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Kolar M, Veber M, Girandon L, Drobnič M. A Biomimetic Osteochondral Scaffold Augmented With Filtered Bone Marrow Aspirate for the Treatment of Joint Surface Lesions in the Knee. Am J Sports Med 2024; 52:1826-1833. [PMID: 38767159 DOI: 10.1177/03635465241247788] [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] [Indexed: 05/22/2024]
Abstract
BACKGROUND Multilayered osteochondral scaffolds are becoming increasingly utilized for the repair of knee joint surface lesions (KJSLs). However, the literature on predictive factors is rather limited. PURPOSE To (1) evaluate the clinical outcomes and safety of a combined single-step approach using a biomimetic collagen-hydroxyapatite scaffold (CHAS) and filtered bone marrow aspirate (fBMA) for the treatment of KJSLs and (2) identify significant predictors of the treatment outcomes. STUDY DESIGN Case series; Level of evidence, 4. METHODS All patients who underwent surgery because of a KJSL (size ≥1.5 cm2; International Cartilage Regeneration & Joint Preservation Society grades 3-4) using the combination above were selected from a hospital registry database (100 patients; minimum 2-year follow-up). Patient characteristics, medical history, knee joint and lesion status, intraoperative details, and cellular parameters of the injected fBMA were collected. The arthroscopic evaluation of chondral and meniscal tissue quality in all knee compartments was performed using the Chondropenia Severity Score. Treatment outcomes were determined clinically using patient-reported outcome measures (Knee Injury and Osteoarthritis Outcome Score, EuroQol-5 Dimensions-3 Levels, EuroQol-Visual Analog Scale, and Tegner Activity Scale) and by assessing the occurrence of serious adverse events and graft failure. Multivariable regression analysis was performed to identify significant predictors of the treatment outcomes. RESULTS At a mean follow-up of 54.2 ± 19.4 months, 78 (87%) patients completed the questionnaires with significant improvements toward the baseline (P < .00625): KOOS Pain subscale from 62 ± 17 to 79 ± 18, KOOS Total score from 57 ± 16 to 70 ± 20, EuroQol-Visual Analog Scale from 61 ± 21 to 76 ± 16, EuroQol-5 Dimensions-3 Levels from 0.57 ± 0.20 to 0.80 ± 0.21, and Tegner Activity Scale from 2.8 ± 1.5 to 3.9 ± 1.9. The graft failure rate was 4%. A longer duration of preoperative symptoms, previous surgery, larger lesions, older age, and female sex were the main negative predictors for the treatment outcomes. The Chondropenia Severity Score and the number of fibroblast colony-forming units in fBMA positively influenced some of the clinical results and safety. CONCLUSION A CHAS augmented with fBMA proved to be an adequate and safe approach for the treatment of KJSLs up to midterm follow-up. Based on the subanalysis of predictive factors, the surgical intervention should be performed in a timely and precise manner to prevent lesion enlargement, deterioration of the general knee cartilage status, and recurrent surgical procedures, especially in older and female patients. When a CHAS is used, the quantity of MSCs seems to play a role in augmentation. REGISTRATION NCT06078072 (ClinicalTrials.gov identifier).
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Affiliation(s)
- Matic Kolar
- Department of Orthopaedic Surgery, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | | | | | - Matej Drobnič
- Department of Orthopaedic Surgery, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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2
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Valladares N, Cabrero Montes MA, Jacobo-Jimenez GJ, Zavala-Cerna MG. Rapid Recovery after Reparation of Full-Thickness Chondral Defects of the Knee with the Use of Hyaluronan (HA)-Based 3-D Scaffold. J Funct Biomater 2023; 14:491. [PMID: 37888156 PMCID: PMC10607491 DOI: 10.3390/jfb14100491] [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: 08/29/2023] [Revised: 09/19/2023] [Accepted: 09/21/2023] [Indexed: 10/28/2023] Open
Abstract
Articular cartilage injuries are found in up to 60% of patients who undergo an arthroscopic knee procedure, and those that totally affect articular cartilage (grade IV) have limited regenerative capacity and extended time for recovery. 3-D scaffolds represent a novel solution to address this type of injury. Our purpose was to analyze the MRI findings and functional status of patients that underwent repair of chondral defects either by microfractures or Hyaluronan (HA) 3-D scaffolding. We conducted a retrospective study of patients with chondral defects. The outcomes analyzed in this study included anatomical changes evaluated by the Henderson score (based on MRI findings) at baseline, 6, and 12 months after surgery, and improvement in functionality evaluated by the Modified Cincinnati Knee Rating System (MCKRS) at baseline and 6 months after surgery. Clinical and demographic characteristics were similar for both groups. There was a statistically significant improvement in Henderson score for the 3-D scaffold-treated group at 6 months versus the microfracture group (p < 0.0001). Improvement in functionality, measured by the MCKRS, was more frequently found in the 3-D scaffold-treated group. In conclusion, the use of HA 3-D scaffolding was superior, with faster recovery evident 6 months after the surgery that progressed to full recovery in all patients a year after surgery. Future studies with a randomized design might help to support our findings. This study provides level III evidence.
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Affiliation(s)
| | | | | | - Maria G Zavala-Cerna
- Laboratorio de Investigación en Inmunología, Unidad Académica Ciencias de la Salud, Universidad Autónoma de Guadalajara, Zapopan 45129, Mexico
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3
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Karami P, Stampoultzis T, Guo Y, Pioletti DP. A guide to preclinical evaluation of hydrogel-based devices for treatment of cartilage lesions. Acta Biomater 2023; 158:12-31. [PMID: 36638938 DOI: 10.1016/j.actbio.2023.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 12/19/2022] [Accepted: 01/05/2023] [Indexed: 01/12/2023]
Abstract
The drive to develop cartilage implants for the treatment of major defects in the musculoskeletal system has resulted in a major research thrust towards developing biomaterial devices for cartilage repair. Investigational devices for the restoration of articular cartilage are considered as significant risk materials by regulatory bodies and therefore proof of efficacy and safety prior to clinical testing represents a critical phase of the multidisciplinary effort to bridge the gap between bench and bedside. To date, review articles have thoroughly covered different scientific facets of cartilage engineering paradigm, but surprisingly, little attention has been given to the preclinical considerations revolving around the validation of a biomaterial implant. Considering hydrogel-based cartilage products as an example, the present review endeavors to provide a summary of the critical prerequisites that such devices should meet for cartilage repair, for successful implantation and subsequent preclinical validation prior to clinical trials. Considerations pertaining to the choice of appropriate animal model, characterization techniques for the quantitative and qualitative outcome measures, as well as concerns with respect to GLP practices are also extensively discussed. This article is not meant to provide a systematic review, but rather to introduce a device validation-based roadmap to the academic investigator, in anticipation of future healthcare commercialization. STATEMENT OF SIGNIFICANCE: There are significant challenges around translation of in vitro cartilage repair strategies to approved therapies. New biomaterial-based devices must undergo exhaustive investigations to ensure their safety and efficacy prior to clinical trials. These considerations are required to be applied from early developmental stages. Although there are numerous research works on cartilage devices and their in vivo evaluations, little attention has been given into the preclinical pathway and the corresponding approval processes. With a focus on hydrogel devices to concretely illustrate the preclinical path, this review paper intends to highlight the various considerations regarding the preclinical validation of hydrogel devices for cartilage repair, from regulatory considerations, to implantation strategies, device performance aspects and characterizations.
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Affiliation(s)
- Peyman Karami
- Laboratory of Biomechanical Orthopedics, Institute of Bioengineering, School of Engineering, EPFL, Lausanne, Switzerland
| | - Theofanis Stampoultzis
- Laboratory of Biomechanical Orthopedics, Institute of Bioengineering, School of Engineering, EPFL, Lausanne, Switzerland
| | - Yanheng Guo
- Laboratory of Biomechanical Orthopedics, Institute of Bioengineering, School of Engineering, EPFL, Lausanne, Switzerland
| | - Dominique P Pioletti
- Laboratory of Biomechanical Orthopedics, Institute of Bioengineering, School of Engineering, EPFL, Lausanne, Switzerland.
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4
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Hopkins T, Roberts S, Richardson JB, Gallacher P, Bailey A, Kuiper JH. Relationship Between Activity Level and Knee Function Is Influenced by Negative Affect in Patients Undergoing Cell Therapy for Articular Cartilage Defects in the Knee. Orthop J Sports Med 2023; 11:23259671231151925. [PMID: 36846815 PMCID: PMC9950618 DOI: 10.1177/23259671231151925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/01/2023] Open
Abstract
Background Increased activity level is generally reported to be positively related to improved knee function after knee surgery. However, little research has been conducted into this relationship on an individual patient basis, or the influence of demographic and psychosocial factors such as patient affect-the subjective experience of emotion. Hypothesis The relationship between postoperative activity level and knee function will vary between patients and will be influenced by the patients' affect and demographic characteristics. Study Design Cohort study; Level of evidence, 3. Methods Activity, knee function, demographic, and affect data were collected from patients enrolled in an ongoing trial for the treatment of articular cartilage lesions at preoperative and 2-, 12-, and 15-month postoperative points. Quantile mixed regression modeling was used to determine the patient-to-patient variation in activity level and knee function. Multiple linear regression and partial correlation analyses were performed to determine whether demographic characteristics and patient affect were associated with this variation. Results A total of 62 patients were included in the study (23 female; 39 male; mean age, 38.3 ± 9.5 years). We found substantial variation between patients in the relationship between activity level and knee function, with most patients (n = 56) demonstrating a positive relation (positive slope), but 6 patients demonstrating a negative relation (negative slope). A negative affect (NA) score was significantly correlated with the slope between activity level and knee function (r S = -0.30; P = .018) and was a significant individual predictor of knee function at 15 months postoperatively (coefficient = -3.5; P = .025). Conclusion Our results suggest that the relationship between activity level and knee function varies between patients. The patients with a higher NA score were likely to report smaller improvements in knee function with increasing activity levels compared with those with a lower NA score.
