Julie C. McCauley

Bipolar fresh osteochondral allografting of the tibiotalar joint

BACKGROUND Tibiotalar arthritis in the young, active patient is a debilitating condition with limited treatment options. Bipolar tibiotalar fresh osteochondral allograft transplantation was conceived as a possible alternative to arthrodesis and arthroplasty. We reported our experience with bipolar ankle osteochondral allografts for the treatment of tibiotalar joint arthritis. METHODS Between 1999 and 2008, we performed bipolar ankle allografts in eighty-eight ankles (eighty-four patients). Eighty-six ankles (eighty-two patients) had a minimum follow-up duration of two years. The mean patient age was forty-four years and 52% of the patients were male. Evaluation included frequency and type of reoperations, the Olerud-Molander Ankle Score, pain, function, and patient satisfaction. Radiographs were evaluated for graft healing, joint space narrowing, and graft collapse. RESULTS The mean duration of follow-up was 5.3 years (range, two to eleven years). Thirty-six (42%) of the eighty-six ankles that had undergone allograft had further surgery since implantation. Of the eighty-six ankles, twenty-five ankles (29%) had undergone graft-related reoperations and were considered clinical failures (ten underwent revision allografts, seven underwent arthrodeses, six underwent conversions to total ankle arthroplasty, and two underwent below-the-knee amputations) and eleven ankles (13%) had had reoperations that were not necessarily related to the graft (e.g., implant removal, debridement, synovectomy, or distraction). Survivorship of the osteochondral allograft was 76% at five years and 44% at ten years. The mean Olerud-Molander Ankle Score was 61 points at the time of the latest follow-up. The majority of patients reported satisfaction (92%) with osteochondral allograft transplantation and less pain (85%) and improved function (83%) after the procedure. CONCLUSIONS Transplantation of a fresh bipolar ankle osteochondral allograft for the treatment of tibiotalar arthritis resulted in acceptable outcomes in this difficult population, with most patients having improved objective and subjective outcome measures. Subjective satisfaction was high in spite of the 29% clinical failure rate. Osteochondral allograft failure did not limit further surgical options. We concluded that transplantation of a bipolar ankle allograft is a useful alternative in carefully selected patients with advanced tibiotalar arthritis.

Fresh Osteochondral Allografts in the Knee Comparison of Primary Transplantation Versus Transplantation After Failure of Previous Subchondral Marrow Stimulation

Background: In most treatment algorithms, osteochondral allograft (OCA) transplantation is regarded as an alternative salvage procedure when other, previous reparative treatments have failed. Purpose: To compare the outcomes of a retrospective matched-pair cohort of (1) primary OCA transplantation and (2) OCA transplantation after failure of previous subchondral marrow stimulation. Study Design: Cohort study; Level of evidence, 3. Methods: An OCA database was used to identify 46 knees that had OCA transplantation performed as a primary treatment (group 1) and 46 knees that underwent OCA transplantation after failure of previous subchondral marrow stimulation (group 2). All patients had a minimum of 2 years’ follow-up. Patients in each group were matched for age (±5 years), diagnosis (osteochondral lesion, degenerative chondral lesion, traumatic chondral injury), and graft size (small, <5 cm2; medium, 5-10 cm2; large, >10 cm2). The groups had similar body mass indexes, sex distributions, and graft locations (femoral condyle, patella, and trochlea. The number and type of further surgeries after the OCA transplantation were assessed; failure was defined as any reoperation resulting in removal of the graft. Functional outcomes were evaluated by use of the modified Merle d’Aubigné-Postel (18-point) scale, International Knee Documentation Committee (IKDC) subjective knee evaluation form, Knee injury and Osteoarthritis Outcomes Score (KOOS), and the Knee Society function (KS-F) scale. Patient satisfaction, according to a 5-point scale from “extremely satisfied” to “dissatisfied,” was recorded at the latest follow-up. Results: Eleven of 46 knees (24%) in group 1 had reoperations, compared with 20 of 46 knees (44%) in group 2 (P = .04). The OCA was classified as a failure in 5 knees (11%) in group 1 and 7 knees (15%) in group 2 (P = .53). At 10 years of follow-up, survivorship of the graft was 87.4% and 86% in groups 1 and 2, respectively. Both groups showed improvement in pain and function on all subjective scores from preoperatively to the latest follow-up (all P < .001). Results showed that 87% of patients in group 1 and 97% in group 2 were “satisfied” or “extremely satisfied” with the OCA transplantation. Conclusion: Favorable results were shown in both groups with significant improvement of functional scores and excellent survivorship. Despite the higher reoperation rate in the previously treated group, previous subchondral marrow stimulation did not adversely affect the survivorship and functional outcome of OCA transplantation.

