Functional Outcomes and Return to Sport After Cartilage Restoration of the Knee in High-level Athletes

Sex does not influence the long-term outcome of matrix-assisted autologous chondrocyte transplantation

PURPOSE

Regenerative techniques for articular cartilage lesions demonstrated heterogeneous clinical results. Several factors may influence the outcome, with sex being one of the most debated. This study aimed at quantifying the long-term influence of sex on the clinical outcome obtained with a regenerative procedure for knee chondral lesions.

METHODS

Matrix-assisted autologous chondrocyte transplantation (MACT) was used to treat 235 knees which were prospectively evaluated with the International Knee Documentation Committee (IKDC), EuroQol visual analogue scale, and Tegner scores at 14-year mean follow-up. A multilevel analysis was performed with the IKDC subjective scores standardised according to the age/sex category of each patient and/or the selection of a match-paired subgroup to compare homogeneous men and women patients.

RESULTS

At 14 years, men and women showed a failure rate of 10.7% and 28.8%, respectively (p < 0.0005). An overall improvement was observed in both sexes. Women had more patellar lesions and men more condylar lesions (p = 0.001), and the latter also presented a higher preinjury activity level (p < 0.0005). Men had significantly higher IKDC subjective scores at all follow-ups (at 14 years: 77.2 ± 18.9 vs. 62.8 ± 23.1; p < 0.0005). However, the analysis of homogeneous match-paired populations of men and women, with standardised IKDC subjective scores, showed no differences between men and women (at 14 years: -1.6 ± 1.7 vs. -1.9 ± 1.6).

CONCLUSION

Men and women treated with MACT for knee chondral lesions presented a significant improvement and stable long-term results. When both sexes are compared with homogeneous match-paired groups, they have similar results over time. However, women present more often unfavourable lesion patterns, which proved more challenging in terms of long-term outcome after MACT.

LEVEL OF EVIDENCE

Level II.

Kinesiophobia and Pain Catastrophizing Leads to Decreased Return to Sport Following Autologous Chondrocyte Implantation but Does Not Affect Return to Work

OBJECTIVE

To evaluate the effect of fear of reinjury on return to sport (RTS), return to work (RTW), and clinical outcomes following autologous chondrocyte implantation (ACI).

DESIGN

A retrospective review of patients who underwent ACI with a minimum of 2 years in clinical follow-up was conducted. Patient-reported outcomes collected included the Visual Analog Scale (VAS) and Knee Injury and Osteoarthritis Outcome Score (KOOS). Kinesiophobia and pain catastrophizing was assessed using the Tampa Scale of Kinesiophobia-11 (TSK-11) and Pain Catastrophizing Scale (PCS), respectively. Patients were surveyed on their RTS and RTW status.

RESULTS

Fifty-seven patients (50.9% female) were included in our analysis. Twenty-two (38.6%) patients did not RTS. Of the 35 patients (61.4%) who returned, nearly half (48.6%) returned at a lower level of play. TSK-11 (P = 0.003), PCS (P = 0.001), and VAS pain scores (P < 0.001) were significantly greater in patients that did not RTS than in those who returned. All KOOS subscores analyzed were significantly lower (P < 0.001) in patients that did not RTS than in those who returned at the same level or higher. Of the 44 (77.2%) patients previously employed, 97.7% returned to work. Increasing TSK-11 scores were associated with lower odds of returning to sport (P = 0.003).

CONCLUSION

Fear of reinjury decreases the likelihood that patients will return to sport after ACI. Patients that do not return to sport report significantly greater levels of fear of reinjury and pain catastrophizing and lower clinical knee outcomes. Nearly all patients were able to return to work after surgery.

LEVEL OF EVIDENCE

IV case series.

Increased kinesiophobia leads to lower return to sport rate and clinical outcomes following osteochondral allograft transplantation of the knee

PURPOSE

The purpose of this study is to describe the postoperative psychological state of patients following osteochondral allograft (OCA) transplantation in the knee and to determine whether patient-perceived kinesiophobia is associated with the rate of return to sport (RTS).

METHODS

A retrospective review of the electronic medical record at a single institution was conducted for all patients that underwent OCA transplantation from January 2010 to 2020. Patient-reported outcomes including the visual analog scale (VAS), knee injury and osteoarthritis outcome score (KOOS) and the Tampa scale of kinesiophobia-11 (TSK-11) were collected. Patients were surveyed regarding their postoperative RTS status.

RESULTS

A total of 38 patients (52.6% female) were included in our analysis. Overall, 24 patients (63.2%) returned to sport with 12 (50%) of these patients returning at a lower level of play. When comparing patients that return to sport to those that did not, patients that return had significantly superior KOOS pain (p = 0.019) and KOOS QOL (p = 0.011). Measures of kinesiophobia (TSK-11) were significantly higher among patients that did not return to sport (p = 0.014), while satisfaction (n.s.) and pain intensity (n.s.) were comparable between groups. Logistic regression models controlling for demographic factors, VAS pain scores and lesion size showed that for every one-point increase in TSK-11 kinesiophobia score, patients were 1.33 times more likely to return to sport at a lower level (p = 0.009). For every one-point increase in TSK-11 scores KOOS QOL decreased by 2.4 points (p < 0.001).

