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A fresh osteochondral allograft alternative
The Journal of Arthroplasty Vol. 17 No. 4 Suppl. 1 2002
A Fresh Osteochondral Allograft Alternative Allan E. Gross, MD, FRCSC,* Phil Aubin, MD, FRCSC,† Henry K. Cheah, MD, FRCSC,† Aileen M. Davis, PhD,‡ and Mohammad T. Ghazavi, MD§
Abstract: Fresh osteochondral allografts were used for post-traumatic knee defects ⬎3 cm in diameter and 1 cm in depth. Harvesting of the grafts was carried out within 24 hours of the death of the donor, and implantation into the recipient was carried out within 72 hours. The grafts were unipolar, fixed by screws, and combined with realignment osteotomy if a deformity existed. Meniscal transplantation also was performed if indicated. The survivorship of all grafts (plateaus and condyles) at 7.5 years was 85%. The survivorship of femoral condyle grafts at 10 years was 85%. Viable hyaline cartilage has been confirmed at 17 years. Key words: fresh osteochondral allografts, post-traumatic, knee, realignment, osteotomy. Copyright 2002, Elsevier Science (USA). All rights reserved.
had to meet the criteria outlined by the American Association of Tissue Banks and be ⬍30 years of age [1]. Harvesting was carried out within 24 hours of the death of the donor (usually immediately after life support was terminated, after the other organs had been harvested). The knee was excised with the capsule intact in the operating room, then kept in Ringer’s lactate with added cefazolin and bacitracin at 4°C. The recipient was admitted to the hospital, and the graft was inserted within 24 hours of the harvest. The surgical approach is direct midline allowing access for the insertion of the allograft and if necessary the osteotomy. The damaged articular surface is resected to a horizontal bed of bleeding cancellous bone, and the graft is shaped and inserted using cancellous screws for rigid fixation. If the meniscus has been excised or is significantly damaged, an allograft meniscus is inserted and fixed to the capsule by interrupted sutures. The graft is not used to correct alignment and should not be placed in a compartment that is bearing more than physiologic load. If a deformity exists, as is often the case, an osteotomy can be performed 6 months before the allograft or simultaneously with the allograft if the osteotomy involves the opposite side of the joint. For example, if
Reconstruction of osteochondral defects of the knee in young active patients always has been a major challenge in orthopaedic surgery. This article presents the surgical technique and long-term results including survivorship analysis of fresh small fragment osteochondral allografts of the knee in young active patients with osteochondral defects secondary to trauma or osteochondritis dissecans. This technique is applicable to articular defects ⬎3 cm in diameter and 1 cm in depth.
Methods Donors were located by the Multiple Organ Retrieval and Exchange Programme of Toronto and From the *Department of Surgery, University of Toronto, and Division of Orthopaedic Surgery, Mount Sinai Hospital; †Reconstructive Surgery, Mount Sinai Hospital; †Clinical Research, University Musculoskeletal Oncology Unit and Division of Orthopaedic Surgery, Mount Sinai Hospital, Toronto, Ontario, Canada; and §Orthopaedic Surgeon Adult Reconstruction, Tehran, Iran. No benefits or funds were received in support of this study. Reprint requests: Allan E. Gross, MD, FRCSC, Division of Orthopaedic Surgery, Mount Sinai Hospital, Suite 476A, 600 University Avenue, Toronto, Ontario M5G 1X5 Canada. E-mail: [email protected] Copyright 2002, Elsevier Science (USA). All rights reserved. 0883-5403/02/1704-1005$35.00/0 doi:10.1054/arth.2002.32447
50
Osteochondral Allografts for Traumatic Knee Defects • Gross et al.
51
Fig. 1. (A) Standing anteroposterior radiograph of both knees shows bilateral tibial plateau fractures worse on the right with a secondary valgus deformity. (B) Standing anteroposterior radiograph 10 years after a fresh osteochondral allograft to replace the lateral tibial plateau done in conjunction with a distal femoral varus osteotomy.
a patient has a lateral tibial fracture and an associated valgus deformity, a distal femoral varus osteotomy and lateral tibial plateau allograft can be carried out at the same time (Fig. 1) [1–3]. If the patient has a loss of the medial femoral condyle and an associated varus deformity, a valgus osteotomy of the tibia and an allograft of the medial femoral condyle can be performed at the same time (Fig. 2) [2,4]. If, however, a fracture of the medial plateau is associated with varus, a valgus osteotomy of the proximal tibia should be performed at least 6 months before the allograft. The patients wear a long leg brace with an ischial ring and a knee lock for 1 year.
