eMedicine Specialties > Orthopedic Surgery > Knee
Osteochondral Grafting of Articular Cartilage Injuries: Treatment
Updated: May 15, 2009
Treatment
Surgical Therapy
The use of large autogenous osteochondral fragments and patellar grafts have been reported, but results of have been mixed, and concern exists regarding donor site morbidity from such large grafts. Interest has increased in the concept of smaller and more uniform cylindrical grafts, obtained locally, that can be implanted into prepared recipient sites in the lesion. Although there are some technical differences between the various commercially marketed techniques in which cylindrical osteochondral plugs are transferred, the overall concepts are similar. The technique can be used in specific situations of deficit size and location in properly selected patients.
Strong data support the ability of cancellous bone plugs to heal, whether the recipient holes have been drilled, trephined, or cored.
The biology of these grafts is well documented in animal and clinical studies. Strong data support the ability of cancellous bone plugs to heal, whether the recipient holes have been drilled, trephined, or cored (see Image 2). Biopsy studies also have shown the ability of transplanted cartilage to survive if placed in a mechanically advantageous position (see Image 3). The advantage of small grafts is obvious. If the hyaline cartilage could survive, there would be a great expectation of resurfacing damaged areas with more congruence than when larger autografts are used.
Biopsy studies have shown the ability of transplanted cartilage to survive if placed in a mechanically advantageous position.
The relative inability to resurface the entire defect area is a persisting concern.
Questions that persist include (1) the fate of the interstices between the cylindrical grafts, (2) the importance of their size in what material forms in this area, (3) the relative inability to resurface the entire defect area (see Image 4), and (4) the concept of "robbing Peter for Paul" in taking cartilage from a healthy part of the knee and placing it into a damaged site.
Preoperative Details
Surgical technique begins with patient positioning. After induction of general or regional anesthesia, a tourniquet is placed high on the thigh. Tourniquet use is not mandatory; however, it may be advantageous later. A leg holder is suggested but not mandatory. Epinephrine may be used in the irrigation fluid at the discretion of the surgeon. As in routine arthroscopic cases, the leg must be able to be flexed to 120° in order to visualize the majority of the femoral condyle and any symptomatic lesions. It is important to achieve this flexion in both a varus and valgus stressed position, depending on the compartment where the pathology is found. Usually, arthroscopy is performed to visualize the defect if this was not done previously.
After determining size and location of the lesion, a decision is made to perform the transplant in either an open or arthroscopic fashion. Generally, patellofemoral articulation is approached via an open procedure. For femoral condyles, there is more latitude in the decision-making process, and the decision is based on many factors. First and foremost is the surgeon's familiarity with the procedure. For the individual surgeon, initial procedures should be done via an open technique unless the surgeon has extensive lab experience. This is true even for cases that appear to be straightforward.
Intimate familiarity with instrumentation is critical, and on a first-time basis, an open procedure allows for more accurate recipient and donor site preparation because the surgeon has total perspective of the instrumentation for both the recipient hole and donor harvesting. The instrumentation is relatively large and cannot be seen easily in its entire circumference arthroscopically. This and the fact that extreme flexion angles occasionally are necessary (which close down the anterior capsule) make this arthroscopic procedure technically demanding. Even an experienced arthroscopist may have orientation problems using the transplant equipment for the first time, and this may prove detrimental.
The second critical factor is the size of the lesion. Femoral condyle defects larger than 1.5 cm in diameter or lesions in which more than half of the lesion is posterior to the center of the weightbearing surface should be approached with an open technique. Gaining perspective arthroscopically is more difficult with larger lesions, making it difficult to place multiple transplants accurately enough to recreate proper contour. For lesions posterior to the weightbearing area, the flexion angle needed makes visualization difficult, and the patella may become an obstacle.
Femoral condyle lesions smaller than 1.5 cm2 are thought to be appropriate for an arthroscopic approach when the surgeon has sufficient experience with the procedure. In reality, these are arbitrary lesion measurements, but until more data concerning the efficacy of the procedure are available, this relative lesion size seems to have become commonly accepted.
Intraoperative Details
Open procedure
Following arthroscopy, an arthrotomy is made over the involved area. A medial or lateral anterior sagittal arthrotomy can be used, as well as a transvastus or subvastus approach for lesions on the medial femoral condyle. For defects of the femoral condyles, the incision should be long enough distally to view the lesion with the knee flexed and should extend proximally to view the superior aspect of the trochlea (where donor grafts can be obtained) with the knee in extension. For the patellofemoral joint, the incision should be long enough to rotate the patella 90° on a longitudinal axis.
After identification of the lesion, all cartilage is removed down to the subchondral bone. The edges of the lesion are taken back to areas of well-attached hyaline cartilage. Abrasion of exposed subchondral bone.
