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Cognetti DJ, Defoor MT, Yuan TT, Sheean AJ. Knee Joint Preservation in Tactical Athletes: A Comprehensive Approach Based upon Lesion Location and Restoration of the Osteochondral Unit. Bioengineering (Basel) 2024; 11:246. [PMID: 38534520 DOI: 10.3390/bioengineering11030246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 02/18/2024] [Accepted: 02/28/2024] [Indexed: 03/28/2024] Open
Abstract
The unique physical demands of tactical athletes put immense stress on the knee joint, making these individuals susceptible to injury. In order to ensure operational readiness, management options must restore and preserve the native architecture and minimize downtime, while optimizing functionality. Osteochondral lesions (OCL) of the knee have long been acknowledged as significant sources of knee pain and functional deficits. The management of OCL is predicated on certain injury characteristics, including lesion location and the extent of subchondral disease. Techniques such as marrow stimulation, allograft and autologous chondrocyte implantation are examined in detail, with a focus on their application and suitability in tactical athlete populations. Moreover, the restoration of the osteochondral unit (OCU) is highlighted as a central aspect of knee joint preservation. The discussion encompasses the biomechanical considerations and outcomes associated with various cartilage restoration techniques. Factors influencing procedure selection, including lesion size, location, and patient-specific variables, are thoroughly examined. Additionally, the review underscores the critical role of post-operative rehabilitation and conditioning programs in optimizing outcomes. Strengthening the surrounding musculature, enhancing joint stability, and refining movement patterns are paramount in facilitating the successful integration of preservation procedures. This narrative review aims to provide a comprehensive resource for surgeons, engineers, and sports medicine practitioners engaged in the care of tactical athletes and the field of cartilage restoration. The integration of advanced preservation techniques and tailored rehabilitation protocols offers a promising avenue for sustaining knee joint health and function in this demanding population.
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Affiliation(s)
- Daniel J Cognetti
- Department of Orthopedic Surgery, Brooke Army Medical Center, 3551 Roger Brooke Drive, San Antonio, TX 78234, USA
| | - Mikalyn T Defoor
- Department of Orthopedic Surgery, Brooke Army Medical Center, 3551 Roger Brooke Drive, San Antonio, TX 78234, USA
| | - Tony T Yuan
- Advanced Exposures Diagnostics, Interventions and Biosecurity Group, 59 Medical Wing, Lackland Air Force Base, San Antonio, TX 78236, USA
- Center for Biotechnology (4D Bio3), Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Andrew J Sheean
- Department of Orthopedic Surgery, Brooke Army Medical Center, 3551 Roger Brooke Drive, San Antonio, TX 78234, USA
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2
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Niethammer TR, Aurich M, Brucker PU, Faber S, Diemer F, Pietschmann MF, Schoch W, Zinser W, Müller PE. Follow-up Treatment after Cartilage Therapy of the Knee Joint - a Recommendation of the DGOU Clinical Tissue Regeneration Working Group. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2024. [PMID: 38224697 DOI: 10.1055/a-2206-7242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/17/2024]
Abstract
The first follow-up treatment recommendation from the DGOU's Clinical Tissue Regeneration working group dates back to 2012. New scientific evidence and changed framework conditions made it necessary to update the follow-up treatment recommendations after cartilage therapy.As part of a multi-stage member survey, a consensus was reached which, together with the scientific evidence, provides the basis for the present follow-up treatment recommendation.The decisive criterion for follow-up treatment is still the defect localisation. A distinction is made between femorotibial and patellofemoral defects. In addition, further criteria regarding cartilage defects are now also taken into account (stable cartilage edge, location outside the main stress zone) and the different methods of cartilage therapy (e. g. osteochondral transplantation, minced cartilage) are discussed.The present updated recommendation includes different aspects of follow-up treatment, starting with early perioperative management through to sports clearance and resumption of contact sports after cartilage therapy has taken place.
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Affiliation(s)
- Thomas R Niethammer
- Muskuloskelettales Universitätszentrum München (MUM), Klinik für Orthopädie und Unfallchirurgie, Klinikum der Universität München, LMU München, München, Deutschland
| | - Matthias Aurich
- Department für Orthopädie, Unfall- und Wiederherstellungschirurgie, Universitätsklinikum Halle (Saale), Halle, Deutschland
- Klinik für Unfall- und Wiederherstellungschirurgie, BG Klinikum Bergmannstrost, Halle (Saale), Deutschland
| | - Peter U Brucker
- ATOS Klinik München, München, Deutschland
- Biomechanik im Sport, Fakultät für Sport- und Gesundheitswissenschaft, Technische Universität München, München
| | - Svea Faber
- Muskuloskelettales Universitätszentrum München (MUM), Klinik für Orthopädie und Unfallchirurgie, Klinikum der Universität München, LMU München, München, Deutschland
| | | | - Matthias F Pietschmann
- Muskuloskelettales Universitätszentrum München (MUM), Klinik für Orthopädie und Unfallchirurgie, Klinikum der Universität München, LMU München, München, Deutschland
- OrthoPraxis Oberhaching, Oberhaching
| | | | - Wolfgang Zinser
- Orthoexpert, Knittelfeld, Österreich
- Metagil Physikalisches Ambulatorium, Knittelfeld, Österreich
| | - Peter E Müller
- Muskuloskelettales Universitätszentrum München (MUM), Klinik für Orthopädie und Unfallchirurgie, Klinikum der Universität München, LMU München, München, Deutschland
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3
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Smith L, Jakubiec A, Biant L, Tawy G. The biomechanical and functional outcomes of autologous chondrocyte implantation for articular cartilage defects of the knee: A systematic review. Knee 2023; 44:31-42. [PMID: 37516029 DOI: 10.1016/j.knee.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 06/07/2023] [Accepted: 07/16/2023] [Indexed: 07/31/2023]
Abstract
PURPOSE Autologous chondrocyte implantation (ACI) is primarily performed in active, young patients to treat knee pain and functional limitations resulting from articular cartilage injury. Nevertheless, the functional outcomes of ACI remain poorly understood. This systematic review aimed to evaluate the biomechanical and functional outcomes of ACI. METHODS Ovid MEDLINE, Embase, and Web of Science were systematically searched using the terms 'Knee OR Knee joint AND Autologous chondrocyte implantation OR ACI'. Inclusion and exclusion criteria were used to screen publications by title, abstract, and full text. Study quality and bias were assessed by two reviewers. Means and standard deviations of all collected variables were calculated and presented in the review. PROSPERO ID CRD42021238768. RESULTS Nineteen articles including 20 ACI cohorts were included. In general, the average range of motion (ROM) improved with clinical (>5°) and statistical significance (p < 0.05) postoperatively: 130.5 ± 14.8° to 136.1 ± 10.2°. Knee strength significantly improved within the first two postoperative years but remained poorer than control groups at final follow-up. No statistical differences were found between ACI and control groups in their ability to perform functional activities like the 6-minute walk test. CONCLUSION Knee range of motion generally improved following ACI. Although, some studies reported that knee strengths remained significantly poorer than healthy controls, particularly >2-years postoperatively, implying that longer-term strength training may benefit patients.However, the volume of research and current level of evidence remain low, thus further research is required to better understand the impact of ACI on knee function and guide future rehabilitative protocols.
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Affiliation(s)
- Lauren Smith
- Division of Medical Education, School of Medical Sciences, The University of Manchester, Manchester, UK
| | - Alexander Jakubiec
- Division of Cell Matrix Biology & Regenerative Medicine, School of Biological Sciences, The University of Manchester, Manchester, UK
| | - Leela Biant
- Division of Cell Matrix Biology & Regenerative Medicine, School of Biological Sciences, The University of Manchester, Manchester, UK; Department of Orthopaedics, Trafford General Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Gwenllian Tawy
- Division of Cell Matrix Biology & Regenerative Medicine, School of Biological Sciences, The University of Manchester, Manchester, UK.
