aim was also to compare the mid-term and long-term outcomes and to evaluate how the knee condition affects the everyday life and sports activities more than 10 years after surgery. MATERIAL AND METHODS Thirty patients of the total of 56 patients (26 patients dropped out of the long-term follow-up) operated in the period between 2001 and 2012 were available for retrospective evaluation of the clinical condition before surgery, at 1, 2, 5 years after surgery and at 10+ years after surgery. The mean follow-up period of patients was 14.5 years (10 - 20.5 years) after surgery. The clinical evaluation was performed using the Lysholm Knee Scoring Scale and the Tegner Activity Scale. RESULTS The mean preoperative Lysholm score of the followed-up study population was 37.5. During the fi rst two years, improvement was achieved to the maximum value of 83.1. At 5 years and subsequently also at more than 10 years after surgery, a slight decline was reported to the mean value of 78.6. When comparing the outcomes at 5 years and at more than 10 years after surgery, the decline in the value was statistically non-signifi cant. The mean value of the Tegner Activity Scale at more than 10 years after surgery was 4.5 points out of 10 points. DISCUSSION Management of a chondral defect especially in younger patients constitutes a common challenge in everyday orthopaedic practice. There are multiple methods at hand, all of which have their pros and cons. The size of the chondral lesion appears to be the limiting and decisive factor. The greatest pitfall are large chondral lesions (>4cm2 ), where many methods fail to yield satisfactory outcomes. One of the suitable options is the autologous chondrocyte implantation method. CONCLUSIONS The clinical outcomes of patients followed-up for more than 10 years after surgery do not show a statistically signifi cant decline compared to the mid-term outcomes. Based on the data obtained, we continue to consider the autologous chondrocyte implantation as an effective method to manage deep chondral defects in the knee. The patients were mostly able to get back to normal life, including their sports activities, with a signifi cant improvement of its quality compared to that before surgery. KEY WORDS: knee joint, chondrocytes, autologous cartilage implantation, long-term.

[Reliability of the Evaluation of MRI Examinations after the Treatment of Chondral Defects in the Knee Joint]. / Spolehlivost hodnocení vysetrení na magnetické rezonanci po osetrení chondrálních defektu kolenního kloubu.

PURPOSE OF THE STUDY This study is a component part of the project focused on cartilage imaging after the treatment of a defect. It aims to compare the evaluation of postoperative status performed by two radiologists with the use of 2D MOCART scoring system and to determine whether this method is a reliable tool for the evaluation of postoperative changes. MATERIAL AND METHODS The study evaluated 78 MRI examinations from 25 patients (one patient had two defects treated), each of whom underwent 3 MRI examinations at 6, 12 and 18 months after surgery. The MRI examinations were performed on Philips Ingenia 3T scanner with 8-channel knee coil, in line with the routine protocol (coronal, sagittal and transversal PD SPAIR, coronal T1, sagittal PD HR, sagittal bFFE). The MRI examinations were evaluated independently by two radiologists using the 2D MOCART (Magnetic Resonance Observation of Cartilage Repair Tissue) score. RESULTS The raters agreed in a total of 592 of 702 evaluations, therefore the inter-rater reliability is high, namely 84.3%. The highest inter-rater agreement was in assessing subchondral lamina and subchondral bone. Whereas the lowest inter-rater agreement was achieved in assessing effusion. The total score showed a very strong and statistically significant correlation (r = 0.893). In eight out of nine questions there was no statistically significant difference between the raters. A significant difference was seen only in the assessment of repair tissue structure. Excellent reliability of the total score was also confirmed by the intraclass correlation coefficient. DISCUSSION The high degree of agreement in assessing the signal intensity of repair tissue was considered very positive as it is generally viewed as the major pitfall in evaluations. On the contrary, subjective perception was confirmed in the evaluation of tissue homogeneity, especially when comparing homogeneity with the adjacent tissue in close vicinity that could have changed already. Surprisingly, the lowest inter-rater concordance was reported in the evaluation of effusion, where in some cases, its volume was underestimated, when traced back retrospectively. CONCLUSIONS The results of this study confirm that despite certain doubts regarding subjective perception of some of the evaluation criteria the 2D MOCART scoring system is a very good and objective tool to evaluate the effects of surgery. Key words: magnetic resonance imaging , hyaline cartilage, classification.

