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De Marziani L, Boffa A, Andriolo L, Di Martino A, Romandini I, Solaro L, Zaffagnini S, Filardo G. Cell-free biomimetic osteochondral scaffold for the treatment of knee articular surface lesions: Clinical outcomes differ based on patient and lesion characteristics. Knee Surg Sports Traumatol Arthrosc 2024. [PMID: 39101253 DOI: 10.1002/ksa.12402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2024] [Revised: 07/13/2024] [Accepted: 07/14/2024] [Indexed: 08/06/2024]
Abstract
PURPOSE A cell-free biomimetic osteochondral scaffold was developed to treat cartilage knee lesions, with positive clinical results documented in small case series. However, clear evidence on patient and lesion characteristics that might affect the outcome is still lacking. The aim of this study is to analyse a large cohort of patients treated with this scaffold to investigate factors that could influence the clinical outcome. METHODS Two hundred and three patients (mean age 30.7 ± 10.9 years) treated with this scaffold were prospectively evaluated at baseline, 6-, 12- and 24-month follow-up. The clinical outcome was analysed using the International Knee Documentation Committee (IKDC) score, and the activity level was assessed with the Tegner score. The influence of patient and lesion characteristics on clinical outcomes was analysed. RESULTS Mild and severe adverse reactions were found in 39.0% and 1.5% of patients, respectively. The failure rate was 2.0%, increasing to 12.3% when including also clinical failures. The IKDC subjective score increased from 43.3 ± 15.9 to 61.0 ± 16.2 at 6 months, 68.3 ± 18.5 at 12 months and 73.8 ± 18.3 at 24 months (p < 0.0005). The Tegner improved from 2.5 ± 1.7 to 4.2 ± 1.7 at 24 months (p < 0.0005), without reaching the pre-injury level (6.0 ± 2.2) (p < 0.0005). The IKDC objective score changed from 68.5% normal and nearly normal knees before the treatment to 90.1% at 24 months. At 24 months, age showed a correlation with the IKDC subjective score (ρ = -0.247; p < 0.0005), women had a lower score (p < 0.0005), as well as patients with patellar lesions (p = 0.002). Previous surgery correlated with lower results (p = 0.003), while better results were found in osteochondritis dissecans (OCD) compared to degenerative lesions (p = 0.001). CONCLUSION This cell-free biomimetic scaffold is a safe and effective treatment for cartilage knee lesions, offering positive clinical results at 2 years with a low failure rate. Better outcomes were observed in younger patients, in lesions of the femoral condyles and in OCD, while joints affected by patellar lesions, patients who underwent previous knee surgery, and women may expect lower results. LEVEL OF EVIDENCE III, Cohort study.
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Affiliation(s)
- Luca De Marziani
- Clinica Ortopedica e Traumatologica 2, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Angelo Boffa
- Clinica Ortopedica e Traumatologica 2, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Luca Andriolo
- Clinica Ortopedica e Traumatologica 2, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Alessandro Di Martino
- Clinica Ortopedica e Traumatologica 2, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Iacopo Romandini
- Clinica Ortopedica e Traumatologica 2, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Luca Solaro
- Clinica Ortopedica e Traumatologica 2, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Stefano Zaffagnini
- Clinica Ortopedica e Traumatologica 2, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Giuseppe Filardo
- Faculty of Biomedical Sciences, Università Della Svizzera Italiana, Lugano, Switzerland
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De Marziani L, Boffa A, Andriolo L, Di Martino A, Filardo G, Zaffagnini S. Chitosan-based scaffold augmentation to microfractures: Stable results at mid-term follow-up in patients with patellar cartilage lesions. J Exp Orthop 2024; 11:e12065. [PMID: 38911189 PMCID: PMC11193853 DOI: 10.1002/jeo2.12065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 05/03/2024] [Accepted: 05/14/2024] [Indexed: 06/25/2024] Open
Abstract
Purpose Patellar cartilage lesions are a frequent and challenging finding in orthopaedic clinical practice. This study aimed to evaluate a chitosan-based scaffold's mid-term clinical and imaging results patients with patellar cartilage lesions. Methods Thirteen patients (nine men, four women, 31.3 ± 12.7 years old) were clinically evaluated prospectively at baseline, 12, 24 and at a final minimum follow-up of 60 months (80.2 ± 14.7) with International Knee Documentation Committee (IKDC) subjective, Knee Injury and Osteoarthritis Outcome Score and Tegner scores. A magnetic resonance analysis was performed at the last follow-up using the Magnetic resonance Observation of CArtilage Repair Tissue (MOCART) 2.0 score. Results An overall significant clinical improvement in the scores was observed from baseline to all follow-ups, with stable clinical results from 24 months to the mid-term evaluation. The IKDC subjective score passed from 46.3 ± 20.0 at baseline to 70.1 ± 21.5 at the last follow-up (p = 0.029). Symptoms' duration before surgery negatively correlated with the clinical improvement from baseline to the final follow-up (p = 0.013) and sex influenced the improvement of activity level from the preoperative evaluation to the final follow-up, with better results in men (p = 0.049). In line with the clinical findings, positive results were documented in terms of cartilage repair quality with a mean MOCART 2.0 score of 72.4 ± 12.5. Conclusions Overall, the use of this chitosan-based scaffold provided satisfactory results with a stable clinical improvement up to mid-term follow-up, which should be confirmed by further high-level studies to be considered a suitable surgical option to treat patients affected by patellar cartilage lesions. Level of Evidence Level IV, prospective case series.
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Affiliation(s)
- Luca De Marziani
- Clinica Ortopedica e Traumatologica 2IRCCS Istituto Ortopedico RizzoliBolognaItaly
| | - Angelo Boffa
- Clinica Ortopedica e Traumatologica 2IRCCS Istituto Ortopedico RizzoliBolognaItaly
| | - Luca Andriolo
- Clinica Ortopedica e Traumatologica 2IRCCS Istituto Ortopedico RizzoliBolognaItaly
| | | | - Giuseppe Filardo
- Applied and Translational Research (ATR) CenterIRCCS Istituto Ortopedico RizzoliBolognaItaly
- Department of Surgery, EOCService of Orthopaedics and TraumatologyLuganoSwitzerland
- Faculty of Biomedical SciencesUniversità della Svizzera ItalianaLuganoSwitzerland
| | - Stefano Zaffagnini
- Clinica Ortopedica e Traumatologica 2IRCCS Istituto Ortopedico RizzoliBolognaItaly
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Gebhardt S, Vollmer M, Zimmerer A, Rochel I, Balcarek P, Niemeyer P, Wassilew GI. Factors Affecting Choice of Surgical Treatment of Cartilage Lesions of the Knee: An Analysis of Data From 5143 Patients From the German Cartilage Registry (KnorpelRegister DGOU). Orthop J Sports Med 2024; 12:23259671241255672. [PMID: 39070901 PMCID: PMC11273558 DOI: 10.1177/23259671241255672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 01/01/2024] [Indexed: 07/30/2024] Open
Abstract
Background Symptomatic full-thickness cartilage lesions of the knee joint are considered an indication for cartilage repair surgery. Patient- and lesion-specific factors like age, nutritional status, etiology of defect, or integrity of corresponding joint surface remain controversial in indicating cartilage repair surgery. Furthermore, the selection of the most suitable cartilage repair technique for a specific cartilage lesion remains debatable. Purpose To evaluate indications and choice of treatment method for cartilage repair surgery, depending on patient- and lesion-specific data from the German Cartilage Registry. Study Design Cross-sectional study; Level of evidence, 3. Methods A total of 6305 consecutive patients who underwent cartilage repair surgery of the knee evaluated and 5143 complete datasets were included in the analysis (follow-up rate, 81.5%). Patient-specific (age, body mass index, smoking status, previous operations, clinical leg axis) and lesion-specific (size, grading, location, etiology) data were provided by the attending surgeon at the time of surgery. Appropriate statistical tests were used to compare data depending on type and normality of data. Multivariable logistic regressions were calculated to investigate independent factors for the choice of specific cartilage repair techniques. Results The median size of treated cartilage lesions was 3.6 cm2, and most defects were of degenerative origin (54.8%). Of the registered patients, 39.2% were categorized as overweight and 19.6% as obese, while 23.3% were smokers. The most prevalently documented operative techniques were the autologous chondrocyte implantation (ACI) (52.4%), bone marrow stimulation (BMS) (17.3%), and BMS augmented with collagen scaffolds (9.3%). Independent factors that made the use of ACI more likely were bigger lesion size, previous surgery at the joint, and lesions located at the trochlea or the patella. On the contrary, BMS or augmented BMS were preferred in older patients, with damaged corresponding joint surface, and with more concomitant surgeries. Conclusion Cartilage repair surgery was indicated irrespective of nutritional status, smoking status, or etiology of the treated lesion. ACI was the most prevalent technique and was preferred for younger patients and patellar lesions. While older patients with degenerative changes to the joint were not excluded from cartilage repair surgery, the use of ACI was restricted.
