Osteoarthritis of the Knee joint
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Osteoarthritis of the Knee joint

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OA knee, Chondrocytes, Exercises, Bicycling, Viscosupplementation, local steroids, surgery, Chondrocyte transplantations.

OA knee, Chondrocytes, Exercises, Bicycling, Viscosupplementation, local steroids, surgery, Chondrocyte transplantations.

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  • AndrasHeijink • Andreas H. Gomoll •Henning Madry • MatejDrobnicˇ • Giuseppe Filardo •Joa˜oEspregueira-Mendes • C. Niek Van Dijk,Knee Surg Sports TraumatolArthrosc (2012) 20:423–435DOI 10.1007/s00167-011-1818-0
  • Viscosupplementation for Osteoarthritis of the Knee: A Systematic Review and Meta-analysis ONLINE FIRSTAnne W.S. Rutjes, PhD; Peter Jüni, MD; Bruno R. da Costa, MSc; Sven Trelle, MD; EvelineNüesch, PhD; and Stephan Reichenbach, MD, MSc[+-] Article and Author InformationAnn Intern Med. 12 June 2012
  • Subchondral Drilling, Abrasion, or Microfracture  Articular chondrocytes reside in an avascular environment and do not usually effect healing when damage to the joint surface is limited to the layer of cartilage(27,47,129). Many investigators have attempted to stimulate cartilage-healing by drilling, abrading, or producing so-called microfractures in the subchondral bone(2,3,19,70,102,116,130,138,191,236). All of these techniques have in common the goal of recruiting pluripotential stem cells from the marrow by penetration of the subchondral bone.
  • Survivorship of high tibialosteotomy in the treatment of osteoarthritis of the knee Finnish registry-based study of 3195 kneesT. T. Niinimäki, MD, Orthopaedic Surgeon1 ; A. Eskelinen, MD, PhD, Orthopaedic Surgeon2; B. S. Mann, FRCS(Tr & Orth), Orthopaedic Surgeon3; M. Junnila, MD, Orthopaedic Surgeon4; P. Ohtonen, MSc, Statistician1; and J. Leppilahti, MD, PhD, Orthopaedic Surgeon1+ Author Affiliations1Oulu University Hospital, PL 21, 90029 OYS, Oulu, Finland. 2Coxa Hospital for Joint Replacement, PL 652, 33101 Tampere, Finland. 3Southmead Hospital, Southmead Road, Westbury-on-Trym, Bristol BS10 5NB, UK. 4Turku University Hospital, PL52, 20521 Turku, Finland. Correspondence should be sent to Mr T. T. Niinimäki; e-mail: tuukka.niinimaki@fimnet.fiAbstractPrevious studies from single centres or single-surgeon series report good early and mid-term results for high tibialosteotomy (HTO) in the treatment of osteoarthritis of the knee. However, the survivorship of HTO at a national level is unknown. This registry-based study included 3195 high HTOs performed between 1987 and 2008. Kaplan-Meier analysis revealed an overall survivorship of 89% (95% confidence interval (CI) 88 to 90) at five years and 73% (95% CI 72 to 75) at ten years, when conversion to total knee replacement was taken as the endpoint. Females and patients aged > 50 years had worse survivorship than males or patients aged ≤ 50 years (hazard ratio (HR) 1.26 (95% CI 1.11 to 1.43) and HR 1.41 (95% CI 1.23 to 1.64), respectively). The survivorship of HTOs performed between 1998 to 2008 was worse than for those performed between 1987 and 1997.
  • Improvements in the surgical technique of total knee replacement (TKR) are continually being sought. There has recently been interest in three-dimensional (3D) pre-operative planning using magnetic resonance imaging (MRI) and CT. The 3D images are increasingly used for the production of patient-specific models, surgical guides and custom-made implants for TKR. The users of patient-specific instrumentation (PSI) claim that they allow the optimum balance of technology and conventional surgery by reducing the complexity of conventional alignment and sizing tools. In this way the advantages of accuracy and precision claimed by computer navigation techniques are achieved without the disadvantages of additional intra-operative inventory, new skills or surgical time.