Clinical Results Between 1972 and 1992, 126 knees of 123 patients with osteochondral defects secondary to trauma (111 cases) or osteochondritis dissecans (15 cases) were reconstructed using fresh small fragment osteochondral allograft. The average age was 35 years (range, 15– 64 years). There were 81 men and 42 women. The location of defects was as follows: tibial plateau (55 lateral, 6 medial, and 2 combined medial and lateral), femoral condyle (27 medial and 23 lateral), bipolar tibial and femoral (7 lateral and 1 medial compartment), and patel-
lofemoral (1 in patellar groove of the femur and 1 in the patella). The grafts, which were 8 to 40 mm thick, were fixed to good bleeding cancellous bone after resecting the defect. In 47 cases, the meniscus was included in the transplant. A total of 68 knees underwent osteotomy to correct alignment (37 distal femoral and 31 upper tibial). Patients were assessed clinically preoperatively and postoperatively using a rating score based on subjective and objective criteria. Radiographic assessment included alignment, graft union, fracture and resorption, joint space narrowing, and osteoarthritis. The average follow up was 7.5 years (range, 1–22 years). A failure was defined as a decrease in knee score or the need for further surgery. Survivorship analysis (Kaplan-Meier life table) showed 95% successful results at 5 years (95% confidence limits, 87–98), 71% success rate at 10 years (95% confidence limits, 56 – 83), and 66% successful results at 20 years (95% confidence limits, 50 – 81). Among 18 failures, 1 case had an arthrodesis, 8 cases had total knee arthroplasty, the graft was removed in 1 case, and 8 cases failed because of a decrease in score but still retained their grafts. Radiographic assessment of 18 failed cases showed 4 collapsed grafts, 7 cases with loss of joint space, and 10 cases with significant osteoarthritis.
52 The Journal of Arthroplasty Vol. 17 No. 4 Suppl. 1 June 2002
Fig. 2. (A) Anteroposterior radiograph of the left knee of a 35-year-old man with post-traumatic loss of half of the medial femoral condyle. (B) Anteroposterior radiograph of the left knee 5 years after medial condyle allograft done in combination with proximal tibial valgus osteotomy.
Except for 2 cases of questionable union, all grafts solidly united to the host– bone 6 to 12 months after surgery. Among clinically successful cases, we noted 5 cases of mild graft collapse (⬍3 mm), 11 cases of decreased joint space, and 18 cases of osteoarthritic changes. Among the cases that showed radiographic changes, 11 were malaligned with overstressing of the graft [1]. In a more recent study, fresh osteochondral allografts were used to repair articular defects in the distal femur in 72 patients. Sixty patients were available for long-term follow-up (mean, 10 years) to determine graft survivorship and patient outcomes using a modified Hospital for Special Surgery score. Of 60 grafts, 12 have failed with 3 having graft removal alone and 9 being converted to total knee arthroplasty. Kaplan-Meier survivorship analysis showed 85% graft survival at 10 years and 74% survival at 15 years. Patients with surviving grafts showed good function, with a mean Hospital for Special Surgery score of 83 points at 10-year follow-up. Ten patients (17%) required meniscal transplantation, and 41 (68%) required realignment osteotomy done simultaneously with the osteochondral allograft. Patients requiring meniscal transplantation, limb realignment, or both had
equally good outcomes at 10 years as patients who underwent osteochondral transplantation alone. Likewise, transplantation to the medial or the lateral condyle had no bearing on long-term outcomes.
Discussion The rationale for fresh osteochondral allografts is clinical and experimental evidence of maintenance of viability and function of chondrocytes after fresh transplantation. There is histologic evidence that the bony part of these grafts can be replaced by host– bone in a uniform fashion in 2 to 3 years, and we have confirmed chondrocyte viability at 17 years [5–7]. The repair of cartilage defects also can be addressed by microfracture, osteochondral allografts, and autologous chondrocyte transplantation [8]. Fresh osteochondral allografts have the advantages of no donor site morbidity and the ability to restore large osteochondral defects of ⬎3 cm in diameter and 1 cm in depth [9 –11]. We have confirmed excellent results and survivorship to 10 years [1,12,13]. We also have confirmed viable
Osteochondral Allografts for Traumatic Knee Defects • Gross et al.
hyaline cartilage in multiple retrieval specimens and biopsy specimens at 17 years [5–7,10,14].