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Affiliation(s)
- Sebastian Gebhardt
- Center for Orthopaedics, Trauma Surgery and Rehabilitation Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Marcus Vollmer
- Institute of Bioinformatics, University Medicine Greifswald, Greifswald, Germany
| | - Alexander Zimmerer
- Center for Orthopaedics, Trauma Surgery and Rehabilitation Medicine, University Medicine Greifswald, Greifswald, Germany
- Orthopädische Klinik Paulinenhilfe, Diakonie-Klinikum Stuttgart, Stuttgart, Germany
| | - Ingo Rochel
- Klinik für Unfallchirurgie, Handchirurgie und Orthopädie, KRH Klinikum Nordstadt, Hannover, Germany
| | - Peter Balcarek
- ARCUS Sportklinik, Pforzheim, Germany
- Department of Trauma Surgery, Orthopaedics and Plastic Surgery, University of Göttingen, Göttingen, Germany
| | - Philipp Niemeyer
- OCM-Orthopädische Chirurgie München, München, Germany
- Klinik für Orthopädie und Traumatologie, Universitätsklinikum Freiburg, Freiburg, Germany
| | - Georgi I. Wassilew
- Center for Orthopaedics, Trauma Surgery and Rehabilitation Medicine, University Medicine Greifswald, Greifswald, Germany
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Boffa A, Andriolo L, Angelelli L, Pizzuti V, Filardo G, Zaffagnini S, Di Martino A. Matrix-Assisted Autologous Chondrocyte Transplantation for the Treatment of Patellofemoral Chondral Lesions: Long-term Results at a Minimum 15-Year Follow-up. Am J Sports Med 2024; 52:2222-2229. [PMID: 39101726 PMCID: PMC11308357 DOI: 10.1177/03635465241260238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 04/03/2024] [Indexed: 08/06/2024]
Abstract
BACKGROUND A few studies have documented the long-term results of chondrocyte-based procedures for the treatment of patellofemoral cartilage lesions, but specific results are lacking after matrix-assisted autologous chondrocyte transplantation (MACT) for patellar and trochlear lesions. PURPOSE To document the clinical results of MACT for the treatment of patellar and trochlear chondral defects at long-term follow-up. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS A total of 44 patients were prospectively evaluated after MACT for patellofemoral lesions. There were 24 patients affected by patellar lesions, 16 by trochlear lesions, and 4 with both patellar and trochlear defects. Clinical outcomes were analyzed using the International Knee Documentation Committee (IKDC) subjective form, EuroQol visual analog scale, and Tegner score for sport activity level before surgery and at follow-up time points of 5, 10, and a minimum of 15 years (mean final follow-up, 17.6 ± 1.6 years). A Kaplan-Meier survival analysis was performed to examine the survival to failure. Failure was defined as the need for a second surgery because of the persistence of symptoms related to the primary defect. RESULTS An overall significant improvement was documented from baseline to the last follow-up. The IKDC subjective score improved in the trochlear group from 41.0 ± 13.3 at baseline to 83.9 ± 21.6 at 5 years (P < .005), remaining stable up to the final follow-up (81.3 ± 20.5). In the patellar group, the IKDC subjective score improved from 36.1 ± 14.4 at baseline to 72.3 ± 17.5 at 5 years (P < .005), remaining stable up to the final follow-up (62.0 ± 20.3). Patients with trochlear lesions presented higher IKDC subjective scores compared with those with patellar lesions at 5 (P = .029), 10 (P = .023), and ≥15 years (P = .006) of follow-up. Similar trends were documented for the Tegner score, while no differences were documented for the EuroQol visual analog scale score between patellar and trochlear lesions. There were 4 failures (9.1%) during the follow-up period. The Kaplan-Meier survival analysis did not show statistically significant differences between trochlear and patellar lesions. CONCLUSION This hyaluronic acid-based MACT technique offered positive and durable clinical outcomes with a low failure rate at long-term follow-up in patients affected by patellofemoral cartilage lesions. However, trochlear and patellar lesions demonstrated a notable difference in terms of clinical findings and sport activity level, with significantly higher results for patients with trochlear lesions but less satisfactory outcomes for patients with patellar lesions.
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Affiliation(s)
- Angelo Boffa
- Clinica Ortopedica e Traumatologica II, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Luca Andriolo
- Clinica Ortopedica e Traumatologica II, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Lucia Angelelli
- Clinica Ortopedica e Traumatologica II, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Valeria Pizzuti
- Clinica Ortopedica e Traumatologica II, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Giuseppe Filardo
- Applied and Translational Research Center, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Stefano Zaffagnini
- Clinica Ortopedica e Traumatologica II, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Alessandro Di Martino
- Clinica Ortopedica e Traumatologica II, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
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Meta F, Clark SC, Tagliero AJ, Hevesi M, Saris DBF, Krych AJ. Athlete-Specific Considerations of Cartilage Injuries. Sports Med Arthrosc Rev 2024; 32:60-67. [PMID: 38978199 DOI: 10.1097/jsa.0000000000000379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/10/2024]
Abstract
Cartilage injuries can present in a diverse setting of anatomic locations, with varying severity, and can impact athletes of all ages and competition levels. Moreover, the timing of when an injury presents introduces an additional dimension to treatment decision-making. Frequently, the level of competition, in conjunction with career trajectory and short-term and long-term athlete goals, will dictate whether a temporary or definitive treatment strategy is ideal. Although indicating the correct therapeutic regimen may prove challenging, understanding the athlete-specific considerations can be essential to meeting the goals of the athlete and other stakeholders involved in the athlete's career. The purpose of this review is to comprehensively present the deliberations a treating physician must consider in managing cartilage injuries within a spectrum of athletic levels ranging from youth to professional levels, with a secondary focus on the presentation of temporizing treatment strategies and associated outcomes.
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Affiliation(s)
- Fabien Meta
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
| | - Sean C Clark
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
| | - Adam J Tagliero
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
| | - Mario Hevesi
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
| | - Daniel B F Saris
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
- Department of Orthopedic Surgery, University Medical Center, Utrecht University, The Netherlands
| | - Aaron J Krych
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
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Salerno M, Andriolo L, Angelelli L, Buda R, Faldini C, Ferruzzi A, Vannini F, Zaffagnini S, Filardo G. Sex does not influence the long-term outcome of matrix-assisted autologous chondrocyte transplantation. Knee Surg Sports Traumatol Arthrosc 2024. [PMID: 38372188 DOI: 10.1002/ksa.12068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 01/08/2024] [Accepted: 01/09/2024] [Indexed: 02/20/2024]
Abstract
PURPOSE Regenerative techniques for articular cartilage lesions demonstrated heterogeneous clinical results. Several factors may influence the outcome, with sex being one of the most debated. This study aimed at quantifying the long-term influence of sex on the clinical outcome obtained with a regenerative procedure for knee chondral lesions. METHODS Matrix-assisted autologous chondrocyte transplantation (MACT) was used to treat 235 knees which were prospectively evaluated with the International Knee Documentation Committee (IKDC), EuroQol visual analogue scale, and Tegner scores at 14-year mean follow-up. A multilevel analysis was performed with the IKDC subjective scores standardised according to the age/sex category of each patient and/or the selection of a match-paired subgroup to compare homogeneous men and women patients. RESULTS At 14 years, men and women showed a failure rate of 10.7% and 28.8%, respectively (p < 0.0005). An overall improvement was observed in both sexes. Women had more patellar lesions and men more condylar lesions (p = 0.001), and the latter also presented a higher preinjury activity level (p < 0.0005). Men had significantly higher IKDC subjective scores at all follow-ups (at 14 years: 77.2 ± 18.9 vs. 62.8 ± 23.1; p < 0.0005). However, the analysis of homogeneous match-paired populations of men and women, with standardised IKDC subjective scores, showed no differences between men and women (at 14 years: -1.6 ± 1.7 vs. -1.9 ± 1.6). CONCLUSION Men and women treated with MACT for knee chondral lesions presented a significant improvement and stable long-term results. When both sexes are compared with homogeneous match-paired groups, they have similar results over time. However, women present more often unfavourable lesion patterns, which proved more challenging in terms of long-term outcome after MACT. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Manuela Salerno
- Applied and Translational Research Center, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Luca Andriolo
- Clinica Ortopedica e Traumatologica 2, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Lucia Angelelli
- Clinica Ortopedica e Traumatologica 2, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Roberto Buda
- Clinica Ortopedica e Traumatologica, Ospedale SS Annunziata, Chieti, Italy
| | - Cesare Faldini
- Clinica Ortopedica e Traumatologica 1, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Alberto Ferruzzi
- Clinica Ortopedica e Traumatologica 1, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Francesca Vannini
- Clinica Ortopedica e Traumatologica 1, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Stefano Zaffagnini
- Clinica Ortopedica e Traumatologica 2, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Giuseppe Filardo
- Applied and Translational Research Center, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
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Bumberger A, Rupp MC, Lattermann C, Kleiner A, Niemeyer P. Increased risk of reoperation and failure to attain clinically relevant improvement following autologous chondrocyte implantation of the knee in female patients and individuals with previous surgeries: a time-to-event analysis based on the German cartilage registry (KnorpelRegister DGOU). Knee Surg Sports Traumatol Arthrosc 2023; 31:5837-5847. [PMID: 37950850 PMCID: PMC10719132 DOI: 10.1007/s00167-023-07615-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 09/28/2023] [Indexed: 11/13/2023]
Abstract
PURPOSE This study aimed to analyze the risk of reoperation following autologous chondrocyte implantation (ACI) of the knee utilizing third-generation ACI products in a time-to-event analysis and report on the associated patient-reported outcome measures (PROM) in case of reoperation. METHODS Patients undergoing ACI were included from a longitudinal database. Patient age, sex, body mass index (BMI), number of previous surgeries, lesion localization, lesion size, symptom duration, as well as time and type of reoperation was extracted. A cox proportional-hazards model was applied to investigate the influence of baseline variables on risk of reoperation. Reoperation was defined as any type of subsequent ipsilateral knee surgery, excluding hardware removal. The Knee Injury and Osteoarthritis Outcome Score (KOOS) was utilized to compare PROM between patients with and without reoperation. RESULTS A total of 2039 patients were included with 1359 (66.7%) having a minimum follow-up of 24 months. There were overall 243 reoperations (prevalence 17.9%). Minor arthroscopic procedures (n = 96, 39.5%) and revision cartilage repair procedures (n = 78, 32.1%) were the most common reoperations. Nineteen patients (0.9%) reported conversion arthroplasty at 17.7 (10.4) months after ACI. Female sex (HR 1.5, 95% CI [1.2, 2.0], p = 0.002) and the presence of 1-2 previous surgeries (HR 1.5, 95% CI [1.1, 2.0], p = 0.010), or more than 2 previous surgeries (HR 1.9, 95% CI [1.2, 2.9], p = 0.004) were significantly associated with increased risk of reoperation following ACI. Significantly less patients surpassed the minimal clinically important difference (MCID) in the reoperation group at 24 months regarding the KOOS subscores pain (OR 1.6, 95% CI [1.1, 2.2]), quality of life (OR 2.2, 95% CI [1.6, 3.2]), symptoms (OR 2.0 [1.4, 2.9]), and sports (OR 2.0 [1.4, 2.8]). CONCLUSION Female patients and individuals with a history of previous surgeries face an elevated risk of requiring reoperation after undergoing ACI, which is associated with failure to attain clinically relevant improvements. A thorough evaluation of the indications for ACI is paramount, particularly when patients have a history of previous surgeries. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Alexander Bumberger
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, AKH Wien, Waehringer Guertel 18-20, 1090, Vienna, Austria.
