Cartilage Repair With or Without Meniscal Transplantation and Osteotomy for Lateral Compartment Chondral Defects of the Knee: Case Series With Minimum 2-Year Follow-up

Clinical and Radiological Outcomes of Medial Meniscal Allograft Transplantation Combined With Realignment Surgery

BACKGROUND

The outcomes of medial meniscal allograft transplantation (MMAT) combined with high tibial osteotomy (HTO) compared with isolated MMAT remain unclear.

PURPOSE

To compare the clinical and radiological results of MMAT combined with HTO and isolated MMAT.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

This retrospective study included 42 consecutive patients, who were divided into group M (isolated MMAT; n = 22) and group H (MMAT combined with HTO with a varus angle >3°; n = 20). Group differences in subjective knee scores, isokinetic muscle strength test, and radiological outcomes (Kellgren-Lawrence grade, mechanical axis, graft extrusion, graft status, and articular cartilage loss) were compared.

RESULTS

The mean follow-up period was 29.2 ± 4.9 months and 27.4 ± 5.3 months for groups M and H, respectively. The Lysholm score improved from 55.4 ± 9.5 to 81.3 ± 9.7 and from 52.6 ± 8.9 to 84.2 ± 10.2 in groups M and H, respectively (both P < .001). The International Knee Documentation Committee subjective score improved from 51.4 ± 10.3 to 79.6 ± 9.4 and from 49.3 ± 11.4 to 81.4 ± 8.3 in groups M and H, respectively (both P < .001). Both groups showed no significant differences in subjective knee scores and isokinetic extensor strength at the final follow-up. The rate of preoperative and postoperative high International Cartilage Regeneration & Joint Preservation Society grade (≥3) did not differ between the 2 groups. Group M showed greater coronal graft extrusion than did group H (3.3 ± 0.7 mm vs 2.7 ± 0.8 mm; P = .014); the rate of pathologic graft extrusion (≥3 mm) was not higher in group M (40.9%) than in group H (20%) with the number of patients available (P = .143). Both groups showed no significant difference in the graft status. Graft tears were observed in 2 patients (9%) in group M and 1 patient (5%) in group H (P = .607).

CONCLUSION

Clinical scores significantly improved after isolated MMAT and MMAT combined with HTO compared with preoperative values, and their short-term outcomes were similar. Postoperative graft extrusion was greater in patients who underwent isolated MMAT, implying that active correction of varus alignment during MMAT may help in intra-articular biomechanics.

Early Complication Rates Are Equivalent Between Isolated Cartilage Restoration and Concomitant Cartilage Restoration and Osteotomy of the Knee

OBJECTIVE

Realignment osteotomy performed concomitantly with cartilage restoration typically requires early restricted weightbearing and can add significant morbidity, potentially leading to an increased risk of early perioperative complications. The purpose of this study was to compare the 30-day complication rates after isolated cartilage restoration (ICR) versus concomitant cartilage restoration and osteotomy (CRO) using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database.

DESIGN

NSQIP registries between 2006 and 2019 were queried using Current Procedural Terminology codes to identify patients undergoing ICR (autologous chondrocyte implantation, osteochondral autograft transfer, or osteochondral allograft transplantation) and CRO (with concomitant high tibial osteotomy, distal femoral osteotomy, and/or tibial tubercle osteotomy). Complications rates between treatment groups were compared using multivariate logistic regression analyses adjusted for sex, age, steroid use, and respiratory status.

RESULTS

A total of 773 ICR and 97 CRO surgical procedures were identified. Mean patient ages were 35.9 years for the ICR group and 31.2 years for the CRO group. Operative time was significantly longer in the CRO group (170.8 min) compared with the ICR group (97.8 min). Multivariate analysis demonstrated no significant differences in rates of PE, VTE, and all-cause readmission between the ICR and CRO groups. No events of wound disruption, SSI and reoperation were found in the CRO group, while the ICR group was characterized by low rates of wound disruption, reoperation, and SSI (<1.1%).

CONCLUSIONS

These findings further support concomitant osteotomy with cartilage restoration when appropriate and aid surgeons in the preoperative counseling of patients undergoing cartilage restoration treatment.

Significant improvements in clinical outcome measures and patient satisfaction after combined all-arthroscopic meniscal allograft transplantation and autologous chondrocyte implantation: A single-centre longitudinal study

PURPOSE

The optimal treatment approach for the complex pathology of meniscal insufficiency and coexisting full-thickness cartilage defects remains unclear. The purpose of this study was to evaluate the viability, safety, and efficacy of this combined surgical approach at medium-term follow-up.

METHODS

This is a single-centre longitudinal study with blinded outcome assessment. All consecutive patients treated with combined all-arthroscopic meniscal allograft transplantation (MAT) with bone bridge fixation and ACI using chondrospheres at our institution between 2001 and 2021 were eligible for inclusion. Twenty patients with an average follow-up of 72.6 ± 34.4 months were included in the statistical analysis. Clinical outcomes were assessed pre- and postoperatively using the IKDC Subjective Knee Form, Lysholm Score, Tegner Activity Scale, KOOS, and Visual Analog Scale (VAS) for patient satisfaction. Failure and reoperation rates were assessed, and cartilage regeneration tissue was evaluated on postoperative MRI.

RESULTS

IKDC scores significantly improved from 52.1 ± 16.9 to 68.5 ± 16.3 (p = 0.003). Lysholm scores improved from 61.5 ± 21.7 to 78.5 ± 12.9 (p = 0.004). Tegner scores improved from 3.5 (1-4) to 4.0 (2-6) (p = 0.014). KOOS scores improved significantly across all subcategories, except 'symptoms', where improvements did not reach statistical significance. VAS for overall patient satisfaction showed improvements but did not reach statistical significance. The combined procedure was successful in 17 patients (85%). Eight patients had to undergo reoperation (40%), comprising mostly small, arthroscopic procedures. Seven reoperations were directly attributable to meniscal allograft transplantation (46.7%). Postoperative Magnetic Resonance Observation of Cartilage Repair Tissue scores were 68.9 ± 16.8 (n = 14).

CONCLUSION

Combined arthroscopic MAT and autologous chondrocyte implantation (ACI) is a viable, safe, and effective treatment approach for younger patients with meniscal insufficiency and coexisting full-thickness cartilage damage, where alternative treatment options are limited. The combined surgical procedure achieved significant improvements in clinical outcome measures and patient satisfaction with acceptable failure and high arthroscopic reoperation rates. MAT is the limiting part of this combined procedure, with most failures and reoperations being attributable to MAT, as opposed to ACI.

LEVEL OF EVIDENCE

Level III.

Effects of Lateral Opening-Wedge Distal Femoral Osteotomy on Meniscal Allograft Transplantation: A Biomechanical Evaluation

Background

Lateral meniscal deficiency with valgus malalignment increases the rate of lateral compartment osteoarthritis. Lateral meniscal allograft transplantation (LMAT) with a concomitant varus-producing opening-wedge distal femoral osteotomy (DFO) is an option yet to be evaluated biomechanically.

