Spherox versus INVOSSA in the

treatment of a geriatric patient suffering

with Osteoarthritis
1902018101
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Articular cartilage, a type of hyaline cartilage, is aneural, alymphatic and devoid of blood vessels
(Bhosale and Richardson.,2008). Specialised cartlidge cells (chondrocytes) make up <10% of the
tissue volume (Vonk et al.,2021). Each chondrocyte is encased within a 2-4 µm thick, collagen VI-
rich pericellular matrix (Davies and Kuiper.,2019), forming a chondron (Wang et al.,2009). These
chondrons sit within a territorial matrix surrounded by a dense extracellular matrix (ECM);
principally composed of water, collagen-II fibres, and proteoglycans (Davies and Kuiper.,2019) with
non-collagenous proteins present in smaller quantities (Buckwalter and Mankin.,1997). As distance
from the cartilage surface increases, there is distinct variation in both chondrocytes and their
surrounding ECM; distributed in four clear architectural zones (Figure 1). Articular cartilage damage,
synonymous with geriatrics (Jain and Ravikumar.,2020) has limited healing potential and often
progresses to osteoarthritis (Davies and Kuiper.,2019). Osteoarthritis is characterised in stages (Figure
2) by: advancing cartilage and meniscus degradation, synovial inflammation, and the formation of
osteophytes (Goldring and Goldring.,2016). Allogenic and autologous chondrocyte implantation
(ACI) strategies are, more so than ever, being implemented in the treatment and management of
osteoarthritis.

Figure 1. A schematic cross section diagram of the articular cartilage structure in a healthy
individual (Buckwalter, Mow and Ratcliffe.,1994). Depicted on the left is the articular cartilage
structure and the underlying subchondral bone. The chondrocytes are clearly organised in four
zones labelled Calcified zone, Deep zone, Middle zone, and Superficial Tangential Zone (SZT).
The right-hand diagram depicts zonal variation in the organisation of collagen fibers. Not shown
on the diagram is scattering of proteoglycans, though this would almost exclusively be limited to
Figure
the middle zone 2. A systematic
with diagram
the distribution of the middle
mirroring four stages
zone of osteoarthritis, as demonstrated in
collagen.
the knee (TeachmeSeries., n.d). Tile I shows the first early stage of articular cartilage
damage with minimal disruption to function and ≈ 10% cartilage loss. Moving to the
right, II depicts the joint space narrowing, early-stage cartilage breakdown and the
occurrence of osteophytes. Stage III illustrates similar pathophysiology to II, however in
III, the area of defect ground is becoming larger, with defects extending down >50%
cartridge depth, through the calcified layer, exposing areas of subchondral bone
(ICRS.,2014). IV depicts Final stage osteoarthritis. There is a severe reduction in joint
space, large osteophytes formed and cartilage defects reaching into the subchondral
bone.
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Autologous methods of treatment (Spherox)-

Spherox is a fourth-generation matrix-associated autologous chondrocyte implantation (ACI) method-
suitable for “repair of symptomatic articular cartilage defects, ≤ 10 cm 2, of the femoral condyle and
the patella” (NICE., 2018). The treatment utilizes spheroids; three-dimensional, spherical aggregates
of human autologous chondrocytes, ex vivo expanded (Figure. 3), and their ECM (Vonk et al., 2021).
The basic principle of Spherox is based on the acquisition of the patients own healthy chondrocytes
from articular cartilage. These chondrocytes undergo in vitro cultivation in a monolayer and 3-D
culture (Figure. 3), where spheroids are formed; the culturing process does not require exogenous
stimuli or growth factor (Niemeyer et al.,2019).
Spherox is approved for use in both the European Union (EMA.,2018) and in the UK (NICE, 2017).
However, as outlined by NICE framework, Spherox treatment can only be offered to patients with
grade III or IV damage (Figure 2.) (NICE.,2018). Moreover, treatment can only be provided if a
patient has not had “previous surgery to repair articular cartilage defects” (NICE.,2018). Since
suboptimal, 3-7 spheroids/cm2 doses often result in osteoarthritis progression (EMA.,2017), NICE set
the minimum dose to 10 spheroids/cm2 (NICE,2018). Spherox contains no animal-based derivatives
thus presenting very few ethical considerations. Hence, no patient exclusions can occur based on
moral or religious grounds (NICE, 2017).
Since Spheroids adhere to the lesion via surface tension (Figure. 4), the need for additional scaffolds
(e.g., a periosteal flap) is negated (Hoburg et al.,2019). Once attached, spheroids produce cartilage
specific ECM proteins (Figure 4), glycosaminoglycans and aggrecan (Eschen et al.,2020), initiating
tissue regeneration. The degree of tissue regeneration has been shown to be directly linked to the level
of aggrecan expression (Bartz et al.,2016).