- OCM, Munich, Germany.
| | - Marco Christopher Rupp
- The Steadman Philippon Research Institute, 181 West Meadows Drive, Suite 400, Vail, CO, USA
- Department of Orthopaedic Sports Medicine, Hospital Rechts Der Isar, Technical University of Munich, Munich, Germany
| | | | - Anne Kleiner
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, AKH Wien, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Philipp Niemeyer
- OCM, Munich, Germany
- Department of Orthopedics and Trauma Surgery, University Medical Center Freiburg, Albert-Ludwig University of Freiburg, Freiburg, Germany
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Reale D, Feltri P, Franceschini M, de Girolamo L, Laver L, Magalon J, Sanchez M, Tischer T, Filardo G. Biological intra-articular augmentation for osteotomy in knee osteoarthritis: strategies and results : A systematic review of the literature from the ESSKA Orthobiologics Initiative. Knee Surg Sports Traumatol Arthrosc 2023; 31:4327-4346. [PMID: 37330935 DOI: 10.1007/s00167-023-07469-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 05/23/2023] [Indexed: 06/20/2023]
Abstract
PURPOSE To assess whether there is evidence supporting the use of augmentation strategies, either cartilage surgical procedures or injective orthobiologic options, to improve the results of osteotomies in knees with osteoarthritis (OA). METHODS A systematic review of the literature was performed on the PubMed, Web of Science and the Cochrane databases in January 2023 on osteotomies around the knee associated with augmentation strategies (either cartilage surgical procedures or injective orthobiologic options), reporting clinical, radiological, or second-look/histological outcomes at any follow-up. The methodological quality of the included studies was assessed with the Coleman Methodology Score (CMS). RESULTS Out of the 7650 records identified from the databases, 42 articles were included for a total of 3580 patients and 3609 knees treated; 33 articles focused on surgical treatments and 9 on injective treatments performed in association with knee osteotomy. Out of the 17 comparative studies with surgical augmentation, only 1 showed a significant clinical benefit of an augmentation procedure with a regenerative approach. Overall, other studies showed no differences with reparative techniques and even detrimental outcomes with microfractures. Regarding injective procedures, viscosupplementation showed no improvement, while the use of platelet-rich plasma or cell-based products derived from both bone marrow and adipose tissue showed overall positive tissue changes which translated into a clinical benefit. The mean modified CMS score was 60.0 ± 12.1. CONCLUSION There is no evidence to support the effectiveness of cartilage surgical treatments combined with osteotomies in terms of pain relief and functional recovery of patients affected by OA in misaligned joints. Orthobiologic injective treatments targeting the whole joint environment showed promising findings. However, overall the available literature presents a limited quality with only few heterogeneous studies investigating each treatment option. This ORBIT systematic analysis will help surgeons to choose their therapeutic strategy according to the available evidence, and to plan further and better studies to optimize biologic intra-articular osteotomy augmentation. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Davide Reale
- Ortopedia e Traumatologia, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Pietro Feltri
- Service of Orthopaedics and Traumatology, Department of Surgery, EOC, 6900, Lugano, Switzerland
| | - Marco Franceschini
- Clinica Ortopedica e Traumatologica 2, IRCCS Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli-1, 40136, Bologna, Italy.
| | - Laura de Girolamo
- Orthopaedic Biotechnology Laboratory, IRCCS Istituto Ortopedico Galeazzi, 20161, Milan, Italy
| | - Lior Laver
- Department of Orthopaedics, Hillel Yaffe Medical Center (HYMC), 38100, Hadera, Israel
- Arthrosport Clinic, Tel-Aviv, Israel
- Rappaport Faculty of Medicine, Technion University Hospital, Israel Institute of Technology, 32000, Haifa, Israel
| | - Jeremy Magalon
- Cell Therapy Department, Hôpital de la Conception, Assistance Publique des Hôpitaux de Marseille (AP-HM), INSERM CIC BT 1409, 13005, Marseille, France
- INSERM, INRA, C2VN, Aix Marseille Univ, 13005, Marseille, France
- SAS Remedex, 13008, Marseille, France
| | - Mikel Sanchez
- Arthroscopic Surgery Unit, Hospital Vithas Vitoria, 01008, Vitoria-Gasteiz, Spain
- Advanced Biological Therapy Unit, Hospital Vithas Vitoria, 01008, Vitoria-Gasteiz, Spain
| | - Thomas Tischer
- Department of Orthopaedic Surgery, University of Rostock, 18051, Rostock, Germany
| | - Giuseppe Filardo
- Service of Orthopaedics and Traumatology, Department of Surgery, EOC, 6900, Lugano, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, 6900, Lugano, Switzerland
- Applied and Translational Research Center, IRCCS Istituto Ortopedico Rizzoli, 40136, Bologna, Italy
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Pechlivanidou E, Antonopoulos I, Margariti RE. Gender equality challenges in orthopaedic surgery: a systematic review. INTERNATIONAL ORTHOPAEDICS 2023; 47:2143-2171. [PMID: 37433883 DOI: 10.1007/s00264-023-05876-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 06/20/2023] [Indexed: 07/13/2023]
Abstract
PURPOSE Several studies have examined gender-equality challenges and ways to improve women's representation and management. Orthopaedic surgeons and patients are less gender equitable than them of other surgical disciplines. This systematic review summarizes these findings and highlights orthopaedic surgery gender inequality. METHODS Search of the PubMed, Embase, and Cochrane databases was carried out to extract human studies investigating the gender gap in orthopaedics, trying to highlight the equality challenges orthopaedic surgery faces. Studies incorporating patients with comorbidities in which gender is a proven risk factor, and pregnant women were excluded. RESULTS This systematic review included 59 studies involving 692,435 people (mean females/males ratio: 4.44), spanning the years 1987-2023. Regarding the targeted population, 35 (59.32%) studies focused on patients, while 24 (40.68%) on physicians. Orthopaedic surgery is described as an unfriendly career field for women as surgeons or sports leading physicians while women are generally under represented in the academic field of orthopaedics. Regarding patients, female gender consists both a risk and prognostic factor influencing the prevalence of degenerative disease and the outcome of the operative treatment in reconstructive orthopaedics. Female gender is a risk factor for multiple sports injuries and influences the pathogenetic mechanisms resulting in ACL reconstruction. Regarding spine surgery, women are less likely to have surgery suggested, and such suggestion underlines severe disease's progression. CONCLUSIONS Gender differences affect orthopaedic patient-physician-healthcare system interactions. Recognizing biases and their patterns is useful to improve the actual situation. By preventing those an unbiased, tolerant, and egalitarian workplace for physicians and a healthcare system that provides the best treatment to patients could be created.
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Affiliation(s)
- Evmorfia Pechlivanidou
- 1st Department of Orthopaedics, P. & A. Kyriakou Children's Hospital, Athens, Greece.
- Department of Hygiene, Epidemiology and Medical Statistics, Medical School, National and Kapodistrian University of Athens, Athens, Greece.
| | - Ioannis Antonopoulos
- Department of Anatomy, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Rodanthi E Margariti
- 1st Department of Orthopaedics, P. & A. Kyriakou Children's Hospital, Athens, Greece
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10
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Patel J, Chen S, Katzmeyer T, Pei YA, Pei M. Sex-dependent variation in cartilage adaptation: from degeneration to regeneration. Biol Sex Differ 2023; 14:17. [PMID: 37024929 PMCID: PMC10077643 DOI: 10.1186/s13293-023-00500-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 03/20/2023] [Indexed: 04/08/2023] Open
Abstract
Despite acknowledgement in the scientific community of sex-based differences in cartilage biology, the implications for study design remain unclear, with many studies continuing to arbitrarily assign demographics. Clinically, it has been well-established that males and females differ in cartilage degeneration, and accumulating evidence points to the importance of sex differences in the field of cartilage repair. However, a comprehensive review of the mechanisms behind this trend and the influence of sex on cartilage regeneration has not yet been presented. This paper aims to summarize current findings regarding sex-dependent variation in knee anatomy, sex hormones' effect on cartilage, and cartilaginous degeneration and regeneration, with a focus on stem cell therapies. Findings suggest that the stem cells themselves, as well as their surrounding microenvironment, contribute to sex-based differences. Accordingly, this paper underscores the contribution of both stem cell donor and recipient sex to sex-related differences in treatment efficacy. Cartilage regeneration is a field that needs more research to optimize strategies for better clinical results; taking sex into account could be a big factor in developing more effective and personalized treatments. The compilation of this information emphasizes the importance of investing further research in sex differences in cartilage biology.
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Affiliation(s)
- Jhanvee Patel
- Stem Cell and Tissue Engineering Laboratory, Department of Orthopaedics, West Virginia University, 64 Medical Center Drive, PO Box 9196, Morgantown, WV, 26506-9196, USA
| | - Song Chen
- Department of Orthopaedics, The General Hospital of Western Theater Command, Chengdu, 610083, Sichuan, China
| | - Torey Katzmeyer
- Stem Cell and Tissue Engineering Laboratory, Department of Orthopaedics, West Virginia University, 64 Medical Center Drive, PO Box 9196, Morgantown, WV, 26506-9196, USA
| | - Yixuan Amy Pei
- Stem Cell and Tissue Engineering Laboratory, Department of Orthopaedics, West Virginia University, 64 Medical Center Drive, PO Box 9196, Morgantown, WV, 26506-9196, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Ming Pei
- Stem Cell and Tissue Engineering Laboratory, Department of Orthopaedics, West Virginia University, 64 Medical Center Drive, PO Box 9196, Morgantown, WV, 26506-9196, USA.
- WVU Cancer Institute, Robert C. Byrd Health Sciences Center, West Virginia University, Morgantown, WV, 26506, USA.
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11
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Satisfactory clinical outcomes with autologous matrix-induced chondrogenesis in the treatment of grade IV chondral injuries of the knee. J ISAKOS 2022; 8:86-93. [PMID: 36435431 DOI: 10.1016/j.jisako.2022.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 10/26/2022] [Accepted: 11/15/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The research aims to evaluate short- and medium-term outcomes of patients treated using autologous matrix-induced chondrogenesis (AMIC) with a hyaluronic acid scaffold (Hyalofast, Anika Therapeutics, MA, USA) in grade IV chondral lesions according to the Outerbridge classification in the knee. METHODS This is a multicentre, non-randomized, retrospective study conducted between 2017 and 2022. To determine the clinical outcome of the patients, the follow-up was done with the subjective International Knee Documentation Committee (IKDC) score, pre-surgery, and with a follow-up at 12, 24, and 32 months. RESULTS Fifty patients (28 female) with a mean age of 45.9 ± 12.7 years were recruited. The mean size of the lesion was 3.5 cm2, and the injuries located in the patella (30%) and trochlear groove (24%) were the most frequent. The total IKDC clinical score significantly increased from baseline to the 32 months of follow-up with a mean difference of 36.4 (95% CI, 29.1-43.7, p < 0.001). Besides, there was a statistically significant improvement in all categories of the IKDC (symptoms, sports activities, function, and activity of daily living) compared between pre-surgery and 24 and 32 months of follow-up. The patients younger than 45 years presented better clinical outcomes than older ones with a difference between medians of 10.40 (95% CI, 1.10-11.50, p = 0.0247), and a negative correlation was found between the 32-month IKDC score and the age. In addition, no statistically significant difference was found when comparing the last results of the IKDC between patients with and without associated surgical procedures or between patients with single and several lesions, neither nor between men and women. The level of satisfaction with the procedure of all the patients, on a score of 1-10, was on average 8 ± 1.5. CONCLUSION Results of this study indicate that patients who underwent the AMIC procedure with hyaluronic acid scaffold for the treatment of grade IV chondral lesions in the knee presented satisfactory results throughout the follow-up. LEVEL OF EVIDENCE Level IV.
