Articular Cartilage Lesions

Damaged articular cartilage can be associated with pain, loss of function, and disability, and can lead to debilitating osteoarthrosis over time. These manifestations can severely impair an individual’s activities of daily living and quality of life. The vast majority of osteochondral lesions occur in the knee with the talar dome and capitulum being the next most frequent sites. The most common locations of lesions are the medial femoral condyle (69%), followed by the weight-bearing portion of the lateral femoral condyle (15%), the patella (5%), and trochlear fossa.^1, Talar lesions are reported to be about 4% of osteochondral lesions.^2,

Treatment

There are 2 main goals of conventional therapy for patients who have significant focal defects of the articular cartilage: symptom relief and articular surface restoration.

First, there are procedures intended primarily to achieve symptomatic relief: débridement (removal of debris and diseased cartilage) and rehabilitation. Second, there are procedures intended to restore the articular surface. Treatments may be targeted to the focal cartilage lesion, and most such treatments induce local bleeding, fibrin clot formation, and resultant fibrocartilage growth. These marrow stimulation procedures include microfracture, abrasion arthroplasty, and drilling, all of which are considered standard therapies.

Microfracture

Microfracture is an arthroscopic procedure in which a small pick creates a network of holes at the base of the articular cartilage lesion, allowing blood into the injured area to form clots and subsequent fibrocartilage growth. Mithoefer et al (2009) examine the efficacy of the microfracture technique for articular cartilage lesions of the knee in a systematic review.^3, Twenty-eight studies (total n=3122 patients) were selected; 6 studies were randomized controlled trials. Microfracture was found to improve knee function in all studies during the first 24 months after the procedure but the reports on durability were conflicting. Solheim et al (2016) reported on a prospective longitudinal study of 110 patients and found that, at a mean of 12 years (range, 10-14 years) after microfracture, 45.5% of patients had poor outcomes, including 43 patients who required additional surgery.^4, The size of the lesion has also been shown to affect outcomes following marrow stimulation procedures.

Abrasion and Drilling

Abrasion and drilling are techniques to remove damaged cartilage. Instead of a drill, high-speed burrs are used in the abrasion procedure.

Fibrocartilage is generally considered to be less durable and mechanically inferior to the original articular cartilage. Thus, various strategies for chondral resurfacing with hyaline cartilage have been investigated. Alternatively, treatments of very extensive and severe cartilage defects may resort to complete replacement of the articular surface either by osteochondral allotransplant or artificial knee replacement.

Osteochondral Grafting

Autologous or allogeneic grafts of osteochondral or chondral tissue have been proposed as treatment alternatives for patients who have clinically significant, symptomatic, focal defects of the articular cartilage. It is hypothesized that the implanted graft’s chondrocytes retain features of hyaline cartilage that is similar in composition and property to the original articulating surface of the joint. If true, the restoration of a hyaline cartilage surface might restore the integrity of the joint surface and promote long-term tissue repair, thereby improving function and delaying or preventing further deterioration.

Both fresh and cryopreserved allogeneic osteochondral grafts have been used with some success. However, cryopreservation decreases the viability of cartilage cells, and fresh allografts may be difficult to obtain and create concerns regarding infectious diseases. As a result, autologous osteochondral grafts have been investigated as an option to increase the survival rate of the grafted cartilage and to eliminate the risk of disease transmission. Autologous grafts are limited by the small number of donor sites; thus, allografts are typically used for larger lesions. In an effort to extend the amount of the available donor tissue, investigators have used multiple, small osteochondral cores harvested from non-weight-bearing sites in the knee for treatment of full-thickness chondral defects. Several systems are available for performing this procedure: the Mosaicplasty System (Smith & Nephew), the OATS (Osteochondral Autograft Transfer System; Arthrex), and the COR and COR2 systems (DePuy Mitek). Although mosaicplasty and autologous osteochondral transplantation may use different instrumentation, the underlying mode of repair is similar (ie, use of multiple osteochondral cores harvested from a non-weight-bearing region of the femoral condyle and autografted into the chondral defect). These terms have been used interchangeably to describe the procedure.

