Osteochondral Autograft Transplantation Research Articles

Satisfaction With Elbow Function and Return Status After Autologous Osteochondral Transplant for Capitellar Osteochondritis Dissecans in High School Baseball Players

Background: Osteochondral autograft transplant (OAT), a surgical treatment for capitellar osteochondritis dissecans (OCD), has favorable rates of elbow recovery and return to sports in adolescents. However, few reports have investigated how long patients continue to play baseball after OAT and their satisfaction with their treatment outcome. Purpose: To evaluate the rate of boys who played baseball and received OAT for OCD in junior high school or earlier (age <15 years) and continued to play baseball in high school and the players’ satisfaction with their elbow function during play. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 32 elbows of boys who played baseball and received OAT at age ≤15 years (mean, 14.1 years) were examined and divided into pitcher (n = 11) and nonpitcher (n = 21) groups according to their player position before surgery. The clinical Timmerman-Andrews score at the end of their high school baseball, participation percentage of players who continued to play baseball, and satisfaction level during play (on a scale of 0-10 during pitching and batting and in a 4-choice format) were compared between the 2 groups. Results: The Timmerman-Andrews scores significantly improved after surgery in both groups, with no significant difference between the groups. Of the 32 players, 30 (93.8%) continued to play baseball throughout high school, including all players in the pitcher group and 19 (90.5%) of those in the nonpitcher group. The percentage of players who continued to pitch was 55.6% (6/11) in the pitcher group. Satisfaction with elbow joint function at the time of pitching was significantly lower in the pitcher group. Further, 5 players reported being “a little unsatisfied” because of elbow pain during pitching. All of the players indicated satisfaction with elbow function during batting. Conclusion: The percentage of players who received OAT for OCD in junior high school and continued to play baseball in high school was favorable. However, satisfaction with elbow function during throwing was lower in pitchers than in nonpitchers. Clinical Relevance: Before surgery, consent should be obtained from patients who are pitchers after it is explained that satisfaction with elbow joint function during pitching could be decreased after OAT.

Developmental engineering of living implants for deep osteochondral joint surface defects.

The repair of deep osteochondral joint surface defects represents a significant unmet clinical need. Importantly, untreated lesions lead to a high rate of osteoarthritis. The current strategies to repair these defects include osteochondral autograft transplantation or "sandwich" strategies combining bone autografts with autologous chondrocyte implantation, with poorly documented long-term outcomes. In this study, we first investigated the capacity of juvenile osteochondral grafts (OCGs) to repair osteochondral defects in skeletally mature rats. With this regenerative model in view, we produced a new biological, bilayered and scaffold-free Tissue Engineered construct (bTEC) for the repair of a deep osteochondral defect of the rat knee. Cylindrical OCGs were excised from the femoral intercondylar groove of the knee of skeletally immature rats (5weeks) and transplanted into osteochondral defects created in skeletally mature rats (11weeks). To create bTECs, micromasses (μMasses) of human periosteum-derived progenitor cells (hPDCs) and human articular chondrocytes (hACs) were produced in vitro using previously optimized chemically defined medium formulations containing growth and differentiation factors including bone morphogenetic proteins. These two μMass types were subsequently implanted as bilayered constructs into osteochondral defects in nude rats. At 4 and 16weeks after surgery, the knees were collected and processed for subsequent 3D imaging analysis and histological evaluation. Micro-computed tomography (μCT), H&E, and Safranin O staining were used to evaluate the degree and quality of tissue repair. The osteochondral unit of the knee joint in 5weeks old rats exhibits an immature phenotype, displaying active subchondral bone formation through endochondral ossification and the absence of a tidemark. When transplanted into skeletally mature animals, the immature OCGs resumed their maturation process, i.e., formed new subchondral bone, established the tidemark, and maintained their Safranin O-positive hyaline cartilage at 16weeks after transplantation. The bTECs (hPDCs + hACs) could partially recapitulate the biology as seen with the immature OCGs, including the formation of the joint surface architecture with typical zonation, ranging from non-mineralized hyaline cartilage in the superficial layers to a progressively mineralized matrix at the interface with a new subchondral bone plate. Cell-based TE constructs mimicking immature OCGs and displaying a hierarchically organized structure comprising of different tissue forming units seem an attractive strategy to treat deep osteochondral defects of the knee.

Radiographic assessment of factors associated with poor outcomes after osteochondral autograft transplantation for capitellar osteochondritis dissecans

