Abstract

The Royal National Orthopaedic Hospital has completed an extensive trial of ACI versus MACI in the treatment of symptomatic osteochondral defects of the knee. A new technique has now been proposed which is quicker and easier to perform. This is the Gel-Type Autologous Chondrocyte Transplantation, CHONDRONTM. At Stanmore CHONDRON has been used for the past 17 months. Our aim was to assess the short term functional outcome of patients who have undergone CHONDRONTM using validated outcome scoring questionnaires. We retrospectively reviewed the notes of 43 patients that had undergone CHONDRONTM over one year ago and scored them using the Modified Cincinnati Score, the Visual Analogue Score and the Benltey Stanmore Functional Rating Score.

Chondral injuries of the knee are extremely common and present a unique therapeutic challenge due to the poor intrinsic healing of articular cartilage. These injuries can lead to significant functional impairment. There are several treatment modalities for articular osteochondral defects, one of which is autologous chondrocyte implantation. Our study evaluates the mid to long term functional outcomes in a cohort of 828 patients who have undergone an autologous chondrocyte implantation procedure (either ACI or MACI), identifying retrospectively factors that may influence their outcome.

The influence of factors including age, sex, presence of osteoarthritis and size and site of lesion have been assessed individually and with multivariate analysis. All patients were assessed using the Bentley Functional Score, Visual Analogue Score and the Cincinnati Functional Score. Assessment were performed pre-operatively and of their status in 2010.

The longest follow-up was 12 years (range 24 to 153 months) with a mean age of 34 years at time of procedure. The mean defect size was 409 mm² (range 64 to 2075 mm²). The distribution of lesions was 51% Medial Femoral Condyle, 12.5% Lateral Femoral Condyle, 18% Patella (single facet), 5% Patella (Multifacet) and 6% Trochlea. 4% had cartilage transplant to multiple sites.

High failure rates were noted in those with previous cartilage regenerative procedures or evidence of early osteoarthritis and those with transplantation to multiple sites.

Autologous chondrocyte implantation is an effective method of decreasing pain and increasing function, however patient selection plays clear role in the success of such procedure.

Chondral injuries of the knee are extremely common and present a unique therapeutic challenge due to the poor intrinsic healing of articular cartilage. These injuries can lead to significant functional impairment. There are several treatment modalities for articular osteochondral defects, one of which is autologous chondrocyte implantation. Our study evaluates the mid to long term functional outcomes in a cohort of 828 patients who have undergone an autologous chondrocyte implantation procedure (either ACI or MACI), identifying retrospectively factors that may influence their outcome.

The influence of factors including age, sex, presence of osteoarthritis and size and site of lesion have been assessed individually and with multivariate analysis. All patients were assessed using the Bentley Functional Score, Visual Analogue Score and the Cincinnati Functional Score. Assessment were performed pre-operatively and of their status in 2010. The majority of patients had several interim scores performed at varying intervals.

The longest follow-up was 12 years (range 24 to 153 months) with a mean age of 34 years at time of procedure. The mean defect size was 486 mm2 (range 64 to 2075 mm2). The distribution of lesions was 51% Medial Femoral Condyle, 12.5% Lateral Femoral Condyle, 18% Patella (single facet), 5% Patella (Multifacet) and 6% Trochlea. 4% had cartilage transplant to multiple sites. 30% failed following this procedure at a mean time of 72 months. 52% patients stated a marked improvement in their functional outcomes within the first two years. 49% stated an excellent result following their procedure.

High failure rate was noted in those with previous cartilage regenerative procedures, transplants occurring on the patella, particularly if involving multifacets. Multiple site cartilage transplantation was also associated with a high failure rate.

Autologous chondrocyte implantation is an effective method of decreasing pain and increasing function, however patient selection plays clear role in the success of such procedure.

The aim of this study was to determine whether the clinical outcome of autologous chondrocyte transplantation was dependent on the timing of a high tibial osteotomy in tibio-femoral mal-aligned knees. Between 2000 and 2005, forty-eight patients underwent autologous chondrocyte implantation with HTO performed at varying times relative to the second stage autologous chondrocyte implantation procedure. 24 patients had HTO performed simultaneously with their second stage cartilage transplantation, (the HTO Simultaneous Group). 5 patients had HTO prior to their cartilage procedure, (the HTO pre-ACI Group) and 19 had HTO performed between 1 to 4 years after their second stage cartilage implantation, (the HTO post-ACI Group). There were 29 men and 19 women with a mean age of 37 years (Range 28 to 50) at the time of their second stage procedure.

