Osteochondral Transplantation Research Articles

Second-Look Arthroscopy Shows Inferior Cartilage after Bone Marrow Stimulation Compared with Other Operative Techniques for Osteochondral Lesions of the Talus: A Systematic Review and Meta-Analysis.

To compare cartilage quality after different surgical interventions for osteochondral lesions of the talus (OLT), evaluated by second-look arthroscopy. Secondary aims were to report concomitant diagnoses, and to correlate cartilage quality with clinical and radiological outcomes. This review hypothesizes that the cartilage repair after bone marrow stimulation (BMS) is inferior to the other available treatment options. PROSPERO ID: CRD42022311489. Studies were retrieved through PubMed, EMBASE (Ovid), and Cochrane Library. Studies were included if they reported cartilage quality after second-look investigation after surgical treatment of OLT. The primary outcome measure was the cartilage quality success and failure rates (%) per surgical intervention group. Correlations between the cartilage quality and clinical or radiological outcomes were calculated. Twenty-nine studies were included, comprising 586 ankles that had undergone second-look arthroscopy on average 16 months after initial surgery. The success rate for BMS was 57% (95% confidence interval [CI] = 48%-65%), for fixation (FIX) 86% (95% CI = 70%-94%), for osteo(chondral) transplantation (OCT) 91% (95% CI = 80%-96%), for cartilage implementation techniques (CITs) 80% (95% CI = 69%-88%), and for retrograde drilling 100% (95% CI = 66%-100%). The success rate of BMS was significantly lower than FIX, OCT, and CIT (P < 0.01). There were no significant differences between other treatment groups. A moderate positive significant correlation between the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score and the International Cartilage Repair Society score (ICRS) was found (ρ = 0.51, P < 0.001). Successful restoration of cartilage quality was found in the majority of surgically treated OLTs. However, BMS yields inferior cartilage quality compared with FIX, OCT, and CIT. Study Design. Systematic review and meta-analysis. Level of evidence. Level IV, systematic review and meta-analysis.

Outcomes and Return to Sport After Knee Osteochondral Allograft Transplant in Professional Athletes.

Limited data are available on the outcomes and return-to-sport rates after osteochondral allograft transplant in professional athletes. To evaluate the experience of a single senior surgeon in treating professional athletes with osteochondral allograft transplant, including analyzing clinical outcomes and return to sport. Case series; Level of evidence, 4. The authors performed a retrospective review of professional athletes treated with primary osteochondral allograft to the knee between January 1, 2001, and January 1, 2021, by a single surgeon. Athletes were required to play at the professional level in their sport and have a minimum of 2 years of follow-up. Return-to-sport rates and timing were evaluated. Patient-reported outcomes were assessed preoperatively and at final follow-up. Reoperations and failures were also tabulated. The study included 15 professional athletes who represented a variety of sports, with follow-up at a mean of 4.91 ± 2.2 years (range, 2.0-9.4 years). The majority (8 athletes; 53%) had undergone prior surgeries to the operative knee. Eleven (73%) returned to sport at a mean of 1.22 ± 0.4 years (range, 0.75-2 years), and of the 8 undergoing isolated osteochondral allograft, 7 (87.5%) returned at 1.28 ± 0.3 years. Ten athletes (66.7% of total; 90.9% of those who returned) returned to sport at the same level or higher compared with before surgery. Significant improvements were seen in each assessed patient-reported outcome score at final follow-up. Two of the 3 (66.7%) patients who underwent concomitant meniscal allograft transplant were able to return to sport at the same level or higher than presurgery. Three (20%) underwent second-look arthroscopy, 1 (6.7%) of whom underwent cartilage debridement of the osteochondral allograft. Osteochondral allograft transplant in professional athletes can result in a high rate of return to play at a similar or higher level as presurgery, even when performed with concomitant procedures such as meniscal allograft transplant. High-level athletes should expect significant postoperative improvement in clinical outcomes.

Increased kinesiophobia leads to lower return to sport rate and clinical outcomes following osteochondral allograft transplantation of the knee.

