Periosteal Cover Research Articles

Cost-efficacy of Knee Cartilage Defect Treatments in the United States

Background: Multiple knee cartilage defect treatments are available in the United States, although the cost-efficacy of these therapies in various clinical scenarios is not well understood. Purpose/Hypothesis: The purpose was to determine cost-efficacy of cartilage therapies in the United States with available mid- or long-term outcomes data. The authors hypothesized that cartilage treatment strategies currently approved for commercial use in the United States will be cost-effective, as defined by a cost <$50,000 per quality-adjusted life-year over 10 years. Study Design: Systematic review. Methods: A systematic search was performed for prospective cartilage treatment outcome studies of therapies commercially available in the United States with minimum 5-year follow-up and report of pre- and posttreatment International Knee Documentation Committee subjective scores. Cost-efficacy over 10 years was determined with Markov modeling and consideration of early reoperation or revision surgery for treatment failure. Results: Twenty-two studies were included, with available outcomes data on microfracture, osteochondral autograft, osteochondral allograft (OCA), autologous chondrocyte implantation (ACI), and matrix-induced ACI. Mean improvement in International Knee Documentation Committee subjective scores at final follow-up ranged from 17.7 for microfracture of defects >3 cm2 to 36.0 for OCA of bipolar lesions. Failure rates ranged from <5% for osteochondral autograft for defects requiring 1 or 2 plugs to 46% for OCA of bipolar defects. All treatments were cost-effective over 10 years in the baseline model if costs were increased 50% or if failure rates were increased an additional 15%. However, if efficacy was decreased by a minimum clinically important amount, then ACI (periosteal cover) of femoral condylar lesions ($51,379 per quality-adjusted life-year), OCA of bipolar lesions ($66,255) or the patella ($66,975), and microfracture of defects >3 cm2 ($127,782) became cost-ineffective over 10 years. Conclusion: Currently employed treatments for knee cartilage defects in the United States are cost-effective in most clinically acceptable applications. Microfracture is not a cost-effective initial treatment of defects >3 cm2. OCA transplantation of the patella or bipolar lesions is potentially cost-ineffective and should be used judiciously.

A large knee osteochondral lesion treated using a combination of osteochondral autograft transfer and second-generation autologous chondrocyte implantation: A case report.

BackgroundFull-thickness knee cartilage defects greater than 4 cm2 are best treated with autologous chondrocyte implantation (ACI). Since the articular cartilage surrounding the site of implantation does not always have the normal thickness desirable for successful engraftment, there may be benefit in combining ACI with osteochondral autograft transfer, which provides immediate restoration of condylar contour and mechanical function.Case presentationA 19 year-old male who sustained a traumatic anterolateral femoral condyle osteochondral fracture underwent arthroscopic knee surgery three months after injury to harvest healthy cartilage to be sent to the Japan Tissue Engineering Co., Ltd. (J-TEC) for cartilage culture. The patient was re-admitted after four weeks to undergo a procedure using the Osteochondral Autograft Transfer System (OATS®) and the J-TEC autologous cultured cartilage (JACC®) system. Three 4.75-mm osteochondral cylindrical cores were harvested from non-weight-bearing areas of the knee and were transplanted to the lateral periphery of the lateral femoral condyle defect. The cultured cartilage was implanted to the remaining defect with a periosteal cover harvested from the anterolateral ridge of the lateral femoral condyle. Continuous passive range of motion exercises and gait retraining were immediately initiated, with strict no weight-bearing precaution on the operated limb. Partial weight-bearing was allowed four weeks after surgery, which was progressed to full weight-bearing after another two weeks.ConclusionACI must be viewed as a complementary procedure to osteochondral transplantation and this hybrid technique appears to be a promising surgical approach and treatment option for large cartilage lesions, especially in the younger population.

