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Mosaicplasty Technique in the Treatment of Isolated Knee Femoral Condyle Osteochondral Lesions - a Retrospective Study* * The present study was conducted at the Orthopedic Department, Hospital Vila Franca de Xira, Portugal.

Abstract

Objective

Focal osteochondral lesions of the knee are found in two thirds of patients undergoing arthroscopy; their treatment, when isolated and especially in young individuals, remains a debating topic. The present study analyzes the results obtained by the application of the mosaicplasty technique on the treatment of isolated knee femoral condyle osteochondral lesions.

Methods

Retrospective study of patients submitted tomosaicplasty and to subjective analyseswith pre- and postsurgery International KneeDocumentation Committee (IKDC) scores.

Results

A total of 13 cases with an average age of 34 years old, with male patients (n = 4; 31%) with an average age of 23 years old (range: 17-31 years old), and female patients (n = 9; 69%) with an average age of 39 years old (range: 16-56 years old); medial versus lateral femoral (n = 11; 85% versus n = 2; 15%); the average size of the lesion was 1.8 cm2 (range: 0.6-4 cm2); average follow-up time: 5.045 ± 3.47 years (range: 1.15-11.01 years). The average preoperative IKDC score was of 31.63 points (± 20.24), the average postoperative IKDC score was of 74.18 points (± 20.26). The difference between the post- and preoperative IKDC scores was of 42.55 (± 21.05) points, being theminimal score increase of 8.1 points andthemaximumscore increaseof82.8 points.Astatistically significant difference (p < 0.001) was found between the IKDC scores before and after the surgery. A statistically significant relation (p = 0.038) was found between the IKDC score increase (the difference between the postoperative and the preoperative scores) and the dimension of the lesion.

Conclusions

Mosaicplasty with osteochondral autograft transfer, when adequately used, can produce excellent results with great durability and functional impact, low morbidity rates and costs. Expansion of the indication criteria shows promising midterm and long-term results.

Keywords:
osteochondritis/ diagnosis; osteochondritis/ surgery; arthroscopy; knee joint; cartilage, articular

Resumo

Objetivo

Lesões osteocondrais focais do joelho são encontradas em dois terços dos pacientes submetidos a artroscopia; seu tratamento, quando isoladas e, principalmente, em indivíduos jovens, ainda é debatido. O presente estudo analisa os resultados obtidos com a aplicação da técnica de mosaicoplastia no tratamento de lesões osteocondrais isoladas do côndilo femoral do joelho.

Métodos

Estudo retrospectivo de pacientes submetidos à mosaicoplastia e análise subjetiva com pontuações do International Knee Documentation Committee (IKDC, na sigla em inglês) antes e após a cirurgia.

Resultados

Um total de 13 casos, com média de idade de 34 anos; pacientes do sexo masculino (n = 4; 31%) apresentaram média de idade de 23 anos (17-31 anos), e pacientes do sexo feminino (n = 9; 69%) apresentaram média de 39 anos; (16-56 anos); femoral medial ou lateral (n = 11, 85% versus n = 2, 15%, respectivamente); o tamanho médio da lesão foi de 1,8 cm2 (0,6-4 cm); o tempo médio de acompanhamento foi de 5,045 ± 3,47 anos (1,15-11,01 anos). A pontuação IKDC média préoperatória foi 31,63 pontos ( ± 20,24), e a pós-operatória foi 74,18 pontos ( ± 20,26). A diferença entre as pontuações IKDC obtidas depois e antes da cirurgia foi de 42,55 ( ± 21,05) pontos, com o aumento mínimo de 8,1 pontos e o aumento máximo de 82,8 pontos. Uma diferença estatística significativa (p < 0,001) foi encontrada entre a pontuação IKDC antes e após a cirurgia. Uma relação estatisticamente significativa (p = 0,038) foi observada entre o aumento da pontuação IKDC (a diferença entre a pontuação pré- e pós-operatória) e as dimensões da lesão.

