Scandinavian Journal of Plastic and Reconstructive Surgery
ISSN: 0036-5556 (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/iphs18
Reconstruction of Articular Cartilage Using Autologous Perichondrial Grafts: A Preliminary Report Ove Engkvist, Sune H. Johansson, Lennart Ohlsén & Tord Skoog To cite this article: Ove Engkvist, Sune H. Johansson, Lennart Ohlsén & Tord Skoog (1975) Reconstruction of Articular Cartilage Using Autologous Perichondrial Grafts: A Preliminary Report, Scandinavian Journal of Plastic and Reconstructive Surgery, 9:3, 203-206, DOI: 10.3109/02844317509022867 To link to this article: http://dx.doi.org/10.3109/02844317509022867
Published online: 08 Jul 2009.
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Citing articles: 12 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=iphs18 Download by: [University of California Santa Barbara]
Date: 14 March 2016, At: 16:25
Scand J Plast Reconstr Surg 9: 203-206, 1975
RECONSTRUCTION OF ARTICULAR CARTILAGE USING AUTOLOGOUS PERICHONDRIAL GRAFTS A Preliminary R e p o r t
Ove Engkvist, Sune H . Johansson, Lennart OhlsCn and Tord Skoog
Downloaded by [University of California Santa Barbara] at 16:25 14 March 2016
From the Department of Plastic Surgery (Head: T . Skoog), University Hospital, Uppsala, Sweden
(Submitted for publication September 16, 1975)
Abstract. In a pilot study of grown-up rabbits perichondrium from the ear was grafted to the joint surface of cavitas glenoidalis from which the normal articular cartilage had been resected. In all cases regeneration of new cartilage occurred. Five clinical cases of arthritis are reported in which, following removal of the degenerated cartilage and grafting of rib perichondrium, articular cartilage regeneration took place.
um was transferred as a free autologous graft to different parts of the body (Sohn & Ohlstn, 1974). These findings stimulated the idea that perichondrium could be used for reconstructive purposes in forming new articular cartilage. EXPERIMENTAL STUDY
The treatment of degenerative arthritis still constitutes a difficult clinical problem. Improvement can often be achieved by arthrodeses or by arthroplasty, with or without the use of ajoint prosthesis. However, the indications for arthrodeses are limited and the function of articular implants are not known from longer periods of follow-up. There is no doubt a need for other alternatives in the treatment of degenerative arthritis of joints, where painless mobility with retained stability is essential. Reconstruction of the joint by replacing the degenerated cartilage with new cartilage would be the ideal solution in these cases. Various techniques for transplantation of mature cartilage have been tried, but so far no clinically useful results have been presented. The discouraging outcome of earlier attempts to regenerate cartilage is undoubtedly due to the fact that the important role of the perichondrium was neglected. The chondrogenic potential of perichondrium was shown in 1972 by Skoog, OhlsCn & Sohn. They demonstrated massive cartilage formation originating from isolated perichondrium in the rabbit’s ear. Later the chondrogenic capacity was shown to remain unchanged when the perichondri-
Material and Method In a pilot study in 30 grown-up rabbits the humeroscapular joint was opened and well exposed by subluxating the humerus. The cartilage of cavitas glenoidalis was then completely removed down to cancellous bone. Perichondrium from the ear was grafted to the bony surface with the “active” chondrogenic surface of the perichondrium facing the joint cavity. The normal cartilage of the humeral caput was left alone. When the graft had been anchored by sutures to the capsular insertion the dislocation of the joint was reduced. The articular head then acted as a stent, offering even compression to the grafted area. In order to reduce mechanical irritation of the graft the operated extremity was amputated at wrist level preventing its use in weight bearing. The humeroscapular joint was, however, not immobilized.
