OSTEOCHONDRAL MOSAICPLASTY FOR THE TREATMENT OF FOCAL CHONDRAL AND OSTEOCHONDRAL LESIONS OF THE KNEE AND TALUS IN THE ATHLETE: Rationale, Indications, Techniques, and Results

doi:10.1016/S0278-5919(05)70129-0

Clinics in Sports Medicine

Volume 18, Issue 1, 1 January 1999, Pages 45-66

https://doi.org/10.1016/S0278-5919(05)70129-0 Get rights and content

Injuries to the athlete's knee and ankle represent major threats to continued participation in sports. These injuries range from minor sprains to extremity-threatening fractures and dislocations. Proper orthopedic management of each injury is essential to a successful outcome as measured by the athlete's return to a preinjury level of participation. This high goal is one of the hallmarks of modern sports medicine treatment. Proper management begins with proper diagnosis, followed by a cascade of treatment options. In contact sports and in those sports involving torsional stresses on the lower extremity joints, focal articular defects, whether chondral, osteochondral, or in conjunction with ligamentous or meniscal injuries, have been one of the more common and beguiling injuries presented to the sports medicine orthopedic surgeon. 7, 40

Over the years, these lesions have been difficult to diagnose and have defied a course of consistently successful treatment. ⁴¹ Invariably, the defect follows a course that causes persistent pain with activities, intermittent swelling, and premature osteoarthritis (OA). Recent advances in understanding the physiology and biomechanical properties of articular cartilage have accelerated clinicians' interest in various treatment options as well as alerted the sports public to new sports medicine horizons. 39, 49 An ever-widening spectrum of choices is becoming available to the athlete. 3, 4, 9, 20, 31, 34, 35, 45, 46 This labyrinth of offerings bears resemblance to the formative days of modern anterior cruciate ligament (ACL) replacement. Many of the early ACL substitutions did show promise initially, but the long-term results were judged as less than optimal. 12, 27 A reproducible treatment pathway became apparent only when the biomechanics of the knee and the biology of the grafts were defined. ⁴² One of the key elements to ACL grafting has been the selection of tissue that has similar properties to the injured ligament. ⁵³

Similarly, in the treatment of focal chondral defects the loss of articular cartilage is best treated by replacement with a like substance (i.e., hyaline-like or hyaline cartilage). Replacement that results in tissue or substance with different chemical and biomechanical properties is predictably inferior (e.g., techniques resulting in fibrocartilage). 3, 26

To date, four chondral replacement procedures have been reported that result in hyaline-like or hyaline cartilage replacement: (1) microfracture or microfracture with grouting, 45, 46 (2) chondrocyte transplantation, 35, 43 (3) fresh cadaver allografts,9, 15 and (4) autogenous osteochondral grafting. 4, 17, 23, 34

1
Microfracture and grouting-microfracture have been reported as producing encouraging early clinical results. In those reports, hybrid repair tissue, composed of fibrocartilage and hyaline-like cartilage, replacement tissue has been cited as forming.
2
Chondrocyte transplantation is an exciting clinical concept that has intrigued doctors and patients alike. 5, 50 The histology has been reported as hyaline-like reparative cartilage.
3
Allografts have been used for years with success and continue to be used for a variety of indications including large post-traumatic defects and after tumor resection. 10, 32 With the use of fresh cadaver osteochondral grafts, long-term survival of the transplanted hyaline cartilage has been reported. ¹⁵
4
Autogenous osteochondral grafting has gained favor in part because of the transplantation of genotypic hyaline cartilage. The mosaicplasty (MP) is such a process. ¹⁸

Results of these procedures in the athletic population have yet to be determined. This article details the nature of MP and its application to the athlete.

MP was developed by Drs. László Hangody and Zoltan Kárpáti of Budapest, Hungary, in an effort to transplant hyaline cartilage that can survive long term as an integrated, fully functioning articular surface. Their work began in the early 1990s, initiated by animal trials and subsequent clinical applications. ¹⁹ Since then, MP has been performed on 463 patients at their center in Hungary and at other centers in the United States and Canada. ²² For the athletes in that series, the major concern, in addition to survival of the grafts as hyaline cartilage, is the involved joint's performances under extreme weight-bearing loads.

Section snippets

THE BASIC SCIENCE RATIONALE FOR OSTEOCHONDRAL GRAFTING

The scientific rationale for osteochondral grafting has been formulated by synthesizing the observations in the animal laboratory, second-look arthroscopy biopsies, and clinical performance of the patients. Professor Miklós Bély of the Morphologic Institute at the National Institute of Rheumatology and Physiotherapy in Budapest, Hungary, has been instrumental in the preparation and interpretation of the histologic specimens.

MP grafts survive, and survive with intact hyaline cartilage (Fig. 1).

