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Osteochondral Allograft Transplantation of the Knee in the Pediatric and Adolescent Population Ryan T

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Osteochondral Allograft Transplantation of the Knee in the Pediatric and Adolescent Population Ryan T The American Journal of Sports Medicine http://ajs.sagepub.com/ Osteochondral Allograft Transplantation of the Knee in the Pediatric and Adolescent Population Ryan T. Murphy, Andrew T. Pennock and William D. Bugbee Am J Sports Med 2014 42: 635 originally published online January 10, 2014 DOI: 10.1177/0363546513516747 The online version of this article can be found at: http://ajs.sagepub.com/content/42/3/635 Published by: http://www.sagepublications.com On behalf of: American Orthopaedic Society for Sports Medicine Additional services and information for The American Journal of Sports Medicine can be found at: Email Alerts: http://ajs.sagepub.com/cgi/alerts Subscriptions: http://ajs.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav >> Version of Record - Feb 28, 2014 OnlineFirst Version of Record - Jan 10, 2014 What is This? Downloaded from ajs.sagepub.com at Harvard Library on May 13, 2014 Osteochondral Allograft Transplantation of the Knee in the Pediatric and Adolescent Population Ryan T. Murphy,* MS, Andrew T. Pennock,y MD, and William D. Bugbee,z§ MD Investigation performed at Scripps Clinic, La Jolla, California, USA Background: Multiple studies in adults have shown that osteochondral allograft transplantation is an effective treatment option for large chondral and osteochondral defects of the knee. Limited outcome data are available on osteochondral allografts in the pediatric and adolescent patient populations. Purpose: To describe a 28-year experience with osteochondral allograft transplantation in patients younger than 18 years with a focus on subjective outcome measures, return to activities, and allograft survivorship. Study Design: Case series; Level of evidence, 4. Methods: A total of 39 patients (43 knees) underwent fresh osteochondral allograft transplantation for treatment of chondral and osteochondral lesions. Twenty-six male and 17 female knees with a mean age of 16.4 years (range, 11.0-17.9 years) at index sur- gery were followed-up at a mean of 8.4 years (range, 1.7-27.1 years). Thirty-four knees (79%) had at least 1 previous surgery. The most common underlying causes of the lesions were osteochondritis dissecans (61%), avascular necrosis (16%), and traumatic chondral injury (14%). Mean allograft size was 8.4 cm2. The most common allograft location was the medial femoral condyle (41.9%), followed by the lateral femoral condyle (35%). Each patient was evaluated with the International Knee Documentation Committee pain, function, and total scores; a modified Merle d’Aubigne´ -Postel (18-point) scale; and Knee Society function score. Failure was defined as revision osteochondral allograft or conversion to arthroplasty. Results: Five knees experienced clinical failure at a median of 2.7 years (range, 1.0-14.7 years). Four failures were salvaged suc- cessfully with another osteochondral allograft transplant. One patient underwent prosthetic arthroplasty 8.6 years after revision allograft. Graft survivorship was 90% at 10 years. Of the knees whose grafts were in situ at latest follow-up, 88% were rated good/excellent (18-point scale). The mean International Knee Documentation Committee scores improved from 42 preoperatively to 75 postoperatively, and the Knee Society function score improved from 69 to 89 (both P \ .05). Eighty-nine percent of patients reported ‘‘extremely satisfied’’ or ‘‘satisfied.’’ Conclusion: With 88% good/excellent results and 80% salvage rate of clinical failures with an additional allograft, osteochondral allograft transplantation is a useful treatment option in pediatric and adolescent patients. Keywords: fresh osteochondral allograft transplantation; adolescent; pediatric; knee; osteochondral defect; cartilage Chondral and osteochondral injuries of the knee are a diffi- lesion is large and occurs in younger patients, for whom cult clinical challenge, particularly in situations where the alternatives such as partial or total knee arthroplasty are rarely advised. Increasing interest in biological alternatives §Address correspondence to William D. Bugbee, MD, Scripps Clinic, has led to the use of a number of surgical interventions 10666 North Torrey Pines Road, MS 116, La Jolla, CA 92037, USA designed to repair or replace diseased or damaged chondral (e-mail: [email protected]). and subchondral tissue. These options include chondro- *University of California, Irvine, Irvine, California, USA. 14 27,31 y plasty, microfracture, autologous osteochondral trans- Rady Children’s Hospital, San Diego, California, USA. 12 3,26 zDivision of Orthopaedic Surgery, Scripps Clinic, La Jolla, California, fer, and