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Niethammer TR, Aurich M, Brucker PU, Faber S, Diemer F, Pietschmann MF, Schoch W, Zinser W, Müller PE. Follow-up Treatment after Cartilage Therapy of the Knee Joint - a Recommendation of the DGOU Clinical Tissue Regeneration Working Group. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2024. [PMID: 38224697 DOI: 10.1055/a-2206-7242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/17/2024]
Abstract
The first follow-up treatment recommendation from the DGOU's Clinical Tissue Regeneration working group dates back to 2012. New scientific evidence and changed framework conditions made it necessary to update the follow-up treatment recommendations after cartilage therapy.As part of a multi-stage member survey, a consensus was reached which, together with the scientific evidence, provides the basis for the present follow-up treatment recommendation.The decisive criterion for follow-up treatment is still the defect localisation. A distinction is made between femorotibial and patellofemoral defects. In addition, further criteria regarding cartilage defects are now also taken into account (stable cartilage edge, location outside the main stress zone) and the different methods of cartilage therapy (e. g. osteochondral transplantation, minced cartilage) are discussed.The present updated recommendation includes different aspects of follow-up treatment, starting with early perioperative management through to sports clearance and resumption of contact sports after cartilage therapy has taken place.
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Affiliation(s)
- Thomas R Niethammer
- Muskuloskelettales Universitätszentrum München (MUM), Klinik für Orthopädie und Unfallchirurgie, Klinikum der Universität München, LMU München, München, Deutschland
| | - Matthias Aurich
- Department für Orthopädie, Unfall- und Wiederherstellungschirurgie, Universitätsklinikum Halle (Saale), Halle, Deutschland
- Klinik für Unfall- und Wiederherstellungschirurgie, BG Klinikum Bergmannstrost, Halle (Saale), Deutschland
| | - Peter U Brucker
- ATOS Klinik München, München, Deutschland
- Biomechanik im Sport, Fakultät für Sport- und Gesundheitswissenschaft, Technische Universität München, München
| | - Svea Faber
- Muskuloskelettales Universitätszentrum München (MUM), Klinik für Orthopädie und Unfallchirurgie, Klinikum der Universität München, LMU München, München, Deutschland
| | | | - Matthias F Pietschmann
- Muskuloskelettales Universitätszentrum München (MUM), Klinik für Orthopädie und Unfallchirurgie, Klinikum der Universität München, LMU München, München, Deutschland
- OrthoPraxis Oberhaching, Oberhaching
| | | | - Wolfgang Zinser
- Orthoexpert, Knittelfeld, Österreich
- Metagil Physikalisches Ambulatorium, Knittelfeld, Österreich
| | - Peter E Müller
- Muskuloskelettales Universitätszentrum München (MUM), Klinik für Orthopädie und Unfallchirurgie, Klinikum der Universität München, LMU München, München, Deutschland
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Holz J, Spalding T, Boutefnouchet T, Emans P, Eriksson K, Brittberg M, Konradsen L, Kösters C, Verdonk P, Högström M, Lind M. Patient-specific metal implants for focal chondral and osteochondral lesions in the knee; excellent clinical results at 2 years. Knee Surg Sports Traumatol Arthrosc 2021; 29:2899-2910. [PMID: 33025052 PMCID: PMC8384793 DOI: 10.1007/s00167-020-06289-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 09/14/2020] [Indexed: 01/04/2023]
Abstract
PURPOSE Surgical treatment options for the management of focal chondral and osteochondral lesions in the knee include biological solutions and focal metal implants. A treatment gap exists for patients with lesions not suitable for arthroplasty or biologic repair or who have failed prior cartilage repair surgery. This study reports on the early clinical and functional outcomes in patients undergoing treatment with an individualised mini-metal implant for an isolated focal chondral defect in the knee. METHODS Open-label, multicentre, non-randomised, non-comparative retrospective observational analysis of prospectively collected clinical data in a consecutive series of 80 patients undergoing knee reconstruction with the Episealer® implant. Knee injury and Osteoarthritis Outcome Score (KOOS) and VAS scores, were recorded preoperatively and at 3 months, 1 year, and 2 years postoperatively. RESULTS Seventy-five patients were evaluated at a minimum 24 months following implantation. Two patients had undergone revision (2.5%), 1 declined participation, and 2 had not completed the full data requirements, leaving 75 of the 80 with complete data for analysis. All 5 KOOS domain mean scores were significantly improved at 1 and 2 years (p < 0.001-0.002). Mean preoperative aggregated KOOS4 of 35 (95% CI 33.5-37.5) improved to 57 (95% CI 54.5-60.2) and 59 (95% CI 55.7-61.6) at 12 and 24 months respectively (p < 0.05). Mean VAS score improved from 63 (95% CI 56.0-68.1) preoperatively to 32 (95% CI 24.4-38.3) at 24 months. The improvement exceeded the minimal clinically important difference (MCID) and this improvement was maintained over time. Location of defect and history of previous cartilage repair did not significantly affect the outcome (p > 0.05). CONCLUSION The study suggests that at 2 years, Episealer® implants are safe with a low failure rate of 2.5% and result in clinically significant improvement. Individualised mini-metal implants with appropriate accurate guides for implantation appear to have a place in the management of focal femoral chondral and osteochondral defects in the knee. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Johannes Holz
- OrthoCentrum Hamburg, Hansastrasse 1-3, 20149, Hamburg, Germany.
