Fixation of Unstable Osteochondritis Dissecans Lesions of the Knee Using Arthroscopic Autogenous Osteochondral Grafting (Mosaicplasty)

doi:10.1016/j.arthro.2007.02.017

Arthroscopy: The Journal of Arthroscopic & Related Surgery

Volume 23, Issue 8, August 2007, Pages 845-851

https://doi.org/10.1016/j.arthro.2007.02.017 Get rights and content

Purpose: A number of surgical techniques have been described for the operative fixation of an unstable osteochondritis dissecans (OCD) lesion in the knee that has failed appropriate nonoperative management. However, no one technique has been universally successful. We report the results of a new fixation technique for unstable OCD lesions using arthroscopic autogenous osteochondral grafting (mosaicplasty). Methods: Twenty patients with OCD lesions (16 International Cartilage Repair Society [ICRS] OCD type II, 3 ICRS OCD type III, and 1 ICRS OCD type IV) who had failed an appropriate course of nonoperative management underwent autogenous osteochondral grafting. The OCD lesions were assessed arthroscopically and then fixed in situ by using multiple 4.5-mm osteochondral dowel grafts harvested from the edges of the femoral trochlea. The lesion was initially fixed with an osteochondral graft passing through the center of the fragment and then stabilized by using further grafts inserted around its periphery. Results: Preoperative International Knee Documentation Committee scores assessed 5 patients as nearly normal, 8 as abnormal, and 7 as severely abnormal. At the 18-month follow-up, all of the knees were scored as normal. The average preoperative visual analog pain score out of 10 was 8.3, which was reduced to 0.8 at 6 months and to 0 at 1 year after surgery. Serial magnetic resonance imaging scans showed healing of the bony part of the lesion in all of the knees 6 months after surgery and continuous articular cartilage healing at 9 months. Conclusions: Autogenous osteochondral grafting of unstable OCD lesions in the knee is a reliable and minimally invasive technique that provides a stable biologic fixation using autogenous bone graft and has few complications. Level of Evidence: Level IV, therapeutic case series.

Section snippets

Methods

Between March 1997 and December 2001, 20 consecutive patients who had been referred to our institution with symptomatic unstable OCD lesions were treated by arthroscopic autogenous osteochondral graft fixation (mosaicplasty). The lesions were all initially diagnosed on MRI scan and confirmed subsequently at the time of arthroscopy. Exclusion criteria included a loose fragment, previous mosaicplasty, a history of patellofemoral pathology, and previous infection. All data were collected

Results

Sixteen of the lesions were ICRS OCD type II, 3 were ICRS OCD type III, and 1 was ICRS OCD type IV. The right knee was affected in 9 of the cases and the left in 11. The lesion was positioned on the lateral aspect of the medial femoral condyle in 19 patients and on the lateral femoral condyle in 1. The average length of follow-up was 3.4 years (range, 2 to 6).

The average age of the patients at the time of surgery was 14.3 years (range, 12 to 27 years) with the physes open in 11 of the cases.

Discussion

The principles of surgical treatment for unstable OCD lesions in the knee are multiple. They should ideally include stable fixation, promotion of a blood supply to the base of the OCD fragment, and bone grafting at the base to promote healing with the articular cartilage over the OCD fragment being left as intact as possible.

A variety of techniques have previously been described and include fixation using simple pins, various types of compression screw devices, corticocancellous bone pegs, and

Conclusions

From the results of this study, we found autogenous osteochondral grafting to be a good technique for the treatment of unstable OCD lesions that have failed adequate nonoperative management. It is a reliable and minimally invasive method that provides a stable biologic fixation using autogenous bone graft and has few complications.

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Cited by (86)

