27

Scand J Rheumatology, Supplement 44, 1982

IV RECONSTRUCTION OF ARTICULAR SURFACE USING AN AUTOGENOUS OSTEOCHONDRAL FRAGMENT FROM THE LATERAL

ASPECT OF THE FEMORAL CONDYLE

An experimental study

Kalevi Osterman and T. Sam Lindholm From the Research Laboratory of the Orthopaedic Hospital of the Invalid Foundation,

Helsinki, Finland, and the Bone Research Group, Research Center, Huddinge University Hospital, Huddinge, Sweden

ABSTRACT. Reconstruction of the weight-bearing joint sur- face was studied experimentally using an osteochondral frag- ment that was detached from the lateral aspect of the lateral femoral condyle. The fragment was f i e d to a defect on the me- dial femoral condyle using an autologous bone transplant. A total of 20 rabbit knees were operated upon, and the results were estimated macroscopically, by histology, tetracycline labelling, and contact microradiography.

The results evaluated 6-200 days postoperatively showed that the joint surface reconstruction using this particular meth- od is difficult and that, in many cases, joint incongruity and secondary osteoarthritic changes develop. However, stability of the osteochondral fragment was obtained, in most cases using the bone transplant fiation technique. The results of this study show that an exact anatomic reconstruction of the articular sur- face forms an essential part in handling a disturbed joint con- gruity.

Reconstruction of the articular surface in cases where the weight-bearing part of a large joint, e. g. the knee, has been damaged and become in- congruent, forms a difficult clinical problem, as the development of a secondary osteoarthritis often leads to severe disability, especially in cases where the joint surface is damaged after the growth period (6, 7, 8). Reconstruction of the ar- ticular surface in experimental conditions has been attempted using various methods, e. g. autogenous transplants (4, 5, 10, 11, 19),

homogenous transplants (5, 10, 11, 13), and xeno- grafts (1, 6, 10).

Clinical results obtained by using homologous transplants have been presented by Pap & Krom- pecher (12), Stryhal& Matejovsky (17) and Wag- ner (18). Transplantation of the patella to the de- fect of the tibia1 joint surface was reported by Ja- cobs (3). In addition to these experiments isolated chondrocyte transplantation has been studied by Bentley & Greer (2), and transplantation of undif- ferentiated mesenchymal tissue, e. g. perichon- drium or periosteum, by Ritsila et al. (14, 15). Wagner (18) has suggested that an osteochondral fragment can be taken from the posterior aspect of the femoral condyle for transplantation.

Exact anatomical restauration of the joint sur- face has been stressed by Lindholm et al. (7). Early and successively increased joint mobiliz- ation has been considered important by many authors (7, 16).

In the present experimental study, possibilities of using an autogenous osteochondral fragment removed from the lateral aspect of the femoral condyle for reconstruction of a defect in the condylar surface was studied.

MATERIAL AND METHODS

A total number of 20 knee joints were operated oral condyle, which was of the same size but of an upon in 10 adult male rabbits weighing about 4 other shape and covered with cartilage and syno- kg. The medial femoral condyle was used for the vium. Fixation of the fragment was secured using operation, and an osteochondral fragment was re- an autologous bone transplant taken from the rib moved from the weight-bearing articular surface. as described by Lindholm & Osterman (9). Post- The defect that was 2-3 mm deep, was recon- operatively, free mobility of the joint was structed by using another osteochondral fragment allowed. The animals were given oxitetracycline that was taken from the lateral aspect of the fem- parenterally, 50 mg per kilogram body weight,

Scan

d J

Rhe

umat

ol D

ownl

oade

d fr

om in

form

ahea

lthca

re.c

om b

y L

eids

Uni

vers

ity o

n 11

/21/

14Fo

r pe

rson

al u

se o

nly.

28 intra-operatively and two weeks before sacrifice in cases where the observation time exceeded this period. fixation.

Special care was used in operative technique so that the tip of the bone transplant was carefully impacted under the articular surface. Anatomical- ly, as exact a reconstruction of the joint surface as possible was aimed at. This was difficult because of the flattened shape of the transplant. Primary

operative result was recorded, and sufficient stab- ility was usually obtained using bone transplant

The observation time varied from 6 to 200 days. The animals were sacrificed using Penthotal. Joint mobility, and macroscopic appearance of the joint surfaces was recorded. The specimens were treated and examined in a similar way as in the previous study (9).

