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Special Focus Section
Patellofemoral Cartilage Restoration: Indications,
Techniques, and Outcomes of Autologous
Chondrocytes Implantation, Matrix-Induced
Chondrocyte Implantation, and Particulated
Juvenile Allograft Cartilage
Betina B. Hinckel, MD, PhD1
Andreas H. Gomoll, MD2
1 Missouri Orthopaedic Institute, University of Missouri,
Columbia, Missouri
2 Cartilage Repair Center, Brigham and Women’s Hospital,
Boston, Massachusetts
Address for correspondence Andreas H. Gomoll, MD, Department of
Orthopaedic Surgery, Brigham and Women’s Hospital, 75 Francis
Street, Boston, MA 02467 (e-mail: agomoll@yahoo.com).
Abstract
Keywords
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knee
patellofemoral
patella
trochlear
cartilage
cartilage repair
ACI
MACI
particulated
transplantation
autologous
chondrocytes
cartilage
articular
DeNovo NT
Focal chondral defects are common in the patellofemoral (PF) joint and can significantly impair the quality of life. The autologous chondrocytes implantation (ACI)
technique has evolved over the past 20 years: the first-generation technique involves
the use of a periosteal patch, the second-generation technique (collagen-cover) uses a
type I/III collagen membrane, and the newest third-generation technique seeds and
cultivates the collagen membrane with chondrocytes prior to implantation and is
referred to as matrix-induced autologous chondrocyte implantation. Particulated
juvenile allograft cartilage (PJAC) (DeNovo NT) is minced cartilage allograft from
juvenile donors. A thorough physical exam is important, especially for issues affecting
the PF joint, to isolate the location and source of pain, and to identify associated
pathologies. Imaging studies allow further characterization of the lesions and identification of associated pathologies and alignment. Conservative management should be
exhausted before proceeding with surgical treatment. Steps of surgical treatment are
diagnostic arthroscopy and biopsy, chondrocytes culture and chondrocyte implantation for the three generations of ACI, and diagnostic arthroscopy and implantation for
PJAC. The techniques and their outcomes will be discussed in this article.
Focal chondral defects of the knee are common and can
significantly impair the quality of life. The patellofemoral
(PF) joint is affected in approximately one-third of the patients
that demonstrate International Cartilage Repair Society (ICRS)
grades 3 and 4 focal defects during knee arthroscopy, especially in younger patients.1,2 Overall, causes for PF cartilage
lesions can be divided into patellar instability, direct trauma,
repetitive microtrauma, maltracking, and idiopathic.
The goal of surgical procedures is to increase quality of life
by improving pain and function, and also, to potentially delay
or prevent the need for knee arthroplasty. Cell-based therapies rely on chondrocytes to produce extracellular matrix
received
April 29, 2017
accepted after revision
August 25, 2017
Copyright © by Thieme Medical
Publishers, Inc., 333 Seventh Avenue,
New York, NY 10001, USA.
Tel: +1(212) 584-4662.
DOI https://doi.org/
10.1055/s-0037-1607294.
ISSN 1538-8506.
Downloaded by: Vanderbilt University. Copyrighted material.
J Knee Surg
Hinckel, Gomoll
and form cartilage. The first generation of autologous chondrocyte implantation (ACI) uses a periosteal patch (pACI) to
contain the chondrocytes.3 The second-generation technique
(collagen-cover [cACI]) replaces periosteum with a type I/III
collagen membrane. The newest third-generation, matrixinduced autologous chondrocyte implantation (MACI) technique seeds and cultivates the collagen membrane with
chondrocytes in the laboratory prior to implantation.4 Particulated juvenile allograft cartilage (PJAC) (DeNovo NT) is
minced cartilage allograft from juvenile donors. These techniques and their outcomes will be discussed in this article.
Clinical Evaluation: History and Physical
Exam
Unfortunately, neither history nor clinical exam is sensitive
or specific for cartilage defects.
It is important to inquire whether there was a precipitating
acute injury, such as direct trauma or patellar dislocation; a
chronic cause, such as repetitive jumping or squatting activities or chronic maltracking, or if it is idiopathic, meaning no
other cause could be identified. Chronic maltracking is usually
related to anatomic abnormalities, which include the same risk
factors that can cause patellar instability. A common combination is trochlear dysplasia, increased tibial-tubercle to
trochlear-groove (TT-TG) distance, and lateral soft tissue contracture that progresses to lateral PF arthritis. As lateral PF
arthritis progresses, lateral soft tissue contracture worsens,
compounding symptoms of laterally based pain. Idiopathic
lesions are usually related to genetic predisposition to osteoarthritis and not restricted to the PF joint. Sometimes the PF joint
is the first compartment to degenerate and the most symptomatic in a setting of what is a truly tricompartmental disease.
In such cases, treatment of the PF lesion alone can result in
early failure due to progression of the disease in the other
compartments. Thus, even mild disease in other compartments should be carefully evaluated.
Common clinical complaints are anterior knee pain. It is
important to identify location (anterior pain, in the margins
of the patella or inside the knee “deep to the patella”),
position of the knee (increased pain with prolonged flexion
and relieved with extension), worse for stairs versus flat
ground, and pain with specific activities (squatting and
kneeling). Swelling is common and it is important to know
the degree, frequency, and related activities, and finally,
mechanical symptoms: catching and locking may be present
as well as a feeling of instability.
Important diagnostic components of the physical exam
include gait analysis; tibiofemoral malalignment and patellar
malalignment (static varus/valgus, dynamic valgus with one
leg squat; increased Q-angle and rotational malalignment,
with increased femoral anteversion and in-toe or out-toe
pattern); patellar malalignment/maltracking (lateral position
and lateral tilt, patella alta, and J-sign and subluxation with
quadriceps contraction in extension); ligamentous and soft
tissue stability/imbalance (tibiofemoral and patellar apprehension, glide test, and tilt test); effusion, crepitus, active and
passive range of motion (spine, hips, and both knees); location
The Journal of Knee Surgery
of pain/tenderness to palpation (medial, lateral, distal, or
retropatellar, and whether it matches the complaints and
the location of the cartilage lesion); and muscle strength,
flexibility, and atrophy (core—abdomen, dorsal, and hip muscles, and lower extremities—quadriceps, hamstrings, and
gastrocnemius).
Imaging
Imaging studies allow characterization of the lesions, identification of associated pathologies (ligaments and meniscus), and alignment.
• Routine knee X-ray (weight-bearing anteroposterior and
flexion posteroanterior, lateral, and axial): It evaluates for
fractures, loose bodies, osteophytes, and joint space narrowing. Joint space narrowing signifies more advanced
degenerative disease instead of a focal lesion. The lateral
view is also important to evaluate anatomy (trochlear
dysplasia, by Dejour’s classification) and alignment (patella height, e.g., Caton–Deschamps, Insall–Salvati). The
axial view is important to evaluate patellar tilt, subluxation, and joint space narrowing. Images with progressive
flexion can be very useful to verify reduction of patellar
tilt. The lack of reduction during early flexion suggests
lateral retinacular tightness.
• Computed tomography (CT): It provides detail of subchondral bone when bony abnormality is suspected, such as
after subchondral drilling, bone grafting, or osteochondral
allograft transplantation, as well as for osteochondritis
dissecans or osteochondral fracture. The addition of intraarticular contrast (CT arthrogram) also allows excellent
visualization of the articular cartilage. Alignment measures, patellar tilt, and the TT-TG distance can be obtained
on axial images.
• Magnetic resonance imaging (MRI): It evaluates articular
cartilage, soft tissues, and bone marrow lesions (subchondral edema). It is helpful to estimate the grade and the size
of the lesion to guide treatment, although MRI frequently
underestimates lesion size by up to 60%.5 Alignment
measures, patellar tilt, and the TT-TG distance can be
obtained from MRIs as well as from CTs.
