CHA P T E R 55

Osteochondral Autograft for

Cartilage Lesions of the Knee
R. David Rabalais, MD
Kenneth G. Swan, Jr., MD
Eric McCarty, MD
Articular cartilage is arguably the most precious body Typical History
tissue to the orthopedic surgeon and his or her patients. ● Age of the patient may vary from adolescence to
Be it orthopedic trauma or sports medicine, the manage- middle age
ment goal is often similar: restoration or maintenance of
● Intermittent pain
the articular cartilage. Isolated cartilage defects can occur
secondary to acute trauma or be atraumatic in nature. The ● Pain elicited by low- or high-impact activities

atraumatic defect is often in the form of osteochondritis (tibiofemoral disease) or stair climbing and prolonged
dissecans, the etiology of which is not fully understood, sitting (patellofemoral disease)
and can be found in juveniles or adults. The distinction ● Recurrent swelling
here is important because patients with open physes have ● Frequently a history of acute or distant trauma,
a much better prognosis with nonoperative treatment.5 including patellar dislocation
Patients with symptomatic focal cartilage defects
● Mechanical symptoms common
are candidates for operative treatment to relieve symp-
toms and also potentially to prevent subsequent arthritic
changes.15 Of the treatment possibilities available, none of
which is ideal, osteochondral autograft transplant surgery
may be the best option in appropriately selected cases.
Physical Examination
Several different transplant systems are available, but the
concept remains the same: the transplantation of full- Typical Findings
thickness osteochondral bone plugs from an area of the ● Effusion
knee that is non–weight bearing or with low contact pres- ● Relatively preserved range of motion
sures to the osteochondral defect of the ipsilateral knee.
● Joint line tenderness (±)

● Patellar instability, apprehension (±)

Preoperative Considerations
Factors Affecting Surgical Planning
History
● Limb malalignment (may compromise repair, require

Patients with focal osteochondral lesions typically present realignment procedure)

with pain and swelling that is intermittent in nature. The ● Concomitant ligamentous injury (may require prior or

history may mimic that of meniscal disease. concomitant reconstruction)

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 Surgical Techniques of the Articular Cartilage
Imaging
Radiography
● Standard anteroposterior and lateral knee views
● Sunrise patellofemoral view to visualize patellar and
trochlear lesions
● Notch view may be best to visualize lateral aspect of
medial femoral condyle (typical location of
osteochondritis dissecans)17
● Mechanical axis view if malalignment is suspected
Other Modalities
● Magnetic resonance imaging is necessary to best
evaluate location and size of articular cartilage lesions.
It is also important for evaluation of menisci,
ligaments, and the remainder of the articular cartilage.
● Bone scans, computed tomography, and tomography
are not as useful as magnetic resonance imaging for
evaluation of osteochondritis dissecans lesions and the
remainder of the knee.
● Contrast arthrography (intra-articular or intravenous)
may prove to be more sensitive than magnetic
resonance imaging alone, which can have a high false-
negative rate.23
● Arthroscopy remains the “gold standard” for evaluation
of articular cartilage lesions.
Indications and Contraindications
Indications
The indications for osteochondral autograft transplant
surgery are narrow. The patient generally has a small, iso-
lated lesion in an otherwise healthy knee. However, con-
comitant ligament, meniscus, or alignment disease may be
present and can be addressed simultaneously or with a
staged procedure.
Typically, during concomitant procedures, the
surgeon performs autologous osteochondral grafting and
anterior cruciate ligament reconstruction or high tibial
osteotomy. During anterior cruciate ligament reconstruc-
tion, the osteochondral grafting should proceed after
meniscal or cartilage disease is addressed and notchplasty
has been performed but before anterior cruciate ligament
graft fixation. Similarly, the osteochondral grafting should
be done before the high tibial osteotomy is performed.
If the procedures are staged, the osteochondral grafting
surgery should be done first.
We prefer to use single-plug autograft transplants on
defects 1 cm2 in diameter or smaller; allograft transplants
are used for larger defects. However, some authors perform
autograft transplantation on defects as large as 4 cm2, with
good results8 with use of multiple plugs.
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ch055-X3447.indd 540
Contraindications
● Generalized arthritis
● Inflammatory arthritis
● Lesions >1 cm for single plugs
2
● Lesion >3 cm for multiple plugs
2
● Uncorrected malalignment or knee instability
Surgical Planning
Osteochondral defects are frequently diagnosed in the
office after the history, physical examination, and interpre-
tation of radiographs and magnetic resonance imaging
scans. The patient and surgeon might then plan for single-
stage surgery with arthroscopic examination of the knee
to assess the defect. If it is applicable, autograft transplan-
tation with single or multiple plugs can be performed. The
number and size of osteochondral plugs required cannot
be determined until the defect is thoroughly examined by
arthroscopy. Defects that are discovered to be excessively
large may require allograft transplantation, which must be
anticipated and planned for. This is typically performed as
a second procedure.
At times, osteochondritis dissecans lesions are not
appreciated preoperatively and are discovered during
routine knee arthroscopy. The morbidity of the procedure
and its rehabilitation process are different from those of a
standard knee arthroscopy. These patients usually require
a second procedure for definitive treatment at a later date
unless the surgeon and patient have discussed this possi-
bility preoperatively.
Surgical Technique
Short Surgical Steps
The short surgical steps for osteochondral autograft trans-
fer are listed in Box 55-1.
Expanded Surgical Technique
Three different systems are commercially available in the
United States. All three are similar but differ in the avail-
able graft sizes and minor variations of technique. This is
shown in Table 55-1. An example of the necessary equip-
ment is shown in Figure 55-1.
Positioning
The patient is placed in the supine position with a lateral
post, and a sandbag is taped to the bed to facilitate a fixed
10/17/2007 2:49:52 PM