Cartilage lesions are debrided sharply back to a circumferentially stable articular cartilage. Abrasion arthroplasty of the exposed subchondral bone is then carried out (see Image 9). This is performed even though the surface will be resurfaced to encourage the interstices between the grafts to form a fibrocartilage grout or seal between the native cartilage and the grafts.
Hangody has shown that at 8 weeks postoperatively, the areas between the cartilage interfaces seal with fibrocartilage that is generated from the abraded subchondral area (see Image 5). The lesion is measured in an attempt to estimate the number and sizes of grafts that will appropriately fill the lesion. An instrument with a known size (generally supplied in the instrumentation) allows for accurate measurement of the lesion (see Image 6). Controversy exists regarding whether larger or smaller grafts should be used. In either case, perpendicular access is critical.
Hangody has shown that at 8 weeks postoperatively, the areas between the cartilage interfaces seal with fibrocartilage that is generated from the abraded subchondral area.
The lesion is measured in an attempt to estimate the number and sizes of grafts that will appropriately fill the lesion. An instrument with a known size (generally supplied in the instrumentation) allows for accurate measurement of the lesion.
The appropriate graft size for a given lesion is an item of current controversy. Some believe that multiple smaller diameter (2.7 mm, 3.5 mm, and 4.5 mm) grafts should be used. Others believe that larger but fewer grafts (>5 mm diameter) should be used. As no data support one opinion over another, the choice appears to be personal. In either case, after sizing the defect, the sizes and number of grafts needed are estimated. The estimate is based on a combination of measurement and experience. Regardless of the choice between large or small grafts, the first grafts obtained and placed are the larger of those chosen. After these are placed, smaller grafts can be used to fine-tune any smaller gaps remaining.
Once the size of the grafts and the number of each size graft are determined, harvesting begins (see Image 7). Typically, harvest sites include the superior trochlear ridge and the intercondylar notch area. Considerable debate exists regarding where the best hyaline cartilage for grafting can be harvested. The periphery of the supracondylar ridge is the most commonly used area, as it has relatively thick hyaline cartilage, is relatively non-weightbearing, and is easily accessible both in an open and arthroscopic technique.
Once the size of the grafts and the number of each size graft are determined, harvesting begins. Typically, harvest sites include the superior trochlear ridge and the intercondylar notch area.
Some reports have suggested use of the medial, rather than lateral, side for fear of earlier and greater patella contact on the lateral side during early flexion. The intercondylar area is useful as well, as it can be approached arthroscopically, although fewer grafts are available due to decreased surface area. Reference to questions regarding quality and shape of the cartilage in this area has been made previously. With perpendicularity again being of utmost importance, appropriate-sized grafts are harvested.
The different commercially available instrumentations have subtle differences, but in the end, cylinders of osteochondral grafts are obtained. The devices used are specially designed tubular chisels, which allow a core of hyaline cartilage, subchondral bone, and cancellous bone to be harvested. Care must be taken to obtain appropriate-length grafts for the defects being addressed. For chondral lesions, grafts generally are 15 mm in length, while for osteochondral defects, slightly longer grafts (20 mm) are needed. Grafts that are too short compromise the surface area of the press fit and are not stable enough. Longer grafts (>20 mm) generally are unnecessary. For the patella, slightly shorter grafts are used owing to its thickness, depending on the facet being resurfaced.
Commercial devices each have a particular way to break or cut the medullary bone base so that the core can be removed. Each has its own recommendations and admonitions for its use. Study this in detail. While inside the harvesting device, the base of the graft is either cut or broken in a controlled manner. Do not spin the extractor to remove the harvester prior to breaking the base, because the graft may become loose in the device, making removal difficult. The grafts are removed from the device by tamping on the cancellous side to avoid damaging the hyaline cartilage.
After the graft is removed, it is inspected for damage. The hyaline cartilage thickness and its appropriate adherence to its subchondral bone are noted. In addition, the angle that the articular cartilage makes with the long axis of the cylinder is examined. Ideally, it should be perpendicular to this axis. The graft is placed in isotonic sodium chloride solution–soaked gauze.
The recipient site now is prepared. The periphery is the best place to start, and attention is directed to the surrounding surfaces, radius of curvature, and donor graft that has been obtained. With this in mind, an appropriate recipient hole is created, so that when filled with the donor graft, it will recreate the surface intended. These holes can be drilled, trephined, or cored, depending on the technique being used. The depth of holes varies. For chondral lesions, about 15 mm is needed, and for osteochondral lesions, 20 mm is necessary. The hole is inspected.
Graft insertion.
