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Objective: To investigate intermediate-term clinical results in patients with concomitant anterior cruciate ligament (ACL) reconstruction and chondral defect treated with high-density autologous chondrocyte implantation (HD-ACI) compared to patients without ACL tear but with a chondral lesion and HD-ACI treatment., Design: Forty-eight patients with focal chondral lesions underwent HD-ACI (24 with ACL reconstruction after an ACL injury and 24 with an intact ACL). Follow-up assessments occurred at 6, 12, and 24 months. Patient-reported knee function and symptoms were assessed using the International Knee Documentation Committee (IKDC) questionnaire, pain was measured using the Visual Analog Scale (VAS), and adverse events were monitored. Physical activity was assessed using the Tegner Activity Level Scale, and cartilage healing was evaluated with the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score., Results: No significant adverse events occurred during follow-up. Both groups showed significant improvements at 2 years compared to baseline (VAS: 8.0 ± 1.3 to 1.4 ± 2.0 [normal ACL]; 7.4 ± 2.3 to 2.1 ± 2.3 [ACL reconstruction]; IKDC: 39.2 ± 10.6 to 76.1 ± 22.0 [intact ACL]; 35.6 ± 12.1 to 74.6 ± 20.9 [ACL reconstruction]). Patients in both groups exceeded the minimal clinically important difference (MCID) for IKDC scores. The Tegner Activity Level Scale decreased immediately after surgery and increased after 2 years, with 70.6% (normal ACL) and 89.5% (ACL reconstruction) returning to their preinjury activity levels. No significant differences in the MOCART score were observed between the groups., Conclusions: ACL reconstruction does not appear to reduce the outcomes (at 2 years) of HD-ACI., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: Treatment strategies for osteochondral defects, for which particulated autologous cartilage transplantation (PACT) is an emerging treatment strategy, aim to restore the structure and function of the hyaline cartilage. Herein, we compared the efficacy of PACT with control or human transforming growth factor-β (rhTGF-β), and clarified the necessity of bone graft (BG) with PACT to treat shallow osteochondral defects in a porcine model., Design: Two skeletally mature male micropigs received 4 osteochondral defects in each knee. The 16 defects were randomized to (1) empty control, (2) PACT, (3) PACT with BG, or (4) rhTGF-β. Animals were euthanized after 2 months and histomorphometry, immunofluorescence analysis, semiquantitative evaluation (O'Driscoll score), and magnetic resonance observation of cartilage repair tissue (MOCART) score were performed., Results: Hyaline cartilages, glycosaminoglycan synthesis, and collagen type II staining were more abundant in the PACT than in the control and rhTGF-β groups. The O'Driscoll score was significantly different between groups ( P < 0.001), with both PACT groups showing superiority ( P = 0.002). PACT had the highest score ( P = 0.002), with improved restoration of subchondral bone compared with PACT with BG. The MOCART score showed significant differences between groups ( P = 0.021); MOCART and O'Driscoll scores showed high correlation (r = 0.847, P < 0.001)., Conclusion: Treatment of osteochondral defects with PACT improved tissue quality compared with that with control or rhTGF-β in a porcine model. BG, in addition to PACT, may be unnecessary for shallow osteochondral defects. Clinical Relevance. BG may not be necessary while performing PACT., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: This study aimed to review the clinical, radiographic, and magnetic resonance imaging (MRI) outcomes of osteochondral autograft transplantation applied to patellar cartilage lesions of patients under 18 years of age., Methods: Data from nine consecutive patients were retrospectively analyzed for indications, preoperative complications, and clinical-radiographic outcomes. Patients were clinically evaluated using the Pedi-IKDC and Lysholm scores. In addition, return to sports and knee pain were assessed. MRI evaluation included an analysis of osteochondral graft integration using the magnetic resonance observation of cartilage repair tissue 2.0 score and radiographic classification of osteoarthritis using the Kellgren-Lawrence system., Results: Nine patients (9 knees, 6 males) with a mean age of 14 years (SD: 1.7, range; 11 to 17 y) were analyzed. Lesions were located on the medial facet (N=5), lateral facet (N=3), and central ridge of the patella (N=1). One or 2 cylindrical osteochondral grafts were transplanted, with a median diameter of 9 mm (range: 8 to 10 mm). The average lesion size was 102.9 mm 2 . At a mean follow-up of 45.1 months (range: 23 to 117 mo), the mean Pedi-IKDC score was 89.2 (SD: 9.8), and the Lysholm score was 94.4 (SD: 4.8). Patients returned to sports in an average of 7.3 months (SD: 2, range: 6 to 12 mo). MRI of 8 patients showed osteochondral graft integration with a mean magnetic resonance observation of cartilage repair tissue 2.0 score of 86.9 (SD: 7, range: 80 to 100). Six knees showed Kellgren-Lawrence grade 0 joint space on radiographs, and 3 showed grade 1. Eight patients were asymptomatic at the last follow-up, and 1 reported occasional mild pain with intense physical activity. One patient developed arthrofibrosis, requiring arthroscopic lysis of adhesions and manipulation., Conclusion: Osteochondral autograft transplantation is a safe and effective technique for treating symptomatic patellar full-thickness chondral lesions in adolescents. Long-term follow-up studies will determine whether the affected area maintains structural and functional integrity over time., Level of Evidence: Level IV-therapeutic study., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To systematically review the literature and analyze clinical outcomes and return-to-sport after surgical management of cartilage injuries in football players., Design: A systematic literature review was performed in August 2023 on PubMed, WebOfScience, and Cochrane Library to collect studies on surgical strategies for cartilage lesions in football players. Methodological quality and risk of bias were assessed with the modified Coleman Methodology score and RoB2 and RoBANS2 tools., Results: Fifteen studies on 409 football players (86% men, 14% women) were included: nine prospective and two retrospective case series, one randomized controlled trial, one prospective comparative study, one case report, and one survey. Bone marrow stimulation (BMS) techniques were the most documented. The lesion size influenced the treatment choice: debridement was used for small lesions (1.1 cm 2 ), BMS, osteochondral autograft transplantation (OAT), matrix-assisted autologous chondrocytes transplantation (MACT), and scaffold-augmented BMS for small/mid-size lesions (2.2-3.0 cm 2 ), and autologous chondrocytes implantation (ACI) for larger lesions (5.8 cm 2 ). The surgical options yielded different results in terms of clinical outcome and return-to-sport, with fastest recovery for debridement and scaffold-augmented BMS. The current evidence is limited with large methodological quality variation (modified Coleman Methodology score 43.5/100) and a high risk of bias., Conclusions: Decision-making in cartilage injuries seems to privilege early return-to-sport, making debridement and microfractures the most used techniques. The lesion size influences the treatment choice. However, the current evidence is limited. Further studies are needed to confirm these findings and establish a case-based approach to treat cartilage injuries in football players based on the specific patient and lesion characteristics and the treatments' potential in terms of both return-to-sport and long-term results., Level of Evidence: Systematic review, level IV., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: The primary aim is to evaluate the relationship between MOCART scores and patient satisfaction, as evaluated by achievement of (1) the Patient Acceptable Symptomatic State (PASS) and (2) the minimal clinically important difference (MCID) for Knee Injury and Osteoarthritis Score Quality of Life (KOOS QoL), for patients undergoing autologous chondrocyte implantation (ACI) for focal Grade IV patellofemoral chondral defects. The secondary aim is to determine the threshold MOCART score which predicts the ability to meet the PASS and the MCID for KOOS QoL., Methods: Patients undergoing ACI for grade IV patellofemoral chondral defects by a single surgeon from 2017 to 2020 were identified by search of the EMR. To determine PASS status, patients were asked, "Do you consider your current level of symptoms to be acceptable?" KOOS QoL scores were also collected. Patients with 6-month postoperative knee MRI, PASS scores, and minimum 2-year follow-up data were included. Paired t tests and Wilcoxon Rank-Sum tests were used to evaluate the relationship between MOCART scores and (1) PASS achievement and (2) achievement of the MCID for KOOS QoL (12.8)., Results: Thirty-four patients were included, with a median age of 35.1 years [IQR: 24.6, 37.1], and BMI of 24.0 kg/m 2 [IQR: 21.5, 28.1]. The median time to postoperative MRI was 6.7 months [IQR: 5.8, 7.9], and average follow-up time was 3.7 ± 1.2 years. Twenty-five patients (74%) achieved PASS, and 18 patients (out of 27 who had postop KOOS QoL Scores, 67%) achieved the MCID for KOOS QoL. Patients who achieved PASS had higher average MOCART scores (61.8 ± 16.0) than those who did not achieve PASS (45.0 ± 12.8, p=0.011), whereas patients who achieved the MCID for KOOS QoL did not have higher MOCART scores than those who did not achieve the MCID (61.9 ± 18.3 versus 53.3 ± 17.1, P = 0.25). There was no relationship between age, sex, lesion size, and lesion location and ability to achieve PASS or MCID for KOOS QoL (p>0.05). A threshold MOCART value of 55 was associated with the highest AUC on ROC analysis for likelihood of achieving PASS (0.778) and MCID for KOOS QoL (0.667)., Conclusion: Higher MOCART scores are associated with an increased likelihood of achieving PASS following patellofemoral ACI. Moreover, MOCART scores > 55 predict the ability to achieve PASS and the MCID for KOOS QoL following patellofemoral ACI., Level of Evidence: IV., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objectives: The aim of this study is to evaluate the relationship between the achievement of clinically significant improvement in patient-reported outcome measures (PROMs) and the postoperative magnetic resonance image (MRI) appearance of matrix-associated chondrocyte implantation (MACI), in conjunction with patellofemoral realignment procedures, for the treatment of grade-IV chondral defects about the patellofemoral joint., Methods: A retrospective review of patients undergoing MACI for grade-IV chondral defects of the patella or trochlea by a single sports-medicine-fellowship-trained surgeon from 2017 to 2020 was performed. Concomitant realignment procedures, including tibial tubercle osteotomy and medial patellofemoral ligament reconstruction, were also performed as needed. Patients with preoperative and minimum 1-year postoperative PROMs and postoperative knee MRI were included. MRI scans were obtained at 6.3 (interquartile range: 5.8, 7.5) months postoperatively. A fellowship-trained musculoskeletal radiologist assigned a Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score (range: 0-100, with 100 equating to complete graft healing) to each MRI. Achievement of the minimal clinically important difference (MCID) for International Knee Documentation Committee (IKDC), Knee Injury and Osteoarthritis Score-Quality of Life, and Kujala scores were determined for each patient. Paired t-tests or Wilcoxon rank-sum tests were used to evaluate for an association between achievement of the MCID for each PROM and MOCART score. The average follow-up time and time from surgery to PROMs were 2.7 ​± ​1.5 years and 1.7 ​± ​0.66 years, respectively., Results: Thirty patients were included. There was a significant improvement in all PROMs from preoperative to postoperative (p ​< ​0.001). More than two-thirds of patients achieved the MCID for each PROM. Patients who achieved the MCID for IKDC had significantly higher MOCART scores (66.5 ​± ​16.2) than those who did not meet the MCID for IKDC (50.6 ​± ​23.6, p ​= ​0.043)., Conclusion: MACI for the treatment of patellofemoral chondral injuries is associated with clinically significant improvement in PROMs at short-term follow-up. Clinically significant improvements in IKDC scores are associated with a more mature MRI appearance of the autologous chondrocyte implantation graft on postoperative MRI, as indicated by higher MOCART scores., Level of Evidence: IV-Case Series., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Sabrina Strickland reports a relationship with Smith and Nephew Inc that includes consulting or advisory, speaking and lecture fees, and travel reimbursement. Sabrina Strickland reports a relationship with Vericel Corporation that includes consulting or advisory and speaking and lecture fees. Additional disclosures for senior author SS: Pacira Therapeutics, Inc. Food and Beverage Smith ​+ ​Nephew, Inc. Food and Beverage ORGANOGENESIS INC. Food and Beverage Engage Uni, LLC Gift DePuy Synthes Sales Inc. Food and Beverage Miach Orthopedics, Inc. Food and Beverage Bioventus LLC Food and Beverage Linvatec Corporation Food and Beverage Miach Orthopaedics Inc. Consulting Fees. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Andreas Gomoll reports a relationship with Vericel Corporation that includes consulting or advisory fees. Andreas Gomoll reports a relationship with Bioventus LLC that includes consulting or advisory fees. Andreas Gomoll reports a relationship with Organogenesis, Inc that includes consulting or advisory fees. Andreas Gomoll reports a relationship with Smith and Nephew Inc that includes consulting or advisory fees. Andreas Gomoll reports a relationship with Joint Restoration Foundation, Inc that includes consulting or advisory fees. Andreas Gomoll reports a relationship with Flexion Therapeutics, Inc that includes consulting or advisory fees. Andreas Gomoll receives hospitality payments from the following Bioventus, LLC, Organogenesis, Inc, Smith and Newphew Inc, Pacira Therapeutics, Flexion Therapeutics, Inc, Aesculap Biologics, LLC. Andreas Gomoll receives payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events for the following: Pacira Therapeutics, Linvatec Corporation, Fidia Pharma USA Inc. Andreas Gomoll has royalty or license for Organogenesis, Inc, and Moximed, Inc., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Gel-based autologous chondrocyte implantation (GACI) enables a simpler and more effective delivery of chondrocytes with reproducible three-dimensional structural restoration of the articular cartilage surface. There is limited documentation of medium-term outcomes. This study assessed safety and effectiveness of GACI for treatment of cartilage defects of the knee., Methods: This multicentric retrospective study was conducted across eight hospitals in India. Patients who had undergone GACI (CARTIGROW®) between 2008 and 2014 for the treatment of focal articular cartilage defects of the knee (mean defect size 4.5 ± 5.8 cm 2 ) in limbs with normal alignment were analyzed. Primary outcomes were changes in Lysholm Knee Scoring Scale score, and Knee Outcome Sports Activity Scale (SAS)., Results: A total of 107 patients (110 knee joints) with mean age 31.0 ± 10.5 years were included. The mean follow-up was 9.8 ± 1.5 years (range 7.85-13.43). Majority had osteochondritis dissecans (n = 51; 46.4%). The mean Lysholm Knee Scoring Scale score (81.23 ± 13.21 vs. 51.32 ± 17.89; p < 0.0001) and SAS score (80.93 ± 8.26 vs. 28.11 ± 12.28; p < 0.0001) improved significantly at follow-up as compared to pre-operative. Magnetic Resonance Observation of Cartilage Repair Tissue score in 39 patients at minimum 2 years follow-up was 84.5 ± 4.3. Among 30 patients who were playing sports before treatment, 17 patients (56.7%) could return to the same or higher level of sports post-transplantation. No major intra-operative or post-operative complications were noted. Four patients warranted revision surgery., Conclusion: GACI is an effective treatment option for large focal articular cartilage defects of the knee with a low complication rate and revision rate and significant improvement in functional scores., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Purpose: Autologous matrix-induced chondrogenesis (AMIC ® ) and microfracture are established treatments for focal chondral defects in the knee, but there are little clinical data concerning these procedures over the long term. This study evaluates the outcomes of AMIC ® compared to microfracture over 10-year follow-up., Methods: Forty-seven patients were randomized and treated either with MFx (n = 13), sutured AMIC ® (n = 17) or glued AMIC ® (n = 17) in a prospective, randomized, controlled multicentre trial. The Modified Cincinnati Knee Score, a visual analogue scale for pain and MOCART score were used to assess outcomes over 10 years post-operatively., Results: All treatment arms improved in the first 2 years, but a progressive and significant deterioration in scores was observed in the MFx group, while both AMIC ® groups remained stable. MOCART scores were comparable between groups., Conclusion: The AMIC ® procedure results in improved patient outcomes in comparison with microfracture up to 10 years following surgery for the repair of focal chondral defects in the knee., Clinicaltrials: gov Identifier: NCT02993510., (© 2024. The Author(s).)

