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.     

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.     

Mosaicplasty for the treatment of femoral head defect after incorrect resorbable screw insertion

Articular cartilage lesions and osteochondral defects remain a difficult problem for the patient and physician. A variety of procedures and treatments have been proposed to lessen symptoms and restore the articular surface. The knee joint has been the focus of the vast majority of these cartilage restoration procedures. Osteochondral defects of the proximal femur are significantly less common, and their management remains poorly defined. This article reports the case of a young man with a deep osteochondral defect of the femoral head caused by penetrated resorbable screw after internal fixation of a displaced large single fragment of the posterior acetabular rim and subsequent treatment using mosaicplasty.     

Traumatic Osteochondral Injury of the Femoral Head Treated by Mosaicplasty: A Report of Two Cases

The increased risk of symptomatic progression towards osteoarthritis after chondral damage has led to the development of multiple treatment options for cartilage repair. These procedures have evolved from arthroscopic lavage and debridement, to marrow stimulation techniques, and more recently, to osteochondral autograft and allograft transplants, and autogenous chondrocyte implantation. The success of mosaicplasty procedures in the knee has led to its application to other surfaces, including the talus, tibial plateau, patella, and humeral capitellum. In this report, we present two cases of a chondral defect to the femoral head after a traumatic hip dislocation, treated with an osteochondral autograft (OATS) from the ipsilateral knee, and the inferior femoral head, respectively, combined with a surgical dislocation of the hip. At greater than 1 year and greater than 5 years of follow-up, MRI studies have demonstrated good autograft incorporation with maintenance of articular surface conformity, and both patients clinically continue to have no pain and full active range of motion of their respective hips. In our opinion, treatment of osteochondral defects in the femoral head surface using a surgical dislocation combined with an OATS procedure is a promising approach, as full exposure of the femoral head can be obtained while preserving its vasculature, thus enabling adequate restoration of the articular cartilage surface.     

Five-year results following autogenous osteochondral transplantation to the femoral head

The rationale for autogenous osteochondral grafting into necrotic areas of the femoral head is to provide hyaline cartilage for areas of main articular contact pressure. The aim of this study was to present our results of autogenous osteochondral grafting to the femoral head in the treatment of avascular necrosis.The mean follow-up of the five patients was 57 months following autogenous osteochondral grafting to the femoral head using DBCS (diamond bone-cutting system). The number of transplanted cylinders varied between one and three, and the diameter of the cylindrical transplants between 9 and 13 mm.Results were unsatisfactory in four of five hips and these underwent total hip replacement a mean of 49 months following DBCS of the hip.In our hands, osteochondral grafting to the femoral head using DBCS had proven technically possible in restoring the articular surface of the femoral head; however, this operation was associated with unsatisfactory results in four of five cases.     

组织工程骨-软骨复合体修复犬股骨头负重区大面积骨软骨缺损的实验研究

目的 探讨采用犬股骨头负重区骨和天然软骨制备的骨-软骨双层支架复合成软骨诱导的骨髓间质干细胞(bone marrow mesenchymal stem cells,BMSCs)修复犬股骨头负重区大面积骨软骨缺损的疗效.方法 利用软骨细胞外基质作为软骨支架部分,犬股骨头负重区骨柱经脱细胞处理后作为骨支架部分,采用相分离技术制备骨-软骨双层支架.将成软骨诱导的BMSCs种植到双层支架上体外构建组织工程骨-软骨复合体,并以此修复犬股骨头负重区大面积骨软骨缺损(直径11 mm,高10 mm),第3、6个月时分别取材,行大体、X线片、组织学、Micro-CT和生物力学等检测.结果 X线片及大体观察:3个月时可见股骨头负重区出现轻度塌陷;6个月时出现严重塌陷,呈重度骨关节炎改变.组织学观察:第3、6个月时软骨缺损部分均以纤维组织或纤维软骨充填,周围软骨退变,骨缺损部分不同程度塌陷,与宿主骨质结合紧密.第3、6个月时骨软骨缺损的骨体积分数均低于正常股骨头,差异有统计学意义.6个月时重建软骨下骨的刚度明显低于正常股骨头,差异有统计学意义.结论 结构性骨-软骨双层支架复合成软骨诱导的BMSCs修复犬股骨头负重区骨软骨缺损效果不佳,易导致股骨头塌陷.

