Both microfracture and osteochondral autografting procedures have been useful in treating osteochondral lesions.
Combining microfracture and osteochondral autografting procedures can extend the size of lesions which can be treated with either technique.
Descriptive laboratory study.
Eight adult goats underwent osteochondral autograft transfer of a 4.5mm femoral trochlea plug into an 8mm full thickness chondral defect in the weight bearing portion of the medial femoral condyle. In the gap region surrounding the autograft, microfracture was performed. The animals were allowed normal activity until the end of the experiment at 6 months, at which time the knees were harvested. At harvest the knees were assessed grossly, and then evaluation was performed by histology and histomorphometry, biochemistry and biomechanics. One animal died at 6 wks from gastroenteritis.
The osteochondral plugs healed well, with integration of the bone and preservation of the chondral cap. The chondral gap between the host site articular cartilage and the transferred plug had decreased from 3 mm at implant to less than 0.1 mm. Histological analysis demonstrated regions of variable cartilage repair, with integration of the cartilage layer at some sites but incomplete healing at others. Histomorphometry demonstrated filling of the chondral gap to 75–85% of the normal volume. Biochemical analysis revealed greater than 90% type II collagen at most sites with some areas containing 80% type II collagen. Biomechanical indentation testing, indicated that the repaired area had variable thickness and stiffness, with a trend of increased stiffness in the bulk graft and decreased softness at the proximal microfracture interface site.
The performance of a combined microfracture and osteochondral autograft transfer (OATS) procedure to resurface a large chondral defect appears promising. Transferred cartilage tissue can successfully be incorporated into a large recipient defect, and microfracture of the surrounding bone can lead to a repair process which remains variable. Attempts need to be made to improve consistency of the repair process. This is a potential treatment option for large chondral defects which does not require a large area of autogenous tissue to be harvested.
CLINICAL RELEVANCE TO SPORTS MEDICINE
This combined technique shows promise for treatment of large chondral defects with a single operative procedure with autogenous tissue which is safe, and potentially would have a shorter period of rehabilitation, similar to that of osteochondral transfers and microfracture in a cost effective setting.
Articular cartilage repair; osteochondral allograft; microfracture; knees
The risk of post-traumatic osteoarthritis following an intra-articular fracture is determined to large extent by the success or failure of osteochondral repair. To measure the efficacy of osteochondral repair in a primate and determine if osteochondral repair differs in the patella (PA) and the medial femoral condyle (FC) and if passive motion treatment affects osteochondral repair, we created 3.2 mm diameter 4.0 mm deep osteochondral defects of the articular surfaces of the PA and FC in both knees of twelve skeletally mature cynomolgus monkeys. Defects were treated with intermittent passive motion (IPM) or castimmobilization (CI) for two weeks, followed by six weeks of ad libitum cage activity. We measured restoration of the articular surface, and the volume, composition, type II collagen concentration and in situ material properties of the repair tissue. The osteochondral repair response restored a mean of 56% of the FC and 34% of the PA articular surfaces and filled a mean of 68% of the chondral and 92% of the osseous defect volumes respectively. FC defect repair produced higher concentrations of hyaline cartilage (FC 83% vs. PA 52% in chondral defects and FC 26% vs. PA 14% in osseous defects) and type II collagen (FC 84% vs. PA 71% in chondral defects and FC 37% vs. PA 9% in osseous defects) than PA repair. IPM did not increase the volume of chondral or osseous repair tissue in PA or FC defects. In both PA and FC defects, IPM stimulated slightly greater expression of type II collagen in chondral repair tissue (IPM 81% vs. CI 74%); and, produced a higher concentration of hyaline repair tissue (IPM 62% vs. CI 42%), but IPM produced poorer restoration of PA articular surfaces (IPM 23% vs. CI 45%). Normal articular cartilage was stiffer, and had a larger Poisson's ratio and less permeability than repair cartilage. Overall CI treated repair tissue was stiffer and less permeable than IPM treated repair tissue. The stiffness, Poisson's ratio and permeability of femoral condyle cast immobilized (FC CI) treated repair tissue most closely approached the normal values. The differences in osteochondral repair between FC and PA articular surfaces suggest that the mechanical environment strongly influences the quality of articular surface repair. Decreasing the risk of posttraumatic osteoarthritis following intra-articular fractures will depend on finding methods of promoting the osteochondral repair response including modifying the intra-articular biological and mechanical environments.
Osteochondritis dissecans (OCD) primarily affects subchondral bone. Multiple drilling, fixation implant or autogenous osteochondral grafts are reported as treatment options. We present the midterm results of cases in which an OCD lesion was treated by osteochondral autograft transfer and drilling.
