Background

Autologous Chondrocyte Implantation (ACI) is a procedure which is gaining acceptance for the treatment of cartilage defects in the knee with good results and a long term durable outcome. Its use in other joints has been limited, mainly to the ankle. We aimed to assess the outcome of ACI in the treatment of chondral and osteochondral defects in the hip.

A new surgical hybrid technique involving the combination of autologous bone plug(s) and autologous chondrocyte implantation (AOsP-ACI) was used and evaluated as a treatment option in 15 patients for repair of large osteochondral defects in knee (N=12) and hip joints (N=3). Autologous Osplugs were used to contour the articular surface and the autologous chondrocytes were injected underneath a biological membrane covering the plug. The average size of the osteochondral defects treated was 4.5cm². The average depth of the bone defect was 26mm. The patients had a significant improvement in their clinical symptoms at 12 months with significant increase in the Lysholm Score and Harris Hip Score (p = 0.031). The repaired tissue was evaluated using Magnetic Resonance Imaging, Computerised Tomography, arthroscopy, histology and immunohistochemistry (for expression of type I and II collagen). Magnetic Resonance Imaging, Computerised Tomography and histology at 12 months revealed that the bone plug became well integrated with the host bone and repair cartilage. Arthroscopic examination at 12 months revealed good lateral integration of the AOsP-ACI with the surrounding cartilage. Immunohistochemistry revealed mixed fibro-hyaline cartilage. We conclude that the hybrid AOsP-ACI technique provides a promising surgical approach for the treatment of patients with large osteochondral defects. This study highlights the use of this procedure in two different weightbearing joints and demonstrates good early results which are encouraging. The long term results need to be evaluated.

Background: Many studies have examined magnetic resonance images (MRI) with a view to the anatomy and signaling properties of the intervertebral disc and adjacent tissues in asymptomatic populations. In this study we have examined MRIs of a discrete population of patients undergoing surgery for symptomatic disc herniations.

Methods: Sixty patients (aged 23–66 years, mean 41.5±8.4) had sagittal T1 and T2- weighted turbo spin echo imaging of the lumbar spine prior to surgery. One disc was herniated at L2-3, 3 at L3-4, 22 at L4-5 and 31 at L5-S1; 3 patients had herniations at both L4-5 and L5-S1. The images were scored for disc narrowing and signal, degree of anterior and posterior bulging and herniation, and assessed for Modic I and II endplate changes and fatty degeneration within the vertebrae. These were carried out for each of 6 discs (T12-S1) for all patients (ie 360 discs and 720 endplates).

Results: There were trends of increasing disc narrowing, disc bulging and fatty degeneration with increasing age in these patients. 83% of patients had disc bulging, 53% had endplate irregularities and 44% had fatty degeneration. There was a significant correlation between patient weight and fatty degeneration. 7.5% of vertebrae (in 22% of patients) demonstrated Modic I changes whilst Modic II changes were seen in 14% of vertebrae (40% of patients). This is considerably higher than the incidence reported in asymptomatic individuals where Modic I changes were seen in 0.7% of vertebrae (3% of individuals) and Modic II changes in 1.9% of vertebrae (10% of individuals).

Conclusion: There is a higher incidence of Modic I and II changes in disc herniation patients than in asymptomatic individuals.

Introduction: Before proceeding to long-term studies, we studied early clinical results of combined Autologous Chondrocyte Implantation (ACI) and Allogenic Meniscus Transplantation (AMT). Meniscus deficient knees develop early osteo-arthritis (OA) of the knee joint. Autologous Cartilage Implantation (ACI) is contraindicated in case of meniscus deficient knees. And on contrary the Allogenic Meniscus Transplantation (AMT) is contraindicated in cartilage defects in the knee joint. But a combination of the two procedures for bone on bone OA might be a solution for this problem. This was the main purpose of our study.

Methods: We studied a consecutive series of eight patients (7 males and 1 female), with an average age= 43 years (29–58), presenting with painful secondary arthritis, due to premature loss of meniscus and chondral defect/s. Median size of the femoral defects was 8.16 cm2 and of the tibial side 2.69 cm2 All patients were treated with a combination of Autologous Chondrocyte implantation (ACI) and Allogenic Meniscus Transplantation (AMT). Chondral defects were covered with periosteum/ Chondroguide membrane, secured in place with in-vitro cultured autologous chondrocytes injected underneath the path. Meniscus placed as load-bearing washer on the surface of ACI of tibia. ACI rehabilitation protocol followed post-operatively. Assessment at the end of one year was done with self-assessed Lysholm score, histology and the MRI scan.

