Third-generation autologous chondrocyte implantation after failed bone marrow stimulation leads to inferior clinical results.

PURPOSE: Third-generation autologous chondrocyte implantation (ACI) is an established and frequently used method and successful method for the treatment of full-thickness cartilage defects in the knee. There are also an increasing number of patients with autologous chondrocyte implantation as a second-line therapy that is used after failed bone marrow stimulation in the patient's history. The purpose of this study is to investigate the effect of previous bone marrow stimulation on subsequent autologous chondrocyte implantation therapy. In this study, the clinical results after the matrix-based autologous chondrocyte implantation in the knee in a follow-up over 3 years postoperatively were analysed. METHODS: Forty patients were included in this study. A total of 20 patients with cartilage defects of the knee were treated with third-generation autologous chondrocyte implantation (Novocart® 3D) as first-line therapy. The mean defect size was 5.4 cm2 (SD 2.6). IKDC subjective score and VAS were used for clinical evaluation after 6, 12, 24 and 36 months postoperatively. The results of these patients were compared with 20 matched patients with autologous chondrocyte implantation as second-line therapy. Matched pair analysis was performed by numbers of treated defects, defect location, defect size, gender, age and BMI. RESULTS: Both the first-line (Group I) and second-line group (Group II) showed significantly better clinical results in IKDC score and VAS score in the follow-up over 3 years compared with the preoperative findings. In addition, Group I showed significantly better results in the IKDC and VAS during the whole postoperative follow-up after 6, 12, 24 and 36 months compared to Group II with second-line autologous chondrocyte implantation (IKDC 6 months p = 0.015, 1 year p = 0.001, 2 years p = 0.001, 3 years p = 0.011). Additionally, we found a lower failure rate in Group I. No revision surgery was performed in Group I. The failure rate in the second-line Group II was 30%. CONCLUSION: This study showed that third-generation autologous chondrocyte implantation is a suitable method for the treatment of full-thickness cartilage defects. Both, Group I and Group II showed significant improvement in our follow-up. However, in comparing the results of the two groups, autologous chondrocyte implantation after failed bone marrow stimulation leads to worse clinical results. LEVEL OF EVIDENCE: III.

Two-Year Follow-Up and Remodeling Kinetics of ChonDux Hydrogel for Full-Thickness Cartilage Defect Repair in the Knee.

OBJECTIVE: To determine performance and repair kinetics of the ChonDux hydrogel scaffold for treating focal articular cartilage defects in the knee over 24 months. DESIGN: This assessor-blinded trial evaluates ChonDux hydrogel scaffold implantation in combination with microfracture in 18 patients across 6 sites. Male and female patients 18 to 65 years of age with full-thickness femoral condyle defects 2 to 4 cm2 in area were enrolled. Eligible patients received ChonDux treatment followed by rehabilitation. Defect volume fill was evaluated after 3, 6 (primary outcome), 12, 18, and 24 months by assessor blinded magnetic resonance imaging (MRI) analysis. Secondary outcomes were T2-weighted MRI relaxation time and patient surveys via visual analogue scale (VAS) pain and International Knee Documentation Committee (IKDC) knee function scoring. RESULTS: ChonDux maintained durable tissue restoration over 24 months with final defect percent fill of 94.2% ± 16.3% and no significant loss of fill volume at any time points. Tissues treated with ChonDux maintained T2 relaxation times similar to uninjured cartilage between 12 and 24 months. VAS pain scoring decreased between 1 and 6 weeks, and IKDC knee function scores improved by approximately 30.1 with ChonDux over 24 months. CONCLUSION: ChonDux treatment is a safe adjunct to microfracture therapy and promotes stable restoration of full thickness articular cartilage defects for at least 24 months.

Fibrocartilaginous emboli in the pediatric population: The role of rehabilitation in facilitating functional recovery.

