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A retrospective analysis of two independent prospective cartilage repair studies: autogenous perichondrial grafting versus subchondral drilling 10 years post-surgery

A retrospective analysis of two independent prospective cartilage repair studies: autogenous perichondrial grafting versus subchondral drilling 10 years post-surgery
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  A retrospective analysis of two independent prospectivecartilage repair studies: autogenous perichondrial graftingversus subchondral drilling 10 years post-surgery Phianne S.J.M. Bouwmeester  a,1 , Roel Kuijer  b,* , George N. Homminga  a ,Sjoerd K. Bulstra  b , Rudolph G.T. Geesink  b a Kliniek Klein Rosendael, P.O. Box 278, 6880 AG Velp, The Netherlands b Department of Orthopaedic Surgery, University Hospital Maastricht, Maastricht University, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands Received 7 February 2001; accepted 22 June 2001 Abstract Background  : Experimental data indicate that perichondrial grafting to restore articular cartilage defects will result in repair withhyaline-like cartilage. In contrast, debridement and drilling results in repair with fibro-cartilage. In this retrospective study the long-term clinical results of both procedures were compared to evaluate the theoretical benefit of repair with hyaline-like tissue. Methods : From two independent studies patients were selected with a cartilage defect in their knee. The selection was performedusing strict inclusion criteria published elsewhere [Bouwmeester et al. Int. Orthop. 21 (1997) 313]. The patients were treated witheither a perichondrium transplantation (PT group,  n ¼ 14) or with an ‘open’ debridement and drilling procedure (DD group, n ¼ 11). The results of both procedures after 10–11 years were evaluated using the Hospital for Special Surgery Knee Score (HSSS),X-ray examination, clinical examination and visual analogue scales (VAS) for pain during walking and at rest. Results : Both procedures resulted in a general improvement compared to the situation before the operation. After an average of 10 years in the PT group there were three failures, in the DD group none, success rates were 78% and 100%, respectively. Whencomparing the successful PT patients with the DD patients, there were no differences in HSSS and VAS data. Both groups showedan equal number of irregular operation surface sites on X-ray (PT 9/11 versus DD 8/10). Conclusions : This study shows that clinically at 10 years follow-up no difference was observed between debridement and drillingand perichondrium transplantation for treatment of an isolated cartilage defect. This raises questions about ongoing research todevelop methods in order to improve the results of debridement and drilling as therapy for an isolated cartilage defect in a youngpatient ( 6 40 years).    2002 Orthopaedic Research Society. Published by Elsevier Science Ltd. All rights reserved. Introduction Articular cartilage defects have a limited repair ca-pacity. Superficial cartilage defects do not heal at all.Full thickness defects penetrating the subchondral boneheal with a fibrous or fibrocartilagenous tissue, which isbiomechanically inferior to hyaline cartilage [30 – 32]. Nevertheless, the current treatment of such defects isfocused on removing diseased tissue and penetrating thesubchondral bone to allow filling of the defect withfibrocartilage [8,13,38]. In our clinic a debridement and drilling procedure is performed.Many methods to restore articular cartilage havebeen investigated in animal models and clinical trialswith varying results [25]. These include transplantationof osteochondral shell grafts, autogenous transplanta-tion of perichondrium or periosteum, chondrocytes ormesenchymal stem cells [4,6,12,22,23,28]. A widely used technique to reduce pain and improve joint function isto shave the damaged cartilage and to drill holes into thesubchondral bone. There is no evidence that shavingalone stimulates repair [34]. The relief is usually tem-porary unless an additional procedure intended to cor-rect the underlying cause of the cartilage damage isperformed as well (patellar realignment/high tibia oste-otomy for varus or valgus abnormalities) [1]. Journal of Orthopaedic Research 20 (2002) 267– * Corresponding author. Tel.: +31-43-3881311/3875038; fax: +31-43-3874893. E-mail address: (R. Kuijer). 