Cartilage Restoration Surgery Research Articles

Poster 254: Osteochondral Allograft Transplantation Using Dowell Technique for the Treatment of Steroid-Associated Osteonecrosis of the Femoral Condyles: Arthroplasty-Free Survival at 5 and 10 Years

Objectives: Steroid-associated osteonecrosis of the femoral condyles is a known complication of long- term or high dose steroid exposure. This is a not infrequent situation for patients with inflammatory conditions such as Lupus or Ulcerative Colitis and in patients with malignancies leukemia requiring bone marrow transplant. Historically, osteonecrosis was a contraindication for osteochondral allograft transplantation (OATS), however, recent evidence has indicated OATS maybe a durable treatment option. While results using the shell OATS technique has been reported in the steroid-associated osteonecrosis population, there is a dearth of information on the long-term survival for the newer dowel OATS technique. The aim of this study was to retrospectively analyze survival of OATS using the dowel technique for the treatment of steroid-associated osteonecrosis of the femoral condyles. Methods: Institutional database was queried to identify eligible patients. Inclusion criteria included diagnosis of aseptic or secondary osteonecrosis of the distal femur, osteochondral allograft transplantation surgical treatment, dowel OATS technique, and history of steroid use for a medical condition. Exclusion criteria included previous cartilage restoration or arthroplasty surgery and incomplete records. No age criteria were used to exclude patients. Patient charts were reviewed for demographic details, information about underlying pathologic condition and steroid exposure, surgical details, and revision OATS or conversation to arthroplasty. Primary outcomes were arthroplasty-free survival and revision-free survival. Results: 27 knees in 25 patients with an average age of 27.6 years (range 16-59 years) were identified with an average follow up of 6.2 years (range 0.7-22 years). Medical conditions included 10 malignancies (5 post-bone marrow transplant) and 13 autoimmune diseases. Distribution of osteonecrosis of the femoral condyles included 1 isolated medial condyle, 5 isolated lateral condyles, 21 medial and lateral condyles. All patients underwent dowel OATS technique. Patients received on average of 2.2 grafts (range 1-5 grafts) with an average combined graft area of 6.67 cm2 (range 1.5 to 20.4 cm2). 10 patients had concomitant procedures and 10 patients had supplemental graft fixation. All patients were treated between 2006 and 2020. Arthroplasty-free survival was 88%, 85%, 60% at 5, 8, 10 years. Revision OATS or arthroplasty free survival was 81%, 77%, 55% at 5, 8, 10 years. Graft failures included 1 revision OATS at 7.7 years secondary to cartilage delamination and 4 conversions to total knee arthroplasty at 1.6, 1.9, 8.7, 9.5 years. Conclusions: Osteochondral Allograft Transplantation is an acceptable and durable treatment option in patients with steroid-associated osteonecrosis with 88% arthroplasty-free survival at 5 years and 60% arthroplasty-free survival at 10 years. Future studies should capture patient reported outcomes and investigate factors leading to arthroplasty conversion such as age at time of OATS, etiology of osteonecrosis, extent of osteonecrosis. [Table: see text]

Surgical Management of Failed Articular Cartilage Surgery in the Knee.

Failure rates of cartilage restoration surgery range from 14% to 43%. When failure of prior cartilage restoration surgery is suspected, a thorough clinical workup should be performed to assess the timing and duration of symptoms. Attention should be paid to patient risk factors such as age, body mass index, and smoking status. Concomitant pathology such as malalignment, ligament insufficiency, and meniscus status must be evaluated before revision surgery. As outlined in our treatment algorithm, the size/location of the lesion and the type of primary procedure will guide planning for revision procedures. [Orthopedics. 2023;46(5):262-272.].

Rate of Conversion to Matrix-Induced Autologous Chondrocyte Implantation After a Biopsy: A Multisurgeon Study

Autologous chondrocyte implantation (ACI) and matrix-induced autologous chondrocyte implantation (MACI) are performed to treat focal chondral defects (FCDs); both are 2-step procedures involving a biopsy, followed by transplantation. There is little published research evaluating ACI/MACI in patients who undergo a biopsy alone. To determine (1) the value of ACI/MACI cartilage biopsies and concomitant procedures in patients with FCDs of the knee and (2) the conversion rate to cartilage transplantation as well as the rate of reoperation. Case series; Level of evidence, 4. A retrospective review was performed of 46 patients (63% female) who underwent a MACI (or ACI) biopsy between January 2013 and January 2018. Preoperative data, intraoperative data, and postoperative outcomes were assessed at a minimum of 2 years after the biopsy. The conversion rate from a biopsy to transplantation and the reoperation rate were calculated and analyzed. Among the 46 patients included, 17 (37.0%) underwent subsequent surgery, with only 12 undergoing cartilage restoration surgery, for an overall transplantation rate of 26.1%. Of these 12 patients, 9 underwent MACI/ACI, 2 underwent osteochondral allograft transplantation (OCA), and 1 underwent particulated juvenile articular cartilage implantation at 7.2 ± 7.5 months after the biopsy. The reoperation rate was 16.7% (1 patient after MACI/ACI and 1 patient after OCA) at 13.5 ± 2.3 months after transplantation. Arthroscopic surgery with debridement, chondroplasty, loose body removal, meniscectomy/meniscal repair, and other treatment approaches of knee compartment abnormalities at the time of a biopsy appeared to be sufficient in improving function and reducing pain in patients with knee FCDs.

