Autologous Chondrocyte Implantation for Treatment of Cartilage Defects of the Knee: What Predicts the Need for Reintervention?
Jungmann PM, Slazmann GM, Scmal H, Pestka JM, Sudkamp NP, & Niemeyer P. American Journal of Sports Medicine. 2012;40(1): 58-67.
Autologous chondrocyte implantation (ACI) aims to repair a chondral defect within the knee by harvesting and growing the patient’s cartilage that is then placed in the defect. The procedure has shown relatively favorable outcomes; however, it still carries a failure rate ranging from 10 to 20 %. Failure of ACI results in a need for another surgery. The purpose of this study was to identify risk factors associated with the need for a second (corrective) surgery after ACI. This study identified 88 patients (21.3%) from a larger cohort (n = 413) who needed a second knee surgery within 5 years after various ACI surgical procedures (completed by multiple surgeons). All 88 patients had at least 2 years follow-up (maximum = 11.8 years). Diagnoses were made during arthroscopic revision surgery, and analyses were made on 12 prognostic (pre-operative) factors (e.g., body mass index [BMI], gender, age). The authors identified four factors as potential risk factors for failure (needing a second/corrective surgery). Patients who were female, had more than one previous surgery on the same joint for any condition, had previous bone marrow stimulation (e.g., microfracture), or had ACI surgical technique involving a periosteal patch were identified as having an increased incidence of reintervention. Surgeon, BMI, and age were not associated with an increased risk of requiring a second surgery.
Clinically, we need to be aware of these potential risk factors as patients are opting for ACI surgery. Awareness that females are more at risk for ACI failure is important; however, there is not much that we can do clinically regarding this beyond education or suggesting alternative treatments. More interestingly, in the athletic population, ACI is sometimes viewed as a surgery to complete once they are done competing. It would be interesting to see physical activity information, as this was not reported for this cohort of patients. However, some athletes are counseled into receiving microfracture (drilling of subchondral bone) surgery first, and then if this fails to try ACI. This study indicates that this recommendation should be reconsidered and that it, in fact, may increase the likelihood of ACI surgeries failing. For ACI to be successful, it may be more appropriate if we viewed ACI as a primary option, as opposed to a “back-up plan.” More than one previous surgery was also identified as a potential factor that increases the likelihood of ACI failure. The types of previous surgeries are not indicated, but as sports medicine professionals, we should be investigating how to mitigate this seemingly unmodifiable risk factor. Lastly, as the ACI surgical techniques are evolving it seems that the type of ACI surgery may have an effect on the outcome. This study looked at three different ACI techniques (i.e., periosteal patch-covered ACI, Chondro-Gide-covered ACI, and matrix associated Bio-Seed-C), and identified that the periosteal patch-covered technique is associated higher incidence of reintervention. As patients are considering which surgeon or technique to have, we, as clinicians, can help to inform the decisions that they are making. Interestingly enough, the follow-up time identified in this study to define a successful ACI intervention was five years. Following these patients for a longer period of time could prove advantageous in identifying the need for any reintervention, and their progression towards osteoarthritis. Furthermore, this cohort only included patients who did not have concomitant ligament/meniscal surgeries. It would be interesting to see the outcomes of this surgery in other cohorts to determine whether or not this is a viable option in these cohorts as well. What are your thoughts on when ACI should be attempted? Has anyone had an athlete or patient who has undergone any ACI technique?
Written by: Nicole Cattano
Reviewed by: Jeffrey Driban
Matrix-induced Autologous Chondrocyte Implantation (MACI) in the Knee
Jungmann PM, Salzmann GM, Schmal H, Pestka JM, Südkamp NP, & Niemeyer P (2012). Autologous chondrocyte implantation for treatment of cartilage defects of the knee: what predicts the need for reintervention? The American Journal of Sports Medicine, 40 (1), 58-67 PMID: 21969180
I've (female) personally had ACI with periosteal patch to bilateral patellas 6 years ago, and last year had DeNovo NT to a new area of damage in one knee. I did have a repeat arthroscopy approximately 5 years post op to clear loose bodies and excessive overgrowth of the periosteal patch. I did not have any concurrent ligamentous or meniscal damage, and at the current time have returned to road cycling and modified weight training. I believe a huge driving force for microfracture prior to ACI is that most insurance companies require a trial and failed cheaper intervention before approving the more expensive ACI. Now, with the advent and apparent successes of the DeNovo NT which is considerably less expensive, perhaps that will begin to change.
Thanks for sharing your personal experience Erin! It is great to hear that you have returned to cycling and weight training. How have you modified your training? I agree that unfortunately clinical decisions are often forced by insurance companies and the almighty dollar. DeNovo does seem relatively promising, and avoids the 2 step surgery process. You mentioned that your original ACI was done on the patella. Is that where your new area of damage was and the DeNovo was completed on? There seems to be a lot of issues with weight-bearing regions after ACI, so I am would wonder if DeNovo is as successful in the role.
I am incredibly grateful to this technology for allowing me to have my active life.
Prior to my first ACI, I was extremely debilitated and having difficulty with ADL's, getting out of a car and off the sofa were very difficult. Stairs were impossible. (I am also a physical therapist.) As far as training, I was only cleared to return to road cycling recently, (Sept 2011) simply due to the crash risk, to allow maximal maturity of the chondrocytes from the original ACI. I have always been a "spinner" as opposed to a 'masher" (I use easier gears and turn my legs over faster to minimize stress on the joints) so I have not really had to modify there. Thankfully I live in flat terrain.
For weight training, I do mostly closed chain single leg work-rear foot elevated split squats, single leg RDL's, SHELC's, pull thru's, etc. Technically I am cleared to do whatever does not hurt.
The DeNovo was completed to the femoral condyle, so a completely different area of damage. The ACI patches were intact and doing well. It's frankly a mystery as to why my cartilage appears to be shearing off, I had no tracking issues and no real trauma. I do have celiac disease, which was diagnosed about 6 years ago and I have been gluten free, but I suspect perhaps there was damage from an active childhood that never healed properly due to nutritional deficiencies prior to the celiac diagnosis.
I had a follow up MRI yesterday to check the progress of the DeNovo and the integrity of the ACI's, so I will let you know how they look. Also, I kept a log here:https://www.kneeguru.co.uk/KNEEtalk/index.php?topic=35819.0 about my rehab.
I'm happy to answer any questions at all-as I said, this technology has allowed me to live my life as I wish, and there is no greater gift.