Objective: We aimed to evaluate the outcomes, survivorship, and complications following multi-surface cartilage procedures at minimum 2-year follow-up., Design: Patients with either (1) single-surface osteochondral allograft transplantation (OCAT) with third-generation matrix-induced autologous cultured chondrocyte implantation (MACI) or particulated juvenile cartilage implantation (DeNovo), or (2) multiple-surface OCAT ± associated MACI/DeNovo procedures for grade IV chondral or osteochondral defects about the knee with minimum 2-year follow-up were analyzed. Patient-reported outcome measures (PROMs), including International Knee Documentation Committee (IKDC) and Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales, were obtained preoperatively and at minimum 2 years postoperatively. The percentage of patients who met the minimal clinically important difference (MCID) for each PROM was reported. Failure was defined as revision OCAT, conversion to patellofemoral/total/unicompartmental joint arthroplasty, or Arthrosurface HemiCAP placement., Results: Of 257 patients identified, 35 were included. There was a significant increase in IKDC, KOOS-pain, KOOS-symptom, KOOS-sport, and KOOS-quality of life scores from preoperative to postoperative evaluation ( P < 0.03 for all). More than 50% of patients met the MCID for each PROM. There were 2 failures, 1 of the patella and 1 of the medial femoral condyle, at 39.7 and 38.6 months postoperatively, respectively., Discussion: Multi-surface cartilage procedures are a safe, efficacious treatment option for multifocal cartilage defects about the knee at short-term follow-up., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: Realignment osteotomy performed concomitantly with cartilage restoration typically requires early restricted weightbearing and can add significant morbidity, potentially leading to an increased risk of early perioperative complications. The purpose of this study was to compare the 30-day complication rates after isolated cartilage restoration (ICR) versus concomitant cartilage restoration and osteotomy (CRO) using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database., Design: NSQIP registries between 2006 and 2019 were queried using Current Procedural Terminology codes to identify patients undergoing ICR (autologous chondrocyte implantation, osteochondral autograft transfer, or osteochondral allograft transplantation) and CRO (with concomitant high tibial osteotomy, distal femoral osteotomy, and/or tibial tubercle osteotomy). Complications rates between treatment groups were compared using multivariate logistic regression analyses adjusted for sex, age, steroid use, and respiratory status., Results: A total of 773 ICR and 97 CRO surgical procedures were identified. Mean patient ages were 35.9 years for the ICR group and 31.2 years for the CRO group. Operative time was significantly longer in the CRO group (170.8 min) compared with the ICR group (97.8 min). Multivariate analysis demonstrated no significant differences in rates of PE, VTE, and all-cause readmission between the ICR and CRO groups. No events of wound disruption, SSI and reoperation were found in the CRO group, while the ICR group was characterized by low rates of wound disruption, reoperation, and SSI (<1.1%)., Conclusions: These findings further support concomitant osteotomy with cartilage restoration when appropriate and aid surgeons in the preoperative counseling of patients undergoing cartilage restoration treatment., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: To investigate whether concomitant autologous bone grafting adversely affects clinical outcome and graft survival after matrix-associated autologous chondrocyte implantation (M-ACI)., Methods: The present study examines registry data of patients who underwent M-ACI with or without autologous bone grafting for large-sized chondral or osteochondral defects. Propensity score matching was performed to exclude potential confounders. A total of 215 patients with similar baseline characteristics were identified. Clinical outcome was assessed at the time of surgery and at 6, 12, 24, 36 and 60 months using the Knee Injury and Osteoarthritis Outcome Score (KOOS). KOOS change, clinical response rate, KOOS subcomponents and failure rate were determined., Results: Patients treated with M-ACI and autologous bone grafting achieved comparable clinical outcomes compared with M-ACI alone. At 24 months postoperatively, the patient-reported outcome (PRO) of patients treated with M-ACI and autologous bone grafting was even significantly better as measured by KOOS (74.9 ± 18.8 vs. 79.2 ± 15.4; p = 0.043). However, the difference did not exceed the minimal clinically important difference (MCID). In patients with M-ACI and autologous bone grafting, a greater change in KOOS relative to baseline was observed at 6 (9.3 ± 14.7 vs. 15.0 ± 14.7; p = 0.004) and 12 months (12.6 ± 17.2 vs. 17.7 ± 14.6; p = 0.035). Overall, a high clinical response rate was observed in both groups at 24 months (75.8% vs. 82.0%; p = n.s.). The estimated survival at the endpoint of reoperation for any reason was 82.1% (SD 2.8) at 8.4 years for isolated M-ACI and 88.7% (SD 2.4) at 8.2 years for M-ACI with autologous bone grafting (p = 0.039)., Conclusions: Even in the challenging cohort of large osteochondral defects, the additional treatment with autologous bone grafting leads to remarkably good clinical outcomes in patients treated with M-ACI. In fact, they tend to benefit more from surgery, have lower revision rates and achieve clinical response rates earlier. Subchondral bone management is critical to the success of M-ACI and should be addressed in the treatment of borderline defects., Level of Evidence: Level III., (© 2024 The Authors. Knee Surgery, Sports Traumatology, Arthroscopy published by John Wiley & Sons Ltd on behalf of European Society of Sports Traumatology, Knee Surgery and Arthroscopy.)

Introduction: The aim of the present study was to evaluate midterm outcomes 5-7 years after matrix-associated autologous chondrocyte implantation (MACI) in the patellofemoral joint., Materials and Methods: Twenty-six patients who had undergone MACI using the Novocart® 3D scaffold were prospectively evaluated. Clinical outcomes were determined by measuring the 36-Item Short-Form Health Survey (SF-36) and International Knee Documentation Committee (IKDC) scores and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) values preoperatively and 3, 6, and 12 months, and a mean of 6 years postoperatively. At the final follow-up, the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score was evaluated., Results: Twenty-two patients with 23 focal cartilage defects (19 patella and four trochlea) were available for the final follow-up. The mean defect size was 4.0 ± 1.9 cm 2 (range 2.4-9.4 cm 2 ). All clinical outcome scores improved significantly until 5-7 years after MACI (SF-36 score, 61.2 ± 19.6 to 83.2 ± 11.6; P = 0.001; IKDC score, 47.5 ± 20.6 to 74.7 ± 15.5; P < 0.001; and WOMAC, 29.8 ± 15.7 to 8.2 ± 10.3; P < 0.001). The mean MOCART score was 76.0 ± 11.0 at the final follow-up. Nineteen of the 22 patients (86.4%) were satisfied with the outcomes after 5-7 years and responded that they would undergo the procedure again., Conclusion: MACI in the patellofemoral joint demonstrated good midterm clinical results with a significant reduction in pain, improvement in function, and high patient satisfaction. These clinical findings are supported by radiological evidence from MOCART scores., Level of Evidence: IV-case series., (© 2024. The Author(s).)