A 12 year-old female presented to the emergency department with a right hemiparesis, headache, and neck pain. Initial neural imaging studies were unremarkable. However, a repeat MRI of the cervical spine during her acute hospitalization showed an acute spinal infarct. Neurological workup was consistent with fibrocartilaginous embolism (FCE) as the etiology. After several weeks of intensive inpatient rehabilitation, the patient demonstrated remarkable functional progress. This case report reviews the comprehensive pediatric literature on FCE with focus on the mechanism of injury, role of imaging studies, treatment options and prognosis. Awareness of the typical clinical history, as well as the signs and symptoms characteristic of FCE will improve the identification of this rare cause of abrupt weakness and potentially facilitate functional recovery.

Meniscal extrusion as booster of osteoarthritis.

Meniscal extrusion (ME) has shown to play a critical but still unclear role in osteoarthritis (OA) development. ME has been described as an important risk factor in the progression of knee OA, as it is involved in the thinning of articular cartilage, joint space narrowing, spontaneous osteonecrosis of the knee and subchondral bone marrow lesions. Meniscal damage of any degree of severity could cause ME in both compartments, but it is commonly associated with severe meniscal tears or root tears mainly in the medial meniscus. Magnetic resonance imaging is the most commonly used imaging modality in the assessment of ME, while ultrasonography may represent a valid alternative with high sensitivity and specificity. Conservative treatment for ME includes physical therapy and rehabilitation to maintain range of motion, corticosteroid injections and intra-articular injections of hyaluronic acid to provide short-term relief of knee pain. The goal of this study is to review standards of current diagnosis and treatment of ME and its relationship to knee OA.

Patients With Chondrolabral Pathology Have Bilateral Functional Impairments 12 to 24 Months After Unilateral Hip Arthroscopy: A Cross-sectional Study.

Study Design Cross-sectional study. Background Functional task performance in patients with chondrolabral pathology following hip arthroscopy is unknown. Objectives To investigate in people with chondrolabral pathology following hip arthroscopy (1) the bilateral differences in functional task performance compared to controls, (2) the association of hip muscle strength with functional task performance, and (3) the association of functional task performance scores with good outcome, as measured by International Hip Outcome Tool score. Methods Seventy-one patients who had unilateral hip arthroscopy for hip pain and 60 controls were recruited. Patient-reported outcomes included the 4 subscales of the International Hip Outcome Tool. Hip muscle strength measures included abduction, adduction, extension, flexion, external rotation, and internal rotation. Functional tasks assessed included the single hop test, the side bridge test, and the single-leg rise test. For aim 1, analyses of covariance tests were used. For aim 2, stepwise multiple linear regression analyses were used. For aim 3, receiver operating characteristic curve analyses were used. Results Compared to controls, the chondrolabral pathology group had significantly worse performance on both legs for each of the functional tasks (P<.001). Greater hip abduction strength was moderately associated with better performance on functional tasks in the chondrolabral pathology group (adjusted R2 range, 0.197-0.407; P<.001). Cutoff values associated with good outcome were 0.37 (hop distance/height) for the single hop, 16 repetitions for the single-leg rise, and 34 seconds for the side bridge test. Conclusion Patients with hip chondrolabral pathology had reduced functional task performance bilaterally 12 to 24 months after unilateral hip arthroscopy when compared to controls. Level of Evidence Therapy/symptom prevalence, level 3b. J Orthop Sports Phys Ther 2016;46(11):947-956. doi:10.2519/jospt.2016.6577.

Norwegican Cartilage Project - a study protocol for a double-blinded randomized controlled trial comparing arthroscopic microfracture with arthroscopic debridement in focal cartilage defects in the knee.

