Long-Term Retrospective Follow-Up of Fresh Osteochondral Allograft Transplantation for Steroid-Associated Osteonecrosis of the Femoral Condyles.

OBJECTIVE: No studies currently exist with long-term follow-up of use of osteochondral allografting (OCA) for treatment of steroid-associated osteonecrosis of femoral condyles in young, active patients who wish to avoid total knee arthroplasty (TKA). We evaluate the extent to which fresh osteochondral allografts can (1) prevent or postpone need for prosthetic arthroplasty and (2) maintain long-term clinically meaningful decrease in pain and improvement in function at mean 11-year follow-up. DESIGN: Twenty-five patients (33 knees) who underwent OCA transplantation for osteonecrosis of the knee between 1984 and 2013 were evaluated, including 22 females and 11 males with average age of 25 years (range, 16-48 years). Mean total allograft surface area was 10.6 cm2 (range, 4.0-19.0 cm2). Evaluation included International Knee Documentation Committee (IKDC) scores, Knee Society function (KS-F) score, and modified (for the knee) Merle d'Aubigné-Postel (18-point) score. RESULTS: OCA survivorship was 90% at 5 years and 82% at 10 years. Twenty-eight of 33 knees (85%) avoided arthroplasty and 25 of 33 knees (73%) avoided other surgical intervention. Mean IKDC pain score improved (P = 0.001) from 7.2 preoperatively to 2.8 at latest follow-up, mean IKDC function score increased (P = 0.005) from 3.3 to 6.5, and mean IKDC total score improved (P = 0.001) from 31.9 to 61.1. Mean KS-F score improved (P = 0.003) from 61.7 to 87.5. Mean modified Merle d'Aubigné-Postel (18-point) score improved (P < 0.001) from 11.4 to 15.1. CONCLUSIONS: Our findings suggest that OCA transplantation is a reasonable surgical treatment option for steroid-associated osteonecrosis of the femoral condyles, with durable long-term outcomes.

Osteochondral Allograft Transplantation of the Femoral Condyle Utilizing a Thin Plug Graft Technique.

BACKGROUND: Previous studies showed clinical benefit and durable results of osteochondral allograft (OCA) transplantation for the treatment of femoral condyle lesions. However, the majority of these studies are difficult to interpret owing to the mixed results of different techniques and anatomic locations. PURPOSE: To evaluate the outcome of OCA transplantation with thin plug grafts for treatment of isolated femoral condyle osteochondral lesions. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: This study included 187 patients (200 knees) who underwent OCA transplantation for isolated osteochondral lesions on the femoral condyle between 1999 and 2014. For all cases, a thin plug technique was used with commercially available surgical instruments and the minimum amount of bone necessary for fixation. Evaluation included International Knee Documentation Committee score, Knee injury and Osteoarthritis Outcome Score, and patient satisfaction. Frequency and type of further surgery were assessed. Failure of the allograft was defined as further surgery involving removal of the allograft. RESULTS: Mean follow-up was 6.7 years (range, 1.9-16.5 years). The mean age of patients at the time of surgery was 31 years, and 63% were male. The medial femoral condyle was affected in 69% of knees. A single thin plug graft was used in 145 knees (72.5%), and 2 grafts were used in 55 knees (27.5%). Mean allograft area was 6.3 cm2, and graft thickness was 6.5 mm (cartilage and bone combined). Further surgery was required for 52 knees (26%), of which 16 (8% of entire cohort) were defined as allograft failures (4 OCA revisions, 1 arthrosurface, 6 unicompartmental knee arthroplasties, and 5 total knee arthroplasties). Median time to failure was 4.9 years. Survivorship of the allograft was 95.6% at 5 years and 91.2% at 10 years. Among patients with grafts remaining in situ at latest follow-up, clinically meaningful improvement in pain, function, and quality of life was reported. Satisfaction was reported by 89% of patients. CONCLUSION: OCA transplantation with a thin plug graft technique is a valuable procedure for the treatment of femoral condyle osteochondral lesions, resulting in significant improvement in clinical scores, high patient satisfaction, and low reoperation and clinical failure rates.

Osteochondral Allograft Transplantation for Osteochondral Lesions of the Talus: Midterm Follow-up.