Surgical Treatment
Indications
ACI, MACI, and PJAC are indicated for the treatment of
medium to large, deep, or full-thickness cartilage defects.
Due to the cost and invasiveness of the procedures, they are
considered second-line treatment for defects smaller than
2 cm2, where it is generally reserved for revision of prior
failed cartilage repair. For larger defects, however, it can be
utilized as a primary procedure due to the lowered efficacy of
procedures such as microfracture or osteochondral autograft
transfer.
The extensive postoperative recovery and rehabilitation,
delayed return to sports and heavy labor, as well as permanent restrictions/recommendations requires a careful preoperative discussion with the patient and family to establish
reasonable expectations and avoid disappointment.
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Patellofemoral Cartilage Restoration
Patellofemoral Cartilage Restoration
Comorbidities and Associated Procedures
Articular comorbidities are a common cause of chondral
defects and potential failure mechanism after cartilage repair. As such, lower extremity malalignment, PF instability
and/or maltracking, and stiffness require careful preoperative assessment and treatment in a staged or concomitant
fashion. Associated procedures that are most commonly
required are tibial tuberosity osteotomy (TTO), lateral retinacular lengthening (LRL), and soft tissue stabilizing procedures such as medial PF ligament (MPFL) reconstruction.
Trochleoplasty may rarely be required.
Surgical Procedure: ACI and MACI
Arthroscopic Assessment and Biopsy
The knee joint is examined under anesthesia to assess
ligamentous stability, range of motion, crepitation, and
patellar mobility and tracking.
Arthroscopy is performed to assess the overall condition of
the knee joint and for cartilage defect(s). It is important to note
the size and location of the defects. Quality and thickness of the
surrounding and opposing cartilage should be assessed.
If the arthroscopic assessment is favorable for ACI/MACI
treatment, a cartilage biopsy is obtained. The cartilage is
usually harvested from the superior and lateral aspect of the
intercondylar notch (►Fig. 1). Alternatively, the medial
aspect of the notch or periphery of the trochlea can be
harvested if needed. A gouge or curette is used to mobilize
a 5-mm wide, 10 to 15 mm long (200–300 mg) strip of
cartilage. It is left attached at one end to avoid losing the
biopsy in the joint. It is then removed with the tissue grasper
or pituitary rongeur and directly placed in sterile transport
medium for shipment.
Fig. 1 Cartilage biopsy. Arthroscopic view of cartilage biopsy of the
superior and lateral portion of intercondylar notch. (Image courtesy
of Andreas H. Gomoll, MD).
Chondrocytes Culture
The biopsy is placed in cryopreservation where it can remain
for up to 5 years. Before the implantation procedure, the cells
are removed from cryopreservation, thawed, and cultured for
an additional 3- to 4-week period. A standard order can yield
up to our vials of 12 million cells each, contained in 0.4 mL of
culture media. In general, the recommendation for ACI is to use
one vial of cells per defect and to aim for a seeding density of 1
to 2 million cells per square centimeters. The cells are delivered
the day before or day of the procedure and expire within
48 hours. In the case of MACI, the cells are cultured per the
standard ACI technique but then seeded onto a collagen
membrane and cultured for several days prior to shipment.
Implantation Technique
Except for patch preparation, fixation, and chondrocyte
implantation, the procedure is identical for ACI and MACI.
Exposure
Adequate exposure is critical to ensure appropriate defect
preparation and implant placement.
The surgery is performed through an anterior approach.
The arthrotomy is parapatellar, medial, or lateral. If patellar
eversion is needed or the center of the trochlear groove
needs to be addressed, the proximal approach is usually
through a longitudinal split of the quadriceps tendon. Subvastus or midvastus approach can be performed per surgeon’s preference. For patellar lesions, the patella usually
needs to be everted, while for trochlear lesions, it may not be
required. The parapatellar approach should be on the same
side of lesions. For central lesions, medial parapatellar is
preferred since the patella can generally more easily be
subluxed laterally. When concomitant procedures are being
performed, the approach that permits good access to all
procedures is the best choice (e.g., medial approach for
medial PF reconstruction and lateral approach for LRL).
Defect Preparation
Careful defect preparation is critical and all degenerated
cartilage should be removed to achieve a stable rim with
vertical shoulders (►Fig. 2). The defect is outlined with a fresh
scalpel down to the subchondral plate, taking as much of the
surrounding cartilage to remove all unstable or undermined
cartilage. The degenerated cartilage is debrided with small ring
or conventional curettes. However, if this would transform a
peripheral defect from a contained to an uncontained lesion, it
is advisable to leave a small rim of degenerated cartilage to sew
into. The debridement includes the zone of calcified cartilage
but maintains an intact subchondral plate. Minor punctate
bleeding is frequently encountered but can usually be controlled with fibrin glue or epinephrine-soaked neuropatties.
The tourniquet should be released during defect preparation to
visualize and address any potential bleeding.
Patch Preparation, Fixation, and Chondrocyte Implantation
For ACI, the lesion is templated with a sterile marking pen
and tracing paper. Our preference is to cut the collagen
membrane dry according to the template, and then the
The Journal of Knee Surgery
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Contraindications include active or recent infection, inflammatory arthritis, significant medical comorbidities, and
inability to follow the complex postoperative rehabilitation.
Uncontained and bipolar lesions are a relative contraindication and require special techniques.
Hinckel, Gomoll
Patellofemoral Cartilage Restoration
Hinckel, Gomoll
porous side is seeded with the chondrocyte solution. In
general, the dry patch will readily absorb the cell suspension,
and after a 5-minute period to allow the cells to preliminarily
soak into and attach to the membrane, the patch can be
placed into the defect. It is placed on the defect with the
porous side containing the cells toward the bone. If additional chondrocyte injection into the defect is desired, the
patch is sutured tight enough to not sit on the bone but rather
be flush with the surrounding cartilage, creating a space
underneath to inject the chondrocyte suspension. Otherwise, the membrane is placed directly on the bone. Resorbable 6–0 suture on a cutting needle, immersed in mineral oil
Fig. 3 Fixation of the membrane in a trochlear lesion and a patellar
lesion. The knots are tied on the patch side, seated below the level of
the adjacent cartilage. (Image courtesy of Andreas H. Gomoll, MD.)
The Journal of Knee Surgery
or glycerin for handling, is utilized for suturing. The sutures
are placed through the patch and then the articular cartilage,
exiting approximately 3 mm away from the defect edge,
everting the edge of the patch slightly to provide a better
seal against the defect wall. The knots are tied on the patch
side, seated below the level of the adjacent cartilage
(►Fig. 3). The suture line is waterproofed with fibrin glue.
If necessary, an opening wide enough to accept an Angiocath
is left in the most superior aspect of the patch to inject the
chondrocytes; this opening is closed with additional suture
and fibrin glue after the defect has been completely filled
with chondrocyte suspension.
For MACI, the chondrocytes are delivered on a preseeded
membrane (►Fig. 4). The membrane is sized according to the
template, then placed with the porous side facing the subchondral bone. The edges are trimmed to ensure there is no
prominence that could compromise the mechanical stability
of the implant during range of motion. The membrane is then
Fig. 4 Matrix-induced autologous chondrocyte implantation membrane. (Image courtesy of Vericel Corporation and Leela Biant, MD.)
Downloaded by: Vanderbilt University. Copyrighted material.
Fig. 2 (A) Cartilage defects in trochlea and patella of the right knee; (B and C) Debrided cartilage defect ([B] patella; [C] trochlea). Degenerated
cartilage should be removed to achieve a stable rim with vertical shoulders bordering on normal cartilage. Area of previous cartilage biopsy can
also be noted near the notch in (A) and (C). (Image courtesy of Andreas H. Gomoll, MD).
