Treatment of unstable osteochondritis dissecans lesions of the knee using autogenous osteochondral grafts (mosaicplasty)

Functional Recovery and Clinical Outcome After Internal Fixation Using Osteochondral Autologous Transplantation for Osteochondritis Dissecans of the Knee

Background

Functional recovery and return to sports after fixation of osteochondritis dissecans (OCD) lesions of the knee with osteochondral autologous transplantation (OAT) have not been well investigated.

Purpose

To retrospectively evaluate the functional recovery and clinical outcomes after internal fixation with OAT for knee OCD.

Study Design

Case series; Level of evidence, 4.

Methods

A consecutive series of patients who underwent OAT for OCD lesions between 2010 and 2020 were initially enrolled in the study. Patients with adult-onset OCD and those who underwent fragment removal and/or mosaicplasty were excluded. Lysholm score, Tegner activity scale, return-to-sports rate (at the practice/training and preinjury levels), and time to return were evaluated. Clinical factors influencing postoperative functional recovery were analyzed.

Results

Included were 24 patients (26 knees); there were 23 male and 1 female patients, with a mean age of 14.7 years. The mean follow-up period was 27.6 months. A total of 17 lesions were located in the medial femoral condyle and 9 in the lateral femoral condyle. The mean Tegner score was 7.0 preoperatively and 6.5 postoperatively, with no significant difference. The return-to-sports rate was 96.2% at the practice/training level and 84.6% at the preinjury level, with an average return time of 5.1 months and 9.6 months, respectively. In a subgroup analysis of knees that returned to preinjury level (n = 22) by lesion location, there was a significant difference between knees with lesions in the lateral femoral condyle (12.9 months) versus the medial femoral condyle (8.1 months) (P = .02). The rate of return to preinjury level after primary surgery was significantly higher than after revision surgery after failed drilling (P = .02).

Conclusion

Return-to-sports rates and clinical outcomes were favorable after fixation with OAT in patients with knee OCD. A shorter time to return to sports was observed in knees with medial lesions compared with lateral lesions. Furthermore, the rate of return to sports at the preinjury level was significantly higher after primary surgery than after revision surgery after drilling.

Fixation of an Osteochondral Lesion of the Femoral Intercondylar Groove Using Autogenous Osteochondral Grafts and Bioabsorbable Pins in a Patient with Open Physes: A Case Report

Osteochondral lesion (OCL) of the patellofemoral (PF) joint is not an uncommon cause of knee pain, and surgery is needed when conservative treatment fails. However, there is a lack of evidence regarding the optimal surgical treatment for OCL of the PF joint. Fixation of OCLs using autogenous osteochondral grafts has been reported to be effective for OCL of the knee. However, in this surgical technique, the biomechanical strength of osteochondral grafts may not be sufficient in patients with open physes due to the specific quality of the cartilage and subchondral bone given their age. There is a lack of studies reporting fixation of the OCL located in the PF joint using autogenous osteochondral grafts. We herein report a case of OCL of the femoral intercondylar groove where autogenous osteochondral grafts augmented with bioabsorbable pins were used to fix the lesion in a 14-year-old patient with open physes. Preoperative MRI revealed a completely detached OCL of the intercondylar groove (36 mm × 20 mm). Although a total of four osteochondral grafts were harvested from the non-weightbearing area of the lateral femoral condyle, cartilage detached from one of the grafts. The quality of the osteochondral grafts was considered to be insufficient for stabilization of the OCL; thus, two bioabsorbable pins were additionally inserted following fixation of the lesion using three osteochondral grafts. After two years of follow-up, postoperative functional scores were favorable without knee pain. The present case suggests that fixation of the OCL using autogenous osteochondral grafts may not be appropriate for young patients with open physes.

Biomechanical Analysis of Unstable Osteochondral Fragment Fixation Using Three Different Techniques: Osteochondral Plug, Bioabsorbable Pin, and Suture Anchor with Tape

Purpose

To compare the initial fixation strength of osteochondral fragment fixations using osteochondral plugs, bioabsorbable pins, and knotless suture anchors.

Methods

Eighteen fresh-frozen immature (6 month old) porcine knees were used. An osteochondral fragment, cut from the articular surface of the medial femoral condyle to achieve a thickness of 5 mm, was used to mimic the unstable osteochondral fragment. It was fixed using three techniques, including two osteochondral plugs (osteochondral plug group), four full-threaded poly l-lactic acid pins (bioabsorbable pin group), and three suture anchors with a 2-0 tape (suture anchor group). Tensile loads at displacements of 1 and 2 mm and ultimate failure load were measured at a cross-head speed of 100 mm/min, and the variables of the three groups were compared statistically using a one-way ANOVA with Tukey’s honestly significant difference test.

Results

There was no significant difference in the tensile load to achieve 1-mm displacement. The load to achieve 2-mm displacement and the ultimate failure load were significantly greater in the suture anchor group than the osteochondral plug group and the bioabsorbable pin group.

Conclusions

Single-pull destructive testing of a fixed articular osteochondral fragment with the force perpendicular to the articular surface, demonstrated no statistical difference in the tensile load to achieve 1-mm displacement, but the load to achieve 2-mm displacement was significantly greater for the three suture anchor-interlocking 2-0 tape constructs than the dual osteochondral plug fixation and the four bioabsorbable pin fixation constructs. Additionally, the three suture anchor-interlocking 2-0 tape construct’s mean single-pull failure load was greater than other two fixation procedures.

Clinical Relevance

To achieve osteochondral fragment union, sufficient fixation strength is critical. However, the initial fixation strength of osteochondral plugs, bioabsorbable pins, and knotless suture anchors for unstable osteochondral lesions remains unclear.

Osteochondral Peg Fixation for Chondral Fragment of the Knee in Adolescent Patients: A Report of Two Cases

INTRODUCTION

Purely chondral injuries of the knee are relatively rare, and no consensus exists on the appropriate treatment in such cases. We describe two adolescent patients with chondral injury of the knee who were successfully treated by osteochondral peg fixation. Patients, Concerns, and Clinical Findings. In case 1, a 14-year-old boy presented with complaints of right knee pain after landing on his leg while playing basketball. Radiography and computerized tomography revealed no abnormalities. However, magnetic resonance imaging revealed a chondral defect in his lateral femoral condyle and a loose chondral fragment measuring 6.5 cm2. In case 2, a 12-year-old boy presented with complaints of left knee pain after a rotational injury while playing baseball. Similar to case 1, magnetic resonance imaging revealed a chondral defect in his lateral femoral condyle and a loose chondral fragment measuring 3.0 cm2. Primary Diagnosis, Interventions, and Outcomes. The two patients were treated by surgical fixation using osteochondral pegs, which were harvested from the femoral condyle. After a year, postoperative computerized tomography and magnetic resonance imaging showed union of the chondral fragment with the osteochondral pegs and surrounding tissue. In both cases, the Lysholm score was 100 points at the final follow-up more than 2 years after surgery.

CONCLUSION

The findings reported herein suggest that osteochondral peg fixation is a feasible treatment option for chondral injury of the knee, with satisfactory outcomes.

