Whole joint MRI assessment of surgical cartilage repair of the knee: cartilage repair osteoarthritis knee score (CROAKS).

OBJECTIVE: To develop a magnetic resonance imaging (MRI) scoring system for follow-up of knee cartilage repair procedures integrating assessment of the repair site and the whole joint called Cartilage Repair OsteoArthritis Knee Score (CROAKS), and to assess its reliability. DESIGN: MRI examinations of 20 patients that had undergone matrix-associated autologous chondrocyte transplantation (MACT) of the knee 12 months before were semi-quantitatively assessed for the repair site using features of the magnetic resonance observation of cartilage repair tissue (MOCART) system and for the whole joint based on experiences with the MRI Osteoarthritis Knee Score (MOAKS) instrument. Intra- and inter-observer reliability was calculated using weighted (w) kappa statistics for plates (medial/lateral tibia, medial/lateral femur, trochlea, patella), compartments (medial tibio-femoral, lateral tibio-femoral, patello-femoral) and the whole joint. For certain features with low prevalence the overall percent agreement was calculated in addition. RESULTS: For cartilage, reliability on a plate level ranged between 0.48 (lateral femur) and 1.00 (medial femur). BML assessment showed comparable results ranging on a plate level between 0.46 and 1.00 with overall percent agreement between 83.3% and 100%. Meniscal morphology assessment ranged between 0.62 and 0.94. For repair site assessment reliability ranged from 0.41 (signal intensity inter-observer) to 1.00 (several features). Overall percent agreement was above 80% for 17 of 22 features assessed (intra- and inter-observer results combined). CONCLUSIONS: Combined scoring of the repair site and whole joint assessment for common osteoarthritis features using CROAKS, which is based on experience with two established semi-quantitative scoring tools, is feasible and may be performed with good to excellent reliability.

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.

In vivo evaluation of biomechanical properties in the patellofemoral joint after matrix-associated autologous chondrocyte transplantation by means of quantitative T2 MRI.

PURPOSE: To determine in vivo biomechanical properties of articular cartilage and cartilage repair tissue of the patella, using biochemical MRI by means of quantitative T2 mapping. METHODS: Twenty MR scans were achieved at 3T MRI, using a new 8-channel multi-function coil allowing controlled bending of the knee. Multi-echo spin-echo T2 mapping was prepared in healthy volunteers and in age- and sex-matched patients after matrix-associated autologous chondrocyte transplantation (MACT) of the patella. MRI was performed at 0° and 45° of flexion of the knee after 0 min and after 1 h. A semi-automatic region-of-interest analysis was performed for the whole patella cartilage. To allow stratification with regard to the anatomical (collagen) structure, further subregional analysis was carried out (deep-middle-superficial cartilage layer). Statistical analysis of variance was performed. RESULTS: During 0° flexion (decompression), full-thickness T2 values showed no significant difference between volunteers (43 ms) and patients (41 ms). Stratification was more pronounced for healthy cartilage compared to cartilage repair tissue. During 45° flexion (compression), full-thickness T2 values within volunteers were significantly increased (54 ms) compared to patients (44 ms) (p < 0.001). Again, stratification was more pronounced in volunteers compared to patients. The volunteer group showed no significant increase in T2 values measured in straight position and in bended position. There was no significant difference between the 0- and the 60-min MRI examination. T2 values in the patient group increased between the 0- and the 60-min examination. However, the increase was only significant in the superior cartilage layer of the straight position (p = 0.021). CONCLUSION: During compression (at 45° flexion), healthy patellar cartilage showed a significant increase in T2-values, indicating adaptations of water content and collagen fibril orientation to mechanical load. This could not be observed within the patella cartilage after cartilage repair (MACT) of the patella, most obvious due to a lack of biomechanical adjustment. LEVEL OF EVIDENCE: III.

[Post-treatment rehabilitation after autologous chondrocyte implantation: State of the art and recommendations of the Clinical Tissue Regeneration Study Group of the German Society for Accident Surgery and the German Society for Orthopedics and Orthopedic Surgery]. / Nachbehandlung bei der autologen Chondrozytentransplantation: Eine Bestandsaufnahme und Empfehlung der AG Klinische Geweberegeneration der DGU/DGOOC.