RESULTS

In two cases, postoperative wound infection de- stroyed the joint, and these cases were excluded from the results.

Macroscopic observations The shape of the osteochondral fragment was ob- served to be flattened in most cases at the begin- ning as well as at the end of the study. However, the shape of the femoral condyle was considered excellent in one case and acceptable in eight cases. In nine cases, the result was considered in- adequate (50%). The clinical results are presented in Fig 1.

Hktology After one week’s observation, the osteochon-

dral fragment had not got fused to the bed, but signs of remodelling could be seen. The articular surface was covered with fibrous tissue, and the bone transplant was visible.

The osteochondral fragment had united, and the bone transplant anchored firmly to the sur- rounding condylar bone. However, the articular surface of the transplant was flattened and covered with fibrous tissue that, in some cases, seemed to form fibrocartilage and covered the tip of the bone transplant (Fig 2).

The fragment seemed to be firmly united to the condylar bed after 5-10 weeks, and it was covered with fibrous tissue. The bone transplant had fused totally, but could still be recognized. Its

tip was covered with fibrous tissue and cartilage. Additionally, the articular surface presented some osteoarthritic changes (Fig 3).

Remodelling of the osteochondral fragment was completed 5 months later. The condylar sur- face was flattened and degenerated.

Fluorescence labelling The osteochondral fragment, the bone transplant, and the operated condyle all showed an intensive fluorescence after 7 days. A thin line between the condyle and the fragment could be seen. The line between the bone transplant and the surrounding bone was clear.

The osteochondral fragment and the bone transplant showed to be united, but the remodell- ing process was still going on after 3-4 weeks. Some oxitetracycline was still seen at the tip of the bone transplant and in the subchondral layer of the osteochondral fragment.

The fragment showed to be totally united after 5 weeks. The joint surface showed irregular in many cases. In some of them, a separate bone is- land resembling an osteochondritis dissecans frag- ment could be seen (Fig 4).

Contact microradiography Calcified tissue was observed in the line between the osteochondral fragment and the condylar bone after 3 4 weeks. The remodelling process was finished after 10 weeks and showed secondary osteons.

DISCUSSION

In this series, the reconstruction of the articular The joint surface was usually flattened, and the surface was difficult from a technical point of cartilage degenerated equalling osteoarthritis. view, and the final results obtained were not as These results seem to support our view that an satisfactory as compared with previous results (9). exact anatomic reconstruction of the articular sur-

2a

Scan

d J

Rhe

umat

ol D

ownl

oade

d fr

om in

form

ahea

lthca

re.c

om b

y L

eids

Uni

vers

ity o

n 11

/21/

14Fo

r pe

rson

al u

se o

nly.

29 The results of this series show that if the defect

in the articular surface is restored using an auto- logous osteochondral fragment, its shape must be as close as ever possible to the original anatomic

face forms an essential part of the joint surface re- construction technique. The fixation procedure of the osteochondral fragment with a bone trans- plant was stable and seemed to suit this purpose

15 -

u)

2 1 0 -

c

well.

Fig. 1.

EI'rlienl Auceplahle Inwlt icrnl

Osteochondral Femoral Tibia1 0 fragmenf and condyle condyle bone francplant rurface Fur face

FiE I

shape.

Fig 2 L

Macroscopic findings of the articular surfaces, the bone trans- plant, and the osteochondral fragment. The fragment was taken from the lateral aspect of the lateral femoral condyle.

The distal femur 23 days after reconstruction of the joint sur- face of the medial femoral condyle. Flattening of the medial condyle is seen (the arrows). The bone transplant had already partially fused to the surrounding bone. The fragment has fused to the articular surface, but no cartilage can be seen.

Fig 3 The articular surface is covered with fibrous tissue 32 days after the operation. The fragment has fused totally to its bed, but the bone trabeculae, which are parallel with the articular surface, can be clearly seen. Remnants of the bone transplant can be seen.

