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Wei S, Lu C, Li S, Zhang Q, Cheng R, Pan S, Wu Q, Zhao X, Tian X, Zeng X, Liu Y. Efficacy and safety of mesenchymal stem cell-derived microvesicles in mouse inflammatory arthritis. Int Immunopharmacol 2024; 131:111845. [PMID: 38531171 DOI: 10.1016/j.intimp.2024.111845] [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: 10/29/2023] [Revised: 02/28/2024] [Accepted: 03/08/2024] [Indexed: 03/28/2024]
Abstract
OBJECTIVE To determine the effective and safe intravenous doses of mesenchymal stem cells (MSCs)-derived microvesicles (MVs) and to elucidate the possible causes of death in mice receiving high-dose MVs. METHODS MVs were isolated from human MSCs by gradient centrifugation. Mice with collagen-induced arthritis were treated with different doses of intravenous MVs or MSCs. Arthritis severity, white blood cell count, and serum C-reactive protein levels were measured. To assess the safety profile of MSCs and MVs, mice were treated with different doses of MSCs and MVs, and LD50 was calculated. Mouse lungs and heart were assessed by live fluorescence imaging, histopathological measurements, and immunohistochemistry to explore the possible causes of death. Serum concentrations of cTnT, cTnI, and CK-MB were determined by ELISA. With the H9C2 cardiomyocyte cell line, cellular uptake of MVs was observed using confocal microscopy and cell toxicity was assessed by CCK-8 and flow cytometry. RESULTS Intravenous treatment with MSCs and MVs alleviated inflammatory arthritis, while high doses of MSCs and MVs were lethal. Mice receiving a maximum dose of MSCs (0.1 mL of MSCs at 109/mL) died immediately, while mice receiving a maximum dose of MVs (0.1 mL of MVs at 1012/mL) exhibited tears, drooling, tachycardia, shortness of breath, unbalanced rollover, bouncing, circular crawling, mania, and death. Some mice died after exhibiting convulsions and other symptoms. All mice died shortly after injecting the maximum dose of MSCs. Histologically, mice receiving high doses of MSCs frequently developed pulmonary embolism, while those receiving high doses of MVs died of myocardial infarction. Consistently, the serum levels of cTnT, cTnI, and CK-MB were significantly increased in the MVs-treated group (P < 0.05). The LD50 of intravenous MVs was 1.60 × 1012/kg. Further, MVs could enter the cell. High doses of MVs induced cell apoptosis, though low concentrations of MVs induced cell proliferation. CONCLUSIONS Appropriate dosages of MVs and MSCs are effective treatments for inflammatory arthritis while MVs and MSCs overdose is unsafe by causing cardiopulmonary complications.
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Affiliation(s)
- Shixiong Wei
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, NO. 1 Shuai Fu Yuan, Wang Fu Jing street, Beijing 100730, China; Department of Rheumatology & Department of Rheumatology and Immunology, West China Hospital, Sichuan University, No.37 Guoxue xiang Wuhou District, Chengdu City, Sichuan Province 610041, China
| | - Chenyang Lu
- Division of Rheumatology, Department of Internal Medicine, The Third Affiliated Hospital, Sun Yat-Sen University, Guangzhou 510630, China
| | - Sujia Li
- Department of Rheumatology & Department of Rheumatology and Immunology, West China Hospital, Sichuan University, No.37 Guoxue xiang Wuhou District, Chengdu City, Sichuan Province 610041, China
| | - Qiuping Zhang
- Department of Rheumatology & Department of Rheumatology and Immunology, West China Hospital, Sichuan University, No.37 Guoxue xiang Wuhou District, Chengdu City, Sichuan Province 610041, China
| | - Ruijuan Cheng
- Department of Rheumatology & Department of Rheumatology and Immunology, West China Hospital, Sichuan University, No.37 Guoxue xiang Wuhou District, Chengdu City, Sichuan Province 610041, China
| | - ShuYue Pan
- Department of Rheumatology & Department of Rheumatology and Immunology, West China Hospital, Sichuan University, No.37 Guoxue xiang Wuhou District, Chengdu City, Sichuan Province 610041, China
| | - QiuHong Wu
- Department of Rheumatology & Department of Rheumatology and Immunology, West China Hospital, Sichuan University, No.37 Guoxue xiang Wuhou District, Chengdu City, Sichuan Province 610041, China
| | - Xueting Zhao
- Department of Rheumatology & Department of Rheumatology and Immunology, West China Hospital, Sichuan University, No.37 Guoxue xiang Wuhou District, Chengdu City, Sichuan Province 610041, China
| | - Xinping Tian
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, NO. 1 Shuai Fu Yuan, Wang Fu Jing street, Beijing 100730, China.
| | - Xiaofeng Zeng
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, NO. 1 Shuai Fu Yuan, Wang Fu Jing street, Beijing 100730, China.
| | - Yi Liu
- Department of Rheumatology & Department of Rheumatology and Immunology, West China Hospital, Sichuan University, No.37 Guoxue xiang Wuhou District, Chengdu City, Sichuan Province 610041, China.
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Bernfort L, Granfeldt D, Ryd L. Individualized metal implants for focal cartilage lesions in the knee can be cost-effective: A simulation on 47-year-old in a Swedish setting. J ISAKOS 2023; 8:197-203. [PMID: 36924825 DOI: 10.1016/j.jisako.2023.02.006] [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: 07/05/2022] [Revised: 02/23/2023] [Accepted: 02/24/2023] [Indexed: 03/17/2023]
Abstract
OBJECTIVES In the aging population, the knee is the joint most commonly causing impaired function and incapacity. While definite treatment by prosthetic replacement is often performed late, symptomatic knee cartilage lesions cause much suffering also in younger ages. Early intervention could, therefore, be instituted at an early stage to the benefit of both patients and society. Small, metal surface, resurfacing implants have been tested with promising results. A system that features patient-specific implants and surgical instruments shows good clinical results and favorable survival rates. This study aims to assess the cost utility of this metal device compared with microfracture (MFX), being the standard procedure in Sweden. METHODS We constructed a simulation model in Excel. In the model, a cohort of 47-year-old patients (which is the mean age of patients treated with the metal implant) with symptomatic knee cartilage lesions received either MFX or metal implantation. Outcomes for the cohort were simulated over 40 years, such as in a previously published model based on MFX, and sensitivity analyses (deterministic and probabilistic) of the results were undertaken. Data on transition probabilities, costs, and quality of life were taken from clinical data, published literature, and official price lists. Only direct medical costs were included. RESULTS Results from the analysis showed that the metal device is a cost-effective treatment strategy compared with MFX. The incremental cost-effectiveness ratio (ICER) reached acceptable levels at ∼5 years postoperatively. Over the full-time horizon of 40 years, the metal device was cost saving with concomitant gains in quality-adjusted life years (QALYs), translating to a dominant treatment strategy. Results were robust according to sensitivity analysis with the initial success rate of up to three years for both metal and MFX having the largest impact. CONCLUSIONS A metal implant may be a cost-effective treatment alternative for patients in their 40's when compared to MFX in a Swedish setting. LEVEL OF EVIDENCE 5 [1].
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Affiliation(s)
- Lars Bernfort
- Department of Medical and Health Sciences, Division of Health Care Analysis, Linköping University, S-581 83 Linköping, Sweden.
| | | | - Leif Ryd
- Senior Medical Advisor, Episurf Medical, S-114 49 Stockholm, Sweden
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Snow M, Mandalia V, Custers R, Emans PJ, Kon E, Niemeyer P, Verdonk R, Gaissmaier C, Roeder A, Weinand S, Zöllner Y, Schubert T. Cost-effectiveness of a new ACI technique for the treatment of articular cartilage defects of the knee compared to regularly used ACI technique and microfracture. J Med Econ 2023; 26:537-546. [PMID: 36974460 DOI: 10.1080/13696998.2023.2194805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
AIMS For patients with cartilage defects of the knee, a new biocompatible and in situ cross-linkable albumin-hyaluronan-based hydrogel has been developed for matrix-associated autologous chondrocyte implantation (M-ACI) - NOVOCART® Inject plus (NInject)1. We aimed to estimate the potential cost-effectiveness of NInject, that is not available on the market, yet compared to spheroids of human autologous matrix-associated chondrocytes (Spherox®)2 and microfracture. MATERIALS AND METHODS An early Markov model was developed to estimate the cost-effectiveness in the United Kingdom (UK) from the payer perspective. Transition probabilities, response rates, utility values and costs were derived from literature. Since NInject has not yet been launched and no prices are available, its costs were assumed equal to those of Spherox®. Cycle length was set at one year and the time horizon chosen was notional patients' remaining lifetime. Model robustness was evaluated with deterministic and probabilistic sensitivity analyses (DSA; PSA) and value of information (VOI) analysis. The Markov model was built using TreeAge Pro Healthcare. RESULTS NInject was cost-effective compared to microfracture (ICER: ₤5,147) while Spherox® was extendedly dominated. In sensitivity analyses, the ICER exceeded conventional WTP threshold of ₤20,000 only when the utility value after successful first treatment with NInject was decreased by 20% (ICER: ₤69,620). PSA corroborated the cost-effectiveness findings of NInject, compared to both alternatives, with probabilities of 60% of NInject undercutting the aforementioned WTP threshold and being the most cost-effective alternative. The VOIA revealed that obtaining additional evidence on the new technology will likely not be cost-effective for the UK National Health Service. LIMITATIONS AND CONCLUSION This early Markov model showed that NInject is cost-effective for the treatment of articular cartilage defects in the knee, compared to Spherox and microfracture. However, as the final price of NInject has yet to be determined, the cost-effectiveness analysis performed in this study is provisional, assuming equal prices for NInject and Spherox.