Abstract：

Objective To investigate the effects of the novel scaffold on repairing large,high-loadbearing osteochondral defects of femoral head in a canine model.Methods The biphasic scaffolds were fabricated using cartilage extracellular matrix (ECM)-derived scaffold (cartilage layer) and acellular bone matrix (bone layer) by phase separation technique.Articular high-load-bearing osteochondral defects with a diameter of 11-mm and the depth of 10-mm were created in femoral heads.The defects were treated with constructs of a biphasic scaffold seeded with chondrogenically induced bone marrow-derived mesenehymal stem cells (BMSCs).The outcomes were evaluated for gross morphology,histological,biomechanical and micro-CT analysis at the third and sixth month after implantation.Results The gross and X-ray results showed femoral head slightly collapsed at the third month and severely collapse at the sixth month.Histological analysis showed cartilage defects were repaired with fibrous tissue or fibrocartilage with severe osteoarthritis and the varied degrees of the collapse of femoral heads were presented.Micro-CT showed that the values of bone volume fraction in defect area were always lower than those of the normal area in the femoral heads.Biomechanical analysis showed rigidity of the subchondral bone in defect area was significantly lower than that in normal area in the femoral heads at the sixth month.Conclusion The ECM-derived,integrated biphasic scaffold seeded with chondrogenically induced BMSCs could not successfully repair the large high-load-bearing osteochondral defects of the femoral head.     

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.     

5-Jahres-Ergebnisse nach autologer Knorpel-Knochen-Transplantation bei Hüftkopfnekrose

The rationale for autogenous osteochondral grafting into necrotic areas of the femoral head is to provide hyaline cartilage for areas of main articular contact pressure. The aim of this study was to present our results of autogenous osteochondral grafting to the femoral head in the treatment of avascular necrosis. The mean follow-up of the five patients was 57 months following autogenous osteochondral grafting to the femoral head using DBCS (diamond bone-cutting system). The number of transplanted cylinders varied between one and three, and the diameter of the cylindrical transplants between 9 and 13 mm. Results were unsatisfactory in four of five hips and these underwent total hip replacement a mean of 49 months following DBCS of the hip. In our hands, osteochondral grafting to the femoral head using DBCS had proven technically possible in restoring the articular surface of the femoral head; however, this operation was associated with unsatisfactory results in four of five cases.     

Treatment of focal osteochondral defects of the acetabulum with osteochondral allograft transplantation

To our knowledge, treatment of focal osteochondral defects of the acetabulum with osteochondral allograft transplantation has not been described. As with osteochondral lesions of other weight-bearing surfaces, these defects may lead to disabling pain and early degenerative changes. In older patients who fail nonoperative treatment, hip arthroplasty is a reliable option to obtain pain relief and restore function. However, in young and active patients, it may be advantageous to restore joint congruity biologically. The clinical success of osteochondral allograft transplantation in the femoral condyles has been well-documented, with over 25 years of experience. We propose similar treatment principles in the hip joint.This article presents the cases of a 24-year-old woman (patient 1) and a 32-year-old man (patient 2) with hip pain and dysfunction secondary to a focal osteochondral defect of the acetabulum. Both were treated with osteochondral allograft transplantation to the defect using a dowel technique. A magnetic resonance image at 18 months in both cases demonstrated incorporation of the allograft bone into the host acetabulum. At 24 months in patient 1 and 42 months in patient 2, radiographs showed no progressive osteoarthritis. Both patients' Hip Outcome Scores were 100 points each.Osteochondral allografts allow large areas to be resurfaced without donor site morbidity, and these grafts provide an immediate functional joint surface. Although it has not been proven in terms of long-term follow-up, we believe that osteochondral allograft transplantation for focal osteochondral defects of the acetabulum in young, active patients is a feasible option to restore joint congruity.     

自体骨髓间充质干细胞复合壳聚糖/羟基磷灰石支架修复兔膝骨软骨缺损

目的 探讨骨髓间充质干细胞(bone mesenehymal stem cells,BMSCs)复合壳聚糖(chitosan,CS)/羟基磷灰石(hydmxyapatite,HA)支架修复兔膝关节局部骨软骨缺损.方法 选健康日本大耳白兔36只,2～3月龄,体重1.7～2.0 kg,每只抽取自体骨髓4～6ml,体外分离培养BMSCs后以2×107/ml密度植于CS/HA支架上体外培养10 h,制成BMSCs-CS/HA支架复合物.将36只实验动物手术制成右膝股骨外侧髁负重区骨缺损模型后,随机分成A、B、C 3组,每组12只.A组植入BMSCs-CS/HA复合物,B组植入单纯CS/HA支架;C组不作任何植入,为空白对照组.分别于术后6周、12周各处死6只动物,取材后进行大体、组织学观察6根据改良Wakitani评分标准进行评分,评估软骨组织的修复情况,并行成组设计方差分析.结果 A组术后6周即可重建关节软骨缺损;修复软骨在观察期内逐渐变厚,软骨下骨有少量骨修复;术后12周透明软骨样修复,表面光整,与周围软骨色泽相近,软骨下骨有部分修复.而B组和C组12周时缺损区仍为纤维软骨样纤维组织修复,色泽浅黄.术后6、12周各组组织学半定量评分显示:股骨髁负重区修复A组评分明显优于B、C组(F=27.26,P＜0.05).结论 自体BMSCs复合CS/HA支架在体内环境下可形成透明软骨修复兔膝关节负重区骨软骨缺损.     