Preparation of the chondral lesion involves débridement and preparation of recipient tunnels. Multiple individual osteochondral cores are harvested from the donor site, typically from a peripheral non-weight-bearing area of the femoral condyle. Donor plugs range from 6 to 10 mm in diameter. The grafts are press fit into the lesion in a mosaic-like fashion into the same-sized tunnels. The resultant surface consists of transplanted hyaline articular cartilage and fibrocartilage, which is thought to provide “grouting” between the individual autografts. Mosaicplasty or autologous osteochondral transplantation may be performed with either an open approach or arthroscopically. Osteochondral autografting has also been investigated as a treatment of unstable osteochondritis dissecans lesions using multiple dowel grafts to secure the fragment. While osteochondral autografting is primarily performed on the femoral condyles of the knee, osteochondral grafts have been used to repair chondral defects of the patella, tibia, and ankle. With osteochondral autografting, the harvesting and transplantation can be performed during the same surgical procedure. Technical limitations of osteochondral autografting are difficulty in restoring concave or convex articular surfaces, the incongruity of articular surfaces that can alter joint contact pressures, short-term fixation strength and load-bearing capacity, donor-site morbidity, and lack of peripheral integration with peripheral chondrocyte death.

Reddy et al (2007) evaluated donor-site morbidity in 11 of 15 patients who had undergone graft harvest from the knee (mean, 2.9 plugs) for treatment of osteochondral lesions of the talus.^5, At an average 47-month follow-up (range, 7-77 months), 5 patients were rated as having an excellent Lysholm Knee Scale score (95-100 points), 2 as good (84-94 points), and 4 as poor (≤64 points). The reported knee problems were instability in daily activities, pain after walking one mile or more, slight limp, and difficulty squatting. Hangody et al (2001) reported that some patients had slight or moderate complaints with physical activity during the first postoperative year but there was no long-term donor-site pain in a series of 36 patients evaluated 2 to 7 years after autologous osteochondral transplantation.^6,

Filling defects with minced or particulated articular cartilage (autologous or allogeneic) is another single-stage procedure being investigated for cartilage repair. The Cartilage Autograft Implantation System (Johnson & Johnson) harvests cartilage and disperses chondrocytes on a scaffold in a single-stage treatment. The Reveille Cartilage Processor (Exactech Biologics) has a high-speed blade and sieve to cut autologous cartilage into small particles for implantation. BioCartilage (Arthrex) consists of a micronized allogeneic cartilage matrix that is intended to provide a scaffold for microfracture. DeNovo NT Graft (Natural Tissue Graft) is produced by ISTO Technologies and distributed by Zimmer. DeNovo NT consists of manually minced cartilage tissue pieces obtained from juvenile allograft donor joints. The tissue fragments are mixed intraoperatively with fibrin glue before implantation in the prepared lesion. It is thought that mincing the tissue helps both with cell migration from the extracellular matrix and with fixation.

A minimally processed osteochondral allograft (Chondrofix; Zimmer) is now available. Chondrofix is composed of decellularized hyaline cartilage and cancellous bone; it can be used “off the shelf” with precut cylinders (7-15 mm). Multiple cylinders may be used to fill a larger defect in a manner similar to autologous osteochondral transplantation or mosaicplasty.

ProChondrix (AlloSource) and Cartiform (Arthrex) are wafer-thin allografts where the bony portion of the allograft is reduced. The discs are laser etched or porated and contain hyaline cartilage with chondrocytes, growth factors, and extracellular matrix proteins. ProChondrix is available in dimensions from 7 to 20 mm and is stored fresh for a maximum of 28 days. Cartiform is cut to the desired size and shape and is stored frozen for a maximum of 2 years. The osteochondral discs are typically inserted after microfracture and secured in place with fibrin glue and/or sutures.

Autologous chondrocyte implantation is another method of cartilage repair involving the harvesting of normal chondrocytes from normal non-weight-bearing articular surfaces, which are then cultured and expanded in vitro and implanted back into the chondral defect. Autologous chondrocyte implantation techniques are discussed in Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions (Policy #013 in the Surgery Section)

Regulatory Status

The U.S. Food and Drug Administration (FDA) regulates human cells and tissues intended for implantation, transplantation, or infusion through the Center for Biologics Evaluation and Research, under Code of Federal Regulation, title 21, parts 1270 and 1271. Osteochondral grafts are included in these regulations.

DeNovo® ET Live Chondral Engineered Tissue Graft (Neocartilage) is marketed by ISTO Technologies outside of the United States. The FDA approved ISTO’s investigational new drug application for Neocartilage in 2006, which allowed ISTO to pursue phase 3 clinical trials of the product in human subjects. However, ISTO’s clinical trial for Neocartilage was terminated due to poor enrollment as of August 31, 2017.

