Autologous matrix-induced chondrogenesis

Autologous matrix-induced chondrogenesis (AMIC) is a treatment for articular cartilage damage. It combines microfracture surgery with the application of a bi-layer collagen I/III membrane. There is tentative short to medium term benefits as of 2017.[1]

The initialism AMIC, often used as a genericized trademark, is a registered trademark of Ed. Geistlich Söhne AG, protected by German Registration No. 30255356 [2] and international Registration No. 840373.[3]

The procedure described below relates specifically to the use of a collagen membrane, but recent advances now allow the use, using the same surgical procedure of non woven bio degradable materials that were initially developed for cell culturing of chondrocytes to be employed. These purely synthetic materials ( contain no animal derived products) are often further enhanced by impregnation of the material with high concentrations of Hyaluronic acid, which has been shown to be required to stimulate the differentiation of stem cells migrating from the bone marrow into chondrocytes (the true cartilage cell) and the resultant synthesis of type 2 collagen, the same native collagen found in the undamaged cartilage tissue. These enhanced synthetic biodegradable materials have been used to treat lesions in the knee, ankle, hip and great toe.

Procedure
See also: Knee cartilage replacement therapy

Autologous Matrix Induced Chondrogenesis (AMIC) surgery is a single step procedure. After arthroscopic evaluation of the cartilage damage and decision for an AMIC procedure a mini arthrotomy is performed. An all-arthroscopic AMIC procedure for repair of cartilage defects of the knee is also possible.[4]

First the cartilage defect is exposed and cleaned whereby all unstable degenerated cartilage, including the calcified cartilage layer, are carefully removed. An imprint of the defect is then taken using a sterile moldable material (e.g. aluminium foil) and transferred to the collagen membrane which is cut to shape. The surgeon then creates tiny holes/fractures in the subchondral bone plate (microfracturing) with a special awl. Blood and bone marrow (containing stem cells) are released forming a blood clot which contains cartilage forming elements. The correctly sized collagen membrane is added to the microfractured area either by fibrin glue (autologous or commercially available) or suturing. Through flexion of the joint, the stable positioning of the membrane is verified and the wound is closed.

An essential requirement for satisfying outcome of the AMIC surgery is the compliance to a strict physical therapy program. Guidelines and recommendations exist, though they have to be adapted to the individual patients needs.

History

The AMIC procedure was first proposed by Behrens in 2003. it aims to extend the use of microfracture surgery to larger cartilage lesions > 2.5 cm2.ref name="Behrens">Behrens P., P. (2005). "Matrixgekoppelte Mikrofrakturierung". Arthroskopie. 18 (3): 193–197. doi:10.1007/s00142-005-0316-0. S2CID 30000568.</ref> Its clinical efficiency in autologous chondrocyte implantation (ACI), another cartilage repair technique for larger cartilage lesions, has been studied.[5][6][7]

In general various factors have been identified known to influence the result after cartilage repair regardless of the technique used. Amongst them are the species and age of the individual, the size and localization of the articular cartilage defect, the surgical technique, and the postoperative rehabilitation protocol.[8][9] The latter has been found especially important for microfracture surgery and therefore for AMIC.[10]

The basic procedure of Microfracture surgery was developed by JR Steadman in the late 80’s and early 90’s. It is a well documented cartilage repair technique and first line treatment option for small cartilage lesions.[11][12][13] AMIC evolved with the aim to improve some of the shortfalls of microfracture surgery as for instance variable repair cartilage volume and functional deterioration over time.[14]

