Abstract
Aims
Hyaline cartilage has a low capacity for regeneration. Untreated osteochondral lesions of the femoral head can lead to progressive and symptomatic osteoarthritis of the hip. The purpose of this study is to analyze the clinical and radiological long-term outcome of patients treated with osteochondral autograft transfer. To our knowledge, this study represents a series of osteochondral autograft transfer of the hip with the longest follow-up.
Methods
We retrospectively evaluated 11 hips in 11 patients who underwent osteochondral autograft transfer in our institution between 1996 and 2012. The mean age at the time of surgery was 28.6 years (8 to 45). Outcome measurement included standardized scores and conventional radiographs. Kaplan-Meier survival curve was used to determine the failure of the procedures, with conversion to total hip arthroplasty (THA) defined as the endpoint.
Results
The mean follow-up of patients treated with osteochondral autograft transfer was 18.5 years (9.3 to 24.7). Six patients developed osteoarthritis and had a THA at a mean of 10.3 years (1.1 to 17.3). The cumulative survivorship of the native hips was 91% (95% confidence interval (CI) 74 to 100) at five years, 62% (95% CI 33 to 92) at ten years, and 37% (95% CI 6 to 70) at 20 years.
Conclusion
This is the first study analyzing the long-term results of osteochondral autograft transfer of the femoral head. Although most patients underwent conversion to THA in the long term, over half of them survived more than ten years. Osteochondral autograft transfer could be a time-saving procedure for young patients with devastating hip conditions who have virtually no other surgical options. A larger series or a similar matched cohort would be necessary to confirm these results which, in view of the heterogeneity of our series, seems difficult to achieve.
Cite this article: Bone Jt Open 2023;4(7):523–531.
Take home message
This is the first study analyzing the long-term results of osteochondral autograft transfer of the femoral head.
Osteochondral autograft transfer could be a time-saving procedure for young patients with devastating hip conditions.
Introduction
Osteochondral defects of the articular surface of the femoral head may result from trauma (e.g. acetabular fracture, Pipkin fracture, hip dislocation), or may occur as part of developmental or metabolic diseases such as femoroacetabular impingement (FAI), acetabular dysplasia, avascular necrosis (AVN), Perthes’ disease (PD), osteochondritis dissecans, and slipped capital femoral epiphysis. These defects cause disruption to the hyaline cartilage layer, which has a limited capacity to heal. When healing does occur, fibrocartilage is produced, which does not offer the same biological and mechanical properties compared to hyaline cartilage. Because of the limited healing capacity, surgical reconstruction of the articular surface is indicated in young patients presenting with a localized osteochondral lesion of the weightbearing zone of the femoral head. The goal of the surgical reconstruction is to restore joint congruity and, whenever possible, postpone progression of the hip to osteoarthritis.1 Common techniques for surgical reconstruction include bone marrow stimulation, autologous chondrocyte implantation,2 or osteochondral auto- or allograft transfer (OAT).3 An additional treatment option is proximal femoral osteotomy, which does not directly address the lesion, but rather moves the lesion out of the weightbearing zone of the hip.4
The principle of OAT is to fill an osteochondral defect with one or more osteochondral plugs in order to recreate a congruent articular surface composed mainly of hyaline cartilage. OAT has been successfully used in the knee and the ankle joint. When performing OAT on the hip joint, multiple options for source plugs are available, including the distal femoral condyles,5-14 allografts,15-19 or hip-to-hip plug transfer.3,20-24 Autografts harvested from the distal femoral condyles are associated with donor site morbidity.25
In our institution, we have used OAT in the hip since 1996. The purpose of this study is to evaluate the long-term outcome of all patients treated for an osteochondral lesion of the femoral head using OAT.
Methods
Patients
Overall, 11 patients who underwent OAT for chondral or osteochondral defects of the femoral head between September 1996 and August 2012 were included in this study. All patients provided written informed consent for the use of their data and images for this study. No patient was lost to follow-up. Patients with a follow-up of less than five years, or inability to give written consent for participation in the study, were excluded from our analysis. Data collection of this retrospective study included age, sex, aetiology, size of osteochondral defect, number of plugs harvested, length of follow-up, clinical and radiological outcomes, complications, and need for further surgery. Conversion to total hip arthroplasty (THA) was designated as the endpoint of the study.