  • Mr Rees is one of a few surgeons in the UK currently using a revolutionary new material called oxidised zirconium also known as oxinium. Oxinium is produced as a result of a chemical process that allows oxygen to absorb into zirconium metal thereby changing only its surface from metal to ceramic. This new material may be considered for young patients (under 65 years of age) undergoing total knee replacement.The actual procedure involves two separate operations. The first involves a day case knee arthroscopy during which the cartilage defect is visualised. The defect is usually on the femur but can be located on the undersurface of the patella or kneecap. The defect has to have certain characteristics in order for the procedure to be suitable in terms of its size (less than 10cm2) and exact location. A very small biopsy of undamaged cartilage is taken from the side of the knee in an area that will not compromise the knee’s function.The biopsy is then immediately transferred into a transport container and sent to a laboratory in Austria where the biopsy is mixed with a liquid collagen matrix (the protein building blocks of cartilage) and incubated for two weeks. A transplant (the new cartilage) is then formed and is fully adjustable in size and thickness to suit the exact defect in the injured knee.At the second operation the knee is opened to expose the defect, which is prepared, and the edges freshened up. The tailor-made transplant is then attached with biological glue called fibrin glue onto the base of the cartilage defect. The operation usually takes about one hour. It will involve a 1-2 day stay in hospital.
  • team of Duke Medicine researchers has engineered cartilage from induced pluripotent stem cells that were successfully grown and sorted for use in tissue repair and studies into cartilage injury and osteoarthritis. The finding is reported online in the Proceedings of the National Academy of Sciences, and suggests that induced pluripotent stem cells, or iPSCs, may be a viable source of patient-specific articular cartilage tissue."This technique of creating induced pluripotent stem cells -- an achievement honored with this year's Nobel Prize in medicine for Shimya Yamanaka of Kyoto University -- is a way to take adult stem cells and convert them so they have the properties of embryonic stem cells," said FarshidGuilak, PhD, Laszlo Ormandy Professor of Orthopaedic Surgery at Duke and senior author of the study."Adult stem cells are limited in what they can do, and embryonic stem cells have ethical issues," Guilak said. "What this research shows in a mouse model is the ability to create an unlimited supply of stem cells that can turn into any type of tissue -- in this case cartilage, which has no ability to regenerate by itself."Articular cartilage is the shock absorber tissue in joints that makes it possible to walk, climb stairs, jump and perform daily activities without pain. But ordinary wear-and-tear or an injury can diminish its effectiveness and progress to osteoarthritis. Because articular cartilage has a poor capacity for repair, damage and osteoarthritis are leading causes of impairment in older people and often requires joint replacement.In their study, the Duke researchers, led by Brian O. Diekman, PhD, a post-doctoral associate in orthopaedic surgery, aimed to apply recent technologies that have made iPSCs a promising alternative to other tissue engineering techniques, which use adult stem cells derived from the bone marrow or fat tissue.One challenge the researchers sought to overcome was developing a uniformly differentiated population of chondrocytes, cells that produce collagen and maintain cartilage, while culling other types of cells that the powerful iPSCs could form.To achieve that, the researchers induced chondrocyte differentiation in iPSCs derived from adult mouse fibroblasts by treating cultures with a growth medium. They also tailored the cells to express green fluorescent protein only when the cells successfully became chondrocytes. As the iPSCs differentiated, the chondrocyte cells that glowed with the green fluorescent protein were easily identified and sorted from the undesired cells.The tailored cells also produced greater amounts of cartilage components, including collagen, and showed the characteristic stiffness of native cartilage, suggesting they would work well repairing cartilage defects in the body."This was a multi-step approach, with the initial differentiation, then sorting, and then proceeding to make the tissue," Diekman said. "What this shows is that iPSCs can be used to make high quality cartilage, either for replacement tissue or as a way to study disease and potential treatments."Diekman and Guilak said the next phase of the research will be to use human iPSCs to test the cartilage-growing technique."The advantage of this technique is that we can grow a continuous supply of cartilage in a dish," Guilak said. "In addition to cell-based therapies, iPSC technology can also provide patient-specific cell and tissue models that could be used to screen for drugs to treat osteoarthritis, which right now does not have a cure or an effective therapy to inhibit cartilage loss."In addition to Guilak and Diekman, study authors include Nicolas Christoforou; Vincent P. Willard; Alex Sun; Johannah Sanchez-Adams; and Kam W. Leong.The National Institutes of Health (AR50245, AR48852, AG15768, AR48182, Training Grant T32AI007217) and the Arthritis Foundation funded the study.Brian O. Diekman, Nicolas Christoforou, Vincent P. Willard, Haosi Sun, Johannah Sanchez

Osteoarthritis of the Knee joint Osteoarthritis of the Knee joint Presentation Transcript

  • Osteoarthritis of Knee Vinod Naneria
  • Definition • The name osteoarthritis comes from three Greek words meaning bone, joint, and inflammation. • It is a progressive disorder of the joints caused by gradual loss of articular cartilage with secondary changes in the bone and synovium.