Conclusões

A mosaicoplastia com transferência de autoenxerto osteocondral, quando adequadamente usada, pode produzir resultados excelentes com grande durabilidade e impacto funcional, baixas taxas de morbidade e baixos custos. A expansão dos critérios de indicação mostra resultados promissores no médio e longo prazo.

Palavras-chave:
osteocondrite/ diagnóstico; osteocondrite/ cirurgia; artroscopia; articulação do joelho; cartilagem articular

Introduction

Focal osteochondral lesions of the knee are found in two thirds of patients undergoing arthroscopy.11 Curl WW, Krome J, Gordon ES, Rushing J, Smith BP, Poehling GG. Cartilage injuries: a review of 31,516 knee arthroscopies. Arthroscopy 1997;13(04):456-460 The treatment of these lesions, when these are isolated and especially in young individuals, remains a debating topic.22 Berta Á, Duska Z, Tóth F, Hangody L. Clinical experiences with cartilage repair techniques: outcomes, indications, contraindications and rehabilitation. Eklem Hastalik Cerrahisi 2015;26(02): 84-96 33 Krych AJ, Harnly HW, Rodeo SA,Williams RJ III. Activity levels are higher after osteochondral autograft transfer mosaicplasty than after microfracture for articular cartilage defects of the knee: a retrospective comparative study. J Bone Joint Surg Am 2012;94 (11):971-978 44 Gudas R, Kalesinskas RJ, Kimtys V, Stankevicius E, Toliusis V, Bernotavicius G, et al. A prospective randomized clinical study of mosaic osteochondral autologous transplantation versus microfracture for the treatment of osteochondral defects in the knee joint in young athletes. Arthroscopy 2005;21(09):1066-1075 Knee replacement surgery is not a good solution, and a technique that can restitute ad integrum, a normal hyaline cartilage articular surface, still does not exist.22 Berta Á, Duska Z, Tóth F, Hangody L. Clinical experiences with cartilage repair techniques: outcomes, indications, contraindications and rehabilitation. Eklem Hastalik Cerrahisi 2015;26(02): 84-96 44 Gudas R, Kalesinskas RJ, Kimtys V, Stankevicius E, Toliusis V, Bernotavicius G, et al. A prospective randomized clinical study of mosaic osteochondral autologous transplantation versus microfracture for the treatment of osteochondral defects in the knee joint in young athletes. Arthroscopy 2005;21(09):1066-1075 55 Smith GD, Knutsen G, Richardson JB. A clinical review of cartilage repair techniques. J Bone Joint Surg Br 2005;87(04): 445-449 66 Bedi A, Feeley BT, Williams RJ 3rd. Management of articular cartilage defects of the knee. J Bone Joint Surg Am 2010;92(04): 994-1009 Presently, the available techniques follow principles of palliation (debridement and chondroplasty), repair (microfracture), and autologous chondrocyte implantation (ACI) restoration, osteochondral autograft transfer (OTA), and osteochondral allograft (OCA).22 Berta Á, Duska Z, Tóth F, Hangody L. Clinical experiences with cartilage repair techniques: outcomes, indications, contraindications and rehabilitation. Eklem Hastalik Cerrahisi 2015;26(02): 84-96 33 Krych AJ, Harnly HW, Rodeo SA,Williams RJ III. Activity levels are higher after osteochondral autograft transfer mosaicplasty than after microfracture for articular cartilage defects of the knee: a retrospective comparative study. J Bone Joint Surg Am 2012;94 (11):971-978 The former, in which we can include mosaicplasty (OTA), has been applied mainly for symptomatic relief and in an attempt to regain an articular surface with biofunctional properties similar to those of an injured joint, aiming for function preservation and less progression of the osteoarticular disease.22 Berta Á, Duska Z, Tóth F, Hangody L. Clinical experiences with cartilage repair techniques: outcomes, indications, contraindications and rehabilitation. Eklem Hastalik Cerrahisi 2015;26(02): 84-96 77 Hangody L, Kish G, Kárpáti Z, Szerb I, Udvarhelyi I. Arthroscopic autogenous osteochondral mosaicplasty for the treatment of femoral condylar articular defects. A preliminary report. Knee Surg Sports Traumatol Arthrosc 1997;5(04): 262-267 88 Hangody L, Füles P. Autologous osteochondral mosaicplasty for the treatment of full-thickness defects of weight-bearing joints: ten years of experimental and clinical experience. J Bone Joint Surg Am 2003;85-A(Suppl 2):25-32 99 Hangody L, Dobos J, Baló E, Pánics G, Hangody LR, Berkes I. Clinical experiences with autologous osteochondral mosaicplasty in an athletic population: a 17-year prospective multicenter study. Am J Sports Med 2010;38(06):1125-1133 The present study aims to analyze the results obtained by the application of the mosaicplasty technique on the treatment of isolated knee femoral condyle osteochondral lesions.