Figure 3. An implant preparation flow chart and Spheroid adhesion diagram

(Vonk et al., 2021). The flowchart commences with a cartilage biopsy being
taken. The autologous chondrocytes gathered from the biopsy are cultured and
expanded, in vitro, before subsequent culturing as spheroids. The culture medium
for spheroid growth is devoid of any supplements and contains only autologous
serum.
1902 0181 01

Figure 4. Graphic representation of the adhesion of spheroids to the defect (EMA.,

2017). Schematic representation of the adhesion (i) of Spherox to the Cartlidge lesion
through adhesion points. This is followed by (ii) widening of the spheroid through
integration into the adhesion area by migration of chondrocytes along the defect area. In
the final remodeling stage (iii) the spheroids become completely integrated. The red
arrows indicate synthesis and secretion of cartilage-specific ECM proteins into the
The efficacy
lesion of Spherox
cavity. Red in the treatment
circles indicate of
cellcartilage lesionswhich
proliferation, has been demonstrated
formulates in numerous
new chondrocytes.
clinical trials. In a phase III trial carried out by Niemeyer et al, 102 patients were randomly (1:1)
allocated treatment, either Spherox (n=52) or microfracture (n=50). Successes were judged by the
Knee injury and Osteoarthritis Outcome Score (KOOS) and magnetic resonance observation of
cartlidge repair tissue (MOCART) scoring system amongst other clinical efficacy criteria. Spherox
passed the test of noninferiority compared to the traditional microfracture treatment (MF) and in one
criterion, Spherox showed superiority. The primary data analysis confirmed the noninferiority of
spheroid-based ACI, even for small cartlidge lesions <4cm 2 treated in their study, for which MF is
deemed the gold standard of care (Niemeyer et al.,2019).
Another phase III trial by Hoburg et al, compared both ACI and MF over a 36-month period.
Similarly, to Niemeyer et al, KOOS showed great improvement. Moreover, echoing Niemeyer et al,
superiority of ACI over microfracture was shown in some criteria (Activities of Daily Living and
Sport and Recreation scores). Identical to Niemeyer et al, the occurrence of adverse events were not
statistically different between both treatments (ACI 77%; MF 74%). Despite a high AE incidence rate
in both cohorts, four of the MF group had treatment failure. There were no such cases in the ACI
group, suggesting the superiority of Spherox.
Additionally, ACI shows greatly beneficial clinical outcomes for geriatrics. In a cohort study by
Niemeyer et al, 74 patients were split into 2 groups by age. Group 1 with an average age of 47.8 and
group 2 with an average age of 31. Both underwent ACI treatment. After 24 months, results showed
there to be no significant statistical difference between the two groups (Figure. 5) (Niemeyer et
al,2010). This is not the case with other osteoarthritis treatments. Total knee arthroplasty, a common
alternate method of treatment, has significantly hindered outcomes in the elderly when compared to
younger patients; severe complications, extended stays in hospital and smaller gains in knee
functionality post-operation can be expected in the elderly (Chenung et al.,2020). Similarly,
significantly better results post MF treatment are expected in patients under 40 when compared to
older patients (Kreuz et al.,2006; Gomoll.,2012).
Clearly, Spherox has good potential for Matt. However, the case study provided mentions the patient
having “established osteoarthritis” in “several quadrants”; the articular cartlidge damaged could be
too severe and the affected area too large, >10cm 2 (NICE,2018), for Spherox to be offered as a viable
 1902 0181 01