| | - Tim Spalding
- grid.412570.50000 0004 0400 5079Department Trauma and Orthopaedics, University Hospital Coventry, Clifford Bridge Road, Coventry, UK
| | - Tarek Boutefnouchet
- grid.412570.50000 0004 0400 5079Department Trauma and Orthopaedics, University Hospital Coventry, Clifford Bridge Road, Coventry, UK
| | - Pieter Emans
- grid.412966.e0000 0004 0480 1382Department of Orthopaedics, Maastricht UMC+, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
| | - Karl Eriksson
- grid.4714.60000 0004 1937 0626Department of Orthopaedics, Stockholm South Hospital, Karolinska Institutet, Sjukhusbacken 10, 118 83 Stockholm, Sweden
| | - Mats Brittberg
- grid.415546.7Cartilage Research Unit, University of Gothenburg, Region Halland Orthopaedics, Kungsbacka Hospital, 434 80 Kungsbacka, Sweden
| | - Lars Konradsen
- grid.411702.10000 0000 9350 8874Department of Orthopaedic Surgery, Bispebjerg Hospital, Bispebjerg Bakke 23, 2400 Bispebjerg, Denmark
| | - Clemens Kösters
- Clinic for Orthopaedics, Trauma and Hand Surgery, Maria-Josef-Hospital Greven, Lindenstr. 29, 48268 Greven, Germany
| | - Peter Verdonk
- Orthoca, AZ Monica Hospitals, Harmoniestraat 68, 2018 Antwerp, Belgium
| | - Magnus Högström
- grid.12650.300000 0001 1034 3451Sports Medicine Umeå AB and Orthopedics, Department of Surgical and Perioperative Sciences, Umeå University, 901 87 Umeå, Sweden
| | - Martin Lind
- grid.154185.c0000 0004 0512 597XDeptartment of Orthopedics, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, 8200 Århus, Denmark
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Ryd L, Flodström K, Manley MT. Patient-Specific Implants for Focal Cartilage Lesions in The Knee: Implant Survivorship Analysis up to Seven Years Post-Implantation. Surg Technol Int 2020; 38:379-386. [PMID: 33352614 DOI: 10.52198/21.sti.38.os1384] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
In the quest for increased surgical precision and improved joint kinematics, Computer-Assisted Orthopedic Surgery (CAOS) shows promising results for both total and partial joint replacement. In the knee, computer-assisted joint design can now be applied to the treatment of younger patients suffering pain and restriction of activity due to focal defects in their femoral articular cartilage. By taking MRI scans of the affected knee and digitally segmenting these scans, we can identify and map focal defects in cartilage and bone. Metallic implants matched to the defect can be fabricated, and guide instrumentation to ensure proper implant alignment and depth of recession in the surrounding cartilage can be designed from segmented MRI scans. Beginning in 2012, a series of 682 patient-specific implants were designed based on MRI analysis of femoral cartilage focal defects, and implanted in 612 knees. A Kaplan-Meier analysis found a cumulative survivorship of 96% at 7-year follow-up from the first implantation. Fourteen (2.3%) of these implants required revision due to disease progression, incorrect implant positioning, and inadequate lesion coverage at the time of surgery. These survivorship data compare favorably with all other modes of treatment for femoral focal cartilage lesions and support the use of patient-specific implants designed from segmented MRI scans in these cases.