The purpose of this study is to describe the postoperative psychological state of patients following osteochondral allograft (OCA) transplantation in the knee and to determine whether patient-perceived kinesiophobia is associated with the rate of return to sport (RTS). A retrospective review of the electronic medical record at a single institution was conducted for all patients that underwent OCA transplantation from January 2010 to 2020. Patient-reported outcomes including the visual analog scale (VAS), knee injury and osteoarthritis outcome score (KOOS)and the Tampa scale of kinesiophobia-11 (TSK-11) were collected. Patients were surveyed regarding their postoperative RTS status. A total of 38 patients (52.6% female) were included in our analysis. Overall, 24 patients (63.2%) returned to sport with 12 (50%) of these patients returning at a lower level of play. When comparing patients that return to sport to those that did not, patients that return had significantly superior KOOS pain (p = 0.019) and KOOS QOL (p = 0.011). Measures of kinesiophobia (TSK-11) were significantly higher among patients that did not return to sport (p = 0.014), while satisfaction (n.s.) and pain intensity (n.s.) were comparable between groups. Logistic regression models controlling for demographic factors, VAS pain scoresand lesion size showed that for every one-point increase in TSK-11 kinesiophobia score, patients were 1.33 times more likely to return to sport at a lower level (p = 0.009). For every one-point increase in TSK-11 scores KOOS QOL decreased by 2.4 points (p < 0.001). Fear of reinjury decreases the likelihood that patients will return to their preoperative level of sport after OCA transplantation. Patients that do not return to sport report significantly greater fear of reinjury and inferior clinical outcomes, despite similar levels of satisfaction and pain compared to those that return. Level III.

Osteochondritis Dissecans Lesions of the Knee: Evidence-Based Treatment.

Osteochondritis dissecans (OCD) of the knee is a potentially disabling condition in adolescent and young adults, which is likely multifactorial in origin. In recent years, there have been notable improvements in identification and treatment. Clinical presentation varies based mostly on OCD lesion stability. Patients with stable lesions generally present with vague knee pain and altered gait while mechanical symptoms and effusion are more common with unstable lesions. Lesions most commonly occur on the lateral aspect of the medial femoral condyle in patients aged 10 to 20 years. Magnetic resonance imaging is vital to diagnose and predict clinical treatment, which is largely based on stability of the fragment. Conservative treatment of stable lesions in patients with open physis is recommended with protected weight-bearing and gradual progression of activities over the course of 3 to 6 months. Stable OCD lesions which failed a nonsurgical course can be treated with transarticular or retrograde drilling while unstable lesions usually require fixation, autologous chondrocyte implantation (ACI), osteochondral autograft transfer (OATS), or osteochondral allograft transplantation. This review highlights the most current understanding of knee OCD lesions and treatment options with the goal of optimizing outcomes in this difficult pathology.

Subchondral Bone Alignment in Osteochondral Allograft Transplants for Large Oval Defects of the Medial Femoral Condyle: Comparison of Lateral versus Medial Femoral Condyle Donors.

Supply-demand mismatch of medial femoral condyle (MFC) osteochondral allografts (OCAs) remains a rate-limiting factor in the treatment of osteochondral defects of the femoral condyle. Surface contour mapping was used to determine whether a contralateral lateral femoral condyle (LFC) versus ipsilateral MFC OCA differs in the alignment of donor:native subchondral bone for large osteochondral defects of the MFC. Thirty fresh-frozen human femoral condyles were matched by tibial width into 10 groups of 3 condyles (MFC recipient, MFC donor, and LFC donor) each for 3 cartilage surgeons (90 condyles). The recipient MFC was imaged using nano-computed tomography scan. Donor oval grafts were harvested from each matched condyle and transplanted into a 17 mm × 36 mm defect created in the recipient condyle. Following the first transplant, the recipient condyle was imaged and superimposed on the native condyle nano-CT scan. The donor plug was removed and the process repeated for the other donor. Surface height deviation and circumferential step-off height deviation were compared between native and donor subchondral bone surfaces for each transplant. There was no statistically significant difference in mean subchondral bone surface deviation (LFC = 0.87 mm, MFC = 0.76 mm, P = 0.07) nor circumferential step-off height (LFC = 0.93 mm, MFC = 0.85 mm, P = 0.09) between the LFC and MFC plugs. There were no significant differences in outcomes between surgeons. There were no significant differences in subchondral bone circumferential step-off or surface deviation between ipsilateral MFC and contralateral LFC oval-shaped OCAs for 17 mm × 36 mm defects of the MFC.

A Prospective Randomized Controlled Trial Investigating Quadriceps Versus Hamstring Tendon Autograft in Anterior Cruciate Ligament Reconstruction

