Comparison of Collagen Graft Fixation Methods in the Porcine Knee: Implications for Matrix-Assisted Chondrocyte Implantation and Second-Generation Autologous Chondrocyte Implantation

Published:December 22, 2015DOI:


      To evaluate the fixation integrity at time zero of a type I/III collagen patch secured to a chondral defect in the porcine knee using methods typically employed in autologous chondrocyte implantation (ACI) and matrix-assisted chondrocyte implantation.


      Twenty-four porcine knee specimens underwent a medial parapatellar arthrotomy. A prefabricated template was used to create cartilage defects of 2 cm2 in the medial femoral condyle. A size-matched collagen patch was fashioned. Four methods of fixation to the chondral defect were analyzed: group 1—saline, group 2—fibrin glue around the periphery of the patch, group 3—fibrin glue applied to the base of the defect and around the periphery of the patch, group 4—6-0 vicryl suture and fibrin glue around the periphery of the patch. Collagen patch fixation was assessed at intervals of 60, 300, 600, 900, and 1,200 cycles from full extension to 90° of flexion, performed manually without application of axial force. Patch fixation was evaluated by 2 independent observers using a customized scoring scale.


      Mean peripheral detachment of the patch and chondral defect uncovering remained less than 25% for all groups. Area of defect uncovering was significantly increased in group 2 compared with group 4 after 900 and 1,200 cycles (P = .0014 and P = .0025, respectively). Fibrin glue applied to the base of the defect, or suturing of the patch, reduced deformation significantly after 900 cycles.


      Suture increases the stability of fixation of a type I/III collagen patch to a chondral defect better than fibrin glue alone in the porcine knee after repetitive cycling, with respect to patch detachment and chondral defect uncovering. Application of fibrin glue to the base of the defect, or securing the patch with suture, decreases collagen patch deformation.