Related Policies

• Meniscal Allografts and Other Meniscal Implants (Policy #023 in the Surgery Section)
• Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions (Policy #013 in the Surgery Section)

a. member is between ages 15 and 55 years;
b. cartilage defect is confirmed by appropriate diagnostic imaging (e.g., MRI, arthroscopic imaging, weight-bearing x-rays);
c. member has had at least 6 months of knee pain that has failed conservative treatment measures (e.g., medications, physical therapy, activity modification, bracing, ice/heat, injections);
d. other cartilage repair techniques (e.g., microfracture, osteochondral autografting or autologous chondrocyte implantation) would be inadequate due to size, location, or depth;
e. member does not have any of the following contraindications:
• presence of synovial disease, inflammation, osteoarthritis, or infection
• history of malignancy or current unresected tumor in the limb
• misalignment and instability of the joint
  (NOTE: correction of underlying joint abnormalities should be done before or at the time of osteochondral allografting.)
• severe obesity (BMI >35 kg/m²).

a. member is between ages 15 and 55 years;
b. cartilage defect is confirmed by appropriate diagnostic imaging (e.g., MRI, arthroscopic imaging, weight-bearing x-rays);
c. documented minimal to absent degenerative changes in the surrounding articular cartilage (Outerbridge grade II or less), and normal-appearing hyaline cartilage surrounding the border of the defect;
d. member has had at least 6 months of knee pain that has failed conservative treatment measures (e.g., medications, physical therapy, activity modification, bracing, ice/heat, injections);
e. member has had inadequate response to a prior arthroscopic or surgical repair procedure (e.g., microfracture);
f. member does not have any of the following contraindications:
• presence of synovial disease, inflammation, osteoarthritis, or infection
• history of malignancy or current unresected tumor in the limb
• misalignment and instability of the joint
  (NOTE: correction of underlying joint abnormalities should be done before or at the time of osteochondral autografting.)
• severe obesity (BMI >35 kg/m²).

Policy Guidelines: (Information to guide medical necessity determination based on the criteria contained within the policy statements above.)

The Outerbridge Classification is the most commonly used classification system to objectively assess chondral and osteochondral injuries of the knee:
Grade 0 = normal cartilage;
Grade I = cartilage with softening and swelling;
Grade II = a partial-thickness defect with fissures on the surface that do not reach subchondral bone or exceed 1.5 cm in diameter;
Grade III = fissuring to the level of subchondral bone in an area with a diameter more than 1.5 cm;
Grade IV = exposed subchondral bone.

Severe obesity (eg, body mass index >35 kg/m²) may affect outcomes due to the increased stress on weight-bearing surfaces of the joint.

Misalignment and instability of the joint are contraindications. Therefore additional procedures, such as repair of ligaments or tendons or creation of an osteotomy for realignment of the joint, may be performed at the same time. In addition, meniscal allograft transplantation may be performed in combination, either concurrently or sequentially, with osteochondral allografting or osteochondral autografting.
________________________________________________________________________________________

Horizon BCBSNJ Medical Policy Development Process:

This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.
___________________________________________________________________________________________________________________________

Index:
Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions
Osteochondral Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions
Mosaicplasty
Osteochondral Autograft Transfer System (OATS)
OATS (Osteochondral Autograft Transfer Procedure)
Osteochondral Allograft
Osteochondral Autograft
CAIS (Cartilage Autograft Implantation System)
Cartilage Autograft Implantation System (CAIS)
Chondrofix
Autologous Minced Cartilage
Allogeneic Minced Cartilage
Minced Cartilage, Autologous or Allogeneic

References:

1. Durur-Subasi I, Durur-Karakaya A, Yildirim OS. Osteochondral Lesions of Major Joints. Eurasian J Med. Jun 2015;47(2):138-144. PMID 26180500

2. Fortin, PP, Balazsy, JJ. Talus fractures: evaluation and treatment.. J Am Acad Orthop Surg, 2001 Apr 3;9(2). PMID 11281635

3. Mithoefer K, McAdams T, Williams RJ, et al. Clinical efficacy of the microfracture technique for articular cartilage repair in the knee: an evidence-based systematic analysis. Am J Sports Med. Oct 2009;37(10):2053-2063. PMID 19251676

