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Arthroscopic gel-type autologous chondrocyte implantation presents histologic evidence of regenerating hyaline-like cartilage in the knee with articular cartilage defect

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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

To investigate the clinical, radiological, and histological results of arthroscopic gel-type autologous chondrocyte implantation (GACI) in treating chondral defects of the knee.

Methods

This study prospectively examined five males and five females with a mean age of 40.3 ± 10.3 years who underwent arthroscopic GACI between March 2012 and February 2013. The gel comprised a mixture of 1 ml of fibrinogen plus 0.1–0.2 ml of thrombin. The mean size of chondral defect was 2.9 ± 1.2 cm2 (range 1.2–5.4 cm2). International knee documentation committee (IKDC) subjective score, knee injury and osteoarthritis outcome score (KOOS), knee society score, and visual analog scale (VAS) for pain were assessed preoperatively and during regular follow-up examinations performed for up to 5 years postoperatively. Serial magnetic resonance imaging was performed for up to 2 years after the surgery to observe healing, using the modified magnetic resonance observation of cartilage repair tissue (MOCART) score. In eight patients, second-look arthroscopy was performed at 1 year after the implantation to assess the status of treated cartilage, and a portion of regenerated cartilage was harvested for histologic evaluation.

Results

The mean VAS score (p = 0.045), IKDC subjective score (p = 0.041), KOOS pain (p = 0.025), KOOS activities of daily living (p = 0.048), and KOOS quality of life (p = 0.029) showed significant improvement at 5 years after the surgery. The modified MOCART evaluation showed that the scores were 59.5 ± 29.4 and 85.0 ± 8.0 at 12 weeks and 2 years after the operation, respectively. Histologic examination demonstrated a mean regenerated cartilage thickness of 3.5 ± 0.8 mm and a mean Oswestry score of 8.2 ± 1.8. Immunohistochemistry analysis showed that the expression of collagen type II was more evident and more evenly distributed than collagen type I in regenerated cartilage. There was a significant correlation between Oswestry score and change in VAS scale from postoperative 2–5 years.

Conclusions

Arthroscopic GACI produces satisfactory clinical and radiologic outcomes, and histologic evaluation confirms sufficient regeneration of hyaline-like cartilage that correlates with improved symptoms. Therefore, it is an acceptable, minimally invasive, and technically simple option for the restoration of cartilage defects of the knee.

Level of evidence

IV.

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Abbreviations

GACI:

Gel-type autologous chondrocyte implantation

IKDC:

International knee documentation committee

KOOS:

Knee injury and osteoarthritis outcome score

VAS:

Visual analog scale

MOCART:

Magnetic resonance observation of cartilage repair tissue

ACI:

Autologous chondrocyte implantation

MACI:

Matrix-induced autologous chondrocyte implantation

ICRS:

International cartilage repair society

KSS:

Knee society score

MRI:

Magnetic resonance imaging

ACL:

Activities of daily living

QOL:

Quality of life

References

  1. Alford JW, Cole BJ (2005) Cartilage restoration, part 1: basic science, historical perspective, patient evaluation, and treatment options. Am J Sports Med 33:295–306

    Article  Google Scholar 

  2. Basad E, Ishaque B, Bachmann G, Sturz H, Steinmeyer J (2010) Matrix-induced autologous chondrocyte implantation versus microfracture in the treatment of cartilage defects of the knee: a 2-year randomised study. Knee Surg Sports Traumatol Arthrosc 18:519–527

    Article  Google Scholar 

  3. Buckwalter JA, Mankin HJ (1998) Articular cartilage: degeneration and osteoarthritis, repair, regeneration, and transplantation. Instr Course Lect 47:487–504

    CAS  PubMed  Google Scholar 

  4. Campbell AB, Pineda M, Harris JD, Flanigan DC (2016) Return to sport after articular cartilage repair in athletes’ knees: a systematic review. Arthroscopy 32:651.e651–668.e651

    Article  Google Scholar 

  5. Choi NY, Kim BW, Yeo WJ, Kim HB, Suh DS, Kim JS et al (2010) Gel-type autologous chondrocyte (Chondron) implantation for treatment of articular cartilage defects of the knee. BMC Musculoskelet Disord 11:103

    Article  Google Scholar 

  6. Dhollander AA, Verdonk PC, Lambrecht S, Verdonk R, Elewaut D, Verbruggen G et al (2012) Short-term outcome of the second generation characterized chondrocyte implantation for the treatment of cartilage lesions in the knee. Knee Surg Sports Traumatol Arthrosc 20:1118–1127

    Article  CAS  Google Scholar 

  7. DiBartola AC, Everhart JS, Magnussen RA, Carey JL, Brophy RH, Schmitt LC et al (2016) Correlation between histological outcome and surgical cartilage repair technique in the knee: A meta-analysis. Knee 23:344–349

    Article  Google Scholar 

  8. Ebert JR, Fallon M, Wood DJ, Janes GC (2017) A Prospective clinical and radiological evaluation at 5 years after arthroscopic matrix-induced autologous chondrocyte implantation. Am J Sports Med 45:59–69

