The Use of All-Arthroscopic Autologous Matrix-Induced Chondrogenesis for the Management of Humeral and Glenoid Chondral Defects in the Shoulder

Assessment of Safe Cartilage Harvesting Quantity in the Shoulder: A Cadaveric Study

Purpose

To evaluate the volume and yield of morselized cartilage that can be harvested from the shoulder for immediate reimplantation and repair.

Methods

A standard arthroscopic approach was used to harvest non–load-bearing cartilage from 5 cadaveric shoulder specimens. Cartilage was separated from the humerus, grasped, added to the cartilage particulator, and morselized to form a cartilage paste. The volume of reclaimed cartilage was measured and compared with average humeral and glenoid defects.

Results

The total yield of cartilage paste following tissue processing that was obtained from the 5 glenohumeral joints ranged from 1.0 mL to 2.4 mL with a mean volume of 1.9 ± 0.5 mL, yielding a theoretical 18.6 cm² ± 5.2 cm² of coverage with a 1-mm monolayer. Previously reported mean glenoid defect size ranges from 1.12 cm² to 2.73 cm², while the mean humeral defect size ranges from 4.22 cm² to 6.00 cm².

Conclusions

This study validated that through a single-stage surgical and processing technique it is possible to obtain a sufficient volume for re-implantable autologous morselized cartilage graft to address most glenohumeral articular cartilage defects.

Clinical Relevance

Chondrocyte grafts have been shown to be effective in cartilage repair. A single-site, single-staged procedure that uses a patient’s autologous shoulder cartilage from the same joint has the potential to reduce morbidity associated with multiple surgical sites, multistaged procedures, or nonautologous tissue in shoulder surgery.

All-arthroscopic AMIC® (AT-AMIC) for the treatment of talar osteochondral defects: A short follow-up case series

INTRODUCTION

Various procedures have been used to treat osteochondral lesions of the talus. Among the new alternatives to treat these lesions, Autologous Matrix-Induced Chondrogenesis (AMIC^®) has proven to provide satisfactory results through medium-term follow-up. The aim of this study is to report early post-operative clinical results of patients submitted to the AT-AMIC^® technique and autologous bone graft, when necessary, for OLT's at a eight-month minimum follow-up.

METHODS

This is case series of 17 consecutive patients that were submitted to AT-AMIC^®, between January of 2016 and April of 2017. Nine men and eight women, between 15 and 67 years were diagnosed with OLTs with the typical history of deep ankle pain and corresponding magnetic resonance imaging injury. Surgery was proposed only after failure of conservative treatment of at least 3 months. Patients answered the AOFAS score preoperatively and at the last follow-up, ranging from 8 to 20 months.

RESULTS

Average size of OLTs were 1.16cm², with Raikin 4 location being the most common (71%). Calcaneal osteotomy was the most common associated procedure, with 18%. Average follow-up was 10.8 months. Average AOFAS before surgery was 46.4, increasing to 89.5 at the last follow-up. This difference was statistically significant with a p-value of <0.001. No complications were observed and no changes in the post-operative protocol were needed.

CONCLUSION

AT-AMIC^® is a reliable and reproducible method of treatment for OLTs, reaching high clinical postoperative scores, with a very low rate of complications. Further comparative study is needed to prove its efficacy.

Functional Medium-Term Results After Autologous Matrix-Induced Chondrogenesis for Osteochondral Lesions of the Talus: A 5-Year Prospective Cohort Study