Arthroscopic versus Open Osteochondral Autograft Transplantation (Mosaicplasty) for Cartilage Damage of the Knee: A Systematic Review

Osteochondral autograft transplantation (OAT) is a surgical option for repairing cartilage damage in knees, and can be performed using open or arthroscopic procedures. The aim of this review was to report clinical outcomes, postoperative complications, defect location, and defect size between open and arthroscopic OATs. Three electronic databases (EMBASE, PUBMED, and MEDLINE) were searched for relevant articles. In regard to eligibility criteria, knee articular damage cases solely treated with OAT were included and cases concomitant with ligament reconstruction, limb realignment, and meniscus repair were excluded. The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and descriptive statistics are presented. A total of 24 studies were included with a total sample of 1,139 patients (532 in open OAT vs. 607 in arthroscopic OAT). Defect size in open OAT was three times larger than that of arthroscopic OAT (2.96 ± 0.76 vs. 0.97 ± 0.48 cm²). In terms of defect location, the medial femoral condyle (MFC) was the most common (75.4%), followed by the lateral femoral condyle (LFC; 12.1%), patella (6.7%), and trochlea (5.7%). All of these defect locations were treated with open OAT, whereas arthroscopic OAT treatments were restricted to the MFC and LFC. The clinical outcomes were overall favorable with the modified Hospital for Special Surgery knee scores being 89.6 ± 8.0 (36.1-month follow-up) versus 90.4 ± 6.0 (89.5-month follow-up) and the Lysholm scores being 81.6 ± 8.9 (44.2-month follow-up) and 83.3 ± 7.4 (12.0-month follow-up) between open and arthroscopic OATs, respectively. Fifty-three postoperative complications were observed (39/279 vs. 14/594) and the most common complication was hemarthrosis (13/39 in open, vs. 1/14 in arthroscopic OAT). The overall clinical outcomes were favorable in open and arthroscopic OATs, whereas open OAT allowed for treatment of lesions approximately three times greater in dimension than in arthroscopic OAT. Also, defect location was restricted to MFC and LFC in arthroscopic OAT. The most common complication was hemarthrosis.

Osteochondritis Dissecans of the Knee: Short-Term Outcomes of a Hybrid Technique to Restore a Partially Salvageable Progeny Fragment

OBJECTIVE

This retrospective case series describes a hybrid fixation technique and determines the clinical outcomes, knee function, and activity level of patients at short-term follow-up.

DESIGN

Seventeen patients (18 knees) with unstable osteochondritis dissecans (OCD) lesions involving the knee were treated with a hybrid fixation technique in which the salvageable fragment was fixed and osteochondral autograft transplantation system (OATS) was used for the unsalvageable fragment. Thirteen lesions involved the medial femoral condyle, 4 involved the lateral femoral condyle, and 1 involved the patella. Mean patient age was 17 years (range 12-28 years). All lesions were International Cartilage Repair Society (ICRS) grade III or IV. The patients were prospectively followed postoperatively. Outcome measures included the International Knee Documentation Committee (IKDC) score, Knee injury and Osteoarthritis Outcome Score (KOOS), and the Tegner activity scale.

RESULTS

At mean follow-up of 36 months (range 24-67.2 months), the mean postoperative KOOS scores, given as mean (SD), were as follows: Quality of Life (QoL) 91.1 (17.0), Activities of Daily Living (ADL) 99.5 (1.5), Sport 94.5 (11.2), Pain 97.4 (5.8), and Symptoms 95.9 (6.5). Mean IKDC score was 96.2 (7.0). There was no significant difference between mean preinjury (7.95, SD = 1.1) and mean postoperative (7.45, SD = 1.5) Tegner scores (P = 0.363). The mean Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score was 87.5 at a mean 7.8 months (range 3-18 months) postoperation. There were no reported complications.

CONCLUSION

The results of this case series suggest that patients with partially salvageable OCD lesions involving the knee can have positive short-term outcomes and can expect a low complication rate when treated with a hybrid technique of fixation with osteochondral autograft transfer.

Unstable Osteochondritis Dissecans of the Glenoid Fixed with Autogenous Osteochondral Plugs in a College Baseball Player: A Case Report

CASE

A 19-year-old college baseball outfielder presented with a 3-month history of right shoulder pain. Radiographs, computed tomography, and magnetic resonance imaging showed a large osteochondral defect at the posterosuperior aspect of the glenoid. Arthroscopic evaluation identified an unstable fragment that was partially attached. Fixation of the osteochondral fragment was achieved with autogenous osteochondral plugs through a posterior arthrotomy. At 8 months after surgery, the patient was able to return to his former competitive level of performance.

CONCLUSION

Osteochondritis dissecans (OCD) rarely affects the glenoid. Fixation of a large glenoid OCD lesion with autogenous osteochondral plugs was a successful treatment in this patient.

Osteochondral Allograft Transplantation Surgery for Osteochondral Lesions of the Talus in Athletes

Osteochondral lesions of the talus (OLTs) continue to be a challenge for the treating surgeon, especially when lesions are refractory to marrow stimulation techniques. The purpose of this study is to evaluate the outcomes of lesions treated with osteochondral allograft transplantation. A review was performed of 30 athletes with 31 OLTs that were refractory to marrow stimulation or predicted to be refractory based on size and location of the lesion. Results were evaluated in terms of occupational outcomes and numeric pain scales. Lesions treated had a mean area of 1.37 (range 0.36 to 3.3) cm². Overall excellent outcomes were achieved in 11 (35%) ankles. Nineteen (61%) ankles achieved good or excellent occupational outcomes, and 12 (39%) ankles demonstrated poor occupational outcomes and the patients were unable to continue their previous active occupations. Patients were found to have a mean pain scale score of 3 (range 0 to 7) of 10 at a mean of 21 (range 10 to 24) months after operative management. Osteochondral allograft transplantation is an option for the treatment of selected athletes with large OLTs, as well as lesions that are refractory to marrow stimulation techniques. The results of this study may help active young patients and their surgeons to better understand outcomes and options in their shared decision-making process.

Juvenile osteochondritis dissecans (JOCD) of the knee: current concepts review

Juvenile osteochondritis dissecans (JOCD) is a joint disorder of the subchondral bone and articular cartilage that affects skeletally immature patients.

The aetiology of JOCD is unknown and the natural history is poorly characterized in part due to inconsistent and largely retrospective literature.

Most OCD in children and adolescents presents as a stable lesion amenable to non-operative treatment or minimally invasive drilling. However, unstable forms can require a more aggressive approach.

This article reviews the most recent literature available and focuses on the pathophysiology, diagnosis and treatment of JOCD of the knee.

Cite this article: EFORT Open Rev 2019;4:201-212. DOI: 10.1302/2058-5241.4.180079

Neither significant osteoarthritic changes nor deteriorating subjective outcomes occur after hybrid fixation of osteochondritis dissecans in the young adult

PURPOSE

The goal of the fixation of painful osteochondritis dissecans of the femoral condyles in adults is to integrate the osteochondral fragment and thus achieve a normal hyaline cartilaginous coverage. The addition of a biological process to primary fixation may result in improved fragment integration (hybrid fixation). Osteochondral plugs may fulfil this role. The aim of this study was to evaluate long-term clinical and radiological results after hybrid fixation of unstable osteochondritis dissecans. The hypothesis was that the rate of secondary osteoarthritis would be low.

METHODS

Nine patients treated by hybrid fixation were retrospectively reviewed at a median follow-up of 10.1 years (range 7-14). The median age at surgery was 21 (range 17-28). Six of them were evaluated as ICRS grade II and three, as ICRS grade III. The mean surface of the lesion was 4.5 cm². All patients were followed up clinically (IKDC, KOOS, Lysholm) and radiologically [Kellgren-Lawrence score (KL)].

RESULTS

During arthroscopic assessment at the time of screw removal (3 months after surgery), the fragments were stable, and autograft plugs were all well integrated. At the most recent follow-up visit, the median IKDC score was 85.8 (range 51.72-100), the KOOS score was 87.7 (52.4-100), and the Lysholm scale score was 89.8 (77-100). In 7 out of 9 patients, radiographs showed a joint space KL grade of 0 or 1.

CONCLUSION

Hybrid fixation for treating osteochondritis dissecans lesions of the femoral condyles using mechanical and biological fixation provides healing of the osteochondral fragments with good long-term outcomes. No significant osteoarthritic change was seen with this technique at a mid-term follow-up.

LEVEL OF EVIDENCE

IV-case series.

Orthopedic Surgical Options for Joint Cartilage Repair and Restoration

The limited natural capacity for articular cartilage to regenerate has led to a continuously broadening array of surgical interventions. Used once patients' symptoms are not relieved by nonoperative management, these share the goals of joint preservation and restoration. Techniques include bone marrow stimulation, whole-tissue transplantation, and cell-based strategies, each with its own variations. Many of these interventions are performed arthroscopically or with extended-portal techniques. Indications, operative techniques, unique benefits, and limitations are presented.