90-degree flexion of the knee. The surgeon should be able
to flex the knee to 120 degrees with ease. A sliding footstep
may be used to allow different angles of knee flexion. Alter-
natively, an arthroscopic leg holder may be used per the
surgeon’s preference. We typically do not drop the foot of
the bed. A tourniquet is applied but not elevated, and the
operative site is prepared and draped. The tourniquet may
be inflated if arthroscopic visualization becomes difficult
from intra-articular bleeding.
Arthroscopy
The surgeon performs a diagnostic arthroscopy of the
knee. Portal sites can be varied to maximize perpendicular
access to the donor and recipient sites. This can be per-
formed with spinal needles before the portals are made. A
Box 55-1 Surgical Steps
1. Perform diagnostic arthroscopy to débride and to measure
the defect; plan number, size, and placement of specific
grafts. The remainder of the procedure can be performed as
a mini-open repair, if desired.
2. Place donor harvester perpendicular to donor site and tamp
harvester to required depth. View measurement on outside
of harvester.
3. Disengage graft from local bed. Method for disengagement
of the graft varies with the system.
4. Remove graft donor assembly from knee with autograft plug
and measure depth of plug.
5. Tamp recipient harvester into defect to desired depth (1 to
2 mm deeper than plug). Keep recipient harvesting tools
perpendicular to articular surface.
6. Insert graft under direct visualization through optional clear
tube. Be careful to keep tube on articular surface during
implantation.
7. Remove clear tube and gently seat graft with plastic tamp
until the graft is flush with the articular surface.
Table 55-1 Specific Aspects of the Commercially Available Osteochondral Autograft Systems
System Graft Sizes (Diameter)
Single-use OATS (Arthrex, Inc., 6-, 8-, and 10-mm plugs
Naples, Fla)
COR repair system (DePuy-Mitek, 4-, 6-, and 8-mm plugs
Norwood, Mass)
MosaicPlasty systems (Smith & 2.7-, 3.5-, 4.5-, 6.5-,
Nephew, Inc., Andover, Mass) and 8.5-mm plugs
ch055-X3447.indd 541
Osteochondral Autograft for Cartilage Lesions of the Knee
central patellar tendon portal can provide good access to
the medial surfaces of the medial and lateral femoral con-
dyles.11 The defect site is identified, and loose debris, car-
tilage flaps, and superficial fibrocartilage are removed with
a mechanized resector. A thorough evaluation of the patel-
lofemoral joint is performed with consideration for donor
site grafting ramifications. The knee is carefully inspected
for loose bodies, with examination of the lateral and medial
gutters and posterior medial and lateral recesses.20 Ex-
amination of the condyles in full flexion is performed to
identify any other defects of the weight-bearing surface.
The defect is measured by use of measurement probes or 55
size-specific cannulas that vary with the particular sys-
tem (Fig. 55-2). The surgeon at this time should evaluate
the curvature of the surrounding articular cartilage and
plan the number and size of grafts to be used. We routinely
use an all-arthroscopic technique, but depending on
the defect’s size and the surgeon’s preference, a mini-
arthrotomy (1 to 2 cm) may be used for both harvest and
implantation. We routinely do not inflate the tourniquet
throughout the procedure.
Figure 55-1 Arthrex Osteochondral Autograft Transfer System (OATS).
Specific Technical Differences Comments
Disengagement of graft from bed Must “lever” graft from donor bed
requires 90-degree rotation from
starting position
Disengagement of donor grafts from “Toothed” harvester allows
bed requires two complete turns undercutting of donor graft from
with T-handle donor bed
“Toggle” graft to remove from donor Dilator used in recipient site to
bed compact surrounding bone;
smaller grafts available
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 Surgical Techniques of the Articular Cartilage
A tions to undercut the graft, minimizing leverage against
B diameter of the reamer used should correspond to the
