The Long-Term Clinical Outcomes Following Autogenous Bone Grafting for Large-Volume Defects of the Knee: 12- to 21-Year Follow-Up - PubMed (original) (raw)

The Long-Term Clinical Outcomes Following Autogenous Bone Grafting for Large-Volume Defects of the Knee: 12- to 21-Year Follow-Up

Lanny Leo Johnson et al. Cartilage. 2014 Apr.

Abstract

Objective: We report the long-term clinical outcomes of patients who underwent autogenous bone grafting of large-volume osteochondral defects of the knee due to osteochondritis dessicans (OCD) and osteonecrosis (ON). This is the companion report to one previous published on the biological response. We hypothesized that these grafts would integrate with host bone and the articular surface would form fibrocartilage providing an enduring clinical benefit.

Design: Three groups (patients/knees) were studied: OCD without a fragment (n = 12/13), OCD with a partial fragment (n = 14/16), and ON (n = 25/26). Twenty-five of 52 patients were available for clinical follow-up between 12 and 21 years. Electronic medical records provided comparison clinical information. In addition, there were plain film radiographs, MRIs, plus repeat arthroscopy and biopsy on 14 patients.

Results: Autogenous bone grafts integrated with the host bone. MRI showed soft tissue covering all the grafts at long-term follow-up. Biopsy showed initial surface fibrocartilage that subsequently converted to fibrocartilage and hyaline cartilage at 20 years. OCD patients had better clinical outcomes than ON patients. No OCD patients were asymptomatic at anytime following surgery. Half of the ON patients came to total knee replacement within 10 years.

Conclusions: Autogenous bone grafting provides an alternative biological matrix to fill large-volume defects in the knee as a singular solution integrating with host bone and providing an enduring articular cartilage surface. The procedure is best suited for those with OCD. The treatment for large-volume articular defects by this method remains salvage in nature and palliative in outcome.

Keywords: arthroscopy; cartilage repair; knee; matrices.

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Conflict of interest statement

Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Figures

Figure 1.

Figure 1.

Patient with OCD who had fragment reattachment and bone grafting under and along side. Arthroscopic view of healing OCD fragment at time of screw removal at 8 weeks. Notice the early fibrous tissue healing adjacent to the fragment. OCD = osteochondritis dessicans.

Figure 2.

Figure 2.

A 24-year-old woman who had previous complete removal of OCD fragment undergoing arthroscopic transcutaneous bone grafting. (A) Bone harvested with specialized surgical instrument from the ipsilateral proximal tibial metaphysis prior to delivery into the surgically prepared defect. (B) Arthroscopic surgical view of the first of several bone grafts being delivered into the medial femoral condylar defect with the same harvesting instrument. (C) The patient returned on advice of the referring physician to assess joint in view of a positive lupus diagnosis. The diagnosis of lupus was never substantiated. Arthroscopic view at 2 years showing healed surface following this procedure. The lesion was well healed. The patient remained asymptomatic through the time of the clinical assessment at 16 years. MRI supporting evidence was illustrated in previous report. OCD = osteochondritis dessicans.

Figure 3.

Figure 3.

Patient with a large osteonecrotic (ON) lesion secondary to chemotherapy and cortisone treatment for acute leukemia (in remission at time of the surgery). He presented with large defects of both medial femoral condyles and both ankles. The size of the lesion necessitated open surgery and bone grafts from both tibial metaphyses and same side iliac crest. Photographs of his right knee were previously reported.(A) Operative photograph of the right knee showing large ON defect. (B) Operative photograph after packing the ON lesion with bone graft from the ipsilateral proximal tibial metaphysis and iliac crest. Notice the failure to replicate the normal condylar contour, which will remain unchanged after healing process has matured. (C) Failure to restore the medial femoral contour seen of plain film radiograph at 16 years postoperatively. (D) Standing AP plain film radiographs at 20 years. Minimal joint space is maintained on each side. Left side staple is from accompanying valgus osteotomy. MRI evidence was shown in the Supplemental Material of the companion report.(E) Photograph of the patient’s active range of motion of his left knee at 20 years. Notice the extension of the right knee. (F) Photograph of the patient’s active range of motion of his right knee at 20 years. Notice the extension of the left knee.

Figure 4.

Figure 4.

Coronal proton density MRI shows cancellous bone graft site on medial femoral condyle. There was radiological evidence of bone graft integration.

Figure 5.

Figure 5.

CT scan in another patient at 15 years 9 months postprocedure shows bone integration on medial femoral condyle after grafting for ON: (A) sagittal and (B) coronal reformatted images.

References

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