treatment. Additionally, Matt may have had previous surgeries on the lesion, rendering Spherox void.
Moreover, numerous undesirable side effects and adverse events are associated with Spherox.
A paper by Niemeyer et al., 2010 investigated the safety and efficacy of Spherox and the effect of
various doses after 4 years. Across all doses there were 126 cases of adverse events (AE) amongst the
63 patients in the study; most common of which were joint effusion and arthralgia with 4 cases of
serious adverse reaction leading to graft failure (Table 1). The overall incidence rates of AE’s in
Niemeyer et al’s study have been collated with Brittberg et al and Saris et al (Table 1)- though in the
latter, ChondroCelect was the ACI treatment used in the study, not Spherox. The collected data
echoes Niemeyer et al’s findings, depicting Joint effusion and Arthralgia with the highest incidence
rates (Table 1). Moreover, the findings also indicate that some patients had recurrent adverse reactions
as the number of patients is lower than the number of recorded events.

Figure 5. Graphical representation of, Subjective International Knee Documentation Committee (IKDC) Score,
Lysholm Score, Cincinnati Score and Tegner Score in the ≥40 and <40 cohort 24 months after ACI treatment.
The results clearly depict similar values in both cohorts across all 4 of the criteria. Obvious overlap in every
criterion standard deviation bar is apparent, suggesting there is no significant statistical difference in the success
of treatment between either age group. Adapted from (Niemeyer et al., 2010).
100 points maximum Lysholm; 100 points maximum IKDC; 100 points maximum Cincinnati score; 10 points
maximum Tegner score.
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Adverse Reaction Number of Patients Number of Events

Joint effusion 68 81
Arthralgia 74 75
Joint swelling 22 23
Joint lock 2 2
Osteonecrosis #
1 1
Osteochondrosis
Table 1. Overview of #adverse reactions, extrapolated from numerous studies. The data1 depicts
#
1
Cartilage hypertrophy
joint effusion and arthralgia 1 of treatment, both showing1a larger
as the most common side effect
Extraskeletal ossification
number of adverse
#
1 multiple occurrences of AE’s
events than patient numbers, suggesting 1 in some
individuals. 4 clear cases of graft rejection are present.
Table adapted from Niemeyer et al.,2019; Brittberg et al., 2018; Saris et al., 2009
#
Serious adverse reaction resulting in graft rejection
N=181

Official data published by the manufacturers of Spherox, European Medicines Agency (Table 2),
gives estimations of the frequency of undesirable effects related to Spherox, depicting a very similar
picture to Table 1.

Table 2. Tabulated list of possible undesirable effects related to Spherox. Estimation of the occurrence of
side effects to Spherox treatment by the European Medical Agency. Similarly, to Table 1, joint effusion and
arthralgia are amongst the most common.
Common (≥ 0.01 to < 0.1); uncommon (≥ 0.001 to < 0.01) and rare (≥ 0.0001 to < 0.001).
Adapted from (EMA., 2017)
System Organ Class Frequency Adverse Reaction
Immune System Disorders Rare Hypersensitivity
Musculoskeletal and Common Joint effusion
connective tissue disorders Arthralgia
Joint Swelling
Uncommon Joint Lock
Rare Osteonecrosis
Osteochondrosis
Injury, poisoning and Uncommon Cartilage hypertrophy
procedural complications

Allogenic method of Treatment (INVOSSA)-

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Transforming growth factor-β (TGF-β) is an anti-inflammatory cytokine with key involvement in