4. Solheim E, Hegna J, Inderhaug E, et al. Results at 10-14 years after microfracture treatment of articular cartilage defects in the knee. Knee Surg Sports Traumatol Arthrosc. May 2016;24(5):1587-1593. PMID 25416965

5. Reddy S, Pedowitz DI, Parekh SG, et al. The morbidity associated with osteochondral harvest from asymptomatic knees for the treatment of osteochondral lesions of the talus. Am J Sports Med. Jan 2007;35(1):80-85. PMID 16957009

6. Hangody L, Kish G, Modis L, et al. Mosaicplasty for the treatment of osteochondritis dissecans of the talus: two to seven year results in 36 patients. Foot Ankle Int. Jul 2001;22(7):552-558. PMID 11503979

7. Gracitelli GC, Moraes VY, Franciozi CE, et al. Surgical interventions (microfracture, drilling, mosaicplasty, and allograft transplantation) for treating isolated cartilage defects of the knee in adults. Cochrane Database Syst Rev. Sep 03 2016;9:CD010675. PMID 27590275

8. Magnussen RA, Dunn WR, Carey JL, et al. Treatment of focal articular cartilage defects in the knee: a systematic review. Clin Orthop Relat Res. Apr 2008;466(4):952-962. PMID 18196358

9. Pareek A, Reardon PJ, Macalena JA, et al. Osteochondral autograft transfer versus microfracture in the knee: a meta-analysis of prospective comparative studies at midterm. Arthroscopy. Oct 2016;32(10):2118-2130. PMID 27487736

10. Harris JD, Cavo M, Brophy R, et al. Biological knee reconstruction: a systematic review of combined meniscal allograft transplantation and cartilage repair or restoration. Arthroscopy. Oct 26 2011;27(3):409-418. PMID 21030203

11. Hangody L, Kish G, Karpati Z, et al. Arthroscopic autogenous osteochondral mosaicplasty for the treatment of femoral condylar articular defects. A preliminary report. Knee Surg Sports Traumatol Arthrosc. Jan 1997;5(4):262-267. PMID 9430578

12. Hangody L, Kish G, Karpati Z, et al. Mosaicplasty for the treatment of articular cartilage defects: application in clinical practice. Orthopedics. Jul 1998;21(7):751-756. PMID 9672912

13. Hangody L, Vasarhelyi G, Hangody LR, et al. Autologous osteochondral grafting--technique and long-term results. Injury. Apr 2008;39(Suppl 1):S32-39. PMID 18313470

14. Solheim E, Hegna J, Oyen J, et al. Osteochondral autografting (mosaicplasty) in articular cartilage defects in the knee: results at 5 to 9 years. Knee. Jan 2010;17(1):84-87. PMID 19666226

15. Solheim E, Hegna J, Oyen J, et al. Results at 10 to 14 years after osteochondral autografting (mosaicplasty) in articular cartilage defects in the knee. Knee. Aug 2013;20(4):287-290. PMID 23482060

16. Marcacci M, Kon E, Delcogliano M, et al. Arthroscopic autologous osteochondral grafting for cartilage defects of the knee: prospective study results at a minimum 7-year follow-up. Am J Sports Med. Dec 2007;35(12):2014- 2021. PMID 17724094

17. Astur DC, Arliani GG, Binz M, et al. Autologous osteochondral transplantation for treating patellar chondral injuries: evaluation, treatment, and outcomes of a two-year follow-up study. J Bone Joint Surg Am. May 21 2014;96(10):816-823. PMID 24875022

18. Nho SJ, Foo LF, Green DM, et al. Magnetic resonance imaging and clinical evaluation of patellar resurfacing with press-fit osteochondral autograft plugs. Am J Sports Med. Jun 2008;36(6):1101-1109. PMID 18337357

19. De Caro F, Bisicchia S, Amendola A, et al. Large fresh osteochondral allografts of the knee: a systematic clinical and basic science review of the literature. Arthroscopy. Apr 2015;31(4):757-765. PMID 25660010

20. Chui K, Jeys L, Snow M. Knee salvage procedures: The indications, techniques and outcomes of large osteochondral allografts. World J Orthop. Apr 18 2015;6(3):340-350. PMID 25893177

