ISAKOS Biologics Series Part I
Systematic Review
Treatment of Articular Cartilage Lesions of the Knee by Microfracture or Autologous Chondrocyte Implantation: A Systematic Review

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Purpose

We performed a systematic review of the treatment of articular cartilage lesions of the knee by microfracture or autologous chondrocyte implantation to determine the differences in patient outcomes after these procedures.

Methods

We searched PubMed/Medline, Embase, and The Cochrane Library databases in the period from January 10 through January 20, 2013, and included 34 articles in our qualitative analysis.

Results

All studies showed improvement in outcome scores in comparison with baseline values, regardless of the treatment modality. The heterogeneity of the results presented in the studies precluded a meta-analysis.

Conclusions

Microfracture appears to be effective in smaller lesions and is usually associated with a greater proportion of fibrocartilage production, which may have an effect on durability and eventual failure. Autologous chondrocyte implantation is an effective treatment that may result in a greater proportion of hyaline-like tissue at the repair site, which may in turn have a beneficial effect on durability and failure; it appears to be effective in larger lesions. Autologous chondrocyte implantation with periosteum has been shown to be associated with symptomatic cartilage hypertrophy more frequently than autologous chondrocyte implantation with collagen membrane. Matrix-associated autologous chondrocyte implantation is technically less challenging than the other techniques available, and in lesions greater than 4 cm2, it has been shown to be more effective than microfracture.

Level of Evidence

Level IV, systematic review of Level I-IV studies.

Section snippets

Methods

A systematic review of the literature was carried out. We searched PubMed/Medline, Embase, and The Cochrane Library databases in the period from January 10 through January 20, 2013. The following Medical Subject Headings were used: “chondral defect and knee”; “microfracture and knee”; “chondrocyte implantation and knee”; and “histology and knee and chondral defect.” The references of identified articles were further reviewed to find related studies. Articles were then examined by the 2 senior

Results

The abstracts of 776 studies were reviewed, and 561 studies were excluded because they were not relevant to the topic, leaving 215 that were examined in detail. Of these studies, 181 met the exclusion criteria, leaving 34 for analysis (Fig 1). The articles were categorized as follows: 7 MF studies4, 5, 6, 7, 8, 9, 10 (Table 1), 18 ACI studies11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28 (Table 2, Table 3, Table 4), and 9 comparative studies29, 30, 31, 32, 33, 34, 35, 36

Discussion

The durability of cartilage repair is dependent on the tissue generated to fill the articular void. Initial reports using animal models suggested that the MF technique was an effective way to generate “hyaline-like” tissue at the site of chondral injury.4, 5 Relatively few authors have included histologic results in human subject studies. Difficulty in obtaining biopsy specimens from otherwise asymptomatic patients has limited the amount of postoperative histologic data available. The initial

Conclusions

Direct comparison of cartilage repair techniques is methodologically challenging with the great variety of techniques, absence of long-term follow-up, and heterogeneity of outcome measures. Generally, it would appear from the literature analyzed in this review that MF is effective in smaller lesions and is usually associated with a greater proportion of fibrocartilage production, which may have an effect on durability and eventual failure. ACI is an effective treatment that may result in a

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    See commentary on page 745

    The authors report that they have no conflicts of interest in the authorship and publication of this article.

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