Recent Achievements in the Development of Biomaterials Improved with Platelet Concentrates for Soft and Hard Tissue Engineering Applications

Platelet concentrates such as platelet-rich plasma, platelet-rich fibrin or concentrated growth factors are cost-effective autologous preparations containing various growth factors, including platelet-derived growth factor, transforming growth factor β, insulin-like growth factor 1 and vascular endothelial growth factor. For this reason, they are often used in regenerative medicine to treat wounds, nerve damage as well as cartilage and bone defects. Unfortunately, after administration, these preparations release growth factors very quickly, which lose their activity rapidly. As a consequence, this results in the need to repeat the therapy, which is associated with additional pain and discomfort for the patient. Recent research shows that combining platelet concentrates with biomaterials overcomes this problem because growth factors are released in a more sustainable manner. Moreover, this concept fits into the latest trends in tissue engineering, which include biomaterials, bioactive factors and cells. Therefore, this review presents the latest literature reports on the properties of biomaterials enriched with platelet concentrates for applications in skin, nerve, cartilage and bone tissue engineering.

Biomimetic biphasic curdlan-based scaffold for osteochondral tissue engineering applications - Characterization and preliminary evaluation of mesenchymal stem cell response in vitro

Osteochondral defects remain a huge problem in medicine today. Biomimetic bi- or multi-phasic scaffolds constitute a very promising alternative to osteochondral autografts and allografts. In this study, a new curdlan-based scaffold was designed for osteochondral tissue engineering applications. To achieve biomimetic properties, it was enriched with a protein component - whey protein isolate as well as a ceramic ingredient - hydroxyapatite granules. The scaffold was fabricated via a simple and cost-efficient method, which represents a significant advantage. Importantly, this technique allowed generation of a scaffold with two distinct, but integrated phases. Scanning electron microcopy and optical profilometry observations demonstrated that phases of biomaterial possessed different structural properties. The top layer of the biomaterial (mimicking the cartilage) was smoother than the bottom one (mimicking the subchondral bone), which is beneficial from a biological point of view because unlike bone, cartilage is a smooth tissue. Moreover, mechanical testing showed that the top layer of the biomaterial had mechanical properties close to those of natural cartilage. Although the mechanical properties of the bottom layer of scaffold were lower than those of the subchondral bone, it was still higher than in many analogous systems. Most importantly, cell culture experiments indicated that the biomaterial possessed high cytocompatibility towards adipose tissue-derived mesenchymal stem cells and bone marrow-derived mesenchymal stem cells in vitro. Both phases of the scaffold enhanced cell adhesion, proliferation, and chondrogenic differentiation of stem cells (revealing its chondroinductive properties in vitro) as well as osteogenic differentiation of these cells (revealing its osteoinductive properties in vitro). Given all features of the novel curdlan-based scaffold, it is worth noting that it may be considered as promising candidate for osteochondral tissue engineering applications.

Freeze-Dried Curdlan/Whey Protein Isolate-Based Biomaterial as Promising Scaffold for Matrix-Associated Autologous Chondrocyte Transplantation-A Pilot In-Vitro Study

The purpose of this pilot study was to establish whether a novel freeze-dried curdlan/whey protein isolate-based biomaterial may be taken into consideration as a potential scaffold for matrix-associated autologous chondrocyte transplantation. For this reason, this biomaterial was initially characterized by the visualization of its micro- and macrostructures as well as evaluation of its mechanical stability, and its ability to undergo enzymatic degradation in vitro. Subsequently, the cytocompatibility of the biomaterial towards human chondrocytes (isolated from an orthopaedic patient) was assessed. It was demonstrated that the novel freeze-dried curdlan/whey protein isolate-based biomaterial possessed a porous structure and a Young's modulus close to those of the superficial and middle zones of cartilage. It also exhibited controllable degradability in collagenase II solution over nine weeks. Most importantly, this biomaterial supported the viability and proliferation of human chondrocytes, which maintained their characteristic phenotype. Moreover, quantitative reverse transcription PCR analysis and confocal microscope observations revealed that the biomaterial may protect chondrocytes from dedifferentiation towards fibroblast-like cells during 12-day culture. Thus, in conclusion, this pilot study demonstrated that novel freeze-dried curdlan/whey protein isolate-based biomaterial may be considered as a potential scaffold for matrix-associated autologous chondrocyte transplantation.

