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POSSIBILITIES OF MOSAIC CHONDROPLASTY OF CARTILAGE DEFECTS OF THE ARTICULAR SURFACES OF THE KNEE JOINT IN OSTEOARTHRITIS
Lartsev Yu.V., Kudashev D.S., Zuev-Ratnikov S.D., Rasputin D.A., Shmelkov A.V., Baranov F.A.
Samara State Medical University, Samara, Russia
At the present time, the pathogenesis of arthrosis is
considered from the perspectives of absolute relationship between processes of
remodeling of the subchondral bone and the hyaline cartilage in response to
biomechanical loads to the joint. Recent studies convincingly show that these
two anatomical formations form a single biocomposite in the joint - a
morphological and functional unit, with an interpenetrating molecular signaling
system and correlating biological and biomechanical adaptive processes. At the
same time, the issue of localization of primary pathological processes of
changes in the structure and composition of joint tissues in osteoarthritis
comes to the forefront of the discussion, since the early postulation of the
primary initiation of destruction and degeneration of articular cartilage is
now being critically evaluated [1, 2].
The features of changes of the destructive-dystrophic
process in the periarticular bone present the adaptation to local biomechanical
and biological signals.
These changes are mediated
by bone cells that modify the architecture and properties of bone through
active cellular modeling and remodeling processes [2, 3]. Developing
microcirculation disorders in the metaphyseal regions of the femur and tibia
with further development of intraosseous venous stasis, bone marrow edema, and
disorganization of homeostasis lead to local ischemia, hypoxia, and cystic
restructuring of the subchondral bone. This causes a violation of the trophism
of the calcified and radial layers of hyaline cartilage with its subsequent
degeneration and the formation of full-layer penetrating defects of the
articular surfaces [4, 5].
Thus, the main pathogenetic mechanism for the
development of chondral defects of the knee joint, both in primary
osteoarthritis and in secondary lesions, is a violation of adequate remodeling
of hyaline cartilage and subchondral bone in response to biomechanical stress.
This leads to the processes of dystrophy and destruction of the anatomical and
functional cartilage/bone system, manifesting as a lesion, primarily of the
articular cartilage as an anatomical structure with an extremely low reparative
potential in evolution [6-8].
Providing conditions for the most complete
regeneration of the affected articular surface is the complex task, the
completeness of the solution of which depends both on the degree of
morphological and functional restoration of the knee joint and on improving the
quality of life of patients with destructive-dystrophic chondral defects [9-11].
The main features of articular surface defects in
osteoarthritis are their size and depth. As a rule, they have an area of more
than 4 cm2, as well as damage degrees III and IV according to the
classifications of Outerbridge (1961) and ICRS (International Cartilage Repair
Society, 2000). In addition, destructive-dystrophic defects of the hyaline
cartilage in the vast majority of cases are located on the articular surface of
the most loaded sections of the internal femoral condyle, which imposes special
requirements on this area in terms of resistance to mechanical stress. All
these factors significantly reduce the effectiveness of such methods of
mesenchymal stimulation as abrasive chondroplasty, subchondral tunneling and
microfracture as a surgical treatment [12-14].
The use of various variants of cellular technologies
in this situation, including the implantation of a culture of autologous
chondrocytes and artificial bioimplants, AMIC technology (autologous
matrix-induced chondrogenesis) is also not widely used today. This is due to
the high cost of this treatment, the unresolved number of legal issues, as well
as the lack of a stable prognosis for positive results [15-17]. Considering the
methods of chondroplasty with the use of cellular technologies, one should also
point out a certain debatability of the pathogenetic substantiation of these
methods of surgical treatment, which essentially consists in replacing bone and
cartilage defects with a cell mass of autologous cultured chondrocytes. Since
the main characteristics of the strength of the hyaline cartilage are provided
by the structural macromolecules of the extracellular matrix, and chondrocytes
occupy no more than 1-1.5 % of the cartilage volume, the calculation of the
restoration of the necessary physical properties of the transplantation area of
full-thickness defects using suspensions of cultured cells in the late
postoperative period is a reason for discussion [13, 18].
