Functional Acetabular Component Positioning During Direct Anterior Approach Hip Arthroplasty Using a Novel Three-Dimensional Virtual Mesh Imaging System With Fluoroscopy.

BACKGROUND: Optimal position of total hip arthroplasty (THA) components is critical for joint mechanics and stability. Acetabular component positioning during supine surgery in direct anterior approach (DAA) THA may be different in the standing position postoperatively, which traditional fluoroscopy is unable to predict. A novel 3-dimensional (3D) image analysis technology (IAT) that uses artificial intelligence to measure the tilt and rotation of the pelvis has enabled prediction of component positioning from supine to standing. The purpose of this study was to compare intraoperative fluoroscopy, non-3D-IAT, and 3D-IAT with postoperative standing radiographs to assess the accuracy of component positioning. METHODS: From 2022 to 2023, 30 consecutive patients (86.6% women, mean age 59 [range, 55 to 67]) undergoing primary DAA THA with the use of the 3D-IAT were identified. A separate cohort of 148 patients from 2020 to 2021 (85% women, mean age 65 [range, 55 to 69]) who underwent DAA THA with non-3D-IAT was used for comparison. Leg length discrepancy (LLD), cup anteversion, and inclination were manually measured on intraoperative fluoroscopic images and digitally measured using IAT. Follow-up evaluation occurred at 1 month with standing pelvis radiographs measured using Ein Bild Röntgen Analyze-Cup software. Measurements were compared via Wilcoxon signed rank tests where P ≤ .05 indicates significantly different measurements. RESULTS: Median LLD, inclination, and anteversion measurements via non-3D-IAT and fluoroscopy were significantly different compared to postoperative standing radiographs (P < .001). The 3D-IAT more accurately predicted LLD, abduction, and anteversion, with values not significantly different from postoperative standing measurements (P = .23, P = .93, and P = .36, respectively). CONCLUSIONS: The use of the 3D-IAT during DAA THA allowed for the more accurate prediction of acetabular component position in the standing position postoperatively.

High Rate of Unplanned Reoperation for Interprosthetic Femur Fractures After Total Hip and Knee Arthroplasty.

BACKGROUND: Interprosthetic femur fractures (IPFFs) are a rare, but devastating complication following total joint arthroplasty. There is limited evidence to help guide their management. The purpose of this study was to describe the features, treatment, and outcomes of surgically managed IPFFs. METHODS: We retrospectively identified 75 patients who had 76 IPFFs. The mean age at the time of IPFF was 75 years (range, 29 to 94), and 78% were women. The mean body mass index was 30 (range, 19 to 51), and the mean follow-up was 3 years (range, 0 to 14). There were 16 Vancouver B1 fractures, 28 Vancouver B2 fractures, 2 Vancouver B3 fractures, and 30 Vancouver C fractures. All B1 fractures underwent open reduction internal fixation (ORIF). All Vancouver B2 and B3 fractures underwent revision arthroplasty, including 1 proximal femur replacement and 1 total femur replacement. Vancouver C fractures were treated with ORIF (n = 20), distal femoral replacement (n = 9), and in 1 case, total femur replacement (n = 1). Kaplan-Meier survivorship was used to calculate 2-year survival free from all-cause reoperation and periprosthetic joint infection (PJI). RESULTS: The 2-year survivorship-free rate from reoperation was 71%. There were 18 reoperations following initial surgical management of the IPFF, including 9 for infection, 3 for refracture, 3 for nonunion, 2 for hardware failure, and 1 for instability. An initial IPFF involving a stemmed femoral total knee arthroplasty component was associated with increased risk for reoperation (P = .007) and PJI (P = .044). There was no difference in survivorship free of reoperation between IPFFs managed with ORIF or revision arthroplasty (P = .72). CONCLUSIONS: An IPFF is a devastating complication following total joint arthroplasty with high reoperation rates, most commonly secondary to PJI. Those IPFFs that occurred between 2 stemmed components were at the highest risk for reoperation.

A Consecutive Series of Vancouver B2 Periprosthetic Femur Fractures Treated With Contemporary Monoblock Versus Modular Revision Stems: Clinical and Radiographic Outcomes.

