Return to sports participation after articular cartilage repair in the knee: scientific evidence

Do reconstructive techniques for osteochondritis dissecans of the skeletally mature knee work? A systematic review and meta-analysis

PURPOSE

Osteochondritis dissecans (OCD) is a common cause of knee pain. Management for adult-onset OCD (AOCD) usually involves surgery. Surgical treatments include palliative, reparative and reconstructive techniques. The aim of this systematic review and meta-analysis is to evaluate the efficacy of reconstructive techniques for the treatment of OCD in skeletally mature knees.

METHODS

A systematic search was carried out on four databases up to November 2023 (Medline, Embase, Cochrane Library, Web of Science). The study was registered on international prospective register of systematic reviews and performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Clinical studies on skeletally mature patients were included, which utilised reconstructive techniques such as autologous chondrocyte implantation (ACI), matrix-induced autologous chondrocyte implantation, osteochondral allograft transplantation surgery or bone marrow-derived cellular transplantation. Demographical data, patient-reported outcome measures and postoperative complications were recorded. Quantitative outcome measures that were comparable across studies were pooled for meta-analysis. A random effects model was used. Heterogeneity was assessed using the I2 statistic and Cochran's Q test. Statistical significance was set at p < 0.05. Risk of bias was assessed using the risk of bias in non-randomised studies - of interventions tool for nonrandomised studies.

RESULTS

Sixteen studies were included with 458 OCD lesions in 432 patients. The average age was 24.9, and 62.6% were male. The mean follow-up time was 61.5 months. At 36 months follow-up, International Knee Documentation Committee (IKDC) subjective, Tegner and EuroQol-visual analogue scale (EQ-VAS) scores improved from 42.4 to 78.6 (standard mean difference [SMD]: 2.47; p < 0.001), 2.27-4.99 (SMD: 2.363; p = 0.002) and 30.4-57.5 (SMD: 2.390; p < 0.001), respectively. Overall complication rate was 8.9%. Smaller OCD lesion sizes resulted in a greater improvement in IKDC subjective (SMD: 2.64 vs. 2.01; p = 0.038), EQ-VAS (SMD: 3.16 vs. 0.95; p = 0.046) and Tegner scores (SMD: 3.13 vs. 1.05; p = 0.007) and had a lower complication rate (p = 0.008). Males showed a larger improvement in IKDC subjective scores than females (SMD: 2.56 vs. 1.56; p = 0.029), while younger patients had a larger improvement in IKDC subjective scores (SMD: 2.71 vs. 2.12; p = 0.045) and fewer complications than older patients (p = 0.003). There were no significant differences between cohorts treated with ACI and those treated with non-ACI reconstructive techniques. Publication bias was not detected (n.s.).

CONCLUSION

Reconstructive techniques used to treat OCD in the skeletally mature knee resulted in significant improvements in clinical and functional outcomes, with a low overall complication rate. Since a younger age leads to a greater improvement in IKDC subjective score and a lower complication rate, surgical intervention should not be delayed, especially in AOCD lesions which are more likely to follow a progressive and unremitting clinical course.

LEVEL OF EVIDENCE

Level III.

Comparable Clinical and Functional Outcomes Between Osteochondral Allograft Transplantation and Autologous Chondrocyte Implantation for Articular Cartilage Lesions in the Patellofemoral Joint at a Mean Follow-up of 5 Years

PURPOSE

To assess clinical outcomes and return to sport (RTS) rates among patients who undergo osteochondral allograft (OCA) transplantation and autologous chondrocyte implantation (ACI) or matrix-induced autologous chondrocyte implantation (MACI), for patellofemoral articular cartilage defects.

METHODS

A retrospective review of patients who underwent an OCA or ACI/MACI from 2010 to 2020 was conducted. Patient-reported outcomes collected included visual analog scale for pain/satisfaction, Knee Injury and Osteoarthritis Outcome Score (KOOS), and RTS. The percentage of patients that met the patient acceptable symptom state for KOOS was recorded. Logistic regression was used to identify predictors of worse outcomes.

RESULTS

A total of 95 patients were included (78% follow-up) with ACI or MACI performed in 55 cases (57.9%) and OCA in 40 (42.1%). A tibial tubercle osteotomy was the most common concomitant procedure for OCA (66%) and ACI/MACI (98%). Overall, KOOS pain was significantly poorer in OCA than ACI/MACI (74.7, 95% confidence interval 68.1-81.1 vs 83.6, 95% confidence interval 81.3, 88.4, P = .012), whereas the remaining KOOS subscores were nonsignificantly different (all P > .05). Overall, RTS rate was 54%, with no significant difference in return between OCA or ACI/MACI (52% vs 58%, P = .738). There were 26 (27%) reoperations and 5 (5%) graft failures in the entire group. Increasing age was associated with lower satisfaction in OCA and poorer outcomes in ACI/MACI, whereas larger lesion area was associated with lower satisfaction and poorer outcomes in ACI/MACI.

CONCLUSIONS

Clinical and functional outcomes were similar in patients who underwent OCA or ACI/MACI for patellofemoral articular cartilage defects at a mean follow-up of 5 years. Patients who received OCA had a greater proportion of degenerative cartilage lesions and, among those with trochlear lesions, reported greater pain at final follow-up than their ACI/MACI counterparts. Overall, increasing age and a larger lesion size were associated with worse patient-reported outcomes.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

A Biomimetic Osteochondral Scaffold Augmented With Filtered Bone Marrow Aspirate for the Treatment of Joint Surface Lesions in the Knee

BACKGROUND

Multilayered osteochondral scaffolds are becoming increasingly utilized for the repair of knee joint surface lesions (KJSLs). However, the literature on predictive factors is rather limited.

PURPOSE

To (1) evaluate the clinical outcomes and safety of a combined single-step approach using a biomimetic collagen-hydroxyapatite scaffold (CHAS) and filtered bone marrow aspirate (fBMA) for the treatment of KJSLs and (2) identify significant predictors of the treatment outcomes.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

All patients who underwent surgery because of a KJSL (size ≥1.5 cm2; International Cartilage Regeneration & Joint Preservation Society grades 3-4) using the combination above were selected from a hospital registry database (100 patients; minimum 2-year follow-up). Patient characteristics, medical history, knee joint and lesion status, intraoperative details, and cellular parameters of the injected fBMA were collected. The arthroscopic evaluation of chondral and meniscal tissue quality in all knee compartments was performed using the Chondropenia Severity Score. Treatment outcomes were determined clinically using patient-reported outcome measures (Knee Injury and Osteoarthritis Outcome Score, EuroQol-5 Dimensions-3 Levels, EuroQol-Visual Analog Scale, and Tegner Activity Scale) and by assessing the occurrence of serious adverse events and graft failure. Multivariable regression analysis was performed to identify significant predictors of the treatment outcomes.

RESULTS

At a mean follow-up of 54.2 ± 19.4 months, 78 (87%) patients completed the questionnaires with significant improvements toward the baseline (P < .00625): KOOS Pain subscale from 62 ± 17 to 79 ± 18, KOOS Total score from 57 ± 16 to 70 ± 20, EuroQol-Visual Analog Scale from 61 ± 21 to 76 ± 16, EuroQol-5 Dimensions-3 Levels from 0.57 ± 0.20 to 0.80 ± 0.21, and Tegner Activity Scale from 2.8 ± 1.5 to 3.9 ± 1.9. The graft failure rate was 4%. A longer duration of preoperative symptoms, previous surgery, larger lesions, older age, and female sex were the main negative predictors for the treatment outcomes. The Chondropenia Severity Score and the number of fibroblast colony-forming units in fBMA positively influenced some of the clinical results and safety.

CONCLUSION

A CHAS augmented with fBMA proved to be an adequate and safe approach for the treatment of KJSLs up to midterm follow-up. Based on the subanalysis of predictive factors, the surgical intervention should be performed in a timely and precise manner to prevent lesion enlargement, deterioration of the general knee cartilage status, and recurrent surgical procedures, especially in older and female patients. When a CHAS is used, the quantity of MSCs seems to play a role in augmentation.

