Tag Archive for: Cartilage repair

Katarzyna Herman, Vetri Kumar, Dawid Szwedowski, Luca Chierici, Alberto Gobbi

Volume 4 | Issue 1 | Jan – April 2019 | Page 34- 37

Author: Katarzyna Herman[1], Vetri Kumar[1], Dawid Szwedowski[1], Luca Chierici[1], Alberto Gobbi[1]

Orthopaedic Arthroscopic Surgery International (OASI) Bioresearch Foundation, Milan, Italy.

Address of Correspondence
Dr.Alberto Gobbi, MD
Orthopaedic Arthroscopic Surgery International (OASI) Bioresearch Foundation, Via G.A. Amadeo 24, 20133, Milan, Italy.
Email: gobbi@cartilagedoctor.it


Articular cartilage is a highly specialized tissue with poor healing potential. Damage to the cartilage following an injury to the joint is prevalent which leads to osteoarthritis. More research is aimed towards tissue regeneration and prevention of degeneration. Efforts to repair and restore the hyaline like cartilage using two-stage procedures such as autologous chondrocyte implantation have led to the development of scaffolds. Bone marrow aspirate concentrate that contains multi potent stem cells which has the potential to differentiate into hyaline like cartilage along with the use of a scaffold is an effective, reliable and single-stage method of cartilage restoration