The mean age at surgery was 28.6 years (8.4 to 44.7). There was a preponderance of male patients (7 males, 4 females). Ten affected hips were on the left side; one was on the right. Conversion to THA occurred in six patients at a mean of 10.3 years (1.1 to 17.3) after the index procedure. The five patients who had not undergone conversion to THA were followed up at a mean of 18.5 years (9.3 to 24.7), with mean age at follow-up 40.2 years (31.3 to 53.2) (Table I).
Table I.
Demographics of patients.
| Patient | Age, yrs | Sex | Side | Pathology | Approach | Additional surgery | Endpoint THA, yrs |
Follow-up, yrs |
|---|---|---|---|---|---|---|---|---|
| 1 | 29.4 | M | L | AVN IIA | KL-Flip | 23.8 | ||
| 2 | 27.2 | F | L | AVN IIB | KL-Flip | Labral resection | 13.7 | |
| 3 | 22.0 | F | L | AVN IIB | KL-Flip | 9.3 | ||
| 4 | 34.1 | M | L | AVN III | Smith-Petersen | Periacetabular osteotomy | 9.2 | |
| 5 | 19.7 | F | L | AVN III | Smith-Petersen | 9.7 | ||
| 6 | 8.4 | M | R | Perthes | Smith-Petersen, Ludloff | Triple osteotomy | 24.7 | |
| 7 | 31.2 | M | L | FAI | KL-Flip | 9.1 | ||
| 8 | 44.7 | F | L | FAI | KL-Flip | 1.1 | ||
| 9 | 21.5 | M | L | Both column | KL Flip, ilioinguinal | ORIF | 20.9 | |
| 10 | 39.8 | M | L | Posterior wall | KL-Flip | ORIF | 17.3 | |
| 11 | 36.5 | M | L | Dislocation | KL-Flip | 15.7 | ||
| Total | 7 M | 1 R | 8 KL-Flip | |||||
| 4 F | 10 L | 3 Smith-Petersen |
-
AVN, avascular necrosis; FAI, femoroacetabular impingement; KL-Flip, Kocher-Langenbeck approach with trochanteric flip osteotomy; L, left; R, right; THA, total hip arthroplasty.
The aetiology or underlying condition that resulted in the osteochondral defect was identified for all patients. Five patients had AVN of the femoral head, two developed cartilaginous defects as a sequelae of FAI, and one due to PD. Three patients had a traumatic lesion of the femoral head. Two were associated with an acetabular fracture, and one with an incarcerated posterior hip dislocation.
Surgical technique
The senior author (EG) performed all surgeries. Eight patients underwent surgical hip dislocation with trochanteric flip osteotomy in the lateral decubitus position via a Kocher-Langenbeck approach.26,27 Three patients were operated in the supine position using a standard Smith-Petersen approach with anterior surgical hip dislocation.28
Intraoperatively, we measured the area of the defect. Osteochondral plugs were harvested from the inferior segment of the femoral head (six patients), or from the femoral trochlea (five patients; Figure 1).
Fig. 1
Harvesting and transplantation of grafts. Osteochondral autografts are harvested either from the anteroinferior parts of the ipsilateral femoral head or from the femoral trochlea of the ipsilateral knee. For precise harvesting from the inferior head, the surgeon should stand in front of the patient. For precise insertion of the transplants, the surgeon has to move towards the back (i.e. at the dorsal side) of the patient.
Additional procedures were performed on eight patients. These included partial labral resection (four patients), trimming of the acetabular rim (one patient), femoral osteochondroplasty (three patients), open reduction and internal fixation (ORIF; two patients), periacetabular osteotomy (PAO; one patient), and triple pelvic osteotomy (one patient). Some additional procedures necessitated additional surgical approaches, including the Ludloff approach (two patients)29 and ilioinguinal approach (one patient).
Postoperative regimen included touchdown weightbearing (1/6 body weight, or 10 to 15 kg) of the involved limb for six weeks. Radiological assessments were performed at six weeks, and progressive weightbearing was allowed when uneventful healing of the greater trochanter was visible. Patients with pelvic osteotomies or ORIF had additional radiographs at three months, and were allowed to fully bear weight when healing of the innominate bone was noted.