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Affiliation(s)
- Martyn Snow
- The Royal Orthopaedic Hospital, Birmingham, UK
- The Robert Jones and Agnes Hunt, Oswestry, UK
| | | | - Roel Custers
- University Medical Center Utrecht, Utrecht, The Netherlands
| | - Pieter J Emans
- Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Elizaveta Kon
- IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
- Casa di Cura Toniolo, Bologna, Italy
| | | | | | | | | | | | - York Zöllner
- Hamburg University of Applied Sciences, Hamburg, Germany
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Suh K, Cole BJ, Gomoll A, Lee SM, Choi H, Ha CW, Lim HC, Kim MK, Ha GY, Suh DC. Cost Effectiveness of Allogeneic Umbilical Cord Blood-Derived Mesenchymal Stem Cells in Patients with Knee Osteoarthritis. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2023; 21:141-152. [PMID: 36136263 PMCID: PMC9834379 DOI: 10.1007/s40258-022-00762-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 05/10/2023]
Abstract
OBJECTIVES The aim of this study was to assess the cost effectiveness of allogeneic umbilical cord blood-derived mesenchymal stem cells with sodium hyaluronate (hUCB-MSC) compared with microfracture in patients with knee cartilage defects caused by osteoarthritis (OA) in South Korea. METHODS A partitioned survival model approach was taken consisting of five mutually exclusive health states: excellent, good, fair, poor, and death over a 20-year time horizon. Utility values were obtained from a randomized clinical trial. Cost data were extracted from a database provided by the Health Insurance Review & Assessment Service, and the utilization of healthcare services was estimated from an expert panel of orthopedic surgeons using a structured questionnaire. The incremental cost-effectiveness ratio (ICER) in terms of quality-adjusted life-years (QALY) was calculated. Deterministic and probabilistic sensitivity analyses were performed. RESULTS In the base case, the incremental costs of US$14,410 for hUCB-MSC therapy along with its associated QALY gain of 0.857 resulted in an ICER of US$16,812 (₩18,790,773) per QALY (95% confidence interval [CI] US$13,408-US$20,828) when compared with microfracture treatment from a healthcare payer perspective. From a societal perspective, the ICER was US$268 (₩299,255) per QALY (95% CI -US$2915 to US$3784). When using a willingness-to-pay threshold of US$22,367/QALY, the probability of hUCB being cost effectiveness compared with microfracture was 99% from the healthcare payer perspective and 100% from the societal perspective. CONCLUSIONS The study demonstrated that hUCB-MSC therapy was cost effective compared with microfracture when treating patients with knee OA. These findings should inform health policy decision makers about considerations for cost-effective therapy for treating knee OA to ultimately enhance population health.
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Affiliation(s)
- Kangho Suh
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, 15217, USA.
| | - Brian J Cole
- Department of Orthopedic Surgery, Rush Oak Park Hospital, Rush Medical College, Chicago, IL, USA
| | - Andreas Gomoll
- Department of Orthopedic Surgery, Hospital for Special Surgery, Weill-Cornell Medical College, New York, NY, USA
| | - Seung-Mi Lee
- Daegu Catholic University College of Pharmacy, Gyeongsan-si, Gyeongbukdo, South Korea
| | - Hangseok Choi
- Chung-Ang University College of Pharmacy, Seoul, South Korea
| | - Chul-Won Ha
- Sungkwunkwan University Samsung Seoul Hospital, Seoul, South Korea
| | | | - Myung Ku Kim
- Inha University School of Medicine, Incheon, South Korea
| | - Gwi-Yeom Ha
- Chung-Ang University College of Pharmacy, Seoul, South Korea
| | - Dong-Churl Suh
- Chung-Ang University College of Pharmacy, Seoul, South Korea
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Olry de Labry-Lima A, Ponce-Polo A, García-Mochón L, Ortega-Ortega M, Pérez-Troncoso D, Epstein D. Challenges for Economic Evaluations of Advanced Therapy Medicinal Products: A Systematic Review. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2023; 26:138-150. [PMID: 36031480 DOI: 10.1016/j.jval.2022.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 06/20/2022] [Accepted: 07/07/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVES Advanced therapy medicinal products (ATMPs) are drugs for human use for the treatment of chronic, degenerative, or life-threatening diseases that are based on genes, tissues, or cells. This article aimed to identify and critically review published economic analyses of ATMPs. METHODS A systematic review of economic analyses of ATMPs was undertaken. Study characteristics, design, sources of data, resources and unit costs, modeling and extrapolation methods, study results, and sensitivity analyses were assessed. RESULTS A total of 46 economic analyses of ATMP (from 45 articles) were included; 4 were cell therapy medicinal products, 33 gene therapy medicinal products, and 9 tissue-engineered products. 30 therapies had commercial marketing approval; 39 studies were cost-utility analysis, 5 were cost-effectiveness analysis, and 2 were cost only studies. Four studies predicted that the ATMP offered a step change in the management of the condition and 10 studies estimated that the ATMP would offer a lower mean cost. CONCLUSIONS Comparison with historical controls, pooling of data, and use of techniques such as mixture cure fraction models should be used cautiously. Sensitivity analyses should be used across a plausible range of prices. Clinical studies need to be designed to align with health technology assessment requirements, including generic quality of life, and payers should aim for clarity of criteria. Regulators and national payers should aim for compatibility of registers to allow interchange of data. Given the increasing reliance on industry-funded economic analyses, careful critical review is recommended.
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Affiliation(s)
- Antonio Olry de Labry-Lima
- Escuela Andaluza de Salud Pública, Granada, Spain; Instituto de Investigación Biosanitaria Ibs, Granada, Spain; CIBER en Epidemiología and Salud Pública (CIBERESP), Spain
| | - Angela Ponce-Polo
- Andalusian Network for the Design & Translation of Advanced Therapies, Sevilla, Spain.
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Primeau CA, Zomar BO, Somerville LE, Joshi I, Giffin JR, Marsh JD. Health Economic Evaluations of Hip and Knee Interventions in Orthopaedic Sports Medicine: A Systematic Review and Quality Assessment. Orthop J Sports Med 2021; 9:2325967120987241. [PMID: 34262974 PMCID: PMC8243245 DOI: 10.1177/2325967120987241] [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: 10/04/2020] [Accepted: 11/24/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The economic burden of musculoskeletal diseases is substantial and growing. Economic evaluations compare costs and health benefits of interventions simultaneously to help inform value-based care; thus, it is crucial to ensure that studies are using appropriate methodology to provide valid evidence on the cost-effectiveness of interventions. This is particularly the case in orthopaedic sports medicine, where several interventions of varying costs are available to treat common hip and knee conditions. PURPOSE To summarize and evaluate the quality of economic evaluations in orthopaedic sports medicine for knee and hip interventions and identify areas for quality improvement. STUDY DESIGN Systematic review; Level of evidence, 3. METHODS The Medline, AMED, OVID Health Star, and EMBASE databases were searched from inception to March 1, 2020, to identify economic evaluations that compared ≥2 interventions for hip and/or knee conditions in orthopaedic sports medicine. We assessed the quality of full economic evaluations using the Quality of Health Economic Studies (QHES) tool, which consists of 16 questions for a total score of 100. We classified studies into quartiles based on QHES score (extremely poor quality to high quality) and we evaluated the frequency of studies that addressed each of the 16 QHES questions. RESULTS A total of 93 studies were included in the systematic review. There were 41 (44%) cost analyses, of which 21 (51%) inappropriately concluded interventions were cost-effective. Only 52 (56%) of the included studies were full economic evaluations, although 40 of these (77%) fell in the high-quality quartile. The mean QHES score was 83.2 ± 19. Authors consistently addressed 12 of the QHES questions; questions that were missed or unclear were related to statistical uncertainty, appropriateness of costing methodology, and discussion of potential biases. The most frequently missed question was whether the cost perspective of the analysis was stated and justified. CONCLUSION The number of studies in orthopaedic sports medicine is small, despite their overall good quality. Yet, there are still many highly cited studies based on low-quality or partial economic evaluations that are being used to influence clinical decision-making. Investigators should follow international health economic guidelines for study design and critical appraisal of studies to further improve quality.
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Affiliation(s)
- Codie A. Primeau
- School of Physical Therapy, Western University, London, Ontario, Canada
- School of Health and Rehabilitation Sciences, Western University, London, Ontario, Canada
- Bone and Joint Institute, Western University, London, Ontario, Canada
| | - Bryn O. Zomar
- School of Physical Therapy, Western University, London, Ontario, Canada
- School of Health and Rehabilitation Sciences, Western University, London, Ontario, Canada
- Bone and Joint Institute, Western University, London, Ontario, Canada
| | | | - Ishita Joshi
- School of Physical Therapy, Western University, London, Ontario, Canada
- School of Health and Rehabilitation Sciences, Western University, London, Ontario, Canada
- Bone and Joint Institute, Western University, London, Ontario, Canada
| | - J. Robert Giffin
- Bone and Joint Institute, Western University, London, Ontario, Canada
- London Health Sciences
Centre, University Hospital, London, Ontario, Canada
- Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Jacquelyn D. Marsh
- School of Physical Therapy, Western University, London, Ontario, Canada
- School of Health and Rehabilitation Sciences, Western University, London, Ontario, Canada
- Bone and Joint Institute, Western University, London, Ontario, Canada
- London Health Sciences
Centre, University Hospital, London, Ontario, Canada
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Lloyd-Williams H, Hughes DA. A systematic review of economic evaluations of advanced therapy medicinal products. Br J Clin Pharmacol 2020; 87:2428-2443. [PMID: 32154598 PMCID: PMC8247439 DOI: 10.1111/bcp.14275] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 02/06/2020] [Accepted: 02/20/2020] [Indexed: 12/14/2022] Open
Abstract
Aims Advanced therapy medicinal products (ATMPs) represent a new category of medicinal products with a potential for transformative improvements in health outcomes but at exceptionally high prices. Routine adoption of ATMPs requires robust evidence of their cost‐effectiveness. Methods A systematic literature review of economic evaluations of ATMPs, including gene therapies, somatic cell therapies and tissue‐engineered products, was conducted. Literature was searched using MedLine, Embase, PubMed, Cochrane Register, the NHS Economic Evaluation Database and the grey literature of health technology assessment organisations with search terms relating to ATMPs and economic evaluations. Titles were screened independently by 2 reviewers. Articles deemed to meet the inclusion criteria were screened independently on abstract, and full texts reviewed. Study findings were appraised critically. Results 4514 articles were identified, of which 23 met the inclusion criteria. There was some evidence supporting the cost‐effectiveness of: chimeric antigen receptor T‐cell therapy axicabtagene–ciloleucel (Yescarta), embryonic neural stem cells, tumour infiltrating lymphocytes, in vitro expanded myoblast, autologous chondrocyte implantation, ex vivo gene therapy (Strimvelis) and voretigene neparvovec (Luxturna). However, estimates of cost‐effectiveness were associated with significant uncertainty and high likelihood of bias, resulting from largely unknown long‐term outcomes, a paucity of evidence on health state utilities and extensive modelling assumptions. Conclusion There are critical limitations to the economic evidence for ATMPs, most notably in relation to evidence on the durability of treatment effect, and the reliability of opinion‐based assumptions necessary when evidence is absent.
