Cartilage Restoration of the Knee: A Systematic Review and Meta-analysis of Level 1 Studies.
Mundi Raman,Bedi Asheesh,Chow Linda,Crouch Sarah,Simunovic Nicole,Sibilsky Enselman Elizabeth,Ayeni Olufemi R
The American journal of sports medicine
BACKGROUND:Focal cartilage defects of the knee are a substantial cause of pain and disability in active patients. There has been an emergence of randomized controlled trials evaluating surgical techniques to manage such injuries, including marrow stimulation (MS), autologous chondrocyte implantation (ACI), and osteochondral autograft transfer (OAT). PURPOSE:A meta-analysis was conducted to determine if any single technique provides superior clinical results at intermediate follow-up. STUDY DESIGN:Systematic review and meta-analysis of randomized controlled trials. METHODS:The MEDLINE, EMBASE, and Cochrane Library databases were systematically searched and supplemented with manual searches of PubMed and reference lists. Eligible studies consisted exclusively of randomized controlled trials comparing MS, ACI, or OAT techniques in patients with focal cartilage defects of the knee. The primary outcome of interest was function (Lysholm score, International Knee Documentation Committee score, Knee Osteoarthritis Outcome Score) and pain at 24 months postoperatively. A meta-analysis using standardized mean differences was performed to provide a pooled estimate of effect comparing treatments. RESULTS:A total of 12 eligible randomized trials with a cumulative sample size of 765 patients (62% males) and a mean (±SD) lesion size of 3.9 ± 1.3 cm(2) were included in this review. There were 5 trials comparing ACI with MS, 3 comparing ACI with OAT, and 3 evaluating different generations of ACI. In a pooled analysis comparing ACI with MS, there was no difference in outcomes at 24-month follow-up for function (standardized mean difference, 0.47 [95% CI, -0.19 to 1.13]; P = .16) or pain (standardized mean difference, -0.13 [95% CI, -0.39 to 0.13]; P = .33). The comparisons of ACI to OAT or between different generations of ACI were not amenable to pooled analysis. Overall, 5 of the 6 trials concluded that there was no significant difference in functional outcomes between ACI and OAT or between generations of ACI. CONCLUSION:There is no significant difference between MS, ACI, and OAT in improving function and pain at intermediate-term follow-up. Further randomized trials with long-term outcomes are warranted.
10.1177/0363546515589167
Matrix-induced autologous chondrocyte implantation versus microfracture in the treatment of cartilage defects of the knee: a 2-year randomised study.
Basad Erhan,Ishaque Bernd,Bachmann Georg,Stürz Henning,Steinmeyer Jürgen
Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA
Cartilage defects occur in approximately 12% of the population and can result in significant function impairment and reduction in quality of life. Evidence for the variety of surgical treatments available is inconclusive. This study aimed to compare the clinical outcomes of patients with symptomatic cartilage defects treated with matrix-induced autologous chondrocyte implantation (MACI or microfracture (MF). Included patients were >or= 18 and <or= 50 years of age with symptomatic, post-traumatic, single, isolated chondral defects (4-10 cm2) and were randomised to receive MACI or MF. Patients were followed up 8-12, 22-26 and 50-54 weeks post-operatively for efficacy and safety evaluation. Outcome measures were the Tegner, Lysholm and ICRS scores. Sixty patients were included in a randomised study (40 MACI, 20 MF). The difference between baseline and 24 months post-operatively for both treatment groups was significant for the Lysholm, Tegner, patient ICRS and surgeon ICRS scores (all P < 0.0001). However, MACI was significantly more effective over time (24 months versus baseline) than MF according to the Lysholm (P = 0.005), Tegner (P = 0.04), ICRS patient (P = 0.03) and ICRS surgeon (P = 0.02) scores. There were no safety issues related to MACI or MF during the study. MACI is superior to MF in the treatment of articular defects over 2 years. MACI and MF are complementary procedures, depending on the size of the defect and symptom recurrence. The MACI technique represents a significant advance over both first and second generation chondrocyte-based cartilage repair techniques for surgeons, patients, health care institutions and payers in terms of reproducibility, safety, intraoperative time, surgical simplicity and reduced invasiveness.