Osteoma of mastoid temporal bone

&lt;p&gt;Osteoma is a benign slow growing bone tumour with predominance in long bones, and is rare in the skull. They are a rare occurrence in the mastoid temporal bone, being usually asymptomatic and treated mainly for cosmetic reasons. We report a case of a young female who presented with a history of swelling in the left post aural region since 10 years. Swelling was gradually increasing in size and was painless. Patient underwent excision of the tumour without any significant complication. As per our knowledge this appears to be the largest tumour reported in literature. The clinical presentation and radiological features of osteoma are characteristic but differential diagnosis should include eosinophilic granuloma, giant cell tumour, monostotic fibrous dysplasia, solitary variant of multiple osteoma, and osteoblastic metastasis. Osteomas present on the mastoid or squamous portion of the temporal bone need to be dealt for cosmetic purposes or if they are causing symptoms, while surgery should include careful removal of periosteal cover and safe margin of the mastoid cortex around it. &lt;/p&gt;

Management of Patellar and Trochlear Chondral Injuries

Patellofemoral chondral injuries are noted in a significant subset of patients with anterior knee pain. These injuries occur as a result of both acute traumatic events and chronic patellofemoral malalignment. Focal grade III and IV chondral defects of the patella or trochlea present a significant management challenge. Anatomic factors, including an increased quadriceps angle, tight lateral retinaculum and weakened vastus medialis oblique muscle produce maltracking, which results in overload of the lateral patellofemoral joint. Patella alta, trochlear dysplasia and hyperlaxity can result in patellofemoral instability and subluxation. These factors play a role in the development of patellofemoral chondral injuries and must be addressed. A trial of 6 months of conservative management is indicated for most patients. Surgical options often include a realignment procedure in addition to treatment of the chondral injury. Traditional cartilage resurfacing techniques including debridement, abrasion arthroplasty and microfracture have been used but are limited by the inferior wear characteristics of the fibrocartilage tissue which forms over the defect. Newer cartilage repair techniques include autologous chondrocyte implantation and osteochondral autograft transfer (mosaicplasty) attempt to repair the chondral defect with hyaline cartilage. Osteochondral allograft transfer is an option for large chondral defects in which the surface contour of the patella or trochlea has been lost. Patellofemoral arthroplasty may be superior to total knee arthroplasty in patients with isolated patellofemoral joint collapse. Newer techniques such as arthroscopic autologous chondrocyte implantation using biologic scaffolds in place of the periosteal cover are currently being investigated.

Free latissimus dorsi flap transfer for subtotal scalp and cranium defect reconstruction: report of seven cases

The purpose of this paper is to review the results of free latissimus dorsi transfer for scalp and cranial reconstruction in the case of large defects with exposed brain tissue, cranial bone without periosteal cover, and dura, which cannot be reconstructed with local flaps or skin grafts. Free latissimus dorsi transfer was carried out in seven patients with subtotal and total scalp defects (two reconstruction after tumor removal, two reconstructions after long-standing osteitis, two tissue breakdown after irradiation, one defect reconstruction after high voltage injury). There were three male and four female patients. The age ranged from 36 to 72 years. Reconstruction was performed with a muscle flap (1) or a myocutaneous flap (6) in combination with a split-thickness skin mesh (1:1.5) graft in a single-stage procedure. In a retrospective clinical study, the following criteria were evaluated: (1) flap healing, (2) aesthetic result, and (3) complications. All flaps healed primarily, and all wounds remained closed without any signs of infection. Complete wound healing was achieved after 4 to 8 weeks, depending on the “take” of the skin grafts. Secondary skin grafting was necessary in two patients, while revision of the donor site was necessary in two patients. From an aesthetic point of view, four patients complained about the appearance of the retroauricular skin island. After removal of the skin island 6 months after the initial operation, all patients judged the result as good or acceptable. Besides the free omentum flap, the free latissimus dorsi transfer is the only option for cover of subtotal or total scalp defects. Compared to the omentum flap, the latissimus dorsi offers more tissue, has less donor site morbidity, and secondary surgery such as cranial bone reconstruction is possible. Contrary to most authors, our preferred donor vessels are maxillary artery and the external jugular vein. To avoid any vascular compression, we use a myocutaneous flap. The skin island must be removed secondarily. In patients where no bone reconstruction is possible or planned, the de-epithelialized skin paddle can be used for correction of a contour defect.