1.Hunter W. On the Structure and Diseases of Articulating Cartilage. Philos Trans RsocLond B Biol Sci 1743; 9:277.
2. Mankin HJ. The response of articular cartilage to mechanical injury. J Bone Joint Surg Am.1982;64(3):460-6.
3. Widuchowski W, Widuchowski J, Trzaska T(2007) Articular cartilage defects: study of 25,124 knee arthroscopies. Knee; 14:177-82
4. Flanigan DC, Harris JD, Trinh TQ, Siston RA, Brophy RH (2010) Prevalence of chondral defects in athletes’ knees: a systematic review. Med Sci Sports Exerc 42:1795–1801
5. Johnson DL, Urban WP Jr, Caborn DN et al (1998) Articular cartilage changes seen with magnetic resonance imaging-detected bone bruises associated with acute anterior cruciate ligament rupture. Am J Sports Med 26:409–414
6. Lohmander LS, Roos H, Dahlberg L et al (1994) Temporal patterns of stromelysin-1, tissue inhibitor, and proteoglycan fragments in human knee joint fluid after injury to the cruciate ligament or meniscus. J Orthop Res 12:21–28
7. Mandelbaum BR, Browne JE, Fu F et al (1998) Articular carti-lage lesions of the knee. Am J Sports Med 26:853–861
8. Kotlarz H, Gunnarsson CL, Fang H, Rizzo JA. Insurer and out-of-pocket costs of osteoarthritis in the US: evidence from national survey data. Arthritis Rheum. 2009 Dec;60(12):3546-53.
9. Takeda H, Nakagawa T, Nakamura K, Engebretsen L. Prevention and management of knee osteoarthritis and knee cartilage injury in sports. Br J Sports Med. 2011 Apr;45(4):304-9. Epub 2011 Feb 25.
10. Marcacci M, Berruto M, Brocchetta D, et al. Articular cartilage engineering with Hyalograft(R) C: 3-year clinical results. Clin OrthopRelat Res 2005;435:96-105.
11. Gobbi A, Kon E, Berruto M, et al. Patellofemoral full-thickness chondral defects treated with second-generation autologous chondrocyte implantation: Results at 5 years’ follow-up. Am J Sports Med 2009;37: 1083-1092
12. Ando W, Tateishi K, Katakai D, et al. In vitro generation of a scaffold-free tissue-engineered construct (TEC) derived from human synovial mesenchymal stem cells: biological and mechanical properties and further chondrogenic potential. Tissue Eng Part A. 2008;14(12): 2041-2049.
13. Caplan AI. Mesenchymal stem cells: cell-based reconstructive ther-apy in orthopedics. Tissue Eng. 2005;11(7-8):1198-1211.
14. Caplan AI. Mesenchymal stem cells: the past, the present, the future. Cartilage. 2010;1(1):6-9.
15. Dimarino AM, Caplan AI, Bonfield TL. Mesenchymal stem cells in tissue repair. Front Immunol. 2013;4:201.
16. Huselstein C, Li Y, He X. Mesenchymal stem cells for carti-lage engineering. Biomed Mater Eng. 2012;22:69-80.
17. Pasquinelli G, Orrico C, Foroni L, Bonafè F, Carboni M, Guarnieri C, et al. Mesenchymal stem cell interaction with a non-woven hyaluronan- based scaffold suitable for tissue repair. J Anat. 2008;213(5):520-30.
18. Lisignoli G, Cristino S, Piacentini A, Zini N, Noël D, Jorgensen C, et al. Chondrogenic differentiation of murine and human mesenchymal stromal cells in a hyaluronic acid scaffold: differences in gene expression and cell morphology. J Biomed Mater Res A. 2006;77(3):497-506.
19. Facchini A, Lisignoli G, Cristino S, Roseti L, De Franceschi L, Marconi E, et al. Human chondrocytes and mesenchymal stem cells grown onto engineered scaffold. Biorheology. 2006;43(3-4):471-80.
20. Nejadnik H, Hui JH, Feng Choong EP, Tai BC, Lee EH. Autologous bone marrow-derived mesenchymal stem cells versus autologous chondrocyte implantation: an observational cohort study. Am J Sports Med. 2010 Jun; 38(6): 1110-6.
21. Gobbi A, Chaurasia S, Karnatzikos G, Nakamura N. Matrix-Induced Autologous Chondrocyte Implantation versus Multipotent Stem Cells for the Treatment of Large Patellofemoral Chondral Lesions: A Nonrandomized Prospective Trial. Cartilage. 2015 Apr;6(2):82-97.
22. Gobbi A, Karnatzikos G, Sankineani SR. One-step surgery with multipotent stem cells for the treatment of large full-thickness chondral defects of the knee. Am J Sports Med. 2014 Mar;42(3):64857.
23. Gobbi A et al. Biologic Arthroplasty for Full-thickness Cartilage Lesions of the Knee: Results at Three Years Follow-up (SS-56) Arthroscopy , Volume 29 , Issue 6 , e27
24. Gobbi A, Karnatzikos G, Scotti C, Mahajan V, Mazzucco L, Grigolo B. One-Step Cartilage Repair with Bone Marrow Aspirate Concentrated Cells and Collagen Matrix in Full-Thickness Knee Cartilage Lesions: Results at 2-Year Follow-up. Cartilage.2011 Jul;2(3):286-99.
25. Gobbi A, Scotti C, Karnatzikos G, Mudhigere A, Castro M, Peretti GM. One-step surgery with multipotent stem cells and Hyaluronan-based scaffold for the treatment of full-thickness chondral defects of the knee in patients older than 45 years. Knee Surgery, Sports Traumatology, Arthroscopy. 2017;25(8):2494-2501.
26. Whyte GP, Gobbi A, Sadlik B. Dry Arthroscopic Single-Stage Cartilage Repair of the Knee Using a Hyaluronic Acid-Based Scaffold With Activated Bone Marrow-Derived Mesenchymal Stem Cells. Arthroscopy Techniques. 2016;5(4):e913-e918.

How to Cite this article: Herman K, Kumar V, Szwedowski D, Chierici L, Gobbi A. HA-BMAC: The Surgical Technique, Pearls and Pitfalls . Asian Journal Arthroscopy. Jan-April 2019;4(1):34-37

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Deepak Goyal, Vishvas Modi

Volume 4 | Issue 1 | Jan – April 2019 | Page 27- 33

Author: Deepak Goyal[1], Vishvas Modi[1]

Saumya Arthroscopy & Sports Knee Clinic,
Ahmedabad, India.

