Modified Magnetic Resonance Observation Of Cartilage Repair Tissue Research Articles

Cartilage Regeneration Using Human Umbilical Cord Blood Derived Mesenchymal Stem Cells: A Systematic Review and Meta-Analysis.

Background and Objectives: Human umbilical-cord-blood-derived mesenchymal stem cells (hUCB-MSCs) have recently been used in clinical cartilage regeneration procedures with the expectation of improved regeneration capacity. However, the number of studies using hUCB-MSCs is still insufficient, and long-term follow-up results after use are insufficient, indicating the need for additional data and research. We have attempted to prove the efficacy and safety of hUCB-MSC treatment in a comprehensive analysis by including all subjects with knee articular cartilage defect or osteoarthritis who have undergone cartilage repair surgery using hUCB-MSCs. We conducted a meta-analysis and demonstrated efficacy and safety based on a systematic review. Materials and Methods: This systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. For this study, we searched the PubMed, Embase, Web of Science, Scopus, and Cochrane Library literature databases up to June 2022. A total of seven studies were included, and quality assessment was performed for each included study using the Newcastle-Ottawa Quality Assessment Scale. Statistical analysis was performed on the extracted pooled clinical outcome data, and subgroup analyses were completed. Results: A total of 570 patients were included in the analysis. In pooled analysis, the final follow-up International Knee Documentation Committee (IKDC) score showed a significant increase (mean difference (MD), -32.82; 95% confidence interval (CI), -38.32 to -27.32; p < 0.00001) with significant heterogeneity (I2 = 93%, p < 0.00001) compared to the preoperative score. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores at final follow-up were significantly decreased (MD, 30.73; 95% CI, 24.10-37.36; p < 0.00001) compared to the preoperative scores, with significant heterogeneity (I2 = 95%, p < 0.00001). The visual analog scale (VAS) score at final follow-up was significantly decreased (MD, 4.81; 95% CI, 3.17-6.46; p < 0.00001) compared to the preoperative score, with significant heterogeneity (I2 = 98%, p < 0.00001). Two studies evaluated the modified Magnetic Resonance Observation of Cartilage Repair Tissue (M-MOCART) score and confirmed sufficient improvement. In a study analyzing a group treated with bone marrow aspiration concentrate (BMAC), there was no significant difference in clinical outcome or M-MOCART score, and the post-treatment International Cartilage Repair Society (ICRS) grade increased. Conclusion: This analysis demonstrated the safety, efficacy, and quality of repaired cartilage following hUCB-MSC therapy. However, there was no clear difference in the comparison with BMAC. In the future, comparative studies with other stem cell therapies or cartilage repair procedures should be published to support the superior effect of hUCB-MSC therapy to improve treatment of cartilage defect or osteoarthritis.

Correlation of the Modified Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) Score with Patient-Reported Outcome Scores for Postoperative Assessment of Ankle Osteochondral Lesions

Category: Ankle; Arthroscopy; Trauma Introduction/Purpose: The MOCART scoring system is commonly used in both the knee and ankle literature to quantitatively assess cartilage repairs on MRI. For both the knee and ankle, MOCART scores have demonstrated little ability to correlate with clinical outcomes such as survey scores. The system also suffers from issues with repeatability and reproducibility of individual scores. This study seeks to analyze the correlation between MOCART scores and PRMOIS scores obtained from the same time period from patients undergoing surgical management of an osteochondral lesion of the talus. It also seeks to determine MOCART's intra-rater reliability by analyzing multiple independent scoring attempts by the same radiologist. We hypothesized that MOCART scores would correlate with PROMIS outcomes and be repeatable for a given rater. Methods: Patients treated for an osteochondral lesion of the talus by a single surgeon in our department were screened for the existence of preoperative and postoperative MRI and survey scores completed within five months of one another. Each MRI was scored using the MOCART system by one radiologist fellowship-trained in musculoskeletal radiology on two separate occasions, with at least one week between scoring attempts. Each MOCART category and the overall score was compared to each PROMIS category. We also compared the presence of cysts and edema, as noted by the raters, to each PROMIS category. Results: MOCART scores were found to be repeatable between scoring attempts for individual categories and especially for the overall score. Preoperative MOCART scores correlated positively to preoperative PROMIS scores for the Physical Function (r= 0.0173), Pain Interference (r=0.1093), and Depression (r=0.0812) domains. Postoperative MOCART scores correlated positively with postoperative PROMIS scores for the Physical Function (r=0.1639) and Global Physical Health (r= 0.2152) domains. Postoperative MOCART scores did not correlate positively to change in PROMIS scores nor did change in MOCART scores correlate positively to change in PROMIS scores as we had expected. One significant correlation existed between postoperative MOCART score and pre to postoperative change in PROMIS Global Mental Health, but the correlation was negative (r= -0.527; p= 0.044). The presence of cyst and edema likewise did not demonstrate any consistent pattern. Conclusion: While the MOCART score may be repeatable for a given reader, it faces significant issues with correlation to PROMIS outcomes. This has been noted before for certain surgical techniques and other outcomes measurements. We find that this pattern holds true more broadly when looking at a range of methods for the treatment of osteochondral lesions. While quantitative evaluation of MRI is important for better understanding cartilage repair techniques, problems with the MOCART system should be acknowledged and solutions considered.

