Abstract
Objectives:
Unique challenges exist in treating patellar cartilage defects such as the contour of the articular surface and the high dynamic shear and compressive forces at the trochlear articulation. When considering restoration techniques osteochondral autograft or allograft can be used when the underlying bone is also involved but for isolated chondral defects, cell-based restoration is the standard of care. Previous literature has demonstrated that success of these cell-based therapies depends on a fully shouldered, stable rim of healthy cartilage to achieve repair stability. More recently, particulated juvenile articular cartilage (PJAC), minced hyaline cartilage from young donors, has demonstrated promising and practical results in the treatment of symptomatic articular defects of the patella and other surfaces. The newer cell-based techniques are more stable than previous options such as autologous chondrocyte implantation (ACI). The purpose of this study is to compare clinical outcomes of PJAC in patients with shouldered versus unshouldered full-thickness cartilage defects of the patella. We hypothesized that there will be no significant difference in short-term clinical outcomes and radiographic cartilage fill between shouldered and unshouldered lesions.
Methods:
A retrospective review of prospectively collected data was conducted on patients treated with PJAC for a full-thickness symptomatic patellar cartilage lesion between March 2014 and August 2019. Magnetic resonance imaging (MRI) was performed for all patients at 6, 12, and 24 months postoperatively and analyzed for percent fill, categorized by 0% to 33%, 34% to 66%, and 67% to 100% fill. Patient-reported outcome measures (PROMs) were obtained preoperatively and at 1, 2 and >2 years postoperatively. Arthroscopic images were independently assessed, and cartilage defect characteristics were documented as shouldered or unshouldered by an orthopaedic surgery resident and an orthopaedic surgery sports fellow. Percent fill on MRI and clinical outcome scores (International Knee Documentation Committee, Kujala, Knee injury and Osteoarthritis Outcome Score – Physical Function Short-Form [KOOS-PS], Knee injury and Osteoarthritis Outcome Score – Quality of Life, The Hospital for Special Surgery Pediatric Functional Activity Brief Scale) were analyzed and correlated with the shouldered or unshouldered classification of the lesions.
Results:
Between March 2014 and August 2019, a total of 70 lesions in 65 patients were treated with PJAC for patellar cartilage lesions. The mean patient age was 26.6 years old (range, 14 – 51) and 76% (n = 53) were female. Twenty-five (36%) knees had undergone prior surgery and average symptom duration was 7.5 years. The average patellar lesion size was 277 mm2 (range, 77 – 800 mm2), the average number of allografts packets used was 2.4 (range, 1 – 5), and the average donor age was 46.1 months (range, 1 – 120). Arthroscopic pictures were available for 64 out of 70 lesions. There was perfect inter-rater reliability of whether the lesions were considered to have a continuous, stable rim (shouldered) or not (unshouldered). Thirty-two lesions were shouldered and the remaining 32 lesions were unshouldered according to their intraoperative pictures. Patients with shouldered lesions reported a significantly lower duration of symptoms than those with unshouldered lesions (5.29 ± 7.12 years vs.10.11 ± 9.85 years, p < 0.05). Patients with shouldered lesions were also significantly more likely to have a prior knee surgery (p < 0.05). Patients did not differ significantly by MRI percent fill in the shouldered versus unshouldered groups (Figure 1). There were no significant differences in baseline, 1-, or 2-year patient-reported outcomes based between patients with shouldered and unshouldered lesions (Table 1). The only statistically significant difference in outcomes was a lower score for KOOS-PS in the unshouldered group at >2 years compared to the shouldered group (p < 0.05), and in the change in KOOS-PS from baseline to 2-years between the 2 groups (p <0.05).
Conclusions:
Patellofemoral joint cartilage defects are difficult to treat due to their unique thickness and topography. Historically, emphasis has been placed on having a stable, fully shouldered defect in order to achieve success of repair with microfracture or ACI. However, with the increased stability of newer cell-based treatments, these unshouldered cartilage lesions do well both clinically and radiographically. Our study found no significant differences between the shouldered and unshouldered groups with regard to both clinical outcomes as well as radiographic cartilage fill. This suggests that, with newer cartilage restoration techniques, whether a lesion is shouldered does not affect the outcomes achieved by these procedures.