Assessment at follow-up
We performed a thorough standardized clinical examination in all patients who had not undergone conversion to THA. The clinical examination included gait assessment, presence of a limp, hip range of motion, leg length assessment, hip abductor force, and impingement testing.
Outcome measures, including Merle d’Aubigné Score (mMdA),30,31 Harris Hip Score (mHHS),32 Hip disability and Osteoarthritis Outcome Score (HOOS),33,34 University of California Los Angeles Activity Score (UCLA),35 and Western Ontario McMaster Universities Osteoarthritis Index (WOMAC)36 were collected. Radiological evaluation included a supine anteroposterior pelvis and cross-table axial view. Heterotopic ossifications was classified according to Brooker et al,37 and osteoarthritis according to Tönnis and Heinecke.38
Statistical analysis
Statistical analysis was conducted with SPSS version 26.0 (IBM, USA). Kaplan-Meier survival analysis was used to determine the failure of the OAT procedure with conversion to THA as the endpoint.
Results
The cumulative survivorship at five years was 91% (95% confidence interval (CI) 74 to 100), at ten years was 62% (95% CI 33 to 92), and at 20 years was 37% (95% CI 6 to 70; Figure 2).
Fig. 2
Kaplan-Meier survivorship. Cumulative survivorship of the native hips at five years was 91% (95% confidence interval (CI) 74 to 100), at ten years was 62% (95% CI 33 to 92), and at 20 years 37% (95% CI 6 to 70). Blue lines indicate the CIs.
At follow-up, the mean mMdA was 15.8 (14 to 18), mean mHHS was 71.7 (40.5 to 97), mean HOOS was 72.3 (45.6 to 99.4), mean UCLA was 5.2 (3 to 7), and mean WOMAC was 68.6 (43.8 to 100).
There were no surgery-related complications including infection, nerve or vascular injuries, or trochanteric nonunion. In addition, no medical complications such as thromboembolic disease were documented. Of the five patients where plugs were taken at the knee, none complained of donor site pain.
The mean defect size of the femoral head, as measured intraoperatively, was 3.9 cm2 (1.2 to 8.3). In two patients whose underlying diagnosis was FAI, an additional full-thickness cartilaginous defect of the superolateral acetabulum was identified measuring 1.1 and 2.4 cm2, respectively. To reconstruct the articular surface, between three and 11 grafts were transferred with diameters of 5.50, 6.40, or 7.45 mm. Grafts were taken from the ipsilateral knee when more than three plugs were needed for repair, as well as in one patient with PD in order to avoid harming the open proximal femoral growth plate. Once the plugs were placed, a mean 1.6 cm2 (0.7 to 4.2) of articular surface was reconstructed, corresponding to 51% (12% to 82%) of the area of the initial defect (Table II).
Table II.
Defect size, number, and diameter of the osteochondral grafts.
| Patient | Defect area, mm2 | Total area replaced | Number of grafts with corresponding diameters and surface areas | Total number | Donor site | |||
|---|---|---|---|---|---|---|---|---|
| mm2 | % | D = 7.45 mm A = 43.6 mm2 |
D = 6.40 mm A = 32.2 mm2 |
D = 5.50 mm A = 23.8 mm2 |
||||
| 1 | 236 | 161 | 68 | 5 | 5 | Knee | ||
| 2 | 141 | 97 | 68 | 3 | 3 | Hip | ||
| 3 | 825 | 97 | 12 | 3 | 3 | Hip | ||
| 4 | 491 | 193 | 39 | 6 | 6 | Knee | ||
| 5 | 825 | 420 | 51 | 8 | 3 | 11 | Knee | |
| 6 | 491 | 71 | 15 | 3 | 3 | Knee | ||
| 7 | 188 | 131 | 69 | 3 | 3 | Hip | ||
| 8 | 314 | 97 | 31 | 3 | 3 | Hip | ||
| 9 | 118 | 97 | 82 | 3 | 3 | Hip | ||
| 10 | 353 | 290 | 82 | 9 | 9 | Knee | ||
| 11 | 346 | 131 | 38 | 3 | 3 | Hip | ||
| Total | 14 | 32 | 6 | 52 | 5 Knee | |||
| 6 Hip | ||||||||
-
A, surface area of graft; D, diameter of graft.
