Rev. bras. ortop. vol.52 número1

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SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

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Original

article

Fresh

osteochondral

knee

allografts

in

Brazil

with

a

minimum

two-year

follow-up

夽

Luís

Eduardo

Passarelli

Tírico

∗

_,

_Marco

_Kawamura

_Demange,

Luiz

Augusto

Ubirajara

Santos,

José

Ricardo

Pécora,

Alberto

Tesconi

Croci,

Gilberto

Luís

Camanho

UniversidadedeSãoPaulo(USP),FaculdadedeMedicina,DepartamentodeOrtopediaeTraumatologia,SãoPaulo,SP,Brazil

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Articlehistory:

Received28March2016 Accepted11April2016

Availableonline28December2016

Keywords:

Kneeinjuries Cartilage,articular

Transplantation,homologous Orthopedics

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Objective:Thepresentstudyaimedtoreporttheresultsofthefirstseriesofcasesoffresh ostechondralallograftsinthekneejointinBrazilwithaminimumfollow-upoftwoyears.

Methods:A protocol of procurement, harvesting, processing, and utilization of fresh osteochondralallograftsinthekneejointwasestablished,beginningwithlegislation mod-ifications,graftharvestingtechniques,immediateprocessing,storageoffreshgrafts,and utilizationoftwosurgicaltechniquesofosteochondraltransplantation.Eightpatientswere treatedandfollowed-upforaminimumoftwoyears.

Results:PatientswereevaluatedwithsubjectiveIKDC,KOOS,andmodifiedMerleD’Aubigne andPostelquestionnaires.MeansubjectiveIKDCscorewas31.99±13.4preoperativeand 81.26±14.7atthelatestfollow-up;preoperativeKOOSscorewas46.8±20.9and postop-erativewas85.24±13.9,indicating asignificant improvementovertime (p<0.01).Mean modified Merle D’Aubigne-Postel score was 8.75±2.25, preoperatively, and 16.1±2.59 postoperatively. Friedman test fornon-parametric samples demonstrated a significant improvementinpostoperativescores(p<0.01).

Conclusion: TheuseoffreshosteochondralallograftsinBrazilisasafeprocedure,withgood clinicalresultsintheshort-andmedium-termforthetreatmentofosteochondrallesions greaterthan4cm2_in_the_knee_joint.

夽

StudyconductedatUniversidadedeSãoPaulo(USP),FaculdadedeMedicina,HospitaldasClínicas,SãoPaulo,SP,Brazil. ∗ _{Corresponding}_author_.

E-mail:luis.tirico@hc.fm.usp.br(L.E.Tírico).

http://dx.doi.org/10.1016/j.rboe.2016.12.009

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Ortopedia _técnicas_de_captac¸ão_de_enxertos,_{processamento}_imediato,_{armazenamento}_a_fresco_dos enxertoseusodeduastécnicascirúrgicasdetransplanteosteocondral.Oitopacientesforam transplantadoseacompanhadoscommínimodedoisanosdeseguimento.

Resultados: OspacientesforamavaliadospormeiodosquestionáriosdoInternationalKnee DocumentationCommittee(IKDC)subjetivo,KneeInjuryandOsteoarthritisOutcomeScore(KOOS) eíndicedeMerleD’AubigneePostelmodificado.Amédiadapontuac¸ãodaescalaIKDC sub-jetivapré-operatóriafoide31,99±13,4ede81,26±14,7nopós-operatórioedaescalaKOOS pré-operatóriafoide46,8±20,9ede85,24±13,9nopós-operatório,commelhoria significa-tivaaolongodotempo(p<0,01).Amédiadapontuac¸ãopeloíndicedeMerleD’Aubigne ePostelmodificadofoide8,75±2,25nopré-operatórioede16,1±2,59nopós-operatório. OresultadodotestedeFriedmanparaamostrasnãoparamétricasdemonstroumelhoria significativaaolongodotempo(p<0,01).

