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Comparison of Juvenile Allogenous Articular Cartilage and Bone

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Comparison of Juvenile Allogenous Articular Cartilage and Bone FAIXXX10.1177/1071100717746627Foot & Ankle InternationalKarnovsky et al 746627research-article2018 Article Foot & Ankle International® 2018, Vol. 39(4) 393 –405 Comparison of Juvenile Allogenous © The Author(s) 2018 Reprints and permissions: sagepub.com/journalsPermissions.nav Articular Cartilage and Bone Marrow DOI:https://doi.org/10.1177/1071100717746627 10.1177/1071100717746627 Aspirate Concentrate Versus Microfracture journals.sagepub.com/home/fai With and Without Bone Marrow Aspirate Concentrate in Arthroscopic Treatment of Talar Osteochondral Lesions In-Depth Sydney C. Karnovsky, BA1, Bridget DeSandis, BA1, Amgad M. Haleem, MD, PhD2,3, Carolyn M. Sofka, MD4, Martin O’Malley, MD5, and Mark C. Drakos, MD5 Abstract Background: The purpose of this study was to compare the functional and radiographic outcomes of patients who received juvenile allogenic chondrocyte implantation with autologous bone marrow aspirate (JACI-BMAC) for treatment of talar osteochondral lesions with those of patients who underwent microfracture (MF). Methods: A total of 30 patients who underwent MF and 20 who received DeNovo NT for JACI-BMAC treatment between 2006 and 2014 were included. Additionally, 17 MF patients received supplemental BMAC treatment. Retrospective chart review was performed and functional outcomes were assessed pre- and postoperatively using the Foot and Ankle Outcome Score and Visual Analog pain scale. Postoperative magnetic resonance images were reviewed and evaluated using a modified Magnetic Resonance Observation of Cartilage Tissue (MOCART) score. Average follow-up for functional outcomes was 30.9 months (range, 12-79 months). Radiographically, average follow-up was 28.1 months (range, 12-97 months). Results: Both the MF and JACI-BMAC showed significant pre- to postoperative improvements in all Foot and Ankle Outcome Score subscales. Visual Analog Scale scores also showed improvement in both groups, but only reached a level of statistical significance (P < .05) in the MF group. There were no significant differences in patient reported outcomes between groups. Average osteochondral lesion diameter was significantly larger in JACI-BMAC patients compared to MF patients, but size difference had no significant impact on outcomes. Both groups produced reparative tissue that exhibited a fibrocartilage composition. The JACI-BMAC group had more patients with hypertrophy exhibited on magnetic resonance imaging (MRI) than the MF group (P = .009). Conclusion: JACI-BMAC and MF resulted in improved functional outcomes. However, while the majority of patients improved, functional outcomes and quality of repair tissue were still not normal. Based on our results, lesions repaired with DeNovo NT allograft still appeared fibrocartilaginous on MRI and did not result in significant functional gains as compared to MF. Level of Evidence: Level III, comparative series. Keywords: osteochondral lesions, juvenile articular cartilage, DeNovo Natural Tissue graft, microfracture, arthroscopic treatment Osteochondral lesions (OCLs) of the talus are increasingly 1 recognized injuries that are commonly associated with Hospital for Special Surgery, New York, NY, USA 2Department of Orthopedic Surgery, Oklahoma University College of acute ankle sprains, fractures, and recurrent ankle instabil- Medicine Health Sciences Center, Oklahoma City, OK, USA ity. They present a challenging clinical problem due to the 3Department of Orthopedic Surgery, Kasr Al-Ainy College of Medicine, poor healing potential of articular hyaline cartilage. Cairo University, Cairo, Egypt 4 Conservative treatment is common in low-grade lesions Department of Radiology and Imaging, Hospital for Special Surgery, New York, NY, USA but has a high failure rate, with larger lesions often requir- 5 8,47 Department of Orthopedic Surgery, Foot and Ankle, Hospital for ing operative treatment. Microfracture (MF) has been Special Surgery, New York, NY, USA considered the primary treatment for symptomatic OCLs as it is a simple, single stage procedure that can be per- Corresponding Author: Sydney C. Karnovsky, BA, Hospital for Special Surgery, 535 E 70th St, formed arthroscopically and has been shown to have good New York, NY 10021, USA. 48,49 to excellent results in approximately 85% of patients. Email: [email protected] 394 Foot & Ankle International 39(4) The procedure involves penetrating the subchondral bone MF supplemented with BMAC (17 patients). Our goal was to to stimulate bleeding from the underlying bone and the compare these groups’ outcomes and to assess the site of car- migration of mesenchymal stem cells into the lesion site. tilage repair using MRI with the previously described mag- These