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4
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Dhillon J, Fasulo SM, Kraeutler MJ, Belk JW, McCulloch PC, Scillia AJ. The Most Common Rehabilitation Protocol After Matrix-Assisted Autologous Chondrocyte Implantation Is Immediate Partial Weight-Bearing and Continuous Passive Motion. Arthrosc Sports Med Rehabil 2022; 4:e2115-e2123. [PMID: 36579035 PMCID: PMC9791827 DOI: 10.1016/j.asmr.2022.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 09/06/2022] [Indexed: 11/19/2022] Open
Abstract
Purpose To perform a systematic review of postoperative rehabilitation protocols for third-generation autologous chondrocyte implantation (ACI) of the knee joint. Methods A systematic review was performed by searching PubMed, Cochrane Library, and EMBASE to locate randomized controlled trials that described a rehabilitation protocol following third-generation ACI of the knee joint. The search terms used were: "autologous" AND "chondrocyte" AND "randomized". Data extracted from each study included various components of postoperative rehabilitation, such as initial weight-bearing (WB) status and time to full WB, the use of continuous passive motion (CPM), the time to return to sports, and physical therapy (PT) modalities used and the timing of their initiation. Results Twenty-five studies (22 Level I, 3 Level II) met inclusion criteria, including a total of 905 patients undergoing treatment with ACI. The average patient age ranged from 29.1 to 54.8 years, and the mean follow-up time ranged from 3 months to 10.0 years. The average lesion size ranged from 1.9 to 5.8 cm2, and the most common lesion location was the medial femoral condyle (n = 494). Twenty studies allowed partial WB postoperatively with all studies permitting full WB within 12 weeks. Twenty studies used CPM in their rehabilitation protocols and initiated its use within 24 hours postoperatively. Among 10 studies that reported time to return to sport, 9 (90%) allowed return by 12 months. While most protocols used strength training as well as the inclusion of proprioceptive training, there was disagreement on the timing and inclusion of specific PT modalities used during the rehabilitation process. Conclusions Based on the included studies, most rehabilitation protocols for third-generation ACI initiate CPM within 24 hours postoperatively and allow partial WB immediately following surgery with progression to full WB within 12 weeks. There is variation of the PT modalities used as well as the timing of their initiation. Level of Evidence Level II, systematic review of Level I-II studies.
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Affiliation(s)
- Jaydeep Dhillon
- Rocky Vista University College of Osteopathic Medicine, Parker, Colorado U.S.A
| | - Sydney M. Fasulo
- Department of Orthopaedic Surgery, St. Joseph’s University Medical Center, Paterson, New Jersey U.S.A
| | - Matthew J. Kraeutler
- Department of Orthopedics & Sports Medicine, Houston Methodist Hospital, Houston, Texas U.S.A.,Address correspondence to Matthew J. Kraeutler, M.D., Department of Orthopedics & Sports Medicine, Houston Methodist Hospital, 6445 Main St., Suite 2300, Houston, TX 77030.
| | - John W. Belk
- University of Colorado School of Medicine, Aurora, Colorado U.S.A
| | - Patrick C. McCulloch
- Department of Orthopedics & Sports Medicine, Houston Methodist Hospital, Houston, Texas U.S.A
| | - Anthony J. Scillia
- Department of Orthopaedic Surgery, St. Joseph’s University Medical Center, Paterson, New Jersey U.S.A.,Academy Orthopaedics, Wayne, New Jersey, U.S.A
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5
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Epanomeritakis IE, Lee E, Lu V, Khan W. The Use of Autologous Chondrocyte and Mesenchymal Stem Cell Implants for the Treatment of Focal Chondral Defects in Human Knee Joints-A Systematic Review and Meta-Analysis. Int J Mol Sci 2022; 23:ijms23074065. [PMID: 35409424 PMCID: PMC8999850 DOI: 10.3390/ijms23074065] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 04/02/2022] [Accepted: 04/03/2022] [Indexed: 12/16/2022] Open
Abstract
Focal chondral defects of the knee occur commonly in the young, active population due to trauma. Damage can insidiously spread and lead to osteoarthritis with significant functional and socioeconomic consequences. Implants consisting of autologous chondrocytes or mesenchymal stem cells (MSC) seeded onto scaffolds have been suggested as promising therapies to restore these defects. However, the degree of integration between the implant and native cartilage still requires optimization. A PRISMA systematic review and meta-analysis was conducted using five databases (PubMed, MEDLINE, EMBASE, Web of Science, CINAHL) to identify studies that used autologous chondrocyte implants (ACI) or MSC implant therapies to repair chondral defects of the tibiofemoral joint. Data on the integration of the implant-cartilage interface, as well as outcomes of clinical scoring systems, were extracted. Most eligible studies investigated the use of ACI only. Our meta-analysis showed that, across a total of 200 patients, 64% (95% CI (51%, 75%)) achieved complete integration with native cartilage. In addition, a pooled improvement in the mean MOCART integration score was observed during post-operative follow-up (standardized mean difference: 1.16; 95% CI (0.07, 2.24), p = 0.04). All studies showed an improvement in the clinical scores. The use of a collagen-based scaffold was associated with better integration and clinical outcomes. This review demonstrated that cell-seeded scaffolds can achieve good quality integration in most patients, which improves over time and is associated with clinical improvements. A greater number of studies comparing these techniques to traditional cartilage repair methods, with more inclusion of MSC-seeded scaffolds, should allow for a standardized approach to cartilage regeneration to develop.
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Affiliation(s)
| | - Ernest Lee
- School of Clinical Medicine, University of Cambridge, Cambridge CB2 0SP, UK; (I.E.E.); (E.L.); (V.L.)
| | - Victor Lu
- School of Clinical Medicine, University of Cambridge, Cambridge CB2 0SP, UK; (I.E.E.); (E.L.); (V.L.)
| | - Wasim Khan
- Department of Trauma and Orthopaedic Surgery, Addenbrooke’s Hospital, University of Cambridge, Cambridge CB2 0QQ, UK
- Correspondence: ; Tel.: +44-(0)-7791-025554
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6
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Abraamyan T, Johnson AJ, Wiedrick J, Crawford DC. Marrow Stimulation Has Relatively Inferior Patient-Reported Outcomes in Cartilage Restoration Surgery of the Knee: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Am J Sports Med 2022; 50:858-866. [PMID: 33890799 DOI: 10.1177/03635465211003595] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Multiple cartilage repair techniques are available for chondral defects in the knee. Optimal treatment is controversial. PURPOSE To evaluate change from baseline in the 5 Knee injury and Osteoarthritis Outcome Score (KOOS) subscales among different cartilage repair techniques of the knee. STUDY DESIGN Systematic review and meta-analysis; Level of evidence, 1A. METHODS Medline and Cochrane Central Register of Controlled Trials (CENTRAL) databases were searched for randomized controlled trials with minimum 1 year follow-up reporting change from baseline KOOS (delta KOOS) subscale values. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed. A meta-analysis was performed on the following surgery types: microfracture (Mfx); augmented microfracture techniques (Mfx+Augment); and culture-based therapies, including autologous chondrocyte implantation (ACI) and matrix-assisted autologous chondrocyte implantation (MACI). A random-effects metaregression model was used. RESULTS A total of 14 randomized trials with a total of 775 patients were included. The KOOS Sport and Recreation (Sport) and KOOS Quality of Life (QOL) were the 2 most responsive subscales after operative intervention. Outcomes from Mfx and Mfx+Augment were not different in any of the 5 KOOS subscales (minimum P > .3). The mean delta KOOS Sport after ACI/MACI was 9.9 points greater than after Mfx (P = .021) and 11.7 points greater than after Mfx+Augment (P = .027). Longer follow-up time correlated with greater delta KOOS Sport (P = .028). Larger body mass index led to greater delta KOOS QOL (P = .045). Larger cartilage defect size correlated with greater delta KOOS Pain and KOOS Activities of Daily Living scores (P = .023 and P = .002, respectively). CONCLUSION The KOOS Sport and QOL were the most responsive subscales after cartilage restoration surgery of the knee. Culture-based therapies (ACI/MACI) led to clinically relevant improvements in the KOOS Sport score compared with marrow stimulation and may be a more appropriate treatment in younger and more active individuals. There were no benefits to Mfx+Augment over Mfx alone in any of the KOOS subscales.
