Introduction

Autologous chondrocytes transplantation is the best documented cartilage repair modality both regarding clinical outcome and biological cartilage repair tissue quality. But the high cost (20-30.000 USD) of cultured cell-based techniques such as autologous chondrocyte implantation (ACI) and new tissue engineered products for articular cartilage repair have limited their use in most countries. Microfracture is the standard cost-effective cartilage repair modality, but the technique has limitations in which lesions that can respond to microfracture treatment, the repair tissue quality and longevity of the clinical outcome.

This has led to increased focus on development of cost-effective cartilage repair methods that avoid cultured cell products and that can improve or out-perform the clinical outcome of standard microfracture treatment. At the present state the following cartilage repair treatment methods have aimed to fulfil the goals of cost-effective cartilage repair

Content

Microfracture enhancing scaffolds

To overcome the disadvantages of microfracture and ACI, a new treatment option has evolved: the single-step scaffold-based treatment of cartilage defects. During this approach, a matrix is implanted in the area of the damaged cartilage to cover the blood

clot after a bone marrow stimulation technique (e.g. microfracture). This technique is also called autologous matrix-induced chondrogenesis (AMIC). The scaffolds are implanted arthroscopically or by a mini-arthrotomy for ‘‘in situ’’ repair, permitting the ingrowing of

mesenchymal stem cells (MSCs) to differentiate into the chondrogenic lineage.

Numerous techniques for microfracture enhancement have been developed. Collagen and hyaluronic acid scaffold application on top of the microfractured area.(de Girolamo 2019) Also, different hydrogels that are applied on top of the microfractured area are development. These hydrogels are based on chitosan, collagen or fibrinogen.(Shive 2015) Several of the microfracture enhancers have demonstrated midterm clinical usage with clinical outcome improvement similar to ACI.

Cost of microfracture enhancer from 1000-2500 USD

Bone marrow cell transplantation

One-step cell-based repair techniques with scaffold associated multipotent cells sourced from bone marrow aspirate concentrate (BMAC) have demonstrated excellent medium-term outcomes in large lesions of comparable size to those treated by 2-step cultured chondrocytes cell-based procedures.(Gobbi 2019). The technique is based on external cells stimulation of cartilage repair by transplanting concentrated bone marrow cells mixed with PRP seeded on a scaffold and fixed with fibrin glue in the cartilage defect. The concept of repair is that the stemcells in marrow cell concentrate can in combination with the growth factors in the platelet rich plasma initiate formation of cartilage repair tissue.

The cost of bone marrow cell transplantation (kits for BMAC and PRP concentration 500 USD)

Autologous cartilage chips implantation

Implantation of Articular Cartilage Chips (ACC) is a principle to implant mature hyaline cartilage into a cartilage defect. This method has been investigated in osteochondral defects in knee where the bone defect were transplanted with autologous cancellous bone from the tibia and the cartilage layer was recreated by cartilage chips from cartilage biopsies taken from the intercondylar notch, the lateral femoral condyles edge or other low weight bearing area, and the cartilage biopsies were chopped into small cartilage chips <0.25-0.5 cm³. The chips are implanted and embedded in fibrin glue.

One clinical study has presented outcome data for the technique. In the study eight patients with osteochondral defects due to osteochondritis dissicans were treated with the combine bone and cartilage chips transplantation. (Christensen 2015) At one-year follow-up subjective outcome improved for IKDC from 39 preoperatively to 68 at one year. Also, KOOS and Tegner scores improved. Healing response based on MR MOCART scores improved from 23 to 53. All patient demonstrated good subchondral bone healing based on CT scanning.

The cost of autologous chips transplantation (0 USD)

References

References

Gobbi A, Whyte GP. Long-term Clinical Outcomes of One-Stage Cartilage Repair

in the Knee With Hyaluronic Acid-Based Scaffold Embedded With Mesenchymal Stem

Cells Sourced From Bone Marrow Aspirate Concentrate. Am J Sports Med. 2019

Jun;47(7):1621-1628.

Christensen BB, Foldager CB, Jensen J, Lind M. Autologous Dual-Tissue

Transplantation for Osteochondral Repair: Early Clinical and Radiological

Results. Cartilage. 2015 Jul;6(3):166-73.

Shive MS, Stanish WD, McCormack R, Forriol F, Mohtadi N, Pelet S, Desnoyers J,

Méthot S, Vehik K, Restrepo A. BST-CarGel® Treatment Maintains Cartilage Repair

Superiority over Microfracture at 5 Years in a Multicenter Randomized Controlled

Trial. Cartilage. 2015 Apr;6(2):62-72.

de Girolamo L, Schönhuber H, Viganò M, Bait C, Quaglia A, Thiebat G, Volpi P.

Autologous Matrix-Induced Chondrogenesis (AMIC) and AMIC Enhanced by Autologous

Concentrated Bone Marrow Aspirate (BMAC) Allow for Stable Clinical and Functional

Improvements at up to 9 Years Follow-Up: Results from a Randomized Controlled

Study. J Clin Med. 2019 Mar 21;8(3). pii: E392. doi: 10.3390/jcm8030392.