BACKGROUND: Over the course of the past two decades autologous chondrocyte implantation (ACI) has become an important surgical technique for treating large cartilage defects. The original method using a periostal flap has been improved by using cell-seeded scaffolds for implantation, the matrix-based autologous chondrocyte implantation (mb-ACI) procedure. MATERIAL AND METHODS: Uniform nationwide guidelines for post-ACI rehabilitation do not exist. A survey was conducted among the members of the clinical tissue regeneration study group concerning the current rehabilitation protocols and the members of the study group published recommendations for postoperative rehabilitation and treatment after ACI based on the results of this survey. RESULTS: There was agreement on fundamentals concerning a location-specific rehabilitation protocol (femoral condyle vs. patellofemoral joint). With regard to weight bearing and range of motion a variety of different protocols exist. Similar to this total agreement on the role of magnetic resonance imaging (MRI) for postsurgical care was found but again a great variety of different protocols exist. CONCLUSIONS: This manuscript summarizes the recommendations of the members of the German clinical tissue regeneration study group on postsurgical rehabilitation and MRI assessment after ACI (level IVb/EBM).

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.

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.

Signal transduction and metabolism in chondrocytes is modulated by lactoferrin.

OBJECTIVE: Activation of granulocytes causes a considerable rise in the concentration of lactoferrin (Lf) in synovial fluid (SF). We here investigate consequences thereof on signal transduction and the balance between catabolic and anabolic metabolism in chondrocytes. METHODS: Signal transduction was analysed in cultured chondrocytes by immunodetection of mitogen activated protein kinases (MAPK) and analysis of Smad2 translocation to the nucleus. Expression levels of matrix metalloproteinases (MMPs) and of aggrecan were measured by reverse-transcription-PCR. The proteolytic activity of MMPs was ascertained by zymography. Expression of the low-density-lipoprotein-receptor-related-protein-1 (LRP-1), a Lf receptor for signalling, was assayed by immunohistochemistry in cartilage and in cultured chondrocytes by immunoblotting. RESULTS: We found LRP-1 expressed in dedifferentiated chondrocytes in culture and in cartilage tissue preferentially on the articular surface where it can encounter Lf within SF. Lf stimulated proliferation of chondrocytes, comparable to transforming growth factor-beta1 (TGFbeta1) and activated p38 and the extracellular-signal regulated-kinases 1/2 (ERK1/2) within minutes. Surprisingly, Lf induced nuclear Smad2 translocation, a signal pathway ascribed to TGFbeta receptor activation. Lf significantly increased the levels of catabolic indicators such as MMP1, MMP2, MMP3 and MMP13 and inhibited aggrecan synthesis. CONCLUSION: Lf is a robust regulator of chondrocyte metabolism, comparable to TGFbeta1. The catabolic influence together with the proliferative stimulus indicates a function as an early phase cytokine, enhancing MMPs, necessary for degradation of damaged tissue and stimulating proliferation of chondrocytes, necessary for reconstruction.

Multimodal approach in the use of clinical scoring, morphological MRI and biochemical T2-mapping and diffusion-weighted imaging in their ability to assess differences between cartilage repair tissue after microfracture therapy and matrix-associated autologous chondrocyte transplantation: a pilot study.