BACKGROUND: Focal lesions to the articular cartilage in the knee might have demolishing consequences to the knee. There exists a wide range of possible surgical procedures targeting these injuries, however no significant differences have been found between these procedures. This may support that the improvement is a result of rehabilitation, and not the surgery itself. Arthroscopic microfracture (MF) treatment has gained popularity, and has become the treatment of choice in patients with knee cartilage defects globally. In this study we want to increase knowledge, both clinical and economic, about arthroscopic microfracture (AF) compared to arthroscopic debridement (AD) and physical rehabilitation both in the short run, and in the long run. METHODS/DESIGN: To compare arthroscopic microfracture with arthroscopic debridement and physiotherapy for the treatment of focal cartilage lesions in the knee, a long-term, double-blinded, randomized controlled multicenter trial will be conducted. A total of 114 men and non-pregnant women with a symptomatic focal full thickness cartilage lesion in the knee less than 2 cm2 will be included in the study. The two treatment allocations will receive identical rehabilitation, which is made up of 3 phases: accommodation, rehabilitation and return to activity. Follow up is 24 months, where all will be invited to participate in late follow ups after 5 and 10 years. The Knee Injury and Osteoarthritis Outcome Score (KOOS) knee-related quality of life (QoL) subscore is the primary endpoint. Clinical parameters, questionnaires and radiologic modalities (Magnetic Resonance Imaging (MRI) and x-ray) will be used as secondary endpoints. DISCUSSION: This is an ongoing multicenter study with a high level of evidence to compare arthroscopic microfracture with arthroscopic debridement and physiotherapy for the treatment of isolated symptomatic full thickness cartilage lesions in the knee joint. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT02637505 (December 15, 2015).

Relationship between quadriceps strength and patellofemoral joint chondral lesions after anterior cruciate ligament reconstruction.

BACKGROUND: The incidence of the patellofemoral joint chondral lesions after anterior cruciate ligament reconstruction (ACLR) is disturbingly high. Few studies have assessed the factors affecting patellofemoral joint chondral lesions postoperatively. HYPOTHESIS: The recovery of quadriceps strength after ACLR could be associated with patellofemoral joint cartilage damage. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A total of 88 patients who underwent arthroscopic anatomic double-bundle ACLR with hamstring autografts received second-look arthroscopy at the time of metal staple removal at an average of 24.1 months (range, 12-51 months) postoperatively. All patients underwent standardized isokinetic strength testing for bilateral quadriceps and hamstrings 1 to 2 days before second-look arthroscopy. The patients were divided into 2 groups: Patients in group 1 had a ≥20% deficit on the peak torque measures for quadriceps compared with that of the contralateral knee, whereas those in group 2 had a <20% deficit on peak torque. Cartilage status at the patellofemoral joint and tibiofemoral joint were evaluated by second-look arthroscopy and the Outerbridge classification. Other assessments included the International Knee Documentation Committee (IKDC) score, Tegner and Lysholm scores, side-to-side difference on KT-2000 arthrometer, and range of motion. RESULTS: There were 42 patients included in group 1 and 46 patients in group 2. The mean postoperative quadriceps peak torque of the involved knee compared with the contralateral knee was 70% (range, 57%-80%) in group 1 and 95% (range, 81%-116%) in group 2. For all patients, a significant worsening was seen in the patellar and trochlear cartilage (P = .030 and <.001, respectively) but not at the medial or lateral tibiofemoral joint after ACLR. A significant worsening in the status of both patellar and trochlear cartilage was seen after ACLR in group 1 (P = .013 and =.011, respectively) and of trochlear cartilage in group 2 (P = .006). Significantly fewer severe chondral lesions of the patella were found in group 2 than in group 1 (proportion of patients whose cartilage grade worsened: 26% vs 48%, P < .05; difference in cartilage grade: 0.09 vs 0.62, P < .05). There was no significant difference for trochlear chondral worsening between the 2 groups. No significant differences were detected between the 2 groups in terms of hamstring strength; Lysholm, Tegner, and IKDC scores; KT-2000 arthrometer anterior laxity; or range of motion. CONCLUSION: Greater than 80% recovery of quadriceps strength after ACLR is associated with less severe patellar cartilage damage at short-term follow-up.

Early resumption of physical activities leads to inferior clinical outcomes after matrix-based autologous chondrocyte implantation in the knee.

