Copyright © 2006 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
Lars Peterson, MD, PhD, MD*,
Gothenburg University, Gothenburg, Sweden
The treatment of articular cartilage injuries has been considered a great therapeutic problem for more than two millennia, with many treatments having been tried but having failed.1
In 1994, an article published in the New England Journal of Medicine, "Treatment of Deep Cartilage Defects in the Knee with Autologous Chondrocyte Transplantation,"2 stimulated thought about a biologic approach to this problem. The authors presented a pilot study of twenty-three patients who were treated with autologous chondrocyte transplantation with use of each patient's own cells, which had been isolated and cultured in the laboratory from cartilage biopsies. Promising results were reported after a follow-up time of thirty-six months, and eleven of fifteen biopsies taken from the repair area showed hyaline-like cartilage, as assessed by independent scientists.
The article was received with some hope for young patients and with scepticism and criticism from orthopaedic surgeons. Later, however, in a longer-term follow-up study, good and excellent results were reported in 84% of the patients who received autologous chondrocyte transplantation as treatment for deep cartilage defects in the knee. In the groups with isolated femoral condylar defects and osteochondritis dissecans lesions, the long-term results reached 90% for good and excellent results over five to eleven years3,4. Since then, these results have been confirmed by other authors world wide4-9.
In the meantime, several authors have tried autologous chondrocyte transplantation in other joints and especially in the ankle joint, where good and excellent results have been reported after treating chondral and osteochondral injuries and osteochondritis dissecans of the talus10,11. Other treatments originally used in the knee, such as autologous osteochondral grafting and microfracture and drilling, have also been tried in the ankle. Hangody et al. reported upwards of 90% good results after mosaicplasty in the talus12. Microfracture and drilling have yielded promising short-term results, but the ultimate repair tissue may be fibrocartilage12. All of these techniques have the advantage of being a one-step procedure compared with autologous chondrocyte transplantation, in which an arthroscopic procedure to harvest the biopsy and evaluate the lesion is a necessary first step followed by a second procedure to perform autologous chondrocyte transplantation.
The present study, reporting on twelve patients with osteochondral talar defects treated with autologous chondrocyte transplantation and followed up for sixty-three months, does confirm the results of previous reported studies. In most instances, autologous chondrocyte transplantation alone has been sufficient treatment for chondral and osteochondral lesions and osteochondral defects of the talus. However, in some cases, the magnitude of osseous involvement must be addressed with autologous bone-grafting and autologous chondrocyte transplantation. In this study, one patient had autologous bone-grafting and autologous chondrocyte transplantation with use of the "sandwich technique,"13 and one patient had retrograde bone-grafting to activate bone-healing.
All patients treated in this study were stable as tested with the anterior drawer maneuver. Because patients with chondral and osteochondral defects of the talus usually have repeated torsional ankle trauma, I recommend as part of the treatment of a talar osteochondral defect that any ankle instability also be treated, thus restoring stability and achieving an optimal environment for the short and long-term survival of the repair tissue.
In the present study, the subjective results were evaluated by several validated scores and the healing was evaluated by magnetic resonance imaging with or without contrast medium, showing acceptable filling of the defects for the most part. No second-look arthroscopies were done because the patients had no complications that necessitated arthroscopy. All patients were able to return to their accustomed sports activities.
The authors are to be congratulated for conducting this long-term pilot study. However, I agree with their conclusion that future randomized controlled studies must be performed. Multicenter studies would be the best way to achieve an acceptable number with long-term follow-up in a reasonable time.
*In support of his research for or preparation of this manuscript, the author received grants or outside funding from Genzyme Biosurgery. The author did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. A commercial entity (Genzyme Biosurgery) paid or directed, or agreed to pay or direct, benefits to a research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author is affiliated or associated.
References
1. Hunter W. On the structure and diseases of articular cartilage. Philos Trans R Soc Lond. 1743;42d:514-21.
2. Brittberg M, Lindahl A, Nilsson A, Ohlsson C, Isaksson O, Peterson L. Treatment of deep cartilage defects in the knee with autologous chondrocyte transplantation. N Engl J Med. 1994;331:889-95.
3. Peterson L, Minas T, Brittberg M, Nilsson A, Sjögren-Jansson E, Lindahl A. Two- to 9-year outcome after autologous chondrocyte transplantation of the knee. Clin Orthop Rel Res. 2000;374:212-34.
4. Peterson L, Brittberg M, Kiviranta I, Akerlund EL, Lindahl A. Autologous chondrocyte transplantation. Biomechanics and long-term durability. Am J Sports Med. 2002;30:2-12.
5. Ochi M, Uchio Y, Kawasaki K, Wakitani S, Iwasa J. Transplantation of cartilage-like tissue made by tissue engineering in the treatment of cartilage defects of the knee. J Bone Joint Surg Br. 2002;84:571-8.
6. Hart JAL. Arthroscopic evaluation of cartilage repair following autologous chondrocyte implantation (ACI) [Paper #124]. Read at the Biennial Congress of the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine; 2003 Mar 8-16, Auckland, New Zealand.
7. Henderson IJ, Tuy B, Connell D, Oakes B, Hettwer WH. Prospective clinical study of autologous chondrocyte implantation and correlation with MRI at three and 12 months. J Bone Joint Surg Br. 2003;85:1060-6.
8. Erggelet C, Steinwachs MR, Reichelt A. The operative treatment of full thickness cartilage defects in the knee joint with autologous chondrocyte transplantation. Saudi Med J. 2000;21:715-21.
9. Gobbi A, Berruto M, Francisco R. Clinical results in patellofemoral full thickness chondral defects treated with Hyalograft®-C: a prospective study at 2-years follow-up. Read at the Annual Meeting of the American Orthopaedic Society for Sports Medicine; 2005 Feb 26; Washington, D.C.
10. Peterson L, Brittberg M, Lindahl A. Autologous chondrocyte transplantation of the ankle. Foot Ankle Clin. 2003;8:291-303.
11. Giannini S, Buda R, Grigolo B, Vannini F. Autologous chondrocyte transplantation in osteochondral lesions of the ankle joint. Foot Ankle Int. 2001;22:513-7.
12. Hangody L, Kish G, Módis L, Szerb I, Gáspár L, Diószegi Z, Kendik Z. Mosaicplasty for the treatment of osteochondritis dissecans of the talus: two to seven year results in 36 patients. Foot Ankle Int. 2001;22:552-8.
13. Peterson L, Minas T, Brittberg M, Lindahl A. Treatment of osteochondritis dissecans of the knee with autologous chondrocyte transplantation: results at two to ten years. J Bone Joint Surg Am. 2003;85 (Suppl 2):17-24.
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