- Email: [email protected]
Treatment options for osteochondral defects
Treatment options for osteochondral defects
collagen, an abundance of proteoglycan, and few chondrocytes. The deep zone makes up 30–40% and is characterized by abundant chondrocytes and tightly packed collagen fibers arranged perpendicular to the osteochondral junction, anchoring the cartilage to the bone. The tidemark represents calcified cartilage adjacent to the subchondral bone.7,8
Ravi Gupta, MS MNAMS FIMSA* Akshay Goel, MS** Manish Pruthi, MS DNB**
PATHOGENESIS Following a chondral fracture, there is minimal inflammatory response due to lack of blood supply in cartilage. Chondrocytes attempt to fill the defect by increasing synthesis of the matrix, which is usually inadequate and eventually leads to degeneration of cartilage. However, when there is an osteochondral fracture, it leads to hemarthrosis and activation of inflammatory response due to fracture of the highly vascular subchondral bone. The inflammatory mediators stimulate migration of mesenchymal cells, which differentiate into chondrocytes that produce type I and type II collagen to fill the defect. The repair can remodel to form a functional articular surface if the defect is small. The newly formed cartilage is however, fibrocartilage and not hyaline and most often the area degenerates over time, leaving exposed subchondral bone.9,10
INTRODUCTION Osteochondral injuries of weight bearing joints constitute a relatively common problem faced by orthopedic surgeons. Until recently, these have been largely underdiagnosed due to limited imaging modalities. However, with the advent of MR imaging and arthroscopy, a large number of these lesions are now being detected.1–3 Most patients present with pain, swelling and mechanical symptoms following a traumatic injury. Knee and ankle joints are the most frequently involved joints.4–6 Most of these lesions, especially full thickness cartilage lesions, have limited healing and result in incongruency due to poor regenerative potential of cartilage.6–8 If left undiagnosed these often cause persistent pain and may lead to early degenerative changes. A number of treatment modalities have been tried for lesions, if diagnosis is made relatively earlier.
DIAGNOSIS Most patients with osteochondral injuries present with pain and swelling of the joint following a traumatic event. One of the first diagnostic tests performed are plain radiographs. In case of large osteochondral fragments the fracture may be detected on radiographs but in many cases with pure chondral or small osteochondral injuries, radiographs may not detect the injury.4,5,11 In such cases with persistent pain, joint effusion, mechanical symptoms, and normal radiographs, further workup is needed. Further diagnostic modalities include knee aspiration, arthrography, CT scan, MR imaging and arthroscopy.1,4,5 Knee aspiration confirms the presence of hemarthrosis. Presence of fat droplets in hemarthrosis indicates the presence of intra articular fracture. Arthrogram is good at detecting these lesions but it is an invasive test.1 Non-invasive tests include bone scan, CT scan and MR imaging. Bone scan can detect a lesion by increased uptake but cannot define the size and location of the lesion.12 CT scan demonstrates excellent definition of bony fragments and allows determination of size, location, and displacement of the fragments. CT is less sensitive in detecting trabecular microfractures. Recent MR scanning techniques such as MR arthrography, magnetization transfer imaging, and fast spin echo sequences have improved the visualization of chondral defects.13,14 Finally, arthroscopy has the advantage of direct visualization of the articular surface and ability to treat the lesions, but cannot evaluate the condition of the underlying subchondral bone.1
ANATOMY OF CARTILAGE Normal cartilage has an extracellular matrix, which is rich in collagen (mainly type II, IX, and XI) and proteoglycans (mainly aggrecan). Aggrecan is a central core protein bearing numerous glycosaminoglycan chains of chondroitin sulfate and keratan sulfate, all capable of retaining molecules of water. The other component consists of isolated chondrocytes, which lie in the matrix. The matrix components are responsible for the tensile strength and resistance to mechanical loading of the articular cartilage. Healthy articular cartilage consists of three distinct layers. The superficial zone constitutes 10–20% of the articular cartilage, and is composed of densely packed collagen fibers aligned parallel to the joint surface. The middle zone makes up approximately 40–60%, and is composed of loosely packed
*Associate Professor, **Senior Resident, Department of Orthopedics, Government Medical College Hospital, Chandigarh. Correspondence: Dr. Ravi Gupta, Associate Professor, Department of Orthopedics, Government Medical College Hospital, Sector 32B, Chandigarh – 160047. Ph: +91-9646121592. E-mail: [email protected]