Objectives:Osteochondral autograft transplantation (OAT) is a treatment option for large, inviable osteochondritis dissecans (OCD) lesions. Many papers have reported good clinical outcomes after OAT; however, we sometimes experience elbows with poor outcomes that show pain and restricted range of motion. Few articles have investigated factor associated with poor outcomes after OAT. The purpose of this study was to retrospectively investigate the clinical outcome and radiographic findings after OAT in elbows with a large capitellar OCD lesion and to elucidate radiographic factors associated with poor clinical outcomes.Methods:Sixty-nine elbows that underwent OAT for large osteochondral dissecans lesions of the capitellum with a minimum of 2-years follow-up were included in this study. They consisted of 65 males and 4 females with a mean age of 14 (range, 12-15) years at surgery. The mean follow-up was 48 months (range, 24-144). Cylindrical osteochondral grafts were harvested from the lateral condyle of the ipsilateral knee. We usually transplant an 8-mm graft in the lateral part of a lesion and add two 6-mm grafts medial to the initial graft. Clinical outcomes, including elbow range of motion and Timmerman and Andrews clinical rating score (T-A score), were retrospectively investigated. We measured cranial migration of the radial head on the preoperative tangential views. We also evaluated the location and orientation of the most lateral graft on the tangential views at 1 month after OAT: 1) the tilting angle (the angle between the graft axis and the vertical line to the radial articular surface), 2) the distance between the most lateral edge of the graft and the center of radial head, 3) protrusion of the graft from the articular surface of the medial capitellum. The paired t-test and Student’s t-test were used for statistical analysis, and the level of significance was set at p<0.05.Results:The mean elbow extension/flexion significantly improve from preoperative -10/125 to postoperative -5/133 (p<0.001 for each). The mean T-A score significantly improved from preoperative 125±43 to 170±34 at 2 years after surgery (p<0.001). We compared the radiographic findings between good outcomes elbows (T-A score >190, n=33) and poor outcomes elbows (T-A score <150, n=18). The cranial migration of the radial head was 0.2mm and 2.1mm, respectively (p<0.001). The tilting angle was larger in the poor group (18±11 degrees) than the good group (9±8 degrees, p=0.002). The graft was significantly located laterally in the good group (6.8±1.6 mm) than the poor group (3.8±2.3 mm, p<0.001). The protrusion tended to be larger in the poor group (0.2±2.7mm) than the good group (-0.7±1.8mm), but the difference was not significant (p=0.17).Conclusion:The outcomes after OAT was good with significant improvement of range of motion and clinical score, but a quarter of patients showed poorer outcomes. The results of this study indicated that the radial head migration before surgery and the location and orientation of the graft were associated with the clinical outcomes. For better surgical outcomes, OAT should be performed before the radiographic changes progress, and surgeons should be careful about the location and orientation of osteochondral grafts.

A Comparison of Functional and Radiographic Outcomes following Microfracture with Extracellular Matrix Augmentation versus Osteochondral Autograft Transplantation for the Treatment of Medium-Sized Osteochondral Lesions of the Talus

Objectives:The aim of this study is to directly compare clinical outcomes following the treatment of medium-sized osteochondral lesions of the talus (OLTs) using a microfracture technique augmented with Extracellular Matrix and Bone Marrow Aspirate Concentrate (MFX) versus OAT to determine which treatment is superior for medium-sized lesions.Methods:Patients treated for an OLT between 2015 and 2018 by a single surgeon, fellowship-trained in sports medicine and foot and ankle, were screened for this study. Retrospective chart review determined treatment, lesion size, lesion location, concurrent injuries, and demographic information. Patients at a minimum of 12 months follow-up, treated with MFX or OAT, and lesions sized 80-165mm2 were eligible for inclusion. All surgical repairs were augmented with an adjuvant mixture of micronized cartilage extracellular matrix and bone marrow aspirate concentrate (ECM-BMAC). Patient-reported functional outcomes were collected through our institution’s prospective Registry database. Patients treated prior to March 2016 were administered preoperative Foot and Ankle Outcome Score questionnaires. Those treated after this date were administered preoperative Physical Function, Pain Interference, Global Physical Health, Global Mental Health, Depression, and Pain Intensity Patient-Reported Outcome Information System (PROMIS) domains. Both FAOS and PROMIS were administered postoperatively. Postoperative MRIs were assessed using a modified magnetic resonance observation of cartilage repair tissue (MOCART) score. Student’s paired and two-group t-tests were used to evaluate for statistically significant pre-to-postoperative change and differences between procedure groups (p less than 0.05).Results:Twenty-seven patients treated with MFX (age range, 14-58) and twenty-three patients treated using OAT (age range, 22-64) were identified. All OAT patients received a single-plug transplantation. The final average lesion size ± standard deviation (SD) for patients treated with MFX was 115.44mm2± 22.51 (range, 156-80mm2) and 121.78mm2± 23.98 (range, 165-80mm2) for those treated using OAT (p=0.34). On average, functional outcome scores improved pre-to-postoperatively across all scales within both groups. Statistically significant improvements were detected in PROMIS Physical Function (Δ=8.32, p=0.01), Pain Interference (Δ=-7.15, p=0.02), Global Physical Health (Δ=5.87, p=0.03), and Pain Intensity (Δ=-7.06, p=0.05) domains for the MFX cohort. For the OAT patient group, significant pre-to-postoperative change was seen in the FAOS subcategories of Pain (Δ=28.70, p=0.03), Sports Activities (Δ=43.12, p<0.01), and Quality of Life (Δ=43.75, p=0.01); overall FAOS score (Δ=29.93, p=0.01); and PROMIS Physical Function (Δ=13.66, p=0.01), Pain Interference (Δ=-14.58, p<0.01), Global Physical Health (Δ=12.2, p=0.01), Depression (Δ=-4.13, p=0.02), and Pain Intensity (Δ=-16.56, p=0.02) domains. On average, with the exception of the postoperative Sports Activities subscale, postoperative FAOS and pre-to-postoperative change in FAOS were higher and greater in the OAT patient group. Similarly, on average, the OAT group had better PROMIS t-scores indicating higher function or less pain and greater pre-to-postoperative change in each PROMIS domain. The OAT cohort’s average postoperative Pain Interference t-score (± SD) of 43.09 (± 5.81) and Depression t-score of 40.06 (± 6.84) were significantly lower than their respective counterparts in the MFX cohort: 50.08 (± 9.47) for Pain Interference and 48.09 (± 7.86) in Depression. (Table 1) Finally, the mean overall MOCART score was 55.67 (± 24.11) within the MFX cohort, average follow-up 15.29 months, and 71 (± 15.60) within the OAT cohort average follow-up 15.8 months. This difference was also statistically significant (p=0.04).Conclusion:The OAT group had a higher MOCART score indicating the use of a single osteochondral autograft plug may result in better structural repair than microfracture abrasion chondroplasty augmented with a mixture of adjuvant ECM-BMAC. In addition, higher average FAOS scores, better average PROMIS t-scores, and greater pre-to-postoperative change in the OAT patient group indicate functional results may be better in this group as well. Specifically, significantly lower Pain Interference and Depression domains and significantly higher Global Mental Health scores indicate patients treated using OAT experience less pain and better psychological benefits postoperatively compared to patients treated using MFX. These results suggest filling the lesion with transplanted autograft bone and native, hyaline cartilage may perform better than and the biomechanically inferior fibrocartilage produced following microfracture even when augmented with adjuvant therapy. OAT may result in better overall clinical outcomes, specifically in a population of patients with medium sized lesions (range, 80 mm2 -165 mm2).

