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LONG-TERM OUTCOMES OF SURGICAL MANAGEMENT OF OSTEOCHONDRITIS DISSECANS WITH MOSAIC AUTOCHONDROPLASTY Bogatov V.B., Sadykov R.Sh.

Sechenov First Moscow State Medical University, Moscow, Russia,

V.I. Razumovsky Saratov State Medical University, Saratov, Russia

 

Articular hyaline cartilage is the specific connective tissue of joints, the function of which consists in provision of smooth sliding of connecting articular surfaces and decreasing loads by means of low coefficient of friction. It has not any blood and lymphatic vessels, as well as approach to predecessor-cells [1, 2]. Absence of nervous ends in its structure explains the absence of pain sensitivity at early stages of a lesion [3].

Currently, there is an actual problem of arrangement of care for patients with degenerative-destructive and traumatic lesions of the articular cartilage since it has not ability to regenerate in any origin of an injury, resulting in subsequent progressing degenerative changes in the joint and irreversible secondary destructive lesions [4, 5]. Defects of articular hyaline cartilage often occur in cases of injuries and degenerative-dystrophic processes. Osteochondritis dissecans is one of the most common lesions of the knee joint. It is characterized by disorders of knee cartilage trophism with subsequent sequestration and detachment of a bone-cartilage fragment. Among knee joint diseases, the percentage of osteochondritis dissecans (OD) is 2 % that is 0.8 % among total structure of orthopedic abnormalities [6]. According to Gowd A.K. et al. (2019), knee joint lesions present 15 % of all inpatients of trauma and orthopedic profile, 5.85 % of which suffer from OD [7].

Men suffer from this disease three times more often than women. The mean age of patients is 24.43 ± 8.63 [8]. It accentuates the actuality of the problem of treatment of this pathology.

Currently, one of the common surgical techniques for OD is mosaic autochondroplasty with bone-cartilage grafts. However, the modern literature does not show the uniform opinion on long term results of such surgical management. Therefore, we carried out a study of long term results of mosaic autochondroplasty at final stages of osteochondritis dissecans.

Objective – to study long-term outcomes of mosaic plasty for osteochondritis dissecans.

 

MATERIALS AND METHODS

The study is based on an analysis of 17 male and female patients at the age of 17-56 with osteochondritis dissecans of stages 3-4 with square of an articular defect from 1.5 to 3.6 cm². The patients were operated in the traumatology and orthopedics unit of Saratov State Medical Academy in 2014-2016.

OD diagnosis was confirmed on the basis of standard orthopedic examination, which included the clinical method (disease anamnesis, orthopedic examination) and radial techniques (X-ray, CT, MRI). During collection of anamnesis data, patients were asked about duration of pain in the knee joint, characteristics, location and intensity of pain, and relationship with physical load. During examination, the range of movements in the joint was estimated with neutral null method, as well as pain intensity during palpation of articular cavity, presence of Wilson's symptom, the volume of the joint as compared to the contralateral healthy joint, and joint deformation.

X-ray examination was conducted in two standard planes − frontal (anterior-posterior) and lateral. It allowed identifying a bone tissue defect, its location and size. However, X-ray examination cannot estimate the changes in the articular cartilage, which is exposed to degenerative changes along with subchondral layer of the bone. If OD was identified during X-ray examination, the patients received MRI of the knee joint since it has some advantages: more precise estimation of defect sizes, cartilage tissue and subjacent subchondral bone condition, identification of a fragmented part of the cartilage, and presence of a free body in the joint cavity. Another advantage of MRI is estimation of time course of progression.

Also the patients received knee CT for presurgical planning, and 3D reconstructions showed precise locations of identified abnormal changes, their volume and spatial orientation. The radial diagnostic techniques allowed estimation of the volume and size of a defect that is the main criterion for presurgical planning. The indications for surgical treatment were absence of effect of conservative treatment, intense pain, limited amplitude of movements in the knee joint, disorder of supporting function of the lower extremity, presence of a bone-cartilage fragment in the joint cavity which caused the blocking of the joint.

Before surgical intervention, somatic health was estimated, and a degree of anesthesiology risk was determined. Radiologic examination (X-ray, MRI and CT) was used for selection of sizes and a site of taking of bone-cartilage autografts at the stage of presurgical planning. The patients were informed with stages of planned surgical treatment and possible consequences, early and long term complications, and future program of rehabilitation procedures according to the informed voluntary agreement for medical manipulations.