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Affiliation(s)
- Torgom Abraamyan
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, Oregon, USA
| | - Alicia J Johnson
- Biostatistics and Design Program, Oregon Health & Science University, Portland, Oregon, USA
| | - Jack Wiedrick
- Biostatistics and Design Program, Oregon Health & Science University, Portland, Oregon, USA
| | - Dennis C Crawford
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, Oregon, USA
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7
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Hurley ET, Davey MS, Jamal MS, Manjunath AK, Alaia MJ, Strauss EJ. Return-to-Play and Rehabilitation Protocols following Cartilage Restoration Procedures of the Knee: A Systematic Review. Cartilage 2021; 13:907S-914S. [PMID: 31855062 PMCID: PMC8808781 DOI: 10.1177/1947603519894733] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE The purpose of this study is to systematically review the literature and to evaluate the reported rehabilitation protocols, return-to-play guidelines, and subsequent rates of return to play following cartilage restoration procedures in the knee. DESIGN MEDLINE, EMBASE, and the Cochrane Library were searched according to the PRISMA guidelines to find studies on cartilage restoration procedures in the knee, including (1) microfracture (Mfx), (2) osteochondral autograft transfer (AOT), (3) osteochondral allograft implantation (OCA), and (4) autologous chondrocyte implantation (ACI). Studies were included if they reported return-to-play data or rehabilitation protocols. RESULTS Overall, 179 studies fit our inclusion criteria, with 48 on Mfx, 34 on AOT, 54 on OCA, and 51 on ACI. The rate of return to play was reported as high as 88.2% with AOT, and as low as 77.2% following OCA, with rates of return to play at the same/higher level as high as 79.3% with AOT, and as low as 57.3% following ACI. The average reported time of return to play was as low as 4.9 months with AOT, and as high as 11.6 months following ACI. CONCLUSIONS The majority of patients are able to return to play following cartilage restoration procedures in the knee, regardless of surgical procedure utilized. However, while the rate of return to play at the same level was similar to the overall rate of return following AOT, there was a large number of patients unable to return to the same level following Mfx, OCA, and ACI. Additionally, there is wide variety in the rehabilitation protocols, and scant literature on return-to-play protocols.
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Affiliation(s)
- Eoghan T. Hurley
- Department of Orthopaedic Surgery, New
York University Langone Health, New York, NY, USA
| | - Martin S. Davey
- Department of Orthopaedic Surgery, New
York University Langone Health, New York, NY, USA
| | - M. Shazil Jamal
- Department of Orthopaedic Surgery, New
York University Langone Health, New York, NY, USA
| | - Amit K. Manjunath
- Department of Orthopaedic Surgery, New
York University Langone Health, New York, NY, USA
| | - Michael J. Alaia
- Department of Orthopaedic Surgery, New
York University Langone Health, New York, NY, USA
| | - Eric J. Strauss
- Department of Orthopaedic Surgery, New
York University Langone Health, New York, NY, USA,Eric J. Strauss, Department of Orthopaedic
Surgery, New York University Langone Health, New York, NY, USA.
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8
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Everhart JS, Jiang EX, Poland SG, Du A, Flanigan DC. Failures, Reoperations, and Improvement in Knee Symptoms Following Matrix-Assisted Autologous Chondrocyte Transplantation: A Meta-Analysis of Prospective Comparative Trials. Cartilage 2021; 13:1022S-1035S. [PMID: 31508998 PMCID: PMC8808777 DOI: 10.1177/1947603519870861] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
OBJECTIVE Though multiple high-level comparative studies have been performed for matrix-assisted autologous chondrocyte transplantation (MACT), quantitative reviews synthesizing best-available clinical evidence on the topic are lacking. DESIGN A meta-analysis was performed of prospective randomized or nonrandomized comparative studies utilizing MACT. A total of 13 studies reporting 13 prospective trials (9 randomized, 5 nonrandomized) were included (658 total study participants at weighted mean 3.1 years follow-up, range 1-7.5 years). RESULTS Reporting and methodological quality was moderate according to mean Coleman (59.4 SD 7.6), Delphi (3.0 SD 2.1), and MINORS (Methodological Index For Non-Randomized Studies) scores (20.2 SD 1.6). There was no evidence of small study or reporting bias. Effect sizes were not correlated with reporting quality, financial conflict of interest, sample size, year of publication, or length of follow-up (P > 0.05). Compared to microfracture, MACT had greater improvement in International Knee Documentation Committee (IKDC)-subjective and Knee Injury and Osteoarthritis Outcome Pain Subscale Score (KOOS)-pain scores in randomized studies (P < 0.05). Accelerated weight-bearing protocols (6 or 8 weeks) resulted in greater improvements in IKDC-subjective and KOOS-pain scores than standard protocols (8 or 11 weeks) for MACT in randomized studies (P < 0.05) with insufficient nonrandomized studies for pooled analysis. CONCLUSIONS Compared to microfracture, MACT has no increased risk of clinical failure and superior improvement in patient-reported outcome scores. Compared to MACT with standardized postoperative weight-bearing protocols, accelerated weight-bearing protocols have no increased risk of clinical failure and show superior improvement in patient-reported outcome scores. There is limited evidence regarding MACT compared to first-generation autologous chondrocyte implantation, mosaicplasty, and mesenchymal stem cell therapy without compelling differences in outcomes.
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Affiliation(s)
- Joshua S. Everhart
- Department of Orthopaedics, The Ohio
State University Wexner Medical Center, Columbus, OH, USA
| | - Eric X. Jiang
- Department of Orthopaedics, The Ohio
State University Wexner Medical Center, Columbus, OH, USA
| | - Sarah G. Poland
- Department of Orthopaedics, The Ohio
State University Wexner Medical Center, Columbus, OH, USA
| | - Amy Du
- Department of Orthopaedics, The Ohio
State University Wexner Medical Center, Columbus, OH, USA
| | - David C. Flanigan
- Department of Orthopaedics, The Ohio
State University Wexner Medical Center, Columbus, OH, USA
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9
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Salonius E, Meller A, Paatela T, Vasara A, Puhakka J, Hannula M, Haaparanta AM, Kiviranta I, Muhonen V. Cartilage Repair Capacity within a Single Full-Thickness Chondral Defect in a Porcine Autologous Matrix-Induced Chondrogenesis Model Is Affected by the Location within the Defect. Cartilage 2021; 13:744S-754S. [PMID: 34308665 PMCID: PMC8804745 DOI: 10.1177/19476035211030988] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
OBJECTIVE Large articular cartilage defects are a challenge to regenerative surgery. Biomaterial scaffolds might provide valuable support for restoration of articulating surface. The performance of a composite biomaterial scaffold was evaluated in a large porcine cartilage defect. DESIGN Cartilage repair capacity of a biomaterial combining recombinant human type III collagen (rhCo) and poly-(l/d)-lactide (PLA) was tested in a porcine model. A full-thickness chondral defect covering the majority of the weightbearing area was inflicted to the medial femoral condyle of the right knee. Spontaneous cartilage repair and nonoperated healthy animals served as controls. The animals were sacrificed after a 4-month follow-up. The repair tissue was evaluated with the International Cartilage Repair Society (ICRS) macroscopic score, ICRS II histological score, and with micro-computed tomography. Additionally, histopathological evaluation of lymph nodes and synovial samples were done for toxicological analyses. RESULTS The lateral half of the cartilage defect in the operated groups showed better filling than the medial half. The mean overall macroscopic score for the rhCo-PLA, spontaneous, and nonoperated groups were 5.96 ± 0.33, 4.63 ± 0.42, and 10.98 ± 0.35, respectively. The overall histological appearance of the specimens was predominantly hyaline cartilage in 3 of 9 samples of the rhCo-PLA group, 2 of 8 of the spontaneous group, and 9 of 9 of the nonoperated group. CONCLUSIONS The use of rhCo-PLA scaffold did not differ from spontaneous healing. The repair was affected by the spatial properties within the defect, as the lateral part of the defect showed better repair than the medial part, probably due to different weightbearing conditions.
