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Andronic O, Lu V, Claydon-Mueller LS, Cubberley R, Khanduja V. Clinical Equipoise in the Management of Patients With Femoroacetabular Impingement Syndrome and Concomitant Tönnis Grade 2 Hip Osteoarthritis or Greater: An International Expert-Panel Delphi Study. Arthroscopy 2024; 40:2029-2038.e1. [PMID: 38158166 DOI: 10.1016/j.arthro.2023.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Revised: 12/17/2023] [Accepted: 12/19/2023] [Indexed: 01/03/2024]
Abstract
PURPOSE To gather global-expert opinion on the management of patients with femoroacetabular impingement syndrome (FAIS) and Tönnis grade 2 hip osteoarthritis (OA) or greater. METHODS An internet-based modified Delphi methodology was used via an online platform (Online Surveys) using the CREDES (Conducting and Reporting Delphi Studies) guidelines. The expert panel comprised 27 members from 18 countries: 21 orthopaedic surgeons (78%), 5 physiotherapists (18%), and 1 dual orthopaedic surgeon-sport and exercise medicine physician (4%). Comments and suggestions were collected during each round, and amendments were performed for the subsequent round. Between each pair of rounds, the steering panel provided the experts with a summary of results and amendments. Consensus was set a priori as minimum agreement of 80%. RESULTS Complete participation (100%) was achieved in all 4 rounds. A final list of 10 consensus statements was formulated. The experts agreed that there is no single superior management strategy for FAIS with Tönnis grade 2 OA and that Tönnis grade 3 OA and the presence of bilateral cartilage defects (acetabular and femoral) is a contraindication for hip preservation surgery. Nonoperative management should include activity modification and physiotherapy with hip-specific strengthening, lumbo-pelvic mobility training, and core strengthening. There was no consensus on the need for 3-dimensional imaging for initial quantification of joint degeneration. CONCLUSIONS There is clinical equipoise in terms of the best management strategy for patients with FAIS and Tönnis grade 2 OA, and therefore, there is an urgent need to perform a randomized controlled trial for this cohort of patients to ascertian the best management strategy. LEVEL OF EVIDENCE Level V, expert opinion.
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Affiliation(s)
- Octavian Andronic
- Department of Orthopaedics, Balgrist University Hospital, University of Zürich, Zürich, Switzerland; Medical Technology Research Centre, Anglia Ruskin University, Chelmsford, England; Department of Trauma and Orthopaedics, Young Adult Hip Service, Addenbrooke's-Cambridge University Hospital, Cambridge, England
| | - Victor Lu
- School of Clinical Medicine, University of Cambridge, Cambridge, England
| | | | - Rachael Cubberley
- Medical Technology Research Centre, Anglia Ruskin University, Chelmsford, England
| | - Vikas Khanduja
- Medical Technology Research Centre, Anglia Ruskin University, Chelmsford, England; Department of Trauma and Orthopaedics, Young Adult Hip Service, Addenbrooke's-Cambridge University Hospital, Cambridge, England.
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Blazey P, Scott A, Ardern CL, Davis JC, Whittaker JL, Losciale JM, Khan KM. Consensus methods in patellofemoral pain: how rigorous are they? A scoping review. Br J Sports Med 2024; 58:733-744. [PMID: 38777386 PMCID: PMC11228197 DOI: 10.1136/bjsports-2023-107552] [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: 04/24/2024] [Indexed: 05/25/2024]
Abstract
OBJECTIVE Clinicians treating patients with patellofemoral pain (PFP) rely on consensus statements to make the best practice recommendations in the absence of definitive evidence on how to manage PFP. However, the methods used to generate and assess agreement for these recommendations have not been examined. Our objective was to map the methods used to generate consensus-based recommendations for PFP and apply four novel questions to assess the rigour of consensus development. DESIGN Scoping review. DATA SOURCES We searched Medline, SPORTDiscus, CINAHL and Embase from inception to May 2022 to identify consensus-derived statements or practice guidelines on PFP. The Joanna Briggs Institute Manual for Evidence Synthesis was followed to map the existing evidence. We measured the consensus methods based on four sets of questions addressing the panel composition, application of the consensus method chosen, agreement process and the use of evidence mapping. ELIGIBILITY CRITERIA All consensus statements or clinical guidelines on PFP were considered. RESULTS Twenty-two PFP consensus statements were identified. Panel composition: 3 of the 22 (14%) consensus groups reported the panellists' experience, 2 (9%) defined a desired level of expertise, 10 (45%) reported panellist sex and only 2 (9%) included a patient. Consensus method: 7 of 22 (32%) reported using an established method of consensus measurement/development. Agreement process: 10 of 22 (45%) reported their consensus threshold and 2 (9%) acknowledged dissenting opinions among the panel. Evidence mapping: 6 of 22 (27%) reported using systematic methods to identify relevant evidence gaps. CONCLUSIONS PFP consensus panels have lacked diversity and excluded key partners including patients. Consensus statements on PFP frequently fail to use recognised consensus methods, rarely describe how 'agreement' was defined or measured and often neglect to use systematic methods to identify evidence gaps.
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Affiliation(s)
- Paul Blazey
- Department of Physical Therapy, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Aging SMART at Vancouver Coastal Health, Vancouver, British Columbia, Canada
| | - Alex Scott
- Department of Physical Therapy, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Aging SMART at Vancouver Coastal Health, Vancouver, British Columbia, Canada
| | - Clare L Ardern
- Department of Physical Therapy, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Aging SMART at Vancouver Coastal Health, Vancouver, British Columbia, Canada
- Sport and Exercise Medicine Research Centre, La Trobe University, Melbourne, Victoria, Australia
| | - Jennifer C Davis
- Applied Health Economics Laboratory, Faculty of Management, The University of British Columbia Okanagan, Kelowna, British Columbia, Canada
| | - Jackie L Whittaker
- Department of Physical Therapy, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
- Arthritis Research Canada, Vancouver, British Columbia, Canada
| | - Justin M Losciale
- Department of Physical Therapy, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
- Arthritis Research Canada, Vancouver, British Columbia, Canada
| | - Karim M Khan
- Department of Family Practice, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
- School of Kinesiology, The University of British Columbia, Vancouver, British Columbia, Canada
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Schneble CA. Detailed Assessment of Confounders is Necessary for Valid Interpretation of the Results in Patellofemoral Cartilage Restoration Studies. Arthroscopy 2024:S0749-8063(24)00255-X. [PMID: 38554813 DOI: 10.1016/j.arthro.2024.03.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 03/21/2024] [Indexed: 04/02/2024]
Abstract
Cartilage restoration procedures have gained increased traction over the years as a treatment for chondral defects in relatively younger patients. A critical assessment of study populations for confounders is vital in order to interpret results in a valid manner. This is particularly true when assessing outcomes of cartilage restoration procedures in the patellofemoral compartment given substantial heterogeneity amongst patients within study populations. Patients often undergo additional procedures (prior or concomitant), have variable anatomy (malalignment, maltracking, and trochlear dysplasia), and variable chondral defect sizes, depths, and locations (lateral patellar facet, medial patellar facet, median patellar ridge, trochlea). Without an assessment of study populations for potential confounders that may influence the results, limited conclusions can be gleaned from any results pertaining to the outcomes of cartilage restoration procedures within the patellofemoral joint. Finally, there are many choices for cartilage restoration (osteochondral autografting, osteochondral allografting, autologous chondrocyte implantation, autologous matrix-induced chondrogenesis and PJAC), different clinical situations where one may confer benefit over the other, yet all seem to result in significant improvement for patients with acceptable failure rates.