One of the most widely used methods of surgical
treatment of patients with chondral defects remains mosaic osteochondral
autoplasty, proposed by L. Hangody in 1992, and currently accounting for 17–27 %
of all chondroplasty options. The method involves the sampling and implantation
of bone and cartilage autografts of different diameters, the donor area of
which is low-load sections of the external and internal condyles of the femur
of the same joint or intercondylar arch anterior to the site of attachment of
the anterior cruciate ligament [1, 19].
The use of mosaic bone and cartilage autoplasty has a
long positive clinical experience. However, in the case of defects of a
destructive-dystrophic nature, this method shows a number of negative factors
that have a negative impact on the processes of reparative chondrogenesis,
thereby reducing the number of positive treatment results in the medium and
long-term follow-up periods. We formulated the disadvantages of osteochondral
mosaic autoplasty when used in patients with osteoarthritis in the form of the
following provisions:
- limited volume of necessary autoplastic material;
- decrease in the area of actively functioning
cartilage in case of receiving grafts from low-load areas, which is associated
with additional injury to joint tissues;
- as a donor material, the use of potentially defective
(dystrophically altered) cartilage tissue (a factor that does not depend on the
causes that led to the formation of a cartilage defect, except for trauma);
- risk of graft dystrophy after “snowman”
transplantation due to the existing destructive-dystrophic process in the
joint;
- chronic pain syndrome in the area of graft
harvesting;
- the risk of developing aseptic inflammation in the
donor area with its conversion to chronic synovitis and the progression of
secondary osteoarthritis.
All of the above facts initiated the development of
new methods of mosaic autochondroplasty, followed by an analysis of the
effectiveness of their use in patients with osteoarthritis of the knee with
full-thickness cartilage defects.
The
objective of the study
- to analyze the mid-term and long-term results of treatment of patients with
full-layer destructive-dystrophic osteochondral defects of the articular
surfaces of the knee joint after using various methods of mosaic chondroplasty.
MATERIALS AND METHODS
We estimated the results of surgical treatment and
performed a comparative analysis for patients with gonarthrosis and
osteochondral defects of the articular surface of the knee. The patients were treated
in the traumatology and orthopedics unit No. 2 of clinics of Samara State
Medical University in 2012-2020.
The study was conducted on the basis of WMA
Declaration of Helsinki (2013), in compliance with the principles of the
tripartite Agreement on Good Clinical Practice, the laws of the Russian
Federation, and the approved protocol. Informed consent
to participate in the study was obtained from each patient.
A total of 94 patients were under our supervision. The
inclusion criteria for the study were as follows: gender – any; age - up to 65
years; the existing verified deforming gonarthrosis of stages II and III
according to Kellgren and Lawrence in the modification of Leuquesne (1982); the
presence of an osteochondral defect of the articular surface of one condyle of
degrees III and IV according to Outerbridge (1961).
The exclusion criteria from the study were: the area
of the defect of the articular surface is more than 7 cm2; a history
of cruciate ligament injury and/or meniscectomy; bilateral damage to the
joints; the presence of concomitant endocrine and metabolic pathologies,
including diabetes mellitus and gout; the presence of a connective tissue
disease of a systemic nature; pregnancy; varus or valgus deformity of the knee
joint; alimentary-constitutional obesity of degree II and above (BMI > 33
kg/m2).
The above inclusion criteria were met by 87 patients
who entered the present study.
With stratified (layered) randomization, all patients
were divided into three groups. Each group received one or another method of
mosaic chondroplasty. Stratification within the framework of the study was
carried out by distributing patients into groups, taking into account the
following factors: gender, age, duration of the disease history (Table 1).
