Juvenile Cartilage Research Articles

(294) Central Pain Syndrome after Particulated Juvenile Articular Cartilage Allograft Transplantation Effectively Treated with Ketamine

Particulated juvenile articular cartilage allograft transplantation (PJACAT) is a rare procedure for treating osteochondral talar lesions. Central pain syndrome (CPS) develops after CNS insult or after central sensitization of a peripheral nerve injury or an inflammatory process. We present a case of CPS after PJACAT that was treated with ketamine after failing multiple analgesics. Patient informed consent was obtained and IRB committee approval was waived. Ketamine to treat CPS is an off-label use. A 56-year-old male with a history of bilateral osteochondral talar lesions status-post bilateral debridement and PJACAT presented to the pain clinic with left ankle pain that was not controlled with an extensive analgesic regimen. The pain was described as pins and needles and was associated with posterior calf tightness. Physical exam revealed purple discoloration of the left foot, toes, and ankle, decreased capillary refill, and mild edema. Vascular and cardiac workup were negative. A lumbar sympathetic block led to only 15% reported pain improvement. The patient received ketamine intravenous infusions of 20-80 mg, over four years, with greater than 50% improvement lasting greater than three weeks, on average, after each infusion. The patient's opioid regimen was consolidated to methadone, gabapentin, and duloxetine. Ketamine's antagonistic properties inhibit the increased nociceptive signaling to the CNS in patients with CPS. Ketamine's effectiveness has been equivocal in treating pain syndromes. Few studies have examined its long-term use and only one study examined its use in CPS, in which a seven-day ketamine course led to a decrease in the patient's analgesic regimen which included opioids. This case report supports the previous literature suggesting that repeat ketamine infusions are needed to sustain analgesia. Though promising, more studies are needed to evaluate the effectiveness and side effects of ketamine's long-term use in treating chronic pain.

Comparative Outcomes for the Treatment of Articular Cartilage Lesions in the Ankle With a DeNovo NT Natural Tissue Graft: Open Versus Arthroscopic Treatment.

Background:The treatment of osteochondral lesions of the talus (OLTs) with a juvenile cartilage allograft is a relatively new procedure. Although other treatment options exist for large OLTs, the potential advantage of a particulated juvenile allograft is the ability to perform the procedure arthroscopically or through a minimal approach. No previous studies have looked at the results of an arthroscopic approach, nor have any compared an arthroscopic technique with an open approach.Purpose:To compare the outcomes of an arthroscopic transfer technique with the previously published open technique.Study Design:Cohort study; Level of evidence, 3.Methods:A total of 34 patients (mean age, 33 years) underwent treatment of talar cartilage lesions with a DeNovo NT Natural Tissue Graft. Of these treatments, 20 were performed arthroscopically and 14 were performed with open arthrotomy. There was no statistically significant difference between the groups with respect to age, lesion width, lesion depth, lesion length, or operative time. The mean lesion area was 107 mm2. The scores from 6 different validated outcome measures were recorded for patients in each group preoperatively and subsequently at 6 months, 1 year, 18 months, and 2 years.Results:Comparing outcome scores at each time point to baseline, there were no statistically significant postoperative differences found between open and arthroscopic approaches with regard to the visual analog scale (VAS) for pain (P = .09), American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale (P = .17), Foot and Ankle Ability Measure (FAAM)–sports subscale (P = .73), Short Form–12 (SF-12) physical health summary (P = .85), SF-12 mental health summary (P = .91), or FAAM–activities of daily living subscale (P = .76).Conclusion:The treatment of talar articular cartilage lesions with a DeNovo NT Natural Tissue Graft demonstrated no significant differences in outcome at 2 years regardless of whether the graft was inserted with an arthroscopic or open technique.Clinical Relevance:Our analysis demonstrated no significant difference between an arthroscopic versus open approach at any time point for the first 2 years after implantation of a juvenile particulated cartilage allograft for large OLTs. With that said, both groups demonstrated improvement from baseline. These findings indicate that surgeons with different levels of comfort utilizing arthroscopic techniques can offer this treatment modality to their patients without altering their planned surgical approach. In addition, this will be particularly helpful in counseling patients for surgery when the extent of the defect will be evaluated intraoperatively. Patients can be counseled that they will likely have the same incisions regardless of whether they require debridement, microfracture, or implantation of a particulated allograft.