Background: Long-term outcomes in larger cohorts after matrix-induced autologous chondrocyte implantation (MACI) are required. Furthermore, little is known about the longer-term clinical and radiological outcomes of MACI performed in the tibiofemoral versus patellofemoral knee joint., Purpose: To present the 10-year clinical and radiological outcomes in patients after MACI and compare outcomes in patients undergoing tibiofemoral versus patellofemoral MACI., Study Design: Case series; Level of evidence, 4., Methods: Between September 2002 and December 2012, 204 patients who underwent MACI were prospectively registered into a research program and assessed preoperatively and at 2, 5, and 10 years postoperatively. Of these patients, 168 were available for clinical review at 10 years, with 151 (of a total of 182) grafts also assessed via magnetic resonance imaging (MRI). Patients were evaluated using the Knee injury and Osteoarthritis Outcome Score, a visual analog scale for pain frequency and severity, satisfaction, and peak isokinetic knee extensor and flexor strength. Limb symmetry indices (LSIs) were calculated for strength measures. Grafts were scored on MRI scans via the MOCART (magnetic resonance observation of cartilage repair tissue) system, with a focus on tissue infill and an overall MRI graft composite score., Results: All patient-reported outcome measures improved ( P < .0001) up to 2 years after surgery. Apart from the significant increase ( P = .004) in the peak isokinetic knee extensor LSI, no other patient-reported outcome measure or clinical score had changed significantly from 2 to 10 years. At the final follow-up, 92% of patients were satisfied with MACI to provide knee pain relief, with 76% satisfied with their ability to participate in sports. From 2 to 10 years, no significant change was seen for any MRI-based MOCART variable nor the overall MRI composite score. Of the 151 grafts reviewed via MRI at 10 years, 14 (9.3%) had failed, defined by graft delamination or no graft tissue on MRI scan. Furthermore, of the 36 patients (of the prospectively recruited 204) who were not available for longer-term review, 7 had already proceeded to total knee arthroplasty, and 1 patient had undergone secondary MACI at the same medial femoral condylar site because of an earlier graft failure. Therefore, 22 patients (10.8%) essentially had graft failure over the period. At the final follow-up, patients who underwent MACI in the tibiofemoral (vs patellofemoral) joint reported significantly better Knee injury and Osteoarthritis Outcome Score subscale scores for Quality of Life ( P = .010) and Sport and Recreation ( P < .001), as well as a greater knee extensor strength LSI ( P = .002). Even though the tibiofemoral group demonstrated better 10-year MOCART scores for tissue infill ( P = .027), there were no other MRI-based differences ( P > .05)., Conclusion: This study reports the long-term review of a prospective series of patients undergoing MACI, demonstrating good clinical scores, high levels of patient satisfaction, and acceptable graft survivorship at 10 years. Patients undergoing tibiofemoral (vs patellofemoral) MACI reported better long-term clinical outcomes, despite largely similar MRI-based outcomes., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: This research has received some funding from the National Health and Medical Research Council (ID254622 and ID1003452) and the Hollywood Private Hospital Research Foundation (RF31 and RF050). This research was approved by the Hollywood Private Hospital (HPH145) Human Research Ethics Committee. J.R.E. has received support for education and research support from Vericel. G.C.J. has shares in Orthocell. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Background: Costal chondrocyte-derived pellet-type autologous chondrocyte implantation (CCP-ACI) has been introduced as a new therapeutic option for the treatment of articular cartilage defects. We had previously conducted a randomized controlled trial comparing CCP-ACI versus microfracture at 1 year postoperatively., Purpose: To compare the efficacy and safety of CCP-ACI versus microfracture for the treatment of articular cartilage defects of the knee at 5 years postoperatively., Study Design: Randomized controlled trial; Level of evidence, 2., Methods: This study describes the mean 5-year follow-up of a previously published prospective clinical trial. The previous prospective trial compared the results of CCP-ACI versus microfracture until 1 year of follow-up. Of the 30 patients who were included in the previous study, 25 were followed up for 5 years. Patients were evaluated based on clinical outcome scores (Lysholm score, International Knee Documentation Committee score, Knee injury and Osteoarthritis Outcome Score [KOOS], and visual analog scale for pain), magnetic resonance imaging findings, and rates of treatment failure at last follow-up., Results: The MOCART (Magnetic Resonance Observation of Cartilage Repair Tissue) score in the CCP-ACI group was significantly higher than that in the microfracture group at 5 years (62.3 vs 26.7, respectively; P < .0001). The Lysholm score and KOOS score in the CCP-ACI group were significantly higher than those in the microfracture group at 5 years (84.5 vs 64.9, respectively, and 390.9 vs 303.0, respectively; P = .023 and P = .017, respectively). There was 1 case of treatment failure that occurred in the microfracture group., Conclusion: The present randomized controlled trial indicated that the results of both procedures clinically and statistically significantly improved at 1 and 5 years' follow-up in treating cartilage defects, but the results of CCP-ACI were superior to those of microfracture. Magnetic resonance imaging conducted at 1 year and 5 years after CCP-ACI revealed statistically significant superior structural integration with native cartilage tissue compared with microfracture., Registration: NCT03545269 (ClinicalTrials.gov)., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: This work was supported by grants from the Ministry of Health and Welfare, Republic of Korea (HI15C0963, HI20C0067). This work was also supported by the National Research Foundation of Korea grant funded by the Ministry of Science and ICT, Republic of Korea (No. RS-2023-00210901). AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Background: Osteochondral defects of the knee due to trauma or osteochondritis are associated with osteoarthritis in the medium term. Defects 2 to 8cm 2 in size can be managed by autologous matrix-induced chondrogenesis (AMIC®), in which sub-chondral micro-fractures are created within the lesion and the defect is then covered by a matrix of type I and type III collagen to induce de novo cartilage formation. Although promising outcomes have been observed in small single-centre cohorts, the medium-term clinical and radiological effectiveness of AMIC® remains to be demonstrated in larger populations. The objective of this study was to evaluate outcomes of patients at least 2 years after AMIC® for knee osteochondral defects., Hypothesis: AMIC® is associated with clinical and radiological improvements after at least 2 years., Material and Method: This multicentre (16 centres), multisurgeon (18 senior orthopaedic surgeons), retrospective study included consecutive patients who underwent AMIC® with Chondro-Gide® membrane implantation between September 2011 and January 2020. The 36-item Short Form quality-of-life (SF-36) score, Knee Injury and Osteoarthritis Outcome Score (KOOS), and International Knee Documentation Committee (IKDC) score were determined before the procedure and during follow-up. The Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score was assessed by magnetic resonance imaging 2 years after the procedure., Results: In total, 101 patients aged 12 to 60 years were included. Mean follow-up was 30 months. Mean defect size was 3.44cm 2 (range, 2-8cm 2 ). Significant improvements were documented in the SF-36 score, KOOS, and IKDC score. The mean MOCART score at 2 years was 75% (range, 20-100)., Discussion: The AMIC® procedure was associated with significant improvements at 2.5 years in patients treated for knee osteochondral defects measuring 2 to 8cm 2 . This method seems to provide similar outcomes to those of other available methods with the advantages of single-step surgery and elimination of osteochondral graft donor-site complications., Level of Evidence: IV, retrospective observational cohort study., (Copyright © 2023 The Authors. Published by Elsevier Masson SAS.. All rights reserved.)

Background: Recently, various types of engineered autologous chondrocyte implantation (ACI) have been developed. Atelocollagen-associated ACI (A-ACI) is the only ACI procedure covered by Japanese Health Insurance since 2013. The indications of the A-ACI are traumatic cartilage defects and osteochondral dissecans (OCD) for knee joints., Purpose: To evaluate midterm clinical results after A-ACI for the treatment for full-thickness cartilage defects of the knee., Methods: Thirteen consecutive patients who underwent A-ACI between 2014 and 2018 had been prospectively enrolled in this study. There were 11 men and 2 women with a mean age of 34 years at the time of surgery. The causes of the cartilage defect were trauma in 10 knees and OCD in 3 knees. The total number of lesions was 15, which were comprised of the medial femoral condyle in 5 knees, the lateral femoral condyle in 5 knees, and the femoral trochlea in 5 knees. The mean size of the lesion was 5.3 cm 2 . Each knee was clinically and radiologically evaluated preoperatively and postoperatively., Results: The mean Lysholm score improved significantly from 74.0 points to 94.0 points (p = 0.008) and each subscale in Knee injury and Osteoarthritis Outcome Score improved significantly (p < 0.001) at the mean final follow-up period of 51 months (range, 36-84 months). The magnetic resonance observation of cartilage repair tissue 2.0 score at the mean follow-up of 38 months was significantly higher than that at 2 months postoperatively (p = 0.014). According to the International Cartilage Repair Society (ICRS) grading scale, 3 knees were graded as normal, 3 knees as nearly normal, and 1 knee as severely abnormal in second-look arthroscopic evaluation at a mean of 22 months (range, 8-41 months) after A-ACI., Conclusion: The present study showed a significant subjective and objective clinical improvement in the A-ACI for large cartilage defects of the knee at a mean follow-up of 51 months (range, 36-84 months)., Competing Interests: Declaration of competing interest The authors declare no conflicts of interest associated with this manuscript., (Copyright © 2022 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.)

Purpose: This study aimed to analyze the risk of reoperation following autologous chondrocyte implantation (ACI) of the knee utilizing third-generation ACI products in a time-to-event analysis and report on the associated patient-reported outcome measures (PROM) in case of reoperation., Methods: Patients undergoing ACI were included from a longitudinal database. Patient age, sex, body mass index (BMI), number of previous surgeries, lesion localization, lesion size, symptom duration, as well as time and type of reoperation was extracted. A cox proportional-hazards model was applied to investigate the influence of baseline variables on risk of reoperation. Reoperation was defined as any type of subsequent ipsilateral knee surgery, excluding hardware removal. The Knee Injury and Osteoarthritis Outcome Score (KOOS) was utilized to compare PROM between patients with and without reoperation., Results: A total of 2039 patients were included with 1359 (66.7%) having a minimum follow-up of 24 months. There were overall 243 reoperations (prevalence 17.9%). Minor arthroscopic procedures (n = 96, 39.5%) and revision cartilage repair procedures (n = 78, 32.1%) were the most common reoperations. Nineteen patients (0.9%) reported conversion arthroplasty at 17.7 (10.4) months after ACI. Female sex (HR 1.5, 95% CI [1.2, 2.0], p = 0.002) and the presence of 1-2 previous surgeries (HR 1.5, 95% CI [1.1, 2.0], p = 0.010), or more than 2 previous surgeries (HR 1.9, 95% CI [1.2, 2.9], p = 0.004) were significantly associated with increased risk of reoperation following ACI. Significantly less patients surpassed the minimal clinically important difference (MCID) in the reoperation group at 24 months regarding the KOOS subscores pain (OR 1.6, 95% CI [1.1, 2.2]), quality of life (OR 2.2, 95% CI [1.6, 3.2]), symptoms (OR 2.0 [1.4, 2.9]), and sports (OR 2.0 [1.4, 2.8])., Conclusion: Female patients and individuals with a history of previous surgeries face an elevated risk of requiring reoperation after undergoing ACI, which is associated with failure to attain clinically relevant improvements. A thorough evaluation of the indications for ACI is paramount, particularly when patients have a history of previous surgeries., Level of Evidence: Level III., (© 2023. The Author(s).)