INDICATIONS

Indications for the use of the MP osteochondral grafting technique were established at the onset of the clinical applications in January 1992. The MP is indicated for the treatment of focal chondral and osteochondral defects in the knee and talus in patients under the age of 45. ¹⁷ This age limit is not arbitrary; rather, it is influenced by the appearance and quality of the surrounding articular cartilage and the physiologic status of the patient.

The technique has been used successfully in

OPERATIVE TECHNIQUES

The MP osteochondral grafting method has been used for a variety of focal, chondral, and osteochondral defects of the femoral condyles, the patella, the femoral sulcus, and the talus. In addition to the arthroscopic technique, a minimally invasive fiberoptic retractor has made formal arthrotomy no longer necessary even in the case of large OCD lesions. ²⁸ Expanded instrumentation is in the development phase for the arthroscopic treatment of patellar and tibial plateau lesions.

MIDAST

At initial arthroscopy, the perpendicular line to the defect is determined. Based on that axis the exposure is made through a medial or lateral 30-mm fat pad–saving incision. This incision is made to the side of the patellar tendon with dissection carried down to the retinaculum. The retinaculum is then incised in line with the skin incision. By undermining the retinaculum either laterally or medially for approximately 1 to 2 cm, the joint can be entered beyond the body of the fat pad through

RESULTS

As of April 1, 1998, the authors have performed 463 MP procedures in Hungary (391) and the United States (72). Fifty-two of those 463 procedures have been performed on competitive athletes with follow-ups of more than 1 year. Table 1 lists those athletes and their follow-up, including their sports activity, diagnosis, length of symptoms, and out-of-sport time prior to treatment, number of MP plugs; the operative method, associated injuries, postoperative knee score (modified Hospital for

DISCUSSION

This review of a specific subgroup of our MP patients brings to light particular restraints of the procedure in managing chondral and OSD defects in the athlete. A number of factors appear to influence the recovery rate and return to sport. The longer the preoperative symptoms are present, the longer the delay in returning to the patient's sport. It is of little surprise that age has a deleterious effect. Athletes over the age of 30 tend to be slower in their recovery and re-enter their sport

CONCLUSION

The surge of interest in the response of articular cartilage to injury has been of particular note to the sports medicine specialist in their treatment of the athletic population. Treatments that address this problem and return the athlete to his or her preinjury activity level have far-reaching implications. The 1-year-plus results of the MP in athletes suggest that a number of preoperative factors influence the outcome: age, duration of symptoms, and coexistent traumatic arthritis. Associated

