Cartilage Repair With or Without Meniscal Transplantation and Osteotomy for Lateral Compartment Chondral Defects of the Knee

Abstract

Background:Treatment decision making for chondral defects in the knee is multifactorial. Articular cartilage pathology, malalignment, and meniscal deficiency must all be addressed to optimize surgical outcomes.Purpose:To determine whether significant clinical improvements in validated clinical outcome scores are observed at minimum 2-year follow-up after articular cartilage repair of focal articular cartilage defects of the lateral compartment of the knee with or without concurrent distal femoral osteotomy and lateral meniscus transplant.Study Design:Case series; Level of evidence, 4.Methods:Symptomatic adults who underwent surgical treatment (microfracture, autologous chondrocyte implantation [ACI], osteochondral autograft or allograft) of full-thickness lateral compartment chondral defects of the knee with or without a postmeniscectomy compartment or valgus malalignment by a single surgeon with minimum 2-year follow-up were analyzed. Validated patient-reported and surgeon-measured outcomes were collected pre- and postsurgery. Pre- and postoperative outcomes were compared via Student t tests.Results:Thirty-five subjects (mean age, 29.6 ± 10.5 years) were analyzed. Patients had been symptomatic for 2.51 ± 3.52 years prior to surgery and had undergone 2.11 ± 1.18 surgeries prior to study enrollment, with a mean duration of follow-up of 3.65 ± 1.71 years. The mean defect size was 4.42 ± 2.06 cm2. Surgeries included ACI (n = 18), osteochondral allograft (n = 14), osteochondral autograft (n = 2), and microfracture (n = 1). There were 18 subjects who underwent concomitant surgery (14 lateral meniscus transplant, 3 distal femoral osteotomy, and 1 combined). Statistically significant (P < .05) and clinically meaningful improvements were observed at final follow-up in Lysholm, subjective International Knee Documentation Committee (IKDS), Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales, Short Form–12 (SF-12) scores, and patient satisfaction. At follow-up, patients undergoing isolated articular cartilage surgery had a significantly higher KOOS quality of life subscore than did those undergoing articular cartilage surgery and lateral meniscus transplant (P = .039). Otherwise, there were no significant postoperative differences between the isolated and combined surgery groups in any outcome score. Five patients underwent 6 reoperations (1 revision osteochondral allograft, 5 chondroplasties). No patient was converted to knee arthroplasty.Conclusion:In patients with lateral compartment focal chondral defects with or without lateral meniscal deficiency and valgus malalignment, surgical cartilage repair and correction of concomitant pathology can significantly improve clinical outcomes at 2-year follow-up with no significant differences between isolated and combined surgery and a low rate of complications and reoperations.

High Tibial Osteotomy following Biologic Replacement of the Knee

“…Placement of the new tibial plateau and femoral condyle allografts with meniscus will correct a few degrees of malalignment. 8,9 However, it is critical to assess the alignment after the fresh grafts are placed to determine the need for osteotomy.…”

“…Most advocate either a staged osteotomy before the transplant or a simulta-neous osteotomy concomitant with the transplant. 4,[8][9][10][11] Waiting until after the transplant to perform a staged osteotomy puts the fresh osteoarticular allografts at a risk of damage from overloading prior to the osteotomy. 12 We prefer to perform simultaneous transplant and osteotomy to prevent our patients from having to go through two separate procedures, each requiring a period of TTWB following surgery.…”

“…3,7 The timing of osteotomy procedures to correct malalignment either before, concurrent, or after allograft implantation has become an area of research interest. 4,[8][9][10] Concurrent osteotomies and allograft transplantation have become increasingly popular due to the decreased patient morbidity from multiple surgeries that require a period of toe-touch weight bearing (TTWB) postoperatively. 7,8 We discuss here our techniques for correcting malalignment that concurrently repair major bipolar knee lesions while transplanting the meniscus.…”

Malalignment: A Requirement for Cartilage and Organ Restoration

“…32 The biomechanical data suggesting the efficacy of combined malalignment correction concomitantly with meniscal and cartilage restoration has been corroborated with clinical studies (Table 3). [1][2][3][4][23][24][25][26][27][28][29][30] It is difficult to compare knee restorative procedure success between the neutralaligned patient and the patient with malalignment because of the increased complexity of knee pathology with the inclusion of malalignment. However, clinical studies suggest that combined osteotomy with meniscal transplantation or comparable clinical outcomes at 2 years as compared with isolated cartilage procedures.…”

“…cartilage restoration (microfracture, ACI, osteochondral allograft, or osteochondral autograft) can lead to comparable results with those achieved for isolated MAT or cartilage restoration. [23][24][25][26][28][29][30]36 Kazi et al 23 recently reported the largest series to-date of MAT with concomitant osteotomy. The authors found that there was comparable survival for MAT combined with osteotomy, when malalignment was present, as compared with isolated MAT in the neutralaligned cohort.…”