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Buyuk AF, Stannard JP, Rucinski K, Crecelius CR, Cook JL. The Missouri Osteochondral Preservation System Is Associated With Better Short-Term Outcomes Than Standard Preservation Methods When Performing Osteochondral Allograft Transplantation Using Shell Grafts for Patellofemoral Lesions. Arthroscopy 2023; 39:650-659. [PMID: 36306891 DOI: 10.1016/j.arthro.2022.10.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 09/28/2022] [Accepted: 10/03/2022] [Indexed: 11/06/2022]
Abstract
PURPOSE To compare outcomes after whole-surface osteochondral allograft (OCA) transplantation using shell grafts for treatment of patellofemoral joint lesions with respect to surfaces treated and OCA preservation method. METHODS With institutional review board approval and informed consent, patients were prospectively enrolled into a registry to follow outcomes after OCA transplantation. Patients who received patellofemoral shell OCA to treat the entire articular surface of the patella, trochlea, or both, and with a minimum of 2-year follow-up data, including patient-reported outcome measures (PROMs), failures, and complications, were included. Functional graft survival was determined based on patients returning to functional activities without need for OCA revision or arthroplasty surgery and calculated using the formula: 100% - (%revision + %failure). Minimum clinically important differences were determined based on previously validated data. Outcomes were compared based on differences in graft preservation methodology (Missouri Osteochondral Preservation System [MOPS] or standard preservation [SP]) and based on surfaces treated (patella, trochlea, or both). RESULTS Fifty-eight patients met inclusion criteria. Mean age was 36.7 years (range 15-60 years) and mean body mass index was 28.9 (range 18-42). OCAs stored using SP methods were transplanted in 12 patients, mean follow-up was (66.1 months; range 54-70 months): OCAs stored using MOPS methods were transplanted in 46 patients, mean follow-up was (44.8 months; range 24-60 months). Graft survival rate at final follow-up was significantly greater (P = .025) for MOPS OCAs (98%) compared with SP OCAs (75%), whereas 2-year functional graft survival rates (MOPS 98% vs SP 83%; P = .1) were not. Reoperation rate was significantly greater (P = .0014) for SP cases compared with MOPS cases. PROMs showed statistically significant and clinically meaningful improvements through 4 years after unipolar patella, unipolar trochlea, and bipolar patellofemoral OCA transplantation using MOPS grafts. Unipolar patella OCA transplantations were associated with significantly more reduction in pain and significantly better PROMs at 1-year compared with unipolar trochlea and bipolar patellofemoral OCAs. CONCLUSIONS OCA transplantation using MOPS shell grafts for unipolar and bipolar patellofemoral resurfacing was associated with statistically significant and clinically meaningful improvements from preoperative levels of pain and function. The 2-year functional graft survival rate was 83% in the SP group and 98% in the MOPS group, such that MOPS was associated with better short-term outcomes than SP methods when performing OCA transplantation using shell grafts for patellofemoral lesions. Patients who received unipolar patella allografts reported the best outcomes in terms of pain and function. LEVEL OF EVIDENCE Level III, retrospective analysis of registry data.
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Affiliation(s)
- Abdul Fettah Buyuk
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, USA
| | - James P Stannard
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, USA; Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri, USA
| | - Kylee Rucinski
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, USA; Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri, USA
| | - Cory R Crecelius
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, USA; Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri, USA
| | - James L Cook
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, USA; Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri, USA.
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Kaplan DJ, Chahla J. Editorial Commentary: Shell Grafts Are Viable in "Select" Cases, and Improved Preservation Techniques May Help Us Improve Our Outcomes. Arthroscopy 2023; 39:660-661. [PMID: 36740288 DOI: 10.1016/j.arthro.2022.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 12/07/2022] [Accepted: 12/16/2022] [Indexed: 02/07/2023]
Abstract
Patellofemoral joint chondral lesions can be challenging to treat with osteochondral allograft plugs because of the complex morphology and biomechanics of the patellofemoral joint Shell allografts replace the entirety of the damaged articular surface with a single osteochondral allograft piece (e.g., the entire trochlea or patella articular surface). Although technically demanding, shell grafts would allow for the treatment of bigger defects, correction of dysplasia, and for the treatment of uncontained lesions. However, shell allografts have historically shown inferior results than focal cylindrical grafts (bone plugs), with failure rates up to 38% based in the published literature. Although evidence exists demonstrating the efficacy of shell grafts in select cases, additional studies from multiple sources are required to support their continued use as well as determine the optimal graft-preservation techniques.
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Delman CM, Haffner M, Rinaldi P, Lum ZC, Jamali AA, Wilson M, Lee CA. Improving Technical Outcome in Osteochondral Allograft Transplantation of the Femoral Trochlea: The Role of Contoured Guides, Experience Level, Graft Size, and Graft Position. Orthop J Sports Med 2023; 11:23259671221145208. [PMID: 36818603 PMCID: PMC9929919 DOI: 10.1177/23259671221145208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 09/13/2022] [Indexed: 02/17/2023] Open
Abstract
Background The use of coring instrumentation for osteochondral allograft (OCA) transplantation of the femoral trochlea is challenging due to the complex topography of this anatomical area. Purpose We sought to determine the effect of flat guides versus guides contoured to the surface of the trochlea on graft step-off in trochlear OCAs performed on a foam bone model. We also determined the effect of surgeon experience level and graft size on step-off. Study Design Controlled laboratory study. Methods Allograft harvesters were produced in 3 different sequential sizes with either a flat or a contoured undersurface. The guides matched one another in all aspects of shape and size except for the undersurface contour. The contoured undersurface generally matched the surface of the bone model trochlea but was not customized to that surface. A total of 72 foam femora were obtained. Identical trochlear stellate lesions of 3 different sizes (small, medium, and large) were created using 3-dimensional printed surface templates. A total of 6 surgeons (3 attending and 3 resident surgeons) performed OCAs of each trochlear lesion. Each surgeon performed 1 graft for each size and each guide type (n = 6 per surgeon). A specialized digital caliper was prepared that allowed the measurement of graft step-off to within 0.01 mm at a distance of 5 mm between the 2 sensors. The measurements were performed at 8 positions around the clockface of the grafts. Results Grafts performed with the contoured guides had a mean step-off of 0.43 ± 0.37 mm. Grafts performed with the flat guides had a mean step-off of 0.74 ± 0.78 mm (P < .0001). Experience level did not have a significant effect on graft step-off (P = .81). There was no identifiable pattern indicating higher step-off at any one position on the clockface. Conclusion In this study, contoured grafts had significantly lower step-offs compared with flat guides. Experience level, clockface position, and graft size did not affect step-off.