References 1. Ghazavi MT, Pritzker KP, Davis AM, Gross AE: Fresh osteochondral allografts for post-traumatic osteochondral defects of the knee. J Bone Joint Surg Br 79:1008, 1997 2. Finkelstein JA, Gross AE, Davis A: Varus osteotomy of the distal part of the femur. J Bone Joint Surg Am 78:1348, 1996 3. Gross AE, Hutchison CR: Realignment osteotomy of the knee: Part 1. distal femoral varus osteotomy for osteoarthritis of the valgus knee. Operative Techniques in Sports Medicine 8:122, 2000 4. Gross AE, Hutchison CR: Realignment osteotomy of the knee: Part 2. proximal valgus tibial osteotomy for osteoarthritis of the varus knee. Operative Techniques in Sports Medicine 8:127, 2000 5. Czitrom AA, Keating S, Gross AE: The viability of articular cartilage in fresh osteochondral allografts after clinical transplantation. J Bone Joint Surg Am 72:574, 1990 6. Kandel RA, Gross AE, Ganel A, et al: Histopathology of failed osteoarticular shell allografts. Clin Orthop 197:103, 1985
53
7. Oakeshott RD, Farine I, Pritzker KP, et al: A clinical and histologic analysis of failed fresh osteochondral allografts. Clin Orthop 233:283, 1988 8. Minas T: A practical algorithm for cartilage repair. Operative Techniques in Sports Medicine 8:141, 2000 9. McDermott AGP, Langer F, Pritzker KPH, Gross AE: Fresh small fragment osteochondral allografts. Clin Orthop 197:96, 1985 10. Locht RC, Gross AE, Langer F: Late osteochondral allograft resurfacing for tibial plateau fractures. J Bone Joint Surg Am 66:329, 1984 11. Zukor DJ, Oakeshott RD, Gross AE: Osteochondral allograft reconstruction of the knee: Part 2. experience with successful and failed fresh osteochondral allografts. Am J Knee Surg 2:182, 1989 12. Beaver RJ, Mahomed M, Backstein D, et al: Fresh osteochondral allografts for post-traumatic defects in the knee: a survivorship analysis. J Bone Joint Surg Br 74:105, 1992 13. Aubin PP, Cheah HK, Davis AM, Gross AE: Long term follow-up of fresh femoral osteochondral allografts for post traumatic knee defects. Clin Orthop 391(suppl):318, 2001 14. McGoveran BM, Pritzker KP, Shasha N, et al: Long term chondrocyte viability in a fresh osteochondral allograft. Am J Knee Surg (accepted for publication)
A Fresh Osteochondral Allograft Alternative Allan E. Gross, MD, FRCSC,* Phil Aubin, MD, FRCSC,† Henry K. Cheah, MD, FRCSC,† Aileen M. Davis, PhD,‡ and Mohammad T. Ghazavi, MD§
Abstract: Fresh osteochondral allografts were used for post-traumatic knee defects ⬎3 cm in diameter and 1 cm in depth. Harvesting of the grafts was carried out within 24 hours of the death of the donor, and implantation into the recipient was carried out within 72 hours. The grafts were unipolar, fixed by screws, and combined with realignment osteotomy if a deformity existed. Meniscal transplantation also was performed if indicated. The survivorship of all grafts (plateaus and condyles) at 7.5 years was 85%. The survivorship of femoral condyle grafts at 10 years was 85%. Viable hyaline cartilage has been confirmed at 17 years. Key words: fresh osteochondral allografts, post-traumatic, knee, realignment, osteotomy. Copyright 2002, Elsevier Science (USA). All rights reserved.
had to meet the criteria outlined by the American Association of Tissue Banks and be ⬍30 years of age [1]. Harvesting was carried out within 24 hours of the death of the donor (usually immediately after life support was terminated, after the other organs had been harvested). The knee was excised with the capsule intact in the operating room, then kept in Ringer’s lactate with added cefazolin and bacitracin at 4°C. The recipient was admitted to the hospital, and the graft was inserted within 24 hours of the harvest. The surgical approach is direct midline allowing access for the insertion of the allograft and if necessary the osteotomy. The damaged articular surface is resected to a horizontal bed of bleeding cancellous bone, and the graft is shaped and inserted using cancellous screws for rigid fixation. If the meniscus has been excised or is significantly damaged, an allograft meniscus is inserted and fixed to the capsule by interrupted sutures. The graft is not used to correct alignment and should not be placed in a compartment that is bearing more than physiologic load. If a deformity exists, as is often the case, an osteotomy can be performed 6 months before the allograft or simultaneously with the allograft if the osteotomy involves the opposite side of the joint. For example, if
Reconstruction of osteochondral defects of the knee in young active patients always has been a major challenge in orthopaedic surgery. This article presents the surgical technique and long-term results including survivorship analysis of fresh small fragment osteochondral allografts of the knee in young active patients with osteochondral defects secondary to trauma or osteochondritis dissecans. This technique is applicable to articular defects ⬎3 cm in diameter and 1 cm in depth.
