17 May Osteochondral Allograft Transplantation: An Alternative to Knee Joint Replacement
Osteochondral allograft transplantation in the knee is an alternative to joint replacement that may be used to treat a young and healthy population with symptomatic cartilage defects. The defect may be identified by MRI and/or arthroscopy. When conservative management has failed, a diagnostic arthroscopy is indicated to asses the location, size, and severity of the defect(s). These findings determine what method is best suited for cartilage restoration. Osteochondral allograft transplantation is indicated for large lesions that have affected the cartilage and subchondral (beneath cartilage) bone. Osteochondral allografts are composed of fresh donor tissue and are procured from tissue banks that follow strict safety guidelines. This article will take you through a case study demonstrating an arthroscopic evaluation, cartilage transplant, and a sample phase 1 protocol for this procedure!
The reality is that cartilage defects in the knee are a common source of pain, swelling, and clicking or locking. Below are the treatment options broken down into nonsurgical and surgical options.
Nonsurgical treatment options include activity modification, icing, bracing (if bow-legged or knock-kneed), physical therapy, anti-inflammatory supplements (glucosamine and chondroitin), medications (oral anti-inflammatories like ibuprofen, Aleve [naproxen], Celebrex [celecoxib]) and/or injections (cortisone, hyaluronic acid viscosupplementation, platelet rich plasma). When nonsurgical treatment options are exhausted, we need to take a look at surgical options to get individuals back to full function.
Surgical treatment varies depending on size, location, and depth of the cartilage defect as well as patient activity level and long-term goals. In order of increasing invasiveness, surgical treatment options include debridement (cartilage shaving), microfracture (drilling subchondral bone to release bone marrow elements), autologous chondrocyte implantation (cell transplant), osteochondral autograft (your tissue), and osteochondral allograft (cadaver tissue). Osteochondral allograft is a surgery that treats knee cartilage lesions with a transplant of cadaver bone and cartilage. Below is surgery from Dr. Brian Cole.
A wide spectrum of chondral disease exists, ranging from superficial articular cartilage injuries to larger, full thickness osteochondral lesions. While some lesions remain asymptomatic, others can be debilitating and prevent a patient from living their desired lifestyle. Observation of focal chondral pathology in the knee is common during knee arthroscopy, and treatment considerations are dependent on size, location, and depth of the defect. The next few images will take you through an arthroscopic evaluation of a chondral lesion.
This patient is a young athlete presenting with osteochondral dissecans of the femur, a condition where lack of blood supply causes fragments of cartilage and bone to separate from the surrounding tissue. This often leads to loose bodies in the knee, knee pain, and joint effusion.
The lesion above is measured at 16 x 16 mm.
CARTILAGE TRANSPLANT- OSTEOCHONDRAL ALLOGRAFT
The ideal candidate for cartilage restoration surgery is the symptomatic young, motivated individual with either normal or correctable comorbidities.
The defect is exposed via an open incision. Note the visible difference between smooth, healthy cartilage and the defect.
After the defect size is confirmed, a drill of matching diameter is used to shape the defect in preparation for the graft.
The graft is prepared. It is cut to the size of the defect and washed with a pulse lavage for sterility. The graft is soaked in bone marrow aspirate concentrate (BMAC) for patients electing to supplement the procedure with stem cells. Rush is currently conducting research to determine if BMAC can improve graft integration.
The osteochondral plug is press fit into the prepared defect! We need to make sure individuals protect the operated site well after surgery. Below is a sample phase 1 protocol after an Osteochondral allograft transplantation.
PHASE 1 PROTOCOL – OSTEOCHONDRAL ALLOGRAFT TRANSPLANTATION
It is to note that rehabilitation protocol is dependent upon transplant location, in this case, the femoral condyle. While this phase I program is specifically designed for individuals post osteochondral allograft transplantation, this protocol will be comparable to many other post-op knee phase I rehabilitation protocols. This protocol is divided into mobility and activation/strengthening exercises!
Click Image Above for the entire protocol with detailed instructions, sets, repetitions, hold times, and frequency of this protocol to perform!
