Surgical Management of Articular Cartilage Defects in the Knee

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Surgical Management of Articular Cartilage Defects in the Knee
Brian J. Cole, Cecilia Pascual-Garrido and Robert C. Grumet
J Bone Joint Surg Am. 2009;91:1778-1790.

                            This information is current as of October 28, 2009

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                                                                                       DEFECTS IN THE KNEE

                    Surgical Management of Articular
                      Cartilage Defects in the Knee
                          By Brian J. Cole, MD, MBA, Cecilia Pascual-Garrido, MD, and Robert C. Grumet, MD

                                    An Instructional Course Lecture, American Academy of Orthopaedic Surgeons

Articular cartilage is vulnerable to                     with which to organize thoughts. In                 salvage operations later. If the symp-
traumatic injury and subsequent de-                      general, surgical options can be grouped            toms persist despite conservative treat-
generation. These changes are likely                     into three categories: palliative (arthro-          ment, subsequent treatments are not
related to the limited capacity for car-                          ´
                                                         scopic debridement and lavage), repar-              impeded by previous management.
tilage repair, poor vascular supply, and                 ative (marrow stimulation techniques),
deficiency in terms of the ability of an                  and restorative (osteochondral grafting             Decision-Making
undifferentiated cell population to re-                  and autologous chondrocyte implanta-                When treating articular cartilage lesions
spond to the insult. While the natural                   tion). All of these techniques have been            in the knee, the surgeon should focus on
history of isolated chondral and osteo-                  reported to improve the clinical status as          patient-specific and defect-specific var-
chondral defects is not predictable,                     compared with the preoperative state.               iables and avoid ‘‘linear thinking.’’ The
clinical experience suggests that, when                  Thus, the appropriate treatment for any             clinical presentation should correlate
left untreated, these lesions do not heal                given cartilage lesion is patient-specific.          with the underlying pathoanatomy. For
and may progress to symptomatic de-                      The size and location of the lesion, the            example, a patient with known classic
generation of the joint1. Therefore, early               physical demands of the patient, and the            osteochondritis dissecans of the medial
surgical intervention for symptomatic                    treatment history all are important                 femoral condyle who reports bilateral
lesions is often suggested in an effort to               preoperative considerations. In addi-               anterior knee pain with stair-climbing
restore normal joint congruity and                       tion, the surgeon must consider what                should be evaluated initially with a
pressure distribution and prevent fur-                   subsequent treatment options are                    presumptive diagnosis of patellofemoral
ther injury. Treatment recommenda-                       available if the current treatment fails to         pain before ascribing the symptoms to
tions are made after an evaluation of                    relieve the symptoms. A realistic and               the osteochondritis dissecans lesion.
symptomatic lesions and should be                        comprehensive understanding of the                  Because the natural history of cartilage
tailored to the specifics of each case.                   patient’s goals is critical to any decision         lesions is not known and the surgical
       The goals of surgical treatment                   regarding how to treat a symptomatic                treatments are neither benign nor as-
are to provide pain relief and improve                   chondral defect. In keeping with these              sociated with a predictable outcome
joint function, thus allowing patients to                principles, the treatment algorithm                 (particularly with regard to the preven-
comfortably perform activities of daily                  consists of a graduated surgical plan.              tion of arthritis), surgical decision-
living and potentially maintain or                       The least destructive and least invasive            making must be taken quite seriously.
return to higher levels of activity. Mul-                treatment option necessary to alleviate                    Understanding and addressing the
tiple algorithms have been described in                  the symptoms and restore joint function             patient’s specific concerns and goals are
an effort to simplify the treatment of                   is performed first. The more extensive               critical to achieving a successful outcome
cartilage lesions. These are useful tools                treatments are reserved for potential               from the patient’s perspective. More spe-

Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member
of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

J Bone Joint Surg Am. 2009;91:1778-90
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                        Fig. 1
                         Treatment algorithm for focal chondral lesions. Before treatment, it is important to assess the
                         presence of correctable lesions. Surgical treatment should be considered for trochlear and patellar
                         lesions only after use of rehabilitation programs has failed. The treatment decision is guided by the
                         size and location of the defect, the patient’s demands, and whether it is first or second-line treatment.
                         ACL = anterior cruciate ligament, PCL = posterior cruciate ligament, MFX = microfracture, OATS =
                         osteochondral autograft transplantation, ACI = autologous chondrocyte implantation, OCA = os-
                         teochondral allograft, AMZ = anteromedialization, 11 = best treatment option, and 12 = possible
                         option depending on patient’s characteristics.