Conclusões: OtransplanteosteocondralafresconoBrasiléumprocedimentoseguro,com bonsresultadosclínicosemcurtoemédioprazoparaotratamentodelesõesosteocondrais maioresdoque4cm2_na_{articulac¸ão}_do_joelho.

Introduction

Chondral lesions in the knee joint affect approximately 900,000UScitizenseachyear,resultinginover200,000 sur-gicalproceduresfordiagnosisandtreatment.1_There_are_no statisticsonthisdiseaseinBrazil.Thegoalinthetreatment oftraumaticchondralandosteochondrallesionsisto reestab-lishanatomyandfunctionofthe jointaswell aseliminate pain.

The treatment of chondral lesions greater than 4cm2 bydebridement or microfracture techniquesdoes not pro-mote good results, asit does notaddress the subchondral boneinjuryandpromotesrepairwithfibrocartilaginoustissue insteadofhyalinecartilage,thereforenotbeingrecommended forthetreatmentoftheseinjuries.2,3_Autologous osteochon-draltransplantationisagoodtreatmentoption,asitpromotes repairwithhyalinecartilageandgraftspossibledefectsofthe subchondralbone.However,itislimitedbythemorbidityof thedonorsite;itcanbeideallyusedininjuriesofupto2.5cm indiameterandupto10mmdeep.4–6

Currently,treatmentoptionsforchondraland osteochon-dralkneelesionslargerthan4cm2_are_autologous_chondrocyte implantationandfreshosteochondralallografts(FOA). Autolo-gouschondrocytetransplantationisacomplextechniquethat requirestwooperationsforbiopsyand celltransplantation, andhasaveryhighcost.7_The_use_of_FOA_for_the_treatment_of largeosteochondrallesionsofthekneeisabiologicaloptionin youngpatients;itsmainadvantageisthatitisatissuewithlive hyalinecartilage,featuringchondrocytesinachondralmatrix withpreservedcollagenfiberarchitecture.8,9

Inothercountries, FOAhavebeenusedfordecades.10–14 Thistechniquewas firstintroducedtotreatpost-traumatic bonedefects.15,16_However,_it_is_now_used_for_the_treatment_of variousdisordersoftheknee,suchasosteochondritis disse-cans(OD),secondaryosteonecrosis,anddegenerativedisease oftheknee,aswellasinfracturesequelae.17–20_The_principle ofFOAistorestorethebiologicalstructureofthejoint,rebuild thearticularhyalinecartilagesurface,andprovidean osteo-chondraltissuecapableofsupportingthemechanicalloadof theindividual.21,22

Tothebestoftheauthors’knowledge,thereareno stud-iesorcasereportsontheuseoftheFOAtechniqueinBrazil, becauseuntil2009the lawsregulatingtissuebanksdidnot allowfreshtissuestobeusedfortransplantationintimefor thereleaseofcultures;itwasnecessarytowaitfortheresults ofthesetestsbeforeuse.23

Thisstudyaimedtoreporttheresultsofthefirstcasesof FOAtransplantationinthekneejointinBrazil,witha mini-mumfollow-upoftwoyears.

Methods

This study was conducted at the Institute of Orthopedics and Traumatology of this institution and was approved by the Ethics Committee for Research Project Analysis (CAPPesq).

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Fig.1–(A)Osteotomyofthefemur10cmabovethejointlinewithoutviolationofthejointcapsule;(B)Tibialosteotomy 2cmbelowtheATT;(C)FinalresultofthepiecebeforetransportationtotheTissueBank.

larger than 4cm2_, _and _whose _chondral _or _{osteochondral} lesionsfailedprevioustreatmentforarticularcartilagerepair. Patientswithinflammatoryarthropathy,withactive infec-tioninthekneeorelsewhereinthebody,andsmokerswere excluded.

Fordonorselection,theinclusionandexclusioncriteriafor musculoskeletaltissuessetforthbytheBrazilianAssociation of Organ Transplantation (Associac¸ão Brasileira de Trans-plantedeÓrgãos[ABTO])wasused,andindividualsbetween 15and45yearswereselected.