Figure 55-2 A, Femoral condyle defect. B, The 8-mm defect sizer.
Graft Harvesting
Available donor sites include the lateral femoral condyle
above the sulcus terminalis, the peripheral aspect of the
medial femoral condyle, and the lateral superior aspect of
the intercondylar notch. The medial aspect of the medial
femoral condyle can be easier to access during graft harvest
because the intra-articular distention can push the patella
laterally.11 Contact pressures may be lower in donor sites
from the distal medial trochlea.1,7 The central condylar
notch is routinely removed during notchplasty (roofplasty)
in anterior cruciate ligament reconstruction, but the cur-
vature is generally concave and has poorer congruity with
typical recipient sites on the lateral and medial femoral
condyles.3 We routinely use the superior medial aspect of
the medial femoral condyle as a donor site. The largest size
amenable to single-plug harvest is 1 cm2 in diameter, as
discussed before. Multiple plugs should be harvested for
defects between 1 and 3 cm2 in diameter.
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ch055-X3447.indd 542
Each system has a T-handle instrument that must be
assembled at the back table and varies with the graft diam-
eter that is to be used. This donor harvester is then inserted
into the knee perpendicular to the articular surface and
held firmly against the cartilage during the extraction.
Holding the donor harvester firmly against the surface
ensures that a cylindrical (not “crooked”) graft is harvested
and helps prevent loss of the graft in the joint during
extraction. The donor harvester is impacted with a mallet
to the desired depth of penetration, usually 15 mm. The
different systems then recommend different techniques to
extract the graft from the surrounding bed. The Osteo-
chondral Autograft Transfer System (OATS) employs a
90-degree rotation both clockwise and counterclockwise
from the starting position. The COR system has a “tooth”
at the distal aspect of the harvester; when the desired
depth is achieved, the T-handle is rotated two full revolu-
the native bone. The MosaicPlasty system recommends
“gentle toggling” to break the deep subchondral bone
before graft removal (Fig. 55-3).
Measure the graft length after removal to plan defect
drilling. This is performed either through reference lines
on the exterior of a clear sheath holding the graft or by
placing the graft on the back table in a moist sponge,
depending on the system used. Reinsertion of the plunger
into the donor site defect can also assist with measurement
of the depth (Fig. 55-4).
Recipient Site Preparation
At this point, the surgeon should have a clear plan for
number of grafts, placement of specific graft plugs, and
depth of each plug. The knee can now be further flexed if
needed to ensure perpendicular drilling of the defect. The
diameter of the graft taken. The appropriately sized reamer
can now be used to drill the recipient hole. Each recipient
hole should be separated from adjacent holes with at least
a 1- to 2-mm bridge. The depth of each recipient hole
should be 1 to 2 mm deeper than the measured plug. This
reduces resultant force during impaction24 and can mini-
mize intraosseous pressure. The MosaicPlasty system rec-
ommends dilation of the recipient hole before insertion.
All loose cartilage and bone fragments can be safely
removed with a small curet (Fig. 55-5).
Graft Implantation
At this time, the graft should be in the delivery tube. The
delivery tube is seated perpendicular to the reamed hole
of matching size and held firmly against the surface. Graft
implantation is achieved by gentle tapping of the impactor
(plunger) with a mallet. The use of excessive force and
large blows should be avoided.24 Once the graft is almost
fully seated and stable in the hole, the delivery tube is
removed (Fig. 55-6). Care should be taken not to shear off
the cartilage cap of the graft when the insertion tube is
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 Osteochondral Autograft for Cartilage Lesions of the Knee