Hybrid fixation in adult osteochondritis dissecans of the knee

Osteochondritis dissecans progresses to osteoarthritis if integration of the fragment is not obtained. The prognosis of osteochondritis dissecans is more severe in adults, as spontaneous integration due to physeal closure does not occur. Hybrid fixation consists in combining screw fixation of the fragment with mosaicplasty through the fragment to promote integration into the native condyle. We describe this technique with reference to 17 patients.

Viability of Cells From Displaced Fragments of the Elbow Osteochondritis Dissecans: Alternative Source of Autologous Chondrocyte Implantation

PURPOSE

To assess the histological properties of cells from displaced fragments obtained from patients with advanced osteochondritis dissecans (OCD) of the elbow and to examine whether these displaced fragments could be used as cell sources for autologous chondrocyte implantation.

METHODS

We harvested 6 displaced fragments from 6 patients who underwent osteochondral mosaicplasty for OCD of the elbow. The displaced fragments were examined histologically and digested to obtain chondrocytes. The cells obtained from young patients and skeletally matured cadaveric donors were examined using quantitative reverse transcription polymerase chain reaction analysis to quantify the expression of chondrocyte marker genes. The cells were cultured in atelocollagen, and the properties of 3-dimensional cultured cartilage were examined.

RESULTS

All 6 displaced fragments contained hyaline cartilage tissue. Chondrocyte marker genes were examined using cells from only 4 patients, because we obtained enough cells in only 4 patients. The relative expression levels of aggrecan, type II, Sox 9 were 2.61, 4.03, and 1.71, respectively. Three-dimensional cultured cartilage from all 6 displaced fragments contained 62.0 pg/cell (range, 22.8-91.3 pg/cell) of glycosaminoglycan and expressed type II collagen in the superficial and middle layer.

CONCLUSIONS

The chondrocytes obtained from the displaced fragments remained viable and exhibited chondrogenic features. These cells may potentially be a cell source of autologous chondrocytes implantation.

CLINICAL RELEVANCE

We have shown that displaced fragments from OCD of the elbow have potential for a cell source for generating 3-dimensional cultured cartilage.

Treatment of unstable osteochondritis dissecans in adults with autogenous osteochondral grafts (Mosaicplasty): long-term results

PURPOSE

the unstable osteochondritis dissecans (OCD-type II and III according to the ICRS classification) of the knee largher than > 2.5 cm(2) in adults are uncommon lesions and there is no consensus on how to treat them. Medium-term studies have reported good results using autogenous osteochondral plugs (mosaicplasty). The aim of this study is to analyze the long-term results of this technique for the treatment of unstable OCD in a selected group of adult patients.

METHODS

four patients with OCD at either one of the femoral condyles were included in this prospective study. The average age was 21.2 years (range, 18-24 years). The OCD lesions were classified as type II in three patients and type III in one patient and the average size was 3.8 cm(2) (range, 2.55-5.1 cm(2)). The lesions were treated in situ with a variable number of autogenous osteochondral plugs (Ø 4.5 mm(2)). The Modified Cincinnati, Lysholm II and Tegner scores were used for clinical and functional evaluation. Magnetic resonance arthrography (MRA) was performed before surgery and at 2, 5 and 10 years after surgery. A modified MOCART score was used to evaluate MRA findings.

RESULTS

the average follow-up duration was ten years and 6 months (range, 10-11 years). No complications occurred. At the final follow-up, all scores (clinical, functional and MOCART) improved. In all but one of the patients MRA showed complete osteochondral repair.

CONCLUSIONS

the fixation of large and unstable OCD lesions with mosaicplasty may be a good option for treating type II or III OCD lesions in adults. The advantages of this technique include stable fixation, promotion of blood supply to the base of the OCD fragment, and grafting of autologous cancellous bone that stimulates healing with preservation of the articular surface.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Juvenile osteochondritis dissecans in the lateral femoral condyle requiring osteochondral autograft as a revision procedure: a case report

Background

The optimal treatment option for osteochondritis dissecans of the knee is still controversial. We report the case of a boy who developed osteochondritis dissecans in the lateral femoral condyles of his bilateral knees requiring repeat surgical procedures. There has been no literature reporting juvenile osteochondritis dissecans of bilateral knees requiring repeat surgical procedures.

Case presentation

A 6-year-old Japanese boy presented with pain in his bilateral knees. Although conservative treatment with prohibition of sports activities was continued for 6 months, healing could not be attained. Conservative treatment consisting of prohibition of sports activities that included running and jumping and use of a brace with a locking mechanism at full extension was applied. He was instructed to walk with the brace. Since his lateral femoral osteochondritis dissecans lesion was located at the contact area during flexion, weight bearing with the use of the brace could effectively unload the lesion. Surgery was subsequently conducted on his left knee which had a more advanced stage lesion. Transchondral drilling was performed because the articular surface maintained its smooth continuity. At 9 months after the surgery, no appreciable healing was observed in the follow-up radiographs. Moreover, during the postoperative time course, lesions suggestive of osteochondritis dissecans in his contralateral right knee had become more evident. Based on the diagnosis of delayed union of bilateral osteochondritis dissecans lesions, a second surgery was attempted. The preceding arthroscopic observation of his left knee showed preserved surface continuity with softening and suspected partial detachment. Considering the delayed healing process observed in this patient, autogenous cylindrical osteochondral graft transplantation (8 mm in diameter) was performed as a revision procedure, while transchondral drilling was performed for the stable osteochondritis dissecans lesion in his right knee. Postoperatively, healing was achieved at 6 months.

Conclusions

Following failed conservative treatment, he underwent arthroscopic drilling; however, the osteochondritis dissecans lesion did not heal requiring revision surgery using a cylindrical autogenous osteochondral graft. Finally, clinical and radiological healing was attained 6 months after the second surgery. Initial presentation at a young age with bilateral lesions may be clinical factors related to poor healing response and susceptibility to stress-related subchondral lesions.

Functional and radiographic outcomes of unstable juvenile osteochondritis dissecans of the knee treated with lesion fixation using bioabsorbable pins

BACKGROUND

The purpose of this study was to evaluate the functional and radiographic outcome of fixation of unstable juvenile osteochondritis dissecans lesions of the knee after a minimum of 2 years of follow-up.

METHODS

A total of 33 unstable juvenile osteochondritis dissecans lesions in 30 patients underwent fixation using bioabsorbable pins through arthrotomy or under arthroscopy. The patients consisted of 23 males and 7 females, and the average age at the time of operation was 14.4 years (range, 11 to 17 y). The functional outcomes were evaluated using the Lysholm score and Hughston's criteria at a mean follow-up of 3.3 years (range, 2.1 to 6.3 y). Healing of the osteochondritis dissecans lesions were confirmed by plain radiographs and magnetic resonance imaging.

RESULTS

The Lysholm score improved significantly at 3 months after the surgery, and was maintained until the final follow-up. Radiographically, 32 of 33 lesions healed after fixation of the lesion (healing rate was 97.0%). Healing was achieved at an average of 2.4 months on plain radiographs and 4.2 months on magnetic resonance imaging. According to Hughston's criteria, 25 patients were graded as excellent, 4 as good, and 1 as poor at the final follow-up.

CONCLUSIONS

The fixation of the unstable juvenile osteochondritis dissecans lesions with bioabsorbable pins demonstrated improved clinical outcomes and radiographic high healing rates at a mean of 3.3 years of follow-up. We advocate this procedure for patients with unstable juvenile osteochondritis dissecans lesions of sufficient quality to enable fixation which will preserve the normal contour of the distal femur.

LEVEL OF EVIDENCE

Level IV-retrospective case series.

Fixation of femoral head fractures with autologous osteochondral transfer (mosaicplasty)

Posterior fracture dislocation of the femoral head is a rare entity usually requiring open reduction and internal fixation. Results of different fixation methods have been reported, including countersinking screws, headless screws, and bioabsorbable implants. Osteochondral autologous transfer (mosaicplasty) is an established method of treatment of full thickness cartilage defects of the knee, ankle, and elbow. At our institution, posterior fracture-dislocations of the femoral head were treated with femoral head fragment fixation using osteochondral autografts through surgical hip dislocation. Osteochondral plugs were harvested from the non-weight-bearing area of the lateral femoral condyle of the knee and used for fixation of the reduced fragment. This article details the technique and its application.