Mosaicplasty for the treatment of osteochondritis dissecans following Legg-Calvé-Perthes disease: a case report and literature review

Legg-Calvé-Perthes disease leads to hip joint deformity. Osteochondritis dissecans following Perthes disease (OCDP) is a less common entity. Treatment options of OCDP are limited. Osteochondral autologous transfer (OATS) is an established method of treatment of full thickness cartilage defects in different locations. This paper presents the case of a 42-year-old patient diagnosed with symptomatic OCDP and treated with lesion fixation using autologous osteochondral grafts via surgical hip dislocation. At the most recent follow-up, 5.5 years after the surgery, the patient did not complain of any pain during rest or activity. He had painless motion with persisting abduction and internal rotation reduction. Harris hip score (HHS) improved from preoperative 62 to 92 points at most recent follow-up. Treatment protocol was discussed in relation to the literature regarding this clinical topic.

The use of osteochondral allograft with bone marrow-derived mesenchymal cells and hinge joint distraction in the treatment of post-collapse stage of osteonecrosis of the femoral head

Osteonecrosis of the femoral head is an entity which occurs mainly in young and active patients aged between 20 and 50. The success of hip joint preserving treatments ranges from 15% to 50% depending on the stage and amount of osteonecrotic lesion. Total hip replacement is indicated in late post-collapse hips but it has unsatisfactory survival because of the wear and osteolysis in young and active patients. Osteochondral allografts have been reported in the treatment of large articular lesions with defects in underlying bone in knee, talus and shoulder. By combining osteoconductive properties of osteochondral allograft with osteogenic abilities of bone marrow-derived mesenchymal cells it has a potential to be an alternative to an autologous graft. The adjunct of hinged joint distraction should minimize stresses in subchondral bone to promote creeping substitution and prevent femoral head collapse. Unlike current treatment modalities, it would provide both structural support and allow bony and articular substitution.

An analysis of pathomorphic forms and diagnostic difficulties in tarso-metatarsal joint injuries

Tarso-metatarsal injuries are rare but frequently missed. Due to the large variation in pathomorphic forms of these injuries, great precision is required when carrying out clinical and X-ray diagnostic procedures. The aim of the study was to describe the different forms of Lisfranc joint injuries and analyse the causes of delayed treatment. The treatment results of acute and chronic injuries were compared in 41 patients, with an average follow-up period of 16 years. Statistically significant poorer results were obtained in the group of chronic cases, based on two functional scores - the AOFAS evaluation questionnaire and the Lublin functional questionnaire. The main factor delaying the start of the proper treatment was diagnostic error during initial admission. The best results were achieved after closed reduction and percutaneous Kirschner wire fixation in acute cases.

Arteria lusoria in patients with a normal and a right-sided aortic arch diagnosed with multi-slice computed tomography: a report of two cases

A retro-oesophageal course of the right subclavian artery is referred to as "arteria lusoria". It may be related to severe compression of the trachea and oesophagus, typically resulting in impaired swallowing. The paper presents two patients with arteria lusoria, which in one patient was an aberrant right subclavian artery and in the other an aberrant left subclavian artery, originating from the right-sided aortic arch. In both cases the diagnosis was made with multi-slice computed tomography. The embryology of the anomalies and clinical status of the patients is discussed. Arteria lusoria should be considered in differential diagnosis in patients with dyspnoea and dysphagia. Multi-slice computed tomography allows this anatomical variant to be reliably visualised.

