Hypertension is the 3rd leading cause of disability worldwide, and a potential link between osteoarthritis and hypertension has been recently revealed. However, its effect on cartilage restoration is yet to be determined. Our aim was to examine whether patients with diagnosed hypertension have an increased risk of graft failure following cartilage repair with either autologous chondrocyte implantation (ACI) or osteochondral allograft transplantation (OCA).
Patients that underwent ACI or OCA transplantation between February 2009 and December 2016 by a single surgeon were included in this study. Inclusion criteria comprised: (1) patients with at least 2-years follow-up; (2) availability of information related to the living habits, including smoking; (3) availability of information related to the presence of hypertension, diabetes mellitus or hyperlipidemia. To identify potential independent risk factors of graft failure, univariate analysis was utilized and those factors which showed significance at a level of p<0.1 were entered in multivariant logistic regression models.
Three-hundred and sixty-eight patients (209 ACI, 159 OCA) were included in our study. In the ACI group univariate screening identified older age (p=0.022), female gender (p=0.072), larger defect size (p=0.016), higher prevalence of hypertension (16.4% vs 4.1%; p=0.007) and smoking (21.3% vs 10.1%; p=0.046) as a predictor of graft failure. Following, multivariate logistic regression analysis revealed female gender (OR 1.02, p=0.048), defect size (OR 1.07, p=0.035) and hypertension (OR 3.73, p=0.023) as significant independent risk factors predicting graft failure after ACI. In the OCA group, baseline demographics and clinical characteristics were similar between the failure and successful group, and none of the included factors demonstrated to be a potential risk factor for graft failure.
Hypertension seems to be an independent predictor of graft failure after ACI but not after OCA transplantation. Consequently, OCA transplantation might be preferred for the treatment of symptomatic cartilage defects if patients present with hypertension.
Chondral and osteochondral lesions in osteoarthritic knees of young patients are a challenge for orthopedic surgeons: the possibility to extend the indication of cartilage regenerative procedures to these patients may allow to delay metal resurfacing. Aim of this study was to analyze the potential of a cartilage regenerative approach to provide a clinical benefit in such patients, documenting the outcome both in terms of clinical improvement and failures, in particular in terms of knee replacement, at long-term follow-up.
Forty-one patients (43±9 years) affected by cartilage lesions (4±2 cm2) in osteoarthritic knees (Kellgren-Lawrence 2-3) underwent matrix-assisted autologous chondrocyte transplantation (MACT) as a salvage procedure. Patients were evaluated with IKDC, EQ-VAS, and Tegner scores before surgery, at 1, 2, 5, 9, and at a final follow-up at mean 15 years (14-18). Failures were also recorded.
An improvement was observed in all scores after surgery, but with a progressive worsening over time. The IKDC score improved from 38.6±16.2 to a maximum of 66.0±18.6 at 2 years (p<0.0005), with a following deterioration until the final evaluation of 56.2±21.7 (p=0.024). A similar trend was confirmed by EQ-VAS. The Tegner score improved at all follow-ups but without achieving the pre-injury level. Patients who underwent combined surgery obtained significantly lower results. During the follow-up period 21 patients were re-operated, 18 with knee replacement, and 3 more patients failed clinically, for a total surgical and clinical failure rate of 59% at 15 years.
The use of cartilage regenerative surgical procedures, like MACT, as salvage procedure for young active patients affected by chondral and osteochondral lesions in osteoarthritic knees, leads to a limited improvement, with high failure rate. Although a minor subpopulation presented good and stable improvement, until responder patients will be profiled, the use of MACT for such challenging indication remains questionable.
Articular cartilage defects represent a complex and very common problem with a high social impact. In recent decades the use of chondrocytes-based regenerative techniques has shown promising results in the short and medium term. The aim of this study is analyze the long-term survival, the clinical results and the prognostic factors obtained in 96 patients treated with arthroscopic Matrix-assisted Autologous Chondrocyte Transplantation.
Ninety-six patients were followed prospectively at 2, 5, 10 years, and at a final follow-up of mean 14 years (range 12-18). The clinical knee evaluation was performed using IKDC subjective score, EQ-VAS and Tegner Score. Seventy-six men and twenty women were enrolled with an average age of 29 ± 11 years. Lesions were located on the CFM in 60 patients, on the CFL in 26 and the trochlea was involved in 10 cases. The etiology of the lesions was traumatic in 35 cases, chronic/degenerative in 42 and 19 patients had osteochondritis dissecans. The mean size of the lesions was 2.4 cm².
