Classification of graft hypertrophy after autologous chondrocyte implantation of full- thickness chondral defects in the knee P.C. Kreuz, M.D., M. Steinwachs,

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Classification of graft hypertrophy after autologous chondrocyte implantation of full- thickness chondral defects in the knee P.C. Kreuz, M.D., M. Steinwachs, Ph.D., C. Erggelet, Ph.D., S.J. Krause, M.D., C. Ossendorf, M.D., D. Maier, M.D., N. Ghanem, Ph.D., M. Uhl, Ph.D., M. Haag, M.D. Osteoarthritis and Cartilage Volume 15, Issue 12, Pages 1339-1347 (December 2007) DOI: 10.1016/j.joca.2007.04.020 Copyright © 2007 Osteoarthritis Research Society International Terms and Conditions

Fig. 1 Chondral defect on the medial femoral condyle measuring 5×3.5cm. The prepared lesion has a stable perpendicular edge of healthy, well-attached viable cartilage surrounding the defect providing a pool to hold the chondrocyte suspension within the defect area. Osteoarthritis and Cartilage 2007 15, 1339-1347DOI: (10.1016/j.joca.2007.04.020) Copyright © 2007 Osteoarthritis Research Society International Terms and Conditions

Fig. 2 ACI with a periosteal cover. The flap is sutured to the surrounding rim of the prepared defect area to create a water-tight chamber. Osteoarthritis and Cartilage 2007 15, 1339-1347DOI: (10.1016/j.joca.2007.04.020) Copyright © 2007 Osteoarthritis Research Society International Terms and Conditions

Fig. 3 Control arthroscopy 12 months after ACI in a 38-year-old man. The defect is completely filled without any fissures or signs of hypertrophy. Osteoarthritis and Cartilage 2007 15, 1339-1347DOI: (10.1016/j.joca.2007.04.020) Copyright © 2007 Osteoarthritis Research Society International Terms and Conditions

Fig. 4 Grading of graft hypertrophy: sagittal T2*-weighted, fat-suppressed gradient-echo-sequences of different grades of hypertrophy. The area of ACI is marked in every MR image with a white arrow. The thickness of the tissue graft is marked with a white bar. As reference value serves the thickness of the surrounding cartilage. It is marked with a white bar as well and set 100%. (a) No hypertrophy: the defect is completely filled without signs of subchondral edema and well integrated in the adjacent cartilage. (b) Grade 1 hypertrophy (≤125%): minimal hypertrophic changes of the graft without any symptoms. (c) Grade 2 hypertrophy (≤150%): mild hypertrophy of 140% compared to the surrounding articular cartilage. (d) Grade 3 hypertrophy (≤200%): moderate hypertrophy of 170% with symptoms of blocking and need for arthroscopic trimming. (e) Grade 4 hypertrophy (>200%): the transplanted area shows a severe graft hypertrophy of 270% with patellar pain and need for a surgical intervention. Osteoarthritis and Cartilage 2007 15, 1339-1347DOI: (10.1016/j.joca.2007.04.020) Copyright © 2007 Osteoarthritis Research Society International Terms and Conditions

Fig. 5 Control arthroscopy 6 months after ACI in a 33-year-old man. The defect is filled with well integrated but extensive hypertrophic repair tissue responsible for clinical symptoms such as blocking, effusion and pain. The hypertrophic area was trimmed down with a shaver to the level of the surrounding cartilage. Osteoarthritis and Cartilage 2007 15, 1339-1347DOI: (10.1016/j.joca.2007.04.020) Copyright © 2007 Osteoarthritis Research Society International Terms and Conditions