Donor site evaluation after autologous osteochondral mosaicplasty for cartilaginous lesions of the elbow joint

Fresh Osteochondral Allograft Transplantation of the Capitellum for the Treatment of Osteochondritis Dissecans

BACKGROUND

Osteochondritis dissecans (OCD) of the humeral capitellum is a rare and challenging condition to treat. Several surgical options exist, but in the last few years, the pendulum has swung from debridement and microfracture to restoration of the articular surface. Osteochondral autografts from the rib and knee have been described, but donor-site morbidity is a concern.

PURPOSE

To expand the results of fresh osteochondral allograft transplantation (FOCAT) in a previously published report with inclusion of additional patients and a longer follow-up period.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

After institutional review board approval, the charts of patients who underwent FOCAT for OCD of the capitellum between 2006 and 2022 by a single surgeon were reviewed. The majority of cases (94%) had unstable lesions (Minami grades 2 and 3). A trial of nonoperative treatment had failed in all. All patients underwent diagnostic arthroscopy, followed by a mini-open, ligament-sparing approach with grafting using commercially available guides and instruments.

RESULTS

A total of 35 patients were identified, of whom 25 were male. The mean age was 16 ± 3.9 years (range, 11-32 years). There were 24 baseball players (19 pitchers and 5 position players), 5 gymnasts, 3 cheerleaders/tumblers, 1 tennis player, 1 student (who did not participate in athletics), and 1 patient with avascular necrosis from chemotherapy. Eighteen patients had a mean flexion contracture of 14.1°± 11.9°. A single osteochondral allograft plug was used in 23 patients (mean diameter, 11.3 ± 2.8 mm), and 12 patients required 2 plugs (Mastercard technique). The mean follow-up was 92.6 ± 54.5 months (range, 24-204 months). There was significant improvement in Oxford (from 25.5 ± 4.9 to 46.7 ± 3.5; P < .00001) and visual analog scale for pain (from 7.5 ± 2 to 0.3 ± 1.0; P < .0001) scores. The mean Single Assessment Numeric Evaluation score at the time of follow-up was 90.6 ± 10.8 (range, 60-100). In overhead athletes, there was significant improvement in the Kerlan-Jobe Orthopaedic Clinic score (from 40.8 ± 11.8 to 90.6 ± 10.8; P < .00001). A postoperative magnetic resonance imaging scan was obtained in 16 (46%) patients at a mean of 32.6 months. In all cases, the graft was incorporated. All overhead athletes were able to return to their sport and perform at the same level or higher for >2 years. Two elbows required a subsequent arthroscopy for loose-body removal; otherwise, there were no other complications.

CONCLUSION

FOCAT is an excellent option for treating OCD lesions of the humeral capitellum. Excellent outcomes and high return-to-sport rates were observed, with midterm follow-up showing no graft failures. FOCAT eliminates donor-site morbidity.

Outcomes of Osteochondral Autologous Transplantation with Ipsilateral Lateral Talar Autograft for Medial Osteochondral Lesions of the Talus

Background

Osteochondral autologous transplantation (OAT) has been widely used in the treatment of osteochondral lesion of the talus (OLT). Previous studies have reported successful outcomes following the use of osteochondral autogenous grafts from the intercondylar notch of the knee or a non-weight-bearing region of the femoral condyle. However, donor-site morbidity of the knee joint has been observed in several cases. This study aimed to investigate the outcomes and safety of OAT with autografts from the ipsilateral lateral talar articular facet as an alternative donor site for medial OLT.

Methods

Among 40 patients who underwent OAT, 29 patients were excluded. Eleven patients who underwent OAT with an osteochondral graft harvested from the ipsilateral lateral talar articular facet from 2011 to 2022 were retrospectively analyzed. The size of OLT was measured on ankle magnetic resonance imaging, including coronal length, sagittal length, depth, and area. Clinical outcomes were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale and a visual analog scale (VAS). Weight-bearing ankle radiographs were obtained postoperatively and at 1 year after surgery.

Results

The average follow-up time after surgery was 64.7 months (range, 14-137 months). The average diameter of lesions was 8.8 mm (range, 8-9.9 mm). The average size of lesions was 51.2 mm2 (range, 33.6-71.3 mm2) , and all lesions included subchondral cysts. The average depth of lesions was 7.3 mm (range, 6.2-9.1 mm). Graft sizes ranged from 8 to 10 mm in diameter (8 mm, n = 1; 10 mm, n = 10) All measured clinical outcomes improved postoperatively, including the AOFAS scores (preoperative, 55.4 ± 9.0; 1-year follow-up, 92.1 ± 7.6; p = 0.001) and VAS scores (preoperative, 5.5 ± 0.7; 1-year follow-up, 1.9 ± 0.8; p = 0.001). All weight-bearing ankle radiographs of the graft and donor sites did not reveal arthritic change in the ankle joint, lateral talar dome collapse, and graft-site delayed union or nonunion at 1 year after surgery.

Conclusions

For a single medial OLT, harvesting autografts from the ipsilateral lateral talar articular facet without knee donor-site morbidities can be a good alternative in OAT for OLT.

Osteochondral Allograft Transplantation to the Capitellum: Technical Considerations of a Mega Osteochondritis Dissecans Technique

Osteochondritis dissecans of the elbow is a rare but debilitating pathology typically found in the adolescent repetitive overhead athlete. In the setting of unstable lesions, mechanical symptoms, or deteriorating function despite appropriate conservative management, surgical osteochondral allograft transplantation of the capitellum is a viable option for even large lesions (>10 mm), with minimal morbidity and good return of function. We describe a technique for performing a large osteochondral allograft transplantation of the capitellum.

Osteochondritis dissecans of the elbow: recent evolution of pathogenesis, imaging, and treatment modalities

Background

The etiology and pathogenesis of osteochondritis dissecans (OCDs) lesions remain controversial.

Methods

This review presents the recent evolution about the healing, imaging, pathogenesis, and how to treat OCD of the capitellum in overhead athletes.

Results

Compressive and shear forces to the growing capitellum can cause subchondral separation, leading to OCD, composed of 3 layers: articular fragment, gap, and underlying bone. Subchondral separation can cause ossification arrest (stage IA), followed by cartilage degeneration (stage IB) or delayed ossification (stage IIA), occasionally leading to osteonecrosis (stage IIB) in the articular fragment. Articular cartilage fracture and gap reseparation make the articular fragment unstable. The mean tilting angle of capitellar OCD is 57.6 degrees in throwers. Anteroposterior radiography of the elbow at 45 degrees of flexion (APR45) can increase the diagnostic reliability, showing OCD healing stages, as follows: I) radiolucency, II) delayed ossification, and III) union. Coronal computed tomography and magnetic resonance imaging with an appropriate tilting angle can also increase the reliability. MRI is most useful to show the instability, although it occasionally underestimates. Sonography contributes to detection of early OCD in adolescent throwers on the field. OCD lesions in the central aspect of the capitellum can be more unstable and may not heal. Cast immobilization has a positive effect on healing for stable lesions. Arthroscopic removal provides early return to sports, although a large osteochondral defect is associated with a poor prognosis. Fragment fixation, osteochondral autograft transplantation, and their hybrid technique have provided better results.

Discussion

Further studies are needed to prevent problematic complications of capitellar OCD, such as osteoarthritis and chondrolysis.

Osteoperiosteal Iliac Autograft Transplantation for Unreconstructable Tibial Plafond After Malunions of Pilon Fractures in Young Patients

BACKGROUND

Malunion of tibial pilon fracture, especially with a large cartilage loss of the tibial plafond, is a tough clinical conundrum. This study describes a joint-preserving technique that mainly involves corrective intraarticular osteotomy and osteoperiosteal iliac autograft transplantation for treating these generally considered unreconstructable tibial plafond.

METHODS

Sixteen patients with an average age of 33.6 years who were treated with this joint-preserving method between 2013 and 2020 were retrospectively analyzed. Ankle distraction was applied in all patients. Additional osteochondral autograft transplantation for talus was performed in 4 patients and supramalleolar osteotomy in 2 patients. The visual analog scale (VAS) score, the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, the 36-Item Short Form Health Survey (SF-36) score, and the ankle range of motion (ROM) were used for outcome analysis. Radiographic assessment was conducted, and the complications were recorded.

RESULTS

At a mean follow-up of 41.1 months, the mean VAS, AOFAS, and SF-36 scores improved from 6.3, 47.6, and 38.0 to 1.7, 84.4, and 70.8, respectively (P < .001 for each). The ankle ROM improved from 27.5 to 32.2 degrees (P = .023). The mean area of ilium blocks was 3.5 cm2, and the mean external fixation time was 94.1 days. Radiographs showed that good osteointegration was found in all patients and no significant progression of osteoarthritis in 15 patients. The major complications included poor incision healing in 2 patients and severe ankle stiffness in 2 patients, with one of them developing considerable varus-type osteoarthritis but reporting no pain. No deep infection, nonunion, or malunion occurred, and no secondary arthrodesis was performed during the final follow-up.

CONCLUSION

Osteoperiosteal iliac autograft transplantation might be an alternative surgical option for reconstructing unreconstructable malunited pilon fractures with a large cartilage loss of the tibial plafond in young patients.

LEVEL OF EVIDENCE

Level IV, case series.

Retrograde Autologous Talar Osteocancellous Bone Grafting for the Treatment of Osteochondral Lesions of the Talus: A Technical Note

Osteochondral lesions of the talus (OLT) are common injuries in young athletes. Various kinds of surgical procedures are available for orthopaedic surgeons, but which surgical technique is the best remains controversial. Many surgical procedures require malleolar osteotomy to obtain appropriate surgical exposure to the OLT because of the anatomic characteristics of the ankle joint. However, malleolar osteotomy is invasive and has a potential risk of complications, such as tibial chondral damage and pseudoarthrosis. This article aims to introduce a novel surgical procedure for the treatment of OLTs: retrograde autologous talar osteocancellous bone grafting without the need for osteotomy and harvesting a graft from anywhere other than the talus. First, an arthroscopic evaluation is performed to verify the location, size, and cartilage quality of the OLT as well as concomitant lesions. After confirming the position of the guide pin using a guide device arthroscopically, a talar osteocancellous bone plug is harvested using a coring reamer. The OLT of the harvested talar bone plug is removed, and under arthroscopy, the talar osteocancellous bone plug is retrogradely inserted into the talar bone tunnel. To stabilize the implanted bone plug, one or two bioabsorbable pins are inserted from the lateral wall of the talus while applying counterforce to the articular surface of the bone plug. The present surgical technique can minimally invasively address the OLT without the need for malleolar osteotomy and harvesting a graft from the knee joint or iliac bone.

