Saris, Daniël B.F.

Objective The purpose of this systematic review is to determine (1) current reported treatment options for isolated tibial plateau (TP) cartilage lesions, (2) patient reported outcomes following various treatments, and (3) complication rate and survivorship following various treatments. Design A literature search of PubMed, the Cochrane Library, and CINAHL was conducted adhering to PRISMA guidelines. Patients were included if they had TP cartilage lesions treated with surgery. Lesion characteristics, surgical procedure details, patient reported outcomes, complication, and failure rates were collected. Results Thirteen studies yielded 205 knees with TP cartilage lesions treated surgically. Ages ranged from 12 to 77 years. Surgical techniques included 138 treated with osteochondral allograft transplantation (OCA), 37 treated with osteochondral autograft transfer system (OATS), 11 treated with microfracture, 11 treated with an osteochondral scaffold, and 8 treated with autologous chondrocyte implantation (ACI). The patient-reported outcome measures were heterogeneous, but all reported improvements with the notable exception of one study evaluating microfracture. The rate of complications ranged from 0% to 4.6%. Failure rate ranged from 22% to 46% for OCA and 0% to 16% for OATS. No failures were reported for the additional techniques. Conclusions Various surgical techniques have been utilized for the treatment of TP cartilage lesions. Patient-reported outcome measures were heterogeneous, but improvements were reported following all surgical treatments except for microfracture, which resulted in decreased scores at mid-term follow-up. The complication rate was low for all techniques described. However, the failure rate was higher following unicondylar OCA for salvage treatment of posttraumatic deformities.

Objective The purpose of this systematic review was to determine (1) treatment options for bipolar cartilage lesions of the knee, (2) patient-reported outcomes following various surgical treatments, and (3) complication and failure rates following surgery. Design A literature search of PubMed, the Cochrane Library, and CINHAL was performed using PRISMA guidelines. Patients were included if they had bipolar cartilage lesions of the knee treated surgically. Lesion characteristics, surgical technique, patient-reported outcomes, complication rates, failure rates, and survivorship were recorded. Results Fourteen studies yielded 301 knees treated surgically. Patient age ranged from 15 to 74 years. Surgical techniques included 138 autologous chondrocyte implantation (ACI), 156 osteochondral allograft transplantation (OCA), and 7 osteochondral autograft transfer system (OATS). Seven studies reported a concomitant procedure rate that ranged from 0% to 88%. Eight studies reported that both reciprocal lesions received surgical treatment, while 6 studies did not specify. Lesion size ranged from 1 to 41 cm 2 . All reported postoperative improvements in patient-reported outcomes, but the measures were very heterogeneous. There were no major complications and the rate of minor complications ranged from 0% to 50%. Survivorship ranged from 40% to 100% for OCA, 76% to 95% for ACI, and 100% for the 1 study evaluating OATS. Conclusions Bipolar cartilage lesions of the knee typically involve a large surface area and are most commonly treated with ACI or OCA, while OATS may be an option for smaller lesions. Improvements in mid-term patient-reported outcomes were reported for all surgical procedures and they can be performed safely with a low rate of major complications.

Objective: To investigate the preclinical feasibility of using bio-airbrush technology for the fully arthroscopic treatment of cartilage defects with a combination of cells and biomaterials. Design: A combination of in vitro , ex vivo , and cadaveric in situ experiments was performed, to evaluate the preclinical feasibility of using bio-airbrush technology for cartilage repair. Cartilage matrix production after airbrushing cells was evaluated. Subsequently, the influence of different spray parameters on successful defect fill was studied. Finally, the surgical feasibility of using bio-airbrush technology was evaluated in situ in cadaveric knees. Results: The most important findings of the presented study are that the matrix producing capacity of the cells was not hampered by airbrushing, air pressure and defect location were important parameters to consider, and using the bio-airbrush was found to be surgically feasible in a CO 2 -insufflated arthroscopic procedure in cadaveric knees. Conclusions: Bio-airbrush using CO 2 arthroscopy would facilitate fully arthroscopic application of (cell laden) two-component in situ gelating biomaterials to cartilage defects, as a treatment for cartilage repair. This would shift the conventional procedures, which are commonly performed using a (mini-)arthrotomy, toward arthroscopy. Impact Statement This study shows that a bio-airbrush can be a clinically feasible instrument for the use in cell transplantations to repair knee cartilage defects. This technology would enable a shift from cartilage repair procedures, which are mostly performed using an arthrotomy, toward a fully arthoscopic approach. In addition, the technology presented could possibly be translated to other fields of research where controlled in situ deposition of cells is required, such as treatment of burn wounds/ulcers/others. Our research has shown that the use of an airbrush is safe, without harming cell viability and performance.