CONCLUSION

Fear of reinjury decreases the likelihood that patients will return to their preoperative level of sport after OCA transplantation. Patients that do not return to sport report significantly greater fear of reinjury and inferior clinical outcomes, despite similar levels of satisfaction and pain compared to those that return.

LEVEL OF EVIDENCE

Level III.

Outcomes and Return to Sport After Knee Osteochondral Allograft Transplant in Professional Athletes

Background

Limited data are available on the outcomes and return-to-sport rates after osteochondral allograft transplant in professional athletes.

Purpose

To evaluate the experience of a single senior surgeon in treating professional athletes with osteochondral allograft transplant, including analyzing clinical outcomes and return to sport.

Study Design

Case series; Level of evidence, 4.

Methods

The authors performed a retrospective review of professional athletes treated with primary osteochondral allograft to the knee between January 1, 2001, and January 1, 2021, by a single surgeon. Athletes were required to play at the professional level in their sport and have a minimum of 2 years of follow-up. Return-to-sport rates and timing were evaluated. Patient-reported outcomes were assessed preoperatively and at final follow-up. Reoperations and failures were also tabulated.

Results

The study included 15 professional athletes who represented a variety of sports, with follow-up at a mean of 4.91 ± 2.2 years (range, 2.0-9.4 years). The majority (8 athletes; 53%) had undergone prior surgeries to the operative knee. Eleven (73%) returned to sport at a mean of 1.22 ± 0.4 years (range, 0.75-2 years), and of the 8 undergoing isolated osteochondral allograft, 7 (87.5%) returned at 1.28 ± 0.3 years. Ten athletes (66.7% of total; 90.9% of those who returned) returned to sport at the same level or higher compared with before surgery. Significant improvements were seen in each assessed patient-reported outcome score at final follow-up. Two of the 3 (66.7%) patients who underwent concomitant meniscal allograft transplant were able to return to sport at the same level or higher than presurgery. Three (20%) underwent second-look arthroscopy, 1 (6.7%) of whom underwent cartilage debridement of the osteochondral allograft.

Conclusion

Osteochondral allograft transplant in professional athletes can result in a high rate of return to play at a similar or higher level as presurgery, even when performed with concomitant procedures such as meniscal allograft transplant. High-level athletes should expect significant postoperative improvement in clinical outcomes.

Surgical Management of Failed Articular Cartilage Surgery in the Knee

Failure rates of cartilage restoration surgery range from 14% to 43%. When failure of prior cartilage restoration surgery is suspected, a thorough clinical workup should be performed to assess the timing and duration of symptoms. Attention should be paid to patient risk factors such as age, body mass index, and smoking status. Concomitant pathology such as malalignment, ligament insufficiency, and meniscus status must be evaluated before revision surgery. As outlined in our treatment algorithm, the size/location of the lesion and the type of primary procedure will guide planning for revision procedures. [Orthopedics. 2023;46(5):262-272.].

Return to Pivoting Sports after Cartilage Repair Surgery of the Knee: A Scoping Review

OBJECTIVE

To perform a scoping literature review evaluating and reporting on outcomes and return to pivoting sports after cartilage procedures. For this review, the following cartilage procedures were evaluated: microfracture, osteochondral autograft transplantation (OAT), osteochondral allograft transplantation (OCA), and autologous chondrocyte implantation (ACI).

DESIGN

The scoping review incorporated articles identified using PubMed (MEDLINE), CINAHL, and Cochrane Central Register of Controlled Trials. Screening of reference lists of included studies and forward citation tracking were performed to identify additional studies. Reported on return to pivoting sports after cartilage surgery written in English language.

RESULTS

Sixteen studies fulfilled the inclusion criteria. The return to sports (RTS) rates after microfracture ranged from 44% to 83%, and to preinjury level from 25% to 75%. The RTS rates after OAT ranged from 87% to 100%, and to preinjury level from 67% to 93%. The RTS rates after OCA ranged from 77% to 80%, and to preinjury level 64%. The RTS rates after ACI ranged from 33% to 96%, and to preinjury level from 26% to 67%.

CONCLUSIONS

There was a high heterogeneity and range in rates of RTS in athletes participating in pivoting sports. Most studies reported high rates of RTS; however, return to preinjury level was lower. These data may be important to clinicians in shared decision making on the type of procedure to be performed and counseling pivoting sports athletes on prognosis and expected RTS rates.

Treatment of Cartilage Defects of the Knee in Military Tactical Athletes: An Overview of Management and Clinical Outcomes

Cartilage defects of the knee are a common problem that can be caused by trauma or chronic repetitive overload and result in debilitating functional limitations. These consequences are of particular significance to military service members, who, by in large, are a group of young, active individuals with professional duties requiring full, unrestricted activity and function. The burden of knee chondral-related disease among military tactical athletes is well established, and systematic approach to the evaluation of a military member with suspected knee chondral pathology facilitates the execution of a surgical procedure that maximizes the likelihood of a return to duty. Despite advances in cartilage restoration surgery, chondral pathology of the knee remains a vexing problem and an omnipresent threat to military medical readiness and warfighter lethality.