Outcomes following Structural Grafting of Distal Femoral Osteochondral Injuries in Patients Aged 40 Years and Older

Abstract

Osteochondral lesions of the distal femur represent a challenging clinical entity, particularly in patients > 40 years of age. Microfracture has demonstrated inferior results in this population with clinical deterioration beyond 1 to 2 years postoperatively. Limited evidence exists to support alternative cartilage restoration procedures. The purpose of this study was to report functional outcomes and activity levels following cartilage restoration procedures in patients > 40 years with symptomatic distal femoral osteochondral lesions. From 2000 to 2012, 61 patients with distal femoral osteochondral injuries were retrospectively identified. Mean follow-up was 3.6 ± 1.4 years; mean age was 51.6 years (range 40–71); 59% were male. Of 61 patients, 35 patients (57%) were treated with synthetic scaffold (SS) plugs (off-label), 14 (23%) with osteochondral allograft (OCA), and 12 (20%) with autologous osteochondral transfer (AOT). Validated outcome measures including activity of daily living (ADL) score, International Knee Documentation Committee (IKDC) subjective evaluation form, and Marx activity scale (MAS) were used. The average lesion size was 3.8 ± 2.1 cm². Lesion size was significantly greater in the OCA group (5.8 ± 1.8 cm²), compared with the SS (3.2 ± 1.9 cm²) and AOT group (3.3 ± 1.8 cm², p ≤ 0.0024). Collectively, outcome scores for the entire population demonstrated significant improvement in ADL (61.36 ± 17.76–76.81 ± 17.2, p < 0.0001) and IKDC scores (40.28 ± 13.28–61.84 ± 20.83, p < 0.001) from baseline to final follow-up, with no significant change in MAS (4.19 ± 5.13–2.59 ± 3.92, p = 0.07). Similarly, subgroup analysis identified that all treatment groups (SS, OCA, and AOT) demonstrated significant improvement in ADL and IKDC scores from preoperative to final postoperative visit (p ≤ 0.0361). MAS scores were maintained in the OCA and AOT groups (p ≥ 0.1704), but significantly decreased in the SS group (4.3 ± 5.2–2.7 ± 4.11, p = 0.0163). Ten patients (16.3%) required revision surgery at a mean of 4.4 years (range 0.3–13.4 years). Cartilage restoration procedures using structural grafts are successful in patients 40 years and older, with improved pain and functional outcome scores compared with preoperative baseline scores. OCA and AOT should primarily be used, given recent concerns with SS implants.

