Effect of cartilage thickness mismatch in osteochondral grafting from knee to talus on articular contact pressures: A finite element analysis

Objectives: The aim of this study was to investigate the effect of cartilage thickness mismatch on tibiotalar articular contact pressure in osteochondral grafting from femoral condyles to medial talar dome using a finite element analysis (FEA). Materials and methods: Flush-implanted osteochondral grafting was performed on the talar centromedial aspect of the dome using osteochondral plugs with two different cartilage thicknesses. One of the plugs had an equal cartilage thickness with the recipient talar cartilage and the second plug had a thicker cartilage representing a plug harvested from the knee. The ankle joint was loaded during a single-leg stance phase of gait. Tibiotalar contact pressure, frictional stress, equivalent stress (von Mises values), and deformation were analyzed. Results: In both osteochondral grafting simulations, tibiotalar contact pressure, frictional stress, equivalent stress (von Mises values) on both tibial and talar cartilage surfaces were restored to near-normal values. Conclusion: Cartilage thickness mismatch does not significantly change the tibiotalar contact biomechanics, when the graft is inserted flush with the talar cartilage surface.

Management of scapholunate advanced collapse and scaphoid nonunion advanced collapse without proximal row carpectomy or four corner fusion

Four corner arthrodesis and proximal row carpectomy are the most common techniques for the management of advanced radiocarpal arthritis due to longstanding scapholunate instability and scaphoid nonunion. The advantages and short comings of each technique have been well defined in the literature. Advancements in joint replacement and arthroscopic surgery have resulted in new operations to manage radiocarpal and midcarpal arthritis. Most of these new procedures are modifications of the two classical operations, but some use modern implants and newer materials. New individualized options, like osteochondral grafting in combination with proximal row carpectomy or (arthroscopic) distal resection of the scaphoid, allowed us to improve our treatment and offer patients less invasive but equally effective procedures. We consider that four corner arthrodesis and proximal row carpectomy should not always be standard management for advanced radiocarpal arthritis.

Early Radiographic Healing and Functional Results After Autologous Osteochondral Grafting for Osteochondritis Dissecans of the Capitellum: Introduction of a New Magnetic Resonance Imaging–Based Scoring System

Background: Autologous osteochondral grafting (OG) is an option in the treatment of capitellar osteochondritis dissecans (COCD). However, radiographic healing after this procedure has not been well documented. Purpose: To develop a magnetic resonance imaging (MRI)–based scoring system specific for evaluating healing after single-plug OG in COCD and to evaluate correlation between radiographic healing and early clinical outcomes. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: Between 2014 and 2017, 183 elbows with COCD were enrolled in a prospective registry. A total of 61 elbows in 59 patients underwent single-plug OG. Of these, 52 elbows in 50 patients had pre- and postoperative MRI scans. Postoperative MRI and clinical outcome data from this group were used to develop the novel BOGIE score (Boston Osteochondral Graft Incorporation in the Elbow), with a possible range of 4 to 12. Results: Median age at surgery was 14.2 years (interquartile range, 13.1-15.0 years). Median clinical follow-up after OG was 12.4 months (interquartile range, 9.5-16.9 months; range, 6-53 months). Compared with before surgery, elbow function at 6 months after surgery and at latest follow-up was significantly improved as measured by the Timmerman and Andrews score (TAS; median: 145 before surgery, 185 at 6 months after surgery, 190 at latest follow-up; P < .001, before vs after surgery), as well as the short version of Disabilities of the Arm, Shoulder and Hand score; median: 21 before surgery, 7 at 6 months after surgery, and 0 at latest follow-up; P < .001 before surgery vs after surgery). Median BOGIE score at 6 months after surgery was 10 (range, 4-12). BOGIE score intraobserver reliability was 0.90 (95% CI, 0.82-0.94) for reader 1 and 0.91 (95% CI, 0.86-0.95) for reader 2. Interobserver reliability between the readers was 0.86 (95% CI, 0.78-0.92). Correlation was observed between the 6-month BOGIE score and the concurrent postoperative objective TAS ( P < .001) as well as total TAS ( P = .01) but not the subjective TAS ( P = .08). Patients who underwent subsequent secondary surgery for persistent symptoms had a significantly lower postoperative BOGIE score at 6 months than those who did not (median, 7.8 vs 10.3; P = .016) Conclusion: Quantitative evaluation for radiologic healing after single-plug OG in COCD is possible. The MRI-based BOGIE score appears to correlate with early clinical function and may be useful as an adjunct tool in decision making on activity progression. The use of a standardized MRI score may improve comparability of outcomes after OG in the literature.

