Introduction & Aims: To assess the efficacy of periosteal ACI (P-ACI) for articular cartilage lesions of the knee, a study was carried out on patients with minimum 5 year follow up including clinical assessment, second look arthroscopy when indicated clinically and MRI evaluation

Method: Between October 2000 and April 2003 the author carried out P-ACI on 164 patients. Of these 104 patients (106 knees – 145 lesions) could be included in this study.

There were 106 single, 35 double and three triple lesions. Seventy-eight lesions were considered traumatic, 63 degenerative and 4 OCD.

Previous surgery was frequent. Arthroscopic debridement (78), meniscal surgery (52), arthroscopic micro-fracture (19), ACL (12), lateral release (6), UTO (4) and extensor realignment (2).

Results: Results were assessed according to the ICRS cartilage repair evaluation package.

Significant improvement was seen in average Activity Level, Objective Knee Examination, Physical Component Score and Mental Component Score. IKDC subjective assessment improved by an average of 21 points.

There were 6 failures, 5 coming to TKR in the course of this study and 1 with advanced degenerative change requiring TKR.

“Second look” arthroscopy was carried out on 75 knees with 102 lesions at average 26 months from implantation for graft hypertrophy/extrusion presenting as painless mechanical symptoms (24), partial or complete periosteal patch loss (8), partial loss of graft (9), adjacent loss of host cartilage (4) and total loss of graft (3).

“Third look” arthroscopy occurred in 35 knees with 35 lesions at average 44.4 months from index implantation for partial loss of graft (8), adjacent host cartilage lesion (8), hypertrophy or periosteal patch detachment (6), new remote cartilage lesion (4) and total loss of graft (2).

“Fourth look” arthroscopy was carried out on 9 knees with 12 lesions at average 59 months from index implantation for adjacent host cartilage loss (4), partial loss of graft (3) and advancing degenerative change (3).

Conclusion: This study supports the efficacy of P-ACI for appropriate articular cartilage lesions of the knee with good clinical outcome and satisfactory repair when assessed arthroscopically Subsequent arthroscopic surgery was frequently required, predominantly related to the periosteal patch in the first year, after which adjacent host cartilage lesions, remote new cartilage lesions and partial loss of the graft became more Significant.

Introduction and Aims: To determine the efficacy of autologous chondrocyte implantation (ACI) in treating focal chondral defects of the knee, we reviewed the two-year treatment outcome of ACI in 53 patients through clinical evaluation, MRI, second-look arthroscopy and core biopsies obtained.

Method: From November 2000 to December 2003, 54 consecutive knees with 72 focal chondral defects (grade III or IV by modified Outerbridge) were treated with ACI using the Peterson periosteal patch technique. In this method, an initial arthroscopy was carried out to confirm the suitability for repair and when appropriate, cells were harvested either from the margins of the lesion, the intercondylar notch or both. The harvested cells were proliferated in vitro. Three to four weeks later, the cells were implanted in the defect with a medial or lateral parapatellar arthrotomy approach. A standardised post-operative rehabilitation protocol was carried out depending on the site of the lesion or lesions.

Results: Improvement in mean subjective score from pre-operative (37.6) to 12 months (56.4) and 24 (60.1) months post-ACI were observed. Knee function levels also improved (86% ICRS III/IV to 66.6% I/II) from pre-operative period to 24 months post-implantation. Objective IKDC score of A or B were observed in 88% pre-operatively. This decreased to 67.9% at three months before improving to 92.5% at 12 months and 94.4% at 24 months post-implantation. Transient deterioration in all these clinical scores was observed at three months before progressive improvement became evident. MRI studies demonstrated 75.3% with at least 50% defect fill, 46.3% with near normal signal, 68.1% with mild/no effusion and also 66.7% with mild/no underlying bone marrow edema at three months. These values improved to 94.2%, 86.9%, 91.3% and 88.4% respectively at 12 months. At 24 months, further improvement to 97%, 97%, 95.6% and 92.6% respectively were observed. Second-look arthroscopy carried out in 22 knees (32 lesions) demonstrated all grafts to be normal / nearly normal based on the International Cartilage Repair Society (ICRS) visual repair assessment while core biopsies from 20 lesions demonstrated 13 (65%) grafts to have hyaline / hyaline-like tissue.

Conclusion: Improvement in clinical and MRI findings obtained from second-look arthroscopy and core biopsies evaluated indicate that, at 24 months post-ACI, the resurfaced focal chondral defects of the knee remained intact and continued to function well.

