Use Of Osteochondral Allografts Research Articles

Poster 256: Is There a Difference Between Medial and Lateral Femoral Condyle Allografts? An Outcome and Survivorship Analysis

Objectives: Focal chondral and osteochondral defects in the knee are problematic and are often difficult to treat. One solution is the use of osteochondral allograft (OCA) transplantation. A majority of the literature deliberates lesions located to the medial femoral condyle (MFC), but little is discussed regarding the lateral femoral condyle (LFC). Given the limited data, the purpose of this study was to compare graft survivorship and patient-reported outcomes (PROs) among patients who underwent OCA transplantation of the MFC or LFC. Methods: A total of 208 patients who underwent primary OCA transplantation of the MFC and 111 patients who underwent primary OCA transplantation of the LFC between 1997 and 2021 were identified from a prospectively collected single-surgeon cartilage registry. Overall, 66% were male and the mean age was 30.5 years. Most patients presented for OCA for osteochondritis dissecans (57%). Mean allograft size was 6.7 cm2. All patients had a minimum 2-year follow-up. Reoperations following the OCA transplantation were captured. Failure of the allograft was defined as removal of the graft (OCA revision or conversion to arthroplasty). PROs were measured both pre and postoperatively using the Knee Injury and Osteoarthritis Outcomes Scores (KOOS), International Knee Documentation Committee (IKDC), and Merle d’Aubigné-Postel scales. Patient satisfaction was also assessed. Results: Patients with MFC grafts were older than patients with LFC grafts (33 years and 26 years respectively; p<0.001) and had a slightly higher BMI (25.6 and 24.4 respectively; p=0.039). There were no differences between groups in regard to diagnosis, sex, number of allografts transplanted, or size of the allograft. Reoperations occurred in 27.9% of patients with MFC grafts and 26.1% of patients with LFC grafts (p=0.737). OCA failure occurred in 12% of MFC grafts and 9% of LFC grafts (p=0.413). The 10-year survivorship was 88% for MFC grafts and 92.9% for LFC grafts (p=0.543) (Figure 1). Among patients who had the allograft in situ at latest follow-up, the mean follow-up duration was 9.4 years for MFC grafts and 8.6 years for LFC grafts (p=0.313). At latest follow-up, KOOS, IKDC, and Merle d’Aubigné-Postel scores were similar between patients with MFC and LFC grafts. Patients with MFC grafts reported a slightly higher rate of satisfaction compared to patients with LFC grafts (93.7% and 86.3% respectively, p=0.041). Conclusions: Little data is available comparing treatment of medial and lateral femoral condyle lesions with osteochondral allografts. Clinical perception is that LFC lesions have inferior outcome to MFC lesions, but we did not find this to be true. We found little difference in reoperation rates and survivorship, as well as patient-reported clinical outcomes as measured on the KOOS, IKDC, and Merle d’Aubigné-Postel scales. There was a small difference in patient satisfaction. We conclude that there is similar outcome when using allografts for either medial or lateral femoral condyle lesions.

Harvest, Transport, and Storage of Fresh Humeral Head Osteochondral Allograft: Step-by-Step Protocol

Articular cartilage defects are not common in the glenohumeral joint and are mostly found in patients after shoulder trauma, in patients with recurrent instability, or in patients who underwent previous surgical treatment. Articular cartilage defects lead to pain and loss of motion, consequently causing shoulder function impairment and reducing quality of life. In young patients, the use of osteochondral allografts for the treatment of humeral head defects may avoid well-known complications of shoulder arthroplasty. The goal of this Technical Note is to describe a step-by-step protocol for the harvesting, transport, and preservation of fresh humeral head osteochondral tissue for use in allograft transplantation.

Chondral Lesions of the Knee: An Evidence-Based Approach.

