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Coladonato C, Perez AR, Sonnier JH, Wilson S, Paul RW, Gawel R, Connors G, Freedman KB, Bishop ME. Evaluating Return to Sports After Surgical Treatment of Unstable Osteochondritis Dissecans of the Knee: A Systematic Review. Orthop J Sports Med 2024; 12:23259671241258489. [PMID: 39131095 PMCID: PMC11307338 DOI: 10.1177/23259671241258489] [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: 09/29/2023] [Accepted: 01/01/2024] [Indexed: 08/13/2024] Open
Abstract
Background Although the incidence of osteochondritis dissecans (OCD) of the knee may be low, an overview and comparison of sports-related outcomes with current surgical management techniques are needed. Purpose To summarize the available evidence regarding outcomes for different surgical treatment options for unstable OCD of the knee in both skeletally mature and immature patients by calculating the return to sports (RTS) rate, the mean RTS time, and other sports-related postoperative outcome measures. Study Design Systematic review; Level of evidence, 4. Methods A systematic review of studies on RTS after surgical correction of unstable OCD within the knee was conducted utilizing PubMed, Embase, and the Cochrane databases. Included were studies discussing the treatment of unstable OCD with minimum 1-year follow-up outcomes. Multivariate analysis was used to compare studies grouped together based on RTS and skeletal maturity. Results Of 2229 articles, 6 studies (197 patients; 198 knees) met the inclusion criteria and were included in our analysis. The percentage of patients who returned to the previous level of sport ranged from 52% to 100%; those returning to any level of sport ranged from 87% to 100%. Clinical outcomes did not differ between patients with open versus closed physes. Osteochondral Autograft Transfer System (OATS) procedures had a 100% RTS rate across several studies with skeletally mature and mixed cohorts, and microfracture had the lowest overall RTS rate (52%). For skeletally immature patients, all examined studies that utilized either open or arthroscopic reduction and internal fixation, 77% and 78%, respectively, had acceptable RTS rates. Arthroscopic fixation had a higher rate of revision surgery in both skeletally mature and immature patients. Conclusion Our analysis indicated that the treatment of unstable OCD lesions using the OATS technique demonstrated high RTS rates across several studies, while microfracture alone exhibited the lowest RTS rate. Both arthroscopic and open internal fixation utilizing bioabsorbable screws yielded satisfactory RTS rates for juvenile patients with OCD.
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Affiliation(s)
| | - Andres R. Perez
- Rothman Orthopaedics Institute, Philadelphia, Pennsylvania, USA
| | | | - Sean Wilson
- Rothman Orthopaedics Institute, Philadelphia, Pennsylvania, USA
| | - Ryan W. Paul
- Rothman Orthopaedics Institute, Philadelphia, Pennsylvania, USA
| | - Richard Gawel
- Rothman Orthopaedics Institute, Philadelphia, Pennsylvania, USA
| | - Gregory Connors
- Rothman Orthopaedics Institute, Philadelphia, Pennsylvania, USA
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Tan CHB, Huang XO, Tay ZQ, Bin Abd Razak HR. Arthroscopic and open approaches for autologous matrix-induced chondrogenesis repair of the knee have similar results: a meta-analysis. J ISAKOS 2024; 9:192-204. [PMID: 37839704 DOI: 10.1016/j.jisako.2023.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 08/24/2023] [Accepted: 10/03/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND Cartilage defects are debilitating injuries that can reduce quality of life in patients. However, the poor regenerative properties of cartilage mean that cartilage repair remains challenging, and many methods have arisen to address that. Autologous matrix-induced chondrogenesis (AMIC®) is a popular technique to manage cartilage defects. Recent advances have allowed AMIC® to be done arthroscopically, instead of a mini-open arthrotomy approach. This systematic review and meta-analysis aims to investigate whether the arthroscopic approach to AMIC® provides better clinical outcomes than does the mini-open approach, in hopes of delineating a gold standard in cartilage repair. METHODS With reference to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, a systematic search of the following databases (PubMed, Embase, Scopus, and Cochrane Library) was performed on 26th October 2022 using a combination of the following search terms: "autologous matrix induced", "chondrogenesis", and "knee". A total of 390 studies were identified, of which, 24 studies were included in our final analysis. RESULTS The arthroscopic approach achieves lower Visual Analogue Scale for pain scores. The International Knee documentation Committee) score and Knee Injury and Osteoarthritis Outcome Score were comparable between arthroscopic and open approaches. The open approach achieves a higher Magnetic Resonance Observation of Cartilage Repair Tissue score. Incidence of reported postoperative complications of revision surgery and knee stiffness was higher for the open approach than for the arthroscopic approach, whereas deep vein thrombosis was higher in the arthroscopic approach. CONCLUSION The AMIC® repair outcomes indicate that the arthroscopic approach does not hold a distinct advantage over the open approach. The choice of approach should consider surgeon expertise, location of lesion, and patient-specific factors. LEVEL OF EVIDENCE Systematic review and meta-analysis; Level III.
