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Peng L, Li H, Deng H, Gao T, Li R, Xu Z, Tian Q, Zhao T, Li J, Yang Y, Wang C, Liu S, Guo Q. Combination of a human articular cartilage-derived extracellular matrix scaffold and microfracture techniques for cartilage regeneration: A proof of concept in a sheep model. J Orthop Translat 2024; 44:72-87. [PMID: 38259590 PMCID: PMC10801125 DOI: 10.1016/j.jot.2023.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 08/16/2023] [Accepted: 09/20/2023] [Indexed: 01/24/2024] Open
Abstract
Background The utilization of decellularized extracellular matrix has gained considerable attention across numerous areas in regenerative research. Of particular interest is the human articular cartilage-derived extracellular matrix (hACECM), which presents as a promising facilitator for cartilage regeneration. Concurrently, the microfracture (MF) technique, a well-established marrow stimulation method, has proven efficacious in the repair of cartilage defects. However, as of the current literature review, no investigations have explored the potential of a combined application of hACECM and the microfracture technique in the repair of cartilage defects within a sheep model. Hypothesis The combination of hACECM scaffold and microfracture will result in improved repair of full-thickness femoral condyle articular cartilage defects compared to the use of either technique alone. Study design Controlled laboratory study. Methods Full-thickness femoral condyle articular cartilage defect (diameter, 7.0 mm; debrided down to the subchondral bone plate) were created in the weight-bearing area of the femoral medial and lateral condyles (n = 24). All of defected sheep were randomly divided into four groups: control, microfracture, hACECM scaffold, and hACECM scaffold + microfracture. After 3, 6 and 12 months, the chondral repair was assessed for standardized (semi-) quantitative macroscopic, imaging, histological, immunohistochemical, mechanics, and biochemical analyses in each group. Result At 3, 6 and 12 months after implantation, the gross view and pathological staining of regenerative tissues were better in the hACECM scaffold and hACECM scaffold + microfracture groups than in the microfracture and control groups; Micro-CT result showed that the parameters about the calcified layer of cartilage and subchondral bone were better in the hACECM scaffold and hACECM scaffold + microfracture groups than the others, and excessive subchondral bone proliferation in the microfracture group. The results demonstrate that human cartilage extracellular matrix scaffold alone is an efficient, safe and simple way to repair cartilage defects. Conclusion hACECM scaffolds combined with/without microfracture facilitate chondral defect repair. The translational potential of this article Preclinical large animal models represent an important adjunct and surrogate for studies on articular cartilage repair, while the sheep stifle joint reflects many key features of the human knee and are therefore optimal experimental model for future clinical application in human. In this study, we developed a human articular cartilage-derived extracellular matrix scaffold and to verify the viability of its use in sheep animal models. Clinical studies are warranted to further quantify the effects of hACECM scaffolds in similar settings.
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Affiliation(s)
- Liqing Peng
- Institute of Orthopedics, the First Medical Center, Chinese PLA General Hospital, Beijing Key Lab of Regenerative Medicine in Orthopedics, Key Laboratory of Musculoskeletal Trauma & War Injuries PLA, No. 28 Fuxing Road, Haidian District, Beijing, 100853, China
- Department of Orthopedics, First People's Hospital of Shuangliu District, No. 120, Chengbeishang Street, Shuangliu District, Chengdu, 610200, China
| | - Hao Li
- Institute of Orthopedics, the First Medical Center, Chinese PLA General Hospital, Beijing Key Lab of Regenerative Medicine in Orthopedics, Key Laboratory of Musculoskeletal Trauma & War Injuries PLA, No. 28 Fuxing Road, Haidian District, Beijing, 100853, China
- School of Medicine, Nankai University, No. 94 Weijin Road, Nankai District, Tianjin, 300071, China
| | - Haoyuan Deng
- Institute of Orthopedics, the First Medical Center, Chinese PLA General Hospital, Beijing Key Lab of Regenerative Medicine in Orthopedics, Key Laboratory of Musculoskeletal Trauma & War Injuries PLA, No. 28 Fuxing Road, Haidian District, Beijing, 100853, China
- School of Medicine, Nankai University, No. 94 Weijin Road, Nankai District, Tianjin, 300071, China
| | - Tianze Gao
- Institute of Orthopedics, the First Medical Center, Chinese PLA General Hospital, Beijing Key Lab of Regenerative Medicine in Orthopedics, Key Laboratory of Musculoskeletal Trauma & War Injuries PLA, No. 28 Fuxing Road, Haidian District, Beijing, 100853, China
- School of Medicine, Nankai University, No. 94 Weijin Road, Nankai District, Tianjin, 300071, China
| | - Runmeng Li
- Institute of Orthopedics, the First Medical Center, Chinese PLA General Hospital, Beijing Key Lab of Regenerative Medicine in Orthopedics, Key Laboratory of Musculoskeletal Trauma & War Injuries PLA, No. 28 Fuxing Road, Haidian District, Beijing, 100853, China
- School of Medicine, Nankai University, No. 94 Weijin Road, Nankai District, Tianjin, 300071, China
| | - Ziheng Xu
- Institute of Orthopedics, the First Medical Center, Chinese PLA General Hospital, Beijing Key Lab of Regenerative Medicine in Orthopedics, Key Laboratory of Musculoskeletal Trauma & War Injuries PLA, No. 28 Fuxing Road, Haidian District, Beijing, 100853, China
- School of Medicine, Nankai University, No. 94 Weijin Road, Nankai District, Tianjin, 300071, China
| | - Qinyu Tian
- Institute of Orthopedics, the First Medical Center, Chinese PLA General Hospital, Beijing Key Lab of Regenerative Medicine in Orthopedics, Key Laboratory of Musculoskeletal Trauma & War Injuries PLA, No. 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Tianyuan Zhao
- Institute of Orthopedics, the First Medical Center, Chinese PLA General Hospital, Beijing Key Lab of Regenerative Medicine in Orthopedics, Key Laboratory of Musculoskeletal Trauma & War Injuries PLA, No. 28 Fuxing Road, Haidian District, Beijing, 100853, China
- School of Medicine, Nankai University, No. 94 Weijin Road, Nankai District, Tianjin, 300071, China
| | - Jianwei Li
- Institute of Orthopedics, the First Medical Center, Chinese PLA General Hospital, Beijing Key Lab of Regenerative Medicine in Orthopedics, Key Laboratory of Musculoskeletal Trauma & War Injuries PLA, No. 28 Fuxing Road, Haidian District, Beijing, 100853, China
- School of Medicine, Nankai University, No. 94 Weijin Road, Nankai District, Tianjin, 300071, China
| | - Yongkang Yang
- Institute of Orthopedics, the First Medical Center, Chinese PLA General Hospital, Beijing Key Lab of Regenerative Medicine in Orthopedics, Key Laboratory of Musculoskeletal Trauma & War Injuries PLA, No. 28 Fuxing Road, Haidian District, Beijing, 100853, China
- School of Medicine, Nankai University, No. 94 Weijin Road, Nankai District, Tianjin, 300071, China
| | - Chao Wang
- Institute of Orthopedics, the First Medical Center, Chinese PLA General Hospital, Beijing Key Lab of Regenerative Medicine in Orthopedics, Key Laboratory of Musculoskeletal Trauma & War Injuries PLA, No. 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Shuyun Liu
- Institute of Orthopedics, the First Medical Center, Chinese PLA General Hospital, Beijing Key Lab of Regenerative Medicine in Orthopedics, Key Laboratory of Musculoskeletal Trauma & War Injuries PLA, No. 28 Fuxing Road, Haidian District, Beijing, 100853, China
- School of Medicine, Nankai University, No. 94 Weijin Road, Nankai District, Tianjin, 300071, China
| | - Quanyi Guo
- Institute of Orthopedics, the First Medical Center, Chinese PLA General Hospital, Beijing Key Lab of Regenerative Medicine in Orthopedics, Key Laboratory of Musculoskeletal Trauma & War Injuries PLA, No. 28 Fuxing Road, Haidian District, Beijing, 100853, China
- School of Medicine, Nankai University, No. 94 Weijin Road, Nankai District, Tianjin, 300071, China
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van Tuijn IM, Emanuel KS, van Hugten PPW, Jeuken R, Emans PJ. Prognostic Factors for the Clinical Outcome after Microfracture Treatment of Chondral and Osteochondral Defects in the Knee Joint: A Systematic Review. Cartilage 2023; 14:5-16. [PMID: 36624991 PMCID: PMC10076892 DOI: 10.1177/19476035221147680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE The objective of this study is to establish which patient and lesion characteristics are related to the clinical outcome after microfracture of cartilage defects in the knee. STUDY DESIGN Systematic review. METHODS After preregistration, PubMed, Embase, and Cochrane were searched for studies that analyzed prognostic factors for the outcome of microfracture treatment in the knee. The criteria for inclusion were outcome measured using Patient-Reported Outcome Measures (PROMs), a clinical study with ≥10 participants receiving microfracture, and a minimal follow-up period of 1 year. RESULTS For none of the investigated prognostic factors, effect size reporting was sufficiently homogeneous to conduct a meta-analysis. However, a majority of the included studies identified higher age, larger lesion size, longer preoperative symptom duration, and previous surgery on the ipsilateral knee, especially meniscectomy and anterior cruciate ligament reconstruction, as factors that are reported to be correlated to a less favorable outcome. A lesion location that does not include the trochlea or the patellofemoral joint and is not weightbearing, a nondegenerative mechanism of injury, and a single lesion were reported as factors that predict a favorable outcome. As to gender, body mass index, preoperative activity level, smoking, and concomitant knee surgery, the included articles were inconclusive or no effect was reported. CONCLUSIONS Several factors correlated with the clinical result after microfracture treatment. However, the information on the effect sizes of the influence on clinical outcome is incomplete due to poor reporting. Large-scale registries or pooling of homogeneous, well-reported data is needed to work toward prognostic models. That would be an important step toward personalized treatment.