Management of chondral lesions of the knee is challenging and requires assessment of several factors including the size and location of the lesion, limb alignment and rotation, and the physical and mental health of the individual patient. There are a multitude of options to address chondral pathologies of the knee that allow individualized treatment for the specific needs and demands of the patient. Osteochondral autograft transfer remains a durable and predictable graft option in smaller lesions (<2 cm2) in the young and active patient population. Both mid-term and long-term results for large chondral lesions (≥3 cm2) of the knee have demonstrated favorable results with the use of osteochondral allograft or matrix-associated chondrocyte implantation. Treatment options for small lesions (<2 cm2) include osteochondral autograft transfer and marrow stimulation and/or microfracture with biologic adjunct, while larger lesions (≥2 cm2) are typically treated with osteochondral allograft transplantation, particulated juvenile articular cartilage, or matrix-associated chondrocyte implantation. Emerging technologies, such as allograft scaffolds and cryopreserved allograft, are being explored for different graft sources to address complex knee chondral pathology; however, further study is needed.

Shorter Storage Time Is Strongly Associated With Improved Graft Survivorship at 5 Years After Osteochondral Allograft Transplantation

Background: Current regulations surrounding the use of osteochondral allografts (OCAs) in the United States require delayed graft release after 14 days to complete infectious disease screening. With a generally accepted expiration time of 28 days in storage, a limited window from 14 to 28 days remains for implantation. Yet, the rates of graft survival and thus optimal time for transplantation within this window remain largely unknown. Hypothesis: OCAs transplanted within 19 to 24 days would have lower failure rates at 5 years than those transplanted at 25 to 27 days. Study Design: Cohort study; Level of evidence, 3. Methods: In this retrospective case series, we analyzed data from patients who underwent OCA transplantation (N = 111) by a single surgeon between February 2014 and December 2016 with at least 2-year follow-up. In total, 56 patients received early transplant grafts (storage time, 19-24 days), and 55 received late transplant grafts (storage time, 25-27 days). Survival analysis with Kaplan-Meier curves was performed using log-rank analysis to compare the groups. Multivariable Cox regression analysis was used to assess the influence of OCA storage duration on graft survival while adjusting for age and defect size. Optimal storage time cutoff associated with graft failure was identified by performing receiver operating characteristic curve analysis and calculating the area under the curve. Results: Patients in the late transplant group had a significantly lower rate of graft survival at 5 years postoperatively (70.4%) as compared with patients in the early transplant group (93.1%; P = .027). When correcting for patient age and defect size, late transplant OCAs demonstrated a 3.4-times greater likelihood of failure versus early transplant OCAs. Receiver operating characteristic analysis suggested that OCA transplantation should ideally occur before 25 days of graft storage. Conclusion: OCA transplantation is a safe and successful treatment option for large osteochondral defects of the knee, with excellent rates of in situ graft survival at 5 years. Prioritizing early transplantation of OCAs to <25 days in storage improves rates of graft survival.

Osteochondral Allograft Transplants for Large Trochlear Defects

Focal articular cartilage injuries in the knee are common and can cause severe morbidity and reduced function. The articular cartilage is avascular and has limited ability to heal, and hence, patients with cartilage injuries have increased risk of progressing to osteoarthritis. Most of the cartilage injuries are located on the femoral condyles. Engaging focal cartilage injuries involving the trochlea are challenging because of the morbidity caused by these injuries and the limited treatment options. Osteochondral allograft transplantation is emerging as a promising treatment for full-thickness articular cartilage defects. Recent studies have reported high success rates with the use of osteochondral allografts. This article reports our technique of osteochondral allograft transplantation for the treatment of a focal full-thickness defect of the trochlea.

Fresh Osteochondral Allograft Transplantation for Treatment of Articular Cartilage Defects of the Knee

Articular cartilage damage of the knee can cause severe morbidity. Owing to its avascular nature, articular cartilage has limited potential for self-healing and increased propensity to progress to osteoarthritis. Treatment of large, full-thickness cartilage defects is still a challenge for orthopaedic surgeons but has recently achieved high success rates with the use of osteochondral allografts. This article details our technique of osteochondral allograft transplantation for the treatment of articular cartilage defects of the knee.

