A prospective randomized clinical study of mosaic osteochondral autologous transplantation versus microfracture for the treatment of osteochondral defects in the knee joint in young athletes

Return to Play Among Elite Basketball Players After Osteochondral Allograft Transplantation of Full-Thickness Cartilage Lesions

Background:

Osteochondral allograft transplantation (OCA) is a recognized option for full-thickness articular cartilage defects of the knee, especially in the setting of large lesions or those involving the subchondral bone. Previous heterogenous studies of athletes have shown a 75% to 79% rate of return to play after the procedure.

Purpose:

To define return-to-play rates in a cohort of elite collegiate and professional basketball players following osteochondral allograft of the knee.

Study Design:

Case series; Level of evidence, 4.

Methods:

Prospectively collected data from an institutional cartilage repair registry were retrospectively reviewed. Patients were eligible for inclusion if they were collegiate or professional basketball players at the time of surgery. Patient demographics, lesion size and location, and surgical details were collected. Postoperative magnetic resonance imaging scans were scored with the OCAMRISS system. Time to return to play and pre- versus postoperative player performance were determined with publicly available internet resources.

Results:

Eleven athletes (4 professional, 7 collegiate) with a total of 14 treated lesions (1 to the medial femoral condyle, 6 to the lateral femoral condyle, 5 to the trochlea, and 2 to the patella) were eligible for study inclusion. Mean lesion size was 509 mm². All patients underwent OCA through an arthrotomy, with fresh grafts. The overall rate of return to play at the same level of competition was 80%. Median time to return to play was 14 months (range, 6-26 months). Among players with available statistics, there was no significant reduction in any performance category.

Conclusion:

OCA in elite basketball players results in an 80% return to previous level of competition, which is consistent with previous reports of athletes playing other sports. Osteochondral allografting is a reasonable option to consider for full-thickness cartilage lesions of the knee, even for elite jumping athletes.

Implantation of a Novel Cryopreserved Viable Osteochondral Allograft for Articular Cartilage Repair in the Knee

Restoration and repair of articular cartilage injuries remain a challenge for orthopaedic surgeons. The standard first-line treatment of articular cartilage lesions is marrow stimulation; however, this procedure can often result in the generation of fibrous repair cartilage rather than the biomechanically superior hyaline cartilage. Marrow stimulation is also often limited to smaller lesions, less than 2 cm². Larger lesions may require implantation of a fresh osteochondal allograft, though a short shelf life, size-matched donor requirements, potential challenges of bone healing, limited availability, and the relatively high price limit the wide use of this therapeutic approach. We present a straightforward, single-stage surgical technique of a novel reparative and restorative approach for articular cartilage repair with the implantation of a cryopreserved viable osteochondral allograft (CVOCA). The CVOCA contains full-thickness articular cartilage and a thin layer of subchondral bone, and maintains the intact native cartilage architecture with viable chondrocytes, growth factors, and extracellular matrix proteins to promote articular cartilage repair. We report the results of a retrospective case series of three patients who presented with articular cartilage lesions more than 2 cm² and were treated with the CVOCA using the presented surgical technique. Patients were followed up to 2 years after implantation of the CVOCA and all three patients had satisfactory outcomes without adverse events. Controlled randomized studies are suggested for evaluation of CVOCA efficacy, safety, and long-term outcomes.

Randomized Study of Long-term (15-17 Years) Outcome After Microfracture Versus Mosaicplasty in Knee Articular Cartilage Defects

BACKGROUND

Few comparative randomized long-term studies on microfracture versus mosaicplasty have been published, and only 2 studies reported a follow-up of 10 years. Hypothesis/Purpose: The purpose was to compare the clinical outcome of microfracture versus mosaicplasty/osteochondral autograft transfer in symptomatic cartilage lesions. The null hypothesis was that the outcome was not statistically different at any point of time.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

Forty patients with articular cartilage defects were randomized to undergo cartilage repair by either microfracture (n = 20) or mosaicplasty (n = 20). Inclusion criteria were as follows: age 18 to 50 years at the time of surgery, 1 or 2 symptomatic focal full-thickness articular chondral defects on the femoral condyles or trochlea, and size 2 to 6 cm². The main outcome variable was the Lysholm knee score recorded before the surgery and at 12 months, median 5 years, median 10 years, and minimum 15 years after the surgery.

RESULTS

Forty patients were included in the study (28 men, 12 women; median age, 32 years; range, 18-48 years). Defects with a median size of 3.5 cm² (range, 2-5 cm²) were treated. A significant increase in the Lysholm score was seen for all subjects- from a mean 53 (SD, 16) at baseline to 69 (SD, 21) at the minimum 15-year follow-up ( P = .001). The mean Lysholm score was significantly higher in the mosaicplasty group than the microfracture group at 12 months, median 5 years, median 10 years, and minimum 15 years: 77 (SD, 17) versus 61 (SD, 22), respectively ( P = .01), at the last follow-up. At all follow-up time points, the difference in mean Lysholm score was clinically significant (>10 points).

CONCLUSION

At short, medium, and long term (minimum 15 years), mosaicplasty results in a better, clinically relevant outcome than microfracture in articular cartilage defects (2-5 cm²) of the distal femur of the knee in patients aged 18 to 50 years.

Good clinical and MRI outcome after arthroscopic autologous chondrocyte implantation for cartilage repair in the knee

PURPOSE

To analyze the clinical outcome and cartilage regeneration after all-arthroscopic Autologous Chondrocyte Implantation (ACI) using chondrospheres® (ACT3D) for the treatment of full-size articular cartilage lesions at the knee.

METHODS

Thirty consecutive patients treated by all-arthroscopic ACI for full-size articular cartilage lesions in an otherwise healthy knee were enrolled. The defects were located on the femoral condyles (n = 18), in the trochlea (n = 7) and at the patella (n = 5). Follow-up consisted of a clinical evaluation with assessment of subjective scores. Patient satisfaction was evaluated on a visual analog scale (VAS). 3-Tesla MRI and T2 mapping of the operated and the contralateral healthy knees were included to control the quality of the regenerated cartilage. The MOCART score was assessed by three blinded independent radiologists.

RESULTS

At the mean follow-up of 3 years ± 10.2 months 26 of the 30 patients (86.6%) were subjectively highly satisfied with the surgical result and assured they would undergo the same procedure again. The mean Lysholm score increased to 77.7 ± 14.6, the mean subjective IKDC significantly to 84.2 ± 5.6 (p < 0.05) and all five subgroups of the KOOS improved significantly (p < 0.05). The subjective outcome was not influenced by the duration of symptoms, age, location, size of defects nor dose of spheroids. The modified MOCART score was a mean of 60 ± 21 (0-80) points. Twenty-four patients (82.7%) were rated higher than 60 points. T2 mapping documented similar cartilage quality of the area of the ACI and the same location at the contralateral knee. Three patients had a MOCART score of 0 with few or no cartilage regeneration on MRI and were considered as failure of the ACI.

CONCLUSION

In this small cohort of 30 patients, minimal invasive all-arthroscopic ACT 3D using spheroids led to convincing clinical short-to-mid-term results with a significant increase in patients quality of life, satisfaction, reduction of pain, and improvement in knee function. The high morphologic integrity and quality of the ACI was reconfirmed by the Mocart Score and T2 mapping.

LEVEL OF EVIDENCE

IV.

Long-term Clinical Outcomes After Microfracture of the Glenohumeral Joint: Average 10-Year Follow-up

BACKGROUND

Microfracture is an effective surgical treatment for full-thickness cartilage defects of the knee; however, little is known regarding long-term outcomes after microfracture in the shoulder.

PURPOSE

To present long-term clinical outcomes of patients undergoing microfracture of full-thickness articular cartilage defects of the glenohumeral joint.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Sixteen consecutive patients (17 shoulders) were retrospectively reviewed who underwent arthroscopic microfracture of the humeral head and/or glenoid surface, with or without additional procedures between 2001 and 2008 and with a minimum follow-up of 8.5 years. All patients completed pre- and postoperative surveys containing the visual analog scale, American Shoulder and Elbow Surgeons form, and Simple Shoulder Test. Complications and reoperations were analyzed. Failure was defined by biological resurfacing or conversion to arthroplasty.

RESULTS

Of the original 16 patients (17 shoulders), 13 patients (14 shoulders) were available for mean follow-up at 10.2 ± 1.8 years after microfracture (range, 8.5-15.8 years), for an overall clinical follow-up rate of 82%. The patients (6 men, 7 women) were 36.1 ± 12.9 years old at time of microfracture. The average size of humeral head defects was 5.20 cm² (range, 4.0-7.84 cm²), and the average size of glenoid defects was 1.53 cm² (range, 1.0-3.75 cm²). Four patients (4 shoulders) underwent at least 1 reoperation, and 3 were considered to have structural failures. The average time to failure was 3.7 years after microfracture (range, 0.2-9.6 years). The overall survival rate was 76.6% at 9.6 years. For these patients, there were statistically significant improvements in visual analog scale, Simple Shoulder Test, and American Shoulder and Elbow Surgeons scores as compared with preoperative values at long-term follow-up ( P < .05 for all), without any significant change from short-term (mean, 2.3 years) to long-term (mean, 10.2 years) follow-up. There was no significant difference in Single Assessment Numeric Evaluation or Short Form-12 Physical or Mental scores between short- and long-term follow-up. When compared with short-term follow-up, in which 2 patients had already failed, 1 additional patient progressed to failure at 9.6 years after the original microfracture. Two patients (2 shoulders) were considered to have clinical failure. Owing to the overall number of failures (3 structural failure and 2 clinical failure), the total long-term success rate of glenohumeral microfracture is 66.7% in the current study.

