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BACKGROUND: Osteochondritis dissecans (OCD) of the humeral capitellum is a rare and challenging condition to treat. Several surgical options exist, but in the last few years, the pendulum has swung from debridement and microfracture to restoration of the articular surface. Osteochondral autografts from the rib and knee have been described, but donor-site morbidity is a concern. PURPOSE: To expand the results of fresh osteochondral allograft transplantation (FOCAT) in a previously published report with inclusion of additional patients and a longer follow-up period. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: After institutional review board approval, the charts of patients who underwent FOCAT for OCD of the capitellum between 2006 and 2022 by a single surgeon were reviewed. The majority of cases (94%) had unstable lesions (Minami grades 2 and 3). A trial of nonoperative treatment had failed in all. All patients underwent diagnostic arthroscopy, followed by a mini-open, ligament-sparing approach with grafting using commercially available guides and instruments. RESULTS: A total of 35 patients were identified, of whom 25 were male. The mean age was 16 ± 3.9 years (range, 11-32 years). There were 24 baseball players (19 pitchers and 5 position players), 5 gymnasts, 3 cheerleaders/tumblers, 1 tennis player, 1 student (who did not participate in athletics), and 1 patient with avascular necrosis from chemotherapy. Eighteen patients had a mean flexion contracture of 14.1°± 11.9°. A single osteochondral allograft plug was used in 23 patients (mean diameter, 11.3 ± 2.8 mm), and 12 patients required 2 plugs (Mastercard technique). The mean follow-up was 92.6 ± 54.5 months (range, 24-204 months). There was significant improvement in Oxford (from 25.5 ± 4.9 to 46.7 ± 3.5; P < .00001) and visual analog scale for pain (from 7.5 ± 2 to 0.3 ± 1.0; P < .0001) scores. The mean Single Assessment Numeric Evaluation score at the time of follow-up was 90.6 ± 10.8 (range, 60-100). In overhead athletes, there was significant improvement in the Kerlan-Jobe Orthopaedic Clinic score (from 40.8 ± 11.8 to 90.6 ± 10.8; P < .00001). A postoperative magnetic resonance imaging scan was obtained in 16 (46%) patients at a mean of 32.6 months. In all cases, the graft was incorporated. All overhead athletes were able to return to their sport and perform at the same level or higher for >2 years. Two elbows required a subsequent arthroscopy for loose-body removal; otherwise, there were no other complications. CONCLUSION: FOCAT is an excellent option for treating OCD lesions of the humeral capitellum. Excellent outcomes and high return-to-sport rates were observed, with midterm follow-up showing no graft failures. FOCAT eliminates donor-site morbidity.
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The patellofemoral (PF) is a challenging location to repair cartilage. While both osteochondral allograft transplantation (OCA) and autologous chondrocyte implantation (ACI) are established as standard therapies for cartilage repair, most treatment algorithms continue to favor ACI for the PF joint, which shows a high rate of success. Today, however, OCA is a treatment of choice to revise prior failed PF cartilage repair. The positive outcomes in this setting encourage indicating OCA for select primary cartilage repair patients, namely those with defects that are uncontained or osteochondral. An advantage of OCA over ACI is that the tissue is more robust, and there may be less need for osteotomy to unload the PF joint. Even for ACI, TTO is reserved for those with abnormal patellar tracking and/or patella height. In terms of return to sports, realistic expectations are required. Return rates have been reported as 67% for NFL players, and 54% for a general population with an average age of 32. Both ACI and OCA are valuable treatment options for PF cartilage defects.
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BACKGROUND: Osteochondral allograft (OCA) transplantation is a well-described technique for the treatment of large, engaging Hill-Sachs lesions (HSLs). Traditionally, OCAs are size-matched to the defect, which can be expensive and time-consuming, and the majority of described techniques require an open approach. Recently, an all-arthroscopic approach to Hill-Sachs OCA transplantation using premade plugs was described, eliminating the need for size-matching and graft harvest. HYPOTHESIS/PURPOSE: The purpose of this study was to evaluate postoperative outcomes of patients who have undergone arthroscopic treatment of HSLs using premade OCA plugs. We hypothesized that these patients would have improved pain and function without recurrent instability. METHODS: A retrospective chart review was performed using operative reports for a single surgeon with search terms "Hill-Sachs" and "allograft." Patients were excluded if an open approach was used or if graft harvest was performed. Postoperative imaging was reviewed to assess for graft incorporation and reconstitution of the HSL. Recurrent instability and reoperation were recorded. Patients completed surveys including the American Shoulder and Elbow Surgeons (ASES) score and the Western Ontario Shoulder Instability Index (WOSI). RESULTS: Five patients were identified through chart review and met inclusion criteria. All patients underwent concurrent labral repair and two patients underwent a concurrent open Latarjet procedure. Postoperative radiographs showed reconstitution of the HSLs in all patients. There were no complications in the postoperative period with no recurrent instability or reoperations in any patient. The average ASES score was 87% (higher score indicating better outcome) with standard deviation 9.7, and the average WOSI score was 27% (lower score indicating better outcome) with standard deviation 8.3. CONCLUSION: Favorable outcomes can be expected after arthroscopic treatment of Hill-Sachs lesions using premade OCA plugs. Further research is needed to assess larger patient cohorts and compare outcomes to size-matched approaches.
