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Long-term results of particulated juvenile allograft cartilage implantation: a case report with eleven-year second-look arthroscopy and review of literature
High-grade osteochondral lesions cause pain, functional limitations, and oftentimes require surgical treatment. Described operative interventions include microfracture, osteochondral autograft transfers, osteochondral allograft transplantation, autologous chondrocyte implantation, and matrix assisted autologous chondrocyte implantation. Another option for recalcitrant cartilaginous defects is particulated juvenile allograft cartilage (PJAC) implantation. Short-term studies into PJAC have yielded promising results in its capacity for hyaline or hyaline-like cartilage regeneration though the long-term outcomes of this procedure are not well understood. We present a case of PJAC implementation to the medial femoral condyle in a 15-year-old female competitive soccer player with 11-year magnetic resonance imaging and arthroscopic second-look follow-up. In addition, we performed a literature review to summarize prior published PJAC outcomes data.
Osteochondral lesions (OCLs) are a challenging problem that can cause long-term pain and significant functional limitations. Higher grade lesions (ie, those involving >50% of the cartilage depth) have shown a limited ability to heal spontaneously and typically require surgical intervention.
Each of these procedures is best suited for specific scenarios and brings with it its own advantages and disadvantages. The diameter, shape, depth, and location of an OCL all factor into a surgeon's cartilage restoration decision-making algorithm.
Patellofemoral cartilage lesions treated with particulated juvenile allograft cartilage: a prospective study with minimum 2-year clinical and magnetic resonance imaging outcomes.
Short-term studies into PJAC have yielded promising results in its capacity for hyaline or hyaline-like cartilage regeneration though the long-term outcomes of this procedure are not well understood. Additionally, comparative analyses between PJAC and other cartilage restoration procedures are scant.
Patellofemoral cartilage lesions treated with particulated juvenile allograft cartilage: a prospective study with minimum 2-year clinical and magnetic resonance imaging outcomes.
Outcomes and predictors of postoperative pain improvement following particulated juvenile cartilage allograft transplant for osteochondral lesions of the talus.
Comparison of juvenile allogenous articular cartilage and bone marrow aspirate concentrate versus microfracture with and without bone marrow aspirate concentrate in arthroscopic treatment of talar osteochondral lesions.
Arthroscopic treatment of osteochondral lesions of the talus using juvenile articular cartilage allograft and autologous bone marrow aspirate concentration.
Preliminary results of a novel single-stage cartilage restoration technique: particulated juvenile articular cartilage allograft for chondral defects of the patella.
2-year postoperative evaluation of a patient with a symptomatic full-thickness patellar cartilage defect repaired with particulated juvenile cartilage tissue.
The objective of this article is 2-fold: summarize prior published findings and review a case of PJAC implantation to the medial femoral condyle (MFC) in a 15-year-old female competitive soccer player with 11-year follow-up.
Case report
The patient was a 15-year-old female who 2 years prior to initial presentation sustained a traumatic right lateral patellar dislocation with spontaneous reduction while playing competitive club soccer. The patient was diagnosed as having a grade II OCL to her medial patellar facet and a grade IV OCL to the lateral aspect of the MFC soon after her initial injury.
Per her original surgeon's operative reports, the patient underwent multiple procedures attempting to fix the MFC OCL (first with bioabsorbable then titanium screw fixation). It was unclear per operative records if the OCL was believed to stem from an injury obtained during play or if it was a previously asymptomatic osteochondritis dissecans lesion. The medial patellar facet OCL was treated with chondroplasty. The patient continued to have pain with activity, mechanical symptoms, and effusions before undergoing arthroscopic removal of hardware, chondroplasty of the MFC OCL, and removal of a medial patellofemoral plica. It was at this point the patient was referred to the senior author (D.N.M.C.) for further management.
The patient was first seen in our office with a chief symptom of right knee pain that increased with athletic activity. She denied any repeat trauma to the joint. Her prior surgical incisions were well healed, and her knee was ligamentously stable. She walked with an antalgic gait and had bilateral hypermobility of the patellae at full extension with apprehension on the right. No systemic laxity was noted on exam. The right knee was notable for tenderness at the medial facet of the patella and MFC. She had pain with patellar excursion in extension and mid-flexion.
Given the patient's extensive history, a set of plain radiographs, magnetic resonance imaging (MRI), and a noncontrast computed tomography scan of the knee were obtained. These were notable for patellofemoral malalignment with an elevated tibial tubercle to trochlear groove distance and an MFC OCL measuring 24 mm (anterior to posterior) × 15 mm (medial to lateral) (Fig. 1). The patient's previously treated medial patellar facet OCL appeared stable and without signal intensity. After thorough discussion of various treatment options, the patient underwent a patellofemoral realignment as described by Fulkerson.
Intraoperative images are shown in Figure 2A-C. The prior medial patellar facet OCL treated by chondroplasty appeared stable. No further chondroplasty at the patella was performed. Postoperatively, the patient was placed into a locked extension brace at 25% partial weight bearing, prescribed cold therapy, and sent to physical therapy for passive range of motion modalities. At 3 weeks postoperatively, she was progressed to 50% partial weightbearing and her brace was unlocked from 0 to 90 degrees of flexion. At 10 weeks postoperatively, she was progressed to weight bearing as tolerated, her brace was completely unlocked, and she was given 3 sequential doses of hyaluronic acid (HA) viscosupplementation over the following month (per D.N.M.C.'s protocol at the time).
Fig. 1Preoperative magnetic resonance imaging arthrogram, (A) computed tomography scan, (B) and computed tomography 3D reconstruction (C) demonstrating the medial femoral condylar osteochondral lesion.
Fig. 2A-C, Clinical photographs demonstrating a grade IV cartilage defect before application of particulated juvenile allograft cartilage graft (A), after application (B), and after sealing the graft with fibrin glue (C). D, Clinical photograph demonstrating complete graft incorporation 9 months postoperatively. E and F, Clinical photographs demonstrating complete graft incorporation 11 years postoperatively without hypertrophy or delamination.
At 9 months postoperatively, the patient had improved pain, no mechanical symptoms, and had returned to activity. Her main symptom was that of sensitivity around her patellofemoral joint arthroplasty realignment osteotomy hardware that was limiting her participation in club soccer. With any prolonged activity, the patient experienced point tenderness at the location of her tibial tubercle screws. The senior author (D.N.M.C.) felt the patient's thin body habitus contributed to hardware-related soft tissue irritation. The patient was taken back for hardware removal and an arthroscopic second look to ensure the OCL was not a source of pain. The hardware was removed uneventfully and her PJAC implantation site was noted to be stable to probing and smooth with complete graft incorporation (Fig. 2D).
