What to ask about a sore joint

Sources

1. A JBJS evidence-based review of chondral lesions of the knee sets management by lesion size, location, limb alignment and rotation, and patient demand rather than by product: osteochondral autograft transfer is described as durable and predictable for smaller lesions (under 2 cm2) in young active patients, while lesions of 2 cm2 or more are typically treated with osteochondral allograft transplantation, particulated juvenile articular cartilage, or matrix-associated chondrocyte implantation, with favourable mid- and long-term results reported for allograft or MACI in large lesions of 3 cm2 or more.

   Dekker TJ, et al. — Chondral Lesions of the Knee: An Evidence-Based Approach.. J Bone Joint Surg Am, 2021. DOI: 10.2106/JBJS.20.01161.

2. FDA biologics licence BL 125603 (Vericel) describes MACI verbatim as "an autologous cellularized scaffold product indicated for the repair of symptomatic, single or multiple full-thickness cartilage defects of the knee with or without bone involvement in adults." The licensed indication is a two-stage surgical implantation for full-thickness DEFECTS of the knee in adults. It is not an injection, it is not licensed for osteoarthritis, and it is not licensed for any joint other than the knee.

   U.S. Food and Drug Administration — MACI (autologous cultured chondrocytes on porcine collagen membrane). FDA, Center for Biologics Evaluation and Research, 2024.

3. The Cochrane review of surgical interventions for isolated cartilage defects of the knee in adults found only three randomised trials, all comparing mosaicplasty with microfracture, reporting 133 participants in total with a mean defect area of 2.8 cm2. It found NO randomised trials of allograft transplantation or drilling at all, judged every trial at high or unclear risk of bias, and rated the quality of evidence very low for every outcome.

   Gracitelli GC, et al. — Surgical interventions (microfracture, drilling, mosaicplasty, and allograft transplantation) for treating isolated cartilage defects of the knee in adults.. Cochrane Database Syst Rev, 2016. DOI: 10.1002/14651858.CD010675.pub2.

4. Among 321 consecutive patients treated with autologous chondrocyte implantation (522 defects), defects previously treated with a marrow stimulation technique failed at 26% versus 8% in defects with no prior penetration of the subchondral bone - a threefold higher failure rate. The order in which procedures are done changes what the later ones can achieve.

   Minas T, et al. — Increased failure rate of autologous chondrocyte implantation after previous treatment with marrow stimulation techniques.. Am J Sports Med, 2009. DOI: 10.1177/0363546508330137.

5. A systematic review of 27 studies of arthroscopic joint-preservation techniques for chondral lesions of the HIP found survival (no revision and no conversion to hip replacement) ranging from 59.1% to 100% for microfracture, 92.9% to 100% for autologous matrix-induced chondrogenesis and 94.4% to 95.7% for microfracture with a chitosan scaffold, on mostly non-comparative evidence.

   Akhtar M, et al. — Outcomes of Arthroscopic Joint Preservation Techniques for Chondral Lesions in the Hip: An Updated Systematic Review.. Arthroscopy, 2024. DOI: 10.1016/j.arthro.2023.11.019.

6. Pooling 16 of 30 studies covering 868 patients, non-operative management of osteochondral lesions of the TALUS achieved clinical success in 45% of patients (95% CI 40% to 50%) at a median 37 months, with radiographic progression of ankle osteoarthritis in 9% (95% CI 6% to 14%). Roughly half of these lesions do acceptably without an operation.

   Buck TMF, et al. — Non-operative management for osteochondral lesions of the talus: a systematic review of treatment modalities, clinical- and radiological outcomes.. Knee Surg Sports Traumatol Arthrosc, 2023. DOI: 10.1007/s00167-023-07408-w.