Cartilage Repair Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
Sports Medicine Center, Funabashi Orthopaedic Hospital, Funabashi, Chiba, Japan.
Am J Sports Med. 2019 Mar;47(4):837-846. doi: 10.1177/0363546518824600. Epub 2019 Feb 13.
Treating bipolar chondral lesions in the patellofemoral (PF) compartment is a challenging problem. There are few reports available on the treatment of bipolar chondral lesions in the PF compartment.
To evaluate the clinical outcomes and graft survivorship after autologous chondrocyte implantation (ACI) for the treatment of bipolar chondral lesions in the PF compartment.
Case series; Level of evidence, 4.
The authors evaluated 58 patients who had ACI by a single surgeon for the treatment of symptomatic bipolar chondral lesions in the PF compartment between November 1995 and June 2014. All 58 patients (60 knees; mean age, 36.6 years) were included with a minimum 2-year follow-up. The mean ± SD sizes of the patellar and trochlear lesions were 5.6 ± 2.7 cm and 4.2 ± 2.8 cm, respectively. Forty-two patients had osteotomy, as they had PF lateral maltracking, patellar instability, or tibiofemoral malalignment. Patients were evaluated with the modified Cincinnati Knee Rating Scale, Western Ontario and McMaster Universities Osteoarthritis Index, visual analog scale, the 36-Item Short Form Health Survey, and a patient satisfaction survey. Radiographs were evaluated with the Iwano classification.
Overall, the survival rates were 83% and 79% at 5 and 10 years, respectively. Of the 49 (82%) knees with retained grafts, all functional scores significantly improved postoperatively with a very high satisfaction rate (88%) at a mean 8.8 ± 4.2 years after ACI (range, 2-16 years). At the most recent follow-up, 28 of 49 successful knees were radiographically assessed (mean, 4.9 years; range, 2-17 years), with no increase of the Iwano classification in 26 knees. Outcomes for 11 patients were considered failures at a mean 2.9 years. Forty-two knees (70%) required a mean 1.0 subsequent surgical procedure. The primary reasons for chondroplasty were hypertrophy of the ACI graft (17; periosteum in 14, collagen membrane in 3), delamination of the ACI graft (5; periosteum in 4, collagen membrane in 1), and new chondral lesions (3). The best survival rates were observed among patients who underwent ACI with concomitant tibial tubercle osteotomy (TTO) as the first procedure without previous failed TTO and/or marrow stimulation technique (91% at 5 and 10 years), while the worst survival rates were observed among patients who had previous marrow stimulation (43% at 5 and 10 years).
Results demonstrated that ACI with concomitant osteotomy, when it is necessary for the treatment of bipolar/kissing lesions in the PF compartments, gives significant improvement in pain and function, with good survival rates at 5 and 10 years (83% and 79%, respectively). The high patient satisfaction rate is encouraging, and a high survival rate can be expected when ACI with a concomitant TTO is performed at the initial surgery for this difficult condition.
治疗髌股（PF）关节面的双极软骨病变是一个具有挑战性的问题。目前，关于 PF 关节面双极软骨病变治疗的报道很少。
评估自体软骨细胞移植（ACI）治疗 PF 关节面双极软骨病变的临床疗效和移植物存活率。
病例系列；证据等级，4 级。
作者评估了 1995 年 11 月至 2014 年 6 月期间，由同一位外科医生采用 ACI 治疗的 58 例有症状的 PF 关节面双极软骨病变患者。所有 58 例患者（60 膝；平均年龄 36.6 岁）均获得至少 2 年的随访。髌股和滑车病变的平均大小分别为 5.6 ± 2.7 cm 和 4.2 ± 2.8 cm。42 例患者由于 PF 外侧不稳定、髌骨不稳定或胫股对线不良而接受了截骨术。采用改良辛辛那提膝关节评分、西部安大略省和麦克马斯特大学骨关节炎指数、视觉模拟评分、36 项简明健康状况调查和患者满意度调查对患者进行评估。采用 Iwano 分类法对 X 线片进行评估。
总体而言，5 年和 10 年的存活率分别为 83%和 79%。在保留移植物的 49 例（82%）膝关节中，所有功能评分均显著改善，术后患者满意度非常高（88%），ACI 后平均 8.8 ± 4.2 年（2-16 年）。在最近的随访中，28 例成功膝关节的影像学评估（平均 4.9 年；范围 2-17 年），26 例膝关节的 Iwano 分类无增加。11 例患者的结果被认为是失败，平均随访时间为 2.9 年。42 例（70%）膝关节需要平均 1.0 次后续手术。软骨成形术的主要原因是 ACI 移植物的肥大（17 例；骨膜 14 例，胶原膜 3 例）、ACI 移植物的分层（5 例；骨膜 4 例，胶原膜 1 例）和新的软骨病变（3 例）。在接受 ACI 联合胫骨结节截骨术（TTO）作为初始手术且无既往 TTO 失败和/或骨髓刺激技术的患者中，观察到最佳的存活率（5 年和 10 年时分别为 91%），而在既往接受骨髓刺激的患者中，观察到最差的存活率（5 年和 10 年时分别为 43%）。
结果表明，对于 PF 关节面的双极/吻接病变，当需要进行 ACI 联合截骨术治疗时，可显著改善疼痛和功能，5 年和 10 年的存活率分别为 83%和 79%（分别为 83%和 79%）。患者满意度高，令人鼓舞，当这种困难的情况在初始手术中采用 ACI 联合 TTO 时，可以获得较高的存活率。