Osteochondral Allograft Transplantation in Patients With Osteochondritis Dissecans of the Knee

Background: Osteochondritis dissecans (OCD) of the knee can be difficult to treat. Cartilage restoration techniques are often indicated when the lesion or fragment cannot be salvaged and the patient remains symptomatic. Fresh osteochondral allograft (OCA) transplantation can restore both bone and cartilage defects characteristic of OCD. Hypothesis: We hypothesized that osteochondral allografting is a successful method for treating OCD of the knee. Study Design: Case series; Level of evidence, 4. Methods: This study comprised 135 patients (149 knees) who underwent OCA for OCD of the knee (type III or IV) between 1997 and 2013 and had a minimum follow-up of 2 years. The median age was 21 years (range, 12-55 years) and 75.8% of the patients were male. The mean allograft size was 7.3 cm2 (range, 2.2-25 cm2). Evaluation included the following: frequency and type of reoperations; modified Merle d’Aubigné and Postel (18-point) scale; International Knee Documentation Committee (IKDC) pain, function, and total scores; and Knee Society function (KS-F) and knee (KS-K) scores. Clinical failure was defined as revision OCA or conversion to arthroplasty. Graft survivorship was determined. Results: The median follow-up time was 6.3 years (range, 1.9-16.8 years) and 62% of participants had more than 5-year follow-up. Thirty-four of 149 knees (23%) had reoperations, of which 12 (8%) were classified as allograft failures (7 OCA revisions, 3 unicompartmental knee arthroplasties, and 2 total knee arthroplasties). OCA survivorship was 95% at 5 years and 93% at 10 years. Of the 137 knees whose grafts were still in situ at the latest follow-up, the mean modified Merle d’Aubigné and Postel (18-point) score was 16.8; IKDC pain, function, and total scores were 2.1, 8.1, and 82.3; and KS-F and KS-K scores were 95.7 and 94.3, respectively. The majority of patients (95%) reported being satisfied with the outcome of their procedure. Conclusion: OCA transplantation was an effective treatment for OCD of the knee, with a low rate of graft failure, significant improvement in pain and function scores, and high patient satisfaction.

Osteochondral Allograft Transplantation of the Femoral Trochlea

Background: Osteochondral allograft (OCA) transplantation is a recognized treatment modality for cartilage damage in the knee. Few reports are available on outcomes of OCA in the patellofemoral joint, and there are no reports on lesions isolated to the femoral trochlea. Purpose: To evaluate graft survivorship and clinical outcomes in patients who had an OCA to the femoral trochlea. Study Design: Case series; Level of evidence, 4. Methods: An OCA database was used to identify 29 knees in 28 patients (mean age, 30.2 years; range, 12-47 years; 8 female, 20 male) who were treated with a fresh OCA transplant limited to the femoral trochlea. The primary outcome was graft survivorship, and the minimum follow-up was 2 years. Clinical outcomes were assessed by the modified Merle d’Aubigné-Postel (18-point) score; Knee Society function (KS-F) score; International Knee Documentation Committee (IKDC) pain, function, and total scores; and University of California, Los Angeles (UCLA) activity score. The OCA patient satisfaction score (5-point scale from extremely satisfied to dissatisfied) was also reported. Results: The mean follow-up period was 7.0 years (range, 2.1-19.9 years). Graft survivorship was 100% at 5 years and 91.7% at 10 years. One patient was converted to a total knee arthroplasty 7.6 years after OCA surgery. The mean modified Merle d’Aubigné-Postel score improved from 13.0 to 16.1, the mean KS-F score from 65.6 to 85.2, and the mean IKDC total score from 38.5 to 71.9; the mean UCLA score was 7.9 postoperatively. Eighty-nine percent of patients were extremely satisfied or satisfied with the outcome of surgery. Conclusion: Fresh OCA transplantation resulted in excellent clinical outcomes in this patient cohort with articular cartilage damage to the femoral trochlea. The procedure resulted in improved pain and function and high patient satisfaction.

