USE OF OSTEOCHONDRAL MOSAICPLASTY IN PATIENTS WITH KNEE JOINT ARTHROSIS DEFORMANS Gilev Ya.Kh., Milyukov A.Yu., Ustyantsev D.D.
Regional Clinical Center of Miners’ Health Protection, Leninsk-Kuznetsky, Russia
USE OF OSTEOCHONDRAL MOSAICPLASTY IN PATIENTS WITH KNEE JOINT ARTHROSIS DEFORMANS
Arthrosis deformans is the most common articular disease in adult population. About one-third of adult population of the world has some radiological signs of arthrosis deformans, although the clinically significant signs of the disease occur only in 9-10 % of adult population. The most common type of the disease is knee joint arthrosis deformans, which affects about 6 % of all adult population [1-4]. Defects of the articular cartilage cause the unpredictability of treatment outcomes and significantly worsen the disease course [5].
The technique of osteochondral mosaicplasty is well tested for replacement of defects in the articular cartilage. The use of automaterial is its main advantage, which provides the graft survival and its transition towards the region of the defect of articular surface of the hyaline cartilage [6-10]. The principle of the technique consists in movement of cylindrical osteochondral grafts (taken from the unloaded region of the medial and lateral femoral condyles) towards the defect region. Grafts are located perpendicular to the defect surface, at the same level as the cartilage surrounding the defect, and graft fixation is achieved by means of press-fit effect [7, 10]. Grafts, which are relocated into the defect, should be located as near as possible to each other. It allows replacing the defect with the hyaline cartilage by 60-80 % [8, 9, 10]. Mosaicplasty technique can replace the chondral defects of 4 cm2 [8, 9, 10].
On the basis of the reviewed literature, the indications for surgery are limited chondral defects, which appear in the loaded region of the femoral condyle after trauma or lesion of one half of the knee joint in development of early arthrosis deformans in patients older 45 years [8-11].
Objective – to present the treatment results of the patients with knee joint arthrosis deformans treated with osteochondral mosaicplasty.
MATERIAS AND METHODS
We have the experience with osteochondral mosaicplasty in 25 patients with knee joint arthrosis deformans with articular cartilage defects.
The study was conducted in compliance with World Medical Association Declaration of Helsinki – Ethical Principles for Medical Research Involving Human Subjects 2013 and the Rules for Clinical Practice in the Russian Federation (the Order by Russian Health Ministry, No.266, June 19, 2003), with written consent for participation in the study and approval by the ethical local committee (the protocol No.131, December 14, 2013).
The proper selection of the patients is the important condition for good results when planning surgery [8-11]. After the literature review and the own clinical experience, we determined the following indications for osteochondral mosaicplasty: 1) presence of limited defects of the articular cartilage in the load zone of the femoral condyle; 2) the cartilage around the defect should have good quality (chondropathy not exceeding the degree 2 according to Outerbridge); 3) necessary amount of good donor material (chondropathy not exceeding the degree 1 according to Outerbridge). The surgery is contraindicated in the following cases: 1) a chondral defect on the tibial condyle; 2) deficiency of donor material as result of an extensive chondral defect; 3) low quality of the cartilage in the donor site; 4) chondral defects after an infection or a tumor. As compared to the literature data, we did not separate the age as the criterion for selecting the patients for surgery, since the selection is based on the data of estimation of the articular cartilage quality after knee arthroscopy. All operations were initiated with diagnostic arthroscopy of the articular cartilage and determination of the indications for osteochondral mosaicplasty.
The surgery was conducted with the following technique. The tourniquet was applied in the region of the middle one-third of the hip. Knee arthrotomy was performed with the parapatellar approach. The approach size was 4-6 cm. The femoral condyle was separated. After flexing the knee joint, we introduced the femoral condyle with the chondral defect into the approach zone. Using the lancet, the low quality hyaline cartilage was dissected along the boundaries of the defect at the right angle. Then 5 mm drill was used for making the channels (15 mm deep) for the grafts in the defect zone. The channels were located perpendicularly to the surface of the subchondral bone over the distance of 1-2 mm to each other along the whole zone of the defect. Appropriate removal of bone chips in the joint cavity is the important moment for formation of the channels. We used our own device (Fig. 1, the RF patent No.2218113, December 10, 2003) for making the necessary amount of cylindrical osteochondral grafts (according to the number of the channels in the defect zone).
Figure 1. The device for harvesting the cylindrical osteochondral grafts
The grafts were taken from the unloaded region of the femoral condyles. Then the grafts were placed into the channels in the defect zone. Fixation of the grafts was achieved by means of creation of press-fit effect, and the grafts were placed at the level of the cartilage surrounding the defect.
25 patients received osteochondral mosaicplasty; it was about 16 % of the patients with knee arthrosis deformans and the articular cartilage defects. The proper selection of the patients during surgery planning determined this number of the interventions and the ratio of the patients. We observed the patients at the age of 39-73. The mean age was 50.3. All patients had the stages 2 or 3 of the disease. The square of the chondral defects was 0.5-3.5 cm2. The mean square of the defect was 2.06 ± 0.21 cm2. During the surgery, the defect was filled with 1-9 osteochondral grafts, but, mostly (14 patients), 6 ones.
After the surgery, the knee joint was immobilized with the posterior plaster bar for 3 weeks. Walking without load to the operated extremity lasted for 6 weeks from the day of the surgery. After completion of immobilization, the patients could perform the movements in the joint and make remedial gymnastics for recovery and strengthening of the musculus quadriceps femoris. Knee joint puncture was obligatory for correcting the hemarthrosis. Prevention of thromboembolic complications was conducted with use of heparin, acetylsalicylic acid (in absence of contraindications) and elastic bandaging of the operated extremity. The prevention of infectious complications was conducted with prescription of short time course of antibiotics of cephalosporin range for all patients.
