Archived Policies - Surgery


Osteochondral Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions

Number:SUR705.020

Effective Date:01-01-2005

End Date:08-14-2007

Coverage:

Osteochondral Autografting or Allografting, by MosaicPlasty, Autograft Transfer System, or any Allografting system, using one or more cores of osteochondral tissue, is considered experimental, investigational or unproven as a technique to repair focal chondral defects (such as the hip, patella, fibula, tibia, and ankle).

Description:

Focal chondral defects of the knee, due to trauma or other conditions such as osteochondritis dissecans, often fail to heal on their own and may be associated with pain, loss of function, disability, and the long-term complication of osteoarthritis.  The ideal resurfacing technique would eliminate the symptoms, restore normal biomechanics of the knee joint, and prevent the long-term emergence of osteoarthritis and the necessity for total knee replacement.  Various methods of cartilage resurfacing have been investigated including marrow-stimulation techniques, such as subchondral drilling, microfracture, and abrasion arthroplasty, all of which are considered standard therapies and all of which attempt to restore the articular surface by inducing the growth of fibrocartilage into the chondral defect. 

The use of both fresh and cryopreserved allogeneic osteochondral grafts has been encouraging.  Cryopreservation decreases the viability of cartilage cells and fresh allografts may be difficult to obtain.  There are concerns regarding infectious diseases when using allografts (from a donor other than the recipient).  For these reasons, autologous (one's own tissue from one location to another) grafts have been under investigation as an option to increase the survival rate of the grafted cartilage and to eliminate the risk of disease transmission.  Autografts have been limited by the small number of donor sites.   Single grafts have been harvested from the patella, femoral condyle, and proximal part of the fibula.  In an effort extend the amount of available donor tissue, investigators have used multiple, small osteochondral cores harvested from various non-weight-bearing sites of the knee.  These two separate procedures are Osteochondral MosaicPlasty and Osteochondral Autograft Transfer System (OATS). 

In the MosaicPlasty procedure, the chondral lesion is excised, and abrasion arthroplasty is performed to refresh the bone base of the defect.  Multiple individual osteochondral cores are harvested from the donor site, typically from a peripheral non-weight-bearing area of the femoral condyle.  The grafts are press fit into the lesion in a mosaic-like fashion within the same-sized drilled recipient tunnels.  The resultant surface consists of transplanted hyaline cartilage and fibrocartilage arising from the abrasion arthroplasty.  The fibrocartilage is thought to provide ‘grouting’ between the individual autografts.  MosaicPlasty may be performed with either an open approach or arthroscopically if the lesion is small and not more than four to six grafts are needed.

The OATS procedure focuses on chondral defects that are associated with chronic tears of the anterior cruciate ligament (ACL), using an arthroscopic approach that can provide access to both the ACL for reconstruction and performance of the autograft.  OATS has been used to treat lesions which are 2 centimeters or less in diameter.  A newer OATS approach to large defects (20 millimeters to 35 millimeters) in the weight-bearing zone has been introduced as “Mega-OATS”. Earlier graft placement was secured with screw fixation; however, later fixation was secured as a press fit of the core plugs, eliminating the secondary hardware removal.  Generally, Mega-OATS remains a salvage procedure.

Although MosaicPlasty and OATS may use different instrumentation, the underlying principle to obtain the autografts is the same and to transfer the cartilage or bone plugs from one area to another damaged area.  The resurfacing concept is similar to a hair transplant. Clinical studies have begun by using osteochondral grafts to repair chondral defects of the hip, patella, tibia, and ankle.

Autologous Chondrocyte Transplantation (ACT) is discussed in a separate policy SUR703.021.

Rationale:

The available evidence consists of single institution case series focusing on chondral lesions of the knee using osteochondral autografts.  The case series includes heterogeneous populations of patients, some of whom are undergoing treatment for additional abnormalities, such as ligament or meniscal repair, and chondral defect may only be identified incidentally.  Therefore, it is not known whether improvement in symptoms can be attributed to the osteochondral autografting or to other components of the surgery.  In addition, no studies compare the results of osteochondral autografting with other established therapies, such as lavage or various marrow-stimulation techniques, including microfracture, subchondral drilling, or abrasion arthroplasty.  Given these limitations, the follow data have been reported.