At 2 years postoperatively, the patient reported pain with increased activity, running, and going up and down stairs. She also reported a catching sensation at the anterior aspect of her knee with occasional swelling. MRI was ordered and notable for the formation of a large medial plica and full incorporation of the PJAC graft without delamination or hypertrophy (Fig. 3A). The patient underwent an arthroscopic plica resection. The MFC articular surface was noted to have smooth surface congruity and no indentation on probe testing.
Fig. 3Axial T2-weighted magnetic resonance imaging sequences demonstrating complete graft incorporation and establishment of the subchondral plate 3 years (A), 4 years (B), 10 years (C), and 11 years (D) postoperatively.
The patient returned to the office 10 years postoperatively after a trauma in which she landed on her right knee during an equestrian accident. She described pain with running and intermittent mechanical symptoms (clicking, locking). MRI was performed and notable for a posterior horn of the lateral meniscus tear. Of note, the MFC was read without chondral defect and no evidence of graft hypertrophy (Fig. 3C). The prior OCL lesion treated by PJAC was found to have a Magnetic Resonance Observation of Cartilage Repair Tissue score of 80.
At 11 years postoperatively from her PJAC implantation and patellofemoral joint arthroplasty realignment, the patient underwent an uneventful arthroscopic partial lateral meniscectomy. The MFC PJAC implantation site was evaluated and found to be well integrated with complete surface congruity and normal probe indentation (Fig. 2E,F). The patient's postoperative course was uncomplicated. She returned to her normal activities including jogging, recreational soccer, and horseback riding.
Discussion
We demonstrate a case of fully incorporated PJAC implementation with both arthroscopic and MRI follow-up at 11 years postoperatively. There is a paucity of literature surrounding long term outcomes of PJAC. The authors summarize 13 prior studies on ankle and knee PJAC implementation in the Table. Six studies were performed on the knee (femoral condyles and/or patella), and 7 were performed on the ankle (talus). Prior published studies with MRI follow-up are limited to a maximum mean of 3.8 years
Patellofemoral cartilage lesions treated with particulated juvenile allograft cartilage: a prospective study with minimum 2-year clinical and magnetic resonance imaging outcomes.
Outcomes and predictors of postoperative pain improvement following particulated juvenile cartilage allograft transplant for osteochondral lesions of the talus.
All studies commented on outcome measures, 6 studies measured mean graft fill on MRI, and 9 studies had arthroscopic second-looks on at least a subset of their patients (typically those with adverse outcomes). Six studies commented on concomitant bony or soft tissue procedures performed alongside PJAC implementation.
TablePrior literature on ankle and knee PJAC implementation.
Outcomes and predictors of postoperative pain improvement following particulated juvenile cartilage allograft transplant for osteochondral lesions of the talus.
Patellofemoral cartilage lesions treated with particulated juvenile allograft cartilage: a prospective study with minimum 2-year clinical and magnetic resonance imaging outcomes.
Comparison of juvenile allogenous articular cartilage and bone marrow aspirate concentrate versus microfracture with and without bone marrow aspirate concentrate in arthroscopic treatment of talar osteochondral lesions.
Arthroscopic treatment of osteochondral lesions of the talus using juvenile articular cartilage allograft and autologous bone marrow aspirate concentration.
Preliminary results of a novel single-stage cartilage restoration technique: particulated juvenile articular cartilage allograft for chondral defects of the patella.
2-year postoperative evaluation of a patient with a symptomatic full-thickness patellar cartilage defect repaired with particulated juvenile cartilage tissue.
Abbreviations: ADL, activities of daily living; AOFAS, American Orthopaedic Foot and Ankle Score; F, female; FAAM, foot and ankle ability measure; FAOS, Foot and Ankle Outcomes Score; HTO, high tibial osteotomy; ICRS, International Cartilage Repair Society Grade; IKDC, International Knee Documentation Committee; KOOS, Knee injury and Osteoarthritis Outcome Score; LFC, lateral femoral condyle; M, male; MAS, Marx Activity Scale; MCS, Mental Health Composite Score; MF, microfracture; MFC, medial femoral condyle; MOCART: Magnetic Resonance Observation of Cartilage Tissue score; MPFL, medial patellofemoral ligament; MRI, magnetic resonance imaging; NA, not applicable; OATS, osteochondral autograft transfer system; OCL, osteochondral lesion; PCS, physical composite score; PFJ, patellofemoral joint arthroplasty; postop, postoperative; preop, preoperative; QOL, quality of life; SF-12, short form survey-12; TKA, total knee arthroplasty: TTO, tibial tubercle osteotomy; VAS, visual analog score.
Values listed as means with standard deviations listed in parentheses or range listed in brackets unless otherwise specified. Bolded values demonstrate significance (P < 0.05).
Although not visualized arthroscopically or radiographically in our patient, variable graft fill is a known complication of PJAC implementation. Graft hypertrophy was noted in 6 studies with an incidence of 0% to 65%.
Outcomes and predictors of postoperative pain improvement following particulated juvenile cartilage allograft transplant for osteochondral lesions of the talus.
Comparison of juvenile allogenous articular cartilage and bone marrow aspirate concentrate versus microfracture with and without bone marrow aspirate concentrate in arthroscopic treatment of talar osteochondral lesions.
Preliminary results of a novel single-stage cartilage restoration technique: particulated juvenile articular cartilage allograft for chondral defects of the patella.
Comparison of juvenile allogenous articular cartilage and bone marrow aspirate concentrate versus microfracture with and without bone marrow aspirate concentrate in arthroscopic treatment of talar osteochondral lesions.
found a 65% incidence of graft hypertrophy in their sample of 20 ankles with PJAC implementation. Notably, they directly compared MF with PJAC and found similar patient reported outcome measures (PROMs) but a statistically significant increase in graft hypertrophy in PJAC samples. No changes in functional outcome scores were noted, however. Challenges exist in further studying graft hypertrophy incidence, as different authors use varying definitions of graft hypertrophy (ie, edge vs depth overgrowth) and varying methods of identification (ie, direct arthroscopic visualization with probing vs MRI).
Compared to PJAC, MF is a more extensively studied cartilage restoration technique.
published histological results at 2 years postoperatively. Elective arthroscopy with cartilage biopsy was performed in 11 of 25 patients who underwent knee PJAC implementation. Histological analyses in 8 of those 11 samples (3 lost to technical errors) found 6 samples with >50% hyaline cartilage fill (trichrome stain scoring with subsequent immunopositivity for type II collagen) and 2 samples with an approximately 50/50 mix of hyaline cartilage and fibrocartilage fill (trichome stain scoring with subsequent type I and II collagen immunopositivity). PJAC products are oftentimes advertised as providing a hyaline-like cartilage outcome which is biomechanically superior to fibrocartilage.
Further histological research is needed with large sample sizes to determine the extent to which PJAC implementation provides hyaline-like cartilage vs a mixed composition of hyaline and fibrocartilage and whether this distinction is important in outcome measures.