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Affiliation(s)
| | - Sally Roberts
- Robert Jones and Agnes Hunt Orthopaedic Hospital, Shropshire,
UK
- J.B.R. is deceased
| | | | - Pete Gallacher
- Robert Jones and Agnes Hunt Orthopaedic Hospital, Shropshire,
UK
| | - Andrea Bailey
- Robert Jones and Agnes Hunt Orthopaedic Hospital, Shropshire,
UK
| | - Jan Herman Kuiper
- Robert Jones and Agnes Hunt Orthopaedic Hospital, Shropshire,
UK
- J.B.R. is deceased
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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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6
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Gillinov SM, Fosam A, Burroughs PJ, Schneble CA, McLaughlin WM, Moran J, Jimenez AE, Grauer JN, Medvecky MJ. Incidence, Timing, and Risk Factors for 5-Year Revision Surgery After Autologous Chondrocyte Implantation in 533 Patients. Am J Sports Med 2022; 50:2893-2899. [PMID: 35916771 DOI: 10.1177/03635465221111115] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Autologous chondrocyte implantation (ACI) can be used to treat focal, full-thickness chondral defects of the knee. However, there is limited large-sample evidence available regarding the incidence, timing, and risk factors for revision surgery after ACI. PURPOSE To assess the 5-year incidence, timing, and risk factors for revision surgery after ACI in a large national cohort. STUDY DESIGN Case series; Level of evidence, 4. METHODS The 2010-2020 PearlDiver database was queried for patients aged 20 to 59 years who underwent primary ACI of the knee without previous chondral procedures or knee arthroplasty. Revision surgery was defined as subsequent revision ACI, osteochondral allograft transplantation, osteochondral autograft transfer, unicompartmental knee arthroplasty, or total knee arthroplasty within 5 years. Kaplan-Meier analysis was used to assess both incidence and timing of revision surgery. Risk factors evaluated for revision surgery included patient age, sex, body mass index (BMI), Elixhauser Comorbidity Index (ECI) score, and previous or concomitant bony realignment procedures. RESULTS In total, 533 patients underwent primary ACI and met inclusion criteria. The 5-year incidence of revision surgery was 10.3%, with 63% of revisions occurring in the first 2 years after surgery. Risk factors associated with revision surgery included female sex (odds ratio, 2.58; 95% CI, 1.22-5.45; P = .013) and BMI ≥35 (odds ratio, 2.24; 95% CI, 1.01-4.94; P = .047). There was no relationship between age, ECI score, or previous or concomitant bony realignment procedures and revision surgery at 5 years (P > .05). CONCLUSION In an analysis of 533 patients who underwent ACI, 10.3% required a subsequent articular cartilage procedure or conversion to knee arthroplasty in the first 5 postoperative years. Revision surgery was greatest in the first 2 postoperative years. Female sex and severe obesity (BMI, ≥35) were associated with increased risk of revision surgery, while age, ECI score, and previous or concomitant bony realignment procedures were not. These findings suggest that treatment of chondral defects of the knee with ACI is associated with durable outcomes at the 5-year follow-up.
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Affiliation(s)
| | - Andin Fosam
- Yale School of Medicine, New Haven, Connecticut, USA
| | | | - Christopher A Schneble
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut, USA
| | - William M McLaughlin
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut, USA
| | - Jay Moran
- Yale School of Medicine, New Haven, Connecticut, USA
| | - Andrew E Jimenez
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut, USA
| | - Jonathan N Grauer
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut, USA
| | - Michael J Medvecky
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut, USA
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7
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Nordberg RC, Otarola GA, Wang D, Hu JC, Athanasiou KA. Navigating regulatory pathways for translation of biologic cartilage repair products. Sci Transl Med 2022; 14:eabp8163. [PMID: 36001677 PMCID: PMC9918326 DOI: 10.1126/scitranslmed.abp8163] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Long-term clinical repair of articular cartilage remains elusive despite advances in cartilage tissue engineering. Only one cartilage repair therapy classified as a "cellular and gene therapy product" has obtained Food and Drug Administration (FDA) approval within the past decade although more than 200 large animal cartilage repair studies were published. Here, we identify the challenges impeding translation of strategies and technologies for cell-based cartilage repair, such as the disconnect between university funding and regulatory requirements. Understanding the barriers to translation and developing solutions to address them will be critical for advancing cell therapy products for cartilage repair to clinical use.
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Affiliation(s)
- Rachel C Nordberg
- Department of Biomedical Engineering, University of California Irvine, Irvine, CA 92697 USA
| | - Gaston A Otarola
- Department of Biomedical Engineering, University of California Irvine, Irvine, CA 92697 USA
| | - Dean Wang
- Department of Orthopaedic Surgery, University of California Irvine Medical Center, Orange, CA 92868, USA
| | - Jerry C Hu
- Department of Biomedical Engineering, University of California Irvine, Irvine, CA 92697 USA
| | - Kyriacos A Athanasiou
- Department of Biomedical Engineering, University of California Irvine, Irvine, CA 92697 USA
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8
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Tisano B, Ellis HB, Wyatt C, Wilson PL. Osteochondral Allograft for Unsalvageable Osteochondritis Dissecans in the Skeletally Immature Knee. Orthop J Sports Med 2022; 10:23259671211072515. [PMID: 35178463 PMCID: PMC8844736 DOI: 10.1177/23259671211072515] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 10/28/2021] [Indexed: 11/15/2022] Open
Abstract
Background: While an excellent option for osteochondral defects in the adult knee, fresh osteochondral allograft (FOCA) in the skeletally immature adolescent knee has been infrequently studied. Purpose: To compare radiographic and patient-reported outcomes (PROs) in skeletally mature and immature adolescents after FOCA in the knee for treatment of unsalvageable osteochondritis dissecans (OCD). Study Design: Cohort study; Level of evidence, 3. Methods: Included were 34 patients (37 knees) who underwent size-matched FOCA of the knee for unsalvageable OCD lesions. All patients were aged ≤19 years and had a minimum of 12 months of follow-up. Patient characteristics, lesion characteristics, reoperations, and PROs were evaluated and compared between patients with open physes (skeletally immature; n = 20) and those with closed physes (skeletally mature; n = 17). Graft failure was defined as the need for revision osteochondral grafting. Postoperative radiographs were analyzed at 1 year and the final follow-up for graft incorporation and classified as A (complete), B (≥50% healed), or C (<50% healed). Results: The mean patient age was 15.4 years (range, 9.6-17.6 years), and the mean follow-up was 2.1 years (range, 1-5.3 years). The mean graft size was 5.0 cm2 and did not differ significantly between the study groups. Patients with open physes were younger (14.7 vs 16.2 years; P = .002) and more commonly male (80% vs 35%; P = .008). At the 1-year follow-up, 85% of immature patients and 82% of mature patients had radiographic healing grades of A or B. Patients with open physes were more likely to achieve complete radiographic union at 1 year (65% vs 15%; P = .007) and demonstrated better Knee injury and Osteoarthritis Outcome Score (KOOS) Daily Living (96.8 vs 88.5; P = .04) and KOOS Quality of Life (87.0 vs 56.8; P = .01) at the final follow-up. Complications were no different in either group, and graft failure occurred in only 1 skeletally mature patient with a trochlear lesion. Conclusion: FOCA treatment for unsalvageable OCD in the young knee may be expected to yield excellent early results. Despite the presence of open physes and immature epiphyseal osteochondral anatomy, equivalent or improved healing and PRO scores compared with those of skeletally mature patients may be expected.
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Affiliation(s)
- Breann Tisano
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Henry B. Ellis
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Scottish Rite for Children Sports Medicine Campus, Frisco, Texas, USA
| | - Chuck Wyatt
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Philip L. Wilson
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Scottish Rite for Children Sports Medicine Campus, Frisco, Texas, USA
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9
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Pettit RJ, Everhart JS, DiBartola AC, Blackwell RE, Flanigan DC. Time Matters: Knee Cartilage Defect Expansion and High-Grade Lesion Formation while Awaiting Autologous Chondrocyte Implantation. Cartilage 2021; 13:1802S-1808S. [PMID: 34894761 PMCID: PMC8804858 DOI: 10.1177/19476035211063866] [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] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE The objective of this study was to assess potential risk factors, including time delay until implantation, for knee cartilage defect expansion or new high-grade defect formation between biopsy and Autologous Chondrocyte Implantation (ACI) or Matrix Autologous Chondrocyte Implantation (MACI). STUDY DESIGN Consecutive knee ACI and MACI cases by a single surgeon (n = 111) were reviewed. The relationship between time between biopsy and staged implantation and (1) progression in primary cartilage defect size and (2) development of a new high-grade (Outerbridge grade ≥3) cartilage defect were determined with adjustment for demographics, body mass index, smoking status, coronal alignment, initial cartilage status, and prior surgery. RESULTS Average size of the primary defect at time of biopsy was 4.50 cm2. Mean time to chondrocyte implantation was 155 days. Defect expansion increased 0.11 cm2 (standard error = 0.03) per month delay to implantation (P = 0.001). Independent predictors of defect expansion were male sex, smaller initial defect size, and delay to implantation (adjusted mean = 0.15 cm2 expansion per month). A total of 16.2% of patients (n = 18/111) developed a new high-grade defect. Independent predictors of a new secondary defect were Outerbridge grade 2 changes (vs. 0-1) on the surface opposing the index defect and delayed implantation (per month increase, adjusted odds ratio = 1.21, 95% confidence interval: 1.01-1.44; P = 0.036). CONCLUSIONS Patients undergoing 2-stage cell-based cartilage restoration with either ACI or MACI demonstrated long delays between stages of surgery, placing them at risk for expanding defects and development of new high-grade cartilage defects. Patients who were male, had smaller initial defect size, and longer time between surgeries were at greater risk for defect expansion. LEVEL OF EVIDENCE III, retrospective comparative study.
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Affiliation(s)
| | | | | | | | - David C. Flanigan
- The Ohio State University Wexner
Medical Center, Columbus, OH, USA,David C. Flanigan, The Ohio State
University Wexner Medical Center, 2835 Fred Taylor Drive, Suite 2200, Columbus,
OH 43202, USA.
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10
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Filardo G, Andriolo L, Angele P, Berruto M, Brittberg M, Condello V, Chubinskaya S, de Girolamo L, Di Martino A, Di Matteo B, Gille J, Gobbi A, Lattermann C, Nakamura N, Nehrer S, Peretti GM, Shabshin N, Verdonk P, Zaslav K, Kon E. Scaffolds for Knee Chondral and Osteochondral Defects: Indications for Different Clinical Scenarios. A Consensus Statement. Cartilage 2021; 13:1036S-1046S. [PMID: 31941355 PMCID: PMC8808892 DOI: 10.1177/1947603519894729] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE To develop patient-focused consensus guidelines on the indications for the use of scaffolds to address chondral and osteochondral femoral condyle lesions. DESIGN The RAND/UCLA Appropriateness Method (RAM) was used to develop patient-specific recommendations by combining the best available scientific evidence with the collective judgement of a panel of experts guided by a core panel and multidisciplinary discussers. A list of specific clinical scenarios was produced regarding adult patients with symptomatic lesions without instability, malalignment, or meniscal deficiency. Each scenario underwent discussion and a 2-round vote on a 9-point Likert-type scale (range 1-3 "inappropriate," 4-6 "uncertain," 7-9 "appropriate"). Scores were pooled to generate expert recommendations. RESULTS Scaffold (chondral vs. osteochondral), patient characteristics (age and sport activity level), and lesion characteristics (etiology, size, and the presence of osteoarthritis [OA]) were considered to define 144 scenarios. The use of scaffold-based procedures was considered appropriate in all cases of chondral or osteochondral lesions when joints are not affected by OA, while OA joints presented more controversial results. The analysis of the evaluated factors showed a different weight in influencing treatment appropriateness: the presence of OA influenced 58.3% of the indications, while etiology, size, and age were discriminating factors in 54.2%, 29.2%, and 16.7% of recommendations, respectively. CONCLUSIONS The consensus identified indications still requiring investigation, but also the convergence of the experts in several scenarios defined appropriate or inappropriate, which could support decision making in the daily clinical practice, guiding the use of scaffold-based procedures for the treatment of chondral and osteochondral knee defects.
