Injuries involving subchondral bone and chondral tissues are found in up to 63 to 66% arthroscopic procedures and represent a challenging entity to treat with an important propensity to progress to osteoarthritis.
Treatment options include osteotomy, microfracture, abrasion arthroplasty, autologous chondrocyte transplantation, mosaicplasty, autologous osteochondral graft, and arthroplasty; however, all these options have limitations and are not suitable to larger, contained full-thickness cartilage defects. Since its early description by Eric Lexner in 1908, osteochondral allograft techniques have evolved to our days with different success rates depending on the technique used. They are mainly indicated for symptomatic defects greater than 3 cm in active young patients in which native cartilage is preferred over arthroplasty. Osteochondral allografts provide viable hyaline cartilage with metabolically active chondrocytes and subchondral bone with remodeling potential to the articular surface and promising results according to evidence.
Osteochondral allografts have been used widely in femoral condyles, tibial plateau, patella, and ankle; however, they have been used in other joints recently, such as the elbow and shoulder.
The goal of osteochondral transplantation is to improve articular function, relieve symptoms, and delay arthroplasty by restoring the articular surface through a biologically active implant. They are especially useful in young active patients and conditions such as osteonecrosis, chondral lesions secondary to traumatic events, fracture malunion, and osteochondritis dissecans.
Main indications for osteochondral allograft transplantation are:
Certain exposures of the patient and the form of the lesion make osteochondral allograft contraindicated. Following are some important contraindications:
Absence of more than 50% of the ipsilateral compartment meniscus may benefit from simultaneous meniscal transplantation.
Advances and standardization of storage techniques have improved chondrocyte viability through long periods. However, cell viability and duration depends on the selected technique. Allografts are hypothermically stored and screened for infectious diseases during 14 days.
Fresh grafts are harvested within 24 hours from the donor’s death and stored at 4°C (39.2°F). Cell viability starts to decline from day 14 to 21. Therefore they should be implanted between 15 to 28 days from its harvest to guarantee viable chondrocytes (up to 70%). However, they should be implanted as soon as the testing period is complete. 28 days is the maximal recommended time for transplantation.
Fresh allografts are the favored technique because evidence shows increased chondrocyte viability, cartilage stiffness, cellularity, and matrix content compared to frozen and cryopreserved osteochondral allografts six months after being implanted.
Frozen allografts and cryopreserved allografts are stored at lower temperatures (-80 degrees C and -70 degrees C, respectively) with a longer maximal storage time; however, with remarkably lower chondrocyte viability after implantation which limits their use.
Thorough preoperative planning with clinical history looking for a history of previous injuries, pain, swelling, effusion, or previous procedures must be noticed. Up to 50% of patients do not have any history of notorious injuries.
Thorough physical exam looking for a range of motion restriction, ligament instability signs, meniscal tear signs, or limb malalignment.
Complete radiographic assessment with a bilateral weight-bearing anteroposterior view, posteroanterior flexion view, true lateral, and axial knee views. Mechanical axis assessment with long leg standing anteroposterior views.
Magnetic resonance imaging (MRI) helps determining an estimated chondral defect’s size and location as well as subchondral bone edema, ligament tears, and meniscal tears. MRI underestimates chondral defects in up to 60% of patients.
The surgical procedure is carried out under general anesthesia, and the following are the requirements:
Knee Osteochondral Allograft Transplantation
Some large defects may require multiple osteochondral plugs. If so, a 1 to 3 mm bridge is left between each socket to avoid convergence between tunnels. Convergence creates free spaces between socket walls, thus leading to inadequate press fit.
The shell technique is especially useful for very large and irregular defects because it allows handcrafting the shape and size of the graft. It is usually used for posterior femoral condyles, trochlea, or tibial plateau post-traumatic defects.
Graft collapse and fragmentation have been reported in about 25% of patients at 12 years follow up.
Symptoms of failure are persistent pain, joint tenderness, and effusion. Early signs associated with allograft failure are X-ray follow up demonstrating sclerosis, osteophytes, subchondral cysts, and joint space obliteration.
There are 12 to 18% of patients undergoing revision or arthroplasty procedures following osteochondral allograft transplantation. Revision cases, osteoarthritis, defects larger than 10 mm, patellofemoral, and bipolar allografts have shown worse survival rates.
Immunological reactions are uncommon because allografts are immunologically inert. The thick extracellular matrix of hyaline cartilage prevents graft’s chondrocytes from exposition to host fluids. Osteochondral allografts are ideally suited for transplantation, matching is based on ABO blood type, and no anti-immunogenic drugs are required.
Infection is a serious complication that occurs in 1.8% of patients and must always be ruled out when persistent pain, swelling, and edema appears. In such cases, surgical debridement, copious irrigation, and graft removal are often necessary.
There are increasing reports about outcomes mainly for chondral defects around the knee.
Histologic studies show high cartilage survivorship reporting ten years mean survival rates ranging from 72 to 85% for femoral condyles, 68 to 88% for the tibial plateau, and 71-78% for patella-femoral grafts.
Bipolar defects treated with bipolar allograft transplantation have shown a 39% survivorship at ten years follow up and a much higher revision/failure rate than unipolar transplantation.
Functional outcome reports improved IKDC scores in 88% of patients and significant improvement in knee pain in 74 to 85% of patients at follow up.
In regard to sports activity studies addressing femoral condyle osteochondral allograft show that 79% of patients return to sports at preinjury levels, whereas up to 88% return to sports at any level at a mean time of 9.6 months. However, quality evidence is still lacking.
There are some factors as body mass index, age at the time of surgery, and the number of previous cartilage preserving procedures that are associated with less favorable outcomes. Patients above 30 years old undergoing surgery have a 3.5 times higher risk of failure, whereas previous procedures increase the risk by 2.5 times. Duration of symptoms and age are facts to consider in athletes. Athletes above 25 years old and those undergoing osteochondral allograft procedures after 12 months of symptoms onset are related to less probability to return to sports at the preinjury level.
The intervention of an interprofessional team is key to achieve the best outcomes. The team should include primary care doctors, orthopedic nurses, radiologists, pain specialists, orthopedic surgeons, and physiotherapists. Rehabilitation must be started immediately after surgery allowing for early continuous passive motion. Continuous passive motion machines are beneficial during the first eight weeks. Early motion helps promote healing and graft vascularization. Quadriceps exercises and leg raises should be performed four times daily. Wearing a knee brace is recommended during this time.
A pain specialist can help manage postoperative pain, focusing on minimizing opioid use. Weight-bearing is delayed for six weeks until graft incorporation is visualized through X-rays. Daily life activities and normalized gait are started at 6 to 12 weeks. Athletes may start an advanced rehabilitation program after 3-4 months with the help of sports physical therapists; however, they must be cautioned against excessive loading on the allograft. During the first 12 months, high impact activities should be avoided as much as possible. Most patients return to sports in a period of 9 months to 1 year after surgery.
Good communication between professionals is crucial to ensure the best outcomes. Physical therapists and nurses play an important role in ensuring therapy adherence. Adherence to postoperative rehabilitation is associated with better outcomes, lower failure, and revision surgery rates. [Level 3]
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