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BACKGROUND: Reduced viability in the deepest zones of osteochondral allografts (OCAs) can weaken the subchondral interface, potentially increasing the risk of failure. This reduction may result from nutritional imbalances due to uneven media distribution or interference from bone marrow elements. PURPOSE: To investigate whether culturing OCAs using a rotary shaker or removing the bone marrow elements would increase graft cellular viability. STUDY DESIGN: Controlled laboratory study. METHODS: Bovine osteochondral explants were stored for 28 days at 4°C under 3 different conditions (n = 6 explants per group): static (control group), rotary shaker at 150 rpm (shaker group), and static after removal of bone marrow elements using a Waterpik device (Waterpik group). Chondrocyte viability was assessed using live/dead staining across the entire tissue and in each zone (superficial, middle, deep). Subchondral bone viability was assessed using TUNEL (terminal deoxynucleotidal transferase-mediated biotin-deoxyuridine triphosphate nick-end labeling) staining to detect apoptotic cells. RESULTS: Both shaker (64.2%; P = .010) and Waterpik (65.6%; P = .005) conditions showed significantly higher chondrocyte viability compared with control (49.8%). When samples were analyzed by zone, the shaker and Waterpik groups displayed higher cellular viability at the middle zone (shaker = 60.6%, P < .001; Waterpik = 56.1%, P < .001) and deep zone (shaker = 63.1%, P = .018; Waterpik = 61.5%, P = .025) than the control group (25.6% at middle zone; 32.8% at deep zone). Additionally, shaker (56.7%; P = .018) and Waterpik (51.4%; P = .007) groups demonstrated a lower percentage of apoptotic cells in subchondral bone compared with control (88.0%). No significant differences were observed between the shaker and Waterpik groups in any of the analyses. CONCLUSION: Both rotary shaking and removal of bone marrow elements during storage of osteochondral explants led to higher chondrocyte viability at the middle and deep zones of the graft compared with the static storage condition. Enhancing nutrition delivery to the graft could improve its quality, potentially improving outcomes of OCA transplantation. CLINICAL RELEVANCE: The use of a rotary shaker or the removal of bone marrow elements may significantly improve the culture conditions, increasing graft viability and integrity after OCA storage.
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Supervivencia Celular , Condrocitos , Animales , Bovinos , Médula Ósea , Cartílago Articular/fisiología , Técnicas de Cultivo de TejidosRESUMEN
Background: Large osteochondral lesions of the humeral head can result from locked posterior dislocations, avascular necrosis, and osteochondritis dissecans. Fresh osteochondral allograft (OCA) transplantation is a treatment option for young patients with focal osteochondral defects of the humeral head. The purpose of this case series was to assess graft survivorship, subjective patient-reported outcomes, and satisfaction among 7 patients who underwent OCA transplantation of the humeral head. Methods: We identified 7 patients who underwent humeral head OCA transplantation between 2008 and 2017. A custom questionnaire including the American Shoulder and Elbow Surgeons score, Quick Disabilities of the Arm, Shoulder, and Hand score (QuickDash), Likert satisfaction, and reoperations was mailed to each patient. Clinical failure was defined as further surgery that involved removal of the allograft. Results: Median follow-up duration was 10 years (range, 4.6 to 13.5 years) with a median age of 21.6 years (range, 18.5 to 43.5 years). Most patients (86%) reported improved function and reduced pain. At the final follow-up, 71% of patients reported ongoing problems with their shoulder including pain, stiffness, clicking/grinding, limited range of motion, and instability. Return to recreational activities was high at 86% but 43% expressed limitations with activity due to their shoulder. Overall satisfaction was high at 71% with mean American Shoulder and Elbow Surgeons and QuickDASH scores at 62.4 and 29.2, respectively. Reoperation after OCA occurred in 1 patient (14%). Conclusion: Among this case series of 7 patients who underwent OCA transplantation of the humeral head, patient satisfaction was high at 10-year follow-up and most returned to recreational activity although most also had persistent shoulder symptoms.