Background: Numerous graft options are available when undertaking anterior cruciate ligament (ACL) reconstruction (ACLR), although a lack of high-quality evidence exists comparing quadriceps (QT) and hamstring (HT) autografts. Purpose: To investigate patient outcomes in patients undergoing HT versus QT ACLR. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: After recruitment and randomization, 112 patients (HT = 55; QT = 57) underwent ACLR. Patients were assessed pre- and postoperatively (6 weeks and 3, 6, 12, and 24 months), with a range of patient-reported outcome measures (PROMs), graft laxity (KT-1000 arthrometer; primary outcome variable), active knee flexion and extension range of motion (ROM), peak isokinetic knee extensor and flexor strength, and a 6-hop performance battery. Limb symmetry indices (LSIs) were calculated for strength and hop measures. Secondary procedures, ACL retears, and contralateral ACL tears were reported. Results: All PROMs and knee ROM measures significantly improved (P < .0001), and no other group differences (P > .05) were observed—apart from the Anterior Cruciate Ligament Return to Sport after Injury (ACL-RSI) score, which was significantly better in the HT group at 3 (P = .008), 6 (P = .010), and 12 (P = .014) months. No significant changes were observed in side-to-side laxity from 6 to 24 months (P = .105), and no group differences were observed (P = .487) at 6 (HT mean, 1.2; QT mean, 1.3), 12 (HT mean, 1.1; QT mean, 1.3), and 24 (HT mean, 1.1; QT mean, 1.2) months. While the HT group demonstrated significantly greater (P < .05) quadriceps strength LSIs at 6 and 12 months, the QT group showed significantly greater (P < .05) hamstring strength LSIs at 6, 12, and 24 months. The HT group showed significantly greater (P < .05) LSIs for the single horizontal (6 months), lateral (6 and 12 months), and medial (6 months) hop tests for distance. Up until 24 months, 1 patient (QT at 22 months) had a retear, with 2 contralateral ACL tears (QT at 19 months; HT at 23 months). Secondary procedures included 5 in the HT group (manipulation under anesthesia, notch debridement, meniscal repair, and knee arthroscopy for scar tissue) and 6 in the QT group (notch debridement, meniscal repair, knee arthroscopy for scar tissue, tibial tubercle transfer, and osteochondral autologous transplantation). Conclusion: Apart from the ACL-RSI, the 2 autograft groups compared well for PROMs, knee ROM, and laxity. However, greater hamstring strength LSIs were observed for the QT cohort, with greater quadriceps strength (and hop test) LSIs in the HT cohort. The longer-term review will continue to evaluate return to sports and later-stage reinjury between the 2 graft constructs. Registration: ACTRN12618001520224p (Australian New Zealand Clinical Trials Registry).

Responsiveness of Patient-Reported Outcome Measures After Large Knee Articular Cartilage Transplantation: A Systematic Review and Meta-analysis

Background: Cartilage transplantation is commonly used to treat large (>4 cm2) articular cartilage defects of the knee. The 2 most common transplants are osteochondral allograft transplantation and autologous chondrocyte implantation. Several patient-reported outcome measures (PROMs) have been used to determine the efficacy of treatment, but it is unknown which measures are the most effective. Purpose: To report the multiple PROMs used after large knee articular cartilage transplantation surgery and to compare the responsiveness between them. Study Design: Meta-analysis; Level of evidence, 4. Methods: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic search of the PubMed/MEDLINE and Web of Science databases was performed. A total of 181 articles met inclusion criteria. Patient and study characteristics were extracted, including pre- and postoperative means for PROMs. From the articles that met inclusion criteria for responsiveness analysis (2+ PROMs reported, 1-year minimum follow-up, reported pre- and postoperative means and standard deviations; n = 131), the authors compared the responsiveness between PROM instruments using effect size and relative efficiency (RE) if a PROM could be compared with another in ≥10 articles. Results: A total of 10,015 patients (10,093 knees; mean age, 34.8 years; mean body mass index, 26.1) were included in this study. The mean follow-up time was 58.3 months (range, 1.5-247.2 months), imaging findings were reported in 80 articles (44.2%), patient satisfaction was reported in 39 articles (21.5%), and range of motion was reported in 10 articles (5.5%). There were 58 unique PROM instruments identified, with the most used being the International Knee Documentation Committee (IKDC) score (n = 118; 65.2%), followed by Knee injury and Osteoarthritis Outcome Score (KOOS) Pain (n = 58; 32.0%), KOOS Sport and Recreation (n = 58; 32.0%), KOOS Quality of Life (n = 57; 31.5%), KOOS Activities of Daily Living (n = 57; 31.5%), and KOOS Symptoms (n = 57; 31.5%). Overall, IKDC was found to have the greatest effect size (1.68) and the best responsiveness of the other PROMs, which include KOOS Pain (RE, 1.38), KOOS Symptoms (RE, 3.06), KOOS Activities of Daily Living (RE, 1.65), KOOS Sport and Recreation (RE, 1.44), Lysholm (RE, 1.76), and Tegner (RE, 1.56). Conclusion: The IKDC is the most responsive PROM after large knee articular cartilage transplantation surgery. The IKDC score is recommended for assessing outcomes after cartilage transplantation surgery.

