A. Yanke (Chicago, US)
Rush University Medical Center Orthopaedic SurgeryPresenter Of 7 Presentations
10.2.3 - Synovial Fluid MMP-1 and VEGF Concentration Correlates with Chondral Defects Severity and Symptoms in the Knee
Abstract
Purpose
This study sought to explore the correlations between preoperative synovial fluid biomarkers, cartilage structural characteristics on MRI, and pre- and postoperative PROs in patients undergoing chondroplasty for focal chondral defects.
Methods and Materials
This study prospectively enrolled patients undergoing chondroplasty for symptomatic focal chondral defects of the knee. Prior to the initiation of arthroscopy, synovial fluid was aspirated from the operative knee. Multiplex ELISA was then performed on the supernatant for several analytes. The relationships between biomarker concentrations, demographic factors, MRI findings as measured by AMADEUS score, and pre- and postoperative PROs were explored via independent t-test or Pearson correlation analysis. Variables significant on univariate analysis were included for multivariate linear regression.
Results
Cartilage defects of greater severity on MRI were significantly associated with increased concentration of MMP-1 and VEGF in synovial fluid (p<.05). Decreased preoperative KOOS Symptoms scores were correlated with increased concentrations of MMP-1 (r = -0.786, p<.001) and VEGF (r= -0.810, p<.001). These variables were non-significant on multivariate regression for KOOS Symptoms, although dominance analysis demonstrated that MMP-1 and VEGF were the greatest contributors to overall model fit, contributing 27.5% and 29.7%, respectively. Increased preoperative VEGF (r= -0.835, p=.019) and MMP-1 (r= -0.788, p=.036) were correlated with decreased improvement, or worsening of WOMAC stiffness score at 6 weeks after chondroplasty, while increased FGF2 (r=0.758, p=.049) and CCL2 (r= 0.777, p=.040) were positively correlated with improvement.
Conclusion
This study demonstrated that the concentration of MMP-1 and VEGF in synovial fluid correlate with cartilage lesion severity and may correlate with patient function and symptoms. These inflammatory biomarkers may be an important target in clinical practice towards improving outcomes when managing chondral defects of the knee.
13.1.2 - The Clinician - Scientist: Pearls for Success
16.3.1 - Anatomic Factors Associated With Osteochondral Allograft Matching For Trochlear Cartilage Defects
Abstract
Purpose
To evaluate anatomic factors of donor and recipient trochleae associated with osteochondral allograft matching for superolateral and central defects in a computer-simulated model.
Methods and Materials
Ten cadaveric trochlear specimens were utilized for this study. Three-dimensional (3D) point cloud models of the trochleae were created using a segmentation software program from CT scans (Mimics, Materialise Inc., Leuven, Belgium). Circular defect models were created virtually at both superolateral (18mm and 22.5mm) and central (18mm, 22.5mm, 30mm) locations. The mean articular step-off was calculated along the periphery of the graft. Demographic and anatomic factors measured include age, sex, laterality, lateral facet width, medial facet width, lateral condyle radius of curvature, trochlear groove radius of curvature, tibial width, trochlear length, and trochlear width. Sulcus angle and sagittal angle at the center of the defect and grafts for the central trochlear location were calculated by a custom-designed program.
Results
On multivariate analysis, sulcus angle difference (β=0.019, p=0.002), sagittal angle difference (β=0.018, p=0.001), and lateral condyle radius of curvature (β=0.015, p=0.003) were significant predictors of articular step-off for 18mm central defects (R2=0.45). For 22.5mm central defects, sulcus angle difference (β=0.029, p<0.001), sagittal angle difference (β=0.025, p<.001), medial facet width (β=0.026, p=0.021), and lateral radius of curvature (β=0.013, p=0.025) were significant. Similarly, for 30mm central defects, sulcus angle difference (β=0.03, p=0.001), lateral radius of curvature (β=.032, p=0.004), and trochlear length (β=0.041, p<0.001), were significant predictors. For 18mm superolateral defects, no significant predictors were identified on multivariate analysis. For 22.5mm superolateral trochlear defects, medial facet width (β=.006, p<0.001) and trochlear length (β=.002, p=0.003) were significantly associated.
Conclusion
Minimizing mismatch in anatomic factors such as sulcus angle, sagittal angle, lateral condyle radius of curvature, and medial facet width may contribute to more optimal graft matching.
16.3.6 - A Randomized Trial of Bone Marrow Aspirate Concentrate for Osteochondral Allograft Transplantation Incorporation
Abstract
Purpose
The purpose of this study was to investigate the effect of bone marrow aspirate concentrate (BMAC) on osseointegration and patient-reported outcome metrics (PROMs) after osteochondral allograft transplantation in a prospective, randomized controlled single-blinded trial.