55

A B

D
C
Figure 55-3 A and B, Arthroscopic graft harvest from the medial aspect of the medial femoral condyle by the donor harvester. C, Harvest performed through a
mini-arthrotomy. D, Donor site after harvest as seen arthroscopically.

Figure 55-4 The 8 × 15-mm osteochondral plug within the 8-mm harvester.

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 Surgical Techniques of the Articular Cartilage
B
A
C
D
Figure 55-5 The osteochondral recipient site is prepared to appropriate depth by use of the recipient harvester through an arthroscopic (A) or mini-open
(B) technique. C, A graduated alignment rod refines the depth and angle of the recipient site, in this case through an open technique. D, Recipient site as
seen arthroscopically.
removed.20 Gentle impaction with a plastic rod or impac-
tor is performed until the surface of the graft is flush with
the level of surrounding articular cartilage. The graft
should not be left proud. This can result in increased
contact pressures25 or increased gap formation at the
graft-tunnel junction with perigraft fissuring, fibroplasia,
and subchondral cavitations.19 If the graft is accidentally
impacted deeper than the surrounding surface, the
surgeon may drill an adjacent small recipient hole and
elevate the graft with an arthroscopic probe to the desired
level.11
Large Defects
Several pitfalls are encountered in addressing large defects.
First, achieving good surface congruity is more difficult.
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ch055-X3447.indd 544
The surgeon should ream recipient sites perpendicular to
the surface in the central areas while increasing obliquity
10 to 15 degrees inward toward the periphery.20 In addi-
tion, care must also be taken not to violate adjacent recipi-
ent holes during reaming. The sequence of graft harvest,
reaming, and implantation should be performed for each
individual hole in a step-by-step manner until the defect
is covered.11 The spacing of 1 to 2 mm between grafts in
the recipient site should be similar to the spacing of grafts
in smaller defects. The surgeon should not obtain all grafts
and then ream all recipient holes.
Wound Closure
The knee is cleared of all debris and irrigated. Standard
wound closure is performed over suction drains.
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 Osteochondral Autograft for Cartilage Lesions of the Knee

55

A B

C D
Figure 55-6 The graft-delivery tube is placed over the donor harvester (A), and the osteochondral plug is delivered into the recipient socket through a mini-
arthrotomy (B) or arthroscopic (C) technique. The osteochondral plug is made flush with the native chondral surface (D).

PEARLS AND PITFALLS ● The surgeon may choose for the patient to avoid nonsteroidal
anti-inflammatory drugs so as not to diminish the healing
Pearls response.

● Full-length alignment films should be considered in all patients. Pitfalls

● Guide pin insertion at the recipient site must be in a perpendicular ● Malalignment must be corrected before or during the OATS procedure;
fashion and in the center of the lesion. The donor graft must be otherwise, the OATS outcome will be suboptimal.
harvested in the same perpendicular plane.
● Mismatch positioning between recipient and donor will risk early failure
● The recipient bed should be drilled with a small 1.6-mm drill bit to of the graft.
enhance the vascular healing response.
● Plan minimal drilling to avoid fracture of subchondral bone.
● Bone edges of the donor plug should be rounded (“bulletized”) with a
● Noncontoured plug may be difficult to insert and require excessive force
rongeur to aid insertion.
on chondrocytes during impaction.
● The donor site may be left as is or “backfilled” with one of several
● Backfilling of the donor defect can potentially result in a source
marketed biosynthetic scaffold materials. Alternatively, the recipient
of additional symptoms or a loose body if it is not done
defect may be plugged back into the donor site and then fixed into
appropriately.
place