Methods Donors were located by the Multiple Organ Retrieval and Exchange Programme of Toronto and From the *Department of Surgery, University of Toronto, and Division of Orthopaedic Surgery, Mount Sinai Hospital; †Reconstructive Surgery, Mount Sinai Hospital; †Clinical Research, University Musculoskeletal Oncology Unit and Division of Orthopaedic Surgery, Mount Sinai Hospital, Toronto, Ontario, Canada; and §Orthopaedic Surgeon Adult Reconstruction, Tehran, Iran. No benefits or funds were received in support of this study. Reprint requests: Allan E. Gross, MD, FRCSC, Division of Orthopaedic Surgery, Mount Sinai Hospital, Suite 476A, 600 University Avenue, Toronto, Ontario M5G 1X5 Canada. E-mail: [email protected] Copyright 2002, Elsevier Science (USA). All rights reserved. 0883-5403/02/1704-1005$35.00/0 doi:10.1054/arth.2002.32447
50
Osteochondral Allografts for Traumatic Knee Defects • Gross et al.
51
Fig. 1. (A) Standing anteroposterior radiograph of both knees shows bilateral tibial plateau fractures worse on the right with a secondary valgus deformity. (B) Standing anteroposterior radiograph 10 years after a fresh osteochondral allograft to replace the lateral tibial plateau done in conjunction with a distal femoral varus osteotomy.
a patient has a lateral tibial fracture and an associated valgus deformity, a distal femoral varus osteotomy and lateral tibial plateau allograft can be carried out at the same time (Fig. 1) [1–3]. If the patient has a loss of the medial femoral condyle and an associated varus deformity, a valgus osteotomy of the tibia and an allograft of the medial femoral condyle can be performed at the same time (Fig. 2) [2,4]. If, however, a fracture of the medial plateau is associated with varus, a valgus osteotomy of the proximal tibia should be performed at least 6 months before the allograft. The patients wear a long leg brace with an ischial ring and a knee lock for 1 year.
Clinical Results Between 1972 and 1992, 126 knees of 123 patients with osteochondral defects secondary to trauma (111 cases) or osteochondritis dissecans (15 cases) were reconstructed using fresh small fragment osteochondral allograft. The average age was 35 years (range, 15– 64 years). There were 81 men and 42 women. The location of defects was as follows: tibial plateau (55 lateral, 6 medial, and 2 combined medial and lateral), femoral condyle (27 medial and 23 lateral), bipolar tibial and femoral (7 lateral and 1 medial compartment), and patel-
lofemoral (1 in patellar groove of the femur and 1 in the patella). The grafts, which were 8 to 40 mm thick, were fixed to good bleeding cancellous bone after resecting the defect. In 47 cases, the meniscus was included in the transplant. A total of 68 knees underwent osteotomy to correct alignment (37 distal femoral and 31 upper tibial). Patients were assessed clinically preoperatively and postoperatively using a rating score based on subjective and objective criteria. Radiographic assessment included alignment, graft union, fracture and resorption, joint space narrowing, and osteoarthritis. The average follow up was 7.5 years (range, 1–22 years). A failure was defined as a decrease in knee score or the need for further surgery. Survivorship analysis (Kaplan-Meier life table) showed 95% successful results at 5 years (95% confidence limits, 87–98), 71% success rate at 10 years (95% confidence limits, 56 – 83), and 66% successful results at 20 years (95% confidence limits, 50 – 81). Among 18 failures, 1 case had an arthrodesis, 8 cases had total knee arthroplasty, the graft was removed in 1 case, and 8 cases failed because of a decrease in score but still retained their grafts. Radiographic assessment of 18 failed cases showed 4 collapsed grafts, 7 cases with loss of joint space, and 10 cases with significant osteoarthritis.
52 The Journal of Arthroplasty Vol. 17 No. 4 Suppl. 1 June 2002
Fig. 2. (A) Anteroposterior radiograph of the left knee of a 35-year-old man with post-traumatic loss of half of the medial femoral condyle. (B) Anteroposterior radiograph of the left knee 5 years after medial condyle allograft done in combination with proximal tibial valgus osteotomy.