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Affiliation(s)
- Chin Hong Ben Tan
- Yong Loo Lin School of Medicine, National University of Singapore, S117597, Singapore
| | - XinYao Oliver Huang
- Yong Loo Lin School of Medicine, National University of Singapore, S117597, Singapore
| | - Zhi Quan Tay
- Yong Loo Lin School of Medicine, National University of Singapore, S117597, Singapore
| | - Hamid Rahmatullah Bin Abd Razak
- Department of Orthopaedic Surgery, Sengkang General Hospital, S544886, Singapore; SingHealth Duke-NUS Musculoskeletal Sciences Academic Clinical Programme, S169857, Singapore.
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Tropf JG, Dickens JF, LeClere LE. Surgical Treatment of Focal Chondral Lesions of the Knee in the Military Population: Current and Future Therapies. Mil Med 2024; 189:e541-e550. [PMID: 37428507 DOI: 10.1093/milmed/usad250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 06/09/2023] [Accepted: 06/27/2023] [Indexed: 07/11/2023] Open
Abstract
INTRODUCTION Chondral and osteochondral defects of the knee are common injuries in the military population that have a significant impact on readiness. Definitive treatment of these injuries is challenging since cartilage has a limited capacity for self-repair and regeneration. Management is particularly challenging in military patients who maintain a higher level of activity similar to athletes. Existing surgical techniques have variable results and often long recovery times, sparking the development of several new innovative technologies to return service members back to duty more quickly and effectively after cartilage injury. The purpose of this article is to review the current and future surgical treatments for chondral and osteochondral knee lesions and their relevance in managing these injuries in the military. METHODS In this review article, we describe the current treatments for chondral and osteochondral defects of the knee, reporting on outcomes in military populations. We explore emerging treatment modalities for cartilage defects, reporting innovations, stage of research, and current data. Published results of each treatment option in military populations are reviewed throughout the article. RESULTS This review includes 12 treatments for chondral lesions. Of these therapies, four are considered synthetic and the remaining are considered regenerative solutions. Regenerative therapies tend to perform better in younger, healthier populations with robust healing capacity. Success of treatment depends on lesions and patient characteristics. Nearly all modalities currently available in the USA were successful in improving patients from presurgical function in the short (<6 months) term, but the long-term efficacy is still challenged. Upcoming technologies show promising results in clinical and animal studies that may provide alternative options desirable for the military population. CONCLUSIONS The current treatment options for cartilage lesions are not entirely satisfactory, usually with long recovery times and mixed results. An ideal therapy would be a single procedure that possesses the ability to enable a quick return to activity and duty, alleviate pain, provide long-term durability, and disrupt the progression of osteoarthritis. Evolving technologies for cartilage lesions are expanding beyond currently available techniques that may revolutionize the future of cartilage repair.
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Affiliation(s)
- Jordan G Tropf
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
- Department of Orthopaedic Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Jonathan F Dickens
- Department of Orthopaedic Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Lance E LeClere
- Department of Orthopaedic Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN 37232, USA
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Pearsall C, Chen AZ, Reynolds AW, Saltzman BM, Ahmad CS, Popkin CA, Redler LH, Trofa DP. Particulated Juvenile Articular Cartilage Allograft Transplantation for Patellofemoral Defects Shows Favorable Return-to-Sport Rates and Patient-Reported Outcomes. Arthroscopy 2024:S0749-8063(24)00153-1. [PMID: 38395270 DOI: 10.1016/j.arthro.2024.02.018] [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: 09/08/2023] [Revised: 02/07/2024] [Accepted: 02/15/2024] [Indexed: 02/25/2024]
Abstract
