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Autologous Osteochondral
Mosaicplasty
Surgical Technique
By Lszl Hangody, MD, PhD, DSc, Gbor K. Rthonyi, MD, Zsfia Duska,
Gbor Vsrhelyi, MD, Pter Fles, MD, and Lszl Mdis, MD, PhD, DSc
Investigation performed at Uzsoki Hospital, Orthopaedic and Trauma Department, Budapest, Hungary
The original scientific article in which the surgical technique was presented was published in JBJS Vol. 85-A, Suppl. 2, pp. 25-32, 2003

INTRODUCTION
The treatment of full-thickness cartilage defects of the articular surfaces of weight-bearing joints is a frequent problem in orthopaedic
practice. Previous experimental and clinical experience with autogenous osteochondral grafting has demonstrated that the transplanted
hyaline cartilage has had a good rate of survival1-4.
It seemed to us that the use of small-sized multiple cylindrical
grafts would permit more tissue to be transplanted while preserving
the integrity of the donor site and that the implantation of grafts in a
mosaic-like fashion would allow progressive contouring of the new
surface5-7.

ABSTRACT
BACKGROUND:
The successful treatment of chondral and osteochondral defects of
the weight-bearing surfaces is a
challenge for orthopaedic surgeons. Autologous osteochondral
transplantation is one method
that can be used to create hyaline
or hyaline-like repair in the defect
area. This paper describes the
results after ten years of clinical
experience with autologous osteochondral mosaicplasty.
METHODS:
Clinical scores, imaging techniques, arthroscopy, histological
examination of biopsy samples,
and cartilage stiffness measurements were used to evaluate the
clinical outcomes and quality of
the transplanted cartilage in 831
patients undergoing mosaicplasty.

FIG. 1
Miniarthrotomy mosaicplasty. The donor-site area is reached by extending the knee.

RESULTS:
According to these investigations, good-to-excellent results
were achieved in 92% of the
patients treated with femoral
condylar implantations, 87% of
those treated with tibial resurfacing, 79% of those treated
with patellar and/or trochlear
continued


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ABSTRACT | continued
mosaicplasties, and 94% of
those treated with talar procedures. Long-term donor-site disturbances, assessed with use of
the Bandi score, showed that
patients had 3% morbidity after
mosaicplasty. Sixty-nine of eightythree patients who were followed
arthroscopically showed congruent gliding surfaces, histological
evidence of the survival of the
transplanted hyaline cartilage,
and fibrocartilage filling of the
donor sites. Complications of the
surgery included four deep infections and thirty-six painful postoperative hemarthroses.

CONCLUSIONS:
On the basis of these promising
results and those of other similar
studies, autologous osteochondral mosaicplasty appears to be
an alternative for the treatment
of small and medium-sized focal
chondral and osteochondral defects of the weight-bearing surfaces of the knee and other
weight-bearing synovial joints.

SURGICAL TECHNIQUE
Autologous osteochondral mosaicplasty involves obtaining smallsized cylindrical osteochondral
grafts (2.7, 3.5, 4.5, 6.5, and 8.5
mm in diameter) from the minimal weight-bearing periphery of
the femoral condyles at the level
of the patellofemoral joint and
transplanting them to prepared
defect sites on the weight-bearing
surfaces. Combinations of different graft sizes allow a 90% to
100% defect-filling rate. Fibrocartilage grouting, stimulated by
abrasion arthroplasty or sharp

FIG. 2
Miniarthrotomy mosaicplasty. The recipient area is reached by flexing the knee.

curettage at the base of the defect,

is expected to complete the new
surface.
Autologous osteochondral
mosaicplasty can be done as an
open procedure, through a mini-

arthrotomy (Figs. 1 and 2), or arthroscopically. The technique of

these surgical procedures is similar. There are only small technical differences at certain steps of
each operation.