All patients received the standard surgical intervention − mosaic autochondroplasty with use of bone-cartilage autografts from low-loaded sites of the knee joint according to Hangody (1997) with opened approach through the mediopatellar incision (Fig. 1) [8]. Ketorol 1 % (1 ml, i.m.) was used for analgesia within the first 24 hours after surgical treatment. Hollow cutters (diameter of 6-10 mm) with T-shaped handle and pull-out plunger were used for taking of cylindrical bone-cartilage autografts with height of 15-20 mm (Fig. 2).

Figure 1

Intrasurgical picture: a) a defect of articular surface; b) preparation of the defect region for implantation of automaterial with hollow cutter.

 

Figure 2

Intrasurgical picture: a) the defect zone after preparation for implantation; b) zone of taking of the autograft from non-loaded site of femoral condyles after substraction.

The graft was fixed in the defect (Fig. 3). The donor site was filled with the spongious allo- or autobone (Fig. 3). After completion of defect plasty, the wound was rained and sutured in layer-by-layer manner with application of aseptic dressing.

Figure 3

Intrasurgical picture: a) appearance of articular surface after autografting; b) donor site after reimplantation.

The inhospital period was 6-7 days. Then patients were discharged, and recommendations for outpatient management were given. Within 4 weeks after surgical management, the knee joint was immobilized with plaster cast. A patient moved with crutches with low load to the operated extremity. After 4 weeks, the cast was removed, and mobilization of knee joint was initiated. Patients received the functional treatment course with mechanic therapy device Artromot K1 Standard for training of the knee joint, and with the exercise bicycle. Adherence to the orthopedic mode was recommended for the whole period of rehabilitation: limited loads relating to sudden movements, jumps and kicks. Full support to the operated lower extremity was allowed after 6 weeks. Physical therapy for the knee joint was carried out.

Long term results of treatment were estimated with values of objective examination, and MRI data. The questionnaire survey was performed before surgical treatment and after 1 year. The questionnaire testing was also used for estimation of results. We selected SF-36 Health Status  Survey» (SF-36) (Russian version). MRI of the knee joint was performed for estimation of surgical management results after 1-3.5 years.

 

RESULTS

Totally, 17 patients were examined who previously received surgical  management for OD of degrees 3-4 in Saratov Research Institute of Traumatology and Orthopedics. All patients received mosaic autochondroplasty with opened technique. The control examination was performed after 1-3.5 years from surgical management and included the orthopedic examination, knee MRI and questionnaire (the table 1).

Table 1

Long term results of mosaic plasty of knee joint in osteochondritis dissecans

	Fine		Good		Satisfactory		Poor
Total	3	17.64 %	5	29.40 %	3	17.64 %	6	35.28 %
Men	1	5.88 %	3	17.64 %	1	5.88 %	4	23.52 %
Women	-	-	2	11.76 %	2	11.76 %	2	11.76 %
Adolescents	2	11.76 %	-	-	-	-	-	-

The rate of poor results of surgical treatment was high (almost each third patient). All these patients required for recurrent radical surgery with total prosthetics within the first 5 years after autochondroplasty. The main cause of poor results was progression of osteoarthritis dissecans in the operated knee joint. Good and excellent results of treatment were received for almost a half of patients. Subsequently, they did not require for  total replacement, but 70 % of these patients suffered from pain in the operated joint during load. Pain was treated with non-steroid anti-inflammatory drugs. One should note that excellent results of treatment were achieved in young patients at the age of 17-18 and in a man at the age of 30.

 

Clinical case No. 1

A patient T., age of 53, addressed to Research Institute of Traumatology and Orthopedics at Saratov State Medical Academy. She complained of pain in the right knee joint, and disordered supporting ability of the right lower extremity. Pain intensified during physical load. Movements in the right knee joint were limited. The joint was enlarged as compared to the healthy one. Collection of anamnesis data showed that these complaints had appeared within 9 months. Conservative treatment was realized according to her place of residence. It included non-steroidal anti-inflammatory drugs, cartilage protectors, intraarticular and periarticular introduction of glucocorticosteroids, local use of ointments with NSAIDs. Conservative treatment included physiotherapy courses: phonophoresis with hydrocortisone, and magnetic therapy for the injured joint site. Conservative treatment did not give any positive results. The pain was increasing, and the right knee function was worsening. The examination showed slight edema of the right knee, and increasing pain during palpation of the external condyle of the right femur. The walking was in the mode, which spared the right knee, with additional support to the cane. Claudication was evident. The range of movements in the knee joint was measured with the standard neutral-null technique. It was 100º/0º/0º. For clarification of the diagnosis, X-ray imaging and MRI of the right knee were performed which showed an articular surface defect of the lateral condyle of the right femur (Fig. 4).