      Clinical Relevance

      In cases where minimally invasive techniques do not allow suture fixation of the collagen patch, scaffold fixation may be compromised during articular motion protocols typically used after second- and third-generation ACI procedures.
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        • Nehrer S.
        • Spector M.
        • Minas T.
        Histologic analysis of tissue after failed cartilage repair procedures.
        Clin Orthop Relat Res. 1999; 365: 149-162
        • Redman S.N.
        • Oldfield S.F.
        • Archer C.W.
        Current strategies for articular cartilage repair.
        Eur Cell Mater. 2005; 9: 23-32
        • Bentley G.
        • Biant L.C.
        • Carrington R.W.
        • et al.
        A prospective, randomised comparison of autologous chondrocyte implantation versus mosaicplasty for osteochondral defects in the knee.
        J Bone Joint Surg Br. 2003; 85: 223-230
        • Cole B.J.
        • Farr J.
        • Winalski C.S.
        • et al.
        Outcomes after a single-stage procedure for cell-based cartilage repair: A prospective clinical safety trial with 2-year follow-up.
        Am J Sports Med. 2011; 39: 1170-1179
        • Gobbi A.
        • Karnatzikos G.
        • Scotti C.
        • Mahajan V.
        • Mazzucco L.
        • Grigolo B.
        One-step cartilage repair with bone marrow aspirate concentrated cells and collagen matrix in full-thickness knee cartilage lesions results at 2-year follow-up.
        Cartilage. 2011; 2: 286-299
        • Knutsen G.
        • Engebretsen L.
        • Ludvigsen T.C.
        • et al.
        Autologous chondrocyte implantation compared with microfracture in the knee. A randomized trial.
        J Bone Joint Surg Am. 2004; 86: 455-464
        • Murphy R.T.
        • Pennock A.T.
        • Bugbee W.D.
        Osteochondral allograft transplantation of the knee in the pediatric and adolescent population.
        Am J Sports Med. 2014; 42: 635-640
        • Zaslav K.
        • Cole B.
        • Brewster R.
        • et al.
        A prospective study of autologous chondrocyte implantation in patients with failed prior treatment for articular cartilage defect of the knee: Results of the Study of the Treatment of Articular Repair (STAR) clinical trial.
        Am J Sports Med. 2009; 37: 42-55
        • Brun P.
        • Dickinson S.C.
        • Zavan B.
        • Cortivo R.
        • Hollander A.P.
        • Abatangelo G.
        Characteristics of repair tissue in second-look and third-look biopsies from patients treated with engineered cartilage: Relationship to symptomatology and time after implantation.
        Arthritis Res Ther. 2008; 10: R132
        • Gikas P.D.
        • Morris T.
        • Carrington R.
        • Skinner J.
        • Bentley G.
        • Briggs T.
        A correlation between the timing of biopsy after autologous chondrocyte implantation and the histological appearance.
        J Bone Joint Surg Br. 2009; 91: 1172-1177
        • Vasiliadis H.S.
        • Wasiak J.
        • Salanti G.
        Autologous chondrocyte implantation for the treatment of cartilage lesions of the knee: A systematic review of randomized studies.
        Knee Surg Sports Traumatol Arthrosc. 2010; 18: 1645-1655
        • Zheng M.H.
        • Willers C.
        • Kirilak L.
        • et al.
        Matrix-induced autologous chondrocyte implantation (MACI): Biological and histological assessment.
        Tissue Eng. 2007; 13: 737-746
        • Baghaban Eslaminejad M.
        • Malakooty Poor E.
        Mesenchymal stem cells as a potent cell source for articular cartilage regeneration.
        World J Stem Cells. 2014; 6: 344-354
        • Kon E.
        • Roffi A.
        • Filardo G.
        • Tesei G.
        • Marcacci M.
        Scaffold-based cartilage treatments: With or without cells? A systematic review of preclinical and clinical evidence.
        Arthroscopy. 2015; 31: 767-775
        • Scharstuhl A.
        • Schewe B.
        • Benz K.
        • Gaissmaier C.
        • Bühring H.J.
        • Stoop R.
        Chondrogenic potential of human adult mesenchymal stem cells is independent of age or osteoarthritis etiology.
        Stem Cells. 2007; 25: 3244-3251
        • Grande D.A.
        • Pitman M.I.
        • Peterson L.
        • Menche D.
        • Klein M.
        The repair of experimentally produced defects in rabbit articular cartilage by autologous chondrocyte transplantation.
        J Orthop Res. 1989; 7: 208-218
        • Brittberg M.
        • Lindahl A.
        • Nilsson A.
        • Ohlsson C.
        • Isaksson O.
        • Peterson L.
        Treatment of deep cartilage defects in the knee with autologous chondrocyte transplantation.
        N Engl J Med. 1994; 331: 889-895
        • Henderson I.
        • Gui J.
        • Lavigne P.
        Autologous chondrocyte implantation: Natural history of postimplantation periosteal hypertrophy and effects of repair-site debridement on outcome.
        Arthroscopy. 2006; 22: 1318-1324.e1
