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Kotlier JL, Lin EH, Fathi A, Iyer AS, Telang SS, Bolia IK, Ahmad A, Petrigliano FA, Liu JN. Commercial Insurance Coverage Criteria for Autologous Chondrocyte Implantation Poorly Reflect Current Research. Cartilage 2024:19476035241276930. [PMID: 39345049 DOI: 10.1177/19476035241276930] [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: 10/01/2024] Open
Abstract
OBJECTIVE The aim of this study is to both quantify and qualify the way insurance companies justify their coverage policies for autologous chondrocyte implantation (ACI) and determine whether these policies align with recent research on the subject. DESIGN The top 11 national commercial health insurance payers for ACI were identified. Coverage policy documents were recovered for 8 payers. These documents were examined, and the type of reference and the level of evidence (LOE) were recorded for each applicable reference. Specific coverage criteria for each individual payer were then extracted and assessed for similarities among commercial payers. Finally, all references cited by each payer were examined to determine whether they mentioned the specific payer criteria. RESULTS This study found that the majority of cited references were primary journal articles (86, 58.1%) and that only 30 (20.2%) references were level I or level II evidence. This study also found significant homogeneity among payer coverage criteria. Cited sources inconsistently mentioned specific payer coverage criteria. In addition, payer criteria tended to be poorly supported by current evidence on ACI. CONCLUSIONS This study demonstrates that commercial insurance payers' coverage policies for ACI poorly cite references, cite a majority of references with low LOE, and cite references which infrequently mention their specific coverage criteria. In addition, payer coverage policies have a high degree of homogeneity and many of their specific criteria are poorly supported by current research on ACI.
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Affiliation(s)
- Jacob L Kotlier
- Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, USA
| | - Eric H Lin
- Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, USA
| | - Amir Fathi
- Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, USA
| | - Avinash S Iyer
- Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, USA
| | - Sahil S Telang
- Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, USA
| | - Ioanna K Bolia
- Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, USA
| | - Aamir Ahmad
- Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, USA
| | - Frank A Petrigliano
- Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, USA
| | - Joseph N Liu
- Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, USA
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Yoon KH, Lee J, Park JY. Costal Chondrocyte-Derived Pellet-Type Autologous Chondrocyte Implantation Versus Microfracture for the Treatment of Articular Cartilage Defects: A 5-Year Follow-up of a Prospective Randomized Trial. Am J Sports Med 2024; 52:362-367. [PMID: 38230875 DOI: 10.1177/03635465231222797] [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: 01/18/2024]
Abstract
BACKGROUND Costal chondrocyte-derived pellet-type autologous chondrocyte implantation (CCP-ACI) has been introduced as a new therapeutic option for the treatment of articular cartilage defects. We had previously conducted a randomized controlled trial comparing CCP-ACI versus microfracture at 1 year postoperatively. PURPOSE To compare the efficacy and safety of CCP-ACI versus microfracture for the treatment of articular cartilage defects of the knee at 5 years postoperatively. STUDY DESIGN Randomized controlled trial; Level of evidence, 2. METHODS This study describes the mean 5-year follow-up of a previously published prospective clinical trial. The previous prospective trial compared the results of CCP-ACI versus microfracture until 1 year of follow-up. Of the 30 patients who were included in the previous study, 25 were followed up for 5 years. Patients were evaluated based on clinical outcome scores (Lysholm score, International Knee Documentation Committee score, Knee injury and Osteoarthritis Outcome Score [KOOS], and visual analog scale for pain), magnetic resonance imaging findings, and rates of treatment failure at last follow-up. RESULTS The MOCART (Magnetic Resonance Observation of Cartilage Repair Tissue) score in the CCP-ACI group was significantly higher than that in the microfracture group at 5 years (62.3 vs 26.7, respectively; P < .0001). The Lysholm score and KOOS score in the CCP-ACI group were significantly higher than those in the microfracture group at 5 years (84.5 vs 64.9, respectively, and 390.9 vs 303.0, respectively; P = .023 and P = .017, respectively). There was 1 case of treatment failure that occurred in the microfracture group. CONCLUSION The present randomized controlled trial indicated that the results of both procedures clinically and statistically significantly improved at 1 and 5 years' follow-up in treating cartilage defects, but the results of CCP-ACI were superior to those of microfracture. Magnetic resonance imaging conducted at 1 year and 5 years after CCP-ACI revealed statistically significant superior structural integration with native cartilage tissue compared with microfracture. REGISTRATION NCT03545269 (ClinicalTrials.gov).
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Affiliation(s)
- Kyoung-Ho Yoon
- Department of Orthopedics, Kyung-Hee University Hospital, Kyung-Hee University, Seoul, Republic of Korea
| | - Jungsun Lee
- R&D Institute, Biosolution, Seoul, Republic of Korea
| | - Jae-Young Park
- Department of Orthopedic Surgery, CHA Bundang Medical Center, CHA University, Seongnam, Republic of Korea
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Dhillon J, Orozco E, Keeter C, Scillia AJ, Harris JD, Kraeutler MJ. Microfracture of Acetabular Chondral Lesions Is Not Superior to Other Cartilage Repair Techniques in Patients With Femoroacetabular Impingement Syndrome: A Systematic Review. Arthroscopy 2024; 40:602-611. [PMID: 37355179 DOI: 10.1016/j.arthro.2023.05.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 05/17/2023] [Accepted: 05/26/2023] [Indexed: 06/26/2023]
Abstract
PURPOSE To perform a systematic review to compare clinical outcomes of hip arthroscopy patients undergoing microfracture (MFx) versus other cartilage repair procedures for chondral lesions of the acetabulum. METHODS A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines by searching PubMed, the Cochrane Library, and Embase to identify comparative studies that directly compared outcomes between MFx and other cartilage repair procedures for full-thickness chondral lesions of the acetabulum identified during hip arthroscopy. The search phrase used was: hip AND arthroscopy AND microfracture. Patients were evaluated based on reoperation rates and patient-reported outcomes. RESULTS Six studies (all Level III evidence) met inclusion criteria, including a total of 202 patients undergoing microfracture (group A) and 327 patients undergoing another cartilage repair procedure (group B). Mean patient age ranged from 35.0 to 45.0 years. Mean follow-up time ranged from 12.0 to 72.0 months. Significantly better patient-reported outcomes (PROs) were found in patients undergoing treatment with bone marrow aspirate concentrate, microfragmented adipose tissue concentrate, autologous matrix-induced chondrogenesis, and a combination of autologous matrix-induced chondrogenesis and bone marrow aspirate concentrate compared with MFx. No studies found significantly better postoperative PROs in group A. The reoperation rate ranged from 0% to 34.6% in group A and 0% to 15.9% in group B. Three of 5 studies reporting on reoperation rate found a significantly greater reoperation rate in group A, with no difference in the other 2 studies. CONCLUSIONS The literature on MFx of acetabular chondral lesions is limited and heterogeneous. Based on the available data, MFx alone results in a greater or equivalent reoperation rate and inferior or equivalent PROs compared with other cartilage repair procedures for acetabular chondral lesions in patients with femoroacetabular impingement syndrome. LEVEL OF EVIDENCE Level III, systematic review of level III studies.
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Affiliation(s)
- Jaydeep Dhillon
- Rocky Vista University College of Osteopathic Medicine, Parker, Colorado, U.S.A
| | - Erin Orozco
- Houston Methodist Hospital, Houston, Texas, U.S.A
| | - Carson Keeter
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, U.S.A
| | - Anthony J Scillia
- Department of Orthopaedic Surgery, St. Joseph's University Medical Center, Paterson, New Jersey, U.S.A.; Academy Orthopaedics, Wayne, New Jersey, U.S.A
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Vardar E, Nam HY, Vythilingam G, Tan HL, Mohamad Wali HA, Engelhardt EM, Kamarul T, Zambelli PY, Samara E. A New Bioactive Fibrin Formulation Provided Superior Cartilage Regeneration in a Caprine Model. Int J Mol Sci 2023; 24:16945. [PMID: 38069268 PMCID: PMC10707130 DOI: 10.3390/ijms242316945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 11/13/2023] [Accepted: 11/17/2023] [Indexed: 12/18/2023] Open
Abstract
The effective and long-term treatment of cartilage defects is an unmet need among patients worldwide. In the past, several synthetic and natural biomaterials have been designed to support functional articular cartilage formation. However, they have mostly failed to enhance the terminal stage of chondrogenic differentiation, leading to scar tissue formation after the operation. Growth factors substantially regulate cartilage regeneration by acting on receptors to trigger intracellular signaling and cell recruitment for tissue regeneration. In this study, we investigated the effect of recombinant insulin-like growth factor 1 (rIGF-1), loaded in fibrin microbeads (FibIGF1), on cartilage regeneration. rIGF-1-loaded fibrin microbeads were injected into full-thickness cartilage defects in the knees of goats. The stability, integration, and quality of tissue repair were evaluated at 1 and 6 months by gross morphology, histology, and collagen type II staining. The in vivo results showed that compared to plain fibrin samples, particularly at 6 months, FibIGF1 improved the functional cartilage formation, confirmed through gross morphology, histology, and collagen type II immunostaining. FibIGF1 could be a promising candidate for cartilage repair in the clinic.
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Affiliation(s)
- Elif Vardar
- Pediatric Orthopedic Department, Children’s Hospital, Chémin de Montétan 16, 1004 Lausanne, Switzerland; (E.V.); (E.-M.E.); (P.-Y.Z.)
| | - Hui Yin Nam
- Tissue Engineering Group, Department of Orthopaedic Surgery (NOCERAL), Faculty of Medicine, Universiti Malaya, Kuala Lumpur 50603, Malaysia; (H.Y.N.); (H.L.T.)
- Nanotechnology and Catalysis Research Centre (NANOCAT), Universiti Malaya, Kuala Lumpur 50603, Malaysia
| | - Ganesh Vythilingam
- Pediatric Surgery Unit, Department of Surgery, Faculty of Medicine, Universiti Malaya, Kuala Lumpur 50603, Malaysia;
| | - Han Ling Tan
- Tissue Engineering Group, Department of Orthopaedic Surgery (NOCERAL), Faculty of Medicine, Universiti Malaya, Kuala Lumpur 50603, Malaysia; (H.Y.N.); (H.L.T.)
| | | | - Eva-Maria Engelhardt
- Pediatric Orthopedic Department, Children’s Hospital, Chémin de Montétan 16, 1004 Lausanne, Switzerland; (E.V.); (E.-M.E.); (P.-Y.Z.)
| | - Tunku Kamarul
- Tissue Engineering Group, Department of Orthopaedic Surgery (NOCERAL), Faculty of Medicine, Universiti Malaya, Kuala Lumpur 50603, Malaysia; (H.Y.N.); (H.L.T.)
| | - Pierre-Yves Zambelli
- Pediatric Orthopedic Department, Children’s Hospital, Chémin de Montétan 16, 1004 Lausanne, Switzerland; (E.V.); (E.-M.E.); (P.-Y.Z.)
| | - Eleftheria Samara
- Pediatric Orthopedic Department, Children’s Hospital, Chémin de Montétan 16, 1004 Lausanne, Switzerland; (E.V.); (E.-M.E.); (P.-Y.Z.)
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Yu S, Shu X, Chen L, Wang C, Wang X, Jing J, Yan G, Zhang Y, Wu C. Construction of ultrasonically treated collagen/silk fibroin composite scaffolds to induce cartilage regeneration. Sci Rep 2023; 13:20168. [PMID: 37978248 PMCID: PMC10656553 DOI: 10.1038/s41598-023-43397-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 09/22/2023] [Indexed: 11/19/2023] Open
Abstract
A novel tissue-specific functional tissue engineering scaffold for cartilage repair should have a three-dimensional structure, good biosafety and biological activity, and should be able to promote cartilage tissue regeneration. This study aimed to determine the effect of ultrasound-treated collagen/silk fibroin (Col/SF) composite scaffolds with good mechanical properties and high biological activity on cartilage repair. The characteristics of the scaffolds with different Col/SF ratios (7:3, 8:2, and 9:1) were determined by scanning electron microscopy, Fourier-transform infrared spectroscopy, and porosity, water absorption, and compression tests. In vitro evaluations revealed the biocompatibility of the Col/SF scaffolds. Results suggested that the optimal ratio of Col/SF composite scaffolds was 7:3. The Col/SF scaffolds induced adipose-derived stem cells to undergo chondrogenic differentiation under chondrogenic culture conditions. The efficiency of Col/SF scaffolds for cartilage regeneration applications was further evaluated using an in vivo model of full-thickness articular cartilage defects in New Zealand rabbits. The Col/SF scaffolds effectively promoted osteochondral regeneration as evidenced by macroscopic, histological, and immunohistochemical evaluation. The study demonstrates that ultrasound-treated Col/SF scaffolds show great potential for repairing cartilage defects.
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Affiliation(s)
- Shunan Yu
- Department of Molecular Orthopedics, Beijing Research Institute of Traumatology and Orthopedics, Beijing, 100035, People's Republic of China
| | - Xiong Shu
- Department of Molecular Orthopedics, Beijing Research Institute of Traumatology and Orthopedics, Beijing, 100035, People's Republic of China
| | - Lei Chen
- Department of Molecular Orthopedics, Beijing Research Institute of Traumatology and Orthopedics, Beijing, 100035, People's Republic of China
| | - Chao Wang
- Department of Molecular Orthopedics, Beijing Research Institute of Traumatology and Orthopedics, Beijing, 100035, People's Republic of China
| | - Xinyu Wang
- Department of Molecular Orthopedics, Beijing Research Institute of Traumatology and Orthopedics, Beijing, 100035, People's Republic of China
| | - Jinzhu Jing
- Animal Laboratory Laboratory, Beijing Research Institute of Traumatology and Orthopedics, Beijing, 100035, People's Republic of China
| | - Guoqiang Yan
- Animal Laboratory Laboratory, Beijing Research Institute of Traumatology and Orthopedics, Beijing, 100035, People's Republic of China
| | - Yanzhuo Zhang
- Department of Molecular Orthopedics, Beijing Research Institute of Traumatology and Orthopedics, Beijing, 100035, People's Republic of China
| | - Chengai Wu
- Department of Molecular Orthopedics, Beijing Research Institute of Traumatology and Orthopedics, Beijing, 100035, People's Republic of China.
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Du S, Elliman SJ, Zeugolis DI, O'Brien T. Carrageenan as a macromolecular crowding agent in human umbilical cord derived mesenchymal stromal cell culture. Int J Biol Macromol 2023; 251:126353. [PMID: 37591431 DOI: 10.1016/j.ijbiomac.2023.126353] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 08/11/2023] [Accepted: 08/14/2023] [Indexed: 08/19/2023]
Abstract
Cell sheet tissue engineering requires prolonged in vitro culture for the development of implantable devices. Unfortunately, lengthy in vitro culture is associated with cell phenotype loss and substantially higher cost of goods, which collectively hinder clinical translation and commercialisation of tissue engineered medicines. Although macromolecular crowding has been shown to enhance and accelerate extracellular matrix deposition, whilst maintaining cellular phenotype, the optimal macromolecular crowding agent still remains elusive. Herein, we evaluated the biophysical properties of seven different carrageenan molecules at five different concentrations and their effect on human umbilical cord-derived mesenchymal stromal cell morphology, viability, metabolic activity, proliferation, extracellular matrix deposition and surface marker expression. All types of carrageenan (CR) assessed demonstrated a hydrodynamic radius increase as a function of increasing concentration; high polydispersity; and negative charge. Two iota CRs were excluded from further analysis due to poor solubility in cell culture. Among the remaining five carrageenans, the lambda medium viscosity type at concentrations of 10 and 50 μg/ml did not affect cell morphology, viability, metabolic activity, proliferation and expression of surface markers and significantly increased the deposition of collagen types I, III and IV, fibronectin and laminin. Our data highlight the potential of lambda medium viscosity carrageenan as a macromolecular crowding agent for the accelerated development of functional tissue engineered medicines.