At the final follow-up, a significant improvement of all clinical scores was found compared to the baseline evaluation and different elements were identified as negative prognostic factors: female sex, age, degenerative etiology, symptoms duration and previous surgery. Eighteen patients failed at final follow-up for a survival rate of 80.5% at 18 years.
Arthroscopic MACT represents a minimally invasive technique with good and stable results even at long term of follow-up. This study allowed to evaluate the survival of the implant more than 15 years after the treatment and to identify important prognostic parameters in the planning of the cartilage treatment, with the aim to obtain better indications for the procedure and more realistic expectations for the patient.
Osteochondritis dissecans is a pathology affecting young patients that involves the entire osteochondral unit. In case of unfixable fragments, regenerative cartilage treatments are a viable solution, but little is known about the use of these procedures for the treatment of juvenile osteochondritis dissecans (JOCD). The aim of this study is to evaluate long-term results offered by matrix-assisted autologous chondrocyte transplantation (MACT) combined with autologous bone grafting for the treatment of JOCD.
Nineteen patients have been enrolled. The mean age at the time of treatment was 16.8 ± 1.5 years, with a mean BMI of 22.9 ± 2.7. The average size of the defects was 2.8 ± 1.2 cm2. All patients were evaluated prospectively before surgery and at 12, 24, 60, and at a final follow-up of 120 months with IKDC scores, EQ-VAS, and Tegner score.
A statistically significant improvement in all clinical scores was observed from baseline evaluation to 120 months of final follow-up. In particular, the IKDC subjective score improved from the pre-operative evaluation of 38.7 ± 17.3 to 74.0 ± 21.8 at 12 months (p<0.0005), with scores remaining stable for up to 120 months (83.8 ± 20.7), with all follow-ups showing a statistically significant improvement compared to the basal value (p<0.0005). Three patients failed at 12 months, for a failure rate of 16% at 10 years of follow-up. Lesions > 3.5 cm2 obtained worse subjective results. In addition, lesion size and female sex significantly correlated with failures.
MACT technique with autologous bone grafting is a valid treatment option for JOCD in case of unfixable fragments. The clinical improvement obtained is significant and stable, with good results maintained for up to 10 years of follow-up and an overall low failure rate. Lesion size and sex could influence the clinical outcome and should be considered in the treatment choice.
Although the recovery of strength has been emphasized following ACI, limited information exists regarding the importance of re-establishing neuromuscular control and coordination. Therefore, the purpose of this study was to determine the relationship among functional performance measures and strength 1-year following ACI and mid-term patient-reported outcomes (PROs).
Thirty-three patients (35±9 yrs, 180±38cm, 90±20kgs) who previously underwent ACI to the knee and had a minimum of two year follow-up were included in the study. All included patients had completed functional tests simulating walking, squatting, rising from sitting, stepping-up and stepping-down using the NeuroCom Long Forceplate(Clackamas, OR) and isokinetic strength testing 1 year following ACI. PROs (IKDC, KOOS, WOMAC, Lysholm, VR-36) were also completed annually following surgery. Spearman Rho correlations were used to determine the relationship between function 1 year following surgery and PRO scores at the last available follow-up (5.25±2.19 years).
Measures of neuromuscular control and coordination (rho=0.39-0.69, p<0.05), including directional control during weight-shifting, symmetry while squatting, single-limb balance, lunge force, and side-to-side differences in step-down and lunge impact forces, along with 1-year PRO scores (rho=0.40-0.67, p<0.05) were correlated with subsequent PRO scores. There was no correlation between peak isokinetic strength in flexion or extension, concentrically or eccentrically, and future PRO scores.
The restoration of neuromuscular control and coordination within the first year following ACI may be a more important clinical benchmark than the restoration of strength. In particular, side-to-side asymmetries in the ability/willingness to generate force or eccentrically load the limb were associated with lower PROs at a mean follow-up of 5 years. Likewise, PRO scores at 1-year were correlated with future follow-up scores, suggesting that a patient’s perceived level of function at 1-year may be indicative of his/her overall prognosis. Therefore, particularly low scores should be examined closely to determine strategies for addressing deficits in function or pain.
To evaluate the clinical outcomes after autologous chondrocyte implantation (ACI) for the treatment of bipolar chondral lesions in the patello-femoral (PF) compartment.