A prospective, ranomised study comparing two techniques of autologous chondrocyte implantation for osteochondral defects in the knee: Periosteum covered versus type I/III collagen covered

Introduction The results for autologous chondrocyte implantation (ACI) in the treatment of full thickness chondral defects in the knee are encouraging. At present two techniques have been described to retain the chondrocyte suspension within the defect. The first involves using a periosteal cover (ACI-P) and the second involves using a type I/III collagen membrane (ACI-C). To the authors knowledge there are no comparative studies of these two techniques in the current literature. We have therefore undertaken such a study to establish if there is a difference between the 2 techniques based on a clinical and arthroscopic assessment. Methods A total of 68 patients with a mean age of 30.52 years with symptomatic articular cartilage defects were randomised to have either ACI-P (33 patients) or ACI-C (35 patients). The mean defect size was 4.54 cm 2. All patients were followed up at 24 months. Results A clinical and functional assessment showed that 74% of patients had a good or excellent result following the ACI-C compared with 67% after the ACI-P at 2 years. Arthroscopy at 1 year also demonstrated similar results for both techniques. However, 36.4% of the ACI-P grafts required shaving for hypertrophy compared with none for the ACI-C grafts at 1 year. Discussion This study has shown no statistical difference between the clinical outcome of ACI-C versus ACI-P at 2 years. A significant number of patients who had the ACI-P required shaving of a hypertrophied graft. We conclude that there is no advantage in using periosteum as a cover for retaining chondrocytes within an osteochondral defect; as a result we advocate the use of an alternative cover such as a manufactured type I/III collagen membrane.

Comparison of four techniques for the fixation of a collagen scaffold in the human cadaveric knee

Four fixation techniques for a fibrinogen and thrombin coated collagen fleece, used as a scaffold in the cartilage repair, were compared simulating the initial postoperative period in the cadaveric knee joints. Full-thickness chondral lesions were made on the medial femoral condyles of seven human cadaveric inferior extremities. Four scaffolds without seeded chondrocytes were implanted into each lesion using four fixation techniques consecutively: self-adhesion without additional material (SA), fibrin sealant (FS), bone sutures (BS), and periosteal cover (PC). After each implantation 150 cycles of continuous passive motion (CPM) were performed. Two cases were additionally exposed to 50 cycles of 10 and 20 kg loading each after the completion of CPM. The scaffolds were evaluated after every 30 cycles, and the fixation strength was tested after the motion was completed. All the SA scaffolds were detached before 60 cycles. The other scaffolds remained stable throughout the testing with only minor disruptions. The endpoint fixation strength was higher for BS and PC than for the FS scaffolds. The FS scaffolds were detached as a result of additional load cycles, while the BS and PC scaffolds showed substantial deformations. SA of tested scaffold did not provide sufficient fixation. The FS fixation was easy to perform and assured satisfactory scaffold stability. BS and PC provided excellent scaffold stability, but the techniques were difficult and caused additional injuries. Regardless of the fixation technique used, the tested collagen scaffold may not be exposed to loading in the initial postoperative period.

Periosteum stimulates subchondral bone densification in autologous chondrocyte transplantation in a sheep model

In this sheep study, we have tested the hypothesis that an osteogenic response is triggered in the subchondral bone by periosteum implanted in full thickness cartilage defects and can be prevented by replacing the periosteum by a cell-free collagen type I/III membrane. Two 7-mm diameter osteochondral defects were made in the trochlea groove and in the medial femoral condyle of one of the knees in each of 15 adult sheep. The animals were divided into three groups (n=5): a control group with untreated cartilage defects, a group treated with autologous chondrocyte transplantation (ACT) and periosteum, and a group treated with ACT in combination with a collagen I/III membrane cover. Histological examination was performed 1 year later. The optical density of the subchondral bone in the histological sections was measured with digital imaging software. There was a dramatic, statistically significant (P<0.0001; power=1) increase in bone density of 45%-70% under defects that were treated with the periosteal cover, compared with the collagen membrane and control groups, which displayed the same bone density. There was no difference in the cartilaginous reparative tissue in the defects in the three groups. Periosteum thus stimulates the remodelling process in subchondral bone. Stiffening of the subchondral bone can lead to degeneration of the overlying reparative cartilaginous tissue because of an increase in the mechanical stress in the tissue. These findings warrant evaluation of subchondral bone changes in patients treated by ACT and the correlation of these changes with clinical outcome.