Results
The complete results of this series will be presented later (Engkvist, to be published). So far only the results after 4, 6, 7 and 8 weeks are available. In 4 rabbits sacrificed after these intervals newly formed cartilage of normal appearance was found to cover the resected joint surface (Fig. 1). On microscopical examination it was evident that cartilage regeneration had taken place and the new tissue demonstrated great similarities to the normal articular cartilage (Fig. 2). Scand J Plasr Reconsrr Surg 9
Downloaded by [University of California Santa Barbara] at 16:25 14 March 2016
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moved and perichondrial grafts, taken from the ribs, were sutured tightly over the bony joint surfaces with their deep, chondrogenic layer facing outwards into the joint. To prevent obliteration of the joint with developing cartilage, a spacing piece of silastic sheeting was inserted between the two grafts. Postoperatively, the hand was firmly bandaged with the metacarpophalangeal joints in 90" flexion. Four months later, when the silastic spacer was removed, both joint surfaces were found to be completely covered by glistening-white, resilient cartilage. There was no visible difference between this newly formed cartilage and that of a normal joint (Fig. 3a-e). The patient returned to Fig. 1 . Appearance of the glenoid cavity in a rabbit, 8 work 2 months after surgery and after 4 months he weeks after resection and perichondrial grafting. Regenerwas back at full capacity doing his original work. ated cartilage covers the articular surface completely. At the second operation a biopsy was taken from the articular surface of the metacarpal head. The One rabbit was treated similary with the excep- microscopic sections demonstrated hyaline cartition that after resection of the articular cartilage the lage, similar to normal articular cartilage and of the denuded bone surface was left without a peri- usual thickness (Fig. 4f-h). A preliminary report of chondrial graft. In this animal no cartilage forma- this case was made by Skoog & Johansson (1975). tion occurred within 10 weeks. Four patients, 50-65 years old, with painful arthrosis of the carpometacarpal joint of the thumb have been operated upon, using the described techCLINICAL APPLICATION nique. Technically it was difficult to reach the deep Case reports part of this joint. The interposing silastic membrane In a saw accident, a 20-year-old carpenter injured was removed after 2-4 months and biopsies were the metacarpophalangeal joint on his long finger. then taken from the joint surfaces. Newly formed Healing was complicated by infection and the pa- cartilage was found in all cases. The clinical results, tient was left with residual arthrosis. There was an however, were not as good as in the first case. After almost complete destruction of cartilage with only 3-6 months these patients still complained of some fragments of cartilage remaining at the edges. In pain and a restricted range of motion, but all of order to restore the joint, these remnants were re- them considered their condition improved.
Fig. 2. Cross section of the humeroscapular' joint in a rabbit, 4 weeks after perichondrial grafting. (a) The joint cavity is seen in the middle with the original joint cartilage of the humerus above and the new cartilage of the scapula below (Htx-eosinx25).(6)Enlarged section of the regenerated cartilage (Htx-eosinx60). Scand J PIast Reconstr Surg 9
Downloaded by [University of California Santa Barbara] at 16:25 14 March 2016
Reconstruction of urticulur cartilage
Fig. 3 . Metacarpophalangealjoint of case I . (a) The de-
205
generated articular cartilage is shown before reconstruction of the joint. (b) After complete resection of the remaining cartilage perichondrial grafts have been sutured to cover the metacarpal head and the proximal end of the phalanx. (c) View of the explored joint 4 months after grafting. The silastic sheet has been extracted and both joint surfaces appear to be completely covered by new, glistening-white cartilage. Roentgenograms ( d ) before; and ( e )4 months after perichondrial grafting. The distance between the bony ends has increased indicating the forma-
tion of new articular cartilage. If)Microscopic section of biopsy taken from the dorsal aspect of the metacarpal head. The thickness of the newly formed articular cartilage and its relation to the underlying cancellous bone is well demonstrated ( ~ 2 0 )(8) . The bone-cartilage junction. The basal layer of the cartilage is highly cellular with clusters of chondrocytes in an axial arrangement. Mitotic cells are present ( ~ 6 0 )(.h ) Towards the cartilage surface the chondrocytes are flattened and have a tangential direction. Deeper down the collagen fibre bundles tend to form arches within the matrix ( ~ 6 0 ) .