Some authors contend that MF is a low-cost alternative with similar outcome measures to PJAC implementation. Karnovsky et al
Comparison of juvenile allogenous articular cartilage and bone marrow aspirate concentrate versus microfracture with and without bone marrow aspirate concentrate in arthroscopic treatment of talar osteochondral lesions.
compared 30 patients who underwent MF and 20 patients who underwent PJAC implantation for talar OCLs. They identified no significant difference in pain, function, or radiographic scores between PJAC and MF cohorts. Dekker et al
argue that PJAC implementation is oftentimes used as a salvage procedure after MF or other cartilage restoration techniques have failed (ie, refractory symptomatology in the setting of continued findings on advanced imaging modalities). This is the case with our patient, who had already undergone 4 prior procedures by different surgeons. A recent systematic review of MF use for knee OCLs found a failure rate (as defined by conversion to arthroplasty) of 11% to 27% within 5 years and 6% to 32% at 10 years.
PJAC implementation, although more costly than MF, less well-studied, and not yet proven to be superior in PROMs, is yet another tool in the surgeon's armamentarium of cartilage restoration techniques. Little evidence exists directly comparing PJAC implementation to other cartilage restoration techniques. In contrast to MF, the authors were unable to find a study directly comparing PJAC to osteochondral allograft application. Osteochondral allografts can be particularly useful in the setting of bone loss or in large OCLs where cost would be a prohibitive factor for cell-based therapies.
The senior author (D.N.M.C.) elected to treat the patient with 3 serial intraarticular HA viscosupplementation injections in the postoperative period after her PJAC implementation. At the time of treatment, it was the author's protocol to augment his cartilage restoration procedures with HA on the basis of animal model studies reporting a short term benefit to articular cartilage defect repairs and a decrease in inflammatory synovitis.
The experimental group showed significantly better defect fill at the 3-month mark and decreased synovitis and osteophyte formation at the 6-month mark.
Although this case utilized PJAC implementation and not MF, the authors contend the interaction between HA and juvenile stem cells may have an even more beneficial effect, especially in light of more recent studies.
Intra-articular injections of mesenchymal stem cell exosomes and hyaluronic acid improve structural and mechanical properties of repaired cartilage in a rabbit model.
The authors recognize contrasting studies have been performed in animal models finding no difference in outcomes between HA and control cartilage restoration protocols,
Intraarticular hyaluronic acid injection after microfracture technique for the management of full-thickness cartilage defects does not improve the quality of repair tissue.
HA augmentation of cartilage restoration techniques is an area ripe for future study. Further discussion surrounding the efficacy of HA in cartilage restoration procedures is outside the scope of this article.
Limitations exist both in this article and the use of PJAC as a cartilage restoration technique. This case report with literature review is limited by its small sample size and subsequent inability to perform statistical analyses. Furthermore, no PROMs were collected for our patient and objective radiographic outcomes were not available for all time points. By all reports, however, she has continued to live an active lifestyle free of daily pain. PJAC can be more costly (approximately $4,950 per package with covers 2.5 cm2) than other cartilage restoration techniques (ie, MF), has a limited shelf-life, and lacks robust literature support.
Editorial commentary: no clear winner when comparing cost-effectiveness of particulated juvenile articular cartilage with matrix-induced autologous chondrocyte implantation: too many assumptions.
More prospective, randomized research is needed to directly compare PROMs, radiographic outcomes, and histological outcomes between varying cartilage restoration techniques. The authors’ objectives were to provide an update on the longest published follow-up of PJAC implementation along with a review of prior studies. This case with greater than 10-year follow-up suggests that PJAC implementation stands as a viable option for patients with full-thickness cartilaginous injuries recalcitrant to other operative modalities.
Conclusion
Outcomes of PJAC implementation have yet to be widely studied. This case report is the first to our knowledge to describe greater than 10-year follow-up in a patient with PJAC implementation for an OCL. Although limited by scope and level of evidence, this case report suggests PJAC implementation may be a viable option for high grade (ie, >50% depth) cartilage injury. Additionally, this case demonstrates PJAC may serve as a treatment alternative for patients who have undergone prior failed cartilage restoration procedures.
Funding
No departmental, institutional, governmental, or commercial funding was used in the preparation of this manuscript.
Ethics approval
Complete written informed consent was obtained from the patient for the publication of this study and accompanying images. This study was considered exempt by our local university institutional review board.
Declaration of competing interest
The authors have no conflicts of interest to declare.
References
Krych AJ
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Cartilage injury in the knee: assessment and treatment options.
Patellofemoral cartilage lesions treated with particulated juvenile allograft cartilage: a prospective study with minimum 2-year clinical and magnetic resonance imaging outcomes.
Outcomes and predictors of postoperative pain improvement following particulated juvenile cartilage allograft transplant for osteochondral lesions of the talus.
Comparison of juvenile allogenous articular cartilage and bone marrow aspirate concentrate versus microfracture with and without bone marrow aspirate concentrate in arthroscopic treatment of talar osteochondral lesions.
Arthroscopic treatment of osteochondral lesions of the talus using juvenile articular cartilage allograft and autologous bone marrow aspirate concentration.
Preliminary results of a novel single-stage cartilage restoration technique: particulated juvenile articular cartilage allograft for chondral defects of the patella.
2-year postoperative evaluation of a patient with a symptomatic full-thickness patellar cartilage defect repaired with particulated juvenile cartilage tissue.
Intra-articular injections of mesenchymal stem cell exosomes and hyaluronic acid improve structural and mechanical properties of repaired cartilage in a rabbit model.
Intraarticular hyaluronic acid injection after microfracture technique for the management of full-thickness cartilage defects does not improve the quality of repair tissue.
Editorial commentary: no clear winner when comparing cost-effectiveness of particulated juvenile articular cartilage with matrix-induced autologous chondrocyte implantation: too many assumptions.
Long-term results of particulated juvenile allograft cartilage implantation: a case report with eleven-year second-look arthroscopy and review of literature
A-C, Clinical photographs demonstrating a grade IV cartilage defect before application of particulated juvenile allograft cartilage graft (A), after application (B), and after sealing the graft with fibrin glue (C). D, Clinical photograph demonstrating complete graft incorporation 9 months postoperatively. E and F, Clinical photographs demonstrating complete graft incorporation 11 years postoperatively without hypertrophy or delamination.
Axial T2-weighted magnetic resonance imaging sequences demonstrating complete graft incorporation and establishment of the subchondral plate 3 years (A), 4 years (B), 10 years (C), and 11 years (D) postoperatively.