Mosaicplasty With High Tibial Osteotomy for Knee Subchondral Insufficiency Fracture Had Better Magnetic Resonance Observation of Cartilage Repair Tissue Scores With Less Bone Marrow Edema and Better Plug Union and Less Plug Necrosis Compared With Mosaicplasty Alone

To determine the magnetic resonance imaging (MRI) findings after mosaicplasty (MOS) for knee subchondral insufficiency fracture (SIFK), and to analyze the relationship between MRI findings and clinical outcomes. We retrospectively reviewed the cases of consecutive patients who underwent MOS for SIFK with/without high tibial osteotomy (HTO) between January 1998 and December 2015. The MRI findings at 12 months after the surgery were assessed by the modified magnetic resonance observation of cartilage repair tissue (MOCART) score to determine the degree of bone marrow edema (BME), plug union, and plug necrosis. The clinical outcomes were assessed by Lysholm score to clarify the minimal clinically important difference (MCID) and patient acceptable symptom state analysis. In total, 58 patients (17 men and 41 women) were enrolled in this study. Among them, 30 knees were treated by MOS alone and 28 knees were treated by MOS with HTO. The MOCART scores of patients who received MOS alone were significantly lower in BME score (P= .0060), plug union score (P= .0216), and in plug necrosis score (P= .0326) than patients who received MOS with HTO. BME lesion was less likely to persist among elderly (odds ratio 1.20, P= .0248) and female (OR 41.8, P= .0118) patients. The MCID of Lysholm score was 6.6 in MOS alone and 8.4 in MOS with HTO cases, but there were no significant association between MRI findings and the postoperative Lysholm score. The MOS with HTO cases had better MOCART scores with less BME, better plug union, and less plug necrosis compared with MOS alone cases. Female and older patients had better resolution of BME, but there was no significant correlation between MRI findings and the postoperative Lysholm score. All cases in both groups showed improvement of Lysholm score exceeding MCID; thus, MOS may be effective as a joint preserving surgery for SIFK. Level IV, clinical case series.

Gender May Affect Mid-Term Outcomes Following Bone Marrow Stimulation for Osteochondral Lesions of the Talus

Category:AnkleIntroduction/Purpose:Bone marrow stimulation (BMS) is typically indicated as a surgical intervention for patients who have symptomatic osteochondral lesions of the talus (OLT). Despite differences in ankle biomechanics and cartilage morphology between male and female patients, there is scant evidence examining whether these differences affect outcomes following BMS. The purpose of this study was to compare the outcomes in female and male patients following BMS in the treatment of OLTs.Methods:A retrospective analysis comparing female and male patients treated with BMS for OLT between 2007 and 2015 was performed. Clinical outcomes were evaluated using the Foot and Ankle Outcome Scores (FAOS) and Short-Form 12 (SF-12). Magnetic resonance imaging (MRI) at final follow-up was evaluated with the modified magnetic resonance observation of cartilage repair tissue (MOCART) score.Results:Thirty-one females and 38 males were included in this study. The mean patient age was 39.6+-16.9 for females and 36.5+-14.5 years for males. There was no significant difference in age, lesion size, follow-up time, and a number of concomitant procedures. Lateral lesions occurred more frequently in male patients (p=0.034). In female patients, the mean FAOS pain score improved from 60.2 +- 15.5 preoperatively to 84.0 +- 8.9 at 1-2 year follow-up (p<0.001), and then decreased to 80.0 +- 13.1 at final follow-up at 3-4 years, which was not statistically significant (p=0.191). In male patients, the mean FAOS pain score improved from 64.7 +- 17.0 preoperatively to 83.1 +- 9.2 at 1-2 year follow-up (p<0.001), and then decreased to 76.0 +- 14.6 at final follow- up at 3-4 years (p=0.023). The mean MOCART scores were 59.3 +- 24.0 in female patients and 67.3 +- 23.6 in male patients (p=0.278).Conclusion:Lateral lesions were more common in male patients possibly indicating an acute traumatic etiology. Medial lesions were more common in female patients indicating potentially a chronic pathology. This may have implications in reducing the incidence of OLT in female patients. The outcomes following BMS in both female and male patients were good with no significant differences in FAOS pain score and MOCART score at short-term follow-up. FAOS scores in male patients were more likely to decrease after 1-2 years post-surgery, implying a possibly faster decline than in female patients.

Long-Term Outcomes of Autograft Osteochondral Transplantation for Osteochondral Lesions of the Talus: Eight to Twelve Years Follow-Up

Category:AnkleIntroduction/Purpose:Autologous osteochondral transplantation (AOT) is a replacement strategy used to treat osteochondral lesions of the talus (OLT), typically reserved for the treatment of lesions of larger sizes, highly cystic lesions, or in patients who have failed previous treatment. The purpose of this study was to evaluate the long-term (>8 years) clinical and radiographic outcomes of AOT for the treatment of OLT in the form of a retrospective case series.Methods:Patients who underwent AOT between 2006 and 2008 were evaluated. Functional outcomes were assessed pre- and post-operatively using the Foot and Ankle Outcome Score (FAOS), and Short-Form-12 (SF-12) general health questionnaire. The most recent post-operative MRI was evaluated with the modified Magnetic resonance Observation of Cartilage Repair Tissue (MOCART) score.Results:Twenty-eight patients who underwent AOT were included and evaluated at a mean follow-up of 122.9 months. The mean FAOS pain subscale improved from 52.7 to 82.9 and the mean SF-12 improved from 30.3 to 58.3 at final follow-up (both, p < 0.01). The mean FAOS pain subscale then decreased to 77.6 at final follow-up, but this decrease was not statistically significant (p=0.293). At the final follow-up, the mean FAOS subscale scores of symptoms, pain, daily activities, sports activities, and quality of life were 66.6, 77.6, 86.0, 60.4, and 53.6, respectively. The mean VAS score was 2.2 at a final follow-up. The mean MOCART score was 83.8 with a mean MRI follow-up of 82.8 months. Ten patients (35.7%) had additional surgery, with the most common procedure being arthroscopic anterior ankle debridement. One patient failed AOT and developed osteoarthritis of the ankle requiring a total ankle replacement.Conclusion:AOT appears to be an effective treatment for OLT with good long-term clinical and radiographic outcomes. Secondary procedures were typically minor and the overall clinical failure rate was low.

Hypothermically Stored Amniotic Membrane for the Treatment of Cartilage Lesions: A Single-Arm Prospective Study with 2-Year Follow-Up.