Treatment of osteochondral lesions in the ankle with a particulated juvenile cartilage allograft

Category: Ankle Introduction/Purpose: Numerous treatment modalities are in use today to treat symptomatic osteochondral lesions in the ankle; however, there are ongoing challenges with the treatment of certain types of lesions and concern regarding the long-term effectiveness of current common techniques. Methods: The purpose of this study was to collect mid and long-term clinical outcomes of pain, function, and activity level (VAS, SF-12, FAAM ADL, FAAM sports) Single-arm, multi-center study collected outcomes prospectively in standard clinic patients who would be undergoing or who had previously undergone treatment with DeNovo NT. The main exclusion criteria were high surgical risk, clinically diagnosed autoimmune diseases, or an active joint infection; all other patients receiving DeNovo NT could be approached for the study. The outcome analysis for this abstract focused on enrolled subjects’ final follow-up to date. Results: Clinical outcomes have been prospectively collected for 24 subjects with a total of 48 months follow-up. Twenty four of the treated lesions were located on the talus, none on the tibia. Out of the 24 patients, 23 had a single lesion and 1 had more than one. The average lesion size was 108.1 mm +/- 60.0 [23]. The Hepple classification was used to categorize each lesion. Interestingly, 19/24 were classified as 3 or higher. Cartilage ICRS was also used for classification. Out of the subjects, 23/24 were ICRS grade 3 or 4. There was also a concomitant procedure for 22/24 patients. Pre and post op VAS scores of 47.5 (+/- 23.1) and 12.2 +/- 17.8. SF-12 scores pre and post of 38.0 +/- 8.5 and 50.1 +/- 8.2. FAAM ADL’s pre and post 60.4 +/- 16.3 and 90.4 +/-11.8. FAAM sport scale scores pre and post 28.8 +/- 16.7 and 74.5 +/- 22.4. all outcome measures were statistically significant. Conclusion: Four year complete data is a challenge in this particular clinical population. This data set encompasses symptomatic osteochondral lesions of the talus treated with particulated juvenile cartilage allograft. The outcomes reflect an improvement in symptoms and patient satisfaction when treated with this technique. Based on these final outcome measures (V AS, SF-12, FAAM ADL’s, FAAM sport scale score) and satisfaction, it can be concluded that this is a viable option to get patients back to their pre-injury state.

First Metatarsal Head Osteochondral Defect Treatment With Particulated Juvenile Cartilage Allograft Transplantation: A Case Series.

Focal damage to articular cartilage, also called an osteochondral defect (OCD), can be a cause of pain and decreased range of motion. Recent advancements have led to transplantation techniques using particulated juvenile articular cartilage allograft. This technique has been applied to the first metatarsal head to a very limited degree, with no published results to our knowledge. The aim of this study was to review the clinical results of patients who underwent particulated juvenile cartilage allograft implantation for first metatarsal head OCDs. We performed a retrospective consecutive case series study. Nine patients, at an average age of 41 years, were treated for symptomatic focal osteochondral defects of the first metatarsal head with particulate cartilage grafting from 2010 to 2016. Patients were contacted by phone to assess interest in returning to the office for follow-up, where weightbearing radiographs of the foot were obtained and a foot examination was performed. At an average follow-up of 3.3 years, 7 of 9 patients reported no pain with recreational activities and no patient required further operations. This patient cohort was physically active, with 6 of 9 listing running as a regular activity. The average overall American Orthopaedic Foot & Ankle Society (AOFAS) Hallux Metatarsophalangeal-Interphalangeal Scale questionnaire score was 85 (maximum 100), AOFAS pain 35.6 (maximum 40), and AOFAS function 40.1 (maximum 45). Patient satisfaction surveys correlated with the AOFAS scores and revealed that 7 of 9 patients were very satisfied with their results, 1 was satisfied, and 1 patient was very dissatisfied. Particulated juvenile cartilage allograft transplantation is a promising treatment option for symptomatic first metatarsophalangeal focal articular cartilage lesions. Further study is needed to demonstrate which lesions respond better to this type of cartilage graft versus traditional marrow-stimulating procedures. Level IV, retrospective case series.