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Affiliation(s)
- Shanshan Du
- Regenerative Medicine Institute (REMEDI), Biomedical Sciences Building, University of Galway, Galway, Ireland; Science Foundation Ireland (SFI) Centre for Research in Medical Devices (CÚRAM), Biomedical Sciences Building, University of Galway, Galway, Ireland
| | | | - Dimitrios I Zeugolis
- Science Foundation Ireland (SFI) Centre for Research in Medical Devices (CÚRAM), Biomedical Sciences Building, University of Galway, Galway, Ireland; Regenerative, Modular & Developmental Engineering Laboratory (REMODEL), Biomedical Sciences Building, University of Galway, Galway, Ireland; Regenerative, Modular & Developmental Engineering Laboratory (REMODEL), Charles Institute of Dermatology, Conway Institute of Biomolecular & Biomedical Research, School of Mechanical & Materials Engineering, University College Dublin (UCD), Dublin, Ireland
| | - Timothy O'Brien
- Regenerative Medicine Institute (REMEDI), Biomedical Sciences Building, University of Galway, Galway, Ireland; Science Foundation Ireland (SFI) Centre for Research in Medical Devices (CÚRAM), Biomedical Sciences Building, University of Galway, Galway, Ireland; Orbsen Therapeutics Ltd, IDA Business Park, Dangan, Galway, Ireland.
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Pohlig F, Wittek M, VON Thaden A, Lenze U, Glowalla C, Minzlaff P, Burgkart R, Prodinger PM. Biomechanical Properties of Repair Cartilage Tissue Are Superior Following Microdrilling Compared to Microfracturing in Critical Size Cartilage Defects. In Vivo 2023; 37:565-573. [PMID: 36881065 PMCID: PMC10026649 DOI: 10.21873/invivo.13115] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 12/28/2022] [Accepted: 12/29/2022] [Indexed: 03/08/2023]
Abstract
BACKGROUND/AIM Common surgical treatment options for large focal chondral defects (FCDs) in the knee include microfracturing (MFX) and microdrilling (DRL). Despite numerous studies addressing MFX and DRL of FDCs, no in vivo study has focused on biomechanical analysis of repair cartilage tissue in critical size FCDs with different amounts of holes and penetration depths. MATERIALS AND METHODS Two round FCDs (d=6 mm) were created on the medial femoral condyle in 33 adult merino sheep. All 66 defects were randomly assigned to 1 control or 4 different study groups: 1) MFX1, 3 holes, 2 mm depth; 2) MFX2, 3 holes, 4 mm depth; 3) DRL1, 3 holes, 4 mm depth; and 4) DRL2, 6 holes, 4 mm depth. Animals were followed up for 1 year. Following euthanasia, quantitative optical analysis of defect filling was performed. Biomechanical properties were analysed with microindentation and calculation of the elastic modulus. RESULTS Quantitative assessment of defect filling showed significantly better results in all treatment groups compared to untreated FCDs in the control group (p<0.001), with the best results for DRL2 (84.2% filling). The elastic modulus of repair cartilage tissue in the DRL1 and DRL2 groups was comparable to the adjacent native hyaline cartilage, while significantly inferior results were identified in both MFX groups (MFX1: p=0.002; MFX2: p<0.001). CONCLUSION More defect filling and better biomechanical properties of the repair cartilage tissue were identified for DRL compared to MFX, with the best results for 6 holes and 4 mm of penetration depth. These findings are in contrast to the current clinical practice with MFX as the gold standard and suggest a clinical return to DRL.
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Affiliation(s)
- Florian Pohlig
- Department of Orthopaedic Surgery, Klinikum Rechts der Isar, Technical University Munich (TUM), Munich, Germany;
| | | | - Anne VON Thaden
- German Center for Neurodegenerative Diseases, Munich, Germany
| | - Ulrich Lenze
- Department of Orthopaedic Surgery, Klinikum Rechts der Isar, Technical University Munich (TUM), Munich, Germany
| | - Claudio Glowalla
- Department of Orthopaedic Surgery, Klinikum Rechts der Isar, Technical University Munich (TUM), Munich, Germany
- BG Unfallklinik Murnau, Murnau am Staffelsee, Germany
| | - Philipp Minzlaff
- Krankenhaus Agatharied, Department of Orthopaedic Surgery and Traumatology, Hausham, Germany
| | - Rainer Burgkart
- Department of Orthopaedic Surgery, Klinikum Rechts der Isar, Technical University Munich (TUM), Munich, Germany
| | - Peter Michael Prodinger
- Krankenhaus Agatharied, Department of Orthopaedic Surgery and Traumatology, Hausham, Germany
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Suh K, Cole BJ, Gomoll A, Lee SM, Choi H, Ha CW, Lim HC, Kim MK, Ha GY, Suh DC. Cost Effectiveness of Allogeneic Umbilical Cord Blood-Derived Mesenchymal Stem Cells in Patients with Knee Osteoarthritis. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2023; 21:141-152. [PMID: 36136263 PMCID: PMC9834379 DOI: 10.1007/s40258-022-00762-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 05/10/2023]
Abstract
OBJECTIVES The aim of this study was to assess the cost effectiveness of allogeneic umbilical cord blood-derived mesenchymal stem cells with sodium hyaluronate (hUCB-MSC) compared with microfracture in patients with knee cartilage defects caused by osteoarthritis (OA) in South Korea. METHODS A partitioned survival model approach was taken consisting of five mutually exclusive health states: excellent, good, fair, poor, and death over a 20-year time horizon. Utility values were obtained from a randomized clinical trial. Cost data were extracted from a database provided by the Health Insurance Review & Assessment Service, and the utilization of healthcare services was estimated from an expert panel of orthopedic surgeons using a structured questionnaire. The incremental cost-effectiveness ratio (ICER) in terms of quality-adjusted life-years (QALY) was calculated. Deterministic and probabilistic sensitivity analyses were performed. RESULTS In the base case, the incremental costs of US$14,410 for hUCB-MSC therapy along with its associated QALY gain of 0.857 resulted in an ICER of US$16,812 (₩18,790,773) per QALY (95% confidence interval [CI] US$13,408-US$20,828) when compared with microfracture treatment from a healthcare payer perspective. From a societal perspective, the ICER was US$268 (₩299,255) per QALY (95% CI -US$2915 to US$3784). When using a willingness-to-pay threshold of US$22,367/QALY, the probability of hUCB being cost effectiveness compared with microfracture was 99% from the healthcare payer perspective and 100% from the societal perspective. CONCLUSIONS The study demonstrated that hUCB-MSC therapy was cost effective compared with microfracture when treating patients with knee OA. These findings should inform health policy decision makers about considerations for cost-effective therapy for treating knee OA to ultimately enhance population health.
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Affiliation(s)
- Kangho Suh
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, 15217, USA.
| | - Brian J Cole
- Department of Orthopedic Surgery, Rush Oak Park Hospital, Rush Medical College, Chicago, IL, USA
| | - Andreas Gomoll
- Department of Orthopedic Surgery, Hospital for Special Surgery, Weill-Cornell Medical College, New York, NY, USA
| | - Seung-Mi Lee
- Daegu Catholic University College of Pharmacy, Gyeongsan-si, Gyeongbukdo, South Korea
| | - Hangseok Choi
- Chung-Ang University College of Pharmacy, Seoul, South Korea
| | - Chul-Won Ha
- Sungkwunkwan University Samsung Seoul Hospital, Seoul, South Korea
| | | | - Myung Ku Kim
- Inha University School of Medicine, Incheon, South Korea
| | - Gwi-Yeom Ha
- Chung-Ang University College of Pharmacy, Seoul, South Korea
| | - Dong-Churl Suh
- Chung-Ang University College of Pharmacy, Seoul, South Korea
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9
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Dhillon J, Fasulo SM, Kraeutler MJ, Belk JW, McCulloch PC, Scillia AJ. The Most Common Rehabilitation Protocol After Matrix-Assisted Autologous Chondrocyte Implantation Is Immediate Partial Weight-Bearing and Continuous Passive Motion. Arthrosc Sports Med Rehabil 2022; 4:e2115-e2123. [PMID: 36579035 PMCID: PMC9791827 DOI: 10.1016/j.asmr.2022.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 09/06/2022] [Indexed: 11/19/2022] Open
Abstract
Purpose To perform a systematic review of postoperative rehabilitation protocols for third-generation autologous chondrocyte implantation (ACI) of the knee joint. Methods A systematic review was performed by searching PubMed, Cochrane Library, and EMBASE to locate randomized controlled trials that described a rehabilitation protocol following third-generation ACI of the knee joint. The search terms used were: "autologous" AND "chondrocyte" AND "randomized". Data extracted from each study included various components of postoperative rehabilitation, such as initial weight-bearing (WB) status and time to full WB, the use of continuous passive motion (CPM), the time to return to sports, and physical therapy (PT) modalities used and the timing of their initiation. Results Twenty-five studies (22 Level I, 3 Level II) met inclusion criteria, including a total of 905 patients undergoing treatment with ACI. The average patient age ranged from 29.1 to 54.8 years, and the mean follow-up time ranged from 3 months to 10.0 years. The average lesion size ranged from 1.9 to 5.8 cm2, and the most common lesion location was the medial femoral condyle (n = 494). Twenty studies allowed partial WB postoperatively with all studies permitting full WB within 12 weeks. Twenty studies used CPM in their rehabilitation protocols and initiated its use within 24 hours postoperatively. Among 10 studies that reported time to return to sport, 9 (90%) allowed return by 12 months. While most protocols used strength training as well as the inclusion of proprioceptive training, there was disagreement on the timing and inclusion of specific PT modalities used during the rehabilitation process. Conclusions Based on the included studies, most rehabilitation protocols for third-generation ACI initiate CPM within 24 hours postoperatively and allow partial WB immediately following surgery with progression to full WB within 12 weeks. There is variation of the PT modalities used as well as the timing of their initiation. Level of Evidence Level II, systematic review of Level I-II studies.
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Affiliation(s)
- Jaydeep Dhillon
- Rocky Vista University College of Osteopathic Medicine, Parker, Colorado U.S.A
| | - Sydney M. Fasulo
- Department of Orthopaedic Surgery, St. Joseph’s University Medical Center, Paterson, New Jersey U.S.A
| | - Matthew J. Kraeutler
- Department of Orthopedics & Sports Medicine, Houston Methodist Hospital, Houston, Texas U.S.A.,Address correspondence to Matthew J. Kraeutler, M.D., Department of Orthopedics & Sports Medicine, Houston Methodist Hospital, 6445 Main St., Suite 2300, Houston, TX 77030.
| | - John W. Belk
- University of Colorado School of Medicine, Aurora, Colorado U.S.A
| | - Patrick C. McCulloch
- Department of Orthopedics & Sports Medicine, Houston Methodist Hospital, Houston, Texas U.S.A
| | - Anthony J. Scillia
- Department of Orthopaedic Surgery, St. Joseph’s University Medical Center, Paterson, New Jersey U.S.A.,Academy Orthopaedics, Wayne, New Jersey, U.S.A
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10
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Wang L, Li H, Cao Y, Song C, Chen Q, Hao J, Zhang W, Tian K. Four cases report: Treatment of knee joint cartilage defects using autologous chondrocyte patch implantation. Front Surg 2022; 9:1015091. [PMID: 36425890 PMCID: PMC9679023 DOI: 10.3389/fsurg.2022.1015091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 10/18/2022] [Indexed: 08/30/2023] Open
Abstract
INTRODUCTION Autologous chondrocyte implantation (ACI) is a crucial method for the treatment of defects in articular cartilage. However, the extant methods for the preparation of autologous chondrocyte patch are relatively complicated and money-consuming. Therefore, an efficient, reliable, easy-to-follow, and cost-effective technique is needed to overcome constraints. This case report aims to introduce an autologous chondrocyte patch fabrication technique to repair knee joint cartilage defects and report our typical cases with a 2-year follow-up. CASE PRESENTATION We described four cases in which patients complained of knee joint pain. According to radiological examination, the patients were diagnosed as knee joint cartilage defect. Arthroscopy and autologous chondrocyte patch implantation were performed as well as a 2-year follow up of patients. The autologous chondrocyte patch for knee joint cartilage repair was fabricated using a "sandwich" technique. The preoperative and postoperative knee function was evaluated by four subjective evaluation systems. MRI was performed for all patients to achieve more intuitionistic observation of the postoperative radiological changes of defect sites. The quality of repaired tissue was evaluated by Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART). Postoperative follow-up showed improvement in clinical and MOCART scores for all patients. However, one patient complained of knee joint pain after walking for a long time or recreational activities from 12- to 18-month postoperatively. The location of pain for this patient was not in accordance with the location of cartilage defect. CONCLUSION The patients undergoing autologous chondrocyte patch implantation demonstrated clinical improvement and good quality of repaired tissue postoperatively. The procedure is an efficient and cost-effective treatment for knee joint cartilage defect in this report. In addition, patients with osteoarthritis carry the risk of a poor outcome after the procedure, and whether to have a procedure should be considered carefully.
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Affiliation(s)
- Le Wang
- Department of Joint and Sports Medicine, First Affiliated Hospital, Dalian Medical University, Dalian, China
| | - Han Li
- Department of Joint and Sports Medicine, First Affiliated Hospital, Dalian Medical University, Dalian, China
| | - Yiguo Cao
- Department of Joint and Sports Medicine, First Affiliated Hospital, Dalian Medical University, Dalian, China
| | - Cheng Song
- Department of Nuclear Medicine, First Affiliated Hospital, Dalian Medical University, Dalian, China
| | - Qi Chen
- Department of Joint and Sports Medicine, First Affiliated Hospital, Dalian Medical University, Dalian, China
| | - Jun Hao
- Department of Joint and Sports Medicine, First Affiliated Hospital, Dalian Medical University, Dalian, China
| | - Weiguo Zhang
- Department of Joint and Sports Medicine, First Affiliated Hospital, Dalian Medical University, Dalian, China
| | - Kang Tian
- Department of Joint and Sports Medicine, First Affiliated Hospital, Dalian Medical University, Dalian, China
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Dhillon J, Decilveo AP, Kraeutler MJ, Belk JW, McCulloch PC, Scillia AJ. Third-Generation Autologous Chondrocyte Implantation (Cells Cultured Within Collagen Membrane) Is Superior to Microfracture for Focal Chondral Defects of the Knee Joint: Systematic Review and Meta-analysis. Arthroscopy 2022; 38:2579-2586. [PMID: 35283221 DOI: 10.1016/j.arthro.2022.02.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Revised: 02/04/2022] [Accepted: 02/06/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE To systematically review randomized controlled trials to compare clinical outcomes of microfracture (MFx) versus third-generation autologous chondrocyte implantation (ACI) for the treatment of focal chondral defects (FCDs) of the knee joint. METHODS A systematic review was performed by searching PubMed, Cochrane Library, and EMBASE to locate randomized controlled trials comparing minimum 2-year clinical outcomes of patients undergoing MFx versus third-generation ACI for FCDs of the knee joint. The search terms used were: "knee" AND "microfracture" AND "autologous chondrocyte" AND "randomized." Patients were evaluated based on treatment failure rates, magnetic resonance imaging, International Cartilage Repair Society scores, and patient-reported outcome scores (Lysholm, Tegner, Knee Injury and Osteoarthritis Outcome Score, modified Cincinnati Knee Rating System, 12-item Short Form Health Survey Physical and Mental, and the EuroQol 5 Dimensions Visual Analog Scale score). RESULTS Six studies (5 Level I, 1 Level II) met inclusion criteria, including a total of 238 patients undergoing MFx and 274 undergoing ACI. Two studies had an overlapping cohort of patients and therefore the study with longer follow-up was used in all analyses. The average follow-up among patients ranged from 2.0 years to 6.0 years. Average lesion size ranged from 1.8 cm2 to 5.0 cm2. Treatment failure ranged from 0% to 1.8% in the ACI group and 2.5% to 8.3% in the MFx group. In 4 studies, ACI patients demonstrated significantly greater improvement in multiple Knee Injury and Osteoarthritis Outcome Score subscores compared with MFx. In 2 studies, patients who received ACI demonstrated significantly greater improvement in the Tegner score compared to MFx, and 1 study showed significantly greater improvement in the Lysholm and ICRS scores for ACI compared with MFx. CONCLUSIONS At short-term follow-up, third-generation ACI demonstrates a lower failure rate and greater improvement in patient-reported outcomes compared with MFx for FCDs of the knee joint. LEVEL OF EVIDENCE II, systematic review of Levels I-II studies.