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Affiliation(s)
- Leif Ryd
- Episurf Medicalm, Stockholm, Sweden
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Baba R, Onodera T, Matsuoka M, Hontani K, Joutoku Z, Matsubara S, Homan K, Iwasaki N. Bone Marrow Stimulation Technique Augmented by an Ultrapurified Alginate Gel Enhances Cartilage Repair in a Canine Model. Am J Sports Med 2018; 46:1970-1979. [PMID: 29763358 DOI: 10.1177/0363546518770436] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The optimal treatment for a medium- or large-sized cartilage lesion is still controversial. Since an ultrapurified alginate (UPAL) gel enhances cartilage repair in animal models, this material is expected to improve the efficacy of the current treatment strategies for cartilage lesions. HYPOTHESIS The bone marrow stimulation technique (BMST) augmented by UPAL gel can induce hyaline-like cartilage repair. STUDY DESIGN Controlled laboratory study. METHODS Two cylindrical osteochondral defects were created in the patellar groove of 27 beagle dogs. A total of 108 defects were divided into 3 groups: defects without intervention (control group), defects with the BMST (microfracture group), and defects with the BMST augmented by implantation of UPAL gel (combined group). At 27 weeks postoperatively, macroscopic and histological evaluations, micro-computed tomography assessment, and mechanical testing were performed for each reparative tissue. RESULTS The defects in the combined group were almost fully covered with translucent reparative tissues, which consisted of hyaline-like cartilage with well-organized collagen structures. The macroscopic score was significantly better in the combined group than in the control group ( P < .05). The histological scores in the combined group were significantly better than those in the control group ( P < .01) and microfracture group ( P < .05). Although the repaired subchondral bone volumes were not influenced by UPAL gel augmentation, the mechanical properties of the combined group were significantly better than those of the microfracture group ( P < .05). CONCLUSION The BMST augmented by UPAL gel elicited hyaline-like cartilage repair that had characteristics of rich glycosaminoglycan and matrix immunostained by type II collagen antibody in a canine osteochondral defect model. The present results suggest that the current technique has the potential to be one of the autologous matrix-induced chondrogenesis techniques of the future and to expand the operative indications for the BMST without loss of its technical simplicity. CLINICAL RELEVANCE The data support the clinical reality of 1-step minimally invasive cartilage-reparative medicine with UPAL gel without harvesting donor cells.
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Affiliation(s)
- Rikiya Baba
- Department of Orthopaedic Surgery, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Tomohiro Onodera
- Department of Orthopaedic Surgery, Graduate School of Medicine, Hokkaido University, Sapporo, Japan.,Global Institution for Collaborative Research and Education (GI-CoRE), Frontier Research Center for Advanced Material and Life Science, Hokkaido University, Sapporo, Japan
| | - Masatake Matsuoka
- Department of Orthopaedic Surgery, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Kazutoshi Hontani
- Department of Orthopaedic Surgery, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Zenta Joutoku
- Department of Orthopaedic Surgery, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Shinji Matsubara
- Department of Orthopaedic Surgery, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Kentaro Homan
- Department of Orthopaedic Surgery, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Norimasa Iwasaki
- Department of Orthopaedic Surgery, Graduate School of Medicine, Hokkaido University, Sapporo, Japan.,Global Institution for Collaborative Research and Education (GI-CoRE), Frontier Research Center for Advanced Material and Life Science, Hokkaido University, Sapporo, Japan
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Lin Y, Li T, Xiong Y, Li J, Fu W. [Research progress of rehabilitation after autologous chondrocyte implantation on knee]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2018; 32:758-763. [PMID: 29905057 PMCID: PMC8414014 DOI: 10.7507/1002-1892.201801034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 04/30/2018] [Indexed: 02/05/2023]
Abstract
Objective To summarize the research progress of rehabilitation after autologous chondrocyte implantation (ACI). Methods The literature related to basic science and clinical practice about rehabilitation after ACI in recent years was searched, selected, and analyzed. Results Based on the included literature, the progress of the graft maturation consists of proliferation phase (0-6 weeks), transition phase (6-12 weeks), remodeling phase (12-26 weeks), and maturation phase (26 weeks-2 years). To achieve early protection, stimulate the maturation, and promote the graft-bone integrity, rehabilitation protocol ought to be based on the biomechanical properties at different phases. Weight-bearing program, range of motion (ROM), and options or facilities of exercise are importance when considering a rehabilitation program. Conclusion It has been proved that the patients need a program with an increasingly progressive weight-bearing and ROM in principles of rehabilitation after ACI. Specific facilities can be taken at a certain phase. Evidences extracted in the present work are rather low and the high-quality and controlled trials still need to improve the rehabilitation protocol.