Thesampleconsistedoffiveorgandonorsandeight recipi-ents(eightknees),whichwereoperatedfromMarchtoOctober 2012.

Harvesting

Inthepresentstudy,alltissuesforFOAwereobtainedfrom organdonors,harvestedinanoperatingroomwithlaminar airflowaftertheheart,liverandkidneyhadbeenharvested. Thekneeswereharvestedasablock;onlytheskinand sub-cutaneoustissuewere dissected,andthejoint capsulewas keptintact. Osteotomywas performedon the distalfemur 10cmabovethejointlineandontheproximaltibiaandfibula, 2cmbelowthedistalpartoftheanteriortibialtuberosity(ATT) (Fig.1A–C_).

Thepieces, asa block, were placed inlactated Ringer’s solutionandtransportedatatemperatureof2◦_–8◦_C._After

har-vesting,tissuesweresenttotheTissueBankforprocessing within12hoftheharvestprocedure.

Processing

Theprocessingstagewas performedin aproperoperating room,classifiedasclass100orISO5,and equippedwitha laminarflowmodule.Thearticularcapsuleofthekneewas opened through the medial parapatellar access route and structuresweremeasuredwithacalipertopairwiththe recip-ientsintheFOAlist.Atthisstage,thearticularcartilagewas analyzedandonlypiecesinwhichthisstructurewasintact wereused.

Pairingwasperformedbycomparingtheactualsizeofthe proximaltibiaoftheaffected kneeatthe levelofthejoint inthe donorand inthe recipient. Thismeasurement was obtainedby assessing this receptor segment through digi-talradiographsoftheaffectedkneeinanteroposteriorview,

discountingthemagnification(Fig.2).Inthedonor,this mea-surementwasmadeusingacaliper.Forlesionsoftheproximal portion ofthe tibia, patella, femoraltrochlea, and massive lesionsofthefemoralcondyles,adifferenceofatmost5mm betweenthedonorandrecipientwasusedasaparameterfor matching.Forfocallesionsofthefemoralcondyle,apositive pairingwasmadewhenthe donorcondylewasequaltoor largerthanthatofthereceiver.

Oncedonorandrecipientwerematched,allanalysisexams were performed.Theselectedtissueswerepackedintriple vacuum-sealedpackages,containingapreservationmedium withnutrients.Ittookameanof14daysforthetissuecultures tobereleased;duringthisperiod,thereceiverwasprepared

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Fig.3–(A)Macroscopicappearanceofosteochondritisdissecanslesionintheleftmedialfemoralcondyle;(B)Donorleft medialfemoralcondylewithacylinderpreparedinthesameanatomicalsiteoftherecipient’sdefect;(C)FOArestoringthe articularsurfaceofthemedialfemoralcondyle;(D)Macroscopiclateralviewofthetransplant,theperfectcongruenceofthe articularsurfaceofthemedialfemoralcondylecanbeobserved.

andthesurgicalprocedurewasscheduledtobeperformedas closeaspossibletothedateofculturerelease.

Storageandpreservation

Themediumusedfortissuepreservationwasthe commer-cialHamF-12– GIBCOwithglutamaxmedium(Invitrogen, Life Technologies, USA), whichcontains aminoacids, vita-mins, and minerals. To the medium, amphotericin B (12.5mg/500mL), streptomycin (50mg/500mL), gentamicin (25mg/500mL), and penicillin G (5,000,000UI/500mL) were addedasprophylaxisagainstmicroorganisms.Tissueswere stored in a refrigerator below 4◦_C _while _awaiting _culture

results.

Surgicaltechnique

Surgerywasscheduledforthedayafterculturesrelease,in ordertominimizethetimebetweencollectionand transplan-tation.

Theknees were approachedbymedialor lateral parap-atellararthrotomydependingonthesiteofthelesiontobe transplanted.Forcasesofmultiplelesions,alargearthrotomy wasmade,similartotheincisionfortotalkneearthroplasty, whichfacilitatedtheaccesstoallstructuresandpreservedthe meniscalinsertionsduringtheaccessroute.Inlesionsofthe posteriorcondyle,inwhichtheapproachisdifficult,the ante-riorhornofthemeniscuswascutradially;themeniscuswas shiftedforbetteraccesstoinjury,withsubsequentsuture.