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12
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Hartman TJ, Nie JW, MacGregor KR, Oyetayo OO, Zheng E, Singh K. Impact of gender on outcomes following single-level anterior lumbar interbody fusion. J Clin Orthop Trauma 2022; 34:102019. [PMID: 36161065 PMCID: PMC9490097 DOI: 10.1016/j.jcot.2022.102019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 08/15/2022] [Accepted: 09/07/2022] [Indexed: 10/31/2022] Open
Abstract
Background There have been a multitude of studies attempting to identify the relationship between gender and postoperative outcomes; however, few studies have examined how this relationship may affect outcomes after anterior lumbar interbody fusion (ALIF) surgery. We aim to better characterize the impact that self-reported gender may have on patient reported outcome measures (PROMs) and achievement rates of minimum clinically important difference (MCID) after ALIF. Methods A retrospective database of a single spine surgeon was searched for patients who had undergone single-level ALIF. Indications for surgery including acute trauma, infection, or malignancy were excluded. The population was separated into cohorts by self-reported gender, female or male. PROMs were recorded and compared within groups to their preoperative baselines and between groups. MCID achievement rate was compared between groups. Results 140 patients were identified for this study, with 68 patients self-identifying as female gender. The male gender cohort was found to have a significantly greater prevalence of hypertension (p = 0.018). Both cohorts showed significant improvement during at least one or more postoperative time points for each evaluated outcome measure (p ≤ 0.048, all). No significant difference in mean PROM scores was noted between cohorts at any time point for any measured outcome. The female gender cohort had significantly greater MCID achievement rates for visual acuity scale (VAS) back pain overall and at the 6-month time point (p ≤ 0.043, both). The female gender cohort also had significantly greater achievement of MCID at the 1-year time point for VAS leg pain (p = 0.017). Conclusion Both female and male gender cohorts demonstrated significant improvement in all outcomes measured at one or more postoperative time points. Postoperative outcomes did not differ by gender. MCID achievement was more common in female patients. Female patients may experience more tangible clinical improvement after ALIF compared to male patients.
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Affiliation(s)
- Timothy J. Hartman
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St. Suite #300, Chicago, IL, 60612, USA
| | - James W. Nie
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St. Suite #300, Chicago, IL, 60612, USA
| | - Keith R. MacGregor
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St. Suite #300, Chicago, IL, 60612, USA
| | - Omolabake O. Oyetayo
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St. Suite #300, Chicago, IL, 60612, USA
| | - Eileen Zheng
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St. Suite #300, Chicago, IL, 60612, USA
| | - Kern Singh
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St. Suite #300, Chicago, IL, 60612, USA
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13
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Anigwe C, Kucirek NK, Feeley BT, Ma CB, Zhang AL, Lansdown DA. Utilization of Autologous Chondrocyte Implantation in the Knee is Increasing While Reoperation Rates Are Decreasing Despite Increasing Preoperative Comorbidities. Arthroscopy 2022; 39:1464-1471.e1. [PMID: 36216132 DOI: 10.1016/j.arthro.2022.08.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 08/27/2022] [Accepted: 08/29/2022] [Indexed: 11/09/2022]
Abstract
PURPOSE The primary purpose of this study was to assess the use of autologous chondrocyte implantation (ACI) procedures in the knee during last decade, and the secondary aims of the study were to determine reoperation rates after ACI and to identify associated risk factors. METHODS A retrospective cohort study from 2010-2020 was performed using the PearlDiver database. The database was queried for the Current Procedural Terminology (CPT) code for ACI performed in any knee location, including the patellofemoral and tibiofemoral joints. Reoperation was defined as interventional knee procedures or total knee arthroplasty after ACI. Reoperations were identified using CPT and International Classification of Diseases codes. Univariate and multivariate logistic regression were used to identify risk factors for reoperation. Significance was defined as P < .05. RESULTS Among the 2010 patients included in this study, there were 90-day and overall reoperation rates of 2.24% and 30.4%, respectively, with an average follow up of 4.8 ± 3.3 years. The most common reoperations included chondroplasty, meniscectomy, and microfracture. There was an increased rate of ACI performed from 2017-2019 (5.53/100,000) compared to 2014-2016 (4.16/100,000; P < .001). ACI surgeries performed in 2017-2019 were associated with decreased risk of reoperation within 2 years relative to 2014-2016 (odds ratio [OR] = 0.70; 95% confidence interval [CI], 0.52-0.94; P = .019). In the entire ACI cohort, older age (OR = 1.07; 95% CI, 1.05-1.09; P < .001) and tobacco use (OR = 2.13; 95% CI, 1.06-3.94; P = .022) were associated with increased risk of conversion to arthroplasty. Male sex was associated with decreased overall reoperation rates (OR = 0.73; 95% CI, 0.60-0.89; P = .002). CONCLUSIONS There has been increasing use of ACI in the knee with decreased risk of reoperation since 2017 and the introduction of matrix-associated autologous chondrocyte implantation. Older age and tobacco use were predictors of increased risk of conversion to arthroplasty. Male sex was associated with decreased risk of reoperation. LEVEL OF EVIDENCE Level IV, retrospective cohort design; database study.
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Affiliation(s)
| | - Natalie K Kucirek
- School of Medicine University of California, San Francisco, California
| | - Brian T Feeley
- Department of Orthopaedic Surgery University of California, San Francisco, California
| | - C Benjamin Ma
- Department of Orthopaedic Surgery University of California, San Francisco, California
| | - Alan L Zhang
- Department of Orthopaedic Surgery University of California, San Francisco, California
| | - Drew A Lansdown
- Department of Orthopaedic Surgery University of California, San Francisco, California.
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14
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Faber S, Niemeyer P, Fickert S. Knorpelersatzverfahren und Regeneration am Knie- und
Hüftgelenk. PHYSIKALISCHE MEDIZIN, REHABILITATIONSMEDIZIN, KURORTMEDIZIN 2022. [DOI: 10.1055/a-1821-7068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
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.
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15
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Faber S, Zinser W, Angele P, Spahn G, Löer I, Zellner J, Hochrein A, Niemeyer P. Does Gender Influence Outcome in Cartilage Repair Surgery? An Analysis of 4,968 Consecutive Patients from the German Cartilage Registry (Knorpel Register DGOU). Cartilage 2021; 13:837S-845S. [PMID: 32476447 PMCID: PMC8808879 DOI: 10.1177/1947603520923137] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The goal was to examine gender differences of patient characteristics and outcome after cartilage repair based on a collective of nearly 5,000 patients. Patient characteristics, accompanying therapies, and outcome (Knee Injury and Osteoarthritis Outcome Score [KOOS], reoperations, patient satisfaction) of 4,986 patients of the German cartilage register DGOU were assessed by t test for possible gender differences. P values <0.05 were considered statistically significant. Women were older than men (38.07 ± 12.54 vs. 26.94 ± 12.394 years, P = 0.002), more often preoperated (0.30 ± 0.63 vs. 0.24 ± 0.55, P = 0.001), and had a longer symptom duration (25.22 ± 41.20 vs. 20.67 ± 35.32 months, P < 0.001). Men had greater mean leg axis malalignment than women (3.24° ± 3.26° vs. 2.67° ± 3.06°, P < 0.001), less favorable meniscal status (P = 0.001), worse defect stage (P = 0.006), and a more severely damaged corresponding articular surface (P = 0.042). At baseline (59.84 ± 17.49 vs. 52.10 ± 17.77, P < 0.001), after 6 months (72.83 ± 15.56 vs. 66.56 ± 17.66, P < 0.001), after 12 months (77.88 ± 15.95 vs. 73.07 ± 18.12, P < 0.001), and after 24 months (79.311 ± 15.94 vs. 74.39 ± 18.81, P < 0.001), men had better absolute KOOS values, but women had better relative KOOS increases 6 months (14.59 ± 17.31 vs. 12.49 ± 16.3, P = 0.005) as well as 12 months postoperatively (20.27 ± 18.6 vs. 17.34 ± 17.79, P = 0.001) compared with preoperatively, although 12 and 24 months postoperatively they were subjectively less satisfied with the outcome (P < 0.001) and had a higher reintervention rate at 24 months (0.17 ± 0.38 vs. 0.12 ± 0.33, P = 0.008). In summary, the present work shows specific gender differences in terms of patient characteristics, defect etiology, defect localization, concomitant therapy, and the choice of cartilage repair procedure. Unexpectedly, contrary to the established scientific opinion, it could be demonstrated that women show relatively better postoperative KOOS increases, despite a higher revision rate and higher subjective dissatisfaction.
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Affiliation(s)
- Svea Faber
- OCM–Orthopädische Chirurgie München,
Munich, Germany,Svea Faber, OCM–Orthopädische Chirurgie
München, Steinerstrasse 6, Munich, Bavaria 812306, Germany.
| | | | - Peter Angele
- Sporthopaedicum,
Berlin–Straubing–Regensburg, Straubing, Germany,Klinik für Unfallchirurgie,
Universitätsklinikum Regensburg, Regensburg, Germany
| | - Gunter Spahn
- Praxisklinik Eisenach, Eisenach,
Germany,Klinik für Unfall-, Hand- und
Wiederherstellungschirurgie, Universitätsklinikum Jena, Jena, Germany
| | | | - Johannes Zellner
- Klinik für Unfallchirurgie,
Caritas-Krankenhaus St. Josef Regensburg, Regensburg, Germany
| | | | - Philipp Niemeyer
- OCM–Orthopädische Chirurgie München,
Munich, Germany,Klinik für Orthopädie und Traumatologie,
Universitätsklinikum Freiburg, Freiburg, Germany
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16
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Andriolo L, Reale D, Di Martino A, De Filippis R, Sessa A, Zaffagnini S, Filardo G. Long-term Results of Arthroscopic Matrix-Assisted Autologous Chondrocyte Transplantation: A Prospective Follow-up at 15 Years. Am J Sports Med 2020; 48:2994-3001. [PMID: 32936677 DOI: 10.1177/0363546520949849] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Matrix-assisted autologous chondrocyte transplantation (MACT) procedures have been developed to overcome some of the limits of first-generation autologous chondrocyte implantation. However, while good autologous chondrocyte implantation results have been documented over time, data are scarce on the long-term MACT results. PURPOSE To evaluate long-term clinical results of a large cohort of patients treated with hyaluronic acid-based MACT for articular cartilage defects of the knee. STUDY DESIGN Case series; Level of evidence, 4. METHODS A long-term evaluation of 113 patients was performed (91 men, 22 women; mean ± SD age, 29.0 ± 10.6 years) for 115 knees affected by chondral and osteochondral lesions of the femoral condyles and trochlea. Of these, 61 knees had undergone previous surgery, while other procedures were combined during the same operation in 48 knees. These patients were prospectively evaluated before surgery and at 2, 5, and 10 years after surgery, as well as at a final mean follow-up of 15 years (range, 12-18 years), with various clinical scores: International Knee Documentation Committee (IKDC), EuroQol visual analog scale (EQ-VAS), and Tegner. Both surgical and clinical failures were documented. RESULTS The IKDC subjective score increased from the basal level of 39.9 ± 14.6 (mean ± SD) to 77.3 ± 20.5 (P < .0005) at 2 years; results remained stable up to the 15-year follow-up (76.9 ± 20.5). EQ-VAS and Tegner scores showed a statistically significant improvement up to 10 years, with a further significant improvement at the final follow-up. A failure rate of 15.0% was documented, which increased to 21.7% when clinical failures were also considered. A worse outcome was found for older age (P < .0005), female sex (P = .002), degenerative lesions (P < .0005), longer duration of symptoms (P = .005), and previous surgery (P < .0005). CONCLUSION Arthroscopic MACT offered good and long-lasting results that were stable over time and resulted in a limited number of failures and reinterventions for up to 15 years of follow-up. Several factors were identified as having a prognostic value: a worse outcome could be expected in older patients, female patients, those affected by lesions with a degenerative cause, those having a longer duration of symptoms, and patients who underwent previous surgery.