Fresh Precut Osteochondral Allograft Core Transplantation for the Treatment of Capitellum Osteochondritis Dissecans

Osteochondritis dissecans (OCD) of the elbow is a disease of unclear etiology that affects young children and adolescents, particularly overhead athletes and gymnasts. Common surgical options include fixation, debridement, loose body removal, and marrow stimulation (microfracture/drilling). For large, deep, and/or uncontained defects, osteochondral autograft transplantation (OAT) has been advocated. However, there are some drawbacks to OAT, particularly related to donor-site morbidity. Fresh osteochondral allograft (OCA) transplantation avoids the donor-site morbidity associated with OAT and has been shown to be effective for treating capitellar OCD. This Technical Note details a surgical technique of OCA transplantation of the capitellum in an adolescent patient using a fresh precut OCA core. This procedure addresses the cartilage defect and loss of subchondral bone associated with OCD without the drawbacks associated with harvesting an autograft. Furthermore, as the graft is readily available, it avoids delays related to the donor–recipient matching process.

Osteochondritis Dissecans of the Capitellum: Management in the Throwing Athlete

Young overhead athletes, such as baseball players and gymnasts, are at risk of developing osteochondritis dissecans lesions of the capitellum. Repetitive microtrauma in conjunction with limited local blood supply likely contribute to the development of these lesions. Adolescent and young adult throwing athletes presenting with lateral-sided elbow pain and stiffness should undergo prompt evaluation and imaging with elbow radiographs. Advanced imaging with computed tomography and magnetic resonance imaging or arthrography can further diagnose these lesions and determine lesion size and stability. Skeletally immature individuals with early, stable lesions should be given a trial of conservative treatment. Lesions failing nonoperative management and unstable lesions may be treated operatively with arthroscopic debridement and microfracture, fragment fixation, or osteochondral autograft transplantation surgery depending on lesion stability, size, and location. A wide variety of surgical techniques and outcomes have been reported. Overall these techniques result in excellent outcomes with good return to sport rates, diminished pain, and improved range of motion.

ARTICULAR CARTILAGE THICKNESS IN PEDIATRIC AND ADOLESCENT KNEES DECREASES WITH AGE AND SKELETAL MATURITY: IMPLICATIONS FOR OSTEOCHONDRAL GRAFTING PROCEDURES