FIG. 3-B
Figs. 3-A and 3-B Illustration (Fig. 3-A) and arthroscopic image (Fig. 3-B) showing the use of
a spinal needle to determine perpendicular access to the defect.
FIG. 3-A


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good access can be gained to the medial surfaces

of both the medial and lateral femoral condyles.
After the defect is identified, its edges are
dbrided to healthy hyaline cartilage with curettes,
a knife blade, or an arthroscopic resector blade. The
base of the lesion is abraded or curetted down to
viable subchondral bone (Figs. 4-A and 4-B). At

FIG. 4-A
Abrasion arthroplasty of the osseous base of the defect and
planning of the ideal filling with use of the drill-guide.

Arthroscopic Technique
Cartilaginous lesions are defined only at arthroscopy.
If the preoperative differential diagnosis includes
such a lesion, the patient should be advised of the
possibility of a mosaicplasty. The patient should be
prepared for an open procedure, as the site may be
inaccessible because of its location posteriorly or because of an inability to flex the knee sufficiently. General or regional anesthesia with tourniquet control is
recommended for this procedure, and prophylactic
antibiotics are used. The patient is positioned supine
with the knee free to flex to 120. The contralateral
extremity is placed in a stirrup.
Portal selection is crucial to gain perpendicular access to the defect site. With use of a spinal
needle, perpendicular access through a working
portal should be checked. Note that these apertures
should be placed more medially than usual to follow the curvature of the femoral condyle (Figs. 3-A
and 3-B). Osteochondritis dissecans of the medial
femoral condyle should be accessed from the lateral
side. With use of a central patellar tendon portal,

FIG. 4-B
Arthroscopic view of the abrasion arthroplasty.

FIG. 4-C
Arthroscopic view of the planning of the ideal filling with use of
a probe.


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CRITICAL CONCEPTS
INDICATIONS:
Focal chondral and osteochondral defects of weight-bearing articular surfaces of the knee
Defects of other diarthrodial
surfaces of the talus, humeral
capitulum, and femoral head
Age of less than fifty years
Diameter of defect ideally between 1 and 4 cm2
Concurrent treatment of instability, malalignment, and meniscal and ligament tears essential
Patient compliance (i.e., compliance with weight-bearing limitation) critical
CONTRAINDICATIONS:
Absolute
Tumor, infection, generalized or
rheumatoid arthritis
Osteoarthritis
Lack of appropriate donor area
Age of greater than fifty years
Defect larger than 8 cm2
Defect deeper than 10 mm
Noncompliant patient

FIG. 5-A
Illustration (Fig. 5-A) and intraoperative images (Fig. 5-B) showing 80%, 90%, and 100%
filling of a defect.

Relative
Age of between forty and fifty
years
Defect between 4 and 8 cm2
Mild osteoarthritic changes
continued

this point, a drill-guide is used to

determine the number of grafts
that are needed. By tapping a
drill-guide down to viable subchondral bone, optimal filling of
the defect can be projected (Fig.
4-C). With use of variable-sized
plugs, the filling rate can be increased from 70% to 90% or
even 100% (Figs. 5-A and 5-B).
During an open procedure,
the peripheral parts of both fem-

FIG. 5-B

oral condyles at the level of the

patellofemoral joint can serve as
donor sites. During the arthroscopic approach, the medial
border of the medial femoral
condyle is recommended as a
primary donor site because distension pushes the patella laterally, allowing perpendicular
access to the medial femoral
condyle. If necessary, the lateral
border can be used as a second-

ary harvest site (Fig. 6). Notch

area grafts are less favorable
as they have a concave hyaline
surface and less elastic subchondral bone.
A standard contralateral
portal is optimal for viewing
the harvest site in a perpendicular axis. The knee should be extended in a stepwise fashion to
access the superior donor sites.
The lower anatomical limit of


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FIG. 6
The graft is harvested by toggling the
harvesting chisel. The recommended
donor-site locations are shaded.