BACKGROUND:: Fresh osteochondral allograft (OCA) transplantation represents a biologic restoration technique as an alternative treatment option for larger osteochondral lesions of the talus (OLT). The purpose of this study was to evaluate midterm outcomes after OCA transplantation for the treatment of OLT. METHODS:: Nineteen patients (20 ankles) received partial unipolar OCA transplant for symptomatic OLT between January 1998 and October 2014. The mean age was 34.7 years, and 53% were male. The average graft size was 3.8 cm2. All patients had a minimum follow-up of 2 years. Outcomes included the American Academy of Orthopaedic Surgeons Foot and Ankle Module (AAOS-FAM), the Olerud-Molander Ankle Score (OMAS), and pain and satisfaction questionnaires. Failure of OCA was defined as conversion to arthrodesis or revision OCA transplantation. RESULTS:: Five of 20 ankles (25%) required further surgery, of which 3 (5%) were considered OCA failures (2 arthrodesis and 1 OCA revision). The mean time to failure was 3.5 (range, 0.9 to 6.7) years. Survivorship was 88.7% at 5 years and 81.3% at 10 years. The median follow-up of the 17 patients with grafts in situ was 9.7 years. The mean OMAS improved significantly from 40 points preoperatively to 71 points postoperatively ( P < .05; range, 5 to 55). The mean postoperative AAOS-FAM core score was 81.5 ± 15 (range, 40.5 to 96.6). Fifteen of 17 patients responded to follow-up questions regarding their ankle; 14 patients reported less pain and better function, and 13 patients were satisfied with the results of the procedure. CONCLUSION:: Our study of midterm results after OCA transplantations showed that this procedure was a reasonable treatment option for large OLT. LEVEL OF EVIDENCE:: Level IV, case series.

Is Patient Satisfaction Associated With Clinical Outcomes After Osteochondral Allograft Transplantation in the Knee?

BACKGROUND: The association between patient satisfaction and patient-reported outcomes after cartilage repair is not well understood. PURPOSE: To investigate the association of patient satisfaction with pain, function, activity level, and quality of life after fresh osteochondral allograft (OCA) transplantation in the knee. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: This study comprised 371 patients (396 knees) who underwent primary OCA transplantation for osteochondral lesions in the knee between 1997 and 2015. Mean ± SD patient age was 31.8 ± 11.6 years, and 62% were male. The majority of grafts (62%) were located on the femoral condyle; the mean number of grafts per knee was 1.5 ± 0.8; and the median graft area was 6.9 cm2 (range, 1.8-50 cm2). Pain, function, activity level, and quality of life were evaluated pre- and postoperatively via International Knee Documentation Committee scores and Knee injury and Osteoarthritis Outcome Scores. Patient satisfaction with the results of the OCA transplantation was assessed postoperatively. All follow-up evaluations occurring at postoperative 1 year or later were included in the analysis. RESULTS: The mean follow-up time was 5.5 years. Overall, the satisfaction rate was 88.1%, and this rate was constant over time. Satisfaction rates varied by diagnosis, age, sex, and anatomic location of the allograft. Postoperative International Knee Documentation Committee pain, function, and total scores differed between patients who were satisfied and not satisfied (all P < .001). All Knee injury and Osteoarthritis Outcome Score subscale results differed between those who were satisfied and not satisfied (all P < .001). Having a diagnosis of osteochondritis dissecans was the only variable that predicted which patients would be satisfied with the results of the allograft, after controlling for age, sex, anatomic location of the graft, and number of grafts. CONCLUSION: A consistently high and durable patient satisfaction rate after OCA transplantation was found. Satisfied patients reported lower pain and higher function, activity levels, and quality of life as compared with patients who were not satisfied. Patients with osteochondritis dissecans had a particularly high level of satisfaction with the OCA procedure.

Does Anterior Cruciate Ligament Reconstruction Affect the Outcome of Osteochondral Allograft Transplantation? A Matched Cohort Study With a Mean Follow-up of 6 Years.

