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Huddleston HP, Wong SE, Cregar WM, Haunschild ED, Alzein MM, Cole BJ, Yanke AB. Bone Marrow Lesions on Preoperative Magnetic Resonance Imaging Correlate With Outcomes Following Isolated Osteochondral Allograft Transplantation. Arthroscopy 2021; 37:3487-3497. [PMID: 33964391 DOI: 10.1016/j.arthro.2021.04.056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 04/15/2021] [Accepted: 04/23/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to investigate the role of preoperative bone marrow lesion (BML) size and location on (1) postoperative patient reported outcomes and (2) postoperative failure and time to failure after osteochondral allograft (OCA) transplantation. METHODS Consecutive patients from 2 senior surgeons who underwent isolated OCA transplantation to the knee from 2009-2018 were identified for the case series. Preoperative magnetic resonance imaging (MRI) was evaluated for BMLs based on 2 classification systems (Welsch et al. and Costa-Paz et al.) by 2 independent graders. BMLs associated with minimum 1-year postoperative outcomes were evaluated, and the effect of BML classification on survivorship was investigated with Kaplan-Meier curves. RESULTS The 77 patients who underwent isolated OCA transplantation (mean follow-up: 39.46 ± 22.67 months) and had preoperative MRIs were included. Within this cohort, 82% of patients demonstrated a BML. The preoperative Costa-Paz et al. classification was significantly positively correlated with the postoperative Visual Analog Scale, International Knee Documentation Committee and Veterans RAND 12-Item Health Survey raw scores for both graders (P < 0.05). Failure occurred in 5 of 65 (8%) patients at a mean of 22.86 ± 12.04 months postoperatively. The presence of BML alone did not significantly affect survival (P = 0.780). However, for 1 grader, the Welsch et al. classification was associated with increased risk of graft failure (P = 0.031). CONCLUSION Preoperative subchondral BMLs were present in 82% of patients undergoing OCA transplantation. We found that more severe BMLs based on the Costa-Paz classification, with increasing involvement in the juxta-articular surface, were correlated with higher postoperative patient-reported functional outcomes after OCA. BMLs may be associated with an increase in graft failure, but their role in this remains unclear. LEVEL OF EVIDENCE IV, Retrospective Case Series.
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Affiliation(s)
| | | | | | | | | | - Brian J Cole
- Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Adam B Yanke
- Rush University Medical Center, Chicago, Illinois, U.S.A..
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2
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Iordache E, Robertson EL, Hirschmann A, Hirschmann MT. Typical MRI-pattern suggests peak maturation of the ACI graft 2 years after third-generation ACI: a systematic review. Knee Surg Sports Traumatol Arthrosc 2021; 29:3664-3677. [PMID: 33270154 DOI: 10.1007/s00167-020-06339-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 10/15/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE The purpose of the present article was (1) to systematically review the current literature and (2) to collect data regarding the postoperative magnetic resonance imaging (MRI) appearance of third-generation autologous chondrocyte implantation (ACI) grafts and (3) to provide an overview of imaging findings at various postoperative time points. METHODS A systematic review of the literature in Medline (Pubmed) and Embase was performed using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Articles which reported the post-operative MRI morphological outcomes following the use of third-generation ACI for treatment of knee cartilage lesions were included. All MRI results were allocated to six different time intervals: ≤ 3 months, > 3-6 months, > 6 months-1 year, > 1 year-2 years, > 2-5 years and > 5 years after surgery. RESULTS A total of 22 studies were included and the study populations ranged from 13 to 180 patients adding up to a total of 951 patients. Parameters such as defect fill, border integration, surface contour, graft morphology and integrity of the subchondral lamina all improve gradually with a peak two years following surgery suggesting complete graft maturation at this time point. After this peak, a statistically insignificant decline is noted for most of the parameters. Signal intensity was found to gradually shift from hyperintense to isointense in the first 36 months and to hypointense later on. Contrarily, subchondral bone edema is not only a postoperative feature of the procedure but also can reappear or persist up to ten years after surgery. As graft failures can appear after two years, consequently, the MRI composite score is also affected. CONCLUSION Recurring patterns in postoperative MRI appearance were observed in certain parameters including defect filling, graft signal intensity and structure, border integration of the graft while parameters like subchondral bone tend to be unpredictable. Given the heterogenous findings in terms of clinical correlation, and relating that aspect to the patterns found in this review, an MRI is justified at three months, one year, two years and five years after surgery, unless the clinical symptomatology and individual patient needs dictate otherwise. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Edna Iordache
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland (Bruderholz, Liestal, Laufen), CH-4101, Bruderholz, Switzerland
| | - Emma L Robertson
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland (Bruderholz, Liestal, Laufen), CH-4101, Bruderholz, Switzerland
| | - Anna Hirschmann
- Radiology, University Hospital Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Michael T Hirschmann
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland (Bruderholz, Liestal, Laufen), CH-4101, Bruderholz, Switzerland.
