Background: The treatment of chondral lesions is still an important challenge for the orthopaedic surgeon. Attempts have been made to restore cartilage lesions by filling the defects with a temporary biocompatible matrix.
Purpose: The authors present their midterm experience with the implantation of alginate beads containing human mature allogenic chondrocytes for the treatment of cartilage lesions in the knee.
Study Design: Case series; Level of evidence, 4.
Methods: A biodegradable, alginate-based biocompatible scaffold containing human mature allogenic chondrocytes was used for the treatment of cartilage lesions in the knee. Twenty-one patients were clinically prospectively evaluated with use of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and a visual analog scale (VAS). The mean follow-up time was 6.3 years (range, 5-8 years). Magnetic resonance imaging (MRI) data were analyzed based on the MOCART (Magnetic Resonance Observation of Cartilage Repair Tissue) system, allowing morphologic assessment of the repair tissue. Magnetic resonance images were taken at 1 year of follow-up and at a mean follow-up of 6.1 years (range, 5-7 years).
Results: During the follow-up period, the WOMAC and VAS scores improved significantly. No signs of clinical deterioration or adverse reactions to the alginate beads/allogenic chondrocyte implantation were observed. Four failures occurred during the follow-up period in this study (19.05%). The MOCART scores were moderate and remained stable in time.
Conclusion: This investigation provided useful information on the efficacy of the implantation of alginate beads containing human mature allogenic chondrocytes for the treatment of cartilage lesions in the knee. The midterm clinical outcome of the presented technique was satisfactory. However, these results were not confirmed by the MRI findings.
Background: Characterized chondrocyte implantation (CCI) results in significantly better early structural tissue regeneration than microfracture (MF), and CCI has a midterm clinical benefit over microfracture.
Purpose: This study was undertaken to evaluate the 5-year clinical outcome of CCI in a randomized comparison with MF for the treatment of symptomatic cartilage defects of the femoral condyles of the knee.
Study Design: Randomized controlled trial; Level of evidence, 1.
Methods: Participants aged 18 to 50 years with a symptomatic isolated International Cartilage Repair Society (ICRS) grade III or IV cartilage lesion of the femoral condyles between 1 and 5 cm2 were randomized to either CCI or MF. Clinical outcomes were measured up to 60 months after surgery using the Knee Injury and Osteoarthritis Outcome Score (KOOS). The main outcome parameter was change from baseline in overall KOOS (oKOOS). Adverse events were monitored.
Results: Fifty-one participants were treated with CCI and 61 with MF. On average, clinical benefit was maintained through the 60-month follow-up period. The average change from baseline in oKOOS was not different between both groups (least squares [LS] mean ± standard error [SE] 18.84 ± 3.58 for CCI vs 13.21 ± 5.63 for MF; P = .116). Treatment failures were comparable (n = 7 in CCI vs n = 10 in MF), although MF failures tended to occur earlier. Subgroup analysis revealed that CCI resulted in better outcome in participants with time since symptom onset of less than 3 years, which was statistically significant and clinically relevant (change in oKOOS <3 years mean ± SE 25.96 ± 3.45 for CCI vs 15.28 ± 3.17 for MF; P = .026 vs oKOOS >3 years mean ± SE 13.09 ± 4.78 for CCI vs 17.02 ± 4.50 for MF, P = .554). Other subgroup analyses such as age (cutoff 35 years) did not show a difference. Female patients showed more failures irrespective of treatment.
Conclusion: At 5 years after treatment, clinical outcomes for CCI and MF were comparable. In the early treatment group, CCI obtained statistically significant and clinically relevant better results than MF. Delayed treatment resulted in less predictable outcomes for CCI. These results provide strong evidence that time since onset of symptoms is an essential variable that should be taken into account in future treatment algorithms for cartilage repair of the knee.
Background: Scaffold-assisted autologous chondrocyte implantation is a clinically effective procedure for cartilage repair, but biomechanical evaluations are still missing.
Purpose: This study was conducted to assess the clinical efficacy, including biomechanical analyses, of BioSeed-C treatment for traumatic and degenerative cartilage defects of the knee.
Study Design: Case series; Level of evidence, 4.
Methods: The authors evaluated the midterm clinical and biomechanical outcome of BioSeed-C, a cell-based fibrin-polymer graft for the treatment of cartilage defects. Clinical outcome at 4-year follow-up was assessed in 52 patients with full-thickness cartilage defects, International Cartilage Repair Society (ICRS) stage III and IV. Clinical scoring was performed preoperatively and 48 months after implantation using the Lysholm score, the International Knee Documentation Committee (IKDC) score, the ICRS score, the Knee injury and Osteoarthritis Outcome Score (KOOS), and the Noyes score. Cartilage regeneration was assessed by magnetic resonance imaging (MRI) using the Henderson-Kreuz score. Biomechanical evaluation was performed by isokinetic strength measurements, comparing healthy and operated knee of each patient.
Results: Clinical evaluation showed significant improvement in the Lysholm (from 51.8 preoperatively to 80.7 at 48 months postoperatively), IKDC (from 47.5 to 71.5), ICRS (from 3.8 to 2.0), KOOS (subcategory pain from 62 to 78, symptoms from 68 to 76, activities of daily living from 68 to 85, sports from 19 to 55, and quality of life from 30 to 55), and Noyes (from 31 to 59) scores (P ≤ .001) 48 months after implantation of BioSeed-C compared with the preoperative situation. The MRI evaluations showed moderate to complete defect filling in 43 of 44 treated patients. Two patients without improvement in the clinical and MRI scores received a total knee endoprosthesis after 4 years. Isokinetic evaluation showed significantly reduced maximum strength capacities for knee flexion and extension at the operated knee compared with the healthy knee (P < .05).