OBJECTIVE: The aim of the present pilot study is to show initial results of a multimodal approach using clinical scoring, morphological magnetic resonance imaging (MRI) and biochemical T2-relaxation and diffusion-weighted imaging (DWI) in their ability to assess differences between cartilage repair tissue after microfracture therapy (MFX) and matrix-associated autologous chondrocyte transplantation (MACT). METHOD: Twenty patients were cross-sectionally evaluated at different post-operative intervals from 12 to 63 months after MFX and 12-59 months after MACT. The two groups were matched by age (MFX: 36.0+/-10.4 years; MACT: 35.1+/-7.7 years) and post-operative interval (MFX: 32.6+/-16.7 months; MACT: 31.7+/-18.3 months). After clinical evaluation using the Lysholm score, 3T-MRI was performed obtaining the MR observation of cartilage repair tissue (MOCART) score as well as T2-mapping and DWI for multi-parametric MRI. Quantitative T2-relaxation was achieved using a multi-echo spin-echo sequence; semi-quantitative diffusion-quotient (signal intensity without diffusion-weighting divided by signal intensity with diffusion weighting) was prepared by a partially balanced, steady-state gradient-echo pulse sequence. RESULTS: No differences in Lysholm (P=0.420) or MOCART (P=0.209) score were observed between MFX and MACT. T2-mapping showed lower T2 values after MFX compared to MACT (P=0.039). DWI distinguished between healthy cartilage and cartilage repair tissue in both procedures (MFX: P=0.001; MACT: P=0.007). Correlations were found between the Lysholm and the MOCART score (Pearson: 0.484; P=0.031), between the Lysholm score and DWI (Pearson:-0.557; P=0.011) and a trend between the Lysholm score and T2 (Person: 0.304; P=0.193). CONCLUSION: Using T2-mapping and DWI, additional information could be gained compared to clinical scoring or morphological MRI. In combination clinical, MR-morphological and MR-biochemical parameters can be seen as a promising multimodal tool in the follow-up of cartilage repair.

[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.

Matrix-based autologous chondrocyte implantation for cartilage repair with HyalograftC: two-year follow-up by magnetic resonance imaging.

OBJECTIVE: Monitoring of articular cartilage repair after matrix-associated autologous chondrocyte implantation with HyalograftC by a new grading system based on non-invasive high-resolution magnetic resonance imaging. PATIENTS AND METHODS: In 23 patients, postoperative magnetic resonance imaging (MRI) was performed between 76 and 120 weeks. In nine of these patients, five MRI examinations were performed at 4, 12, 24, 52 and 104 weeks after HyalograftC implant. The repair tissue was described with separate variables: degree of defect repair in width and length, signal intensity of the repair tissue and status of the subchondral bone. For these variables a grading system with point scale evaluation was applied. CONCLUSION: High-resolution MRI provides a non-invasive tool for monitoring the development of cartilage repair tissue following HyalograftC technology, shows a good correlation with clinical outcome and may help to differentiate abnormal repair tissue from a normal maturation process.

Autologous chondrocyte implantation (ACI) for cartilage defects of the knee: A guideline by the working group "Clinical Tissue Regeneration" of the German Society of Orthopaedics and Trauma (DGOU).

BACKGROUND: Autologous chondrocyte implantation (ACI) is an established and well-accepted procedure for the treatment of localised full-thickness cartilage defects of the knee. METHODS: The present review of the working group "Clinical Tissue Regeneration" of the German Society of Orthopaedics and Trauma (DGOU) describes the biology and function of healthy articular cartilage, the present state of knowledge concerning therapeutic consequences of primary cartilage lesions and the suitable indication for ACI. RESULTS: Based on best available scientific evidence, an indication for ACI is given for symptomatic cartilage defects starting from defect sizes of more than three to four square centimetres; in the case of young and active sports patients at 2.5cm(2), while advanced degenerative joint disease needs to be considered as the most important contraindication. CONCLUSION: The present review gives a concise overview on important scientific background and the results of clinical studies and discusses the advantages and disadvantages of ACI. LEVEL OF EVIDENCE: Non-systematic Review.

Impact of high field (3.0 T) magnetic resonance imaging on diagnosis of osteochondral defects in the ankle joint.