BACKGROUND: Few studies have evaluated the influence of anterior cruciate ligament (ACL) reconstruction on the outcome of cartilage repair. Hypothesis/Purpose: The purpose was to investigate the association between ACL reconstruction and functional outcomes after osteochondral allograft (OCA) transplantation. The hypothesis was that patients treated with OCA transplantation who had a history of ACL reconstruction would have inferior clinical outcomes and lower osteochondral graft survivorship when compared with a matched group of patients undergoing OCA transplantation without a history of ACL reconstruction. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: This study compared 31 knees that underwent OCA transplantation with a history of ACL reconstruction (OCA and ACL group) and 62 knees treated with isolated OCA transplantation (OCA group) that had an intact ACL. Groups were matched by age, diagnosis, year of surgery, and graft size. Minimum follow-up was 2 years. Frequency and type of reoperation were assessed. Clinical failure was defined as revision OCA transplantation or conversion to arthroplasty. Subjective outcome measures included International Knee Documentation Committee scores, Knee injury and Osteoarthritis Outcome Scores, and patient satisfaction. RESULTS: Clinical failure occurred in 3 of 31 knees (9.7%) in the OCA and ACL group and 6 of 62 knees (9.7%) in the OCA group ( P ≤ .999). Five- and 10-year survivorship of the OCA was 94.7% and 82.3% for the OCA and ACL group and 93.4% and 79.6% for OCA group, respectively ( P = .979). Mean follow-up was 6.2 ± 3.3 years among all knees with grafts in situ. Changes from preoperative to latest follow-up visit (difference scores) on all subjective outcome measures were greater in the OCA group; however, none of the difference scores were statistically significant. Satisfaction with the results of OCA transplantation was reported in 78.3% of the OCA and ACL group and 71.7% of the OCA group ( P = .551). CONCLUSION: Treatment of cartilage lesions with OCA transplantation proved to be reliable and effective regardless of a history of ACL reconstruction as demonstrated by the improvements in outcome scores, long survivorship, and high satisfaction rates. History of ACL reconstruction did not influence outcome of OCA transplantation.

Lesion Size Does Not Predict Outcomes in Fresh Osteochondral Allograft Transplantation.

BACKGROUND: Cartilage repair algorithms use lesion size to choose surgical techniques when selecting a cartilage repair procedure. The association of fresh osteochondral allograft (OCA) size with graft survivorship and subjective patient outcomes is still unknown. PURPOSE: To determine if lesion size (absolute or relative) affects outcomes after OCA transplantation. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: The study included 156 knees in 143 patients who underwent OCA transplantation from 1998 to 2014 for isolated femoral condyle lesions. The mean age was 29.6 ± 11.4 years, and 62.9% were male. The majority of patients (62.2%) presented for cartilage repair because of osteochondritis dissecans. The mean graft area, used as a surrogate for absolute size of the lesion, was 6.4 cm2 (range, 2.3-11.5 cm2). The relative size of the lesion was calculated as the tibial width ratio (TWR; ratio of graft area to tibial width) and affected femoral condyle ratio (AFCR; ratio of graft area to affected femoral condyle width) using preoperative radiographs. All patients had a minimum follow-up of 2 years. Further surgical procedures were documented, and graft failure was defined as revision OCA transplantation or conversion to arthroplasty. International Knee Documentation Committee (IKDC) pain, function, and total scores were obtained. Satisfaction with OCA transplantation was assessed. RESULTS: The mean follow-up among patients with grafts remaining in situ was 6.0 years (range, 1.9-16.5 years). The OCA failure rate was 5.8%. Overall survivorship of the graft was 97.2% at 5 years and 93.5% at 10 years. No difference in postoperative outcomes between groups was found in absolute or relative size. Change in IKDC scores (from preoperative to latest follow-up) was greater for knees with large lesions compared to knees with small lesions, among all measurement methods. Overall satisfaction with the results of OCA transplantation was 89.8%. CONCLUSION: The size of the lesion, either absolute or relative, does not influence outcomes after OCA transplantation for isolated femoral condyle lesions of the knee.

Long-term Follow-up of Revision Osteochondral Allograft Transplantation of the Ankle.

BACKGROUND: Osteochondral allograft (OCA) transplantation is a useful alternative for treatment of posttraumatic ankle arthritis in young patients but has a relatively high failure rate and further procedures are often required. The purpose of this study was to evaluate outcomes of patients who underwent revision OCA transplantation of the ankle after failed primary OCA transplantation. METHODS: Twenty patients underwent revision OCA transplantation of the ankle between 1988 and 2015. Mean age was 44 years, 55% (11 of 20) were female. The mean time from primary to revision OCA was 3.0 ± 1.7 years. All patients had a minimum follow-up of 2 years. Outcomes included the American Academy of Orthopaedic Surgeons Foot and Ankle Module (AAOS-FAM) and questionnaires evaluating pain and satisfaction. Failure of the revision OCA was defined as a conversion to arthroplasty, arthrodesis, or amputation. RESULTS: Ten of 20 ankles required further surgery, of which 30% (6 of 20) were considered OCA revision failures (4 arthrodeses, 1 arthroplasty, and 1 amputation). The mean time to failure was 6.7 (range, 0.6-13.1) years. Survivorship of the revision OCA was 84% at 5 years and 65% at 10 years. The 14 patients with grafts remaining in situ had an average follow-up of 10.3 years; mean AAOS-FAM Core Score was 70.5 (range, 42.3-99). Of the patients who answered the follow-up questions, 4 of 7 reported moderate to severe pain, and 5 of 12 were satisfied with the results of the procedure. CONCLUSION: Although the results of revision ankle OCA transplantation are not inferior to primary OCA transplantation, the high rates of persistent pain, further surgery, and graft failure suggest that the indications for OCA as a revision procedure should be carefully evaluated, with proper patient selection. Considering the treatment alternatives, revising a failed OCA transplantation can be a useful treatment option, especially for young and active patients who wish to avoid arthrodesis or arthroplasty. LEVEL OF EVIDENCE: Level IV, case series.