Joint Preservation of the 1st MTP

Category: Midfoot/Forefoot Introduction/Purpose: Focal damage to articular cartilage and the supporting subchondral plate, commonly referred to as an osteochondral defect (OCD), can be a cause of joint pain and subsequent decreased range of motion. There are few studies specifically describing these lesions in the first metatarsophalangeal (MTP) joint, where they are traditionally grouped into hallux rigidus. There exists an opportunity for early detection and intervention with the intent to prevent deterioration and improve patient outcomes. One contemporary treatment concept is to implant particulated juvenile cartilage allograft to restore articular cartilage. The aim of our study was to review the clinical results of patients that had undergone this procedure for first metatarsal head OCDs. Methods: After IRB approval, a retrospective review of a consecutive case series was studied utilizing the records of three foot and ankle surgeons. Inclusion criteria included all adult patients who were a minimum of one year post surgery and consented to participate. Patient demographics and preoperative visual analog scale (VAS) pain level were recorded from a standardized intake sheet. From the operative note, the OCD size and location was recorded, as well as any concomitant procedures. At a minimum follow up of one year, we obtained objective measurements of arthritis grade and subjective considerations of pain and function, including VAS pain level, Foot Function Index (FFI) questionnaire, the American Orthopaedic Foot and Ankle Society (AOFAS) Hallux Metatarsophalangeal-Interphalangeal scale, and an overall patient satisfaction score. Results: Nine patients met inclusion criteria, 4 males and 5 females. The average age was 41 years old (±11.77, range 21-65). The mean preoperative VAS pain score was 57.50 (±18.32, range 30-80). Four OCDs were located centrally on the first metatarsal head. The average OCD size intraoperatively was 30 mm2 (range 16-49). The average time since surgery was 3.26 years (±1.21, range 1.41-5.62). Average first MTP dorsiflexion was 41.78 degrees (±20.70, range 6-70). The average postoperative hallux rigidus classification was grade 2 (range 1-3). The mean VAS pain score improved to 5.22 (±8.44, range 0-20). The average AOFAS score was 88 (±15.91, range 52-100). The average FFI score was 8.04 (±12.60, range 0-30.6). All but one patient were satisfied or very satisfied with their results. Conclusion: At an average of 3.26 years postoperatively, patients had improved pain, did not show significant progression of their first MTP joint degeneration, and were satisfied with their results. Patients reported very little, if any, limitations in their activity level. We believe that articular damage of the first MTP should be viewed in the same way as OCD lesions in larger joints with emphasis on early detection and treatment to avoid the progression to arthritis. Particulated juvenile cartilage allograft is a valuable tool for surgeons to use in treating focal articular defects of the first metatarsal head.

Efficacy of Particulated Juvenile Cartilage Allograft Transplantation for Osteochondral Lesions of the Talus

Category: Ankle, Arthroscopy, Basic Sciences/Biologics, Sports Introduction/Purpose: Symptomatic osteochondral lesions of the talus (OLTs) are difficult to treat. As such, a broad array of cartilage treatment options exist. Despite the various techniques, many patients require multiple procedures due to persistent pain, failure of cartilage adherence, or persistent mechanical symptoms. The cartilage replacement technique, particulated juvenile cartilage allograft transplantation (PJCAT), is a novel treatment option supported by the benefits of ease of application, no need for perpendicular access to the OLT, and the delivery of viable hyaline cartilage. However, there is minimal clinical data to support this treatment option. The purpose of this study was to determine the efficacy of PJCAT. Methods: After obtaining IRB approval, we conducted a retrospective review of patients that underwent PJCAT for the treatment of OLTs at a single academic institution. From 2012 to 2015, 18 patients were identified. However, one patient died of an unrelated cause and two patients were lost to follow-up leaving 15 patients (7 males and 8 females) whom had a minimum of 12 months of follow up (mean 34.6, range, 12-51 months). The mean age of this cohort was 32.7 years (15-48) at time of surgery with BMI average 29.9 (18.8-40.2). The primary outcome was failure of the procedure defined as: recurrent or worsening symptoms with corresponding imaging demonstrating delamination, and/or the need for a secondary cartilage restoration procedure. Variables studied included: size of lesion denoted by MRI, intraoperative size, etiology (traumatic versus atraumatic), location of lesion, sex, age, and history of prior surgery. Results: Failure of primary procedure as defined by continued pain with corresponding imaging and/or necessity of secondary cartilage procedure after use of PJCAT was 40% (6/15). Preoperative MRI size (188.7 +/- 81.7mm2 vs. 113.5 +/- 50.5mm2, p<0.05) was significant predictors of PJCAT failure. Furthermore, male sex was predictive of failure(p<0.05). Age, BMI, etiology, technique (open versus arthroscopic), history of prior surgery nor location were predictors of failure. Lastly, patients with lesions greater than 125mm2 area were at a statistically significant increased risk of clinical failure. Functional outcome scores were significantly better at final follow-up in the patients who had undergone successful treatment versus those who did not: AOFAS score (89.4 +/- 8.4 vs. 65.8 +/- 26.7) and FAOS total (77.9 +/- 13.2 vs. 47.9 +/- 24.8). Conclusion: These findings demonstrate the association of preoperative MRI lesion size, intraoperative lesion size and male sex as risk factors for failure of PJCAT setting of an already difficult to treat pathology.

