Original Research

Reoperation Rates After Cartilage Restoration Procedures in the Knee: Analysis of a Large US Commercial Database

Publish date: June 4, 2018

References

Farr J, Cole B, Dhawan A, Kercher J, Sherman S. Clinical cartilage restoration: evolution and overview. Clin Orthop Relat Res. 2011;469(10):2696-2705. doi:10.1007/s11999-010-1764-z.
Alford JW, Cole BJ. Cartilage restoration, part 1: basic science, historical perspective, patient evaluation, and treatment options. Am J Sports Med. 2005;33(2):295-306. doi:10.1177/03635465004273510.
Alford JW, Cole BJ. Cartilage restoration, part 2: techniques, outcomes, and future directions. Am J Sports Med. 2005;33(3):443-460. doi:10.1177/0363546505274578.
Gudas R, Gudaitė A, Pocius A, et al. Ten-year follow-up of a prospective, randomized clinical study of mosaic osteochondral autologous transplantation versus microfracture for the treatment of osteochondral defects in the knee joint of athletes. Am J Sports Med. 2012;40(11):2499-2508. doi:10.1177/0363546512458763.
Saris DBF, Vanlauwe J, Victor J, et al. Treatment of symptomatic cartilage defects of the knee: characterized chondrocyte implantation results in better clinical outcome at 36 months in a randomized trial compared to microfracture. Am J Sports Med. 2009;37(suppl 1):10-19. doi:10.1177/0363546509350694.
McCormick F, Harris JD, Abrams GD, et al. Survival and reoperation rates after meniscal allograft transplantation: analysis of failures for 172 consecutive transplants at a minimum 2-year follow-up. Am J Sports Med. 2014;42(4):892-897. doi:10.1177/0363546513520115.
Miller DJ, Smith MV, Matava MJ, Wright RW, Brophy RH. Microfracture and osteochondral autograft transplantation are cost-effective treatments for articular cartilage lesions of the distal femur. Am J Sports Med. 2015;43(9):2175-2181. doi:10.1177/0363546515591261.
Campbell AB, Pineda M, Harris JD, Flanigan DC. Return to sport after articular cartilage repair in athletes' knees: a systematic review. Arthroscopy. 2016;32(4):651-668.
Chalmers PN, Vigneswaran H, Harris JD, Cole BJ. Activity-related outcomes of articular cartilage surgery: a systematic review. Cartilage. 2013;4(3):193-203.
Bentley G, Biant LC, Vijayan S, Macmull S, Skinner JA, Carrington RW. Minimum ten-year results of a prospective randomised study of autologous chondrocyte implantation versus mosaicplasty for symptomatic articular cartilage lesions of the knee. JBone Joint Surg Br. 2012;94(4):504-509. doi:10.1177/1947603513481603.
Beris AE, Lykissas MG, Kostas-Agnantis I, Manoudis GN. Treatment of full-thickness chondral defects of the knee with autologous chondrocyte implantation: a functional evaluation with long-term follow-up. Am J Sports Med. 2012;40(3):562-567.
Chahal J, Gross AE, Gross C, et al. Outcomes of osteochondral allograft transplantation in the knee. Arthroscopy. 2013;29(3):575-588. doi:10.1177/0363546511428778.
Emmerson BC, Görtz S, Jamali AA, Chung C, Amiel D, Bugbee WD. Fresh osteochondral allografting in the treatment of osteochondritis dissecans of the femoral condyle. Am J Sports Med. 2007;35(6):907-914. doi:10.1177/0363546507299932.
Gudas R, Stankevičius E, Monastyreckienė E, Pranys D, Kalesinskas R. Osteochondral autologous transplantation versus microfracture for the treatment of articular cartilage defects in the knee joint in athletes. Knee Surg Sports Traumatol Arthrosc. 2006;14(9):834-842. doi:10.1007/s00167-006-0067-0.
