Fresh osteochondral allografting for steroid-associated osteonecrosis of the femoral condyles

Abstract

Background: Osteonecrosis is a complication of corticosteroid therapy with limited treatment options in young, active patients. These options include debridement, core decompression, osteotomy, allografting, and partial or total knee replacement. Few studies exist regarding the use of osteochondral allografts for treatment of steroid-associated osteonecrosis.

Questions/purposes: We asked if fresh osteochondral allografts would (1) heal to host bone in the presence of osteonecrosis, (2) provide a clinically meaningful decrease in pain and improvement in function, and (3) prevent or postpone the need for prosthetic arthroplasty.

Patients and methods: Twenty-two patients (28 knees) who underwent osteochondral allografting for high-grade, corticosteroid-associated osteonecrosis were evaluated. Their average age was 24.3 years (range, 16-44 years). The mean graft surface area was 10.8 cm(2) (range, 5.0-19.0 cm(2)). Evaluation included a modified (for the knee) D'Aubigné and Postel (18-point) score, International Knee Documentation Committee (IKDC), and Knee Society function scores. The minimum followup was 25 months (mean, 67 months; range, 25-235 months).

Results: Five knees failed. The graft survival rate was 89% (25 of 28). The mean D'Aubigné and Postel score improved from 11.3 to 15.8; 19 of 25 (76%) had a score greater than 15. The mean IKDC pain score improved from 7.1 to 2.0, mean IKDC function score from 3.5 to 8.3, and mean Knee Society function score from 60.0 to 85.7.

Conclusions: Our data suggest osteochondral allografting is a reasonable salvage option for osteonecrosis of the femoral condyles. TKA was avoided in 27 of the 28 of knees at last followup.

Level of evidence: Level IV, case series. See Guidelines for Authors for a complete description of levels of evidence.

Fig. 1

A posteroanterior, 45° flexion (Rosenberg) view radiograph demonstrating steroid-associated osteonecrosis of the left lateral femoral condyle in a 44-year-old woman.

Fig. 2

An intraoperative photograph shows the donor condyle with ink markings outlining dimensions of the planned shell allograft.

Fig. 3

A lateral view of the prepared shell allograft shows the thickness of the compound graft aimed at restoring subchondral bone loss secondary to osteonecrosis.

Fig. 4

A photograph shows a comparison view of the shell allograft (left) and removed pathologic recipient osteoarticular segment (right).

Fig. 5

An intraoperative photograph of the osteochondral allograft in situ in anatomic position after fixation with five bioabsorbable chondral darts shows restoration of the weightbearing portion of the lateral femoral condyle.

Fig. 6

An intraoperative photograph shows a reconstruction of the medial femoral condyle using two plug-type allografts.

Fig. 7

A Rosenberg view radiograph taken 3 months postoperatively, of the same patient as in Fig. 1, shows ongoing osseointegration of the osseous graft portion and restoration of the left lateral femoral condyle articular surface.