Rehabilitation after one-stage anterior cruciate reconstruction and osteochondral grafting

At least 10-20% of all ACL reconstructions require additional cartilage repair. The aim of this study was to compare the activity recovered by patients after one-stage open ACL reconstruction and osteochondral autologous grafting of articular cartilage lesions and after isolated open ACL reconstruction. The study group included 21 patients with chronic ACL deficiency and grade III or IV cartilage lesion according to the ICRS scale who were treated with combined ACL reconstruction and osteochondral grafting in one step. The control group included 32 patients with chronic ACL insufficiency and no chondral deficit higher than grade I on the ICRS scale who underwent isolated reconstruction of the ligament. For the assessment, the Lysholm and Gillquist (L&G) score and the functional Marshall score were used. Both groups displayed a statistically significant improvement in the L&G score and the Marshall score between the preoperative and 12-month assessments. The mean gain in L&G score over this period was 30.66+/-7.79 in the study group and 31.65+/-6.96 in the control group. The difference between the control group and the study group was not significant. The difference between 12 months and initial assessment was counted. The mean gain in Marshall score was 9.05+/-3.81 in the study group and 10.71+/-3.43 in the control group. The difference between the initial and the 12-month evaluation was statistically significant (p=0.49). Return to normal activity was slower and patient satisfaction was lower during the first year after operation in the study group than in the control group, however the overall advantage of the one-step operation outweighs the slightly inferior functional results at 12 months.

[Difficulties and dangers of arthroplasty in valgus knee deformity]

In orthopaedic surgeon's opinion arthroplasty in knee joints with valgus deformity is very difficult and risky than in those without deformation or in varus angulation. The authors in the paper analysed deformity morphologies in valgus knees, observed intra-operative problems, as well as obtained results and complications and compare them with those occurred in varus knees. Observations were based on 33 joints (30 persons, 27 females, 3 males), which were operated by primary cemented total knee replacements. The patients' age ranged from 41 to 82 years. The knee function was measured on the base of HSS rating score. The results of HSS obtained before surgery were compared with those from the last control visit. Relaying on surgery reports, analyses of the procedure and the solutions needed to correct the deformity were done. On the basis of X-rays the alignment and positions of the prostheses were evaluated. The results obtained in valgus knees were comparable with TKA in varus knees. The complication rate and necessity of additional steps of the procedure is higher in valgus deformation.

[The results of primary total knee arthroplasty with bone stock restoration by autologous grafts from resected bony ends]

AIM OF THE STUDY

The aim of the study is the comparison of results of primary total knee arthroplasty with large bone stock deficiencies treated with autologous bone grafts from resected joint ends (both solid and morselized) with the group of patients in whom knee arthroplasty was made without the need of bone grafting.

MATERIAL AND METHOD

342 primary total knee replacements implanted till the end of 2004 at Orthopaedic and Traumatology Department in Lublin were examined. Bone stock defects were treated in 37 knees (35 patients). The necessity of reconstruction resulted from destruction of knee joint surfaces in advanced degenerative osteoarthritic processes or rheumatic disease. Autologous solid bone grafting was used in 22 knees, morselized in 13, meanwhile 2 different required both types of grafts. The medial tibial condyle bone stock defects were the most frequent--26 knees. Control group consists of 39 knees in 33 patients treated in the same period without the need for bone grafting and prostheses were implanted directly on resected surfaces. Preoperative and postoperative knee function was established with Hospital for Special Surgery Score (HSS). The X-rays were analyzed with the special regard for: correctness of implants placing, presence of radiolucence zones both around implants and grafts, and bone grafts healing.

RESULTS

The analysis of subsequent X-rays showed bone grafts healing (both solid and morselized) in 21 knees. In 4 knees progressive bone grafts lysis was observed. The remaining knees showed the presence of grafts and lack of evidence of healing in surrounding host bone. No differences were observed in number of intra- and postoperative complications, radiographic knee replacements geometry and long-term clinical results in both groups of patients.

CONCLUSIONS

1) Results of total knee replacements with autologous bone grafting for bone stock reconstruction are comparable with the results of TKR without the need for bone grafting. 2) Natural harvesting of the graft material from resected joint ends and effectiveness of reconstruction increase the value of the method. 3) The durability of early good results need further examination.