Address of Correspondence
Dr (Prof) Deepak Goyal
Saumya Arthroscopy & Sports Knee Clinic,
Ahmedabad, India.
Email: deepak@knee.in


Autologous chondrocyte implantation (ACI) is one such technique that has the ability to provide a hyaline (like) repair of the localized cartilage lesions, even when they are of a big size. However, the procedure must be chosen very wisely because of its stringent indications and contraindications. Decision to do ACI procedure is very crucial and the surgeon must come to the decision after a detailed clinic-radiological examination. Gel based ACI is one such technique that allows a 3-dimensional distribution of the autologous cultured chondrocytes in a scaffold that is made of fibrin glue. The technique takes away the common complications that were associated with 1st and 2nd generation ACI; like graft hypertrophy, poor access to the lesion, membrane suturing, monolayer distribution etc. The purpose of this paper is to discuss the indications, contraindications, decision making and preoperative planning for the gel based autologous chondrocyte implantation technique in detail along with the surgical procedure, postoperative rehabilitation and the possible complications.


1. Ossendorf C, Kaps C, Kreuz PC, Burmester GR, Sittinger M, Erggelet C. Treatment of posttraumatic and focal osteoarthritic cartilage defects of the knee with autologous polymer-based three-dimensional chondrocyte grafts: 2-year clinical results. Arthritis Res Ther. 2007;9(2):R41.
2. Oussedik S, Tsitskaris K, Parker D. Treatment of articular cartilage lesions of the knee by microfracture or autologous chondrocyte implantation: a systematic review. Arthroscopy. 2015;31(4):732-744.
3. Goyal D, Keyhani S, Lee EH, Hui JHP. Evidence-Based Status of Microfracture Technique: A Systematic Review of Level I and II Studies. Arthroscopy. 2013;29(9):1579-1588.
4. Bark S, Riepenhof H, Gille J. AMIC Cartilage Repair in a Professional Soccer Player. Case Rep Orthop. 2012;2012:364342.
5. Gille J, Behrens P, Schulz AP, Oheim R, Kienast B. Matrix-Associated Autologous Chondrocyte Implantation: A Clinical Follow-Up at 15 Years. Cartilage. 2016;7(4):309-315.
6. Minas T, Ogura T, Bryant T. Autologous Chondrocyte Implantation. JBJS Essent Surg Tech. 2016;6(2):e24.
7. Bartlett W, Skinner JA, Gooding CR, et al. Autologous chondrocyte implantation versus matrix-induced autologous chondrocyte implantation for osteochondral defects of the knee: a prospective, randomised study. J Bone Joint Surg Br. 2005;87(5):640-645.
8. Behrens P, Bitter T, Kurz B, Russlies M. Matrix-associated autologous chondrocyte transplantation/implantation (MACT/MACI)–5-year follow-up. Knee. 2006;13(3):194-202.
9. Pavesio A, Abatangelo G, Borrione A, et al. Hyaluronan-based scaffolds (Hyalograft C) in the treatment of knee cartilage defects: preliminary clinical findings. Novartis Found Symp. 2003;249:203-217; discussion 229-233, 234-238, 239-241.
10. Schneider U, Rackwitz L, Andereya S, et al. A prospective multicenter study on the outcome of type I collagen hydrogel-based autologous chondrocyte implantation (CaReS) for the repair of articular cartilage defects in the knee. Am J Sports Med. 2011;39(12):2558-2565.
11. Niemeyer P, Albrecht D, Andereya S, et al. Autologous chondrocyte implantation (ACI) for cartilage defects of the knee: A guideline by the working group “Clinical Tissue Regeneration” of the German Society of Orthopaedics and Trauma (DGOU). Knee. 2016;23(3):426-435.