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Affiliation(s)
- Connor M. Delman
- Department of Orthopaedic Surgery, University of California, Davis, School of Medicine, Sacramento, California, USA
| | - Max Haffner
- Department of Orthopaedic Surgery, University of California, Davis, School of Medicine, Sacramento, California, USA
| | - Peter Rinaldi
- Department of Orthopaedic Surgery, University of California, Davis, School of Medicine, Sacramento, California, USA
| | - Zach C. Lum
- Sports Medicine Associates of South Florida, Weston, Florida, USA
| | - Amir A. Jamali
- Joint Preservation Institute, Walnut Creek, California, USA.,Amir A. Jamali, MD, Joint Preservation Institute, 100 N. Wiget Lane, Suite 200, Walnut Creek, CA 94598, USA ()
| | - Machelle Wilson
- Division of Biostatistics, Department of Public Health Sciences University of California, Davis School of Medicine, Sacramento, California, USA
| | - Cassandra A. Lee
- Department of Orthopaedic Surgery, University of California, Davis, School of Medicine, Sacramento, California, USA
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Yokoe T, Tajima T, Yamaguchi N, Morita Y, Chosa E. Fixation of an Osteochondral Lesion of the Femoral Intercondylar Groove Using Autogenous Osteochondral Grafts and Bioabsorbable Pins in a Patient with Open Physes: A Case Report. Medicina (B Aires) 2022; 58:medicina58111528. [PMID: 36363485 PMCID: PMC9695273 DOI: 10.3390/medicina58111528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 10/17/2022] [Accepted: 10/24/2022] [Indexed: 11/05/2022] Open
Abstract
Osteochondral lesion (OCL) of the patellofemoral (PF) joint is not an uncommon cause of knee pain, and surgery is needed when conservative treatment fails. However, there is a lack of evidence regarding the optimal surgical treatment for OCL of the PF joint. Fixation of OCLs using autogenous osteochondral grafts has been reported to be effective for OCL of the knee. However, in this surgical technique, the biomechanical strength of osteochondral grafts may not be sufficient in patients with open physes due to the specific quality of the cartilage and subchondral bone given their age. There is a lack of studies reporting fixation of the OCL located in the PF joint using autogenous osteochondral grafts. We herein report a case of OCL of the femoral intercondylar groove where autogenous osteochondral grafts augmented with bioabsorbable pins were used to fix the lesion in a 14-year-old patient with open physes. Preoperative MRI revealed a completely detached OCL of the intercondylar groove (36 mm × 20 mm). Although a total of four osteochondral grafts were harvested from the non-weightbearing area of the lateral femoral condyle, cartilage detached from one of the grafts. The quality of the osteochondral grafts was considered to be insufficient for stabilization of the OCL; thus, two bioabsorbable pins were additionally inserted following fixation of the lesion using three osteochondral grafts. After two years of follow-up, postoperative functional scores were favorable without knee pain. The present case suggests that fixation of the OCL using autogenous osteochondral grafts may not be appropriate for young patients with open physes.
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Affiliation(s)
- Takuji Yokoe
- Correspondence: ; Tel.: +81-985-85-0986; Fax: 81-985-84-2931
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Hoburg A, Niemeyer P, Laute V, Zinser W, Becher C, Kolombe T, Fay J, Pietsch S, Kuźma T, Widuchowski W, Fickert S. Sustained superiority in KOOS subscores after matrix-associated chondrocyte implantation using spheroids compared to microfracture. Knee Surg Sports Traumatol Arthrosc 2022; 31:2482-2493. [PMID: 36269383 DOI: 10.1007/s00167-022-07194-x] [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] [Received: 01/07/2022] [Accepted: 10/03/2022] [Indexed: 11/05/2022]
Abstract
PURPOSE To evaluate the safety and efficacy of matrix-associated autologous chondrocyte implantation (ACI) using spheroids in comparison to arthroscopic microfracture for the treatment of symptomatic cartilage defects of the knee. METHODS In a prospective multicenter-controlled trial, patients aged between 18 and 50 years, with single symptomatic focal cartilage defects between 1 and 4 cm2 (mean 2.6 ± 0.8, median 2.75, range 1.44-5.00) in the knee were randomized to treatment with ACI with spheroids (n = 52) or microfracture (n = 50). Primary clinical outcome was assessed by the Knee Injury and Osteoarthritis Outcome Score (KOOS). Analyses were performed in a defined hierarchical manner where outcomes of ACI were first compared to baseline values followed by a comparison to the microfracture group with repeated-measures ANCOVA with a non-inferiority approach. Subgroup analyses were performed to investigate the influence of age and defect size on the overall KOOS. Secondary clinical outcomes were the magnetic resonance observation of cartilage repair tissue (MOCART), modified Lysholm score and International Knee Documentation Committee (IKDC) examination form. Safety data focused on adverse events. Here the 5 years results are presented at which there were 33 observed cases in the ACI group and 30 in the microfracture group. RESULTS The overall KOOS and its five subscores were significantly improved compared to baseline for both the ACI and microfracture group. Non-inferiority of ACI to microfracture was confirmed for the overall KOOS and the subscores, while for the subscores activities of daily living, quality of life and sports and recreation of the threshold for superiority was passed. In the ACI group, a notably more rapid initial improvement of the KOOS was found at three months for the older age group compared to the younger age group and the microfracture group. No other differences were found based on age or defect size. In addition, clinical improvement was found for the MOCART, modified Lysholm and IKDC examination form both the ACI and microfracture group. No safety concern related to either treatment was observed. CONCLUSION This study confirms the safety and efficacy of matrix-associated ACI with spheroids at a mid to long-term follow-up. Non-inferiority of ACI to microfracture was confirmed for the overall KOOS and all subscores, while superiority was reached for the subscores activities of daily living, quality of life and sports and recreation in the ACI group. This underlines the importance of ACI for the young and active patients. LEVEL OF EVIDENCE I.