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older individuals with osteoarthritic knees and the results vary widely.27,28 Also, there does not appear to be a consensus as to the appropriate depth of penetration of the area of injury.29–31 The result is formation of fibrocartilage, which has inferior biomechanical properties compared to hyaline cartilage.6
Table 1 Surgical options for osteochondral lesions. Procedure Internal fixation Abrasion chondroplasty Microfracture Autologous chondrocyte transplantation Allograft Mosaicplasty
Indications Large osteochondral defects without marked osteoarthritis Most research done in osteoarthritis patients Indicated in older individuals without high demands Best results for lesions < 2 cm, age < 35 yrs, BMI < 25 kg/m2 Adequate facilities for chondrocyte culture Best for lesion up to 2 cm
Microfracture This technique involves making penetrations of the subchondral bone to stimulate chondrocyte proliferation and differentiation. An arthroscopic awl is used to make the microfractures. It is also important to debride any remaining local articular cartilage. Steadman et al. noted that the tissue regenerated appears to be a mixture of both hyaline and fibrocartilage.32 As with any procedure to repair compromised articular cartilage, the postoperative regimen is central to success. A study examining the role of continuous passive motion (CPM) in the postoperative management of patients undergoing microfracture showed a statistically significant difference in the grade of tissue observed on “second-look” arthroscopy.33 Asik et al. in study of 90 patients had shown significant improvement in average Lysholm score at 68 months. Best results in their study were seen in lesion < 2 cm, age < 35 years and BMI < 25 kg/m2.34 Steadman et al had shown improvement in 80% of patients (72 patients) on 11 years’ follow-up using this technique.35 Unfortunately, there are no large randomized, controlled studies of this procedure. As with other subchondral penetration techniques, there is a reliance on a fibrocartilaginous tissue for repair of the chondral lesion.17,18 The authors have experience of drilling multiple drill holes in two sportspersons; 19 years (female) with defect of 5 cm and 22 years with defect of 4.5 cm. The multiple drill holes were made arthroscopically by using 1.2 mm K wire. The follow-up at 3 years and 2 years, respectively shows improvement in Lysholm Knee score from pre-operative values of 45 and 35 to postoperative values of 70 and 75, respectively (Figure 1).
Larger osteochondral lesions (avg. 8 cm2) Younger age group (< 60 yrs) < 45 yrs of age Lesion size 1–4 cm2
TREATMENT Various treatment options exist for treatment of osteochondral fractures. In a young patient with large osteochondral fragment presenting acutely it is preferable to reduce and internally fix the fragment. However, in cases of small osteochondral defects or cases detected late, the fragment can be excised and the osteochondral defect then needs to be treated.1 Several treatment options have been described for these lesions (Table 1). Older techniques like debridement, microfracture technique, abrasion arthroplasty or Pridie’s perforations had limited success. This was because they lead to formation of fibrocartilage which has poor biomechanical properties as compared to hyaline cartilage.15–18 Newer techniques are being developed that lead to formation of hyaline tissue at these articular defects. These techniques include periosteal and perichondral grafts, morselised osteochondral mixtures, autologous chondrocyte transplantation, autologous osteochondral transplantation and osteochondral allograft.19–24 Internal Fixation In case of large osteochondral fragments, internal fixation can be performed. Various methods of fixation have been described and include Kirschner wires, cannulated small fragment screws and Acutrak or Herbert screws.25,26 Stable internal fixation restores the native hyaline cartilage and allows early mobilization. Problems include loosening of K wires, and need for second surgery for removal of hardware.
Autologous Chondrocyte Transplantation One of the latest of the autologous chondrocyte transplantation techniques involves harvesting cells from a non-involved area of the joint, multiplying them in culture, and then transplanting them to the area of involvement. The cells are then kept in the defect by a periosteal flap, which is sutured into place. Peterson et al. had shown 92% improvement for femoral and 65% for patellar lesions at 2–7 years’ follow-up using this technique.36 However, this technique has limited application as it requires special training and use of laboratory facilities.37,38 Furthermore, in countries like India with the patient bearing all the expenses by himself, this technique is economically less feasible.