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BACKGROUND: The surgical management of large osteochondral lesions of the femoral head in young, active patients remains controversial. Fresh osteochondral allograft (OCA) transplantation can be a highly effective treatment for these lesions in some patients. This study investigated survivorship as well as clinical and radiographic outcomes after fresh OCA transplantation at a minimum 2-year follow-up (mean, 6.6 years; range, 0.6 to 13.7 years). METHODS: A retrospective review of 29 patients who underwent plug OCA transplantation for focal femoral head osteochondral lesions between 2008 and 2021 was performed. Patients were assessed clinically using the modified Harris Hip score (mHHS) preoperatively and at each follow-up visit. Postoperative radiographs were evaluated for graft integrity and osteoarthritis severity. Kaplan-Meier survivorship analyses with 95% confidence intervals (CIs) were performed for the endpoint of conversion to total hip arthroplasty (THA). RESULTS: Overall graft survivorship for included patients was 78.4% (95% CI: 62.9 to 93.9) and 62.7% (95% CI: 39.6 to 85.8) at 5 and 10 years, respectively. There were ten patients (34.5%) who underwent conversion to THA. There was a significant difference using the log-rank test between survival for patients who had a preoperative diagnosis of osteonecrosis (ON) versus those who had other diagnoses (P = .002). The ten-year survival for those who had ON was 41.8% (95% CI: 4.8 to 78.8), and the ten-year survival for diagnoses other than ON was 85.7% (95% CI: 59.8 to 100). The mean mHHS score improved significantly (P < .001) from 48.9 (19 to 84) preoperatively to 77.4 (35 to 100) at the final follow-up. There were twenty patients (69.0%) who had mHHS ≥ 70 at the latest follow-up. Arthritic progression, indicated by an increase in the Kellgren and Lawrence grade, occurred in 7 hips (26.9%). CONCLUSIONS: An OCA transplantation is a viable treatment option for osteochondral defects of the femoral head in young, active patients who have minimal preexisting joint deformity. It may delay the progression of arthritis and the need for THA. Patients who had a preoperative diagnosis of ON had worse clinical outcomes than those who had other diagnoses.
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BACKGROUND: A major limitation of osteochondral allografts (OCA) is the deterioration of cartilage health associated with cell death during prolonged storage. However, little is known about the mechanisms that contribute to chondrocyte death during storage. PURPOSE/HYPOTHESIS: This study aimed to determine whether bioactive lipid metabolites accumulate in the storage media of OCA and whether they are associated with a loss of chondrocyte viability during prolonged storage. It was hypothesized that free fatty acids (FFAs) would accumulate over time in the storage media of OCA and adversely affect cartilage health during storage. STUDY DESIGN: Controlled laboratory study. METHODS: A group of 21 (n = 6-8 OCA/treatment group) fresh human hemicondylar OCA tissues and media were analyzed after 7, 28, and 68 days of prolonged cold (4°C) storage. Targeted mass spectrometry analysis was used to quantify bioactive FFAs, as well as primary (lipid hydroperoxide [ROOH]) and secondary (malondialdehyde) lipid oxidation products. Chondrocyte viability was measured using a fluorescence-based live/dead assay and confocal microscopy. RESULTS: The concentration of all targeted fatty acid metabolites in storage media was significantly increased with increased cold storage time (P < .05). ROOH was significantly higher on day 28 of cold storage. No difference in secondary ROOH products in storage media was observed. Chondrocyte viability significantly declined in both the en face and the vertical cross-sectional analysis with increased cold storage time and inversely correlated with fatty acid metabolites (P < .05). CONCLUSION: It is well established that elevated levels of certain FFAs and lipid oxidation products can alter cell function and cause cell death via lipotoxicity and other mechanisms. This work is the first to identify elevated levels of FFA metabolites and primary oxidation lipid products in the storage media from clinical OCA. The concentrations of FFA metabolites were measured at levels (>100 µM) known to induce cell death and were directly correlated with chondrocyte viability. CLINICAL RELEVANCE: These findings provide important targets for understanding why cartilage health declines during cold storage, which can be used to optimize media formulations and improve graft health.
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Muerte Celular , Condrocitos , Humanos , Condrocitos/metabolismo , Ácidos Grasos no Esterificados/metabolismo , Supervivencia Celular , Aloinjertos , Adulto , Persona de Mediana Edad , Masculino , Cartílago Articular/metabolismo , Femenino , Metabolismo de los LípidosRESUMEN
Resumen Introducción : Las lesiones osteocondrales de rodilla son una afección frecuente en jóvenes. Los trasplantes alogénicos usando injerto congelado se presentan como una opción de tratamiento en pacientes con lesiones grandes o sin zona dadora. Este trabajo buscó analizar retrospectivamente los resultados funcionales y la tasa de falla de los trasplantes osteocondrales con injerto cadavérico congelado. Métodos : Se incluyeron pacientes sometidos a tras plantes osteocondrales de rodilla con injerto cadavérico congelado en nuestra institución, entre 2014 y 2019, con dos años de seguimiento mínimo. Variables evaluadas: edad al momento de la intervención, escalas funciona les International Knee Documentation Committee (IKDC) y Lysholm pre y post operatorios, complicaciones y tasa de falla. Resultados : Incluimos 25 pacientes. La edad media fue de 43.5 años (RIQ 29-50), 45% fueron mujeres y el seguimiento promedio fue de 83 meses (DS 54.6). El ta maño promedio del defecto osteocondral fue de 4 cm2. La escala de Lysholm promedio pre y postoperatorio fue de 39 (DS 19.3) y 82 (DS 15.4) respectivamente (p < 0.01). El IKDC promedio pre y postoperatorio fue de 42 (DS 13.8) y 60 (DS 13.5) respectivamente (p < 0.01). La tasa de falla fue del 20% (n=5). Discusión : Los pacientes presentaron una mejoría postoperatoria evidenciada en los resultados funcio nales, y una tasa de falla del 20%. El uso de trasplante osteocondral congelado se presenta como un recurso útil para el tratamiento de lesiones condrales graves.