Abstract Focal cartilage defects lead to significant pain and disability, prompting the development of various options for biologic restoration of the articular surface. Although each technique and biologic implant provides various advantages and associated limitations, matrix‐induced autologous chondrocyte implantation (MACI) has gained popularity given promising long‐term results. We present a technique for the facile implantation of MACI membranes using cookie cutter instrumentation to aid in defect debridement and graft preparation. The technique described allows for efficient operative workflow while ensuring the creation of vertical, stable defect edges and a form‐fitting MACI membrane in a readily implemented fashion. Technique Video video See video under supplementary data.

Background: The lack of a standardized system for describing cell therapies acts as a barrier to advancement in clinical and basic research and practice. The aim of this study was to establish an international expert consensus on strategies to improve standardization and transparency when describing cell therapies. The secondary aim was to develop a consensus among experts on the contents of a standardized tool for describing cell therapies. Methods: The need for expert consensus on strategies to improve cell therapy communication was confirmed at the American Academy of Orthopaedic Surgeons/National Institutes of Health Optimizing Clinical Use of Biologics Symposium in 2018. A working group of 6 experts convened an international consensus process involving clinicians and basic scientists using validated Delphi methodology. This iterative process was used to define statements on communication of cell therapies and develop a standardized tool for describing cell therapies. Results: Thirty-four experts completed 3 rounds survey with use of the Delphi process. After 3 rounds, 27 statements relating to existing nomenclature, solutions to improve communication, ideal characteristics of a framework, mandatory elements of a new framework, and future work to facilitate application reached consensus with >80% agreement and <5% disagreement. Consensus was reached on the contents of a tool for improving standardization and transparency when describing cell therapies. This tool, dubbed “DOSES,” is based on the reporting of 5 core items: donor (i.e., autologous, allogeneic, xenogeneic), origin of tissue, separation from other cell types/preparation method, exhibited cell characteristics associated with behavior, and the site of delivery. Conclusions: This study has established expert consensus on the communication of cell therapies. The DOSES tool has been developed to improve standardization and transparency in describing cell therapies. Clinical Relevance: The DOSES tool for describing cell therapies can be utilized by researchers, clinicians, regulators, and industry professionals to improve standardization and transparency when describing cell therapies. The use of this tool may allow clinicians and patients to better understand the characteristics of current and future cell preparations.

AbstractBone marrow edema (BME) can be a late finding in osteoarthritis or a sign of subchondral insufficiency. The purpose of this study was to describe the magnetic resonance imaging (MRI) finding we refer to as “osteomeniscal impact edema” (OMIE), or reactive BME adjacent to a displaced meniscus flap tear. In addition, this edema pattern is compared with a control group of medial meniscus posterior root tears (MMPRT) with subchondral insufficiency edema. MRI records from 2000 to 2017 were retrospectively reviewed for studies that showed the presence of a medial meniscus displaced flap tear and an adjacent area of BME. The selected MRIs were matched to an equal number of MMPRT MRI studies. All MRI studies were assessed for cartilage surface grade using the modified Outerbridge classification system and for the extent of accompanying structural abnormalities using the whole-organ magnetic resonance imaging score. Descriptive statistics and hypothesis testing were utilized to compare the MRI findings between groups. Twenty-two flap tear (OMIE group) patients with a mean age of 57 (SD: 15) and 22 root tear (MMPRT) group patients with a mean age of 61 (SD: 10) were included. MRIs in the OMIE group showed a distinctive pattern of focal, peripheral edema adjacent to the meniscus flap tear, compared with more diffuse, central edema in the MMPRT group. Quantitatively, MRIs of the MMPRT group showed significantly worse mean femoral Outerbridge scores (3.72 vs. 2.68, p < 0.0001), more severe central (1.63 vs. 0.5, p = 0.0007) and posterior (0.31 vs. 0.0, p = 0.04) subchondral edema grades, and a higher incidence of tibial subchondral fractures (3 vs. 0, p = 0.036). Meniscus flap tears may present with a distinct MRI pattern of focal, adjacent, peripheral edema, which we refer to as OMIE. Patients with meniscus flap tears showed significantly less arthritic change, lower subchondral edema grades, and a lower incidence of insufficiency fractures and subchondral collapse compared with the diffuse overload edema pattern found with root tears. The Level of Evidence for this study is III.

