Advances in Cartilage Repair

Osteochondral lesions of the ankle joint are typically associated with a traumatic etiology and present with ankle pain and swelling. Conservative management yields unsatisfactory results because of the poor healing capacity of the articular cartilage. Smaller lesions (<100 mm² or <10 mm) can be treated with less invasive procedures such as arthroscopic debridement, anterograde drilling, scaffold-based therapies, and augmentation with biological adjuvants. For patients with large lesions (>100 mm² or >10 mm), cystic lesions, uncontained lesions, or patients who have failed prior bone marrow stimulation, management with autologous osteochondral transplantation is indicated.

Osteochondral lesions of the talar dome

Ankle pain and/or instability is a frequent, non-specific reason for consultation, and may reveal an osteochondral lesion of the talar dome (OLTD). There are 2 types of OLTD: (1) posteromedial, usually idiopathic, wide and deep, featuring isolated pain with severe functional impact; (2) anterolateral, often implicating trauma and associated in 30% of cases with lateral ligament involvement, in a clinical presentation associating pain and instability. The aim of the present study was to review the issue of OLTD, with 5 questions: HOW TO ESTABLISH THE DIAGNOSIS, WITH WHAT WORK-UP?: There are no specific clinical signs. A diagnosis of OLTD should be considered in all cases of painful and/or unstable ankle and especially in case of history of sprain. The clinical work-up screens systematically for laxity or associated hindfoot malalignment. CT-arthrography is the gold-standard, enabling morphologic analysis of OLTD. WHAT CLASSIFICATIONS SHOULD BE USED?: CT-arthrography determines length, depth and any cartilage dissection, classifying OLTD in 3 grades. Grade 1 is a lesion<10mm in length and<5mm in depth. Grade 2 is>10mm in length and/or>5mm in depth with intact cartilage around the lesion. Grade 3 is the same as grade 2 but with overlying cartilage dissection. WHAT ARE THE CURRENT TREATMENT INDICATIONS?: After failure of 6 months' well-conducted medical treatment (sports rest, analgesics, physiotherapy), surgical options in France today comprise microfracture in grade 1 OLTD, raising the fragment, freshening the floor of the lesion and fixing the fragment (known as "lift, drill, fill, fix" (LDFF)) in grade 2, and mosaicplasty in grade 3. WHAT ARE THE PROSPECTS FOR FUTURE TREATMENTS AND THEIR ROLES?: Treatments are progressing and improving. Ideal treatment should restore hyaline cartilage to prevent secondary osteoarthritis. Matrix and cell culture techniques need to be validated. WHAT RESULTS CAN BE EXPECTED AND WHAT SHOULD PATIENTS BE TOLD?: Management according to grade secures AOFAS scores≥80/100 in 80% of cases, whatever the grade. Return to sport is feasible in 80% of case, at a mean 6 months. Progression is satisfactory after treatment adapted to the lesion. LEVEL OF EVIDENCE: V, expert opinion.

Double membrane platelet-rich fibrin (PRF) - Synovium succeeds in regenerating cartilage defect at the knee: An experimental study on rabbit

Background

This study aims to prove the healing results (regeneration) in cartilage defects using a combination treatment of microfractures and transplantation synovium-platelet rich fibrin (S-PRF).

Methods

A cartilage defect was made in the trochlear groove of the knee of adult New Zealand white rabbits, and was classified into three treatment groups. The group 1 was cartilage defect without treatment, 2 with microfracture treatment, and 3 with microfracture covered with a synovium-platelet rich fibrin (S-PRF) membrane. Twelve weeks after the intervention, the animals were macroscopically and histologically examined, and evaluated by the International Cartilage Repair Society (ICRS). Additionally, the expression of aggrecan and type 2 collagen was examined by real-time-PCR.

Results

The ICSR scores for macroscopic were significantly higher in the microfracture and S-PRF transplant group than in the other groups. Also, the ICSR scores for histology were significantly higher in this group. The expression of aggrecan and type 2 collagen was higher in the group that received complete treatment.

Conclusions

Microfractures and transplantation of synovium-platelet rich fibrin (S-PRF) can regenerate knee cartilage defects which have been shown to increase the expression of mRNA aggrecan and mRNA type 2 collagen resulting in excellent repair.

Comparative efficacy of osteochondral autologous transplantation and microfracture in the knee: an updated meta-analysis of randomized controlled trials

INTRODUCTION

More than 19% of patients undergoing knee arthroscopies suffers from articular cartilage defects. The chondral or osteochondral lesion has negative impacts on the knee joints function and the life quality of patients. However, the treatment remains challenging as hyaline cartilage is not renewable. The purpose of this study was to systematically analyze the data of randomized controlled trials for comparing the postoperative outcomes between osteochondral autologous transplantation (OAT) and microfracture (MF) procedure. We hypothesized that the outcomes were better in OAT than MF procedure.

MATERIALS AND METHODS

A systematic literature search of the EMBASE, Pubmed, and Cochrane Library databases was conducted based on PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The outcome measures include: the rate of excellent or good results, the rate of return to sports, the failure rate, osteoarthritis rate, International Cartilage Repair Society (ICRS) score, Lysholm Knee Score, and Tegner scale. The statistical analysis was completed using Review Manager (RevMan, version 5.3) software.