Background:Quantifying native cartilage thickness in pediatric and adolescent knees can help match donor and recipient sites for articular cartilage restoration procedures such as osteochondral autograft transplantation (OATS) and osteochondral allograft transplantation (OCA).Hypothesis/Purpose:The purpose of the current study was to quantify articular cartilage thickness in pediatric and adolescent knees using magnetic resonance imaging (MRI). We hypothesized that cartilage thickness is inversely correlated with skeletal maturity and age.Methods:One hundred and twenty MRI scans were evaluated in a cohort of patients 9 to 18 years old without osteochondral lesions, chondral wear or pathology, intraarticular fractures, history of knee surgery, or inflammatory arthropathy. Measurements of articular cartilage thickness at the medial femoral condyle, lateral femoral condyle, lateral trochlea, and patella were made on axial, coronal, and sagittal MRI scans (Figure 1). Skeletal maturity was categorized as ‘open’, ‘closing’, or ‘closed’ based on the status of the proximal tibial and distal femoral growth plates. Descriptive statistics was used to evaluate cartilage thickness by age and sex. Independent samples t-test, analysis of variance (ANOVA), and linear regression were performed to investigate for associations with sex, skeletal maturity, and age.Results:On the femur, cartilage was thickest at the lateral trochlea with mean articular thickness of 4.2 ± 1.4 mm in males and 3.6 ± 1.3 mm in females (p=0.015) (Table 1). Skeletally immature patients with open physes had significantly thicker cartilage at the medial femoral condyle, lateral femoral condyle, and lateral trochlea compared to patients with closing and closed physes (Figure 2). Linear regression analysis also revealed a significant association between femoral cartilage thickness and age (Figure 3). Age explained 63% of the variance at the medial femoral condyle (B=6.1, p<0.001), 64% of the variance at the lateral femoral condyle (B=4.9, p<0.001), and 68% of the variance at the lateral trochlea (B=8.2, p<0.001) (Table 2). In contrast, cartilage thickness at the patella did not significantly vary by age, sex, or skeletal maturity (Figures 2 and 4).Conclusion:There is a strong inverse association between increasing age and cartilage thickness of the femoral condyles and lateral trochlea. In particular, pediatric knees demonstrate relatively thick cartilage at the lateral trochlea that decreases with age. This information will help surgeons understand recipient site anatomy and identify appropriate donor site tissue for articular cartilage restoration procedures such as OATS and OCA in children and adolescents.Tables:Table 1.Mean articular cartilage thickness of the femur and patellaCombined (n=120)Male(n=40)Female(n=60) p valueMedial femoral condyle3.2 ± 1.03.5 ± 1.02.9 ± 0.80.001Lateral femoral condyle2.8 ± 0.72.9 ± 0.72.7 ± 0.70.056Lateral trochlea3.9 ± 1.44.2 ± 1.43.6 ± 1.30.015Median ridge of patella4.2 ± 0.94.4 ± 0.94.1 ± 0.90.080Medial facet of patella4.7 ± 1.04.8 ± 1.04.6 ± 0.90.320Lateral facet of patella4.6 ± 0.84.7 ± 0.84.5 ± 0.80.185Table 2.Linear regression of articular cartilage thickness of the femur and patella by ageR2 B p valueMedial femoral condyle0.636.1<0.001Lateral femoral condyle0.644.9<0.001Lateral trochlea0.688.2<0.001Median ridge of patella0.024.80.090Medial facet of patella0.045.50.032Lateral facet of patella0.0014.50.741Figures:Figure 1.Measurements of patellofemoral articular cartilage thickness Measurements of articular cartilage thickness were made on (A) coronal, (B, C) sagittal, and (D) axial magnetic resonance imaging (MRI) of the knee. For the medial femoral condyle, cartilage thickness was measured at five regions: midpoint of the medial condyle (MFC) and midpoints of Cahill zones 1 (MID1), 2 (MID2), B (MIDB) and C (MIDC). Similarly, measurements of cartilage thickness of the lateral femoral condyle were made at the midpoint of the lateral condyle (LFC) and midpoints of Cahill zones 4 (MID4), 5 (MID5), B (MIDB), and C (MIDC). Measurement of the lateral trochlea was made at midpoint of Cahill zone A (MIDA). Measurements on the patella were made at the midpoint of the medial facet (MF), midpoint of the lateral facet (LF), and the median ridge (MR) on axial and sagittal MRI scans. Figure 2.Mean articular cartilage thickness of the femur and patella by growth plate statusFigure 3.Mean articular cartilage thickness of the femur by ageFigure 4.Mean articular cartilage thickness of the patella by age

Surgical Techniques for Knee Cartilage Repair: An Updated Large-Scale Systematic Review and Network Meta-analysis of Randomized Controlled Trials

The aim of this study was to investigate the most appropriate surgical interventions for patients with knee articular cartilage defects from the level I randomized clinical trials. We searched five databases for level I randomized clinical trials. Treatments were compared if reported in more than one study using network meta-analysis to boost the number of included studies per comparison. We studied 21 articles that included 891 patients. Traumatic lesion was the most common cause in the included patients. There were significantly higher failure rates in the microfracture (MF) group compared to autologous chondrocyte implantation (ACI) group at 10-year follow-up. Moreover, osteochondral autograft transplantation (OAT) showed significantly more excellent or good results at > 3-year follow-up compared to MF, whereas MF showed significantly more poor results versus ACI and matrix-induced autologous chondrocyte implantation (MACI). Furthermore, OAT showed significantly more poor results than MACI at 1-year follow-up. Similarly, patients who underwent OAT had higher return-to-activity rates than those with MF. It is noteworthy that the Knee injury and Osteoarthritis Outcome Score was higher in patients who underwent characterized chondrocyte implantation or MACI compared to MF. Finally, there were no significant differences among the various interventions regarding reintervention, biopsy types or adverse events. According to the P scores for interventions ranking, there was a disagreement concerning the best intervention; however, MF was always ranked as the last. Cartilage repair techniques, rather than MF, provide higher quality repair of tissue and have lower failure and higher return-to-activity rates. Moreover, OAT had significantly more excellent or good results compared to MF, whereas MF had significantly more poor results than ACI and MACI. Future studies need to have longer follow-up periods and more representative populations to investigate the efficacy and safety of these interventions. Level I: meta-analysis of Level I studies.

The Role of Antimicrobial Neutrophil Extract in Modification of the Inflammatory Response During Osteochondral Autograft and Allograft Transplantation in Rabbits

Osteochondral autograft or allograft transplantation is one of the surgical options for the management of large cartilage defects; however, the mechanisms of cartilage healing after this procedure, especially the immunological mechanisms, are not fully understood. The present study examined whether a grafting procedure changed the in-vitro responses of neutrophils and monocyte-derived macrophages (MDMs). Additionally, antimicrobial neutrophil extract (ANE) was assessed for its ability to modulate excessive cellular responses during and after implantation. The neutrophil secretory response was tested by measuring enzyme release and free radical generation, while the MDM response was evaluated by assessing morphological and functional changes of the cells after polarization. Osteochondral implantation evoked a transient secretory response by circulating neutrophils, but MDMs were not activated postoperatively. ANE from rabbit blood may be considered as a modulator of the inflammatory response because of its influence on neutrophils and MDMs. Inhibition of the neutrophil secretory response prevents complications that may arise following excessive activity of these cells. Stimulation of MDMs with ANE induces formation of a partial anti-inflammatory phenotype with enhanced regenerative properties.

