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Editorial Commentary: Trends in Cartilage Surgery—Who Is Steering the Ship?

      Abstract

      With myriad cartilage surgery techniques available, including marrow stimulation, autologous osteochondral transfer, osteochondral allograft transplantation, and autologous chondrocyte implantation, treatment of knee articular cartilage injuries has become increasingly complex. Recent evidence suggests that advanced cartilage restoration procedures may provide improved outcomes and durability when compared with marrow stimulation techniques. When investigating orthopaedic surgeons early in practice, it appears that utilization of marrow stimulation techniques has decreased, an encouraging trend that is in line with recent evidence. However, it is important to consider how other factors not investigated, including insurance approval and payor reimbursement, may influence these trends moving forward.
      The complex world of cartilage surgery remains full of uncertainty, with each additional study seemingly providing more questions than answers. Over the past 20 years, myriad cartilage procedures have been introduced or reinvented, including marrow stimulation techniques (MSTs), autologous osteochondral transfer (AOT), osteochondral allograft transplantation (OCA), and autologous chondrocyte implantation (ACI), just to name a few. Each procedure has shown promising early outcomes when applied in the appropriate setting prior to succumbing to long-term follow-up with deteriorating outcomes, high rates of morbidity, complications, or reoperation. In the article “Cartilage Restoration Surgery: Incidence Rates, Complications, and Trends as Reported by the American Board of Orthopaedic Surgery Part II Candidates,” Frank, Cotter, Hannon, Harrast, and Cole
      • Frank R.M.
      • Cotter E.J.
      • Hannon C.P.
      • Harrast J.J.
      • Cole B.J.
      Cartilage restoration surgery: Incidence rates, complications, and trends as reported by the American Board of Orthopaedic Surgery Part II candidates.
      explore the utilization of several cartilage surgery techniques over the past 13 years by orthopaedic surgeons who are presumably early in their clinical practice. The authors should be commended for their work, which helps us understand where we have been to give us a better sense of where we may be going with respect to cartilage surgery.
      The authors demonstrate several interesting findings that expand on work that our group previously published using American Board of Orthopaedic Surgery (ABOS) data, which identified a decrease in the overall number of cartilage surgery procedures performed by ABOS Part II candidates in more recent years, driven primarily by declining chondroplasty and microfracture utilization.

      Hancock KJ, Westermann RR, Shamrock AG, Duchman KR, Wolf BR, Amendola A. Trends in knee articular cartilage treatments: An American Board of Orthopaedic Surgery Database study. J Knee Surg. February 28, 2018. [Epub ahead of print.]