Follow-up Treatment after Cartilage Therapy of the Knee Joint - a Recommendation of the DGOU Clinical Tissue Regeneration Working Group.

The first follow-up treatment recommendation from the DGOU's Clinical Tissue Regeneration working group dates back to 2012. New scientific evidence and changed framework conditions made it necessary to update the follow-up treatment recommendations after cartilage therapy.As part of a multi-stage member survey, a consensus was reached which, together with the scientific evidence, provides the basis for the present follow-up treatment recommendation.The decisive criterion for follow-up treatment is still the defect localisation. A distinction is made between femorotibial and patellofemoral defects. In addition, further criteria regarding cartilage defects are now also taken into account (stable cartilage edge, location outside the main stress zone) and the different methods of cartilage therapy (e.g. osteochondral transplantation, minced cartilage) are discussed.The present updated recommendation includes different aspects of follow-up treatment, starting with early perioperative management through to sports clearance and resumption of contact sports after cartilage therapy has taken place.

Modified osteochondral autograft transplantation for steroid-induced osteonecrosis of femoral head in idiopathic thrombocytopenic purpura: a case report and literature

Osteochondral autograft transplantation (OAT) has been commonly applied in the knee and ankle while the technique has not yet been a popularity in the femoral head. In this article, we present a 28-year-old female patient, who has a history of 1-year-use of glucocorticoid in the treatment of idiopathic thrombocytopenic purpura, with steroid-induced osteonecrosis of the femoral head (SONFH). She underwent surgical hip dislocation, osteochondroplasty, OAT, and internal fixation. Her Harris Hip Score improved from 64 to 82 in 36 months to follow-up. The case is valuable considering that a single, instead of several, 1.5 cm autograft was harvested from the non-bearing part of the same femoral head. This modification dispensed with the need of surgery for harvesting autograft from knee or ankle and reduced the structural vulnerability brought by the multihole donor part of the femoral head.

Outcomes of Osteochondral Autologous Transplantation with Ipsilateral Lateral Talar Autograft for Medial Osteochondral Lesions of the Talus.

Osteochondral autologous transplantation (OAT) has been widely used in the treatment of osteochondral lesion of the talus (OLT). Previous studies have reported successful outcomes following the use of osteochondral autogenous grafts from the intercondylar notch of the knee or a non-weight-bearing region of the femoral condyle. However, donor-site morbidity of the knee joint has been observed in several cases. This study aimed to investigate the outcomes and safety of OAT with autografts from the ipsilateral lateral talar articular facet as an alternative donor site for medial OLT. Among 40 patients who underwent OAT, 29 patients were excluded. Eleven patients who underwent OAT with an osteochondral graft harvested from the ipsilateral lateral talar articular facet from 2011 to 2022 were retrospectively analyzed. The size of OLT was measured on ankle magnetic resonance imaging, including coronal length, sagittal length, depth, and area. Clinical outcomes were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale and a visual analog scale (VAS). Weight-bearing ankle radiographs were obtained postoperatively and at 1 year after surgery. The average follow-up time after surgery was 64.7 months (range, 14-137 months). The average diameter of lesions was 8.8 mm (range, 8-9.9 mm). The average size of lesions was 51.2 mm2 (range, 33.6-71.3 mm2) , and all lesions included subchondral cysts. The average depth of lesions was 7.3 mm (range, 6.2-9.1 mm). Graft sizes ranged from 8 to 10 mm in diameter (8 mm, n = 1; 10 mm, n = 10) All measured clinical outcomes improved postoperatively, including the AOFAS scores (preoperative, 55.4 ± 9.0; 1-year follow-up, 92.1 ± 7.6; p = 0.001) and VAS scores (preoperative, 5.5 ± 0.7; 1-year follow-up, 1.9 ± 0.8; p = 0.001). All weight-bearing ankle radiographs of the graft and donor sites did not reveal arthritic change in the ankle joint, lateral talar dome collapse, and graft-site delayed union or nonunion at 1 year after surgery. For a single medial OLT, harvesting autografts from the ipsilateral lateral talar articular facet without knee donor-site morbidities can be a good alternative in OAT for OLT.