Comparative Outcomes for Treatment of Articular Cartilage Lesions in the Ankle with Particulated Juvenile Cartilage Allograft

Category: Ankle Introduction/Purpose: Treatment of osteochondral defects of the talus with particulated juvenile cartilage allograft is a relatively new procedure. Although other treatment options exist for large osteochondral defects of the talus, the potential advantage of particulated juvenile allograft is the ability to perform the procedure arthroscopically or through a minimal approach. No previous studies have looked at the results of an arthroscopic approach and no previous studies have compared an arthroscopic technique to an open approach. The purpose of this study was to compare the outcomes of an arthroscopic transfer technique to the previously published open technique. Methods: A total of 34 patients underwent treatment of talar cartilage lesions with juvenile particulated cartilage allograft. Twenty of these were done arthroscopically and 14 were done with an open arthrotomy. There was no statistically significant difference between the groups with respect to age, lesion width, lesion depth, lesion length, or operative time. Scores for 6 different validated outcome measures were recorded for patients in each group pre-operatively and subsequently at 6 months, 1 year, 18 months, and 2 years. Results: Comparing outcome measurements at each data point to baseline, there were no statistically significant post-operative differences found between open and arthroscopic approaches with regards to VAS Pain Scale, AOFAS Ankle-Hindfoot Scale, Foot and Ankle Ability Measure - Sport Scale, or SF12 Physical Health Scale. Conclusion: Treatment of talar articular cartilage lesions with particulated juvenile cartilage allograft is associated with improved outcomes at 2 years with regards to several validated outcome measures regardless of technique utilized. At 2 years follow up, there were no statistically significant differences in outcomes utilizing an arthroscopic technique versus open technique with the numbers given. This data supports the use of particulated juvenile cartilage allograft utilizing either arthroscopic or open techniques.

Management of Osteochondral Lesions of the Talar Dome

Osteochondral lesion of the talus (OLT) is a common condition associated with ankle injury that brings challenges in the diagnosis and treatment. Symptoms related to this condition are nonspecific including pain, swelling, stiffness, and mechanical symptoms of locking and catching. While the natural history of the OLTs is not well understood, surgical treatment is often required especially in chronic cases and acute cases with displaced articular fragments. Arthroscopic treatment of the OLTs aims to restore ankle joint function and pain relief by the removal of the chondral or osteochondral fragment, debridement and stabilization of cartilage rim and subchondral bone, and stimulate healing of the bone and damaged cartilage. In patients with a large lesion or after a failure of previous bone marrow stimulation, biologic restoration techniques including the use of particulate juvenile cartilage techniques, autogenous chondrocyte implantation, and osteochondral autograft or allograft transplantation may have role. This article summarizes the contemporary concepts in the clinical evaluation and treatment of OLTs with particular emphasis on surgical strategies.

Mid-Term Results of Particulated Juvenile Articular Cartilage Allograft Transplantation to the Knee

