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     

Osteochondritis dissecans of the lateral femoral condyle following total resection of the discoid lateral meniscus

Purpose: The purpose of this study was to describe the clinical presentation of 6 athletically active children with symptomatic osteochondritis dissecans (OCD) of the lateral femoral condyle following total resection for a torn discoid lateral meniscus and to discuss its cause. Type of Study: Case series. Methods: Six patients in whom OCD affecting the lateral femoral condyle developed after total resection of the discoid lateral meniscus participated in a detailed clinical, radiologic, and arthroscopic review. The average age at the time of meniscectomy was 9 years (range, 6 to 12 years). At a mean of 50 months (range, 36 to 65 months) after surgery they developed recurrent pain in the treated knee; all had radiologic abnormalities at the lateral femoral condyle consistent with OCD. Before the recurrence of pain, all patients had been continuously engaged in sports activity. Radiologic and arthroscopic findings of the OCD lesions were assessed. Clinical outcomes of surgical treatment for OCD were also documented. Results: The radiographic evaluation showed all lesions to be in the central portion of the lateral femoral condyle on the anteroposterior views and posteriorly next to a line extending distally from the posterior femoral cortex on the lateral views. Arthroscopic evaluation revealed softening in 2 knees, a separated fragment in 2 knees, and a completely loose fragment in 2 knees. All lesions were treated surgically, including 2 drillings of the lesion, 2 fixations of separated fragment, and 2 excisions of loose bodies with drilling. At an average follow-up period of 51 months (range, 22 to 77 months), all patients but 1 were asymptomatic. Conclusions: Repeated impaction in sports activities on the immature osteochondral structures under altered mechanical force transmission after total resection of the discoid meniscus might be a predisposing factor in the development of OCD in the lateral femoral condyle.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 6 (July-August), 2001: pp 608–612     

Osteochondritis dissecans of the lateral femoral condyle of the knee joint.

Differences in the features of osteochondritis dissecans (OCD) affecting the lateral and medial femoral condyles were investigated in 13 patients (14 knees) treated from 1991 to 1994. OCD affected the lateral femoral condyle in 6 knees (lateral group) and the medial condyle in 8 knees (medial group). The lateral group was younger (mean age, 14 v. 20 years). The radiological stage (Brückl) of the lateral group was stage 2 in 3 knees and stage 3 in 3. The lateral menisci were all discoid and the condylar articular surface of the lesions was normal in two knees, softened in 3 and detached in 1. The medial group comprised 1 knee in stage 2, 1 in stage 3, 1 in stage 4, and 5 in stage 5. The OCD lesion showed softening in 2 knees and detachment in 6. Repetitive abnormal stress on weaker osteochondral structures in the growing period produced by a discoid meniscus during growth may cause OCD of the lateral femoral condyle.     

A comparison of abrasion burr arthroplasty and subchondral drilling in the treatment of full-thickness cartilage lesions in the rabbit

The purpose of this study was to observe the difference in healing of full-thickness articular cartilage defects treated with burr arthroplasty versus subchondral drilling. Cartilage was shaved off the medial femoral condyles of 39 rabbits without penetrating the subchondral plate. In left knees, two 2.0-mm holes were drilled into the condyle until bleeding was obtained. Right knees underwent a burr arthroplasty until punctate bleeding was observed. Animals were sacrificed at 6, 12, and 24 weeks postoperatively. Joint resurfacing and degenerative changes were evaluated grossly and histologically. Degenerative changes in the cartilage surface were observed with both treatments. Rabbits undergoing subchondral drilling had increased fibrocartilaginous healing with time, with a slight increase in degenerative changes. With burr arthroplasty, there was significant decrease in cartilaginous coverage of the exposed surface as well as progressive increase in degenerative changes. Although both techniques are suboptimal, histological evidence at 6 months suggests that subchondral drilling may result in a longer-lived repair than abrasion arthroplasty in the treatment of full-thickness lesions.     

Chondral defects of the knee

The surgical treatment of a young adult with a localized defect in the articular cartilage of the knee most commonly employs arthroscopic shaving and/or subchondral drilling. Fresh osteochondral allografting is an alternative that is being performed with increasing frequency. As of June 1993, fresh osteochondral allografts have been used in 90 knees in our institution. Thirty-eight of these knees have been evaluated two or more years postoperatively, and a successful result was obtained in 76%. If the lesion was confined to the medial condyle, the success rate was 86%, but when both reciprocal surfaces were replaced (bipolar) the success rate was 56%.     

