The Sequential Improvement in Clinical Outcome Following Autologous Chondrocyte Implantation a 7 year follow up

BA Rogers, TWR Briggs

The Royal National Orthopaedic Hospital, Stanmore

Cartilage
Avascular Aneural Hypocellular Devoid of undifferentiated cells

Background
Advances in cell culture and tissue scaffolds Autologous chondrocyte implantation Treatment option for osteochondral defects on articulating joint surfaces

ACI & MACI

cultured chondrocytes fluid cell suspension under a periosteal cover ACI-P Porcine type I/III collagen membrane seeded with cultured chondrocytes termed matrix induced ACI ( MACI )

Methods
Prospective, single surgeon study 156 patients Up to 7 year follow up Annual clinical outcome ACI and MACI Subset of ongoing multi-centre study Response rate : over 85% annually

Clinical Outcome Assessment

1. 2. 3. 4. 5. 6. 7. Modified Cincinnati Rating (0-100) Visual Analogue Score (0-10) Bentley Functional Rating Score (0-5) Lysholm & Gilchrist Score (0-100) Patient Functional Outcome (0-10) Brittberg (poor, fair, good or excellent) Patient rating (better, same, worse)

Patient Numbers
Number ACI 57 Age 31.6 (15-51) 36.9 (18-52) Male 31 Female 26

MACI

99

57

42

Location of osteochondral defects

ACI
Medial Femoral Condyle Lateral Femoral Condyle Trochlear Patella Total 39 (61.9%) 13 (20.6%) 2 (3.2%) 9 (14.3%) 63 MACI 66 (58.9%) 21 (18.8%) 6 (5.4%) 19 (17.0%) 112

Previous Investigations
ACI (57) M ACI (99) None 2 6 Arthroscopy 45 76 Debridement 7 8 ACL reconstruction 2 5 M enisectomy 9 1 Drilling/microfracture 7 7 M osaicplasty 2 9 Fixation osteochondral fragment 1 2 Carbon fibre pads 1 0 Removal loose body 4 4 Lateral release 3 4 Previous ACI 0 3

Cincinnati Rating 100 80 60 40 20 0

Results

Modified Cincinnati Rating

Follow Up

re -O p 1 ye ar 2 ye ar s 3 ye ar s 4 ye ar s 5 ye ar s 6 ye ar s 7 ye ar s

ACI ACI

Visual Analogue Score Bentley Functional Rating score

7 6 Visual Analogue Score 5 4 3 2 1 0 Pre-op 1 year 2 year 3 year 4 year 5 year 6 year 7 year 3.5 Bentley Functional Rating Score 3 2.5 2 1.5 1 0.5 0

ACI - VAS MACI - VAS ACI - Bentley MACI - Bentley

Lysholm & Gilchrist Patient Function & Outcome Scores

100 90 80 Lysholm & Gilchrist 70 60 50 40 30 20 10 0 Pre-op 1 year 2 year 3 year 4 year 5 year 6 year 7 year 10 9 8 Patient Functional Outcome 7 6 5 4 3 2 1 0

MACI - LG ACI-LG MACI PFOS ACI-PFOS

Brittberg
100 80 Percentage 60 40 20 0 Pre- 1 year 2 year 3 year 4 year 5 year 6 year 7 year op MACI - excellent/good ACI - excellent/good MACI - fair/poor ACI - fair/poor

Summary Of Clinical Scoring

Modified Cincinnati

Patient Outcome Function Lysholm & Gilchrist

1. Significant improvement to pre-op (p<0.0001) 2. 1 year ACI score superior to MACI (p<0.05) 3. ACI & MACI scores similar at 2 years (ie p>>0.05)

Summary Of Clinical Scoring

Visual Analogue Score Bentley Functional Rating Score Patient Outcome Function Score

1. Significant improvement to pre-op (p<0.0001) 2. Continued sequential improvement 3. ACI & MACI scores similar at 1 & 2 years for VAS and POFx (p>>0.05)

Summary Of Clinical Scoring

Patient Rating Score Brittberg score
(more subjective clinical rating scores)

Continuing improvements

Discussion
No control
No follow up of similar patient cohort

One surgeon Non-blind No histological correlation to outcome

Conclusion
Further evidence of the benefit of transplanting autologous chondrocytes Results suggest MACI has a superior rate of clinical improvement in comparison to ACI Further clinical and histological evidence will be required to fully validate either technique.

Thank You
Acknowledgements
Mr Carrington Mr Skinner Prof Bentley