Treatment of unstable knee osteochondritis dissecans in the young adult: results and limitations of surgical strategies—The advantages of allografts to address an osteochondral challenge

Abstract

Joint surface incongruence resulting from osteochondritis dissecans (OCD) alters the articular physiologic congruence, increasing the contact stress on adjacent joint surfaces and accelerating wear and the cascade of joint degeneration. Accordingly, the restoration of articular surface integrity is of major importance, especially in young adults where, in lesions left untreated or following simple fragment excision, early osteoarthritis can be anticipated. Therefore, the treatment algorithm in unstable knee OCD of the young adult foresees surgical options to restore the articular surface. Several procedures have been proposed, including refixation of the detached fragment bone marrow stimulation, osteochondral autograft implantation, fresh osteochondral allograft transplantation, and cell-based or cell-free regenerative techniques. The aim of this review was to summarize the evidence for these surgical strategies, reporting their results and limitations. The overall evidence documents positive results for each of the assorted surgical procedures applied to treat unstable OCD, thus indicating support for their selected use to treat osteochondral defects paying particular attention to their specific indications for the lesion characteristics. The fixation of a good quality fragment should be pursued as a first option, while unfixable small lesions may benefit from autografts. For large lesions, available cell-based or cell-free osteochondral scaffold are a feasible solution but with limitation in terms of regenerated tissue quality. In this light, fresh allografts may offer articular surface restoration with viable physiologic osteochondral tissue providing a predictably successful outcome, and therefore they may currently represent the most suitable option to treat unstable irreparable OCD lesion in young adults. Level of evidence V.

Multi-layer cell-free scaffolds for osteochondral defects of the knee: a systematic review and meta-analysis of clinical evidence

“…Several techniques have been developed over the years to address knee osteochondral lesions, in order to relieve pain, restore function and possibly delay osteoarthritis (OA) onset [ 14 ]. Traditional surgical approaches consist of autologous or allogenic osteochondral tissue transplantation to provide an immediate viable tissue at the lesion site [ 23 , 25 , 31 ]. These techniques demonstrated promising results up to long-term follow-up, but they also showed several drawbacks, such as a significant donor site morbidity for autologous osteochondral transplantation (OAT), and high cost, limited availability, and contamination risk for osteochondral allograft transplantation (OCA) [ 21 , 31 , 75 ].…”

Osteochondral autograft transplantation versus autologous bone-cartilage paste grafting for the treatment of knee osteochondritis dissecans

“…OAT: pre-surg-24 months p = 0.337; pre-surg-84 months p = 0.060; 24-84 months p = 0.289; PG: pre-surg-24 months p = 0.075; pre-surg-84 months p = 0.089; 24-84 months p = 0.995; OAT vs PG: pre-surg p = 0.074; 24 months p = 0.325; 84 months p = 0.221 autologous chondrocyte transplantation (MACT), which can be combined with an autologous bone grafting in order to reconstruct both bone and cartilage, and provide articular surface restoration [21]. However, both techniques are limited by high costs and require two separate surgical procedures with demanding technical surgical issues, and inferior outcomes have been demonstrated in larger lesions [22]. The research for less expensive one-step procedures led to the development of biphasic cell-free osteochondral scaffolds, which were also applied in OCD lesions.…”

“…Nevertheless, MRI findings reported an incomplete bone regeneration, as reported also in other studies [24], demonstrating the difficulty to properly regenerate a physiologic subchondral bone tissue. To this regard, better results were proved for another procedure able of restoring the entire osteochondral unit in a single surgical procedure [22], the transplantation of fresh osteochondral allografts [25]. This demonstrated good clinical results also in knee OCD, but its main limitation is represented by graft availability and regulatory restrictions, with organization and distribution issues concurring to limit the possible application of this procedure to a few countries [22].…”

Internal Fixation of Osteochondritis Dissecans of the Knee Leads to Good Long-Term Outcomes and High Degree of Healing without Differences between Fixation Devices

“…The use of fresh osteochondral allograft would be a perfect solution to provide immediate congruent restoration of the articular surface with structurally competent subchondral bone and the associated viable chondral surface, with no size limitations. That would lead to good clinical results [19]. Unfortunately, the availability of the tissue, the high cost of the technique and some issues around the organization, conservation and distribution of the tissues prevent the spread of this technology.…”