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Affiliation(s)
- Iris M van Tuijn
- Department of Orthopedic Surgery, Joint Preserving Clinic, Maastricht University Medical Center+, Maastricht, The Netherlands
- Department of Orthopedic Surgery, CAPHRI Care and Public Health Research Institute, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Kaj S Emanuel
- Department of Orthopedic Surgery, Joint Preserving Clinic, Maastricht University Medical Center+, Maastricht, The Netherlands
- Department of Orthopedic Surgery and Sports Medicine and Amsterdam Movement Sciences, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - Pieter P W van Hugten
- Department of Orthopedic Surgery, Joint Preserving Clinic, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Ralph Jeuken
- Department of Orthopedic Surgery, Joint Preserving Clinic, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Pieter J Emans
- Department of Orthopedic Surgery, Joint Preserving Clinic, Maastricht University Medical Center+, Maastricht, The Netherlands
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Suh K, Cole BJ, Gomoll A, Lee SM, Choi H, Ha CW, Lim HC, Kim MK, Ha GY, Suh DC. Cost Effectiveness of Allogeneic Umbilical Cord Blood-Derived Mesenchymal Stem Cells in Patients with Knee Osteoarthritis. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2023; 21:141-152. [PMID: 36136263 PMCID: PMC9834379 DOI: 10.1007/s40258-022-00762-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 05/10/2023]
Abstract
OBJECTIVES The aim of this study was to assess the cost effectiveness of allogeneic umbilical cord blood-derived mesenchymal stem cells with sodium hyaluronate (hUCB-MSC) compared with microfracture in patients with knee cartilage defects caused by osteoarthritis (OA) in South Korea. METHODS A partitioned survival model approach was taken consisting of five mutually exclusive health states: excellent, good, fair, poor, and death over a 20-year time horizon. Utility values were obtained from a randomized clinical trial. Cost data were extracted from a database provided by the Health Insurance Review & Assessment Service, and the utilization of healthcare services was estimated from an expert panel of orthopedic surgeons using a structured questionnaire. The incremental cost-effectiveness ratio (ICER) in terms of quality-adjusted life-years (QALY) was calculated. Deterministic and probabilistic sensitivity analyses were performed. RESULTS In the base case, the incremental costs of US$14,410 for hUCB-MSC therapy along with its associated QALY gain of 0.857 resulted in an ICER of US$16,812 (₩18,790,773) per QALY (95% confidence interval [CI] US$13,408-US$20,828) when compared with microfracture treatment from a healthcare payer perspective. From a societal perspective, the ICER was US$268 (₩299,255) per QALY (95% CI -US$2915 to US$3784). When using a willingness-to-pay threshold of US$22,367/QALY, the probability of hUCB being cost effectiveness compared with microfracture was 99% from the healthcare payer perspective and 100% from the societal perspective. CONCLUSIONS The study demonstrated that hUCB-MSC therapy was cost effective compared with microfracture when treating patients with knee OA. These findings should inform health policy decision makers about considerations for cost-effective therapy for treating knee OA to ultimately enhance population health.
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Affiliation(s)
- Kangho Suh
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, 15217, USA.
| | - Brian J Cole
- Department of Orthopedic Surgery, Rush Oak Park Hospital, Rush Medical College, Chicago, IL, USA
| | - Andreas Gomoll
- Department of Orthopedic Surgery, Hospital for Special Surgery, Weill-Cornell Medical College, New York, NY, USA
| | - Seung-Mi Lee
- Daegu Catholic University College of Pharmacy, Gyeongsan-si, Gyeongbukdo, South Korea
| | - Hangseok Choi
- Chung-Ang University College of Pharmacy, Seoul, South Korea
| | - Chul-Won Ha
- Sungkwunkwan University Samsung Seoul Hospital, Seoul, South Korea
| | | | - Myung Ku Kim
- Inha University School of Medicine, Incheon, South Korea
| | - Gwi-Yeom Ha
- Chung-Ang University College of Pharmacy, Seoul, South Korea
| | - Dong-Churl Suh
- Chung-Ang University College of Pharmacy, Seoul, South Korea
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Sun D, Liu X, Xu L, Meng Y, Kang H, Li Z. Advances in the Treatment of Partial-Thickness Cartilage Defect. Int J Nanomedicine 2022; 17:6275-6287. [PMID: 36536940 PMCID: PMC9758915 DOI: 10.2147/ijn.s382737] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 11/23/2022] [Indexed: 04/17/2024] Open
Abstract
Partial-thickness cartilage defects (PTCDs) of the articular surface is the most common problem in cartilage degeneration, and also one of the main pathogenesis of osteoarthritis (OA). Due to the lack of a clear diagnosis, the symptoms are often more severe when full-thickness cartilage defect (FTCDs) is present. In contrast to FTCDs and osteochondral defects (OCDs), PTCDs does not injure the subchondral bone, there is no blood supply and bone marrow exudation, and the nearby microenvironment is unsuitable for stem cells adhesion, which completely loses the ability of self-repair. Some clinical studies have shown that partial-thickness cartilage defects is as harmful as full-thickness cartilage defects. Due to the poor effect of conservative treatment, the destructive surgical treatment is not suitable for the treatment of partial-thickness cartilage defects, and the current tissue engineering strategies are not effective, so it is urgent to develop novel strategies or treatment methods to repair PTCDs. In recent years, with the interdisciplinary development of bioscience, mechanics, material science and engineering, many discoveries have been made in the repair of PTCDs. This article reviews the current status and research progress in the treatment of PTCDs from the aspects of diagnosis and modeling of PTCDs, drug therapy, tissue transplantation repair technology and tissue engineering ("bottom-up").
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Affiliation(s)
- Daming Sun
- Wuhan Sports University, Wuhan, People’s Republic of China
- Department of Orthopedics, Wuhan Third Hospital, Tongren Hospital of Wuhan University, Wuhan, People’s Republic of China
| | - Xiangzhong Liu
- Department of Orthopedics, Wuhan Third Hospital, Tongren Hospital of Wuhan University, Wuhan, People’s Republic of China
| | - Liangliang Xu
- Wuhan Sports University, Wuhan, People’s Republic of China
| | - Yi Meng
- Wuhan Sports University, Wuhan, People’s Republic of China
| | - Haifei Kang
- Biomedical Materials and Engineering Research Center of Hubei Province, Wuhan University of Technology, Wuhan, People’s Republic of China
| | - Zhanghua Li
- Department of Orthopedics, Wuhan Third Hospital, Tongren Hospital of Wuhan University, Wuhan, People’s Republic of China
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Promoting endogenous articular cartilage regeneration using extracellular matrix scaffolds. Mater Today Bio 2022; 16:100343. [PMID: 35865410 PMCID: PMC9294195 DOI: 10.1016/j.mtbio.2022.100343] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 06/23/2022] [Accepted: 06/25/2022] [Indexed: 12/13/2022] Open
Abstract
Articular cartilage defects fail to heal spontaneously, typically progressing to osteoarthritis. Bone marrow stimulation techniques such as microfracture (MFX) are the current surgical standard of care; however MFX typically produces an inferior fibro-cartilaginous tissue which provides only temporary symptomatic relief. Here we implanted solubilised articular cartilage extracellular matrix (ECM) derived scaffolds into critically sized chondral defects in goats, securely anchoring these implants to the joint surface using a 3D-printed fixation device that overcame the need for sutures or glues. In vitro these ECM scaffolds were found to be inherently chondro-inductive, while in vivo they promoted superior articular cartilage regeneration compared to microfracture. In an attempt to further improve the quality of repair, we loaded these scaffolds with a known chemotactic factor, transforming growth factor (TGF)-β3. In vivo such TGF-β3 loaded scaffolds promoted superior articular cartilage regeneration. This study demonstrates that ECM derived biomaterials, either alone and particularly when combined with exogenous growth factors, can successfully treat articular cartilage defects in a clinically relevant large animal model.
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Bong GSY, Lee YHD. Injectable Scaffold with Microfracture using the Autologous Matrix-Induced Chondrogenesis (AMIC) Technique: A Prospective Cohort Study. Malays Orthop J 2022; 16:86-93. [PMID: 36589380 PMCID: PMC9791906 DOI: 10.5704/moj.2211.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 02/24/2022] [Indexed: 12/13/2022] Open
Abstract
Introduction Autologous matrix-induced chondrogenesis (AMIC) is a one-step surgical cartilage repair procedure involving the insertion of a scaffold into the chondral defect after microfracture. BST-CarGel [Smith and Nephew, Watford, England] is an injectable chitosan-based scaffold which can more easily fill defects with irregular shapes and be used to treat vertical or roof chondral lesions. The study aims to evaluate the clinical outcomes of knee cartilage repair with microfracture surgery and BST-CarGel using the AMIC technique for a minimum of two years. Materials and methods A prospective study of patients undergoing cartilage repair with microfracture surgery and BST-CarGel at our institution from 2016 to 2019 was performed. Clinical outcomes were determined using the Lysholm Knee Scoring System and Knee Injury and Osteoarthritis Outcome Score (KOOS). These questionnaires were administered before the surgery and at a minimum of two years after surgery. Results A total of 21 patients were identified and recruited into the study. 31 cartilage defects were seen and treated in 21 knees. These included horizontal lesions (e.g., trochlear, lateral tibial plateau), vertical lesions (e.g., medial femoral condyle, lateral femoral condyle) and inverted lesions (e.g., patella). No complications or reoperations were seen in our study population. For the average duration of follow-up of 42.5±8.55 months, there was an average improvement in Lysholm score of 25.8±18.6 and an average improvement in KOOS score of 22.5±15.0. Conclusion BST-CarGel with microfracture surgery using the AMIC technique is a safe and effective treatment for cartilage defects in the short to medium term.
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Affiliation(s)
- GSY Bong
- Department of Orthopaedic Surgery, Tan Tock Seng Hospital, Singapore,Corresponding Author: Gerard Si Yong Bong, Department of Orthopaedic Surgery, Tan Tock Seng Hospital, 11 Jln Tan Tock Seng, Singapore 308433
| | - YHD Lee
- Department of Orthopaedic Surgery, National University Hospital, Singapore
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Ogata K, Moriyama M, Matsumura-Kawashima M, Kawado T, Yano A, Nakamura S. The Therapeutic Potential of Secreted Factors from Dental Pulp Stem Cells for Various Diseases. Biomedicines 2022; 10:biomedicines10051049. [PMID: 35625786 PMCID: PMC9138802 DOI: 10.3390/biomedicines10051049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 04/18/2022] [Accepted: 04/27/2022] [Indexed: 11/16/2022] Open
Abstract
An alternative source of mesenchymal stem cells has recently been discovered: dental pulp stem cells (DPSCs), including deciduous teeth, which can thus comprise potential tools for regenerative medicine. DPSCs derive from the neural crest and are normally implicated in dentin homeostasis. The clinical application of mesenchymal stem cells (MSCs) involving DPSCs contains various limitations, such as high cost, low safety, and cell handling issues, as well as invasive sample collection procedures. Although MSCs implantation offers favorable outcomes on specific diseases, implanted MSCs cannot survive for a long period. It is thus considered that their mediated mechanism of action involves paracrine effects. It has been recently reported that secreted molecules in DPSCs-conditioned media (DPSC-CM) contain various trophic factors and cytokines and that DPSC-CM are effective in models of various diseases. In the current study, we focus on the characteristics of DPSC-CM and their therapeutic potential against various disorders.
