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