Treatment of Cartilage Defects of the Knee in Military Tactical Athletes: An Overview of Management and Clinical Outcomes.

Cartilage defects of the knee are a common problem that can be caused by trauma or chronic repetitive overload and result in debilitating functional limitations. These consequences are of particular significance to military service members, who, by in large, are a group of young, active individuals with professional duties requiring full, unrestricted activity and function. The burden of knee chondral-related disease among military tactical athletes is well established, and systematic approach to the evaluation of a military member with suspected knee chondral pathology facilitates the execution of a surgical procedure that maximizes the likelihood of a return to duty. Despite advances in cartilage restoration surgery, chondral pathology of the knee remains a vexing problem and an omnipresent threat to military medical readiness and warfighter lethality.

The Sound of Cartilage Repair: The Importance of Using Pitch and Volume Cues in Cartilage Restoration Surgery

Articular cartilage defects are common and can result in substantial pain and disability, prompting operative intervention, which commonly includes chondral debridement. Controlled defect preparation up to but not beyond the calcified cartilage layer is key to clinical success, but this remains technically challenging. We present a technique highlighting the substantial decrease in curette stroke volume and associated shift to a lower pitch when achieving satisfactory open cartilage defect debridement. These audiologic cues correlate well with histologic accuracy of debridement. Therefore, quantifiable pitch and volume changes serve as valuable technical cues for precise defect preparation at the time of joint preservation surgery. ClassificationsI: knee, II: cartilage.

Marrow Stimulation Has Relatively Inferior Patient-Reported Outcomes in Cartilage Restoration Surgery of the Knee: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Background: Multiple cartilage repair techniques are available for chondral defects in the knee. Optimal treatment is controversial. Purpose: To evaluate change from baseline in the 5 Knee injury and Osteoarthritis Outcome Score (KOOS) subscales among different cartilage repair techniques of the knee. Study Design: Systematic review and meta-analysis; Level of evidence, 1A. Methods: Medline and Cochrane Central Register of Controlled Trials (CENTRAL) databases were searched for randomized controlled trials with minimum 1 year follow-up reporting change from baseline KOOS (delta KOOS) subscale values. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed. A meta-analysis was performed on the following surgery types: microfracture (Mfx); augmented microfracture techniques (Mfx+Augment); and culture-based therapies, including autologous chondrocyte implantation (ACI) and matrix-assisted autologous chondrocyte implantation (MACI). A random-effects metaregression model was used. Results: A total of 14 randomized trials with a total of 775 patients were included. The KOOS Sport and Recreation (Sport) and KOOS Quality of Life (QOL) were the 2 most responsive subscales after operative intervention. Outcomes from Mfx and Mfx+Augment were not different in any of the 5 KOOS subscales (minimum P > .3). The mean delta KOOS Sport after ACI/MACI was 9.9 points greater than after Mfx (P = .021) and 11.7 points greater than after Mfx+Augment (P = .027). Longer follow-up time correlated with greater delta KOOS Sport (P = .028). Larger body mass index led to greater delta KOOS QOL (P = .045). Larger cartilage defect size correlated with greater delta KOOS Pain and KOOS Activities of Daily Living scores (P = .023 and P = .002, respectively). Conclusion: The KOOS Sport and QOL were the most responsive subscales after cartilage restoration surgery of the knee. Culture-based therapies (ACI/MACI) led to clinically relevant improvements in the KOOS Sport score compared with marrow stimulation and may be a more appropriate treatment in younger and more active individuals. There were no benefits to Mfx+Augment over Mfx alone in any of the KOOS subscales.

The Importance of Staging Arthroscopy for Chondral Defects of the Knee.