cifically, patients often express concerns                 family commitments, risk-aversion                   those who are relatively young. Finally,
about whether it is safe to remain active                 (desire to avoid subsequent surgical                one must carefully search for associated
despite symptoms and whether a delay in                   procedures), responsiveness and reha-               pathological conditions, such as mal-
surgical intervention precludes certain                   bilitation after previous surgical treat-           alignment, ligament insufficiency, and
treatment options because of disease                      ments, and the patient’s specific                    concomitant meniscal deficiency, that
progression. In addition, knowledge of the                concerns related to his or her problem              may contribute to treatment failure and
specific marginal improvements that a                      are all important preoperative consid-              should be corrected before or during the
procedure should provide gives the pa-                    erations. While chronologic age is often            surgery to treat the chondral lesion.
tient a reasonable expectation regarding                  cited as a relative indication or contra-                  Defect-specific variables include
the outcome. Unfortunately, the lack of                   indication to cartilage repair, it is really        defect location, number, size, depth,
understanding of the natural history of                   physiologic age that determines the                 and geometry; the condition of the sub-
these defects makes it difficult to advise                 patient’s eligibility for a non-arthroplasty        chondral bone and surrounding cartilage;
patients, and it is best to carry out careful             solution. Typically, patients who be-               and the degree of containment. The
discussions on a case-by-case basis.                      come symptomatic in the fourth or fifth              condition of the apposing surface, which
       Patient age, body mass index,                      decade of life have concomitant chon-               is often overlooked, is also an important
symptom type (weight-bearing pain,                        dral and subchondral disease involving              variable. Even minor areas of early de-
non-weight-bearing pain, swelling, me-                    apposing articular surfaces that pre-               generation make achieving a satisfactory
chanical symptoms, giving-way, and                        cludes a biologic treatment option. In              clinical outcome challenging. Specific
aggravation of symptoms related to                        addition, the results of partial and total          management of each of these defect-
walking on level ground as opposed to                     knee arthroplasty are predictably grati-            specific variables increases the likelihood
stair-climbing), occupation and/or                        fying and satisfy most patients, even               of a good clinical outcome.
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Treatment Algorithm
Malalignment, ligament insufficiency,
and concomitant meniscal deficiency
are assessed and, when necessary, are
treated with a concomitant or staged
osteotomy (high tibial, distal femoral, or
tibial tuberosity), ligament reconstruc-
tion, and perhaps a meniscal allograft
transplantation2. Patellofemoral lesions
are often treated with a simultaneous
realignment procedure such as antero-
medialization of the tibial tuberosity.
Anteromedialization is more successful
for lateral patellofemoral lesions than
it is for lesions located along the
medial aspect of the patellofemoral
joint3. Medial patellofemoral lesions
are treated with a more vertically
oriented anteromedialization2. The
treatment algorithm for chondral le-
sions is guided by the lesion size and
location and the patient activity level
(Fig. 1).                                                                           Fig. 2
       Primary repair is done for any                                               Microfracture. A: Holes should be created 2 to 3 mm
chondral injury that is amenable to                                                 apart, beginning at the periphery of the lesion. Great
fixation. Any acute osteochondral frag-                                              care should be taken to prevent confluence of the
ment or in situ and unstable osteo-                                                 holes. B: A surgical awl is used to create the holes.
chondritis dissecans lesion is repaired                                             The awl is kept perpendicular to the subchondral
primarily. It is particularly critical to fix                                        plate. C: The defect fills with fibrin clot, which is
large fragments (>1 cm2) from the                                                   contained by the vertical walls of intact cartilage
weight-bearing portion of the femoral                                               surrounding the lesion.
condyles. The basic principles for pri-
mary repair include elevation of the                  reparative, or regenerative). Marrow                        lesions with bone loss typically require
unstable fragment, debridement of the                 stimulation techniques are typically a                      an osteochondral allograft.
fibrous base, microfracture if necessary               first-line treatment. These techniques                              Treatment is also guided by the
to gain access to the subchondral blood               are often used for smaller lesions                          location of the lesion. For example,
supply to promote healing, bone-grafting              (<2 cm2), or in patients with larger                        osteochondral allografts are used for
of areas of cystic changes or bone loss,              lesions (>3 cm2) and modest physical or                     femoral condyle lesions because they
and rigid fixation of the fragment under               physiologic demand levels. Small lesions                    allow accurate anatomic reconstruction.
compression. Headless-compression-                    in high-demand patients or those for                        Lesions of the patellofemoral joint are
screw fixation, with subsequent screw                  whom marrow stimulation has failed                          often treated with autologous chondro-
removal in younger patients after eight               can be treated with one or two 10-mm                        cyte implantation because the lesions
weeks of non-weight-bearing, is often                 osteochondral autografts harvested                          are small and the varying anatomic
used. Continuous passive motion for up                from the lateral femoral trochlea just                      concavity and convexity make structural
to six hours each day is recommended.                 proximal to the sulcus terminalis.                          grafts too difficult to fit in place. The tibia
Because fragments can settle over time,               Larger lesions (>2.5 cm2) are typically                     remains a difficult articular surface to
even headless screws can become                       more amenable to osteochondral allo-                        treat. Small tibial lesions that are found
prominent and damage the apposing                     grafting or autologous chondrocyte                          when the femoral articular cartilage is
surface. In addition, performing a                    implantation. Autologous chondrocyte                        being restored are commonly treated
second-look arthroscopy to evaluate the               implantation is advised for younger                         with marrow stimulation techniques.
defect helps the surgeon to judge the                 patients with shallow lesions, especially                   Other options include the utilization of
success of the procedure and to provide               of the patellofemoral joint. This method                    osteochondral autografts placed in a
accurate advice to the patient.                       does not violate the subchondral bone                       retrograde manner with use of a cannu-
       Patients with lesions that cannot              and minimizes the impact on future                          lated reamer system (Arthrex, Naples,
be repaired primarily may benefit from                 treatment such as osteochondral allo-                       Florida). The use of osteochondral allo-
another type of treatment (palliative,                graft transplantation. Larger, deeper                       grafts with an intact meniscus and
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     Fig. 3
     Microfracture. A: A chondral lesion in the femoral condyle. B: The lesion was carefully d´ brided, with the surgeon making sure that it had stable
     vertical borders. C: Microfracture holes were created in the subchondral bone, allowing a fibrin clot to fill the defect.