REGISTRATION

NCT06078072 (ClinicalTrials.gov identifier).

Kinesiophobia and Pain Catastrophizing Leads to Decreased Return to Sport Following Autologous Chondrocyte Implantation but Does Not Affect Return to Work

OBJECTIVE

To evaluate the effect of fear of reinjury on return to sport (RTS), return to work (RTW), and clinical outcomes following autologous chondrocyte implantation (ACI).

DESIGN

A retrospective review of patients who underwent ACI with a minimum of 2 years in clinical follow-up was conducted. Patient-reported outcomes collected included the Visual Analog Scale (VAS) and Knee Injury and Osteoarthritis Outcome Score (KOOS). Kinesiophobia and pain catastrophizing was assessed using the Tampa Scale of Kinesiophobia-11 (TSK-11) and Pain Catastrophizing Scale (PCS), respectively. Patients were surveyed on their RTS and RTW status.

RESULTS

Fifty-seven patients (50.9% female) were included in our analysis. Twenty-two (38.6%) patients did not RTS. Of the 35 patients (61.4%) who returned, nearly half (48.6%) returned at a lower level of play. TSK-11 (P = 0.003), PCS (P = 0.001), and VAS pain scores (P < 0.001) were significantly greater in patients that did not RTS than in those who returned. All KOOS subscores analyzed were significantly lower (P < 0.001) in patients that did not RTS than in those who returned at the same level or higher. Of the 44 (77.2%) patients previously employed, 97.7% returned to work. Increasing TSK-11 scores were associated with lower odds of returning to sport (P = 0.003).

CONCLUSION

Fear of reinjury decreases the likelihood that patients will return to sport after ACI. Patients that do not return to sport report significantly greater levels of fear of reinjury and pain catastrophizing and lower clinical knee outcomes. Nearly all patients were able to return to work after surgery.

LEVEL OF EVIDENCE

IV case series.

Treatment of Knee Chondral Defects in Athletes

Cartilage lesions of the knee are a challenging problem, especially for active individuals and athletes who desire a return to high-load activities. They occur both through chronic repetitive loading of the knee joint or through acute traumatic injury and represent a major cause of pain and time lost from sport. They can arise as isolated lesions or in association with concomitant knee pathology. Management of these defects ultimately requires a sound understanding of their pathophysiologic underpinnings to help guide treatment. Team physicians should maintain a high index of suspicion for underlying cartilage lesions in any patient presenting with a knee effusion, whether painful or not. A thorough workup should include a complete history and physical examination. MRI is the most sensitive and specific imaging modality to assess these lesions and can provide intricate detail not only of the structure and composition of cartilage, but also of the surrounding physiological environment in the joint. Treatment of these lesions consists of both conservative or supportive measures, as well as surgical interventions designed to restore or regenerate healthy cartilage. Because of the poor inherent capacity for healing associated with hyaline cartilage, the vast majority of symptomatic lesions will ultimately require surgery. Surgical treatment options range from simple arthroscopic debridement to large osteochondral reconstructions. Operative decision-making is based on numerous patient- and defect-related factors and requires open lines of communication between the athlete, the surgeon, and the rest of the treatment team. Ultimately, a positive outcome is based on the creation of a durable, resistant repair that allows the athlete to return to pain-free sporting activities.

Rehabilitation of Soccer Players' Knee Injuries: Cartilage Reconstruction, Anterior Cruciate Ligament Surgery, and Intensive Recovery-A Pilot Study

Knee injuries, particularly anterior cruciate ligament (ACL) damage and cartilage defects, are highly prevalent among athletes and affect their sports performance and long-term joint function. The purpose of this research was to evaluate the effectiveness of a comprehensive combination therapy approach for individuals with ACL and cartilage injuries. Twelve professional soccer players aged 18 to 30 years underwent bone-tendon-bone ACL reconstruction, microfracture cartilage repair surgery, and hyaluronic acid scaffold treatment. Early postoperative rehabilitation included immediate supervised physiotherapy and complete weight bearing. Follow-up assessments involved clinical evaluations, functional joint assessments, and magnetic resonance imaging (MRI) scans to measure cartilage defect repair and symptom alleviation. The results showed that patients resumed pain-free activities within 3-4 weeks and returned to their pre-injury level within 4.5 months. MRI demonstrated the absence of inflammatory reactions, repair of marrow edema, and the emergence of new cartilage. Six months and one year after surgery, the Knee Injury and Osteoarthritis Outcome Score (KOOS) and the Short Form (36) Health Survey (SF-36) questionnaire results demonstrated considerable improvement in patients' health condition and quality of life. Overall, the study suggests that the combination of Hyalofast membranes, microfracture surgery, tissue adhesive, and intensive postoperative physical therapy may be a potential alternative to commonly used treatments for patients with ACL rupture, allowing them to recover efficiently and return to sports activities.

Hyalofast Cartilage Repair Surgery with a Full Load-Bearing Rehabilitation Program One Day after Operation Reduces the Time for Professional Athletes to Return to Play

Background and Objectives: This study evaluated the effectiveness of Hyalofast cartilage repair surgery with an early, full load-bearing rehabilitation program one day after the operation for reducing the time needed for professional athletes to return to play. Materials and Methods: This prospective study included 49 patients aged between 19 and 38 years who had undergone surgical reconstruction of cartilage using the microfracture technique combined with a Hyalofast scaffold. All patients were active professional athletes. Early rehabilitation was implemented from the first postoperative day, fully loading the operated limb. A clinical evaluation was based on the KOOS and SF-36 questionnaires used during subsequent follow-up visits. All patients underwent magnetic resonance imaging (MRI) to evaluate the effect of the surgery after one year. Results: The clinical results demonstrated a statistically significant improvement in the number of complaints about pain and in the quality of life of the patients, measured in all of the applied scales, with comparisons made between six months or one year post-surgery and pre-surgery. Importantly for athletes, the parameter related to sports and recreation improved from 14 ± 11.1 to 95 ± 7.7 6 months after surgery and to 99.8 ± 1.8 one year after surgery. The overall quality of life score improved from 30 ± 18 to 88 ± 8.8 one year after surgery. Conclusions: These results show that this approach significantly shortened the time needed for the athletes to return to sports at the same level as before the surgery (athletes returned to sports in approximately 2.5-3 months). The mean follow-up time was 19.75 months. This technique can be considered a viable option for the treatment of cartilage injuries in professional athletes, allowing them to return to play more quickly in a safe and healthy way.

Empfehlungen der AG Klinische Geweberegeneration zur Behandlung von Knorpelschäden am Kniegelenk

The Working Group of the German Orthopedic and Trauma Society (DGOU) on Tissue Regeneration has published recommendations on the indication of different surgical approaches for treatment of full-thickness cartilage defects in the knee joint in 2004, 2013 and 2016. Based upon new scientific knowledge and new developments, this recommendation is an update based upon the best clinical evidence available. In addition to prospective randomised controlled clinical trials, this also includes studies with a lower level of evidence. In the absence of evidence, the decision is based on a consensus process within the members of the working group.The principle of making decision dependent on defect size has not been changed in the new recommendation either. The indication for arthroscopic microfracturing has been reduced up to a defect size of 2 cm² maximum, while autologous chondrocyte implantation is the method of choice for larger cartilage defects. Additionally, matrix-augmented bone marrow stimulation (mBMS) has been included in the recommendation for defects ranging from 1 to 4.5 cm². For the treatment of smaller osteochondral defects, in addition to osteochondral transplantation (OCT), mBMS is also recommended. For larger defects, matrix-augmented autologous chondrocyte implantation (mACI/mACT) in combination with augmentation of the subchondral bone is recommended.

Comparative efficacy of osteochondral autologous transplantation and microfracture in the knee: an updated meta-analysis of randomized controlled trials

INTRODUCTION

More than 19% of patients undergoing knee arthroscopies suffers from articular cartilage defects. The chondral or osteochondral lesion has negative impacts on the knee joints function and the life quality of patients. However, the treatment remains challenging as hyaline cartilage is not renewable. The purpose of this study was to systematically analyze the data of randomized controlled trials for comparing the postoperative outcomes between osteochondral autologous transplantation (OAT) and microfracture (MF) procedure. We hypothesized that the outcomes were better in OAT than MF procedure.