Purpose/Hypothesis

The purpose of this study was to clarify the biomechanical effects of the realignment procedure in the setting of LMAT. We hypothesized that (1) given the dependence of the lateral compartment on the lateral meniscus, a DFO and increasing degrees of varus would be insufficient to restore lateral compartment pressures to normal from a lateral meniscus-deficient state, and that (2) LMAT would restore lateral compartment pressures to the intact state while DFO would decrease lateral compartment pressures for any given state of the meniscus.

Study Design

Controlled laboratory study.

Methods

Ten cadaveric knees underwent opening-wedge varus-producing DFO secured by an external fixator. Anatomic alignment was standardized to 6° of mechanical valgus, and each joint was tested in full extension. Submeniscal placement of thin film pressure sensors allowed for the recording of contact pressure, peak contact pressure, and contact area. The specimens were loaded on a biaxial dynamic testing machine with loading angles between 9° valgus and 6° varus of mechanical alignment. Conditions tested included intact meniscus, meniscal deficiency, and meniscal transplantation.

Results

Isolated varus-producing DFO to 6° in the meniscus-deficient state failed to restore joint pressures and contact areas to the intact state, with significant changes in mean contact pressure (175%), mean peak contact pressure (135%), and contact area (-41%) (all P < .05 vs intact), while LMAT restored all outcome measures (all P > .05 compared with intact). After LMAT, every additional 1° of DFO correction contributed to a decrease in the mean contact pressure, peak pressure, and contact area of 5.6% (-0.0479 N/mm²), 5.9% (-0.154 N/mm²), and 1.4% (-6.99 mm²) for the lateral compartment and 7.3% (+0.034 N/mm²), 12.6% (+0.160 N/mm²), and 4.3% (+20.53 mm²) for the medial compartment, respectively.

Conclusion

Isolated DFO was inadequate to restore load distribution in meniscus-deficient knees, while concomitant LMAT restored near normal forces and improved the lateral compartment biomechanical profile.

Clinical Relevance

Our findings support the concomitant use of LMAT and varus-producing DFO in the setting of lateral meniscal deficiency with valgus malalignment. This study provides tools for the orthopaedic surgeon to individualize the correction for each patient.

Inconsistent Reporting of Preauthorization Medical Criteria for Osteochondral Allograft Transplantation Surgery

BACKGROUND

Although osteochondral allograft (OCA) transplantation has been a standard treatment for patients with osteochondral lesions, there is a disagreement in commercial payers' medical criteria regarding the definition of medical suitability and thus authorization for OCA transplantation. The primary goal of this study was to understand where consensus between a committee of experienced cartilage restoration surgeon scientists and payer policies existed and where there was significant disagreement.

METHODS

U.S. private payers were identified by reviewing health insurance market research literature. Medical criteria were then obtained from publicly available payer medical polices. A literature review was conducted to identify supporting evidence for consensus statements based on private payer medical criteria. The MOCA (Metrics of Osteochondral Allograft) Committee, 30 experienced surgeons and subject-matter experts in OCA transplantation, used a Likert scale of 1 (strongly disagree) to 5 (strongly agree) to rank each statement. The extent of agreement and disagreement among participants was measured for each statement. Consensus was defined as agreement or disagreement of >75%.

RESULTS

Fifty-seven statements regarding relevant medical criteria for OCA transplantation were included in the survey. All 30 MOCA Committee members completed the survey (100% response rate). Over half of the statements (52.6%) did not reach consensus. Of the remaining 27 statements that reached consensus, respondents agreed or strongly agreed with 16 statements, and disagreed or strongly disagreed with 11 statements. Inconsistent voting was observed for statements related to osteoarthritis, inflammation, and degenerative changes.

CONCLUSIONS

Commercial payers are not consistent in the medical criteria used to define patient eligibility for authorization of OCA transplantation. In contrast, an expert panel of cartilage surgeons reached a consensus that OCA transplantation was clearly suitable for a variety of specific indications. This study demonstrates the need to standardize medical criteria for cartilage restoration based on the most current literature, as well as in conjunction with experienced cartilage restoration experts.

LEVEL OF EVIDENCE

Therapeutic Level V . See Instructions for Authors for a complete description of levels of evidence.

After Chondroplasty, Patient Election to Proceed With Cartilage Transplantation Is Closely and Additively Associated With Preoperative AMADEUS (Area Measurement And DEpth Underlying Structure) Grade, Condylar Involvement, Knee Injury and Osteoarthritis Outcome Score Pain Score, and Veterans Rand 12-Item Health Survey Physical Score

Purpose

To identify risk factors for patient election to proceed with cartilage transplant after staging chondroplasty.

Methods

This study retrospective reviewed patients prospectively enrolled at the time of staging chondroplasty, with early election defined as patient decision to proceed to cartilage transplantation within 6 months of chondroplasty. Cox proportional hazards analysis was used to determine univariate predictors of conversion, and a predictive calculator, the Cartilage Early Return for Transplant score, was formulated using stepwise regression employing the Akaike information criterion. Receiver operator curves and the area under the curve were used to evaluate the predictive ability of the final model on the studied patient population.

Results

Sixty-five knees (63 patients) were evaluated, with an overall transplant election rate of 27.7% within 6 months after chondroplasty. Based on multivariate results, the final Akaike information criterion-driven Cartilage Early Return for Transplant score employed preoperative Knee Injury and Osteoarthritis Outcome Score Pain Score, Veterans Rand 12-Item Health Survey Physical Score, condylar involvement, and AMADEUS (Area Measurement And DEpth Underlying Structure) score to generate a 0- to 7-point risk-stratification system with a 3% early election to proceed to transplant risk in the 0- to 2-point score group, 33% risk in the 3- to 4-point group, and 79% risk in the 5+-point group (P < .01) and an overall AUC of 0.906 (P < .01).

Conclusions

Risk of early patient election to pursue cartilage transplantation after chondroplasty is closely and additively associated with preoperative AMADEUS grade, condylar involvement, Knee Injury and Osteoarthritis Outcome Score Pain Score, and Veterans Rand 12-Item Health Survey Physical Score.

Clinical Relevance

Understanding risk factors for conversion to cartilage transplantation may improve preoperative planning and counseling prior to staging chondroplasty.

Differences in Clinical and Functional Outcomes Between Osteochondral Allograft Transplantation and Autologous Chondrocyte Implantation for the Treatment of Focal Articular Cartilage Defects

Background:

Articular cartilage pathology can result from a spectrum of origins, including trauma, osteochondritis dissecans, avascular necrosis, or degenerative joint disease.

Purpose:

To compare the differences in clinical and patient-reported outcomes after autologous chondrocyte implantation (ACI) versus osteochondral allograft transplantation (OCA) in patients with focal articular cartilage defects without underlying bone loss.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

A retrospective review identified patients who underwent ACI or OCA between 2008 and 2016 for isolated grades 3 and 4 articular cartilage defects without underlying bone loss. Outcome measures included the Knee injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR), International Knee Documentation Committee (IKDC) evaluation, and 12-Item Short Form Health Survey–Physical Component (SF-12-P) scores. Defect location, size, complications, and rate of subsequent surgery were determined.