PURPOSE To report return-to-sport rates, postoperative patient-reported outcomes (PROs), complication rates, and reoperation rates of a cohort of patients undergoing particulated juvenile articular cartilage (PJAC) allograft transplantation for patellofemoral articular cartilage defects. METHODS We performed a single-institution retrospective review of all patients with patellofemoral articular cartilage defects who received PJAC allograft transplantation from 2014 to 2022. Baseline demographic characteristics and surgical data, including concomitant surgical procedures, were collected. Clinical outcomes recorded included return-to-sport rates, complications, reoperations, and the following PRO scores: Kujala knee score, Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference score, and PROMIS Physical Function score. RESULTS Forty-one knees with a mean age of 23.4 ± 9.7 years and mean follow-up period of 30.3 months (range, 12-107 months) were included. The mean postoperative PROMIS Pain Interference, PROMIS Physical Function, and Kujala knee scores were 47.4 ± 7.7, 52.2 ± 10.8, and 81.7 ± 16.1, respectively, reflecting low residual anterior knee pain and a return to normal function. For patients playing organized sports at the high school and collegiate levels, the overall return-to-sport rate was 100% (17 of 17). During follow-up, complications developed in 12 knees (29.3%), the most common of which was anterior-based knee pain, and 6 knees (14.6%) required a total of 8 reoperations, which occurred from 6 to 32 months postoperatively. CONCLUSIONS The 100% return-to-sport rate and satisfactory PRO scores in our study suggest that PJAC allograft transplantation can effectively address patellofemoral cartilage defects in many patients. The complication and reoperation rates of 29.3% and 14.6%, respectively, are consistent with the challenging and heterogeneous etiology and treatment of patellofemoral articular defects. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- Christian Pearsall
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, New York, U.S.A
| | - Aaron Z Chen
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, New York, U.S.A
| | - Alan W Reynolds
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, New York, U.S.A
| | - Bryan M Saltzman
- Department of Orthopedic Surgery, OrthoCarolina, Charlotte, North Carolina, U.S.A
| | - Christopher S Ahmad
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, New York, U.S.A
| | - Charles A Popkin
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, New York, U.S.A
| | - Lauren H Redler
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, New York, U.S.A
| | - David P Trofa
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, New York, U.S.A..
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Triana J, Li ZI, Rao N, Kingery MT, Strauss EJ. Return to Play After Knee Articular Cartilage Restoration: Surgical Options, Rehabilitation Protocols, and Performance Outcomes. Curr Rev Musculoskelet Med 2023; 16:575-586. [PMID: 37804418 PMCID: PMC10733247 DOI: 10.1007/s12178-023-09872-w] [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] [Accepted: 09/27/2023] [Indexed: 10/09/2023]
Abstract
PURPOSE OF REVIEW Numerous cartilage restoration techniques have proven to be effective in the treatment of articular cartilage defects. The ultimate goal of these procedures is to improve pain and function, thereby increasing the likelihood of a patient's return to physical activity. Postoperative rehabilitation is a key component for a successful and expedient return to activities. The purpose of this article is to review the current literature regarding common surgical options, rehabilitation protocols, and performance outcomes after operative treatment of articular cartilage defects. RECENT FINDINGS Studies have demonstrated improved short- to long-term outcomes in a majority of techniques. However, the clinical benefits of microfracture are short-lived, which has led to the use of alternative procedures. Rehabilitation protocols are not standardized, but emphasis has been placed on bracing, weightbearing, early continuous passive range of motion, and strengthening to improve function. There is growing evidence to suggest that accelerated rehabilitation after matrix-induced autologous chondrocyte implantation may result in superior outcomes compared to delayed rehabilitation. Overall, most techniques result in satisfactory rates of return to play, though existing comparative studies typically include patients with heterogeneous pathology, complicating effective synthesis of outcomes data. In appropriately selected patients, cartilage restoration procedures after articular cartilage injury result in favorable patient-reported clinical outcomes and high rates of return to play. While studies emphasize the critical role that rehabilitation plays with respect to outcomes after surgery, there are substantial inconsistencies in protocols across techniques.
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Affiliation(s)
- Jairo Triana
- Department of Orthopedic Surgery, New York University Langone Health, 301 East 17th Street, New York, NY, 10016, USA.
