Early results of autologous chondrocyte implantation in the talus

Autologous chondrocyte implantation (ACI) has been used most commonly as a treatment for cartilage defects in the knee and there are few studies of its use in other joints. We describe ten patients with an osteochondral lesion of the talus who underwent ACI using cartilage taken from the knee and were prospectively reviewed with a mean follow-up of 23 months. In nine patients the satisfaction score was 'pleased' or 'extremely pleased', which was sustained at four years. The mean Mazur ankle score increased by 23 points at a mean follow-up of 23 months. The Lysholm knee score returned to the pre-operative level at one year in three patients, with the remaining seven showing a reduction of 15% at 12 months, suggesting donor-site morbidity. Nine patients underwent arthroscopic examination at one year and all were shown to have filled defects and stable cartilage. Biopsies taken from graft sites showed mostly fibrocartilage with some hyaline cartilage. The short-term results of ACI for osteochondral lesions of the talus are good despite some morbidity at the donor site.     

自体骨软骨马赛克移植成形术后膝关节供区部位发病率的系统评价

目的：对自体骨软骨马赛克移植成形术后膝关节供区部位发病率进行概述。方法：通过计算机检索2010年1月至2021年4月20日PubMed,EMbase,万方医学网和中国知网发表的评估马赛克成形术后膝关节供区发病率的相关研究文献,根据纳入与排除标准进行文献筛选,质量评价及数据提取,对移植的骨软骨柱个数和大小与供区发病率之间的相关性进行研究。结果：共纳入13篇文献,共661例患者。统计分析结果表明马赛克成形术后膝关节供体部位发病率为8.6%（57/661）,最常见的供区发病率主诉是膝关节疼痛感4.2%（28/661）。供体数目与术后供区发病率之间不存在相关性（P=0.424,N=10）;供体直径大小与术后供区发病率之间同样不存在相关性（P=0.699,N=7）。结论：自体骨软骨移植/马赛克成形术中的骨软骨柱采集通常会导致相当大的供区发病率8.6%（57/661）,最常见的供区发病率主诉是膝关节疼痛感,且供体部位发病率与骨软骨柱的数量和大小之间并没有明显的相关性,因此临床上对供体任何部位,数量和大小骨软骨骨柱的采集,都应该意识到其潜在的供体部位发病风险。     

Mosaicplasty: long-term follow-up

The successful treatment of chondral and osteochondral defects of the weightbearing surfaces is a challenge for orthopaedic surgeons. Autologous osteochondral transplantation is one method that can be used to create a hyaline or hyaline-like repair in the defect area. Ten years of clinical experience with autologous osteochondral mosaicplasty are described. Clinical scores, imaging techniques, arthroscopy, histological examination of biopsy samples, and cartilage stiffness measurements were used to evaluate the clinical outcomes and quality of the transplanted cartilage in a total of 831 patients who underwent mosaicplasty. According to our investigations, good-to-excellent results were achieved in 92% of the patients treated with femoral condylar implantations, in 87% of those treated with tibial resurfacing, in 79% of those treated with patellar and/or trochlear mosaicplasties, and in 94% of those treated with talarprocedures. Long-term donor-site disturbances, which were assessed using the Bandi score, showed that patients had 3% morbidity after mosaicplasty. Sixty-nine of 83 patients who were followed arthroscopically showed congruent gliding surfaces, histological evidence of the survival of the transplanted hyaline cartilage, and fibrocartilage filling of the donor sites. Four deep infections and 36 painful postoperative hemarthroses were experienced as complications arising from the surgical procedures. On the basis of both these promising results and also those of other similar studies, autologous osteochondral mosaicplasty would appears to be an alternative for the treatment of small and medium-sized focal chondral and osteochondral defects of the weightbearing surfaces of the knee and other weightbearing synovial joints.     