RESULTS

The systematic search identified 7 studies with a total of 346 patients. The pooled result showed significant differences between the two groups in the rate of return to sports and failure. The following outcome scores showed significant improvement (pre- vs postoperatively): Lysholm score (p = 0.02), Tegner scale (p < 0.00001), and ICRS score (p < 0.00001). The differences were not significant in the excellent or good results and the rate of osteoarthritis.

CONCLUSION

The patients in OAT group may return to play quicker, even return to pre-injury level of activity compared to the MF group. OAT is better than MF procedure in accordance with Lysholm score, Tegner score, ICRS score, and the rate of failure. However, few studies have reported long-term outcomes and there has no uniform criteria for safe return to sports. Further research is needed.

LEVEL OF EVIDENCE

Level II, meta-analysis of randomized controlled trials.

Promoting endogenous articular cartilage regeneration using extracellular matrix scaffolds

Articular cartilage defects fail to heal spontaneously, typically progressing to osteoarthritis. Bone marrow stimulation techniques such as microfracture (MFX) are the current surgical standard of care; however MFX typically produces an inferior fibro-cartilaginous tissue which provides only temporary symptomatic relief. Here we implanted solubilised articular cartilage extracellular matrix (ECM) derived scaffolds into critically sized chondral defects in goats, securely anchoring these implants to the joint surface using a 3D-printed fixation device that overcame the need for sutures or glues. In vitro these ECM scaffolds were found to be inherently chondro-inductive, while in vivo they promoted superior articular cartilage regeneration compared to microfracture. In an attempt to further improve the quality of repair, we loaded these scaffolds with a known chemotactic factor, transforming growth factor (TGF)-β3. In vivo such TGF-β3 loaded scaffolds promoted superior articular cartilage regeneration. This study demonstrates that ECM derived biomaterials, either alone and particularly when combined with exogenous growth factors, can successfully treat articular cartilage defects in a clinically relevant large animal model.

Limited evidence of adjuvant biologics with bone marrow stimulation for the treatment of osteochondral lesion of the talus: a systematic review

PURPOSE

To evaluate the complication rates, continuous functional outcome scores, and return to play data following bone marrow stimulation (BMS) versus biologics ± BMS for the treatment of osteochondral lesion of the talus (OLT).

METHODS

A systematic review was performed. The PubMed and Embase databases were searched using specific search terms and eligibility criteria according to the PRISMA guidelines. The level of evidence was assessed using published criteria by The Journal of Bone & Joint Surgery, and the quality of evidence using the Modified Coleman Methodology Score. Continuous variables were presented as mean ± standard deviation and categorical variables as frequencies (percentages).

RESULTS

BMS versus BMS + hyaluronic acid (HA): no complications in either treatment arm were reported. The mean American Orthopaedic Foot and Ankle Society score was 43.5 to 67.3 points and 44.0 to 72.4 points, respectively. The mean 10 mm Visual Analogue Scale pain score was 7.7 to 3.8 points and 7.5 to 2.5 points, respectively. BMS versus BMS + concentrated bone marrow aspirate (CBMA): the pooled overall complication rate was 17/64 (26.6%) versus 11/71 (15.5%), respectively (non-significant). The pool revision rate was 15/64 (23.4%) versus 6/71 (8.5%), respectively (p = 0.016). There has been a notable poor reporting of complication rates for the use of ADSC and PRP as adjuvant biological therapies to BMS for the treatment of OLT.

CONCLUSION

There was an overall limited comparative clinical evidence of adjuvant biologics with BMS versus BMS alone for the treatment of OLT. BMS + HA and BMS + CBMA can provide superior outcomes, albeit the currently limited evidence. Further studies are warranted to establish the true clinical superiority of the various biologics ± BMS versus BMS alone. These studies must also compare the various biologics against one another to determine, if any, the optimal biologic for OLT. Clinicians should counsel patients accordingly on these findings as required.

LEVEL OF EVIDENCE

Level III.

Surgical management of concurrent lateral ankle instability and osteochondral lesions of the talus increases dynamic sagittal ankle range of motion

PURPOSE

A biomechanical study, in which imaging modalities are used to strictly include patients with concurrent lateral ankle instability (LAI) and osteochondral lesions of the talus (OLT), is needed to demonstrate the static and dynamic ankle range of motion (ROM) restriction in these patients, and determine whether ankle ROM restriction can be corrected postoperatively.

METHODS

Eight patients with concurrent LAI and OLT treated with the arthroscopic modified Broström procedure and microfracture were recruited from June 2019 to January 2020. Patients were assessed using outcome scales, static ankle ROM, and a stair descent gait analysis for dynamic ankle ROM, a day prior to surgery and one year postoperatively. Eight healthy subjects were assessed using the same modalities upon recruitment. Operative outcomes and variables during stair descent were documented and compared among the preoperative, postoperative, and healthy groups. A curve analysis, one-dimensional statistical parametric mapping, was performed to compare the dynamic ankle kinematics and muscle activation curves over the entire normalised time series.