Table 1. Stratified randomization of patients by groups
|
Groups Sign |
First group |
Second group |
Third group |
|
|
Gender |
male |
6 |
7 |
5 |
|
female |
23 |
24 |
22 |
|
|
Age |
30-39 years |
2 |
1 |
2 |
|
40-49 years |
7 |
6 |
5 |
|
|
50-59 years |
13 |
15 |
12 |
|
|
60-65 years |
7 |
9 |
8 |
|
|
Disease duration |
< 1 year |
5 |
4 |
4 |
|
1-3 years |
6 |
8 |
6 |
|
|
3-5 years |
11 |
10 |
11 |
|
|
> 5 years |
7 |
9 |
6 |
|
The first group of patients (29 patients) underwent
mosaic osteochondral autoplasty according to the classical method proposed by
L. Hangody. To replace the defect, osteochondral autografts of the same joint
were used as a plastic material, the donor area of which was located on
low-load areas.
In the second group (31 patients), surgical
intervention was performed using the method developed at the department for
chondroplasty of cartilage defects of the articular surface (RF patent No.
2239377). The method is based on the classical technique of mosaic
chondroplasty, while it has an important difference, which consists in the use
of bone spongy autografts of the iliac wing to replace the defect area.
The third clinical group included 27 patients whose
surgical treatment was performed using a new method of chondroplasty of
articular surfaces (RF patent No. 2484784). The main difference of this
operation, in which the osteochondral defect is replaced using the well-known
technique of mosaic chondroplasty, is the additional formation of a non-free
muscle flap from the abdomen of the tender muscle, followed by its passage
through a specially formed channel in the metaphyseal zone under the bases of
bone and cartilage autografts in the area of implantation.
In all cases, the specialized set of tools for
chondroplasty Acufex (Smith & Nephew) was used during the main stages of
surgical intervention.
Patients of all groups were comparable in terms of sex,
age and comorbidity. The age of the patients ranged from 30 to 65 years, and
the mean age was 53.2 years. There were 66 women (76.4 %) and 21 men (23.6 %)
(Table 2). The area and localization of articular surface defects in the
observed patients are presented in Table 3.
Table 2. Distribution of patients by age and sex
|
Age Gender |
30-39 |
40-49 |
50-59 |
60-65 |
Total |
|
Male |
2 |
4 |
10 |
5 |
21 |
|
Female |
3 |
14 |
29 |
20 |
66 |
|
Total |
5 |
18 |
39 |
25 |
87 |
Table 3. Area and localization of observed chondral defects
|
Defect area |
3.0-3.9 |
4.0-4.9 |
5.0-5.9 |
6.0-6.9 |
Total |
|
Medial condyle |
5 |
11 |
34 |
32 |
82 |
|
Lateral condyle |
0 |
1 |
2 |
2 |
5 |
|
Total |
5 |
12 |
36 |
34 |
87 |
Before the main stage of the operation, all patients
underwent video arthroscopy of the knee joint, during which the state of the
intraarticular structures was analyzed, as well as the localization, area, and
degree of damage to the articular cartilage (according to Outerbridge). If
necessary, we performed debridement, shaving of the articular cartilage around
the defect and smoothing the edges of the latter. Next, we proceeded directly
to performing mosaic chondroplasty according to the method corresponding to the
group in which the patient was included. In all cases, this stage of the
operation was performed openly, after performing medial parapatellar
arthrotomy.
If the surgical technique of mosaic osteochondral
autoplasty according to L. Hangody, used in patients of the first group, is well
known and described in detail in the specialized literature, then the
description of the methods of operations in patients of the second and third
groups requires detailed description.
In patients of the second group, we developed a method
for replacing osteochondral defects of the articular surface (RF patent No.
2239377), the main stages of which are presented below.
After arthrotomy, the area of the articular surface
defect is visualized and its characteristics are finally evaluated (Fig. 1).
Then, along the border of the scar tissue, the edges of the cartilage defect
are modeled up to a visible healthy layer. Channels are formed in the
subchondral bone perpendicular to the contour of the subchondral bone using
hollow cutters with a diameter of 4.5 to 8 mm and a depth of 20 mm (Fig. 2).