Figure 4

Osteochondritis dissecans (partial wedge-shaped osteochondropathy of articular surface of external condyle of right femur): a. b) MRI of knee joint in frontal and sagittal planes (the arrow indicates the articular surface defect).

After confirmation of the diagnosis, the patient was admitted to Research Institute of Traumatology and Orthopedics at Saratov State Medical University. Mosaic osteochondroplasty with bone-cartilage autografts was carried out under spinal analgesia. During surgery, an articular surface defect (1.5 × 2.6 cm) was found on the external condyle. The donor site was the unloaded surface of the lateral condyle of the femur. The cylindrical cutter (8 mm diameter) with T-shaped handle and pull-out plunger was used for taking of 4 bone-cartilage fragments with subsequent implanting into the defect site with use of the impactor as close as possible. After completion of implantation, the wound was prepared, drained and sutured in layer-by-layer manner. After transfer from the surgery room to the hospital ward, the right lower extremity was immobilized from the middle one-third of the femur to the foot for 6 months. In the early  postsurgical period, the patient received NSAIDs for pain treatment. On the 5th day after surgery, the patient was discharged from the hospital. The sutures were removed after 14 days. The wound healed with primary tension.

After 2 years and 8 months from the surgery, MRI of the operated knee joint was conducted (Fig. 5). It showed uneven thinning of the hyaline cartilage: the site of the autograft taking was visible on the unloaded surface of the lateral condyle. Also subchondral erosion was found. The joint cavity had some fluid (knee joint synovitis). During clinical examination, the patient had some complaints of pain and limited movements in the right knee joint and joint deformation.

Figure 5

Knee joint after 2.8 years from mosaic autoosteochondroplasty for Osteochondritis dissecans: a, b) MRI of knee joint (the arrow indicates the articular surface defect).

The patient moved with additional support to the cane. Claudication was evident. The examination showed the right knee edema, and increasing pain during palpation in the region of the external condyle of the right femur, axial load and palpation in the plane of the joint cavity. The range of motions in the knee joint was 80º/0º/0º. The data collection showed that surgical management had not give expected results since pain syndrome, deformation and disordered function of the right knee showed progression. At the present time, the patient receives conservative treatment: NSAIDs, intraarticular and periarticular introduction of glucocorticosteroids, local use of ointments with NSAIDs. According to SF-36, pain values (P) were high: 9 points (maximal possible rate − 11). Physical functioning (PF) was low: 14 points (maximal possible − 30, minimal − 10). Due to the defect in the lateral condyle of the right femur, secondary knee arthrosis of degree 2, intense pain and disordered function of the right lower extremity, the patient needed for surgical management − total arthroplasty of the right knee joint).

 

Clinical case No. 2

A patient P., age of 19, male. He addressed to Research Institute of Traumatology and Orthopedics at Saratov State Medical University. He had complaints of pain in the left knee joint, disordered supporting ability of the left lower extremity. Pain appeared 4 months before addressing for medical care. After physical load, the patient could note the joint edema and its increasing size as compared to the healthy one. Subsequently, pain became persistent, with a trend to progression. By the statement of the patient, he received 3 months of outpatient treatment with NSAIDs, cartilage protectors and ointments with NSAIDs. X-ray imaging and MRI were conducted for clarification of the diagnosis. They showed formation of necrotic bed in the medial condyle on the articular surface. A sequester of 0.7 × 0.8 × 0.9 cm was found (Fig. 6). After confirmation of osteochondritis dissecans, the patient was admitted to Research Institute of Traumatology and Orthopedics. Mosaic autochondroplasty for bone-cartilage defects was conducted.

Figure 6

Osteochondritis dissecans (necrotic contents is on surface of medial condyle of left knee joint): a, b) MRI of knee joint (the arrow indicates the articular surface defect).

Surgery was conducted under spinal analgesia − mosaic osteochondroplasty with bone-cartilage autografts. The donor site was the unloaded surface of the lateral condyle of the femur.

One year later, control MRI was conducted (Fig. 7). Two years later, MRI (Fig. 8), CT (Fig. 9) and X-ray imaging (Fig. 10) of the operated joint were performed.