maintenance of metabolic homeostasis and the structural integrity of articular cartilage by controlling
the proliferation and differentiation of chondrocytes (Van Beuningen et al., 1994). Numerous studies
have shown TGF-β1 involvement in the stimulation of proteoglycan synthesis in chondrocytes (Van
Osch et al., 1998; Beuningen et al., 1994) and the growth of chondrocytes in articular cartlidge
(Redini et al., 1991). Among all TGF-β, TGF-β1 is regarded as the most important factor for articular
cartilage formation (Ha et al., 2012). Hence, TGF-β1 is of particular interest as a possible anabolic
target for osteoarthritis therapy given its role in cartlidge development and maturation (Van Der
Kraan.,2017).
INVOSSA, also referred to as TissueGene-C/TG-C, is an example of a successful ex vivo, cell
mediated gene therapy that targets TGF-β for the therapeutic regeneration of cartlidge tissue via a
singular intra-articular injection (Figure 6). Though not yet licensed in the UK (NIHR.,2021),
INVOSSA completed phase III trials in the US (Vardar.,2021) and has been implemented in South
Korea since 2017 (Evans et al.,2018).
Initially, chondrocytes are harvested from a single allogenic donor, often a polydactyl infant (Evans et
al., 2018; Cherian et al., 2015). These unmolested allogenic chondrocytes (hChonJ) are mixed in a 3:1
ratio with irradiated, virally transduced chondrocytes of the same origin, with upregulated TGF-β1
(hChonJb#7) (Lee.,2018). The 1:3 mixing of transduced chondrocytes and untransduced, unirradiated
chondrocytes acts to amplify and extend the TGF- β1 effects. Irradiation of the cells limits possible
malignancies via uncontrolled transformation but permits continued secretion and synthesis of TGF-
β1 (Evans et al.,2018).

Figure 6. INVOSSA production and administration method (Evans et al., 2018).

Chondrocytes are harvested from a polydactyl individual. Some cells are irradiated
and retrovirally transduced to over express TGF-β1. These are mixed with
unmolested chondrocytes from the same donor before being injected into the knee.
1902 0181 01

Despite INVOSSA not yet having approval for use in the UK, its success has been well documented
in numerous studies. In a phase I trial, Ha et al evaluated the success of various doses of INVOSSA
using the Knee Society Clinical Rating System (KSCRS) knee score, Western Ontario and McMaster
Universities Osteoarthritis Index (WOMAC) and magnetic resonance image scanning (MRI). KSCRS
evaluates pain, joint stability, and range of motion, with a perfect score being 100; higher scores
directly correlate to better results (Insall et al.,1989). 12 months post treatment, there was a clear
upward trend in pain reduction (limited only to mid and high dose groups) as well as increased range
of motion across all dose groups. Thus, the KSCRS score increased following the clinical symptom
improvement. In regard to the WOMAC score, 58% of the patients in the study reported a marked
decreased. WOMAC scores range from 0 to 96 where 0 represents ideal joint health (Hmamochi et
al.,2012), hence a reduced score is symbolic of symptomatic improvements (Tubach et al., 2005);
suggesting the success of the INVOSSA treatment. Moreover, MRI results showed the appearance of
regenerated cartlidge after only 6 months (Figure 7), albeit a small amount.

Figure 7. A Proton-density coronal magnetic resonance image of a patient, post INVOSSA, at

baseline (c) and 6 months (d) (Ha et al., 2012). C shows stage IV articular cartlidge lesion. The
arrow on D indicates the subtle regenerated cartlidge at the weight bearing, lateral femoral
condyle only 6 months after treatment.

A phase II study by Lee et al evaluated the safety and efficacy of TissueGene-C over a 24-month
period. Similarly, to Ha et al functionality, pain scores and MRI were used to assess efficacy. The
MRIs, after 12 months, showed drastically reduced progression of cartlidge damage and synovitis in
the INVOSSA cohort when compared to the placebo group. Moreover, the IKDC (International Knee
Documentation Committee) score, (similar to KSCRS; compares knee symptoms and functionality
with 100 being the highest score), in the TG-C group showed vast improvement with no severe
adverse events reported.
A Multicentre, Phase III Clinical Trial carried about by Kim et al further echoes the findings from
both the Phase I and II trials. 163 patients with knee osteoarthritis were randomly assigned TG-C or a
placebo. Results of the trial showed statistically significant improvements in functionality.
Furthermore, there showed to be a 25% reduction in pain score at 26, 39 and 52 weeks when
 1902 0181 01

compared to those in the placebo group, surpassing the ‘20% reduction in pain score’ threshold to
indicate clinically meaningful functional improvement (Pham et al., 2004).
Though trials, for the most part, depict the success of INVOSSA, there are numerous AE’s, some of
them severe (Table 3), associated with TG-C treatment. The most common reported AE is joint
effusion followed by arthralgia (identical to Spherox (Table 1)). In rare circumstances, potentially life
threating conditions such as bladder cancer, cerebral haemorrhage and carotid artery stenosis have
been reported in INVOSSA patients (Kim et al.,2018). Additional, cells injected during treatment
have a short half-life and are unable to proliferate; multiple doses may be required for sufficient
therapeutic action (Grol and Lee.,2018), thus increasing the likelihood of numerous health
complications associated with repeated joint injections (Cheng and Abdi,2007).