Preoperative Validation of the Patient-Reported Outcomes Measurement Information System in Patients With Articular Cartilage Defects of the Knee

To validate the Patient-Reported Outcomes Measurement Information System (PROMIS) physical function computer adaptive test (PF CAT) with current patient-reported outcome (PRO) instruments in patients with cartilage injuries of the knee. Patients scheduled for osteochondral autograft or allograft transplant, microfracture, autologous chondrocyte implantation, allograft cartilage resurfacing, and chondroplasty were prospectively enrolled in the study and completed PROMIS PF CAT, Knee Injury and Osteoarthritis Outcome Score (KOOS activities of daily living, pain, symptoms, sport, and quality of life), Short Form-36 Health Survey (SF-36 physical function [PF] and Physical Component Summary), and EuroQol-5 Dimension questionnaires. The Spearman correlation coefficient was used to compare instruments. Instrument correlations were defined as excellent (>0.7), excellent to good (0.61-0.69), good (0.4 to 0.6), and poor (<0.39), with significance defined as P < .05. A total of 293 knees in 275 patients (54.5% male) undergoing 319 cartilage procedures were analyzed. The most commonly performed cartilage procedure was chondroplasty (n= 118; 37.0%), followed by microfracture (n= 100; 31.3%). The mean age was 34.0 ± 14.7 and the mean body mass index was 30.0 ± 6.9. The PROMIS PF CAT had an excellent correlation with the SF-36 PF (r= 0.819; P < .001), SF-36 Physical Component Summary (r= 0.766; P < .001), KOOS activities of daily living (r= 0.733; P < .001), KOOS Sport (r= 0.709; P < .001), and EuroQol-5 Dimension (r= 0.752; P < .001) instruments; an excellent-good correlation with the KOOS pain (r= 0.662; P < .001), and KOOS quality of life (r= 0.640; P < .001) scores; and a good correlation with the KOOS symptoms (r= 0.519; P < .001) scale. The PROMIS PF CAT had no floor or ceiling effects and the smallest question burden (mean 4.17 ± 0.93 questions). Dimensionality analyses demonstrated that the smallest amount of unexplained variance was present in the PROMIS PF CAT (3.6%). The PROMIS PF CAT is an effective tool for preoperative outcome assessment in patients with cartilage defects of the knee. It correlates strongly with legacy PRO measures of physical function with no ceiling and floor effects and a minimal time burden for completion. Further study is warranted to determine postoperative performance and to evaluate the responsiveness of PROMIS to change within a patient. III; Prognostic retrospective comparative study.

Treatment of Large Osteochondral Lesions with Adjuvant Micronized Allogenic Cartilage Extracellular Matrix and Bone Marrow Aspirate Concentrate Reduces Rate of Postoperative Adjacent Cysts

Category:Ankle, Arthroscopy, SportsIntroduction/Purpose:Previous studies have established a correlation between the size of osteochondral lesions (OCLs) and the relative success of outcomes following surgical repair. Poorer results have been associated with traditional microfracture for lesions larger than 150 mm2. In these cases, osteochondral autograft transplantation (OAT) has shown to be a generally effective treatment despite associated disadvantages that include donor site morbidity, need to perform an osteotomy, and formation of postoperative adjacent cysts. The purpose of this study was to assess the effect of using a micronized allogenic cartilage extracellular matrix (ECM) mixed with bone marrow aspirate concentrate (BMAC) as an adjuvant therapy to augment and potentially improve the quality of repair achieved using OAT to treat larger lesions.Methods:Seventy cases (average age 38) treated by a fellowship-trained foot and ankle surgeon for an osteochondral lesion using OAT between December 2009 and June 2018 were identified. Retrospective chart review determined that 40 patients received adjuvant micronized ECM mixed with BMAC (average follow-up 25.6 months) while 30 had only BMAC injected into the joint or lesion (average follow-up 81.9 months). Preoperative lesion size, lesion location, and any concurrent injuries were also recorded. Foot and Ankle Outcome Scores (FAOS) were completed pre- and postoperatively through the prospective registry database at the authors’ institution. Structural integrity of reparative cartilage was assessed on available postoperative MRIs using a modified magnetic resonance observation of cartilage repair tissue (MOCART) score. In addition, the presence of postoperative edema and adjacent cystic changes were recorded. Linear regression analysis was performed to analyze differences in MOCART scores, FAOS, postoperative rate of adjacent cysts, and postoperative rate of edema.Results:Twenty-four postoperative MRIs, average follow-up 14.04 (SD 9.52) months, were available for the ECM+BMAC adjuvant therapy group. Twenty-one MRIs, average follow-up 35.06 months (SD 28.41), were available for the non-adjuvant therapy group. 20.8% of the ECM+BMAC group exhibited signs of postoperative cysts compared to 60.9% of patients in the non- adjuvant therapy OAT group (p<0.01). Similarly, 66.7% of ECM+BMAC patients had edema postoperatively versus 90.5% of patients in the non-adjuvant therapy cohort (p = 0.05). MOCART scores were similar in each group: 68.33 (SD=15.99) in the OAT and ECM+BMAC group and 65.95 (SD=22.50) in the non-adjuvant therapy group. Finally, the post-operative FAOS Symptoms scores were significantly greater in patients receiving adjuvant therapy (p=0.03).Conclusion:Using micronized allogenic cartilage ECM mixed with BMAC to augment traditional OAT helps reduce the rate of postoperative adjacent cysts and edema. In addition, greater increases in patient reported functional outcome scores indicate this adjuvant therapy may help improve clinical outcomes. Application of this adjuvant therapy could be especially useful in allowing easier treatment of non-circular lesions of amorphous shapes. By improving integration of OAT into surrounding bone and reducing the rate of postoperative cysts, adjuvant therapy may improve long-term outcomes for large OCLs.