CONCLUSION

Treating full-thickness symptomatic chondral defects of the glenohumeral joint with microfracture can result in long-term improved function and reduced pain for some patients. However, in this case series, 21.4% of patients required conversion to arthroplasty <10 years after the index microfracture procedure, and 33% to 42% of patients were considered to have potential clinical failure. Additional studies with larger patient cohorts are needed.

Fixation of Traumatic Chondral-Only Fragments of the Knee in Pediatric and Adolescent Athletes: A Retrospective Multicenter Report

Background:

While traditional biological principles have suggested that fragments consisting of cartilage alone cannot be reaffixed to bone with expectable long-term healing, case reports of successful healing after fixation in younger patients indicate that this concept remains incompletely explored.

Purpose:

To evaluate the presenting features, techniques, healing rates, and clinical and radiological results in a cohort of pediatric and adolescent athletes who underwent fixation of traumatic chondral-only fragments in the knee.

Study Design:

Case series; Level of evidence, 4.

Methods:

Patient registries at 2 tertiary care children’s hospitals were reviewed to identify patients ≤18 years old who underwent fixation of a “chondral-only” fragment in the knee, defined as the inability to visualize the fragment on injury radiographs or discern bone on the articular portion of a fragment intraoperatively. The mechanism of injury, fragment features, fixation technique, and postoperative clinical course, including timing of sports clearance, healing on postoperative magnetic resonance imaging (MRI), and any complications or reoperations, were assessed.

Results:

Fifteen patients with a median age at surgery of 12.7 years (interquartile range [IQR], 11.7-14.2 years) and median follow-up of 12.0 months (IQR, 6.0-19.2 months) were analyzed. All patients sustained an acute knee injury before surgery. The injured sites, as assessed on MRI, were the patella (n = 6), trochlea (n = 5), and lateral femoral condyle (n = 4). The median fragment surface area was 492.0 mm² (IQR, 400.0-787.5 mm²). Fixation with bioabsorbable implants was performed in all patients at a median of 1.6 weeks (IQR, 1.0-2.6 weeks) after the injury. One patient (7%) sustained a fall 8 weeks postoperatively, requiring secondary surgery for excision of a dislodged fragment, and 1 patient (7%) underwent unrelated patellar stabilization surgery 3.4 years postoperatively, at which time the fragment was found to be stable. MRI was performed in 9 of 14 patients with retained fragments (median, 12.0 months postoperatively), with 5 patients (56%) showing restoration of the cartilage contour and the resolution of subchondral edema; 2 patients showed thinning but intact cartilage, 1 had cartilage thickening, and 1 had subchondral edema, fissuring, and cystic changes. The median time to return to sports for all 15 patients was 26.0 weeks (IQR, 22.8-40.9 weeks), including 2 patients who required second surgery and returned to sports at 26.1 and 191.1 weeks.

Conclusion:

Fixation of traumatic chondral-only fragments using bioabsorbable implants may result in successful short-term healing in the majority of pediatric and adolescent athletes.

Microspheres containing decellularized cartilage induce chondrogenesis in vitro and remain functional after incorporation within a poly(caprolactone) filament useful for fabricating a 3D scaffold

In this study, articular cartilage was decellularized preserving a majority of the inherent proteins, cytokines, growth factors and sGAGs. The decellularized cartilage matrix (dCM) was then encapsulated in poly(lactic acid) microspheres (MS + dCM) via double emulsion. Blank microspheres without dCM, MS(-), were also produced. The microspheres were spherical in shape and protein encapsulation efficiency within MS + dCM was 63.4%. The sustained release of proteins from MS + dCM was observed over 4 weeks in vitro. Both MS + dCM and MS(-) were cytocompatible. The sustained delivery of retained growth factors and cytokines from MS + dCM promoted cell migration in contrast to MS(-). Subsequently, chondrogenesis of human mesenchymal stem cells was upregulated in presence of MS + dCM as evidenced from immunohistochemistry, biochemical quantification and qPCR studies. Specifically, collagen II, aggrecan and SOX 9 gene expression were increased in the presence of MS + dCM by an order or more in magnitude compared to MS(-) with concomitant downregulation of hypertrophic genes (COL X) despite being cultured in the absence of chondrogenic media, (p < 0.05). Lastly, microspheres containing alkaline phosphatase (MS + ALP), a surrogate to assess the thermal stability of dCM proteins, incorporated within poly(caprolactone) filaments showed that the enzyme remained functional after filament production by melt extrusion. The establishment of a novel, thermally stable process for producing filaments containing chondroinductive microspheres provides evidence supporting subsequent development of a clinically-relevant, 3D scaffold fabricated from them for osteochondral regeneration and repair.

Do Outcomes of Osteochondral Allograft Transplantation Differ Based on Age and Sex? A Comparative Matched Group Analysis

BACKGROUND

The effect of patient age or sex on outcomes after osteochondral allograft transplantation (OCA) has not been assessed.

PURPOSE

To determine clinical outcomes for male and female patients aged ≥40 years undergoing OCA compared with a group of patients aged <40 years.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A review of prospectively collected data of consecutive patients who underwent OCA by a single surgeon with a minimum follow-up of 2 years was conducted. The reoperation rate, failure rate, and patient-reported outcome scores were reviewed. All outcomes were compared between patients aged <40 or ≥40 years, with subgroup analyses conducted based on patient sex. Failure was defined as revision OCA, conversion to knee arthroplasty, or gross appearance of graft failure at second-look arthroscopic surgery. Descriptive statistics, Fisher exact or chi-square testing, and Mann-Whitney U testing were performed, with P < .05 set as significant.

RESULTS

A total of 170 patients (of 212 eligible patients; 80.2% follow-up) who underwent OCA with a mean follow-up of 5.0 ± 2.7 years (range, 2.0-15.1 years) were included, with 115 patients aged <40 years (mean age, 27.6 ± 7.3 years; 58 male, 57 female) and 55 patients aged ≥40 years (mean age, 44.9 ± 4.0 years; 33 male, 22 female). There were no differences in the number of pre-OCA procedures between the groups ( P = .085). There were no differences in the reoperation rate (<40 years: 38%; ≥40 years: 36%; P = .867), time to reoperation (<40 years: 2.12 ± 1.90 years; ≥40 years: 3.43 ± 3.43 years; P = .126), or failure rate (<40 years: 13%; ≥40 years: 16%; P = .639) between the older and younger groups. Patients in both groups demonstrated significant improvement in Lysholm (both: P < .001), International Knee Documentation Committee (IKDC) (both: P < .001), Knee Injury and Osteoarthritis Outcome Score (KOOS) (both: P < .001), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) (both: P < .001), and Short Form-12 (SF-12) physical (both: P < .001) scores compared with preoperative values. Patients aged ≥40 years demonstrated significantly higher KOOS symptom ( P = .015) subscores compared with patients aged <40 years. There were no significant differences in the number of complications, outcome scores, or time to failure between the sexes. In patients aged <40 years, female patients experienced failure significantly more quickly than male patients ( P = .039). In contrast, in patients aged ≥40 years, male patients experienced failure significantly more quickly than female patients ( P = .046).

CONCLUSION

This study provides evidence that OCA is a safe and reliable treatment option for osteochondral defects in patients aged ≥40 years. Male and female patients had similar outcomes. Patients aged <40 years demonstrated lower KOOS symptom subscores postoperatively compared with older patients, potentially attributable to higher expectations of return to function postoperatively as compared with older patients.

The use of osteochondral flaps in the treatment of carpal disorders

Vascularized osteochondral flaps have been described for use in reconstruction of the wrist, providing the benefits of osteochondral grafts in addition to the benefit of osseous and subchondral perfusion via the microvascular pedicle. Various harvest sites have been described including the medial and lateral femoral trochlea and the proximal third metatarsal. The reconstructed surfaces described include the cartilage surfaces of the scaphoid, lunate, capitate and radius. The ability to transfer analogous osteochondral surfaces poses the possibility for new motion-preserving alternatives for difficult articular problems previously treated with salvage procedures. A description of the procedures and reported outcomes are provided, as well as a discussion of the role of these procedures in the future of wrist surgery.

The Effect of Growth Hormone on Chondral Defect Repair

Objective Focal chondral defects alter joint mechanics and cause pain and debilitation. Microfracture is a surgical technique used to treat such defects. This technique involves penetration of subchondral bone to release progenitor cells and growth factors from the marrow to promote cartilage regeneration. Often this results in fibrocartilage formation rather than structured hyaline cartilage. Some reports have suggested use of growth hormone (GH) with microfracture to augment cartilage regeneration. Our objective was to test whether intra-articular (IA) GH in conjunction with microfracture, improves cartilage repair in a rabbit chondral defect model. We hypothesized that GH would exhibit a dose-dependent improvement in regeneration. Design Sixteen New Zealand white rabbits received bilateral femoral chondral defects and standardized microfracture repair. One group of animals ( n = 8) received low-dose GH by IA injection in the left knee, and the other group ( n = 8) received high-dose GH in the same manner. All animals received IA injection of saline in the contralateral knee as control. Serum assays, macroscopic grading, and histological analyses were used to assess any improvements in cartilage repair. Results Peripheral serum GH was not elevated postoperatively ( P = 0.21). There was no improvement in macroscopic grading scores among either of the GH dosages ( P = 0.83). Scoring of safranin-O-stained sections showed no improvement in cartilage regeneration and some evidence of increased bone formation in the GH-treated knees. Conclusions Treatment with either low- or high-dose IA GH does not appear to enhance short-term repair in a rabbit chondral defect model.

Long-term clinical follow-up of microfracture versus mosaicplasty in articular cartilage defects of medial femoral condyle

BACKGROUND

The purpose of this study was to evaluate the outcome after cartilage repair surgery in focal defects of the knee by microfracture versus mosaicplasty.

