surgical management of articular cartilage defects in the knee · 2014-09-05 · an instructional...

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2009;91:1778-1790. J Bone Joint Surg Am.Brian J. Cole, Cecilia Pascual-Garrido and Robert C. Grumet

Surgical Management of Articular Cartilage Defects in the Knee

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InstructionalCourse LecturesThe American Academy of Orthopaedic SurgeonsMARY I. O’CONNOREDITOR, VOL. 59

COMMITTEEMARY I. O’CONNORCHAIRMAN

FREDERICK M. AZARPAUL J. DUWELIUSKENNETH A. EGOLPAUL TORNETTA III

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Printed with permission of the American Academy ofOrthopaedic Surgeons. This article, as well as other lecturespresented at the Academy’s Annual Meeting, will be availablein March 2010 in Instructional Course Lectures, Volume 59.The complete volume can be ordered online at www.aaos.org,or by calling 800-626-6726 (8 A.M.-5 P.M., Central time).

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Surgical Management of ArticularCartilage Defects in the Knee

By Brian J. Cole, MD, MBA, Cecilia Pascual-Garrido, MD, and Robert C. Grumet, MD

An Instructional Course Lecture, American Academy of Orthopaedic Surgeons

Articular cartilage is vulnerable totraumatic injury and subsequent de-generation. These changes are likelyrelated to the limited capacity for car-tilage repair, poor vascular supply, anddeficiency in terms of the ability of anundifferentiated cell population to re-spond to the insult. While the naturalhistory of isolated chondral and osteo-chondral defects is not predictable,clinical experience suggests that, whenleft untreated, these lesions do not healand may progress to symptomatic de-generation of the joint1. Therefore, earlysurgical intervention for symptomaticlesions is often suggested in an effort torestore normal joint congruity andpressure distribution and prevent fur-ther injury. Treatment recommenda-tions are made after an evaluation ofsymptomatic lesions and should betailored to the specifics of each case.

The goals of surgical treatmentare to provide pain relief and improvejoint function, thus allowing patients tocomfortably perform activities of dailyliving and potentially maintain orreturn to higher levels of activity. Mul-tiple algorithms have been described inan effort to simplify the treatment ofcartilage lesions. These are useful tools

with which to organize thoughts. Ingeneral, surgical options can be groupedinto three categories: palliative (arthro-scopic debridement and lavage), repar-ative (marrow stimulation techniques),and restorative (osteochondral graftingand autologous chondrocyte implanta-tion). All of these techniques have beenreported to improve the clinical status ascompared with the preoperative state.Thus, the appropriate treatment for anygiven cartilage lesion is patient-specific.The size and location of the lesion, thephysical demands of the patient, and thetreatment history all are importantpreoperative considerations. In addi-tion, the surgeon must consider whatsubsequent treatment options areavailable if the current treatment fails torelieve the symptoms. A realistic andcomprehensive understanding of thepatient’s goals is critical to any decisionregarding how to treat a symptomaticchondral defect. In keeping with theseprinciples, the treatment algorithmconsists of a graduated surgical plan.The least destructive and least invasivetreatment option necessary to alleviatethe symptoms and restore joint functionis performed first. The more extensivetreatments are reserved for potential

salvage operations later. If the symp-toms persist despite conservative treat-ment, subsequent treatments are notimpeded by previous management.

Decision-MakingWhen treating articular cartilage lesionsin the knee, the surgeon should focus onpatient-specific and defect-specific var-iables and avoid ‘‘linear thinking.’’ Theclinical presentation should correlatewith the underlying pathoanatomy. Forexample, a patient with known classicosteochondritis dissecans of the medialfemoral condyle who reports bilateralanterior knee pain with stair-climbingshould be evaluated initially with apresumptive diagnosis of patellofemoralpain before ascribing the symptoms tothe osteochondritis dissecans lesion.Because the natural history of cartilagelesions is not known and the surgicaltreatments are neither benign nor as-sociated with a predictable outcome(particularly with regard to the preven-tion of arthritis), surgical decision-making must be taken quite seriously.

Understanding and addressing thepatient’s specific concerns and goals arecritical to achieving a successful outcomefrom the patient’s perspective. More spe-

Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a memberof their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

J Bone Joint Surg Am. 2009;91:1778-90

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THE JOURNAL OF BONE & JOINT SURGERY d J B J S .ORG

VOLUME 91-A d NUMBER 7 d JULY 2009SURGICAL MANAGEMENT OF ARTICULAR CART ILAGE

DEFECTS IN THE KNEE

cifically, patients often express concernsabout whether it is safe to remain activedespite symptoms and whether a delay insurgical intervention precludes certaintreatment options because of diseaseprogression. In addition, knowledgeof thespecific marginal improvements that aprocedure should provide gives the pa-tient a reasonable expectation regardingthe outcome. Unfortunately, the lack ofunderstanding of the natural history ofthese defects makes it difficult to advisepatients, and it is best to carry out carefuldiscussions on a case-by-case basis.

Patient age, body mass index,symptom type (weight-bearing pain,non-weight-bearing pain, swelling, me-chanical symptoms, giving-way, andaggravation of symptoms related towalking on level ground as opposed tostair-climbing), occupation and/or

family commitments, risk-aversion(desire to avoid subsequent surgicalprocedures), responsiveness and reha-bilitation after previous surgical treat-ments, and the patient’s specificconcerns related to his or her problemare all important preoperative consid-erations. While chronologic age is oftencited as a relative indication or contra-indication to cartilage repair, it is reallyphysiologic age that determines thepatient’s eligibility for a non-arthroplastysolution. Typically, patients who be-come symptomatic in the fourth or fifthdecade of life have concomitant chon-dral and subchondral disease involvingapposing articular surfaces that pre-cludes a biologic treatment option. Inaddition, the results of partial and totalknee arthroplasty are predictably grati-fying and satisfy most patients, even

those who are relatively young. Finally,one must carefully search for associatedpathological conditions, such as mal-alignment, ligament insufficiency, andconcomitant meniscal deficiency, thatmay contribute to treatment failure andshould be corrected before or during thesurgery to treat the chondral lesion.