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 Surgical Techniques of the Articular Cartilage
Postoperative Considerations
● The patient is observed in postoperative recovery.
● Drains are removed before discharge.
● The operative dressing is changed at 48 hours.
● Perioperative antibiotics are instituted at the surgeon’s
preference.
● Continuous passive motion is begun on the first
postoperative day.
Complications
● Infection
● Hematoma formation
● Poor motion
● Thromboembolic events
● Reflex sympathetic dystrophy
● Loose body formation
● Dislodgement or loosening of the graft
● Donor site morbidity
● Progression of osteoarthritis
● Continued symptoms from the affected region
Rehabilitation
● Non–weight bearing is maintained for 6 weeks.
● Toe-touch weight bearing is continued until 8 to 12
weeks to ensure full graft maturation.
● Continuous passive motion is prescribed for 4 to 6
weeks, 4 hours per day.
● Active and passive range of motion is instituted as the
patient can tolerate motion.
● High-impact activities are avoided until 16 to 20
weeks.
Results
The results in the literature are generally good for patients
with small defects. The results in the literature are difficult
to interpret because of differences in operative technique,
defect size, and donor site location. In addition, the major-
ity of published reports are less than optimal in that they
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ch055-X3447.indd 546
are of level IV evidence. Results are summarized in Table
55-2. Three of the more significant studies are described
here.
Hangody and Fules10 reported the most extensive
experience in the literature, with 831 patients with auto-
logous osteochondral transplantation (mosaicplasty) at
10 years, with 92% good to excellent results for femoral
condyle implantations. The results significantly decreased
for tibial plateau defects (87%) and patella-trochlea defects
(79%); donor site disturbances were identified in 3% of the
patients.
Horas et al12 reported a prospective, randomized
study comparing 40 patients who underwent either autol-
ogous chondrocyte implantation (20) or OATS (20) for
lesions 3.2 to 5.6 cm2 at 2 years of follow-up. The postop-
erative Lysholm scores were lower at 6, 12, and 24 months
in the autologous chondrocyte–implantation group; the
Meyers and Tegner scoring systems were equal in the two
groups at 24 months.
Gudas et al8 published a prospective randomized
study comparing arthroscopic mosaic osteochondral autol-
ogous transplantation (28) with microfracture (29) in 57
femoral condyle lesions smaller than 4 cm2 at 37.1 months.
The authors reported 96% good to excellent results in the
osteochondral autologous transplantation group compared
with 52% for the microfracture group with the Hospital
for Special Surgery and International Cartilage Repair
Society scoring systems.
Conclusion
There are several options for the orthopedic surgeon in
addressing the patient with a focal cartilage defect of
the knee. Osteochondral autografting with either single
or multiple plugs provides the surgeon with a viable
solution to the defect smaller than 3 cm2. Single plugs
are appropriate for defects smaller than 1 cm2, whereas
multiple plugs are appropriate for defects smaller
than 3 cm2. This technique can be used in combination
with other knee procedures, such as anterior cruciate
ligament reconstruction and high tibial osteotomy.
The procedure is straightforward and supported by
the published literature to be as good as if not superior
to other techniques, such as microfracture and autologous
chondrocyte implantation, for defects in this size range.
Further research must be explored to better define its
place in cartilage restoration surgery. We recommend that
the articular cartilage surgeon become familiar with all
available techniques to provide the best care to the
patient.
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 Osteochondral Autograft for Cartilage Lesions of the Knee

Table 55-2 Brief Overview of Results of OATS in the Literature

Author Number Follow-up Results Scoring Type of Study Level of

System Evidence

Hangody and 831 10 years 92% good–excellent Bandi Case series IV

Fules10 (2003) (femoral condyles) Mosaicplasty

Horas et al12 40 (20 OATS 24 months Lysholm lower at 6, 12, Lysholm Prospective, randomized II
(2003) vs. 20 ACI) 24 months for ACI Tegner OATS (multiple plugs) vs.
Tegner equal at 24 ACI
months

Gudas et al8
(2005)
57 (28 OATS
vs. 29
37.1 months 96% good–excellent
with OATS
HSS
ICRS
Prospective, randomized
OATS (multiple plugs) vs.
II
55
microfracture) 52% good–excellent microfracture
with microfracture

Chow et al6 30 45.1 months 83% good–excellent, Lysholm Case series IV

(2004) Lysholm IKDC Multiple plugs
87% “normal knee,”
IKDC

Koualis et al13 18 27.2 months 12 “normal” ICRS Case series IV

(2004) 6 “near normal” Mosaicplasty

Andres et al2 19 (22 knees) 24 months 88% of mosaicplasty WOMAC Comparative case series III
(2003) with osteoarthritis SF-36 Mosaicplasty in
“improved” VAS osteoarthritis

Outerbridge 16 (18 knees) 7.6 years 83% good Cincinnati Case series with patella IV
et al18 (2000) donor graft, single graft

Laprell and 29 8.1 years 26/29 “normal” or ICRS Case series (one or IV
Petersen14 “nearly normal” two plugs)
(2001)

Ma et al16 18 42 months 89% good–excellent Lysholm Case series (multiple plugs) IV

(2004) Tegner

Bobic4 (1996) 10 2 years “Promising results” Case series IV

OATS (multiple plugs) + ACL
reconstruction

Sharpe et al22 13 3 years 10/13 with “significant KSS Case series IV

(2005) improvement” OATS (multiple plugs) + ACI

Sanders et al21 21 22 months Maximum signal Case series of magnetic IV

(2001) intensity of grafts resonance imaging
at 4-6 weeks results, multiple plugs

ACI, autologous chondrocyte implantation; ACL, anterior cruciate ligament; HSS, Hospital for Special Surgery; ICRS, International Cartilage Repair Society;
IKDC, International Knee Documentation Committee; KSS, Knee Society Score; SF-36, short form 36 health survey; VAS, visual analogue scale; WOMAC,
Western Ontario and McMaster Universities Osteoarthritis Index.

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