In another case the method of perichondrial grafting was used in joint reconstruction. A 5-year-old boy with macrodactylia of his right big toe was treated by epiphysiodesis of both phalanges. After
half a year it was found that the proximal epiphysial line of the proximal phalanx was still open. To secure retardation of growth, the proximal third of the proximal phalanx was resected; thereby the enScand J Plast Reconstr Surg 9
Downloaded by [University of California Santa Barbara] at 16:25 14 March 2016
206
0.Engkvist et al.
tire epiphysis was removed including the epiphysial cartilage. After resection the bone surface was COvered with a perichondrial graft and a silastic membrane was interposed between the graft and the intact head of the first metatarsal bone. Three months later a thick layer of cartilage had formed covering the resected end of the proximal phalanx. The reconstructed articular surface was slightly concave and fitted well to the metatarsal head. In conclusion, the cases reported here demonstrate that free perichondrial grafts can be successfully used for reconstruction of articular cartilage. Microscopic sections demonstrated that the generated cartilage replicates the normal structure of articular cartilage.
Scand J PIast Reconstr Surg 9
REFERENCES Engkvist, 0. Reconstruction of articular cartilage using autologous perichondrial grafts. An experimental study in rabbits. Scund J Plust Reconstr Surg, to be published. Skoog, T., Ohlstn, L. & Sohn, S. A. 1972. Perichondrial potential for cartilaginous regeneration. Scand J Plast Reconstr Surg 6 , 123. Skoog, T. & Johansson, S. H . 1975. Nytt ledbrosk fran transplanterat perikondrium. Liikartidningen 72, 1789. Sohn, S. A. & Ohlsen, L. 1974. Growth of cartilage from a free perichondrial graft placed across a defect in a rabbit’s trachea. PIasr Reconstr Surg 53, 5 5 .
ISSN: 0036-5556 (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/iphs18
Reconstruction of Articular Cartilage Using Autologous Perichondrial Grafts: A Preliminary Report Ove Engkvist, Sune H. Johansson, Lennart Ohlsén & Tord Skoog To cite this article: Ove Engkvist, Sune H. Johansson, Lennart Ohlsén & Tord Skoog (1975) Reconstruction of Articular Cartilage Using Autologous Perichondrial Grafts: A Preliminary Report, Scandinavian Journal of Plastic and Reconstructive Surgery, 9:3, 203-206, DOI: 10.3109/02844317509022867 To link to this article: http://dx.doi.org/10.3109/02844317509022867
Published online: 08 Jul 2009.
Submit your article to this journal
Article views: 5
View related articles
Citing articles: 12 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=iphs18 Download by: [University of California Santa Barbara]
Date: 14 March 2016, At: 16:25
Scand J Plast Reconstr Surg 9: 203-206, 1975
RECONSTRUCTION OF ARTICULAR CARTILAGE USING AUTOLOGOUS PERICHONDRIAL GRAFTS A Preliminary R e p o r t
Ove Engkvist, Sune H . Johansson, Lennart OhlsCn and Tord Skoog
Downloaded by [University of California Santa Barbara] at 16:25 14 March 2016
From the Department of Plastic Surgery (Head: T . Skoog), University Hospital, Uppsala, Sweden
(Submitted for publication September 16, 1975)
Abstract. In a pilot study of grown-up rabbits perichondrium from the ear was grafted to the joint surface of cavitas glenoidalis from which the normal articular cartilage had been resected. In all cases regeneration of new cartilage occurred. Five clinical cases of arthritis are reported in which, following removal of the degenerated cartilage and grafting of rib perichondrium, articular cartilage regeneration took place.
