Key trends on incorporating knee allografts into orthopedic ORs

Question: Fresh osteochondral allografts use increased over the past couple of years. Will the trend continue?

William Bugbee, MD (Scripps Health, La Jolla, Calif.): Yes, because it's proven effective. Once surgeons are comfortable with it they'll realize it's hassle-free. Changing techniques is daunting but the instrumentation and technique for a cartilage transplant is fairly straightforward. The other complaint has been it takes a long time to receive the allograft but these days it takes less than a month.

Brian Cole, MD (Rush University Medical Center, Chicago, Ill.): When we look at the frequency of utilizing osteochondral allografts over the last 10 year for the treatment of symptomatic articular cartilage problems, it has increased dramatically to the point where we are performing nearly 100 transplants each year. Initially, at Rush, we often used cell-based treatment for non-bone defects in younger patients. We were concerned that using an osteochondral allograft would potentially lead to subsequent problems related to the development of a symptomatic osteochondral problem. However, the procedure has become easier, more efficient, and cost-effective with predictably good outcomes. We recently published outcomes in elite athletes with successful results related to return to sports. Among the older age group, fresh osteochondral allografts seem to work as well or better than other joint replacement treatments when the disease is relatively limited.

Q: What factors affect which cartilage therapy you use?

BC: Insurance coverage is highly variable across the country and graft availability can be an issue. In Illinois, we are a procurement state with an active donor program. In states that do not have established donor programs, graft availability can be an issue.

WB: I've been an advocate for allografts for just about any cartilage problem. Now it's becoming clear that allografts are helpful for the worst and most difficult cases, but also effective for the more straightforward procedures.

Q: What challenges do you face when using fresh osteochondral allografts?

WB: There are still some logistical issues getting the patients and allografts ready as soon as possible to preserve the allograft's variability. We look at different ways to store the graft. Getting the patient, graft, and insurance approval can be difficult in some cases, especially for physicians starting out. It takes persistence because you have to write letters and have the patients appeal negative decisions in some cases.

BC: There are some scheduling challenges with donated tissue. Once we obtain the graft, we try to perform the procedure as soon as we can to maintain the fitness of the graft. Insurance reimbursement is rarely a challenge at this point. The trochlea is more challenging to topographically match the graft than the femur. We are working on different ways to prepare the graft for larger defects.

Q: What are the important factors of deciding on which tissue bank to use?

BC: The processes tissue banks follow are reasonably uniform to the best of my knowledge. The FDA has solid regulations for the best practices in cleanliness.

For me, it's about the service. You have to have a very good relationship with the people who touch these grafts from donation time to implantation. There are 25 to 30 people who are in touch with the graft in some way, directly or indirectly, before getting to the patient; if one person fails, you won't have everything you need. You can't take it for granted because things can go awry.

WB: You want a tissue bank with a proven track record of safety and recovery processing and storage protocol that is validated and demonstrates high graft viability.

Q: Why do you think using fresh osteochondral allografts is a good option for your patients?

WB: First and foremost, we have shown through long clinical experience that it's effective. There is a lot of data showing how osteochondral allografts work and when they work, and which patients benefit most. Secondly, the osteochondral allografts are versatile. They handle a large spectrum of issues we see. Thirdly, the rehabilitation is simple and rapid.

BC: It's a good option because now we have 10-year follow-up survivorship data that exceeds 85 percent. Now even elite athletes can return to play after they've been treated with this technology. The fresh osteochondral allograft use in my practice has more than tripled over the past five years. Last year, we were the number one implanter in the country. When you look at all the options, fresh osteochondral allografts are emerging as a dominant strategy.

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