Materials and Methods:
Between 2002 and 2006, 14 knees with International Cartilage Repair Society (ICRS-OCD) type II and III lesions were treated in our clinic using osteochondral autograft transfer and drilling by arthroscopic or open surgery. The average age of our patients was 22.14 years (range 17-29 years) and average followup was of 24.3 months (range 11-40 months). Lesion type was ICRS type II in five patients (35.7%) and ICRS type III in nine patients (64.3%). In cases with ICRS-OCD type II lesions, in situ fixation was applied following circumferential multiple drilling, while mosaicplasty was done following debridement and multiple drilling in cases with ICRS-OCD type III lesion. Mosaicplasty was performed in the lesion area by an average of 2.5 (range 1-3) cylindrical osteochondral autografts. Patients were not allowed to perform loading activities for 3 weeks in the postoperative period; movement was initiated by using CPM device in the early phase; full range of motion was achieved in third week, and full weight bearing was permitted in 6 to 8 weeks
While 6 and 8 patients were classified preoperatively as fair and poor, respectively, according to Hughston scale, excellent and good results were obtained postoperatively in 10 and 4 patients, respectively. During the followup, no problems were detected in any of the patients in the regions where osteochondral graft was harvested.
Biologic fixation or mosaicplasty and drilling as a technique to treatment of the lesion in OCD by osteochondral autograft transfer has resulted in good and excellent clinical outcomes in our patients and it is considered that providing blood flow to subchondral bone by circumferencial drilling leads to an increase in the robustness of biological internal fixation and shortens the duration of recovery.
Osteochondritis dissecans; Hughston scale; knee; mosaicplasty
Symptomatic chondral or osteochondral defects of the talus reduce the quality of life of many patients. Although their pathomechanism is well understood, it is well known that different aetiologic factors play a role in their origin. Additionally, it is well recognised that the talar articular cartilage strongly differs from that in the knee. Despite this fact, many recommendations for the management of talar cartilage defects are based on approaches that were developed for the knee. Conservative treatment seems to work best in paediatric and adolescent patients with osteochondritis dissecans. However, depending on the size of the lesions, surgical approaches are necessary to treat many of these defects. Bone marrow stimulation techniques may achieve good results in small lesions. Large lesions may be treated by open procedures such as osteochondral autograft transfer or allograft transplantation. Autologous chondrocyte transplantation, as a restorative procedure, is well investigated in the knee and has been applied in the talus with increasing popularity and promising results but the evidence to date is poor. The goals of the current article are to summarise the different options for treating chondral and osteochondral defects of the talus and review the available literature.
Cartilage defect; Talus; Repair techniques; Arthroscopy; Marrow stimulation; Mosaicplasty; Autologous chondrocyte implantation
Sequelae of Perthes disease commonly manifests as complex hip pathomorphology including coxa magna, coxa brevis, and acetabular dysplasia. These abnormalities contribute to femoroacetabular impingement and early osteoarthritis. This report describes our experience with correction of the proximal femoral deformity associated with Perthes disease via surgical dislocation, osteochondroplasty (SDO), trochanteric advancement, and treatment of intra-articular chondrolabral injury.
Between January 2003 and January 2009, 14 patients with Perthes disease (4 female and 10 male patients) with an average age of 19.6 years (range 14 – 28) were treated with SDO and trochanteric advancement. One patient had a subsequent staged periacetabular osteotomy to improve acetabular coverage. Patient histories, physical exams, operative findings, and pre and postoperative radiographs were evaluated.
Operative findings demonstrated 6 acetabular cartilage lesions, 6 labral lesions, and 4 femoral osteochondritis dissecans (OCD) lesions treated with autografts. Mean center trochanteric distance improved from −20 mm to −1 mm. 4/14 hips deteriorated 1 Tönnis grade and 1/14 hips 2 grades. The Harris hip scores improved from an average of 62 preoperatively (range 51–72) to 95 postoperatively (range 93–97) versus 71 (range 65–76) to 88.6 (range 63–100) in the hips without OCD lesions. There was no statistically significant difference in the age, pre or postoperative HHS between the OCD and non-OCD groups. Mean follow up was 45 months. There were no major perioperative complications and all patients in both groups have their native hip to date.
The typical adult sequelae of Perthes disease predispose the hip to the development of chondrolabral injury and poor clinical function. Treatment with SDO and trochanteric advancement reduces impingement, improves hip biomechanics and allows treatment of intra-articular pathology. The described approach is associated with clinical improvement without major perioperative complication. Additionally, we have found a high rate of OCD lesions of the femoral head in Perthes hips undergoing surgical dislocation. Osteochondral autograft transfer from the resected femoral head-neck junction been found in the 4 patients treated thus far to be safe and effective with comparable clinical and radiographic outcomes to those hips without OCD lesions.
To compare long-term functional and radiological outcome following microfracture technique (MF) versus osteochondral autologous transplantation (OAT) mosaicplasty for treating focal chondral lesions of the knee.
Twenty-five patients (mean age 32.3 years, SD 7.7) with a full-thickness (International Cartilage Repair Society grade 3 or 4) chondral lesion of the articulating surface of the femur were randomized to either MF (n = 11) or OAT mosaicplasty (n = 14). At a median follow-up of 9.8 years (range 4.9–11.4), the patients were evaluated using Lysholm score (n = 25), Knee Injury and Osteoarthritis Outcome Score (KOOS, n = 25), isokinetic quadriceps measurement and hamstring strength measurement (n = 22) and standing radiographs (n = 23).