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Affiliation(s)
- Giuseppe Filardo
- Applied and Translational Research (ATR)
Center, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Luca Andriolo
- Clinica Ortopedica e Traumatologica 2,
IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy,Luca Andriolo, Clinica Ortopedica e
Traumatologica 2, IRCCS Istituto Ortopedico Rizzoli, Via Di Barbiano, 1/10,
Bologna 40136, Italy.
| | - Peter Angele
- Clinic for Trauma and Reconstructive
Surgery, University Hospital Regensburg, Regensburg, Bayern, Germany,Sporthopaedicum Regensburg, Regensburg,
Germany
| | - Massimo Berruto
- UOS Knee SURGERY-1st University Clinic
of Orthopaedics, ASST Pini-CTO, Milan, Italy
| | - Mats Brittberg
- Cartilage Research Unit, University of
Gothenburg, Gothenburg, Sweden,Region Halland Orthopaedics, Kungsbacka
Hospital, Kungsbacka, Sweden
| | - Vincenzo Condello
- Joint Preservation and Reconstructive
Surgery and Sports Medicine Unit, Humanitas Castelli Clinic, Bergamo, Lombardy,
Italy
| | - Susan Chubinskaya
- Department of Pediatrics, Orthopedic
Surgery & Medicine (Section of Rheumatology), Rush University Medical Center,
Chicago, IL, USA
| | - Laura de Girolamo
- Orthopaedic Biotechnology Laboratory,
IRCCS Istituto Ortopedico Galeazzi, Milano, Italy
| | - Alessandro Di Martino
- Clinica Ortopedica e Traumatologica 2,
IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Berardo Di Matteo
- Department of Biomedical Sciences,
Humanitas University, Rozzano, Milan, Italy,Humanitas Clinical and Research
Center- IRCCS, Via Manzoni 56, 20089, Rozzano - Milan, Italy
| | - Justus Gille
- Department of Trauma and Orthopaedic
Surgery, University Hospital Schleswig-Holstein, Campus Luebeck, Luebeck,
Germany
| | - Alberto Gobbi
- Orthopaedic Arthroscopic Surgery
International (OASI) Bioresearch Foundation, Milan, Italy
| | - Christian Lattermann
- Department of Orthopaedic Surgery,
Division of Sports Medicine, Center for Cartilage Repair, Brigham and Women’s
Hospital, Harvard Medical School, Boston, MA, USA
| | - Norimasa Nakamura
- Institute for Medical Science in
Sports, Osaka Health Science University, Osaka, Japan
| | - Stefan Nehrer
- Center for Regenerative Medicine,
Danube University, Krems an der Donau, Austria
| | - Giuseppe M. Peretti
- IRCCS Istituto Ortopedico Galeazzi,
Milan, Italy,Department of Biomedical Sciences for
Health, University of Milan, Milan, Italy
| | - Nogah Shabshin
- Department of Radiology, Emek Medical
Center, Clalit Healthcare Services, Afula, Israel,Department of Radiology, PennMedicine,
Philadelphia, PA, USA
| | - Peter Verdonk
- ORTHOCA, AZ Monica Hospitals, Antwerp,
Belgium,Aspetar Hospital, Doha, Qatar
| | - Kenneth Zaslav
- Ortho Virginia, Virginia Commonwealth
University, Richmond, VA, USA
| | - Elizaveta Kon
- Department of Biomedical Sciences,
Humanitas University, Rozzano, Milan, Italy,Humanitas Clinical and Research
Center- IRCCS, Via Manzoni 56, 20089, Rozzano - Milan, Italy,Department of Traumatology,
Orthopedics and Disaster Surgery, First Moscow State Medical University of the
Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russian
Federation
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11
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DiBartola AC, Magnussen RA, Wiet M, Everhart JS, Emery CF, Schmitt L, Flanigan DC. Predictors of poor pre-operative psychological status among patients with cartilage defects. Knee 2021; 33:11-16. [PMID: 34537536 DOI: 10.1016/j.knee.2021.08.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 07/02/2021] [Accepted: 08/25/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND We evaluated the risk factors for pain catastrophizing, kinesiophobia, and elevated depressive symptoms among patients undergoing high-grade cartilage defect surgery. We hypothesized that cartilage patients would demonstrate high scores on pain catastrophizing, kinesiophobia, and depression testing prior to surgery. METHODS Two hundred and ten patients undergoing surgery for high-grade cartilage defects (56% chondroplasty, 36% microfracture, 22% autologous chondrocyte implantation) completed a preoperative survey before undergoing surgery. Outcome scores assessed were: International Knee Documentation Committee-Symptom (IKDC-S) score, Tegner activity score, Pain catastrophizing scale (PCS), Tampa scale for kinesiophobia (TSK-11), and Patient Health Questionnaire depression scale (PHQ-9). Multivariate logistic regression was used to determine what pre-operative factors predicted pain catastrophizing, kinesiophobia, and elevated depressive symptoms. RESULTS The mean pre-operative Tegner score was 5.8 (SD 2.4) and IKDC-S score was 44.7 (SD 11.1). Prior to surgery, 19% had abnormal pain catastrophizing (PCS ≥ 20 points), 14.4% had moderate-severe depression (PHQ ≥ 10), and 49.0% had high kinesiophobia (TSK-11 ≥ 25). Lower pre-operative Tegner scores predicted moderate-severe depressive symptoms (per point decrease, OR 1.36, 95% CI 1.06, 1.76; p = 0.008). Predictors of elevated pain catastrophizing were lower pre-operative IKDC-S scores (per 5-point decrease, OR 1.28, 95% CI 1.08, 1.51; p = 0.002) and symptom duration >6 months (OR 2.20 CI 1.14, 4.32; p = 0.02). A lower pre-operative IKDC-S score (per 5-point decrease, OR 1.17, CI 1.03, 1.33; p = 0.02) predicted elevated kinesiophobia. CONCLUSION Low self-reported function, low activity level and symptom duration greater than six months are associated with poor preoperative psychological status.
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Affiliation(s)
- Alex C DiBartola
- Department of Orthopaedics, Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Robert A Magnussen
- Department of Orthopaedics, Ohio State University Wexner Medical Center, Columbus, OH, United States; Department of Orthopaedics, Sports Medicine, Ohio State University, Wexner Medical Center, United States
| | - Matthew Wiet
- The Ohio State University College of Medicine, Ohio State University, Wexner Medical Center, United States
| | | | - Charles F Emery
- Department of Psychology, Ohio State University, Columbus, OH, United States
| | - Laura Schmitt
- Division of Physical Therapy, School of Health and Rehabilitation Sciences, Ohio State University and Jameson Crane Sports Medicine Research Institute, Ohio State University, United States
| | - David C Flanigan
- Department of Orthopaedics, Ohio State University Wexner Medical Center, Columbus, OH, United States; Department of Orthopaedics, Sports Medicine, Ohio State University, Wexner Medical Center, United States; Cartilage Restoration Program, Ohio State University, Wexner Medical Center, United States.
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12
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Cole BJ, Redondo ML, Cotter EJ. Articular Cartilage Injuries of the Knee: Patient Health Literacy, Expectations for Management, and Clinical Outcomes. Cartilage 2021; 12:139-145. [PMID: 30486654 PMCID: PMC7970381 DOI: 10.1177/1947603518816429] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE The purpose of this article is to review the orthopedic literature regarding patient understanding of articular cartilage disease, interpret literature reporting patient expectations for surgical management of articular cartilage injuries of the knee, and review patient-reported outcomes and patient satisfaction with management of these injuries. DESIGN A retrospective review of the current literature using the PubMed database (1980-current) was performed on July 15, 2017. The search terms used were "patient understanding knee cartilage," "patient satisfaction knee cartilage," "patient expectation knee cartilage," and "patient reported outcomes knee cartilage." All searches were filtered to human studies and English language only and were reviewed by 2 independent reviewers. Studies not relevant to articular cartilage injury and/or surgical management in the knee were excluded. Additional references were found by backtracing references from obtained articles. RESULTS The published study search results for the terms: "patient understanding knee cartilage," "patient satisfaction knee cartilage," "patient expectation knee cartilage," and "patient reported outcomes knee cartilage" displayed a total of 873 studies. Two independent reviewers screen all studies A total of 50 published studies were relevant and included. CONCLUSION The subjective and objective clinical outcomes reported are inconsistently obtained resulting in difficulty drawing comparisons between studies. While the relationship between preoperative patient expectations and patient-reported outcomes and patient satisfaction has yet to be well developed, authors have reported patient and injury specific variables associated with superior and inferior outcomes. In conclusion, more work is needed to correlate patient-reported outcomes and satisfaction for cartilage treatments with preoperative expectations and health literacy.
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Affiliation(s)
- Brian J. Cole
- Division of Sports Medicine,
Department of Orthopaedic Surgery, Rush University Medical Center, Chicago,
IL, USA,Brian J. Cole, Department of
Orthopaedic Surgery, Cartilage Restoration Center at Rush University,
Medical Center Midwest Orthopaedic at Rush, 1611 West Harrison Street,
Chicago, IL 60612, USA.
| | - Michael L. Redondo
- Division of Sports Medicine,
Department of Orthopaedic Surgery, Rush University Medical Center, Chicago,
IL, USA
| | - Eric J. Cotter
- Department of Orthopedics and
Rehabilitation, University of Wisconsin Madison School of Medicine and
Public Health, Madison, WI, USA
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13
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Becher C, Imhoff A. [Guidelines for the treatment of unicompartmental cartilage defects of the knee-Cartilage repair, osteotomy, mini-implant or arthroplasty?]. DER ORTHOPADE 2021; 50:88-95. [PMID: 33337504 DOI: 10.1007/s00132-020-04051-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The treatment of unicompartmental cartilage defects offers a large variety of therapeutic options. With help of an algorithm, decision-making for the most suitable treatment approach is supported. Correction of malalignment is key for successful treatment. Defect size, influencing factors such as "age" and prior treatments play an important role in choosing the most appropriate operative treatment option.