Defect-specific variables includedefect location, number, size, depth,and geometry; the condition of the sub-chondral bone and surrounding cartilage;and the degree of containment. Thecondition of the apposing surface, whichis often overlooked, is also an importantvariable. Even minor areas of early de-generation make achieving a satisfactoryclinical outcome challenging. Specificmanagement of each of these defect-specific variables increases the likelihoodof a good clinical outcome.

Fig. 1

Treatment algorithm for focal chondral lesions. Before treatment, it is important to assess thepresence of correctable lesions. Surgical treatment should be considered for trochlear and patellarlesions only after use of rehabilitation programs has failed. The treatment decision is guided by thesize and location of the defect, the patient’s demands, andwhether it is first or second-line treatment.ACL = anterior cruciate ligament, PCL = posterior cruciate ligament, MFX = microfracture, OATS =

osteochondral autograft transplantation, ACI = autologous chondrocyte implantation, OCA = os-teochondral allograft, AMZ = anteromedialization, 11 = best treatment option, and12 = possibleoption depending on patient’s characteristics.

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Treatment AlgorithmMalalignment, ligament insufficiency,and concomitant meniscal deficiencyare assessed and, when necessary, aretreated with a concomitant or stagedosteotomy (high tibial, distal femoral, ortibial tuberosity), ligament reconstruc-tion, and perhaps a meniscal allografttransplantation2. Patellofemoral lesionsare often treated with a simultaneousrealignment procedure such as antero-medialization of the tibial tuberosity.Anteromedialization is more successfulfor lateral patellofemoral lesions thanit is for lesions located along themedial aspect of the patellofemoraljoint3. Medial patellofemoral lesionsare treated with a more verticallyoriented anteromedialization2. Thetreatment algorithm for chondral le-sions is guided by the lesion size andlocation and the patient activity level(Fig. 1).

Primary repair is done for anychondral injury that is amenable tofixation. Any acute osteochondral frag-ment or in situ and unstable osteo-chondritis dissecans lesion is repairedprimarily. It is particularly critical to fixlarge fragments (>1 cm2) from theweight-bearing portion of the femoralcondyles. The basic principles for pri-mary repair include elevation of theunstable fragment, debridement of thefibrous base, microfracture if necessaryto gain access to the subchondral bloodsupply to promote healing, bone-graftingof areas of cystic changes or bone loss,and rigid fixation of the fragment undercompression. Headless-compression-screw fixation, with subsequent screwremoval in younger patients after eightweeks of non-weight-bearing, is oftenused. Continuous passive motion for upto six hours each day is recommended.Because fragments can settle over time,even headless screws can becomeprominent and damage the apposingsurface. In addition, performing asecond-look arthroscopy to evaluate thedefect helps the surgeon to judge thesuccess of the procedure and to provideaccurate advice to the patient.

Patients with lesions that cannotbe repaired primarily may benefit fromanother type of treatment (palliative,

reparative, or regenerative). Marrowstimulation techniques are typically afirst-line treatment. These techniquesare often used for smaller lesions(<2 cm2), or in patients with largerlesions (>3 cm2) and modest physical orphysiologic demand levels. Small lesionsin high-demand patients or those forwhom marrow stimulation has failedcan be treated with one or two 10-mmosteochondral autografts harvestedfrom the lateral femoral trochlea justproximal to the sulcus terminalis.Larger lesions (>2.5 cm2) are typicallymore amenable to osteochondral allo-grafting or autologous chondrocyteimplantation. Autologous chondrocyteimplantation is advised for youngerpatients with shallow lesions, especiallyof the patellofemoral joint. This methoddoes not violate the subchondral boneand minimizes the impact on futuretreatment such as osteochondral allo-graft transplantation. Larger, deeper

lesions with bone loss typically requirean osteochondral allograft.

Treatment is also guided by thelocation of the lesion. For example,osteochondral allografts are used forfemoral condyle lesions because theyallow accurate anatomic reconstruction.Lesions of the patellofemoral joint areoften treated with autologous chondro-cyte implantation because the lesionsare small and the varying anatomicconcavity and convexity make structuralgrafts too difficult to fit in place. The tibiaremains a difficult articular surface totreat. Small tibial lesions that are foundwhen the femoral articular cartilage isbeing restored are commonly treatedwith marrow stimulation techniques.Other options include the utilization ofosteochondral autografts placed in aretrograde manner with use of a cannu-lated reamer system (Arthrex, Naples,Florida). The use of osteochondral allo-grafts with an intact meniscus and

Fig. 2

Microfracture. A: Holes should be created 2 to 3 mmapart, beginning at the periphery of the lesion. Greatcare should be taken to prevent confluence of theholes. B: A surgical awl is used to create the holes.The awl is kept perpendicular to the subchondralplate. C: The defect fills with fibrin clot, which iscontained by the vertical walls of intact cartilagesurrounding the lesion.

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concomitant realignment has been re-ported for the treatment of larger lesionsof the tibial plateau, especially afterfracture and the development of sec-ondary arthritis, with graft survival ratesof up to 65% at fifteen years4.