Lynch TS, Patel RM, Benedick A, Amin NH, Jones MH, Miniaci A. Systematic review of autogenous osteochondral transplant outcomes. Arthroscopy. 2015;31(4):746-754. doi:10.1016/j.arthro.2014.11.018.
Niemeyer P, Porichis S, Steinwachs M, et al. Long-term outcomes after first-generation autologous chondrocyte implantation for cartilage defects of the knee. Am J Sports Med. 2014;42(1):150-157. doi:10.1177/0363546513506593.
Ulstein S, Årøen A, Røtterud J, Løken S, Engebretsen L, Heir S. Microfracture technique versus osteochondral autologous transplantation mosaicplasty in patients with articular chondral lesions of the knee: a prospective randomized trial with long-term follow-up. Knee Surg Sports Traumatol Arthrosc. 2014;22(6):1207-1215. doi:10.1007/s00167-014-2843-6.
Montgomery S, Foster B, Ngo S, et al. Trends in the surgical treatment of articular cartilage defects of the knee in the United States. Knee Surg Sports Traumatol Arthrosc. 2014;22(9):2070-2075. doi:10.1007/s00167-013-2614-9.
Salzmann GM, Sah B, Südkamp NP, Niemeyer P. Reoperative characteristics after microfracture of knee cartilage lesions in 454 patients. Knee Surg Sports Traumatol Arthrosc. 2013;21(2):365-371. doi:10.1007/s00167-012-1973-y.
Mithoefer K, McAdams T, Williams RJ, Kreuz PC, Mandelbaum BR. Clinical efficacy of the microfracture technique for articular cartilage repair in the knee: an evidence-based systematic analysis. Am J Sports Med. 2009;37(10):2053-2063. doi:10.1177/0363546508328414.
Wajsfisz A, Makridis KG, Djian P. Arthroscopic retrograde osteochondral autograft transplantation for cartilage lesions of the tibial plateau: a prospective study. Am J Sports Med. 2013;41(2):411-415. doi:10.1177/0363546512469091.
Harris JD, Siston RA, Brophy RH, Lattermann C, Carey JL, Flanigan DC. Failures, re-operations, and complications after autologous chondrocyte implantation–a systematic review. Osteoarthritis Cartilage. 2011;19(7):779-791. doi:10.1016/j.joca.2011.02.010.
Abrams GD, Frank RM, Gupta AK, Harris JD, McCormick FM, Cole BJ. Trends in meniscus repair and meniscectomy in the United States, 2005-2011. Am J Sports Med. 2013;41(10):2333-2339. doi:10.1177/0363546513495641.
Montgomery SR, Ngo SS, Hobson T, et al. Trends and demographics in hip arthroscopy in the United States. Arthroscopy. 2013;29(4):661-665. doi:10.1016/j.arthro.2012.11.005.
Yeranosian MG, Arshi A, Terrell RD, Wang JC, McAllister DR, Petrigliano FA. Incidence of acute postoperative infections requiring reoperation after arthroscopic shoulder surgery. Am J Sports Med. 2014;42(2):437-441. doi:10.1177/0363546513510686.
Zhang AL, Montgomery SR, Ngo SS, Hame SL, Wang JC, Gamradt SC. Arthroscopic versus open shoulder stabilization: current practice patterns in the United States. Arthroscopy. 2014;30(4):436-443. doi:10.1016/j.arthro.2013.12.013.
Werner BC, Carr JB, Wiggins JC, Gwathmey FW, Browne JA. Manipulation under anesthesia after total knee arthroplasty is associated with an increased incidence of subsequent revision surgery. J Arthroplasty. 2015;30(suppl 9):72-75. doi:10.1016/j.arth.2015.01.061.
Carr JB 2nd, Werner BC, Browne JA. Trends and outcomes in the treatment of failed septic total knee arthroplasty: comparing arthrodesis and above-knee amputation. J Arthroplasty. 2016;31(7):1574-1577. doi:10.1016/j.arth.2016.01.010.