1 Tel.: +31-26-3620680.0736-0266/02/$ - see front matter    2002 Orthopaedic Research Society. Published by Elsevier Science Ltd. All rights reserved.PII: S0736-0266(01)00099-7  Debridement of an incongruent cartilage can decreasethe mechanical and inflammatory symptoms of unstableflaps or from fibrillation or other distortion from ana-tomy. Repair tissue can reduce symptoms but it does notprevent deterioration of the cartilage [25].Rib perichondrium when transplanted into a cartilagedefect produces a repair tissue that resembles hyalinecartilage [2,15 – 17,22,23,26,27,35]. In an animal model, this newly formed cartilage has been shown to have thesame visco-elastic properties as hyaline cartilage [3].Neocartilage with histological and biochemical qualitiessimilar to that of normal articular cartilage has beenreported one year after perichondrial grafting in rabbitknees [9,10,14,17,23]. In 1986 Homminga was the first to use rib perichondrium as therapy to restore articularcartilage defects in the knee. In 1990 he reported on 25patients from a prospective study. In these patients, 30chondral lesions of the knee were treated with autoge-nous perichondrium [22]. Fibrin glue was used to fix thegraft [18,44]. After an immobilization period of twoweeks in a plaster of Paris, the operated knee was sub- jected to continuous passive motion [41]. This group of patients was extended to 88 unto 1992. The only exclu-sion criterion used was age ( < 55 years). Analysis of theresults at 3- to 5-year follow-up revealed that peric-hondrial transplantation could be performed with asuccess rate of approximately 90%, provided the inclu-sion criteria were: age under 40 years, no previous drill-ing or shaving of the defect, no more than one graft at thetime of operation and no more than osteoarthritis gradetwo in other parts of the knee [6] (grading according toDandy and Jackson [11] and Outerbridge [36]). The purpose of this study was to establish whetherthe theoretical improvement of repair of cartilage de-fects with hyaline-like cartilage (perichondrial grafting)compared to repair with fibrocartilage (debridement anddrilling) would result in improved results clinically. Patients and methods This study was approved for by the local ethics committee and wasperformed in accordance with the ethical standards laid down in the1994 Declaration of Helsinki. An informed consent of the patients wasobtained prior to inclusion in the study.From the group of 88 patients, operated between 1986 and 1992,fourteen patients met the inclusion criteria: age  6 40 years, no previ-ous drilling or shaving of the defect, no more than one graft at the timeof operation and no more than osteoarthritis grade two in other partsof the knee [6] (see Introduction), and were selected. In three patientsthe perichondrium transplantation had failed, they had been reoper-ated. One patient had his ACL reconstructed in the same operation.The data of these four patients are not included in this study. Theremaining 10 patients were seen in our out clinic (PT group). Five rightand five left knees were treated in three women and seven men. Themean age was 25 years (17–37) and the mean follow-up was 118months (85–142) (Table 1). The average defect size was 2 : 5 cm 2 (range0 : 5  –  6 : 0 cm 2 ). The mean duration of complaints before the operationwas 29 months (4–48). In 5/10 patients a trauma was the cause of thearticular cartilage defect. In the other five patients the cause of thedefect was unknown. Six defects were situated in the medial femoralcondyle, four defects in the patella were grafted.From a separate prospective study of 150 patients on debridementand drilling (inclusion criterion: age  < 55 years) 11 patients were se-lected using the same inclusion criteria as used for the PT group (DDgroup). Six right and five left knees were treated in four women andTable 1Patients in which cartilage defects were treated with a perichondrium transplantationPatient Age a FU b Defect c Size d Tr e PC f  PrHSS g HSS/FU h HSS/FU h Remarks1 i 26 (77) r pat (2.5)  )  (120) (78) (64/7) Patellectomy2 17 113 l pat 6.0 + 5 88 98/17 100/1133 22 (129) r mfc (3.0) + (12) (57.9) (92.5/12) (100/129) ACL reconstr.4 25 132 r mfc 1.5  )  15 72 97.5/12 80/1325 22 94 r pat 2.5 + 36 64.5 88.5/12 69/946 36 85 r pat 2.3  )  36 80 97/11 88/857 