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Background: There is no standardized rehabilitation protocol after osteochondral allograft (OCA) transplantation surgery to the distal femur. The spectrum of recommendations includes restrictions to toe-touch weightbearing (TTWB) for 6 weeks and immediate weightbearing as tolerated (WBAT). Purpose/Hypothesis: The purpose of this study was to compare outcomes for immediate unrestricted WBAT to restricted TTWB after OCA transplantation to the distal femur. It was hypothesized that the immediate WBAT protocol would be noninferior to delayed, restricted TTWB. Study Design: Retrospective cohort study. Methods: A total of 74 patients who underwent press-fit, dowel technique OCA transplantation to the femoral condyle(s) for contained (International Cartilage Repair Society grade 3-4) lesions were identified in the Metrics of Osteochondral Allograft multicenter database: 36 patients (18 women/18 men) who were prescribed TTWB were allocated to the control cohort and 38 patients (21 women/17 men) who were prescribed WBAT were allocated to the test cohort. Baseline characteristics were similar except for larger grafts in test patients (3.4 vs 2.7 cm2; P = .004) and higher body mass index (BMI) in control patients (27.8 vs 24.9 kg/m2; P = .01). Failure rates, final patient-reported outcome (PRO) scores, and PRO score changes from baseline were compared between the cohorts. Multiple regression was used to control for potential confounders and investigate noninferiority using minimal clinically important differences (MCIDs). Results: The mean follow-up was 2 years (range, 1-5 years) in both cohorts. Both cohorts showed significant improvement in all PRO scores, with no significant between-group differences in failure rates, final PRO scores, or PRO changes from baseline. There were 3 cases of failure in each cohort (control cohort: allograft revision [n = 2], debridement [n = 1]; test cohort: chondroplasty [n = 2], conversion to total knee arthroplasty [n = 1]). Regression analysis showed that adjusted differences in final PRO scores based on weightbearing protocol were minor and less than MCIDs when controlling for age, sex, graft size, BMI, and allograft location. Analysis of the MCIDs with respect to the lower bounds of the confidence intervals indicated that WBAT was noninferior to TTWB with a reasonable degree of confidence (range, 84.1%-99.9% confidence). Conclusion: Results indicated that immediate unrestricted WBAT after OCA transplantation to the distal femur was equally safe and effective compared to restricted TTWB.

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OBJECTIVE: To collate current literature pertaining to the published reports of indications for, and outcomes of, osteochondral allograft (OCA) transplantations in the shoulder so as to guide surgeons in the management of various etiologies of osteochondral lesions in this joint. DESIGN: A systematic review of the current literature was performed in February 2022 in the PubMed, Cochrane, and EMBASE databases using specific search terms and predetermined inclusion/exclusion criteria. RESULTS: One-hundred-twenty-three articles were initially identified, 30 full-text articles were assessed for eligibility, and 17 articles met inclusion criteria. Data were collected for study characteristics, etiology, lesion size/location, intervention/type of graft used, follow-up, and outcomes. In total, 83 shoulders were included (n = 83) in the review with an average follow-up of 45.7 months. Nine specific indications for OCA transplantation in the shoulder included: reverse Hill-Sachs lesions (33), Hill-Sachs lesions (22), pain pump chondrolysis (10), recurrent shoulder instability (7), osteoarthritis/degenerative changes (5), radiofrequency chondrolysis (2), prominent suture anchors (2), glenoid lesion (1), and osteochondritis dissecans (1). Seventeen patients had concomitant surgeries and two patients were lost to follow-up. Of the total 83 shoulders, 68 had favorable outcomes and 13 had unfavorable outcomes as determined by graft incorporation, pain scores, functionality/ROM, patient-reported satisfaction, and/or requirement for revision/arthroplasty. Of the 13 with unfavorable outcomes, a disproportionate number had concomitant surgeries and/or were performed for pain pump chondrolysis (6). CONCLUSIONS: The use of OCAs appears to be a viable option for a variety of difficult-to-treat shoulder pathologies, particularly those characterized by isolated osteochondral injuries.