BACKGROUND: Tapered fluted titanium (TFT) stems are the implant design of choice for managing Vancouver B2 periprosthetic femur fractures (PFFs), producing reliable results over the past few decades. The aim of this study was to compare the radiographic and clinical outcomes of Vancouver B2 PFFs treated with contemporary monoblock versus modular TFTs. METHODS: A consecutive series of 113 patients (72 women, 64%, mean age 70 years [range, 26 to 96]) who had a B2 PFF were treated with either a monoblock (n = 42) or modular (n = 71) TFT stem between 2008 and 2021. The mean body mass index was 30 ± 7. The mean follow-up was 2.9 years. A radiographic review was performed to assess leg length and offset restoration, endosteal cortical contact length, and stem subsidence. Kaplan-Meier analyses were used to determine survivorship without revision, reoperation, or dislocation. RESULTS: There was no difference in the restoration of leg length (0.3 ± 8.0 mm) or offset (2.8 ± 8.2 mm) between the monoblock and modular cohorts (P > .05). Mean endosteal cortical contact length (47.2 ± 26.6 versus 46.7 ± 2 6.4 mm, P = .89) and stem subsidence (2.7 ± 3.5 versus 2.4 ± 3.2 mm, P = .66) did not differ. No difference in patient-reported outcome measures (Hip Disability and Osteoarthritis Outcome Score-Joint Replacement; Veterans RAND 12 Item Health Survey Physical and Mental; visual analog score; and Lower Extremity Activity Scale) between the groups was observed. Survivorship at 2 years free from reoperation, revision, and dislocation was 90.4, 90.3, and 97.6%, respectively, for the monoblock cohort; and 84.0, 86.9, and 90.0%, respectively, for the modular cohort. CONCLUSIONS: No significant differences in radiographic or clinical outcomes were observed between patients treated with monoblock or modular TFTs in this large series of B2 PFFs.

Similar Outcomes After Osteochondral Allograft Transplantation in Anterior Cruciate Ligament-Intact and -Reconstructed Knees: A Comparative Matched-Group Analysis With Minimum 2-Year Follow-Up.

PURPOSE: To compare failure rates and clinical outcomes of osteochondral allograft transplantation (OCA) in anterior cruciate ligament (ACL)-intact versus ACL-reconstructed knees at midterm follow-up. METHODS: After a priori power analysis, a prospective registry of patients treated with OCA for focal chondral lesions ≥2 cm2 in size with minimum 2-year follow-up was used to match ACL-reconstructed knees with ACL-intact knees by age, sex, and primary chondral defect location. Exclusion criteria included meniscus transplantation, realignment osteotomy, or other ligamentous injury. Complications, reoperations, and patient responses to validated outcome measures were reviewed. Failure was defined by any procedure involving allograft removal/revision or conversion to arthroplasty. Kaplan-Meier analysis and multivariate Cox regression were performed to evaluate the association of ACL reconstruction (ACLR) with failure. RESULTS: A total of 50 ACL-intact and 25 ACL-reconstructed (18 prior, 7 concomitant) OCA patients were analyzed. The mean age was 36.2 years (range, 14-62 years). Mean follow-up was 3.9 years (range, 2-14 years). Patient demographics and chondral lesion characteristics were similar between groups. ACL-reconstructed patients averaged 2.2 ± 1.9 prior surgeries on the ipsilateral knee compared with 1.4 ± 1.4 surgeries for ACL-intact patients (P = .014). Grafts used for the last ACLR included bone-patellar tendon-bone autograft, hamstring autograft, Achilles tendon allograft, and tibialis allograft (data available for only 11 of 25 patients). At final follow-up, 22% of ACL-intact and 32% of ACL-reconstructed patients had undergone reoperation. OCA survivorship was 90% and 96% at 2 years and 79% and 85% at 5 years in ACL-intact and ACL-reconstructed patients, respectively (P = .774). ACLR was not independently associated with failure. Both groups demonstrated clinically significant improvements in the Short Form-36 pain and physical functioning, International Knee Documentation Committee subjective, and Knee Outcome Survey-Activities of Daily Living scores at final follow-up (P < .001), with no significant differences in preoperative, postoperative, and change scores between groups. CONCLUSIONS: OCA in the setting of prior or concomitant ACLR does not portend higher failure rates or compromise clinical outcomes. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Initial Outcomes of Single versus Multiple-Plug Osteochondral Allograft Transplantation for Osteochondral Defects of the Knee: A Matched Cohort Analysis.