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Affiliation(s)
- E. Salonius
- Department of Orthopaedics and
Traumatology, Clinicum, University of Helsinki, Helsinki, Finland,Department of Surgery, Päijät-Häme
Central Hospital, Lahti, Finland,E. Salonius, Department of Orthopaedics and
Traumatology, Clinicum, University of Helsinki, Biomedicum Helsinki,
Haartmaninkatu 8, Helsinki, 00014, Finland.
| | - A. Meller
- University of Helsinki, HiLIFE–Helsinki
Institute of Life Science Laboratory Animal Center, Helsinki, Finland
| | - T. Paatela
- Department of Orthopaedics and
Traumatology, Clinicum, University of Helsinki, Helsinki, Finland,Department of Orthopaedics and
Traumatology, Helsinki University Hospital, Helsinki, Finland
| | - A. Vasara
- Department of Orthopaedics and
Traumatology, Clinicum, University of Helsinki, Helsinki, Finland,Department of Orthopaedics and
Traumatology, Helsinki University Hospital, Helsinki, Finland
| | - J. Puhakka
- Department of Orthopaedics and
Traumatology, Clinicum, University of Helsinki, Helsinki, Finland,Department of Orthopaedics and
Traumatology, Helsinki University Hospital, Helsinki, Finland
| | - M. Hannula
- Department of Electronics and
Communications Engineering, Tampere University of Technology, BioMediTech, Institute
of Biosciences and Medical Technology, Tampere, Pirkanmaa, Finland
| | - A.-M. Haaparanta
- Department of Electronics and
Communications Engineering, Tampere University of Technology, BioMediTech, Institute
of Biosciences and Medical Technology, Tampere, Pirkanmaa, Finland
| | - I. Kiviranta
- Department of Orthopaedics and
Traumatology, Clinicum, University of Helsinki, Helsinki, Finland,Department of Orthopaedics and
Traumatology, Helsinki University Hospital, Helsinki, Finland
| | - V. Muhonen
- Department of Orthopaedics and
Traumatology, Clinicum, University of Helsinki, Helsinki, Finland
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10
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Ebert JR, Fallon M, Wood DJ, Janes GC. An accelerated 6-week return to full weight bearing after matrix-induced autologous chondrocyte implantation results in good clinical outcomes to 5 years post-surgery. Knee Surg Sports Traumatol Arthrosc 2021; 29:3825-3833. [PMID: 33459833 DOI: 10.1007/s00167-020-06422-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 12/15/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE To investigate the mid-term outcomes of an accelerated return to full weight bearing (WB) after matrix-induced autologous chondrocyte implantation (MACI). METHODS This randomized study allocated 35 patients (37 knees) to a 6 week (n = 18) or 8 week (n = 19) return to full WB after MACI. Patients were evaluated pre-operatively and at 1, 2 and minimum 5 years (range 5.5-7 years), using the KOOS, SF-36, visual analogue pain scale, 6-min walk test and active knee range of motion (ROM). Peak isokinetic knee extensor and flexor strength was assessed, with limb symmetry indices (LSIs) calculated. Magnetic resonance imaging (MRI) was undertaken to evaluate the repair tissue, and an MRI composite score was calculated. RESULTS While no group differences (n.s.) were observed, significant improvement was observed for all patient-reported outcome measures (p < 0.05), 6-min walk distance (p = 0.040), active knee flexion (p = 0.002) and extension (p < 0.0001) ROM, and the LSI for peak knee extensor strength (p < 0.0001). At final review, 87.5% (6 weeks) and 82.4% (8 weeks) of patients were satisfied overall. A non-significant decline (n.s.) was observed for the MRI composite score from 1-year post-surgery to final review, with no significant MRI-based differences (n.s.) between groups. At final review, two grafts (6-week n = 1, 8-week n = 1) demonstrated MRI-based graft failure, while an additional patient had progressed toward knee arthroplasty (8.1% failure rate at minimum 5 years). CONCLUSIONS The 6-week return to full WB after MACI provided comparable clinical and MRI-based outcomes beyond 5 years post-surgery, without jeopardizing the graft. This 6-week WB protocol is faster than those previously proposed and studied. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Jay R Ebert
- School of Human Sciences (Exercise and Sport Science), The University of Western Australia, 35 Stirling Highway, Crawley, WA, 6009, Australia.
- HFRC Rehabilitation Clinic, 117 Stirling Highway, Nedlands, WA, 6009, Australia.
| | - Michael Fallon
- Perth Radiological Clinic, Subiaco, Perth, WA, 6008, Australia
| | - David J Wood
- School of Surgery (Orthopaedics), University of Western Australia, Crawley, Perth, WA, 6009, Australia
| | - Gregory C Janes
- Perth Orthopaedic and Sports Medicine Centre, West Perth, WA, 6005, Australia
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11
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Iordache E, Robertson EL, Hirschmann A, Hirschmann MT. Typical MRI-pattern suggests peak maturation of the ACI graft 2 years after third-generation ACI: a systematic review. Knee Surg Sports Traumatol Arthrosc 2021; 29:3664-3677. [PMID: 33270154 DOI: 10.1007/s00167-020-06339-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 10/15/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE The purpose of the present article was (1) to systematically review the current literature and (2) to collect data regarding the postoperative magnetic resonance imaging (MRI) appearance of third-generation autologous chondrocyte implantation (ACI) grafts and (3) to provide an overview of imaging findings at various postoperative time points. METHODS A systematic review of the literature in Medline (Pubmed) and Embase was performed using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Articles which reported the post-operative MRI morphological outcomes following the use of third-generation ACI for treatment of knee cartilage lesions were included. All MRI results were allocated to six different time intervals: ≤ 3 months, > 3-6 months, > 6 months-1 year, > 1 year-2 years, > 2-5 years and > 5 years after surgery. RESULTS A total of 22 studies were included and the study populations ranged from 13 to 180 patients adding up to a total of 951 patients. Parameters such as defect fill, border integration, surface contour, graft morphology and integrity of the subchondral lamina all improve gradually with a peak two years following surgery suggesting complete graft maturation at this time point. After this peak, a statistically insignificant decline is noted for most of the parameters. Signal intensity was found to gradually shift from hyperintense to isointense in the first 36 months and to hypointense later on. Contrarily, subchondral bone edema is not only a postoperative feature of the procedure but also can reappear or persist up to ten years after surgery. As graft failures can appear after two years, consequently, the MRI composite score is also affected. CONCLUSION Recurring patterns in postoperative MRI appearance were observed in certain parameters including defect filling, graft signal intensity and structure, border integration of the graft while parameters like subchondral bone tend to be unpredictable. Given the heterogenous findings in terms of clinical correlation, and relating that aspect to the patterns found in this review, an MRI is justified at three months, one year, two years and five years after surgery, unless the clinical symptomatology and individual patient needs dictate otherwise. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Edna Iordache
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland (Bruderholz, Liestal, Laufen), CH-4101, Bruderholz, Switzerland
| | - Emma L Robertson
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland (Bruderholz, Liestal, Laufen), CH-4101, Bruderholz, Switzerland
| | - Anna Hirschmann
- Radiology, University Hospital Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Michael T Hirschmann
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland (Bruderholz, Liestal, Laufen), CH-4101, Bruderholz, Switzerland.
