Surgical treatment options (microfracture, drilling, mosaicplasty, and allograft transplantation) for cartilage injuries of the knee in adults

What is the medical problem?

The layer of cartilage covering the knee joint surfaces helps protect the joint and reduce friction during movement. Cartilage injuries of the knee in adults can result from trauma, such as during sport, or from a cartilage disease (osteochondritis). If left untreated, cartilage injuries do not mend by themselves and can lead to significant destruction of the joint (osteoarthritis).

What treatments are available?

A number of treatment options are available for cartilage injuries but are often aimed at treating symptoms such as pain rather than providing a cure. Non-surgical methods, such as physical therapy, may relieve symptoms but cannot heal cartilage injuries. Microfracture, drilling, mosaicplasty, and allograft transplantation are increasingly available surgical treatments that attempt to preserve the joint.

What are microfracture, drilling, mosaicplasty, and allograft transplantation?

Microfracture and drilling are minimally invasive surgeries (key hole surgery) that promote bleeding from the bone to create a clot in the cartilage defect. This can then form a tissue similar to cartilage. Mosaicplasty is an osteochondral transplant in which tissue is harvested from a less-demanding area of the knee to cover a cartilage defect in a more important area. Allograft transplantation treatment uses tissue harvested from fresh cadavers to cover only the injured area.

Which of these surgical techniques works better in practice?

This review examines the evidence from randomised controlled trials that compared two or more of these surgical methods in clinical practice.

We searched a number of medical databases up to February 2016 and found three studies that compared mosaicplasty versus microfracture. These studies reported results for a total of 133 participants, the majority of whom were young adults and male. No trials of allograft transplantation or drilling were identified.

One study conducted at a single centre found better patient-reported function after mosaicplasty at 1, 2, 3, and 10 years follow-up. However, the other studies did not find a difference in function (two studies), pain (one study) or activities of daily living (one study) between mosaicplasty and microfracture in the long term (6 to 10 years follow-up). Treatment failure, with recurrence of symptoms, occurred with both procedures. Data pooled from the three trials showed half as many people had treatment failure in the mosaicplasty group. However, more evidence is required to test whether this is a true finding. The evidence regarding activity levels in the long term was inconclusive.

We considered that all the evidence for these outcomes was very low quality. This means that we are unsure of these results, which are likely to change when more evidence becomes available.

Conclusions

The currently available evidence is not enough to conclude whether mosaicplasty or microfracture is better for treating isolated cartilage defects of the knee in adults. Treatment failure occurred with both methods. Further research is needed to define the best surgical option for treating isolated cartilage defects.

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.

Read the full abstract...
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 strategy: 

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.

Share/Save