Hangody, the principal investigator of the MosaicPlasty technique, has authored several different summaries and case series.  Since it is likely that these reports contain overlapping populations of patients, only the most recent report with any detail on patient outcomes is reviewed here.  In a 1997 article, Hangody and colleagues refer to a 1992-1994 comparison study of MosaicPlasty and abrasion arthroplasty.  No details of this study are provided, except to note that the MosaicPlasty patients had significantly improved Hospital for Special Surgery (HSS) knee scores, compare to those undergoing abrasion arthroplasty.  Since that time, the authors have abandoned abrasion arthroplasties.  In a 1998 article, Hangody and colleagues reported that a total of 227 patients had been treated with MosaicPlasty, with at least a 3-year follow-up in 57 patients, 39 of whom underwent additional procedures, such as anterior cruciate ligament repair or meniscal resection.  The mean age at the time of surgery was 31.4 years.  An average of eight grafts was used in creating the Mosaicplasty.  Second-look arthroscopy was performed on 19 patients at 12 weeks to five years post-surgery.  In 12 of the 19 cases, the transplanted cartilage was examined histologically, which demonstrated hyaline cartilage.  Visual inspection of the remaining transplanted cartilage revealed smooth, solid surfaces in all but three cases.  Although the patients’ subjective responses were evaluated with the HSS knee scores, the article does not report how these scores changed before and after the procedure.  A prior study from the same group of investigators reported that the donor sites consisted of fibrocartilage. 

Bobic, the principal investigator of the OATS procedure, published a case series of 12 patients who underwent the procedure at the same time of an ACL repair.  Nine of these patients underwent arthroscopy after one year.  The graft sites had normal shiny appearance, although they had a raised contour.  Other patient outcomes were not reported.

In summary, the available scientific literature published in the peer-reviewed literature is inadequate to evaluate the effectiveness and durability of either the MosaicPlasty or OATS procedures.  While randomized clinical trials focusing on treatment options for chondral defects is admittedly difficult to conduct, the available case series are both small in number, contain heterogenous patients and lack complete follow up to permit conclusions.  There is also no long-term follow-up regarding potential morbidity related to multiple donor sites.

A search of the literature was performed for the period of 2001 through September 2004.  No additional articles were identified that would alter the above conclusions; therefore, the policy statement is unchanged.  Additional case series were identified that focused on osteochondral autografting for the knee and talus (ankle), but the data are inadequate to permit scientific conclusions.  Horas and colleagues reported a study of 40 patients, with an articular lesion of the femoral condyle, who were randomly assigned to undergo either autologous chondrocyte transplantation or osteochondral autografting.  The authors reported that both treatments resulted in a decrease in symptoms, although those in the osteochondral autografting group responded more quickly.  As noted by the authors, interpretation of the results of this study is limited by the lack of a control group.  The autologous chondrocyte transplantation literature also mentions this issue.

Another 2004 study group reported donor-site morbidity after the OATS procedure.  Two patients were studied and both had fibrocartilage hypertrophy at the donor sites that contributed to knee pain and occasional locking.  Additional arthroscopic surgery was required to trim the fibrocartilage regrowth.  One anecdotal article, published in 2000, reported loose bodies from the donor site as a complication after the osteochondral autograft for the treatment of osteochondritis dissecans.  Additional arthroscopic procedures were completed to repair the osteochondral defect with autogenous bone grafting. 

An additional search of the literature was performed, focusing on the use of allografts.  While osteochondral allografts may be used in patient with large chondral defects, frequently as a result of trauma, no published literature was identified in which osteochondral allografts were used arthroscopically to resurface focal chondral defects. 

Thus osteochondral autografting or allografting by the OATS procedure or MosaicPlasty is not supported by the evidence in the peer-reviewed medical literature that demonstrates an improvement in net health outcome through use of the OATS procedure or MosaicPlasty or demonstrates that the OATS procedure or MosaicPlasty is as beneficial as established alternatives.

Contract:

Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply. If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

Coding:

This service should not be confused with ACT; however, providers may use 29866 when billing ACT.  Therefore, the claim should be reviewed when 29866 is billed.


Medicare Coverage:

Medicare does not have a national position on this service. It is subject to local carrier discretion. Please refer to the local carrier for more information.

References:

Bobic, V. Arthroscopic osteochondral autograft transplantation in anterior cruciate ligament reconstruction: A preliminary clinical study. Knee Surgery, Sports Traumatology, Arthroscopy (4): 262-4.

