Autologous Chondrocyte Implantation: Transarthroscopic Implantation of Hyalograft (Hyaff 11) with Autologous Chondrocytes

Chapter 9D Autologous Chondrocyte Implantation


Transarthroscopic Implantation of Hyalograft (Hyaff 11) with Autologous Chondrocytes




Introduction


To facilitate the implantation of cultured chondrocytes and make it possible to perform an autologous chondrocyte implantation (ACI) procedure transarthroscopically, different porous scaffolds have been developed. One such material is based on the benzylic ester of hyaluronic acid (Hyaff 11, Fidia Advanced Biopolymers, Abano Terme, Italy) and consists of a network of 20-μm-thick fibers with interstices of variable sizes.


It has been demonstrated to be an optimal physical support to allow cell-cell contacts, cluster formation, and extracellular matrix deposition and to deliver differentiated chondrocytes.1,2


The cells harvested from the patient are expanded and then seeded onto the scaffold where the cells are able to redifferentiate and retain a chondrocytic phenotype even after a long period of in vitro expansion in monolayer culture1,2 (Fig. 9D-1). The Hyalograft with cultured chondrocytes may be implanted by press fitting directly into the lesion as described by Kon et al.3 The scaffold has self-adhesive properties, but most often additional fibrin glue is needed for a secure positioning. In this chapter, the authors describe a modified implantation technique: the “folded blanket” technique for the knee and for the ankle.





Technical Overview


Cartilage is harvested as described in Chapter 9C. The cell culture takes a longer time to grow compared to when cells are transplanted as suspension. After 4 to 5 weeks, the scaffold is delivered as 2 × 2 cm large patches (Fig. 9D-2). Depending on the quality of the cultured cells, the seeded scaffolds have different strength.




Operative Technique for the Knee


A high anteromedial or anterolateral portal is created, and a standard arthroscopy is performed in supine position.


The arthroscopic Hyalograft-chondrocyte technique is applicable for defects at the medial and lateral femoral condyle, trochlea, tibial plateau, and in some rare cases when reachable also for the patella.


For a defect at the medial femoral condyle, a medial suprameniscal portal is created. This portal is needed to introduce the matrix into the joint.


A half pipe introducer may be used to introduce the scaffold into the joint.


The defect has already been debrided as described in Chapter 3. The central part of the defect is treated by a microfracture awl to get a fixation point (mushroom fixation) (Fig. 9D-3).



The chondrocyte-seeded matrix is then cut with a scissor or scalpel to the approximate size of the defect (Fig. 9D-4).



The scaffold is covered with a thin fibrin glue layer (Fig. 9D-5), grasped with an arthroscopic grasp instrument with plain surfaces (Fig. 9D-6), and introduced into the joint along the half pipe intruder to reach the defect (Fig. 9D-7).





The pressure controlled pump may be stopped intermittently during the procedure. (The operation may also be done in CO2.)


The scaffold is released from the grasper and with a smooth arthroscopy obturator caught and moved into the defect. The central part of the scaffold is pressed gently into the fixation point.


Some extra fibrin glue is injected over the implanted scaffold, and the scaffold is compressed toward the defect bottom with a curved smooth tonsil elevator. If the scaffold is oversized, the edges may be folded like a blanket into the defect to fill it up entirely (Fig. 9D-8).


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Jul 12, 2016 | Posted by in RHEUMATOLOGY | Comments Off on Autologous Chondrocyte Implantation: Transarthroscopic Implantation of Hyalograft (Hyaff 11) with Autologous Chondrocytes

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