Osteochondral Allograft Transplantation for Knee Lesions after Failure of Cartilage Repair Surgery

Objective: The objective of this study was to assess the outcome of osteochondral allograft (OCA) transplantation as a salvage procedure after various cartilage repair surgeries. Design: One hundred sixty-four knees in 163 patients (mean age = 32.6 years; range = 11-59 years; 55% males) were treated with OCA transplantation after subchondral marrow stimulation (SMS), osteochondral autograft transplantation (OAT), and autologous chondrocyte implantation (ACI). The majority of previous procedures were isolated SMS in 145 knees (88.4%). Mean allograft size was 8.5 ± 7.9 cm2. The most common location was in femoral condyle. The number and type of reoperations on the operative knee were assessed. Failure of the OCA transplantation was defined as any reoperation resulting in removal of the allograft. Functional outcomes were evaluated. Results: Sixty-eight knees had reoperations after OCA transplantation. Thirty-one knees (18.9%) were classified as allograft failures. The median time to failure was 2.6 ± 6.8 years (range = 0.7-23.4 years). Survivorship of the graft was 82% at 10 years and 74.9% at 15 years. Patients whose grafts were still in situ had a mean of 8.5 ± 5.6 years of follow-up. Scores on all functional outcomes scales improved significantly from preoperatively to latest follow-up. Eighty-nine percent of OCA transplantation patients reported being “extremely satisfied” or “satisfied.” Conclusion: Despite the high reoperation rate, OCA transplantation is a successful salvage surgical treatment after cartilage repair procedures. This cohort showed improved survivorship and functional outcomes of OCA transplantation after SMS, ACI, and OAT.

Revision Osteochondral Allograft Transplantations: Do They Work?

Background: Primary fresh osteochondral allograft transplantation is a useful treatment option for osteochondral lesions in the knee. Clinical failure of primary osteochondral allograft transplantation may require further surgery, including revision osteochondral allograft transplantation. Purpose: To evaluate outcomes of patients who have undergone revision osteochondral allograft transplantation of the knee. Study Design: Case series; Level of evidence, 4. Methods: This series included 33 patients (33 knees) who underwent revision osteochondral allograft transplantation between 1983 and 2012, were at least 2 years out from surgery, and had a minimum 2-year follow-up. Clinical evaluations included the International Knee Documentation Committee pain, function, and total scores; Knee Society function score; and modified Merle d’Aubigné and Postel scale. Failure of the revision allograft was defined as conversion to partial or total knee arthroplasty. Results: The mean follow-up after revision osteochondral allograft transplantation was 10 years, with 75% of patients having more than 5 years’ follow-up. Thirteen patients (39%) had failed results after revision osteochondral allograft transplantation, with a mean time to failure of 5.5 years. The remaining 20 patients (61%) had surviving revision allografts, with a mean graft survival of 10 years. Mean pain and function scores at the last follow-up were improved. Survivorship of the revision allograft was 61% at 10 years. Conclusion: Revision osteochondral allograft transplantation of the knee demonstrated acceptable clinical outcomes, although they were inferior to primary allograft transplantation procedures. Revision osteochondral allograft transplantation may be considered an option for patients with a failed primary osteochondral allograft.

Use of Intraoperative X-rays to Optimize Component Position and Leg Length During Total Hip Arthroplasty

Proper femoral and acetabular component position and leg length equality are important intraoperative considerations during total hip arthroplasty. Unfortunately, traditional surgical techniques often lead to suboptimal component position, and such deviations have been associated with increased rates of prosthetic wear, dislocation, component loosening, and patient dissatisfaction. Although surgical navigation has been shown to improve reproducibility of component alignment, such technology is not universally available and is associated with significant costs and additional surgical/anesthetic time. In the current study, we found that a routine intraoperative pelvic radiograph could successfully identify malpositioned components and leg length inequalities and could allow for successful correction of identified problems. Unexpected component malposition and leg length inequality occurred in only 1.5% of cases where an intraoperative pelvic radiograph was utilized.

Accuracy of a hand-held surgical navigation system for tibial resection in total knee arthroplasty

BACKGROUND Accuracy of total knee arthroplasty (TKA) implant placement and overall limb are important goals of TKA technique. METHODS The accuracy and ease of use of an accelerometer-based hand-held navigation system for tibial resection during TKA was examined in 90 patients. Preoperative goals for sagittal alignment, navigation system assembly time, resection time, and tourniquet time were evaluated. Coronal and sagittal alignment was measured postoperatively. RESULTS The average coronal tibial component alignment was 0.43° valgus; 6.7% of patients had tibial coronal alignment outside of ±3° varus/valgus. The difference between the intraoperative goal and radiographically measured posterior tibial slope was 0.5°. The average time to completion of the tibial cut was 4.6 minutes. CONCLUSION The accelerometer-based hand-held navigation system was accurate for tibial coronal and sagittal alignment during TKA, with no additional surgical time compared with conventional instrumentation.