Surgical OptionsMarrow Stimulation Technique(Microfracture)The microfracture marrow stimulationtechnique is carried out with a surgicalawl to penetrate the subchondral bone.The violation of the subchondral platepromotes bleeding and the local mi-gration of stem cells and other anabolicfactors that support the formation of a‘‘superclot.’’ It is believed that the plu-ripotent nature of these stem cells allowsthe formation of reparative fibrocarti-lage tissue5 (Fig. 2).

Critical to the success of thistechnique is the creation of vertical wallsof stable articular cartilage to create a‘‘well-shouldered’’ lesion. This improvesthe local mechanical environment dur-ing healing by reducing shear andcompression. All unstable cartilage isremoved when the lesion site is pre-pared. The calcified cartilage layer iscarefully debrided, and surgical awls areused to penetrate the subchondral bone(Fig. 3). The holes are placed perpen-dicular to the bone surface, 2 to 3 mmapart, and confluence is avoided. Post-operative rehabilitation is guided bythe location of the lesion, but typicallyit involves up to six weeks of non-weight-bearing and the use of acontinuous-passive-motion machinefor six hours per day. Patients with a

lesion in the patellofemoral joint wear abrace with a flexion stop of 30! to limitpatellofemoral contact; weight-bearingis permitted.

The best outcomes of this tech-nique are seen in younger patients withsmall traumatic lesions6. After two and

five years of follow-up, Knutsen et al.7

found no difference between the out-comes of microfracture and those ofautologous chondrocyte implantationfor femoral condyle lesions, but patientswith smaller lesions treated with mi-crofracture did better than those with

Fig. 4

Osteochondral autograft trans-plantation. A and B: Depending onthe defect size, one or multipleosteochondral plugs can be usedto fill the defect. The plugs are of-ten harvested from the intercon-dylar notch or from the margins ofthe lateral or medial condylesabove the sulcus terminalis. C:This sagittal section shows howthe osteochondral graft should beplaced in order to fill the defect.

Fig. 3

Microfracture. A: A chondral lesion in the femoral condyle.B: The lesion was carefully debrided, with the surgeonmaking sure that it had stablevertical borders. C: Microfracture holes were created in the subchondral bone, allowing a fibrin clot to fill the defect.

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larger lesions. Similarly, Gudas et al.observed that, among patients withlesions exceeding 2 cm2 in the centralpart of the medial femoral condyle,those treated with microfracture hadlower clinical outcome scores than didthose treated with an osteochondralautograft transplantation (Table I)8.Location also plays a role in the successof marrow stimulation techniques,with better results seen after the treat-ment of femoral condyle lesions9.

Osteochondral AutograftTransplantationOsteochondral autograft transplanta-tion is the transfer of one or more

cylindrical osteochondral autograftsinto the cartilage defect, providing acongruent hyaline-cartilage-coveredsurface (Fig. 4). The autografts areharvested from the non-weight-bearingperiphery of the femoral trochlea orthe margin of the intercondylar notch.With a combination of different graftsizes, 90% to 100% of the defect canbe filled10. This technique is limited bythe amount of donor tissue available inthe knee, and donor site morbidityincreases as more tissue is harvested.Osteochondral autograft transplanta-tion is best for small lesions (<2 cm2),but good clinical results have beenreported11 with lesions between 2 and

4 cm2. The use of ‘‘mega’’ osteochon-dral autograft transplants (‘‘mega-OATS’’) from the posterior part of thefemoral condyle for large osteochon-dral lesions (>4 cm2) has had goodclinical results at 5.5 yearspostoperatively12.

Osteochondral autograft trans-plantation can be done through a smallarthrotomy or entirely arthroscopically.To harvest donor grafts perpendicular tothe surface,we prefer to obtain the donorplugs through a small lateral arthrotomybecause the lateral edge of the patella caninterfere with an arthroscopic harvest.The plugs are then implanted arthro-scopically. There are many available

Fig. 5

Osteochondral autograft transplantation. A: Identification of the lesion on the medial femoral condyle. B: A sizer is used to determine the number and sizeof the autografts. In this case, the lesion measured 8mm in diameter. C: An 8-mm plug was harvested. D: The donor-plug position should be flush with thesurrounding articular cartilage.

TABLE I Demographic Data and Outcomes in Studies Comparing Microfracture with Other Cartilage Restoration Procedures !

Author(s) Group 1 Group 2No. ofPatients

MeanAge (yr)

MeanLesion

Size (cm2)LesionLocation

Saris et al.25 Autolog.chondrocyteimplant.

Microfract. 118 33.9 Range, 2.4-2.6 Med. and lat.fem. condyles

Knutsen et al.7 Autolog.chondrocyteimplant.

Microfract. 80 Notreported

Notreported

89% med. fem.condyle; 11% lat.fem. condyle

Gudas et al.8 Osteochondralautografttransplant.

Microfract. 60 24.3 2.8 84% med. fem.condyle, 16% lat.fem. condyle

Knutsen et al.26 Autolog.chondrocyteimplant.

Microfract. 80 32.2 4.8 89% med. fem.condyle; 11% lat.fem. condyle

*HSS = Hospital for Special Surgery, and SF-36 = Short Form-36.

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commercial systems that provide a seriesof donor and recipient harvesting tubesto create a press-fit implant of up to10mm indiameter. A sizing guide is usedto determine the number and size ofgrafts that are needed. A properly sizedgraft harvester with a collared pin isintroduced perpendicular to the donorsite (Fig. 5) to a depth of approximately12 to 15 mm. The recipient socket iscreated to a depth that is 2 mm less thanthe length of the donor graft. It isimportant to maintain a perpendicularrelationship between the donor graftand the articular surface to create well-defined vertical walls in the recipientsocket, as this facilitates congruent plugplacement (Fig. 5, C). The donor plugis placed over the recipient site andgently advanced into the defect, where itis often left slightly proud. The chon-drocytes can be damaged during im-paction; therefore, it is critical to avoidhigh loads when inserting the graft13.The final plug position should be flushwith the surrounding articular cartilage(Fig. 5, D). Postoperatively, patientsare protected from weight-bearing forsix weeks and use a continuous-passive-motion machine six hours per day.