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Cogan CJ, Friedman J, You J, Zhang AL, Feeley BT, Ma CB, Lansdown DA. Prior Bone Marrow Stimulation Surgery Influences Outcomes After Cell-Based Cartilage Restoration: A Systematic Review and Meta-analysis. Orthop J Sports Med 2022; 9:23259671211035384. [PMID: 35146031 PMCID: PMC8822078 DOI: 10.1177/23259671211035384] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 04/30/2021] [Indexed: 01/06/2023] Open
Abstract
Background: Cell-based cartilage restoration with autologous chondrocyte implantation (ACI) is a safe and effective treatment for symptomatic cartilage lesions. Many patients undergoing ACI have a history of prior surgery, including bone marrow stimulation (BMS). There is mounting evidence that a history of prior BMS may impede healing of the ACI graft. Purpose/Hypothesis: The purpose of this study was to compare the failure rates of primary ACI with ACI after prior BMS. We hypothesized that ACI after BMS would have a significantly higher failure rate (defined as reoperation, conversion to arthroplasty, and/or imaging-based failure) compared with primary ACI. Study Design: Systematic review; Level of evidence, 4. Methods: A literature search was performed by use of PubMed and Embase databases for relevant articles published through October 2, 2020, to identify studies evaluating outcomes and failures rates of ACI after prior BMS in the knee. Results: Included were 11 studies comprising 1479 ACI procedures. The mean age at surgery ranged from 18.3 to 39.1 years, and the mean follow-up ranged from 3 to 20.6 years. All studies reported failure rates. The overall failure rate was significantly higher in the patients who underwent ACI after BMS, at 26.4% compared with 14.8% in the ACI group (P < .001). Meta-analysis demonstrated an increased risk of failure in patients with a history of prior BMS (log odds ratio = –0.90 [95% confidence interval, –1.38 to –0.42]). Conclusion: This systematic review demonstrated that failure rates were significantly higher for patients treated with ACI after BMS relative to patients undergoing ACI without prior BMS. This finding has important implications when considering the use of BMS for defects that are amenable to cell-based restoration and when determining treatment options after failed BMS. Registration: PROSPERO (CRD42020180387).
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Affiliation(s)
- Charles J Cogan
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, USA
| | - James Friedman
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Jae You
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Alan L Zhang
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Brian T Feeley
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, USA
| | - C Benjamin Ma
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Drew A Lansdown
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, USA
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Hede KTC, Christensen BB, Olesen ML, Thomsen JS, Foldager CB, Toh WS, Lim SK, Lind MC. Mesenchymal Stem Cell Extracellular Vesicles as Adjuvant to Bone Marrow Stimulation in Chondral Defect Repair in a Minipig Model. Cartilage 2021; 13:254S-266S. [PMID: 34308681 PMCID: PMC8804773 DOI: 10.1177/19476035211029707] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE This study evaluated the effects of mesenchymal stem cell-extracellular vesicles (MSC-EVs) on chondrocyte proliferation in vitro and on cartilage repair in vivo following bone marrow stimulation (BMS) of focal chondral defects of the knee. METHODS Six adult Göttingen minipigs received 2 chondral defects in each knee. The pigs were randomized to treatment with either BMS combined with MSC-EVs or BMS combined with phosphate-buffered saline (PBS). Intraarticular injections MSC-EVs or PBS were performed immediately after closure of the surgical incisions, and at 2 and 4 weeks postoperatively. Repair was evaluated after 6 months with gross examination, histology, histomorphometry, immunohistochemistry, and micro-computed tomography (µCT) analysis of the trabecular bone beneath the defect. RESULTS Defects treated with MSC-EVs had more bone in the cartilage defect area than the PBS-treated defects (7.9% vs. 1.5%, P = 0.02). Less than 1% of the repair tissue in both groups was hyaline cartilage. International Cartilage and Joint Preservation Society II histological scoring showed that defects treated with MSC-EVs scored lower on "matrix staining" (20.8 vs. 50.0, P = 0.03), "cell morphology" (35.4 vs. 53.8, P = 0.04), and "overall assessment" (30.8 vs. 52.9, P = 0.03). Consistently, defects treated with MSC-EVs had lower collagen II and higher collagen I areal deposition. Defects treated with MSC-EVs had subchondral bone with significantly higher tissue mineral densities than PBS-treated defects (860 mg HA/cm3 vs. 838 mg HA/cm3, P = 0.02). CONCLUSION Intraarticular injections of MSC-EVs in conjunction with BMS led to osseous ingrowth that impaired optimal cartilage repair, while enhancing subchondral bone healing.
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Affiliation(s)
- Kris T. C. Hede
- Orthopedic Research Laboratory, Aarhus
University Hospital, Aarhus N, Denmark
| | | | - Morten L. Olesen
- Orthopedic Research Laboratory, Aarhus
University Hospital, Aarhus N, Denmark
| | | | - Casper B. Foldager
- Orthopedic Research Laboratory, Aarhus
University Hospital, Aarhus N, Denmark
| | - Wei Seong Toh
- Faculty of Dentistry, National
University of Singapore, Singapore
- Department of Orthopaedic Surgery, Yong
Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Sai Kiang Lim
- Institute of Molecular and Cell
Biology, Agency for Science, Technology and Research, Singapore
| | - Martin C. Lind
- Orthopedic Research Laboratory, Aarhus
University Hospital, Aarhus N, Denmark
- Sports Trauma Clinic, Aarhus University
Hospital, Aarhus N, Denmark
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Jeuken RM, van Hugten PPW, Roth AK, Timur UT, Boymans TAEJ, van Rhijn LW, Bugbee WD, Emans PJ. A Systematic Review of Focal Cartilage Defect Treatments in Middle-Aged Versus Younger Patients. Orthop J Sports Med 2021; 9:23259671211031244. [PMID: 34676269 PMCID: PMC8524698 DOI: 10.1177/23259671211031244] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 03/22/2021] [Indexed: 01/08/2023] Open
Abstract
Background: Focal cartilage defects are often debilitating, possess limited potential for
regeneration, are associated with increased risk of osteoarthritis, and are
predictive for total knee arthroplasty. Cartilage repair studies typically
focus on the outcome in younger patients, but a high proportion of treated
patients are 40 to 60 years of age (ie, middle-aged). The reality of current
clinical practice is that the ideal patient for cartilage repair is not the
typical patient. Specific attention to cartilage repair outcomes in
middle-aged patients is warranted. Purpose: To systematically review available literature on knee cartilage repair in
middle-aged patients and include studies comparing results across different
age groups. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic search was performed in EMBASE, MEDLINE, and the Cochrane
Library database. Articles were screened for relevance and appraised for
quality. Results: A total of 21 articles (mean Coleman Methodology Score, 64 points) were
included. Two out of 3 bone marrow stimulation (BMS) studies, including 1
using the microfracture technique, revealed inferior clinical outcomes in
middle-aged patients in comparison with younger patients. Nine cell-based
studies were included showing inconsistent comparisons of results across age
groups for autologous chondrocyte implantation (ACI). Bone marrow aspirate
concentrate showed age-independent results at up to 8 years of follow-up. A
negative effect of middle age was reported in 1 study for both ACI and BMS.
Four out of 5 studies on bone-based resurfacing therapies (allografting and
focal knee resurfacing implants [FKRIs]) showed age-independent results up
to 5 years. One study in only middle-aged patients reported better clinical
outcomes for FKRIs when compared with biological repairs. Conclusion: Included studies were heterogeneous and had low methodological quality. BMS
in middle-aged patients seems to only result in short-term improvements.
More research is warranted to elucidate the ameliorating effects of
cell-based therapies on the aging joint homeostasis. Bone-based therapies
seem to be relatively insensitive to aging and may potentially result in
effective joint preservation. Age subanalyses in cohort studies, randomized
clinical trials, and international registries should generate more evidence
for the large but underrepresented (in terms of cartilage repair)
middle-aged population in the literature.
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Affiliation(s)
- Ralph M Jeuken
- Maastricht University Medical Center, Maastricht, the Netherlands
| | | | - Alex K Roth
- Maastricht University Medical Center, Maastricht, the Netherlands
| | - Ufuk Tan Timur
- Maastricht University Medical Center, Maastricht, the Netherlands
| | | | | | - William D Bugbee
- Department of Orthopaedic Surgery, Scripps Clinic, La Jolla, California, USA
| | - Pieter J Emans
- Maastricht University Medical Center, Maastricht, the Netherlands
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Kim MS, Koh IJ, In Y. Porcine-Derived Collagen-Augmented Chondrogenesis Technique for Treating Knee Cartilage Defects. JBJS Essent Surg Tech 2021; 11:ST-D-20-00028. [PMID: 34650827 DOI: 10.2106/jbjs.st.20.00028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Articular cartilage is virtually incapable of self-healing in the event of a defect. Microfracture is the most frequently used bone marrow stimulation technique1, but there is the limitation of unpredictable quality of the cartilage repair following bone marrow stimulation2. To resolve the shortcomings of the microfracture technique, various reinforcing technologies have been developed, including the porcine-derived collagen-augmented chondrogenesis technique (C-ACT)3. The collagen gel utilized in that procedure is a product called CartiFill (Sewon Cellontech), made from highly purified pig-derived type-I collagen. It has been modified into an atelocollagen, by removing telopeptides, to virtually eliminate the risk of rejection. The collagen matrix provides not only a 3-dimensional structure for cartilage differentiation, but also mechanical support3,4. Description Porcine-derived C-ACT is initiated by creating a mixture of atelocollagen, thrombin, and fibrinogen. First, thrombin is mixed with atelocollagen and placed in one arm of an assembled Y-shaped syringe, and fibrinogen is placed in the other arm. The articular cartilage defect site is confirmed in a routine arthroscopic procedure. The articular margin is debrided, and the calcified lesion is cleanly removed. Then, microfractures are created. After creating a more extended incision at the anteromedial portal, the microfracture site is prepared by removing moisture. The prepared atelocollagen mixture is applied to the defect site as a single layer, although a second layer can be formed 1 to 2 minutes later. After 5 minutes, the stability is verified by range of motion of the knee.Indications for this procedure include (1) cartilage defects in the knee, including knee osteoarthritis and knee traumatic arthritis; (2) knee osteoarthritis with a Kellgren-Lawrence grade of 3 or less; (3) hip-knee-ankle malalignment of <5° or a deformity that is able to be surgically corrected; and (4) knee stability, or instability that is able to be surgically corrected.Contraindications for this procedure include (1) patient or family history of autoimmune disease, (2) history of anaphylactic reaction, (3) history of hypersensitivity to an implant, (4) history of allergy to porcine or bovine protein, and (5) inflammatory arthritis such as rheumatoid and gouty arthritis.C-ACT is a procedure for cartilage repair, and the effects of this procedure can be limited in cases with a deep subchondral bone defect; however, there is no limit to the size of the cartilage defect in terms of patient selection for C-ACT. Alternatives There are several alternatives to C-ACT, ranging from the simple microfracture technique to autologous chondrocyte implantation5, matrix-induced autologous chondrocyte implantation6, autologous matrix-induced chondrogenesis7, osteochondral autograft transplantation8, and stem cell therapy. There are various ways to recover from an articular cartilage defect, but C-ACT does not require a 2-stage technique, as is necessary with both autologous chondrocyte implantation procedures. Therefore, C-ACT has the advantages of ease of operation and being a single-stage procedure3,9. Rationale C-ACT can be classified as an upgraded version of microfracture, which is the most common treatment method for articular cartilage defects. With the microfracture technique, repaired cartilage is limited to fibrous cartilage and does not include hyaline cartilage3,4. However, a recent study reported that C-ACT exhibited a superior quality of repaired cartilage compared with microfracture3,4. Expected Outcomes Previous studies have reported favorable results with the use of C-ACT3,4. Kim et al.4 compared atelocollagen augmentation with microfracture alone in patients undergoing medial opening wedge high tibial osteotomy for the treatment of medial compartment osteoarthritis. Although there was no clinical difference between the 2 groups, the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score and the International Cartilage Repair Society II score were superior in the atelocollagen augmentation group. In addition, the microfracture group formed fibrous-like cartilage compared with the hyaline-like cartilage created in the atelocollagen augmentation group. A recent multicenter randomized study compared the use of C-ACT and microfracture and found that C-ACT exhibited significantly better results in several MOCART subscores and quantitative T2 mapping, indicating a histologically superior form of repaired cartilage compared with microfracture3. According to recent research, microfracture is superior to autologous chondrocyte implantation in terms of cost-effectiveness10. Similar results appear to be applicable to C-ACT. C-ACT requires an additional $1,300 for material costs; however, C-ACT showed better cartilage regeneration on magnetic resonance imagining and histology3,4, and higher rate of patients meeting the 20%-improvement rate in visual analogue scale pain scores at 24 months postoperatively compared with microfracture3. Long-term studies will be needed to assess whether histological superiority of C-ACT is reflected in meaningful improvements to clinical outcomes. Important Tips Debride all of the damaged cartilage to subchondral bone and remove the calcified layer without interfering with tissue repairTake special care when creating the atelocollagen mixture to ensure that it is accurately manufacturedDry the defect site with use of suction or gauze to aid in atelocollagen adhesion when applying atelocollagen.