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Affiliation(s)
- Arnd Hoburg
- Med Center 360 degree Berlin, Kieler Straße 1, 12163, Berlin, Germany.
| | - Philipp Niemeyer
- Department of Orthopedic Surgery and Traumatology, University Hospital, Freiburg, Germany.,OCM Clinic, Munich, Germany
| | - Volker Laute
- Med Center 360 degree Berlin, Kieler Straße 1, 12163, Berlin, Germany
| | - Wolfgang Zinser
- Department of Orthopedic Surgery and Traumatology, St. Vinzenz-Hospital, Dinslaken, Germany
| | - Christoph Becher
- Department of Orthopedic Surgery, Medical University Annastift, Hannover, Germany
| | - Thomas Kolombe
- Traumatology and Reconstructive Surgery, DRK Hospital, Luckenwalde, Germany
| | - Jakob Fay
- Department of Traumatology and Arthroscopic Surgery, Lubinus Clinicum, Kiel, Germany
| | - Stefan Pietsch
- Department of Orthopedic Surgery and Traumatology, Rudolf Elle Hospital, Eisenberg, Germany
| | - Tomasz Kuźma
- Department of Orthopedic Surgery and Traumatology, Center of Sports Medicine, Orthopedic Clinic, Warsaw, Poland
| | | | - Stefan Fickert
- Sporthopaedicum Straubing, Straubing, Germany.,Department of Orthopedic Surgery and Traumatology, Medical Faculty Mannheim, University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany
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Yanke AB, Hevesi M, Dandu N, Trasolini NA, Darwish RY, Zavras AG, Cole BJ. After Chondroplasty, Patient Election to Proceed With Cartilage Transplantation Is Closely and Additively Associated With Preoperative AMADEUS (Area Measurement And DEpth Underlying Structure) Grade, Condylar Involvement, Knee Injury and Osteoarthritis Outcome Score Pain Score, and Veterans Rand 12-Item Health Survey Physical Score. Arthrosc Sports Med Rehabil 2022; 4:e1903-e1912. [PMID: 36579045 PMCID: PMC9791869 DOI: 10.1016/j.asmr.2022.07.005] [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: 10/05/2021] [Revised: 07/11/2022] [Accepted: 07/13/2022] [Indexed: 12/31/2022] Open
Abstract
Purpose To identify risk factors for patient election to proceed with cartilage transplant after staging chondroplasty. Methods This study retrospective reviewed patients prospectively enrolled at the time of staging chondroplasty, with early election defined as patient decision to proceed to cartilage transplantation within 6 months of chondroplasty. Cox proportional hazards analysis was used to determine univariate predictors of conversion, and a predictive calculator, the Cartilage Early Return for Transplant score, was formulated using stepwise regression employing the Akaike information criterion. Receiver operator curves and the area under the curve were used to evaluate the predictive ability of the final model on the studied patient population. Results Sixty-five knees (63 patients) were evaluated, with an overall transplant election rate of 27.7% within 6 months after chondroplasty. Based on multivariate results, the final Akaike information criterion-driven Cartilage Early Return for Transplant score employed preoperative Knee Injury and Osteoarthritis Outcome Score Pain Score, Veterans Rand 12-Item Health Survey Physical Score, condylar involvement, and AMADEUS (Area Measurement And DEpth Underlying Structure) score to generate a 0- to 7-point risk-stratification system with a 3% early election to proceed to transplant risk in the 0- to 2-point score group, 33% risk in the 3- to 4-point group, and 79% risk in the 5+-point group (P < .01) and an overall AUC of 0.906 (P < .01). Conclusions Risk of early patient election to pursue cartilage transplantation after chondroplasty is closely and additively associated with preoperative AMADEUS grade, condylar involvement, Knee Injury and Osteoarthritis Outcome Score Pain Score, and Veterans Rand 12-Item Health Survey Physical Score. Clinical Relevance Understanding risk factors for conversion to cartilage transplantation may improve preoperative planning and counseling prior to staging chondroplasty.
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Affiliation(s)
- Adam B. Yanke
- Address correspondence to Adam B. Yanke, M.D., Ph.D., 1611 W. Harrison St., St 300, Chicago, IL 60612.
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Next Generation Cartilage Repair and the Pre-arthroplasty Patient. OPER TECHN SPORT MED 2022. [DOI: 10.1016/j.otsm.2022.150956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Gillinov SM, Fosam A, Burroughs PJ, Schneble CA, McLaughlin WM, Moran J, Jimenez AE, Grauer JN, Medvecky MJ. Incidence, Timing, and Risk Factors for 5-Year Revision Surgery After Autologous Chondrocyte Implantation in 533 Patients. Am J Sports Med 2022; 50:2893-2899. [PMID: 35916771 DOI: 10.1177/03635465221111115] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Autologous chondrocyte implantation (ACI) can be used to treat focal, full-thickness chondral defects of the knee. However, there is limited large-sample evidence available regarding the incidence, timing, and risk factors for revision surgery after ACI. PURPOSE To assess the 5-year incidence, timing, and risk factors for revision surgery after ACI in a large national cohort. STUDY DESIGN Case series; Level of evidence, 4. METHODS The 2010-2020 PearlDiver database was queried for patients aged 20 to 59 years who underwent primary ACI of the knee without previous chondral procedures or knee arthroplasty. Revision surgery was defined as subsequent revision ACI, osteochondral allograft transplantation, osteochondral autograft transfer, unicompartmental knee arthroplasty, or total knee arthroplasty within 5 years. Kaplan-Meier analysis was used to assess both incidence and timing of revision surgery. Risk factors evaluated for revision surgery included patient age, sex, body mass index (BMI), Elixhauser Comorbidity Index (ECI) score, and previous or concomitant bony realignment procedures. RESULTS In total, 533 patients underwent primary ACI and met inclusion criteria. The 5-year incidence of revision surgery was 10.3%, with 63% of revisions occurring in the first 2 years after surgery. Risk factors associated with revision surgery included female sex (odds ratio, 2.58; 95% CI, 1.22-5.45; P = .013) and BMI ≥35 (odds ratio, 2.24; 95% CI, 1.01-4.94; P = .047). There was no relationship between age, ECI score, or previous or concomitant bony realignment procedures and revision surgery at 5 years (P > .05). CONCLUSION In an analysis of 533 patients who underwent ACI, 10.3% required a subsequent articular cartilage procedure or conversion to knee arthroplasty in the first 5 postoperative years. Revision surgery was greatest in the first 2 postoperative years. Female sex and severe obesity (BMI, ≥35) were associated with increased risk of revision surgery, while age, ECI score, and previous or concomitant bony realignment procedures were not. These findings suggest that treatment of chondral defects of the knee with ACI is associated with durable outcomes at the 5-year follow-up.