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Affiliation(s)
- Huw Lloyd-Williams
- Centre for Health Economics and Medicines Evaluation, Bangor University, Wales, UK
| | - Dyfrig A Hughes
- Centre for Health Economics and Medicines Evaluation, Bangor University, Wales, UK
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Niemeyer P, Schubert T, Grebe M, Hoburg A. Treatment Costs of Matrix-Associated Autologous Chondrocyte Implantation Compared With Microfracture: Results of a Matched-Pair Claims Data Analysis on the Treatment of Cartilage Knee Defects in Germany. Orthop J Sports Med 2019; 7:2325967119886583. [PMID: 31840030 PMCID: PMC6896134 DOI: 10.1177/2325967119886583] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Articular cartilage damage is caused by traumatic sport accidents or age-related degeneration and might lead to osteoarthritis, which represents a socioeconomic burden to society. Cartilage damage in the knee is commonly treated surgically with microfracture (MFX) or matrix-associated autologous chondrocyte implantation (MACI). PURPOSE To quantify the initial and follow-up costs associated with MFX and MACI treatments from the viewpoint of statutory health insurance in Germany. STUDY DESIGN Economic decision analysis; Level of evidence, 2. METHODS This comparative study was based on an anonymized representative claims data set of 4 million patients covered by statutory health insurance in Germany. Patients undergoing outpatient or inpatient treatment with MACI or MFX for cartilage damage in the knee between January 1, 2012, and December 31, 2013, were included and evaluated over 5 years. Groups (MACI and MFX) were adjusted via propensity score matching before initial treatment. The matched groups were compared regarding their outpatient, inpatient, pharmaceutical, and other costs during the 5-year period. RESULTS In total, 127 patients per group were analyzed (59.1% male, 40.9% female; mean age, 37 years). In the year of the initial surgical procedure, costs were €14,804.13 in the MACI group and €5458.59 in the MFX group. In years 2 and 3 after initial surgery, treatment costs were comparable between patients treated with MACI (€2897.97 and €2114.87, respectively) and MFX (€2842.66 and €1967.42, respectively), with slightly higher treatment costs for those treated with MACI. In years 4 and 5 after surgery, costs were less in patients treated with MACI (€2154.79 and €1478.08, respectively) than in those treated with MFX (€2232.57 and €2061.63, respectively). Costs related to revision surgery were, on average, €3732 for MACI and €3765 for MFX. Thus, additional costs in years with revision surgery were €1672 for MACI and €1915 for MFX. CONCLUSION This was the first study to analyze a large representative population claims database with propensity score matching, and results indicated that follow-up costs of patients treated with MACI and MFX began to converge over time. We found that total costs for MACI were higher than for MFX but that additional costs for MACI were lower than previously reported. Perceived morbidity may have little to do with cost.
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Affiliation(s)
- Philipp Niemeyer
- Department of Orthopedics and Trauma Surgery, University Medical Center, Albert Ludwig University of Freiburg, Freiburg, Germany
- OCM Orthopädische Chirurgie München, Munich, Germany
| | | | | | - Arnd Hoburg
- Gelenk- und Wirbelsäulen-Zentrum Steglitz, Berlin, Germany
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Armoiry X, Cummins E, Connock M, Metcalfe A, Royle P, Johnston R, Rodrigues J, Waugh N, Mistry H. Autologous Chondrocyte Implantation with Chondrosphere for Treating Articular Cartilage Defects in the Knee: An Evidence Review Group Perspective of a NICE Single Technology Appraisal. PHARMACOECONOMICS 2019; 37:879-886. [PMID: 30426462 DOI: 10.1007/s40273-018-0737-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Chondrosphere (Spherox) is a form of autologous chondrocyte implantation (ACI). It is licensed for repair of symptomatic articular cartilage defects of the femoral condyle and the patella of the knee with defect sizes up to 10 cm2 in adults. In a single technology appraisal (STA) [TA508] undertaken by the National Institute of Health and Care Excellence (NICE), Warwick Evidence was the Evidence Review Group (ERG) invited to independently review the evidence submitted by the manufacturer, Co.Don. The clinical effectiveness data came from their COWISI randomised controlled trial (RCT), which compared Chondrosphere with microfracture (MF). The timing of this appraisal was unfortunate given that MF was no longer the most relevant comparator because NICE had contemporaneously published guidance approving ACI in place of MF. Moreover, the COWISI RCT enrolled mostly patients with small defect sizes. Evidence of clinical effectiveness for Chondrosphere used in people with larger defect size came from another RCT, which compared three doses of Chondrosphere and that by design could not provide evidence comparing Chondrosphere to any other forms of ACI. To estimate the relative clinical performance of Chondrosphere versus other ACI, Co.Don conducted an indirect treatment comparison by network meta-analyses (NMA). The NMA was flawed in that the distribution of population characteristics that are effect modifiers greatly differed across the treatment comparisons of the network. The ERG questioned both the appropriateness of the NMA and the validity of the resulting estimates. Co.Don estimated the cost-effectiveness of Chondrosphere using a lifetime Markov model with all patients receiving the first repair during the first cycle of the model then moving into one of three health states: success, no further repair (NFR), or a second repair, if necessary. Subsequent to the first cycle, those who were a success either remained a success or moved to second repair. All those in NFR remained in NFR. The cost-effectiveness of Chondrosphere compared to other ACI forms relied on the clinical effectiveness estimates of success and failure rates obtained from the company's indirect comparisons, the validity of which the ERG questioned. The company revised cost-effectiveness estimates for Chondrosphere versus MF and for Chondrosphere versus matrix-applied characterised autologous cultured chondrocyte implant (MACI) were £4360 and around £18,000 per quality-adjusted life year gained, respectively. NICE recommended ACI using Chondrosphere for treating symptomatic articular cartilage defects of the femoral condyle and patella of the knee in adults only if certain requirements were met.
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Affiliation(s)
- Xavier Armoiry
- Warwick Evidence, Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL, UK
| | | | - Martin Connock
- Warwick Evidence, Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL, UK
| | - Andrew Metcalfe
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Pamela Royle
- Warwick Evidence, Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL, UK
| | | | - Jeremy Rodrigues
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, OX3 7HE, UK
| | - Norman Waugh
- Warwick Evidence, Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL, UK
| | - Hema Mistry
- Warwick Evidence, Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL, UK.
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Abstract
To convince policy-makers or funders of health care of the value of orthopaedic interventions, we need to consider value for money (cost-effectiveness), as well as clinical effectiveness. This article provides an introduction to health economics to set the scene for papers on the use of allografts in the knee.
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The cost-effectiveness of osteochondral allograft transplantation in the knee. Knee Surg Sports Traumatol Arthrosc 2019; 27:1739-1753. [PMID: 30721344 PMCID: PMC6541582 DOI: 10.1007/s00167-019-05392-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 01/30/2019] [Indexed: 01/28/2023]
Abstract
PURPOSE Osteochondral allografts (OCA) consist of a layer of hyaline cartilage and a layer of underlying bone. They are used to repair combined defects of articular cartilage and bone. Such defects often occur in people far too young to have knee arthroplasty, for whom the main alternative to OCA is conservative symptomatic care, which will not prevent development of osteoarthritis. The aim of this report was to assess the cost-effectiveness of osteochondral allograft transplantation in the knee. METHODS Systematic review of evidence on clinical effectiveness and economic modelling. RESULTS The evidence on osteochondral allograft transplantation comes from observational studies, but often based on good quality prospective registries of all patients having such surgery. Without controlled trials, it was necessary to use historical cohorts to assess the effect of osteochondral grafts. There is good evidence that OCA are clinically effective with a high graft survival rate over 20 years. If an OCA graft fails, there is some evidence that revision with a second OCA is also effective, though less so than primary OCA. Economic modelling showed that osteochondral allograft transplantation was highly cost-effective, with costs per quality adjusted life year much lower than many other treatments considered cost effective. CONCLUSIONS Osteochondral allograft transplantation appears highly cost-effective though the cost per quality adjusted life year varies according to the widely varying costs of allografts. Based on one small study, revision OCA also appears very cost-effective, but more evidence is needed. LEVEL OF EVIDENCE II.