At follow-up, two of the five patients who had not been converted to THA reported poor hip function, discomfort in activities of daily living, and pain. One of these patients presented more than 24 years after the index operation and demonstrated severe radiological osteoarthritis. The second patient, presenting 9.3 years the index operation, had been diagnosed with systemic lupus erythematosus. This patient demonstrated AVN of the opposite hip and bilateral AVN of the femoral condyles (Figure 3). One patient, who presented at eight years of age with PD and an osteochondral defect, was treated with OAT and triple pelvic osteotomy. This patient developed secondary FAI and underwent a second surgical hip dislocation 7.5 years after the index procedure. At 24.8 years’ follow-up (Figure 4), this patient presented with an excellent result. In addition, two patients showed radiological osteoarthritis > Tönnis grade I, and one patient demonstrated Brooker class II heterotopic ossification.
Fig. 3
a) Preoperative coronal MRI of a 22-year-old female patient with lupus erythematosus presenting with stage IIB avascular necrosis of the femoral head. b) Intraoperative view showing the stabilization of the necrotic area with careful implantation of three hip-to-hip transplants.
Fig. 4
a) Eight-year-old male patient with Perthes’ disease. Coronal MRI indicating the extent of the necrosis as well as a slight lateral extrusion of the femoral head. b) Intraoperative view showing the stabilization of the necrotic area with three osteochondral autografts taken from the ipsilateral knee joint. c) Anteroposterior pelvis views of the same patient at last follow-up, 24.7 years after the index procedure, shows a clinical and radiologically normal right hip joint.
Discussion
In our series of 11 patients, six (55%) underwent conversion to a THA at a mean of 10.3 years after the index OAT surgery. The five patients who maintained their native hips were evaluated at a mean of 18.5 years. Survivorship at ten years was calculated to be 62.3% dropping down to 37.4% at 20 years. Follow-up mean outcome scores revealed mMdA to be good (15.8), mHHS to be fair (71.7), HOOS was 72.3, UCLA was 5.2, and WOMAC was 68.8.
For patients undergoing conversion to THA, we identified major risk factors as AVN stage III or greater, or additional cartilaginous lesions of the acetabulum. Two patients with AVN stage III were converted to THA at 9.2 and 9.7 years, respectively. Two patients with FAI and concomitant cartilage defects of the superolateral acetabulum underwent conversion to THA at 1.1 and 9.1 years, respectively. Two of three patients having traumatic damage to the femoral head were converted to THA at 15.7 and 17.3 years. Given the small size and heterogeneity of our series, as well as a lack of a matched comparison group, we cannot definitively conclude that these represent the most important risk factors.
Conversion to THA was necessary in three (60%) of the five patients whose plugs were harvested from the ipsilateral knee. By contrast, two (33%) out of the six patient whose plugs were harvested from the inferior femoral head were converted to THA. This may underline the importance of restoring a perfect congruity of the joint. When harvesting the grafts from the knee, some plugs have to be taken at different angles with regard to the cartilaginous surface, making graft orientation and perfect reconstruction of the femoral head more difficult (Figure 5).
Fig. 5
A 29-year-old male patient with stage IIA avascular necrosis of the femoral head treated with osteochondral auto- or allograft transfer (OAT). The grafts were taken from the ipsilateral knee joint. In knee-to-hip transfer, perfect reconstruction is difficult to obtain from a technical perspective. The intraoperative view shows an incongruous femoral head surface due to incorrect placement of two grafts (arrows). At 23.8 years’ follow-up, this patient had not undergone conversion to THA.