Abrasion Chondroplasty Abrasion chondroplasty stimulates the repair response by creating a full-thickness lesion at the site of incomplete cartilage injury. This allows a blood clot containing pluripotent stem cells to accumulate at the defect. This eventually forms fibrocartilage.15 Abrasion chondroplasty has mostly been limited to
Allografting Allografting involves the transplantation of osteochondral grafts to an area of focal cartilage damage. Allografting has the benefit of not having the size limitations of autografting. In addition, the morbidity of harvesting autograft material is eliminated. The ability to fashion an orthotopic graft allows closer match
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Relative contraindications include generalised osteoarthritis, inflammatory arthritis and infection.46,49 Hangody initially popularized Mosaicplasty in 1990s.46 Initial studies were conducted in animal models.44 Later clinical models by Hangody et al. reported 91% excellent and good results in 57 patients with osteochondral lesions.46–48 Similar studies by other authors have shown equally encouraging results. Chow et al. in a study of 30 patients found 83.3% had excellent to good results.47 Jacob et al. in a study of 52 patients had improved function in knee in 92% cases after a follow-up of 37 months.52 Ozturk et al. performed mosaicplasty for lesions up to 2.5 cm2 in size and had excellent to good results in 18 of the 19 knees.50 A multicenter, prospective study by Hangody et al. involving 413 patients compared four arthroscopic resurfacing techniques: Pridie drilling, abrasion arthroplasty, microfracture (a fibrocartilage type cartilage repair), and mosaicplasty (a hyaline cartilage type resurfacing procedure). That study showed that hyaline-like resurfacing provides a substantially better clinical outcome than the other techniques, especially after 3, 4, and 5 years.53 There have been some concerns regarding donor site morbidity but until date, no study has shown that graft harvest can lead to degenerative changes or significant morbidity.46
Figure 1 Multiple drill holes.
of the anatomy at the surgical site.39,40 Bugbee et al. had shown good to excellent results in 79% of patients at 2 years’ followup in osteochondral lesions of average 8 cm2 size.41 The obvious downside to allografting is the inability to eliminate the risk of disease transmission. Modern laboratory techniques and stringent guidelines by tissue banks have significantly lowered the risk, but it is still an issue in selecting allograft material. There are immunologic considerations in placing osteochondral grafts. Freezing has been found to decrease the antigenicity, but apparently at the sacrifice of providing viable chondrocytes at transplantation.42,43
Authors Experience The authors have experience of using the technique of mosaicplasty for defects up to 4 cm in 6 patients. In the last 5 years, the authors have used the technique of mosaicplasty with good to excellent midterm results in 6 patients. The average age of the patients was 22.2 years and all were males. Two patients had associated loose bodies that were removed at the time of surgery. The average follow-up was 3.8 years (range 2–5 years). The functional evaluation was done with Lyscholm Knee Score which improved from an average pre-operative value of 48.5 (range 40–55) to average postoperative value of 88 (range 75–95).