12. Goyal D, Goyal A, Adachi N. Subchondral Bone: Healthy Soil for the Healthy Cartilage. In: Gobbi A, Espregueira-Mendes J, Lane JG, Karahan M, eds. Bio-Orthopaedics. Berlin, Heidelberg: Springer Berlin Heidelberg; 2017:479-486.
13. Cole BJ, Corpus KT, Bajaj S, et al. Prospective Evaluation of Autologous Chondrocyte Implantation Procedure: Minimum Seven-Year Follow-Up (SS-26). Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2011;27(5):e43-e44.
14. Goyal D, Goyal A, Keyhani S, Lee EH, Hui JHP. Evidence-based status of second- and third-generation autologous chondrocyte implantation over first generation: a systematic review of level I and II studies. Arthroscopy. 2013;29(11):1872-1878.
15. Goyal D, Keyhani S, Goyal A, Lee EH, Hui JHP, Vaziri AS. Evidence-Based Status of Osteochondral Cylinder Transfer Techniques: A Systematic Review of Level I and II Studies. Arthroscopy. 2014;30(4):497-505.
16. Pietschmann MF, Horng A, Niethammer T, et al. Cell quality affects clinical outcome after MACI procedure for cartilage injury of the knee. Knee Surg Sports Traumatol Arthrosc. 2009;17(11):1305-1311.
17. Vanlauwe J, Saris DBF, Victor J, et al. Five-year outcome of characterized chondrocyte implantation versus microfracture for symptomatic cartilage defects of the knee: early treatment matters. Am J Sports Med. 2011;39(12):2566-2574.
18. Gillogly SD, Myers TH, Reinold MM. Treatment of full-thickness chondral defects in the knee with autologous chondrocyte implantation. J Orthop Sports Phys Ther. 2006;36(10):751-764.
19. Hamby TS, Gillogly SD, Peterson L. Treatment of patellofemoralarticular cartilage injuries with autologous chondrocyte implantation. Operative Techniques in Sports Medicine. 2002;10(3):129-135.
20. Rosenberg TD, Paulos LE, Parker RD, Coward DB, Scott SM. The forty-five-degree posteroanterior flexion weight-bearing radiograph of the knee. J Bone Joint Surg Am. 1988;70(10):1479-1483.
21. Zbojniewicz AM, Laor T. Imaging of osteochondritis dissecans. Clin Sports Med. 2014;33(2):221-250.
22. Karim AR, Cherian JJ, Jauregui JJ, Pierce T, Mont MA. Osteonecrosis of the knee: review. Ann Transl Med. 2015;3(1):6.
23. Houpt JB, Pritzker KP, Alpert B, Greyson ND, Gross AE. Natural history of spontaneous osteonecrosis of the knee (SONK): a review. Semin Arthritis Rheum. 1983;13(2):212-227.
24. Kellgren JH, Lawrence JS. Radiological assessment of osteo-arthrosis. Ann Rheum Dis. 1957;16(4):494-502.
25. Altman R, Asch E, Bloch D, et al. Development of criteria for the classification and reporting of osteoarthritis. Classification of osteoarthritis of the knee. Diagnostic and Therapeutic Criteria Committee of the American Rheumatism Association. Arthritis Rheum. 1986;29(8):1039-1049.
26. Spector TD, Hart DJ, Byrne J, Harris PA, Dacre JE, Doyle DV. Definition of osteoarthritis of the knee for epidemiological studies. Ann Rheum Dis. 1993;52(11):790-794.
27. Goyal D, Goyal A, Adachi N. Joint Preservation Surgery for Medial Compartment Osteoarthritis. Arthrosc Tech. 2017;6(3):e717-e728.
28. Recht MP, Resnick D. Magnetic resonance imaging of articular cartilage: an overview. Top Magn Reson Imaging. 1998;9(6):328-336.
29. De Smet AA, Fisher DR, Graf BK, Lange RH. Osteochondritis dissecans of the knee: value of MR imaging in determining lesion stability and the presence of articular cartilage defects. AJR Am J Roentgenol. 1990;155(3):549-553.