Abstract Introduction : Knee osteochondral lesions represent a frequent pathology within young active patients. One possible indication for severe lesions or in case of im possibility of harvesting an autograft is the use of fresh frozen allograft. The objective of this study was to ret rospectively analyze functional results and failure rate after osteochondral transplants using fresh frozen al lografts. Methods : We analyzed data from patients who under went knee osteochondral transplant using mosaicplasty technique with fresh frozen allografts at our institution between 2014 and 2019. We included those patients with at least two-year follow-up. Demographic characteristics such as age at the moment of intervention and size of the defect were included. Functional results were assessed using pre and postoperative Lysholm and IKDC scores. Patients who underwent a knee replacement were considered failures. Results : Twenty-five patients were included. The me dian age was 43.5 years (IQR 29-50), 45% were female and the mean follow-up was 83 months (SD 54.6). Mean osteochondral defect size was 4 cm2. Mean pre and post operative Lysholm scores were 39 (SD 19.3) and 82 (SD 15.4) respectively (p < 0.01). Mean pre and postoperative IKDC scores were 42 (SD 13.8) and 60 (SD 13.5) respec tively (p < 0.01). Five patients (20%) underwent a knee replacement afterwards and were considered failures. Discussion : Our results after a mean seven-year follow-up evidenced an overall improvement in func tional scores and a failure rate of 20%. Osteochondral transplant using fresh frozen allografts is a reliable and feasible treatment for patients with large osteochondral defects.
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Introduction: Transplantation with fresh cadaveric osteochondral allograft (FOCA) is frequently used in defects of the femoral condyle and tibial plateau to preserve the knee joint. However, the use of FOCA in bipolar lesions remains controversial in cases with bipolar defects and a history of infection. Case Report: We present a 21-year-old male patient with a massive post-traumatic osteochondral defect of the lateral compartment of the knee and a history of infection, treated by a two-stage approach. In stage 1, infection was eradicated, and joint function recovered with aggressive debridement, polymethyl methacrylate beads, bone cement spacers, and Judet's quadricepsplasty. In stage 2, transplantation was performed with a bipolar FOCA. All treatments were planned using 3D-printed models. Conclusion: The two-stage approach and 3D planning can increase the chances of transplant success by preparing the future allograft bed and obtaining an optimal match between the cadaveric allograft and the patient's defect in cases with potential contraindications, such as a bipolar lesion in the femoral condyle and tibial plateau and a history of infection. A combined approach may lead to a more beneficial outcome for the patient to preserve joint function and improve quality of life.
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The meniscus of the knee serves as a crucial load-bearing structure, and its damage can significantly impact weight distribution. In addressing focal meniscal defects, segmental meniscal allograft transplantation (SMALT) emerges as an innovative solution. Here, we detail a case involving a young, active female who underwent SMALT augmented with osteochondral allograft transplantation (OCA) and bone marrow aspirate concentration (BMAC). The patient, a 40-year-old former Division I volleyball player, previously underwent arthroscopic procedures and presented with knee pain alongside complex lateral meniscus tear evident in magnetic resonance imaging (MRI) findings. Initial arthroscopy revealed multiple tears, including segmental deficiency at the posterior horn-body junction and a horizontal cleavage tear. Despite failed attempts at repair due to the meniscal gap, a second-stage lateral SMALT was performed, with the allograft soaked in the patient's BMAC, supplemented with OCA to the lateral femoral condyle. Rehabilitation protocols tailored to both SMALT and OCA were implemented. This represents the first documented instance of lateral SMALT, extending the scope of viable solutions for segmental meniscal deficiencies, and marking a significant milestone in orthopedic practice.
