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ICL #1: Tissue Engineering of Cartilage for Clinical Defects Monday, April 4, 2005 • Great Hall 4, 5, 6

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ICL #1: Tissue Engineering of Cartilage for Clinical Defects Monday, April 4, 2005 • Great Hall 4, 5, 6 ICL #1: Tissue Engineering of Cartilage for Clinical Defects Monday, April 4, 2005 • Great Hall 4, 5, 6 Chair: Mitsuo Ochi, MD, PhD Faculty: Karl Almqvist, MD, PhD, Christoph Erggelet, MD, PhD, Maurilio Marcacci, MD TISSUE ENGINEERING OF CARTILAGE: CHONDRAL LESION 2nd GENERATION AUTOLOGOUS 63% INCIDENCE IN 31516 ARTHROSCOPIES CHONDROCYTE TRANSPLANTATION 9 20% grade IV 9 35% no associated lesions M. MARCACCI E. KON, S. ZAFFAGNINI Orthopaedics and Sports Traumatology Department University of Bologna Rizzoli Orthopaedic Institute, Italy Curl 97 OBJECTIVES ACI CLINICAL RESULTS AUTOLOGOUS CHONDROCYTE FIRST GENERATION SECOND GENERATION TRANSPLANTATION ON 3D SCAFFOLD (MATRIX) 9 5- 10 YEAR F-UP 9 1- 2 YEAR FOLLOW-UP 9 82% SATISFACTORY 9 90% SATISFACTORY PURPOSE RESULTS RESULTS 9 67% HYALINE LIKE 9 85% HYALINE LIKE TISSUE CARTILAGE - TO REDUCE IMPLANT MORBIDITY 9 72% NORMAL 9 BIOMECHANICS? - TO AVOID PERIOSTEAL FLAP USE BIOMECHANICS 9 OPEN SURGERY- 9ARTHROSCOPIC IMPLANT - TO ENHANCE CELL PROLIFERATION 9 PERIOSTEAL FLAP 9 NO PERIOSTEAL FLAP AND MATURATION Peterson 2002 Marcacci, Zaffagnini, Kon 2003 MATERIALS AND METHODS DEVELOPMENT OF ARTHROSCOPIC HYALURONIC ACID SCAFFOLD IMPLANT TECHNIQUE OPTIMAL SUPPORT FOR ANIMAL STUDIES DEFECT TREATED WITH HYAFF + CONDROCYTES CELL CARTILAGE VS RE-DIFFERENTATION MATRIX HYAFF ALONE AND ADHESION DEPOSITION TO HYAFF FIBER BETTER REGENERATED TISSUE Grigolo, Biomat. 2002 Solchaga, J.Orthop.Res,2000 Brun, J.Biomed.Mat.Res. 1999 Aigner, J.biomed.Mat.Res. 1998 MARCACCI et al. Knee Surg. Sport Arth. 2002 1 RESULTS RESULTS MATERIALS METHODS AND 100 125 PATIENTS OPERATED BY ARTHROSCOPIC TECHNIQUE 20 40 60 80 0 Follow-up months IKDC: CL 1 INICAL EVALUATION (ICRS) 39,2 24 months24 months 36 Mann-Whitney; p=0,039 FROM 2000 ARE PROSPECTIVELY EVALUATED Mean Score 100 26,9 6 10 20 30 40 50 60 70 80 90 CLINICAL EVA MEAN SUBJECTIVE IKDC IMPROVEMENT LUATION 0 35 patientsmonths at 24and36 follow up (ICRS) AGE 91 PATIENTS FOLLOW UP FOLLOW 12 MONTHS ACHIEVED Subjective Knee Evaluation 41.4 Pre-op. 12 CLINICAL EVALUATION 44,2 ± (ICRS) 14.0 MRI + ARTHROSCOPY 28,5 24 months Follow-up 72.5 100 20 40 60 80 over 30 under 30 0 58 PATIENTS ± 24 MONTHS FOLLOW UP FOLLOW 19.5 ACHIEVED 24 months 36 months 30 24 CLINICAL EVALUATION 39,9 ACTIVITY (ICRS) Mann-Whitney; p=0,026 MRI + ARTHROSCOPY 36 months Follow-up 84.7 31 ± 47,5 16.9 35 PATIENTS 36 MONTHS MONTHS 36 FOLLOW UP FOLLOW ACHIEVED level of Sport Competitive or High Sport Amateur or no 36 CLINICAL EVALUATION (ICRS) MRI + ARTHROSCOPY RESULTS RESULTS RESULTS % 24 condyles medial Symptomatic Patients Patients Symptomatic 10 20 30 40 2 trochlea 9 condyle lateral 0 IKDC: Normal Improved patients: 91.7 % IKDC: 28 (according toICRS guidelines) Normal / Nearly Normal: 88,2 % BIOPSY EVALUATION Nearly Normal Mean Score 2 100 Pre-op Follow-up 10 20 30 40 50 60 70 80 90 Subjective Knee Evaluation 35 patients at 36 months follow up follow months 36 at patients 35 0 35 patients at 36 months follow up follow months 36 at patients 35 Objective Knee Evaluation 16 41.4 Pre-op. Follow-up ± 70 BIOPSIES 17 14.0 Abnormal 84.7 27 MEAN SIZE 2,7 cm² 2,7 SIZE MEAN Mean improvement 88% ± UniversityBristol, of UK 16.9 Asymptomatic