The number of channels in the recipient zone is always individual and is
determined by the need to completely fill the entire area of the defect. In
this case, it is necessary to keep walls up to 3 mm thick between the formed
channels. This makes it possible to increase the area of contact of autografts
with bone tissue in the recipient zone and preserve their trophism under
conditions of destructive-dystrophic damage to bone tissue.
Figure 1. Visualization of an osteochondral defect in the
area of the medial femoral condyle after knee arthrotomy
Figure 2. View of the defect area (recipient zone) after
preparation for transplantation: five channels Ø = 8 mm and three
channels Ø = 6.5 mm were formed
The next step is access to the iliac crest of the ipsilateral side with a direct incision in its projection, retreating 2-3 cm posteriorly from the spina iliaca anterior superior. From the wing and body of the ilium, donor autografts of the appropriate size and in the required amount are formed (Fig. 3).
Figure 3. View of the donor area – the crest and wing of
the ilium after the collection of bone autografts
At the end, donor bone autografts are alternately introduced into the prepared area of the osteochondral defect of the articular surface by means of a tight fit (press-fit) so that the distal part of the grafts is located at the level of the articular cartilage surrounding the defect (Fig. 4 a, b).
Figure 4. Anterior (a) and lateral (b) articular surface
defect after completion of mosaic osteochondral autoplasty
Our experience has shown that if the area of a
chondral defect is up to 4 cm2, it can be completely replaced with
grafts taken only from the iliac wing. In case of lesions of the articular
surface of a larger area, we perform chondroplasty with use of a combination of
spongy bone autografts of the iliac wing with bone and cartilage autografts of
low and unloaded sections of the joint. At the same time, the use of spongy
bone autografts makes it possible to replace 50-60 % of the entire area of the
defect.
For patients of the third clinical group, we used the
second method developed by us for autochondroplasty of articular surface
defects (RF patent No. 2484784). Its development is based on the results of
experimental work on modeling cartilage defects and their surgical treatment,
performed on the basis of the Institute of Experimental Medicine and
Biotechnology of the Samara State Medical University. Also,
our studies confirmed the data of the works of some authors on the importance
of the subchondral bone of the metaepiphyses of long tubular bones in the
pathogenesis of destructive-dystrophic lesions of the joints and substantiated
the need to correct the microcirculation and metabolism of this zone when
performing chondroplasty. For this purpose, we used the technique of myoplasty
with a non-free muscle autograft, which is successfully used, in particular, in
the treatment of bone tissue lesions of long tubular bones in chronic
osteomyelitis.
Surgery was performed as follows. After performing the
stage of mosaic chondroplasty with osteochondral autografts from lightly loaded
parts of the joint, an additional skin incision up to 2-3 cm long is made along
the inner surface of the knee joint in the projection of the tender muscle (m.
gracilis). At the next stage, it is isolated with the formation of a non-free
muscle flap, followed by fixation on a holder. Subsequently, through the same
access under the control of radiography in the femoral condyle in the
metaphyseal zone under the base of the bone and cartilage autografts in the defect
zone, a transverse channel up to 4-5 cm long is formed transossally. A
schematic representation of the surgical intervention is shown in Figure 5.
Figure 5. Myoplasty of the metaphyseal region of the
internal condyle of the femur m.gracilis: a) formation of a muscle
autograft (m.gracilis); b) introduction of the formed autograft under the
base of bone and cartilage grafts
The protocol of postoperative management of patients
of all clinical groups was completely identical. It is based on the principle
of complete limitation of the supporting load on the limb for 6 weeks. However,
the main condition is the early onset of flexion-extensor movements. Patients
from the second day after surgery received exercises on the apparatus for
robotic mechanotherapy of the lower limb (CPM - continuous passive motion).
In addition, in the perioperative period, all patients
received systemic antibiotic prophylaxis in the form of parenteral
administration before the incision (30 minutes) of 2nd generation
cephalosporins (2 g) and then 2 g each every 12 hours after surgery. Also, a
single protocol of drug symptomatic therapy was implemented for all patients.
