Minced Cartilage Implantation

The incidence of chondral and osteochondral defects is increasing due to the raised activity profile of the population and modern, continually improving MRI diagnostic methods. The incidence of cartilaginous defects in the knee among athletes is given as up to 36 % [13]. 

Untreated lesions cause higher mechani­cal loading of the surrounding intact cartilage [9, 16, 18] and have an effect on the subchondral bone [27] and on the intra-artikular mlieu, with an increase of cytokine concentration [14] and thus a premature onset of osteo­arthritis. This not only limits the patients’ function, but also causes consi­derable costs to the public health system. Thus, suitable cartilage reconstruction techniques with the specific regeneration of hyaline- or hyaline-like cartilage are required. A number of different surgi­cal procedures are already available for the treatment of focal chondral lesions, including techniques like bone marrow stimulation (microfracture (MFx), auto­logous matrix-induced chondrogenesis (AMIC)), osteochondral auto- or allograft transplantation surgery (OATS), and autologous chondrocyte implan­tation (ACI) [5, 11 – 13, 33]. Since each of these techniques has pros and cons, the treatment of chondral lesions has not been standardised and remains a challenge. 

ACI is currently seen as the treatment of choice for moderate to large chondral defects, since this procedure leads to hyaline- or hyaline-like cartilage substance with good long-term clinical outcomes [6, 7, 15, 17, 28]. The disadvantages of ACI are the high labo­ratory costs for cell expansion, limited availability in some cases, and the need for two-step surgical procedures [5, 12, 32]. In order to overcome these disadvantages, one-step procedures such as the implantation of fragmented auto­logous or allogenic cartilage have been deve­loped (Minced Cartilage Implantation (MCI)). The underlying principle was already described in the early 1980s by Albrecht et al. [1, 2] and picked up again by Lu et al. in 2006 [22]. Over the past few years interest in MCI has grown considerably especially due to several advantages, such as being a single stage procedure that can be performed in an arthroscopic or mini-arthrotomy surgical approach and may offer strong biologic potential [5, 32].

Biology

In their in vivo milieu chondrocytes have the potential to proliferate phy­siologically [3, 32]. Furthermore, mechanical stimuli play an important role in chondrocyte proliferation and chondrogenic differentiation [36, 37]. This complex biochemical and biomechanical intra-articular milieu, that can barely be reproduced in vitro, could be a major advantage regarding the biological potential of the MCI procedure. It has been shown that mincing healthy cartilage “activates” the chondrocytes and leads to a physiological reaction with chondrogenic proliferation and the production of extracellular matrix (ECM) [22 – 24, 32]. Mincing can be achieved with a scalpel, specially developed min­cing devices, or arthroscopic shavers [19, 20, 32]. The cartilage is harvested from the margins of the chondral defect or from zones of the joint that are subjected to less loading. The outgrowth of activated chondrycytes is promoted by this enlargement of the tissue surface [4, 5, 20, 22, 32]. Ultimately this leads to the regeneration of hyaline and/or hyaline-like cartilage [22, 32, 35].

Surgical technique

The preoperative planning of a chondro­plasty procedure includes a mandatory MRI and conventional radiographs (whole-leg) [31] to detect and treat any comorbidities such as ligamentous instability, meniscus defects or mecha­nical axial malalignment. The final planning of the chondroplasty is only completed following detailed arthroscopic diagnostic investigation of the defect. The cartilage can then be harvested with osteochondral cylinders from zones that are barely load-bearing (e.g. the intercondylar notch), or using ring curettes and shavers [31, 33]. When using osteochondral cylinders the cartilage must be separated from the bone and then minced with a scalpel or shaver until it has reached a paste-like consis­tency. During arthroscopic cartilage harvesting this is done exclusively with a shaver [33]. After preparing the defect and creating stable cartilage margins the joint is aspirated, the defect zone is dried, and the minced cartilage is introduced into the defect. Depending on the technique being used, autologous thrombin and PRP, fibrin glue and/or a membrane are used for stable fixation of the fragments [25, 26, 31 – 33].  

Clinical data

Clinical evidence on autologous MCI is still limited [8, 10, 25]. In 2015, Christensen et al. [8] treated eight patients with osteochondrosis dissecans of the knee joint with a combination of auto­logous bone graft and autologous cartilage fragments embedded in fibrin glue (autologous dual-tissue transplantation (ADTT)). One year later there was a marked improvement in the MOCART score (Magnetic Resonance Observation of Cartilage Repair Tissue) from 22 to 52 points. In 2019, Massen et al. [25] conducted a consecutive two-year study of patients with (osteo-)chondral lesions who had been treated with autologous MCI. At the final follow-­up examination a significant reduction in pain was observed. Moreover, a significant radiological improvement in the MOCART score was seen. In 2020, Cugat et al. [10] treated 15 patients with full-surface (osteo-)chondral lesions using autologous MCI embedded in platelet-poor plasma (PPP) and PRP. After 15 months they also observed statistically significantly better scores on the visual analogue scale (VAS) for pain, the Lysholm score, the subjective International Knee Documentation Committee (IKDC) score, the Western Ontario and the McMaster Universities Osteoarthritis Index (WOMAC) for pain and function, the Lequesne-Index and the Short Form 12 (SF-12). While the above-named clinical studies were conducted on the knee joint, autologous MCI is also used in other joints (hip, shoulder, ankle) [21, 29, 30, 34]. In summary it may be said that the clinical data to date show good results with low complication and revision rates which are comparable to other cartilage repair techniques (ACI). 