The use of osteochondral allograft with bone marrow-derived mesenchymal cells and hinge joint distraction in the treatment of post-collapse stage of osteonecrosis of the femoral head

Osteonecrosis of the femoral head is an entity which occurs mainly in young and active patients aged between 20 and 50. The success of hip joint preserving treatments ranges from 15% to 50% depending on the stage and amount of osteonecrotic lesion. Total hip replacement is indicated in late post-collapse hips but it has unsatisfactory survival because of the wear and osteolysis in young and active patients. Osteochondral allografts have been reported in the treatment of large articular lesions with defects in underlying bone in knee, talus and shoulder. By combining osteoconductive properties of osteochondral allograft with osteogenic abilities of bone marrow-derived mesenchymal cells it has a potential to be an alternative to an autologous graft. The adjunct of hinged joint distraction should minimize stresses in subchondral bone to promote creeping substitution and prevent femoral head collapse. Unlike current treatment modalities, it would provide both structural support and allow bony and articular substitution.

Failures in bipolar fresh osteochondral allograft for the treatment of end-stage knee osteoarthritis

Bipolar fresh osteochondral allografts (BFOA) recently became a fascinating option for articular cartilage replacement, in particular in those young patients non-suitable for traditional replacement because of age. While the use of osteochondral allografts for the treatment of focal osteochondral lesions in the knee is well established, their use in the treatment of end-stage arthritis is far more controversial. The purpose of this paper is to describe our experience in a series of seven patients who underwent a resurfacing of both tibio-femoral and patello-femoral joints by BFOA. From 2005 to 2007, seven patients (mean age 35.2 ± 6.3 years) underwent BFOA for end-stage arthritis of the knee. Patients were evaluated clinically, radiographically and by CT scan preoperatively and at established intervals up to the final follow-up. No intra-operative complications occurred. Nevertheless, joint laxity and aseptic effusion, along with a progressive chondrolysis, lead to early BFOA failure in six patients, which were revised by total knee arthroplasty at 19.5 ± 3.9 months follow-up. Only one patient, who received the allograft to convert a knee arthrodesis, gained a satisfactory result at the last follow-up control. BFOA in the knee joint still remains an inapplicable option in the treatment of post-traumatic end-stage arthritis of the young patient, due to the high rate of failure. Further studies are necessary in order to investigate the causes of failure and improve the applicability of this method. Still, after extensive counselling with the patient, BFOA may represent a salvage procedure aimed to revise scarcely tolerated knee arthrodesis. Retrospective case series, Level IV.

Cartilage Repair in the Knee: Part III

The third issue of this four-issue series is focused on the importance of the bone-cartilage interface with respect to resurfacing treatments in the knee. Hoemann and co-authors address the basic science of the bone-cartilage interface and its relevance to current and future methods of cartilage repair. Miniaci and McCoy review the indications and outcomes associated with osteochondral autografts. Bugbee and colleagues address the use of osteochondral allografts, and in related work, Stoker and co-authors present a novel system for osteochondral allograft preservation that has the potential to markedly improve storage time and graft quality. As with our previous issues, these authors have done a wonderful job in accomplishing our goals of presenting a comprehensive, patient-based approach, discussing the science behind the surgery, and providing the most current and groundbreaking information to you as knee surgeons.

The use of osteochondral allografts in the management of cartilage defects.

Large symptomatic osteochondral defects in a young active population represent a therapeutic challenge for orthopedic surgeons, since standard interventions such as debridement, microfracture and autologous osteochondral transfer are not suitable for the treatment of these larger lesions. Fresh osteochondral allograft transplantation provides a surgical option for these challenging defects, both as a primary procedure and for salvage of prior failed treatment attempts. This article reviews the basic science, indications, technique, and evidence for osteochondral allograft transplantation in the knee.