Keywords

knee - cartilage restoration - articular cartilage - osteochondral defect

• References

• 1 Heir S, Nerhus TK, Røtterud JH , et al. Focal cartilage defects in the knee impair quality of life as much as severe osteoarthritis: a comparison of knee injury and osteoarthritis outcome score in 4 patient categories scheduled for knee surgery. Am J Sports Med 2010; 38 (2) 231-237
• 2 Bedi A, Feeley BT, Williams III RJ. Management of articular cartilage defects of the knee. J Bone Joint Surg Am 2010; 92 (4) 994-1009
• 3 Krych AJ, Harnly HW, Rodeo SA, Williams III RJ. Activity levels are higher after osteochondral autograft transfer mosaicplasty than after microfracture for articular cartilage defects of the knee: a retrospective comparative study. J Bone Joint Surg Am 2012; 94 (11) 971-978
• 4 Gudas R, Gudaite A, Pocius A , et al. Ten-year follow-up of a prospective, randomized clinical study of mosaic osteochondral autologous transplantation versus microfracture for the treatment of osteochondral defects in the knee joint of athletes. Am J Sports Med 2012; 40 (11) 2499-2508
• 5 Gobbi A, Karnatzikos G, Kumar A. Long-term results after microfracture treatment for full-thickness knee chondral lesions in athletes. Knee Surg Sports Traumatol Arthrosc 2014; 22 (9) 1986-1996
• 6 Biant LC, Bentley G, Vijayan S, Skinner JA, Carrington RW. Long-term results of autologous chondrocyte implantation in the knee for chronic chondral and osteochondral defects. Am J Sports Med 2014; 42 (9) 2178-2183
• 7 Rose T, Craatz S, Hepp P , et al. The autologous osteochondral transplantation of the knee: clinical results, radiographic findings and histological aspects. Arch Orthop Trauma Surg 2005; 125 (9) 628-637
• 8 Emmerson BC, Görtz S, Jamali AA, Chung C, Amiel D, Bugbee WD. Fresh osteochondral allografting in the treatment of osteochondritis dissecans of the femoral condyle. Am J Sports Med 2007; 35 (6) 907-914
• 9 Ghazavi MT, Pritzker KP, Davis AM, Gross AE. Fresh osteochondral allografts for post-traumatic osteochondral defects of the knee. J Bone Joint Surg Br 1997; 79 (6) 1008-1013
• 10 Chu CR, Convery FR, Akeson WH, Meyers M, Amiel D. Articular cartilage transplantation. Clinical results in the knee. Clin Orthop Relat Res 1999; (360) 159-168
• 11 Gudas R, Gudaitė A, Mickevičius T , et al. Comparison of osteochondral autologous transplantation, microfracture, or debridement techniques in articular cartilage lesions associated with anterior cruciate ligament injury: a prospective study with a 3-year follow-up. Arthroscopy 2013; 29 (1) 89-97
• 12 Nho SJ, Foo LF, Green DM , et al. Magnetic resonance imaging and clinical evaluation of patellar resurfacing with press-fit osteochondral autograft plugs. Am J Sports Med 2008; 36 (6) 1101-1109
• 13 Kreuz PC, Erggelet C, Steinwachs MR , et al. Is microfracture of chondral defects in the knee associated with different results in patients aged 40 years or younger?. Arthroscopy 2006; 22 (11) 1180-1186
• 14 Rosenberger RE, Gomoll AH, Bryant T, Minas T. Repair of large chondral defects of the knee with autologous chondrocyte implantation in patients 45 years or older. Am J Sports Med 2008; 36 (12) 2336-2344
• 15 Niemeyer P, Köstler W, Salzmann GM, Lenz P, Kreuz PC, Südkamp NP. Autologous chondrocyte implantation for treatment of focal cartilage defects in patients age 40 years and older: a matched-pair analysis with 2-year follow-up. Am J Sports Med 2010; 38 (12) 2410-2416
• 16 Mithoefer K, Hambly K, Della Villa S, Silvers H, Mandelbaum BR. Return to sports participation after articular cartilage repair in the knee: scientific evidence. Am J Sports Med 2009; 37 (Suppl. 01) 167S-176S
• 17 Meehan JP, Danielsen B, Kim SH, Jamali AA, White RH. Younger age is associated with a higher risk of early periprosthetic joint infection and aseptic mechanical failure after total knee arthroplasty. J Bone Joint Surg Am 2014; 96 (7) 529-535