Hangody and Karpati14 evaluatedthe survival of the transplanted hyalinecartilage. The graft undergoes osseous

incorporation to the subchondral bonewhile the transplanted cartilage inte-grates with the adjacent host articularcartilage with fibrocartilage. Recently,Hangody et al.11 evaluated clinicaloutcomes at a mean of fourteen yearsafter 1097 osteochondral autografttransplantation procedures. Encourag-ing results in this large multicenterseries support the use of this techniquefor the treatment of small and mediumfocal chondral and osteochondral de-fects of the knee. The osteochondralautograft transplantation procedurehas been compared with other cartilagerestoration procedures (Table II).

Osteochondral AllograftTransplantationOsteochondral allograft transplantationprovides an option for treatment oflarger lesions (>2.5 cm2) or those withsubstantial bone loss. It is normally asecond-line treatment option, but canbe a first-line treatment for high-demand patients with large lesions.

Osteochondral allograft trans-plantation can be used to resurfacelarge, deep defects with mature hyalinearticular cartilage while also filling anyunderlying osseous defect. Tissuematching and immunosuppressionare not necessary because the trans-

planted chondrocytes are isolated bythe cartilage matrix and not exposed tothe host immune surveillance15. Theallografts can be ‘‘fresh’’ or frozen.Fresh grafts are normally maintainedat 4!C in standard or enriched culturemedium for no more than twenty-eightdays, which allows chondrocytes tosurvive after transplantation. Frozenallografts are maintained at 240!Cfor years. The fresh allografts elicit aminimal immune response, the chon-drocytes survive, and the bone is suc-cessfully revascularized16-18.

Allograft transplantation can bedone arthroscopically; however, it ismore often performed through a smallarthrotomy. The allograft is slowlywarmed from 4!C to 37!C by placingit in normal saline solution at roomtemperature. The slow warming min-imizes damage to the graft19. The lesionis sized with a template, and a corre-spondingly sized reamer is used toconvert the defect to a circular recip-ient socket with a uniform depth of 6 to8 mm (Fig. 6). This bone depth facil-itates graft implantation and limits theamount of immunogenic donor bonethat is implanted. A sterile marking penis used to mark the 12 o’clock positionof the lesion to orient the donor plugappropriately. An instrumentation

TABLE I (continued)

MeanDuration ofFollow-up

ClinicalOutcome*

HistologicalFindings

AdditionalFindings*

18 mo Improvement in bothgroups; no significantdifference

Better structural repair inautolog. chondrocyteimplant. group

5 yr 77% good clinicalresults in both groups;no significant difference

No significant difference Younger patients did betterin both groups

3 yr HSS score significantlysuperior in osteochondralautograft transplant.group (p < 0.01)

100% hyaline cartilage inosteochondral autografttransplant. group; 57%fibrocartilage, 43% fibroelastictissue in microfract. group

Patients <30 yr old had betterclinical scores; HSS scores betterfor traumatic lesions thanosteochondritis dissecanslesions; HSS scores lowerfor lesions of >2 cm2 inmicrofract. group

2 yr SF-36 score significantlysuperior in microfract.group

No significant difference inthe percent of fibrocartilagetissue

Patients <30 yr old had betteroutcomes; SF-36 scores higherfor esions of <4 cm2 inmicrofract. group

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system is used to size and harvest acylindrical plug from the allograft (Fig.7). The donor graft is drilled through itsentire depth with a harvester underirrigation with normal saline solution.

The graft is extracted, and a ruler is usedto measure and mark the four quadrantsof the graft at the depth of the previouslymeasured recipient sites. Before inser-tion, pulsatile lavage (approximately 2 L)

is used to remove the residual blood andbone-marrow elements from the allo-graft to reduce the risk of disease trans-mission and graft immunogenicity. Thegraft is then press-fit into the socket by

Fig. 6

Osteochondral allograft transplantation. A: The procedure is typically performed through a small arthrotomy to expose the lesion.B: A reamer is used to convert the defect to a circular recipient socket with a uniform depth of 6 to 8 mm.

TABLE II Demographic Data and Outcomes in Studies of Osteochondral Autograft Transplantation !

Author(s) Group 1Group 2

(or 2 and 3)No. ofPatients

MeanAge (yr)

Mean LesionSize (cm2) Lesion Location

Hangody et al.11 Osteochondralautografttransplant.

— 1097 36 Not reported 798 fem. condyle,147 patellofemoral,31 tibia, 98 talus,8 capitellum, 3 hum.head, 11 fem. head

Marcacci et al.27 Osteochondralautografttransplant.

— 30 29.3 <2.5 Med. and lat. fem.condyles

Gobbi et al.6 Osteochondralautografttransplant.

Microfract.;chondroplasty

32 Osteochondralautografttransplant.: 27;microfract.: 24;chondroplasty: 32

Osteochondralautografttransplant.: 4;microfract.: 4.5;chondroplasty: 3.7

Talus

Dozin et al.28 Debrid. thenautolog.chondrocyteimplant.

Debrid. thenosteochondralautografttransplant.

47 Autolog.chondrocyteimplant.: 29;osteochondralautografttransplant.: 27

Autolog.chondrocyteimplant.: 1.97;osteochondralautografttransplant.: 1.88

Autolog. chondrocyteimplant.: 73% fem.condyle, 27% patella;osteochondral autografttransplant.: 68% fem.condyle; 32% patella

Bentley et al.29 Osteochondralautografttransplant.