Fresh Osteochondral Allografting for Steroid-associated Osteonecrosis of the Femoral Condyles

Osteonecrosis is a complication of corticosteroid therapy with limited treatment options in young, active patients. These options include debridement, core decompression, osteotomy, allografting, and partial or total knee replacement. Few studies exist regarding the use of osteochondral allografts for treatment of steroid-associated osteonecrosis. We asked if fresh osteochondral allografts would (1) heal to host bone in the presence of osteonecrosis, (2) provide a clinically meaningful decrease in pain and improvement in function, and (3) prevent or postpone the need for prosthetic arthroplasty. Twenty-two patients (28 knees) who underwent osteochondral allografting for high-grade, corticosteroid-associated osteonecrosis were evaluated. Their average age was 24.3 years (range, 16-44 years). The mean graft surface area was 10.8 cm(2) (range, 5.0-19.0 cm(2)). Evaluation included a modified (for the knee) D'Aubigné and Postel (18-point) score, International Knee Documentation Committee (IKDC), and Knee Society function scores. The minimum followup was 25 months (mean, 67 months; range, 25-235 months). Five knees failed. The graft survival rate was 89% (25 of 28). The mean D'Aubigné and Postel score improved from 11.3 to 15.8; 19 of 25 (76%) had a score greater than 15. The mean IKDC pain score improved from 7.1 to 2.0, mean IKDC function score from 3.5 to 8.3, and mean Knee Society function score from 60.0 to 85.7. Our data suggest osteochondral allografting is a reasonable salvage option for osteonecrosis of the femoral condyles. TKA was avoided in 27 of the 28 of knees at last followup. Level IV, case series. See Guidelines for Authors for a complete description of levels of evidence.

The subchondral bone in articular cartilage repair: current problems in the surgical management.

As the understanding of interactions between articular cartilage and subchondral bone continues to evolve, increased attention is being directed at treatment options for the entire osteochondral unit, rather than focusing on the articular surface only. It is becoming apparent that without support from an intact subchondral bed, any treatment of the surface chondral lesion is likely to fail. This article reviews issues affecting the entire osteochondral unit, such as subchondral changes after marrow-stimulation techniques and meniscectomy or large osteochondral defects created by prosthetic resurfacing techniques. Also discussed are surgical techniques designed to address these issues, including the use of osteochondral allografts, autologous bone grafting, next generation cell-based implants, as well as strategies after failed subchondral repair and problems specific to the ankle joint. Lastly, since this area remains in constant evolution, the requirements for prospective studies needed to evaluate these emerging technologies will be reviewed.

The Use Osteochondral Allograft in the Treatment of a Severe Femoral Head Fracture

This study reviews the second case in the literature involving the use of frozen osteochondral allograft to reconstruct a femoral head fracture-dislocation. The case involved significant, unreconstructable damage to the weightbearing area of the femoral head in an 18-year-old male. Clinical and diagnostic imaging follow up at 46 months revealed that despite magnetic resonance imaging and radiographic evidence of progressive arthrosis in the hip, including subchondral cystic change in the femoral head and localized cartilage loss in the acetabulum and femoral head, the patient had excellent function with no complications (Harris hip score 100, hip dysfunction and osteoarthritis outcome score 62, musculoskeletal function assesment score 22, SF-36 score 81). The use of osteochondral allograft may serve as a useful tool for the orthopaedic surgeon faced with an unreconstructable femoral head fracture-dislocation in a young patient.

Osteochondral allograft transplantation in the knee

Despite significant improvements for the past 20 years in the treatment of full-thickness chondral defects with the use of chondroprotective biological methods (microfracture, autologous chondrocyte transplantation, osteochondral autograft, and periosteal graft), the treatment of large osteochondral defects in young and physically active population is still challenging. Alternatives for the treatment of chondral defects exceeding 3 cm in size are limited, and among them, allografts have been used longer than any other treatment methods with the most favorable results. The success rates for osteochondral allograft transplantation have been reported as 95%, 71%, and 66% at 5, 10, and 20 years, respectively. Factors that adversely affect long-term results include advanced age, allograft transplantation to both sides of the joint, inappropriate loading, osteoarthritis, and osteonecrosis due to steroid use. Today, as a result of improvements in tissue-organ transplantation, increased availability of fresh tissue from donors, and increased demand from patients and physicians, there has been growing interest in the use of osteochondral allografts in selected patients to delay arthroplasty for chondral defects.