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Affiliation(s)
- Man Soo Kim
- Department of Orthopaedic Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - In Jun Koh
- Department of Orthopaedic Surgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yong In
- Department of Orthopaedic Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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Nanofibrous hyaluronic acid scaffolds delivering TGF-β3 and SDF-1α for articular cartilage repair in a large animal model. Acta Biomater 2021; 126:170-182. [PMID: 33753316 DOI: 10.1016/j.actbio.2021.03.013] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 03/03/2021] [Accepted: 03/04/2021] [Indexed: 02/07/2023]
Abstract
Focal cartilage injuries have poor intrinsic healing potential and often progress to osteoarthritis, a costly disease affecting almost a third of adults in the United States. To treat these patients, cartilage repair therapies often use cell-seeded scaffolds, which are limited by donor site morbidity, high costs, and poor efficacy. To address these limitations, we developed an electrospun cell-free fibrous hyaluronic acid (HA) scaffold that delivers factors specifically designed to enhance cartilage repair: Stromal Cell-Derived Factor-1α (SDF-1α; SDF) to increase the recruitment and infiltration of mesenchymal stem cells (MSCs) and Transforming Growth Factor-β3 (TGF-β3; TGF) to enhance cartilage tissue formation. Scaffolds were characterized in vitro and then deployed in a large animal model of full-thickness cartilage defect repair. The bioactivity of both factors was verified in vitro, with both SDF and TGF increasing cell migration, and TGF increasing matrix formation by MSCs. In vivo, however, scaffolds releasing SDF resulted in an inferior cartilage healing response (lower mechanics, lower ICRS II histology score) compared to scaffolds releasing TGF alone. These results highlight the importance of translation into large animal models to appropriately screen scaffolds and therapies, and will guide investigators towards alternative growth factor combinations. STATEMENT OF SIGNIFICANCE: This study addresses an area of orthopaedic medicine in which treatment options are limited and new biomaterials stand to improve patient outcomes. Those suffering from articular cartilage injuries are often destined to have early onset osteoarthritis. We have created a cell-free nanofibrous hyaluronic acid (HA) scaffold that delivers factors specifically designed to enhance cartilage repair: Stromal Cell-Derived Factor-1α (SDF-1α; SDF) to increase the recruitment and infiltration of mesenchymal stem cells (MSCs) and Transforming Growth Factor-β3 (TGF-β3; TGF) to enhance cartilage tissue formation. To our knowledge, this study is the first to evaluate such a bioactive scaffold in a large animal model and demonstrates the capacity for dual growth factor release.
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13
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Migliorini F, Eschweiler J, Maffulli N, Schenker H, Driessen A, Rath B, Tingart M. Autologous Matrix Induced Chondrogenesis (AMIC) Compared to Microfractures for Chondral Defects of the Talar Shoulder: A Five-Year Follow-Up Prospective Cohort Study. Life (Basel) 2021; 11:life11030244. [PMID: 33809441 PMCID: PMC8001819 DOI: 10.3390/life11030244] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 03/09/2021] [Accepted: 03/15/2021] [Indexed: 11/16/2022] Open
Abstract
Introduction: Many procedures are available to manage cartilage defects of the talus, including microfracturing (MFx) and Autologous Matrix Induced Chondrogenesis (AMIC). Whether AMIC or MFx are equivalent for borderline sized defects of the talar shoulder is unclear. Thus, the present study compared the efficacy of primary isolated AMIC versus MFx for borderline sized focal unipolar chondral defects of the talar shoulder at midterm follow-up. Methods: Patients undergoing primary isolated AMIC or MFx for focal unipolar borderline sized chondral defects of the talar shoulder were recruited prospectively. For those patients who underwent AMIC, a type I/III collagen resorbable membrane was used. The outcomes of interest were: Visual Analogic Scale (VAS), Tegner Activity Scale, American Orthopedic Foot and Ankle Score (AOFAS). The Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) was assessed by a blinded radiologist, who had not been involved in the clinical management of the patients. Data concerning complication rate and additional procedures were also collected. Results: The mean follow-up was 43.5 months. The mean age of the 70 patients at operation was 32.0 years, with a mean defect size of 2.7 cm2. The mean length of hospitalization was shorter in the MFx cohort (p = 0.01). No difference was found between the two cohorts in terms of length of prior surgery symptoms and follow-up, mean age and BMI, sex and side, and defect size. At a mean follow-up of 43.5 months, the AOFAS (p = 0.03), VAS (p = 0.003), and Tegner (p = 0.01) scores were greater in the AMIC group. No difference was found in the MOCART score (p = 0.08). The AMIC group evidenced lower rates of reoperation (p = 0.008) and failure (p = 0.003). Conclusion: At midterm follow-up, AMIC provides better results compared to MFx.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopedics and Trauma Surgery, University Clinic Aachen, RWTH Aachen University Clinic, 52064 Aachen, Germany; (F.M.); (J.E.); (H.S.); (A.D.); (B.R.); (M.T.)
| | - Jörg Eschweiler
- Department of Orthopedics and Trauma Surgery, University Clinic Aachen, RWTH Aachen University Clinic, 52064 Aachen, Germany; (F.M.); (J.E.); (H.S.); (A.D.); (B.R.); (M.T.)
| | - Nicola Maffulli
- School of Pharmacy and Bioengineering, Keele University School of Medicine, Staffordshire ST4 7QB, UK
- Barts and the London School of Medicine and Dentistry, London E1 2AD, UK
- Centre for Sports and Exercise Medicine, Queen Mary University of London, Mile End Hospital, London E1 4DG, UK
- Department of Orthopedics, Klinikum Wels-Grieskirchen, A-4600 Wels, Austria
- Correspondence:
| | - Hanno Schenker
- Department of Orthopedics and Trauma Surgery, University Clinic Aachen, RWTH Aachen University Clinic, 52064 Aachen, Germany; (F.M.); (J.E.); (H.S.); (A.D.); (B.R.); (M.T.)
| | - Arne Driessen
- Department of Orthopedics and Trauma Surgery, University Clinic Aachen, RWTH Aachen University Clinic, 52064 Aachen, Germany; (F.M.); (J.E.); (H.S.); (A.D.); (B.R.); (M.T.)
| | - Björn Rath
- Department of Orthopedics and Trauma Surgery, University Clinic Aachen, RWTH Aachen University Clinic, 52064 Aachen, Germany; (F.M.); (J.E.); (H.S.); (A.D.); (B.R.); (M.T.)
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84081 Baronissi, Italy
| | - Markus Tingart
- Department of Orthopedics and Trauma Surgery, University Clinic Aachen, RWTH Aachen University Clinic, 52064 Aachen, Germany; (F.M.); (J.E.); (H.S.); (A.D.); (B.R.); (M.T.)
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Primeau CA, Zomar BO, Somerville LE, Joshi I, Giffin JR, Marsh JD. Health Economic Evaluations of Hip and Knee Interventions in Orthopaedic Sports Medicine: A Systematic Review and Quality Assessment. Orthop J Sports Med 2021; 9:2325967120987241. [PMID: 34262974 PMCID: PMC8243245 DOI: 10.1177/2325967120987241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 11/24/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The economic burden of musculoskeletal diseases is substantial and growing. Economic evaluations compare costs and health benefits of interventions simultaneously to help inform value-based care; thus, it is crucial to ensure that studies are using appropriate methodology to provide valid evidence on the cost-effectiveness of interventions. This is particularly the case in orthopaedic sports medicine, where several interventions of varying costs are available to treat common hip and knee conditions. PURPOSE To summarize and evaluate the quality of economic evaluations in orthopaedic sports medicine for knee and hip interventions and identify areas for quality improvement. STUDY DESIGN Systematic review; Level of evidence, 3. METHODS The Medline, AMED, OVID Health Star, and EMBASE databases were searched from inception to March 1, 2020, to identify economic evaluations that compared ≥2 interventions for hip and/or knee conditions in orthopaedic sports medicine. We assessed the quality of full economic evaluations using the Quality of Health Economic Studies (QHES) tool, which consists of 16 questions for a total score of 100. We classified studies into quartiles based on QHES score (extremely poor quality to high quality) and we evaluated the frequency of studies that addressed each of the 16 QHES questions. RESULTS A total of 93 studies were included in the systematic review. There were 41 (44%) cost analyses, of which 21 (51%) inappropriately concluded interventions were cost-effective. Only 52 (56%) of the included studies were full economic evaluations, although 40 of these (77%) fell in the high-quality quartile. The mean QHES score was 83.2 ± 19. Authors consistently addressed 12 of the QHES questions; questions that were missed or unclear were related to statistical uncertainty, appropriateness of costing methodology, and discussion of potential biases. The most frequently missed question was whether the cost perspective of the analysis was stated and justified. CONCLUSION The number of studies in orthopaedic sports medicine is small, despite their overall good quality. Yet, there are still many highly cited studies based on low-quality or partial economic evaluations that are being used to influence clinical decision-making. Investigators should follow international health economic guidelines for study design and critical appraisal of studies to further improve quality.