Patellofemoral Cartilage Restoration
Hinckel, Gomoll
Fig. 5 Matrix-induced autologous chondrocyte implantation. The
membrane is implanted in a trochlear groove defect, fixed by fibrin
glue. (TImage courtesy of Vericel Corporation and Leela Biant, MD.)
Fig. 6 Particulated juvenile allograft cartilage (DeNovo NT) applied
directly to a patellar lesion. The pieces are arranged in one layer and
close together (touching or almost touching). Fibrin glue is added.
The whole implant is recessed below the margins of the defect
(1 mm). (Image courtesy of Andreas H. Gomoll, MD.)
Surgical Procedure—PJAC
PJAC consists of allograft articular cartilage from donors
younger than 13 years old that has been cut into 1-mm
cubes.6 It differentiates from the ACI and MACI for being a
one-step procedure, since it does not require the biopsy. Still,
many times a diagnostic arthroscopy is necessary to confirm
all lesions present, best determine lesion characteristics
(location, size, and bone status), and evaluate the quality
and thickness of the surrounding and opposing cartilage.
Juvenile chondrocytes have been shown to perform better in
the production of the extracellular matrix,7 which may result
in an improved cartilage quality, specially, in older patients
or that ones that have a more degenerated cartilage.
Preparation of the defect is similar to ACI and MACI. The
depth of the defect should be greater than the implant (> 1 mm).
The lesion area is calculated: one packet of PJAC covers 2.0 to
2.5 cm2. Although not clearly defined, most experts agree that
lesion size after debridement should be between 1 and 6 cm2.8
Relative contraindications are bipolar lesions that could shear
against each other (may be covered with collagen patch to better
protect the graft) and subchondral bone loss (unless concomitant bone grafting).9 For preparation, the excess of the media is
discarded. The pieces should be arranged in one layer and close
together (touching or almost touching each other) (►Fig. 6).
Fibrin glue is added and the whole implant should be recessed
below the shoulders of the defect (1 mm). This is important to
decrease the compressive and sheer forces on the implant. Wait
for 5 to 10 minutes for the fibrin glue to cure. The preparation
can be directly inside the defect or on the back table through the
use of a mold, for example, aluminum foil pressed into the
defect. When prepared directly inside the defect, it is helpful to
change the position of the knee for the defect to be as horizontal
as possible. When prepared on the back table, fibrin glue is
added to the cartilage fragments and allowed to cure. Then, the
implant is glued into the defect with fibrin glue. For bipolar
lesions or when there are concerns with stability (such as
uncontained lesions), the PJAC implant can be covered by a
type I/III collagen membrane (►Fig. 7).
For ACI, MACI, and PJAC, we minimize the use of intraarticular drains as to avoid damage to the patch. When drains
are utilized, it should be without suction and with care to
position the tubing away from the defect. Key characteristics
and differences among the ACI, MACI, and PJAC are summarized in ►Table 1.
Special Situations
Osteochondral lesions: Bony defects deeper than 6 to 8 mm
should be considered for staged or concomitant autologous
bone grafting from the proximal tibia or distal femur.
Uncontained defect: Membrane should be fixed by transosseous sutures or small suture anchors to ensure mechanical
stability.
Intralesional osteophytes: Should be burred down to the
level of the surrounding subchondral plate with a highspeed bur under constant cold irrigation.
Fig. 7 Particulated juvenile allograft cartilage (DeNovo NT) implant covered
by a I/III collagen membrane. (Image courtesy of Andreas H. Gomoll, MD.)
The Journal of Knee Surgery
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secured with either fibrin glue only (►Fig. 5), or additional
sutures can be placed around the periphery if there are concerns
for stability. The knee is then ranged to ensure secure fixation.
Patellofemoral Cartilage Restoration
Hinckel, Gomoll
ACI
MACI
PJAC
Stages
Two stage
Two stage
One stage
Size
One vial contains 12 million cells
Every 1 cm2 should
have 1 million cells
One vial provides a patch
of 4 5 cm2
One packet sufficient for area
of 2.0–2.5 cm2
Chondrocytes
activity
Dependent on patient’s cartilage status
Dependent on patient’s
cartilage status
From a juvenile
Technique
Requires meticulous suture of the
membrane to contain chondrocytes
Easier handling than ACI
Membrane can be glued
May be applied
arthroscopically
Cartilage pieces can be glued
Location
Anywhere on patellofemoral
Anywhere on
patellofemoral
Anywhere on patellofemoral.
May need back table preparation
when the defect cannot be horizontal
Special
situations
Needs transosseous sutures or
anchor fixation for
uncontained lesions
More adequate for
uncontained lesions
May need addition of membrane in
uncontained lesions
Cost
Expensive
Expensive
Moderate
Availability
FDA approved for femoral
condyles and trochlea
FDA approved for
all surfaces
in the knee joint
Available in the United States as not
FDA regulated; insurance often
labels as experimental
Rehabilitation
If purely PF defect repair can be weight bearing in full extension. CPM for 6 weeks. Avoid single leg flexed knee loading (stairs,
squatting) for 3 mo or longer depending on size of defect
Abbreviations: ACI, autologous chondrocyte implantation; CPM, continual passive motion; FDA, food and Drug Administration; MACI, matrixinduced autologous chondrocyte implantation; PF, patellofemoral; PJAC, particulated juvenile allograft cartilage.
Rehabilitation
Immediate protected motion is encouraged. A continual passive motion machine is used 6 to 8 hours a day for the first
6 weeks. The motion is progressed toward 90 degrees over the
first 2 to 3 weeks. When no osteotomy was performed, weight
bearing as tolerated is permitted for PF defects with the knee in
a brace locked in extension. Avoid single leg flexed knee loading
(stairs, squatting) for 3 months or longer depending on size of
defect. Running and plyometrics are restricted for 12 months
and most strenuous cutting activities for 18 months until the
graft has fully matured.
Complications
Standard complications of knee surgery include deep vein
thrombosis, wound infection, arthrofibrosis, and neurovascular
injury. Complications specific to the cell-based therapy discussed here include failure to form an appropriate repair tissue
(biologic failure) and delamination of a well-formed graft
(mostly traumatic failure).10,11 Hypertrophy of the graft is
more common in the first generation of ACI than the second
generation of ACI and MACI.11–14 It is also a complication
reported after PJAC.15
Evaluation of Outcomes and Long-Term
Recommendations
Cartilage repair procedure are less frequently performed for
the PF compartment than for the condyles.16,17 However,
patients treated for ACI have a higher proportion of PF lesions
compared with other treatments, such as osteochondral alloThe Journal of Knee Surgery
graft (OCA), microfracture (MFx), and osteochondral autograft
tranfer (OAT).16,18 Conversely, patients with PF cartilage
lesions also more commonly undergo ACI instead of other
treatments, such as OCA, MFx, and OAT, compared with
patients with lesions in the femoral condyle.19,20 A few factors
contribute to this finding. As the shapes of the patella and
trochlea are more highly variable than the condyles and
plateaus, morphology matching is harder to achieve, particularly with the involvement of the central trochlear groove and
median patellar ridge. As a result, focal contained lesions of the
patella and trochlea may be more technically amenable to cell
therapy techniques rather than osteochondral procedures,
which require contour matching between donor and recipient
for unipolar lesions. Although small lesions in the femoral
condyles can be considered for MFx or OAT, these procedures
are less suitable for the PF joint because of reported poor
results of MFx in the PF21 and donor-site morbidity in the
trochlea after OAT procedures.
Clinical evidence for cell-based therapy in the PF joint is
mostly based on case series, including long-term follow-up
studies (over 10 years).22–24 There are no randomized controlled trials specifically for the treatment of PF cartilage
defects comparing outcomes of cell-based therapy to MFx or
other treatments such as OAT and OCA.