        • Henderson I.
        • Tuy B.
        • Oakes B.
        Reoperation after autologous chondrocyte implantation. Indications and findings.
        J Bone Joint Surg Br. 2004; 86: 205-211
        • Marlovits S.
        • Zeller P.
        • Singer P.
        • Resinger C.
        • Vécsei V.
        Cartilage repair: Generations of autologous chondrocyte transplantation.
        Eur J Radiol. 2006; 57: 24-31
        • Gooding C.R.
        • Bartlett W.
        • Bentley G.
        • Skinner J.A.
        • Carrington R.
        • Flanagan A.
        A prospective, randomised study comparing two techniques of autologous chondrocyte implantation for osteochondral defects in the knee: Periosteum covered versus type I/III collagen covered.
        Knee. 2006; 13: 203-210
        • Niemeyer P.
        • Lenz P.
        • Kreuz P.C.
        • et al.
        Chondrocyte-seeded type I/III collagen membrane for autologous chondrocyte transplantation: Prospective 2-year results in patients with cartilage defects of the knee joint.
        Arthroscopy. 2010; 26: 1074-1082
        • Steinwachs M.
        • Kreuz P.C.
        Autologous chondrocyte implantation in chondral defects of the knee with a type I/III collagen membrane: A prospective study with a 3-year follow-up.
        Arthroscopy. 2007; 23: 381-387
        • Cortese F.
        • McNicholas M.
        • Janes G.
        • et al.
        Arthroscopic delivery of matrix-induced autologous chondrocyte implant international experience and technique recommendations.
        Cartilage. 2012; 3: 156-164
        • Filardo G.
        • Kon E.
        • Andriolo L.
        • Di martino A.
        • Zaffagnini S.
        • Marcacci M.
        Treatment of “patellofemoral” cartilage lesions with matrix-assisted autologous chondrocyte transplantation: A comparison of patellar and trochlear lesions.
        Am J Sports Med. 2014; 42: 626-634
        • Filardo G.
        • Vannini F.
        • Marcacci M.
        • et al.
        Matrix-assisted autologous chondrocyte transplantation for cartilage regeneration in osteoarthritic knees: Results and failures at midterm follow-up.
        Am J Sports Med. 2013; 41: 95-100
        • Filardo G.
        • Kon E.
        • Andriolo L.
        • Di matteo B.
        • Balboni F.
        • Marcacci M.
        Clinical profiling in cartilage regeneration: Prognostic factors for midterm results of matrix-assisted autologous chondrocyte transplantation.
        Am J Sports Med. 2014; 42: 898-905
        • Gomoll A.H.
        • Gillogly S.D.
        • Cole B.J.
        • et al.
        Autologous chondrocyte implantation in the patella: A multicenter experience.
        Am J Sports Med. 2014; 42: 1074-1081
        • Mcnickle A.G.
        • L'heureux D.R.
        • Yanke A.B.
        • Cole B.J.
        Outcomes of autologous chondrocyte implantation in a diverse patient population.
        Am J Sports Med. 2009; 37: 1344-1350
        • Bekkers J.E.
        • Tsuchida A.I.
        • Malda J.
        • et al.
        Quality of scaffold fixation in a human cadaver knee model.
        Osteoarthritis Cartilage. 2010; 18: 266-272
        • Drobnic M.
        • Radosavljevic D.
        • Ravnik D.
        • Pavlovcic V.
        • Hribernik M.
        Comparison of four techniques for the fixation of a collagen scaffold in the human cadaveric knee.
        Osteoarthr Cartil. 2006; 14: 337-344
        • Efe T.
        • Füglein A.
        • Heyse T.J.
        • et al.
        Fibrin glue does not improve the fixation of press-fitted cell-free collagen gel plugs in an ex vivo cartilage repair model.
        Knee Surg Sports Traumatol Arthrosc. 2012; 20: 210-215
        • Efe T.
        • Schofer M.D.
        • Füglein A.
        • et al.
        An ex vivo continuous passive motion model in a porcine knee for assessing primary stability of cell-free collagen gel plugs.
        BMC Musculoskelet Disord. 2010; 11: 283
        • Landis J.R.
        • Koch G.G.
        The measurement of observer agreement for categorical data.
        Biometrics. 1977; 33: 159-174
        • Marlovits S.
        • Striessnig G.
        • Kutscha-lissberg F.
        • Resinger C.
        • Aldrian S.M.
        • Trattnig S.
        Early postoperative adherence of matrix-induced autologous chondrocyte implantation for the treatment of full-thickness cartilage defects of the femoral condyle.
        Knee Surg Sports Traumatol Arthrosc. 2005; 13: 451-457
        • Howard J.S.
        • Mattacola C.G.
        • Romine S.E.
        • Lattermann C.
        Continuous passive motion, early weight bearing, and active motion following knee articular cartilage repair: Evidence for clinical practice.
        Cartilage. 2010; 1: 276-286
        • Ronken S.
        • Arnold M.P.
        • Ardura garcía H.
        • Jeger A.
        • Daniels A.U.
        • Wirz D.
        A comparison of healthy human and swine articular cartilage dynamic indentation mechanics.
        Biomech Model Mechanobiol. 2012; 11: 631-639