  • Osteoarthritis – oldest • Remains of the dinosaur Diplodocus show evidence of osteoarthritis 150 million years ago. • Earliest evidence of human osteoarthritis has been found in the remains of Neanderthal man. ( 0.6 – 0.03 M) New man from a valley
  • Knee joint of an Elephant
  • Knee joint of a bird
  • Osteoarthritis • 10% adult population across the world • About a quarter of all consultations in general practice. • Symptoms of the disease manifest much late. • There is no known cure of the disease. Progress can be controlled or delayed
  • Articular cartilage - unique • • • • No blood supply, No lymphatic drainage, No neural elements, Chondrocytes are shielded from immunological recognition. • 60 – 80% of human cartilage is water.
  • Chondrocytes • Chondrocytes are the cellular manufacturing sites of cartilage and are responsible for the production and maintenance of the surrounding matrix . Chondrocyte
  • Collagens: • Protein macromolecules that contain characteristic helical amino acid chains. • Provide the tensile strength and form of cartilage • Proteoglycans are attached to the collagen framework.
  • Proteoglycan • It consist of a core protein, Aggrecan, to which are covalently bound glycosaminoglycan side chains of chondroitin and keratan sulfate. • These charged side chains account for the hydration and resistance to compression of the cartilage matrix.
  • Cartilage Matrix Organization Zones • • • • • Superficial (gliding) – cells are horizontal, Middle (transitional) – cells are crisscross, Deep (radial) – cells are perpendicular, Calcified cartilage. Subchondral bone.
  • Articular Cartilage Matrix Organization Zones • Morphologic, biochemical & functional differences between zones based on depth from articular surface. • Superficial – shearing • Deep - compression
  • Normal Articular Cartilage
  • Articular cartilage in Osteoarthritis
  • Pathogenesis of osteoarthritis of the knee • Chronological age is the single most important risk factor. • In younger patients unfavourable biomechanical environment at the joint is the main cause. • This results in mechanical demand that exceeds the ability of a joint to repair and maintain itself, predisposing the articular cartilage to premature degeneration. Chondrocyte apoptosis - telomere or mechanical overloading
  • OA is characterized by two phases • A biosynthetic phase, during which the Chondrocytes, attempt to repair the damaged extracellular matrix. • A degradative phase, in which the activity of enzymes produced by the chondrocytes digests the matrix, matrix synthesis is inhibited, and the consequent erosion of the cartilage is accelerated.
  • Sequence of events • • • • • Superficial layer abrasion, Superficial layer fissuring, Attempt at repair by chondrocytes, Excess production of new cells and matrixes, Deep layer cleavage.
  • Sequence of events • Chondrocytes start secreting lysosomal enzymes which start dissolving matrixes. • Release of degradation products in the joint leading to synovitis • Loss of shock absorption property • Subchondral bone fractures • Healing of subchondral fractures by sclerosis, and osteophyte formation.