Articular Cartilage Autografting/Mosaicplasty Principles Mosaicplasty is based on using multiple small cylindrical osteochondral grafts for reconstruction, which allow a more congruent surface as compared to a single large osteochondral graft. These grafts are harvested from the relatively less weight bearing areas of the knee joint around the patellofemoral region, rim of femoral trochlea, etc. Due to the low load stresses in this region and the small size of the graft, donor site morbidity is limited. The donor site tunnel usually heals with cancellous bone forming with a cover of fibrocartilagenous tissue. The hyaline cartilage of the graft has been found to survive and there is integration of transplanted cartilage with surrounding tissue.44–46 Mosaicplasty has been commonly used for medium to small sized osteochondral defects of the weight-bearing region of femoral condyles. Recently, use of mosaicplasty in areas like talar dome, humeral capitular and femoral head has been described. Ideal diameter of defect is between 1 cm2 and 4 cm2.45,46 The limiting factor is the donor site availability of graft. Age is another limiting factor with fifty years being the upper limit.47,48 Any coexisting disorders of the joint including ligament injuries with instability, meniscus tears or mechanical axis malalignment must be treated concurrently. Any patient undergoing mosaicplasty must be willing to participate in postoperative rehabilitation which involves restricted weight bearing for 4–6 weeks. JCOT Vol 1 No 1
Surgical Technique Autologous osteochondral mosaicplasty can be done as an open procedure, through a miniarthrotomy, or arthroscopically. The technique of these surgical procedures is similar. We perform this technique arthroscopically by using the disposable instrumentation of mosaicplasty [Arthrex, USA] (Figure 2). Patient is positioned supine with the knee allowed to flex up to 120°. The opposite limb is placed in a stirrup. The lesion is defined arthroscopically and the defect is identified (Figure 3). Its edges are debrided to healthy hyaline cartilage with curettes/a knife blade or an arthroscopic resector blade. The base of the lesion is then abraded or curetted down to viable subchondral bone. A drill-guide is used to determine the number of grafts that are needed. By tapping the drill-guide down to viable subchondral bone, optimal filling of the defect can be projected. Both femoral condyles at the level of the patellofemoral joint can serve as donor sites during open procedure. During the arthroscopic approach, the medial border of the medial femoral condyle is recommended as a primary donor site. If necessary, 18
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the lateral border can be used as a secondary harvest site. A properly sized tubular chisel is introduced perpendicular to the donor site (Figure 4). This harvester device is then tapped into the donor site. A depth of 15 mm is usually recommended for resurfacing of cartilage defects and a depth of 25 mm is appropriate for osteochondral defects because, in the latter case, the grafts should fill the bone loss as well. After tapping and toggling, the chisel is removed and the graft is delivered from the harvester with use of a chisel guard. It is very important to push out the grafts from the osseous end to avoid damaging the hyaline cartilage cap. Insertion of the grafts is done using the universal guide. As a first step in the implantation, this guide is tapped into the osseous base of the defect. The 3 mm long cutting edge is introduced into the osseous base with use of the shoulder of this device to help to define a perpendicular access to that part of the defect. With the assistance of this universal guide, a recipient tunnel is created with use of the appropriately sized drill-bit.
A dilator is then used to create a conical shaped recipient tunnel for easy insertion of the transplanted graft. The depth of the recipient tunnel is usually 2 mm less than the harvested graft i.e. 13 mm (Figure 5). Finally, insertion of the graft is done with an adjustable plunger to match the surface of the graft to the surrounding articular surface. The second site is marked keeping in mind that the defect will not be in the weight bearing area (Figure 6). Grafts are then inserted using systematic sequence of drilling, dilating and delivering. Finally, the surface is inspected for proper placement of the graft (Figure 7). In uncontained or marginal lesions, the grafts are implanted in a perpendicular fashion. When all of the holes are filled, the knee is put through a range of motion with varus and valgus stress to seat the grafts fully and to ensure their press-fit stability. The portals are closed, and the joint is drained with negative suction drain inserted through the superior portal. After surgery, a crepe bandage is used to diminish bleeding from the donor sites.46,50,51
Figure 2 Disposable instrumentation for the technique.
Figure 4 Tubular chisel tapped perpendicular to surface at the donor site.
Figure 3 Identify the defect and debride loose bodies.
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A
B
Figure 5 Recipient tunnel (2 mm less than the donor—13 mm in this case).
During this whole period active knee motion is allowed and encouraged.50,51
CONCLUSION Osteochondral injuries require a high index of suspicion for early diagnosis. A number of treatment modalities are at hand if the diagnosis is made relatively earlier. Mosaicplasty is a good procedure with affordable cost and gives consistent results. For larger defects, the salvage procedures like microfractures or drilling multiple drill holes are the only option. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. ♦
Figure 6 Marking the second donor site on the side of the patella.