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Osteochondral allograft (OCA) transplantation is an increasingly available biologic treatment option for a range of intraarticular aetiologies. To our knowledge, no prior publication has documented the use of this technology to treat a lesion of the proximal humerus secondary to avascular necrosis (AVN). We describe our experience treating a 42-year-old female executive with idiopathic AVN of the proximal humerus with a fresh osteochondral allograft. Computed tomography (CT) at 3 months post-op showed full bony incorporation and a restored native joint contour. Over the initial 7 months post-operatively, she reported continued improvements in pain and function as measured by quick Disabilities of the Arm, Shoulder, and Hand (DASH) scores. She was discharged from physical therapy after 6 months, reporting no rest pain, full active and passive range of motion, and unrestricted occupational and recreational activity.

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PURPOSE: To evaluate the 5-year rate of survival without undergoing arthroplasty or high tibial osteotomy (HTO) in subjects with mild-to-moderate medial compartment knee osteoarthritis (OA) who were treated with an implantable shock absorber (ISA) system. METHODS: Three prospective, sequential, multicenter, international, single-arm clinical trials were conducted comprising subjects who received an ISA for symptomatic medial knee OA after failing ≥ 6 months of conservative therapy. Study outcomes were analyzed cumulatively and by enrollment group when all subjects' follow-up data exceeded the 2-year threshold after ISA implantation. Primary outcome was survival rate without conversion to arthroplasty/HTO. Secondary outcomes were changes in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and function scores after ISA implantation. RESULTS: All 171 enrolled subjects (age 51 ± 9 years, body-mass index 28.5 ± 3.5 kg/m2, 38% female; study knee Kellgren-Lawrence score 2.7 ± 0.9 points) were followed for a minimum of 2, and up to 5, years after device implantation. Overall, 90.6% (155/171) of subjects survived without requiring arthroplasty/HTO at last follow-up (mean 3.2 ± 1.6 years). The Kaplan-Meyer median 3- and 5-year survival-without-arthroplasty point estimates were 89.8% (95% CI 86.5‒95.7%) and 84.9% (95% CI 75.1‒91.1%), respectively. The median 3-year estimated survival rate for the most recent study (n = 81) was 97.3%. The mean WOMAC Pain score decreased 71% from baseline to last follow-up after ISA implantation, from 58 ± 13 to 16 ± 17 points (p < 0.0001). The Function score improved 69%, decreasing from 56 ± 18 to 17 ± 17 points (p < 0.0001). CONCLUSIONS: In younger patients with mild-to-moderate symptomatic medial compartment knee OA, implantation of the ISA device resulted in a 5-year survival rate of 85% from undergoing arthroplasty or HTO. The ISA system may be an effective treatment option for working-age patients with medial knee OA who are not candidates for or do not desire more invasive surgical approaches. LEVEL OF EVIDENCE: II.

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OBJECTIVE: Up to 10 million Americans below the age of 65 years have symptomatic knee osteoarthritis (OA) and may not yet be candidates for arthroplasty. In response, a subcutaneous implantable shock absorber (ISA) that unloads the knee has been developed. The safety and effectiveness of ISA treatment were compared against a surgical unloading control, high tibial osteotomy (HTO). DESIGN: This was a prospective open-label cohort study with a historical control arm. Subjects underwent ISA placement or HTO. The primary endpoint was a composite variable combining pain, function, specific adverse events, integrity of implant or hardware, and conversion to subsequent surgery. Pain and function outcomes (Western Ontario and McMaster Universities Arthritis Index scores) were assessed through 24 months. Adverse events were tracked. RESULTS: The primary endpoint demonstrated superiority of the ISA arm versus the HTO arm, with 85.6% of ISA subjects meeting all criteria compared with 65.5% of HTO subjects. In addition, all 5 secondary endpoints showed superiority of ISA over HTO. At 24 months, the proportions of subjects considered responders were 95.8% (ISA) versus 87.9% (HTO) for pain and 91.7% (ISA) versus 81.3% (HTO) for function. The ISA procedure was well tolerated, with 13.4 days to full weightbearing status versus 58.0 days for the HTO arm. CONCLUSIONS: Treatment with an ISA demonstrated noninferiority and superiority versus treatment with HTO in subjects aged 25-65 years who had OA of the medial knee. Treatment with ISA has high clinical benefit and is durable through at least 24 months.