There were no significant differences in Lysholm score, KOOS, isokinetic muscle strength or radiographic osteoarthritis between MF-treated patients and OAT mosaicplasty-treated patients at follow-up. Mean Lysholm score at follow-up was 69.7 [95 % confidence interval (CI), 55.1–84.4] for the MF group and 62.6 (95 % CI, 52.6–72.6) for the OAT mosaicplasty group.
At long-term follow-up, there were no significant differences between patients treated with MF and patients treated with OAT mosaicplasty in patient-reported outcomes, muscle strength or radiological outcome.
Level of evidence
Therapeutic study, Level II.
Chondral lesion; Microfracture; Mosaicplasty; Long-term follow-up; Lysholm; KOOS
Osteochondral lesions of the talus are being recognized as an increasingly common injury. They are most commonly located postero-medially or antero-laterally, while centrally located lesions are uncommon. Large osteochondral lesions have significant biomechanical consequences and often require resurfacing with osteochondral autograft transfer, mosaicplasty, autologous chondrocyte implantation (or similar methods) or osteochondral allograft transplantation. Allograft procedures have become popular due to inherent advantages over other resurfacing techniques. Cartilage viability is one of the most important factors for successful clinical outcomes after transplantation of osteochondral allografts and is related to storage length and intra-operative factors. While there is abundant literature about osteochondral allograft transplantation in the knee, there are few papers about this procedure in the talus. Failure of non-operative management, initial debridement, curettage or microfractures are an indication for resurfacing. Patients should have a functional ankle motion, closed growth plates, absence of cartilage lesions on the tibial side. This paper reviews the published literature about osteochondral allograft transplantation of the talus focusing on indications, pre-operative planning, surgical approaches, postoperative management, results and complications of this procedure.
Background Focal chondral lesion is a common cause of chronic wrist pain. The best treatment remains unknown. We have developed a technique of arthroscopic transplantation of an osteochondral autograft from the knee joint to the distal radius with satisfactory clinical results.
Materials and Methods Between December 2006 and December 2010, four patients (average age 31 years) with posttraumatic osteochondral lesions over the dorsal lunate fossa were treated with arthroscopic osteochondral grafting. Pre- and postoperative motion, grip strength, wrist functional performance score, pain score, and return to work status were charted. Postoperative computed tomography (CT) scan, magnetic resonance imaging (MRI), and second-look arthroscopy were performed to assess graft incorporation.
Description of Technique With the arthroscope in the 3-4 portal, synovitis over the dorsal lunate fossa was débrided to uncover the underlying osteochondral lesion. We employed the 6-mm trephine of the Osteoarticular Transfer System (OATS) to remove the osteochondral defect. Osteochondral graft was harvested from the lateral femoral condyle and delivered into the wrist joint arthroscopically.
Results In all cases, grafts incorporation was completed by 3-4 months postoperative. All patients showed improvement in the wrist performance score (preoperative 27.5, postoperative 39 out of 40) with no pain on final follow-up at average 48.5 months (range 24-68 months). Grip strength improved from 62.6 to 98.2% of the contralateral side. Motion improved from 115.5 to 131.3°. X-ray images showed preserved joint space. Patient satisfaction was high with no complication.
Conclusion An arthroscopic-assisted transfer of an osteochondral graft is a viable treatment option for chondral defects of the distal radius.
wrist arthroscopy; osteochondral graft; radiocarpal joint; wrist surgery; focal; osteochondral defect
Osteochondral lesion of the talus (OLT) is a broad term used to describe an injury or abnormality of the talar articular cartilage and adjacent bone. A variety of terms have been used to refer to this clinical entity, including osteochondritis dissecans (OCD), osteochondral fracture and osteochondral defect. Whether OLT is a precursor to more generalised arthrosis of the ankle remains unclear, but the condition is often symptomatic enough to warrant treatment. In more than one third of cases, conservative treatment is unsuccessful, and surgery is indicated. There is a wide variety of treatment strategies for osteochondral defects of the ankle, with new techniques that have substantially increased over the last decade. The common treatment strategies of symptomatic osteochondral lesions include nonsurgical treatment, with rest, cast immobilisation and use of nonsteroidal anti-inflammatory drugs (NSAIDs). Surgical options are lesion excision, excision and curettage, excision combined with curettage and microfracturing, filling the defect with autogenous cancellous bone graft, antegrade (transmalleolar) drilling, retrograde drilling, fixation and techniques such as osteochondral transplantation [osteochondral autograft transfer system (OATS)] and autologous chondrocyte implantation (ACI). Furthermore, smaller lesions are symptomatic and when left untreated, OCDs can progress; current treatment strategies have not solved this problem. The target of these treatment strategies is to relieve symptoms and improve function. Publications on the efficacy of these treatment strategies vary. In most cases, several treatment options are viable, and the choice of treatment is based on defect type and size and preferences of the treating clinician.