The effects of alendronate on the suppression of bone resorption and the promotion of cartilage formation in the human mosaicplasty donor site: A randomized, double-blind, placebo-controlled prospective study

BACKGROUND

We previously reported that early alendronate administration accelerated bone formation and improved the quality of repaired cartilage in the donor site in rabbits. To investigate whether alendronate administration has effects in humans similar to those observed in rabbits.

METHODS

The study cohort included 35 patients over the age of 12-years old who underwent mosaicplasty without osteoporotic therapy from March 2011 to October 2012. The donor sites were medial or lateral in the patellofemoral joint. Placebo (P) or Bonalon containing 35 mg of alendronate (A) was administered orally every week for 8 weeks. The cohort comprised 15 male and 20 female, including 14 right and 21 left knees. The mean age at the time of surgery was 57.1 years. Bone formation was examined using computer tomography and lateral knee radiography, and cartilage formation was examined using magnetic resonance imaging (MRI), second-look assessment, and intraoperative acoustic evaluation. The clinical outcomes were assessed using the Japanese Orthopaedic Association knee score and visual analog scale (VAS). Bone and cartilage formation in the donor site and clinical outcomes were assessed at 3, 6, and 12 months after mosaicplasty.

RESULTS

The ratio of TRAP-5b in group A was significantly smaller than that in group P at 2 and 8 weeks after mosaicplasty. The extent of bone formation in the donor sites in group A was significantly greater than that in group P at 3 and 6 months after mosaicplasty. Cartilage formation did not differ significantly between the two groups as determined by MRI, macroscopic assessment, and intraoperative acoustic evaluation. Clinical outcomes did not differ significantly between the two groups, and no negative clinical outcomes were observed.

CONCLUSION

Early alendronate administration accelerated bone formation but not cartilage formation in the mosaicplasty donor site in humans.

Autologous osteochondral transplantation for focal femoral condyle defects: Comparison of mosaicplasty by arthrotomy vs. arthroscopy

BACKGROUND

While many studies have reported the outcomes of open mosaicplasty, data on arthroscopic mosaicplasty are scarce. Only two cadaver studies have compared arthrotomy and arthroscopy. Moreover, the patello-femoral joint, which is the main donor site, has never been assessed using a specific functional score. The objective of this in vivo study was to compare arthrotomy and arthroscopy for mosaicplasty using both a global functional knee score and a specific score of the patello-femoral joint.

HYPOTHESIS

The arthroscopic technique results in better functional patello-femoral outcomes.

MATERIAL AND METHODS

We retrospectively compared two groups of 17 patients who underwent mosaicplasty for focal condylar cartilage defects, at our department between 2009 and 2019. Functional outcomes were assessed using the Kujala score and the Lysholm score, at least 1 year after surgery. The return to sports was assessed using the Tegner score.

RESULTS

Mean follow-up was 67.4±15.9 months in the arthrotomy group and 45.2±35.1 months in the arthroscopy group (p<0.01). Cartilage defect size was similar in the two groups (arthrotomy: 1.21±0.91cm²; arthroscopy: 0.92±1.23cm²; p=0.052). The mean Kujala score was 85±21.3 in the arthrotomy group and 91.9±13.7 in the arthroscopy group (p=0.064). The mean Lysholm score was 83.9±19.8 with arthrotomy and 89.5±14.9 with arthroscopy (p=0.1). The Kujala score was greater than 95 in 4 (26%) arthrotomy patients and 13 (81%) arthroscopy patients (p=0.003). The Lysholm score was higher than 95 in 4 (26%) arthrotomy patients and 12 (75%) arthroscopy patients (p=0.012). No patient underwent surgical revision for autograft failure.

DISCUSSION

This is the first clinical study comparing arthrotomy and arthroscopy for mosaicplasty. Clinical outcomes were good with both techniques. The proportion of patients with excellent Lysholm and Kujala functional scores was significantly higher in the arthroscopy group than in the arthrotomy group. This result may be ascribable to decreased donor-site morbidity obtained with arthroscopy.

LEVEL OF EVIDENCE

IV, retrospective observational comparative study.

Biological reconstruction of the joint: Concepts of articular cartilage regeneration and their scientific basis

Articular cartilage injuries are common. The diagnosis of these injuries is often delayed and may lead to early osteoarthritis. Treatment depends on many factors but mainly on the stage and size of the lesion. The anatomy of articular cartilage is complex, and it is an avascular, aneural, and alymphatic structure. Recently, more emphasis is laid on its anatomy and biomechanics to understand the regeneration process of articular cartilage.

Both Debridement and Microfracture Produce Excellent Results for Osteochondritis Dissecans Lesions of the Capitellum: A Systematic Review

Purpose

To analyze the available literature pertaining to the indications, outcomes, and complications of both microfracture (MFX) and simple debridement for capitellar osteochondritis dissecans (OCD).

Methods

A comprehensive literature review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) criteria. Studies were included if they evaluated OCD of the capitellum that underwent either arthroscopic debridement (AD) or MFX. The risk of bias was assessed using the Methodological Index for Non-randomized Studies (MINORS) scale. Patient demographic characteristics, imaging findings, return-to-sport rates, patient-reported outcomes, range of motion (ROM), complications, failures, and reoperations were recorded.

Results

Eleven studies with 327 patients (332 elbows) met the inclusion criteria. Methodological Index for Non-randomized Studies (MINORS) scores ranged from 63% to 75% and showed considerable heterogeneity. Both AD and MFX showed improvement in patient outcome scores, ROM, and return to play, although the data precluded relative conclusions. Improvement in motion after MFX ranged from 4.9° to 5° of flexion, 5° to 22.6° of extension, 1° to 2° of pronation, and 0.5° to 2° of supination, whereas after AD, it ranged from –4° to 6° of flexion and –0.4° to 14° of extension, with prono-supination noted in only 1 study. The rate of return to play at a similar level of preinjury athletic competition ranged from 55% to 75% after MFX and from 40% to 100% after AD. Lesion location was discussed in only 1 study. Postoperative imaging trended toward early degenerative changes, most commonly of the radial head. Complications were only reported in 1 MFX study; in all cases, the complication was transient ulnar nerve neurapraxia. Reoperation rates ranged from 0% to 10%, and reoperation was most commonly performed to address radial head enlargement. Five studies reported no reoperations.

Conclusions

Both AD and MFX for capitellar OCD appear to yield excellent improvements in pain, ROM, patient outcome scores, and return to sport. Given that comparable mid-term outcomes can be achieved with debridement alone, without the use of MFX, similarly to recent prospective studies in the knee, AD alone may be a reasonable approach to relatively small OCD defects.

Level of Evidence

Level IV, systematic review of studies, all Level IV evidence.

Early Results of Single-plug Autologous Osteochondral Grafting for Osteochondritis Dissecans of the Capitellum in Adolescents

BACKGROUND

Osteochondral autologous transplantation surgery (OATS) has been advocated for unstable osetochondritis dissecans (OCD) lesions of the adolescent capitellum, though limited information is available regarding clinical and radiographic results in North American patients. We hypothesize that single-plug OATS is safe and effective in alleviating pain and restoring function in unstable OCD.

METHODS

Twenty-eight patients with unstable OCD treated with single-plug OATS were evaluated. Mean age at surgery was 14.2 years; there were 14 males. Etiology of OCD was presumed to be sports participation, including baseball (n=5) and gymnastics (n=11). Indications for surgery included unstable, deep OCD lesions; 2 lesions were uncontained, and 3 patients (11%) had OATS after failed prior surgery. OATS was performed by an anconeus muscle-splitting approach; donor grafts were harvested from the lateral femoral condyle by small arthrotomy. Functional outcomes were quantified using the Timmerman instrument. Median clinical and radiographic follow-up was 6.3 months (range, 5.0 to 27.0 mo) and 5.7 months (range, 5.0 to 26.7 mo), respectively. Furthermore, all patients returned functional questionnaires at a median of 9 months postoperatively (range, 5 to 27 mo).

RESULTS

Of the 26 patients who reported preoperative tenderness, 19 (73%) patients had no tenderness at most recent clinical follow-up (P=0.02). Of 18 patients with restricted elbow motion preoperatively, 13 had achieved full range of motion (P=0.10). Both elbow flexion and extension improved significantly [flexion: median change (interquartile range)=10 degrees (0 to 10 degrees), P=0.009; extension: 0 degree (-5 to 0 degrees), P <0.001). On postoperative magnetic resonance imaging, 86% (P<0.001) of elbows had restoration of articular congruity and 93% had complete graft incorporation. Objective [median change (interquartile range)=5 degrees (0 to 15 degrees)], subjective [25 degrees (15 to 40 degrees)], and overall [35 degrees (15 to 45 degrees)] Timmerman scores improved significantly (P=0.001, <0.001, and <0.001, respectively). Of the 13 patients with >6 months follow-up, 9 patients (69%) had returned to their primary sport (P=0.27) and 100% had returned to general sports participation. There were no postoperative complications. At final follow-up, all donor knees were asymptomatic with full motion and strength.

CONCLUSION

Single-plug OATS is safe and effective in improving pain and elbow function in adolescents with unstable OCD, with high return to sports rates and little donor-site morbidity.

LEVEL OF EVIDENCE

Level IV-case series.

Preliminary evaluation of an osteochondral autograft, a prosthetic implant, and a biphasic absorbable implant for osteochondral reconstruction in a sheep model

OBJECTIVE

To determine the ability of three implants to enhance the healing of osteochondral defects: (1) a biphasic construct composed of calcium phosphate (CaP) and chitosan/cellulosic polymer, (2) a titanium-polyurethane implant, and (3) an osteochondral autograft.

STUDY DESIGN

Experimental study.

ANIMALS

Ten adult female sheep.

METHODS

In five sheep, an 8-mm diameter osteochondral defect was created on the medial femoral condyle of a stifle and filled with a synthetic titanium-polyurethane implant. In five sheep, a similar defect was filled with an osteochondral autograft, and the donor site was filled with a biphasic construct combining CaP granules and a chitosan/cellulosic polymer. Sheep were monitored daily for lameness. Stifle radiographs and MRI were evaluated at 20 weeks, prior to animals being humanely killed. Surgical sites were evaluated with histology, microcomputed tomography, and scanning electron microscopy.