      Frank et al.
      • Frank R.M.
      • Cotter E.J.
      • Hannon C.P.
      • Harrast J.J.
      • Cole B.J.
      Cartilage restoration surgery: Incidence rates, complications, and trends as reported by the American Board of Orthopaedic Surgery Part II candidates.
      expand on our previous work by individually categorizing cartilage procedures, including arthroscopic and open AOT and OCA, ACI, and MSTs while excluding chondroplasty, which has become increasingly difficult to accurately analyze owing to recent billing and coding changes.
      • Legrand M.
      Coding for knee arthroscopy and chondroplasty.
      The authors similarly report an overall decrease in the number of cartilage procedures performed, driven primarily by decreased utilization of MST, whereas the incidence of open AOT and OCA procedures increased. Although still the most frequently performed cartilage surgery procedure, decreased utilization of MST in recent years may be influenced by recent literature suggesting deteriorating long-term results following MST compared with more advanced cartilage procedures.
      • Gudas R.
      • Gudaite A.
      • Pocius A.
      • et al.
      Ten-year follow-up of a prospective, randomized clinical study of mosaic osteochondral autologous transplantation versus microfracture for the treatment of osteochondral defects in the knee joint of athletes.
      • Brittberg M.
      • Recker D.
      • Ilgenfritz J.
      • Saris D.B.F.
      Matrix-applied characterized autologous cultured chondrocytes versus microfracture: Five-year follow-up of a prospective randomized trial.
      • Solheim E.
      • Hegna J.
      • Strand T.
      • Harlem T.
      • Inderhaug E.
      Randomized study of long-term (15-17 years) outcome after microfracture versus mosaicplasty in knee articular cartilage defects.
      Additionally, there is a growing body of literature to suggest that ACI outcomes may be negatively influenced by prior surgery with MST, insinuating that MST may indeed burn a bridge if advanced surface-based cartilage procedures are being considered.
      • Lamplot J.D.
      • Schafer K.A.
      • Matava M.J.
      Treatment of failed articular cartilage reconstructive procedures of the knee: A systematic review.
      • Minas T.
      • Gomoll A.H.
      • Rosenberger R.
      • Royce R.O.
      • Bryant T.
      Increased failure rate of autologous chondrocyte implantation after previous treatment with marrow stimulation techniques.
      • Pestka J.M.
      • Bode G.
      • Salzmann G.
      • Sudkamp N.P.
      • Niemeyer P.
      Clinical outcome of autologous chondrocyte implantation for failed microfracture treatment of full-thickness cartilage defects of the knee joint.
      • 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.
      In our opinion, these are encouraging trends, because AOT and OCA, despite being more invasive, offer a better opportunity to restore a hyaline or hyaline-like cartilage matrix that theoretically better replicates the anatomy and biomechanical characteristics of the native knee joint. Given the unique practice situation of the surgeon cohort being investigated, these trends likely serve as a surrogate measure for evolving practice patterns at institutions with residency and fellowship training programs.
      In recent years, decision making in cartilage surgery has become arguably more complex than any other area of orthopaedic surgery. Cartilage surgery options for symptomatic patients requires careful analysis of the pertinent lesion characteristics, including the size and location of the cartilage lesion, the degree of subchondral bony involvement, and any prior treatment(s), as well as a careful understanding of the patient's goals and expectations. Decision making is not significantly aided by the largely equivocal results reported in well-designed randomized controlled trials,
      • Knutsen G.
      • Drogset J.O.
      • Engebretsen L.
      • et al.
      A randomized multicenter trial comparing autologous chondrocyte implantation with microfracture: Long-term follow-up at 14 to 15 years.
      • Ulstein S.
      • Aroen A.
      • Rotterud J.H.
      • Loken S.
      • Engebretsen L.
      • Heir S.
      Microfracture technique versus osteochondral autologous transplantation mosaicplasty in patients with articular chondral lesions of the knee: A prospective randomized trial with long-term follow-up.
      • Zeifang F.
      • Oberle D.
      • Nierhoff C.
      • Richter W.
      • Moradi B.
      • Schmitt H.
      Autologous chondrocyte implantation using the original periosteum-cover technique versus matrix-associated autologous chondrocyte implantation: A randomized clinical trial.
      further fueling the orthopaedic training mantra that when multiple procedures exist for a given entity, it is because no singular procedure provides consistently great outcomes. Still, it is important for readers to understand that other extraneous factors not reported within the ABOS dataset, namely insurance and payor status, may ultimately dominate the decision-making process. In our experience, it has become more and more common for third-party payors to decline reimbursement for any advanced cartilage restoration procedures, including AOT, OCA, and ACI, unless the patient has failed prior MST. This potentially payor-influenced decision is in conflict with several previously mentioned studies demonstrating inferior long-term outcomes when comparing MST with other cartilage surgery techniques
      • Gudas R.
      • Gudaite A.
      • Pocius A.
      • et al.
      Ten-year follow-up of a prospective, randomized clinical study of mosaic osteochondral autologous transplantation versus microfracture for the treatment of osteochondral defects in the knee joint of athletes.
      • Brittberg M.
      • Recker D.
      • Ilgenfritz J.
      • Saris D.B.F.
      Matrix-applied characterized autologous cultured chondrocytes versus microfracture: Five-year follow-up of a prospective randomized trial.
      • Solheim E.
      • Hegna J.
      • Strand T.
      • Harlem T.
      • Inderhaug E.
      Randomized study of long-term (15-17 years) outcome after microfracture versus mosaicplasty in knee articular cartilage defects.
      and often leaves the patient and treating physician in a difficult situation. The payor influence is not captured by the ABOS dataset, and this makes us question how this may influence decision making for ABOS Part II candidates.
      In conclusion, the investigation by Frank et al.
      • Frank R.M.
      • Cotter E.J.
      • Hannon C.P.
      • Harrast J.J.
      • Cole B.J.
      Cartilage restoration surgery: Incidence rates, complications, and trends as reported by the American Board of Orthopaedic Surgery Part II candidates.
      of recent ABOS Part II candidates demonstrates interesting trends in cartilage surgery. In what has become a fascinatingly complex area within orthopaedics, we interpret their data as an encouraging sign that evidence-based practice is being employed by recent trainees and training institutions teaching cartilage surgery techniques. However, it is important to consider that factors beyond the characteristics of the cartilage lesion and patient in question, including approval and reimbursement by third-party payors, may influence decision making and are not considered within the ABOS dataset and many other datasets frequently used for big data orthopaedic research. Moving forward, it will be increasingly important for physicians performing cartilage surgery to thoughtfully and accurately report the outcomes of these procedures to allow physicians to appropriately treat a heterogenous collection of cartilage lesions within a diverse patient population without undue external pressures.

      Supplementary Data

      References

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        • Cole B.J.
        Cartilage restoration surgery: Incidence rates, complications, and trends as reported by the American Board of Orthopaedic Surgery Part II candidates.
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        Ten-year follow-up of a prospective, randomized clinical study of mosaic osteochondral autologous transplantation versus microfracture for the treatment of osteochondral defects in the knee joint of athletes.
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