Fresh-stored osteochondral allografts for the treatment of femoral head defects: surgical technique and preliminary results

Purpose

The purpose of this study was to present the preliminary clinical and radiographic outcomes of the treatment of femoral head osteochondral defects in eight consecutive symptomatic patients with fresh-stored osteochondral allografts via a trochanteric osteotomy.

Methods

This study included all consecutive patients treated in our department between 2008 and 2010 for worsening pain and mechanical symptoms of femoral head osteochondral defects. Each patient had preoperative routine hip radiographs and a preoperative magnetic resonance imaging study that determined and recorded the defect size and femoral head diameters. Allograft donors were identified through the Multiple Organ Retrieval and Exchange program (Ontario, Canada).

Results

The osteochondral defects were secondary to osteochondritis dissecans in four patients, avascular necrosis in three and femoral head fracture without dislocation in one. The patients’ average age at surgery was 23.7 (range 17–42), and the average follow-up was 41 months (range 24–54). Follow-up included clinical and radiographic examinations at standard intervals. The average Harris hip scores improved from 57.7 (range 50–65) points preoperatively to 83.9 (range 72–94) points at latest follow-up. Five patients had good-to-excellent clinical outcomes, and one had a fair outcome. One patient was converted to a total hip arthroplasty due to progression of arthritis. Another patient’s graft subsided and he underwent a successful repeat transplantation. An additional patient required the removal of the screws transfixing her trochanter due to persistent irritation.

Conclusions

These findings indicate that fresh-stored osteochondral allograft transplantation using a trochanteric slide and surgical dislocation is a viable treatment option for femoral head defects in young patients.     

History of osteochondral allograft transplantation

Osteochondral defects or injuries represent the most challenging entities to treat, especially when occur to young and active patients. For centuries, it has been recognized that such defects are almost impossible to treat. However, surgeons have never stopped the effort to develop reliable methods to restore articular cartilage and salvage the endangered joint function. Osteochondral allograft transplantation in human was first introduced by Eric Lexer in 1908. Since that era, several pioneers have been worked in the field of osteochondral allotransplantation, presenting and developing the basic research, the methodology and the surgical techniques. Herein we present in brief, the history and the early clinical results of osteochondral allograft transplantation in human.     

Focal osteochondral necrosis of the femoral head of an adult after Legg-Calve-Perthes disease in childhood

In the treatment of circumscribed osteochondral lesions of the knee and the ankle joint autologous osteochondral transplantation (AOT) has been established as one of the possible operative therapies. However, there is less experience with the use of AOT on other joints (shoulder, elbow). The care of osteochondral defects of the hip joint with autologous osteochondral transplantation can still be regarded as an absolute rarity. Facing a focal osteochondral necrosis in a young female adult after LCP disease in childhood, we report about an autologous osteochondral transplantation at the femoral head using the diamond bone cutting system.     

Surgical hip dislocation for osteochondral transplantation as a salvage procedure for a femoral head impaction fracture

Obturator anterior hip dislocation is very rare. Poor results are described in patients with additional large transchondral fractures and treatment of these injuries remains challenging. Appropriate treatment recommendations are missing in the literature. This case report introduces surgical hip dislocation for osteochondral autograft transplantation with graft harvest from the nonweightbearing area of the head-neck junction as a salvage procedure in a large femoral head defect. We report the treatment and outcome of a 48-year-old man who sustained an anterior dislocation of the left hip after a motorcycle accident. After initial closed reduction in the emergency room, imaging analysis revealed a large osteochondral defect of the femoral head within the weightbearing area (10 × 20 mm, depth: 5 mm). The hip was exposed with a surgical hip dislocation using a trochanteric osteotomy. An osteochondral autograft was harvested from a nonweightbearing area of the femoral head and transferred into the defect. The patient was prospectively examined clinically and radiologically. Two years postoperatively, the patient was free of pain and complaints. The function of the injured hip was comparable to that of the contralateral, healthy hip and showed satisfying radiologic results. Surgical hip dislocation with a trochanteric flip osteotomy is a simple, one-step technique that allows full inspection of the hip to treat osteochondral femoral defects by osteochondral transplantation. The presented technique, used as a salvage procedure in a large femoral head defect, yielded good clinical and satisfying radiologic outcomes at the midterm.     