Most common PF lesions treated by cell-based therapy are
lesions in the medial patellar facet and central or panpatellar lesions.25,26
Although initial studies reported poor clinical outcomes
for ACI in the PF joint,3 current studies report good to
excellent results in 71 to 93% of the cases.27–31 Improvement
of clinical outcomes are reported in several case series of ACI,
MACI, and PJAC (►Table 2).
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Table 1 Key characteristics and differences among ACI, MACI, and PJAC in the patellofemoral joint
2y
Mean 59 18 mo
Knee, patella/mean 4.7 cm2
Knee, trochlea/mean 4.5 cm2
Median 3.1 y (0.5–5.1 y)
Mean 26.2 mo in realignment group and 28.9 mo in
without realignment group
Knee, patella/mean 2.91 cm2
in realignment group and
3.22 cm2 in without
realignment group
Knee, PF/patella mean
5.4 cm2, trochlea mean
4.3 cm2, bipolar mean
8.8 cm2
> 2 y, mean 46 mo
Follow-up
Knee, PF/patella 4.86 cm2
and trochlea 5.22 cm2
Defect location/size
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Mean 31.2 y
Case series (total 39 patients,
46 lesions, patella 14,
trochlea 18, bipolar 7)
Farr (2007)27
pACI
Mean 37.1 y
Case series
(trochlea 40)—48%
after failed MFx
Mandelbaum
et al (2007)10
pACI
Mean 30.5 y
Gobbi
et al (2006)38
MACI
Case series (total 32,
patella 22, trochlea 10)
Henderson and
Lavigne (2006)32
pACI
Mean 32.1 y in
realignment group and
35.1 y in without
realignment group
Minas and
Bryant (2005)28
Comparative retrospective study
(patella 44)
Age
Mean 37.5 y
Study type (number, characteristics of subjects/defects)
Case series (total 45, patella 10,
trochlea 11, patella þ trochlea 24)
Author (y)
pACI
PF only studies
Procedure
Table 2 Clinical studies—ACI, MACI, and PJAC
(Continued)
Concomitant PF realignment procedures:
TTO 73.7%, LRR 5.1%, MPFL
80% of the patients rated themselves as
good, very good, or excellent at final
follow-up
Bipolar lesions had similar outcomes as single
lesions
Patients with TTO had similar results as the
ones without Lysholm improved from 56 to
86
VAS resting pain from 2 to 0
VAS maximum pain from 8 to 4
Graft hypertrophy: 12 cases (20%)
Arthroscopy: ICRS score of 11 from maximum
12 points
Concomitant PF realignment procedures:
TTO 13%
Modified Cincinnati improved from 3.1 1.0
to 6.4 1.7
11 patients experienced 17 subsequent
procedures (adhesions in 4 cases, periosteal
flap detachment in 4 cases, chondromalacia
in 4 cases)
IKDC improved: from 0 to 43.8% normal, from
18.8 to 46.9% nearly normal
Better outcomes with lesions 3 cm2 and
trochlea vs. patella
MRI: 71.9% with >50% refill, 84.4% mild or
absent subchondral edema
Histology: 64.5% collagen type II and 1.2%
collagen type I
Concomitant or staged PF realignment
procedures: 22 (50%) patients—TTO þ LRR in
patients with abnormal tracking on arthroscopy
Multiple lesions including trochlea and condyles
in 9 patients total
Results: good or excellent was 86% in
realignment group and 54.5% in without
realignment group
IKDC, modified Cincinnati and SF-36 improved
in both groups with increased improvement in
the realignment group
71% patients rated outcome good or
excellent, 22% as fair, and 7% as poor
KSS improved from 53 to 74
Modified Cincinnati improved from 3.84 to 5.76
Results and comments
Patellofemoral Cartilage Restoration
Hinckel, Gomoll
The Journal of Knee Surgery
Author (y)
Niemeyer
et al (2008)37
Gigante
et al (2009)30
Pascual-Garrido
et al (2009)29
Gobbi
et al (2009)39
Bonner
et al (2010)47
Vanlauwe
et al (2012)33
Procedure
pACI and cACI
MACI
pACI
MACI
PJAC
cACI
Table 2 (Continued)
The Journal of Knee Surgery
Mean 34.3 y
Mean 31 y
Mean 31.8 y
Mean 31.2 y
36 y
Mean 30.9 y
Case series (patella 70)
Case series (patella 14)
Case series (total 52 patients, patella 19, trochlea 28, bipolar 5)
Case series (total 34, patella 21,
trochlea 9, multiple 4)
Case report patella
Case series (total 38: patella 28,
trochlea 7, and both 3)
> 2 y, mean 37 mo
>5y
Knee, PF/mean 4.45 cm2
Knee, PF/4.89 cm2
Mean 4 y
Knee, PF/mean 4.2 cm2
2y
3y
Knee, patella/mean 4 cm2
Knee, patella
Mean 38.4 mo
Follow-up
Knee, patella/mean
4.41 2.15 cm2
Defect location/size
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Age
Study type (number, characteristics of subjects/defects)
Concomitant and previous PF realignment
procedures: TTO 15 (39%)
VAS pain improvement from 62.1 to 27.4
KOOS improvement from 73.6 19.1
Failures: 5 (13%)
Adverse events: joint crepitation (18) and
arthrofibrosis (7)
IKDC improved from 32 to 85
KOOS pain from 67 to 94
MRI: full defect filling and nearly complete
resolution of the preoperative subchondral
bone edema
Significant improvement at 2 and 5 y
There was a decline between 2 and 5y
Degenerative lesions had greater decline in
outcomes
IKDC improvement from 46.09 19.3 to
77.06 17.0 at 2 y and 70.39 21.4 at 5 y
Biopsy samples with hyaline line
Concomitant and previous PF realignment
procedures: TTO 61.5%, LRR 23%, MPFL
reconstruction 2%
Subgroup analysis: isolated ACI, ACI plus
realignment, or ACI plus realignment
procedure with history of a failed MFx
Results: overall 71% good or excellent
Both realignment groups had better
outcomes than ACI alone
All patients had TT-TG > 20 mm and
increased lateral patellar tilt by CT
Concomitant PF realignment procedures:
TTO all patients
93% of excellent and good outcomes
Lysholm improved from 55 to 92.5
Tegner improved from 1 to 4
Kujala improved from 52 to 88.5
No serious complications.
Reoperation: 2 screw removals
Concomitant PF realignment procedures: none
Lysholm 73.0 22.4 and IKDC 62 21.5 at
follow-up (no preoperative data)
Better results at lateral facet lesions
Cincinnati sports activity improvement from
34.4 33.9 to 61.5 21.5
Results and comments
Patellofemoral Cartilage Restoration
Hinckel, Gomoll
Author (y)
Vasiliadis
et al (2011)11
Macmull
et al (2012)26
Teo
et al (2013)48
Tompkins
et al (2013)49
Gomoll
et al (2014)25
Procedure
pACI
cACI and MACI
pACI and BMSC
PJAC
pACI
Table 2 (Continued)
Knee, patella/mean
Mean 26.4 9.1
Mean 33 y
Case series (patella 15)
Case series multicenter
(patella 110)
Mean 90 mo
Mean 28.8 10.2 mo
Mean 72 mo
Downloaded by: Vanderbilt University. Copyrighted material.