Early results of one-stage knee extensor realignment and autologous osteochondral grafting

We treated 49 patients with recurrent patellar dislocations or persistent patellar subluxations. Chondral defects were graded according to the International Cartilage Repair Society (ICRS). Thirty patients (group I) had chondral defects grade I or II, and 19 patients (group II) had chondral defects grade III or IV. All patients were treated with proximal and distal realignment of the knee extensor mechanism, but group II also had a simultaneous autologous osteochondral grafting of the chondral defect. Patients were followed for 2 years and clinically assessed using the Marshall score comparing the two groups. Apart from a slower recovery in group II, the clinical and functional results were almost the same at the final follow-up.

Treatment outcome after one-stage reconstruction of the anterior cruciate ligament and mosaicplasty of the articular cartilage of the knee

Background. Chronic rotational instability of the knee after damage to the anterior cruciate ligament (ACL) fairly quickly produces undesirable secondary changes in the joint. Concomitant damage may affect the meniscus or the articular cartilage of the femoral condyle. The purpose of our study was to compare outcome in patients who had undergone one-stage surgical repair of damage to the ACL and articular cartilage. Material and methods. We studied 17 patients with associated cartilage and ligament damage. The control group consisted of 36 patients with isolated ACL damage. Joint function was assessed according to the Marshall Scale and the Lysholm and Gilquist Scale. Examinations were performed before treatment, 2 and 6 weeks post-operatively, and again 3, 6 and 12 months after surgery. Results. In the course of rehabilitation we observed a slightly slower recovery in the patients with combined damage up to 6 months after surgery. There were no statistically significant differences in rehabilitation outcome at the end of the observation period Conclusions. This treatment method has the potential to permanently remedy knee slippage and cancel its early effects. The surgical outcome in repair of damage to the patellofemoral joint, combined with centralization of the knee's extension apparatus, are comparable at 2 years to centralization of the patella alone when the normal structure of the articular cartilage has been perserved.

[Intramedullary interlocking of humeral fractures and nonunions with Seidel nail]

The advantages and disadvantages of interlocking Seidel's nails determined by their construction and the way of insertion were presented on the basis of own experience and literature. The advantages are strength and shape of the nails which are conductive to fragments stability and make insertion into humerus medullar canal easier. The tools set for insertion and locking of distal part. It doesn't truly protect from torsion displacements. Locking takes place by draw for a few weeks by external immobilization. The Seidel's nail has also disadvantages associated with proximal insertion. Unavoidable injury of supraspinatus tendon insertion can be the reason of loss of shoulder function. The antegrade fixation can cause pushing distal fragment downward by tip of the nail. It is necessary to control it's insertion under image intensifier. Presented disadvantages of Seidel's nail fixation didn't result in any problems in humerus fractures or pseudoarthroses healing. In one case it was necessary to perform additional decortication and space of fracture fulfillment with bone grafts.

Treatment outcome after patellar re-alignment by one-stage correction of the axis of the knee extensor and mosaicplasty of the patellofemoral joint

Background. Patellar misalignment is often accompanied by damage to the chondral surface of the patello-femoral joint. The goal of surgical treatment is to address the primary cause by correcting the axis of knee flexion. In the Orthopedics and Traumatology Clinic in Lublin, Poland, we repair damaged cartilage and align the knee extensor in a one-stage operation. The goal of the present study is to compare the course of recovery and outcome in patients operated for recurrent patellar dislocation, in whom chondral damage in the patello-femoral joint is discovered intraoperatively. Material and methods. In a prospective experiment, 14 patients treated in our clinic from 2001 to 2003 were evaluated. The axis of the knee extensor was corrected both proximally and peripherally. Third- or fourth-degree chondral damage according to the ICRS scale was repaired by mosaicplasty. Outcome was evaluated by systematic assessment using the Marshall scale. The control group consisted of patients in whom only realignment was performed due to the absence of chondral damage. Results. Recovery was slower after combined treatment than in the control group. Two years post-operatively the functional outcomes in both groups were comparable, with no statistically significant differences. Conclusions. The treatment method described here gives reason to hope for long-term remediation of patellar misalignment, and removes the effects of earlier abnormalities. After 2 years, the functional outcome after repair to patello-femoral articular cartilage combined with patellar realignment are comparable to those achieved in patients not requiring repair of articular cartilage during patellar realignment.