Osteochondral lesions; Osteochondritis dissecans; Talus; Foot and ankle; Cartilage damage; Subchondral bone
Many surgical techniques, including microfracture, periosteal and perichondral grafts, chondrocyte transplantation, and osteochondral grafts, have been studied in an attempt to restore damaged articular cartilage. However, there is no consensus regarding the best method to repair isolated articular cartilage defects of the knee.
We compared postoperative functional outcomes, followup MRI appearance, and arthroscopic examination after microfracture (MF), osteochondral autograft transplantation (OAT), or autologous chondrocyte implantation (ACI).
We prospectively investigated 30 knees with MF, 22 with OAT, and 18 with ACI. Minimum followup was 3 years (mean, 5 years; range, 3–10 years). We included only patients with isolated cartilage defects and without other knee injuries. The three procedures were compared in terms of function using the Lysholm knee evaluation scale, Tegner activity scale, and Hospital for Special Surgery (HSS) score; modified Outerbridge cartilage grades using MRI; and International Cartilage Repair Society (ICRS) repair grade using arthroscopy.
All three procedures showed improvement in functional scores. There were no differences in functional scores and postoperative MRI grades among the groups. Arthroscopy at 1 year showed excellent or good results in 80% after MF, 82% after OAT, and 80% after ACI. Our study did not show a clear benefit of either ACI or OAT over MF.
Owing to a lack of superiority of any one treatment, we believe MF is a reasonable option as a first-line therapy given its ease and affordability relative to ACI or OAT.
Level of Evidence
Level II, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
Osteochondral transplantation is a successful treatment for full-thickness cartilage defects, which without treatment would lead to early osteoarthritis. Restoration of surface congruency and stability of the reconstruction may be jeopardized by early mobilization. To investigate the biomechanical effectiveness of osteochondral transplantation, we performed a standardized osteochondral transplantation in eight intact human cadaver knees, using three cylindrical plugs on a full-thickness cartilage defect, bottomed on one condyle, unbottomed on the contralateral condyle. Surface pressure measurements with Tekscan pressure transducers were performed after five conditions. In the presence of a defect the border contact pressure of the articular cartilage defect significantly increased to 192% as compared to the initially intact joint surface. This was partially restored with osteochondral transplantation (mosaicplasty), as the rim stress subsequently decreased to 135% of the preoperative value. Following weight bearing motion two out of eight unbottomed mosaicplasties showed subsidence of the plugs according to Tekscan measurements. This study demonstrates that a three-plug mosaicplasty is effective in restoring the increased border contact pressure of a cartilage defect, which may postpone the development of early osteoarthritis. Unbottomed mosaicplasties may be more susceptible for subsidence below flush level after (unintended) weight bearing motion.
Biomechanics; Cartilage; Articular/pathology; Humans; Knee Joint/Surgery; Pressure; Surface Properties; Transplantation; Autologous; Weight-bearing
Osteochondral autograft transfer (OAT) aims at restoring normal articular cartilage surface geometry and articular contact mechanics. To date, no studies have evaluated the contact mechanics of the canine stifle following OAT. Additionally, there are no studies that evaluated the role of the meniscus in contact mechanics following OAT in human or canine femorotibial joints. The objective of this study was to measure the changes in femorotibial contact areas (CA), mean contact pressure (MCP) and peak contact pressure (PCP) before and after osteochondral autograft transplantation (OAT) of a simulated lateral femoral condylar cartilage defect with an intact lateral meniscus and following lateral meniscectomy.
With an intact lateral meniscus, creation of an osteochondral defect caused a decrease in MCP and PCP by 11% and 30%, respectively, compared to the intact stifle (p < 0.01). With an intact meniscus, implanting an osteochondral graft restored MCP and PCP to 96% (p = 0.56) and 92% (p = 0.41) of the control values. Lateral meniscectomy with grafting decreased CA by 54% and increased PCP by 79% compared to the intact stifle (p < 0.01).
OAT restored contact pressures in stifles with a simulated lateral condylar defect when the meniscus was intact. The lateral meniscus has a significant role in maintaining normal contact pressures in both stifles with a defect or following OAT. Meniscectomy should be avoided when a femoral condylar defect is present and when performing OAT.
Osteochondral autograft transfer; Contact mechanics; Pressure; Meniscus; Meniscectomy
AIM: To investigate donor site’s area histological and immunohistochemical knee cartilage appearances after resurfacing iatrogenic defects with biosynthetic plugs orautografts.
METHODS: Thirty New Zealand White rabbits were used in this study. A full-thickness cylindrical defect of 4.5 mm (diameter) × 7 mm (depth) was created with a hand drill in the femoral groove of every animal. In Group A (n = 10) the defect of the donor site was repaired with a biosynthetic osteochondral plug, in Group B (n = 10) with an osteochondral autograft, while in Group C (control group of 10) rabbits were left untreated.