Survivorship of 157 Arthroscopic Meniscal Allograft Transplants Using Bone Fixation at a Mean of 7 Years and Prognostic Factors Analysis

Background: Meniscal allograft transplantation (MAT) is an accepted and effective treatment option in the context of unsalvageable menisci, particularly in young and active patients. It has been shown to reduce pain and improve knee function in previously symptomatic patients. However, there is still limited knowledge about the long-term survival rates of allografts, the durability of clinical results, and the influence of patient-specific parameters, such as leg alignment, tibial slope, and preoperative International Cartilage Regeneration & Joint Preservation Society (ICRS) grade. Purpose: To determine (1) the long-term clinical success rate after MAT with bony fixation in a large, single-center cohort of consecutive patients, and (2) if patient-specific and procedural variables influence the clinical, anatomic, and subjective outcomes and risk of failure. Study Design: Case-control study; Level of evidence, 3. Methods: Data on 185 consecutive knees undergoing MAT in a single institution were prospectively collected and screened for inclusion in this study. The minimum follow-up time was 2 years. Radiographic variables (ICRS grade and Kellgren-Lawrence grade) were assessed preoperatively and at follow-up. Subjective patient-reported outcome measures (PROMs) (Lysholm score, Knee injury and Osteoarthritis Outcome Score [KOOS] including subscores, International Knee Documentation Committee [IKDC] score, and visual analog scale [VAS] score) were collected preoperatively and at follow-up. Clinical failure was defined as revision surgery due to graft failure or conversion to total knee arthroplasty. Anatomic failure was considered a tear covering >20% of the allograft, any peripheral tear, and unstable peripheral fixation leading to dislocation of the graft. Subjective failure was defined as Lysholm score ≤65. Preoperative tibial slope and leg alignment were assessed. Survival analyses were performed using the Kaplan-Meier estimate. Univariate and multivariate analyses were performed to determine risk factors for clinical and anatomic failure. Results: A total of 157 knees met inclusion criteria. After a mean follow-up time of 7 ± 3.5 years, 127 (80.9%) knees were free of clinical, anatomic, and subjective failure. Fourteen (8.9%) knees experienced clinical failure, 26 (16.6%) knees were identified as having experienced anatomic failure, and 13 (8.3%) patients experienced subjective failure with a reported Lysholm score of ≤65 at a mean follow-up of 7 years. Concurrent osteochondral allograft transplantation was identified as a predictor of both clinical (hazard ratio [HR], 4.55; 95% CI, 1.46-14.17; P = .009) and anatomic (HR, 3.05; 95% CI, 1.34-6.92; P = .008) failure. Cartilage damage of ICRS grade 3 or 4 of the index compartment conveyed an increased risk for clinical (HR, 3.41; 95% CI, 1.05-11.01; P = .04) and anatomic (HR, 3.04; 95% CI, 1.31-7.11; P = .01) failure. High-grade cartilage damage preoperatively (HR, 10.67; 95% CI, 1.037-109.768; P = .046), patient age >25 years (HR, 5.44; 95% CI, 0.120-246.070; P = .384), and a body mass index >30 (HR, 2.24; 95% CI, 0.748-6.705; P = .149) were associated with subjective failure. PROMs including KOOS and IKDC were significantly improved at final follow-up compared with preoperative scores across all measurements (P < .005). Conclusion: MAT showed good to excellent clinical results at a mean follow-up of 7 years. Low ICRS lesion grade was associated with a higher clinical and anatomic survival rate. Patients with concurrent OCA transplantation are at a higher risk of clinical and anatomic failure, but still report significantly improved PROMs. These results suggest that MAT has a lasting beneficial effect both in isolation and in complex cases with ≥1 concurrent procedures.

Treatment of osteochondritis dissecans

Osteochondritis dissecans (OD) is arare condition with an incidence of 30/100,000. It especially affects male patients aged 10-20years old. During the staged progression the osteochondral fragments can detach from their base. These can damage the adjacent articular cartilage, which can lead to premature osteoarthritis. Most commonly affected are the knee, ankle and elbow joints. The exact pathogenesis of OD has so far not been clearly confirmed. Several risk factors that can lead to the development of OD are discussed. These include repeated microtrauma and vascularization disorders that can lead to ischemia of the subchondral bone and to aseparation of the fragments close to the joint and therefore to the development of free joint bodies. For an adequate clarification patients should undergo athorough radiological evaluation including X‑ray imaging followed by magnetic resonance imaging (MRI) to assess the integrity of the cartilage-bone formation with determination of the OD stage. The assessment is based on criteria of the International Cartilage Repair Society (ICRS). The instability of the cartilage-bone fragment increases with higher stages. StagesI andII with stable cartilage-bone interconnection can be treated conservatively. For stagesIII andIV, i.e., instability of the OD fragment or the presence of free fragments, surgical treatment should be performed. Primarily, refixation of afree joint body should be carried out depending on the size and vitality of the fragment. In cases of unsuccessful conservative treatment or fixation, adebridement, if necessary in combination with a bone marrow stimulating procedure, can be employed corresponding to the size of the defect. For larger cartilage defects, an osteochondral graft transplantation should be considered. Overall, OD lesions in stagesI andII show agood healing tendency under conservative treatment. In cases of incipient unstable OD, refixation can also lead to good clinical and radiological results.

