Validation of the Knee Injury and Osteoarthritis Outcome Score (KOOS) for the treatment of focal cartilage lesions

Treatment of Large Cartilage Defects in the Knee by Hydrogel-Based Autologous Chondrocyte Implantation: A 5-Year Follow-Up of a Prospective, Multicenter, Single-Arm Phase III Trial

ObjectiveTo evaluate efficacy and safety at 5 years after treatment with hydrogel-based autologous chondrocyte implantation (ACI) for large cartilage defects in the knee.DesignProspective, multicenter, single-arm, Phase III clinical trial. ACI was performed in 100 patients with focal full-thickness cartilage defects ranging from 4 to 12 cm2 in size. The primary outcome measure was the responder rate (defined as improvement by ≥10 points) at 2 years using the Knee Injury and Osteoarthritis Outcome Score (KOOS).ResultsThe preoperative overall KOOS was 39.8 points and continuously increased to 84.7 points at 5 years (mean increase 44.1 points, 95% CI = 40.4-47.9, P < 0.0001). The primary study endpoint (i.e., a KOOS responder rate of >40%) was descriptively met at each assessment timepoint from 3 months to 5 years (Month 3: 75.5%, 95% CI = 65.6-83.8; Year 2: 93.0%, 95% CI = 86.1-97.1, Year 5: 92.8%, 95% CI = 85.7-97.0). International Knee Documentation Committee (IKDC) subjective and objective scores and quality of life assessments (EQ-5D-5L) supported the results seen for the KOOS. The overall treatment failure rate at 5 years was 1%. All treatment-related adverse events were of mild or moderate intensity and mostly occurred within the first year after treatment.ConclusionsHydrogel-based ACI has been shown to be a safe and effective treatment option for patients with large knee cartilage defects with sustained efficacy up to 5 years as demonstrated by consistent and clinically relevant improvements in all investigated efficacy variables. No remarkable adverse events or safety issues were noted.

Correlation and Comparative Evaluation of MOCART and MOCART 2.0 for Assessing Cartilage Repair

Background and Objectives: Chondral and osteochondral lesions can lead to osteoarthritis if untreated, making accurate assessment of cartilage repair outcomes essential for optimizing treatment strategies. The objective of this study was to compare MOCART and MOCART 2.0 and to evaluate the clinical utility of both across different surgical cartilage repair techniques and various time points. Material and Methods: This study included 111 patients (age: 35 ± 10, 35% female) who underwent cartilage repair surgery of the knee between September 2015 and March 2022. A total of 188 postoperative magnetic resonance images were evaluated using MOCART and MOCART 2.0. The correlations between both scores, as well as to the change in Patient-Reported Outcome Measures (PROMs), were determined. Results: MOCART 2.0 scores (66 ± 13) were significantly higher than MOCART scores (58 ± 13, p < 0.001). Positive correlation was observed between scoring systems (r = 0.837, p < 0.001). There was no significant correlation between MOCART or MOCART 2.0 scores and the change in PROMs. Noticeably, there was a statistically significant correlation between both MOCART and MOCART 2.0 in the AutoCart subgroup across multiple timepoints for the change in PROMs. Conclusions: Based on radiographic-clinical outcome discordance, clinicians should not rely solely on MOCART or MOCART 2.0 scores when evaluating cartilage repair success but instead prioritize patient-reported functional improvements while using imaging as a complementary assessment tool.

Comparison of Three Different Techniques for the Treatment of Cartilage Lesions-Matrix-Induced Autologous Chondrocyte Implantation (MACI) Versus Autologous Matrix-Induced Chondrogenesis (AMIC) and Arthroscopic Minced Cartilage-A 2-Year Follow-Up on Patient-Reported Pain and Functional Outcomes

Background/Objectives: The treatment of cartilage damage is an ongoing challenge. Several techniques have been developed to address this problem. Matrix-Induced Autologous Chondrocyte Implantation (MACI) is often referred to as the "gold standard" for cartilage treatment. Numerous long-term outcome studies also have reported favorable results with Autologous Matrix-Induced Chondrogenesis (AMIC). Minced Cartilage Implantation (MCI) is a recently developed arthroscopic method. This technique has demonstrated promising outcomes, with the prospect of longer-term results still under investigation. This study aims to directly compare the patient-reported outcomes of these three techniques over a 2-year follow-up period. Methods: A total of N = 48 patients were included in the retrospective matched pair analysis (n = 16 MACI, n = 16 AMIC, n = 16 MCI). VAS, KOOS-Pain, and KOOS-Symptoms scores served as primary outcomes; the KOOS-ADL and -QOL and the Tegner Activity Scale (TAS) served as secondary outcomes. Results: All three groups did not differ from each other in the primary or secondary outcomes. Pain and function significantly improved from pre-surgery to two years after (VAS: p < 0.000; ES: η2 = 0.27; KOOS-Pain: p < 0.000; ES: η2 = 0.30; KOOS-Symptoms: p = 0.000; ES: η2 = 0.26; KOOS-ADL: p > 0.000; ES: η2 = 0.20; KOOS-QOL: p > 0.000; ES: η2 = 0.30). There was no significant effect of time on the activity level. Conclusions: All three procedures show good patient-reported outcomes, low complication rates, and long graft longevity in the 2-year follow-up. Therefore, all three methods seem to be equally recommendable for the treatment of cartilage lesions.

Knee injury and osteoarthritis outcome score and knee society score for the minimal clinically important differences after cruciate-retaining total knee arthroplasty: Two-year follow up

BACKGROUND

This study investigated changes in the Knee Injury and Osteoarthritis Outcome Score (KOOS), 2011 Knee Society Score (KSS), and minimal clinically important differences (MCIDs) of these scores preoperatively to 2 years after total knee arthroplasty (TKA).

METHODS

This single-center retrospective study included 168 patients who underwent primary cruciate-retaining (CR) TKA using the subvastus approach. The KOOS and KSS were assessed preoperatively and during the 3-month, 6-month, 1-year, and 2-year follow ups. The MCIDs of the KOOS and KSS were calculated using distribution-based methods with standard deviation.

RESULTS

All patient-reported outcome measures improved considerably from preoperatively to 3 months postoperatively. KOOS pain and symptom scores considerably improved at approximately 2 years postoperatively, with KOOS activities of daily living (ADL) and sports/recreation subscale scores showing rapid improvement within 3 months, followed by smaller gains. MCID thresholds for KOOS subscales were as follows: pain, 14.3-15.3; symptoms, 14.1-15.6; ADL, 15.2-16.0; sport/recreation, 11.7-11.8; and quality of life, 13.6-14.4. KSS objective knee indicators and satisfaction improved considerably approximately 2 years postoperatively; however, scores on the expectation and functional activity subscales did not improve after 1 year. MCID thresholds for KSS subscales were as follows: objective knee indicators, 4.6-4.7; satisfaction, 4.9-5.0; expectation, 2.4; and functional activities, 12.0-12.3.

CONCLUSIONS

Improvements in the KSS objective knee indicators and KOOS subjective pain and symptom scores were similar over the 2-year follow up. These findings may help better understand the expected outcomes of CR-type TKA, especially in severe osteoarthritis cases, thereby informing patient counseling.

Inconsistencies in clinically significant outcome metrics for knee cartilage repair: a systematic review

To systematically review the variability of reporting of clinically significant outcomes (CSOs) including minimal clinically important difference (MCID), substantial clinical benefit (SCB) and patient acceptable symptom state (PASS), and threshold calculation methods following surgical treatments for cartilage defects of the knee. A systematic review was performed using the 2020 Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. A literature search was performed on August 12th, 2024, using the PubMed, Embase, and Scopus online databases for human clinical studies with publication dates ranging from 2010 to 2024 reporting on MCID, SCB, or PASS following surgical treatments for cartilage defects of the knee. Study demographics, patient-reported outcome measures (PROMs), CSO thresholds, and methods of CSO calculation were collected. A total of 19 studies (n = 3659 patients) with an average follow-up of 36.5 months were included. A total of 14 (93.3%) studies reported MCID, six (31.8%) studies reported SCB, and five (26.3%) studies reported PASS. Of the included studies, 16 (80%) referenced another study for calculating their CSO whereas three (20%) studies calculated their own CSO. A total of 16 different PROMs were reported among the included studies. Eight studies utilized the anchor-based method for CSO calculation, ten studies used both the anchor and the distribution-based methods for calculation, while only one study used the distribution-based method alone. There is considerable variation in the reporting and calculation methods of MCID, SCB, and PASS for different PROMs following surgical treatments for cartilage defects of the knee.Level of Evidence: IV, Systematic Review of Level I-IV studies.

Microfragmented Adipose Tissue Injection Reduced Pain Compared With a Saline Control Among Patients With Symptomatic Osteoarthritis of the Knee During 1-Year Follow-Up: A Randomized Controlled Trial

PURPOSE

To evaluate the effectiveness of microfragmented adipose tissue (MFAT) for pain relief and improved joint functionality in osteoarthritis (OA) of the knee in a randomized controlled clinical trial with 1-year follow-up.

METHODS

Seventy-five patients were stratified by baseline pain level and randomized to 1 of 3 treatment groups: MFAT, corticosteroid (CS), or saline control (C) injection. Patients 18 years of age or older, diagnosed with symptomatic OA of the knee, with radiographic evidence of OA of the knee and a visual analog pain scale score of 3 of 10 or greater were included. Patients were excluded if they had any previous intra-articular knee injection, current knee ligamentous instability, or an allergy to lidocaine/corticosteroid. The visual analog pain scale, Western Ontario and McMaster Universities Osteoarthritis Index, and the Knee Injury and Osteoarthritis Outcome score (KOOS) were recorded preprocedure and at 2 weeks, 6 weeks, 3 and 6 months, and 1-year follow-up.

RESULTS

MFAT demonstrated consistent and statistically significant improvements across all primary outcome measures for joint pain and functionality compared with C. For MFAT, there was a significant improvement over baseline at each follow-up, with median (95% confidence interval) KOOS Pain score changes of 18.1 (11.1-26.4) at week 2 to 27.8 (19.4-37.5) at 1 year. For CS, the median KOOS pain score reached a maximum of 22.2 (15.3-30.6) at week 2, only to level off to 13.9 (-2.8 to 29.2), a level not statistically different from baseline, at 1 year. The median changes for C hovered around 6 to 11 points, with statistically significant improvements over baseline indicating a placebo effect. Similar trends were seen for the Western Ontario and McMaster Universities Osteoarthritis Index Pain score and VAS Pain score.

CONCLUSIONS

In this study, MFAT demonstrated a clinically significant improvement in primary outcome scores compared with the C group, whereas the CS group only showed statistically significant improvement compared with the C group at 2 and 6 weeks. This finding indicates that MFAT may be a viable alternative treatment for patients with OA of the knee who fall into the orthopaedic treatment gap.

LEVEL OF EVIDENCE

Level II, partially blinded, randomized controlled clinical trial.

