Prior Bone Marrow Stimulation Surgery Influences Outcomes After Cell-Based Cartilage Restoration: A Systematic Review and Meta-analysis

Abstract

Background: Cell-based cartilage restoration with autologous chondrocyte implantation (ACI) is a safe and effective treatment for symptomatic cartilage lesions. Many patients undergoing ACI have a history of prior surgery, including bone marrow stimulation (BMS). There is mounting evidence that a history of prior BMS may impede healing of the ACI graft. Purpose/Hypothesis: The purpose of this study was to compare the failure rates of primary ACI with ACI after prior BMS. We hypothesized that ACI after BMS would have a significantly higher failure rate (defined as reoperation, conversion to arthroplasty, and/or imaging-based failure) compared with primary ACI. Study Design: Systematic review; Level of evidence, 4. Methods: A literature search was performed by use of PubMed and Embase databases for relevant articles published through October 2, 2020, to identify studies evaluating outcomes and failures rates of ACI after prior BMS in the knee. Results: Included were 11 studies comprising 1479 ACI procedures. The mean age at surgery ranged from 18.3 to 39.1 years, and the mean follow-up ranged from 3 to 20.6 years. All studies reported failure rates. The overall failure rate was significantly higher in the patients who underwent ACI after BMS, at 26.4% compared with 14.8% in the ACI group ( P < .001). Meta-analysis demonstrated an increased risk of failure in patients with a history of prior BMS (log odds ratio = –0.90 [95% confidence interval, –1.38 to –0.42]). Conclusion: This systematic review demonstrated that failure rates were significantly higher for patients treated with ACI after BMS relative to patients undergoing ACI without prior BMS. This finding has important implications when considering the use of BMS for defects that are amenable to cell-based restoration and when determining treatment options after failed BMS. Registration: PROSPERO (CRD42020180387).

Platelet-Rich Plasma and Adipose-Derived Mesenchymal Stem Cells in Association with Arthroscopic Microfracture of Knee Articular Cartilage Defects: A Pilot Randomized Controlled Trial

“…It is cost-effective and not technically demanding, with an extremely low rate of patient morbidity. Moreover, it does not compromise the possibility of further additional surgeries [ 21 , 22 ] though a recent systematic review by Cogan et al demonstrated a higher failure rate for patients treated with autologous chondrocytes implantation (ACI) after a prior bone marrow stimulation technique (like microfracture) [ 23 ]. Moreover many studies demonstrated that the quality of cartilage repair tissue and the clinical outcomes are significantly better for patients with smaller chondral lesions [ 24 – 26 ]; therefore, the bigger chondral lesions should be addressed by recurring to more aggressive therapies.…”

Outcomes and Return to Sport After Knee Osteochondral Allograft Transplant in Professional Athletes

“…24 In contrast, autologous chondrocyte implant, although appropriate for larger defect areas, has worse outcomes after prior marrow stimulation and is not well-suited for deeper osteochondral defects or for those with subchondral change. 5 Osteochondral allograft transplant is a facile solution to treat deep and large osteochondral lesions, typically at least 2 cm 2 in surface area. By fitting an allograft osteochondral plug in a congruent fashion to the patient's articular surface, osteochondral allograft transplant provides a viable option for defects with extensive subchondral edema, even in the setting of prior marrow stimulation, without donor site morbidity.…”

“… 24 In contrast, autologous chondrocyte implant, although appropriate for larger defect areas, has worse outcomes after prior marrow stimulation and is not well-suited for deeper osteochondral defects or for those with subchondral change. 5 …”

Microdrilling Resulted in Less Subchondral Bone Destruction Than a Traditional Microfracture Awl for Articular Cartilage Defect Bone Marrow Stimulation

“…When performing the bone marrow stimulation procedure, it is important to note that the structural and functional architecture of the subchondral bone is of the utmost importance and can play a vital role in the long-term outcome of the index bone marrow stimulation procedure, as well as on any subsequent cartilage procedure that may follow. 13 , 14 Although previous literature has shown good short-term outcomes in appropriately selected patients, recent literature has suggested that the outcomes of bone marrow stimulation may worsen after 5 years, primarily because of the poor quality of the fibrocartilage replacement tissue that is formed. 7 , 15 The size of the instrument, depth of penetration into the subchondral bone, and resulting trabecular compaction around the channel have been implicated in this fibrocartilage tissue, because it may affect the ability of the technique to cause regeneration versus degeneration.…”