    Article  Google Scholar 

  9. Ebert JR, Schneider A, Fallon M, Wood DJ, Janes GC (2017) A comparison of 2-year outcomes in patients undergoing tibiofemoral or patellofemoral matrix-induced autologous chondrocyte implantation. Am J Sports Med 45:3243–3253

    Article  Google Scholar 

  10. Ebert JR, Smith A, Fallon M, Wood DJ, Ackland TR (2014) Correlation between clinical and radiological outcomes after matrix-induced autologous chondrocyte implantation in the femoral condyles. Am J Sports Med 42:1857–1864

    Article  Google Scholar 

  11. Enea D, Cecconi S, Busilacchi A, Manzotti S, Gesuita R, Gigante A (2012) Matrix-induced autologous chondrocyte implantation (MACI) in the knee. Knee Surg Sports Traumatol Arthrosc 20:862–869

    Article  Google Scholar 

  12. Filardo G, Kon E, Andriolo L, Di Matteo B, Balboni F, Marcacci M (2014) Clinical profiling in cartilage regeneration: prognostic factors for midterm results of matrix-assisted autologous chondrocyte transplantation. Am J Sports Med 42:898–905

    Article  Google Scholar 

  13. Gille J, Behrens P, Schulz AP, Oheim R, Kienast B (2016) Matrix-associated autologous chondrocyte implantation: a clinical follow-up at 15 years. Cartilage 7:309–315

    Article  Google Scholar 

  14. Gooding CR, Bartlett W, Bentley G, Skinner JA, Carrington R, Flanagan A (2006) A prospective, randomised study comparing two techniques of autologous chondrocyte implantation for osteochondral defects in the knee: periosteum covered versus type I/III collagen covered. Knee 13:203–210

    Article  CAS  Google Scholar 

  15. Jin YZ, Lee JH (2018) Mesenchymal stem cell therapy for bone regeneration. Clin Orthop Surg 10:271–278

    Article  Google Scholar 

  16. Kim MK, Choi SW, Kim SR, Oh IS, Won MH (2010) Autologous chondrocyte implantation in the knee using fibrin. Knee Surg Sports Traumatol Arthrosc 18:528–534

    Article  Google Scholar 

  17. Kirilak Y, Pavlos NJ, Willers CR, Han R, Feng H, Xu J et al (2006) Fibrin sealant promotes migration and proliferation of human articular chondrocytes: possible involvement of thrombin and protease-activated receptors. Int J Mol Med 17:551–558

    CAS  PubMed  Google Scholar 

  18. Knutsen G, Engebretsen L, Ludvigsen TC, Drogset JO, Grontvedt T, Solheim E et al (2004) Autologous chondrocyte implantation compared with microfracture in the knee. A randomized trial. J Bone Joint Surg Am 86-a:455–464

    Article  Google Scholar 

  19. Konst YE, Benink RJ, Veldstra R, van der Krieke TJ, Helder MN, van Royen BJ (2012) Treatment of severe osteochondral defects of the knee by combined autologous bone grafting and autologous chondrocyte implantation using fibrin gel. Knee Surg Sports Traumatol Arthrosc 20:2263–2269

    Article  Google Scholar 

  20. Kreuz PC, Kalkreuth RH, Niemeyer P, Uhl M, Erggelet C (2018) Long-term clinical and MRI results of matrix-assisted autologous chondrocyte implantation for articular cartilage defects of the knee. Cartilage. https://doi.org/10.1177/19476035187564631947603518756463

    Article  PubMed  PubMed Central  Google Scholar 

  21. Marlovits S, Striessnig G, Resinger CT, Aldrian SM, Vecsei V, Imhof H et al (2004) Definition of pertinent parameters for the evaluation of articular cartilage repair tissue with high-resolution magnetic resonance imaging. Eur J Radiol 52:310–319

    Article  Google Scholar 

  22. Munirah S, Samsudin OC, Chen HC, Salmah SH, Aminuddin BS, Ruszymah BH (2007) Articular cartilage restoration in load-bearing osteochondral defects by implantation of autologous chondrocyte-fibrin constructs: an experimental study in sheep. J Bone Joint Surg Br 89:1099–1109

    Article  CAS  Google Scholar 

  23. Nawaz SZ, Bentley G, Briggs TW, Carrington RW, Skinner JA, Gallagher KR et al (2014) Autologous chondrocyte implantation in the knee: mid-term to long-term results. J Bone Joint Surg Am 96:824–830

    Article  Google Scholar 

  24. Niemeyer P, Salzmann G, Feucht M, Pestka J, Porichis S, Ogon P et al (2014) First-generation versus second-generation autologous chondrocyte implantation for treatment of cartilage defects of the knee: a matched-pair analysis on long-term clinical outcome. Int Orthop 38:2065–2070

    Article  Google Scholar 

  25. Nixon AJ, Sparks HD, Begum L, McDonough S, Scimeca MS, Moran N et al (2017) Matrix-induced autologous chondrocyte implantation (MACI) using a cell-seeded collagen membrane improves cartilage healing in the equine model. J Bone Joint Surg Am 99:1987–1998