35 142 l mfc 1.8  )  48 78.9 89.5/12 97/1428 i 37 (54) r mfc (2.0)  )  (24) (53) (99 /17) Valg. tib. osteot.9 i 30 (56) r mfc (6.3)  )  (24) (72.6) (78.5/25) Drilling10 22 115 r pat 2.0 + 24 79.8 100/17 98/11511 27 127 l mfc 0.5  )  48 86.5 100/11 94/12712 24 137 l mfc 3.8 + 4 63.3 95.5/11 100/13713 21 100 l mfc 3.0  )  48 79 93.2/8 99/10014 22 140 r mfc 1.5 + 26 75.5 87.5/16 87/140Mean 25 118 2.5 29 76.8 94.7/13 91.2/119 a Age at the time of the operation. b Total follow-up in months. c Place of defect: pat ¼ patella, mfc ¼ medial femoral condyle. d Size of defect in cm 2 . e Previous trauma. f  Pre-operative duration of complaints in months. g Hospital for special surgery score before the operation. h Hospital for special surgery score at number of months post-operative. i Failed PT. Data in between brackets were not included in calculations.268  P.S.J.M. Bouwmeester et al. / Journal of Orthopaedic Research 20 (2002) 267–273  seven men between 1978 and 1992. The average follow-up was 131months (73–247) and the average age was 31 years (20–38) (Table 2).The average defect size was 3 : 1 cm 2 (range 0 : 8  –  8 : 8 cm 2 ). The meanduration of complaints before the operation was 23 months (3–48). In6/11 patients the articular cartilage defect was caused by a trauma. Thecause of the defect in the other five patients was unknown. Six defectswere situated in the patella, four defects in the medial femoral condyleand one in the lateral femoral condyle. Operation technique perichondrial arthroplasty Perichondrial arthroplasty was performed by two surgeons, whoalso performed the previous animal study [23]. The procedure has beendescribed previously [6,22]. Briefly, the affected leg was exsanguinated. The knee was opened through a medial para-patellar incision and thepatella was dislocated laterally if necessary. The chondral lesion wasidentified and sharply cleaned until point bleeding of the subchondralbone. Point bleeding was thought to provide for a cellular passagethrough a better contact with the subchondral bone. The surroundingcartilage was cut in order to demarcate the lesion. An oblique incisionwas made over the lower part of the left side of the chest. The fascia of the rectus muscle was split transversely and the muscle in the line of itsfibers. Thenthe perichondrium wasremovedincludingitschondrogeniclayer from the cartilaginous part of one of the lower ribs. The graft wascut to the size of the defect. The perichondrial graft was placed on thesubchondralbonewiththe chondralsidefacingthe jointspaceandfixedwith fibrin glue (Tissucol  , Immuno, Vienna) [18,37]; it was then firmlypressed to the underlying bone with wet gauze for 1 min. The knee wasmoved to assure proper fixation of the graft. The patella was relocatedandthe woundclosed.Afteranimmobilization periodof twoweeks inaplaster of Paris the operated knee was subjected to continuous passivemotion for another two weeks [39,44,45]. Movement was encouraged, but for grafted lesions of the patella or the intercondylar groove theflexion was limited to 30  . Four weeks after the operation, patients weremobilizednon-weightbearing;activemovementswereencouraged. Fullweight bearing was allowed three months after the operation. Operation technique debridement Two different experienced surgeons performed the debridement anddrilling operations. The affected leg was exsanguinated. The knee wasopened through a medial para patellar incision and the patella wasdislocated laterally if necessary. The chondral lesion was identified andloose cartilage flaps were removed. Thin drill holes were made using a1.2 mm drill until point bleeding from the subchondral bone was vis-ible [38]. After rinsing the knee with Ringers lactate, the patella wasrelocated and the wound closed. The after-treatment consisted of fourweeks non-weight bearing but active movements were encouraged. Fullweight bearing was started three months after the operation. Analysis The results were evaluated by means of the Hospital for SpecialSurgery Knee Score (HSSS) for knee function [39], X-ray examinationand visual analogue scales (VAS) for pain during walking and at rest.The data of the PT group at approximately one-year follow-up are alsogiven. For statistical analysis, a paired  t -test was used. Results In the PT group three perichondrium transplanta-tions failed. In patient number 1 the patella