Treatment of glenoid chondral defect using micronized allogeneic cartilage matrix implantation

Favorable short-term outcomes of micronized allogenic cartilage scaffold for glenoid cartilage defects associated with posterior glenohumeral instability

Purpose

To determine clinical outcomes associated with micronized allogenic cartilage scaffold use for treatment of posterior glenoid cartilage defects at 2 years.

Study Design

Case series.

Methods

A retrospective analysis of prospectively collected data was performed on a consecutive series of patients who underwent arthroscopic treatment of a symptomatic posterior glenoid cartilage defect with micronized allogenic cartilage scaffold between January 2019 and December 2020. The primary outcome was subjective shoulder value (SSV) at latest follow-up. Secondary outcomes included visual analog scale (VAS), recurrence of instability, and range of motion (ROM).

Results

Seven patients, including 4 in the setting of primary posterior instability and 3 in the setting of recurrent symptoms after arthroscopic posterior glenohumeral stabilization, were included in the analysis with a mean follow up of 2.6 years (range, 2-3.7 years). Statistically significant improvements were seen in SSV (median = 40, interquartile range [IQR] = 40-50 before surgery; vs median = 85, IQR = 67.5-87.5 after surgery; P = .018) and VAS (median = 4, IQR = 4-6.3 before surgery; vs median = 1, IQR = 0-1.5 after surgery; P = .010). No significant differences were seen in ROM. There were no cases of recurrent instability or reoperation.

Conclusions

The use of micronized allogenic cartilage scaffold for glenoid cartilage defects is associated with clinical improvement at 2-year follow-up. This is the case when performed in conjunction with index posterior labral repair when there is a concomitant glenoid cartilage defect or when performed in the setting of persistent pain and mechanical symptoms after prior posterior labral repair.

Level of Evidence

Level IV, therapeutic case series.

Cartilage Tissue Engineering in Practice: Preclinical Trials, Clinical Applications, and Prospects

Articular cartilage defects significantly compromise the quality of life in the global population. Although many strategies are needed to repair articular cartilage, including microfracture, autologous osteochondral transplantation, and osteochondral allograft, the therapeutic effects remain suboptimal. In recent years, with the development of cartilage tissue engineering, scientists have continuously improved the formulations of therapeutic cells, biomaterial-based scaffolds, and biological factors, which have opened new avenues for better therapeutics of cartilage lesions. This review focuses on advances in cartilage tissue engineering, particularly in preclinical trials and clinical applications, prospects, and challenges.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

IV.

Arthroscopic Management Strategies for Glenohumeral Articular Cartilage Lesions and Defects

Glenoid articular cartilage lesions are a source of shoulder pain and can occur in the setting of glenohumeral instability and degenerative shoulder disease. Glenolabral articular disruption lesions have been reported to be associated with worse outcomes after arthroscopic repair of labral tears. There are relatively few published studies evaluating outcomes after surgical treatment of glenoid articular lesions; however, it is generally accepted that management should consist of restoring the glenoid articular surface, minimizing exposed articular defect, and re-establishing capsulolabral integrity to achieve stability. We present arthroscopic strategies to manage these glenoid articular defects through debridement, abrasion, microfracture, capsulolabral advancement and labral interposition.

Biological Mechanisms for Cartilage Repair Using a BioCartilage Scaffold: Cellular Adhesion/Migration and Bioactive Proteins