RESULTS

Clinical outcomes were satisfactory regardless of the tested biomaterials. All implants appeared in place on imaging studies. Osteointegration of prosthetic implants varied between sites, with limited ingrowth of new bone into the titanium structure. Autografts and biphasic constructs were consistently well integrated in subchondral bone. All autografts except one contained a cartilage surface, and all biphasic constructs except one partially restored hyaline cartilage surface.

CONCLUSION

Biphasic constructs supported hyaline cartilage and subchondral bone regeneration, although restoration of the articular cartilage was incomplete.

CLINICAL IMPACT

Biphasic constructs may provide an alternative treatment for osteochondral defects, offering a less invasive approach compared with autologous grafts and eliminating the requirement for a prosthetic implant.

Autologous stem cell-derived chondrocyte implantation with bio-targeted microspheres for the treatment of osteochondral defects

BACKGROUND

Chondral injury is a common problem around the world. Currently, there are several treatment strategies for these types of injuries. The possible complications and problems associated with conventional techniques lead us to investigate a minimally invasive and biotechnological alternative treatment. Combining tissue-engineering and microencapsulation technologies provide new direction for the development of biotechnological solutions. The aim of this study is to develop a minimal invasive tissue-engineering approach, using bio-targeted microspheres including autologous cells, for the treatment of the cartilage lesions.

METHOD

In this study, a total of 28 sheeps of Akkaraman breed were randomly assigned to one of the following groups: control (group 1), microfracture (group 2), scaffold (group 3), and microsphere (group 4). Microspheres and scaffold group animals underwent adipose tissue collection prior to the treatment surgery. Mesenchymal cells collected from adipose tissue were differentiated into chondrocytes and encapsulated with scaffolds and microspheres. Osteochondral damage was conducted in the right knee joint of the sheep to create an animal model and all animals treated according to study groups.

RESULTS

Both macroscopic and radiologic examination showed that groups 3 and 4 have resulted better compared to the control and microfracture groups. Moreover, histologic assessments indicate hyaline-like cartilage formations in groups 3 and 4.

CONCLUSION

In conclusion, we believe that the bio-targeted microspheres can be a more effective, easier, and safer approach for cartilage tissue engineering compared to previous alternatives.

Donor Site Evaluation After Osteochondral Autograft Transplantation for Capitellar Osteochondritis Dissecans

BACKGROUND

Osteochondral autograft transplantation (OAT) for capitellar osteochondritis dissecans (OCD) requires harvesting of tissue from the asymptomatic knee joint. However, donor site morbidity (DSM) in such cases remains unclear.

PURPOSE

To evaluate DSM and postoperative radiographic findings in patients undergoing OAT for advanced capitellar OCD.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Eighty-six juvenile athletes underwent OAT for advanced capitellar OCD. The 2000 International Knee Documentation Committee subjective score, rate of return to sports, and symptoms in the donor knee were assessed at a mean follow-up of 86 months (range, 28-185 months). Additionally, 49 of the 86 patients were assessed by radiographic and magnetic resonance imaging (MRI) findings of the knee donor site. DSM was defined according to the usual criterion (persistent symptoms for >1 year or the need for subsequent intervention) and a stricter criterion (the presence of any symptoms, such as effusion, patellofemoral complaints, crepitation, unspecified disturbance, stiffness, pain/instability during activities, and osteoarthritic change). The stricter criterion was also used to allocate patients into a DSM group and a no-DSM group.

RESULTS

Two and 11 patients were determined to have DSM according to the usual and stricter criteria, respectively. All patients returned to the competitive level of their sports. The mean International Knee Documentation Committee score was 99.0. MRI findings showed abnormal signal intensity in 17 patients (35%) and hypertrophic changes in 11 patients (22%) at the donor harvest sites. The MOCART (magnetic resonance observation of cartilage repair tissue) score was higher in the no-DSM group (mean, 68.2) than in the DSM group (mean, 52.9) (P = .027).

CONCLUSION

OAT for juvenile athletes with advanced capitellar OCD provided good clinical outcomes. The DSM rate was relatively low (2.3%) with the usual criterion but high (12.8%) with the stricter criterion. MRI showed an abnormal signal intensity and hypertrophy in some cases.

[Mid-term results in the treatment of osteochondritis dissecans of the femoral condyles using osteochondral grafting (mosaic arthroplasty)]

Several surgical procedures, including mosaic arthroplasty, can be used to treat patients with cartilage loss in the femoral condyles. This study aims to assess mid-term clinical and radiological results as well as the main prognostics elements. We conducted a retrospective epidemiological study over a period of 15 years. During the study period we collected data from 35 workable medical records of patients with osteochondritis dissecans of the femoral condyles treated by mosaic arthroplasty, with an average follow-up of 24 months. The level of complaints as well as preoperative knee function were evaluated and compared with the healthy knee according to the International Cartilage Repair Society (ICRS) score, the International Knee Documentation Committee (IKDC) score and visual analogue scale (VAS). It was less than 60% in 27 patients. During the follow-up period, the results were analyzed according to Hughston's functional and radiological criteria. After an average follow-up of 24 months, algoneurodystrophy was reported in 5 cases with a single case of haemarthrosis. A net ICRS score improvement was observed with a mean increasing from 54% to 74% on the follow-up visit. Most of patients were satisfied or very satisfied (82.9%). The elements of good prognosis recognized in our study included: a mean time between symptom onset and surgery of less of 18 months, having deep lesions with a diameter less than 02 cm and having lesions in the internal condyle. The treatment of cartilage loss is necessarily based on the correction of its direct and indirect causes namely the morphotype, the laxity and meniscus capital. No consensus in the decision-making was reached and no one could confirm the superiority of a technique in relation to the other but we can say that cartilage defect which sizes from 2 to 4 cm² may be the best indication for mosaic arthroplasty.

Osteochondritis dissecans lesions of the capitellum in overhead athletes: a review of current evidence and proposed treatment algorithm

PURPOSE OF THE REVIEW

To review the most recent literature on osteochondritis dissecans (OCD) lesions of the capitellum in overhead athletes and describe a treatment algorithm based on current best evidence and surgeon experience.

RECENT FINDINGS

Recent research has included larger cohort studies with longer follow-up as well as quality systematic reviews and meta-analyses. These studies have focused on understanding how lesion characteristics such as size, location, and appearance on advanced imaging can predict treatment success. Current literature continues to support nonoperative management for stable lesions. Operative intervention is generally required for unstable lesions and treatment strategies are largely dictated by lesion size and location: debridement or reparative techniques for small lesions while larger lesions or those in high-stress locations are better served by bone and/or cartilage restoration procedures. There has been a rising interest in the use of allograft materials and cell-based therapies. Overhead athletes are uniquely predisposed to capitellar OCD due to the nature of forces applied to the radiocapitellar joint during repeated activity in the overhead position. Despite improvements in operative techniques, successful use of alternative graft materials, and a better understanding of how lesion characteristics influence results, there is still much to learn about this challenging disorder. Future research should focus on comparing operative techniques, refining their indications, and further developing a reliable treatment algorithm that best serves the overhead athlete.

Osteochondral Autograft Transplantation Technique Augmented by an Ultrapurified Alginate Gel Enhances Osteochondral Repair in a Rabbit Model

BACKGROUND

One of the most important limitations of osteochondral autograft transplantation (OAT) is the adverse effect on donor sites in the knee. To decrease the number and/or size of osteochondral defects, we devised a method with biomaterial implantation after OAT.

HYPOTHESIS

OAT augmented by ultrapurified alginate (UPAL) gel enhances cartilage repair capacity.

STUDY DESIGN

Controlled laboratory study.

METHODS

Seventy-five osteochondral defects in rabbits were divided into 3 groups: osteochondral defects with OAT alone, defects with OAT augmented by UPAL gel (combined group), and defects without intervention as controls. Macroscopic and histological evaluations of the reparative tissues were performed at 4 and 12 weeks postoperatively. Histological evaluation of graft cartilage degradation was also performed. To evaluate the effects of UPAL gel on graft healing, repaired bone volumes and osseointegration of the graft were evaluated. Collagen orientation and the mechanical properties of the reparative tissue and graft cartilage were also evaluated qualitatively.

RESULTS

The macroscopic and histological evaluations of the combined group were significantly superior to the other groups at 12 weeks postoperatively. Regarding degenerative change of the graft, the histological scores of the combined group were significantly higher than those of the OAT-alone group. The values of repaired subchondral bone volumes and osseointegration of the graft were almost identical in both groups. Collagen orientation and the mechanical properties of the reparative tissue and graft cartilage were significantly better in the combined group than in the other groups.

CONCLUSION

Administration of UPAL gel in OAT enhanced cartilage repair and protected graft cartilage without inhibiting subchondral bone repair and graft survival.

CLINICAL RELEVANCE

OAT augmented by UPAL gel decreases the number and/or size of osteochondral grafts, minimizing the risk of donor site morbidity. This combination technique has the potential to improve clinical outcomes and expand the surgical indications for OAT.

Factors Influencing the Results in Matrix-Associated Autologous Chondrocyte Implantation: A 2 - 5 Year Follow-Up Study

Background

This study aimed to investigate the outcomes of matrix-associated autologous chondrocyte implantation (MACI) on the treatment of osteochondral lesions in the knee joint and to determine the factors affecting the functional results.

Methods

The study included 34 patients with a cartilage defect in the knee joint who were applied MACI® (GenzymeBiosurgery, Cambridge, Massachusetts, USA) technique between the years 2010 - 2015. The defect localizations and sizes, past surgeries were recorded. The clinical results were measured with Cincinnati and Lysholm scores.

Results

As a result of the repeated measures at postoperatively, it was found that the patients had increased Lysholm and Cincinnati functional scores in all follow-up periods (P = 0.0001). When the mean value of Lysholm and Cincinnati functional scores were assessed according to BMI group, no statistically significant difference was determined (P = 0.941 and P = 0.779). The measurements at 6 and 12 months of the follow-up indicated that the mean scores of the group with no concomitant pathologies were significantly higher than those of the group with concomitant pathologies.

Conclusions

The MACI application provides good and stable outcomes for focal cartilage damage in young patients. In order to obtain significant results after autologous chondrocyte implantation, the selection of appropriate patients without concomitant pathologies is required.

Costal Osteochondral Autograft for Advanced Osteochondritis Dissecans of the Humeral Capitellum in Adolescent and Young Adult Athletes: Clinical Outcomes with a Mean Follow-up of 4.8 Years

BACKGROUND

Costal osteochondral grafting is a technique to achieve anatomical and biological repair of articular defects. Some small series of clinical applications of this procedure for advanced osteochondritis dissecans of the humeral capitellum, with short-term follow-up, have been reported; however, longer-term outcomes remain unclear. The purpose of this study was to clarify longer-term clinical outcomes of costal osteochondral autografts in the treatment of advanced osteochondritis dissecans of the humeral capitellum.