ObjectiveThe purpose of this study was to determine the safety and efficacy of hypothermically stored amniotic membrane (HSAM) for the treatment of cartilage lesions of the knee using imaging, patient-reported outcomes (PROs), second-look arthroscopy, and histology. Patients were treated with HSAM and followed for 2 years.DesignSubjects with focal chondral lesions of the femur (International Cartilage Repair Society grade 3-4) were enrolled in this single-arm prospective study. Standard of care imaging was completed. PROs, including the Knee Injury and Osteoarthritis Outcome Score (KOOS), Marx Activity Scale, and Visual Analog Scale (VAS), were collected at baseline and at 3, 6, 12, 18, and 24 months. Three subjects underwent an optional arthroscopy and biopsy of the repair at 24 months.ResultsTen subjects were enrolled and completed the study. At 24 months, KOOS Sports & Recreation improved 173.3% and Quality of Life improved 195.3% from baseline. Marx Activity Scale increased 266.8% from 12 to 24 months. VAS scores improved 84.8% and 81.0% from baseline to 24 months for average and maximum pain. Modified Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) scoring showed that 7 of 10 subjects had complete defect repair and filling by 24 months. Biopsy staining for collagen II revealed integration and remodeling of HSAM into a mix of hyaline-like cartilage and fibrocartilage matrix.ConclusionThis study provides evidence supporting the safety and efficacy of HSAM for treating symptomatic cartilage lesions. Subjects showed a high degree of defect fill and integration with the native cartilage and reported improvements in pain and function post-treatment. Results provide important original data for future clinical trials.

No Difference in Outcomes Following Osteochondral Allograft with Fresh Precut Cores Compared to Hemi-Condylar Allografts.

The purpose of the current study is to evaluate the clinical and radiographic outcomes at early to midterm follow-up between fresh precut cores versus hemi-condylar osteochondral allograft (OCAs) in the treatment of symptomatic osteochondral lesions. A retrospective review of patients who underwent an OCA was performed. Patient matching between those with OCA harvested from an allograft condyle/patella or a fresh precut allograft core was performed to generate 2 comparable groups. The cartilage at the graft site was assessed with use of a modified Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) scoring system and patient-reported outcomes were collected. Overall, 52 total patients who underwent OCA with either fresh precut OCA cores (n = 26) and hemi-condylar OCA (n = 26) were pair matched at a mean follow-up of 34.0 months (range 12 months to 99 months). The mean ages were 31.5 ± 10.7 for fresh precut cores and 30.9 ± 9.8 for hemi-condylar (P = 0.673). Males accounted for 36.4% of the overall cohort, and the mean lesion size for fresh precut OCA core was 19.6 mm2 compared to 21.2 mm2 for whole condyle (P = 0.178). There was no significant difference in patient-reported outcomes including Visual Analogue Scale, Knee Injury and Osteoarthritis Outcome Score for Joint Replacement, and Tegner (P > 0.5 for each), or in MOCART score (69.2 vs. 68.3, P = 0.93). This study found that there was no difference in patient-reported clinical outcomes or MOCART scores following OCA implantation using fresh precut OCA cores or size matched condylar grafts at early to midterm follow-up.

Outcomes Following Microfracture for Osteochondral Lesions of the Talus in Female Patients

Category:Ankle; Arthroscopy; SportsIntroduction/Purpose:Microfracture (Mfx) is typically indicated for patients who have symptomatic osteochondral lesions of the talus (OLT) which are smaller in size. However, there is scant literature focusing exclusively on female patients, who may require specific consideration as compared to male counterparts. The purpose of this study was to evaluate the outcomes of Mfx in the treatment of OLT in the females population.Methods:A retrospective analysis comparing patients treated with Mfx for OLT was performed, to include all patients treated between 2007 and 2015. Clinical outcomes were evaluated using the Foot and Ankle Outcome Scores (FAOS) and Short-Form 12 (SF-12). Magnetic resonance imaging (MRI) at final follow-up was evaluated with the modified magnetic resonance observation of cartilage repair tissue (MOCART) score.Results:Thirty-one females were included. The mean patient age was 39.6 +- 17.2 years with mean follow-up of 48.4 +- 24.8 months. The mean preoperative and postoperative FAOS score was 53.3 +- 22.9 and 73.2 +- 18.2 (p < 0.001), and the mean preoperative and postoperative SF-12 score was 40.6 +- 11.1 and 56 +- 15.1 (p < 0.001). The final MOCART score was 59.3 +-24.5. Overall, 6 (19.4%) patients required a further surgery, 4 patients (12.9%) were considered failures, 2 (6.5%) patients required a distraction arthroplasty and 2 patients (6.5%) required a repeat bone marrow stimulation.Conclusion:The outcomes following Mfx for OLT in females were good at mid term follow up. However, the final MOCART scores were poor, indicating poor cartilage repair tissue and a poor harbinger for long term outcomes.

A Comparison of Functional and Radiographic Outcomes following Microfracture with Extracellular Matrix Augmentation versus Osteochondral Autograft Transplantation for the Treatment of Medium-Sized Osteochondral Lesions of the Talus