Early postoperative adherence of matrix-induced autologous chondrocyte implantation for the treatment of full-thickness cartilage defects of the femoral condyle

Matrix-induced autologous chondrocyte implantation (MACI) is a tissue-engineering technique for the treatment of full-thickness articular cartilage defects and requires the use of a three-dimensional collagen type I-III membrane seeded with cultured autologous chondrocytes. The cell-scaffold construct is implanted in the debrided cartilage defect and fixed only with fibrin glue, with no periosteal cover or further surgical fixation. In a clinical pilot study, the MACI technique was used for the treatment of full-thickness, weight-bearing chondral defects of the femoral condyle in 16 patients. All patients were followed prospectively and the early postoperative attachment rate, 34.7 days (range: 22-47) after the scaffold implantation, was determined. With the use of high-resolution magnetic resonance imaging (MRI), the transplant was graded as completely attached, partially attached, or detached. In 14 of 16 patients (87.5%), a completely-attached graft was found, and the cartilage defect site was totally covered by the implanted scaffold and repair tissue. In one patient (6.25%), a partial attachment occurred with partial filling of the chondral defect. A complete detachment of the graft was found in one patient (6.25%), which resulted in an empty defect site with exposure of the subchondral bone. Interobserver variability for the MRI grading of the transplants showed substantial agreement (kappa=0.775) and perfect agreement (kappa(w)=0.99). In conclusion, the implantation and fixation of a cell-scaffold construct in a deep cartilage defect of the femoral condyle with fibrin glue and with no further surgical fixation leads to a high attachment rate 34.7 days after the implantation, as determined with high resolution MRI.

Reduction Malarplasty

Although many societies consider prominent cheekbones attractive, when the midface roundness reaches an excessive proportion this distinction may become undesirable. Besides the issue of hypertrophy, malar asymmetry in any individual may also require correction. Reduction malarplasty is performed through a vertical incision in the canine fossa. After the zygomaticus muscles are bluntly divided and retracted, the periosteal cover is elevated from the cortex. With a high-speed cutting burr, the malar eminence is then drilled until the desired height is achieved. The wound is irrigated and closed. We have performed this procedure successfully in eight patients with up to eighteen months follow-up. Transient loss of zygomaticus muscle function and numbness from traction on the infraorbital nerve occurred in two patients. All patients were completely satisfied with the improvement in their frontal profile. This operation requires a detailed understanding of the mid-face anatomy and the surgical boundaries of the malar bone but will result in a more sculptured front-face outline.

The Role of Nonvascularized Toe Phalanx Transplantation

Stabilization of boneless finger stumps or lengthening of partially aplastic digits in congenital malformations is difficult, because the bone graft, placed on top of the existing bone, will undergo resorption. Only the periosteum-covered proximal toe phalanx will withstand resorption and show a complete take. With the toe phalanx, including the plantar plate and the collateral ligaments of the metatarsophalangeal joint as a half-joint, it is possible to construct a new joint with the cartilage-covered distal end of the recipient bone (metacarpal or proximal phalanx) as the proximal half-joint. Flexor and extensor tendons exist in almost all cases. Between 1976 and 1990, 97 toe phalanx transplantations were performed in 57 children. The indications were boneless digital stumps with partial absence of digits and large bone defects in fingers in symbrachydactyly and ring-constriction syndrome. Follow-up examinations of 44 patients with 69 transplanted toe phalanges (95% of the patients operated on by March 1989) have shown a 100% take of the bone graft, provided it had been unsplit and the periosteal cover undamaged. The earlier in life the operation was performed, the more postoperative growth was recorded. The shortening of the donor toe was less because a tendon interposition was used. A joint construction was attempted in 64 digits with variable results. The range of active motion varied between 0 (fusion) and 90 degrees.