Patient-Reported Outcomes for Large Bipolar Osteochondral Allograft Transplantation in Combination with Realignment Osteotomies for the Knee

Abstract

Effective treatment for bipolar articular cartilage lesions in the knee remains a clinical challenge. Lower extremity malalignment is a risk factor for treatment failures, which can be addressed by tibial or femoral osteotomy. The purpose of this study was to compare outcomes among patients who underwent knee joint restoration by osteochondral allograft (OCA) transplantation with concurrent or staged realignment osteotomy. With Institutional Review Board approval, patients undergoing bipolar OCA transplantation with concurrent or staged distal femoral osteotomy (DFO) or high tibial osteotomy (HTO) were analyzed. Patients were categorized by osteotomy type (DFO and HTO) and timing (concurrent and staged). Patient-reported outcome measures (PROMs), revisions, failures, and complications were examined preoperatively (baseline), 3, 6, 12, and 24 months after OCA transplantation; change scores from preoperative values were used for analysis. A total of 23 patients met inclusion criteria (15 males); 13 (56.5%) received HTO (5 concurrent), while 10 (43.5%) received DFO (5 concurrent). There were no significant differences in complication rates between concurrent and staged osteotomies. Primary bipolar OCA transplantation with osteotomy was associated with successful outcomes in 70% of patients; four patients underwent revision (17.4%) and three (13.0%) failed and were treated by total knee arthroplasty. Further, the four patients undergoing revision met functional criteria for success at final follow-up, resulting in a 2-year functional survival rate of 87.4%. Aside from Patient-Reported Outcomes Measurement Information System (PROMIS) physical function, all PROMs for concurrent and staged osteotomies improved from baseline to 2 years postoperatively. Concurrent osteotomies of both types were associated with significantly lower pain scores at 12 months (p = 0.04), compared with staged osteotomies. Apart from Single Assessment Numerical Evaluation (SANE), more PROM improvement was observed for concurrent osteotomies at 2 years. Improvements in PROMs for patients undergoing OCA transplantation combined with osteotomy were observed at 2-year follow-up. PROMs for concurrent osteotomy were consistently greater than staged osteotomy, lending support to addressing lower extremity malalignment with bipolar OCA transplantation in the knee during a single surgery when possible.

Return to Sport and Work after Randomization for Knee Distraction versus High Tibial Osteotomy: Is There a Difference?

“…[12][13][14] However, osteochondral allograft transplantation techniques can successfully restore joint function in young (up to 55 years of age) and active patients with large focal or multifocal articular cartilage lesions. [15][16][17] High tibial osteotomy (HTO) has also been increasingly advocated to treat this younger patient population 18,19 and thus expected to rise in the coming years. The pooled 10-year HTO survivorship, using KA as an endpoint, was 92% for opening-wedge HTO and 85% for closing wedge HTO.…”

Diagnosis and Management of Articular Cartilage and Meniscus Pathology in the Posterior Cruciate Ligament-Injured Knee

“…40,41 If staged ACL reconstruction and/or realignment osteotomy is required, the timing for these subsequent procedures is coordinated accordingly. 40,42 The other key factor in successfully managing these cases is the postoperative rehabilitation process. 43,44 Postoperative management has been well documented to be a critical component in avoiding treatment failure and optimizing success with respect to return to work, return to sport, and patient-reported outcome measures.…”

Postoperative Management for Articular Cartilage Surgery in the Knee

“…Concomitant surgical procedures such as tibial and femoral osteotomies to correct limb alignment are frequently performed in conjunction with bipolar OCA transplantation in the knee. 10 As such, healing at the osteotomy site should be taken into consideration for rehabilitation protocol design, monitoring, and progression. Meniscus allograft transplant is often performed in conjunction with tibiofemoral bipolar OCA transplantation, which will dictate the early ROM limitations.…”

“…It is also important to remember that concomitant procedures to treat comorbidities in the affected knee are commonly performed in conjunction with cartilage repair and restoration procedures, including tibial and femoral osteotomies, meniscal repair and transplant, and anterior cruciate ligament (ACL) reconstruction. 6,[8][9][10] Although there is limited evidence for rehabilitation guidelines for these combined procedures, therapists should base rehabilitation restrictions and progression on the most atrisk procedure.…”