- University of Basel, Basel, Switzerland.
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3
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Logerstedt DS, Ebert JR, MacLeod TD, Heiderscheit BC, Gabbett TJ, Eckenrode BJ. Effects of and Response to Mechanical Loading on the Knee. Sports Med 2021; 52:201-235. [PMID: 34669175 DOI: 10.1007/s40279-021-01579-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2021] [Indexed: 11/30/2022]
Abstract
Mechanical loading to the knee joint results in a differential response based on the local capacity of the tissues (ligament, tendon, meniscus, cartilage, and bone) and how those tissues subsequently adapt to that load at the molecular and cellular level. Participation in cutting, pivoting, and jumping sports predisposes the knee to the risk of injury. In this narrative review, we describe different mechanisms of loading that can result in excessive loads to the knee, leading to ligamentous, musculotendinous, meniscal, and chondral injuries or maladaptations. Following injury (or surgery) to structures around the knee, the primary goal of rehabilitation is to maximize the patient's response to exercise at the current level of function, while minimizing the risk of re-injury to the healing tissue. Clinicians should have a clear understanding of the specific injured tissue(s), and rehabilitation should be driven by knowledge of tissue-healing constraints, knee complex and lower extremity biomechanics, neuromuscular physiology, task-specific activities involving weight-bearing and non-weight-bearing conditions, and training principles. We provide a practical application for prescribing loading progressions of exercises, functional activities, and mobility tasks based on their mechanical load profile to knee-specific structures during the rehabilitation process. Various loading interventions can be used by clinicians to produce physical stress to address body function, physical impairments, activity limitations, and participation restrictions. By modifying the mechanical load elements, clinicians can alter the tissue adaptations, facilitate motor learning, and resolve corresponding physical impairments. Providing different loads that create variable tensile, compressive, and shear deformation on the tissue through mechanotransduction and specificity can promote the appropriate stress adaptations to increase tissue capacity and injury tolerance. Tools for monitoring rehabilitation training loads to the knee are proposed to assess the reactivity of the knee joint to mechanical loading to monitor excessive mechanical loads and facilitate optimal rehabilitation.
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Affiliation(s)
- David S Logerstedt
- Department of Physical Therapy, University of the Sciences in Philadelphia, Philadelphia, PA, USA.
| | - Jay R Ebert
- School of Human Sciences (Exercise and Sport Science), University of Western Australia, Perth, WA, Australia.,Orthopaedic Research Foundation of Western Australia, Perth, WA, Australia.,Perth Orthopaedic and Sports Medicine Research Institute, Perth, WA, Australia
| | - Toran D MacLeod
- Department of Physical Therapy, Sacramento State University, Sacramento, CA, USA
| | - Bryan C Heiderscheit
- Orthopedics and Rehabilitation, University of Wisconsin-Madison, Madison, WI, USA
| | - Tim J Gabbett
- Gabbett Performance Solutions, Brisbane, QLD, Australia.,Centre for Health Research, University of Southern Queensland, Ipswich, QLD, Australia
| | - Brian J Eckenrode
- Department of Physical Therapy, Arcadia University, Glenside, PA, USA
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Lyu J, Zhang Y, Zhu W, Li D, Lin W, Chen K, Xia J. Correlation between the subchondral bone marrow lesions and cartilage repair tissue after matrix-associated autologous chondrocyte implantation in the knee: a cross-sectional study. Acta Radiol 2021; 62:1072-1079. [PMID: 33183061 DOI: 10.1177/0284185120969955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The contribution of the subchondral bone in the development and progression of osteoarthritis (OA) has long been recognized, but its role in cartilage repair procedures has only recently attracted more attention. PURPOSE To explore the correlation between the cartilage repair tissue (RT) and the subchondral bone marrow lesions (BMLs) after matrix-associated autologous chondrocyte implantation (MACI) in the knee joint. MATERIAL AND METHODS A total of 30 patients who underwent MACI in the knee from January 2015 to June 2018 and follow-up magnetic resonance imaging (MRI) scan were recruited in this study. The MRI results of cartilage RT were evaluated using