Autologous osteochondral mosaicplasty for treatment of a posttraumatic defect of the lateral tibial plateau: a case report with two-year follow-up

Posttraumatic osteochondral defects following a tibial plateau fracture are common and a serious complication that may lead to the development of posttraumatic arthrosis. Successful reconstruction of the tibial plateau must include restoration of limb alignment, repair of bone defects, restoration of the articular cartilage, and preservation of the menisci. When osteochondral defects are present, the use of bulk bone grafts to restore the original articular surface anatomy of the tibial plateau is difficult due to incongruity between the graft and the original joint surface. Recognizing this, an autologous osteochondral transplantation utilizing the mosaic technique was performed successfully on a 32-year-old male alpine skier with a posttraumatic osteochondral defect following a tibial plateau fracture. At 2 years postsurgery, the patient had regained the capacity to perform most activities of daily living and to participate in sports. Clinical examination revealed an improvement of the Lysholm score from 48 points to 72 points.     

Autologous osteochondral grafting in the knee: indication,results, and reflections

The use of multiple autologous osteochondral plugs (mosaicplasty) for repair of articular cartilage defects is a well-accepted technique. Since 1995, the authors have used mosaicplasty to treat more than 110 patients with cartilage defects of the knee, hip, and ankle. The first 52 consecutive patients who had mosaicplasty of the knee and have an average followup of 37 months (range, 24-56 months) were examined. Indications for surgical treatment were osteochondritis dissecans, acute trauma, and posttraumatic lesions of the femorotibial joint, femoropatellar maltracking with recurrent episodes of patella dislocations, and distinct femoropatellar arthrosis. Preoperatively, cartilage defects were classified as International Cartilage Repair Society Grade III lesions in 23 patients and Grade IV lesions in 29 patients. Two years after surgery, an increased level of knee function was found in 86% of the patients. At the latest followup, improved knee function was observed in 92% of the patients. In four patients, reoperation was necessary because of graft failure. Complications and reoperation rate were related to large surface lesions. Autologous osteochondral transplantation is a valid option for the treatment of full-thickness osteochondral defects. However, the method is limited by the defect size and the number of plugs to be taken at the donor site.     

关节镜下带骨软骨镶嵌移植修复软骨病损

目的：探讨关节镜下同体同关节内带骨软骨镶嵌式移植,治疗关节软骨病损的可行性。方法：采用美国戴安娜镶嵌式骨软骨移植器,关节镜下进行同关节非负重关节面提供骨软骨移植条块修复关节负重面的软骨病损。结果：手术15例,术后随访12－21个月,平均15个月,优良率达89．6％。结论：关节镜下同体同关节带骨软骨镶嵌移植对治疗关节应力性局限性软骨病及创伤性软骨缺损的45岁以下患者是一个效果确实、值得推广的方法。     

Classification and treatment of severe ankle articular segment deficits: osteochondral allograft reconstruction

Severe ankle degeneration can be a devastating problem for young adults. Although ankle fusion continues to be the gold standard, inherent long-term problems are related to this treatment option. Further advances in total ankle prosthetic arthroplasty are needed before this treatment option can be considered suitable in a younger population. The use of fresh osteochondral allograft transplantation can provide an alternative treatment option without precluding future salvage procedures. Future studies may further define the role immunosuppression can play in improving fresh osteochondral allograft viability.     

