The Long-Term Clinical Outcomes Following Autogenous Bone Grafting for Large-Volume Defects of the Knee

Abstract

Objective:We report the long-term clinical outcomes of patients who underwent autogenous bone grafting of large-volume osteochondral defects of the knee due to osteochondritis dessicans (OCD) and osteonecrosis (ON). This is the companion report to one previous published on the biological response. We hypothesized that these grafts would integrate with host bone and the articular surface would form fibrocartilage providing an enduring clinical benefit.Design:Three groups (patients/knees) were studied: OCD without a fragment (n = 12/13), OCD with a partial fragment (n = 14/16), and ON (n = 25/26). Twenty-five of 52 patients were available for clinical follow-up between 12 and 21 years. Electronic medical records provided comparison clinical information. In addition, there were plain film radiographs, MRIs, plus repeat arthroscopy and biopsy on 14 patients.Results:Autogenous bone grafts integrated with the host bone. MRI showed soft tissue covering all the grafts at long-term follow-up. Biopsy showed initial surface fibrocartilage that subsequently converted to fibrocartilage and hyaline cartilage at 20 years. OCD patients had better clinical outcomes than ON patients. No OCD patients were asymptomatic at anytime following surgery. Half of the ON patients came to total knee replacement within 10 years.Conclusions:Autogenous bone grafting provides an alternative biological matrix to fill large-volume defects in the knee as a singular solution integrating with host bone and providing an enduring articular cartilage surface. The procedure is best suited for those with OCD. The treatment for large-volume articular defects by this method remains salvage in nature and palliative in outcome.

Autologous Chondrocyte Implantation “Sandwich” Technique Compared With Autologous Bone Grafting for Deep Osteochondral Lesions in the Knee

“…This relatively high failure rate was consistent with our results that showed that 2 of 3 patients with AVN failed after ABG alone (1 patient with ACI at 5 months; the other patient with TKA at 15 years). Moreover, when considering that they treated an older population (mean age, 47 years) than our cohort (mean age, 30 years in the ACI sandwich group), ABG alone appears not to be a suitable option for young, active patients who were counseled to have lessened expectations for symptoms and activities after ABG by Johnson et al 22…”

“…Recently, Johnson et al 22 have reported long-term outcomes after ABG for the treatment of OCD and osteonecrosis. Their cohort of patients with OCD included 2 different groups: one with ABG plus repair of the cartilage fragment and the other one with ABG without the cartilage fragment.…”

“…ABG and the ACI sandwich technique were performed as previously described. 22,31,46 For ABG, after arthrotomy, the chondral defect was removed, and the sclerotic or necrotic bone was debrided back to healthy-appearing bone and cartilage tissue with a high-speed bur under constant irrigation (Figure 1). The base of the bony cavity was multiply drilled to enhance the blood supply and healing.…”

“…36 However, once defects become deeper (>8-15 mm) and have associated subchondral cystic and sclerotic bone changes, the osteochondral unit requires bone and cartilage restoration. Techniques for deep osteochondral defects include osteochondal autograft transplantation, 19 fresh matched osteochondral allograft transplantation (OCA), 14,16,17 autologous bone grafting (ABG) in isolation, 22,44 and the recently described ACI sandwich technique. 3,4,31,46…”

What I Have Seen and Learned Since Looking Through an Arthroscope: 43 Years and Counting

“…4 When the more severe pathological articular disruption of largevolume femoral defects of the knee were treated by arthroscopy, the results were similar regarding avoidance or delay of total knee surgery. 32 Even more amazing was one patient with the largest of bilateral femoral lesions. At 17 years following surgery, he had a normal range of motion of both knees and unaided normal ambulation.…”