RESULTS

The functional outcomes of patients with concurrent LAI and OLT were significantly worse than those of healthy subjects preoperatively, but were partially improved postoperatively. Patients had decreased static and dynamic ROM preoperatively, and static ROM did not significantly increase postoperatively (preoperative, 39.6 ± 11.3; postoperative, 44.9 ± 7.1; healthy, 52.0 ± 4.6; p = 0.021). Patients showed increased dynamic ankle flexion ROM (preoperative, 41.2 ± 11.6; postoperative, 53.6 ± 9.0; healthy, 53.9 ± 3.4; p = 0.012) postoperatively, as well as increased peroneus longus activation (preoperative, 35.8 ± 12.0; postoperative, 55.4 ± 25.1; healthy, 71.9 ± 13.4; p = 0.002) and muscle co-contraction of the tibialis anterior and peroneus longus (preoperative, 69.4 ± 23.4; postoperative, 88.4 ± 9.3; healthy, 66.2 ± 18.1; p = 0.045).

CONCLUSIONS

Patients with concurrent LAI and OLT had decreased static and dynamic sagittal ankle ROM and altered neuromuscular activation patterns. The arthroscopic modified Broström procedure and microfracture did not significantly increase the static sagittal ankle ROM. However, the dynamic sagittal ankle ROM, peroneus longus activation and muscle co-contraction of the tibialis anterior and peroneus longus increased postoperatively.

LEVEL OF EVIDENCE

IV.

Glenoid microfracture in active-duty military patients: minimum 5-year follow-up demonstrates 75% survival

Background

To present midterm patient-reported outcomes and survivorship data of active-duty military patients undergoing microfracture for full-thickness cartilage defects of the glenoid.

Methods

All consecutive patients from January 2013 through December 2016 who underwent glenoid microfracture for full-thickness cartilage injuries with complete outcome scores were identified. Twenty patients met the final inclusion criteria for the study, and all were active-duty military at the time of surgery. A separate subgroup analysis was performed to determine if dominant-shoulder involvement portends worse outcomes.

Results

The mean follow-up was 81.45 ± 19.43 months (range, 60-108). Of the 20 patients, 5 required a secondary surgical procedure within 5 years of their index procedure, with an average time to failure of 45.6 ± 13.15 months. For the 15 patients who did not fail, there was a statistically significant increase in the mean American Shoulder and Elbow Surgeons score (57.20 vs. 88.27, P < .0001) and Single Assessment Numeric Evaluation (45.00 vs. 86.33, P < .0001). Mean pain decreased significantly as measured by the pain visual analog scale (5.40 vs. 1.37, P < .0001). Range of motion in forward elevation, external rotation, and internal rotation did not change significantly postoperatively (P = .4528, .4810, and .1919, respectively). Concomitant procedures did not predict changes in pain, American Shoulder and Elbow Surgeons, or Single Assessment Numeric Evaluation scores. A majority of patients (13/20, 65%) were able to remain on unrestricted military active-duty service, but 7 (35%) underwent medical discharge, including the 5 patients who had experienced treatment failure, plus 2 additional patients.

Conclusion

Glenoid microfracture can result in pain relief and symptomatic improvement for a select group of active-duty military patients, with 75% survivorship at 5 years. Approximately one in three (35%) patients, however, were unable to remain on active-duty military service.

Chondral delamination of the knee and its management: a case report and review article

Chondral delamination is the separation or debonding of the articular cartilage from the underlying subchondral bone. The hyaline cartilage has a limited capacity for healing, meaning it does not possess the innate ability to restore its normal structure or to heal the subchondral bone once detached from it. The purpose of this article is to report the outcomes of a microfracture technique used to manage chondral delamination in a 59-year-old male; we also reviewed the treatment options mentioned in the literature. The patient was admitted to the Department of Orthopedic Surgery complaining of recurrent severe right knee pain with multiple episodes of knee locking, denying any direct or twisting trauma to the knee. The plain X-ray showed mild degenerative changes with articular surface irregularity. On Magnetic resonance imaging, wide chondral delamination was noted in the medial femoral condyle. After 12 months' post-op, his condition improved. No locking was observed. Pain improved in comparison to the pre-operative levels. The international knee documentation committee improved from 26.4% to 52.9%. In a follow-up magnetic resonance imaging, the adhesion of most parts of the delaminated cartilage.

Lesion size and varus malalignment are the major determinants leading to poorer clinical outcomes after combined microfracture treatment for focal cartilage lesions during anterior cruciate ligament reconstruction

The purposes of this study were to evaluate the clinical effects of microfracture (MFX) performed for Outerbridge grade 3 or 4 focal cartilage lesion during the same surgery with arthroscopic anterior cruciate ligament (ACL) reconstruction and to analyze the major determinants of these potential effects on the clinical outcome. The clinical and radiographic data of 119 patients were evaluated. The mean follow-up time was 32.6 ± 6 months. Isolated arthroscopic ACL reconstruction was performed in 70 patients (Group 1), whereas MFX for Outerbridge grade 3 or 4 chondral lesion during ACL surgery was performed in 49 patients (Group 2). Visual analogue scale (VAS) score, Lysholm knee score, and Tegner activity scale were the instruments used as outcome measures to evaluate the clinical status of the patients. Routine X-ray and MRI were also performed for all patients pre-operatively as well as at the latest follow-up visit. Lineer regression analysis was performed to determine major factors predicting the poorer clinical outcome. Clinical outcomes were similar between isolated ACL reconstruction and combined procedure. On the other hand, according to lineer regression analysis, cartilage lesion size > 2 cm² and > 5 degrees of varus alignment were detected as the major determinants leading to poorer outcomes in combined ACL reconstruction and MFX.Level of evidence: III - Retrospective Comparative Study.