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Affiliation(s)
- Jaydeep Dhillon
- College of Osteopathic Medicine, Rocky Vista University, Parker, Colorado
| | - Alex P Decilveo
- Department of Orthopaedic Surgery, St. Joseph's University Medical Center, Paterson, New Jersey
| | - Matthew J Kraeutler
- Department of Orthopaedic Surgery, St. Joseph's University Medical Center, Paterson, New Jersey.
| | - J Wilson Belk
- University of Colorado School of Medicine, Aurora, Colorado
| | | | - Anthony J Scillia
- Department of Orthopaedic Surgery, St. Joseph's University Medical Center, Paterson, New Jersey; Academy Orthopaedics, Wayne, New Jersey, U.S.A
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12
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Evuarherhe A, Condron NB, Knapik DM, Haunschild ED, Gilat R, Huddleston HP, Kaiser JT, Parvaresh KC, Wagner KR, Chubinskaya S, Yanke AB, Cole BJ. Effect of Mechanical Mincing on Minimally Manipulated Articular Cartilage for Surgical Transplantation. Am J Sports Med 2022; 50:2515-2525. [PMID: 35736385 DOI: 10.1177/03635465221101004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Point-of-care treatment options for medium to large symptomatic articular cartilage defects are limited. Minced cartilage implantation is an encouraging single-stage option, providing fresh viable autologous tissue with minimal morbidity and cost. PURPOSE To determine the histological properties of mechanically minced versus minimally manipulated articular cartilage. STUDY DESIGN Controlled laboratory study. METHODS Remnant articular cartilage was collected from fresh femoral condylar allografts. Cartilage samples were divided into 4 groups: cartilage explants with or without fibrin glue and mechanically minced cartilage with or without fibrin glue. Samples were cultured for 42 days. Chondrocyte viability was assessed using live/dead assay. Cellular migration and outgrowth were monitored using bright-field microscopy. Extracellular matrix deposition was assessed via histological staining. Proteoglycan content and synthesis were assessed using dimethylmethylene blue assay and radiolabeled 35S-sulfate, respectively. Type II collagen (COL2A1) gene expression was analyzed via polymerase chain reaction. RESULTS The mean viability of minced cartilage particles (34% ± 14%) was not significantly reduced compared with baseline (46% ± 13%) on day 0 (P = .90). After culture, no significant difference in the percentage of live cells was appreciated between mechanically minced (58% ± 23%) and explant (73% ± 14%) cartilage in the presence of fibrin glue (P = .52). The addition of fibrin glue did not significantly affect the viability of cartilage samples. The qualitative assessment revealed comparable cellular migration and outgrowth between groups. Proteoglycan synthesis was not significantly different between groups. Histological analysis findings were positive for COL2A1 in all groups, and matrix formation was appreciated in all groups. COL2A1 expression in minced cartilage (1.72 ± 1.88) was significantly higher than in explant cartilage (0.15 ± 0.07) in the presence of fibrin glue (P = .01). CONCLUSION Mechanically minced articular cartilage remained viable after 42 days of culture in vitro and was comparable with cartilage explants with regard to cellular migration, outgrowth, and extracellular matrix synthesis. CLINICAL RELEVANCE Mechanically minced articular cartilage is an encouraging intervention for the treatment of symptomatic cartilage defects. Further translational work is warranted to determine the viability of minced cartilage implantation as a single-stage therapeutic intervention in vivo.
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Affiliation(s)
- Aghogho Evuarherhe
- Midwest Orthopaedics at Rush University Medical Center, Chicago, Illinois, USA
| | - Nolan B Condron
- Midwest Orthopaedics at Rush University Medical Center, Chicago, Illinois, USA
| | - Derrick M Knapik
- Midwest Orthopaedics at Rush University Medical Center, Chicago, Illinois, USA
| | - Eric D Haunschild
- Midwest Orthopaedics at Rush University Medical Center, Chicago, Illinois, USA
| | - Ron Gilat
- Midwest Orthopaedics at Rush University Medical Center, Chicago, Illinois, USA
| | - Hailey P Huddleston
- Midwest Orthopaedics at Rush University Medical Center, Chicago, Illinois, USA
| | - Joshua T Kaiser
- Midwest Orthopaedics at Rush University Medical Center, Chicago, Illinois, USA
| | - Kevin C Parvaresh
- Midwest Orthopaedics at Rush University Medical Center, Chicago, Illinois, USA
| | - Kyle R Wagner
- Midwest Orthopaedics at Rush University Medical Center, Chicago, Illinois, USA
| | - Susan Chubinskaya
- Midwest Orthopaedics at Rush University Medical Center, Chicago, Illinois, USA
| | - Adam B Yanke
- Midwest Orthopaedics at Rush University Medical Center, Chicago, Illinois, USA
| | - Brian J Cole
- Midwest Orthopaedics at Rush University Medical Center, Chicago, Illinois, USA
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13
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Franceschini M, Boffa A, Andriolo L, Di Martino A, Zaffagnini S, Filardo G. The 50 most-cited clinical articles in cartilage surgery research: a bibliometric analysis. Knee Surg Sports Traumatol Arthrosc 2022; 30:1901-1914. [PMID: 35034148 DOI: 10.1007/s00167-021-06834-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 12/02/2021] [Indexed: 12/31/2022]
Abstract
PURPOSE Articular cartilage lesions remain a challenge for orthopedic surgeons. The identification of the most important articles can help identifying the most influential techniques of the past, the current prevalent focus, and emerging strategies. The aim of this study was to identify milestones and trends in cartilage research. METHODS This study is a bibliometric analysis based on published articles. All citation count data included in the "Scopus database" were used to identify eligible studies up to December 2020. The 50 most-cited articles on cartilage surgery were ranked based on the citation count and analyzed regarding citation density and quality (Coleman score and RoB 2.0 tool). A further search was performed to identify the most promising clinical studies among the latest publications on cartilage surgery. RESULTS Different kinds of cartilage treatments were investigated in the 50 most-cited clinical articles. Regenerative techniques with chondrocytes were the most reported with a total of 23 articles, followed by microfracture technique in 17 articles and mosaicplasty or osteochondral autograft transplantation (OAT) in 11. Forty-five articles focused on the knee. A higher citation density was found in the most recent articles (p = 0.004). The study of the most promising landmarks of the most recent articles showed new cell-free or tissue engineering-based procedures and an overall increasing quality of the published studies. CONCLUSION This bibliometric analysis documented an increasing interest in cartilage surgery, with efforts toward high-quality studies. Over the years, the focus switched from reconstructive toward regenerative techniques, with emerging options including cell-free and tissue-engineering strategies to restore the cartilage surface. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Marco Franceschini
- Clinica Ortopedica e Traumatologica 2, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Angelo Boffa
- Clinica Ortopedica e Traumatologica 2, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Luca Andriolo
- Clinica Ortopedica e Traumatologica 2, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy.
| | - Alessandro Di Martino
- Clinica Ortopedica e Traumatologica 2, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Stefano Zaffagnini
- Clinica Ortopedica e Traumatologica 2, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Giuseppe Filardo
- Applied and Translational Research (ATR) Center, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy.,Service of Orthopaedics and Traumatology, Department of Surgery, EOC, Lugano, Switzerland.,Facoltà Di Scienze Biomediche, Università della Svizzera Italiana, Lugano, Switzerland
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14
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Dávila Castrodad IM, Kraeutler MJ, Fasulo SM, Festa A, McInerney VK, Scillia AJ. Improved Outcomes with Arthroscopic Bone Marrow Aspirate Concentrate and Cartilage-Derived Matrix Implantation versus Chondroplasty for the Treatment of Focal Chondral Defects of the Knee Joint: A Retrospective Case Series. Arthrosc Sports Med Rehabil 2022; 4:e411-e416. [PMID: 35494291 PMCID: PMC9042738 DOI: 10.1016/j.asmr.2021.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 10/26/2021] [Indexed: 11/21/2022] Open
Abstract
Purpose To compare the outcomes of patients undergoing treatment of focal chondral defects (FCDs) of the knee joint with chondroplasty versus bone marrow aspirate concentrate (BMAC) and cartilage-derived matrix (CDM) implantation. Methods A retrospective chart review was performed for patients diagnosed with Outerbridge grade 3-4 FCDs. Patients were included if they were treated arthroscopically with BMAC/CDM implantation or chondroplasty alone between March 2016 and May 2019 and had more than 1-year follow-up. Postoperative outcomes included the visual analog scale (VAS) for pain; University of California, Los Angeles (UCLA) activity scores; Knee Outcome Survey (KOS) Activities of Daily Living (ADL) and Sports subscores; postoperative corticosteroid or hyaluronic acid injections; subsequent surgeries; and conversion to total knee arthroplasty. Results A total of 98 patients were identified with a mean follow-up in BMAC/CDM of 24 months (range 13-41 months) and in chondroplasty of 44 months (range 34-55 months). A subanalysis was performed to control for significant differences in age, which yielded 39 patients, ages 40-60 years. Within the subanalysis group, mean VAS scores were significantly lower in the BMAC/CDM group (1.7 vs 4.4; P = .005) and mean UCLA scores were significantly greater (7.1 vs 5.0; P = .002). Mean improvement in VAS and UCLA scores were similar between the BMAC/CDM and chondroplasty groups (–3.7 vs –1.3; P = .71, 1.9 vs 0.1; P = .14, respectively). Mean KOS ADL and Sports subscores were significantly greater among patients in the BMAC/CDM group (87% vs 55%; P = .001, 71% vs 41%; P = .002, respectively). There were no differences in postoperative injections, subsequent surgeries, or conversion to total knee arthroplasty between the BMAC/CDM and chondroplasty groups. Conclusions Patients with grade 3-4 FCDs of the knee had improved postoperative outcomes when treated with BMAC/CDM implantation versus chondroplasty alone, as evidenced by a significant improvement in VAS and UCLA scores and significantly greater postoperative KOS ADL, and KOS Sport subscores. Level of Evidence IV, therapeutic case series.
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15
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Cogan CJ, Friedman J, You J, Zhang AL, Feeley BT, Ma CB, Lansdown DA. Prior Bone Marrow Stimulation Surgery Influences Outcomes After Cell-Based Cartilage Restoration: A Systematic Review and Meta-analysis. Orthop J Sports Med 2022; 9:23259671211035384. [PMID: 35146031 PMCID: PMC8822078 DOI: 10.1177/23259671211035384] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 04/30/2021] [Indexed: 01/06/2023] Open
Abstract
Background: Cell-based cartilage restoration with autologous chondrocyte implantation (ACI) is a safe and effective treatment for symptomatic cartilage lesions. Many patients undergoing ACI have a history of prior surgery, including bone marrow stimulation (BMS). There is mounting evidence that a history of prior BMS may impede healing of the ACI graft. Purpose/Hypothesis: The purpose of this study was to compare the failure rates of primary ACI with ACI after prior BMS. We hypothesized that ACI after BMS would have a significantly higher failure rate (defined as reoperation, conversion to arthroplasty, and/or imaging-based failure) compared with primary ACI. Study Design: Systematic review; Level of evidence, 4. Methods: A literature search was performed by use of PubMed and Embase databases for relevant articles published through October 2, 2020, to identify studies evaluating outcomes and failures rates of ACI after prior BMS in the knee. Results: Included were 11 studies comprising 1479 ACI procedures. The mean age at surgery ranged from 18.3 to 39.1 years, and the mean follow-up ranged from 3 to 20.6 years. All studies reported failure rates. The overall failure rate was significantly higher in the patients who underwent ACI after BMS, at 26.4% compared with 14.8% in the ACI group (P < .001). Meta-analysis demonstrated an increased risk of failure in patients with a history of prior BMS (log odds ratio = –0.90 [95% confidence interval, –1.38 to –0.42]). Conclusion: This systematic review demonstrated that failure rates were significantly higher for patients treated with ACI after BMS relative to patients undergoing ACI without prior BMS. This finding has important implications when considering the use of BMS for defects that are amenable to cell-based restoration and when determining treatment options after failed BMS. Registration: PROSPERO (CRD42020180387).
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Affiliation(s)
- Charles J Cogan
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, USA
| | - James Friedman
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Jae You
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Alan L Zhang
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Brian T Feeley
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, USA
| | - C Benjamin Ma
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Drew A Lansdown
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, USA
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16
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The Induced Pluripotent Stem Cells in Articular Cartilage Regeneration and Disease Modelling: Are We Ready for Their Clinical Use? Cells 2022; 11:cells11030529. [PMID: 35159338 PMCID: PMC8834349 DOI: 10.3390/cells11030529] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 01/29/2022] [Accepted: 02/01/2022] [Indexed: 02/01/2023] Open
Abstract
The development of induced pluripotent stem cells has brought unlimited possibilities to the field of regenerative medicine. This could be ideal for treating osteoarthritis and other skeletal diseases, because the current procedures tend to be short-term solutions. The usage of induced pluripotent stem cells in the cell-based regeneration of cartilage damages could replace or improve on the current techniques. The patient’s specific non-invasive collection of tissue for reprogramming purposes could also create a platform for drug screening and disease modelling for an overview of distinct skeletal abnormalities. In this review, we seek to summarise the latest achievements in the chondrogenic differentiation of pluripotent stem cells for regenerative purposes and disease modelling.
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17
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Anders S, Grifka J. [Surgical treatment of focal cartilage defects in the knee : Indications, techniques, modifications and results]. DER ORTHOPADE 2022; 51:151-164. [PMID: 35076725 DOI: 10.1007/s00132-022-04220-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The treatment strategies for focal cartilage damage in the knee are multifarious. For established procedures, such as microfracturing (MFX), autologous matrix-induced chondrogenesis (AMIC), osteochondral transplantation (OCT) and autologous chondrocyte transplantation (ACT), well-founded, partly comparative long-term studies and overlapping size-dependent differential indications are available. Innovative cell sources, the utilization of biological scaffolds as well as biologic agents and various combinations, have recently become the focus of scientific attention; however, high regulatory demands are restricting their use in Germany. The success of every procedure is dependent on the appropriate indications, the treatment of comorbidities, such as axis deviations or ligamentous instability, the surgeon's experience and an adequate follow-up treatment.
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Affiliation(s)
- S Anders
- Orthopädische Klinik für die Universität Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Deutschland.
| | - J Grifka
- Orthopädische Klinik für die Universität Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Deutschland
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18
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Hinckel BB, Thomas D, Vellios EE, Hancock KJ, Calcei JG, Sherman SL, Eliasberg CD, Fernandes TL, Farr J, Lattermann C, Gomoll AH. Algorithm for Treatment of Focal Cartilage Defects of the Knee: Classic and New Procedures. Cartilage 2021; 13:473S-495S. [PMID: 33745340 PMCID: PMC8808924 DOI: 10.1177/1947603521993219] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To create a treatment algorithm for focal grade 3 or 4 cartilage defects of the knee using both classic and novel cartilage restoration techniques. DESIGN A comprehensive review of the literature was performed highlighting classic as well as novel cartilage restoration techniques supported by clinical and/or basic science research and currently being employed by orthopedic surgeons. RESULTS There is a high level of evidence to support the treatment of small to medium size lesions (<2-4 cm2) without subchondral bone involvement with traditional techniques such as marrow stimulation, osteochondral autograft transplant (OAT), or osteochondral allograft transplant (OCA). Newer techniques such as autologous matrix-induced chondrogenesis and bone marrow aspirate concentrate implantation have also been shown to be effective in select studies. If subchondral bone loss is present OAT or OCA should be performed. For large lesions (>4 cm2), OCA or matrix autologous chondrocyte implantation (MACI) may be performed. OCA is preferred over MACI in the setting of subchondral bone involvement while cell-based modalities such as MACI or particulated juvenile allograft cartilage are preferred in the patellofemoral joint. CONCLUSIONS Numerous techniques exist for the orthopedic surgeon treating focal cartilage defects of the knee. Treatment strategies should be based on lesion size, lesion location, subchondral bone involvement, and the level of evidence supporting each technique in the literature.