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Affiliation(s)
- Christoph Becher
- IZO - Internationales Zentrum für Orthopädie, ATOS Klinik Heidelberg, Bismarckstr. 9-15, 69115, Heidelberg, Deutschland.
| | - Andreas Imhoff
- Abteilung für Sportorthopädie, Klinikum rechts der Isar, Technische Universität München (TUM), München, Deutschland
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14
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Saltzman BM, Redondo ML, Beer A, Cotter EJ, Frank RM, Yanke AB, Cole BJ. Wide Variation in Methodology in Level I and II Studies on Cartilage Repair: A Systematic Review of Available Clinical Trials Comparing Patient Demographics, Treatment Means, and Outcomes Reporting. Cartilage 2021; 12:7-23. [PMID: 30378453 PMCID: PMC7755973 DOI: 10.1177/1947603518809398] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND The management of complex cartilage pathology in young, otherwise healthy patients can be difficult. PURPOSE To determine the nature of the design, endpoints chosen, and rate at which the endpoints were met in published studies and ongoing clinical trials that investigate cartilage repair and restoration procedures. STUDY DESIGN Systematic review. METHODS A systematic review of the publicly available level I/II literature and of the publicly listed clinical trials regarding cartilage repair and restoration procedures for the knee was conducted adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS Seventeen published studies and 52 clinical trials were included. Within the 17 published studies, the most common procedure studied was microfracture (MFX) + augmentation (N = 5; 29.4%) and the most common comparison/control group was MFX (N = 10; 58.8%). In total, 13 different cartilage procedure groups were evaluated. For published studies, the most common patient-reported outcome (PRO) measures assessed is the Knee Injury and Osteoarthritis Outcome Score (KOOS) and Visual Analog Scale-Pain (VAS) (N = 10 studies, 58.8% each, respectively). Overall, there are 10 different PROs used among the included studies. Ten studies demonstrate superiority, 5 demonstrate noninferiority, and 2 demonstrate inferiority to the comparison or control groups. For the clinical trials included, the most common procedure studied is MFX + augmentation (N = 16; 30.8%). The most common PRO assessed is KOOS (N = 36 trials; 69.2%), and overall there are 24 different PROs used among the included studies. CONCLUSIONS Recently published studies and clinical trials evaluate a variety of cartilage repair and restoration strategies for the knee, most commonly MFX + augmentation, at various time points of outcome evaluation, with KOOS and VAS scores being used most commonly. MFX remains the most common comparison group for these therapeutic investigations. Most studies demonstrate superiority versus comparison or control groups. Understanding the nature of published and ongoing clinical trials will be helpful in the investigation of emerging technologies required to navigate the regulatory process while studying a relatively narrow population of patients.
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Affiliation(s)
| | | | - Adam Beer
- Rush University Medical Center, Chicago, IL, USA
| | - Eric J. Cotter
- University of Wisconsin Madison School of Medicine and Public Health, Madison, WI, USA
| | | | | | - Brian J. Cole
- Rush University Medical Center, Chicago, IL, USA,Brian J. Cole, Rush University Medical Center, 1611 West Harrison Street, Suite 300, Chicago, IL 60612-3833, USA.
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15
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Ackermann J, Ogura T, Duerr RA, Barbieri Mestriner A, Gomoll AH. Preoperative Mental Health Has a Stronger Association with Baseline Self-Assessed Knee Scores than Defect Morphology in Patients Undergoing Cartilage Repair. Cartilage 2020; 11:309-315. [PMID: 29972067 PMCID: PMC7298602 DOI: 10.1177/1947603518783484] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE The purpose of this study was to assess potential correlations between the mental component summary of the Short Form-12 (SF-12 MCS), patient characteristics or lesion morphology, and preoperative self-assessed pain and function scores in patients undergoing autologous chondrocyte implantation (ACI). DESIGN A total of 290 patients underwent ACI for symptomatic cartilage lesions in the knee. One hundred and seventy-eight patients were included in this study as they completed preoperative SF-12, Knee injury and Osteoarthritis Outcome Score (KOOS), Tegner, Lysholm, and International Knee Documentation Committee (IKDC) scores. Age, sex, smoker status, body mass index, Worker's Compensation, previous surgeries, concomitant surgeries, number of defects, lesion location in the patella, and total defect size were recorded for each patient. Pearson's correlation and multivariate regression models were used to distinguish associations between these factors and preoperative knee scores. RESULTS The SF-12 MCS showed the strongest bivariate correlation with all KOOS subgroups (P < 0.001) (except KOOS Symptom; P = 0.557), Tegner (P = 0.005), Lysholm (P < 0.001), and IKDC scores (P < 0.001). In the multivariate regression models, the SF-12 MCS showed the strongest association with all KOOS subgroups (P < 0.001) (except KOOS Symptom; P = 0.91), Lysholm (P = 0.001), Tegner (P = 0.017), and IKDC (P < 0.001). CONCLUSION In patients with symptomatic cartilage defects of the knee, preoperative patient mental health has a strong association with self-assessed pain and functional knee scores. Further studies are needed to determine if preoperative mental health management can improve preoperative symptoms and postoperative outcomes.
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Affiliation(s)
- Jakob Ackermann
- Cartilage Repair Center and Center for
Regenerative Medicine, Brigham and Women’s Hospital, Harvard Medical School, Harvard
University, Boston, MA, USA,Jakob Ackermann, Cartilage Repair Center,
Brigham and Women’s Hospital, 850 Boylston Street, Suite 120, Chestnut Hill, MA
02467, USA.
| | - Takahiro Ogura
- Sports Medicine Center, Funabashi
Orthopaedic Hospital, Funabashi, Japan
| | - Robert A. Duerr
- Cartilage Repair Center and Center for
Regenerative Medicine, Brigham and Women’s Hospital, Harvard Medical School, Harvard
University, Boston, MA, USA
| | - Alexandre Barbieri Mestriner
- Cartilage Repair Center and Center for
Regenerative Medicine, Brigham and Women’s Hospital, Harvard Medical School, Harvard
University, Boston, MA, USA,Universidade Federal de São Paulo, São
Paulo, Brazil
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16
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Lee S, Frank RM, Christian DR, Cole BJ. Analysis of Defect Size and Ratio to Condylar Size With Respect to Outcomes After Isolated Osteochondral Allograft Transplantation. Am J Sports Med 2019; 47:1601-1612. [PMID: 31072116 DOI: 10.1177/0363546519841378] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Osteochondral allograft transplantation (OCA) is a successful knee joint preservation technique; however, the effects of defect size and defect size:condyle ratio (DSCR) are poorly understood. PURPOSE To quantify clinical outcomes of isolated OCA of the knee based on defect size and DSCR. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS Data from patients who underwent OCA of the knee without major concomitant procedures by a single surgeon were analyzed at a minimum follow-up of 2 years. Osteochondral defect size was measured intraoperatively, and femoral condyle size was measured with preoperative imaging. Patient-reported outcomes, reoperations, and survival rates were analyzed per defect size and DSCR, comparing males and females and patients <40 and ≥40 years old. RESULTS Sixty-eight patients were included, of whom 57% were male (mean ± SD: age, 34.5 ± 10.3 years; follow-up, 5.2 ± 2.6 years). Mean osteochondral defect size and DSCR were 3.48 ± 1.72 cm2 and 0.2 ± 0.1, respectively. Defect size was larger among males as compared with females (3.97 ± 1.71 cm2 vs 2.81 ± 1.16 cm2, P = .005), while DSCRs were not significantly different between sexes ( P = .609). The cohort as a whole demonstrated improvements in the following scores: Lysholm, International Knee Documentation Committee, Knee injury and Osteoarthritis Outcome Score, Western Ontario and McMaster Universities Osteoarthritis Index, and 12-Item Short Form Health Survey Physical ( P < .05). There were 27 reoperations (39.7%) at a mean of 2.5 ± 1.92 years and 8 failures (11.8%) at a mean of 2.62 ± 1.3 years. Mean DCSR was higher among patients with graft failure (0.26 ± 0.20 vs 0.19 ± 0.07, P = .049). After stratification by age, failures among patients ≥40 years old were associated with a larger defect size (mean 5.37 ± 3.50 cm2 vs 3.22 ± 1.32 cm2, P = .03) and higher DSCR (mean 0.30 ± 0.25 vs 0.19 ± 0.06, P = .05) when compared with nonfailures. Failures among patients <40 years old were not significantly associated with defect size or DSCR ( P > .05) as compared with nonfailures. CONCLUSION Patients undergoing isolated OCA transplantation demonstrated significant clinical improvements and a graft survival of 88.2% at 5.2 years. Failures overall were associated with a larger DSCR, and failures among patients ≥40 years old with a larger DSCR and larger defect size. Increasing defect size among males was positively correlated with some improved outcomes, although this was not maintained in analysis of the DSCR, suggesting similar prognosis after OCA regardless of sex. CLINICAL RELEVANCE Failed osteochondral allografts are associated with larger defect sizes and defect:condyle ratios in this study, providing additional information to surgeons for appropriate patient consultation.
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Affiliation(s)
- Simon Lee
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Rachel M Frank
- Department of Orthopedic Surgery, University of Colorado, Denver, Colorado, USA
| | - David R Christian
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Brian J Cole
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
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17
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Wang D, Chang B, Coxe FR, Pais MD, Wickiewicz TL, Warren RF, Rodeo SA, Williams RJ. Clinically Meaningful Improvement After Treatment of Cartilage Defects of the Knee With Osteochondral Grafts. Am J Sports Med 2019; 47:71-81. [PMID: 30481044 DOI: 10.1177/0363546518808030] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Mosaicplasty and fresh osteochondral allograft transplantation (OCA) are popular cartilage restoration techniques that involve the single-stage implantation of viable, mature hyaline cartilage-bone dowels into chondral lesions of the knee. Recently, there has been greater focus on what represents a clinically relevant change in outcomes reporting, and commonly applied metrics for measuring clinical significance include the minimal clinically important difference (MCID) and substantial clinical benefit (SCB). PURPOSE To define the MCID and SCB after mosaicplasty or OCA for the International Knee Documentation Committee (IKDC) subjective form and Knee Outcome Survey-Activities of Daily Living (KOS-ADL) and to determine patient factors that are predictive of achieving the MCID and SCB after mosaicplasty or OCA. STUDY DESIGN Cohort study (diagnosis); Level of evidence, 3. METHODS An institutional cartilage registry was reviewed to identify patients who underwent mosaicplasty or OCA. The decision to perform either mosaicplasty or OCA was generally based on chondral defect size. The IKDC and KOS-ADL were administered preoperatively and at a minimum of 2 years postoperatively. Patient responses to the outcome measures were aggregated, and the MCID and SCB of these outcome scores were calculated with anchor-based methods. Multivariate analysis adjusted for age and sex was performed to identify patient factors predictive of achieving the MCID and SCB. RESULTS Of the 372 eligible patients, 151 (41%) were lost to follow-up, 46 (12%) had incomplete preoperative outcome scores and 2 were treated with OCA of the tibia and therefore excluded. In total, 173 knees were analyzed (n = 173 patients; mean age, 33.0 years; 37% female). Seventy-five (43%) and 98 (57%) knees were treated with mosaicplasty and OCA, respectively. The mean ± SD MCIDs for the IKDC and KOS-ADL were 17 ± 3.9 and 10 ± 3.7, respectively. The SCBs for the IKDC and KOS-ADL were 30 ± 6.9 and 17 ± 3.9, respectively. Univariate analysis demonstrated no association between procedure (mosaicplasty or OCA) and likelihood of achieving the MCID or SCB. In the multivariate analysis, lower preoperative IKDC and KOS-ADL scores, higher preoperative Marx Activity Rating Scale scores, lower preoperative 36-Item Short Form Health Survey pain scores, and a history of ≤1 prior ipsilateral knee surgical procedure were predictive of achieving the MCID and/or SCB. CONCLUSION These values can be used to define a clinically meaningful improvement for future outcome studies. For surgeons considering mosaicplasty or OCA for their patients, these results can help guide clinical decision making and manage patient expectations before surgery.