Noninferiority meta-analysis of autologous vs allogeneic osteochondral transplantation for the treatment of osteochondral defects of the knee confounded by defect size differences
2023, Journal of Cartilage and Joint Preservation
Autologous and allogeneic osteochondral transplantations are widely employed for knee osteochondral defects (OCDs). However, there has been a lack of consensus on the efficacy of autografts vs allografts.
To evaluate the complication profile following autologous vs allogeneic osteochondral transplantation for knee OCDs.
PubMed and Embase.
Clinical studies that reported complication rates following autologous or allogeneic osteochondral transplantation for knee OCDs.
Meta-analysis of proportions using the restricted maximum-likelihood method after the Freeman-Tukey double-arcsine transformation.
There were 35 studies with 2647 and 2569 OCDs included before and after lost to follow-up, respectively. Graft failure rates were not significantly lower in autografts vs allografts in all analyses: as reported (6.23% vs 10.81%, respectively; P = .63), best-case (6.00% vs 10.24%, respectively; P = .66) and worst-case analyses (7.46% vs 14.43%, respectively; P = .42). In the subgroup of mean follow-up time <36 months, graft failure rates were significantly lower in autografts vs allografts in all analyses.
The meta-analysis was confounded by the inherent differences in mean defect sizes of the autograft and allograft arms.
Overall graft failure and revision rates were lower in autograft vs allograft for the treatment of knee OCDs but this may have been confounded by the inherent differences in mean defect sizes between the groups. Further studies on autografts for larger-sized knee OCDs and allografts for smaller-sized knee OCDs are warranted to better complete the noninferiority analysis.
Internal Fixation of Unstable OCD Lesions with Metal Compression Screws: Techniques and Outcomes
2023, Operative Techniques in Sports Medicine
Osteochondritis dissecans (OCD) is a pathologic condition that affects the subchondral bone and overlying articular cartilage with variable degrees of instability and detachment. The specific etiology is frequently unknown; however, it is thought to result from multifactorial contributions including acute trauma, recurrent microtrauma, inflammation, or inherited diseases involving vascular perfusion and ossification anomalies. Treatment is largely dictated by patient symptoms and their association with lesion stability, location, skeletal maturity, activity goals, and surgeon preference. Stable lesions can frequently be treated nonoperatively, but unstable lesions typically require surgical intervention that addresses lesion instability where possible. Arthroscopy is used to initially visualize and evaluate the lesion, followed by reduction and internal fixation. If the fragment is salvageable with a bony base, internal fixation with metal compression screws is a reliable strategy for enhancing patient outcomes with low rates of reoperation and failure. This review will focus on the surgical indications, techniques, and outcomes of internal fixation with metal compression screws in unstable OCD lesions of the knee.
Autologous osteochondral transplantation for focal femoral condyle defects: Comparison of mosaicplasty by arthrotomy vs. arthroscopy
2022, Orthopaedics and Traumatology: Surgery and Research
Citation Excerpt :
Autologous osteochondral transplantation (OAT) by mosaicplasty is a surgical technique used to treat cartilage defects of the knee. Many studies have demonstrated good outcomes in this indication [1–27]. The first arthroscopic mosaicplasty was performed in 1993 by Matsusue et al. [28].
While many studies have reported the outcomes of open mosaicplasty, data on arthroscopic mosaicplasty are scarce. Only two cadaver studies have compared arthrotomy and arthroscopy. Moreover, the patello-femoral joint, which is the main donor site, has never been assessed using a specific functional score. The objective of this in vivo study was to compare arthrotomy and arthroscopy for mosaicplasty using both a global functional knee score and a specific score of the patello-femoral joint.
The arthroscopic technique results in better functional patello-femoral outcomes.
We retrospectively compared two groups of 17 patients who underwent mosaicplasty for focal condylar cartilage defects, at our department between 2009 and 2019. Functional outcomes were assessed using the Kujala score and the Lysholm score, at least 1 year after surgery. The return to sports was assessed using the Tegner score.