Introduction Talar dome lesions are a common accompaniment of ankle injury resulting in ongoing symptoms and functional disability with current management resulting in fibrocartilaginous repair and failure to reconstitute the articular surface. In this study, the application of autologous chondrocyte implantation (ACI) for talar dome lesions was evaluated.

Methods Between August 2001 and February 2003, eight patients with osteochondral lesions of the talus were treated with ACI. All patients underwent initial arthroscopy to harvest healthy chondrocytes for cultivation. Cells were re-implanted after three to four weeks, with a medial or lateral malleolar osteotomy using a periosteal patch harvested from the distal tibia. Post-operatively, early ankle motion was allowed but non-weight bearing advised until union of osteotomy. Clinical assessment was pre-operatively and at three, six, nine, and 12 months post-operatively. Second-look arthroscopy with biopsy for histological examination was performed at removal of internal fixation. Four males and four females with a mean age of 40 years (range 22 to 59) are presented. Pre and postoperative clinical evaluation was done using the American Orthopaedic Foot and Ankle Society Hindfoot Score.

Results The mean pre-operative score was 58.4 (range 26 to 97); at three months, it was 62 (range 32 to 84); at six months 70.6 (range 66 to 92); at nine months 79 (range 66 to 92) and at 12 months 81.5 (range 79 to 84). MRI done in four patients at three months post-ACI showed good fill in three and slight over fill in one. Minimal subchondral edema was evident in one patient. Two patients with MRI 12 months post-ACI also revealed good fill with residual bone marrow oedema. Second-look arthroscopy and biopsy at implant removal in five patients were done at a mean of six months (range 2.5 to 9) post-ACI. Arthroscopy showed the transplants were level with the surrounding tissue. Four patients had biopsies showing hyaline-like cartilage which has all the properties of normal hyaline except for the increased cell density while one biopsy revealed fibro-hyaline tissue. Marginal biopsies taken demonstrated integration of neo-cartilage to adjacent cartilage.

Conclusions This study although with a limited sample, demonstrates the viability of ACI as treatment for osteochondral defects of the talus. Short-term results demonstrated clinical improvement from pre-operative to post-operative condition compatible with findings at second-look arthroscopy and histologic examination.

We have reviewed 22 patients from a total of 135 treated by autologous chondrocyte implantation (ACI) who had undergone further surgery for pain in the knee and mechanical symptoms after a mean of 10.5 months. There were 31 grafted lesions. At operation the findings included lifting (24/31) and detachment (3/31) of periosteal patches for which arthroscopic shaving was performed. Chondroplasty was undertaken on two new lesions, another required an ACI and a further patient required trimming of a meniscus.

The mechanical symptoms resolved within two weeks. At the last review, two to 14 months from reoperation; 68% had improved, and 86% had normal or nearly normal IKDC scores. Of the 31 lesions, 30 (97%) had normal or nearly normal visual repair scores.

Biopsy showed good integration with subchondral bone and the marginal interface in all specimens, most of which showed hyaline or hyaline-like cartilage (70%). Troublesome mechanical symptoms required surgery in 13% of ACI-treated patients and were attributed to periosteal extrusion. Simple arthroscopic debridement was curative.

Articular cartilage has compressive stiffness determined primarily by the matrix which is quite characteristic and distinct from that of degenerative articular cartilage or regenerative fibrocartilage. Alterations evident when articular cartilage begins to degenerate include a decrease in proteoglycan content and water content and resultant reduction in stiffness. Regenerative fibro-cartilage has greatly reduced stiffness with functional implications. Identification of cartilaginous stiffness for various sites of normal articular cartilage in the knee is important to enable comparison measures of suspected degenerative cartilage and regenerative articular cartilage either hyaline, fibrocartilage or mixed. The aim of this study was to map the in vivo biomechanical properties of normal human articular knee cartilage using the Artscan 1000 arthroscopic cartilage stiffness tester (Artscan Oy, Finland). It has been shown that the Artscan 1000 is reliable when measuring the stiffness of thin articular cartilage (Lyra et al., 1999). Over a period of 12 months, 94 patients (age 15–69 yr) undergoing a knee arthroscopy consented to having their normal articular surfaces biomechanically evaluated for stiffness. Cartilage stiffness (N) was defined by the mean indenter force at each site where the applied force on the measurement rod equalled 10 ±1.5 N. Medial femoral condyle stiffness (M ±SD; 3.71 ±1.28 N) was greater than all other sites and was significantly greater than mean values obtained for proximal, distal and lateral trochlea (1.87 ±0.91, 2.44 ±1.02 and 2.69 ±1.52 N, respectively); medial (1.71 ±0.70 N) and lateral patella (2.18 ±1.03 N); and medial and lateral tibial plateau for all subjects (2.33 ±.1.26 and 2.27 ±1.19 N, respectively; p < 0.05). There were no significant differences between sexes for each site. There was no trend for cartilage stiffness to be lower in patients over forty compared to younger patients for both sexes for all sites. There was, however, statistically significant less stiffness of the distal trochlea for females under 40 years when compared to that of females older than 40 years. The clinical significance of this is under review. Further research involving the characterisation of cartilage stiffness in pathological situations and evaluation of stiffness following articular cartilage repair is now possible.

