Mechanical vs. Radiofrequency-Based Debridement in the Treatment of Articular Cartilage Lesions (ACT)

A Prospective, Double Blinded, Multicenter, Randomized, Controlled Trial to Evaluate Mechanical Debridement vs. Radiofrequency-Based Debridement in the Treatment of Articular Cartilage Lesions

The purpose of this study is to evaluate changes in clinical and imaging outcomes following arthroscopic treatment of a single medial femoral chondral lesion plus partial medial meniscectomy by Radiofrequency-Based debridement or Mechanical Debridement in subjects ≥ eighteen (18) years of age.

Study Overview

• Status: Terminated
• Conditions: Chondral Lesion Plus Partial Medial Meniscectomy
• Intervention / Treatment: Device: Mechanical Debridement; Device: RF-Based Debridement

Detailed Description

This is a non-inferiority, prospective, double blinded, multi-center, randomized, controlled, adaptive study design with enrollment of 82 randomized subjects at up to 13 study sites. Study duration will be until the last subject enrolled reaches 104 weeks post-operative.

The study will be comprised of two parts:

Part I: Part I will require all Investigators perform 1 to 3 procedures using the Quantum 2 Controller plus Paragon T2 ICW Wand or the WEREWOLF Controller plus FLOW 50 Wand. Investigators must be qualified by training to perform procedures prior to use of either study device. This purpose of Part I will be to minimize variability with the recommended directions for use established in the instructions for use (IFU). Part I subjects will be followed per protocol follow-up requirements, and will be included in the safety population only. These subjects will be additive (to the safety population) to the 82 randomized subjects planned as part of the primary evaluation in Part II.

Part II: Part II will consist of 82 randomized subjects. Each Investigator may initiate enrollment of subjects in this part of the study following completion of Part I requirements. The Part II study implements a randomized adaptive study design, whereby an interim analysis will be conducted for sample size re-assessment. There is no intention of reducing the sample size as a result of this interim analysis; however, the sample size may be increased to either establish the non-inferiority and/or may be increased sufficiently to establish superiority depending on the results of the interim analysis.

• Study Type: Interventional
• Enrollment (Actual): 148
• Phase: Not Applicable

Contacts and Locations

Study Locations

• United States
  • Arizona
    • Tucson, Arizona, United States, 85712
      • Tucson Orthopaedic Institute
  • Florida
    • Gulf Breeze, Florida, United States, 32561
      • Andrews Research and Education Foundation, Inc.
  • Indiana
    • Greenwood, Indiana, United States, 46143
      • Orthopaedic Research Foundation, Inc.
  • Ohio
    • Columbus, Ohio, United States, 43221
      • Ohio State University
  • Pennsylvania
    • State College, Pennsylvania, United States, 16801
      • University Orthopedics Center
  • Texas
    • Houston, Texas, United States, 77070
      • Methodist Center For Orthopedic Surgery
    • Odessa, Texas, United States, 79761
      • Basin Orthopedic Surgical Specialists

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (ADULT, OLDER_ADULT)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria

Subjects MUST meet ALL of the following criteria to be included in the study:

1. Given written informed consent on the IRB/REB approved Consent Form specific to the study, prior to study participation
2. Is male or non pregnant female ≥ eighteen (18) years of age
3. MRI within 9 months of enrollment into this study confirming presence of a medial femoral chondral lesion and medial meniscal tear requiring a partial meniscectomy (as determined by the Investigator)
4. Must present with pain in the index knee of moderate or severe (> 30 mm) as measured by the VAS
5. Must be able to understand English (written and oral)
6. Must be available to come to all study related visits and is physically and mentally willing and able to comply with all post-operative evaluations
7. Must be in general good health (as determined by the Investigator) based on screening assessments and medical history

Intra-operative Inclusion Criteria

Subjects MUST meet ALL of the following criteria to be included in the study:

1. Arthroscopic confirmation of a lesion requiring treatment meeting the following parameters:

1. Single, treatable chondral lesion, localized to the medial femoral condyle,
2. ICRS Grade 2 with widely displaceable fibrillation or flaps or Grade 3A,
3. < 4cm2 in size

Exclusion Criteria

Subjects will be excluded from the study, if they meet ANY one (1) of the following criteria:

1. Body Mass Index (BMI) > 40 or index joint pain is due to BMI (as determined by Investigator)
2. Requires bilateral knee surgery

3. Any of the following conditions:

   1. active joint infections
   2. is immunocompromised, has Sickle Cell disease, has a primary bone disease (e.g., Paget's disease) or disorders that may adversely affect the healing process, or is terminally ill
   3. inflammatory rheumatoid arthritis or other systemic inflammatory arthritis (i.e., gout)
   4. metastatic and/or neoplastic disease
   5. infectious, highly communicable diseases (e.g., active tuberculosis or active hepatitis)
   6. coagulation disorder or patient is receiving anti-coagulants
   7. documented evidence of a history (e.g. liver testing) of drug/alcohol abuse within 12 months of enrollment into this study
   8. diagnosed with a behavioral condition which could affect their ability to accurately comply with the study (e.g. developmental delay, attention deficit disorder, and autism)

4. Any of the following conditions in the index limb or joint:

   1. Grade III or greater osteoarthritis as determined by AP radiograph (Kellgren-Lawrence classification)
   2. systemic steroid therapy or steroid intra-articular therapy within 4 weeks of enrollment into this study
   3. intra-articular viscosupplementation within 3 months of enrollment into this study
   4. osteomyelitis, septicemia, or other infections that may spread to other areas of the body
   5. fractures, osteocysts or osteolysis
   6. recurrent patellar instability (e.g., subluxation or dislocation)
   7. severe Varus or Valgus knee deformities (as determined by Investigator)
   8. symptomatic tear of the lateral meniscus
   9. avascular necrosis
   10. synovial disorders (e.g., pigmented villanodular synovitis)
   11. previous total or partial meniscectomy
   12. requires reconstruction or replacement of medial or lateral meniscus
   13. knee instability, malalignment, or patellar tracking dysfunction
   14. prior treatment for cartilage repair, including but not limited to ACI, Mosaicplasty and/or marrow stimulation procedures
   15. prior knee tendon and/or ligament repair or patellar surgery within 6 months of enrollment into this study

5. Any of the following conditions in the contralateral limb or joint:

   1. greater than minimal abnormality as shown by clinical exam and/or imaging
   2. scheduled or to be scheduled for surgery over the course of this study
   3. involvement causing abnormal ambulation and non-compliance with post-operative rehabilitation guideline
6. The subject has implanted metallic devices (insulin pumps, nerve stimulators, etc), medically implanted clips or other electronically, magnetically or mechanically activated implants that would contraindicate undergoing an MRI scan of the knee
7. The subject has claustrophobia that would inhibit their ability to undergo an MRI scan of the index knee
8. Receiving prescription narcotic pain medication for conditions unrelated to the index knee condition
9. Cardiac pacemaker or other electronic implant(s)
10. Pregnant and/or intending to become pregnant during this study period
11. Participated in a clinical study within 30 days of enrollment into this study, or who is currently participating in another clinical study.
12. Is a prisoner, or is known or suspected to be transient
13. Is involved with Worker's Compensation unrelated to the index knee
14. Is involved with health-related litigation

Intra-operative Exclusion Criteria

Subjects will be excluded from the study, if they meet ANY one (1) of the following criteria:

1. Has more than 1 chondral lesion requiring treatment
2. Requires concomitant procedures (i.e., anterior cruciate ligament repair, high tibial osteotomy), excluding partial medial meniscectomy
3. Has a medial meniscal tear not requiring treatment
4. Has a medial meniscal tear requiring a procedure other than partial meniscectomy
5. Has a lateral meniscal tear requiring treatment

Study Plan

How is the study designed?