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Affiliation(s)
- Dean Wang
- Department of Orthopaedic Surgery, University of California, Irvine, Orange, California, USA.,Sports Medicine Service, Hospital for Special Surgery, New York, New York, USA
| | - Brenda Chang
- Biostatistics Core, Hospital for Special Surgery, New York, New York, USA
| | - Francesca R Coxe
- Sports Medicine Service, Hospital for Special Surgery, New York, New York, USA
| | - Mollyann D Pais
- Sports Medicine Service, Hospital for Special Surgery, New York, New York, USA
| | - Thomas L Wickiewicz
- Sports Medicine Service, Hospital for Special Surgery, New York, New York, USA
| | - Russell F Warren
- Sports Medicine Service, Hospital for Special Surgery, New York, New York, USA
| | - Scott A Rodeo
- Sports Medicine Service, Hospital for Special Surgery, New York, New York, USA
| | - Riley J Williams
- Sports Medicine Service, Hospital for Special Surgery, New York, New York, USA
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18
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Ackermann J, Ogura T, Duerr RA, Mestriner AB, Gomoll AH. Mental Health Has No Predictive Association With Self-Assessed Knee Outcome Scores in Patients After Osteochondral Allograft Transplantation of the Knee. Orthop J Sports Med 2018; 6:2325967118812363. [PMID: 30560141 PMCID: PMC6293379 DOI: 10.1177/2325967118812363] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Patient-reported outcome (PRO) measures are progressively utilized as
evaluation tools in preoperative and postoperative assessments in
orthopaedic practice. Identifying the potential utility of psychosocial
factors to predict patient-reported pain and functional outcomes is of
increasing interest to determine which patients will derive the greatest
benefit from surgical treatment. Purpose/Hypothesis: The purpose of this study was to determine potential predictive associations
between the preoperative 12-Item Short Form Health Survey Mental Component
Summary (SF-12 MCS) score, patient characteristics or osteochondral
allograft (OCA) morphology, and PROs in patients who underwent OCA
transplantation. We hypothesized that poor preoperative mental health is
associated with diminished PROs at final follow-up. Study Design: Case-control study; Level of evidence, 3. Methods: A total of 67 patients with a mean follow-up of 2.7 ± 1.0 years (range, 2-6
years) with complete preoperative and at least 24-month postoperative SF-12
MCS, Knee injury and Osteoarthritis Outcome Score (KOOS), Tegner, Lysholm,
and International Knee Documentation Committee (IKDC) scores were included
in this study. Pearson correlation coefficients and linear regression models
were used to distinguish associations between age, sex, smoking status, body
mass index, workers’ compensation, previous surgery, concomitant surgery,
number of grafts, defect location, total graft size, SF-12 MCS score, and
postoperative PRO scores as well as their improvement from baseline
(delta). Results: The SF-12 MCS showed significant correlation with the KOOS Activities of
Daily Living subscale (P = .015), KOOS Sport/Recreation
subscale (P = .024), and IKDC (P = .039).
In the multivariable linear regression models, the SF-12 MCS had no
predictive association with any PRO measure. Patient sex contributed
significantly to the final regression models of the KOOS Sport/Recreation
(P = .042), Tegner score (P = .024),
and Lysholm score (P = .031). The SF-12 MCS showed no
bivariate correlation with changes in any PRO score (delta)
(P > .05). Conclusion: Preoperative mental health status did not predict perceived functional
outcomes as assessed by PRO measures at final follow-up. Female sex was
negatively correlated with KOOS Sport/Recreation, Tegner, and Lysholm
scores.
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Affiliation(s)
- Jakob Ackermann
- Sports Medicine Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Takahiro Ogura
- Sports Medicine Center, Funabashi Orthopaedic Hospital, Funabashi, Japan
| | - Robert A Duerr
- Cartilage Repair Center and Center for Regenerative Medicine, Brigham and Women's Hospital, Harvard Medical School, Harvard University, Boston, Massachusetts, USA
| | - Alexandre Barbieri Mestriner
- Cartilage Repair Center and Center for Regenerative Medicine, Brigham and Women's Hospital, Harvard Medical School, Harvard University, Boston, Massachusetts, USA.,Universidade Federal de São Paulo, São Paulo, Brazil
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19
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Merkely G, Ackermann J, Lattermann C. Articular Cartilage Defects: Incidence, Diagnosis, and Natural History. OPER TECHN SPORT MED 2018. [DOI: 10.1053/j.otsm.2018.06.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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20
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Lin Y, Li T, Xiong Y, Li J, Fu W. [Research progress of rehabilitation after autologous chondrocyte implantation on knee]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2018; 32:758-763. [PMID: 29905057 PMCID: PMC8414014 DOI: 10.7507/1002-1892.201801034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 04/30/2018] [Indexed: 02/05/2023]
Abstract
Objective To summarize the research progress of rehabilitation after autologous chondrocyte implantation (ACI). Methods The literature related to basic science and clinical practice about rehabilitation after ACI in recent years was searched, selected, and analyzed. Results Based on the included literature, the progress of the graft maturation consists of proliferation phase (0-6 weeks), transition phase (6-12 weeks), remodeling phase (12-26 weeks), and maturation phase (26 weeks-2 years). To achieve early protection, stimulate the maturation, and promote the graft-bone integrity, rehabilitation protocol ought to be based on the biomechanical properties at different phases. Weight-bearing program, range of motion (ROM), and options or facilities of exercise are importance when considering a rehabilitation program. Conclusion It has been proved that the patients need a program with an increasingly progressive weight-bearing and ROM in principles of rehabilitation after ACI. Specific facilities can be taken at a certain phase. Evidences extracted in the present work are rather low and the high-quality and controlled trials still need to improve the rehabilitation protocol.
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Affiliation(s)
- Yipeng Lin
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Tao Li
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Yan Xiong
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Jian Li
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Weili Fu
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041,
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21
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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: 138] [Impact Index Per Article: 23.0] [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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Abstract
The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability, and Health (ICF). The purpose of these revised clinical practice guidelines is to review recent peer-reviewed literature and make recommendations related to meniscus and articular cartilage lesions. J Orthop Sports Phys Ther. 2018;48(2):A1-A50. doi:10.2519/jospt.2018.0301.
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Ebert JR, Schneider A, Fallon M, Wood DJ, Janes GC. A Comparison of 2-Year Outcomes in Patients Undergoing Tibiofemoral or Patellofemoral Matrix-Induced Autologous Chondrocyte Implantation. Am J Sports Med 2017; 45:3243-3253. [PMID: 28910133 DOI: 10.1177/0363546517724761] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Matrix-induced autologous chondrocyte implantation (MACI) has demonstrated encouraging clinical results in the treatment of knee chondral defects. However, earlier studies suggested that chondrocyte implantation in the patellofemoral (PF) joint was less effective than in the tibiofemoral (TF) joint. PURPOSE To compare the radiological and clinical outcomes of those undergoing MACI to either the femoral condyles or PF joint. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS A total of 194 patients were included in this analysis, including 127 undergoing MACI to the medial (n = 94) and lateral (n = 33) femoral condyle, as well as 67 to the patella (n = 35) or trochlea (n = 32). All patients were evaluated clinically (Knee injury and Osteoarthritis Outcome Score [KOOS], visual analog scale, Short Form-36) before surgery and at 3, 12, and 24 months after surgery, while magnetic resonance imaging (MRI) was undertaken at 3, 12, and 24 months, with the MOCART (magnetic resonance observation of cartilage repair tissue) scoring system employed to evaluate the quality and quantity of repair tissue, as well as an MRI composite score. Patient satisfaction was evaluated. RESULTS No significant group differences ( P > .05) were seen in demographics, defect size, prior injury, or surgical history, while the majority of clinical scores were similar preoperatively. All clinical scores significantly improved over time ( P < .05), with a significant group effect observed for KOOS activities of daily living ( P = .008), quality of life ( P = .008), and sport ( P = .017), reflecting better postoperative scores in the TF group. While the PF group had significantly lower values at baseline for the KOOS activities of daily living and quality of life subscales, it actually displayed a similar net improvement over time compared with the TF group. At 24 months, 93.7% (n = 119) and 91.0% (n = 61) of patients were satisfied with the ability of MACI to relieve their knee pain, 74.0% (n = 94) and 65.7% (n = 44) with their ability to participate in sport, and 90.5% (n = 115) and 83.6% (n = 56) satisfied overall, in the TF and PF groups, respectively. MRI evaluation via the MOCART score revealed a significant time effect ( P < .05) for the MRI composite score and graft infill over the 24-month period. While subchondral lamina scored significantly better ( P = .002) in the TF group, subchondral bone scored significantly worse ( P < .001). At 24 months, the overall MRI composite score was classified as good/excellent in 98 TF patients (77%) and 54 PF patients (81%). CONCLUSION MACI in the PF joint with concurrent correction of PF maltracking if required leads to similar clinical and radiological outcomes compared with MACI on the femoral condyles.