Autologous osteochondral mosaicplasty grafting

Successful management of chondral and osteochondral defects of the weight-bearing joint surfaces has always been a challenge for orthopedic surgeons and rehabilitation specialists. Autologous osteochondral mosaic transplantation technique is one of the recently evolved methods to create hyaline or hyaline-like repair tissue in the pathologic area. Clinical evaluation, various imaging techniques, arthroscopy (second look), histological examination of biopsy samples, and measurements of cartilage mechanical properties are used to evaluate the merits of outcomes and quality of the transplanted cartilage. According to our investigations, good to excellent results were achieved in more than 92% of patients treated with femoral condylar implantations, 87% of those treated with tibial resurfacing, 79% of those treated with patellar and/or trochlear mosaicplasties, and 94% of those treated with talar procedures. Long-term donor-site discrepancies, assessed with use of the Bandi Score, showed that patients had 3% morbidity after mosaicplasty. Sixty-nine of 89 patients who were followed up with a second-look arthroscopy showed congruent gliding surfaces, histological evidence of the survival of the transplanted hyaline cartilage, and fibrocartilage filling of the donor sites. In a series of 831 consecutive patients, very few complications have been observed. These included 4 deep infections and 36 painful postoperative intra-articular bleedings. On the basis of these results and those of other similar studies, autologous osteochondral mosaicplasty appears to be a promising alternative for the treatment of small- and medium-sized focal chondral and osteochondral defects of the weight-bearing surfaces of the knee and other weight-bearing synovial joints.     

Editorial Commentary: Is the Cure Worse Than the Disease? Harvesting Autologous Osteochondral Transfer Plugs for Treatment of Lesions of the Elbow

For autologous osteochondral transfer procedures for osteochondritis dessicans of the elbow, surgeons usually use the knee or ribs as donor sites. This procedure is not without donor site complications. Finding local donor sites is important to reducing the overall morbidity of this procedure.     

Cartilage repair of the talus

The cause of a typical osteochondral lesion of the talus is traumatic; if symptomatic, several options exist. Because nonoperative treatment results in no more than 50% good to excellent results, the following types of surgery are in clinical use: (1) debridement and drilling, (2) osteochondral transfer, and (3) autologous chondrocyte transplantation. Reported good to excellent results are at least 80% in the short term. Currently available data allow no recommendation of a specific therapy for a specific lesion. Advocates of drilling and debridement accept that the repair tissue is fibrocartilage; osteochondral transfer includes a donor side morbidity. We are still at the beginning of cartilage repair; it will take time before a certain type of lesion can be treated with the best modality because that requires comparative randomized prospective studies with a long follow-up. All modern cartilage repair techniques, that were initially investigated at the knee joint, are now in use for ankle osteochondral lesions. Reported short-term success rates are greater than 80%. Further improvements will depend on the understanding of the pathogenesis and the role of contributing factors (eg, instability).     

Editorial Commentary: “Elbow-to-Elbow” Capitellar Osteochondral Autologous Transplantation for Osteochondritis Dissecans—Are We Closer to the Holy Grail of Osteochondral Graft?

The knee or rib has been used routinely as a donor site for capitellar osteochondral autologous transplantation (osteoarticular transplantation) procedures with promising results. However, donor-site morbidity is a bitter truth that has led surgeons to pursue alternatives to the ipsilateral elbow. The non-articulating radial head and the lateral olecranon tip show acceptable topography and histology. However, size limitations require additional and clinical study.     