Knee, patella/mean
5.4 2.7 cm2
Knee, patella/no data
Mean 16.8 y
Case series (23 patella; 20 ACI and
3 BMSC)—OCD
Mean 40.3 mo
Knee, patella/4.75 cm2
Mean 34.8 y
Case series (total 48, cACI 25,
MACI 23)
Mean 12.6 y
Knee, PF/mean 5.5 cm2 per
lesion, 1.7 lesions per patient
Mean 35
Case series (total 92, patella 39,
trochlea 8, bipolar 18, multiple
including patella or trochlea 27)
Follow-up
Defect location/size
Age
Study type (number, characteristics of subjects/defects)
(Continued)
Location of the defect: distal 11%, lateral 3%,
medial 15%, and central/pan-patellar 72%
Concomitant PF realignment procedures:
TTO 75%, LRR 41%, advancement of vastus
medialis 20%, trochleoplasty 5%, IKDC
improved from 40 14 to 69 20
Cincinnati improvement from 3.2 1.2 to
6.2 1.8
There was no difference between polarity,
containment, concomitant realignment,
defect location, defect size, and sex
Failures: 8%
Final follow-up and no preoperative data
IKDC: 73.3 17.6
Kujala: 79 (range, 55–99)
Tegner: 5 (range, 3–9),
VAS pain 1.9 1.4
MRI: 73% with normal or nearly normal
cartilage repair
Concomitant PF realignment procedures:
TTO 4, Roux–Goldthwaite 2
IKDC score improved from 45 to 75
Tegner–Lysholm improved from 2.5 to 4
Lysholm–Gillquist improved from 50 to 70
Concomitant PF realignment procedures:
none
Location of lesion: medial 20, lateral 13 and
diffuse 15
Medial facet had better outcomes
Results: good and excellent 40% on cACI and
56% on MACI
VAS pain improved from 6.4 to 4.5
Modified Cincinnati improved from 45.13 to
54.81
Concomitant and previous PF realignment
procedures: total 38, TTO þ medial plication þ LRR þ proximal trochleoplasty 22,
only TTO 9, medial plication þ trochleoplasty 1, LRR þ trochleoplasty 1
Similar outcomes between realignment and
without realignment groups
Worse results for bipolar lesions
Complications: hypertrophy 16% on with
realignment and 39% on without realignment; serious complications (arthrofibrosis,
delamination, multiple surgeries) 29% on
with realignment and 13% on without
realignment
Results and comments
Patellofemoral Cartilage Restoration
Hinckel, Gomoll
The Journal of Knee Surgery
The Journal of Knee Surgery
Buckwalter
et al (2014)34
Meyerkort
et al (2014)35
Gillogly
et al (2014)31
Ebert
et al (2015)13
PJAC
MACI
pACI
MACI
Age
Mean 22.5 y
Mean 42.3 y
Mean 31 y
Mean 37.5 y
Study type (number, characteristics of subjects/defects)
Case series (patella 13)
Case series (total 24, patella 15,
trochlea 9)
Case series (total 25)
Case series (total 47, patella 24,
trochlea 23)
Bentley
et al (2003)41
Bartlett
et al (2005)12
pACI/cACI
and OAT
cACI and MACI
Mean 33.7 y in cACI and
33.4 y in MACI
RCT cACI (total 44 patients, 59
defects, patella 20, trochlea
9–49% PF) vs. MACI (total 47
patients, 53 defects, patella 16,
trochlea 6—41.5% of defects)
Mean 7.6 y
2y
Knee, patella/6.5 cm 2
Knee, PF/mean 3.3 cm2
Knee, all locations/mean
6 cm2 in cACI and 6.1 cm2 in
MACI
1y
Mean 19 mo
5y
Knee, PF/mean 3.5 cm2
Knee, all locations/mean
4.66 cm2
Mean 8.2 mo (0.67–32.7)
Follow-up
Knee, patella
Defect location/size
Downloaded by: Vanderbilt University. Copyrighted material.
Mean 31.3 y
RCT pACI (total 58, patella 20,
trochlea 1–36% PF) vs. OAT (total
42, patella 5, trochlea 2—16.6%
PF)
Studies including significant number of PF lesions
Author (y)
Procedure
Table 2 (Continued)
Overall outcomes:
Clinical improvement in both groups.
Modified Cincinnati improved by 17.6 in the
cACI and 19.6 in MACI
Arthroscopy: ICRS good to excellent in 79.2%
of cACI and 66.6% of MACI
Histology: Hyaline-like cartilage or hyalinelike cartilage with fibrocartilage in 43.9% of
cACI and 36.4% of MACI. Hypertrophy of the
graft was 9% in cACI group and 6% in MACI
Reoperation was 9% in each group
For patellar lesions 85% had excellent or good
results with ACI vs. 60% with OAT, but not
statistically significant
Overall outcomes:
Modified Cincinnati and Stanmore scores and
objective clinical assessment showed that
88% had excellent or good results after ACI
compared with 69% after OAT
Arthroscopy (at 1 y) excellent or good repairs
in 82% after ACI and in 34% after OAT
KOOS improved in all subscales
VAS pain improved from 5.4 1.4 to
1.8 1.1
MRI: 40.4% complete graft infill, 6.4% hypertrophic graft, 31.9% with 50 to 100% graft
infill, 17 < 50% tissue infill, and 4.3% graft
failure
All patients showed maltracking on arthroscopy
Concomitant PF realignment procedures:
TTO 25, trochleoplasty 4
Results: Good to excellent 83%, fair 13%, and
poor 4%
Similar results too all locations of lesions
Failures: 1 patient undergoing PF arthroplasty
Concomitant and previous PF realignment
procedures: TTO þ LRR, 9 patients (37.5%)
KOOS pain subscale improved from 60 to
80.6
KOOS ADL subscale 69.3 to 88.3
SF-36 improved from 36.4 to 45.1
MRI: complete infill 32 and >50% infill 50% of
patients
Concomitant PF realignment procedures:
6 (43%) TTO for TT-TG > 10 mm
KOOS: improved from 58.4 þ 15.7 to
69.2 þ 18.6
Results and comments
Patellofemoral Cartilage Restoration
Hinckel, Gomoll
McNickle
et al (2009)50
Peterson
et al (2010)24
Ebert
et al (2011)40
pACI
pACI
MACI
Bentley
et al (2012)51
Rosenberger
et al (2008)43
pACI
cACI and OAT
Author (y)
Procedure
Table 2 (Continued)
Mean 30.3 y
Mean 33.3 y
Between 10 and 69 y
Case series (total 140, patella 21,
trochlea 13—38% PF)
Case series (total 224 patients,
patella 73 lesions, trochlea 47
lesions)
Case series (total 46, patella 11,
trochlea 9—43.4% PF)
The Journal of Knee Surgery
Knee all locations/mean cACI
(4.40 cm2) and OAT
(3.99 cm2)
Knee, all locations/from 1
to > 5 cm2
Knee, all locations/mean
5.3 cm2
Knee, all locations/mean
5.2 3.5 cm2
Knee, all locations/means
4.7 cm2 per defect and
9.8 cm2 per knee
Defect location/size
Between 10 and 12 y
5y
10–20 y, mean 12.8 y
Mean 4.3 y
Mean 4.7 y
Follow-up
Downloaded by: Vanderbilt University. Copyrighted material.