PURPOSE: Matrix-based autologous chondrocyte implantation is a well-established operation procedure for full cartilage defects. When to resume physical activity after matrix-based autologous chondrocyte implantation is controversial. Our hypothesis was that early resumption of physical activity leads to a worse clinical outcome after matrix-based autologous chondrocyte implantation in the knee two years post-operatively. Physical activity is defined as any kind of impact sport. METHODS: Forty-four patients with cartilage defects of the knee were treated with matrix-based autologous chondrocyte implantation (Novocart3D). All patients were assessed preoperatively and after a period of 24 months with the University of California Los Angeles (UCLA) Activity score. The return to physical activities or sports after matrix-based autologous chondrocyte implantation was documented. Patients were evaluated using the International Knee Documentation Committee Knee Examination Form and visual analogue scale for pain after 6, 12 and 24 months. RESULTS: Fifty-five percent showed an unchanged level of physical activity in the UCLA Activity score post-operatively. About 35% showed a lower level and 10% a higher level of physical activity. The average return to physical activities or sports after matrix-based autologous chondrocyte implantation procedure was 10.2 months. Patients with a later return of sports after 12 months showed significantly better clinical results after two years. In particular, patients who started practicing impact sport after 12 months post-operatively showed significantly better results. CONCLUSION: Resuming physical activity including impact sports without waiting at least 12 months after the operation leads to inferior outcomes up to 24 months after matrix-based autologous chondrocyte implantation. LEVEL OF EVIDENCE: Level IV.

Is arthroscopic surgery beneficial in treating non-traumatic, degenerative medial meniscal tears? A five year follow-up.

PURPOSE: The aim of this prospective randomized intervention study was to evaluate the outcome at a 2 and 5 year follow-up whether combined arthroscopic surgery followed by exercise therapy was superior to the same exercise therapy alone when treating non-traumatic, degenerative medial meniscal tears. METHODS: Ninety-six middle-aged patients with MRI-verified degenerative medial meniscus tear and radiographic osteoarthritis grade ≤1 (Ahlbäck) participated in the study. Radiographic examination was done before randomization and after 5 years. The patients were randomly assigned to either arthroscopic treatment followed by exercise therapy for 2 months or to the same exercise therapy alone. At the start of the study and at the follow-ups at 24 and 60 months the patients answered three questionnaires KOOS, Lysholm Knee Scoring Scale and Tegner Activity Scale and made pain ratings on the Visual Analogue Scale (VAS). RESULTS: Both groups showed highly significant clinical improvements from baseline to the follow-ups at 24 and 60 months on all subscales of KOOS, Lysholm Knee Scoring Scale and VAS (p < 0.0001). No group differences were found at any of the testing occasions. One third of the patients that were treated with exercise therapy alone did not feel better after the treatment but were improved after arthroscopic surgery. According to radiographic findings two patients from each group had a slight progression of their osteoarthritis after 5 years. CONCLUSION: The findings indicate that arthroscopic surgery followed by exercise therapy was not superior to the same exercise therapy alone for this type of patients. Consequently, exercise therapy can be recommended as initial treatment. However, one third of the patients from the exercise group still had disabling knee symptoms after exercise therapy but improved to the same level as the rest of the patients after arthroscopic surgery with partial meniscectomy. LEVEL OF EVIDENCE: I.

The role of physical medicine and rehabilitation in haemophiliac patients.

Physical medicine and rehabilitation aim to evaluate, diagnose and treat disability in haemophiliac patients, while preventing injury or deterioration. They also aim to maintain the greatest degree of functional capacity and independence in patients with haemophilia, or to return them to that state. Rehabilitation, together with clotting factor replacement therapy, has revolutionized the management of these patients in developed countries and reduced their morbidity/mortality rates. A knowledge of the musculoskeletal signs and symptoms of haemophilia is essential for providing a treatment which is suitable and customized. Physical medicine and rehabilitation techniques, which are based on physical means, are intended to reduce the impact which these injuries and their consequences or sequelae can have on the quality of life of patients with haemophilia. Under ideal haemostatic control conditions (primary prophylaxis), people with haemophilia could achieve good physical condition which will allow them to enjoy both physical activity and a daily life without limitations. Currently, children undergoing primary prophylaxis are quite close to this ideal situation. For these physical activities to be carried out, the safest possible situations must be sought.

Practice in rehabilitation after cartilage therapy: an expert survey.