21. Nielsen ES, McCauley JC, Pulido PA, et al. Return to sport and recreational activity after osteochondral allograft transplantation in the knee. Am J Sports Med. Jun 2017;45(7):1608-1614. PMID 28375642

22. Gracitelli GC, Meric G, Briggs DT, et al. Fresh osteochondral allografts in the knee: comparison of primary transplantation versus transplantation after failure of previous subchondral marrow stimulation. Am J Sports Med. Apr 2015;43(4):885-891. PMID 25817190

23. Zengerink M, Struijs PA, Tol JL, et al. Treatment of osteochondral lesions of the talus: a systematic review. Knee Surg Sports Traumatol Arthrosc. Feb 2010;18(2):238-246. PMID 19859695

24. Gobbi A, Francisco RA, Lubowitz JH, et al. Osteochondral lesions of the talus: randomized controlled trial comparing chondroplasty, microfracture, and osteochondral autograft transplantation. Arthroscopy. Oct 2006;22(10):1085-1092. PMID 17027406

25. Choi WJ, Park KK, Kim BS, et al. Osteochondral lesion of the talus: is there a critical defect size for poor outcome? Am J Sports Med. Oct 2009;37(10):1974-1980. PMID 19654429

26. Chuckpaiwong B, Berkson EM, Theodore GH. Microfracture for osteochondral lesions of the ankle: outcome analysis and outcome predictors of 105 cases. Arthroscopy. Jan 2008;24(1):106-112. PMID 18182210

27. Cuttica DJ, Smith WB, Hyer CF, et al. Osteochondral lesions of the talus: predictors of clinical outcome. Foot Ankle Int. Nov 2011;32(11):1045-1051. PMID 22338953

28. Ramponi L, Yasui Y, Murawski CD, et al. Lesion size is a predictor of clinical outcomes after bone marrow stimulation for osteochondral lesions of the talus. Am J Sports Med. Jun 2017;45(7):1698-1705. PMID 27852595

29. Haleem AM, Ross KA, Smyth NA, et al. Double-plug autologous osteochondral transplantation shows equal functional outcomes compared with single-plug procedures in lesions of the talar dome: a minimum 5-year clinical follow-up. Am J Sports Med. Aug 2014;42(8):1888-1895. PMID 24948585

30. Shimozono, YY, Hurley, EE, Nguyen, JJ, Deyer, TT, Kennedy, JJ. Allograft Compared with Autograft in Osteochondral Transplantation for the Treatment of Osteochondral Lesions of the Talus.. J Bone Joint Surg Am, 2018 Nov 7;100(21). PMID 30399078

31. Yoon HS, Park YJ, Lee M, et al. Osteochondral autologous transplantation is superior to repeat arthroscopy for the treatment of osteochondral lesions of the talus after failed primary arthroscopic treatment. Am J Sports Med. Aug 2014;42(8):1896-1903. PMID 24907287

32. Imhoff AB, Paul J, Ottinger B, et al. Osteochondral transplantation of the talus: long-term clinical and magnetic resonance imaging evaluation. Am J Sports Med. Jul 2011;39(7):1487-1493. PMID 21372316

33. Kreuz PC, Steinwachs M, Erggelet C, et al. Mosaicplasty with autogenous talar autograft for osteochondral lesions of the talus after failed primary arthroscopic management: a prospective study with a 4-year follow-up. Am J Sports Med. Jan 2006;34(1):55-63. PMID 16157849

34. Georgiannos D, Bisbinas I, Badekas A. Osteochondral transplantation of autologous graft for the treatment of osteochondral lesions of talus: 5- to 7-year follow-up. Knee Surg Sports Traumatol Arthrosc. Dec 2016;24(12):3722-3729. PMID 25326766

35. Diniz, PP, Pacheco, JJ, Flora, MM, Quintero, DD, Stufkens, SS, Kerkhoffs, GG, Batista, JJ, Karlsson, JJ, Pereira, HH. Clinical applications of allografts in foot and ankle surgery.. Knee Surg Sports Traumatol Arthrosc, 2019 Feb 6. PMID 30721345

36. van Dijk CN. Editorial commentary: Bulk osteochondral talar grafts compromise future arthrodesis or prosthesis. Arthroscopy. Jan 2017;33(1):223-224. PMID 28003071