Mean cACI (30.9 y) and
OAT (31.6 y)
Mean 48.6 y
Case series (total 56 patients, 117
defects, patella 26, trochlea 34,
kissing lesions PF 14—51% PF)–>
45 y
RCT cACI (58) vs. OAT (42) (total
100, patella 25, trochlea 3—28%
PF)
Age
Study type (number, characteristics of subjects/defects)
(Continued)
Of 33 revision procedures 3 failures required
PF arthroplasty
Overall outcomes:
cACI better outcomes
Cincinnati from nonfailed: cACI (excellent/
good—73%) OAT (excellent/good—60%)
Failures: cACI (17%) and OAT (55%)
Overall outcomes:
Improvement in all KOOS and SF-36 subscales
as well as the 6-min walk test and active knee
extension
MRI: good to excellent fill graft was 77, 84, 86,
and 67% (3, 12, 24 and 5 y, respectively). Signal
intensity was good to excellent in 23, 72, 94,
and 96% (3, 12, 24, and 5 y, respectively)
No correlations existed between clinical and
MRI-based outcome measures
Concomitant PF realignment procedures:
46%, including TTO, MPFL reconstruction,
and LRR
Overall outcomes:
74% status as better or the same and 92%
would do surgery again
Lysholm improvement: from 60.3 to 69.5
Tegner improvement: from 7.2 to 8.2
Bipolar lesions had worse final outcomes than
multiple unipolar lesions
Meniscal injuries, previous marrow procedures, and age did not affect final outcomes
Concomitant and previous PF realignment
procedures: TTO 38 (27%) and 15 (10%) LRR
Overall outcomes:
75% patients were completely or mostly satisfied; 83% would have the procedure again
IKDC improvement from 34 to 64, and Lysholm improvement from 41 to 69
16% required ACI debridement postoperative
Failures: 6.4%
Age and worker’s compensation are independent predictors of outcomes
Concomitant PF realignment procedures:
TTO (11)
Failures: 8 failures (14%)—5 failures were in
patella or trochlea (8.3% failure rate for PF joint)
Overall outcomes:
Additional arthroscopy: 24 patients (43%) for
periosteal-related problems and adhesions; 88% of
these patients experienced lasting improvement
81% of patients would again undergo ACI
Results and comments
Patellofemoral Cartilage Restoration
Hinckel, Gomoll
Author (y)
Minas
et al (2014)23
Nawaz
et al (2014)44
Niemeyer
et al (2014)22
Farr
et al (2014)15
Cvetanovich
et al (2016)42
Procedure
pACI
pACI and cACI
pACI
PJAC
cACI
Table 2 (Continued)
The Journal of Knee Surgery
Femoral condyles and trochlea/2.7 0.8
Mean 37.0 11.1 y
Mean 16.7 y
Case series (total 25, 11—44%
trochlea)
Case series (total 37, patella 7,
and trochlea 7—36% PF)
IKDC improved from 45.7 15.9 to
73.6 14.1
KOOS pain score improved from 64.1 16.4
to 83.7 10.5
KOOS activity of daily living improved from
73.8 16.2 to 91.5 10.6
MRI: graft infill of 109.7% 62.9% with mild
hypertrophy in 6 lesions (20.7%)
Histology: all chondrocytes were viable in the
majority of the sections, II collagen type II
was more frequent than type I
Similar results between PF and tibiofemoral
Concomitant PF realignment procedures:
TTO 9, LRR 2 and MPFL reconstruction 2
Overall outcomes:
IKDC subjective improvement from 34.9 to 64.6
subsequent surgery: 37.8% (most commonly,
chondral debridement [54%])
Mean 4.6 2.4 y
In the PF group, all but 1 were satisfied or very
satisfied
Overall outcomes:
VAS pain improvement from 7.2 1.9 to
2.1 2.1
Lysholm improvement from 42.0 22.5 to
71.0 17.4
2y
Mean 10.9 y
Lateral femoral condyle procedures survived
the longest and MFC and patella had higher
risk of failure
Overall outcomes:
Survivorship: 78% at 5 y and 51% beyond 10 y
VAS pain improvement: from 5.95 to 3.56
Modified Cincinnati improvement: from
46.91 to 66.74
5 failure rate with previous procedure
(excluding debridement), such as MFx
No increase in failures with larger lesions
Concomitant PF realignment procedures:
TTO 64 (30.4%), LRR 130 (62%), and vastus
medialis obliquus advancement 39 (18.6%)
PF graft failed earlier than grafts in the
tibiofemoral compartment (70 vs. 79% at 10
y); however, long-term survivorship was not
significantly different (70 vs. 73% at 15 y)
Survivorship: 79% at 5 y, and 71% at 10 y
Improved function: 75% (WOMAC 39 21–23 16, Knee Society Score (KSS) from
54 18 to 79 19)
Failures: 25%
Increased failure risk with previous MFx and
lesion > 15 cm2
> 10 y, mean 12 y
Mean 6.2 y
Results and comments
Follow-up
Downloaded by: Vanderbilt University. Copyrighted material.
Knee, all locations/mean
4.0 2.2 cm2
Knee, all locations/mean
6.5 4.0 cm2
Mean 33.3 y
Case series (total 70, patella 14,
trochlea 2—23% PF)
Knee, all locations/mean
4.09 cm2
Knee, all locations/mean
8.4 5.5 cm2 (1.7 lesions
per knee)
Mean 34 y
Mean 36 y
Case series (210)
Defect location/size
Case series (total 827, patella 200,
trochlea 50—30% PF)
Age
Study type (number, characteristics of subjects/defects)
Patellofemoral Cartilage Restoration
Hinckel, Gomoll
Hinckel, Gomoll
To a large extent, improved outcomes are due to correction of
maltracking by osteotomy and soft tissue procedures. Associated
procedures to correct malalignment or unload the PF compartment are very frequent: TTO is performed in 30 to 75% of the
patients in most series.25,27–29,32–35 Some studies report better
results in patients with associated TTO,29,32,36 while others
report similar results between the ones associated and not
associated with the TTO when selective osteotomy is performed
based on defect location.25,27 Frequent indications for osteotomy
are malalignment as determined on imaging studies (increased
lateral tilt and increased TT-TG distance), clinical maltracking
noticed during arthroscopy, and lesion characteristics, such as
lateral or inferior location in the patella, lateral location in the
trochlea, and bipolar lesions.25,27–32 Lateral retinacular release is
performed in 20 to 60% in most case series,11,23,25,29 frequently
associated with TTO. Although MPFL reconstruction is less
frequently performed, it is an important procedure to correct
instability in the absence of bony malalignment and should not
be overlooked.
Some variables affect the final outcomes. Location of the
lesion has been reported with contradicting results. Of two
studies on isolated ACI (no associated procedures such as TTO),
one had better outcomes in medial lesions,26 and the other in
lateral lesions.37 Those studies did not report alignment
characteristics; therefore, variability in patients’ characteristics can be responsible for the different study results. One
study that included selective TTO showed no difference in
regard to location of patellar lesion.25 One study found better
outcomes in patellar lesions than in trochlear lesions.38 Degenerative lesions had worse outcomes in one study.39 Two
studies reported worse outcomes in bipolar lesions11,24 and
two studies reported similar outcomes.25,27 One study found
better outcomes in lesions <3 cm2,38 while in another, size did
not affect outcomes.25 Containment and sex did not affect
results in one study.25
MRI studies reported on defect fill and quality of signal
increase with time.40 Complete fill occurs in approximately
30 to 40%,13,35 with more than 70% of patients with >50% of
defect fill.38 One study reported no correlation between the
repair seen by MRI and clinical outcomes.40
On arthroscopy, good to excellent repair can be seen in
>80% of cases.12,27,41
Histologic studies showed the formation of hyaline-like
cartilage,12,39 with a greater proportion of collagen type II
than type I30,38 and viable chondrocytes.15
Most common reported complications were graft hypertrophy,11–15 particularly with the first-generation ACI, arthrofibrosis,10,11,42 crepitation,33 and flap delamination or
detachment.10,11 Clinical failure that required subsequent
procedures occurred between 8 and 13%.25,33,43
When comparing the results in the PF compartment to the
femoral condyles, some found similar clinical outcomes,14,42
while others reported better outcomes in the femoral condyles.44 Minas et al found that PF grafts failed earlier than
grafts in the tibiofemoral compartment; however, long-term
survivorship was similar.23
Due to the lack of comparative studies between treatment
options and large variability among patients, meta-analyses
The Journal of Knee Surgery
Downloaded by: Vanderbilt University. Copyrighted material.