concomitant realignment has been re-                    lesion in the patellofemoral joint wear a           five years of follow-up, Knutsen et al.7
ported for the treatment of larger lesions              brace with a flexion stop of 30° to limit            found no difference between the out-
of the tibial plateau, especially after                 patellofemoral contact; weight-bearing              comes of microfracture and those of
fracture and the development of sec-                    is permitted.                                       autologous chondrocyte implantation
ondary arthritis, with graft survival rates                   The best outcomes of this tech-               for femoral condyle lesions, but patients
of up to 65% at fifteen years4.                          nique are seen in younger patients with             with smaller lesions treated with mi-
                                                        small traumatic lesions6. After two and             crofracture did better than those with
Surgical Options
Marrow Stimulation Technique
The microfracture marrow stimulation
technique is carried out with a surgical
awl to penetrate the subchondral bone.
The violation of the subchondral plate
promotes bleeding and the local mi-
gration of stem cells and other anabolic
factors that support the formation of a
‘‘superclot.’’ It is believed that the plu-
ripotent nature of these stem cells allows
                                                                                                            Fig. 4
the formation of reparative fibrocarti-
                                                                                                            Osteochondral autograft trans-
lage tissue5 (Fig. 2).
                                                                                                            plantation. A and B: Depending on
       Critical to the success of this
                                                                                                            the defect size, one or multiple
technique is the creation of vertical walls
                                                                                                            osteochondral plugs can be used
of stable articular cartilage to create a
                                                                                                            to fill the defect. The plugs are of-
‘‘well-shouldered’’ lesion. This improves
the local mechanical environment dur-                                                                       ten harvested from the intercon-
ing healing by reducing shear and                                                                           dylar notch or from the margins of
compression. All unstable cartilage is                                                                      the lateral or medial condyles
removed when the lesion site is pre-                                                                        above the sulcus terminalis. C:
pared. The calcified cartilage layer is                                                                      This sagittal section shows how
carefully debrided, and surgical awls are                                                                   the osteochondral graft should be
used to penetrate the subchondral bone                                                                      placed in order to fill the defect.
(Fig. 3). The holes are placed perpen-
dicular to the bone surface, 2 to 3 mm
apart, and confluence is avoided. Post-
operative rehabilitation is guided by
the location of the lesion, but typically
it involves up to six weeks of non-
weight-bearing and the use of a
continuous-passive-motion machine
for six hours per day. Patients with a
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     TABLE I Demographic Data and Outcomes in Studies Comparing Microfracture with Other Cartilage Restoration Procedures                                                  ä

                                                                                     No. of              Mean                 Lesion                         Lesion
         Author(s)                 Group 1                   Group 2                Patients            Age (yr)            Size (cm )                      Location
    Saris et al.             Autolog.                       Microfract.                   118             33.9            Range, 2.4-2.6               Med. and lat.
                             chondrocyte                                                                                                               fem. condyles
    Knutsen et al.           Autolog.                       Microfract.                    80           Not               Not                          89% med. fem.
                             chondrocyte                                                                reported          reported                     condyle; 11% lat.
                             implant.                                                                                                                  fem. condyle
    Gudas et al.             Osteochondral                  Microfract.                    60             24.3                   2.8                   84% med. fem.
                             autograft                                                                                                                 condyle, 16% lat.
                             transplant.                                                                                                               fem. condyle

    Knutsen et al.           Autolog.                       Microfract.                    80             32.2                   4.8                   89% med. fem.
                             chondrocyte                                                                                                               condyle; 11% lat.
                             implant.                                                                                                                  fem. condyle

    *HSS = Hospital for Special Surgery, and SF-36 = Short Form-36.

