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Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions

Section: Surgery
Effective Date: July 01, 2018
Revised Date: November 14, 2019

Description

Autologous or allogeneic grafts of osteochondral or chondral tissue have been proposed as treatment alternatives for individuals who have clinically significant, symptomatic, focal defects of the articular cartilage. It is hypothesized that the implanted graft’s chondrocytes retain features of hyaline cartilage that is similar in composition and property to the original articulating surface of the joint. If true, the restoration of a hyaline cartilage surface might restore the integrity of the joint surface and promote long-term tissue repair, thereby improving function and delaying or preventing further deterioration.

Both fresh and cryopreserved allogeneic osteochondral grafts have been used with some success. However, cryopreservation decreases the viability of cartilage cells and fresh allografts may be difficult to obtain and create concerns regarding infectious diseases. As a result, autologous osteochondral grafts have been investigated as an option to increase the survival rate of the grafted cartilage and to eliminate the risk of disease transmission. Autologous grafts are limited by the small number of donor sites; thus, allografts are typically used for larger lesions.

Preparation of the chondral lesion involves débridement and preparation of recipient tunnels. Multiple individual osteochondral cores are harvested from the donor site, typically from a peripheral non-weight-bearing area of the femoral condyle. Donor plugs range from 6 to 10 mm in diameter. The grafts are press fit into the lesion in a mosaic-like fashion into the same-sized tunnels. The resultant surface consists of transplanted hyaline articular cartilage and fibrocartilage, which is thought to provide “grouting” between the individual autografts. Mosaicplasty or AOT may be performed with either an open approach or arthroscopically. Osteochondral autografting has also been investigated as a treatment of unstable osteochondritis dissecans lesions using multiple dowel grafts to secure the fragment. While osteochondral autografting is primarily performed on the femoral condyles of the knee, osteochondral grafts have been used to repair chondral defects of the patella, tibia, and ankle. With osteochondral autografting, the harvesting and transplantation can be performed during the same surgical procedure. Technical limitations of osteochondral autografting are difficulty in restoring concave or convex articular surfaces, the incongruity of articular surfaces that can alter joint contact pressures, short-term fixation strength and load-bearing capacity, donor-site morbidity, and lack of peripheral integration with peripheral chondrocyte death.

Filling defects with minced or particulated articular cartilage (autologous or allogeneic) is another single-stage procedure being investigated for cartilage repair. The Cartilage Autograft Implantation System (Johnson & Johnson) harvests cartilage and disperses chondrocytes on a scaffold in a single-stage treatment. The Reveille Cartilage Processor (Exactech Biologics) has a high-speed blade and sieve to cut autologous cartilage into small particles for implantation. BioCartilage (Arthrex) consists of a micronized allogeneic cartilage matrix that is intended to provide a scaffold for microfracture. DeNovo NT Graft (Natural Tissue Graft) is produced by ISTO Technologies and distributed by Zimmer. DeNovo NT consists of manually minced cartilage tissue pieces obtained from juvenile allograft donor joints. The tissue fragments are mixed intraoperatively with fibrin glue before implantation in the prepared lesion. It is thought that mincing the tissue helps both with cell migration from the extracellular matrix and with fixation.

A minimally processed osteochondral allograft (Chondrofix; Zimmer) is now available. Chondrofix is composed of decellularized hyaline cartilage and cancellous bone; it can be used “off the shelf” with precut cylinders (7-15 mm). Multiple cylinders may be used to fill a larger defect in a manner similar to AOT or mosaicplasty.

ProChondrix (AlloSource) and Cartiform (Arthrex) are wafer-thin allografts where the bony portion of the allograft is reduced. The discs are laser etched or porated and contain hyaline cartilage with chondrocytes, growth factors, and extracellular matrix proteins. ProChondrix is available in dimensions from 7 to 20 mm and is stored fresh for a maximum of 28 days. Cartiform is cut to the desired size and shape and is stored frozen for a maximum of two years. The osteochondral discs are typically inserted after microfracture and secured in place with fibrin glue and/or sutures.

Criteria

Fresh osteochondral allografting may be considered medically necessary as a technique to repair:

  • Full-thickness chondral defects of the knee caused by acute or repetitive trauma when other cartilage repair techniques (e.g., microfracture, osteochondral autografting or autologous chondrocyte implantation) would be inadequate due to lesion size, location, or depth
  • Large (area >1.5 cm2) or cystic (volume >3.0 cm3) osteochondral lesions of the talus when autografting would be inadequate due to lesion size, depth, or location.
  • Revision surgery after failed prior marrow stimulation for large (area >1.5 cm2) or cystic (volume >3.0 cm3) osteochondral lesions of the talus when autografting would be inadequate due to lesion size, depth or location.