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Affiliation(s)
- Codie A. Primeau
- School of Physical Therapy, Western University, London, Ontario, Canada
- School of Health and Rehabilitation Sciences, Western University, London, Ontario, Canada
- Bone and Joint Institute, Western University, London, Ontario, Canada
| | - Bryn O. Zomar
- School of Physical Therapy, Western University, London, Ontario, Canada
- School of Health and Rehabilitation Sciences, Western University, London, Ontario, Canada
- Bone and Joint Institute, Western University, London, Ontario, Canada
| | | | - Ishita Joshi
- School of Physical Therapy, Western University, London, Ontario, Canada
- School of Health and Rehabilitation Sciences, Western University, London, Ontario, Canada
- Bone and Joint Institute, Western University, London, Ontario, Canada
| | - J. Robert Giffin
- Bone and Joint Institute, Western University, London, Ontario, Canada
- London Health Sciences
Centre, University Hospital, London, Ontario, Canada
- Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Jacquelyn D. Marsh
- School of Physical Therapy, Western University, London, Ontario, Canada
- School of Health and Rehabilitation Sciences, Western University, London, Ontario, Canada
- Bone and Joint Institute, Western University, London, Ontario, Canada
- London Health Sciences
Centre, University Hospital, London, Ontario, Canada
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15
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Management of Patellar Chondral Defects with Autologous Matrix Induced Chondrogenesis (AMIC) Compared to Microfractures: A Four Years Follow-Up Clinical Trial. Life (Basel) 2021; 11:life11020141. [PMID: 33668454 PMCID: PMC7918926 DOI: 10.3390/life11020141] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 02/08/2021] [Accepted: 02/10/2021] [Indexed: 02/06/2023] Open
Abstract
Introduction: Evidence on the management of chondral defects of the patella arises from studies in which the patellofemoral joint was treated together with the femorotibial joint and primary and revision settings. Furthermore, the superiority of Autologous Matrix Induced Chondrogenesis (AMIC) over microfractures (MFx) for patellar chondral defects is uncertain. Therefore, the present study compared primary isolated AMIC versus MFx for focal unipolar chondral defects of the patellar facet joints at midterm follow-up. Methods: Patients undergoing AMIC or isolated MFx surgery for borderline-sized focal unipolar chondral defects of the patellar facet joints were followed at our institution. All surgeries were performed in the same fashion by experienced surgeons. A parapatellar arthrotomy was adopted in all surgeries. The outcomes of interest were: Visual Analogic Scale (VAS), Tegner Activity Scale, International Knee Documentation Committee (IKDC), and the Lysholm scores. The Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) was assessed by a blinded radiologist, who had not been involved in the clinical management of the patients. Results: 38 patients were enrolled in the present study: 27 underwent AMIC, and 11 MFx. The mean follow-up was 45.1 months. The mean age of the patients at baseline was 34.5 years. The mean size of the defect was 2.6 cm2. The MFx cohort experienced a shorter length of the hospitalization (P = 0.008). There was no difference in terms of follow-up and previous symptoms duration, mean age, sex, side, defect size, and BMI. At last follow-up, the AMIC cohort reported greater IKDC (P = 0.01), Lysholm (P = 0.009), and Tegner (P = 0.02), along with a low rate of failure (P = 0.02). VAS was lower in the AMIC group (P = 0.002). No difference was found in the MOCART score (P = 0.09), rates of revision (P = 0.06), and arthroplasty (P = 0.2). Conclusion: The AMIC procedure achieves greater IKDC and Lysholm score, and a significant reduction of the VAS score in the management of patellar chondral defects. The Tegner scale demonstrated greater activity after AMIC procedure. Finally, the AMIC group evidenced a lower rate of failure. Similarity was found on MOCART score, rates of revision, and arthroplasty between the two procedures.
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Howell M, Liao Q, Gee CW. Surgical Management of Osteochondral Defects of the Knee: An Educational Review. Curr Rev Musculoskelet Med 2021; 14:60-66. [PMID: 33587261 PMCID: PMC7930143 DOI: 10.1007/s12178-020-09685-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/17/2020] [Indexed: 12/24/2022]
Abstract
PURPOSE OF REVIEW Numerous surgical techniques are available to treat osteochondral defects of the knee. The aim of this review is to analyse these procedures, including their methodology, outcomes and limitations, to create a treatment algorithm for optimal management. RECENT FINDINGS Osteochondral defects of the knee significantly alter the biomechanics of the joint. This can cause symptomatic and functional impairment as well as considerable risk of progressive joint degeneration. Surgical interventions aim to restore a congruent, durable joint surface providing symptomatic relief and reducing the risk of early arthritic changes. These methods include fixation, chondroplasty, microfracture, autologous matrix-induced chondrogenesis, autograft transplants, allograft transplants and autologous chondrocyte implantation. There is currently much debate as to which of these methods provides optimal treatment of osteochondral defects. The overall evidence supports the use of each technique depending on the individual characteristics of the lesion. New technologies provide exciting prospects; however, long-term outcomes for these are not yet available.
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Affiliation(s)
- Matthew Howell
- Department of Trauma and Orthopaedics, The Queen Elizabeth University Hospital, 1345 Govan Rd, Glasgow, Scotland
| | - Quintin Liao
- Department of Trauma and Orthopaedics, University Hospital Wishaw, 50 Netherton St, Wishaw, Scotland.
| | - Christopher W Gee
- Department of Trauma and Orthopaedics, University Hospital Wishaw, 50 Netherton St, Wishaw, Scotland
- Department of Arthroplasty and Soft Tissue Knee Surgery, Golden Jubilee National Hospital, Agamemnon St, Clydebank, Scotland
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Mayo BC, Ravella KC, Onsen L, Bobko A, Schwarzman GR, Steffes MJ, Miller A, Hutchinson MR. Is There an Association Between Authors' Conflicts of Interest and Outcomes in Clinical Studies Involving Autologous Chondrocyte Implantation? Orthop J Sports Med 2021; 9:2325967120979988. [PMID: 33623797 PMCID: PMC7876765 DOI: 10.1177/2325967120979988] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 08/10/2020] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Autologous chondrocyte implantation (ACI) is an increasingly popular technique for the treatment of articular cartilage defects. Because several companies have financial interests in ACI, it is important to consider possible conflicts of interest when evaluating studies reporting outcomes of ACI. PURPOSE To determine whether there is an association between authors' financial conflicts of interest and the outcomes of ACI studies. STUDY DESIGN Cross-sectional study. METHODS A search of PubMed and MEDLINE databases for "autologous chondrocyte implantation" was performed. Clinical studies published after 2012 through May 15, 2019, and in English were included. Studies were determined to have financial conflicts of interest if any contributing author had relevant conflicts, either self-reported in the published study's disclosures section or reported online in the American Academy of Orthopaedic Surgeons Disclosure database or the Centers for Medicare & Medicaid Services Open Payments database. The outcomes of each study were rated as favorable, equivocal, or unfavorable based on predefined criteria and then tested for association with conflicts of interest through use of the Fisher exact test. RESULTS A total of 79 studies met the inclusion criteria. Nearly all studies were of level 3 or 4 evidence. Conflicts of interest were established in 51.90% of studies (n = 41). Conflicts that were not self-reported by the authors were discovered in 18% of studies. The level of evidence was not associated with conflict of interest. No statistically significant difference was found in the rate of favorable outcomes between studies with conflicts (92.68%) and those with no conflicts (81.58%) (P = .126). Publications by US authors were more likely to have financial conflicts of interest (P = .003). CONCLUSION Favorable results were reported in a majority of studies involving ACI. No statistical association was found between the frequency of favorable outcomes and the presence of financial conflicts of interest, country of authorship, or level of evidence. There was a trend toward more favorable outcomes in studies with conflicts of interest. Additionally, nearly 20% of publications had possible conflicts found online that were not self-reported. It is critical for orthopaedic surgeons to judiciously evaluate published studies and consider financial conflicts of interest before performing ACI techniques on patients.
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Affiliation(s)
| | | | - Leonard Onsen
- University of Illinois at Chicago, Chicago, Illinois, USA
| | - Aimee Bobko
- University of Illinois at Chicago, Chicago, Illinois, USA
| | | | | | - Adam Miller
- University of Illinois at Chicago, Chicago, Illinois, USA
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Desai S, Jayasuriya CT. Implementation of Endogenous and Exogenous Mesenchymal Progenitor Cells for Skeletal Tissue Regeneration and Repair. Bioengineering (Basel) 2020; 7:E86. [PMID: 32759659 PMCID: PMC7552784 DOI: 10.3390/bioengineering7030086] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 07/25/2020] [Accepted: 07/30/2020] [Indexed: 02/06/2023] Open
Abstract
Harnessing adult mesenchymal stem/progenitor cells to stimulate skeletal tissue repair is a strategy that is being actively investigated. While scientists continue to develop creative and thoughtful ways to utilize these cells for tissue repair, the vast majority of these methodologies can ultimately be categorized into two main approaches: (1) Facilitating the recruitment of endogenous host cells to the injury site; and (2) physically administering into the injury site cells themselves, exogenously, either by autologous or allogeneic implantation. The aim of this paper is to comprehensively review recent key literature on the use of these two approaches in stimulating healing and repair of different skeletal tissues. As expected, each of the two strategies have their own advantages and limitations (which we describe), especially when considering the diverse microenvironments of different skeletal tissues like bone, tendon/ligament, and cartilage/fibrocartilage. This paper also discusses stem/progenitor cells commonly used for repairing different skeletal tissues, and it lists ongoing clinical trials that have risen from the implementation of these cells and strategies. Lastly, we discuss our own thoughts on where the field is headed in the near future.