Mean follow-up was 67.4 ± 15.9 months in the arthrotomy group and 45.2 ± 35.1 months in the arthroscopy group (p < 0.01). Cartilage defect size was similar in the two groups (arthrotomy: 1.21 ± 0.91 cm²; arthroscopy: 0.92 ± 1.23 cm²; p = 0.052). The mean Kujala score was 85 ± 21.3 in the arthrotomy group and 91.9 ± 13.7 in the arthroscopy group (p = 0.064). The mean Lysholm score was 83.9 ± 19.8 with arthrotomy and 89.5 ± 14.9 with arthroscopy (p = 0.1). The Kujala score was greater than 95 in 4 (26%) arthrotomy patients and 13 (81%) arthroscopy patients (p = 0.003). The Lysholm score was higher than 95 in 4 (26%) arthrotomy patients and 12 (75%) arthroscopy patients (p = 0.012). No patient underwent surgical revision for autograft failure.
This is the first clinical study comparing arthrotomy and arthroscopy for mosaicplasty. Clinical outcomes were good with both techniques. The proportion of patients with excellent Lysholm and Kujala functional scores was significantly higher in the arthroscopy group than in the arthrotomy group. This result may be ascribable to decreased donor-site morbidity obtained with arthroscopy.
IV, retrospective observational comparative study.
Autologous osteochondral transplantation for focal femoral condyle defects: Comparison of mosaicplasty by arthrotomy vs. arthroscopy
2022, Revue de Chirurgie Orthopedique et Traumatologique
Les résultats des mosaïcplasties réalisées à ciel ouvert sont nombreux mais peu d’études rapportent les résultats sous arthroscopie. Seulement deux études cadavériques comparent arthroscopie et arthrotomie. Par ailleurs, l’articulation fémoropatellaire, principal site donneur, n’a jamais été évaluée par un score fonctionnel spécifique. Le but de notre étude in vivo est de comparer l’arthrotomie et l’arthroscopie à travers un score fonctionnel global du genou et un score fonctionnel spécifique fémoropatellaire.
Deux groupes de 17 patients, opérés dans notre service entre 2009 et 2019 d’une mosaïcplastie pour lésion cartilagineuse focale d’un condyle fémoral, ont été rétrospectivement comparés. Le résultat fonctionnel a été évalué par les scores Kujala et Lysholm au suivi minimum de 1 an, ainsi que le retour au sport, évalué par l’échelle de Tegner.
Le recul moyen était de 67,4 mois (±15,9) dans le groupe arthrotomie et de 45,2 mois (± 35,1) dans le groupe arthroscopie (p < 0,01). La taille du défect cartilagineux était similaire dans les deux groupes (1,21 cm² ± 0,91 (arthrotomie) versus 0,92 cm² ± 1,23 (arthroscopie) (p = 0,052). Le score moyen de Kujala était de 85 (±21,3) dans le groupe arthrotomie et de 91,9 (± 13,7) dans le groupe arthroscopie (p = 0,064). Le score moyen de Lysholm était de 83,9 (± 19,8) dans le groupe arthrotomie et de 89,5 (±14,9) dans le groupe arthroscopie (p = 0,1). Quatre (26 %) patients avaient un score de Kujala supérieure à 95 dans le groupe arthrotomie et treize (81 %) patients dans le groupe arthroscopie (p = 0,003). Quatre (26 %) patients avaient un score de Lysholm supérieur à 95 dans le groupe arthrotomie et douze (75 %) patients dans le groupe arthroscopie (p = 0,012). Il n’y avait aucune reprise chirurgicale pour échec de l’autogreffe.
Notre étude constitue la première étude clinique comparant l’arthroscopie à l’arthrotomie dans la mosaïcplastie et rapporte de bons résultats cliniques avec chacune de ces techniques. Nous retrouvons significativement plus de patient avec un excellent score fonctionnel (Lysholm et Kujala) dans le groupe arthroscopie par rapport au groupe arthrotomie. Cette amélioration pourrait être expliquée par une diminution de la morbidité au site donneur grâce à l’arthroscopie.
IV ; Etude observationnelle descriptive.
Unestable knee osteochondritis dissecans: arthroscopic fixation with bio-absorbable device
2021, Revista Espanola de Cirugia Ortopedica y Traumatologia
La osteocondritis disecante (OCD) de rodilla es una patología osteoarticular, cuyo tratamiento aún sigue siendo debatido. Nuestro objetivo fue analizar los pacientes intervenidos mediante fijación interna con implante bioabsorbible, asistido por artroscopia.
Se realizó análisis utilizando mediana y rango intercuartílico (P₂₅-P₇₅), con un seguimiento de 9 pacientes (10 rodillas) intervenidos con fijación por lesión osteocondral grado III. Tras un mínimo de 12 meses, fueron evaluados los cuestionarios KOOS, IKDC, la satisfacción y fue realizado un control de RNM.
Se observó consolidación ósea por RNM en el 80% de las intervenciones en el primer año, con un retardo de consolidación en el 20%. La mediana para la edad fue de 15 años. La media de seguimiento fue de 5,93 años. Los 10 casos tuvieron localización en el cóndilo interno. Las OCD no presentaban conminución ni necrosis. El 40% de las lesiones valoradas preoperatoriamente en RNM como estables, se describieron como inestables bajo artroscopia, precisando fijación interna. Fueron diferenciados 2 grupos de osteocondritis: OCD juvenil (60%) y OCD del adulto (40%). En cuanto al cuestionario IKDC, se obtuvo una mejoría de 29,5 (22,25, 37,52). En KOOS, se obtuvo una mejoría en síntomas de 18,07, en dolor de 29,12, en actividades cotidianas de 23,53, en función (deporte, actividades recreativas) de 35 y en calidad de vida de 34,42.