With average follow-up of 72 months we have demonstrated a significant functional benefit in performing the HTO either prior to or simultaneously with the ACI procedure in the mal-aligned knee. The failure rate in the Post-ACI group was 45% compared to the Pre-ACI and Simultaneous group, with failure rates of 20% and 25%, respectively.

An HTO performed prior to or simultaneously with an autologous chondrocyte implantation procedure in the mal-aligned knee, provides a significant protective effect by reducing the failure rate by approximately 50%.

Introduction

Autologous chondrocyte implantation (ACI) is contra-indicated in a joint rendered unstable by a ruptured anterior cruciate ligament (ACL). We present our experience of ACI repair with ACL reconstruction

Articular cartilage implantation (ACI) and associated procedures (MACI = Matrix-assisted cartilage implantation) are now established treatments for osteochondral defects in the knee. The quality of repair in terms of histological appearance is frequently not known, whilst the correlation of histology results with functional outcomes remains undefined. Histological data of the quality of the repair tissue is sparse and a precise classification proved difficult.

This was a single-centre, prospective study. Over 12 years (1998-2010) 406 patients that underwent articular cartilage implantation procedures at our institution (ACI = 170, MACI = 205) had biopsies taken at the 1-2 year interval, in order to assess whether these contained ‘hyaline-like’ cartilage, ‘mixed hyaline-like with fibrocartilage’, fibrocartilage or fibrous tissue alone.

Histological sections of the biopsies were prepared and stained with haematoxylin, eosin and proteoglycan stains and viewed under polarised light. All biopsies were studied by a single histopathologist in a specialist, dedicated musculoskeletal laboratory.

All patients were assessed by the Cincinnati, Bentley and Visual Analogue scores both pre-operatively and at the time of the review.

The findings revealed that 56 patients healed with ‘hyaline-like’ cartilage (14.9%), 103 with ‘mixed’ (27.5%), 179 with fibrocartilage (47.7%) and 37 with fibrous tissue (9.9%).

These findings showed that 42.4% of defects were filled with ‘hyaline-like’ or ‘mixed’ cartilage, with 70% of these achieving a ‘fair’ to ‘excellent’ functional outcome. This was also observed in the fibrocartilage group, where 72% achieved similar results. Predictably 89% of the patients that healed by fibrous tissue had a poor functional outcome.

This study shows that 71% of patients whose osteochondral defects healed by either ‘hyaline-like’, ‘mixed’ or fibrocartilage experienced an improvement in the function. In contrast, only 11% of the patients whose defects filled with fibrous tissue, showed some functional improvement. Additionally, this data indicates the advantage of biopsies in assessing the overall results of cartilage implantation procedures.

Patients with osteochondrodysplasia frequently require Total Hip Arthroplasty at a younger age, as a result of early degenerative disease of the hip joint. The outcome of Modular Total Hip Arthroplasty in this group of patients has been reported previously. In this retrospective study we evaluated the outcome of custom made (CADCAM) Total Hip Arthroplasty in patients with osteochondrodysplasia.

Between 1974 and 2009, twenty one CADCAM Total Hip Arthroplasty procedures were performed in fourteen patients in our institution. There were eight female and six male patients, with the mean age at time of surgery of 40.95 years (20 to 78). The patients were followed up clinically and with the Harris hip score for a mean of 7.12 years (0.5 to 17 years).

Four of the twenty-one hips (23.8%) required revision surgery at a mean of 11.54 years (6.5 to 17 years); one required it for aseptic loosening of the femoral component; one required complete revision of the acetabular component; one required exchange of acetabular liner; and one was for symptomatic non-union of a lesser trochanter avulsion.

This study shows encouraging clinical outcomes of custom made (CADCAM) Total Hip Arthroplasty in patients with osteochondrodysplasia,

Purpose

The rate of arthroplasty or osteotomy in patients who had undergone autologous chondrocyte implantation (ACI) for osteochondral defects in the knee was determined. Furthermore, we investigated whether any radiographic evidence of osteoarthritis (OA) prior to ACI was associated with poorer outcome following surgery.

Introduction

We report the initial 2 and 3 year follow-up results of this randomised controlled trial of autologous chondrocyte implantation (ACI) using porcine-derived collagen membrane as a cover (ACI-C) versus matrix-carried autologous chondrocyte implantation (MACI) for the treatment of osteochondral defects of the knee.

Aims

To investigate (1) The relationship between macroscopic grading and durability of cartilage repair following collagen-covered autologous chondrocyte implantation (ACI-C) in the knee; (2) The influence of histology on durability of cartilage repair; (3) The relationship between macroscopic appearance and histology of repair tissue.