Objectives:The aim of this study is to directly compare clinical outcomes following the treatment of medium-sized osteochondral lesions of the talus (OLTs) using a microfracture technique augmented with Extracellular Matrix and Bone Marrow Aspirate Concentrate (MFX) versus OAT to determine which treatment is superior for medium-sized lesions.Methods:Patients treated for an OLT between 2015 and 2018 by a single surgeon, fellowship-trained in sports medicine and foot and ankle, were screened for this study. Retrospective chart review determined treatment, lesion size, lesion location, concurrent injuries, and demographic information. Patients at a minimum of 12 months follow-up, treated with MFX or OAT, and lesions sized 80-165mm2 were eligible for inclusion. All surgical repairs were augmented with an adjuvant mixture of micronized cartilage extracellular matrix and bone marrow aspirate concentrate (ECM-BMAC). Patient-reported functional outcomes were collected through our institution’s prospective Registry database. Patients treated prior to March 2016 were administered preoperative Foot and Ankle Outcome Score questionnaires. Those treated after this date were administered preoperative Physical Function, Pain Interference, Global Physical Health, Global Mental Health, Depression, and Pain Intensity Patient-Reported Outcome Information System (PROMIS) domains. Both FAOS and PROMIS were administered postoperatively. Postoperative MRIs were assessed using a modified magnetic resonance observation of cartilage repair tissue (MOCART) score. Student’s paired and two-group t-tests were used to evaluate for statistically significant pre-to-postoperative change and differences between procedure groups (p less than 0.05).Results:Twenty-seven patients treated with MFX (age range, 14-58) and twenty-three patients treated using OAT (age range, 22-64) were identified. All OAT patients received a single-plug transplantation. The final average lesion size ± standard deviation (SD) for patients treated with MFX was 115.44mm2± 22.51 (range, 156-80mm2) and 121.78mm2± 23.98 (range, 165-80mm2) for those treated using OAT (p=0.34). On average, functional outcome scores improved pre-to-postoperatively across all scales within both groups. Statistically significant improvements were detected in PROMIS Physical Function (Δ=8.32, p=0.01), Pain Interference (Δ=-7.15, p=0.02), Global Physical Health (Δ=5.87, p=0.03), and Pain Intensity (Δ=-7.06, p=0.05) domains for the MFX cohort. For the OAT patient group, significant pre-to-postoperative change was seen in the FAOS subcategories of Pain (Δ=28.70, p=0.03), Sports Activities (Δ=43.12, p<0.01), and Quality of Life (Δ=43.75, p=0.01); overall FAOS score (Δ=29.93, p=0.01); and PROMIS Physical Function (Δ=13.66, p=0.01), Pain Interference (Δ=-14.58, p<0.01), Global Physical Health (Δ=12.2, p=0.01), Depression (Δ=-4.13, p=0.02), and Pain Intensity (Δ=-16.56, p=0.02) domains. On average, with the exception of the postoperative Sports Activities subscale, postoperative FAOS and pre-to-postoperative change in FAOS were higher and greater in the OAT patient group. Similarly, on average, the OAT group had better PROMIS t-scores indicating higher function or less pain and greater pre-to-postoperative change in each PROMIS domain. The OAT cohort’s average postoperative Pain Interference t-score (± SD) of 43.09 (± 5.81) and Depression t-score of 40.06 (± 6.84) were significantly lower than their respective counterparts in the MFX cohort: 50.08 (± 9.47) for Pain Interference and 48.09 (± 7.86) in Depression. (Table 1) Finally, the mean overall MOCART score was 55.67 (± 24.11) within the MFX cohort, average follow-up 15.29 months, and 71 (± 15.60) within the OAT cohort average follow-up 15.8 months. This difference was also statistically significant (p=0.04).Conclusion:The OAT group had a higher MOCART score indicating the use of a single osteochondral autograft plug may result in better structural repair than microfracture abrasion chondroplasty augmented with a mixture of adjuvant ECM-BMAC. In addition, higher average FAOS scores, better average PROMIS t-scores, and greater pre-to-postoperative change in the OAT patient group indicate functional results may be better in this group as well. Specifically, significantly lower Pain Interference and Depression domains and significantly higher Global Mental Health scores indicate patients treated using OAT experience less pain and better psychological benefits postoperatively compared to patients treated using MFX. These results suggest filling the lesion with transplanted autograft bone and native, hyaline cartilage may perform better than and the biomechanically inferior fibrocartilage produced following microfracture even when augmented with adjuvant therapy. OAT may result in better overall clinical outcomes, specifically in a population of patients with medium sized lesions (range, 80 mm2 -165 mm2).

Comparison of Bone Marrow Aspirate Concentrate and Allogenic Human Umbilical Cord Blood Derived Mesenchymal Stem Cell Implantation on Chondral Defect of Knee: Assessment of Clinical and Magnetic Resonance Imaging Outcomes at 2-Year Follow-Up

Biological repair of cartilage lesions remains a significant clinical challenge. A wide variety of methods involving mesenchymal stem cells (MSCs) have been introduced. Because of the limitation of the results, most of the treatment methods have not yet been approved by the Food and Drug Administration (FDA). However, bone marrow aspirate concentrate (BMAC) and human umbilical cord blood derived mesenchymal stem cells (hUCB-MSCs) implantation were approved by Korea FDA. The aim of this study was to evaluate clinical and magnetic resonance imaging (MRI) outcomes after two different types of MSCs implantation in knee osteoarthritis. Fifty-two patients (52 knees) who underwent cartilage repair surgery using the BMAC (25 knees) and hUCB-MSCs (27 knees) were retrospectively evaluated for 2 years after surgery. Clinical outcomes were evaluated according to the score of visual analogue scale (VAS), the International Knee Documentation Committee (IKDC) subjective, and the Knee Injury and Osteoarthritis Outcome Score (KOOS). Cartilage repair was assessed according to the modified Magnetic Resonance Observation of Cartilage Repair Tissue (M-MOCART) score and the International Cartilage Repair Society (ICRS) cartilage repair scoring system. At 2-year follow-up, clinical outcomes including VAS, IKDC, and KOOS significantly improved (P < 0.05) in both groups; however, there were no differences between two groups. There was no significant difference in M-MOCART [1-year (P = 0.261), 2-year (P = 0.351)] and ICRS repair score (P = 0.655) between two groups. Both groups showed satisfactory clinical and MRI outcomes. Implantation of MSCs from BMAC or hUCB-MSCs is safe and effective for repairing cartilage lesion. However, large cases and a well-controlled prospective design with long-term follow-up studies are needed.