Although several prior studies have described the outcomes of osteochondral allograft (OCA) transplantation for single osteochondral lesions, there is a paucity of comparative data on outcomes of single versus multiple OCA transplants. We aimed to describe the initial outcomes of single-plug versus multiple-plug knee OCA transplants at a minimum of 1 year of follow-up. We hypothesized that there would be no difference in patient-reported outcome measures (PROMs) between patients undergoing single-plug and multiple-plug OCA transplants at a minimum of 1 year of follow-up. We retrospectively reviewed the prospectively collected data of patients undergoing OCA transplantation for large (>2 cm2) osteochondral defects of the knee. Thirty patients who underwent multiple-plug (2 + ) OCA transplants (either single surface using the snowman technique or multi-surface) were 1:1 age, sex, and body mass index (BMI) matched with 30 patients who underwent single-plug OCA transplants. PROMs, including the International Knee Documentation Committee (IKDC) and Knee Injury and Osteoarthritis Outcome Score (KOOS) subscores, were obtained both preoperatively and at a minimum of 1 year postoperatively. Failure was defined as a revision OCA or conversion to unicompartmental knee arthroplasty (UKA) or total knee arthroplasty (TKA). The cohort comprised 30 females (31 affected left knees), with an average age of 37 ± 10.3 years and median follow-up of 2.0 years (interquartile range: 1.7-2.5 years). There was a significant increase in PROMs from the preoperative to the postoperative period for the entire cohort and the single-plug versus multiple-plug subgroups (p < 0.01). There was no difference between the groups with respect to the percentage of patients who achieved the minimal clinically important difference (MCID) for each PROM (p > 0.05). There were two failures, both in the single-plug group, with a mean time to failure of 3.5 years. There was no difference in the initial outcomes between patients undergoing single-plug versus multiple-plug OCA transplant at the short-term follow-up. LEVEL OF EVIDENCE:: Level IV, case series.

Early Recovery Outcomes in Patients Undergoing Contemporary Posterior Approach Total Hip Arthroplasty: Each Week Shows Progress.

Background: Little is known about patients' postoperative week-by-week progress after undergoing posterior approach total hip arthroplasty (THA) with regard to pain, function, return to work, and driving. Purpose: We sought to evaluate a large cohort of patients undergoing posterior approach THA with modified posterior hip precautions to better understand the trajectory of recovery. Methods: Patients at a single institution undergoing primary posterior approach THA by fellowship-trained arthroplasty surgeons were prospectively enrolled. Patient functional status and early rehabilitation recovery milestones were evaluated preoperatively and each week postoperatively for 6 weeks. Results: Of 312 patients who responded to weekly questionnaires, there were varying response rates per question. At 1 week after surgery, 15% (39/256) of respondents had returned to work, increasing to 57% (129/225) at week 6. At 6 weeks, 77% of patients (174/225) had returned to driving; 25% (56/225) were taking pain medication (including prescription opioids or nonsteroidal anti-inflammatory drugs); and 15% (34/225) were using assistive devices (down from 91%, 78%, 56%, 35%, and 27% at weeks 1, 2, 3, 4, and 5, respectively). Average postoperative Hip dysfunction and Osteoarthritis Outcome Score for Joint Replacement and Lower Extremity Functional Scale scores were significantly higher than preoperative scores. Respondents reported significantly less pain at each week postoperatively than the previous week. Conclusion: These findings suggest that there may be an expected pathway for recovery after posterior THA using perioperative pain protocols, modified postoperative precautions, and physical therapy protocols to improve patient outcomes after THA, with most patients returning to normal at 4 weeks. Defining the expected recovery timeline may help surgeons in counseling patients preoperatively and guiding their recovery.

Impact of Patient-Reported Allergies on Early Postoperative Opioid Use and Outcomes Following Ambulatory Hand Surgery.