| | - Zachary I Li
- Department of Orthopedic Surgery, New York University Langone Health, 301 East 17th Street, New York, NY, 10016, USA
| | - Naina Rao
- Department of Orthopedic Surgery, New York University Langone Health, 301 East 17th Street, New York, NY, 10016, USA
| | - Matthew T Kingery
- Department of Orthopedic Surgery, New York University Langone Health, 301 East 17th Street, New York, NY, 10016, USA
| | - Eric J Strauss
- Department of Orthopedic Surgery, New York University Langone Health, 301 East 17th Street, New York, NY, 10016, USA
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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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Becher C, Megaloikonomos PD, Lind M, Eriksson K, Brittberg M, Beckmann J, Verdonk P, Högström M, Konradsen L, Holz J, Franz A, Feucht MJ, Kösters C, van Buul G, Sköldenberg O, Emans PJ, Boutefnouchet T, Nathwani D, McNicholas MJ, O'Donnell T, Spalding T, Stålman A, Ostermeier S, Imhoff AB, Shearman AD, Hirschmann M. High degree of consensus amongst an expert panel regarding focal resurfacing of chondral and osteochondral lesions of the femur with mini-implants. Knee Surg Sports Traumatol Arthrosc 2023; 31:4027-4034. [PMID: 37173573 DOI: 10.1007/s00167-023-07450-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 05/02/2023] [Indexed: 05/15/2023]
Abstract
INTRODUCTION The rationale for the use of mini-implants for partial resurfacing in the treatment of femoral chondral and osteochondral lesions is still under debate. The evidence supporting best practise guidelines is based on studies with low-level evidence. A consensus group of experts was convened to collaboratively advance towards consensus opinions regarding the best available evidence. The purpose of this article is to report the resulting consensus statements. METHODS Twenty-five experts participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted via an online survey of two rounds, for initial agreement and comments on the proposed statements. An in-person meeting between the panellists was organised during the 2022 ESSKA congress to further discuss and debate each of the statements. A final agreement was made via a final online survey a few days later. The strength of consensus was characterised as: consensus, 51-74% agreement; strong consensus, 75-99% agreement; unanimous, 100% agreement. RESULTS Statements were developed in the fields of patient assessment and indications, surgical considerations and postoperative care. Between the 25 statements that were discussed by this working group, 18 achieved unanimous, whilst 7 strong consensus. CONCLUSION The consensus statements, derived from experts in the field, represent guidelines to assist clinicians in decision-making for the appropriate use of mini-implants for partial resurfacing in the treatment of femoral chondral and osteochondral lesions. LEVEL OF EVIDENCE Level V.
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Affiliation(s)
- Christoph Becher
- International Centre for Orthopedics, ATOS Clinic Heidelberg, Bismarckstr. 9-15, 69115, Heidelberg, Germany.
| | | | - Martin Lind
- Department of Orthopedics, Aarhus University Hospital, Aarhus, Denmark
| | - Karl Eriksson
- Department of Orthopaedic Surgery, Stockholm South Hospital, Department of Clinical Science and Education Karolinska Institutet, Stockholm, Sweden
| | - Mats Brittberg
- Cartilage Research Unit, Region Halland Orthopaedics, Varberg Hospital, University of Gothenburg, Varberg, Sweden
| | - Johannes Beckmann
- Department of Orthopaedics and Traumatology, Barmherzige Brüder Hospital, Munich, Germany
| | | | - Magnus Högström
- Department of Surgical and Perioperative Sciences, Sports Medicine Umeå and Orthopedics, Umeå University, Umeå, Sweden
| | - Lars Konradsen
- Department of Orthopedic Surgery, Bispebjerg-Frederiksberg Hospital, Copenhagen, Denmark
| | | | - Alois Franz
- Hospital for Orthopedic Surgery and Sports Medicine, Siegen, Germany
| | - Matthias J Feucht
- Orthopaedic Clinic Paulinenhilfe, Diakonie-Hospital, Stuttgart, Germany
| | - Clemens Kösters
- Department of Traumatology and Orthopedics, Maria-Josef-Hospital Greven, Greven, Germany
| | - Gerben van Buul
- Department of Orthopaedics, Sint Maartenskliniek, Nijmegen, The Netherlands
| | - Olof Sköldenberg
- Department of Clinical Sciences at Danderyd Hospital, Division of Orthopaedics, Karolinska Institute, Stockholm, Sweden
| | - Pieter J Emans
- Department of Orthopaedic Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Tarek Boutefnouchet
- University Hospitals Birmingham NHS Trust, Mindelsohn Way, Edgbaston, Birmingham, UK
| | | | | | | | - Tim Spalding
- Cleveland Clinic London, University Hospital Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Anders Stålman
- Department of Molecular Medicine and Surgery, Stockholm Sports Trauma Research Center, Karolinska Institute, Stockholm, Sweden
| | | | - Andreas B Imhoff
- Department of Orthopaedic Sports Medicine, Technical University of Munich, Munich, Germany
| | - Alexander D Shearman
- Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Michael Hirschmann
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland, Bruderholz, Switzerland
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Tampieri A, Kon E, Sandri M, Campodoni E, Dapporto M, Sprio S. Marine-Inspired Approaches as a Smart Tool to Face Osteochondral Regeneration. Mar Drugs 2023; 21:md21040212. [PMID: 37103351 PMCID: PMC10145639 DOI: 10.3390/md21040212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 03/23/2023] [Accepted: 03/24/2023] [Indexed: 03/30/2023] Open
Abstract
The degeneration of osteochondral tissue represents one of the major causes of disability in modern society and it is expected to fuel the demand for new solutions to repair and regenerate the damaged articular joints. In particular, osteoarthritis (OA) is the most common complication in articular diseases and a leading cause of chronic disability affecting a steady increasing number of people. The regeneration of osteochondral (OC) defects is one of the most challenging tasks in orthopedics since this anatomical region is composed of different tissues, characterized by antithetic features and functionalities, in tight connection to work together as a joint. The altered structural and mechanical joint environment impairs the natural tissue metabolism, thus making OC regeneration even more challenging. In this scenario, marine-derived ingredients elicit ever-increased interest for biomedical applications as a result of their outstanding mechanical and multiple biologic properties. The review highlights the possibility to exploit such unique features using a combination of bio-inspired synthesis process and 3D manufacturing technologies, relevant to generate compositionally and structurally graded hybrid constructs reproducing the smart architecture and biomechanical functions of natural OC regions.