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Purpose: To define the criteria for coverage for a cartilage restoration procedure and osteochondral allograft (OCA) transplantation and to investigate coverage for OCA procedures among private payer medical policies. Methods: A systematic search of private payer websites was conducted to identify publicly available 2018 OCA medical policies. Medical criteria related to patient demographics, defect characteristics, and previous treatment were analyzed. Trends in coverage for treatment of talus and patella and the extent of restrictiveness of medical policies were evaluated from 2016 to 2018. The extent of restrictiveness of a policy was defined by number of medical criteria established by payer policies. Policies with >5, 3-5, and <3 specified criteria for OCAs were considered strongly, moderately, and weakly restrictive, respectively. Results: In total, 49 private payer medical policies for OCA transplantation were identified. Extracted criteria varied greatly between medical policies. Ten different defect size ranges were reported across payer policies. Criteria for patient body mass index was specified in 63% of policies. Criteria for failed arthroscopic or traditional surgical procedure were identified in 20% of the policies. More than one half of policies (51%) specified knee defect location to load-bearing surfaces. Analysis of trends in positive coverage statements and restrictiveness showed an increase from 4.7% in 2016 to 39.5% for talus, 4.7% to 7.0% for patella, and a slight shift (4.7% of payers) toward weakly restrictive medical policies. Conclusions: This study demonstrates wide variability and inconsistencies in published criteria among OCA medical policies. Clinical Relevance: This study informs clinicians of the current state of coverage for OCA transplantation, providing insights into the variability of payer policies and potential impact.

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BACKGROUND: Although osteochondral allograft (OCA) transplantation has been a standard treatment for patients with osteochondral lesions, there is a disagreement in commercial payers' medical criteria regarding the definition of medical suitability and thus authorization for OCA transplantation. The primary goal of this study was to understand where consensus between a committee of experienced cartilage restoration surgeon scientists and payer policies existed and where there was significant disagreement. METHODS: U.S. private payers were identified by reviewing health insurance market research literature. Medical criteria were then obtained from publicly available payer medical polices. A literature review was conducted to identify supporting evidence for consensus statements based on private payer medical criteria. The MOCA (Metrics of Osteochondral Allograft) Committee, 30 experienced surgeons and subject-matter experts in OCA transplantation, used a Likert scale of 1 (strongly disagree) to 5 (strongly agree) to rank each statement. The extent of agreement and disagreement among participants was measured for each statement. Consensus was defined as agreement or disagreement of >75%. RESULTS: Fifty-seven statements regarding relevant medical criteria for OCA transplantation were included in the survey. All 30 MOCA Committee members completed the survey (100% response rate). Over half of the statements (52.6%) did not reach consensus. Of the remaining 27 statements that reached consensus, respondents agreed or strongly agreed with 16 statements, and disagreed or strongly disagreed with 11 statements. Inconsistent voting was observed for statements related to osteoarthritis, inflammation, and degenerative changes. CONCLUSIONS: Commercial payers are not consistent in the medical criteria used to define patient eligibility for authorization of OCA transplantation. In contrast, an expert panel of cartilage surgeons reached a consensus that OCA transplantation was clearly suitable for a variety of specific indications. This study demonstrates the need to standardize medical criteria for cartilage restoration based on the most current literature, as well as in conjunction with experienced cartilage restoration experts. LEVEL OF EVIDENCE: Therapeutic Level V . See Instructions for Authors for a complete description of levels of evidence.