Microenvironmentally optimized 3D-printed TGFβ-functionalized scaffolds facilitate endogenous cartilage regeneration in sheep

Clinically, microfracture is the most commonly applied surgical technique for cartilage defects. However, an increasing number of studies have shown that the clinical improvement remains questionable, and the reason remains unclear. Notably, recent discoveries revealed that signals from regenerated niches play a critical role in determining mesenchymal stem cell fate specification and differentiation. We speculate that a microenvironmentally optimized scaffold that directs mesenchymal stem cell fate will be a good therapeutic strategy for cartilage repair. Therefore, we first explored the deficiency of microfractures in cartilage repair. The microfracture not only induced inflammatory cell aggregation in blood clots but also consisted of loose granulation tissue with increased levels of proteins related to fibrogenesis. We then fabricated a functional cartilage scaffold using two strong bioactive cues, transforming growth factor-β3 and decellularized cartilage extracellular matrix, to modulate the cell fate of mesenchymal stem cells. Additionally, poly(ε-caprolactone) was also coprinted with extracellular matrix-based bioinks to provide early mechanical support. The in vitro studies showed that microenvironmentally optimized scaffolds exert powerful effects on modulating the mesenchymal stem cell fate, such as promoting cell migration, proliferation and chondrogenesis. Importantly, this strategy achieved superior regeneration in sheep via scaffolds with biomechanics (restored well-organized collagen orientation) and antiapoptotic properties (cell death-related genes were also downregulated). In summary, this study provides evidence that microenvironmentally optimized scaffolds improve cartilage regeneration in situ by regulating the microenvironment and support further translation in human cartilage repair. STATEMENT OF SIGNIFICANCE: Although microfracture (MF)-based treatment for chondral defects has been commonly used, critical gaps exist in understanding the biochemistry of MF-induced repaired tissue. More importantly, the clinically unsatisfactory effects of MF treatment have prompted researchers to focus on tissue engineering scaffolds that may have sufficient therapeutic efficacy. In this manuscript, a 3D printing ink containing cartilage tissue-specific extracellular matrix (ECM), methacrylate gelatin (GelMA), and transforming growth factor-β3 (TGF-β3)-embedded polylactic-coglycolic acid (PLGA) microspheres was coprinted with poly(ε-caprolactone) (PCL) to fabricate tissue engineering scaffolds for chondral defect repair. The sustained release of TGF-β3 from scaffolds successfully directed endogenous stem/progenitor cell migration and differentiation. This microenvironmentally optimized scaffold produced improved tissue repair outcomes in the sheep animal model, explicitly guiding more organized neotissue formation and therefore recapitulating the anisotropic structure of native articular cartilage. We hypothesized that the cell-free scaffolds might improve the clinical applicability and become a new therapeutic option for chondral defect repair.

Short-term outcomes following dehydrated micronized allogenic cartilage versus isolated microfracture for treatment of medial talar osteochondral lesions

BACKGROUND

Osteochondral lesions of the talus (OLTs) have been traditionally treated with bone marrow stimulation techniques such as microfracture. However, conventional microfracture results in a biomechanically weaker repair tissue of predominantly type I collagen. Acellular micronized cartilage matrix (MCM) serves as a bioactive scaffold to restore hyaline cartilage. The purpose was to compare short-term outcomes after microfracture with and without augmentation with MCM for medial-sided OLTs.

METHODS

A retrospective review was performed between 2010-2019 for medial-sided OLTs undergoing treatment with either microfracture augmented with MCM or isolated microfracture. The MCM was hydrated with either bone marrow aspirate concentrate (BMAC) or platelet-rich plasma (PRP). Outcomes included visual analogue scale (VAS) pain scores, Foot and Ankle Activity Measure (FAAM) scores, return-to-daily activities, and return-to-sport.

RESULTS

48 patients (14 MCM with PRP, 6 MCM with BMAC; 28 isolated microfracture) with average age 35.5 years (range: 13.8-67.2 years) and mean follow-up 4.0 ± 3.4 years (range,.13-10.7) were included. There was no difference in average lesion size between MCM and microfracture groups (64.0 ± 49.4 mm² versus 57.3 ± 44.2 mm², P = .63) and a trend toward larger lesion size for BMAC compared to PRP (106.5 ± 59.2 versus 45.9 ± 32.1 mm², P = .056). There was no difference in time to return-to-activity (83.5 ± 18.8 versus 87.3 ± 49.1 days) or return-to-sports (151.9 ± 62.2 versus 165 ± 99.2 days) with MCM versus isolated microfracture. However, the MCM group had a significantly greater improvement in VAS pain score at final follow-up (4.9 ± 2.2 versus 2.7 ± 2.6, P = .0032) and significantly higher post-operative FAAM-Activities of Daily Living subscale scores (97.2 ± 8.2 versus 79.7 ± 32.8, P = .033).

CONCLUSIONS

Augmenting microfracture with MCM hydrated with PRP or BMAC may result in beneficial changes in pain scores and activities of daily living, but similar return-to-activities and return-to-sport times compared to microfracture alone in management of medial OLT.

LEVEL OF EVIDENCE

IV.