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INTRODUCTION: Knee osteochondral lesions represent a frequent pathology within young active patients. One possible indication for severe lesions or in case of impossibility of harvesting an autograft is the use of fresh frozen allograft. The objective of this study was to retrospectively analyze functional results and failure rate after osteochondral transplants using fresh frozen allografts. METHODS: We analyzed data from patients who underwent knee osteochondral transplant using mosaicplasty technique with fresh frozen allografts at our institution between 2014 and 2019. We included those patients with at least two-year follow-up. Demographic characteristics such as age at the moment of intervention and size of the defect were included. Functional results were assessed using pre and postoperative Lysholm and IKDC scores. Patients who underwent a knee replacement were considered failures. RESULTS: Twenty-five patients were included. The median age was 43.5 years (IQR 29-50), 45% were female and the mean follow-up was 83 months (SD 54.6). Mean osteochondral defect size was 4 cm2. Mean pre and postoperative Lysholm scores were 39 (SD 19.3) and 82 (SD 15.4) respectively (p < 0.01). Mean pre and postoperative IKDC scores were 42 (SD 13.8) and 60 (SD 13.5) respectively (p < 0.01). Five patients (20%) underwent a knee replacement afterwards and were considered failures. DISCUSSION: Our results after a mean seven-year follow-up evidenced an overall improvement in functional scores and a failure rate of 20%. Osteochondral transplant using fresh frozen allografts is a reliable and feasible treatment for patients with large osteochondral defects.
Introducción: Las lesiones osteocondrales de rodilla son una afección frecuente en jóvenes. Los trasplantes alogénicos usando injerto congelado se presentan como una opción de tratamiento en pacientes con lesiones grandes o sin zona dadora. Este trabajo buscó analizar retrospectivamente los resultados funcionales y la tasa de falla de los trasplantes osteocondrales con injerto cadavérico congelado. Métodos: Se incluyeron pacientes sometidos a trasplantes osteocondrales de rodilla con injerto cadavérico congelado en nuestra institución, entre 2014 y 2019, con dos años de seguimiento mínimo. Variables evaluadas: edad al momento de la intervención, escalas funcionales International Knee Documentation Committee (IKDC) y Lysholm pre y post operatorios, complicaciones y tasa de falla. Resultados: Incluimos 25 pacientes. La edad media fue de 43.5 años (RIQ 29-50), 45% fueron mujeres y el seguimiento promedio fue de 83 meses (DS 54.6). El tamaño promedio del defecto osteocondral fue de 4 cm2. La escala de Lysholm promedio pre y postoperatorio fue de 39 (DS 19.3) y 82 (DS 15.4) respectivamente (p < 0.01). El IKDC promedio pre y postoperatorio fue de 42 (DS 13.8) y 60 (DS 13.5) respectivamente (p < 0.01). La tasa de falla fue del 20% (n=5). Discusión: Los pacientes presentaron una mejoría postoperatoria evidenciada en los resultados funcionales, y una tasa de falla del 20%. El uso de trasplante osteocondral congelado se presenta como un recurso útil para el tratamiento de lesiones condrales graves.
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Aloinjertos , Cartílago Articular , Humanos , Femenino , Masculino , Adulto , Estudios Retrospectivos , Persona de Mediana Edad , Estudios de Seguimiento , Cartílago Articular/cirugía , Cartílago Articular/trasplante , Aloinjertos/trasplante , Resultado del Tratamiento , Articulación de la Rodilla/cirugía , Trasplante Óseo/métodos , Criopreservación/métodosRESUMEN
OBJECTIVE: The osteochondral allograft procedure uses grafts constructed larger than the recipient site to stabilize the graft, in what is known as the press-fit technique. This research aims to characterize the relationships between press-fit size, insertion forces, and cell viability in ovine and human osteochondral tissue. DESIGN: Human (4 donors) and ovine (5 animals) articular joints were used to harvest osteochondral grafts (4.55 mm diameter, N = 33 Human, N = 35 Ovine) and create recipient sites with grafts constructed to achieve varying degrees of press fit (0.025-0.240 mm). Donor grafts were inserted into recipient sites while insertion forces were measured followed by quantification of chondrocyte viability and histological staining to evaluate the extracellular matrix. RESULTS: Both human and ovine tissues exhibited similar mechanical and cellular responses to changes in press-fit. Insertion forces (Human: 3-169 MPa, Ovine: 36-314 MPa) and cell viability (Human: 16%-89% live, Ovine: 2%-76% live) were correlated to press-fit size for both human (force: r = 0.539, viability: r = -0.729) and ovine (force: r = 0.655, viability: r = -0.714) tissues. In both species, a press-fit above 0.14 mm resulted in reduced cell viability below a level acceptable for transplantation, increased insertion forces, and reduced linear correlation to press-fit size compared to samples with a press-fit below 0.14 mm. CONCLUSIONS: Increasing press-fit size required increased insertion forces and resulted in reduced cell viability. Ovine and human osteochondral tissues responded similarly to impact insertion and varying press-fit size, providing evidence for the use of the ovine model in allograft-related research.
