Rehabilitation and Return-to-Play Criteria After Fresh Osteochondral Allograft Transplantation: A Systematic Review

Abstract

Background: Fresh osteochondral allograft (OCA) is a treatment option that allows for the transfer of size-matched allograft cartilage and subchondral bone into articular defects of the knee. Although long-term studies show good functional improvement with OCA, there continues to be wide variability and a lack of consensus in terms of postoperative rehabilitation protocols and return to sport. Purpose: To systematically review the literature and evaluate the reported rehabilitation protocols after OCA of the knee, including weightbearing and range of motion (ROM) restrictions as well as return-to-play criteria. Study Design: Systematic review; Level of evidence, 4. Methods: PubMed, EMBASE, Cumulative Index of Nursing Allied Health Literature, SPORTDiscus, and Cochrane databases were searched according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for studies on knee OCA. Studies were included if they reported return-to-play data or postsurgical rehabilitation protocols. Results: A total of 62 studies met the inclusion criteria, with a total of 3451 knees in 3355 patients. Concomitant procedures were included in 30 of these studies (48.4%). The most commonly cited rehabilitation protocols included weightbearing restrictions and ROM guidelines in 100% and 90% of studies, respectively. ROM was most commonly initiated within the first postoperative week, with approximately half of studies utilizing continuous passive motion. Progression to weightbearing as tolerated was reported in 60 studies, most commonly at 6 weeks (range, immediately postoperatively to up to 1 year). Of the 62 studies, 37 (59.7%) included an expected timeline for either return to play or return to full activity, most commonly at 6 months (range, 4 months to 1 year). Overall, 13 studies (21.0%) included either objective or subjective criteria to determine return to activity within their rehabilitation protocol. Conclusion: There is significant heterogeneity for postoperative rehabilitation guidelines and the return-to-play protocol after OCA of the knee in the literature, as nearly half of the included studies reported use of concomitant procedures. However, current protocols appear to be predominantly time-based without objective criteria or functional assessment. Therefore, the authors recommend the development of objective criteria for patient rehabilitation and return-to-play protocols after OCA of the knee.

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

“…A recent systematic review by Stark et al analyzing the postoperative protocols for 3451 knees across 62 studies explored the important factors in the rehabilitation protocol, including range of motion (ROM) in 56 studies, bracing in 37 studies, weightbearing restrictions in 62 studies, and return to sport criteria after OCA transplantation in 41 studies. 87 Of the studies that reported ROM in this review, 78.6% of authors initiate motion within the 1st week postoperatively, with the remaining authors beginning motion during the 2nd or 4th week postoperatively. 87 The majority of these authors allowed for unrestricted ROM at their respective time points.…”

“… 87 Of the studies that reported ROM in this review, 78.6% of authors initiate motion within the 1st week postoperatively, with the remaining authors beginning motion during the 2nd or 4th week postoperatively. 87 The majority of these authors allowed for unrestricted ROM at their respective time points. For patellofemoral lesions, more restrictive protocols may be indicated as multiple authors have advocated limiting postoperative ROM to <30–45 o of flexion to avoid overload of the patella and trochlea.…”

“… 89–91 In terms of rehabilitation exercises, most surgeons initiate closed-chain and open-chain exercises at 4 and 8 weeks postoperatively, respectively. 87 …”

“… 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. 76 , 87 , 97 The most appropriate time for when full weightbearing is permitted should be patient-specific as the physical and psychological benefits of early weightbearing and individual demand of the patient must be weighed against the potential excess strain on the transplanted graft and risk of failure. Return to sport following OCA transplantation presents a further challenge to the treating physician, as the physical demands across sport and competition level vary widely, as does the recovery process for each individual patient.…”

“… 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. Quantitative measurements such as jump testing and movement screens aid in return to sport evaluations to determine strength and movement patterns in the surgical extremity.…”