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Affiliation(s)
- Luca Andriolo
- ‖ Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Davide Reale
- ‖ Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Alessandro Di Martino
- ‖ Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Roberto De Filippis
- ‖ Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Andrea Sessa
- Ortopedia Bentivoglio, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Stefano Zaffagnini
- ‖ Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Giuseppe Filardo
- Applied and Translational Research Center, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
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17
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Long-term Results of Matrix-assisted Autologous Chondrocyte Transplantation Combined With Autologous Bone Grafting for the Treatment of Juvenile Osteochondritis Dissecans. J Pediatr Orthop 2020; 40:e115-e121. [PMID: 31107345 DOI: 10.1097/bpo.0000000000001404] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Osteochondritis dissecans is a pathology affecting young patients that involves the entire osteochondral unit. In the case of unfixable fragments, regenerative cartilage treatments are a viable solution, but little is known about the use of these procedures for the treatment of juvenile osteochondritis dissecans (JOCD). The aim of this study was to evaluate the long-term results offered by matrix-assisted autologous chondrocyte transplantation combined with autologous bone grafting for the treatment of JOCD. METHODS Nineteen patients have been enrolled. The mean age at the time of treatment was 16.8±1.5 years, with a mean body mass index of 22.9±2.7. The average size of the defects was 2.8±1.2 cm. All patients were evaluated prospectively before surgery and at 12, 24, 60, and at a final follow-up of 120 months with International Knee Documentation Committee scores, EuroQol-Visual Analogue Scale, and the Tegner Score. RESULTS A statistically significant improvement in all clinical scores was observed from baseline evaluation to 120 months of final follow-up. In particular, the International Knee Documentation Committee subjective score improved from the preoperative evaluation of 38.7±17.3 to 74.0±21.8 at 12 months (P<0.0005), with scores remaining stable for up to 120 months (83.8±20.7), with all follow-ups showing a statistically significant improvement compared with the basal value (P<0.0005). Three patients failed at 12 months, for a failure rate of 16% at 10 years of follow-up. Lesions >3.5 cm obtained worse subjective results. In addition, lesion size and female sex were significantly associated with failures. CONCLUSIONS The matrix-assisted autologous chondrocyte transplantation technique with autologous bone grafting is a valid treatment option for JOCD in case of unfixable fragments. The clinical improvement obtained is significant and stable, with good results maintained for up to 10 years of follow-up and an overall low failure rate. Lesion size and sex could influence the clinical outcome and should be considered in the treatment choice. LEVEL OF EVIDENCE Level IV-case series.
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18
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Gursoy S, Akkaya M, Simsek ME, Gursoy M, Dogan M, Bozkurt M. Factors Influencing the Results in Matrix-Associated Autologous Chondrocyte Implantation: A 2 - 5 Year Follow-Up Study. J Clin Med Res 2019; 11:137-144. [PMID: 30701007 PMCID: PMC6340672 DOI: 10.14740/jocmr3711] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 12/24/2018] [Indexed: 12/28/2022] Open
Abstract
Background This study aimed to investigate the outcomes of matrix-associated autologous chondrocyte implantation (MACI) on the treatment of osteochondral lesions in the knee joint and to determine the factors affecting the functional results. Methods The study included 34 patients with a cartilage defect in the knee joint who were applied MACI® (GenzymeBiosurgery, Cambridge, Massachusetts, USA) technique between the years 2010 - 2015. The defect localizations and sizes, past surgeries were recorded. The clinical results were measured with Cincinnati and Lysholm scores. Results As a result of the repeated measures at postoperatively, it was found that the patients had increased Lysholm and Cincinnati functional scores in all follow-up periods (P = 0.0001). When the mean value of Lysholm and Cincinnati functional scores were assessed according to BMI group, no statistically significant difference was determined (P = 0.941 and P = 0.779). The measurements at 6 and 12 months of the follow-up indicated that the mean scores of the group with no concomitant pathologies were significantly higher than those of the group with concomitant pathologies. Conclusions The MACI application provides good and stable outcomes for focal cartilage damage in young patients. In order to obtain significant results after autologous chondrocyte implantation, the selection of appropriate patients without concomitant pathologies is required.
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Affiliation(s)
- Safa Gursoy
- Department of Orthopedics, Ankara Yildirim Beyazit University, Ankara, Turkey
| | - Mustafa Akkaya
- Department of Orthopedics, Ankara Yildirim Beyazit University, Ankara, Turkey
| | - Mehmet Emin Simsek
- Ankara Yildirim Beyazit University, Yenimahalle Training and Research Hospital, Ankara, Turkey
| | - Merve Gursoy
- Department of Radiology, Izmir Democracy University, Izmir, Turkey
| | - Metin Dogan
- Department of Orthopedics, Ankara Yildirim Beyazit University, Ankara, Turkey
| | - Murat Bozkurt
- Department of Orthopedics, Ankara Yildirim Beyazit University, Ankara, Turkey
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19
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No evidence for combining cartilage treatment and knee osteotomy in osteoarthritic joints: a systematic literature review. Knee Surg Sports Traumatol Arthrosc 2018; 26:3290-3299. [PMID: 29453488 DOI: 10.1007/s00167-018-4871-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 02/12/2018] [Indexed: 01/09/2023]
Abstract
PURPOSE To assess whether the combination of HTO and cartilage treatment produced an additional clinical benefit compared to HTO alone. The secondary aim was to identify if there was any difference among different cartilage procedures in terms of healing potential and clinical outcome. METHODS A systematic review of the literature was performed on PubMed database by three independent observers according to the following inclusion criteria: clinical reports of any level of evidence, written in the English language, with no time limitation, about HTO associated with cartilage surgical and injective treatment, including surveys reporting clinical, radiological, or second-look outcomes at any follow-up time. RESULTS The database search identified 1956 records: 21 studies were included for the final analysis, for a total of 1068 patients; 10 case series and 11 comparative studies. While overall good results were reported in the case series, the analysis of the comparative studies showed less uniform results. Among the eight studies investigating HTO with cartilage surgical procedures, improved tissue regeneration was found in 5/8 studies, whereas a clinical improvement was reported only in two studies. Three studies on HTO combination with injective treatment showed better tissue regeneration and clinical benefit. CONCLUSIONS Literature presents low-quality studies, with only few heterogeneous comparative papers. While surgical treatments targeting only the cartilage layer did not achieve clinical improvements, injective treatments targeting the overall joint environment showed promising findings. This prompts further research towards the development of treatments able to improve knee osteotomies outcomes. However, until new evidence will prove otherwise, there is no indication for a combined cartilage treatment in routine clinical practice. LEVEL OF EVIDENCE Level IV.
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Zarkadis NJ, Belmont PJ, Zachilli MA, Holland CA, Kinsler AR, Todd MS, Pallis MP, Waterman BR. Autologous Chondrocyte Implantation and Tibial Tubercle Osteotomy for Patellofemoral Chondral Defects: Improved Pain Relief and Occupational Outcomes Among US Army Servicemembers. Am J Sports Med 2018; 46:3198-3208. [PMID: 30307742 DOI: 10.1177/0363546518800713] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The occupational and functional results of patellofemoral autologous chondrocyte implantation (ACI) are underreported. This investigation sought to establish clinical outcomes and rates for return to work in a predominantly high-demand military cohort undergoing this procedure. PURPOSE To determine the return-to-work, pain relief, and perioperative complication rates in a high-demand athletic cohort undergoing patellofemoral ACI. STUDY DESIGN Case series; Level of evidence, 4. METHODS All military servicemembers from 2 military medical centers undergoing ACI for high-grade patellofemoral chondral defects between 2006 and 2014 were identified, and data were abstracted from their medical records and clinical databases. Demographic and surgical variables were obtained for patients with at least 2 years of postoperative follow-up, and perioperative complications, rates of return to work, and survivorship from revision were quantified. RESULTS Seventy-two patients (72%) had >2-year follow-up and had patellofemoral ACI for high-grade chondral defects, with 66 knees (91%) undergoing a concomitant offloading tibial tubercle osteotomy. Mean follow-up was 4.3 years (range, 2.0-9.9 years). The mean ± SD age was 34.4 ± 6.1 years; 86% were male; and 57% were involved in military occupational specialties of heavy or very heavy demand. Second-generation patellofemoral ACI with a type I/III collagen membrane was used for 85% of knees. Most defects were isolated to the patella (n = 40, 55%). The mean total defect surface area was 4.5 ± 2.9 cm2 (range, 2.7-13.5 cm2). Fifty-six servicemembers (78%) returned to their occupational specialties. Three patients (4.1%) were classified as having surgical failures, requiring subsequent knee arthroplasty (n = 2) or a revision chondral procedure (n = 1). Mean visual analog scores improved significantly from 6.5 ± 1.5 to 3.2 ± 2.1 ( P < .0001). Multivariate analysis identified use of a periosteal patch as the only significant independent predictor for surgical ( P = .013) and overall ( P = .033) failures. Age <30 years ( P = .019), female sex ( P = .019), and regular tobacco use ( P = .011) were independent predictors of overall failure. CONCLUSION For patellofemoral chondral defects without a failed primary procedure, second-generation ACI successfully returned to work 78% of patients of moderate to very heavy occupational demand with significantly decreased patient-reported knee pain. Risk factors after ACI for patellofemoral articular lesions for overall failure were age <30 years, female sex, and tobacco use, while surgical and overall failures were associated with periosteal patch use.