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BACKGROUND: Multiple cartilage repair techniques are available for chondral defects in the knee. Optimal treatment is controversial. PURPOSE: To evaluate change from baseline in the 5 Knee injury and Osteoarthritis Outcome Score (KOOS) subscales among different cartilage repair techniques of the knee. STUDY DESIGN: Systematic review and meta-analysis; Level of evidence, 1A. METHODS: Medline and Cochrane Central Register of Controlled Trials (CENTRAL) databases were searched for randomized controlled trials with minimum 1 year follow-up reporting change from baseline KOOS (delta KOOS) subscale values. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed. A meta-analysis was performed on the following surgery types: microfracture (Mfx); augmented microfracture techniques (Mfx+Augment); and culture-based therapies, including autologous chondrocyte implantation (ACI) and matrix-assisted autologous chondrocyte implantation (MACI). A random-effects metaregression model was used. RESULTS: A total of 14 randomized trials with a total of 775 patients were included. The KOOS Sport and Recreation (Sport) and KOOS Quality of Life (QOL) were the 2 most responsive subscales after operative intervention. Outcomes from Mfx and Mfx+Augment were not different in any of the 5 KOOS subscales (minimum P > .3). The mean delta KOOS Sport after ACI/MACI was 9.9 points greater than after Mfx (P = .021) and 11.7 points greater than after Mfx+Augment (P = .027). Longer follow-up time correlated with greater delta KOOS Sport (P = .028). Larger body mass index led to greater delta KOOS QOL (P = .045). Larger cartilage defect size correlated with greater delta KOOS Pain and KOOS Activities of Daily Living scores (P = .023 and P = .002, respectively). CONCLUSION: The KOOS Sport and QOL were the most responsive subscales after cartilage restoration surgery of the knee. Culture-based therapies (ACI/MACI) led to clinically relevant improvements in the KOOS Sport score compared with marrow stimulation and may be a more appropriate treatment in younger and more active individuals. There were no benefits to Mfx+Augment over Mfx alone in any of the KOOS subscales.

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BACKGROUND: Studies have reported favorable clinical outcomes after osteochondral allograft (OCA) transplantation to treat osteochondral defects and have demonstrated that healing of the osseous component may be critical to outcomes. However, there is currently no consensus on the optimal modality to evaluate osseous healing. PURPOSE: To define parameters for OCA healing using computed tomography (CT) and to investigate whether osseous healing identified using CT is correlated with improved pain and function on patient-reported outcomes (PROs) collected closest in time to the postoperative CT scan and at final follow-up. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Of 118 patients who underwent OCA transplantation for articular cartilage defects of the knee over the 10-year study period, 60 were included in final analysis based on completion of CT scans at 5.8 ± 1.9 months postoperatively and PROs collected preoperatively and postoperatively. CT parameters, including osseous incorporation, bone density, subchondral bone congruency, and cystic changes, were summarized for each patient relative to the cohort. Parameters were assessed for inter- and intrarater reliability as well as for covariation with patient characteristics and surgical variables. Structural equation modeling was used to assess correlation of CT parameters with change in PROs from preoperatively to those collected closest in time to CT acquisition and at the final follow-up. RESULTS: Bone incorporation was the most reliable CT parameter. The summarized scores for CT scans were normally distributed across the study population. Variance in CT parameters was independent of age, sex, body mass index, prior surgery, number of grafts, lesion size, and location. No significant correlation (P > .12 across all comparisons) was identified for any combination of CT parameter and change in PROs from baseline for outcomes collected either closest to CT acquisition or at the final follow-up (mean, 38.2 ± 19.9 months; range, 11.6-84.9 months). There was a uniformly positive association between change in PROs and host bone density but not graft bone density, independent of patient characteristics and surgical factors. CONCLUSION: CT parameters were independent of clinical or patient variables within the study population, and osseous incorporation was the most reliable CT parameter. Metrics collected from a single postoperative CT scan was not correlated with clinical outcomes at ≥6-month longitudinal follow-up.