larger lesions. Similarly, Gudas et al.                     cylindrical osteochondral autografts                      4 cm2. The use of ‘‘mega’’ osteochon-
observed that, among patients with                          into the cartilage defect, providing a                    dral autograft transplants (‘‘mega-
lesions exceeding 2 cm2 in the central                      congruent hyaline-cartilage-covered                       OATS’’) from the posterior part of the
part of the medial femoral condyle,                         surface (Fig. 4). The autografts are                      femoral condyle for large osteochon-
those treated with microfracture had                        harvested from the non-weight-bearing                     dral lesions (>4 cm2) has had good
lower clinical outcome scores than did                      periphery of the femoral trochlea or                      clinical results at 5.5 years
those treated with an osteochondral                         the margin of the intercondylar notch.                    postoperatively12.
autograft transplantation (Table I)8.                       With a combination of different graft                            Osteochondral autograft trans-
Location also plays a role in the success                   sizes, 90% to 100% of the defect can                      plantation can be done through a small
of marrow stimulation techniques,                           be filled10. This technique is limited by                  arthrotomy or entirely arthroscopically.
with better results seen after the treat-                   the amount of donor tissue available in                   To harvest donor grafts perpendicular to
ment of femoral condyle lesions9.                           the knee, and donor site morbidity                        the surface, we prefer to obtain the donor
                                                            increases as more tissue is harvested.                    plugs through a small lateral arthrotomy
Osteochondral Autograft                                     Osteochondral autograft transplanta-                      because the lateral edge of the patella can
Transplantation                                             tion is best for small lesions (<2 cm2),                  interfere with an arthroscopic harvest.
Osteochondral autograft transplanta-                        but good clinical results have been                       The plugs are then implanted arthro-
tion is the transfer of one or more                         reported11 with lesions between 2 and                     scopically. There are many available

Fig. 5
Osteochondral autograft transplantation. A: Identification of the lesion on the medial femoral condyle. B: A sizer is used to determine the number and size
of the autografts. In this case, the lesion measured 8 mm in diameter. C: An 8-mm plug was harvested. D: The donor-plug position should be flush with the
surrounding articular cartilage.
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   TABLE I (continued)

   Duration of                       Clinical                                         Histological                                      Additional
    Follow-up                       Outcome*                                           Findings                                         Findings*

     18 mo               Improvement in both                                Better structural repair in
                         groups; no significant                              autolog. chondrocyte
                         difference                                         implant. group

       5 yr              77% good clinical                                  No significant difference                     Younger patients did better
                         results in both groups;                                                                         in both groups
                         no significant difference
       3 yr              HSS score significantly                             100% hyaline cartilage in                    Patients <30 yr old had better
                         superior in osteochondral                          osteochondral autograft                      clinical scores; HSS scores better
                         autograft transplant.                              transplant. group; 57%                       for traumatic lesions than
                         group (p < 0.01)                                   fibrocartilage, 43% fibroelastic               osteochondritis dissecans
                                                                            tissue in microfract. group                  lesions; HSS scores lower
                                                                                                                         for lesions of >2 cm in
                                                                                                                         microfract. group
       2 yr              SF-36 score significantly                           No significant difference in                  Patients <30 yr old had better
                         superior in microfract.                            the percent of fibrocartilage                 outcomes; SF-36 scores higher
                         group                                              tissue                                       for esions of <4 cm in
                                                                                                                         microfract. group

commercial systems that provide a series                incorporation to the subchondral bone                planted chondrocytes are isolated by
of donor and recipient harvesting tubes                 while the transplanted cartilage inte-               the cartilage matrix and not exposed to
to create a press-fit implant of up to                   grates with the adjacent host articular              the host immune surveillance15. The
10 mm in diameter. A sizing guide is used               cartilage with fibrocartilage. Recently,              allografts can be ‘‘fresh’’ or frozen.
to determine the number and size of                     Hangody et al.11 evaluated clinical                  Fresh grafts are normally maintained
grafts that are needed. A properly sized                outcomes at a mean of fourteen years                 at 4°C in standard or enriched culture
graft harvester with a collared pin is                  after 1097 osteochondral autograft                   medium for no more than twenty-eight
introduced perpendicular to the donor                   transplantation procedures. Encourag-                days, which allows chondrocytes to
site (Fig. 5) to a depth of approximately               ing results in this large multicenter                survive after transplantation. Frozen
12 to 15 mm. The recipient socket is                    series support the use of this technique             allografts are maintained at 240°C
created to a depth that is 2 mm less than               for the treatment of small and medium                for years. The fresh allografts elicit a
the length of the donor graft. It is                    focal chondral and osteochondral de-                 minimal immune response, the chon-
important to maintain a perpendicular                   fects of the knee. The osteochondral                 drocytes survive, and the bone is suc-
relationship between the donor graft                    autograft transplantation procedure                  cessfully revascularized16-18.
and the articular surface to create well-               has been compared with other cartilage                      Allograft transplantation can be
defined vertical walls in the recipient                  restoration procedures (Table II).                   done arthroscopically; however, it is
socket, as this facilitates congruent plug                                                                   more often performed through a small
placement (Fig. 5, C). The donor plug                   Osteochondral Allograft                              arthrotomy. The allograft is slowly
is placed over the recipient site and                   Transplantation                                      warmed from 4°C to 37°C by placing
gently advanced into the defect, where it               Osteochondral allograft transplantation              it in normal saline solution at room
is often left slightly proud. The chon-                 provides an option for treatment of                  temperature. The slow warming min-
drocytes can be damaged during im-                      larger lesions (>2.5 cm2) or those with              imizes damage to the graft19. The lesion
paction; therefore, it is critical to avoid             substantial bone loss. It is normally a              is sized with a template, and a corre-
high loads when inserting the graft13.                  second-line treatment option, but can                spondingly sized reamer is used to
The final plug position should be flush                   be a first-line treatment for high-                   convert the defect to a circular recip-
with the surrounding articular cartilage                demand patients with large lesions.                  ient socket with a uniform depth of 6 to
(Fig. 5, D). Postoperatively, patients                         Osteochondral allograft trans-                8 mm (Fig. 6). This bone depth facil-
are protected from weight-bearing for                   plantation can be used to resurface                  itates graft implantation and limits the
six weeks and use a continuous-passive-                 large, deep defects with mature hyaline              amount of immunogenic donor bone
motion machine six hours per day.                       articular cartilage while also filling any            that is implanted. A sterile marking pen
       Hangody and Karpati14 evaluated
                          ´ ´                           underlying osseous defect. Tissue                    is used to mark the 12 o’clock position
the survival of the transplanted hyaline                matching and immunosuppression                       of the lesion to orient the donor plug
cartilage. The graft undergoes osseous                  are not necessary because the trans-                 appropriately. An instrumentation
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   TABLE II Demographic Data and Outcomes in Studies of Osteochondral Autograft Transplantation                                                                      ä