Clinical assessment of treatment outcomes, i.e., the
severity of pain syndrome and functionality of the knee joint, was performed
using the following systems recommended by the Osteoarthritis Research Society
International (OARSI): Lequesne algofunctional index, WOMAC osteoarthritis
index, and Oxford knee score (OKS) [1, 18]. Clinical and functional results of
treatment were assessed before surgery and at 3, 12 and 36 months after
surgery. In addition, to objectify the analysis of structural changes in the
articular surface of the transplantation area, patients underwent radiography
and magnetic resonance imaging (MRI) of the knee joint. These studies were
performed before and after surgery (after 12 months).
Comparisons between groups were performed using
nonparametric Kruskal-Wallis analysis of variance followed by group comparisons
using the Mann-Whitney-Wilcoxon test. The critical values of the level of
statistical significance when testing the null hypothesis were taken equal to p
≤ 0.05. The obtained results were statistically processed using the STATISTICA
software package (Statistica for Windows, Release 6.1, StatSoft Inc., USA).
RESULTS OF THE STUDY
Index values and scales of clinical assessment before treatment, 3, 12 and 36 months after treatment are presented in tables 4-7.
Table 4. Index values and scales of clinical evaluation before treatment, points (M ± σ)
|
Values |
First group |
Second
group |
Third
group |
pI-II |
pI-III |
pII-III |
|
Total WOMAC index |
903 ± 43.4 |
851 ± 62.2 |
889 ± 43.7 |
0.165 |
0.098 |
0.109 |
|
Algofunctional index by M. Lequesne |
8.31 ± 0.38 |
7.45 ± 0.13 |
8.17 ± 0.55 |
0.124 |
0.137 |
0.059 |
|
Oxford knee score (OKS) value |
33.17 ± 2.1 |
39.57 ± 0,14 |
38.27 ± 0.57 |
0.086 |
0.121 |
0.261 |
Table 5. Values of indices and scales of clinical assessment 3 months after treatment, points (M ± σ)
|
Values |
First group |
Second
group |
Third
group |
pI-II |
pI-III |
pII-III |
|
Total WOMAC index |
769 ± 27.5 |
715 ± 68.2 |
781 ± 46.9 |
0.069 |
0.133 |
0.057 |
|
Algofunctional index by M. Lequesne |
6.09 ± 0.27 |
5.73 ± 0.23 |
5.76 ± 0.19 |
0.073 |
0.082 |
0.197 |
|
Oxford knee score (OKS) value |
31.07 ± 0.35 |
33.67 ± 0.11 |
34.29 ± 0.15 |
0.052 |
< 0.05 |
0.092 |
Table 6. Values of indices and scales of clinical assessment 12 months after treatment, points (M ± σ)
|
Values |
First group |
Second
group |
Third
group |
pI-II |
pI-III |
pII-III |
|
Total WOMAC index |
651 ± 79.3 |
584 ± 43.8 |
603 ± 37.4 |
0.069 |
0.133 |
0.064 |
|
Algofunctional index by M. Lequesne |
5.07 ± 0.18 |
3.48 ± 0.64 |
4.11 ± 0.24 |
< 0.05 |
< 0.05 |
0.057 |
|
Oxford knee score (OKS) value |
26.31 ± 0.11 |
24.06 ± 0.29 |
21.89 ± 0.41 |
0.053 |
< 0.05 |
0.087 |
Table 7. Values of indices and scales of clinical assessment 36 months after treatment, points (M ± σ)
|
Values |
First group |
Second
group |
Third
group |
pI-II |
pI-III |
pII-III |
|
Total WOMAC index |
509 ± 37.2 |
437 ± 58.4 |
479 ± 29.1 |
< 0.05 |
0.081 |
0.128 |
|
Algofunctional index by M. Lequesne |
3.62 ± 0.24 |
2.19 ± 0.27 |
2.34 ± 0.11 |
< 0.05 |
< 0.05 |
0.163 |
|
Oxford knee score (OKS) value |
21.98 ± 0.14 |
17.72 ± 0.38 |
19.11 ± 0.18 |
< 0.05 |
0.052 |
0.095 |
Evaluation of the results of treatment showed an
improvement in the studied parameters in all groups of observed patients.