Results:

Overall, 148 patients were included: 82 (55%) underwent ACI and 66 (45%) underwent OCA. The mean age at the time of surgery was 31.2 years within the ACI cohort and 37.7 years within the OCA cohort (P < .001); the mean follow-up for both cohorts was 6.7 years (P = .902). Within the ACI group, 28 (34%) patients had multifocal defects, 21 (26%) had defects confined to the femoral condyles, and 33 (40%) had defects in the patellofemoral region. Within the OCA group, 23 (35%) patients had multifocal defects, 30 (46%) had confined femoral condyle lesions, and 13 (20%) had patellofemoral defects. When comparing by lesion location, there were no significant differences in KOOS JR, and IKDC scores between the ACI and OCA cohorts (P < .05). There was, however, a significant difference for SF-12-P scores for FDD trochlear lesions. In both cohorts, traumatic patellofemoral pathology demonstrated lower patient-reported outcomes and higher failure rates than degenerative lesions. The overall rate of failure, defined as graft failure with revision surgery and/or conversion to arthroplasty, was significantly greater in the OCA group (21% vs 4%; P = .002).

Conclusion:

Study results indicated that ACI provides similar outcomes to OCA with or without concomitant procedures for the treatment of symptomatic articular cartilage defects in all lesion locations and may have a lower revision rate for multifocal and condylar lesions.

Rehabilitation and Return-to-Play Criteria After Fresh Osteochondral Allograft Transplantation: A Systematic Review

Background:

Fresh osteochondral allograft (OCA) is a treatment option that allows for the transfer of size-matched allograft cartilage and subchondral bone into articular defects of the knee. Although long-term studies show good functional improvement with OCA, there continues to be wide variability and a lack of consensus in terms of postoperative rehabilitation protocols and return to sport.

Purpose:

To systematically review the literature and evaluate the reported rehabilitation protocols after OCA of the knee, including weightbearing and range of motion (ROM) restrictions as well as return-to-play criteria.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

PubMed, EMBASE, Cumulative Index of Nursing Allied Health Literature, SPORTDiscus, and Cochrane databases were searched according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for studies on knee OCA. Studies were included if they reported return-to-play data or postsurgical rehabilitation protocols.

Results:

A total of 62 studies met the inclusion criteria, with a total of 3451 knees in 3355 patients. Concomitant procedures were included in 30 of these studies (48.4%). The most commonly cited rehabilitation protocols included weightbearing restrictions and ROM guidelines in 100% and 90% of studies, respectively. ROM was most commonly initiated within the first postoperative week, with approximately half of studies utilizing continuous passive motion. Progression to weightbearing as tolerated was reported in 60 studies, most commonly at 6 weeks (range, immediately postoperatively to up to 1 year). Of the 62 studies, 37 (59.7%) included an expected timeline for either return to play or return to full activity, most commonly at 6 months (range, 4 months to 1 year). Overall, 13 studies (21.0%) included either objective or subjective criteria to determine return to activity within their rehabilitation protocol.

Conclusion:

There is significant heterogeneity for postoperative rehabilitation guidelines and the return-to-play protocol after OCA of the knee in the literature, as nearly half of the included studies reported use of concomitant procedures. However, current protocols appear to be predominantly time-based without objective criteria or functional assessment. Therefore, the authors recommend the development of objective criteria for patient rehabilitation and return-to-play protocols after OCA of the knee.

Wide Variation in Methodology in Level I and II Studies on Cartilage Repair: A Systematic Review of Available Clinical Trials Comparing Patient Demographics, Treatment Means, and Outcomes Reporting

BACKGROUND

The management of complex cartilage pathology in young, otherwise healthy patients can be difficult.

PURPOSE

To determine the nature of the design, endpoints chosen, and rate at which the endpoints were met in published studies and ongoing clinical trials that investigate cartilage repair and restoration procedures.

STUDY DESIGN

Systematic review.

METHODS

A systematic review of the publicly available level I/II literature and of the publicly listed clinical trials regarding cartilage repair and restoration procedures for the knee was conducted adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

Seventeen published studies and 52 clinical trials were included. Within the 17 published studies, the most common procedure studied was microfracture (MFX) + augmentation (N = 5; 29.4%) and the most common comparison/control group was MFX (N = 10; 58.8%). In total, 13 different cartilage procedure groups were evaluated. For published studies, the most common patient-reported outcome (PRO) measures assessed is the Knee Injury and Osteoarthritis Outcome Score (KOOS) and Visual Analog Scale-Pain (VAS) (N = 10 studies, 58.8% each, respectively). Overall, there are 10 different PROs used among the included studies. Ten studies demonstrate superiority, 5 demonstrate noninferiority, and 2 demonstrate inferiority to the comparison or control groups. For the clinical trials included, the most common procedure studied is MFX + augmentation (N = 16; 30.8%). The most common PRO assessed is KOOS (N = 36 trials; 69.2%), and overall there are 24 different PROs used among the included studies.

CONCLUSIONS

Recently published studies and clinical trials evaluate a variety of cartilage repair and restoration strategies for the knee, most commonly MFX + augmentation, at various time points of outcome evaluation, with KOOS and VAS scores being used most commonly. MFX remains the most common comparison group for these therapeutic investigations. Most studies demonstrate superiority versus comparison or control groups. Understanding the nature of published and ongoing clinical trials will be helpful in the investigation of emerging technologies required to navigate the regulatory process while studying a relatively narrow population of patients.

Osteochondral Autograft Transplant as a Potential Salvage Procedure for Articular Cartilage Defects of the Lateral Compartment in Lateral Meniscus-Deficient Knees: Results From a Country With Limited Availability of Meniscal Transplant

Background:

The treatment of a meniscus-deficient knee is challenging, especially when patients are young and active and are not favorable candidates for prosthetic joint replacement.

Hypothesis:

We hypothesized that osteochondral autologous transplant (OAT) alone can be considered a salvage treatment for patients with cartilage damage of the lateral compartment of the knee, even with lateral meniscal deficiency, if the knee alignment is close to neutral.

Study Design:

Case series; Level of evidence, 4.

Methods:

Patients with lateral meniscal deficiency, whose femorotibial angle was 170° to 180° and who underwent OAT on the lateral compartment of the knee without concomitant realignment osteotomy, were retrospectively included in this study. The International Knee Documentation Committee (IKDC) subjective score and the Japanese Orthopaedic Association score for knee osteoarthritis (JOA knee score) were recorded. The International Cartilage Repair Society (ICRS) cartilage repair assessment was used to evaluate the repaired cartilage at second-look arthroscopy.