Objectives:Full-thickness chondral defects of the knee in the young, active patient remain a concerning orthopedic entity given the low capacity for natural regeneration of articular cartilage and limited established treatment options. In the knee, transplantation of particulated juvenile articular cartilage (Zimmer DeNovo NT) has been shown in small studies with only short-term outcomes to have excellent potential. This is the first study that has followed patients greater than 2 years.Methods:All patients at a single institution who underwent a DeNovo NT cartilage transplant procedure for single or multiple lesions of the knee between 2010 and 2014 were identified. All patients had an MRI pre-operatively. Size and location of defects treated were recorded intra-operatively, as were all concomitant procedures. MRI was performed at a minimum of 6 months post-operatively. MRIs were all read by musculoskeletal radiologists and repair tissue evaluated by the MOCART (Magentic Resonance Observation of Cartilage Repair Tissue) score. All patients were administered the Lysholm questionnaire pre and postoperatively.Results:26 patients (28 knees) were identified, 17:9 M:F, and average age 33.7 years (21-49 years). A total of 34 Outerbridge grade IV cartilage lesions were treated, 10 lesions on the MFC, 6 on the LFC, 13 on the patella and 5 on the trochlea. Average cross sectional area of the lesions was 3.075 cm2; average area of MFC lesions was 2.844cm2, LFC 2.69 cm2, patellar lesions 3.795cm2, and trochlea lesions 2.195 cm2. Associated procedures included patellar realignment in 16/28 (tibial tubercle osteotomy in 12, VMO advancement in 4); 6 MPFL reconstructions and 10 lateral releases. ACL reconstruction occurred in 7/28 knees and partial meniscectomy in 9. There were 11 returns to the OR, 3 for MUA, 9 for arthroscopic debridement (including 5 hypertrophic graft tissue, 1 loose body and 2 further microfractures of a prior or new lesion). On MRIs at 6 months post-op. The average MOCART score was 54.7 (range 20-85). 12/17 had fill of the defect, 3 had >50% fill; 10 had full border integration and 5/17 were isointense on T2. More than half of patients with greater than 1 post-operative MRI showed a progressive increase in their MOCART score with increasing time since surgery. Average pre-op Lysholm score was 51.99 (SD 15.24, range 29.17-68.76). At an average of 4.8 years post-operatively, the mean Lysholm was 86.37 (SD 10.72, range 70.84-100). This improvement in Lysholm scores was statistically significant, p< 0.001.Conclusion:This study clearly shows that this particulated juvenile cartilage transplant procedure has good short term and lasting results. MRI findings confirm that it achieves good ingrowth and integration. In our analysis, there is a trend towards increasing MOCART scores with time, but this did not reach statistical significance. This is the first study that confirms excellent outcomes following DeNovo NT cartilage transplantation in the knee are maintained at a mid-term follow up of nearly 5 years.

Osteochondral Defects of Talus treated with Juvenile Cartilage Transplant Cells

To prove that Juvenile Cartilage cells have a role in the treatment of Osteochondral Defect (OCD) of the Talus. This is Retrospective case series with clinical follow up. We obtained appropriate IRB approval for reviewing our cases of OCD of Talus treated with transplanted cartilage cells. OCD of the Talus is initially treated with trial of splintage, activity modification, NSAIDS and Physical therapy. When patients do not respond to nonoperative measures the standard surgical intervention is debridement with or without micro-fracture or an OATS procedure In out Institution for the cases which needed surgical Intervention we treated them with an ankle arthroscopic debridement of the lesion and a synovectomy. We then proceeded to transplant juvenile allograft cartilage cells(Denovo, Zimmer) to cover the defect. Patients were nonweight bearing 2 weeks in a splint. Patients then were placed in a CAM walker for next 4 weeks with PWB and PT. Patients were evaluated postop and foot and ankle scores were obtained through a combination of clinical exam and telephonic questionnaire. we had total of seven cases between 2012 to 2016 with an average followup of 8 months. The first 2 cases had an arthroscopy - arthrotomy for cartilage cell transplant. The last 5 cases have all been performed arthroscopically. we had age range form 17 to 56 and both males( 5) and females( 2) At last followup 5 cases had an excellent result with a foot and ankle score over 97( 100) one patient had a fair result. FA score 75-80. One patient at 4 months complained that symptoms were no different at 4 month mark. FA Score 50. Early results for Cartilage cell transplants for OCD of the Talus have been good. We need a larger series and longer followup hopefully with a multicenre blinded trail to see if these results will be worth the extra cost and risks involved.

