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Review
. 2021 Oct 15;9(10):23259671211031244.
doi: 10.1177/23259671211031244. eCollection 2021 Oct.

A Systematic Review of Focal Cartilage Defect Treatments in Middle-Aged Versus Younger Patients

Ralph M Jeuken  1 , Pieter P W van Hugten  1 , Alex K Roth  1 , Ufuk Tan Timur  1 , Tim A E J Boymans  1 , Lodewijk W van Rhijn  1 , William D Bugbee  2 , Pieter J Emans  1
Affiliations
Review

A Systematic Review of Focal Cartilage Defect Treatments in Middle-Aged Versus Younger Patients

Ralph M Jeuken et al. Orthop J Sports Med. .

Abstract

Background: Focal cartilage defects are often debilitating, possess limited potential for regeneration, are associated with increased risk of osteoarthritis, and are predictive for total knee arthroplasty. Cartilage repair studies typically focus on the outcome in younger patients, but a high proportion of treated patients are 40 to 60 years of age (ie, middle-aged). The reality of current clinical practice is that the ideal patient for cartilage repair is not the typical patient. Specific attention to cartilage repair outcomes in middle-aged patients is warranted.

Purpose: To systematically review available literature on knee cartilage repair in middle-aged patients and include studies comparing results across different age groups.

Study design: Systematic review; Level of evidence, 4.

Methods: A systematic search was performed in EMBASE, MEDLINE, and the Cochrane Library database. Articles were screened for relevance and appraised for quality.

Results: A total of 21 articles (mean Coleman Methodology Score, 64 points) were included. Two out of 3 bone marrow stimulation (BMS) studies, including 1 using the microfracture technique, revealed inferior clinical outcomes in middle-aged patients in comparison with younger patients. Nine cell-based studies were included showing inconsistent comparisons of results across age groups for autologous chondrocyte implantation (ACI). Bone marrow aspirate concentrate showed age-independent results at up to 8 years of follow-up. A negative effect of middle age was reported in 1 study for both ACI and BMS. Four out of 5 studies on bone-based resurfacing therapies (allografting and focal knee resurfacing implants [FKRIs]) showed age-independent results up to 5 years. One study in only middle-aged patients reported better clinical outcomes for FKRIs when compared with biological repairs.

Conclusion: Included studies were heterogeneous and had low methodological quality. BMS in middle-aged patients seems to only result in short-term improvements. More research is warranted to elucidate the ameliorating effects of cell-based therapies on the aging joint homeostasis. Bone-based therapies seem to be relatively insensitive to aging and may potentially result in effective joint preservation. Age subanalyses in cohort studies, randomized clinical trials, and international registries should generate more evidence for the large but underrepresented (in terms of cartilage repair) middle-aged population in the literature.

Keywords: bone marrow stimulation; bone-based; cartilage; cell-based; middle-aged; repair.

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Conflict of interest statement

One or more of the authors has declared the following potential conflict of interest or source of funding: W.D.B. has received consulting fees from JRF Ortho and Arthrex. P.J.E. has received consulting fees from Episurf and KioMed. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Figures

Figure 1.
Figure 1.
PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flowchart showing the yield of the initial search and exclusion of studies leading to the 21 included studies.
See this image and copyright information in PMC

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