Figure 7

1 year after mosaic autoosteochondroplasty for osteochondritis dissecans: a, b, c) MRI of knee joint (the arrow indicates the articular surface defect); d) zone of graft taking.

Figure 8

MRI of knee joint 2 years after mosaic autochondroplasty for osteochondritis dissecans: a, b, c) the articular surface defect (indicated by the arrow); d) zone of graft taking.

Figure 9

CT of knee joint 2 years after mosaic autoosteochondroplasty for osteochondritis dissecans: a, b, c) the arrow indicates the articular surface defect; d) zone of graft taking.

Figure 10

X-ray imaging of knee joint in two standard planes (a, b) 2 years after mosaic autoosteochondroplasty for osteochondritis dissecans (the arrow indicates the articular surface defect). 

MRI showed some postsurgical changes and bone marrow edema. Some consequences of chondroplasty were found in medial regions of articular surface. The hyaline cartilage was traced unevenly at this level, with non-homogenous MRI signal.

CT data showed a postsurgical defect on articular surface of the medial condyle of the left femur with clear smooth contour of 0.8 × 0.5 × 1.2 cm.

Control X-ray images showed a postsurgical defect along the articular surface of the medial condyle of the left femur with clear smooth contour.

During clinical examination, the patient had some complaints concerning pain in the left knee. He could move without additional support. However, active sports initiated and intensified pain. The joint had correct shape. There was no edema. Pain was intensifying during palpation in the site of the internal condyle of the left femur. The range of movements in the knee joint was 110º/0º/0º. According to SF-36, pain (P) was moderate: 6 points among 11 possible. Physical functioning (PF) was low: 22 points among 30 possible (minimal − 10). The anamnesis data showed that surgical management had decreased the pain syndrome, but had not removed it. Currently, the patient needs for NSAIDs.

The clinical examples show some possible negative consequences of surgical management by means of mosaic autochondroplasty for OD at the late stages of the disease.

 

DISCUSSION

The study results correspond to data by other authors [9, 10] and show that a surgical intervention, such as mosaic autoosteochondroplasty, presents a quite traumatic type of surgical treatment of OD. Also predominance of poor results in our study is probably associated with selection of patients with final stages of OD, and, as result, with the most intense changes in the subchondral region and in the cartilage. Also it can be associated with quality of donor materials for grafting which is potentially inappropriate according to some authors [11, 12, 13]. The significant problem of mosaic autochondroplasty for adolescents and for some massive defects > 3.5 cm² is presented by natural limitation of material sampling which did not allow complete compensation of the square of the articular defect. It is the significant disadvantage of this technique which does not give expected results [14].

Therefore, autografting of bone-cartilage fragments in OD is wide-spread now, but it does not solve the problem of this disease to the full degree. During surgery, a surgeon can select the sizes of grafts, but a defect is not always covered with a single graft. The evident and significant disadvantage of this technique is limited amount of donor articular cartilage, i.e. a defect is not completed completely in some cases, and the radius of the curvature does not correspond to the lost one. It is also actual for a limitation due to anatomic mismatch between the plasty zone and the implant, when strength and elasticity of the cartilage decrease by means of its thickness. The procedure of the autograft taking is also traumatic. It often causes pain during walking owing to disorder of articular surface congruence. Soft tissues are exposed to mechanic injuries, including synovial cover of the knee joint, which activates the inflammatory mediators, macrophages and lytic enzymes which make aggressive influence on all structures of the knee joint. Synovial fluid specifically influences on the site of contact of the implant with the plasty zone, resulting in its instability. Also this type of surgical management often causes sclerosing of articular surfaces and early development of knee arthrosis with subsequent total arthroplasty. It is the significant disadvantage of this technique.

 

CONCLUSION

1. Mosaic autochondroplasty is the modern technique of surgical management of osteochondritis dissecans, with achievement of good results in 50% of patients.

2. Good results of treatment are expected in young patients with small defects of articular surface.

3. The main cause of poor results of this surgical management is progressing arthropathy deformans.

 

Information on financing and conflict of interests

The study was conducted without sponsorship. It was conducted as a part of the initiative plan of Research Institute of Traumatology and Orthopedics, Saratov State Medical University, "Improvement in techniques of diagnosis, treatment and prevention of injuries and diseases of locomotor and nervous systems". The registration number АААА-А18-118060790019-0. The authors declare the absence of any clear and potential conflicts of interests relating to publication of this article.