Table 3. Tabulated frequency of adverse events and severe adverse events from a combination of clinical
trials. Joint Effusion was present in 11 of 157 subject across 3 studies, arthralgia in 8 patients from 145 in
2 trials and fracture of any description occurred in 5 patients of 157 from 3 studies. Bladder Cancer,
Cerebral Haemorrhage and Carotid Artery Stenosis were present in only 4 of 224 patients across 4 clinical
trials.
#
A serious adverse event that could result in death, threaten the life of a patient, result in disability, or
require hospitalisation.
Adapted from (Kim et al., 2018; NIHR.,2017; Ha et al., 2012; Cherian et al., 2015)

Adverse Event Frequency (%) Source

Joint Effusion 7.00 (Kim et al., 2018); (NIHR.,2017);
(Ha et al., 2012)
Arthralgia 5.52 (Kim et al., 2018); (NIHR.,2017)
Fracture# 3.18 (Kim et al., 2018); (NIHR.,2017);
(Ha et al., 2012)
Bladder Cancer# <1.00 (Kim et al., 2018); (NIHR.,2017);
(Ha et al., 2012); (Cherian et al.,
2015)
Cerebral Haemorrhage# <1.00 (Kim et al., 2018); (NIHR.,2017);
(Ha et al., 2012); (Cherian et al.,
2015)
Carotid Artery Stenosis# <1.00 (Kim et al., 2018); (NIHR.,2017);
(Ha et al., 2012); (Cherian et al.,
2015)

The nature of allogenic regenerative medicine often leads to ethical concerns. In the case of
INVOSSA, the polydactyl infant donor brings rise to religion and morality problems, leading to some
exemptions from treatment. In addition, studies have shown the likely contamination of INVOSSA
with the HEK293 cell line (Evans.,2019; Ghivizzani et al.,2021). Derived from human embryonic
kidney, HEK293 is often used to engineer retrovirus vectors of the type required in IVOSSA
treatment. Thus, manifestation of further ethical problems.
1902 0181 01

Conclusion-
Neither INVOSSA nor Spherox are perfect for Matt, however the latter appears to be the most
advantageous, especially for a man of his age. Current gold standard methods have significantly
hindered success in the elderly, Spherox does not (Niemeyer et al,2019). Moreover, there are few
ethical or religious concerns with ACI, preventing possible treatment exceptions (NICE,2018); the
same cannot be said about INVOSSA.
The commonality of joint effusion and arthralgia in both treatments is a drawback, though INVOSSA,
dissimilarly to Spherox, has been linked with potentially life-threatening AE’s. Neither Matt’s lesions
size nor stage of osteoarthritis are known. Excessively large lesions or late-stage OA would render
Spherox unsuitable, as would previous surgery on the lesions (NICE,2018). Hence, neither treatment
is ideal, but Spherox shows to be advantageous over INVOSSA in the treatment of Matt.
1902 0181 01