METHODS

A cohort of 102 patients undergoing microfracture (n=52) or mosaicplasty (n=50) of a single articular cartilage defect in the medial femoral condyle of ≤50mm² was evaluated by Lysholm score before surgery, at six months, 12months, five years, 10years, and 15-18years after surgery.

RESULTS

Median age of patients at the time of surgery was 36years (range 16-58) and median follow-up time was 16years (range 14-18). Defects were treated with a median size of three square centimetres (range one to five). A significant increase was seen in the Lysholm score from mean 48 (SD 16) at baseline to 66 (SD 23; P<0.001) at the 15-18year follow-up. The Lysholm score was higher in the mosaicplasty group at six months, 12months, five years and 10years (P<0.05 for all comparisons). These differences were clinically significant at all points (>10 points). However, at the final follow-up, the difference (eight points) did not reach statistical significance.

CONCLUSIONS

In the short-term, medium-term and long-term (10years), mosaicplasty in a single cartilage defect size one to five square centimetres of the femoral condyle resulted in clinically relevant better outcome than microfracture. However, at 15-18years after the surgery such a difference could not be found. In the six month to 10-15year (after surgery) perspective, the mosaicplasty procedure offered a better outcome in this type of lesion.

LEVEL OF EVIDENCE

Level III.

Comparative efficacy of cartilage repair procedures in the knee: a network meta-analysis

PURPOSE

While numerous randomized controlled trials have compared surgical treatments for cartilage defects of the knee, the comparative efficacy of these treatments is still poorly understood. The goal of this network meta-analysis was to synthesize these randomized data into a comprehensive model allowing pairwise comparisons of all treatment options and treatment rankings based on multiple measures of efficacy. We hypothesized that advanced chondral procedures would have improved outcomes when compared to microfracture.

METHODS

The MEDLINE, COCHRANE and EMBASE databases were searched systematically up to January 2015. The primary outcome was re-operation measured at 2, 5 and 10 years. Secondary outcomes included Tegner and Lysholm scores, the presence of hyaline cartilage on post-operative biopsy and graft hypertrophy. A random-effects network meta-analysis was performed, and the results are presented as odds ratios and mean differences with 95 % CIs. We ranked the comparative effects of all treatments with surface under the cumulative ranking probabilities.

RESULTS

Nineteen RCT from 15 separate cohorts including 855 patients were eligible for inclusion. No differences were seen in re-operation rates at 2 years. At 5 years osteochondral autografts (OC Auto) had a lower re-operation rate than microfracture (OR 0.03, 95 % CI 0.00-0.49), and at 10 years OC Auto had a lower re-operation rate than microfracture (OR 0.34, 95 % CI 0.12-0.92), but a higher re-operation rate than second-generation ACI (OR 5.81, 95 % CI 2.33-14.47). No significant differences in Tegner or Lysholm scores were seen at 2 years. Functional outcome data at 5 and 10 years were not available. Hyaline repair tissue was more common with OC Auto (OR 16.13, 95 % CI 2.80-92.91) and 2nd generation ACI (OR 7.69, 95 % CI 1.17-50) than microfracture, though the clinical significance of this is unknown. Second-generation ACI (OR 0.12, 95 % CI 0.02-0.59) and MACI (OR 0.13, 95 % CI 0.03-0.59) had significantly lower rates of graft hypertrophy than first-generation ACI. Second-generation ACI, OC Auto and MACI were the highest ranked treatments (in order) when all outcome measures were included.

CONCLUSIONS

Microfracture and advanced cartilage repair techniques have similar re-operation rates and functional outcomes at 2 years. However, advanced repair techniques provide higher-quality repair tissue and might afford lower re-operation rates at 5 and 10 years.

LEVEL OF EVIDENCE

Meta-analysis studies, Level I.

Development of chondrocyte-seeded electrosprayed nanoparticles for repair of articular cartilage defects in rabbits

Due to limited self-healing capacity in cartilages, there is a rising demand for an innovative therapy that promotes chondrocyte proliferation while maintaining its biofunctionality for transplantation. Chondrocyte transplantation has received notable attention; however, the tendencies of cell de-differentiation and de-activation of biofunctionality have been major hurdles in its development, delaying this therapy from reaching the clinic. We believe it is due to the non-stimulative environment in the injured cartilage, which is unable to provide sustainable physical and biological supports to the newly grafted chondrocytes. Therefore, we evaluated whether providing an appropriate matrix to the transplanted chondrocytes could manipulate cell fate and recovery outcomes. Here, we proposed the development of electrosprayed nanoparticles composed of cartilage specific proteins, namely collagen type II and hyaluronic acid, for implantation with pre-seeded chondrocytes into articular cartilage defects. The fabricated nanoparticles were pre-cultured with chondrocytes before implantation into injured articular cartilage. The study revealed a significant potential for nanoparticles to support pre-seeded chondrocytes in cartilage repair, serving as a protein delivery system while improving the survival and biofunctionality of transplanted chondrocytes for prolonged period of time.

Arthroscopic Transplantation of Osteochondral Autograft for Treatment of Cartilage Defects in the Wrist

Focal chondral lesions are a common cause of chronic wrist pain, with no ideal treatment. The authors developed arthroscopic transplantation of osteochondral autograft from lateral femoral condyle to distal radius with satisfactory outcome in 4 consecutive patients between December 2006 and December 2010. In all cases, graft incorporation was completed by 3 months to 4 months postoperation. All patients showed improvement in wrist function with no pain at follow-up at an average of 70.5 months (range 24-116 months). Second-look arthroscopy in 3 patients confirmed the preservation of normal articular cartilage. Patient satisfaction was high with no complications.

Clinical Outcomes of Donor Sites After Osteochondral Graft Harvest From Healthy Knees

Background:

The use of autologous osteochondral grafts has become popular in the treatment of small, isolated, well-contained articular cartilage defects. However, donor site morbidity is a problem, and few reports are available of donor site morbidity after mosaicplasty.

Purpose:

To examine the clinical outcomes of donor sites after osteochondral grafts from healthy knees.

Study Design:

Case series; Level of evidence, 4.

Methods:

Between September 1997 and September 2011, there were 40 patients (40 knees; 32 men, 8 women; 31 right knees, 9 left knees) with asymptomatic osteochondral graft donor sites used for autologous transfer; all had a follow-up period of >2 years. The mean patient age at surgery was 21.0 years (range, 12-58 years). The recipient sites included the elbow (n = 28), contralateral knee (n = 5), and ankle (n = 7). The mean diameter of the grafted plugs was 7.5 mm (range, 4.5-9 mm), and the mean number of grafted plugs was 2.2 (range, 1-3). At a mean follow-up of 43.1 months (range, 24-177 months), knee symptoms, return to sport, ability to sit straight in Japanese style, and radiological changes of the patellofemoral joint were evaluated. Whether operative age, follow-up period, and diameter or number of the grafted plugs were risk factors was analyzed statistically. Significance was defined as P < .05.

Results:

Thirty-four patients had no knee symptoms, and 4 patients had occasional mild knee pain. Two patients underwent reoperation for arthrofibrosis and not for cartilage defect. Twenty-seven patients had complete return to sports, and 32 patients could sit straight; donor site morbidity was not the cause of failure to return to sports or inability to sit straight. The radiological changes became worse in 3 patients, and the risk factor for degenerative change was older operative age.

Conclusion:

When osteochondral plugs were obtained from healthy knees, 34 patients (85%) were asymptomatic at follow-up. No donor site defects required surgical intervention due to persistent symptoms.

Effects of Autogenous Bone Marrow Aspirate Concentrate on Radiographic Integration of Femoral Condylar Osteochondral Allografts

BACKGROUND

Transplantation of fresh osteochondral allografts (OCAs) is an attractive treatment option for symptomatic articular cartilage lesions in young, healthy patients. Because the lack of OCA bone integration can be a cause of treatment failure, methods for speeding and enhancing OCA bone integration to mitigate this potential complication are highly desirable.

PURPOSE

To determine if autogenous bone marrow aspirate concentrate (BMC) treatment of large femoral condylar OCAs would be associated with superior radiographic OCA bone integration compared with nontreated allografts during the critical first 6 months after surgery.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A review of patients enrolled in a prospective registry who were treated with transplantation of large OCAs to one or both femoral condyles at our institution from March 12, 2013 to March 14, 2016 was performed. Patients were stratified into 2 groups based on BMC treatment versus no BMC treatment; the treatment was nonrandomized and was rooted in a shift in practice and a continuing effort to optimize OCA transplantation at our institution. Patients were excluded if they did not have orthogonal view radiographs performed at 6 weeks, 3 months, and 6 months postoperatively. Each condyle undergoing OCA transplantation was assessed individually by an independent musculoskeletal radiologist, who was blinded to the treatment group and time point. OCAs were assessed with respect to graft integration (0%-100%; 0 = no integration, 100 = complete integration) and degree of sclerosis (0-3; 0 = normal, 1 = mild sclerosis, 2 = moderate sclerosis, and 3 = severe sclerosis) of the graft at each time point.

RESULTS

This study identified 17 condyles in 15 patients who underwent OCA transplantation without BMC and 29 condyles in 22 patients who underwent OCA transplantation with BMC. The BMC group had significantly ( P = .033) higher graft integration scores at 6 weeks, 3 months, and 6 months after surgery. Graft sclerosis was significantly ( P = .017) less in the BMC group at 6 weeks and 3 months, with no significant difference at 6 months after surgery. When combining the groups to examine the influence of smoking on graft integration, nonsmokers had significantly ( P = .007) higher graft integration scores at 6 months.