Methods and Materials
Patients undergoing osteochondral allograft transplantation of the knee were consented and enrolled. Prior to surgery, patients were randomized into either the BMAC or sham incision groups. In the BMAC group, the osteochondral allograft plug was soaked in BMAC for a minimum of 2 minutes prior to implantation. All patients underwent postoperative computed tomography (CT) scanning at 6 months postoperatively and completed PROMs preoperatively, 6 months, and 1 year postoperatively. Two board-eligible orthopaedic surgeons blinded to treatment allocation independently assessed and graded each CT according to the ACTOCA system proposed by Gelber et al.
Results
Thirty-six patients enrolled between April 2018 to December 2020 (17 female, 19 male) were included for analysis. There were no significant differences between the BMAC and non-BMAC groups in graft signal density (Grader 1: p=0.283, Grader 2: p=0.467), osseous integration (both graders: p=0.489), surface percentage with discernible cleft (Grader 1: 0.287, Grader 2: 0.469), or intra-articular fragments (Grader 1: p=0.617, Grader 2: p=0.810) (Table 1). Significantly fewer patients receiving BMAC demonstrating cystic changes >3 mm (Grader 1: p=0.015, Grader 2: p=0.05) (Figure 1). At 1 year, BMAC patients reported significantly better WOMAC Pain (87.82±14.26 vs 75.80±15.56, p=0.043) and trended towards improved PROMIS Pain (54.14±8.31 vs 61.79±5.24, p=0.09).
Conclusion
Patients receiving BMAC soaked OCA grafts demonstrated no difference from controls with respect to graft signal intensity, osseous integration, intra-articular fragments, or discernible graft-host clefts at 6-months postoperatively. BMAC patients had a significantly lower occurrence of large (>3 mm) cystic changes. At 1 year, BMAC patients reported significantly less pain than controls on WOMAC Pain, with similar trends on PROMIS Pain Interference.
16.3.10 - Long-Term Outcomes of Osteochondral Allograft Transplantation to the Humeral Head
Abstract
Purpose
To evaluate survivorship, patient satisfaction, and long-term functional outcomes of humeral head osteochondral allograft (OCA) transplantation in patients with isolated focal chondral defects.
Methods and Materials
A registry of consecutive patients undergoing humeral head OCA transplantation between 2004 and 2012 was retrospectively reviewed. Treatment failure was defined as conversion to total shoulder arthroplasty (TSA). Patients completed Simple Shoulder Test (SST), American Shoulder and Elbow Surgeons Shoulder Score (ASES), and Short Form 12 (SF-12) Physical and Mental outcome assessments. Patient satisfaction and sport activity outcomes were also assessed. Postoperative outcomes were compared to baseline scores using Student’s t-tests with statistical significance defined as P<0.05.
Results
20 patients were identified, of which 13 (65%) had completed follow-up and were included in the analysis. Five patients (38.6%) failed treatment and underwent TSA at an average 3.91 ± 4.25 years (range 0.97-11.0) after index surgery. The average follow-up of the remaining eight patients (4 females, 4 males, mean age 26.8 ± 10.2 years) was 12.0 ± 3.1 years (range 7.6-15.7 years). Mean scores of all outcome assessments were higher at final follow-up than at baseline, but the difference was significant only in SST scores (Table 1). Patient satisfaction varied, with four patients reporting extreme satisfaction, one reporting moderate satisfaction, two reporting somewhat satisfaction, and one reporting no satisfaction. Only three of the eight patients were able to return to sport, two at the same level of competition and one at a lower level of competition.
Conclusion
The results of this case series suggest that the reported short and mid-term outcome improvements of humeral head OCA transplantation diminish at long-term time points. Moreover, athletes should be counseled on sport activity outcome probabilities. Despite these limitations, patient satisfaction rates with regards to long-term outcomes are generally favorable.
24.3.8 - Intra-Articular Injections in the Treatment of Knee Osteoarthritis: A Systematic Review and Network Meta-Analysis
Abstract
Purpose
The purpose of this study was to construct an algorithm to optimize clinical outcomes prior to definitive surgical management in patients with symptomatic knee OA.
Methods and Materials
A systematic review of randomized controlled trials on IA injections for symptomatic knee OA without severe degenerative changes from the inception of databases to December 18th, 2019 was performed. Interventions were compared via arm-based Bayesian network meta-analysis in a random-effects model and interventions ranked for each domain (ROM, pain, PROs) via surface under the cumulative ranking curves.
Results
A total of 39 studies comprising 2,764 knees (60% females, age 57 ± 4 years, follow-up 10 ± 5 months) were included. There were no significant differences in preoperative PROs between injection groups. Interventions ranked highest for improved ROM included fetal-derived mesenchymal stem cells (MSC.Fetal), adipose-derived mesenchymal stem cells (MSC.Ad), and bone-marrow derived stem cells (MSC.BM). Interventions ranked highest for improved pain included all MSC injections and platelet rich plasma (PRP), with or without hyaluronic acid (HA). These injections ranked equally high within the Western Ontario and McMaster Universities Arthritis Index (WOMAC) and Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales. Corticosteroid and HA injections ranked relatively poorly across all ROM, pain, and PRO domains.