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Top 50 Most-Cited Studies about Osteochondritis Dissecans
2024, Arthroscopy, Sports Medicine, and Rehabilitation
To determine the 50 most frequently cited studies on osteochondritis dissecans (OCD) and to conduct a bibliometric analysis of these studies.
We performed a search within the Clarivate Web of Science database, identifying articles published before December 2022 that encompass topics related to OCD. The search was conducted using the keywords “Osteochondritis Dissecans OR Osteochondritis OR Dissecans.”Search results were then filtered using predetermined guidelines and criteria, and the 50 most-cited articles were selected for analysis. Extracted data included title, journal, design, main topic, joint, citations, year, country of origin, and level of evidence.
The search yielded 3,865 articles. The 50 most-cited articles were published between 1957 and 2018, with the greatest proportion published from 2000 to 2009 (60%). The most frequently studied topic was treatment (68%), followed by etiology (14%) and imaging (8%). The majority of articles had Level IV evidence (36%) and the largest proportion focused on the knee joint (36%), followed by the ankle (32%), and elbow (6%). The mean citation count per article was 287 (range: 157-1,050), with the most-cited articles primarily published from 2000 to 2003. The leading country of origin was the United States, accounting for 19 publications.
Most of the top 50 most-cited articles regarding OCD are about treatment, and the knee is the most-studied joint. The majority of the articles were Level IV evidence and were published in the United States between 2000 and 2009.
The top 50 most-cited studies list will provide researchers, medical students, residents, and fellows with a foundational list of the most important and influential academic contributions regarding osteochondritis dissecans (OCD).
Size of cartilage defects and the need for repair: a systematic review
2022, Journal of Cartilage and Joint Preservation
Cartilage defects are treated with a wide array of non-operative and surgical procedures. Optimal choice of treatment depends on lesion depth and size.
To review and summarize current data on the management of cartilage injuries in joints as it relates to defect size.
MEDLINE, Cochrane Central Register of Controlled Trials & Cochrane Library, CINHAL.
Inclusion: (1) Studies investigating patients who underwent cartilage repair of the shoulder, elbow, hip, knee, and ankle. (2) Studies reporting outcome measures and treated lesion size. Exclusion: (1) No mention of defect size. (2) Joints not mentioned above. (3) <12 months clinical follow-up. (4) Unavailable full English or full texts.
Selection procedure and homogeneity of patient population and preoperative and postoperative care were examined. Attrition bias was scored based on the percentage follow-up of the primary outcome parameter. Level of evidence was determined according to the guidelines of the Oxford Center for Evidence-Based Medicine.
Small lesions sized 1.5 cm² are often either fixated or conservatively treated, lesions sized >1.5 cm² mostly addressed with cell-based therapies such as autologous cartilage implantation (ACI), or matrix associated cartilage implantation (MACI). Large lesions often are the domain of osteochondral autograft transfer system (OATS).
Prospective randomized controlled studies are not available for every joint and many studies represent case studies with limited implications for treatment decisions.
Evidence-based treatment selection based on cartilage defect size can be beneficial.
276559.
Long-term (10-25 years) outcomes of knee osteochondral autologous transplantation in soccer players
2022, Journal of Cartilage and Joint Preservation
Citation Excerpt :
This widely used procedure was described by Hangody et al. in 1992 and has been used for knee lesions since 1992. The exact surgical methodology and indications are detailed in the cited articles.18-22 According to several studies, mosaicplasty has good or excellent clinical results in football players in more than 80% of the cases.15,23,24
Osteochondral lesions in the knee can occur in a high percentage of soccer players. Untreated, symptomatic osteochondral lesions can lead to reduced athletic performance, early career-ending, and the premature onset of knee osteoarthritis. One of the treatment options is osteochondral autologous transplantation with the mosaicplasty technique. The study aims to investigate the long-term outcomes of the procedure in the athletic population.
In a single-center retrospective study, the long-term outcomes of knee mosaicplasty procedures in soccer players between 1992 and 2011 were investigated. Using International Knee Documentation Committee and Bandi score to evaluate the knee function, Tegner score to measure activity, and MOCART 2.0 score to describe cartilage surface. Players' skill level was divided into professional, competitive, and recreational groups.
Fifty-five out of 73 soccer players were included; 25 had MRI at the last follow-up control. The average follow-up time was 17,54 years (10,32-24,91). The mean International Knee Documentation Committee score was 68.52 ± 16.01 (33-87), MOCART was 70.8 ± 18.12 (25-95), and 80% of the patient had a good Bandi score. The mean size of the defects was 2,08 cm² ± 1,19 (1-5 cm²) and overall return to sport time was 7,78 ± 2,96 (4-12) months.
The knee mosaicplasty procedure has a good long-term result, with no significant decrease in functional scores compared to other studies even after 20 years from the surgery. Therefore, osteochondral autologous transplantation is a reasonable option for soccer players with small to medium-sized osteochondral lesions in the knee.
Long-term outcomes of talus osteochondral autologous transplantation in soccer players: 24 mosaicplasty with more than 10 years of follow-up
2022, Journal of Cartilage and Joint Preservation
Around 17% to 40% of professional soccer players' joint injuries affect the ankle. Although their incidence rate is relatively low, it is necessary to treat the cartilage and osteochondral talus injury in most cases, particularly in athletes. According to the latest International Consensus Meeting on Cartilage Repair of the Ankle implicates that there is not enough evidence to make a proper guideline; therefore, the study aims to investigate the long-term outcomes of talar mosaicplasty.
In a single-center retrospective study, the long-term outcomes of talus mosaicplasty procedures in soccer players between 1997 and 2011 were investigated. A combination of scores was used: the FAOS (Foot and Ankle Outcome Score) and Bandi score in order to evaluate the ankle and donor site function, the Tegner scores to measure activity, and the MOCART 2.0 (Magnetic Resonance Observation of Cartilage Repair Tissue) score to describe cartilage surface. Players' skill level was divided into professional, competitive, and recreational groups.
Twenty-four soccer players were included; 13 had MRI at the last follow-up control. The average follow-up time was 13.84 ± 3.65 (10.22-22.82) years. The mean FAOS score was 86.16 ± 16.05 (24-99), MOCART was 50.76 ± 12.55 (25-70), and 87% of the patients had a good to excellent Bandi score. The overall return to sport was 11.4 ± 4.8 (3.6-24) months.
Mosaicplasty has a good long-term functional outcome score and proved to be a reliable treatment option for the athletic population.
Mosaicplasty Using Grafts From the Upper Tibiofibular Joint
2017, Arthroscopy Techniques
Autologous mosaicplasty has been widely used for the treatment of focal, full-thickness, articular cartilage lesions of the knee and ankle joints. Commonly, the autografts are harvested from non–weight-bearing areas of the knee joint, leading to associated donor-site morbidity and representing a considerable disadvantage. This Technical Note presents a mosaicplasty procedure for harvesting autologous osteochondral plugs from the upper tibiofibular joint to repair articular cartilage defects. With this technique, it is possible to achieve low or no risk of donor-site morbidity, being therefore a safe and favorable option to treat large cartilage defects. Because of its minimal size-related restrictions, it enables harvesting larger plugs (filling an area up to 5 cm²) without any additional iatrogenic complications. Hence, mosaicplasty using the upper tibiofibular joint autografts can overcome many of the reported complications associated with osteochondral autograft harvesting. Thus, the upper tibiofibular joint articular surface should be considered as a safe and reliable autograft source for harvesting osteochondral plugs.
A Comparison of the Outcomes for Cartilage Defects of the Knee Treated With Biologic Resurfacing Versus Focal Metallic Implants
2017, Arthroscopy - Journal of Arthroscopic and Related Surgery
To compare the results of focal metallic resurfacing with biologic procedures in patients more than 35 years of age with isolated, full thickness defects of the femoral condyle.
A total of 61 patients met the selection criteria resulting in 30 patients treated with biological procedures, including debridement, microfracture, osteochondral autograft transplantation, osteochondral allograft, and autologous chondrocyte implantation (BIO group), and 32 patients treated with focal metallic resurfacing (CAP group). The BIO and CAP groups were matched according to treatment location, defect grade and size, and age profile. Outcomes included Western Ontario and McMaster Osteoarthritis Index (WOMAC), Short Form-12, and satisfaction. The primary combination endpoint was determined as a 20% improvement (minimum clinically important difference-20) on WOMAC pain and function at 2 years and no additional index lesion-related surgical intervention. Safety and effectiveness were also reported.
Thirty patients in the BIO group (mean age of 44.6, range 35-64) had an average follow-up of 2.6 years and 32 patients in the CAP group (mean age 47.9, range 37-68) were followed for 2.0 years. Fifty-three percent in the BIO group and 75% in the CAP group achieved success per the endpoint definition. The mean total WOMAC score improved significantly for both groups (BIO: 57-78; P < .001) (CAP: 41-86; P < .001). The physical component score (Short Form-12 PCS) improved significantly in the CAP group only (30-36.4; P < .001). Good to excellent patient satisfaction was achieved by 80% in BIO and 91% in CAP. There were 4 secondary procedures on the index lesion in the BIO group and 2 in the CAP group.
Careful patient selection can achieve high satisfaction rates with both biological and focal metal resurfacing procedures for the treatment of isolated focal chondral lesions of the femoral condyle in the knee. Focal metallic resurfacing results in similar clinical outcomes and provides excellent success rates at short-term follow-up.
Level III comparative study.