The mean time of the follow-up was estimated. The disease progression was assessed with X-ray imaging, intensity of pain syndrome – with Leken’s algofunctional index (points).
The statistical analysis of the data was conducted with IBM SPSS Statistics 20. Kolmogorov-Smirnov test was used for estimation of distribution of the quantitative values. Since the distribution of most data corresponded to the normal distribution law, the quantitative variables are presented as Ì ± m, where M – mean arithmetic, m – error of the mean.
The qualitative signs are presented as absolute and relative (%) values. The differences in the quantitative variables were identified with Student’s non-parametric test. The differences were statistically significant with p < 0.05.
RESULTS AND DISCUSSION
The study of the long term results was conducted for 15 patients for the period from 1 to 5 years after the treatment. The mean period of observation was 2 years and 7 months. The radiological study did not show any signs of staged progression of the disease in 93.4 % of the patients. The evident clinical improvement with decreasing pain syndrome was observed. So, the mean Leken’s index was 15.68 ± 0.28 points before the treatment, 7.78 ± 1.34 points 1 year and more after the treatment (p < 0.005) [12].
But there is an unsolved question of the efficiency of the technique in prolonged follow-up of the patients with knee joint arthrosis deformans who received mosaicplasty [10]. The appearance of knee replacement technique in our clinic allowed tracing the further results in the part of the patients. We have two cases of follow-up of the outcomes of osteochondral mosaicplasty for the period of 16 years. Both patients were operated in 1999 and 2001. After completion of the treatment, both patients had been demonstrating the persistent remission of the disease with arresting pain syndrome over 10 years. After 10 years of remission, both patients demonstrated the gradual progression and increase of pain syndrome resulting in development of pain syndrome persistent to conservative therapy, with further prescription of knee replacement in 2015 and 2017 correspondingly.
The patient D., age of 41, was admitted to Regional Clinical Center of Miners’ Health Protection on November 1, 1999. The diagnosis was: “Right knee joint arthrosis deformans, stage 2 with lesion of patellofemoral junction, defect of cartilage of medial femoral condyle” (Fig. 2).
Figure 2. The X-ray images of the right knee joint (1999)
The patient suffered from a knee joint injury 3 years before admission. The outpatient conservative treatment was conducted. After the examination and the presurgical preparation, the surgery was carried out on November 3, 1999: arthroscopy of the right knee joint. The joint revision showed a chondral defect of the medial condyle of the right femoral bone (Fig. 3). Right knee arthrotomy was conducted through the parapatellar approach of 5 cm. The osteochondral mosaicplasty of the medial condyle of the femoral bone was performed. Six grafts were placed into the chondral defect (Fig. 4-8). One day after the surgery, the patient reported on ease from pain in the operated knee joint at night time.
Figure 3. The defect of entocondyle of the right hip (arthroscopic view)
Figure 4. The defect of entocondyle of the right hip (arthrotomy)
Figure 5. Transplant procurement
Figure 6. Donor site
Figure 7. The defect filled with grafts
Figure 8. The grafts in the defect (arthroscopic view)
The wound was healed with primary tension. The sutures were removed on the 10th day after the surgery. Plaster immobilization lasted for 3 weeks after the surgery. Then the motions in the knee joint were initiated. The non-weight-bearing ambulation on crutches was during 6 weeks after the surgery. Remedial gymnastics was oriented to strengthening and recovery of the right musculus quadriceps femoris. The period of working disability was 4 months. The patient resumed his professional activity (operator of rock removing machines).
14 months after the surgery, the patient received the control arthroscopy of the right knee joint. The chondral defect on the medial condyle of the femoral bone was replaced with the regenerate (Fig. 9). Also the laterolysis of the right patella was conducted during arthroscopy. The functional outcome of the treatment was estimated after 4 years after the osteochondral mosaicplasty (Fig. 10-11). The examination showed the decrease in the value of Leken’s algofunctional index from 16 to 8 points.
Figure 9. The cartilage defect replaced with the regenerate
Figure 10. The control X-ray images of the right knee joint (2003)
Figure 11. The functional result after 4 years
During 10 years after completion of the treatment, the patient had been noting the persistent remission of the disease with full disappearance of pain syndrome. He had been working within his specialty (operator of rock removing machines). Since 2012, the patient had been noting the appearance and increase of pain in the right knee joint. The outpatient courses of conservative treatment were conducted two times per year. Due to increasing pain syndrome, the patent received the arthroscopy and revision of the right knee joint on March 25, 2014. The revision showed the articular cartilage on the medial condyle and the femoral bone block, absence of cartilage on the patella, and chondropathy of degrees 3-4 in the lateral regions of the joint. After arthroscopy at the background of conservative therapy, the patient noted the improvement in his condition within 3 months. The pain syndrome returned and became resistant to the conservative therapy. The replacement of the right knee joint was offered. The procedure was conducted on June 9, 2015 (Fig. 12-14).
Figure 12. The X-ray images of the right knee joint (2015)
Figure 13. The condition of the cartilage of the right knee joint (joint replacement stage)
Figure 14. The X-ray images of the right knee joint
The postsurgical period was without complications. The healing was primary. The function of the right lower extremity restored.
CONCLUSION
Therefore, active use of osteochondral mosaicplasty for patients with knee joint arthrosis deformans and chondral cartilage defects gives the positive effect with improvement in functional results of treatment and prediction of the disease course, as well as delays the knee joint replacement upon condition of proper selection of patients.
Information about financing and conflict of interests
The study was conducted without sponsorship.
The authors declare the absence of any clear and potential conflicts of interests relating to publication of this article.