CONCLUSION

Large femoral condylar OCAs treated with autogenous BMC before implantation showed superior radiographic integration to bone and less sclerosis during the initial 6-month postoperative period. BMC treatment of OCAs may mitigate the failure of OCA bone healing.

Functional outcomes after patellar autologous osteochondral transplantation

PURPOSE

The aim of the present study was to assess clinical evaluation of patients who underwent autologous osteochondral transplantation of the patella.

METHODS

This prospective study assessed outcomes of 20 patients who underwent patellar autologous osteochondral transplantation at four time-points: preoperatively, 3 days, 6 months, and 2 years after surgery. The following outcomes were assessed at each time-point: pain (VAS), gait, swelling, trophic status, muscle strength, patellar mobility, and range of motion. The Tegner scale was also applied for each time-point.

RESULTS

All parameters improved, except for patellar mobility, which did not show any change. Pain score decreased from 7.1 (SD 2.3) to 2.4 (SD 2.6) at the 2-year assessment; limping decreased from 70 % before surgery to 15 % 2 years later; swelling scores decreased from an average of 1.8 (SD 0.8) 3 days after surgery to 0.5 (SD 0.7) at the 2-year assessment; muscle strength increased from 3.9 (SD 0.8) to 4.7 (SD 0.7) points at final follow-up; and the range of motion increased from 84 (SD 16.2) to 132 (SD 10.7) degrees 2 years later. Tegner score before surgery ranged from 0 to 5, and after 2 years, it ranged from 5 to 9.

CONCLUSION

Autologous osteochondral transplantation for the treatment of patellar chondral lesion was associated with significant improvement in pain, gait, swelling, and range of motion 2 years after surgery, achieving scores similar to uninjured knees. Most of them were able to return to sports activity after 6 months (recreational level) and 2 years (competitive level).

LEVEL OF EVIDENCE

IV.

Return to sport after the surgical management of articular cartilage lesions in the knee: a meta-analysis

PURPOSE

Optimal surgical treatment of chondral defects in an athletic population remains highly controversial and has yet to be determined. The purpose of this review was to (1) report data on return to sport and (2) compare activity and functional outcome measures following various cartilage restoration techniques.

METHODS

A comprehensive review was performed for studies with return-to-sport outcomes after microfracture (MFX), osteochondral autograft transfer (OAT), osteochondral allograft transplantation (OCA), and autologous chondrocyte implantation (ACI). All studies containing return-to-sport participation with minimum 2-year post-operative activity-based outcomes were included. A meta-analysis comparing rate of return to sport between each surgical intervention was conducted using a random-effects model.

RESULTS

Forty-four studies met inclusion criteria (18 Level I/II, 26 Level III/IV). In total, 2549 patients were included (1756 M, 793 F) with an average age of 35 years and follow-up of 47 months. Return to sport at some level was 76 % overall, with highest rates of return after OAT (93 %), followed by OCA (88 %), ACI (82 %), and MFX (58 %). Osteochondral autograft transfer showed the fastest return to sports (5.2 ± 1.8 months) compared to 9.1 ± 2.2 months for MFX, 9.6 ± 3.0 months for OCA and 11.8 ± 3.8 months for ACI (P < 0.001). A meta-regression was conducted due to heterogeneity in preoperative factors such as patient age, lesion size, and preoperative Tegner score. None of these factors were found to be significant determinants for rate of return to sport.

CONCLUSION

In conclusion, in this meta-analysis of 2549 athletes, cartilage restoration surgery had a 76 % return to sport at mid-term follow-up. Osteochondral autograft transfer offered a faster recovery and appeared to have a higher rate of return to preinjury athletics, but heterogeneity in lesion size, athlete age, and concomitant surgical procedures are important factors to consider when assessing individual athletes. This study reports on the rate of return to sport in athletes undergoing various procedures for symptomatic chondral defects.

LEVEL OF EVIDENCE

IV.

Transferência de autoenxerto osteocondral para tratamento de osteocondrite dissecante em côndilo femoral de cão

RESUMO Na osteocondrite dissecante (OCD), a articulação do ombro é mais comumente afetada, mas o joelho é ocasionalmente lesionado, o que, muitas vezes, passa desapercebido. O tratamento cirúrgico precoce é indicado para remover cartilagem solta, aliviar a dor e minimizar a artrose. Benefícios putativos da transferência de autoenxerto osteocondral em relação às técnicas convencionais incluem a reconstrução exata do contorno subcondral e articular, recobrimento da superfície com cartilagem hialina e criação de uma barreira imediata entre o líquido sinovial e o osso subcondral. O objetivo deste trabalho é relatar a técnica de transferência de autoenxerto osteocondral para o tratamento da osteocondrite do côndilo femoral. Um cão da raça Bull Terrier foi tratado cirurgicamente por meio da técnica de transferência de autoenxerto osteocondral, após ter sido diagnosticado com OCD do côndilo femoral, apresentando melhora clínica significativa e completa recuperação aos 30 dias de pós-operatório.

Osteochondral Allograft Transplantation for Treatment of Focal Patellar Osteochondral Lesion

Patellar osteochondral lesions are common and particularly disabling injuries that can affect young and highly active patients. If enough functional impairment, ranging from difficulty climbing stairs to pain with squatting, is present, surgical treatment may be warranted. For the treatment of these lesions, various techniques have been described, including autologous osteochondral transplantation, as well as microfracture surgery. However, these are not without disadvantages. Although morbidity is noted in cases of autologous osteochondral transplantation, uncertain and possibly unsustainable results are associated with the microfracture procedure. Therefore, we present an alternative surgical treatment option for this pathology. The objective of this Technical Note is to describe our preferred approach for an osteochondral allograft transplant procedure to treat a focal patellar osteochondral lesion.

Age Is Not a Contraindication for Cartilage Surgery: A Critical Analysis of Standardized Outcomes at Long-term Follow-up

BACKGROUND

Age is commonly accepted as a negative prognostic factor in cartilage surgery, and cutoff values of 30 to 40 years have been previously suggested as treatment indication. However, the lower outcome scores documented in older patients do not take in consideration the decreasing requirements of an aging joint.

PURPOSE

To analyze the real effect of age in terms of recovery with respect to the functional level expected for different age categories of patients treated for cartilage lesions.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients with International Cartilage Repair Society (ICRS) grade 3-4 defects, involving femoral condyles or trochlea without osteoarthritis, were treated with arthroscopic matrix-assisted autologous chondrocyte transplantation; 157 patients were evaluated with IKDC subjective and Tegner scores before surgery and then after 2 and 10 years. Results were first evaluated by dividing patients into 2 age groups according to the generally approved cutoff value of 40 years. The analysis was then repeated after the scores of each patient were standardized according to the score achievable per the normative data in healthy patients for the corresponding sex and age category.

RESULTS

A significant improvement in all scores was observed. IKDC subjective score improved from 38.9 ± 14.5 to 74.7 ± 21.8 at 10 years. When a cutoff value of 40 years was used, older patients reached a significantly worse IKDC subjective value at 10 years (65.8 ± 24.3 vs 77.2 ± 20.4, P = .007). However, different findings were obtained after the scores were standardized. Although optimal results were still found in younger patients (<30 years), patients older than 40 years also appeared to benefit from the treatment, and no significant differences were noted compared with the younger population.

CONCLUSION

The benefit of cartilage treatments in patients with increasing age but without any sign of osteoarthritis was higher than previously reported in literature. In fact, when the decreasing functional level expected by an aging population was considered, standardized results showed an overall benefit after cartilage treatment in patients older than 40 years that was not significantly different from the outcome achieved in younger patients. Thus, age is not a strict contraindication as previously suggested, and future studies should consider standardization of data to prove the real age limit of cartilage treatments.

Terapias Celulares y Productos de Ingeniería de Tejidos para el Tratamiento de Lesiones Condrales de Rodilla

El cartílago articular es un tejido vulnerable a las lesiones de diferente etiología; siendo uno de los más afectados,  el cartílago de la rodilla. Aunque la mayoría de los tratamientos convencionales reducen los síntomas, generalmente conducen a la formación de fibrocartílago; el cual, posee características diferentes a las del cartílago hialino de las articulaciones.  Son pocas las aproximaciones terapéuticas que promueven el  reemplazo del tejido dañado por cartílago hialino funcional; las más exitosas son las denominadas terapias avanzadas, que aplican células y  productos de ingeniería de tejidos con el fin de estimular la regeneración del cartílago. La mayoría de ellas se basan en colocar soportes  hechos con biomateriales de diferente origen, que sembrados o no con células exógenas o endógenas, reemplazan al cartílago dañado y promueven su regeneración. Este  trabajo revisa algunas de las aproximaciones terapéuticas enfocadas en la regeneración del cartílago articular de rodilla; así como, los biomateriales más empleados en la elaboración de soportes para terapia celular e ingeniería de tejido cartilaginoso.

Does Prior Cartilage Restoration Impact Outcomes Following Knee Arthroplasty?

This study compared patients who failed a cartilage restoration procedure and underwent ipsilateral knee arthroplasty with matched control subjects undergoing knee arthroplasty without prior cartilage restoration. Although patients with a failed cartilage procedure derived benefit from knee arthroplasty, their magnitude of improvement and final outcomes scores were lower than the matched control subjects. In this cohort, the cartilage patients also experienced little to no benefit from cartilage restoration, suggesting that unmeasured shared patient characteristics may play a role. This information can be used to counsel this difficult patient population on expected outcomes following arthroplasty procedures. Further research identifying characteristics of responders to treatment remains critical to refine clinical decision-making for this difficult patient group.

