A New Concept of Mosaicplasty: Autologous Osteoperiosteal Cylinder Graft Covered With Cellularized Scaffold
Abstract: A concern regarding osteochondral autograft transfer for chondral defects is donor-site morbidity of the knee, the most common source of the autograft. To avoid the drawbacks of osteochondral autograft transfer, a cylindrical osteoperiosteal graft harvested from the iliac crest covered by a same-sized cylinder of hyaluronic acidebased polymer scaffold pretreated with bone marrow aspirate concentrate and transferred to the chondral defect recipient site in the exact size for restoration of the subchondral bone and the articular cartilage.
Introduction (With Video Illustration)
Although successful results have been reported by arthroscopic microfracture and abrasion arthroplasty for osteochondral lesions with subchondral defect of limited depth, large and deep subchondral defects or subchondral cysts may require restoration of the defect in the subchondral bone together with the articular cartilage.1-4 Osteochondral autograft transfer (OAT) that includes transfer of cylinders from knee to ankle is a widely used technique for these types of lesions; however, donor-site morbidity is a major concern.2,4,5 Highly variable rates have been reported for donor-site morbidity after knee-to-talus autologous osteochondral transplantation, which ranges from 0% to 54.5% in short- to mid-term follow-up.
In this technique, to avoid the drawbacks of osteochondral autograft transfer, a cylindrical osteoperiosteal graft harvested form iliac crest is covered by a samesized cylinder of scaffold pretreated by bone marrow aspirate concentrate (BMAC) and transferred to the recipient site in the exact size for restoration of the subchondral bone and the articular cartilage.
Patient Evaluation, Imaging, and Indications
The technique can be employed in young patients with articular cartilage lesions severe enough to cause functional limitations, in whom the morbidity of OAT is also to be avoided. It is particularly of use for lesions that present with large subchondral cysts in computed tomography scans (Fig 1 A-C) and degeneration of the overlying cartilage in MRI (Fig 2 A-C).
Surgical Technique
The surgical video is shown in Video 1. Standard ankle arthroscopy is performed through anteromedial and anterolateral portals. Examination of intraarticular structures with the probe may show softening of the articular cartilage. A curette may be introduced through the soft cartilage to evacuate the contents of the subchondral cyst. A mini-incision may be performed to expose the joint. The margins of the cyst and the damaged part of the articular cartilage that has been marked during arthroscopy is sharply delineated with a scalpel and all the contents of the cyst are removed by a curette (Fig 3). The recipient area is prepared by an appropriate size of Osteoarticular Transfer System trephine (10 mm), which is introduced to a depth of 15 mm, in this patient while the ankle was in plantar flexion (Fig 4). Then, the wound is closed with a salinedampened sponge and the iliac crest is prepared for graft harvest. After a mini-incision on skin and subcutaneous tissue of the iliac crest, an osteoperiosteal cylinder of 15 mm deep with its overlying periosteum is removed from the posterior iliac crest using a 10-mm donor harvester (Fig 5). The graft is then extruded and trimmed as 12 mm. The ankle is re-exposed, recipient field is irrigated, and after a nanofracture is performed at the base, the graft is inserted into the defect until its upper surface is 3 mm lower than the cartilage level (Fig 6). Meanwhile on the surgical side, the anterior iliac crest is prepared for harvesting of the BMAC. Bone marrow of 60 mL was aspirated through the bone marrow aspiration needle and the aspirate is concentrated by BMAC2-60-01 procedure pack (Macallan Terumo, Plymouth, MA) of the Harvest BMAC Cellular Therapy System. This system usually produces 7 to 10 mL of mesenchymal stem cells. This BMAC is then injected to the cylindrical hyaluronic acid-based polymer scaffold (CARTILAGO MATRIX; Biolot Medical, Ankara, Turkey) and kept soaked for several minutes (Fig 7) The scaffold is dried and placed on the surface and fixed by fibrin glue (Tissel 4 mm; Baxter, Deerfield, IL). After waiting for 4 minutes, stability of graft is confirmed by gentle joint movements. Layers of the wound are closed accordingly, and a compressive bandage is applied to the joint (Table 1).
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