Results:

The study included 10 patients (mean ± SD age, 31.7 ± 19.7 years; 3 men and 7 women) who had ICRS grade 4 cartilage lesions (mean size, 3.5 ± 1.7 cm²); the mean follow-up was 73.8 ± 42.5 months. From preoperative assessment to final follow-up, the mean IKDC subjective score improved significantly from 53.5 ± 10.0 to 85.4 ± 10.1, and the mean JOA knee score improved significantly from 81.0 ± 8.4 to 95.6 ± 5.3 (P = .004 for both). One patient with a femorotibial angle of 170° underwent revision distal femoral osteotomy owing to prolonged symptoms and progression of the valgus deformity, and 2 other patients with femorotibial angles of 170° and 171° also exhibited progression of valgus malalignment or low clinical scores postoperatively. Patients with a favorable femorotibial angle (174°-178°) exhibited relieved symptoms and preservation of femorotibial angle alignment within 1° of change at follow-up. At second-look arthroscopy (n = 8 patients), 6 patients had an ICRS score of nearly normal or normal.

Conclusion:

In the study patients, for which a meniscal allograft was unavailable, the OAT procedure was able to relieve the symptoms associated with cartilage lesions, even with lateral meniscal deficiency, when the femorotibial angle alignment was close to neutral.

Analysis of Defect Size and Ratio to Condylar Size With Respect to Outcomes After Isolated Osteochondral Allograft Transplantation

BACKGROUND

Osteochondral allograft transplantation (OCA) is a successful knee joint preservation technique; however, the effects of defect size and defect size:condyle ratio (DSCR) are poorly understood.

PURPOSE

To quantify clinical outcomes of isolated OCA of the knee based on defect size and DSCR.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data from patients who underwent OCA of the knee without major concomitant procedures by a single surgeon were analyzed at a minimum follow-up of 2 years. Osteochondral defect size was measured intraoperatively, and femoral condyle size was measured with preoperative imaging. Patient-reported outcomes, reoperations, and survival rates were analyzed per defect size and DSCR, comparing males and females and patients <40 and ≥40 years old.

RESULTS

Sixty-eight patients were included, of whom 57% were male (mean ± SD: age, 34.5 ± 10.3 years; follow-up, 5.2 ± 2.6 years). Mean osteochondral defect size and DSCR were 3.48 ± 1.72 cm² and 0.2 ± 0.1, respectively. Defect size was larger among males as compared with females (3.97 ± 1.71 cm² vs 2.81 ± 1.16 cm², P = .005), while DSCRs were not significantly different between sexes ( P = .609). The cohort as a whole demonstrated improvements in the following scores: Lysholm, International Knee Documentation Committee, Knee injury and Osteoarthritis Outcome Score, Western Ontario and McMaster Universities Osteoarthritis Index, and 12-Item Short Form Health Survey Physical ( P < .05). There were 27 reoperations (39.7%) at a mean of 2.5 ± 1.92 years and 8 failures (11.8%) at a mean of 2.62 ± 1.3 years. Mean DCSR was higher among patients with graft failure (0.26 ± 0.20 vs 0.19 ± 0.07, P = .049). After stratification by age, failures among patients ≥40 years old were associated with a larger defect size (mean 5.37 ± 3.50 cm² vs 3.22 ± 1.32 cm², P = .03) and higher DSCR (mean 0.30 ± 0.25 vs 0.19 ± 0.06, P = .05) when compared with nonfailures. Failures among patients <40 years old were not significantly associated with defect size or DSCR ( P > .05) as compared with nonfailures.

CONCLUSION

Patients undergoing isolated OCA transplantation demonstrated significant clinical improvements and a graft survival of 88.2% at 5.2 years. Failures overall were associated with a larger DSCR, and failures among patients ≥40 years old with a larger DSCR and larger defect size. Increasing defect size among males was positively correlated with some improved outcomes, although this was not maintained in analysis of the DSCR, suggesting similar prognosis after OCA regardless of sex.

CLINICAL RELEVANCE

Failed osteochondral allografts are associated with larger defect sizes and defect:condyle ratios in this study, providing additional information to surgeons for appropriate patient consultation.

Treatment options for the symptomatic post-meniscectomy knee

PURPOSE

To provide a current review on the evidence for management of the symptomatic meniscus-deficient knee.

METHODS

A literature review was performed detailing the natural history and origin of symptoms in a meniscus-deficient knee, in addition to strategies for non-surgical management, meniscus scaffolds, meniscus allograft transplantation (MAT), isolated cartilage repair, unloading osteotomies, meniscus prosthesis, and joint replacements which were revealed as treatment possibilities.

RESULTS

Meniscus deficiency was recognized to lead to an early onset knee osteoarthritis (OA). A subset of patients develop post-meniscectomy syndrome: dull and nagging pain after a short pain-free interval subsequently to meniscectomy, which can be accompanied by transient effusions. Evidence for non-surgical management of post-meniscectomy knee pain is lacking. Two available meniscus scaffolds, indicated for symptomatic segmental meniscus deficiency, show pain relief at mid-term follow-up, and effect on joint preservation is unclear. MAT represents a durable solution for sub/total meniscus deficiency (80% survival at 10 years), but it is still considered a temporary solution for post-meniscectomy pain. MAT may also reduce the progression of OA. Isolated cartilage repair without a meniscus reconstruction is commonly performed, but better results were reported with preserved or reconstructed menisci. Osteotomies are used in the combination of misaligned knee and meniscus reconstruction or as pain solution for irreversible unilateral knee structural changes following a meniscectomy. Polycarbonate-urethane medial meniscus prosthesis is currently undergoing clinical trial. Joint replacements should be limited to later stages of post-meniscectomy OA.

CONCLUSIONS

Post-meniscectomy pain syndrome and post-meniscectomy knee OA are common findings after meniscus resection. Short-term pain relief is provided by non-surgical management, mid-term pain relief by meniscus scaffolds, and long-term relief by MAT, though each has differing indications. In later stages, osteotomies and joint replacements are indicated.

LEVEL OF EVIDENCE

IV.

Higher survivorship following meniscal allograft transplantation in less worn knees justifies earlier referral for symptomatic patients: experience from 240 patients

PURPOSE

To analyse the clinical outcome and survivorship of meniscal allograft transplantation (MAT), performed in a single unit, specifically to assess the impact of concomitant operations and the influence of articular cartilage lesions on outcome.

METHOD

A prospective case series analysis of 240 patients undergoing MAT with follow-up greater than 12 months (range 1-10 years) was performed. Group A represented patients with good chondral surfaces (ICRS 0-3A); Group B had good chondral surfaces with concomitant realignment osteotomy. Group C had good chondral surfaces with ACL reconstruction performed at the same time. Groups D and E had bare bone on one or both surfaces respectively. Kaplan-Meier survivorship and PROMS including Lysholm, KOOS, Tegner, and IKDC subjective scores were analysed.