自体柱状骨软骨移植修复股骨头软骨缺损的实验研究

目的探讨用自体股骨头非负重区骨软骨移植修复股骨头负重区软骨缺损。方法选用成年杂种犬18只,36个髋关节股骨头,随机抽取2只动物4个股骨头作为正常对照。分别凿取股骨头负重区及非负重区相同柱状骨软骨换位移植,于术后4、8、12、24及48周进行大体观察、组织学检查、电镜观察、CT、ECT及MRI检查。结果实验组移植后的骨软骨存活,骨软骨色泽及组织学检测显示移植的软骨细胞、骨细胞形态与正常对照组比较无显著差异,电镜观察显示其成骨细胞、骨细胞及软骨细胞与正常对照组无明显差异。结论股骨头非负重区骨软骨修复股骨头负重区软骨缺损,能达到骨愈合及修复软骨缺损的目的。     

Management in avascular necrosis of the femoral head (author's transl)]

For differentiated indication for operative treatment of avascular necrosis of the femoral head following points have to be considered: age, sex and profession of the patient, precedent treatments, state of contralateral and neighbouring joints. -- Methods of operation: Osteotomy for redistribution, filling with spongious bone and muscle-pedicle-bone graft, transplantation of homeoplastic osteochondral cups of the femoral head, Smith-Petersen-Cup arthroplasty- alloarthroplastic replacement of the femoral head, total replacement of the hip joint, resection of the femoral head and angulation-osteotomy of the diaphysis, arthrodesis of the hip joint. These methods are discussed with regard to personal conditions, surgical techniques, postoperative treatment as well as their advantages and disadvantages. There is no causative treatment of avascular necrosis of the femoral head. Therefore it is especially important to use the different methods appropriate to the special situation.     

Autologous osteochondral transplantation using the diamond bone-cutting system (DBCS): 6–12 years’ follow-up of 35 patients with osteochondral defects at the knee joint

Thirty-five patients with severe osteochondral defects were treated by autologous osteochondral transplantation between 1986 and 1992. The majority of patients (27) suffered from osteochondrosis dissecans, while 8 patients presented with posttraumatic osteochondral defects. The grafts were harvested with a diamond bone cutter from the posterior part of the medial or lateral femoral condyle. In 29 patients the lesion was located at the lateral part of the medial femoral condyle, in 3 it was at the lateral femoral condyle, and in 3 at the patella. Twenty-nine patients could be examined at the follow-up between 6 and 12 years later (mean follow up 8.1 years). Using the standard cartilage evaluation form, the transplanted knees of 12 patients were graded as normal (grade I), 14 knees were nearly normal (grade II), while 3 patients presented with an abnormal result (grade III). All 3 of them had a varus malalignment and refused a high tibial correction osteotomy against our advice. No patient was assessed as severely abnormal (grade IV). The majority of patients improved their activity level and the functional status of the joint. Twelve patients developed new radiological signs of osteoarthrosis with a decrease in the radiological score of Kellgren and Lawrence by about one stage. We conclude that autologous osteochondral transplantation with the diamond bone-cutting system is an effective method in the treatment of severe osteochondral defects. Received: 17 April 2000     

骨软骨原位覆盖可吸收螺钉治疗股骨头骨折

目的总结骨软骨原位覆盖可吸收螺钉治疗股骨头骨折的效果。方法 28例股骨头骨折,按Pipkin分型：Ⅰ型8例,Ⅱ型13例,Ⅲ型1例,Ⅳ型6例。均采用骨软骨原位覆盖可吸收螺钉固定股骨头骨折;Ⅲ型骨折采用股骨近端支撑钢板固定股骨颈骨折;Ⅳ型骨折髋臼骨折片较小可去除,骨折片较大时可采用可吸收螺钉或重建钢板固定。结果所有患者术后无伤口感染发生,均伤愈出院。术后随访25例,平均随访25（2～63）个月,疗效评价：优16例,良5例,可3例,差1例。结论应用骨软骨原位覆盖可吸收螺钉治疗股骨头骨折突破了可吸收材料禁用于关节内骨折的禁忌,是一种实用、有效的方法。     