T2* relaxation time. Subchondral BMLs were also qualitatively evaluated by use of the two-dimensional proton density-weighted fat-suppressed (2D-PD-FS) and three-dimensional dual-echo steady-state (3D-DESS) sequences. RESULTS The univariate analysis displayed a significant negative correlation between subchondral BMLs and cartilage RT (P < 0.01). In the minimally adjusted model (only age, sex, and body mass index [BMI] adjusted), the results did not show obvious changes (β = -6.54, 95% confidence interval [CI] = -10.99 to -2.09; P = 0.008). After adjustment for the full models (age, sex, BMI, defect size, combined injury, and preoperative duration of symptoms adjusted), the connection was also detected (β = -6.66, 95% CI -11.82 to -1.50; P = 0.019). CONCLUSION After MACI, the subchondral BMLs are significantly correlated with cartilage RT-T2* relaxation time. The role of subchondral bone in cartilage repair procedures should not be underestimated.
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Affiliation(s)
- Jialing Lyu
- Department of Radiology, the First Affiliated Hospital of Shenzhen University, Health Science Center, Shenzhen Second People’s Hospital, Shenzhen, Guangdong Province, PR China
| | - Yindi Zhang
- Department of Radiology, the First Affiliated Hospital of Shenzhen University, Health Science Center, Shenzhen Second People’s Hospital, Shenzhen, Guangdong Province, PR China
| | - Weimin Zhu
- Department of Sports Medicine, the First Affiliated Hospital of Shenzhen University, Health Science Center, Shenzhen Second People’s Hospital, Shenzhen, Guangdong Province, PR China
| | - Dingfu Li
- Department of Radiology, the First Affiliated Hospital of Shenzhen University, Health Science Center, Shenzhen Second People’s Hospital, Shenzhen, Guangdong Province, PR China
| | - Weiqiang Lin
- Department of Radiology, the First Affiliated Hospital of Shenzhen University, Health Science Center, Shenzhen Second People’s Hospital, Shenzhen, Guangdong Province, PR China
| | - Kang Chen
- Department of Sports Medicine, the First Affiliated Hospital of Shenzhen University, Health Science Center, Shenzhen Second People’s Hospital, Shenzhen, Guangdong Province, PR China
| | - Jun Xia
- Department of Radiology, the First Affiliated Hospital of Shenzhen University, Health Science Center, Shenzhen Second People’s Hospital, Shenzhen, Guangdong Province, PR China
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5
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López-Alcorocho JM, Guillén-Vicente I, Rodríguez-Iñigo E, Navarro R, Caballero-Santos R, Guillén-Vicente M, Casqueiro M, Fernández-Jaén TF, Sanz F, Arauz S, Abelow S, Guillén-García P. High-Density Autologous Chondrocyte Implantation as Treatment for Ankle Osteochondral Defects. Cartilage 2021; 12:307-319. [PMID: 30880428 PMCID: PMC8236657 DOI: 10.1177/1947603519835898] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
PURPOSE Two-year follow-up to assess efficacy and safety of high-density autologous chondrocyte implantation (HD-ACI) in patients with cartilage lesions in the ankle. DESIGN Twenty-four consecutive patients with International Cartilage repair Society (ICRS) grade 3-4 cartilage lesions of the ankle were included. Five million chondrocytes per cm2 of lesion were implanted using a type I/III collagen membrane as a carrier and treatment effectiveness was assessed by evaluating pain with the visual analogue scale (VAS) and American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score at baseline, 12-month, and 24-month follow-up, together with dorsal and plantar flexion. Magnetic resonance observation for cartilage repair tissue (MOCART) score was used to evaluate cartilage healing. Histological study was possible in 5 cases. RESULTS Patients' median age was 31 years (range 18-55 years). Median VAS score was 8 (range 5-10) at baseline, 1.5 (range 0-8) at 12-month follow-up, and 2 (rang e0-5) at 24-month follow-up (P < 0.001). Median AOFAS score was 39.5 (range 29-48) at baseline, 90 (range 38-100) at 12-month follow-up, and 90 (range 40-100) at 24-month follow-up (P < 0.001). Complete dorsal flexion significantly increased at 12 months (16/24, 66.7%) and 24 months (17/24, 70.8%) with regard to baseline (13/24, 54.2%) (P = 0.002). MOCART at 12- and 24-month follow-ups were 73.71 ± 15.99 and 72.33 ± 16.21. Histological study confirmed that neosynthetized tissue was cartilage with hyaline extracellular matrix and numerous viable chondrocytes. CONCLUSION HD-ACI is a safe and effective technique to treat osteochondral lesions in the talus, providing good clinical and histological results at short- and mid-term follow-ups.