A prospective randomized controlled trial comparing biphasic cartilage repair implant with microfracture in small chondral lesions of knee: findings at five-year-follow-up

BACKGROUND

Full-thickness cartilage defects have a significant impact on the function of joints in young adults, and the treatment of cartilage defects has been a challenge, as cartilage tissue is an avascular tissue. This study aimed to compare the clinical and radiological outcomes of Biphasic Cartilage Repair Implant (BiCRI) and microfracture treatments for knee cartilage defects.

METHODS

This randomized controlled clinical trial enrolled patients with symptomatic knee chondral lesions smaller than 3 cm2. They were randomized to either the BiCRI (n = 11) or microfracture (n = 10) treatment groups. BiCRI or microfracture surgical procedures were performed on the patients, who were subsequently followed for a period of five years. Primary outcome measures included the International Knee Documentation Committee (IKDC) score, Knee Injury and Osteoarthritis Outcome Score (KOOS), Visual Analog Scale (VAS) score, Magnetic Resonance Imaging (MRI) measured cartilage thickness, and the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score.

RESULTS

21 patients were enrolled, who were subsequently followed for a period of five years. Both BiCRI and microfracture treatments demonstrated significant improvements in IKDC, KOOS and VAS scores, with no significant differences between the two. MRI analysis indicated a significant increase in minimum cartilage thickness with BiCRI treatment (median of difference: 1 mm, P = 0.026)), in contrast to the nonsignificant change in the microfracture group (median of difference: 1 mm, P = 0.102). The MOCART scores revealed a significant increase percentage of isointense signal intensity identical to the adjacent articular cartilage (P = 0.03) in the BiCRI group from the 2-year to the 5-year mark, while the scores remained stable in the microfracture group. Moreover, the BiCRI technique displayed superior performance in graft infill at 5 years (P = 0.008), border integration at 5 years (P = 0.04), surface contour at 2 years (P = 0.04) compared to microfracture.

CONCLUSIONS

Both BiCRI and microfracture treatments showed significant effectiveness in improving clinical outcomes in patients with small symptomatic articular cartilage defects of the knee, with the BiCRI group demonstrating a superior radiological outcome than microfracture, over a five-year period. However, the sample size of our study is relatively small to reach a definite conclusion, and further studies with larger sample size and longer follow up are recommended. Trial registration The trial was registered on ClinicalTrials.gov under the identifier NCT01477008.

Rapid preparation of injectable dual-network hydrogels for biomedical applications using UV-triggered sulfhydryl click reactions

The use of hydrogels to mimic natural cartilage implantation can effectively solve the current problems of insufficient cartilage donors and low rate of injury healing. In particular, injectable hydrogels are less invasive in clinical applications and better able to fill uneven injury surfaces. Here, we prepared NorCS and CS-SH by modifying chitosan with 5-norbornene-2-carboxylic acid and N-Acetyl-L-cysteine, respectively. Dual-network hydrogels were prepared by using UV-triggered thiol-ene click reaction between NorCS and CS-SH and the metal coordination between SA and Ca2+. The prepared hydrogels can be cross-linked quickly and exhibit excellent degradability, self-healing and injectable properties. At the same time, the hydrogel also showed good cytocompatibility and could significantly restore the motor function of mice. This study provides an effective strategy for preparing injectable hydrogels capable of rapid cross-linking.

Evaluating Knee Recovery Beyond Patient Reports: A Comparative Study of Smart Implantable Device-Derived Gait Metrics Versus Patient-Reported Outcome Measures in Total Knee Arthroplasty

BACKGROUND

Total Knee Arthroplasty (TKA) is frequently performed for advanced osteoarthritis, with patient-reported outcome measures (PROMs) traditionally reporting on efficacy. These subjective evaluations, although useful, may inaccurately reflect post-TKA activity levels. With technological advancements, smart implantable devices (SIDs) offer objective, real-time gait metrics, potentially providing a more accurate postoperative recovery assessment. This study compares these objective metrics with PROMs to evaluate TKA success more effectively.

METHODS

We conducted a retrospective cohort study with 88 participants undergoing TKA using a SID. Eligible patients were aged 18 years or older and had advanced osteoarthritis. We excluded those who had bilateral TKAs, joint infections, or neuromuscular disease. The SID system collected daily gait metrics, including step count, distance traveled, walking speed, stride length, cadence, and functional knee range of motion. The PROMs, including Knee Injury and Osteoarthritis Outcome Score-Joint Replacement, Veterans Rand 12 Physical Component Summary, and Veterans Rand 12 Mental Component Summary, were analyzed against SID gait metrics. Among the 88 patients, 80 provided continuous data over 12 weeks.

RESULTS

All gait metrics, except stride length, significantly increased at the 12-week point (P < .05). The PROMs also significantly improved postoperatively (P < .05). Initial low positive correlations between 12-week PROMs and SID metrics decreased after adjusting for demographic variables, leaving only weak correlations between the Veterans Rand 12 Physical Component Summary and Knee Injury and Osteoarthritis Outcome Score-Joint Replacement with functional knee range of motion (r = 0.389, P = .002; r = 0.311, P = .014, respectively), and Veterans Rand 12 Mental Component Summary with step count (r = 0.406, P = .001) and distance traveled (r = 0.376, P = .003).

CONCLUSIONS

This study indicates that both PROMs and SID gait metrics show significant improvements post-TKA, though they correlate weakly with each other, suggesting a possible discrepancy between perceived recovery and actual functional improvement. The SID gait metrics might provide a valuable addition to traditional PROMs by offering an objective representation of physical capabilities unaffected by patient compliance or subjective perceptions of recovery. Further research is needed to validate these findings in larger populations and to explore whether integrating SID metrics can enhance long-term functional outcomes.

Drop in survivorship 13 years after AMIC procedures in aligned knees: A long-term follow-up

PURPOSE

Autologous matrix-induced chondrogenesis (AMIC) showed promising short-term results comparable to microfracture. This study aims to assess the 19-year outcomes of AMIC, addressing the lack of long-term data.

METHODS

Retrospective cohort of 34 knees treated with AMIC underwent a 19-year follow-up. The primary outcome was AMIC survival, considering total knee arthroplasty as a failure event. Survival analysis for factors that were associated with longer survival of the AMIC was also performed. Clinical and radiological outcome scores were analysed for the AMIC group.

RESULTS

Twenty-three knees were available for follow-up analysis. Of these, 14 (61%) underwent revision surgery for total knee arthroplasty (TKA). The mean time was 13.3 ± 2.5 years (range: 9-17 years). Secondary outcomes showed that increased age at surgery (hazard ratio [HR]: 1.05; p = 0.021) and larger defect size (HR: 1.95; p = 0.018) were risk factors for failure. Concomitant proximal tibial osteotomy (HR: 0.22; p = 0.019) was associated with longer survival. The remaining nine knees (39%) were analysed as a single group. The mean clinical score at follow-up of 18.6 ± 0.9 SD years was 79.5 ± 19.7 SD for the Lysholm score, 1.8 ± 1.5 SD for the visual analog scale score, 74.2 ± 22.4 SD for the KOOS score and a median of 3 (range: 3-4) for the Tegner activity scale.

CONCLUSIONS

The mean survival time of 13.3 years indicates the durability of AMIC in properly aligned knees. Nonetheless, despite a 61% conversion to TKA, the knees that persisted until the 19-year follow-up remained stable, underscoring the procedure's longevity and consistent clinical outcomes.

LEVEL OF EVIDENCE

Level IV.

Acellular Particulated Costal Allocartilage Improves Cartilage Regeneration in High Tibial Osteotomy: Data From a Randomized Controlled Trial

OBJECTIVE

This study aimed to compare short-term arthroscopic and clinical outcomes between microfractures with (treatment group) and without (control group) acellular particulated costal allocartilage in patients undergoing concurrent high tibial osteotomy (HTO).

DESIGN

This retrospective cohort study enrolled 19 and 21 patients in the treatment and control groups, respectively, and reviewed them at a minimum 2-year follow-up after HTO. Cartilage regeneration status was evaluated according to the International Cartilage Repair Society-Cartilage Repair Assessment (ICRS-CRA) grading and Koshino's macroscopic staging systems during medial locked plate removal. Patient-reported measures, including the visual analog scale pain score, Knee Injury and Osteoarthritis Outcome Score, and International Knee Documentation Committee score, assessed clinical outcomes.

RESULTS

The total points of the ICRS-CRA grading system were significantly higher in the treatment group than in the control group (7.7 ± 3.8 vs 4.2 ± 3.0, respectively; P = 0.007). Likewise, the cartilage status according to Koshino's macroscopic staging system was better in the treatment group (P = 0.022). Patient-reported functional outcomes significantly improved postoperatively but were equivalent between the study groups at the final follow-up.

CONCLUSIONS

Microfractures augmented with acellular particulated costal allocartilage resulted in better repair quality than microfractures alone at a minimum 2-year follow-up after HTO, but functional outcomes improved similarly for both treatment approaches.

Management of patellar and trochlear cartilage lesions with matrix-induced autologous chondrocyte implantation in conjunction with patellofemoral realignment procedures improves patient-reported outcomes and magnetic resonance image appearance

OBJECTIVES

The aim of this study is to evaluate the relationship between the achievement of clinically significant improvement in patient-reported outcome measures (PROMs) and the postoperative magnetic resonance image (MRI) appearance of matrix-associated chondrocyte implantation (MACI), in conjunction with patellofemoral realignment procedures, for the treatment of grade-IV chondral defects about the patellofemoral joint.

METHODS

A retrospective review of patients undergoing MACI for grade-IV chondral defects of the patella or trochlea by a single sports-medicine-fellowship-trained surgeon from 2017 to 2020 was performed. Concomitant realignment procedures, including tibial tubercle osteotomy and medial patellofemoral ligament reconstruction, were also performed as needed. Patients with preoperative and minimum 1-year postoperative PROMs and postoperative knee MRI were included. MRI scans were obtained at 6.3 (interquartile range: 5.8, 7.5) months postoperatively. A fellowship-trained musculoskeletal radiologist assigned a Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score (range: 0-100, with 100 equating to complete graft healing) to each MRI. Achievement of the minimal clinically important difference (MCID) for International Knee Documentation Committee (IKDC), Knee Injury and Osteoarthritis Score-Quality of Life, and Kujala scores were determined for each patient. Paired t-tests or Wilcoxon rank-sum tests were used to evaluate for an association between achievement of the MCID for each PROM and MOCART score. The average follow-up time and time from surgery to PROMs were 2.7 ​± ​1.5 years and 1.7 ​± ​0.66 years, respectively.

RESULTS

Thirty patients were included. There was a significant improvement in all PROMs from preoperative to postoperative (p ​< ​0.001). More than two-thirds of patients achieved the MCID for each PROM. Patients who achieved the MCID for IKDC had significantly higher MOCART scores (66.5 ​± ​16.2) than those who did not meet the MCID for IKDC (50.6 ​± ​23.6, p ​= ​0.043).

CONCLUSION

MACI for the treatment of patellofemoral chondral injuries is associated with clinically significant improvement in PROMs at short-term follow-up. Clinically significant improvements in IKDC scores are associated with a more mature MRI appearance of the autologous chondrocyte implantation graft on postoperative MRI, as indicated by higher MOCART scores.

LEVEL OF EVIDENCE

IV-Case Series.