BACKGROUND: Current cartilage therapy modalities like microfracture, ACT/MACT, AMIC or osteochondral transplantation are important tools to treat symptomatic (osteo)chondral lesions of the knee joint. However, until now there exists no high-level evidence based accepted rehabilitation plan for the postoperative treatment. HYPOTHESIS/PURPOSE: This survey describes the predominantly used rehabilitation plan as implemented by expert musculoskeletal surgeons for operatively treated (osteo)chondral lesions. STUDY DESIGN: Survey and systematic review. METHODS: An electronic questionnaire covering general and specific items concerning aftercare following cartilage therapy in the knee joint was designed and disposed to analyze rehabilitation programs among a population of expert musculoskeletal surgeons of the AGA (Society of arthroscopy and joint surgery). All instructors (304 in 01/2011) were included into the survey. A total of 246 (80.9 %) instructors answered the questionnaire. RESULTS: The predominant used therapy to treat cartilage lesions is microfracture and for osteochondral lesions the osteochondral transplantation. Physiotherapy starts directly after surgery and takes more than 6 weeks. Most surgeons do not immobilize patients after surgery and use partial weight-bearing for up to 5 weeks. The change from partial to full weight-bearing is done step-wise with a 20-kg/week increase. Free ROM is allowed by the majority of instructors (55 %) directly after surgery. A CPM-device is also used directly and up to 5 weeks. Swimming and biking are allowed after 6 weeks, running is allowed after 12 weeks and contact sports after 24 weeks. Most instructors do not use braces in the aftercare procedure, but nearly all (93 %) prescribe crutches. Typical drugs used during the aftercare are NSAID, Heparin and antibiotics. For most instructors (79 % respectively 75 %) knee stability and a straight leg axis are necessary for a successful cartilage therapy. If a concomitant therapy like ACL reconstruction or an osteotomy is performed, aftercare is mainly dependent on cartilage therapy (62 % respectively 59 % of instructors). CONCLUSIONS: Today there exists no detailed rehabilitation program for treatment after a cartilage-related operation on the basis of an evidence-based level I study. The reason might be that many variables contribute to a specific aftercare procedure. Therefore, the survey of experienced surgeons may help to identify the most promising rehabilitation regime for today, at least until evidence-based level I studies are accomplished.

Postoperative management of patients with articular cartilage repair.

The efficacy of the rehabilitative process following articular cartilage repair in the knee can be the factor that determines the patient's long-term success, especially for return to sport. Articular cartilage repairs show great promise in allowing patients to return to their former level of function and, when complimented with an appropriate postoperative rehabilitation program, can be highly successful in allowing return to even very high level athletics. This article seeks to overview the most recent evidence regarding the general rehabilitation process for the common types of cartilage repair, discuss common complications which may arise, and determine an athlete's readiness to return to sport. We also address postoperative pain control, evaluation of a patient's progress through rehab, and adjustments to be made when there are comorbidities present.

Rehabilitation and return-to-sports activity after debridement and bone marrow stimulation of osteochondral talar defects.

An osteochondral defect (OD) is a lesion involving the articular cartilage and the underlying subchondral bone. ODs of the talus can severely impact on the quality of life of patients, who are usually young and athletic. The primary treatment for ODs that are too small for fixation, consists of arthroscopic debridement and bone marrow stimulation. This article delineates levels of activity, determines times for return to activity and reviews the factors that affect rehabilitation after arthroscopic debridement and bone marrow stimulation of a talar OD. Articles for review were obtained from a search of the MEDLINE database up to January 2012 using the search headings 'osteochondral defects', 'bone marrow stimulation', 'sports/activity', 'rehabilitation', various other related factors and 'talus'. English-, Dutch- and German-language studies were evaluated.The review revealed that there is no consensus in the existing literature about rehabilitation times or return-to-sports activity times, after treatment with bone marrow stimulation of ODs in the talus. Furthermore, scant research has been conducted on these issues. The literature also showed that potential factors that aid rehabilitation could include youth, lower body mass index, smaller OD size, mobilization and treatment with growth factors, platelet-rich plasma, biphosphonates, hyaluronic acid and pulse electromagnetic fields. However, most studies have been conducted in vitro or on animals. We propose a scheme, whereby return-to-sports activity is divided into four phases of increasing intensity: walking, jogging, return to non-contact sports (running without swerving) and return to contact sports (running with swerving and collision). We also recommend that research, conducted on actual sportsmen, of recovery times after treatment of talar ODs is warranted.

The cartilage degeneration and joint motion of bipolar hemiarthroplasty.