El implante bioabsorbible es una opción válida, reproducible, para lesiones inestables con integridad de la lesión, con una gran mejora de la función, de la calidad de vida y con escasez de complicaciones.
Knee ostheochondritis dissecans is an osteochondral disease, whose treatment is still debated. The purpose this study was to analyze the patients attached with bioabsorbable nail, assisted by arthroscopy.
Analysis was performed using median and interquartile range (P₂₅-P₇₅), with a follow-up of 9 patients (10 knees) operated for stage III osteochondral lesions. After a minimum of 12 months, the KOOS, IKDC, satisfaction questionnaires were evaluated and a MR control was perfomed.
Bone healing was observed in 80% of patients in the first year, with a delay in union in 20%. The median for age was 15 years. The average follow-up was 5.93 years. All cases were located in the internal condyle. The OCD lesions did not show comminution or necrosis. The 40% of stable lesions, according to preoperative MR, were unestable in arthroscopy and it were attached with internal nail. Two groups of osteochondral lesions were differentiated: juvenile OCD (60%) and adult OCD (40%); all of them were stage III lesions. IKDC questionnaire results were an improvement of 29.5 (22.25, 37.52). In the KOOS questionnaire, an improvement was obtained in symptoms of 18.07, in pain of 29.12, in daily living 25.53, in function (sports, recreational activities) of 35 and in quality of life of 34.42.
The bioabsorbable nail is a valid, reproducible option for unestable lesions with lesion integrity, with great improvement in function, quality of life and with few complications.
OCD Injuries in the Paediatric and Adult Population
2020, Evidence-Based Management of Complex Knee Injuries: Restoring the Anatomy to Achieve Best Outcomes
Osteochondritis dissecans (OCD) is a focal pathological lesion involving the subchondral bone. It most commonly involves the knee and can result in significant damage to the overlying articular cartilage, leading to loose bodies, accelerated joint degeneration and pain. It is classically categorised into juvenile and adult forms, with many juvenile patients having favourable outcomes with nonoperative management, whereas adult patients predominantly require operative treatments. There are multiple proposed theories regarding the aetiology of the disease; however, there is no agreed-on cause. Imaging studies, specifically magnetic resonance imaging (MRI), play an important role in diagnosing and characterising OCD lesions. In addition to a patient’s skeletal maturity, characteristics including the lesion size, location and stability are among the most important prognostic factors used to guide treatment decisions. OCD lesions that require operative management can be treated by reparative or restorative techniques. Reparative techniques are generally first attempted and include drilling, loose body excision and internal fixation. Restorative treatments are reserved for patients with lesions that have failed reparative attempts or are deemed not amenable to repair. These operative treatments include microfracture, osteochondral autograft transplantation, osteochondral allograft and autologous chondrocyte implantation techniques. Ultimately the majority of patients have favourable outcomes with these treatment strategies; however, further comparative studies are essential for establishing ideal guidelines for the appropriate management of this complex pathological condition of the knee.

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: The authors report no conflict of interest.

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Original ArticleFixation of Unstable Osteochondritis Dissecans Lesions of the Knee Using Arthroscopic Autogenous Osteochondral Grafting (Mosaicplasty)

Section snippets

Methods

Results

Discussion

Conclusions

Arthroscopy

Arthroscopy

Arthroscopy

Arthroscopy

Arthroscopy

Arthroscopy

Evaluation of cartilage injuries and repair

J Bone Joint Surg Am

Surgical fixation of massive osteochondritis dissecans lesion using cylindrical osteochondral plugs

Arthroscopy

Current state of evaluation of knee ligament injuriesThe new IKDC knee evaluation form

Orthopade

Osteochondritis dissecans of the knee in childrenA comparison of MRI and arthroscopic findings

J Bone Joint Surg Br

Arthroscopic versus conservative treatment of OCD lesions of the knee: Value of MRI in therapy planning and follow-up

Arthroscopy

Original Article
Fixation of Unstable Osteochondritis Dissecans Lesions of the Knee Using Arthroscopic Autogenous Osteochondral Grafting (Mosaicplasty)