High-grade osteochondral lesions cause pain, functional limitations, and oftentimes require surgical treatment. Described operative interventions include microfracture, osteochondral autograft transfers, osteochondral allograft transplantation, autologous chondrocyte implantation, and matrix assisted autologous chondrocyte implantation. Another option for recalcitrant cartilaginous defects is particulated juvenile allograft cartilage (PJAC) implantation. Short-term studies into PJAC have yielded promising results in its capacity for hyaline or hyaline-like cartilage regeneration though the long-term outcomes of this procedure are not well understood. We present a case of PJAC implementation to the medial femoral condyle in a 15-year-old female competitive soccer player with 11-year magnetic resonance imaging and arthroscopic second-look follow-up. In addition, we performed a literature review to summarize prior published PJAC outcomes data.
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28: 914–922 Crossref | PubMed | Scopus (32) | Google ScholarSee all References The objective of this article is 2-fold: summarize prior published findings and review a case of PJAC implantation to the medial femoral condyle (MFC) in a 15-year-old female competitive soccer player with 11-year follow-up.
Case report
The patient was a 15-year-old female who 2 years prior to initial presentation sustained a traumatic right lateral patellar dislocation with spontaneous reduction while playing competitive club soccer. The patient was diagnosed as having a grade II OCL to her medial patellar facet and a grade IV OCL to the lateral aspect of the MFC soon after her initial injury.3x3Brittberg, M and Winalski, CS. Evaluation of cartilage injuries and repair. J Bone Joint Surg Am. 2003;
85-A: 58–69 Crossref | PubMed | Scopus (953) | Google ScholarSee all References Per her original surgeon's operative reports, the patient underwent multiple procedures attempting to fix the MFC OCL (first with bioabsorbable then titanium screw fixation). It was unclear per operative records if the OCL was believed to stem from an injury obtained during play or if it was a previously asymptomatic osteochondritis dissecans lesion. The medial patellar facet OCL was treated with chondroplasty. The patient continued to have pain with activity, mechanical symptoms, and effusions before undergoing arthroscopic removal of hardware, chondroplasty of the MFC OCL, and removal of a medial patellofemoral plica. It was at this point the patient was referred to the senior author (D.N.M.C.) for further management.
The patient was first seen in our office with a chief symptom of right knee pain that increased with athletic activity. She denied any repeat trauma to the joint. Her prior surgical incisions were well healed, and her knee was ligamentously stable. She walked with an antalgic gait and had bilateral hypermobility of the patellae at full extension with apprehension on the right. No systemic laxity was noted on exam. The right knee was notable for tenderness at the medial facet of the patella and MFC. She had pain with patellar excursion in extension and mid-flexion.
Given the patient's extensive history, a set of plain radiographs, magnetic resonance imaging (MRI), and a noncontrast computed tomography scan of the knee were obtained. These were notable for patellofemoral malalignment with an elevated tibial tubercle to trochlear groove distance and an MFC OCL measuring 24 mm (anterior to posterior) × 15 mm (medial to lateral) (Fig. 1Fig. 1). The patient's previously treated medial patellar facet OCL appeared stable and without signal intensity. After thorough discussion of various treatment options, the patient underwent a patellofemoral realignment as described by Fulkerson.20x20Fulkerson, JP, Becker, GJ, Meaney, JA, Miranda, M, and Folcik, MA. Anteromedial tibial tubercle transfer without bone graft. Am J Sports Med. 1990;
18: 490–496 (discussion 496-497) Crossref | PubMed | Scopus (266) | Google ScholarSee all References Her MFC OCL was treated using a PJAC implantation (DeNovo NT; Zimmer Biomet) through a medial parapatellar approach as described by Farr.8x8Farr, J, Cole, BJ, Sherman, S, and Karas, V. Particulated articular cartilage: CAIS and DeNovo NT. J Knee Surg. 2012;
25: 23–29 Crossref | PubMed | Scopus (97) | Google ScholarSee all References Intraoperative images are shown in Figure 2Figure 2A-C. The prior medial patellar facet OCL treated by chondroplasty appeared stable. No further chondroplasty at the patella was performed. Postoperatively, the patient was placed into a locked extension brace at 25% partial weight bearing, prescribed cold therapy, and sent to physical therapy for passive range of motion modalities. At 3 weeks postoperatively, she was progressed to 50% partial weightbearing and her brace was unlocked from 0 to 90 degrees of flexion. At 10 weeks postoperatively, she was progressed to weight bearing as tolerated, her brace was completely unlocked, and she was given 3 sequential doses of hyaluronic acid (HA) viscosupplementation over the following month (per D.N.M.C.'s protocol at the time).
Fig. 1
Preoperative magnetic resonance imaging arthrogram, (A) computed tomography scan, (B) and computed tomography 3D reconstruction (C) demonstrating the medial femoral condylar osteochondral lesion.
A-C, Clinical photographs demonstrating a grade IV cartilage defect before application of particulated juvenile allograft cartilage graft (A), after application (B), and after sealing the graft with fibrin glue (C). D, Clinical photograph demonstrating complete graft incorporation 9 months postoperatively. E and F, Clinical photographs demonstrating complete graft incorporation 11 years postoperatively without hypertrophy or delamination.
At 9 months postoperatively, the patient had improved pain, no mechanical symptoms, and had returned to activity. Her main symptom was that of sensitivity around her patellofemoral joint arthroplasty realignment osteotomy hardware that was limiting her participation in club soccer. With any prolonged activity, the patient experienced point tenderness at the location of her tibial tubercle screws. The senior author (D.N.M.C.) felt the patient's thin body habitus contributed to hardware-related soft tissue irritation. The patient was taken back for hardware removal and an arthroscopic second look to ensure the OCL was not a source of pain. The hardware was removed uneventfully and her PJAC implantation site was noted to be stable to probing and smooth with complete graft incorporation (Fig. 2Fig. 2D).
At 2 years postoperatively, the patient reported pain with increased activity, running, and going up and down stairs. She also reported a catching sensation at the anterior aspect of her knee with occasional swelling. MRI was ordered and notable for the formation of a large medial plica and full incorporation of the PJAC graft without delamination or hypertrophy (Fig. 3Fig. 3A). The patient underwent an arthroscopic plica resection. The MFC articular surface was noted to have smooth surface congruity and no indentation on probe testing.
Fig. 3
Axial T2-weighted magnetic resonance imaging sequences demonstrating complete graft incorporation and establishment of the subchondral plate 3 years (A), 4 years (B), 10 years (C), and 11 years (D) postoperatively.