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Afzali T, Fangel MV, Vestergaard AS, Rathleff MS, Ehlers LH, Jensen MB. Cost-effectiveness of treatments for non-osteoarthritic knee pain conditions: A systematic review. PLoS One 2018; 13:e0209240. [PMID: 30566527 PMCID: PMC6300294 DOI: 10.1371/journal.pone.0209240] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 12/03/2018] [Indexed: 01/23/2023] Open
Abstract
INTRODUCTION Knee pain is common in adolescents and adults and is associated with an increased risk of developing knee osteoarthritis. The aim of this systematic review was to gather and appraise the cost-effectiveness of treatment approaches for non-osteoarthritic knee pain conditions. METHOD A systematic review was conducted according to the PRISMA guidelines and registered on PROSPERO (CRD42016050683). The literature search was done in MEDLINE via PubMed, EMBASE, The Cochrane Library, and the National Health Service Economic Evaluation Database. Study selection was carried out by two independent reviewers and data were extracted using a customized extraction form. Study quality was assessed using the Consensus on Health Economic Criteria list. RESULTS Fifteen studies were included. The majority regarded the treatment of anterior cruciate ligament (ACL) injuries, but we also identified studies evaluating other knee pain conditions such as meniscus injuries, cartilage defects, and patellofemoral pain syndrome. Study interventions were categorized as surgical or non-surgical interventions. The surgical interventions included ACL reconstruction, chondrocyte implantation, meniscus scaffold procedure, meniscal allograft transplantation, partial meniscectomy, microfracture, and different types of autografts and allografts. The non-surgical management consisted of physical therapy, rehabilitation, exercise, counselling, bracing, and advice. In general, for ACL injuries surgical management alone or in combination with rehabilitation appeared to be cost-effective. The quality of the economic evaluations was of moderate to high quality. CONCLUSION There was insufficient evidence to give a firm overview of cost-effective interventions for non-osteoarthritic knee pain, but surgical treatment of acute ACL injury appeared cost-effective. There is very little data regarding the cost-effectiveness of non-surgical interventions for non-traumatic knee conditions.
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Affiliation(s)
- Tamana Afzali
- Center for General Practice at Aalborg University, Aalborg, Denmark
| | - Mia Vicki Fangel
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Anne Sig Vestergaard
- Danish Center for Healthcare Improvements, Department of Business and Management, Aalborg University, Aalborg, Denmark
| | | | - Lars Holger Ehlers
- Danish Center for Healthcare Improvements, Department of Business and Management, Aalborg University, Aalborg, Denmark
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Mistry H, Connock M, Pink J, Shyangdan D, Clar C, Royle P, Court R, Biant LC, Metcalfe A, Waugh N. Autologous chondrocyte implantation in the knee: systematic review and economic evaluation. Health Technol Assess 2018; 21:1-294. [PMID: 28244303 DOI: 10.3310/hta21060] [Citation(s) in RCA: 145] [Impact Index Per Article: 24.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The surfaces of the bones in the knee are covered with articular cartilage, a rubber-like substance that is very smooth, allowing frictionless movement in the joint and acting as a shock absorber. The cells that form the cartilage are called chondrocytes. Natural cartilage is called hyaline cartilage. Articular cartilage has very little capacity for self-repair, so damage may be permanent. Various methods have been used to try to repair cartilage. Autologous chondrocyte implantation (ACI) involves laboratory culture of cartilage-producing cells from the knee and then implanting them into the chondral defect. OBJECTIVE To assess the clinical effectiveness and cost-effectiveness of ACI in chondral defects in the knee, compared with microfracture (MF). DATA SOURCES A broad search was done in MEDLINE, EMBASE, The Cochrane Library, NHS Economic Evaluation Database and Web of Science, for studies published since the last Health Technology Assessment review. REVIEW METHODS Systematic review of recent reviews, trials, long-term observational studies and economic evaluations of the use of ACI and MF for repairing symptomatic articular cartilage defects of the knee. A new economic model was constructed. Submissions from two manufacturers and the ACTIVE (Autologous Chondrocyte Transplantation/Implantation Versus Existing Treatment) trial group were reviewed. Survival analysis was based on long-term observational studies. RESULTS Four randomised controlled trials (RCTs) published since the last appraisal provided evidence on the efficacy of ACI. The SUMMIT (Superiority of Matrix-induced autologous chondrocyte implant versus Microfracture for Treatment of symptomatic articular cartilage defects) trial compared matrix-applied chondrocyte implantation (MACI®) against MF. The TIG/ACT/01/2000 (TIG/ACT) trial compared ACI with characterised chondrocytes against MF. The ACTIVE trial compared several forms of ACI against standard treatments, mainly MF. In the SUMMIT trial, improvements in knee injury and osteoarthritis outcome scores (KOOSs), and the proportion of responders, were greater in the MACI group than in the MF group. In the TIG/ACT trial there was improvement in the KOOS at 60 months, but no difference between ACI and MF overall. Patients with onset of symptoms < 3 years' duration did better with ACI. Results from ACTIVE have not yet been published. Survival analysis suggests that long-term results are better with ACI than with MF. Economic modelling suggested that ACI was cost-effective compared with MF across a range of scenarios. LIMITATIONS The main limitation is the lack of RCT data beyond 5 years of follow-up. A second is that the techniques of ACI are evolving, so long-term data come from trials using forms of ACI that are now superseded. In the modelling, we therefore assumed that durability of cartilage repair as seen in studies of older forms of ACI could be applied in modelling of newer forms. A third is that the high list prices of chondrocytes are reduced by confidential discounting. The main research needs are for longer-term follow-up and for trials of the next generation of ACI. CONCLUSIONS The evidence base for ACI has improved since the last appraisal by the National Institute for Health and Care Excellence. In most analyses, the incremental cost-effectiveness ratios for ACI compared with MF appear to be within a range usually considered acceptable. Research is needed into long-term results of new forms of ACI. STUDY REGISTRATION This study is registered as PROSPERO CRD42014013083. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Hema Mistry
- Warwick Evidence, Division of Health Sciences, University of Warwick, Coventry, UK
| | - Martin Connock
- Warwick Evidence, Division of Health Sciences, University of Warwick, Coventry, UK
| | - Joshua Pink
- Warwick Evidence, Division of Health Sciences, University of Warwick, Coventry, UK
| | - Deepson Shyangdan
- Warwick Evidence, Division of Health Sciences, University of Warwick, Coventry, UK
| | - Christine Clar
- Warwick Evidence, Division of Health Sciences, University of Warwick, Coventry, UK
| | - Pamela Royle
- Warwick Evidence, Division of Health Sciences, University of Warwick, Coventry, UK
| | - Rachel Court
- Warwick Evidence, Division of Health Sciences, University of Warwick, Coventry, UK
| | - Leela C Biant
- Department of Trauma and Orthopaedic Surgery, University of Manchester, Manchester, UK
| | - Andrew Metcalfe
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Norman Waugh
- Warwick Evidence, Division of Health Sciences, University of Warwick, Coventry, UK
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14
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Elvidge J, Bullement A, Hatswell AJ. Cost Effectiveness of Characterised Chondrocyte Implantation for Treatment of Cartilage Defects of the Knee in the UK. PHARMACOECONOMICS 2016; 34:1145-1159. [PMID: 27318837 DOI: 10.1007/s40273-016-0423-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
INTRODUCTION Until recently, treatment options for damage to cartilage in the knee were limited to the use of microfracture or, occasionally, mosaicplasty. The developments of autologous and characterised chondrocyte implantation have provided new treatment options but have large upfront costs. The objective of this study was to estimate the cost effectiveness of characterised chondrocyte implantation in the UK National Health Service. METHODS An economic model was constructed in Microsoft Excel®, with patients undergoing either microfracture or chondrocyte implantation. Following treatment failure, patients can undergo a series of interventions, ultimately ending in knee replacement. Effectiveness and utility were modelled using clinical trial data, which were supplemented with synthesised registry data, and costs were taken from published sources. Results were expressed in clinical events, quality-adjusted life-years (QALYs) and British pounds. Both costs and outcomes were discounted at 3.5 % per year. RESULTS Chondrocyte implantation is estimated to reduce the lifetime probability of knee replacement by 50 % in comparison with microfracture, and to increase QALYs by 0.72 (16.57 vs. 15.85). Costs were estimated to be £23,307 for chondrocyte implantation, and £8008 for microfracture, with the incremental cost of £15,299 for chondrocyte implantation reflecting reduced resource use offsetting some of the procedure cost. These values gave a cost per QALY gained of £21,245. CONCLUSION Chondrocyte implantation is estimated to provide substantial patient benefits over a lifetime horizon, with a considerable increase in QALYs. Despite the increase in costs, the procedure is cost effective at standard thresholds used in the UK.
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Affiliation(s)
| | | | - Anthony J Hatswell
- BresMed, 84 Queen Street, Sheffield, S1 2DW, UK.
- Department of Statistical Science, University College London, Gower Street, London, WC1E 6BT, UK.
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de Windt TS, Sorel JC, Vonk LA, Kip MMA, Ijzerman MJ, Saris DBF. Early health economic modelling of single-stage cartilage repair. Guiding implementation of technologies in regenerative medicine. J Tissue Eng Regen Med 2016; 11:2950-2959. [DOI: 10.1002/term.2197] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2015] [Revised: 12/24/2015] [Accepted: 03/14/2016] [Indexed: 12/15/2022]
Affiliation(s)
- Tommy S. de Windt
- Department of Orthopaedics; University Medical Centre Utrecht; Utrecht the Netherlands
| | - Juliette C. Sorel
- Department of Orthopaedics; University Medical Centre Utrecht; Utrecht the Netherlands
| | - Lucienne A. Vonk
- Department of Orthopaedics; University Medical Centre Utrecht; Utrecht the Netherlands
| | - Michelle M. A. Kip
- Department of Health Technology and Services Research, MIRA Institute for Biomedical Technology and Technical Medicine; University of Twente; Enschede the Netherlands
| | - Maarten J. Ijzerman
- Department of Health Technology and Services Research, MIRA Institute for Biomedical Technology and Technical Medicine; University of Twente; Enschede the Netherlands
| | - Daniel B. F. Saris
- Department of Orthopaedics; University Medical Centre Utrecht; Utrecht the Netherlands
- MIRA Institute for Biotechnology and Technical Medicine; University of Twente; Enschede the Netherlands
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Autologe Knorpelzelltransplantation. ARTHROSKOPIE 2016. [DOI: 10.1007/s00142-016-0064-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Fabrication of High-Aspect-Ratio 3D Hydrogel Microstructures Using Optically Induced Electrokinetics. MICROMACHINES 2016; 7:mi7040065. [PMID: 30407438 PMCID: PMC6189970 DOI: 10.3390/mi7040065] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Revised: 03/04/2016] [Accepted: 03/11/2016] [Indexed: 11/17/2022]
Abstract
We present a rapid hydrogel polymerization and prototyping microfabrication technique using an optically induced electrokinetics (OEK) chip, which is based on a non-UV hydrogel curing principle. Using this technique, micro-scale high-aspect-ratio three-dimensional polymer features with different geometric sizes can be fabricated within 1–10 min by projecting pre-defined visible light image patterns onto the OEK chip. This method eliminates the need for traditional photolithography masks used for patterning and fabricating polymer microstructures and simplifies the fabrication processes. This technique uses cross-link hydrogels, such as poly(ethylene glycol) (PEG)-diacrylate (PEGDA), as fabrication materials. We demonstrated that hydrogel micropillar arrays rapidly fabricated using this technique can be used as molds to create micron-scale cavities in PDMS (polydimethylsiloxane) substrates. Furthermore, hollow, circular tubes with controllable wall thicknesses and high-aspect ratios can also be fabricated. These results show the potential of this technique to become a rapid prototyping technology for producing microfluidic devices. In addition, we show that rapid prototyping of three-dimensional suspended polymer structures is possible without any sacrificial etching process.