Treatment of Large Osteochondral Lesions with Adjuvant Micronized Allogenic Cartilage Extracellular Matrix and Bone Marrow Aspirate Concentrate Reduces Rate of Postoperative Adjacent Cysts

Category:Ankle, Arthroscopy, SportsIntroduction/Purpose:Previous studies have established a correlation between the size of osteochondral lesions (OCLs) and the relative success of outcomes following surgical repair. Poorer results have been associated with traditional microfracture for lesions larger than 150 mm2. In these cases, osteochondral autograft transplantation (OAT) has shown to be a generally effective treatment despite associated disadvantages that include donor site morbidity, need to perform an osteotomy, and formation of postoperative adjacent cysts. The purpose of this study was to assess the effect of using a micronized allogenic cartilage extracellular matrix (ECM) mixed with bone marrow aspirate concentrate (BMAC) as an adjuvant therapy to augment and potentially improve the quality of repair achieved using OAT to treat larger lesions.Methods:Seventy cases (average age 38) treated by a fellowship-trained foot and ankle surgeon for an osteochondral lesion using OAT between December 2009 and June 2018 were identified. Retrospective chart review determined that 40 patients received adjuvant micronized ECM mixed with BMAC (average follow-up 25.6 months) while 30 had only BMAC injected into the joint or lesion (average follow-up 81.9 months). Preoperative lesion size, lesion location, and any concurrent injuries were also recorded. Foot and Ankle Outcome Scores (FAOS) were completed pre- and postoperatively through the prospective registry database at the authors’ institution. Structural integrity of reparative cartilage was assessed on available postoperative MRIs using a modified magnetic resonance observation of cartilage repair tissue (MOCART) score. In addition, the presence of postoperative edema and adjacent cystic changes were recorded. Linear regression analysis was performed to analyze differences in MOCART scores, FAOS, postoperative rate of adjacent cysts, and postoperative rate of edema.Results:Twenty-four postoperative MRIs, average follow-up 14.04 (SD 9.52) months, were available for the ECM+BMAC adjuvant therapy group. Twenty-one MRIs, average follow-up 35.06 months (SD 28.41), were available for the non-adjuvant therapy group. 20.8% of the ECM+BMAC group exhibited signs of postoperative cysts compared to 60.9% of patients in the non- adjuvant therapy OAT group (p<0.01). Similarly, 66.7% of ECM+BMAC patients had edema postoperatively versus 90.5% of patients in the non-adjuvant therapy cohort (p = 0.05). MOCART scores were similar in each group: 68.33 (SD=15.99) in the OAT and ECM+BMAC group and 65.95 (SD=22.50) in the non-adjuvant therapy group. Finally, the post-operative FAOS Symptoms scores were significantly greater in patients receiving adjuvant therapy (p=0.03).Conclusion:Using micronized allogenic cartilage ECM mixed with BMAC to augment traditional OAT helps reduce the rate of postoperative adjacent cysts and edema. In addition, greater increases in patient reported functional outcome scores indicate this adjuvant therapy may help improve clinical outcomes. Application of this adjuvant therapy could be especially useful in allowing easier treatment of non-circular lesions of amorphous shapes. By improving integration of OAT into surrounding bone and reducing the rate of postoperative cysts, adjuvant therapy may improve long-term outcomes for large OCLs.

Outcomes Following Treatment of Talar Osteochondral Lesions with a Mixture of Particulate Allogenic Cartilage Extracellular Matrix and Bone Marrow Aspirate Concentrate: A Case Control Series

Objectives: There continues to be a general lack of consensus regarding the optimal treatment for osteochondral lesions of the talus (OLTs). Microfracture, once considered the gold-standard, has been associated with poor long-term results due to the formation of biomechanically inferior reparative fibrocartilage as opposed to hyaline cartilage. Particulate allogenic cartilage extracellular matrix offers a promising solution as an adjuvant therapy; however, there is currently minimal objective evidence to indicate its effect on post-operative outcomes. This study compares post-operative radiographic and clinical outcomes following treatment of OLTs with an adjuvant mixture of particulate cartilage extracellular matrix and bone marrow aspirate concentrate (BMAC) against outcomes following microfracture with or without BMAC. Methods: Patients diagnosed with an OLT and treated by a fellowship-trained orthopedic surgeon were screened for inclusion. Those whose surgical intervention included microfracture, microfracture augmented with BMAC alone, or microfracture augmented with a mixture of BMAC and particulate allogenic cartilage extracellular matrix were eligible for this case-control study. Lesion size, location, and concurrent injuries were recorded following retrospective chart review. Foot and Ankle Outcome Scores (FAOS) were collected pre-operatively and at a minimum of 1 year post-operatively through the prospective Registry database at the authors’ institution. Modified magnetic resonance observation of cartilage repair tissue (MOCART) scoring evaluated the structural quality of repaired lesions on MRIs collected greater than six months post-operatively. Differences in post-operative MOCART and FAOS scores were evaluated using ANOVA tests. Results: Forty-seven patients treated with microfracture alone, forty-seven treated with microfracture augmented by BMAC, and fifty-two treated with an adjuvant mixture of particulate allogenic cartilage extracellular matrix and BMAC were identified at a minimum of 2 years post-operatively. Average MOCART scores were significantly different between treatment groups (p=0.03). At an average follow-up of 10.86 months, patients who received adjunctive therapy had an average MOCART score of 73.5 ± 11.13. At an average follow-up of 23.06 months and 43.6 months respectively, patients treated with microfracture and BMAC and microfracture alone scored 63.33 ± 22.23 and 55 ± 23.92. There was no detectable statistically significant difference in post-operative FAOS scores between treatment groups. With respect to revision surgery, two patients (3.84%) originally treated with adjuvant particulate cartilage extracellular matrix and BMAC have required a secondary surgery as opposed to nine patients (9.57%) treated with microfracture and BMAC or microfracture alone. Conclusion: Increases in post-operative FAOS scores compared to pre-operative FAOS scores for all treatment groups indicate patients’ function and symptoms improved regardless of intervention received. However, significantly higher MOCART scores for the particulate cartilage extracellular matrix and BMAC treatment group suggest adjuvant treatment may help achieve better post-operative fill and structural integrity. Thus, long-term outcomes and the quality of reparative tissues may be improved through use of adjuvant treatments such as particulate allogenic cartilage extracellular matrix and BMAC.

Arthroscopic gel-type autologous chondrocyte implantation presents histologic evidence of regenerating hyaline-like cartilage in the knee with articular cartilage defect.