The patient returned to the office 10 years postoperatively after a trauma in which she landed on her right knee during an equestrian accident. She described pain with running and intermittent mechanical symptoms (clicking, locking). MRI was performed and notable for a posterior horn of the lateral meniscus tear. Of note, the MFC was read without chondral defect and no evidence of graft hypertrophy (Fig. 3Fig. 3C). The prior OCL lesion treated by PJAC was found to have a Magnetic Resonance Observation of Cartilage Repair Tissue score of 80.21x21Schreiner, MM, Raudner, M, Marlovits, S et al. The MOCART (Magnetic Resonance Observation of Cartilage Repair Tissue) 2.0 knee score and atlas. Cartilage. 2021;
13: 571s–587s Crossref | PubMed | Scopus (56) | Google ScholarSee all References At 11 years postoperatively from her PJAC implantation and patellofemoral joint arthroplasty realignment, the patient underwent an uneventful arthroscopic partial lateral meniscectomy. The MFC PJAC implantation site was evaluated and found to be well integrated with complete surface congruity and normal probe indentation (Fig. 2Fig. 2E,F). The patient's postoperative course was uncomplicated. She returned to her normal activities including jogging, recreational soccer, and horseback riding.
Discussion
We demonstrate a case of fully incorporated PJAC implementation with both arthroscopic and MRI follow-up at 11 years postoperatively. There is a paucity of literature surrounding long term outcomes of PJAC. The authors summarize 13 prior studies on ankle and knee PJAC implementation in the TableTable. Six studies were performed on the knee (femoral condyles and/or patella), and 7 were performed on the ankle (talus). Prior published studies with MRI follow-up are limited to a maximum mean of 3.8 years6x6Wang, T, Belkin, NS, Burge, AJ et al. Patellofemoral cartilage lesions treated with particulated juvenile allograft cartilage: a prospective study with minimum 2-year clinical and magnetic resonance imaging outcomes. Arthroscopy. 2018;
34: 1498–1505 Abstract | Full Text | Full Text PDF | PubMed | Scopus (31) | Google ScholarSee all References whereas prior published studies with arthroscopic follow-up are limited to a maximum mean of 3.5 years.10x10Heida, KA Jr., Tihista, MC, Kusnezov, NA, Dunn, JC, and Orr, JD. Outcomes and predictors of postoperative pain improvement following particulated juvenile cartilage allograft transplant for osteochondral lesions of the talus. Foot Ankle Int. 2020;
41: 572–581 Crossref | Scopus (6) | Google ScholarSee all References All studies commented on outcome measures, 6 studies measured mean graft fill on MRI, and 9 studies had arthroscopic second-looks on at least a subset of their patients (typically those with adverse outcomes). Six studies commented on concomitant bony or soft tissue procedures performed alongside PJAC implementation.
TablePrior literature on ankle and knee PJAC implementation.
Author
Year
Mean follow-up (mo)
Sample size (patients, no.)
Sample size (OCLs, no.)
Mean age (y)
Sex (M, F), no.
Chondral defect grade (ICRS)
Chondral defect location (%)
Mean chondral defect size (mm2)
Concurrent procedures
Second-look arthroscopy (patients, no.)
Second-look arthroscopy OCL findings
Presence of postop MRI (% OCLs)
Mean lesion graft fill on MRI (%)
Outcome measure
Findings
Preop
Postop
P value
Waterman9x9Waterman, BR, Waterman, SM, McCriskin, B, Beck, EC, and Graves, RM. Particulated juvenile articular cartilage allograft for treatment of chondral defects of the knee: short-term survivorship with functional outcomes. J Surg Orthop Adv. 2021;
30: 10–13 Google ScholarSee all References
Heida10x10Heida, KA Jr., Tihista, MC, Kusnezov, NA, Dunn, JC, and Orr, JD. Outcomes and predictors of postoperative pain improvement following particulated juvenile cartilage allograft transplant for osteochondral lesions of the talus. Foot Ankle Int. 2020;
41: 572–581 Crossref | Scopus (6) | Google ScholarSee all References
2020
41.8
33
33
32.3
26, 7
III/IV
Medial talus (48), lateral talus (52)
131.4
NA
9
5 defects with excellent graft maturation, 2 with failed graft maturation, 2 with graft hypertrophy
NA
NA
VAS pain
5.9 (1.4)
2.7 (1.3)
<0.001
AOFAS hindfoot-ankle
59.8 (9.7)
59.8 (8.9)
<0.001
Chopra11x11Chopra, V, Chang, D, Ng, A, Kruse, DL, and Stone, PA. Arthroscopic treatment of osteochondral lesions of the talus utilizing juvenile particulated cartilage allograft: a case series. J Foot Ankle Surg. 2020;
59: 436–439 Abstract | Full Text | Full Text PDF | PubMed | Scopus (3) | Google ScholarSee all References
2020
24
32
32
40.7
9, 23
NA
Talus (100)
NA
NA
NA
NA
NA
NA
FAOS ADL
88% good or excellent
FAOS pain
82% good or excellent
Wang6x6Wang, T, Belkin, NS, Burge, AJ et al. Patellofemoral cartilage lesions treated with particulated juvenile allograft cartilage: a prospective study with minimum 2-year clinical and magnetic resonance imaging outcomes. Arthroscopy. 2018;
34: 1498–1505 Abstract | Full Text | Full Text PDF | PubMed | Scopus (31) | Google ScholarSee all References
Karnovsky12x12Karnovsky, SC, DeSandis, B, Haleem, AM, Sofka, CM, O’Malley, M, and Drakos, MC. Comparison of juvenile allogenous articular cartilage and bone marrow aspirate concentrate versus microfracture with and without bone marrow aspirate concentrate in arthroscopic treatment of talar osteochondral lesions. Foot Ankle Int. 2018;
39: 393–405 Crossref | PubMed | Scopus (35) | Google ScholarSee all References
2018
21.3
20
20
36.6
13, 7
NA
Medial talus (90), lateral talus (10)
170
4 Brostrom, 2 removal hardware, 2 removal loose body
5
5 graft failures (2 with subsequent MF, 3 with OATS)
DeSandis13x13DeSandis, BA, Haleem, AM, Sofka, CM, O’Malley, MJ, and Drakos, MC. Arthroscopic treatment of osteochondral lesions of the talus using juvenile articular cartilage allograft and autologous bone marrow aspirate concentration. J Foot Ankle Surg. 2018;
57: 273–280 Abstract | Full Text | Full Text PDF | PubMed | Scopus (25) | Google ScholarSee all References
2018
24
46
46
37.6
21, 25
NA
Talus (100)
161
NA
4
4 graft failures: 1 with subsequent MF, 1 OATS, 1 bone graft, 1 debridement
48
18% >50% infill, 64% hypertrophy, 18% exposed subchondral bone
FAOS overall
48.0 (13.8)
66.0 (21.8)
0.004
FAOS pain
55.8 (28)
71.6 (24.3)
0.006
FAOS symptoms
59.6 (20.8)
66.5 (23.6)
0.18
FAOS ADL
68.1 (20.6)
81.0 (24.2)
0.01
FAOS sports
38.9 (20.4)
58.6 (31.0)
0.004
FAOS QOL
23.1 (17.4)
49.5 (29.0)
<0.001
SF-12
63.0 (16.0)
75.6 (17.8)
0.023
MOCART
NA
46.8
NA