Background: Patient-reported allergies (PRAs) are associated with suboptimal orthopaedic surgery outcomes and may serve as a proxy for mental health. While mental health disorders are known risk factors for increased opioid use, less is known about how PRAs impact opioid use after orthopedic surgery. The purpose of this study was to investigate the association between PRAs and postoperative opioid use, pain, and satisfaction following hand surgery. Methods: Patients who underwent ambulatory hand surgery at a single institution from May 2017 to March 2019 were retrospectively reviewed. Various scores, including the Mindfulness Attention Awareness Scale (MAAS), were collected preoperatively. Postoperatively, patients completed a 2-week pain diary, satisfaction, and visual analog scale (VAS) pain scores. Opioid consumption was converted to oral morphine equivalents (OMEs) using standard conversions. Results: A total of 137 patients were divided into 2 groups based on presence (≥1) (n = 73) or absence (0) (n = 64) of PRAs. At baseline, the ≥ 1 PRA group had significantly higher female composition (P < .001) and pain (P < .001) and lower PROMIS mental health scores (P = .044). Postoperative OME consumption averaged 42.5 (range 0-416) in the entire cohort, with no differences between groups. Among patients with ≥ 1 PRA, increasing number of allergies significantly correlated with increasing OME consumption across all time points (week 1, P = .016; week 2, P = .001; total, P = .005). Conclusions: The presence of PRAs did not impact postoperative narcotic usage, pain, or satisfaction. Increasing numbers of PRAs did, however, significantly correlate with higher narcotic use. These results may have implications for postoperative pain management in this population.

Preoperative Grades of Osteoarthritis and Meniscus Volume Correlate with Clinical Outcomes of Osteochondral Graft Treatment for Cartilage Defects in the Knee.

OBJECTIVE: To identify preoperative imaging-based indicators of knee degeneration that correlate with graft failure risk and postoperative clinical outcome scores after osteochondral graft treatment for chondral defects of the knee. DESIGN: Prospectively collected data from 113 patients (mean age, 34 years; 65% male) treated with mosaicplasty or osteochondral allograft transplantation (OCA) was reviewed. Four different aspects of knee degeneration were examined based on preoperative radiographs or magnetic resonance imaging: (1) Osteoarthritis using the Kellgren-Lawrence (KL) grading system, (2) meniscus volume, (3) meniscus quality, and (4) synovitis. Primary outcomes included graft failure, defined by removal/revision of the graft or conversion to arthroplasty, and patient responses to clinical outcome scores. RESULTS: Forty-one knees (36%) underwent mosaicplasty, and 72 knees (64%) underwent OCA. Mean duration of follow-up was 4.5 years (range, 2-14 years). A preoperative KL grade of ≥3 was correlated with increased failure rates (P = 0.01), lower postoperative International Knee Documentation Committee form (IKDC), Activities of Daily Living of the Knee Outcome Survey (KOS-ADL), and Overall Condition scores (P < 0.01), and decreased improvement in Overall Condition scores (P = 0.01). Within an individual tibiofemoral compartment, a preoperative meniscus volume grade of ≥3 (indicating <50% meniscus volume remaining) was correlated with increased condylar graft failure rates (P < 0.01). Preoperative meniscus quality and synovitis grades were not associated with graft failure rates or clinically meaningful differences in postoperative outcome scores. CONCLUSIONS: Greater preoperative osteoarthritis and meniscus volume loss were correlated with increased graft failure rates after osteochondral graft treatment for chondral defects of the knee.

Orthopaedic Surgery Residency Match After an Early-Exposure Research Program for Medical Students.

INTRODUCTION: The purpose of this study was to determine the proportion of students matching in orthopaedic surgery after a structured, early-exposure mentored research program and what factors were associated with those students compared with participants who matched in other specialties. METHODS: Program data were reviewed from 2007 to 2015. Multivariable binary logistic regression analysis was used to evaluate student and research factors associated with orthopaedic surgery match. RESULTS: Of 174 students, 117 (67%) matched into surgical residency programs, with 49% (n = 85) matching into orthopaedic surgery. The percentage of women matching into orthopaedic surgery (37%) was less than that of men (53%), which, however, increased over the study period. Students who matched in orthopaedic surgery had greater numbers of publications (3.55 [range 0 to 17] average publications) compared with students who matched in other specialties (1.98 (range 0 to 11) average publications). The average number of publications per student increased from 0.79 (±1.44, range 0 to 10, 40%) preprogram to 1.95 (±2.28, range 0 to 11, 71%) postprogram. Measured factors associated with orthopaedic surgery match were publications with program mentor, postprogram first authorship, and total publications. DISCUSSION: Approximately half of the participants matched into orthopaedic surgery. Analysis showed that research productivity increased after program participation and was statistically associated with increased likelihood of orthopaedic surgery match.