View all citing articles on Scopus

: Address reprint requests to Gary Kish, MD, St. George Medical 109 Hillside Drive Portsmouth, NH 03801

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OSTEOCHONDRAL MOSAICPLASTY FOR THE TREATMENT OF FOCAL CHONDRAL AND OSTEOCHONDRAL LESIONS OF THE KNEE AND TALUS IN THE ATHLETE: Rationale, Indications, Techniques, and Results

Section snippets

THE BASIC SCIENCE RATIONALE FOR OSTEOCHONDRAL GRAFTING

INDICATIONS

OPERATIVE TECHNIQUES

MIDAST

RESULTS

DISCUSSION

CONCLUSION

Operative techniques in orthopaedics

Operative Techniques in Orthopaedics

Operative Techniques in Orthopaedics

Arthroscopy

Operative Techniques in Orthopaedics

Arthroscopy

Operative Techniques in Orthopaedics

Operative Techniques in Orthorpaedics

Operative Techniques in Orthopaedics

Chondromalacia patellae and femoro-patellare artorse

Helv Chir Acta

In-vitro evaluation of drugs proposed as chondroprotective agents

Int J Tissue React

Arthroscopic osteochondral autogenous graft transplantation anterior cruciate ligament reconstruction: A preliminary report

Knee Surg Sports Traumatol Arthrosc

Treatment of deep cartilage defects in the knee with autologous chondrocyte implantation

N Engl J Med

Articular cartilage part III: Degeneration and osteoarthrosis, repair, regeneration, and transplantation

J Bone Joint Surg Am

Articular surface injuries

Immunization against heterologous type II collagen induces arthritis in mice

Nature

The operative technique of fresh osteochondral allografting of the knee

Operative Techniques in Orthopaedics

Fresh osteochondral allografts of the femoral condyle

Clin Orthop

Bone and cartilage allotransplantation: A review of 14 years of research and clinical studies

Clin Orthop

Reconstruction of the anterior cruciate ligament using a torn meniscus

J Bone Joint Surg Am

Induction of cartilage degradation in experimental arthritis produced by allogenic and xenogeneic proteoglycan amigens

Connect Tissue Res

Studies on cartilage formation XIX: Oxygen and glucose supply of the regenerating articular surface

Acta Biol Hung

A new surgical treatment of localized cartilaginous defects of the knee

Hung J Orthop Trauma