Purpose: To test the technical aspects and feasibility of seeding a combination of meniscus cells isolated from a rapid digestion protocol and mesenchymal stromal cells (MSCs) (20:80 ratio) into a meniscus scaffold for the development of a one-stage arthroscopic procedure for meniscus regeneration. Methods: A cadaveric study was performed using nine fresh frozen human cadaveric knee joints. Two different arthroscopic cell-seeding methods were applied to the Collagen Meniscus Implant (CMI ® ) as carrier scaffold: either (1) seeding before arthroscopic surgical implantation of the scaffold or (2) after implantation of the scaffold. The cells were injected inside the scaffold, using fast green-stained fibrin glue as carrier, to macroscopically visualize the amount of fibrin glue. Macroscopic pictures and confocal microscopy analyses were used to determine cell distribution and viability. In addition, the DNA content in the cell-seeded scaffold was determined. In addition, different concentrations of Liberase were examined to find the optimal concentration for rapid digestion of meniscus tissue. Results: Macroscopically, seeding before implantation showed a better distribution of fast green-stained fibrin glue carrier than seeding the scaffold before surgical implantation. In addition, it resulted in significantly more cells and a better cell distribution compared with seeding the scaffold after arthroscopic implantation. Both seeding methods did not affect cell viability. After rapid digestion, 0.0125% Liberase resulted in the highest cell isolation efficiency. Conclusions: This study demonstrates that living human meniscus cells can be isolated efficiently, combined with MSCs in 20:80 ratio, and uniformly delivered into a currently available meniscus scaffold. This scaffold can then be arthroscopically implanted, creating a one-stage solution for partial meniscal deficiency. Impact Statement Meniscus injury remains the most common indication for orthopedic surgery, but loss of functioning meniscus tissue is strongly correlated with development of early osteoarthritis. However, current clinical options for tissue engineering of the meniscus are limited. This study demonstrates the feasibility of combining human meniscus cells with mesenchymal stromal cells to enhance a meniscus scaffold for meniscus regeneration in a one-stage solution for partial meniscal deficiency.

Background: The preoperative assessment of cartilage lesions is critical to surgical planning and decision making. The accurate radiographic determination of acetabular cartilage damage has remained elusive for modern imaging modalities, including magnetic resonance imaging (MRI) and magnetic resonance arthrography (MRA). While risk factors have been individually described, no multivariable system exists for predicting high-grade cartilage damage. Purpose: To determine the preoperative predictors of grade 3 to 4 acetabular labrum articular disruption (ALAD) lesions. Study Design: Case-control study; Level of evidence, 3. Cohort study (diagnosis); Level of evidence, 1. Methods: Retrievable radiographs were reviewed from primary hip arthroscopic procedures performed at 2 high-volume institutions between December 2007 and April 2017. The predictive value of demographic and radiographic factors for the intraoperative documentation of ALAD grade 3 to 4 damage was analyzed and entered into a multivariable model, and a statistically guided scoring system for the damage risk was created using the Akaike information criterion. The scoring system was then prospectively validated on 167 patients who underwent primary hip arthroscopy between April 2017 and February 2018. Results: A total of 652 primary hip arthroscopic procedures in 614 patients (390 female, 224 male; mean age, 33.2 ± 12.5 years; mean body mass index, 26.9 ± 5.5 kg/m 2 ) from 2007 to 2017 were analyzed. Male sex (odds ratio [OR], 3.11; P < .01), age ≥35 years (OR, 1.96; P < .01), cam morphology (alpha angle >55°) (OR, 2.96; P < .01), and Tönnis grade 1 to 2 (grade 1: OR, 4.14; P < .01, and grade 2: OR, 9.29; P < .01) were univariate risk factors for intraoperatively documented high-grade damage. A multivariable scoring system, the Rapidly Assessed Predictor of Intraoperative Damage (RAPID) score (0-5 points), was generated based on sex, Tönnis grade, and cam morphology. Patients with increasing RAPID scores had an increasing risk of damage, with a 10.5% risk for those with 0 points and an 88.0% risk for those with 5 points ( P < .01). The area under the curve was 0.75 for the study group and 0.76 for the validation group ( P = .94). Conclusion: While preoperative MRI has diagnostic value for hip arthroscopic surgery, the RAPID score provides added benefit as a readily employable, in-clinic system for predicting high-grade cartilage damage. The discriminatory value of the RAPID score compares favorably with previous MRI and MRA studies. This information will help the clinician and patient plan for high-grade damage and identify potential targets for cartilage treatment.