Resorbable pin refixation of an osteochondral fracture of the lateral femoral condyle due to traumatic patellar dislocation: case management, follow-up and strategy in adolescents

AIM: Intraarticular osteochondral fractures resulting from traumatic patellar dislocation in children are reported most frequently between 13 and 15 years of age. Fracture localization concerns, apart from loose intraarticular bodies, the inferiomedial patellar facet and the lateral femoral condyle. Osteochondral fractures of the lateral femoral condyle with more than 50 % of its surface are extremely rare and reported infrequently. METHOD: We report a traumatic patellar dislocation in a 14 year old patient that let to an osteochondral fracture of the lateral femoral condyle. MRI-scan demonstrated an extensive fracture size concerning more than 50 % of the condylar surface with intraarticular dislocation. Initially arthroscopic surgery followed an open reduction and internal refixation of the osteochondral fragment with resorbable, poly-p-dioxanon pins. RESULTS: Follow-up MRI-scan revealed 7 weeks after surgery an adequate repositioning of the fragment with correct pin placement. Second-look arthroscopy demonstrated an osteochondral reintegration of the fragment within a period of 7 months after prior surgery. CONCLUSION: Resorbable poly-p-dioxanon pins as a mean for refixation of an osteochondral, intraarticular fracture in an adolescent, with an arthroscopic confirmed acceptable result, seem to be a considerable therapy option.     

Treatment of osteochondritis dissecans of the knee joint

Osteochondritis dissecans (OD) is a lesion of the subchondral bone which can result in sequestration of the osteochondral lesion. It is categorized into 4 stages, and juvenile and adult forms depending on the distal femoral physis maturity. Prognosis and treatment depends on age and stage. Prognosis is favorable in stable lesions (stage I and II) at typical location (medial femoral condyle) in a child with open physes. Therefore non-operative treatment is indicated. If there is no response to non-operative treatment drilling to create channels for potential revascularization can be done. In unstable lesions (stage III and IV) operative treatment is necessary. Long-term results after excision of the fragment with or without drilling of the defect site are poor. Therefore refixation of an intact osteochondral fragment or biologic reconstruction should be tried.     

急性髌骨脱位的关节镜下诊断与治疗

目的 探讨急性髌骨脱位的关节镜下表现,评价关节镜下治疗方法对其的疗效.方法 2001年2月至2003年12月,共收治急性髌骨脱位16例17膝,女12例,男4例,1例女性患者为双侧发病.年龄14～31岁,平均21.9岁.从发生髌骨脱位到手术的时间间隔为3～25 d,平均13.6 d.术前对所有患者进行放射学检查,观察髌骨的形态和位置、股骨滑车角、髌骨外侧半脱位和下肢对线的状况.临床测量Q角和全身关节松弛度.全部手术均在关节镜监视下施行.首先引流关节内血肿,而后进行全面的关节内探查,取出游离的软骨和骨软骨碎片,施行软骨成形术,修整损伤的软骨面,最后松解外侧支持带以及紧缩缝合内侧支持带.结果 关节镜下表现包括关节内血肿,股骨外侧髁和髌骨内侧骨软骨损伤,游离体形成以及内侧支持结构撕裂.所有病例均获得随访,随访时间1.5～3.5年,平均2.1年,均未发生感染等严重并发症,也无关节内大量血肿和髌骨缺血性坏死发生.全部病例膝关节活动度恢复正常,恢复至术前的活动水平,未发生再脱位.5例患者术后早期主诉髌骨内侧存在牵拉感和弹响.所有病例均未出现重度髌股关节退行性改变.结论 关节镜手术是诊断和治疗急性髌骨脱位的优良方法,操作简便,疗效可靠.     

Therapie der Osteochondrosis dissecans des Kniegelenks

Osteochondritis dissecans (OD) is a lesion of the subchondral bone which can result in sequestration of the osteochondral lesion. It is categorized into 4 stages, and juvenile and adult forms depending on the distal femoral physis maturity. Prognosis and treatment depends on age and stage. Prognosis is favorable in stable lesions (stage I and II) at typical location (medial femoral condyle) in a child with open physes. Therefore non-operative treatment is indicated. If there is no response to non-operative treatment drilling to create channels for potential revascularization can be done. In unstable lesions (stage III and IV) operative treatment is necessary. Long-term results after excision of the fragment with or without drilling of the defect site are poor. Therefore refixation of an intact osteochondral fragment or biologic reconstruction should be tried.     