An evidence-based update on the management of articular cartilage defects in the hip

Objective

Articular cartilage defects in the hip joint pose a significant surgical challenge and remain one of the most important determinants of success following arthroscopic intervention of the hip. The aim of this literature review was to report on the best available evidence on the various treatment options utilised for articular cartilage defects in the hip.

Material and methods

A comprehensive literature search was performed on PubMed from its inception to October 2021 using the following search strategy: ((hip) and (cartilage or chondral) and (repair or regeneration or restoration or implantation or chondroplasty or chondrogenic)). Two reviewers (KHSK, MG) independently reviewed titles and abstracts to identify articles for the final analysis. Articles were included if they were original research studies (randomised control trials, cohort studies, case-control studies, or comparative studies) on treatment of hip cartilage defects in humans reporting on a minimum of 5 patients. A total of 1172 articles were identified from the initial literature search. Following a thorough selection process, 35 articles were included in the final analysis to synthesise the evidence.

Results

Debridement, microfracture, autologous chondocyte implanatation (ACI) and matrix-induced ACI (MACI) are shown to have good short-to medium-term results. Injectable ACI and MACI have been developed to enable these procedures to be performed via arthroscopic surgery to reduce the post-operative morbidity associated with surgery with promising early results. Large cartilage defects which involved the sub-chondral bone may need the use of osteochondral grafts either autograft or allograft. Newer biological solutions have been developed to potentially deliver a single-stage procedure for hip cartilage injuries but longer-term results are still awaited.

Conclusion

Accurate identification of the extent of the injury helps stratify the defect and plan appropriate treatment. Several surgical techniques have shown good short to medium-term outcomes with ACI, AMIC, mosaicplasty and microfracture. Recent advances have enabled the use of injectable MACI and bioscaffolds which show promising results but in the shorter term. However, one needs to be mindful of the techniques which can be used in their surgical setting with the available resources. In order to thoroughly evaluate the benefits of the different surgical techniques for hip cartilage defects, large scale prospective multi-centre studies are necessary. Perhaps inclusion of such procedures in registries may also yield meaningful and pragmatic results.

Hyaluronic acid as an adjunct to microfracture in the treatment of osteochondral lesions of the talus: a systematic review of randomized controlled trials

BACKGROUND

Osteochondral lesions of the talus (OLT) are common after ankle trauma. Studies have shown that bioactive substances, such as hyaluronic acid (HA), alone, or in combination, with surgical treatment could improve cartilage regeneration and repair, but the effect of HA on patient reported outcomes is unclear.

METHODS

Literature searches were performed across four databases (PubMed, SPORTDiscus, Scopus, and The Cochrane Library) for randomized controlled trials in which at least one treatment arm involved use of HA as an adjunct to microfracture to treat patients with OLT. Primary outcomes included the American Orthopaedic Foot and Ankle Society scores (AOFAS), and the Visual Analog Scale (VAS) for pain. The level of evidence and methodological quality were evaluated using the Modified Coleman Methodology Score (MCMS).

RESULTS

Three randomized studies were eligible for review with a total of 132 patients (35, 40, 57 patients, respectively) and follow-up ranged from 10.5 to 25 months. Utilization of HA at the time of microfracture resulted in greater improvement in AOFAS scores compared to microfracture alone. The pooled effect size was moderate (Standardized Mean Difference [SMD] 0.45, 95% Confidence Interval [CI] 0.06, 0.84; P = .02) and between-study heterogeneity was low (I-squared = 0%). Utilization of HA during microfracture also led to greater improvement in VAS-pain scores compared to microfracture alone. The pooled effect size was very large (SMD -3.86, 95% CI -4.75, - 2.97; P < .001) and heterogeneity was moderate (I-squared = 69%).

CONCLUSION

Hyaluronic acid injection as an adjunct to arthroscopic MF in OLT provides clinically important improvements in function and pain at short-term follow-up compared to MF alone. Future longer-term follow-up studies are warranted to investigate the durability of MF with HA for treatment of OLT.

Osteochondral lesion of the talus: What are we talking about?

INTRODUCTION

The analysis of osteochondral lesions of talus (OLT) is currently mostly descriptive, not permitting an understanding of the different nosological frameworks of these lesions. Better knowledge of the characteristics of patients with OLT should make it possible to optimize the surgical indications and anticipate the associated lesions, which should not be overlooked. The main objective of this study was, therefore, to assess the characteristics of patients with OLT, and to analyze the lesions encountered.

HYPOTHESIS

OLTs correspond to variable entities responding to specific treatments.

MATERIAL AND METHOD

This was a prospective multicenter descriptive study including all patients operated on for an OLT, aged between 15 and 65 years, across 10 French specialist centers. The demographic, clinical and radiological data of the patients were analyzed.

RESULTS

OLTs predominantly affect males and patients in their thirties. Two types of OLT should be distinguished: a lateral OLT; smaller and more superficial, most often presenting with painful instability, in the context of trauma, and a medial OLT; more frequent, wider and deeper.

DISCUSSION

Two nosological frameworks exist for OLTs, and correspond to precise surgical indications: medial lesions of more than 10mm² and more than 5mm in depth, with isolated anteromedial pain and significant functional impairment, most often idiopathic, generally requiring treatment by osteochondral autografts. Lateral lesions less than 5mm in depth and less than 10mm², often superficial, following trauma or ankle laxity, associated with lateral ligament damage in one-third of cases, and a clinical presentation associated to instability and pain, requiring treatment most often by microfracture with associated ligament repair.