  • Treatment chart Medical Surgical Regenerative
  • Treatment Option - Medical Life style modifications Physiotherapy Nsaids Braces Supports
  • Treatment Option - invasive Injections (Hydrocortisone – Hyaluronic acid) Arthroscopy (debridement) Alignment corrective surgery (HTO) Total / partial joint replacement Regenerative medicine ( cartilage transplantation)
  • Life style modification: • • • • • • • Sitting on ground Squatting Sit-ups Climbing Commode High heels Shoe modification (lateral wedges) • Cane/walker • Braces
  • Life style • • • • • • Walking instead of running, Use alternative exercise program Walking within the limit of pain. Walk on soft earth. Limp if required. Overweight Patients, should lose a minimum of five percent (5%) of body weight. • low-impact aerobic fitness exercises. Don’t scratch your wounds
  • Life style • • • • • • Range of motion/flexibility exercises. Swimming is good exercise. Quadriceps strengthening (static) Delay quadriceps against resistance or avoid it. Use of high heel increases anterior knee pain. Correct your shoe frequently if the heel is getting wear from one side.
  • Role of Physiotherapist • Specific instruction should be given for better cooperation from physio in the interest of patient. – – – – – – – Pain: Heat therapy, SWD, US ROM: bicycle, CPM, free swing, Stretching Correction of deformity, Strengthening of Quad + Hamstrings Static Quadriceps, Improvement in gait & Balance, Resistive exercises – with weights? Choice of modalities should be left to physiotherapist
  • Exercises – 4 Ds • Golden rules: – – – – Do it Do it regularly Do it correctly Do not over do it Exercises for prevention of OA knee is like brushing teeth. It should be gentle & continuous for rest of the life. Free cycling for 5 – 10 minutes at zero resistance. Can be repeated twice a day Free cycling for 5 – 10 minutes / 5 km are very good form of exercise. Static cycle is better. It help in cartilage nutrition by CPM type action. Can be repeated twice a day. Bicycling for knee arthritis is not a weight reduction tool, overdoing can damage the knee further. Skipping: Soft surface – in garden or wooden platform. Avoid high impact. overdoing can damage the knee further.
  • Free cycling • Free cycling for 5 – 10 minutes / 5 km are very good form of exercise. • Static cycle is better. • It help in cartilage nutrition by CPM type action. • Can be repeated twice a day. • Bicycling for knee arthritis is not a weight reduction tool, overdoing can damage the knee further. ZERO - RESISTANCE
  • overdoing can damage the knee further. Free cycling for 5 – 10 minutes at zero resistance. Can be repeated twice a day.
  • Skipping • Skipping • Soft surface – in garden or wooden platform • Avoid high impact.
  • Treadmill • Climbing uphill increases loading on the damaged cartilage and at times precipitate acute pain and effusion in knee. • It is a high impact exercise. • Specially precipitate PF pain.
  • Patello-femoral pain
  • Braces • Instability / lack of confidence, • Insecurity / apprehension • Meniscus tear • Ligamentous laxity • Unicompartmental disease
  • Life style modification • Unilateral joint unloading braces are not recommended for general use. They are commonly prescribed for unicompartmental disease of the knee.
  • Acupuncture • There is no recommendations for or against the use of acupuncture as an adjunctive therapy for pain relief in patients with symptomatic OA of the knee.