Conclusion: The clinical outcomes 4 years after graft implantation are good despite a persisting strength deficit. Implanting BioSeed-C is a promising treatment option for cartilage defects of the knee. More emphasis should be put on the rehabilitation of muscular strength.
Background: Aging is responsible for degenerative changes in all cartilage elements, thus impairing its properties and healing potential. Most studies on surgical procedures for cartilage focus on young patients because these procedures are generally not considered suitable for older patients.
Purpose: To analyze the clinical outcome of cartilage lesion treatment using second-generation autologous chondrocyte implantation (ACI) techniques in patients more than 40 years old with no clear signs of osteoarthritis, to understand their real potential in relation to aging, the failure rate, and complications in older patients.
Study Design: Case series; Level of evidence, 4.
Methods: Sixty-one patients with grade III to IV cartilaginous lesions of the condyles with no clear signs of osteoarthritis and a minimum age of 40 years were treated with second-generation ACI and prospectively evaluated at 5 years’ follow-up. Twenty-two patients were treated with arthroscopic Hyalograft C implantation, and 39 underwent the open Chondro-Gide MACI procedure.
Results: A significant improvement in both subjective and objective evaluations was observed. The International Knee Documentation Committee (IKDC) subjective score improved from 36.8 ± 8.4 to 68.1 ± 21.8 at the final evaluation. The failure rate was 20%. A faster improvement was observed in the group treated with the arthroscopic Hyalograft C technique, whereas similar scores were found at the 24-month follow-up and final evaluation.
Conclusion: A clinical improvement was found in patients more than 40 years old, who in most cases benefited from second-generation ACI with good results lasting at medium-term follow-up. However, the results were inferior with respect to those previously found for younger populations, and the failure rate at medium-term follow-up was also higher. These findings were consistent in the 2 treatment groups. The only difference was the faster recovery when the arthroscopic approach was used.
Background: Autologous chondrocyte implantation (ACI) has become an accepted option for the treatment of chondral defects in carefully selected patients. Current recommendations limit this procedure to younger patients, as insufficient data are available to conclusively evaluate outcomes in patients older than 45 years.
Hypothesis: Cartilage repair with ACI in patients older than 45 years results in substantially different outcomes than those previously reported for younger age groups.
Study Design: Case series; Level of evidence, 4.
Methods: This prospective cohort study reviewed patients ≥45 years of age at the time of treatment with ACI. The clinical evaluation included a patient satisfaction questionnaire and four validated rating scales: Short Form-36, Modified Cincinnati Rating Scale, WOMAC (Western Ontario and McMaster Universities) Osteoarthritis Index, and the Knee Society Score.
Results: A total of 56 patients ≥45 years of age were treated with ACI. The average patient age at index surgery was 48.6 years (range, 45–60 years). The minimum follow-up was 2 years (range, 2–11 years; mean, 4.7 years). The cohort included 36 men and 20 women. The mean transplant size was 4.7 cm2 per defect (range, 1–15.0 cm2) and 9.8 cm2 per knee (range, 2.5–31.6 cm2). Twenty-eight patients (50%) underwent concomitant osteotomies to address malalignment. There were 8 failures (14%): 6 of 15 (40%) in patients receiving workers’ compensation (WC) and 2 of 41 (4.9%) in non-WC patients. Additional arthroscopic surgical procedures were required in 24 patients (43%) for periosteal-related problems and adhesions; 88% of these patients experienced lasting improvement. At their latest available follow-up, 72% of patients rated themselves as good or excellent, 78% felt improved, and 81% would again choose ACI as a treatment option.
Conclusion: Our results showed a failure rate of ACI in older patients that is comparable with rates reported in younger patient groups. The procedure is associated with a substantial rate of reoperations, mostly for the arthroscopic treatment of graft hypertrophy, similar to that in younger patients.
Background: Osteochondritis dissecans lesions of the knee in adult patients frequently require surgical intervention. However, the ideal method of osteochondral fragment fixation remains uncertain.
Purpose: This study was undertaken to determine the clinical, functional, and radiographic outcomes of bioabsorbable fixation for unstable osteochondritis dissecans lesions involving the femoral condyles of the knee in skeletally mature patients.
Study Design: Case series; Level of evidence, 4.
Methods: Skeletally mature patients with an unstable osteochondritis dissecans lesion of the femoral condyle (Ewing and Voto stages II-IV) treated with bioabsorbable internal fixation and minimum 1-year follow-up were included in this retrospective study cohort. Pre- and postoperative radiographs were reviewed and postoperative Lysholm and International Knee Documentation Committee (IKDC) scores were documented.
Results: A total of 21 knees in 21 patients satisfied the inclusion criteria, and 3 patients were lost to follow-up. The remaining 18 patients were evaluated at a mean of 59 months after surgery (range, 12-154 months). The 14 male and 4 female patients had a mean age of 19 years at the time of surgery (range, 14-39 years). Ewing and Voto classification included 8 stage II lesions, 9 stage III lesions, and 1 stage IV lesion. Fragment fixation methods included bioabsorbable nails (11), pins (3), darts (2), screws (1), and combined screws and darts (1). Mean postoperative Lysholm and IKDC scores were 85 and 82, respectively. Fragment union occurred in 12 knees (67%); the remaining 6 knees (33%) required removal of the loose fragment. Of the 11 patients treated with bioabsorbable nails, 2 (18%) required reoperation for nail back-out.
Conclusion: The authors recommend caution when using bioabsorbable fixation for osteochondritis dissecans lesions in skeletally mature patients because of the low rate of clinical healing and high complication rate. Failure with unthreaded fixation devices may be caused by inadequate compression and not necessarily be related to bioabsorbability.