PrehabX Sample Video
After surgery, it is very common to have swelling and edema in the knee. To help control the swelling and prevent a serious complication called a deep vein thrombosis from forming in your calf, it is imperative to perform ankle pumps. Contracting your calf muscle keeps blood flowing in the veins and arteries and helps decrease swelling in the knee.
To perform this exercise lie on your back or sit with your feet out Point your toes down then back up again.
SEATED HEEL RAISES
This exercise is designed to strengthen the muscles behind your shin bone.
Position yourself seated in a chair or on a surface with your bottom supported and your feet positioned under your knees. Raise your heels by pushing the front of your feet and your toes into the ground. Slowly lower your heels in a controlled manner and repeat.
SEATED KNEE FLEXION PROM OFF TABLE
Sitting on a bed or couch, remove your knee immobilizer Place the non-affected leg underneath the surgical leg. While assisting yourself, slowly let gravity help as your knee goes into flexion. Use your non-affected leg to assist the surgical leg on the way back up.
SEATED KNEE EXTENSION PROM
Get into a comfortable position on a chair or bed with your foot elevated and supported on towel roll. Let gravity pull your knee into extension and/or use your hands as needed to help move your knee into extension. Hold until your knee begins to feel a little uncomfortable – not painful. Then relax your leg. Repeat every hour.
IMPROVE KNEECAP MOBILITY
– Position yourself long-sitting with your legs and bottom supported on a surface. Also, keep your back supported if possible
– Using the webspace of your hand or your fingers, gently mobilize your patella (kneecap) in all four directions (up, down, side-to-side) and hold each position for ten seconds. You should not be putting pressure down into your knee cap as this may be uncomfortable, instead focus on gliding your kneecap in all four directions. Repeat as prescribed.
– Use your other knee cap as a reference for how your kneecap on your affected knee should ideally move.
This is an easy way to begin activating the gluteal muscles. Either perform this in a seated position or while lying face up. Think about tucking the tailbone underneath you to ensure yourself of activating these muscles.
SIDE LYING HIP ADDUCTOR ISOMETRICS
Lie on your side. Squeeze your thigh and knee first, in particular, the inside part of your thigh. While maintaining the squeeze, slowly lift up your leg. You should feel the muscles on the inside part of your thigh working. Do not let your hips/core move. Keep them tight the entire time!
STRAIGHT LEG RAISE
HOW: Start by lying on your back. Bend your opposite knee. The first step is to perform a very strong quadriceps set by squeeze your thigh as hard as you can. Keeping this constant squeeze, tighten your core muscles and then lift your leg up. Think of making your leg as long as straight as you can while lifting. Then slowly lower back down to starting position.
FEEL: You should feel an entire contraction of the front thigh muscles.
COMPENSATION: You should not be feeling these exercise exclusively in the front of your hip. If you only feel the muscles in the front of your hip working, it means you are not squeezing your thigh hard enough. Maintaining the thigh squeeze is the most important part of this exercise!
This exercise (quad set) is paramount to getting re-gaining active control your quadriceps muscles, which is the muscle on the front of your thigh. After an injury (which includes surgery), there is lots of swelling in the knee that accumulates. This swelling leads to a phenomenon called atherogenic inhibition, in which there is an inability to completely contract a muscle despite no injury to the muscle or innervating nerve. To combat this, lots of practice and developing a new “brain-body connection” is required. Follow this foolproof guide to wake your quad back up!
Laying on the ground or table and place a rolled up towel/shirt under your knee. This will act as a lever which will make it easier to activate your quadriceps muscle. Attempt to squeeze your quadriceps muscle using these cues.
– Really focus on squeezing your quad.
– Sometimes touching the muscle, massaging it, or hitting it can help
– Think about moving your kneecap up and into your hip socket
– Push your knee down into the towel roll
– Lift your heel off the table
– Move your shin bone in the shape of a “J” by moving your knee down and your heel up at the same time
– Squeeze both quadriceps at the same time
SIDE LYING HIP ABDUCTION
PrehabX Sample Video
-Lie on your side with your affected leg on top
-Bend your bottom leg
-Slightly squeeze your core. Maintain this activation throughout the entire exercise
-Push your bottom knee into the ground to keep your pelvis stable
-Straight your top leg and lift it up and back. The key is that you are not just lifting the leg up, but also BACK a bit
-You should feel a deep muscle burning in the back of your hips where your glutes are, not in the front of your hips. If you feel it in the front of your hips, make sure your hips are pointed directly ahead of you and not up to the sky, and also check that you are lifting the top leg backward
It is to note that rehabilitation protocol is dependent upon transplant location, in this case, the femoral condyle. See briancolemd.com for additional rehabilitation protocols and more literature on cartilage restoration.