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Affiliation(s)
- Jay R Ebert
- School of Human Sciences, University of Western Australia, Crawley, Perth, Western Australia, Australia
| | - Adrian Schneider
- Perth Orthopaedic and Sports Medicine Centre, West Perth, Western Australia, Australia
| | - Michael Fallon
- Perth Radiological Clinic, Subiaco, Perth, Western Australia, Australia
| | - David J Wood
- School of Surgery (Orthopaedics), University of Western Australia, Crawley, Perth, Western Australia, Australia
| | - Gregory C Janes
- Perth Orthopaedic and Sports Medicine Centre, West Perth, Western Australia, Australia
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Schuette HB, Kraeutler MJ, McCarty EC. Matrix-Assisted Autologous Chondrocyte Transplantation in the Knee: A Systematic Review of Mid- to Long-Term Clinical Outcomes. Orthop J Sports Med 2017; 5:2325967117709250. [PMID: 28620621 PMCID: PMC5464387 DOI: 10.1177/2325967117709250] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Background: Matrix-assisted autologous chondrocyte transplantation (MACT) is a surgical treatment option for articular cartilage lesions of the knee joint. Purpose: To investigate mid- to long-term clinical outcomes of MACT in the patellofemoral (PF) and tibiofemoral (TF) joints. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review was performed by searching PubMed, Embase, and the Cochrane Library to find studies evaluating minimum 5-year clinical outcomes of patients undergoing MACT in the knee joint. Search terms used were knee, matrix, and autologous chondrocyte. Patients were evaluated based on treatment failure rates, magnetic resonance imaging, and subjective outcome scores. Study methodology was assessed using the Modified Coleman Methodology Score (MCMS). Results: Ten studies (two level 1, one level 2, one level 3, and six level 4 evidence) were identified that met inclusion and exclusion criteria, for a total of 442 TF patients and 136 PF patients. Treatment failure occurred in 9.7% of all patients, including 4.7% of PF patients and 12.4% of TF patients (P = .037). Weighted averages of subjective outcome scores, including Knee injury and Osteoarthritis Outcome Score, Short Form–36 Health Survey, and Tegner scores, improved from baseline to latest follow-up in both TF and PF patients. The mean MCMS was found to be 57.4, with a standard deviation of 18.5. Conclusion: Patients undergoing MACT in the knee show favorable mid- to long-term clinical outcomes. A significantly higher treatment failure rate was found in patients undergoing MACT in the TF joint compared with the PF joint.
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Affiliation(s)
- Hayden B Schuette
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Matthew J Kraeutler
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Eric C McCarty
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, USA
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Repair of osteochondral defects with in vitro engineered cartilage based on autologous bone marrow stromal cells in a swine model. Sci Rep 2017; 7:40489. [PMID: 28084417 PMCID: PMC5234019 DOI: 10.1038/srep40489] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 12/06/2016] [Indexed: 12/27/2022] Open
Abstract
Functional reconstruction of large osteochondral defects is always a major challenge in articular surgery. Some studies have reported the feasibility of repairing articular osteochondral defects using bone marrow stromal cells (BMSCs) and biodegradable scaffolds. However, no significant breakthroughs have been achieved in clinical translation due to the instability of in vivo cartilage regeneration based on direct cell-scaffold construct implantation. To overcome the disadvantages of direct cell-scaffold construct implantation, the current study proposed an in vitro cartilage regeneration strategy, providing relatively mature cartilage-like tissue with superior mechanical properties. Our strategy involved in vitro cartilage engineering, repair of osteochondral defects, and evaluation of in vivo repair efficacy. The results demonstrated that BMSC engineered cartilage in vitro (BEC-vitro) presented a time-depended maturation process. The implantation of BEC-vitro alone could successfully realize tissue-specific repair of osteochondral defects with both cartilage and subchondral bone. Furthermore, the maturity level of BEC-vitro had significant influence on the repaired results. These results indicated that in vitro cartilage regeneration using BMSCs is a promising strategy for functional reconstruction of osteochondral defect, thus promoting the clinical translation of cartilage regeneration techniques incorporating BMSCs.
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Abstract
One of the most important issues facing cartilage tissue engineering is the inability to move technologies into the clinic. Despite the multitude of current research in the field, it is known that 90% of new drugs that advance past animal studies fail clinical trials. The objective of this review is to provide readers with an understanding of the scientific details of tissue engineered cartilage products that have demonstrated a certain level of efficacy in humans, so that newer technologies may be developed upon this foundation. Compared to existing treatments, such as microfracture or autologous chondrocyte implantation, a tissue engineered product can potentially provide more consistent clinical results in forming hyaline repair tissue and in filling the entirety of the defect. The various tissue engineering strategies (e.g., cell expansion, scaffold material, media formulations, biomimetic stimuli, etc.) used in forming these products, as collected from published literature, company websites, and relevant patents, are critically discussed. The authors note that many details about these products remain proprietary, not all information is made public, and that advancements to the products are continuously made. Nevertheless, by understanding the design and production processes of these emerging technologies, one can gain tremendous insight into how to best use them and also how to design the next generation of tissue engineered cartilage products.
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Huang BJ, Hu JC, Athanasiou KA. Cell-based tissue engineering strategies used in the clinical repair of articular cartilage. Biomaterials 2016; 98:1-22. [PMID: 27177218 DOI: 10.1016/j.biomaterials.2016.04.018] [Citation(s) in RCA: 260] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 04/15/2016] [Accepted: 04/20/2016] [Indexed: 12/12/2022]
Abstract
One of the most important issues facing cartilage tissue engineering is the inability to move technologies into the clinic. Despite the multitude of current research in the field, it is known that 90% of new drugs that advance past animal studies fail clinical trials. The objective of this review is to provide readers with an understanding of the scientific details of tissue engineered cartilage products that have demonstrated a certain level of efficacy in humans, so that newer technologies may be developed upon this foundation. Compared to existing treatments, such as microfracture or autologous chondrocyte implantation, a tissue engineered product can potentially provide more consistent clinical results in forming hyaline repair tissue and in filling the entirety of the defect. The various tissue engineering strategies (e.g., cell expansion, scaffold material, media formulations, biomimetic stimuli, etc.) used in forming these products, as collected from published literature, company websites, and relevant patents, are critically discussed. The authors note that many details about these products remain proprietary, not all information is made public, and that advancements to the products are continuously made. Nevertheless, by understanding the design and production processes of these emerging technologies, one can gain tremendous insight into how to best use them and also how to design the next generation of tissue engineered cartilage products.
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Affiliation(s)
- Brian J Huang
- Department of Biomedical Engineering, University of California Davis, USA.
| | - Jerry C Hu
- Department of Biomedical Engineering, University of California Davis, USA.
| | - Kyriacos A Athanasiou
- Department of Biomedical Engineering, University of California Davis, USA; Department of Orthopedic Surgery, University of California Davis, USA.
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29
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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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Kim YS, Choi YJ, Koh YG. Mesenchymal stem cell implantation in knee osteoarthritis: an assessment of the factors influencing clinical outcomes. Am J Sports Med 2015; 43:2293-301. [PMID: 26113522 DOI: 10.1177/0363546515588317] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Several clinical studies have reported on cell-based treatment using mesenchymal stem cells (MSCs) for cartilage regeneration in knee osteoarthritis (OA). However, little is known about the factors that influence the clinical outcomes after surgery. PURPOSE/HYPOTHESIS This study aimed to investigate the clinical outcomes of MSC implantation in patients with knee OA and assess the factors that are associated with clinical outcomes. The hypothesis was that factors may exist that could influence clinical outcomes. STUDY DESIGN Case series; Level of evidence, 4. METHODS A total of 49 patients (55 knees) were retrospectively evaluated after MSC implantation for knee OA. The inclusion criteria were patients who had an isolated full-thickness cartilage lesion and Kellgren-Lawrence OA grade 1 or 2. Clinical outcomes were measured with the International Knee Documentation Committee (IKDC) score, Tegner activity score, and patients' overall satisfaction with the surgery. Statistical analyses were performed to determine the effect of different factors on the clinical outcome. RESULTS The mean pre- and postoperative IKDC and Tegner activity scores significantly improved from 37.7 ± 6.3 to 67.3 ± 9.5 (IKDC) and from 2.2 ± 0.7 to 3.8 ± 0.7 (Tegner) (P < .001 for both). Twenty-four patients reported their overall satisfaction with the surgery as excellent (43.6%), 17 as good (30.9%), 11 as fair (20.0%), and 3 as poor (5.5%). There were significant differences in clinical outcomes at the final follow-up among the age and lesion size groups (P < .05 for all). Multivariate analyses showed high prognostic significance related to patient age and lesion size, and scatter plots suggested a cutoff age of 60 years and a cutoff lesion size of 6.0 cm(2) for the optimum identification of poor clinical outcomes (P < .05 for both). CONCLUSION The clinical outcomes of MSC implantation for knee OA are encouraging. Patient age and lesion size are important factors that affect clinical outcomes; thus, these may serve as a basis for preoperative surgical decisions. Cutoff points exist for the risk of clinical failure in patients older than 60 years and those with a lesion size larger than 6.0 cm(2).
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Affiliation(s)
- Yong Sang Kim
- Center for Stem Cell & Arthritis Research, Department of Orthopaedic Surgery, Yonsei Sarang Hospital, Seoul, Korea
| | - Yun Jin Choi
- Center for Stem Cell & Arthritis Research, Department of Orthopaedic Surgery, Yonsei Sarang Hospital, Seoul, Korea
| | - Yong Gon Koh
- Center for Stem Cell & Arthritis Research, Department of Orthopaedic Surgery, Yonsei Sarang Hospital, Seoul, Korea
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Mithoefer K, Peterson L, Zenobi-Wong M, Mandelbaum BR. Cartilage issues in football-today's problems and tomorrow's solutions. Br J Sports Med 2015; 49:590-6. [PMID: 25878075 PMCID: PMC4413687 DOI: 10.1136/bjsports-2015-094772] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2015] [Indexed: 02/05/2023]
Abstract
Articular cartilage injury is prevalent in football players and results from chronic joint stress or acute traumatic injuries. Articular cartilage injury can often result in progressive painful impairment of joint function and limit sports participation. Management of articular cartilage injury in athletes aims to return the player to competition, and requires effective and durable joint surface restoration that resembles normal hyaline articular cartilage that can withstand the high joint stresses of football. Existing articular cartilage repair techniques can return the athlete with articular cartilage injury to high-impact sports, but treatment does not produce normal articular cartilage, and this limits the success rate and durability of current cartilage repair in athletes. Novel scientific concepts and treatment techniques that apply modern tissue engineering technologies promise further advancement in the treatment of these challenging injuries in the high demand athletic population. We review the current knowledge of cartilage injury pathophysiology, epidemiology and aetiology, and outline existing management algorithms, developing treatment options and future strategies to manage articular cartilage injuries in football players.