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Gupta, et al 48. Marcacci M, Kon E, Zaffagnini S, et al. Multiple osteochondralarthroscopic grafting (mosaicplasty) for cartilage defects of the knee: prospective study results at 2 year follow-up. Arthroscopy 2005;21:462–70. 49. Bobic V. Arthroscopic osteochondral autograft transplantation in anterior cruciate ligament reconstruction: a preliminary clinical study. Knee Surg Sports Traumatol Arthrosc 1996;3:262–4. 50. Oztürk A, Ozdemir MR, Ozkan Y. Osteochondral autografting (mosaicplasty) in grade IV cartilage defects in the knee joint: 2–7 results. Int Orthop 2006;30:200–4.
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collagen, an abundance of proteoglycan, and few chondrocytes. The deep zone makes up 30–40% and is characterized by abundant chondrocytes and tightly packed collagen fibers arranged perpendicular to the osteochondral junction, anchoring the cartilage to the bone. The tidemark represents calcified cartilage adjacent to the subchondral bone.7,8
Ravi Gupta, MS MNAMS FIMSA* Akshay Goel, MS** Manish Pruthi, MS DNB**
PATHOGENESIS Following a chondral fracture, there is minimal inflammatory response due to lack of blood supply in cartilage. Chondrocytes attempt to fill the defect by increasing synthesis of the matrix, which is usually inadequate and eventually leads to degeneration of cartilage. However, when there is an osteochondral fracture, it leads to hemarthrosis and activation of inflammatory response due to fracture of the highly vascular subchondral bone. The inflammatory mediators stimulate migration of mesenchymal cells, which differentiate into chondrocytes that produce type I and type II collagen to fill the defect. The repair can remodel to form a functional articular surface if the defect is small. The newly formed cartilage is however, fibrocartilage and not hyaline and most often the area degenerates over time, leaving exposed subchondral bone.9,10
INTRODUCTION Osteochondral injuries of weight bearing joints constitute a relatively common problem faced by orthopedic surgeons. Until recently, these have been largely underdiagnosed due to limited imaging modalities. However, with the advent of MR imaging and arthroscopy, a large number of these lesions are now being detected.1–3 Most patients present with pain, swelling and mechanical symptoms following a traumatic injury. Knee and ankle joints are the most frequently involved joints.4–6 Most of these lesions, especially full thickness cartilage lesions, have limited healing and result in incongruency due to poor regenerative potential of cartilage.6–8 If left undiagnosed these often cause persistent pain and may lead to early degenerative changes. A number of treatment modalities have been tried for lesions, if diagnosis is made relatively earlier.
DIAGNOSIS Most patients with osteochondral injuries present with pain and swelling of the joint following a traumatic event. One of the first diagnostic tests performed are plain radiographs. In case of large osteochondral fragments the fracture may be detected on radiographs but in many cases with pure chondral or small osteochondral injuries, radiographs may not detect the injury.4,5,11 In such cases with persistent pain, joint effusion, mechanical symptoms, and normal radiographs, further workup is needed. Further diagnostic modalities include knee aspiration, arthrography, CT scan, MR imaging and arthroscopy.1,4,5 Knee aspiration confirms the presence of hemarthrosis. Presence of fat droplets in hemarthrosis indicates the presence of intra articular fracture. Arthrogram is good at detecting these lesions but it is an invasive test.1 Non-invasive tests include bone scan, CT scan and MR imaging. Bone scan can detect a lesion by increased uptake but cannot define the size and location of the lesion.12 CT scan demonstrates excellent definition of bony fragments and allows determination of size, location, and displacement of the fragments. CT is less sensitive in detecting trabecular microfractures. Recent MR scanning techniques such as MR arthrography, magnetization transfer imaging, and fast spin echo sequences have improved the visualization of chondral defects.13,14 Finally, arthroscopy has the advantage of direct visualization of the articular surface and ability to treat the lesions, but cannot evaluate the condition of the underlying subchondral bone.1
ANATOMY OF CARTILAGE Normal cartilage has an extracellular matrix, which is rich in collagen (mainly type II, IX, and XI) and proteoglycans (mainly aggrecan). Aggrecan is a central core protein bearing numerous glycosaminoglycan chains of chondroitin sulfate and keratan sulfate, all capable of retaining molecules of water. The other component consists of isolated chondrocytes, which lie in the matrix. The matrix components are responsible for the tensile strength and resistance to mechanical loading of the articular cartilage. Healthy articular cartilage consists of three distinct layers. The superficial zone constitutes 10–20% of the articular cartilage, and is composed of densely packed collagen fibers aligned parallel to the joint surface. The middle zone makes up approximately 40–60%, and is composed of loosely packed