MATERIALS AND METHODS

A systematic literature search of the EMBASE, Pubmed, and Cochrane Library databases was conducted based on PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The outcome measures include: the rate of excellent or good results, the rate of return to sports, the failure rate, osteoarthritis rate, International Cartilage Repair Society (ICRS) score, Lysholm Knee Score, and Tegner scale. The statistical analysis was completed using Review Manager (RevMan, version 5.3) software.

RESULTS

The systematic search identified 7 studies with a total of 346 patients. The pooled result showed significant differences between the two groups in the rate of return to sports and failure. The following outcome scores showed significant improvement (pre- vs postoperatively): Lysholm score (p = 0.02), Tegner scale (p < 0.00001), and ICRS score (p < 0.00001). The differences were not significant in the excellent or good results and the rate of osteoarthritis.

CONCLUSION

The patients in OAT group may return to play quicker, even return to pre-injury level of activity compared to the MF group. OAT is better than MF procedure in accordance with Lysholm score, Tegner score, ICRS score, and the rate of failure. However, few studies have reported long-term outcomes and there has no uniform criteria for safe return to sports. Further research is needed.

LEVEL OF EVIDENCE

Level II, meta-analysis of randomized controlled trials.

Knorpelersatzverfahren und Regeneration am Knie- und Hüftgelenk

Die operative Therapie von Knorpelschäden am Kniegelenk hat sich in den letzten Jahren von vorsichtigen Anfängen mit innovativen Therapieansätzen zu einem festen und etablierten Baustein der gelenkerhaltenden Therapie entwickelt. Hingegen hat sich am Hüftgelenk erst in den letzten 10 Jahren, basierend auf einem erweiterten Verständnis grundlegender mechanischer Pathomechanismen, die gelenkerhaltende Hüftchirurgie und insbesondere die Knorpeltherapie etabliert. Der Beitrag stellt die zur Verfügung stehenden Techniken vor.

Update: Posttreatment Imaging of the Knee after Cartilage Repair

Focal cartilage lesions are common pathologies at the knee joint that are considered important risk factors for the premature development of osteoarthritis. A wide range of surgical options, including but not limited to marrow stimulation, osteochondral auto- and allografting, and autologous chondrocyte implantation, allows for targeted treatment of focal cartilage defects. Arthroscopy is the standard of reference for the assessment of cartilage integrity and quality before and after repair. However, deep cartilage layers, intrachondral composition, and the subchondral bone are only partially or not at all visualized with arthroscopy. In contrast, magnetic resonance imaging offers noninvasive evaluation of the cartilage repair site, the subchondral bone, and the soft tissues of the joint pre- and postsurgery. Radiologists need to be familiar with the different surgical procedures available and their characteristic postsurgical imaging appearances to assess treatment success and possible complications adequately. We provide an overview of the most commonly performed surgical procedures for cartilage repair at the knee and typical postsurgical imaging characteristics.

Good medium-term functional results in reconstruction of lateral femoral condyle osteochondral lesions

INTRODUCTION

Results of autologous osteochondral graft (mosaicplasty) are well-reported for the medial femoral condyle but much less for the lateral femoral condyle. The main aim of the present study was to assess results specifically for lateral condyle reconstruction. The secondary objective was to compare results according to the two main etiologies: osteochondritis dissecans (OCD) and osteochondral fracture (OCF).

HYPOTHESIS

The study hypothesis was that medium-term functional and radiological results of lateral femoral condyle autologous osteochondral graft are good.

MATERIAL AND METHODS

A single-center retrospective continuous study included 24 patients with symptomatic focal lateral femoral condyle osteochondral lesion treated by osteochondral autograft, at a minimum 24 months' follow-up. Mosaicplasty was performed for lesions <200 mm², with associated fixation for lesions >200 mm² with viable osteochondral fragments. IKDC, Lysholm and KOOS functional scores and pain on visual analog scale (VAS) were collected at last follow-up. Progression toward osteoarthritis was assessed on comparative X-ray.

RESULTS

Twenty patients were analyzed (11 OCD, 9 OCF) at a mean of 66.4±44 months. Mean pain on VAS was 1.8±2 out of 10. Mean subjective IKDC, Lysholm and global KOOS scores were respectively 68.1±26, 76.5±22 and 73.9±21. Two patients showed Ahlbäck grade 2 lateral femorotibial osteoarthritis. Functional results were comparable between OCD and OCF.

CONCLUSION

Reconstruction of lateral femoral condyle osteochondral lesion by osteochondral autograft gave good medium-term functional results, whatever the etiology. Longer-term studies are needed to assess progression toward osteoarthritis and functional deterioration over time.

LEVEL OF EVIDENCE

IV; retrospective study.

Differences in Clinical and Functional Outcomes Between Osteochondral Allograft Transplantation and Autologous Chondrocyte Implantation for the Treatment of Focal Articular Cartilage Defects

Background:

Articular cartilage pathology can result from a spectrum of origins, including trauma, osteochondritis dissecans, avascular necrosis, or degenerative joint disease.

Purpose:

To compare the differences in clinical and patient-reported outcomes after autologous chondrocyte implantation (ACI) versus osteochondral allograft transplantation (OCA) in patients with focal articular cartilage defects without underlying bone loss.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

A retrospective review identified patients who underwent ACI or OCA between 2008 and 2016 for isolated grades 3 and 4 articular cartilage defects without underlying bone loss. Outcome measures included the Knee injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR), International Knee Documentation Committee (IKDC) evaluation, and 12-Item Short Form Health Survey–Physical Component (SF-12-P) scores. Defect location, size, complications, and rate of subsequent surgery were determined.

Results:

Overall, 148 patients were included: 82 (55%) underwent ACI and 66 (45%) underwent OCA. The mean age at the time of surgery was 31.2 years within the ACI cohort and 37.7 years within the OCA cohort (P < .001); the mean follow-up for both cohorts was 6.7 years (P = .902). Within the ACI group, 28 (34%) patients had multifocal defects, 21 (26%) had defects confined to the femoral condyles, and 33 (40%) had defects in the patellofemoral region. Within the OCA group, 23 (35%) patients had multifocal defects, 30 (46%) had confined femoral condyle lesions, and 13 (20%) had patellofemoral defects. When comparing by lesion location, there were no significant differences in KOOS JR, and IKDC scores between the ACI and OCA cohorts (P < .05). There was, however, a significant difference for SF-12-P scores for FDD trochlear lesions. In both cohorts, traumatic patellofemoral pathology demonstrated lower patient-reported outcomes and higher failure rates than degenerative lesions. The overall rate of failure, defined as graft failure with revision surgery and/or conversion to arthroplasty, was significantly greater in the OCA group (21% vs 4%; P = .002).

Conclusion:

Study results indicated that ACI provides similar outcomes to OCA with or without concomitant procedures for the treatment of symptomatic articular cartilage defects in all lesion locations and may have a lower revision rate for multifocal and condylar lesions.

Cell-based treatment options facilitate regeneration of cartilage, ligaments and meniscus in demanding conditions of the knee by a whole joint approach

PURPOSE

This article provides an update on the current therapeutic options for cell-based regenerative treatment of the knee with a critical review of the present literature including a future perspective on the use of regenerative cell-based approaches. Special emphasis has been given on the requirement of a whole joint approach with treatment of comorbidities with aim of knee cartilage restoration, particularly in demanding conditions like early osteoarthritis.

METHODS

This narrative review evaluates recent clinical data and published research articles on cell-based regenerative treatment options for cartilage and other structures around the knee RESULTS: Cell-based regenerative therapies for cartilage repair have become standard practice for the treatment of focal, traumatic chondral defects of the knee. Specifically, matrix-assisted autologous chondrocyte transplantation (MACT) shows satisfactory long-term results regarding radiological, histological and clinical outcome for treatment of large cartilage defects. Data show that regenerative treatment of the knee requires a whole joint approach by addressing all comorbidities including axis deviation, instability or meniscus pathologies. Further development of novel biomaterials and the discovery of alternative cell sources may facilitate the process of cell-based regenerative therapies for all knee structures becoming the gold standard in the future.