Treatment failures (revision or arthroplasty) after knee osteochondral allograft transplantation with minimum two-year follow-up

BackgroundKnee osteochondral allograft transplantation (OCAT) has been associated with good short- to mid-term outcomes, however, treatment failures occur more frequently than desired. This study used data from a lifelong outcomes registry to analyze knee OCAT treatment failure rates, variables associated with knee OCAT treatment failures, and outcomes after revision or arthroplasty surgery for knee OCAT treatment failures. MethodsPatient outcomes were followed after knee OCAT performed using standard preservation (SP) or Missouri Osteochondral Preservation System (MOPS®) allografts. The study population consisted of patients undergoing primary OCAT with ≥ 2-year follow-up. For comparisons, the treatment failure population was defined by patients in the study population with documented treatment failure (revision or arthroplasty) with ≥ 2-year follow-up after failure. Functional graft survival was defined as no further need for revision surgery after primary or revision OCAT. ResultsA total of 262 patients (n = 136 males; 51.9%) were analyzed. SP grafts were used for 59 cases and MOPS grafts were used for 203 cases. Treatment failure was documented in 61 cases (23.3%). MOPS grafts were 3.3 times more likely to be associated with functional graft survival. SP grafts, older patient age, higher BMI, tibiofemoral bipolar OCAT and non-adherence to the postoperative rehabilitation protocol were significantly associated with treatment failure. ConclusionsKnee OCAT resulted in functional graft survival at short- to mid-term follow-up in the majority (70–88%) of cases. In addition, revision of primary OCAT resulted in functional graft survival for at least 2 years after revision surgery in the majority (66%) of patients.Level of Evidence: 2, prospective cohort study.

Intermediate-Term Clinical Outcomes after Autologous Osteochondral Transplantation for Lateral Osteochondral Lesions of the Talus

Intermediate-Term Clinical Outcomes after Autologous Osteochondral Transplantation for Lateral Osteochondral Lesions of the Talus

Limited evidence in support of bone marrow aspirate concentrate as an additive to the bone marrow stimulation for osteochondral lesions of the talus: a systematic review and meta‐analysis

AbstractPurposeBone marrow aspirate concentrate can be used as an additive to surgical treatment of osteochondral lesions of the talus. This systematic literature review aims to study the effect of the additional use of bone marrow aspirate concentrate on top of a surgical treatment for osteochondral lesions of the talus on clinical outcomes compared to surgical treatment alone.MethodsAn online literature search was conducted using PubMed (Medline), Embase (Ovid), and the Cochrane library for all studies comparing a surgical intervention with bone marrow aspirate concentrate, with a surgical intervention without bone marrow aspirate concentrate. The methodological quality was rated according to the methodological index for non‐randomised studies checklist. The primary outcome measure were clinical outcomes. Secondary outcome measures consisted of revision rate, complication rate, radiographic outcome measures and histological analyses. Subgroups were created based on type of surgical intervention used in the studies. If multiple articles were included in a subgroup, a linear random‐effects model was used to compare the bone marrow aspirate concentrate‐augmented group with the control group.ResultsOut of 1006 studies found, eight studies with a total of 718 patients were included. The methodological quality, assessed according to the methodological index for non‐randomised studies checklist, was weak. A significantly better functional outcome measures (p &lt; 0.05) was found in the subgroup treated with bone marrow stimulation + bone marrow aspirate concentrate compared to the group treated with bone marrow stimulation alone, based on three non‐blinded studies. No significant differences regarding clinical outcomes were found in the subgroups comparing matrix‐induced autologous chondrocyte implantation with matrix‐induced bone marrow aspirate concentrate, osteochondral autologous transplantation alone with osteochondral autologous transplantation + bone marrow aspirate concentrate and autologous matrix‐induced chondrogenesis plus peripheral blood concentrate vs. matrix‐associated stem cell transplantation bone marrow aspirate concentrate.ConclusionThere is insufficient evidence to support a positive effect on clinical outcomes of bone marrow aspirate concentrate as an additive to surgical treatment of osteochondral lesions of the talus. However, based on the safety reports and initial results, sufficiently powered, patient‐ and researcher‐blinded, prospective randomised controlled trials are justified and recommended. Until then, we advise not to implement a therapy (addition of bone marrow aspirate concentrate) without clinical evidence that justifies the additional costs involved.Level of evidenceLevel III.

Meniscal Allograft Transplantation Concomitant With Cartilage Repair for Symptomatic Lateral Meniscus-Deficient Knees With Over Two Years of Follow-up.

