Osteochondral Allograft Transplantation in Professional Athletes: Rehabilitation and Return to Play

Abstract

For the treatment of large chondral and osteochondral defects of the knee, osteochondral allograft transplantation (OCA) is an effective solution with relatively high rates of return to sport. In professional athletes, rehabilitation following OCA is a critical component of the process of returning the athlete to full sports activity and requires a multidisciplinary team approach with frequent communication between the surgical and rehabilitation teams (physical therapists, athletic trainers, coaching staff). In this review, we describe our five-phase approach to progressive rehabilitation of the professional athlete after OCA, which takes into account the biological processes of healing and optimization of neuromuscular function required for the demands of elite-level sport. The principles of early range of motion, proper progression through the kinetic chain, avoidance of pain and effusion, optimization of movement, regimen individuation, and integration of sports-specific activities underlie proper recovery.

Osteochondral Allografts in Knee Surgery: Narrative Review of Evidence to Date

“…This decision requires a multidisciplinary approach between the physician, physical therapists, athletic training staff, and athlete. 92 Across 37 studies, the expected timeline from surgery to return to play ranged from 4 months to 1 year, with most authors (62.2%) favoring return to sport at 6 months. 87 Though many protocols report time after surgery as the critical measure, objective functional assessment measures should be utilized instead.…”

“… 87 Patel et al recommended keeping the knee brace locked in extension during weightbearing to minimize shear forces on the knee joint until 2 weeks postoperatively when quadriceps control has been established, at which time the brace can be discontinued at week 4 postoperatively. 92 …”

“… 98 Furthermore, evaluation tools analyzing restoration of quadriceps strength, conditioning, and ability to perform sport specific-skills are important metrics in an athlete’s assessment prior to return to sport. 92 One limitation of the included studies is the lack of standardized sport-specific protocols for return to play since the demands of different sports result in different loads across the knee joint. In addition to functional assessment tools, some authors have advocated for advanced imaging with MRI and CT to assess graft incorporation, with full incorporation required prior to advancing an athlete back to full activity.…”

“…87 Patel et al recommended keeping the knee brace locked in extension during weightbearing to minimize shear forces on the knee joint until 2 weeks postoperatively when quadriceps control has been established, at which time the brace can be discontinued at week 4 postoperatively. 92 Weightbearing protocols for condylar OCA transplantation also vary significantly among surgeons, with a recent trend of more permissive postoperative weightbearing protocols. 87 Initial partial weightbearing was reported by only about 30% of authors, with the most common protocol initiating weightbearing at 2 weeks, and others withholding weightbearing until 6 weeks postoperatively.…”

“…87 Limiting weightbearing in the early postoperative period may help avoid excessive forces that may displace the graft or cause apoptosis and proteoglycan loss within the articular cartilage; however, this must be balanced with the benefits of healthy moderate mechanical loading across the articular cartilage that promotes an anabolic chondrocyte response and transfer of nutrients from the synovial fluid. [92][93][94][95][96] From a high-volume center, 20% foot flat weightbearing for 1-2 weeks is permitted postoperatively, followed by progression to full weightbearing and functional activity. 92 For patellofemoral OCA transplantation, the majority of studies allowed for immediate weightbearing as tolerated in a knee brace locked in extension while restricting knee flexion postoperatively.…”