10.1007/s00167-009-1028-1
Autologous Chondrocyte Implantation Versus Microfracture in the Knee: A Meta-analysis and Systematic Review.
Gou Guo-Hau,Tseng Feng-Jen,Wang Sheng-Hao,Chen Pao-Ju,Shyu Jia-Fwu,Weng Ching-Feng,Pan Ru-Yu
Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association
PURPOSE:To compare clinical outcomes among patients with fractures of knee cartilage who were treated with autologous chondrocyte implantation (ACI) or microfracture (MF). METHODS:A systematic review was made of randomized controlled trials of articular cartilage lesions of the knee treated with ACI or MF that were published between January 2000 and November 2018 and catalogued in 4 major databases. The outcomes of clinical score, quality of life (QoL), pain relief score, and failure rate were assessed. RESULTS:A final group of 12 randomized controlled trials were included that enrolled a total of 659 patients with knee cartilage lesions: 332 patients had received ACI and 327 patients had undergone MF. Patients ranged in age from 25 to 41 years, and the majority were male. Lesion size ranged from 2.3 to 10.0 cm. Pooled analysis found no significant difference in the improvement in International Knee Documentation Committee and Lysholm scores or overall Knee Injury and Osteoarthritis Outcome Score measures between patients in the ACI and MF groups at 1-year, 2-year, and 5-year follow-up examinations or in failure rate at 2-year, 3-year, and 5-year follow-up timepoints. However, patients treated with ACI had a significant benefit in activities of daily living at follow-up of 5 years or less compared with patients treated with MF. ACI treatment also showed better improvement in QoL and pain relief than MF at 5-year and 2-year follow-up examinations, respectively. CONCLUSIONS:The pooled analysis found no significant difference in the improvement in International Knee Documentation Committee or Lysholm scores or overall Knee Injury and Osteoarthritis Outcome Score measures between patients in the ACI and MF groups at 1 to 5 years of follow-up. Patients treated with ACI may have a significant benefit in activities of daily living, QoL, and pain relief compared with patients treated with MF, although clinical relevance may not be achieved. LEVEL OF EVIDENCE:Level II, systematic review of Level I and II investigations.
10.1016/j.arthro.2019.06.033
Comparative efficacy of osteochondral autologous transplantation and microfracture in the knee: an updated meta-analysis of randomized controlled trials.
Archives of orthopaedic and trauma surgery
INTRODUCTION:More than 19% of patients undergoing knee arthroscopies suffers from articular cartilage defects. The chondral or osteochondral lesion has negative impacts on the knee joints function and the life quality of patients. However, the treatment remains challenging as hyaline cartilage is not renewable. The purpose of this study was to systematically analyze the data of randomized controlled trials for comparing the postoperative outcomes between osteochondral autologous transplantation (OAT) and microfracture (MF) procedure. We hypothesized that the outcomes were better in OAT than MF procedure. MATERIALS AND METHODS:A systematic literature search of the EMBASE, Pubmed, and Cochrane Library databases was conducted based on PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The outcome measures include: the rate of excellent or good results, the rate of return to sports, the failure rate, osteoarthritis rate, International Cartilage Repair Society (ICRS) score, Lysholm Knee Score, and Tegner scale. The statistical analysis was completed using Review Manager (RevMan, version 5.3) software. RESULTS:The systematic search identified 7 studies with a total of 346 patients. The pooled result showed significant differences between the two groups in the rate of return to sports and failure. The following outcome scores showed significant improvement (pre- vs postoperatively): Lysholm score (p = 0.02), Tegner scale (p < 0.00001), and ICRS score (p < 0.00001). The differences were not significant in the excellent or good results and the rate of osteoarthritis. CONCLUSION:The patients in OAT group may return to play quicker, even return to pre-injury level of activity compared to the MF group. OAT is better than MF procedure in accordance with Lysholm score, Tegner score, ICRS score, and the rate of failure. However, few studies have reported long-term outcomes and there has no uniform criteria for safe return to sports. Further research is needed. LEVEL OF EVIDENCE:Level II, meta-analysis of randomized controlled trials.
10.1007/s00402-021-04075-9
Repair and tissue engineering techniques for articular cartilage.