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18
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Clavé A, Potel JF, Servien E, Neyret P, Dubrana F, Stindel E. Third-generation autologous chondrocyte implantation versus mosaicplasty for knee cartilage injury: 2-year randomized trial. J Orthop Res 2016; 34:658-65. [PMID: 26742454 DOI: 10.1002/jor.23152] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Accepted: 12/29/2015] [Indexed: 02/04/2023]
Abstract
Numerous surgical techniques have been developed to treat osteochondral defects of the knee. A study reported encouraging outcomes of third-generation autologous chondrocyte implantation achieved using the solid agarose-alginate scaffold Cartipatch®. Whether this scaffold is better than conventional techniques remains unclear. This multicenter randomized controlled trial compared 2-year functional outcomes (IKDC score) after Cartipatch® versus mosaicplasty in patients with isolated symptomatic femoral chondral defects (ICRS III and IV) measuring 2.5-7.5 cm(2) . In addition, a histological evaluation based on the O'Driscoll score was performed after 2 years. We needed 76 patients to demonstrate an at least 10-point subjective IKDC score difference with α = 5% and 90% power. During the enrolment period, we were able to include 55 patients, 30 of them were allocated at random to Cartipatch® and 25 to mosaicplasty. After 2 years, eight patients had been lost to follow-up, six in the Cartipatch® group, and two in the mosaicplasty group. The baseline characteristics of the two groups were not significantly different. The mean IKDC score and score improvement after 2 years were respectively 73.7 ± 20.1 and 31.8 ± 20.8 with Cartipatch® and 81.5 ± 16.4 and 44.4 ± 15.2 with mosaicplasty. The 12.6-point absolute difference in favor of mosaicplasty is statistically significant. Twelve adverse events were recorded in the Cartipatch® group against six in the mosaicplasty group. After 2 years, functional outcomes were significantly worse after Cartipatch® treatment compared to mosaicplasty for isolated focal osteochondral defects of the femur.
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Affiliation(s)
- Arnaud Clavé
- Université de Bretagne Occidentale, Faculté de Médecine, 22 avenue Camille Desmoulins, 29200, Brest, France.,Service de Chirurgie Orthopédique et Traumatologique de la Cavale Blanche, CHRU Brest, bd Tanguy Prigent, 29200, Brest, France.,LaTIM, INSERM UMR 1101, 2 av Foch, 29609, Brest Cedex, France
| | | | - Elvire Servien
- Centre Albert Trillat, service de chirurgie orthopédique, Hôpital de la Croix-Rousse, Hospices civils de Lyon, 103 grande rue de la Croix-Rousse, 69004, Lyon, France
| | - Philippe Neyret
- Centre Albert Trillat, service de chirurgie orthopédique, Hôpital de la Croix-Rousse, Hospices civils de Lyon, 103 grande rue de la Croix-Rousse, 69004, Lyon, France
| | - Frédéric Dubrana
- Université de Bretagne Occidentale, Faculté de Médecine, 22 avenue Camille Desmoulins, 29200, Brest, France.,Service de Chirurgie Orthopédique et Traumatologique de la Cavale Blanche, CHRU Brest, bd Tanguy Prigent, 29200, Brest, France
| | - Eric Stindel
- Université de Bretagne Occidentale, Faculté de Médecine, 22 avenue Camille Desmoulins, 29200, Brest, France.,Service de Chirurgie Orthopédique et Traumatologique de la Cavale Blanche, CHRU Brest, bd Tanguy Prigent, 29200, Brest, France.,LaTIM, INSERM UMR 1101, 2 av Foch, 29609, Brest Cedex, France
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19
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Affiliation(s)
- Magdalini Papadaki
- Regenerative Medicine Program, Innovate UK, North Star House, North Star Avenue, Swindon, SN2 1UE, UK
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20
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Bisson I, Green E, Sharpe M, Herbert C, Hyllner J, Mount N. Landscape of current and emerging cell therapy clinical trials in the UK: current status, comparison to global trends and future perspectives. Regen Med 2016; 10:169-79. [PMID: 25835481 DOI: 10.2217/rme.14.71] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Cell Therapy Clinical Trial and Preclinical Research databases have been established by the Cell Therapy Catapult to document current and future cell therapy clinical trials in the UK. We identified 41 ongoing trials in April 2014, an increase of seven trials from April 2013. In addition, we identified 45 late-stage preclinical research projects. The majority of the clinical trials are early phase, primarily led by academic groups. The leading therapeutic areas are cancer, cardiology and neurology. The trends in the UK are also seen globally. As the field matures, more later phase and commercial studies will emerge and the challenges will likely evolve into how to manufacture sufficient cell quantities, manage complex logistics for multi-center trials and control cost.
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Affiliation(s)
- Isabelle Bisson
- Cell Therapy Catapult, 12th Floor Tower Wing, Guys Hospital, Great Maze Pond, London, SE1 9RT, UK
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McLawhorn AS, Southren D, Wang YC, Marx RG, Dodwell ER. Cost-Effectiveness of Bariatric Surgery Prior to Total Knee Arthroplasty in the Morbidly Obese: A Computer Model-Based Evaluation. J Bone Joint Surg Am 2016; 98:e6. [PMID: 26791039 DOI: 10.2106/jbjs.n.00416] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Obesity is associated with adverse outcomes and increased costs after total knee arthroplasty. Bariatric surgery is an effective treatment for morbid obesity, but its cost-effectiveness for weight loss prior to total knee arthroplasty is unknown. The purpose of this study was to evaluate the cost-effectiveness of bariatric surgery prior to total knee arthroplasty for patients in whom medical treatment of obesity and knee osteoarthritis had failed. METHODS A state-transition Markov model was constructed to compare the cost-utility of two treatment protocols for patients with morbid obesity and end-stage knee osteoarthritis: (1) immediate total knee arthroplasty and (2) bariatric surgery two years prior to the total knee arthroplasty. The probability of transition for each health state and its utility were derived from the literature. Costs, expressed in 2012 United States dollars, were estimated with use of administrative and claims data. Costs and utilities were discounted at 3% annually, and effectiveness was expressed in quality-adjusted life-years (QALYs). The principal outcome measure was the incremental cost-effectiveness ratio (ICER). One-way, two-way, and probabilistic sensitivity analyses were performed, using $100,000 per QALY as the threshold willingness to pay. RESULTS Morbidly obese patients undergoing total knee arthroplasty alone had lower QALYs gained than patients who underwent bariatric surgery two years prior to the total knee arthroplasty. The ICER between these two procedures was approximately $13,910 per QALY, well below the threshold willingness to pay. Results were stable across broad value ranges for independent variables. Probabilistic sensitivity analysis found that the median ICER was $14,023 per QALY (95% confidence interval, $4875 to $51,210 per QALY). CONCLUSIONS This model supports bariatric surgery prior to total knee arthroplasty as a cost-effective option for improving outcomes in morbidly obese patients with end-stage knee osteoarthritis who are indicated for total knee arthroplasty. LEVEL OF EVIDENCE Economic and Decision Analysis Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Alexander S McLawhorn
- Department of Orthopedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for A.S. McLawhorn:
| | - Daniel Southren
- Columbia University College of Physicians & Surgeons, 630 West 168th Street, New York, NY 10032
| | - Y Claire Wang
- Department of Health Policy and Management, Columbia Mailman School of Public Health, 600 West 168th Street, 6th Floor, New York, NY 10032
| | - Robert G Marx
- Department of Orthopedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for A.S. McLawhorn:
| | - Emily R Dodwell
- Department of Orthopedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for A.S. McLawhorn:
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Kon E, Filardo G, Shani J, Altschuler N, Levy A, Zaslav K, Eisman JE, Robinson D. Osteochondral regeneration with a novel aragonite-hyaluronate biphasic scaffold: up to 12-month follow-up study in a goat model. J Orthop Surg Res 2015; 10:81. [PMID: 26018574 PMCID: PMC4486417 DOI: 10.1186/s13018-015-0211-y] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Accepted: 05/04/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The regeneration of articular hyaline cartilage remains an elusive goal despite years of research. Recently, an aragonite-hyaluronate (Ar-HA) biphasic scaffold has been described capable of cartilage regeneration over a 6-month follow-up period. This study was conducted in order to assess the fate of the regenerated osteochondral tissue in a 12-month-long validated caprine model. HYPOTHESIS/PURPOSE The hypothesis was that the implantation of the Ar-HA implant leads to tissue regeneration and maturation. STUDY DESIGN A two-arm caprine model of a critical osteochondral defect compares the fate of acute osteochondral defects (group A) to Ar-HA implanted defects (group B). METHODS Critical 6 mm in diameter and 10-mm in depth osteochondral defects were created in the load-bearing medial femoral condyle of 20 mature goats and randomized into two groups. In group A (n = 6), a blood clot spontaneously filled the defect; in group B (n = 14), a single Ar-HA implant reconstructed the defect. The animals were sacrificed after either 6 or 12 months. Parameters assessed included clinical evaluation, x-rays, micro-CT, ultrasound and histology at both time points, and specimen high-field magnetic resonance imaging with T2 mapping at the 12-month time point. RESULTS In most group A animals, the defects were not reconstructed (1/3 at 6 months, and 0/3 at 12 months). Defects in group B were mostly reconstructed (5/7 at 6 months and 6/7 at 12 months). Group A defects were either empty or contained fibrous repair tissue; while group B filling was compatible with hyaline cartilage and normal bone. CONCLUSION Ar-HA scaffolds implanted in critical osteochondral defects result in hyaline cartilage formation and subchondral bone regeneration. The results improved at the 12-month time point compared to the 6-month time point, indicating a continuous maturation process without deterioration of the repair tissue. CLINICAL RELEVANCE Osteochondral defects are common in humans; the results of the current study suggest that an acellular Ar-HA scaffold might induce cartilage and subchondral bone regeneration.