METHODS

Seventy-two patients with an osteochondral defect of the humeral capitellum were treated with costal osteochondral autograft and followed for a minimum of 3 years (mean follow-up, 57 months; range, 36 to 147 months). The mean patient age was 14.3 years. Clinical outcomes, including elbow range of motion, Timmerman and Andrews clinical rating score, donor-site morbidity, responses to a questionnaire regarding a return to sporting activities, and radiographic findings, were evaluated.

RESULTS

The mean elbow range of extension/flexion increased significantly, from -21°/122° preoperatively to -4°/136° postoperatively (p < 0.001). The mean clinical rating score improved significantly, from 101 to 190 by the latest follow-up (p < 0.001). The overall clinical score-based assessment was excellent for 60 patients, good for 9, and fair for 3. Seventy of the 72 patients returned to their original sport. The remaining 2 patients had changed sporting activities before surgery and did not return to baseball, despite satisfactory clinical results.

CONCLUSIONS

Costal osteochondral autograft successfully achieved anatomical and biological reconstruction in the treatment of advanced osteochondritis dissecans of the humeral capitellum.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Osteochondral autograft transplantation for isolated patellofemoral osteoarthritis

BACKGROUND

The purpose of this retrospective study was to evaluate clinical outcomes of osteochondral autograft transplantation (OAT) for isolated patellofemoral (PF) osteoarthritis (OA).

METHODS

OAT was performed in seven patients (six men, one woman; mean age, 61.1years) with isolated PF OA. The mean duration of follow up was 46.9months (range, 24-84months). Clinical outcomes were evaluated preoperatively and postoperatively according to the International Knee Documentation Committee (IKDC) objective score and the knee scoring system of the Japanese Orthopaedic Association (JOA) score. The International Cartilage Repair Society (ICRS) score was recorded in three cases that underwent second-look arthroscopies postoperatively. For morphological evaluation, the Kellgren and Lawrence (KL) classification and the modified magnetic resonance observation of cartilage repair tissue (MOCART) score were used.

RESULTS

The mean IKDC and JOA scores were both significantly improved. The percentage of normal and nearly normal on the IKDC score was increased from 28.6% (2/7) to 85.7% (6/7) (P=0.05). The mean JOA score was improved from 80.0 (range, 65.0-85.0) to 95.0 (range, 90.0-100) (P=0.0008). The mean ICRS scores were 10.3 (nearly normal) in the three cases that underwent second-look arthroscopies postoperatively. Regarding KL classification, the grade was unchanged in five cases (two cases in grade 1, three cases in grade 2) and improved in two cases (from grade 3 to 2, from grade 4 to 3). The mean modified MOCART score was 67.9 (range, 60.0-75) at 12-month follow up. There were no complications, and satisfaction was obtained in all cases. The study design was case series: level IV.

CONCLUSIONS

All clinical scores improved significantly postoperatively. Osteochondral plugs were transplanted perpendicular to the articular surface to obtain good congruity of the repaired articular surface. In this way, OAT is an effective procedure to prevent progression of isolated PF OA.

Clinical Outcomes of Donor Sites After Osteochondral Graft Harvest From Healthy Knees

Background:

The use of autologous osteochondral grafts has become popular in the treatment of small, isolated, well-contained articular cartilage defects. However, donor site morbidity is a problem, and few reports are available of donor site morbidity after mosaicplasty.

Purpose:

To examine the clinical outcomes of donor sites after osteochondral grafts from healthy knees.

Study Design:

Case series; Level of evidence, 4.

Methods:

Between September 1997 and September 2011, there were 40 patients (40 knees; 32 men, 8 women; 31 right knees, 9 left knees) with asymptomatic osteochondral graft donor sites used for autologous transfer; all had a follow-up period of >2 years. The mean patient age at surgery was 21.0 years (range, 12-58 years). The recipient sites included the elbow (n = 28), contralateral knee (n = 5), and ankle (n = 7). The mean diameter of the grafted plugs was 7.5 mm (range, 4.5-9 mm), and the mean number of grafted plugs was 2.2 (range, 1-3). At a mean follow-up of 43.1 months (range, 24-177 months), knee symptoms, return to sport, ability to sit straight in Japanese style, and radiological changes of the patellofemoral joint were evaluated. Whether operative age, follow-up period, and diameter or number of the grafted plugs were risk factors was analyzed statistically. Significance was defined as P < .05.

Results:

Thirty-four patients had no knee symptoms, and 4 patients had occasional mild knee pain. Two patients underwent reoperation for arthrofibrosis and not for cartilage defect. Twenty-seven patients had complete return to sports, and 32 patients could sit straight; donor site morbidity was not the cause of failure to return to sports or inability to sit straight. The radiological changes became worse in 3 patients, and the risk factor for degenerative change was older operative age.

Conclusion:

When osteochondral plugs were obtained from healthy knees, 34 patients (85%) were asymptomatic at follow-up. No donor site defects required surgical intervention due to persistent symptoms.

Anconeus Muscle-Pedicle Bone Graft With Periosteal Coverage for Osteochondritis Dissecans of the Humeral Capitellum

Background:

Treatment of advanced osteochondritis dissecans (OCD) of the capitellum is controversial, especially in moderate-sized lesions.

Purpose:

To establish a treatment algorithm for capitellum OCD, we tried to determine the utility of and problems associated with anconeus muscle-pedicle bone graft with periosteal coverage (ABGP) for the treatment of moderate-sized articular OCD defects of the capitellum.

Study Design:

Case series; Level of evidence, 4.

Methods:

According to our protocol for elbow OCD, 16 patients (15 males, 1 female; age range, 12-17 years; mean age, 14.4 years) with a moderate-sized OCD lesion of the humeral capitellum were treated with ABGP. All patients had a full-thickness, unstable OCD lesion that was 10 to 15 mm in diameter. Clinical results and postoperative images, including radiographs and magnetic resonance imaging (MRI), were evaluated at a mean follow-up of 31 months (range, 24-66 months).

Results:

All but 1 patient had functional improvement after the procedure and returned to previous sporting activities within 6 months. One female patient needed 1 year for functional recovery due to development of postoperative chronic regional pain syndrome (CRPS). Two patients required additional surgery, including shaving of the protruding cartilage, and they returned to their previous level of activity. Mean arc of range of flexion-extension motion was 117° preoperatively and 129° at follow-up (P = .031). Mean elbow function as assessed with the clinical rating system of Timmerman and Andrews was 136 preoperatively and 186 at follow-up (P = .00012). Bony union of the graft as demonstrated by trabecular bone bridging on radiography was obtained within 3 months in all patients. Postoperative MRI was examined for 14 patients at 6 to 12 months after the procedure; the MRIs showed near-normal articular surface integrity in 9 of the 14 patients (64%) and underlying bony structure in 10 of the 14 patients (71%).

Conclusion:

Improvement after ABGP was obtained within 6 months in all except 1 patient, who developed CRPS. Postoperative radiography and MRI revealed near-normal articular surface integrity or underlying bony structure. This procedure is useful as a surgical option for a moderate-sized articular OCD lesion in the elbow.

Clinical Outcome After Arthroscopic Debridement and Microfracture for Osteochondritis Dissecans of the Capitellum

BACKGROUND

Various surgical treatment techniques have been developed to treat capitellar osteochondritis dissecans; however, the optimal technique remains the subject of ongoing debate.

PURPOSE

To evaluate clinical outcomes after arthroscopic debridement and microfracture for advanced capitellar osteochondritis dissecans.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Between 2008 and 2015, the authors followed 77 consecutive patients (81 elbows) who underwent arthroscopic debridement and microfracture, and loose body removal if needed, for advanced capitellar osteochondritis dissecans. Seventy-one patients (75 elbows) with a minimum follow-up of 1 year were included. The mean age was 16 years (SD, ±3.3 years; range, 11-26 years) and the mean follow-up length was 3.5 years (SD, ±1.9 years; range, 1-8.2 years). Based on CT and/or MRI results, 71 lesions were classified as unstable and 4 as stable. Clinical elbow outcome (pain, function, and social-psychological effect) was assessed using the Oxford Elbow Score (OES) at final follow-up (OES range, 0-48). Range of motion and return to sports were recorded. Multivariable linear regression analysis was performed to determine predictors of postoperative OES.

RESULTS

Intraoperatively, there were 3 grade 1 lesions, 2 grade 2 lesions, 10 grade 3 lesions, 1 grade 4 lesion, and 59 grade 5 lesions. The mean postoperative OES was 40.8 (SD, ±8.0). An open capitellar physis was a predictor of better elbow outcome (5.8-point increase; P = .025), as well as loose body removal/grade 4-5 lesions (6.9-point increase; P = .0020) and shorter duration of preoperative symptoms (1.4-point increase per year; P = .029). Flexion slightly improved from 134° to 139° ( P < .001); extension deficit slightly improved from 8° to 3° ( P < .001). Pronation ( P = .47) and supination did not improve ( P = .065). Thirty-seven patients (55%) returned to their primary sport at the same level, and 5 patients (7%) returned to a lower level. Seventeen patients (25%) did not return to sport due to elbow-related symptoms, and 10 patients (13%) did not return due to non-elbow-related reasons. No complications were recorded.

CONCLUSION

Arthroscopic debridement and microfracture for advanced capitellar osteochondritis dissecans provide good clinical results, especially in patients with open growth plate, loose body removal, and shorter duration of symptoms. However, only 62% of patients in this study returned to sports.

Return to sporting activity after osteochondral autograft transplantation for Freiberg disease in young athletes

INTRODUCTION

Freiberg disease is defined as osteochondrosis of the metatarsal head and typically occurs in adolescents with sporting activity. This study aimed to evaluate the sporting activity of young athletes after osteochondral autograft transplantation (OAT) for Freiberg disease.

MATERIALS AND METHODS

OAT for Freiberg disease was conducted in 12 consecutive patients between August 2008 and November 2014. The present study evaluated 10 of these patients who both undertook sporting activity preoperatively and were teenagers at the time of surgery. Clinical evaluations were performed based on the Japanese Society for Surgery of the Foot lesser metatarsophalangeal-interphalangeal scale (JSSF scale) and range of motion (ROM) of the operated metatarsophalangeal joint preoperatively and at the final follow-up (mean 24.6 months). Whether patients were able to return to sporting activity and time until return to sporting activity were evaluated, including the Halasi score to reflect the level of sporting activity. Regarding symptoms at the donor knee, the Lysholm knee scale score was evaluated at the final follow-up.

