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Autologous Matrix-Induced Chondrogenesis (AMIC) E REVISTA ESPAÑOLA DE ARTROSCOPIA Y CIRUGÍA ARTICULAR Asociación Española de Artroscopia Vol. 28. Issue 1. No. 71. January 2021 ISSN: 2792-2154 (printed) 2792-2162 (online) Monograph: Treatment of chondral ulcers Autologous matrix-induced chondrogenesis (AMIC) E. Sánchez Alepuz1,2,3, J. Part Soriano1,3, I. Peregrin Nevado2,3, J. Zurriaga Carda2,3, J. M. Gómez Alessandri1,3, J. Vicente Díaz2,3, R. Calero Ferrandiz1,3 1 Department of Orthopedic Surgery and Traumatology. Unión de Mutuas. Valencia (Spain) 2 Department of Orthopedic Surgery and Traumatology. IMED Valencia. Burjassot, Valencia (Spain) 3 Grupo de Estudio e Investigación del Cartílago Articular de Valencia (GEICAV) (Spain) Correspondence: Received 8 July 2019 Dr. Joan Part Soriano Accepted 16 October 2020 E-mail: [email protected] Available online: January 2021 ABSTRACT RESUMEN Objective: To analyze the evolution and current status of the au- Condrogénesis inducida por matrices (AMIC) tologous matrix-induced chondrogenesis (AMIC) technique and know its underlying biological principles, as well as the results Objetivo: examinar la evolución y la situación actual de la técni- of its use in treating chondral lesions. ca AMIC y conocer los principios biológicos sobre los que se sus- Method: A literature review is made of the basic science re- tenta, así como los resultados de su utilización en el tratamiento ferred to cartilage injuries, the surgical technique, and clinical de las lesiones condrales. outcomes versus other chondral repair and regeneration tech- Método: se realiza una revisión de la bibliografía sobre la ciencia niques. básica relativa a las lesiones de cartílago, la técnica quirúrgica y Results: According to the published studies, AMIC improves pain los resultados clínicos respecto a otras técnicas de reparación y and the clinical and functional scores, affording better outcomes regeneración condral. than microfracture surgery and with results similar to those of Resultados: en los estudios publicados, la técnica AMIC consi- other repair techniques. gue mejoría del dolor y de las escalas clínicas y funcionales, ob- Conclusions: Matrix-induced chondrogenesis is a safe, techni- teniendo mejores resultados que las microfracturas y similares cally reproducible and effective technique for the treatment of a otras técnicas reparativas. cartilage injuries, with good clinical outcomes for the patients. Conclusiones: la condrogénesis inducida por matrices es una However, long-term studies are needed to assess the evolution técnica segura, técnicamente reproducible y efectiva para el of the results over time. tratamiento de las lesiones de cartílago, con buenos resultados Level of evidence: 5. clínicos para los pacientes. No obstante, hacen falta estudios a Clinical relevance: It is important to know one of the options largo plazo para conocer su evolución con el tiempo. available for the treatment of chondral lesions. Within the range Nivel de evidencia: 5. of existing treatments, AMIC is a relatively novel technique af- Relevancia clínica: es importante conocer una de las opciones fording promising results. de que disponemos para el tratamiento de las lesiones condra- les. Dentro del abanico de tratamientos que existen, la técnica AMIC es relativamente novedosa y con resultados prometedores. Key words: Chondrogenesis. AMIC. Chondral lesion. Matrix, scaf- Palabras clave: Condrogénesis. AMIC. Lesión condral. Matriz. Re- fold. Chondral repair. paración condral. https://doi.org/10.24129/j.reacae.28171.fs1907031 FS © 2021 Fundación Española de Artroscopia. Published by Imaidea Interactiva in FONDOSCIENCE® (www.fondoscience.com). This is an Open Access article under license CC BY-NC-ND (www.creativecommons.org/licenses/by-nc-nd/4.0/). Rev Esp Artrosc Cir Articul. 2021;28(1):27-35 27 Autologous matrix-induced chondrogenesis (AMIC) Introduction Behrens(14,15) introduced autologous matrix-induced chondrogenesis (AMIC) - a technique that combines mi- The treatment of joint cartilage defects constitutes one crofractures with the application of a biodegradable type of the main challenges in current orthopedic surgery. The I/III collagen membrane that stabilizes and protects the reported incidence of chondral lesions among individuals clot formed by the microfractures. The matrix or scaffold between 40-50 years of age is 60%(1). These defects give is affixed to the cartilage defect by means of sutures or rise to alterations that may result in considerable pain and fibrin glue. This procedure can be carried out via a miniar- functional limitation, and moreover pose a risk of oste- throtomy or adopting a fully arthroscopic approach, and oarthrosis over the long term(2,3). In addition, it has been moreover offers the advantage of requiring