                                                       Group 2                   No. of            Mean            Mean Lesion
       Author(s)               Group 1               (or 2 and 3)               Patients          Age (yr)          Size (cm )                     Lesion Location
   Hangody et al.           Osteochondral                   —                    1097              36            Not reported                798 fem. condyle,
                            autograft                                                                                                        147 patellofemoral,
                            transplant.                                                                                                      31 tibia, 98 talus,
                                                                                                                                             8 capitellum, 3 hum.
                                                                                                                                             head, 11 fem. head

   Marcacci et al.          Osteochondral                   —                      30              29.3                 <2.5                 Med. and lat. fem.
                            autograft                                                                                                        condyles
   Gobbi et al.             Osteochondral           Microfract.;                   32        Osteochondral       Osteochondral               Talus
                            autograft               chondroplasty                            autograft           autograft
                            transplant.                                                      transplant.: 27;    transplant.: 4;
                                                                                             microfract.: 24;    microfract.: 4.5;
                                                                                             chondroplasty: 32   chondroplasty: 3.7
   Dozin et al.               e
                            D´ brid. then             e
                                                    D´ brid. then                  47        Autolog.            Autolog.                    Autolog. chondrocyte
                            autolog.                osteochondral                            chondrocyte         chondrocyte                 implant.: 73% fem.
                            chondrocyte             autograft                                implant.: 29;       implant.: 1.97;             condyle, 27% patella;
                            implant.                transplant.                              osteochondral       osteochondral               osteochondral autograft
                                                                                             autograft           autograft                   transplant.: 68% fem.
                                                                                             transplant.: 27     transplant.: 1.88           condyle; 32% patella
   Bentley et al.           Osteochondral           Autolog.                      100              31.3                  4.66                53% med. fem. condyle;
                            autograft               chondrocyte                                                                              18% lat. fem. condyle;
                            transplant.             implant.                                                                                 25% patella; 3% trochlea;
                                                                                                                                             1% tibial plateau

   *HSS = Hospital for Special Surgery.

system is used to size and harvest a                          The graft is extracted, and a ruler is used            is used to remove the residual blood and
cylindrical plug from the allograft (Fig.                     to measure and mark the four quadrants                 bone-marrow elements from the allo-
7). The donor graft is drilled through its                    of the graft at the depth of the previously            graft to reduce the risk of disease trans-
entire depth with a harvester under                           measured recipient sites. Before inser-                mission and graft immunogenicity. The
irrigation with normal saline solution.                       tion, pulsatile lavage (approximately 2 L)             graft is then press-fit into the socket by

            Fig. 6
            Osteochondral allograft transplantation. A: The procedure is typically performed through a small arthrotomy to expose the lesion.
            B: A reamer is used to convert the defect to a circular recipient socket with a uniform depth of 6 to 8 mm.
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   TABLE II (continued)

    Duration of                                                                                                                                    Additional
     Follow-up                         Clinical Outcome*                                  Histological Findings                                    Findings*