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Affiliation(s)
- Betina B. Hinckel
- Department of Orthopedic Surgery,
William Beaumont Hospital, Taylor, MI, USA
| | - Dimitri Thomas
- UNC Orthopedics and Sports Medicine at
Lenoir, Kinston, NC, USA
| | - Evan E. Vellios
- Sports Medicine and Shoulder Surgeon
Southern California Orthopedic Institute (SCOI), Van Nuys, CA, USA
| | | | - Jacob G. Calcei
- Department of Orthopaedic Surgery,
University Hospitals of Cleveland, Case Western Reserve University, Cleveland, OH,
USA
| | - Seth L. Sherman
- Division of Sports Medicine, Department
of Orthopedic Surgery, School of Medicine, Stanford University, Palo Alto, CA,
USA
| | | | - Tiago L. Fernandes
- University of São Paulo, Institute of
Orthopedics and Traumatology, Sports Medicine–FIFA, São Paulo, SP, Brazil
| | - Jack Farr
- OrthoIndy Knee Preservation and
Cartilage Restoration Center, School of Medicine, Indiana University, Indianapolis,
IN, USA
| | - Christian Lattermann
- Division of Sports Medicine,
Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston, MA,
USA
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Turhan AU, Açıl S, Gül O, Öner K, Okutan AE, Ayas MS. Treatment of knee osteochondritis dissecans with autologous tendon transplantation: Clinical and radiological results. World J Orthop 2021; 12:867-876. [PMID: 34888147 PMCID: PMC8613687 DOI: 10.5312/wjo.v12.i11.867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 07/28/2021] [Accepted: 09/17/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Defect treatment with tendon autograft in osteochondral lesions has been published in the literature with an experimental study in dogs. To demonstrate that it is possible to treat knee osteochondral lesions with the technique of autologous tendon transplantation.
AIM To evaluate the clinical and radiological results of patients with knee osteochondral lesions who were treated with autologous tendon transplantation.
METHODS Twenty patients (22 knees) with osteochondritis dissecans (OCD) lesions involving the knee were treated with autologous tendon transplantation between 2005-2018. All lesions were International Cartilage Repair Society grade IV. All patients were evaluated clinically at final follow-up with knee injury and osteoarthritis outcome score (KOOS); and radiologically with magnetic resonance observation and cartilage repair tissue (MOCART) and Kellgren-Lawrence (KL) classification.
RESULTS A total of 20 patients (22 knees) with a mean age of 25.5± 6.8 years were included. The average defect size was 4.2 ± 2.1 cm2, and the average defect depth was 0.9 ± 0.4 cm. Total KOOS score was preoperatively 29.4 ± 5.5 and was later found to be 81.5 ± 5.9 after an average of 68.7 ± 37.7 mo follow-up. The mean MOCART score was 56.2 ± 10.7. Preoperatively, all of the patients had KL grades of 0–1; during the follow-up period, 80% of the patients showed no radiological progress of osteoarthritis. Patients with less than 4 cm2 lesion had statistically significantly better overall KOOS than patients whose more than 4 cm2 lesion, particularly in sport and quality of life subscales.
CONCLUSION The autologous tendon transplantation is a single-step, safe, simple, cost-effective method for the treatment of knee OCD with satisfactory clinical and radiological outcomes, particularly in patients with less than 4 cm2 lesion.
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Affiliation(s)
- Ahmet Uğur Turhan
- Department of Orthopedics and Traumatology, Karadeniz Technical University Faculty of Medicine, Trabzon 61080, Turkey
| | - Sezgin Açıl
- Department of Orthopedics and Traumatology, Tirebolu State Hospital, Giresun 28100, Turkey
| | - Orkun Gül
- Department of Orthopedics and Traumatology, Medical Park Trabzon Hospital, Trabzon 61080, Turkey
| | - Kerim Öner
- Department of Orthopedics and Traumatology, Karadeniz Technical University Faculty of Medicine, Trabzon 61080, Turkey
| | - Ahmet Emin Okutan
- Department of Orthopedics and Traumatology, Samsun Training and Research Hospital, Samsun 55100, Turkey
| | - Muhammet Salih Ayas
- Department of Orthopedics and Traumatology, Erzurum Regional Training and Research Hospital, Erzurum 25070, Turkey
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Anders S, Grifka J. [Surgical treatment of focal cartilage defects in the knee : Indications, techniques, modifications and results]. Z Rheumatol 2021; 80:855-867. [PMID: 34581873 DOI: 10.1007/s00393-021-01084-2] [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] [Accepted: 08/19/2021] [Indexed: 11/27/2022]
Abstract
The treatment strategies for focal cartilage damage in the knee are multifarious. For established procedures, such as microfracturing (MFX), autologous matrix-induced chondrogenesis (AMIC), osteochondral transplantation (OCT) and autologous chondrocyte transplantation (ACT), well-founded, partly comparative long-term studies and overlapping size-dependent differential indications are available. Innovative cell sources, the utilization of biological scaffolds as well as biologic agents and various combinations, have recently become the focus of scientific attention; however, high regulatory demands are restricting their use in Germany. The success of every procedure is dependent on the appropriate indications, the treatment of comorbidities, such as axis deviations or ligamentous instability, the surgeon's experience and an adequate follow-up treatment.
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Affiliation(s)
- S Anders
- Orthopädische Klinik für die Universität Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Deutschland.
| | - J Grifka
- Orthopädische Klinik für die Universität Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Deutschland
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Schuette HB, Kraeutler MJ, Schrock JB, McCarty EC. Primary Autologous Chondrocyte Implantation of the Knee Versus Autologous Chondrocyte Implantation After Failed Marrow Stimulation: A Systematic Review. Am J Sports Med 2021; 49:2536-2541. [PMID: 33156690 DOI: 10.1177/0363546520968284] [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: 01/31/2023]
Abstract
BACKGROUND Marrow stimulation (MST) surgery, which includes microfracture, subchondral drilling, and abrasion arthroplasty, and autologous chondrocyte implantation (ACI) are 2 surgical options to treat articular cartilage lesions in the knee joint. Recent studies have suggested worse outcomes when ACI is used after failed MST. PURPOSE To investigate the failure rates and clinical outcomes of primary knee ACI versus ACI after failed MST surgery (secondary ACI). STUDY DESIGN Systematic review. METHODS A systematic review was performed by searching the PubMed, Embase, and Cochrane Library databases to identify studies evaluating clinical outcomes of patients undergoing primary versus secondary ACI of the knee joint. The search terms used were as follows: "knee" AND ("autologous chondrocyte implantation" OR "osteochondral allograft") AND (microfracture OR "marrow stimulation"). Patients undergoing primary ACI (group A) were compared with those undergoing secondary ACI (group B) based on treatment failure rates and patient-reported outcomes (PROs). RESULTS Seven studies (2 level 2 studies, 5 level 3 studies) were identified and met inclusion criteria, including a total of 1335 patients (group A: n = 838; group B: n = 497). The average patient age in all studies was 34.2 years, and the average lesion size was 5.43 cm2. Treatment failure occurred in 14.0% of patients in group A and 27.6% of patients in group B (P < .00001). Four studies reported PROs. One study found significantly better Subjective International Knee Documentation Committee scores (P = .011), visual analog scale (VAS) pain scores (P = .028), and VAS function scores (P = .005) in group A. Another study found significantly better Knee injury and Osteoarthritis Outcome Score (KOOS) Pain scores (P = .034), KOOS Activities of Daily Living scores (P = .024), VAS pain scores (P = .014), and VAS function scores (P = .032) in group A. Two studies found no significant difference in PROs between groups A and B (P < .05). CONCLUSION Patient-reported improvement can be expected in patients undergoing primary or secondary ACI of the knee joint. Patients undergoing secondary ACI have a significantly higher risk of treatment failure and may have worse subjective outcomes compared with patients undergoing primary ACI.
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Affiliation(s)
- Hayden B Schuette
- Department of Orthopedics, OhioHealth/Doctors Hospital, Columbus, Ohio, USA
| | - Matthew J Kraeutler
- Department of Orthopaedic Surgery, St. Joseph's University Medical Center, Paterson, New Jersey, USA
| | - John B Schrock
- Marian University College of Osteopathic Medicine, Indianapolis, Indiana, USA
| | - Eric C McCarty
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, USA
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Nanofibrous hyaluronic acid scaffolds delivering TGF-β3 and SDF-1α for articular cartilage repair in a large animal model. Acta Biomater 2021; 126:170-182. [PMID: 33753316 DOI: 10.1016/j.actbio.2021.03.013] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 03/03/2021] [Accepted: 03/04/2021] [Indexed: 02/07/2023]
Abstract
Focal cartilage injuries have poor intrinsic healing potential and often progress to osteoarthritis, a costly disease affecting almost a third of adults in the United States. To treat these patients, cartilage repair therapies often use cell-seeded scaffolds, which are limited by donor site morbidity, high costs, and poor efficacy. To address these limitations, we developed an electrospun cell-free fibrous hyaluronic acid (HA) scaffold that delivers factors specifically designed to enhance cartilage repair: Stromal Cell-Derived Factor-1α (SDF-1α; SDF) to increase the recruitment and infiltration of mesenchymal stem cells (MSCs) and Transforming Growth Factor-β3 (TGF-β3; TGF) to enhance cartilage tissue formation. Scaffolds were characterized in vitro and then deployed in a large animal model of full-thickness cartilage defect repair. The bioactivity of both factors was verified in vitro, with both SDF and TGF increasing cell migration, and TGF increasing matrix formation by MSCs. In vivo, however, scaffolds releasing SDF resulted in an inferior cartilage healing response (lower mechanics, lower ICRS II histology score) compared to scaffolds releasing TGF alone. These results highlight the importance of translation into large animal models to appropriately screen scaffolds and therapies, and will guide investigators towards alternative growth factor combinations. STATEMENT OF SIGNIFICANCE: This study addresses an area of orthopaedic medicine in which treatment options are limited and new biomaterials stand to improve patient outcomes. Those suffering from articular cartilage injuries are often destined to have early onset osteoarthritis. We have created a cell-free nanofibrous hyaluronic acid (HA) scaffold that delivers factors specifically designed to enhance cartilage repair: Stromal Cell-Derived Factor-1α (SDF-1α; SDF) to increase the recruitment and infiltration of mesenchymal stem cells (MSCs) and Transforming Growth Factor-β3 (TGF-β3; TGF) to enhance cartilage tissue formation. To our knowledge, this study is the first to evaluate such a bioactive scaffold in a large animal model and demonstrates the capacity for dual growth factor release.
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Mayo BC, Ravella KC, Onsen L, Bobko A, Schwarzman GR, Steffes MJ, Miller A, Hutchinson MR. Is There an Association Between Authors' Conflicts of Interest and Outcomes in Clinical Studies Involving Autologous Chondrocyte Implantation? Orthop J Sports Med 2021; 9:2325967120979988. [PMID: 33623797 PMCID: PMC7876765 DOI: 10.1177/2325967120979988] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 08/10/2020] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Autologous chondrocyte implantation (ACI) is an increasingly popular technique for the treatment of articular cartilage defects. Because several companies have financial interests in ACI, it is important to consider possible conflicts of interest when evaluating studies reporting outcomes of ACI. PURPOSE To determine whether there is an association between authors' financial conflicts of interest and the outcomes of ACI studies. STUDY DESIGN Cross-sectional study. METHODS A search of PubMed and MEDLINE databases for "autologous chondrocyte implantation" was performed. Clinical studies published after 2012 through May 15, 2019, and in English were included. Studies were determined to have financial conflicts of interest if any contributing author had relevant conflicts, either self-reported in the published study's disclosures section or reported online in the American Academy of Orthopaedic Surgeons Disclosure database or the Centers for Medicare & Medicaid Services Open Payments database. The outcomes of each study were rated as favorable, equivocal, or unfavorable based on predefined criteria and then tested for association with conflicts of interest through use of the Fisher exact test. RESULTS A total of 79 studies met the inclusion criteria. Nearly all studies were of level 3 or 4 evidence. Conflicts of interest were established in 51.90% of studies (n = 41). Conflicts that were not self-reported by the authors were discovered in 18% of studies. The level of evidence was not associated with conflict of interest. No statistically significant difference was found in the rate of favorable outcomes between studies with conflicts (92.68%) and those with no conflicts (81.58%) (P = .126). Publications by US authors were more likely to have financial conflicts of interest (P = .003). CONCLUSION Favorable results were reported in a majority of studies involving ACI. No statistical association was found between the frequency of favorable outcomes and the presence of financial conflicts of interest, country of authorship, or level of evidence. There was a trend toward more favorable outcomes in studies with conflicts of interest. Additionally, nearly 20% of publications had possible conflicts found online that were not self-reported. It is critical for orthopaedic surgeons to judiciously evaluate published studies and consider financial conflicts of interest before performing ACI techniques on patients.
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Affiliation(s)
| | | | - Leonard Onsen
- University of Illinois at Chicago, Chicago, Illinois, USA
| | - Aimee Bobko
- University of Illinois at Chicago, Chicago, Illinois, USA
| | | | | | - Adam Miller
- University of Illinois at Chicago, Chicago, Illinois, USA
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Trengove A, Di Bella C, O'Connor AJ. The Challenge of Cartilage Integration: Understanding a Major Barrier to Chondral Repair. TISSUE ENGINEERING PART B-REVIEWS 2021; 28:114-128. [PMID: 33307976 DOI: 10.1089/ten.teb.2020.0244] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Articular cartilage defects caused by injury frequently lead to osteoarthritis, a painful and costly disease. Despite widely used surgical methods to treat articular cartilage defects and a plethora of research into regenerative strategies as treatments, long-term clinical outcomes are not satisfactory. Failure to integrate repair tissue with native cartilage is a recurring issue in surgical and tissue-engineered strategies, seeing eventual degradation of the regenerated or surrounding tissue. This review delves into the current understanding of why continuous and robust integration with native cartilage is so difficult to achieve. Both the intrinsic limitations of chondrocytes to remodel injured cartilage, and the significant challenges posed by a compromised biomechanical environment are described. Recent scaffold and cell-based techniques to repair cartilage are also discussed, and limitations of existing methods to evaluate integrative repair. In particular, the importance of evaluating the mechanical integrity of the interface between native and repair tissue is highlighted as a meaningful assessment of any strategy to repair this load-bearing tissue. Impact statement The failure to integrate grafts or biomaterials with native cartilage is a major barrier to cartilage repair. An in-depth understanding of the reasons cartilage integration remains a challenge is required to inform cartilage repair strategies. In particular, this review highlights that integration of cartilage repair strategies is frequently assessed in terms of the continuity of tissue, but not the mechanical integrity. Given the load-bearing nature of cartilage, evaluating integration in terms of interfacial strength is essential to assessing the potential success of cartilage repair methods.