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Affiliation(s)
| | - Chathuraka T. Jayasuriya
- Department of Orthopaedics, Warren Alpert Medical School of Brown University and the Rhode Island Hospital, Providence, RI 02903, USA;
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Silva AN, Lim WAJ, Cheok JWG, Gatot C, Tan HCA. Autologous collagen-induced chondrogenesis versus microfracture for chondral defects of the knee: Surgical technique and 2-year comparison outcome study. J Orthop 2020; 22:294-299. [PMID: 32616991 DOI: 10.1016/j.jor.2020.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 06/06/2020] [Indexed: 10/24/2022] Open
Abstract
Objective Osteochondral lesions of the knee affect patients from all age groups with arthroscopic microfracture being the current gold standard of treatment of such lesions. Autologous collagen-induced chondrogenesis (ACIC) is a novel procedure that has recently been gaining popularity. This study aims to compare the 6 and 24 month post-operative outcomes between patients undergoing microfracture only and microfracture with ACIC. Methods Patients from both groups were assessed pre-operatively, at 6 and 24 months post-operatively for functional outcomes using SF-36 and IKDC scoring (International Knee Documentation Committee Subjective Knee Form). Results Both groups showed improved SF-36 and IKDC scores at 6 and 24 months, however patients who underwent ACIC showed better SF-36 mental component and IKDC scores 24 months after surgery. Conclusion This demonstrates that ACIC is an effective, single-stage, joint-preserving procedure which is comparable, if not better, in treating chondral defects.
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Affiliation(s)
- Amila N Silva
- Singapore General Hospital, Outram Road, 169608, Singapore
| | | | | | - Cheryl Gatot
- Singapore General Hospital, Outram Road, 169608, Singapore
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Glasbrenner J, Petersen W, Raschke MJ, Steiger M, Verdonk R, Castelli CC, Zappalà G, Fritschy D, Herbort M. Matrix-Augmented Bone Marrow Stimulation With a Polyglycolic Acid Membrane With Hyaluronan vs Microfracture in Local Cartilage Defects of the Femoral Condyles: A Multicenter Randomized Controlled Trial. Orthop J Sports Med 2020; 8:2325967120922938. [PMID: 32528994 PMCID: PMC7263152 DOI: 10.1177/2325967120922938] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 02/17/2020] [Indexed: 11/17/2022] Open
Abstract
Background Microfracture (MF) is an established operative treatment for small, localized chondral defects of the knee joint. There is evidence from animal studies that matrix augmentation of bone marrow stimulation (m-BMS) can improve the quality of the repair tissue formation. Purpose To evaluate the therapeutic outcome of a matrix made of polyglycolic acid and hyaluronan as compared with a conventional MF technique. Study Design Randomized controlled trial; Level of evidence, 1. Methods Patients between the ages of 18 and 68 years who had an articular femoral cartilage defect of 0.5 to 3 cm2 in the weightbearing area of the femoral condyles with indication for MF were included in this study. Patients were randomized and treated with either MF or m-BMS with Chondrotissue. Defect filling, as assessed on magnetic resonance imaging (MRI), at postoperative 12 weeks was defined as the primary outcome measure, with follow-up MRI at weeks 54 and 108. Follow-up data were also collected at 12, 54, and 108 weeks after surgery and included patient-reported clinical scores: visual analog scale for pain, Knee injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee score, and 36-Item Short Form Health Survey. Results MRI scans confirmed cartilage repair tissue formation in both groups 12 weeks after treatment. There was no significant difference between the m-BMS and MF groups in the percentage of defect filling at 12, 54, and 108 weeks postoperatively. No significant difference was found in terms of patient-reported clinical scores. Both groups showed significant improvement in 4 KOOS subscales-Pain, Activities of Daily Living, Sport and Recreation, and Quality of Life-at 54 and 108 weeks after treatment. Conclusion This is the first randomized controlled trial comparing m-BMS with a polyglycolic acid matrix with hyaluronan with MF. The use of the Chondrotissue implant in m-BMS has been proven to be a safe procedure. No difference was found between m-BMS and MF in terms of patient-reported outcome scores and MRI assessment until postoperative 2 years. Long-term follow-up studies including histological assessment are desirable for further investigation. Registration EUCTR2011-003594-28-DE (EU Clinical Trials Register).
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Affiliation(s)
- Johannes Glasbrenner
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Wolf Petersen
- Department of Orthopedics and Trauma Surgery, Martin Luther Hospital Berlin, Berlin, Germany
| | - Michael J Raschke
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Matthias Steiger
- Institute of Clinical Radiology, University Hospital Münster, Münster, Germany
| | - René Verdonk
- Department of Orthopedic Surgery and Traumatology, Ghent University Hospital, Ghent, Belgium
| | - Claudio C Castelli
- Department of Orthopaedic and Trauma Surgery, ASST Papa Giovanni XXIII Bergamo, Bergamo, Italy
| | - Giorgio Zappalà
- Department of Orthopaedic and Trauma Surgery, ASST Papa Giovanni XXIII Bergamo, Bergamo, Italy
| | - Daniel Fritschy
- Department of Orthopedic Surgery, Geneva University Hospital, Geneva, Switzerland
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21
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Lo Monaco M, Gervois P, Beaumont J, Clegg P, Bronckaers A, Vandeweerd JM, Lambrichts I. Therapeutic Potential of Dental Pulp Stem Cells and Leukocyte- and Platelet-Rich Fibrin for Osteoarthritis. Cells 2020; 9:cells9040980. [PMID: 32326610 PMCID: PMC7227024 DOI: 10.3390/cells9040980] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 04/07/2020] [Accepted: 04/13/2020] [Indexed: 12/18/2022] Open
Abstract
Osteoarthritis (OA) is a degenerative and inflammatory joint disorder with cartilage loss. Dental pulp stem cells (DPSCs) can undergo chondrogenic differentiation and secrete growth factors associated with tissue repair and immunomodulation. Leukocyte- and platelet-rich fibrin (L-PRF) emerges in regenerative medicine because of its growth factor content and fibrin matrix. This study evaluates the therapeutic application of DPSCs and L-PRF in OA via immunomodulation and cartilage regeneration. Chondrogenic differentiation of DPSCs, with or without L-PRF exudate (ex) and conditioned medium (CM), and of bone marrow-mesenchymal stem cells was compared. These cells showed differential chondrogenesis. L-PRF was unable to increase cartilage-associated components. Immature murine articular chondrocytes (iMACs) were cultured with L-PRF ex, L-PRF CM, or DPSC CM. L-PRF CM had pro-survival and proliferative effects on unstimulated and cytokine-stimulated iMACs. L-PRF CM stimulated the release of IL-6 and PGE2, and increased MMP-13, TIMP-1 and IL-6 mRNA levels in cytokine-stimulated iMACs. DPSC CM increased the survival and proliferation of unstimulated iMACs. In cytokine-stimulated iMACs, DPSC CM increased TIMP-1 gene expression, whereas it inhibited nitrite release in 3D culture. We showed promising effects of DPSCs in an in vitro OA model, as they undergo chondrogenesis in vitro, stimulate the survival of chondrocytes and have immunomodulatory effects.
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Affiliation(s)
- Melissa Lo Monaco
- Cardio & Organ Systems (COST), Biomedical Research Institute (BIOMED), Hasselt University, 3590 Diepenbeek, Belgium; (P.G.); (J.B.); (A.B.); (I.L.)
- Department of Veterinary Medicine, Integrated Veterinary Research Unit (IVRU) - Namur Research Institute for Life Science (NARILIS), University of Namur, 5000 Namur, Belgium;
- Correspondence: ; Tel.: +32-(0)-26-92-09
| | - Pascal Gervois
- Cardio & Organ Systems (COST), Biomedical Research Institute (BIOMED), Hasselt University, 3590 Diepenbeek, Belgium; (P.G.); (J.B.); (A.B.); (I.L.)
| | - Joel Beaumont
- Cardio & Organ Systems (COST), Biomedical Research Institute (BIOMED), Hasselt University, 3590 Diepenbeek, Belgium; (P.G.); (J.B.); (A.B.); (I.L.)
- Maastricht Radiation Oncology (MaastRO) Lab, GROW—School for Oncology and Developmental Biology, Maastricht University, 6229ER Maastricht, The Netherlands
| | - Peter Clegg
- Department of Musculoskeletal and Ageing Sciences, Institute of Lifecourse and Medical Sciences, University of Liverpool, L7 8TX Liverpool, UK;
| | - Annelies Bronckaers
- Cardio & Organ Systems (COST), Biomedical Research Institute (BIOMED), Hasselt University, 3590 Diepenbeek, Belgium; (P.G.); (J.B.); (A.B.); (I.L.)
| | - Jean-Michel Vandeweerd
- Department of Veterinary Medicine, Integrated Veterinary Research Unit (IVRU) - Namur Research Institute for Life Science (NARILIS), University of Namur, 5000 Namur, Belgium;
| | - Ivo Lambrichts
- Cardio & Organ Systems (COST), Biomedical Research Institute (BIOMED), Hasselt University, 3590 Diepenbeek, Belgium; (P.G.); (J.B.); (A.B.); (I.L.)
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Lloyd-Williams H, Hughes DA. A systematic review of economic evaluations of advanced therapy medicinal products. Br J Clin Pharmacol 2020; 87:2428-2443. [PMID: 32154598 PMCID: PMC8247439 DOI: 10.1111/bcp.14275] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 02/06/2020] [Accepted: 02/20/2020] [Indexed: 12/14/2022] Open
Abstract
Aims Advanced therapy medicinal products (ATMPs) represent a new category of medicinal products with a potential for transformative improvements in health outcomes but at exceptionally high prices. Routine adoption of ATMPs requires robust evidence of their cost‐effectiveness. Methods A systematic literature review of economic evaluations of ATMPs, including gene therapies, somatic cell therapies and tissue‐engineered products, was conducted. Literature was searched using MedLine, Embase, PubMed, Cochrane Register, the NHS Economic Evaluation Database and the grey literature of health technology assessment organisations with search terms relating to ATMPs and economic evaluations. Titles were screened independently by 2 reviewers. Articles deemed to meet the inclusion criteria were screened independently on abstract, and full texts reviewed. Study findings were appraised critically. Results 4514 articles were identified, of which 23 met the inclusion criteria. There was some evidence supporting the cost‐effectiveness of: chimeric antigen receptor T‐cell therapy axicabtagene–ciloleucel (Yescarta), embryonic neural stem cells, tumour infiltrating lymphocytes, in vitro expanded myoblast, autologous chondrocyte implantation, ex vivo gene therapy (Strimvelis) and voretigene neparvovec (Luxturna). However, estimates of cost‐effectiveness were associated with significant uncertainty and high likelihood of bias, resulting from largely unknown long‐term outcomes, a paucity of evidence on health state utilities and extensive modelling assumptions. Conclusion There are critical limitations to the economic evidence for ATMPs, most notably in relation to evidence on the durability of treatment effect, and the reliability of opinion‐based assumptions necessary when evidence is absent.