Surgical options for articular defects of the knee

Cartilage and osteochondral defects of the knee can in most cases be treated with total knee replacement in the elderly population. However, these lesions pose a difficult treatment problem in the younger patient. A number of surgical options are available today to address this increasingly common condition and each has its own indications and limitations. This article reviews debridement and microfracture, fixation, metallic spacing devices, autologous chondrocyte implantation, osteochondral autograft transplantation, fresh cadaveric allografts and osteotomies. In addition, possible future developments are discussed.

Is platelet-rich plasma able to enhance the results of arthroscopic microfracture in early osteoarthritis and cartilage lesion over 40 years of age?

Most studies suggested that arthroscopic microfracture is effective method at only less than 40 years of age. Thus, the authors thought that "how can this indication regarding age be extended?," and tried to find a way to use this technique effectively over 40 years of age. The aim of this study was the first to report the results regarding the PRP as an adjunct for arthroscopic microfracture in the early osteoarthritic (OA) knee with cartilage lesion over 40 years of age. 49 patients who underwent arthroscopic microfracture for cartilage lesion sized less than 4 cm(2) with early OA, aged 40-50 years, were enrolled and randomly divided into 2 groups: a control group with only arthroscopic microfracture (25 patients) and a study group with arthroscopic microfracture and PRP (24 patients). The patients were prospectively evaluated with VAS, IKDC score at preoperative and postoperative 1, 6, 12, and 24 months. And we perform second arthroscopies in 10 patients of each group to identify the extent of cartilage restoration at 4-6 months postoperatively. There were significant improvements in clinical results between preoperative evaluation and postoperative 2 years in both groups (p = 0.017). In the postoperative 2 years, clinical results showed significantly better in the study group than in the control group (p = 0.012). In post-arthroscopic finding, hardness and elasticity degree was better in the study group. The PRP injection with arthroscopic microfracture would be improved the results in early osteoarthritic knee with cartilage lesion in 40-50 years old, and the indication of this technique could be extended to 50 years.

Can fresh osteochondral allografts restore function in juveniles with osteochondritis dissecans of the knee?

BACKGROUND

Failure of initial treatment for juvenile osteochondritis dissecans (OCD) may require further surgical intervention, including microfracture, autograft chondrocyte implantation, osteochondral autografting, and fresh osteochondral allografting. Although allografts and autografts will restore function in most adults, it is unclear whether fresh osteochondral allograft transplantations similarly restore function in skeletally immature patients who failed conventional treatment.

QUESTIONS/PURPOSES

Therefore, we determined function in (1) daily activity; (2) sports participation; and (3) healing (by imaging) in children with juvenile OCD who failed conventional therapy and underwent fresh osteochondral allograft transplantation.

METHODS

We retrospectively reviewed 11 children with OCD of the knee treated with a fresh stored osteochondral allograft between 2004 and 2009 (six males and five females). The average age of the children at the time of their allograft surgery was 15.2 years (range, 13-20 years). The clinical assessments included physical examination, radiography, MRI, and a modified Merle D'Aubigné-Postel score. The size of the allograft was an average of 5.11 cm(2). The minimum followup was 12 months (average, 24 months; range, 12-41 months).

RESULTS

All patients had returned to activities of daily living without difficulties at 6 months and returned to full sports activities between 9 and 12 months after surgery. The modified Merle D'Aubigné-Postel score improved from an average of 12.7 preoperatively to 16.3 at 24 months postoperatively. Followup radiographs at 2 years showed full graft incorporation and no demarcation between the host and graft bone.

CONCLUSIONS

Our observations suggested fresh osteochondral allografts restored short-term function in patients with juvenile OCD who failed standard treatments.

LEVEL OF EVIDENCE

Level IV, case series. See Guidelines for Authors for a complete description of levels of evidence.

Ten-year follow-up of a prospective, randomized clinical study of mosaic osteochondral autologous transplantation versus microfracture for the treatment of osteochondral defects in the knee joint of athletes

BACKGROUND

Various techniques have proven to be effective for treating articular cartilage defect (ACD) and osteochondral defect (OCD) of the knee joint, but knowledge regarding which method is best still remains uncertain.

PURPOSE

To evaluate and compare the outcomes of mosaic-type osteochondral autologous transplantation (OAT) and microfracture (MF) procedures for the treatment of articular cartilage defects of the knee joint in young active athletes. This article represents an update of the clinical results at 10 years.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

Between 1998 and 2002, a total of 60 athletes with a mean age of 24.3 years (range, 15-40 years) and with a symptomatic ACD or OCD in the knee were randomized to undergo either OAT or MF. Patients were then evaluated postoperatively using the International Cartilage Repair Society (ICRS) score, Tegner activity score, radiographs, and magnetic resonance imaging. The mean follow-up time was 10.4 years (range, 9-11 years).

RESULTS

Three to 10 years after the OAT and MF procedures, patients had lower ICRS and Tegner scores (P < .05), but both groups still had significant clinical improvement over presurgery scores according to ICRS scores at 10-year follow-up. Statistically significantly better results were detected in patients in the OAT group compared with those in the MF group at 10 years (P < .005). At 10-year follow-up, there were 15 failures (26%), including 4 failures (14%) of the OAT and 11 failures (38%) of MF treatment (P < .05). Seven patients (25%) from the OAT group and 14 patients (48%) from the MF group had radiographic evidence of Kellgren-Lawrence grade I osteoarthritis at 10 years, but these differences were not significant (P = .083) or related to the clinical results. The ICRS and Tegner scores of younger athletes (<25 years at the time of primary surgery) remained significantly higher after 10 years compared with older patients (P < .05); 15 of 20 patients (75%) in the OAT group and 8 of 22 patients (37%) in the MF group maintained the same physical activity level.

CONCLUSION

The OAT technique for ACD or OCD repair in the athletic population allows for a higher rate of return to and maintenance of sports at the preinjury level compared with MF.

Osteochondral autograft transplantation for juvenile osteochondritis dissecans of the knee: a series of twelve cases

PURPOSE

The purpose of this study was to evaluate the clinical outcomes of osteochondral autograft transplantation (OAT) for juvenile osteochondritis dissecans (JOCD) lesions of the knee, especially time to return to sports.

METHODS

Twelve knee JOCD lesions with OCD grade 3 and 4 categorised by magnetic resonance imaging (MRI) were treated with OAT. Nine male and two female skeletally immature patients averaging 13.7 years old were included. The OCD lesions were assessed arthroscopically and then fixed in situ using multiple osteochondral plugs harvested under fluoroscopy from the distal femoral condyle without damaging the physis. International Cartilage Repair Society (ICRS) score and Lysholm score were assessed pre- and postoperatively.

RESULTS

After a mean follow-up of 26.2 ± 15.1 months, the International Knee Documentation Committee (IKDC) subjective score significantly improved (p < 0.01). According to the IKDC score, objective assessment showed that ten of 12 (83 %) had excellent results (score: A) after OAT and significantly improved (p < 0.01). Based on ICRS criteria, results were satisfactory in all patients. No patients experienced complications at the graft harvest site. All patients returned to their previous level of athletic activity at an average of 5.7 months after the surgery.

CONCLUSIONS

OAT for JOCD of the knee provided satisfactory results in all patients at a mean follow-up of 26.2 months.

Effectiveness and limitations of autologous osteochondral grafting for the treatment of articular cartilage defects in the knee

PURPOSE

To evaluate the effectiveness and limitations of autologous osteochondral grafting for the treatment of articular cartilage defects in the knee.

METHODS

The subjects were 40 patients who had undergone autologous osteochondral grafting. Fifteen knees had cartilage defects combined with anterior cruciate ligament tears (ACL group), 15 knees had cartilage defects combined with osteoarthritis (OA group), and 10 knees had cartilage defects combined with osteochondral dissecans (OCD group). From one to five osteochondral pegs were harvested from the less-weight-bearing periphery of the articular surface of the femoral condyle and grafted to cartilage defects. The clinical results were assessed based on the Lysholm score and radiographic and magnetic resonance imaging (MRI) image assessment.