LEVEL OF EVIDENCE

III.

Anatomic based microfracture technique of insertion for rotator cuff repair in Vietnamese people: Case series study

Abstract

Postoperative tendon healing is still a matter of concern after rotator cuff repair. Several techniques have been introduced to help improve this healing process. Among them, the bone marrow is commonly used source and a research subject for methods using stem cells to promote wound healing process. A number of studies have shown that bone marrow stem cells can travel up through the holes on the rotator cuff insertion sites, contributing into the rotator cuff repair process, increasing the efficiency of tendon healing and improving clinical results.

Patients and methods

Cross-sectional descriptive study was performed on 41 rotator cuff tear patients. The microfractures for these patients were calculated beforehand, which have great depth but small diameter, based on the anatomical characteristic of the rotator cuff tear insertions of Vietnamese people. Patients' rotator cuff tendon healing processes were evaluated using ultrasound after surgery. Final tendon healing and clinical results ultimately rely on MRI assessments, classified according to Sugaya's classification, UCLA and ASES scale.

Results

No cases of rupture and fracture of the greater tubercle was recorded. There was a clear progression of tendon healing on ultrasound according to postoperative follow-up time-stamps (1 month, 3 months). MRI images evaluation also reveals at the latest follow-up time, according to Sugaya classification, the ratio of tendon healing was 87.8%, while the percentage of re-rupture was 12.2%. ASES and average UCLA scale were collected at the end of the study, respectively as 95.41 ± 5.45 and 32.36 ± 2.53.

Conclusion

The technique's microfractures characteristics based on the rotator cuff tear insertion anatomy ensures a secure, straightforward approach along with promising results in terms of tendon healing rate and postoperative functional outcomes.

Microfracture of Acetabular Rim After Segmental Labral Resection to Restore the Morphology and Function of Labrum: A Retrospective Study of More than 2 Years Follow-up

Objective

To report on the clinical outcome of patients undergoing combined arthroscopic treatment of labral resection and microfracture at the rim of acetabulum at a minimum 2‐year follow‐up.

Methods

The retrospective study included 38 patients undergoing hip arthroscopy for irreparable labral injury from 24 February 2014 to 26 February 2018. Thirteen patients were excluded owing to patient refusal of participation and concomitant diseases like synovial chondromatosis and dysplasia hip. The study group consisted of patients undergoing combined arthroscopic labral resection and microfracture at the rim of acetabulum (MICRO Group: 20 patients), arthroscopic labral resection alone (RESEC Group: five patients). Postoperative three‐dimensional (3D) double‐echo steady‐state (DESS) sequence with radial imaging at 3 Tesla were obtained and fluoroscopic image of the involved hip under distraction were used to observe the restoration of vacuum effect. Patient‐reported outcome scores (PROs) including the Harris Hip Score (HHS), Visual Analogue Score (VAS), Hip Outcome Score Activities of Daily Living Subscale (HOS‐ADL), Hip Outcome Score Sport‐Specific Subscale (HOS‐SSS) were collected and compared between two groups.

Results

All patients were followed up for at least 6 months. The follow‐up time of RESEC group is longer than MICRO group (46.6 months vs 23.9 months, P < 0.05). The 3D DESS imaging demonstrated intermediate signal intensity at the relative area where the labrum resected followed by microfracture at the acetabular rim in MICRO group. Meanwhile, regrowth of labrum‐like tissue was not observed in MRI imaging of the RESEC group. Furthermore, vacuum effect was more apparent in MICRO group compared with RESEC group. All PROs in both groups showed a statistically significant improvement at follow‐up compared with preoperative levels. RESEC group: HHS (73.0 vs 93.8, P < 0.05); HOS‐ADL (51.5 vs 89.1, P < 0.05); HOS‐SSS (47.8 vs 88.3, P < 0.05); VAS (6.4 vs 2.0, P < 0.05). MICRO group: HHS (70.5 vs 91.5, P < 0.05); HOS‐ADL (52.4 vs 87.0, P < 0.05); HOS‐SSS (48.1 vs 86.5, P < 0.05); VAS (6.3 vs 1.6, P < 0.05). One patient of MICRO group had transient neurapraxias of the pudendal nerve that resolved completely by 3 months. There showed no statistically significant difference between groups regarding the preoperative and postoperative PROs.

Conclusion

Compared to labral resection, combined arthroscopic labral resection and microfracture at the rim of acetabulum is able to fulfill the labral defect area with the potential to restore the seal effect of labrum as an effective and safe option for irreparable segmental labral tears.

Surgical interventions of Freiberg's disease: A systematic review

BACKGROUND

Freiberg's disease is an osteonecrosis of the metatarsal head bone. Numerous surgical interventions can be provided; however, the literature is limited in systematic reviews discussing the various options. The study aimed to systematically review the quantity and quality of literatures exploring the surgical interventions.

METHODS

Fifty articles were found to be relevant for assessing the efficacy of common surgical interventions. The articles were assigned a level of evidence (I-V) to assess their quality. Next, the studies were reviewed to provide a grade of recommendation (A-C, I).

RESULTS

Two studies were found at level III that explored osteotomy and autologous transplantation; the other studies were level IV-V. There is poor evidence (grade C) in supporting of joint sparing and joint sacrificing for Freiberg's disease.

