Articular cartilage injuries lead to progressive degeneration of the joint with subsequent progression to osteoarthritis, which currently becomes a serious health and economic issue. Due to limited capability for self-regeneration, cartilage repair remains a challenge for the present-day orthopedics. Currently, available therapeutic methods fail to provide satisfactory results. A search for other strategies that could regenerate a hyaline-like tissue with a durable effect and adequate mechanical properties is underway. Tissue engineering strategies comprise the use of an appropriately chosen scaffold in combination with seeding cells. Mesenchymal stem cells (MSC) provide an interesting new option in regenerative medicine with solid preclinical data and first promising clinical results. They act not only through direct cartilage formation, but also due to paracrine effects, such as releasing trophic factors, anti-inflammatory cytokines, and promoting angiogenesis. The MSC can be applied in an allogeneic setting without eliciting a host immune response. Out of the various available sources, MSC derived from Wharton's jelly of an umbilical cord seem to have many advantages over their counterparts. This article details a novel, single-staged, and minimally invasive technique for cartilage repair that involves dry arthroscopic implantation of scaffold-embedded allogenic mesenchymal stem cells isolated from umbilical cord Wharton's jelly.
Cell-based cartilage repair procedures are becoming more widely available and have shown promising potential to treat a wide range of cartilage lesion types and sizes, particularly in the knee joint. More recently, techniques have evolved from 2-step techniques that use autologous chondrocyte expansion to 1-step techniques that make use of mesenchymal stem cells (MSCs) embedded onto biocompatible scaffolding. Our 1-step technique has been further developed to provide cell-based cartilage repair using MSCs that have the potential to be used in an off-the-shelf manner, without the need for autologous tissue harvest. Precursor MSCs can be isolated in abundance from the Wharton's jelly of umbilical cord tissue. These cells have been shown to have the desired capacity for proliferation, differentiation, and release of trophic factors that make them an excellent candidate for use in the clinical setting to provide cell-based restoration of hyaline-like cartilage. Although allogeneic in nature, these cells stimulate little or no host immune response and can be stored for long periods while maintaining viability. We present a technique of cartilage repair in the knee using Wharton's jelly–derived MSCs embedded onto scaffolding and implanted in a minimally invasive fashion using dry arthroscopy.
Cartilage injury of the knee that is associated with significant subchondral bone loss can result in great morbidity, and treatment options that provide durable repair are limited. Osteochondral autograft and allograft reconstruction of these lesions has been used extensively; however, these techniques often require a more invasive surgical exposure, and restoring the natural articular surface radius of curvature can be challenging, particularly in larger lesions. Cell-based repair of these lesions, using autologous chondrocytes in conjunction with bone grafting, has been used with success, although this procedure requires the patient to undergo 2 operations, and access is often restricted due to the high associated costs. Comparable medium-term clinical outcomes have been shown with scaffold-associated mesenchymal stem cell grafting, and this cell-based procedure may also be performed arthroscopically to minimize patient morbidity. In cases of cartilage injury associated with bone loss, this procedure has great potential to repair osteochondral injury when used in conjunction with bone grafting. We present the one-step arthroscopic technique of biologic inlay osteochondral reconstruction in the knee, using an autologous bone graft and a hyaluronic acid-based scaffold embedded with bone marrow aspirate concentrate, to treat full-thickness cartilage lesions associated with significant subchondral bone loss.
The technique of all-arthroscopic autologous matrix-induced chondrogenesis (AMIC)-aided repair of patellar cartilage lesions using a retraction system and dry arthroscopy has been recently described. We report the first clinical and radiological data at a short-term follow-up. Twelve patients underwent AMIC-aided cartilage repair for a patellar lesion. All steps of the procedure were performed arthroscopically, which include the use of an intra-articularly placed retraction plate for distraction of the patellofemoral joint and evacuation of saline solution for collagen matrix insertion and fixation. Clinical assessment performed before surgery and at a mean follow-up time of 38 months (range: 24-70) included the following scores: Knee Injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee (IKDC), and visual analog scale (VAS). Magnetic resonance imaging was performed at the follow-up examination, including the magnetic resonance observation of cartilage repair tissue (MOCART) score. The mean KOOS and IKDC scores increased significantly ( < 0.01) from 50.3 and 37.4 points preoperatively to 90.1 and 79.4 postoperatively. The VAS score decreased from 7.8 to 2.3 points. Mean MOCART score at follow-up was 58.3 points. Cartilage repair of patellar lesions aided by a retraction system in a dry arthroscopy setup is a promising approach. Further studies are needed to evaluate this procedure and compare it to existing matrix implantation techniques. The level of evidence for the study is 4 (case series).
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