*Associate Professor, **Senior Resident, Department of Orthopedics, Government Medical College Hospital, Chandigarh. Correspondence: Dr. Ravi Gupta, Associate Professor, Department of Orthopedics, Government Medical College Hospital, Sector 32B, Chandigarh – 160047. Ph: +91-9646121592. E-mail: [email protected]
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older individuals with osteoarthritic knees and the results vary widely.27,28 Also, there does not appear to be a consensus as to the appropriate depth of penetration of the area of injury.29–31 The result is formation of fibrocartilage, which has inferior biomechanical properties compared to hyaline cartilage.6
Table 1 Surgical options for osteochondral lesions. Procedure Internal fixation Abrasion chondroplasty Microfracture Autologous chondrocyte transplantation Allograft Mosaicplasty
Indications Large osteochondral defects without marked osteoarthritis Most research done in osteoarthritis patients Indicated in older individuals without high demands Best results for lesions < 2 cm, age < 35 yrs, BMI < 25 kg/m2 Adequate facilities for chondrocyte culture Best for lesion up to 2 cm
Microfracture This technique involves making penetrations of the subchondral bone to stimulate chondrocyte proliferation and differentiation. An arthroscopic awl is used to make the microfractures. It is also important to debride any remaining local articular cartilage. Steadman et al. noted that the tissue regenerated appears to be a mixture of both hyaline and fibrocartilage.32 As with any procedure to repair compromised articular cartilage, the postoperative regimen is central to success. A study examining the role of continuous passive motion (CPM) in the postoperative management of patients undergoing microfracture showed a statistically significant difference in the grade of tissue observed on “second-look” arthroscopy.33 Asik et al. in study of 90 patients had shown significant improvement in average Lysholm score at 68 months. Best results in their study were seen in lesion < 2 cm, age < 35 years and BMI < 25 kg/m2.34 Steadman et al had shown improvement in 80% of patients (72 patients) on 11 years’ follow-up using this technique.35 Unfortunately, there are no large randomized, controlled studies of this procedure. As with other subchondral penetration techniques, there is a reliance on a fibrocartilaginous tissue for repair of the chondral lesion.17,18 The authors have experience of drilling multiple drill holes in two sportspersons; 19 years (female) with defect of 5 cm and 22 years with defect of 4.5 cm. The multiple drill holes were made arthroscopically by using 1.2 mm K wire. The follow-up at 3 years and 2 years, respectively shows improvement in Lysholm Knee score from pre-operative values of 45 and 35 to postoperative values of 70 and 75, respectively (Figure 1).
Larger osteochondral lesions (avg. 8 cm2) Younger age group (< 60 yrs) < 45 yrs of age Lesion size 1–4 cm2
TREATMENT Various treatment options exist for treatment of osteochondral fractures. In a young patient with large osteochondral fragment presenting acutely it is preferable to reduce and internally fix the fragment. However, in cases of small osteochondral defects or cases detected late, the fragment can be excised and the osteochondral defect then needs to be treated.1 Several treatment options have been described for these lesions (Table 1). Older techniques like debridement, microfracture technique, abrasion arthroplasty or Pridie’s perforations had limited success. This was because they lead to formation of fibrocartilage which has poor biomechanical properties as compared to hyaline cartilage.15–18 Newer techniques are being developed that lead to formation of hyaline tissue at these articular defects. These techniques include periosteal and perichondral grafts, morselised osteochondral mixtures, autologous chondrocyte transplantation, autologous osteochondral transplantation and osteochondral allograft.19–24 Internal Fixation In case of large osteochondral fragments, internal fixation can be performed. Various methods of fixation have been described and include Kirschner wires, cannulated small fragment screws and Acutrak or Herbert screws.25,26 Stable internal fixation restores the native hyaline cartilage and allows early mobilization. Problems include loosening of K wires, and need for second surgery for removal of hardware.