Chondral Defect Repair with Particulated Juvenile Cartilage Allograft

Objectives:To evaluate the functional outcomes and morphologic appearance of repair tissue in patients with symptomatic knee articular cartilage defects treated with minced juvenile articular cartilage (DeNovo NT).Methods:Thirty-four patients underwent treatment of cartilage defects of the knee with minced juvenile articular cartilage allograft. Mean postoperative follow up was 33.6 months. MRIs were obtained at 24-months (16 patients) and 48-months or greater (13 patients). MRIs were evaluated for greyscale cartilage repair assessment score and quantitative T2 mapping. Baseline clinical outcome scores (IKDC, ADL, Marx Activity Rating Scale) were obtained prior to surgery, and at a minimum follow up interval of 24-months.Results:The mean IKDC and ADL scores significantly improved following surgery. The magnitude of improvement in IKDC scores was 30 (Std Dev 31). The Marx activity Rating Scale score demonstrated a resumption of pre-operative activity levels, Figure 1a. Donor age had no significant effect on functional outcomes scores of treated patients. MRI assessment revealed greater than 66% lesion fill (a score of 2) in 80% of patients. A trend toward significance in difference in % lesion fill was observed when patients were grouped according to donor age ≤ 5 vs. > 5 years (p = 0.09), Figure 1b. Lesion fill did not correlate with functional outcome score. Using one-way analysis of variance with post-hoc testing, a significant difference was found between T2 mapping of the deep zones of the graft and normal cartilage (p=0.003), Table 1.1.a. Graphical presentation of pre-operative and post-operative Marx Activity Scores (MAS), International Knee Documentation Committee Score (IKDC) and Knee Outcomes Survey Activities of Daily Living Score (ADL).b. Donore age-based analysis of percentage lesion fill by volume. % fill was scored on a scale of 0 – 3, where 0 = less than 33% fill, 1 = 33 – 66% fill and 2 = > 66% fill.T2 Mapping at 18+ MonthsNMeanSDP-ValueP-ValueGraft - Deep1139.26.90.0010.003*Graft - Superficial1143.99.9Integration Zone - Deep1135.35.80.01Integration Zone - Superficial1138.76.3Normal - Deep1130.23.8<0.0001Normal - Superficial1138.16.1 Conclusion:Functional outcome scores significantly improved in patients treated with minced juvenile articular cartilage (De Novo NT) for the treatment of symptomatic articular cartilage lesions of the knee. Activity levels, as noted by the Marx Activity Scale were preserved. Morphologic analysis demonstrated greater than 66% lesion fill in 80% of the patients studied. T2 mapping demonstrated the sensitivity to assess differences between repair tissue and native cartilage.

Combined Particulated Juvenile Cartilage Allograft Transplantation and Medial Patellofemoral Ligament Reconstruction for Symptomatic Chondral Defects in the Setting of Recurrent Patellar Instability

Successful management of patellar osteochondral lesions has proved difficult, with unreliable outcomes reported using traditional cartilage repair and restoration procedures. Unique considerations for this type of defect include the multiplanar contours of the articular surface of the patella, high compressive and shear forces with knee range of motion that may disrupt graft healing, and the potential need for concomitant surgery to address patellar malalignment and instability. We describe our preferred method for treatment of a symptomatic chondral defect in the setting of recurrent patellar instability using particulated juvenile articular cartilage allograft transplantation and medial patellofemoral ligament reconstruction with semitendinosus allograft. Distinct advantages of this cartilage restoration technique include single-stage restoration of relevant cartilage pathology and the ability to easily contour the graft to the size and shape of the chondral defect.

Particulated Juvenile Articular Cartilage Allograft Transplantation for Osteochondral Talar Lesions.

To report on our institution's early results from juvenile particulate cartilage allograft transplantation of the talus. Because of the relative rarity of the procedure at the talus, it was decided to provide a comprehensive understanding of the currently available evidence via a 2-part study with (1) a systematic review of the literature and (2) a retrospective single-center cohort study of the authors' patients, their demographics, and their early outcomes. (1) Four studies were included with 33 ankles with a weighted mean follow-up of 14.3 months. Only 1 ankle (3.3%) was converted to a revision open osteochondral allograft with medial malleolar osteotomy at 16 months postoperative; 6 (18.2%) required nonrevision type reoperations at an average of 15 months postoperative. (2) Six patients with mean age 35.7 ± 14.4 years were evaluated from the authors' institution at mean 13.04 ± 8.35 months' follow-up. All reported subjective improvements in pain and motion, and functional improvements, although postoperative magnetic resonance imaging in 3 patients at time points between 3 months and 2 years postoperative demonstrate persistent subchondral edema and nonuniform chondral surface in the talus. There were no intraoperative or postoperative complications, and there have been no reoperations. Preliminary data suggest that treatment of large, traumatic or atraumatic, symptomatic osteochondral talar defects with particulated juvenile cartilage transplantation may improve patient subjective complaints of pain and function. Systematic review of the available literature highlights the need for future prospective, larger cohort studies of its use on the talus but suggests similar potential for the technology.