- University of Basel, Basel, Switzerland.
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12
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Chamorro-Moriana G, Sevillano JL, Perez-Cabezas V. Versatile GCH Control Software for Correction of Loads Applied to Forearm Crutches During Gait Recovery Through Technological Feedback: Development and Implementation Study. J Med Internet Res 2021; 23:e27602. [PMID: 34550073 PMCID: PMC8495581 DOI: 10.2196/27602] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 06/24/2021] [Accepted: 07/27/2021] [Indexed: 01/26/2023] Open
Abstract
Background Measuring weight bearing is an essential aspect of clinical care for lower limb injuries such as sprains or meniscopathy surgeries. This care often involves the use of forearm crutches for partial loads progressing to full loads. Therefore, feasible methods of load monitoring for daily clinical use are needed. Objective The main objective of this study was to design an innovative multifunctional desktop load-measuring software that complements GCH System 2.0–instrumented forearm crutches and monitors the applied loads, displaying real-time graphical and numerical information, and enabling the correction of inaccuracies through feedback technology during assisted gait. The secondary objective was to perform a preliminary implementation trial. Methods The software was designed for indoor use (clinics/laboratories). This software translates the crutch sensor signal in millivolts into force units, records and analyzes data (10-80 Hz), and provides real-time effective curves of the loads exerted on crutches. It covers numerous types of extrinsic feedback, including visual, acoustic (verbal/beeps), concurrent, terminal, and descriptive feedback, and includes a clinical and research use database. An observational descriptive pilot study was performed with 10 healthy subjects experienced in bilateral assisted gait. The Wilcoxon matched-pairs signed-rank test was used to evaluate the load accuracy evolution of each subject (ie, changes in the loads exerted on crutches for each support) among various walks, which was interpreted at the 95% confidence level. Results GCH Control Software was developed as a multifunctional desktop tool complementing GCH System 2.0–instrumented forearm crutches. The pilot implementation of the feedback mechanism observed 96/100 load errors at baseline (walk 0, no feedback) with 7/10 subjects exhibiting crutch overloading. Errors ranged from 61.09% to 203.98%, demonstrating heterogeneity. The double-bar feedback found 54/100 errors in walk 1, 28/100 in walk 2, and 14/100 in walk 3. The first walk with double-bar feedback (walk 1) began with errors similar to the baseline walk, generally followed by attempts at correction. The Wilcoxon matched-pairs signed-rank test used to evaluate each subject’s progress showed that all participants steadily improved the accuracy of the loads applied to the crutches. In particular, Subject 9 required extra feedback with two single-bar walks to focus on the total load. The participants also corrected the load balance between crutches and fluency errors. Three subjects made one error of load balance and one subject made six fluctuation errors during the three double-bar walks. The latter subject performed additional feedback with two balance-bar walks to focus on the load balance. Conclusions GCH Control Software proved to be useful for monitoring the loads exerted on forearm crutches, providing a variety of feedback for correcting load accuracy, load balance between crutches, and fluency. The findings of the complementary implementation were satisfactory, although clinical trials with larger samples are needed to assess the efficacy of the different feedback mechanisms and to select the best alternatives in each case.
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Affiliation(s)
- Gema Chamorro-Moriana
- Department of Physiotherapy, Area of Physiotherapy Research Group CTS-305, University of Seville, Seville, Spain
| | - Jose Luis Sevillano
- Department of Architecture and Technology of Computers, Robotics and Technology of Computers Research Group TEP-108, University of Seville, Seville, Spain
| | - V Perez-Cabezas
- Department of Nursing and Physiotherapy, Empowering Health by Physical Activity, Exercise and Nutrition Research Group CTS-1038, University of Cadiz, Cadiz, Spain
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13
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Saris TFF, de Windt TS, Kester EC, Vonk LA, Custers RJH, Saris DBF. 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. Am J Sports Med 2021; 49:941-947. [PMID: 33591794 DOI: 10.1177/0363546520988069] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- Tim F F Saris
- Orthopaedic Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Tommy S de Windt
- Orthopaedic Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Esmee C Kester
- Orthopaedic Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Lucienne A Vonk
- Orthopaedic Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Roel J H Custers
- Orthopaedic Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Daniel B F Saris
- Orthopaedic Surgery, University Medical Center Utrecht, Utrecht, the Netherlands.,Reconstructive medicine, University of Twente, Enschede, the Netherlands.,Orthopedics and Sports Medicine, Mayo Clinic, Rochester, Minnesota, USA
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14
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Everhart JS, Harris KM, Schiele SE, Abouljoud M, Eikenberry A, Emery CF, Flanigan DC. Individual Coping Strategies Are Associated with Patient-Reported Satisfaction upon Completion of Rehabilitation following Sports-Related Knee Surgery. J Knee Surg 2020; 33:1225-1231. [PMID: 31284319 DOI: 10.1055/s-0039-1693416] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
We sought to determine whether individual coping strategies and optimism are associated with satisfaction after sports-related knee surgery at the time of rehabilitation completion and whether the association between coping strategies/optimism and satisfaction varies by surgical procedure or length of rehabilitation. A total of 104 recreational and competitive athletes who underwent knee surgery completed preoperative assessments for intrinsic optimism using the revised Life Orientation Test and coping strategies using the brief Coping Orientations to the Problem Experience inventory. Postoperative assessments at completion of rehabilitation (mean: 5.5-month follow-up.; maximum: 15 months) included satisfaction with surgery, return to prior level of sport, and International Knee Documentation Committee (IKDC-S) symptom scores. Eighty-one percent were satisfied after completion of rehabilitation with a 68% return to prior level of sport. Irrespective of surgical procedure or length of rehabilitation (p > 0.25, all comparisons), greater reliance on others for emotional support as a coping mechanism increased risk of dissatisfaction after surgery (per point: odds ratio [OR]: 1.75; confidence interval [CI]: 1.13-2.92; p = 0.01), whereas greater use of positive reframing as a coping mechanism was protective (per point: OR: 0.43; CI: 0.21-0.82; p = 0.009). Intrinsic optimism was not predictive of postoperative satisfaction (p = 0.71). Satisfied patients had mean 13.5 points higher IKDC-S scores at follow-up than unsatisfied patients (p = 0.001). Patients who returned to prior level of sport had significantly higher satisfaction scores than patients who had not. Irrespective of surgical procedure or length of rehabilitation, use of positive reframing and reliance on others for emotional support are positive and negative predictors, respectively, of satisfaction after sports-related knee surgery. Preoperative optimism is not predictive of postoperative satisfaction.