Methodology

Retrospective analyses of patients with knee osteochondral lesions, selected and submitted to the mosaicplasty repair technique in our institution between 2001 and 2015. The inclusion criteria were: patients ≤ 60 years old, with single osteochondral femoral condyle lesion (Outerbrige III/IV) < 4 cm2 in the preoperative MRI (International Cartilage Repair Society – ICRS) and confirmed arthroscopically, with follow-up of at least 1 year. Patients with associated lesions (e.g., tibia or patella), malalignment, or previous realignment surgery, were excluded (Table 1).

Table 1
Inclusion and exclusion criteria

The procedure was performed using the Osteochondral Autograft Transfer System (OATS) (Arthrex, Inc., Naples, FL, USA) and according to the technique described by Hangody77 Hangody L, Kish G, Kárpáti Z, Szerb I, Udvarhelyi I. Arthroscopic autogenous osteochondral mosaicplasty for the treatment of femoral condylar articular defects. A preliminary report. Knee Surg Sports Traumatol Arthrosc 1997;5(04): 262-267, by arthroscopy with a mini arthrotomy for graft harvesting and transfer from its location (trochlear circumferential non-weight bearing area) to the osteochondral defect. (Fig. 1). Postoperative protocol with weight bearing restriction for 2 weeks, followed by partial weight bearing (10–20% of the body weight) until the 6th week, total weight bearing until 6 months, and unrestricted activity thereafter.

Fig. 1
Operative technique: (a) osteochondral lesion of the medial femoral condyle; (b) donor site - trochlear circumferential non-weight bearing area; (c) and (d) final repair.

The patients were submitted to subjective evaluation with the International Knee Documentation Committee (IKDC) form, in the period between the lesion and the surgery, and again 1 year after the surgery. Data analyses were made with IBM SPSS Statistics for Windows, Version 22.0 (IBM Corp., Armonk, NY, USA).

Results

From the analyses of the 13 cases eligible for the present study (Table 2), we have found an average age of 34 years old, with male patients (n= 4; 31%) with an average age of 23 years old (range: 17–31 years old), and female patients (n= 9; 69%) with an average age of 39 years old (range: 16–56 years old). Lesions affected more the medial femoral condyle compared with the lateral (n= 11; 85% versus n= 2; 15%) and the observed average size of the lesion was 1.8 cm2 (0.6–4), 7 of which were > 2 cm2. The average follow-up time of the patients was of 5.045 ± 3.47 years (range: 1.15–11.01 years). During the 1st year, none of the patients developed infections or complications in the donor site; 1 of the patients (female, 54 years old) was submitted to a total knee arthroplasty (TKA) 13 months after the mosaicplasty (6 years later, the TKA was revised). The average preoperative IKDC score was of 31.63 points (±20.24), whereas the average postoperative IKDC score was of 74.18 points (±20.26). The difference between the post- and preoperative IKDC scores was of 42.55 (±21.05) points, being the minimal score increase of 8.1 points, and the maximum score increase of 82.8 points (Fig. 2). A statistically significant difference (p< 0.001) was found between the IKDC scores before and after the surgery – paired samples Wilcoxon test (Fig. 3). Statistically significant correlations between the IKDC score and age or gender were not found. However, a statistically significant relation (p= 0.038) was found between the IKDC score increase (the difference between the postoperative and the preoperative scores) and the dimension of the lesion.

