Mental Health Has No Predictive Association With Self-Assessed Knee Outcome Scores in Patients After Osteochondral Allograft Transplantation of the Knee

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.

Mood Disorders Are Associated with Increased Perioperative Opioid Usage and Health Care Costs in Patients Undergoing Knee Cartilage Restoration Procedure

OBJECTIVE

To identify the prevalence of mood disorder diagnoses in patients undergoing cartilage transplantation procedures and determine the relationship between mood disorders, opioid usage, and postoperative health care costs.

DESIGN

Patients with current procedural terminology (CPT) codes for osteochondral autograft transplantation (OAT), osteochondral allograft transplantation (OCA), and autologous chondrocyte implantation (ACI) were identified in the Truven Health Marketscan database (January 2009-September 2014). Patients were grouped based on having a preoperative mood disorder diagnosis (preMDD). Preoperative opioids, postoperative opioids ≥90 days, and health care costs within the year postoperative were compared for those with and without mood disorders. Costs were analyzed, adjusting for preoperative cost, sex, age, and opioid usage, for those with and without mood disorders.

RESULTS

A total of 3,682 patients were analyzed (ACI: 690, OAT: 1,294, OCA: 1,698). A quarter of patients had preMDD (ACI: 25.4%, OAT: 20.6%, OCA: 22.7%). Postoperative opioid use was more prevalent in preMDD patients (OAT: 37.1% vs. 24.1%, P < 0.001; OCA: 30.4% vs. 24.8%, P = 0.032; ACI: 33.7% vs. 26.2%, P = 0.070) (odds ratio [OR] ranged from 1.29 to 1.86). First-year postoperative log-transformed costs were significantly greater for preMDD patients (ACI: $7,733 vs. $5,689*, P = 0.012; OAT: $5,221 vs. $3,823*, P < 0.001; OCA: $6,973 vs. $3,992*, P < 0.001; *medians reported). The estimated adjusted first postoperative year cost increase for preMDD OCA patients was 41.7% (P < 0.001) and 28.0% for OAT patients (P = 0.034). There was no statistical difference for ACI patients (P = 0.654).

CONCLUSION

Cartilage transplantation patients have a high prevalence of preoperative mood disorders. Opioid use and health care costs were significantly greater for patients with preoperative mood disorder diagnoses.

LEVEL OF EVIDENCE

Level III, retrospective therapeutic study.

SF-36 Physical Component Score Is Predictive of Achieving a Clinically Meaningful Improvement after Osteochondral Allograft Transplantation of the Femur

BACKGROUND

Osteochondral allograft (OCA) transplantation is an increasingly common treatment for patients with symptomatic focal chondral lesions of the knee. There has been increasing interest in determining predictive factors to maximize patient benefit after this operation. The aim of the present study is to evaluate the predictive association of the physical component (PCS) and mental component (MCS) scores of the Short Form 36 (SF-36) questionnaire for achievement of the minimal clinically important difference (MCID) after OCA transplantation.

METHODS

This retrospective study of a longitudinally maintained institutional registry included 91 patients who had undergone OCA transplantation for symptomatic focal osteochondral lesions of the femoral condyle. Included patients were those with complete preoperative questionnaires for the SF-36 and IKDC and completed postoperative IKDC at 2-year follow-up. Multivariate analysis was performed evaluating predictive association of the preoperative MCS and PCS with achievement of the MCID for the IKDC questionnaire.

RESULTS

Logistic multivariate modeling demonstrated a statistically significant association between lower preoperative PCS and achievement of the MCID (P = 0.022). A defect diameter >2 cm was also associated with achievement of MCID (P = 0.049). Preoperative MCS did not demonstrate a significant association (P = 0.09) with achievement of the MCID.

CONCLUSIONS

For this cohort of 91 patients, the preoperative SF-36 PCS and lesion size were predictive of achievement of the MCID at 2-year follow-up after femoral OCA transplantation. These findings support an important role of baseline physical health scores for predicting which patients will obtain a meaningful clinical benefit from this surgery.

Influence of mental health on postoperative outcomes in patients following biceps tenodesis

PURPOSE

To evaluate the relationship between preoperative mental health measured by the Short-Form 12 health survey mental component score and outcomes after isolated biceps tenodesis.

METHODS

The American Shoulder and Elbow Surgeons form (ASES), Single Assessment Numeric Evaluation (SANE), Constant-Murley score (CMS), and visual analog scale (VAS) for pain were administered preoperatively and at 6 and 12 months postoperatively to consecutive patients undergoing isolated biceps tenodesis between 2014 and 2018. Minimal clinically important difference, substantial clinical benefit (SCB), patient-acceptable symptom state (PASS), and rates of achievement were calculated. Patients were stratified by mental health status based on preoperative scores on the Short-Form 12 health survey mental component score. Multivariate logistic regression was performed to evaluate preoperative mental health status on achievement of minimal clinically important difference, SCB, and PASS.

RESULTS

Patients demonstrated significant improvements in all outcome measures (P < .001). Patients with depression reported inferior postoperative scores on all patient-reported outcome measures. Low preoperative mental health score significantly predicted reduced likelihood to achieve SCB (odds ratio [OR]: 0.38, 95% confidence interval [CI]: 0.17-0.81, P = .01) and PASS (OR: 0.28, 95% CI: 0.12-0.65, P = .003) on the ASES form, SANE (OR: 0.24, 95% CI: 0.10-0.61, P = .003), CMS (OR: 0.25, 95% CI: 0.08-0.77, P = .016), and VAS pain (OR: 0.01, 95% CI: 0.00-0.31, P = .008).

CONCLUSION

Patients with depression reported inferior scores on all postoperative patient-reported outcome measures and demonstrated lower odds of achieving the SCB and PASS on the ASES form and PASS on the SANE, CMS, and VAS pain, compared with nondepressed patients.

The Effect of Mechanical Leg Alignment on Cartilage Restoration With and Without Concomitant High Tibial Osteotomy

PURPOSE

To assess graft survivorship in patients who underwent autologous chondrocyte implantation (ACI) or osteochondral allograft transplantation (OCA) for the treatment of focal full-thickness cartilage lesions on the medial femoral condyle with and without concomitant high tibial osteotomy (HTO), depending on the preoperative lower-extremity alignment. A secondary purpose was to retrospectively evaluate associated factors for ACI and OCA graft failures.

METHODS

A total of 168 patients who underwent cartilage repair with ACI or OCA with or without HTO for focal chondral defects on the medial femoral condyle by a single surgeon between March 2007 and February 2018 were included. Clinical notes, operative reports, and radiographic imaging were reviewed for each patient. Detailed Kaplan-Meier analyses were performed based on patient's mechanical axis alignment. In a subanalysis, failures and nonfailures in patients treated with ACI or OCA were comparatively evaluated.

RESULTS

In ACI, neutral mechanical alignment resulted in a significantly longer graft survival compared with slight valgus alignment (P = .003 and P = .05, respectively). No significant differences in survivorship were seen based on mechanical axis alignment in OCA patients (P > .05). Patients who were considered failures after ACI presented significantly more often with valgus alignment (P = .002), whereas failures in the OCA group were more often female and smokers (P = .025; P = .034).

CONCLUSIONS

In summary, the results of this study suggest that neutral mechanical axis alignment, regardless if physiologic or through HTO, improves survivorship in patients undergoing medial compartment ACI. Neutral alignment also showed a trend towards improved survivorship in patients after OCA, but this did not reach statistical significance.

LEVEL OF EVIDENCE

Case-Series; Level of evidence, 4.