This study aims to evaluate the role of staging arthroscopy in the diagnosis of knee chondral defects and subsequent surgical planning prior to autologous chondrocyte implantation (ACI), osteochondral allograft transplantation (OCA), and meniscus allograft transplantation (MAT). All patients who underwent staging arthroscopy prior to ACI, OCA, or MAT at our institution from 2005 to 2015 were identified. Medical records were reviewed to document the diagnosis and treatment plan based on symptoms, magnetic resonance imaging (MRI) findings and previous operative records. Operative records of the subsequent staging arthroscopy procedure were reviewed to document the proposed treatment plan after arthroscopy. All changes in treatment plan following staging arthroscopy were recorded. Univariate analyses were performed to identify any significant predictors for likelihood to change. A total of 98 patients were included in our analysis. A change in surgical plan was made following arthroscopy in 36 patients (36.7%). Fourteen patients (14.3%) were found to have additional defects that warranted cartilage restoration surgery. In 15 patients (15.3%), at least one defect that was originally thought to warrant cartilage restoration surgery was found to be amenable to debridement alone. The surgical plan was changed from ACI to OCA in four cases (4.1%) and OCA to ACI in one case (1%). A previously proposed MAT was deemed unwarranted in one case (1%), and a planned meniscal repair was changed to MAT in another (1%). Patient age, sex, and the affected knee compartment were not predictors for a change in surgical plan. Body mass index (BMI) was significantly higher in patients who had a change in surgical plan (29.5 kg/m2) compared with those who did not (26.5 kg/m2). A change in surgical plan was more likely to occur for trochlear lesions (46.4%) compared with other articular surface lesions (p = 0.008). The results of our study indicate that staging arthroscopy is an important step in determining the most appropriate treatment plan for chondral defects and meniscal deficiency, particularly those with trochlear cartilage lesions.

Patellofemoral Cartilage Restoration: A Systematic Review and Meta-analysis of Clinical Outcomes

Background: Many surgical options for treating patellofemoral (PF) cartilage lesions are available but with limited evidence comparing their results. Purpose: To determine and compare outcomes of PF cartilage restoration techniques. Study Design: Systematic review and meta-analysis. Methods: PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) guidelines were followed by utilizing the PubMed, EMBASE, and Cochrane Library databases. Inclusion criteria were clinical studies in the English language, patient-reported outcomes after PF cartilage restoration surgery, and >12 months’ follow-up. Quality assessment was performed with the Coleman Methodology Score. Techniques were grouped as osteochondral allograft transplantation (OCA), osteochondral autograft transfer (OAT), chondrocyte cell–based therapy, bone marrow–based therapy, and scaffolds. Results: A total of 59 articles were included. The mean Coleman Methodology Score was 71.8. There were 1937 lesions (1077 patellar, 390 trochlear, and 172 bipolar; 298 unspecified). The frequency of the procedures was as follows, in descending order: chondrocyte cell–based therapy (65.7%), bone marrow–based therapy (17.2%), OAT (8%), OCA (6.6%), and scaffolds (2.2%). When compared with the overall pooled lesion size (3.9 cm2; 95% CI, 3.5-4.3 cm2), scaffold (2.2 cm2; 95% CI, 1.8-2.5 cm2) and OAT (1.5 cm2; 95% CI, 1.1-1.9 cm2) lesions were smaller (P < .001), while chondrocyte cell–based therapy lesions were larger (4.7 cm2; 95% CI, 4.1-5.3 cm2; P = .039). Overall, the instability pool was 11.9%, and the anatomic risk factors pool was 32.1%. Statistically significant improvement was observed on at least 1 patient-reported outcome in chondrocyte cell–based therapy (83%), OAT (78%), OCA (71%), bone marrow–based therapy (64%), and scaffolds (50%). There were no significant differences between any group and the overall pooled change in International Knee Documentation Committee score (30.2; 95% CI, 27.4-32.9) and Lysholm score (25.2; 95% CI, 16.9-33.5). There were no significant differences between any group and the overall pooled rate in minor complication rate (7.6%; 95% CI, 4.7%-11.9%) and major complication rate (8.3%; 95% CI, 5.7%-12.0%); however, OCA had a significantly greater failure rate (22.7%; 95% CI, 14.6%-33.4%) as compared with the overall rate (6.8%; 95% CI, 4.7%-9.5%). Conclusion: PF cartilage restoration leads to improved clinical outcomes, with low rates of minor and major complications. There was no difference among techniques; however, failures were higher with OCA.

Cartilage Restoration of Patellofemoral Lesions: A Systematic Review.

