Name: Clinical Support for Fresh OCA Use in the Knee
Uploaded: 2025-05-21T00:00:00Z
Channel: Arthrex
Description: William D. Bugbee, MD (San Diego, CA), discusses the role of fresh osteochondral allograft use in the knee and reviews the abundant clinical studies supporting the technique from the past 30 years.

Knee

<p>William D. Bugbee, MD (San Diego, CA), discusses the role of fresh osteochondral allograft use in the knee and reviews the abundant clinical studies supporting the technique from the past 30 years.</p>

Not Hidden

English  - en

video

VID1-004126-en-US | A | Clinical Support for Fresh OCA Use in the Knee

William D. Bugbee, MD

Human

Surgeons presenting one or more clinical cases

Chirurg:innen präsentieren einen oder mehrere klinische Fälle

Videos von Fallpräsentationen

Case Presentation Videos

Cirurgiões que apresentam um ou mais casos clínicos.

Vídeos apresentações de casos

Cirujanos que presentan uno o más casos clínicos.

Video presentaciones de casos

Clinical Support for Fresh OCA Use in the Knee

Hello, I'm doctor William Bugbee. I'm the chief of joint reconstruction and joint preservation at Scripps Clinic in La Jolla, California. Today, I'd like to talk to you about fresh osteochondral grafting, what's new, and what you should know. I've been performing allograft procedures for over 25 years and saw my first graft in about 1983, so I have a great experience and I hope that I can share that with you today. There's an evolving landscape of osteochondral allograft transplantation. It has become increasingly popular and very useful for both salvage and complex conditions and very simple conditions. First line treatment for large and small lesions allografts are available. They're versatile, simple and reliable, and the clinical data shows that over many years utilized with confidence in an athletic population as well, which is really important. Today's public, the OSI proposition still makes sense. Originally, we realized this was a good procedure because it involved intact, mature hyaline cartilage, which bypassed the complexity of tissue regeneration with challenging precursors and cells such as chondrocytes and stem cells. What it basically involves is a bone healing paradigm, which is a very fundamental biologic paradigm and well understood process by surgeons and patients alike. Osteochondral repair also aligns with the increasing understanding of the functional osteochondral unit in health and disease. The one other issue that comes up quite a bit now is the safety of allograft tissue. Over the number of decades, there's been little or no safety concerns, and immunology concerns, which are theoretical and scientifically interesting, have remained manageable and clinically insignificant. The diaspora of Allografts. As a result of this, all over the world, there are procedures and programs worldwide, not just in North America. And there's been a remarkable innovation in techniques with reliability and reproducibility of surgical procedures due to innovations in instrumentation, and there's been an increase in allograft based cartilage repair products in the public domain. Technical aspects of allograft surgery are complex, but most allografts are performed with simple plugs. There's an argument of whether you should use thin or thick plugs, and my preference is a thin plug that's no more than seven millimetres thick. There are ways to do what we call a snowman two plugs together, or a so-called biani that's an oval or oblong graft that can fit a more complex type of lesion. Additionally, we've shown that using lateral femoral condyle grafts to medial to help with the availability seems to be okay up to 20mm in size. And there are technical ways to perform patellofemoral joint resurfacing in complex surfaces. Fresh OCA tissue is important to understand where this comes from. Recovery process and storing is evolving. We have tissue banks that are validated procedures. The demand is much more than the availability, but timely access to graph tissue is important. Nowadays, a surgeon can actually schedule a case and be relatively sure that a graph will be there for that case. This allows for logistics to be improved with scheduling cases. We are working diligently to improve the quality of stored graphs. There are also available off the shelf pre-cut OCA plugs up to about 15 or 16mm, and an actual allograft for almost any joint surface is available as a specialty graft. From our experience in over a thousand of these. There are no significant safety concerns when you get a graft from an experienced graft processor and supplier. The grafting in the United States tissue banking. You don't need to know a lot about this, but you have to know because you're putting a living tissue into your patient. We've worked long and hard to make this safe and reliable. And what you know now, and what our current models show, is that within 28 days, I'm. I'm happy with the viability and quality of a graft tissue. Many researchers are looking at extended storage, but right now I don't think that's clinically relevant. But it may be so in the future. So let's pivot to indications for osteochondral grafting in the knee. I have my favorites by far and away my favorite indications. Osteochondritis dissecans a bone and cartilage disease focal defect that's