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Toyooka S, Moatshe G, Persson A, Engebretsen L. Return to Pivoting Sports after Cartilage Repair Surgery of the Knee: A Scoping Review. Cartilage 2023; 14:17-25. [PMID: 36661094 PMCID: PMC10076897 DOI: 10.1177/19476035221141416] [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: 01/21/2023] Open
Abstract
OBJECTIVE To perform a scoping literature review evaluating and reporting on outcomes and return to pivoting sports after cartilage procedures. For this review, the following cartilage procedures were evaluated: microfracture, osteochondral autograft transplantation (OAT), osteochondral allograft transplantation (OCA), and autologous chondrocyte implantation (ACI). DESIGN The scoping review incorporated articles identified using PubMed (MEDLINE), CINAHL, and Cochrane Central Register of Controlled Trials. Screening of reference lists of included studies and forward citation tracking were performed to identify additional studies. Reported on return to pivoting sports after cartilage surgery written in English language. RESULTS Sixteen studies fulfilled the inclusion criteria. The return to sports (RTS) rates after microfracture ranged from 44% to 83%, and to preinjury level from 25% to 75%. The RTS rates after OAT ranged from 87% to 100%, and to preinjury level from 67% to 93%. The RTS rates after OCA ranged from 77% to 80%, and to preinjury level 64%. The RTS rates after ACI ranged from 33% to 96%, and to preinjury level from 26% to 67%. CONCLUSIONS There was a high heterogeneity and range in rates of RTS in athletes participating in pivoting sports. Most studies reported high rates of RTS; however, return to preinjury level was lower. These data may be important to clinicians in shared decision making on the type of procedure to be performed and counseling pivoting sports athletes on prognosis and expected RTS rates.
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Affiliation(s)
- Seikai Toyooka
- Department of Orthopaedic Surgery, Oslo Sports Trauma Research Center, Oslo University Hospital, Oslo, Norway
- Department of Orthopaedic Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Gilbert Moatshe
- Department of Orthopaedic Surgery, Oslo Sports Trauma Research Center, Oslo University Hospital, Oslo, Norway
| | - Andreas Persson
- Department of Orthopaedic Surgery, Oslo Sports Trauma Research Center, Oslo University Hospital, Oslo, Norway
| | - Lars Engebretsen
- Department of Orthopaedic Surgery, Oslo Sports Trauma Research Center, Oslo University Hospital, Oslo, Norway
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Fibrin glue does not promote migration and proliferation of bone marrow derived mesenchymal stem cells in collagenic membranes: an in vitro study. Sci Rep 2022; 12:20660. [PMID: 36450814 PMCID: PMC9712600 DOI: 10.1038/s41598-022-25203-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 11/28/2022] [Indexed: 12/02/2022] Open
Abstract
During Autologous Matrix-Induced Chondrogenesis (AMIC), the membrane is often glued into the chondral defect. However, whether fibrin glue influences cells proliferation and migration remain unclear. This study evaluated the impact of fibrin glue addition to biologic membranes loaded with bone marrow-derived mesenchymal stem cells (B-MSCs). A porcine derived collagen membrane (Cartimaix, Matricel GmbH, Germany) was used. B-MSCs were harvested from three different unrelated donors. The membranes were embedded in mounting medium with DAPI (ABCAM, Cambridge, UK) and analysed at 1-, 2-, 3-, 4-, 6-, and at 8-week follow-up. The DAPI ties the DNA of the cell nucleus, emitting blue fluorescence. DAPI/nuclei signals were analysed with fluorescence microscopy at 100-fold magnification. The group without fibrin glue demonstrated greater migration of the B-MSCs within the membrane at week 4 (P < 0.001), 6 (P < 0.001), and 8 (P < 0.001). No difference was found at week 1, 2, and 3. The group without fibrin glue demonstrated greater proliferation of B-MSCs within the membrane. These differences were significant at week 1 (P = 0.02), 2 (P = 0.008), 3 (P = 0.0009), 4 (P < 0.0001), 6 (P < 0.0001), 8 (P < 0.0001). Concluding, in the present setting, the use of fibrin in a collagenic biomembrane impairs B-MSCs proliferation and migration in vitro.