To investigate the clinical, radiological, and histological results of arthroscopic gel-type autologous chondrocyte implantation (GACI) in treating chondral defects of the knee. This study prospectively examined five males and five females with a mean age of 40.3 ± 10.3years who underwent arthroscopic GACI between March 2012 and February 2013. The gel comprised a mixture of 1ml of fibrinogen plus 0.1-0.2ml of thrombin. The mean size of chondral defect was 2.9 ± 1.2cm2 (range 1.2-5.4cm2). International knee documentation committee (IKDC) subjective score, knee injury and osteoarthritis outcome score (KOOS), knee society score, and visual analog scale (VAS) for pain were assessed preoperatively and during regular follow-up examinations performed for up to 5years postoperatively. Serial magnetic resonance imaging was performed for up to 2years after the surgery to observe healing, using the modified magnetic resonance observation of cartilage repair tissue (MOCART) score. In eight patients, second-look arthroscopy was performed at 1year after the implantation to assess the status of treated cartilage, and a portion of regenerated cartilage was harvested for histologic evaluation. The mean VAS score (p = 0.045), IKDC subjective score (p = 0.041), KOOS pain (p = 0.025), KOOS activities of daily living (p = 0.048), and KOOS quality of life (p = 0.029) showed significant improvement at 5years after the surgery. The modified MOCART evaluation showed that the scores were 59.5 ± 29.4 and 85.0 ± 8.0 at 12weeks and 2years after the operation, respectively. Histologic examination demonstrated a mean regenerated cartilage thickness of 3.5 ± 0.8mm and a mean Oswestry score of 8.2 ± 1.8. Immunohistochemistry analysis showed that the expression of collagen type II was more evident and more evenly distributed than collagen type I in regenerated cartilage. There was a significant correlation between Oswestry score and change in VAS scale from postoperative 2-5years. Arthroscopic GACI produces satisfactory clinical and radiologic outcomes, and histologic evaluation confirms sufficient regeneration of hyaline-like cartilage that correlates with improved symptoms. Therefore, it is an acceptable, minimally invasive, and technically simple option for the restoration of cartilage defects of the knee. IV.

Concentrated Bone Marrow Aspirate May Decrease Postoperative Cyst Occurrence Rate in Autologous Osteochondral Transplantation for Osteochondral Lesions of the Talus

To clarify if the use of concentrated bone marrow aspirate (CBMA) would affect both postoperative functional outcomes and magnetic resonance imaging (MRI) outcomes compared with those of autologous osteochondral transplantation (AOT) alone; in addition, to assess the efficacy of CBMA reducing the presence of postoperative cyst formation following AOT in the treatment of osteochondral lesions of the talus. Fifty-four (92%) of 59 eligible patients who underwent AOT between 2004 and 2008 were retrospectively assessed at a minimum of 5-year follow-up. Twenty-eight patients were treated with AOT and CBMA (AOT/CBMA group) and 26 patients were treated with AOT alone (AOT-alone group). Clinical outcomes were evaluated using the Foot and Ankle Outcome Scores (FAOS) and Short-Form 12 (SF-12) preoperatively and at final follow-up. Postoperative MRI was evaluated with the modified Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) scoring system. Cyst formation was also evaluated on postoperative MRI. The mean FAOS and SF-12 significantly improved in both the AOT/CBMA and AOT-alone groups, but there were no statistical differences between groups in FAOS (80.5 vs 75.5, P= .225) and SF-12 (71.1 vs 69.6, P= .756) at final follow-up. Additionally, there was no difference in the mean MOCART score (80.4 vs 84.3, P= .484); however, AOT/CBMA did result in a statistically lower rate of cyst formation (46.4% vs 76.9%, P= .022). No significant differences were found in the mean postoperative FAOS and SF-12 between patients with and without cysts postoperatively. CBMA reduced postoperative cyst occurrence rate in patients treated with AOT; however, CBMA did not result in significant differences in medium term functional outcomes and MOCART score in patients who underwent AOT. Level III, retrospective comparative trial.

The Effect of Containment Type on Clinical Outcome in Osteochondral Lesions of the Talus Treated with Autologous Osteochondral Transplantation

Category: Ankle Introduction/Purpose: Operative management for osteochondral lesions of the talus (OLT) can be broadly divided into reparative techniques, including bone marrow stimulation (BMS), and replacement techniques, including autologous osteochondral transplantation (AOT). Predictors of outcome of BMS have been established as lesion size, containment of the lesion, and previous surgery. Predictors of outcome of AOT or allograft transplantation have been established as body mass index and the requirement for greater than 2 grafts. However, containment of the lesions has not been assessed as a predictor of outcome in patients undergoing AOT to date. Therefore, the purpose of the current study is to clarify the effect of the containment of OLT on clinical and radiological outcomes in patients who underwent AOT procedure for the treatment of OLT. Methods: A retrospective cohort study comparing patients with contained type and uncontained type OLT was undertaken, to include all patients who underwent AOT procedure for the treatment of OLT between 2006 and 2014. Analyses were performed by grouping the patients according to the containment type, location, and both the type of containment and location. Clinical outcomes were evaluated using the Foot and Ankle Outcome Scores (FAOS) and Short-Form 12 (SF-12) preoperatively and at the final follow-up. Magnetic resonance imaging (MRI) at 2 years follow-up was evaluated with modified magnetic resonance observation of cartilage repair tissue (MOCART) score. Comparisons between groups were made with the Man-Whitney U test for continuous variables and the?2 or Fisher exact test for categorical variables. Multivariate regression models were used to evaluate factors affecting postoperative FAOS, SF-12 and MOCART scores. A value of p &lt; 0.05 was considered statistically significant. Results: Ninety-four patients were included, with 31 with a contained type OLT and 63 with an uncontained type OLT. The median follow-up time were 45 months in contained type and 52 months in uncontained type. The mean FAOS and SF-12 improved significantly after surgery in both contained and uncontained lesions (p&lt;0.001). The mean postoperative FAOS in contained type was higher than uncontained type (89.5 vs 80.2, p=0.009), but no significant differences were found between uncontained and contained type in postoperative SF-12 and MOCART score. The multivariate regression models showed that patients with contained type OLT had approximately 10 points better scores in FAOS compared to uncontained type (p=0.006) (Table 1). Patients who had previous microfracture performed worse postoperative FAOS than those who did not (p =0.004). Conclusion: Patients with contained type OLT experienced better clinical outcomes than those with uncontained type OLT following AOT procedure for the treatment of OLT. However, the AOT procedure still provided good clinical and MRI outcomes in both contained type and uncontained type OLT at the mid-term follow-up.

