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Mosaicplasty
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Mosaicplasty

Untreated joint (articular) cartilage defects can eventually lead to degeneration of the joint and disability, in terms of joint function. Several cartilage repair techniques exist for the treatment of cartilage defects.

Among these, mosaicplasty was introduced into clinical practice in 1992, and it is based on the mosaic-like transplantation of several small, cylindrical plugs of bone and cartilage, known as ‘osteochondral grafts’, to provide an even resurfaced area.

Intended audience

This article is intended for anyone suffering from damage to their articular cartilage and their families who would like to find out about mosaicplasty, as well as anyone interested in cartilage problems.

What is Mosaicplasty?

Mosaicplasty is a technique in which cartilage (‘chondral’) lesions and bone and cartilage (‘osteochondral’) lesions are repaired by harvesting and transplanting cylindrical plugs of bone and cartilage. In the knee, these plugs are taken from less weight-bearing areas, termed ‘donor sites’, and inserted into drilled tunnels in the defective section of the cartilage.

The transplanted hyaline cartilage is capable of surviving and produces a more durable surface than the fibrous repair tissue that would have formed if the defective cartilage had been left to heal on its own.

Repair of the donor site occurs via natural healing processes. The tunnels become filled with cancellous bone and the surface is covered with fibrocartilage built by marrow-derived cells.

Implanting the grafts in a mosaic-like fashion allows the effective management of small and medium-sized localised, or ‘focal’, defects. Clinical experience shows that the majority of focal defects belong to this category. Mosaicplasty ensures good results in most cases, and the findings of experimental arthroscopies and laboratory assessments confirm what have been seen clinically in patients underoging the procedure.

The development of the mosaicplasty technique began at the beginning of 1990s, and the first clinical application was in February 1992. During the subsequent years, clinical data have been reported by various authors, confirming the results seen in animal models. Since 1995, the procedure has been used with similar success in several institutions all over the world.

Small-sized, single focal lesions of the femoral condyles are the main indication for mosaicplasty procedures; however, defects on the tibial, patellar and trochlear surfaces can be also treated by osteochondral grafting. Besides osteochondral defects of the knee, a frequent indication for mosaicplasty is lesions of the talus.

The availability of donor sites and certain technical considerations limit the optimal size of defect that can be successfully covered to 1–4 cm2. Due to a decreased capacity for repair, 50 years of age is the recommended upper age limit for mosaicplasty.

Mosaicplasty is not recommended if osteoarthritis or rheumatoid arthritis is present, or lesions caused by infection or tumours. This is because the survival of the transplanted hyaline cartilage on the recipient site is hindered by these conditions.

Figures

Mosaicplasty

What are the advantages and disadvantages of Mosaicplasty?

What are the advantages of Mosaicplasty?

The main advantage of mosaicplasty is that it helps to improve the patient’s quality of life by eliminating the complaints caused by osteochondral/chondral lesions. Another advantage is that it delays further deterioration of the condition.

During the procedure, the patients’ own bone and cartilage is used to resurface the lesion; allergic or immunological reactions cannot therefore be expected following mosaicplasty.

Microfracture could be an alternative technique for the treatment of these lesions, but it covers the defect area with fibrocartilage, which has poor biomechanical properties and clinical outcomes. In contrast, mosaicplasty aims to provide hyaline or hyaline-like cartilage.

What are the disadvantages of Mosaicplasty?

General complications that are common following lower limb surgery such as septic or thromboembolic complications can be prevented by strict aseptic conditions, single-shot antibiotics and drugs to prevent thrombosis.

Surgery-specific complications can include problems following removal of the cartilage at the donor site, such as patellofemoral complaints, pain or swelling following strenuous physical activity. These are not frequent complications – a study on mosaicplasty with 17 years of follow-up showed that less than 3% of all operated cases had long-term donor site morbidity.

Excessive postoperative bleeding from the donor tunnels is also a potential postoperative complication, and can occur in 7%–8% of the cases. Postoperative drainage, application of ice packs and elastic bandages can reduce the frequency of this complication.

Frequently Asked Questions (FAQs)

When can I return to work/sport/daily activities?

The final goal of rehabilitation is to allow the patients’ return to all daily and sporting activities. It takes approximately 4–5 months to form a composite hyaline-like surface over the transplanted area that is able to tolerate shear forces.

Returning to sports activities depends on the depth and extent of the defect, and the state of the neuromuscular system. If the patients’ strength, power, endurance, balance and flexibility are not sufficient, sports activity should be postponed.

It should be noted that mosaicplasty is usually combined with the treatment of other joint problems, such as reconstruction of a ligament, corrective bone removal (osteotomy), meniscus removal (meniscectomy), or suture/replacement of a torn meniscus. Treatment of accompanying pathologies requires a special adaption of the rehabilitation protocol in most cases, and can change and extend the time periods indicated above.

How long before I can start walking again?

Walking with two crutches without weight-bearing can be started immediately. Walking with two crutches and partial loading (typically starting with 25% of your body weight) can usually start after 2–4 weeks, and full weight-bearing without crutches can resume after 3–5 weeks. However, your surgeon will decide on your weight bearing status based on your pathology and treatment.

How long will I be in hospital?

This is typically an outpatient procedure and you will go home the same day.

What will happen to the holes in my knee where the grafts were taken from?

The donor holes will go through the body’s natural healing processes: eventually the tunnels will be filled with bone and the surface will be covered by fibrocartilage tissue.

Could the surgery be avoided or delayed?

Cartilage repair is not an urgent surgery. It can certainly be delayed, and patients have the choice not to have any surgical treatment at all. It must be noted, however, that these lesions have a very poor ability to regenerate and, without surgery, the condition will get worse, causing more complaints.

Further reading
  • Hangody L, Feczkó P, Kemény D et al. Autologous osteochondral mosaicplasty for the treatment of full thickness cartilage defects of the knee and ankle. Clinical Orthopaedics 2001, 391: October, Suppl. 328-337.
  • Hangody L, Dobos J, Balo E, Panics G, Hangody LR, Berkes I. Clinical experiences with autologous osteochondral mosaicplasty in an athletic population: a 17-year prospective multicenter study. American Journal of Sports Medicine 2010, 38:(6) pp. 1125-1133.
  • Hangody L, Füles P. Autologous osteochondral mosaicplasty for the treatment of full thickness defects of weight bearing joints – 10 years experimental and clinical experiences. J Bone Joint Surg. 2003, 85-A: Supplement(2):25-32.
Untreated joint (articular) cartilage…
ICRShttps://cartilage.org/content/uploads/icrs.jpg
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