Hangody, L., Kish, G., et. al. Arthroscopic autogenous osteochondral mosaicplasty for the treatment of femoral condylar articular defects. A preliminary report. Knee Surgery, Sports Traumatology, Arthroscopy (1997) 5 (4); 262-7.

Hangody, L., Kish, G., et. al. Treatment of osteochondritis dissecans of the talus: Use of the mosaicplasty technique – a preliminary report. Foot Ankle International (1997 October) 18 (10): 628-34.

Hangody, L., Kish, G., et. al. MosaicPlasty for the treatment of articular cartilage defects: Application in clinical practice (see comments). Orthopedics (1998 July) 21(7): 751-6.

Fitzpatrick P.L. and D.A. Morgan. Fresh osteochondral allografts: A 6-10 year review. Australian and New Zealand Journal of Surgery. (1998 August) 68 (8): 573-9.

Attmanspacher, W., Dittrich, V., et. al. Experiences with arthroscopic therapy of chondral and osteochondral defects of the knee joint with OATS (Osteochondral Autograft Transfer System). (Published in German). Zentralblatt Fur Chirurgie (2000) 125 (6): 494-9.

Horas, U., Schnettler, R., et. al. Osteochondral transplantation versus autogenous chondrocyte transplantation. A prospective comparative clinical study. (Article in German). Chirug (2000 September) 71 (9): 1090-7.

Kim, S.J. and S.J. Shin. Loose bodies after arthroscopic osteochondral autograft in osteochondral dissecans of the knee. (2000 October) 16 (7): E16.

Cain, E.L. and W.G. Clancy. Treatment algorithm for osteochondral injuries of the knee. Clinical Sports Medicine (2001 April) 20 (2): 321-42.

Matsusue, Y., Kotake, T., et. al. Arthroscopic osteochondral autograft transplantation for chondral lesion of the tibial plateau of the knee. Arthroscopy (2001 July) 17 (6): 653-9.

Osteochondral Autografts in the Treatment of Articular Cartilage Lesions. Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (2001 August 15) Surgery 7.01.78.

Burkart, A.C., Schoettle, P.B., et. al. Surgical therapeutic possibilities of cartilage damage. Unfallchirug (2001 September) 104 (9): 798-807.

The Morgan Kalman Clinic – Morgan, Craig D., Osteochondral Autograft Transfer (OAT) – (Chondral Resurfacing) 2001. Arthroscopy Association of North America (12 October 2001) <http://www.aana.org/concepts/articles/ostauto_morgan.html>.

Gautier, E., Kolker, D., et. al. Treatment of cartilage defects of the talus by autologous osteochondral grafts. Journal of Bone and Joint Surgery – British Volume. (2002 March) 84 (2): 237-44.

Wang, C.J. Treatment of focal articular cartilage lesions of the knee with autogenous osteochondral grafts: A 2- to 4-year follow-up study. Archives of Orthopaedic and Traumatic Surgery (2002 April) 122 (3): 169-72.

Agneskirchner, J.D., Brucker, P., et. al. Large osteochondral defects of the femoral condyle: Press-fit transplantation of the posterior femoral condyle (MEGA-OATS). Knee Surgery, Sports Traumatology, Arthroscopy (2002 May) 10 (3): 160-8.

Al-Shaikh, R.A., Chou, L.B., et. al. Autologous osteochondral grafting for talar cartilage defects. Foot and Ankle International (2002 May) 23 (5): 381-9.

Brucker, P., Agneskirchner, J.D., et. al. Mega-OATS (Published in German). Unfallchirurg (2002 May) 105 (5): 443-9.

Jakob, R.P., Franz, T., et. al. Autologous osteochondral grafting in the knee: Indication, results, and reflections. Clinical Orthopaedics and Related Research. (2002 August) (401): 170-84.

Osteochondral Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions. Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (2003 January) Surgery 7.01.78.

Horas, U., Pelinkovic, D., et. al. Autologous chondrocyte implantation and osteochondral cylinder transplantation in cartilage repair of the knee joint.  A prospective comparative trial. Journal of Bone and Joint Surgery – American Volume (2003 February) 85-A (2): 185-92.

Ueblacker, P., Burkart, A., et. al. Retrograde cartilage transplantation on the proximal and distal tibias. Arthroscopy (2004 January) 20 (1): 73-8.

LaPrade, R.F. and J.C. Botker. Donor-site morbidity after osteochondral autograft transfer procedures. Arthroscopy (2004 September) 20 (7): e69-73.

Policy History:

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