This study aimed to systematically analyze the postoperative clinical, functional, and imaging outcomes, complications, reoperations, and failures following patellofemoral cartilage restoration surgery. This review was conducted according to the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). PubMed, EMBASE, and Cochrane Library databases were searched up to August 31, 2018, to identify clinical studies that assessed surgical outcomes of patellofemoral cartilage restoration surgery. The Methodological Index for Non-Randomized Studies (MINORS) was used to assess study quality. Forty-two studies were included comprising 1,311 knees (mean age of 33.7 years and 56% males) and 1,309 patellofemoral defects (891 patella, 254 trochlear, 95 bipolar, and 69 multiple defects, including the patella or trochlea) at a mean follow-up of 59.2 months. Restoration techniques included autologous chondrocyte implantation (56%), particulated juvenile allograft cartilage (12%), autologous matrix-induced chondrogenesis (9%), osteochondral autologous transplantation (9%), and osteochondral allograft transplantation (7%). Significant improvement in at least one score was present in almost all studies and these surpassed the minimal clinically important difference threshold. There was a weighted 19%, 35%, and 6% rate of reported complications, reoperations, and failures, respectively. Concomitant patellofemoral surgery (51% of patients) mostly did not lead to statistically different postoperative outcomes. Numerous patellofemoral restoration techniques result in significant functional improvement with a low rate of failure. No definitive conclusions could be made to determine the best surgical technique since comparative studies on this topic are rare, and treatment choice should be made according to specific patient and defect characteristics. Level IV, systematic review of level II to IV studies.

The Clinical Important Difference and Patient Acceptable State for Patient-reported Outcome Measures among Patients Treated with Knee Cartilage Restoration Procedures

There are no published studies evaluating both the patient acceptable symptomatic state (PASS) and clinically important difference (CID) for patient reported outcomes (PROMs) in patients undergoing knee cartilage restoration surgery. The purpose of this study is to determine CID and PASS values in the knee cartilage restoration population for the International Knee Documentation Committee (IDKC) Subjective Knee Score, Lysholm Score, and Knee Injury and Osteoarthritis Outcome Score (KOOS).

The Importance of Staging Arthroscopy for Chondral Defects of the Knee

Objectives: Chondral injures of the knee are a common source of pain in athletes. The specificity and sensitivity of MRI in evaluating chondral defects of the knee have been found to be as low as 73% and 42%, respectively. Staging arthroscopy is a more accurate method of evaluating the articular surfaces of the knee prior to cartilage restoration surgery or meniscal allograft transplantation (MAT). Addressing all concomitant pathology can be important for the success of cartilage restoration surgery, and treatment plan may change based on the extent and location of cartilage damage. The purpose of this study is to evaluate the role of staging arthroscopy in the diagnosis of chondral defects prior to autologous chondrocyte implantation (ACI), osteochondral allograft transplantation (OCA) and MAT, and to elucidate its utility in surgical planning prior to these procedures. Methods: All patients who have undergone ACI, OCA or MAT of the knee with prior staging arthroscopy at our institution between January 2005 and May 2015 were included in our review. Cases in which defects were evaluated during another procedure, such as anterior cruciate ligament reconstruction or treatment of meniscal pathology, were excluded. Any patients who did not have a documented staging arthroscopy procedure were also excluded. Medical records were reviewed to document the diagnosis and treatment plan based on symptoms, MRI findings and previous operative records. Operative records of the subsequent staging arthroscopy procedure were then reviewed to document the number of chondral defects with corresponding size and grade, any concomitant meniscal pathology, and the proposed treatment plan after arthroscopic visualization of the knee. All changes in treatment plan following staging arthroscopy were recorded. Results: A total of 98 patients were included in our review with 52 females and 46 males. The mean age of our patient population was 32.3 (range 15.3-57.9), and the mean BMI was 27.58 (range 15.8-41.6). The primary diagnosis was articular cartilage pathology in 86 cases (87.8%) and meniscal deficiency in 12 cases (12.2%). A total of 46 patients (47%) had a change in plan following staging arthroscopy. Fourteen patients (14.3%) were found to have additional defects that warranted cartilage restoration surgery. Thirteen patients (13.3%) were found to have defects that did not warrant cartilage restoration surgery, and instead were managed with debridement chondroplasty. Surgical plan was changed from ACI to OCA in 4 cases (4.1%) and OCA to ACI in 1 case (1%). A previously proposed plan of MAT was deemed unwarranted in 1 case (1%), and an initial plan of meniscal repair was changed to MAT in another (1%). In 19 cases (19.4%), staging arthroscopy was used to determine whether OCA or ACI was most appropriate. Of these, 8 (42.1%) were treated with OCA, 8 (42.1%) underwent ACI, 1 (5.3%) received minced juvenile cartilage allograft transplant, and 2 (10.5%) had debridement chondroplasty alone. Conclusion: To our knowledge, this is the first study to provide empirical evidence on the clinical value of staging arthroscopy prior to ACI, OCA and MAT. Based on our review, a change in treatment plan was made in 47% of cases in which staging arthroscopy was used to evaluate articular cartilage surfaces. Therefore, the results of our study indicate that staging arthroscopy is an important step in determining the most appropriate treatment plan for chondral defects prior to OCA, ACI and MAT.