cells within the clotted blood may then remodel and netic resonance observation of cartilage repair tissue become fibrocartilage in an attempt to fill the defect. (MOCART) semiquantitative grading system36 to compare However, fibrocartilage is biomechanically inferior com- the quality of repair tissue produced by the two different pared to native hyaline cartilage and may degrade more procedures. quickly over time.20 In addition, MF is less effective in 2 treating larger lesions (>150 mm ) and lesions on the Methods shoulder of the talar dome. These lesions often require sec- ondary procedures such as osteochondral allograft or auto- After approval was obtained from our institutional review graft transplantation (OATs) or autologous chondrocyte board, the institution’s foot and ankle registry was searched implantation,4,9,11,24,27,31,42 each of which has its own short- using relevant Current Procedural Terminology codes for all comings including possible donor site morbidity, the patients who underwent either MF or JACI-BMAC for an potential need for an osteotomy, or necessity for multiple osteochondral lesion of the talus between 2006 and 2014. procedures.6,36,40 Patients were excluded if they were smokers, had rheumatoid These limitations have led researchers to explore novel or inflammatory joint disease, uncontrolled diabetes, an auto- approaches to deliver cells and growth factors to an immune disorder, or systemic inflammatory disease, or were osteochondral defect to produce a more normal hyaline immune suppressed. A total of 50 patients fit the inclusion cri- cartilage.4 Juvenile allogenic chondrocyte implantation teria and composed the study cohort. Of these 50 patients, 30 with bone marrow aspirate concentrate (JACI-BMAC) is an had undergone arthroscopic MF treatment and 20 had received all-arthroscopic procedure that has the potential to repro- arthroscopic DeNovo NT for JACI-BMAC treatment. Within duce hyaline cartilage without the morbidity and technical the arthroscopic MF treatment group, 17 patients received difficulties associated with other cartilage restorative tech- BMAC in addition to MF, based on surgeon preference. All niques. DeNovo NT (Natural Tissue) graft (Zimmer Inc, patients had an MRI at least 1 year postoperatively. Patients Warsaw, IN) is a prepackaged particulated articular carti- with concurrent ankle instability were also identified, with lage allograft derived from donors 2-12 years old. It con- ankle instability being defined on routine stress X-rays as a tains immature juvenile chondrocytes with a high metabolic talar tilt of greater than 10 degrees varus or an anterior drawer activity and the reported ability to regenerate hyaline-like of greater than or equal to 10 mm. For patients that presented cartilage.1,22 The graft is implanted into the defect and with concurrent ankle instability, the instability was addressed secured with a fibrin sealant diluted with BMAC. The use by performing a lateral ankle stabilization procedure using of BMAC is indicated as it has been shown to improve the either the Brostrom-Gould15 or lateral ligament reconstruc- biomechanical and structural components of the reparative tion, depending on the surgeon’s preference. There were 7 tissue.13,24,28,43 There are few prior investigations that report patients who underwent procedures for instability in the MF the clinical and radiographic outcomes of this procedure in group, with 4 receiving lateral ligament reconstructions and 3 the ankle which have shown promising results and improved receiving Brostrom stabilizations. In the DeNovo group, 4 clinical outcome; however, they are Level IV studies with- patients underwent a procedure for instability, and all 4 had out a comparison group, lack objective outcome measures Brostrom-Gould type stabilizations (Table 1). and often have subjective outcome scores which are not Retrospective chart review was performed and patient validated.12,36 To our knowledge, there are no comparative demographic information was recorded. There were 27 studies in the literature which meet those criteria. True com- females and 23 males who composed the patient popula- parisons between JACI-BMAC and existing cartilage repair tion overall, with an average age of 37.2 (range, 9 to 74) techniques are needed to determine the role of DeNovo NT years. In the MF group, there were 15 females and 15 in relation to other cartilage resurfacing procedures, specifi- males, with an average age of 37.7 (range, 9 to 74) years, cally MF, the current standard of care. while there were 13 females and 7 males, with an average Our hypothesis was that the JACI-BMAC procedure age of 36.6 (range, 16 to 52) years, in the JACI-BMAC would be superior to MF in treating osteochondral lesions of group. Pre- and postoperative functional outcome scores the talus. We thought patients undergoing
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