LUCA ANDRIOLO,

G. FILARDO, F. DE CARO, E. KON,

S. ZAFFAGNINI and M. MARCACCI

I ORTHOPAEDIC CLINIC - BIOMECHANICS LAB.

Dir. Prof. M. Marcacci

NANO-BIOTECHNOLOGY LAB.

Dir. E. Kon

BOLOGNA UNIVERSITY

RIZZOLI ORTHOPAEDIC INSTITUTE

DO CARTILAGE LESIONS AFFECT THE

CLINICAL OUTCOME OF ANTERIOR

CRUCIATE LIGAMENT RECONSTRUCTION?

A SYSTEMATIC REVIEW

INTRODUCTION

200 000 ACL TEARS/YEAR IN US

130 000 ACL RECONSTRUCTION/YEAR IN US

ACL TEARS: COMMON PATHOLOGY

Mall NA, AJSM 2014

CARTILAGE AND ACL TEARS?

25 - 40 %

Andernord D, AJSM 2014

Csintalan RP, AJSM 2013

INTRODUCTION

LEAD TO OSTEOARTHRITIS

IMPORTANCE OF EARLY STABILIZATION (↑ TIME = ↑ LESIONS)

CARTILAGE LESIONS IN UNSTABLE KNEES

Levy AS, OCNA 2003; Hirose J, AJSM 2013

INFLUENCE ON OUTCOME?

NEED OF TREATMENT?

CARTILAGE LESIONS IN STABILIZED KNEES

Church S, JBJSBr 2005; Joseph IntOrth 2008; Barenius B, KSSTA 2013

SYSTEMATIC REVIEW

Filardo G, de Caro F, Andriolo L et al. KSSTA 2016

ENGLISH ARTICLE, NO TIME LIMITATION

CLINICAL AND RADIOLOGICAL RESULTS OF

ACL SURVEYS

CORRELATION BETWEEN RESULTS AND THE

PRESENCE OF CARTILAGE LESIONS AT THE

TIME OF ACL RECONSTRUCTION

INFLUENCE OF CARTILAGE LESIONS ON THE OUTCOME

OF ACL RECONSTRUCTION?

MANAGEMENT OF CARTILAGE DEFECTS

ASSOCIATED WITH ACL LESIONS?

((ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION) OR (ACL

RECONSTRUCTION))

AND

((CARTILAGE) OR (CHONDRAL LESION) OR (OSTEOCHONDRAL LESION)

OR (CHONDRAL DEFECT) OR (OSTEOCHONDRAL DEFECT))

MATERIALS AND METHODS

PUBMED RESEARCH

37 STUDIES

INCLUDED IN

SYSTEMATIC REVIEW

1165 RECORDS

SCREENED

89 FULL-TEXT

ASSESSED FOR

ELEGIBILITY

Filardo G, de Caro F, Andriolo L et al. KSSTA 2016

RESULTS

3 NATIONAL REGISTRY STUDY

1 RANDOMIZED CONTROLLED TRIAL

1 COMPARATIVE STUDIES

18 CASE SERIES

4 RETROSPECTIVE CASE SERIES

RESULTS: OUTCOME

Wasserstein D, OsteoCart 2015 Hirose J, AJSM 2013 Ichiba A, AOTS 2009

Dunn WR, JBJS 2015 Rotterud JH, AJSM 2013 Shelbourne KD, AJSM 2009

Ahn JH, KSSTA 2015 Gudas R, Arthroscopy 2013 Hanypsiak BT, AJSM 2008

Sandon A, KSSTA 2014 Barenius B, KSSTA 2013 Lebel B, AJSM 2008

Andernord D, AJSM 2014 Murray JR, AJSM 2012 Nakamura N, KSSTA 2008

Cox CL, AJSM 2014 Rotterud JH, KSSTA 2012 Asano H, Arthroscopy 2004

Krych AJ, KSSTA 2014 Oiestad BE, AJSM 2010 Shelbourne KD, JBJSAm 2003

McAllister DR, JKS 2014 Pernin J, AJSM 2010 Asano H, JKS 2002

Csintalan RP, AJSM 2013 Widuchowski W, AJSM 2009 Shelbourne KD, AJSM 2000

27 ARTICLES

54.000 PATIENTS

RESULTS: OUTCOME

32% CARTILAGE

LESIONS

6 A

RT

IC

LE

S

RESULTS: OUTCOME

NO CORRELATION WITH OUTCOME

Ahn JH, KSSTA 2015

Widuchowski W, AJSM 2009

Andernord D, AJSM 2014

Csintalan RP, AJSM 2013

Hanypsiak BT, AJSM 2008

Nakamura N, KSSTA 2008

AT 15 YEARS F-UP NO SIGNIFICANT DIFFERENCE BETWEEN

PATIENTS WITH OR WITHOUT CARTILAGE LESIONS FOR

CLINICAL SCORES (LYSHOLM, TEGNER AND IKDC)

NO ASSOCIATION BETWEEN THE PRESENCE OF AN INITIAL

CARTILAGE LESION AND THE CLINICAL SCORES AFTER 12 YY

THE EARLY REVISION RATE WAS 1.6%. PATIENTS WITH

CARTILAGE INJURY WHO RECEIVED AN HT AUTOGRAFT WERE

LESS LIKELY TO UNDERGO REVISION SURGERY

CARTILAGE INJURY DOES NOT INFLUENCE THE PROBABILITY

TO HAVE A FURTHER CARTILAGE REOPERATION, INDEPEN-

DENTLY OF THE INITIAL TREATMENT.