RESULTS

The mean JSSF scale showed a significant improvement at the final follow-up (p < 0.01). The mean ROM in extension and flexion improved at the final follow-up (p < 0.01, and p < 0.05, respectively). All patients were able to return to sporting activity at a mean time of 3.5 months postoperatively and the Halasi score showed no significant change. The mean Lysholm knee scale score was 97.9 (range 89-100) points at the final follow-up.

CONCLUSIONS

All young athletes who underwent OAT for Freiberg disease achieved early return to almost equal sporting activity postoperatively and exhibited a significant improvement of the ROM of the metatarsophalangeal joint with almost no knee pain.

Arthroscopic Treatment of Capitellum Osteochondritis Dissecans With Micronized Allogeneic Cartilage Scaffold

Osteochondritis dissecans (OCD) of the capitellum is a common disorder that causes pain and functional limitation in the adolescent elbow. Although conservative management is the first line of treatment, surgical intervention is usually recommended for patients with persistent mechanical symptoms, loose bodies, or unstable lesions. Elbow arthroscopy has become the gold standard to evaluate and treat symptomatic OCD lesions. Arthroscopic debridement and bone marrow stimulation have been shown to yield good short-term results. Unfortunately, long-term follow-up has shown less favorable outcomes, with degenerative changes frequently documented. Current marrow stimulation techniques promote the formation of fibrocartilage, which is known to be less durable than hyaline cartilage. We describe an arthroscopic technique of debridement and drilling supplemented with a micronized allogeneic cartilage scaffold to address OCD lesions of the capitellum in an effort to promote hyaline cartilage formation.

Donor-site morbidity after osteochondral autologous transplantation for osteochondritis dissecans of the capitellum: a systematic review and meta-analysis

PURPOSE

To determine the rate of donor-site morbidity after osteochondral autologous transplantation (OATS) for capitellar osteochondritis dissecans.

METHODS

A literature search was performed in PubMed/MEDLINE, Embase, and Cochrane Library to identify studies up to November 6, 2016. Criteria for inclusion were OATS for capitellar osteochondritis dissecans, reported outcomes related to donor sites, ≥10 patients, ≥1 year follow-up, and written in English. Donor-site morbidity was defined as persistent symptoms (≥1 year) or cases that required subsequent intervention. Patient and harvest characteristics were described, as well as the rate of donor-site morbidity. A random effects model was used to calculate and compare weighted group proportions.

RESULTS

Eleven studies including 190 patients were included. In eight studies, grafts were harvested from the femoral condyle, in three studies, from either the 5th or 6th costal-osteochondral junction. The average number of grafts was 2 (1-5); graft diameter ranged from 2.6 to 11 mm. In the knee-to-elbow group, donor-site morbidity was reported in 10 of 128 patients (7.8%), knee pain during activity (7.0%) and locking sensations (0.8%). In the rib-to-elbow group, one of 62 cases (1.6%) was complicated, a pneumothorax. The proportion in the knee-to-elbow group was 0.04 (95% CI 0.0-0.15), and the proportion in the rib-to-elbow group was 0.01 (95% CI 0.00-0.06). There were no significant differences between both harvest techniques (n.s.).

CONCLUSIONS

Donor-site morbidity after OATS for capitellar osteochondritis dissecans was reported in a considerable group of patients.

LEVEL OF EVIDENCE

Level IV, systematic review of level IV studies.

Knee donor-site morbidity after mosaicplasty - a systematic review

BACKGROUND

Mosaicplasty has been associated with good short- to long-term results. Nevertheless, the osteochondral harvesting is restricted to the donor-site area available and it may lead to significant donor-site morbidity.

PURPOSE

Provide an overview of donor-site morbidity associated with harvesting of osteochondral plugs from the knee joint in mosaicplasty procedure.

METHODS

Comprehensive search using Pubmed, Cochrane Library, SPORTDiscus and CINAHL databases was carried out through 10th October of 2016. As inclusion criteria, all English-language studies that assessed the knee donor-site morbidity after mosaicplasty were accepted. The outcomes were the description and rate of knee donor-site morbidity, sample's and cartilage defect's characterization and mosaicplasty-related features. Correlation between mosaicplasty features and rate of morbidity was performed. The methodological and reporting quality were assessed according to Coleman's methodology score.

RESULTS

Twenty-one studies were included, comprising a total of 1726 patients, with 1473 and 268 knee and ankle cartilage defects were included. The defect size ranged from 0.85 cm2 to 4.9 cm2 and most commonly 3 or less plugs (averaging 2.9 to 9.4 mm) were used. Donor-site for osteochondral harvesting included margins of the femoral trochlea (condyles), intercondylar notch, patellofemoral joint and upper tibio-fibular joint. Mean donor-site morbidity was 5.9 % and 19.6 % for knee and ankle mosaicplasty procedures, respectively. Concerning knee-to-knee mosaicplasty procedures, the most common donor-site morbidity complaints were patellofemoral disturbances (22 %) and crepitation (31 %), and in knee-to-ankle procedures there was a clear tendency for pain or instability during daily living or sports activities (44 %), followed by patellofemoral disturbances, knee stiffness and persistent pain (13 % each). There was no significant correlation between rate of donor-site morbidity and size of the defect, number and size of the plugs (p > 0.05).

CONCLUSIONS

Osteochondral harvesting in mosaicplasty often results in considerable donor-site morbidity. The donor-site morbidity for knee-to-ankle (16.9 %) was greater than knee-to-knee (5.9 %) mosaicplasty procedures, without any significant correlation between rate of donor-site morbidity and size of the defect, number and size of the plugs. Lack or imcomplete of donor-site morbidity reporting within the mosaicplasty studies is a concern that should be addressed in future studies.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I-IV studies.

Fresh osteochondral allograft transplantation for osteochondritis dissecans of the capitellum in baseball players

BACKGROUND

Osteochondritis dissecans (OCD) of the capitellum is a rare yet debilitating injury seen in young athletes. This is the first report in the literature describing fresh osteochondral allograft transplantation (FOCAT) to treat OCD of the capitellum.

METHODS

Nine male baseball players (mean age, 15.3; range, 14-18 years), with OCD of the capitellum were treated with FOCAT. There were 6 pitchers and 3 position players. A ligament-sparing, mini-open approach was used. A fresh femoral hemicondyle was used as a donor source. Of the 9 patients, 7 required 1 plug and 2 required 2 plugs. The average plug diameter was 11 mm (range, 8-18 mm). Five plugs were press fit, and 4 required additional fixation. Clinical outcomes were evaluated at a mean follow-up of 48.4 months (range, 11-90 months). Preoperative and postoperative outcome scores were calculated using the paired t test.

RESULTS

The Mayo Elbow Performance score improved from an average 57.8 to 98.9 (P < .01). The Oxford Elbow Score improved from 22.4 to 44.8 (P < .01). The Disabilities of the Arm, Shoulder and Hand score improved from 35.2 to 5.4 (P < .01). The visual analog scale score improved from 7.8 to 0.5 (P < .01). The Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow score improved from 32.6 to 82.5 (P < .01). All patients returned to throwing and were still active in their sport or played at least 2 years of baseball before leaving the sport unrelated to the elbow.

CONCLUSIONS

FOCAT for OCD of the capitellum in properly selected cases is a viable treatment with significant functional improvement and pain reduction in throwers.

Clinical and MRI Donor Site Outcomes Following Autologous Osteochondral Transplantation for Talar Osteochondral Lesions

BACKGROUND

Autologous osteochondral transplantation (AOT) has an inherent risk of donor site morbidity (DSM). The reported rates of DSM vary from 0% to 50%, with few studies reporting clinical or imaging outcomes at the donor site as a primary outcome and even fewer report these outcomes when a biosynthetic plug backfill is employed. Although TruFit (Smith & Nephew, Andover, MA) plugs have been removed from the market for regulatory purposes, biphasic plugs (including TruFit plugs) have been used for several years and the evaluation of these is therefore pertinent.

METHODS

Thirty-nine patients who underwent forty AOT procedures of the talus, with the donor graft being taken from the ipsilateral knee, were included. Postoperative magnetic resonance imaging (MRI) was used to assess the donor site graded with magnetic resonance observation of cartilage repair tissue (MOCART) scoring. Lysholm scores were collected preoperatively, at the time of magnetic resonance imaging (MRI), and again at 24 months and at final follow-up to assess clinical outcomes. Statistical analysis was performed to establish if there was any correlation between MRI assessment of the donor site and clinical outcomes. The mean patient age was 36.2 ± 15.7 years with a mean follow-up of 41.8 ± 16.7 months.

RESULTS

All patient donor site defects were filled with OBI TruFit biphasic plugs. DSM was encountered in 12.5% of the patient cohort at 24 months, and in these patients, the Lysholm score was a mean 87.2 ± 5.0. At final follow-up, DSM was reduced to 5%. Lysholm scores for the entire cohort were 98.4 ± 4.6 and 99.4 ± 3.1 at 24 months and final follow-up, respectively. MRI of the donor sites were taken at an average of 18.1 ± 13.5 (range, 3-48) months postoperatively and the mean MOCART score was 60.0 ± 13.5. No correlation was found between the MOCART score and Lysholm outcomes at the donor knee (P = .43, r = 0.13).

CONCLUSION

Low incidence of DSM and good functional outcomes were achieved with AOT. Additionally, MRI findings did not predict clinical outcomes in our study.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Osteochondritis dissecans of the elbow

Capitellar osteochondritis dissecans (OCD) can be a significant problem in adolescent overhead athletes. The cause is likely multifactorial secondary to repetitive stresses, biomechanical mismatch, and a tenuous vascular supply of the capitellum. Recent literature reveals that the prevalence is likely higher than previously thought. This, in conjunction with increased levels of athletic competition in children at younger ages, has fed the recent interest in this topic. The literature continues to show that non-operative treatment is still successful for stable lesions. Unstable lesions, therefore, have been the focus of the new literature regarding operative management and outcomes. The aim of this paper is to provide a summary of current literature and an up-to-date approach to the diagnosis, evaluation, and treatment of osteochondritis dissecans of the capitellum.