Symptom Chronicity and Tobacco Use: Differences in Athletic and Nonathletic Candidates for Cartilage Surgery.

To determine whether there are differences in symptomatic knee cartilage defects and rates of tobacco use among age-matched athletes versus nonathletes undergoing initial arthroscopic knee surgery who meet demographic and radiographic criteria for cartilage restoration surgery. Age-matched athletes (n = 186) and nonathletes (n = 159) age 40 or less with a body mass index (BMI) of 35 kg/m2 or less (mean 26.8 SD 4.1) and <50% joint space narrowing on weight-bearing radiographs were included. All patients had a symptomatic Outerbridge grade 2 or higher cartilage defect visualized during knee arthroscopy. Relationship between athletic status and chronicity of knee symptoms prior to surgery and tobacco use status, cartilage defect Outerbridge grade, size, and location at time of surgery were characterized. Nonathletes were more likely to smoke (P < 0.001) and had higher BMI (P = 0.005). Duration of symptoms prior to surgery was shorter among athletes (P < 0.001). Grade 4 defects were equally prevalent (P = 0.96) as were multicompartment grade 3-4 lesions (P = 0.12). Mean grade 3-4 defect size was similar in lateral (P = 0.96) and medial compartments (P = 0.82). There was a trend toward larger anterior compartment defects in nonathletes (P = 0.07). Among age-matched athletes and nonathletes with symptomatic cartilage defects who meet demographic criteria for cartilage restoration, nonathletes were more likely to smoke and have a longer duration of symptoms prior to treatment. Athletes tended to present earlier but with similar size defects compared to nonathletes, supporting accelerated treatment of defects in athletes and caution toward allowing continued athletic participation in patients with known cartilage defects.

Cartilage Restoration Surgery: Incidence Rates, Complications, and Trends as Reported by the American Board of Orthopaedic Surgery Part II Candidates

To evaluate the current status of advanced cartilage restoration procedures among newly trained orthopaedic surgeons in the United States. The American Board of Orthopaedic Surgery database was queried to identify all advanced cartilage restoration procedure cases submitted by American Board of Orthopaedic Surgery part II board certification examination candidates from 2003 to 2015. All documented autologous chondrocyte implantation, autologous osteochondral transfer, osteochondral allograft transplantation, and marrow stimulation techniques (MSTs) procedures were analyzed. Analysis was performed to describe trends in annual incidence, types of complications, concomitant procedures, and geographical differences in incidence of advanced cartilage procedures. From 2003 to 2015, a total of 2,827 surgeons submitted 7,522 cartilage restoration procedures, with 7,060 cases documented as MST (80.01%). The number of cartilage cases decreased significantly from 2003 to in 2015 (P <.001), with MST having the largest decline (P < .001). The incidence of open osteochondral allograft transplantation (odds ratio= 1.35; P= .023) and open autologous osteochondral transfer (odds ratio= 0.84; P= .004) increased over the study period. Overall, the majority of patients (57.0%) were male; however, female patients were on average significantly older than male patients (P < .001). Cartilage procedures were performed concomitantly with a realignment osteotomy procedure in 1.7% of cases. The incidence of surgical complications increased throughout the study period from 2.9% in 2003 to 9.5% in 2015 (P<.001). Cartilage restoration procedures, specifically MSTs, are being decreasingly performed among recently trained orthopaedic surgeons. In contrast, complication rates have been increasing since 2003, demonstrating a possible paradigm shift toward more complex cartilage procedures, specifically osteochondral grafting procedures. This study demonstrates a significant decline in the use of MSTs by recently trained orthopaedic surgeons. In addition, an increase in several more complex cartilage restoration procedures was found. Taken in sum, these changes may reflect a shift in residency and fellowship training away from marrow stimulation procedures that elicit a fibrocartilage reparative tissue and toward more complex procedures that provide a more hyaline-like articular cartilage surface.

Learning From Failure in Cartilage Repair Surgery: An Analysis of the Mode of Failure of Primary Procedures in Consecutive Cases at a Tertiary Referral Center.