Background and objective The treatment for symptomatic meniscus-deficient knees with cartilage defects remains challenging on account of insufficient meniscal substitutes. One solution for this might involve combining meniscal allograft transplantation (MAT) and cartilage repair. In this study, we aimed to analyze the effectiveness and safety of MAT concomitant with cartilage repair for symptomatic lateral meniscus-deficient knees in a setting with limited availability of meniscal transplants in Japan. Methods Nine patientswho underwent MAT concomitant with osteochondral transplantation (five) and/or autologous chondrocyte implantations (seven) were followed up for at least two years (mean: 51.2 months, range: 24-84 months). Their demographic data and other characteristics were as follows - mean age: 51.7 years, range: 36-67 years; men/women: 4/5; cause: trauma/discoid meniscus: 8/1; cartilage defect size: mean: 6.7 cm2/knee, range: 1.0-11.3. The effectiveness and safety were evaluated clinically by using the Lysholm Knee Scoring Scale(LKSS) and Japanese Orthopaedic Association (JOA) knee score, physical examination, X-rays, and MRI preoperatively and at one, 12, and 24 months after the implantation. Differences between the variables were analyzed using the Friedman test and Scheffe's multiple comparisons. Results The median LKSS and JOA scores significantly improved from 70 points (range: 21-80) and 35 (25-45) preoperatively to 86.5 (65-98) and 87.5 (80-95) at 24 months after surgery, respectively (p<0.001, p=0.0013). The range of motion (ROM), femorotibial angle, and the lateral joint space showed no significant changes. However, lateral meniscal extrusions (LMEs) increased by 3.0 mm (range: 0-6.3 mm) at one month postoperatively and remained unchanged until two years postoperatively. Treatment failure occurred in one case, which was revised by total knee arthroplasty (TKA) at 18 months postoperatively. Additional surgeries were needed in some cases: lateral meniscal tear (three cases), contracture (two cases), and patellar instability (one case). However, neither infection nor allergic reaction was observed in the blood exams. Conclusions Although MAT concomitant with cartilage repair showed good clinical outcomes, half of the cases needed additional surgeries. Based on our findings, this technique should be adopted only in select cases and performed bya handful of highly experienced surgeons.

Evidence-based machine learning algorithm to predict failure following cartilage procedures in the knee

IntroductionClinical decision-making is highly based on expert opinion. Machine learning is increasingly used to develop patient-specific risk prediction analysis to improve patient selection prior to surgery. ObjectivesTo develop machine learning algorithms to predict failure of surgical procedures that address cartilage defects of the knee and detect variables associated with failure. MethodsAn institutional database was queried for cartilage procedures performed between 2000 and 2018. Failure was defined as revision cartilage surgery or knee arthroplasty. One hundred and one preoperative and intraoperative features were evaluated as potential predictors. Four machine learning algorithms were trained and internally validated. ResultsOne thousand and ninety-one patients with a minimum follow-up of 2 years were included and underwent chondroplasty (n = 560; 51%), osteochondral allograft transplantation (n = 306; 28%), microfracture (n = 150; 14%), autologous chondrocyte implantation (n = 39; 4%), or osteochondral autograft transplantation (n = 36; 3%). The Random Forest algorithm was the best-performing algorithm, with an area under the curve of 0.765 and a Brier score of 0.135. The most important features for predicting failure were symptom duration, age, body mass index, lesion grade, and total lesion area. Local Interpretable Model-agnostic Explanations analysis provided patient-specific comparisons for the risk of failure of an individual patient being assigned various types of cartilage procedures. ConclusionsMachine learning algorithms were accurate in predicting the risk of failure following cartilage procedures of the knee, with the most important features in descending order being symptom duration, age, body mass index, lesion grade, and total lesion area. Machine learning algorithms may be used to compare the risk of failure of specific patient-procedure combinations in the treatment of cartilage defects of the knee.

Long-term outcomes after osteochondral allograft transplantation to the humeral head.