Autologous matrix-induced chondrogenesis (AMIC) has gained popularity in the treatment of osteochondral lesions of the talus. Previous studies have presented promising short-term results for AMIC talar osteochondral lesion repair, a 1-step technique using a collagen type I/III bilayer matrix. The aim of the present study was to investigate the mid-term effects. The 5-year results of a prospective cohort study are presented. All patients underwent an open AMIC procedure for a talar osteochondral lesion. Data analysis included general demographic data, preoperative magnetic resonance imaging findings, intraoperative details, and German version of the Foot Function Index (FFI-D) scores preoperatively and at 1 and 5 years after surgery. The primary outcome variable was the longitudinal effect of the procedure, and the influence of various variables on the outcome was tested. Of 47 consecutive patients, 21 (45%) were included. Of the 21 patients, 8 were female (38%) and 13 were male (62%), with a mean age of 37 ± 15 (range 15 to 62) years and a body mass index of 26 ± 5 (range 20 to 38) kg/m². The defect size was 1.4 ± 0.9 (range 0.2 to 4.0) cm². The FFI-D decreased significantly from preoperatively to 1 year postoperatively (56 ± 18 versus 33 ± 25; p = .003), with a further, nonsignificant decrease between the 1- and 5-year follow-up examination (33 ± 25 versus 24 ± 21; p = .457). Similar results were found for the FFI-D subscales of function and pain. The body mass index and lesion size showed a positive correlation with the preoperative FFI-D overall and subscale scores. These results showed a significant improvement in pain and function after the AMIC procedure, with a significant return to sports by the 5-year follow-up point. The greatest improvement overall was seen within the first year; however, further clinical satisfaction among the patients was noticeable after 5 years.

Mid-term outcome of arthroscopic AMIC for the treatment of articular cartilage defects in the knee joint is equivalent to mini-open procedures

INTRODUCTION

We present the first retrospective study that compares two various autologous matrix-induced chondrogenesis (AMIC) surgical interventions to repair grade III-IV cartilage defects in the knee. Patients who underwent minimally invasive (arthroscopy) or open (mini-arthrotomy) AMIC were followed up to 2 years to investigate if minimally invasive AMIC is superior to open procedures.

MATERIALS AND METHODS

Overall n = 50 patients with focal and contained grade III-IV articular cartilage defects in the knee joint were followed in a consecutive cohort study. 20 patients were treated arthroscopically (female 7, male 13; age: mean 38.2 years, range 18-70 years; BMI: mean 27.0, range 18.7-34.7; defect size: mean 3.1 cm², range 1.0-6.0 cm²), and 30 patients via mini-arthrotomy (female 13, male 17; age: mean 34.4 years, range 14-53 years, BMI: mean 23.9, range 18.4-28.7; defect size: mean 3.4 cm², range 1.5-12.0 cm²). The primary defect localization was the medial femoral condyle.

RESULTS

AMIC led to a significant improvement of VAS pain, KOOS and Lysholm scoring for up to 2 years compared to pre-op. Outcome analysis revealed no significant differences between the two different surgical approaches.

CONCLUSIONS

Our results suggest that mini-open AMIC is equivalent to the arthroscopic procedure. The anticipatory hypothesis that minimally invasive approaches bring greater patient benefit per se could not be confirmed. Therefore, we recommend to perform AMIC where indicated and suggest that the surgeon's personal skills profile guide the choice of surgical approach.

LEVEL OF EVIDENCE

III.

[Options in joint-preserving surgical treatment of osteoarthritis]

BACKGROUND

The treatment of glenohumeral arthritis represents a major challenge in highly active younger patients. In these patients, an endoprosthetic treatment often achieves only unsatisfactory results with a limited lifetime of the implant.

OBJECTIVES

The aim of the study was to identify joint-preserving therapies for glenohumeral arthritis.

MATERIALS AND METHODS

For this study, an extensive and selective literature search was performed.

RESULTS

There are several options available for joint-preserving treatment of glenohumeral arthritis. In addition to arthroscopic debridement with treatment of concomitant pathologies, CAM procedures (CAM: comprehensive arthroscopic management) according to Millett, as well as the interposition of allografts are other options. For all therapy options, an improved range of motion and pain reduction is described. A joint gap of <2 mm, bipolar cartilage lesions and age are described as risk factors for failure of the therapies.

DISCUSSION

Short and mid-term results have been described for arthroscopic debridement, but there are no long-term and high-quality studies to enable us to make clear recommendations. The CAM procedure and the interposition of an allograft are demanding procedures that should be reserved for experienced arthroscopists. The therapies are an option for younger patients in accordance with individual decisions and realistic expectations.

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.