Basics of Biologic Joint Reconstruction

This case is a typical example of biologic joint reconstruction: a healthy joint in a young patient developed accelerated degeneration due to subtotal lateral meniscectomy. Cartilage repair alone would have addressed the defect, but not its etiology, resulting in a very high chance of early recurrence of cartilage damage.

Conclusion

Cartilage damage encompasses a wide spectrum, ranging from focal chondral defects all the way to tricompartmental osteoarthritis. While the latter is beyond the capabilities of current cartilage repair procedures, earlier stages in the disease process can be managed successfully with cartilage repair. However, careful attention is required to correctly identify and address the frequently present comorbidities involved in the degenerative disease process, such as malalignment and meniscal deficiency.

Disclosures

Dr. Gomoll is a consultant for Genzyme Biosurgery and receives book royalties from SLACK Publishing.

Dr. Gomoll is an orthopedic surgeon in the department of orthopaedic surgery cartilage repair center at Brigham and Women’s Hospital, Harvard Medical School, in Chestnut Hill, Mass. He is a consultant for Genzyme Biosurgery.

References

1. Curl WW, Krome J, Gordon ES, Rushing J, Smith BP, Poehling GG. Cartilage injuries: A review of 31,516 knee arthroscopies. Arthroscopy. 1997;13:456-460.
2. Heir S, Nerhus TK, Rotterud JH, et al. Focal cartilage defects in the knee impair quality of life as much as severe osteoarthritis: A comparison of knee injury and osteoarthritis outcome score in 4 patient categories scheduled for knee surgery. Am J Sports Med. 2010;38:231-237.
3. Brittberg M, Lindahl A, Nilsson A, Ohlsson C, Isaksson O, Peterson L. Treatment of deep cartilage defects in the knee with autologous chondrocyte transplantation. N Engl J Med. 1994;331:889-895.
4. Minas T, Bryant T. The role of autologous chondrocyte implantation in the patellofemoral joint. Clin Orthop Relat Res. 2005;(436):30-39.
5. Farr J. Autologous chondrocyte implantation improves patellofemoral cartilage treatment outcomes. Clin Orthop Relat Res. 2007;463:187-194.
6. Henderson IJ, Lavigne P. Periosteal autologous chondrocyte implantation for patellar chondral defect in patients with normal and abnormal patellar tracking. Knee. 2006;13:274-279.
7. Bullens PH, van Loon CJ, de Waal Malefijt MC, Laan RF, Veth RP. Patient satisfaction after total knee arthroplasty: A comparison between subjective and objective outcome assessments. J Arthroplasty. 2001;16:740-747.
8. Hawker G, Wright J, Coyte P, et al. Health-related quality of life after knee replacement. J Bone Joint Surg Am. 1998;80:163-173.
9. Koskinen E, Eskelinen A, Paavolainen P, Pulkkinen P, Remes V. Comparison of survival and cost-effectiveness between unicondylar arthroplasty and total knee arthroplasty in patients with primary osteoarthritis: A follow-up study of 50,493 knee replacements from the Finnish Arthroplasty Register. Acta Orthopaedica. 2008;79:499-507.
10. Gioe TJ, Novak C, Sinner P, Ma W, Mehle S. Knee arthroplasty in the young patient: Survival in a community registry. Clin Orthop Relat Res. 2007;464:83-87.
11. Vazquez-Vela Johnson G, Worland RL, Keenan J, Norambuena N. Patient demographics as a predictor of the ten-year survival rate in primary total knee replacement. J Bone Joint Surg Br. 2003;85:52-56.
12. Sibanda N, Copley LP, Lewsey JD, et al. Revision rates after primary hip and knee replacement in England between 2003 and 2006. PLoS medicine. 2008;5:e179.
13. Lonner JH, Hershman S, Mont M, Lotke PA. Total knee arthroplasty in patients 40 years of age and younger with osteoarthritis. Clin Orthop Relat Res. 2000:85-90.
14. Rand JA, Trousdale RT, Ilstrup DM, Harmsen WS. Factors affecting the durability of primary total knee prostheses. J Bone Joint Surg Am. 2003;85:259-265.
15. Deehan DJ, Murray JD, Birdsall PD, Pinder IM. Quality of life after knee revision arthroplasty. Acta Orthopaedica. 2006;77:761-766.
16. Rosenberg TD, Paulos LE, Parker RD, Coward DB, Scott SM. The forty-five-degree posteroanterior flexion weight-bearing radiograph of the knee. J Bone Joint Surg Am. 1988;70:1479-1483.
