Autologous chondrocyte implantation combined with anterior cruciate ligament reconstruction: similar short-term results in comparison with isolated cartilage repair in ligament intact joints.

PURPOSE: Both acute ruptures of the anterior cruciate ligament (ACL) as well as chronic ACL insufficiency show a high association with focal cartilage defects of the knee. However, the results after combined ACL reconstruction and cartilage repair are not well investigated. The aim of the present study was to investigate the short-term outcomes after autologous chondrocyte implantation (ACI) in combination with ACL reconstruction and to compare the results with patients who underwent isolated ACI in ligament intact knees. METHODS: All patients who were registered in the German Cartilage Registry with ACI for focal cartilage defects in the knee joint in combination with ACL reconstruction and who completed the 24 month follow-up were included in the study group. A matched-pair procedure according to gender, defect location, defect size, and age was used to create a control group of patients with isolated ACI in ACL intact joints. The Knee Injury and Osteoarthritis Outcome Score (KOOS) and the numeric analog scale for pain (NAS) were used to assess the preoperative state as well as the clinical outcomes 12 and 24 months after surgery. RESULTS: A total of 34 patients were included in both the study group (age mean 33.3 ± SD 8.8 years) and the control group (33.6 ± 8.4 years) with a median defect size of 466 (25%-75% IQR 375-600) mm2 and 425 (IQR 375-600) mm2, respectively. In comparison with the preoperative state (median 67, IQR 52-75), the study group showed a significant increase of the total KOOS after 12 months (78, IQR 70-86; p = 0.014) and after 24 months (81, IQR 70-84; p = 0.001). The NAS for pain did not change significantly in the postoperative course. In comparison with the control group there was no significant difference for the total KOOS neither preoperative (control group median 67, IQR 52-73) nor at any postoperative time point (12 months: 82, IQR 67-93; 24 months: 81, IQR 71-91). CONCLUSION: The clinical short-term outcomes after ACI at the knee joint in combination with ACL reconstruction are good and similar to the results after isolated ACI in ligament intact knees. LEVEL OF EVIDENCE: III.

Decision making for concomitant high tibial osteotomy (HTO) in cartilage repair patients based on a nationwide cohort study of 4968 patients.

BACKGROUND: High tibial osteotomy (HTO) for varus deformities is a common concomitant treatment in cartilage surgery. Aim of the present study was to analyze factors influencing the decision towards accompanying HTO in patients with cartilage defects of the medial femoral condyle, such as the amount of varus deformity. METHODS: Data from 4986 patients treated for cartilage defects of the knee from the German Cartilage Registry (KnorpelRegister DGOU) were used for the current analysis. Seven hundred and thirty-six patients fulfilled the inclusion criteria. Their data were analyzed for factors influencing the decision towards performing a concomitant HTO using t test, univariate and multivariate binary logistic regression models. RESULTS: The break point at which the majority of patients receive a concomitant HTO is 3° of varus deformity. Several factors apart from the amount of varus deformity (5.61 ± 2.73° vs. 1.72 ± 2.38°, p < 0.00) differed significantly between the group of patients with HTO and those without. These included defect size (441.6 ± 225.3 mm2 vs. 386.5 ± 204.2 mm2, p = 0.001), symptom duration (29.53 ± 44.58 months vs. 21.85 ± 34.17 months, p = 0.021), defect grade (62.5% IVa/IVb vs. 57.3% IVa/IVb, p = 0.014), integrity of corresponding joint surface (10.8% grade III-IV vs. 0.2% grade III-IV, p < 0.001), meniscus status (15.5% > 1/3 resected vs. 4.4% > 1/3 resected, p < 0.001) and number of previous surgeries (1.01 ± 1.06 vs. 0.75 ± 1.00, p = 0.001). In the stepwise multivariate binary logistic regression test, only the amount of varus deformity, symptom duration and quality of the corresponding joint surface remained significant predictors associated with performing a concomitant HTO. CONCLUSION: Based upon data from a nationwide cohort, additional HTO in context with cartilage repair procedures of the medial femoral condyle is frequently performed even in mild varus deformities less than 5°. Other factors also seem to influence decision for HTO.

What parameters affect knee function in patients with untreated cartilage defects: baseline data from the German Cartilage Registry.