Posterior interbody fusion in the treatment of diseases and injuries of the thoraco-lumbar spine

Background. The aim of our study was to evaluate the effectiveness of posterior interbody spondylodesis with autogenous bone grafts in the treatment of diseases and injuries of the thoraco-lumbar spine. Material and methods. In the period 1994-2003 122 patients were treated in the Orthopedics and Traumatology Department of the Skubiszewski Medical University of Lublin with posterior interbody fusion. The indications for surgery were spondylolisthesis in 24 patients, and injuries to the thoraco-lumbar spine in 98 patients. Results. Intraoperative injury of the spinal dura occurred in 4 patients. Graft migration to the vertebral canal with radicular pain occurred in one patient 4 weeks after surgery. Bone graft incorporation was observed in all patients. There was no breakage of instrumentation or loss of spondylolisthesis reduction. Conclusions. Posterior interbody fusion is an effective method of treatment to achieve durable stability of injured segments of the thoraco-lumbar spine.

[One-stage approach to the anterior and posterior vertebral column in operative treatment of advanced traumatic and neoplastic changes of the thoraco-lumbar spine]

There were presented indications and operative technique of one-stage approach to anterior and posterior part of the thoraco-lumbar spine. Presented technique gave chance to control antero-lateral and posterior aspects of the spine. There were 2 patients with delayed compressions of the vertebral bodies in lumbar part with severe kyphotic deformity. Those deformities were the cause of progression of neural symptoms in a few months after injury. Another 4 patients had the spinal tumours. In one case it was giant-cell tumour which destroyed body and the arch of Th12. In two patients metastases of renal cancer infiltrated L2 and L3. The last one had breast cancer metastasis into Th12. In all patients it was necessary to control anterior and posterior columns of the spine to restore its axis and the shape of spinal canal.

[Treatment methods for complications of forearm diaphyses fractures, first stabilized with plates]

A short series 8 patients with complications and failures of forearm shafts fractures treated with screws and plates was analysed. There were 2 pseudoarthroses of ulna, delayed union of radial shafts in 4 cases in which 2 had plates loosening. The additional 2 patients had the refractures of radius shortly after metal removal. The intraoperative investigation presented that main cause of delayed unions and pseudoarthroses was insufficient blood supply to the bony ends due to circulation destruction during plates implantation. All 8 patients had finally obtained union after second stage procedure. It was consisted of plates and screws removal, refreshing of fragments ends, cancerous auto grafts implantation and plaster cast immobilization. Intramedullary stabilization with Rush pins was performed in 6 patients. The additional 2 had such wide bone destruction after primary plates stabilization that intramedullary fixation was risky.

[Repair of focal chondral lesions of femoral condyles treated with osteochondral autografts]

A series of 15 patients with focal chondral lesions of the femoral condyles were treated at the Orthopaedics Department of the University of Medical Sciences of Lublin between 1998-2000. The patients' age varied from 20 to 72 years and the follow-up period from 6 months to 2.5 years. Osteochondritis dissecans was observed in 9 patients. Articular cartilage defects associated with chronic ligament instability was noted in 5 cases and 1 patient suffered from a chondral fracture of the lateral femoral condyle during a traumatic luxation of the patella. The depth of the lesions was graded according to ICRS scale. Grade IV was found in 11 cases and the remaining 4 cases had grade III lesions. The defects were treated with osteochondral autografts using OATS instrumentation set. Results were prospectively evaluated according to the HSS score. The preoperative value of HSS score ranged from 28 to 51 points (average 40.3). During follow-up the score values ranged from 76 to 91 points (average 84.7 points). All patients regained full range of motion in the knee, although in one case arthroscopic release of intraarticular adhesions was performed 6 months after chondroplasty. The lowest HSS values at follow-up were found in elderly patients with concomitant mild degenerative changes in the lateral knee compartment and in the patello-femoral joint. All patients had MRI examination early post-op, then after 6, 12 and 24 months from the procedure. MRI confirmed proper structure of the grafted cartilage but bony parts of the graft did not integrate with the surroundings.