However, the analysis revealed a significant difference in clinical and
functional recovery in patients of the second and third groups compared to the
first group. This difference in treatment results is most pronounced in the
late (12 months) and long-term (36 months) periods after surgery. At the same
time, it should be noted that the results of treatment in patients of the
second and third clinical groups in the long-term follow-up were quite similar
in value (total WOMAC index − 437 ± 58.4 and 479 ± 29.1, M. Lequesne's
algofunctional index - 2.19 ± 0.27 and 2.34 ± 0.11, Oxford knee score - 17.72 ±
0.38 and 19.11 ± 0.18, respectively). We attribute this to the creation of
optimal conditions for regeneration processes when using the proposed methods
of chondroplasty. It should be noted that in the second clinical group, the use
of spongy bone autografts taken extra-articularly showed their greater
integration with the surrounding tissues and a significantly pronounced
morphological reorganization. This greatly distinguishes them from grafts taken
in the same affected joint, with obviously altered destructive-dystrophic
process of bone and cartilage tissues, and also leads to a decrease in joint
traumatization intraoperatively.
In the third clinical group, despite the use of
osteochondral autografts from lightly loaded parts of the joint, myoplasty of
the metaphyseal area of transplantation leads to an improvement in local blood
circulation and activates trophic processes, which ensures complete
osseointegration of the bone part of the grafts in the recipient zone and
creates optimal conditions for cartilage tissue repair processes.
When analyzing radiographs of the knee joint in
frontal and lateral projections performed in the standing position, changes in
the subchondral bone, the structure of the metaphyseal region of the affected
condyle, and the degree of progression of radiological symptoms of
osteoarthrosis were evaluated. Magnetic resonance imaging was used to analyze
the state of the articular cartilage, pathological changes in intra-articular
soft tissues, and also verified the severity and localization of bone marrow
edema with an assessment of the dynamics of its changes.
During estimation of X-ray images, the radiologic symptoms of
progression of destructive dystrophic lesion of the joint in view of increasing
sclerosing of the subchondral bone of femoral condyles and asymmetric narrowing
of X-ray joint space were observed in the late period (12 months) after surgery
in 5 (17.2 %) patients of the group 1. Identical
dynamics of the pathological process during this observation period in the
second and third groups was visualized in 4 (12.9 %) and 5 (18.5 %) patients,
respectively. 36 months after chondroplasty, the progression of radiological
symptoms of osteoarthrosis was recorded in 11 (37.9 %) patients of the first
group, 7 (22.6 %) patients of the second group, and 8 (29.6 %) patients of the
third group. In other words, the method of surgical intervention affects the
changes in the X-ray pattern in all study groups (c2 = 6.8, p < 0.05).
When
studying magnetic resonance tomograms of the knee joint at the twelfth month
after surgery, 8 (27.5 %) patients of the first group showed the thinning of
the articular hyaline cartilage in the transplantation area. The moderate
perifocal edema was visualized in the affected femoral condyle and cystic
restructuring of the subchondral bone in the form single or multiple cavities
with characteristic fluid signals and the presence of a sclerotic rim. In
addition, in patients of this group, edema of the bone marrow of the donor area
(the lateral epiphysis of the femur) was verified, which indicated the
development of a chronic inflammatory process in this area. In the second and
third groups, the development of degenerative changes in the hyaline cartilage,
most pronounced in the area of chondroplasty, was visualized in 5 (16.1 %) and
6 (22.2 %) patients, respectively.
At
a follow-up period of 36 months, the progression of degenerative-dystrophic
lesions of the cartilage of the articular surfaces of both the femur and tibia
was observed in 12 (41.3 %) patients of the first group. Similar changes in the
articular cartilage in the second group were less pronounced and were observed
in 9 (29 %) patients. In patients of the third clinical group, the progression
of destructive-dystrophic cartilage lesions with preservation of perifocal bone
marrow edema of the affected femoral condyle was visualized in 10 (37 %) cases.