Outcomes of Patellofemoral Osteochondral Lesions Treated With Structural Grafts in Patients Older Than 40 Years

Background Chondral lesions in the patellofemoral compartment represent a difficult entity to treat among active patients, with no clear consensus on the optimal treatment strategy. The purpose of this study was to review the functional outcomes of patients >40 years old with primary patellofemoral osteochondral lesions who underwent a cartilage restoration procedure with a structural graft. Methods Following institutional review board approval, 35 patients >40 years treated for patellofemoral chondral or osteochondral injuries were retrospectively identified. Seventeen (47%) had prior surgery (mean 1.4 procedures, range 1-4). Average follow-up was 3.6 ± 1.6 years. Average patient age was 51.5 years (range 40-72 years); 54% were male. Twenty-six (74%) had isolated trochlear lesions, 7 had isolated patellar lesions (20%), while 2 (6%) had bipolar lesions. Twenty patients (57%) were treated with synthetic biphasic scaffold plugs (SS), 9 (26%) with fresh osteochondral allograft (OCA) and 6 (17%) with osteochondral autograft transfer (OAT). Outcomes were measured with validated measures: Activity of Daily Living Score (ADL), International Knee Documentation Committee (IKDC) Subjective Evaluation form, and Marx Activity Scale (MAS). Results The average lesion size for the entire cohort was 3.1 ± 1.7 cm². Average defect size was 2.6 ± 1.7 cm² for the SS group, 4.3±1.5 cm² for the OCA group, and 2.9 ± 0.8 cm² for the OAT group ( P > 0.051). Outcome scores for the entire population demonstrated significant improvement in ADL ( P = 0.002) and IKDC scores ( P = 0.004) between baseline and final follow-up, while MAS scores were maintained ( P = 0.51). Conclusion Structural grafts are a viable treatment option for symptomatic focal osteochondral lesions of the patellofemoral joint in patients 40 years and older, with anticipated improvements in pain and function and maintenance of preoperative activity levels.

Effects of mechanical loading on human mesenchymal stem cells for cartilage tissue engineering

Today, articular cartilage damage is a major health problem, affecting people of all ages. The existing conventional articular cartilage repair techniques, such as autologous chondrocyte implantation (ACI), microfracture, and mosaicplasty, have many shortcomings which negatively affect their clinical outcomes. Therefore, it is essential to develop an alternative and efficient articular repair technique that can address those shortcomings. Cartilage tissue engineering, which aims to create a tissue-engineered cartilage derived from human mesenchymal stem cells (MSCs), shows great promise for improving articular cartilage defect therapy. However, the use of tissue-engineered cartilage for the clinical therapy of articular cartilage defect still remains challenging. Despite the importance of mechanical loading to create a functional cartilage has been well demonstrated, the specific type of mechanical loading and its optimal loading regime is still under investigation. This review summarizes the most recent advances in the effects of mechanical loading on human MSCs. First, the existing conventional articular repair techniques and their shortcomings are highlighted. The important parameters for the evaluation of the tissue-engineered cartilage, including chondrogenic and hypertrophic differentiation of human MSCs are briefly discussed. The influence of mechanical loading on human MSCs is subsequently reviewed and the possible mechanotransduction signaling is highlighted. The development of non-hypertrophic chondrogenesis in response to the changing mechanical microenvironment will aid in the establishment of a tissue-engineered cartilage for efficient articular cartilage repair.

Autologous Cartilage Chip Transplantation Improves Repair Tissue Composition Compared With Marrow Stimulation

BACKGROUND

Repair of chondral injuries by use of cartilage chips has recently demonstrated clinical feasibility.

PURPOSE

To investigate in vivo cartilage repair outcome of autologous cartilage chips compared with marrow stimulation in full-thickness cartilage defects in a minipig model.

STUDY DESIGN

Controlled laboratory study.

METHODS

Six Göttingen minipigs received two 6-mm chondral defects in the medial and lateral trochlea of each knee. The two treatment groups were (1) autologous cartilage chips embedded in fibrin glue (ACC) (n = 12) and (2) marrow stimulation (MST) (n = 12). The animals were euthanized after 6 months, and the composition of repair tissue was quantitatively determined using histomorphometry. Semiquantitative evaluation was performed by means of the International Cartilage Repair Society (ICRS) II score. Collagen type II staining was used to further evaluate the repair tissue composition.

RESULTS

Significantly more hyaline cartilage was found in the ACC (17.1%) compared with MST (2.9%) group ( P < .01). Furthermore, the ACC group had significantly less fibrous tissue (23.8%) compared with the MST group (41.1%) ( P < .01). No significant difference in fibrocartilage content was found (54.7% for ACC vs 50.8% for MST). The ACC group had significantly higher ICRS II scores for tissue morphological characteristics, matrix staining, cell morphological characteristics, surface assessment, mid/deep assessment, and overall assessment ( P < .05). The ACC-treated defects had significantly more collagen type II staining (54.5%) compared with the MST-treated defects (28.1%) ( P < .05).

CONCLUSION

ACC transplant resulted in improved quality of cartilage repair tissue compared with MST at 6 months postoperatively.

CLINICAL RELEVANCE

Further studies are needed to investigate ACC as a possible alternative first-line treatment for focal cartilage injuries in the knee.

Surgical treatments of cartilage defects of the knee: Systematic review of randomised controlled trials

BACKGROUND

The aim of this systematic review was to identify high quality randomised controlled trials (RCTs) and to provide an update on the most appropriate surgical treatments for knee cartilage defects.

METHODS

Two reviewers independently searched three databases for RCTs comparing at least two different treatment techniques for knee cartilage defects. The search strategy used terms mapped to relevant subject headings of MeSH terms. Strict inclusion and exclusion criteria were used to identify studies with patients aged between 18 and 55 years with articular cartilage defects sized between one and 15cm². Risk of bias was performed using a Coleman Methodology Score. Data extracted included patient demographics, defect characteristics, clinical outcomes, and failure rates.

RESULTS

Ten articles were included (861 patients). Eight studies compared microfracture to other treatment; four to autologous chondrocyte implantation (ACI) or matrix-induced ACI (MACI); three to osteochondral autologous transplantation (OAT); and one to BST-Cargel. Two studies reported better results with OAT than with microfracture and one reported similar results. Two studies reported superior results with cartilage regenerative techniques than with microfracture, and two reported similar results. At 10years significantly more failures occurred with microfracture compared to OAT and with OAT compared to ACI. Larger lesions (>4.5cm²) treated with cartilage regenerative techniques (ACI/MACI) had better outcomes than with microfracture.

CONCLUSIONS

Based on the evidence from this systematic review no single treatment can be recommended for the treatment of knee cartilage defects. This highlights the need for further RCTs, preferably patient-blinded, using an appropriate reference treatment or a placebo procedure.

Allografts: Osteochondral, Shell, and Paste

There is an increasing need for articular cartilage restoration procedures. Hyaline cartilage lacks intrinsic healing capacity. Persistent osteochondral defects can lead to early and rapid degenerative changes. Microfracture and autologous chondrocyte implantation provide reasonable outcomes for smaller defects without bone loss. However, these techniques have limited effectiveness for lesions greater than 4 cm² or with significant bony involvement. Ostochondral allografts provide an option for these lesions. This article reviews osteochondral allografts for articular defects. Emerging options provide different approaches to difficult cartilage defects. We discuss current screening, procurement, and storage methods, surgical techniques, outcomes, and bacterial/viral transmission.

Osteochondral Autologous Transplantation

Osteochondral autologous transplantation (OAT) is a treatment strategy for small and medium sized focal articular cartilage defects in the knee. This article reviews the indications, surgical techniques, outcomes, and limitations of OAT for the management of symptomatic chondral and osteochondral lesions in the knee joint.

Accelerated Return to Sport After Osteochondral Autograft Plug Transfer

Background:

Previous studies have reported varying return-to-sport protocols after knee cartilage restoration procedures.

Purpose:

To (1) evaluate the time for return to sport in athletes with an isolated chondral injury who underwent an accelerated return-to-sport protocol after osteochondral autograft plug transfer (OAT) and (2) evaluate clinical outcomes to assess for any consequences from the accelerated return to sport.

Study Design:

Case series; Level of evidence, 4.

Methods:

An institutional cohort of 152 OAT procedures was reviewed, of which 20 competitive athletes met inclusion and exclusion criteria. All patients underwent a physician-directed accelerated rehabilitation program after their procedure. Return to sport was determined for all athletes. Clinical outcomes were assessed using International Knee Documentation Committee (IKDC) and Tegner scores as well as assessment of level of participation on return to sport.

Results:

Return-to-sport data were available for all 20 athletes; 13 of 20 athletes (65%) were available for clinical evaluation at a mean 4.4-year follow-up. The mean time for return to sport for all 20 athletes was 82.9 ± 25 days (range, 38-134 days). All athletes were able to return to sport at their previous level and reported that they were satisfied or very satisfied with their surgical outcome and ability to return to sport. The mean postoperative IKDC score was 84.5 ± 9.5. The mean Tegner score prior to injury was 8.9 ± 1.7; it was 7.7 ± 1.9 at final follow-up.

Conclusion:

Competitive athletes with traumatic chondral defects treated with OAT managed using this protocol had reduced time to preinjury activity levels compared with what is currently reported, with excellent clinical outcomes and no serious long-term sequelae.

Suspended Manufacture of Biological Structures

A method for the production of complex cell-laden structures is reported, which allows high-levels of spatial control over mechanical and chemical properties. The potential of this method for producing complicated tissues is demonstrated by manufacturing a complex hard/soft tissue interface and demonstrating that cell phenotype can be maintained over four weeks of culture.

Long-term Outcomes of Autologous Chondrocyte Implantation in Adolescent Patients

BACKGROUND

Treating symptomatic articular cartilage lesions is challenging, especially in adolescent patients, because of longer life expectancies and higher levels of functional activity. For this population, long-term outcomes after autologous chondrocyte implantation (ACI) remain to be determined.