关节镜自体骨软骨移植治疗膝关节软骨损伤

目的观察自体骨软骨移植治疗膝关节软骨缺损的效果。方法对7例膝关节股骨髁负重部位软骨损伤患者行膝关节镜清理术。摘除关节腔游离软骨碎块2例，半月板部分切除3例，髌上滑膜内侧皱襞切除3例。在股骨内侧髁部取自体骨软骨柱3～5枚，移植到股骨内侧髁软骨损伤部位。结果7例患者手术后伤口Ⅰ期愈合。随访期内6例患者疼痛症状消失。关节肿胀、假性交锁症状均消失。X线片显示移植骨软骨位置良好。结论自体软骨移植能缓解关节软骨损伤后出现疼痛、交锁症状，修复后的软骨为透明软骨。     

Repair of cartilage defects. Technical aspects

Efficacious treatment of chondral and osteochondral defects of the weight bearing surfaces represents a real challenge for the orthopaedic surgeon. Treatment options for full thickness cartilage defects are discussed in this paper. Poor biomechanical characteristics of the reparative fibrocartilage promoted by "traditional resurfacing techniques" provide only moderate clinical outcome in the treatment of such lesions. During the last decade several new efforts have been expressed to provide a hyaline or hyaline-like gliding surface for a full thickness defected area on the weight bearing surface. Among several surgical procedures, autologous osteochondral transplantation methods, including osteochondral mosaicplasty, chondrocyte transplantation, periosteal and perichondrial resurfacement and allograft transplantation are the favoured "new methods". Experimental background, operative techniques and clinical results of these new procedures are detailed in this overview. According to the early and medium term experiences of these methods it seems that a hyaline or hyaline-like resurfacement of the defected area can provide a more durable gliding surface and a better clinical outcome than the so called "traditional resurfacing techniques". Autologous osteochondral mosaicplasty--as an easy, one-step procedure, providing a relatively quick rehabilitation--can be an alternative in the treatment of small and medium sized lesions. Excellent clinical outcome, low costs of the treatment and short rehabilitation time represent the main advantages of this method. Autologous chondrocyte transplantation seems to be a promising option in the treatment of larger full thickness defects but requires relatively expensive two-step procedure and longer rehabilitation period. Both of the above mentioned techniques have femoral, tibial, patellofemoral and talar applications as well. According to the present recommendations transplantation of osteochondral allografts can be indicated at massive osteochondral lesions. There are less experiences with the clinical use of periosteal and perichondrial resurfacing techniques and biomaterials. Beside the promising early and medium term results of these methods the authors express that a successful treatment of the full-thickness cartilage damages of the weight bearing surfaces depends not only the way of the cartilage repair but on the treatment of the underlying cause as well. According to this statement for an effective treatment of full thickness defects on the weight bearing surfaces requires careful patient selection, complex operative plan and well organized treatment course.     

同体骨软骨镶嵌移植术修复关节软骨病损

目的　探讨同体同关节内骨软骨镶嵌式移植 ,治疗关节软骨病损的可行性。方法　采用美国镶嵌式骨软骨移植器 ,通过开放或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 6例 ,术后随访 5～ 9个月 ,平均 6个月 ,均达到优良效果。结论　同体关节骨软骨镶嵌移植对治疗关节应力性局灶性软骨病、创伤性软骨缺损的45岁以下病人是一个效果确实、值得推广的方法     

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。     

Fresh osteochondral allografts for post-traumatic defects in the knee. A survivorship analysis.

Fresh osteochondral allografts were used to repair post-traumatic osteoarticular defects in 92 knees. At the time of grafting, varus or valgus deformities were corrected by upper tibial or supracondylar femoral osteotomies. A survivorship analysis was performed in which failure was defined as the need for a revision operation or the persistence of the pre-operative symptoms. There was a 75% success rate at five years, 64% at ten years and 63% at 14 years. The failure rate was higher for bipolar grafts than for unipolar and the results in patients over the age of 60 years were poor. The outcome did not depend on the sex of the patient and the results of allografts in the medial and lateral compartments of the knee were similar. Careful patient selection, correction of joint malalignment by osteotomy, and rigid fixation of the graft are all mandatory requirements for success. We recommend this method for the treatment of post-traumatic osteochondral defects in the knees of relatively young and active patients.