  • Prolotherapy or proliferation therapy • It involves injecting an nonpharmacological and non-active irritant solution into the region of tendons or ligaments. • It re-initiate the inflammatory process that deposits new additional fibres to repair a perceived injury. • dextrose, lidocaine, phenol, glycerine, or cod liver oil extract. The injection is given into joints or tendons where they connect to bone Not covered by Medicare in USA
  • Pain Relievers • Patients with symptomatic OA of the knee can receive one of the following analgesics for pain unless there are contraindications to this treatment: • Acetaminophen • NSAIDs only in acute flare for short term. • Avoid them in cases of hypertension, CRF and CAD. • Oral cortisone have no role. Tx - Malaria by Crocin Prolonged use can cause neuropathic joint
  • Glucosamine & Chondroitin • Chondroitin is the most abundant glycosaminoglycan in cartilage and is responsible for the resiliency of cartilage. • Oral consumption of the substances may increase the rate of formation of new cartilage by providing more of the necessary building blocks. Approved by FDA as food supplements Not recommended by AAOS for OA
  • Chondroprotactive drugs • Recommendations for or against Glucosamine and/or Chondroitin sulfate or hydrochloride are inconclusive for symptomatic OA of the knee. • There are proteoglycons synthesised by chondrocytes in normal cartilage, there supplementation logically have no effect in disease progression. FDA – food supplements
  • Diacerein (interleukin alpha 1 blocker) • The IL-1 mediated enhancement of collagenase production in chondrocytes is actively inhibited by Diacerein. • Diacerein has a different spectrum of antiinflammatory activity to that of the classical NSAIDs naproxen and ibuprofen. While NSAID drugs inhibit cyclooxygenase, diacerein does not inhibit prostaglandin synthesis. Inflammation is a response to disease and not the cause of disease
  • Diacerein • Inhibition of IL-1, which distinguishes it from other drugs indicated for the treatment of osteoarthritis • Stimulate anabolic processes. • Diacerein and rhein inhibit the production of IL-1b by chondrocytes in the superficial and deep zones of human osteoarthritic cartilage Anti-inflammatory reduce pain in brain not at knee
  • Role of Vitamin D and calcium • A weak quadriceps due to Vitamin D deficiency can be a precipitating factor for early OA. • A weak muscle increases mechanical overloading on the knee articular surface. • There can be disuse quadriceps weakness due to pain. • Vitamin D and calcium can be supplemented.
  • Osteoporosis & Osteoarthritis • • • • Do not coexist together. BMI 22 & > – OA BMI below 22 (< 19) OS Both can have a presenting symptom of difficulty in getting up from sitting position (typical of OA). This is due to Vitamin D deficiency.
  • Injections • Visco supplementations. • Hydrocortisone. • Benefit of viscosupplementation in patients with symptomatic osteoarthritis is minimal or nonexistent. • Increased risks for serious adverse events and local adverse events, the administration of these preparations should be discouraged.
  • Intra-Articular Injections • Intra-articular corticosteroids for short-term pain relief for patients with symptomatic OA of the knee. • AAOS does not recommend the routine use of intra-articular corticosteroids, for patients with mild to moderate symptomatic OA of the knee. • It may give symptomatic relief for few months. • It can precipitate early damage in young patients due to over activity on a damaged cartilage. Rest for 2 -3 weeks after a shot
  • Corticosteroids • Known anti-inflammatory, but their mechanism of action is not completely known. • Corticosteroids inhibit the accumulation of inflammatory cells, such as leukocytes and neutrophils. • They prevent phagocytosis, lysosomal enzyme release, and the synthesis of several inflammatory mediators. Ideal for elderly who are sedentary and not fit for surgery
  • Hyaluronic acid • The name derived from the Greek word hyalos meaning vitreous, and uronic acid. • Normally secreted in the synovium by Type B synoviocytes. • Act as a lubricant and shock absorber. • It is made of approximately 12,500 disaccharide units and have molecular weight of 5 million daltons. • In pathological condition, the concentration and molecular weight of indigenous hyaluronic acid is reduced.
  • Hyaluronic acid • Hyaluronic acid has both viscous and elastic properties. • At high shear forces, hyaluronic acid exhibits increased elastic properties and reduced viscosity. • The opposite is true with low shear forces. • Therefore, hyaluronic acid acts as a shock absorber during fast movements, and a lubricant during slow movement.
  • Hyaluronic acid • The use of HA as VS began in the late 1960s by Biotrics, Inc. The material was taken from human umbilical cord. • The chondro-protective effects of HA has not been clinically proven. • The FDA classified VS as medical devices; • AAOS does not recommend it for patients with mild to moderate symptomatic OA of the knee. • Can be used for the patient who are on waiting list for TKR.
  • Arthroscopy Procedures • • • • • • • • • Joint debridement Removal of mechanical obstructions, Joint lavage Drilling of sclerotic lesions Abrasion chondroplasty Autologous chondrocyte transplantation Mosaicplasty Cartilage transplantation Regenerative medicine
  • Arthroscopy • Recommendations for performing arthroscopy with debridement or lavage in patients with a primary diagnosis of symptomatic OA of the knee is not conclusive. • Arthroscopic partial meniscectomy or loose body removal is advisable, in patients who have primary signs and symptoms of a torn meniscus and/or a loose body.