[Evaluation of the anterior cruciate ligament injury treatment results using patellar tendon grafts]

The analysed material consisted of 38 cases of chronic knee insufficiency because of anterior cruciate ligament injury. Patients were divided into 2 groups. The first group (18 patients) was treated with 1/3 patellar tendon graft (B-T-B) stabilised by sutures on either screws or staples with a 4-5 week immobilisation period post-op. The second group (20 patients) had graft fixation with interferential screws and no post-op immobilisation. Statistically significant better results were achieved in the group treated with interferential screws. The results were evaluated using HSS and Lysholm and Gillquist rating scores.

[Total knee replacement with modular Kinemax endoprosthesis in osteoarthritis and rheumatoid arthritis]

One to 7 years results (mean 3 years) of modular kinematic knee arthroplasty were compared in rheumatoid (RA, n = 29) and idiopathic (OA, n = 28) arthritis female patients. Comparisons of means showed lower age at surgery (59 yr. v. 66 yr., p = 0.002), lower body mass (66 kg v. 75 kg, p = 0.001) and lower Hospital for Special Surgery scoring (71.7 v. 80, p = 0.05) in RA patients. Two RA knees with prosthesis showed after 2-3 years deterioration of the previously good result. Late infections were indication for removal of the prosthesis in two patients with RA. Two patients of this group died due to complications of the disease. Authors point that knee arthroplasty carries higher risk in rheumatoid than in idiopathic osteoarthritis.

[Difficulties and complications while treating long bone fractures with locked intramedullary nailing]

Retrospective assessment of results of treatment for femoral or tibial fracture and/or malunion in 33 patients (10 females and 23 males) operated on at Orthopedic Department in Lublin during last 4 years are presented. All patients had locked intramedullary nailing done, all fractures healed. Pitfalls and complications of the method at every stage of treatment are presented on the basis of literature and author's own experience. Means for avoidance of the complications are discussed. The method of locked intramedullary nailing proved to be liberal for technical errors at surgery.

[Osteochondritis dissecans of the patella]

Symptoms and treatment of 16 years old patient who had osteochondritis dissecans of the patella is discussed. The separated cartilaginous fragment has been surgically removed, subchondral bone multiply drilled. After 3 months of exercises patient returned to the normal level of physical activity.

[Partial patellectomy in treatment of fresh fractures of the patella]

The late results of partial patellectomy in treatment of fracture of the apex or the 1/3 of the peripheral patella have been presented. Fourteen patients were evaluated. Attention was paid to the dependence of the result on the correct surgical technique. Full painless range of movements in the operated on knee was achieved in 7 persons. In the other 7 patients, extension of the knee was full but flexion was moderately limited. Periodical pain occurs in 3 persons.

[Resection of the patella and plasty of the knee by the de la Caffiniere method]

The surgical technique of patellectomy with preservation of continuity of the extension apparatus of the knee by the de la Caffinière method and the early results of treatment in 8 operated on patients have been presented. The indications for surgery were: posttraumatic stiffness of the knee in extension in 4 patients, patello-femoral arthrosis with preserved wide range of movement in 3 patients, fresh multi-fragmented fracture of the patella without rupture of the extension apparatus in one patient. The good treatment result was obtained in 6 patients (3 treated for patello-femoral arthrosis, 1 for fresh fracture of the patella, and 2 for stiffness of the knee in extension). The poor results in the other 2 patients operated on or stiffness of the knee in extension were due to large damage of the cartilaginous surface of the condyles and extensive intra- and periarticular adhesions.