The results for autologous chondrocyte implantation (ACI) in the treatment of osteochondral defects in the knee are encouraging. At present, two techniques have been described to retain the chondrocyte suspension within the defect. The first involves using a periosteal flap harvested from the distal femur and the second involves using a type I/III collagen membrane. To the authors' knowledge there are no comparative studies of these two techniques in the current literature.

A total of 68 patients with a mean age of 30.52 years (range 15 to 52 years) with symptomatic articular cartilage defects were randomised to have either ACI with a periosteal cover (33 patients) or ACI with a type I/III collagen cover (35 patients). The mean defect size was 4.54 cm² (range 1 to 12 cm²). All patients were followed up at 24 months.

A functional assessment using the Modified Cincinnati score showed that 74% of patients had a good or excellent result following the ACI with collagen cover compared with 67% after the ACI with periosteum cover at 2 years (p>0.05). Arthroscopy at 1 year also demonstrated similar results for both techniques. However, 36.4% of the periosteum covered grafts required shaving for hypertrophy compared with 1 patient for the collagen covered technique.

This prospective, randomised study has shown no statistical difference between the clinical outcome of ACI with a periosteal cover versus ACI with a collagen cover at 2 years. A significant number of patients who had the ACI with periosteum technique required shaving of a hypertrophied graft within the first year of surgery. We conclude that there is no advantage in using periosteum as a cover for retaining the chondrocytes within an osteochondral defect; as a result we advocate the use of an alternative cover such as a porcine-derived, type I/III collagen membrane.

Purpose

We report on minimum 2 year follow-up results of 71 patients randomised to autologous chondrocyte implantation (ACI) using porcine-derived collagen membrane as a cover (ACI-C) and matrix-induced autologous chondrocyte implantation (MACI) for the treatment of osteochondral defects of the knee.

Autologous chondrocyte implantation (ACII) has been shown to have favourable results in the treatment of symptomatic chondral and osteochondral lesions. However, there are few reports on the outcomes of this technique in adolescents.

The aim was to assess functional outcome and pain relief in adolescents undergoing autologous chondrocyte implantation (ACI).

Thirty-one adolescent patients undergoing ACI or Matrix-assisted chondrocyte implantation (MACI) were identified from a larger prospective study. Mean age was 16.3 years (range 14 – 18) with a mean follow-up of 66.3 months (12–126 months).

There were 22 males and nine females. All patients were symptomatic; 30 had isolated lesions and one had multiple lesions. Patients were assessed pre and postoperatively using the Visual Analogue Score (VAS), the Stanmore/Bentley Functional Rating Score and the Modified Cincinnati Rating System.

The mean VAS improved from 5.8 pre-operatively to 2 post-operatively. The Stanmore/Bentley Functional Rating Score improved from 2.9 to 0.9 whilst the Modified Cincinnati Rating System improved from 49.8 pre-operatively to 81.3 postoperatively with 87% of patients achieving excellent or good results. All postoperative scores exhibited statistically significant improvement from pre-operative scores.

The results show that, in this particular group of patients, this procedure produces reduction in pain and a statistically significant improvement in function postoperatively. We strongly recommend this procedure in the management of adolescents with symptomatic chondral defects.

High Tibial Osteotomy (HTO) is a recognised method of correction for knee joint malalignment and unicom-partmental osteoarthritis. Long-term results of this technique have been reported and are favourable. Good results have also been reported with Autologous Chondrocyte Implantation (ACI-C, MACI). Malalignment, if present, should be corrected when ACI is performed. Although results have been reported for either procedure separately, the outcomes of combined HTO-ACI remain unreported. The aim of this study was to evaluate functional outcome in patients undergoing combined HTO-ACI procedures.

Twenty three patients undergoing a combined ACI-HTO procedure were identified retrospectively from a larger trial of patients undergoing ACI for symptomatic chondral defects. The mean age of the patients was 36 (28 – 49). The mean follow-up was 54 months (12 – 108) and mean defect size was 689mm2 (range 350 – 1200). Nine patients had ACI-C and HTO, the remainder having MACI and HTO. Pre and post-operative assessment was carried out using the Visual Analogue Score (VAS), the Bentley Functional Rating Score and the Modified Cincinnati Rating System.