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Migliorini F, Eschweiler J, Götze C, Driessen A, Tingart M, Maffulli N. Matrix-induced autologous chondrocyte implantation (mACI) versus autologous matrix-induced chondrogenesis (AMIC) for chondral defects of the knee: a systematic review. Br Med Bull 2022; 141:47-59. [PMID: 35175354 PMCID: PMC9351375 DOI: 10.1093/bmb/ldac004] [Citation(s) in RCA: 2] [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] [Accepted: 01/26/2022] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Chondral defects of the knee are common and their treatment is challenging. SOURCE OF DATA PubMed, Google scholar, Embase and Scopus databases. AREAS OF AGREEMENT Both autologous matrix-induced chondrogenesis (AMIC) and membrane-induced autologous chondrocyte implantation (mACI) have been used to manage chondral defects of the knee. AREAS OF CONTROVERSY It is debated whether AMIC and mACI provide equivalent outcomes for the management of chondral defects in the knee at midterm follow-up. Despite the large number of clinical studies, the optimal treatment is still controversial. GROWING POINTS To investigate whether AMIC provide superior outcomes than mACI at midterm follow-up. AREAS TIMELY FOR DEVELOPING RESEARCH AMIC may provide better outcomes than mACI for chondral defects of the knee. Further studies are required to verify these results in a clinical setting.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopaedic and Trauma Surgery, RWTH University Hospital Aachen, Pauwellstr. 31, 52074 Aachen, Germany
| | - Jörg Eschweiler
- Department of Orthopaedic and Trauma Surgery, RWTH University Hospital Aachen, Pauwellstr. 31, 52074 Aachen, Germany
| | - Christian Götze
- Department of Orthopaedic Surgery, Auguste-Viktoria Clinic, Ruhr University Bochum, Am Kokturkanal 2, 32545 Bad Oeynhausen, Germany
| | - Arne Driessen
- Department of Orthopaedic and Trauma Surgery, RWTH University Hospital Aachen, Pauwellstr. 31, 52074 Aachen, Germany
| | - Markus Tingart
- Department of Orthopaedic and Trauma Surgery, RWTH University Hospital Aachen, Pauwellstr. 31, 52074 Aachen, Germany
| | - Nicola Maffulli
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081 Baronissi (SA), Italy.,Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, 275 Bancroft Road, London E1 4DG, UK.,School of Pharmacy and Bioengineering, Keele University Faculty of Medicine, Thornburrow Drive, Stoke on Trent, ST5 5BG, UK
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Cinti F, Vezzoni L, Vezzoni A. A New Generation of Osteochondral Autograft Transfer System for the Treatment of Osteochondritis Dissecans of the Femoral Condyle: Clinical Experience in 18 Dogs. Vet Comp Orthop Traumatol 2022; 35:198-204. [PMID: 35272365 DOI: 10.1055/s-0042-1744181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES The aim of this study was to describe the clinical application and outcome of osteochondral autograft transfer using the COR system (COR; DePuy Synthes, Warsaw, Indiana, United States) for the treatment of osteochondritis dissecans (OCD) of the femoral condyle in dogs. METHODS Medical records of dogs that were treated for OCD of the femoral condyle using the COR system between February 2013 and March 2020 were retrospectively reviewed. The results of pre- and postoperative clinical and radiographic examinations were evaluated. RESULTS Twenty stifles (18 dogs; 15 lateral and 5 medial femoral condyles) met the inclusion criteria. A single graft transfer was done in six stifle joints and mosaicplasty in 14 (2 grafts in 9/14 stifles; 3 grafts in 5/14 stifles). Proper anatomic reconstruction was confirmed intraoperatively and radiographically in all dogs. There were no major and three minor postoperative complications. At 3 months, 15 of 20 stifles (14 of 18 dogs) had no lameness or radiographic signs of inflammation. At 6 months, 12 of 13 dogs had no lameness or discomfort, and four of 13 stifles had radiographic evidence of moderate osteoarthritis. CLINICAL SIGNIFICANCE Treatment of OCD of the femoral condyle using the COR system is feasible in dogs, with low complications and provides a satisfactory short-term outcome.
