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Osteochondral autograft for cartilage lesions of the knee


OVERVIEW

Chapter synopsis

Osteochondral autograft transplant surgery (OATS) remains an important technique for medium (1 to 3 cm 2 ) chondral and osteochondral defects. When appropriate indications are met, very good success rates can be expected. Meticulous technique for single-plug or multiple-plug (“mosaicplasty”) transplant surgery is imperative to achieve a congruent articulation.

Important points

  • Physical examination findings are often unimpressive. Operative decision-making is based more on history, radiographs, or magnetic resonance imaging scans, and initial arthroscopic findings.

  • Inappropriate indications or overlooking contraindications may lead to early autograft failure.

  • Indications: Isolated small to medium (1 to 3 cm 2 ) full-thickness chondral or osteochondral lesions.

  • Contraindications: Generalized or inflammatory arthritis, uncorrected malalignment, uncorrected knee instability

  • Technique can be performed arthroscopically or via an open technique. Larger defects that require multiple plugs, are best performed via an open technique.

Clinical/surgical pearls

Preoperatively

  • Thoroughly evaluate need for malalignment correction or ligament stabilization before OATS.

  • Ensure patient can comply with prolonged non-weight-bearing status postoperatively.

Intraoperatively

  • Make sure graft harvest, recipient site coring, and graft implantation are performed with a trajectory perpendicular to the articular surface.

Postoperatively

  • Monitor patient for painful hemarthrosis that may limit range of motion.

Clinical/surgical pitfalls

  • Postoperative hemarthrosis may occur secondary to donor site defect. Backfilling the donor site with bone and cartilage cored from recipient site may help healing and prevent hemarthrosis.

  • Drains are placed intraoperatively and may be removed in the recovery room or the next day.

  • If hemarthrosis develops, aspiration may be required in the office on the follow-up visit to alleviate pain and maximize early range of motion.

Introduction

Articular cartilage defects are a relatively common problem encountered by sports medicine physicians. Isolated cartilage defects can occur secondary to acute trauma or can be atraumatic in nature. The latter often occurs in the form of osteochondritis dissecans, the cause of which is not fully understood, and can be found in juveniles and adults. The distinction is important because patients with open physis have a much better prognosis with nonoperative treatment.

Patients with symptomatic focal cartilage defects are candidates for operative treatment to relieve symptoms and also to prevent subsequent arthritic changes. Surgical treatment options include arthroscopic debridement, microfracture, autologous chondrocyte implantation (ACI), matrix-induced chondrocyte transplantation, osteochondral autograft transplant surgery (OATS), and osteochondral allograft transplantation. OATS may be the best option in appropriately selected patients. There are several different transplant systems available, but the concept remains the same: the transplantation of full-thickness osteochondral bone plugs from an area of the knee that is nonweight-bearing or has low contact pressures to the osteochondral defect of the ipsilateral knee.

Preoperative considerations

History

  • Age of the patient may vary from adolescence to middle age

  • Intermittent pain, swelling, mechanical symptoms

  • Pain elicited by low- or high-impact activities

  • Frequently a history of acute or distant trauma, including patellar dislocation, meniscal disruption

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