The Mean VAS score improved from 7.4 (4 – 10) pre-operatively to 2.9 (0 – 6) post-operatively at the latest follow-up (p< 0.0001). The Bentley Functional Rating Score improved from 2.9 (2 – 4) to 1.8 (0 – 4), which was statistically significant (p< 0.0001). The Modified Cincinnati Rating System improved from 35.2 (20 – 49) pre-operatively to 68.7 (46 – 85) post-operatively (p< 0.0001). Fourteen patients underwent biopsy of the graft site at a mean of 13.7 months: 21% of biopsies were hyaline-like cartilage, 36% were mixed hyaline/fibrocartilage, 29 % were fibrocartilage and 14% were fibrous tissue.

Combining high tibial osteotomy with autologous chondrocyte implantation is an effective method of decreasing pain and increasing function in the short term. Further evaluation of this procedure is required.

Introduction: Autologous Chondrocyte Implantation (ACI) is a treatment option for symptomatic, full-thickness chondral/osteochondral injuries. Goals of surgery and rehabilitation include replacement of damaged cartilage with hyaline/hyaline-like cartilage, leading eventually to improved level of function. Intermediate and long-term results are promising in terms of functional improvement.

Purpose: To explore the hypothesis that non-hyaline cartilage repair tissue is associated with worse functional outcome and to assess whether the quality of the repair tissue formed following ACI improves with time post-surgery.

Methods and Results: Two hundred and forty eight patients who underwent ACI at our institution were studied, having had post-implantation biopsies of the repair tissue. Mean timing of biopsy was 14.8 months (range 3–55). 59 biopsies showed hyaline tissue (24%), 67 mixed hyaline and fibrocartilage (27%), 113 biopsies were fibrocartilage only (46%) and 9 patients had a fibrous tissue biopsy result (9%). 126 patients (51%) had hyaline tissue in the regenerate and demonstrated a mean Modified Cincinnati Rating Score (MCRS) of 84 and a mean Lysholm Score of 88 at last follow-up (Group 1). 122 patients (49%) had no hyaline tissue in the regenerate and scored a mean MCRS of 71 and a mean Lysholm Score of 73 (Group 2). Both Groups 1 and 2 demonstrated a statistically significant improvement in functional outcome between pre and post-operative scores (p< 0.0001). There was significant difference in post-operative scores between Groups 1 and 2 suggesting that presence of hyaline tissue in the regenerate is associated with improved functional outcome (p< 0.05). Finally, our statistical analysis suggested that if time post-implantation doubles, then the likelihood of a favourable histological outcome increases significantly.

Conclusion: ACI forms a durable repair tissue that remodels and continues to improve in quality with time. Poor functional outcome may reflect the presence of a non-hyaline cartilage repair tissue.

Introduction: Autologous chondrocyte implantation (ACI) has been used to treat patella cartilage lesions but several studies have indicated poorer results compared to lesions on the femoral condyles. This paper investigates the effectiveness of two different methods of ACI; porcine-derived collagen membrane as a cover (ACI-C) and matrix-carried autologous chondrocyte implantation (MACI).

Methods: 124 patients (mean age 33.5) with symptomatic osteochondral lesions in the patella were selected to undergo either ACI (56 patients) or MACI (68 patients). 1 year following surgery patients underwent check arthroscopy to assess the graft. Functional assessment was performed pre-operatively, at 6 months and yearly by using the modified Cincinnati score (MCS).

Results: 37.5% of patients experienced good or excellent clinical results according to the MCS in the ACI group compared with 69.2% in the MACI group (p = 0.0011). The mean MCS improved from 43.7 pre-operatively to 49.8 2 years following surgery in the ACI group, whereas in the MACI group the improvement was from 44.6 to 60.6 (p=0.07). Arthroscopic assessment showed a good to excellent International Cartilage Repair Society score in 89.7% of ACI-C grafts and 69.6% of MACI grafts (p = 0.08). There was a higher re-operation rate (p = 0.044) in the ACI group (29%) compared with MACI (10%).

Conclusions: The results from this paper suggest that MACI is more successful in the treatment of patella cartilage lesions than ACI even though arthroscopic assessment showed the converse to be true. The higher complication and re-operation rate suggests that we should be treating such patients with MACI.

High tibial osteotomy (HTO) is a recognised method of correction for knee joint malalignment and unicompartmental osteoarthritis. The long term results of this technique have been reported and are favourable. Autologous chondrocyte implantation (ACI-C, MACI) has also been reported to have good results It is advised that malalignment, if present, should be corrected if ACI is to be performed. Although results have been reported for either procedure separately, the outcomes of combined HTO-ACI remain unreported.

To evaluate functional outcome in a group of patients undergoing combined HTO-ACI procedures.