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Affiliation(s)
- Huw Lloyd-Williams
- Centre for Health Economics and Medicines Evaluation, Bangor University, Wales, UK
| | - Dyfrig A Hughes
- Centre for Health Economics and Medicines Evaluation, Bangor University, Wales, UK
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23
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Cell-Free Scaffolds as a Monotherapy for Focal Chondral Knee Defects. MATERIALS 2020; 13:ma13020306. [PMID: 31936591 PMCID: PMC7014136 DOI: 10.3390/ma13020306] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 12/30/2019] [Accepted: 01/06/2020] [Indexed: 12/15/2022]
Abstract
Chondral knee defects have a limited ability to be repaired. Current surgical interventions have been unable to regenerate articular cartilage with the mechanical properties of native hyaline cartilage. The use of a scaffold-based approach is a potential solution. Scaffolds are often implanted with cells to stimulate cartilage regeneration, but cell-based therapies are associated with additional regulatory restrictions, an additional surgical procedure for cell harvest, time for cell expansion, and the associated costs. To overcome these disadvantages, cell-free scaffolds can be used in isolation allowing native cells to attach over time. This review discusses the optimal properties of scaffolds used for chondral defects, and the evidence for the use of hydrogel scaffolds and hydrogel-synthetic polymer hybrid scaffolds. Preclinical and clinical studies have shown that cell-free scaffolds can support articular cartilage regeneration and have the potential to treat chondral defects. However, there are very few studies in this area and, despite the many biomaterials tested in cell-based scaffolds, most cell-free studies focused on a specific type I collagen scaffold. Future studies on cell-free scaffolds should adopt the modifications made to cell-based scaffolds and replicate them in the clinical setting. More studies are also needed to understand the underlying mechanism of cell-free scaffolds.
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Niemeyer P, Schubert T, Grebe M, Hoburg A. Treatment Costs of Matrix-Associated Autologous Chondrocyte Implantation Compared With Microfracture: Results of a Matched-Pair Claims Data Analysis on the Treatment of Cartilage Knee Defects in Germany. Orthop J Sports Med 2019; 7:2325967119886583. [PMID: 31840030 PMCID: PMC6896134 DOI: 10.1177/2325967119886583] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Articular cartilage damage is caused by traumatic sport accidents or age-related degeneration and might lead to osteoarthritis, which represents a socioeconomic burden to society. Cartilage damage in the knee is commonly treated surgically with microfracture (MFX) or matrix-associated autologous chondrocyte implantation (MACI). PURPOSE To quantify the initial and follow-up costs associated with MFX and MACI treatments from the viewpoint of statutory health insurance in Germany. STUDY DESIGN Economic decision analysis; Level of evidence, 2. METHODS This comparative study was based on an anonymized representative claims data set of 4 million patients covered by statutory health insurance in Germany. Patients undergoing outpatient or inpatient treatment with MACI or MFX for cartilage damage in the knee between January 1, 2012, and December 31, 2013, were included and evaluated over 5 years. Groups (MACI and MFX) were adjusted via propensity score matching before initial treatment. The matched groups were compared regarding their outpatient, inpatient, pharmaceutical, and other costs during the 5-year period. RESULTS In total, 127 patients per group were analyzed (59.1% male, 40.9% female; mean age, 37 years). In the year of the initial surgical procedure, costs were €14,804.13 in the MACI group and €5458.59 in the MFX group. In years 2 and 3 after initial surgery, treatment costs were comparable between patients treated with MACI (€2897.97 and €2114.87, respectively) and MFX (€2842.66 and €1967.42, respectively), with slightly higher treatment costs for those treated with MACI. In years 4 and 5 after surgery, costs were less in patients treated with MACI (€2154.79 and €1478.08, respectively) than in those treated with MFX (€2232.57 and €2061.63, respectively). Costs related to revision surgery were, on average, €3732 for MACI and €3765 for MFX. Thus, additional costs in years with revision surgery were €1672 for MACI and €1915 for MFX. CONCLUSION This was the first study to analyze a large representative population claims database with propensity score matching, and results indicated that follow-up costs of patients treated with MACI and MFX began to converge over time. We found that total costs for MACI were higher than for MFX but that additional costs for MACI were lower than previously reported. Perceived morbidity may have little to do with cost.
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Affiliation(s)
- Philipp Niemeyer
- Department of Orthopedics and Trauma Surgery, University Medical Center, Albert Ludwig University of Freiburg, Freiburg, Germany
- OCM Orthopädische Chirurgie München, Munich, Germany
| | | | | | - Arnd Hoburg
- Gelenk- und Wirbelsäulen-Zentrum Steglitz, Berlin, Germany
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Niemeyer P, Schubert T, Grebe M, Hoburg A. Matrix-Associated Chondrocyte Implantation Is Associated With Fewer Reoperations Than Microfracture: Results of a Population-Representative, Matched-Pair Claims Data Analysis for Cartilage Defects of the Knee. Orthop J Sports Med 2019; 7:2325967119877847. [PMID: 31673564 PMCID: PMC6804358 DOI: 10.1177/2325967119877847] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Background: Symptomatic cartilage defects of the knee are commonly surgically treated by microfracture (MFX) or matrix-associated chondrocyte implantation (M-ACI). Several randomized controlled trials have compared MFX and M-ACI, showing a tendency to lower reoperation rates for M-ACI, but results vary widely between studies. Purpose: To compare reoperation rates after MFX and M-ACI in cartilage defects of the knee outside clinical trials in a representative sample of the population. Study Design: Cohort study; Level of evidence, 3. Methods: This study was based on anonymized, population-representative claims data of 4 million insured persons in Germany. Patients who underwent MFX or M-ACI for cartilage defects of the knee with a follow-up of 2 years were compared. The primary endpoint was the need for a reoperation, defined as a claim for a second surgical procedure from the same patient at the knee joint (27 procedure codes), meniscus and cartilage (35 procedure codes), or patella (102 procedure codes) or the need for knee replacement (11 procedure codes). Group comparisons were performed using log-rank tests, with a 2-sided P value of <.05 to indicate significance. For adjusted analysis, propensity score matching was applied. Age, sex, comedications, and comorbidities were used as matching parameters. Results: A total of 6425 patients fulfilled the inclusion criteria: 6273 treated with MFX and 152 treated with M-ACI (mean age, 53 and 36 years, respectively). In the 2 years after treatment, 1271 patients in the MFX group needed a reoperation compared with 19 in the M-ACI group (20.3% vs 12.5%, respectively; P = .0199). For adjusted analysis after propensity score matching, 127 patients per group were analyzed. Their mean age was 37 years. At the end of the second follow-up year, 28 and 16 patients needed reoperations in the MFX and M-ACI groups, respectively (22.0% vs 12.6%, respectively; P = .0498). Conclusion: This study used a representative sample of the population and a broad definition of a reoperation, thus expanding evidence from clinical trials. We found a significant advantage of M-ACI in reoperation rates 2 years after treatment. After adjusting for age, sex, comedications, and comorbidities, M-ACI still showed significantly lower reoperation rates after 2 years.
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Affiliation(s)
- Philipp Niemeyer
- Department of Orthopedics and Trauma Surgery, University Medical Center Freiburg, Albert Ludwig University of Freiburg, Freiburg, Germany.,OCM Orthopädische Chirurgie München, Munich, Germany
| | | | | | - Arnd Hoburg
- Gelenk- und Wirbelsäulen-Zentrum Steglitz, Berlin, Germany
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26
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Fossum V, Hansen AK, Wilsgaard T, Knutsen G. Collagen-Covered Autologous Chondrocyte Implantation Versus Autologous Matrix-Induced Chondrogenesis: A Randomized Trial Comparing 2 Methods for Repair of Cartilage Defects of the Knee. Orthop J Sports Med 2019; 7:2325967119868212. [PMID: 31555714 PMCID: PMC6749791 DOI: 10.1177/2325967119868212] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background: Autologous matrix-induced chondrogenesis (AMIC) is a single-stage alternative to autologous chondrocyte implantation for treatment of localized cartilage defects of the knee. To our knowledge, no randomized controlled trial exists comparing the 2 methods. Purpose: To evaluate any difference in the outcome of AMIC as compared with collagen-covered autologous chondrocyte implantation (ACI-C). Study Design: Randomized controlled trial; Level of evidence, 2. Methods: A prospective randomized controlled clinical trial was designed to assess any differences in the outcomes between ACI-C and AMIC for the treatment of ≥1 chondral or osteochondral defects of the distal femur and/or patella. The inclusion period was set to 3 years, and the aim was to include 80 patients (40 in each group). Patient inclusion was broad, with few exclusion criteria. The primary outcome was change in Knee injury and Osteoarthritis Outcome Score (KOOS) at 2 years as compared with baseline. The secondary outcomes were the number of failures in each group at 2 years and the change in KOOS subscale, Lysholm, and pain visual analog scale (VAS) scores at 2 years as compared with baseline. A 2-sample t test with a significance level of P < .05 was used to compare the change in score from baseline between groups. Results: A total of 41 patients over 3 years were included in the study: 21 in the ACI-C group and 20 in the AMIC group. All the patients had prior surgery to the index knee. At 2-year follow-up, the clinical scores for both groups improved significantly from baseline. No significant differences between groups were seen in the change from baseline for KOOS (AMIC, 18.1; ACI-C, 10.3), any of the KOOS subscales, the Lysholm score (AMIC, 19.7; ACI-C, 17.0), or the VAS pain score (AMIC, 30.6; ACI-C, 19.6). Two patients in the AMIC group had progressed to a total knee replacement by the 2-year follow-up as compared with none in the ACI-C group. Conclusion: At 2-year follow-up, no significant differences were found regarding outcomes between ACI-C and AMIC. Mid- and long-term results will be important. Registration: NCT01458782 (ClinicalTrials.gov identifier).