TwotypesofsurgicaltechniquesforFAO wereused:the osteochondralcylindertechnique,inwhichaspecific instru-mentwasusedtopreparetherecipient bedandthe donor graft(BiotechnologyOrtopediaImportac¸ãoeExportac¸ãoLtd.;

Fig.3);andthesurfacetechnique,inwhichboththereceiver andthedonorwerepreparedmanuallywiththeaidofchisels, curettes,andabonesaw(Fig.4).

Thedonorgraftwastakenfromthesameanatomical loca-tionasthelesionintherecipient.Forthis,thetissuebankwas askedforadonorgraftthatcorrespondedtothelesionofthe recipient.

Functionalassessment

Patientswereevaluatedpreoperatively,intraoperatively,and postoperatively through the International Knee Documen-tation Committee (IKDC) 2000 Subjective Knee Evaluation Form,24 _the _Knee_Injury _and _{Osteoarthritis} _Outcome _Score (KOOS),25_and_the_Merle_D’Aubigne_and_Postel_Score,_modified fortheknee26,27_for_a_detailed_assessment_of_the_lesion_and_of limbfunction.

Statisticalanalysis

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Fig.4–(A)Osteonecrosissequelaeinthelateralfemoralcondyle(LFC)withlateralparapatellaraccessrouteandmedial patellarluxation;(B)LFCofthedonorduringsurgery;(C)Aspectoftheprovisionalfixationofthegraftshowingthe congruenceofthearticularsurface;(D)FinalfixationoftheLFCthatrestorestheanatomyofthejoint.

Forstatisticallysignificantdifferences,atypeI_error_equal toorlowerthan5%wasadopted.SPSSv.20.0softwareforMac wasusedindataanalysis.

Results

EightFOAwereconductedfromMarch2012toOctober2012, from five donors and eight operated knees. Patients were followed-upforatleasttwoyearsaftersurgery(30–37months). FivepatientshadaninitialdiagnosisofOD,onepatienthad post-chemotherapyfemoralcondyle necrosis,and two had post-traumaticsequelae.Themean ageofthetransplanted patientswas 30.1years (17–44)and themean transplanted area was 10.6cm2 _(4.6–22.4_cm2_). _Mean _number _of _days betweenharvestingandtransplantationwas15.3(14–16)and meannumberofsurgeriespriortoFOAwastwo(0–4)(Table1). Sixtransplantswereperformedinthefemoralcondyle,onein thetibialplateauwiththemeniscus,andoneinthepatella.

Onepatientwaslosttofollow-upatsixmonths(patient5); inthiscase,alldataofthescoreswerereplacedbytheworst valueamongallpatients,whichcharacterizedtheuseofthe worstcasescenarioandanalysisbyintentiontotreatbynot excludingthispatientfromthestudy.

MeanpreoperativeIKDCsubjectivescorewas31.99±13.4 and 81.26±14.7 postoperatively. Mean preoperative KOOS was 46.8±20.9 and 85.24±13.9 postoperatively. ANOVA

indicatedthatpatientsshowedsignificantimprovementover time,whencomparingpreoperativeandpostoperativeresults (p<0.01).

ThemeanmodifiedMerleD’AubigneandPostelScorefor thekneewas8.75±2.25preoperativelyand16.1±2.59 post-operatively. The Friedman test fornonparametric samples indicatedthatthepatientsshowedsignificantimprovement over time,whencomparing preoperativeand postoperative results(p<0.01).

Discussion

FOAtransplantationinthekneejointwerenotperformeduntil 2009inBrazil,asthelegislationinthecountrydidnotallow thestorageoffreshtissueslongenoughfortheprocedureto beperformedsafely.28_This_study_is_the_first_reported_use_of FOAinSouthAmerica.