CONCLUSION

Overall, cell-based regenerative cartilage therapy of the knee has shown tremendous development over the last years and has become the standard of care for large and isolated chondral defects. It has shown success in the treatment of traumatic, osteochondral defects but also for degenerative cartilage lesions in the demanding condition of early OA. Future developments and alternative cell sources may help to facilitate cell-based regenerative treatment for all different structures around the knee by a whole joint approach.

LEVEL OF EVIDENCE

IV.

Matrix-Associated Autologous Chondrocyte Implantation with Spheroid Technology Is Superior to Arthroscopic Microfracture at 36 Months Regarding Activities of Daily Living and Sporting Activities after Treatment

OBJECTIVE

Matrix-associated autologous chondrocyte implantation (ACI) and microfracture (MF) are well-established treatments for cartilage defects of the knee. However, high-level evidence comparing microfracture and spheroid technology ACI is limited.

DESIGN

Prospective, phase III clinical trial with patients randomized to ACI (N = 52) or MF (N = 50). Level of evidence: 1, randomized controlled trial. Both procedures followed standard protocols. For ACI 10 to 70 spheroids/cm² were administered. Primary outcome measure was the Knee Injury and Osteoarthritis Outcome Score (KOOS). This report presents results for 36 months after treatment.

RESULTS

Both ACI and MF showed significant improvement over the entire 3-year observation period. For the overall KOOS, noninferiority of ACI (the intended primary goal of the study) was formally confirmed; additionally, for the subscores "Activities of Daily Living" and "Sport and Recreation," superiority of ACI over MF was shown at descriptive level. Occurrence of adverse events were not different between both treatments (ACI 77%; MF 74%). Four patients in the MF group required reoperation which was defined as treatment failure. No treatment failure was reported for the ACI group.

CONCLUSIONS

Patients treated with matrix-associated ACI with spheroid technology showed substantial improvement in various clinical outcomes after 36 months. The advantages of ACI compared with microfracture was underlined by demonstrating noninferiority, in overall KOOS and superiority in the KOOS subscores "Activities of Daily Living" and "Sport and Recreation." In the present study, subgroups comparing different age groups and defect sizes showed comparable clinical outcomes.

Effect of Systemic Administration of Granulocyte Colony-Stimulating Factor on a Chronic Partial-Thickness Cartilage Defect in a Rabbit Knee Joint

OBJECTIVE

Cartilage lesions in the knee joint can lead to joint mechanics changes and cause knee pain. Bone marrow stimulation (BMS) promotes cartilage regeneration by perforating the subchondral bone just below the injury and inducing bone marrow cells. This study aimed to investigate whether systemic administration of granulocyte colony-stimulating factor (G-CSF) with BMS improves repair of chronic partial-thickness cartilage defects (PTCDs).

DESIGN

Eighteen 6-month-old New Zealand white rabbits were divided into 3 groups: control (C, n = 6), BMS alone (n = 6), and BMS + G-CSF (n = 6). Partial cartilage defects with 5 mm diameter were created in the trochlear region of both knees; after 4 weeks, the BMS alone and BMS + G-CSF groups underwent BMS; G-CSF (50 µg/kg) or saline was administered subcutaneously for 5 days starting from 3 days before BMS. At 8 and 16 weeks after cartilage defect creation, the area of cartilage defects was macroscopically and histologically evaluated.

RESULTS

International Cartilage Repair Society (ICRS) grades for macroscopic assessment were 0, 0.7, and 0.7 at 8 weeks and 0, 1.2, and 1.3 at 16 weeks in the C, BMS, and BMS + G-CSF groups, respectively. Wakitani scores for histological assessment were 9.8, 8.7, and 8.2 at 8 weeks and 9.5, 9, and 8.2 at 16 weeks in the C, BMS, and BMS + G-CSF groups, respectively. The BMS + G-CSF group showed significantly more repair than the C group, but there was no difference from the BMS group.

CONCLUSIONS

The effect of BMS and G-CSF on chronic PTCDs in mature rabbit knees was limited.

Clinical evaluation after matrix-associated autologous chondrocyte transplantation : a comparison of four different graft types

Aims

The aim of this retrospective study was to determine if there are differences in short-term clinical outcomes among four different types of matrix-associated autologous chondrocyte transplantation (MACT).

Methods

A total of 88 patients (mean age 34 years (SD 10.03), mean BMI 25 kg/m² (SD 3.51)) with full-thickness chondral lesions of the tibiofemoral joint who underwent MACT were included in this study. Clinical examinations were performed preoperatively and 24 months after transplantation. Clinical outcomes were evaluated using the International Knee Documentation Committee (IKDC) Subjective Knee Form, the Brittberg score, the Tegner Activity Scale, and the visual analogue scale (VAS) for pain. The Kruskal-Wallis test by ranks was used to compare the clinical scores of the different transplant types.

Results

The mean defect size of the tibiofemoral joint compartment was 4.28 cm² (SD 1.70). In total, 11 patients (12.6%) underwent transplantation with Chondro-Gide (matrix-associated autologous chondrocyte implantation (MACI)), 40 patients (46.0%) with Hyalograft C (HYAFF), 21 patients (24.1%) with Cartilage Regeneration System (CaReS), and 15 patients (17.2%) with NOVOCART 3D. The mean IKDC Subjective Knee Form score improved from 35.71 (SD 6.44) preoperatively to 75.26 (SD 18.36) after 24 months postoperatively in the Hyalograft group, from 35.94 (SD 10.29) to 71.57 (SD 16.31) in the Chondro-Gide (MACI) group, from 37.06 (SD 5.42) to 71.49 (SD 6.76) in the NOVOCART 3D group, and from 45.05 (SD 15.83) to 70.33 (SD 19.65) in the CaReS group. Similar improvements were observed in the VAS and Brittberg scores.

Conclusion

Two years postoperatively, there were no significant differences in terms of outcomes. Our data demonstrated that MACT, regardless of the implants used, resulted in good clinical improvement two years after transplantation for localized tibiofemoral defects.

Cite this article: Bone Joint Res 2021;10(7):370–379.

The Relationship Between Patient Expectations and Functional Outcomes in Patients Undergoing Cartilage Repair of the Knee: A Mixed Methods Study

CONTEXT

Patient expectations have been shown to be a major predictor of outcomes. Fulfilled expectations have been linked to increased patient satisfaction and rehabilitation adherence. Expectations may be influenced by a variety of factors, including patient characteristics, preoperative function, or disease characteristics. It is currently unknown what factors may influence patient expectations prior to cartilage repair of the knee, and to what degree. Furthermore, understanding the importance and values of those expectations for recovery using mixed methods has not previously been conducted in this patient population. The purpose of this mixed methods study is to examine and explore the relationships between patient expectations and functional outcome in patients undergoing cartilage repair of the knee.

DESIGN

A mixed methods design was used.

METHODS

Twenty-one patients scheduled to undergo cartilage repair of the knee were included. Participants completed the Hospital for Special Surgery Knee Surgery Expectations Survey and the Knee Injury and Osteoarthritis Outcome Score at their preoperative visit. Knee Injury and Osteoarthritis Outcome Scores were also obtained at 3 and 6 months postsurgery. A selected sample of 6 participants participated in semi-structured interviews 6 months postsurgery. Pearson correlation coefficients were used to determine relationships between expectations and functional outcome.

RESULTS

Patients have moderate expectations for recovery, and these expectations were positively associated with preoperative pain, activities of daily living, and quality of life. Expectations also correlated with symptoms 3 months postsurgery, but there were no other significant correlations between preoperative expectations and postoperative function in the short term. Four qualitative themes emerged as participants described how previous recovery experiences shaped their expectations.