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Affiliation(s)
- Vegard Fossum
- Department of Orthopaedic Surgery, The University Hospital of North Norway, Tromsø, Norway
| | - Ann Kristin Hansen
- Department of Orthopaedic Surgery, The University Hospital of North Norway, Tromsø, Norway.,Department of Clinical Medicine, UiT-The Arctic University of Norway, Tromsø, Norway
| | - Tom Wilsgaard
- Centre for Quality Improvement and Development, The University Hospital of North Norway, Tromsø, Norway.,Department of Community Medicine, UiT-The Arctic University of Norway, Tromsø, Norway
| | - Gunnar Knutsen
- Department of Orthopaedic Surgery, The University Hospital of North Norway, Tromsø, Norway
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Patel JM, Saleh KS, Burdick JA, Mauck RL. Bioactive factors for cartilage repair and regeneration: Improving delivery, retention, and activity. Acta Biomater 2019; 93:222-238. [PMID: 30711660 PMCID: PMC6616001 DOI: 10.1016/j.actbio.2019.01.061] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Revised: 01/25/2019] [Accepted: 01/29/2019] [Indexed: 12/29/2022]
Abstract
Articular cartilage is a remarkable tissue whose sophisticated composition and architecture allow it to withstand complex stresses within the joint. Once injured, cartilage lacks the capacity to self-repair, and injuries often progress to joint wide osteoarthritis (OA) resulting in debilitating pain and loss of mobility. Current palliative and surgical management provides short-term symptom relief, but almost always progresses to further deterioration in the long term. A number of bioactive factors, including drugs, corticosteroids, and growth factors, have been utilized in the clinic, in clinical trials, or in emerging research studies to alleviate the inflamed joint environment or to promote new cartilage tissue formation. However, these therapies remain limited in their duration and effectiveness. For this reason, current efforts are focused on improving the localization, retention, and activity of these bioactive factors. The purpose of this review is to highlight recent advances in drug delivery for the treatment of damaged or degenerated cartilage. First, we summarize material and modification techniques to improve the delivery of these factors to damaged tissue and enhance their retention and action within the joint environment. Second, we discuss recent studies using novel methods to promote new cartilage formation via biofactor delivery, that have potential for improving future long-term clinical outcomes. Lastly, we review the emerging field of orthobiologics, using delivered and endogenous cells as drug-delivering "factories" to preserve and restore joint health. Enhancing drug delivery systems can improve both restorative and regenerative treatments for damaged cartilage. STATEMENT OF SIGNIFICANCE: Articular cartilage is a remarkable and sophisticated tissue that tolerates complex stresses within the joint. When injured, cartilage cannot self-repair, and these injuries often progress to joint-wide osteoarthritis, causing patients debilitating pain and loss of mobility. Current palliative and surgical treatments only provide short-term symptomatic relief and are limited with regards to efficiency and efficacy. Bioactive factors, such as drugs and growth factors, can improve outcomes to either stabilize the degenerated environment or regenerate replacement tissue. This review highlights recent advances and novel techniques to enhance the delivery, localization, retention, and activity of these factors, providing an overview of the cartilage drug delivery field that can guide future research in restorative and regenerative treatments for damaged cartilage.
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Affiliation(s)
- Jay M Patel
- McKay Orthopaedic Research Laboratory, Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, United States; Translational Musculoskeletal Research Center, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA 19104, United States
| | - Kamiel S Saleh
- McKay Orthopaedic Research Laboratory, Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, United States; Translational Musculoskeletal Research Center, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA 19104, United States
| | - Jason A Burdick
- McKay Orthopaedic Research Laboratory, Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, United States; Translational Musculoskeletal Research Center, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA 19104, United States; Department of Bioengineering, School of Engineering and Applied Science, University of Pennsylvania, Philadelphia, PA 19104, United States
| | - Robert L Mauck
- McKay Orthopaedic Research Laboratory, Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, United States; Translational Musculoskeletal Research Center, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA 19104, United States; Department of Bioengineering, School of Engineering and Applied Science, University of Pennsylvania, Philadelphia, PA 19104, United States.
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28
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Song SJ, Park CH. Microfracture for cartilage repair in the knee: current concepts and limitations of systematic reviews. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:S108. [PMID: 31576315 DOI: 10.21037/atm.2019.05.11] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Sang Jun Song
- Department of Orthopaedic Surgery, College of Medicine, Graduate School, Kyung Hee University, Seoul, Korea
| | - Cheol Hee Park
- Department of Medicine, Graduate School, Kyung Hee University, Seoul, Korea
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29
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[Magnetic resonance imaging following cartilage repair of focal chondral lesions]. Radiologe 2019; 59:722-731. [PMID: 31168773 DOI: 10.1007/s00117-019-0552-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Focal cartilage lesions are common pathologies of weight-bearing joints. Clinical presentation ranges from asymptomatic patients to severe, pain-related movement deficits. Moreover, focal chondral lesions are risk factors for the development of osteoarthritis. There are various treatment options involving both surgical and nonsurgical treatments. Musculoskeletal radiologists should be aware of the various surgical options as well as the postsurgical imaging characteristics to depict whether the encountered imaging findings reflect the normal postoperative course or are indicative of a treatment failure. OBJECTIVES We aim to describe the most common surgical procedures for the repair of focal cartilage lesions and their typical postsurgical appearance on MRI studies. MATERIALS AND METHODS The literature in PubMed was searched with the terms "focal articular cartilage lesions", "chondral lesions", "MOCART", "Microfracture", "Osteochondral Autograft Transfer", "mosaicplasty", "Osteochondral Allograft Transplantation", "OATS", "OCT", "Autologous Chondrocyte Implantation", "ACI", "Matrix-Assisted Chondrocyte Implantation", "Autologous Matrix-induced Chondrogenesis". RESULTS Surgical methods for the treatment of focal cartilage lesions as well as the MR imaging features are explained.
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30
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Martín AR, Patel JM, Zlotnick HM, Carey JL, Mauck RL. Emerging therapies for cartilage regeneration in currently excluded 'red knee' populations. NPJ Regen Med 2019; 4:12. [PMID: 31231546 PMCID: PMC6542813 DOI: 10.1038/s41536-019-0074-7] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 04/29/2019] [Indexed: 12/13/2022] Open
Abstract
The field of articular cartilage repair has made significant advances in recent decades; yet current therapies are generally not evaluated or tested, at the time of pivotal trial, in patients with a variety of common comorbidities. To that end, we systematically reviewed cartilage repair clinical trials to identify common exclusion criteria and reviewed the literature to identify emerging regenerative approaches that are poised to overcome these current exclusion criteria. The term “knee cartilage repair” was searched on clinicaltrials.gov. Of the 60 trials identified on initial search, 33 were further examined to extract exclusion criteria. Criteria excluded by more than half of the trials were identified in order to focus discussion on emerging regenerative strategies that might address these concerns. These criteria included age (<18 or >55 years old), small defects (<1 cm2), large defects (>8 cm2), multiple defect (>2 lesions), BMI >35, meniscectomy (>50%), bilateral knee pathology, ligamentous instability, arthritis, malalignment, prior repair, kissing lesions, neurologic disease of lower extremities, inflammation, infection, endocrine or metabolic disease, drug or alcohol abuse, pregnancy, and history of cancer. Finally, we describe emerging tissue engineering and regenerative approaches that might foster cartilage repair in these challenging environments. The identified criteria exclude a majority of the affected population from treatment, and thus greater focus must be placed on these emerging cartilage regeneration techniques to treat patients with the challenging “red knee”.
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Affiliation(s)
- Anthony R Martín
- 1McKay Orthopaedic Research Laboratory, Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104 USA.,2Translational Musculoskeletal Research Center, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA 19104 USA
| | - Jay M Patel
- 1McKay Orthopaedic Research Laboratory, Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104 USA.,2Translational Musculoskeletal Research Center, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA 19104 USA
| | - Hannah M Zlotnick
- 1McKay Orthopaedic Research Laboratory, Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104 USA.,2Translational Musculoskeletal Research Center, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA 19104 USA.,3Department of Bioengineering, School of Engineering and Applied Science, University of Pennsylvania, Philadelphia, PA 19104 USA
| | - James L Carey
- 1McKay Orthopaedic Research Laboratory, Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104 USA
| | - Robert L Mauck
- 1McKay Orthopaedic Research Laboratory, Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104 USA.,2Translational Musculoskeletal Research Center, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA 19104 USA.,3Department of Bioengineering, School of Engineering and Applied Science, University of Pennsylvania, Philadelphia, PA 19104 USA
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Ahn J, Kim SA, Kim KW, Oh JH, Kim SJ. Optimization of TGF-β1-transduced chondrocytes for cartilage regeneration in a 3D printed knee joint model. PLoS One 2019; 14:e0217601. [PMID: 31120999 PMCID: PMC6532938 DOI: 10.1371/journal.pone.0217601] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 05/14/2019] [Indexed: 11/19/2022] Open
Abstract
A cell therapy product of transforming growth factor (TGF)-β1-transduced chondrocytes has been commercialized to treat osteoarthritis of the knee via intra-articular injection. The need for arthroscopic application of the cells to simultaneously treat intra-articular pathologies of knee osteoarthritis is increasingly urgent. The purpose of this study was to optimize TGF-β1-transduced chondrocytes for arthroscopic application. The optimal composition of chondrocytes and thrombin was initially determined by measuring the consolidation time of a diverse ratio of chondrocytes and thrombin mixed with 1 ml of fibrinogen. The consolidation time of the diverse ratio of fibrinogen and atelocollagen mixed with the determined optimal ratio of chondrocytes and thrombin was evaluated. The mixture of the determined optimal ratio of TGF-β1-transduced chondrocytes, atelocollagen, fibrinogen, and thrombin was applied to the cartilage defect of the 3D printed knee joint model arthroscopically. The status of the mixture in the defect was then evaluated. Chondrogenic activities of TGF-β1-transduced chondrocytes mixed with atelocollagen were evaluated. The determined ratio of TGF-β1-transduced chondrocytes to thrombin was 8:2 and that of fibrin to atelocollagen was also 8:2. Excellent maintenance of conformation of the mixture of TGF-β1-transduced chondrocytes, atelocollagen, fibrinogen, and thrombin in the cartilage defect of the 3D printed knee joint model was observed arthroscopically. Increased chondrogenic activities were observed in the group of TGF-β1-transduced chondrocytes mixed with atelocollagen. TGF-β1-transduced chondrocytes can be applied arthroscopically to treat cartilage defects of the knee at an optimized mixing ratio of atelocollagen, fibrinogen, and thrombin.
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Affiliation(s)
- Jiyong Ahn
- Department of Orthopaedic Surgery, College of Medicine, The Catholic University of Korea, Uijenong bu si, Gyeonggi-do, South Korea
| | - Seon Ae Kim
- Department of Orthopaedic Surgery, College of Medicine, The Catholic University of Korea, Uijenong bu si, Gyeonggi-do, South Korea
| | - Ki Won Kim
- Department of Orthopaedic Surgery, College of Medicine, The Catholic University of Korea, Uijenong bu si, Gyeonggi-do, South Korea
| | - Joon Hyuck Oh
- Department of Orthopaedic Surgery, College of Medicine, The Catholic University of Korea, Uijenong bu si, Gyeonggi-do, South Korea
| | - Seok Jung Kim
- Department of Orthopaedic Surgery, College of Medicine, The Catholic University of Korea, Uijenong bu si, Gyeonggi-do, South Korea
- * E-mail:
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Årøen A, Devitt BM. Penny-wise and pound-foolish. Knee Surg Sports Traumatol Arthrosc 2018; 26:985-988. [PMID: 29427219 PMCID: PMC5876256 DOI: 10.1007/s00167-018-4852-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Accepted: 01/31/2018] [Indexed: 11/26/2022]
Affiliation(s)
- Asbjørn Årøen
- Department of Orthopedic surgery, Institute of clinical Medicine, Akershus University Hospital, Campus Ahus University of Oslo, Oslo, Norway.
- Oslo Sports Trauma center, NIH, Oslo, Norway.
| | - Brian M Devitt
- OrthoSport Victoria, Epworth Richmond, 89 Bridge road, Richmond, VIC, 3121, Australia.
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