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The Working Group of the German Orthopedic and Trauma Society (DGOU) on Tissue Regeneration has published recommendations on the indication of different surgical approaches for treatment of full-thickness cartilage defects in the knee joint in 2004, 2013 and 2016. Based upon new scientific knowledge and new developments, this recommendation is an update based upon the best clinical evidence available. In addition to prospective randomised controlled clinical trials, this also includes studies with a lower level of evidence. In the absence of evidence, the decision is based on a consensus process within the members of the working group.The principle of making decision dependent on defect size has not been changed in the new recommendation either. The indication for arthroscopic microfracturing has been reduced up to a defect size of 2 cm 2 maximum, while autologous chondrocyte implantation is the method of choice for larger cartilage defects. Additionally, matrix-augmented bone marrow stimulation (mBMS) has been included in the recommendation for defects ranging from 1 to 4.5 cm 2 . For the treatment of smaller osteochondral defects, in addition to osteochondral transplantation (OCT), mBMS is also recommended. For larger defects, matrix-augmented autologous chondrocyte implantation (mACI/mACT) in combination with augmentation of the subchondral bone is recommended., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Objectives: Knee cartilage damage is a common cause of referral for orthopedic surgery. Treatment aims to reduce pain and symptoms by repairing cartilage. Microfracture, the current standard of care, yields good short-term clinical outcomes; however, treatment might fail after 2-3 years. A Chitosan-Beta glycerolphosphate-based medical device (BST-CarGel) is used as an adjunct to microfracture and demonstrates improvements in quantity and quality of repaired tissue, potentially reducing the risk of treatment failure. This study aimed to establish the economic value of BST-CarGel vs microfracture alone in knee cartilage repair from the societal perspective, using Germany as the reference market., Methods: A decision tree with a 20-year time-horizon was constructed, in which undesirable clinical events were inferred following initial surgery. These events consisted of pain management, surgery, and total knee replacement. Clinical outcomes were taken from the pivotal clinical trial, supplemented by other literature. Data and assumptions were validated by a Delphi panel. All relevant resource use and costs for procedures and events were considered., Results: In a group of patients with all lesion sizes, the model inferred that BST-CarGel yields a positive return on investment at year 4 (with 20-year cumulative cost savings of €6448). Reducing the incremental risk of treatment failure gap between the device and microfracture by 25-50% does not alter this conclusion. Cost savings are greatest for patients with large lesions; results for patients with small lesions are more modest., Limitations: Clinical evidence for microfracture and other interventions varies in quality. Comparative long-term data are lacking. The comparison is limited to microfracture and looks only at costs without considering quality-of-life., Conclusion: BST-CarGel potentially represents a cost-saving alternative for patients with knee cartilage injury by reducing the risk of clinical events through regeneration of chondral tissue with hyaline characteristics. Since the burden of this condition is high, both to the patient and society, an effective and economically viable alternative is of importance.

Purpose: Although traumatic osteochondral fractures of the knee represent a common pathology of the knee joint, there is no general agreement concerning specific treatment of this entity. This meta-analysis was initiated in order to evaluate scientific evidence on different treatment options for acute osteochondral fractures of the knee., Methods: For this purpose an OVID-based systematic literature search was performed including the following databases: MEDLINE, MEDLINE preprints, Embase, CINAHL, Life Science Citations, British National Library of Health and Cochrane Central Register of Controlled Trials. The literature search period was from 1946 to January 2012, which led to the identification of 1,226 articles. After applying study-specific inclusion criteria a total of 19 studies with clinical follow-up of 638 patients were included. The methodology of these studies was systematically analysed by means of the Coleman Methodology Score. Outcome and success rates were evaluated depending on treatment applied., Results: All studies (n = 19) identified represent case series (evidence-based medicine level IV) and included a total of 638 patients. The average post-operative follow-up was 46 ± 27 months (range 3.75-108). The mean number of study subjects per study was 33 ± 44 patients (range 4-169). The average Coleman Methodology Score was 29 ± 17 points (range 5-72). Six different scoring systems were used for clinical assessment. The overall clinical success rate was 83% and varied between 45 and 100%., Conclusions: This meta-analysis reveals a significant lack of scientific evidence for treatment of osteochondral fractures of the knee. No valid conclusion can be drawn from this study concerning the recommendation of a specific treatment algorithm. Nevertheless, the overall failure rate of 17% underlines that an acute osteochondral fracture of the knee represents an important pathology which is not a self-limiting injury and needs further investigation.