Osteochondral Allograft Transplantation and Opening Wedge Tibial Osteotomy: Clinical Results of a Combined Single Procedure.

Objective To evaluate the outcome of patients who have undergone simultaneous osteotomy and osteochondral allograft (OCA) transplantation. Our hypothesis is that use of high tibial osteotomy and fresh OCA in a combined procedure is safe and effective without increasing morbidity in comparison to OCA alone. Design A case series of 17 patients underwent tibial osteotomy and simultaneous OCA during a single surgery. Osteotomy was indicated when axial alignment was within the affected compartment. Patients had a minimum of 2 years of follow-up after surgery. The mean graft size was 8.7 cm2, with 82% located on the medial femoral condyle alone and 18% involving the medial femoral condyle and one or more other sites. Data collection included demographics, osteotomy correction, graft site(s) and area, and clinical evaluation. Failure was defined as conversion to arthroplasty. Results Two of 17 patients (12%) failed at a mean of 9.3 years. The remaining 15 patients (88%) had intact allografts with mean survival of 8.1 years (SD 3.3). Five patients (29%) had an additional procedure, all undergoing osteotomy hardware removal. Of those with surviving allografts, mean pain and function scores improved significantly from the preoperative to postoperative assessment and International Knee Documentation Committee total scores improved significantly from 40.9 ± 15.4 preoperative to 75.5 ± 24.0 at latest follow-up ( P = 0.003); 92% of patients were satisfied with the results of the surgery. No postoperative complications occurred. Conclusion Combining high tibial osteotomy and OCA in properly selected patients is safe and effective.

Fresh Osteochondral Allograft Transplantation for Spontaneous Osteonecrosis of the Knee: A Case Series.

BACKGROUND: Spontaneous osteonecrosis of the knee (SONK) is a clinical entity identified by acute knee pain usually associated with joint effusion, with radiographic findings of a radiolucent defect on the weightbearing area of the femoral condyle. Conservative treatment is initially undertaken; however, surgical procedures are often necessary. Historically, surgical options have included core decompression, cartilage repair, high tibial osteotomy, or joint arthroplasty. Few studies in the literature have reported the use of fresh osteochondral allograft (OCA) for the treatment of SONK lesions. HYPOTHESIS: OCA transplantation is an effective treatment for SONK lesions on the medial femoral condyle. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A case series was analyzed of 7 patients treated with OCA for large SONK lesions of the medial femoral condyle with a minimum 4-year follow-up. All patients experienced failure of at least 6 months of conservative treatment and declined arthroplasty as the form of definitive treatment for medial femoral condyle lesion. All patients underwent OCA of the medial femoral condyle. Mean lesion size was 4.6 cm2 (range, 3.24-6.25 cm2), with a mean condylar width of 41.7 mm (range, 35.4-48.6 mm), resulting in a median proportion (lesion size/condylar width) of 56.8% (range, 32.7%-62.6%). The median surface allograft area was 5.1 cm2 (range, 3.2-6.3 cm2). RESULTS: The median follow-up was 7.1 years (range, 4.5-14.1 years). No patient had additional surgery following OCA transplant; the allograft failure rate was 0%. Subjective outcome scores from the International Knee Documentation Committee, Knee injury and Osteoarthritis Outcome Score, and modified Merle d'Aubigné-Postel scale improved from preoperative assessment to the latest follow-up. All patients were extremely satisfied with the results of the OCA transplant. CONCLUSION: Fresh OCA transplantation demonstrated excellent efficacy, durability, and satisfaction in this group of patients with isolated stage 2 and 3 SONK lesions who had experienced failure of conservative treatment. Fresh osteochondral allografts are an attractive method for surgical management of selected patients with spontaneous osteonecrosis of the knee.