Conclusion
PRP and MSC injections offer excellent clinical improvements in pain, ROM, and PROs, exceeding minimal clinically important difference thresholds. On the other hand, CSI and HA injections, in isolation, demonstrated relatively poor clinical outcomes with often non-statistically significant effects for pain, ROM, and PRO outcomes. Thus, for patients with symptomatic knee OA amenable to treatment by injection, the authors recommend either PRP, with or without HA, or MSC injection.
P199 - MRI Correlations of Bone Marrow Lesions and Patient Reported Outcomes after Microfracture
Abstract
Purpose
The purpose of this study was to investigate the role of preoperative BML size and quality on (1) preoperative, postoperative, and change in PROs and (2) failure in patients undergoing microfracture for focal chondral defects of femur.
Methods and Materials
Patients who underwent a femoral microfracture from 2004 to 2018 were identified. Preoperative magnetic resonance imaging (MRI) was evaluated for BMLs based on two classification systems (Welsch et al. and Costa-Paz et al.) by two graders. BML interrater reliability was assessed and preoperative BMLs in each classification system were evaluated in association with preoperative, postoperative, and change in PROs as well as survival analysis to subsequent surgery.
Results
A total of 43 patients (minimum 1-year follow-up) met inclusion criteria and completed final follow-up at a mean of 4.1 ± 2.6 years. For grader 1 and 2, 77% and 79% of the cohort had a BML, respectively. Preoperatively, BML size was significantly associated with KOOS Pain for Grader 1 (r=0.281, p=0.044) and Grader 2 (r=0.326, p=0.018). Changes in IKDC were significantly associated with Costa-Paz for both Graders (Grader 1: r=0.456, p=0.008; Grader 2: r=0.511, p=0.002). There were a total of 9 failures (6 OCAs, 1 MACI, 1 ACI, and 1 TKA) at a mean of 2.96 ± 3.14 years. The presence of a BML had a positive effect on microfracture survivorship (p = 0.007).
Conclusion
The presence of a BML was not associated with inferior survivorship or postoperative outcomes. This may be in part due to the ability of microfracture to result in fibrocartilage fill, which may be less sensitive to subchondral abnormalities such as BML compared to other restoration procedures where either hyaline cartilage is involved, such as in an ACI, or when osseous incorporation between the graft and subchondral bone is important, such as in an OCA.
Meeting Participant Of
- S. Kennedy (San Diego, US)
- S. Lin (Taipei, TW)
- B. Tiberiu (Targu-Mures, RO)
- D. Wang (Orange, US)
- M. Zheng (City Beach, AU)
- R. Levato (Utrecht, NL)
- Y. Henrotin (Liège, BE)
- P. Niemeyer (Munich, DE)
- K. Byers (Centennial, US)
- A. Lindahl (Göteborg, SE)
- A. Pavesio (Durham, US)
- A. Levy (Millburn, US)
- M. Pei (Morgantown, US)
- A. Yanke (Chicago, US)
- A. Shetty (Canterbury, GB)
Presenter Of 1 Presentation
P199 - MRI Correlations of Bone Marrow Lesions and Patient Reported Outcomes after Microfracture
Abstract
Purpose
The purpose of this study was to investigate the role of preoperative BML size and quality on (1) preoperative, postoperative, and change in PROs and (2) failure in patients undergoing microfracture for focal chondral defects of femur.
Methods and Materials
Patients who underwent a femoral microfracture from 2004 to 2018 were identified. Preoperative magnetic resonance imaging (MRI) was evaluated for BMLs based on two classification systems (Welsch et al. and Costa-Paz et al.) by two graders. BML interrater reliability was assessed and preoperative BMLs in each classification system were evaluated in association with preoperative, postoperative, and change in PROs as well as survival analysis to subsequent surgery.
Results
A total of 43 patients (minimum 1-year follow-up) met inclusion criteria and completed final follow-up at a mean of 4.1 ± 2.6 years. For grader 1 and 2, 77% and 79% of the cohort had a BML, respectively. Preoperatively, BML size was significantly associated with KOOS Pain for Grader 1 (r=0.281, p=0.044) and Grader 2 (r=0.326, p=0.018). Changes in IKDC were significantly associated with Costa-Paz for both Graders (Grader 1: r=0.456, p=0.008; Grader 2: r=0.511, p=0.002). There were a total of 9 failures (6 OCAs, 1 MACI, 1 ACI, and 1 TKA) at a mean of 2.96 ± 3.14 years. The presence of a BML had a positive effect on microfracture survivorship (p = 0.007).
Conclusion
The presence of a BML was not associated with inferior survivorship or postoperative outcomes. This may be in part due to the ability of microfracture to result in fibrocartilage fill, which may be less sensitive to subchondral abnormalities such as BML compared to other restoration procedures where either hyaline cartilage is involved, such as in an ACI, or when osseous incorporation between the graft and subchondral bone is important, such as in an OCA.