Twenty three patients undergoing a combined ACI-HTO procedure were identified retrospectively from a larger trial of patients undergoing ACI for symptomatic chondral defects. The mean follow-up was 54 months (range 12 – 108) and the mean defect size was 689 mm2 (range 350 – 1200). Nine patients had ACI-C and HTO, the remainder having MACI and HTO. Pre and postoperative assessment was carried out using the Visual Analogue Score (VAS), the Bentley Functional Rating Score and the Modified Cincinnati Rating System.

The Mean VAS score improved from 7.4 pre-operatively to 2.9 post-operatively (p< 0.0001). The Bentley Functional Rating Score improved from 2.9 to 1.8 (p< 0.0001) whilst the Modified Cincinnati Rating System improved from 35.2 pre-operatively to 68.7 post-operatively (p< 0.0001). There was no significant difference between ACI-C and MACI. Two patients developed a non union at a mean of 13 months and a further two patients had a failure of the chondrocyte graft at a mean of 22.5 months.

Combining high tibial osteotomy with autologous chondrocyte implantation is an effective method of decreasing pain and increasing function at mean of 54 months follow-up. Further follow-up is required to assess the long term outcomes of these combined procedures.

Introduction: Autologous Chondrocyte Implantation (ACI) is a treatment option for full-thickness chondral, or osteochondral injuries that are painful and debilitating. Goals of surgery and rehabilitation include replacement of damaged cartilage with hyaline or hyaline-like cartilage, leading eventually to improved level of function. Intermediate and long-term results are promising in terms of functional and clinical improvement.

Purpose: To explore the hypothesis that the quality of the repair tissue, formed following Autologous Chondrocyte Implantation (ACI), improves with time post-surgery.

Methods and Results: Two hundred and forty eight patients who underwent autologous chondrocyte implantation in our institution were studied after having had post implantation biopsies of the repair tissue. Mean timing of biopsy was 14.8 months (range 3–55). 59 biopsies gave hyaline tissue (24%), 67 mixed hyaline and fibrocartilage (27%), 113 biopsies were fibrocartilage only (46%) and 9 patients had a fibrous tissue biopsy result (9%). Due to NHS restraints and waiting list targets biopsies were actually performed at various time points post implantation allowing us to statistically correlate histological findings with the maturity of the repair tissue.

Our statistical analysis suggests that if time post implantation doubles then the likelihood of a favourable histological outcome increases significantly.

Conclusion: Autologous chondrocyte implantation forms a durable repair tissue that remodels and continues to improve in quality with time. It is recommended that for future research/study purposes 24 months is used as an optimal time to look at histology, since our data show that outcome is still improving until this point.

Introduction: Initial results for the management of osteochondral defects with both ACI-C and MACI have been encouraging, showing significant clinical improvement. This single-centre study set out to determine any significant difference in outcomes between ACI-C and MACI.

Aim: Reporting three year follow up of clinical and arthroscopic assessment of prospective analysis of ACI-C and MACI used in the management of symptomatic, full-thickness chondral and osteochondral defects in the knee.

Method: Following assessment arthroscopy and harvesting of chondrocytes for culture, patients were randomised into the ACI-C or MACI arm and underwent their respective procedures one month later. In ACI-C a covered technique is employed using a porcine-derived type I/III collagen membrane sutured in place; MACI requires cultured autologous chondrocytes to be seeded in a bi-layered type I/III collagen membrane which is glued into position. An arthroscopy was performed at 12 and 24 months postprocedure to assess graft coverage and biopsies taken to determine extent of hyaline, mixed and fibro-cartilage proliferation.

Results: 102 patients underwent either ACI-C (44) or MACI (58) with an average age of 33.6 (14–52). Mean Cincinnati knee rating scores recorded prior to assessment arthroscopy for ACI-C: 45.2 (10 – 94) and MACI: 45.5 (10 – 90) showed improvement at follow up with 63% of patients in the ACI-C group scoring good or excellent at three years, and 60% in the MACI group. ICRS arthroscopy scores were good or excellent in 91.4% of ACI-C and 76.1% of MACI patients at 24 months. Biopsies of the transplants at 24 months revealed proliferation of hyaline and mixed cartilage (hyaline and fibro-cartilage) in 48.6% of the ACI-C and 30.5% of the MACI patients.

Conclusion: Results to date suggest significant clinical and arthroscopic improvement following ACI-C and MACI, with evidence of proliferation of hyaline cartilage at the transplant site. Limited differences are noted between the outcomes of the two techniques.