Introduction: The AMADEUS (Area Measurement And DEpth and Underlying Structures) score has advanced to a commonly used tool for MRI-based chondral defect severity grading prior to cartilage knee surgery. It was the intention of this study to assess the AMADEUS for a potential correlation with clinical data by patient-reported outcome measures (PROMs)., Methods: A total of 51 patients undergoing ACI (autologous chondrocyte implantation) between 2016 and 2022 were found eligible and retrospectively analyzed. All patients were registered in the German Cartilage Registry prior to surgery and follow-up data were collected using the Knee Osteoarthritis Outcome score (KOOS), the International Knee Documentation Committee (IKDC) Form and the numeric rating scale (NRS). Pre-operative MRI images were scored by three raters using the AMADEUS classification system, and an overall AMADEUS score was calculated which was subsequently correlated with pre- and post-operative PROMs., Results: Mean patient age was 32.67 ± 8.37 years and mean defect size area 343.04 mm 2  ± 139.45 mm 2 . No correlative capacity of the pre- and postoperative IKDC, KOOS or NRS scores was found with the AMADEUS final score or any of its subscores. From the pre- to postoperative visit, a significant improvement of the PROMs (IKDC: 45.53 ± 21.00 vs. 59.83 ± 17.93, p = 0.04; KOOS Pain: 58.00 ± 16.70 vs. 76.06 ± 19.20, p = 0.03; KOOS ADL: 64.17 ± 18.76 vs. 82.11 ± 16.68, p < 0.01; KOOS Sports: 26.11 ± 18.52 vs. 50.56 ± 23.94, p = 0.01; KOOS QOL: 25.50 ± 14.26 ± 45.28 ± 19.03, p = 0.00) was found. Intraclass correlation coefficients showed an overall good interrater agreement for the AMADEUS total score (ICC = 0.75)., Conclusions: Study results suggest no correlative capacity of the AMADEUS with routinely used PROMs in patients undergoing ACI. Therefore, radiographically assessed cartilage defect characteristics poorly translate to pre- and postoperative patient-reported outcome data., (© 2023. The Author(s).)

Purpose: Osteochondral knee defects usually affect young, active patients and may alter knee biomechanics and progressively lead to joint degeneration. Various treatment options exist with autologous, impaction bone grafting in combination with autologous matrix-induced chondrogenesis (BG-AMIC) being a less-expensive, one-step, promising option. The purpose of this study is to evaluate the clinical and radiological mid-term outcomes of large osteochondral lesions treated with BG-AMIC, identify a possible correlation between the two and report postoperative complications and reoperation rate., Methods: A retrospective analysis of 25 patients treated with the BG-AMIC technique for knee osteochondral lesions was performed. Patients were assessed using the following PROMs: the IKDC, the KOOS and the Lysholm score, the Tegner activity scale and a patient acceptable symptom state (PASS). The EQ-5D-5L score was used to assess health-related quality of life. Radiological assessment was performed using the MOCART 2.0 score on a 3 T MRI., Results: At a mean of 3.8 (± 0.8)-year follow-up, all functional scores increased significantly (p < 0.005) when compared to the preoperative baseline. IKDC increased from 44.5 (± 15.9) to 81.4 (± 14.7), KOOS from 41.5 (± 16.1) to 91.6 (± 11.6) and Lysholm from 54.4 (± 23) to 95.2 (± 5.5) (p < 0.005). The EQ-5D-5L score also revealed a significant improvement [59.9 (± 25) to 93.4 (± 10.2), p < 0.005]. Mean Tegner score reached pre-injury levels. The PASS was positive in 100% of patients. The minimum clinically important difference was reached in all PROMs except for the KOOS Sports subscale. There were no re-operations. Morphological evaluation of the repair tissue using the MOCART 2.0 score revealed a mean total score of 52.8 (± 30.5). A statistically significant, positive correlation was found between the MOCART 2.0 score and the IKDC score, the KOOS ADL subscale and the EQ-5D-5L (p < 0.05)., Conclusion: BG-AMIC is a safe and reliable option for treating deep, knee osteochondral lesions, providing a statistically significant and clinically important improvement in patient-reported outcomes. No complications were noticed, and no re-operations were performed after the procedure. A moderate positive correlation between the MOCART 2.0 score and the IKDC, KOOS ADL and EQ-5D-5L was noticed. However, this correlation is not necessarily clinically relevant, and excellent clinical results can be expected even in patients with low MOCART scores., Level of Evidence: III., (© 2023. The Author(s) under exclusive licence to European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA).)

Objective: Osteochondral lesions of the talus (OLT) is a common and clinically challenging disease. The optimal management is still under debate. The purpose of this prospective study was to investigate the feasibility and clinical outcomes of autologous costal osteochondral transplantation (ACOT) for the treatment of cystic OLT., Methods: From November 2021 to April 2023, five patients underwent autologous costal osteochondral transplantation (ACOT) for cystic OLT. The demographic data was described, including age, gender, lesion size and location. We prospectively evaluated their functional and imaging outcomes of the five patients for 12 months postoperatively, including numeric rating score (NRS) for pain when walking, Tegner score, American Orthopedic Foot & Ankle Society (AOFAS) score and Foot and Ankle Ability Measure (FAAM) score, and imaging results. A paired t-test was used for preoperative and postoperative comparison of the paired-design dataset., Results: The average age was 36.6 ± 11.1 years. The average diameter of chondral lesions was 14.95 ± 2.71 mm, the average diameter of subchondral cysts was 10.66 ± 1.84 mm, and their average depth was 10.40 ± 1.86 mm. At 12 months postoperatively, the clinical function indexes improved significantly, including NRS (from 5.2 ± 2.3 to 0), Tegner score (from 3.2 ± 0.4 to 5.8 ± 0.4), AOFAS score (from 72.8 ± 10.0 to 98.2 ± 4.0), and FAAM score (FAAM/ADL from 61.2 ± 24.7 to 99.3 ± 1.6; FAAM/Sports from 32.5 ± 13.73 to 96.3 ± 8.4). Their magnetic resonance observation of cartilage repair tissue (MOCART) scores reached 78.0 ± 7.6 points. ICRS scores of three patients were nearly normal (10 or 11 points). The biopsy of the surviving grafts showed plenty of hyaline cartilage matrix and scattered chondrocytes histologically. No major severe complications were reported during the 12 months follow-up., Conclusion: ACOT could significantly relieve the symptoms of patients with OLT and improve their clinical function at short-term follow-up. ACOT might be a feasible and useful method for repairing OLT with subchondral cysts., (© 2023 The Authors. Orthopaedic Surgery published by Tianjin Hospital and John Wiley & Sons Australia, Ltd.)

Purpose: Autologous chondrocyte implantation (ACI) is primarily performed in active, young patients to treat knee pain and functional limitations resulting from articular cartilage injury. Nevertheless, the functional outcomes of ACI remain poorly understood. This systematic review aimed to evaluate the biomechanical and functional outcomes of ACI., Methods: Ovid MEDLINE, Embase, and Web of Science were systematically searched using the terms 'Knee OR Knee joint AND Autologous chondrocyte implantation OR ACI'. Inclusion and exclusion criteria were used to screen publications by title, abstract, and full text. Study quality and bias were assessed by two reviewers. Means and standard deviations of all collected variables were calculated and presented in the review., Prospero Id: CRD42021238768., Results: Nineteen articles including 20 ACI cohorts were included. In general, the average range of motion (ROM) improved with clinical (>5°) and statistical significance (p < 0.05) postoperatively: 130.5 ± 14.8° to 136.1 ± 10.2°. Knee strength significantly improved within the first two postoperative years but remained poorer than control groups at final follow-up. No statistical differences were found between ACI and control groups in their ability to perform functional activities like the 6-minute walk test., Conclusion: Knee range of motion generally improved following ACI. Although, some studies reported that knee strengths remained significantly poorer than healthy controls, particularly >2-years postoperatively, implying that longer-term strength training may benefit patients.However, the volume of research and current level of evidence remain low, thus further research is required to better understand the impact of ACI on knee function and guide future rehabilitative protocols., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: LB received consultancy fees from CO.DON in 2019, Contura in 2022, and Bioventus in 2022. LB has also received payment for educational events from Medacta International. LB is currently the President of the British Association for Surgery of the Knee, sits on the Finance Committee for the International Cartilage Regeneration & Joint Preservation Society, and is on the Editorial Board of the Journal of ISAKOS. The other authors declare that they have no competing interests., (Copyright © 2023 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: This study surveyed Dutch orthopedic surgeons on the management of cartilage defects in the knee and the adherence to the recently updated Dutch knee cartilage repair consensus statement (DCS)., Methods: A web-based survey was sent to 192 Dutch knee specialists., Results: The response rate was 60%. Microfracture, debridement and osteochondral autografts are performed by the majority, 93%, 70% and 27% of respondents, respectively. Complex techniques are used by < 7%. Microfracture is mainly considered in defects 1-2 cm 2 (by > 80%) but also in 2-3 cm 2 (by > 40%). Concomitant procedures, e.g., malalignment corrections, are performed by 89%. Twenty-one percent of surgeons treat patients aged 40-60 years. Microfracture, debridement and autologous chondrocyte implantation are not considered to be highly affected by age > 40 years by any of the respondents (0-3%). Moreover, for the middle-aged there is a large spread in treatments considered. In case of loose bodies, the majority (84%) only performs refixation in the presence of attached bone., Conclusion: Small cartilage defects in ideal patients may be well treated by general orthopedic surgeons. The matter becomes complicated in older patients, or in case of larger defects or malalignment. The current study reveals some knowledge gaps for these more complex patients. Referral to tertiary centers might be indicated, as is stated by the DCS, and this centralization should enhance knee joint preservation. Since the data from present study are subjective, registration of all separate cartilage repair cases should fuel objective analysis of clinical practice and adherence to the DCS in the future., (© 2023. The Author(s).)

Background: Osteochondral injury is a common sports injury, and hyaline cartilage does not regenerate spontaneously when injured. However, there is currently no gold standard for treating osteochondral defects. Osteochondral autograft transplantation (OAT) is widely used in clinical practice and is best used to treat small osteochondral lesions in the knee that are < 2 cm 2 in size. Autologous dual-tissue transplantation (ADTT) is a promising method with wider indications for osteochondral injuries; however, ADTT has not been evaluated in many studies. This study aimed to compare the radiographic and histological results of ADTT and OAT for treating osteochondral defects in a porcine model., Methods: Osteochondral defects were made in the bilateral medial condyles of the knees of 12 Dian-nan small-ear pigs. The 24 knees were divided into the ADTT group (n = 8), OAT group (n = 8), and empty control group (n = 8). At 2 and 4 months postoperatively, the knees underwent gross evaluation based on the International Cartilage Repair Society (ICRS) score, radiographic assessment based on CT findings and the magnetic resonance observation of cartilage repair tissue (MOCART) score, and histological evaluation based on the O'Driscoll histological score of the repair tissue., Results: At 2 months postoperatively, the ICRS score, CT evaluation, MOCART score, and O'Driscoll histological score were significantly better in the OAT group than the ADTT group (all P < 0.05). At 4 months postoperatively, the ICRS score, CT evaluation, MOCART score, and O'Driscoll histological score tended to be better in the OAT group than the ADTT group, but these differences did not reach statistical significance (all P > 0.05)., Conclusions: In a porcine model, ADTT and OAT are both effective treatments for osteochondral defects in weight bearing areas. ADTT may be useful as an alternative procedure to OAT for treating osteochondral defects., (© 2023. The Author(s).)

