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Published on: September 29, 2018
Comparative efficacy of cartilage repair procedures in the knee: a network meta-analysis
Jonathan C Riboh1, Gregory L Cvetanovich2, Brian J Cole2
1Duke University School of Medicine, DUMC Box 3371, Durham, NC, 27710, USA. jriboh@gmail.com.
Purpose:
While numerous randomized controlled trials have compared surgical treatments for cartilage defects of the knee, the comparative efficacy of these treatments is still poorly understood. The goal of this network meta-analysis was to synthesize these randomized data into a comprehensive model allowing pairwise comparisons of all treatment options and treatment rankings based on multiple measures of efficacy. We hypothesized that advanced chondral procedures would have improved outcomes when compared to microfracture.
Methods:
The MEDLINE, COCHRANE and EMBASE databases were searched systematically up to January 2015. The primary outcome was re-operation measured at 2, 5 and 10 years. Secondary outcomes included Tegner and Lysholm scores, the presence of hyaline cartilage on post-operative biopsy and graft hypertrophy. A random-effects network meta-analysis was performed, and the results are presented as odds ratios and mean differences with 95 % CIs. We ranked the comparative effects of all treatments with surface under the cumulative ranking probabilities.
Results:
Nineteen RCT from 15 separate cohorts including 855 patients were eligible for inclusion. No differences were seen in re-operation rates at 2 years. At 5 years osteochondral autografts (OC Auto) had a lower re-operation rate than microfracture (OR 0.03, 95 % CI 0.00-0.49), and at 10 years OC Auto had a lower re-operation rate than microfracture (OR 0.34, 95 % CI 0.12-0.92), but a higher re-operation rate than second-generation ACI (OR 5.81, 95 % CI 2.33-14.47). No significant differences in Tegner or Lysholm scores were seen at 2 years. Functional outcome data at 5 and 10 years were not available. Hyaline repair tissue was more common with OC Auto (OR 16.13, 95 % CI 2.80-92.91) and 2nd generation ACI (OR 7.69, 95 % CI 1.17-50) than microfracture, though the clinical significance of this is unknown. Second-generation ACI (OR 0.12, 95 % CI 0.02-0.59) and MACI (OR 0.13, 95 % CI 0.03-0.59) had significantly lower rates of graft hypertrophy than first-generation ACI. Second-generation ACI, OC Auto and MACI were the highest ranked treatments (in order) when all outcome measures were included.
Conclusions:
Microfracture and advanced cartilage repair techniques have similar re-operation rates and functional outcomes at 2 years. However, advanced repair techniques provide higher-quality repair tissue and might afford lower re-operation rates at 5 and 10 years.
Level Of Evidence:
Meta-analysis studies, Level I.
Insights
Advanced cartilage repair techniques show similar short-term outcomes to microfracture but offer better long-term results and tissue quality. These advanced methods may reduce re-operation rates over time for knee cartilage defects.
Area of Science:
- Orthopedic surgery
- Regenerative medicine
- Biomaterials science
Background:
- Knee cartilage defects are common and challenging to treat.
- Numerous surgical options exist, but comparative efficacy is unclear.
- Microfracture is a common but potentially suboptimal treatment.
Purpose of the Study:
- To conduct a network meta-analysis comparing surgical treatments for knee cartilage defects.
- To rank treatments based on efficacy measures including re-operation rates and functional scores.
- To evaluate if advanced chondral procedures outperform microfracture.
Main Methods:
- Systematic search of MEDLINE, COCHRANE, and EMBASE databases up to January 2015.
- Included 19 randomized controlled trials (RCTs) with 855 patients.
- Performed random-effects network meta-analysis, assessing re-operation rates, functional scores, hyaline cartilage presence, and graft hypertrophy.
Main Results:
- No significant differences in re-operation or functional scores at 2 years.
- Osteochondral autografts (OC Auto) showed lower re-operation rates than microfracture at 5 and 10 years.
- Advanced techniques like OC Auto and second-generation autologous chondrocyte implantation (ACI) produced higher-quality repair tissue.
Conclusions:
- Microfracture and advanced cartilage repair show comparable 2-year outcomes.
- Advanced techniques may offer reduced re-operation rates and improved tissue quality at 5 and 10 years.
- Second-generation ACI, OC Auto, and MACI were ranked highest overall.
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