title: Classification of graft hypertrophy after autologous chondrocyte implantation of full-thickness chondral defects in the knee.
abstract: OBJECTIVE
  Graft hypertrophy is a major complication seen in autologous chondrocyte implantation (ACI) with a periosteal flap. We present the first magnetic resonance imaging (MRI) classification for periosteal hypertrophy including a grading of clinical symptoms and the surgical consequences.
  
  
  METHODS
  One hundred and two patients with isolated chondral defects underwent an ACI covered with periosteum and were evaluated preoperatively, 6, 18 and 36 months after surgery. Exclusion criteria were meniscal pathologies, axial malpositioning and ligament instabilities. Baseline clinical scores were compared with follow-up data by paired Wilcoxon-tests for the modified Cincinnati knee, the ICRS (International Cartilage Repair Society) and a new MRI score including the parameters defect filling, subchondral edema, effusion, cartilage signal and graft hypertrophy. Hypertrophic changes were graded from 1 (minimal) to 4 (severe).
  
  
  RESULTS
  All scores showed significant improvement (P<0.001) over the entire study period. Patients with femoral lesions had significantly better results than patients with patella lesions after 18 and 36 months postoperative (P<0.03). Periosteal hypertrophy occurred in 28% of all patients. Fifty percent of all patella implants developed hypertrophic changes. No patient with grade 1, and all patients with grade 4 hypertrophy had to undergo revision surgery. The Pearson correlation between graft hypertrophy and ICRS score was 0.78 after 6 months, and 0.69 after 36 months (P<0.01). Inclusion of graft hypertrophy in the MRI score improves the correlation to clinical scores from 0.6 to 0.69.
  
  
  CONCLUSIONS
  Grading graft hypertrophy helps to identify patients needing an early shaving of the graft. Its integration into an MRI score improves correlation with clinical scores. Re-operation depends on the grade of hypertrophy and clinical symptoms.
authors.affiliation: Department of Orthopaedic and Trauma Surgery, University Medical Center Freiburg, Hugstetterstrasse 55, 79106 Freiburg, Germany.
authors.forename: P C
authors.initials: PC
authors.lastname: Kreuz
authors.forename: M
authors.initials: M
authors.lastname: Steinwachs
authors.forename: C
authors.initials: C
authors.lastname: Erggelet
authors.forename: S J
authors.initials: SJ
authors.lastname: Krause
authors.forename: C
authors.initials: C
authors.lastname: Ossendorf
authors.forename: D
authors.initials: D
authors.lastname: Maier
authors.forename: N
authors.initials: N
authors.lastname: Ghanem
authors.forename: M
authors.initials: M
authors.lastname: Uhl
authors.forename: M
authors.initials: M
authors.lastname: Haag
mesh_terms: D000293:Adolescent; D000328:Adult; D002357:Cartilage Diseases / Q000145:classification / Q000473:pathology / Q000601:surgery*; D017690:Cell Transplantation / Q000379:methods; D019902:Chondrocytes / Q000637:transplantation*; D005260:Female; D006085:Graft Survival; D006801:Humans; D006984:Hypertrophy; D007719:Knee Joint / Q000473:pathology / Q000601:surgery*; D008279:Magnetic Resonance Imaging / Q000379:methods; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D010521:Periosteum / Q000473:pathology*; D011446:Prospective Studies; D012086:Reoperation; D014182:Transplantation, Autologous