  • Cartilage Replacement • Autologous transplantation – from one place to another in same knee. (Mosiacplasy) • Autologous – grow in lab – transplantation (two stage – harvesting – growth in lab – reimplantation with or without matrixes) • Stem cell – cartilage grow in lab – transplantation (iPP, induced mesenchymal pleuripotant stem cells – from bone marrow, skin, and other donar sites.
  • Abrasion and Micro-fracture surgery • Abrasive procedures aimed at triggering cartilage production. • Abrasion, drilling, and micro fractures rely on the phenomenon of spontaneous repair of the cartilage tissue following vascular injury to the subchondral bone, which allow inflow of naturally circulating stem cells (progenitors) in the blood. Proteoglycon are resistant to neovascularization
  • Autologous chondrocyte transplantation Mosaicplasy - Technique • The patient’s chondrocytes are removed arthroscopically from a non load-bearing area. • 10,000 cells are harvested and grown in vitro for approximately six weeks until the population reaches 10-12 million cells. • Then these cells are injected into the cartilage defect of the patient.
  • Autologous chondrocyte transplantation Mosaicplasy - Technique • These cells are held in place by a periosteal flap, which is sutured over the area to serve as a watertight lid. • The implanted chondrocytes then divide and integrate with surrounding tissue and potentially generate hyaline-like cartilage.
  • Technique cont…… • A second generation technique, called Carticel II uses a "fleece matrix" implanted with chondrocyte cells that is arthroscopically inserted into the joint. This procedure is known as matrix autologous chondrocyte implantation or (MACI) and is available in Germany, UK, and Australia
  • Mosaicplasy
  • Chondroplasty
  • Chondroplasty
  • Corrective -Surgery • High Tibial Osteotomy • Realignment osteotomy is an option in active patients with symptomatic unicompartmental OA of the knee with mal-alignment. • It can be done as an isolated procedure or may be combined with chondroplasty or menisectomy.
  • High tibial osteotomy • The fundamental goals is to unload diseased articular surfaces and to correct angular deformity at the tibiofemoral articulation. • HTO is effective for managing OA with varus, osteochondritis dissecans, osteonecrosis, posterolateral instability, and chondral resurfacing.
  • High Tibial Osteotomy • Improved instrumentation and fixation plates for medial opening / lateral closing wedge osteotomy, • Dynamic external fixation for medial opening wedge osteotomy, • Concomitantly correcting mal-alignment when performing chondral resurfacing procedures (ie, autologous chondrocyte transplantation, mosaicplasty, and microfracture).
  • High tibial osteotomy • A valgus alignment of 6° and 10° of valgus, regardless of condylar width, baseline tibiofemoral alignment, body weight, or chondral defect size, demonstrated complete unloading of the medial compartment, which favors cartilage repair at these alignments.
  • High Tibial Osteotomy
  • High Tibial Oateotomy
  • Spontaneous correction due to stress fracture
  • Replacement Surgery • • • • • Total knee replacement Patient’s specific knee replacement Unicondylar replacement Patello-femoral replacement Meniscus replacement Metallurgy - replacing biology Metallurgy has a date of expiry
  • Uni-condylar replacement Patello – femoral replacement oxidised zirconium” oxinium”
  • Our experience • We did our first THR in 1985. • We were amongst the first to start TKR on a routine basis way back 1993. • We conducted a national workshop on THR in 1987.
  • INOR TKR
  • Bilateral TKR
  • An interesting case 1995 - 2012
  • Tissue engineering • Defined as the application of engineering science and technology to the combined field of cellular and molecular biology with the goal of regulating the growth, differentiation, and metabolic activity of cells that are either transplanted or recruited to heal or regenerate a joint surface
  • Regeneration: Growth of New Cartilage • Because of the limited capacity of cartilage to heal, a more attractive approach is to transplant cells or a tissue with chondrogenic potential into the joint (socalled biological resurfacing). • Bentley and Greer were apparently the first to show that chondrocytes could be transplanted into articular cartilage defects and improve healing compared with that in controls. • Chondrocytes, stem cells, an undifferentiated tissue (such as periosteum or perichondrium) containing stem cells or chondrocyte precursors, or any combination of these can be used.