Objective. BioCartilage is a desiccated, particulated cartilage allograft used for repair of focal cartilage defects. It is mixed with a biologic such as bone marrow concentrate (BMC), pressed into a contained defect, and sealed with fibrin glue. The objective of this study was to assess if BioCartilage could serve as a bioactive scaffold by affecting cellular adhesion, cellular migration, or the release interleukin-1 receptor antagonist protein (IL-1RA), and to identify its full proteomic makeup. Design. Cartilage explants were used to model confined defects. BioCartilage was mixed with BMC, grafted into defects, and sealed with 1 of 5 fibrin glues. Constructs were cultured for 24 or 48 hours and then processed for live/dead microscopy. Chondrocyte and mesenchymal stem cell (MSC) adhesion on BioCartilage was assessed using scanning electron microscopy. Conditioned medium from cultures and the biologics used in the study were assayed for IL-1RA. The protein footprint of BioCartilage was determined using bottom-up proteomics. Results. BioCartilage supported chondrocyte and MSC attachment within 24 hours, and cell viability was retained in all constructs at 24 and 48 hours. Fibrin glue did not inhibit cell attachment. BMC had the highest concentration of IL-1RA. Proteomics yielded 254 proteins, including collagens, proteoglycans, and several bioactive proteins with known anabolic roles including cartilage oligomeric matrix protein. Conclusions. This study suggests that BioCartilage has the chemical composition and architecture to support cell adherence and migration and to provide bioactive proteins, which together should have biologics advantages in cartilage repair beyond its role as a scaffold.

The GLAD Lesion: are the definition, diagnosis and treatment up to date? A Systematic Review

INTRODUCTION

Although GLAD lesions are quite common, only sporadic case reports describe surgical techniques and clinical outcomes. Even if cartilage defects can result from various pathogenic mechanisms, the resulting defect has some similarities with GLAD, and its management can be a starting point to treat both types of lesion. Aim of the present study is to find a commonly accepted definition for GLAD lesions in order to understand its pathogenesis, diagnosis and possible treatments.

METHODS

A search of PubMed (MEDLINE) database has been performed in June 2020 to identify relevant articles including a combination of the following search terms: "GlenoLabral Articular Disruption" OR "GLAD" AND "shoulder" AND "cartilage, articular".

RESULTS

Abstract evaluation included 31 articles in the full-text review. Various studies showed that the performance of MR arthrography in the detection of glenohumeral cartilage lesions, including GLAD lesions, was moderate. Different therapeutic solutions have been described. Arthroscopic debridement of the lesion and reattachment of the labrum have been often used. In case of large articular defects, the labrum could be advanced in the cartilage defect to cover it. In case of cartilage flap with reparable margins, this could be reattached with different suture constructs. Neglected GLAD lesions following a chronic trauma or shoulder instability have not been described in literature.

CONCLUSIONS

The definition of GLAD injury has changed over the time. Many authors associate this lesion with shoulder instability, with trauma in abduction and extra rotation, while Neviaser's original definition described stable shoulders following a trauma in adduction.

Matrix-Induced Autologous Chondrycte Implantation for a Glenoid Chondral Defect: A Case Report

CASE

We describe the case of a 33-year-old man who had a 1.5 × 2 cm chondral defect of the right glenoid that that was discovered on arthroscopy and was successfully treated with matrix-induced autologous chondrocyte implantation (MACI). At 2 years postoperatively, the patient's Constant score and American Shoulder and Elbow Surgeons (ASES) shoulder score improved by 44 and 51.6 points, respectively.

CONCLUSION

Chondral lesions of the glenoid are rare and are a challenge to manage. This case represents a successful outcome with MACI, thus providing surgeons with an option for treating these difficult problems.

Effects of Micronized Cartilage Matrix on Cartilage Repair in Osteochondral Lesions of the Talus

BACKGROUND

The repair of osteochondral lesions remains a challenge due to its poor vascularity and limited healing potential. Micronized cartilage matrix (MCM) is dehydrated, decellularized, micronized allogeneic cartilage matrix that contains the components of native articular tissue and is hypothesized to serve as a scaffold for the formation of hyaline-like tissue. Our objective was to demonstrate in vitro that the use of MCM combined with mesenchymal stem cells (MSCs) can lead to the formation of hyaline-like cartilage tissue in a single-stage treatment model.