Long-term results of arthroscopic partial lateral meniscectomy in knees without associated damage

We evaluated the outcome of partial lateral meniscectomy of 31 knees in 29 patients whose knees were otherwise normal. The mean follow-up was 10.3 years. According to the Lysholm score, 14 knees were rated as excellent, four as good, five as fair and eight as poor, with a mean score of 80.5 points. Radiologically, only one lateral compartment was classified as grade 0, eight as grade 1, nine as grade 2, 11 as grade 3, and two as grade 4 according to Tapper and Hoover. No significant (p < 0.05) correlation was found between the amount of tissue resected and the subjective, clinical and radiological outcome. Although early results of lateral meniscectomy may be satisfactory, we have demonstrated that in the long term there was a high incidence of degenerative changes, a high rate of reoperation (29%) and a relatively low functional outcome score.     

A morphologic,biochemical, and biomechanical assessment of short-term effects of osteochondral autograft plug transfer in an animal model

Purpose: The objective of this study was to assess the short-term changes that occur after an osteochondral autograft plug transfer from the femoral trochlea to the medial femoral condyle in a goat model. Type of Study: Articular cartilage repair animal study. Methods: Six adult male goats were used in this study. Two 4.5-mm osteochondral plugs were transferred from the superolateral femoral trochlea to 2 recipient sites in the central portion of the medial femoral condyle for a survival period of 12 weeks. Postmortem, the global effects of the procedure were assessed by gross morphologic inspection and by analyzing the synovial DNA for inflammatory response. The recipient sites were also evaluated histologically and biomechanically. Metabolic activity was determined by ³⁵SO₄ uptake, and viability was assessed using a live/dead stain and by confocal laser microscopy. Results: There was no evidence of significant gross morphologic or histologic changes in the operative knee as a result of the osteochondral donor or recipient sites. The patella, tibial plateau, and medial meniscus did not show any increased degenerative changes as a result of articulating against the donor or recipient sites of the osteochondral autografts. Analysis of synovial DNA revealed no inflammatory response. Biomechanically, 6- to 7-fold greater stiffness was noted in the cartilage of the transferred plugs compared with the control medial femoral condyle. Furthermore, on histologic examination, the healing subchondral bone interface at the recipient site had increased density. Glycosaminoglycan synthesis as determined by ³⁵SO₄ uptake was upregulated in the transplanted cartilage plug relative to the contralateral control, showing a repair response at the site of implantation. And finally, confocal microscopy showed 95% viability of the transferred plugs in the medial femoral condyle region. Conclusions: Our findings demonstrate the ability to successfully transfer an osteochondral autograft plug with maintenance of chondrocyte cellular viability. The transferred cartilage is stiffer than the control medial femoral condyle cartilage, and there is concern regarding the increased trabecular mass in the healing subchondral plate, but these do not result in increased degenerative changes of the opposing articular surfaces in the short term.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 8 (October), 2001: pp 856–863     

MRI Evaluation of Isolated Arthroscopic Partial Meniscectomy Patients at a Minimum Five-Year Follow-up

Background The risk of radiographic knee degeneration after partial or total meniscectomy is well documented, but no prior study has employed cartilage-sensitive MRI technology to assess degenerative changes after meniscectomy. Hypothesis Arthroscopic partial meniscectomy results in early articular cartilage wear and subchondral bony degeneration, even in the absence of clinical symptoms, and these findings can be evaluated with cartilage-sensitive MRI. Study design Retrospective cohort. Methods Twenty-nine patients (ages: 15–40) who had undergone isolated arthroscopic partial medial or lateral meniscectomy with at least 5-year follow-up were evaluated. All patients had arthroscopically normal articular cartilage at the time of initial meniscectomy. Seventeen patients (18 knees) underwent partial medial meniscectomy (MM) and 12 patients underwent partial lateral meniscectomy (LM) with mean follow-up of 8.4 and 7.1 years, respectively. Follow-up evaluation included physical examination, outcome questionnaires, and cartilage-sensitive MRI examination with modified Outerbridge grading of articular surfaces. Results Outerbridge grades II–IV were noted in 64% of medial compartment joint surfaces in group MM knees versus 33% of lateral compartment joint surfaces in group LM knees. Abnormal cartilage surfaces (grades II–IV), subchondral sclerosis, and condylar squaring were all significantly more frequent after medial meniscectomy (p < 0.05). Groups MM and LM had no significant differences among outcome scores, which remained excellent in both groups. A significant negative correlation was found between the severity of cartilage wear and functional scoring in the MM group, suggesting that functional disability lags behind early MRI evidence of degeneration. Conclusions Despite optimal preoperative prognostic factors and excellent functional outcomes, MRI evidence of early articular cartilage degeneration was present in both partial medial and lateral meniscectomy patients at a minimum 5-year follow-up. Results support the use of cartilage-sensitive MRI as a noninvasive screening technique to evaluate cartilage changes after arthroscopic partial meniscectomy and may help to counsel the high-risk patient in regard to postoperative activity.     