Autolog.chondrocyteimplant.

100 31.3 4.66 53% med. fem. condyle;18% lat. fem. condyle;25% patella; 3% trochlea;1% tibial plateau

*HSS = Hospital for Special Surgery.

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hand after careful alignment of the fourquadrants to the recipient site (Fig. 8). Ifthe implanted allograft is particularlylarge, fixation may be augmented withbioabsorbable or metal compressionscrews.

Postoperatively, weight-bearingis limited to toe-touch for the first sixweeks. Patients with a patellofemoralgraft are allowed to bear weight astolerated in extension and generallyare limited to 45! of flexion during thefirst four weeks. Continuous passivemotion is used immediately after thesurgery. A return to normal activitiesof daily living and light sports activityis considered at eight to twelvemonths.

Subjective improvement can beexpected in 75% to 85% of patients afterosteochondral allograft implantationfor properly selected chondral lesions4,20

(Table III).

Autologous Chondrocyte ImplantationAutologous chondrocyte implantationis ideal for symptomatic, unipolar, well-contained chondral or osteochondraldefects measuring between 2 and 10 cm2

with bone loss of less than 6 to 8 mm.It is typically a second-line treatmentafter at least arthroscopic debridementhas been performed.

The first stage of autologouschondrocyte implantation is an arthro-scopic evaluation of the size and depthof the focal chondral lesion and acartilage biopsy. The total volume of thebiopsied material should be approxi-mately 200 to 300 mg. The second stageis implantation of the cells. This is doneusually no sooner than six weeks afterthe biopsy. At the time of implantation,the defect is prepared by removingany existing fibrocartilage down tothe underlying calcified layer. Verticalwalls are created at the periphery of the

lesion with use of a combination of anumber-15 blade and sharp ring curets.After debridement, the tourniquet, ifused, should be deflated, and completehemostasis should be obtained. Theuse of cotton pledgets soaked withepinephrine may help to obtain hemo-stasis (Fig. 9).

Next, a periosteal patch is har-vested from the proximal-medial partof the tibia, just distal to the pesanserinus insertion, through a separateincision. The patch should be at least2 mm larger than the defect. Thepatch edges are detached with anumber-15 scalpel blade and elevatedwith a sharp, curved periosteal elevator,beginning distally. Synthetic collagen-membrane substitutes are commer-cially available (Chondro-Gide;Geistlich Biomaterials, Wolhusen,Switzerland) and can be used as asubstitute for the periosteal patch. The

TABLE II (continued)

MeanDuration ofFollow-up Clinical Outcome* Histological Findings

AdditionalFindings*

14 yr Rate of good-to-exc.results: 92% for fem.condylar implant., 87%for tibial resurfacings,74% for patellar and/ortrochlear mosaicplasties,93% for talar proc.

Graft survival in81 of 98

Comorbidities shouldbe assessed; postop.bleeding from donorsite—prevention withdonor site biodegradableplugs

Range, 2-7 yr 77% good clinical results Not performed MRI showed goodintegration and survivalof graft in 60%

54 mo No clinical differenceamong 3 treatmentgroups

Not performed Results of microfract.and osteochondralautograft transplant.better for smalllesions

Complete recovery in88% of mosaicplasty groupand 68% of autolog.chondrocyte implant.group (p = 0.093)

Not performed 14 patients improvedsignificantly with debrid.

19 mo Modified Cincinnati score>55 for 88% of autolog.chondrocyte implant.group and 74% ofosteochondral autografttransplant. group

74% with hyaline-like orfibrocartilage tissueinautolog. chondrocyteimplant. group; notreported for osteochondralautograft transplant.

Technique documentedplacing plugs slightlyprominently

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use of these scaffolds not only reducesoperating time but also has been shownto avoid typical problems related to theperiosteum21.

The patch or scaffold is thensewn to the cartilage. When perios-teum is used, the cambium layer isplaced toward the lesion. With the

Chondro-Gide scaffold, the poroussurface should be placed toward thelesion with the smooth side facing out.Sutures (6-0 Vicryl [polyglactin]) are

Fig. 7

Osteochondral allograft transplantation.A: Fresh donor femoral condyle.B: The condyle is trimmed to create a flat surface toplace on the workstation. This cut is made parallel to the potential harvest site. C:Condyle securely fixed to the workstation.D: Graft template placed on the condyle to match the bottom of the recipient site.

Fig. 8

Osteochondral allograft transplantation. A: After removal of the plug, depth-measurement markings are made on the graft to match the measurements ofthe recipient socket in four quadrants. B:Matching of the donor plug. The depth of bone should be limited to 8 to 10mm to facilitate graft implantation andlimit the amount of immunogenic donor bone that is implanted. C: The graft is press-fit into the socket by hand after careful alignment of the four quadrantsto the recipient site. The graft is flush with the recipient articular surface.

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TABLE III Demographic Data and Outcomes in Studies of Osteochondral Allograft Transplantation

Author(s)

Type ofOsteochondral

Allograft

MeanAge(yr)

Type ofStudy

No. ofPatients

LesionLocation

MeanDuration ofFollow-up Outcome*

AdditionalFindings

Grosset al.30

Failedfresh

47 Histological 69 Knee(exactlocationnotspecified)

<1, 2-5,>5 yr

Cartilage:viablechondrocytes,normal matrixand structurein middle anddeep layers.Bone:creepingsubstitution

Davidsonet al.31

Fresh 32 Clinical,histological,MRI

8 (10knees)

6 med.fem.condyle,2 trochlea,2 med.fem.condyleandtrochlea

40 mo Clinical:improvementsin SF-36, IKDC,Tegner, Lysholmscores(p < 0.05).Histological:cellular densityand viabilitysimilar in hostand donorcartilage. MRI:improvementin Outerbridgescore

Prevention ofshort-termdegenerativechanges

McCullochet al.32

Fresh 35 Clinical,radiographic

25 Fem.condyle

3 yr Clinical:improvementsin Lysholm,IKDC, KOOS,SF-12 scores(p < 0.05); 84%of patientssatisfied.Radiographic:88% had graftincorporation

Patients withuncorrectedmalalignmentdid worse;clinicalresultsdid notdeterioratewithincreasingage of graft

Jamaliet al.33

Freshpatellofem.