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Affiliation(s)
- Joshua S Everhart
- Sports Medicine, Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Kristie M Harris
- Department of Psychology, the Ohio State University, Columbus, Ohio
| | - Steven E Schiele
- Department of Psychology, the Ohio State University, Columbus, Ohio
| | - Moneer Abouljoud
- Sports Medicine, Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Alexander Eikenberry
- Sports Medicine, Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Charles F Emery
- Department of Psychology, the Ohio State University, Columbus, Ohio
| | - David C Flanigan
- Sports Medicine, Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio
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15
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Lin CC, Chu CJ, Chou PH, Liang CH, Liang PI, Chang NJ. Beneficial Therapeutic Approach of Acellular PLGA Implants Coupled With Rehabilitation Exercise for Osteochondral Repair: A Proof of Concept Study in a Minipig Model. Am J Sports Med 2020; 48:2796-2807. [PMID: 32749853 DOI: 10.1177/0363546520940306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Osteochondral (OC) repair presents a significant challenge to clinicians. However, whether the use of acellular spongy poly(lactic-co-glycolic acid) (PLGA) scaffolding plus treadmill exercise as a rehabilitation program regenerates OC defects in a large-animal model has yet to be determined. HYPOTHESIS PLGA scaffolding plus treadmill exercise may offer improved OC repair for both high and low weightbearing regions in a minipig model. STUDY DESIGN Controlled laboratory study. METHODS A total of 9 mature minipigs (18 knees) were randomly divided into the treadmill exercise (TRE) group or sedentary (SED) group. All pigs received critically sized OC defects in a higher weightbearing region of the medial condyle and a lower weightbearing region of the trochlear groove. In each minipig, a PLGA scaffold was placed in the defect of the right knee (PLGA subgroup), and the defect of the left knee was untreated (empty defect [ED] subgroup). The TRE group performed exercises in 3 phases: warm-up, 3 km/h for 5 minutes; main exercise, 4 km/h for 20 minutes; and cool-down, 3 km/h for 5 minutes. The total duration was about 30 minutes whenever possible. The SED group was allowed free cage activity. RESULTS At 6 months, the TRE-PLGA group showed the highest gross morphology scores and regenerated a smooth articular surface covered with new hyaline-like tissue, while the defects of the other groups remained and contained nontransparent tissue. Histologically, the TRE-PLGA group also revealed sound OC integration, chondrocyte-like cells embedded in lacunae, abundant glycosaminoglycans, a sound collagen structure, and modest inflammatory cells with an inflammatory response (ie, tumor necrosis factor-α, interleukin-6). In addition, in the medial condyle region, the TRE-PLGA group (31.80 ± 3.03) had the highest total histological scores (TRE-ED: 20.20 ± 5.76; SED-PLGA: 10.25 ± 6.24; SED-ED: 11.75 ± 6.50; P = .004). In the trochlear groove region, the TRE-PLGA group (30.20 ± 6.42) displayed significantly higher total histological scores (TRE-ED: 19.60 ± 7.00; SED-PLGA: 10.00 ± 5.42; SED-ED: 11.25 ± 5.25; P = .006). In contrast, the SED-PLGA and SED-ED groups revealed an irregular surface with abrasion, fibrotic tissue with an empty void and inflammatory cells, disorganized collagen fibers, and less glycosaminoglycan deposition. Micro-computed tomography analysis revealed that the TRE-PLGA group had integrated OC interfaces with continued remodeling in the subchondral bone. Furthermore, comparing the 2 defect regions, no statistically significant differences in cartilage regeneration were detected, indicating the suitability of this regenerative approach for both high and low weightbearing regions. CONCLUSION Implanting an acellular PLGA scaffold plus treadmill exercise promoted articular cartilage regeneration for both high and low weightbearing regions in minipigs. CLINICAL RELEVANCE This study suggests the use of a cell-free porous PLGA scaffold and treadmill exercise rehabilitation as an alternative therapeutic strategy for OC repair in a large-animal knee joint model. This combined effect may pave the way for biomaterials and exercise regimens in the application of OC repair.
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Affiliation(s)
- Chih-Chan Lin
- Department of Medical Research, Chi Mei Medical Center, Tainan City, Taiwan
| | - Chih-Jou Chu
- Department of Sports Medicine, Kaohsiung Medical University, Kaohsiung City, Taiwan
| | - Pei-Hsi Chou
- Department of Sports Medicine, Kaohsiung Medical University, Kaohsiung City, Taiwan.,PhD Program in Biomedical Engineering, Kaohsiung Medical University, Kaohsiung City, Taiwan
| | - Chun-Hao Liang
- Department of Sports Medicine, Kaohsiung Medical University, Kaohsiung City, Taiwan
| | - Peir-In Liang
- Department of Pathology, Kaohsiung Medical University, Kaohsiung City, Taiwan
| | - Nai-Jen Chang
- Department of Sports Medicine, Kaohsiung Medical University, Kaohsiung City, Taiwan.,PhD Program in Biomedical Engineering, Kaohsiung Medical University, Kaohsiung City, Taiwan.,Regenerative Medicine and Cell Therapy Research Center, Kaohsiung Medical University, Kaohsiung City, Taiwan
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16
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Abstract
PURPOSE OF REVIEW To review the current basic science and clinical literature on mesenchymal stem cell (MSC) therapy for articular cartilage defects and osteoarthritis of the knee. RECENT FINDINGS MSCs derived from bone marrow, adipose, and umbilical tissue have the capacity for self-renewal and differentiation into the chondrocyte lineage. In theory, MSC therapy may help restore cartilage focally or diffusely where nascent regenerative potential in the intra-articular environment is limited. Over the last several years, in vitro and animal studies have elucidated the use of MSCs in isolation as injectables, in combination with biological delivery media and scaffolding, and as surgical adjuvants for cartilage regeneration and treatment of knee degenerative conditions. More recently, clinical and translational literature has grown more convincing from early descriptive case series to randomized controlled trials showing promise in efficacy and safety. Studies describing MSC for knee cartilage regeneration applications are numerous and varied in quality. Future research directions should include work on elucidating optimal cell concentration and dosing, as well as standardization in methodology and reporting in prospective trials. Backed by promise from in vitro and animal studies, preliminary clinical evidence on MSC therapy shows promise as a nonoperative therapeutic option or an adjuvant to existing surgical cartilage restoration techniques. While higher quality evidence to support MSC therapy has emerged over the last several years, further refinement of methodology will be necessary to support its routine clinical use.
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17
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Ebert JR, Fallon M, Ackland TR, Janes GC, Wood DJ. Minimum 10-Year Clinical and Radiological Outcomes of a Randomized Controlled Trial Evaluating 2 Different Approaches to Full Weightbearing After Matrix-Induced Autologous Chondrocyte Implantation. Am J Sports Med 2020; 48:133-142. [PMID: 31765228 DOI: 10.1177/0363546519886548] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Longer term outcomes after matrix-induced autologous chondrocyte implantation (MACI) are lacking, while early postoperative weightbearing (WB) management has traditionally been conservative. PURPOSE To investigate the longer term clinical and radiological outcomes after an 8-week (vs 12-week) WB protocol after MACI. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS A randomized study design allocated 70 patients to an 8- (n = 34) or 12-week (n = 36) approach to full WB after MACI of the medial or lateral femoral condyle. Patients were evaluated preoperatively; at 3, 12, and 24 months after surgery; and at 5 and 10 years after surgery. At 10 years (range, 10.5-11.5 years), 60 patients (85.7%; 8 weeks: n = 29; 12 weeks: n = 31) were available for review. Clinical outcomes included patient-reported outcomes, maximal isokinetic knee extensor and flexor strength, and functional hop capacity. High-resolution magnetic resonance imaging (MRI) was undertaken to assess the quality and quantity of repair tissue per the MOCART (magnetic resonance observation of cartilage repair tissue) system. A combined MRI composite score was also evaluated. RESULTS Clinical and MRI-based scores for the full cohort significantly improved (P < .05) over the 10-year period. Apart from the Tegner activity score, which improved (P = .041), as well as tissue structure (P = .030), which deteriorated, there were no further statistically significant changes (P > .05) from 5 to 10 years. There were no 10-year differences between the 2 WB rehabilitation groups. At 10 years, 81.5% and 82.8% of patients in the 8- and 12-week groups, respectively, demonstrated good-excellent tissue infill. Graft failure was observed on MRI at 10 years in 7 patients overall, which included 4 located on 10-year MRI (8 weeks: n = 1; 12 weeks: n = 3) and a further 3 patients (8 weeks: n = 1; 12 weeks: n = 2) not included in the current analysis who proceeded to total knee arthroplasty. At 10 years, 93.3% of patients were satisfied with MACI for relieving their pain, with 83.3% satisfied with their ability to participate in sport. CONCLUSION MACI provided high satisfaction levels and tissue durability beyond 10 years. The outcomes of this randomized trial demonstrate a safe 8-week WB rehabilitation protocol without jeopardizing longer term outcomes.