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Large osteochondral defects are a major challenge in orthopedics, for which osteochondral allograft (OCA) transplantation is nowadays considered as an option, especially in young patients. However, a major issue with OCA is the need for graft storage, which ensures adequate cartilage integrity over time. The aim of this study was to test how long a Ringer-based storage solution can provide good graft quality after explantation and thus meet the requirements for OCA. For this purpose, human osteochondral allografts of the knee and ankle were analyzed. Live/Dead analysis was performed and glycosaminoglycan, as well as hydroxyproline content, were measured as crucial chondrocyte integrity factors. Furthermore, biomechanical tests focusing on stress relaxation and elastic compression modulus were performed. The critical value of 70% living chondrocytes, which corresponds to a number of 300 cells/mm², was reached after an average of 16 weeks of storage. In addition, a constant cell shrinkage was observed over time. The amount of glycosaminoglycan and hydroxyroline showed a slight and constant decrease over time, but no significant differences when compared from Day 0 to the values at Weeks 40-43. Biomechanical testing also revealed no significant differences at the different time points. Therefore, the results show that the Ringer-based storage solution at 4°C is able to provide a chondrocyte survival of 70% until Week 16. This is comparable to previously published storage solutions. Therefore, the study contributes to the establishment of a Ringer-based osteochondral allograft transplantation system for countries where medium-based storage solution cannot be approved.
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Aloinjertos , Condrocitos , Glicosaminoglicanos , Soluciones Isotónicas , Solución de Ringer , Humanos , Condrocitos/trasplante , Adulto , Persona de Mediana Edad , Masculino , Femenino , Trasplante Óseo/métodos , Cartílago Articular/fisiología , Hidroxiprolina , Soluciones Preservantes de ÓrganosRESUMEN
The unique physical demands of tactical athletes put immense stress on the knee joint, making these individuals susceptible to injury. In order to ensure operational readiness, management options must restore and preserve the native architecture and minimize downtime, while optimizing functionality. Osteochondral lesions (OCL) of the knee have long been acknowledged as significant sources of knee pain and functional deficits. The management of OCL is predicated on certain injury characteristics, including lesion location and the extent of subchondral disease. Techniques such as marrow stimulation, allograft and autologous chondrocyte implantation are examined in detail, with a focus on their application and suitability in tactical athlete populations. Moreover, the restoration of the osteochondral unit (OCU) is highlighted as a central aspect of knee joint preservation. The discussion encompasses the biomechanical considerations and outcomes associated with various cartilage restoration techniques. Factors influencing procedure selection, including lesion size, location, and patient-specific variables, are thoroughly examined. Additionally, the review underscores the critical role of post-operative rehabilitation and conditioning programs in optimizing outcomes. Strengthening the surrounding musculature, enhancing joint stability, and refining movement patterns are paramount in facilitating the successful integration of preservation procedures. This narrative review aims to provide a comprehensive resource for surgeons, engineers, and sports medicine practitioners engaged in the care of tactical athletes and the field of cartilage restoration. The integration of advanced preservation techniques and tailored rehabilitation protocols offers a promising avenue for sustaining knee joint health and function in this demanding population.
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BACKGROUND: Osteochondral allograft transplantation (OCAT) is an accepted knee joint-preserving treatment strategy for focal osteochondral lesions that is often conducted in combination with meniscal allograft transplantation (MAT). Despite its frequent and simultaneous utilization, there remains a lack in the literature reporting on outcomes and failure rates after concomitant procedures. PURPOSE: To determine (1) the midterm clinical success rate after OCAT+MAT in comparison with a matched-pair cohort undergoing isolated OCAT, (2) whether patient-specific and procedural variables influence the risk of failure, and (3) patient-reported outcome measures over time. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A single-center matched-pair cohort study was conducted investigating outcomes in patients who underwent OCAT of the medial or lateral femoral condyle with and without MAT between 2004 and 2020. Patients were matched 1:1 by age (±5 years), sex (male or female), body mass index (±5), and grouped Kellgren and Lawrence grade (grades 0-1 or 2-4). The minimum follow-up time was 2 years. Radiographic variables (International Cartilage Regeneration & Joint Preservation Society [ICRS] grade and Kellgren and Lawrence grade) were assessed preoperatively and at follow-up. Subjective patient-reported outcome measures (Lysholm score, Knee injury and Osteoarthritis Outcome Score [KOOS] including subscores, International Knee Documentation Committee [IKDC] score, and visual analog scale score) were collected preoperatively and at follow-up. Clinical failure was defined as revision surgery for graft failure or conversion to total knee arthroplasty. Patient-reported, clinical, and radiographic outcomes were compared between groups. RESULTS: In total, 66 patients (33 treated with isolated OCAT, 33 treated with OCAT+MAT; 57.6% male) with a mean age of 26.3 years (range, 18-62 years) were followed for a mean of 5.6 years (minimum, 2 years; range, 24-218 months). The 2 cohorts showed no difference in Kellgren and Lawrence grade postoperatively (P = .59). There was a significantly higher ICRS grade detected at follow-up in the OCAT+MAT group (2.81 ± 1.10) compared with the OCAT group (2.04 ± 0.96) (P < .05). There were no statistically significant differences between the groups regarding reoperation rate (OCAT: n = 6; OCAT+MAT: n = 13; P = .116), time to reoperation (OCAT: 46.67 ± 47.27 months vs OCAT+MAT: 28.08 ± 30.16 months; P = .061), and failure rate (OCAT: n = 4 [12.1%] vs OCAT+MAT: n = 5 [15.2%]; P = .66). In the OCAT+MAT group, an increase of tibial slope by 1° conferred a 1.65-fold increase in the hazard for failure over decreased slope (hazard ratio, 1.65; 95% CI, 1.10-2.50; P < .05). The overall survival rate was 86% at a mean follow-up of 5.6 years. Patient-reported outcome scores were significantly improved at the final follow-up compared with preoperative status. No significant differences were seen between groups with respect to subjective IKDC, Lysholm, Tegner, and KOOS results, except for the KOOS Symptoms subscale score, which was significantly higher in the OCAT+MAT group than in the OCAT group (mean difference, 14.6; P < .05) and did exceed the minimal clinically important difference threshold of 10.7. CONCLUSION: Midterm results after isolated OCAT and OCAT+MAT show high rates of healing and sustainable subjective improvement of knee function and quality of life. However, it should be noted that the difference in reoperation rate and time to reoperation between the groups is arguably clinically important and that lack of statistical significance may be because of low power. These results imply that isolated OCAT is an efficient joint-preserving treatment that can be combined with MAT in well-selected patients with meniscal insufficiency without negative influence on global clinical outcomes.
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Meniscos Tibiales , Calidad de Vida , Humanos , Masculino , Femenino , Adulto , Estudios de Cohortes , Estudios de Seguimiento , Meniscos Tibiales/trasplante , Análisis por Apareamiento , Articulación de la Rodilla/cirugía , Reoperación , AloinjertosRESUMEN
BACKGROUND: Fresh osteochondral allograft (OCA) transplantation is a viable treatment option for osteochondral defects of the talus. However, sufficient data are not available on patients' participation in sports or recreational activities after the procedure. PURPOSE: To assess whether patients undergoing OCA transplantation of the talus participated in sports or recreational activities postoperatively. STUDY DESIGN: Case series; level of evidence, 4. METHODS: A total of 36 ankles in 34 patients underwent OCA transplantation of the talus. At a mean follow-up of 9.2 years, information on participation in sports or recreational activities pre- and postoperatively was obtained, as well as postoperative pain, function, and satisfaction. RESULTS: The mean age at the time of surgery was 36.1 years (range, 20.5-57.7 years), and 50% of patients were men. The mean graft size was 3.6 cm2 (range, 1-7.2 cm2) or 41.1% of the talar dome. Before the injury, 63.9% of patients (23/36 ankles) reported being highly competitive athletes or well trained and frequently sporting; 36.1% of patients (13/36 ankles) reported sometimes sporting or were nonsporting. Also, 66.7% of patients (24/36 ankles) were able to participate in sports or recreational activities after OCA transplantation and 50% (18/36 ankles) were still participating in sports or recreational activities at the latest follow-up. In a subset of well-trained or highly competitive athletes, 73.9% (17/23 ankles) were able to return to sports or recreational activities at any point after OCA transplantation, and 65.2% (15/23 ankles) were still participating at the latest follow-up. Further surgery occurred in 16.7% of patients (6/36 ankles). Graft survivorship was 94.3% at 5 years and 85.3% at 10 years. There was a significant improvement in the mean Olerud-Molander Ankle Scores, and the mean Foot and Ankle Ability Measure scores were high postoperatively. Moreover, 79.4% of patients (27/34 ankles) were either satisfied or extremely satisfied with the allograft surgery. CONCLUSION: Fresh OCA transplantation is a reasonable surgical option for osteochondral defects of the talus for young, active patients who have failed previous operative management or have massive defects.