RISK FACTORS FOR POSTOP INSTABILITY WERE II° MCL

INJURY AND DELAYED RECONSTRUCTION. CARTILAGE AND

MENISCUS LESIONS DID NOT INFLUENCE POSTOP INSTABILITY

AT SECOND LOOK ARTHROSCOPY SIGNIFICANT RECOVERY OF

CHONDRAL LESIONS OF FEMORAL CONDYLES WAS SEEN BUT

NOT OF THE PATELLO-FEMORAL AND TIBIAL PLATEAU.

21 A

RT

IC

LE

S

RESULTS: OUTCOME

CORRELATION WITH OUTCOME

SECOND-LOOK

MRI

Asano H, Arthroscopy 2004

Hirose J, AJSM 2013

RETURN TO SPORT Krych AJ, KSSTA 2014 Sandon A, KSSTA 2014

CLINICAL SCORES Barenius B, KSSTA 2013 Rotterud JH, KSSTA 2012

Cox CL, AJSM 2014 Rotterud JH, AJSM 2013

Wasserstein D, OstCar 2015 Dunn WR, JBJS 2015

Asano H, JKS 2002 McAllister DR, JKS 2014

Gudas R, Arthroscopy 2013 Ichiba A, AOTS 2009

Lebel B, AJSM 2008 Oiestad BE, AJSM 2010

Pernin J, AJSM 2010 Murray JR, AJSM 2012

Shelbourne KD, JBJSA 2003 Shelbourne KD, AJSM 2000 OA PROGRESSION

Shelbourne KD, AJSM 2009

DISCUSSION

ESPECIALLY FULL-THICKNESS CARTILAGE LESIONS

DO CARTILAGE LESIONS

INFLUENCE THE OUTCOME

OF ACL RECONSTRUCTION?

YES

Wasserstein D, OsteoCart 2015; Cox CL, AJSM 2014; Rotterud JH, AJSM 2013

DISCUSSION

TO TREAT OR

NOT TO TREAT…

ESPECIALLY FULL-THICKNESS CARTILAGE LESIONS

DO CARTILAGE LESIONS

INFLUENCE THE OUTCOME

OF ACL RECONSTRUCTION?

?

YES

Wasserstein D, OsteoCart 2015; Cox CL, AJSM 2014; Rotterud JH, AJSM 2013

BUT

… AND HOW ?

RESULTS: MANAGEMENT

Rotterud JH, AJSM 2016 Imade S, Knee 2013

van Duijvenbode DC, Knee 2016 Osti L, KSSTA 2010

Tahami SM, ABJS 2015 Gaweda K, IntOrt 2006

Dhinsa BS, Ind J Ort 2015 Amin AA, IntOrt 2006

Gudas R, Arthroscopy 2013 Klinger HM, KSSTA 2003

10 ARTICLES

CARTILAGE LESIONS

NEGATIVELY INFLUENCE

THE OUTCOME

TRY TO TREAT

CARTILAGE

LESIONS

… BUT HOW ?

RESULTS: MANAGEMENT

Rotterud JH, AJSM 2016

MF SHOWED ADVERSE EFFECTS (88 pts) AND

DEBRIDEMENT SHOWED NO EFFECTS (78 pts)

COMPARED WITH NO TREATMENT (181 pts) IN

PTS WITH FULL-THICKNESS LESIONS AT 2 YY

van Duijvenbode DC, Knee 2016 PATIENTS WITH PRIOR ACLR SUFFERING FROM CARTILAGE-ASSOCIATED

PAIN CAN BENEFIT FROM CARTILAGE REPAIR WITH GACI

Tahami SM, ABJS 2015 15 PTS TREATED WITH MF vs 15 PTS WITHOUT CARTILAGE LESIONS. AT

1 YEAR NO SIGNIFICANT DIFFERENCE BETWEEN THE TWO GROUPS

Dhinsa BS, Ind J Ort 2015 COMBINED (vs DELAYED) ACL+ACI PRODUCES GOOD TO EXCELLENT

OUTCOMES WITH REDUCED COST AND IMPACT ON THE PATIENT

Gudas R, Arthroscopy 2013 SCORES BETTER FOR OAT vs MF OR DEBRIDMENT. GROUP WITHOUT

CARTILAGE LESIONS BETTER THAN AOT GROUP

Imade S, Knee 2013 NO SCORE DIFFERENCE WAS FOUND BETWEEN DRILLING AND OAT

GROUP, WITH BETTER RESULTS AT SECOND LOOK FOR OAT GROUP

Gaweda K, IntOrt 2006 RETURN TO NORMAL ACTIVITY AND PATIENT'S SATISFACTION ARE

SLOWER IN OAT GROUP vs PTS WITHOUT CARTILAGE LESIONS.

Osti L, KSSTA 2010 SHORT-TERM GOOD RESULTS OBTAINED WITH MF, BUT THERE IS NO

EFFICACY OF THESE TECHNIQUES IN PREVENTING OA.

Amin AA, IntOrt 2006 GOOD RESULTS IN PATIENTS WITH COMBINED ACI+ACL PROCEDURES

(vs SUBSEQUENT). COMBINATION MAY RESULT LESS COSTLY.

Klinger HM, KSSTA 2003 GOOD RESULTS FOR OAT COMBINED TO ACL IN 21 PTS AFTER 32 M

WITHOUT ANY ADDED MORBIDITY

CONCLUSIONS

CARTILAGE LESIONS ARE COMMON

IN ACL RECONSTRUCTION (32%)

NEGATIVE INFLUENCE ON OUTCOME

AFTER ACL RECONSTRUCTION

(21/27 ARTICLES)

NEED TO TREAT, ESPECIALLY DEEP

CARTILAGE LESIONS

UNSATISFIYING RESULTS FOR

MICROFRACTURES

PROMISING RESULTS WITH OAT

AND REGENERATIVE TECHNIQUES

NEED FOR FURTHER STUDIES

LOW

EVIDENCE

Thank You!