Osteochondral Autografting (OCG)
DESCRIPTION
Osteochondral autografting (OCG) is a surgical procedure used to repair full-thickness chondral defects involving a joint. Mosaicplasty and osteochondral autograft transfer system (OATS) are systems used to perform this procedure.
Mosaicplasty involves the harvesting of multiple individual osteochondral cores from the donor site, typically from a peripheral non-weight-bearing area of the femoral condyle. The grafts are pressed into the lesion in a mosaic-like fashion. The resultant surface consists of transplanted hyaline cartilage and fibrocartilage arising from the abrasion arthroplasty. The fibrocartilage is thought to act as a grout between the individual autografts. Mosaicplasty is performed as an open procedure or arthroscopically.
The OATS procedure focuses on chondral defects associated with chronic tears of the anterior cruciate ligament (ACL). The procedure is performed arthroscopically.
Autologous minced cartilage is also being evaluated as a treatment of articular cartilage lesions. Currently, minced cartilage techniques are either not approved in the United States and/or in the early stages of development and testing.
POLICY
Osteochondral autografting is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Osteochondral autografting for all other indications is considered investigational.
Osteochondral autografting for the treatment of focal articular cartilage lesions using autologous minced cartilage is considered investigational.
MEDICAL APPROPRIATENESS
Osteochondral autografting is considered medically appropriate if ALL of the following criteria are met:
Indicated for ANY ONE of the following:
Cartilage defects of the knee if ALL the following are met:
Focal, full thickness (grade III or IV) unipolar lesions on the weight bearing surface of the femoral condyles, trochlea, or patella that are 1 - 2.5 cm2 in size
Symptomatic full-thickness cartilage defects caused by acute or repetitive trauma
Inadequate response to a prior surgical procedure (such as micro-grafting, autologous chondrocyte implantation)
There is evidence of growth plate closure in adolescents
There is a clinical determination that the individual is not yet a candidate for joint replacement
Documented minimal to absent degenerative changes in the surrounding articular cartilage (Outerbridge grade II or less)
Normal appearing hyaline cartilage surrounding the border of the defect
Normal knee biomechanics, or alignment and stability achieved concurrently with osteochondral autografting
Osteochondral lesions of the talus if ALL of the following are met:
Treatment is indicated for ANY ONE of the following:
Lesion greater than 1.5 cm2
Cystic lesion with volume greater than 3.0 cm
Revision surgery after failed marrow stimulation procedure
IMPORTANT REMINDERS
Any specific products referenced in this policy are just examples and are intended for illustrative purposes only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available. These examples are contained in the parenthetical e.g. statement.
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan or government program (e.g., TennCare), the express terms of the health plan or government program will govern.
SOURCES
American Academy of Orthopaedic Surgeons. (2010). The diagnosis and treatment of osteochondritis dissecans. Guideline and evidence report. Retrieved June 29, 2017 from https://www.aaos.org.
American Orthopaedic Foot and Ankle Society. (2022). Position Statement the use of osteochondral transplantation for the treatment of osteochondral lesions of the talus. Retrieved March 6, 2023 from https://www.aofas.org/docs/default-source/research-and-policy/osteochondral-lesions-position-statement.pdf?sfvrsn=95e8c93b_4.
Biant, L., McNicholas, M., Sprowson, A., & Spalding, T. (2015). The surgical management of symptomatic articular cartilage defects of the knee: Consensus statements from United Kingdom knee surgeons. The Knee, 22, 446-449. (Level 2 evidence)
BlueCross BlueShield Association. Evidence Positioning System. (5:2022). Autografts and allografts in the treatment of focal articular cartilage lesions (7.01.78). Retrieved March 6, 2023 from https://www.evidencepositioningsystem.com/. (62 articles and/or guidelines reviewed)
Dahmen, J., Lambers, K., Reilingh, M., van Bergen, C., Stufkens, S., Kerkhoffs, G. (2017). No superior treatment for primary osteochondral defects of the talus. Knee Surgery, Sports Traumatology, Arthroscopy, 26 (7), 2142-2157. (Level 1 evidence).
Gobbi, A., Francisco, R. A., Lubowitz, J. H., Allegra, F., & Canata, G. (2006). Osteochondral lesions of the talus: Randomized controlled trial comparing chondroplasty, microfracture, and osteochondral autograft transplantation. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 22 (10), 1085–1092. Abstract retrieved January 19, 2022 from PubMed database.
Lambers, K., Dahmen, J., Reilingh, M., van Bergen, C., Stufkens, S., & Kerkhoffs G. (2018). No superior surgical treatment for secondary osteochondral defects of the talus. Knee Surgery, Sports Traumatology, Arthroscopy, 26 (7), 2158–2170. (Level 2 evidence)
National Institute for Health and Care Excellence. (2018, March). Mosaicplasty for symptomatic articular cartilage defects of the knee. Retrieved July 6, 2018 from www.nice.org.uk.
Pareek, A., Reardon, P., Maak, T., Levy, B., Stuiart, M., & Krych, A. (2016). Long-term outcomes after osteochondral autograft transfer: A systematic review at mean follow-up of 10.2 years. Arthroscopy: The Journal of Arthroscopic and Related Surgery, 32 (6), 1174-1184. (Level 2 evidence)
Solheim, E., Hegna, J., & Inderhaug, E. (2017). Long-term clinical follow-up of microfracture versus mosaicplasty in articular cartilage defects of medial femoral condyle. Knee, 24 (6), 1402–1407. Abstract retrieved April 28, 2020 from PubMed database.
Solheim, E., Hegna, J., Strand, T., Harlem, T., & Inderhaug, E. (2018). Randomized study of long-term (15-17 years) outcome after microfracture versus mosaicplasty in knee articular cartilage defects. The American Journal of Sports Medicine, 46 (4), 826–831. Abstract retrieved January 19, 2022 from PubMed database.
Winifred S. Hayes, Inc. Medical Technology Directory. (2017, May; last update search June 2021). Comparative effectiveness review of mosaicplasty for treatment of articular cartilage injuries. Retrieved January 19, 2022 from www.Hayesinc.com/subscribers. (68 articles and/or guidelines reviewed)
Zamborsky, R., & Danisovic, L. (2020). Surgical techniques for knee cartilage repair: An updated large-scale systematic review and network meta-analysis of randomized controlled trials. Arthroscopy, 36 (3), 845-858. Abstract retrieved February 9, 2021 from PubMed database.
ORIGINAL EFFECTIVE DATE: 10/1998
MOST RECENT REVIEW DATE: 4/13/2023
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