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Affiliation(s)
- Anna Trengove
- Department of Biomedical Engineering, The University of Melbourne, Melbourne, Australia
| | - Claudia Di Bella
- Department of Surgery, St. Vincent's Hospital, The University of Melbourne, Melbourne, Australia.,Department of Orthopedics, St. Vincent's Hospital Melbourne, Melbourne, Australia
| | - Andrea J O'Connor
- Department of Biomedical Engineering, The University of Melbourne, Melbourne, Australia
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25
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Shah SS, Lee S, Mithoefer K. Next-Generation Marrow Stimulation Technology for Cartilage Repair: Basic Science to Clinical Application. JBJS Rev 2021; 9:e20.00090. [PMID: 33512974 DOI: 10.2106/jbjs.rvw.20.00090] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
» Given the relatively high prevalence of full-thickness articular cartilage lesions, including in patients who are <40 years of age, and an inability to detect some of these lesions until the time of arthroscopy, there is value in performing a single-stage cartilage procedure such as marrow stimulation (MS). » While the positive outcomes of first-generation MS (namely microfracture) have been observed to drop off after 24 months in several studies, improvements have been seen when compared with preoperative conditions for lesions that are 2 to 3 cm2 in size, and MS is considered to be a procedure with technical simplicity, fairly short surgical times, and relatively low morbidity. A recent study showed that autologous chondrocyte implantation (ACI) and osteochondral allograft (OCA) transplantation remain viable treatment options for chondral defects of the knee in the setting of failed MS. » Basic science principles that have been elucidated in recent years include (1) the creation of vertical walls during defect preparation, (2) an increased depth of subchondral penetration, (3) a smaller awl diameter, and (4) an increased number of subchondral perforations, which are all thought to help resolve issues of access to the mesenchymal stromal cells (MSCs) and the subchondral bone structure/overgrowth issues. » Pioneering and evolving basic science and clinical studies have led to next-generation clinical applications, such as a hyaluronic acid-based scaffold (ongoing randomized controlled trial [RCT]), an atelocollagen-based gel (as described in a recently published RCT), a micronized allogeneic cartilage scaffold (as described in a recently completed prospective cohort study), and a biosynthetic hydrogel that is composed of polyethylene glycol (PEG) diacrylate and denatured fibrinogen (as described in an ongoing prospective study). » This review summarizes important points for defect preparation and the recent advances in MS techniques and identifies specific scaffolding augmentation strategies (e.g., mesenchymal augmentation and scaffold stimulation [MASS]) that have the capacity to advance cartilage regeneration in light of recent laboratory and clinical studies.
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Affiliation(s)
- Sarav S Shah
- Division of Sports Medicine, Department of Orthopaedic Surgery, New England Baptist Hospital, Boston, Massachusetts
| | - Sonia Lee
- Department of Orthopaedic Surgery, Tufts University School of Medicine, Boston, Massachusetts
| | - Kai Mithoefer
- Department of Orthopedics and Sports Medicine, Harvard Vanguard Medical Associates, Boston, Massachusetts
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REPARATIVE CHONDROGENESIS AT RATS SHINBONE PROXIMAL EPIPHYPHIS TRAUMATIC INJURY WITH THE USE OF WARTON DRUGS STAR CELLS MEZENCHENICHEMIS IN THE EXPERIMENT. WORLD OF MEDICINE AND BIOLOGY 2021. [DOI: 10.26724/2079-8334-2021-3-77-249-254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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27
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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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28
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Kim JH, Heo JW, Lee DH. Clinical and Radiological Outcomes After Autologous Matrix-Induced Chondrogenesis Versus Microfracture of the Knee: A Systematic Review and Meta-analysis With a Minimum 2-Year Follow-up. Orthop J Sports Med 2020; 8:2325967120959280. [PMID: 33209942 PMCID: PMC7645765 DOI: 10.1177/2325967120959280] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Accepted: 04/10/2020] [Indexed: 12/16/2022] Open
Abstract
Background: Microfracture (MFx) is the most common procedure for treating chondral
lesions in the knee; however, initial improvements decline after 2 years.
Autologous matrix-induced chondrogenesis (AMIC) may overcome this
shortcoming by combining MFx with collagen scaffolds. However, the outcomes
of AMIC and MFx in the knee have not been compared. Purpose: To compare the clinical and radiological outcomes of AMIC and MFx over a
minimum 2-year follow-up. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic search of the MEDLINE, Embase, and Cochrane Library databases
identified studies of patients who underwent AMIC or MFx and that reported
validated clinical outcome measure and/or radiological evaluation findings
at a follow-up of ≥2 years. There were 2 reviewers who performed study
selection, a risk of bias assessment, and data extraction. Results: Overall, 29 studies were included in this systematic review. The mean
improvement on the Lysholm score, Tegner activity scale, and visual analog
scale for pain did not differ significantly between the 2 procedures. The
mean improvement on the International Knee Documentation Committee (IKDC)
subjective score was significantly greater in the AMIC (45.9 [95% CI,
36.2-55.5]) than in the MFx (27.2 [95% CI, 23.3-31.1]) group
(P < .001). In addition, the mean magnetic resonance
observation of cartilage repair tissue score was significantly higher in the
AMIC (69.3 [95% CI, 55.1-83.5]) versus MFx (41.0 [95% CI, 27.3-54.7]) group
(P = .005), and the mean adequate defect filling rate
on magnetic resonance imaging scans was significantly better in the AMIC
(77.3% [95% CI, 66.7%-87.9%]) versus MFx (47.9% [95% CI, 29.2%-66.6%]) group
(P = .008) (odds ratio, 1.58 [95% CI, 1.07-2.33]). Conclusion: No significant differences in clinical outcomes, except for the IKDC
subjective score, were found between the AMIC and MFx groups. Greater
improvement in IKDC subjective scores and magnetic resonance imaging
findings were seen in patients treated with AMIC compared with MFx at a
minimum 2-year follow-up.
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Affiliation(s)
- Jun-Ho Kim
- Department of Orthopedic Surgery, Seoul Medical Center, Seoul, Republic of Korea
| | - Jae-Won Heo
- Department of Orthopedic Surgery, Bareunsesang Hospital, Seongnam, Republic of Korea
| | - Dae-Hee Lee
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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29
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Human articular cartilage is orthotropic where microstructure, micromechanics, and chemistry vary with depth and split-line orientation. Osteoarthritis Cartilage 2020; 28:1362-1372. [PMID: 32645403 PMCID: PMC7697147 DOI: 10.1016/j.joca.2020.06.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 06/25/2020] [Accepted: 06/27/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Quantitative, micrometer length scale assessment of human articular cartilage is essential to enable progress toward new functional tissue engineering approaches, including utilization of emerging 3D bioprinting technologies, and for improved computational modeling of the osteochondral unit. Thus the objective of this study was to characterize the structural organization, material properties, and chemical composition of human skeletally mature articular cartilage with respect to depth and defined morphological features: normal to the articulating surface, parallel to the split-line, and transverse to the split-line. METHOD Three samples from the lateral femoral condyles of 4 healthy adult donors (55-61 years old) were evaluated via histology, second harmonic generation, microindentation, and Raman spectroscopy. All metrics were evaluated as a function of depth and direction relative to the split-line. RESULTS All donors presented with intact and healthy tissue. Collagen fiber orientation varied significantly between testing directions and with increasing depth from the articular surface. Both compressive and tensile modulus increased significantly with depth and differed across the middle and deep zones and depended on orthogonal direction relative to the split-line. Similarly, matrix components varied with both depth and direction, where chondroitin sulfate steadily increased with depth while collagen prevalence was highest in the surface layer. CONCLUSIONS Microscale measurements of human articular cartilage demonstrate that properties are both depth-dependent and orthotropic and depend on the underlying tissue structure and composition. These findings improve upon existing knowledge establishing more accurate measurements, with greater degree of depth and spatial specificity, as inputs for tissue engineering and computational modeling.
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30
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Wolf MT, Zhang H, Sharma B, Marcus NA, Pietzner U, Fickert S, Lueth A, Albers GHR, Elisseeff JH. Two-Year Follow-Up and Remodeling Kinetics of ChonDux Hydrogel for Full-Thickness Cartilage Defect Repair in the Knee. Cartilage 2020; 11:447-457. [PMID: 30280586 PMCID: PMC7488951 DOI: 10.1177/1947603518800547] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To determine performance and repair kinetics of the ChonDux hydrogel scaffold for treating focal articular cartilage defects in the knee over 24 months. DESIGN This assessor-blinded trial evaluates ChonDux hydrogel scaffold implantation in combination with microfracture in 18 patients across 6 sites. Male and female patients 18 to 65 years of age with full-thickness femoral condyle defects 2 to 4 cm2 in area were enrolled. Eligible patients received ChonDux treatment followed by rehabilitation. Defect volume fill was evaluated after 3, 6 (primary outcome), 12, 18, and 24 months by assessor blinded magnetic resonance imaging (MRI) analysis. Secondary outcomes were T2-weighted MRI relaxation time and patient surveys via visual analogue scale (VAS) pain and International Knee Documentation Committee (IKDC) knee function scoring. RESULTS ChonDux maintained durable tissue restoration over 24 months with final defect percent fill of 94.2% ± 16.3% and no significant loss of fill volume at any time points. Tissues treated with ChonDux maintained T2 relaxation times similar to uninjured cartilage between 12 and 24 months. VAS pain scoring decreased between 1 and 6 weeks, and IKDC knee function scores improved by approximately 30.1 with ChonDux over 24 months. CONCLUSION ChonDux treatment is a safe adjunct to microfracture therapy and promotes stable restoration of full thickness articular cartilage defects for at least 24 months.
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Affiliation(s)
- Matthew T. Wolf
- Translational Tissue Engineering Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA,Department of Ophthalmology, Johns Hopkins University School of Medicine, Baltimore, MD, USA,Bloomberg-Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University, Baltimore, MD, USA
| | - Hong Zhang
- Translational Tissue Engineering Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA,Department of Chemical and Biomolecular Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Blanka Sharma
- J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, FL, USA
| | | | - Uwe Pietzner
- Department of Arthroscopic Surgery and Sport Traumatology, Clinic for Orthopedics and Trauma Surgery, Dietrich-Bonhoeffer-Klinikum Neubrandenburg, Altentreptow, Germany
| | - Stefan Fickert
- Sporthopaedicum Straubing Berlin Regensburg, Straubing, Germany,University Medical Centre Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Achim Lueth
- Praxisclinic Zaehringen, Department of Orthopedics, Freiburg, Germany
| | - G. H. Robert Albers
- AVE Orthopedic Clinics, Huizen, Netherlands,Abteilung Orthopaedie/Unfallchirurgie, Diakonissenkrankenhaus, Schladming, Austria
| | - Jennifer H. Elisseeff
- Translational Tissue Engineering Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA,Department of Ophthalmology, Johns Hopkins University School of Medicine, Baltimore, MD, USA,Bloomberg-Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University, Baltimore, MD, USA,Jennifer H. Elisseeff, Department of Ophthalmology, Johns Hopkins University School of Medicine, 5031 Smith Building, 400 North Broadway, Baltimore, MD 21231, USA.
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31
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Irani S, Tavakkoli S, Pezeshki‐Modaress M, Taghavifar E, Mohammadali M, Daemi H. Electrospun nanofibrous alginate sulfate scaffolds promote mesenchymal stem cells differentiation to chondrocytes. J Appl Polym Sci 2020. [DOI: 10.1002/app.49868] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Shiva Irani
- Department of Biology, Science and Research Branch Islamic Azad University Tehran Iran
| | - Sajjad Tavakkoli
- Department of Biology, Science and Research Branch Islamic Azad University Tehran Iran
| | | | - Elham Taghavifar
- Department of Biology, Science and Research Branch Islamic Azad University Tehran Iran
| | - Marjan Mohammadali
- Department of Biology, Science and Research Branch Islamic Azad University Tehran Iran
| | - Hamed Daemi
- Department of Cell Engineering Cell Science Research Center, Royan Institute for Stem Cell Biology and Technology, ACECR Tehran Iran
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32
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Kraeutler MJ, Aliberti GM, Scillia AJ, McCarty EC, Mulcahey MK. Microfracture Versus Drilling of Articular Cartilage Defects: A Systematic Review of the Basic Science Evidence. Orthop J Sports Med 2020; 8:2325967120945313. [PMID: 32913875 PMCID: PMC7443991 DOI: 10.1177/2325967120945313] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 03/31/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Microfracture (MFx) is one of the most common techniques used for the treatment of articular cartilage defects, although recently there has been a trend toward the use of drilling rather than MFx for the treatment of these defects. PURPOSE To perform a systematic review of basic science studies to determine the effect of microfracture versus drilling for articular cartilage repair. STUDY DESIGN Systematic review. METHODS A systematic review was performed by searching PubMed, the Cochrane Library, and EMBASE to identify basic science studies comparing outcomes of MFx versus drilling. The search phrase used was microfracture AND (drilling OR microdrilling). Inclusion criteria were basic science studies that directly compared the effect of MFx versus drilling on subchondral bone, bone marrow stimulation, and cartilage regeneration. RESULTS A total of 7 studies met the inclusion criteria and were included in this systematic review. Of these, 4 studies were performed in rabbits, 1 study in sheep, and 2 studies in humans. All of the included studies investigated cartilage repair in the knee. In the animal studies, microfracture produced fractured and compacted bone and led to increased osteocyte necrosis compared with drilling. Deep drilling (6 mm) was superior to both shallow drilling (2 mm) and MFx in terms of increased subchondral hematoma with greater access to marrow stroma, improved cartilage repair, and increased mineralized bone. However, the overall quality of cartilage repair tissue was poor regardless of marrow stimulation technique. In 2 studies that investigated repair tissue after MFx and/or drilling in human patients with osteoarthritis and cartilage defects, the investigators found that cartilage repair tissue did not achieve the quality of normal hyaline articular cartilage. CONCLUSION In the limited basic science studies that are available, deep drilling of cartilage defects in the knee resulted in improved biological features compared with MFx, including less damage to the subchondral bone and greater access to marrow stroma. Regardless of marrow stimulation technique, the overall quality of cartilage regeneration was poor and did not achieve the characteristics of native hyaline cartilage. Overall, there is a general lack of basic science literature comparing microfracture versus drilling for focal chondral defects.
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Affiliation(s)
| | - Gianna M. Aliberti
- Tulane University School of Medicine, Department of Orthopaedic Surgery, New
Orleans, Louisiana, USA
| | - Anthony J. Scillia
- St. Joseph’s University Medical Center, Paterson, New Jersey,
USA
- New Jersey Orthopaedic Institute, Wayne, New Jersey, USA
| | - Eric C. McCarty
- University of Colorado School of Medicine, Department of Orthopedics, Aurora, Colorado,
USA
| | - Mary K. Mulcahey
- Tulane University School of Medicine, Department of Orthopaedic Surgery, New
Orleans, Louisiana, USA
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33
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Frank JK, Heuberer PR, Laky B, Anderl W, Pauzenberger L. Glenohumeral Microfracturing of Contained Glenohumeral Defects: Mid- to Long-term Outcome. Arthrosc Sports Med Rehabil 2020; 2:e341-e346. [PMID: 32875298 PMCID: PMC7451850 DOI: 10.1016/j.asmr.2020.04.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 04/29/2020] [Indexed: 01/29/2023] Open
Abstract
Purpose To report mid- to long-term clinical and radiological outcomes after microfracturing for symptomatic chondral defects of the glenohumeral joint. Methods All patients who underwent glenohumeral arthroscopic microfracturing between 2002 and 2012 at a single center were considered for inclusion in this retrospective study. Clinical outcome was evaluated using the Constant Score, Oxford Shoulder Score, and Subjective Shoulder Value. Progression of joint space narrowing, sclerosis, marginal osteophytes, and presence of cysts over time were assessed using 4 different radiological grading systems. Results A total of 16 patients (n = 9 female, n = 7 male) with a mean age of 51.8 ± 12.6 years at the time of surgery and a mean follow-up of 122 ± 51.2 months (range, 61-204 months) were included in this retrospective study. Nine patients (56.3%) showed an isolated chondral defect, while 7 patients (43.8%) had concomitant pathologies. Constant Score (60.3 ± 12.7 vs. 85.9 ± 9.3; P < .001), Oxford Shoulder Score (29.0 ± 5.8 vs. 42.4 ± 4.5; P < .001), and Subjective Shoulder Value (23.9 ± 7.4 vs. 84.3 ± 10.9; P < .001) changed significantly from pre- to postoperative. The majority of patients (88%) were able to return to their preoperative level of activity. Three patients (19.8%) developed radiological signs of progressive glenohumeral degeneration during the study period. However, only 1 patient (6.25%) showed a progression of arthritic changes of more than 1 grade according to radiographic classifications. Two patients (12.5%) underwent revision surgery to a hemi shoulder arthroplasty during the study period at 12 and 36 months after the initial procedure. Conclusions Glenohumeral microfracturing is commonly performed together with other procedures, but seems to be a feasible treatment option for contained cartilage lesions in active patients reproducibly yielding good mid- to long-term outcome. Level of Evidence Level IV, therapeutic case series.