OBJECTIVE: To evaluate high field magnetic resonance (MR) imaging for imaging of osteochondral defects. MATERIALS AND METHODS: Nine osteochondral defects were simulated in three cadaveric talus specimens using a diamond drill. All specimens were examined on a 1.0 T MR unit and a 3.0 T MR unit. A T2-weighted turbo spin-echo (TSE) sequence with a 2 mm slice thickness and a 256 x 256 matrix size was used on both scanners. The visibility of the osteochondral separation and the presence of susceptibility artifacts at the drilling bores were scored on all images. RESULTS: Compared to the 1.0 T MR unit, the protocol on the 3.0 T MR unit allowed a better delineation of the disruption of the articular cartilage and a better demarcation of the subchondral defect. Differences regarding the visualization of the subchondral defect were found to be statistically significant (P<0.05). Differences with regard to susceptibility artifacts at the drilling bores were not statistically significant (P>0.05). The average SNR was higher using 3.0 T MRI (SNR=12), compared to 1.0 T MRI (SNR=7). CONCLUSION: High field MRI enables the acquisition of images with sufficient resolution and higher SNR and has therefore the potential to improve the staging of osteochondral defects.

[The German Cartilage Registry (KnorpelRegister DGOU) for evaluation of surgical treatment for cartilage defects: experience after six months including first demographic data]. / Das KnorpelRegister DGOU zur Erfassung von Behandlungsergebnissen nach Knorpeloperationen: Erfahrungen nach 6 Monaten und erste epidemiologische Daten.

The German Cartilage Registry (KnorpelRegister DGOU) has been introduced in October 2013 and aims on the evaluation of patients who underwent cartilage repair for symptomatic cartilage defects. It represents a nation-wide cohort study which has been introduced by the working group "Tissue Regeneration" of the Germany Society of Orthopaedic Surgery and Traumatology and is technically based upon a web-based remote data entry (RDE) system. The present article describes first experiences with the registry including patient and treatment characteristics. Between October 2013 and April 2014, a total of 230 patients who had undergone surgical cartilage repair for symptomatic full-thickness cartilage defects of the knee has been included in the German Cartilage Registry from 23 cartilage repair centres. Mean age was 37.11 years (SD 13.61) and mean defect size was 3.68 cm(2) (SD 0.23). Since the introduction of the KnorpelRegister DGOU the total number of registered patients has increased steadily up to the most recent figure of 72 patients within one month. Patients were treated mainly according to the recommended therapies. The highest percentage in therapy is represented by the bone marrow stimulation techniques (55.02 %) as well as by the autologous chondrocyte transplantation (34.92 %). Unlike the patient collective in the majority of prospective randomised controlled trials, the patient population within the registry shows a high proportion of patients with accompanying pathologies, with an age of more than 50 years at the time of treatment and with unfavourably assessed accompanying pathologies such as an affection of the opposite cartilage surface or a previously resected meniscus. In summary, the technical platform and forms of documentation of the KnorpelRegister DGOU have proved to be very promising within the first six months. Unlike data from other clinical trials, the previous analysis of the patients' data and therapies reflects successfully the actual medical care situation of patients with cartilage defects of the knee joint. This analysis also provides new information on subgroups of patients that have not yet been recorded in the scientific literature. This will be part of the first analysis of clinical treatment data. An expansion of the KnorpelRegister DGOU to patients with cartilage defects of the ankle and hip joints is already decided upon and initialised.

Biocompatibility of polyethylene terephthalate (Trevira hochfest) augmentation device in repair of the anterior cruciate ligament.

The biocompatibility of a 3 mm band made of polyethylene terephthalate (Trevira hochfest) has been tested in an experimental study within right knee joints of 60 sheep. After transsecting the anterior cruciate ligament (ACL), two randomized groups were formed. In group I, the ACL was repaired according to the Marshall technique whilst in group II an additional 3 mm polyethylene terephthalate (PET) augmentation band was implanted using the through-the-condyle (TTC) procedure. To assess the biocompatibility of the augmentation device the knee joints of both groups were punctured and the synovial fluids were analyzed before, as well as 2, 6, 16, 26, and 52 weeks after the operation. In addition, the histologic appearance of excised suprapatellar pouches and ipsilateral inguinal and popliteal lymphatic noduli were examined. Comparing both groups no significant differences were found neither before nor after the augmented and non-augmented ACL repair. No pathological increase in the total protein concentration occurred after operation and no significant differences versus the preoperative analysis were found. No synovitis signalling a decrease in the glucose concentration was observed. The cytological examination revealed no increase of the leukocyte cell count results. Within the synovial specimen neither free nor phagocytosed PET wearparticles could be detected. In groups I and II the histological appearance of excised popliteal and inguinal lymphatic noduli showed a normal result. In 25% of the PET augmented ACL repairs, a slight concentration of PET wearparticles and solitary, multinuclear giant foreign body cells could be seen in the histological preparations of suprapatellar pouches.