Scan

d J

Rhe

umat

ol D

ownl

oade

d fr

om in

form

ahea

lthca

re.c

om b

y L

eids

Uni

vers

ity o

n 11

/21/

14Fo

r pe

rson

al u

se o

nly.

30 REFERENCES

1 . Allbrook, D. & Kirkaldy-Willis, W.H.: The restoration of articular surfaces after joint excision. An experimental study with cartilage implants. J Bone Jt Surg 40-B: 742, 1958.

2. Bently, G. & Greer 111, R. B.: Homotransplantation of iso- lated epiphyseal and articular cartilage chondrocytes into joint surface of rabbit. J Bone Jt Surg 50-B: 184, 1971.

3. Jacobs, E. E.: Patellar graft for severely depressed com- minuted fractures of the lateral tibia1 condyle. J Bone Jt Surg 47-A: 842, 1965.

4. Kettelkamp, D. B.: Experimental autologous joint trans- plantation. CIin Orthop 87: 138, 1972.

5 . Linden, van der, A. J.: Articular cartilage plasty. Arch Chir Neerl 24: 279, 1972.

6. Linden, B. C.: Osteochondritis dissecans. The natural course and incidence in femur condyles. Thesis, Lund, Sweden, 1976.

7. Lindholm, S., Pylkkanen, P. & Osterman, K.: Fixation of osteochondral fragments in the knee joint. A clinical sur- vey. CIin Orthop 126: 256, 1977.

8. Lindholm, T. S. & Osterman, K.: Internal fixation of the fragment of osteochondritis dissecans in the hip using bone transplants. J Bone Jt Surg 62-8: 43, 1980.

9. Lindholm, T. S. & Osterman, K.: Reconstruction of articu- lar surface by transplantation of an osteochondral frag- ment to the femoral condyle using a bone transplant. An experimental study. Scand J Rheumatology, Suppl 44, 1982.

10. Lloyd, 0. J., McTavish, D. R., Soriano, S., Wiley, A. M. & Young, M. H.: Fate of articular cartilage in joint trans- plantation. Can J Surg 16: 306, 1973.

1 1 . McKibbin, B.: lmmature joint cartilage and the homograft reaction. J Bone Jt Surg 53-8: 123, 1971.

12. Pap, K. & Krompecher, S.: Arthroplasty of the knee. Ex- perimental and clinical experiences. J Bone J t Surg 4 3 4 : 523, 1961.

13. Riede, U. N. & Mihatsch, J. M.: Zellen und Matrix irn orthop-Homotransplantierten Epiphysenknorpel. Beitr Path 149: 336, 1973.

14. Ritsila, V & Alhopuro, S.: Regeneration of articular carti- lage defects with free pericondrial grafts. IRCS Medical Science: Connective Tissue, Skin and Bone Transplantation 3: 49, 1975.

15. Ritsila, V., Poussa, M., Rubak, J., Snellman, 0. & Oster- man, K.: Reconstruction of patellar cartilage lesions using perichondrial or periosteal grafts. Proceedings of the Finnish Orthopaedic Association 2: 101, 1979.

16. Salter, R. B., Simmonds, D. F., Malcom, B. W., Rumble, E. J. & MacMichael, D.: The effects of continuous passive motion on the healing of articular cartilage defects. An ex- perimental investigation in rabbits. J Bone J t Surg 5 7 4 : 570, 1975.

17. Stryhal, F. & Matejovsky, 2.: Erfahrungen mit homoplas- tischen osteokartilaginaren Femurkopfkappentransplanta- tionen. 2 Orthop 110: 708, 1972.

18. Wagner, H.: Moglichkeiten und klinische Erfahrungen mit der Knorpeltransplantation. 2 Orthop 110: 705, 1972.

19. Wigren, A. & Olerud, S.: Reincorporation of an avascular articular surface bearing fragment. Acta SOC Med Upsal 76: 63, 1971.

Scan

d J

Rhe

umat

ol D

ownl

oade

d fr

om in

form

ahea

lthca

re.c

om b

y L

eids

Uni

vers

ity o

n 11

/21/

14Fo

r pe

rson

al u

se o

nly.