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Affiliation(s)
- Filippo Cinti
- Clinica Veterinaria Vezzoni, Cremona, Italy.,Clinica Veterinaria Apuana-Anicura, Marina di Carrara, Italy
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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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Doyle SE, Snow F, Duchi S, O’Connell CD, Onofrillo C, Di Bella C, Pirogova E. 3D Printed Multiphasic Scaffolds for Osteochondral Repair: Challenges and Opportunities. Int J Mol Sci 2021; 22:12420. [PMID: 34830302 PMCID: PMC8622524 DOI: 10.3390/ijms222212420] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 11/11/2021] [Accepted: 11/12/2021] [Indexed: 12/19/2022] Open
Abstract
Osteochondral (OC) defects are debilitating joint injuries characterized by the loss of full thickness articular cartilage along with the underlying calcified cartilage through to the subchondral bone. While current surgical treatments can provide some relief from pain, none can fully repair all the components of the OC unit and restore its native function. Engineering OC tissue is challenging due to the presence of the three distinct tissue regions. Recent advances in additive manufacturing provide unprecedented control over the internal microstructure of bioscaffolds, the patterning of growth factors and the encapsulation of potentially regenerative cells. These developments are ushering in a new paradigm of 'multiphasic' scaffold designs in which the optimal micro-environment for each tissue region is individually crafted. Although the adoption of these techniques provides new opportunities in OC research, it also introduces challenges, such as creating tissue interfaces, integrating multiple fabrication techniques and co-culturing different cells within the same construct. This review captures the considerations and capabilities in developing 3D printed OC scaffolds, including materials, fabrication techniques, mechanical function, biological components and design.
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Affiliation(s)
- Stephanie E. Doyle
- Electrical and Biomedical Engineering, School of Engineering, RMIT University, Melbourne, VIC 3000, Australia; (F.S.)
- ACMD, St Vincent’s Hospital Melbourne, Fitzroy, VIC 3065, Australia; (S.D.); (C.O.); (C.D.B.)
| | - Finn Snow
- Electrical and Biomedical Engineering, School of Engineering, RMIT University, Melbourne, VIC 3000, Australia; (F.S.)
| | - Serena Duchi
- ACMD, St Vincent’s Hospital Melbourne, Fitzroy, VIC 3065, Australia; (S.D.); (C.O.); (C.D.B.)
- Department of Surgery, The University of Melbourne, St Vincent’s Hospital Melbourne, Fitzroy, VIC 3065, Australia
- ARC Centre of Excellence for Electromaterials Science, Intelligent Polymer Research Institute, University of Wollongong, Wollongong, NSW 2522, Australia
| | - Cathal D. O’Connell
- Electrical and Biomedical Engineering, School of Engineering, RMIT University, Melbourne, VIC 3000, Australia; (F.S.)
- ACMD, St Vincent’s Hospital Melbourne, Fitzroy, VIC 3065, Australia; (S.D.); (C.O.); (C.D.B.)
| | - Carmine Onofrillo
- ACMD, St Vincent’s Hospital Melbourne, Fitzroy, VIC 3065, Australia; (S.D.); (C.O.); (C.D.B.)
- Department of Surgery, The University of Melbourne, St Vincent’s Hospital Melbourne, Fitzroy, VIC 3065, Australia
- ARC Centre of Excellence for Electromaterials Science, Intelligent Polymer Research Institute, University of Wollongong, Wollongong, NSW 2522, Australia
| | - Claudia Di Bella
- ACMD, St Vincent’s Hospital Melbourne, Fitzroy, VIC 3065, Australia; (S.D.); (C.O.); (C.D.B.)
- Department of Surgery, The University of Melbourne, St Vincent’s Hospital Melbourne, Fitzroy, VIC 3065, Australia
- Department of Orthopaedics, St Vincent’s Hospital Melbourne, Fitzroy, VIC 3065, Australia
| | - Elena Pirogova
- Electrical and Biomedical Engineering, School of Engineering, RMIT University, Melbourne, VIC 3000, Australia; (F.S.)