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Affiliation(s)
- Elizaveta Kon
- II Orthopedic division and NanoBiotechnology Lab, Rizzoli Orthopedic Institute, Bologna, Italy.
| | - Giuseppe Filardo
- II Orthopedic division and NanoBiotechnology Lab, Rizzoli Orthopedic Institute, Bologna, Italy.
| | | | | | - Andrew Levy
- Center for Advanced Sports Medicine, Knee and Shoulder, Millburn, NJ, USA.
| | - Ken Zaslav
- Cartilage Restoration Center: Advanced Orthopedic Centers and Clinical Prof. Orthopedic Surgery V.C.U. Med. Ctr., Richmond, VA, USA.
| | - John E Eisman
- Osteoporosis and Translational Research, UNSW University, Sydney, NSW, Australia.
| | - Dror Robinson
- Department of Orthopedics, Rabin Medical Center, Petah Tikwa, Israel.
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Konopka JF, Gomoll AH, Thornhill TS, Katz JN, Losina E. The cost-effectiveness of surgical treatment of medial unicompartmental knee osteoarthritis in younger patients: a computer model-based evaluation. J Bone Joint Surg Am 2015; 97:807-17. [PMID: 25995491 PMCID: PMC4430101 DOI: 10.2106/jbjs.n.00925] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Surgical options for the management of medial compartment osteoarthritis of the varus knee include high tibial osteotomy, unicompartmental knee arthroplasty, and total knee arthroplasty. We sought to determine the cost-effectiveness of high tibial osteotomy and unicompartmental knee arthroplasty as alternatives to total knee arthroplasty for patients fifty to sixty years of age. METHODS We built a probabilistic state-transition computer model with health states defined by pain, postoperative complications, and subsequent surgical procedures. We estimated transition probabilities from published literature. Costs were determined from Medicare reimbursement schedules. Health outcomes were measured in quality-adjusted life-years (QALYs). We conducted analyses over patients' lifetimes from the societal perspective, with health and cost outcomes discounted by 3% annually. We used probabilistic sensitivity analyses to account for uncertainty in data inputs. RESULTS The estimated discounted QALYs were 14.62, 14.63, and 14.64 for high tibial osteotomy, unicompartmental knee arthroplasty, and total knee arthroplasty, respectively. Discounted total direct medical costs were $20,436 for high tibial osteotomy, $24,637 for unicompartmental knee arthroplasty, and $24,761 for total knee arthroplasty (in 2012 U.S. dollars). The incremental cost-effectiveness ratio (ICER) was $231,900 per QALY for total knee arthroplasty and $420,100 per QALY for unicompartmental knee arthroplasty. Probabilistic sensitivity analyses showed that, at a willingness-to-pay (WTP) threshold of $50,000 per QALY, high tibial osteotomy was cost-effective 57% of the time; total knee arthroplasty, 24%; and unicompartmental knee arthroplasty, 19%. At a WTP threshold of $100,000 per QALY, high tibial osteotomy was cost-effective 43% of time; total knee arthroplasty, 31%; and unicompartmental knee arthroplasty, 26%. CONCLUSIONS In fifty to sixty-year-old patients with medial unicompartmental knee osteoarthritis, high tibial osteotomy is an attractive option compared with unicompartmental knee arthroplasty and total knee arthroplasty. This finding supports greater utilization of high tibial osteotomy for these patients. The cost-effectiveness of high tibial osteotomy and of unicompartmental knee arthroplasty depend on rates of conversion to total knee arthroplasty and the clinical outcomes of the conversions.
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Affiliation(s)
- Joseph F. Konopka
- Orthopedic and Arthritis Center for Outcomes Research (J.F.K., J.N.K., and E.L.), Department of Orthopedic Surgery (J.F.K., T.S.T., J.N.K., and E.L.), Brigham and Women’s Hospital, 75 Francis Street, BC-4016, Boston, MA 02115. E-mail address for E. Losina:
| | - Andreas H. Gomoll
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, 850 Boylston Street, Chestnut Hill, MA 02467
| | - Thomas S. Thornhill
- Orthopedic and Arthritis Center for Outcomes Research (J.F.K., J.N.K., and E.L.), Department of Orthopedic Surgery (J.F.K., T.S.T., J.N.K., and E.L.), Brigham and Women’s Hospital, 75 Francis Street, BC-4016, Boston, MA 02115. E-mail address for E. Losina:
| | - Jeffrey N. Katz
- Orthopedic and Arthritis Center for Outcomes Research (J.F.K., J.N.K., and E.L.), Department of Orthopedic Surgery (J.F.K., T.S.T., J.N.K., and E.L.), Brigham and Women’s Hospital, 75 Francis Street, BC-4016, Boston, MA 02115. E-mail address for E. Losina:
| | - Elena Losina
- Orthopedic and Arthritis Center for Outcomes Research (J.F.K., J.N.K., and E.L.), Department of Orthopedic Surgery (J.F.K., T.S.T., J.N.K., and E.L.), Brigham and Women’s Hospital, 75 Francis Street, BC-4016, Boston, MA 02115. E-mail address for E. Losina:
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de Windt TS, Vonk LA, Buskermolen JK, Visser J, Karperien M, Bleys RLAW, Dhert WJA, Saris DBF. Arthroscopic airbrush assisted cell implantation for cartilage repair in the knee: a controlled laboratory and human cadaveric study. Osteoarthritis Cartilage 2015; 23:143-50. [PMID: 25241243 DOI: 10.1016/j.joca.2014.09.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Revised: 09/04/2014] [Accepted: 09/05/2014] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The objective of this study was to investigate the feasibility of arthroscopic airbrush assisted cartilage repair. METHODS An airbrush device (Baxter) was used to spray both human expanded osteoarthritic chondrocytes and choncrocytes with their pericellular matrix (chondrons) at 1 × 10(6) cells/ml fibrin glue (Tissucol, Baxter) in vitro. Depth-dependent cell viability was assessed for both methods with confocal microscopy. Constructs were cultured for 21 days to assess matrix production. A controlled human cadaveric study (n = 8) was performed to test the feasibility of the procedure in which defects were filled with either arthroscopic airbrushing or needle extrusion. All knees were subjected to 60 min of continuous passive motion and scored on outline attachment and defect filling. RESULTS Spraying both chondrocytes and chondrons in fibrin glue resulted in a homogenous cell distribution throughout the scaffold. No difference in viability or matrix production between application methods was found nor between chondrons and chondrocytes. The cadaveric study revealed that airbrushing was highly feasible, and that defect filling through needle extrusion was more difficult to perform based on fibrin glue adhesion and gravity-induced seepage. Defect outline and coverage scores were consistently higher for extrusion, albeit not statistically significant. CONCLUSION Both chondrons and chondrocytes can be evenly distributed in a sprayed fibrin glue scaffold without affecting viability while supporting matrix production. The airbrush technology is feasible, easier to perform than needle extrusion and allows for reproducible arthroscopic filling of cartilage defects.
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Affiliation(s)
- T S de Windt
- Department of Orthopaedics, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - L A Vonk
- Department of Orthopaedics, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - J K Buskermolen
- Department of Developmental BioEngineering, University of Twente, Enschede, The Netherlands.
| | - J Visser
- Department of Orthopaedics, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - M Karperien
- Department of Developmental BioEngineering, University of Twente, Enschede, The Netherlands.
| | - R L A W Bleys
- Department of Anatomy, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - W J A Dhert
- Department of Orthopaedics, University Medical Center Utrecht, Utrecht, The Netherlands; Faculty of Veterinary Medicine, University of Utrecht, Utrecht, The Netherlands.
| | - D B F Saris
- Department of Orthopaedics, University Medical Center Utrecht, Utrecht, The Netherlands; MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, The Netherlands.
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25
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Davies BM, Rikabi S, French A, Pinedo-Villanueva R, Morrey ME, Wartolowska K, Judge A, MacLaren RE, Mathur A, Williams DJ, Wall I, Birchall M, Reeve B, Atala A, Barker RW, Cui Z, Furniss D, Bure K, Snyder EY, Karp JM, Price A, Carr A, Brindley DA. Quantitative assessment of barriers to the clinical development and adoption of cellular therapies: A pilot study. J Tissue Eng 2014; 5:2041731414551764. [PMID: 25383173 PMCID: PMC4221931 DOI: 10.1177/2041731414551764] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Accepted: 07/20/2014] [Indexed: 01/08/2023] Open
Abstract
There has been a large increase in basic science activity in cell therapy and a growing portfolio of cell therapy trials. However, the number of industry products available for widespread clinical use does not match this magnitude of activity. We hypothesize that the paucity of engagement with the clinical community is a key contributor to the lack of commercially successful cell therapy products. To investigate this, we launched a pilot study to survey clinicians from five specialities and to determine what they believe to be the most significant barriers to cellular therapy clinical development and adoption. Our study shows that the main concerns among this group are cost-effectiveness, efficacy, reimbursement, and regulation. Addressing these concerns can best be achieved by ensuring that future clinical trials are conducted to adequately answer the questions of both regulators and the broader clinical community.