Harnessing Peptide-Based Hydrogels for Enhanced Cartilage Tissue Engineering

Cartilage tissue engineering remains a formidable challenge due to its complex, avascular structure and limited regenerative capacity. Traditional approaches, such as microfracture, autografts, and stem cell delivery, often fail to restore functional tissue adequately. Recently, there has been a surge in the exploration of new materials that mimic the extracellular microenvironment necessary to guide tissue regeneration. This review investigates the potential of peptide-based hydrogels as an innovative solution for cartilage regeneration. These hydrogels, formed via supramolecular self-assembly, exhibit excellent properties, including biocompatibility, ECM mimicry, and controlled biodegradation, making them highly suitable for cartilage tissue engineering. This review explains the structure of cartilage and the principles of supramolecular and peptide hydrogels. It also delves into their specific properties relevant to cartilage regeneration. Additionally, this review presents recent examples and a comparative analysis of various peptide-based hydrogels used for cartilage regeneration. The review also addresses the translational challenges of these materials, highlighting regulatory hurdles and the complexities of clinical application. This comprehensive investigation provides valuable insights for biomedical researchers, tissue engineers, and clinical professionals aiming to enhance cartilage repair methodologies.

Neutral to slightly undercorrected mechanical leg alignment provides superior long-term results in patients undergoing matrix-associated autologous chondrocyte implantation

PURPOSE

The aim of this study was to evaluate the role of leg alignment on long-term clinical outcome after matrix-associated autologous chondrocyte implantation (M-ACI) and to define an individualized target range to optimize clinical outcome.

METHODS

The present study examined patients who underwent M-ACI of the femoral condyle. The Knee Injury and Osteoarthritis Outcome Score (KOOS) and Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) were used to assess the results. Clinical outcomes were related to Patient Acceptable Symptomatic State (PASS). For intra- and interobserver reliability of mechanical tibiofemoral angle, mechanical medial proximal tibial angle and mechanical lateral distal femoral angle, we calculated intraclass correlation coefficients using a two-way mixed model with absolute agreement. A regression model and receiver-operating characteristics curve were used to identify an individual range of alignment where a favourable clinical outcome could be expected in the long term.

RESULTS

Additional osteotomy was performed in 50% of patients with similar clinical outcomes as physiologically aligned patients (p > 0.05). The curve-fitting regression model identified a target range of -2.5° valgus to 4.5° varus for ideal postoperative alignment (R2 = 0.12, p = 0.01). Patients within this range were more likely to achieve PASS (70% vs. 27%, p = 0.001). In medially treated defects, a refined range of -2.5° valgus to 4° varus alignment was found (R2 = 0.15, p = 0.01). These patients were more likely to achieve PASS (67% vs. 30%, p = 0.01) and showed favourable postoperative KOOS and MOCART scores (p = 0.02). Patients with lateral defects were more likely to achieve PASS within a range of -2° valgus and 0.5° varus (90% vs. 45%, p = 0.03) and showed favourable postoperative KOOS and MOCART scores (p = not significant).

CONCLUSIONS

An individual range of leg alignment-whether achieved by osteotomy or physiologic alignment-should be respected in M-ACI treatment. A neutral to slightly undercorrected alignment favours the postoperative outcome after M-ACI. When planning surgery for patients with focal cartilage defects of the femoral condyle, these ranges should be recognized as critical factors.

LEVEL OF EVIDENCE

Level III.

Minimum 10-Year Outcomes of Matrix-Induced Autologous Chondrocyte Implantation in the Knee: A Systematic Review

BACKGROUND

Matrix-induced autologous chondrocyte implantation (MACI) is an established cell-based therapy for the treatment of chondral defects of the knee. As long-term outcomes are now being reported in the literature, it is important to systematically review available evidence to better inform clinical practice.

PURPOSE

To report (1) subjective patient-reported outcomes (PROs) and (2) the rate of graft failure, reoperation, and progression to total knee arthroplasty (TKA) after undergoing MACI of the knee at a minimum 10-year follow-up.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A comprehensive search of Ovid MEDLINE and Epub Ahead of Print, In-Process & Other Non-Indexed Citations and Daily; Ovid Embase; Ovid Cochrane Central Register of Controlled Trials; Ovid Cochrane Database of Systematic Reviews; and Scopus from 2008 to September 15, 2022, was conducted in the English language. Study eligibility criteria included (1) full-text articles in the English language, (2) patients undergoing a MACI within the knee, (3) clinical outcomes reported, and (4) a minimum 10-year follow-up.

RESULTS

In total, 168 patients (99 male, 69 female; mean age, 37 years [range, 15-63 years]; mean body mass index, 26.2 [range, 18.6-39.4]) representing 188 treated chondral defects at a minimum 10-year follow-up after MACI were included in this review. Significant and durable long-term improvements were observed across multiple PRO measures. Follow-up magnetic resonance imaging (MRI), when performed, also demonstrated satisfactory defect fill and an intact graft in the majority of patients. The all-cause reoperation rate was 9.0%, with an overall 7.4% rate of progression to TKA at 10 to 17 years of follow-up.

CONCLUSION

At a minimum 10-year follow-up, patients undergoing MACI for knee chondral defects demonstrated significant and durable improvements in PROs, satisfactory defect fill on MRI-based assessment, and low rates of reoperation and TKA. These data support the use of MACI as a long-term treatment of focal cartilage defects of the knee.

Item-Specific Knee Injury and Osteoarthritis Outcome Score Characterization of Patients With Medial Meniscus Root Tear

Background

Most studies regarding medial meniscus posterior root tear (MMPRT) report total Knee injury and Osteoarthritis Outcome Score (KOOS) subscale values as important patient-reported outcomes, but there are few symptom-specific characterizations of patients with MMPRT.

Purpose/Hypothesis

The purpose of this study was to characterize the prevalence and severity of symptoms and functional limitations among patients with MMPRT based on item-level KOOS responses. It was hypothesized that patients with MMPRT would show similar symptoms to those of other meniscal tear types, with items from the KOOS pain subscale forming a majority of the most severe and prevalent symptoms.

Study Design

Cross-sectional study; Level of evidence, 3.

Methods

The records of 1466 patients with medial meniscus root tear between January 2017 and December 2021 at a single institution were reviewed. KOOS subscale scores and item-specific responses from initial evaluation were collected for each patient. Each KOOS item was scored on a scale from 1 (none/least severe) to 5 (extreme/most severe). Median and mean item-level responses were calculated and ranked in order of most to least severe. For statistical analysis, item-level prevalence rates were calculated as the proportion of patients reporting at least mild symptoms and ranked from most to least prevalent.

Results

Included were 61 patients with MMPRT verified on magnetic resonance imaging (MRI). The most severe items according to item-level KOOS response were as follows: awareness of knee problem (mean, 4.62 [95% CI, 4.47-4.78]), difficulty jumping (mean, 4.06 [95% CI, 3.73-4.39]), difficulty twisting or pivoting (mean, 4.04 [95% CI, 3.76-4.32]), difficulty kneeling (mean, 3.98 [95% CI, 3.65-4.31]), and modification of lifestyle (mean, 3.94 [95% CI, 3.69-4.20]). The most prevalent items were knee stiffness later in the day, pain going up- or downstairs, difficulty ascending stairs, difficulty getting in and out of the car, difficulty twisting or pivoting, awareness of knee problem, and modification of lifestyle, with all patients reporting at least mild symptoms for each. Of the 11 most severe and prevalent symptoms, 8 came from the KOOS-Pain item-specific responses.

Conclusion

Pain-related items made up a majority of the most severe and most prevalent symptoms as identified by the item-specific KOOS responses. However, meniscal symptoms commonly seen in other tear types, such as clicking and knee stiffness, were still quite prevalent in patients with MMPRT.

Hydrogel-Based Matrix-Associated Autologous Chondrocyte Implantation Shows Greater Substantial Clinical Benefit at 24 Months Follow-Up than Microfracture: A Propensity Score Matched-Pair Analysis

OBJECTIVE

To compare substantial clinical benefit (SCB) of a hydrogel-based, matrix-associated autologous chondrocyte implantation (M-ACI) method versus microfracture (MFx) in the treatment of knee cartilage defects.

DESIGN

Propensity score matched-pair analysis, using the MFx control group of a phase III study as comparator for M-ACI treatment in a single-arm phase III study, resulting in 144 patients in the matched-pair set.

RESULTS

Groups were comparable regarding baseline Knee Injury and Osteoarthritis Outcome Score (KOOS), sex, age, body mass index, symptom duration, smoking status, and previous knee surgeries. Defect sizes in the M-ACI group were significantly larger than in the MFx group (6.4 cm2 vs. 3.7 cm2). Other differences concerned location, number, and etiology of defects that were not considered to influence the interpretation of results. At 24 months, significantly more patients in the M-ACI group achieved SCB in KOOS pain (72.2% vs. 48.6%; P = 0.0108), symptoms (84.7% vs. 61.1%, P = 0.0039), sports/recreation (84.7% vs. 56.9%, P = 0.0008), and quality of life (QoL; 72.2% vs. 44.4%, P = 0.0014). The SCBs for KOOS activities in daily living and International Knee Documentation Committee score were higher for M-ACI but not significantly different from MFx. The SCB rates consistently favored M-ACI from 3 months onward. The highest improvements from baseline at 24 months in patients with SCB were observed for KOOS sports/rec. (M-ACI: 60.8 points, MFx: 55.9 points) and QoL (M-ACI: 58.1, MFx: 57.4).

CONCLUSION

Hydrogel-based M-ACI demonstrated superior SCB in KOOS pain, symptoms, sports/rec., and QoL compared with MFx in patients with knee cartilage defects through 2 years follow-up.

The AMADEUS score is not a sufficient predictor for functional outcome after autologous chondrocyte implantation (ACI) of the knee: data from the German Cartilage Registry (KnorpelRegister DGOU)

INTRODUCTION

The AMADEUS (Area Measurement And DEpth and Underlying Structures) score has advanced to a commonly used tool for MRI-based chondral defect severity grading prior to cartilage knee surgery. It was the intention of this study to assess the AMADEUS for a potential correlation with clinical data by patient-reported outcome measures (PROMs).

METHODS

A total of 51 patients undergoing ACI (autologous chondrocyte implantation) between 2016 and 2022 were found eligible and retrospectively analyzed. All patients were registered in the German Cartilage Registry prior to surgery and follow-up data were collected using the Knee Osteoarthritis Outcome score (KOOS), the International Knee Documentation Committee (IKDC) Form and the numeric rating scale (NRS). Pre-operative MRI images were scored by three raters using the AMADEUS classification system, and an overall AMADEUS score was calculated which was subsequently correlated with pre- and post-operative PROMs.