Abbreviations: ACI, autologous chondrocyte implantation; ADL, activities of daily living; BMSC, bone marrow-derived mesenchymal stem cell; cACI, collagen cover; ICRS, International Cartilage Repair Society;
IKDC, International Knee Documentation Committee; KOOS, Knee Injury and Osteoarthritis Outcome Score; LRR, lateral retinacular release; MOCART, magnetic resonance observation of cartilage repair tissue;
MPFL, medial patellofemoral ligament; MRI, magnetic resonance imaging; OAT, osteochondral autograft transfer; OCD, osteochondritis dissecans; pACI, periosteum autologous chondrocyte implantation; PF,
patellofemoral; PJAC, particulated juvenile allograft cartilage; RCT, randomized controlled trial; SF-36, Short Form-36; TTO, tibial tuberosity osteotomy; TT-TG, tibial-tuberosity troclear-groove distance; VAS, visual
analog scale; w, weeks; y, years.
Similar results between PF and tibiofemoral
Overall outcomes:
Mean inability to work 13.6 11.0 wk
Return to sports: 73.1%
High-impact as well as start-stop sports were
generally substituted for low-intensity
exercises
Mean 5.3 2.3 y
Mean 36.2 y
Pestka
et al (2016)14
cACI
Case series (total 130, patella 45,
and trochlea 12—44.3% PF)
Knee, all locations/mean
4.4 1.7 cm2
Results and comments
Age
Study type (number, characteristics of subjects/defects)
Author (y)
Procedure
Table 2 (Continued)
Defect location/size
Follow-up
Patellofemoral Cartilage Restoration
Hinckel, Gomoll
are difficult and systematic reviews were inconclusive in regard
to which are the best treatments methods for PF focal and
advanced cartilage lesions.19,20,45 Nonetheless, ACI (all generations) is the most performed procedure in the PF joint.19,20
Among the different generations of ACI (pACI, cACI, and
MACI), there was weak evidence that cACI outcomes are
better than pACI, and that MACI is comparable with both.46
There is good evidence favoring an accelerated weight-bearing regimen after MACI.46 There is currently no evidence that
supports scaffold-based ACI or arthroscopic implantation
over first-generation ACI.46
Results of the most clinically relevant ACI, MACI, and PJAC
studies in the PF compartment are listed in ►Table 2. In
addition, important studies that included a reasonable number of PF cartilage lesions are also included in ►Table 2.
Conclusion
The PF compartment is affected in approximately one-third
of patients with grades 3 and 4 ICRS focal defects seen during
knee arthroscopy, especially in younger patients. The main
etiologies for PF cartilage lesions are patellar instability,
direct trauma, repetitive microtrauma, maltracking, and
idiopathic. Chronic maltracking is usually related to anatomic abnormalities such as trochlear dysplasia, increased
TT-TG distance, and lateral soft tissue contracture. Articular
comorbidities are a common cause of chondral defects and
potential failure mechanism after cartilage repair. As such,
lower extremity malalignment, PF instability and/or maltracking, and stiffness require careful preoperative assessment and treatment in a staged or concomitant fashion.
Associated procedures that are most commonly required are
TTO, LRL, soft tissue stabilizing procedures such as MPFL
reconstruction, and trochleoplasty.
ACI, MACI, and PJAC are indicated for the treatment of
medium to large full-thickness cartilage defects. There is increasing evidence that these procedures provide improved pain
and function even for patients with cartilage defects in the PF
joint who historically were not considered for cartilage repair.
References
8
9
10
11
12
13
14
15
16
17
18
19
20
21
1 Curl WW, Krome J, Gordon ES, Rushing J, Smith BP, Poehling GG.
2
3
4
5
6
7
Cartilage injuries: a review of 31,516 knee arthroscopies. Arthroscopy 1997;13(04):456–460
Arøen A, Løken S, Heir S, et al. Articular cartilage lesions in 993
consecutive knee arthroscopies. Am J Sports Med 2004;32(01):
211–215
Brittberg M, Lindahl A, Nilsson A, Ohlsson C, Isaksson O, Peterson L.
Treatment of deep cartilage defects in the knee with autologous
chondrocyte transplantation. N Engl J Med 1994;331(14):889–895
Behrens P, Bitter T, Kurz B, Russlies M. Matrix-associated autologous
chondrocyte transplantation/implantation (MACT/MACI)–5-year
follow-up. Knee 2006;13(03):194–202
Gomoll AH, Yoshioka H, Watanabe A, Dunn JC, Minas T. Preoperative measurement of cartilage defects by MRI underestimates
lesion size. Cartilage 2011;2(04):389–393
Farr J, Yao JQ. Chondral defect repair with particulated juvenile
cartilage allograft. Cartilage 2011;2(04):346–353
Bonasia DE, Martin JA, Marmotti A, et al. Cocultures of adult and
juvenile chondrocytes compared with adult and juvenile chondral
The Journal of Knee Surgery
22
23
24
25
26
fragments: in vitro matrix production. Am J Sports Med 2011;
39(11):2355–2361
Farr J, Cole BJ, Sherman S, Karas V. Particulated articular cartilage:
CAIS and DeNovo NT. J Knee Surg 2012;25(01):23–29
Riboh JC, Cole BJ, Farr J. Particulated articular cartilage for
symptomatic chondral defects of the knee. Curr Rev Musculoskelet Med 2015;8(04):429–435
Mandelbaum B, Browne JE, Fu F, et al. Treatment outcomes of
autologous chondrocyte implantation for full-thickness articular
cartilage defects of the trochlea. Am J Sports Med 2007;35(06):
915–921
Vasiliadis HS, Lindahl A, Georgoulis AD, Peterson L. Malalignment
and cartilage lesions in the patellofemoral joint treated with
autologous chondrocyte implantation. Knee Surg Sports Traumatol Arthrosc 2011;19(03):452–457
Bartlett W, Skinner JA, Gooding CR, et al. Autologous chondrocyte
implantation versus matrix-induced autologous chondrocyte implantation for osteochondral defects of the knee: a prospective,
randomised study. J Bone Joint Surg Br 2005;87(05):640–645
Ebert JR, Fallon M, Smith A, Janes GC, Wood DJ. Prospective clinical
and radiologic evaluation of patellofemoral matrix-induced autologous chondrocyte implantation. Am J Sports Med 2015;43(06):
1362–1372
Pestka JM, Feucht MJ, Porichis S, Bode G, Südkamp NP, Niemeyer P.
Return to sports activity and work after autologous chondrocyte
implantation of the knee: which factors influence outcomes? Am J
Sports Med 2016;44(02):370–377
Farr J, Tabet SK, Margerrison E, Cole BJ. Clinical, radiographic, and
histological outcomes after cartilage repair with particulated
juvenile articular cartilage: a 2-year prospective study. Am J
Sports Med 2014;42(06):1417–1425
Krych AJ, Pareek A, King AH, Johnson NR, Stuart MJ, Williams RJ III.