PURPOSE: The outcomes of bipolar hemiarthoplasty for osteonecrosis of femoral head have been disappointing due to cartilage degeneration and osteolysis. We investigated the cartilage degeneration, joint motion, and factors associated with osteolysis. METHODS: We retrospectively reviewed 134 bipolar hemiarthroplasties. The wear rate of acetabular cartilage was calculated. The ranges of motion of outer bearing and inner bearing were determined, and the ratio (O/I ratio) was calculated. RESULTS: The mean degeneration rate of acetabular cartilage was 0.34 ± 0.35 mm/year. We could observe that the outer bearing motion was dominant, but decreased over time. In addition, the degeneration rate of cartilage and the decline rate of outer bearing motion of the osteolysis group were significantly higher than those of the control group. CONCLUSIONS: Close observation is needed in cases of high degeneration rate of cartilage and rapid decline of outer bearing motion due to possibility of osteolysis.

Arthroscopic treatment of hip chondral defects: autologous chondrocyte transplantation versus simple debridement--a pilot study.

PURPOSE: To compare the effectiveness of simple arthroscopic debridement versus arthroscopic autologous chondrocyte transplantation (ACT) for the treatment of hip chondral lesions. METHODS: We carried out a controlled retrospective study of 30 patients affected by a post-traumatic hip chondropathy of the third or fourth degree, according to the Outerbridge classification, measuring 2 cm² in area or more. Of these patients, 15 underwent arthroscopic ACT, whereas the other 15 underwent arthroscopic debridement. The 2 groups were similar in age, sex, degree, and location of the pathology. All the patients were assessed before and after the procedure with the Harris Hip Score (HHS). RESULTS: In both groups the mean follow-up was approximately 74 months (range, 72 to 76 months). The mean size of the defect was 2.6 cm². The patients who underwent ACT (group A) improved after the procedure compared with the group that underwent debridement alone (group B). The mean HHS preoperatively was 48.3 (95% confidence interval [CI], 45.4 to 51.2) in group A and 46 (95% CI, 42.7 to 49.3) in group B (P = .428 [no significant difference]). The final HHS was 87.4 (95% CI, 84.3 to 90.5) in group A and 56.3 (95% CI, 54.4 to 58.7) in group B (P < .001 [significant difference]). CONCLUSIONS: This study indicates that an ACT procedure can be used in the hip for acetabular chondral defects. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Olive leaf extract facilitates healing of experimental cartilaginous injuries in rabbits.

We investigated the restorative effect of orally administered olive leaf extract (OLE) on experimentally produced cartilaginous injuries in rabbits. In total, three holes in the left stifle joint, including one in the medial trochlear ridge and two in the trochlear sulcus (proximal and distal) of articular cartilage, were prepared surgically using a drill. For the control group only tap water alone was administered daily, and for the OLE group a water-based solution of OLE (500 mg/kg/day) was administered daily. The injured areas were observed macroscopically and histologically at 3 weeks after the operation. The results indicate that OLE facilitated healing of the three holes and increased the weight of the biceps femoris muscle. Histological examination revealed that in the OLE group, matured cartilage tissues and connective tissues were mixed with regenerated or maturing cartilage tissues with massive proliferation in the injured parts, around which the proliferation of undifferentiated blast cells and the tissue with cartilage substrates were observed. The histological score of the OLE group was significantly lower than that of the control group. The percentage of proliferating cell nuclear antigen-positive cartilage cells in the OLE group was higher than in the control group. Mean density of the restored area observed with Safranin O staining was higher in the OLE group than in the control group. Therefore, OLE is effective for enhancing the healing of cartilaginous injuries. OLE may also have a beneficial effect of slowing and reducing the pathogenesis of degenerative joint diseases in humans.

The use of continuous passive motion following knee cartilage defect surgery: a systematic review.