[Two-Year Results of Modified AMIC Technique for Treatment of Cartilage Defects of the Knee]. / Dvouleté výsledky modifikované AMIC techniky v lécbe chondrálních defektu kolenního kloubu.

PURPOSE OF THE STUDY Damage to hyaline cartilage represents a serious problem due to its limited capacity of regeneration. Currently, there are several treatment options available. The purpose of this study is to evaluate the success rate of treatment of chondral and osteochondral defects of the knee joint using the modified AMIC (Autologous Matrix-Induced Chondrogenesis) technique, combining microfractures of the base and the implantation of the type I collagen-based cell-free implant over a two-year period. MATERIAL AND METHODS The prospective study of the success rate of treatment by the modified AMIC technique included 15 patients (13 men and 2 women) with a defect confirmed by MRI and appropriate indication criteria. The mean age at the time of implantation was 33.4 years (range 19-47 years). The mean size of a treated defect was 3.66 ± 1.71 cm2 (range 2.00-7.05 cm2). The clinical outcomes were monitored through the Knee Injury and Osteoarthritis Outcome Score (KOOS), the Lysholm score and the Tegner activity scale preoperatively and subsequently at 6, 12 and 24 months postoperatively. Control MRI was conducted at 6, 12 and 18 months postoperatively. The MRI finding was evaluated using the Magnetic Observation of Cartilage Repair Tissue (MOCART) score. RESULTS The total KOOS score was 44.69 ± 7.71 preoperatively, while postoperatively it gradually increased up to 80.45 ± 8.97 (p < 0.001) at 24 months. The Lysholm score significantly rise from 43.47 ± 11.87 preoperatively to the mean value of 81.60 ± 13.07 (p < 0.001) at 24 months postoperatively. The preoperative Tegner score was 3.53 ± 1.41. At 24 months, there was a statistically significant increase to 5.40 ± 1.70 (p = 0.003). The mean MOCART score at 18 months postoperatively was 74.67 ± 14.08. At the end of the monitored period, a complete filling of the defect site by tissue was achieved in 73.33% patients. A complete integration with adjacent cartilage was seen in 66.67% patients and homogenous structure of newly formed tissue was reported in 80% of patients. DISCUSSION In recent years, cell-free implants (the so-called scaffolds or carriers) have been used ever more frequently in treating localised cartilage defects. Their main effect should consist in helping the cells penetrate the defect site and support new cartilage tissue formation. In order to improve the efficacy of cell-free implants, a new therapeutic technique was developed, combining the microfractures of the base with the use of cell-free scaffold AMIC (Autologous Matrix-Induced Chondrogenesis). Our modification of the original AMIC technique consists in the use of a type I collagen-based scaffold instead of the original collagen membrane constituted by collagen type I and III. Based on the statistical processing of results, the modified AMIC technique has shown a statistically significant improvement compared to the preoperative values of the KOOS questionnaire and all its sub-groups, the Lysholm core and the Tegner activity scale. These good clinical outcomes correlate with the results obtained by other authors using both the original method and the modified AMIC technique. CONCLUSIONS The modified AMIC technique using the cell-free type I collagen-based implant appears to be a safe, accessible and onestage technique to treat localised chondral and osteochondral defects of the knee joint up to the size of 8 cm2. Key words: hyaline cartilage, chondral defect, AMIC, scaffold, knee.

[Management of Osteochondral Lesions of the Ankle Joint by Implantation of Autologous Chondrocytes]. / Lécba osteochondrálních lézí hlezenního kloubu metodou implantace autologních chondrocytu.