Surgical Technique and Clinical Outcomes of Osteochondral Autograft Transplantation for Large Osteonecrotic Lesions of the Femoral Condyle With Residual Normal Cartilage: The Eyeglass Technique.

Background:Osteochondral autograft transplantation (OAT) is usually performed for a defect that is <400 mm2 because of the limitations of autografts.Purpose:To present the surgical technique and clinical outcomes of OAT using the eyeglass technique for large osteonecrotic lesions of the femoral condyle (LOFs) (>400 mm2) with residual normal cartilage.Study Design:Cohort study; Level of evidence, 3.Methods:Cases (group 1) included 15 patients (18 knees) who underwent OAT using the eyeglass technique for LOFs with residual normal cartilage, while controls (group 2) included 11 patients (11 knees) who underwent OAT using the standard technique for small osteonecrotic lesions of the femoral condyle (≤400 mm2). Clinical outcomes were evaluated preoperatively and at the final follow-up (group 1, 56 months; group 2, 48 months) according to the International Knee Documentation Committee (IKDC) objective grade, the IKDC subjective score, and the Japanese Orthopaedic Association (JOA) score.Results:The mean lesion size was 685 mm2 in group 1 and 230 mm2 in group 2. Patients in group 1 had postoperative scores equivalent to those in group 2. The postoperative IKDC subjective scores in group 1 (mean, 86.9) and group 2 (mean, 87.0) showed no significant difference at the final follow-up (P = .653). For postoperative IKDC objective grades, 83.3% of group 1 and 81.8% of group 2 were graded as “nearly normal” or better, and no significant intergroup difference was found for the IKDC objective grade (P = .989). Also, no significant intergroup difference was found for the postoperative JOA score (group 1, 93.9; group 2, 81.4; P = .480). Nine second-look arthroscopic procedures were performed in group 1 compared with 4 in group 2, and all patients had plugs that were graded as “nearly normal” or better by the International Cartilage Repair Society classification system.Conclusion:The postoperative results of patients who underwent OAT using the eyeglass technique for large osteonecrotic lesions (>400 mm2) were equivalent to the results of patients who underwent OAT using the standard technique for small osteonecrotic lesions (≤400 mm2).

Autologous Osteochondral Graft for Early Posttraumatic Arthritis of Tibiotalar Joints After Comminuted Pilon Fractures in Young Patients

Posttraumatic arthritis of tibiotalar joints after AO/OTA type C3 pilon fractures, especially in young patients with a significant osteochondral defect in the tibial plafond joint surface, is a challenging situation. We report a joint-preserving technique using autologous osteochondral graft in combination with ankle distraction and supramalleolar osteotomy (SMOT), if necessary, to improve its outcome. Seventeen patients with an average age of 32.1 years with Takakura grade 1 to 3A posttraumatic arthritis of the tibiotalar joint after AO/OTA type C3 pilon fractures received osteochondral autograft transplantation, ankle distraction, and SMOT, when supramalleolar malalignment was present, between February 2010 and November 2015. The visual analog scale (VAS), Short-Form 36 (SF-36) score, American Orthopaedic Foot & Ankle Society (AOFAS) score, and ankle range of motion were used for outcome analysis. Radiographic assessment of any SMOT and the apparent joint space was performed. Fourteen patients were followed for an average of 18 months. The VAS, SF-36, and AOFAS scores as well as the ankle range of motion all improved significantly at the last follow-up after the surgery (P < .01). No deep surgical site infection, donor site complication, nonunion, osteochondral block loosening, or resorption was noted. No secondary arthrodesis was needed at the end of follow-up. Autologous osteochondral graft transplantation in combination with ankle distraction and SMOT was a promising joint-preserving technique for early posttraumatic arthritis of tibiotalar joint after severe pilon fractures in young patients. Level IV, case series.

Donor Site Evaluation After Osteochondral Autograft Transplantation for Capitellar Osteochondritis Dissecans