Design Details

• Primary Purpose: TREATMENT
• Allocation: RANDOMIZED
• Interventional Model: PARALLEL
• Masking: DOUBLE

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
ACTIVE_COMPARATOR: Mechanical Debridement; Mechanical shaver removes areas of damaged tissue	Device: Mechanical Debridement; mechanical shaver that removes areas of damaged tissue; Other Names: Mechanical Shaver
ACTIVE_COMPARATOR: RF-based Debridement; Electrical energy removes areas of damaged tissue (Coblation®)	Device: RF-Based Debridement; Electrical energy that removes areas of damaged tissue (Coblation®); Other Names: Paragon T2 ICW, FLOW 50 wand

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change From Baseline in Knee and Osteoarthritis Outcomes Scores (KOOS) at Week 52 Post-operative	The scores of 5 subscales of KOOS (i.e., Pain, other Symptoms, Function in daily living [ADL], Function in Sport and Recreation [Sport/Rec] and knee related Quality of Life [QoL]) at Baseline, Week 52 and change from Baseline were summarized descriptively by treatment group. The average of KOOS subscale scores was considered as the primary endpoint. For any subject if the value of effectiveness parameter was missing at Week 52 then it was imputed by last observed post-Baseline value (LOCF method). Each subscale response is based on a 5-point Likert system with each response score ranging from 0 (no problems) to 4 (extreme problems). Each subscale score is calculated independently. A score of 100 indicated no problems and a score of 0 indicated extreme problems. KOOS subscale score = 100 - (mean of the observed items within the subscale x100 / 4)	Postop Week 52