RESULTS: Twenty-four weeks postoperatively, smooth articular cartilage was found macroscopically in some trocleas’ surfaces; in all others, an articular surface with discontinuities was observed. Twenty-eight out of 30 animals were found with predominantly viable chondrocytes leaving the remaining two -which were found only in the control group- with partially viable chondrocytes. However, histology revealed many statistical differences between the groups as far as the International Cartilage Repair Society (ICRS) categories are concerned. Immunofluoresence also revealed the presence of collagen II in all specimens of Group B, whereas in Group A collagen II was found in less specimens. In Group C collagen IIwas not found.
CONCLUSION: The matrix, cell distribution, subchondral bone and cartilage mineralization ICRS categories showed statistically differences between the three groups. Group A was second, while group B received the best scores; the control group got the worst ICRS scores in these categories. So, the donor site area, when repairing osteochondral lesions with autografting systems, is better amended with osteochondral autograft rather than bone graft substitute implant.
Autografts; Synthetic plug; Osteochondral defects; Rabbit model; animal study; Donor site; Immunofluoresence; Histological evaluation; International Cartilage Repair Society score
Cam-type, pincer, and mixed femoroacetabular impingement (FAI) are accepted causes of labral and acetabular rim injury; however, the abnormal contact stresses associated with motion may damage other areas of the hip. Although cartilage damage to the femoral head has been reported previously in athletes, FAI-associated focal parafoveal chondral defects differ from previously reported lesions and represent a rare manifestation of the complex pathomechanics associated with FAI.
We describe the clinical, radiographic, and surgical characteristics of a rare focal anterolateral parafoveal femoral chondral defect associated with FAI.
We retrospectively reviewed 10 patients with symptomatic FAI diagnosed with this unique focal defect confirmed at the time of surgical dislocation. Patients presented with hip pain, clinical findings of FAI, and, frequently, with an identifiable lesion on MRI arthrography. The minimum clinical followup was 12 months (mean, 29 months; range, 12–72 months).
The consistent characteristics of these lesions associated with FAI differ from previously reported femoral chondral damage reported after hip dislocation or lateral impact in that there was no discrete injury such as a fall or dislocation/subluxation, no associated traumatic femoral lesion, and all were localized to the posterosuperior femoral head. Eight of 10 were diagnosed preoperatively using MR arthrography.
Despite radiographic similarities to findings of osteoarthritis and osteonecrosis, these FAI-associated femoral chondral defects were amenable to surgical reconstruction using first- or second-generation cartilage repair techniques during surgical treatment of impingement. The etiology of these lesions may be related to complex intraarticular forces generated by FAI-associated transient hip subluxation or forceful nonconcentric motion.
Level of Evidence
Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
Articular cartilage has limited capacity to repair. Defects greater than 3 mm heal with formation of inferior fibrous cartilage. Therefore, many attempts have been made to find the ideal graft for larger cartilage lesions. Different grafts, such as untreated or cryopreserved osteochondral transplants, have been used with variable success.
Photo-oxidized osteochondral grafts were implanted in both femoral condyles of one ovine knee. Untreated xenogeneic and autogeneic grafts served as controls. Three groups of 8 sheep each were formed and they were sacrificed 6, 12 or 18 months after surgery.
The macroscopic evaluation of the condyle and graft showed a well-maintained cartilage surface in most grafts at all time points. However, the host cartilage matrix deteriorated considerably in all xenogeneic, most autogeneic and fewer of the photo-oxidized grafts at 12 and 18 months, respectively. The blue colour of the photo-oxidized grafts resulting from the process of photo-oxidation was visible in all grafts at 6 months, had diminished at 12 months and had completely disappeared at 18 months after surgery. Histologically a loss of matrix staining was almost never noticed in untreated xenografts, transiently at 6 months in photo-oxidized grafts and increased at 12 and 18 months. Fusion between graft and host cartilage could be seen in photo-oxidized grafts at 12 and 18 months, but was never seen in autografts and xenografts.
The photo-oxidation of osteochondral grafts and its use as transplant appears to have a beneficial effect on cartilage and bone remodelling. Osteochondral grafts pre-treated with photo-oxidation may be considered for articular cartilage replacement and therefore may delay artificial joint replacements in human patients.
The appropriate surgical technique for the treatment of unstable osteochondral lesions of the knee remains unclear and had been traditionally described with an open arthrotomy. Administration of bone grafting material in the knee may be performed for a variety of pathologic conditions, including unstable osteochondritis dissecans, traumatic osteochondral defects, or subchondral fracture nonunion, or for preparation of residual tunnels during revision anterior cruciate ligament reconstruction. Although various grafting materials have been described in the literature, cancellous autograft remains the gold standard for treatment safety and efficacy. We describe a successful technique for arthroscopic delivery of autogenous bone graft during fixation of unstable osteochondral lesions of the knee. When the indication for grafting is established, cancellous autograft is harvested from the proximal tibia, undergoes morcellation, and is soaked in bone marrow aspirate obtained through the harvest window. The bone graft is then packed into a modified tuberculin syringe. After arthroscopic preparation of the unstable osteochondral fragment and the respective donor surface, the tuberculin syringe is placed through a standard arthroscopy portal and the bone graft is introduced into the defect under direct visualization, followed by an appropriate osteochondral fixation technique.