autologous chondrocyte implantation. USA. Numerous studies have reported on the outcome of patients k One or more of the authors has declared the following potential con- undergoing each of these procedures with clinical success flict of interest or source of funding: W.D.B. is a consultant to the Joint reported between 50% and 90% depending on the diagnosis, Restoration Foundation; receives royalties from DePuy, Zimmer Biolog- lesion size, previous treatment, and patient characteristics. ics, and Smith & Nephew; is a consultant for DePuy, Smith & Nephew, Zimmer, and Moximed; owns stock in Moximed, OrthoAlign, and Alexan- However, few studies have focused on the use of cartilage 20,21,25,28 drea Research Technologies; and receives research support from restoration procedures in young patients. OrthoAlign, Alter-G, and Joint Restoration Foundation. Fresh osteochondral allograft transplantation has been utilized in knee joints for more than 100 years. Lexer19 The American Journal of Sports Medicine, Vol. 42, No. 3 DOI: 10.1177/0363546513516747 Ó 2014 The Author(s) kReferences 1, 2, 4, 6, 8, 11, 12, 18, 21, 22, 24, 25, 30. 635 Downloaded from ajs.sagepub.com at Harvard Library on May 13, 2014 636 Murphy et al The American Journal of Sports Medicine TABLE 1 TABLE 2 Patient Information and Clinical Assessment Surgical History of Patients Who Underwent Operative Treatment on the Knee Before Receiving Clinical Information Results an Osteochondral Allograft (n = 34) No. of patients studied 39 No. Percentage Total No. of knees studied 43 Mean age at time of surgery, y (range) 16.4 (11.0-17.9) Procedure Sex, No. of knees Arthroscopic 26 76.5 Male 26 Arthroscopic and open 5 14.7 Female 17 Open 3 8.8 Body mass index, kg/m2 (range) 24.4 (18.8-51.0) Total 34 No. of knees with a previous surgery (%) 34 (79.1) Chondral debridement 18 31.6 Mean No. of previous surgeries (range) 1.5 (1-3) Subchondral marrow stimulation 14 24.6 Mean allograft size, cm2 (range) 8.4 (2.2-20.8) Loose body removal 13 22.8 Underlying cause of lesions, No. Partial lateral meniscus 3 5.3 Osteochondritis dissecans 26 Total lateral meniscus 2 3.5 Avascular necrosis 7 Osteotomy 2 3.5 Traumatic chondral injury 6 Physeal staple 1 1.8 Other osteochondral fracture 2 Osteochondral allograft transplantation 1 1.8 Degenerative chondral lesion 2 Pin fixation 1 1.8 Location of graft, No. Extensor mechanism 1 1.8 Medial femoral condyle 18 Autologous bone graft 1 1.8 Lateral femoral condyle 15 Total 57a Patella 3 Trochlea 2 aSeveral patients had more than 1 procedure. Tibial plateau 1 Multiple sites 4 No. of grafts patients with large osteochondral lesions due to osteochon- 130dritis dissecans, osteonecrosis, or trauma, for example. The 210purpose of this study was to investigate the outcome of 33osteochondral allograft transplantation performed in the knee joint in patients younger than 18 years. first reported on the use of hemijoint transplants in 1908. 8,11,23 Gross popularized the use of allografts for posttrau- MATERIALS AND METHODS matic reconstruction of the knee in the 1970s and 1980s. More recently, many authors have reported good to excel- Patient Selection and Outcome Assessment lent short- and medium-term success using fresh refriger- ated osteochondral allografts for treatment of such Since 1983, under institutional review board approval, clin- conditions as osteochondritis dissecans and focal chondral ical data were prospectively collected to evaluate the out- lesions.5,6,17,22,32 come of fresh osteochondral allograft transplantation in The basic fundamentals of fresh osteochondral allograft the knee. We used this database to identify pediatric and transplantation involve the transplantation of mature hyaline adolescent patients who underwent knee allograft trans- cartilage containing viable chondrocytes along with a variable plantation. Our inclusion criteria were those who were an amount of supporting subchondral bone to replace a chondral age younger than 18 years at the time of surgery and or osteochondral defect.9 Theallograftboneisincorporated were at least 2 years past the date of the index surgery. into the recipient through the process of creeping substitution, Thirty-nine patients (43 knees) were identified who and the donor chondrocytes survive transplantation support- underwent osteochondral allograft transplantation at an ing the hyaline matrix. Multiple retrieval10,13,33 and basic sci- age younger than 18 years (Table 1). Previous surgical entific studies29 have given support to this ‘‘fresh allograft treatment was performed on 34 of 43 (79%) of the knees, paradigm’’ and demonstrated the biological response to fresh with a total of 57 procedures performed (Table 2). Three osteochondral allograft implantation. patients underwent simultaneous bilateral allograft trans- While results of fresh osteochondral allograft
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