Dekker14x14Dekker, TJ, Steele, JR, Federer, AE, Easley, ME, Hamid, KS, and Adams, SB. Efficacy of particulated juvenile cartilage allograft transplantation for osteochondral lesions of the talus. Foot Ankle Int. 2018;
39: 278–283 Crossref | PubMed | Scopus (25) | Google ScholarSee all References
2018
34.6
15
15
32.7
7, 8
NA
Medial talus (60), lateral talus (40)
143
NA
3
3 graft failures: 2 with subsequent OATs, 1 bulk allograft
NA
NA
AOFAS hindfoot-ankle
NA
80
NA
FAOS overall
NA
66
NA
Farr7x7Farr, J, Tabet, SK, Margerrison, E, and 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: 1417–1425 Crossref | PubMed | Scopus (141) | Google ScholarSee all References
2014
24
25
29
37
18, 7
III/IV
Femoral condyle (62), trochlea (38)
270
NA
11 (elective)
9 grafts full integration, 1 partial delamination, 1 full delamination, mild graft hypertrophy 20%
100
110% graft fill
IKDC
45.7 (15.9)
73.6 (14.1)
<0.001
VAS pain
43.7 (24.4)
11.1 (15.2)
<0.001
KOOS pain
64.1 (16.4)
83.7 (10.5)
<0.05
KOOS symptoms
64.6 (17.2)
81.4 (11.3)
<0.05
KOOS ADL
73.8 (16.2)
91.5 (10.6)
<0.05
KOOS sports
44.6 (25.9)
68.3 (20.5)
<0.05
KOOS QOL
31.8 (19.2)
59.9 (20.7)
<0.05
Histology
8 samples studied, 6 with >50% hyaline cartilage, 2 with equal parts hyaline and fibrocartilage
Buckwalter15x15Buckwalter, JA, Bowman, GN, Albright, JP, Wolf, BR, and Bollier, M. Clinical outcomes of patellar chondral lesions treated with juvenile particulated cartilage allografts. Iowa Orthop J. 2014;
34: 44–49 PubMed | Google ScholarSee all References
2014
8.2
13
17
22.5
3, 10
IV
Patella (100)
NA
6 TTO
1
1 graft full integration
KOOS overall
58.4
69.2
<0.04
Tompkins16x16Tompkins, 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: 1661–1670 Abstract | Full Text | Full Text PDF | PubMed | Scopus (86) | Google ScholarSee all References
2013
28.8
13
15
26.4
NA
IV
Patella (100)
240
2 MPFL, 5 TTO, 3 MPFL/TTO
3
2 with graft hypertrophy
100
89
IKDC
NA
73.3
NA
KOOS pain
NA
84.2
NA
KOOS symptoms/ stiffness
NA
85
NA
KOOS ADL
NA
88.9
NA
KOOS sports
NA
62
NA
KOOS QOL
NA
60.8
NA
Kujala
NA
79
NA
Tegner activity
NA
5
NA
VAS pain
NA
1.9
NA
MRI-ICRS
NA
8.0 (2.8)
NA
Coetzee17x17Coetzee, JC, Giza, E, Schon, LC et al. Treatment of osteochondral lesions of the talus with particulated juvenile cartilage. Foot Ankle Int. 2013;
34: 1205–1211 Crossref | PubMed | Scopus (86) | Google ScholarSee all References
2013
16.2
23
24
35
12, 11
IV
Medial talus (79), lateral talus (21)
125
10 (hardware removals, treatment for impingement, synovitis, instability, osteophytes, and malalignment)
6
2 lesions with partial debridements (hypertrophy vs partial delamination)
Abbreviations: ADL, activities of daily living; AOFAS, American Orthopaedic Foot and Ankle Score; F, female; FAAM, foot and ankle ability measure; FAOS, Foot and Ankle Outcomes Score; HTO, high tibial osteotomy; ICRS, International Cartilage Repair Society Grade; IKDC, International Knee Documentation Committee; KOOS, Knee injury and Osteoarthritis Outcome Score; LFC, lateral femoral condyle; M, male; MAS, Marx Activity Scale; MCS, Mental Health Composite Score; MF, microfracture; MFC, medial femoral condyle; MOCART: Magnetic Resonance Observation of Cartilage Tissue score; MPFL, medial patellofemoral ligament; MRI, magnetic resonance imaging; NA, not applicable; OATS, osteochondral autograft transfer system; OCL, osteochondral lesion; PCS, physical composite score; PFJ, patellofemoral joint arthroplasty; postop, postoperative; preop, preoperative; QOL, quality of life; SF-12, short form survey-12; TKA, total knee arthroplasty: TTO, tibial tubercle osteotomy; VAS, visual analog score.
Values listed as means with standard deviations listed in parentheses or range listed in brackets unless otherwise specified. Bolded values demonstrate significance (P < 0.05).
Although not visualized arthroscopically or radiographically in our patient, variable graft fill is a known complication of PJAC implementation. Graft hypertrophy was noted in 6 studies with an incidence of 0% to 65%.7x7Farr, J, Tabet, SK, Margerrison, E, and 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: 1417–1425 Crossref | PubMed | Scopus (141) | Google ScholarSee all References,9x9Waterman, BR, Waterman, SM, McCriskin, B, Beck, EC, and Graves, RM. Particulated juvenile articular cartilage allograft for treatment of chondral defects of the knee: short-term survivorship with functional outcomes. J Surg Orthop Adv. 2021;
30: 10–13 Google ScholarSee all References,10x10Heida, KA Jr., Tihista, MC, Kusnezov, NA, Dunn, JC, and Orr, JD. Outcomes and predictors of postoperative pain improvement following particulated juvenile cartilage allograft transplant for osteochondral lesions of the talus. Foot Ankle Int. 2020;
41: 572–581 Crossref | Scopus (6) | Google ScholarSee all References,12x12Karnovsky, SC, DeSandis, B, Haleem, AM, Sofka, CM, O’Malley, M, and Drakos, MC. Comparison of juvenile allogenous articular cartilage and bone marrow aspirate concentrate versus microfracture with and without bone marrow aspirate concentrate in arthroscopic treatment of talar osteochondral lesions. Foot Ankle Int. 2018;
39: 393–405 Crossref | PubMed | Scopus (35) | Google ScholarSee all References,16x16Tompkins, 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: 1661–1670 Abstract | Full Text | Full Text PDF | PubMed | Scopus (86) | Google ScholarSee all References,17x17Coetzee, JC, Giza, E, Schon, LC et al. Treatment of osteochondral lesions of the talus with particulated juvenile cartilage. Foot Ankle Int. 2013;
34: 1205–1211 Crossref | PubMed | Scopus (86) | Google ScholarSee all References Karnovsky et al12x12Karnovsky, SC, DeSandis, B, Haleem, AM, Sofka, CM, O’Malley, M, and Drakos, MC. Comparison of juvenile allogenous articular cartilage and bone marrow aspirate concentrate versus microfracture with and without bone marrow aspirate concentrate in arthroscopic treatment of talar osteochondral lesions. Foot Ankle Int. 2018;
39: 393–405 Crossref | PubMed | Scopus (35) | Google ScholarSee all References found a 65% incidence of graft hypertrophy in their sample of 20 ankles with PJAC implementation. Notably, they directly compared MF with PJAC and found similar patient reported outcome measures (PROMs) but a statistically significant increase in graft hypertrophy in PJAC samples. No changes in functional outcome scores were noted, however. Challenges exist in further studying graft hypertrophy incidence, as different authors use varying definitions of graft hypertrophy (ie, edge vs depth overgrowth) and varying methods of identification (ie, direct arthroscopic visualization with probing vs MRI).