Osteochondral transplantation to treat osteochondral lesions in the elbow

BACKGROUND: Effective treatment of osteochondral lesions in the elbow remains challenging. Arthroscopic débridement and microfracture or retrograde drilling techniques are often insufficient and provide only temporary symptomatic relief. The purpose of this study was to evaluate the treatment of these lesions with osteochondral autografts. METHODS: From 1999 to 2002, seven patients with osteochondral lesions of the capitellum humeri (five patients), trochlea (one patient), or radial head (one patient) were treated with cylindrical osteochondral grafts, which were harvested from the non-weight-bearing area of the proximal aspect of the lateral femoral condyle. The patients (three female and four male patients with an average age of seventeen years) were evaluated preoperatively and postoperatively, with an average follow-up of fifty-nine months. The Broberg and Morrey score was chosen for functional evaluation of the elbow (with regard to motion, pain, strength, activities of daily living, and stability), and the American Shoulder and Elbow Surgeons score was used for the analysis of pain. All patients had imaging studies done preoperatively to evaluate the defect and postoperatively to assess the ingrowth and viability of the graft. The ipsilateral knee was examined for donor-site morbidity. RESULTS: The Broberg and Morrey score improved from a mean (and standard deviation) of 76.3 +/- 13.2 preoperatively to 97.6 +/- 2.7 postoperatively, and pain scores were significantly reduced (p < 0.05). The mean elbow extension lag of 4.7 degrees +/- 5.8 degrees was reduced to 0 degrees postoperatively. Compared with the contralateral side, there was a mean preoperative flexion lag of 12.9 degrees +/- 13.8 degrees . At the time of the final follow-up, flexion was free and was equal bilaterally in all patients. None of the plain radiographs made at the time of follow-up showed any degenerative changes or signs of osteoarthritis. The postoperative magnetic resonance imaging scans showed graft viability and a congruent chondral surface in all seven patients. No donor-site morbidity was noted at one year postoperatively. CONCLUSIONS: The osteochondral autograft procedure described in the present study provides the opportunity to retain viable hyaline cartilage for the repair of osteochondral lesions in the elbow while restoring joint congruity and function and perhaps reducing the risk of osteoarthritis. These medium-term results suggest that the risks of a two-joint procedure are modest and justifiable. In addition, the described technique provides an option for revision surgery after the failure of other surgical procedures.     

Autologous osteochondral grafting for talar cartilage defects

The purpose of this study was to evaluate the clinical results of Osteochondral Autograft Transfer System (OATS) for the treatment of symptomatic osteochondral defects of the talus using standardized outcome analysis. Nineteen patients with symptomatic osteochondral defect (OCD) of the talus were treated with autologous osteochondral grafting. There were six men and 13 women. The average age was 32 years (range, 18 to 48 years). The average duration of symptoms prior to surgery was 4.2 years (range, three months to 12 years). All patients had failed nonoperative treatment, and 13 (68%) patients had failed prior excision, curettage and/or drilling of the lesion. The average size of the lesion prior to autografting was 12 mm x 10 mm (range, 10 x 5 mm to 20 x 20 mm). Donor plugs were harvested from the trochlear border of the ipsilateral femoral condyle. Ankle exposure was obtained with a medial malleolar osteotomy in 13 patients, arthrotomy in five patients and lateral malleolar osteotomy in one patient. Clinical evaluations were performed for both the recipient ankle and donor knee using the AOFAS Ankle/Hindfoot Scale and Lysholm knee scale, respectively. The average follow-up time was 16 months (range, 12 to 30 months). The average postoperative AOFAS ankle score was 88 (range, 60 to 100). Most patients had occasional mild pain, but excellent function, range of motion, stability and alignment. The average postoperative ankle score for the 13 patients who failed prior surgery was 91 (range, 84 to 100). The average postoperative Lysholm knee score was 97 (range, 87 to 100). Only two patients had mild knee pain. Postoperative radiographs were available for 13 patients. There was no evidence of graft subsidence and all grafts healed. All malleolar osteotomies united. Seventeen (89%) patients said that they would undergo the procedure again. The results of osteochondral autograft transplant for OCD lesions of the talus demonstrate excellent postoperative ankle scores including improvement of pain and function with minimal knee donor site morbidity. Also, our results indicate that this is an effective salvage procedure following failed previous procedures and for patients with longstanding symptoms.     

Donor-site morbidity and anterior knee problems after anterior cruciate ligament reconstruction using autografts