Management of big osteochondral defects of the knee using osteochondral allografts with the MEGA-OATS technique

Treatment of osteochondral defects in weight-bearing areas of the knee, especially when they are sizeable and involve considerable subchondral bone loss, is a challenging problem. We report our experience on the use of osteochondral allografts with the MEGA-OATS technique in the management of large osteochondral defects of the knee in young patients. Five patients (3 male and 2 female) were included in this study; their age ranged from 22 to 41 years and the mean size of the defect covered was 30×30 mm. They were followed for a minimum of 2.5 years (mean: 32.8 months, range 30–36). An age- and size-matched fresh frozen, non-irradiated distal femoral allograft was used to obtain the donor plug, which was then inserted in the recipient area in a press-fit fashion. Patients' Lysholm knee score increased from 37.8 pre-operatively to 73.8 post-operatively. Tegner activity score increased in all five patients; it improved from a mean of 2 pre-operatively (range 1–3) to 4 post-operatively (range 2–7). Four out of five patients returned to work and three went back to sporting activities. With this technique one can cover sizeable osteochondral defects, and compensate for significant subchondral bone loss, while accurate reconstruction of the curvature of the femoral condyle is allowed. We believe that it is a viable salvage option in young patients with big osteochondral defects of the knee. It offers very satisfactory functional results and does not compromise patients' future options.

Osteonecrosis of the knee: current clinical concepts.

Osteonecrosis of the knee should be differentiated into two main categories: (1) primary, spontaneous, or idiopathic osteonecrosis and (2) secondary osteonecrosis (e.g., secondary to factors such as steroid therapy, systemic lupus erythematosus, alcoholism, Caisson decompression sickness, Gaucher's disease, hemoglobinopathies, etc.). Spontaneous or primary osteonecrosis of the knee presents with an acute knee pain in elderly patients. It is three times more common in women than in men. Traumatic and vascular theories have been proposed as a causative factor of osteonecrosis of the knee, but the precise etiology still remains speculative. High index of clinical awareness and a good history and physical examination are essential to make an early, accurate diagnosis. Plain radiographs are often normal during the early course of the disease and, in such instances, radioisotope bone scan and magnetic resonance imaging may be helpful. In the early stage of the disease, nonoperative treatment is indicated and many patients, if diagnosed early, have a benign course with a satisfactory pain relief and a good knee function. In patients with advanced stage of the disease, treatment options include arthroscopic debridement, curettage or drilling of the lesion, bone grafting, high tibial osteotomy, use of osteochondral allograft, and unicompartmental or total knee arthroplasty. The choice of treatment should be based on factors such as age of the patient, severity of symptoms, activity level and functional demands on the knee, site and stage of the lesion, and extent of deformity and secondary osteoarthritis. The clinical features and treatment of steroid-induced osteonecrosis of the knee are briefly discussed. In recent years, "postmeniscectomy" osteonecrosis has been reported, but at present its prevalence and pathophysiology remain unknown. It is possible that this may be a preexisting condition that was not recognized at the time of initial consultation or osteonecrosis may develop after meniscectomy in occasional cases.

Osteochondral allografts for limb salvage.

Use of osteochondral allografts has increased over the past 10 years in combination with improved procedures for bone procurement and storage, the development of protocols for tumor staging and diagnosis, successful adjuvant therapies that prolong survival, and greater emphasis on improved quality of life for persons with aggressive neoplasms of bone. The success rate after allograft implantation is high; there is also a high rate of complications. Comprehensive, effective nursing care is among the essential requisites for a successful, uncomplicated outcome.