Fig. 2
Results: graphic bar showing the preoperative and postoperative IKDC score for each patient of the study. Age and follow-up in years; Size in cm2. Abbreviations: F, female; IKDC, International Knee Documentation Committee; LFC, lateral femoral condyle; M, male; MFC, medial femoral condyle. -Δ IKDC = post-operative IKDC – pre-operative IKDC.

Fig. 3
Boxplot graphic showing preoperative and postoperative IKDC scores, using paired samples, nonparametric Wilcoxon test with IBM SPSS Statistics for Windows, Version 22.0–p< 0.001. Abbreviations: IKDC, International Knee Documentation Committee.

Table 2
Patients included in the study group

Discussion

The treatment of articular cartilage lesions comprises procedures of palliation (debridement and chondroplasty), repair (microfracture), and reconstruction (ACI, OTA, and OCA).22 Berta Á, Duska Z, Tóth F, Hangody L. Clinical experiences with cartilage repair techniques: outcomes, indications, contraindications and rehabilitation. Eklem Hastalik Cerrahisi 2015;26(02): 84-96 44 Gudas R, Kalesinskas RJ, Kimtys V, Stankevicius E, Toliusis V, Bernotavicius G, et al. A prospective randomized clinical study of mosaic osteochondral autologous transplantation versus microfracture for the treatment of osteochondral defects in the knee joint in young athletes. Arthroscopy 2005;21(09):1066-1075 1010 McNickle AG, Provencher MT, Cole BJ. Overview of existing cartilage repair technology. Sports Med Arthrosc Rev 2008;16 (04):196-201 Their application is driven by clinical and morphological criteria. According to the most recent literature reviews that discuss the treatment of osteochondral lesions of the knee, lesions with dimensions < 2 cm2 are best treated through microfracture (first-line option) or OTA.1111 Richter DL, Schenck RC Jr, Wascher DC, Treme G. Knee Articular Cartilage Repair and Restoration Techniques: A Review of the Literature. Sports Health 2016;8(02):153-160 The latter shows more longevity and durability of results, especially among high functional demand patients, when compared with microfractures.33 Krych AJ, Harnly HW, Rodeo SA,Williams RJ III. Activity levels are higher after osteochondral autograft transfer mosaicplasty than after microfracture for articular cartilage defects of the knee: a retrospective comparative study. J Bone Joint Surg Am 2012;94 (11):971-978 44 Gudas R, Kalesinskas RJ, Kimtys V, Stankevicius E, Toliusis V, Bernotavicius G, et al. A prospective randomized clinical study of mosaic osteochondral autologous transplantation versus microfracture for the treatment of osteochondral defects in the knee joint in young athletes. Arthroscopy 2005;21(09):1066-1075 When lesions range from 2 to 4 cm2, they should be treated by OTA or by ACI.33 Krych AJ, Harnly HW, Rodeo SA,Williams RJ III. Activity levels are higher after osteochondral autograft transfer mosaicplasty than after microfracture for articular cartilage defects of the knee: a retrospective comparative study. J Bone Joint Surg Am 2012;94 (11):971-978 Regarding lesions with dimensions ≥ 4cm2, OTA morbidity is not neglectable, which is a reason why these should be approached with ACI or OCA (being the latter especially applied in extensive post-traumatic lesions or osteochondritis dissecans).33 Krych AJ, Harnly HW, Rodeo SA,Williams RJ III. Activity levels are higher after osteochondral autograft transfer mosaicplasty than after microfracture for articular cartilage defects of the knee: a retrospective comparative study. J Bone Joint Surg Am 2012;94 (11):971-978 Osteochondral autograft transfer, like other reconstructive techniques, confers good symptomatic and functional results and prevents the progression