28 Clinical,radiographic

18 Patellofem. 94 mo Clinical: 5failures;good resultsin 60%.Radiographic:no signs ofpatellofemoralarthrosis in 10of 12

Nopatellofemoralbonealignmentproc.performed

Grosset al.4

Fresh 27 Clinicaloutcome

60 30 med.fem.condyle;30 lat.fem.condyle

10 yr Survival: 95%at 5 yr,85% at 10 yr,65% at 15 yr

Comorbiditiesshouldbe assessedand correctedin sameprocedure

*IKDC = International Knee Documentation Committee, KOOS = Knee Injury and Osteoarthritis Outcome Score, and SF-12 = Short Form-12.

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first passed into the patch approxi-mately 2 mm from the edge and thenpassed through the cartilage at a depthof 2 to 3 mm below the cartilagesurface. Sutures should be placed ap-proximately 4 mm apart, and a gapshould be maintained in the upperedge to allow chondrocyte implanta-tion (Fig. 10). The edges of the patchare sealed with fibrin glue, and a water-

tightness test is performed with an 18-gauge angiocatheter. The chondrocytesare then delivered through the openingwith use of an angiocatheter. After thecells have been implanted, the openinggap is closed with suture and fibringlue (Fig. 9, C).

Postoperatively, patients with afemoral condyle lesion are kept non-weight-bearing and use a continuous-

passive-motion machine. Patients witha patellofemoral lesion are permittedfull weight-bearing with the knee inextension. Continuous passive motionfor six to eight hours per day at onecycle per minute is used for six weeksafter the surgery. A return to normalactivities of daily living and sportsactivities is allowed six months afterthe surgery.

Fig. 9

Autologous chondrocyte implantation. A: A chondral lesion in the patella. B: Preparation of the defect. C: After the chondrocytes are delivered, the gap isclosed with suture and fibrin glue.

TABLE IV Demographic Data and Clinical Outcomes in Studies of Autologous Chondrocyte Implantation !

Author(s) No. of Patients Mean Age (yr) Mean Lesion Size (cm2)

Zaslav et al.34 126 with autologouschondrocyte implant. afterother failed cartilage proc.(multicenter study)

34.5 4.63

Rosenberger et al.35 56; 50% withconcomitantosteotomies

48.6 (range,45-60); all >45

4.7 (range, 1-15.0)

Mandelbaum et al.36 40 Range, 16-48 4.5

Kreuz et al.37 118 with isolatedchondral lesion

35 (range, 18-50)

Knutsen et al.7 40 with autologouschondrocyte implant.,40 with microfract.

Steinwachs and Kreuz38 63 34

*VAS = visual analog scale, SF-36 = Short Form-36, and ICRS = International Cartilage Repair Society.

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It is estimated that autologouschondrocyte implantation has beenperformed in >10,000 patients world-wide. The procedure has better resultswhen it is done for lesions in thefemoral condyle or in patients witha patellofemoral lesion who are under-going a concomitant realignment pro-cedure22-24. There have been severalstudies comparing autologous chon-drocyte implantation with otherbiologic reconstructive procedures(Table IV).

OverviewArticular cartilage defects of the kneeare common. Treatment options rangefrom palliative (debridement) to repar-ative (marrow stimulation) to restora-tive (osteochondral grafting andautologous chondrocyte implantation).All of these techniques improve theclinical status compared with the pre-operative state. Decision-making isdone case by case and is guided by thepatient’s physical and physiologic de-mand level, previous failed treatment,and the location and size of the defect.

It is critical that the surgeon alsoconsider what subsequent treatmentoptions might be necessary should thefirst-line treatment fail to relieve thesymptoms.

Brian J. Cole, MD, MBACecilia Pascual-Garrido, MDRobert C. Grumet, MDDepartments of Orthopedic Surgery (B.J.C.,C.P.-G., and R.C.G.) and Anatomy and CellBiology (B.J.C.), Rush University MedicalCenter, 1725 West Harrison Street,Suite 1063, Chicago, IL 60612.E-mail address for B.J. Cole:[email protected] address for C. Pascual-Garrido:[email protected] address for R.C. Grumet:[email protected]

Printed with permission of the AmericanAcademy of Orthopaedic Surgeons. This article,as well as other lectures presented at theAcademy’s Annual Meeting, will be available inMarch 2010 in Instructional Course Lectures,Volume 59. The complete volume can beordered online at www.aaos.org, or by calling800-626-6726 (8 A.M.-5 P.M., Central time).

Fig. 10

Autologous chondrocyte implantation. A:Injection of the chondrocytes under theupper edge of the patch. The cells shouldbe injected slowly. B: A periosteal patchwith the cambium layer facing down intothe defect is carefully sutured onto thetop of the defect. Chondrocytes are in-jected into the contained defect.