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Affiliation(s)
- Benjamin M Davies
- Botnar Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Sarah Rikabi
- Botnar Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Anna French
- The Oxford-UCL Centre for the Advancement of Sustainable Medical Innovation (CASMI), University of Oxford, Oxford, UK
| | - Rafael Pinedo-Villanueva
- Botnar Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK ; MRC Lifecourse Epidemiology Unit, Southampton General Hospital, Southampton, UK
| | - Mark E Morrey
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Karolina Wartolowska
- Botnar Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Andrew Judge
- Botnar Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK ; MRC Lifecourse Epidemiology Unit, Southampton General Hospital, Southampton, UK
| | - Robert E MacLaren
- Nuffield Laboratory of Ophthalmology, University of Oxford, Oxford, UK
| | - Anthony Mathur
- NIHR Cardiovascular Biomedical Research Unit, London Chest Hospital, London, UK ; Department of Cardiology, Barts Health NHS Trust, London, UK ; Department of Clinical Pharmacology, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - David J Williams
- Centre for Biological Engineering, Wolfson School of Mechanical and Manufacturing Engineering, Loughborough University, Loughborough, UK
| | - Ivan Wall
- Department of Biochemical Engineering, University College London, London, UK ; Department of Nanobiomedical Science & BK21 Plus NBM Global Research Center for Regenerative Medicine, Dankook University, Cheonan, Republic of Korea ; Biomaterials and Tissue Engineering Lab, Department of Nanobiomedical Science and WCU Research Center, Dankook University, Cheonan, Republic of Korea
| | | | - Brock Reeve
- Harvard Stem Cell Institute, Cambridge, MA, USA
| | - Anthony Atala
- Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Richard W Barker
- The Oxford-UCL Centre for the Advancement of Sustainable Medical Innovation (CASMI), University of Oxford, Oxford, UK
| | - Zhanfeng Cui
- Oxford Centre for Tissue Engineering and Bioprocessing, University of Oxford, Oxford, UK
| | - Dominic Furniss
- Botnar Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Kim Bure
- Sartorius Stedim, Göttingen, Germany
| | - Evan Y Snyder
- Sanford-Burnham Medical Research Institute, La Jolla, CA, USA ; Department of Pediatrics, University of California, San Diego, La Jolla, CA, USA ; Sanford Consortium for Regenerative Medicine, La Jolla, CA, USA
| | - Jeffrey M Karp
- Harvard Stem Cell Institute, Cambridge, MA, USA ; Division of Biomedical Engineering, Department of Medicine, Center for Regenerative Therapeutics, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA ; Harvard-MIT Division of Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, MA, USA ; Harvard Medical School, Cambridge, MA, USA
| | - Andrew Price
- Botnar Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Andrew Carr
- Botnar Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK ; The Oxford-UCL Centre for the Advancement of Sustainable Medical Innovation (CASMI), University of Oxford, Oxford, UK
| | - David A Brindley
- Botnar Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK ; The Oxford-UCL Centre for the Advancement of Sustainable Medical Innovation (CASMI), University of Oxford, Oxford, UK ; Harvard Stem Cell Institute, Cambridge, MA, USA ; Centre for Behavioural Medicine, UCL School of Pharmacy, University College London, London, UK
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Brindley DA, French A, Suh J, Roberts M, Davies B, Pinedo-Villanueva R, Wartolowska K, Rooke K, Kramm A, Judge A, Morrey M, Chandra A, Hurley H, Grover L, Bingham I, Siegel B, Rattley MS, Buckler RL, McKeon D, Krumholz K, Hook L, May M, Rikabi S, Pigott R, Morys M, Sabokbar A, Titus E, Laabi Y, Lemaitre G, Zahkia R, Sipp D, Horne R, Bravery C, Williams D, Wall I, Snyder EY, Karp JM, Barker RW, Bure K, Carr AJ, Reeve B. The implementation of novel collaborative structures for the identification and resolution of barriers to pluripotent stem cell translation. Stem Cells Dev 2014; 22 Suppl 1:63-72. [PMID: 24304079 DOI: 10.1089/scd.2013.0403] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Increased global connectivity has catalyzed technological development in almost all industries, in part through the facilitation of novel collaborative structures. Notably, open innovation and crowd-sourcing-of expertise and/or funding-has tremendous potential to increase the efficiency with which biomedical ecosystems interact to deliver safe, efficacious and affordable therapies to patients. Consequently, such practices offer tremendous potential in advancing development of cellular therapies. In this vein, the CASMI Translational Stem Cell Consortium (CTSCC) was formed to unite global thought-leaders, producing academically rigorous and commercially practicable solutions to a range of challenges in pluripotent stem cell translation. Critically, the CTSCC research agenda is defined through continuous consultation with its international funding and research partners. Herein, initial findings for all research focus areas are presented to inform global product development strategies, and to stimulate continued industry interaction around biomanufacturing, strategic partnerships, standards, regulation and intellectual property and clinical adoption.
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Affiliation(s)
- David A Brindley
- 1 Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Nuffield Orthopaedic Centre, University of Oxford , Oxford, United Kingdom
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Frappier J, Stanish W, Brittberg M, Steinwachs M, Crowe L, Castelo D, Restrepo A. Economic evaluation of BST-CarGel as an adjunct to microfracture vs microfracture alone in knee cartilage surgery. J Med Econ 2014; 17:266-78. [PMID: 24601747 DOI: 10.3111/13696998.2014.897626] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVES Knee cartilage damage is a common cause of referral for orthopedic surgery. Treatment aims to reduce pain and symptoms by repairing cartilage. Microfracture, the current standard of care, yields good short-term clinical outcomes; however, treatment might fail after 2-3 years. A Chitosan-Beta glycerolphosphate-based medical device (BST-CarGel) is used as an adjunct to microfracture and demonstrates improvements in quantity and quality of repaired tissue, potentially reducing the risk of treatment failure. This study aimed to establish the economic value of BST-CarGel vs microfracture alone in knee cartilage repair from the societal perspective, using Germany as the reference market. METHODS A decision tree with a 20-year time-horizon was constructed, in which undesirable clinical events were inferred following initial surgery. These events consisted of pain management, surgery, and total knee replacement. Clinical outcomes were taken from the pivotal clinical trial, supplemented by other literature. Data and assumptions were validated by a Delphi panel. All relevant resource use and costs for procedures and events were considered. RESULTS In a group of patients with all lesion sizes, the model inferred that BST-CarGel yields a positive return on investment at year 4 (with 20-year cumulative cost savings of €6448). Reducing the incremental risk of treatment failure gap between the device and microfracture by 25-50% does not alter this conclusion. Cost savings are greatest for patients with large lesions; results for patients with small lesions are more modest. LIMITATIONS Clinical evidence for microfracture and other interventions varies in quality. Comparative long-term data are lacking. The comparison is limited to microfracture and looks only at costs without considering quality-of-life. CONCLUSION BST-CarGel potentially represents a cost-saving alternative for patients with knee cartilage injury by reducing the risk of clinical events through regeneration of chondral tissue with hyaline characteristics. Since the burden of this condition is high, both to the patient and society, an effective and economically viable alternative is of importance.
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Correlation of synovial cytokine expression with quality of cells used for autologous chondrocyte implantation in human knees. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2014; 24:1563-70. [DOI: 10.1007/s00590-014-1436-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2013] [Accepted: 03/02/2014] [Indexed: 11/26/2022]
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Koerber F, Rolauffs B, Rogowski W. Early evaluation and value-based pricing of regenerative medicine technologies. Regen Med 2013; 8:747-58. [DOI: 10.2217/rme.13.69] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Since the first pioneering scientists explored the potential of using human cells for therapeutic purposes the branch of regenerative medicine has evolved to become a mature industry. The focus has switched from ‘what can be done‘ to ‘what can be commercialized‘. Timely health economic evaluation supports successful marketing by establishing the value of a product from a healthcare system perspective. This article reports results from a research project on early health economic evaluation in collaboration with developers, clinicians and manufacturers. We present an approach to determine an early value-based price for a new treatment of cartilage defects of the knee from the area of regenerative medicine. Examples of using evaluation results for the purpose of business planning, market entry, preparing the coverage decision and managed entry are discussed.
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Affiliation(s)
- Florian Koerber
- Helmholtz Center Munich, German Research Center for Environmental Health (GmbH), Ingolstädter Landstrasse 1, 85764 Neuherberg, Germany
| | - Bernd Rolauffs
- Siegfried Weller Institute for Trauma Research, Department of Trauma Surgery, BG Trauma Clinic, Eberhard Karls University, 72076 Tuebingen, Germany
- Massachusetts Institute of Technology, Center for Biomedical Engineering, Cambridge, MA 02319, USA
| | - Wolf Rogowski
- Helmholtz Center Munich, German Research Center for Environmental Health (GmbH), Ingolstädter Landstrasse 1, 85764 Neuherberg, Germany
- Institute & Outpatient Clinic for Occupational, Social & Environmental Medicine, Clinical Center, Ludwig Maximilians University, Ziemssenstraße 1, 80336 Munich, Germany
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30
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Kreuz PC, Müller S, von Keudell A, Tischer T, Kaps C, Niemeyer P, Erggelet C. Influence of sex on the outcome of autologous chondrocyte implantation in chondral defects of the knee. Am J Sports Med 2013; 41:1541-8. [PMID: 23729686 DOI: 10.1177/0363546513489262] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Sex-specific outcomes have been reported in anterior cruciate ligament reconstruction as well as in osteoarthrosis progression, but there are currently no related published data on autologous chondrocyte implantation (ACI). The present prospective study was performed to investigate sex-dependent differences in the results after ACI. HYPOTHESIS The clinical and magnetic resonance imaging (MRI) results after ACI of the knee are influenced by the patient's sex. STUDY DESIGN Cohort study; Level of evidence, 2. METHODS The midterm clinical and MRI results of a cell-based fibrin-polymer graft for the treatment of full-thickness cartilage defects were evaluated preoperatively and 6, 12, and 48 months after surgery in 52 patients (male:female ratio, 25:27; average age, 35.6 years). Depending on the sex and the location of the defects (femoral condyles, n = 32; patellofemoral compartment, n = 20), patients were assigned to 4 different groups. Baseline clinical scores were compared with follow-up data by paired Wilcoxon tests for the Lysholm score and the International Knee Documentation Committee (IKDC) scoring system. Sex-specific differences were evaluated with the Mann-Whitney U test. The MRI evaluation was performed with the Henderson score at final follow-up. RESULTS Clinical scores improved in all groups over the whole study period (P < .05). Compared with female patients, male patients achieved significantly better results in the Lysholm score at all time intervals and in the IKDC score at 6 and 12 months after surgery (P < .05). In a subgroup analysis, female patients with patellar defects had the worst results in both clinical scores. With the available number of patients, MRI evaluation at 48 months after surgery revealed no significant difference in defect fill between male and female patients (P > .05). The Pearson correlation coefficient between both clinical scores and the MRI parameters of defect fill and cartilage signal was significant (P < .05). CONCLUSION Autologous chondrocyte implantation is a promising treatment option for full-thickness cartilage defects of male and female knee joints. Female patients with patellar defects have worse prognostic factors.
