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Autologous Collagen-Induced Chondrogenesis: Single-Stage Arthroscopic Cartilage Repair Technique

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Autologous Collagen-Induced Chondrogenesis: Single-Stage Arthroscopic Cartilage Repair Technique n Feature Article Autologous Collagen-induced Chondrogenesis: Single-stage Arthroscopic Cartilage Repair Technique ASODE ANANTHRAM SHETTY, MD; SEOK JUNG KIM, MD; PRAVEEN BILAGI, MD; DAVID STELZENEDER, MD abstract Full article available online at Healio.com/Orthopedics. Search: 20130426-30 Autologous collagen-induced chondrogenesis is a novel, single-staged arthroscopic carti- lage repair technique using microdrilling and atelocollagen or fibrin gel application under carbon dioxide insufflation. Atelocollagen is a highly purified type I collagen obtained following the treatment of skin dermis with pepsin and telopeptide removal, making it nonimmunogenic. In this procedure, atelocollagen mixed with fibrinogen and thrombin in a 2-way syringe can maintain the shape of the articular surface approximately 5 min- utes after application due to the reaction between the thrombin and fibrinogen. Carbon dioxide insufflation facilitates the application of the gel under dry conditions. Ten patients Figure: Intraoperative photograph showing the in- (mean age, 38 years) with symptomatic chondral defects in the knee who were treated strument setup during arthroscopic cartilage repair using the autologous collagen-induced chondro- arthroscopically with microdrilling and atelocollagen application were retrospectively genesis technique. analyzed. All defects were International Cartilage Repair Society grade III or IV and were 2 to 8 cm2 in size intraoperatively. For the clinical assessment, Lysholm score was as- sessed preoperatively and at 2-year follow-up. All patients underwent morphological magnetic resonance imaging at 1.5-Tesla at 1-year follow-up. Mean Magnetic Resonance Imaging Observation of Cartilage Repair Tissue score at 1-year follow-up was 70.4620.2 (range, 15-95). The Magnetic Resonance Imaging Observation of Cartilage Repair Tissue score for patellar lesions was similar to that of lesions in other locations: 73.3611.7 vs 68.1625.5, respectively. This technique had encouraging clinical results at 2-year follow- up. Morphological magnetic resonance imaging shows good cartilage defect filling, and the biochemical magnetic resonance imaging suggests hyaline-like repair tissue. The authors are from the Kent Knee Unit (AAS, SJK, PB, DS), Spire Alexandra Hospital, Chatham; the Faculty of Health and Social Sciences (AAS), Canterbury Christ Church University, Chatham Maritime; Medway Maritime Hospital (PB), Gillingham, Kent, United Kingdom; the Department of Orthopedic Surgery (SJK), Uijeongbu St Mary’s Hospital, The Catholic University of Korea, Kumoh-dong, Uijeongbu City, Gyeonggi-do, Korea; and the Department of Orthopaedics (DS), Medical University of Vienna, Vienna, Austria. The authors have no relevant financial relationships to disclose. The authors thank Linda Dineen and her surgical team at Spire Alexandra Hospital for their support and Professor Siegfried Trattnig from Vienna for his advice on cartilage magnetic resonance imaging. Correspondence should be addressed to: Seok Jung Kim, MD, Department of Orthopedic Surgery, Uijeongbu, St Mary’s Hospital, The Catholic University of Korea, Kumoh-dong, Uijeongbu City, Gyeonggi-do, 480-717, Korea ([email protected]). doi: 10.3928/01477447-20130426-30 e648 ORTHOPEDICS | Healio.com/Orthopedics AUTOLOGOUS COLLAGEN-INDUCED CHONDROGENESIS | SHETTY ET AL hondral defects in young to from undergoing au- middle-aged patients are com- tologous collagen- Cmonly seen in clinical practice.1,2 induced chondro- Although several treatments designed to genesis (ACIC). All regenerate cartilage have had encourag- patients undergoing ing results, none have proved to be simple ACIC between April and effective. Microfracture predominant- 2009 and December ly produces fibrocartilage.3 Autologous 2009 were included chondrocyte implantation is considered in the study. All pa- an effective procedure to produce hyaline- tients gave informed like cartilage.4,5 However, it is expensive consent to undergo and involves 2-stage surgical procedures, the procedure. with the associated morbidity of arthroto- my and harvesting a small portion of nor- Surgical Technique mal articular cartilage. All procedures Cell-free collagen type I gels or scaf- were performed folds combined with marrow stimulation under general an- 1 techniques have been used successfully esthesia. The stan- Figure 1: Intraoperative photograph showing the instrument setup during for cartilage repair.6-12 Atelocollagen is a dard anterolateral arthroscopic cartilage repair using the autologous collagen-induced chon- highly purified type I collagen obtained and anteromedial drogenesis technique. following the treatment