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 seven (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.
Summary of Evidence
Knee Lesions
For individuals who have full-thickness articular cartilage lesions of the knee who receive an osteochondral autograft, the evidence includes randomized controlled trials (RCTs), systematic reviews of RCTs, and longer-term observational studies. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. Several systematic reviews have evaluated osteochondral autografting for cartilage repair in the short- and mid-term. Compared with abrasion techniques (e.g., microfracture, drilling), there is evidence that osteochondral autografting decreases failure rates and improves outcomes in individuals with medium-size lesions (e.g., 2-6 cm2) when measured at longer follow-up. This is believed to be due to the higher durability of hyaline cartilage compared with fibrocartilage from abrasion techniques. There appears to be a relatively narrow range of lesion size for which osteochondral autografting is most effective. The best results have also been observed with lesions on the femoral condyles, although treatment of lesions on the trochlea and patella may also improve outcomes. Correction of malalignment is important for the success of the procedure. The evidence suggests that osteochondral autografts may be considered an option for moderate-sized, symptomatic, full-thickness, chondral lesions of the femoral condyle, trochlea, or patella. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.
For individuals who have full-thickness articular cartilage lesions of the knee when autografting would be inadequate due to lesion size, location, or depth who receive a fresh osteochondral allograft, the evidence includes case series and systematic reviews of case series. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. Due to the lack of alternatives, this procedure may be considered a salvage operation in younger individuals for full-thickness chondral defects of the knee caused by acute or repetitive trauma when other cartilage repair techniques (e.g., microfracture, osteochondral autografting, autologous chondrocyte implantation) would be inadequate due to lesion size, location, or depth. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.
Ankle Lesions
For individuals who have primary full-thickness articular cartilage lesions of the ankle less than 1.5 cm2 who receive an osteochondral autograft, the evidence includes observational studies and a systematic review of these studies. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. A systematic review found similar improvements in outcomes following microfracture and autologous osteochondral transplantation. Given the success of marrow stimulation procedures for smaller lesions (less than1.5 cm2) and the increase in donor-site morbidity with graft harvest from the knee, current evidence does not support the use of autologous osteochondral transplantation as a primary treatment for smaller articular cartilage lesions of the ankle. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.
For individuals who have large (area greater than1.5 cm2) or cystic (volume greater than 3.0 cm3) full-thickness articular cartilage lesions of the ankle who receive an osteochondral autograft, the evidence includes a RCT and several observational studies. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. A RCT in individuals with large lesions found similar efficacy for autologous osteochondral transplantation, marrow stimulation, and arthroplasty at two (2)-year follow-up. Longer-term results were not reported in the RCT. However, observational studies with longer-term follow-up (4-5 years) have shown favorable results for individuals with large or cystic lesions receiving osteochondral autograft transplantation. Limitations of the published evidence preclude determining the effects of the technology on health outcomes. Studies on the standard treatment for ankle lesions, marrow stimulation, have reported positive outcomes for patients with small lesions of the ankle (less than1.5 cm2), but have generally reported high failure rates for individuals with large (greater than1.5 cm2) lesions. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.
For individuals who have osteochondral lesions of the ankle that have failed primary treatment who receive an osteochondral autograft, the evidence includes two (2) nonrandomized comparative trials and several case series. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. The best evidence for revision autologous osteochondral transplantation comes from a nonrandomized comparative study that found better outcomes with autologous osteochondral transplantation than with repeat marrow stimulation. This finding is supported by case series that have indicated good-to-excellent results at mid-term and longer-term follow-up with revision autologous osteochondral transplantation. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.
For individuals who have primary full-thickness articular cartilage lesions of the ankle less than1.5 cm2 who receive a fresh osteochondral allograft, there is little evidence. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. Because microfracture is effective as a primary treatment for lesions less than 1.5 cm2 and autologous osteochondral transplantation is effective as a revision procedure, use of allograft for small primary cartilage lesions has not been reported. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.
For individuals who have large (area greater than1.5 cm2) or cystic (volume greater than 3.0 cm3) cartilage lesions of the ankle when autografting would be inadequate, who receive a fresh osteochondral allograft, the evidence includes a small number of individuals in a RCT and systematic reviews of case series. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. The majority of individuals in the RCT were individuals with revision osteochondral lesions, so conclusions about the few individuals with primary lesions could not be made. The systematic reviews of case series reported improvements in ankle scores and decreases in pain scores, though 25% of individuals needed additional surgery and 13% experienced either graft nonunion, resorption, or symptom persistence in one (1) systematic review. For particularly large lesions, marrow stimulation techniques have been found to be ineffective, and obtaining an adequate volume of autograft may cause significant morbidity. For these reasons, osteochondral allografts may be a considered option for large lesions of the ankle. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.
For individuals who have revision osteochondral lesions of the ankle when autografting would be inadequate, who receive a fresh osteochondral allograft, the evidence includes a RCT. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. Most of the patients in the RCT had failed a prior microfracture. The RCT found that outcomes were statistically similar with osteochondral allografts compared with autografts. However, failure rates due to nonunion were higher in individuals in the allograft group compared with individuals in the autograft group. For particularly large lesions, marrow stimulation techniques have been found to be ineffective, and obtaining an adequate volume of autograft may cause significant morbidity. For these reasons, osteochondral allografts may be a considered an option for revision of large lesions of the ankle. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.
Elbow Lesions
For individuals who have full-thickness articular cartilage lesions of the elbow who receive an osteochondral autograft, the evidence includes a meta-analysis of case series. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. Osteochondritis dissecans of the elbow typically occurs in individuals who play baseball or do gymnastics. Although the meta-analysis suggested a benefit of osteochondral autographs compared with debridement or fixation, RCTs are needed to determine the effects of the procedure with greater certainty. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.
Shoulder Lesions
For individuals who have full-thickness articular cartilage lesions of the shoulder who receive an osteochondral autograft, the evidence includes a case series. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. Evidence on osteochondral autografting for the shoulder is very limited. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.
Knee, Ankle, Elbow, or Shoulder Lesions
For individuals who have full-thickness articular cartilage lesions of the knee, ankle, elbow, or shoulder who receive autologous or allogeneic minced or particulated articular cartilage, the evidence includes a small RCT and small case series. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. The evidence on autologous minced cartilage includes a small RCT. The evidence on allogeneic juvenile minced cartilage includes a few small case series. The case series have suggested an improvement in outcomes compared with preoperative measures, but there is also evidence of subchondral edema, nonhomogeneous surface, graft hypertrophy, and delamination. For articular cartilage lesions of the knee, further evidence, preferably from RCTs, is needed to evaluate the effect on health outcomes compared with other procedures. There are fewer options for articular cartilage lesions of the ankle. However, further study in a larger number of individuals is needed to assess the short- and long-term effectiveness of this technology. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.
For individuals who have full-thickness articular cartilage lesions of the knee, ankle, elbow, or shoulder who receive decellularized osteochondral allograft plugs, the evidence includes small case series. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. The case series reported delamination of the implants and high failure rates. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.
For individuals who have full-thickness articular cartilage lesions of the knee, ankle, elbow, or shoulder who receive reduced osteochondral allograft discs, the evidence includes very small case series. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.