RESULTS

Overall survivorship was 96.7% at 1 year, 87% at 5 years and 82.2% at 7 years. Groups A-C (knees without significant chondral damage) had significantly improved survivorship (95% at 5 years) compared to Groups D, E (full-thickness chondral wear) with 77% survivorship at 5 years. Survivorship and PROMS were equivalent between Groups A-C. Groups D and E had similar PROMS to Group A, but did have a higher failure rate. Overall 27% required further operative intervention.

CONCLUSIONS

Meniscal transplantation is clinically effective in treating patients with symptomatic meniscal deficiency. Where indicated, the addition of osteotomy or ACL reconstruction achieves results similar to patients undergoing simple meniscal transplantation in stable and normally aligned knees. Survivorship is lower in patients with full-thickness chondral loss and future treatments should, therefore, be directed at improving success in this at-risk group. The results support encouragement for earlier referral of symptomatic patients to a specialist meniscal reconstruction centre before a significant chondral damage is sustained.

LEVEL OF EVIDENCE

III.

[Meniscal lesion. A pre-osteoarthritic condition of the knee joint]

BACKGROUND

A close relationship between meniscal damage and articular cartilage exist. Likewise, (partial) meniscectomy may lead to the development of osteoarthritis (OA).

OBJECTIVES

With a special emphasis on therapeutic consequences for orthopaedic surgeons, the structural and functional relationship between meniscal tears/extrusion and cartilage loss, and/or the effect of meniscectomy or meniscal repair on the development of OA, are emphasized.

MATERIALS AND METHODS

A selective literature review with implementation of own research findings.

RESULTS

The close topographical and functional interplay between the menisci and the tibiofemoral cartilage is the basis for the clinically important relationship between meniscal damage and cartilage degeneration. In particular, due to its close connection to tibiofemoral OA, a degenerative meniscal lesion represents a pre-osteoarthritic condition. Meniscus extrusion is also often associated with tibiofemoral OA. Even large cartilage defects can cause meniscus lesions. Partial meniscectomy is strongly associated with the incidence and risk of progression of OA. Clinical results are particularly problematic after partial resection of the lateral meniscus. Although the use of arthroscopic partial resection for degenerative meniscal lesions has been controversially discussed, no long-term studies are available. A large number of studies emphasize the medium-term value of meniscus reconstruction compared to partial meniscus resection. Combined meniscus and cartilage damage are complex cases, and the value of a simultaneous therapy remains unclear.

CONCLUSIONS

Preserving the meniscus is the first step towards cartilage repair. Randomized and controlled studies will provide better information on the long-term outcomes of meniscal resection and repair with regard to OA development.

Establishing Clinically Significant Outcomes After Meniscal Allograft Transplantation

Background:

Traditionally, the primary outcome in meniscal allograft transplantation (MAT) has been long-term survivorship; however, short-term clinically significant outcomes are necessary to fully evaluate patient improvement after surgery.

Purpose:

To (1) establish the minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS) with respect to patient-reported outcome measures (PROMs) and (2) evaluate preoperative and intraoperative variables correlated with achieving these threshold values.

Study Design:

Cohort study (diagnosis); Level of evidence, 2.

Methods:

A prospectively maintained institutional registry was queried for all MATs performed between 1999 and 2017. The following PROM scores were collected: International Knee Documentation Committee (IKDC) score, Lysholm score, and Knee injury and Osteoarthritis Outcome Score (KOOS). Patients who completed preoperative and postoperative PROMs within a 1-month window were included to calculate the distribution-based MCID at this interval. An anchor question regarding satisfaction with surgery was asked at the same time point and was employed to determine the PASS using nonparametric receiver operating characteristic curve/area under the curve analysis. Multivariate regression analysis was performed to correlate patient demographics, medical history, and concomitant procedures to propensity in achieving the MCID and PASS.

Results:

A total of 98 patients who underwent MAT met the inclusion/exclusion criteria, of whom 10 underwent concomitant ligamentous procedures, 65 underwent concomitant cartilage procedures, and 7 underwent concomitant realignment procedures. The mean patient age was 29.4 ± 9.0 years, and the mean body mass index (BMI) was 26.8 ± 5.2 kg/m². The distribution-based MCID and PASS were determined for the Lysholm score (12.3 and 66.5) and IKDC (9.9 and 36.0) as well as the KOOS Pain (9.9 and N/A ), Symptoms (9.7 and 73.0), Activities of Daily Living (9.5 and N/A), Sport (13.3 and N/A), and Quality of Life (14.6 and 53.0) subscales, respectively. A preoperative Short Form Physical Component Summary (SF PCS) score greater than 32.0 was predictive of postoperative satisfaction. Patients with work-related claims had a reduced likelihood of achieving the MCID for the IKDC and the PASS for the KOOS Symptoms. An increased BMI was also associated with failing to achieve the PASS for the KOOS Quality of Life (QOL).

Conclusion:

This study established the MCID and PASS for the Lysholm score, IKDC, and KOOS in patients undergoing MAT. Workers’ compensation and higher BMI were associated with failing to achieve clinically significant values. Lower preoperative Lysholm, IKDC, and KOOS scores were predictive of achieving the MCID, while higher preoperative SF PCS scores were associated with achieving satisfaction after MAT.

Management of Chondral Lesions of the Knee: Analysis of Trends and Short-Term Complications Using the National Surgical Quality Improvement Program Database

PURPOSE

To provide updated surgical trends of cartilage procedures differentiated by the classic groups of palliative, repair, and restorative modalities.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was queried from 2010-2016 for the following cartilage procedures: chondroplasty, microfracture, arthroscopic osteochondral autograft or allograft transplantation, open osteochondral autograft or allograft transplantation, and autologous chondrocyte implantation. Demographic variables and short-term (30-day) complications were analyzed with 1-way analysis of variance and post hoc analysis. Linear regression analysis was performed to analyze trends over time.

RESULTS

A total of 15,609 procedures performed between 2010 and 2016 were analyzed. On average, 342.2 ± 27.9 cartilage procedures were performed per 100,000 operations. There was a linear increase in the management of overall cartilage procedures per 100,000 operations (P = .002). There were also linear increases in arthroscopic osteochondral autograft transplantation, arthroscopic osteochondral allograft transplantation, open osteochondral autograft transplantation, open osteochondral allograft transplantation, and autologous chondrocyte implantation (P < .001, P = .037, P = .001, P = .006, and P = .002, respectively). Meniscectomy was the most frequently performed concomitant procedure (9.7%-64.2% of cases). Chondroplasty and microfracture showed no change in frequency over time (P = .140 and P = .720, respectively). The overall complication rate was 2.1% for chondroplasty, 1.4% for microfracture, 1.8% for arthroscopic osteochondral autograft transplantation, 1.0% for arthroscopic osteochondral allograft transplantation, 1.4% for open osteochondral autograft transplantation, 1.1% for open osteochondral allograft transplantation, and 0.75% for autologous chondrocyte implantation. Deep vein thrombosis was the most common complication, occurring in 0.4% to 1.0% of cases. No statistically significant difference was found in complication rates between procedures (P = .105).