   14 yr                          Rate of good-to-exc.                                 Graft survival in                                  Comorbidities should
                                  results: 92% for fem.                                81 of 98                                           be assessed; postop.
                                  condylar implant., 87%                                                                                  bleeding from donor
                                  for tibial resurfacings,                                                                                site—prevention with
                                  74% for patellar and/or                                                                                 donor site biodegradable
                                  trochlear mosaicplasties,                                                                               plugs
                                  93% for talar proc.
   Range, 2-7 yr                  77% good clinical results                            Not performed                                      MRI showed good
                                                                                                                                          integration and survival
                                                                                                                                          of graft in 60%
   54 mo                          No clinical difference                               Not performed                                      Results of microfract.
                                  among 3 treatment                                                                                       and osteochondral
                                  groups                                                                                                  autograft transplant.
                                                                                                                                          better for small
                                  Complete recovery in                                 Not performed                                      14 patients improved
                                  88% of mosaicplasty group                                                                                                  e
                                                                                                                                          significantly with d´ brid.
                                  and 68% of autolog.
                                  chondrocyte implant.
                                  group (p = 0.093)

   19 mo                          Modified Cincinnati score                             74% with hyaline-like or                           Technique documented
                                  >55 for 88% of autolog.                              fibrocartilage tissue                               placing plugs slightly
                                  chondrocyte implant.                                 inautolog. chondrocyte                             prominently
                                  group and 74% of                                     implant. group; not
                                  osteochondral autograft                              reported for osteochondral
                                  transplant. group                                    autograft transplant.

hand after careful alignment of the four                 Autologous Chondrocyte Implantation                      lesion with use of a combination of a
quadrants to the recipient site (Fig. 8). If             Autologous chondrocyte implantation                      number-15 blade and sharp ring curets.
the implanted allograft is particularly                  is ideal for symptomatic, unipolar, well-                        ´
                                                                                                                  After debridement, the tourniquet, if
large, fixation may be augmented with                     contained chondral or osteochondral                      used, should be deflated, and complete
bioabsorbable or metal compression                       defects measuring between 2 and 10 cm2                   hemostasis should be obtained. The
screws.                                                  with bone loss of less than 6 to 8 mm.                   use of cotton pledgets soaked with
       Postoperatively, weight-bearing                   It is typically a second-line treatment                  epinephrine may help to obtain hemo-
is limited to toe-touch for the first six                                               ´
                                                         after at least arthroscopic debridement                  stasis (Fig. 9).
weeks. Patients with a patellofemoral                    has been performed.                                             Next, a periosteal patch is har-
graft are allowed to bear weight as                              The first stage of autologous                     vested from the proximal-medial part
tolerated in extension and generally                     chondrocyte implantation is an arthro-                   of the tibia, just distal to the pes
are limited to 45° of flexion during the                  scopic evaluation of the size and depth                  anserinus insertion, through a separate
first four weeks. Continuous passive                      of the focal chondral lesion and a                       incision. The patch should be at least
motion is used immediately after the                     cartilage biopsy. The total volume of the                2 mm larger than the defect. The
surgery. A return to normal activities                   biopsied material should be approxi-                     patch edges are detached with a
of daily living and light sports activity                mately 200 to 300 mg. The second stage                   number-15 scalpel blade and elevated
is considered at eight to twelve                         is implantation of the cells. This is done               with a sharp, curved periosteal elevator,
months.                                                  usually no sooner than six weeks after                   beginning distally. Synthetic collagen-
       Subjective improvement can be                     the biopsy. At the time of implantation,                 membrane substitutes are commer-
expected in 75% to 85% of patients after                 the defect is prepared by removing                       cially available (Chondro-Gide;
osteochondral allograft implantation                     any existing fibrocartilage down to                       Geistlich Biomaterials, Wolhusen,
for properly selected chondral lesions4,20               the underlying calcified layer. Vertical                  Switzerland) and can be used as a
(Table III).                                             walls are created at the periphery of the                substitute for the periosteal patch. The
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               Fig. 7
               Osteochondral allograft transplantation. A: Fresh donor femoral condyle. B: The condyle is trimmed to create a flat surface to
               place on the workstation. This cut is made parallel to the potential harvest site. C: Condyle securely fixed to the workstation.
               D: Graft template placed on the condyle to match the bottom of the recipient site.

use of these scaffolds not only reduces                         The patch or scaffold is then                 Chondro-Gide scaffold, the porous
operating time but also has been shown                    sewn to the cartilage. When perios-                 surface should be placed toward the
to avoid typical problems related to the                  teum is used, the cambium layer is                  lesion with the smooth side facing out.
periosteum21.                                             placed toward the lesion. With the                  Sutures (6-0 Vicryl [polyglactin]) are

Fig. 8
Osteochondral allograft transplantation. A: After removal of the plug, depth-measurement markings are made on the graft to match the measurements of
the recipient socket in four quadrants. B: Matching of the donor plug. The depth of bone should be limited to 8 to 10 mm to facilitate graft implantation and
limit the amount of immunogenic donor bone that is implanted. C: The graft is press-fit into the socket by hand after careful alignment of the four quadrants
to the recipient site. The graft is flush with the recipient articular surface.
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TABLE III Demographic Data and Outcomes in Studies of Osteochondral Allograft Transplantation

                 Type of          Mean                                                                  Mean
              Osteochondral       Age               Type of               No. of         Lesion      Duration of                                      Additional
Author(s)        Allograft         (yr)              Study               Patients       Location      Follow-up            Outcome*                    Findings

Gross          Failed               47            Histological             69          Knee          <1, 2-5,           Cartilage:
et al.         fresh                                                                   (exact        >5 yr              viable
                                                                                       location                         chondrocytes,
                                                                                       not                              normal matrix
                                                                                       specified)                        and structure
                                                                                                                        in middle and
                                                                                                                        deep layers.