RESULTS

Mean patient age was 32.67 ± 8.37 years and mean defect size area 343.04 mm2 ± 139.45 mm2. No correlative capacity of the pre- and postoperative IKDC, KOOS or NRS scores was found with the AMADEUS final score or any of its subscores. From the pre- to postoperative visit, a significant improvement of the PROMs (IKDC: 45.53 ± 21.00 vs. 59.83 ± 17.93, p = 0.04; KOOS Pain: 58.00 ± 16.70 vs. 76.06 ± 19.20, p = 0.03; KOOS ADL: 64.17 ± 18.76 vs. 82.11 ± 16.68, p < 0.01; KOOS Sports: 26.11 ± 18.52 vs. 50.56 ± 23.94, p = 0.01; KOOS QOL: 25.50 ± 14.26 ± 45.28 ± 19.03, p = 0.00) was found. Intraclass correlation coefficients showed an overall good interrater agreement for the AMADEUS total score (ICC = 0.75).

CONCLUSIONS

Study results suggest no correlative capacity of the AMADEUS with routinely used PROMs in patients undergoing ACI. Therefore, radiographically assessed cartilage defect characteristics poorly translate to pre- and postoperative patient-reported outcome data.

Bipolar Lesions of the Knee Are Associated With Inferior Clinical Outcome Following Articular Cartilage Regeneration. A Propensity Score-Matched Analysis Including 238 Patients of the German Cartilage Registry (KnorpelRegister DGOU)

PURPOSE

To determine whether bipolar lesions (BL) are associated with inferior clinical outcome following articular cartilage regeneration (CR) compared to unipolar lesions (UL).

METHODS

A registry-based study, including patients undergoing isolated CR for focal knee cartilage lesions was performed. Lesions were considered UL or BL depending on the opposing cartilage. Propensity score matching was applied to eliminate potential confounders. Two groups comprising 119 patients with similar baseline characteristics were matched. The Knee Injury and Osteoarthritis Outcome Score (KOOS) at baseline, 6, 12, 24, and 36 months following CR served as primary outcome measure. KOOS improvement, reaching the minimal clinically important difference (MCID), KOOS subcomponents, and failure rates were calculated.

RESULTS

Autologous chondrocyte implantation (ACI) was the most frequently performed procedure in both groups with 63.0% (BL) and 46.6% (UL). There was a significant difference regarding KOOS at 24 months between UL (76.39 ± 14.96) and BL (69.83 ± 18.83; P = .028), which did not exceed the threshold of MCID. No significant difference was detected at any other follow-up. KOOS improvement from baseline was lower in the BL group at all follow-ups and peaked at 36 months in both groups (UL [26.00 ± 16.12] vs. BL [16.63 ± 17.29]; P = .024). The failure rate in the BL group was higher at 8.2% (9/110) compared to the UL group at 3.9% (4/98) (P = .256).

CONCLUSIONS

BL were associated with worse clinical outcome 2 years following CR compared to UL. However, both groups showed an ongoing clinical improvement up to 3 years postoperatively and a low failure rate. While inferior clinical improvement and a lower clinical response rate may be expected in BL patients, the observed differences do not justify excluding these patients from CR.

LEVEL OF EVIDENCE

Level III, retrospective comparative prognostic trial.

No Deficits in Functional Outcomes of the Contralateral Limb Are Seen When the Hamstring Is Harvested for Augmentation of Small Diameter Ipsilateral Hamstring Autograft

Purpose

To evaluate clinical outcomes of the contralateral, nonoperative limb in patients undergoing contralateral hamstring (HS) autograft harvest compared with patients undergoing ipsilateral HS autograft harvest alone.

Methods

This study included 96 patients who underwent isolated anterior cruciate ligament reconstruction (ACLR) using 4-stranded HS autograft (n = 85) or 4-stranded HS autograft augmented with contralateral HS (n = 13) due to inclusion of ipsilateral graft diameter <8 mm. Isokinetic flexion and extension strength and dynamic performance of the ipsilateral and contralateral limbs and limb symmetry index (LSI) were evaluated at 6 months' postoperatively. Rates of contralateral native ACL tear at minimum 2 years also were compared. For all comparisons, P < .05 was considered statistically significant.

Results

Normalized isokinetic knee flexion and extension strength of the contralateral limb did not differ between cohorts (P = .34; P = .21, respectively). LSI for knee extension peak torque and knee flexion peak torque did not differ between cohorts (P = .44; P = .67, respectively). No difference in LSI was seen for any dynamic performance testing (single leg hop, P = .97; triple leg hop, P = .14; 6-m timed hop, P = .99). No difference was observed in International Knee Documentation Committee (P = .99) or Knee Injury and Osteoarthritis Outcome Score subscale measures (P = .39-.86). No difference in rates of contralateral knee native ACL tears were seen between cohorts (HS autograft + contralateral HS augmentation, n = 2, 15.4%; HS autograft, n = 7, 8.4%; P = .26).

Conclusions

In this study, at the time of return to sport, we found no differences in contralateral limb functional performance or limb symmetry measurements between patients undergoing contralateral HS autograft harvest for augmentation of smaller (<8 mm) diameter HS autografts harvested from the injured extremity.

Level of Evidence

Level III, retrospective cohort study.

Nonpharmacological approaches for pain and symptoms of depression in people with osteoarthritis: systematic review and meta-analyses

People with osteoarthritis often experience pain and depression. These meta-analyses examined and compared nonpharmacological randomized controlled trials (RCTs) for pain and symptoms of depression in people living with osteoarthritis. RCTs published up until April 2022 were sourced by searching electronic databases EMBASE, PUBMED & MEDLINE, Web of Science, CINAHL and PEDro. Random-effects meta-analyses were performed to calculate pooled effect sizes (ES) and 95% confidence intervals (CI) for pain and depression. Subgroup analyses examined intervention subtypes. For pain, 29 interventions (n = 4382; 65 ± 6.9 years; 70% female), revealed a significant effect on reducing pain (ES = 0.43, 95% CI [0.25, 0.61], p < 0.001). Effect sizes were significant (p < 0.001) for movement meditation (ES = 0.52; 95% CI [0.35, 0.69]), multimodal approaches (ES = 0.37; 95% CI [0.22, 0.51]), and psychological therapy (ES = 0.21; 95% CI [0.11, 0.31]), and significant (p = 0.046) for resistance exercise (ES = 0.43, 95% CI [- 0.07, 0.94]. Aerobic exercise alone did not improve pain. For depression, 28 interventions (n = 3377; 63 ± 7.0 years; 69% female), revealed a significant effect on reducing depressive symptoms (ES = 0.29, 95% CI [0.08, 0.49], p < 0.001). Effect sizes were significant for movement meditation (ES = 0.30; 95% CI [0.06, 0.55], p = 0.008) and multimodal interventions (ES = 0.12; 95% CI [0.07, 0.18], p < 0.001). Resistance/aerobic exercise or therapy alone did not improve depressive symptoms. Mind-body approaches were more effective than aerobic/resistance exercise or therapy alone for reducing pain and depression in people with osteoarthritis.Systematic review registration: PROSPERO CRD42022338051.

Particulated Costal Allocartilage With Microfracture Versus Microfracture Alone for Knee Cartilage Defects: A Multicenter, Prospective, Randomized, Participant- and Rater-Blinded Study

Background

Microfracture is the first-line treatment for cartilage defects; however, the suboptimal quality of the repaired cartilage remains an issue.

Purpose/Hypothesis

The aim of this first in-human study was to compare the clinical efficacy and safety of a combination of particulated costal allocartilage and microfracture versus microfracture alone in treating knee cartilage defects. We hypothesized that the particulated costal allocartilage with microfracture would result in superior cartilage repair quality and better clinical outcomes at 48 weeks postoperatively.

Study Design

Randomized controlled trial; Level of evidence, 1.

Methods

Patients with cartilage defects were allocated randomly to the treatment group (particulated costal allocartilage with microfracture) and control group (microfracture alone). Magnetic resonance imaging (MRI) outcomes of cartilage repair (the primary outcome measure) were evaluated at the 48-week follow-up using the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score. Patient-reported clinical outcomes (visual analog scale [VAS] pain score, Knee injury and Osteoarthritis Outcome Score [KOOS], and International Knee Documentation Committee score) and adverse events were evaluated at 12, 24, and 48 weeks postoperatively.

Results

Overall, 88 patients were included (44 patients each in the treatment and control groups). The total MOCART score at 48 weeks postoperatively was significantly higher in the treatment group than in the control group (P < .001). Among the 9 MOCART variables, 6 were significantly superior in the treatment versus the control group: degree of repair and defect filling (P < .001), integration to the border zone (P < .001), surface (P = .006), structure (P = .011), signal intensity of the repair tissue (P < .001), and subchondral lamina (P = .005). There were significant between-group differences in KOOS-Pain (P = .014), KOOS-Activities of Daily Living (P = .010), KOOS-Sports (P = .029), and KOOS-Symptoms (P = .039) at 12 weeks postoperatively and in VAS pain (P = .012) and KOOS-Pain (P = .005) at 24 weeks postoperatively. At 48 weeks postoperatively, clinical outcomes were comparable between the groups.

Conclusion

Microfracture augmented with particulated costal allocartilage resulted in superior cartilage repair quality compared with microfracture alone in terms of MRI evaluation of the knee joint cartilage defect at the 48-week follow-up. Functional outcomes were favorable for both treatments at final follow-up.

Registration

KCT0004936 (Clinical Research Information Service [CRiS] of the Republic of Korea).

Cross-Culturally Adapted Versions of Patient Reported Outcome Measures for the Lower Extremity

Background

A large number of patient reported outcome measures (PROMs) have been developed in the English language for various lower extremity orthopaedic pathologies. Twenty different PROMs were recommended for 15 specific musculoskeletal lower extremity pathologies or surgeries. However, the availability of cross-culturally adapted versions of these recommended PROMs is unknown.

Purpose

The purpose of this study was to identify the cross-culturally adapted versions of recommended PROMs for individuals experiencing orthopedic lower extremity pathologies or undergoing surgeries, and to identify the psychometric evidence that supports their utilization.

Study design

Literature Review.

Methods

PubMed, Embase, Medline, Cochrane, CINAHL, SPORTDisucs and Scopus were searched for cross-culturally adapted translated studies through May 2022. The search strategy included the names of the 20 recommended PROMs from previous umbrella review along with the following terms: reliability, validity, responsiveness, psychometric properties and cross-cultural adaptation. Studies that presented a non-English language version of the PROM with evidence in at least one psychometric property to support its use were included. Two authors independently evaluated the studies for inclusion and independently extracted data.

Results

Nineteen PROMS had cross-culturally adapted and translated language versions. The KOOS, WOMAC, ACL-RSL, FAAM, ATRS, HOOS, OHS, MOXFQ and OKS were available in over 10 different language versions. Turkish, Dutch, German, Chinese and French were the most common languages, with each language having more than 10 PROMs with psychometric properties supporting their use. The WOMAC and KOOS were both available in 10 languages and had all three psychometric properties of reliability, validity, and responsiveness supporting their use.

Conclusion

Nineteen of the 20 recommended instruments were available in multiple languages. The PROM most frequently cross-culturally adapted and translated were the KOOS and WOMAC. PROMs were most frequently cross-culturally adapted and translated into Turkish. International researchers and clinicians may use this information to more consistently implement PROMs with the most appropriate psychometric evidence available to support their use.

Level of evidence

3a.