37. VanTienderen RJ, Dunn JC, Kusnezov N, et al. Osteochondral allograft transfer for treatment of osteochondral lesions of the talus: a systematic review. Arthroscopy. Jan 2017;33(1):217-222. PMID 27546173

38. Ahmad J, Jones K. Comparison of osteochondral autografts and allografts for treatment of recurrent or large talar osteochondral lesions. Foot Ankle Int. Jan 2016;37(1):40-50. PMID 26333683

39. Gaul, FF, Trico, LL, McCauley, JJ, Pulido, PP, Bugbee, WW. Osteochondral Allograft Transplantation for Osteochondral Lesions of the Talus: Midterm Follow-up.. Foot Ankle Int, 2018 Nov 2;40(2). PMID 30383977

40. Westermann RW, Hancock KJ, Buckwalter JA, et al. Return to sport after operative management of osteochondritis dissecans of the capitellum: a systematic review and meta-analysis. Orthop J Sports Med. Jun 2016;4(6):2325967116654651. PMID 27482526

41. Kirsch, JJ, Thomas, JJ, Khan, MM, Townsend, WW, Lawton, JJ, Bedi, AA. Return to Play After Osteochondral Autograft Transplantation of the Capitellum: A Systematic Review.. Arthroscopy, 2017 Apr 18;33(7). PMID 28413129

42. Sato, KK, Iwamoto, TT, Matsumura, NN, Suzuki, TT, Nishiwaki, YY, Oka, YY, Nakamura, TT. Costal Osteochondral Autograft for Advanced Osteochondritis Dissecans of the Humeral Capitellum in Adolescent and Young Adult Athletes: Clinical Outcomes with a Mean Follow-up of 4.8 Years.. J Bone Joint Surg Am, 2018 Jun 6;100(11). PMID 29870440

43. Bexkens R, Ogink PT, Doornberg JN, et al. Donor-site morbidity after osteochondral autologous transplantation for osteochondritis dissecans of the capitellum: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc. Jul 2017;25(7):2237-2246. PMID 28391550

44. Kircher J, Patzer T, Magosch P, et al. Osteochondral autologous transplantation for the treatment of full- thickness cartilage defects of the shoulder: results at nine years. J Bone Joint Surg Br. Apr 2009;91(4):499-503. PMID 19336811

45. Cole BJ, Farr J, Winalski CS, et al. Outcomes after a single-stage procedure for cell-based cartilage repair: a prospective clinical safety trial with 2-year follow-up. Am J Sports Med. Jun 2011;39(6):1170-1179. PMID 21460066

46. Farr J, Tabet SK, Margerrison E, et al. Clinical, radiographic, and histological outcomes after cartilage repair with particulated juvenile articular cartilage: a 2-year prospective study. Am J Sports Med. Apr 9 2014;42(6):1417- 1425. PMID 24718790

47. Tompkins M, Hamann JC, Diduch DR, et al. Preliminary results of a novel single-stage cartilage restoration technique: particulated juvenile articular cartilage allograft for chondral defects of the patella. Arthroscopy. Oct 2013;29(10):1661-1670. PMID 23876608

48. Saltzman BM, Lin J, Lee S. Particulated juvenile articular cartilage allograft transplantation for osteochondral talar lesions. Cartilage. Jan 2017;8(1):61-72. PMID 27994721

49. Bleazey S, Brigido SA. Reconstruction of complex osteochondral lesions of the talus with cylindrical sponge allograft and particulate juvenile cartilage graft: provisional results with a short-term follow-up. Foot Ankle Spec. Oct 2012;5(5):300-305. PMID 22935411

50. Coetzee JC, Giza E, Schon LC, et al. Treatment of osteochondral lesions of the talus with particulated juvenile cartilage. Foot Ankle Int. Sep 2013;34(9):1205-1211. PMID 23576118

51. Dekker, TT, Steele, JJ, Federer, AA, Easley, MM, Hamid, KK, Adams, SS. Efficacy of Particulated Juvenile Cartilage Allograft Transplantation for Osteochondral Lesions of the Talus.. Foot Ankle Int, 2017 Dec 22;39(3). PMID 29262723

52. DeSandis, BB, Haleem, AA, Sofka, CC, O'Malley, MM, Drakos, MM. Arthroscopic Treatment of Osteochondral Lesions of the Talus Using Juvenile Articular Cartilage Allograft and Autologous Bone Marrow Aspirate Concentration.. J Foot Ankle Surg, 2018 Jan 7;57(2). PMID 29305041