Introduction: Articular cartilage has compressive stiffness determined primarily by the matrix and it is quite characteristic and distinct from that of degenerative articular cartilage or regenerative fibrocartilage.Alterations that are evident when articular cartilage begins to degenerate include a decrease in proteoglycan content and water content and resultant reduction in stiffness. Regenerative fibrocartilage has greatly reduced stiffness with functional implications. Identification of cartilaginous stiffness for various sites of normal articular cartilage in the knee is important to enable comparison measures of suspected degenerative cartilage and regenerative articular cartilage either hyaline, fibrocartilage or mixed.

Aim: To map the biomechanical properties of normal human articular cartilage in vivo using the Artscan 1000 arthroscopic cartilage stiffness tester (Artscan Oy, Finland).

Method: Over a period of 12 months, 94 patients (aged 15 to 69 years) undergoing a knee arthroscopy consented to having their normal articular surfaces evaluated biomechanically for stiffness. Cartilage stiffness (N) was defined by the mean indenter force at each site where the applied force on the measurement rod equalled 10 ±1.5N.

`Results: Medial femoral condyle stiffness (mean ± SD; 3.71 ± 1.28N) was greater than all other sites and was significantly greater than mean values obtained for proximal, distal and lateral trochlea (1.87 ± 0.91, 2.44 ±1.02 and 2.69 ±1.52N, respectively); medial (1.71 ± 0.70N) and lateral patella (2.18 ± 1.03N); and medial and lateral tibial plateaux for all subjects (2.33 ± 1.26 and 2.27 ± 1.19N, respectively; p < 0.05). There were no significant differences between sexes for each site. There was no trend for cartilage stiffness to be lower in patients over forty compared with younger patients for both sexes, for all sites. There was however, statistically significant less stiffness of the distal trochlea for females under 40 when compared with that of females older than 40 years. The clinical significance of this is under review.

Conclusion: Further research involving the characterisation of cartilage stiffness in pathological situations and evaluation of stiffness following articular cartilage repair is now possible.

We reviewed 32 ankles in 30 patients at an average of five years after a Watson-Jones tenodesis. All but one patient had had ankle pain before operation and 19 had had clicking, catching, or locking of the ankle. Eleven of these had an ankle arthrotomy at the time of ligament reconstruction for intraarticular pathology. At review seven of 23 ankles had a significant decrease in ankle motion, and five in subtalar motion, but only two were unstable on examination. Twenty-one ankles, however, caused some pain on activity and nine were tender on palpation. These findings indicate intra-articular degeneration or injury rather than simple instability. Radiographs of 16 ankles showed good varus and anterior-drawer stability. Seven had talocrural osteoarthritis, but only four showed grade-1 subtalar osteoarthritis. We found no correlation between follow-up time and long-term results. The Watson-Jones tenodesis provides good rotational and lateral ankle instability and does not appear to lead to subtalar degeneration.

We report the clinical and arthroscopic findings in 20 cases of medial meniscal cyst with a mean follow-up of 20 months. These were studied prospectively from a series of 7435 knee arthroscopies in which there were 1246 stable non-arthritic knees with medial meniscal tears. The diagnosis on referral was incorrect in seven, and incomplete in seven. There was coexistent meniscal injury in 17 (85%), but in the other three no tear was visible at arthroscopy. Ten knees had additional intra-articular abnormalities. Treatment of the cyst was by open resection in 12 and arthroscopic evaluation at meniscectomy in seven. In one case the cyst resolved after arthroscopic partial meniscectomy alone. Meniscal tears were treated by arthroscopic partial medial meniscectomy. Medial meniscal cysts are an important but under-diagnosed cause of knee pain and are frequently related to arthroscopically diagnosable and treatable meniscal pathology. Treatment should be directed towards both the meniscus and the cyst, which may require open surgery.