CONCLUSIONS

Formalized patient and caregiver education, prehabilitation, and the use of psychological skills during rehabilitation may help to manage patient expectations and provide more focused and individualized care, thus improving outcomes.

Cartiform Implantation for focal cartilage defects in the knee: A 2-year clinical and magnetic resonance imaging follow-up study

The purpose of this study was to evaluate clinical and magnetic resonance imaging (MRI) outcomes in patients who underwent cryopreserved viable osteochondral allograft (CVOCA) implantation for focal cartilage defects in the knee at a minimum of 2-years postoperatively. This is a retrospective follow-up study of twelve patients who underwent CVOCA implantation from 2013 to 2015 by a single surgeon for a International Cartilage Repair Society (ICRS) grade 3 or 4 chondral defect. Patient-reported outcome (PRO) measurements and MRI were obtained 2-years postoperatively. Collected PRO measures included: International Knee Documentation Committee (IKDC) form; Visual Analog Scale (VAS) pain score; Veterans RAND 12-Item Health Survey (VR-12); Knee Injury and Osteoarthritis Outcome Score (KOOS); and Western Ontario McMaster Universities Osteoarthritis Index (WOMAC). Patients completed a standard return to work and sports/recreation survey. A blinded, fellowship-trained musculoskeletal radiologist independently evaluated each MRI to determine the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score. Mean follow-up was 2.1 years (2.0-2.3). There were 6 women and 6 men with a mean age of 46.2 ± 11.9 years. Mean PRO scores were: IKDC 72.6 ± 17.4; VAS 2.9 ± 2.8; WOMAC 84.2 ± 15.1; KOOS- Pain 83.8 ± 18.5, Symptoms 77.6 ± 16.0, ADL 88.0 ± 16.9, Sports/Rec 67.7 ± 33.3, QOL 54.8 ± 24.2; and VR-12 PCS 45.0 ± 8.5 and MCS 51.1 ± 9.5. The mean MOCART score was 59.5 ± 12.9. To our knowledge, this is the largest study to report clinical and MRI outcomes of CVOCA implantation in the knee. With positive functional outcomes and lack of failures at 2-year follow-up, CVOCA is a promising treatment option for focal chondral defects in the knee.

STUDY DESIGN

Retrospective case series, Level of evidence 4.

Postoperative Management for Articular Cartilage Surgery in the Knee

The postoperative rehabilitation team plays a crucial role in optimizing outcomes after articular cartilage surgery. A comprehensive approach to postoperative physical therapy that considers the type of surgery, location in the knee, concurrent procedures, and patient-specific factors is imperative. While postoperative rehabilitation protocols should be specific to the patient and type of surgery performed and include phased rehabilitation goals and activities, the key principles for postoperative rehabilitation apply across the spectrum of articular cartilage surgeries and patients. These key principles consist of preoperative assessments that include physical, mental, and behavioral components critical to recovery; education and counseling with respect to expectations and compliance; and careful monitoring and adjustments throughout the rehabilitation period based on consistent communication among rehabilitation, surgical, and imaging teams to ensure strict patient compliance with restrictions, activities, and timelines to optimize functional outcomes after surgery.

Third generation autologous chondrocyte implantation is a good treatment option for athletic persons

PURPOSE

Autologous chondrocyte implantation is an established method for the treatment of joint cartilage damage. However, to date it has not been established that autologous chondrocyte implantation is an appropriate procedure for cartilage defects therapy in athletic persons. The aim of this study is to analyze if third-generation autologous chondrocyte implantation is an appropriate treatment for athletic persons with full cartilage defect of the knee joints.

METHODS

A total of 84 patients were treated with third-generation autologous chondrocyte implantation (NOVOCART^® 3D). The mean follow-up time was 8 years (5-14). Sports activity was measured via UCLA Activity Score and Tegner Activity Scale before the onset of knee pain and postoperatively in an annual clinical evaluation. 41 athletic persons and 43 non-athletic persons (UCLA-Cut-off: 7; Tegner Activity Scale-Cut-off: 4) were analyzed. Patient reported outcomes were captured using IKDC subjective, KOOS, Lysholm score and VAS score on movement.

RESULTS

Patient reported outcomes (IKDC, VAS at rest, VAS on movement) showed significant improvement (p < 0.001) postoperatively. Athletic persons demonstrated significantly better results than non-athletic persons in the analyzed outcome scores (IKDC: p < 0.01, KOOS: p < 0.01, Lysholm score: p < 0.01). 96.4% of the patients were able to return to sport and over 50% returned or surpassed their preinjury sports level. The remaining patients were downgraded by a median of two points on the UCLA- and 2.5 on the Tegner Activity Scale. A shift from high-impact sports to active events and moderate or mild activities was found. Furthermore, it was shown that preoperative UCLA score and Tegner Activity Scale correlated significantly with the patient reported outcome postoperatively.

CONCLUSION

Autologous chondrocyte implantation is a suitable treatment option for athletic persons with full-thickness cartilage defects in the knee. The return to sports activity is possible, but includes a shift from high-impact sports to less strenuous activities.

Return-to-Sport Review for Current Cartilage Treatments

The return to play outcome is an important measure for orthopaedic sports medicine treatments. This variable is especially important when discussing cartilage treatments because there are many different cartilage options available to athletes with articular injuries and this population is particularly interested in the ability to return to activities. Although many outcome variables are considered in any surgical procedure, the return-to-sport variable is focused on an active population and can be tailored to that patient's sport-specific goals. In this article, we will review some of the most recent and up-to-date articles describing return-to-sport outcomes for various knee cartilage treatments. This article will focus on the most common current knee cartilage treatments including microfracture, autologous chondrocyte implantation, osteochondral autograft transplant, and osteochondral allograft transplantation.

Is There a Role for Cartilage Imaging in Athletes?

This article reviews implications for cartilage imaging in athletes in the setting of (1) acute chondral injury diagnosis, (2) evaluation and follow-up of conservative and surgical therapy, and (3) evaluation of cartilage as a surrogate for meniscal function and joint stability. Focal knee cartilage defects are common in athletic populations. Athletes with articular cartilage injury may initially be able to return to sport with conservative therapy; however, a reduction of athletic ability and progression to osteoarthritis is expected in athletes with untreated severe chondral injury. For diagnostic and pre- and postsurgical evaluation purposes, morphological magnetic resonance (MR) assessment of the articular cartilage with high-resolution protocols is crucial. Although not widely implemented for clinical use, compositional MR techniques have great potential for monitoring the development and progression of biochemical and microstructural changes in cartilage extracellular matrix before gross morphological changes occur.

Returning to Work After Articular Cartilage Repair Intervention: A Systematic Review

Background:

The process of returning to work after cartilage treatment has not been studied in depth, even though a better understanding of potential outcomes could lead to significant benefits for the general population.

Purpose:

To determine which surgical interventions are most effective in helping patients return to work after cartilage repair and to identify factors that affect the ability to return to work.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

This systematic review followed PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines in analyzing reports on articular cartilage treatment and return to work published from January 1966 (when the first system of classifying articular cartilage injuries based on the mechanism of injuries and type of lesions was developed) to January 2019. General surgical information and available clinical scores were used to assess outcomes.

Results:

Only 5 studies describing 283 patients were found to be relevant to our objectives and were therefore included in the analysis. Autologous chondrocyte implantation (ACI) and osteochondral allografts were the only 2 procedures for which information was included regarding patient return to work rates. The mean (overall) return-to-work time after a cartilage repair operation was 4.80 ± 3.02 months. ACI was the most common procedure (3 studies; 227 patients). Return to work after ACI or ACI with high tibial osteotomy (HTO) occurred in almost 100% of cases, whereas the rate of return to work was 51.78% for patients who underwent osteochondral allograft (P < .01); further, patients who had ACI or ACI+HTO returned to work sooner compared with patients who underwent osteochondral allograft. The Knee injury and Osteoarthritis Outcome Score (KOOS) and Single Assessment Numerical Evaluation (SANE) scores were significantly higher in patients who fully returned to work. No significant difference was found in rates of return to work after ACI related to sex, area of the lesion, or size of the defect.