Results: Mean pre-operaive Lysholm score was 49 (17–75). This increased to a mean of 66 (26–87) at 1 year, an average increase of 16.4 points. Average one-year satisfaction score was 3 and they were back to all active life style. Five out of eight patients showed significant functional improvement at last post-operative follow-up (2 to 6 years; mean of 3.2 years). Complications were aseptic synovitis in 3 cases. Three failures were noted showig persistant pain and swelling in one, rupture of meniscus in second and third patient had a knee replacement. Arthroscopy at 1 year showed a stable meniscus with all healed peripheral margins in all except in one case with some thinning with no evidence of rejection. Histology of meniscus showed a fibrocartilage well populated with viable cells and the peripheral zone was well vascularised and integrated with capsule. Biopsy of ACI site was predominantly of fibrocartilage with good basal integration with subchondral bone. On MRI scan, allogenic meniscus was well integrated with capsule along the line of repair, showing foci of variable signal intensities within the meniscus. There was no evidence of meniscal subluxation in all but one case showing mild extrusion. ACI graft site showed a varied appearance, with 3 grafts showing focal grade 3to 4 changes.

Conclusion: Seven out of eight patients improved post-operatively at one year, in terms of pain relief and increased activity. It’s possible to combine these two techniques together. Short-term outcomes are satisfactory. We could not find any deleterious effects of combining these two techniques together. So we conclude that, this might act as a one step towards a biological knee replacement.

Background: Articular cartilage injuries are very common. Small defects don’t heal on their own and large defects can’t regenerate new cartilage. This would largely be due to the fact that chondrocytes are embedded in a firm and tough matrix and hence can’t migrate to the defect site to regenerate a new cartilage tissue. So ultimate fate is patient getting early osteoarthritis. Cartilage defects in the knee may be symptomatic and cause pain, swelling and catching. There are several different surgical procedures available to treat cartilage injuries, but no method has been judged superior. The ultimate aim of the treatment is restoration of normal knee function by regeneration of hyaline cartilage in the defect, and to achieve a complete integration to the surrounding cartilage and underlying bone. Arthroscopic debridement and lavage may give symptomatic relief for a limited time. Autologous Chondrocytes Implantation (ACI) was first described in 1994. Encouraging primary results were reported, and further research was promoted. Long-term results are encouraging. ACI is being done in Robert Jones & Agnes Hunt orthopaedic Hospital, Oswestry since last 8 years.

Methods: We studied a cohort of first 118 patients who underwent ACI for knee joint in this institute, focussing on their mid-term results. Patients having chondral defects were offered ACI. They all were explained the procedure and informed written consent was obtained. Patients filled in a self-assessed Lysholm forms before the operation. They also underwent pre-operative MRI scan of knee joint. ACI procedure consisted of three stages— Stage I —Arthroscopic harvest biopsy of cartilage and chondrocytes culture in lab. Stage II—Arthrotomy of the knee. The defect edges were freshened, covered by periosteum or chondroguide, which was sutured to the cartilage with 6-0 vicryl. Chondrocytes were injected underneath this patch. Post-op CPM and Physiotherapy. Stage III—1-year arthroscopic surgery. Assessment was done with Lysholm score, MRI scan, histological and arthroscopic analysis. Patients were followed up clinically thereafter with yearly Lysholm scores.

Results: 118 patients with an average age of 35 years (15–59) underwent ACI for knee in last 8 years. 93 patients had single defect, 24 had multiple (> 1) chondral defects, with mean area 4.81 cm2. MRI showed a good integration of defect with surrounding cartilage with varied signal intensities. About 55–56% patients underwent some or other form of trimming, which improved immediate results. However only 50 % of these were symptomatic. Defects on MFC did well as compared to other sites, followed by on trochlea. Defects on patella showed poor results, though the number is less for comparison. Total 79 specimens of 1-year histology showed good healing with formation of fibrocartilage (40), mixed (20) and hyaline (8), fibrous tissue (6), bone in 1 case and inconclusive in 2 cases. Mean pre-op Lysholm score was 50.16. Average score at one year was found to be 69.52.

Conclusion: Results of ACI are encouraging. Patients continued to improve slowly over a period of time, achieving maximum function between one and 2 years post-surgery. Our study showed that there after their scores remained static.

In a prospective study we attempted to define the role of lumbar discography in the investigation of patients with low back pain with or without non-dermatomal pain in the lower limb. The records of 195 patients were studied at least two years after a technically successful operation. Of 137 patients in whom discography had revealed disc disease and provoked symptoms, 89% derived significant and sustained clinical benefit from operation. Of 25 patients whose discs showed morphological abnormality but had no provocation of symptoms on discography only 52% had clinical success. These findings support the continued use of lumbar discography for the investigation of this particular group of patients.