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Affiliation(s)
- Kai Mithoefer
- Department of Orthopedics and Sports Medicine, Harvard Vanguard Medical Associates, Harvard Medical School, Boston, Massachusetts, USA
| | - Lars Peterson
- Department of Orthopedic Surgery, University of Gothenburg, Gothenburg, Sweden
| | - Marcy Zenobi-Wong
- Cartilage Engineering and Regeneration Laboratory, ETH Zurich, Zurich, Switzerland
| | - Bert R Mandelbaum
- Santa Monica Orthopedics and Sports Medicine Foundation, Los Angeles, USA
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Shive MS, Stanish WD, McCormack R, Forriol F, Mohtadi N, Pelet S, Desnoyers J, Méthot S, Vehik K, Restrepo A. BST-CarGel® Treatment Maintains Cartilage Repair Superiority over Microfracture at 5 Years in a Multicenter Randomized Controlled Trial. Cartilage 2015; 6:62-72. [PMID: 26069709 PMCID: PMC4462252 DOI: 10.1177/1947603514562064] [Citation(s) in RCA: 112] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE The efficacy and safety of BST-CarGel®, a chitosan scaffold for cartilage repair was compared with microfracture alone at 1 year during a multicenter randomized controlled trial in the knee. This report was undertaken to investigate 5-year structural and clinical outcomes. DESIGN The international randomized controlled trial enrolled 80 patients, aged 18 to 55 years, with grade III or IV focal lesions on the femoral condyles. Patients were randomized to receive BST-CarGel® treatment or microfracture alone, and followed standardized 12-week rehabilitation. Co-primary endpoints of repair tissue quantity and quality were evaluated by 3-dimensional MRI quantification of the degree of lesion filling (%) and T2 relaxation times. Secondary endpoints were clinical benefit measured with WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) questionnaires and safety. General estimating equations were used for longitudinal statistical analysis of repeated measures. RESULTS Blinded MRI analysis demonstrated that BST-CarGel®-treated patients showed a significantly greater treatment effect for lesion filling (P = 0.017) over 5 years compared with microfracture alone. A significantly greater treatment effect for BST-CarGel® was also found for repair tissue T2 relaxation times (P = 0.026), which were closer to native cartilage compared to the microfracture group. BST-CarGel® and microfracture groups showed highly significant improvement at 5 years from pretreatment baseline for each WOMAC subscale (P < 0.0001), and there were no differences between the treatment groups. Safety was comparable for both groups. CONCLUSIONS BST-CarGel® was shown to be an effective mid-term cartilage repair treatment. At 5 years, BST-CarGel® treatment resulted in sustained and significantly superior repair tissue quantity and quality over microfracture alone. Clinical benefit following BST-CarGel® and microfracture treatment were highly significant over baseline levels.
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Affiliation(s)
| | - William D. Stanish
- Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Robert McCormack
- Department of Orthopedic Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Nicholas Mohtadi
- University of Calgary Sports Medicine Centre, Calgary, Alberta, Canada
| | - Stéphane Pelet
- Department of Orthopedics, CHA-Pavillon Enfant-Jésus, Quebec, Quebec, Canada
| | | | | | - Kendra Vehik
- Department of Epidemiology and Biostatistics, University of South Florida, Tampa, Florida, USA
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Akgun I, Unlu MC, Erdal OA, Ogut T, Erturk M, Ovali E, Kantarci F, Caliskan G, Akgun Y. Matrix-induced autologous mesenchymal stem cell implantation versus matrix-induced autologous chondrocyte implantation in the treatment of chondral defects of the knee: a 2-year randomized study. Arch Orthop Trauma Surg 2015; 135:251-263. [PMID: 25548122 DOI: 10.1007/s00402-014-2136-z] [Citation(s) in RCA: 99] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Indexed: 12/20/2022]
Abstract
BACKGROUND Cell-based strategies that combine in vitro- expanded autologous chondrocytes with matrix scaffolds are currently preferred for full-thickness cartilage lesions of the knee ≥2 cm(2). Although this approach is reasonable, continuing advances in the field of cartilage repair will further expand the options available to improve outcomes. HYPOTHESIS/PURPOSE In the present clinical study, we compared the outcomes of matrix-induced autologous mesenchymal stem cell implantation (m-AMI) with matrix-induced autologous chondrocyte implantation (m-ACI) for the treatment of isolated chondral defects of the knee. STUDY DESIGN Prospective, single-site, randomized, single-blind pilot study. METHODS Fourteen patients with isolated full-thickness chondral lesions of the knee >2 cm(2) were randomized into two treatment groups: m-AMI and m-ACI. Outcomes were assessed pre-operatively and 3, 6, 12 and 24 months post-operatively. RESULTS Clinical evaluations revealed that improvement from pre-operation to 24 months post-operation occurred in both groups (p < 0.05). At all follow-up intervals, m-AMI demonstrated significantly better functional outcomes (motion deficit and straight leg raise strength) than did m-ACI (p < 0.05). At all follow-up intervals, m-AMI demonstrated significantly better subjective sub-scale scores for pain, symptoms, activities of daily living and sport and recreation of the knee injury and osteoarthritis outcome score (KOOS) than did m-ACI (p < 0.05). Additionally, m-AMI demonstrated significantly better (p < 0.05) scores than m-ACI for the quality of life sub-scale of the KOOS and visual analog scale (VAS) severity at the 6-month follow-up. The Tegner activity score and VAS frequency were not significantly different between the two groups. Graft failure was not observed on magnetic resonance imaging at the 24-month follow-up. m-AMI and m-ACI demonstrated very good-to-excellent and good-to-very good infill, respectively, with no adverse effects from the implant, regardless of the treatment. CONCLUSION For the treatment of isolated full-thickness chondral lesion of the knee, m-AMI can be used effectively and may potentially accelerate recovery. A larger patient cohort and follow-up supported by histological analyses are necessary to determine long-term outcomes.
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Affiliation(s)
- Isık Akgun
- Department of Orthopaedics and Traumatology, Cactus Healthcare, Istanbul, Turkey
| | - Mehmet C Unlu
- Department of Orthopedics and Traumatology, Cerrahpasa Medical Faculty, Istanbul University, 34303, Kocamustafapasa, Istanbul, Turkey.
| | - Ozan A Erdal
- Department of Orthopedics and Traumatology, Cerrahpasa Medical Faculty, Istanbul University, 34303, Kocamustafapasa, Istanbul, Turkey
| | - Tahir Ogut
- Department of Orthopedics and Traumatology, Cerrahpasa Medical Faculty, Istanbul University, 34303, Kocamustafapasa, Istanbul, Turkey
| | - Murat Erturk
- Department of Medical Microbiology, Karadeniz Technical University, Trabzon, Turkey
| | | | - Fatih Kantarci
- Department of Radiology, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Gurkan Caliskan
- Department of Orthopedics and Traumatology, Kanuni Sultan Suleyman State Hospital, Istanbul, Turkey
| | - Yamac Akgun
- Genetics and Molecular Biologist, Cellular Biologist, Trinity School of Medicine, Atlanta, USA
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Zhang Z, Zhong X, Ji H, Tang Z, Bai J, Yao M, Hou J, Zheng M, Wood DJ, Sun J, Zhou SF, Liu A. Matrix-induced autologous chondrocyte implantation for the treatment of chondral defects of the knees in Chinese patients. DRUG DESIGN DEVELOPMENT AND THERAPY 2014; 8:2439-48. [PMID: 25525334 PMCID: PMC4266264 DOI: 10.2147/dddt.s71356] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Articular cartilage injury is the most common type of damage seen in clinical orthopedic practice. The matrix-induced autologous chondrocyte implant (MACI) was developed to repair articular cartilage with an advance on the autologous chondrocyte implant procedure. This study aimed to evaluate whether MACI is a safe and efficacious cartilage repair treatment for patients with knee cartilage lesions. The primary outcomes were the Knee Injury and Osteoarthritis Outcome Score (KOOS) domains and magnetic resonance imaging (MRI) results, compared between baseline and postoperative months 3, 6, 12, and 24. A total of 15 patients (20 knees), with an average age of 33.9 years, had a mean defect size of 4.01 cm(2). By 6-month follow-up, KOOS results demonstrated significant improvements in symptoms and knee-related quality of life. MRI showed significant improvements in four individual graft scoring parameters at 24 months postoperatively. At 24 months, 90% of MACI grafts had filled completely and 10% had good-to-excellent filling of the chondral defect. Most (95%) of the MACI grafts were isointense and 5% were slightly hyperintense. Histologic evaluation at 15 and 24 months showed predominantly hyaline cartilage in newly generated tissue. There were no postoperative complications in any patients and no adverse events related to the MACI operation. This 2-year study has confirmed that MACI is safe and effective with the advantages of a simple technique and significant clinical improvements. Further functional and mechanistic studies with longer follow-up are needed to validate the efficacy and safety of MACI in patients with articular cartilage injuries.
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Affiliation(s)
- Zhongwen Zhang
- Department of Orthopedics, General Hospital of Chinese People's Armed Police Forces (CAPF), Beijing
| | - Xin Zhong
- Department of MRI Center, General Hospital of CAPF, Beijing, People's Republic of China
| | - Huiru Ji
- Department of Orthopedics, General Hospital of Chinese People's Armed Police Forces (CAPF), Beijing
| | - Zibin Tang
- Department of Orthopedics, General Hospital of Chinese People's Armed Police Forces (CAPF), Beijing
| | - Jianpeng Bai
- Department of Orthopedics, General Hospital of Chinese People's Armed Police Forces (CAPF), Beijing
| | - Minmin Yao
- Department of Orthopedics, General Hospital of Chinese People's Armed Police Forces (CAPF), Beijing
| | - Jianlei Hou
- Department of Orthopedics, General Hospital of Chinese People's Armed Police Forces (CAPF), Beijing
| | - Minghao Zheng
- Center for Orthopedic Research, School of Surgery and Pathology, University of Western Australia, Perth, Western Australia, Australia
| | - David J Wood
- Center for Orthopedic Research, School of Surgery and Pathology, University of Western Australia, Perth, Western Australia, Australia
| | - Jiazhi Sun
- Department of Pharmaceutical Sciences, College of Pharmacy, University of South Florida, Tampa, FL, USA
| | - Shu-Feng Zhou
- Department of Pharmaceutical Sciences, College of Pharmacy, University of South Florida, Tampa, FL, USA ; Guizhou Provincial Key Laboratory for Regenerative Medicine, Stem Cell and Tissue Engineering Research Center and Sino-US Joint Laboratory for Medical Sciences, Guiyang Medical University, Guiyang, Guizhou
| | - Aibing Liu
- Medical Research Center, General Hospital of Chinese People's Armed Police Forces (CAPF), Beijing, People's Republic of China
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Ebert JR, Smith A, Fallon M, Wood DJ, Ackland TR. Degree of preoperative subchondral bone edema is not associated with pain and graft outcomes after matrix-induced autologous chondrocyte implantation. Am J Sports Med 2014; 42:2689-98. [PMID: 25216496 DOI: 10.1177/0363546514548022] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Matrix-induced autologous chondrocyte implantation (MACI) is an established technique for the repair of knee chondral defects. While a number of factors may affect the clinical outcome, little is known about the influence of subchondral bone abnormalities at the time of surgery on pain and graft outcomes after MACI. PURPOSE To investigate the association between subchondral bone marrow edema within 3 months before MACI surgery on preoperative and postoperative reported pain and symptoms as well as postoperative graft outcomes. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS This retrospective study was undertaken in 56 patients undergoing MACI with clinical and radiological assessments before surgery and at 3, 12, 24, and 60 months after surgery. Patients were assessed using the Pain and Symptoms subscales of the Knee Injury and Osteoarthritis Outcome Score (KOOS). High-resolution magnetic resonance imaging (MRI) was used to evaluate the severity of preoperative subchondral bone marrow edema, while graft infill and an MRI composite graft score were evaluated after surgery via the magnetic resonance observation of cartilage repair tissue (MOCART) scoring system. Linear regression utilizing generalized estimating equations was used to investigate the association between preoperative subchondral bone marrow edema scores and preoperative and postoperative KOOS subscores as well as postoperative MRI-based scores of graft repair. RESULTS The degree of preoperative subchondral bone marrow edema was not significantly associated with postoperative outcomes, whereby there was no evidence of a difference between edema subgroups over all time points for the KOOS-Pain subscore (P = .644), KOOS-Symptoms subscore (P = .475), or MRI composite score (P = .685) after adjustment for potential confounders of age, body mass index, defect size, and defect location. CONCLUSION No association was demonstrated between the severity of preoperative subchondral bone marrow edema with postoperative patient-reported knee pain or symptoms or postoperative graft repair assessed via MRI.