To present two new approaches to acetabular surgery that were established in Berne, and which aim at enhanced visualization and anatomical reconstruction of acetabular fractures.
The trochanteric flip osteotomy allows for surgical hip dislocation, and was introduced as a posterior approach for acetabular fracture management involving the posterior column and wall. For acetabular fractures predominantly involving the anterior column and the quadrilateral plate, the Pararectus approach is described.
Full exposure of the hip joint, as provided by the trochanteric flip osteotomy, facilitates anatomical reduction of acetabular or femoral head fractures and safe positioning of the anterior column screw in transverse or T-shaped fractures. Additionally, the approach enables osteochondral transplantation as a salvage procedure for severe chondral femoral head damage and osteoplasty of an associated inadequate offset at the femoral head–neck junction. The Pararectus approach allows anatomical restoration with minimal access morbidity, and combines advantages of the ilioinguinal and modified Stoppa approaches.
Utilization of the trochanteric flip osteotomy eases visualization of the superior aspect of the acetabulum, and enables the evaluation and treatment of chondral lesions of the femoral head or acetabulum and labral tears. Displaced fractures of the anterior column with a medialized quadrilateral plate can be addressed successfully through the Pararectus approach, in which surgical access is associated with minimal morbidity. However, long-term results following the two presented Bernese approaches are needed to confirm that in the treatment of complex acetabular fractures the rate of poor results in almost one-third of all cases (as currently yielded using traditional approaches) might be reduced by the utilization of the presented novel approaches.
Acetabulum; Osteosynthesis; Hip; Geriatric trauma; Pararectus approach; Surgical hip dislocation
Slipped capital femoral epiphysis (SCFE), causing posterior and inferior displacement and retroversion of the femoral head, is a well-recognized etiology for femoroacetabular impingement (FAI) and can lead to premature arthritis in the young adult. The treatment of malunited SCFE remains controversial. Surgical dislocation and subcapital correction osteotomy (SCO) has been described as a powerful method to correct the proximal femoral deformity.
Between January 2003 and January 2010, 11 patients (12 hips) with closed femoral physes and symptomatic FAI from malunited SCFE were treated with surgical dislocation and SCO. We performed a retrospective review of patient histories, physical exams, operative findings, and pre and postoperative anteroposterior (AP) and groin lateral (GLat) radiographs. Mean follow-up was 61 months.
There were 4 female and 7 male patients with an average age of 15 years at the time of SCO. On the AP radiograph the mean inferior femoral head displacement (AP epiphyseal-neck angle) was significantly improved (-26° to -6°, p<0.001). On the groin lateral radiograph the mean posterior femoral head displacement (Lateral epiphyseal-neck angle) was significantly improved (-45° to -3°, p<0.001). The mean alpha angle was also significantly improved on both views (AP: 85° to 56°, P<0.001; GLat: 85° to 46°, p<0.001). Operative findings included one femoral osteochondral defect, 8 Outerbridge grade 3-4 acetabular cartilage lesions, and 10 labral lesions. Significant improvement of the mean Harris hip score (HHS) was seen at latest follow-up (54 to 77, p=0.016). Complications occurred in 4 of the 12 cases with AVN in two patients, a worse postoperative HHS in one patient, and failure of fixation treated successfully with revision open reduction internal fixation in one patient.
Subcapital correction osteotomy as an adjunct to surgical dislocation and osteochondroplasty can be used to correct the deformity of the proximal femur associated with malunited SCFE. Normalization of proximal femoral anatomy may postpone progression to severe osteoarthritis and thus delay the need for arthroplasty in this young patient population. However, surgeons and patients should be aware that the risks of this procedure in this population are significant.
The purpose of this study was to present the preliminary clinical and radiographic outcomes of the treatment of femoral head osteochondral defects in eight consecutive symptomatic patients with fresh-stored osteochondral allografts via a trochanteric osteotomy.
This study included all consecutive patients treated in our department between 2008 and 2010 for worsening pain and mechanical symptoms of femoral head osteochondral defects. Each patient had preoperative routine hip radiographs and a preoperative magnetic resonance imaging study that determined and recorded the defect size and femoral head diameters. Allograft donors were identified through the Multiple Organ Retrieval and Exchange program (Ontario, Canada).