Reference List-
Bartz, C., Meixner, M., Giesemann, P., Roël, G., Bulwin, G.C. and Smink, J.J., 2016. An ex vivo
human cartilage repair model to evaluate the potency of a cartilage cell transplant. Journal of
translational medicine, 14(1), pp.1-15.
Bhosale, A.M. and Richardson, J.B., 2008. Articular cartilage: structure, injuries and review of
management. British medical bulletin, 87(1), pp.77-95.
Brittberg M, Recker D, Ilgenfritz J, Saris DBF, Group SES (2018) Matrix-applied characterized
autologous cultured chondrocytes versus microfracture: fve-year follow-up of a prospective
randomized trial. Am J Sports Med 46:1343–1351
Buckwalter, J.A. and Mankin, H.J., 1997. Articular cartilage: part I. Journal of Bone and joint surgery,
79(4), p.600.
Cheng, J. and Abdi, S., 2007. Complications of joint, tendon, and muscle injections. Techniques in
Regional Anesthesia and Pain Management, 11(3), pp.141-147.
Cherian, J.J., Parvizi, J., Bramlet, D., Lee, K.H., Romness, D.W. and Mont, M.A., 2015. Preliminary
results of a phase II randomized study to determine the efficacy and safety of genetically engineered
allogeneic human chondrocytes expressing TGF-β1 in patients with grade 3 chronic degenerative joint
disease of the knee. Osteoarthritis and cartilage, 23(12), pp.2109-2118.
Cheung, A., Fu, H., Cheung, M.H., Chan, W.K.V., Chan, P.K., Yan, C.H. and Chiu, K.Y., 2020. How
well do elderly patients do after total knee arthroplasty in the era of fast-track surgery? Arthroplasty,
2(1), pp.1-6.
Clontech. 2019. Certificate of Analysis- GP2-293 Packaging Cell Line. Available at:
https://www.takarabio.com/documents/Certificate%20of%20Analysis/631458/631458-101513.pdf.
(Accessed: 19 October 2021).
Davies, R.L. and Kuiper, N.J., 2019. Regenerative medicine: a review of the evolution of autologous
chondrocyte implantation (ACI) therapy. Bioengineering, 6(1), p.22.
Erggelet, C. and Vavken, P., 2016. Microfracture for the treatment of cartilage defects in the knee
joint–A golden standard?. Journal of clinical orthopaedics and trauma, 7(3), pp.145-152.
Eschen, C., Kaps, C., Widuchowski, W., Fickert, S., Zinser, W., Niemeyer, P. and Roël, G., 2020.
Clinical outcome is significantly better with spheroid-based autologous chondrocyte implantation
manufactured with more stringent cell culture criteria. Osteoarthritis and Cartilage Open, 2(1),
p.100033.
European Medicines Agency (EMA) (2018). Spherox. Available at:
https://www.ema.europa.eu/en/medicines/human/EPAR/spherox (Accessed: 16 October 2021).
European Medicines Agency (EMA) 2017. Spherox, INN-spheroids of human autologous matrix-
associated chondrocytes. Available at: https://www.ema.europa.eu/en/documents/product-
information/spherox-epar-product-information_en.pdf (Accessed: 16 October 2021).
Evans, C.H, Christopher H. "The vicissitudes of gene therapy." (2019): Bone and Joint Research. 469-
471.
Evans, C.H., Ghivizzani, S.C. and Robbins, P.D., 2018. Gene delivery to joints by intra-articular
injection. Human gene therapy, 29(1), pp.2-14.
1902 0181 01