Osteochondral allografting for all other joints is considered investigational

Osteochondral autografting, using one or more cores of osteochondral tissue, may be considered medically necessary:

  • For the treatment of symptomatic full-thickness cartilage defects of the knee caused by acute or repetitive trauma in individuals who have had an inadequate response to a prior surgical procedure, when all of the following have been met:
    • Adolescent individuals should be skeletally mature with documented closure of growth plates (e.g., ≥15 years). Adult individuals should be too young to be considered an appropriate candidate for total knee arthroplasty or other reconstructive knee surgery (e.g., ≤55 years)
    • Focal, full-thickness (grade III or IV) unipolar lesions on the weight-bearing surface of the femoral condyles, trochlea, or patella that are between 1 and 2.5 cm2 in size.
    • Documented minimal to absent degenerative changes in the surrounding articular cartilage (Outerbridge grade II or less), and normal-appearing hyaline cartilage surrounding the border of the defect
    • Normal knee biomechanics or alignment and stability achieved concurrently with osteochondral grafting.
  • Large (area >1.5 cm2) or cystic (volume >3.0 cm3) osteochondral lesions of the talus
  • Revision surgery after failed marrow stimulation for osteochondral lesion of the talus.

Osteochondral autografting for all other joints and any indications other than those listed above is considered investigational

Treatment of focal articular cartilage lesions with autologous minced or particulated cartilage is considered investigational

Treatment of focal articular cartilage lesions with allogeneic minced or particulated cartilage is considered investigational

Treatment of focal articular cartilage lesions with decellularized osteochondral allograft plugs (e.g., Chondrofix) is considered investigational

Treatment of focal articular cartilage lesions with reduced osteochondral allograft discs (e.g., ProChondrix, Cartiform) is considered investigational

Procedure Codes

27415

27416

28446

29866

29867

Diagnosis Codes

M12.561

M12.562

M12.569

M17.0

M17.10

M17.11

M17.12

M17.2

M17.30

M17.31

M17.32

M17.4

M17.5

M17.9

M23.8X1

M23.8X2

M23.8X9

M23.90

M23.91

M23.92

M25.861

M25.862

M25.869

M85.671

M85.672

M85.679

M89.8x6

M89.9

M93.261

M93.262

M93.269

M93.271

M93.272

M93.279

M94.8x6

M94.9

S89.80XA

S89.80XD

S89.80XS

S89.81XA

S89.81XD

S89.81XS

S89.82XA

S89.82XD

S89.82XS

S89.90xA

S89.90xD

S89.90xS

Professional Statements and Societal Positions Guidelines

Practice Guidelines and Position Statements

Ankle

American Orthopedic Foot and Ankle Society

The American Orthopedic Foot and Ankle Society (2018) issued a position statement on the use of osteochondral transplantation for the treatment of osteochondral lesions of the talus.] In the statement, the Society "endorses the use of osteochondral autograft and allograft transplantation for the treatment of osteochondral lesion of the talus, especially large diameter lesions, cystic lesions, and those that have failed previous surgical treatment. AOFASdoes not consider these procedures to be experimental in a patient population that has failed nonoperative management."

International Consensus Group on Cartilage Repair of the Ankle

The International Consensus Group on Cartilage Repair of the Ankle (2017) convened to review the best available evidence and developconsensus statements to guide management ofindividuals needing cartilage repair of the ankle.The Consensus Group, consistingof 75 experts from 25 countries, acknowledged that evidence in the field of cartilage repair of the ankle is both low-quality and at low-levels, One topic addressed by the Consensus Group was the use of osteochondralallografts. Through a process based on the Delphi method of achieving consensus, the following recommendations were issued:

  • Osteochondral allograft plugs may be preferred over autografts in the following conditions: lesions >1.5 cm; knee osteoarthritis; history of knee infection; individuals expressing concern of donor site morbidity of the knee. (grade of evidence: prospective cohort study)
  • The source of osteochondral allograftplugs for the ankle should come from the ankle, not the knee. (grade of evidence: basic science)
  • There is an absence of clinical evidence and clinical experience for the use of decellularizedosteochondral allograft plugs.
  • The preferred type of allograft for the ankle is fresh, non-frozen. (grade of evidence: basic science)

Elbow

American Academy of Orthopedic Surgeons

In 2010 guidelines, which remain available on the American Academy of Orthopedic Surgeons website in 2018, on the diagnosis and treatment of osteochondritis dissecans, the Academy was unable to recommend for or against a specific cartilage repair technique in symptomatic skeletally immature or mature individuals with an unsalvageable osteochondritis dissecans lesion.

A 2010 Academy review of articular cartilage restoration methods stated that “osteochondral autografting is generally used for smaller focal lesions of the femoral condyle no greater than 1.5 to 2 cm.”

Knee

The National Institute for Health and Care Excellence (2018) issued a new guidance, mosaicplasty for symptomatic articular cartilage defects of the knee (IPG607).The guidance states that the evidence for safety and efficacy of mosaicplasty for knee cartilage defects is adequate to support the use of the procedure.

Links

S-5078

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