Femoral condyle resurfacing using an inlay metal implant: low revision rate of 266 patients in a 5-10 years follow-up

PURPOSE

To assess the clinical outcome and survival of an inlay resurfacing prosthesis for focal femoral condyle chondral and osteochondral defects.

METHODS

Two hundred sixty-six patients (mean age, 38.25 years; range 25-56 years) with symptomatic femoral condyle chondral and osteochondral defects were reviewed. The mean follow-up period was 7.3 years (range 5-10 years). The medial femoral condyle was involved in 229 and the lateral condyle in 37 patients. Previous cartilage surgery was done in 235 patients. All patients were treated with focal femoral condyle resurfacing with the HemiCAP^® device. The preoperative and the last follow-up values of the Knee Injury and Osteoarthritis Outcome Score (KOOS), Oxford Knee Score (OKS), 36-item Short Form Survey (SF-36) and Visual Analogue Scale (VAS) were examined. Complications, reoperation rate and survival were analyzed.

RESULTS

At the last follow-up, all clinical score values showed significant improvement as compared with the corresponding preoperative values (p < 0.001). Age presented a negative correlation with KOOS (p = 0.03) and SF-36 improvement (p = 0.014). Kellgren-Lawrence grade influenced OKS (p = 0.036). BMI, gender, side, medial or lateral condyle and size did not affect the outcome. Patients who had previous biological cartilage procedures demonstrated better clinical improvement in comparison with those that did not have prior surgery (p < 0.05). Survival was 96.2% at 10 years, using as endpoint implant revision or/and progression of osteoarthritis. The cumulative hazard for any-reason reoperation was 12.0%.

CONCLUSIONS

Femoral condyle resurfacing using the HemiCAP^® device is an effective treatment option to address focal chondral and osteochondral defects. It can be successfully used either as a primary procedure or after prior biological cartilage reconstruction. Subjective clinical outcomes are expected to be good to excellent in mid- to long term, while reoperation and revision rates are low. Progression of osteoarthritis is the most common mode of failure; thus, patient selection is very important.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Sensor-based telerehabilitation system increases patient adherence after knee surgery

OBJECTIVES

Implementing evidence-based recommendations with the option of patient-individualised and situation-specific adaptations in telerehabilitation may increase adherence with improved clinical outcome.

METHODS

As part of a registry-embedded hybrid design (part 1), digital medical device (DMD)-usage in a home-based setting was analysed in a multinational registry. The DMD combines an inertial motion-sensor system with instructions for exercises and functional tests on smartphones. A prospective, single-blinded, patient-controlled, multicentre intervention study (DRKS00023857) compared implementation capacity of the DMD to standard physiotherapy (part 2). Usage patterns by health care providers (HCP) were assessed (part 3).

RESULTS AND CONCLUSION

Registry raw data (10,311 measurements) were analysed from 604 DMD-users, demonstrating clinically expected rehabilitation progression post knee injuries. DMD-users performed tests for range-of-motion, coordination and strength/speed enabling insight to stage-specific rehabilitation (χ2 = 44.9, p<0.001). Intention-to-treat-analysis (part 2) revealed DMD-users to have significantly higher adherence to the rehabilitation intervention compared to the matched patient-control-group (86% [77-91] vs. 74% [68-82], p<0.05). DMD-users performed recommended exercises at home with higher intensity (p<0.05). HCP used DMD for clinical decision making. No adverse events related to the DMD were reported. Adherence to standard therapy recommendations can be increased using novel high quality DMD with high potential to improve clinical rehabilitation outcome, enabling evidence-based telerehabilitation.

The AMADEUS score is not a sufficient predictor for functional outcome after high tibial osteotomy

PURPOSE

The Area Measurement And Depth Underlying Structures (AMADEUS) classification system has been proposed as a valuable tool for magnetic resonance (MR)-based grading of preoperatively encountered chondral defects of the knee joint. However, the potential relationship of this novel score with clinical data was yet to determine. It was the primary intention of this study to assess the correlative relationship of the AMADEUS with patient reported outcome scores in patients undergoing medial open-wedge high tibial valgus osteotomy (HTO). Furthermore, the arthroscopic ICRS (International Cartilage Repair Society) grade evaluation was tested for correlation with the AMADEUS classification system.

METHODS

This retrospective, monocentric study found a total of 70 individuals that were indicated for HTO due to degenerative chondral defects of the medial compartment between 2008 and 2019. A preoperative MR image as well as a pre-osteotomy diagnostic arthroscopy for ICRS grade evaluation was mandatory for all patients. The Knee Osteoarthritis Outcome Score (KOOS) including its five subscale scores (KOOS-ADL, KOOS-QOL, KOOS-Sports, KOOS-Pain, KOOS-Symptoms) was obtained preoperatively and at a mean follow-up of 41.2 ± 26.3 months. Preoperative chondral defects were evaluated using the AMADEUS classification system and the final AMADEUS scores were correlated with the pre- and postoperative KOOS subscale sores. Furthermore, arthroscopic ICRS defect severity was correlated with the AMADEUS classification system.

RESULTS

There was a statistically significant correlation between the AMADEUS BME (bone marrow edema) subscore and the KOOS Symptoms subscore at the preoperative visit (r = 0.25, p = 0.04). No statistically significant monotonic association between the AMADEUS total score and the AMADEUS grade with pre- and postoperative KOOS subscale scores were found. Intraoperatively obtained ICRS grade did reveal a moderate correlative relation with the AMADEUS total score and the AMADEUS grade (r = 0.28, p = 0.02).

CONCLUSIONS

The novel AMADEUS classification system largely lacks correlative capacity with patient reported outcome measures in patients undergoing HTO. The MR tomographic appearance of bone marrow edema is the only parameter predictive of the clinical outcome at the preoperative visit.

The Effect of Smoking on the Outcome of Matrix-Based Autologous Chondrocyte Implantation: Data from the German Cartilage Registry

Smoking is known to have various deleterious effects on health. However, it is not clear whether smoking negatively affects the postoperative outcome following matrix-based autologous cartilage implantation (MACI) in the knee. The purpose of this study was to evaluate the effect of smoking on the outcome of MACI in the knee. A total of 281 patients receiving MACI in the knee between 2015 and 2018 were registered in the German Cartilage Database. The cohort was divided into ex-smokers, smokers, and nonsmokers. Data regarding the Knee Injury and Osteoarthritis Outcome Score (KOOS), the numeric rating scale (NRS) for pain, and satisfaction with the outcome were analyzed and compared. Follow-ups were performed at 6, 12, and 24 months after surgery. Of the 281 patients, 225 (80.1%) were nonsmokers, 43 (15.3%) were smokers, and 13 (4.6%) were ex-smokers. The three groups were comparable with respect to age, sex, body mass index (BMI), height, defect size, the need for additional reconstruction of the subchondral bone defect, number of previous knee surgeries, and defect location. However, nonsmokers had a significantly lower weight as compared with smokers. Besides a significantly lower preoperative NRS of nonsmokers as compared with smokers, there were no significant differences between the three groups with respect to KOOS, NRS, and satisfaction at 6, 12, and 24 months of follow-ups. The present study of data retrieved from the German Cartilage Registry suggests that the smoking status does not influence the outcome of MACI in the knee.

Minced Autologous Chondral Fragments with Fibrin Glue as a Simple Promising One-Step Cartilage Repair Procedure: A Clinical and MRI Study at 12-Month Follow-Up

OBJECTIVE

The aim of this study was to investigate early radiological and clinical outcome of autologous minced cartilage treatment as a single-step treatment option in patients with a chondral or osteochondral lesion (OCL) in the knee.

DESIGN

Eighteen patients with an OCL in the knee were included. Cartilage from healthy-appearing loose bodies and/or the periphery of the defect were minced into small chips and sealed in the defect using fibrin glue. Preoperatively, and at 3 (n = 14) and 12 (n = 18) months follow-up, magnetic resonance imaging (MRI) was performed. The Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) 2.0 score was used to assess the cartilage repair tissue on MRI at 12 months. The International Knee Documentation Score, Knee Injury and Osteoarthritis Outcome Score, EuroQoL-5D, and Visual Analogue Scale pain were collected preoperatively and 12 months after surgery.

RESULTS

Three months postoperative, MRI showed complete defect filling in 11 out of 14 patients. Mean MOCART 2.0 score at 12 months was 65.0 ± 18.9 with higher scores for lateral femoral chondral lesions compared to medial femoral chondral lesions (75.8 ± 14.3, 52.5 ± 15.8 respectively, P = 0.02). Clinical and statistical significant improvements were observed in the patient-reported outcome measures at 12 months postoperatively compared to preoperatively.

CONCLUSION

Treatment of OCLs using the autologous minced cartilage procedure resulted in good cartilage repair measured by MOCART 2.0. Clinically relevant improvements were observed in the clinical scores. This study suggests autologous minced cartilage as a promising, single-step treatment for OCLs.

Effusion detected by ultrasonography and overweight may predict the risk of knee osteoarthritis in females with early knee osteoarthritis: a retrospective analysis of Iwaki cohort data

BACKGROUND

Knee osteoarthritis (OA) has enormous medical and socioeconomic burdens, which early diagnosis and intervention can reduce. We investigated the influence of knee effusion on the progression of knee OA in patients with early knee OA.

METHODS

A total of 404 participants without radiographic knee OA were assessed from a 3-year longitudinal analysis. Participants were classified into non-OA and early knee OA groups. The effusion area (mm²) was quantified using ultrasonography. Receiver operating characteristic and logistic regression analyses were performed.

RESULTS

At the 3-year follow-up, 114 of 349 knees (32%) had progressed from non-OA and 32 of 55 knees (58%) had progressed from early knee OA to radiographic knee OA. Logistic regression analysis showed that female sex (odds ratio [OR] 3.36, 95% confidence interval [CIs] 2.98-5.42), early knee OA (OR 2.02, 95% CI 1.08-3.75), body mass index (OR 1.11, 95% CI 1.02-1.19), and effusion area (OR 1.01, 95% CI 1.01-1.02) were significantly correlated with knee OA progression. Women who were overweight (body mass index ≥ 25 kg/m²) with more severe effusion had a higher risk of OA progression (area under the curve = 0.691, OR = 6.00) compared to those not overweight (area under the curve = 0.568, OR = 1.91).

CONCLUSION

Knee effusion may be an indicator of the progression of early-stage knee OA.

Reliability and Validity of the Knee Injury and Osteoarthritis Outcome Score in Patients Undergoing Unicompartmental Knee Arthroplasty

BACKGROUND

The Knee Injury and Osteoarthritis Outcome Score (KOOS) was developed to document outcomes from knee injury, including the impact of osteoarthritis on knee function. The purpose of this study is to determine the reliability and validity of the KOOS subscales for evaluating outcomes following unicompartmental knee arthroplasty (UKA).

METHODS

KOOS Pain, Activities of Daily Living (ADL), Sport, Symptoms, and Quality of Life (QoL) scores collected from 172 patients who underwent UKA were used in the analysis. KOOS subscales were tested for reliability and validity of scores through a Rasch model analysis.