was re-moved after 77 months because of ongoing pain. Thiswas done for an srcinal defect of 2 : 50 cm 2 , followed byan unsuccessful debridement. Patient number 8 under-went a high tibia osteotomy after 54 months for theunresolved pain in his medial compartment, based on adefect of 2 : 00 cm 2 on his medial femoral condyle. Inpatient number 9 the graft was removed and the lesion,6 : 25 cm 2 , was treated with debridement and drillingafter 56 months. This patient was free of symptoms afterthis last procedure. All other transplants were firmlyfixed to the subchondral bone. This was established atcontrol arthroscopy one-year post-operative. In the DDgroup no patients were excluded. HSSS  From the remaining patients in the PT group themean HSS score changed from 76.8 pre-operative to Table 2Patients in which a cartilage defect was treated with open debridement and drillingPatient Age a FU b Defect c Size d Tr e PC f  PrHSS g HSS h 1 31 73 l mfc 0.8  )  10 77 862 28 75 l mfc 4.5  )  9 77 993 36 222 r lfc 2.3  )  36 85 944 38 205 r pat 2.3 + 48 76 995 32 140 l pat 1.0  )  36 68 846 33 79 r pat 3.0 + 36 80 997 37 247 l pat 2.3  )  18 91 918 31 79 r mfc 8.8 + 3 26.4 979 20 79 r pat 4.5 + 5 90 9710 25 80 l mfc 2.3 + 5 85 9911 32 165 r pat 2.0 + 48 91 97Mean 31 131 3.1 23 77 94.7 a Age at the time of the operation. b Total follow-up in months. c Place of defect: pat ¼ patella, mfc ¼ medial femoral condyle, lfc ¼ lateral femoral condyle. d Size of defect in cm 2 . e Previous trauma. f  Pre-operative duration of complaints in months. g Hospital for special surgery score before the operation. h Hospital for special surgery score at indicated follow-up. P.S.J.M. Bouwmeester et al. / Journal of Orthopaedic Research 20 (2002) 267–273  269  91.2 at the last follow-up. In the debridement group thescores were 77 to 94.7. No significant difference could bedetected with the numbers available (Tables 1 and 2). VAS  The VAS for walking improved in the PT group from2.4 after one year to 2.2 after 10 years. In rest the scoreschanged from 1.5 to 1.0, respectively. After 10 years theresults in the DD group were: VAS for walking 1.1 andin rest 0.7 (Table 3). No significant difference could bedetected with the numbers available. X-ray examination On some X-rays increases in subchondral sclerosiswere seen. In the PT group this was the case in 3/10patients and in the DD group 4/10. One patient refusedthe X-ray because of her pregnancy. A similar numberof spurs were seen in the DD group, 4/10, as comparedto the PT group, 3/10. Irregularities such as calcifica-tions of the graft, or subchondral sclerosis and thick-ening of the debrided site were seen in both groups. Inthe PT group 9/10 X-rays showed marked irregularitiesand in the DD group this was the case in 8/10 X-rays.The changes seen were to the same extent in both groupsat the last follow-up (Figs. 1 and 2). Clinical examination All patients underwent a clinical examination. Theresults of these examinations have been incorporated inthe HSS score. One of the 11 patients who underwentperichondrium transplantation, still had pain on thedonor site (rib) after 10 years. Table 3Results of VAS during walking and at rest in PT and DD groupsPatient Grp a Wlk/Rst b At FU c Wlk/Rst At FU Remarks Pat Grp a Wlk/Rst At FU1 d PT (7.5/7.0) (7) Patellect. 1 DD 4.4/2.9 732 PT 0.7/0.0 17 0.2/0.3 113 2 DD 0.7/0.2 753 d PT (3.0/2.5) (12) (0.0/0.0) (129) ACL rec. 3 DD 1.2/0.4 2234 PT 3.5/3.0 12 2.0/0.5 132 4 DD 0.3/0.3 2055 PT 1.6/0.0 12 8.1/4.6 94 5 DD 4.0/3.7 1526 PT 0.7/0.4 11 3.8/0.2 85 6 DD 0.0/0.0 797 PT 6.0/5.3 12 4.3/3.7 142 7 DD 0.1/0.1 2478 d PT (0.2/0.1) (17) Valg T.O. 8 DD 0.2/0.3 799 d PT (4.7/0.6) (25) Drilling 9 DD 1.2/0.0 7910 PT 0.0/0.0 17 0.2/0.1 115 10 DD 0.0/0.0 8011 PT 2.5/2.6 11 2.3/0.2 127 11 DD 0.0/0.0 16512 PT 6.0/4.0 11 0.0/0.0 13713 PT 0.0/0.0 8 0.0/0.0 10014 PT 3.0/0.0 16 1.4/0.0 140Mean PT 2.4/1.5 13 2.2/1.0 119 DD 1.1/0.7 132 a PT ¼ Perichondrial arthroplasty group, DD ¼ Debridement group. b Visual analogue scale for walking and in rest. c Follow-up in months. d The data of patients 1, 3, 8 and 9 (PT-group) were excluded (given in brackets).Fig. 1. X ray of patient 3 from PT group at 129 months post-operative.Arrow indicates calcification of the graft/subchondral sclerosis on themedial femoral condyle.270  P.S.J.M. Bouwmeester et al. / Journal of Orthopaedic Research 20 (2002) 267–273  Discussion In this study the long-term effects of repairing artic-ular cartilage defects using perichondrial arthroplastyversus open debridement with drilling were examined.Perichondrial or periosteal arthroplasty for repair of articular cartilage defects are experimental proceduresthat may result in repair with hyaline-like cartilage[7,35,40]. It was considered important to know whether potential repair with hyaline-like cartilage (PT) wouldclinically perform better compared to repair with fi-brocartilage (DD, our ‘golden standard’) in the longterm.In a previous, prospective study criteria for peric-hondrial arthroplasty were established, as to performthe procedure with a success rate of approximately 90%[6]. Perichondrial grafting proved only to be successfulwhen traumatic cartilage defects in otherwise healthy joints were treated in patients  6 40 years of age.From two independent, prospective studies (PT 88,DD 150), only few patients met these criteria and couldbe selected (PT 14, DD 11). The majority of the patientswere excluded because of degenerative cartilage worsethan grade 2 at arthroscopy. The selection of patientsfrom two different prospective studies explains the dif-ference in follow-up. All patients complying with theinclusion criteria were included, without any selectionafterwards. The small number of patients did not allowfor proper statistical analysis. This limits the value of thestudy.The mean period of pre-operative complaints was 29months in the PT group and 23 months in the DDgroup. These are thought to be comparable. We do notthink the results are affected by a more chronic disorderin the patients treated with PT than in the ones treatedwith DD. The mean size of the defects in the DD groupis larger than that of the PT group. It can be expectedthat smaller defects are more easily repaired than largeones. This would be disadvantageous for the DD group.However, the results of the DD group are at least asgood as those for the PT group. So the difference in sizeof the defect is not expected to affect the conclusions of this study.Both perichondrial grafting and debridement anddrilling were performed via arthrotomy, which wascommon in those days. Nowadays debridement anddrilling is almost always performed during arthroscopy,which compared to arthrotomy results in far lessmorbidity. Perichondrial grafting always has to be per-formed via an ‘open’ procedure, which is a disadvan-tage. Another disadvantage of perichondrial grafting isthe second operation site. In three patients of the PTgroup the PT failed (Table 1). In these cases pain did notsubside sufficiently and additional operations were nec-essary in which the perichondrial transplants were re-moved. These patients were no longer followed as beingPT patients. The success rate of perichondrial grafting inthis study was thus 78% (11/14). In patient 3 (Table 1)an ACL reconstruction was performed during the sameprocedure. The srcinal complaints of this patient werequite distinctive and as such could be evaluated prop-erly. However, the reconstruction of the ACL is con-sidered to affect the outcome of the HSS score. Theresults of this patient, although included in Table 1,were excluded from the overall result.The calcifications of the grafts seen on X-rays arealarming. Although the clinical results were not affectedthus far, such calcifications may cause failure of trans-plants in the very long term. Preliminary results indicatethat calcification of perichondrial grafts can be inhibitedor prevented by giving patients indomethacin using aprotocol similar to that used to prevent ectopic boneformation [6,29,33,42]. The results of the DD group were unexpectedly good(100%). Results from studies by Dzioba and Timoneyet al. [13,43] showed success rates of debridement and drilling of 69% and 63%, respectively. These differencesare probably due to the strict inclusion criteria used inour study. According to literature data patients youngerthan 40 years seem to do better, almost regardless of which treatment had been performed. Fig. 2. X-ray of patient 10 from DD group at 80 months post-opera-tive. Arrow indicates calcification of the repair tissue/subchondralsclerosis on the medial femoral condyle. P.S.J.M. Bouwmeester et al. / Journal of Orthopaedic Research 20 (2002) 267–273  271
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