关节镜下微骨折术联合自体骨软骨移植治疗膝关节股骨髁大面积软骨损伤

目的探讨关节镜下微骨折术联合自体骨软骨移植(osteochondral autologous transplantation,OAT)治疗膝关节股骨髁大面积(4~6 cm^2)软骨损伤的疗效。方法2016年3月-2017年6月,采用关节镜下微骨折术联合OAT治疗22例膝关节股骨髁大面积软骨损伤患者。其中男16例,女6例;年龄22~60岁,平均38.6岁。致伤原因:交通事故伤8例,运动损伤14例。病程1~6个月,平均3.4个月。股骨内侧髁损伤15例,外侧髁损伤7例;软骨损伤面积4~6 cm^2,平均4.98 cm^2。软骨损伤国际软骨修复协会(ICRS)分级:Ⅲ级9例,Ⅳ级13例。伴半月板损伤18例。术前疼痛视觉模拟评分(VAS)为(6.36±1.25)分,Lysholm评分为(36.00±7.77)分。结果术后切口均Ⅰ期愈合。患者均获随访,随访时间2~3年,平均2.3年。术后2年时VAS评分为(1.27±0.94)分,Lysholm评分为(77.82±6.21)分,均较术前明显改善(t=16.595,P=0.000;t=21.895,P=0.000)。术后2年,MRI显示软骨缺损区修复良好。结论关节镜下微骨折术联合OAT治疗膝关节股骨髁大面积软骨损伤早期疗效较好。     

Autoarthroplasty of knee cartilage defects by osteoperiosteal grafts

Five fresh osteochondral fractures of the knee, which could not be fixed because of extensive fragmentation, were treated by excision of the fragments and reconstruction of the joint surface defect by an autogenous osteoperiosteal graft. The procedure was also used for joint surface reconstruction in sclerotic osteochondritis of the femoral condyle (nine knees) and grave patellofemoral chondromalacia (three knees). Plaster cast immobilization for 3 weeks was used in the two early cases. In all other cases, we employed a passive motion apparatus for 2 days postoperatively, followed by active mobilization in a knee brace with extension-flexion 30 to 90 degrees (femoral condyle reconstruction) or 0 to 45 degrees (patellar reconstruction). Gradual free movements were started 3 weeks postoperatively. The results after 1.5 to 6.5 years were satisfactory in all but one case. One arthroscopic removal of the loose graft was performed, as were two arthroscopic graft margin shavings. Three other reoperations were unrelated to the osteoperiosteal reconstruction. It appears that periosteal reconstruction should be considered in local osteochondral lesions, where excision of the injured cartilage is mandatory. The results were best in fresh trauma cases and younger people.     

Late-stage Freiberg disease treated by osteochondral plug transplantation: a case series

BACKGROUND: The purpose of this study was to investigate the clinical, radiological and arthroscopic results of osteochondral plug transplantation for late-stage Freiberg disease. MATERIALS AND METHODS: We examined 4 consecutive cases of late-stage Freiberg disease of the second metatarsal head. All 4 patients were female with an average age of 12. Osteochondral plug transplantation was performed, harvesting from a nonweightbearing site of the upper lateral femoral condyle of the ipsilateral knee. Clinical evaluation using the American Orthopaedic Foot and Ankle Society (AOFAS) Lesser Metatarsophalangeal-Interphalangeal Scale was performed before surgery and at the final followup. Magnetic resonance imaging (MRI) was performed before surgery and at 6 and 12 months after surgery. Furthermore, arthroscopic evaluation was performed at 12 months after surgery. The mean follow up was 52 (range 36 to 72) months. RESULTS: At the final follow up, the average AOFAS score improved from 70.8 points preoperatively to 97.5 points. Although MRI at 6 months after surgery showed an obvious but slight osteochondral plug-subchondral bone interface, healing of the osteochondral plug was confirmed at 12 months after surgery in all patients. With respect to the patients' arthroscopic findings at 12 months after surgery, two of our patients had an International Cartilage Repair Society Cartilage Repair Assessment Score of normal and 2 had a score of nearly normal. CONCLUSION: Osteochondral plug transplantation for late-stage Freiberg disease yielded satisfactory results upon arthroscopic and radiological evaluations at 12 months after surgery and clinical evaluation for all four cases.     