Osteochondral Autograft Transportation vs Arthroscopic Fragment Resectionfor Large Capitellar Osteochondritis Dissecans in Adolescent Athletes - A Minimum of 5-year Follow-up

Objectives: Small capitellar osteochondritis dissecans (OCD) lesions have shown excellent functional and radiographic outcomes after arthroscopic (AS) fragment resection in previous studies. However, surgical options for unstable large capitellar OCD lesions in skeletally immature athletes remains controversial. Before 2007, we exclusively performed AS fragment resection for all inviable lesions regardless of lesion size. However, we initiated to perform osteochondral grafting for selected larger lesions in the year of 2007. The purpose of this study is to investigate functional outcomes and radiographic changes after osteochondral grafting and AS fragment resection for unstable large capitellar OCD lesions(>1/2 radial head diameter) in skeletally immature athletes with a minimum of 5-years follow-up. Methods: Group 1 consisted of 19 elbows in 19 patients (19 males; 16 baseball, 2 badminton and 1 gymnastics) that underwent osteochondral grafting for capitellar OCD (mean age, 14; range, 13-15), and the mean follow-up was 8 years (range; 5-11). Group 2 consisted of 21 elbows in 19 patients (17 males and 2 females; 16 baseball, 2 gymnastics and1 handball) that underwent AS fragment resection (mean age, 14. range, 13-15), and the mean follow-up was 8 years (range, 5-10). Preoperatively, the mean transverse diameter of lesions was 13 mm (range, 11-14) in Group 1 and 13 mm (range, 10-16) in Group 2. Superior migration of the radial head (>2-mm side-to-side difference) was seen in four elbows in Group 1 and one elbow in Group 2. Radial head enlargement with more than 20% of the contralateral side was seen in seven elbows in Group 1 and one elbow in Group 2. Functional scores (JOA score, DASH score and patient satisfaction), range of motion (ROM), and radiographic findings including Kellgren-Lawrence osteoarthritis (OA) grade were evaluated and compared between the groups. Results: All patients returned to sports activity. Functional scores at the final follow-up were not different between Group 1 and 2: JOA score, 90 (range, 68-100) vs 91 (range, 82-100); DASH score, 1 (range, 0-7) vs 3 (range, 0-14); Patient satisfaction, 84 (range, 50-100) vs 81 (range, 50-100). Flexion ROM at the final follow-up did not show significant improvement in both groups compared to preoperative values, though there was a significant difference at the final follow-up between the groups: Group 1, 133º (range, 115-150º); Group 2, 133º (range, 120-145º). Extension ROM showed significant improvement in both groups (P<.001 for both): Group 1, -18º (range, -35-0º) to -8º (range, -22-10º); Group 2, -17º (range, -50-0º) to 0º (range, -10-20º). Group 2 had significantly better extension than Group 1 at the final follow-up (P =.003). OA change progressed in 12 elbows (63%) in Group 1 and in 9 elbows (47%) in Group 2. There were four grade 3 OA elbows in Group 1, which preoperatively had superior migration and enlargement of the radial head. No elbows showed severe OA change in Group 2. Conclusion: Functional outcomes and radiological findings after both osteochondral grafting and AS fragment resection for unstable large capitellar OCD lesions in adolescent athletes were satisfactory with a mean follow-up of 8 years. However, grade 3 OA were seen after osteochondral grafting in four elbows with preoperativesuperior migration of the radial head. Osteochondral grafting should be performed before radiographical changes become severe.