of skin dermis arthroscopic por- with pepsin and telopeptide removal, tals were used to which makes it nonimmunogenic. It is evaluate the knee using normal saline were dried using cotton buds, which were used in medical, cosmetic, and research under pressure (approximately systolic introduced through the joint using plastic fields. Its physical properties are virtually blood pressure). After assessing the de- tubing. For patellar and trochlear lesions, identical to natural, nonsoluble collagen. fects, the lesions were debrided down to a patellar clamp (AO or Lewin bone clamp Therefore, it is used as a collagen scaffold the subchondral bone using a curette and [DePuy Synthes Ltd, Hertfordshire, United in tissue regeneration. shaver. A stable shoulder was established Kingdom]) was applied to lift the patella This article describes a novel ar- at the margin of the defect. Microdrilling and further open the joint. throscopic surgical technique that can be was performed using the 45° angled drill For the injection procedure, two 1-mL performed using microdrilling and atelo- (Powerpick drill; Arthrex Ltd, Sheffield, syringes and a Y-shaped mixing catheter collagen gel. Patients can be discharged United Kingdom). Drill holes were made connected to a 20-gauge needle (inner the same day as their surgery. The hypoth- at 3-mm intervals to a depth of 6 mm diameter, 0.9 mm; length, 90 mm) were esis was that this technique would provide (Figures 1-3). used. One syringe was filled with 1 mL cartilage regeneration and improve symp- The second part of the procedure was of fibrinogen (Tisseel; Baxter, Thetford, toms in patients with isolated cartilage de- performed under dry arthroscopic condi- United Kingdom), and the other syringe fects of the knee. tions using carbon dioxide (CO2) insuf- was filled with 0.9 mL of atelocolla- flation. Carbon dioxide was introduced at gen (CartiFill; RMS Innovations U.K., MATERIALS AND METHODS 20 mm Hg pressure with a flow rate of 20 Hertfordshire, United Kingdom) and 0.1 Patients L/min using a Wolf cannula (Karl Storz mL of thrombin (50 IU). The 20-gauge This was a retrospective study consist- GmbH, Tuttlingen, Germany) and dispos- needle was inserted through 1 of the por- ing of symptomatic patients with isolated able tubing with a filter (Insufflation tub- tals or an appropriate separate portal to ac- full-thickness (International Cartilage ing with Wolf adaptor; Leonhard Lang UK cess the lesion. Repair Society/Outerbridge grade III/IV) Ltd, Stroud, United Kingdom) through a Under arthroscopic vision, the gel was cartilage lesions. The defect sizes were superolateral portal. applied into the defect. The CO2 pressure 2 to 8 cm2. Mean6SD patient age was To make the joint completely dry, re- and the adhesiveness of the gel allowed at- 44.9611.2 years (range, 26-63 years). sidual normal saline in the joint was aspi- tachment even against gravity, especially Patients with generalized osteoarthritis, rated using gentle suction with a 20-mL sy- to patellar defects. Once the first layer of more than 5° of malalignment, and an ringe and an angled suction tube (Exmoor, gel was applied and after a delay of 1 to age older than 65 years were excluded Taunton, United Kingdom). The lesions 2 minutes, the gel was injected under the MAY 2013 | Volume 36 • Number 5 e649 n Feature Article first layer to achieve full defect filling. The gel usually hardened within 5 min- utes, and then it was shaped in situ using a McDonalds dissector [Bolton Surgical Ltd, Sheffield, United Kingdom] (Figure 3). 2A 2B Once this was established, the CO2 was switched off, and the knee was in- sufflated with normal saline under pres- sure. The stability of the graft was further ascertained by moving the knee through 2C 2D a full range of motion several times fol- lowed by visual inspection. The skin was closed with sutures or steri-strips. Rehabilitation All patients underwent a standardized rehabilitation protocol. Patients were ad- vised to partially weight bear on crutches for 6 weeks postoperatively. Gradually, 2E 2F increased loads were applied during the Figure 2: Photographs showing instruments first 6 weeks. Flexion was only restricted used for the autologous collagen-induced chon- drogenesis technique in the knee joint. Full (A) in patients with patellofemoral defects. In and close (B) views of the 45º angled Microdrill. these patients, flexion to 30° was allowed Cotton bud with cover to allow dry insertion into within the first 2 weeks and was gradually the joint shown separately (C) and together (D). increased to 90° at 6 weeks postoperative- Angled suction tube and syringe (E). Patella clamp (F). Carbon dioxide insufflation cannula ly. After that, the full range of motion was and tube (superolateral portal) (G). approached. 2G Clinical Assessment All patients were assessed using the Lysholm score preoperatively and at 2-year follow-up. Magnetic
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