CONCLUSION

Poor evidence exists to support the surgical interventions for Freiberg's disease, higher quality trials are needed to support the increasing application of these surgical techniques.

LEVEL OF EVIDENCE

Level IV, Systematic review.

Prospective Multiparametric Magnetic Resonance Monitoring of Changes in Lesions of Hyaline Cartilage of the Knee Joint After Treatment by Microfractures and Implantation of Biological Collagen Type I Matrix Implants

RATIONALE AND OBJECTIVES

This study's aims were to depict changes in cartilage quality after surgical intervention using magnetic resonance (MR) examination and in content of glycosaminoglycans chains (GAGs) after two types of surgeries - chondral defect treatment by microfractures and scaffold implantation in combination with microfractures.

MATERIALS AND METHODS

Twenty-five patients were studied: 14 with implants, 11 with microfractures. MR examination was made before surgery and 6, 12, and 18 months thereafter. Qualitative changes in cartilage were observed by means of delayed gadolinium enhanced magnetic resonance imaging of cartilage sequence using Gd-DTPA2- and Gd-DOTA. In each examination, GAGs content was determined at three locations: the defect, its surroundings, and a non-load-bearing reference area.

RESULTS

Measured indices showed no statistically significant differences in changes within the defect area when comparing the two treatment types at individual time points of 6, 12, and 18 months. In the case of microfracture treatment, more substantial decrease in GAGs concentration occurred at month 6, whereas the greatest decline occurred at month 12 when using an implant. Change in GAGs content and decline in cartilage quality were substantial also in the reference area and close surroundings.

CONCLUSIONS

Hyaline cartilage behaves as a unified whole, and change in GAGs content was marked also in locations with no morphological damage. Over the monitored period, no statistically significant difference between treatment types was noted as measured by GAGs content in the defect or its close surroundings. dGEMRIC is suitable for monitoring cartilage quality even if use of Gd-DTPA2- is not possible, because comparable results were achieved using Gd-DOTA.

Footprint preparation with nanofractures in a supraspinatus repair cuts in half the retear rate at 1-year follow-up. A randomized controlled trial

PURPOSE

To evaluate if adding nanofractures to the footprint of a supraspinatus tear repair would have any effect in the outcomes at one-year follow-up.

METHODS

Multicentric, triple-blinded, randomized trial with 12-months follow-up. Subjects with isolated symptomatic reparable supraspinatus tears smaller than 3 cm and without grade 4 fatty infiltration were included. These were randomized to two groups: In the Control group an arthroscopic supraspinatus repair was performed; in the Nanofracture group the footprint was additionally prepared with nanofractures (1 mm wide, 9 mm deep microfractures). Clinical evaluation was done with Constant score, EQ-5D-3L, and Brief Pain Inventory. The primary outcome was the retear rate in MRI at 12-months follow-up. Secondary outcomes were: characteristics of the retear (at the footprint or at the musculotendinous junction) and clinical outcomes.

RESULTS

Seventy-one subjects were randomized. Two were lost to follow-up, leaving 69 participants available for assessment at 12-months follow-up (33 in the Control group and 36 in the Nanofracture Group). The Nanofracture group had lower retear rates than the Control group (7/36 [19.4%] vs 14/33 [42.4%], differences significant, p = 0.038). Retear rates at the musculotendinous junction were similar but the Nanofracture group had better tendon healing rates to the bone (34/36 [94.4%] vs. 24/33 [66.71%], p = 0.014). Clinically both groups had significant improvements, but no differences were found between groups.

CONCLUSION

Adding nanofractures at the footprint during an isolated supraspinatus repair lowers in half the retear rate at 12-months follow-up. This is due to improved healing at the footprint.

LEVEL OF EVIDENCE

Level I.

[Cartilage repair procedures for early osteoarthritis]

BACKGROUND

Commonly used cartilage repair procedures have been established for focal cartilage lesions; however, degenerative lesions with accompanying changes of other intraarticular structures are much more common in clinical practice. This stage, in which classic radiological signs of osteoarthritis are absent, is called early osteoarthritis and is characterized by impaired joint homeostasis with biomechanical and biochemical changes that can have a negative effect on regenerative cartilage therapy procedures.

INDICATION

Cartilage repair procedures are indicated for symptomatic focal early osteoarthritis, defined as cartilage degeneration ICRS grades I or II around a focal cartilage defect ICRS grades III or IV. In more advanced osteoarthritis with significant narrowing of the joint space, cartilage repair procedures are generally contraindicated.

THERAPY

The most studied cartilage repair procedure for early osteoarthritis is autologous chondrocyte implantation, which has shown acceptable results in case series, although higher failure rates are to be expected compared to focal, traumatic cartilage lesions. The use of bone marrow-stimulating techniques seems to be limited in early osteoarthritis and should only be used in cases of lesion < 2 cm² and very little surrounding cartilage degeneration. Concomitant surgical procedures, especially unloading osteotomies, are very important.

Bone marrow aspirate concentration provided better results in cartilage regeneration to microfracture in knee of osteoarthritic patients

PURPOSE

To determine whether microfracture with bone marrow aspirate concentrate (BMAC) improves functional outcome and cartilage regeneration better than microfracture alone in patients undergoing high tibial osteotomy (HTO) for medial unicompartmental osteoarthritis (OA).