RESULTS

KOOS Sport, KOOS ADL, and KOOS QoL had good evidence of reliability with acceptable person reliability, person separation, and item reliability. For overall scale functioning, KOOS Pain, Symptoms, and ADL all had 1 question that did not have an acceptable value for infit or outfit mean square value. Questions in KOOS Sport and QoL all had acceptable values. There was a positive, linear relationship between the Short-Form 12 Physical Component Summary and the KOOS subscales which indicated good evidence of convergent validity. These associations were also seen when the cohort was separated in medial and lateral UKA.

CONCLUSION

Two of the 5 KOOS subscales (KOOS Sport and KOOS QoL) were considered adequate in measuring outcomes, as well as reliability. The KOOS ADL had borderline values; however, it had adequate infit and outfit values. The KOOS Pain and Symptom score performed poorly in this analysis. For documenting outcomes following UKA, this study supports the use of KOOS ADL, Sport, and QoL.

Do Patellar Tendon Repairs Have Better Outcomes than Quadriceps Tendon Repairs? A Prospective Cohort Analysis

Patellar tendon (PT) and quadriceps tendon (QT) ruptures represent significant injuries and warrant surgical intervention in most patients. Outcome data are predominantly retrospective analyses with low sample sizes. There are also minimal data comparing QT and PT repairs and the variables impacting patient outcomes. The level of evidence of the study is level II (prognosis). From the prospective OME cohort, 189 PT or QT repairs were performed between February 2015 and October 2019. Of these, 178 were successfully enrolled (94.2%) with 1-year follow-up on 141 (79.2%). Baseline demographic data included age, sex, race, BMI, years of education, smoking status, and baseline VR-12 MCS score. Surgical and follow-up data included surgeon volume, fixation technique, baseline, and 1-year Knee Injury and Osteoarthritis Outcome Score-Pain (KOOS-Pain), Knee Injury and Osteoarthritis Outcome Score-Physical Function (KOOS-PS), and 1-year Patient Acceptable Symptom State (PASS) scores and complications. Multivariable regression analysis was utilized to identify prognosis and significant risk factors for outcomes-specifically, whether KOOS-Pain or KOOS-PS were different between QT versus PT repairs. There were 59 patients in the PT cohort and 82 patients in QT cohort. Baseline demographic data demonstrated that PT cohort was younger (45.1 vs. 59.5 years, p <0.001), included significantly fewer patients of White race (51.7 vs. 80.0%, p = 0.001), lesser number of years of education (13.9 vs. 15.2 years, p = 0.020), a higher percentage of "high" surgeon volume (72.9% vs. 43.9%, p = 0.001) and 25.4% of PT repairs had supplemental fixation (QT had zero, p <0.001). Multivariable analysis identified gender (female-worse, p = 0.001), years of education (higher-better, p = 0.02), and baseline KOOS-Pain score (higher-better, p <0.001) as the risk factors that significantly predicted KOOS-Pain score. The risk factors that significantly predicted KOOS-PS were gender (female worse, p = 0.033), race (non-White-worse, p <0.001), baseline VR-12 MCS score (higher-better, p <0.001), and baseline KOOS-PS score (higher better, p = 0.029). KOOS-Pain and KOOS-PS scores improved after both QT and PT repairs. Patient reported pain and function at 1 year were similar between PT and QT repairs after adjusting for known risk factors. Multivariable analysis identified female gender and low baseline KOOS scores as predictors for worse outcomes.

Isolated ballistic femoral condyle fractures: a case series of eighteen patients

PURPOSE

Ballistic fractures of the femoral condyles are rare injuries with limited literature to help guide treatment. The purpose of this study is to report on the presentation, management, and outcomes for patients with isolated ballistic condylar fractures.

METHODS

Eighteen patients between ages 16 and 65 with low-energy ballistic injuries isolated to the femoral condyles (OTA 33B) were included, 15 with CT imaging. Clinical records and imaging were reviewed, as well as treatment strategy. Fractures were classified by AO/OTA classification. Outcome and follow-up data were gathered at outpatient appointments and telephone calls.

RESULTS

Of the 18 patients, 78% were treated operatively (61% with open reduction and internal fixation, 17% with removal of foreign body alone). There were two instances of traumatic vascular injury and no neurologic injuries. Furthermore, there were no identified infections. Only 58% of the patients had follow-up for more than 6 weeks with average KOOS Jr. Score of 50, and average VAS pain score of 5.2.

CONCLUSIONS

Ballistic femoral condyle fractures are rare Orthopaedic injuries seen in relatively high frequency at our institution. Most (78%) were treated operatively and with few complications. These fractures are not easily classified according to common classification schemes and may benefit from more rigorous study to guide treatment and anticipate outcomes.

Safety and Efficacy of Matrix-Associated Autologous Chondrocyte Implantation With Spheroids for Patellofemoral or Tibiofemoral Defects: A 5-Year Follow-up of a Phase 2, Dose-Confirmation Trial

Background:

Matrix-associated autologous chondrocyte implantation (ACI) is a well-established treatment for cartilage defects. High-level evidence at midterm follow-up is limited, especially for ACI using spheroids (spherical aggregates of ex vivo expanded human autologous chondrocytes and self-synthesized extracellular matrix).

Purpose:

To assess the safety and efficacy of 3-dimensional matrix-associated ACI using spheroids to treat medium to large cartilage defects on different locations in the knee joint (patella, trochlea, and femoral condyle) at 5-year follow-up.

Study Design:

Cohort study; Level of evidence, 2.

Methods:

A total of 75 patients aged 18 to 50 years with medium to large (4-10 cm²), isolated, single cartilage defects, International Cartilage Repair Society grade 3 or 4, were randomized on a single-blind basis to treatment with ACI at 1 of 3 dose levels: 3 to 7, 10 to 30, or 40 to 70 spheroids/cm² of defect size. Outcomes were assessed via changes from baseline Knee injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee score, and modified Lysholm assessments at 1- and 5-year follow-up. Structural repair was evaluated using MOCART (magnetic resonance observation of cartilage repair tissue) score. Treatment-related adverse events were assessed up to 5 years for all patients. The overall KOOS at 12 months was assessed for superiority versus baseline in a 1-sample, 2-sided t test.

Results:

A total of 73 patients were treated: 24 in the low-dose group, 25 in the medium-dose group, and 24 in the high-dose group. The overall KOOS improved from 57.0 ± 15.2 at baseline to 73.4 ± 17.3 at 1-year follow-up (P < .0001) and 76.9 ± 19.3 at 5-year follow-up (P < .0001), independent of the applied dose. The different defect locations (patella, trochlea, and weightbearing part of the femoral condyles; P = .2216) and defect sizes (P = .8706) showed comparable clinical improvement. No differences between the various doses were observed. The overall treatment failure rate until 5 years was 4%. Most treatment-related adverse events occurred within the first 12 months after implantation, with the most frequent adverse reactions being joint effusion (n = 71), arthralgia (n = 14), and joint swelling (n = 9).

Conclusion:

ACI using spheroids was safe and effective for defect sizes up to 10 cm² and showed maintenance of efficacy up to 5 years for all 3 doses that were investigated.

Registration:

NCT01225575 (ClinicalTrials.gov identifier); 2009-016816-20 (EudraCT number).

The subjective knee value is a valid single-item survey to assess knee function in common knee disorders

INTRODUCTION

The patient's perspective plays a key role in judging the effect of knee disorders on physical function. We have introduced the Subjective Knee Value (SKV) to simplify the evaluation of individual's knee function by providing one simple question. The purpose of this prospective study was to validate the SKV with accepted multiple-item knee surveys across patients with orthopaedic knee disorders.

MATERIALS AND METHODS

Between January through March 2020, consecutive patients (n = 160; mean age 51 ± 18 years, range from 18 to 85 years, 54% women) attending the outpatient clinic for knee complaints caused by osteoarthritis (n = 69), meniscal lesion (n = 45), tear of the anterior cruciate ligament (n = 23) and focal chondral defect (n = 23) were invited to complete a knee-specific survey including the SKV along with the Knee Injury Osteoarthritis Outcome Score (KOOS) and the International Knee Documentation Committee subjective knee form (IKDC-S). The Pearson correlation coefficient was used to evaluate external validity between the SKV and each patient-reported outcome measure (PROM) separately. Furthermore, patient's compliance was assessed by comparing responding rates.

RESULTS

Overall, the SKV highly correlated with both the KOOS (R = 0.758, p < 0.05) and the IKDC-S (R = 0.802, p < 0.05). This was also demonstrated across all investigated diagnosis- and demographic-specific (gender, age) subgroups (range 0.509-0.936). No relevant floor/ceiling effects were noticed. The responding rate for the SKV (96%) was significantly higher when compared with those for the KOOS (81%) and the IKDC-S (83%) (p < 0.05).

CONCLUSION

At baseline, the SKV exhibits acceptable validity across all investigated knee-specific PROMs in a broad patient population with a wide array of knee disorders. The simplified survey format without compromising the precision to evaluate individual's knee function justifies implementation in daily clinical practice.

LEVEL OF EVIDENCE

II, cohort study (diagnosis).

Concomitant full-thickness cartilage lesions do not affect patient-reported outcomes at minimum 10-year follow-up after ACL reconstruction

PURPOSE

To compare patients with a concomitant full-thickness cartilage lesion and anterior cruciate ligament (ACL) injury to patients with an isolated ACL injury at 10-15 years post ACL reconstruction.

METHODS

This is a longitudinal follow-up of a cohort of 89 patients that were identified in the Norwegian National Knee Ligament Registry and included in the index study in 2007. The study group consisted of 30 patients that underwent ACL reconstruction and had a concomitant, isolated full-thickness cartilage lesion (International Cartilage Repair Society [ICRS] grade 3-4). Each study patient was matched with two control patients who underwent ACL reconstruction but had no cartilage lesions (ICRS grade 1-4) (n = 59). At a median follow-up of 10.2 years (range 9.9-15.6), 65 patients (74%) completed the Knee Injury and Osteoarthritis Outcome Score (KOOS), which was the main outcome measure, resulting in 23 pairs after matching.

RESULTS

At a follow-up of 10-15 years after ACL reconstruction, no significant differences in KOOS were found between patients with a concomitant full-thickness cartilage lesion and patients without cartilage lesions. There was also no significant difference between the two groups when comparing the change over time in KOOS scores from preoperative to follow-up. Both groups showed significant improvement in all KOOS subscales from preoperative to follow-up, except for in the Symptoms subscale for the control group. The greatest improvement was in the QoL subscale for the study group.

CONCLUSION

ACL-reconstructed patients with a full-thickness cartilage lesion did not report worse outcomes at 10-15 years after surgery compared with patients with an isolated ACL injury. Our findings support that there is no long-term negative effect of a concomitant cartilage lesion in an ACL-reconstructed knee. These findings should be considered when discussing treatment and informing about the expected long-term outcome after ACL reconstruction to patients with such combined injuries.

LEVEL OF EVIDENCE

II.

Focal articular surface replacement as primary treatment for focal chondral defects of the femoral condyles: A series of 157 cases

BACKGROUND

Focal chondral defects (FCDs) of the femoral condyle are common. Treatment has heretofore primarily consisted of non-surgical and biological treatments. Focal articular surface replacement (FASR) is an emerging technique utilizing small implants to essentially fill the FCD. Here we report functional outcome and re-operation rates following FASR as a primary treatment for FCDs of the femoral condyles.