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Affiliation(s)
| | - Andin Fosam
- Yale School of Medicine, New Haven, Connecticut, USA
| | | | - Christopher A Schneble
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut, USA
| | - William M McLaughlin
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut, USA
| | - Jay Moran
- Yale School of Medicine, New Haven, Connecticut, USA
| | - Andrew E Jimenez
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut, USA
| | - Jonathan N Grauer
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut, USA
| | - Michael J Medvecky
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut, USA
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Gelber PE, Ramírez-Bermejo E, Grau-Blanes A, Gonzalez-Osuna A, Fariñas O. Computerized tomography scan evaluation after fresh osteochondral allograft transplantation of the knee correlates with clinical outcomes. INTERNATIONAL ORTHOPAEDICS 2022; 46:1539-1545. [PMID: 35411436 PMCID: PMC9166817 DOI: 10.1007/s00264-022-05373-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 03/06/2022] [Indexed: 11/17/2022]
Abstract
Purpose
To determine the correlation between the assessment computed tomography osteochondral allograft (ACTOCA) scoring system and clinical outcomes scores. The hypothesis was that the ACTOCA score would show sufficient correlation to support its use in clinical practice. Methods We prospectively collected data from all consecutive patients who underwent cartilage restitution with fresh osteochondral allograft (FOCA) transplantation for osteochondral lesions of the knee and had a minimum follow-up of two years. CT scans were performed at three, six and 24 months post-operatively. A musculoskeletal radiologist blinded to the patients’ medical history evaluated the scans using the ACTOCA scoring system. Clinical outcomes collected preoperatively and at three, six and 24 months postoperatively were evaluated using the International Knee Documentation Committee (IKDC), Kujala, the Western Ontario Meniscal Evaluation Tool (WOMET), and the Tegner Activity Scale. Results The mean total ACTOCA score showed a statistically significant correlation with the clinical outcome. The correlation was optimal at 24 months. We found a high negative correlation with the IKDC, Kujala and Tegner (− 0.737; − 0.757, and − 0.781 respectively), and a moderate negative correlation with WOMET (− 0.566) (p < 0.001). IKDC, Kujala, WOMET, and Tegner scores showed a significant continuous improvement in all scores (p < 0.001). Conclusion The mean total ACTOCA score showed a linear correlation with clinical results in IKDC, Kujala, WOMET, and Tegner scores, being the highest at 24 months post-surgery. This finding supports the use of ACTOCA to standardize CT scan reports following fresh osteochondral allograft transplantation in the knee.
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Affiliation(s)
- Pablo Eduardo Gelber
- Department of Orthopaedic Surgery, Hospital de La Santa Creu I Sant Pau, Universitat Autonoma de Barcelona, C/Sant Quintí 89, 08041, Barcelona, Catalunya, Spain.
- ICATME-Hospital Universitari Dexeus, Universitat Autonoma de Barcelona, Barcelona, Spain.
| | - Eduard Ramírez-Bermejo
- Department of Orthopaedic Surgery, Hospital de La Santa Creu I Sant Pau, Universitat Autonoma de Barcelona, C/Sant Quintí 89, 08041, Barcelona, Catalunya, Spain
| | - Alex Grau-Blanes
- Department of Orthopaedic Surgery, Hospital de La Santa Creu I Sant Pau, Universitat Autonoma de Barcelona, C/Sant Quintí 89, 08041, Barcelona, Catalunya, Spain
| | - Aránzazu Gonzalez-Osuna
- Department of Orthopaedic Surgery, Hospital de La Santa Creu I Sant Pau, Universitat Autonoma de Barcelona, C/Sant Quintí 89, 08041, Barcelona, Catalunya, Spain
| | - Oscar Fariñas
- Barcelona Tissue Bank, Banc de Sang I Teixits, Barcelona, Spain
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Kuwabara A, Cinque M, Ray T, Sherman SL. Treatment Options for Patellofemoral Arthritis. Curr Rev Musculoskelet Med 2022; 15:90-106. [PMID: 35118631 PMCID: PMC9083346 DOI: 10.1007/s12178-022-09740-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/29/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE OF REVIEW To present a synthesis of recent literature regarding the treatment of patellofemoral arthritis RECENT FINDINGS: Risk factors of PFJ OA include patella malalignment or maltracking, injury to supportive structures including the MPFL, dysfunction of hamstring and quadriceps coordination, lower limb alignment, trochlear dysplasia, patellar trauma, or ACL surgery. Special physical exam maneuvers include patellar grind test, apprehension test, and lateral patellar tilt angle. Radiographs that should be obtained first-line include weight bearing bilateral AP, lateral, and Merchant views. CT and MRI are used to assess trochlear dysplasia, excessive patellar height, and TT-TG distance. Non-operative management options discussed include non-pharmacologic treatment (patient education, self-management, physical therapy, weight loss), ESWT, cold therapy, taping, bracing, and orthotics. Pharmacologic management options discussed include NSAIDs, acetaminophen, oral narcotics, and duloxetine. Injection therapies include glucocorticoids, hyaluronic acid, PRP, and other regenerative therapies (BMAC, adipose, or mesenchymal stem cells). Other treatment options include radiofrequency ablation and botulinum toxin. The algorithm for the surgical treatment of PFJ OA can begin with arthroscopic assessment of the PF articular cartilage to address mechanical symptoms and to evaluate/treat lateral soft tissue with or without overhanging lateral osteophytes. If patients fail to have symptomatic improvement, a TTO can be considered in those patients less than 50 years of age or active patients >50 years old. In patients with severe PFJ OA, refractory to the above treatments, PFA should be considered. While early PFA design and technique were less than encouraging, more recent implant design and surgical technique have demonstrated robust results in the literature. Patellofemoral osteoarthritis is a challenging orthopedic problem to treat, in that it can often affect younger patients, with otherwise well-functioning knees. It is a unique entity compared to TF OA with distinct epidemiology, biomechanics and risk factors and treatment options.
