Sports Medicine Research: In the Lab & In the Field: 10 Year Comparison of Surgery Techniques for Knee Cartilage Defects (Sports Med Res)


Friday, November 30, 2012

10 Year Comparison of Surgery Techniques for Knee Cartilage Defects

Ten-Year Follow-up of a Prospective, Randomized Clinical Study of Mosaic Osteochondral Autologous Transplantation Versus Microfracture for the Treatment of Osteochondral Defects in the Knee Joint of Athletes

Gudas R, Gudaite A, Pocius A, Gudiene A, Cekanauskas E, Monastyreckiene E, &
Basevicius A.  American Journal of Sports Medicine. 40: 2499 - . DOI:10.1177/0363546512458763

Osteo- and articular- chondral defects are becoming more common problems in the athletic population.  While there are many options available to treat these defects, it still remains unclear which is the best option, specifically in the long-term.  Therefore, the purpose of this prospective randomized study was to compare the 10 year outcomes between defects repaired with a microfracture procedure versus those repaired with an osteochondral autologous transplantation (OAT).  Fifty-seven patients met inclusion criteria (i.e., no evidence of chondromalacia, osteoarthritis, concomitant meniscal injury, or malalignment; not overweight; lesion < 4cm2; and age < 41 years old), were randomized to a surgical group, and attended follow-up approximately 10 years post-surgery.  Patients were reevaluated approximately 10 years post-surgery.  Cartilage integrity was analyzed using magnetic resonance imaging as well as International Cartilage Repair Society outcome scores and Tegner scales were used to assess activity levels, and osteoarthritis severity was assessed using radiographs.  All of these outcomes were assessed pre-surgery as well as 10 years post-surgery.  Overall, the OAT procedure resulted in better clinical outcomes, including less failures (e.g., pain resulting in another surgery), lower incidence of osteoarthritis, and higher activity levels compared to the group that received the microfracture procedure.  Subanalyses of defect type (articular- or osteochondral in nature) revealed that articular defects have superior outcomes compared to osteochondral defects.  Lastly, activity levels decreased across all defect types, as well as surgical type, but was significantly decreased when the defect was larger in size (> 2 cm2).

This is the first apparent study to investigate surgical repair of cartilage defects in a highly competitive athletic population.  Clinically, it appears that the OAT procedure has a superior outcome when compared to the microfracture procedure.  It is interesting that this study investigated return to a high level of athletic competition.  Some surgeons recommend not returning to athletics following this type of surgery, and merely resuming a physically active life to improve long term outcomes.  It would be of interest if the authors investigated osteoarthritis incidence or severity when correlated with activity level post-surgery.  It may be that those that returned to higher levels of activity result in greater incidence of osteoarthritis.  Furthermore, an articular-defect seems like it is not as dire of an injury as a defect into the subchondral bone.  It may be that these defects are entirely separate injuries and should be treated differently based on this premise. It is very interesting as to the inclusion/exclusion criteria of this study.  This group looked at a very specific group of athletes that needed to be active in a sport a minimum of 6 days per week.  Could it be that this is “too much” activity after an injury like this?  These athletes had no other concomitant ligamentous or meniscal injuries; I wonder what the outcomes would be like for athletes that do have concomitant injury? Does anyone have any experiences dealing with either of these types of defects or surgeries?

Written by: Nicole Cattano 
Reviewed by: Stephen Thomas

Related Posts:
Gudas, R., Gudaite, A., Pocius, A., Gudiene, A., Cekanauskas, E., Monastyreckiene, E., & Basevicius, A. (2012). Ten-Year Follow-up of a Prospective, Randomized Clinical Study of Mosaic Osteochondral Autologous Transplantation Versus Microfracture for the Treatment of Osteochondral Defects in the Knee Joint of Athletes The American Journal of Sports Medicine, 40 (11), 2499-2508 DOI: 10.1177/0363546512458763


Nate said...

I have seen literature on the incidence of OA following ACL injury and reconstruction that included other mensical and condral injuries. They found that people with these injuries had an increased risk of developing OA earlier in life. So I agree it would be interesting to see more specific literature on surgery combinations that produce the best long term outcomes for patients especially in the athletic population. I also agree that it would be interesting to see what kind of activity level is optimal following these types of injuries. I think that with further research we can start to answer the question: are we providing the best care for our athletes in the long term or are we setting them up for poor long term outcomes by getting them back to play quickly?

Nicole Cattano said...

Nate-I couldn't agree with you more. I think that this is going to require a little bit of a shift in the culture of the profession. And I think it is going to be very difficult to help athletes to see longer term. Surgery had advanced so much that it allows for earlier RTP, but I seriously question if this is right for the athlete's long term health. Thanks for your comment!

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