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Affiliation(s)
- Juan Manuel López-Alcorocho
- Department of Traumatology and Research
Unit, Clínica CEMTRO, Madrid, Spain,Juan Manuel López-Alcorocho, Research Unit,
Clínica CEMTRO, Avda. Ventisquero de la Condesa 42, 28035 Madrid, Spain.
| | | | | | - Ramón Navarro
- Department of Traumatology and Research
Unit, Clínica CEMTRO, Madrid, Spain
| | | | | | - Mercedes Casqueiro
- Department of Traumatology and Research
Unit, Clínica CEMTRO, Madrid, Spain
| | | | - Fernando Sanz
- Department of Traumatology and Research
Unit, Clínica CEMTRO, Madrid, Spain
| | - Santiago Arauz
- Department of Traumatology and Research
Unit, Clínica CEMTRO, Madrid, Spain
| | - Steve Abelow
- Department of Traumatology and Research
Unit, Clínica CEMTRO, Madrid, Spain
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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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7
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Song JH, Bin SI, Kim JM, Lee BS. Postoperative Subchondral Bone Marrow Lesion Is Associated With Graft Extrusion After Lateral Meniscal Allograft Transplantation. Am J Sports Med 2020; 48:3163-3169. [PMID: 33017182 DOI: 10.1177/0363546520959316] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Adverse effects of graft extrusion after meniscal allograft transplantation (MAT) are difficult to assess and can be determined only in the long term using a simple radiograph. Recently, subchondral bone marrow lesions (BMLs) detected on magnetic resonance imaging (MRI) scans have been used to evaluate the outcomes or prognoses of various knee surgeries. However, whether subchondral BMLs on MRI scans reflect the effects of allograft extrusion remains unclear. HYPOTHESIS Subchondral BML in the lateral compartment of the knee joint on postoperative MRI scans would be associated with graft extrusion after lateral MAT. STUDY DESIGN Case-control study; Level of evidence, 3. METHODS Overall, 170 patients with lateral MAT between 2008 and 2013 were classified into extrusion (≥3 mm) and nonextrusion (<3 mm) groups based on findings on MRI scans obtained 3 to 6 months postoperatively. Subchondral BMLs in the lateral compartment were evaluated on the latest MRI scans. To exclude any bone marrow signal changes other than those caused by allograft extrusion, the latest MRI scans were compared with those obtained 3 to 6 months postoperatively. Only subchondral BMLs that occurred after that time point were counted. The association between allograft extrusion and subchondral BML was assessed using chi-square analysis. Logistic regression analysis was performed to control other related factors, including age, sex, body mass index, time from previous meniscectomy, alignment, and cartilage status at the time of MAT. Clinical outcomes according to subchondral BML were evaluated using the Lysholm score. RESULTS Of the 170 patients, 20 (11.8%) had subchondral BML on the latest MRI scans at a mean 53.6 ± 31.2 months postoperatively, with 14 and 6 patients in the extrusion and nonextrusion groups, respectively. Chi-square analysis showed a significant association between allograft extrusion and subchondral BMLs (P = .025). Logistic regression analysis showed that extrusion and age were significant factors associated with subchondral BML (P = .011 and .004, respectively). However, no differences were observed in the Lysholm scores in accordance with the subchondral BML (P = .248). CONCLUSION Subchondral BMLs on postoperative MRI scans were associated with graft extrusion after lateral MAT. However, there was no difference in clinical outcomes according to subchondral BML.