Case study

A 37-year-old patient, an active sportsman, consulted us after multiple left knee sprains; first sprain in 2005. Since then intermittent symptoms in the left knee joint, prone to swell. The clinical examination showed articular effusion with pain on pressure over the medial joint space and mild crepitation in the medial compartment when testing movement, ROM extension/flexion 3-0-145° pain-free. Joint with stable ligaments. The Knee Injury and Osteoarthritis Outcome Score (KOOS) for pain was 50 before surgery, the quality of life score for the knee was 25 points, and 44 for activities of daily living (0 = extreme knee problems, 100 = no knee-related impairment). The Marx activity rating scale (MARS) was initially 0 points (0 = lowest physical and sporting acti­vity, 16 = highest physical and sporting activity). The MRI showed grade 4 cartilage damage over the medial femoral condyle (Fig. 1). The preoperative AMADEUS score for the medial cartilage lesion was 60 points. Minced cartilage implantation was indicated. 

The arthroscopic operation with the implantation of minced cartilage in the medial femoral condyle using the pro­duct Autocart (Arthrex) was performed. During the operation we diagnosed a 3 cm² ICRS grade 3B chondral lesion over the medial femoral condyle (Fig. 2). The postoperative course was complication-free. Follow-up treatment consisted of six weeks’ partial 15 kg weight-­bearing on the left. The range of motion was limited to 60° for weeks one, two and three, and to 90° for weeks four, five and six. The patient was initially splinted with a Mecron brace, which was replaced with a rigid frame brace in the later course. He had physiotherapy for three months after surgery. At the check-up two months after surgery he still had some residual symptoms with a ROM in extension/flexion of 0-0-90° and his quadriceps muscles were still weakened.

Fig. 2 Intra-operative arthroscopic images showing the untreated cartilage damage (a)
and the lesion after preparation of stable cartilage margins (b) and implantation of the minced cartilage (c).

After eight months the patient then reported a satisfactory surgical outcome with improved movement and a clinically irritation-free knee joint. One year after surgery the patient was still satisfied and was able to re-initiate low-impact sporting activities (cycling). After two years the patient had reached his regular everyday level, and inten­si­fi­cation of sporting activities in the low-­impact range was possible. The clinical outcome parameters showed an improvement in the KOOS score for pain (from 50 to 53 points), knee-related quality of life (from 25 to 38 points) and activities of daily living (from 44 to 71 points). The MARS had also increased from 0 points before the operation to 6 points afterwards. The MRI two years after surgery showed a corresponding satisfactory outcome with a MOCART score of 95 points (Fig. 3).

Summary and outlook

On the basis of the available in vitro and in vivo data, autologous MCI is a pro­mising one-step chondral repair pro­cedure with great biological and clinical potential. Further medium- to long-term comparative studies on large patient cohorts with clinical, functional and radiological data are required to determine the optimal defect size for MCI and the durability of the repair cartilage, and to enable comparison with other, established chondral repair procedures.

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Autoren

Dr. med. Jakob Hax

ist Assistenzarzt Hüft- und Kniechirurgie an der Schulthess Klinik Zürich.
Seine Forschungstätigkeit liegt in der Hüft- und Kniechirurgie, Gelenkserhalt und Gelenksrekonstruktion. Sein Schwerpunkt in der Sportorthopädie/-traumatologie ist die Knorpelrekonstruktion.

Prof. Dr. med. Gian Salzmann

ist Facharzt für Orthopädie und Unfallchirurgie. Er hat seinen Lehrauftrag an der medizinischen Fakultät der Universität Freiburg im Breisgau. Sein Fachgebiet ist die Kniechirurgie. Er ist Partner am Gelenkzentrum Rhein-Main und Leitender Oberarzt Sektion Kniechirurgie an der Schulthess Klinik in Zürich. Professor Salzmann ist AGA Instruktor und beratender Arzt der Eintracht Frankfurt, Fußball.

PD Dr. med. Armin Runer

ist Assistenzarzt für Unfallchirurgie und Orthopädie an der Sektion Sportorthopädie, Klinikum Rechts der Isar, TU München. Außerdem betreut er die HC Innsbruck – Die Haie (Eishockey) sowie die Italienische Faustball Nationalmannschaft.