关节镜下行膝关节自体软骨移植术后早期个体化康复训练疗效分析

目的分析关节镜下行膝关节自体软骨移植术后早期个体化康复训练的疗效。 方法选取2016年1月至2017年1月在湖州市第一人民医院接受关节镜下软骨移植修复膝关节软骨缺损治疗的37例患者。其中股骨内髁负重面软骨损伤27例,股骨外髁负重面软骨损伤10例;按照国际软骨修复协会标准分级,软骨缺损深度分别为Ⅱ级3例、Ⅲ级34例;34例软骨损伤面积为1.5～3.0 cm²,3例大于3 cm²。术前通过评估建立功能档案,参与康复学堂,制定个体化康复训练方案。术后按训练方案进行早期功能锻炼。采用Brittberg-Peterson功能评定标准评估患者自体软骨移植前后膝关节功能。采用配对t检验比较患者自体软骨移植前后Brittberg-Peterson功能评分。P<0.05为差异有统计学意义。 结果截至2017年1月,37例患者术后随访12～20个月,均无失访。术后12个月行膝关节MRI检查,示原软骨缺损区软骨表面平整,移植骨软骨柱位置良好。经康复训练后,37例患者膝关节Brittberg-Peterson功能评定标准评分平均为(62.2±1.4)分,低于术前(81.6±1.2)分,差异有统计学意义(t＝63.21,P<0.05);其中关节绞锁、关节肿胀、跑步困难、关节疼痛等13项指标较术前均有明显改善(P均<0.05)。 结论早期个体化康复训练对关节镜下膝关节自体软骨移植术后膝关节功能的恢复有显著作用。     

Modified technique for unipolar allograft ankle replacement: midterm follow-up. A case report

The management of tibiotalar arthritis remains a clinical challenge. Conventional treatment relies primarily upon arthrodesis or prosthetic arthroplasty. Fresh osteochondral total ankle allograft transplantation has been reported in limited cases. We report the case of a 42-year-old male who underwent a tibial refrigerated osteochondral allograft and a talar refrigerated osteochondral mosiacplasty. At 66-month follow-up, the patient demonstrated no limp with walking and was able to participate in tennis and snow skiing with no pain. His Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index, total WOMAC score, and American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale score were 0, 94, and 98, respectively. The final radiograph showed complete integration of the allograft with mild joint space narrowing. Osteochondral allografting for ankle arthritis may be considered an option in select patients.     

Chondral and osteochondral fractures

The incidence of traumatic chondral and osteochondral fractures and their role in the development of joint degeneration are not fully elucidated. While assessing traumatic knee injuries, one important criterion for the diagnosis of chondral fractures is to remember the possibility of a chondral or osteochondral fracture. Symptoms in osteochondral fractures are more obvious and cause severe pain and difficulty in movement of knee with hemarthrosis. The presence of hemarthrosis facilitates the diagnosis of an osteochondral fracture. Chondral and osteochondral fractures may be associated with other intra-articular pathologies. There are two main mechanisms of these fractures, including a direct effect causing avulsion or impaction and, a more common mechanism, flexion-rotation force to the knee, which is also the mechanism for an acute patellar dislocation. It is known that arthroscopic treatment is the best method for the diagnosis and treatment of chondral and osteochondral fractures. In osteochondral lesions, the aim of treatment is to restore the congruity of articular surfaces. In agreement with literature data, our clinical experience favors internal fixation as the most effective method for the treatment of osteochondral fractures.     

Knee salvage procedures: The indications,techniques and outcomes of large osteochondral allografts

The overall incidence of osteochondral defect in the general population is estimated to be 15 to 30 per 100000 people. These lesions can become symptomatic causing pain, swelling and decreased function of the knee, and may eventually progress to osteoarthritis. In the young and active population, partial or total knee arthroplasty (TKA) is rarely the treatment of choice due to risk of early failure. Osteochondral allograft transplantation has been demonstrated to be a safe and effective treatment of large osteochondral and chondral defects of the knee in appropriately selected patients. The treatment reduces pain, improves function and is a viable limb salvage procedure for patients, especially young and active patients for whom TKA is not recommended. Either large dowels generated with commercially available equipment or free hand shell allografts can be implanted in more posterior lesions. Current recommendations for fresh allografts stored at 4C advise implantation within 21-28 d of procurement for optimum chondrocyte viability, following screening and testing protocols. Higher rates of successful allograft transplantation are observed in younger patients, unipolar lesions, normal or corrected malalignment, and defects that are treated within 12 mo of symptom onset. Patients with bipolar lesions, uncorrectable malalignment, advanced osteoarthritis, and those over 40 tend to have less favourable outcomes.     