CONCLUSIONS

Cartilage restoration is becoming an increasingly popular modality to address chondral defects. Minimal complication rates suggest that these procedures may be safely performed concomitantly with other interventions.

LEVEL OF EVIDENCE

Level IV, retrospective database analysis.

Management of Long-Term Complications in the Setting of Lateral Meniscal Deficiency After Saucerization of a Discoid Lateral Meniscus in an Adolescent Patient: A Case Report and Review of the Literature

CASE

A 14-year-old adolescent with bilateral discoid menisci who had previously undergone discoid meniscal saucerization presented with pain and mechanical knee symptoms bilaterally. She had a torn left discoid lateral meniscus, a right lateral meniscal deficiency with an associated osteochondral defect, and valgus collapse of the right femur. She underwent successful repair of the left discoid meniscus as well as a femoral osteotomy, a meniscal transplant, and an osteochondral allograft transplantation in the right knee.

CONCLUSION

New treatment paradigms following initial interventions for discoid menisci are discussed. Patients may benefit from longer follow-up after discoid meniscal surgery, and providers should consider joint-preserving techniques early in the setting of meniscal deficiency.

Does Treatment of the Tibia Matter in Bipolar Chondral Defects of the Knee? Clinical Outcomes with Greater Than 2 Years Follow-up

PURPOSE

To compare the osteochondral allograft (OCA) outcomes of bipolar defects with isolated femoral defects and to investigate the optimal treatment of bipolar defects by comparing femoral OCA with tibial debridement to femoral OCA and tibial microfracture.

METHODS

A series of patients with 2-year follow-up from March 2004 to September 2015 after femoral OCA for bipolar chondral defects was identified. Group 1 contained patients with tibial defects treated with debridement and group 2 contained patients with microfractured tibial defects. A third group (group 3) with isolated femoral defects treated with OCA was identified and matched by gender, body mass index (BMI), laterality, and OCA size to groups 1 and 2. Patient-specific, defect-specific, intraoperative, and postoperative data including patient-reported outcomes were collected on all patients. The study groups were compared using analyses of variance, paired sample t tests, and χ-square analyses.

RESULTS

Thirty-six patients who had femoral OCA for bipolar lesions were identified with 20 patients in group 1 and 16 patients in group 2. Group 3 had 20 patients. There were no differences between the 3 groups in terms of gender (P = .616), BMI (P = .271), number of previous surgeries (P = .451), femoral or tibial defect size (P = .296), and OCA size (P = .981). Preoperative to postoperative patient-reported clinical outcomes (PROs) revealed statistical and clinically meaningful improvement in all 3 groups, but did not differ between groups. Patient-specific and defect-specific factors did not correlate with PROs. The graft survivorship for group 1 was 85% at 4.5 years, 100% for group 2 at 2.5 years, and 95% for group 3 at 3.8 years.

CONCLUSIONS

Regardless of tibial treatment, patients with bipolar defects treated with femoral OCA have clinically meaningful improvements in PROs and excellent graft survivorship comparable to isolated femoral OCAs at more than 2 years.

LEVEL OF EVIDENCE

Level III, case-control study.

Outcomes of Osteochondral Allograft Transplantation With and Without Concomitant Meniscus Allograft Transplantation: A Comparative Matched Group Analysis

BACKGROUND

Osteochondral allograft transplantation (OCA) is often performed with concomitant meniscus allograft transplantation (MAT) as a strategy for knee joint preservation, although to date, the effect of concomitant MAT on outcomes and failure rates after OCA has not been assessed.

PURPOSE

To determine clinical outcomes for patients undergoing OCA with MAT as compared with a matched cohort of patients undergoing isolated OCA.

STUDY DESIGN

Control study; Level of evidence, 3.

METHODS

Patients who underwent OCA of the medial or lateral femoral condyle without concomitant MAT by a single surgeon were compared with a matched group of patients who underwent OCA with concomitant MAT (ipsilateral compartment). The patients were matched per age, sex, body mass index, and number of previous ipsilateral knee operations ±1. Patient-reported outcomes, complications, reoperations, and survival rates were compared between groups.

RESULTS

One hundred patients undergoing OCA (50 isolated, 50 with MAT) with a mean ± SD follow-up of 4.9 ± 2.7 years (minimum, 2 years) were included (age, 31.7 ± 9.8 years; 52% male). Significantly more patients underwent OCA to the medial femoral condyle (n = 59) than the lateral femoral condyle (n = 41, P < .0001). Patients underwent 2.7 ± 1.7 operations on the ipsilateral knee before OCA. There were no significant differences between the groups regarding reoperation rate (n = 18 for OCA with MAT, n = 17 for OCA without MAT, P = .834), time to reoperation (2.2 ± 2.4 years for OCA with MAT, 3.4 ± 2.7 years for OCA without MAT, P = .149), or failure rates (n = 7 [14%] for OCA with MAT, n = 7 [14%] for OCA without MAT, P > .999). There were no significant differences in patient-reported clinical outcome scores between the groups at final follow-up. There was no significant difference in failure rates between patients undergoing medial femoral condyle OCA (n = 12, 15.3%) and lateral femoral condyle OCA (n = 5, 12.2%, P = .665).

CONCLUSION

These results imply that with appropriate surgical indications to address meniscus deficiency in patients otherwise indicated for OCA and despite the added surgical time and complexity of concomitant MAT, outcomes are favorable, with an 86% OCA graft survivorship at 5 years. This information can be used to counsel patients undergoing OCA with concomitant MAT as part of a knee joint preservation strategy.

Clinical Outcomes After Microfracture of the Knee: Midterm Follow-up

Background:

Microfracture is a single-stage arthroscopic procedure used to treat small- and medium-sized cartilage defects, the clinical results of which have been mixed to date.

Purpose:

To retrospectively evaluate prospectively collected patient-reported outcomes (PROs) after microfracture as well as to determine patient-related and defect-related factors associated with clinical outcomes and which factors predict the need for additional surgery.

Study Design:

Case-control study; Level of evidence, 3.

Methods:

All patients between the ages of 10 and 70 years who underwent microfracture by the senior author for a focal chondral defect of the knee between January 1, 2005, and March 1, 2010, were eligible for study enrollment. Patients were excluded if they underwent concomitant procedures that violated the subchondral bone. Functional outcomes were determined using preoperative and final follow-up PROs, including the Lysholm, International Knee Documentation Committee (IKDC), Knee injury and Osteoarthritis Outcome Score (KOOS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Short Form–12 (SF-12), and overall satisfaction scores. Patient-related factors (sex, age, body mass index [BMI]) and defect-related factors (lesion size, location, concomitant procedures, prior procedures) were analyzed for correlations with outcome scores. All patient-related and defect-related factors were also analyzed as predictors for subsequent surgery.

