Management of Large Focal Chondral and Osteochondral Defects in the Knee

2020 ◽  
Vol 33 (12) ◽  
pp. 1187-1200
Author(s):  
Jacob G. Calcei ◽  
Taylor Ray ◽  
Seth L. Sherman ◽  
Jack Farr
Keyword(s):  
Articular Cartilage ◽  
Clinical Outcomes ◽  
Osteochondral Allograft ◽  
Cartilage Defects ◽  
Osteochondral Defects ◽  
Focal Lesions ◽  
Cartilage Restoration ◽  
Intervention Patient ◽  
Chondrocyte Implantation ◽  
Autologous Chondrocyte

AbstractLarge, focal articular cartilage defects of the knee (> 4 cm2) can be a source of significant morbidity and often require surgical intervention. Patient- and lesion-specific factors must be identified when evaluating a patient with an articular cartilage defect. In the management of large cartilage defects, the two classically utilized cartilage restoration procedures are osteochondral allograft (OCA) transplantation and cell therapy, or autologous chondrocyte implantation (ACI). Alternative techniques that are available or currently in clinical trials include a hyaluronan-based scaffold plus bone marrow aspirate concentrate, a third-generation autologous chondrocyte implant, and an aragonite-based scaffold. In this review, we will focus on OCA and ACI as the mainstay in management of large chondral and osteochondral defects of the knee. We will discuss the techniques and associated clinical outcomes for each, while including a brief mention of alternative treatments. Overall, cartilage restoration techniques have yielded favorable clinical outcomes and can be successfully employed to treat these challenging large focal lesions.

scholarly journals Hip Microfracture

Cartilage ◽  
2010 ◽  
Vol 1 (2) ◽  
pp. 127-136 ◽  
Author(s):  
Kevin C. McGill ◽  
Charles A. Bush-Joseph ◽  
Shane J. Nho
Keyword(s):  
Osteochondral Allograft ◽  
Preoperative Imaging ◽  
Cartilage Defects ◽  
Focal Lesions ◽  
Hip Injury ◽  
Clinical Series ◽  
Chondrocyte Implantation ◽  
Low Probability ◽  
Outerbridge Grade ◽  
Autologous Chondrocyte

Microfracture is a marrow-stimulating technique used in the hip to treat cartilage defects associated with femoro-acetabular impingement, instability, or traumatic hip injury. These defects have a low probability of healing spontaneously and therefore often require surgical intervention. Originally adapted from the knee, microfracture is part of a spectrum of cartilage repair options that include palliative procedures such as debridement and lavage, reparative procedures such as marrow-stimulating techniques (abrasion arthroplasty and microfracture), and restorative procedures such as autologous chondrocyte implantation and osteochondral allograft/autografts. The basic indications for microfracture of the hip include focal and contained lesions typically less than 4 cm in diameter, full-thickness (Outerbridge grade IV) defects in weightbearing areas, unstable lesions with intact subchondral bone, and focal lesions without evidence of surrounding chondromalacia. Although not extensively studied in the hip, there are some small clinical series with promising early outcomes. Although the widespread use of microfracture in the hip is hindered by difficulties in identifying lesions on preoperative imaging and instrumentation to circumvent the femoral head, this technique continues to gain acceptance as an initial treatment for small, focal cartilage defects.

A 20-Year Follow-up After First-Generation Autologous Chondrocyte Implantation

2017 ◽  
Vol 45 (12) ◽  
pp. 2751-2761 ◽  
Author(s):  
Takahiro Ogura ◽  
Brian A. Mosier ◽  
Tim Bryant ◽  
Tom Minas
Keyword(s):  
Articular Cartilage ◽  
Clinical Outcomes ◽  
Autologous Chondrocyte Implantation ◽  
First Generation ◽  
Short Form ◽  
Cartilage Defects ◽  
Sf 36 ◽  
Chondrocyte Implantation ◽  
Autologous Chondrocyte