um was transferred as a free autologous graft to different parts of the body (Sohn & Ohlstn, 1974). These findings stimulated the idea that perichondrium could be used for reconstructive purposes in forming new articular cartilage. EXPERIMENTAL STUDY
The treatment of degenerative arthritis still constitutes a difficult clinical problem. Improvement can often be achieved by arthrodeses or by arthroplasty, with or without the use of ajoint prosthesis. However, the indications for arthrodeses are limited and the function of articular implants are not known from longer periods of follow-up. There is no doubt a need for other alternatives in the treatment of degenerative arthritis of joints, where painless mobility with retained stability is essential. Reconstruction of the joint by replacing the degenerated cartilage with new cartilage would be the ideal solution in these cases. Various techniques for transplantation of mature cartilage have been tried, but so far no clinically useful results have been presented. The discouraging outcome of earlier attempts to regenerate cartilage is undoubtedly due to the fact that the important role of the perichondrium was neglected. The chondrogenic potential of perichondrium was shown in 1972 by Skoog, OhlsCn & Sohn. They demonstrated massive cartilage formation originating from isolated perichondrium in the rabbit’s ear. Later the chondrogenic capacity was shown to remain unchanged when the perichondri-
Material and Method In a pilot study in 30 grown-up rabbits the humeroscapular joint was opened and well exposed by subluxating the humerus. The cartilage of cavitas glenoidalis was then completely removed down to cancellous bone. Perichondrium from the ear was grafted to the bony surface with the “active” chondrogenic surface of the perichondrium facing the joint cavity. The normal cartilage of the humeral caput was left alone. When the graft had been anchored by sutures to the capsular insertion the dislocation of the joint was reduced. The articular head then acted as a stent, offering even compression to the grafted area. In order to reduce mechanical irritation of the graft the operated extremity was amputated at wrist level preventing its use in weight bearing. The humeroscapular joint was, however, not immobilized.
Results
The complete results of this series will be presented later (Engkvist, to be published). So far only the results after 4, 6, 7 and 8 weeks are available. In 4 rabbits sacrificed after these intervals newly formed cartilage of normal appearance was found to cover the resected joint surface (Fig. 1). On microscopical examination it was evident that cartilage regeneration had taken place and the new tissue demonstrated great similarities to the normal articular cartilage (Fig. 2). Scand J Plasr Reconsrr Surg 9
Downloaded by [University of California Santa Barbara] at 16:25 14 March 2016
204
0.Engkvist et al.
moved and perichondrial grafts, taken from the ribs, were sutured tightly over the bony joint surfaces with their deep, chondrogenic layer facing outwards into the joint. To prevent obliteration of the joint with developing cartilage, a spacing piece of silastic sheeting was inserted between the two grafts. Postoperatively, the hand was firmly bandaged with the metacarpophalangeal joints in 90" flexion. Four months later, when the silastic spacer was removed, both joint surfaces were found to be completely covered by glistening-white, resilient cartilage. There was no visible difference between this newly formed cartilage and that of a normal joint (Fig. 3a-e). The patient returned to Fig. 1 . Appearance of the glenoid cavity in a rabbit, 8 work 2 months after surgery and after 4 months he weeks after resection and perichondrial grafting. Regenerwas back at full capacity doing his original work. ated cartilage covers the articular surface completely. At the second operation a biopsy was taken from the articular surface of the metacarpal head. The One rabbit was treated similary with the excep- microscopic sections demonstrated hyaline cartition that after resection of the articular cartilage the lage, similar to normal articular cartilage and of the denuded bone surface was left without a peri- usual thickness (Fig. 4f-h). A preliminary report of chondrial graft. In this animal no cartilage forma- this case was made by Skoog & Johansson (1975). tion occurred within 10 weeks. Four patients, 50-65 years old, with painful arthrosis of the carpometacarpal joint of the thumb have been operated upon, using the described techCLINICAL APPLICATION nique. Technically it was difficult to reach the deep Case reports part of this joint. The interposing silastic membrane In a saw accident, a 20-year-old carpenter injured was removed after 2-4 months and biopsies were the metacarpophalangeal joint on his long finger. then taken from the joint surfaces. Newly formed Healing was complicated by infection and the pa- cartilage was found in all cases. The clinical results, tient was left with residual arthrosis. There was an however, were not as good as in the first case. After almost complete destruction of cartilage with only 3-6 months these patients still complained of some fragments of cartilage remaining at the edges. In pain and a restricted range of motion, but all of order to restore the joint, these remnants were re- them considered their condition improved.