Fox, A., Bedi, A. and Rodeo, S. (2009) "The Basic Science of Articular Cartilage: Structure,
Composition, and Function", Sports Health: A Multidisciplinary Approach, 1(6), pp. 461-468. doi:
10.1177/1941738109350438.
Ghivizzani, S.C, Evans, C.H. and Robbins, P.D., 2021. Orthopaedic Gene Therapy: Twenty-Five
Years On. JBJS reviews, 9(8), p.e20.
Goldring, S.R.; Goldring, M.B. Changes in the osteochondral unit during osteoarthritis: Structure,
function, and cartilage–bone crosstalk. Nat. Rev. Rheumatol. 2016, 12, 632–644
Gomoll, A.H., 2012. Microfracture and augments. The journal of knee surgery, 25(01), pp.009-016.
Grol, M.W. and Lee, B.H., 2018. Gene therapy for repair and regeneration of bone and cartilage.
Current opinion in pharmacology, 40, pp.59-66.
Ha, C.W., Noh, M.J., Choi, K.B. and Lee, K.H., 2012. Initial phase I safety of retrovirally transduced
human chondrocytes expressing transforming growth factor-beta-1 in degenerative arthritis patients.
Cytotherapy, 14(2), pp.247-256.
Hmamouchi, I., Allali, F., Tahiri, L., Khazzani, H., El Mansouri, L., Alla, S.A.O., Abouqal, R. and
Hajjaj-Hassouni, N., 2012. Clinically important improvement in the WOMAC and predictor factors
for response to non-specific non-steroidal anti-inflammatory drugs in osteoarthritic patients: a
prospective study. BMC research notes, 5(1), pp.1-9.
Hoburg, A., Löer, I., Körsmeier, K., Siebold, R., Niemeyer, P., Fickert, S. and Ruhnau, K. (2019)
"Matrix-Associated Autologous Chondrocyte Implantation Is an Effective Treatment at Midterm
Follow-up in Adolescents and Young Adults", Orthopaedic Journal of Sports Medicine, 7(4), p.
232596711984107. doi: 10.1177/2325967119841077.
Hoburg, A., Niemeyer, P., Laute, V., Zinser, W., Becher, C., Kolombe, T., Fay, J., Pietsch, S.,
Kuźma, T., Widuchowski, W. and Fickert, S., 2020. Matrix-associated autologous chondrocyte
implantation with spheroid technology is superior to arthroscopic microfracture at 36 months
regarding activities of daily living and sporting activities after treatment. Cartilage,
p.1947603519897290.
Insall, J.N., Dorr, L.D., Scott, R.D. and Scott, W.N., 1989. Rationale of the Knee Society clinical
rating system. Clinical orthopaedics and related research, (248), pp.13-14.
International Cartilage Repair Society (ICRS). 2014. Cartilage Injury Evaluation Package. Available
at: https://cartilage.org/content/uploads/2014/10/ICRS_evaluation.pdf (Accessed: 16 October 2021).
Jain, K.B. and Ravikumar, P., 2020. Recent advances in treatments of cartilage regeneration for knee
osteoarthritis. Journal of Drug Delivery Science and Technology, p.102014.
Kim, M.K., Ha, C.W., In, Y., Cho, S.D., Choi, E.S., Ha, J.K., Lee, J.H., Yoo, J.D., Bin, S.I., Choi,
C.H. and Kyung, H.S., 2018. A multicenter, double-blind, phase III clinical trial to evaluate the
efficacy and safety of a cell and gene therapy in knee osteoarthritis patients. Human gene therapy
Clinical development, 29(1), pp.48-59.
Lee, B., 2018. INVOSSA, a first-in-class of cell and gene therapy for osteoarthritis treatment: the
phase III trial. Osteoarthritis and Cartilage, 26, pp.S43-S44.
Mobasheri, A. and Martín-Vasallo, P., 2019. Over-Production of Therapeutic Growth Factors for
Cartilage Regeneration by Protein Production Platforms and Protein Packaging Cell Lines: A
Narrative Review of the Current State-of-the-Art.
1902 0181 01