METHODS

Retrospective analysis of a prospectively collected database including 327 FASR procedures was performed to identify patients who underwent FASR of the femoral condyle with a modular cementless metallic implant (HemiCAP^TM) as a primary procedure. Knee Injury and Osteoarthritis Outcome Score (KOOS), Oxford Knee Score (OKS), SF-36 Health Status Survey (SF-36) and Visual Analog Scale (VAS) were collected before and 6 weeks, 6 months, and 4 years after surgery. Implant revision and re-operation rate were recorded.

RESULTS

157 patients were included with a mean follow-up of 9.4 ± 1.3 years (range 7.0 to 11.4 years). The average age was 40.2 ± 5.3 years, 85% involved the medial condyle, and the average defect size was 3.6 ± 0.5 cm². Primary FASR resulted in functional improvement on the KOOS (+52%), OKS (+69%) and SF-36 (+50%) scores and a reduction in VAS scores (-70%) at 4-year follow-up. Revision rate was 0.64% and the re-operation rate was 11%.

CONCLUSION

This retrospective case-series supports primary FASR with HemiCAP^TM implants as an alternative to biological procedures to treat medium-sized FCDs (2.5-4 cm²) of the femoral condyle, although long-term follow-up is necessary to determine if the clinical outcome and low revision rate can be maintained.

Matrix-Associated Autologous Chondrocyte Implantation with Spheroid Technology Is Superior to Arthroscopic Microfracture at 36 Months Regarding Activities of Daily Living and Sporting Activities after Treatment

OBJECTIVE

Matrix-associated autologous chondrocyte implantation (ACI) and microfracture (MF) are well-established treatments for cartilage defects of the knee. However, high-level evidence comparing microfracture and spheroid technology ACI is limited.

DESIGN

Prospective, phase III clinical trial with patients randomized to ACI (N = 52) or MF (N = 50). Level of evidence: 1, randomized controlled trial. Both procedures followed standard protocols. For ACI 10 to 70 spheroids/cm² were administered. Primary outcome measure was the Knee Injury and Osteoarthritis Outcome Score (KOOS). This report presents results for 36 months after treatment.

RESULTS

Both ACI and MF showed significant improvement over the entire 3-year observation period. For the overall KOOS, noninferiority of ACI (the intended primary goal of the study) was formally confirmed; additionally, for the subscores "Activities of Daily Living" and "Sport and Recreation," superiority of ACI over MF was shown at descriptive level. Occurrence of adverse events were not different between both treatments (ACI 77%; MF 74%). Four patients in the MF group required reoperation which was defined as treatment failure. No treatment failure was reported for the ACI group.

CONCLUSIONS

Patients treated with matrix-associated ACI with spheroid technology showed substantial improvement in various clinical outcomes after 36 months. The advantages of ACI compared with microfracture was underlined by demonstrating noninferiority, in overall KOOS and superiority in the KOOS subscores "Activities of Daily Living" and "Sport and Recreation." In the present study, subgroups comparing different age groups and defect sizes showed comparable clinical outcomes.

The MOCART (Magnetic Resonance Observation of Cartilage Repair Tissue) 2.0 Knee Score and Atlas

OBJECTIVE

Since the first introduction of the MOCART (Magnetic Resonance Observation of Cartilage Repair Tissue) score, significant progress has been made with regard to surgical treatment options for cartilage defects, as well as magnetic resonance imaging (MRI) of such defects. Thus, the aim of this study was to introduce the MOCART 2.0 knee score - an incremental update on the original MOCART score - that incorporates this progression.

MATERIALS AND METHODS

The volume of cartilage defect filling is now assessed in 25% increments, with hypertrophic filling of up to 150% receiving the same scoring as complete repair. Integration now assesses only the integration to neighboring native cartilage, and the severity of surface irregularities is assessed in reference to cartilage repair length rather than depth. The signal intensity of the repair tissue differentiates normal signal, minor abnormal, or severely abnormal signal alterations. The assessment of the variables "subchondral lamina," "adhesions," and "synovitis" was removed and the points were reallocated to the new variable "bony defect or bony overgrowth." The variable "subchondral bone" was renamed to "subchondral changes" and assesses minor and severe edema-like marrow signal, as well as subchondral cysts or osteonecrosis-like signal. Overall, a MOCART 2.0 knee score ranging from 0 to 100 points may be reached. Four independent readers (two expert readers and two radiology residents with limited experience) assessed the 3 T MRI examinations of 24 patients, who had undergone cartilage repair of a femoral cartilage defect using the new MOCART 2.0 knee score. One of the expert readers and both inexperienced readers performed two readings, separated by a four-week interval. For the inexperienced readers, the first reading was based on the evaluation sheet only. For the second reading, a newly introduced atlas was used as an additional reference. Intrarater and interrater reliability was assessed using intraclass correlation coefficients (ICCs) and weighted kappa statistics. ICCs were interpreted according to Koo and Li; weighted kappa statistics were interpreted according to the criteria of Landis and Koch.

RESULTS

The overall intrarater (ICC = 0.88, P < 0.001) as well as the interrater (ICC = 0.84, P < 0.001) reliability of the expert readers was almost perfect. Based on the evaluation sheet of the MOCART 2.0 knee score, the overall interrater reliability of the inexperienced readers was poor (ICC = 0.34, P < 0.019) and improved to moderate (ICC = 0.59, P = 0.001) with the use of the atlas.

CONCLUSIONS

The MOCART 2.0 knee score was updated to account for changes in the past decade and demonstrates almost perfect interrater and intrarater reliability in expert readers. In inexperienced readers, use of the atlas may improve interrater reliability and, thus, increase the comparability of results across studies.

Assessing knee functionality: systematic review of validated outcome measures

BACKGROUND

Functional rating scales allow clinicians to document and quantify alterations and progression of recovery processes. There is neither awareness of numerous knee scales nor are they easy to find or compare to select the most suitable.

OBJECTIVES

We aimed to compile validated knee functional rating tools and analyse the methodological quality of their validation studies. Also, we aimed to provide an operational document of the outcome measures addressing descriptions of parameters, implementations, instructions, interpretations and languages, to identify the most appropriate for future interventions.

METHODS

A systematic review involved a search of PubMed, Web of Science, CINAHL, Scopus, and Dialnet databases from inception through September 2020. The main inclusion criteria were available functional rating scales/questionnaires/indexes for knees and validation studies. Methodological quality was analyzed with the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) and COnsensus-based Standards for the selection of health Measurement Instruments Risk of Bias (COSMIN-RB).

RESULTS

We selected 73 studies. The studies investigated 41 knee rating tools (general, 46%, and specific, 54%) and 71 validations, including 29,742 individuals with knee disorders. QUADAS-2 obtained the best results in patient selection and index test (applicability section). COSMIN-RB showed the highest quality in construct validity (most analyzed metric property). The specific tools were mainly designed for prosthesis and patellofemoral and anterior cruciate ligament injuries. More considered issues were specific function (93%), especially gait, pain/sensitivity (81%), and physical activity/sports (56%).

CONCLUSIONS AND IMPLICATIONS

We conducted a necessary, useful, unlimited-by-time and feasible compilation of validated tools for assessing knee functional recovery. The methodological quality of the validations was limited. The best validations were for the Copenhagen Knee Range of Motion Scale in osteoarthritis and arthroplasties, Knee Outcome Survey Activities of Daily Living and Lysholm Knee Score for general knee disorders and the Tegner Activity Score for anterior cruciate ligament injuries. The operational document for the scales provides necessary data to identify the most appropriate.

A Pilot Clinical Study of Hyperacute Serum Treatment in Osteoarthritic Knee Joint: Cytokine Changes and Clinical Effects

The serum fraction of platelet-rich fibrin (hyperacute serum) has been shown to improve cartilage cell proliferation in in vitro osteoarthritic knee joint models. We hypothesize that hyperacute serum may be a potential regenerative therapeutic for osteoarthritic knees. In this study, the cytokine milieu at the synovial fluid of osteoarthritic knee joints exposed to hyperacute serum intraarticular injections was investigated. Patients with knee osteoarthritis received three injections of autologous hyperacute serum; synovial fluid was harvested before each injection and clinical monitoring was followed-up for 6 months. Forty osteoarthritic-related cytokines, growth factors and structural proteins from synovial fluid were quantified and analysed by Multivariate Factor Analysis. Hyperacute serum provided symptomatic relief regarding pain and joint stability for OA patients. Both patients "with" and "without effusion knees" had improved VAS, KOOS and Lysholm-Tegner scores 6 months after of hyperacute serum treatment. Synovial fluid analysis revealed two main clusters of proteins reacting together as a group, showing strong and significant correlations with their fluctuation patterns after hyperacute serum treatment. In conclusion, hyperacute serum has a positive effect in alleviating symptoms of osteoarthritic knees. Moreover, identified protein clusters may allow the prediction of protein expression, reducing the number of investigated proteins in future studies.

Cross-cultural validation of Hindi version Knee Injury and Osteoarthritis Outcome Score (KOOS) in osteoarthritis knee

PURPOSE

To assess the reliability, validity and responsiveness of the Hindi version of the Knee Injury and Osteoarthritis Outcome Score (H-KOOS) in osteoarthritic knee.

METHODS

Two hundred and fourteen patients of osteoarthritis knee (OA) between 40 and 80 years of age were evaluated with H-KOOS, Short form health survey (SF12v2) and the WHOQOL-BREF questionnaire. The H-KOOS was re-evaluated after 48 h in 125 patients to assess the test-retest reliability. For responsiveness, 40 patients were treated with the intra-articular hyaluronic acid injection, and the effect was assessed after 6 weeks.

RESULTS

Most of the domains in H-KOOS did not show a ceiling effect. The floor values were observed in 3.75% of patients in sports/recreation function and 2.75% of patients in Quality of life (QoL). The test-retest reliability was excellent with the Intraclass-Correlation-Coefficient (ICC) ranging from 0.89 to 0.94. Internal consistency as assessed using Cronbach's alpha coefficient was acceptable for pain, activities of daily living (ADL) and sport/recreation function (range 0.86-0.93); however, symptoms and QoL had weak internal consistency. There were moderate to strong correlations (r = 0.35 to 0.6) between domains measuring similar constructs in H-KOOS, SF12v2 and WHOQOL-BREF indicating good convergent construct validity. The responsiveness as measured by the effect size (ES) and standardized response mean (SRM) was large for pain (ES 0.9, SRM 0.8), moderate for Sport/Rec (ES 0.66, SRM 0.2) and small for ADL, QoL and Symptoms subscales.

CONCLUSION

The Hindi version KOOS is a valid, reliable and responsive measure to evaluate osteoarthritis knee with minimal ceiling and floor effects.

LEVEL OF EVIDENCE

Prospective cohort study, level II.

Simple Knee Value: a simple evaluation correlated to existing knee PROMs

PURPOSE

The Simple Knee Value (SKV) is an outcome score in which patients are asked to grade their knee function as a percentage of that of a normal knee. The primary aim of this study was to validate the SKV by measuring its correlation with existing knee-related PROMs.