PURPOSE: To evaluate the factors influencing the baseline Knee Injury and Osteoarthritis Outcome Score (KOOS) in patients with knee cartilage defects and planned cartilage repair surgery and to provide baseline KOOS data from a large patient population. MATERIAL AND METHODS: Between October 2013 and April 2017, a total of 2815 patients assigned for cartilage repair surgery were included into the German Cartilage Registry (KnorpelRegister DGOU) and their data were analyzed for the present study. Multivariate regression model and ANOVA were used to detect patient- and defect-specific factors with an influence on baseline KOOS. In addition, KOOS baseline data was calculated and compared according to these parameters. RESULTS: Sex, age, body mass index (BMI), and smoking status were revealed as patient-specific factors, and defect location and the number of previous knee and cartilage operations were revealed as defect-specific factors with a significant influence on baseline KOOS. Most subscores were affected in accordance with the total KOOS. Interestingly, defect ICRS grade, defect size, and symptom duration had no significant influence. The mean baseline KOOS was 56.7 (± 17.9). Men had significantly higher mean overall KOOS (60 ± 17.3 vs. 51.8 ± 17.6, p < 0.001) than women, and patients with a BMI over 30 and smokers scored significantly lower (58.07 ± 17.67 vs. 50.32 ± 17.29, p < 0.001; 57.64 ± 17.86 vs. 53.59 ± 18.06, p < 0.001). Patients with two or more previous knee operations as well as patients with more than one previous cartilage procedure also showed significantly lower overall KOOS (57.19 ± 17.89 vs. 54.56 ± 17.58, p < 0.001; 57.68 ± 18.01 vs. 52.72 ± 17.58, p < 0.001). CONCLUSION: Several factors influencing baseline KOOS data in patients with knee cartilage defects assigned for cartilage repair surgery could be detected. Their individual influence in the multivariate linear regression model was not very strong. Baseline data according to these criteria is presented in this paper.

Effect of Previous Knee Surgery on Clinical Outcome After ACI for Knee Cartilage Defects: A Propensity Score-Matched Study Based on the German Cartilage Registry (KnorpelRegister DGOU).

BACKGROUND: Autologous chondrocyte implantation (ACI) is an established procedure for the treatment of cartilage damage in the knee joint. At present, it is still unclear how previous surgery influences outcome after ACI. PURPOSE: To evaluate the effect of previous knee surgery related or nonrelated to the treated cartilage defect on clinical outcome after ACI for knee cartilage defects. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: An overall 730 patients with ACI who underwent previous unspecific knee surgery, whether related to the defect being currently treated or not, were identified from a cohort of 5961 patients registered in the German Cartilage Registry. Propensity score matching was used to match these patients to 690 patients with analogous characteristics but without previous surgery. Subsequently, 317 patients with previously failed cartilage treatment at the defect site were identified and compared with a matched collective of 254 patients without previous cartilage treatment. In a subgroup analysis, the type of previous cartilage surgery was additionally investigated. Outcome was evaluated by Knee injury and Osteoarthritis Outcome Score (KOOS), visual analog scale for pain, rate of reintervention, and patient satisfaction up to 36 months. A chi-square test was used to compare categorial variables and an unpaired t test to compare continuous variables. RESULTS: Patients with previous knee surgery not related to the cartilage defect showed a lower KOOS at 6 months (68.3 vs 70.8; P = .026), while patients with previous cartilage surgery showed significantly lower KOOS values at all follow-up time points when compared with patients without any previous knee or cartilage surgery (all P < .05). A comparison of KOOS values in patients with previous therapy at the cartilage defect with ACI versus bone marrow stimulation did not show any significant differences at any follow-up. CONCLUSION: Previously failed cartilage treatment at the defect site represents a negative prognostic factor up to 3 years after ACI. However, this influence appears to be independent of the type of previous treatment at the defect site and applies equally to failed bone marrow stimulation as well as previous ACI. In contrast, a negative effect of previous surgery to the knee unrelated to the cartilage defect could not be shown in the 3-year follow-up.

Does Gender Influence Outcome in Cartilage Repair Surgery? An Analysis of 4,968 Consecutive Patients from the German Cartilage Registry (Knorpel Register DGOU).

The goal was to examine gender differences of patient characteristics and outcome after cartilage repair based on a collective of nearly 5,000 patients. Patient characteristics, accompanying therapies, and outcome (Knee Injury and Osteoarthritis Outcome Score [KOOS], reoperations, patient satisfaction) of 4,986 patients of the German cartilage register DGOU were assessed by t test for possible gender differences. P values <0.05 were considered statistically significant. Women were older than men (38.07 ± 12.54 vs. 26.94 ± 12.394 years, P = 0.002), more often preoperated (0.30 ± 0.63 vs. 0.24 ± 0.55, P = 0.001), and had a longer symptom duration (25.22 ± 41.20 vs. 20.67 ± 35.32 months, P < 0.001). Men had greater mean leg axis malalignment than women (3.24° ± 3.26° vs. 2.67° ± 3.06°, P < 0.001), less favorable meniscal status (P = 0.001), worse defect stage (P = 0.006), and a more severely damaged corresponding articular surface (P = 0.042). At baseline (59.84 ± 17.49 vs. 52.10 ± 17.77, P < 0.001), after 6 months (72.83 ± 15.56 vs. 66.56 ± 17.66, P < 0.001), after 12 months (77.88 ± 15.95 vs. 73.07 ± 18.12, P < 0.001), and after 24 months (79.311 ± 15.94 vs. 74.39 ± 18.81, P < 0.001), men had better absolute KOOS values, but women had better relative KOOS increases 6 months (14.59 ± 17.31 vs. 12.49 ± 16.3, P = 0.005) as well as 12 months postoperatively (20.27 ± 18.6 vs. 17.34 ± 17.79, P = 0.001) compared with preoperatively, although 12 and 24 months postoperatively they were subjectively less satisfied with the outcome (P < 0.001) and had a higher reintervention rate at 24 months (0.17 ± 0.38 vs. 0.12 ± 0.33, P = 0.008). In summary, the present work shows specific gender differences in terms of patient characteristics, defect etiology, defect localization, concomitant therapy, and the choice of cartilage repair procedure. Unexpectedly, contrary to the established scientific opinion, it could be demonstrated that women show relatively better postoperative KOOS increases, despite a higher revision rate and higher subjective dissatisfaction.