Only a few papers show a medium-term follow-up of patients treated with OAT. Many authors report experience with one or two cases and follow-ups of between one and eight years.3,5,6,8-10–12-15,19-24,39 They are few reports of follow-up on OAT procedures having more than two patients. Rittmeister et al40 reported disappointing results in patients treated with mosaicplasty for AVN of the femoral head, with four out of five patients requiring a prosthesis at an average of 49 months postoperatively. Girard et al1 analyzed the short-term clinical and radiological findings in a series of ten patients with a mean follow-up of 29 months. At the latest follow-up, the HHS was 79.5 points and the UCLA score was 5.8. There was no reported conversion to THA. Gagala et al7 described a series of seven patients with AVN IIA or B treated with OAT: at a mean follow-up of 46 months, the patients had a HHS of 87.85 points. One conversion to THA was performed at 18 months postoperatively. In a second group of 13 patients (14 hips) with AVN ARCO IIC, III, or IV, OAT was combined with allogenic bone graft. Five patients underwent conversion to THA secondary to head collapse between seven and 12 months following the index procedure. Kosashvili et al16 reported on a series of eight patients with a mean follow-up of 41 months; one hip was converted to THA. Johnson et al22 reported on a series of five patients with 4.5 years’ follow-up, a mean HHS of 86.6, and no conversion to THA. Sonnega et al41 performed OAT arthroscopically in four patients with no conversion to THA, though follow-up in this series was limited. Viamont-Guerra et al42 described the results of 27 patients operated through a Hueter approach. At 39 months’ mean follow-up, only one hip was converted to THA. More detailed data of case reports and case series are shown in Table III and Table IV.
Table III.
Review of the literature: case reports.
| Author | Year | Cases | Approach | Donor site | Plugs | Defect size | Follow-up, mths | Conversion to THA |
|---|---|---|---|---|---|---|---|---|
| Hart et al5 | 2003 | 1 | KL-Flip | Knee | 4 | 14 mm | 60 | NR |
| Weisz39 | 2006 | 1 | KL-Flip | Knee | 3 | 10 × 33 mm | 48 | 0 |
| Sotereanos et al20 | 2008 | 1 | KL-Flip | Hip | 3 | 15 mm | 66 | 0 |
| Evans and Providence15 | 2010 | 1 | KL-Flip | Allograft | 1 | 25 × 25 mm | 12 | 0 |
| Nam et al3 | 2010 | 1 | KL-Flip | Knee | 3 | 20 × 8 mm | 12 | 0 |
| 1 | KL-Flip | Hip | 1 | 10 mm | 60 | 0 | ||
| Krych et al6 | 2012 | 2 | KL-Flip | Knee | 20 × 8 mm 20 × 20 mm |
51 | 0 | |
| Kilicoglu et al8 | 2015 | 1 | KL-Flip | Knee | 3/2 | NR | 96 | 0 |
| Kubo et al9 | 2015 | 1 | Arthroscopy | Knee | 1 | 8.5 mm | NR | NR |
| Anthonissen et al10 | 2016 | 1 | KL-Flip | Knee | 4 | 5 cm2 | 24 | 0 |
| Won et al21 | 2016 | 1 | KL-Flip | Hip | 1 | 10 × 25 mm | 12 | 0 |
| Kocedal et al11 | 2017 | 1 | Arthroscopy | Knee | 1 | 10 mm | 26 | 0 |
| Kong12 | 2017 | 1 | KL-Flip | Knee and Hip | 4 1 |
NR | 19 | 0 |
| Uchida et al13 | 2017 | 2 | Arthroscopy | Knee | 1 | 8.5 mm 10 mm |
36 12 |
0 0 |
| Jamali et al17 | 2019 | 1 | KL-Flip | Allograft | 3 | 25 × 25 mm | 12 | 1 |
| Moreau et al18 | 2019 | 1 | KL-Flip | Allograft | 1 | 35 × 32 mm | 96 | 0 |
| Garcia-Mansilla et al19 | 2020 | 1 | KL-Flip | Allograft | 1 | 18 × 24 mm | 6 | 0 |
| Kaymaz et al23 | 2020 | 1 | KL-Flip | Hip | 6 | 20 × 30 mm | 18 | 0 |
| Coulomb et al14 | 2021 | 1 | Hueter | Knee | 3 | 20 × 30 mm | 12 | 0 |
| Palazón-Quevedo et al24 | 2021 | 2 | KL-Flip | Hip | 3 | 20 × 8 mm | 48 60 |
0 0 |
-
KL-Flip, Kocher-Langenbeck approach with trochanteric flip osteotomy; NR, not reported; THA, total hip arthroplasty.