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Affiliation(s)
| | - Philipp R Heuberer
- Vienna Shoulder & Sports Clinic, Vienna, Austria.,Austrian Research Group for Regenerative and Orthopedic Medicine (AURROM), Vienna, Austria
| | - Brenda Laky
- Vienna Shoulder & Sports Clinic, Vienna, Austria.,Austrian Research Group for Regenerative and Orthopedic Medicine (AURROM), Vienna, Austria
| | - Werner Anderl
- Vienna Shoulder & Sports Clinic, Vienna, Austria.,Austrian Research Group for Regenerative and Orthopedic Medicine (AURROM), Vienna, Austria
| | - Leo Pauzenberger
- Vienna Shoulder & Sports Clinic, Vienna, Austria.,Sports Surgery Clinic, Dublin, Ireland
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Doulgkeroglou MN, Di Nubila A, Niessing B, König N, Schmitt RH, Damen J, Szilvassy SJ, Chang W, Csontos L, Louis S, Kugelmeier P, Ronfard V, Bayon Y, Zeugolis DI. Automation, Monitoring, and Standardization of Cell Product Manufacturing. Front Bioeng Biotechnol 2020; 8:811. [PMID: 32766229 PMCID: PMC7381146 DOI: 10.3389/fbioe.2020.00811] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 06/23/2020] [Indexed: 12/18/2022] Open
Abstract
Although regenerative medicine products are at the forefront of scientific research, technological innovation, and clinical translation, their reproducibility and large-scale production are compromised by automation, monitoring, and standardization issues. To overcome these limitations, new technologies at software (e.g., algorithms and artificial intelligence models, combined with imaging software and machine learning techniques) and hardware (e.g., automated liquid handling, automated cell expansion bioreactor systems, automated colony-forming unit counting and characterization units, and scalable cell culture plates) level are under intense investigation. Automation, monitoring and standardization should be considered at the early stages of the developmental cycle of cell products to deliver more robust and effective therapies and treatment plans to the bedside, reducing healthcare expenditure and improving services and patient care.
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Affiliation(s)
- Meletios-Nikolaos Doulgkeroglou
- Regenerative, Modular & Developmental Engineering Laboratory, National University of Ireland Galway, Galway, Ireland.,Science Foundation Ireland, Centre for Research in Medical Devices, National University of Ireland Galway, Galway, Ireland
| | - Alessia Di Nubila
- Regenerative, Modular & Developmental Engineering Laboratory, National University of Ireland Galway, Galway, Ireland.,Science Foundation Ireland, Centre for Research in Medical Devices, National University of Ireland Galway, Galway, Ireland
| | | | - Niels König
- Fraunhofer Institute for Production Technology, Aachen, Germany
| | - Robert H Schmitt
- Production Engineering Cluster, RWTH Aachen University, Aachen, Germany
| | - Jackie Damen
- STEMCELL Technologies Inc., Vancouver, BC, Canada
| | | | - Wing Chang
- STEMCELL Technologies Ltd., Cambridge, United Kingdom
| | - Lynn Csontos
- STEMCELL Technologies Ltd., Cambridge, United Kingdom
| | - Sharon Louis
- STEMCELL Technologies Inc., Vancouver, BC, Canada
| | | | - Vincent Ronfard
- College System of Pharmacy, University of North Texas Health Science Center, Fort Worth, TX, United States.,Cutiss AG, Zurich, Switzerland.,HairClone, Manchester, United Kingdom
| | - Yves Bayon
- Medtronic - Sofradim Production, Trévoux, France
| | - Dimitrios I Zeugolis
- Regenerative, Modular & Developmental Engineering Laboratory, National University of Ireland Galway, Galway, Ireland.,Science Foundation Ireland, Centre for Research in Medical Devices, National University of Ireland Galway, Galway, Ireland
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Słynarski K, de Jong WC, Snow M, Hendriks JAA, Wilson CE, Verdonk P. Single-Stage Autologous Chondrocyte-Based Treatment for the Repair of Knee Cartilage Lesions: Two-Year Follow-up of a Prospective Single-Arm Multicenter Study. Am J Sports Med 2020; 48:1327-1337. [PMID: 32267734 DOI: 10.1177/0363546520912444] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND There is an unmet need for a single-stage cartilage repair treatment that is cost-effective and chondrocyte-based. PURPOSE To evaluate the safety and preliminary efficacy of autologous freshly isolated primary chondrocytes and bone marrow mononucleated cells (MNCs) seeded into a PolyActive scaffold in patients with symptomatic cartilage lesions of the knee. STUDY DESIGN Case series; Level of evidence, 4. METHODS A total of 40 patients with symptomatic knee cartilage lesions were treated with freshly isolated autologous chondrocytes combined with bone marrow MNCs delivered in a biodegradable load-bearing scaffold. The treatment requires only 1 surgical intervention and is potentially a cost-effective alternative to autologous chondrocyte implantation. The primary chondrocytes and bone marrow MNCs were isolated, washed, counted, mixed, and seeded into a load-bearing scaffold in the operating room. Patients were followed up at 3, 6, 12, 18, and 24 months. Primary endpoints were treatment-related adverse events up to 3 months, adverse implant effects between 3 and 24 months, and the implant success rate at 3 months as measured by lesion filling. RESULTS Successful lesion filling (≥67% on magnetic resonance imaging) was found in 40 patients at 3 months and in 32 of the 32 patients analyzed at 24 months. Significant improvement over baseline was found for visual analog scale for pain from 3 months onward; Knee injury and Osteoarthritis Outcome Score (KOOS)-Pain and KOOS-Activities of Daily Living from 6 months onward; for KOOS-Symptoms and Stiffness, KOOS-Quality of Life and International Knee Documentation Committee from 12 months onward; and for KOOS-Sport and Recreation from 18 months onward. Hyaline-like repair tissue was found in 22 of 31 patients available for biopsy. Arthralgia and joint effusion were the most common adverse events. Scaffold delamination and adhesions led to removal of the implant in 2 patients. CONCLUSION The treatment of knee cartilage lesions with autologous primary chondrocytes and bone marrow MNCs, both isolated and seeded into a load-bearing PolyActive scaffold within a single surgical intervention, is safe and clinically effective. Good lesion fill and sustained clinically important and statistically significant improvement in all patient-reported outcome scores were found throughout the 24-month study. Hyaline-like cartilage was observed on biopsy specimen in at least 22 of the 40 patients. REGISTRATION NCT01041885 (ClinicalTrials.gov identifier).
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Affiliation(s)
| | - Willem Cornelis de Jong
- Cartilage Repair Systems, LLC, New York, New York, USA.,CellCoTec BV, Bilthoven, the Netherlands
| | - Martyn Snow
- The Royal Orthopaedic Hospital, Birmingham, UK
| | | | - Clayton Ellis Wilson
- Cartilage Repair Systems, LLC, New York, New York, USA.,CellCoTec BV, Bilthoven, the Netherlands
| | - Peter Verdonk
- Antwerp Orthopedic Center, AZ Monica, Antwerp, Belgium.,Antwerp University Hospital, Antwerp, Belgium
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Kim T, Haskell A. Patient-Reported Outcomes After Structural Autograft for Large or Cystic Talar Dome Osteochondral Lesions. Foot Ankle Int 2020; 41:549-555. [PMID: 32088985 DOI: 10.1177/1071100720907313] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND While smaller talar dome osteochondral lesions (OCLs) are successfully treated with bone marrow stimulation techniques, the optimal treatment for large or cystic OCLs remains controversial. This study tested the hypothesis that transferring structural autograft bone from the distal tibia to the talus for large or cystic OCLs improves pain and function. METHODS Thirty-two patients with large or cystic OCLs underwent structural bone grafting from the ipsilateral distal tibia to the talar dome. Patients were assessed with subjective patient-centered tools and objective clinical outcomes. Average age was 48.6 ± 14.9 years, and average follow-up was 19.5 ± 13.3 months. Average lesion area was 86.2 ± 23.5 mm2, and average depth was 8.4 ± 3.0mm. RESULTS At final follow-up, improvement compared to preoperative scores was seen in American Orthopaedic Foot & Ankle Society (65.4 ± 21.2 to 86.9 ± 15.0, P < .05), Foot Function Index (48.9 ± 20.8 to 21.1 ± 18.9, P < .05), visual analog scale for pain (4.7 ± 3.0 to 1.4 ± 1.5, P < .05), and Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (40.4 ± 5.4 to 45.5 ± 7.4, P < .05) scores. There was no improvement in PROMIS pain interference (54.7 ± 18.1 to 52.4 ± 7.3, P > .05). Satisfaction with surgery was 8.4 ± 1.3/10, and 96% of patients would have the procedure again. Ninety-four percent of patients returned to work and/or play. One patient had a deep vein thrombosis 6 weeks postoperatively, and 1 patient underwent ankle fusion at 18 months postoperatively. CONCLUSION This study demonstrates that structural bone graft harvested from the distal tibia transferred to the talus was a safe and effective treatment for large and cystic OCLs. Outcomes compare favorably to other described techniques for treatment of these injuries. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- Todd Kim
- Palo Alto Medical Foundation, University of California, San Francisco, Burlingame, CA, USA
| | - Andrew Haskell
- Palo Alto Medical Foundation, University of California, San Francisco, Burlingame, CA, USA
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Boffa A, Previtali D, Altamura SA, Zaffagnini S, Candrian C, Filardo G. Platelet-Rich Plasma Augmentation to Microfracture Provides a Limited Benefit for the Treatment of Cartilage Lesions: A Meta-analysis. Orthop J Sports Med 2020; 8:2325967120910504. [PMID: 32341925 PMCID: PMC7175068 DOI: 10.1177/2325967120910504] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 02/01/2020] [Indexed: 01/06/2023] Open
Abstract
Background: Microfracture is the most common first-line option for the treatment of small chondral lesions, although increasing evidence shows that the clinical benefit of microfracture decreases over time. Platelet-rich plasma (PRP) has been suggested as an effective biological augmentation to improve clinical outcomes after microfracture. Purpose: To evaluate the clinical evidence regarding the application of PRP, documenting safety and efficacy of this augmentation technique to improve microfracture for the treatment of cartilage lesions. Study Design: Systematic review; Level of evidence, 3. Methods: A systematic review was performed in PubMed, EBSCOhost database, and the Cochrane Library to identify comparative studies evaluating the clinical efficacy of PRP augmentation to microfracture. A meta-analysis was performed on articles that reported results for visual analog scale (VAS) for pain, International Knee Documentation Committee (IKDC), and American Orthopaedic Foot and Ankle Society (AOFAS) scores. Risk of bias was documented through use of the Cochrane Collaboration Risk of Bias 2.0 and Risk of Bias in Non-randomized Studies of Interventions assessment tools. The quality assessment was performed according to the Grading of Recommendations Assessment, Development and Evaluation guidelines. Results: A total of 7 studies met the inclusion criteria and were included in the meta-analysis: 4 randomized controlled trials, 2 prospective comparative studies, and 1 retrospective comparative study, for a total of 234 patients. Of the 7 studies included, 4 studies evaluated the effects of PRP treatment in the knee, and 3 studies evaluated effects in the ankle. The analysis of all scores showed a difference favoring PRP treatment in knees (VAS, P = .002 and P < .001 at 12 and 24 months, respectively; IKDC, P < .001 at both follow-up points) and ankles (both VAS and AOFAS, P < .001 at 12 months). The improvement offered by PRP did not reach the minimal clinically important difference (MCID). Conclusion: PRP provided an improvement to microfracture in knees and ankles at short-term follow-up. However, this improvement did not reach the MCID, and thus it was not clinically perceivable by the patients. Moreover, the overall low evidence and the paucity of high-level studies indicate further research is needed to confirm the potential of PRP augmentation to microfracture for the treatment of cartilage lesions.
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Affiliation(s)
- Angelo Boffa
- Clinica Ortopedica e Traumatologica 2, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Davide Previtali
- Orthopaedic and Traumatology Unit, Ospedale Regionale di Lugano, EOC, Lugano, Switzerland
| | | | - Stefano Zaffagnini
- Clinica Ortopedica e Traumatologica 2, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
- Stefano Zaffagnini, MD, Clinica Ortopedica e Traumatologica 2, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy ()
| | - Christian Candrian
- Orthopaedic and Traumatology Unit, Ospedale Regionale di Lugano, EOC, Lugano, Switzerland
| | - Giuseppe Filardo
- Orthopaedic and Traumatology Unit, Ospedale Regionale di Lugano, EOC, Lugano, Switzerland
- Applied and Translational Research Center, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
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Li X, Guo W, Zha K, Jing X, Wang M, Zhang Y, Hao C, Gao S, Chen M, Yuan Z, Wang Z, Zhang X, Shen S, Li H, Zhang B, Xian H, Zhang Y, Sui X, Qin L, Peng J, Liu S, Lu S, Guo Q. Enrichment of CD146 + Adipose-Derived Stem Cells in Combination with Articular Cartilage Extracellular Matrix Scaffold Promotes Cartilage Regeneration. Theranostics 2019; 9:5105-5121. [PMID: 31410204 PMCID: PMC6691381 DOI: 10.7150/thno.33904] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 06/11/2019] [Indexed: 12/11/2022] Open
Abstract
Heterogeneity of mesenchymal stem cells (MSCs) influences the cell therapy outcome and the application in tissue engineering. Also, the application of subpopulations of MSCs in cartilage regeneration remains poorly characterized. CD146+ MSCs are identified as the natural ancestors of MSCs and the expression of CD146 are indicative of greater pluripotency and self-renewal potential. Here, we sorted a CD146+ subpopulation from adipose-derived mesenchymal stem cells (ADSCs) for cartilage regeneration. Methods: CD146+ ADSCs were sorted using magnetic activated cell sorting (MACS). Cell surface markers, viability, apoptosis and proliferation were evaluated in vitro. The molecular signatures were analyzed by mRNA and protein expression profiling. By intra-articular injections of cells in a rat osteochondral defect model, we assessed the role of the specific subpopulation in cartilage microenvironment. Finally, CD146+ ADSCs were combined with articular cartilage extracellular matrix (ACECM) scaffold for long term (3, 6 months) cartilage repair. Results: The enriched CD146+ ADSCs showed a high expression of stem cell and pericyte markers, good viability, and immune characteristics to avoid allogeneic rejection. Gene and protein expression profiles revealed that the CD146+ ADSCs had different cellular functions especially in regulation inflammation. In a rat model, CD146+ ADSCs showed a better inflammation-modulating property in the early stage of intra-articular injections. Importantly, CD146+ ADSCs exhibited good biocompatibility with the ACECM scaffold and the CD146+ cell-scaffold composites produced less subcutaneous inflammation. The combination of CD146+ ADSCs with ACECM scaffold can promote better cartilage regeneration in the long term. Conclusion: Our data elucidated the function of the CD146+ ADSC subpopulation, established their role in promoting cartilage repair, and highlighted the significance of cell subpopulations as a novel therapeutic for cartilage regeneration.