The osteochondral defects were secondary to osteochondritis dissecans in four patients, avascular necrosis in three and femoral head fracture without dislocation in one. The patients’ average age at surgery was 23.7 (range 17–42), and the average follow-up was 41 months (range 24–54). Follow-up included clinical and radiographic examinations at standard intervals. The average Harris hip scores improved from 57.7 (range 50–65) points preoperatively to 83.9 (range 72–94) points at latest follow-up. Five patients had good-to-excellent clinical outcomes, and one had a fair outcome. One patient was converted to a total hip arthroplasty due to progression of arthritis. Another patient’s graft subsided and he underwent a successful repeat transplantation. An additional patient required the removal of the screws transfixing her trochanter due to persistent irritation.
These findings indicate that fresh-stored osteochondral allograft transplantation using a trochanteric slide and surgical dislocation is a viable treatment option for femoral head defects in young patients.
The aim of this study was to evaluate subsidence tendency, surface congruency, chondrocyte survival and plug incorporation after osteochondral transplantation in an animal model. The potential benefit of precise seating of the transplanted osteochondral plug on the recipient subchondral host bone (‘bottoming’) on these parameters was assessed in particular.
In 18 goats, two osteochondral autografts were harvested from the trochlea of the ipsilateral knee joint and inserted press-fit in a standardized articular cartilage defect in the medial femoral condyle. In half of the goats, the transplanted plugs were matched exactly to the depth of the recipient hole (bottomed plugs; n = 9), whereas in the other half of the goats, a gap of 2 mm was left between the plugs and the recipient bottom (unbottomed plugs; n = 9). After 6 weeks, all transplants were evaluated on gross morphology, subsidence, histology, and chondrocyte vitality.
The macroscopic morphology scored significantly higher for surface congruency in bottomed plugs as compared to unbottomed reconstructions (P = 0.04). However, no differences in histological subsidence scoring between bottomed and unbottomed plugs were found. The transplanted articular cartilage of both bottomed and unbottomed plugs was vital. Only at the edges some matrix destaining, chondrocyte death and cluster formation was observed. At the subchondral bone level, active remodeling occurred, whereas integration at the cartilaginous surface of the osteochondral plugs failed to occur. Subchondral cysts were found in both groups.
In this animal model, subsidence tendency was significantly lower after ‘bottomed’ versus ‘unbottomed’ osteochondral transplants on gross appearance, whereas for histological scoring no significant differences were encountered. Since the clinical outcome may be negatively influenced by subsidence, the use of ‘bottomed’ grafts is recommended for osteochondral transplantation in patients.
Autologous osteochondral transplantation; Osteochondral defect; Cartilage repair; Cartilage defect; Histology
Young patients with cartilage defects in the hip present a complex problem for the treating physician with limited treatment modalities available. Cartilage repair/replacement techniques have shown promising results in other joints, however, the literature regarding the hip joint is limited. The purpose of the current study is to conduct a systematic review of clinical outcomes following various treatments for chondral lesions of the hip and define the techniques for the treatment of these cartilage defects. The full manuscripts of 15 studies were reviewed for this systematic review including case studies, case series, and clinical studies. A variety of techniques have been reported for the treatment of symptomatic chondral lesions in the hip. Microfracture, cartilage repair, autologous chondrocyte implantation, mosaicplasty, and osteochondral allografting have all been used in very limited case series. Although good results have been reported, most studies lack both a control group and a large number of patients. However, the reported results in this article do provide a good foundation for treatments and stimulant for further study in an inherently difficult to treat young patient population with articular cartilage defects in the hip.
Hip; Cartilage; Sports; Musculoskeletal; Operative treatment
Traumatic chondral lesions of the knee are common in football and rugby players. The diagnosis is often confirmed by arthroscopy which can be therapeutic by performing microfracture. Prospective information about the clinical results after microfracture is still limited.
To evaluate the short-term outcome of microfractured lesions in professional football ad rugby players in terms of healing and ability to return to play.
Twenty-four consecutive professional male players with isolated full-thickness articular cartilage defects on weight-bearing surface of femoral condyles were treated with microfracture. Clinical assessment of healing was done at three, six, 12 and at 18 months by using modified Cincinnati subjective and objective functional scoring. All 24 subjects were periodically scanned by 3-Tesla MRI on the day of the clinical evaluations and scored by the Henderson MRI classification for cartilage healing. A second look arthroscopy was carried out in 10 players five to seven months after surgery to evaluate lesion healing by using ICRS scoring system. This was done due to presence of discrepancy between a "normal" MRI and persistent clinical symptoms.
This study showed that 83.3% of players' resume full training between five to seven months (mean: 6.2) after microfracture of full-thickness chondral lesions of weight-bearing surface of the knee. Function and MRI knee scores of the 24 subjects gradually improved over 18 months, and showed good correlation in assessing healing after microfracture at six, 12 and 18 months (r2 = 0.993, 0.986 and 0.993, respectively) however, the second look arthroscopy score proved to have stronger strength of association with function score than MRI score.