Background: The conventional operative method to treat an osteochondral lesion of the talus (OLT) is through bone marrow stimulation (BMS). Autologous osteochondral transplantation (AOT) is being used as an alternative option in cases with a large OLT, accompanying subchondral cyst, and/or failed BMS. We aimed to compare the intermediate-term clinical and radiologic results between medial and lateral OLTs after an AOT procedure., Methods: Among the patients who underwent AOT, 45 cases with at least 3 years' follow-up were included in this retrospective study. We had 15 cases of lateral lesions and selected 30 cases of medial lesions matched for age and gender. Lateral lesions were resurfaced without an osteotomy; medial lesion resurfacing was combined with a medial malleolar osteotomy. Clinical assessment was performed using the Foot and Ankle Outcome Score (FAOS) and Foot and Ankle Ability Measure (FAAM). Radiographic assessment included the irregularity of articular surface (subchondral plate), the progression of degenerative arthritis, and the change of the talar tilt., Results: The mean FAOS and FAAM scores significantly improved after surgery in both groups. Up to 1 year postoperatively, there was significant difference in FAAM scores between the both groups (mean 75.3 points in medial group and 87.2 points in lateral group, P  < .001). Delayed union or malunion of the malleolar osteotomy was found in 4 cases (13%) in the medial group. In addition, the progression of joint degeneration was observed in 3 cases (10%) in the medial group. There were no significant differences in the irregularity of articular surface and the change of talar tilt between both groups., Conclusion: A comparison between medial and lateral OLTs treated with AOT demonstrated comparable intermediate-term clinical outcomes. However, patients with medial OLT required a longer period to restore ability for daily and sport activities. In addition, we found more complications and higher rate of progression in the radiologic arthritis grade after medial malleolar osteotomy., Level of Evidence: Level IV, retrospective comparative study.

Purpose: To evaluate the mid- and long-term efficacy of autologous chondrocyte implantation (ACI) and matrix-assisted chondrocyte implantation (MACI) to treat patients with knee cartilage defects in the presence of osteoarthritis (OA)., Methods: PubMed and Cochrane databases were systematically searched for studies describing the treatment of knee OA with ACI or MACI (Kellgren-Lawrence (KL) ≥ 1, minimum follow-up 36 months). Results were reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines and included Lysholm, Western Ontario McMaster University and International Knee Documentation Committee scores., Results: Of the 127 full-text articles assessed for eligibility, only five studies were selected based on inclusion/exclusion criteria (2 on ACI and 3 on MACI). In both groups, the defects were mainly located at femoral level, size 2.2-15.1 cm 2 in the ACI and 2.0-7.6 cm 2 in the MACI group. ACI was mostly used for patients affected by KL I, whereas MACI for patients with KL II-IV. The data obtained from 235 patients (161 ACI, 74 MACI) showed that ACI and MACI sustained stable clinical improvements up to 11 and 15 years, respectively, with a failure rate of about 10% up to 11 years. Scarce biological details regarding chondrocyte implantation were reported., Conclusions: ACI and MACI procedures for the treatment of knee cartilage lesions associated to OA showed long-term success and allowed delaying arthroplasty. Additional trials reporting homogenous data and precise patient characterization are needed to conduct an effective literature meta-analysis and identify the clinical relevance of these procedures., Level of Evidence: IV., (© 2022. The Author(s) under exclusive licence to European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA).)

Introduction: Even though an increased interest in the use of the EFAS Score (European Foot and Ankle Society) has been observed, no data comparing it with radiological findings has been presented in the literature. Accordingly, the aim of this study is to investigate how the post-operative integration of the AMIC ® (autologous matrix-induced chondrogenesis)-membrane for osteochondral lesion of the talus using the MOCART (Magnetic Resonance Observation of Cartilage Repair Tissue) - Score is related to the clinical satisfaction of the patients., Material and Methods: A group of 24 patients aged between 17 and 63 (with a mean age of 35.7) were included at least 1 year post-operatively. They had all undergone an AMIC ® -procedure of the talus. MRI findings using the MOCART Score were correlated to the EFAS Score at the same time point., Results: Our main results showed no correlation between the MOCART-Score and the EFAS-Score (R = - 0.08). There was also no correlation between the MOCART-Score, the FFI-Score (Foot and Function Index) (R = 0.2) and the MOXFQ-Score (Manchester-Oxford Foot Questionnaire) (R = 0.12). There was no correlation between components of the MOCART-Score with the EFAS-Score (R between - 0.32 and 0.23)., Conclusion: Our results question whether the MRI (a standard part of AMIC ® -procedure-of-the-ankle post-operative follow-up) is still the most appropriate tool for post-operative control. They also offer a starting point for future discussion regarding the need for post-operative MRI and the use of other radiological diagnostics in relation to clinical satisfaction., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Symptomatic osteochondral lesions of the talus (OLTs) often require surgical intervention. There are various surgical methods. A generally valid, stage-dependent therapeutic algorithm does not exist. The aim of our study is to show long- term results of an alternative technique that combines retrograde drilling, debridement performed under arthroscopic visualization, and autologous bone grafting., Methods: The surgical technique was performed in 24 patients with medial or lateral OLTs, and the data were analyzed retrospectively. In our technique, the affected subchondral bone was overdrilled retrogradely and resected under arthroscopic visualization (ossoscopy) without violating the cartilage. The resulting defect was filled with autologous bone from the medial tibia metaphysis. Outcome parameters were the numeric rating scale (NRS), the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, and range of motion (ROM). The Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score was assessed and a possible correlation with the clinical outcome scores was calculated. Data concerning complication rates were also collected., Results: The mean surface size of the OLTs was 0.9 ± 0.3 cm 2 . The mean follow-up was 89 months. The AOFAS score improved significantly from 57.7 points preoperatively to 88.8 points at the final follow-up ( P  < .0001). The pain value measured by the NRS decreased significantly from 8 to a pain level of 2. ROM improved in 37.5% of the patients for dorsiflexion and 29.2% for plantarflexion. There were no significant correlations between the MOCART score and the AOFAS score or the pain value on NRS., Conclusion: Retrograde drilling, ossoscopy, and autologous bone grafting for OLTs is a promising technique with good long-term results. The patients' satisfaction rate, especially in OLT stages 2 and 3, was excellent., Level of Evidence: Level IV, case series.

Purpose: To evaluate the safety and efficacy of matrix-associated autologous chondrocyte implantation (ACI) using spheroids in comparison to arthroscopic microfracture for the treatment of symptomatic cartilage defects of the knee., Methods: In a prospective multicenter-controlled trial, patients aged between 18 and 50 years, with single symptomatic focal cartilage defects between 1 and 4 cm 2 (mean 2.6 ± 0.8, median 2.75, range 1.44-5.00) in the knee were randomized to treatment with ACI with spheroids (n = 52) or microfracture (n = 50). Primary clinical outcome was assessed by the Knee Injury and Osteoarthritis Outcome Score (KOOS). Analyses were performed in a defined hierarchical manner where outcomes of ACI were first compared to baseline values followed by a comparison to the microfracture group with repeated-measures ANCOVA with a non-inferiority approach. Subgroup analyses were performed to investigate the influence of age and defect size on the overall KOOS. Secondary clinical outcomes were the magnetic resonance observation of cartilage repair tissue (MOCART), modified Lysholm score and International Knee Documentation Committee (IKDC) examination form. Safety data focused on adverse events. Here the 5 years results are presented at which there were 33 observed cases in the ACI group and 30 in the microfracture group., Results: The overall KOOS and its five subscores were significantly improved compared to baseline for both the ACI and microfracture group. Non-inferiority of ACI to microfracture was confirmed for the overall KOOS and the subscores, while for the subscores activities of daily living, quality of life and sports and recreation of the threshold for superiority was passed. In the ACI group, a notably more rapid initial improvement of the KOOS was found at three months for the older age group compared to the younger age group and the microfracture group. No other differences were found based on age or defect size. In addition, clinical improvement was found for the MOCART, modified Lysholm and IKDC examination form both the ACI and microfracture group. No safety concern related to either treatment was observed., Conclusion: This study confirms the safety and efficacy of matrix-associated ACI with spheroids at a mid to long-term follow-up. Non-inferiority of ACI to microfracture was confirmed for the overall KOOS and all subscores, while superiority was reached for the subscores activities of daily living, quality of life and sports and recreation in the ACI group. This underlines the importance of ACI for the young and active patients., Level of Evidence: I., (© 2022. The Author(s) under exclusive licence to European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA).)

Background: Debate continues as to whether surgical treatment with chondral-regeneration devices is superior to microfracture for focal articular cartilage defects in the knee., Purpose: To evaluate the superiority of scaffold-associated chondral-regeneration procedures over microfracture by assessing: (1) Patient-reported outcomes; (2) Intervention failure; (3) Histological quality of cartilage repair., Study Design: A three-concept keyword search strategy was designed, in accordance with PRISMA guidelines: (i) knee (ii) microfracture (iii) scaffold. Four databases (Ovid Medline, Embase, CINAHL and Scopus) were searched for comparative clinical trials (Level I-III evidence). Critical appraisal used two Cochrane tools: the Risk of Bias tool (RoB2) for randomized control trials and the Risk of Bias in Non-randomized Studies-of Interventions (ROBINS-I). Study heterogeneity permitted qualitative analysis with the exception of three patient-reported scores, for which a meta-analysis was performed., Results: Twenty-one studies were identified (1699 patients, age range 18-66 years): ten randomized control trials and eleven non-randomized study interventions. Meta-analyses of the International Knee Documentation Committee (IKDC), Knee Injury And Osteoarthritis Outcome Score (KOOS) for pain and activities of daily living, and Lysholm score demonstrated statistically significant improvement in outcomes for scaffold procedures compared to microfracture at two years. No statistical difference was seen at five years., Conclusion: Despite the limitations of study heterogeneity, scaffold-associated procedures appear to be superior to MF in terms of patient-reported outcomes at two years though similar at five years. Future evaluation would benefit from studies using validated clinical scoring systems, reporting failure, adverse events and long-term clinical follow up to determine technique safety and superiority., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Crown Copyright © 2023. Published by Elsevier B.V. All rights reserved.)

Purpose: This systematic review evaluated the efficacy and safety of autologous chondrocyte implantation (ACI) for chondral defects of the knee in skeletally immature patients. Current available data from patients reported outcome measures (PROMs) and complications were collected, analyzed, and discussed., Methods: This systematic review was conducted according to the PRISMA guidelines. The following databases were accessed in May 2022: PubMed, Google scholar, Embase, and Scopus. All the clinical studies investigating the efficacy of ACI to manage chondral defects of the knee in skeletally immature patients were accessed. Articles treating patients with surgical procedures other than ACI were not eligible, nor were studies with a follow-up shorter than 12 months., Results: Data from 9 studies (251 procedures) were collected. 32% (80 of 251) of patients were females. The mean length of follow-up was 44.2 ± 29.4 (range, 12-115) months. The mean age of the patients was 16.4 ± 0.7 (range, 15-17) years. The Knee injury and Osteoarthritis Outcome Score (KOOS) and International Knee Document Committee (IKDC) increased of + 41.9/100 (P = 0.003) and + 33.2/100 (P =  < 0.0001) points, respectively. The Lysholm Knee Score improved of + 20.6/100 (P = 0.02) points. The Visual Analogue Scale (VAS) for pain reduced of - 3.6/10 (P = 0.004) points. The Tegner scale did not show any statistically significant improvement from baseline to follow-up (P = n.s.). The rate of graft hypertrophy was 12.5% (5 of 40 patients), and the rate of failure 5.6% (8 of 142 patients)., Conclusion: ACI for chondral defects of the knee is effective to improve PROMs in skeletally immature patients. The safety profile of ACI still remains controversial., Level of Evidence: III., (© 2022. The Author(s).)