It should be noted that the symptoms of progression of osteoarthrosis of
the operated joint revealed by radiography and MRI were not accompanied by
worsening of the clinical manifestations of the disease in a significant number
of cases. Evidence of this is the fact that at the follow-up period of 36
months after surgery, only one of the observed patients underwent total knee
arthroplasty due to a significant decrease in the quality of life due to the
development of a clinically manifest terminal stage of osteoarthritis.
DISCUSSION
Currently, there is a clear trend towards an increase in the number of
operations of unicondylar knee arthroplasty in patients with
destructive-dystrophic monocondylar osteochondral defects of the articular
surfaces. However, this surgical intervention has a number of potential risks
and debatable points, which include the problem of expectations and real
satisfaction of patients after this surgical intervention, ambiguous long-term
clinical results, replacement of two articular surfaces with damage to only
one, the prospective impossibility of converting to total arthroplasty in case
of the development of a number of complications and, finally, the conscious
refusal of patients from unicondylar arthroplasty [4, 6].
Despite the existing skepticism towards the use of mosaic chondroplasty
in osteoarthritis, the scientific data of numerous authors and the results
obtained in the study convincingly show the possibility of its successful
clinical application in deforming gonarthrosis of stages II and III. However,
this can be achieved with a careful and balanced assessment of concomitant
factors that determine the outcome of the intervention [1, 3].
An interesting macroscopic picture of the transplanted area in patients
with progressive osteoarthritis of the knee after a previous history of
chondroplasty, obtained during clinical observation in patients who underwent
total arthroplasty, convincingly speaks to us about the effectiveness of using
mosaic autoplasty in destructive-dystrophic joint damage. In the area of
autoplasty of the femoral condyle, these observations clearly visualized the
formed fibrous cartilage tissue, which was macroscopically changed like the
rest of the surrounding articular surface, as well as the absence of fatal
destructive changes (Fig. 6).
Figure 6. The area of the articular surface of the
internal femoral condyle after autochondroplasty of the defect with spongy bone
autografts 6 years later (circled)
CONCLUSION
The use of mosaic osteochondral autoplasty for destructive-dystrophic
defects of the cartilage of the knee joint is pathogenetically justified, and
the effectiveness of the method of surgical restoration of the articular
surface lies in achieving a pronounced clinical remission and ensuring
functional restoration of the joint. In osteoarthritis, accompanied by the
formation of monocondylar full-thickness chondral defects, it can be used as
one of the main methods of organ-preserving surgical interventions.
In patients with full-layer destructive-dystrophic cartilage defects of
the articular surface, a comparative analysis of the results of their surgical
treatment showed that the highest efficiency of mosaic autochondroplasty was
found in groups of patients where methods of surgical intervention were used
that were not based on the postulation of the priority of simple mechanical
filling of the defect area with bone and cartilage transplants, but based on
the modern understanding of the role of bone tissue both in the pathogenesis of
osteoarthritis and in the processes of reparative regeneration,
interdependently occurring in the subchondral, metaphyseal bone and articular
cartilage. This moment is, from our point of view, fundamentally important,
since the result of the processes of morphological restructuring of the hyaline
cartilage of transplants, and, consequently, the restoration of the mechanical
properties of the transplantation area, to a large extent determine the quality
of the bone of the transplanted structures and the transplantation area itself.
The results obtained in this study make it possible to recommend the
proposed methods of chondroplasty for use in clinical practice and open up
opportunities for their further improvement.
Funding and conflict of interest information
The study was not sponsored. The work was carried out in accordance with
the research plan of the department and clinic of traumatology, orthopedics and
extreme surgery named after academician A.F. Krasnov, Samara State Medical
University of the Ministry of Health of Russia.
The authors declare the absence of obvious and potential conflicts of
interest related to the publication of this article.
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