30. Lecouvet FE, van de Berg BC, Maldague BE, et al. Early irreversible osteonecrosis versus transient lesions of the femoral condyles: prognostic value of subchondral bone and marrow changes on MR imaging. AJR Am J Roentgenol. 1998;170(1):71-77.
31. Mont MA, Baumgarten KM, Rifai A, Bluemke DA, Jones LC, Hungerford DS. Atraumatic osteonecrosis of the knee. J Bone Joint Surg Am. 2000;82(9):1279-1290.
32. Björkengren AG, AlRowaih A, Lindstrand A, Wingstrand H, Thorngren KG, Pettersson H. Spontaneous osteonecrosis of the knee: value of MR imaging in determining prognosis. AJR Am J Roentgenol. 1990;154(2):331-336.
33. Healy WL. Osteonecrosis of the knee detected only by magnetic resonance imaging. Orthopedics. 1991;14(6):703-704.
34. Goyal D, Goyal A, Brittberg M. Consideration of religious sentiments while selecting a biological product for knee arthroscopy. Knee Surg Sports Traumatol Arthrosc. 2013;21(7):1577-1586.
35. Goyal D, Palkhiwala B. Cover Image. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2013;29(3):A9.
36. Goyal D. The overlay ACI technique for extra-large osteochondral lesions of the knee joint. 2nd Congress of Asian Cartilage Repair Society at Seoul, Korea, 2014.
37. Choi N-Y, Kim B-W, Yeo W-J, et al. Gel-type autologous chondrocyte (Chondron) implantation for treatment of articular cartilage defects of the knee. BMC Musculoskelet Disord. 2010;11:103.
38. Gillogly SD, Voight M, Blackburn T. Treatment of articular cartilage defects of the knee with autologous chondrocyte implantation. J Orthop Sports Phys Ther. 1998;28(4):241-251.
39. Reinold MM, Wilk KE, Dugas JR, Cain EL, Gillogly SD. Rehabilitation Guidelines: Autologous Chondrocyte Implantation Using Carticel. Cambridge, MA: Genzyme Biosurgery; 2004.
40. Reinold MM, Wilk KE, Macrina LC, Dugas JR, Cain EL. Current concepts in the rehabilitation following articular cartilage repair procedures in the knee. J Orthop Sports Phys Ther. 2006;36(10):774-794.
41. Peterson L, Minas T, Brittberg M, Nilsson A, Sjögren-Jansson E, Lindahl A. Two- to 9-year outcome after autologous chondrocyte transplantation of the knee. Clin Orthop Relat Res. 2000;(374):212-234.
42. Peterson L, Brittberg M, Kiviranta I, Akerlund EL, Lindahl A. Autologous chondrocyte transplantation. Biomechanics and long-term durability. Am J Sports Med. 2002;30(1):2-12.
43. Peterson L, Vasiliadis HS, Brittberg M, Lindahl A. Autologous chondrocyte implantation: a long-term follow-up. Am J Sports Med. 2010;38(6):1117-1124.
44. Pareek A, Carey JL, Reardon PJ, Peterson L, Stuart MJ, Krych AJ. Long-Term Outcomes after Autologous Chondrocyte Implantation: A Systematic Review at Mean Follow-Up of 11.4 Years. Cartilage. 2016;7(4):298-308.
45. Kim MK, Choi SW, Kim SR, Oh IS, Won MH. Autologous chondrocyte implantation in the knee using fibrin. Knee Surg Sports Traumatol Arthrosc. 2010;18(4):528-534.
46. Wood JJ, Malek MA, Frassica FJ, et al. Autologous cultured chondrocytes: adverse events reported to the United States Food and Drug Administration. J Bone Joint Surg Am. 2006;88(3):503-507.
47. Niemeyer P, Pestka JM, Kreuz PC, et al. Characteristic complications after autologous chondrocyte implantation for cartilage defects of the knee joint. Am J Sports Med. 2008;36(11):2091-2099.

How to Cite this article: Goyal & Modi. Gel Based Autologous Chondrocyte Implantation: The Surgical Technique. Asian Journal Arthroscopy. Jan-April 2019;4(1):27-33 .

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