AsthefirststudyofFOAinBrazil,onlypatientsbetween15 and45yearsoldwithahistoryoftraumaticoracquiredlesions ofthekneegreater than4cm2 _were_included, _and_patients withdegenerativelesionswereexcluded.

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6 LFC 5.2 15 Cylinder 17 OD 2

7 MFC 4.8 16 Cylinder 18 OD 2

8 MFC 13 16 Cylinder 38 OD 2

Har,harvest; LFC, lateralfemoralcondyle; MFC,medial femoral condyle;Fx, fracture; OD, osteochondritisdissecans;post-chem, post-chemotherapy;Tx,transplantation.

ormortuaries.Todate,harvestinginthesefacilitiesinBrazil isnotpossibleduetolegalaspects,whichlimitsthenumber ofgraftsavailablefortransplantation.

Afterbeingharvested,graftsweresentimmediatelytothe tissuebankforprocessing,whichoccurredwithin12hofthe procedure. This agility between harvesting and processing allowedfor a short interval between collection and trans-plantation (15.3 days), a fact that contributes to increased cell viability of the transplanted chondrocytes in cartilage graftswhencomparedwithgraftsstoredforlongerperiods.30 Anotherfactorthatcontributedtotheshorttimebetween har-vestingandtransplantationwasthefactthatallgraftswere harvestedwithina100kmradiusfromthecityofSãoPaulo, withnoneedforairtransportation,whichdecreasedthetime intervalbetweenharvestingandtransplantation.

Transplantswereperformedusingtwosurgicaltechniques: osteochondralcylinderandsurface.Thespecificinstruments fortheosteochondralcylindertechniquewerenotavailable inBrazilatthebeginningofthisstudy;therefore,an instru-mentalsetwasmanufacturedbyanationalcompanyforthe surgicalprocedurewiththistechnique.Inthistechnique,the diameter ofthe osteochondralcylinder ofthe donor must beequalto or 1mm smaller than the recipient bed. How-ever,intheinstrumentsetused,thisdifferencewasslightly greaterthantheoptimum;therefore,itwasnecessaryto fix-atesomegraftswith3-mmcannulatedcompressionscrews, whichwereremovedbyarthroscopy12weeksafter transplan-tation.

Clinicalevaluationsmadethroughobjectiveandsubjective questionnaires(IKDC,KOOS,andmodifiedMerle D’Aubigne andPostel)demonstratedasignificantimprovementbetween thepreoperativeperiodandlastfollow-up(p<0.01).Onlyone patienthadapostoperativecomplicationatfollow-up. This patienthad a historyofmedialtibial plateaufracture that developedacuteinfectionafterfracturefixation;itwastreated withserialsurgicaldebridementandremovalofanyhardware material. Thispatient had a recurrence ofthe prior infec-tion three months after the osteochondral transplantation (threeyearsafterthefracture),withgraftfailure.Radiographic imagesofallotherpatientsshowedincorporationofthegrafts, withoutsubchondralcystformationorgraftcollapse.Patients returnedtotheirdailyactivitiesofworkandleisure,aswellas tolow-impactsports.Thelevelofpatientsatisfactionwiththe procedurewasconsideredhighbyalltransplantrecipients.

Thepresentstudyhasseverallimitations.Ithadasmall sampleofpatients,withashortfollow-upperiod,andwithout acontrolgroupforcomparisonofresults.Anotherlimitationis thefactthattwosurgicaltechniqueswereevaluatedtogether, whichmaypresentdifferentresultsduetothedifferencein thesizeofthegraftsandsurgicaltechnicaldifficulties.

Conclusion

InBrazil,FOAisasafeprocedurewithgoodclinicalresultsin theshortandmediumtermforthetreatmentofosteochondral lesionsofthekneejointlargerthan4cm2_._This_is_a_complex procedurethatreliesonadatabaseofspecializedtissuesanda surgicalteamtrainedinharvestingandprocessingthetissue.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

Acknowledgements

TotheteamsoftheTissueBankandtheKneeGroupofthis institutionfortheircooperationwiththepresentstudy.

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