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form Scores From Baseline.	The scores of three domains of IKDC Subjective Knee Evaluation Form (i.e., [1] symptoms, including pain, stiffness, swelling, locking/catching, and giving way; [2] sports and daily activities; and [3] current knee function) at Baseline, each of scheduled post-operative visits and changes from Baseline were summarized descriptively by treatment group. Change from Baseline in IKDC = IKDC at Baseline + Pseudo-site + Treatment + Treatment*Pseudo-site The IKDC score was interpreted by summing the scores for the individual questions and then transforming the score to a scale that ranged from 0 to 100: Individual domain IKDC score = [raw score - lowest possible score/range of scores] x 100 The IKDC total score was interpreted as higher scores = higher function, lower scores = lower function. Treatment*Pseudo-site interaction term was non-significant at the 0.05 level and hence was dropped from the statistical method.	Baseline, Postop Weeks 6, 12, 24, 36, 52, and 104/Early Termination (ET)
Number of Participants Stratified by Generalized Laxity Level on IKDC Knee Evaluation	Knee examination with respect to generalized laxity (tight, normal, lax) were summarized as number and percent of subjects in treatment group for Baseline and post-operative follow-up visits. The IKDC Knee Evaluation Form was comprised of 3 domains: 1) symptoms including pain, stiffness, swelling, locking/catching, and giving way; 2) sports and daily activities; and 3) current knee function and knee function prior to knee injury. There were 18 questions and the raw score was transformed to a 0 to 100 scale score as follows: IKDC score = (raw score - lowest possible score / range of scores) x100	Baseline, Postop Weeks 6, 12, 24, 36, 52, and 104/ET
Number of Participants Stratified by Alignment Level on IKDC Knee Evaluation	Knee examination with respect to alignment (obvious varus, normal, obvious valgus) were summarized as number and percent of subjects in treatment group for Baseline and post-operative follow-up visits. The IKDC Knee Evaluation Form was comprised of 3 domains: 1) symptoms including pain, stiffness, swelling, locking/catching, and giving way; 2) sports and daily activities; and 3) current knee function and knee function prior to knee injury. There were 18 questions and the raw score was transformed to a 0 to 100 scale score as follows: IKDC score = (raw score - lowest possible score / range of scores) x100	Baseline, Postop Weeks 6, 12, 24, 36, 52, and 104/ET
Number of Participants Stratified by Patellar Position Level on IKDC Knee Evaluation	Knee examination with respect to patella position (obvious baja, normal, obvious alta) were summarized as number and percent of subjects in treatment group for Baseline and post-operative follow-up visits. The IKDC Knee Evaluation Form was comprised of 3 domains: 1) symptoms including pain, stiffness, swelling, locking/catching, and giving way; 2) sports and daily activities; and 3) current knee function and knee function prior to knee injury. There were 18 questions and the raw score was transformed to a 0 to 100 scale score as follows: IKDC score = (raw score - lowest possible score / range of scores) x100	Baseline, Postop Weeks 6, 12, 24, 36, 52, and 104/ET
Number of Participants Stratified by Patella Subluxation/Dislocation Level on IKDC Knee Evaluation	Knee examination with respect to patella subluxation/ dislocation (centered, subluxable, subluxed and dislocated) were summarized as number and percent of subjects in treatment group for Baseline and post-operative follow-up visits. The IKDC Knee Evaluation Form was comprised of 3 domains: 1) symptoms including pain, stiffness, swelling, locking/catching, and giving way; 2) sports and daily activities; and 3) current knee function and knee function prior to knee injury. There were 18 questions and the raw score was transformed to a 0 to 100 scale score as follows: IKDC score = (raw score - lowest possible score / range of scores) x100	Baseline, Postop Weeks 6, 12, 24, 36, 52, and 104/ET
Change in KOOS Scores From Baseline	The scores of 5 subscales of Knee Injury and Osteoarthritis Outcome Score (KOOS) (i.e., pain, other symptoms, function in daily living [ADL], function in sport and recreation [Sport/Rec], and knee-related Quality of Life [QoL]) change from Baseline were summarized descriptively by treatment group. An ANCOVA model was used to compare the differences in the devices for change from Baseline in the KOOS subscale score at each of the scheduled post-operative visits. Each subscale response was based on a 5-point Likert system with each response score ranging from 0 (no problems) to 4 (extreme problems). A score of 100 indicated no problems and a score of 0 indicated extreme problems. The KOOS calculations were calculated as follows: Individual KOOS subscale scores = 100 - (mean of the observed items within the subscale x100) / 4 Change from Baseline in KOOS at Week (x) or Day (x) = KOOS at Week (x) or Day (x) - KOOS at Baseline	Baseline, Postop Weeks 6, 12, 24, 36, 52, and 104/ET
Change in Visual Analog Scale (VAS) Scores From Baseline	The VAS knee pain scores were assessed at Baseline, post-operative visits (Day 10, Weeks 6, 12, 24, 36, 52, and 104/ET) and change from Baseline were summarized descriptively by treatment group. An ANCOVA model was used to compare the differences in the devices for change from Baseline in the VAS knee pain score at each of the scheduled post-operative visits. The model had change in VAS knee pain as the response variable and treatment, Baseline VAS knee pain, site, treatment-by-site interaction, lesion-grade, and lesion-grade interaction as independent variables. Scores ranged from 0 to 100 with pain intensity measured as none, mild, moderate, or severe: No pain (0-4) Mild pain (5-44) Moderate pain (45-74) Severe pain (75-100) VAS scores were calculated as: Change in VAS knee pain score from Baseline at Week (x) or Day (x) = VAS knee pain at Week (x) or Day (x) - VAS knee pain at Baseline	Baseline, Postop Day 10, Weeks 6, 12, 24, 36, 52, and 104/ET