We evaluated 58 patients who had ACI for the treatment of symptomatic bipolar chondral lesions in the PF compartment. All 58 patients (60 knees) were included with a minimum of 2 year follow-up. Forty-two patients had osteotomy as those had patellofemoral lateral maltracking, patellar instability, or tibiofemoral malalignment. Patients were evaluated with the modified Cincinnati Knee Rating Scale, Western Ontario and McMaster Universities Osteoarthritis Index, Visual Analogue Scale, the Short Form 36, and a patient satisfaction survey. Radiographs were evaluated with Iwano classification.
Overall, the survival rate was 83% and 79% at 5 and 10 years, respectively. Of the 49 (82%) knees with retained grafts, all functional scores significantly improved postoperatively with a very high satisfaction rate (88%) at a mean of 8.8 years after ACI. At the most recent follow-up, 28 of 49 successful knees were radiographically assessed (average, 4.9 years postoperatively), with no significant osteoarthritis progression (P = 0.1573). Outcomes for 11 patients were considered as failures at a mean of 2.9 years. The best survival rates were observed in patients who underwent ACI with concomitant tibial tubercle osteotomy (TTO) done as a first procedure without previous failed TTO and/or marrow stimulation technique (91% at both 5 and 10 years), while the worst survival rates were observed in patients who had previous marrow stimulation technique (43% at both 5 and 10 years).
Our results demonstrated that ACI with concomitant osteotomy when it is necessary for the treatment of bipolar lesions in the PF compartments gives significant improvement in pain and function with a good survival rate of 83% and 79% at 5 and 10 years, respectively.
The aim of this work was to analyze the long-term clinical outcome of MACI treatment for cartilage repair in the knee
Eighty-six patients (71 male and 15 female) with cartilage lesions in the knee treated with MACI.Patient’s mean age ± SD was 31.1 ± 10.0 years. Most patients usually practiced sports (65.9%), being 8.9% of them professional athletes. Patients had 1 lesion as a median (Minimum – Maximum: 1 – 4 lesions) and were more frequently located at the medium femoral condyle (53%), patella (22%) and lateral femoral condyle (20%). Treatment outcome at 1, 2 and 7 years was evaluated with the Visual Analogic Scale for pain, theInternational Knee Documentation Committee (IKDC) questionnaire and mobility. Presence of inflammation was also recorded
One year after implantation, mean pain significantly decreased from respect to baseline and continued like this 2 and 7 years post-op (Basal:7.3±1.6; 1 year: 2.8 ± 2.1; 2 years: 1.8 ± 2.0; 7 years: 2.2 ± 2.7; p<0.001, ANOVA). Difference of IKDC mean with respect to basal determination was 28.6 (95% CI: 24.3 – 32.9) at 1-year follow-up; 37.2 (95% CI: 32.0 – 42.4) at 2-year follow-up and 34.3 (95% CI: 28.2 – 40.5) 7 years post-op. Minimum Clinically Important Difference (MCID) of IKDC at 12 months is 16.7. The contrast for the mean IKDC differences at the different time points showed that they were statistically higher than 16.7 (p<0.001; Student’s T test) in all cases. The percentage of patients with complete mobility and without inflammation significantly increased 1 year post-op and continued like this 7 years after (p<0.001; Chi-square Test, in the 3 cases).
MACI is an effective technique in the long-term follow-up. Results on Pain and IKDC score suggest that patients perceive a real improvement in the knee 7 years after implantation
Cartilage defects in the patellofemoral joint (PFJ) can be caused by either traumatic or non-traumatic/degenerative events to the PFJ. Yet, no previous study has evaluated the effect of cartilage defect etiology on clinical outcomes after autologous chondrocyte implantation (ACI) to the PFJ. The purpose of this study was therefore to determine the relationship between cartilage lesion etiology and clinical outcomes after ACI in the PFJ.
A retrospective review of all patients that underwent ACI in the PFJ by a single surgeon was performed. Patient factors, cartilage lesion etiology and morphology, and pre- and postoperative patient-reported outcomes measures (PROMs) were collected. Patients were stratified into three groups based on the etiology of PFJ cartilage lesions: patellar instability (group 1); non-traumatic lesions including chondromalacia, osteochondritis dissecans and degenerative defects (group 2); and post-traumatic lesions excluding patellar dislocations (group 3). A clinical comparison was established between groups based on PROMs and failure rates.