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Affiliation(s)
- Yipeng Lin
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Tao Li
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Yan Xiong
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Jian Li
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Weili Fu
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041,
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Mistry H, Connock M, Pink J, Shyangdan D, Clar C, Royle P, Court R, Biant LC, Metcalfe A, Waugh N. Autologous chondrocyte implantation in the knee: systematic review and economic evaluation. Health Technol Assess 2018; 21:1-294. [PMID: 28244303 DOI: 10.3310/hta21060] [Citation(s) in RCA: 138] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The surfaces of the bones in the knee are covered with articular cartilage, a rubber-like substance that is very smooth, allowing frictionless movement in the joint and acting as a shock absorber. The cells that form the cartilage are called chondrocytes. Natural cartilage is called hyaline cartilage. Articular cartilage has very little capacity for self-repair, so damage may be permanent. Various methods have been used to try to repair cartilage. Autologous chondrocyte implantation (ACI) involves laboratory culture of cartilage-producing cells from the knee and then implanting them into the chondral defect. OBJECTIVE To assess the clinical effectiveness and cost-effectiveness of ACI in chondral defects in the knee, compared with microfracture (MF). DATA SOURCES A broad search was done in MEDLINE, EMBASE, The Cochrane Library, NHS Economic Evaluation Database and Web of Science, for studies published since the last Health Technology Assessment review. REVIEW METHODS Systematic review of recent reviews, trials, long-term observational studies and economic evaluations of the use of ACI and MF for repairing symptomatic articular cartilage defects of the knee. A new economic model was constructed. Submissions from two manufacturers and the ACTIVE (Autologous Chondrocyte Transplantation/Implantation Versus Existing Treatment) trial group were reviewed. Survival analysis was based on long-term observational studies. RESULTS Four randomised controlled trials (RCTs) published since the last appraisal provided evidence on the efficacy of ACI. The SUMMIT (Superiority of Matrix-induced autologous chondrocyte implant versus Microfracture for Treatment of symptomatic articular cartilage defects) trial compared matrix-applied chondrocyte implantation (MACI®) against MF. The TIG/ACT/01/2000 (TIG/ACT) trial compared ACI with characterised chondrocytes against MF. The ACTIVE trial compared several forms of ACI against standard treatments, mainly MF. In the SUMMIT trial, improvements in knee injury and osteoarthritis outcome scores (KOOSs), and the proportion of responders, were greater in the MACI group than in the MF group. In the TIG/ACT trial there was improvement in the KOOS at 60 months, but no difference between ACI and MF overall. Patients with onset of symptoms < 3 years' duration did better with ACI. Results from ACTIVE have not yet been published. Survival analysis suggests that long-term results are better with ACI than with MF. Economic modelling suggested that ACI was cost-effective compared with MF across a range of scenarios. LIMITATIONS The main limitation is the lack of RCT data beyond 5 years of follow-up. A second is that the techniques of ACI are evolving, so long-term data come from trials using forms of ACI that are now superseded. In the modelling, we therefore assumed that durability of cartilage repair as seen in studies of older forms of ACI could be applied in modelling of newer forms. A third is that the high list prices of chondrocytes are reduced by confidential discounting. The main research needs are for longer-term follow-up and for trials of the next generation of ACI. CONCLUSIONS The evidence base for ACI has improved since the last appraisal by the National Institute for Health and Care Excellence. In most analyses, the incremental cost-effectiveness ratios for ACI compared with MF appear to be within a range usually considered acceptable. Research is needed into long-term results of new forms of ACI. STUDY REGISTRATION This study is registered as PROSPERO CRD42014013083. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Hema Mistry
- Warwick Evidence, Division of Health Sciences, University of Warwick, Coventry, UK
| | - Martin Connock
- Warwick Evidence, Division of Health Sciences, University of Warwick, Coventry, UK
| | - Joshua Pink
- Warwick Evidence, Division of Health Sciences, University of Warwick, Coventry, UK
| | - Deepson Shyangdan
- Warwick Evidence, Division of Health Sciences, University of Warwick, Coventry, UK
| | - Christine Clar
- Warwick Evidence, Division of Health Sciences, University of Warwick, Coventry, UK
| | - Pamela Royle
- Warwick Evidence, Division of Health Sciences, University of Warwick, Coventry, UK
| | - Rachel Court
- Warwick Evidence, Division of Health Sciences, University of Warwick, Coventry, UK
| | - Leela C Biant
- Department of Trauma and Orthopaedic Surgery, University of Manchester, Manchester, UK
| | - Andrew Metcalfe
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Norman Waugh
- Warwick Evidence, Division of Health Sciences, University of Warwick, Coventry, UK
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Clinical Outcomes After Autologous Chondrocyte Implantation in Adolescents' Knees: A Systematic Review. Arthroscopy 2016; 32:1905-16. [PMID: 27161508 DOI: 10.1016/j.arthro.2016.03.007] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Revised: 03/02/2016] [Accepted: 03/04/2016] [Indexed: 02/07/2023]
Abstract