RESULTS

The median follow-up duration was 24 months (range from 12 to 41 months). The mean Lysholm score following treatment was improved in all groups. The patients who had cartilage defects combined with OA had a significantly poorer prognosis than did those with cartilage defects combined with ACL or OCD. In the OA group, advanced stage and an alignment abnormality were correlated with poor prognosis. Advanced age was correlated with poor prognosis. Other parameters showed no significant difference in prognosis.

CONCLUSION

Autologous osteochondral grafting was found to be an effective technique for treating relatively young patients who had cartilage defects combined with ACL injury or OCD, but this technique showed limited results in treating cartilage defects based on advanced patient age and degenerative changes in the cartilage.

LEVEL OF EVIDENCE

Diagnostic studies-investigating a diagnostic test, Level III.

Fresh osteochondral allograft for the treatment of cartilage defects of the talus: a retrospective review

BACKGROUND

Osteochondral lesions of the talar dome can cause substantial functional impairment and present a difficult treatment dilemma. Interest has recently focused on fresh osteochondral allografts as a promising treatment alternative. The purpose of this study was to evaluate the clinical outcome of osteochondral lesions of the talus treated with a fresh osteochondral allograft.

METHODS

We performed a transfer of fresh osteochondral allograft in forty-two patients with a symptomatic, refractory osteochondral lesion of the talus. Complete postoperative follow-up was achieved for thirty-eight patients with an average age of 44.2 years. Clinical evaluation was performed with use of the American Orthopaedic Foot & Ankle Society ankle-hindfoot score and a visual analog pain scale. All scores were obtained from either a retrospective chart review or a direct patient interview. All patients were also asked about their subjective satisfaction with the procedure. Magnetic resonance images were acquired for fifteen patients, to assess graft incorporation, subsidence, articular cartilage congruity, osteoarthritis, and stability with use of the De Smet criteria.

RESULTS

The average duration of follow-up after osteochondral allograft transplantation was 37.7 months. Graft failure occurred in four patients. With the inclusion of scores before revision for those with graft failure, the mean visual analog pain scale score improved from 8.2 to 3.3 points, and the mean American Orthopaedic Foot & Ankle Society ankle-hindfoot score improved from 52 to 79 points. Patient satisfaction with the outcome was rated as excellent, very good, or good by twenty-eight of the thirty-eight patients and as fair or poor by ten patients. Of the fifteen magnetic resonance imaging scans, most showed minimal graft subsidence, reasonable graft stability, and persistent articular congruence.

CONCLUSIONS

In our experience, transplantation of fresh osteochondral allograft is a viable and effective method for the treatment of osteochondral lesions of the talus as evidenced by improvements in pain and function.

Chondral repair of the knee joint using mosaicplasty

Mosaicplasty grafting is performed by transferring one or more cylindral osteochondral autografts from a low weight-bearing area of the knee towards the defective site, usually the femoral condyle. Numerous biomechanical, histological, animal and clinical studies have evaluated the different technical aspects of this procedure. The preoperative work-up encompasses an evaluation of functional disturbances, alignment, knee stability and imaging (CT arthrography or MRI with cartilage sequences). The surgical procedure includes harvesting the grafts by mini-arthrotomy of the medial or lateral trochlea and a stage for arthroscopic graft insertion. The ICRS classification is used to describe the defect (area, depth, location) before and then after debridement. A few, large diameter grafts are harvested from the trochlea across from the defect. The graft plugs are transplanted by press-fit, flush with the cartilage, along a convergent plane in recipient sockets of exactly the same depth. Each stage, harvesting, drilling and insertion is repeated until all the full-thickness gap region has been covered. Postoperative movement is free but weight-bearing is delayed for 2 to 4 weeks. Mosaicplasty is indicated in young patients (under 50), with symptomatic chondral or osteochondral defects of less than 3 cm in the weight-bearing part of the femoral condyle. Pre-osteoarthritis is an absolute contraindictation for this procedure. Any misalignment (of more than 5°) or sagittal instability is treated simultaneously. This is a difficult and demanding procedure.

Hybrid fixation: evaluation of a novel technique in adult osteochondritis dissecans of the knee

PURPOSE

Treatment of osteochondritis dissecans of the adult knee requires bone and cartilage integration of the loose fragment. Screw fixation provides primary stability but does not guarantee bony consolidation. Additional biological fixation using osteochondral grafts-hybrid fixation-could improve fragment integration.

METHODS

The study included seven patients [median age 21 years (15-29)] who underwent surgery for Bedouelle IIB or III osteochondritis dissecans of the medial femoral condyle. The technique involved metal screw fixation of the fragment. Mosaicplasty grafts were then press-fitted through the fragment. Cancellous autograft was utilized in the cases of subchondral bone loss. Patients were followed up clinically and radiologically (Hughston score). Screws were removed arthroscopically at 3 months and the cartilage graded using the International Cartilage Repair Society score. Fragment integration was evaluated by MRI Arthrogram (4 patients).

RESULTS

Median follow-up was 27 months (7-35). Median clinical Hughston score was 2 (0-3) preoperatively and 4 (2-4) postoperatively. Median radiological Hughston score was 3 (2-4) and 4 (3-4). During arthroscopic removal of metalwork, osteochondritis fragments were well integrated in all cases. The International Cartilage Repair Society score was I in one patients, II in five, and III in one. Postoperative MRI arthrograms confirmed that cartilage and bone integration was complete.

CONCLUSIONS

Isolated screw fixation of osteochondritis dissecans in adults provides poor bony integration. Mosaicplasty is an alternative but does not retain normal condylar anatomy. The hybrid fixation technique adds a biological "booster" to osteochondritis fixation, with excellent short-term outcome. Further studies are required to investigate the long-term results.

Magnetic Resonance Imaging of Cartilage Repair: A Review

Articular cartilage lesions are a common pathology of the knee joint, and many patients may benefit from cartilage repair surgeries that offer the chance to avoid the development of osteoarthritis or delay its progression. Cartilage repair surgery, no matter the technique, requires a noninvasive, standardized, and high-quality longitudinal method to assess the structure of the repair tissue. This goal is best fulfilled by magnetic resonance imaging (MRI). The present article provides an overview of the current state of the art of MRI of cartilage repair. In the first 2 sections, preclinical and clinical MRI of cartilage repair tissue are described with a focus on morphological depiction of cartilage and the use of functional (biochemical) MR methodologies for the visualization of the ultrastructure of cartilage repair. In the third section, a short overview is provided on the regulatory issues of the United States Food and Drug Administration (FDA) and the European Medicines Agency (EMEA) regarding MR follow-up studies of patients after cartilage repair surgeries.

Midterm results of biologic fixation or mosaicplasty and drilling in osteochondritis dissecans

BACKGROUND

Osteochondritis dissecans (OCD) primarily affects subchondral bone. Multiple drilling, fixation implant or autogenous osteochondral grafts are reported as treatment options. We present the midterm results of cases in which an OCD lesion was treated by osteochondral autograft transfer and drilling.

MATERIALS AND METHODS

Between 2002 and 2006, 14 knees with International Cartilage Repair Society (ICRS-OCD) type II and III lesions were treated in our clinic using osteochondral autograft transfer and drilling by arthroscopic or open surgery. The average age of our patients was 22.14 years (range 17-29 years) and average followup was of 24.3 months (range 11-40 months). Lesion type was ICRS type II in five patients (35.7%) and ICRS type III in nine patients (64.3%). In cases with ICRS-OCD type II lesions, in situ fixation was applied following circumferential multiple drilling, while mosaicplasty was done following debridement and multiple drilling in cases with ICRS-OCD type III lesion. Mosaicplasty was performed in the lesion area by an average of 2.5 (range 1-3) cylindrical osteochondral autografts. Patients were not allowed to perform loading activities for 3 weeks in the postoperative period; movement was initiated by using CPM device in the early phase; full range of motion was achieved in third week, and full weight bearing was permitted in 6 to 8 weeks

RESULTS

While 6 and 8 patients were classified preoperatively as fair and poor, respectively, according to Hughston scale, excellent and good results were obtained postoperatively in 10 and 4 patients, respectively. During the followup, no problems were detected in any of the patients in the regions where osteochondral graft was harvested.