Change in 12-Item Short Form Survey (SF-12) Scores From Baseline - Physical Component Summary (PCS) Score	SF-12 PCS scores at Baseline, post-operative visits (Weeks 6, 12, 24, 36, 52 and 104) and changes from Baseline were summarized descriptively by treatment group. The SF-12 health survey categories included: physical functioning, role functioning physical, bodily pain, general health, vitality, social functioning, role functioning emotional, and mental health. An ANCOVA model was used to compare the difference in the devices for change from Baseline in the SF-12 PCS scores at each of the scheduled post-operative visits. The model had change in SF-12 PCS score as the response variable and treatment, Baseline SF-12 PCS score, site, treatment-by-site interaction, lesion-grade and treatment-by-lesion grade interaction as independent variables. Results were expressed as the PCS. Scores could range from 0 (the worst) to 100 (the best). SF-12 scores for PCS were calculated as: Change in SF-12 PCS score from Baseline at Week (x) = PCS score at Week (x) - PCS score at Baseline	Baseline, Postop Weeks 6, 12, 24, 36, 52, and 104/ET
Change in SF-12 Scores From Baseline - Mental Component Summary (MCS) Score	SF-12 MCS scores at Baseline, post-operative visits (Weeks 6, 12, 24, 36, 52, and 104) and changes from Baseline were summarized descriptively by treatment group. The SF-12 health survey categories included: physical functioning, role functioning physical, bodily pain, general health, vitality, social functioning, role functioning emotional, and mental health. An ANCOVA model was used to compare the difference in the devices for change from Baseline in the SF-12 MCS scores at each of the scheduled post-operative visits. The model had change in SF-12 MCS score as the response variable and treatment, Baseline SF-12 MCS score, site, treatment-by-site interaction, lesion-grade and treatment-by-lesion grade interaction as independent variables. Results were expressed as the MCS. Scores could range from 0 (the worst) to 100 (the best). SF-12 scores for MCS were calculated as: Change in SF-12 MCS score from Baseline at Week (x) = MCS score at Week (x) - MCS score at Baseline	Baseline, Postop Weeks 6, 12, 24, 36, 52, and 104/ET
Change in EuroQoL 5 Dimensions, 5 Level Scale (EQ-5D-5L) Scores From Baseline (EQ-5D-5L Summary Total Score)	The EQ-5D-5L and EQ-VAS surveys were assessed at the specified time points. The EQ-5D-5L score was composed of 5 dimensions to assess mobility, self-care, usual activities, pain/discomfort, and anxiety/depression based on participant's responses. Each individual category calculated a score of between -1 and +1. A score of -1 showed the worst improvement and a score of +1 showed the most improvement. Summary total scores for EQ-5D-5L were calculated as: Change in EQ-5D-5L score from Baseline at Week (x) or Day (x) = EQ-5D-5L score at Week (x) or Day (x) - EQ-5D-5L score at Baseline	Baseline, Postop Day 10, Weeks 6, 12, 24, 36, 52, and 104/ET
Change in EQ-5D-5L Scores From Baseline (EQ-VAS Summary Total Score)	The EQ-5D-5L and EQ-VAS surveys were assessed at the specified time points. The EQ-5D-5L score was composed of 5 dimensions to assess mobility, self-care, usual activities, pain/discomfort, and anxiety/depression based on participant's responses. The EQ-VAS score ranged from 0 to 100 with higher scores representing better health and lower scores representing worse health. Summary total scores for EQ-VAS were calculated as: Change in EQ-VAS score from Baseline at Week (x) or Day (x) = EQ-VAS score at Week (x) or Day (x) - EQ-VAS score at Baseline	Baseline, Postop Day 10, Weeks 6, 12, 24, 36, 52, and 104/ET
Subject Satisfaction Postoperatively at Weeks 52 and 104	Subjects were questioned regarding their satisfaction with study treatment for knee pain.	Postop Weeks 52 and 104/ET
Magnetic Resonance Imaging (MRI) and International Cartilage Repair Society (ICRS) Chondral Lesion Assessments	MRIs were obtained post-operatively at Day 10, obtained during the time period of Day 10 through Week 52, and again obtained during the time period of Week 52 through Week 104/ET). The images were evaluated using ICRS assessments of chondral lesions to determine the percentage of change in cartilage lesions over time post-operatively. ICRS partial-thickness chondral lesion assessment scores: Low-grade defect = less than 50% High-grade defect = 50% to 99%	Postop Day 10, Day 10 to Week 52, Week 52 to Week 104/ET

Collaborators and Investigators

• Sponsor: Smith & Nephew, Inc.
• Investigators: Principal Investigator: Jack Farr II, MD, Orthopaedic Research Foundation, Inc.; Study Chair: Beate Hansen, MD, PhD, Vice President, Global Clinical Strategy

Study record dates

Study Major Dates

• Study Start (ACTUAL): March 8, 2013
• Primary Completion (ACTUAL): May 4, 2017
• Study Completion (ACTUAL): July 21, 2017

Study Registration Dates

• First Submitted: February 15, 2013
• First Submitted That Met QC Criteria: March 1, 2013
• First Posted (ESTIMATE): March 4, 2013

Study Record Updates

• Last Update Posted (ACTUAL): March 28, 2019
• Last Update Submitted That Met QC Criteria: March 7, 2019
• Last Verified: March 1, 2019

More Information

Terms related to this study

• Keywords: Knee; Cartilage; Radiofrequency; Debridement; Meniscectomy; Meniscus; Coblation; Articular cartilage; Arthroscopic knee surgery; Cartilage defect; Cartilage lesion; MR imaging; Mechanical debridement; Mechanical shaver; Torn meniscus; Damaged cartilage
• Other Study ID Numbers: SM-2012-02