of degenerative changes. Moreover, it presents some advantages, such as its low cost, the absence of immunological reactions and of infectious transmission (when compared with OCA), and can be performed in a single surgical time.22 Berta Á, Duska Z, Tóth F, Hangody L. Clinical experiences with cartilage repair techniques: outcomes, indications, contraindications and rehabilitation. Eklem Hastalik Cerrahisi 2015;26(02): 84-96 33 Krych AJ, Harnly HW, Rodeo SA,Williams RJ III. Activity levels are higher after osteochondral autograft transfer mosaicplasty than after microfracture for articular cartilage defects of the knee: a retrospective comparative study. J Bone Joint Surg Am 2012;94 (11):971-978 77 Hangody L, Kish G, Kárpáti Z, Szerb I, Udvarhelyi I. Arthroscopic autogenous osteochondral mosaicplasty for the treatment of femoral condylar articular defects. A preliminary report. Knee Surg Sports Traumatol Arthrosc 1997;5(04): 262-267 88 Hangody L, Füles P. Autologous osteochondral mosaicplasty for the treatment of full-thickness defects of weight-bearing joints: ten years of experimental and clinical experience. J Bone Joint Surg Am 2003;85-A(Suppl 2):25-32 99 Hangody L, Dobos J, Baló E, Pánics G, Hangody LR, Berkes I. Clinical experiences with autologous osteochondral mosaicplasty in an athletic population: a 17-year prospective multicenter study. Am J Sports Med 2010;38(06):1125-1133 This procedure, when used in lesions ranging from 2 to 4 cm2, has more efficacy and durability; as shown in our study (which analyzed lesions up to these dimensions), a correlation with statistical significance between the gain in IKDC scores and the lesion size can be made. The known complication rate is low, as observed in our study group. Results tend to be good in the medium to long term, being worse with increasing age, in females, and in greater size defects (> 4 cm2).22 Berta Á, Duska Z, Tóth F, Hangody L. Clinical experiences with cartilage repair techniques: outcomes, indications, contraindications and rehabilitation. Eklem Hastalik Cerrahisi 2015;26(02): 84-96 33 Krych AJ, Harnly HW, Rodeo SA,Williams RJ III. Activity levels are higher after osteochondral autograft transfer mosaicplasty than after microfracture for articular cartilage defects of the knee: a retrospective comparative study. J Bone Joint Surg Am 2012;94 (11):971-978 The significant improvement in the IKDC score seen in our study, when comparing the pre- and postoperative status, is in line with other recent studies that use this or other functional evaluation scores.99 Hangody L, Dobos J, Baló E, Pánics G, Hangody LR, Berkes I. Clinical experiences with autologous osteochondral mosaicplasty in an athletic population: a 17-year prospective multicenter study. Am J Sports Med 2010;38(06):1125-1133 1212 Solheim E, Hegna J, Øyen J, Harlem T, Strand T. Results at 10 to 14 years after osteochondral autografting (mosaicplasty) in articular cartilage defects in the knee. Knee 2013;20(04): 287-290 1313 Reverte-Vinaixa MM, Joshi N, Diaz-Ferreiro EW, Teixidor-Serra J, Dominguez-Oronoz R. Medium-term outcome of mosaicplasty for grade III-IV cartilage defects of the knee. J Orthop Surg (Hong Kong) 2013;21(01):4-9

Conclusion

Hyaline cartilage regeneration is not possible nowadays, and remains the greatest goal to be achieved in the treatment of osteochondral lesions. Mosaicplasty with OTA, when adequately used, can produce excellent results, with great durability and functional impact, low morbidity rates and costs. Although it has restricted indications, expansion of the criteria for its use has shown promising mid-term and long-term results, as shown in the recent literature.