Matrix-Associated Autologous Chondrocyte Implantation Is an Effective Treatment at Midterm Follow-up in Adolescents and Young Adults.

BACKGROUND: Autologous chondrocyte implantation (ACI) is an established method for treating cartilage defects in the knee of adult patients. However, less is known about its effectiveness in adolescents. HYPOTHESIS: Third-generation matrix-associated ACI (MACI) using spheroids (co.don chondrosphere/Spherox) is an effective and safe treatment for articular cartilage defects in adolescents aged 15 to 17 years, with outcomes comparable with those for young adults aged 18 to 34 years. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A total of 71 patients (29 adolescents, 42 young adults) who had undergone ACI using spheroids were evaluated retrospectively in this multicenter study. For adolescents, the mean defect size was 4.6 ± 2.4 cm2, and the follow-up range was 3.5 to 8.0 years (mean, 63.3 months). For young adults, the mean defect size was 4.7 ± 1.2 cm2, and the follow-up range was 3.8 to 4.3 years (mean, 48.4 months). At the follow-up assessment, outcomes were assessed by using validated questionnaires (Knee injury and Osteoarthritis Outcome Score [KOOS], International Knee Documentation Committee [IKDC] subjective knee evaluation form and current health assessment form, and modified Lysholm score), the magnetic resonance observation of cartilage repair tissue (MOCART) score, and if relevant, time to treatment failure. Safety was assessed by the treatment failure rate. RESULTS: No significant difference between the 2 study groups was found for KOOS, IKDC, or MOCART scores, with all patients achieving high functional values. A significant difference was found in the modified Lysholm score, favoring the young adult group over the adolescent group (22.3 ± 1.9 vs 21.0 ± 2.4, respectively; P = .0123). There were no differences between the rates of treatment failure, with 3% in the adolescent group and 5% in the young adult group. CONCLUSION: Third-generation MACI using spheroids is a safe and effective treatment for large cartilage defects of the knee in adolescents at midterm follow-up. Outcomes are comparable with those for young adults after ACI.

A prospective multicenter study on the outcome of type I collagen hydrogel-based autologous chondrocyte implantation (CaReS) for the repair of articular cartilage defects in the knee.

BACKGROUND: The Cartilage Regeneration System (CaReS) is a novel matrix-associated autologous chondrocyte implantation (ACI) technique for the treatment of chondral and osteochondral lesions (Outerbridge grades III and IV). For this technology, no expansion of the chondrocytes in a monolayer culture is needed, and a homogeneous cell distribution within the gel is guaranteed. PURPOSE: To report a prospective multicenter study of matrix-associated ACI of the knee using a new type I collagen hydrogel (CaReS). STUDY DESIGN: Case series; Level of evidence, 4. METHODS: From 2003 to 2008, 116 patients (49 women and 67 men; mean age, 32.5 ± 8.9 years) had CaReS implantation of the knee in 9 different centers. On the basis of the International Cartilage Repair Society (ICRS) Cartilage Injury Evaluation Package 2000, the International Knee Documentation Committee (IKDC) score, pain score (visual analog scale [VAS]), SF-36 score, overall treatment satisfaction and the IKDC functional status were evaluated. Patient follow-up was performed at 3, 6, and 12 months after surgery and annually thereafter. Mean follow-up was 30.2 ± 17.4 months (range, 12-60 months). There were 67 defects of the medial condyle, 14 of the lateral, 22 of the patella/trochlea, and 3 of the tibial plateau, and 10 patients had 2 lesions. The mean defect size was 5.4 ± 2.4 cm(2). Thirty percent of the defects were <4 cm(2) and 70% were >4 cm(2). RESULTS: The IKDC score improved significantly from 42.4 ± 13.8 preoperatively to 70.5 ± 18.7 (P < .001) at latest follow-up. Global pain level significantly decreased (P < .001) from 6.7 ± 2.2 preoperatively to 3.2 ± 3.1 at latest follow-up. There also was a significant increase of both components of the SF-36 score. The overall treatment satisfaction was judged as very good or good in 88% by the surgeon and 80% by the patient. The IKDC functional knee status was grade I in 23.4%, II in 56.3%, III in 17.2%, and IV in 3.1% of the patients. CONCLUSION: Matrix-associated ACI employing the CaReS technology for the treatment of chondral or osteochondral defects of the knee is a safe and clinically effective treatment that yields significant functional improvement and improvement in pain level. However, further investigation is necessary to determine the long-term viability and clinical outcome of this procedure.