Background:As the number of cartilage restoration procedures is increasing, so is the number of revision procedures. However, there remains limited information on the reasons for failure of primary cartilage restoration procedures.Purpose:To determine the common modes of failure in primary cartilage restoration procedures to improve surgical decision making and patient outcomes.Study Design:Case series; Level of evidence, 4.Methods:Patients who presented for revision after failed cartilage repair surgery were evaluated for factors contributing to failure of the primary procedure. All revision cases performed by a single surgeon at a tertiary center for failed cartilage restoration over a 6-year time frame were identified. In all cases, the medical records, preoperative radiographs, and magnetic resonance imaging scans were reviewed by 2 experienced cartilage surgeons. The cause for failure was categorized as malalignment, meniscal deficiency, graft or biologic failure, or instability. Univariate and descriptive statistics regarding patient demographics, index procedure, lesion location and size, and mechanism of failure were analyzed.Results:A total of 59 cases in 53 patients (32 male, 21 female) met the inclusion criteria. The mean patient age at the time of revision was 27.6 years, and the mean body mass index was 28.4 kg/m2. Failed index surgical procedures included 35 microfractures (59%), 12 osteochondral allograft transplantations (20%), 10 osteochondral autograft transfers (17%), 2 nonviable osteochondral allografts (3%), and 2 particulated juvenile chondral allografts (3%). The mean lesion size was 4.4 cm2. Reasons for failure included 33 cases with untreated malalignment (56%), 16 with graft failure (27%), 11 with untreated meniscal deficiency (19%), and 3 with untreated instability (5%); 4 cases demonstrated multiple reasons for failure.Conclusion:The most commonly recognized reason for failure was untreated malalignment. While biologic and graft failures will occur, the majority of failures were attributed to untreated background factors such as malalignment, meniscal deficiency, and instability. The stepwise approach of considering and addressing alignment, meniscal volume, and stability remains essential in cartilage restoration surgery.

Shoulder cartilage regeneration : Indications, possibilities, surgical implementation

Asymptomatic cartilage lesions of the shoulder are frequent. Symptomatic lesions are treated analogously to other hyaline cartilage bearing joints and can be treated arthroscopically in the vast majority of cases. The therapeutic options can be subdivided into resection, stimulation and transplantation of the defect cartilage. There are only a few reports about outcome after cartilage restoration surgery in the literature, and microfracturing is the surgical technique that has been most investigated.

Early Rates of Revision of Knee Cartilage Restoration Surgery and Conversion to Arthroplasty within Five Years

Objectives:To examine the early rates of revision surgery for common knee cartilage restoration procedures performed in the United States, and subsequent conversion to total or unicondylar knee arthroplasty within five years.Methods:Using the MarketScan Research Databases (Truven Health Analytics), we examined all patients who underwent knee microfracture (CPT 29879), autologous chondrocyte implantation (ACI) (CPT 27412) or osteochondral grafting (CPT 27415, 27416, 29866, 29867), within the encompassed timeframe (2003-2014), and who remained tracked within the system for two contiguous years post-operatively to assess rate of revision surgery for complications and five contiguous years to assess revision to either total or unicondylar knee arthroplasty.Results:Although microfracture remains the most common articular cartilage restorative procedure, its rates have been slowly declining since 2009, where as rates of ACI and osteochondral grafting have remained relatively stable (Image). 76,304 microfracture patients, average age 48.3 (SD=13.6), with minimum follow-up of 2 years were examined. 6,366 patients (8.3%) underwent at least one revision cartilage procedure within two years. 93% of these patients had either repeat microfracture or chondroplasty, 4.7% underwent osteochondral grafting, and 2.3% underwent ACI. 1,030 patients (1.3%) required repeat surgery secondary to stiffness or infection: 94% of these patients required manipulation under anesthesia (MUA) and the remaining 6% required open or arthroscopic incision and drainage (I&D). 24,892 patients who underwent microfracture were enrolled for at least 5 years. 428 (1.7%) of these patients subsequently underwent knee arthroplasty within 5 years. Of the 868 patients who underwent ACI as the index procedure, 139 patients (16.0%) underwent a revision cartilage procedure within two years; most commonly chondroplasty (77.8%). Average age of ACI patients was 34.5 (SD=13.5). 46 ACI patients (2.1%) returned to the OR for complications; most commonly MUA for stiffness (98.3%). Of the 233 ACI patients who were enrolled for 5 years, 16 (6.9%) of patients underwent knee arthroplasty. 2,151 patients underwent osteochondral grafting as the index procedure, with the average age being 34.5 (SD=14.1). 331 (15.4%) patients underwent revision cartilage surgery, most commonly arthroscopic chondroplasty (52.6%). 107 (5%) of patients underwent surgery for complications, most commonly MUA (80.3%). Of the 741 patients who underwent osteochondral grafting that were enrolled for 5 years, 16 (2.2%) subsequently underwent conversion to knee arthroplasty.Conclusion:While the incidence of arthroscopic microfracture has been slowly decreasing since 2009, it remains the most common cartilage restorative procedure performed in the USA. Of the procedures examined, those undergoing ACI were more likely to require subsequent chondroplasty, where as patients undergoing osteochondral grafting were more likely to require MUA for stiffness. Conversion to arthroplasty within five years was lowest in the microfracture group and highest in the ACI group. The most common revision cartilage procedure was chondroplasty and most common complication requiring surgery was stiffness in all groups. Data from this study may help providers better inform patients on the rates of revision surgery and efficacy of these procedures in delaying total joint arthroplasty.