Some techniques call for impacting the internal cancellous bone of the created tunnel in order to remove any impediment to placement of the graft. The graft then is tamped gently into the recipient hole (see Image 12). It need not bottom out, as it is a circumferential press that creates stability. Following this, successive grafts are harvested and placed.
Grafting is started at the periphery of the lesion, closest to the major part of the weightbearing area. The sequence of progression is to fill this major weightbearing periphery and work toward the center. As noted above, regardless of the commercial system being used, the larger of the grafts are used primarily, followed by smaller grafts that fill in any gaps left by the larger grafts.
Depending on the number of grafts needed, spacing of the grafts must be planned. The grafts should not lie directly side by side, as stability will be compromised. Approximately 0.5-1 mm of bone is left between each graft. This ensures a solid wall for the press fit. In addition, care must be taken so that convergence does not cause the grafts to hit each other, which will damage the cancellous bone of its base and affect its stability and ability to be fully seated. Occasionally, this cannot be avoided, as the radius of curvature changes too rapidly. If convergence happens at depth, this should not pose a problem.
In short, grafts should be inserted more for their tangence to the articular surface than to avoid deep convergence. Recipient holes generally are drilled 2-3 mm past the length of the individual donor grafts. The sequence of recipient hole creation and recipient hole filling is important, as recipient hole filling affects subsequent holes. Avoid the urge to save time by creating all of the holes first with the thought of filling them later. It is acceptable to obtain multiple donor grafts if the size and numbers needed are adequate. As the defect is filled from the periphery, grafts progress from larger to smaller, enabling fine-tuning of the amount of coverage achieved.
Finally, the surface is examined to ensure that the grafts are at proper depth. At first, it may be prudent to leave the grafts too proud (approximately 1 mm) rather than too deep, as extraction, though possible, can be difficult and risks damaging the grafts. The knee is taken through a final range of motion. Routine closure is done in layers. Use of a drain is optional.
Arthroscopic technique
The arthroscopic approach is technically challenging. Both location and lesion size determine whether the experienced surgeon chooses this route. Again, perpendicular access and portal placement are critical. Generally, portals are slightly more central than usual, as the approach to the main weightbearing areas points more centrally than expected. Following debridement and subchondral abrasion, the lesion is measured for size.
If the working portal being used does not appear to be perpendicular, knee flexion can be altered or a spinal needle can be used to reassess proper portal placement and perpendicular position. Multiple viewing angles are used to be sure that the measuring device is flush on the lesion from edge to edge to accurately gauge its size, to determine the number and size(s) of grafts needed, and to assess the direction that is perpendicular to the surface. This is more difficult arthroscopically, and experience with the open technique is of benefit.
Donor grafts are obtained from either the supracondylar ridge or the intercondylar notch. The medial trochlea is easier to approach when using the scope. As the knee inflates with fluid, the patella naturally moves laterally away from the medial ridge. The lateral side is used for the intercondylar notch. This site is useful when only a few grafts are needed. The supracondylar ridge can be approached using the arthroscopic donor instrumentation via a portal or small open incision. As in the open procedure, care must be taken to ensure that the harvesting device is perpendicular to the articular surface.
Generally, the ipsilateral inferior portal can be used to visualize the harvest sites. When taking multiple transplants arthroscopically, it is important to remember that the previous donor site must be visualized while taking subsequent grafts. If the previous donor site cannot be seen, there is risk of breaking into that site. Therefore, taking grafts in succession is suggested, going away from the visualization portal. In this way, the edge of the donor site can be seen and protected from being broken through.
Graft insertion.
Either a cylindrical chisel or drill creates recipient holes. Care must be taken, as significant changes of curvature radius require marked changes in approach angle of the device creating the recipient hole. Perform multiple visual checks before committing to coring or drilling. With some instrumentation devices, a dilator is used to smooth and compact the recipient canal of cancellous bone. This is helpful in arthroscopic procedures, as irrigation fluid can cause narrowing of the canal secondary to cancellous bone swelling. In addition, debris can find its way into the canal and inhibit graft insertion. The grafts are impacted into place with specialized tamps, and the next recipient hole is created if necessary (see Image 12 ). Wounds are closed in routine fashion, and a compression dressing is placed on the knee.
Postoperative Details
Controversy exists over postoperative protocols for these procedures. Some use fewer and larger grafts and recommend shorter (2- to 3-d) periods of non-weightbearing. For most techniques and surgeons who have performed them, especially for larger lesions, when smaller grafts were used, a more cautious attitude toward weightbearing originally was used (6-8 wk), but the approach has become more aggressive (2-3 wk).