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Affiliation(s)
- Jay R Ebert
- School of Human Sciences (Exercise and Sport Science), University of Western Australia, Crawley, Western Australia, Australia.,HFRC Rehabilitation Clinic, Nedlands, Western Australia, Australia
| | - Michael Fallon
- Perth Radiological Clinic, Subiaco, Western Australia, Australia
| | - Timothy R Ackland
- School of Human Sciences (Exercise and Sport Science), University of Western Australia, Crawley, Western Australia, Australia
| | - Gregory C Janes
- Perth Orthopaedic & Sports Medicine Centre, West Perth, Western Australia, Australia
| | - David J Wood
- School of Surgery (Orthopaedics), University of Western Australia, Crawley, Western Australia, Australia
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18
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Wu Z, Lu H, Yao J, Zhang X, Huang Y, Ma S, Zou K, Wei Y, Yang Z, Li J, Zhao J. GABARAP promotes bone marrow mesenchymal stem cells-based the osteoarthritis cartilage regeneration through the inhibition of PI3K/AKT/mTOR signaling pathway. J Cell Physiol 2019; 234:21014-21026. [PMID: 31020644 DOI: 10.1002/jcp.28705] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Revised: 04/02/2019] [Accepted: 04/10/2019] [Indexed: 12/16/2022]
Abstract
Osteoarthritis (OA) is a degenerative disease of the cartilage prevalent in the middle-aged and elderly demographic. Direct transplantation of bone marrow mesenchymal stem cells (BMSCs) or stem cell-derived chondrocytes into the damaged cartilage is a promising therapeutic strategy for OA, but is limited by the poor survival and in situ stability of the chondrocytes. Autophagy is a unique catabolic pathway conserved across eukaryotes that maintains cellular homeostasis, recycles damaged proteins and organelles, and promotes survival. The aim of this study was to determine the role of the proautophagic γ-aminobutyric acid receptor-associated protein (GABARAP) on the therapeutic effects of BMSCs-derived chondrocytes in a rat model of OA, and elucidate the underlying mechanisms. Anterior cruciate ligament transection (ACLT) was performed in Sprague-Dawley rats to simulate OA, and the animals were injected weekly with recombinant human His6-GABARAP protein, BMSCs-derived differentiated chondrocytes (DCs) or their combination directly into the knee cartilage. The regenerative effects of GABARAP and/or DCs were determined in term of International Cartilage Repair Society scores and cartilage thickness. The combination treatment of DCs and GABARAP significantly increased the levels of the ECM proteins Col II and SOX9, indicating formation of hyaline-like cartilage, and decreased chondrocyte apoptosis and inflammation. DCs + GABARAP treatment also upregulated the mediators of the autophagy pathway and suppressed the PI3K/AKT/mTOR pathway, indicating a mechanistic basis of its therapeutic action.
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Affiliation(s)
- Zhengyuan Wu
- Department of Orthopaedics Trauma and Hand Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Huiping Lu
- Department of Pathology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Jun Yao
- Department of Bone and Joint Surgery, The First Affliated Hospital of Guangxi Medical University, Nanning, China
| | - Xiaohan Zhang
- Department of Orthopaedics Trauma and Hand Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Yimei Huang
- Department of Orthopaedics Trauma and Hand Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Shiting Ma
- Department of Orthopaedics Trauma and Hand Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Kai Zou
- Department of Orthopaedics Trauma and Hand Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Yan Wei
- Department of Pathology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Zhengyi Yang
- Department of Orthopaedics Trauma and Hand Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Jia Li
- Department of Pathology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Jinmin Zhao
- Department of Orthopaedics Trauma and Hand Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
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19
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Erickson BJ, Strickland SM, Gomoll AH. Indications, Techniques, Outcomes for Matrix-Induced Autologous Chondrocyte Implantation (MACI). OPER TECHN SPORT MED 2018. [DOI: 10.1053/j.otsm.2018.06.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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20
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Lin Y, Li T, Xiong Y, Li J, Fu W. [Research progress of rehabilitation after autologous chondrocyte implantation on knee]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2018; 32:758-763. [PMID: 29905057 PMCID: PMC8414014 DOI: 10.7507/1002-1892.201801034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 04/30/2018] [Indexed: 02/05/2023]
Abstract
Objective To summarize the research progress of rehabilitation after autologous chondrocyte implantation (ACI). Methods The literature related to basic science and clinical practice about rehabilitation after ACI in recent years was searched, selected, and analyzed. Results Based on the included literature, the progress of the graft maturation consists of proliferation phase (0-6 weeks), transition phase (6-12 weeks), remodeling phase (12-26 weeks), and maturation phase (26 weeks-2 years). To achieve early protection, stimulate the maturation, and promote the graft-bone integrity, rehabilitation protocol ought to be based on the biomechanical properties at different phases. Weight-bearing program, range of motion (ROM), and options or facilities of exercise are importance when considering a rehabilitation program. Conclusion It has been proved that the patients need a program with an increasingly progressive weight-bearing and ROM in principles of rehabilitation after ACI. Specific facilities can be taken at a certain phase. Evidences extracted in the present work are rather low and the high-quality and controlled trials still need to improve the rehabilitation protocol.
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Affiliation(s)
- Yipeng Lin
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Tao Li
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Yan Xiong
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Jian Li
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Weili Fu
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041,
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Kraeutler MJ, Belk JW, Carver TJ, McCarty EC. Is Delayed Weightbearing After Matrix-Associated Autologous Chondrocyte Implantation in the Knee Associated With Better Outcomes? A Systematic Review of Randomized Controlled Trials. Orthop J Sports Med 2018; 6:2325967118770986. [PMID: 29770344 PMCID: PMC5946627 DOI: 10.1177/2325967118770986] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background: Proper rehabilitation after matrix-associated autologous chondrocyte implantation (MACI) is essential to restore a patient’s normal function without overloading the repair site. Purpose: To evaluate the current literature to assess clinical outcomes of MACI in the knee based on postoperative rehabilitation protocols, namely, the time to return to full weightbearing (WB). Study Design: Systematic review; Level of evidence, 1. Methods: A systematic review was performed to locate studies of level 1 evidence comparing the outcomes of patients who underwent MACI with a 6-week, 8-week, or 10/11-week time period to return to full WB. Patient-reported outcomes assessed included the Knee injury and Osteoarthritis Outcome Score (KOOS), Tegner activity scale, Short Form Health Survey–36 (SF-36), and visual analog scale (VAS) for pain frequency and severity. Results: Seven studies met the inclusion criteria, including a total of 136 patients (138 lesions) who underwent MACI. Treatment failure had occurred in 0.0% of patients in the 6-week group, 7.5% in the 8-week group, and 8.3% in the 10/11-week group at a mean follow-up of 2.5 years (P = .46). KOOS, SF-36, and VAS scores in each group improved significantly from preoperatively to follow-up (P < .001). Conclusion: Patients undergoing MACI in the knee can be expected to experience improvement in clinical outcomes with the rehabilitation protocols outlined in this work. No significant differences were seen in failure rates based on the time to return to full WB.