PURPOSE

To evaluate long-term outcomes in adolescents after ACI using survival analyses, validated outcome questionnaires, and standard radiographs.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

We performed a review of prospectively collected data from patients who underwent ACI between 1996 and 2013. We evaluated 27 patients aged <18 years old (29 knees; mean age, 15.9 years) who were treated by a single surgeon for symptomatic, full-thickness articular cartilage lesions over a mean 9.6-year follow-up (median, 13 years; range, 2-19 years). A mean of 1.5 lesions per knee were treated over a mean total surface area of 6.2 cm² (range, 2.0-23.4 cm²) per knee. Survival analysis was performed using the Kaplan-Meier method, with graft failure as the end point. The modified Cincinnati Knee Rating Scale, Western Ontario and McMaster Universities Osteoarthritis Index, visual analog scale, and Short Form 36 scores were used to evaluate clinical outcomes. Patients also self-reported knee function and satisfaction. Standard radiographs were evaluated using Kellgren-Lawrence grades.

RESULTS

Both 5- and 10-year survival rates were 89%. All clinical scores improved significantly postoperatively. A total of 96% of patients rated knee function as better after surgery, and all patients indicated that they would undergo the same surgery again. Approximately 90% rated knee-specific outcomes as good or excellent and were satisfied with the procedure. At last follow-up, 12 of 26 successful knees were radiographically assessed (mean, 5.6 years postoperatively), with no significant osteoarthritis progression. Three knees were considered failures, which were managed by autologous bone grafting or osteochondral autologous transplantation. Twenty knees required subsequent surgical procedures. These were primarily associated with periosteum and were arthroscopically performed.

CONCLUSION

ACI resulted in satisfactory survival rates and significant improvements in function, pain, and mental health for adolescent patients over a long-term follow-up. ACI was associated with very high satisfaction postoperatively, despite the subsequent procedure rate being relatively high primarily because of the use of periosteum. If periosteum is used, this rate should be a consideration when discussing ACI with patients and their parents.

Biodegradable poly-L-lactide-co-glycolide copolymer pin fixation of a traumatic patellar osteochondral fragment in an 11-year-old child: A novel surgical approach

Treating displaced patellar bone fractures in growing children remains a challenge for orthopedic surgeons. Removal of loose bone fragments may prolong healing time and result in early onset osteoarthrosis. Therefore, primary fixation of osteochondral fragments is preferred. Metallic pin and screw implants are typically used for fixation, as there is little evidence available regarding the use of modern biodegradable implants in traumatic patellar fractures of a premature skeleton. The present report describes a novel operative technique using headless poly-L-lactide-co-glycolide (PLGA) pins in treating an 11-year-old girl with a patellar fracture from a cycling injury. The surgical technique of this procedure is described in detail in the current report. Excellent subjective outcomes were achieved from this surgery, with superb bone healing according to follow-up radiographic and computerized tomography scans. In conclusion, the results of this case indicate that, similarly to osteochondritis, intra-articular osteochondral fractures in children may be fixed using biodegradable PLGA pins. Randomized clinical trials should be performed to confirm this finding and evaluate the use of PLGA pins as a treatment for adolescent osteochondral fractures.

Biological and functional evaluation of a novel pyrolytic carbon implant for the treatment of focal osteochondral defects in the medial femoral condyle: assessment in a canine model

Background

Osteochondral defects continue to be a clinical treatment challenge, and when left untreated, may cause pain and functional impairment. Pyrolytic carbon is a unique isotropic biomaterial used in heart valve and small joint replacements due to its excellent wear properties and biocompatibility with bone and articular cartilage. Therefore, a proposed solution is to utilize a focal pyrolytic carbon hemiarthroplasty implant as an alternative resurfacing treatment strategy for isolated cartilage lesions.

Methods

A canine model (n = 9) was used to evaluate the in vivo histologic response and function of a pyrolytic carbon implant replacing a full-thickness osteochondral defect in the medial femoral condyle (MFC) of the knee. The gross appearance and histologic results were compared to an identical cobalt-chromium (Co-Cr) alloy implant placed in a defect in the contralateral MFC and evaluated up to 52 weeks.

Results

Extensive bone incorporation to the stem portion was observed for both implant types. The total mean histologic score for the cartilage of the MFC surrounding the pyrolytic carbon implants was significantly improved compared to that of the Co-Cr alloy implants at all evaluation periods (p < 0.05). Histologic grading and gross observations at 52 weeks for pyrolytic carbon implants were similar to those of Co-Cr alloy implants at 24 weeks. At 24 weeks, the mean total histologic score for Co-Cr alloy implants was 11.6 ± 0.7 (0–16 range point; 16 = normal appearance), while at 52 weeks, the mean total score for the pyrolytic carbon implants was 11.7 ± 1.3. Mean total histologic score of opposing medial tibia cartilage for the pyrolytic carbon implants was superior to that of the Co-Cr alloy group at all evaluation periods and significantly improved over the Co-Cr alloy implant group at 24 weeks (p = 0.001) and 52 weeks (p < 0.001).

Conclusions

Use of a pyrolytic carbon implant for reconstruction of a focal cartilage defect demonstrated effective implant fixation and superior in vivo response compared to an identical Co-Cr alloy implant.

Knee donor-site morbidity after mosaicplasty - a systematic review

BACKGROUND

Mosaicplasty has been associated with good short- to long-term results. Nevertheless, the osteochondral harvesting is restricted to the donor-site area available and it may lead to significant donor-site morbidity.

PURPOSE

Provide an overview of donor-site morbidity associated with harvesting of osteochondral plugs from the knee joint in mosaicplasty procedure.

METHODS

Comprehensive search using Pubmed, Cochrane Library, SPORTDiscus and CINAHL databases was carried out through 10th October of 2016. As inclusion criteria, all English-language studies that assessed the knee donor-site morbidity after mosaicplasty were accepted. The outcomes were the description and rate of knee donor-site morbidity, sample's and cartilage defect's characterization and mosaicplasty-related features. Correlation between mosaicplasty features and rate of morbidity was performed. The methodological and reporting quality were assessed according to Coleman's methodology score.

RESULTS

Twenty-one studies were included, comprising a total of 1726 patients, with 1473 and 268 knee and ankle cartilage defects were included. The defect size ranged from 0.85 cm2 to 4.9 cm2 and most commonly 3 or less plugs (averaging 2.9 to 9.4 mm) were used. Donor-site for osteochondral harvesting included margins of the femoral trochlea (condyles), intercondylar notch, patellofemoral joint and upper tibio-fibular joint. Mean donor-site morbidity was 5.9 % and 19.6 % for knee and ankle mosaicplasty procedures, respectively. Concerning knee-to-knee mosaicplasty procedures, the most common donor-site morbidity complaints were patellofemoral disturbances (22 %) and crepitation (31 %), and in knee-to-ankle procedures there was a clear tendency for pain or instability during daily living or sports activities (44 %), followed by patellofemoral disturbances, knee stiffness and persistent pain (13 % each). There was no significant correlation between rate of donor-site morbidity and size of the defect, number and size of the plugs (p > 0.05).

CONCLUSIONS

Osteochondral harvesting in mosaicplasty often results in considerable donor-site morbidity. The donor-site morbidity for knee-to-ankle (16.9 %) was greater than knee-to-knee (5.9 %) mosaicplasty procedures, without any significant correlation between rate of donor-site morbidity and size of the defect, number and size of the plugs. Lack or imcomplete of donor-site morbidity reporting within the mosaicplasty studies is a concern that should be addressed in future studies.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I-IV studies.

Osteochondral Autograft Transfer Versus Microfracture in the Knee: A Meta-analysis of Prospective Comparative Studies at Midterm

PURPOSE

To compare microfracture (MFX) and osteochondral autograft transfer (OAT) surgical techniques to determine (1) postoperative activity level, (2) subjective patient outcomes, (3) failure rates, and (4) assess if any lesion characteristics favored one technique over the other.

METHODS

A comprehensive review of literature was performed of all studies comparing MFX and OAT. Studies included were all prospective studies that reported on activity-based outcome measures such as Tegner activity scores and subjective outcomes such as the International Knee Documentation Committee score. Failure rates, as determined by the publishing authors, were recorded for each study. Meta-analyses were conducted using a random-effects model. Paired standardized mean differences (Hedges's g to account for small sample bias) were used for continuous outcome measures, and risk ratios (Mantel-Haenszel method for small sample bias) for dichotomous outcome measures.

RESULTS

Six prospective studies satisfied the eligibility criteria and included 249 patients (186 male, 120 female) with an average age of 26.4 years and follow-up of 67.2 months. Tegner scores were superior in patients treated with OAT compared with MFX (ΔOAT-MFX for pre-post scores = 0.94 Tegner points, standardized mean difference [SMD] = 0.469, P = .005). Failure rates of MFX were higher than OAT (OAT = 11%, MFX = 32%, risk ratio = 2.42, P < .036). OAT was superior to MFX at 3 years in relation to subjective outcome scores (SMD = 0.404, P = .008). When assessing OAT lesions larger than 3 cm², OAT was superior to MFX with respect to activity level (SMD = 0.506, P = .001).

CONCLUSIONS

OAT may achieve higher activity levels and lower risk of failure when compared with MFX for cartilage lesions greater than 3 cm² in the knee, although there was no significant difference for lesions less than 3 cm² at midterm. However, because of variability in patient-specific factors such as age, preinjury activity level, lesion location and size, the superiority of OAT over MFX cannot be generalized to all patient populations and therefore requires individualized patient care.

LEVEL OF EVIDENCE

Level II, meta-analysis of Level I and II studies.