STATISTICAL ANALYSIS

Statistical analysis of this study was primarily descriptive to demonstrate the incidence for each code at each time interval. One-way analysis of variance, Chi-square analysis, and contingency tables were used to compare the incidence of each type of procedure throughout the various time intervals. A P-value of < 0.05 was considered statistically significant. Statistical analysis was performed using SPSS v.20 (International Business Machines).

RESULTS

A total of 47,207 cartilage procedures were performed from 2007 to 2011, including 43,576 MFX (92.3%) 640 ACI (1.4%), 386 open OATS (0.82%), 997 arthroscopic OATS (2.11%), 714 open OCA (1.51%), and 894 arthroscopic OCA (1.89%) procedures. A summary of the procedures performed, broken down by age and sex, is provided in Tables 1 and 2. A total of 25,149 male patients (53.3%) underwent surgical procedures compared to 22,058 female patients (46.7%). For each category of procedure (MFX, ACI, OATS, OCA), there was a significantly higher proportion of males than females undergoing surgery (P < .0001 for all). Surgical treatment with MFX was consistently the most frequently performed surgery across all age groups (92.31%), while cell-based therapy with ACI was the least frequently performed procedure across all age ranges (1.36%). Restorative OATS and OCA techniques were performed with the greatest frequency in the 15-year-old to 19-year-old age group, but were not utilized in patients over 64 years of age (Table 2).

Table 2. Breakdown of MFX, ACI, OATS, and OCA Procedures by Age
Age (y)	MFX	ACI	OATS	OCA
10 to 14	572	22	74	47
15 to 19	1984	83	254	235
20 to 24	1468	54	140	144
25 to 29	1787	74	152	176
30 to 34	2824	114	152	204
35 to 39	4237	96	153	210
40 to 44	5441	103	166	217
45 to 49	7126	57	149	180
50 to 54	7004	25	83	140
55 to 59	6410	12	40	40
60 to 64	4409	0	20	15
65 to 69	269	0	0	0
70 to 74	45	0	0	0
Total	43,576	640	1383	1608

Abbreviations: ACI, autologous chondrocyte implantation; MFX, microfracture; OCA, osteochondral allograft; OATS, osteochondral autograft transplantation.

A summary of all reoperation data is provided in Tables 3 to 7 and Figures 1 and 2. The weighted average reoperation rates for all procedures were 5.87% at 90 days, 11.94% at 1 year, and 14.90% at 2 years following the index cartilage surgery. Patients who underwent MFX had reoperation rates of 6.05% at 90 days, 11.80% at 1 year, and 14.65% at 2 years. Patients who underwent ACI had reoperation rates of 4.53% at 90 days, 23.28% at 1 year, and 29.69% at 2 years. Patients who had open and arthroscopic OATS had reoperation rates of 3.122% and 5.12% at 90 days, 6.74% and 8.53% at 1 year, and 7.51% and 10.13% at 2 years, respectively. Patients who underwent open and arthroscopic OCA had reoperation rates of 2.52% and 3.91% at 90 days, 7.14% and 6.60% at 1 year, and 13.59% and 10.85% at 2 years (Table 3). There was a statistically significantly increased risk for reoperation following ACI within all intervals compared to all other surgical techniques (P < .0001); however, MFX had a greater risk factor (P < .0001) for conversion to arthroplasty at 6.70%. There was no significant difference between failure rates (revision OATS/OCA or conversion to arthroplasty) between the restorative treatment options, with 14 failures for OATS (9.52% of reoperations at 2 years) compared to 22 failures for OCA (12.7% of reoperations at 2 years, P = .358). Among the entire cohort of cartilage surgery patients, arthroscopic chondroplasty was the most frequent procedure performed at the time of reoperation at all time points assessed, notably accounting for 33.08% of reoperations 2 years following microfracture, 51.58% of reoperations at 2 years following ACI, 53.06% of reoperations at 2 years following OATS, and 54.07% of reoperations at 2 years following OCA (Figure 3, Tables 4–7).