Conclusion:

The vast majority of published results on articular cartilage repair do not include data on return to work. Although available data on articular cartilage repair in the general population reveal a high rate of return to work, including those patients treated with ACI, the data do not stratify patients by the type and demand of work. No randomized studies have examined return-to-work rates. Hence, authors should include these data in future studies. A refined definition of work intensity, rather than just return to work, may provide a clearer picture of the relative effectiveness of different surgical interventions. To that end, the authors propose a return to work prognostic score called the Prognostic Cartilage Repair Return to Work Score, or PROCART-RTW score.

Association Between Isokinetic Knee Strength and Perceived Function and Patient Satisfaction With Sports and Recreational Ability After Matrix-Induced Autologous Chondrocyte Implantation

Background:

Returning to a sound level of activity after matrix-induced autologous chondrocyte implantation (MACI) is important to patients. Evaluating the patient’s level of satisfaction with his or her sports and recreational ability is critical.

Purpose:

To investigate (1) satisfaction with sports and recreational ability after MACI and (2) the role that knee strength plays in self-reported knee function and satisfaction.

Study Design:

Case-control study; Level of evidence, 3.

Methods:

Isokinetic knee strength was assessed in 97 patients at 1, 2, and 5 years after MACI to calculate hamstrings-quadriceps ratios and peak knee extensor and flexor torque limb symmetry indices (LSIs). The Sports and Recreation subscale of the Knee injury and Osteoarthritis Outcome Score (KOOS Sports/Rec) was completed. A satisfaction scale was used to evaluate how satisfied the patients were with their ability to return to recreational activities and their ability to participate in sport. Associations between knee strength LSI, KOOS Sports/Rec, and satisfaction with recreational and sporting activities were assessed through use of multivariable linear and logistic regression, with adjustment for confounders. Mediation analysis was conducted to assess the extent to which self-reported knee function mediated associations between strength LSI and satisfaction.

Results:

Satisfaction with the ability to return to recreational activities was achieved in 82.4%, 85.6%, and 85.9% of patients at 1, 2, and 5 years, respectively, and satisfaction with sports participation was achieved in 55.7%, 73.2%, and 68.5% of patients at 1, 2, and 5 years, respectively. Knee extension torque LSIs were associated with KOOS Sports/Rec after adjustment for confounders over 1, 2, and 5 years (5-year regression coefficient, 6.0 points; 95% CI, 1.4-10.7; P = .012). KOOS Sports/Rec was associated with the likelihood of being satisfied at all time points (recreation: 5-year adjusted odds ratio [OR], 2.26; 95% CI, 1.48-3.46; P < .001; and sports: 5-year adjusted OR, 1.98; 95% CI, 1.47-2.68; P < .001). In a multivariable mediation model, the knee extension torque LSI was associated with satisfaction directly (standardized coefficient, 0.16; 95% CI, 0.03-0.28; P = .017) and indirectly via KOOS Sports/Rec (standardized coefficient, 0.19; 95% CI, 0.01-0.38; P = .027), the latter representing 55% of the total association of knee extension torque LSI with satisfaction.

Conclusion:

Knee extensor symmetry was associated with satisfaction in recreational and sporting ability, both directly and indirectly, via self-reported sports and recreation–related knee function. Restoring strength deficits after MACI is important for achieving optimal outcomes.

The Scaffold-Articular Cartilage Interface: A Combined In Vitro and In Silico Analysis Under Controlled Loading Conditions

The optimal method to integrate scaffolds with articular cartilage has not yet been identified, in part because of our lack of understanding about the mechanobiological conditions at the interface. Our objective was to quantify the effect of mechanical loading on integration between a scaffold and articular cartilage. We hypothesized that increased number of loading cycles would have a detrimental effect on interface integrity. The following models were developed: (i) an in vitro scaffold-cartilage explant system in which compressive sinusoidal loading cycles were applied for 14 days at 1 Hz, 5 days per week, for either 900, 1800, 3600, or 7200 cycles per day and (ii) an in silico inhomogeneous, biphasic finite element model (bFEM) of the scaffold-cartilage construct that was used to characterize interface micromotion, stress, and fluid flow under the prescribed loading conditions. In accordance with our hypothesis, mechanical loading significantly decreased scaffold-cartilage interface strength compared to unloaded controls regardless of the number of loading cycles. The decrease in interfacial strength can be attributed to abrupt changes in vertical displacement, fluid pressure, and compressive stresses along the interface, which reach steady-state after only 150 cycles of loading. The interfacial mechanical conditions are further complicated by the mismatch between the homogeneous properties of the scaffold and the depth-dependent properties of the articular cartilage. Finally, we suggest that mechanical conditions at the interface can be more readily modulated by increasing pre-incubation time before the load is applied, as opposed to varying the number of loading cycles.

Low rate of return to pre-injury sport level in athletes after cartilage surgery: a 10-year follow-up study

PURPOSE

Although articular surface is frequently damaged in athletes, results in terms of return to sport and level of activity after cartilage surgery remain rather unpredictable and poorly documented. The aim of this study is to evaluate the clinical outcome in terms of rate and level of return to sport in a group of competitive athletes who underwent matrix-assisted autologous chondrocyte transplantation (MACT), as well as the impact on their athletic career.

METHODS

Thirty-one male patients (mean age 22.6 ± 6.3 years) p racticing sport at competitive level, affected by focal chondral/osteochondral lesions of the distal femur, were enrolled and treated with arthroscopic hyaluronan-based MACT. Patients were evaluated prospectively at 1-year intervals with the IKDC subjective, Tegner, and EuroQol VAS scores during their pre-operative visit and subsequent follow-ups for up to 10 years. Return to sport in terms of level, time and maintenance of the activity level was documented, together with surgical or clinical failures.

RESULTS

A marked improvement in all scores was found: IKDC increased from 40.3 ± 13.4 to 81.7 ± 14.4 (p < 0.0005) at 12 months; a further improvement was observed at 2 years (89.5 ± 11.3; p = 0.008), then results were stable for up to 10 years (87.3 ± 13.6). The analysis of return to sport documented that 64.5% of patients were able to return at a competitive level, and 58.1% performed at the same pre-injury level, with activity rates decreasing over time. The rate of patients returning to competitive level was 84% in those without previous surgery (vs. 33% who had undergone previous surgery), 87% for those with traumatic lesions (vs. 33% and 50% for degenerative and OCD lesions, respectively), and 92.3% in younger patients (age < 20 years). Among these factors, multivariate analysis demonstrated that previous surgery was the single most influencing factor for returning to the same sport level (p = 0.010).

CONCLUSIONS

These long-term results showed that chondrocyte-based regenerative approach has some limitations in terms of sport-related outcomes. The level of high functional knee restoration needed for such high-demanding activity level can be challenging to achieve, especially in patients with a more compromised joint homeostasis. Return to sport rate varies significantly according to specific patient and lesion characteristics and best results are obtained in young patients with traumatic lesions without previous surgery, which should be considered when treating athletes affected by cartilage lesions.

LEVEL OF EVIDENCE

IV.

Return to Sport and Sports-Specific Outcomes After Osteochondral Allograft Transplantation in the Knee: A Systematic Review of Studies With at Least 2 Years' Mean Follow-Up

PURPOSE

To report current data on return-to-sport rates and sports-specific patient-reported outcomes after osteochondral allograft (OCA) transplantation for cartilage defects of the knee.

METHODS

We performed a systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines that included studies from 1975 to 2018 with a minimum 2-year mean follow-up that reported return-to-sport rates or sports-specific patient-reported outcomes. Outcomes, reoperations, and complications were provided in table format, and a subjective analysis was performed.

RESULTS

This review included 13 studies with 772 patients who underwent OCA transplantation at a mean of 24 to 91 months' follow-up. The return-to-sport rate ranged from 75% to 82%. For patient-reported outcomes, the Knee Injury and Osteoarthritis Score Sport increased in 4 studies, the Tegner activity scale score increased in 3 studies but decreased in 1, and the Marx activity scale score increased in 1 study but decreased in 2. Studies reporting improvements in the Cincinnati Knee Score and Knee Injury and Osteoarthritis Score Sport reached the minimal clinically important difference. The reoperation rate was high (ranging from 34% to 53% in more than half of studies), with reoperations primarily performed for loose body removal or debridement.