We evaluated the clinical evidence of using continuous passive motion postoperatively after treating articular cartilage lesions of the knee. We hypothesized that postoperatively, the use of continuous passive motion improves the outcomes of cartilage restoration procedures. Multiple medical databases (MEDLINE, EMBASE, CINAHL, PubMed, Sport-Discus, and Cochrane) were searched for Level I through IV evidence with specific study inclusion and exclusion criteria. The following key words were searched: microfracture, mosaicplasty, OATS, ACI, osteochondral autograft, osteochondral allograft, autologous chondrocyte implantation, autologous chondrocyte transplantation, CPM, continuous passive motion, motion therapy, postoperative knee rehabilitation, cartilage, knee. All studies were independently reviewed by the authors and the references were checked for any missed articles. Four Level III studies were identified that met inclusion criteria for our hypothesis. No randomized, controlled studies were identified. A meta-analysis could not be performed as a result of the heterogeneity of the procedures and outcome measures. Definitive conclusions regarding the benefits of continuous passive motion postoperatively in knee cartilage surgery could not be made secondary to this heterogeneity. Continuous passive motion is commonly used postoperatively following cartilage surgery. Unfortunately, the clinical evidence (only 4 studies) to support the use of continuous passive motion is lacking despite an overwhelming abundance of basic science support and the common clinical practice of continuous passive motion implementation postoperatively in knee cartilage restoration procedures. There is a great need for well-conducted, high-level evidence studies to address this void in our literature.

Autologous chondrocyte implantation for treatment of focal cartilage defects in patients age 40 years and older: A matched-pair analysis with 2-year follow-up.

BACKGROUND: Autologous chondrocyte implantation (ACI) is an accepted surgical treatment in patients with isolated cartilage defects of the knee. Age has been considered as a limiting factor and the technique has not been recommended in patients older than 40 to 50 years. Nevertheless, some more recent studies report satisfying clinical results in middle-aged patients. HYPOTHESIS: Analogous to the microfracture technique, age over 40 years is associated with inferior clinical outcome after ACI. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Thirty-seven patients with an average age of 47.8 years (group 1) were matched with 37 patients with an average age of 31 years (group 2). Both groups underwent ACI for treatment of isolated cartilage defects of the knee. All patients were enrolled prospectively and followed for a period of 24 months using International Knee Documentation Committee (IKDC), Lysholm scale, Cincinnati sports scale, and Tegner activity evaluation instruments. RESULTS: Statistical analysis revealed a significant increase in function after ACI in both groups as early as 6 months after surgery until the end of the study period. There was only a slight tendency for better clinical outcome in younger patients (IKDC at 24 months: group 1, 72.2 ± 15.8 [standard deviation]; group 2: 76.1 ± 14.1; P = .261; Lysholm at 24 months: group 1: 80.42 ± 15.37; group 2: 80.65 ± 12.01), no statistical significant differences were found between patients of group 1 and group 2 at any of the time points investigated. CONCLUSION: In contrast to other cartilage repair techniques, patients 40 years and older do not have an inferior outcome up to 24 months after ACI for isolated cartilage defects when compared with younger patients.

In-advance trans-medullary stimulation of bone marrow enhances spontaneous repair of full-thickness articular cartilage defects in rabbits.

Mesenchymal stromal cells (MSCs), especially those lying close to cartilage defects, are an important cell source for cartilage regeneration. We hypothesize that a larger number of MSCs might become available, if the bone marrow in the immediate vicinity of the subchondral bone is stimulated for MSCs in advance of the creation of cartilage defects. A trans-medullary passage-way reaching the immediate vicinity of the subchondral bone was created 4 days prior to the creation of cartilage defects. In another setting, basic fibroblast growth factor (bFGF) was administered through the trans-medullary passage-way in order to augment the stimulation of MSCs. The rabbits were killed at various times after the creation of cartilage defects. Triple staining of bromodeoxyuridine (BrdU), CD44 and CD45 and histological evaluation were subsequently performed. A considerable proportion of the proliferating cells were identified as bone-marrow-derived MSCs. Enumeration of BrdU-positive cells demonstrated that trans-medullary stimulation, especially with bFGF, increased the number of proliferating cells. The histological grading score of trans-medullary stimulation with bFGF group was superior to that of the other groups. Thus, in-advance stimulation of the bone marrow effectively increases the number of proliferating cells. The putative progenitor cells for chondrocytes stimulated thereby are likely to be recruited to the osteochondral defects at the appropriate time, contributing to the repair of full-thickness articular cartilage defects at the early follow-up time point.