UNLABELLED: PUPOSE OF THE STUDY The treatment of osteochondral lesions of weight-bearing joints remains a serious therapeutic challenge, largely due to the minimal ability of articular hyaline cartilage to regenerate. The authors present the long-term clinical and MRI results of treating deep chondral and osteochondral defects of the ankle joint by the method of implantation of autologous chondrocytes in the form of a solid chondrograft. MATERIAL AND METHODS The method of solid chondrograft implantation in the ankle joint was used in our Department from the year 2003. Between 2003 and 2013, this method was used in 31 patients, 16 men and 15 women. Their average age at the time of implantation was 29 years (16 to 50 years). The follow-up period ranged from 16 to 145 months (average, 57 months). The clinical outcome was evaluated using the Mazur questionnaire. At follow-up all patients underwent regular MRI examinations and the results were assessed on the basis of Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) scores. Twelve patients required a second-look arthroscopy. RESULTS A comparison of the Mazur pre-operative scores with those obtained at 1, 2 and 5 years post-operatively showed marked improvement of ankle joint function. The average pre-operative value of 30.0 (based on responses of 31 patients) increased to the average of 89.7 (based on results of 11 patients). At 1 year post-operatively, the average MOCART score for a group of 18 patients was 78.3; at 5 post-operative years, the average value for nine patients examined was 77.0. Complete filling of defects at 1 year of follow-up was found in 88.1% and , at 5 years, it was recorded in 83.3% of the patients examined. DISCUSSION The articular hyaline cartilage is a highly differentiated tissue and its ability of repair is very limited. Therefore every damage to the articular surface should be regarded as a pre-arthritic condition// disease. Currently, there are several options of treating a damaged articular cartilage, but none of them makes its complete healing certain. A lot of studies concerned with longterm results of implanting autologous chondrocytes in the knee are available in the literature, but only few authors present long-term clinical and radiographic outcomes of ankle joint treatment similar to ours. CONCLUSIONS Based on our clinical and MRI results, the method of autologous chondrocyte implantation can be recommended since it has good long-term results, provides repair of articular cartilage and allows for patients' return to activities of daily living. KEY WORDS: chondral defect, hyaline cartilage, autologous chondrocyte, ankle joint.

[Most frequent causes of autologous graft failure in anterior cruciate ligament replacement]. / Nejcastejsí príciny selhání autologních náhrad predního zkrízeného vazu kolenního kloubu.

PURPOSE OF THE STUDY: The aim of this retrospective study was to present a comprehensive overview of the causes of bone-tendon-bone (BTB) autograft failure after primary anterior cruciate ligament (ACL) reconstruction. MATERIAL AnD METHODS: Between 2003 and 2013, we performed revision ACL replacement in 47 patients who had undergone primary BTB autograft ACL reconstruction in other hospitals. The group consisted of 16 women (aged 25 to 48 years) and 31 men (25 to 46 years). Surgery was performed on the right knee in 26 and on the left knee in 21 patients. In each of the 47 patients, two different assessments were made: 1. Analysis of causes of failure based on surgical protocols and/or intra-operative video records taken during most of the procedures. 2. Evaluation of bone tunnel location on lateral knee radiograms, using the method described by Harner for femoral tunnels and that reported by Stäubli and Rauschning for tibial tunnels. RESULTS: The most frequent cause of knee instability, occurring in 51.1% of the patients, was new trauma to the knee. nontraumatic instability in the remaining 48.9% was due to insuffiiency of the graft, and resulted from an incorrect surgical technique (42.5%) or biological causes (6.4%). The most common surgical mistake found was incorrect bone tunnel placement in the tibia or femur, with a malpositioned femoral tunnel being most frequent. This was diagnosed in 32 patients (68.1% of all patients) and, in 17, was the main or major cause of BTB graft failure. DISCUSSION: Based on relevant literature data and our experience, principles for prevention of graft failure after ACL reconstruction can be summarised as follows: 1. harvest of a suffiiently strong BTB autograft 2. accurate anatomical bone tunnel placement 3. appropriate tension of the BTB autograft 4. preventing graft impingement 5. secure graft fiation 6. early functional rehabilitation with an accent on delaying full weight-bearing on the knee (6 to 9 months post-operatively) CONCLUSIONS: New trauma to the knee is the most frequent cause of BTB autograft failure after ACL reconstruction. This can be avoided by participating in a professionally guided rehabilitation programme and not returning to sports activities earlier than 9 months after ACL reconstruction. The most common technical error in ACL reconstruction is non-anatomical tunnel placement in the tibia and femur. Femoral tunnel malposition is most frequent while incorrect tibial tunnel placement, which does not inflence graft failure so much, is less common.