Background: Osteochondral autograft transplantation (OAT) for capitellar osteochondritis dissecans (OCD) requires harvesting of tissue from the asymptomatic knee joint. However, donor site morbidity (DSM) in such cases remains unclear. Purpose: To evaluate DSM and postoperative radiographic findings in patients undergoing OAT for advanced capitellar OCD. Study Design: Case series; Level of evidence, 4. Methods: Eighty-six juvenile athletes underwent OAT for advanced capitellar OCD. The 2000 International Knee Documentation Committee subjective score, rate of return to sports, and symptoms in the donor knee were assessed at a mean follow-up of 86 months (range, 28-185 months). Additionally, 49 of the 86 patients were assessed by radiographic and magnetic resonance imaging (MRI) findings of the knee donor site. DSM was defined according to the usual criterion (persistent symptoms for >1 year or the need for subsequent intervention) and a stricter criterion (the presence of any symptoms, such as effusion, patellofemoral complaints, crepitation, unspecified disturbance, stiffness, pain/instability during activities, and osteoarthritic change). The stricter criterion was also used to allocate patients into a DSM group and a no-DSM group. Results: Two and 11 patients were determined to have DSM according to the usual and stricter criteria, respectively. All patients returned to the competitive level of their sports. The mean International Knee Documentation Committee score was 99.0. MRI findings showed abnormal signal intensity in 17 patients (35%) and hypertrophic changes in 11 patients (22%) at the donor harvest sites. The MOCART (magnetic resonance observation of cartilage repair tissue) score was higher in the no-DSM group (mean, 68.2) than in the DSM group (mean, 52.9) (P = .027). Conclusion: OAT for juvenile athletes with advanced capitellar OCD provided good clinical outcomes. The DSM rate was relatively low (2.3%) with the usual criterion but high (12.8%) with the stricter criterion. MRI showed an abnormal signal intensity and hypertrophy in some cases.

Opioid Prescription Refills After Osteochondral Procedures of the Knee

(1) To assess the incidence of postoperative opioid prescription refills in patients undergoing osteochondral autograft transplant (OAT) and osteochondral allograft transplant (OCA) procedures of the knee; (2) to evaluate the effect of filling preoperative opioid prescriptions on the incidence of postoperative filling; and (3) to assess the impact of age, sex, and diagnosis of low-back pain on postoperative opioid prescription filling. The Humana administrative claims database was queried for patients undergoing knee OAT and OCA procedures between 2007 and 2017 by use of Current Procedural Terminology codes. Patients were stratified by age, diagnosis of low-back pain, preoperative opioid use, autograft and allograft procedures, and open and arthroscopic procedures. Preoperative opioid users were defined as those having filled an opioid prescription within 3months before surgery. The relative risk (risk ratio) for opioid prescription refills was calculated monthly for 12months. Multivariate logistic regression analysis was performed to determine odds ratios (ORs) at 3, 6, and 12months. We identified 300 patients: 133 (44%) underwent OAT and 167 (56%) underwent OCA procedures. Of the patients, 236 (79%) were aged 49years or younger, and 31% of patients filled opioid prescriptions preoperatively. Of those who filled preoperative opioid prescriptions, 28% were still filling prescriptions 12months after surgery. Multivariate analysis showed an increased risk of opioid prescription filling at 3months (OR, 7.46 [95% confidence interval (CI), 3.26-17.38]), 6months (OR, 15.41 [95% CI, 5.52-41.99]), and 12months (OR, 13.45 [95% CI, 5.41-33.75]) postoperatively in preoperative opioid users. Filling opioid prescriptions preoperatively increased the risk of postoperative filling of opioid prescriptions after cartilage restoration procedures of the knee. Over 30% of patients were found to have filled an opioid prescription preoperatively. Univariate analysis showed that ageof 50years or older and low-back pain increased the risk of postoperative prescription refilling, but only age of 50years or older provided a significantly increased risk at 3months postoperatively using a multivariate analysis. Level III, retrospective case-control study.

Accurate Reporting of Concomitant Procedures Is Highly Variable in Studies Investigating Knee Cartilage Restoration.

Successful clinical outcomes following cartilage restoration procedures are highly dependent on addressing concomitant pathology. The purpose of this study was to document methods for evaluating concomitant procedures of the knee when performed with articular cartilage restoration techniques, and to review their reported findings in high-impact clinical orthopedic studies. We hypothesized that there are substantial inconsistencies in reporting clinical outcomes associated with concomitant procedures relative to outcomes related to isolated cartilage repair. A total of 133 clinical studies on articular cartilage repair of the knee were identified from 6 high-impact orthopedic journals between 2011 and 2017. Studies were included if they were primary research articles reporting clinical outcomes data following surgical treatment of articular cartilage lesions with a minimum sample size of 5 patients. Studies were excluded if they were review articles, meta-analyses, and articles reporting only nonclinical outcomes (e.g., imaging, histology). A full-text review was then used to evaluate details regarding study methodology and reporting on the following variables: primary cartilage repair procedure, and the utilization of concomitant procedures to address additional patient comorbidities, including malalignment, meniscus pathology, and ligamentous instability. Each study was additionally reviewed to document variation in clinical outcomes reporting in patients that had these comorbidities addressed at the time of surgery. All studies reported on the type of primary cartilage repair procedure, with autologous chondrocyte implantation (ACI) noted in 43% of studies, microfracture (MF) reported in 16.5%, osteochondral allograft (OCA) in 15%, and osteochondral autograft transplant (OAT) in 8.2%. Regarding concomitant pathology, anterior cruciate ligament (ACL) reconstruction (24.8%) and meniscus repair (23.3%) were the most commonly addressed patient comorbidities. A total of 56 studies (42.1%) excluded patients with malalignment, meniscus injury, and ligamentous instability. For studies that addressed concomitant pathology, 72.7% reported clinical outcomes separately from the cohort treated with only cartilage repair. A total of 16.5% of studies neither excluded nor addressed concomitant pathologies. There was a significant amount of variation in the patient reported outcome scores used among the studies, with the majority of studies reporting International Knee Documentation Committee (IKDC) and Knee Injury and Osteoarthritis Outcomes Score (KOOS) in 47.2% and 43.6% of articles, respectively. In this study on knee cartilage restoration, recognition and management of concomitant pathology is inadequately reported in approximately 28% of studies. Only 30% of articles reported adequate treatment of concomitant ailments while scoring their outcomes using one of a potential 18 different scoring systems. These findings highlight the need for more standardized methods to be applied in future research with regard to inclusion, exclusion, and scoring concomitant pathologies with regard to treatment of cartilage defects in the knee.