CONCLUSIONS

This systematic review of 13 studies suggests that OCA transplantation for cartilage defects allows most athletes to return to sport (range, 75%-82%). Most studies reported improvements in sports-specific patient-reported outcomes at follow-up and reached the minimal clinically important difference. However, the reoperation rate was high in several studies, with a large percentage of patients requiring loose body removal or debridement. The long-term survival of the allografts is largely unknown, but this study suggests OCA transplantation consistently improves function in athletes with chondral injuries.

LEVEL OF EVIDENCE

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

Cartilage Restoration Surgery: Incidence Rates, Complications, and Trends as Reported by the American Board of Orthopaedic Surgery Part II Candidates

PURPOSE

To evaluate the current status of advanced cartilage restoration procedures among newly trained orthopaedic surgeons in the United States.

METHODS

The American Board of Orthopaedic Surgery database was queried to identify all advanced cartilage restoration procedure cases submitted by American Board of Orthopaedic Surgery part II board certification examination candidates from 2003 to 2015. All documented autologous chondrocyte implantation, autologous osteochondral transfer, osteochondral allograft transplantation, and marrow stimulation techniques (MSTs) procedures were analyzed. Analysis was performed to describe trends in annual incidence, types of complications, concomitant procedures, and geographical differences in incidence of advanced cartilage procedures.

RESULTS

From 2003 to 2015, a total of 2,827 surgeons submitted 7,522 cartilage restoration procedures, with 7,060 cases documented as MST (80.01%). The number of cartilage cases decreased significantly from 2003 to in 2015 (P <.001), with MST having the largest decline (P < .001). The incidence of open osteochondral allograft transplantation (odds ratio = 1.35; P = .023) and open autologous osteochondral transfer (odds ratio = 0.84; P = .004) increased over the study period. Overall, the majority of patients (57.0%) were male; however, female patients were on average significantly older than male patients (P < .001). Cartilage procedures were performed concomitantly with a realignment osteotomy procedure in 1.7% of cases. The incidence of surgical complications increased throughout the study period from 2.9% in 2003 to 9.5% in 2015 (P < .001).

CONCLUSIONS

Cartilage restoration procedures, specifically MSTs, are being decreasingly performed among recently trained orthopaedic surgeons. In contrast, complication rates have been increasing since 2003, demonstrating a possible paradigm shift toward more complex cartilage procedures, specifically osteochondral grafting procedures.

CLINICAL RELEVANCE

This study demonstrates a significant decline in the use of MSTs by recently trained orthopaedic surgeons. In addition, an increase in several more complex cartilage restoration procedures was found. Taken in sum, these changes may reflect a shift in residency and fellowship training away from marrow stimulation procedures that elicit a fibrocartilage reparative tissue and toward more complex procedures that provide a more hyaline-like articular cartilage surface.

Large fresh osteochondral allografts for the hip: growing the evidence

INTRODUCTION

Articular cartilage lesions of the hip are difficult to effectively treat. Osteochondral allograft (OCA) transplantation in the knee has been associated with long-term success, but OCA for the hip has not been extensively studied. Here, we present the clinical and radiological outcomes from a cohort of 10 patients treated with fresh OCA transplants for large osteochondral defects of the femoral head and/or acetabulum.

METHODS

10 patients who had undergone osteochondral allograft transplantation of the femoral head and/or acetabulum at our institution between 2013 and 2016 were identified from our Institutional Review Board-approved registry. Hip disability and Osteoarthritis Outcome Score (HOOS) was used to track patient progress.

RESULTS

10 patients with an average clinical follow-up of 1.4 years were included in this study. 4 patients were treated solely with OCA plugs for femoral head defects, while the remaining 6 received femoral OCA plugs and at least 1 concomitant procedure for additional intraarticular pathology. 7 patients (70%) had successful functional outcomes, while 3 (30%) had unsuccessful outcomes and were subsequently converted to total hip arthroplasty (THA) 5 to 29 months after OCA.

CONCLUSIONS

OCA transplantation can be an effective treatment strategy for young, healthy individuals with articular cartilage lesions of the hip. Smoking, avascular necrosis aetiology, acetabular involvement and concomitant procedures may be risk factors for unsuccessful outcomes necessitating salvage with THA. Long-term clinical studies to refine indications and determine functional outcomes and survival rates are warranted.

No evidence for the most appropriate postoperative rehabilitation protocol following anterior cruciate ligament reconstruction with concomitant articular cartilage lesions: a systematic review

PURPOSE

Anterior cruciate ligament (ACL) rupture commonly occurs in conjunction with articular cartilage injury. However, there is no consensus on the most appropriate rehabilitation which should be carried out for ACL reconstruction (ACLR) and the surgical management of articular cartilage lesions of the knee. The purpose of this study was to systematically review the literature to investigate the recommended rehabilitation protocol for patients undergoing ACLR with concomitant articular cartilage injury with a view to develop guidelines on the most appropriate treatment.

METHODS

Two reviewers independently searched five database for randomised controlled trials (RCTs), non-randomised comparative and retrospective cohort studies (CS) describing the management of concomitant ACL rupture and articular cartilage injury and the postoperative rehabilitation regimen. Risk of bias was performed using a modified Downs & Black's checklist. The primary outcome was specific rehabilitation protocols including weight-bearing status, immobilisation, continuous passive motion (CPM), and return to play criteria. Secondary outcomes included patient-reported outcomes. A best evidence synthesis was performed.

RESULTS

The review yielded six studies which reported on rehabilitation techniques. All studies were of low methodological quality. There was considerable variability in not only the chondral lesion reported but also the treatment techniques utilised and especially the rehabilitation regimes. No consensus was found on weight-bearing status, postoperative immobilisation, the use of CPM, or return to play criteria. Given the quality of the papers, there was no evidence to recommend any specific rehabilitation regime in the postoperative management of concomitant ACLR and articular cartilage lesions.

CONCLUSION

This systematic review revealed that despite how common concomitant ACL rupture and articular cartilage injury is, there is no evidence to support one, most appropriate rehabilitation protocol. From a clinical perspective, decisions on postoperative rehabilitation for patients undergoing ACLR and treatment of articular cartilage lesions should be made on a case-by-case basis with criteria-based progression until more robust evidence becomes available. A list of specific rehabilitation protocols based on the cartilage restoration technique is provided.

LEVEL OF EVIDENCE

IV.

Autologous chondrocyte implantation in the knee: systematic review and economic evaluation

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.

Knee Pain and Mobility Impairments: Meniscal and Articular Cartilage Lesions Revision 2018

The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability, and Health (ICF). The purpose of these revised clinical practice guidelines is to review recent peer-reviewed literature and make recommendations related to meniscus and articular cartilage lesions. J Orthop Sports Phys Ther. 2018;48(2):A1-A50. doi:10.2519/jospt.2018.0301.

Emerging Concepts in Treating Cartilage, Osteochondral Defects, and Osteoarthritis of the Knee and Ankle

The management and treatment of cartilage lesions, osteochondral defects, and osteoarthritis remain a challenge in orthopedics. Moreover, these entities have different behaviors in different joints, such as the knee and the ankle, which have inherent differences in function, biology, and biomechanics. There has been a huge development on the conservative treatment (new technologies including orthobiologics) as well as on the surgical approach. Some surgical development upraises from technical improvements including advanced arthroscopic techniques but also from increased knowledge arriving from basic science research and tissue engineering and regenerative medicine approaches. This work addresses the state of the art concerning basic science comparing the knee and ankle as well as current options for treatment. Furthermore, the most promising research developments promising new options for the future are discussed.

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.

