[Surgical treatment of a juxtaarticular bonecyst communicating with the ankle joint in a severe haemophilia A case]. / Felso ugróízülettel kommunikáló csontcysta sebészi kezelése súlyos A-haemophiliás betegen.

The authors report the case of a 19-year-old male patient with inhibitor-positive factor VIII deficiency. The patient had painful, limited range of motion and swelling in the left toe, due to haemarthrosis 1-2 times a month. The MR images depicted a bone cyst penetrating into the tibiotalar joint space at the distal end of the left tibia. Due to the size and localisation of the cyst, there was a high chance of a pathological fracture with a potential intraarticular component. The clinical scenario was complicated by the high level of antifactor VIII antibodies. To prevent pathological fracture and stop the recurrence of haemarthrosis, the authors decided to debride the cavity and fill it with bone chips. During the operation and the postoperative period the patient recieved recombinant clotting factor substitution and standard thromboprophylaxis. Despite the high risk of bleeding complication, the patient had neither bleeding nor thomboembolic complication. Further bleeding into the joint space has not been reported by the patient since the surgery. The authors aim to draw attention to this rare, but significant disease, the role of the haemophilia centers and the importance of the coordinated multidisciplinary treatment. Orv Hetil. 2019; 160(17): 679-682.

A clinical feasibility study to evaluate the safety and efficacy of PEOT/PBT implants for human donor site filling during mosaicplasty.

UNLABELLED: Mosaicplasty has become a well-accepted treatment modality for articular cartilage lesions in the knee. Postoperative bleeding remains potentially concerning. This study evaluates the porous poly(ethylene oxide)terephthalate/poly(butylene terephthalate) (PEOT/PBT) implants used for donor site filling. Empty donor sites were the controls. After 9 months, MRI, macroscopical and histological analysis were carried out. Treated defects did not cause postoperative bleeding. No adverse events or inflammatory response was observed. PEOT/PBT implants were well integrated. Empty controls occasionally showed protrusion of repair tissue at the defect margins. Surface stiffness was minimally improved compared to controls. Existing polymer fragments indicated considerable biodegradation. Histological evaluation of the filled donor sites revealed congruent fibrocartilaginous surface repair with proteoglycan-rich domains and subchondral cancellous bone formation with interspersed fibrous tissue in all implanted sites. The PEOT/PBT implants successfully reduce donor site morbidity and postoperative bleeding after mosaicplasty. LEVEL OF EVIDENCE: II.

Autologous osteochondral grafting--technique and long-term results.

BACKGROUND: Efficacious treatment of chondral and osteochondral defects of weightbearing articular surfaces is a daily challenge in musculoskeletal care. Autogenous osteochondral transplantation represents a possible solution for creating hyaline or hyaline-like repair in the affected area that has a noninflammatory pathoorigin. This paper discusses the experimental background and over 15 years of clinical experience with autologous osteochondral mosaicplasty. METHODS: Several series of animal studies and subsequent clinical practice of over 1,000 mosaicplasty patients were assessed to confirm the survival of transplanted hyaline cartilage and fibrocartilage filling of donor sites located on relatively less weightbearing surfaces, as well as donor-site disturbances and morbidity. Histological evaluations of dog and horse implantations as well as several series of clinical evaluations in the human material are summarized in this paper. Clinical scores, different types of imaging techniques, second-look arthroscopies, histological examination of biopsy samples, and cartilage stiffness measurements were used to evaluate the clinical outcomes and quality of the transplanted cartilage. RESULTS: Analysis of clinical scores has shown good to excellent results in 92% of patients with femoral condylar implantations, 87% of tibial resurfacements, 74% of patellar and/or trochlear mosaicplasties and 93% of talar procedures. Longterm donor-site complaints measured by the Bandi score were minor and present only in 3% of patients. 81 out of the 98 control arthroscopies represented congruent and good gliding surfaces and histologically proven survival of the transplanted hyaline cartilage as well as fibrocartilage covering of the donor sites. Complications in the entire patient group were four deep infections and four deep venous thromboses. In nearly 8% of the cases excessive intraarticular bleeding was observed in the early postoperative period, as a minor complication of the procedure. Multicentric, comparative, prospective evaluation of 413 arthroscopic resurfacing procedures (mosaicplasty, Pridie drilling, abrasion arthroplasty and microfracture cases in homogenised subgroups) demonstrated that mosaicplasty resulted in favourable clinical outcome in the long-term follow-up compared to other three techniques. Durability of the early results was confirmed in long-term evaluations both of the femoral condylar implantations and talar mosaicplasties. CONCLUSIONS: According to our encouraging results in this increasingly large series, supported by similar findings from other centres, it seems that autologous osteochondral mosaicplasty may be an alternative for small and medium-sized focal chondral and osteochondral defects of weightbearing surfaces of the knee and other weightbearing synovial joints.