Concentrated Bone Marrow Aspirate May Decrease Postoperative Cystic Occurrence Rate in Autologous Osteochondral Transplantation for Osteochondral Lesions of the Talus

Category: Ankle Introduction/Purpose: Autologous Osteochondral Transplantation (AOT) provides excellent clinical outcomes for osteochondral lesions of the talus (OLT), however, there is concern regarding the presence of cysts at the bone interface. The presence of subchondral bone cysts has been previously shown to be correlated with graft failure, and high rates of postoperative subchondral cysts formation of up to 75% at short-term follow-up have been reported. Concentrated bone marrow aspirate (CBMA) may have the potential to improve integration between the graft and native articular cartilage and bone, and may reduce interface cyst production. The purpose of this study was to clarify the efficacy of CBMA in AOT as compared with AOT alone, regarding the presence of postoperative cyst formation, postoperative functional outcomes and magnetic resonance imaging (MRI) outcomes. Methods: Patients who underwent AOT between 2004 and 2008 were retrospectively assessed at a minimum of 5-year follow-up. Twenty-eight patients were treated with AOT and CBMA (AOT/CBMA group) and 26 patients were treated with AOT alone (AOT alone group). Clinical outcomes were evaluated using the Foot and Ankle Outcome Scores (FAOS) and Short-Form 12 (SF-12) preoperatively and at final follow-up. Postoperative MRI was evaluated with the modified Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) scoring system. Cystic formation was evaluated on postoperative MRI, and cyst diameter and cyst location were assessed. Results: Fifty-four of 59 eligible patients were included. Of those, 28 patients were treated with AOT and CBMA and 26 patients were treated with AOT alone. The mean FAOS and SF-12 significantly improved in both AOT/CBMA and AOT alone groups, but there were no statistical differences between groups in FAOS (80.6 vs 75.4, p = 0.217) and SF-12 (71.1 vs 69.2, p = 0.694) at final follow-up. Additionally, there was no difference in the mean MOCART Score (80.4 vs 84.3, p = 0.484). However, AOT/CBMA did result in a statistically lower rate of cyst formation (46.4% vs 76.9%, p = 0.022) (Table 1). No statistical differences were found between groups in cyst location and cyst diameter (table 1). Conclusion: CBMA reduced the postoperative cystic occurrence rate in patients treated with AOT, although CBMA did not result in significant differences in functional outcomes nor MOCART score in patients who underwent AOT.

Effect of the Containment Type on Clinical Outcomes in Osteochondral Lesions of the Talus Treated With Autologous Osteochondral Transplantation

Background: Uncontained-type osteochondral lesions of the talus (OLTs) have been shown to have inferior clinical outcomes after treatment with bone marrow stimulation. While autologous osteochondral transplantation (AOT) is indicated for larger lesions, no study has reported on the prognostic significance of the containment of OLTs treated with the AOT procedure. Purpose: To clarify the effect of the containment of OLTs on clinical and radiological outcomes in patients who underwent AOT for OLTs. Study Design: Case control study; Level of evidence, 3. Methods: A retrospective cohort study comparing patients with contained-type and uncontained-type OLTs was undertaken to include all patients who underwent AOT for the treatment of OLTs between 2006 and 2014. Analyses were performed by grouping the patients according to the containment type. Clinical outcomes were evaluated using the Foot and Ankle Outcome Score (FAOS) and the 12-Item Short Form Health Survey (SF-12) preoperatively and at final follow-up. Magnetic resonance imaging (MRI) at 2 years’ follow-up was evaluated with the modified magnetic resonance observation of cartilage repair tissue (MOCART) score. Multivariate regression models were used to evaluate factors affecting postoperative FAOS, SF-12, and MOCART scores. Results: Ninety-four patients were included: 31 patients with a contained-type OLT and 63 patients with an uncontained-type OLT. The median patient age was 34 years (interquartile range [IQR], 28-48 years) in the contained-type group and 36 years (IQR, 27-46 years) in the uncontained-type group. The median follow-up time was 45 months (IQR, 38-63 months) in the contained-type group and 52 months (IQR, 40-66 months) in the uncontained-type group. The median FAOS and SF-12 scores improved significantly after surgery in both contained-type and uncontained-type lesions (P < .001). The median postoperative FAOS score of patients with contained-type OLTs was higher than that of patients with uncontained-type OLTs (91.7 vs 85.0, respectively; P = .009), but no significant differences were found between the contained-type and uncontained-type groups for postoperative SF-12 and MOCART scores. The multivariate regression models showed that patients with contained-type OLTs had an approximately 10-point better score on the FAOS compared with patients with uncontained-type OLTs (P = .006). There was a nonsignificant trend for the rate of cystic occurrence in uncontained-type OLTs to be higher than that of contained-type OLTs (55.6% vs 38.7%, respectively; P = .125). Conclusion: Patients with contained-type OLTs experienced better clinical outcomes than those with uncontained-type OLTs after AOT for the treatment of OLTs. However, the AOT procedure still provided good clinical and MRI outcomes in both contained-type and uncontained-type OLTs at midterm follow-up.