References

  • 1
    Curl WW, Krome J, Gordon ES, Rushing J, Smith BP, Poehling GG. Cartilage injuries: a review of 31,516 knee arthroscopies. Arthroscopy 1997;13(04):456-460
  • 2
    Berta Á, Duska Z, Tóth F, Hangody L. Clinical experiences with cartilage repair techniques: outcomes, indications, contraindications and rehabilitation. Eklem Hastalik Cerrahisi 2015;26(02): 84-96
  • 3
    Krych AJ, Harnly HW, Rodeo SA,Williams RJ III. Activity levels are higher after osteochondral autograft transfer mosaicplasty than after microfracture for articular cartilage defects of the knee: a retrospective comparative study. J Bone Joint Surg Am 2012;94 (11):971-978
  • 4
    Gudas R, Kalesinskas RJ, Kimtys V, Stankevicius E, Toliusis V, Bernotavicius G, et al. A prospective randomized clinical study of mosaic osteochondral autologous transplantation versus microfracture for the treatment of osteochondral defects in the knee joint in young athletes. Arthroscopy 2005;21(09):1066-1075
  • 5
    Smith GD, Knutsen G, Richardson JB. A clinical review of cartilage repair techniques. J Bone Joint Surg Br 2005;87(04): 445-449
  • 6
    Bedi A, Feeley BT, Williams RJ 3rd. Management of articular cartilage defects of the knee. J Bone Joint Surg Am 2010;92(04): 994-1009
  • 7
    Hangody L, Kish G, Kárpáti Z, Szerb I, Udvarhelyi I. Arthroscopic autogenous osteochondral mosaicplasty for the treatment of femoral condylar articular defects. A preliminary report. Knee Surg Sports Traumatol Arthrosc 1997;5(04): 262-267
  • 8
    Hangody L, Füles P. Autologous osteochondral mosaicplasty for the treatment of full-thickness defects of weight-bearing joints: ten years of experimental and clinical experience. J Bone Joint Surg Am 2003;85-A(Suppl 2):25-32
  • 9
    Hangody L, Dobos J, Baló E, Pánics G, Hangody LR, Berkes I. Clinical experiences with autologous osteochondral mosaicplasty in an athletic population: a 17-year prospective multicenter study. Am J Sports Med 2010;38(06):1125-1133
  • 10
    McNickle AG, Provencher MT, Cole BJ. Overview of existing cartilage repair technology. Sports Med Arthrosc Rev 2008;16 (04):196-201
  • 11
    Richter DL, Schenck RC Jr, Wascher DC, Treme G. Knee Articular Cartilage Repair and Restoration Techniques: A Review of the Literature. Sports Health 2016;8(02):153-160
  • 12
    Solheim E, Hegna J, Øyen J, Harlem T, Strand T. Results at 10 to 14 years after osteochondral autografting (mosaicplasty) in articular cartilage defects in the knee. Knee 2013;20(04): 287-290
  • 13
    Reverte-Vinaixa MM, Joshi N, Diaz-Ferreiro EW, Teixidor-Serra J, Dominguez-Oronoz R. Medium-term outcome of mosaicplasty for grade III-IV cartilage defects of the knee. J Orthop Surg (Hong Kong) 2013;21(01):4-9
  • *
    The present study was conducted at the Orthopedic Department, Hospital Vila Franca de Xira, Portugal.

Publication Dates

  • Publication in this collection
    29 July 2019
  • Date of issue
    May-Jun 2019

History

  • Received
    07 Jan 2018
  • Accepted
    28 May 2018
Sociedade Brasileira de Ortopedia e Traumatologia Al. Lorena, 427 14º andar, 01424-000 São Paulo - SP - Brasil, Tel.: 55 11 2137-5400 - São Paulo - SP - Brazil
E-mail: rbo@sbot.org.br