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Affiliation(s)
- Ju-Ho Song
- University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Seong-Il Bin
- University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Jong-Min Kim
- University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Bum-Sik Lee
- University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Republic of Korea
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8
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Merkely G, Farr J, Saris D, Lattermann C. Cartilage Surface Treatment: Factors Affecting Success and Failure Mechanisms. OPER TECHN SPORT MED 2020. [DOI: 10.1016/j.otsm.2019.150711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Kim MS, Koh IJ, Sohn S, Sung HS, In Y. Degree of Preoperative Subchondral Bone Marrow Lesion Is Associated With Postoperative Outcome After Medial Opening Wedge High Tibial Osteotomy. Am J Sports Med 2019; 47:2454-2463. [PMID: 31287714 DOI: 10.1177/0363546519858996] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND In osteoarthritis of the knee, subchondral bone marrow lesion (BML) is known to be significantly associated with the severity of pain. However, little is known about the influence of preoperative BML on postoperative outcomes after medial opening wedge high tibial osteotomy (MOWHTO). PURPOSE To compare patient-reported outcomes for those who underwent MOWHTO according to the severity of BML based on magnetic resonance imaging. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS A total of 136 patients who underwent MOWHTO between June 2011 and May 2016 with clinical and radiologic assessments before and after surgery were retrospectively enrolled. Patients were divided into 2 groups according to the presence or absence of BMLs. They were then subdivided into 4 or 3 groups based on the sum of BML scores of the medial femoral condyle and tibial plateau according to MRI (magnetic resonance imaging) Osteoarthritis Knee Score or Filardo classification, respectively. Associations between the severity of BML and postoperative 1- and 2-year Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) subscores were evaluated through linear regression analysis. At postoperative 2 years, the rate of patients having a WOMAC score improvement of 15 points based on minimum clinically important difference and patient satisfaction were compared between groups. RESULTS BMLs were present in 96 (70.6%) of 136 cases. There were no significant differences in demographics or radiographic variables between groups according to the presence/absence or severity of BMLs (all P > .05). There was a significant association between preoperative or 1-year postoperative WOMAC pain/function score and the extent or intensity of BMLs (all P < .05). After adjusting for age, body mass index, osteoarthritis grade, and hip-knee-ankle angle, the significance persisted in the association between the extent or intensity of BMLs and WOMAC pain/function score at 1 year after surgery (all P < .05). However, a significant association was not found at postoperative 2 years (all P > .05). All groups showed similar rates of WOMAC score showing 15 points of improvement and satisfaction after MOWHTO (all P > .05). At 2 years after surgery, 82.5% of patients with BMLs were satisfied with their operation, as compared with 84.4% of those without BMLs (P = .801). CONCLUSION Although worse clinical outcomes were associated with severe BML during the recovery period, MOWHTO provided a high degree of clinical improvement on patient-reported outcomes regardless of the severity of BML at 2 years postoperatively.
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Affiliation(s)
- Man Soo Kim
- Department of Orthopedic Surgery, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - In Jun Koh
- Department of Orthopaedic Surgery, St Paul's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sueen Sohn
- Department of Orthopedic Surgery, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hoon Seok Sung
- Department of Orthopedic Surgery, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yong In
- Department of Orthopedic Surgery, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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10
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Merkely G, Ogura T, Bryant T, Minas T. Severe Bone Marrow Edema Among Patients Who Underwent Prior Marrow Stimulation Technique Is a Significant Predictor of Graft Failure After Autologous Chondrocyte Implantation. Am J Sports Med 2019; 47:1874-1884. [PMID: 31251661 DOI: 10.1177/0363546519853584] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [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) is a well-established cartilage repair procedure; however, numerous studies have shown higher ACI graft failure rates after prior marrow stimulation techniques (MSTs). PURPOSE To identify which factors may predict decreased graft survival after ACI among patients who underwent a prior MST. A secondary aim was to investigate the specificity of these predictors. STUDY DESIGN Case-control study; Level of evidence, 3. METHODS In this review of prospectively collected data, the authors analyzed 38 patients who had failed prior MST surgery and subsequently underwent collagen-covered ACI (case group). The case group was divided into graft failure ACI (n = 8, 21%) and successful ACI (n = 30, 79%). Fourteen clinical variables were categorized and analyzed to determine predictors for failure of the ACI graft: age, body mass index, sex, defect characteristics (number, size, location, etiology, type), presence of kissing lesion, intraoperative presence of intralesional osteophyte, time between an MST and ACI, previous surgery, duration of the symptoms, and concomitant surgical procedure. Preoperative magnetic resonance imaging (MRI) was used to evaluate the severity of subchondral bone marrow edema (BME), graded I (absent) to IV (severe), and the presence of subchondral cyst, hypertrophic sclerosis, and intralesional osteophyte. The effects of these MRI findings on the graft survivor were also investigated. Concurrently, a control group without a prior MST was matched to investigate the specificity of the previously determined predictors. These patients were matched individually according to age, sex, body mass index, and outcome of the procedure (failure [n = 8] or successful [n = 30] per the case group). RESULTS In the case group, the presence of preoperative severe BME was significantly higher among patients with failed ACI as compared with patients with successful ACI (P < .001). In the control group, the presence of severe BME was not significantly different between the failure and successful groups (P = .747). The ACI graft failure rate among patients with a prior MST and preoperative grade IV BME was 83.7% at 5 years postoperatively, resulting in a significantly lower survival rate as compared with patients with a prior MST and without severe BME (5-year graft failure rate, 6.5%; P < .001). All the other parameters did not differ significantly. CONCLUSION After a prior MST, the presence of grade IV BME by MRI was a predictive factor for graft failure among patients who then underwent second-generation ACI.