MORE ABOUT OSTEOCHONDRAL ALLOGRAFT
- Osteochondral allograft is outpatient surgery that may take 45 minutes to 2 hours, depending on the size, location, and the number of lesions being treated.
- Most patients require pain medication for 1 to 2 weeks following surgery.
- Most patients start physical therapy the week after surgery.
- Most patients use a continuous passive motion (CPM) machine for 6 to 8 hours/day for 6 weeks.
- Most patients use crutches and are non-weight bearing for the first 6 weeks following surgery, and gradually return to full weight bearing over 8 to 12 weeks.
- Return to sports activities is typically initiated at 8 months following surgery.
When used in the appropriate cases, osteochondral allograft transplantation is clinically proven to have favorable outcomes and high rates of satisfaction. It is a viable alternative to joint replacement in young, healthy patients with symptomatic cartilage defects.
Frank RM, Lee S, Cotter EJ, Hannon CP, Leroux T, Cole BJ. Outcomes of Osteochondral Allograft Transplantation With and Without Concomitant Meniscus Allograft Transplantation: A Comparative Matched Group Analysis. Am J Sports Med. 2018; 46(3): 573-580.
McCarthy MA, Meyer MA, Weber AE, Levy DM, Tilton AK, Yanke AB, Cole BJ. Can Competitive Athletes Return to High-Level Play After Osteochondral Allograft Transplantation of the Knee? Arthroscopy. 2017; 33(9): 1712-17.
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, 35: 411-420, 2007.
All photos are property of Brian Cole MD, MBA
For more information on basic science, technique, outcomes, and rehabilitation protocols visit briancolemd.com
ABOUT THE AUTHOR
Dr. Brian Cole is an orthopedic sports medicine surgeon at Midwest Orthopaedics at Rush and a Professor of Orthopaedics, Anatomy and Cell Biology at Rush University Medical Center. Dr. Cole is Managing Partner of Midwest Orthopaedics and is the Department’s Associate Chairman and the Section Head of the Cartilage Research and Restoration Center. He is the Chairman of Surgery at Rush Oak Park Hospital and leads the Rush Orthopedic Master’s Program. Dr. Cole also holds several leadership positions in national and international orthopedic societies.
Honors awarded to Dr. Cole range from the “Best Doctors in America” since 2004 and “Top Doctor” in Chicagoland since 2003. In 2006, he was featured on the cover of Chicago Magazine as “Chicago’s Top Doctor.” In 2009, he was selected as NBA Team Physician of the Year and Orthopedics This Week has named Dr. Cole as one of the top 20 sports medicine, knee and shoulder specialists repeatedly over the last 5 years as selected by his peers. Dr. Cole’s patients describe his practice as compassionate, available and willing to offer novel solutions to avoid surgery whenever possible. Testimonials to the surgical care that Dr. Cole’s team provides are frequently featured and shared.
Dr. Cole’s research interests include Cartilage Restoration, therapeutic biologics and regenerative medicine, and minimally invasive surgical techniques for the treatment of the knee, elbow, and shoulder. He has published more than 1,000 articles and 8 textbooks on orthopedic surgery and sports medicine, has lectured nationally and internationally on more than 2,000 occasions and has appeared as an expert on several TV documentaries. He received an MD and MBA from the University of Chicago, completed his orthopedic residency at the Hospital for Special Surgery at Cornell Medical Center, and a Sports Medicine fellowship at the University of Pittsburgh.
His professional career outside of academia includes serving as team physician for the Chicago Bulls, co-team physician for the Chicago White Sox, and a team physician for the Chicago Fire, Chicago Dogs, and DePaul University. He has served as co-host for 8 years on the talk-show Sports Medicine Weekly The Score radio, formally on ESPN Radio.