Third-generation autologous chondrocyte implantation versus mosaicplasty for knee cartilage injury: 2-year randomized trial

Numerous surgical techniques have been developed to treat osteochondral defects of the knee. A study reported encouraging outcomes of third-generation autologous chondrocyte implantation achieved using the solid agarose-alginate scaffold Cartipatch®. Whether this scaffold is better than conventional techniques remains unclear. This multicenter randomized controlled trial compared 2-year functional outcomes (IKDC score) after Cartipatch® versus mosaicplasty in patients with isolated symptomatic femoral chondral defects (ICRS III and IV) measuring 2.5-7.5 cm(2) . In addition, a histological evaluation based on the O'Driscoll score was performed after 2 years. We needed 76 patients to demonstrate an at least 10-point subjective IKDC score difference with α = 5% and 90% power. During the enrolment period, we were able to include 55 patients, 30 of them were allocated at random to Cartipatch® and 25 to mosaicplasty. After 2 years, eight patients had been lost to follow-up, six in the Cartipatch® group, and two in the mosaicplasty group. The baseline characteristics of the two groups were not significantly different. The mean IKDC score and score improvement after 2 years were respectively 73.7 ± 20.1 and 31.8 ± 20.8 with Cartipatch® and 81.5 ± 16.4 and 44.4 ± 15.2 with mosaicplasty. The 12.6-point absolute difference in favor of mosaicplasty is statistically significant. Twelve adverse events were recorded in the Cartipatch® group against six in the mosaicplasty group. After 2 years, functional outcomes were significantly worse after Cartipatch® treatment compared to mosaicplasty for isolated focal osteochondral defects of the femur.

Evaluation of Knee Donor and Elbow Recipient Sites for Osteochondral Autologous Transplantation Surgery in Capitellar Osteochondritis Dissecans

BACKGROUND

Osteochondral autologous transplantation surgery (OATS) has been advocated for treatment of osteochondritis dissecans (OCD) of the capitellum in adolescents. However, little information is available regarding the optimal knee harvest site to match the contour and cartilage thickness of the recipient elbow lesion.

PURPOSE

To characterize the capitellar anatomic structure in adolescents with and without OCD and to compare these measurements to normal adolescent knees to identify the optimal site for osteochondral graft harvest.

STUDY DESIGN

Controlled laboratory study.

METHODS

Twenty-one patients with OCD were analyzed. Twenty-two patients with normal elbows and 25 age-, weight-, and height-matched patients with normal knees were also identified. Cartilage radii of curvatures (ROCs) in the sagittal and coronal-axial planes were measured on magnetic resonance imaging (MRI) of normal capitella and 5 sites (posterior lateral femoral condyle, medial and lateral middle trochlear ridges, and medial and lateral inferior trochlear ridges) in normal knees. Differences in ROC between the knee donor and capitellar recipient sites were calculated based on a 10-mm osteochondral plug diameter.

RESULTS

Overall, the mean apex differences between graft and recipient sites ranged from 0.4 to 0.9 mm, and mean edge differences ranged from 0.5 to 1.4 mm in the coronal-axial dimension. Of all knee sites tested, the posterior lateral femoral condyle had average ROCs (19.1 mm sagittal; 14.1 mm axial) most like the capitellum (10.6 mm sagittal, 12.6 mm coronal-axial), resulting in minimal apex and edge differences (apex difference = -0.6 mm; coronal-axial side difference = -0.5 mm; no sagittal side difference). Of the anterior nonweightbearing sites, the inferior medial trochlear ridge (28.3 mm sagittal ROC; 13.2 mm coronal-axial ROC) demonstrated the lowest apex and side differences when compared with the capitellum (apex difference = -0.8 mm; coronal-axial side difference = -0.8 mm; no sagittal side difference). The frequently used middle lateral trochlear ridge (28.8 mm sagittal; 8.7 mm coronal-axial ROCs) had the largest side difference (apex distance = -0.8 mm; coronal-axial side difference = -1.4 mm; no sagittal side difference).

CONCLUSION/CLINICAL RELEVANCE

In cases where a large single-plug OATS is considered, a 10-mm plug from the anterior nonweightbearing aspect of the distal femur is calculated to result in ≤1 mm of articular incongruity at the recipient capitellum. The inferior medial trochlear ridge should be considered as a donor site for OATS procedures for OCD given its accessibility and favorable geometry.

Evaluating Joint Morbidity after Chondral Harvest for Autologous Chondrocyte Implantation (ACI): A Study of ACI-Treated Ankles and Hips with a Knee Chondral Harvest

OBJECTIVE

To establish if harvesting cartilage to source chondrocytes for autologous chondrocyte implantation (ACI) results in donor site morbidity.

DESIGN

Twenty-three patients underwent ACI for chondral defects of either the ankle or the hip. This involved cartilage harvest from the knee (stage I), chondrocyte expansion in the laboratory and implantation surgery (stage II) into the affected joint. Prior to chondral harvest, no patient had sought treatment for their knee. Lysholm knee scores were completed prior to chondral harvest and annually post-ACI. Histological analyses of the donor site were performed at 12.3 ± 1.5 months for 3 additional patients who had previously had ACI of the knee.

RESULTS

The median preoperative Lysholm score was 100, with no significant differences observed at either 13.7±1.7 months or 4.8±1.8 years postharvest (median Lysholm scores 91.7 and 87.5, respectively). Patients whose cartilage was harvested from the central or medial trochlea had a significantly higher median Lysholm score at latest follow-up (97.9 and 93.4, respectively), compared with those taken from the intercondylar notch (median Lysholm score 66.7). The mean International Cartilage Repair Society (ICRS) II histological score for the biopsies taken from the donor site of 3 additional knee ACI patients was 117 ± 10 (maximum score 140).

CONCLUSIONS

This study suggests that the chondral harvest site in ACI is not associated with significant joint morbidity, at least up to 5 years postharvest. However, one should carefully consider the location for chondral harvest as this has been shown to affect knee function in the longer term.

Internal Fixation of Unstable In Situ Osteochondritis Dissecans Lesions of the Capitellum

BACKGROUND

Limited data exist regarding the indications and expected outcomes of internal fixation of unstable in situ osteochondritis dissecans (OCD) lesions of the capitellum. The objective of this investigation was to characterize healing rates, clinical results, and functional outcomes of internal fixation of unstable in situ OCD lesions in adolescents.

METHODS

Retrospective analysis was performed of 26 elbows in 24 patients who underwent internal fixation for unstable in situ OCD. Mean age at surgery was 14.1 years; 7 patients had open physes. Mean lesion width and thickness were 12.0 and 5.4 mm, respectively. Demographic, clinical, and radiographic variables of patients who went on to healing versus revision procedures were compared with univariate analysis. Classification and regression tree analysis identified optimal threshold values associated with healing. Functional outcomes were assessed with the Mayo Elbow Performance Score, Timmerman, and Pediatric Outcomes Data Collection Instrument scores. Mean clinical follow-up was 39 months (range, 12 to 96 mo).

RESULTS

Twenty of 26 elbows healed. Patients who healed were younger (P=0.01) and had smaller sagittal plane lesion widths (P=0.03) than patients who underwent revision. Classification and regression tree analysis identified 15.3 years and 13 mm as the threshold values distinguishing patients who did and did not heal. Overall, mean arc of elbow motion improved from 109 degrees preoperatively to 127 degrees at last follow-up (P=0.001). Mean Mayo Elbow Performance Score improved from 68 to 92 (P<0.001). Of 18 questionnaire respondents, two thirds reported full return to their prior level of sports participation without elbow complaint; 9 had excellent final Timmerman scores, 5 good, and 4 fair. Mean Pediatric Outcomes Data Collection Instrument upper extremity and sports scores were 98 and 93, respectively.

CONCLUSIONS

Healing, return to sports, and good to excellent functional outcomes may be expected in the majority of patients undergoing internal fixation of unstable in situ OCD lesions of the capitellum, particularly in younger patients with lesions <13 mm in sagittal width. Higher levels of evidence must further differentiate the optimal surgical treatments of unstable OCD.

LEVEL OF EVIDENCE

Level IV.

Short-term clinical results of arthroscopic osteochondral fixation for elbow osteochondritis dissecans in teenaged baseball players

BACKGROUND

Reports regarding arthroscopic fixation of the osteochondral fragments for elbow osteochondritis dissecans (OCD) are few. This study assessed the clinical outcomes of arthroscopic fixation of unstable osteochondral fragments by using absorbable pins over a postoperative period of at least 1 year.

METHODS

The patients were 13 adolescent baseball players with a mean age of 14 years (range, 12-16 years) who underwent OCD of primary lesions at International Cartilage Repair Society grades III and IV. The patients were evaluated by using validated outcome measures at a mean follow-up period of 24 months (range, 12-50 months).

RESULTS

The mean (standard deviation) score in the disability/symptom section of the Disabilities of the Arm, Shoulder, and Hand improved from 12.4 (6.0) before the surgery to 0.5 (1.2) after the surgery, and the sports section improved from 74.5 (25.4) to 1.4 (5.2). The mean (standard deviation) extension improved from -11° (10.8) to -2° (3.9; P < .001). The mean (SD) flexion improved from 129° (11.6) to 137° (5.6; P = .040). All patients were able to resume playing baseball, and 9 (69%) resumed playing at the same position as before their injuries.

CONCLUSIONS

The clinical results of arthroscopic osteochondral fragment fixation in the teenaged baseball players with elbow OCD, albeit obtained over only a short period, were favorable. This arthroscopic treatment enables repair of lesions and is considered appropriate for unstable OCD during the adolescent growth spurt.

Comparison of Arthroscopic Microfracture for Osteochondral Lesions of the Talus With and Without Subchondral Cyst

BACKGROUND

Although various treatment modalities for an osteochondral lesion of the talus (OLT) with a subchondral cyst have been recommended previously, the primary treatment methods for such conditions have yet to be conclusively determined. Moreover, few comprehensive studies have compared the outcomes of cases where patients were treated with microfracture for OLT with and without subchondral cysts.

PURPOSE

To evaluate the clinical outcomes after arthroscopic microfractures performed as a primary treatment for OLT with a subchondral cyst.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

The study cohort consisted of 102 patients (102 ankles) who underwent arthroscopic microfracture for small to midsized OLT. The ankles were divided into a cyst group (45 ankles) and a noncyst group (57 ankles).The American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale, visual analog scale (VAS), and Ankle Activity Score (AAS) were used to compare the clinical outcomes between the groups over a mean follow-up period of 48 months.

