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Background: Multiple knee cartilage defect treatments are available in the United States, although the cost-efficacy of these therapies in various clinical scenarios is not well understood. Purpose/Hypothesis: The purpose was to determine cost-efficacy of cartilage therapies in the United States with available mid- or long-term outcomes data. The authors hypothesized that cartilage treatment strategies currently approved for commercial use in the United States will be cost-effective, as defined by a cost <$50,000 per quality-adjusted life-year over 10 years. Study Design: Systematic review. Methods: A systematic search was performed for prospective cartilage treatment outcome studies of therapies commercially available in the United States with minimum 5-year follow-up and report of pre- and posttreatment International Knee Documentation Committee subjective scores. Cost-efficacy over 10 years was determined with Markov modeling and consideration of early reoperation or revision surgery for treatment failure. Results: Twenty-two studies were included, with available outcomes data on microfracture, osteochondral autograft, osteochondral allograft (OCA), autologous chondrocyte implantation (ACI), and matrix-induced ACI. Mean improvement in International Knee Documentation Committee subjective scores at final follow-up ranged from 17.7 for microfracture of defects >3 cm2 to 36.0 for OCA of bipolar lesions. Failure rates ranged from <5% for osteochondral autograft for defects requiring 1 or 2 plugs to 46% for OCA of bipolar defects. All treatments were cost-effective over 10 years in the baseline model if costs were increased 50% or if failure rates were increased an additional 15%. However, if efficacy was decreased by a minimum clinically important amount, then ACI (periosteal cover) of femoral condylar lesions ($51,379 per quality-adjusted life-year), OCA of bipolar lesions ($66,255) or the patella ($66,975), and microfracture of defects >3 cm2 ($127,782) became cost-ineffective over 10 years. Conclusion: Currently employed treatments for knee cartilage defects in the United States are cost-effective in most clinically acceptable applications. Microfracture is not a cost-effective initial treatment of defects >3 cm2. OCA transplantation of the patella or bipolar lesions is potentially cost-ineffective and should be used judiciously. [ABSTRACT FROM AUTHOR]

Background: The time required to develop a secondary cartilage or meniscal injury in the medial compartment after anterior cruciate ligament (ACL) injury is not well understood. Purpose: To determine the association between time delay until ACL reconstruction and the presence of medial compartment Outerbridge grade 3 or 4 chondral injury or medial meniscal tear requiring treatment. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 609 patients underwent primary ACL reconstruction at a single institution at a median 46 days between injury and surgery (61.4% male; mean age, 26.5 years [SD, 11.1]). Chondral status was graded according to Outerbridge criteria at the time of surgery. Multivariate regression analysis was used to assess the relationship between time delay until surgery and medial compartment chondral injury or meniscal injury requiring treatment. Adjustment was performed as needed for patient demographics, sporting activity, and prior knee injuries. Time until surgery had a nonlinear association with medial compartment health and was more effectively described in discrete intervals rather than as a continuous variable. The optimal time intervals to predict medial compartment health were determined by comparison of Bayes information criterion values between fully adjusted regression models. Results: After controlling for relevant confounders, delay of surgery >8 weeks had an increased likelihood of a medial meniscal tear requiring partial meniscectomy (adjusted odds ratio [aOR], 2.30; 95% CI, 1.04-5.12; P = .04) and a decreased likelihood of a meniscal tear requiring repair (aOR, 0.50; 95% CI, 0.32-0.76; P = .001). Delay of surgery >5 months had an increased likelihood of a medial Outerbridge grade ≥3 chondral defect (aOR, 3.11; 95% CI, 1.64-5.87; P = .001) or a grade 4 defect (aOR, 3.84; 95% CI, 1.75-8.45; P = .001). Conclusion: From the time of ACL injury, risk of an irreparable medial meniscal tear found at the time of ACL reconstruction is significantly increased by 8 weeks, and risk of high-grade medial chondral damage is increased by 5 months. [ABSTRACT FROM AUTHOR]

Background: Knee osteoarthritis (OA) severity on radiographs is not a reliable predictor of symptom severity. The purpose of this study was to determine whether full-thickness defects or OA grade are predictive of the progression to total knee arthroplasty in older patients without end-stage arthritis.Methods: This study included 1,319 adults aged 45 to 79 years (mean age [and standard deviation], 61.0 ± 9.2 years) who were enrolled in the Osteoarthritis Initiative, a prospective multicenter study with median 9-year follow-up data. All participants had Kellgren-Lawrence grade-0 to 3 (no to moderate) OA on bilateral radiographs; patients with grade-4 (severe) OA were excluded. The presence and total surface area of full-thickness cartilage defects on the tibia or the weight-bearing portion of the femoral condyle were determined. The risk of total knee arthroplasty due to defect presence and size as well as OA grade was determined with Cox proportional-hazards modeling after controlling for baseline variables including, but not limited to, age, sex, race, weight, knee alignment, symptom severity, quality-of-life scores, and activity level.Results: Four hundred and ninety-six patients (37.6%) had full-thickness defects. The incidence of knee arthroplasty was 0.57% per person-year for adults without a full-thickness defect and 2.15% for those with a defect. After adjusting for confounders, the presence of a full-thickness defect increased the risk of total knee arthroplasty regardless of OA grade, with higher risk demonstrated for larger (≥2 cm) defects (hazard ratio [HR] = 5.27 [95% confidence interval (CI) = 2.70 to 10.3]; p < 0.001) compared with smaller (<2 cm) defects (HR = 2.65 [95% CI = 1.60 to 4.37]; p < 0.001). Compared with nonarthritic knees (grade 0 to 1), mild arthritis (grade 2) did not increase total knee arthroplasty risk (HR = 0.71 [95% CI = 0.31 to 1.60]); moderate arthritis (grade 3) increased total knee arthroplasty risk in adults without a full-thickness defect (HR = 3.15 [95% CI = 1.34 to 7.40]; p = 0.009) but not in adults with a defect (HR = 0.64 [95% CI = 0.28 to 1.49]; p = 0.30).Conclusions: Full-thickness cartilage defects were a major determinant of future knee arthroplasty in older adults with minimal to moderate OA, even after adjusting for baseline knee symptom severity. Baseline radiographic severity grade was only associated with future total knee arthroplasty risk in the absence of a full-thickness defect.Level Of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]