DESIGN

In group 1 (no wash), 250 µL MCM was reconstituted in 150 µL Dulbecco's phosphate-buffered saline (DPBS) for 5 minutes. Group 2 (saline wash) included 250 µL MCM washed in 20 mL DPBS for 30 minutes, then aspirated to remove all DPBS and reconstituted in 150 µL DPBS. Group 3 (serum wash): 250µL MCM washed in 20 mL DPBS for 30 minutes, then aspirated and reconstituted in 150 µL fetal bovine serum. Each group was then added to 50 µL solution of MSC suspended in DPBS at a concentration of 1.2 × 10⁶ cells/350 µL. After 3 weeks, the defects were extracted and sectioned to perform viability and histologic analyses.

RESULTS

Stem cells without rehydration of the MCM showed almost no viability whereas near complete cell viability was seen after rehydration with serum or saline solution, ultimately leading to chondrogenic differentiation and adhesion to the MCM particles.

CONCLUSION

We have shown in this proof-of-concept in vitro study that MCM can serve as a scaffold for the growth of cartilage tissue for the treatment of osteochondral lesions.

Treatment of Articular Cartilage Injuries in the Glenohumeral Joint

Articular cartilage injuries in the glenohumeral joint present a unique and difficult problem for the patient and surgeon alike. Various etiologies exist for the development of these cartilage lesions; therefore, treatment options are vast and must be chosen thoughtfully, especially in the young, active patient. Across all treatment modalities, the goal is for the patient to regain lasting function and mobility while decreasing pain.

Effectiveness of Biologic Factors in Shoulder Disorders

Background:

Shoulder pathology can cause significant pain, discomfort, and loss of function that all interfere with activities of daily living and may lead to poor quality of life. Primary osteoarthritis and rotator cuff diseases with its sequalae are the main culprits. Management of shoulder disorders using biological factors gained an increasing interest over the last years. This interest reveals the need of effective treatments for shoulder degenerative disorders, and highlights the importance of a comprehensive and detailed understanding of the rapidly increasing knowledge in the field.

Methods:

This study will describe most of the available biology-based strategies that have been recently developed, focusing on their effectiveness in animal and clinical studies.

Results:

Data from in vitro work will also be briefly presented; in order to further elucidate newly acquired knowledge regarding mechanisms of tissue degeneration and repair that would probably drive translational work in the next decade. The role of platelet rich-plasma, growth factors, stem cells and other alternative treatments will be described in an evidence-based approach, in an attempt to provide guidelines for their clinical application. Finally, certain challenges that biologic treatments face today will be described as an initiative for future strategies.

Conclusion:

The application of different growth factors and mesenchymal stem cells appears as promising approaches for enhancing biologic repair. However, data from clinical studies are still limited, and future studies need to improve understanding of the repair process in cellular and molecular level and evaluate the effectiveness of biologic factors in the management of shoulder disorders.

Osteochondral Autograft Transfer Technique for Glenoid Osteochondral Defect

Glenoid osteochondral defects can be a significant source of pain and disability in an active population. Many treatments are available, but most joint-preserving procedures are limited to debridement, abrasion chondroplasty, or marrow-stimulation techniques, all of which depend on healthy underlying bone and none of which address underlying bony pathology. Osteochondral autograft transfer has been a successful form of treatment for lesions in the knee, elbow, and ankle, especially when subchondral bone is involved. We describe an arthroscopic method of treating glenoid osteochondral lesions with an osteochondral autograft transfer using a graft from the patient's ipsilateral knee. This technique addresses both cartilage and osseous pathology with minimal morbidity and provides a good biological restorative option for patients with isolated glenoid osteochondral defects.

Cartilage lesions of the patella: management after acute patellar dislocation

Articular cartilage injuries to the patella are frequent after patellar dislocation. The management of these acute cartilage injuries in the acute setting can be challenging. It is well documented that acute fixation is the optimal choice for treatment of osteochondral injuries. This article discusses the challenges and potential treatment options for acute chondral/osteochondral injuries to the patella after acute patellar dislocation.