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Healio
Issue: August 2007
August 01, 2007
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Consider the pros and cons in choosing osteochondral allografts or autografts

Autografts can lead to donor site morbidity, while allograft has a risk of disease transmission.

Issue: August 2007

While osteochondral autografts and allografts can be used to successfully treat cartilage lesions, each has assets and liabilities.

At the American Orthopaedic Society for Sports Medicine Specialty Day meeting, Thomas R. Carter, MD, discussed the benefits and drawbacks of osteochondral autografts and allografts, and explained the indications for these procedures.

“In my hands, autografts are used for lesions 2 to 2.5 cm2 or less, possibly primary in high-demand patients or those who have significant bone loss [and] usually secondary in low-demand patients,” Carter said during his presentation. He added that he uses allografts in lesions that are larger than 2 cm2 and where there is significant bone loss, depending upon the availability and cost factors.

Carter noted that the ideal autograft patient is 35 years old or younger with a 1- to 2.5-cm2 defect. In these patients, autograft procedures can inexpensively provide good results and hyaline cartilage. In a study of 104 autograft procedures performed in patients at an average age of 34 with less than 2.5 mm lesions, Carter and his colleagues found no cases of donor site morbidity at 1- to 5-years follow-up.

 

2.5-cm defect prior to treatment
This arthroscopic image shows a 2.5-cm defect prior to treatment.

Two years after treatment
A second look arthroscopy shows the knee two years after treatment with osteochondral allograft.

Images: Carter TR

An International Knee Documentation Committee (IKDC) evaluation of 52 cases also revealed that 96% had decreased pain and 77% had increased activity.

Carter also cited research by Laszlo Hangody, MD, who treated 831 patients with osteochondral autografts and found good to excellent results in 92% of femoral condyle cases, 87% of tibial procedures and 79% of patellofemoral cases. “And he said that he only had three donor site morbidities,” Carter said. The downside: limited donor sites, a potential for morbidity and technical difficulty.

Osteochondral allografts

In comparison to autografts, osteochondral allografts have no morbidity, long-term follow-up and the ability to treat larger lesions. “The cons: possible disease transmission, immune response, availability and cost,” Carter said.

He cited research by Alan E. Gross, MD, which found a 95% survivorship at 5 years and 85% survivorship at 10 years in 60 patients with femoral condylar lesions treated with allografts and survivorship rates of 95% and 80% at 5 and 10 years, respectively, in 65 patients treated for tibial plateau defects.

In a study of 211 allografted patients, investigators from the University of California in San Diego found an overall success rate of 84% at a mean follow-up of 4.3 years and that 93% of femoral and 76% of patellofemoral defects were successfully treated with the procedure. However, Carter noted that success rates dropped for the treatment of bipolar lesions in the tibia (50%) and patellofemoral region (69%).

Allografts typically cost $10,000 compared to a few hundred dollars for the autograft instruments, Carter told Orthopedics Today. Disease transmission also remains a worry for surgeons using allografts.

“The risk is present, but limited if you have proper screening and procurement,” Carter said. “It is vitally important to know where you are getting your tissue.”

Screening, immune response

Surgeons should ensure that their tissue supplier is American Association of Tissue Banks — certified, Carter said. HIV and hepatitis have historically posed concerns for surgeons using allografts and he noted that nucleic acid testing cannot readily exclude hepatis C.

“Obviously, you still have to worry about the bacteria infection,” he told Orthopedics Today.

He also noted that immune response can occur. “Even though there’s talk about the cells being well-imbedded within the articular cartilage, there are surface antigens that can evoke a response. Therefore, it is recommended that the grafts not be used for collagen vascular disease or inflammatory joint processes.”

For more information:
  • Thomas R. Carter, MD, can be reached at The Orthopedic Clinic Association, P.C., 2222 East Highland Ave, Ste 300, Phoenix, AZ 85016; 602-277-6211; e-mail: tcarter@tocamd.com. He is a consultant for Arthrex and CryoLife and has received royalties through Arthrex.
References:
  • Bobic V, Morgan C, Carter T. Osteochondral autologous graft transfer. Oper Tech Sports Med. 2000; 8:168-178.
  • Bugbee WD, Convery FR. Osteochondral allograft transplantation. Clin Sports Med. 1999; 18:67-75.
  • Carter TR. Symposium: Articular cartilage restoration — Osteochondral autografts and allografts. Presented at the American Orthopaedic Society for Sports Medicine Specialty Day meeting. Feb. 17, 2007. San Diego.
  • Gross AD, Shasha N, Aubin P. Long-term follow-up of the use of fresh osteochondral allografts for posttraumatic knee defects. Clin Orthop Relat Res. 2005;435:79-87.
  • Hangody L, Fules P. Autologous osteochondral mosaicplasty for the treatment of full-thickness defects of weightbearing joints: Ten years of experimental and clinical experience. J Bone Joint Surg Am. 2003;85-Suppl 2:25-32.