Results:

Overall, 101 patients (102 knees; 55 male, 46 female; mean age, 35.87 ± 12.52 years; mean BMI, 26.3 ± 5.5 kg/m²; mean defect size, 2.635 ± 1.805 cm²) were included. Lesion location included 44.90% at the medial femoral condyle, 21.43% at the trochlea, 11.22% at the lateral femoral condyle, 10.20% at multiple sites, 8.16% at the patella, and 4.08% at the tibial plateau. Microfracture was performed alone in 72 of 102 (71%) knees. At a mean follow-up of 5.66 ± 2.54 years (range, 2-11 years), clinically meaningful and statistically significant improvements were seen in all PROs (P < .05) except the SF-12 mental component score. Patients who had an isolated tibial plateau defect or multiple defects demonstrated reduced improvements in the symptom rate (P = .0237). Patients with a BMI >30 kg/m² had lower postoperative scores on the KOOS activities of daily living subscale (P = .0261) and poorer WOMAC function and WOMAC pain scores (P = .029 and .0307, respectively). Patient BMI, age, sex, defect location, concomitant procedures, and operative side were not significant predictors for additional surgery. Larger defect size (>3.6 cm²) and prior knee surgery were independent risk factors for additional knee surgery after microfracture.

Conclusion:

After microfracture, all PROs demonstrated clinically and statistically significant improvements at 5.7 years. Functionally, male patients benefited more from microfracture than female patients. Microfracture of tibial lesions and multisite microfracture provided less benefit than microfracture of isolated femoral defects. Larger lesion size (>3.6 cm²) and prior knee surgery predicted the need for additional knee surgery after microfracture.

The Influence of Full-Thickness Chondral Defects on Outcomes Following Meniscal Allograft Transplantation: A Comparative Study

PURPOSE

To compare a series of patients who underwent meniscus allograft transplantation (MAT) with full-thickness chondral defects (FTD) with those with no chondral defect (ND) with regard to the following: change in patient-reported outcomes (PROs) from baseline to 2-year follow-up and baseline to the final follow-up (including comparisons to minimal clinically important differences), complications and complication rates, reoperations and reoperation rates/timing, and failures and time to failure (revision MAT or conversion to total knee arthroplasty).

METHODS

Patients who underwent isolated medial or lateral MAT between September 1997 and March 2013 with a minimum of 2 years of follow-up were retrospectively identified and split into 2 groups based on the presence or absence of FTD (femoral condyle or tibial plateau) identified intraoperatively after debridement to allow for a better understanding of the lesion characteristics (when applicable): ND (Outerbridge grade 0/I) or FTD (Outerbridge grade IV). Patients with osteochondritis dissecans were eligible for inclusion, as were those with isolated single lesions, multiple lesions, or bipolar lesions. Those with a moderate Outerbridge grade (II and III)-whether treated or neglected-were excluded given the poorer reliability of grading intermediate lesions. Indications for MAT included those patients with subjective complaints (persistent joint-line pain) and objective findings (previous meniscectomy or nonviable meniscus state with pain localized to the affected compartment) of functional meniscal deficiency. All lateral MAT patients used a bridge-in-slot surgical technique, as did most medial MAT patients (few patients with earlier surgical dates received a keyhole technique). All FTD were treated concurrently at the time of index MAT with cartilage restoration procedures (microfracture, autologous chondrocyte implantation, DeNovo particulate cartilage grafting, or osteochondral auto/allografting). Reoperations, failures (revision MAT or conversion to arthroplasty), and PRO deltas were reported comparing baseline to 2-year follow-up and baseline to the final follow-up. Intergroup comparisons were made using Bonferroni-adjusted independent sample t-tests for continuous variables and χ-square for categorical variables.

RESULTS

A total of 91 patients (22 ND and 69 FTD) were identified and followed for a mean 4.48 ± 2.63 and 3.84 ± 2.47 years, respectively. There were no significant between-group differences in age, body mass index, or number of prior surgeries. The mean chondral lesion size in the FTD group was 4.43 ± 2.5 cm². Concomitant anterior cruciate ligament reconstruction was performed significantly more in ND-group patients than FTD-group patients (8 [38.1%] vs 8 [11.8%], P = .004). There were no differences between ND-group and FTD-group patients in concomitant realignment procedures performed (2 [9.1%] vs 7 [10.1%], P = .986), or prior ligament reconstruction (9 [40.9%] vs 18 [26.1%], P = .111) or realignment procedure (0 [0%] vs 0 [0%]). FTD-group patients underwent concomitant osteochondral allograft (69.6%), autologous chondrocyte implantation (18.8%), microfracture (13.0%), osteochondral autograft (4.3%), or DeNovo juvenile particulate cartilage implantation (1.4%). A comparison of the patient groups found no statistically significant differences in PROs preoperatively (P > .003 for all). Intergroup comparisons of both the 2-year and final follow-up delta PRO scores showed no statistically (P > .003 for all) or clinically (number of PROs meeting minimal clinically important differences) significant differences. One complication occurred (fractured hardware) in the FTD-group patients (1.3%). There were no differences in the number of subsequent surgeries (revision MAT: ND, 2 (10.0%) vs FTD, 8 (12.9%); P = .845) or failures (conversion to total knee arthroplasty: ND, 1 (5.0%) vs FTD, 2 (3.3%); P = .646).

CONCLUSIONS

When comparing a patient series with FTD who underwent MAT with a patient series with ND, there were no differences in the change in individual PROs from preoperative to the final follow-up. Similarly, there were no differences in complications or failure between those with ND or FTD diagnosed intraoperatively. The results of the current study suggest that chondral damage identified and treated by cartilage restoration means at the time of MAT may not affect the clinical outcomes of MAT.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Meniscal Allograft Transplantation With Concomitant Osteochondral Allograft Transplantation

Surgical strategies for knee joint preservation are numerous, with the procedure(s) of choice for a given patient dependent on the status of the articular cartilage, meniscus, overall alignment, and ligamentous stability. For patients with large, isolated, osteochondral defects of the articular cartilage of the femoral condyle, osteochondral allograft transplantation (OCA) is often performed in an effort to reduce pain and improve function. Similarly, for appropriately indicated patients with symptomatic meniscus deficiency, meniscus allograft transplantation (MAT) is an excellent surgical solution. Often patients require concomitant MAT and OCA as part of a joint preservation strategy. In this Technical Note, we describe the surgical technique for performing arthroscopic-assisted concomitant lateral MAT and lateral femoral condyle OCA as part of a knee joint preservation strategy.

Multiple Osteochondral Allograft Transplantation with Concomitant Tibial Tubercle Osteotomy for Multifocal Chondral Disease of the Knee

Symptomatic patellofemoral chondral lesions are a challenging clinical entity, as these defects may result from persistent lateral patellar maltracking or repetitive microtrauma. Anteromedializing tibial tubercle osteotomy has been shown to be an effective strategy for primary and adjunctive treatment of focal or diffuse patellofemoral disease to improve the biomechanical loading environment. Similarly, osteochondral allograft transplantation has proven efficacy in physiologically young, high-demand patients with condylar or patellofemoral lesions, particularly without early arthritic progression. The authors present the surgical management of a young athlete with symptomatic tricompartmental focal chondral defects with fresh osteochondral allograft transplantation and anteromedializing tibial tubercle osteotomy.