To "Heed the Call" Amidst the COVID-19 Pandemic: Perspectives From 4 Incoming Orthopaedic Surgery Interns.

As incoming orthopaedic surgery interns, we enter the workforce amidst a global pandemic-a pivotal moment in history. We do not know what the landscape will look like later this summer, but it will most likely be different for each of us and from those of our predecessors. Regardless whether COVID-19 will still be rampant or under better control, we know that we can start our internship and orthopaedic residency embracing a set of principles to "heed the call" no matter the circumstance.

Abductor Deficiency-Induced Recurrent Instability After Total Hip Arthroplasty.

¼ Operative intervention for deficient hip abductor muscles may require muscle transfer or the use of synthetic materials, possibly with biologic augmentation, to help stabilize the hip joint and prevent further dislocation following total hip arthroplasty (THA). ¼ Direct repair of the abductor mechanism onto the greater trochanter can be used in patients who present with instability <15 months following primary THA. ¼ Augmentation of soft tissue with acellular dermal allografts can be considered for patients with abductor avulsion that requires posterior capsular reconstruction. ¼ The Achilles tendon + calcaneal bone allograft is indicated for patients who have undergone multiple prior revision surgeries, who have experienced failure of nonoperative management, and have tissue inadequacy in the posterior wall of the hip joint. ¼ The gluteus maximus tendon transfer is indicated in patients with chronic abductor tears, limited or loss of function in the gluteus medius and minimus, and a fully functioning gluteus maximus. ¼ Vastus lateralis transfer may benefit patients with a history of multiple revision procedures, large separation between the gluteus medius tendon and the proximal part of the femur, and the ability to observe the postoperative protocol of splinting for 6 weeks. ¼ The latissimus dorsi tendon transfer should be reserved as a reconstructive procedure for patients with acute abductor insufficiency, such as those who have undergone extensive tumor resection. ¼ Synthetic mesh can be used to enable capsular reconstruction and prosthesis stabilization in patients undergoing salvage procedures for tumors of the hip and associated soft tissues. ¼ Synthetic ligament prostheses can be used in patients with recurrent posterior dislocations in the setting of normal components. ¼ The fascia lata plasty is indicated for patients with recurrent posterior instability without an identifiable cause. ¼ Although the quality of literature is limited, surgical interventions utilizing techniques of soft-tissue augmentation have shown promising outcomes with regard to pain relief, limping, ambulation, and the reduction of instability following THA.

Does Medial-Row Fixation Technique Affect the Retear Rate and Functional Outcomes After Double-Row Transosseous-Equivalent Rotator Cuff Repair?

BACKGROUND: Double-row transosseous-equivalent (TOE) rotator cuff repair techniques have been widely accepted because of their superior biomechanical properties when compared with arthroscopic single-row repair. Concerns regarding repair overtensioning with medial-row knot tying have led to increased interest in knotless repair techniques; however, there is a paucity of clinical data to guide the choice of technique. HYPOTHESIS: Arthroscopic TOE repair techniques using knotless medial-row fixation will demonstrate lower retear rates and greater improvements in the Constant score relative to conventional knot-tying TOE techniques. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: A systematic review of 3 databases (PubMed, Cochrane, and Embase) was performed using PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) guidelines. Inclusion criteria were English-language studies that examined repair integrity or Constant scores after arthroscopic rotator cuff repair with TOE techniques. Two investigators independently screened results for relevant articles. Data regarding the study design, surgical technique, retear rate, and Constant shoulder score were extracted from eligible studies. A quality assessment of all articles was performed using the Methodological Index for Non-Randomized Studies (MINORS) criteria. RESULTS: The systematic review identified a total of 32 studies (level of evidence, 1-4) that met inclusion and exclusion criteria. Of the 32 studies, 5 reported on knotless TOE techniques, 25 reported on knot-tying TOE techniques, and 2 reported on both. In the knotless group, retear rates ranged from 6% to 36%, and Constant scores ranged from 38-65 (preoperative) to 73-83 (postoperative). In the knot-tying group, retear rates ranged from 0% to 48%, and Constant scores ranged from 42-64 (preoperative) to 55-96 (postoperative). CONCLUSION: Despite several theoretical advantages of knotless TOE repair, both knotless and knot-tying techniques reported considerable improvement in functional outcomes after rotator cuff repair. Although tendon failure rates showed a downward trend in knotless studies, additional prospective studies are warranted to better understand the role of medial-row fixation on tendon repair integrity and postoperative clinical outcomes.

