CC BY-NC-ND 4.0 · Rev Bras Ortop (Sao Paulo) 2019; 54(03): 316-321
DOI: 10.1055/s-0039-1691763
Artigo Original | Original Article
Sociedade Brasileira de Ortopedia e Traumatologia. Published by Thieme Revnter Publicações Ltda Rio de Janeiro, Brazil

Mosaicplasty Technique in the Treatment of Isolated Knee Femoral Condyle Osteochondral Lesions – a Retrospective Study[*]

Article in several languages: português | English
Samir Karmali
1   Departamento Ortopédico, Hospital Vila Franca de Xira, Vila Franca de Xira, Portugal
,
Rui Guerreiro
1   Departamento Ortopédico, Hospital Vila Franca de Xira, Vila Franca de Xira, Portugal
,
Daniel Sá da Costa
1   Departamento Ortopédico, Hospital Vila Franca de Xira, Vila Franca de Xira, Portugal
,
Jorge Fonseca
1   Departamento Ortopédico, Hospital Vila Franca de Xira, Vila Franca de Xira, Portugal
,
2   Departamento Ortopédico, Unidade de Ombro e Cotovelo, Hospital Privado de Gaia, Vila Nova de Gaia, Portugal
› Author Affiliations
Further Information

Address for correspondence

Ricardo Gonçalves, MD
Departamento Ortopédico, Unidade de Ombro e Cotovelo
Hospital Privado de Gaia, Rua Fernão de Magalhães, n° 2, Fração E, 24 4404-501, Vila Nova de Gaia
Portugal   

Publication History

07 January 2018

28 May 2018

Publication Date:
27 June 2019 (online)

 

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 to mosaicplasty and to subjective analyses with pre- and postsurgery International Knee Documentation 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 the minimal score increase of 8.1 points and the maximum score increase of 82.8 points. A statistically 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 mid-term and long-term results.


#

Introduction

Focal osteochondral lesions of the knee are found in two thirds of patients undergoing arthroscopy.[1] The treatment of these lesions, when these are isolated and especially in young individuals, remains a debating topic.[2] [3] [4] 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.[2] [4] [5] [6] 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).[2] [3] 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.[2] [7] [8] [9] 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.


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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 criteria

Age ≥ 16 years old and ≤ 60 years old

Isolated femoral condyle osteochondral lesion

Grade III/IV (Outerbrigde)

Size ≤ 4 cm2

Follow-up > 1 year

Exclusion criteria

Associated lesions (e.g., tibia or patella)

Malalignment or previous realignment surgery

Ligamentar instability

Inflammatory disease

The procedure was performed using the Osteochondral Autograft Transfer System (OATS) (Arthrex, Inc., Naples, FL, USA) and according to the technique described by Hangody[7], 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.

Zoom Image
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).


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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.

Zoom Image
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.
Zoom Image
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

n

Age (years)

Gender[*]

Localization[**]

Size (cm2)

Preoperative IKDC

Postoperative IKDC

Follow-up (years)

1

25

M

MFC

1

79.3

100

3.00

2

16

F

MFC

3

46

90.8

11.01

3

16

F

LFC

4

36.8

88.5

11.01

4

17

M

MFC

2

3.3

44.8

8.01

5

54

F

MFC

1

54

62.1

6.79

6

18

M

MFC

3

18.4

92

4.00

7

36

F

MFC

2

17.2

100

2.00

8

30

F

LFC

1

40.2

85.1

3.00

9

42

F

MFC

0.6

17.2

44.8

2.36

10

48

F

MFC

2

12.6

72.4

1.15

11

56

F

MFC

0.9

27.6

50.6

2.78

12

31

M

MFC

1

34.5

74.7

7.97

13

53

F

MFC

2

24.1

58.6

2.51


#

Discussion

The treatment of articular cartilage lesions comprises procedures of palliation (debridement and chondroplasty), repair (microfracture), and reconstruction (ACI, OTA, and OCA).[2] [4] [10] 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.[11] The latter shows more longevity and durability of results, especially among high functional demand patients, when compared with microfractures.[3] [4] When lesions range from 2 to 4 cm2, they should be treated by OTA or by ACI.[3] 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).[3] 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.[2] [3] [7] [8] [9] 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).[2] [3] 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.[9] [12] [13]


#

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.


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Conflitos de Interesses

Os autores declaram não haver conflitos de interesses.

* The present study was conducted at the Orthopedic Department, Hospital Vila Franca de Xira, Portugal.


  • Referências

  • 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 III RJ. 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 III RJ. 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. 02) 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 Jr RC, 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

Address for correspondence

Ricardo Gonçalves, MD
Departamento Ortopédico, Unidade de Ombro e Cotovelo
Hospital Privado de Gaia, Rua Fernão de Magalhães, n° 2, Fração E, 24 4404-501, Vila Nova de Gaia
Portugal   

  • Referências

  • 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 III RJ. 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 III RJ. 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. 02) 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 Jr RC, 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

Zoom Image
Fig. 1 Técnica cirúrgica: (a) lesão osteocondral do côndilo femoral medial; (b) área doadora - área troclear circunferencial sem sustentação de peso; (c) e (d) reparo final.
Zoom Image
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.
Zoom Image
Fig. 2 Resultados: o gráfico em barras mostra a pontuação do IKDC antes e após a cirurgia em cada paciente do estudo. Idade e acompanhamento em anos; Tamanho em cm2. Abreviaturas: F, feminino; IKDC, International Knee Documentation Committee; LFC, côndilo femoral lateral; M, masculino; MFC, côndilo femoral medial; -Δ IKDC = IKDC pós-operatório - IKDC pré-operatório.
Zoom Image
Fig. 3 Os gráficos em boxplot mostram as pontuações de IKDC antes e após a cirurgia, com análise estatística por teste não paramétrico de Wilcoxon de amostras pareadas, realizado no IBM SPSS Statistics for Windows, Versão 22.0) – p < 0,001. Abreviações: IKDC, International Knee Documentation Committee.
Zoom Image
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.
Zoom Image
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.