PURPOSE To perform a systematic review of the use of autologous chondrocyte implantation (ACI) in the adolescent knee. SPECIFIC AIMS (1) quantify clinical outcomes of ACI in adolescent knees, (2) identify lesion and patient factors that correlate with clinical outcome, and (3) determine the incidence of complications of ACI in adolescents. METHODS PubMed, MEDLINE, SCOPUS, CINAHL, and Cochrane Collaboration Library databases were searched systematically. Outcome scores recorded included the International Knee Documentation Committee score, the International Cartilage Repair Society score, the Knee Injury and Osteoarthritis Outcome Score, the visual analog scale, the Bentley Functional Rating Score, the Modified Cincinnati Rating System, Tegner activity Lysholm scores, and return athletics. Outcome scores were compared among studies based on proportion of adolescents achieving specific outcome quartiles at a minimum 1-year follow-up. Methodologic quality of studies was evaluated by Coleman Methodology Scores (CMSs). RESULTS Five studies reported on 115 subjects who underwent ACI with periosteal cover (ACI-P; 95, 83%), ACI with type I/type III collagen cover (ACI-C; 6, 5%), or matrix-induced ACI (MACI; 14, 12%). Mean patient age was 16.2 years (range, 11 to 21 years). All studies were case series. Follow-up ranged from 12 to 74 months (mean, 52.3 months). Mean defect size was 5.3 cm(2) (range, 0.96 to 14 cm(2)). All studies reported improvement in clinical outcomes scores. Graft hypertrophy was the most common complication (7.0%). The mean preoperative clinical outcome percentage (based on percentage of outcome scale used) was 37% (standard deviation [SD], 18.9%) and the mean postoperative clinical outcome percentage was 72.7% (SD, 16.9%). The overall percentage increase in clinical outcome scores was 35.7% (SD, 14.2%). Mean CMS was 47.8 (SD, 8.3). CONCLUSIONS Cartilage repair in adolescent knees using ACI provides success across different clinical outcomes measures. The only patient- or lesion-specific factor that influenced clinical outcome was the shorter duration of preoperative symptoms. LEVEL OF EVIDENCE Level IV, systemic review of Level I-IV studies.
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Abstract
One of the most important issues facing cartilage tissue engineering is the inability to move technologies into the clinic. Despite the multitude of current research in the field, it is known that 90% of new drugs that advance past animal studies fail clinical trials. The objective of this review is to provide readers with an understanding of the scientific details of tissue engineered cartilage products that have demonstrated a certain level of efficacy in humans, so that newer technologies may be developed upon this foundation. Compared to existing treatments, such as microfracture or autologous chondrocyte implantation, a tissue engineered product can potentially provide more consistent clinical results in forming hyaline repair tissue and in filling the entirety of the defect. The various tissue engineering strategies (e.g., cell expansion, scaffold material, media formulations, biomimetic stimuli, etc.) used in forming these products, as collected from published literature, company websites, and relevant patents, are critically discussed. The authors note that many details about these products remain proprietary, not all information is made public, and that advancements to the products are continuously made. Nevertheless, by understanding the design and production processes of these emerging technologies, one can gain tremendous insight into how to best use them and also how to design the next generation of tissue engineered cartilage products.
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Zhang C, Cai YZ, Lin XJ. Autologous chondrocyte implantation: Is it likely to become a saviour of large-sized and full-thickness cartilage defect in young adult knee? Knee Surg Sports Traumatol Arthrosc 2016; 24:1643-50. [PMID: 25986097 DOI: 10.1007/s00167-015-3643-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Accepted: 05/05/2015] [Indexed: 01/19/2023]
Abstract
PURPOSE A literature review of the first-, second- and third-generation autologous chondrocyte implantation (ACI) technique for the treatment of large-sized (>4 cm(2)) and full-thickness knee cartilage defects in young adults was conducted, examining the current literature on features, clinical scores, complications, magnetic resonance image (MRI) and histological outcomes, rehabilitation and cost-effectiveness. METHODS A literature review was carried out in the main medical databases to evaluate the several studies concerning ACI treatment of large-sized and full-thickness knee cartilage defects in young adults. RESULTS ACI technique has been shown to relieve symptoms and improve functional assessment in large-sized (>4 cm(2)) and full-thickness knee articular cartilage defect of young adults in short- and medium-term follow-up. Besides, low level of evidence demonstrated its efficiency and durability at long-term follow-up after implantation. Furthermore, MRI and histological evaluations provided the evidence that graft can return back to the previous nearly normal cartilage via ACI techniques. Clinical outcomes tend to be similar in different ACI techniques, but with simplified procedure, low complication rate and better graft quality in the third-generation ACI technique. CONCLUSION ACI based on the experience of cell-based therapy, with the high potential to regenerate hyaline-like tissue, represents clinical development in treatment of large-sized and full-thickness knee cartilage defects. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Chi Zhang
- Department of Orthopedics, The First Affiliated Hospital, College of Medicine Zhejiang University, 79 Qingchun Road, Hangzhou, 310008, China.,Center for Sport Medicine, The First Affiliated Hospital, College of Medicine Zhejiang University, Hangzhou, China
| | - You-Zhi Cai
- Department of Orthopedics, The First Affiliated Hospital, College of Medicine Zhejiang University, 79 Qingchun Road, Hangzhou, 310008, China.,Center for Sport Medicine, The First Affiliated Hospital, College of Medicine Zhejiang University, Hangzhou, China
| | - Xiang-Jin Lin
- Department of Orthopedics, The First Affiliated Hospital, College of Medicine Zhejiang University, 79 Qingchun Road, Hangzhou, 310008, China. .,Center for Sport Medicine, The First Affiliated Hospital, College of Medicine Zhejiang University, Hangzhou, China.