The authors review the current knowledge on donor site–related problems after using different types of autografts for anterior cruciate ligament (ACL) reconstruction and make recommendations on minimizing late donor-site problems. Postoperative donor-site morbidity and anterior knee pain following ACL surgery may result in substantial impairment for patients. The selection of graft, surgical technique, and rehabilitation program can affect the severity of pain that patients experience. The loss or disturbance of anterior sensitivity caused by intraoperative injury to the infrapatellar nerve(s) in conjunction with patellar tendon harvest is correlated with donor-site discomfort and an inability to kneel and knee-walk. The patellar tendon at the donor site has significant clinical, radiographic, and histologic abnormalities 2 years after harvest of its central third. Donor-site discomfort correlates poorly with radiographic and histologic findings after the use of patellar tendon autografts. The use of hamstring tendon autografts appears to cause less postoperative donor-site morbidity and anterior knee problems than the use of patellar tendon autografts. There also appears to be a regrowth of the hamstring tendons within 2 years of the harvesting procedure. There is little known about the effect on the donor site of harvesting fascia lata and quadriceps tendon autografts. Efforts should be made to spare the infrapatellar nerve(s) during ACL reconstruction using patellar tendon autografts. Reharvesting the patellar tendon cannot be recommended due to significant clinical, radiographic, and histologic abnormalities 2 years after harvesting its central third. It is important to regain full range of motion and strength after the use of any type of autograft to avoid future anterior knee problems. If randomized controlled trials show that the long-term laxity measurements following ACL reconstruction using hamstring tendon autografts are equal to those of patellar tendon autografts, we recommend the use of hamstring tendon autografts because there are fewer donor-site problems.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 9 (November-December), 2001: pp 971–980     

Osteochondral multiple autograft transfer (OMAT) for the treatment of cartilage defects in the knee joint

The ideal articular cartilage repair tissue should be durable and well-integrated. We have been performing osteochondral multiple autograft transfers (OMAT) since 1996 with the experience we had using carbon fiber implants. We call this technique OMAT instead of mosaicplasty because we use uniform osteochondral autografts. Osteochondral multiple autograft transfer (OMAT) was performed either by arthrotomy or arthroscopy on 12 patients (6 male and 6 female) for the treatment of cartilage defects in the knee joint. The patients ranged in age from 20 to 63 years (mean: 38 years). All had weightbearing-related pain or decrease in the range of motion. None had instability or malalignment. The average follow-up time was 4 years (range: 2 to 8 years). Clinical results were satisfactory. All of the paients were improved initially by the procedure and 85% are still pain free. The mean Lysholm knee rating score was 56 points preoperatively and 86 points postoperatively. Second-look arthroscopy (five patients) demonstrated a normal shiny appearance and color of the grafted area. We observed slight joint effusion postoperatively that disappeared in two months. There was no donor site morbidity. OMAT is a promising surgical technique for the treatment ofarticular cartilage defects. Long-term follow-up with more patients and histological and biomechanical evaluation of chondral interfaces are the subjects of our continuing study.     

Osteochondral transplantation for the treatment of osteochondral defects at the talus with the Diamond twin system® and graft harvesting from the posterior femoral condyles

Background

The aim of this study is to analyze clinical results after osteochondral cylinder transplantation for osteochondral defects at the medial or lateral talar dome using the Diamond twin system (Karl Storz). We hypothesize that grafts harvesting from the posterior femoral condyles are associated with less donor site morbidity than reported by previous studies.

Methods

We have surgically treated 20 patients with an osteochondral defect of the talus by osteochondral transplantation with the Diamond twin system via an osteotomy of the ankle. The osteochondral cylinders were harvested from the posterior aspects of the femoral condyles of the ipsilateral knee. The defects at donor site were filled with a bone substitute of tricalcium phosphate (Synthricer, Karl Storz). The mean age was 25.4 years. After a mean time of 12.6 months, the screws at the medial malleolus were removed and an arthroscopy was performed. The functional outcome was evaluated with the visual analog scale for pain at walking, running, stair climbing, quality of life at the time of implant removal and at a mean follow-up of 25.8 months. Activity was assessed with the Tegner scale. Knee function was evaluated with the Lysholm score.

Results

In one case, the osteochondral cylinder did not heal and an osteochondral fragment was removed arthroscopically. In all other cases, the osteochondral cylinder was stable with surrounding cartilage. The average ICRS Cartilage Repair Assessment was 10.1 points (±1.3). All malleolar osteotomies healed radiologically. In 15 patients, a synovectomy and local debridement of the ankle were performed at second-look arthroscopy. Ankle pain at walking, running and stair climbing as measured by a visual analog scale (10-0) decreased significantly from preoperatively to the first follow-up (mean 12.6 months) and to the second follow-up (mean 25.8 months). The ankle-related quality of life increased significantly from preoperatively to postoperatively. There was no significant change in the Lysholm score. The activity measured with the Tegner activity scale increased significantly from preoperatively to the last follow-up, but only two out of nine patients continued pivoting sports.