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Affiliation(s)
- Anne Kuwabara
- Department of Orthopaedic Surgery, Division of Physical Medicine and Rehabilitation, Stanford University, 450 Broadway Street, Pavilion C, 4th Floor, Redwood City, CA 94063 USA
| | - Mark Cinque
- Department of Orthopaedic Surgery, Division of Physical Medicine and Rehabilitation, Stanford University, 450 Broadway Street, Pavilion C, 4th Floor, Redwood City, CA 94063 USA
| | - Taylor Ray
- Department of Orthopaedic Surgery, Division of Physical Medicine and Rehabilitation, Stanford University, 450 Broadway Street, Pavilion C, 4th Floor, Redwood City, CA 94063 USA
| | - Seth Lawrence Sherman
- Department of Orthopaedic Surgery, Division of Physical Medicine and Rehabilitation, Stanford University, 450 Broadway Street, Pavilion C, 4th Floor, Redwood City, CA 94063 USA
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Hoburg A, Niemeyer P, Laute V, Zinser W, John T, Becher C, Izadpanah K, Diehl P, Kolombe T, Fay J, Siebold R, Fickert S. Safety and Efficacy of Matrix-Associated Autologous Chondrocyte Implantation With Spheroids for Patellofemoral or Tibiofemoral Defects: A 5-Year Follow-up of a Phase 2, Dose-Confirmation Trial. Orthop J Sports Med 2022; 10:23259671211053380. [PMID: 35071653 PMCID: PMC8777354 DOI: 10.1177/23259671211053380] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 07/14/2021] [Indexed: 11/15/2022] Open
Abstract
Background: Matrix-associated autologous chondrocyte implantation (ACI) is a
well-established treatment for cartilage defects. High-level evidence at
midterm follow-up is limited, especially for ACI using spheroids (spherical
aggregates of ex vivo expanded human autologous chondrocytes and
self-synthesized extracellular matrix). Purpose: To assess the safety and efficacy of 3-dimensional matrix-associated ACI
using spheroids to treat medium to large cartilage defects on different
locations in the knee joint (patella, trochlea, and femoral condyle) at
5-year follow-up. Study Design: Cohort study; Level of evidence, 2. Methods: A total of 75 patients aged 18 to 50 years with medium to large (4-10
cm2), isolated, single cartilage defects, International
Cartilage Repair Society grade 3 or 4, were randomized on a single-blind
basis to treatment with ACI at 1 of 3 dose levels: 3 to 7, 10 to 30, or 40
to 70 spheroids/cm2 of defect size. Outcomes were assessed via
changes from baseline Knee injury and Osteoarthritis Outcome Score (KOOS),
International Knee Documentation Committee score, and modified Lysholm
assessments at 1- and 5-year follow-up. Structural repair was evaluated
using MOCART (magnetic resonance observation of cartilage repair tissue)
score. Treatment-related adverse events were assessed up to 5 years for all
patients. The overall KOOS at 12 months was assessed for superiority versus
baseline in a 1-sample, 2-sided t test. Results: A total of 73 patients were treated: 24 in the low-dose group, 25 in the
medium-dose group, and 24 in the high-dose group. The overall KOOS improved
from 57.0 ± 15.2 at baseline to 73.4 ± 17.3 at 1-year follow-up
(P < .0001) and 76.9 ± 19.3 at 5-year follow-up
(P < .0001), independent of the applied dose. The
different defect locations (patella, trochlea, and weightbearing part of the
femoral condyles; P = .2216) and defect sizes
(P = .8706) showed comparable clinical improvement. No
differences between the various doses were observed. The overall treatment
failure rate until 5 years was 4%. Most treatment-related adverse events
occurred within the first 12 months after implantation, with the most
frequent adverse reactions being joint effusion (n = 71), arthralgia (n =
14), and joint swelling (n = 9). Conclusion: ACI using spheroids was safe and effective for defect sizes up to 10
cm2 and showed maintenance of efficacy up to 5 years for all
3 doses that were investigated. Registration: NCT01225575 (ClinicalTrials.gov identifier); 2009-016816-20 (EudraCT
number).
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Affiliation(s)
| | - Philipp Niemeyer
- Department of Orthopedic Surgery and Traumatology, Freiburg University Hospital, Germany and OCM Clinic, Munich, Germany
| | | | - Wolfgang Zinser
- Department of Orthopedic Surgery and Traumatology, St. Vinzenz Hospital, Dinslaken, Germany
| | - Thilo John
- Clinic for Traumatology and Orthopedic Surgery, DRK Hospital Westend, Berlin, Germany
| | - Christoph Becher
- Department of Orthopaedic Surgery, Hannover Medical School, Diakovere Annastift, Hannover, Germany
| | - Kaywan Izadpanah
- Department of Orthopedic and Trauma Surgery, Freiburg University Hospital, Freiburg, Germany
| | - Peter Diehl
- Department of Orthopedic Surgery and Traumatology, Orthopedic Center Munich East, Munich, Germany
| | - Thomas Kolombe
- Traumatology and Reconstructive Surgery, DRK Hospital, Luckenwalde, Germany
| | - Jakob Fay
- Department of Traumatology and Arthroscopic Surgery, Lubinus Clinicum, Kiel, Germany
| | - Rainer Siebold
- Center for Hip, Knee and Foot Surgery, ATOS Clinic, Heidelberg, Germany
| | - Stefan Fickert
- Sporthopaedicum, Straubing, Germany
- Department of Orthopedic Surgery and Traumatology, Mannheim University Hospital, Mannheim, Germany
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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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16
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Roberti Di Sarsisa T, Fiore M, Coco V, Govoni M, Vivarelli L, Rani N, Del Piccolo N, Dallari D. Fresh Osteochondral Allograft Transplantation in Osteochondritis Dissecans in the Knee Joint. Life (Basel) 2021; 11:life11111205. [PMID: 34833081 PMCID: PMC8622509 DOI: 10.3390/life11111205] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 10/27/2021] [Accepted: 11/05/2021] [Indexed: 02/07/2023] Open
Abstract
Osteochondritis dissecans (OCD) is a chronic and painful joint condition that can occur from childhood through to adult life. Microtrauma, vascular insufficiency, or abnormal endochondral ossification are the most common causes of OCD. Reconstructive techniques for OCD of the knee are typically necessary when either non-operative or reparative/regenerative operative treatments fail, or when the OCD is irreversible. To analyze the clinical outcomes and failure rates of fresh osteochondral allograft transplantation (FOCA) used as a reconstructive strategy in OCD patients, an in-depth search was carried out on the PubMed, Scopus, and Web of Science databases concerning the existing evidence related to the use of FOCA for OCD patients in the knee joint. A total of 646 studies were found through the search and 2 studies were added after a cross-referenced examination of the articles within the bibliography. Six studies with a total of 303 OCD lesions treated with FOCA, with a mean follow-up of 6.3 years, were included. Although a limited number of low-level evidence studies on this topic are available in previous research, satisfactory clinical results and survival rates of the reconstruction are reported. However, to better define the real advantages of FOCA in the healing process of OCD lesions, comparative studies with different techniques are needed.
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17
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Ossendorff R, Walter SG, Salzmann GM. [Patellofemoral cartilage repair]. SPORTVERLETZUNG-SPORTSCHADEN 2021; 35:202-209. [PMID: 34474494 DOI: 10.1055/a-1491-2622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Anterior knee pain is a frequent symptom in young athletes. Symptomatic patellofemoral cartilage defects can occur after trauma, especially after patellar dislocation. Numerous cartilage repair methods are currently available. Due to co-pathologies, the outcome after patellofemoral cartilage repair is inferior to the treatment of cartilage defects of the tibiofemoral joint. Adequate addressing of coexisting pathologies is essential for treatment success. This review provides an overview of the different techniques of patellofemoral cartilage repair.
