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      Knee Articular Cartilage Repair and Restoration Techniques : A Review of the Literature

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          Abstract

          Context:

          Isolated chondral and osteochondral defects of the knee are a difficult clinical challenge, particularly in younger patients for whom alternatives such as partial or total knee arthroplasty are rarely advised. Numerous surgical techniques have been developed to address focal cartilage defects. Cartilage treatment strategies are characterized as palliation (eg, chondroplasty and debridement), repair (eg, drilling and microfracture [MF]), or restoration (eg, autologous chondrocyte implantation [ACI], osteochondral autograft [OAT], and osteochondral allograft [OCA]).

          Evidence Acquisition:

          PubMed was searched for treatment articles using the keywords knee, articular cartilage, and osteochondral defect, with a focus on articles published in the past 5 years.

          Study Design:

          Clinical review.

          Level of Evidence:

          Level 4.

          Results:

          In general, smaller lesions (<2 cm 2) are best treated with MF or OAT. Furthermore, OAT shows trends toward greater longevity and durability as well as improved outcomes in high-demand patients. Intermediate-size lesions (2-4 cm 2) have shown fairly equivalent treatment results using either OAT or ACI options. For larger lesions (>4 cm 2), ACI or OCA have shown the best results, with OCA being an option for large osteochondritis dissecans lesions and posttraumatic defects.

          Conclusion:

          These techniques may improve patient outcomes, though no single technique can reproduce normal hyaline cartilage.

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          Most cited references 40

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          Outcomes of microfracture for traumatic chondral defects of the knee: average 11-year follow-up.

          In this study, we measured functional outcomes of patients treated arthroscopically with microfracture for full-thickness traumatic defects of the knee. A case series of patients with 7 to 17 years' follow-up. Between 1981 and 1991, a total of 72 patients (75 knees) met the following inclusion criteria: (1) traumatic full-thickness chondral defect, (2) no meniscus or ligament injury, and (3) age 45 years and younger (range, 13 to 45 years). Seventy-one knees (95%) were available for final follow-up (range, 7 to 17 years). All patients completed self-administered questionnaires preoperatively and postoperatively. The following results were significant at the P <.05 level. Significant improvement was recorded for both Lysholm (scale 1 to 100; preoperative, 59; final follow-up, 89) and Tegner (1 to 10; preoperative, 3; final follow-up, 6) scores. At final follow-up, the SF-36 and WOMAC scores showed good to excellent results. At 7 years after surgery, 80% of the patients rated themselves as "improved." Multivariate analysis revealed that age was a predictor of functional improvement. Over the 7- to 17-year follow-up period (average, 11.3 years), patients 45 years and younger who underwent the microfracture procedure for full-thickness chondral defects, without associated meniscus or ligament pathology, showed statistically significant improvement in function and indicated that they had less pain.
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            A randomized trial comparing autologous chondrocyte implantation with microfracture. Findings at five years.

            The optimal treatment for cartilage lesions has not yet been established. The objective of this randomized trial was to compare autologous chondrocyte implantation with microfracture. This paper represents an update, with presentation of the clinical results at five years. Eighty patients who had a single chronic symptomatic cartilage defect on the femoral condyle in a stable knee without general osteoarthritis were included in the study. Forty patients were treated with autologous chondrocyte implantation, and forty were treated with microfracture. We used the International Cartilage Repair Society, Lysholm, Short Form-36, and Tegner forms to collect clinical data, and radiographs were evaluated with use of the Kellgren and Lawrence grading system. At two and five years, both groups had significant clinical improvement compared with the preoperative status. At the five-year follow-up interval, there were nine failures (23%) in both groups compared with two failures of the autologous chondrocyte implantation and one failure of the microfracture treatment at two years. Younger patients did better in both groups. We did not find a correlation between histological quality and clinical outcome. However, none of the patients with the best-quality cartilage (predominantly hyaline) at the two-year mark had a later failure. One-third of the patients in both groups had radiographic evidence of early osteoarthritis at five years. Both methods provided satisfactory results in 77% of the patients at five years. There was no significant difference in the clinical and radiographic results between the two treatment groups and no correlation between the histological findings and the clinical outcome. One-third of the patients had early radiographic signs of osteoarthritis five years after the surgery. Further long-term follow-up is needed to determine if one method is better than the other and to study the progression of osteoarthritis.
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              Autologous chondrocyte implantation compared with microfracture in the knee. A randomized trial.

              New methods have been used, with promising results, to treat full-thickness cartilage defects. The objective of the present study was to compare autologous chondrocyte implantation with microfracture in a randomized trial. We are not aware of any previous randomized studies comparing these methods. Eighty patients without general osteoarthritis who had a single symptomatic cartilage defect on the femoral condyle in a stable knee were treated with autologous chondrocyte implantation or microfracture (forty in each group). We used the International Cartilage Repair Society, Lysholm, Short Form-36 (SF-36), and Tegner forms to collect data. An independent observer performed a follow-up examination at twelve and twenty-four months. Two years postoperatively, arthroscopy with biopsy for histological evaluation was carried out. The histological evaluation was done by a pathologist and a clinical scientist, both of whom were blinded to each patient's treatment. In general, there were small differences between the two treatment groups. At two years, both groups had significant clinical improvement. According to the SF-36 physical component score at two years postoperatively, the improvement in the microfracture group was significantly better than that in the autologous chondrocyte implantation group (p = 0.004). Younger and more active patients did better in both groups. There were two failures in the autologous chondrocyte implantation group and one in the microfracture group. No serious complications were reported. Biopsy specimens were obtained from 84% of the patients, and histological evaluation of repair tissues showed no significant differences between the two groups. We did not find any association between the histological quality of the tissue and the clinical outcome according to the scores on the Lysholm or SF-36 form or the visual analog scale. Both methods had acceptable short-term clinical results. There was no significant difference in macroscopic or histological results between the two treatment groups and no association between the histological findings and the clinical outcome at the two-year time-point. Therapeutic study, Level I-1a (randomized controlled trial [significant difference]). See Instructions to Authors for a complete description of levels of evidence.
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                Author and article information

                Journal
                Sports Health
                Sports Health
                SPH
                spsph
                Sports Health
                SAGE Publications (Sage CA: Los Angeles, CA )
                1941-7381
                1941-0921
                12 October 2015
                March 2016
                1 March 2017
                : 8
                : 2
                : 153-160
                Affiliations
                []Department of Orthopaedics, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
                Author notes
                [* ]Dustin L. Richter, MD, Department of Orthopaedics, University of New Mexico Health Sciences Center, MSC 10 5600, Albuquerque, NM 87131 (email: dustin.richter1818@ 123456gmail.com ).
                Article
                10.1177_1941738115611350
                10.1177/1941738115611350
                4789925
                26502188
                © 2015 The Author(s)
                Categories
                Current Research
                Custom metadata
                March/April 2016

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