Table 3. Comparison of Return to OR Following MFX, ACI, OCA, and OATS
Procedure	Total No. of Cases in Study Period	No. of Reoperations at 90 Days	Return to OR Rate at 90 Days	No. of Reoperations at 1 Year	Return to OR Rate at 1 Year	No. of Reoperations at 2 Years	Return to OR Rate at 2 Years
MFX	43,576	2636	6.05%	5142	11.80%	6385	14.65%
ACI	640	29	4.53%	149	23.28%	190	29.69%
Open OATS	386	12	3.12%	26	6.74%	29	7.51%
Arthroscopic OATS	997	51	5.12%	85	8.53%	101	10.13%
Open OCA	714	18	2.52%	51	7.14%	97	13.59%
Arthroscopic OCA	894	161	3.91%	59	6.60%	97	10.85%
Weighted average for all procedures			5.87%		11.94%		14.90%

Abbreviations: ACI, autologous chondrocyte implantation; MFX, microfracture; OCA, osteochondral allograft; OATS, osteochondral autograft transplantation; OR, operating room.

Table 4. Rate of Return to OR Following MFX (n = 43,574)
Procedure	*CPT* Code	90 Days	1 Year	2 Years
Knee arthroscopy	29870	54	122	162
Knee arthroscopic drainage and lavage	29871	84	102	104
Arthroscopic adhesions débridement	29874	300	468	549
Arthroscopic synovectomy	29875	324	528	611
Major arthroscopic synovectomy	29876	557	926	1087
Knee arthroscopic chondroplasty	29877	1063	1722	2112
Arthroscopic lysis of adhesions	29884	61	129	171
Patellar arthroplasty	27438	0	38	49
Medial or lateral knee arthroplasty	27446	51	242	328
Medial and lateral knee arthroplasty	27447	142	865	1212
Total		2636	5142	6385
Return to OR		6.05%	11.80%	14.65%

Abbreviations: CPT, Current Procedural Terminology; MFX, microfracture; OR, operating room.

Table 5. Rate of Return to OR Following ACI (n = 640)
Procedure	*CPT* Code	90 Days^a	1 Year^a	2 Years^a
Revision ACI	27412	29	33	35
Knee arthroscopy	29870	-1	-1	-1
Knee arthroscopic drainage and lavage	29871	-1	-1	-1
Arthroscopic adhesions débridement	29874	0	-1	-1
Arthroscopic synovectomy	29875	-1	-1	-1
Major arthroscopic synovectomy	29876	-1	12	20
Knee arthroscopic chondroplasty	29877	-1	71	98
Arthroscopic lysis of adhesions	29884	-1	33	37
Patellar arthroplasty	27438	0	0	0
Medial or lateral knee arthroplasty	27446	0	-1	-1
Medial and lateral knee arthroplasty	27447	0	-1	-1
Total		29	149	190
Return to OR		4.53%	23.28%	29.69%

^aA -1 denotes No. <11 within the PearlDiver database, and exact numbers are not reported due to patient privacy considerations.

Abbreviations: ACI, autologous chondrocyte implantation; CPT, Current Procedural Terminology; OR, operating room.

Table 6. Rate of Return to OR Following OATS (n = 1320)
Procedure	*CPT* Code	90 Days	1 Year	2 Years
Knee arthroscopy	29870	0	0	0
Knee arthroscopic drainage and lavage	29871	0	0	0
Arthroscopic adhesions débridement	29874	0	12	13
Arthroscopic synovectomy	29875	0	0	14
Major arthroscopic synovectomy	29876	16	25	28
Knee arthroscopic chondroplasty	29877	17	58	78
Arthroscopic lysis of adhesions	29884	0	0	0
Patellar arthroplasty	27438	0	0	0
Medial or lateral knee arthroplasty	27446	0	0	0
Medial and lateral knee arthroplasty	27447	0	0	14
Total		33	95	147
Return to OR		2.50%	7.20%	11.14%

Abbreviations: CPT, Current Procedural Terminology; OATS, osteochondral autograft transplantation; OR, operating room.

Table 7. Rate of Return to OR Following OCA Transplantation (n = 1531)
Procedure	*CPT* Code	90 Days	1 Year	2 Year
Knee arthroscopy	29870	0	0	0
Knee arthroscopic drainage and lavage	29871	0	0	0
Arthroscopic adhesions débridement	29874	0	15	19
Arthroscopic synovectomy	29875	0	0	0
Major arthroscopic synovectomy	29876	0	20	38
Knee arthroscopic chondroplasty	29877	22	59	93
Arthroscopic lysis of adhesions	29884	0	0	0
Patellar arthroplasty	27438	0	0	0
Medial or lateral knee arthroplasty	27446	0	0	0
Medial and lateral knee arthroplasty	27447	0	0	22
Total		22	94	172
Return to OR		1.44%	6.14%	11.23%

Abbreviations: CPT, Current Procedural Terminology; OCA, osteochondral allograft; OR, operating room.

