Correlation between the AMADEUS score and preoperative clinical patient-reported outcome measurements (PROMs) in patients undergoing matrix-induced autologous chondrocyte implantation (MACI)

The AMADEUS score is not a sufficient predictor for functional outcome after autologous chondrocyte implantation (ACI) of the knee: data from the German Cartilage Registry (KnorpelRegister DGOU)

INTRODUCTION

The AMADEUS (Area Measurement And DEpth and Underlying Structures) score has advanced to a commonly used tool for MRI-based chondral defect severity grading prior to cartilage knee surgery. It was the intention of this study to assess the AMADEUS for a potential correlation with clinical data by patient-reported outcome measures (PROMs).

METHODS

A total of 51 patients undergoing ACI (autologous chondrocyte implantation) between 2016 and 2022 were found eligible and retrospectively analyzed. All patients were registered in the German Cartilage Registry prior to surgery and follow-up data were collected using the Knee Osteoarthritis Outcome score (KOOS), the International Knee Documentation Committee (IKDC) Form and the numeric rating scale (NRS). Pre-operative MRI images were scored by three raters using the AMADEUS classification system, and an overall AMADEUS score was calculated which was subsequently correlated with pre- and post-operative PROMs.

RESULTS

Mean patient age was 32.67 ± 8.37 years and mean defect size area 343.04 mm2 ± 139.45 mm2. No correlative capacity of the pre- and postoperative IKDC, KOOS or NRS scores was found with the AMADEUS final score or any of its subscores. From the pre- to postoperative visit, a significant improvement of the PROMs (IKDC: 45.53 ± 21.00 vs. 59.83 ± 17.93, p = 0.04; KOOS Pain: 58.00 ± 16.70 vs. 76.06 ± 19.20, p = 0.03; KOOS ADL: 64.17 ± 18.76 vs. 82.11 ± 16.68, p < 0.01; KOOS Sports: 26.11 ± 18.52 vs. 50.56 ± 23.94, p = 0.01; KOOS QOL: 25.50 ± 14.26 ± 45.28 ± 19.03, p = 0.00) was found. Intraclass correlation coefficients showed an overall good interrater agreement for the AMADEUS total score (ICC = 0.75).

CONCLUSIONS

Study results suggest no correlative capacity of the AMADEUS with routinely used PROMs in patients undergoing ACI. Therefore, radiographically assessed cartilage defect characteristics poorly translate to pre- and postoperative patient-reported outcome data.

Differences in the Severity and Location of Patellofemoral Cartilage Damage Between Instability Patients With and Without Patella Alta

Background

Patella alta is a risk factor for recurrent patellar instability. Differences in chondral injury in patients with patellar instability between patella alta and patella norma have not been evaluated.

Purpose

To analyze whether preoperative cartilage damage differs in severity and location between patellar instability patients with and without patella alta.

Study Design

Cohort study; Level of evidence, 3.

Methods

Patients with patellar instability who underwent patellar realignment surgery at a single institution with preoperative magnetic resonance imaging (MRI) scans were included. After measurement of Caton-Deschamps index (CDI) on MRI, patients were divided into patella alta (CDI ≥1.3) and patella norma groups. The area measurement and depth and underlying structures (AMADEUS) score was used to quantify cartilage defect severity on MRI.

Results

A total of 121 patients were divided into patella alta (n = 50) and patella norma (n = 71) groups. The groups did not differ significantly in sex ratio, age at MRI, body mass index, mean reported number of previous dislocations, or mean interval between first reported dislocation and date of MRI. A total of 34 (68%) of the patella alta group and 44 (62%) of the patella norma group had chondral defects (P = .625) with no significant between-group differences in defect size (P = .419). In both groups, chondral injuries most affected the medial patellar facet (55% in patella alta vs 52% in patella norma), followed by the lateral facet (25% vs 18%), and lateral femoral condyle (10% vs 14%). A smaller proportion of patients had full-thickness defects in the patella alta compared with the patella norma group (60% vs 82%; P = .030). The overall AMADEUS score was higher for the patella alta versus the patella norma group (68.9 vs 62.1; P = .023), indicating superior articular cartilage status.

Conclusion

Patients with patella alta had less severe cartilage injury after patellar instability, including a lower proportion with full-thickness defects and better overall cartilage grade. The location of injury when present was similar between alta and norma, with most defects affecting the medial facet, lateral facet, and lateral femoral condyle in descending frequency.