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CRITICAL CONCEPTS | continued

PITFALLS:
Perpendicular graft harvest and
implantation is essential to
achieve an even surface on the
host area. Nonperpendicular
harvest and insertion may result in step-offs on the surface.
Close monitoring with use of
the arthroscope and varied
viewing angles helps to avoid
such problems.
Graft sinkage below the host
surface should be avoided.
Regular use of the delivery
tamp can help to avoid insertion of the grafts too deeply. If
the graft has been inserted too
deeply, the following steps are
recommended. First, insert the
drill-guide next to the toodeeply implanted graft. Second, drill an appropriate recipient hole. Third, remove the
guide and use the arthroscopic
probe to elevate the previously
implanted graft to the proper
level through the recipient hole
adjacent to the implanted graft
(Fig. 15). As soon as the appropriate graft level has been
achieved, continue the recommended sequence for the further insertions.
The larger the defect, the higher
the rate of donor-site morbidity
and the greater the difficulty of
forming a congruent surface.

FIG. 7
A, Illustration showing the chisel in situ with the graft inside. The chisel is toggled, without rotation, to free the graft. B, The graft is then removed from the harvesting chisel.

graft harvest is the sulcus terminalis (i.e., the top of the intercondylar notch).
A properly sized tubular
chisel is introduced perpendicular to the donor site (Fig. 6). This
harvester device is then tapped

into the donor site. A depth of 15

mm is usually recommended for
resurfacing of cartilage defects
and a depth of 25 mm is appropriate for osteochondral defects
because, in the latter case, the
grafts should fill the bone loss as

Harvesting grafts for a surface

defect in another joint requires
the opening of an otherwise
healthy knee joint.
Early weight-bearing can cause
the grafts to sink. Therefore,
proper patient selection, regular follow-up, and well-trained
therapists help the patient to
adhere to the postoperative
protocol.


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FIG. 9
Intraoperative (A) and arthroscopic (B) images demonstrating the drilling of the recipient
tunnel.

FIG. 8
Illustration showing drilling of the recipient tunnel (top), dilation of the recipient
tunnel (middle), and insertion of the
graft (bottom).

well. After tapping and then

toggling with no rotation, the
chisel is removed and the graft
is delivered from the harvester
with use of a chisel guard (Fig.
7). It is very important to push
out the graft from the osseous
end to avoid damaging the hyaline cartilage cap.
Insertion of the grafts is
done through the universal
guide. As a first step in the implantation, this guide is tapped
into the osseous base of the defect. The 3-mm-long cutting
edge is introduced into the
osseous base with use of the
shoulder of this device to help
to define a perpendicular access
to that part of the defect. With
the assistance of this universal
guide, a recipient tunnel is created with an appropriately sized
drill-bit (Figs. 8 [top] and 9). A
dilator is then used to create a

FIG. 10
Intraoperative (A) and arthroscopic (B) images demonstrating the dilation of the recipient
tunnel.

FIG. 11
A and B, Arthroscopic images demonstrating the delivery of the graft.

conical-shaped recipient tunnel

for easy insertion of the transplanted graft (Figs. 8 [middle]
and 10). Finally, insertion of the

graft is done with an adjustable

plunger to match the surface of
the graft to the surrounding articular surface (Figs. 8 [bottom]


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and 11). With use of this stepby-step sequence (drilling, dilating, and delivering), all of the
grafts are inserted. Step-by-step
implantation ensures a safe pressfit fixation. In unconfined or
marginal lesions, the grafts are
implanted in a perpendicular
fashion. When all of the holes
are filled, the knee is put through
a range of motion with varus
and valgus stress to seat the
grafts fully and to ensure their
press-fit stability (Fig. 12).
The portals are closed, and
the joint is drained through a
superior portal. After surgery,
an elastic bandage is used to
diminish bleeding from the donor sites.

FIG. 12
The knee is flexed and extended in a functional test of the resurfaced area.