Fig. 2. Cross section of the humeroscapular' joint in a rabbit, 4 weeks after perichondrial grafting. (a) The joint cavity is seen in the middle with the original joint cartilage of the humerus above and the new cartilage of the scapula below (Htx-eosinx25).(6)Enlarged section of the regenerated cartilage (Htx-eosinx60). Scand J PIast Reconstr Surg 9
Downloaded by [University of California Santa Barbara] at 16:25 14 March 2016
Reconstruction of urticulur cartilage
Fig. 3 . Metacarpophalangealjoint of case I . (a) The de-
205
generated articular cartilage is shown before reconstruction of the joint. (b) After complete resection of the remaining cartilage perichondrial grafts have been sutured to cover the metacarpal head and the proximal end of the phalanx. (c) View of the explored joint 4 months after grafting. The silastic sheet has been extracted and both joint surfaces appear to be completely covered by new, glistening-white cartilage. Roentgenograms ( d ) before; and ( e )4 months after perichondrial grafting. The distance between the bony ends has increased indicating the forma-
tion of new articular cartilage. If)Microscopic section of biopsy taken from the dorsal aspect of the metacarpal head. The thickness of the newly formed articular cartilage and its relation to the underlying cancellous bone is well demonstrated ( ~ 2 0 )(8) . The bone-cartilage junction. The basal layer of the cartilage is highly cellular with clusters of chondrocytes in an axial arrangement. Mitotic cells are present ( ~ 6 0 )(.h ) Towards the cartilage surface the chondrocytes are flattened and have a tangential direction. Deeper down the collagen fibre bundles tend to form arches within the matrix ( ~ 6 0 ) .
In another case the method of perichondrial grafting was used in joint reconstruction. A 5-year-old boy with macrodactylia of his right big toe was treated by epiphysiodesis of both phalanges. After
half a year it was found that the proximal epiphysial line of the proximal phalanx was still open. To secure retardation of growth, the proximal third of the proximal phalanx was resected; thereby the enScand J Plast Reconstr Surg 9
Downloaded by [University of California Santa Barbara] at 16:25 14 March 2016
206
0.Engkvist et al.
tire epiphysis was removed including the epiphysial cartilage. After resection the bone surface was COvered with a perichondrial graft and a silastic membrane was interposed between the graft and the intact head of the first metatarsal bone. Three months later a thick layer of cartilage had formed covering the resected end of the proximal phalanx. The reconstructed articular surface was slightly concave and fitted well to the metatarsal head. In conclusion, the cases reported here demonstrate that free perichondrial grafts can be successfully used for reconstruction of articular cartilage. Microscopic sections demonstrated that the generated cartilage replicates the normal structure of articular cartilage.
Scand J PIast Reconstr Surg 9
REFERENCES Engkvist, 0. Reconstruction of articular cartilage using autologous perichondrial grafts. An experimental study in rabbits. Scund J Plust Reconstr Surg, to be published. Skoog, T., Ohlstn, L. & Sohn, S. A. 1972. Perichondrial potential for cartilaginous regeneration. Scand J Plast Reconstr Surg 6 , 123. Skoog, T. & Johansson, S. H . 1975. Nytt ledbrosk fran transplanterat perikondrium. Liikartidningen 72, 1789. Sohn, S. A. & Ohlsen, L. 1974. Growth of cartilage from a free perichondrial graft placed across a defect in a rabbit’s trachea. PIasr Reconstr Surg 53, 5 5 .