Patients Asymptomatic Prof. A (1,4-4,3 cm²) 6 Severely Abnormal . Hollander 2 42 2 RESULTS RESULTS TOTAL ANALYSIS ASYMPTOMATIC PATIENTS 70 BIOPSIES 42 BIOPSIES MEAN FOLLOW UP: 14.5 months 100% 100% 10.9 30.7 80% 80% 52.9 53.6 Fibrocartilage 89.1 Fibrocartilage 60% 60% Mixed tissue Mixed tissue 40% 40% 69.3 Hyaline Hyaline 20% 47.1 20% 46.4 0% 0% ≤ 18 months > 18 months ≤ 18 months > 18 months n=56 n=14 n=5 n=37 DISCUSSION Example Classification: Hyaline 36 months HYALOGRAFT C ADVANTAGES Istology Immunohistochemistry Polarized light 9 EXCELLENT HANDLING PROPERTIES 9 NO PERIOSTEAL FLAP REQUIRED 9 SUITABLE FOR LARGE DEFECTS 9 CAN BE APPLIED BY MINI-OPEN OR (H&E) (collagene I) ARTHROSCOPIC TECHNIQUE Proteoglycans Immunohistochemistry Biochemical 9 analysis REDUCED SURGICAL AND RECOVERY TIME Collagen I : 5.5 % 9 NO SURGICAL OR GRAFT RELATED Collagen II: 50.5 % COMPLICATIONS GAGs: 11.8 % 9 GOOD HYSTOLOGICAL RESULTS (% dry weight) (safranin O) (collagene II) FUTURE DEVELOPMENT FUTURE DEVELOPMENT 9 GROWTH FACTORS / GENETHERAPY 9 CELLS 9 MECHANICAL CONDITIONING 9 NEW CELL CULTURING TECNOLOGIES 9 RANDOMIZED CLINICAL STUDIES 9 MATRIX 9 COLLAGEN 9 HYALURONAN 9 FIBRIN 9 PLA, PGA, PLGA OSTEOCHONDRAL ARTICULAR 9 HYALURONIAN+HA RECONSTRUCTION? 3 Rizzoli Orthopaedic Institute, Bologna 4 ICL #2: Current Concepts in Posterolateral Instability of the Knee Monday, April 4, 2005 • Grand Ballroom West Chair: Robert LaPrade, MD, PhD Faculty: Lars Engebretsen, MD, PhD, Steinar Johansen, MD and Fred Wentorf, MD NOTES I. Introduction/Incidence A. Mechanism 1. Hyperextension 2. Varus blow 3. Noncontact twisting B. Incidence 1. 6-11% MRI studies 2. Previous underestimated C. Importance 1. Do not heal 2. Lead to residual instability/DJD 3. Compromise cruciate ligament reconstructions II. Applied Anatomy of the Posterolateral Knee (LaPrade) A. Fibular Collateral Ligament (FCL) 1. Primary stabilizer to varus opening 2. Femoral attachment - proximal/ posterior to lateral epicondyle 3. Fibular attachment - midway along lateral fibular head B. Popliteus Complex 1. Important stabilizer to posterolateral rotation of the knee 2. Popliteus tendon • 18.5 mm from FCL attachment on femur • attaches on anterior fifth of popliteal sulcus • anterior to FCL attachment • important static and dynamic stabilizer 3. Popliteofibular Ligament (PFL) • originates at popliteus musculo- tendinous junction • attaches to medial aspect of posterior fibular styloid (posterior division) and anterior medial downslope of styloid (anterior division) • important static stabilizer of external rotation C. Mid-Third Lateral Capsular Ligament 1. Secondary stabilizer to varus opening 2. Thickening of lateral midline capsule - equivalent to “deep MCL" 3. Meniscotibial portion - frequently injured. Site of Segond fracture and soft-tissue Segond injuries. D. Biceps Femoris Complex 1. Two heads - through attachments to capsule, FCL, tibia, and fibula - help to dynamically stabilize the lateral com- partment of the knee 2. Short Head Biceps Femoris • 5 components at the knee • main attachments are to fibular styloid, posterolateral capsule, and an anterior tibial arm 3. Long Head Biceps Femoris • 5 components at the knee • main attachments are to fibular styloid • biceps bursa – landmark for FCL attachment III. Diagnosis of Posterolateral Knee Complex (PLC) Injuries (LaPrade) A. History 1. Usually due to varus or hyperextension injuries 2. Fifteen percent have a common peroneal nerve injury 3. Majority (but not all) occur as combined