53. Farr J, Gracitelli GC, Shah N, et al. High failure rate of a decellularized osteochondral allograft for the treatment of cartilage lesions. Am J Sports Med. Aug 2016;44(8):2015-2022. PMID 27179056

54. Johnson CC, Johnson DJ, Garcia GH, et al. High short-term failure rate associated with decellularized osteochondral allograft for treatment of knee cartilage lesions. Arthroscopy. Dec 2017;33(12):2219-2227. PMID 28967543

55. American Orhopaedic Foot and Ankle Society. Position Statement: The Use of Osteochondral Transplantation for the Treatment of Osteochondral Lesions of the Talus. https://www.aofas.org/docs/default-source/research-and-policy/osteochondral-lesions-position-statement.pdf?sfvrsn=95e8c93b_2. Accessed March 4, 2020.

56. Smyth, NN, Murawski, CC, Adams, SS, Berlet, GG, Buda, RR, Labib, SS, Nunley, JJ, Raikin, SS, Ackermann, JJ, Andrews, CC, Angthong, CC, Batista, JJ, Baur, OO, Bayer, SS, Becher, CC, Boakye, LL, Brown, AA, Calder, JJ, Canata, GG, Carreira, DD, Clanton, TT, Dahmen, JJ, D'Hooghe, PP, DiGiovanni, CC, Dombrowski, MM, Drakos, MM, Ferkel, RR, Ferrao, PP, Fortier, LL, Glazebrook, MM, Giza, EE, Gomaa, MM, Grtz, SS, Haleem, AA, Hamid, KK, Hangody, LL, Hannon, CC, Haverkamp, DD, Hertel, JJ, Hintermann, BB, Hogan, MM, Hunt, KK, Hurley, EE, Karlsson, JJ, Kearns, SS, Kennedy, JJ, Kerkhoffs, GG, Kim, HH, Kong, SS, Lambers, KK, Lee, JJ, Lee, KK, Ling, JJ, Longo, UU, Marangon, AA, McCollum, GG, Mitchell, AA, Mittwede, PP, Nehrer, SS, Niemeyer, PP, O'Malley, MM, Osei-Hwedieh, DD, Paul, JJ, Pearce, CC, Pereira, HH, Popchak, AA, Prado, MM, Reilingh, MM, Rothrauff, BB, Schon, LL, Shimozono, YY, Simpson, HH, Sofka, CC, Spennacchio, PP, Stone, JJ, Sullivan, MM, Takao, MM, Tanaka, YY, Thordarson, DD, Tuan, RR, Valderrabano, VV, van Bergen, CC, van Dijk, CC, van Dijk, PP, Vannini, FF, Vaseenon, TT, Walther, MM, Wiewiorski, MM, Xu, XX, Yasui, YY, Yinghui, HH, Yoshimura, II, Younger, AA, Zhang, ZZ. Osteochondral Allograft: Proceedings of the International Consensus Meeting on Cartilage Repair of the Ankle.. Foot Ankle Int, 2018 Sep 15;39(1_suppl). PMID 30215308

57. American Academy of Orthopaedic Surgeons Diagnosis and Treatment of Osteochondritis Dissecans Work Group. The diagnosis and treatment of osteochondritis dissecans: Guideline and evidence report. 2010, December 4; https://aaos.org/globalassets/quality-and-practice-resources/osteochondritis-dissecans/osteochondritis-dissecan-clinical-practice-guideline.pdf. Accessed March 4, 2020.

58. Chambers HG, Shea KG, Anderson AF, et al. American Academy of Orthopaedic Surgeons clinical practice guideline on: the diagnosis and treatment of osteochondritis dissecans. J Bone Joint Surg Am. Jul 18 2012;94(14):1322-1324. PMID 22810404

59. Trice ME, Bugbee WD, Greenwald AS, et al. Articular cartilage restoration: A review of currently available methods. 2010; http://orl-inc.com/wp-content/uploads/2016/03/Cartilage-Repair-2010.pdf. Accessed March 4, 2020.

60. National Institute for Health and Care Excellence. Mosaicplasty for symptomatic articular defects of the knee [IPG607]. https://www.nice.org.uk/guidance/ipg607. Accessed March 4, 2020.

Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)

CPT*

27415
27416
28446
29866
29867