Long-term outcomes of osteochondral allograft (OCA) transplantation to the humeral head have been sparsely reported in the literature. To evaluate outcomes and survivorship of OCA transplantation to the humeral head in patients with osteochondral defects at a minimum of 10years of follow-up. A registry of patients who underwent humeral head OCA transplantation between 2004 and 2012 was reviewed. Patients completed pre and postoperative surveys including the American Shoulder and Elbow Surgeons score, Simple Shoulder Test, Short Form 12 (SF-12), and the visual analog scale. Failure was defined by conversion to shoulder arthroplasty. Fifteen of 21 (71%) patients with a minimum of ten year of follow-up (mean: 14.2±2.40) were identified. Mean patient age was 26.1±8.8years at the time of transplantation and eight (53%) patients were male. Surgery was performed on the dominant shoulder in 11 of the 15 (73%) cases. The use of local anesthetic delivered via an intra-articular pain pump was the most often reported underlying etiology of chondral injury (n=9; 60%). Eight (53%) patients were treated with an allograft plug, while seven (47%) patients were treated with a mushroom cap allograft. At final follow-up, mean American Shoulder and Elbow Surgeons (49.9 to 81.1; P=.048) and Simple Shoulder Test (43.1 to 83.3; P=.010) significantly improved compared to baseline. Changes in mean SF-12 physical (41.4 to 48.1; P=.354), SF-12 mental (57.5 to 51.8; P=.354), and visual analog scale (4.0 to 2.8; P=.618) did not reach statistical significance. Eight (53%) patients required conversion to shoulder arthroplasty at an average of 4.8±4.7years (range: 0.6-13.2). Kaplan-Meier graft survival probabilities were 60% at 10years and 41% at 15years. OCA transplantation to the humeral head can result in acceptable long-term function for patients with osteochondral defects. While patient-reported outcomes metrics were generally improved compared to baseline, OCA graft survival probabilities diminished with time. The findings from this study can be used to counsel future patients with significant glenohumeral cartilage injuries and set expectations about the potential for further surgery.

Multi-Surface Cartilage Defects about the Knee Treated with Cartilage Restoration Procedures Show Good Outcomes and Survivorship at Minimum 2-Year Follow-Up.

We aimed to evaluate the outcomes, survivorship, and complications following multi-surface cartilage procedures at minimum 2-year follow-up. Patients with either (1) single-surface osteochondral allograft transplantation (OCAT) with third-generation matrix-induced autologous cultured chondrocyte implantation (MACI) or particulated juvenile cartilage implantation (DeNovo), or (2) multiple-surface OCAT ± associated MACI/DeNovo procedures for grade IV chondral or osteochondral defects about the knee with minimum 2-year follow-up were analyzed. Patient-reported outcome measures (PROMs), including International Knee Documentation Committee (IKDC) and Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales, were obtained preoperatively and at minimum 2 years postoperatively. The percentage of patients who met the minimal clinically important difference (MCID) for each PROM was reported. Failure was defined as revision OCAT, conversion to patellofemoral/total/unicompartmental joint arthroplasty, or Arthrosurface HemiCAP placement. Of 257 patients identified, 35 were included. There was a significant increase in IKDC, KOOS-pain, KOOS-symptom, KOOS-sport, and KOOS-quality of life scores from preoperative to postoperative evaluation (P < 0.03 for all). More than 50% of patients met the MCID for each PROM. There were 2 failures, 1 of the patella and 1 of the medial femoral condyle, at 39.7 and 38.6 months postoperatively, respectively. Multi-surface cartilage procedures are a safe, efficacious treatment option for multifocal cartilage defects about the knee at short-term follow-up.

Treatment of Articular Cartilage Defects: A Descriptive Analysis of Clinical Characteristics and Global Trends Reported from 2001 to 2020.

To evaluate the clinical characteristics and global trends in the surgical treatment of articular cartilage defects. Studies in English published between January 1, 2001 and December 31, 2020 were retrieved from MEDLINE, WOS, INSPEC, SCIELO, KJD, and RSCI on the "Web of Science." Patient data were extracted, including age, sex, defect location and laterality, duration of follow-up and symptoms, and body mass index (BMI). Data were further stratified according to the surgical method, lesion location, procedural type and geographical area, and time period. A comparative analysis was performed. Overall, 443 studies involving 26,854 patients (mean age, 35.25 years; men, 60.5%) were included. The mean lesion size and patient BMI were 3.51 cm2 and 25.61 kg/m2, respectively. Cartilage defects at the knees, talus, and hips affected 20,850 (77.64%), 3,983 (14.83%), and 1,425 (5.31%) patients, respectively. The numbers of patients who underwent autologous chondrocyte implantation, arthroscopic debridement/chondroplasty, osteochondral allograft (OCA), osteochondral autologous transplantation, and microfracture were 7,114 (26.49%), 5,056 (18.83%), 3,942 (14.68%), 3,766 (14.02%), and 2,835 (10.56%), respectively. European patients were the most numerous and youngest. North American patients had the largest defects. The number of patients increased from 305 in 2001 to 3,017 in 2020. In the last 5 years, the frequency of OCAs showed a greatly increasing trend. Clinical characteristics and global trends in the surgical treatment of articular cartilage defects were revealed. The choice of operation should be based on the patient characteristics and defect location, size, and shape, as well as the patient's preference.