Autologous osteochondral graft for traumatic defects of finger joints

Finger joint defects in 16 adults were treated with an autologous osteochondral graft from the base of the second metacarpal, the radial styloid, the base of the third metacarpal or the trapezoid and these patients were followed up from between 12 and 62 months. There was no donor site morbidity. One patient had resorption of the graft and developed pain. The joint was subsequently fused. The mean range of movement was 55.8% of the opposite normal joint. At follow up, 15 patients had no discomfort or mild discomfort. Three had mild narrowing of the joint space and two had slight joint subluxation. Only two patients with concomitant severe injury to the same limb had difficulty performing daily activities. Ten were open injuries and these had poorer outcomes. A hemicondylar defect of a finger joint can be treated using an osteochondral graft obtained from the same hand.     

Total knee replacement in previous recipients of fresh osteochondral allograft transplants

BACKGROUND: Fresh osteochondral allograft transplantation is a treatment option for young patients with osteochondral lesions of the knee. The present study evaluated the surgical complexity of, and the prevalence of complications related to, total knee arthroplasty in patients who had had a previous osteochondral graft transplantation. METHODS: A retrospective analysis was performed on thirty-three consecutive patients (thirty-five knees) who underwent total knee arthroplasty from 1974 to 2000 after having had a previous transplantation of a fresh osteochondral allograft into the same knee. The mean duration of follow-up was ninety-two months. Perioperative data were analyzed with regard to etiology, preoperative impairment, intraoperative technical complications, early and late postoperative complications, and postoperative functional and subjective outcomes. The Knee Society clinical rating system was used for clinical evaluation beginning in 1990. RESULTS: Four knees required additional techniques for exposure. Three knees required stemmed components, one knee required a tibial augment, and two knees required morselized grafts. The mean Knee Society objective score (available for eighteen knees) improved from 34.7 preoperatively to 87.9 at the time of the latest follow-up, and the mean Knee Society function score improved from 45 to 82. The mean range of motion of all knees improved from 85 degrees to 105 degrees . Six of the thirty-five knees underwent revision total knee arthroplasty because of aseptic loosening, with two knees being revised within two years after the index total knee arthroplasty. CONCLUSIONS: Total knee arthroplasty after previous fresh osteochondral allograft transplantation provides improvements in knee function and range of motion, with manageable technical difficulties. Compared with routine total knee arthroplasty, an increased rate of early revision can be expected.     

Autogenous osteochondral transplantation of the second metatarsal head

A case of an osteochondral defect of the second metatarsal head treated with autogenous osteochondral transplantation from the talonavicular joint is presented. At 6-months follow-up, the patient had returned to previous activities with no complaints. MRI evaluation showed good congruency of the joint surface and complete incorporation of the osteochondral autograft.     

Neuropathic arthropathy as a possible cause of failure of a whole joint allograft. A case report

This report illustrates the fate of a whole joint allograft in a 23-year-old male with chondrosarcoma of the right hip. An extraarticular resection of the right proximal femur and surrounding pelvis was performed. Reconstruction was carried out with a fresh-frozen cadaveric allograft of articulated proximal femur and acetabulum with the capsule intact. Excellent union at the junction of host bone with the allograft was demonstrated roentgenographically 12 months later. Nineteen months after the operation, as weight bearing proceeded, sudden onset of instability of the joint occurred without pain. Collapse of the allograft with partial dissolution of the femoral head and acetabulum were observed roentgenographically. Reconstruction was achieved with a prosthetic implant. The roentgenographic and pathologic features of the allograft are suggestive of neuropathic arthropathy; however, the possibility of allograft rejection cannot be excluded but seems unlikely.     