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Huang BJ, Hu JC, Athanasiou KA. Cell-based tissue engineering strategies used in the clinical repair of articular cartilage. Biomaterials 2016; 98:1-22. [PMID: 27177218 DOI: 10.1016/j.biomaterials.2016.04.018] [Citation(s) in RCA: 260] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 04/15/2016] [Accepted: 04/20/2016] [Indexed: 12/12/2022]
Abstract
One of the most important issues facing cartilage tissue engineering is the inability to move technologies into the clinic. Despite the multitude of current research in the field, it is known that 90% of new drugs that advance past animal studies fail clinical trials. The objective of this review is to provide readers with an understanding of the scientific details of tissue engineered cartilage products that have demonstrated a certain level of efficacy in humans, so that newer technologies may be developed upon this foundation. Compared to existing treatments, such as microfracture or autologous chondrocyte implantation, a tissue engineered product can potentially provide more consistent clinical results in forming hyaline repair tissue and in filling the entirety of the defect. The various tissue engineering strategies (e.g., cell expansion, scaffold material, media formulations, biomimetic stimuli, etc.) used in forming these products, as collected from published literature, company websites, and relevant patents, are critically discussed. The authors note that many details about these products remain proprietary, not all information is made public, and that advancements to the products are continuously made. Nevertheless, by understanding the design and production processes of these emerging technologies, one can gain tremendous insight into how to best use them and also how to design the next generation of tissue engineered cartilage products.
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Affiliation(s)
- Brian J Huang
- Department of Biomedical Engineering, University of California Davis, USA.
| | - Jerry C Hu
- Department of Biomedical Engineering, University of California Davis, USA.
| | - Kyriacos A Athanasiou
- Department of Biomedical Engineering, University of California Davis, USA; Department of Orthopedic Surgery, University of California Davis, USA.
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Revision surgery after third generation autologous chondrocyte implantation in the knee. INTERNATIONAL ORTHOPAEDICS 2015; 39:1615-22. [PMID: 25947902 DOI: 10.1007/s00264-015-2792-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Accepted: 04/04/2015] [Indexed: 01/30/2023]
Abstract
PURPOSE Third generation autologous chondrocyte implantation (ACI) is an established treatment for full thickness cartilage defects in the knee joint. However, little is known about cases when revision surgery is needed. The aim of the present study is to investigate the complication rates and the main reasons for revision surgery after third generation autologous chondrocyte implantation in the knee joint. It is of particular interest to examine in which cases revision surgery is needed and in which cases a "wait and see" strategy should be used. METHODS A total of 143 consecutive patients with 171 cartilage defects were included in this study with a minimum follow-up of two years. All defects were treated with third generation ACI (NOVACART®3D). Clinical evaluation was carried out after six months, followed by an annual evaluation using the International Knee Documentation Committee (IKDC) subjective score and the visual analogue scale (VAS) for rest and during activity. Revision surgery was documented. RESULTS The revision rate was 23.4 % (n = 36). The following major reasons for revision surgery were found in our study: symptomatic bone marrow edema (8.3 %, n = 3), arthrofibrosis (22.2 %, n = 8) and partial graft cartilage deficiency (47.2 %, n = 17). The following revision surgery was performed: retrograde drilling combined with Iloprost infusion therapy for bone marrow oedema (8.4 %, n = 3), arthroscopic arthrolysis of the suprapatellar recess (22.2 %, n = 8) and microfracturing/antegrade drilling (47.3 %, n = 17). Significant improvements of clinical scores after revision surgery were observed. CONCLUSION Revision surgery after third generation autologous chondrocyte implantation is common and is needed primarily in cases with arthrofibrosis, partial graft cartilage deficiency and symptomatic bone marrow oedema resulting in a significantly better clinical outcome.