a single sur- seen that such patients present clinical situations similar gical step. to those of individuals with osteoarthrosis in wait of total In recent years there has been an increase in the num- knee replacement surgery, with even poorer clinical scores ber of AMIC-like procedures, with variations in the surgical than those in wait of anterior cruciate ligament reconstruc- technique and type of matrix employed. There are prom- tion(4). All this is attributable to the high specialization of ising lines of research on the addition of growth factors to cartilage tissue, allowing correct load transmission and af- the matrix, resulting in selective recruitment and stimula- fording a uniform joint contact surface. Nevertheless, repair tion of the mesenchymal cells(16-18). Such factors moreover potential is very limited, due to the avascular nature and could activate the chondrocytes surrounding the healthy low mitotic activity of the chondrocytes(5). cartilage to fill the osteochondral defect. The purpose of The aim of most treatments is to create a congruent the present study was to review the underlying biological joint surface with competent biomechanical properties, principles, the surgical technique, and the current clinical restore joint function, and prevent degeneration to oste- status of matrix-induced chondrogenesis. oarthrosis. Such surgical treatment methods include re- pair techniques, regenerative procedures and palliative techniques(6). Repair techniques involve the use of tissue Basic science histologically different from cartilage, while regenerative procedures are characterized by complete replacement of Mesenchymal stem cells, MSC, are progenitor cells found the damaged tissue, maintaining the same architecture in a great variety of adult tissues, including the bone and biomechanical properties. marrow(19). These cells are able to differentiate towards The repair techniques include bone marrow stimula- the formation of mesodermal tissues, including carti- tion strategies, which have been in use since 1959, when lage, bone and adipose tissue(20). In order for this to occur, Pridie(7) introduced subchondral perforation surgery. This however, correct interaction among the MSCs, the extra- technique was subsequently improved upon by Stead- cellular matrix (ECM) proteins and growth factors (GFs) is man(8) with microfracture surgery, in which motor-driven essential(21). Tallheden(22) observed that MSCs from microf- perforation was eliminated in order to avoid heat-induced ractures exhibited the same phenotypic plasticity as the necrosis. This technique exposes the chondral lesions to chondrogenic cells of the basal substrate. Kramer in turn mesenchymal stromal cells ( MSCs) from the bone marrow. demonstrated that collagen matrixes satisfactorily house This exposure to cells and growth factors forms a clot that the cells from the bone marrow, since he was able to iso- induces lesion repair(9). An important element introduced late MSCs from the matrixes(23). by Steadman is the correct preparation of the damaged An ideal matrix is able to imitate the biology, architec- zone through curettage of the calcified cartilage layer and ture and mechanical properties of native cartilage, with removal of all the pathological cartilage tissue to the tran- sufficient structural strength to support the mechanical re- sition to healthy cartilage, in order to secure a bed better quirements of the joint. It must prove stable in the tissue able to accommodate the mentioned clot. environment and allow cell migration and adhesion, as well At present, the nanofracture technique has been de- as proliferation and differentiation. Furthermore, the mate- veloped thanks to improved understanding of the archi- rial must be biodegradable and undergo remodelling while tecture and function of subchondral bone. The mentioned the new cartilage is formed and replaces the original struc- technique uses a smaller diameter needle allowing better ture, without releasing harmful degradation products and penetration of the subchondral bone, without compact- without stimulating an inflammatory response that could ing the margins of the perforations. This favours greater prove negative for tissue regeneration(24,25). preservation of the trabecular structure, with posterior Although the AMIC technique was originally described remodelling more similar to native subchondral bone(10,11). with the use of a type I/III collagen membrane(15) (Chon- In addition, in vivo studies have shown that the histologi- dro-Gide®, Geistlich Biomaterials, Wolhausen, Switzer- cal qualities of the cartilage obtained are more similar to land), different matrixes comprising different materials hyaline cartilage than those resulting from microfracture have been used for this procedure.
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