Return to sport after the surgical management of articular
cartilage lesions in the knee: a meta-analysis. Knee Surg Sports
Traumatol Arthrosc 2016. Doi: 10.1007/s00167-016-4262-3
Oussedik S, Tsitskaris K, Parker D. Treatment of articular cartilage
lesions of the knee by microfracture or autologous chondrocyte
implantation: a systematic review. Arthroscopy 2015;31(04):732–744
DiBartola AC, Wright BM, Magnussen RA, Flanigan DC. Clinical
outcomes after autologous chondrocyte implantation in adolescents’ knees: a systematic review. Arthroscopy 2016;32(09):
1905–1916
Mouzopoulos G, Borbon C, Siebold R. Patellar chondral defects: a
review of a challenging entity. Knee Surg Sports Traumatol
Arthrosc 2011;19(12):1990–2001
Noyes FR, Barber-Westin SD. Advanced patellofemoral cartilage
lesions in patients younger than 50 years of age: is there an ideal
operative option? Arthroscopy 2013;29(08):1423–1436
Kreuz PC, Steinwachs MR, Erggelet C, et al. Results after microfracture of full-thickness chondral defects in different compartments in the knee. Osteoarthritis Cartilage 2006;14(11):1119–1125
Niemeyer P, Porichis S, Steinwachs M, et al. Long-term outcomes
after first-generation autologous chondrocyte implantation for
cartilage defects of the knee. Am J Sports Med 2014;42(01):
150–157
Minas T, Von Keudell A, Bryant T, Gomoll AH. The John Insall
Award: a minimum 10-year outcome study of autologous chondrocyte implantation. Clin Orthop Relat Res 2014;472(01):41–51
Peterson L, Vasiliadis HS, Brittberg M, Lindahl A. Autologous
chondrocyte implantation: a long-term follow-up. Am J Sports
Med 2010;38(06):1117–1124
Gomoll AH, Gillogly SD, Cole BJ, et al. Autologous chondrocyte
implantation in the patella: a multicenter experience. Am J Sports
Med 2014;42(05):1074–1081
Macmull S, Jaiswal PK, Bentley G, Skinner JA, Carrington RW,
Briggs TW. The role of autologous chondrocyte implantation in
the treatment of symptomatic chondromalacia patellae. Int
Orthop 2012;36(07):1371–1377
Downloaded by: Vanderbilt University. Copyrighted material.
Patellofemoral Cartilage Restoration
27 Farr J. Autologous chondrocyte implantation improves patellofe-
28
29
30
31
32
33
34
35
36
37
38
39
moral cartilage treatment outcomes. Clin Orthop Relat Res 2007;
463(463):187–194
Minas T, Bryant T. The role of autologous chondrocyte implantation in the patellofemoral joint. Clin Orthop Relat Res 2005;(436):
30–39
Pascual-Garrido C, Slabaugh MA, L’Heureux DR, Friel NA, Cole BJ.
Recommendations and treatment outcomes for patellofemoral
articular cartilage defects with autologous chondrocyte implantation: prospective evaluation at average 4-year follow-up. Am J
Sports Med 2009;37(Suppl 1):33S–41S
Gigante A, Enea D, Greco F, et al. Distal realignment and patellar
autologous chondrocyte implantation: mid-term results in a
selected population. Knee Surg Sports Traumatol Arthrosc
2009;17(01):2–10
Gillogly SD, Arnold RM. Autologous chondrocyte implantation
and anteromedialization for isolated patellar articular cartilage
lesions: 5- to 11-year follow-up. Am J Sports Med 2014;42(04):
912–920
Henderson IJ, Lavigne P. Periosteal autologous chondrocyte implantation for patellar chondral defect in patients with normal
and abnormal patellar tracking. Knee 2006;13(04):274–279
Vanlauwe JJ, Claes T, Van Assche D, Bellemans J, Luyten FP.
Characterized chondrocyte implantation in the patellofemoral
joint: an up to 4-year follow-up of a prospective cohort of 38
patients. Am J Sports Med 2012;40(08):1799–1807
Buckwalter JA, Bowman GN, Albright JP, Wolf BR, Bollier M. Clinical
outcomes of patellar chondral lesions treated with juvenile particulated cartilage allografts. Iowa Orthop J 2014;34:44–49
Meyerkort D, Ebert JR, Ackland TR, et al. Matrix-induced autologous chondrocyte implantation (MACI) for chondral defects in
the patellofemoral joint. Knee Surg Sports Traumatol Arthrosc
2014;22(10):2522–2530
Trinh TQ, Harris JD, Siston RA, Flanigan DC. Improved outcomes
with combined autologous chondrocyte implantation and patellofemoral osteotomy versus isolated autologous chondrocyte
implantation. Arthroscopy 2013;29(03):566–574
Niemeyer P, Steinwachs M, Erggelet C, et al. Autologous chondrocyte implantation for the treatment of retropatellar cartilage
defects: clinical results referred to defect localisation. Arch
Orthop Trauma Surg 2008;128(11):1223–1231
Gobbi A, Kon E, Berruto M, Francisco R, Filardo G, Marcacci M.
Patellofemoral full-thickness chondral defects treated with Hyalograft-C: a clinical, arthroscopic, and histologic review. Am J
Sports Med 2006;34(11):1763–1773
Gobbi A, Kon E, Berruto M, et al. Patellofemoral full-thickness
chondral defects treated with second-generation autologous
40
41
42
43
44
45
46
47
48
49
50
51
Hinckel, Gomoll
chondrocyte implantation: results at 5 years’ follow-up. Am J
Sports Med 2009;37(06):1083–1092
Ebert JR, Robertson WB, Woodhouse J, et al. Clinical and magnetic
resonance imaging-based outcomes to 5 years after matrixinduced autologous chondrocyte implantation to address articular cartilage defects in the knee. Am J Sports Med 2011;39(04):
753–763
Bentley G, Biant LC, Carrington RW, et al. A prospective, randomised comparison of autologous chondrocyte implantation versus mosaicplasty for osteochondral defects in the knee. J Bone
Joint Surg Br 2003;85(02):223–230
Cvetanovich GL, Riboh JC, Tilton AK, Cole BJ. Autologous chondrocyte implantation improves knee-specific functional outcomes and health-related quality of life in adolescent patients.
Am J Sports Med 2017;45(01):70–76
Rosenberger RE, Gomoll AH, Bryant T, Minas T. Repair of large
chondral defects of the knee with autologous chondrocyte implantation in patients 45 years or older. Am J Sports Med 2008;36
(12):2336–2344
Nawaz SZ, Bentley G, Briggs TW, et al. Autologous chondrocyte
implantation in the knee: mid-term to long-term results. J Bone
Joint Surg Am 2014;96(10):824–830
van Jonbergen HP, Poolman RW, van Kampen A. Isolated patellofemoral osteoarthritis. Acta Orthop 2010;81(02):199–205
Goyal D, Goyal A, Keyhani S, Lee EH, Hui JH. Evidence-based status
of second- and third-generation autologous chondrocyte implantation over first generation: a systematic review of level I and II
studies. Arthroscopy 2013;29(11):1872–1878
Bonner KF, Daner W, Yao JQ. 2-year postoperative evaluation of a
patient with a symptomatic full-thickness patellar cartilage defect repaired with particulated juvenile cartilage tissue. J Knee
Surg 2010;23(02):109–114
Teo BJ, Buhary K, Tai BC, Hui JH. Cell-based therapy improves
function in adolescents and young adults with patellar osteochondritis dissecans. Clin Orthop Relat Res 2013;471(04):1152–1158
Tompkins M, Hamann JC, Diduch DR, et al. Preliminary results of a
novel single-stage cartilage restoration technique: particulated
juvenile articular cartilage allograft for chondral defects of the
patella. Arthroscopy 2013;29(10):1661–1670
McNickle AG, L’Heureux DR, Yanke AB, Cole BJ. Outcomes of
autologous chondrocyte implantation in a diverse patient population. Am J Sports Med 2009;37(07):1344–1350
Bentley G, Biant LC, Vijayan S, Macmull S, Skinner JA, Carrington
RW. Minimum ten-year results of a prospective randomised study
of autologous chondrocyte implantation versus mosaicplasty for
symptomatic articular cartilage lesions of the knee. J Bone Joint
Surg Br 2012;94(04):504–509
The Journal of Knee Surgery
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Patellofemoral Cartilage Restoration
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