NICE, 2017. Autologous chondrocyte implantation for treating symptomatic articular cartilage defects
of the knee. Available at: https://www.nice.org.uk/guidance/ta477/documents/final-appraisal-
determination-document (Accessed: 16 October 2021).
NICE, 2017. Single Technology Appraisal Autologous chondrocyte implantation with chondrosphere
for treating articular cartilage defects [ID851] Committee Papers. Available at:
https://www.nice.org.uk/guidance/ta508/documents/committee-papers. (Accessed: 19 October 2021).
NICE, 2018. Autologous chondrocyte implantation using Chondrosphere for treating symptomatic
articular cartilage defects of the knee. Available at:
https://www.nice.org.uk/guidance/ta508/resources/autologous-chondrocyte-implantation-using-
chondrosphere-for-treating-symptomatic-articular-cartilage-defects-of-the-knee-pdf-82606726260421
(Accessed: 17 October 2021).
Niemeyer, P, Köstler, W, Salzmann, GM, Lenz, P, Kreuz, PC, Südkamp, NP. 2010. Autologous
chondrocyte implantation for treatment of focal cartilage defects in patients age 40 years and older: a
matched-pair analysis with 2-year follow-up. Am J Sports Med.;38(12):2410–2416.
Niemeyer, P., Laute, V., Zinser, W., Becher, C., Kolombe, T., Fay, J., Pietsch, S., Kuźma, T.,
Widuchowski, W. and Fickert, S., 2019. A prospective, randomized, open-label, multicenter, phase III
noninferiority trial to compare the clinical efficacy of matrix-associated autologous chondrocyte
implantation with spheroid technology versus arthroscopic microfracture for cartilage defects of the
knee. Orthopaedic journal of sports medicine, 7(7), p.2325967119854442.
NIHR, 2021. Tonogenchoncel-L (Invossa) Gene Therapy for Regeneration of Cartilage in Patients
with Degenerative Arthritis or Osteoarthritis of the Knee. Available at:
https://www.io.nihr.ac.uk/report/tonogenchoncel-l-invossa-gene-therapy-for-regeneration-of-
cartilage-in-patients-with-degenerative-arthritis-or-osteoarthritis-of-the-knee/. (Accessed: 19 October
2021).
Paxton, S., Knibbs, A. and Peckham, M. (2003) Leeds University, “The Leeds Histology Guide”.
Available at: https://www.histology.leeds.ac.uk/credits.php (Accessed: 12 October 2021).
Pham, T., van der Heijde, D.M.F.M., Altman, R.D., Anderson, J.J., Bellamy, N., Hochberg, M.,
Simon, L., Strand, V., Woodworth, T. and Dougados, M., 2004. OMERACT-OARSI initiative:
Osteoarthritis Research Society International set of responder criteria for osteoarthritis clinical trials
revisited. Osteoarthritis and cartilage, 12(5), pp.389-399.
Redini, F., Daireaux, M., Mauviel, A., Galera, P., Loyau, G. and Pujol, J.P., 1991. Characterization of
proteoglycans synthesized by rabbit articular chondrocytes in response to transforming growth factor-
β (TGF-β). Biochimica et Biophysica Acta (BBA)-Molecular Cell Research, 1093(2-3), pp.196-206.
Riedl, M., Vadalà, G., Papalia, R. and Denaro, V., 2020. Three-dimensional, Scaffold-Free,
Autologous Chondrocyte Transplantation: A Systematic Review. Orthopaedic Journal of Sports
Medicine, 8(9), p.2325967120951152.
Saris, Daniel BF, Johan Vanlauwe, Jan Victor, Karl Fredrik Almqvist, Rene Verdonk, Johan
Bellemans, and Frank P. Luyten. "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." The American journal of sports medicine 37, no.
1_suppl (2009): 10-19.
Tubach, F., Ravaud, P., Baron, G., Falissard, B., Logeart, I., Bellamy, N., Bombardier, C., Felson, D.,
Hochberg, M., van der Heijde, D. and Dougados, M., 2005. Evaluation of clinically relevant changes
1902 0181 01

in patient reported outcomes in knee and hip osteoarthritis: the minimal clinically important
improvement. Annals of the rheumatic diseases, 64(1), pp.29-33.
Van Beuningen, H.M., Van der Kraan, P.M., Arntz, O.J. and Van den Berg, W.B., 1994.
Transforming growth factor-beta 1 stimulates articular chondrocyte proteoglycan synthesis and
induces osteophyte formation in the murine knee joint. Laboratory investigation; a journal of technical
methods and pathology, 71(2), pp.279-290.
Van Der Kraan, P.M., 2017. The changing role of TGFβ in healthy, ageing and osteoarthritic joints.
Nature Reviews Rheumatology, 13(3), pp.155-163.
Van Osch, G.J., Van Der Veen, S.W., Buma, P. and Verwoerd-Verhoef, H.L., 1998. Effect of
transforming growth factor-β on proteoglycan synthesis by chondrocytes in relation to differentiation
stage and the presence of pericellular matrix. Matrix Biology, 17(6), pp.413-424.
Vonk, L.A., Roël, G., Hernigou, J., Kaps, C. and Hernigou, P., 2021. Role of matrix-associated
autologous chondrocyte implantation with spheroids in the treatment of large chondral defects in the
knee: a systematic review. International Journal of Molecular Sciences, 22(13), p.7149.
Wang, Q.G.; Nguyen, B.; Thomas, C.R.; Zhang, Z.; El Haj, A.J.; Kuiper, N.J. Molecular profiling of
single cells in response to mechanical force: Comparison of chondrocytes, chondrons and
encapsulated chondrocytes. Biomaterials 2009, 31, 1619–1625.