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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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Boffa A, Solaro L, Poggi A, Andriolo L, Reale D, Di Martino A. Multi-layer cell-free scaffolds for osteochondral defects of the knee: a systematic review and meta-analysis of clinical evidence. J Exp Orthop 2021; 8:56. [PMID: 34331140 PMCID: PMC8324705 DOI: 10.1186/s40634-021-00377-4] [Citation(s) in RCA: 13] [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: 06/18/2021] [Accepted: 07/23/2021] [Indexed: 01/13/2023] Open
Abstract
Purpose The aim of this study was to analyze the clinical results provided by multi-layer cell-free scaffolds for the treatment of knee osteochondral defects. Methods A systematic review was performed on PubMed, Web of Science, and Cochrane to identify studies evaluating the clinical efficacy of cell-free osteochondral scaffolds for knee lesions. A meta-analysis was performed on articles reporting results of the International Knee Documentation Committee (IKDC) and Tegner scores. The scores were analyzed as improvement from baseline to 1, 2, and ≥ 3 years of follow-up. The modified Coleman Methodology Score was used to assess the study methodology. Results A total of 34 studies (1022 patients) with a mean follow-up of 35 months was included. Only three osteochondral scaffolds have been investigated in clinical trials: while TruFit® has been withdrawn from the market for the questionable results, the analysis of MaioRegen and Agili-C™ provided clinical improvements at 1, 2, and ≥ 3 years of follow-up (all significantly higher than the baseline, p < 0.05), although with a limited recovery of the sport-activity level. A low rate of adverse events and an overall failure rate of 7.0% were observed, but the overall evidence level of the available studies is limited. Conclusions Multi-layer scaffolds may provide clinical benefits for the treatment of knee osteochondral lesions at short- and mid-term follow-up and with a low number of failures, although the sport-activity level obtained seems to be limited. Further research with high-level studies is needed to confirm the role of multi-layer scaffold for the treatment of knee osteochondral lesions.
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Affiliation(s)
- Angelo Boffa
- Clinica Ortopedica E Traumatologica 2, IRCCS Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli, 1 - 40136, Bologna, Italy
| | - Luca Solaro
- Clinica Ortopedica E Traumatologica 2, IRCCS Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli, 1 - 40136, Bologna, Italy
| | - Alberto Poggi
- Clinica Ortopedica E Traumatologica 2, IRCCS Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli, 1 - 40136, Bologna, Italy.
| | - Luca Andriolo
- Clinica Ortopedica E Traumatologica 2, IRCCS Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli, 1 - 40136, Bologna, Italy
| | - Davide Reale
- Clinica Ortopedica E Traumatologica 2, IRCCS Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli, 1 - 40136, Bologna, Italy
| | - Alessandro Di Martino
- Clinica Ortopedica E Traumatologica 2, IRCCS Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli, 1 - 40136, Bologna, Italy
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Migliorini F, Eschweiler J, Spiezia F, van de Wall BJM, Knobe M, Tingart M, Maffulli N. Arthroscopy versus mini-arthrotomy approach for matrix-induced autologous chondrocyte implantation in the knee: a systematic review. J Orthop Traumatol 2021; 22:23. [PMID: 34152483 PMCID: PMC8217351 DOI: 10.1186/s10195-021-00588-6] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 06/03/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Matrix-induced autologous chondrocyte implantation (mACI) can be performed in a full arthroscopic or mini-open fashion. A systematic review was conducted to investigate whether arthroscopy provides better surgical outcomes compared with the mini-open approach for mACI in the knee at midterm follow-up. METHODS This systematic review was conducted following the PRISMA guidelines. The literature search was performed in May 2021. All the prospective studies reporting outcomes after mACI chondral defects of the knee were accessed. Only studies that clearly stated the surgical approach (arthroscopic or mini-open) were included. Only studies reporting a follow-up longer than 12 months were eligible. Studies reporting data from combined surgeries were not eligible, nor were those combining mACI with less committed cells (e.g., mesenchymal stem cells). RESULTS Sixteen studies were included, and 770 patients were retrieved: 421 in the arthroscopy group, 349 in the mini-open. The mean follow-up was 44.3 (12-60) months. No difference between the two groups was found in terms of mean duration of symptoms, age, body mass index (BMI), gender, defect size (P > 0.1). No difference was found in terms of Tegner Score (P = 0.3), Lysholm Score (P = 0.2), and International Knee Documentation Committee (IKDC) Score (P = 0.1). No difference was found in the rate of failures (P = 0.2) and revisions (P = 0.06). CONCLUSION Arthroscopy and mini-arthrotomy approaches for mACI in knee achieve similar outcomes at midterm follow-up. LEVEL OF EVIDENCE II, systematic review of prospective studies.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopaedic and Trauma Surgery, RWTH University Hospital Aachen, Pauwelsstraße 30, 52074, Aachen, Germany.
| | - Jörg Eschweiler
- Department of Orthopaedic and Trauma Surgery, RWTH University Hospital Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Filippo Spiezia
- Department of Orthopaedic and Trauma Surgery, Ospedale San Carlo Potenza, Potenza, Italy
| | - Bryan J M van de Wall
- Department of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Matthias Knobe
- Department of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Markus Tingart
- Department of Orthopaedic and Trauma Surgery, RWTH University Hospital Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Nicola Maffulli
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081, Baronissi, SA, Italy.,School of Pharmacy and Bioengineering, Keele University School of Medicine, Thornburrow Drive, Stoke on Trent, England.,Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, Queen Mary University of London, 275 Bancroft Road, London, E1 4DG, England
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