Autologous Chondrocyte Transplantation One of the latest of the autologous chondrocyte transplantation techniques involves harvesting cells from a non-involved area of the joint, multiplying them in culture, and then transplanting them to the area of involvement. The cells are then kept in the defect by a periosteal flap, which is sutured into place. Peterson et al. had shown 92% improvement for femoral and 65% for patellar lesions at 2–7 years’ follow-up using this technique.36 However, this technique has limited application as it requires special training and use of laboratory facilities.37,38 Furthermore, in countries like India with the patient bearing all the expenses by himself, this technique is economically less feasible.
Abrasion Chondroplasty Abrasion chondroplasty stimulates the repair response by creating a full-thickness lesion at the site of incomplete cartilage injury. This allows a blood clot containing pluripotent stem cells to accumulate at the defect. This eventually forms fibrocartilage.15 Abrasion chondroplasty has mostly been limited to
Allografting Allografting involves the transplantation of osteochondral grafts to an area of focal cartilage damage. Allografting has the benefit of not having the size limitations of autografting. In addition, the morbidity of harvesting autograft material is eliminated. The ability to fashion an orthotopic graft allows closer match
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Relative contraindications include generalised osteoarthritis, inflammatory arthritis and infection.46,49 Hangody initially popularized Mosaicplasty in 1990s.46 Initial studies were conducted in animal models.44 Later clinical models by Hangody et al. reported 91% excellent and good results in 57 patients with osteochondral lesions.46–48 Similar studies by other authors have shown equally encouraging results. Chow et al. in a study of 30 patients found 83.3% had excellent to good results.47 Jacob et al. in a study of 52 patients had improved function in knee in 92% cases after a follow-up of 37 months.52 Ozturk et al. performed mosaicplasty for lesions up to 2.5 cm2 in size and had excellent to good results in 18 of the 19 knees.50 A multicenter, prospective study by Hangody et al. involving 413 patients compared four arthroscopic resurfacing techniques: Pridie drilling, abrasion arthroplasty, microfracture (a fibrocartilage type cartilage repair), and mosaicplasty (a hyaline cartilage type resurfacing procedure). That study showed that hyaline-like resurfacing provides a substantially better clinical outcome than the other techniques, especially after 3, 4, and 5 years.53 There have been some concerns regarding donor site morbidity but until date, no study has shown that graft harvest can lead to degenerative changes or significant morbidity.46
Figure 1 Multiple drill holes.
of the anatomy at the surgical site.39,40 Bugbee et al. had shown good to excellent results in 79% of patients at 2 years’ followup in osteochondral lesions of average 8 cm2 size.41 The obvious downside to allografting is the inability to eliminate the risk of disease transmission. Modern laboratory techniques and stringent guidelines by tissue banks have significantly lowered the risk, but it is still an issue in selecting allograft material. There are immunologic considerations in placing osteochondral grafts. Freezing has been found to decrease the antigenicity, but apparently at the sacrifice of providing viable chondrocytes at transplantation.42,43
Authors Experience The authors have experience of using the technique of mosaicplasty for defects up to 4 cm in 6 patients. In the last 5 years, the authors have used the technique of mosaicplasty with good to excellent midterm results in 6 patients. The average age of the patients was 22.2 years and all were males. Two patients had associated loose bodies that were removed at the time of surgery. The average follow-up was 3.8 years (range 2–5 years). The functional evaluation was done with Lyscholm Knee Score which improved from an average pre-operative value of 48.5 (range 40–55) to average postoperative value of 88 (range 75–95).