Conclusions

Autologous osteochondral grafting with the Diamond twin system is a reliable treatment option for symptomatic osteochondral defects of the talus. After 1 year, the majority of patients had still some complaints. However, after screw removal and second-look arthroscopy, the pain and ankle-related quality of life further improved.

Clinical relevance

The donor site morbidity after graft harvesting from the posterior aspects of the femoral condyles is lower than previously reported.     

Meniscal transplantation in symptomatic patients less than fifty years old

BACKGROUND: The purpose of this study was to prospectively evaluate the results of meniscal transplantation in a consecutive series of younger patients treated for pain in the tibiofemoral compartment following a previous meniscectomy. METHODS: Forty cryopreserved menisci were implanted into thirty-eight patients. Sixteen knees also had an osteochondral autograft transfer, and nine had a knee ligament reconstruction. The clinical outcome and failure rate of all transplants were evaluated at a mean of forty months postoperatively. Meniscal allograft characteristics were determined with use of a rating system that combined subjective, clinical, and magnetic resonance imaging factors. RESULTS: Thirty-four (89%) of the thirty-eight patients rated the knee condition as improved. Before surgery, thirty patients (79%) had pain with daily activities, but only four (11%) had such pain at the time of the latest follow-up. While noteworthy pain was present in the tibiofemoral compartment in all forty knees before surgery, twenty-seven knees (68%) had no pain and thirteen (33%) had only mild compartment pain at the time of the latest follow-up. Twenty-nine patients (76%) returned to light low-impact sports without problems. Concomitant osteochondral autograft transfer and knee ligament reconstruction procedures improved knee function and did not increase the rate of complications. Meniscal allograft characteristics were normal in seventeen knees (43%), altered in twelve (30%), and failed in eleven (28%). CONCLUSIONS: The short-term results of meniscal transplantation are encouraging in terms of reducing knee pain and increasing function; however, long-term transplant function and any chondroprotective effects remain unknown and require further investigation.     

Stadiengerechte operative Knorpeltherapie

Chondral or osteochondral lesions are typical injuries in orthopaedics and traumatology. Since there is no regeneration of damaged articular cartilage, these lesions can lead to premature osteoarthritis. Therefore, an adequate therapy for these injuries is an important goal. Nowadays, common methods in cartilage therapy are procedures for the recruitment of mesenchymal stem cells: autologous osteochondral transplantation and autologous chondrocyte transplantation. Currently, autologous osteochondral transplantation is the only procedure that allows the replacement of the defect with hyaline cartilage. However, this procedure has the problem of donor-site morbidity and limited availability of transplants. Stem cell recruiting procedures and autologous chondrocyte transplantation normally achieve a regeneration of the defect with only fibrocartilage tissue, but both can achieve good medium-term clinical results. Each of these therapeutic principles has certain major indications. In order to select an adequate therapy, the classification of chondral or osteochondral lesion is needed. From a multiplicity of classification systems, those of the ICRS are of particular clinical relevance.     

Stage oriented surgical cartilage therapy. Current situation

Chondral or osteochondral lesions are typical injuries in orthopaedics and traumatology. Since there is no regeneration of damaged articular cartilage, these lesions can lead to premature osteoarthritis. Therefore, an adequate therapy for these injuries is an important goal. Nowadays, common methods in cartilage therapy are procedures for the recruitment of mesenchymal stem cells: autologous osteochondral transplantation and autologous chondrocyte transplantation. Currently, autologous osteochondral transplantation is the only procedure that allows the replacement of the defect with hyaline cartilage. However, this procedure has the problem of donor-site morbidity and limited availability of transplants. Stem cell recruiting procedures and autologous chondrocyte transplantation normally achieve a regeneration of the defect with only fibrocartilage tissue, but both can achieve good medium-term clinical results. Each of these therapeutic principles has certain major indications. In order to select an adequate therapy, the classification of chondral or osteochondral lesion is needed. From a multiplicity of classification systems, those of the ICRS are of particular clinical relevance.     