ligamentous injuries (ACL/PLC, PCL/PLC most common) B. External Rotation Recurvation Test (Hughston, 1980) 1. Lift up the big toe 2. Observe for increased recurvation and relative varus 3. Usually indicative of a combined PLC/cruciate ligament injury C. Varus Stress Test at 30º (Hughston, 1966) 1. Fingers over joint line to assess amount of opening 2. Apply varus stress through foot/ankle 3. Compare opening to contralateral (normal) knee 4. FCL needs to be torn D. Posterolateral Drawer Test (Hughston, 1980) 1. Knee flexed to 90º, foot external rotation to 15º (I sit on the foot) 2. Apply a gentle posterolateral rotation force and assess amount of posterolateral rotation (compare to normal contralateral knee) 3. Popliteus complex injury E. Dial Test (Gollehon, 1987; Grood, 1988) 1. Assesses ER component of posterolateral knee injury (Grood, 1988; Veltri, 1995) 2. Perform with knee flexed over side of examining bed, apply an external rotation force through the foot and look for external rotation of the tibial tubercle 3. Increased amount of external rotation at 30º indicates a posterolateral knee injury (avg. 13º- 15º) 4. Dial test at 90º • isolated posterolateral knee injury – slightly decreased external rotation compared to 30º (may not be visually detectable difference) (usually 5º ER) Χ an increased amount of external rotation is indication of a combined PCL/posterolateral knee injury (Gollehon, 1987; Grood, 1988) or a combined ACL/ posterolateral knee injury (Wroble, 1993) (avg. 13º- 16º) F. Reverse Pivot Shift Test (Jakob, 1981) 1. Largest variability among all motion tests - 35% in normal knees (Cooper, 1991) 2. Knee flexed to 90º, foot externally rotated 3. Knee is then extended. If subluxed in flexion, the knee is reduced by the iliotibial band as it changes function from a flexor to an extender of the knee 4. Indication of a popliteus complex injury G. Varus Thrust Gait 1. Usually (but not always) have underlying varus alignment 2. Patients learn to adapt with flexed knee gait H. Radiographs • AP varus thrust or bilateral stress x-ray (10º- 15º knee flexion) • AP (Segond, arcuate fractures) • Long leg alignment x-ray (chronics) I. MRI (LaPrade, 2000) a. Thin slice (2mm), include entire fibular head/styloid, add coronal obliques b. Iliotibial band • superficial layer • attachment at Gerdy’s tubercle c. Long head biceps femoris • direct arm • anterior arm d. Short head biceps femoris • direct arm • anterior arm e. Fibular collateral ligament f. Popliteus complex • femoral attachment • popliteomeniscal fascicles • popliteofibular ligament g. Fabellofibular ligament J. Arthroscopic Evaluation (LaPrade, 1997) a. “Drive-through” sign – > 1 cm lateral joint line opening b. Popliteus attachment c. Mid-third lateral capsular ligament • meniscofemoral • meniscotibial d. Popliteomeniscal fascicles e. Coronary ligament IV. Biomechanics of the Posterolateral Knee (Wentorf) A. Varus instability • FCL is major restraint to varus at all knee flexion angles. The popliteus complex, posterolateral capsule (including FFL, PFL), and cruciates also play an important role in preventing varus 1. Grood, et al, 1988 • After FCL cut, additional sectioning of popliteus tendon and other structures (PFL, capsule, etc) increases varus 2. Gollehon, et al, 1987 • After FCL cut, additional sectioning of popliteus tendon increases varus 3. Cruciate ligaments and varus • Recruited with deficient posterolateral complex (PLC) to resist varus a.
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