Clinical Management in Early OA

Knee osteoarthritis affects an important percentage of the population throughout their life. Several factors seem to be related to the development of knee osteoarthritis including genetic predisposition, gender, age, meniscal deficiency, lower limb malalignments, joint instability, cartilage defects, and increasing sports participation. The latter has contributed to a higher prevalence of early onset of knee osteoarthritis at younger ages with this active population demanding more consistent and durable outcomes. The diagnosis is complex and the common signs and symptoms are often cloaked at these early stages. Classification systems have been developed and are based on the presence of knee pain and radiographic findings coupled with magnetic resonance or arthroscopic evidence of early joint degeneration. Nonsurgical treatment is often the first-line option and is mainly based on daily life adaptations, weight loss, and exercise, with pharmacological agents having only a symptomatic role. Surgical treatment shows positive results in relieving the joint symptomatology, increasing the knee function and delaying the development to further degenerative stages. Biologic therapies are an emerging field showing early promising results; however, further high-level research is required.

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.

Sporting Activity Is Reduced 11 Years After First-Generation Autologous Chondrocyte Implantation in the Knee Joint

BACKGROUND

Little is known about long-term sporting activity after periosteal autologous chondrocyte implantation (ACI-P) and its correlation to clinical, morphological, and ultrastructural cartilage characteristics on magnetic resonance imaging (MRI).

PURPOSE

To evaluate long-term sporting activity after ACI-P and to correlate with clinical and MRI findings.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Patients who underwent ACI-P for isolated cartilage defects of the knee joint between 1997 and 2001 were analyzed for sporting ability for 3 different time points: lifetime until the onset of pain, the year before ACI-P, and 11 years (range, 9.0-13.4 years) postoperatively. Sporting activity was assessed and patients' level of activity scaled using standardized questionnaires. MRI scans of the affected knee joint at follow-up were analyzed using the MOCART (magnetic resonance observation of cartilage repair tissue) score and T2 mapping.

RESULTS

Seventy of 86 patients (81% follow-up rate) consisting of 25 female and 45 male patients, with a mean age of 33.3 ± 10.2 years at the time of surgery, mean defect size of 6.5 ± 4.0 cm², and 1.17 treated defects per patient, agreed to participate in the study at a mean 10.9 ± 1.1 years after ACI-P. Fifty-nine patients (69% of total; 84% of follow-up) agreed to MRI, allowing the complete evaluation of 71 transplant sites. Before the onset of symptoms (lifetime), 95.7% of patients played a mean 6.0 sporting activities at a competitive level. In the year before ACI-P, 81.4% of patients played a mean 3.4 sporting activities in 2.4 sessions during 5.4 hours per week at a recreational level. At follow-up, 82.9% of the patients played a mean 3.0 sporting activities in 1.8 sessions during 3.0 hours per week at a recreational level. In contrast to objective factors, 65.6% of the patients felt that their subjective sporting ability had improved or strongly improved after ACI-P, whereas 12.9% felt that their situation had declined or strongly declined, and 21.4% stated that their sporting ability had undergone no change because of surgery. Factors of sporting activity correlated significantly with clinical long-term outcomes. MRI analysis with a mean repair tissue T2 relaxation time of 35.2 milliseconds and mean MOCART score of 44.9 showed no conclusive significant correlation to sporting activity. Level of performance was the only sporting activity factor to show a weak correlation with subgroups of the MOCART score.

CONCLUSION

The premorbid level of sporting and recreational activities cannot be achieved 11 years after ACI-P. The MRI results determined at this time point did not conclusively correlate with long-term sporting activity.

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.

Return to Sport and Recreational Activity After Osteochondral Allograft Transplantation in the Knee

BACKGROUND

Osteochondral allograft (OCA) transplantation is an integral part of the cartilage repair paradigm, but insufficient data are available regarding return to sport or recreational activity after the procedure.

PURPOSE

The purpose of this study was to determine if athletic patients undergoing OCA transplantation returned to sport, assess reasons for not returning to sport, and ascertain patient and graft-related characteristics that differed between those who returned or did not return to sport. The secondary aims were to assess graft survivorship and patient-reported subjective outcome measures (pain, function, satisfaction) among athletic patients undergoing OCA transplantation.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

We identified 149 knees in 142 patients who participated in sport or recreational activity before a cartilage injury (45% highly competitive athletes and 55% well-trained and frequently sporting) and underwent OCA transplantation in the knee. The mean age was 31.2 years and 58.4% were male. Information on preinjury and postoperative participation in sport or recreational activity was collected. Patients not returning to sport after OCA transplantation were mailed a questionnaire to assess why. Postoperative pain, function, and satisfaction scores were obtained, and further surgery on the operative knee was documented.

RESULTS

At a mean follow-up of 6 years, 75.2% of knees returned to sport or recreational activity. Among those who did not return to sport, knee-related issues and lifestyle changes were cited as reasons why. Patients who did not return to sport were more likely to be female, have injured their knee in an activity other than sport, and have a larger graft size. The diagnosis and anatomic location also differed. Overall, 71% of knees reported having "very good" to "excellent" function, and 79% were able to participate in a high level of activity (moderate, strenuous, or very strenuous) postoperatively. After OCA transplantation, 25.5% of knees underwent further surgery; 14 knees (9.4% of entire cohort) were considered allograft failures. Among the 135 knees that had the graft remaining in situ, pain and function improved from preoperatively to the latest follow-up on all measures, and 91% of patients were satisfied with the results of the surgery.

CONCLUSION

OCA transplantation is a successful treatment option for athletes and highly active patients who sustain a cartilage injury to their knee. The majority of patients returned to sport or recreational activity.

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.

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.

Long-term outcome of grade III and IV chondral injuries of the knee treated with Steadman microfracture technique

INTRODUCTION

The aim of our study is to demonstrate the effectiveness of Steadman microfracture technique in the management of high-grade chondral defects at the level of the knee by clinical follow-ups at eleven years.

MATERIALS AND METHODS

This is a study conducted on fifteen patients suffering from Outerbridge grade III and IV chondral lesions of the knee, who underwent Steadman microfracture surgery between 2003 and 2004. Selective exclusion criteria to prevent that other treatments or comorbidities could invalidate the results were used. Patients were clinically evaluated with Lysholm and IKDC scale scores before surgery and at follow-ups at eleven years.

RESULTS

There has been an improvement in the Lysholm scores (59.33 ± 18.2 at time zero vs 82.13 ± 14.16 at time t; p value: 0.0342) and in the IKDC scores (45.13 ± 17.07 at time zero vs 68.66 ± 21.47 at time t; p value: 0.04) that appears statistically significant.

DISCUSSION

Currently microfracture surgery is not indicated in patients with high-grade chondral defects, but at the same time, it is a technique of easy execution, low cost and good results. The clinical improvement observed appears statistically significant, but we have also noticed a slight clinical worsening in two patients, possibly caused by: improper treatment, new trauma, incorrect rehabilitation and age at time of surgery.

CONCLUSIONS

The study has shown significant clinical improvements in patients, despite the fact that indications to the use of microfracture are still very limited and selective. It's essential to underline the importance of the single patient assessment process, taking into account a variety of aspects including the site, the number and extent of the lesion, the degree of functionality, activity level, age and previous trauma. This shows the importance of a comprehensive assessment of the patient in order to choose the most suitable surgical option, which not necessarily has to strictly adhere to standard practice.

Osteochondral lesions of the talus in the athlete: up to date review

PURPOSE OF REVIEW

Osteochondral lesions of the talus (OLT) are common injuries in athletes. The purpose of this study is to comprehensively review the clinical results and return to sport capacity in athletes following treatment for OLT.

RECENT FINDINGS

Reparative procedures, such as bone marrow stimulation, and replacement procedures, such as autologous osteochondral transplantation, provide good clinical outcomes in short- and mid-term follow-up in the athlete. Recently, biological augmentation and scaffold-based therapies have been shown to improve clinical and radiological outcomes in OLT in both the general population and athletes. Most studies are of a low level of evidence. Studies analyzing the return to sport capability in athletes are further lacking. High-level evidence and well-designed clinical trials are required to establish the most effective treatment protocol.