RESULTS

The mean AOFAS ankle-hindfoot scores were 64.8 in the cyst group and 66.2 in the noncyst group preoperatively. These improved to 91.8 and 91.3, respectively, at the final follow-up. The mean VAS scores were 7.5 in the cyst group and 7.3 in the noncyst group preoperatively; these improved to 2.3 and 2.2, respectively, at the final follow-up. The mean AAS in the cyst group and the noncyst group improved from 2.7 and 2.6 preoperatively to 6.7 and 6.5 at the final follow-up, respectively. In terms of radiographic stage improvements, the cyst group showed no change in 18 ankles (40%) and showed improvements of 1 grade in 13 ankles (28.9%), 2 grades in 9 ankles (20%), 3 grades in 3 ankles (6.7%), and 4 grades in 2 ankles (4.4%). The noncyst group showed no change in 17 ankles (29.8%) and showed improvements of 1 grade in 11 ankles (19.3%), 2 grades in 11 ankles (19.3%), 3 grades in 14 ankles (24.6%), and 4 grades in 4 ankles (7.0%). No significant differences were found between the groups in terms of the AOFAS score, VAS score, AAS, or radiographic stage improvements.

CONCLUSION

OLT with and without subchondral cysts treated with arthroscopic microfracture showed similarly good clinical results. The study results suggest that microfracture could be a primary treatment strategy for treating small to midsized OLT regardless of the existence of subchondral cysts.

Osteochondral autograft plug transfer for treatment of osteochondritis dissecans of the capitellum in adolescent athletes

BACKGROUND

Osteochondritis dissecans (OCD) of the capitellum is a condition most commonly seen in adolescents involved in repetitive overhead sports and can profoundly affect ability to return to play and long-term elbow function. Treatment of large, unstable defects in the elbow with osteochondral autograft plug transfer has not been adequately studied.

METHODS

We retrospectively identified 11 teenaged patients with large (>1 cm(2)) capitellar OCD treated with osteochondral autograft plug transfer. Average age at the time of surgery was 14.5 years (range, 13-17 years). Outcome measures obtained included return to play, preoperative and postoperative elbow range of motion, Disabilities of Arm, Shoulder and Hand (DASH; Institute for Work and Health, Toronto, ON, Canada) by telephone interview, and osseous integration on radiographs. All 11 patients were available for evaluation at an average of 22.7 months (range, 6-49 months) postoperatively.

RESULTS

All patients were involved in competitive high school athletics and returned to at least their preinjury level of play. Average return to play was 4.4 months (range 3-7 months). The average final DASH was 1.4 (95% confidence interval, 0.6-2.1), and the average final sport-specific DASH was 1.7 (95% confidence interval -1.8 to 5.2). Elbow range of motion significantly improved, including improvement in flexion from a preoperative average of 126° to a postoperative average of 141° (P = .009) and improvement in extension from a preoperative average of 21° to a postoperative average of 5° (P = .006).

CONCLUSIONS

Treatment of large, unstable OCD lesions of the capitellum in adolescent athletes allows reliable return to play, is safe, and has good clinical outcomes at short-term follow-up.

Topographic analysis of the capitellum and distal femoral condyle: finding the best match for treating osteochondral defects of the humeral capitellum

PURPOSE

The purpose of this study was to determine the donor zone of most congruent topographic match by comparing 4 donor sites from the femur with 4 potential recipient sites of osteochondritis dissecans at the capitellum.

METHODS

Computed tomography was performed on 5 right elbows and 6 right medial and 6 right lateral distal femoral hemicondyles, which included the femoral notch. Three-dimensional computed tomography models were created and exported into point-cloud models. A local coordinate map of the distal humerus and distal femoral articular surfaces was created. The capitellum was compared with the medial and lateral distal femoral condyles, with 2 donor zones in each condyle (medial trochlea and medial intercondylar notch or lateral trochlea and lateral intercondylar notch). In each capitellum 4 combinations of 10-mm defects were simulated (central and lateral, 30° and 45° anterior to shaft of humerus), resulting in 480 capitellum-femur comparative combinations being tested. The capitellum surfaces were virtually placed on a point on the femoral articular surface in 3-dimensional space. The least distances (i.e., the shortest distance from the point in question to the corresponding point in space) between the point clouds on the distal humerus and distal femoral articular surfaces were calculated.

RESULTS

There was a less than 0.1-mm difference in the topographic articular surface match among the 4 commonly used donor sites of the distal femur and 4 recipient sites of the capitellum. However, the best match for any given 10-mm capitellar defect (central 30°, central 45°, lateral 30°, and lateral 45°) was the same such that the lateral trochlea on the femur always yielded the best fit compared with the 3 other graft locations (P < .005).

CONCLUSIONS

Our results indicate that there is a less than 0.1-mm difference in the topographic articular surface match among the 4 commonly used donor sites of the distal femur and the capitellum. The findings suggest that all 4 donor sites provide close articular matching for the capitellum articular surface, with the lateral trochlea articular surface providing the best match.

CLINICAL RELEVANCE

These data suggest that a single donor plug may be obtained from multiple sites in the knee and placed into capitellar lesions with an excellent topographic articular surface match. The findings of our study will be useful to surgeons when managing capitellar osteochondritis dissecans lesions.

Arthroscopic fragment fixation using hydroxyapatite/poly-L-lactate Acid thread pins for treating elbow osteochondritis dissecans

BACKGROUND

Various procedures, such as arthroscopic debridement, osteochondral transplantation, and bone plug fixation, have been described for the treatment of osteochondritis dissecans (OCD) of the humeral capitellum. However, the use of hydroxyapatite/poly-L-lactate acid (HA/PLLA) thread pins to fix the osteochondral fragment in an OCD lesion is a recent development.

HYPOTHESIS

Adolescent throwing athletes would return to preinjury levels of function after arthroscopic osteochondral fragment fixation using HA/PLLA thread pins.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Enrolled in this prospective cohort study were 18 adolescent baseball players (mean age, 14.2 years; range 12-16, years) with elbow OCD who underwent arthroscopic fragment fixation with HA/PLLA thread pins between 2006 and 2009. All patients were affected on their dominant side. Plain radiographs taken before surgery showed an open physis in 13 patients (72%) and a closed physis in 5 patients (28%). During surgery, the condition of the OCD lesion was evaluated by use of the International Cartilage Research Society (ICRS) classification system; there were 5 grade II, 11 grade III, and 2 grade IV cases. Outcomes were assessed after 3 years (mean, 39 months; range, 36-50 months). Elbow function was measured using the Timmerman and Andrews score and the Mayo Elbow Performance Index. Return to sports activity was assessed as higher than preinjury, same level, lower level, or no return to sports.

RESULTS

The mean Timmerman and Andrews score improved significantly from 126.6±6.5 to 197.5±1.5, and the mean Mayo Elbow Performance Index improved significantly from 68.0±2.1 to 98.06±0.9 (P=.0001 for both). Mean elbow extension improved significantly from -10°±10.4° to -0.8°±5.2° (P=.006), and mean flexion improved significantly from 123.1°±17.9° to 138.6°±6.1° (P=.001). Three patients had a loss of extension greater than 5°. Five patients returned to a higher level of sports activity, 10 patients returned to the same level, and 2 patients returned to a lower level. A remaining patient did not return to baseball. In one patient, the lesion did not heal, resulting in fragmentation at 1 year after surgery. This patient consequently underwent revision arthroscopy to remove the lesion, and he eventually returned to sports at the same level of activity.

CONCLUSION

Arthroscopic fragment fixation using HA/PLLA thread pins provides a beneficial clinical outcome to adolescent baseball players with humeral capitellar OCD.

Treatment of osteochondral lesions in the elbow: results after autologous osteochondral transplantation

BACKGROUND

Osteochondral lesions in the elbow still remain a challenging field of surgery. In recent years promising clinical results were described for the osteochondral transplantation technique. The aim of this retrospective study was to evaluate the clinical and radiological outcome in the mid-term follow-up of a large cohort of patients following osteochondral transplantation in the elbow.

METHODS

18 patients with advanced osteochondral lesions of the elbow treated by autologous osteochondral autograft cylinders and a minimum follow-up of 36 months were included in the study. The Broberg-Morrey score (BMS) and the American Shoulder and Elbow score (ASES) were used to assess elbow function and pain, respectively. The joint status was analyzed using plain radiographs and MRI scans taken from all patients at recent follow-up. In addition, the ipsilateral knee joint was examined for donor-site morbidity using the Lysholm knee score.

RESULTS

14 patients were evaluated with a mean follow-up of 7 years (range 3-14 years). The mean BMS was 95.1 (range 72-100) points. The ASES score also showed promising results: pain at worst 1.5 (range 0-5) points, pain at rest 0.4 (range 0-5) points, pain lifting loads 2.8 (range 0-8) points, repetitive movement pain 1.5 (range 0-8) points. The range of motion of the injured elbow was free and equal to the contralateral side. Signs of osteoarthritis could be found on plain radiographs in three patients. The MRIs at follow-up showed graft viability in all patients. However, a slight incongruency of the chondral surface could be detected in two patients. The average Lysholm score was 90.9 (range 0-70) points.

CONCLUSIONS

Osteochondral transplantation in the elbow leads to both clinical and radiographic good-to-excellent mid-term results and therefore represents a reasonable treatment option for advanced osteochondral lesions in the elbow.

LEVEL OF EVIDENCE

Retrospective study; Therapeutic Level IV.

Costal osteochondral autograft for reconstruction of advanced-stage osteochondritis dissecans of the capitellum

BACKGROUND

Advanced-stage osteochondritis dissecans of the capitellum affecting the lateral wall may result in osteoarthritis, and suitable treatment is needed to avoid permanent deformation and impaired function. We aimed to assess postoperative outcomes of costal osteochondral autograft for treatment of this condition.

METHODS

We included 22 young overhead athletes (mean age, 13.9 years) with advanced osteochondritis dissecans of the humeral capitellum who underwent costal osteochondral autograft. All patients had elbow pain and wide-range articular cartilage lesions. We evaluated clinical and radiographic outcomes at a mean follow-up of 27 months (range, 12-77 months).

RESULTS

All patients achieved rapid functional improvement and returned to their former sports activity levels. The baseball players were able to play catch within 62 to 164 days (mean, 107 days) and returned to full pitching activity within 123 to 339 days (mean, 226 days). We assessed mean elbow function by the clinical rating system of Timmerman and Andrews and the Japanese Orthopaedic Association sports score; the scores improved from 121.5 and 53.7 points preoperatively to 169.2 points and 86.1 points, respectively, at the time of follow-up. Four patients required additional minor surgical procedures, including screw removal, loose body removal, and shaving off of spur formation. No patient showed obvious radiographic changes of osteoarthritis. All patients were satisfied with the final outcomes and had good functional recovery.

