Safety and efficacy of matrix-associated autologous chondrocyte implantation with spheroid technology is independent of spheroid dose after 4 years

  • Philipp NiemeyerEmail author
  • Volker Laute
  • Wolfgang Zinser
  • Thilo John
  • Christoph Becher
  • Peter Diehl
  • Thomas Kolombe
  • Jakob Fay
  • Rainer Siebold
  • Stefan Fickert



The aim of this study was to investigate the effect of product dose in autologous chondrocyte implantation (ACI) for the treatment of full-thickness cartilage defects of the knee and to assess its influence on clinical and morphological mid-term outcome.


Seventy-five patients were included in this single-blind, randomised, prospective, controlled clinical trial. Patients were assigned randomly to three different dose groups [low (3–7 spheroids/cm2), medium (10–30 spheroids/cm2), or high (40–70 spheroids/cm2)] and assessed using standardised clinical and morphological scoring systems (KOOS, IKDC, MOCART) for 4 years following the intervention.


The analysis population comprised 75 patients (22 women, 53 men) aged 34 ± 9 years. Defect sizes ranged from 2 to 10 cm2 following intraoperative debridement. The assessment of the primary variable ‘overall KOOS’ showed a statistically significant improvement, compared with baseline, for each dose group, i.e., at baseline the mean ‘overall KOOS’ scores were 60.4 ± 13.6, 59.6 ± 15.4, and 51.1 ± 15.4 for the low-, medium-, and high-dose groups, respectively, and 57.0 ± 15.2 for ‘all patients’. After 48 months those values improved to 80.0 ± 14.7, 84.0 ± 14.9, and 66.9 ± 21.5 in the respective dose groups and 77.1 ± 18.6 for ‘all patients’. Pairwise comparisons of these dose groups did not reveal any statistically significant differences. Likewise, assessment of the subjective IKDC score revealed no statistically significant differences between the three dose groups up to the 48-month visit. However, between 12 and 48 months there was a low, but steady, improvement in the low-dose group and a substantial amelioration in the medium-dose group. The mean MOCART total scores 3 months after treatment were 59.8 ± 10.9, 64.5 ± 10.3, and 64.7 ± 9.4 for the low-, medium-, and high-dose groups, and 62.9 ± 10.3 for ‘all patients’; 48 months after treatment these were 73.9 ± 13.1, 78.0 ± 12.4, and 74.3 ± 14.0 for the respective dose groups and 75.5 ± 13.1 for ‘all patients’.


Results of this study confirm the efficacy and safety of the applied “advanced therapy medicinal product”; no dose dependence was found either for the incidence or for the severity of any adverse reactions. All doses applied in the present study led to significant clinical improvement over time and can therefore be regarded as effective doses. The influence of product doses in the range investigated seems to be low and can be neglected. Thus, the authorised dose range of 10–70 spheroids/cm2 confirmed by this clinical trial offers a broad therapeutic window for the surgeon applying the product, thereby reducing the risk of over- or underdosing.

Level of evidence



Autologous chondrocyte implantation Cartilage lesion Knee surgery Patella Randomised clinical trial 



The present study was funded by the company CO.DON AG, Teltow, Germany.

Compliance with ethical standards

Conflict of interest

The present study has been financed by the company Co.don (Teltow, Germany) has been part of the approval process for european market authorization by the European Medicinal Agency (EMA). All authors received grants for limited educational purposes and financial support for conducting the present study.

Ethical approval

All procedures performed in this studies were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments. Ethical approval for this study was obtained from Heidelberg University (2009-016466-82).


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Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2020

Authors and Affiliations

  • Philipp Niemeyer
    • 1
    • 2
    Email author
  • Volker Laute
    • 3
  • Wolfgang Zinser
    • 4
  • Thilo John
    • 5
  • Christoph Becher
    • 6
  • Peter Diehl
    • 7
  • Thomas Kolombe
    • 8
  • Jakob Fay
    • 9
  • Rainer Siebold
    • 10
  • Stefan Fickert
    • 11
    • 12
  1. 1.Department of Orthopedic Surgery and TraumatologyFreiburg University HospitalMunichGermany
  2. 2.OCM ClinicMunichGermany
  3. 3.Joint and Spine Centre BerlinBerlinGermany
  4. 4.Department of Orthopedic Surgery and TraumatologySt. Vinzenz-Hospital DinslakenDinslakenGermany
  5. 5.Clinic for Traumatology and Orthopedic SurgeryDRK Hospital Westend BerlinBerlinGermany
  6. 6.Department of Orthopedic SurgeryMedical University Annastift HanoverHanoverGermany
  7. 7.Department of Orthopedic Surgery and TraumatologyOrthopedic Center Munich EastMunichGermany
  8. 8.Traumatology and Reconstructive SurgeryDRK Hospital LuckenwaldeLuckenwaldeGermany
  9. 9.Department of Traumatology and Arthroscopic SurgeryLubinus Clinicum KielKielGermany
  10. 10.Center for Hip, Knee and Foot SurgeryATOS Clinic HeidelbergHeidelbergGermany
  11. 11.Sporthopaedicum StraubingStraubingGermany
  12. 12.Department of Orthopedic Surgery and TraumatologyMannheim University HospitalMannheimGermany

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