Clinically Meaningful Improvement After Treatment of Cartilage Defects of the Knee With Osteochondral Grafts.

BACKGROUND: Mosaicplasty and fresh osteochondral allograft transplantation (OCA) are popular cartilage restoration techniques that involve the single-stage implantation of viable, mature hyaline cartilage-bone dowels into chondral lesions of the knee. Recently, there has been greater focus on what represents a clinically relevant change in outcomes reporting, and commonly applied metrics for measuring clinical significance include the minimal clinically important difference (MCID) and substantial clinical benefit (SCB). PURPOSE: To define the MCID and SCB after mosaicplasty or OCA for the International Knee Documentation Committee (IKDC) subjective form and Knee Outcome Survey-Activities of Daily Living (KOS-ADL) and to determine patient factors that are predictive of achieving the MCID and SCB after mosaicplasty or OCA. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: An institutional cartilage registry was reviewed to identify patients who underwent mosaicplasty or OCA. The decision to perform either mosaicplasty or OCA was generally based on chondral defect size. The IKDC and KOS-ADL were administered preoperatively and at a minimum of 2 years postoperatively. Patient responses to the outcome measures were aggregated, and the MCID and SCB of these outcome scores were calculated with anchor-based methods. Multivariate analysis adjusted for age and sex was performed to identify patient factors predictive of achieving the MCID and SCB. RESULTS: Of the 372 eligible patients, 151 (41%) were lost to follow-up, 46 (12%) had incomplete preoperative outcome scores and 2 were treated with OCA of the tibia and therefore excluded. In total, 173 knees were analyzed (n = 173 patients; mean age, 33.0 years; 37% female). Seventy-five (43%) and 98 (57%) knees were treated with mosaicplasty and OCA, respectively. The mean ± SD MCIDs for the IKDC and KOS-ADL were 17 ± 3.9 and 10 ± 3.7, respectively. The SCBs for the IKDC and KOS-ADL were 30 ± 6.9 and 17 ± 3.9, respectively. Univariate analysis demonstrated no association between procedure (mosaicplasty or OCA) and likelihood of achieving the MCID or SCB. In the multivariate analysis, lower preoperative IKDC and KOS-ADL scores, higher preoperative Marx Activity Rating Scale scores, lower preoperative 36-Item Short Form Health Survey pain scores, and a history of ≤1 prior ipsilateral knee surgical procedure were predictive of achieving the MCID and/or SCB. CONCLUSION: These values can be used to define a clinically meaningful improvement for future outcome studies. For surgeons considering mosaicplasty or OCA for their patients, these results can help guide clinical decision making and manage patient expectations before surgery.

Graft-Recipient Anteroposterior Mismatch Does Not Affect the Midterm Clinical Outcomes of Osteochondral Allograft Transplantation of the Femoral Condyle.