Purpose: The primary purpose of this study was to assess the use of autologous chondrocyte implantation (ACI) procedures in the knee during last decade, and the secondary aims of the study were to determine reoperation rates after ACI and to identify associated risk factors., Methods: A retrospective cohort study from 2010-2020 was performed using the PearlDiver database. The database was queried for the Current Procedural Terminology (CPT) code for ACI performed in any knee location, including the patellofemoral and tibiofemoral joints. Reoperation was defined as interventional knee procedures or total knee arthroplasty after ACI. Reoperations were identified using CPT and International Classification of Diseases codes. Univariate and multivariate logistic regression were used to identify risk factors for reoperation. Significance was defined as P < .05., Results: Among the 2010 patients included in this study, there were 90-day and overall reoperation rates of 2.24% and 30.4%, respectively, with an average follow up of 4.8 ± 3.3 years. The most common reoperations included chondroplasty, meniscectomy, and microfracture. There was an increased rate of ACI performed from 2017-2019 (5.53/100,000) compared to 2014-2016 (4.16/100,000; P < .001). ACI surgeries performed in 2017-2019 were associated with decreased risk of reoperation within 2 years relative to 2014-2016 (odds ratio [OR] = 0.70; 95% confidence interval [CI], 0.52-0.94; P = .019). In the entire ACI cohort, older age (OR = 1.07; 95% CI, 1.05-1.09; P < .001) and tobacco use (OR = 2.13; 95% CI, 1.06-3.94; P = .022) were associated with increased risk of conversion to arthroplasty. Male sex was associated with decreased overall reoperation rates (OR = 0.73; 95% CI, 0.60-0.89; P = .002)., Conclusions: There has been increasing use of ACI in the knee with decreased risk of reoperation since 2017 and the introduction of matrix-associated autologous chondrocyte implantation. Older age and tobacco use were predictors of increased risk of conversion to arthroplasty. Male sex was associated with decreased risk of reoperation., Level of Evidence: Level IV, retrospective cohort design; database study., (Copyright © 2022 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: There is an increasing interest in subchondral bone changes and intralesional bony overgrowth (ILBO) after cartilage repair. Their clinical and predictive relevance is unclear and debated., Purpose: To evaluate the long-term development of ILBO and bone marrow edema-like signals (BMELSs) after autologous chondrocyte implantation (ACI) treatment of cartilage defects to find any predictive factors for their appearance., Study Design: Case series; Level of evidence, 4., Methods: A total of 130 patients with 160 cartilage defects in the knee joint treated with third-generation ACI were included in this study. Radiological scores as the MOCART (magnetic resonance observation of cartilage repair tissue), the MOCART 2.0 and the 3D-MOCART using magnetic resonance imaging (MRI), and patient-reported outcome measures such as the Knee injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee (IKDC) score, Noyes Sports Activity Rating Scale (NSARS) score, and Tegner Activity Scale (TAS) score were evaluated between 60 and 120 months (mean, 88 months) postoperatively. The radiological evaluation focused on the occurrence and size of subchondral bone changes, BMELSs, and ILBO during short-, medium-, and long-term follow-up., Results: In long-term evaluation of clinical data, the IKDC score increased preoperatively from 36 to 64, the overall KOOS from 43 to 64, the NSARS score from 30 to 67, and the TAS score from 2 to 3.7. The mean MOCART score was 73; the MOCART 2.0, 69; and the 3D-MOCART, 69 and 70. The authors observed ILBO in 77% and BMELSs in 74% of patients after 60 to 120 months. Previous cartilage surgeries and osteochondral defect buildup showed higher rates of these abnormalities. Early lesions of the subchondral lamina did not predict ILBO in long-term follow-up, but BMELSs predicted later appearance with decreasing size., Conclusion: Subchondral changes frequently appeared in long-term MRI evaluation of patients after ACI. BMELSs showed a decreasing diameter over the years, while the size of ILBO increased in the later follow-ups. These findings did not affect the clinical outcome in the study population. However, osteoarthritis is likely to progress. The degenerative effect and influence on longer-term outcomes needs to be clarified in future studies.

Background: Stratification is required to ensure that only patients likely to benefit receive autologous chondrocyte implantation (ACI). It would be advantageous to identify biomarkers to predict ACI outcome that are measurable in blood, avoiding the need for an invasive synovial fluid harvest., Purpose: To assess if proteomic analyses can be used to identify novel candidate blood biomarkers in individuals who respond well or poorly to ACI., Study Design: Controlled laboratory study., Methods: Isobaric tagging for relative and absolute quantitation (iTRAQ) mass spectrometry was used to assess the proteome in plasma pooled from ACI responders (mean Lysholm improvement after ACI, 33; n = 10) or nonresponders (mean, -13; n = 10), collected at the time of surgery for cartilage harvest (stage 1) or implantation of culture-expanded chondrocytes (stage 2). An alternative proteomic method, label-free quantitation liquid chromatography-tandem mass spectrometry, was used to analyze plasma samples (majority matched to iTRAQ) individually. Differentially abundant proteins (±2.0-fold) were analyzed from both proteomic data sets, and markers of interest identified via pooled iTRAQ were validated via immunoassay of individual samples., Results: Protein differences could be detected in the plasma preoperatively between ACI responders and nonresponders (16 proteins; ≥±2.0-fold change; P < .05) using iTRAQ proteomics. The most pronounced plasma proteome shift was evident in response to stage 1 surgery in ACI nonresponders, with 48 proteins being differentially abundant between the procedures. Label-free quantitation liquid chromatography-tandem mass spectrometry analysis of these same plasma samples (nonpooled) resulted in very few proteins being identified that were significantly differentially abundant. However, this work highlighted cartilage acidic protein 1 as being increased preoperatively in nonresponders as compared with responders., Conclusions: This study is the first to use proteomic techniques to profile the plasma of individuals treated with ACI. Despite iTRAQ analysis of pooled plasmas indicating that there are differences in the plasma proteome between responders and nonresponders to ACI, these findings were not replicated when assessed using an alternative nonpooled technique. This study highlights some of the difficulties in profiling the plasma proteome in an attempt to identify novel biomarkers. Regardless, cartilage acidic protein 1 has been identified as a protein candidate, which is detectable in plasma and can predict outcome to ACI before treatment., Clinical Relevance: Candidate plasma protein biomarkers identified in this study have the potential to help determine which patients will be best suited to treatment with ACI.

Purpose: Different surgical techniques to manage cartilage defects are available, including microfracture (MFx), autologous chondrocyte implantation (ACI), osteoarticular auto- or allograft transplantation (OAT), autologous matrix-induced chondrogenesis (AMIC). This study investigated the patient-related prognostic factors on the clinical outcomes of surgically treated knee and ankle cartilage defects., Methods: This study followed the PRISMA statement. In May 2022, the following databases were accessed: PubMed, Google Scholar, Embase, and Scopus. All the studies investigating the outcomes of surgical management for knee and/or talus chondral defects were accessed. Only studies performing mesenchymal stem cells transplantation, OAT, MFx, ACI, and AMIC were considered. A multiple linear model regression analysis through the Pearson Product-Moment Correlation Coefficient was used., Results: Data from 184 articles (8905 procedures) were retrieved. Female sex showed a positive moderate association with visual analogue scale at last follow-up (P = 0.02). Patient age had a negative association with the American Orthopaedic Foot and Ankle Score (P = 0.04) and Lysholm Knee Scoring Scale (P = 0.03). BMI was strongly associated with graft hypertrophy (P = 0.01). Greater values of VAS at baseline negatively correlate with lower values of Tegner Activity Scale at last follow-up (P < 0.0001)., Conclusion: The clinical outcomes were mostly related to the patients' performance status prior surgery. A greater BMI was associated with greater rate of hypertrophy. Female sex and older age evidenced fair influence, while symptom duration prior to the surgical intervention and cartilage defect size evidenced no association with the surgical outcome. Lesion size and symptom duration did not evidence any association with the surgical outcome., (© 2022. The Author(s).)

Background: There are limited randomized controlled trials with long-term outcomes comparing autologous chondrocyte implantation (ACI) versus alternative forms of surgical cartilage management within the knee., Purpose: To determine at 5 years after surgery whether ACI was superior to alternative forms of cartilage management in patients after a failed previous treatment for chondral or osteochondral defects in the knee., Study Design: Randomized controlled trial; Level of evidence, 1., Methods: In total, 390 participants were randomly assigned to receive either ACI or alternative management. Patients aged 18 to 55 years with one or two symptomatic cartilage defects who had failed 1 previous therapeutic surgical procedure in excess of 6 months prior were included. Dual primary outcome measures were used: (1) patient-completed Lysholm knee score and (2) time from surgery to cessation of treatment benefit. Secondary outcome measures included International Knee Documentation Committee and Cincinnati Knee Rating System scores, as well as number of serious adverse events. Analysis was performed on an intention-to-treat basis., Results: Lysholm scores were improved by 1 year in both groups (15.4 points [95% CI, 11.9 to 18.8] and 15.2 points [95% CI, 11.6 to 18.9]) for ACI and alternative, with this improvement sustained over the duration of the trial. However, no evidence of a difference was found between the groups at 5 years (2.9 points; 95% CI, -1.8 to 7.5; P = .46). Approximately half of the participants (55%; 95% CI, 47% to 64% with ACI) were still experiencing benefit at 5 years, with time to cessation of treatment benefit similar in both groups (hazard ratio, 0.97; 95% CI, 0.72 to 1.32; P > .99). There was a differential effect on Lysholm scores in patients without previous marrow stimulation compared with those with marrow stimulation ( P = .03; 6.4 points in favor of ACI; 95% CI, -0.4 to 13.1). More participants experienced a serious adverse event with ACI ( P = .02)., Conclusion: Over 5 years, there was no evidence of a difference in Lysholm scores between ACI and alternative management in patients who had previously failed treatment. Previous marrow stimulation had a detrimental effect on the outcome of ACI., Registration: International Standard Randomised Controlled Trial Number: 48911177.