CONCLUSION

Costal osteochondral autograft gave satisfactory results for advanced osteochondritis dissecans of the humeral capitellum with extensive lesions affecting the lateral wall.

Outcomes of an open autologous osteochondral plug graft for capitellar osteochondritis dissecans: time to return to sports

BACKGROUND

Autologous osteochondral plug grafts have been used for capitellar osteochondritis dissecans (OCD), and good clinical results have been described. However, little is known about the optimal timing of return to sports.

PURPOSE

To investigate the clinical outcomes of open autologous osteochondral plug grafts for capitellar OCD and to address the timing of return to sports.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Thirty-three male patients with a mean age at the time of surgery of 13.6 years (range, 11-17 years) and with advanced lesions of capitellar OCD underwent a procedure using open autologous osteochondral plug grafts. All patients played baseball, and the lesion affected their throwing side. Thirteen lesions were arthroscopically classified as International Cartilage Repair Society (ICRS) OCD III and 20 lesions as ICRS OCD IV. The mean size of the lesions (sagittal × coronal) was 16 × 14 mm. One to 3 osteochondral plug grafts, with a mean diameter of 7 mm (range, 5-9 mm), were harvested from the lateral femoral condyle and transplanted to the defects. Patients were allowed to begin throwing after 3 months and to return to sports after 6 months. The mean follow-up was 28.4 months (range, 12-76 months), during which elbow pain, Timmerman and Andrews scores, return to sports, and radiographs were evaluated.

RESULTS

After surgery, 30 patients (91%) had no elbow pain, and 3 patients (9%) had occasional mild throwing pain. The mean total arc of elbow motion increased significantly from 116° to 133° (P < .05). The mean Timmerman and Andrews score improved significantly from 143 to 190 (P < .05). All except 2 patients returned to a competitive level at which they had previously played after a mean of 6.9 months (range, 6-14 months). One patient chose another sport, and another retired from baseball after high school graduation. All patients achieved graft incorporation, and there was no postoperative enlargement of osteophytes on radiographs. One patient had mild anterior knee pain at the donor site during exercise. The remaining patients had no knee pain. The mean Lysholm score was 99.8.

CONCLUSION

The results of this study indicate that an open autologous osteochondral plug graft allows a return to the previous competitive level of throwing by a mean of 7 months postoperatively.

Reconstruction with vascularized medial femoral condyle flaps in hindfoot and ankle defects: a report of two cases

In this article, we report using free vascularized medial femoral condyle (MFC) flaps for reconstruction of bone defects and nonunion of the hindfoot and ankle in two patients. One patient had an open calcaneal fracture and hindfoot bone defect with impaired gait due to Achilles tendon functional loss. The second patient had nonunion with a chondral defect of the talus after a fall. Following uneventful recoveries, good objective and subjective results were achieved in terms of pain reduction and improved gait in both patients. No further operative intervention was needed during a 3-year follow-up period. The versatility of the corticoperiosteal graft from the MFC makes it an important reconstructive tool for addressing several major surgical problems of bony nonunion in the extremities, including posttraumatic reconstruction of hindfoot and ankle disorders.

Osteochondritis dissecans of the elbow

Osteochondritis dissecans affects the elbow of many young, skeletally immature athletes. The incidence of OCD in the elbow is second to its occurrence in the knee and similar to the incidence in the ankle. Young, athletically active individuals are at increased risk for developing this problem. There is a predilection for those involved in overhead-dominant sports and sports that require the arm to be a weight-bearing limb. The diagnosis is occurring earlier because of an increased awareness of the entity and the increased use of advanced imaging techniques, primarily magnetic resonance imaging. This earlier diagnosis has led to an increase in treatment ideas and modalities and ultimately improved care and outcomes.

Mosaicplasty for osteochondral lesions of the talus: a report of two cases

Two women (24 and 27 years old) noted pain in the affected ankle of several years' duration. Radiography and magnetic resonance imaging revealed osteochondral lesions of the talus in both patients. The lesion sites measured 1.3 × 1.0 × 0.4 cm (0.52 cm(3)) and 2.0 × 1.9 × 0.5 cm (1.9 cm(3)). Each patient received a medial malleolar osteotomy with mosaicplasty. Donor plugs were obtained from the ipsilateral knee in both patients. Surgery was performed successfully in both patients without complications. At 2-year follow-up, both patients had recovered good ankle function, with no donor site morbidity. American Orthopedic Foot and Ankle Society ankle/hindfoot scores improved in the affected ankles from 16 to 84 in case 1 and from 43 to 87 in case 2. Mosaicplasty is effective in treating stage III or IV osteochondral lesions of the talus and results in good-to-excellent recovery of function.

Osteochondral autologous transfer combined with valgus high tibial osteotomy: long-term results and survivorship analysis

BACKGROUND

Deep osteochondral defects of the medial femoral condyle in young and active patients are a serious condition that might lead to early osteoarthritis of the knee joint. Concomitant varus malalignment most likely promotes this process because of overloading of the medial compartment. Osteochondral autologous transfer (OAT) combined with valgus high tibial osteotomy (HTO) might therefore be a comprehensive solution to preserve long-term knee function in these patients.

PURPOSE

To evaluate clinical long-term results and analyze survival rates (conversion to knee joint arthroplasty) after combined OAT and valgus HTO in young and active patients with symptomatic osteochondral defects of the medial femoral condyle and concomitant varus malalignment.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Between 1998 and 2008, combined OAT and valgus HTO was performed in 86 patients with deep osteochondral defects of the medial femoral condyle and concomitant varus malalignment >2°; 74 patients (86%) were available for follow-up evaluation. The mean age of patients was 38 years, and the mean follow-up time was 7.5 years. Knee function was assessed using the Lysholm score, and pain intensity was measured using the visual analog scale (VAS). The survival rates of this combined procedure were evaluated. Failure was defined as conversion to knee joint arthroplasty during the follow-up period.

RESULTS

Adjusted to follow-up time, the Lysholm score showed a mean increase of 33 points (95% CI, 27.1-39.4; P < .001) from 40 to 73, representing a significant improvement compared with preoperatively. The VAS score decreased by a mean of 4.8 points (95% CI, 4.1-5.5; P < .001) from 7.5 to 2.7, and 93% of the patients were satisfied with the results of the operative procedure. Mean survival rates were 95.2% ± 2.7% at 5 years, 93.2% ± 3.3% at 7 years, and 90.1% ± 4.4% at 8.5 years after surgery.

CONCLUSION

Combined OAT and valgus HTO is an option to successfully treat patients with deep osteochondral defects of the medial femoral condyle and concomitant varus malalignment. Significantly improved knee function, decreased pain intensity, and a high survivorship rate can be expected up to 8.5 years postoperatively.

Mapping of cartilage depth in the knee and elbow for use in osteochondral autograft procedures

BACKGROUND

Osteochondritis dissecans (OCD) of the elbow is a problematic condition that affects a fair number of young athletes. One treatment option is the use of osteochondral autografts, which are commonly taken from donor sites on the less weightbearing surfaces of the knee.

PURPOSE

To use magnetic resonance imaging (MRI) to assess the cartilage depths of sites in the knee and elbow that are commonly used as donor and recipient sites to optimize depth matching for osteochondral autograft procedures.

STUDY DESIGN

Descriptive laboratory study.

METHODS

All knee and elbow MRI scans acquired from 3-T machines in patients aged 16 to 25 years within a single hospital system were reviewed. Studies were excluded if there had been previous surgery on the joint or if there were significant chondral defects in the areas to be measured. All cartilage depth measurements were independently performed by 3 different physicians to the nearest 0.01 mm. At the elbow, 6 locations on the capitellum and 2 on the trochlea were chosen. At the knee, 4 locations along the anterior-lateral femoral condyle, 5 surrounding the intercondylar notch, and 1 on both the medial- and lateral-posterior femoral condyles were chosen.

RESULTS

There were 111 knee MRI (74 male, 37 female) and 94 elbow MRI (85 male, 9 female) scans that met all inclusion criteria. The average cartilage depths from each investigator were then averaged to provide an overall mean depth at each location. All average cartilage depths within the knee were thicker than those in the elbow, where the averaged mean thickness of all the 8 measured sites was 1.27 mm (range, 0.78-1.63 mm). Within the knee, the thinnest areas of cartilage, and therefore closest matches, were discovered at the posterior pole of the medial femoral condyle (mean ± SD, 1.95 ± 0.46 mm) and at the distal-most anterior-lateral femoral condyle (1.85 ± 0.46 mm). The average variance between the mean cartilage depths measured by each investigator for each location was 0.12 mm in the elbow and 0.22 mm in the knee.

CONCLUSION

Average cartilage depths in the knee were thicker than those in the elbow at all sites measured. The thinnest areas in the knee were the posterior aspect of the medial femoral condyle and the distal-most aspect of the anterior-lateral femoral condyle.

CLINICAL RELEVANCE

This study provides the surgeon with meaningful data on average cartilage depths at common donor sites in the knee and recipient sites in the elbow.

Osteochondral autograft transplantation for malunited intra-articular fracture of the proximal interphalangeal joint: a case report

INTRODUCTION

Malunited intra-articular fracture of the proximal inter-phalangeal (PIP) joint sometimes causes problems, such as range of motion (ROM) limitation in the joint or lack of digital dexterity; however, the treatment method has not yet been established. We report a juvenile case of osteochondral autograft tranplantation to treat a malunited intra-articular fracture of the middle finger.

CASE REPORT

A 14-year-old boy was injured at the right middle finger by a baseball impact and underwent conservative treatment. At 5 months after the injury, he complained of continuing pain and restricted ROM. Plain X-ray and CT images showed a bony defect in the articular surface of the PIP joint of the right middle finger. He was diagnosed with malunited intra-articular fracture of the PIP joint and underwent surgical treatment. First, through a palmar incision, a columnar-shaped drill hole was made at the recipient site of osteochondral defect. Then a cylindrical osteochondral plug, 4.5 mm in diameter, harvested from the knee, was inserted into the recipient hole and press-fitted. One year after surgery, the patient has neither pain nor ROM limitation of the finger and the knee joint. MRI showed smooth articular surface of the PIP joint.

DISCUSSION

The benefits of our method include use of articular cartilage as a reconstruction material, availability for a relatively large cartilage defect, and stability of the autograft for the press-fitting method, which enable early mobilization exercise after surgery.