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Affiliation(s)
- Nicholas J Zarkadis
- Department of Orthopaedic Surgery and Rehabilitation, William Beaumont Army Medical Center, El Paso, Texas, USA
| | - Philip J Belmont
- Department of Orthopaedic Surgery and Rehabilitation, William Beaumont Army Medical Center, El Paso, Texas, USA
| | - Michael A Zachilli
- Department of Orthopaedic Surgery and Rehabilitation, William Beaumont Army Medical Center, El Paso, Texas, USA
| | - Courtney A Holland
- Department of Orthopaedic Surgery and Rehabilitation, William Beaumont Army Medical Center, El Paso, Texas, USA
| | - Allison R Kinsler
- Department of Orthopaedic Surgery and Rehabilitation, William Beaumont Army Medical Center, El Paso, Texas, USA
| | - Michael S Todd
- Department of Orthopaedic Surgery and Rehabilitation, William Beaumont Army Medical Center, El Paso, Texas, USA
| | - Mark P Pallis
- Department of Orthopaedic Surgery and Rehabilitation, William Beaumont Army Medical Center, El Paso, Texas, USA
| | - Brian R Waterman
- Department of Orthopaedic Surgery and Rehabilitation, William Beaumont Army Medical Center, El Paso, Texas, USA
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Mistry H, Connock M, Pink J, Shyangdan D, Clar C, Royle P, Court R, Biant LC, Metcalfe A, Waugh N. Autologous chondrocyte implantation in the knee: systematic review and economic evaluation. Health Technol Assess 2018; 21:1-294. [PMID: 28244303 DOI: 10.3310/hta21060] [Citation(s) in RCA: 145] [Impact Index Per Article: 24.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The surfaces of the bones in the knee are covered with articular cartilage, a rubber-like substance that is very smooth, allowing frictionless movement in the joint and acting as a shock absorber. The cells that form the cartilage are called chondrocytes. Natural cartilage is called hyaline cartilage. Articular cartilage has very little capacity for self-repair, so damage may be permanent. Various methods have been used to try to repair cartilage. Autologous chondrocyte implantation (ACI) involves laboratory culture of cartilage-producing cells from the knee and then implanting them into the chondral defect. OBJECTIVE To assess the clinical effectiveness and cost-effectiveness of ACI in chondral defects in the knee, compared with microfracture (MF). DATA SOURCES A broad search was done in MEDLINE, EMBASE, The Cochrane Library, NHS Economic Evaluation Database and Web of Science, for studies published since the last Health Technology Assessment review. REVIEW METHODS Systematic review of recent reviews, trials, long-term observational studies and economic evaluations of the use of ACI and MF for repairing symptomatic articular cartilage defects of the knee. A new economic model was constructed. Submissions from two manufacturers and the ACTIVE (Autologous Chondrocyte Transplantation/Implantation Versus Existing Treatment) trial group were reviewed. Survival analysis was based on long-term observational studies. RESULTS Four randomised controlled trials (RCTs) published since the last appraisal provided evidence on the efficacy of ACI. The SUMMIT (Superiority of Matrix-induced autologous chondrocyte implant versus Microfracture for Treatment of symptomatic articular cartilage defects) trial compared matrix-applied chondrocyte implantation (MACI®) against MF. The TIG/ACT/01/2000 (TIG/ACT) trial compared ACI with characterised chondrocytes against MF. The ACTIVE trial compared several forms of ACI against standard treatments, mainly MF. In the SUMMIT trial, improvements in knee injury and osteoarthritis outcome scores (KOOSs), and the proportion of responders, were greater in the MACI group than in the MF group. In the TIG/ACT trial there was improvement in the KOOS at 60 months, but no difference between ACI and MF overall. Patients with onset of symptoms < 3 years' duration did better with ACI. Results from ACTIVE have not yet been published. Survival analysis suggests that long-term results are better with ACI than with MF. Economic modelling suggested that ACI was cost-effective compared with MF across a range of scenarios. LIMITATIONS The main limitation is the lack of RCT data beyond 5 years of follow-up. A second is that the techniques of ACI are evolving, so long-term data come from trials using forms of ACI that are now superseded. In the modelling, we therefore assumed that durability of cartilage repair as seen in studies of older forms of ACI could be applied in modelling of newer forms. A third is that the high list prices of chondrocytes are reduced by confidential discounting. The main research needs are for longer-term follow-up and for trials of the next generation of ACI. CONCLUSIONS The evidence base for ACI has improved since the last appraisal by the National Institute for Health and Care Excellence. In most analyses, the incremental cost-effectiveness ratios for ACI compared with MF appear to be within a range usually considered acceptable. Research is needed into long-term results of new forms of ACI. STUDY REGISTRATION This study is registered as PROSPERO CRD42014013083. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Hema Mistry
- Warwick Evidence, Division of Health Sciences, University of Warwick, Coventry, UK
| | - Martin Connock
- Warwick Evidence, Division of Health Sciences, University of Warwick, Coventry, UK
| | - Joshua Pink
- Warwick Evidence, Division of Health Sciences, University of Warwick, Coventry, UK
| | - Deepson Shyangdan
- Warwick Evidence, Division of Health Sciences, University of Warwick, Coventry, UK
| | - Christine Clar
- Warwick Evidence, Division of Health Sciences, University of Warwick, Coventry, UK
| | - Pamela Royle
- Warwick Evidence, Division of Health Sciences, University of Warwick, Coventry, UK
| | - Rachel Court
- Warwick Evidence, Division of Health Sciences, University of Warwick, Coventry, UK
| | - Leela C Biant
- Department of Trauma and Orthopaedic Surgery, University of Manchester, Manchester, UK
| | - Andrew Metcalfe
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Norman Waugh
- Warwick Evidence, Division of Health Sciences, University of Warwick, Coventry, UK
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Perdisa F, Kon E, Sessa A, Andriolo L, Busacca M, Marcacci M, Filardo G. Treatment of Knee Osteochondritis Dissecans With a Cell-Free Biomimetic Osteochondral Scaffold: Clinical and Imaging Findings at Midterm Follow-up. Am J Sports Med 2018; 46:314-321. [PMID: 29100468 DOI: 10.1177/0363546517737763] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Osteochondritis dissecans (OCD) is a developmental condition of subchondral bone that may result in secondary separation and instability of the overlying articular cartilage, which in turn may lead to degeneration of the overall joint and early osteoarthritis. Biphasic scaffolds have been developed to address defects of the entire osteochondral unit by reproducing the different biological and functional requirements and guiding the growth of both bone and cartilage. PURPOSE To evaluate midterm clinical and imaging results after cell-free osteochondral scaffold implantation for the treatment of knee OCD. STUDY DESIGN Case series; Level of evidence, 4. METHODS Twenty-seven patients (8 women, 19 men; mean age, 25.5 ± 7.7 years) were treated for knee OCD, with International Cartilage Repair Society (ICRS) grade 3 to 4 lesions with a mean size of 3.4 ± 2.2 cm2 (range, 1.5-12 cm2), and prospectively evaluated for up to 5 years using the ICRS classification system and the Tegner score. Eighteen patients underwent magnetic resonance imaging (MRI) at 24 and 60 months of follow-up, and the graft was evaluated using the magnetic resonance observation of cartilage repair tissue (MOCART) score for the cartilage layer, while a specific score was used for subchondral bone. RESULTS All patients significantly improved their clinical scores at each follow-up until their final evaluation. The mean International Knee Documentation Committee (IKDC) subjective score improved from 48.4 ± 17.8 to 82.2 ± 12.2 at 2 years ( P < .0005), and it then remained stable for up to 5 years postoperatively (90.1 ± 12.0). The mean Tegner score increased from 2.4 ± 1.7 preoperatively to 4.4 ± 1.6 at 2 years ( P = .001), with a further increase up to 5.0 ± 1.7 at 5 years of follow-up ( P < .0005 vs preoperatively), reaching almost the preinjury level (5.7 ± 2.2). The MOCART score showed stable results between 24 and 60 months, whereas the subchondral bone status significantly improved over time. No correlation was found between MRI findings and clinical outcomes. CONCLUSION This 1-step cell-free scaffold implantation procedure showed good and stable results for up to 60 months of follow-up for the treatment of knee OCD. MRI showed abnormalities, in particular at the subchondral bone level, but there was an overall improvement of features over time. No correlation was found between imaging and clinical findings.
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Affiliation(s)
- Francesco Perdisa
- II Orthopaedic and Traumatologic Clinic, Rizzoli Orthopaedic Institute, Bologna, Italy
| | - Elizaveta Kon
- Department of Biomedical Sciences, Humanitas University, Milano, Italy.,Knee Joint Reconstruction Center, 3rd Orthopaedic Division, Humanitas Clinical Institute, Milano, Italy
| | - Andrea Sessa
- II Orthopaedic and Traumatologic Clinic, Rizzoli Orthopaedic Institute, Bologna, Italy
| | - Luca Andriolo
- II Orthopaedic and Traumatologic Clinic, Rizzoli Orthopaedic Institute, Bologna, Italy
| | - Maurizio Busacca
- Department of Radiology and Diagnostic Imaging, Rizzoli Orthopaedic Institute, Bologna, Italy
| | - Maurilio Marcacci
- Department of Biomedical Sciences, Humanitas University, Milano, Italy
| | - Giuseppe Filardo
- Nano-Biotechnology Laboratory, Rizzoli Orthopaedic Institute, Bologna, Italy
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Filardo G, de Caro F, Andriolo L, Kon E, Zaffagnini S, Marcacci M. Do cartilage lesions affect the clinical outcome of anterior cruciate ligament reconstruction? A systematic review. Knee Surg Sports Traumatol Arthrosc 2017; 25:3061-3075. [PMID: 27043346 DOI: 10.1007/s00167-016-4097-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 03/15/2016] [Indexed: 12/30/2022]
Abstract
PURPOSE To document the available evidence on the influence of cartilage lesions on the results of anterior cruciate ligament (ACL) surgery and their management to optimize the final outcome. METHODS A systematic review was performed on the PubMed database on articles dealing with cartilage lesions detected at the time of ACL reconstruction, by looking both for their influence on the clinical outcome and the results of their treatment. Reports on clinical, radiological, or second-look outcomes at any follow-up were included. Exclusion criteria were preclinical studies, reviews, or studies not reporting clinical, radiological, or second-look outcome after primary ACL reconstruction. RESULTS Thirty-seven studies were included for the final analysis. Twenty-seven focused on the influence of cartilage lesions on clinical outcome after ACL reconstruction in 47,837 patients. In total, 21/27 articles showed a correlation with a poorer outcome in terms of subjective, objective, and radiographic findings. Lesion location and depth influenced final results. Only 9.0 % of these defects were treated in the analysed studies, and only 10 manuscripts of overall low level evaluated the results of combined cartilage-ACL treatments. CONCLUSION The majority of the literature supports the clinical relevance of cartilage lesions which are correlated with a poorer outcome after ACL reconstruction. Nonetheless, a large amount of chondral defects are actually not addressed, also considering the poor evidence for the benefits provided by cartilage treatments. In fact, only a few studies specifically focused on how to manage cartilage lesions found during ACL reconstruction and there is a lack of indications for the most appropriate treatment approach. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Giuseppe Filardo
- II Orthopaedic and Traumatologic Clinic - Biomechanics and Technology Innovation Laboratory, Rizzoli Orthopaedic Institute, Via Di Barbiano, 1/10, 40136, Bologna, Italy
| | - Francesca de Caro
- II Orthopaedic and Traumatologic Clinic - Biomechanics and Technology Innovation Laboratory, Rizzoli Orthopaedic Institute, Via Di Barbiano, 1/10, 40136, Bologna, Italy
| | - Luca Andriolo
- II Orthopaedic and Traumatologic Clinic - Biomechanics and Technology Innovation Laboratory, Rizzoli Orthopaedic Institute, Via Di Barbiano, 1/10, 40136, Bologna, Italy.