Background: Treating articular cartilage defects is a demanding problem. Although several studies have reported durable and improved clinical outcomes after autologous chondrocyte implantation (ACI) over a long-term period, there is no report with over 20 years’ follow-up. Purpose: To evaluate clinical outcomes after first-generation ACI for the treatment of knees with disabling, large single and multiple cartilage defects for which patients wished to avoid prosthetic arthroplasty, with a minimum of 20 years’ follow-up. Study Design: Case series; Level of evidence, 4. Methods: The authors reviewed prospectively collected data from 23 patients (24 knees; mean age, 35.4 years [range, 13-52 years]) undergoing ACI for the treatment of symptomatic, full-thickness articular cartilage lesions. A mean of 2.1 lesions per knee were treated over a mean total surface area of 11.8 cm2 (range, 2.4-30.5 cm2) per knee. Kaplan-Meier survival analysis and functional outcome scores, including the modified Cincinnati Knee Rating System, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Short Form–36 (SF-36), were used. Patients also self-reported an improvement in pain with a visual analog scale and a satisfaction survey. Results: The 20-year survival rate was 63% (95% CI, 40%-78%). The evaluation of the 15 knees with retained grafts demonstrated that all clinical scores except the WOMAC subscore for stiffness and SF-36 mental component summary score improved significantly and were sustained to 20 years postoperatively. Ninety-three percent of these patients rated knee-specific outcomes as good or excellent. The outcomes for 9 of 24 knees were considered failures, including 5 undergoing revision ACI and 4 being converted to arthroplasty at a mean of 1.7 and 5.9 years, respectively. Only 1 of 5 knees that underwent revision ACI was converted to arthroplasty at 1.9 years after the index surgery, and the other 4 patients were able to maintain their biological knee. Overall, 20 years later, 79% of patients maintained their native knee, for which they initially sought treatment, and were satisfied when evaluated. Conclusion: First-generation ACI provided satisfactory survival rates and significant clinical improvements over a 20-year follow-up, which offers an important standard for comparison with newer-generation ACI technologies of the future.

Matrix-Induced Autologous Chondrocyte Implantation (MACI) Grafting for Osteochondral Lesions of the Talus

2009 ◽  
Vol 30 (9) ◽  
pp. 810-814 ◽  
Author(s):  
Timothy E. Schneider ◽  
Sriram Karaikudi
Keyword(s):  
Articular Cartilage ◽  
Autologous Chondrocyte Implantation ◽  
Case Series ◽  
Treatment Method ◽  
Cartilage Defects ◽  
Osteochondral Lesions ◽  
Osteochondral Defects ◽  
Level Of Evidence ◽  
Chondrocyte Implantation ◽  
Autologous Chondrocyte

Background: Articular cartilage is limited in its ability to repair itself. Matrix-induced Autologous Chondrocyte Implantation (MACI) is an established treatment method for such articular cartilage defects in the knee. Recently the technique has been used in the ankle. We present a series of patients treated with MACI for osteochondral defects of the ankle, and assess the functional and clinical results. Materials and Methods: From August 2003 to February 2006, 20 patients underwent MACI grafting for osteochondral defects in the ankle. Age ranged from 19 to 61 (mean, 36) years. Mean followup was 21.1 months. Clinical and functional evaluations were conducted using the AOFAS scoring system. Results: The mean size was 233 mm2. There was a significant improvement in mean AOFAS score from 60 (range, 25 to 87) to 87 (range, 41 to 100) ( p < 0.0001). Overall improvement in pain scores was also significant ( p < 0.0001). All osteotomies healed. Four patients required hardware removal and two underwent arthroscopic debridement for anterior impingement. There were two failures which are awaiting subsequent procedures. Conclusion: We believe MACI is a reliable treatment method for talar osteochondral defects. The method usually requires an intra-articular osteotomy, although this proved to be a reasonably simple aspect of the procedure for the treatment of cartilage defects of the talus. Level of Evidence: IV, Case Series

Comparative Effectiveness of Cartilage Repair With Respect to the Minimal Clinically Important Difference

2019 ◽  
Vol 47 (13) ◽  
pp. 3284-3293 ◽  
Author(s):  
Kristofer J. Jones ◽  
Benjamin V. Kelley ◽  
Armin Arshi ◽  
David R. McAllister ◽  
Peter D. Fabricant
Keyword(s):  
Clinical Outcomes ◽  
Cartilage Repair ◽  
Meta Analysis ◽  
Osteochondral Allograft ◽  
Time Points ◽  
Outcome Scores ◽  
Chondrocyte Implantation ◽  
Autologous Chondrocyte