17. Potter HG, Chong le R. Magnetic resonance imaging assessment of chondral lesions and repair. J Bone Joint Surg Am. 2009;91(Suppl 1):126-131.
18. Murray JR, Chitnavis J, Dixon P, et al. Osteochondritis dissecans of the knee: Long-term clinical outcome following arthroscopic debridement. Knee. 2007;14:94-98.
19. Wright RW, McLean M, Matava MJ, Shively RA. Osteochondritis dissecans of the knee: Long-term results of excision of the fragment. Clin Orthop Relat Res. 2004:239-243.
20. Jaiswal PK, Macmull S, Bentley G, Carrington RW, Skinner JA, Briggs TW. Does smoking influence outcome after autologous chondrocyte implantation? A case-controlled study. J Bone Joint Surg Br. 2009;91:1575-1578.
21. Kreuz PC, Steinwachs MR, Erggelet C, et al. Results after microfracture of full-thickness chondral defects in different compartments in the knee. Osteoarthritis Cartilage. 2006;14:1119-1125.
22. Bentley G, Biant LC, Carrington RW, et al. A prospective, randomised comparison of autologous chondrocyte implantation versus mosaicplasty for osteochondral defects in the knee. J Bone Joint Surg Br. 2003;85:223-230.
23. Knutsen G, Engebretsen L, Ludvigsen TC, et al. Autologous chondrocyte implantation compared with microfracture in the knee. A randomized trial. J Bone Joint Surg Am. 2004;86-A:455-464.
24. Asik M, Ciftci F, Sen C, Erdil M, Atalar A. The microfracture technique for the treatment of full-thickness articular cartilage lesions of the knee: Midterm results. Arthroscopy. 2008;24:1214-1220.
25. Hangody L, Dobos J, Balo E, Panics G, Hangody LR, Berkes I. Clinical experiences with autologous osteochondral mosaicplasty in an athletic population: A 17-year prospective multicenter study. Am J Sports Med. 2010;38:1125-1133.
26. Mithoefer K, McAdams T, Williams RJ, Kreuz PC, Mandelbaum BR. Clinical efficacy of the microfracture technique for articular cartilage repair in the knee: An evidence-based systematic analysis. Am J Sports Med. 2009;37:2053-2063.
27. Mithoefer K, Williams RJ, 3rd, Warren RF, Wickiewicz TL, Marx RG. High-impact athletics after knee articular cartilage repair: A prospective evaluation of the microfracture technique. Am J Sports Med. Sep 2006;34:1413-1418.
28. Steadman JR, Briggs KK, Rodrigo JJ, Kocher MS, Gill TJ, Rodkey WG. Outcomes of microfracture for traumatic chondral defects of the knee: Average 11-year follow-up. Arthroscopy. 2003;19:477-484.
29. Gudas R, Kalesinskas RJ, Kimtys V, et al. A prospective randomized clinical study of mosaic osteochondral autologous transplantation versus microfracture for the treatment of osteochondral defects in the knee joint in young athletes. Arthroscopy. 2005;21:1066-1075.
30. Hangody L, Fules P. Autologous osteochondral mosaicplasty for the treatment of full-thickness defects of weight-bearing joints: Ten years of experimental and clinical experience. J Bone Joint Surg Am. 2003;85-A(Suppl 2):25-32.
31. Bartlett W, Skinner JA, Gooding CR, et al. Autologous chondrocyte implantation versus matrix-induced autologous chondrocyte implantation for osteochondral defects of the knee: A prospective, randomised study. J Bone Joint Surg Br. 2005;87:640-645.
32. Peterson L, Minas T, Brittberg M, Nilsson A, Sjogren-Jansson E, Lindahl A. Two- to 9-year outcome after autologous chondrocyte transplantation of the knee. Clin Orthop Relat Res. 2000:212-234.
33. Shasha N, Aubin PP, Cheah HK, Davis AM, Agnidis Z, Gross AE. Long-term clinical experience with fresh osteochondral allografts for articular knee defects in high demand patients. Cell Tissue Bank. 2002;3:175-182.
34. Gortz S, Bugbee WD. Allografts in articular cartilage repair. J Bone Joint Surg Am. 2006;88:1374-1384.
35. McCulloch PC, Kang RW, Sobhy MH, Hayden JK, Cole BJ. Prospective evaluation of prolonged fresh osteochondral allograft transplantation of the femoral condyle: Minimum 2-year follow-up. Am J Sports Med. 2007;35:411-420.
36. Gooding CR, Bartlett W, Bentley G, Skinner JA, Carrington R, Flanagan A. A prospective, randomised study comparing two techniques of autologous chondrocyte implantation for osteochondral defects in the knee: Periosteum covered versus type I/III collagen covered. Knee. 2006;13:203-210.