Clinical results of osteochondral allografts in the treatment of osteochondral defects

There have been very few clinical reports on osteochondral allograft in Japan. In the allograft we did for osteochondral defects of the knee, seven fresh grafts and four frozen grafts were used. In six of the seven fresh grafts, the surface presented macroscopically and/or arthroscopically the appearance of almost complete normality. From the histological study of the cartilage for biopsy which was obtained from the fresh graft at postoperative fifteen months, the cell viability, though decreased in the superficial layer, was fairly normal and profusely produced proteoglycan stained with safranin-O in both the middle and the deep layers. The cell viability, however, was decreased remarkably or disappeared in all three layers in the biopsy cartilage taken from the frozen graft at over one year postoperatively. The eight of the eleven knees treated with the osteochondral allograft have preserved the joint space on one foot standing radiogram and revealed good function clinically.     

Arthroscopic osteochondral transplantation: Histologic results

Purpose: Localized, full-thickness articular cartilage defects of the femoral condyle are challenging. This report presents the histology of clinical cases obtained at intervals from 2 to 12 months after arthroscopic osteochondral transplantation. Type of Study: Longitudinal cohort study. Methods: Patients found at arthroscopy to have full-thickness femoral condyle defects between 1 and 3.5 cm in diameter underwent arthroscopic osteochondral transplantation. Exclusion criteria were associated tibial defects, patellar defects, or generalized arthritic change. The grafts taken from the superior and lateral intercondylar femoral notch were press-fit into holes drilled into the defect starting adjacent to the articular cartilage margin. Cancellous bone bridges were maintained between grafts. At various time intervals from 2 to 12 months after the osteochondral transplantation, arthroscopic biopsy specimens of the recipient sites were obtained. Results: Ten patients (5 male, 5 female) enrolled at 2 centers were evaluated arthroscopically at various intervals up to 13 months after osteochondral transplantation. The average patient age was 40 years (range, 17 to 65 years). One to 3 plugs had been harvested and inserted. Seven patients underwent biopsy at intervals ranging up to 12 months postoperatively. All showed maintenance of the integrity of the grafts with living chondrocytes and osteocytes. Donor sites filled without grafting and were covered with fibrocartilagenous scar. No complications occurred in this group. Conclusions: These histologic results suggest that arthroscopic osteochondral transplantation is a viable alternative for treating full-thickness chondral defects, with the grafts retaining their integrity and living chondrocytes and osteocytes observed in the grafts for up to 12 months after implantation.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 8 (October), 2001: pp 832–835     

Large Osteochondral Defects of the Distal Tibia Plafond After Septic Arthritis of the Ankle Joint Treated by Arthrodiastasis and Iliac Bone Graft: A Case Report

Bone defects after septic arthritis of the ankle joint result in arthrodesis and severe loss of ankle motion. This must be prevented in young athletes. We report the case of a 17-year-old male patient with large osteochondral defects in the distal tibia plafond after septic arthritis, in whom iliac bone graft and arthrodiastasis were performed to preserve ankle motion. He was diagnosed with septic arthritis of the ankle joint postoperatively at the age of 16 years. After irrigation and hardware removal, C-reactive protein level was normal. However, he experienced continuous pain and could not walk; he was referred to our hospital. Computed tomography showed large osteochondral defects in the medial tibia plafond occupying ∼30% of the plafond articular surface. Simultaneous iliac bone block graft and arthrodiastasis with an external fixator were performed. We placed iliac bone graft into the defect in the medial tibia plafond using the anterior approach, and we placed an external fixator with hinge and tractioned and fixed the ankle joint. One week postoperatively, range of motion training of the ankle was started. We removed the foot ring at 3 months and the external fixator at 4 months postoperatively. The patient started jogging at 8 months and performing long jump at 1 year postoperatively. The Japanese Society for Surgery of the Foot ankle/hindfoot scale improved from 56 to 97 points at 2-year follow-up. Despite large osteochondral defects with septic arthritis, arthrodiastasis and iliac bone graft were beneficial for preserving the ankle joint and its function.