[Distal femoral osteotomy using a lateral opening wedge technique]

OBJECTIVE

To shift the weight-bearing axis of the lower limb medially by opening a lateral-based metaphyseal osteotomy at the distal femur.

INDICATIONS

Femoral-based valgus malalignment and symptomatic lateral unicompartimental osteoarthritis, lateral hyperpression syndrome, cartilage therapy of the lateral compartment, lateral meniscal replacement/transplantation, medial instability with valgus thrust, reconstruction of the medial collateral ligament, patellar instability and/or maltracking.

CONTRAINDICATIONS

Advanced cartilage damage (>grade 2) or subtotal meniscal loss of the medial compartment, age >65 years (relative), nicotine abuse, body mass index >30, flexion contracture >25°, corrections with a wedge base >10 mm in case of congenital deformities, inflammatory or septic arthritis, severe osteoporosis.

SURGICAL TECHNIQUE

Lateral approach to the distal femur; biplanar osteotomy (frontal + axial osteotomy), gradual opening of the osteotomy, osteotomy fixation with a locking plate.

POSTOPERATIVE MANAGEMENT

Free range of motion. Partial weight bearing with 20 kg for 2 weeks, followed by progressive weight bearing thereafter.

RESULTS

Mean improvement of knee scores from 20-30 points and mean 10-year survival rate of 80% in patients with lateral unicompartimental osteoarthritis. Mean complication rate of 9%.

Osteochondral Allograft Transplantation of the Knee: Analysis of Failures at 5 Years

BACKGROUND

Osteochondral allograft transplantation (OAT) is being performed with increasing frequency, and the need for reoperations is not uncommon.

PURPOSE

To quantify survival for OAT and report findings at reoperations.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A review of prospectively collected data of 224 consecutive patients who underwent OAT by a single surgeon with a minimum follow-up of 2 years was conducted. The reoperation rate, timing of reoperation, procedure performed, and findings at surgery were reviewed. Failure was defined by revision OAT, conversion to knee arthroplasty, or gross appearance of graft failure at second-look arthroscopic surgery.

RESULTS

A total of 180 patients (mean [±SD] age, 32.7 ± 10.4 years; 52% male) who underwent OAT with a mean follow-up of 5.0 ± 2.7 years met the inclusion criteria (80% follow-up). Of these, 172 patients (96%) underwent a mean of 2.5 ± 1.7 prior surgical procedures on the ipsilateral knee before OAT. Forty-eight percent of OAT procedures were isolated, while 52% were performed with concomitant procedures including meniscus allograft transplantation (MAT) in 65 (36%). Sixty-six patients (37%) underwent a reoperation at a mean of 2.5 ± 2.5 years, with 32% (21/66) undergoing additional reoperations (range, 1-3). Arthroscopic debridement was performed in 91% of patients with initial reoperations, with 83% showing evidence of an intact graft; of these, 9 ultimately progressed to failure at a mean of 4.1 ± 1.9 years. A total of 24 patients (13%) were considered failures at a mean of 3.6 ± 2.6 years after the index OAT procedure because of revision OAT (n = 7), conversion to arthroplasty (n= 12), or appearance of a poorly incorporated allograft at arthroscopic surgery (n = 5). The number of previous surgical procedures was independently predictive of reoperations and failure; body mass index was independently predictive of failure. Excluding the failed patients, statistically and clinically significant improvements were found in the Lysholm score, International Knee Documentation Committee score, Knee injury and Osteoarthritis Outcome Score, and Short Form-12 physical component summary at final follow-up ( P < .001 for all), with inferior outcomes (albeit overall improved) in patients who underwent a reoperation.

CONCLUSION

In this series, there was a 37% reoperation rate and an 87% allograft survival rate at a mean of 5 years after OAT. The number of previous ipsilateral knee surgical procedures was predictive of reoperations and failure. Of the patients who underwent arthroscopic debridement with an intact graft at the time of arthroscopic surgery, 82% experienced significantly improved outcomes, while 18% ultimately progressed to failure. This information can be used to counsel patients on the implications of a reoperation after OAT.

Long-term Outcomes After Osteochondral Allograft: A Systematic Review at Long-term Follow-up of 12.3 Years

PURPOSE

To (1) evaluate long-term outcomes of osteochondral allograft (OCA) with regard to clinical outcome scores, reoperation and failure rates, and (2) examine if certain factors predispose patients to worse outcomes.

METHODS

A comprehensive review was performed with specific inclusion criteria for studies with long-term outcomes after OCA. Studies reported on patient clinical scores such as Hospital for Special Surgery score, Knee Society Score (knee and function score), and Lysholm score. Reoperation and failure rates were recorded for each study. Modified Coleman Methodology Scores assessed study methodological quality.

RESULTS

Five studies with a total of 291 patients (55% male, 45% female) and average age of 34.8 years (range, 15 to 69 years) were included. Of all lesions, 67% were on the femoral condyles, 29% on the tibial plateau, and 4% were patellofemoral. All scores (Knee Society Function Score, Knee Society Knee Score, and Lysholm score) have significant mean improvement from preoperative to final follow-up. The mean postoperative Hospital for Special Surgery score was 84.1. The mean failure rate was 25% at 12.3 years with a reoperation rate of 36%. A total of 72% of the failures were conversion to total (68%) or unicompartmental (4%) knee arthroplasty and 28% involved graft removal, graft fixation, and graft revision. Patellofemoral lesions (83%) had a significantly higher reoperation rate than lesions involving the tibial plateau or the femoral condyles (34%, P = .01).

CONCLUSIONS

Overall, OCA demonstrated significant improvements in clinical outcome scores and good durability with successful outcomes in 75% of the patients at 12.3 years after surgery. Patellofemoral lesions are associated with decreased clinical improvement and more frequent reoperations. The orthopaedic literature is limited by heterogeneity in surgical technique, lesion and patient characteristics, and reporting of nonstandardized outcome measures.

LEVEL OF EVIDENCE

Level IV, systematic review of Level II and IV studies.

Malalignment: A Requirement for Cartilage and Organ Restoration

The treatment of combined knee pathology is a challenging problem that requires careful attention to all aspects of the underlying disease. This is true of the interplay among malalignment and meniscal or articular cartilage restoration in the knee. Optimal outcomes are contingent on a comprehensive preoperative evaluation of patient-specific factors (patient expectations, patient age, and activity level), as well as disease-specific factors of the knee. Surgical intervention for meniscal or chondral deficiencies without attention to malalignment will lead to inferior outcomes. The focus of this review is to highlight the importance of malalignment correction when treating meniscal and articular cartilage pathology. This objective will be accomplished by outlining the approach to the preoperative evaluation, discussing the indications for surgical intervention, reviewing the preferred surgical techniques for correcting coronal malalignment of the knee, and providing a discussion of clinical outcomes.