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Affiliation(s)
- Jay R Ebert
- School of Sport Science, Exercise and Health, University of Western Australia, Crawley, Perth, Australia
| | - Anne Smith
- The School of Physiotherapy and Curtin Health Innovation Research Institute, Curtin University, Bentley, Perth, Australia
| | | | - David J Wood
- School of Surgery (Orthopaedics), University of Western Australia, Crawley, Perth, Australia
| | - Timothy R Ackland
- School of Sport Science, Exercise and Health, University of Western Australia, Crawley, Perth, Australia
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Ebert JR, Smith A, Fallon M, Wood DJ, Ackland TR. Correlation Between Clinical and Radiological Outcomes After Matrix-Induced Autologous Chondrocyte Implantation in the Femoral Condyles. Am J Sports Med 2014; 42:1857-64. [PMID: 24890782 DOI: 10.1177/0363546514534942] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Matrix-induced autologous chondrocyte implantation (MACI) is an established technique for the repair of knee chondral defects, although the correlation between clinical and radiological outcomes after surgery is poorly understood. PURPOSE To determine the correlation between clinical and radiological outcomes throughout the postoperative timeline to 5 years after MACI. STUDY DESIGN Cohort study (diagnosis); Level of evidence, 3. METHODS This retrospective study was undertaken in 83 patients (53 male, 30 female) with complete clinical and radiological follow-up at 1, 2, and 5 years after MACI. The mean age of patients was 38.9 years (range, 13-62 years), with a mean body mass index (BMI) of 26.6 kg/m(2) (range, 16.8-34.8 kg/m(2)), mean defect size of 3.3 cm(2) (range, 1-9 cm(2)), and mean preoperative duration of symptoms of 9.2 years (range, 1-46 years). Patients indicated for MACI in this follow-up were 13 to 65 years of age, although they were excluded if they had a BMI >35 kg/m(2), had undergone prior extensive meniscectomy, or had ongoing progressive inflammatory arthritis. Patients were assessed clinically using the Knee Injury and Osteoarthritis Outcome Score (KOOS). Magnetic resonance imaging (MRI) was used to evaluate the graft using a 1.5-T or 3-T clinical scanner; the MRI assessment included 8 parameters of graft repair (infill, signal intensity, border integration, surface contour, structure, subchondral lamina, subchondral bone, and effusion) based on the magnetic resonance observation of cartilage repair tissue (MOCART) score as well as an MRI composite score. The degree of an association between the MRI parameters and the KOOS subscales at each postoperative time point was assessed with the Spearman correlation coefficient (SCC), and significance was determined at P < .05. Ethics approval was obtained from the appropriate hospital and university Human Research Ethics Committees, and informed consent was gathered from all patients. RESULTS The only MRI parameter displaying consistent evidence of an association with the KOOS subscales was effusion, with a pattern of increasing strength of correlations over time and statistically significant associations at 5 years with KOOS-Pain (SCC, 0.25; P = .020), KOOS-Activities of Daily Living (SCC, 0.26; P = .018), and KOOS-Sport (SCC, 0.32; P = .003). Apart from a significant correlation between subchondral lamina and KOOS-Sport at 1 year (SCC, 0.27; P = .016), no further significant findings were observed. CONCLUSION Apart from some consistent evidence of an association between the KOOS and effusion, this analysis demonstrated a limited correlative capacity between clinical and radiological outcomes up to 5 years after surgery.
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Affiliation(s)
- Jay R Ebert
- School of Sport Science, Exercise and Health, The University of Western Australia, Crawley, Australia
| | - Anne Smith
- School of Physiotherapy and Curtin Health Innovation Research Institute, Curtin University, Bentley, Australia
| | | | - David J Wood
- School of Surgery (Orthopaedics), The University of Western Australia, Crawley, Australia
| | - Timothy R Ackland
- School of Sport Science, Exercise and Health, The University of Western Australia, Crawley, Australia
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Saris D, Price A, Widuchowski W, Bertrand-Marchand M, Caron J, Drogset JO, Emans P, Podskubka A, Tsuchida A, Kili S, Levine D, Brittberg M, Trc T, Slynarski K, Sanson BJ, Bezuidenhoudt M. Matrix-Applied Characterized Autologous Cultured Chondrocytes Versus Microfracture: Two-Year Follow-up of a Prospective Randomized Trial. Am J Sports Med 2014; 42:1384-94. [PMID: 24714783 DOI: 10.1177/0363546514528093] [Citation(s) in RCA: 217] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Randomized controlled trials studying the efficacy and safety of matrix-applied characterized autologous cultured chondrocytes (MACI) versus microfracture (MFX) for treating cartilage defects are limited. PURPOSE To compare the clinical efficacy and safety of MACI versus MFX in the treatment of patients with symptomatic cartilage defects of the knee. STUDY DESIGN Randomized controlled clinical trial; Level of evidence, 1. METHODS Patients enrolled in the SUMMIT (Demonstrate the Superiority of MACI implant to Microfracture Treatment) trial had ≥1 symptomatic focal cartilage defect (Outerbridge grade III or IV; ≥3 cm(2)) of the femoral condyles or trochlea, with a baseline Knee Injury and Osteoarthritis Outcome Score (KOOS) pain value <55. The co-primary efficacy endpoint was the change in the KOOS pain and function subscores from baseline to 2 years. Histological evaluation and magnetic resonance imaging (MRI) assessments of structural repair tissue, treatment failure, the remaining 3 KOOS subscales, and safety were also assessed. RESULTS Of the 144 patients treated, 137 (95%) completed the 2-year assessment. Patients had a mean age of 33.8 years and a mean lesion size of 4.8 cm(2). The mean KOOS pain and function subscores from baseline to 2 years were significantly more improved with MACI than with MFX (pain: MACI, 37.0 to 82.5 vs MFX, 35.5 to 70.9; function: MACI, 14.9 to 60.9 vs MFX, 12.6 to 48.7; P = .001). A significant improvement in scores was also observed on the KOOS subscales of activities of daily living (MACI, 43.5 to 87.2 vs MFX, 42.6 to 75.8; P < .001), knee-related quality of life (MACI, 18.8 to 56.2 vs MFX, 17.2 to 47.3; P = .029), and other symptoms (MACI, 48.3 to 83.7 vs MFX, 44.4 to 72.2; P < .001) for patients treated with MACI compared with MFX. Repair tissue quality was good as assessed by histology/MRI, but no difference was shown between treatments. A low number of treatment failures (nonresponders: MACI, 12.5% vs MFX, 31.9%; P = .016) and no unexpected safety findings were reported. CONCLUSION The treatment of symptomatic cartilage knee defects ≥3 cm(2) in size using MACI was clinically and statistically significantly better than with MFX, with similar structural repair tissue and safety, in this heterogeneous patient population. Moreover, MACI offers a more efficacious alternative than MFX with a similar safety profile for the treatment of symptomatic articular cartilage defects of the knee.
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Affiliation(s)
- Daniel Saris
- University Medical Center Utrecht, Utrecht, the Netherlands Reconstructive Medicine, Tissue Regeneration, MIRA Institute, University of Twente, Enschede, the Netherlands
| | - Andrew Price
- NIHR Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Wojciech Widuchowski
- District Hospital of Orthopedics and Trauma Surgery, Department of Knee Surgery, Arthroscopy and Sports Traumatology, Piekary Slaskie, Poland
| | | | - Jacob Caron
- St Elisabeth Ziekenhuis, Afdeling Orthopedie, Tilburg, the Netherlands
| | - Jon Olav Drogset
- Department of Orthopaedics, Trondheim University Hospital, Trondheim, Norway
| | - Pieter Emans
- Academisch Ziekenhuis Maastricht, Afdeling Orthopedie, Maastricht, the Netherlands
| | - Ales Podskubka
- First Faculty of Medicine, Charles University in Prague, Hospital Bulovka, Prague, Czech Republic
| | - Anika Tsuchida
- University Medical Center Utrecht, Utrecht, the Netherlands
| | - Sven Kili
- Genzyme Biosurgery (now Sanofi Biosurgery), Oxford, UK
| | - David Levine
- Genzyme Biosurgery (now Sanofi Biosurgery), Cambridge, Massachusetts, USA
| | - Mats Brittberg
- Region Halland Orthopedics, Kungsbacka Hospital, Kungsbacka, Sweden
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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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Clinical rehabilitation guidelines for matrix-induced autologous chondrocyte implantation on the tibiofemoral joint. J Orthop Sports Phys Ther 2014; 44:102-19. [PMID: 24175609 DOI: 10.2519/jospt.2014.5055] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Autologous chondrocyte implantation (ACI) has become an established technique for the repair of full-thickness chondral defects in the knee. Matrix-induced ACI (MACI) is the third and current generation of this surgical technique, and, while postoperative rehabilitation following MACI aims to restore normal function in each patient as quickly as possible by facilitating a healing response without overloading the repair site, current published guidelines appear conservative, varied, potentially outdated, and often based on earlier ACI surgical techniques. This article reviews the existing evidence-based literature pertaining to cell loading and postoperative rehabilitation following generations of ACI. Based on this information, in combination with the technical benefits provided by third-generation MACI in comparison to its surgical predecessors, we present a rehabilitation protocol for patients undergoing MACI in the tibiofemoral joint that has now been implemented for several years by our institution in patients with MACI, with good clinical outcomes.
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