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Affiliation(s)
- Gergo Merkely
- Cartilage Repair Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Traumatology, Semmelweis University, Budapest, Hungary
| | - Takahiro Ogura
- Cartilage Repair Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Sports Medicine Center Funabashi Orthopedic Hospital, Funabashi, Japan
| | - Tim Bryant
- Cartilage Repair Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Tom Minas
- Cartilage Repair Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Paley Orthopedic and Spine Institute, West Palm Beach, Florida, USA
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11
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Saltzman BM, Riboh JC. Subchondral Bone and the Osteochondral Unit: Basic Science and Clinical Implications in Sports Medicine. Sports Health 2018; 10:412-418. [PMID: 29932862 PMCID: PMC6116098 DOI: 10.1177/1941738118782453] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Context: Articular cartilage injuries and early osteoarthritis are among the most common
conditions seen by sports medicine physicians. Nonetheless, treatment options for
articular degeneration are limited once the osteoarthritic cascade has started. Intense
research is focused on the use of biologics, cartilage regeneration, and transplantation
to help maintain and improve cartilage health. An underappreciated component of joint
health is the subchondral bone. Evidence Acquisition: A comprehensive, nonsystematic review of the published literature was completed via a
PubMed/MEDLINE search of the keywords “subchondral” AND “bone” from database inception
through December 1, 2016. Study Design: Clinical review. Level of Evidence: Level 4. Methods: Articles collected via the database search were assessed for the association of bone
marrow lesions and osteoarthritis, cartilage regeneration, and ligamentous and meniscal
injury; the clinical disorder known as painful bone marrow edema syndrome; and the
subchondral bone as a target for medical and surgical intervention. Results: A complex interplay exists between the articular cartilage of the knee and its
underlying subchondral bone. The role of subchondral bone in the knee is intimately
related to the outcomes from cartilage restoration procedures, ligamentous injury,
meniscal pathology, and osteoarthritis. However, subchondral bone is often neglected
when it should be viewed as a critical element of the osteochondral unit and a key
player in joint health. Conclusion: Continued explorations into the intricacies of subchondral bone marrow abnormalities
and implications for the advent of procedures such as subchondroplasty will inform
further research efforts on how interventions aimed at the subchondral bone may provide
durable options for knee joint preservation.