The AMADEUS score is not a sufficient predictor for functional outcome after high tibial osteotomy

PURPOSE

The Area Measurement And Depth Underlying Structures (AMADEUS) classification system has been proposed as a valuable tool for magnetic resonance (MR)-based grading of preoperatively encountered chondral defects of the knee joint. However, the potential relationship of this novel score with clinical data was yet to determine. It was the primary intention of this study to assess the correlative relationship of the AMADEUS with patient reported outcome scores in patients undergoing medial open-wedge high tibial valgus osteotomy (HTO). Furthermore, the arthroscopic ICRS (International Cartilage Repair Society) grade evaluation was tested for correlation with the AMADEUS classification system.

METHODS

This retrospective, monocentric study found a total of 70 individuals that were indicated for HTO due to degenerative chondral defects of the medial compartment between 2008 and 2019. A preoperative MR image as well as a pre-osteotomy diagnostic arthroscopy for ICRS grade evaluation was mandatory for all patients. The Knee Osteoarthritis Outcome Score (KOOS) including its five subscale scores (KOOS-ADL, KOOS-QOL, KOOS-Sports, KOOS-Pain, KOOS-Symptoms) was obtained preoperatively and at a mean follow-up of 41.2 ± 26.3 months. Preoperative chondral defects were evaluated using the AMADEUS classification system and the final AMADEUS scores were correlated with the pre- and postoperative KOOS subscale sores. Furthermore, arthroscopic ICRS defect severity was correlated with the AMADEUS classification system.

RESULTS

There was a statistically significant correlation between the AMADEUS BME (bone marrow edema) subscore and the KOOS Symptoms subscore at the preoperative visit (r = 0.25, p = 0.04). No statistically significant monotonic association between the AMADEUS total score and the AMADEUS grade with pre- and postoperative KOOS subscale scores were found. Intraoperatively obtained ICRS grade did reveal a moderate correlative relation with the AMADEUS total score and the AMADEUS grade (r = 0.28, p = 0.02).

CONCLUSIONS

The novel AMADEUS classification system largely lacks correlative capacity with patient reported outcome measures in patients undergoing HTO. The MR tomographic appearance of bone marrow edema is the only parameter predictive of the clinical outcome at the preoperative visit.

Fixation of the Membrane during Matrix-Induced Autologous Chondrocyte Implantation in the Knee: A Systematic Review

Introduction: It is unclear whether the type of membrane used for matrix-assisted autologous chondrocyte implantation (mACI) influences results. A systematic review was conducted to investigate the midterm results of the three most common types of membrane fixation for mACI. Methods: This systematic review was conducted according to the 2020 PRISMA checklist. PubMed, Google Scholar, Embase, and Scopus online databases were accessed in August 2022. All the prospective clinical trials reporting outcomes of mACI in the knee were considered. Studies that describe the modality of membrane fixation (glued, glued, and sutured, no fixation) used for mACI were eligible. Studies that conducted a minimum of 12 months of follow-up were considered. The outcomes of interest were the Tegner Activity Scale and International Knee Documentation Committee (IKDC) score. The rate of failure and revisions were also collected. Results: Data from 26 studies (1539 procedures; 554 of 1539 (36%) were women) were retrieved. The mean follow-up was 42.6 (12 to 84) months. No difference between the groups was found in terms of mean duration of symptoms, age, BMI, gender, and defect size (P > 0.1). No difference was found in terms of the Tegner score (P = 0.3). When no fixation was used, a statistically significant higher IKDC compared to the other groups (P = 0.02) was evidenced. No difference was found in the rate of failure (P = 0.1). The no-fixation group evidenced a statistically significant lower rate of revisions (P = 0.02). Conclusions: No membrane fixation for mACI in the knee scored better than the fastening techniques at the midterm follow-up.

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

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.

The Predictive Value of Early Postoperative MRI-Based Bone Marrow Parameters for Mid-Term Outcome after MACI with Autologous Bone Grafting at the Knee

OBJECTIVE

The aim of this study was to longitudinally determine the prognostic value of early postoperative quantitative 3T-MRI (magnetic resonance imaging) parameters of subchondral bone marrow for 2-year clinical and MRI outcome after matrix-associated autologous chondrocyte implantation (MACI) with autologous bone grafting (ABG) at the knee.

DESIGN

Consecutive subjects who received MACI with ABG for treatment of focal osteochondral defects received MRI follow-up 3, 6, 12, and 24 months postoperatively. Quantitative MRI included bone marrow edema-like lesion (BMEL) volume measurements and single-voxel magnetic resonance spectroscopy (MRS; n = 9) of the subchondral bone marrow. At 2-year follow-up, morphological MRI outcome included MOCART (magnetic resonance observation of cartilage repair tissue) 2.0 scores. Clinical outcomes were assessed using Lysholm scores.