Cartilage repair strategies in the knee: A survey of Turkish surgeons

Objectives

The purpose of this study was to analyze the trends in cartilage repair strategies among Turkish orthopedic surgeons for isolated focal (osteo)chondral lesions of the knee joint.

Materials and methods

A web-based survey of 21 questions consisting of surgical indications, techniques and time to return to sports was developed to investigate the preferences of members of the TOTBID and the TUSYAD.

Results

A total of 147 surgeons answered the questionnaire.70% of the respondents were TUSYAD members. 82% of respondents had at least five years experience in arthroscopy. Half of the surgeons indicated that patient age of 50 was the upper limit for cartilage repair. Irrespective of activity level, microfracture (60–67%) was the most frequently used technique for lesions smaller 2.5 cm². In lesions larger than 4 cm², MACI was the most commonly advocated procedure (67%). In patients with high activity levels, mosaicplasty was the first choice (69%) for lesions between 2.5 and 4 cm² in size, followed by MACI (27%).

Conclusion

Patient age, activity level, BMI and lesion size were important determinants for the choice of treatment of isolated chondral lesions in the knee. These results reflect the choices of experienced knee surgeons in the country. Although not widely performed in Turkey and has limited reimbursement by the health care system, the first choice for defects over 4 cm² was second generation ACI. Third party payers & health reimbursement authorities should take into account that large defects require methods which are relatively expensive and need high technology. Cross-sectional survey, Level II.

Shoulder Activity Level is Associated With Type of Employment and Income in the Normative Population Without Shoulder Disorders

BACKGROUND

Socioeconomic variables influence various healthcare issues in different ways. The effect of socioeconomic variables on the shoulder has not been well studied. Because activity level, defined by how much a patient actually does, is an important patient outcome measure and prognostic factor for the shoulder, studying its association with occupation and income will advance our understanding of how these variables relate to shoulder disorders, treatments, and outcomes.

QUESTIONS/PURPOSE

We asked: (1) Does shoulder activity score correlate with income level, stratified by gender? (2) Do different employment groups-heavy, moderate, light, student, retired-have different shoulder activity scores, as stratified by gender? (3) Is type of sports participation (contact or overhead) associated with income level, employment type, race, or household size?

METHODS

A survey collected the Brophy and Marx shoulder activity score and demographic information, such as age, gender, race, income, type of employment, and household size from 1625 individuals 18 years and older with no current or previous shoulder pain or injury who are members of a research panel matched to the United States population by age, gender, household income and size, race/ethnicity, and geography. Men and women were analyzed separately. Activity level was controlled for age.

RESULTS

Shoulder activity correlated with income level among men (R = 0.03; p < 0.001) and women (R = 0.06; p = 0.0002). For men, heavy employment had the highest Shoulder Activity Scale (SAS) level (12.1 ± 4.9), which was more than SAS levels in sedentary (9.1 ± 4.5; mean difference, 3.0; 95% CI, 2.5-3.6; p = 0.001), student (8.8 ± 5.1; mean difference, 3.3; 95% CI, 3.0-3.7; p = 0.007), retired (8.0 ± 4.6; mean difference, 4.1; 95% CI, 3.6-4.7; p = 0.0001), and not working (7.5 ± 5.3; mean difference, 4.6; 95% CI, 4.6-4.6; p < 0.001) categories; similarly, for women, heavy employment had the highest SAS level (12.0 ± 5.8). However, as there were few women working in heavy labor, the only significant difference in women was between moderate employment (8.8 ± 4.2) and sedentary employment (7.0 ± 4.1; mean difference, 1.8; 95% CI, 1.6-1.9; p = 0.0015). Participation in contact (19.9% vs 12.0%; p = 0.006) and overhead sports (25.2% vs 14.2%; p < 0.001) was greater among males with higher incomes.

CONCLUSIONS

Shoulder activity level is related to the socioeconomic factors of income and type of employment. Heavy laborers have higher shoulder activity level, likely directly related to their work. Individuals with higher incomes also have higher shoulder activity level, probably attributable to recreation as evidenced by their greater participation in contact and overhead sports. Independent of the underlying cause, these patients probably are more likely to seek treatment for shoulder disorders and may be more challenging to treat because of their elevated activity level. Future research should focus on how elevated activity level in these populations affects their risk for shoulder disorders, and their use of and outcomes from treatment for these disorders.

LEVEL OF EVIDENCE

Level IV, prognostic study.

Long-Term Outcomes after Autologous Chondrocyte Implantation: A Systematic Review at Mean Follow-Up of 11.4 Years

OBJECTIVE

Autologous chondrocyte implantation (ACI) has not been proven to be durable over the long-term. The purpose of this systematic review was (1) to evaluate activity level and knee function, (2) to evaluate reoperation and failure rates, and (3) to analyze risk factors for reoperation and failure of ACI at minimum long-term follow-up.

DESIGN

A comprehensive review was performed for studies with long-term outcomes after ACI for cartilage defect repair. Studies reported outcome scores such as Tegner score, Lysholm score, and International Knee Documentation Society (IKDC) score along with rates of failure and reoperation. Modified Coleman Methodology Scores were calculated to assess study methodological quality.

RESULTS

Nine studies with a total of 771 patients with a mean age of 33.4 ± 2.5 years, mean defect size of 5.9 ± 1.6 cm(2), and mean follow-up of 11.4 years were included. Tegner score, Lysholm score, and IKDC score change from preoperative to final follow-up was 1.1 (95% CI 0.8-1.4, P < 0.001), 24.9 points (95% CI 18.8-31, P < 0.001), and 16.5 points (95% CI 5.4-27.5, P < 0.01), respectively. The mean failure and reoperation rates were 18% and 37%, respectively. Increased age and lesion size (>4.5 cm(2)) were significantly correlated with increased risk of reoperation and failure.

CONCLUSIONS

Overall, ACI demonstrated successful outcomes in 82% of patients over the long-term. Increased patient age and lesion size greater than 4.5 cm(2) were risk factors for a higher reoperation and failure rate. Nonetheless, this review is limited by heterogeneity in surgical technique, and lesion and patient characteristics.

Surgical interventions (microfracture, drilling, mosaicplasty, and allograft transplantation) for treating isolated cartilage defects of the knee in adults

BACKGROUND

Cartilage defects of the knee are often debilitating and predispose to osteoarthritis. Microfracture, drilling, mosaicplasty, and allograft transplantation are four surgical treatment options that are increasingly performed worldwide. We set out to examine the relative effects of these different methods.

OBJECTIVES

To assess the relative effects (benefits and harms) of different surgical interventions (microfracture, drilling, mosaicplasty, and allograft transplantation) for treating isolated cartilage defects of the knee in adults.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, CENTRAL, EMBASE, MEDLINE, SPORTDiscus, LILACS, trial registers and conference proceedings up to February 2016.

SELECTION CRITERIA

Any randomised or quasi-randomised trials that evaluated surgical interventions (microfracture, drilling, mosaicplasty, and allograft transplantation) for treating isolated cartilage defects of the knee in adults.

DATA COLLECTION AND ANALYSIS

At least two review authors independently selected studies, assessed risk of bias and extracted data. Intervention effects were assessed using risk ratios (RR) for dichotomous data and mean differences (MD) for continuous data, with 95% confidence intervals (CI). Data were pooled using the fixed-effect model, where possible.

MAIN RESULTS

We included three randomised controlled trials comparing mosaicplasty versus microfracture for isolated cartilage defects in adults. Two trials were single-centre trials and one involved three centres. These small trials reported results for a total of 133 participants, of whom 79 (59%) were male. Mean participant age in the three trials ranged from 24.4 years to 32.3 years. All studies included grade 3 or 4 cartilage lesions (International Cartilage Repair Society (ICRS) classification). The defect area ranged from 1.0 cm² to 6.0 cm²; the mean area in all three trials was 2.8 cm². No trials of allograft transplantation or drilling were identified.All trials were judged as being at high or unclear risk of performance and reporting bias. We judged that the quality of evidence was very low for all outcomes. For individual outcomes, we downgraded the quality of evidence by one or two levels for risk of bias, one level for indirectness where there were data from a single-centre trial only, one or two levels for imprecision where there were wide confidence intervals and an insufficient number of events, and one level for inconsistency reflecting heterogeneity. This means that we are very uncertain about the estimates for all outcomes.There is very low quality evidence from one single-centre trial (57 participants), which included athletes only, that mosaicplasty resulted in higher patient-reported function scores (probably the IKDC 2000 subjective knee evaluation score) compared with microfracture (range 0 to 100; higher score = better function) at one year follow-up (MD 10.29 favouring mosaicplasty, 95% CI 7.87 to 12.71). Very low quality evidence from the same trial showed that this effect persisted in the long term at 10 years follow-up. However, there is very low quality evidence from the two other trials (72 participants) of little difference in patient-reported function, assessed via the Lysholm score (range 0 to 100; higher score = better function), between the two groups at long-term follow-up (MD -1.10 favouring microfracture, 95% CI -4.54 to 2.33). One trial (25 participants) provided very low quality evidence of no significant difference between the two groups in quality of life or pain at long-term follow-up. Pooled results for treatment failure - primarily symptom recurrence - reported at long-term follow-up (means ranging from 6.3 to 1.4 years) in the three trials (129 participants) favoured mosaicplasty (10/64 versus 20/65; RR 0.47, 95% CI 0.24 to 0.90). Based on an illustrative risk of 379 treatment failures per 1000 patients treated with microfracture, there is very low quality evidence that 201 fewer patients (95% CI 38 to 288 fewer) would have treatment failure after mosaicplasty. All three trials reported activity scores but due to clear statistical and clinical heterogeneity, we did not pool the long term Tegner score results. There was very low quality evidence from one study (57 participants) of higher Tegner scores - indicating greater activity - at intermediate-term and long-term follow-up in the mosaicplasty group; however, the between-group difference may not be clinically important. The other two trials provided very low quality evidence of no significant difference between the two groups in activity scores.

