A comparison of patient-reported outcomes and arthroscopic findings between drilling and autologous osteochondral grafting for the treatment of articular cartilage defects combined with anterior cruciate ligament injury

A higher incidence of chondral injuries on the medial femoral condyle in concomitant ACL ruptures, no significant difference in treatment: A systematic review

PURPOSE

The associated damage to articular cartilage in anterior cruciate ligament (ACL) injured patients is a well-recognized phenomenon; however, there is a relative paucity in the literature regarding the different treatment techniques and outcomes. The purpose of this systematic review was to identify patients treated for acute ACL rupture and associated cartilage injury, with interest in the surgical management of these chondral injuries and any difference in patient-reported outcome measures (PROMs) differing techniques.

METHODS

A systematic review was performed looking for treatment or management of International Cartilage Repair Society grade 3 or 4 articular cartilage injury at the time of ACL reconstruction.

RESULTS

Seventeen studies fit the criteria, a total of 892 patients were included, 64.6% were male with a mean age of 33.7 and the average time to follow-up was 41.7 months. 68.2% of the lesions were on the medial femoral condyle (MFC) with a mean lesion size of 3.9 cm2. Six different operative methods of dealing with chondral lesions were identified, there was no significant difference in PROMs between the techniques, although there was a significant difference between the preoperative and postoperative outcome measures.

CONCLUSIONS

The systematic review found that chondral defects on the MFC are more common in concomitant ACL injuries, despite the pattern of bone bruising being more common on the lateral femoral condyle as reported in the literature. It also found no significant difference in the PROMs between the six different techniques identified for the concomitant management of ACL reconstruction and chondral defects.

LEVEL OF EVIDENCE

Level II.

Concomitant full-thickness cartilage lesions do not affect patient-reported outcomes at minimum 10-year follow-up after ACL reconstruction

PURPOSE

To compare patients with a concomitant full-thickness cartilage lesion and anterior cruciate ligament (ACL) injury to patients with an isolated ACL injury at 10-15 years post ACL reconstruction.

METHODS

This is a longitudinal follow-up of a cohort of 89 patients that were identified in the Norwegian National Knee Ligament Registry and included in the index study in 2007. The study group consisted of 30 patients that underwent ACL reconstruction and had a concomitant, isolated full-thickness cartilage lesion (International Cartilage Repair Society [ICRS] grade 3-4). Each study patient was matched with two control patients who underwent ACL reconstruction but had no cartilage lesions (ICRS grade 1-4) (n = 59). At a median follow-up of 10.2 years (range 9.9-15.6), 65 patients (74%) completed the Knee Injury and Osteoarthritis Outcome Score (KOOS), which was the main outcome measure, resulting in 23 pairs after matching.

RESULTS

At a follow-up of 10-15 years after ACL reconstruction, no significant differences in KOOS were found between patients with a concomitant full-thickness cartilage lesion and patients without cartilage lesions. There was also no significant difference between the two groups when comparing the change over time in KOOS scores from preoperative to follow-up. Both groups showed significant improvement in all KOOS subscales from preoperative to follow-up, except for in the Symptoms subscale for the control group. The greatest improvement was in the QoL subscale for the study group.

CONCLUSION

ACL-reconstructed patients with a full-thickness cartilage lesion did not report worse outcomes at 10-15 years after surgery compared with patients with an isolated ACL injury. Our findings support that there is no long-term negative effect of a concomitant cartilage lesion in an ACL-reconstructed knee. These findings should be considered when discussing treatment and informing about the expected long-term outcome after ACL reconstruction to patients with such combined injuries.

LEVEL OF EVIDENCE

II.

Functional outcome of osteochondral autograft is equivalent in stable knee and in anterior cruciate ligament reconstruction

INTRODUCTION

Anterior cruciate ligament (ACL) tears are associated in 10% to 20% of cases with extensive traumatic focal osteochondral damage. Ligament reconstruction may require osteochondral autograft for symptomatic osteochondral lesions. Combined ACL and chondral or osteochondral reconstruction is poorly evaluated in the literature; osteochondral reconstruction in stable knee better documented. The objective of this study was to compare functional results after osteochondral autograft transfer (OAT) for significant symptomatic femoral condyle defect, in stable or stabilised knees (concomitant ACL reconstruction). The hypothesis was that functional results are equivalent in both groups.