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Affiliation(s)
- Bryan M Saltzman
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Jonathan C Riboh
- Department of Orthopedic Surgery, Section of Sports Medicine, Duke University, Durham, North Carolina
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Saltzman BM, Cotter EJ, Stephens JP, Cvetanovich GL, Madden B, Wang K, Yanke AB, Cole BJ. Preoperative Tibial Subchondral Bone Marrow Lesion Patterns and Associations With Outcomes After Isolated Meniscus Allograft Transplantation. Am J Sports Med 2018; 46:1175-1184. [PMID: 29382216 DOI: 10.1177/0363546517751690] [Citation(s) in RCA: 19] [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 The association between preoperative tibial subchondral bone marrow lesion (BML) patterns and outcomes after isolated meniscus allograft transplantation (MAT) are unknown. PURPOSE To determine (1) if a superior classification means exists (ie, high interrater reliability [IRR]) for grading tibial subchondral BML before isolated MAT and (2) whether quality and/or severity of preoperative tibial subchondral BML patterns was associated with clinical outcomes and/or failure rates after isolated MAT. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS All patients who underwent isolated MAT with a single surgeon between October 2006 and February 2017 were identified. Three means were evaluated to quantify the degree of subchondral BML in the affected tibial-sided compartment: Welsch et al, based on maximum diameter of the lesion; Costa-Paz et al, based on appearance and location of the lesion; and Filardo et al, based on severity of findings. IRR was generated and compared among the 3 classifications. The preoperative magnetic resonance imaging (MRI) subchondral BML grading scheme with the highest IRR was then used to assess for associations with postoperative outcomes for those patients with >2-year follow-up, per a Spearman correlation matrix with each reviewer's grades. RESULTS In total, 60 MRI scans were available for subchondral BML grading. Grader 1 identified the presence of subchondral BML in the tibia of the affected compartment in 40 (66.7%) of the available MRI scans, as compared with 38 (63.3%) for grader 2. The calculated IRRs with the Welsch et al and Costa-Paz et al classifications were rated "strong/almost perfect" agreement. A significant correlation was demonstrated between grader 1 with the Welsch et al grading scheme and outcome measures of KOOS pain (Knee injury and Osteoarthritis Outcome Score; negative correlation, P = .05), WOMAC pain (Western Ontario and McMaster Universities Osteoarthritis Index; positive correlation, P = .026), and Marx Activity Rating Scale (negative correlation, P = .019). A significant correlation was demonstrated between grader 2 with the Costa-Paz et al grading scheme and postoperative satisfaction (positive correlation, P = .018). There were no significant differences in survivorship based on gradings. CONCLUSION Nearly two-thirds of patients who undergo isolated MAT have subchondral BML on preoperative MRI. Our findings suggest that increasing BML size (Welsch et al) is correlated with worse postoperative pain measures (KOOS pain, WOMAC pain) and worse activity ratings (Marx Activity Rating Scale). Additionally, increasing disruption or depression of the normal contour of the cortical surface, with or without lesion contiguity with the subjacent articular surface (Costa-Paz et al), is correlated with greater postoperative satisfaction.
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Affiliation(s)
- Bryan M Saltzman
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Eric J Cotter
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Jeffrey P Stephens
- Department of Orthopedic Surgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Gregory L Cvetanovich
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Brett Madden
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Kevin Wang
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Adam B Yanke
- 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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Dhollander A, Verdonk P, Tirico LEP, Gomoll AH. Treatment of failed cartilage repair: State of the Art. J ISAKOS 2016. [DOI: 10.1136/jisakos-2016-000057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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14
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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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15
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Meric G, Gracitelli GC, McCauley JC, Pulido PA, Chang EY, Chung CB, Bugbee WD. Osteochondral Allograft MRI Scoring System (OCAMRISS) in the Knee: Interobserver Agreement and Clinical Application. Cartilage 2015; 6:142-9. [PMID: 26175859 PMCID: PMC4481388 DOI: 10.1177/1947603515573987] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION Osteochondral allograft (OCA) transplantation is a suitable treatment option for large osteochondral defects. Magnetic resonance imaging (MRI) is an objective, reproducible, noninvasive monitoring tool for postoperative assessment after cartilage surgery. OBJECTIVE To correlate Osteochondral Allograft MRI Scoring System (OCAMRISS) in patients undergoing OCA transplantation in the knee with clinical outcomes and determine interobserver agreement of this scoring system. METHODS Fifteen patients underwent OCA transplantation in the knee and received a postoperative MRI. Four examiners read each MRI and completed an OCAMRISS. Interobserver agreement and intraclass correlation coefficients (ICCs) were assessed. Clinical outcomes were evaluated. Correlation between the OCAMRISS and clinical outcomes was calculated using Spearman's correlation coefficients. RESULTS Interobserver agreement on individual features of the OCAMRISS was superior (κ = 0.81-1.0) in 65% of comparisons, substantial (κ = 0.61-0.8) in 14%, moderate (κ = 0.41-0.6) in 18%, and fair (κ = 0.21-0.4) in 3%. Agreement among readers was very strong for the cartilage, bone, ancillary, and total scores with 96% of comparisons having an ICC >0.80. International Knee Documentation Committee (IKDC) function scores were correlated with OCAMRISS cartilage score (ρ = 0.53, P = 0.044) and total score (ρ = 0.67, P = 0.006). The Knee injury and Osteoarthritis Outcome Score (KOOS) sports/recreation subscale was correlated with OCAMRISS ancillary score (ρ = 0.58, P = 0.049) and total score (ρ = 0.64, P = 0.024). No correlation was observed with subchondral bone features of OCAMRISS and any of the outcome scores. CONCLUSIONS The recently described OCAMRISS is a reproducible grading system for in vivo evaluation after osteochondral allograft transplantation.