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Affiliation(s)
- Xu Li
- Institute of Orthopedics, Chinese PLA General Hospital; Beijing Key Lab of Regenerative Medicine in Orthopaedics; Key Laboratory of Musculoskeletal Trauma & War Injuries,PLA; 28 Fuxing Road, Haidian District, Beijing 100853, China
- School of Medicine, Nankai University, Tianjin, 300071, China
- Musculoskeletal Research Laboratory, Department of Orthopaedics and Traumatology, Innovative Orthopaedic Biomaterial and Drug Translational Research Laboratory, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, China
| | - Weimin Guo
- Institute of Orthopedics, Chinese PLA General Hospital; Beijing Key Lab of Regenerative Medicine in Orthopaedics; Key Laboratory of Musculoskeletal Trauma & War Injuries,PLA; 28 Fuxing Road, Haidian District, Beijing 100853, China
- Department of Orthopaedic Surgery, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Kangkang Zha
- School of Medicine, Nankai University, Tianjin, 300071, China
| | - Xiaoguang Jing
- Institute of Orthopedics, Chinese PLA General Hospital; Beijing Key Lab of Regenerative Medicine in Orthopaedics; Key Laboratory of Musculoskeletal Trauma & War Injuries,PLA; 28 Fuxing Road, Haidian District, Beijing 100853, China
| | - Mingjie Wang
- Institute of Orthopedics, Chinese PLA General Hospital; Beijing Key Lab of Regenerative Medicine in Orthopaedics; Key Laboratory of Musculoskeletal Trauma & War Injuries,PLA; 28 Fuxing Road, Haidian District, Beijing 100853, China
| | - Yu Zhang
- Institute of Orthopedics, Chinese PLA General Hospital; Beijing Key Lab of Regenerative Medicine in Orthopaedics; Key Laboratory of Musculoskeletal Trauma & War Injuries,PLA; 28 Fuxing Road, Haidian District, Beijing 100853, China
| | - Chunxiang Hao
- Institute of Orthopedics, Chinese PLA General Hospital; Beijing Key Lab of Regenerative Medicine in Orthopaedics; Key Laboratory of Musculoskeletal Trauma & War Injuries,PLA; 28 Fuxing Road, Haidian District, Beijing 100853, China
| | - Shuang Gao
- Center for Biomedical Material and Tissue Engineering, Academy for Advanced Interdisciplinary Studies, Peking University, Beijing 100871, China
| | - Mingxue Chen
- Institute of Orthopedics, Chinese PLA General Hospital; Beijing Key Lab of Regenerative Medicine in Orthopaedics; Key Laboratory of Musculoskeletal Trauma & War Injuries,PLA; 28 Fuxing Road, Haidian District, Beijing 100853, China
| | - Zhiguo Yuan
- Institute of Orthopedics, Chinese PLA General Hospital; Beijing Key Lab of Regenerative Medicine in Orthopaedics; Key Laboratory of Musculoskeletal Trauma & War Injuries,PLA; 28 Fuxing Road, Haidian District, Beijing 100853, China
| | - Zhenyong Wang
- Institute of Orthopedics, Chinese PLA General Hospital; Beijing Key Lab of Regenerative Medicine in Orthopaedics; Key Laboratory of Musculoskeletal Trauma & War Injuries,PLA; 28 Fuxing Road, Haidian District, Beijing 100853, China
| | - Xueliang Zhang
- Institute of Orthopedics, Chinese PLA General Hospital; Beijing Key Lab of Regenerative Medicine in Orthopaedics; Key Laboratory of Musculoskeletal Trauma & War Injuries,PLA; 28 Fuxing Road, Haidian District, Beijing 100853, China
| | - Shi Shen
- Institute of Orthopedics, Chinese PLA General Hospital; Beijing Key Lab of Regenerative Medicine in Orthopaedics; Key Laboratory of Musculoskeletal Trauma & War Injuries,PLA; 28 Fuxing Road, Haidian District, Beijing 100853, China
| | - Haojiang Li
- Institute of Orthopedics, Chinese PLA General Hospital; Beijing Key Lab of Regenerative Medicine in Orthopaedics; Key Laboratory of Musculoskeletal Trauma & War Injuries,PLA; 28 Fuxing Road, Haidian District, Beijing 100853, China
| | - Bin Zhang
- Institute of Orthopedics, Chinese PLA General Hospital; Beijing Key Lab of Regenerative Medicine in Orthopaedics; Key Laboratory of Musculoskeletal Trauma & War Injuries,PLA; 28 Fuxing Road, Haidian District, Beijing 100853, China
| | - Hai Xian
- Institute of Orthopedics, Chinese PLA General Hospital; Beijing Key Lab of Regenerative Medicine in Orthopaedics; Key Laboratory of Musculoskeletal Trauma & War Injuries,PLA; 28 Fuxing Road, Haidian District, Beijing 100853, China
| | - Yuan Zhang
- School of Medicine, Nankai University, Tianjin, 300071, China
| | - Xiang Sui
- Institute of Orthopedics, Chinese PLA General Hospital; Beijing Key Lab of Regenerative Medicine in Orthopaedics; Key Laboratory of Musculoskeletal Trauma & War Injuries,PLA; 28 Fuxing Road, Haidian District, Beijing 100853, China
| | - Ling Qin
- Musculoskeletal Research Laboratory, Department of Orthopaedics and Traumatology, Innovative Orthopaedic Biomaterial and Drug Translational Research Laboratory, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, China
| | - Jiang Peng
- Institute of Orthopedics, Chinese PLA General Hospital; Beijing Key Lab of Regenerative Medicine in Orthopaedics; Key Laboratory of Musculoskeletal Trauma & War Injuries,PLA; 28 Fuxing Road, Haidian District, Beijing 100853, China
| | - Shuyun Liu
- Institute of Orthopedics, Chinese PLA General Hospital; Beijing Key Lab of Regenerative Medicine in Orthopaedics; Key Laboratory of Musculoskeletal Trauma & War Injuries,PLA; 28 Fuxing Road, Haidian District, Beijing 100853, China
| | - Shibi Lu
- Institute of Orthopedics, Chinese PLA General Hospital; Beijing Key Lab of Regenerative Medicine in Orthopaedics; Key Laboratory of Musculoskeletal Trauma & War Injuries,PLA; 28 Fuxing Road, Haidian District, Beijing 100853, China
| | - Quanyi Guo
- Institute of Orthopedics, Chinese PLA General Hospital; Beijing Key Lab of Regenerative Medicine in Orthopaedics; Key Laboratory of Musculoskeletal Trauma & War Injuries,PLA; 28 Fuxing Road, Haidian District, Beijing 100853, China
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Song SJ, Park CH. Microfracture for cartilage repair in the knee: current concepts and limitations of systematic reviews. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:S108. [PMID: 31576315 DOI: 10.21037/atm.2019.05.11] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Sang Jun Song
- Department of Orthopaedic Surgery, College of Medicine, Graduate School, Kyung Hee University, Seoul, Korea
| | - Cheol Hee Park
- Department of Medicine, Graduate School, Kyung Hee University, Seoul, Korea
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Ahn J, Kim SA, Kim KW, Oh JH, Kim SJ. Optimization of TGF-β1-transduced chondrocytes for cartilage regeneration in a 3D printed knee joint model. PLoS One 2019; 14:e0217601. [PMID: 31120999 PMCID: PMC6532938 DOI: 10.1371/journal.pone.0217601] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 05/14/2019] [Indexed: 11/19/2022] Open
Abstract
A cell therapy product of transforming growth factor (TGF)-β1-transduced chondrocytes has been commercialized to treat osteoarthritis of the knee via intra-articular injection. The need for arthroscopic application of the cells to simultaneously treat intra-articular pathologies of knee osteoarthritis is increasingly urgent. The purpose of this study was to optimize TGF-β1-transduced chondrocytes for arthroscopic application. The optimal composition of chondrocytes and thrombin was initially determined by measuring the consolidation time of a diverse ratio of chondrocytes and thrombin mixed with 1 ml of fibrinogen. The consolidation time of the diverse ratio of fibrinogen and atelocollagen mixed with the determined optimal ratio of chondrocytes and thrombin was evaluated. The mixture of the determined optimal ratio of TGF-β1-transduced chondrocytes, atelocollagen, fibrinogen, and thrombin was applied to the cartilage defect of the 3D printed knee joint model arthroscopically. The status of the mixture in the defect was then evaluated. Chondrogenic activities of TGF-β1-transduced chondrocytes mixed with atelocollagen were evaluated. The determined ratio of TGF-β1-transduced chondrocytes to thrombin was 8:2 and that of fibrin to atelocollagen was also 8:2. Excellent maintenance of conformation of the mixture of TGF-β1-transduced chondrocytes, atelocollagen, fibrinogen, and thrombin in the cartilage defect of the 3D printed knee joint model was observed arthroscopically. Increased chondrogenic activities were observed in the group of TGF-β1-transduced chondrocytes mixed with atelocollagen. TGF-β1-transduced chondrocytes can be applied arthroscopically to treat cartilage defects of the knee at an optimized mixing ratio of atelocollagen, fibrinogen, and thrombin.
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Affiliation(s)
- Jiyong Ahn
- Department of Orthopaedic Surgery, College of Medicine, The Catholic University of Korea, Uijenong bu si, Gyeonggi-do, South Korea
| | - Seon Ae Kim
- Department of Orthopaedic Surgery, College of Medicine, The Catholic University of Korea, Uijenong bu si, Gyeonggi-do, South Korea
| | - Ki Won Kim
- Department of Orthopaedic Surgery, College of Medicine, The Catholic University of Korea, Uijenong bu si, Gyeonggi-do, South Korea
| | - Joon Hyuck Oh
- Department of Orthopaedic Surgery, College of Medicine, The Catholic University of Korea, Uijenong bu si, Gyeonggi-do, South Korea
| | - Seok Jung Kim
- Department of Orthopaedic Surgery, College of Medicine, The Catholic University of Korea, Uijenong bu si, Gyeonggi-do, South Korea
- * E-mail:
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Changing trends in the use of cartilage restoration techniques for the patellofemoral joint: a systematic review. Knee Surg Sports Traumatol Arthrosc 2019; 27:854-867. [PMID: 30232541 DOI: 10.1007/s00167-018-5139-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 09/06/2018] [Indexed: 12/14/2022]
Abstract
PURPOSE The patellofemoral (PF) joint contains the thickest articular cartilage in the human body. Chondral lesions to this area are often misdiagnosed and can predispose to secondary osteoarthritis if left untreated. Treatment options range from arthroscopic debridement to cartilage restoration techniques such as microfracture (MFx), autologous chondrocyte implantation (ACI), and osteochondral autograft transplantation. The purpose of this study was to systematically assess the trends in surgical techniques, outcomes, and complications of cartilage restoration of the PF joint. METHODS This review has been conducted according to the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA). The electronic databases PubMed, MEDLINE, and EMBASE were searched from January 1, 2007 to April 30, 2018. The Methodological Index for Non-randomized Studies (MINORS) was used to assess study quality. A two-proportion z test was used to determine whether the differences between the proportions of cartilage restoration techniques used from 2007 to 2012 and 2013-2018 were statistically significant. RESULTS Overall, 28 studies were identified, including 708 patients (824 knees) with a mean age of 39.5 ± 10.5 years and a mean follow-up of 39.1 ± 16.0 months. Majority of patients were treated with ACI (45.5%) and MFx (29.6%). A significant increase in the use of the third generation ACI occurred with a simultaneous decreased usage of the conventional MFx over the last 5 years (p < 0.001). All techniques had significant (p < 0.05) improvements in clinical outcomes. The overall complication rate was 9.2%, of which graft hypertrophy (2.7%) was the most prevalent. CONCLUSIONS ACI was the most common restoration technique. The use of third generation ACI has increased with a concurrent decline in the use of conventional MFx over the latter half of the past decade (p < 0.001). Overall, the various cartilage restoration techniques reported improvements in patient reported outcomes with low complication rates. Definitive conclusions on the optimal treatment remain elusive due to a lack of high-quality comparative studies. LEVEL OF EVIDENCE Level IV, Systematic Review of Level-II-IV studies.
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Walter SG, Ossendorff R, Schildberg FA. Articular cartilage regeneration and tissue engineering models: a systematic review. Arch Orthop Trauma Surg 2019; 139:305-316. [PMID: 30382366 DOI: 10.1007/s00402-018-3057-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Cartilage regeneration and restoration is a major topic in orthopedic research as cartilaginous degeneration and damage is associated with osteoarthritis and joint destruction. This systematic review aims to summarize current research strategies in cartilage regeneration research. MATERIALS AND METHODS A Pubmed search for models investigating single-site cartilage defects as well as chondrogenesis was conducted and articles were evaluated for content by title and abstract. Finally, only manuscripts were included, which report new models or approaches of cartilage regeneration. RESULTS The search resulted in 2217 studies, 200 of which were eligible for inclusion in this review. The identified manuscripts consisted of a large spectrum of research approaches spanning from cell culture to tissue engineering and transplantation as well as sophisticated computational modeling. CONCLUSIONS In the past three decades, knowledge about articular cartilage and its defects has multiplied in clinical and experimental settings and the respective body of research literature has grown significantly. However, current strategies for articular cartilage repair have not yet succeeded to replicate the structure and function of innate articular cartilage, which makes it even more important to understand the current strategies and their impact. Therefore, the purpose of this review was to globally summarize experimental strategies investigating cartilage regeneration in vitro as well as in vivo. This will allow for better referencing when designing new models or strategies and potentially improve research translation from bench to bedside.
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Affiliation(s)
- Sebastian G Walter
- Clinic for Orthopedics and Trauma Surgery, University Hospital Bonn, Sigmund-Freud-Str. 25, 53105, Bonn, Germany
| | - Robert Ossendorff
- Clinic for Orthopedics and Trauma Surgery, University Hospital Bonn, Sigmund-Freud-Str. 25, 53105, Bonn, Germany
| | - Frank A Schildberg
- Clinic for Orthopedics and Trauma Surgery, University Hospital Bonn, Sigmund-Freud-Str. 25, 53105, Bonn, Germany.
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Abstract
Hyaline articular cartilage is critical for the normal functioning of the knee joint. Untreated focal cartilage defects have the potential to rapidly progress to diffuse osteoarthritis. Over the last several decades, a variety of interventions aiming at preserving articular cartilage and preventing osteoarthritis have been investigated. Reparative cartilage procedures, such as microfracture, penetrate the subchondral bone plate in effort to fill focal cartilage defects with marrow elements and stimulate fibrocartilaginous repair. In contrast, restorative cartilage procedures aim to replace the defective articular surface with autologous or allogeneic hyaline cartilage. This review focuses on the preservation of articular cartilage, and discusses the current reparative and restorative surgical techniques available for treating focal cartilage defects.
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Houck DA, Kraeutler MJ, McCarty EC, Bravman JT. Fixed- Versus Adjustable-Loop Femoral Cortical Suspension Devices for Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis of Biomechanical Studies. Orthop J Sports Med 2018; 6:2325967118801762. [PMID: 30364394 PMCID: PMC6196635 DOI: 10.1177/2325967118801762] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background: Fixed- and adjustable-loop femoral cortical suspension devices are commonly used for femoral graft fixation during anterior cruciate ligament reconstruction (ACLR). Purpose: To compare the biomechanical results of fixed- versus adjustable-loop femoral cortical suspension devices in studies simulating ACLR with an isolated device and/or specimen setup using porcine femora and bovine flexor tendons. Study Design: Systematic review. Methods: Two independent reviewers searched PubMed, Embase, and the Cochrane Library databases to find studies comparing the biomechanical strength of fixed- and adjustable-loop cortical suspension devices for ACLR with isolated device and/or specimen setups using porcine femora and bovine flexor tendons. Studies that compared both devices with similar biomechanical methods were included. Data extracted included displacement during cyclic loading, ultimate load to failure, and mode of failure of the different cortical suspension devices for ACLR. Results: Six studies were identified that met the inclusion criteria, including a total of 76 fixed-loop devices and 120 adjustable-loop devices. Load to failure was significantly different (P < .0001), with the strongest fixation device being the ToggleLoc with ZipLoop adjustable-loop device (1443.9 ± 512.3 N), compared with the Endobutton CL fixed-loop device (1312.9 ± 258.1 N; P = .04) and the TightRope RT adjustable-loop device (863.8 ± 64.7 N; P = .01). Cyclic displacement was significantly different, with Endobutton CL (3.7 ± 3.9 mm) showing the least displacement, followed by ToggleLoc with ZipLoop (4.9 ± 2.3 mm) and TightRope RT (7.7 ± 11.1 mm) (P < .0001). Mode of failure was statistically different between the 3 groups (P = .01), with suture failure accounting for 83.8% of TightRope RT devices, 69.4% of ToggleLoc with ZipLoop devices, and 60.3% of Endobutton CL devices. Conclusion: Current biomechanical data suggest that the ToggleLoc with ZipLoop device is the strongest fixation device at “time zero” in terms of ultimate load to mechanical failure. However, the Endobutton CL device demonstrated the least cyclic displacement, which may be a more clinically applicable measure of device superiority.
