Do Self-Reported Drug Allergies Influence Clinically Significant Outcome Improvement Following Osteochondral Allograft Transplantation? A Nested Cohort Study

Immune Hypersensitivity Is Associated With Higher Graft Failure Rate After Osteochondral Allograft Transplantation of the Knee

Purpose

To analyze the effects of 1 or more patient-reported allergies on clinical outcomes, in particular graft failure rate, and patient-reported outcomes (PROs) following osteochondral allograft transplantation (OCA) of the knee.

Methods

Retrospective review of patients who underwent knee OCA from August 2010 to May 2021 with a minimum of 2-year follow-up. Patients were initially divided into 2 cohorts: those with at least 1 allergy and those without any allergies. Clinical outcomes assessed included graft failure, reoperation rates, deep vein thrombosis/pulmonary embolism, and manipulation under anesthesia/lysis of adhesions (MUA/LOA). PROs assessed, including the visual analog scale (VAS) for pain and satisfaction, the Knee injury and Osteoarthritis Outcome Score (KOOS), and return to sport rates, were compared.

Results

In total, 285 patients were included with a mean clinical follow-up of 4.8 ± 2.0 years. The allergy cohort had a significantly higher rate of graft failure (P = .008). In a regression analysis controlling for confounding variables, graft failure remained significantly associated with the presence of medication allergies (odds ratio [OR], 3.631; 95% CI, 1.139-11.577; P = .029). Furthermore, an increasing number of allergies were associated with an increased rate of graft failure (OR, 1.644; 95% CI, 1.074-2.515; P = .022). There was no difference in rate of reoperation, complications, infection, and MUA/LOA. Of the 100 patients who completed PROs, there was no difference in VAS satisfaction, pain, and any of the KOOS outcome scores or return to sport.

Conclusions

The presence of 1 or more patient-reported allergies was shown to be significantly associated with OCA graft failure. Furthermore, an increasing number of patient-reported allergies were associated with a higher rate of graft failure. However, there were no significant differences in VAS satisfaction or pain, KOOS symptom, quality of life, pain, or return to sport in patients with at least 1 patient-reported allergy and those without allergies.

Level of Evidence

Level III, retrospective cohort study.

Patients with higher numbers of allergies have lower levels of anti-inflammatory cytokines and increased pain at the time of ACL reconstruction

BACKGROUND

Synovial fluid biomarkers are well studied indicators of inflammation and healing in the setting of orthopedic injuries. However, it has not been studied if patients with one or more allergies have a difference in the concentrations of synovial fluid inflammatory cytokines compared to patients without allergies. The purpose of the current study is to analyze the concentration of 10 pro- and anti-inflammatory cytokines in the synovial fluid of isolated ACL injury patients with and without at least one allergy.

STUDY DESIGN

Retrospective Case-Control.

METHODS

A database of patients who underwent surgery for isolated ACL injury between September 2011 and July 2023 was analyzed. All patients had SF aspirated from the operative knee prior to the surgical incision and the concentrations of pre- and anti-inflammatory biomarkers were quantified. From this cohort, 24 patients were identified to have allergies by chart review. These patients were matched 1:1 to 24 patients without allergies based on age and sex.

RESULTS

There were no significant differences between the allergy and no allergy cohorts with respect to age (28.5 ± 10.3 vs. 29.5 ± 8.9, p = 0.76) and sex (70.8 % female vs. 70.8 % female, p = 1.00). The allergy cohort had a decreased concentration of TIMP-1 (492.41 ± 616.20 ng/mL vs. 1041.48 ± 942.04 ng/mL, p = 0.03) and IL-1Ra (101.70 ± 93.37 pg/mL vs. 359.94 ± 399.77 pg/mL, p = 0.01) compared to patients without allergies. A linear regression analysis found a significant association between increasing number of patients reported allergies and decreasing concentration of TIMP-1 (β = -231.59, p = 0.03) and IL-1Ra (β = -71.69p = 0.03) concentrations when controlling for age and sex. Finally, the allergy cohort was found to have a significantly higher value for the VAS pain scale at the time of surgery (26.84 ± 24.73 vs. 7.37 ± 10.98, p < 0.01) compared to those without an allergy.

CONCLUSION

Patients undergoing ACL reconstruction with at least one allergy were found to have decreased concentrations of the anti-inflammatory cytokines TIMP-1 and IL-1Ra in their synovial fluid compared to those without allergies on the day of surgery. Furthermore, an increase in total number of allergies was found to be an associated with a decrease in TIMP-1 and IL-1Ra levels. Finally, the allergy cohort also had a higher value for the VAS pain scale at the time of surgery, implicating the role of a patient's innate immune system to their biologic and symptomatic response to injury.

Characteristics and Clinical Outcomes After Osteochondral Allograft Transplantation for Treating Articular Cartilage Defects: Systematic Review and Single-Arm Meta-analysis of Studies From 2001 to 2020

Background

Osteochondral allograft transplantation (OCA) treats symptomatic focal cartilage defects with satisfactory clinical results.

Purpose

To comprehensively analyze the characteristics and clinical outcomes of OCA for treating articular cartilage defects.

Study Design

Systematic review; Level of evidence, 4.

Methods

We searched Embase, PubMed, Cochrane Database, and Web of Science for studies published between January 1, 2001, and December 31, 2020, on OCA for treating articular cartilage defects. Publication information, patient data, osteochondral allograft storage details, and clinical outcomes were extracted to conduct a comprehensive summative analysis.

Results

In total, 105 studies involving 5952 patients were included. The annual reported number of patients treated with OCA increased from 69 in 2001 to 1065 in 2020, peaking at 1504 cases in 2018. Most studies (90.1%) were performed in the United States. The mean age at surgery was 34.2 years, and 60.8% of patients were male and had a mean body mass index of 26.7 kg/m2. The mean lesion area was 5.05 cm2, the mean follow-up duration was 54.39 months, the mean graft size was 6.85 cm2, and the number of grafts per patient was 54.7. The failure rate after OCA was 18.8%, and 83.1% of patients reported satisfactory results. Allograft survival rates at 2, 5, 10, 15, 20, and 25 years were 94%, 87.9%, 80%, 73%, 55%, and 59.4%, respectively. OCA was mainly performed on the knee (88.9%). The most common diagnosis in the knee was osteochondritis dissecans (37.9%), and the most common defect location was the medial femoral condyle (52%). The most common concomitant procedures were high tibial osteotomy (28.4%) and meniscal allograft transplantation (24.7%). After OCA failure, 54.7% of patients underwent revision with primary total knee arthroplasty.

Conclusion

The annual reported number of patients who underwent OCA showed a significant upward trend, especially from 2016 to 2020. Patients receiving OCA were predominantly young male adults with a high body mass index. OCA was more established for knee cartilage than an injury at other sites, and its best indication was osteochondritis dissecans. This analysis demonstrated satisfactory long-term postoperative outcomes.