Fresh Osteochondral Allograft Transplantation in Osteochondritis Dissecans in the Knee Joint

Fresh osteochondral allograft transplantation for knee full-thickness articular cartilage lesions using femoral head of living donors: short-term results

BACKGROUND

Fresh osteochondral allograft transplantation is a good treatment option of cartilage defects. However, this treatment option is not available in all countries due to limited graft availability and tissue banks limitations. The purpose of this study is to assess the short term functional and imaging outcomes of fresh osteochondral allograft transplantation in the knee using the femoral head of living donors.

HYPOTHESIS

Fresh osteochondral allografts from the femoral heads of living donors is a valid graft source for management of distal Femur cartilage defects. This technique can improve functional knee scores with good radiological outcomes.

STUDY DESIGN

Prospective case series.

METHODS

Fifteen patients with full thickness cartilage defects of the distal femur underwent osteochondral allograft transplantation from the femoral heads of living donors. Grafts were transplanted by both shell and multiple dowels techniques. The average follow up duration was 18.3 months (range, 12-25 months). Patients were evaluated by Lysholm and International Knee Documentation Committee (IKDC) scores, radiography and MR imaging using Osteochondral Allograft MRI Scoring System (OCAMRISS).

RESULTS

There was a statistically significant improvement (P < 0.001) in both Lysholm and IKDC average scores at 6 months and 12 months postoperative. Postoperative MRI was done at an average 6.8 months (range, 5-11 months) postoperative. The mean total OCAMRISS score was 3.4 (range, 1-7). A second look arthroscopy was done in four patients and showed intact articular cartilage in all three patients.

CONCLUSION

Femoral head of living donors is a valid new source for fresh osteochondral allograft transplantation of knee osteochondral lesions. Short term results showed improvement in clinical assessment scores. Follow up imaging showed graft incorporation and good MRI scores.

Osteochondritis Dissecans Lesions of the Knee: Evidence-Based Treatment

Osteochondritis dissecans (OCD) of the knee is a potentially disabling condition in adolescent and young adults, which is likely multifactorial in origin. In recent years, there have been notable improvements in identification and treatment. Clinical presentation varies based mostly on OCD lesion stability. Patients with stable lesions generally present with vague knee pain and altered gait while mechanical symptoms and effusion are more common with unstable lesions. Lesions most commonly occur on the lateral aspect of the medial femoral condyle in patients aged 10 to 20 years. Magnetic resonance imaging is vital to diagnose and predict clinical treatment, which is largely based on stability of the fragment. Conservative treatment of stable lesions in patients with open physis is recommended with protected weight-bearing and gradual progression of activities over the course of 3 to 6 months. Stable OCD lesions which failed a nonsurgical course can be treated with transarticular or retrograde drilling while unstable lesions usually require fixation, autologous chondrocyte implantation (ACI), osteochondral autograft transfer (OATS), or osteochondral allograft transplantation. This review highlights the most current understanding of knee OCD lesions and treatment options with the goal of optimizing outcomes in this difficult pathology.

Cyclic Stability of Locking Plate Augmented with Intramedullary Polymethyl Methacrylate (PMMA) Strut Fixation for Osteoporotic Humeral Fractures: A Biomechanical Study

The locking plate may provide improved fixation in osteoporotic bone; however, it has been reported to fail due to varus collapse or screw perforation of the articular surface, especially in osteoporotic bone with medial cortex comminution. Using bone graft as an intramedullary strut together with plate fixation may result in a stronger construct. However, the drawbacks of bone grafts include limited supply, high cost, and infection risk. PMMA (so-called bone cement) has been widely used for implant fixation due to its good mechanical properties, fabricability, and biocompatibility. The risk of donor-site infection and the drawbacks of allografting may be overcome by considering PMMA struts as alternatives to fibular grafts for humeral intramedullary grafting surgeries. However, the potential effects of intramedullary PMMA strut on the dynamic behaviour of osteoporotic humerus fractures remain unclear. This study aimed to investigate the influence of an intramedullary PMMA strut on the stability of unstable proximal humeral fractures in an osteoporotic synthetic model. Two fixation techniques, a locking plate alone (non-strut group) and the same fixation augmented with an intramedullary PMMA strut (with-strut group), were cyclically tested in 20 artificial humeral models. Axially cyclic testing was performed to 450 N for 10,000 cycles, intercyclic motion, cumulated fragment migration, and residual deformation of the constructs were determined at periodic cyclic intervals, and the groups were compared. Results showed that adding an intramedullary PMMA strut could decrease 1.6 times intercyclic motion, 2 times cumulated fracture gap migration, and 1.8 times residual deformation from non-strut fixation. During cycling, neither screw pull-out, cut-through, nor implant failure was observed in the strut-augmented group. We concluded that the plate-strut mechanism could enhance the cyclic stability of the fixation and minimize the residual displacement of the fragment in treating osteoporotic proximal humeral unstable fractures. The PMMA strut has the potential to substitute donor bone and serve as an intramedullary support when used in combination with locking plate fixation. The intramedullary support with bone cement can be considered a solution in the treatment of osteoporotic proximal humeral fractures, especially when there is medial comminution.