Compared to PJAC, MF is a more extensively studied cartilage restoration technique.1x1Krych, AJ, Saris, DBF, Stuart, MJ, and Hacken, B. Cartilage injury in the knee: assessment and treatment options. J Am Acad Orthop Surg. 2020;
28: 914–922 Crossref | PubMed | Scopus (32) | Google ScholarSee all References Its technique is reproducible and its biologic effects are relatively consistent.1x1Krych, AJ, Saris, DBF, Stuart, MJ, and Hacken, B. Cartilage injury in the knee: assessment and treatment options. J Am Acad Orthop Surg. 2020;
28: 914–922 Crossref | PubMed | Scopus (32) | Google ScholarSee all References One theorized benefit of PJAC implementation over MF is its propensity to develop hyaline or hyaline-like cartilage. In 2014, Farr et al7x7Farr, J, Tabet, SK, Margerrison, E, and 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: 1417–1425 Crossref | PubMed | Scopus (141) | Google ScholarSee all References published histological results at 2 years postoperatively. Elective arthroscopy with cartilage biopsy was performed in 11 of 25 patients who underwent knee PJAC implementation. Histological analyses in 8 of those 11 samples (3 lost to technical errors) found 6 samples with >50% hyaline cartilage fill (trichrome stain scoring with subsequent immunopositivity for type II collagen) and 2 samples with an approximately 50/50 mix of hyaline cartilage and fibrocartilage fill (trichome stain scoring with subsequent type I and II collagen immunopositivity). PJAC products are oftentimes advertised as providing a hyaline-like cartilage outcome which is biomechanically superior to fibrocartilage.5x5Wixted, CM, Dekker, TJ, and Adams, SB. Particulated juvenile articular cartilage allograft transplantation for osteochondral lesions of the knee and ankle. Expert Rev Med Devices. 2020;
17: 235–244 Crossref | Scopus (5) | Google ScholarSee all References,8x8Farr, J, Cole, BJ, Sherman, S, and Karas, V. Particulated articular cartilage: CAIS and DeNovo NT. J Knee Surg. 2012;
25: 23–29 Crossref | PubMed | Scopus (97) | Google ScholarSee all References Further histological research is needed with large sample sizes to determine the extent to which PJAC implementation provides hyaline-like cartilage vs a mixed composition of hyaline and fibrocartilage and whether this distinction is important in outcome measures.
Some authors contend that MF is a low-cost alternative with similar outcome measures to PJAC implementation. Karnovsky et al12x12Karnovsky, SC, DeSandis, B, Haleem, AM, Sofka, CM, O’Malley, M, and Drakos, MC. Comparison of juvenile allogenous articular cartilage and bone marrow aspirate concentrate versus microfracture with and without bone marrow aspirate concentrate in arthroscopic treatment of talar osteochondral lesions. Foot Ankle Int. 2018;
39: 393–405 Crossref | PubMed | Scopus (35) | Google ScholarSee all References compared 30 patients who underwent MF and 20 patients who underwent PJAC implantation for talar OCLs. They identified no significant difference in pain, function, or radiographic scores between PJAC and MF cohorts. Dekker et al14x14Dekker, TJ, Steele, JR, Federer, AE, Easley, ME, Hamid, KS, and Adams, SB. Efficacy of particulated juvenile cartilage allograft transplantation for osteochondral lesions of the talus. Foot Ankle Int. 2018;
39: 278–283 Crossref | PubMed | Scopus (25) | Google ScholarSee all References argue that PJAC implementation is oftentimes used as a salvage procedure after MF or other cartilage restoration techniques have failed (ie, refractory symptomatology in the setting of continued findings on advanced imaging modalities). This is the case with our patient, who had already undergone 4 prior procedures by different surgeons. A recent systematic review of MF use for knee OCLs found a failure rate (as defined by conversion to arthroplasty) of 11% to 27% within 5 years and 6% to 32% at 10 years.22x22Orth, P, Gao, L, and Madry, H. Microfracture for cartilage repair in the knee: a systematic review of the contemporary literature. Knee Surg Sports Traumatol Arthrosc. 2020;
28: 670–706 Crossref | Scopus (48) | Google ScholarSee all References PJAC implementation, although more costly than MF, less well-studied, and not yet proven to be superior in PROMs, is yet another tool in the surgeon's armamentarium of cartilage restoration techniques. Little evidence exists directly comparing PJAC implementation to other cartilage restoration techniques. In contrast to MF, the authors were unable to find a study directly comparing PJAC to osteochondral allograft application. Osteochondral allografts can be particularly useful in the setting of bone loss or in large OCLs where cost would be a prohibitive factor for cell-based therapies.1x1Krych, AJ, Saris, DBF, Stuart, MJ, and Hacken, B. Cartilage injury in the knee: assessment and treatment options. J Am Acad Orthop Surg. 2020;
28: 914–922 Crossref | PubMed | Scopus (32) | Google ScholarSee all References
The senior author (D.N.M.C.) elected to treat the patient with 3 serial intraarticular HA viscosupplementation injections in the postoperative period after her PJAC implementation. At the time of treatment, it was the author's protocol to augment his cartilage restoration procedures with HA on the basis of animal model studies reporting a short term benefit to articular cartilage defect repairs and a decrease in inflammatory synovitis.23x23Tytherleigh-Strong, G, Hurtig, M, and Miniaci, A. Intra-articular hyaluronan following autogenous osteochondral grafting of the knee. Arthroscopy. 2005;
21: 999–1005 Abstract | Full Text | Full Text PDF | PubMed | Scopus (33) | Google ScholarSee all References,24x24Legović, D, Zorihić, S, Gulan, G et al. Microfracture technique in combination with intraarticular hyaluronic acid injection in articular cartilage defect regeneration in rabbit model. Coll Antropol. 2009;
33: 619–623 Google ScholarSee all References,25x25Strauss, E, Schachter, A, Frenkel, S, and Rosen, J. The efficacy of intra-articular hyaluronan injection after the microfracture technique for the treatment of articular cartilage lesions. Am J Sports Med. 2009;
37: 720–726 Crossref | PubMed | Scopus (80) | Google ScholarSee all References,26x26Tuncay, I, Erkocak, OF, Acar, MA, and Toy, H. The effect of hyaluronan combined with microfracture on the treatment of chondral defects: an experimental study in a rabbit model. Eur J Orthop Surg Traumatol. 2013;