Asunto(s)
Cartílago Articular , Fracturas Intraarticulares , Astrágalo , Masculino , Humanos , Adulto Joven , Adulto , Persona de Mediana Edad , Femenino , Astrágalo/trasplante , Estudios de Seguimiento , Trasplante Óseo/métodos , Trasplante Homólogo , Aloinjertos , Resultado del TratamientoRESUMEN
Background: Osteochondral allograft transplantation (OCAT) allows the restoration of femoral condyle osteochondritis dissecans (OCD) lesions using an osteochondral unit. When OCD lesions are irreparable, or treatments have failed, OCAT is an appropriate approach for revision or salvage surgery. Based on its relative availability, cost-effectiveness, lack of donor site morbidity, and advances in preservation methods, OCAT is also an attractive option for primary surgical treatment for femoral condyle OCD. Hypothesis: OCAT for large femoral condyle OCD lesions would be highly successful (>90%) based on significant improvements in knee pain and function, with no significant differences between primary and salvage procedure outcomes. Study Design: Cohort study; Level of evidence, 3. Methods: Patients were enrolled into a registry for assessing outcomes after OCAT. Those patients who underwent OCAT for femoral condyle OCD and had a minimum of 2-year follow-up were included. Reoperations, treatment failures, and patient-reported outcomes were compared between primary and salvage OCAT cohorts. Results: A total of 22 consecutive patients were included for analysis, with none lost to the 2-year follow-up (mean, 40.3 months; range, 24-82 months). OCD lesions of the medial femoral condyle (n = 17), lateral femoral condyle (n = 4), or both condyles (n = 1) were analyzed. The mean patient age was 25.3 years (range, 12-50 years), and the mean body mass index was 25.2 kg/m2 (range, 17-42 kg/m2). No statistically significant differences were observed between the primary (n = 11) and salvage (n = 11) OCAT cohorts in patient and surgical characteristics. Also, 91% of patients had successful outcomes at a mean of >3 years after OCAT with 1 revision in the primary OCAT cohort and 1 conversion to total knee arthroplasty in the salvage OCAT cohort. For both primary and salvage OCATs, patient-reported measures of pain and function significantly improved at the 1-year and final follow-up, and >90% of patients reported that they were satisfied and would choose OCAT again for treatment. Conclusion: Based on the low treatment failure rates in conjunction with statistically significant and clinically meaningful improvements in patient-reported outcomes, OCAT can be considered an appropriate option for both primary and salvage surgical treatment in patients with irreparable OCD lesions of the femoral condyles.
RESUMEN
Osteochondral allograft (OCA) transplantation involves grafting of natural hyaline cartilage and supporting subchondral bone into the cartilage defect area to restore its biomechanical and tissue structure. However, differences in biomechanical properties and donor-host matching may impair the integration of articular cartilage (AC). This study analyzed the biomechanical properties of the AC in different regions of different sites of the knee joint and provided a novel approach to OCA transplantation. Intact stifle joints from skeletally mature pigs were collected from a local abattoir less than 8 h after slaughter. OCAs were collected from different regions of the joints. The patella and the tibial plateau were divided into medial and lateral regions, while the trochlea and femoral condyle were divided into six regions. The OCAs were analyzed and compared for Young's modulus, the compressive modulus, and cartilage thickness. Young's modulus, cartilage thickness, and compressive modulus of OCA were significantly different in different regions of the joints. A negative correlation was observed between Young's modulus and the proportion of the subchondral bone (r = - 0.4241, P < 0.0001). Cartilage thickness was positively correlated with Young's modulus (r = 0.4473, P < 0.0001) and the compressive modulus (r = 0.3678, P < 0.0001). During OCA transplantation, OCAs should be transplanted in the same regions, or at the closest possible regions to maintain consistency of the biomechanical properties and cartilage thickness of the donor and recipient, to ensure smooth integration with the surrounding tissue. A 7 mm depth achieved a higher Young's modulus, and may represent the ideal length.
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Aloinjertos , Cartílago Articular , Articulación de la Rodilla , Animales , Cartílago Articular/fisiología , Articulación de la Rodilla/fisiología , Articulación de la Rodilla/cirugía , Fenómenos Biomecánicos , Porcinos , Módulo de Elasticidad , Trasplante Óseo/métodosRESUMEN
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.
RESUMEN
OBJECTIVE: Supply-demand mismatch of medial femoral condyle (MFC) osteochondral allografts (OCAs) remains a rate-limiting factor in the treatment of osteochondral defects of the femoral condyle. Surface contour mapping was used to determine whether a contralateral lateral femoral condyle (LFC) versus ipsilateral MFC OCA differs in the alignment of donor:native subchondral bone for large osteochondral defects of the MFC. DESIGN: Thirty fresh-frozen human femoral condyles were matched by tibial width into 10 groups of 3 condyles (MFC recipient, MFC donor, and LFC donor) each for 3 cartilage surgeons (90 condyles). The recipient MFC was imaged using nano-computed tomography scan. Donor oval grafts were harvested from each matched condyle and transplanted into a 17 mm × 36 mm defect created in the recipient condyle. Following the first transplant, the recipient condyle was imaged and superimposed on the native condyle nano-CT scan. The donor plug was removed and the process repeated for the other donor. Surface height deviation and circumferential step-off height deviation were compared between native and donor subchondral bone surfaces for each transplant. RESULTS: There was no statistically significant difference in mean subchondral bone surface deviation (LFC = 0.87 mm, MFC = 0.76 mm, P = 0.07) nor circumferential step-off height (LFC = 0.93 mm, MFC = 0.85 mm, P = 0.09) between the LFC and MFC plugs. There were no significant differences in outcomes between surgeons. CONCLUSIONS: There were no significant differences in subchondral bone circumferential step-off or surface deviation between ipsilateral MFC and contralateral LFC oval-shaped OCAs for 17 mm × 36 mm defects of the MFC.