Continue to: Discussion...

References

Farr J, Cole B, Dhawan A, Kercher J, Sherman S. Clinical cartilage restoration: evolution and overview. Clin Orthop Relat Res. 2011;469(10):2696-2705. doi:10.1007/s11999-010-1764-z.
Alford JW, Cole BJ. Cartilage restoration, part 1: basic science, historical perspective, patient evaluation, and treatment options. Am J Sports Med. 2005;33(2):295-306. doi:10.1177/03635465004273510.
Alford JW, Cole BJ. Cartilage restoration, part 2: techniques, outcomes, and future directions. Am J Sports Med. 2005;33(3):443-460. doi:10.1177/0363546505274578.
Gudas R, Gudaitė A, Pocius A, et al. Ten-year follow-up of a prospective, randomized clinical study of mosaic osteochondral autologous transplantation versus microfracture for the treatment of osteochondral defects in the knee joint of athletes. Am J Sports Med. 2012;40(11):2499-2508. doi:10.1177/0363546512458763.
Saris DBF, Vanlauwe J, Victor J, et al. Treatment of symptomatic cartilage defects of the knee: characterized chondrocyte implantation results in better clinical outcome at 36 months in a randomized trial compared to microfracture. Am J Sports Med. 2009;37(suppl 1):10-19. doi:10.1177/0363546509350694.
McCormick F, Harris JD, Abrams GD, et al. Survival and reoperation rates after meniscal allograft transplantation: analysis of failures for 172 consecutive transplants at a minimum 2-year follow-up. Am J Sports Med. 2014;42(4):892-897. doi:10.1177/0363546513520115.
Miller DJ, Smith MV, Matava MJ, Wright RW, Brophy RH. Microfracture and osteochondral autograft transplantation are cost-effective treatments for articular cartilage lesions of the distal femur. Am J Sports Med. 2015;43(9):2175-2181. doi:10.1177/0363546515591261.
Campbell AB, Pineda M, Harris JD, Flanigan DC. Return to sport after articular cartilage repair in athletes' knees: a systematic review. Arthroscopy. 2016;32(4):651-668.
Chalmers PN, Vigneswaran H, Harris JD, Cole BJ. Activity-related outcomes of articular cartilage surgery: a systematic review. Cartilage. 2013;4(3):193-203.
Bentley G, Biant LC, Vijayan S, Macmull S, Skinner JA, Carrington RW. Minimum ten-year results of a prospective randomised study of autologous chondrocyte implantation versus mosaicplasty for symptomatic articular cartilage lesions of the knee. JBone Joint Surg Br. 2012;94(4):504-509. doi:10.1177/1947603513481603.
Beris AE, Lykissas MG, Kostas-Agnantis I, Manoudis GN. Treatment of full-thickness chondral defects of the knee with autologous chondrocyte implantation: a functional evaluation with long-term follow-up. Am J Sports Med. 2012;40(3):562-567.
Chahal J, Gross AE, Gross C, et al. Outcomes of osteochondral allograft transplantation in the knee. Arthroscopy. 2013;29(3):575-588. doi:10.1177/0363546511428778.
Emmerson BC, Görtz S, Jamali AA, Chung C, Amiel D, Bugbee WD. Fresh osteochondral allografting in the treatment of osteochondritis dissecans of the femoral condyle. Am J Sports Med. 2007;35(6):907-914. doi:10.1177/0363546507299932.
Gudas R, Stankevičius E, Monastyreckienė E, Pranys D, Kalesinskas R. Osteochondral autologous transplantation versus microfracture for the treatment of articular cartilage defects in the knee joint in athletes. Knee Surg Sports Traumatol Arthrosc. 2006;14(9):834-842. doi:10.1007/s00167-006-0067-0.
Lynch TS, Patel RM, Benedick A, Amin NH, Jones MH, Miniaci A. Systematic review of autogenous osteochondral transplant outcomes. Arthroscopy. 2015;31(4):746-754. doi:10.1016/j.arthro.2014.11.018.