Autologous chondrocyte transplantation/implantation (ACT/ACI) is an established and recognised procedure for the treatment of localised full-thickness cartilage defects of the knee. The present review of the working group "Clinical Tissue Regeneration" of the German Society of Orthopaedics and Traumatology (DGOU) describes the biology and function of healthy articular cartilage, the present state of knowledge concerning potential consequences of primary cartilage lesions and the suitable indication for ACI. Based on current evidence, an indication for ACI is given for symptomatic cartilage defects starting from defect sizes of more than 3-4 cm2; in the case of young and active sports patients at 2.5 cm2. Advanced degenerative joint disease is the single most important contraindication. The review gives a concise overview on important scientific background, the results of clinical studies and discusses advantages and disadvantages of ACI., (Georg Thieme Verlag KG Stuttgart · New York.)

Retropatellar cartilage defects treated with autologous chondrocyte implantation (ACI) are still associated with inferior clinical outcome compared to defects being located on the femoral condyles. This is partly because of the biomechanical characteristics of the patellofemoral section of the joint, in which, in contrast to the medial or lateral compartments of the knee joint, prejudicial shearing forces are dominant. The patellar ridge has a particularly important role in the reduction of these shearing forces. The double eye technique was developed as a modification of ACI with preserving the important patellar ridge for the treatment of retropatellar cartilage defects extending beyond the patellar ridge and involving the medial and lateral retropatellar facets. This technique provides for a separate reconstruction of the medial and the lateral facets by means of ACI, but the ridge region is preserved to maintain the original thickness of cartilage at this point. The present paper describes the "double eye" technique as a modification of autologous chondrocyte transplantation (ACI) for treatment of cartilage defects of the patella, that involve both lateral and medial facets, and gives first clinical results of 11 patients. The average follow-up was 41.6 (+/-15.0) months, and the average age at diagnosis was 40.4 (+/-10.1) years. The Lysholm score, the subjective IKDC score, and the ICRS score were the instruments used to measure the outcome. This paper focuses on the introduction of the double eye technique with preservation of the patella ridge in the treatment of retropatellar cartilage lesion. Nevertheless, first clinical results of 11 patients are given, with an average Lysholm score of 75 (+/-14) points and an average subjective IKDC score of 60 (+/-14). Objective evaluation according to the criteria of the IKDC score showed very good or good treatment results in 9 of the 11 cases, with only 2 poor results. In conclusion, with the double eye modification presented in this paper, the potential for successful results in the treatment of combined cartilage defects of the medial and lateral facets of the patella is high; it takes into account the specific biomechanical properties of the patella ridge. The procedure needs further evaluation in clinical studies involving larger numbers of patients so that the indications can be determined more precisely.

Introduction: Most of all osteochondral talar lesions are located in the middle and posterior area of the talar surface. Malleolar osteotomy is often used to access the defect but may be associated with malunion or secondary osteoarthritis. We present an alternative approach to the talus with temporary removal and replacement of a tibial bone block and compare it with other anterior approaches described in the literature., Patients and Methods: Thirteen patients (5 males, 8 females) with an average age of 27.2 years and an osteochondral talar lesion were included in our study. All patients were previously operated on the same ankle. Ten lesions were caused by a sports injury. The average follow up was 45 months. The patients were evaluated before and after surgery using the ankle and hindfood score (AOFAS). For the analyses baseline clinical data were compared with follow up data using the Wilcoxon test., Results: The overall improvement between the preoperative and postoperative AOFAS scores was an average of 34.9 points (P=0.0002). No complications occurred at the site of the tibial bone block and the donor site at the talus. There were no patients with recurrence or an ankle osteoarthrosis in the follow up period., Conclusion: The removal of a tibial bone block and its subsequent replacement is a useful technique to access osteochondral talar lesions for osteochondral transplantation for which arthroscopic interventions have failed. The results are comparable to other anterior approaches described in the literature.