Changes in the ratio of type-I and type-II collagen expression during monolayer culture of human chondrocytes.

We compared the changes in the ratio of type-I and type-II collagen in monolayer cultures of human articular chondrocytes (HAC). HAC were isolated from samples of cartilage from normal joints and cultivated in monolayer for up to 46 days. Expression of collagen type-I and type-II was determined by immunocytochemistry, Western blotting, and the nested reverse transcription polymerase chain reaction (RT-PCR), and quantified by real-time PCR. The transition from a spherical morphology to the flattened morphology of an anchorage-dependent culture was accompanied by a rapid change in the collagen phenotype with the replacement of collagen type II by collagen type I. This was confirmed by immunocytochemistry and Western blotting between days 21 and 28. Using techniques for the analysis of gene transcription (nested RT-PCR and real-time PCR), a complete switch of collagen gene expression was not observed. Expression of collagen type I increased 100-fold during the culture time. That of collagen type II was found during the entire period and decreased more than 100-fold. The main finding was that expression of the genes encoding collagen type I and II was highly time-dependent and the ratio of collagen type II to I (CII/CI), defined as an index of cell differentiation, was significantly higher (215- to 480-fold) at the beginning of the culture. At the end of the experimental culture time, ratios between 0.1 and 1 were reached.

Collagen expression in tissue engineered cartilage of aged human articular chondrocytes in a rotating bioreactor.

This study describes the culture and three-dimensional assembly of aged human articular chondrocytes under controlled oxygenation and low shear stress in a rotating-wall vessel. Chondrocytes cultured in monolayer were released and placed without any scaffold as a single cell suspension in a rotating bioreactor for 12 weeks. Samples were analyzed with immunohistochemistry, molecular biology and electron microscopy. During serial monolayer cultures chondrocytes dedifferentiated to a "fibroblast-like" structure and produced predominantly collagen type I. When these dedifferentiated cells were transferred to the rotating bioreactor, the cells showed a spontaneous aggregation and formation of solid tissue during the culture time. Expression of collagen type II and other components critical for the extracellular cartilage matrix could be detected. Transmission electron microscopy revealed a fine network of randomly distributed collagen fibrils. This rotating bioreactor proves to be a useful tool for providing an environment that enables dedifferentiated chondrocytes to redifferentiate and produce a cartilage-specific extracellular matrix.

[Meniscus lesions after isolated anterior cruciate ligament rupture]. / Meniskusläsionen nach isolierter vorderer Kreuzbandruptur.

In this retrospective study the meniscal status of 34 patients with untreated complete anterior cruciate ligament (ACL) tears is reported. The anterior cruciate ligament injury was initially documented by examination under anesthesia and arthroscopy. Treatment in all cases consisted of a standard protocol of early rehabilitation and bracing. The mean follow-up was 7.3 years. Twenty-two (65%) patients showed signs of meniscal pathology at an average of 2.5 years after the ACL injury during the follow-up period. Rearthroscopy was performed and showed a higher incidence of medial meniscus tears (53%) than lesions of the lateral meniscus (41%). The most common tear of the medial meniscus was the bucket-handle type, followed by the flap tear and the single longitudinal split of the posterior horn. Secondary reconstruction of the ACL was necessary in 18 patients (82%) complaining of symptoms indicative of permanent anterior instability of the knee. The remaining 4 patients had rearthroscopy 3.5 years after the ACL injury and a partial meniscectomy and ACL reconstruction was performed. 12 patients (35%) had no symptoms or signs of joint instability or meniscal pathology during the follow-up period, but discontinued their sporting activities. This study indicates the increasing incidence of meniscal tears during ACL insufficiency. We recommend that patients with ruptures of the anterior cruciate ligament should be investigated for meniscal tears and that early ligament reconstruction of the knee and meniscal repair or partial meniscectomy should be considered simultaneously.