AUTHORS' CONCLUSIONS

We found no evidence from randomised controlled trials on allograft transplantation or drilling. The very low quality evidence from RCTs comparing mosaicplasty with microfracture is insufficient to draw conclusions on the relative effects of these two interventions for treating isolated cartilage defects of the knee in adults. Of note is that treatment failure, with recurrence of symptoms, occurred with both procedures. Further research is needed to define the best surgical option for treating isolated cartilage defects. We suggest the greatest need is for multi-centre RCTs comparing reconstructive procedures (mosaicplasty versus allograft transplantation) for large osteochondral lesions and reparative procedures (microfracture versus drilling) for small chondral lesions.

Prevalence of Articular Cartilage Lesions and Surgical Clinical Outcomes in Football (Soccer) Players' Knees: A Systematic Review

PURPOSE

To systematize the available scientific literature on the prevalence of articular cartilage and/or osteochondral lesions in football (soccer) players' knees, and overview the surgical procedures and functional outcomes and return to sports.

METHODS

A comprehensive search using Pubmed, Cochrane Library, SPORTDiscus, and CINAHL databases was carried out until September 30, 2015. All English language studies that assessed the outcomes of a surgical technique for the treatment of articular cartilage lesions in football players' knees, with a minimum follow-up of 12 months, were included. The reference list of the most relevant papers was screened. The main outcomes of interest were the clinical, arthroscopy or imaging primary outcomes and the return to sports rate. The methodological and reporting qualities were assessed according to Coleman methodology score.

RESULTS

The search provided 485 titles and abstracts. Five studies were eligible for inclusion (mean Coleman score of 37.2 points), comprising a total of 183 football players with a mean age of 25.7 years. A total of 217 articular cartilage and/or osteochondral lesions were reported, where the medial and lateral femoral condyles were the most common sites of lesion. The surgical procedures investigated were mosaicplasty, microfracture, autologous chondrocyte implantation, and chondral debridement.

CONCLUSIONS

No definitive conclusion could be made in respect to the best current surgical technique for articular cartilage and osteochondral lesions. Microfracture and mosaicplasty can provide a faster return to competition and faster clinical and functional results, whereas autologous chondrocyte implantation and/or matrix-induced autologous chondrocytes implantation procedures can enhance longstanding clinical and functional results.

LEVEL OF EVIDENCE

Level IV, systematic review of Level III and IV studies.

Cartilage Restoration of the Knee: A Systematic Review and Meta-analysis of Level 1 Studies

BACKGROUND

Focal cartilage defects of the knee are a substantial cause of pain and disability in active patients. There has been an emergence of randomized controlled trials evaluating surgical techniques to manage such injuries, including marrow stimulation (MS), autologous chondrocyte implantation (ACI), and osteochondral autograft transfer (OAT).

PURPOSE

A meta-analysis was conducted to determine if any single technique provides superior clinical results at intermediate follow-up.

STUDY DESIGN

Systematic review and meta-analysis of randomized controlled trials.

METHODS

The MEDLINE, EMBASE, and Cochrane Library databases were systematically searched and supplemented with manual searches of PubMed and reference lists. Eligible studies consisted exclusively of randomized controlled trials comparing MS, ACI, or OAT techniques in patients with focal cartilage defects of the knee. The primary outcome of interest was function (Lysholm score, International Knee Documentation Committee score, Knee Osteoarthritis Outcome Score) and pain at 24 months postoperatively. A meta-analysis using standardized mean differences was performed to provide a pooled estimate of effect comparing treatments.

RESULTS

A total of 12 eligible randomized trials with a cumulative sample size of 765 patients (62% males) and a mean (±SD) lesion size of 3.9 ± 1.3 cm(2) were included in this review. There were 5 trials comparing ACI with MS, 3 comparing ACI with OAT, and 3 evaluating different generations of ACI. In a pooled analysis comparing ACI with MS, there was no difference in outcomes at 24-month follow-up for function (standardized mean difference, 0.47 [95% CI, -0.19 to 1.13]; P = .16) or pain (standardized mean difference, -0.13 [95% CI, -0.39 to 0.13]; P = .33). The comparisons of ACI to OAT or between different generations of ACI were not amenable to pooled analysis. Overall, 5 of the 6 trials concluded that there was no significant difference in functional outcomes between ACI and OAT or between generations of ACI.

CONCLUSION

There is no significant difference between MS, ACI, and OAT in improving function and pain at intermediate-term follow-up. Further randomized trials with long-term outcomes are warranted.

Correlation between histological outcome and surgical cartilage repair technique in the knee: A meta-analysis

BACKGROUND

Compare histological outcomes after microfracture (MF), autologous chondrocyte implantation (ACI), and osteochondral autograft transfer (OATS).

METHODS

Literature review using PubMed MEDLINE, SCOPUS, Cumulative Index for Nursing and Allied Health Literature (CINAHL), and Cochrane Collaboration Library. Inclusion criteria limited to English language studies International Cartilage Repair Society (ICRS) grading criteria for cartilage analysis after ACI (autologous chondrocyte implantation), MF (microfracture), or OATS (osteochondral autografting) repair techniques.

RESULTS

Thirty-three studies investigating 1511 patients were identified. Thirty evaluated ACI or one of its subtypes, six evaluated MF, and seven evaluated OATS. There was no evidence of publication bias (Begg's p=0.48). No statistically significant correlation was found between percent change in clinical outcome and percent biopsies showing ICRS Excellent scores (R(2)=0.05, p=0.38). Percent change in clinical outcome and percent of biopsies showing only hyaline cartilage were significantly associated (R(2)=0.24, p=0.024). Mean lesion size and histological outcome were not correlated based either on percent ICRS Excellent (R(2)=0.03, p=0.50) or percent hyaline cartilage only (R(2)=0.01, p=0.67). Most common lesion location and histological outcome were not correlated based either on percent ICRS Excellent (R(2)=0.03, p=0.50) or percent hyaline cartilage only (R(2)=0.01, p=0.67).

CONCLUSIONS

Microfracture has poorer histologic outcomes than other cartilage repair techniques. OATS repairs primarily are comprised of hyaline cartilage, followed closely by cell-based techniques, but no significant difference was found cartilage quality using ICRS grading criteria among OATS, ACI-C, MACI, and ACI-P.

LEVEL OF EVIDENCE

IV, meta-analysis.

Osteochondritis dissecans of the knee

Osteochondritis Dissecans (OCD) is a condition for which the aetiology remains unknown. It affects subchondral bone and secondarily its overlying cartilage and is mostly found in the knee. It can occur in adults, but is generally identified when growth remains, when it is referred to as juvenile OCD. As the condition progresses, the affected subchondral bone separates from adjacent healthy bone, and can lead to demarcation and separation of its associated articular cartilage. Any symptoms which arise relate to the stage of the disease. Early disease without separation of the lesion results in pain. Separation of the lesion leads to mechanical symptoms and swelling and, in advanced cases, the formation of loose bodies.

Early identification of OCD is essential as untreated OCD can lead to the premature degeneration of the joint, whereas appropriate treatment can halt the disease process and lead to healing. Establishing the stability of the lesion is a key part of providing the correct treatment. Stable lesions, particularly in juvenile patients, have greater propensity to heal with non-surgical treatment, whereas unstable or displaced lesions usually require surgical management.

This article discusses the aetiology, clinical presentation and prognosis of OCD in the knee. It presents an algorithm for treatment, which aims to promote healing of native hyaline cartilage and to ensure joint congruity.

Take home message: Although there is no clear consensus as to the best treatment of OCD, every attempt should be made to retain the osteochondral fragment when possible as, with a careful surgical technique, there is potential for healing even in chronic lesions

Cite this article: Bone Joint J 2016;98-B:723–9.

Long-term Outcomes After Osteochondral Autograft Transfer: A Systematic Review at Mean Follow-up of 10.2 Years

PURPOSE

To evaluate (1) activity level and knee function, (2) reoperation and failure rates, and (3) risk factors for reoperation and failure of osteochondral autograft transfer (OAT) at minimum long-term follow-up.

METHODS

A comprehensive review was performed for long-term outcomes after OAT. Studies reported on activity-based outcomes (Tegner Activity Scale) and clinical outcomes (Lysholm score and International Knee Documentation Committee score). Reoperation and failure rates, as defined by the publishing authors, were recorded for each study. Modified Coleman Methodology Scores were calculated to assess study methodological quality.

RESULTS

Ten studies with a total of 610 patients with an average age of 27.0 years at the time of surgery and a mean follow-up of 10.2 years were included. The mean defect size was 2.6 cm(2) (range, 0.9 to 20.0 cm(2)). The mean duration of symptoms before surgery was 4.8 years. From preoperative to final follow-up, International Knee Documentation Committee scores and Lysholm scores improved significantly by 42.4 (95% confidence interval [CI], 31.8 to 53.1, P < .001) and 21.1 (95% CI, 12.2 to 30.0, P < .01), respectively. Tegner score did not improve significantly (0.76, 95% CI, -0.83 to 2.36, P = .35). Overall failure rate was 28% and reoperation rate was 19%. Increased age, previous surgery, and defect size positively correlated with increased risk of failure. Concomitant surgical procedures negatively correlated with failure rate.

CONCLUSIONS

Overall, OAT showed successful outcomes in 72% of patients at long-term follow-up. Increased age, previous surgery, and defect size correlated positively with failure rate, whereas success improved with concomitant surgical procedures. Nonetheless, this systematic review is limited by heterogeneity in a surgical technique, lesion and patient characteristics, and reporting of nonstandardized outcome measures.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I-IV studies.