Osteochondral Allograft Transplantation of the Medial Femoral Condyle With Orthobiologic Augmentation and Graft-Recipient Microfracture Preparation

Osteochondritis dissecans (OCD) has been recognized for over 100 years yet still poses treatment challenges owing to both the avascular nature of articular cartilage and the inability to generate hyaline cartilage. The knee is most commonly involved, and without repair, patients have chronic knee pain, loose bodies, and early-onset osteoarthritis. There are a number of surgical techniques for repairing OCD, some of which are still being refined. Currently, common procedures used to treat OCD lesions include microfracture, autologous chondrocyte implantation, osteochondral autograft transplantation, and osteochondral allograft transplantation. In this Technical Note, we describe osteochondral allograft transplantation with the addition of platelet-rich plasma and graft-recipient microfracture. We believe the micropores augment the osteoconductive and osteoinductive properties of the allograft and aid in the incorporation of the allograft plug by improving angiogenesis, enhancing clot formation in the allograft, and providing a homogeneous environment for remodeling.

Osteochondral Autograft Transplantation Technique Augmented by an Ultrapurified Alginate Gel Enhances Osteochondral Repair in a Rabbit Model

Background: One of the most important limitations of osteochondral autograft transplantation (OAT) is the adverse effect on donor sites in the knee. To decrease the number and/or size of osteochondral defects, we devised a method with biomaterial implantation after OAT. Hypothesis: OAT augmented by ultrapurified alginate (UPAL) gel enhances cartilage repair capacity. Study Design: Controlled laboratory study. Methods: Seventy-five osteochondral defects in rabbits were divided into 3 groups: osteochondral defects with OAT alone, defects with OAT augmented by UPAL gel (combined group), and defects without intervention as controls. Macroscopic and histological evaluations of the reparative tissues were performed at 4 and 12 weeks postoperatively. Histological evaluation of graft cartilage degradation was also performed. To evaluate the effects of UPAL gel on graft healing, repaired bone volumes and osseointegration of the graft were evaluated. Collagen orientation and the mechanical properties of the reparative tissue and graft cartilage were also evaluated qualitatively. Results: The macroscopic and histological evaluations of the combined group were significantly superior to the other groups at 12 weeks postoperatively. Regarding degenerative change of the graft, the histological scores of the combined group were significantly higher than those of the OAT-alone group. The values of repaired subchondral bone volumes and osseointegration of the graft were almost identical in both groups. Collagen orientation and the mechanical properties of the reparative tissue and graft cartilage were significantly better in the combined group than in the other groups. Conclusion: Administration of UPAL gel in OAT enhanced cartilage repair and protected graft cartilage without inhibiting subchondral bone repair and graft survival. Clinical Relevance: OAT augmented by UPAL gel decreases the number and/or size of osteochondral grafts, minimizing the risk of donor site morbidity. This combination technique has the potential to improve clinical outcomes and expand the surgical indications for OAT.

A case report: Osteochondral autograft transplantation using the femoral head for spontaneous osteonecrosis of the knee with massive bone defect

A case report: Osteochondral autograft transplantation using the femoral head for spontaneous osteonecrosis of the knee with massive bone defect

Osteochondral Autograft Transplant (Mosaicplasty) for Knee Articular Cartilage Defects.

Osteochondral autograft transplant (mosaicplasty) is a cartilage repair procedure for patients with knee articular cartilage lesions of a substantial size (>3 cm2). Patient selection is key to a successful result; patients with established osteoarthritis or systematic disorders such as rheumatoid arthritis should not undergo surgery. An exercise program involving neuromuscular training for a minimum of 3 months should be attempted before proceeding to osteochondral autograft transplant. The procedure can, in many cases, be performed arthroscopically. Patients should, however, provide consent for a mini-arthrotomy as this might be needed to achieve optimal access for graft harvesting and insertion. The procedure, in general, consists of 4 major steps. (1) At the initial arthroscopic examination, the size and localization of the defect are assessed after a proper debridement has been performed. The number and size of autografts needed can thereafter be assessed. (2) Graft harvesting is then performed from the periphery of the non-weight-bearing trochlea. (3) To prepare for graft insertion at the recipient site, a drill guide is inserted perpendicular to the joint surface in the defect to allow graft sockets to be reamed. (4) Grafts should be spaced approximately 3 mm apart to avoid confluence of tunnels and weakening of condyles. The orientation and depth of insertion of the grafts are key to mimic the native curvature of the affected joint surface. After an initial phase of non-weight-bearing focusing on range of motion, a gradual increase in neuromuscular exercises is recommended. Patients are typically advised to delay their return to sports until 6 months at the earliest. Results after mosaicplasty have shown that the procedure improves subjective outcomes, compared with baseline function, for up to 10 years after surgery. The additional effect over traditional microfracture treatment is, however, reduced over time. A study evaluating early factors affecting outcomes after cartilage repair procedures (including mosaicplasty) found that a series of factors, such as the time from the onset of symptoms to surgery, number and size of lesions, location and quality of surrounding cartilage, as well as concomitant meniscal injuries, were important3.