Objectives: The purpose of this study was to report long-term follow-up of skeletally immature OCD lesions treated operatively and non-operatively and determine risk factors for persistent knee pain at final follow-up. Methods: A large, geographic database of over 500,000 patients was reviewed in this case series to identify and confirm patients with OCD of the knee. Presenting radiographs and MRI were reviewed. Clinical course including operative management, persistent knee pain, and conversion to TKA were obtained and analyzed through review of clinical and operative notes. Results: 95 skeletally immature patients (70 males, 25 females) with OCD lesions diagnosed at a mean age of 13 years (range: 7-16) were followed for a mean of 14 years (range: 2-40). 53 patients (56%) were treated operatively and 42 patients (44%) were treated non-operatively. At final follow up, 13 patients with a mean age of 30 years noted persistent knee pain, 8 (15%) treated operatively versus 5 (12%) treated non-operatively. Risk factors for knee pain were female gender, patellar lesion location, and unstable lesions (Table 1). Four patients (8%) treated operatively and two (5%) treated non-operatively developed symptomatic osteoarthritis at a mean of 28.6 years following diagnosis. One patient treated operatively and two treated non-operatively converted to TKA at a mean of 37 years following diagnosis. Mean age at TKA was 52 years, significantly younger than that observed for primary TKA at our institution (p = 0.004). Conclusion: Patients with skeletally immature OCD lesions have an estimated 14% rate of persistent knee pain, 6% risk of symptomatic osteoarthritis, and 3% risk of conversion to TKA at a mean of 14 years following time of diagnosis. Female patients, patellar lesions, and unstable lesions demonstrated increased risk of persistent knee pain at final follow-up. Patients with OCD of the knee convert to TKA at a significantly younger age than that of the general primary TKA population. [Table: see text]

Objective Osteochondritis dissecans (OCD) is a knee disorder of predominately pediatric populations. Because of low incidence, it has traditionally been difficult to study OCD. The purpose of this study was to report long-term outcomes of skeletally immature OCD lesions and determine risk factors for persistent knee pain at final follow-up. Design A geographic database of more than 500,000 patients was reviewed to identify patients with knee OCD. Clinical course including operative management, persistent knee pain, and total knee arthroplasty (TKA) were analyzed through review of radiographs, magnetic resonance images, and physician notes. Results A total of 95 skeletally immature patients (70 male, 25 female, mean age 12.5 ± 2.0 years) were followed for a mean of 14 years (range, 2-40 years). Fifty-three patients were treated operatively and 42 were treated nonoperatively. At final follow-up, 13 patients noted persistent knee pain, 8 treated operatively versus 5 treated nonoperatively. Risk factors for knee pain were female gender, patellar lesions, and unstable lesions. Four patients (8%) treated operatively and 2 patients (5%) treated nonoperatively developed symptomatic osteoarthritis at a mean of 28.6 years following diagnosis. Three patients underwent TKA at a mean age of 52 years, significantly younger than that observed for primary TKA at our institution ( P = 0.004). Conclusions Skeletally immature OCD patients have promising histories, with an estimated 14% risk of persistent knee pain, 6% symptomatic osteoarthritis, and 3% conversion to TKA at 14 years’ mean follow-up. Females, patellar lesions, and unstable lesions demonstrated increased persistent knee pain risk. Patients with OCD undergo TKA at a significantly younger age than the general population.