Arthroscopic Juvenile Allograft Cartilage Implantation for Cartilage Lesions of the Hip

Cartilage lesions in the hip are of high prevalence. Most of these lesions are treated with microfracture. Microfracture has relatively good subjective outcomes for smaller lesions; however, it is limited by the ability to reproduce hyaline cartilage, especially in older patients. For larger chondral defects, we present a technique using juvenile allograft cartilage implantation implanted arthroscopically to treat cartilage lesions in the hip. The purpose of this technical note is to describe the arthroscopic technique for treating chondral lesions in the hip with allograft juvenile cartilage.

Does Ligamentous Laxity Protect Against Chondral Injury in Patients with Patellofemoral Instability?

Objectives:Hypermobility may be a risk factor for musculoskeletal injuries during sports participation. However, we have seen a low incidence of chondral injuries requiring treatment in patients undergoing medial patellofemoral ligament (MPFL) reconstruction for patellofemoral instability. It is unknown if patients with ligamentous laxity, who are at an increased risk for patellofemoral instability, are somewhat protected from chondral injury. We hypothesize in patients undergoing MPFL reconstruction for patellofemoral instability, patients with ligamentous laxity will be less likely to have chondral defects requiring surgical intervention.Methods:171 patients (32 male, 139 female) average age 22 years (range 11-57) with patellofemoral instability were rated with the Beighton-Horan (BH) scale for constitutional ligamentous laxity (0-9). Preoperative MRIs were evaluated (chondral injury present/absent, size of chondral injury, Outerbridge grade) and intra-operative arthroscopic findings noted (chondral injury present/absent, size of chondral injury, Outerbridge grade, surgical intervention yes/no, type of surgical intervention) of 79 non-lax (BH<6) and 92 ligamentously lax patients (BH≥6) (LAX) undergoing MPFL reconstruction. Anatomic measurements were documented for each patient including: tibial tubercle-trochlear groove (TT-TG) distance, Caton-Deschamps (C/D) ratio for patellar height, and the Dejour classification of trochlear dysplasia. Surgical interventions included chondroplasty, microfracture, particulated juvenile cartilage implantation (DeNovo, Zimmer, Warsaw, IN), osteochondral fracture fixation or osteochondral allograft transplantation (OATS).Results:58/171 (33.9%) required a surgical intervention for a chondral defect: chondroplasty 29/58 (50%), microfracture 16/58 (27.6%), particulated juvenile cartilage implantation 18/58 (31%), osteochondral fracture fixation 2/58 (3.5%), and OATS 2/58 (3.5%). There was no difference in the proportion of additional procedures in LAX vs. non-lax (p=0.475). There was no difference in the proportion of patellar chondral injuries sustained (LAX 29.3% vs. non-lax 45.7%) (p=0.538) but LAX patients had a lower proportion of patellar grade IV chondral injury compared to non-lax (p=0.026). There was no difference in the proportion of femoral chondral injuries sustained (LAX 13.1% vs. non-lax 26.4%) (p=0.073) but LAX patients had a lower proportion of femoral grade IV chondral injury compared to non-lax (p=0.023). There was no association of chondral injury with trochlear morphology (p=0.843), patellar height (p=0.303), TT-TG (p=0.874), number of instability events (p=0.878), age at time of surgery (p=0.482), and contact vs. non-contact mechanism of injury (p=0.772).Conclusion:LAX patients had a lower proportion of severe patellar and femoral cartilage injuries. There was no significant difference in the proportions of injuries, however there were 2x the proportion of femoral chondral injuries and 1.5x the proportion of patellar chondral injuries in non-lax vs. LAX, which is clinically significant.

DeNovo NT Particulated Juvenile Cartilage Implant.

Biological repair of focal chondral defects represents a significant clinical challenge as cartilage lacks intrinsic healing ability. Although it can be difficult to measure the objective success of cartilage repair techniques, the primary objective is symptom relief leading to less pain and improved function for the patient. Likely, the most important key to success is proper clinical indications. Second to this, the type of cartilage treatment utilized should be based on lesion location, size, depth, and other patient factors. One such treatment is DeNovo Natural Tissue. This method relies on the ability of juvenile chondrocytes to migrate from cartilage explants after being secured in a cartilage defect. Although approximately 8700 cases have been performed since 2007, long-term clinical outcomes are not yet available. However, basic science and early clinical data are promising.