• 18 Kim KT, Lee S, Ko DO, Seo BS, Jung WS, Chang BK. Causes of failure after total knee arthroplasty in osteoarthritis patients 55 years of age or younger. Knee Surg Relat Res 2014; 26 (1) 13-19
• 19 Aggarwal VK, Goyal N, Deirmengian G, Rangavajulla A, Parvizi J, Austin MS. Revision total knee arthroplasty in the young patient: is there trouble on the horizon?. J Bone Joint Surg Am 2014; 96 (7) 536-542
• 20 Stambough JB, Clohisy JC, Barrack RL, Nunley RM, Keeney JA. Increased risk of failure following revision total knee replacement in patients aged 55 years and younger. Bone Joint J 2014; 96-B (12) 1657-1662
• 21 Camp CL, Stuart MJ, Krych AJ. Current concepts of articular cartilage restoration techniques in the knee. Sports Health 2014; 6 (3) 265-273
• 22 Moran CJ, Pascual-Garrido C, Chubinskaya S , et al. Restoration of articular cartilage. J Bone Joint Surg Am 2014; 96 (4) 336-344
• 23 Gallo RA, Feeley BT. Cartilage defects of the femoral trochlea. Knee Surg Sports Traumatol Arthrosc 2009; 17 (11) 1316-1325
• 24 Kreuz PC, Steinwachs MR, Erggelet C , et al. Results after microfracture of full-thickness chondral defects in different compartments in the knee. Osteoarthritis Cartilage 2006; 14 (11) 1119-1125
• 25 Williams III RJ, Harnly HW. Microfracture: indications, technique, and results. Instr Course Lect 2007; 56: 419-428
• 26 Hangody L, Ráthonyi GK, Duska Z, Vásárhelyi G, Füles P, Módis L. Autologous osteochondral mosaicplasty. Surgical technique. J Bone Joint Surg Am 2004; 86-A (Suppl. 01) 65-72
• 27 Hangody L, Feczkó P, Bartha L, Bodó G, Kish G. Mosaicplasty for the treatment of articular defects of the knee and ankle. Clin Orthop Relat Res 2001; ;(391, Suppl): S328-S336
• 28 Hangody L, Füles P. Autologous osteochondral mosaicplasty for the treatment of full-thickness defects of weight-bearing joints: ten years of experimental and clinical experience. J Bone Joint Surg Am 2003; 85-A (Suppl. 02) 25-32
• 29 Chahal J, Gross AE, Gross C , et al. Outcomes of osteochondral allograft transplantation in the knee. Arthroscopy 2013; 29 (3) 575-588
• 30 Getgood AMJ, Kew SJ, Brooks R , et al. Evaluation of early-stage osteochondral defect repair using a biphasic scaffold based on a collagen-glycosaminoglycan biopolymer in a caprine model. Knee 2012; 19 (4) 422-430
• 31 McNickle AG, Provencher MT, Cole BJ. Overview of existing cartilage repair technology. Sports Med Arthrosc Rev 2008; 16 (4) 196-201
• 32 Williams RJ, Gamradt SC. Articular cartilage repair using a resorbable matrix scaffold. Instr Course Lect 2008; 57: 563-571
• 33 Gelber PE, Batista J, Millan-Billi A , et al. Magnetic resonance evaluation of TruFit® plugs for the treatment of osteochondral lesions of the knee shows the poor characteristics of the repair tissue. Knee 2014; 21 (4) 827-832
• 34 Farr J, Gracitelli G, Gomoll AH. Decellularized osteochondral allograft for the treatment of cartilage lesions in the knee. Orthop J Sport Med 2015; 3 (2) xx
• 35 Joshi N, Reverte-Vinaixa M, Díaz-Ferreiro EW, Domínguez-Oronoz R. Synthetic resorbable scaffolds for the treatment of isolated patellofemoral cartilage defects in young patients: magnetic resonance imaging and clinical evaluation. Am J Sports Med 2012; 40 (6) 1289-1295
• 36 Marx RG, Stump TJ, Jones EC, Wickiewicz TL, Warren RF. Development and evaluation of an activity rating scale for disorders of the knee. Am J Sports Med 2001; 29 (2) 213-218
• 37 Lee GW, Son JH, Kim JD, Jung GH. Is platelet-rich plasma able to enhance the results of arthroscopic microfracture in early osteoarthritis and cartilage lesion over 40 years of age?. Eur J Orthop Surg Traumatol 2013; 23 (5) 581-587
• 38 Ebert JR, Fallon M, Robertson WB , et al. Radiological assessment of accelerated versus traditional approaches to postoperative rehabilitation following matrix-induced autologous chondrocyte implantation. Cartilage 2011; 2 (1) 60-72