Introduction: Early results using injectable autologous chondrocyte implantation (ACI) for the treatment of full thickness acetabular cartilage defects have been promising. However, so far there is no information on radiological results after injectable ACI using spheroids. The purpose of this sturdy was to (1) investigate the quality of tissue repair on MRI and (2) investigate the correlation between the MRI results and clinical results at a minimum follow-up of 24 months after third generation ACI in full thickness acetabular cartilage defects. It was hypothesized that ACI shows good MRI results in patients with large full thickness acetabular cartilage defects 24 months after surgery. It was also hypothesized that there is a correlation between postoperative clinical and MRI morphological results at a minimum follow-up of 24 months., Study Design: Retrospective case series., Materials and Methods: Patients with ACI for full thickness acetabular cartilage defects > 2 cm 2 were evaluated by preoperative and postoperative clinical scoring tools including the modified Harris Hip Score (mHHS), the International Hip Outcome Tool (iHOT-33), and the Subjective Hip Value (SHV) as well as a high resolution indirect arthro-MRI 24 months after surgery utilizing an identical imaging protocol for all patients. The magnetic resonance observation of cartilage repair tissue (MOCART) scoring system was used to classify the repair tissue on MRI. Demographic patient data was evaluated for influencing factors for pre- and postoperative clinical as well as radiological results., Results: Thirty six consecutive patients (5 women/31 men, average age 32.9 years) had undergone two stage ACI procedure. The average size of the cartilage defect was 5.0 (2-6) cm 2 . The average follow-up was 29.9 (24-42) months. Four patients were not available for the final follow-up (follow-up rate 89%). The postoperative average MOCART score was 82.2 (± 14.2). MOCART score showed medium correlation of the item defect fill and the postoperative mHHS (r = 0.384, p = 0.043). There was no correlation of the other items or the total score with postoperative results. The patients showed significant improvement in the outcome measurements between preoperative and postoperative in the mHHS, the iHOT-33, and the SHV., Conclusions: Despite the large acetabular cartilage defects included in this study, ACI showed good MRI results with complete defect fill in 87.5% after a minimum 24-month follow-up. Statistically significant correlation of MRI and clinical results could only be seen with the item defect fill. Further research with longer follow-up is needed to evaluate the long-term results of ACI in acetabular cartilage defects., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Loose bodies (LBs) from patients with osteochondritis dissecans (OCD) are usually removed and discarded during surgical treatment of the defect. In this study, we address the question of whether these LBs contain sufficient viable and functional chondrocytes that could serve as a source for autologous chondrocyte implantation (ACI) and how the required prolonged in vitro expansion affects their phenotype. Chondrocytes were isolated from LBs of 18 patients and compared with control chondrocyte from non-weight-bearing joint regions ( n = 7) and bone marrow mesenchymal stromal cells (BMSCs, n = 6) obtained during primary arthroplasty. No significant differences in the initial cell yield per isolation and the expression of the chondrocyte progenitor cell markers CD44 + /CD146+ were found between chondrocyte populations from LBs (LB-CH) and control patients (Ctrl-CH). During long-term expansion, LB-CH exhibited comparable viability and proliferation rates to control cells and no ultimate cell cycle arrest was observed within 12 passages respectively 15.3 ± 1.1 mean cumulative populations doublings (CPD). The chondrogenic differentiation potential was comparable between LB-CH and Ctrl-CH, but both groups showed a significantly higher ability to form a hyaline cartilage matrix in vitro than BMSC. Our data suggest that LBs are a promising cell source for obtaining qualitatively and quantitatively suitable chondrocytes for therapeutic applications, thereby circumventing donor site morbidity as a consequence of the biopsies required for the current ACI procedure.

Smoking is known to have various deleterious effects on health. However, it is not clear whether smoking negatively affects the postoperative outcome following matrix-based autologous cartilage implantation (MACI) in the knee. The purpose of this study was to evaluate the effect of smoking on the outcome of MACI in the knee. A total of 281 patients receiving MACI in the knee between 2015 and 2018 were registered in the German Cartilage Database. The cohort was divided into ex-smokers, smokers, and nonsmokers. Data regarding the Knee Injury and Osteoarthritis Outcome Score (KOOS), the numeric rating scale (NRS) for pain, and satisfaction with the outcome were analyzed and compared. Follow-ups were performed at 6, 12, and 24 months after surgery. Of the 281 patients, 225 (80.1%) were nonsmokers, 43 (15.3%) were smokers, and 13 (4.6%) were ex-smokers. The three groups were comparable with respect to age, sex, body mass index (BMI), height, defect size, the need for additional reconstruction of the subchondral bone defect, number of previous knee surgeries, and defect location. However, nonsmokers had a significantly lower weight as compared with smokers. Besides a significantly lower preoperative NRS of nonsmokers as compared with smokers, there were no significant differences between the three groups with respect to KOOS, NRS, and satisfaction at 6, 12, and 24 months of follow-ups. The present study of data retrieved from the German Cartilage Registry suggests that the smoking status does not influence the outcome of MACI in the knee., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: Matrix-induced autologous chondrocyte implantation (MACI) has shown promising results in the treatment of osteochondral lesions of the knee. A recent study showed similar viability comparing chondrocytes harvested from the intercondylar notch compared to those harvested from osteochondral loose bodies. However, there is limited evidence assessing how these different biopsies perform clinically. The goal of this study was to compare both radiographic and patient-reported outcomes in patients with patellar and femoral osteochondral lesions treated with MACI using either a standard intercondylar notch biopsy or an osteochondral loose body biopsy., Methods: A retrospective study was performed on all pediatric autologous chondrocyte implantation procedures performed from 2014 to 2017 at a single institution. Patients were divided into 2 groups: one group had cartilage derived from a standard intercondylar notch biopsy (n=9) and the other group had cartilage derived from an osteochondral loose body found within the ipsilateral knee (n=10). At a minimum of 1-year postimplantation, magnetic resonance imagings of the operative knee were performed and the Magnetic Resonance Observation of Cartilage Repair Tissue Knee Score (MOCART 2.0) knee score was used to assess the integrity and quality of the cartilage repair tissue. Interclass correlation coefficients were calculated between the 2 groups. International Knee Documentation Committee (IKDC) outcome scores were determined at a minimum 2 years post-implantation., Results: The interclass correlation coefficient between three independent examiners for the MOCART scoring was excellent at 0.94. With regards to the MOCART score, the loose body group had an insignificant 17-point lower median score at 63 [interquartile range (IQR): 58 to 89] compared to the intercondylar group at 80 (IQR: 65 to 90) ( P =0.15). There was no difference in IKDC scores with the loose body group having a median score of 82 (IQR: 65 to 95) and the intercondylar group having a median score of 84 (IQR: 53 to 99) ( P =0.90)., Conclusion: These results demonstrate that osteochondral loose bodies can be used as viable harvest site in MACI procedures with no difference in functional and radiographic outcomes at 2 years postimplantation. This may limit both short and long-term donor site morbidity., Level of Evidence: Level III-retrospective comparative study., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: More than 19% of patients undergoing knee arthroscopies suffers from articular cartilage defects. The chondral or osteochondral lesion has negative impacts on the knee joints function and the life quality of patients. However, the treatment remains challenging as hyaline cartilage is not renewable. The purpose of this study was to systematically analyze the data of randomized controlled trials for comparing the postoperative outcomes between osteochondral autologous transplantation (OAT) and microfracture (MF) procedure. We hypothesized that the outcomes were better in OAT than MF procedure., Materials and Methods: A systematic literature search of the EMBASE, Pubmed, and Cochrane Library databases was conducted based on PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The outcome measures include: the rate of excellent or good results, the rate of return to sports, the failure rate, osteoarthritis rate, International Cartilage Repair Society (ICRS) score, Lysholm Knee Score, and Tegner scale. The statistical analysis was completed using Review Manager (RevMan, version 5.3) software., Results: The systematic search identified 7 studies with a total of 346 patients. The pooled result showed significant differences between the two groups in the rate of return to sports and failure. The following outcome scores showed significant improvement (pre- vs postoperatively): Lysholm score (p = 0.02), Tegner scale (p < 0.00001), and ICRS score (p < 0.00001). The differences were not significant in the excellent or good results and the rate of osteoarthritis., Conclusion: The patients in OAT group may return to play quicker, even return to pre-injury level of activity compared to the MF group. OAT is better than MF procedure in accordance with Lysholm score, Tegner score, ICRS score, and the rate of failure. However, few studies have reported long-term outcomes and there has no uniform criteria for safe return to sports. Further research is needed., Level of Evidence: Level II, meta-analysis of randomized controlled trials., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objective: The effectiveness of autologous osteoperiosteal transplantation (AOPT) for the treatment of large cystic talar osteochondral lesions (OCLs) should be further evaluated, and the postoperative cartilage coverage is questionable. The purpose of this retrospective observational study was to investigate the clinical outcomes of AOPT for the treatment of large cystic talar OCLs and to report second-look arthroscopic results., Methods: From June 1, 2017, to June 1, 2021, all talar OCLs at our center were reviewed. Painful cystic lesions treated with AOPT were included in the study. The American Orthopaedic Foot and Ankle Society (AOFAS; 0-100 points) ankle-hindfoot score, Foot Function Index (FFI; 0-100 points), visual analog scale (VAS; 0-10 points) score, and Tegner score (0-10 points) were used to describe pain and functional outcomes. Furthermore, complications, patient-reported satisfaction degrees, imaging results (including computed tomography and magnetic resonance), and second-look arthroscopic evaluation data were also collected for analysis., Results: A total of 29 cases were eligible for the study, and 26 responded to the latest follow-up request, with a mean follow-up duration of 30.2 (range, 12-57) months. The AOFAS score improved from 69.2 ± 10.9 preoperatively to 80.9 ± 10.0 at the latest follow-up (p = 0.000). The FFI score improved from 30.4 ± 18.4 preoperatively to 16.3 ± 14.0 at the latest follow-up (p = 0.000). The VAS pain score improved from 4.0 ± 2.1 preoperatively to 2.5 ± 2.0 at the latest follow-up (p = 0.001). No donor site morbidity was found. The mean postoperative MOCART score was 57.7 ± 9.5. Second-look arthroscopy showed a fibrillated cartilage-like surface at the lesion site in most cases, while two cases exhibited a nearly normal surface., Conclusion: The transplantation of osteoperiosteal cylinder autografts taken from the iliac crest for the treatment of large cystic talar OCLs yielded acceptable clinical results. Good integration of the bony part was observed, but cartilage regeneration remained uncertain., (© 2022 The Authors. Orthopaedic Surgery published by Tianjin Hospital and John Wiley & Sons Australia, Ltd.)

Objective: The objective of this study was to evaluate the best available mid- to long-term evidence of surgical procedures for the treatment of localized full-thickness cartilage defects of the knee., Design: Systematic review using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines of Level 1 randomized clinical trials (RCTs), meta-analyses of RCTs and systematic reviews with a minimum follow-up of 5 years. Data extracted included patient demographics, defect characteristics, clinical and radiological outcomes, as well as treatment failures., Results: Six RCTs and 3 Level 1 systematic reviews were included. Two RCTs compared microfracture (MFx) to periosteum-covered autologous chondrocyte implantation (ACI-P), 1 to matrix-associated ACI (M-ACI) and 2 to osteochondral autograft transplantation (OAT). One study compared OAT to collagen membrane covered ACI (ACI-C). The 3 Level 1 systematic reviews/meta-analyses assessed the outcome of MFx, OAT, and various ACI methods in RCTs. OAT showed significantly better outcomes compared with MFx. In the 2 RCTs comparing ACI-P and MFx, no significant differences in clinical outcomes were seen, whereas significantly better outcomes were reported for M-ACI versus MFx in 1 study including patients with larger defects (5 cm 2 ), and for ACI-C versus OAT in terms of Cincinnati Score. Higher failure rates were reported for MFx compared with OAT and for OAT compared with ACI-C, while no significant differences in failure rates were observed for ACI-P compared to MFx., Conclusion: Restorative cartilage procedures (ACI-C or M-ACI and OAT) are associated with better long-term clinical outcomes including lower complication and failure rates when compared with reparative techniques (MFx). Among the restorative procedures, OAT seems to be inferior to ACI especially in larger defects after longer follow-up periods., Level of Evidence: Level I: Systematic review of Level I studies.