Davidson       Fresh                32            Clinical,              8 (10         6 med.        40 mo              Clinical:                 Prevention of
et al.                                            histological,          knees)        fem.                             improvements              short-term
                                                  MRI                                  condyle,                         in SF-36, IKDC,           degenerative
                                                                                       2 trochlea,                      Tegner, Lysholm           changes
                                                                                       2 med.                           scores
                                                                                       fem.                             (p < 0.05).
                                                                                       condyle                          Histological:
                                                                                       and                              cellular density
                                                                                       trochlea                         and viability
                                                                                                                        similar in host
                                                                                                                        and donor
                                                                                                                        cartilage. MRI:
                                                                                                                        in Outerbridge

McCulloch      Fresh                35            Clinical,                25          Fem.           3 yr              Clinical:                 Patients with
et al.                                            radiographic                         condyle                          improvements              uncorrected
                                                                                                                        in Lysholm,               malalignment
                                                                                                                        IKDC, KOOS,               did worse;
                                                                                                                        SF-12 scores              clinical
                                                                                                                        (p < 0.05); 84%           results
                                                                                                                        of patients               did not
                                                                                                                        satisfied.                 deteriorate
                                                                                                                        Radiographic:             with
                                                                                                                        88% had graft             increasing
                                                                                                                        incorporation             age of graft

Jamali         Fresh                28            Clinical,                18          Patellofem.   94 mo              Clinical: 5               No
et al.         patellofem.                        radiographic                                                          failures;                 patellofemoral
                                                                                                                        good results              bone
                                                                                                                        in 60%.                   alignment
                                                                                                                        Radiographic:             proc.
                                                                                                                        no signs of               performed
                                                                                                                        arthrosis in 10
                                                                                                                        of 12

Gross          Fresh                27            Clinical                 60          30 med.       10 yr              Survival: 95%             Comorbidities
et al.                                            outcome                              fem.                             at 5 yr,                  should
                                                                                       condyle;                         85% at 10 yr,             be assessed
                                                                                       30 lat.                          65% at 15 yr              and corrected
                                                                                       fem.                                                       in same
                                                                                       condyle                                                    procedure

*IKDC = International Knee Documentation Committee, KOOS = Knee Injury and Osteoarthritis Outcome Score, and SF-12 = Short Form-12.
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     TABLE IV Demographic Data and Clinical Outcomes in Studies of Autologous Chondrocyte Implantation                                                                ä
                Author(s)                                        No. of Patients                         Mean Age (yr)                      Mean Lesion Size (cm )
         Zaslav et al.                                    126 with autologous                                34.5                                      4.63
                                                          chondrocyte implant. after
                                                          other failed cartilage proc.
                                                          (multicenter study)
         Rosenberger et al.                               56; 50% with                                 48.6 (range,                         4.7 (range, 1-15.0)
                                                          concomitant                                  45-60); all >45

         Mandelbaum et al.                                               40                            Range, 16-48                                    4.5

         Kreuz et al.                                     118 with isolated                            35 (range, 18-50)
                                                          chondral lesion

         Knutsen et al.                                   40 with autologous
                                                          chondrocyte implant.,
                                                          40 with microfract.
         Steinwachs and Kreuz                                            63                                  34

    *VAS = visual analog scale, SF-36 = Short Form-36, and ICRS = International Cartilage Repair Society.

first passed into the patch approxi-                              tightness test is performed with an 18-                 passive-motion machine. Patients with
mately 2 mm from the edge and then                               gauge angiocatheter. The chondrocytes                   a patellofemoral lesion are permitted
passed through the cartilage at a depth                          are then delivered through the opening                  full weight-bearing with the knee in
of 2 to 3 mm below the cartilage                                 with use of an angiocatheter. After the                 extension. Continuous passive motion
surface. Sutures should be placed ap-                            cells have been implanted, the opening                  for six to eight hours per day at one
proximately 4 mm apart, and a gap                                gap is closed with suture and fibrin                     cycle per minute is used for six weeks
should be maintained in the upper                                glue (Fig. 9, C).                                       after the surgery. A return to normal
edge to allow chondrocyte implanta-                                     Postoperatively, patients with a                 activities of daily living and sports
tion (Fig. 10). The edges of the patch                           femoral condyle lesion are kept non-                    activities is allowed six months after
are sealed with fibrin glue, and a water-                         weight-bearing and use a continuous-                    the surgery.