Lesion Location Mean Duration of Follow-up Outcome*

102 (67%) med. fem.condyle; 27 (18%) lat.fem. condyle; 24(16%) trochlea

48 mo 76% were treatment successes; no difference between results ofmarrow stimulating proc. and debrid. at prim. op.; mean improvementsin Cincinnati, VAS, and SF-36 scores from baseline to all time points(p < 0.001)

4.7 yr (range, 2-11) 8 failures (14%); additional arthroscopic proc. required in 24 patients(43%) for periosteal-related problems and adhesions; 88% of thesepatients had lasting improvement, 78% felt improved, and 81% wouldagain choose autologous chondrocyte implant. as a treatment option

Trochlea 59 ± 18 mo Significant improvement in Cincinnati score, overall condition(3.1 points preop. to 6.4 points postop.), pain (2.6 to 6.2 points),swelling (3.9 to 6.3 points); no failed implant

78 fem. condyle;17 trochlea;23 patella

Clinical andMRI eval. at6, 18, and 36 mo

Patients with regular (1-3 times/wk) or competitive (4-7 times/wk)sports involvement had significantly better ICRS and Cincinnati scoresthan patients with no or rare sports involvement (p < 0.01); correlationbetween sports activity levels and clinical scores significant(increasing from 6 to 18 mo, 18 to 36 mo postop.)

89% med. fem.condyle; 11% lat.fem. condyle

2 yr 77% good clinical results in both groups; no significant differencebetween groups; younger patients did better in each group

Fem. condyle,trochlea, patella

6, 18, and 36 mo Evaluation of autologous chondrocyte implant. with type I/III collagenmembrane; significant improvement in ICRS and modified Cincinnatiscores (p < 0.01); graft hypertrophy can be avoided by using a collagenmembrane

TABLE IV (continued)

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References

1. Maletius W, Messner K. The effect of partialmeniscectomy on the long-term prognosis of kneeswith localized, severe chondral damage. A twelve-to-fifteen-year followup. Am J Sports Med. 1996;24:258-62.

2. Rue JP, Yanke AB, Busam ML, McNickle AG, ColeBJ. Prospective evaluation of concurrent meniscustransplantation and articular cartilage repair: minimum2-year follow-up. Am J Sports Med. 2008;36:1770-8.

3. Farr J. Autologous chondrocyte implantation im-proves patellofemoral cartilage treatment outcomes.Clin Orthop Relat Res. 2007;463:187-94.

4. Gross AE, Shasha N, Aubin P. Long-term followupof the use of fresh osteochondral allografts forposttraumatic knee defects. Clin Orthop Relat Res.2005;435:79-87.

5. Shapiro F, Koide S, Glimcher MJ. Cell origin anddifferentiation in the repair of full-thickness defectsof articular cartilage. J Bone Joint Surg Am. 1993;75:532-53.

6. Gobbi A, Francisco RA, Lubowitz JH, Allegra F,Canata G. Osteochondral lesions of the talus:randomized controlled trial comparing chondroplasty,microfracture, and osteochondral autograft trans-plantation. Arthroscopy. 2006;22:1085-92. Erratumin: Arthroscopy. 2008;24:247.

7. Knutsen G, Drogset JO, Engebretsen L, GrøntvedtT, Isaksen V, Ludvigsen TC, Roberts S, Solheim E,Strand T, Johansen O. A randomized trial comparingautologous chondrocyte implantation with microfrac-ture. Findings at five years. J Bone Joint Surg Am.2007;89:2105-12.

8. Gudas R, Kalesinskas RJ, Kimtys V, StankeviciusE, Toliusis V, Bernotavicius G, Smailys A. A pro-spective randomized clinical study of mosaic osteo-chondral autologous transplantation versusmicrofracture for the treatment of osteochondraldefects in the knee joint in young athletes. Arthros-copy. 2005;21:1066-75.

9. Kreuz PC, Steinwachs MR, Erggelet C, Krause SJ,Konrad G, Uhl M, Sudkamp N. Results after micro-fracture of full-thickness chondral defects in differentcompartments in the knee. Osteoarthritis Cartilage.2006;14:1119-25.

10. Hangody L, Rathonyi GK, Duska Z, Vasarhelyi G,Fules P, Modis L. Autologous osteochondral mo-saicplasty. Surgical technique. J Bone Joint Surg Am.2004;86 Suppl 1:65-72.

11. Hangody L, Vasarhelyi G, Hangody LR, Sukosd Z,Tibay G, Bartha L, Bodo G. Autologous osteochondralgrafting—technique and long-term results. Injury.2008;39(Suppl 1):S32-9.

12. Braun S, Minzlaff P, Hollweck R, Wortler K,Imhoff AB. The 5.5-year results of MegaOATS—autologous transfer of the posterior femoral condyle:a case-series study. Arthritis Res Ther. 2008;10:R68.

13. Pylawka TK, Wimmer M, Cole BJ, Virdi AS,Williams JM. Impaction affects cell viability inosteochondral tissues during transplantation. J KneeSurg. 2007;20:105-10.

14. Hangody L, Karpati Z. [New possibilities in themanagement of severe circumscribed cartilage dam-age in the knee]. Magy Traumatol Ortop KezsebPlasztikai Seb. 1994;37:237-43. Review. Hungarian.

15. Czitrom AA, Keating S, Gross AE. The viability ofarticular cartilage in fresh osteochondral allograftsafter clinical transplantation. J Bone Joint Surg Am.1990;72:574-81.

16. Acosta CA, Izal I, Ripalda P, Forriol F. Cellviability and protein composition in cryopreservedcartilage. Clin Orthop Relat Res. 2007;460:234-9.

17. Williams JM, Virdi AS, Pylawka TK, Edwards RB3rd, Markel MD, Cole BJ. Prolonged-fresh preserva-tion of intact whole canine femoral condyles for thepotential use as osteochondral allografts. J OrthopRes. 2005;23:831-7.

18. Pearsall AW 4th, Tucker JA, Hester RB, HeitmanRJ. Chondrocyte viability in refrigerated osteochon-dral allografts used for transplantation within theknee. Am J Sports Med. 2004;32:125-31.