Autologous osteochondral mosaicplasty grafting.

Successful management of chondral and osteochondral defects of the weight-bearing joint surfaces has always been a challenge for orthopedic surgeons and rehabilitation specialists. Autologous osteochondral mosaic transplantation technique is one of the recently evolved methods to create hyaline or hyaline-like repair tissue in the pathologic area. Clinical evaluation, various imaging techniques, arthroscopy (second look), histological examination of biopsy samples, and measurements of cartilage mechanical properties are used to evaluate the merits of outcomes and quality of the transplanted cartilage. According to our investigations, good to excellent results were achieved in more than 92% of patients treated with femoral condylar implantations, 87% of those treated with tibial resurfacing, 79% of those treated with patellar and/or trochlear mosaicplasties, and 94% of those treated with talar procedures. Long-term donor-site discrepancies, assessed with use of the Bandi Score, showed that patients had 3% morbidity after mosaicplasty. Sixty-nine of 89 patients who were followed up with a second-look arthroscopy showed congruent gliding surfaces, histological evidence of the survival of the transplanted hyaline cartilage, and fibrocartilage filling of the donor sites. In a series of 831 consecutive patients, very few complications have been observed. These included 4 deep infections and 36 painful postoperative intra-articular bleedings. On the basis of these results and those of other similar studies, autologous osteochondral mosaicplasty appears to be a promising alternative for the treatment of small- and medium-sized focal chondral and osteochondral defects of the weight-bearing surfaces of the knee and other weight-bearing synovial joints.

[Total knee arthroplasty in hemophilic arthropathy]. / Térdprotézis/beültetés arthropathia haemophilica esetén.

The case of a bilateral total knee arthroplasty in a hemophiliac patient is presented below. Postoperative blood loss, required factor substitution, complications after surgery were observed. Functional results were evaluated using the Hospital for Special Surgery Score. The pathophysiology of hemophilic arthropathy is reviewed also. The arthroplasties were performed using factor substitution and a tourniquet, posterior stabilized prosthesis was implanted on both sides. The average postoperative blood-loss was 700 ml. After the first procedure hemarthrosis occurred, other complications were not observed. Follow-up time was 164 weeks in the first case and 112 in the second. The average improvement in Hospital for Special Surgery Score was 34 points reaching 97,5 points postoperatively. Range of movement was 0-120 degrees on the right and 0-135 degrees on the left side. The authors emphasize the importance of the adequate hematological and anaesthetical background when performing surgery in a hemophiliac patient.

Experimental results of donor site filling for autologous osteochondral mosaicplasty.

PURPOSE: Autologous osteochondral mosaicplasty has become a treatment option for focal chondral and osteochondral defects in recent years. Excessive postoperative bleeding from the donor site was reported as a possible complication of the procedure. The purpose of this study was to investigate different biodegradable materials for donor site filling, which could prevent excessive postoperative bleeding from these sites but would allow reasonable blood clot formation on the articular surfaces of donor tunnels. TYPE OF STUDY: Basic science evaluation. METHODS: In an experimental model, "donor site plugs" made from hydroxylapatite, carbon fiber, polyglyconate-B, compressed collagen, and 2 versions of polycaprolactones were used to fill the bony tunnels created by harvesting. These materials were tested in 100 knees of 50 German Shepherd dogs to determine the quality of the repair tissue formation on the surfaces of the harvesting holes filled by these materials. Arthroscopies of the dogs were performed at several intervals, from 4 weeks to 26 weeks, and macroscopic studies were performed on euthanized animals between 8 weeks and 30 weeks to evaluate donor site filling and coverage. Empty donor tunnels served as controls for the evaluation of the different filling materials. RESULTS: All tested materials effectively decreased postoperative bleeding. Hydroxylapatite, carbon rods, polyglyconate-B, and melted polycaprolactone materials showed a good integration to the surrounding cancellous bone, but these fillings showed only a limited repair tissue formation, even at 30 weeks postoperatively. Second-look arthroscopy and histologic evaluation of necropsies showed the best fibrocartilage coverage after filling by compressed collagen. Technical details of the filling also had certain importance in the quality of the repair tissue formation. CONCLUSIONS: According to histologic results, compressed collagen appears to be a good material to fill donor tunnels of osteochondral graft harvest. This material is substituted gradually by bone formation and its articular surface can serve as an appropriate scaffold for fibrocartilage coverage created by the natural intrinsic repair process.