Cartiform Implantation for focal cartilage defects in the knee: A 2-year clinical and magnetic resonance imaging follow-up study
Introduction
The rise in sports participation in the young and middle-aged population has led to an increased prevalence and incidence of focal articular cartilage defects in these patients.1, 2, 3 The management of articular cartilage defects presents one of the most challenging clinical problems for orthopaedic surgeons. Given the limited potential for intrinsic healing of articular cartilage, these patients are at an increased risk of debilitating joint pain, dysfunction, and degenerative arthritis.2, 3, 4, 5, 6, 7, 8 Current cartilage restoration procedures include marrow stimulation (e.g. microfracture), autologous surface cellular procedures such as autologous chondrocyte implantation (ACI) and matrix-associated chondrocyte implantation (MACI), allograft surface cellular procedures (e.g. particulated juvenile articular cartilage and micronized adult articular cartilage), osteochondral autograft transfer system (OATS) procedure and osteochondral allograft (OCA) implantation.4,9, 10, 11, 12, 13, 14, 15, 16, 17 Each restoration technique has its own advantages and disadvantages.4,18
The management of larger defects (>2 cm2), International Cartilage Repair Society (ICRS) Grade 3 (>50% articular cartilage) and Grade 4 (full-thickness defect extending to the subchondral bone), presents specific challenges. For example, the donor-site morbidity associated with OATS limits the cartilage defect size that can be treated. ACI/MACI involves a minimum of two surgeries, one for tissue harvest and the other for cell implantation. ACI/MACI procedures are very expensive, and complications related to graft implantation such as tissue hypertrophy have been reported, particularly with ACI.19, 20, 21, 22 Patients who have uncontained, inaccessible, multiple, or very large lesions; subchondral sclerosis; or advanced degenerative changes are not typically suitable candidates for MACI implantation. Additionally, the timeline for return to running and to full sports is extensive.23, 24, 25
Fresh OCA implantation is a cartilage restoration procedure that involves the implantation of a cadaver graft consisting of intact articular cartilage and its subchondral bone into the defect. Advantages of the procedure include immediate implantation in a single surgery, lack of donor-site morbidity, and the ability to restore large defects, including those with poor containment. Fresh OCA allograft offers the advantage of implanting refrigerated cartilage with viable chondrocytes. The disadvantages of fresh OCA include the increased potential of disease transmission, the immune response to the subchondral bone, a moderate frequency of reactive synovitis, graft cost, graft availability, and surgical time constraints given graft expiration within a few weeks.26
Several studies have been performed to assess the outcomes of the above procedures, but there is little data evaluating the use of cryopreserved OCAs. Cartiform (Arthrex; Naples, FL) is a cryopreserved viable osteochondral allograft (CVOCA) that is a surface graft. Advantages of CVOCA include a shelf life of 2 years when stored at −80 °C, ease of implantation, and favorable cost and accessibility in comparison to fresh OCA and ACI/MACI.27, 28, 29 Additionally, the grafts can be used with moderately and poorly contained lesions. When the subchondral bone is involved, bone graft can be placed deep to the graft prior to implantation in the same stage.
The purpose of this study is to evaluate both the clinical and MRI outcomes of patients who have undergone CVOCA implantation for the treatment of ICRS Grade 3 and 4 cartilage defects in the knee 2-years postoperatively. We hypothesized that CVOCA will provide a successful surgical treatment for high-grade, focal articular cartilage defects of the knee, with minimal failure rates, both clinically and radiographically.
Section snippets
Patient selection
After institutional review board approval (HP-00066115), we retrospectively identified all patients who underwent CVOCA implantation by the senior surgeon (CHB) at a single center from 2013 to 2015. Patients who underwent concomitant surgery to the knee where the CVOCA was implanted were also included. Many of these patients had undergone concomitant meniscal or ligament surgery. These patients were included, as it is important to understand the results of CVOCA implantation both with and
Results
Twelve patients who underwent CVOCA implantation between 2013 and 2015 by the senior surgeon (CHB) satisfied the inclusion and exclusion criteria for this study and were available for follow-up. The mean follow-up was 2.1 years (range, 2.0–2.3 years). Participant demographics are provided in Table 1. There were 6 females and 6 males with a mean age of 46.2 years (range, 28.2–59.2). Ten patients participated in recreational sports, 3 patients were competitive sport athletes, and 5 patients were
Discussion
This retrospective follow-up study of 12 patients at a minimum of 2 years after CVOCA implantation demonstrates satisfactory outcomes with respect to patient reported outcomes and MRI imaging. There were no reported complications or graft failures, and patients reliably returned to activity. One MFC graft patient (patient 7) underwent a successful repeat arthroscopy for pain in the lateral compartment. The average cartilage defect and graft size was 2.4 cm2 (range, 0.9–4.8 cm2), putting the
Conclusion
To the best of our knowledge, this is the largest series to report clinical and MRI outcomes in patients undergoing CVOCA implantation for the treatment of focal cartilage defects in the knee. The implant demonstrated no clinical or MRI failures and no complications at 2-year follow-up. The short term results were comparable to outcomes of fresh OCA. Longer-term clinical outcomes and cost analyses of the CVOCA in comparison to other cartilage grafting techniques remain to be determined.
Funding
Institutional research funding from Arthrex related to this work.
Approval
This study was approved by the Institutional Review Board (IRB) Committee at the University of Maryland, Baltimore (HP-00066115).
Declaration of competing interest
Dr. Craig H. Bennett is an Arthrex Consultant.
Dr. Henn reports non-financial research support from Arthrex, Inc., related to the submitted work.
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