BACKGROUND: For the treatment of femoral condyle cartilage defects with osteochondral allograft transplantation (OCA), many surgeons have relaxed their graft-recipient size-matching criteria given the limited allograft supply. However, since the anteroposterior (AP) length is typically correlated with the radius of curvature for a given condyle, a large mismatch in graft-recipient AP length can indicate a corresponding mismatch in the radius of curvature, leading to articular incongruity after implantation. PURPOSE: To evaluate the association between femoral condyle graft-recipient AP mismatch and clinical outcomes of OCA. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: A retrospective review was conducted of patients treated with OCA for femoral condyle chondral defects from 2000 to 2015. Graft characteristics, including AP and mediolateral dimensions, were gathered from vendor-specific allograft offering documents. Patient condyle dimensions were measured on preoperative magnetic resonance imaging. Reoperations and patient responses to validated outcome measures were reviewed. Failure was defined by any partial removal/revision of the allograft or conversion to knee arthroplasty. A multivariable logistic regression model was fitted to examine the association of AP mismatch with OCA failure while adjusting for patient age and number of previous ipsilateral knee surgical procedures. RESULTS: A total of 69 knees from 69 patients (mean age, 35.7 years; 71% male) met the inclusion criteria. Mean duration of follow-up was 4 years (range, 2-16 years). The mean absolute graft-recipient AP mismatch was 6.7 mm (range, 0-20 mm; P < .01). At final follow-up, 19 knees had failed. There was no significant difference in the mean absolute AP mismatch between failures (8.1 mm) and nonfailures (6.2 mm; P = .17). Multivariate logistic regression revealed that AP mismatch was not associated with graft failure ( P = .14). At final follow-up, significant improvements were noted in the 36-Item Short Form Health Survey, International Knee Documentation Committee subjective form, and Knee Outcome Survey-Activities of Daily Living ( P < .01 for all). Magnitude of AP mismatch was not associated with postoperative outcome scores or achievement of minimal clinically significant differences in outcome scores. CONCLUSION: Magnitude of graft-recipient AP mismatch was not associated with midterm OCA failure rates or patient-reported outcome scores, suggesting that AP length mismatch within the limits measured here is not a contraindication for graft acceptance.

Osteochondral Allograft Transplantation of the Knee in Patients Aged 40 Years and Older.

BACKGROUND: Treatment of large chondral defects of the knee among patients aged ≥40 years remains a difficult clinical challenge owing to preexisting joint degeneration and the lack of treatment options short of arthroplasty. PURPOSE: To characterize the survivorship, predictors of failure, and clinical outcomes of osteochondral allograft transplantation (OCA) of the knee among patients aged ≥40 years. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Prospectively collected data were reviewed for 54 consecutive patients aged ≥40 years who were treated with OCA. Preoperative levels of osteoarthritis (according to Kellgren-Lawrence classification) and meniscal volume and quality were graded from review of radiographs and magnetic resonance imaging. Complications, reoperations, and patient responses to validated outcome measures were reviewed. A minimum follow-up of 2 years was required for analysis. Failure was defined by any removal or revision of the allograft or conversion to arthroplasty. RESULTS: Among 51 patients (mean age, 48 years; range, 40-63 years; 65% male), a total of 52 knees had symptomatic focal cartilage lesions (up to 2 affected areas) that were classified as Outerbridge grade 4 at the time of OCA and did not involve substantial bone loss requiring shell allografts or additional bone grafting. Mean duration of follow-up was 3.6 years (range, 2-11 years). After OCA, 21 knees (40%) underwent reoperation, including 14 failures (27%) consisting of revision OCA (n = 1), unicompartmental knee arthroplasty (n = 5), and total knee arthroplasty (n = 8). Mean time to failure was 33 months, and 2- and 4-year survivorship rates were 88% and 73%, respectively. Male sex (hazard ratio = 4.18, 95% CI = 1.12-27.13) and a higher number of previous ipsilateral knee operations (hazard ratio = 1.70 per increase in 1 surgical procedure, 95% CI = 1.03-2.83) were predictors of failure. A higher Kellgren-Lawrence osteoarthritis grade on preoperative radiographs was associated with higher failure rates in the Kaplan-Meier analysis but not the multivariate model. At final follow-up, clinically significant improvements were noted in the pain (mean score, 47.8 to 67.6) and physical functioning (56.8 to 79.1) subscales of the Short Form-36, as well as the International Knee Documentation Committee subjective form (45.0 to 63.6), Knee Outcome Survey-Activities of Daily Living (64.5 to 80.1), and overall condition statement (4.5 to 6.8) ( P < .001). No significant changes were noted for the Marx Activity Rating Scale (5.1 to 3.9, P = .789). CONCLUSION: A higher failure rate was found in this series of patients aged ≥40 years who were treated with OCA as compared with other studies of younger populations. However, for select older patients, OCA can be a good midterm treatment option for cartilage defects of the knee.