Graft Maturation of Autologous Chondrocyte Implantation

Background: Autologous chondrocyte implantation (ACI) using tissue-engineered cartilage is a successful therapy for full-thickness cartilage lesions in the knee joint. However, in vivo graft maturation is still unclear. Purpose: The aim of this prospective study was to analyze graft maturation after ACI in the knee using objective T2 mapping in correlation with the clinical outcomes within a 3-year postoperative course. Study Design: Case series; Level of evidence, 4. Methods: A total of 13 patients with isolated cartilage defects of the knee were treated with Novocart 3D, a matrix-based ACI procedure in the knee joint. The patients had complete data from International Knee Documentation Committee (IKDC) scores and MRI examinations for 6 to 36 months postoperatively. All cartilage defects were arthroscopically classified as Outerbridge grades III and IV. The mean area of the cartilage defect was 5.6 cm2. Postoperative clinical and MRI examinations were conducted at 6, 12, 24, and 36 months after surgery. The modified magnetic resonance observation of cartilage repair tissue (MOCART) score was used to evaluate the quality and integration of the Novocart 3D implants on MRI. The T2 relaxation time values of the ACI graft and healthy native cartilage areas were determined to assess graft maturation using T2 mapping. Results: The T2 relaxation times of the ACI graft showed significant improvement, with decreasing values from 41.6 milliseconds at 6-month follow-up to 32.4 and 30.9 milliseconds after 24 and 36 months, respectively. These values were similar to the T2 relaxation times of the native surrounding cartilage. There was no correlation between the clinical outcomes (IKDC score) and T2 relaxation time values. Conclusion: The T2 relaxation time in the repaired tissue showed similar values compared with normal hyaline cartilage. Graft maturation after ACI in the knee joint needs at least 1 year, with ongoing adjustment of the T2 relaxation time values compared with native surrounding cartilage. A correlation between increasing ACI graft maturation and clinical outcomes (IKDC score) could not be found with the data available.

Double-Plug Autologous Osteochondral Transplantation Shows Equal Functional Outcomes Compared With Single-Plug Procedures in Lesions of the Talar Dome

Background: Autologous osteochondral transplantation (AOT) is used for large (>100-150 mm2) or cystic osteochondral lesions (OCLs) of the talus. Larger lesions may require using more than 1 graft to fill the defect. While patients with larger OCLs treated with microfracture exhibit inferior clinical outcomes, there is little evidence regarding the effect of lesion size and number of grafts required on clinical and radiological outcomes after AOT. Hypothesis: Larger OCLs of the talar dome treated by double-plug AOT (dp-AOT) have inferior clinical and radiological MRI outcomes compared with smaller OCLs requiring single-plug AOT (sp-AOT). Study Design: Cohort study; Level of evidence, 3. Methods: Fourteen consecutive patients with a large OCL (mean, 208 ± 54 mm2) treated using dp-AOT with a minimum 5-year follow-up were matched by age and sex to a control cohort of 28 patients who underwent sp-AOT for a smaller OCL (mean, 74 ± 26 mm2) over the same period. Functional outcomes were assessed both pre- and postoperatively using the Foot and Ankle Outcome Score (FAOS) and Short Form–12 (SF-12) general health questionnaire. Mean follow-up was 85 months (range, 65-118 months). Latest postoperative MRI was evaluated with modified magnetic resonance observation of cartilage repair tissue (MOCART) score. Results: There was no significant difference between groups demographically (P > .05). All patients with dp-AOT and sp-AOT showed a significant pre- to postoperative increase in FAOS and SF-12 scores (P < .001). When comparing preoperative scores for both groups, there was no statistical significance between sp-AOT and dp-AOT scores (FAOS, P = .719; SF-12, P = .947). There was no significant difference in functional scores between the 2 groups postoperatively for both FAOS (P = .883) and SF-12 (P = .246). Mean MOCART scores did not exhibit any statistically significant difference between groups (P = .475). Two patients complained of knee donor site stiffness (4.8%), which later resolved. Conclusion: Patients with large OCLs treated using a dp-AOT procedure did not show inferior clinical or radiological outcomes compared with those treated with sp-AOT at a minimum 5-year follow-up. The dp-AOT procedure is as effective as sp-AOT in treating larger OCLs of the talar dome in the intermediate term, with similar high postoperative clinical and radiological outcomes.

Implantation of tissue-engineered cartilage-like tissue for the treatment for full-thickness cartilage defects of the knee

The purposes of this study were to evaluate early- to midterm clinical results after implantation of tissue-engineered cartilage-like tissue for the treatment for full-thickness cartilage defects of the knee and to identify the factors affecting the final clinical results. Tissue-engineered cartilage-like tissue was prepared by culturing autologous chondrocytes in atelocollagen gel for 3-4 weeks. A total of 73 knees of 72 patients with full-thickness cartilage defects were implanted with this tissue-engineered cartilage-like tissue. The follow-up of these patients for >5 years (range 5-11 years, median 8.0 years) is reported. The patients were evaluated clinically using a rating scale, as well as arthroscopically, biomechanically, and histologically. A modified magnetic resonance observation of cartilage repair tissue (MOCART) system was used to quantify the magnetic resonance imaging (MRI) findings of the lesions. The patient or defect factors influencing the final clinical outcomes were also investigated. Clinical rating improved significantly after implantation of tissue-engineered cartilage-like tissue. Arthroscopic findings at 2 years after implantation were graded as normal or nearly normal according to the International Cartilage Repair Society (ICRS) scale in 64 of 73 knees (87.7%). Biomechanically, stiffness of the graft almost equalled the surrounding normal cartilage (87.9-102.5%) at 2 years after implantation. Histologically, overall assessment of the repaired tissue by ICRS Visual Assessment Scale II was 70.4 ± 20.8. The average MOCART score was 13.5 ± 11.3 (0-45) preoperatively, 66.6 ± 16.8 (10-90) at 1 year after implantation, 70.4 ± 16.1 (15-90) at 2 years after implantation, and 72.5 ± 17.4 (15-95) at the final follow-up, indicating that MRI results were maintained. Among the factors investigated, only arthroscopic grade of the repaired lesion at 2 years after implantation was significantly correlated with the final clinical scores. Implantation of tissue-engineered cartilage-like tissue for the cartilage defects of the knee was effective in short- to midterm post-operatively. This procedure can be proposed as one option for repairing full-thickness cartilage defect of the knee. IV.