MATERIAL & METHOD

This was a single-centre retrospective comparative observational study of patients consecutively operated on between 2000 and 2018. Fifty patients met the inclusion criteria and were divided into two groups: Group 1 (OAT+ACL, n=13) and group 2 (OAT on stable knee, n=37). The following criteria were recorded at follow-up: pain (VAS), KOOS, IKDC and Lysholm scores and Hughston radiologic score, and time to return to sport. Mean follow-up was 79.7±60 months in group 1 and 86.4±62 months in group 2.

RESULTS

Ten patients were included for analysis in group 1 and 30 in group 2. Cartilage lesion size was comparable between groups: 1.6±1.20 cm² for group 1 and 2.3±1.3 cm² for group 2 (ns). One complication (infection with favourable course) was observed in group 2. Sport was resumed at 8.7±2.7 vs. 8.4±3.3 months, respectively. Mean subjective scores were respectively 83.3±7.4 and 75.4±14 for Lysholm, 89.7±7.8 and 89.7±19.6 for KOOS, 78±13.7 and 72.2±12.9 for subjective IKDC, 0.5±0.5 and 0.8±0.9 for pain on VAS and 3 and 3 for radiological Hughston radiologic score, with no significant differences between groups.

CONCLUSION

Symptomatic focal osteochondral lesions treated by osteochondral autograft transfer gives the same outcome on stable or stabilised knee.

LEVEL OF EVIDENCE

IV; retrospective study.

Measuring Outcomes in Knee Articular Cartilage Pathology

Measuring outcomes following treatment of knee articular cartilage lesions is crucial to determine the natural history of disease and the efficacy of treatments. Outcome assessments for articular cartilage treatments can be clinical (based on failure, lack of healing, reoperation, need for arthroplasty), radiographic (X-ray, MRI), histologic, or patient reported and functional. The purpose of this review is to discuss the application and properties of patient-reported outcomes (PROs) with a focus on articular cartilage injuries and surgery in the knee. The most frequently used and validated PROs for knee articular cartilage studies include: the Knee injury and Osteoarthritis and Outcome Score, International Knee Documentation Committee Subjective Knee Form, and Lysholm score as knee-specific measures; the Marx Activity Rating Scale and Tegner Activity Scale as activity measures; and EQ-5D and SF-36/12 as generic quality-of-life measures. Incorporating these validated PROs in studies pertaining to knee articular cartilage lesions will allow researchers to fully capture clinically relevant outcomes that are most important to patients.

Do cartilage lesions affect the clinical outcome of anterior cruciate ligament reconstruction? A systematic review

PURPOSE

To document the available evidence on the influence of cartilage lesions on the results of anterior cruciate ligament (ACL) surgery and their management to optimize the final outcome.

METHODS

A systematic review was performed on the PubMed database on articles dealing with cartilage lesions detected at the time of ACL reconstruction, by looking both for their influence on the clinical outcome and the results of their treatment. Reports on clinical, radiological, or second-look outcomes at any follow-up were included. Exclusion criteria were preclinical studies, reviews, or studies not reporting clinical, radiological, or second-look outcome after primary ACL reconstruction.

RESULTS

Thirty-seven studies were included for the final analysis. Twenty-seven focused on the influence of cartilage lesions on clinical outcome after ACL reconstruction in 47,837 patients. In total, 21/27 articles showed a correlation with a poorer outcome in terms of subjective, objective, and radiographic findings. Lesion location and depth influenced final results. Only 9.0 % of these defects were treated in the analysed studies, and only 10 manuscripts of overall low level evaluated the results of combined cartilage-ACL treatments.

CONCLUSION

The majority of the literature supports the clinical relevance of cartilage lesions which are correlated with a poorer outcome after ACL reconstruction. Nonetheless, a large amount of chondral defects are actually not addressed, also considering the poor evidence for the benefits provided by cartilage treatments. In fact, only a few studies specifically focused on how to manage cartilage lesions found during ACL reconstruction and there is a lack of indications for the most appropriate treatment approach.

LEVEL OF EVIDENCE

IV.

Effect on Patient-Reported Outcomes of Debridement or Microfracture of Concomitant Full-Thickness Cartilage Lesions in Anterior Cruciate Ligament-Reconstructed Knees: A Nationwide Cohort Study From Norway and Sweden of 357 Patients With 2-Year Follow-up

BACKGROUND

The treatment of concomitant cartilage lesions in anterior cruciate ligament (ACL)-injured knees is debatable.