CONCLUSION

Biologic fixation or mosaicplasty and drilling as a technique to treatment of the lesion in OCD by osteochondral autograft transfer has resulted in good and excellent clinical outcomes in our patients and it is considered that providing blood flow to subchondral bone by circumferencial drilling leads to an increase in the robustness of biological internal fixation and shortens the duration of recovery.

Arthroscopic surgery in children

Arthroscopic surgery for children and adolescents is developing fast, thanks to technical progress in adult arthroscopy, improved knowledge of child joint disorders, and instrument miniaturization. The specificity of arthroscopy in children lies, on the one hand, in the small joint size and, on the other, in the presence of neighboring growth plates. There also exist specific pathologies as well as differences in indications in pathologies common to children and adults. These specificities need to be known, and adapted techniques and equipment require to be used, given which arthroscopy is feasible even in infants. Growth plate must be respected, and the residual growth of the operated segment (e.g., in knee ligament reconstruction) needs to be known. Joint decoaptation often does not require traction, and any stress maneuvers (valgus/varus) need to be gentle. The knee is by far the most frequently implicated joint in child arthroscopy, partly due to a rise in sports injuries. There is a variety of traumatic pathologies (osteochondral or meniscal/ligament tears, etc.) and of indications. Arthroscopy in children is safe, given awareness of these indications and respect of certain precautions. The advantages over conventional open surgery are the same as in adults: simpler postoperative course, faster functional recovery and better esthetic result. Arthroscopy will continue to develop in pediatrics in coming years.

Fixation of detached osteochondritis dissecans lesions with bioabsorbable pins: clinical and histologic evaluation

PURPOSE

The purpose was to evaluate the effect of fixation of detached free fragments of osteochondritis dissecans (OCD) (International Cartilage Repair Society OCD IV) on not only the clinical outcome, including functional and radiographic assessment, but also postoperative second-look arthroscopic and histologic evaluation.

METHODS

Nine International Cartilage Repair Society OCD IV fragments were fixed with bioabsorbable pins made of poly-L-lactic acid after curettage of the bed and bone grafting. In 4 cases with severe cartilage damage in the fragments, after resection of the damaged part, trimmed fragments were fixed and osteochondral autologous transplantation was performed to cover the remaining defects. The follow-up period was at least 2 years (range, 2 to 3 years). Lysholm score and computed tomography (CT)/magnetic resonance imaging (MRI), second-look arthroscopy, and biopsy findings were examined postoperatively.

RESULTS

All patients ultimately could return to previous sports activity, and the mean postoperative Lysholm score was 97 (range, 90 to 100). At 6 months, CT/MRI scans showed complete union and smooth continuity of articular surface in all cases. Second-look arthroscopy in 7 cases showed that fixed fragments were stable and that there were no progressive degenerative changes in the cartilage. Postoperative histologic examination in 4 cases showed almost normal cartilage from surface to bottom in terms of viability and quality. In addition, new bone trabeculae were covering dead bone trabeculae, which is called creeping substitution.

CONCLUSIONS

Our study shows good short-term clinical results, as well as confirmation of healing on CT/MRI and second-look arthroscopy.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

A prospective, randomized clinical study of osteochondral autologous transplantation versus microfracture for the treatment of osteochondritis dissecans in the knee joint in children

PURPOSE

The aim of this study was to compare the outcomes of the arthroscopic mosaic-type osteochondral autologous transplantation (OAT) and microfracture (MF) procedures for the treatment of osteochondritis dissecans (OCD) defects of the femoral condyles of the knee joint in children under the age of 18 years.

TYPE OF STUDY

Prospective, randomized clinical study.

METHODS

Between 2001 and 2005, a total of 50 children with a mean age of 14.3 years (12 to 18) and with symptomatic lesions of the OCD in the femoral condyle of the knee were randomized to undergo either the OAT or the MF procedure. Only those children with grade 3 or 4 (OCD) in the medial or lateral femoral condyle (according to International Cartilage Repair Society, ICRS) were included in the study. Forty-seven patients (94%) were available for follow-up. There were 25 patients in the OAT group and 22 patients in the MF group. The mean duration of symptoms was 23.54+/-4.24 months and the mean follow-up was 4.2 years (range from 3 to 6 y), and none of the children had prior surgical interventions to the affected knee. Children were evaluated using ICRS score, x-rays, magnetic resonance imaging, and second-look arthroscopies.

RESULTS

After 1 year, both groups had significant clinical improvement (P<0.05) and the ICRS functional and objective assessment showed that 23 of 25 (92%) patients had excellent or good results after OAT compared with 19 of 22 (86%) after MF (NS), but 19 of 23 (83%) after OAT and only 12 of 19 (63%) after MF procedure maintained excellent or good results after 4.2 years (range from 3 to 6 y). The MF group showed significant deterioration over the 4.2 years follow-up (P<0.05), but still had significant clinical improvement compared with pretreatment evaluation (P=0.004). There were 9 of 22 (41%) failures in the MF group, and none in the OAT group. Magnetic resonance imaging evaluation according to the ICRS evaluation system showed excellent or good repairs in 19 of 21 patients (91%) after OAT compared with 10 of 18 (56%) after MF.

CONCLUSIONS

At an average of 4.2 years follow-up, our prospective, randomized, clinical study in children under the age of 18 years has shown significant superiority of the mosaic-type OAT over MF for the treatment of osteochondritis dissecans defects in the knee. However, our study has shown that both MF and OAT give encouraging clinical results for children under the age of 18 years.

LEVEL OF EVIDENCE

Level 1: randomized controlled trial, significant difference.

Management of articular cartilage defects of the knee

Articular cartilage has a poor intrinsic capacity for healing. The goal of surgical techniques to repair articular cartilage injuries is to achieve the regeneration of organized hyaline cartilage. Microfracture and other bone marrow stimulation techniques involve penetration of the subchondral plate in order to recruit mesenchymal stem cells into the chondral defect. The formation of a stable clot that fills the lesion is of paramount importance to achieve a successful outcome. Mosaicplasty is a viable option with which to address osteochondral lesions of the knee and offers the advantage of transplanting hyaline cartilage. However, limited graft availability and donor site morbidity are concerns. Transplantation of an osteochondral allograft consisting of intact, viable articular cartilage and its underlying subchondral bone offers the ability to address large osteochondral defects of the knee, including those involving an entire compartment. The primary theoretical advantage of autologous chondrocyte implantation is the development of hyaline-like cartilage rather than fibrocartilage in the defect, which presumably leads to better long-term outcomes and longevity of the healing tissue. Use of synthetic scaffolds is a potentially attractive alternative to traditional cartilage procedures as they are readily available and, unlike allogeneic tissue transplants, are associated with no risk of disease transmission. Their efficacy, however, has not been proven clinically.

Current concepts in pediatric and adolescent arthroscopy

Arthroscopy continues to grow as a treatment modality for pediatric and adolescent orthopaedic pathologies. In recent years arthroscopic procedures previously reserved for adult patients have become more frequently used in the treatment of younger individuals. Advancements in arthroscopic instrumentation including smaller arthroscopes and tools have made the constraint of smaller joint spaces in the pediatric and adolescent populations less of a limiting factor when addressing surgical options for care. This is valuable considering the consistent increase in pediatric sports- and activity-related injuries, of which many are treatable arthroscopically. Currently, arthroscopy is indicated for the treatment of various chronic and acute injuries of the shoulder, elbow, wrist, hip, knee, and ankle. This review aims to highlight the current literature regarding arthroscopy in this population while also offering treatment algorithms, rehabilitation guidelines, and surgical tips for various pathologies in pediatric and adolescent patients.