Fresh Osteochondral Allograft Transplantation for Fractures of the Knee

Objective The purpose of this study was to evaluate functional outcomes and allograft survivorship among patients with knee fracture who underwent fresh osteochondral allograft (OCA) transplantation as a salvage treatment option. Design Retrospective analysis of prospectively collected data. Setting Department of Orthopaedic Surgery at one hospital. Patients Fresh OCAs were implanted for osteochondral lesions after knee fracture in 24 males and 15 females with an average age of 34 years. Twenty-nine lesions (74%) were tibial plateau fractures, 6 (15%) were femoral condyle fractures, and 4 (10%) were patella fractures. Main Outcome Measurements Clinical evaluation included modified Merle d’Aubigné-Postel (18-point), International Knee Documentation Committee, and Knee Society function scores, and patient satisfaction. Failure of OCA was defined as revision OCA or conversion to total knee arthroplasty (TKA). Results Nineteen of 39 knees (49%) had further surgery. Ten knees (26%) were considered OCA failures (3 OCA revisions, 6 TKA, and 1 patellectomy). Survivorship of the OCA was 82.6% at 5 years and 69.6% at 10 years. Among the 29 knees (74%) that had the OCA still in situ, median follow-up was 6.6 years. Pain and function improved from preoperative to latest follow-up; 83% of patients reported satisfaction with OCA results. Conclusion OCA transplantation is a useful salvage treatment option for osteochondral lesions caused by knee fracture. Although the reoperation rate was high, successful outcome was associated with significant clinical improvement.

Return to Sport and Recreational Activity Following Osteochondral Allograft Transplantation in the Knee

Objectives: Osteochondral allograft (OCA) transplantation is an integral part of the cartilage repair paradigm. There is little data regarding return to sport or recreational activity after OCA. The purpose of the present study was to 1) determine if athletic patients undergoing OCA returned to sport, 2) assess reason(s) why in those who did not, 3) and ascertain patient and graft-related characteristics that differed between those who returned or did not return to sport. Methods: Our institution’s OCA database was used to identify 149 knees in 142 patients who participated in sport or recreational activity prior to cartilage injury (45% highly-competitive athletes and 55% well-trained and frequently sporting) and had a minimum follow-up of 1 year (Table 1). The average age was 31 years and 59% were male. The majority of patients (68%) sustained a sports-related injury to their knee and 89% had undergone previous surgery (mean 2.1). Median time from onset of symptoms to OCA transplantation was 2.7 years. Pre-injury and postoperative participation in sport or recreational activity was collected. Patients not returning to their pre-injury level of sport were mailed a questionnaire to assess why, which included knee and lifestyle-related reason(s). Standard objective and subjective outcome measures were also obtained. Further surgery on the operative knee was documented. Results: At a mean follow-up of 6 years, 76% (113 of 149 knees) returned to sport or recreational activity. Among the 113, 28% returned to the same level of pre-injury sport, 48% partially returned (returned to one or more but not all of the same sports or activities), and 25% returned to a different sport or activity. Among the 24% (36 of 149 knees) who did not return to sport or activity, reasons included lifestyle events such as starting a family, changing careers, end of organized sports, knee-related issues, and worry about re-injuring the knee. Postoperatively, 79% of knees were able to participate in a high level of activity (moderate, strenuous, or very strenuous activities), and 71% reported having “very good” to “excellent” function. Thirty-eight of 149 knees (26%) had further surgery following the OCA, of which 14 knees (9% of entire cohort) were considered OCA failures. Survivorship of the OCA at 6 years was 90%. Patients who did not return to sport following OCA were more likely to be female, have injured their knee in an activity other than sports, and had a larger graft size (Table 1). Diagnosis and anatomical location also differed between groups. Conclusion: OCA transplantation is a successful treatment option for athletes and highly active patients who sustain a cartilage injury to their knee. The majority of patients (76%) returned to sport or recreational activity following the OCA and 28% of those patients returned to the same level of pre-injury sport or activity. Patients often reported that their failure to return to sport was due to lifestyle characteristics such as family or career changes rather than knee-related problems.