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18
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Patel RM, Wright-Chisem J, Williams RJ. Anteriorizing Tibial Tubercle Osteotomy for Patellofemoral Cartilage Lesions. Arthrosc Tech 2021; 10:e2181-e2187. [PMID: 34504759 PMCID: PMC8417512 DOI: 10.1016/j.eats.2021.05.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 05/26/2021] [Indexed: 02/03/2023] Open
Abstract
Patellofemoral chondral lesions are common and can lead to significant pain. A tibial tubercle osteotomy (TTO) functions to mechanically unload the patellofemoral joint and improve the clinical success of cartilage restoration procedures. The type of TTO performed is based on several factors. There is a subset of patients with patellofemoral cartilage disease who would benefit from a pure anteriorization of the tibial tubercle. We describe our technique for a pure anteriorization TTO, which functions to safely unload the patellofemoral joint in the appropriately indicated patient.
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Affiliation(s)
- Ronak M. Patel
- Address correspondence to Ronak M. Patel, M.D., Hospital for Special Surgery, 535 E. 70th St., New York, NY 10021.
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19
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Gowd AK, Weimer AE, Rider DE, Beck EC, Agarwalla A, O'Brien LK, Alaia MJ, Ferguson CM, Waterman BR. Cartilage Restoration for Tibiofemoral Bipolar Lesions Results in Promising Failure Rates: A Systematic Review. Arthrosc Sports Med Rehabil 2021; 3:e1227-e1235. [PMID: 34430903 PMCID: PMC8365214 DOI: 10.1016/j.asmr.2021.03.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 03/31/2021] [Indexed: 02/08/2023] Open
Abstract
Purpose The purpose of the present study is to systematically review the available literature for management of bipolar lesions within the tibiofemoral joint and determine whether tibiofemoral cartilage restoration is an effective treatment modality. Methods PubMed and MEDLINE databases were queried between 2000 and 2020 using the following keywords: “osteochondral” and “knee” and “microfracture,” “autologous chondrocyte implantation (ACI),” or “transplantation." Articles were reviewed for the presence of a bipolar or “kissing” tibiofemoral lesion and reported lesion size, concomitant procedures, failure rates, and time to failure. Results After screening 1,295 articles, there were 4 articles available for analysis and a total of 152 knees involving the management of bipolar tibiofemoral lesions. Age ranged from 14 to 60 years, and mean follow-up was between 12 and 240 months. There was 1 retrospective cohort study (36 knees) and 3 case series (mean, 38.7 ± 17.5 knees). There were 58 knees treated with bipolar osteochondral allograft (OCA) transplantation, 58 knees treated with bipolar ACI, 20 knees treated with femoral OCA and tibial debridement, and 16 knees treated with femoral OCA and tibial microfracture. There were 37 failures (24.3%): 16 patients (10.5%) were converted to unicompartmental or total knee arthroplasty, 4 restorative procedures (2.6%) were revised, and 8 patients (1.6%) had unsatisfactory outcomes only. The remaining 15 failures (9.9%) had an unspecified combination of objective failure. The mean rate of failure ranged between 0% and 44.1% (I2 = 83.2%). The mean time to failure ranged between 2.7 and 4.1 years (I2 = 79.1%). Conclusions Cartilage restoration, through both ACI and OCA, had failure rates between 0% and 44% in patients with bipolar lesions of the tibiofemoral compartment. Although a higher level of evidence is required to prove efficacy, the current study demonstrates midterm survivorship rates between 55% and 100%, which may delay the need for secondary arthroplasty. Level of Evidence Level IV, systematic review of Level IV studies.
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Affiliation(s)
- Anirudh K Gowd
- Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina, U.S.A
| | - Alexander E Weimer
- Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina, U.S.A
| | - Danielle E Rider
- Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina, U.S.A
| | - Edward C Beck
- Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina, U.S.A
| | | | - Lisa K O'Brien
- Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina, U.S.A
| | - Michael J Alaia
- New York University Langone Health, New York, New York, U.S.A
| | - Cristin M Ferguson
- Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina, U.S.A
| | - Brian R Waterman
- Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina, U.S.A
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Gowd AK, Weimer AE, Rider DE, Beck EC, Agarwalla A, O'Brien LK, Alaia MJ, Ferguson CM, Waterman BR. Cartilage Restoration of Bipolar Lesions Within the Patellofemoral Joint Delays Need for Arthroplasty: A Systematic Review of Rates of Failure. Arthrosc Sports Med Rehabil 2021; 3:e1189-e1197. [PMID: 34430900 PMCID: PMC8365210 DOI: 10.1016/j.asmr.2021.02.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 02/10/2021] [Indexed: 02/08/2023] Open
Abstract
Purpose The purpose of the present review is to systematically review the available literature for failure rates and complications of cartilage restoration of bipolar chondral defects in the patellofemoral (PF) joint to assess the ability to treat these lesions without arthroplasty. Methods PubMed and MEDLINE databases were queried between 2000 to 2020 using the keywords "osteochondral" and "knee" and "microfracture," "autologous chondrocyte implantation (ACI)," or "transplantation." Patient selection included patients with bipolar chondral lesions of the patellofemoral joint that were treated with cartilage restoration procedures. Treatment of PF joints were reviewed for surgical indications/technique, rates of failure, defect characteristics, and time to failure. For the purposes of this study, failure was defined by each individual author on their respective studies. Results After screening 1,295 articles, there were 8 publications analyzed quantitatively and 10 articles analyzed both quantitatively and qualitatively. A total of 249 knees involved bipolar lesions of the patellofemoral joint. The weighted average age was 36.5 ± 10.4 years, and weighted average follow-up was 89.0 ± 31.7 months. There were failures in 0% to 50% of cases, revision procedures in 0% to 10% of cases, conversion to arthroplasty in in 0% to 50% of cases, and unsatisfactory outcome without revision in 0% to 8.3% of cases. The range in average failure rate was 0% to 50.0% (I2 = 68.0%), whereas the range in average time to failure was 2.9 to 6.8 years (I2 = 79.0%). Conclusion From the available data, established cartilage restoration procedures may provide favorable patient-reported function, avoidance of secondary surgery, and joint preservation in at least 80% of patients at short- to mid-term follow-up. Level of Evidence Level IV, systematic review of Level IV studies.