Articular Cartilage Autografting/Mosaicplasty Principles Mosaicplasty is based on using multiple small cylindrical osteochondral grafts for reconstruction, which allow a more congruent surface as compared to a single large osteochondral graft. These grafts are harvested from the relatively less weight bearing areas of the knee joint around the patellofemoral region, rim of femoral trochlea, etc. Due to the low load stresses in this region and the small size of the graft, donor site morbidity is limited. The donor site tunnel usually heals with cancellous bone forming with a cover of fibrocartilagenous tissue. The hyaline cartilage of the graft has been found to survive and there is integration of transplanted cartilage with surrounding tissue.44–46 Mosaicplasty has been commonly used for medium to small sized osteochondral defects of the weight-bearing region of femoral condyles. Recently, use of mosaicplasty in areas like talar dome, humeral capitular and femoral head has been described. Ideal diameter of defect is between 1 cm2 and 4 cm2.45,46 The limiting factor is the donor site availability of graft. Age is another limiting factor with fifty years being the upper limit.47,48 Any coexisting disorders of the joint including ligament injuries with instability, meniscus tears or mechanical axis malalignment must be treated concurrently. Any patient undergoing mosaicplasty must be willing to participate in postoperative rehabilitation which involves restricted weight bearing for 4–6 weeks. JCOT Vol 1 No 1
Surgical Technique Autologous osteochondral mosaicplasty can be done as an open procedure, through a miniarthrotomy, or arthroscopically. The technique of these surgical procedures is similar. We perform this technique arthroscopically by using the disposable instrumentation of mosaicplasty [Arthrex, USA] (Figure 2). Patient is positioned supine with the knee allowed to flex up to 120°. The opposite limb is placed in a stirrup. The lesion is defined arthroscopically and the defect is identified (Figure 3). Its edges are debrided to healthy hyaline cartilage with curettes/a knife blade or an arthroscopic resector blade. The base of the lesion is then abraded or curetted down to viable subchondral bone. A drill-guide is used to determine the number of grafts that are needed. By tapping the drill-guide down to viable subchondral bone, optimal filling of the defect can be projected. Both femoral condyles at the level of the patellofemoral joint can serve as donor sites during open procedure. During the arthroscopic approach, the medial border of the medial femoral condyle is recommended as a primary donor site. If necessary, 18
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the lateral border can be used as a secondary harvest site. A properly sized tubular chisel is introduced perpendicular to the donor site (Figure 4). This harvester device is then tapped into the donor site. A depth of 15 mm is usually recommended for resurfacing of cartilage defects and a depth of 25 mm is appropriate for osteochondral defects because, in the latter case, the grafts should fill the bone loss as well. After tapping and toggling, the chisel is removed and the graft is delivered from the harvester with use of a chisel guard. It is very important to push out the grafts from the osseous end to avoid damaging the hyaline cartilage cap. Insertion of the grafts is done using the universal guide. As a first step in the implantation, this guide is tapped into the osseous base of the defect. The 3 mm long cutting edge is introduced into the osseous base with use of the shoulder of this device to help to define a perpendicular access to that part of the defect. With the assistance of this universal guide, a recipient tunnel is created with use of the appropriately sized drill-bit.
A dilator is then used to create a conical shaped recipient tunnel for easy insertion of the transplanted graft. The depth of the recipient tunnel is usually 2 mm less than the harvested graft i.e. 13 mm (Figure 5). Finally, insertion of the graft is done with an adjustable plunger to match the surface of the graft to the surrounding articular surface. The second site is marked keeping in mind that the defect will not be in the weight bearing area (Figure 6). Grafts are then inserted using systematic sequence of drilling, dilating and delivering. Finally, the surface is inspected for proper placement of the graft (Figure 7). In uncontained or marginal lesions, the grafts are implanted in a perpendicular fashion. When all of the holes are filled, the knee is put through a range of motion with varus and valgus stress to seat the grafts fully and to ensure their press-fit stability. The portals are closed, and the joint is drained with negative suction drain inserted through the superior portal. After surgery, a crepe bandage is used to diminish bleeding from the donor sites.46,50,51
Figure 2 Disposable instrumentation for the technique.
Figure 4 Tubular chisel tapped perpendicular to surface at the donor site.
Figure 3 Identify the defect and debride loose bodies.
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A
B
Figure 5 Recipient tunnel (2 mm less than the donor—13 mm in this case).
During this whole period active knee motion is allowed and encouraged.50,51
CONCLUSION Osteochondral injuries require a high index of suspicion for early diagnosis. A number of treatment modalities are at hand if the diagnosis is made relatively earlier. Mosaicplasty is a good procedure with affordable cost and gives consistent results. For larger defects, the salvage procedures like microfractures or drilling multiple drill holes are the only option. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. ♦
Figure 6 Marking the second donor site on the side of the patella.
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