Osteochondral defects of the upper extremity treated with particulated juvenile cartilage transfer.

We present the novel use of particulated juvenile cartilage transfer in the upper extremity. Our patient is an active duty solider with an osteochondral defect (OCD) of the capitellum that he sustained after an improvised explosive devise injury to his left elbow.

Arthroscopic Management of a Glenohumeral Osteochondral Defect Using Particulated Juvenile Cartilage Allograft: A Case Report.

A sixteen-year-old high school varsity quarterback was referred to us for evaluation of right shoulder pain two months after an injury sustained during a football tackle. The patient reported being substantially limited in his ability to perform vigorous activity because of pain and the sensation that his shoulder was about to dislocate. Evaluation showed a Bankart tear and a focal full-thickness glenoid osteochondral defect. The tear was treated with Bankart repair, and the osteochondral defect was filled arthroscopically with particulated juvenile cartilage graft. The patient returned to full sports activity without restriction at nine months after surgery and, at two years of follow-up, remained pain free with full range of motion and strength and no symptoms of instability. The current case suggests that particulated juvenile cartilage may be effective in the treatment of osteochondral lesions of the glenoid.

Restoring Cartilage: The Holy Grail of Orthopaedics.

Theoretically, articular cartilage restoration should be a solvable biological/mechanical problem. But repairing, restoring, or replacing hyaline cartilage and the matrix that supports it presents formidable physiological and physical challenges. For decades, researchers have been investigating many different methods of cartilage repair, and no approach has yet risen to “gold standard” status. As the “Current Concepts Review” in the February 19, 2014, edition of JBJS points out, the main strategy for cartilage “self-repair” is bone marrow stimulation, primarily via microfracture. Restorative/replacement approaches focus on cartilaginous constructs composed of allogenic, autogenic, or tissue-engineered materials. This month’s “Case Connections” looks at four cases involving three different restorative/replacement approaches to cartilage defects. The variable outcomes emphasize the gaps between theoretical and clinical solutions to this common skeletal problem. In the June 24, 2015, edition of JBJS Case Connector, Ramirez et al. report on a high-school quarterback whose full-thickness glenoid osteochondral defect was filled arthroscopically with particulated juvenile cartilage allograft. The sixteen-year-old football player presented with a two-month history of right shoulder pain and a feeling of instability, precipitated by a tackle during a football game. Physical exam revealed forward shoulder elevation to 150° with moderate pain but no muscle atrophy. External rotation was 60°, and the shoulder rotated internally to the T7 vertebral level with pain and crepitus. Anterior apprehension, relocation, and load-shift tests were all positive. Radiographs showed a 2 × 2-cm lucency in the inferior-central region of the glenoid. MRI showed an anterior-inferior labral tear and an osteochondral glenoid defect that measured 1.7 × 2.5 cm. After a period of unsuccessful nonoperative management, diagnostic arthroscopy revealed a displaced anterior-inferior labrum and a full-thickness, 1.5 × 1.5-cm cartilage defect of the inferior-central region of the glenoid. Surgeons repaired the labrum arthroscopically and then dried the surface of the defect by …

Advances and Current Concepts of Cartilage Repair in the Patellofemoral Joint

The patellofemoral (PF) joint poses a unique challenge to the cartilage surgeon owing to its physiologically high forces (compression and shear) and multiple degrees of mobility. The recognition of malalignment and instability in patients with chondral lesions, is imperative and plays a significant role in the cartilage treatment algorithm. The goal of PF restoration is to return the articular surface as close to the natural state as possible while correcting malalignment to prevent abnormal loading and at the same time effecting a stable environment. Although cartilage repair outcomes in the tibiofemoral joint have improved over the years, the PF joint reported outcomes remain more variable. Many authors continue to work to optimize comfort and function at the PF joint with specific emphasis on malalignment, stability, and articular cartilage repair on the patella. Technological advances in microfracture, particulated juvenile cartilage allograft transplantation, and autologous chondrocyte implantation are providing the necessary catalyst for research to include well-designed studies, which focus on the PF joint. The purpose of this article is to inform the reader about the current state of the art in chondral repair using cell-based approaches, beyond osteochondral allografts, which are discussed elsewhere in this issue.