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Affiliation(s)
- Gokhan Meric
- Shiley Center for Orthopaedic Research and Education at Scripps Clinic, La Jolla, CA, USA,Department of Orthopaedic Surgery, Balikesir University, Balikesir, Turkey
| | - Guilherme C. Gracitelli
- Shiley Center for Orthopaedic Research and Education at Scripps Clinic, La Jolla, CA, USA,Department of Orthopaedic Surgery, Federal University of São Paulo, São Paulo, Brazil
| | - Julie C. McCauley
- Shiley Center for Orthopaedic Research and Education at Scripps Clinic, La Jolla, CA, USA
| | - Pamela A. Pulido
- Shiley Center for Orthopaedic Research and Education at Scripps Clinic, La Jolla, CA, USA
| | - Eric Y. Chang
- Radiology Service, VA San Diego Healthcare System, San Diego, CA, USA,Department of Radiology, University of California, San Diego Medical Center, La Jolla, CA, USA
| | - Christine B. Chung
- Radiology Service, VA San Diego Healthcare System, San Diego, CA, USA,Department of Radiology, University of California, San Diego Medical Center, La Jolla, CA, USA
| | - William D. Bugbee
- Shiley Center for Orthopaedic Research and Education at Scripps Clinic, La Jolla, CA, USA,Department of Orthopaedic Surgery, Scripps Clinic, La Jolla, CA, USA
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16
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Salzmann GM, Niemeyer P, Vogt S, Kreuz P, Arnold M, Fritz J, Mujeeb A, Rosenberger R, Steinwachs M, Angele P. Practical execution of defect preparation prior to surgical cartilage intervention: results from a representative meeting survey among experts. SPRINGERPLUS 2015; 4:682. [PMID: 27385105 PMCID: PMC4637330 DOI: 10.1186/s40064-015-1451-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 10/19/2015] [Indexed: 11/24/2022]
Abstract
During a specialised orthopedic meeting held on ‘the state of the art in cartilage defect repair’, all previously fully-registered participants were requested to participate in an electronic survey by the use of a moderator-presented “Power Point Presentation-based” 9-item questionnaire. The aim of this survey was to assess indication, approach, and treatment execution of cartilage defect debridement prior to planned microfracture (MFX) or autologous chondrocyte implantation (ACI). All participants completed the questionnaire (n = 146) resulting in a return rate of 100 %. An uncertainty exists as to whether the removal of the calcifying layer prior to cartilage repair must be carried out or not. The same was true for the acceptability of subchondral bleeding prior to microfracturing and its handling prior to autologous chondrocyte implantation. There is a degree of unanimity among experts regarding the management of osteophytes and bone marrow edema. In a homogenous society collective of consultants that frequently deal with cartilage defective pathologies, there still remain a significant heterogeneity in selected topics of defect debridement.
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Affiliation(s)
- Gian M Salzmann
- Department of Orthopaedic Surgery, Schulthess Clinic, Lengghalde 2, 8008 Zurich, Switzerland
| | - Philipp Niemeyer
- Department of Orthopedics and Trauma Surgery, Albert-Ludwigs University Medical Center Freiburg, 79106 Freiburg, Germany
| | | | - Peter Kreuz
- Orthopädie, Uniklinik Rostock, Rostock, Germany
| | | | | | - Ayeesha Mujeeb
- Department of Biomedical Engineering, College of Engineering, Peking University, 100871 Beijing, China
| | | | | | - Peter Angele
- Department of Trauma Surgery, University Medical Center Regensburg, Franz Josef Strauß Allee 11, 93042 Regensburg, Germany
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