23: 753–758 Crossref | Scopus (8) | Google ScholarSee all References In a rabbit model, Strauss et al25x25Strauss, E, Schachter, A, Frenkel, S, and Rosen, J. The efficacy of intra-articular hyaluronan injection after the microfracture technique for the treatment of articular cartilage lesions. Am J Sports Med. 2009;
37: 720–726 Crossref | PubMed | Scopus (80) | Google ScholarSee all References created articular cartilage defects to the MFC. These defects were subsequently treated with MF.25x25Strauss, E, Schachter, A, Frenkel, S, and Rosen, J. The efficacy of intra-articular hyaluronan injection after the microfracture technique for the treatment of articular cartilage lesions. Am J Sports Med. 2009;
37: 720–726 Crossref | PubMed | Scopus (80) | Google ScholarSee all References The experimental group was treated with serial HA injections whereas the control group received saline injections.25x25Strauss, E, Schachter, A, Frenkel, S, and Rosen, J. The efficacy of intra-articular hyaluronan injection after the microfracture technique for the treatment of articular cartilage lesions. Am J Sports Med. 2009;
37: 720–726 Crossref | PubMed | Scopus (80) | Google ScholarSee all References The experimental group showed significantly better defect fill at the 3-month mark and decreased synovitis and osteophyte formation at the 6-month mark.25x25Strauss, E, Schachter, A, Frenkel, S, and Rosen, J. The efficacy of intra-articular hyaluronan injection after the microfracture technique for the treatment of articular cartilage lesions. Am J Sports Med. 2009;
37: 720–726 Crossref | PubMed | Scopus (80) | Google ScholarSee all References Although this case utilized PJAC implementation and not MF, the authors contend the interaction between HA and juvenile stem cells may have an even more beneficial effect, especially in light of more recent studies.27x27Wong, KL, Zhang, S, Wang, M et al. Intra-articular injections of mesenchymal stem cell exosomes and hyaluronic acid improve structural and mechanical properties of repaired cartilage in a rabbit model. Arthroscopy. 2020;
36: 2215–2228.e2212 Abstract | Full Text | Full Text PDF | Scopus (43) | Google ScholarSee all References,28x28Wong, CC, Sheu, SD, Chung, PC et al. Hyaluronic acid supplement as a chondrogenic adjuvant in promoting the therapeutic efficacy of stem cell therapy in cartilage healing. Pharmaceutics. 2021;
13: 432 Crossref | Scopus (6) | Google ScholarSee all References The authors recognize contrasting studies have been performed in animal models finding no difference in outcomes between HA and control cartilage restoration protocols,29x29Mendelson, S, Wooley, P, Lucas, D, and Markel, D. The effect of hyaluronic acid on a rabbit model of full-thickness cartilage repair. Clin Orthop Relat Res. 2004;
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3: 20–26 Crossref | Scopus (8) | Google ScholarSee all References and human studies purporting the benefit of serial HA injections in this population are limited.31x31Shang, XL, Tao, HY, Chen, SY, Li, YX, and Hua, YH. Clinical and MRI outcomes of HA injection following arthroscopic microfracture for osteochondral lesions of the talus. Knee Surg Sports Traumatol Arthrosc. 2016;
24: 1243–1249 Crossref | Scopus (28) | Google ScholarSee all References HA augmentation of cartilage restoration techniques is an area ripe for future study. Further discussion surrounding the efficacy of HA in cartilage restoration procedures is outside the scope of this article.
Limitations exist both in this article and the use of PJAC as a cartilage restoration technique. This case report with literature review is limited by its small sample size and subsequent inability to perform statistical analyses. Furthermore, no PROMs were collected for our patient and objective radiographic outcomes were not available for all time points. By all reports, however, she has continued to live an active lifestyle free of daily pain. PJAC can be more costly (approximately $4,950 per package with covers 2.5 cm2) than other cartilage restoration techniques (ie, MF), has a limited shelf-life, and lacks robust literature support.4x4Aldawsari, K, Alrabai, HM, Sayed, A, and Alrashidi, Y. Role of particulated juvenile cartilage allograft transplantation in osteochondral lesions of the talus: a systematic review. Foot Ankle Surg. 2021;
27: 10–14 Crossref | Scopus (6) | Google ScholarSee all References,5x5Wixted, CM, Dekker, TJ, and Adams, SB. Particulated juvenile articular cartilage allograft transplantation for osteochondral lesions of the knee and ankle. Expert Rev Med Devices. 2020;
17: 235–244 Crossref | Scopus (5) | Google ScholarSee all References,32x32Meeks, B and Flanigan, D. Editorial commentary: no clear winner when comparing cost-effectiveness of particulated juvenile articular cartilage with matrix-induced autologous chondrocyte implantation: too many assumptions. Arthroscopy. 2022;
38: 1264–1266 Abstract | Full Text | Full Text PDF | Scopus (1) | Google ScholarSee all References More prospective, randomized research is needed to directly compare PROMs, radiographic outcomes, and histological outcomes between varying cartilage restoration techniques. The authors’ objectives were to provide an update on the longest published follow-up of PJAC implementation along with a review of prior studies. This case with greater than 10-year follow-up suggests that PJAC implementation stands as a viable option for patients with full-thickness cartilaginous injuries recalcitrant to other operative modalities.
Conclusion
Outcomes of PJAC implementation have yet to be widely studied. This case report is the first to our knowledge to describe greater than 10-year follow-up in a patient with PJAC implementation for an OCL. Although limited by scope and level of evidence, this case report suggests PJAC implementation may be a viable option for high grade (ie, >50% depth) cartilage injury. Additionally, this case demonstrates PJAC may serve as a treatment alternative for patients who have undergone prior failed cartilage restoration procedures.
Funding
No departmental, institutional, governmental, or commercial funding was used in the preparation of this manuscript.
Ethics approval
Complete written informed consent was obtained from the patient for the publication of this study and accompanying images. This study was considered exempt by our local university institutional review board.
Declaration of competing interest
The authors have no conflicts of interest to declare.
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