A case report of an adult with bilateral osteochondritis dissecans of the femoral condyles in both knees

INTRODUCTION

There are several possible treatment options for the treatment of focal cartilage defects in the knee. Determining the appropriate treatment option to compensate for an osteochondral defect caused by osteochondritis dissecans (OCD) in adults is difficult. This study was conducted to clarify the importance of Autogenous Osteochondral Grafting by a mosaicplasty method in treating OCD, relieving pain, and improving knee function.

CASE REPORT

Our study is a case report of a young female patient with osteochondritis dissecans in both the medial and lateral femoral condyles of both knees. Three of these were treated with autogenous osteochondral grafting using a mosaicplasty method. The case was done in 2016 and followed up for 5 years, where the functional results were evaluated according to International Knee Documentation Committee (IKDC Questionnaire) and the pain was assessed on a visual analogue scale (VAS).

DISCUSSION

There were no complications associated with surgery. We observed improvement in knee function according to the IKDC questionnaire from 38 before surgery to 85 after a year of surgery and her pain decreased significantly according to the visual analogue scale (VAS) from 7 before surgery to 1 after a year of surgery and continued until the end of the follow-up period.

CONCLUSION

Autologous osteochondral grafting with the mosaicplasty method is a good treatment option to treat osteochondritis dissecans (OCD) in the knee, as it helps to relieve pain and improve the functional state of the knee.

Osteochondral Allografts in Knee Surgery: Narrative Review of Evidence to Date

Knee articular cartilage defects can result in significant pain and loss of function in active patients. Osteochondral allograft (OCA) transplantation offers a single-stage solution to address large chondral and osteochondral defects by resurfacing focal cartilage defects with mature hyaline cartilage. To date, OCA transplantation of the knee has demonstrated excellent clinical outcomes and long-term survivorship. However, significant variability still exists among clinicians with regard to parameters for graft acceptance, surgical technique, and rehabilitation. Technologies to optimize graft viability during storage, improve osseous integration of the allograft, and shorten recovery timelines after surgery continue to evolve. The purpose of this review is to examine the latest evidence on treatment indications, graft storage and surgical technique, patient outcomes and survivorship, and rehabilitation after surgery.

Treatment of Knee Osteochondral Fractures

Osteochondral lesions (OCLs) that are frequently encountered in skeletally immature and adult patients are more common than once thought, and their incidence rate is rising. These lesions can appear in many synovial joints of the body, such as the shoulder, elbow, hip, and ankle, occurring most often in the knee. The term osteochondral lesion includes a vast spectrum of pathologies such as osteochondritis dissecans, osteochondral defects, osteochondral fractures, and osteonecrosis of the subchondral bone. When considering this, the term osteochondral fracture is preserved only for an osteochondral defect that combines disruption of the articular cartilage and subchondral bone. These fractures commonly occur after sports practice and are associated with acute lateral patellar dislocations. Many of these lesions are initially diagnosed by plain radiographs; however, a computed tomography (CT) scan or magnetic resonance imaging (MRI) can add significant value to the diagnosis and treatment. Treatment methods may vary depending on the location and size of the fracture, fragment instability, and skeletal maturity. The paper reports a 14-year-old boy case with an osteochondral fracture due to sports trauma. The medical approach involved an arthrotomy of the knee, drainage of the hematoma, two Kirschner wires (K-wires) for temporary fixation to restructure anatomic alignment, and a titanium Herbert screw fixing the fracture permanently. The patient had a favorable postoperative outcome with no residual pain, adequate knee stability, and a normal range of motion. The mobility of the knee was fully recovered.