Niemeyer P, Porichis S, Steinwachs M, et al. Long-term outcomes after first-generation autologous chondrocyte implantation for cartilage defects of the knee. Am J Sports Med. 2014;42(1):150-157. doi:10.1177/0363546513506593.
Ulstein S, Årøen A, Røtterud J, Løken S, Engebretsen L, Heir S. Microfracture technique versus osteochondral autologous transplantation mosaicplasty in patients with articular chondral lesions of the knee: a prospective randomized trial with long-term follow-up. Knee Surg Sports Traumatol Arthrosc. 2014;22(6):1207-1215. doi:10.1007/s00167-014-2843-6.
Montgomery S, Foster B, Ngo S, et al. Trends in the surgical treatment of articular cartilage defects of the knee in the United States. Knee Surg Sports Traumatol Arthrosc. 2014;22(9):2070-2075. doi:10.1007/s00167-013-2614-9.
Salzmann GM, Sah B, Südkamp NP, Niemeyer P. Reoperative characteristics after microfracture of knee cartilage lesions in 454 patients. Knee Surg Sports Traumatol Arthrosc. 2013;21(2):365-371. doi:10.1007/s00167-012-1973-y.
Mithoefer K, McAdams T, Williams RJ, Kreuz PC, Mandelbaum BR. Clinical efficacy of the microfracture technique for articular cartilage repair in the knee: an evidence-based systematic analysis. Am J Sports Med. 2009;37(10):2053-2063. doi:10.1177/0363546508328414.
Wajsfisz A, Makridis KG, Djian P. Arthroscopic retrograde osteochondral autograft transplantation for cartilage lesions of the tibial plateau: a prospective study. Am J Sports Med. 2013;41(2):411-415. doi:10.1177/0363546512469091.
Harris JD, Siston RA, Brophy RH, Lattermann C, Carey JL, Flanigan DC. Failures, re-operations, and complications after autologous chondrocyte implantation–a systematic review. Osteoarthritis Cartilage. 2011;19(7):779-791. doi:10.1016/j.joca.2011.02.010.
Abrams GD, Frank RM, Gupta AK, Harris JD, McCormick FM, Cole BJ. Trends in meniscus repair and meniscectomy in the United States, 2005-2011. Am J Sports Med. 2013;41(10):2333-2339. doi:10.1177/0363546513495641.
Montgomery SR, Ngo SS, Hobson T, et al. Trends and demographics in hip arthroscopy in the United States. Arthroscopy. 2013;29(4):661-665. doi:10.1016/j.arthro.2012.11.005.
Yeranosian MG, Arshi A, Terrell RD, Wang JC, McAllister DR, Petrigliano FA. Incidence of acute postoperative infections requiring reoperation after arthroscopic shoulder surgery. Am J Sports Med. 2014;42(2):437-441. doi:10.1177/0363546513510686.
Zhang AL, Montgomery SR, Ngo SS, Hame SL, Wang JC, Gamradt SC. Arthroscopic versus open shoulder stabilization: current practice patterns in the United States. Arthroscopy. 2014;30(4):436-443. doi:10.1016/j.arthro.2013.12.013.
Werner BC, Carr JB, Wiggins JC, Gwathmey FW, Browne JA. Manipulation under anesthesia after total knee arthroplasty is associated with an increased incidence of subsequent revision surgery. J Arthroplasty. 2015;30(suppl 9):72-75. doi:10.1016/j.arth.2015.01.061.
Carr JB 2nd, Werner BC, Browne JA. Trends and outcomes in the treatment of failed septic total knee arthroplasty: comparing arthrodesis and above-knee amputation. J Arthroplasty. 2016;31(7):1574-1577. doi:10.1016/j.arth.2016.01.010.

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Reoperation Rates After Cartilage Restoration Procedures in the Knee: Analysis of a Large US Commercial Database

References

STATISTICAL ANALYSIS

RESULTS

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