Osteochondral transplantation using autografts from the upper tibio-fibular joint for the treatment of knee cartilage lesions

Abstract

Purpose Treatment of large cartilage lesions of the knee in weight-bearing areas is still a controversy and challenging topic. Autologous osteochondral mosaicplasty has proven to be a valid option for treatment but donor site morbidity with most frequently used autografts remains a source of concern. This study aims to assess clinical results and safety profile of autologous osteochondral graft from the upper tibio-fibular joint applied to reconstruct symptomatic osteochondral lesions of the knee. Methods Thirty-one patients (22 men and 9 women) with grade 4 cartilage lesions in the knee were operated by mosaicplasty technique using autologous osteochondral graft from the upper tibio-fibular joint, between 1998 and 2006. Clinical assessment included visual analog scale (VAS) for pain and Lysholm score. All patients were evaluated by MRI pre-and post-operatively regarding joint congruency as good, fair (inferior to 1 mm incongruence), and poor (incongruence higher than 1 mm registered in any frame). Donor zone status was evaluated according to specific protocol considering upper tibio-fibular joint instability, pain, neurological complications, lateral collateral ligament insufficiency, or ankle complaints. Results Mean age at surgery was 30.1 years (SD 12.2). In respect to lesion sites, 22 were located in weight-bearing area of medial femoral condyle, 7 in lateral femoral condyle, 1 in trochlea, and 1 in patella. Mean follow-up was 110.1 months (SD 23.2). Mean area of lesion was 3.3 cm 2 (SD 1.7), and a variable number of cylinders were used, mean 2.5 (SD 1.3). Mean VAS score improved from 47.1 (SD 10.1) to 20.0 (SD 11.5); p = 0.00. Similarly, mean Lysholm score increased from 45.7 (SD 4.5) to 85.3 (SD 7.0); p = 0.00. The level of patient satisfaction was evaluated, and 28 patients declared to be satisfied/very satisfied and would do surgery again, while 3 declared as unsatisfied with the procedure and would not submit to surgery again. These three patients had lower clinical scores and kept complaints related to the original problem but unrelated to donor zone. MRI score significantly improved at 18-24 months comparing with pre-operative (p = 0.004). No radiographic or clinical complications related to donor zone with implication in activity were registered. Conclusions This work corroborates that mosaicplasty technique using autologous osteochondral graft from the upper tibio-fibular joint is effective to treat osteochondral defects in the knee joint. No relevant complications related to donor zone were registered. Level of evidence Case series, Level IV.

Knee donor-site morbidity after mosaicplasty – a systematic review

“…of previous surgeriesNo. concomitant proceduresFollow-up (months)Radiological outcomesSatisfaction (%)Return to sports activity (%)Second-look arthroscopy (%)ComplicationsKnee Atik et al (2005)Minimal weightbearing area of the patellofemoral joint or the intercondylar notch area3.5≤5N.R.N.R.N.R.48Normal shiny appearance and color of the grafted area (100 %) a N.R.N.R.42Slight joint effusion ( n  = 12). Espregueira-Mendes et al (2012)Upper tibio-fibular jointN.R.2.5 (1-6)N.R.N.R.N.R.110.1MRI-scoring system: good (26 %), fair (65 %) and poor (10 %) d 90N.R.N.R.N.R. Gudas et al (2005)Lateral/medial margin of the femoral trochlea5.54.3 (3-6)21.30N.R.37.1ICRS: 27 (96 %) good to excellent results. cd N.R.9350Superficial infection ( n  = 2). Hangody et al (2008)Margin of the medial and lateral femoral condyle superior to the sulcus terminalis and notch area (for larger defects)N.R.N.R.N.R.N.R.783At least 12N.R.N.R.N.R.10Deep infections ( n  = 4), painful haemarthroses ( n  = 56), minor thromboembolic complications ( n  = 4). Hangody et al (2010)Margin of the medial and lateral femoral condyle superior to the sulcus terminalis4.5-8.52.7 (1-9)N.R.N.R.225115.2Fairbank: grades I-II in 19 % and grades II-III in 8% c 90917Septic arthritis ( n  = 2), intra-articular hemorage ( n  = 2). Jakob et al (2002)Medial and the lateral edging of the femoral trochlea and notch area (for larger defects)6.36 (1-16)N.R.34737ICRS: nearly normal (grade II) in 91% d Demarcating border (<1 mm) between the grafted surface and the surrounding cartilage d Smooth or slightly fibrillated surface of autografts d 885224Reflex sympathetic dystrophy ( n  = 1), graft failure ( n  = 4), severe infection ( n  = 1) and postoperative joint stiffness ( n  = 1). K...…”

“…In this sense, several alternative donor-site areas for mosaicplasty harvesting have been proposed. While the posterior femoral condyles and the calcaneal tuberosity cartilage were considered as unsuitable donor-site alternatives for osteochondral autografting (Calder et al 2015; Thaunat & Beaufils 2010), the lower weight-bearing area of the patellofemoral joint and the upper tibio-fibular joint showed promising results in humans without donor-site morbidity associated (Espregueira-Mendes et al 2012; Atik et al 2005). …”

Good clinical outcome after osteochondral autologous transplantation surgery for osteochondral lesions of the talus but at the cost of a high rate of complications: a systematic review

“…Articles show contradictory results regarding the influence of number and size of grafts on surgery outcome 18 25 28 36 39 45 54. To come to any conclusions, further research on this subject and on donor site morbidity is required.…”

Current concepts: tissue engineering and regenerative medicine applications in the ankle joint

“…Still, despite several successes reported by the followers of this technique [106], up to now there is no evidence-based medicine to support their use, with no proven cost-effective advantages as compared to ‘classic’ treatment options such as microfractures or osteochondral grafting techniques (OAT, mosaicplasty) [107–111]. …”