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Niethammer TR, Valentin S, Gülecyüz MF, Roßbach BP, Ficklscherer A, Pietschmann MF, Müller PE. Bone Marrow Edema in the Knee and Its Influence on Clinical Outcome After Matrix-Based Autologous Chondrocyte Implantation: Results After 3-Year Follow-up. Am J Sports Med 2015; 43:1172-9. [PMID: 25784628 DOI: 10.1177/0363546515573935] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Third-generation autologous chondrocyte implantation (ACI) is an established method for treatment of full-thickness cartilage defects in the knee joint. Subchondral bone marrow edema (BME) is frequently observed after ACI, with unknown pathogenesis and clinical relevance. PURPOSE To investigate the occurrence and clinical relevance of BME after third-generation ACI in the knee joint during the postoperative course of 36 months. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS A total of 38 circumscribed full-thickness cartilage defects in 30 patients were included in this study. All defects were treated with third-generation ACI (Novocart 3D). A standardized MRI examination was carried out after 1.5, 3, 6, 12, 24, and 36 months. Bone marrow edema was observed in 78.9% of defects over the postoperative course, with initial occurrence in the first 12 months. The size of the BMEs were determined according to their maximum diameter and were classified as small (<1 cm), medium (<2 cm), large (<4 cm), and very large (diffuse; >4 cm). Clinical outcomes in patients were analyzed by use of the International Knee Documentation Committee (IKDC) scoring system and a visual analog scale for pain. RESULTS There were 5.3% (n=2) small, 28.9% (n=11) medium, 34.2% (n=13) large, and 10.5% (n=4) very large BMEs. In a subgroup analysis, cartilage defects of the medial femoral condyle showed significantly higher frequency of BME than did patellar defects. Clinical scores showed significant improvements throughout the entire study course (P<.05). Clinical patient outcome did not correlate with presence of BME at any time period (P>.05). CONCLUSION Midterm clinical results of the matrix-based third-generation ACI showed a substantial amount of BME over a 36-month follow-up, but this did not correlate with worse clinical outcome. Patients with femoral cartilage defects were more often affected than were those with patellar cartilage defects.
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Affiliation(s)
- Thomas R Niethammer
- Department of Orthopaedic Surgery, Physical Medicine and Rehabilitation, University Hospital of Munich, Munich, Germany
| | - Siegfried Valentin
- Department of Orthopaedic Surgery, Physical Medicine and Rehabilitation, University Hospital of Munich, Munich, Germany
| | - Mehmet F Gülecyüz
- Department of Orthopaedic Surgery, Physical Medicine and Rehabilitation, University Hospital of Munich, Munich, Germany
| | - Björn P Roßbach
- Department of Orthopaedic Surgery, Physical Medicine and Rehabilitation, University Hospital of Munich, Munich, Germany
| | - Andreas Ficklscherer
- Department of Orthopaedic Surgery, Physical Medicine and Rehabilitation, University Hospital of Munich, Munich, Germany
| | - Matthias F Pietschmann
- Department of Orthopaedic Surgery, Physical Medicine and Rehabilitation, University Hospital of Munich, Munich, Germany
| | - Peter E Müller
- Department of Orthopaedic Surgery, Physical Medicine and Rehabilitation, University Hospital of Munich, Munich, Germany
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Niethammer TR, Safi E, Ficklscherer A, Horng A, Feist M, Feist-Pagenstert I, Jansson V, Pietschmann MF, Müller PE. Graft maturation of autologous chondrocyte implantation: magnetic resonance investigation with T2 mapping. Am J Sports Med 2014; 42:2199-204. [PMID: 24993867 DOI: 10.1177/0363546514538756] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Autologous chondrocyte implantation (ACI) using tissue-engineered cartilage is a successful therapy for full-thickness cartilage lesions in the knee joint. However, in vivo graft maturation is still unclear. PURPOSE The aim of this prospective study was to analyze graft maturation after ACI in the knee using objective T2 mapping in correlation with the clinical outcomes within a 3-year postoperative course. STUDY DESIGN Case series; Level of evidence, 4. METHODS A total of 13 patients with isolated cartilage defects of the knee were treated with Novocart 3D, a matrix-based ACI procedure in the knee joint. The patients had complete data from International Knee Documentation Committee (IKDC) scores and MRI examinations for 6 to 36 months postoperatively. All cartilage defects were arthroscopically classified as Outerbridge grades III and IV. The mean area of the cartilage defect was 5.6 cm(2). Postoperative clinical and MRI examinations were conducted at 6, 12, 24, and 36 months after surgery. The modified magnetic resonance observation of cartilage repair tissue (MOCART) score was used to evaluate the quality and integration of the Novocart 3D implants on MRI. The T2 relaxation time values of the ACI graft and healthy native cartilage areas were determined to assess graft maturation using T2 mapping. RESULTS The T2 relaxation times of the ACI graft showed significant improvement, with decreasing values from 41.6 milliseconds at 6-month follow-up to 32.4 and 30.9 milliseconds after 24 and 36 months, respectively. These values were similar to the T2 relaxation times of the native surrounding cartilage. There was no correlation between the clinical outcomes (IKDC score) and T2 relaxation time values. CONCLUSION The T2 relaxation time in the repaired tissue showed similar values compared with normal hyaline cartilage. Graft maturation after ACI in the knee joint needs at least 1 year, with ongoing adjustment of the T2 relaxation time values compared with native surrounding cartilage. A correlation between increasing ACI graft maturation and clinical outcomes (IKDC score) could not be found with the data available.