We aimed to investigate the local application methods of platelet-rich plasma (PRP) and the effect and safety of PRP scaffolding combined with osteochondral autograft transfer (OAT) in the treatment of full-thickness articular cartilage defects of the femoral condyle. Patients with cartilage defects of the femoral condyle were treated with OAT combined with PRP scaffolding between July 2017 and December 2020. Preoperative magnetic resonance imaging (MRI) and computed tomography were utilized to assess the size, location, and severity of the osteochondral defects. X-ray and MRI images of the knee were obtained at the final follow-up to assess the osseointegration and integrity of the implanted articular cartilage. Osteoarthritic changes in the knee joint were evaluated using the Kellgren-Lawrence grading system. Clinical status was assessed using the visual analog scale (VAS), International Knee Documentation Committee (IKDC), and Lysholm scores before the treatment and at the final follow-up. Complications and patient satisfaction were recorded to assess the safety of this combination therapy. Twenty-one patients were recruited, with a mean follow-up duration of 18.23 ± 6.84 months. The mean lesion size was 2.3 ± 0.59 cm 2 . The mean platelet concentration in PRP at baseline was 6.27 ± 0.63 times greater than that in the peripheral blood. The VAS, IKDC, and Lysholm scores had improved significantly at the final follow-up ( P < 0.001). No serious complications such as joint infection, deep venous thrombosis, or hematoma were observed. Eighteen patients (85.72%) were satisfied with their knee function and quality of life at the final follow-up. Three patients (14.28%) complained of mild anterior knee pain, which was relieved by oral administration of nonsteroidal anti-inflammatory drugs. MRI examinations of all patients showed bony consolidation and the defect surface was covered with cartilage-like tissue. X-ray evaluations indicated that osteoarthritis in two knees (9.5%) had progressed from grade 1 to grade 2 at the final follow-up. The preliminary results showed that OAT combined with PRP may be a safe and effective technique for the treatment of full-thickness articular cartilage defects in the knee., (Creative Commons Attribution license.)

Purpose: To investigate clinical and magnetic resonance (MR) imaging results of patients undergoing patella stabilization with either open flake refixation (oFR) or autologous chondrocyte implantation (ACI) and concomitant soft tissue patella stabilization after sustaining primary, acute patella dislocation with confirmed chondral and/or osteochondral flake fractures. It was hypothesized that refixation will lead to better results than ACI at mid-term follow-up., Methods: A retrospective chart review was conducted to identify all patients undergoing oFR or ACI after sustaining (osteo-)chondral flake fractures and concomitant soft tissue patella stabilization following primary, acute patella dislocation between 01/2012 and 09/2018 at the author's institution. Patients were excluded if they were aged < 14 years or > 30 and had previous knee surgeries at the index knee. Clinical outcomes were assessed using the Tegner activity score, Kujala score, subjective IKDC score, and the KOOS score at a minimum follow-up of 24 months postoperatively. MR images were assessed using the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) 2.0 knee score. Thirty patients were included in the study, with 16 patients assorted to the oFR group and 14 patients to the ACI group (Follow-up 81%)., Results: Demographic data did not show significant group differences (oFR: 6 females, 10 males; age 26.9 ± 5.6 years, FU: 57 months (27-97 months); ACI: 9 females, 5 males; age 25.5 ± 4.9 years, FU: 51 months (29-91 months); n.s.). Defect location was similar in both groups (oFR: 12 × patella/4 × lateral femoral condyle; ACI: 12/2; n.s.). Both groups showed excellent clinical outcomes, with no statistically significant difference between both the groups (oFR group vs. ACI group: Tegner: 5.1 ± 1.8 vs. 5.1 ± 1.4; Kujala: 86.1 ± 12.6 vs. 84.9 ± 9.1; IKDC: 83.8 ± 15.0 vs. 83.6 ± 11.3; KOOS: 83.3 ± 14.0 vs. 83.6 ± 12.0; n.s.). One patient in each group suffered a patella re-dislocation and needed revision surgery. The MOCART 2.0 score showed good results for the oFR group (68.2 ± 11.1) and the ACI group (61.1 ± 16.9) while no significant differences were noted between both the groups. The inter-rater reliability was excellent (0.847)., Conclusion: Open refixation of (osteo-)chondral fragments in patients after sustaining acute patella dislocation with (osteo)-chondral flake fractures led to good clinical and radiological results at a minimum follow of 24 months, showing that it is a good surgical option in the treatment algorithm. However, if open refixation is not possible, ACI may be an excellent fallback option in these younger patients with equally good clinical and radiological outcomes, but requiring a second minimally invasive surgery., Level of Evidence: III., (© 2022. The Author(s).)

Background: In 2011, the European Foot and Ankle Society developed a Score (EFAS Score) to generate a standardized questionnaire for several European languages. The aim of this study is to analyse how the newly defined score correlates with already established function scores., Methods: This study is a monocentric prospective study. The questionnaires were completed at least 12 months postoperatively at the same time point. All patients had undergone surgery with the Autologous Matrix-Induced Chondrogenesis® procedure for osteochondral lesions of the talus., Results: A total of 69 patients (33 women, 36 men) participated in the study. The EFAS Score correlates very strongly with the Manchester-Oxford Foot Questionnaire (MOXFQ) and strongly with the Foot Function Index (FFI)., Conclusion: This study shows that the EFAS Score correlates significantly with the FFI and the MOXFQ. The EFAS seems to be a more patient-friendly alternative due to fewer questions and response choices., Competing Interests: Declarations of Competing Interest The declaration of competing interest is none., (Copyright © 2022 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.)

Purpose: Scaffold-based autologous chondrocyte implantation is a well-established treatment for cartilage defects in the knee joint. Hydrogel-based autologous chondrocyte implantation using an in situ polymerizable biomaterial is a relatively new treatment option for arthroscopic cartilage defects. It is therefore important to determine if there are significant differences in the outcomes. The aim of this study is to compare the outcomes (using subjective parameters) of hydrogel-based autologous chondrocyte implantation (NOVOCART ® Inject) with the outcomes of scaffold based autologous chondrocyte Implantation (NOVOCART ® 3D) using biphasic collagen scaffold., Methods: The data of 50 patients, which were paired with 25 patients in each treatment group, was analyzed. The main parameters used for matching were gender, number of defects and localization. Both groups were compared based on Visual Analogue Scale (VAS) and subjective IKDC scores, both of which were examined pre-operatively and after 6, 12 and 24 months., Results: Significant benefits in both VAS and IKDC scores after 2 years of follow-up in both groups were found. Comparing the groups, the results showed that in the hydrogel-based autologous chondrocyte implantation group, significant changes in IKDC scores are measurable after 6 months, while it takes 12 months until they are seen in the scaffold based autologous chondrocyte group., Conclusion: Hydrogel-based autologous chondrocyte and scaffold based autologous chondrocyte show comparable improvements and significant benefits to the patients' subjective well-being after a 2-year-follow-up., Level of Evidence: III., (© 2022. The Author(s).)

Background: To analyze the outcomes of Bone marrow aspirate concentrate and Matrix-Induced Chondrogenesis (BMIC) in Osteochondral Lesions of the Talus (OLTs)., Methods: Patients with OLTs treated with BMIC from June 2013 to July 2020 were included. Visual Analogue Scale (VAS), Foot Function Index (FFI), and Foot Ankle Outcome Score (FAOS) before treatment and at last follow-up were subjected to analysis., Results: Forty-five patients were included and mean follow-up was 39.1 months (range, 13-97 months). Mean lesion size and depth were 180.7 ± 110.4 mm 2 and 9.6 ± 3.7 mm, respectively. BMIC was performed without malleolar osteotomy in 36 patients (80%) and bone graft was performed in 42 (93.3%). VAS, FFI, and FAOS improved significantly. No complication occurred and no revision was required., Conclusions: The BMIC procedure is feasible and should be considered a viable treatment option for OLTs associated with large subchondral bone defects., (Copyright © 2022 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.)

Autologous matrix induced chondrogenesis (AMIC) is a bone marrow stimulating technique used for the surgical management of chondral defects of the talus. The present study evaluated the clinical outcomes and imaging of AMIC as revision procedure for failed AMIC surgery for osteochondral defects of the talus. Forty-eight patients with symptomatic osteochondral defects who received a revision AMIC were evaluated after a minimum of two years follow-up. Patients with previous procedures rather than AMIC, those who required additional surgical procedures (e.g. ligament repair or deformity correction), or those who had evidence of kissing, bilateral, or multiple lesions were excluded. Outcome parameters included the Visual Analogic Scale (VAS), Tegner Activity Scale, the American Orthopedic Foot and Ankle Score (AOFAS), and the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score. All patients were followed by an assessor who was not involved in the clinical management. 27 patients were enrolled in the present study. The mean age of the patient was 34.9 ± 3.1 years, and the mean BMI 27.2 ± 5.1 kg/m 2 . The mean defect surface area was 2.8 ± 1.9 cm 2 . The mean follow-up was 44.3 ± 21.4 months. The mean hospital length of stay was 4.4 ± 1.4 days. At final follow-up, the mean VAS score was 4.1 ± 3.1, the mean Tegner 3.5 ± 1.6, the mean AOFAS 58.8 ± 20.6. The preoperative MOCART score was 22.1 ± 13.7 points, the postoperative MOCART score was 42.3 ± 27.9 points (+ 20.2%; P = 0.04), respectively. 30% (8 of 27 patients) experienced persistent pain and underwent a further chondral procedure. Concluding, AMIC could be a viable option as revision procedure for failed AMIC in recurrent symptomatic osteochondral defects of the talus. The PROMs indicated that patients were moderately satisfied with the procedure, and the MOCART score demonstrated a significant improvement from baseline to the last follow-up. A deeper understanding in prognostic factors and patient selection is critical to prevent failures., (© 2022. The Author(s).)

Background: Autologous chondrocyte implantation (ACI) can be used to treat focal, full-thickness chondral defects of the knee. However, there is limited large-sample evidence available regarding the incidence, timing, and risk factors for revision surgery after ACI., Purpose: To assess the 5-year incidence, timing, and risk factors for revision surgery after ACI in a large national cohort., Study Design: Case series; Level of evidence, 4., Methods: The 2010-2020 PearlDiver database was queried for patients aged 20 to 59 years who underwent primary ACI of the knee without previous chondral procedures or knee arthroplasty. Revision surgery was defined as subsequent revision ACI, osteochondral allograft transplantation, osteochondral autograft transfer, unicompartmental knee arthroplasty, or total knee arthroplasty within 5 years. Kaplan-Meier analysis was used to assess both incidence and timing of revision surgery. Risk factors evaluated for revision surgery included patient age, sex, body mass index (BMI), Elixhauser Comorbidity Index (ECI) score, and previous or concomitant bony realignment procedures., Results: In total, 533 patients underwent primary ACI and met inclusion criteria. The 5-year incidence of revision surgery was 10.3%, with 63% of revisions occurring in the first 2 years after surgery. Risk factors associated with revision surgery included female sex (odds ratio, 2.58; 95% CI, 1.22-5.45; P = .013) and BMI ≥35 (odds ratio, 2.24; 95% CI, 1.01-4.94; P = .047). There was no relationship between age, ECI score, or previous or concomitant bony realignment procedures and revision surgery at 5 years ( P > .05)., Conclusion: In an analysis of 533 patients who underwent ACI, 10.3% required a subsequent articular cartilage procedure or conversion to knee arthroplasty in the first 5 postoperative years. Revision surgery was greatest in the first 2 postoperative years. Female sex and severe obesity (BMI, ≥35) were associated with increased risk of revision surgery, while age, ECI score, and previous or concomitant bony realignment procedures were not. These findings suggest that treatment of chondral defects of the knee with ACI is associated with durable outcomes at the 5-year follow-up.