Patients in Hangody's early series were encouraged to remain non-weightbearing for approximately 6-8 weeks to allow for cancellous bone healing. This period is not arbitrary, as excessive compressive pressure may tend to force the transplants into a more recessed position prior to cancellous healing. In his original animal studies with dogs in 1991, Hangody showed early 4-week healing of cancellous bone cylinders. However, when the animals were allowed to bear weight immediately after surgery, approximately one third of the grafts in weightbearing areas showed subsidence. None of the grafts in non-weightbearing areas showed any sign of subsidence. This prompted the suggestion of non-weightbearing for 6-8 weeks in early clinical use.
Since 1994, in the largest series to date, Hangody has revised his suggestions to 2-3 weeks of non-weightbearing, with a slow progression through partial weightbearing on to full weightbearing over the following 2-3 weeks. Larger lesions probably require a more conservative approach postoperatively, as more grafts generally are used to resurface a larger area. There is not enough follow-up information to determine what is needed for each size and depth of lesion. Smaller lesions may need less respite from weightbearing, but this area of discussion is still open to debate.
When surgery is performed on the trochlear groove, retropatellar area, or both, weightbearing is allowed while a knee immobilizer is worn. This decreases the contact pressures at the patellofemoral joint. The immobilizer can be removed for sedentary activity and range-of-motion exercises during the initial 3-week postoperative period, followed by progressive unsupported weightbearing.
Follow-up
For excellent patient education resources, visit eMedicine's Foot, Ankle, Knee, and Hip Center and Breaks, Fractures, and Dislocations Center. Also, see eMedicine's patient education articles Knee Pain and Knee Injury.
Complications
Donor site morbidity remains a concern for osteochondral transplantation. Hangody recognized a 3% complication rate, which included excessive postoperative bleeding (with the larger of his grafts) and donor site pain. In the long term, he has not noted any deleterious effects of graft harvest. Arthroscopic follow-up of the graft sites shows filling of the defects with connective tissue at depth and a fibrocartilage cap at the surface. In these situations, no evidence of degeneration is present at the site of or the opposite side of the joint. Work is underway to develop plugs to fill these defects to reduce the incidence of immediate postoperative bleeding and to further promote filling of the defect.
Another concern is that the various techniques call for harvesting of osteochondral grafts from nonarticular areas. However, it has been demonstrated that these areas are indeed contact and stress bearing.
In a study specifically targeting donor sites, significant contact stresses were recorded from 0-1100 of knee motion. This was done by creating donor site defects by obtaining round osteochondral plugs (8 mm in diameter) from some of the recommended sites. The lateral superior trochlear area above the femoral condyles and medial and lateral intercondylar notch areas were used as areas of harvest. Unfortunately, no data were reported from one of the more favored locations of harvest, the medial femoral condyle periphery of the patellofemoral joint.
No long-term studies demonstrate whether articular contact contributes to degenerative changes at these donor sites. However, data exist confirming increased stress concentration at the rim of weightbearing osteochondral defects in smaller lesions than these. The long-term clinical significance of these findings is unknown. Certainly, utmost care must be taken to ensure that the areas of harvest are remote from major weightbearing areas.
Work currently is underway to assess bone cores and articular surfaces via MRI. This will be helpful, as the techniques learned will be beneficial to improve the diagnosis of cartilage injuries and assess transplants. During this assessment, an interesting observation has been made. Significant metallic debris has been noted at the sites of implantation of osteochondral plugs. Definitive etiology is uncertain. However, some of the devices that use disposable instruments for implantation are thought to possibly be at risk for shedding metallic debris. The decreased tough material of disposable instruments comes into question, as reported cases of outright device failure and collapse of coring devices may represent a more catastrophic failure, with more subtle failure and debris generation going unnoticed at the time of surgery. The significance or long-term problems related to this debris is unknown, but its occurrence must be considered while performing postoperative MRIs.
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Further Reading
Related eMedicine topics
Patellofemoral Arthritis
Patellofemoral Joint Syndromes
Osteoarthritis
Osteonecrosis, Knee
Osteochondritis Dissecans
Total Knee Arthroplasty
Clinical guideline
The use of autologous chondrocyte implantation for the treatment of cartilage defects in knee joints.
Clinical trials
Evaluation of the CR Plug (Allograft) for the Treatment of a Cartilage Injury in the Knee
Comparison of BioCart™II With Microfracture for Treatment of Cartilage Defects of the Femoral Condyle
Reparation of Cartilage Injuries in the Human Knee by Implantation of Fresh Human Allogenic Chondrocytes
Keywords
articular cartilage injury, osteochondral grafts, OATS, osteoarticular transfer surgery, osteochondral pathology, partial-thickness cartilage injuries, full-thickness cartilage injuries, knee injuries, degenerative arthrosis, knee joint arthrosis, articular disorders of the patellofemoral joint, trochlear replacement systems, articular cartilage lesions, osteochondral lesions, hyaline cartilage defects