Does operative fixation of an osteochondritis dissecans loose body result in healing and long-term maintenance of knee function?

BACKGROUND

Osteochondritis dissecans (OCD) can progress to loose body formation, resulting in a grade IV defect. The decision to fix versus excise the loose body is controversial. Published operative fixation outcomes are small case series with short follow-up.

HYPOTHESIS

Operative fixation (ORIF) of the loose body into the grade IV defect will heal and approximate "normal" knee function at long-term follow-up.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Twelve patients were identified who underwent ORIF of a knee OCD loose body into the grade IV osteochondral defects ranging in size from 2.0 to 8.0 cm(2) (mean, 3.5 cm(2)). After 12 weeks, hardware was removed, and healing was assessed. Long-term outcomes were assessed with a Knee injury and Osteoarthritis Outcome Score (KOOS) and a Marx activity score.

RESULTS

Arthroscopy for screw removal revealed stable healing in 92% (11 of 12) of patients. No patients required subsequent surgery for a loose body. At an average of 9.2 years' follow-up (range, 3.8-15.8 years), 83% (10 of 12) of patients completed the KOOS. The KOOS subscale scores for pain (mean, 87.8; range, 67-100), other symptoms (mean, 81.8; range, 61-96), function in activities of daily living (mean, 93.1; range, 72-100), and sports and recreation function (mean, 74.0; range, 40-100) were not significantly lower than those of published age-matched controls. However the KOOS subscale score for knee-related quality of life (mean, 61.9; range, 31-88) was significantly lower (P = .003).

CONCLUSION

Operative fixation of grade IV OCD loose bodies results in stable fixation. At an average 9 years after surgery, patients did not have symptoms of osteoarthritis pain and had normal function in activities of daily life. However, patients reported significantly lower knee-related quality of life. Operative fixation of OCD loose bodies is a better alternative to lesion excision.

The effect of overlapping on the primary stability of osteochondral grafts in mosaicplasty

Our goal was to determine the primary stability of overlapping osteochondral grafts used in mosaicplasty by studying the effect of overlapping in an ex vivo model. Osteochondral grafts, 10 mm in diameter, were transplanted from the trochlea of cow femurs to the weight-bearing area of the lateral femoral condyle with 0, 15, or 30% overlap. The grafts were pushed in with a probe at a rate of 2 mm/min, and load (N)-displacement (mm) curves were recorded. In Group I (control, 0% overlap), insertion 1 and 2 mm below the cartilage level could be reached at 572.3 +/- 273.6 and 999.3 +/- 427.6 N, respectively. In Group II (15% overlap), insertion 1 and 2 mm below the cartilage level could be reached at 263.6 +/- 91.7 and 746.6 +/- 88.0 N, respectively. In Group III (30% overlap), insertion 1 and 2 mm below the cartilage level could be reached at 179.4 +/- 31.2 and 657.0 +/- 106.5 N, respectively. The loads that were necessary to produce a 1-mm dent in the grafts were significantly different between Groups I and II and Groups I and III (p < 0.05). These results suggest that stability may be reduced by graft overlapping in mosaicplasty surgery. The results of this ex vivo animal study contribute to a more complete understanding of the primary stability of osteochondral grafts in an overlapping position as well as postoperative protocols.

Bilateral osteochondritis dissecans of the lateral trochlea of the femur: a case report

Osteochondritis dissecans of the bilateral trochlea of femur is unusual case for orthopedic surgeon. The patient was a healthy 15-year-old male with symptomatic osteochondritis dissecans of the bilateral distal lateral femoral condyle of the trochlea. A surgery on the bilateral knee joints was performed simultaneously. The osteochondral free fragment of the right knee was resected by a minimum open surgery after arthroscopic evaluation. In the left knee the fragment was stabilized with multiple cortical bone pegs harvested from the proximal tibia. The surgery was successful, and the patient was able to play basketball 3 months postoperatively. The course of the right knee is currently under careful observation because of the possibility of recurrence. The left knee has remained in an excellent condition for 18 months following surgery with bone pegs.

Autologous osteochondral grafting--technique and long-term results

BACKGROUND

Efficacious treatment of chondral and osteochondral defects of weightbearing articular surfaces is a daily challenge in musculoskeletal care. Autogenous osteochondral transplantation represents a possible solution for creating hyaline or hyaline-like repair in the affected area that has a noninflammatory pathoorigin. This paper discusses the experimental background and over 15 years of clinical experience with autologous osteochondral mosaicplasty.

METHODS

Several series of animal studies and subsequent clinical practice of over 1,000 mosaicplasty patients were assessed to confirm the survival of transplanted hyaline cartilage and fibrocartilage filling of donor sites located on relatively less weightbearing surfaces, as well as donor-site disturbances and morbidity. Histological evaluations of dog and horse implantations as well as several series of clinical evaluations in the human material are summarized in this paper. Clinical scores, different types of imaging techniques, second-look arthroscopies, histological examination of biopsy samples, and cartilage stiffness measurements were used to evaluate the clinical outcomes and quality of the transplanted cartilage.

RESULTS

Analysis of clinical scores has shown good to excellent results in 92% of patients with femoral condylar implantations, 87% of tibial resurfacements, 74% of patellar and/or trochlear mosaicplasties and 93% of talar procedures. Longterm donor-site complaints measured by the Bandi score were minor and present only in 3% of patients. 81 out of the 98 control arthroscopies represented congruent and good gliding surfaces and histologically proven survival of the transplanted hyaline cartilage as well as fibrocartilage covering of the donor sites. Complications in the entire patient group were four deep infections and four deep venous thromboses. In nearly 8% of the cases excessive intraarticular bleeding was observed in the early postoperative period, as a minor complication of the procedure. Multicentric, comparative, prospective evaluation of 413 arthroscopic resurfacing procedures (mosaicplasty, Pridie drilling, abrasion arthroplasty and microfracture cases in homogenised subgroups) demonstrated that mosaicplasty resulted in favourable clinical outcome in the long-term follow-up compared to other three techniques. Durability of the early results was confirmed in long-term evaluations both of the femoral condylar implantations and talar mosaicplasties.

CONCLUSIONS

According to our encouraging results in this increasingly large series, supported by similar findings from other centres, it seems that autologous osteochondral mosaicplasty may be an alternative for small and medium-sized focal chondral and osteochondral defects of weightbearing surfaces of the knee and other weightbearing synovial joints.

[Treatment of osteochondritis dissecans of the knee joint]

Osteochondritis dissecans (OD) is a lesion of the subchondral bone which can result in sequestration of the osteochondral lesion. It is categorized into 4 stages, and juvenile and adult forms depending on the distal femoral physis maturity. Prognosis and treatment depends on age and stage. Prognosis is favorable in stable lesions (stage I and II) at typical location (medial femoral condyle) in a child with open physes. Therefore non-operative treatment is indicated. If there is no response to non-operative treatment drilling to create channels for potential revascularization can be done. In unstable lesions (stage III and IV) operative treatment is necessary. Long-term results after excision of the fragment with or without drilling of the defect site are poor. Therefore refixation of an intact osteochondral fragment or biologic reconstruction should be tried.

Fixation with autogenous osteochondral grafts for the treatment of osteochondritis dissecans (stages III and IV)

This paper presents a clinical and functional assessment of the cases of osteochondritis dissecans (OCD) treated with small mosaicplasty type osteochondral grafts. Between 1999 and 2004, we operated on 12 knees with OCD stages III and IV. They were assessed using the International Cartilage Research Society (ICRS) scale, the Visual Analogue Scale (VAS) scale, X-ray and magnetic resonance imaging (MRI). The study was carried out using a clinical series, was retrospective and had a level of evidence of 4. Before surgery, all patients were in classes III and IV on the ICRS scale (four in class III and eight in class IV). At the time of surgery, the patient age was 27.5 +/- 7.9 years, with male predominance (75%). Eleven of the cases were assessed as classes I and II on the ICRS scale (seven in class I and four in class II), with one patient in class IV. X-ray assessment was less favourable, revealing alterations in the articular space in 75% of cases. The results show that this technique enables the biological fixation of fragments and, functionally, the clinical results obtained were very good. The osteochondral grafts avoid the implantation of foreign material and make use of bone fragments of the same rigidity as the OCD fragment. We conclude that the technique described is an excellent alternative to the techniques normally used for the fixation of stage III and IV OCD.