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Affiliation(s)
- Darby A Houck
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Matthew J Kraeutler
- Department of Orthopaedic Surgery, St Joseph's Regional Medical Center, Paterson, New Jersey, USA
| | - Eric C McCarty
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Jonathan T Bravman
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, USA
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Zhang Y, Liu S, Guo W, Wang M, Hao C, Gao S, Zhang X, Li X, Chen M, Jing X, Wang Z, Peng J, Lu S, Guo Q. Human umbilical cord Wharton's jelly mesenchymal stem cells combined with an acellular cartilage extracellular matrix scaffold improve cartilage repair compared with microfracture in a caprine model. Osteoarthritis Cartilage 2018; 26:954-965. [PMID: 29391278 DOI: 10.1016/j.joca.2018.01.019] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 01/16/2018] [Accepted: 01/22/2018] [Indexed: 02/07/2023]
Abstract
OBJECTIVE As a novel and promising seed cell, human umbilical cord Wharton's jelly mesenchymal stem cells (hWJMSCs) are widely applied in tissue engineering. However, whether hWJMSCs can better repair and regenerate the articular cartilage in big animals than microfracture (MF, a predominant clinical treatment strategy for damaged cartilage) is unclear. Evaluation of the validity, and safety of hWJMSCs in a caprine model with a full-thickness femoral condyle articular cartilage defect, compared with MF is required. METHODS After cultivation and identification, hWJMSCs were seeded in an acellular cartilage extracellular matrix (ACECM)-oriented scaffold to construct cell-scaffold complex. Six goats with full-thickness femoral condyle articular cartilage defects were randomized to MF (microfracture group, MFG) and cell-scaffold complexes (experimental group, EG). At 2 and 4 weeks, joint fluid was used to assess immuno-inflammatory responses. At 6 and 9 months, all goats were euthanized for assessment of morphology, and magnetic resonance imaging (MRI), histology staining, and evaluation of the elasticity modulus and glycosaminoglycan (GAG) contents of the repaired regions. RESULTS There were no significant differences between the two groups in immuno-inflammatory parameters. MRI demonstrated higher-quality cartilage and complete subchondral bone at defect sites in the EG at 9 months. Histological staining showed that extracellular cartilage, cartilage lacuna and collagen type II levels were higher in the EG compared to the MFG, while the EG exhibited a higher elasticity modulus. CONCLUSIONS The hWJMSCs-ACECM scaffold complex achieved better quality repair and regeneration of hyaline cartilage without cartilage-inducing factor, while retaining the structure and functional integrity of the subchondral bone, compared with MF.
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Affiliation(s)
- Y Zhang
- Institute of Orthopaedics, Chinese PLA General Hospital, Beijing Key Lab of Regenerative Medicine in Orthopaedics, Key Laboratory of Musculoskeletal Trauma & War Injuries, PLA, 28 Fuxing Road, Haidian District, Beijing 100853, China; Institute of Orthopaedics, Drum Tower Hospital of Nanjing University Medical School, 321 Zhongshan Road, Gulou District, Nanjing 210008, China
| | - S Liu
- Institute of Orthopaedics, Chinese PLA General Hospital, Beijing Key Lab of Regenerative Medicine in Orthopaedics, Key Laboratory of Musculoskeletal Trauma & War Injuries, PLA, 28 Fuxing Road, Haidian District, Beijing 100853, China
| | - W Guo
- Institute of Orthopaedics, Chinese PLA General Hospital, Beijing Key Lab of Regenerative Medicine in Orthopaedics, Key Laboratory of Musculoskeletal Trauma & War Injuries, PLA, 28 Fuxing Road, Haidian District, Beijing 100853, China
| | - M Wang
- Institute of Orthopaedics, Chinese PLA General Hospital, Beijing Key Lab of Regenerative Medicine in Orthopaedics, Key Laboratory of Musculoskeletal Trauma & War Injuries, PLA, 28 Fuxing Road, Haidian District, Beijing 100853, China
| | - C Hao
- Institute of Anesthesia, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing 100853, China
| | - S Gao
- Academy for Advanced Interdisciplinary Studies, Peking University, No. 5 Yiheyuan Road, Haidian District, Beijing CN 154007, China
| | - X Zhang
- Shanxi Traditional Chinese, No. 46 Binzhou West Street, YingZe District, Taiyuan 030001, China
| | - X Li
- School of Medicine, Naikai University, Tianjin 300071, China
| | - M Chen
- Institute of Orthopaedics, Chinese PLA General Hospital, Beijing Key Lab of Regenerative Medicine in Orthopaedics, Key Laboratory of Musculoskeletal Trauma & War Injuries, PLA, 28 Fuxing Road, Haidian District, Beijing 100853, China
| | - X Jing
- First Department of Orthopedics, First Affiliated Hospital of Jiamusi University, Jiamusi 154007, China
| | - Z Wang
- Institute of Orthopaedics, Chinese PLA General Hospital, Beijing Key Lab of Regenerative Medicine in Orthopaedics, Key Laboratory of Musculoskeletal Trauma & War Injuries, PLA, 28 Fuxing Road, Haidian District, Beijing 100853, China
| | - J Peng
- Institute of Orthopaedics, Chinese PLA General Hospital, Beijing Key Lab of Regenerative Medicine in Orthopaedics, Key Laboratory of Musculoskeletal Trauma & War Injuries, PLA, 28 Fuxing Road, Haidian District, Beijing 100853, China
| | - S Lu
- Institute of Orthopaedics, Chinese PLA General Hospital, Beijing Key Lab of Regenerative Medicine in Orthopaedics, Key Laboratory of Musculoskeletal Trauma & War Injuries, PLA, 28 Fuxing Road, Haidian District, Beijing 100853, China
| | - Q Guo
- Institute of Orthopaedics, Chinese PLA General Hospital, Beijing Key Lab of Regenerative Medicine in Orthopaedics, Key Laboratory of Musculoskeletal Trauma & War Injuries, PLA, 28 Fuxing Road, Haidian District, Beijing 100853, China.
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Baba R, Onodera T, Matsuoka M, Hontani K, Joutoku Z, Matsubara S, Homan K, Iwasaki N. Bone Marrow Stimulation Technique Augmented by an Ultrapurified Alginate Gel Enhances Cartilage Repair in a Canine Model. Am J Sports Med 2018; 46:1970-1979. [PMID: 29763358 DOI: 10.1177/0363546518770436] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The optimal treatment for a medium- or large-sized cartilage lesion is still controversial. Since an ultrapurified alginate (UPAL) gel enhances cartilage repair in animal models, this material is expected to improve the efficacy of the current treatment strategies for cartilage lesions. HYPOTHESIS The bone marrow stimulation technique (BMST) augmented by UPAL gel can induce hyaline-like cartilage repair. STUDY DESIGN Controlled laboratory study. METHODS Two cylindrical osteochondral defects were created in the patellar groove of 27 beagle dogs. A total of 108 defects were divided into 3 groups: defects without intervention (control group), defects with the BMST (microfracture group), and defects with the BMST augmented by implantation of UPAL gel (combined group). At 27 weeks postoperatively, macroscopic and histological evaluations, micro-computed tomography assessment, and mechanical testing were performed for each reparative tissue. RESULTS The defects in the combined group were almost fully covered with translucent reparative tissues, which consisted of hyaline-like cartilage with well-organized collagen structures. The macroscopic score was significantly better in the combined group than in the control group ( P < .05). The histological scores in the combined group were significantly better than those in the control group ( P < .01) and microfracture group ( P < .05). Although the repaired subchondral bone volumes were not influenced by UPAL gel augmentation, the mechanical properties of the combined group were significantly better than those of the microfracture group ( P < .05). CONCLUSION The BMST augmented by UPAL gel elicited hyaline-like cartilage repair that had characteristics of rich glycosaminoglycan and matrix immunostained by type II collagen antibody in a canine osteochondral defect model. The present results suggest that the current technique has the potential to be one of the autologous matrix-induced chondrogenesis techniques of the future and to expand the operative indications for the BMST without loss of its technical simplicity. CLINICAL RELEVANCE The data support the clinical reality of 1-step minimally invasive cartilage-reparative medicine with UPAL gel without harvesting donor cells.
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Affiliation(s)
- Rikiya Baba
- Department of Orthopaedic Surgery, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Tomohiro Onodera
- Department of Orthopaedic Surgery, Graduate School of Medicine, Hokkaido University, Sapporo, Japan.,Global Institution for Collaborative Research and Education (GI-CoRE), Frontier Research Center for Advanced Material and Life Science, Hokkaido University, Sapporo, Japan
| | - Masatake Matsuoka
- Department of Orthopaedic Surgery, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Kazutoshi Hontani
- Department of Orthopaedic Surgery, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Zenta Joutoku
- Department of Orthopaedic Surgery, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Shinji Matsubara
- Department of Orthopaedic Surgery, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Kentaro Homan
- Department of Orthopaedic Surgery, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Norimasa Iwasaki
- Department of Orthopaedic Surgery, Graduate School of Medicine, Hokkaido University, Sapporo, Japan.,Global Institution for Collaborative Research and Education (GI-CoRE), Frontier Research Center for Advanced Material and Life Science, Hokkaido University, Sapporo, Japan
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Kraeutler MJ, Belk JW, Carver TJ, McCarty EC. Is Delayed Weightbearing After Matrix-Associated Autologous Chondrocyte Implantation in the Knee Associated With Better Outcomes? A Systematic Review of Randomized Controlled Trials. Orthop J Sports Med 2018; 6:2325967118770986. [PMID: 29770344 PMCID: PMC5946627 DOI: 10.1177/2325967118770986] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background: Proper rehabilitation after matrix-associated autologous chondrocyte implantation (MACI) is essential to restore a patient’s normal function without overloading the repair site. Purpose: To evaluate the current literature to assess clinical outcomes of MACI in the knee based on postoperative rehabilitation protocols, namely, the time to return to full weightbearing (WB). Study Design: Systematic review; Level of evidence, 1. Methods: A systematic review was performed to locate studies of level 1 evidence comparing the outcomes of patients who underwent MACI with a 6-week, 8-week, or 10/11-week time period to return to full WB. Patient-reported outcomes assessed included the Knee injury and Osteoarthritis Outcome Score (KOOS), Tegner activity scale, Short Form Health Survey–36 (SF-36), and visual analog scale (VAS) for pain frequency and severity. Results: Seven studies met the inclusion criteria, including a total of 136 patients (138 lesions) who underwent MACI. Treatment failure had occurred in 0.0% of patients in the 6-week group, 7.5% in the 8-week group, and 8.3% in the 10/11-week group at a mean follow-up of 2.5 years (P = .46). KOOS, SF-36, and VAS scores in each group improved significantly from preoperatively to follow-up (P < .001). Conclusion: Patients undergoing MACI in the knee can be expected to experience improvement in clinical outcomes with the rehabilitation protocols outlined in this work. No significant differences were seen in failure rates based on the time to return to full WB.
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Affiliation(s)
- Matthew J Kraeutler
- Department of Orthopaedic Surgery, Seton Hall-Hackensack Meridian School of Medicine, South Orange, New Jersey, USA
| | - John W Belk
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Trevor J Carver
- 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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Liu CY, Li CD, Wang L, Ren S, Yu FB, Li JG, Ma JX, Ma XL. Function scores of different surgeries in the treatment of knee osteoarthritis: A PRISMA-compliant systematic review and network-meta analysis. Medicine (Baltimore) 2018; 97:e10828. [PMID: 29794771 PMCID: PMC6393067 DOI: 10.1097/md.0000000000010828] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 04/30/2018] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Osteoarthritis (OA) is the third most common diagnosis made by general practitioners in older patients. The aim of this study was to compare the function scores of different surgeries in the treatment of knee osteoarthritis (KOA). METHODS Cohort studies about different surgical treatments for KOA were included with a comprehensive search in PubMed, Cochrane Library, and Embase. The standard mean difference (SMD) value was evaluated and the surface under the cumulative ranking (SUCRA) curve was drawn with a combination of direct and indirect evidence. A total of 265 eligible patients were enrolled and served as the nonoperative treatment group, osteotomy group, unicompartmental knee arthroplasty (UKA) group, total knee arthroplasty (TKA) group, and arthroscopic surgery group. Before surgery, 6 months after surgery, 1 year after surgery and 5 years after surgery, the hospital for special surgery (HSS) knee score, Lysholm score, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, and American knee society score (KSS) were recorded. RESULTS A total of 9 cohort studies including 954 patients with KOA were finally enrolled into the study. The network-meta analysis revealed that osteotomy and UKA treatments showed a better efficacy on improving the function score. Our cohort study further confirmed that, a higher HSS knee score after 1 year and higher Lysholm score after 6 months and 1 year were observed in the osteotomy and UKA groups, while better HSS knee score and KSS after 6 months and 1 year were showed in the osteotomy and TKA groups. In the TKA group, Lysholm score and KSS were higher and WOMAC score was lower after 5 years than other groups. WOMAC score was lowest in the UKA group after 6 months, 1 year and 5 years of surgery. CONCLUSION These results provide evidence that function scores of patients with KOA were improved by osteotomy, UKA, TKA, and arthroscopic surgery. And osteotomy and UKA showed better short-term efficacy, while TKA appeared better long-term efficacy.
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Affiliation(s)
| | | | - Liang Wang
- Department of Bone Trauma, The Sixth People's Hospital of Ji’nan City, Ji’nan, PR China
| | - Shan Ren
- Department of Bone and Joint Surgery
| | - Fu-Bin Yu
- Department of Bone and Joint Surgery
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Aae TF, Randsborg PH, Lurås H, Årøen A, Lian ØB. Microfracture is more cost-effective than autologous chondrocyte implantation: a review of level 1 and level 2 studies with 5 year follow-up. Knee Surg Sports Traumatol Arthrosc 2018; 26:1044-1052. [PMID: 29128878 PMCID: PMC5876257 DOI: 10.1007/s00167-017-4802-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 11/08/2017] [Indexed: 02/08/2023]
Abstract
PURPOSE Focal cartilage defects in the knee may have devastating effect on the knee joint, where two of the main surgical treatment options are microfracture and autologous chondrocyte implantation. Comparative studies have failed to establish which method yields the best clinical results. A cost-effectiveness analysis of microfracture and autologous chondrocyte implantation would contribute to the clinical decision process. METHODS A PubMed search identifying level I and level II studies with 5 year follow-up was performed. With the data from these studies, decision trees with associated service provision and costs connected to the two different techniques were designed. In addition to hospital costs, we included costs connected to physiotherapy following surgery. To paint a broader cost picture, we also included indirect costs to the society due to productivity loss caused by work absence. RESULTS Four high-quality studies, with a follow-up of 5 years, met the inclusion criteria. A total of 319 patients were included, 170 undergoing microfracture and 149 autologous chondrocyte implantation. The re-operation rate was 23 (13.5%) following microfracture, and 18 (12.1%) for autologous chondrocyte implantation. Both groups achieved substantially better clinical scores at 5 years compared to baseline. Microfracture was more cost-effective when comparing all clinical scores. CONCLUSION Microfracture is associated with both lower costs and lower cost per point increase in patient reported outcome measures. There is a need of well-designed, high-quality randomized controlled trials before reliable conclusions regarding cost-effectiveness in the long run is possible. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Tommy Frøseth Aae
- Department of Orthopedic Surgery, Kristiansund Hospital, 6518 Kristiansund, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Per-Henrik Randsborg
- Department of Orthopedic Surgery, Akershus University Hospital, 1478 Lørenskog, Norway
| | - Hilde Lurås
- Institute of Clinical Medicine, University of Oslo, Campus Ahus, 1478 Lørenskog, Norway
- Department of Health Services Research, Akershus University Hospital, 1478 Lørenskog, Norway
| | - Asbjørn Årøen
- Department of Orthopedic Surgery, Akershus University Hospital, 1478 Lørenskog, Norway
- Institute of Clinical Medicine, University of Oslo, Campus Ahus, 1478 Lørenskog, Norway
- Oslo Sports Trauma Research Center (OSTRC), Norwegian School of Sports Sciences, postboks 4014 Ullevål Stadion, 0806 Oslo, Norway
| | - Øystein Bjerkestrand Lian
- Department of Orthopedic Surgery, Kristiansund Hospital, 6518 Kristiansund, Norway
- Institute of Neuromedicine, Faculty of Medicine, Norwegian University of Science and Technology, 7491 Trondheim, Norway
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