METHODS

Among 436 patients treated with HTO for medial unicompartmental OA with varus deformity between 2010 and 2016, clinical outcomes were retrospectively compared between the microfracture alone group (group I, 43 cases) and microfracture with BMAC augmentation group (group II, 48 cases). Of these, 64 patients underwent a second-look arthroscopic assessment. Clinical outcomes were compared based on the Knee Society Score (KSS), International Knee Documentation Committee (IKDC) subjective score, and Western Ontario and McMaster Universities Arthritis Index (WOMAC). Cartilage regeneration was assessed according to Koshino's staging system and the International Cartilage Repair Society (ICRS) Cartilage Repair Assessment (CRA) grading system.

RESULTS

At the last follow-up, there were no significant intergroup differences in terms of KSS for pain and function (p > 0.05). Moreover, WOMAC scores were similar between the two groups (p > 0.05). Regarding second-look arthroscopy findings, according to Koshino's staging system, there was no significant intergroup difference in terms of defect coverage (p = 0.187). However, group II showed a significantly better mean CRA score than group I (p = 0.035).

CONCLUSION

There were no significant differences in clinical outcomes and cartilage regeneration between the groups. However, the CRA score was significantly higher with BMAC augmentation and microfracture than microfracture alone. Therefore, BMAC augmentation had a synergistic effect for a better cartilage regeneration, although studies with a longer follow-up might help to confirm whether microfracture with BMAC augmentation would ensure better clinical outcomes than microfracture alone for the treatment of knee OA.

Studies of Articular Cartilage Repair from 2009 to 2018: A Bibliometric Analysis of Articles

Objective

To perform a bibliometric analysis of research on articular cartilage repair published in Chinese and English over the past decade. Fundamental and clinical research topics of high interest were further comparatively analyzed.

Methods

Relevant studies published from 1 January 2009 to 31 December 2018 (10 years) were retrieved from the Wanfang database (Chinese articles) and six databases, including MEDLINE, WOS, INSPEC, SCIELO, KJD, and RSCI on the website “Web of Science” (English articles), using key words: “articular cartilage” AND “injury” AND “repair”. The articles were categorized according to research focuses for a comparative analysis between those published in Chinese vs English, and further grouped according to publication date (before and after 2014). A comparative analysis was performed on research focus to characterize the variation in research trends between two 5‐year time spans. Moreover, articles were classified as basic and clinical research studies.

Results

Overall, 5762 articles were retrieved, including 2748 in domestic Chinese journals and 3014 in international English journals. A total of 4937 articles focused on the top 10 research topics, with the top 3 being stem cells (32.1%), tissue‐engineered scaffold (22.8%), and molecular mechanisms (16.4%). Differences between the numbers of Chinese and English papers were observed for 3 topics: chondrocyte implantation (104 vs 316), osteochondral allograft (27 vs 86), and microfracture (127 vs 293). The following topics gained more research interest in the second 5‐year time span compared with the first: microfracture, osteochondral allograft, osteochondral autograft, stem cells, and tissue‐engineered scaffold. Articles with a focus on three‐dimensional‐printing technology have shown the fastest increase in publication numbers. Among 5613 research articles, basic research studies accounted for the majority (4429), with clinical studies described in only 1184 articles. The top 7 research topics of clinical studies were: chondrocyte implantation (28.7%), stem cells (21.9%), microfracture (19.2%), tissue scaffold (10.6%), osteochondral autograft (10.5%), osteochondral allograft (6.3%), and periosteal transplantation (2.8%).

Conclusion

Studies focused on stem cells and tissue‐engineered scaffolds led the field of damaged articular cartilage repair. International researchers studied allograft‐related implantation approaches more often than Chinese researchers. Traditional surgical techniques, such as microfracture and osteochondral transplantation, gained high research interest over the past decade.

Managing Chondral Lesions: A Literature Review and Evidence-Based Clinical Guidelines

BACKGROUND

Articular cartilage lesions are becoming increasingly common. Optimum diagnosis and management of chondral defects cause a lot of dilemma. A number of surgical methods have been reported in the literature for treating focal cartilage defects. There is a lack of consensus on the most effective management strategy, with newer surgical and cell-based treatments being advocated regularly.

STUDY DESIGN AND METHODS

A clinical review is constructed by appraising the published literature about clinical evaluation and diagnostic modalities for articular cartilage defects and subsequent surgical procedures, management strategies employed for such lesions. Prominent available databases (PUBMED, EMBASE, Cochrane) were also searched for trials comparing functional outcomes following cartilage procedures. Synthesis of a practical management guideline is then attempted based on the evidence assessed.

RESULTS

Systematic examination and optimal use of diagnostic imaging are an important facet of cartilage defect management. Patient and lesion factors greatly influence the outcome of cartilage procedures and must be considered while planning management. Smaller lesions < 2 cm² respond well to all treatment modalities. Autologous osteochondral transplants (OATs) are effective in high activity individuals with intermediate lesions. For larger lesions > 4 cm², newer generation autologous chondrocyte implantation (ACI) has shown promising and durable results. Stem cells with scaffolds may provide an alternate option. Orthobiologics are a useful adjunct to the surgical procedures, but need further evaluation.

CONCLUSIONS

Most treatment modalities have their role in appropriate cases and management needs to be individualized for patients. The search for the perfect cartilage restoration procedure continues.