Fig. 9
Autologous chondrocyte implantation. A: A chondral lesion in the patella. B: Preparation of the defect. C: After the chondrocytes are delivered, the gap is
closed with suture and fibrin glue.
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  TABLE IV (continued)

          Lesion Location            Mean Duration of Follow-up                                                    Outcome*

     102 (67%) med. fem.                  48 mo                                      76% were treatment successes; no difference between results of
     condyle; 27 (18%) lat.                                                                                        e
                                                                                     marrow stimulating proc. and d´ brid. at prim. op.; mean improvements
     fem. condyle; 24                                                                in Cincinnati, VAS, and SF-36 scores from baseline to all time points
     (16%) trochlea                                                                  (p < 0.001)
                                          4.7 yr (range, 2-11)                       8 failures (14%); additional arthroscopic proc. required in 24 patients
                                                                                     (43%) for periosteal-related problems and adhesions; 88% of these
                                                                                     patients had lasting improvement, 78% felt improved, and 81% would
                                                                                     again choose autologous chondrocyte implant. as a treatment option
     Trochlea                             59 ± 18 mo                                 Significant improvement in Cincinnati score, overall condition
                                                                                     (3.1 points preop. to 6.4 points postop.), pain (2.6 to 6.2 points),
                                                                                     swelling (3.9 to 6.3 points); no failed implant
     78 fem. condyle;                     Clinical and                               Patients with regular (1-3 times/wk) or competitive (4-7 times/wk)
     17 trochlea;                         MRI eval. at                               sports involvement had significantly better ICRS and Cincinnati scores
     23 patella                           6, 18, and 36 mo                           than patients with no or rare sports involvement (p < 0.01); correlation
                                                                                     between sports activity levels and clinical scores significant
                                                                                     (increasing from 6 to 18 mo, 18 to 36 mo postop.)
     89% med. fem.                        2 yr                                       77% good clinical results in both groups; no significant difference
     condyle; 11% lat.                                                               between groups; younger patients did better in each group
     fem. condyle
     Fem. condyle,                        6, 18, and 36 mo                           Evaluation of autologous chondrocyte implant. with type I/III collagen
     trochlea, patella                                                               membrane; significant improvement in ICRS and modified Cincinnati
                                                                                     scores (p < 0.01); graft hypertrophy can be avoided by using a collagen

                                                             It is estimated that autologous                        It is critical that the surgeon also
                                                       chondrocyte implantation has been                            consider what subsequent treatment
                                                       performed in >10,000 patients world-                         options might be necessary should the
                                                       wide. The procedure has better results                       first-line treatment fail to relieve the
                                                       when it is done for lesions in the                           symptoms.
                                                       femoral condyle or in patients with
                                                       a patellofemoral lesion who are under-
                                                       going a concomitant realignment pro-
                                                       cedure22-24. There have been several                         Brian J. Cole, MD, MBA
                                                       studies comparing autologous chon-                           Cecilia Pascual-Garrido, MD
                                                       drocyte implantation with other                              Robert C. Grumet, MD
                                                       biologic reconstructive procedures                           Departments of Orthopedic Surgery (B.J.C.,
                                                                                                                    C.P.-G., and R.C.G.) and Anatomy and Cell
                                                       (Table IV).                                                  Biology (B.J.C.), Rush University Medical
                                                                                                                    Center, 1725 West Harrison Street,
                                                       Overview                                                     Suite 1063, Chicago, IL 60612.
                                                       Articular cartilage defects of the knee                      E-mail address for B.J. Cole:
                                                       are common. Treatment options range                
                                                       from palliative (debridement) to repar-                      E-mail address for C. Pascual-Garrido:
                                                       ative (marrow stimulation) to restora-
Fig. 10                                                                                                             E-mail address for R.C. Grumet:
                                                       tive (osteochondral grafting and                   
Autologous chondrocyte implantation. A:                autologous chondrocyte implantation).
Injection of the chondrocytes under the                All of these techniques improve the                          Printed with permission of the American
upper edge of the patch. The cells should              clinical status compared with the pre-                       Academy of Orthopaedic Surgeons. This article,
be injected slowly. B: A periosteal patch              operative state. Decision-making is                          as well as other lectures presented at the
with the cambium layer facing down into                                                                             Academy’s Annual Meeting, will be available in
                                                       done case by case and is guided by the                       March 2010 in Instructional Course Lectures,
the defect is carefully sutured onto the               patient’s physical and physiologic de-                       Volume 59. The complete volume can be
top of the defect. Chondrocytes are in-                mand level, previous failed treatment,                       ordered online at, or by calling
jected into the contained defect.                      and the location and size of the defect.                     800-626-6726 (8 A.M.-5 P.M., Central time).
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                                                           d             d
                                                                                             DEFECTS IN THE KNEE

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