Autogenous Osteochondral Graft Associated with IGF-1 in Induced Articular Cartilage Lesion in Rabbits

Background: Articular cartilage has a limited capacity for regeneration and of the various treatments proposed, none have reached appropriate therapeutic effectiveness. This study aimed to evaluate autogenous osteochondral grafts in intact or macerated format, in association with or without insulin-like growth factor type-1 (IGF-1) in the repair of osteochondral defects induced in the femoral trochlear groove of rabbits.Materials, Methods & Results: Seventeen healthy White New Zealand rabbits were selected for this study. The rabbits were female, six months old, and had an average body weight of 4.5 kg. All 34 stifle joints were subjected to autogenous osteochondral grafting in the femoral trochlear groove. The joints were divided into four groups designated as intact osteochondral graft with IGF-1 (INT + IGF), intact osteochondral graft with physiological solution (INT + FIS), macerated osteochondral graft with IGF-1 (MAC + IGF), and macerated osteochondral graft with physiological solution (MAC + FIS). Serial evaluations were performed by orthopedic and radiographic examination. After 6 and 12 weeks postoperatively, the grafted area was subjected to macroscopic, histological, and immunohistochemical analyses. Although no statistically significant differences were found between the groups in relation to clinical, macroscopic, histological, and immunohistochemical aspects, a tendency of IGF-1 to promote tissue repair was evident. In the radiographic evaluation, the articular surface and the recipient site in both groups with IGF-1 showed significantly more effective filling (P ≤ 0.05). Regardless of the group, collagen type 2 production, as assessed by immunohistochemistry, was found to be appropriate on the grafted articular surface.Discussion: In extensive cartilage lesions, the use of intact osteochondral grafts may be infeasible due to donor site morbidity. An alternative is the use of macerated osteochondral grafts, which cover a larger area and act as a support and cellular source in the repair process. Growth factors have been evaluated in association with grafted tissues to aid tissue repair, and IGF-1 is currently prominent. In the radiographic analysis of the present study, when comparing sites subjected to osteochondral grafting, presence of the whole graft evidenced adequate local filling in all groups. However, graft integration was apparently rapid and effective in the INT + IGF and MAC + IGF groups from the sixth and ninth weeks of the procedure, respectively. In the macroscopic evaluation at the twelfth week, graft integration with the original cartilaginous tissue was more evident, especially in both groups treated with IGF-1. It is likely that the property of IGF-1 to increase chondrogenesis in the cartilage repair of articular lesions in vivo may have contributed to these results in radiographic and macroscopic examinations. Histological examination showed no significant difference between groups in the same period of time; however, it was observed that addition of IGF-1 promoted a more evident tissue reaction and cellular activation, potentiating the process of reabsorption and repair in the grafted tissue. Immunohistochemical analysis showed similar immunoreactivity for collagen type 2 in all groups as early as the sixth week. However, a small portion of these tissues cannot be considered true hyaline cartilage due to the absence of some typical features. In summary, addition of IGF-1 to the autogenous osteochondral graft seemed to stimulate reabsorption and replacement processes in the grafted tissue. The grafts showed adequate ability to repair articular cartilage, displaying formation of collagen type 2 similar to that in the original tissue.

Hip Cartilage Restoration: Available Evidence and Current Trends

Treatment of cartilage pathology is controversial. In the hip, it is even more so as identification and treatment of early cartilage disease are relatively new and little evidence exists. With the advent and more widespread use of hip arthroscopy, easier access to the hip joint is available, and adequate treatment is possible with less morbidity. Many treatment options exist for cartilage lesions including nonoperative treatment, debridement, microfracture, acetabuloplasty, cartilage fixation, cartilage scaffolds, autologous chondrocyte implantation, and osteochondral grafting. While far from definitive, the current evidence suggests that smaller cartilage lesions (< 4 cm2) have good results with most treatments while larger lesions fare better with treatments that produce hyaline-like cartilage. The most cost-effective arthroscopic treatments of smaller cartilage lesions include acetabuloplasty and microfracture, while larger lesions should be considered for autologous matrix-induced chondrogenesis or matrix-assisted autologous chondrocyte implantation. Larger cartilage lesions with bone disease are more adequately treated with open procedures such as osteochondral grafting or total hip arthroplasty.