  • Autogenous periosteal grafts • Osteochondral defects in the knees of rabbits that were resurfaced with use of autogenous periosteal grafts healed with predominantly hyaline cartilage containing more than 90 percent type-II collagen and normal water, proteoglycan, chondroitin, and keratan sulfate contents.
  • Autogenous periosteal grafts • A patch of periosteum sewn over an articular defect in the knee. A small volume of autogenous chondrocytes, which had been grown in culture for two to three weeks after having been isolated from biopsy specimens of cartilage obtained during an earlier arthroscopy, was injected beneath the patch. The second stage of the procedure was performed through an open arthrotomy.
  • Experimental • intra-articular injection of growth factors, such as transforming growth factor-ß1, insulin-like growth factor-1, bone morphogenetic proteins, fibroblast growth factor, and epidermal growth factor. • A single injection of transforming growth factorß1 stimulated a persistent increase in cartilage proteoglycan synthesis and content, but multiple injections induced substantial synovitis, synovial hyperplasia, and formation of osteophytes .
  • Scaffolds • The many substances that have been tested include nonabsorbable materials, such as carbon fiber, Dacron, and Teflon; porous metal plugs; absorbable polymers or copolymers, such as polyglycolic acid and polylactic acid; fibrin and collagen.
  • Future - Dolly
  • Dolly (5 July 1996 – 14 February 2003) was a female domestic sheep, and the first mammal to be cloned from an adult somatic cell, using the process of nuclear transfer. Dolly was born on 5 July 1996 to three mothers (one provided the egg, another the DNA and a third carried the cloned embryo to term). She was created using the technique of somatic cell nuclear transfer, where the cell nucleus from an adult cell is transferred into an unfertilised oocyte (developing egg cell) that has had its nucleus removed. The hybrid cell is then stimulated to divide by an electric shock, and when it develops into a blastocyst it is implanted in a surrogate mother.
  • Dolly • Normal age of sheep is around 11-12 years. • Dolly lived for six years. • It was speculated that Dolly's genetic age was six years, the same age as the sheep from which she was cloned. The basis for this idea was the finding that Dolly's telomeres were short, which is typically a result of the ageing process.
  • Nobel Prize in medicine 2012 Shinya Yamanaka & Sir John B. Gurdon Discovered that the developmental clock could be turned back in mature cells, transforming them into immature cells with the ability to become any tissue in the body — pleuripotent stem cells. (iPS)
  • Illuminating Chondrogenesis: Pictured are murine induced pluripotent stem cells undergoing chondrogenesis. In addition to type II collagen (red), F-actin (magenta), and nucleus (blue), upon differentiation cells express green fluorescent protein under the control of a chondrocyte-specific promoter. Diekman et al. employed cell sorting to produce tissue-engineered cartilage for potential use in treating cartilage defects or discovering new drugs for osteoarthritis.
  • Future • Some day we will be able to replace a part or the whole articular cartilage by new cartilages cells developed in lab by induced Mesenchymal Stem cells. • It will be something like changing a punctured tire as and when needed.
  • Journey Continue………….
  • It is a crime to think “small” - A.P.J. Abdul Kalam
  • DISCLAIMER • Information contained and transmitted by this presentation is based on personal experience and collection of cases at Choithram Hospital & Research centre, Indore, India, during last 34 years. • It is intended for use only by the students of orthopaedic surgery. • Views and opinion expressed in this presentation are personal. • Depending upon the x-rays and clinical presentations, viewers can make their own opinion. • For any confusion please contact the sole author for clarification. • Every body is allowed to copy or download and use the material best suited to him. I am not responsible for any controversies arise out of this presentation. • For any correction or suggestion please contact naneria@yahoo.com