METHODS

This was a prospective study conducted at a teaching hospital to assess the SKV's validity. The study enrolled 47 young patients (16-54 years old), 49 older patients (≥ 55 years) and 30 healthy controls. A paper questionnaire consisting of the Lysholm, IKDC, KOOS, WOMAC and SKV was given to subjects three times (enrolment, 1-month preoperative visit and 6 months postoperative visit). The criterion validity of the SKV was determined by correlating it to existing knee PROMs using the Spearman correlation coefficient (S). SKV test-retest reliability was assessed by the intraclass correlation coefficient (ICC) between two time points (initial consultation at enrolment and preoperative visit, reflecting the same clinical condition). Responsiveness to change was determined by comparing the SKV scores before and after surgery (enrolment consultation and 6 months postoperative). Discriminative ability was determined by comparing the SKV distribution in patients and controls.

RESULTS

There was a strong and significant correlation between the SKV and the gold standard Lysholm, IKDC, KOOS and WOMAC in the younger patients and the older patients (p < 0.0001). The reliability between the SKV at the initial consultation and before surgery was excellent (ICC 0.862, 95% CI 0.765; 0.921) in the younger patients, and moderate (ICC 0.506, 95% CI 0.265; 0.688) in the older patients. The SKV was responsive to change in both patient groups (p < 0.0001 for the SKV before versus 6 months after surgery). Like the other knee-specific PROMs (p < 0.0001), the SKV was able to distinguish between patients and controls (p < 0.0001).

CONCLUSIONS

The SKV is valid as it is significantly correlated to existing knee PROMs. It is also reliable, responsive to change and discriminating. Its simplicity gives it many advantages and it can be used by physicians in their daily practice.

LEVEL OF EVIDENCE

Level II.

The Relationship Between Patient Expectations and Functional Outcomes in Patients Undergoing Cartilage Repair of the Knee: A Mixed Methods Study

CONTEXT

Patient expectations have been shown to be a major predictor of outcomes. Fulfilled expectations have been linked to increased patient satisfaction and rehabilitation adherence. Expectations may be influenced by a variety of factors, including patient characteristics, preoperative function, or disease characteristics. It is currently unknown what factors may influence patient expectations prior to cartilage repair of the knee, and to what degree. Furthermore, understanding the importance and values of those expectations for recovery using mixed methods has not previously been conducted in this patient population. The purpose of this mixed methods study is to examine and explore the relationships between patient expectations and functional outcome in patients undergoing cartilage repair of the knee.

DESIGN

A mixed methods design was used.

METHODS

Twenty-one patients scheduled to undergo cartilage repair of the knee were included. Participants completed the Hospital for Special Surgery Knee Surgery Expectations Survey and the Knee Injury and Osteoarthritis Outcome Score at their preoperative visit. Knee Injury and Osteoarthritis Outcome Scores were also obtained at 3 and 6 months postsurgery. A selected sample of 6 participants participated in semi-structured interviews 6 months postsurgery. Pearson correlation coefficients were used to determine relationships between expectations and functional outcome.

RESULTS

Patients have moderate expectations for recovery, and these expectations were positively associated with preoperative pain, activities of daily living, and quality of life. Expectations also correlated with symptoms 3 months postsurgery, but there were no other significant correlations between preoperative expectations and postoperative function in the short term. Four qualitative themes emerged as participants described how previous recovery experiences shaped their expectations.

CONCLUSIONS

Formalized patient and caregiver education, prehabilitation, and the use of psychological skills during rehabilitation may help to manage patient expectations and provide more focused and individualized care, thus improving outcomes.

Clinically Significant Outcomes Following the Treatment of Focal Cartilage Defects of the Knee With Microfracture Augmentation Using Cartilage Allograft Extracellular Matrix: A Multicenter Prospective Study

PURPOSE

To determine the short-term outcomes following microfracture augmented with cartilage allograft extracellular matrix for the treatment of symptomatic focal cartilage defects of the adult knee.

METHODS

Forty-eight patients enrolled by 8 surgeons from 8 separate institutions were included in this study. Patients underwent microfracture augmented by cartilage allograft extracellular matrix (BioCartilage; Arthrex, Naples, FL) and were followed at designated time points (3, 6, 12, and 24 months) to assess patient-reported outcomes (PROs), clinically significant outcomes (CSOs), and failure and complication rates. Magnetic resonance imaging (MRI) was offered at 2 years postoperatively regardless of symptomatology, and Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) 2.0 score was documented.

RESULTS

PRO compliance was 81.3% at 6 months, 72.9% at 12 months, and 47.9% at 2 years. All joint-specific and function-related PROs significantly improved compared to baseline at 3, 6, 12, 18, and 24 months of follow-up (P < .01), apart from Marx activity scale, which demonstrated a significant decline in postoperative scores at 2 years (P = .034). The percentage of patients achieving CSOs (as defined for microfracture) at 2 years was 90% for minimal clinically important difference and 85% for patient acceptable symptomatic state. Patient factors including age, sex, body mass index, symptoms duration, smoking, presence of a meniscal tear, lesion size, and location were not associated with CSO achievement at 2 years. One patient (2.1%) failed treatment 9.5 months postoperatively due to graft delamination and required a reoperation consisting of arthroscopic debridement. One complication (2.1%) consisting of complaints of clicking, grinding, and crepitus 15 months following the index procedure was reported. Two-year postoperative MRI demonstrated a mean 40.5 ± 22.9 MOCART 2.0 score.

CONCLUSIONS

In this preliminary study, we found cartilage allograft extracellular matrix to be associated with improvement in functional outcomes, high rates of CSO achievement, and low failure and complication rates at 2-year follow-up.

LEVEL OF EVIDENCE

Level III, prospective multicenter cohort study.

Five-Year Outcome of 1-Stage Cell-Based Cartilage Repair Using Recycled Autologous Chondrons and Allogenic Mesenchymal Stromal Cells: A First-in-Human Clinical Trial

BACKGROUND

Long-term clinical evaluation of patient outcomes can steer treatment choices and further research for cartilage repair. Using mesenchymal stromal cells (MSCs) as signaling cells instead of stem cells is a novel approach in the field.

PURPOSE

To report the 5-year follow-up of safety, clinical efficacy, and durability after treatment of symptomatic cartilage defects in the knee with allogenic MSCs mixed with recycled autologous chondrons in first-in-human study of 1-stage cartilage repair.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

This study is an investigator-driven study aiming at the feasibility and safety of this innovative cartilage repair procedure. Between 2013 and 2014, a total of 35 patients (mean ± SD age, 36 ± 8 years) were treated with a 1-stage cartilage repair procedure called IMPACT (Instant MSC Product Accompanying Autologous Chondron Transplantation) for a symptomatic cartilage defect on the femoral condyle or trochlear groove. Subsequent follow-up after initial publication was performed annually using online patient-reported outcome measures with a mean follow-up of 61 months (range, 56-71 months). Patient-reported outcome measures included the KOOS (Knee injury and Osteoarthritis Outcome Score), visual analog scale for pain, and EuroQol-5 Dimensions. All clinical data and serious adverse events, including additional treatment received after IMPACT, were recorded. A failure of IMPACT was defined as a chondral defect of at least 20% of the index lesion with a need for a reintervention including a surgical procedure or an intra-articular injection.

RESULTS

Using allogenic MSCs, no signs of a foreign body response or serious adverse reactions were recorded after 5 years. The majority of patients showed statistically significant and clinically relevant improvement in the KOOS and all its subscales from baseline to 60 months: overall, 57.9 ± 16.3 to 78.9 ± 17.7 (P < .001); Pain, 62.3 ± 18.9 to 79.9 ± 20.0 (P = .03); Function, 61.6 ± 16.5 to 79.4 ± 17.3 (P = .01); Activities of Daily Living, 69.0 ± 19.0 to 89.9 ± 14.9 (P < .001); Sports and Recreation, 32.3 ± 22.6 to 57.5 ± 30.0 (P = .02); and Quality of Life, 25.9 ± 12.9 to 55.8 ± 26.8 (P < .001). The visual analog scale score for pain improved significantly from baseline (45.3 ± 23.6) to 60 months (15.4 ± 13.4) (P < .001). Five cases required reintervention.

CONCLUSION

This is the first study showing the midterm safety and efficacy of the proof of concept that allogenic MSCs augment 1-stage articular cartilage repair. The absence of serious adverse events and the clinical outcome support the longevity of this unique concept. These data support MSC-augmented chondron transplantation (IMPACT) as a safe 1-stage surgical solution that is considerably more cost-effective and a logistically advantageous alternative to conventional 2-stage cell-based therapy for articular chondral defects in the knee.

Impact or no impact for women with mild knee osteoarthritis? A Bayesian meta-analysis of two RCT's with contrasting interventions

OBJECTIVE

We aim to predict the probability of a benefit from two contrasting exercise programs for a woman with a new diagnosis of mild knee osteoarthritis (OA). The short and long-term effects of aquatic resistance training (ART) and high-impact aerobic land training (HLT) compared with the control will be estimated.

METHODS

Original data sets from two previously conducted randomised controlled trials (RCT) were combined and used in a Bayesian meta-analysis. Group differences in multiple response variables were estimated. Variables included cardiorespiratory fitness, dynamic maximum leg muscle power, maximal isometric knee extension and flexion force, pain, other symptoms and quality of life. The statistical model included a latent commitment variable for each female participant.

RESULTS

ART has 55% - 71% probability of benefits in the outcome variables and as the main effect, the intervention outperforms the control in cardiorespiratory fitness with a probability of 71% immediately after the intervention period. HLT has 46% - 63% probability of benefits after intervention with the outcome variables, but differently from ART, the positive effects of physical performance fade away during the follow-up period. Overall, the differences between groups were small and the variation in the predictions between individuals was high.

CONCLUSIONS

Both interventions had benefits but ART has a slightly higher probability of long-term benefits on physical performance. Because of high individual variation and no clear advantage of one training method over the other, personal preferences should be considered in the selection of the exercise program to ensure highest commitment to training.

Measuring Outcomes in Knee Articular Cartilage Pathology

Measuring outcomes following treatment of knee articular cartilage lesions is crucial to determine the natural history of disease and the efficacy of treatments. Outcome assessments for articular cartilage treatments can be clinical (based on failure, lack of healing, reoperation, need for arthroplasty), radiographic (X-ray, MRI), histologic, or patient reported and functional. The purpose of this review is to discuss the application and properties of patient-reported outcomes (PROs) with a focus on articular cartilage injuries and surgery in the knee. The most frequently used and validated PROs for knee articular cartilage studies include: the Knee injury and Osteoarthritis and Outcome Score, International Knee Documentation Committee Subjective Knee Form, and Lysholm score as knee-specific measures; the Marx Activity Rating Scale and Tegner Activity Scale as activity measures; and EQ-5D and SF-36/12 as generic quality-of-life measures. Incorporating these validated PROs in studies pertaining to knee articular cartilage lesions will allow researchers to fully capture clinically relevant outcomes that are most important to patients.