References
  1. Shaikh, N; Seah, MKT; Khan, WS (18 July 2017). "Systematic review on the use of autologous matrix-induced chondrogenesis for the repair of articular cartilage defects in patients". World Journal of Orthopedics. 8 (7): 588–601. doi:10.5312/wjo.v8.i7.588. PMC 5534408. PMID 28808630.
  2. "Deutsche Patent- und Markenamt (DPMA), registration # 30255356". 2002-11-11. Retrieved 2013-01-25.
  3. "World Intellectual Property Organization (WIPO), registration # 840373". 2004-08-18. Retrieved 2013-01-25.
  4. Piontek, Tomasz; Ciemniewska-Gorzela Kinga; Szulc Andrzej; Naczk Jakub; Słomczykowski Michał (30 August 2011). "All-arthroscopic AMIC procedure for repair of cartilage defects of the knee". Knee Surgery, Sports Traumatology, Arthroscopy. 20 (5): 922–925. doi:10.1007/s00167-011-1657-z. ISSN 0942-2056. PMC 3332359. PMID 21910000.
  5. Gomoll AH, Probst C, Farr J, Cole BJ, Minas T (November 2009). "Use of a type I/III bilayer collagen membrane decreases reoperation rates for symptomatic hypertrophy after autologous chondrocyte implantation". Am J Sports Med. 37 Suppl 1: 20S–23S. doi:10.1177/0363546509348477. ISSN 0363-5465. PMID 19841142. S2CID 206524323.
  6. Steinwachs M, Kreuz PC (April 2007). "Autologous chondrocyte implantation in chondral defects of the knee with a type I/III collagen membrane: A prospective study with a 3-year follow-up". Arthroscopy. 23 (4): 381–387. doi:10.1016/j.arthro.2006.12.003. ISSN 1526-3231. PMID 17418330.
  7. Gooding CR, Bartlett W, Bentley G, Skinner JA, Carrington R, Flanagan A (Jun 2006). "A prospective, randomised study comparing two techniques of autologous chondrocyte implantation for osteochondral defects in the knee: Periosteum covered versus type I/III collagen covered". Knee. 13 (3): 203–10. doi:10.1016/j.knee.2006.02.011. ISSN 0968-0160. PMID 16644224.
  8. Alford JW, Cole BJ (Mar 2005). "Cartilage restoration, part 2: techniques, outcomes, and future directions". Am J Sports Med. 33 (3): 443–460. doi:10.1177/0363546505274578. ISSN 0363-5465. PMID 15716263. S2CID 11361026.
  9. Steinwachs MR, Guggi T, Kreuz PC (Apr 2008). "Marrow stimulation techniques". Injury. 39 Suppl 1: S26–31. doi:10.1016/j.injury.2008.01.042. ISSN 0020-1383. PMID 18313469.
  10. Hurst JM, Steadman JR, O'Brien L, Rodkey WG, Briggs KK (Apr 2010). "Rehabilitation following microfracture for chondral injury in the knee". Clin Sports Med. 29 (2): 257–65, viii. doi:10.1016/j.csm.2009.12.009. ISSN 1556-228X. PMID 20226318.
  11. Steadman JR, Rodkey WG, Singleton SB, Briggs KK (October 1997). "Microfracture technique for full-thickness chondral defects: Technique and clinical results". Oper Tech Orthop. 7 (4): 300–304. doi:10.1016/S1048-6666(97)80033-X.
  12. Steadman JR, Rodkey WG, Rodrigo JJ (Oct 2001). "Microfracture: surgical technique and rehabilitation to treat chondral defects". Clin Orthop Relat Res. 391 (391 Suppl): S362–9. doi:10.1097/00003086-200110001-00033. ISSN 0009-921X. PMID 11603719.
  13. Steadman JR, Briggs KK, Rodrigo JJ, Kocher MS, Gill TJ, Rodkey WG (May–Jun 2003). "Outcomes of microfracture for traumatic chondral defects of the knee: average 11-year follow-up". Arthroscopy. 19 (5): 477–84. doi:10.1053/jars.2003.50112. ISSN 1526-3231. PMID 12724676.
  14. Mithoefer K, McAdams T, Williams RJ, Kreuz PC, Mandelbaum BR (Oct 2009). "Clinical efficacy of the microfracture technique for articular cartilage repair in the knee: an evidence-based systematic analysis". Am J Sports Med. 37 (10): 2053–63. doi:10.1177/0363546508328414. ISSN 1552-3365. PMID 19251676. S2CID 206523609.
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