    Article  Google Scholar 

  26. Ogura T, Bryant T, Minas T (2017) Long-term outcomes of autologous chondrocyte implantation in adolescent patients. Am J Sports Med 45:1066–1074

    Article  Google Scholar 

  27. Ogura T, Bryant T, Mosier BA, Minas T (2018) Autologous chondrocyte implantation for bipolar chondral lesions in the tibiofemoral compartment. Am J Sports Med 46:1371–1381

    Article  Google Scholar 

  28. Ogura T, Mosier BA, Bryant T, Minas T (2017) A 20-year follow-up after first-generation autologous chondrocyte implantation. Am J Sports Med 45:2751–2761

    Article  Google Scholar 

  29. Oussedik S, Tsitskaris K, Parker D (2015) Treatment of articular cartilage lesions of the knee by microfracture or autologous chondrocyte implantation: a systematic review. Arthroscopy 31:732–744

    Article  Google Scholar 

  30. Roberts S, McCall IW, Darby AJ, Menage J, Evans H, Harrison PE et al (2003) Autologous chondrocyte implantation for cartilage repair: monitoring its success by magnetic resonance imaging and histology. Arthritis Res Ther 5:R60–R73

    Article  Google Scholar 

  31. Ruta DJ, Villarreal AD, Richardson DR (2016) Orthopedic surgical options for joint cartilage repair and restoration. Phys Med Rehabil Clin N Am 27:1019–1042

    Article  Google Scholar 

  32. Samsudin EZ, Kamarul T (2016) The comparison between the different generations of autologous chondrocyte implantation with other treatment modalities: a systematic review of clinical trials. Knee Surg Sports Traumatol Arthrosc 24:3912–3926

    Article  Google Scholar 

  33. Saris DB, Vanlauwe J, Victor J, Haspl M, Bohnsack M, Fortems Y et al (2008) Characterized chondrocyte implantation results in better structural repair when treating symptomatic cartilage defects of the knee in a randomized controlled trial versus microfracture. Am J Sports Med 36:235–246

    Article  Google Scholar 

  34. Siebold R, Suezer F, Schmitt B, Trattnig S, Essig M (2018) Good clinical and MRI outcome after arthroscopic autologous chondrocyte implantation for cartilage repair in the knee. Knee Surg Sports Traumatol Arthrosc 26:831–839

    Article  Google Scholar 

  35. Todd KH, Funk KG, Funk JP, Bonacci R (1996) Clinical significance of reported changes in pain severity. Ann Emerg Med 27:485–489

    Article  CAS  Google Scholar 

  36. van Duijvenbode DC, Jonkers FJ, Konst YE, van Royen BJ, Benink RJ, Hoozemans MJ (2016) Gel-type autologous chondrocyte implantation for cartilage repair in patients with prior ACL reconstruction: a retrospective 2 year follow-up. Knee 23:241–245

    Article  Google Scholar 

Download references

Funding

This study was supported by a grant from Sewon Cellontech, and was approved by the IRB of Yonsei University College of Medicine.

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Authors and Affiliations

  1. Department of Orthopedic Surgery, Severance Hospital, Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea

    Tae-Hwan Yoon, Min Jung, Chong-Hyuk Choi, Hyoung-Sik Kim, Yun-Seok Choi & Sung-Hwan Kim

  2. Department of Radiology, Severance Biomedical Science Institute, Yonsei University College of Medicine, Seoul, Republic of Korea

    Young-Han Lee

  3. Department of Orthopedic Surgery, YonseSarang Hospital, Seoul, Republic of Korea

    Sung-Jae Kim

  4. Department of Orthopedic Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul, 06237, Republic of Korea

    Sung-Hwan Kim

Authors
  1. Tae-Hwan Yoon
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  2. Min Jung
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  4. Hyoung-Sik Kim
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Contributions

The project was coordinated by TH Yoon, SJ Kim, and SH Kim. TH Yoon drafted the manuscript, together with M Jung, HS Kim, YS Choi, CH Choi, and YH Lee. SH Kim generated the concept of the study. The design of the study, acquisition of data, analysis and interpretation of data were all done jointly by all authors. SJ Kim, HS Kim, and SH Kim revised the final draft critically for important intellectual content, and approved the version to be submitted. All of the authors agreed to be accountable for all aspects of the work to make sure that any questions related to its accuracy or integrity are appropriately investigated and resolved.

Corresponding author

Correspondence to Sung-Hwan Kim.

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Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

Prior to the study, we received approval from our institutional review board (IRB number:4-2012-0618).

Informed consent

Informed consent was obtained from all patients before their enrollment in the study.

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Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplement 1. Histologic results of eight patients who underwent biopsy during second-look arthroscopy, and MR images taken before surgery and at postoperative year 2.

Supplementary material 1 (DOCX 31477 kb)

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Yoon, TH., Jung, M., Choi, CH. et al. Arthroscopic gel-type autologous chondrocyte implantation presents histologic evidence of regenerating hyaline-like cartilage in the knee with articular cartilage defect. Knee Surg Sports Traumatol Arthrosc 28, 941–951 (2020). https://doi.org/10.1007/s00167-019-05572-6

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