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Affiliation(s)
- Matthew J Kraeutler
- Department of Orthopaedic Surgery, Seton Hall-Hackensack Meridian School of Medicine, South Orange, New Jersey, USA
| | - John W Belk
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Trevor J Carver
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Eric C McCarty
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, USA
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Thrush C, Porter TJ, Devitt BM. No evidence for the most appropriate postoperative rehabilitation protocol following anterior cruciate ligament reconstruction with concomitant articular cartilage lesions: a systematic review. Knee Surg Sports Traumatol Arthrosc 2018; 26:1065-1073. [PMID: 29511820 DOI: 10.1007/s00167-018-4882-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Accepted: 02/28/2018] [Indexed: 01/29/2023]
Abstract
PURPOSE Anterior cruciate ligament (ACL) rupture commonly occurs in conjunction with articular cartilage injury. However, there is no consensus on the most appropriate rehabilitation which should be carried out for ACL reconstruction (ACLR) and the surgical management of articular cartilage lesions of the knee. The purpose of this study was to systematically review the literature to investigate the recommended rehabilitation protocol for patients undergoing ACLR with concomitant articular cartilage injury with a view to develop guidelines on the most appropriate treatment. METHODS Two reviewers independently searched five database for randomised controlled trials (RCTs), non-randomised comparative and retrospective cohort studies (CS) describing the management of concomitant ACL rupture and articular cartilage injury and the postoperative rehabilitation regimen. Risk of bias was performed using a modified Downs & Black's checklist. The primary outcome was specific rehabilitation protocols including weight-bearing status, immobilisation, continuous passive motion (CPM), and return to play criteria. Secondary outcomes included patient-reported outcomes. A best evidence synthesis was performed. RESULTS The review yielded six studies which reported on rehabilitation techniques. All studies were of low methodological quality. There was considerable variability in not only the chondral lesion reported but also the treatment techniques utilised and especially the rehabilitation regimes. No consensus was found on weight-bearing status, postoperative immobilisation, the use of CPM, or return to play criteria. Given the quality of the papers, there was no evidence to recommend any specific rehabilitation regime in the postoperative management of concomitant ACLR and articular cartilage lesions. CONCLUSION This systematic review revealed that despite how common concomitant ACL rupture and articular cartilage injury is, there is no evidence to support one, most appropriate rehabilitation protocol. From a clinical perspective, decisions on postoperative rehabilitation for patients undergoing ACLR and treatment of articular cartilage lesions should be made on a case-by-case basis with criteria-based progression until more robust evidence becomes available. A list of specific rehabilitation protocols based on the cartilage restoration technique is provided. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Ciaran Thrush
- OrthoSport Victoria Research Unit, Epworth Healthcare, Melbourne, Australia
| | - Tabitha J Porter
- OrthoSport Victoria Research Unit, Epworth Healthcare, Melbourne, Australia
| | - Brian M Devitt
- OrthoSport Victoria Research Unit, Epworth Healthcare, Melbourne, Australia.
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Ebert JR, Schneider A, Fallon M, Wood DJ, Janes GC. A Comparison of 2-Year Outcomes in Patients Undergoing Tibiofemoral or Patellofemoral Matrix-Induced Autologous Chondrocyte Implantation. Am J Sports Med 2017; 45:3243-3253. [PMID: 28910133 DOI: 10.1177/0363546517724761] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Matrix-induced autologous chondrocyte implantation (MACI) has demonstrated encouraging clinical results in the treatment of knee chondral defects. However, earlier studies suggested that chondrocyte implantation in the patellofemoral (PF) joint was less effective than in the tibiofemoral (TF) joint. PURPOSE To compare the radiological and clinical outcomes of those undergoing MACI to either the femoral condyles or PF joint. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS A total of 194 patients were included in this analysis, including 127 undergoing MACI to the medial (n = 94) and lateral (n = 33) femoral condyle, as well as 67 to the patella (n = 35) or trochlea (n = 32). All patients were evaluated clinically (Knee injury and Osteoarthritis Outcome Score [KOOS], visual analog scale, Short Form-36) before surgery and at 3, 12, and 24 months after surgery, while magnetic resonance imaging (MRI) was undertaken at 3, 12, and 24 months, with the MOCART (magnetic resonance observation of cartilage repair tissue) scoring system employed to evaluate the quality and quantity of repair tissue, as well as an MRI composite score. Patient satisfaction was evaluated. RESULTS No significant group differences ( P > .05) were seen in demographics, defect size, prior injury, or surgical history, while the majority of clinical scores were similar preoperatively. All clinical scores significantly improved over time ( P < .05), with a significant group effect observed for KOOS activities of daily living ( P = .008), quality of life ( P = .008), and sport ( P = .017), reflecting better postoperative scores in the TF group. While the PF group had significantly lower values at baseline for the KOOS activities of daily living and quality of life subscales, it actually displayed a similar net improvement over time compared with the TF group. At 24 months, 93.7% (n = 119) and 91.0% (n = 61) of patients were satisfied with the ability of MACI to relieve their knee pain, 74.0% (n = 94) and 65.7% (n = 44) with their ability to participate in sport, and 90.5% (n = 115) and 83.6% (n = 56) satisfied overall, in the TF and PF groups, respectively. MRI evaluation via the MOCART score revealed a significant time effect ( P < .05) for the MRI composite score and graft infill over the 24-month period. While subchondral lamina scored significantly better ( P = .002) in the TF group, subchondral bone scored significantly worse ( P < .001). At 24 months, the overall MRI composite score was classified as good/excellent in 98 TF patients (77%) and 54 PF patients (81%). CONCLUSION MACI in the PF joint with concurrent correction of PF maltracking if required leads to similar clinical and radiological outcomes compared with MACI on the femoral condyles.
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Affiliation(s)
- Jay R Ebert
- School of Human Sciences, University of Western Australia, Crawley, Perth, Western Australia, Australia
| | - Adrian Schneider
- Perth Orthopaedic and Sports Medicine Centre, West Perth, Western Australia, Australia
| | - Michael Fallon
- Perth Radiological Clinic, Subiaco, Perth, Western Australia, Australia
| | - David J Wood
- School of Surgery (Orthopaedics), University of Western Australia, Crawley, Perth, Western Australia, Australia
| | - Gregory C Janes
- Perth Orthopaedic and Sports Medicine Centre, West Perth, Western Australia, Australia
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24
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Kane MS, Lau K, Crawford DC. Rehabilitation and Postoperative Management Practices After Osteochondral Allograft Transplants to the Distal Femur: A Report From the Metrics of Osteochondral Allografts (MOCA) Study Group 2016 Survey. Sports Health 2017; 9:555-563. [PMID: 28719761 PMCID: PMC5665113 DOI: 10.1177/1941738117717011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Context: We present the current spectrum of postoperative management practices for patients receiving distal femur osteochondral allograft (OCA) transplants. Evidence Acquisition: The Joint Restoration Foundation database was examined in cooperation with the Metrics of Osteochondral Allografts study group to identify 121 surgeons who had performed at least 1 OCA transplant in the past year; 63% of surgeons responded. Study Design: Clinical survey. Level of Evidence: Level 3. Results: Postoperative weightbearing restrictions ranged from immediate nonweightbearing with full weightbearing by 12 weeks to immediate weightbearing as tolerated. Most surgeons who performed fewer (<10) OCA transplants per year followed the most restrictive protocol, while surgeons who performed more (>20) OCA transplants per year followed the least restrictive protocol. One-third of surgeons with the most restrictive protocol were more likely to change their protocol to be less restrictive over time, while none of those with the least restrictive protocol changed their protocol over time. Fifty-five percent of surgeons permitted return to full activity at 26 weeks, while 27% of surgeons lifted restrictions at 16 weeks. Conclusion: Characterization of the spectrum of postoperative management practices after OCA transplantation provides a foundation for future investigations regarding patient outcomes and associated cost to establish best practice guidelines. Fundamentally, surgeons with more experience with this procedure tended to be more aggressive with their postoperative rehabilitation guidelines. Most commonly, rehabilitation provided for some degree of limited weightbearing; however, the spectrum also included immediate full weightbearing practices.
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Affiliation(s)
- Marie S Kane
- Department of Orthopaedics & Rehabilitation, Oregon Health & Science University, Portland, Oregon
| | - Karlee Lau
- Department of Orthopaedics & Rehabilitation, Oregon Health & Science University, Portland, Oregon
| | - Dennis C Crawford
- Department of Orthopaedics & Rehabilitation, Oregon Health & Science University, Portland, Oregon
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