RESULTS

Among a total of 18 subjects (mean age: 28.7 ± 8.4 years, n = 14 males) with defects at the medial or lateral (n = 15 and n = 3, respectively) condyle, mean BMEL volume decreased from 4.9 cm³ at 3 months to 2.0 cm³ at 2-year follow-up (P = 0.040). MRS-based bone marrow water T2 showed a decrease from 20.7 ms at 1-year follow-up to 16.8 ms at 2-year follow-up (P = 0.040). Higher BMEL volume at 6 months correlated with lower 2-year Lysholm (R = -0.616, P = 0.015) and MOCART 2.0 scores (R = -0.567, P = 0.027). Larger early postoperative BMEL volumes at 3 months (R = -0.850, P = 0.007) and 6 months (R = -0.811, P = 0.008) correlated with lower MRS-based unsaturated lipid fractions at 2-year follow-up. Furthermore, patients with early postoperative bony defects showed worse MOCART 2.0 (P = 0.044) and Lysholm scores (P = 0.017) after 24 months.

CONCLUSION

Low subchondral BMEL volume and optimal restoration of the subchondral bone at early postoperative time points predict better 2-year clinical and MRI outcomes after MACI with ABG.

Can the MRI based AMADEUS score accurately assess pre-surgery chondral defect severity according to the ICRS arthroscopic classification system?

Purpose

The AMADEUS (Area Measurement And DEpth and Underlying Structures) scoring and grading system has been proposed for the MRI based evaluation of untreated focal chondral defects around the knee. The clinical practicability, its correlation with arthroscopically assessed grading systems (ICRS – International Cartilage Repair Society) and thereby its clinical value in terms of decision making and guiding prognosis was yet to determine.

Methods

From 2008 to 2019 a total of 89 individuals were indicated for high tibial valgus osteotomy (HTO) due to tibial varus deformity and concomitant chondral defects of the medial compartment of the knee. All patients received a preoperative MRI (1.5 Tesla or 3.0 Tesla) and pre-osteotomy diagnostic arthroscopy. Chondral defects of the medial compartment were scored and graded with the MRI based AMADEUS by three independent raters and compared to arthroscopic defect grading by the ICRS system. Interrater and intrarater reliability as well as correlation analysis with the ICRS classification system were assessed.

Results

Intraclass correlation coefficients for the various subscores of the AMADEUS showed an overall good to excellent interrater agreement (min: 0.26, max: 0.80). Intrarater agreement turned out to be substantially inferior (min: 0.08, max: 0.53). Spearman correlation revealed an overall moderate correlative association of the AMADEUS subscores with the ICRS classification system, apart from the defect area subscore. Sensitivity of the AMADEUS to accurately identify defect severity according to the ICRS was 0.7 (0.69 for 3.0 Tesla MRI, 0.67 for 1.5 Tesla MRI). The mean AMADEUS grade was 2.60 ± 0.81 and the mean ICRS score 2.90 ± 0.63.

Conclusions

Overall, the AMADEUS with all its subscores shows moderate correlation with the arthroscopic chondral grading system according to ICRS. This suggests that chondral defect grading by means of the MRI based AMADEUS is well capable of influencing and guiding treatment decisions. Interrater reliability shows overall good agreement.

Correlation of the Histological ICRS II Score and the 3D MOCART Score for the Analysis of Aged Osteochondral Regenerates in a Large Animal Model

OBJECTIVE

Reliable outcome measures are essential to predict the success of cartilage repair techniques. Histology is probably the gold standard, but magnetic resonance imaging (MRI) has the potential to decrease the need for invasive histological biopsies. The 3D magnetic resonance observation of cartilage repair tissue (MOCART) score is a reliable yet elaborate tool. Moreover, literature is controversial concerning the correlation of histology and MRI.

DESIGN

To test the applicability of the International Cartilage Regeneration and Joint Preservation Society (ICRS) II and MOCART 3D score for the evaluation of aged osteochondral regenerates in a large animal model, and to identify correlating histological and MRI parameters. Osteochondral defects in medial femoral condyles of n = 12 adult sheep were reconstructed with biodegradable bilayer implants. About 19.5 months postoperation, n = 10 joints were analyzed with MRI (3D MOCART score). Histological samples were analyzed using the ICRS II score; both pre- and post-training. The intraclass correlation coefficient, the inter-rater reliability, and the 95% confidence interval were calculated. Matching histological and MRI parameters were tested for correlation.

RESULTS

We found a statistically significant correlation of all histological parameters. MRI parameters reflecting "overall" assessments had very strong inter-rater correlations. Statistically significant strong correlations were found for the MRI parameters defect filling, cartilage interface, bone interface, and surface. For defect overall (MRI) and overall assessment (ICRS II), we found a significant yet mild correlation.