truly amenable to grafting. Additionally, focal traumatic cartilage defects, degenerative cartilage lesions, osteonecrosis, spontaneous osteonecrosis, and another one of my favorites fracture malunion such as tibial plateau fracture, where I think people should be careful but I still utilize graphs in treating osteoarthritis. I would use this in a young patient, but it is not a reliable procedure in a middle aged patient with osteoarthritis. Additionally, surgeons should know that grafting are a workhorse for cartilage repair for failed previous cartilage surgeries. So I would say allografts can be used for small lesions, and I wouldn't waste time with low yield techniques that just delay the appropriate treatment. So in summary, my favorite indications were osteochondritis dissecans in any joint actually, but particularly in the knee tibial plateau, mal unions and those rare cases and isolated trochlear lesions. So what about other joints? We focus on the knee because that's where primarily grafting is used. But there's quite a bit of ways to use allografts in the ankle for osteochondral lesions even, and post-traumatic arthritis. Certain indications in the shoulder, such as reverse hill-sachs lesions, AVN and Glenoid deficiency in the elbow. Again, osteochondritis dissecans very few indications in the hip. They're just not that many isolated lesions that don't include dysplasia or advanced arthritis. So that would be similarly a fracture osteonecrosis and the rare case of osteochondritis dissecans. So my favorites after the knee would be the ankle osteochondral lesion and humeral head defects. Clinical results have been published by many authors and many locations. There's a large volume of scientific work. Unfortunately, there are no level one studies because it is very difficult to do a level one study without grafting. The takeaways really are this results depend on patient age and diagnosis. For focal defects, they are. The results are not sensitive to the size of the lesion or remarkably, previous surgery which is unlike ACI, microfracture or other treatments. The ideal cartilage repair patient has an excellent result. So these are some of the papers we have reported on that show. Just this. We don't think it matters what size the lesion is. And if you do it as an initial first line rather than a second line, it doesn't seem to matter. But again, do the right operation the first time in my opinion. My best experience with grafting is in this perfect patient. These patients are rare in the cartilage world, but someone under 30 with a focal defect and of the femoral condyle and trochlea, or a lesion size is less than eight square centimeters. And these patients are. Results are spectacular and may be better than any other cartilage repair procedure. 99% survivorship and over 93% patient satisfaction. But we also have to talk about the other end of the spectrum. What shouldn't you do with an allograft. So my worst experience over time is trying to treat arthritis in middle aged patients with cartilage restoration and joint preservation. So a word of caution patients really want to avoid joint replacement. But sometimes doing an allograft procedure or any joint preservation procedure in a middle aged patient who's on the arthritis scale probably shouldn't be done. And there's a lot of reasons for this. There's just these people have probably got genetic predisposition and allograft like other cartilage surgeries, is not going to change the natural history or the disease of the joint, it's only going to repair the damaged tissue. This table summarizes what we know from analyzing over 1000 fresh allografts in the knee. As I mentioned earlier, age, diagnosis, and lesion size are important, but this gives a numeric value to this. If you have a older patient with osteoarthritis, their risk of failure from grafting is five times. That would be for a young person with osteochondritis dissecans. This doesn't mean you shouldn't do it, but this means you should do allografts in some of these other diagnoses, or large lesions, or older patients carefully and with a shared decision making with your patient. This summarizes a relationship between the clinical outcome of allografts in people with osteoarthritis versus the traditional arthroplasty or osteotomy techniques. And this shows in a 30 to 50 year old population total, and partial knee replacement still has a higher clinical effect than grafting. And this is why I use allografts in middle aged arthritic patients. Rarely there are problems with allografts, not just with the disease of arthritis. We still have a limited supply with a limited shelf life, but we're working hard to fix that. When you see failure, it usually means subchondral, bone cyst and failure of the bone healing. But you can also see graft delamination. Clinically, progression of disease is quite common. The technical aspects of complex surfaces and difficult to access anatomic locations are clinically relevant for the surgeon, such as the tibial plateau or trochlea become intimidating when access or geography makes it more challenging. But please stay tuned. There's lots of innovation and new ideas. So my take home message is that allografts work well, and if you keep it simple and do the right procedure and the right patient, it works brilliantly.