Surgical interventions (microfracture, drilling, mosaicplasty, and allograft transplantation) for treating isolated cartilage defects of the knee in adults

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Date
2016Author
Gracitelli, Guilherme Conforto [UNIFESP]
Moraes, Vinícius Ynoe de [UNIFESP]
Franciozi, Carlos Eduardo da Silveira [UNIFESP]
Luzo, Marcus Vinicius Malheiros [UNIFESP]
Belloti, Joao Carlos [UNIFESP]
Type
RevisãoISSN
1469-493XIs part of
Cochrane Database Of Systematic ReviewsDOI
10.1002/14651858.CD010675.pub2Metadata
Show full item recordAbstract
Background
Cartilage defects of the knee are often debilitating and predispose to osteoarthritis. Microfracture, drilling, mosaicplasty, and allograft
transplantation are four surgical treatment options that are increasingly performed worldwide. We set out to examine the relative effects
of these different methods.
Objectives
To assess the relative effects (benefits and harms) of different surgical interventions (microfracture, drilling, mosaicplasty, and allograft
transplantation) for treating isolated cartilage defects of the knee in adults.
Search methods
We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, CENTRAL, EMBASE, MEDLINE, SPORTDiscus, LILACS, trial registers and conference proceedings up to February 2016.
Selection criteria
Any randomised or quasi-randomised trials that evaluated surgical interventions (microfracture, drilling, mosaicplasty, and allograft
transplantation) for treating isolated cartilage defects of the knee in adults.
Data collection and analysis
At least two review authors independently selected studies, assessed risk of bias and extracted data. Intervention effects were assessed
using risk ratios (RR) for dichotomous data and mean differences (MD) for continuous data, with 95% confidence intervals (CI). Data
were pooled using the fixed-effect model, where possible.
Main results
We included three randomised controlled trials comparing mosaicplasty versus microfracture for isolated cartilage defects in adults.
Two trials were single-centre trials and one involved three centres. These small trials reported results for a total of 133 participants, of
whom 79 (59%) were male. Mean participant age in the three trials ranged from 24.4 years to 32.3 years. All studies included grade 3 or 4 cartilage lesions (International Cartilage Repair Society (ICRS) classification). The defect area ranged from 1.0 cm² to 6.0 cm²;
the mean area in all three trials was 2.8 cm². No trials of allograft transplantation or drilling were identified.
All trials were judged as being at high or unclear risk of performance and reporting bias. We judged that the quality of evidence was
very low for all outcomes. For individual outcomes, we downgraded the quality of evidence by one or two levels for risk of bias, one
level for indirectness where there were data from a single-centre trial only, one or two levels for imprecision where there were wide
confidence intervals and an insufficient number of events, and one level for inconsistency reflecting heterogeneity. This means that we
are very uncertain about the estimates for all outcomes.
There is very low quality evidence from one single-centre trial (57 participants), which included athletes only, that mosaicplasty resulted
in higher patient-reported function scores (probably the IKDC 2000 subjective knee evaluation score) compared with microfracture
(range 0 to 100; higher score = better function) at one year follow-up (MD 10.29 favouring mosaicplasty, 95% CI 7.87 to 12.71).
Very low quality evidence from the same trial showed that this effect persisted in the long term at 10 years follow-up. However, there
is very low quality evidence from the two other trials (72 participants) of little difference in patient-reported function, assessed via the
Lysholm score (range 0 to 100; higher score = better function), between the two groups at long-term follow-up (MD -1.10 favouring
microfracture, 95% CI -4.54 to 2.33). One trial (25 participants) provided very low quality evidence of no significant difference between
the two groups in quality of life or pain at long-term follow-up. Pooled results for treatment failure - primarily symptom recurrence -
reported at long-term follow-up (means ranging from 6.3 to 1.4 years) in the three trials (129 participants) favoured mosaicplasty (10/
64 versus 20/65; RR 0.47, 95% CI 0.24 to 0.90). Based on an illustrative risk of 379 treatment failures per 1000 patients treated with
microfracture, there is very low quality evidence that 201 fewer patients (95% CI 38 to 288 fewer) would have treatment failure after
mosaicplasty. All three trials reported activity scores but due to clear statistical and clinical heterogeneity, we did not pool the long term
Tegner score results. There was very low quality evidence from one study (57 participants) of higher Tegner scores - indicating greater
activity - at intermediate-term and long-term follow-up in the mosaicplasty group; however, the between-group difference may not be
clinically important. The other two trials provided very low quality evidence of no significant difference between the two groups in
activity scores.
Authors’ conclusions
We found no evidence from randomised controlled trials on allograft transplantation or drilling. The very low quality evidence from
RCTs comparing mosaicplasty with microfracture is insufficient to draw conclusions on the relative effects of these two interventions
for treating isolated cartilage defects of the knee in adults. Of note is that treatment failure, with recurrence of symptoms, occurred
with both procedures. Further research is needed to define the best surgical option for treating isolated cartilage defects. We suggest
the greatest need is for multi-centre RCTs comparing reconstructive procedures (mosaicplasty versus allograft transplantation) for large
osteochondral lesions and reparative procedures (microfracture versus drilling) for small chondral lesions.
Citation
Cochrane Database Of Systematic Reviews. Hoboken, n. 9, p. CD010675, 2016.Keywords
Osteochondral Autologous TransplantationTerm-Follow-Up
Articular-Cartilage
Chondrocyte Implantation
Chondral Defects
Randomized-Trial
Marrow-Stimulation
Level I
Lesions
Repair
Sponsorship
Escola Paulista de Medicina - Universidade Federal de Sasimilar to o Paulo, BrazilCollections
- EPM - Artigos [17701]
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