Nature reviews. Rheumatology
Chondral and osteochondral lesions due to injury or other pathology commonly result in the development of osteoarthritis, eventually leading to progressive total joint destruction. Although current progress suggests that biologic agents can delay the advancement of deterioration, such drugs are incapable of promoting tissue restoration. The limited ability of articular cartilage to regenerate renders joint arthroplasty an unavoidable surgical intervention. This Review describes current, widely used clinical repair techniques for resurfacing articular cartilage defects; short-term and long-term clinical outcomes of these techniques are discussed. Also reviewed is a developmental pipeline of acellular and cellular regenerative products and techniques that could revolutionize joint care over the next decade by promoting the development of functional articular cartilage. Acellular products typically consist of collagen or hyaluronic-acid-based materials, whereas cellular techniques use either primary cells or stem cells, with or without scaffolds. Central to these efforts is the prominent role that tissue engineering has in translating biological technology into clinical products; therefore, concomitant regulatory processes are also discussed.
10.1038/nrrheum.2014.157
Knee Articular Cartilage Repair and Restoration Techniques: A Review of the Literature.
Richter Dustin L,Schenck Robert C,Wascher Daniel C,Treme Gehron
Sports health
CONTEXT:Isolated chondral and osteochondral defects of the knee are a difficult clinical challenge, particularly in younger patients for whom alternatives such as partial or total knee arthroplasty are rarely advised. Numerous surgical techniques have been developed to address focal cartilage defects. Cartilage treatment strategies are characterized as palliation (eg, chondroplasty and debridement), repair (eg, drilling and microfracture [MF]), or restoration (eg, autologous chondrocyte implantation [ACI], osteochondral autograft [OAT], and osteochondral allograft [OCA]). EVIDENCE ACQUISITION:PubMed was searched for treatment articles using the keywords knee, articular cartilage, and osteochondral defect, with a focus on articles published in the past 5 years. STUDY DESIGN:Clinical review. LEVEL OF EVIDENCE:Level 4. RESULTS:In general, smaller lesions (<2 cm(2)) are best treated with MF or OAT. Furthermore, OAT shows trends toward greater longevity and durability as well as improved outcomes in high-demand patients. Intermediate-size lesions (2-4 cm(2)) have shown fairly equivalent treatment results using either OAT or ACI options. For larger lesions (>4 cm(2)), ACI or OCA have shown the best results, with OCA being an option for large osteochondritis dissecans lesions and posttraumatic defects. CONCLUSION:These techniques may improve patient outcomes, though no single technique can reproduce normal hyaline cartilage.
10.1177/1941738115611350
Current concepts of articular cartilage restoration techniques in the knee.
Camp Christopher L,Stuart Michael J,Krych Aaron J
Sports health
CONTEXT:Articular cartilage injuries are common in patients presenting to surgeons with primary complaints of knee pain or mechanical symptoms. Treatment options include comprehensive nonoperative management, palliative surgery, joint preservation operations, and arthroplasty. EVIDENCE ACQUISITION:A MEDLINE search on articular cartilage restoration techniques of the knee was conducted to identify outcome studies published from 1993 to 2013. Special emphasis was given to Level 1 and 2 published studies. STUDY DESIGN:Clinical review. LEVEL OF EVIDENCE:Level 3. RESULTS:CURRENT SURGICAL OPTIONS WITH DOCUMENTED OUTCOMES IN TREATING CHONDRAL INJURIES IN THE KNEE INCLUDE THE FOLLOWING: microfracture, osteochondral autograft transfer, osteochondral allograft transplant, and autologous chondrocyte transplantation. Generally, results are favorable regarding patient satisfaction and return to sport when proper treatment algorithms and surgical techniques are followed, with 52% to 96% of patients demonstrating good to excellent clinical outcomes and 66% to 91% returning to sport at preinjury levels. CONCLUSION:Clinical, functional, and radiographic outcomes may be improved in the majority of patients with articular cartilage restoration surgery; however, some patients may not fully return to their preinjury activity levels postoperatively. In active and athletic patient populations, biological techniques that restore the articular surface may be options that provide symptom relief and return patients to their prior levels of function.
10.1177/1941738113508917