19. Pylawka TK, Virdi AS, Cole BJ, Williams JM.Reversal of suppressed metabolism in prolongedcold preserved cartilage. J Orthop Res.2008;26:247-54.

20. Muscolo DL, Ayerza MA, Aponte-Tinao LA, AbaloE, Farfalli G. Unicondylar osteoarticular allografts ofthe knee. J Bone Joint Surg Am. 2007;89:2137-42.

21. Haddo O, Mahroof S, Higgs D, David L, Pringle J,Bayliss M, Cannon SR, Briggs TW. The use ofChondrogide membrane in autologous chondrocyteimplantation. Knee. 2004;11:51-5.

22. Brittberg M, Lindahl A, Nilsson A, Ohlsson C,Isaksson O, Peterson L. Treatment of deep cartilagedefects in the knee with autologous chondrocytetransplantation. N Engl J Med. 1994;331:889-95.

23. Peterson L, Minas T, Brittberg M, Nilsson A,Sjogren-Jansson E, Lindahl A. Two- to 9-year outcomeafter autologous chondrocyte transplantation of theknee. Clin Orthop Relat Res. 2000;374:212-34.

24. Peterson L, Brittberg M, Kiviranta I, Akerlund EL,Lindahl A. Autologous chondrocyte transplantation.Biomechanics and long-term durability. Am J SportsMed. 2002;30:2-12.

25. Saris DB, Vanlauwe J, Victor J, Haspl M,Bohnsack M, Fortems Y, Vandekerckhove B, AlmqvistKF, Claes T, Handelberg F, Lagae K, van derBauwhede J, Vandenneucker H, Yang KG, Jelic M,Verdonk R, Veulemans N, Bellemans J, Luyten FP.Characterized chondrocyte implantation results inbetter structural repair when treating symptomaticcartilage defects of the knee in a randomizedcontrolled trial versus microfracture. Am J SportsMed. 2008;36:235-46.

26. Knutsen G, Engebretsen L, Ludvigsen TC,Drogset JO, Grøntvedt T, Solheim E, Strand T,Roberts S, Isaksen V, Johansen O. Autologouschondrocyte implantation compared with microfrac-ture in the knee. A randomized trial. J Bone Joint SurgAm. 2004;86:455-64.

27. Marcacci M, Kon E, Delcogliano M, Filardo G,Busacca M, Zaffagnini S. Arthroscopic autologousosteochondral grafting for cartilage defects of the

knee: prospective study results at a minimum 7-yearfollow-up. Am J Sports Med. 2007;35:2014-21.

28. Dozin B, Malpeli M, Cancedda R, Bruzzi P,Calcagno S, Molfetta L, Priano F, Kon E, Marcacci M.Comparative evaluation of autologous chondrocyteimplantation and mosaicplasty: a multicentered ran-domized clinical trial. Clin J Sport Med. 2005;15:220-6.

29. Bentley G, Biant LC, Carrington RW, Akmal M,Goldberg A, Williams AM, Skinner JA, Pringle J. Aprospective, randomised comparison of autologouschondrocyte implantation versus mosaicplasty forosteochondral defects in the knee. J Bone Joint SurgBr. 2003;85:223-30.

30. Gross AE, Kim W, Las Heras F, Backstein D,Safir O, Pritzker KP. Fresh osteochondral allograftsfor posttraumatic knee defects: long-term followup.Clin Orthop Relat Res. 2008;466:1863-70.

31. Davidson PA, Rivenburgh DW, Dawson PE, RozinR. Clinical, histologic, and radiographic outcomesof distal femoral resurfacing with hypothermicallystored osteoarticular allografts. Am J Sports Med.2007;35:1082-90.

32. McCulloch PC, Kang RW, Sobhy MH, Hayden JK,Cole BJ. Prospective evaluation of prolonged freshosteochondral allograft transplantation of the femo-ral condyle: minimum 2-year follow-up. Am J SportsMed. 2007;35:411-20.

33. Jamali AA, Emmerson BC, Chung C, Convery FR,Bugbee WD. Fresh osteochondral allografts: resultsin the patellofemoral joint. Clin Orthop Relat Res.2005;437:176-85.

34. Zaslav K, Cole B, Brewster R, DeBerardino T,Farr J, Fowler P, Nissen C; STAR Study PrincipalInvestigators. A prospective study of autologouschondrocyte implantation in patients with failed priortreatment for articular cartilage defect of the knee:results of the Study of the Treatment of ArticularRepair (STAR) clinical trial. Am J Sports Med.2009;37:42-55.

35. Rosenberger RE, Gomoll AH, Bryant T, Minas T.Repair of large chondral defects of the knee withautologous chondrocyte implantation in patients 45years or older. Am J Sports Med. 2008;36:2336-44.

36. Mandelbaum B, Browne JE, Fu F, Micheli LJ,Moseley JB Jr, Erggelet C, Anderson AF. Treatmentoutcomes of autologous chondrocyte implantation forfull-thickness articular cartilage defects of the troch-lea. Am J Sports Med. 2007;35:915-21.

37. Kreuz PC, Steinwachs M, Erggelet C, Lahm A,Krause S, Ossendorf C, Meier D, Ghanem N, Uhl M.Importance of sports in cartilage regeneration afterautologous chondrocyte implantation: a prospectivestudy with a 3-year follow-up. Am J Sports Med.2007;35:1261-8.

38. Steinwachs M, Kreuz PC. Autologous chondro-cyte implantation in chondral defects of the kneewith a type I/III collagen membrane: a prospectivestudy with a 3-year follow-up. Arthroscopy.2007;23:381-7.

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