Internal fixation of undisplaced lesions of osteochondritis dissecans in the knee

A total of 11 patients (12 knees) with stable lesions of osteochondritis dissecans of the knee underwent arthroscopic fixation of the fragments using polylactide bioabsorbable pins. The site of the lesion was the medial femoral condyle in ten knees and the lateral femoral condyle in two. The mean age of the patients was 14.8 years (12 to 16). At a mean follow-up of 32.4 months (13 to 38 months) all fragments had MRI evidence of union. One patient developed early transient synovitis, which resolved with non-steroidal anti-inflammatory medication. All patients returned to sporting activities within eight months of operation and did not require a period of immobilisation.     

Long-term results of arthroscopic synovectomy for seropositive rheumatoid arthritis: 6-16 year review

We prospectively studied a consecutive series of 25 knees (21 patients) treated with arthroscopic synovectomy for seropositive rheumatoid arthritis. All patients had pain and swelling and were in the early stages of the disease process (Larsen grade 2 or less). Three patients were lost to follow-up. At a mean of 8 years from operation two knees underwent total knee replacement with another two knees required a further arthroscopic synovectomy. One patient continued to experience intermittent mild synovitis. The range of movement was maintained or improved by surgery in 73% of cases but radiological evidence of degenerative change was seen in all knees. We discuss the technical difficulties associated with arthroscopic synovectomy that were associated with a small complication rate. In appropriately selected patients unresponsive to medical therapy, arthroscopic synovectomy can give safe and reliable results.     

Improved repair of chondral and osteochondral defects in the ovine trochlea compared with the medial condyle

Associations between topographic location and articular cartilage repair in preclinical animal models are unknown. Based on clinical investigations, we hypothesized that lesions in the ovine femoral condyle repair better than in the trochlea. Full‐thickness chondral and osteochondral defects were simultaneously established in the weightbearing area of the medial femoral condyle and the lateral trochlear facet in sheep, with chondral defects subjected to subchondral drilling. After 6 months in vivo, cartilage repair and osteoarthritis development was evaluated by macroscopic, histological, immunohistochemical, and biochemical analyses. Macroscopic and histological articular cartilage repair and type‐II collagen immunoreactivity were better in the femoral trochlea, regardless of the defect type. Location‐independently, osteochondral defects induced more osteoarthritic degeneration of the adjacent cartilage than drilled chondral lesions. DNA and proteoglycan contents of chondral defects were higher in the condyle, reflecting physiological topographical differences. The results indicate that topographic location dictates the structural patterns and biochemical composition of the repair tissue in sheep. These findings suggest that repair of cartilage defects at different anatomical sites of the ovine stifle joint needs to be assessed independently and that the sheep trochlea exhibits cartilage repair patterns reflective of the human medial femoral condyle. © 2013 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 31:1772–1779, 2013     

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。     

Arthroscopic osteochondral autograft transplantation for chondral lesion of the tibial plateau of the knee

Arthroscopic osteochondral autograft transplantation is often used to treat chondral/osteochondral lesions of the femoral condyle of the knee. However, arthroscopic autologous osteochondral grafting to the tibial plateau has not been reported. We report the surgical technique and the clinical course of a patient who underwent engraftment by this method. A 26-year-old man developed symptoms of pain and catching in his knee. Arthroscopy revealed a deep chondral lesion, 10 × 15 mm in size, down to the subchondral bone on the posterocentral area of the lateral tibial plateau. The injured cartilage was debrided using a curette and an abrader until normal healthy cartilage bordered the debrided defect. An osteochondral plug, 10 mm in diameter and 20 mm long, the chondral surface of which was orientated 25° obliquely, was harvested from the most peripheral and proximal part of the lateral patellar groove. A bony hole was created in the center of the defect through the tibia using a core reamer. The osteochondral plug was inserted from the tibial window through the bony hole. To enhance the stability of the osteochondral fragment, bioactive ceramic fillers were used to fill the space below the plug. A second-look arthroscopy 10 months after surgery showed that the grafted osteochondral plug was well adapted and integrated into the surrounding cartilage on the lateral tibial plateau.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 6 (July-August), 2001: pp 653–659