Background: Recent studies demonstrated a 5% increase in cartilage repair procedures annually in the United States. There is currently no consensus regarding a superior technique, nor has there been a comprehensive evaluation of postoperative clinical outcomes with respect to a minimal clinically important difference (MCID). Purpose: To determine the proportion of available cartilage repair studies that meet or exceed MCID values for clinical outcomes improvement over short-, mid-, and long-term follow-up. Study Design: Systematic review and meta-analysis. Methods: A systematic review was performed via the Medline, Scopus, and Cochrane Library databases. Available studies were included that investigated clinical outcomes for microfracture (MFX), osteoarticular transfer system (OATS), osteochondral allograft transplantation, and autologous chondrocyte implantation/matrix-induced autologous chondrocyte implantation (ACI/MACI) for the treatment of symptomatic knee chondral defects. Cohorts were combined on the basis of surgical intervention by performing a meta-analysis that utilized inverse-variance weighting in a DerSimonian-Laird random effects model. Weighted mean improvements in International Knee Documentation Committee (IKDC), Lysholm, and visual analog scale for pain (VAS pain) scores were calculated from preoperative to short- (1-4 years), mid- (5-9 years), and long-term (≥10 years) postoperative follow-up. Mean values were compared with established MCID values per 2-tailed 1-sample Student t tests. Results: A total of 89 studies with 3894 unique patients were analyzed after full-text review. MFX met MCID values for all outcome scores at short- and midterm follow-up with the exception of VAS pain in the midterm. OATS met MCID values for all outcome scores at all available time points; however, long-term data were not available for VAS pain. Osteochondral allograft transplantation met MCID values for IKDC at short- and midterm follow-up and for Lysholm at short-term follow-up, although data were not available for other time points or for VAS pain. ACI/MACI met MCID values for all outcome scores (IKDC, Lysholm, and VAS pain) at all time points. Conclusion: In the age of informed consent, it is important to critically evaluate the clinical outcomes and durability of cartilage surgery with respect to well-established standards of clinical improvement. MFX failed to maintain VAS pain improvements above MCID thresholds with follow-up from 5 to 9 years. All cartilage repair procedures met MCID values at short- and midterm follow-up for IKDC and Lysholm scores; ACI/MACI and OATS additionally met MCID values in the long term, demonstrating extended maintenance of clinical benefits for patients undergoing these surgical interventions as compared with MFX.

Microfracture Versus Autologous Chondrocyte Implantation for Articular Cartilage Lesions in the Knee: A Systematic Review of 5-Year Outcomes

2017 ◽  
Vol 46 (4) ◽  
pp. 995-999 ◽  
Author(s):  
Matthew J. Kraeutler ◽  
John W. Belk ◽  
Justin M. Purcell ◽  
Eric C. McCarty
Keyword(s):  
Systematic Review ◽  
Articular Cartilage ◽  
Clinical Outcomes ◽  
Autologous Chondrocyte Implantation ◽  
Patient Reported Outcome ◽  
Significant Difference ◽  
Patient Reported ◽  
Chondrocyte Implantation ◽  
Autologous Chondrocyte

Background: Microfracture (MFx) and autologous chondrocyte implantation (ACI) are 2 surgical treatment options used to treat articular cartilage injuries of the knee joint. Purpose: To compare the midterm to long-term clinical outcomes of MFx versus ACI for focal chondral defects of the knee. Study Design: Systematic review. Methods: A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to locate studies (level of evidence I-III) comparing the minimum average 5-year clinical outcomes of patients undergoing MFx versus ACI. Search terms used were “knee,” “microfracture,” “autologous chondrocyte implantation,” and “autologous chondrocyte transplantation.” Patients were evaluated based on treatment failure rates, magnetic resonance imaging, and patient-reported outcome scores (Lysholm, Knee Injury and Osteoarthritis Outcome Score [KOOS], and Tegner scores). Results: Five studies (3 level I evidence, 2 level II evidence) were identified that met the inclusion criteria, including a total of 210 patients (211 lesions) undergoing MFx and 189 patients (189 lesions) undergoing ACI. The average follow-up among all studies was 7.0 years. Four studies utilized first-generation, periosteum-based ACI (P-ACI), and 1 study utilized third-generation, matrix-associated ACI (M-ACI). Treatment failure occurred in 18.5% of patients undergoing ACI and 17.1% of patients undergoing MFx ( P = .70). Lysholm and KOOS scores were found to improve for both groups across studies, without a significant difference in improvement between the groups. The only significant difference in patient-reported outcome scores was found in the 1 study using M-ACI in which Tegner scores improved to a significantly greater extent in the ACI group compared with the MFx group ( P = .003). Conclusion: Patients undergoing MFx or first/third-generation ACI for articular cartilage lesions in the knee can be expected to experience improvement in clinical outcomes at midterm to long-term follow-up without any significant difference between the groups.

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