PURPOSE

To evaluate the effect of debridement or microfracture (MF) compared with no treatment of concomitant full-thickness (International Cartilage Repair Society [ICRS] grades 3-4) cartilage lesions on patient-reported outcomes after ACL reconstruction.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Six hundred forty-four patients who underwent primary unilateral ACL reconstruction and had a concomitant full-thickness cartilage lesion treated simultaneously by debridement (n = 129) or MF (n = 164), or underwent no treatment (n = 351) of the cartilage lesion, registered in the Norwegian and Swedish National Knee Ligament Registries from 2005 to 2008 were included. The Knee Injury and Osteoarthritis Outcome Score (KOOS) was used to measure patient-reported outcomes. At a mean follow-up of 2.1 ± 0.2 years after surgery, 357 (55%) patients completed the KOOS. Linear regression analyses were used to evaluate the effect of debridement or MF on the KOOS.

RESULTS

No significant effects of debridement were detected in the unadjusted or adjusted regression analyses on any of the KOOS subscales at 2-year follow-up. The MF treatment of the cartilage lesions had significant negative effects at 2-year follow-up on the KOOS Sport and Recreation (Sport/Rec) (regression coefficient [β] = -8.9; 95% confidence interval [CI], -15.1 to -1.5) and Knee-Related Quality of Life (QoL) (β = -8.1; 95% CI, -14.1 to -2.1) subscales in the unadjusted analyses. When adjusting for confounders, MF had significant negative effects on the same KOOS subscales of Sport/Rec (β = -8.6; 95% CI, -16.4 to -0.7) and QoL (β = -7.2; 95% CI, -13.6 to -0.8). For the remaining KOOS subscales of Pain, Symptoms, and Activities of Daily Living, there were no significant unadjusted or adjusted effects of MF.

CONCLUSION

MF of concomitant full-thickness cartilage lesions showed adverse effects on patient-reported outcomes at 2-year follow-up after ACL reconstruction. Debridement of concomitant full-thickness cartilage lesions showed neither positive nor negative effects on patient-reported outcomes at 2-year follow-up after ACL reconstruction.

Effect of anterior cruciate ligament rupture on secondary damage to menisci and articular cartilage

OBJECTIVE

The aim of this study was to evaluate the effect of anterior cruciate ligament (ACL) rupture on secondary damage to menisci and articular cartilage.

METHOD

A total of 366 patients with knee ACL rupture were divided into the following six groups based on the time span from the initial injury to ACL reconstruction: (1) <1.5months; (2) between 1.5 and three months; (3) between three and six months; (4) between six and 12months; (5) between 12 and 24months, and (6) >24months. During ACL reconstruction, impairment of meniscal or chondral integrity was systematically documented.

RESULTS

Of the 366 patients involved in this study, meniscal and chondral damage were found in 223 (60.9%) and 75 (20.5%) patients, respectively. In addition, the incidence of medial meniscal and chondral damage was significantly increased when ACL reconstruction was delayed. The incidence of medial meniscal and chondral damage was found to be 6.1 and 9.9 times higher in patients with a time from initial injury (TFI) of >24months than those with a TFI of <1.5months, respectively.

CONCLUSION

In this study, correlations between secondary damage to the menisci and/or the articular cartilage and time after initial injury were found in Chinese population. Our data suggested that ACL reconstruction should be performed as early as possible after ACL rupture to avoid secondary meniscal and/or chondral damage. It is recommended that the best time range for ACL reconstruction is between four and six weeks after initial injury.

Outcomes in orthopedics and traumatology: translating research into practice

Clinical research is focused in generating evidence that is feasible to be applicable to practitioners. However, translating research-focused evidence into practice may be challenging and often misleading. This article aims is to pinpoint these challenges and suggest some methodological safeguards, taking platelet-rich plasma therapies and knee osteochondral injuries as examples. Studies and systematic reviews involving the following concepts will be investigated: clinically relevant outcomes, systematic errors on sample calculation, internal and external validity. Relevant studies on platelet-rich plasma for muscle-tendon lesions and updates on osteochondral lesions treatment were included in this analysis. Authors and clinicians should consider these concepts for the implementation and application of dissemination of the best evidence. Research results should be challenged by a weighted analysis of its methodological soundness and applicability. Level of Evidence V, Therapeutic Studies - Investigating the Results of Treatment.