37. Gomoll AH, Probst C, Farr J, Cole BJ, Minas T. Use of a type I/III bilayer collagen membrane decreases reoperation rates for symptomatic hypertrophy after autologous chondrocyte implantation. Am J Sports Med. 2009;37:20S-23S.
38. Kandel RA, Gross AE, Ganel A, McDermott AG, Langer F, Pritzker KP. Histopathology of failed osteoarticular shell allografts. Clin Orthop Relat Res. 1985(197):103-110.
39. Williams SK, Amiel D, Ball ST, et al. Analysis of cartilage tissue on a cellular level in fresh osteochondral allograft retrievals. Am J Sports Med. 2007;35:2022-2032.
40. Mroz TE, Joyce MJ, Steinmetz MP, Lieberman IH, Wang JC. Musculoskeletal allograft risks and recalls in the United States. J Am Acad Orthop Surg. 2008;16:559-565.
41. Emmerson BC, Gortz S, Jamali AA, Chung C, Amiel D, Bugbee WD. Fresh osteochondral allografting in the treatment of osteochondritis dissecans of the femoral condyle. Am J Sports Med. 2007;35:907-914.
42. Meyers MH, Akeson W, Convery FR. Resurfacing of the knee with fresh osteochondral allograft. J Bone Joint Surg Am. 1989;71:704-713.
43. Pearsall AW 4th, Tucker JA, Hester RB, Heitman RJ. Chondrocyte viability in refrigerated osteochondral allografts used for transplantation within the knee. Am J Sports Med. 2004;32:125-131.
44. Williams SK, Amiel D, Ball ST, et al. Prolonged storage effects on the articular cartilage of fresh human osteochondral allografts. J Bone Joint Surg Am. 2003;85-A:2111-2120.
45. Sharma L, Song J, Felson DT, Cahue S, Shamiyeh E, Dunlop DD. The role of knee alignment in disease progression and functional decline in knee osteoarthritis. JAMA. 2001;286:188-195.
46. Brouwer GM, van Tol AW, Bergink AP, et al. Association between valgus and varus alignment and the development and progression of radiographic osteoarthritis of the knee. Arthritis Rheum. 2007;56:1204-1211.
47. Wright JM, Crockett HC, Slawski DP, Madsen MW, Windsor RE. High tibial osteotomy. J Am Acad Orthop Surg. 2005;13:279-289.
48. Farr J. Autologous chondrocyte implantation improves patellofemoral cartilage treatment outcomes. Clin Orthop. 2007;463:187-194.
49. Shasha N, Aubin P, Cheah H, Davis A, Agnidis Z. Long-term clincal experience with fresh osteochondral allografts for articular knee defects in high demand patients. Cell Tissue Bank. 2002;3:175-182.
50. Beck PR, Thomas AL, Farr J, Lewis PB, Cole BJ. Trochlear contact pressures after anteromedialization of the tibial tubercle. Am J Sports Med. 2005;33:1710-1715.
51. Minas T, Bryant T. The role of autologous chondrocyte implantation in the patellofemoral joint. Clin Orthop. 2005;436:30-39.
52. Henderson I, Lavigne P. Periosteal autologous chondrocyte implantation for patellar chondral defect in patients with normal and abnormal patellar tracking. Knee. 2006;13:274-279.
53. Jones R, Keene G, Learmouth D, et al. Direct measurement of hoop strains in the intact and torn human medial meniscus. Clin Biomech. 1996;11:295-300.
54. Paletta Jr. G, Manning T, Snell E, Parker R, Bergfeld R. The effect of allograft meniscal replacement on intraarticular contact area and pressures in the human knee. Am J Sports Med. 1997;25:692-698.
55. Verma N, Kolb E, Cole B, et al. The effects of medial meniscal transplantation techniques on intra-articular contact pressures. J Knee Surg. 2008;21:20-26.
56. Verdonk PC, Verstraete KL, Almqvist KF, et al. Meniscal allograft transplantation: Long-term clinical results with radiological and magnetic resonance imaging correlations. Knee Surg Sports Traumatol Arthrosc. 2006;14:694-706.
57. Szomor ZL, Martin TE, Bonar F, Murrell GA. The protective effects of meniscal transplantation on cartilage. An experimental study in sheep. J Bone Joint Surg Am. 2000;82:80-88.
58. Farr J, Rawal A, Marberry K. Concomitant meniscal allograft transplantation and autologous chondrocyte implantation: Minimum 2-year follow-up. Am J Sports Med. 2007;35:1459-1466.
59. Rue J, Yanke A, Busam M, McNickle A, Cole B. Prospective evaluation of concurrent meniscus transplantation and articular cartilage repair: Minimum 2-year follow-up. Am J Sports Med. 2008;36:1770-1778.