| | - Elizaveta Kon
- II Orthopaedic and Traumatologic Clinic - Biomechanics and Technology Innovation Laboratory, Rizzoli Orthopaedic Institute, Via Di Barbiano, 1/10, 40136, Bologna, Italy.,Nano-Biotechnology Laboratory, Rizzoli Orthopaedic Institute, Bologna, Italy
| | - Stefano Zaffagnini
- II Orthopaedic and Traumatologic Clinic - Biomechanics and Technology Innovation Laboratory, Rizzoli Orthopaedic Institute, Via Di Barbiano, 1/10, 40136, Bologna, Italy
| | - Maurilio Marcacci
- II Orthopaedic and Traumatologic Clinic - Biomechanics and Technology Innovation Laboratory, Rizzoli Orthopaedic Institute, Via Di Barbiano, 1/10, 40136, Bologna, Italy
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Berruto M, Ferrua P, Pasqualotto S, Uboldi F, Maione A, Tradati D, Usellini E. Long-term follow-up evaluation of autologous chondrocyte implantation for symptomatic cartilage lesions of the knee: A single-centre prospective study. Injury 2017; 48:2230-2234. [PMID: 28803652 DOI: 10.1016/j.injury.2017.08.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 08/02/2017] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Autologous Chondrocyte Implantation (ACI) has been the first technique in reconstruction of a valid articular surface. The aim of this study was to evaluate clinical results of this technique at an average follow up of 162±27months (range 88-208) in a group of patients who underwent ACI. MATERIALS AND METHODS 32 patients were operated between 1997 and 2007 for chondral lesions or osteochondritis dissecans of the knee. Mean size of the defect was 5.48cm2±1.53 (range 2-9). Nine patients were treated with I generation technique and 23 with II generation. All patients were evaluated with Subjective IKDC and Tegner Activity Scales for clinical outcomes and with EQ-VAS for a quantitative measure of health after intervention, starting from pre-operative period and at regular follow up (minimum 88 months-maximum 208 months). RESULTS A significant increment of all scores was noticed comparing preoperative and postoperative results. In particular medium IKDC score increased from 40.3±9.6 in preoperative evaluation to 74.2±11.6 at one year (p<0.00001) and to 83.9±10.4 at 5 years follow up (p<0.001). Mean IKDC values at the last follow-up were 80.3±14.2, showing no statistical differences with those obtained at five-year follow-up. Tegner Activity Scale values increased from 2.8±1.1 preoperatively to 4.1±1.1 (p<0.0001) after one year and to 6±1.1 at five years (p<0.0001). Mean Tegner Activity Scale values decreased to 4.8±1.4 at the last follow-up. EQ-VAS evaluation showed superposable results comparing the 5 years evaluation with the ones at a medium follow up of 162±27months. DISCUSSION The most important finding is the reliability at long-term of ACI technique, which in our series gave excellent clinical results. No statistical differences were observed between first- and second-generation. Clinical outcomes were significantly better for defects in the femoral condyles, influenced by age (worse results over 30 years old). CONCLUSIONS ACI represents a valid technique for chondral and osteochondral lesions of the knee in a population heterogeneous for age, sex and activity level with good results even at a long term follow up.
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Affiliation(s)
- M Berruto
- SSD Chirurgia Articolare del Ginocchio, Istituto Ortopedico Gaetano Pini, Milan, Italy.
| | - P Ferrua
- SSD Chirurgia Articolare del Ginocchio, Istituto Ortopedico Gaetano Pini, Milan, Italy
| | - S Pasqualotto
- SSD Chirurgia Articolare del Ginocchio, Istituto Ortopedico Gaetano Pini, Milan, Italy
| | - F Uboldi
- SSD Chirurgia Articolare del Ginocchio, Istituto Ortopedico Gaetano Pini, Milan, Italy
| | - A Maione
- SSD Chirurgia Articolare del Ginocchio, Istituto Ortopedico Gaetano Pini, Milan, Italy
| | - D Tradati
- SSD Chirurgia Articolare del Ginocchio, Istituto Ortopedico Gaetano Pini, Milan, Italy
| | - E Usellini
- SSD Chirurgia Articolare del Ginocchio, Istituto Ortopedico Gaetano Pini, Milan, Italy
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Foldager CB, Farr J, Gomoll AH. Patients Scheduled for Chondrocyte Implantation Treatment with MACI Have Larger Defects than Those Enrolled in Clinical Trials. Cartilage 2016; 7:140-8. [PMID: 27047636 PMCID: PMC4797242 DOI: 10.1177/1947603515622659] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE To compare characteristics for patients scheduled for autologous chondrocyte implantation with matrix-assisted chondrocyte implantation (MACI) with those enrolled in clinical trials and to describe differences in patient selection between countries. DESIGN Anonymized data from patients scheduled for MACI treatment in the knee in Europe and Australia/Asia were obtained from the Genzyme/Sanofi database. Average age, defect size, and male-female ratio were analyzed and compared by country. Clinical cohort studies and prospective comparative trials using autologous chondrocyte implantation and related treatments were identified and weighted average age, weighted defect size, and male-female ratio were analyzed and compared with data from the database. RESULTS From the database 2,690 patients were included with mean age 33.7 years and male-female ratio of 67:33. Mean defect size was 5.64 cm(2) and 70% of the defects were 3 to 10 cm(2). There were significant differences between patients' mean defect sizes between countries. Sixty-nine studies (57 cohorts and 12 prospective comparative trials) with a total of 5,449 patients were identified. The combined weighted mean age was 34.2 years, and the combined weighted mean defect size was 4.89 cm(2). Patients scheduled for MACI had significantly larger defects that those included in clinical trials. There was no significant difference in age. No differences were found between cohorts and prospective comparative trials. CONCLUSION The vast majority of patients scheduled for autologous chondrocyte implantation with MACI have chondral defect comparable to that generally recommended, but differences exist between countries. Patients enrolled in clinical trials have significantly smaller defects than those undergoing treatment outside controlled trials.
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Affiliation(s)
- Casper Bindzus Foldager
- Orthopaedic Research Lab, Institute for Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark,Casper Bindzus Foldager, Orthopaedic Research Lab, Aarhus University Hospital, Nørrebrogade 44, Building 1A, 8000 Aarhus C, Denmark.
| | - Jack Farr
- Indiana University School of Medicine, OrthoIndy Cartilage Restoration Center, Indianapolis, IN, USA
| | - Andreas H. Gomoll
- Cartilage Repair Center, Brigham & Women’s Hospital, Harvard Medical School, Boston, MA, USA
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Filardo G, Andriolo L, Balboni F, Marcacci M, Kon E. Cartilage failures. Systematic literature review, critical survey analysis, and definition. Knee Surg Sports Traumatol Arthrosc 2015; 23:3660-9. [PMID: 25193571 DOI: 10.1007/s00167-014-3272-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Accepted: 08/25/2014] [Indexed: 11/24/2022]
Abstract
PURPOSE While midterm results of matrix-assisted autologous chondrocyte transplantation (MACT) are now available, less attention has been paid to the evaluation of failures of this surgical approach. Aim of this study was to analyse how "failures" are generally defined in cartilage surgery, in order to understand how the survival rate may change according to different definitions of failure. METHODS A systematic review on MACT in the knee was conducted to report failure rates as well as different failure definitions in the available literature. Afterwards, we analysed the survival curve at 8.5-year follow-up of a survey of 193 patients treated with MACT. Using different definitions to identify failures, we compared how the survival rate changed according to the different definitions of failure. RESULTS The systematic review on 93 papers showed that the average failure rate reported on 3,289 patients was 5.2 % at a mean 34 months of follow-up. However, 41 studies (44.1 %) did not even consider this aspect, and failures were variously defined, thus generating confusing data that make a meta-analysis or a study comparison meaningless. The failure analysis of the MACT survey showed that the survival curve changed significantly depending on the definition applied; in fact, the failure rate ranged from 3.6 to 33.7 %. According to a critical literature and survey analysis, we proposed a combined surgical- and improvement-based definition which led to a failure rate of 25.9 % at midterm/long-term follow-up. CONCLUSION Nowadays, failure definitions of cartilage treatments differ in scientific articles, thus generating confusion and heterogeneous data even when applied to the same cohort of patients. While the literature analysis shows a low number of failures, this study demonstrated that if properly addressed with a comprehensive definition, the real failure rate of cartilage surgical procedures in the knee is higher than previously reported. Recognizing failures would give a better understanding and a more realistic prognosis to patients and physicians seeking treatment for cartilage lesions. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Giuseppe Filardo
- II Clinic - Biomechanics Laboratory, Rizzoli Orthopaedic Institute, Via Di Barbiano, 1/10, 40136, Bologna, Italy.
| | - Luca Andriolo
- II Clinic - Biomechanics Laboratory, Rizzoli Orthopaedic Institute, Via Di Barbiano, 1/10, 40136, Bologna, Italy.
| | - Federica Balboni
- II Clinic - Biomechanics Laboratory, Rizzoli Orthopaedic Institute, Via Di Barbiano, 1/10, 40136, Bologna, Italy.
| | - Maurilio Marcacci
- II Clinic - Biomechanics Laboratory, Rizzoli Orthopaedic Institute, Via Di Barbiano, 1/10, 40136, Bologna, Italy.
| | - Elizaveta Kon
- II Clinic - Biomechanics Laboratory, Rizzoli Orthopaedic Institute, Via Di Barbiano, 1/10, 40136, Bologna, Italy.