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Affiliation(s)
- Peter C Kreuz
- Department of Orthopaedic Surgery, University Medical Center Rostock, Doberanerstr. 142, 18057 Rostock, Germany.
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31
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Warren V. Understanding regenerative medicine: a commissioner’s viewpoint. Regen Med 2013; 8:227-32. [DOI: 10.2217/rme.13.5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Stein S, Strauss E, Bosco J. Advances in the Surgical Management of Articular Cartilage Defects: Autologous Chondrocyte Implantation Techniques in the Pipeline. Cartilage 2013; 4:12-9. [PMID: 26069648 PMCID: PMC4297107 DOI: 10.1177/1947603512463226] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE The purpose of this review is to gain insight into the latest methods of articular cartilage implantation (ACI) and to detail where they are in the Food and Drug Administration approval and regulatory process. DESIGN A PubMed search was performed using the phrase "Autologous Chondrocyte Implantation" alone and with the words second generation and third generation. Additionally, clinicaltrials.gov was searched for the names of the seven specific procedures and the parent company websites were referenced. RESULTS Two-Stage Techniques: BioCart II uses a FGF2v1 culture and a fibrinogen, thrombin matrix, whereas Hyalograft-C uses a Hyaff 11 matrix. MACI uses a collagen I/III matrix. Cartipatch consists of an agarose-alginate hydrogel. Neocart uses a high-pressure bioreactor for culturing with a type I collagen matrix. ChondroCelect makes use of a gene expression analysis to predict chondrocyte proliferation and has demonstrated significant clinical improvement, but failed to show superiority to microfracture in a phase III trial. One Step Technique: CAIS is an ACI procedure where harvested cartilage is minced and implanted into a matrix for defect filling. CONCLUSION As full thickness defects in articular cartilage continue to pose a challenge to treat, new methods of repair are being researched. Later generation ACI has been developed to address the prevalence of fibrocartilage with microfracture and the complications associated with the periosteal flap of first generation ACI such as periosteal hypertrophy. The procedures and products reviewed here represent advances in tissue engineering, scaffolds and autologous chondrocyte culturing that may hold promise in our quest to alter the natural history of symptomatic chondral disease.
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Affiliation(s)
| | - Eric Strauss
- NYU Hospital for Joint Diseases, New York, NY, USA
| | - Joseph Bosco
- NYU Hospital for Joint Diseases, New York, NY, USA
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Schuurman W, Klein TJ, Dhert WJA, van Weeren PR, Hutmacher DW, Malda J. Cartilage regeneration using zonal chondrocyte subpopulations: a promising approach or an overcomplicated strategy? J Tissue Eng Regen Med 2012; 9:669-78. [PMID: 23135870 DOI: 10.1002/term.1638] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2012] [Revised: 08/30/2012] [Accepted: 09/27/2012] [Indexed: 01/01/2023]
Abstract
Cartilage defects heal imperfectly and osteoarthritic changes develop frequently as a result. Although the existence of specific behaviours of chondrocytes derived from various depth-related zones in vitro has been known for over 20 years, only a relatively small body of in vitro studies has been performed with zonal chondrocytes and current clinical treatment strategies do not reflect these native depth-dependent (zonal) differences. This is surprising since mimicking the zonal organization of articular cartilage in neo-tissue by the use of zonal chondrocyte subpopulations could enhance the functionality of the graft. Although some research groups including our own have made considerable progress in tailoring culture conditions using specific growth factors and biomechanical loading protocols, we conclude that an optimal regime has not yet been determined. Other unmet challenges include the lack of specific zonal cell sorting protocols and limited amounts of cells harvested per zone. As a result, the engineering of functional tissue has not yet been realized and no long-term in vivo studies using zonal chondrocytes have been described. This paper critically reviews the research performed to date and outlines our view of the potential future significance of zonal chondrocyte populations in regenerative approaches for the treatment of cartilage defects. Secondly, we briefly discuss the capabilities of additive manufacturing technologies that can not only create patient-specific grafts directly from medical imaging data sets but could also more accurately reproduce the complex 3D zonal extracellular matrix architecture using techniques such as hydrogel-based cell printing.
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Affiliation(s)
- W Schuurman
- Department of Orthopaedics, University Medical Center Utrecht, The Netherlands.,Department of Equine Sciences, Faculty of Veterinary Sciences, Utrecht University, The Netherlands
| | - T J Klein
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove, Australia
| | - W J A Dhert
- Department of Orthopaedics, University Medical Center Utrecht, The Netherlands.,Faculty of Veterinary Sciences, University of Utrecht, The Netherlands
| | - P R van Weeren
- Department of Equine Sciences, Faculty of Veterinary Sciences, Utrecht University, The Netherlands
| | - D W Hutmacher
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove, Australia
| | - J Malda
- Department of Orthopaedics, University Medical Center Utrecht, The Netherlands.,Institute of Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove, Australia
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Abstract
Joint destruction occurs in both osteoarthritis and rheumatoid arthritis. Even in the era of biologic agents, this destruction can be delayed but not averted. As cartilage has limited ability to self-regenerate, joint arthroplasty is required. Here, we outline current tissue engineering procedures (including autologous chondrocyte implantation and in situ mesenchymal stem cell recruitment) that are routinely applied for the regenerative treatment of injured or early osteoarthritic cartilage. Potential future regenerative therapies, including administration of multipotent or pluripotent stem cells, are also discussed. In the future, cell-free, material-based (for cartilage lesions) or cell-free, factor-based (for osteoarthritic cartilage) therapies to facilitate the recruitment of repair cells and improve cartilage metabolism are likely to become more important. Moreover, delivery of anti-inflammatory factors or immunomodulatory cells could be a regenerative treatment option for rheumatoid arthritis. Tissue engineering faces a crucial phase to translate products into clinical routine and the regulatory framework for cell-based products in particular is an important issue.
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Dhollander AAM, Verdonk PCM, Lambrecht S, Verdonk R, Elewaut D, Verbruggen G, Almqvist KF. Short-term outcome of the second generation characterized chondrocyte implantation for the treatment of cartilage lesions in the knee. Knee Surg Sports Traumatol Arthrosc 2012; 20:1118-27. [PMID: 22065295 DOI: 10.1007/s00167-011-1759-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2011] [Accepted: 10/27/2011] [Indexed: 01/16/2023]
Abstract
PURPOSE To evaluate short-term clinical and MRI outcome of the second generation characterized chondrocyte implantation (CCI) for the treatment of cartilage defects in the knee. METHODS Thirty-two patients aged 15-51 years with single International Cartilage Repair Society (ICRS) grade III/IV symptomatic cartilage defects of different locations in the knee were treated with CCI using a synthetic collagen I/III membrane to cover the defect. Clinical outcome was measured over 36 months by the Knee injury and Osteoarthritis Outcome Score (KOOS) and Visual Analogue Scale (VAS) for pain. Serial magnetic resonance imaging (MRI) scans of 22 patients were scored using the original and modified Magnetic resonance Observation of Cartilage Repair Tissue (MOCART) system. RESULTS The patients included in this study showed a significant gradual clinical improvement after CCI. The MRI findings of this pilot study were considered to be promising. No signs of deterioration were observed. A complete or hypertrophic filling was observed in 76.5% of the cases at 24 months of follow-up. No preventive effect of an avital membrane on the occurrence of hypertrophic repair tissue was observed on MRI. Three failures were observed among the 32 patients until now (9.4%). CONCLUSIONS This investigation provided useful information on the efficacy of this treatment. The short-term clinical and MRI outcome are promising. Large-scale and long-term trials are mandatory to confirm the results and the reliability of this procedure. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- A A M Dhollander
- Department of Orthopaedic Surgery and Traumatology, Ghent University Hospital, De Pintelaan 185, 9000 Ghent, Belgium.
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Abstract
BACKGROUND Stem cells are easily accessible and have great potential for healing articular cartilage defects. These features make stem cell therapy an appealing approach for treating severely impaired joint function. SOURCES OF DATA Clinical and basic research articles and literature reviews. AREAS OF AGREEMENT Stem cells possess the potential to build articular cartilage. Malalignment and instability corrections and proper rehabilitation are crucial prerequisites for surgical procedures involving stem cell therapy. Smoking reduces the result. AREAS OF CONTROVERSY Ethical concerns remain unresolved. No standards are established for inducing stem cell potential, optimizing culturing media or harvesting. The risk of failure has not been determined. GROWING POINTS Surgical scaffolds can improve results. Care givers should focus on re-educating patients. Improved funding is needed for developing the therapy. AREAS TIMELY FOR DEVELOPING RESEARCH Define guidelines for stem cell therapy and demonstrate effectiveness.
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Affiliation(s)
- Asbjørn Arøen
- Oslo Sports Trauma Research Center and Department of Orthopedic Surgery, Akershus University Hospital, Lørenskog, N-1478 Lørenskog, Norway.
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