Comparison of bioabsorbable pins and nails in the fixation of adult osteochondritis dissecans fragments of the knee: an outcome of 30 knees

BACKGROUND

The optimal device for the fixation of osteochondritis dissecans fragments of the knee remains controversial and lacks long-term results.

PURPOSE

To review a group of young adults with osteochondritis dissecans of the knee treated with arthroscopic fixation of the fragment using bioabsorbable pins and nails and to examine the medium-term outcome of the fixation via magnetic resonance imaging and clinical evaluation.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Twenty-eight patients (30 knees) with osteochondritis dissecans of the knee were treated with arthroscopic fixation using bioabsorbable, self-reinforced poly-L-lactide pins and nails. All patients were young adult males with closed physes. The average follow-up time was 5.4 years (range, 3-12). At follow-up, magnetic resonance imaging studies were used to evaluate subchondral bone healing, and the outcome was evaluated by the Kujala score.

RESULTS

The functional results were excellent or good for 73% of the patients in the nail group versus 35% in the pin group. The lesions treated were large, with an average size of 447 mm(2), affecting the weightbearing area in the majority of the patients. On magnetic resonance imaging, incomplete bone consolidation was predominant in the pin group.

CONCLUSIONS

Arthroscopic fixation with bioabsorbable nails seems to be a suitable method of repair for osteochondritis dissecans of the adult knee and appears to be superior to arthroscopic fixation with bioabsorbable pins.

Fixation of unstable osteochondritis dissecans lesions of the knee using arthroscopic autogenous osteochondral grafting (mosaicplasty)

PURPOSE

A number of surgical techniques have been described for the operative fixation of an unstable osteochondritis dissecans (OCD) lesion in the knee that has failed appropriate nonoperative management. However, no one technique has been universally successful. We report the results of a new fixation technique for unstable OCD lesions using arthroscopic autogenous osteochondral grafting (mosaicplasty).

METHODS

Twenty patients with OCD lesions (16 International Cartilage Repair Society [ICRS] OCD type II, 3 ICRS OCD type III, and 1 ICRS OCD type IV) who had failed an appropriate course of nonoperative management underwent autogenous osteochondral grafting. The OCD lesions were assessed arthroscopically and then fixed in situ by using multiple 4.5-mm osteochondral dowel grafts harvested from the edges of the femoral trochlea. The lesion was initially fixed with an osteochondral graft passing through the center of the fragment and then stabilized by using further grafts inserted around its periphery.

RESULTS

Preoperative International Knee Documentation Committee scores assessed 5 patients as nearly normal, 8 as abnormal, and 7 as severely abnormal. At the 18-month follow-up, all of the knees were scored as normal. The average preoperative visual analog pain score out of 10 was 8.3, which was reduced to 0.8 at 6 months and to 0 at 1 year after surgery. Serial magnetic resonance imaging scans showed healing of the bony part of the lesion in all of the knees 6 months after surgery and continuous articular cartilage healing at 9 months.

CONCLUSIONS

Autogenous osteochondral grafting of unstable OCD lesions in the knee is a reliable and minimally invasive technique that provides a stable biologic fixation using autogenous bone graft and has few complications.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Comparison of the stability of various internal fixators used in the treatment of osteochondritis dissecans--a mechanical model

The purpose of this study was to determine what characteristics of fixation devices used in the treatment of osteochondritis dissecans (OCD) contribute to improved stability to resist shear loading. An OCD model was designed using rigid polyurethane foam. Each specimen consisted of two components, an osteochondral fragment and a corresponding defect. A total of 40 specimens were prepared and assigned to one of four groups: control (no extrinsic stabilizer); two 2-mm-diameter Kirschner wires (K-wires), 40 mm in length; one threaded washer and a 28-mm screw; and one threaded washer and a 38 mm screw. Each specimen was mounted onto an Iosipescu shear test fixture and subjected to shear loads at a pseudo-static displacement rate of 0.075 mm/s. All groups demonstrated some stability; controls were significantly less stable than all other groups. The group with the threaded washer and 38-mm screw demonstrated the greatest stability (p < 0.001), and no difference was noted between the K-wire and 28-mm screw groups. These results suggest that, in this OCD model, friction conferred some intrinsic stability to resist loads in shear. However, stability was improved with the use of long implants that compressed the fragments together.

Results of arthroscopic fixation of osteochondritis dissecans lesion of the knee with cylindrical autogenous osteochondral plugs

BACKGROUND

In situ fixation of unstable lesions of osteochondral dissecans of the knees with cylindrical osteochondral autograft transplantation has been reported to provide excellent results with healing of the osteochondral dissecans fragment.

PURPOSE

To evaluate the clinical results and magnetic resonance imaging findings of the osteochondral dissecans of knees treated with in situ fixation of the osteochondral fragments with osteochondral autograft transplantation.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Twelve knees (12 patients; mean age, 16.0 years) with osteochondral dissecans lesions were treated with in situ fixation with autogenous osteochondral plugs. The mean lesion size was 2.4 cm(2) (range, 1.0-4.9 cm(2)). The osteochondral dissecans lesions were located on the medial femoral condyle in 10 patients and on the lateral femoral condyle in 2 patients. Seven lesions were located in the weightbearing area. The International Cartilage Repair Society classification in arthroscopic findings was grade II in 1 patient, grade III in 8 patients, and grade IV in 3 patients. All patients were evaluated with the Hughston Rating Scale form with the mean follow-up at 4.5 years (range, 2.8-5.9 years). The interface between the osteochondral fragment and subchondral bone and changes in donor site of the osteochondral graft were evaluated with T2-weighted magnetic resonance image up to 12 months postoperatively.

RESULTS

The Hughston Rating Scale scored 8 knees as excellent, 3 as good, and 1 as fair. The interface between the osteochondral fragment and subchondral bone had disappeared on magnetic resonance image by 3 months postoperatively in all cases. No complications arising from the donor site area were observed. Signal intensity of donor site changed from high signal preoperatively to homogeneous surrounding cancellous bone by 1 year postoperatively.

CONCLUSION

Biological fixation of the osteochondral dissecans lesion with cylindrical osteochondral autograft provided healing of the osteochondral fragments.

Mobilization of bone marrow-derived mesenchymal stem cells into the injured tissues after intraarticular injection and their contribution to tissue regeneration

The purpose of present study was to evaluate active mobilization effect of mesenchymal stem cells (MSCs) into injured tissues after intraarticular injection of MSCs, and to evaluate their contribution to tissue regeneration. MSCs, which were obtained from green fluorescent protein (GFP) transgenic Sprague-Dawley (SD) rat and cultivated, were injected into normal SD rats in which multiple tissues had been injured including anterior cruciate ligament (ACL), medial meniscus, and articular cartilage of the femoral condyles. At 4 weeks after injection of MSCs, fluorescent microscopic observation, immunohistochemical or histological examinations were performed to evaluate mobilization of MSCs into injured tissue and their contribution to tissue regeneration. In the group of 1 x 10(6) MSCs injection, GFP positive cells could mobilize into the injured ACL alone in all 8 knees. In the group of 1 x 10(7) MSCs injection, GFP positive cells were observed in the injured site of ACL in all 8 knees and in the injured site of medial meniscus and cartilage of femoral condyles in 6 of 8 knees. More interestingly, extracellular matrix stained by toluidine blue was present around GFP positive cells in the injured femoral condyles cartilage and medial meniscus, indicating tissue regeneration. Intraarticularly injected MSCs could mobilize into the injured tissues, and probably contributed to tissue regeneration. This study demonstrated the possibility of intraarticular injection of MSCs for the treatment of intraarticular tissue injuries including ACL, meniscus, or cartilage. If this treatment option is established, it can be minimally invasive compared to conventional surgeries for these tissues.