[Biocompatibility of polyethylene terephthalate--PET--(Trevira strong)--an in vivo study of the sheep knee]. / Die Biokompatibilität von Polyäthylenterephthalat--PET--(Trevira hochfest)--eine In-vivo-Studie am Schafknie.

The anterior cruciate ligament was transected at the femoral origin in the right stifle joint of 25 sheep. The ligaments were re-inserted using the Marshall technique, and reinforced with a 3 mm band made of polyethylene terephthalate--PET--(Trevira hochfest) using the through-the-condyle (TTC) procedure, and re-attached--with a preload of 20 N--to the femoral and tibial condyle with two 4 mm staples. To assess the biocompatibility of the augmentation band, the synovial fluid was analysed for total protein and glucose concentration 2, 6, 24, and 56 weeks after implantation, and a total and differential cell count performed. No significant differences were found before and after implantation of the PET band. No pathological increase in the total protein concentration occurred after implantation (normal range: > 3.0 g/dl), and no significant differences vs. the preoperative analysis were found. No synovitis-signalling decrease in the glucose concentration (normal range: > 40 mg/dl) was observed. The preoperative glucose concentration of 87 +/- 12.84 mg/dl showed no significant difference from the postoperative concentration of 95 +/- 13.58 mg/dl. The cytological examination revealed no increase in the leucocyte counts (normal range: 3 leucocytes/HPF). Neither free nor phagocytosed wear particles were seen.

Equine articular chondrocytes on MACT scaffolds for cartilage defect treatment.

Treatment of cartilage defects poses challenging problems in human and veterinary medicine, especially in horses. This study examines the suitability of applying scaffold materials similar to those used for human cartilage regeneration on equine chondrocytes. Chondrocytes gained from biopsies of the talocrural joint of three horses were propagated in 2D culture and grown on two different scaffold materials, hyaluronan (HYAFF®) and collagen (BioGide®), and evaluated by light and electron microscopy. The equine chondrocytes developed well in both types of materials. They were vital and physiologically highly active. On the surface of the scaffolds, they formed cell multilayers. Inside the hyaluronan web, the chondrocytes were regularly distributed and spanned the large scaffold fibre distances by producing their own matrix sheath. Half-circle-like depressions occasionally found in the cell membrane were probably related to movement on the flexible matrix sheath. Inside the dense collagen scaffold, only single cells were found. They passed through the scaffold strands by cell shape adaptation. This study showed that the examined scaffold materials can be used for equine chondrocyte cultivation. Chondrocytes tend to form multilayers on the surface of both, very dense and very porous scaffolds, and have strategies to span between and move in large gaps.

[Autologous chondrocyte implantation (ACI) for cartilage defects of the knee: a guideline by the working group "Tissue Regeneration" of the German Society of Orthopaedic Surgery and Traumatology (DGOU)]. / Stellenwert der autologen Chondrozytentransplantation (ACT) in der Behandlung von Knorpelschäden des Kniegelenks - Empfehlungen der AG Klinische Geweberegeneration der DGOU.

Autologous chondrocyte transplantation/implantation (ACT/ACI) is an established and recognised procedure for the treatment of localised full-thickness cartilage defects of the knee. The present review of the working group "Clinical Tissue Regeneration" of the German Society of Orthopaedics and Traumatology (DGOU) describes the biology and function of healthy articular cartilage, the present state of knowledge concerning potential consequences of primary cartilage lesions and the suitable indication for ACI. Based on current evidence, an indication for ACI is given for symptomatic cartilage defects starting from defect sizes of more than 3-4 cm2; in the case of young and active sports patients at 2.5 cm2. Advanced degenerative joint disease is the single most important contraindication. The review gives a concise overview on important scientific background, the results of clinical studies and discusses advantages and disadvantages of ACI.