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Affiliation(s)
- Anirudh K Gowd
- Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina
| | - Alexander E Weimer
- Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina
| | - Danielle E Rider
- Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina
| | - Edward C Beck
- Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina
| | | | - Lisa K O'Brien
- Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina
| | - Michael J Alaia
- New York University Langone Health, New York, New York, U.S.A
| | - Cristin M Ferguson
- Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina
| | - Brian R Waterman
- Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina
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21
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Arthroscopic Subchondral Drilling Followed by Injection of Peripheral Blood Stem Cells and Hyaluronic Acid Showed Improved Outcome Compared to Hyaluronic Acid and Physiotherapy for Massive Knee Chondral Defects: A Randomized Controlled Trial. Arthroscopy 2021; 37:2502-2517. [PMID: 34265388 DOI: 10.1016/j.arthro.2021.01.067] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 01/18/2021] [Accepted: 01/25/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to evaluate the safety and efficacy of intra-articular injections of autologous peripheral blood stem cells (PBSCs) plus hyaluronic acid (HA) after arthroscopic subchondral drilling into massive chondral defects of the knee joint and to determine whether PBSC therapy can improve functional outcome and reduce pain of the knee joint better than HA plus physiotherapy. METHODS This is a dual-center randomized controlled trial (RCT). Sixty-nine patients aged 18 to 55 years with International Cartilage Repair Society grade 3 and 4 chondral lesions (size ≥3 cm2) of the knee joint were randomized equally into (1) a control group receiving intra-articular injections of HA plus physiotherapy and (2) an intervention group receiving arthroscopic subchondral drilling into chondral defects and postoperative intra-articular injections of PBSCs plus HA. The coprimary efficacy endpoints were subjective International Knee Documentation Committee (IKDC) and Knee Injury and Osteoarthritis Outcome Score (KOOS)-pain subdomain measured at month 24. The secondary efficacy endpoints included all other KOOS subdomains, Numeric Rating Scale (NRS), and Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) scores. RESULTS At 24 months, the mean IKDC scores for the control and intervention groups were 48.1 and 65.6, respectively (P < .0001). The mean for KOOS-pain subdomain scores were 59.0 (control) and 86.0 (intervention) with P < .0001. All other KOOS subdomain, NRS, and MOCART scores were statistically significant (P < .0001) at month 24. Moreover, for the intervention group, 70.8% of patients had IKDC and KOOS-pain subdomain scores exceeding the minimal clinically important difference values, indicating clinical significance. There were no notable adverse events that were unexpected and related to the study drug or procedures. CONCLUSIONS Arthroscopic marrow stimulation with subchondral drilling into massive chondral defects of the knee joint followed by postoperative intra-articular injections of autologous PBSCs plus HA is safe and showed a significant improvement of clinical and radiologic scores compared with HA plus physiotherapy. LEVEL OF EVIDENCE Level I, RCT.
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22
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Reconstruction of Large Osteochondral Lesions in the Knee: Focus on Fixation Techniques. Life (Basel) 2021; 11:life11060543. [PMID: 34200546 PMCID: PMC8226590 DOI: 10.3390/life11060543] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 04/28/2021] [Accepted: 06/04/2021] [Indexed: 11/17/2022] Open
Abstract
Large (>3 cm2), focal osteochondral lesions (OCL) may result in poor functional outcomes and early secondary osteoarthritis of the knee. The surgical management of these OCL remains challenging. The treatment strategy must be tailored to various aspects, including lesion-specific (e.g., size, location, chronicity), joint-specific (e.g., instability, limb alignment, meniscal status), and patient-specific factors (e.g., age, activity level, comorbidities). Simple chondroplasty and bone marrow stimulation (BMS) techniques should be reserved for smaller lesions, as they only realize midterm clinical benefits, related to inferior wear characteristics of the induced fibrocartilage (type I collagen). Therefore, much attention has been focused on surgical restoration with hyaline cartilage (type II collagen), based on chondrocyte transplantation and matrix-assisted autologous chondrocyte implantation (MACI). Limited graft availability, staged procedures (MACI), and high treatment costs are limitations of these techniques. However, acute traumatic OCL of the femoral condyles and patellofemoral joint may also be suitable for preservation by surgical fixation. Early detection of the fragment facilitates primary repair with internal fixation. The surgical repair of the articular surface may offer promising clinical and cost-effective benefits as a first-line therapy but remains under-investigated and potentially under-utilized. As a unique characteristic, the fixation technique allows the anatomic restoration of the hyaline articular surface with native cartilage and the repair of the subchondral bone. In this manuscript, we present a case series of large OCL around the knee that were preserved by surgical fixation. Furthermore, various implants and techniques reported for this procedure are reviewed.
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Cowie RM, Bowland P, Baji D, Fermor HL, Ingham E, Fisher J, Jennings LM. An experimental simulation model to assess wear of the porcine patellofemoral joint. PLoS One 2021; 16:e0250077. [PMID: 33901210 PMCID: PMC8075233 DOI: 10.1371/journal.pone.0250077] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 03/30/2021] [Indexed: 12/05/2022] Open
Abstract
A range of surgical techniques and osteochondral interventions have been developed for early stage chondral/osteochondral repair interventions in the knee however, methods for functional, pre-clinical assessment of these therapies are limited. In this study, a method for simulating physiological loading and motion in the porcine patellofemoral joint was developed using a 6-axis simulator. As an example of how the method can be used, the influence of surgical positioning of osteochondral allografts in the patella on cartilage wear, deformation and damage and graft stability was investigated in this porcine patellofemoral joint model. The functional performance of allografts implanted either optimally (flush with the cartilage surface) or 1 mm proud of the cartilage surface was compared to a positive control (stainless steel pin implanted 1 mm proud of the cartilage surface), a negative control (no intervention) and a defect model. Allografts implanted flush with the surrounding cartilage could restore the articulating surface of the patella resulting in low wear, damage and deformation of the opposing cartilage surface, similar to that of the negative control group. Implanting the graft proud of the patella surface resulted in cartilage lesions on the femoral trochlea (ICRS grade 2) and a cartilage volume difference of 2.0 ± 3.9 mm3; the positive controls resulted in more severe lesions, a higher volume difference (14.2 ± 7.4 mm3) which in some cases exposed subchondral bone (ICRS grade 4). Defects in the patella caused deformation of the opposing cartilage surface. All grafts implanted in the patella subsided over the duration of the study. This study demonstrated a method that can be used to evaluate osteochondral repair strategies in the patellofemoral joint applying physiological loading and motions.
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Affiliation(s)
- Raelene M. Cowie
- Institute of Medical and Biological Engineering, School of Mechanical Engineering, University of Leeds, Leeds, United Kingdom
| | - Philippa Bowland
- Institute of Medical and Biological Engineering, School of Mechanical Engineering, University of Leeds, Leeds, United Kingdom
| | - Divya Baji
- Institute of Medical and Biological Engineering, School of Mechanical Engineering, University of Leeds, Leeds, United Kingdom
| | - Hazel L. Fermor
- Faculty of Biological Sciences, Institute of Medical and Biological Engineering, University of Leeds, Leeds, United Kingdom
| | - Eileen Ingham
- Faculty of Biological Sciences, Institute of Medical and Biological Engineering, University of Leeds, Leeds, United Kingdom
| | - John Fisher
- Institute of Medical and Biological Engineering, School of Mechanical Engineering, University of Leeds, Leeds, United Kingdom
| | - Louise M. Jennings
- Institute of Medical and Biological Engineering, School of Mechanical Engineering, University of Leeds, Leeds, United Kingdom
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