Eighty patients that underwent ACI in the PFJ with a mean follow-up of 3.9 ±2.1 yearswere enrolled in this study. Patient’s mean age was 30.4 ± 9.4 years. Patients in group 1 were significantly younger (n = 26; 25.2 ±7.7 years) than group 2 (n = 31; 32.9 ±10.5 years) (p = 0.005) and group 3 (n = 23; 32.6 ± 7.6 years) (p = 0.008). Body mass index averaged 26.42 ± 4.5 kg/m2, with a significant difference between group 1 (24.7 ± 3.7 kg/m2) and group 3 (28.8 ± 4.3 kg/m2) (p = 0.006). Neither pre- or post-operative PROMs differed between the groups (p > 0.05). No difference was seen in success rates between the groups (96.2% vs. 83.9% vs. 91.3%, p = 0.301).
Cartilage lesion etiology does not influence clinical outcomes after ACI in the PFJ.
To evaluate the short-term outcomes of autologous chondrocyte implantation (ACI) associated with an atelocollagen-based scaffold against cartilage injuries in the knee joint.
All patients who received implantation of the atelocollagen-based scaffold ACI were included in the registry of a multicenter study conducted by six institutions. Patient demographics (age, sex and the total size of injured cartilage lesions) and clinical outcomes evaluated by Knee Osteoarthritis and injury Outcome Score (KOOS) and Lysholm score were prospectively collected before surgery and at six and 12 months after surgery. Clinical outcomes were compared between three age categories (I: 15-29 years, II: 30-44 years, III: 45-59 years) and by the size of the defect. Magnetic resonance imaging (MRI) exam was performed at six and 12 months after implantation, and the morphology and quality of the repaired tissue were assessed with magnetic resonance observation of cartilage repair tissue (MOCART) evaluation and quantitative analysis of T2 mapping. Only patients who were followed for at least one year after surgery were included for analysis in the current study.
Twenty-six patients (14 males, 12 females, mean age 41.0 years old) were included in the study. All KOOS scores for symptom, pain, activities in daily living, sports, and quality of life, as well as Lysholm score, showed improvement at one year after surgery. There was no significant difference in improvement of clinical outcomes between any age categories, and between large or small cartilage defects. The MRI evaluation revealed improvement in the morphology and quality assessed by parameters such as defect filling and tissue signal intensity, but subchondral bone degeneration tends to progress one year after the implantation.
The overall short-term clinical outcomes after ACI associated with atelocollagen-based scaffold were favorable regardless of patient age or the size of the cartilage defect. Improvement of the implanted tissue was confirmed by MRI.
The influence of trochlear dysplasia on the clinical outcomes of autologous chondrocyte implantation (ACI) to the patellofemoral joint (PFJ) has not been studied yet. The purpose of this study was to evaluate the influence of trochlear dysplasia on clinical outcomes after ACI for the treatment of large cartilage lesions in the PFJ with a follow-up range of 2 to 5.6 years.
A retrospective review of prospectively collected data of all patients that underwent ACI for focal cartilage defect repair in the PFJby a single surgeon was performed.Patient factors, lesion morphology, and pre- and postoperative patient-reported outcomes measures (PROMs) were collected, including the Knee Injury and Osteoarthritis Outcome Score (KOOS), Lysholm, Tegner and International Knee Documentation Committee (IKDC). Two independent observers assessed preoperative imaging to determine the presence and grade of trochlear dysplasia according to Dejour and Lippacher classifications. Patients were stratified into two groups based on the presence or absence of trochlear dysplasia, and patients without trochlear dysplasia served as controls. Patients were matched 1:1 for sex, age, BMI, lesion size and location.
Forty-six patients that underwent ACI in the PFJ with a mean follow-up of 3.7 ±1.9 yearswere enrolled in this study. Patient’s mean age was 30.1 ±8.8 years. Interobserver reliability (k) was 0.774 for the Dejour and 0.924 for the Lippacher classification (p < 0.001). PROMs at final follow-up did not differ between both groups (p > 0.05). No difference was seen regarding success rates between both groups (95.7% vs. 95.7%, p > 0.999). No difference in clinical outcome was seen between patients with high-grade dysplasia and patients without dysplasia (p > 0.05).
ACI in the PFJ provides favorable outcomes in patients with trochlear dysplasia, which are in fact comparable to those of matched patients with normal trochlear anatomy.