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Enderlein D, Nielsen T, Christiansen SE, Faunø P, Lind M. Clinical outcome after reconstruction of the medial patellofemoral ligament in patients with recurrent patella instability. Knee Surg Sports Traumatol Arthrosc 2014; 22:2458-64. [PMID: 25007722 DOI: 10.1007/s00167-014-3164-5] [Citation(s) in RCA: 108] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Accepted: 06/29/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE We present the clinical results of a large consecutive, prospective, single-clinic series of patients treated with medial patellofemoral ligament (MPFL) reconstruction for recurrent patellar instability. METHODS The study included 224 patients undergoing MPFL reconstruction in a total of 240 knees between 2008 and 2011. Indication for surgery was two or more patellar dislocations and ADL limitations due to patella instability. SURGICAL PROCEDURE A gracilis tendon autograft was fixed in drill holes in the medial edge of the patella and with screws at the femoral MPFL insertion point. Outcomes were evaluated with the Kujala Anterior Knee Pain Score and pain scores preoperatively and at follow-up (12-60 months). Furthermore, incidences of re-dislocations, subluxations and revision surgery were evaluated. RESULTS The Kujala score improved from 62.5 (17) to 80.4 (18) (p<0.001) at the 1-year follow-up. Pain during activity improved from 3.2 (2.6) to 1.3 (2.7) at 1 year (p<0.001). The revision rate was 2.8%. Some degree of pain at the medial femoral condyle was seen in 30% of the patients. The reconstruction was supplemented with a tibial tuberosity osteotomy in 23% of cases. The outcome for these patients did not differ from that of patients with isolated MPFL reconstruction. Female gender BMI>30, age>30 years and grade 3-4 cartilage injury predisposed a poor subjective outcome. CONCLUSIONS The present study is the largest MPFL reconstruction patient material reported to date. MPFL reconstruction with a gracilis tendon autograft consistently normalised the patella stability and improved knee function. Moderate medial pain was seen. Age above 30, obesity, cartilage injury and female gender are predictors of a poor subjective outcome. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Ditte Enderlein
- Division of Sports Trauma, Orthopaedic Department, Aarhus University Hospital, Tage Hansens Gade 2, 8000, Aarhus C, Denmark
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Pachowsky ML, Werner S, Marlovits S, Stelzeneder D, Renner N, Trattnig S, Welsch GH. 3D-isotropic high-resolution morphological imaging and quantitative T2 mapping as biomarkers for gender related differences after matrix-associated autologous chondrocyte transplantation (MACT). J Orthop Res 2014; 32:1341-8. [PMID: 25042251 DOI: 10.1002/jor.22682] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Accepted: 06/10/2014] [Indexed: 02/04/2023]
Abstract
The aim of this study was to determine in vivo high-resolution morphological and biochemical gender related differences in cartilage repair tissue (MACT). Forty patients were examined clinically and by MR scans at 3T-MRI (coronal 3D True-FISP sequence for morphologic assessment and multi-echo spin-echo T2-mapping for biochemical assessment of healthy cartilage and MACT cartilage). Mean T2 values in repair tissue in the deep zone showed significantly shorter T2 times in females (p = 0.009, female 43.5 ± 9.8 vs. male 48.2 ± 7.7 ms). The superficial zone showed higher T2 values than the deep zone in both the groups (female 48.5 ± 9.8, males 52.6 ± 11.0 ms) without significant difference between female and male patients. Native control cartilage showed no statistically significant differences for T2 between females and males. The subdivisions "structure of the repair tissue" and "subchondral bone" of the MOCART score showed statistically significant differences between females and males (p = 0.026 and p = 0.007) as well as the Lysholm score (p = 0.03). Our investigations revealed differences between female and male patients after MACT of the knee in clinical outcome and advanced morphological and biochemical MRI. The presented imaging biomarkers can depict subtle changes after cartilage regeneration procedures and might help to understand gender related differences after cartilage repair procedures.
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Affiliation(s)
- Milena L Pachowsky
- High Field MR Centre, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria; Department of Trauma and Orthopaedic Surgery, University Hospital of Erlangen, Erlangen, Germany
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Abstract
OBJECTIVE Patellofemoral instability is common and affects a predominantly young age group. Chondral injury occurs in up to 95%, and includes osteochondral fractures and loose bodies acutely and secondary degenerative changes in recurrent cases. Biomechanical abnormalities, such as trochlear dysplasia, patella alta, and increased tibial tuberosity-trochlear groove distance, predispose to both recurrent dislocations and patellofemoral arthrosis. DESIGN In this article, we review the mechanisms of chondral injury in patellofemoral instability, diagnostic modalities, the distribution of lesions seen in acute and episodic dislocation, and treatments for articular cartilage lesions of the patellofemoral joint. RESULTS Little specific evidence exists for cartilage treatments in patellofemoral instability. In general, the results of reparative and restorative procedures in the patellofemoral joint are inferior to those observed in other compartments of the knee. CONCLUSION Given the increased severity of chondral lesions and progression to osteoarthritis seen with recurrent dislocations, careful consideration should be given to early stabilisation in patients with predisposing factors.
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Affiliation(s)
- Timothy Lording
- Frankston Hospital, Frankston, Victoria, Australia
- Groupement Hospitalier Nord, Université Lyon 1, Lyon, France
| | | | - Elvire Servien
- Groupement Hospitalier Nord, Université Lyon 1, Lyon, France
| | - Philippe Neyret
- Groupement Hospitalier Nord, Université Lyon 1, Lyon, France
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Filardo G, Kon E, Andriolo L, Di Matteo B, Balboni F, Marcacci M. Clinical profiling in cartilage regeneration: prognostic factors for midterm results of matrix-assisted autologous chondrocyte transplantation. Am J Sports Med 2014; 42:898-905. [PMID: 24481827 DOI: 10.1177/0363546513518552] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Matrix-assisted autologous chondrocyte transplantation (MACT) was developed to overcome the limitations of first-generation autologous chondrocyte implantation. Although short-term/midterm results are now available for a small series of patients, the literature still lacks studies on large cohorts of patients evaluated at midterm/long-term follow-up. PURPOSE Not all patients can have the same benefit from this procedure. The aim of this study is to analyze a large cohort of patients treated with hyaluronan-based MACT to perform clinical profiling and to highlight the patient- and lesion-specific aspects that play a key role in determining the prognosis. STUDY DESIGN Case series; Level of evidence, 4. METHODS A total of 142 patients were treated for lesions involving the femoral condyles and trochleae; 133 knees were followed up yearly for 7 years. The average size of the defects was 2.3 ± 1.0 cm2. The origin was traumatic in 44 cases and degenerative in 57 cases, and 32 knees were affected by osteochondritis dissecans (OCD). The clinical outcome was analyzed using the International Knee Documentation Committee (IKDC), EuroQol visual analog scale, and Tegner scores. The influence of the following factors was analyzed: sex, age, body mass index, site, lesion origin, lesion size, previous or combined surgery, and symptom duration. RESULTS A marked improvement in all scores was found: the IKDC subjective score increased from the basal level of 39.6 ± 14.4 to 71.9 ± 19.8 (P < .0005) at 12 months; a further improvement was observed at 24 months (77.0 ± 20.5; P < .0005). The results were stable over time up to the 7-year evaluation (77.4 ± 22.1). The failure rate was 10.7%. Better results were seen in the trochleae, and among femoral condyles, the following factors were found to influence the clinical outcome positively: traumatic and OCD origin, male sex, short symptom duration (for traumatic lesions), small lesion size (for OCD), young age, and no previous surgery. CONCLUSION Treatment with MACT provides good and stable clinical results. Injury origin, sex, symptom duration, lesion size, lesion site, age, and previous surgery might determine the final outcome and can be used as a sort of clinical profiling to guide the surgeon in the choice of this procedure and in giving realistic expectations to patients requiring cartilage treatment.
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Affiliation(s)
- Giuseppe Filardo
- Berardo Di Matteo, Biomechanics Laboratory, Rizzoli Orthopaedic Institute, Via di Barbiano, 1/10 Bologna, 40136 Italy.
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Filardo G, Kon E, Andriolo L, Di Martino A, Zaffagnini S, Marcacci M. Treatment of "patellofemoral" cartilage lesions with matrix-assisted autologous chondrocyte transplantation: a comparison of patellar and trochlear lesions. Am J Sports Med 2014; 42:626-34. [PMID: 24302700 DOI: 10.1177/0363546513510884] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Matrix-assisted autologous chondrocyte transplantation (MACT) has been shown to offer good outcomes at midterm follow-up, but results are heterogeneous among different patients and lesion types. Being part of the same joint, both patellar and trochlear cartilage lesions are commonly considered to be affected by the same treatment issues, and therefore, it is common practice to report results obtained treating these lesions together. PURPOSE To determine, in a large cohort of patients prospectively followed at midterm follow-up for patellofemoral chondral defects, if patellar and trochlear defects actually represent different clinical conditions with different healing potentials after cartilage treatment. STUDY DESIGN Cohort study; Level of evidence, 2. METHODS A total of 49 consecutive patients with full-thickness patellofemoral chondral lesions of the knee were treated with MACT at the authors' institute and followed prospectively for a minimum follow-up of 5 years. Among these 49 patients, 28 were affected by patellar lesions, 17 were affected by trochlear lesions, and 4 had both patellar and trochlear defects. The clinical outcome was analyzed with International Knee Documentation Committee (IKDC) subjective, EuroQol visual analogue scale (EQ-VAS), Kujala, and Tegner scores. RESULTS A statistically significant improvement in all scores was observed after treatment. Patellar lesions required more realignment procedures and were more common in women. The comparative analysis showed better results for trochlear lesions compared with patellar lesions at all follow-ups, with mean IKDC scores at 5-year follow-up of 89.6 ± 12.7 and 69.7 ± 17.6, respectively (P < .0005). Better results were also shown for the mean Kujala score (92.4 ± 14.7 vs 81.5 ± 12.7, respectively; P = .012) and mean EQ-VAS score (90.0 ± 10.8 vs 81.9 ± 11.7, respectively; P = .027). Finally, the sport activity level evaluated with the Tegner score confirmed the same trend; even though neither patellar nor trochlear lesion groups reached the preinjury level, both improved after treatment, with a significantly higher improvement in the trochlear lesion group (5.9 ± 1.8 vs 3.9 ± 1.7, respectively; P < .0005). CONCLUSION Patient characteristics differ between patellar and trochlear cartilage defects, and moreover, the results obtained are significantly different, with a markedly good outcome in cases with trochlear lesions and less satisfactory results for patients affected by cartilage lesions of the patella. Thus, patellar and trochlear defects should be considered separately when evaluating the outcome of cartilage treatments in this anatomic region.
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Affiliation(s)
- Giuseppe Filardo
- Luca Andriolo, Biomechanics Laboratory, Rizzoli Orthopaedic Institute, Via Di Barbiano, 1/10 - 40136 Bologna, Italy.
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