FIG. 13
Intraoperative photograph, made during open mosaicplasty on the femoral trochlea,
demonstrating an extended approach.

Open Mosaicplasty
Whenever arthroscopy is not
practical, a miniarthrotomy
through a medial or an anterolateral sagittal or oblique incision can be used. An extended
approach is sometimes necessary for tibial or patellotrochlear defects (Fig. 13). The steps
of the procedure are identical
to those of the arthroscopic
method. Mosaicplasty outside
of the knee requires arthroscopic
graft harvest from the knee and
open access to the affected bone
(talus, femoral head, humeral
head, or capitulum) (Fig. 14).
Postoperative Management
Postoperatively, the drain should
be removed at twenty-four hours.
Appropriate pain control as well
as the use of nonsteroidal antiinflammatory drugs can lessen
the patients complaints. Post-


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Gbor Vsrhelyi, MD
Pter Fles, MD
Lszl Mdis, MD, PhD, DSc
Uzsoki Hospital, Orthopaedic and Trauma Department, Mexiki Street 62, 1145 Budapest, Hungary. E-mail address: hangody@axelero.hu
In support of their research or preparation of
this manuscript, one or more of the authors
received grants or outside funding from the
Hungarian Health Ministry. In addition, one or
more of the authors received payments or other
benefits or a commitment or agreement to provide such benefits from a commercial entity (royalty payment after mosaicplasty instrumentation,
Smith and Nephew Endoscopy, Inc., Andover,
Massachusetts). No commercial entity paid or
directed, or agreed to pay or direct, any benefits
to any research fund, foundation, educational
institution, or other charitable or nonprofit
organization with which the authors are affiliated or associated.
The line drawings in this article are the
work of Daniel Mller of Haderer & Mller
(art@ilustracao-biomedica.com).

FIG. 14
Intraoperative photograph made during open mosaicplasty of the femoral head. The harvest site was the ipsilateral knee.

FIG. 15
Elevation of a too-deeply implanted graft.

operative prophylaxis against

thrombosis is recommended.
Postoperative rehabilitation,
in general terms, starts with
immediate unrestricted passive
motion with non-weight-bearing

for two to three weeks followed by

partial weight-bearing for two to
three weeks.
Lszl Hangody, MD, PhD, DSc
Gbor K. Rthonyi, MD
Zsfia Duska

REFERENCES
1. Campanacci M, Cervellati C, Donati U.
Autogenous patella as replacement for a
resected femoral or tibial condyle. A report
of 19 cases. J Bone Joint Surg Br.
1985;67:557-63.
2. Fabbricciani C, Schiavone Panni A,
Delcogliano A, et al. Osteochondral autograft in the treatment of osteochondritis
dissecans of the knee. In: American Orthopaedic Society for Sports Medicine Annual
Meeting, Orlando, Florida; 1994. p 78-9.
3. Outerbridge HK, Outerbridge AR, Outerbridge RE. The use of a lateral patellar autologous graft for the repair of a large
osteochondral defect in the knee. J Bone
Joint Surg Am. 1995;77:65-72.
4. Yamashita F, Sakakida K, Suzu F, Takai S.
The transplantation of an auto-geneic osteochondral fragment for osteochondritis
dissecans of the knee. Clin Orthop.
1985;201:43-50.
5. Hangody L, Karpati Z. [New possibilities
in the management of severe circumscribed cartilage damage in the knee].
Magy Traumatol Ortop Kezseb Plasztikai
Seb. 1994;37:237-43. Hungarian.
6. Hangody L, Kish G, Krpti Z, Udvarhelyi
I, Szigeti I, Bely M. Autogenous osteochondral graft technique for replacing knee
cartilage defects in dogs. Orthopedics.
1997;5:175-81.
7. Hangody L, Feczk P, Bartha L, Bod G,
Kish G. Mosaicplasty for the treatment of
articular defects of the knee and ankle.
Clin Orthop. 2001;391 (Suppl):S328-36.