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Affiliation(s)
- Thomas R Niethammer
- Department of Orthopaedic Surgery, Physical Medicine and Rehabilitation, University Hospital of Munich, Grosshadern Campus, Munich, Germany
| | - Elem Safi
- Department of Orthopaedic Surgery, Physical Medicine and Rehabilitation, University Hospital of Munich, Grosshadern Campus, Munich, Germany
| | - Andreas Ficklscherer
- Department of Orthopaedic Surgery, Physical Medicine and Rehabilitation, University Hospital of Munich, Grosshadern Campus, Munich, Germany
| | - Annie Horng
- Institute of Clinical Radiology, Ludwig Maximilians University Munich, Campus Grosshadern, Munich, Germany
| | - Markus Feist
- Department of Orthopaedic Surgery, Physical Medicine and Rehabilitation, University Hospital of Munich, Grosshadern Campus, Munich, Germany
| | - Isa Feist-Pagenstert
- Department of Orthopaedic Surgery, Physical Medicine and Rehabilitation, University Hospital of Munich, Grosshadern Campus, Munich, Germany
| | - Volkmar Jansson
- Department of Orthopaedic Surgery, Physical Medicine and Rehabilitation, University Hospital of Munich, Grosshadern Campus, Munich, Germany
| | - Matthias F Pietschmann
- Department of Orthopaedic Surgery, Physical Medicine and Rehabilitation, University Hospital of Munich, Grosshadern Campus, Munich, Germany
| | - Peter E Müller
- Department of Orthopaedic Surgery, Physical Medicine and Rehabilitation, University Hospital of Munich, Grosshadern Campus, Munich, Germany
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Patient-oriented and performance-based outcomes after knee autologous chondrocyte implantation: a timeline for the first year of recovery. J Sport Rehabil 2014; 23:223-34. [PMID: 24589660 DOI: 10.1123/jsr.2013-0094] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
CONTEXT It is well established that autologous chondrocyte implantation (ACI) can require extended recovery postoperatively; however, little information exists to provide clinicians and patients with a timeline for anticipated function during the first year after ACI. OBJECTIVE To document the recovery of functional performance of activities of daily living after ACI. PATIENTS ACI patients (n = 48, 29 male; 35.1 ± 8.0 y). INTERVENTION All patients completed functional tests (weight-bearing squat, walk-across, sit-to-stand, step-up/over, and forward lunge) using the NeuroCom long force plate (Clackamas, OR) and completed patient-reported outcome measures (International Knee Documentation Committee Subjective Knee Evaluation Form, Lysholm, Western Ontario and McMaster Osteoarthritis Index [WOMAC], and 36-Item Short-Form Health Survey) preoperatively and 3, 6, and 12 mo postoperatively. MAIN OUTCOME MEASURES A covariance pattern model was used to compare performance and self-reported outcome across time and provide a timeline for functional recovery after ACI. RESULTS Participants demonstrated significant improvement in walk-across stride length from baseline (42.0% ± 8.9% height) at 6 (46.8% ± 8.1%) and 12 mo (46.6% ± 7.6%). Weight bearing on the involved limb during squatting at 30°, 60°, and 90° was significantly less at 3 mo than presurgery. Step-up/over time was significantly slower at 3 mo (1.67 ± 0.69 s) than at baseline (1.49 ± 0.33 s), 6 mo (1.51 ± 0.36 s), and 12 mo (1.40 ± 0.26 s). Step-up/over lift-up index was increased from baseline (41.0% ± 11.3% body weight [BW]) at 3 (45.0% ± 11.7% BW), 6 (47.0% ± 11.3% BW), and 12 mo (47.3% ± 11.6% BW). Forward-lunge time was decreased at 3 mo (1.51 ± 0.44 s) compared with baseline (1.39 ± 0.43 s), 6 mo (1.32 ± 0.05 s), and 12 mo (1.27 ± 0.06). Similarly, forward-lunge impact force was decreased at 3 mo (22.2% ± 1.4% BW) compared with baseline (25.4% ± 1.5% BW). The WOMAC demonstrated significant improvements at 3 mo. All patient-reported outcomes were improved from baseline at 6 and 12 mo postsurgery. CONCLUSIONS Patients' perceptions of improvements may outpace physical changes in function. Decreased function for at least the first 3 mo after ACI should be anticipated, and improvement in performance of tasks requiring weight-bearing knee flexion, such as squatting, going down stairs, or lunging, may not occur for a year or more after surgery.
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