Table IV.
Review of the literature: case series.
| Author | Year | Cases | Approach | Donor site | Plugs | Defect size | Follow-up, mths | Conversion to THA |
|---|---|---|---|---|---|---|---|---|
| Rittmeister40 | 2005 | 5 | Hueter | 1 × knee, 4 × hip | 1 to 3 | 14 to 90 mm | 57 | 4 (mean 49 mths) |
| Girard1 | 2011 | 10 | KL-Flip | Hip | NR | 4.8 (3 to 9) cm2 | 29 | 0 |
| Gagala7 | 2013 | 7 | KL-Flip | Knee | 3 to 5 | NR | 46 | 1 |
| 14 | KL-Flip | Knee + bone graft | 3 to 5 | NR | 33 | 5 | ||
| Kosashvili16 | 2013 | 8 | KL-Flip | Allograft | 1 | NR | 41 | 1 |
| Johnson22 | 2017 | 5 | KL-Flip | Hip | 1 × 1 4 × 3 |
10 to 40 mm | 54 | 0 |
| Sonnega41 | 2019 | 4 | Arthroscopy | Knee | 1 | 8 mm | NR | 0 |
| Viamont-Guerra42 | 2019 | 27 | Hueter | Hip | 1 to 8 | 1.6 (0.8 to 4) cm2 | 39 | 1 |
| Own study | 2022 | 11 | KL-Flip SP |
Knee or hip | 3 to 11 knee-hip 6 × 3 hip-hip |
3.9 (1.2 to 8.3) cm2 | 168 | 6 |
-
KL-Flip, Kocher-Langenbeck approach with trochanteric flip osteotomy; NR, not reported; SP, Smith-Petersen; THA, total hip arthroplasty.
Our study has some limitations: first, it represents a retrospective study with no control group, and therefore level IV evidence. Second, the different and varied underlying pathologies, in the context of a small number of participants, limit the ability to propose strong conclusions. Third, most patients in this series had additional interventions to OAT related to the different underlying pathologies (e.g. ORIF, PAO). Strengths of our study is the long follow-up, no loss of patients, and a single surgeon’s series of patients.
To summarize, OAT is intented to reconstruct damaged articular surface with a layer of hyaline cartilage, and has been established as a reasonable technique for articular surface repair in the knee and the ankle joint. In the hip joint, the procedure is feasible but technically demanding. This study represents one of the longest follow-ups of a series of osteochondral autografts of the femoral head. Although the majority of hips underwent conversion to THA during the long follow-up, over half of the patients survived more than ten years. While a larger series or a similar matched cohort would be necessary for definitive confirmation, we believe OAT is a safe option across a variety of underlying pathologies, and may delay the need for THA conversion.
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Author contributions
C. Passaplan: Conceptualization, Methodology, Investigation, Formal analysis, Writing – original draft.
M. Hanauer: Investigation, Formal analysis, Writing – review & editing.
L. Gautier: Formal analysis.
V. M. Stetzelberger: Formal analysis.
J. M. Schwab: Formal analysis, Supervision, Writing – review & editing.
M. Tannast: Formal analysis, Supervision, Writing – review & editing.
E. Gautier: Conceptualization, Methodology, Investigation, Formal analysis, Supervision, Writing – review & editing.
Funding statement
The authors disclose receipt of the following financial or material support for the research, authorship, and/or publication of this article: this work has been supported by the Ortho Trauma Foundation and the HFR Research Fund.
ICMJE COI statement
M. Tannast reports institutional research support grants from Fribourg Hospital HFR, and consulting fees from DePuy Synthes, unrelated to this study.
Data sharing
All data generated or analyzed during this study are included in the published article and/or in the supplementary material.
Ethical review statement
The Regional Ethical Committee for Medical and Health Research approved this study (Project-ID: CER-VD 2021-01008), and written informed consent was obtained from all the participants.
Open access funding
The open access fee for this study was provided by institutional research support grants from Fribourg Hospital HFR.
© 2023 Author(s) et al. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives (CC BY-NC-ND 4.0) licence, which permits the copying and redistribution of the work only, and provided the original author and source are credited. See https://creativecommons.org/licenses/by-nc-nd/4.0/