CONCLUSIONS

The ICRS II and the 3D MOCART score are applicable to aged osteochondral regenerates. Prior training on the scoring systems is essential. Select MRI and histological parameters correlate; however, the only statistically significant correlation was found for overall assessment.

Quantitative 3-T Magnetic Resonance Imaging After Matrix-Associated Autologous Chondrocyte Implantation With Autologous Bone Grafting of the Knee: The Importance of Subchondral Bone Parameters

BACKGROUND

Matrix-associated autologous chondrocyte implantation (MACI) with autologous bone grafting (ABG) is an effective surgical treatment for osteochondral defects. Quantitative magnetic resonance imaging (MRI) techniques are increasingly applied as noninvasive biomarkers to assess the biochemical composition of cartilage repair tissue.

PURPOSE

To evaluate the association of quantitative MRI parameters of cartilage repair tissue and subchondral bone marrow with magnetic resonance morphologic and clinical outcomes after MACI with ABG of the knee.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Qualitative and quantitative 3 T MRI of the knee was performed in 21 patients (16 male) at 2.5 years after MACI with ABG at the medial (18/21) or lateral (3/21) femoral condyle for the treatment of osteochondral defects. Morphologic MRI sequences were assessed using MOCART (magnetic resonance observation of cartilage repair tissue) 2.0 scores. T2 relaxation time measurements for the assessment of cartilage repair tissue (CRT2) were obtained. Single-voxel magnetic resonance spectroscopy was performed in underlying subchondral bone marrow (BM) and at both central femoral condyles. The presence of pain and Tegner scores were noted. Statistical analyses included Student t tests, correlation analyses, and multivariate regression models.

RESULTS

The mean defect size was 4.9 ± 1.9 cm². At a follow-up of 2.5 ± 0.3 years, 9 of 21 patients were asymptomatic. Perfect defect filling was achieved in 66.7% (14/21) of patients. MOCART 2.0 scores (74.1 ± 18.4) did not indicate pain (68.3 ± 19.0 [pain] vs 81.7 ± 15.4 [no pain]; P = .102). However, knee pain was present in 85.7% (6/7) of patients with deep bony defects (odds ratio, 8.0; P = .078). Relative CRT2 was higher in hypertrophic cartilage repair tissue than in repair tissue with normal filling (1.54 ± 0.42 vs 1.13 ± 0.21, respectively; P = .022). The underlying BM edema-like lesion (BMEL) volume was larger in patients with underfilling compared with patients with perfect defect filling (1.87 ± 1.32 vs 0.31 ± 0.51 cm³, respectively; P = .002). Patients with severe pain showed a higher BMEL volume (1.2 ± 1.3 vs 0.2 ± 0.4 cm³, respectively; P = .046) and had a higher BM water fraction (26.0% ± 12.3% vs 8.6% ± 8.1%, respectively; P = .026) than did patients without pain.

CONCLUSION

Qualitative and quantitative MRI parameters including the presence of subchondral defects, CRT2, BMEL volume, and BM water fraction were correlated with cartilage repair tissue quality and clinical symptoms. Therefore, the integrity of subchondral bone was associated with outcomes after osteochondral transplantation.

Recent Trends in Decellularized Extracellular Matrix Bioinks for 3D Printing: An Updated Review

The promise of regenerative medicine and tissue engineering is founded on the ability to regenerate diseased or damaged tissues and organs into functional tissues and organs or the creation of new tissues and organs altogether. In theory, damaged and diseased tissues and organs can be regenerated or created using different configurations and combinations of extracellular matrix (ECM), cells, and inductive biomolecules. Regenerative medicine and tissue engineering can allow the improvement of patients' quality of life through availing novel treatment options. The coupling of regenerative medicine and tissue engineering with 3D printing, big data, and computational algorithms is revolutionizing the treatment of patients in a huge way. 3D bioprinting allows the proper placement of cells and ECMs, allowing the recapitulation of native microenvironments of tissues and organs. 3D bioprinting utilizes different bioinks made up of different formulations of ECM/biomaterials, biomolecules, and even cells. The choice of the bioink used during 3D bioprinting is very important as properties such as printability, compatibility, and physical strength influence the final construct printed. The extracellular matrix (ECM) provides both physical and mechanical microenvironment needed by cells to survive and proliferate. Decellularized ECM bioink contains biochemical cues from the original native ECM and also the right proportions of ECM proteins. Different techniques and characterization methods are used to derive bioinks from several tissues and organs and to evaluate their quality. This review discusses the uses of decellularized ECM bioinks and argues that they represent the most biomimetic bioinks available. In addition, we briefly discuss some polymer-based bioinks utilized in 3D bioprinting.