Return to sport after the surgical management of articular cartilage lesions in the knee: a meta-analysis.

Optimal surgical treatment of chondral defects in an athletic population remains highly controversial and has yet to be determined. The purpose of this review was to (1) report data on return to sport and (2) compare activity and functional outcome measures following various cartilage restoration techniques. A comprehensive review was performed for studies with return-to-sport outcomes after microfracture (MFX), osteochondral autograft transfer (OAT), osteochondral allograft transplantation (OCA), and autologous chondrocyte implantation (ACI). All studies containing return-to-sport participation with minimum 2-year post-operative activity-based outcomes were included. A meta-analysis comparing rate of return to sport between each surgical intervention was conducted using a random-effects model. Forty-four studies met inclusion criteria (18 Level I/II, 26 Level III/IV). In total,2549 patients were included (1756 M, 793 F) with an average age of 35years and follow-up of 47months. Return to sport at some level was 76% overall, with highest rates of return after OAT (93%), followed by OCA (88%), ACI (82%), and MFX (58%). Osteochondral autograft transfer showed the fastest return to sports (5.2±1.8months) compared to 9.1±2.2months for MFX, 9.6±3.0months for OCA and 11.8±3.8months for ACI (P<0.001). A meta-regression was conducted due to heterogeneity in preoperative factors such as patient age, lesion size, and preoperative Tegner score. None of these factors were found to be significant determinants for rate of return to sport. In conclusion, in this meta-analysis of 2549 athletes, cartilage restoration surgery had a 76% return to sport at mid-term follow-up. Osteochondral autograft transfer offered a faster recovery and appeared to have a higher rate of return to preinjury athletics, but heterogeneity in lesion size, athlete age, and concomitant surgical procedures are important factors to consider when assessing individual athletes. This study reports on the rate of return to sport in athletes undergoing various procedures for symptomatic chondral defects. IV.

Lateral Opening-wedge Distal Femoral Osteotomy: Pain Relief, Functional Improvement, and Survivorship at 5Years.

Distal femoral varus osteotomy may be used to treat valgus knee malalignment or to protect a knee compartment in which cartilage restoration surgery (such as osteochondral or meniscus allografting) has been performed. Medial closing-wedge osteotomy has demonstrated good success in treatment of osteoarthritis in published series, but few studies have evaluated distal femoral lateral opening-wedge osteotomy in terms of correction of deformity, pain and function, and survivorship. (1) Does lateral opening-wedge osteotomy lead to accurate correction? (2) What pain and function levels do patients experience after lateral opening-wedge osteotomy? (3) What are the nonunion, complication, and reoperation rates after lateral opening-wedge osteotomy? Between 2000 and 2010, we performed 40 distal femoral osteotomies. Two knees (two patients) underwent a medial closing-wedge osteotomy and were excluded from the present study. Thirty-eight knees (97%) in 36 patients were lateral opening-wedge varus-producing osteotomies; of those, 31 knees (82%) in 30 patients had followup at a minimum of 2years (mean, 5years; SD, 2; range, 2-12years) and comprised the study population. The indications for osteotomy included symptomatic lateral compartment arthritis with clinical valgus deformity or a cartilage or meniscal defect in the lateral compartment with clinical valgus alignment. The study population was stratified into two groups based on reason for osteotomy: patients with isolated symptomatic lateral compartment arthritis (arthritis group; 19 knees [61%]) and patients who underwent joint preservation procedures including osteochondral allograft transplantation or meniscal allograft transplantation (joint preservation group; 12 knees [39%]). Data collection from our institution's osteotomy database included patient demographics, lower extremity coronal alignment, and operative details. Pain and function were measured preoperatively and postoperatively using the International Knee Documentation Committee (IKDC) score. Time to radiographic union, complications, and reoperations were recorded. Twenty-one of 31 knees had postoperative radiographic data available for review. Of these, seven of 15 knees in the arthritis group and three of six knees in the joint preservation group were within the correction goal of±3° from neutral mechanical alignment. In the arthritis group, the mean IKDC total score improved from 47 (SD, 15) preoperatively to 67 (SD, 10) postoperatively. In the joint preservation group, the mean IKDC total score improved from 36 (SD, 12) preoperatively to 62 (SD, 18) postoperatively. One nonunion occurred in the arthritis group. No postoperative complications were experienced. Ten knees in the arthritis group and six knees in the joint preservation group had additional surgery after the osteotomy, consisting primarily of hardware removal, arthroscopy for cartilage-related conditions, or conversion to arthroplasty. Survivorship at 5years, with conversion to arthroplasty as the endpoint, was 74% in the arthritis group and 92% in the joint preservation group. Lateral opening-wedge distal femoral osteotomy was less accurate in correction of valgus deformity than expected, but the procedure was associated with improved knee pain and function scores. Our clinical and radiographic results are comparable to published series evaluating medial closing-wedge distal femoral osteotomy. Achieving our desired correction of±3° from neutral alignment was clinically difficult. An improved method of preoperative templating and refinement of the intraoperative technique may improve this. Future studies with more patients and longer followup will provide clarity on this topic. Level IV, therapeutic study.