Except for 2 cases of questionable union, all grafts solidly united to the host– bone 6 to 12 months after surgery. Among clinically successful cases, we noted 5 cases of mild graft collapse (⬍3 mm), 11 cases of decreased joint space, and 18 cases of osteoarthritic changes. Among the cases that showed radiographic changes, 11 were malaligned with overstressing of the graft [1]. In a more recent study, fresh osteochondral allografts were used to repair articular defects in the distal femur in 72 patients. Sixty patients were available for long-term follow-up (mean, 10 years) to determine graft survivorship and patient outcomes using a modified Hospital for Special Surgery score. Of 60 grafts, 12 have failed with 3 having graft removal alone and 9 being converted to total knee arthroplasty. Kaplan-Meier survivorship analysis showed 85% graft survival at 10 years and 74% survival at 15 years. Patients with surviving grafts showed good function, with a mean Hospital for Special Surgery score of 83 points at 10-year follow-up. Ten patients (17%) required meniscal transplantation, and 41 (68%) required realignment osteotomy done simultaneously with the osteochondral allograft. Patients requiring meniscal transplantation, limb realignment, or both had
equally good outcomes at 10 years as patients who underwent osteochondral transplantation alone. Likewise, transplantation to the medial or the lateral condyle had no bearing on long-term outcomes.
Discussion The rationale for fresh osteochondral allografts is clinical and experimental evidence of maintenance of viability and function of chondrocytes after fresh transplantation. There is histologic evidence that the bony part of these grafts can be replaced by host– bone in a uniform fashion in 2 to 3 years, and we have confirmed chondrocyte viability at 17 years [5–7]. The repair of cartilage defects also can be addressed by microfracture, osteochondral allografts, and autologous chondrocyte transplantation [8]. Fresh osteochondral allografts have the advantages of no donor site morbidity and the ability to restore large osteochondral defects of ⬎3 cm in diameter and 1 cm in depth [9 –11]. We have confirmed excellent results and survivorship to 10 years [1,12,13]. We also have confirmed viable
Osteochondral Allografts for Traumatic Knee Defects • Gross et al.
hyaline cartilage in multiple retrieval specimens and biopsy specimens at 17 years [5–7,10,14].
References 1. Ghazavi MT, Pritzker KP, Davis AM, Gross AE: Fresh osteochondral allografts for post-traumatic osteochondral defects of the knee. J Bone Joint Surg Br 79:1008, 1997 2. Finkelstein JA, Gross AE, Davis A: Varus osteotomy of the distal part of the femur. J Bone Joint Surg Am 78:1348, 1996 3. Gross AE, Hutchison CR: Realignment osteotomy of the knee: Part 1. distal femoral varus osteotomy for osteoarthritis of the valgus knee. Operative Techniques in Sports Medicine 8:122, 2000 4. Gross AE, Hutchison CR: Realignment osteotomy of the knee: Part 2. proximal valgus tibial osteotomy for osteoarthritis of the varus knee. Operative Techniques in Sports Medicine 8:127, 2000 5. Czitrom AA, Keating S, Gross AE: The viability of articular cartilage in fresh osteochondral allografts after clinical transplantation. J Bone Joint Surg Am 72:574, 1990 6. Kandel RA, Gross AE, Ganel A, et al: Histopathology of failed osteoarticular shell allografts. Clin Orthop 197:103, 1985
53
7. Oakeshott RD, Farine I, Pritzker KP, et al: A clinical and histologic analysis of failed fresh osteochondral allografts. Clin Orthop 233:283, 1988 8. Minas T: A practical algorithm for cartilage repair. Operative Techniques in Sports Medicine 8:141, 2000 9. McDermott AGP, Langer F, Pritzker KPH, Gross AE: Fresh small fragment osteochondral allografts. Clin Orthop 197:96, 1985 10. Locht RC, Gross AE, Langer F: Late osteochondral allograft resurfacing for tibial plateau fractures. J Bone Joint Surg Am 66:329, 1984 11. Zukor DJ, Oakeshott RD, Gross AE: Osteochondral allograft reconstruction of the knee: Part 2. experience with successful and failed fresh osteochondral allografts. Am J Knee Surg 2:182, 1989 12. Beaver RJ, Mahomed M, Backstein D, et al: Fresh osteochondral allografts for post-traumatic defects in the knee: a survivorship analysis. J Bone Joint Surg Br 74:105, 1992 13. Aubin PP, Cheah HK, Davis AM, Gross AE: Long term follow-up of fresh femoral osteochondral allografts for post traumatic knee defects. Clin Orthop 391(suppl):318, 2001 14. McGoveran BM, Pritzker KP, Shasha N, et al: Long term chondrocyte viability in a fresh osteochondral allograft. Am J Knee Surg (accepted for publication)