Outcomes and complications of fibular head resection

The fibular head is often used as donor graft material for reconstruction of defects of the distal radius. However little is known on the safety of such a procedure. This report describes the long-term donor-site morbidity following the procedure. Fourteen patients who underwent simple or marginal resections of the proximal fibula between 1990 and 2007 were reviewed. Subjective donor-site morbidity, knee and ankle range of motion and instability, presence of sensory or motor function loss, gait and fibular regeneration were assessed. The mean age at surgery was 25 years; six were male, eight were female and the mean follow-up was 11 years. Abnormal clinical findings were present in 10 patients (71.4 %): nine patients (64.3 %) had Grade 2 varus laxity at the knee confirmed by stress radiographs; one had sensory loss in the distribution of the superficial peroneal nerve. Patients with varus laxity had significantly higher mean age at surgery than those without varus laxity (p = 0.001). None had deformity at the knee or ankle. The range of joint movements was normal. All had a normal tibiotalar angle and none had proximal migration of the fibula. One patient demonstrated near-complete regeneration of the fibula. Donor-site morbidity following simple and marginal resection of the proximal fibula is acceptable. Older patients had a higher risk of demonstrable varus laxity at the knee but proximal fibula resection in children appears to be safe.     

Editorial Commentary: Osteochondral Lesions of the Talus: All,Nothing, or Something in Between

Osteochondral lesions of the talus occur with relatively frequency, often as the sequelae of benign ankle sprains, and are only surpassed by the knee and elbow as more common locations. While microfracture of the talus is the most common first-line surgical treatment performed at the time of ankle arthroscopy, marrow stimulation alone results in fibrocartilaginous repair tissue rather than true hyaline-like articular cartilage. In addition, the benefits of bone marrow stimulation for the treatment of large (>150 mm²), deep (>7 mm), or cystic lesions is limited. Autologous osteochondral transplant has emerged as one such treatment option for large lesions that may address underlying bone loss and reconstitute articular cartilage. The utility of autologous osteochondral transplant also must be interpreted with an understanding of the potential complications, including donor-site morbidity. In addition, it is important to decompress, curettage, and back fill associated cysts with bone graft. When cysts are not treated aggressively, patients may have ongoing bone marrow edema and pain.     

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.     

No mid-term difference in mosaicplasty in previously treated versus previously untreated patients with osteochondral lesions of the talus

Introduction Osteochondral transplantations, albeit technically challenging, appear promising not only in knee joint lesions, but also in the treatment of talus lesions. We hypothesized that in patients suffering osteochondral lesions of the talus, favorable outcomes are obtained in patients undergoing primary mosaicplasty as compared to patients undergoing secondary mosaicplasty. Materials and methods Over a 3-year period (1998–2001), 14 patients (six male, eight female, median age 22 years) were treated with an autologous osteochondral transplantation of the talus. Eight patients were previously untreated (group I). Six patients had previous ankle procedures, such as microfracturing (group II). The median follow-up was 24 months and 100% complete at 12 months. The functional outcome was evaluated at least at 6 weeks, 12 weeks, and 1 year after surgery using pain on a visual analog scale (VAS) and sports activity was recorded at 1 year after surgery. In ten patients, magnetic resonance imaging (MRI) of the ankle was performed at 1 year after surgery (group I/II: 7/3). Results Overall ankle pain was decreased from 6.9 ± 2.1 to 4.0 ± 2.8 postoperatively. The mean knee pain for the donor knee was 2.6 ± 2.4. We found no significant difference between the primary mosaicplasty group and the secondary mosaicplasty group with regard to pain. MRI scans of ten patients showed a complete incorporation of the osteochondral cylinders at 1 year after surgery. Conclusion Favorable outcomes were obtained in patients undergoing primary mosaicplasty as compared to patients undergoing secondary mosaicplasty. We found no significant difference among patients with previous ankle surgery in contrast to those without, with a median 24-months follow-up.