Continuous Passive Motion following Cartilage Surgery: Does a Common Protocol Exist?

Continuous passive motion (CPM) devices have the potential to improve the histological content as well as the rate and volume of chondrogenesis in repair tissue following chondral injury. However, clinical evidence is lacking to support broad implementation of CPM following cartilage restoration procedures. We searched PubMed, CINAHL, SPORTDiscus, and Cochrane for such terms as knee, continuous passive motion, CPM, ACI, ACT, autologous chondrocyte implantation, autologous chondrocyte transplantation, microfracture, marrow-stimulation technique, mosaicplasty, osteochondral autograft, and osteochondral allograft. Inclusion criteria were all English-language studies of human subjects, evidence levels I to IV, reporting the use of CPM following cartilage repair or restoration surgery in the knee. One hundred and seven studies met inclusion criteria. Sixty-three studies reported the use of CPM following autologous chondrocyte implantation; 28 reported the use of CPM following microfracture; 13 reported the use of CPM following osteochondral autograft; and 15 reported the use of CPM following osteochondral allograft (several studies reported < 1 type of cartilage procedure, which explains why the sum of all studies reporting a particular procedure [119] is greater than the number of studies included in the review [107]). Of the 5723 patients included, 60.8% were treated with autologous chondrocyte implantation, 23.1% were treated with microfracture, 6.4% were treated with osteochondral autograft, and 9.7% were treated with osteochondral allograft. Of the 6612 total defects, 5043 (76.3%) were tibiofemoral and 1569 (23.7%) were patellofemoral. Most reports of CPM use after cartilage restoration procedures did not include specific information on how it was implemented. Overall, the description of CPM protocols in published knee articular cartilage surgery studies was disappointing. The majority of studies did not describe common variables such as the duration of CPM therapy, the initiation of CPM therapy, and the initial range of motion used. The most commonly prescribed parameters within a CPM regimen are initiated on the first postoperative day, with an initial range-of-motion of 0 to 30 degrees and a frequency of 1 cycle per minute, and for 6 to 8 hours daily over 6 weeks. The lack of consistent standardized reporting of postoperative CPM protocols provides an impetus to researchers and clinicians to more clearly define and describe their use following knee articular surgery.

Current concepts of articular cartilage restoration techniques in the knee.

Context:Articular cartilage injuries are common in patients presenting to surgeons with primary complaints of knee pain or mechanical symptoms. Treatment options include comprehensive nonoperative management, palliative surgery, joint preservation operations, and arthroplasty.Evidence Acquisition:A MEDLINE search on articular cartilage restoration techniques of the knee was conducted to identify outcome studies published from 1993 to 2013. Special emphasis was given to Level 1 and 2 published studies.Study Design:Clinical review.Level of Evidence:Level 3.Results:Current surgical options with documented outcomes in treating chondral injuries in the knee include the following: microfracture, osteochondral autograft transfer, osteochondral allograft transplant, and autologous chondrocyte transplantation. Generally, results are favorable regarding patient satisfaction and return to sport when proper treatment algorithms and surgical techniques are followed, with 52% to 96% of patients demonstrating good to excellent clinical outcomes and 66% to 91% returning to sport at preinjury levels.Conclusion:Clinical, functional, and radiographic outcomes may be improved in the majority of patients with articular cartilage restoration surgery; however, some patients may not fully return to their preinjury activity levels postoperatively. In active and athletic patient populations, biological techniques that restore the articular surface may be options that provide symptom relief and return patients to their prior levels of function.