We confirmed that microfracture is a safe and effective procedure in treating isolated traumatic chondral lesions of the load-bearing areas of the knee. Healing as defined by subjective symptoms and evaluated by MRI and a modified knee function score occurred between 5 to 7 months in most cases, which is a reasonable absence period for the majority of players to resume their normal sports activity without risking contracts and careers. MRI correlated well with the functional knee score, but neither of these methods were totally reliable in confirming healing at the defect site. Arthroscopic probing is therefore still the gold standard in our view. From a strict scientific stand point an untreated control group would be valuable to demonstrate that microfracture does not just mirror the natural course of healing.
Aim. The aim of our study was to assess macro– and microscopically the knee cartilaginous lesions outcome treated by mosaicplasty.
Material and method Our study included 32 patients which underwent mosaicplasty for nondegenerative cartilaginous lesions of the knee and a second look arthroscopy. In 21 patients, minibiopsies from the repaired lesion were performed under arthroscopic control (from the cartilaginous region of the transplanted osteocartilaginous grafts and from the spaces between grafts). All repaired lesions were carefully examined during arthroscopy and all harvested minifragments were studied by optical microscopy (staining method – hematoxylin eosin).
Results Macroscopically, the articular surface of the repaired cartilaginous lesions was smooth and congruent to the adjacent surfaces. The aspect and resistance to compression of grafted area was similar to those of the normal surrounding cartilage. The transferred cartilage maintained its height, being at the level of the neighboring cartilage. One year postoperatively, the limits of the cartilaginous autografts were still visible. Two years postoperatively, these limits were no longer visible. Microscopically, the region of the former lesion was constituted mainly by viable hyaline cartilage. Fibrous cartilaginous tissue was visualized in the spaces between the grafts.
Conclusions The second look arthroscopy showed that after mosaicplasty the repaired articular surface was smooth, leveled, homogenous and congruent to adjacent cartilage. The spaces between grafts are progressively covered by fibrous cartilaginous tissue with a more textured and uneven surface. Mosaicplasty is a biological surgical technique which restores the normal osteocartilaginous architecture of the most part of the grafted area. The transplanted osteocartilaginous cylindrical grafts maintain its viability and mechanical properties.
arthroscopy; minibiopsy; histopathology; osteocartilaginous autografts
Lateral Patella dislocations are common injuries seen in the active and young adult populations. Our study focus was to evaluate medial patellofemoral ligament (MPFL) injury patterns and associated knee pathology using Magnetic Resonance Imaging studies.
MRI studies taken at one imaging site between January, 2007 to January, 2008 with the final diagnosis of patella dislocation were screened for this study. Of the 324 cases that were found, 195 patients with lateral patellar dislocation traumatic enough to cause bone bruises on the lateral femoral trochlea and the medial facet of the patella were selected for this study. The MRI images were reviewed by three independent observers for location and type of MPFL injury, osteochondral defects, loose bodies, MCL and meniscus tears. The data was analyzed as a single cohort and by gender.
This study consisted of 127 males and 68 females; mean age of 23 yrs. Tear of the MPFL at the patellar attachment occurred in 93/195 knees (47%), at the femoral attachment in 50/195 knees (26%), and at both the femoral and patella attachment sites in 26/195 knees (13%). Attenuation of the MPFL without rupture occurred in 26/195 knees (13%). Associated findings included loose bodies in 23/195 (13%), meniscus tears 41/195 (21%), patella avulsion/fracture in 14/195 (7%), medial collateral ligament sprains/tears in 37/195 (19%) and osteochondral lesions in 96/195 knees (49%). Statistical analysis showed females had significantly more associated meniscus tears than the males (27% vs. 17%, p = 0.04). Although not statistically significant, osteochondral lesions were seen more in male patients with acute patella dislocation (52% vs. 42%, p = 0.08).
Patients who present with lateral patella dislocation with the classic bone bruise pattern seen on MRI will likely rupture the MPFL at the patellar side. Females are more likely to have an associated meniscal tear than males; however, more males have underlying osteochondral lesions. Given the high percentage of associated pathology, we recommend a MRI of the knee in all patients who present with acute patella dislocation.
Complications of patellar dislocation include osteochondral injury of the lateral femoral condyle and patella. Most cases of osteochondral injury occur in the anterior region, which is the non-weight-bearing portion of the lateral femoral condyle. We describe two patients with osteochondral injury of the weight-bearing surface of the lateral femoral condyle associated with lateral dislocation of the patella. The patients were 18- and 11-year-old females. Osteochondral injury occurred on the weight-bearing surface distal to the lateral femoral condyle. The presence of a free osteochondral fragment and osteochondral injury of the lateral femoral condyle was confirmed on MRI and reconstruction CT scan. Treatment consisted of osteochondral fragment fixation or microfracture, as well as patellar stabilization. Osteochondral injury was present in the weight-bearing portion of the lateral femoral condyle in both patients, suggesting that the injury was caused by friction between the patella and lateral femoral condyle when the patella was dislocated or reduced at about 90° flexion of the knee joint. These findings indicate that patellar dislocation may occur and osteochondral injury may extend to the weight-bearing portion of the femur even in deep flexion, when the patella is stabilized on the bones of the femoral groove.