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BACKGROUND: Osteochondral allograft (OCA) transplantation has evolved into a first-line treatment for large chondral and osteochondral defects, aided by advancements in storage protocols and a growing body of clinical evidence supporting successful clinical outcomes and long-term survivorship. Despite the body of literature supporting OCAs, there still remains controversy and debate in the surgical application of OCA, especially where high-level evidence is lacking. PURPOSE: To develop consensus among an expert group with extensive clinical and scientific experience in OCA, addressing controversies in the treatment of chondral and osteochondral defects with OCA transplantation. STUDY DESIGN: Consensus statement. METHODS: A focus group of clinical experts on OCA cartilage restoration participated in a 3-round modified Delphi process to generate a list of statements and establish consensus. Questions and statements were initially developed on specific topics that lack scientific evidence and lead to debate and controversy in the clinical community. In-person discussion occurred where statements were not agreed on after 2 rounds of voting. After final voting, the percentage of agreement and level of consensus were characterized. A systematic literature review was performed, and the level of evidence and grade were established for each statement. RESULTS: Seventeen statements spanning surgical technique, graft matching, indications, and rehabilitation reached consensus after the final round of voting. Of the 17 statements that reached consensus, 11 received unanimous (100%) agreement, and 6 received strong (80%-99%) agreement. CONCLUSION: The outcomes of this study led to the establishment of consensus statements that provide guidance on surgical and perioperative management of OCAs. The findings also provided insights on topics requiring more research or high-quality studies to further establish consensus and provide stronger evidence.

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BACKGROUND: Cartilage lesions of the patellofemoral joint constitute a frequent abnormality. Patellofemoral conditions are challenging to treat because of complex biomechanics and morphology. PURPOSE: To develop a consensus statement on the functional anatomy, indications, donor graft considerations, surgical treatment, and rehabilitation for the management of large chondral and osteochondral defects in the patellofemoral joint using a modified Delphi technique. STUDY DESIGN: Consensus statement. METHODS: A working group of 4 persons generated a list of statements related to the functional anatomy, indications, donor graft considerations, surgical treatment, and rehabilitation for the management of large chondral and osteochondral defects in the patellofemoral joint to form the basis of an initial survey for rating by a group of experts. The Metrics of Osteochondral Allografts (MOCA) expert group (composed of 28 high-volume cartilage experts) was surveyed on 3 occasions to establish a consensus on the statements. In addition to assessing agreement for each included statement, experts were invited to propose additional statements for inclusion or to suggest modifications of existing statements with each round. Predefined criteria were used to refine statement lists after each survey round. Statements reaching a consensus in round 3 were included within the final consensus document. RESULTS: A total of 28 experts (100% response rate) completed 3 rounds of surveys. After 3 rounds, 36 statements achieved a consensus, with over 75% agreement and less than 20% disagreement. A consensus was reached in 100.00% of the statements relating to functional anatomy of the patellofemoral joint, 88.24% relating to surgical indications, 100.00% relating to surgical technical aspects, and 100.00% relating to rehabilitation, with an overall consensus of 95.5%. CONCLUSION: This study established a strong expert consensus document relating to the functional anatomy, surgical indications, donor graft considerations for osteochondral allografts, surgical technical aspects, and rehabilitation concepts for the management of large chondral and osteochondral defects in the patellofemoral joint. Further research is required to clinically validate the established consensus statements and better understand the precise indications for surgery as well as which techniques and graft processing/preparation methods should be used based on patient- and lesion-specific factors.

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OBJECTIVE: The purpose of this manuscript is to analyze the evidence regarding etiopathogenesis of knee osteochondritis dissecans (OCD) lesions through a systematic review, so to summate the current understanding of the origin and progression of this pathologic articular processes. DESIGN: A systematic review of the literature was performed on the PubMed and Cochrane databases on October 2017 by 2 independent authors and included all levels of evidence. This included all English language literature, pertaining specifically to etiopathology of knee OCD with exclusions for review articles and expert opinion. Of 965 identified records, 154 full-text articles were assessed for eligibility and 86 studies met the inclusion criteria. RESULTS: According to these studies, the etiology of OCD can be of a biological or mechanical origin: 40 articles proposed a biological hypothesis, including genetic causes (27), ossification center deficit (12), and endocrine disorders (9); conversely, 52 articles supported a mechanical hypothesis, including injury/overuse (18), tibial spine impingement (5), discoid meniscus (16), and biomechanical alterations (20) as the cause of the onset of OCD. The pathogenic processes were investigated by 36 of these articles, with a focus on subchondral bone fracture and ischemia as the ultimate events leading to OCD. CONCLUSIONS: Biological and mechanical factors are found to result in subchondral bone remodeling alterations, acting independently or more likely synergically in the progression of knee OCD. The former includes genetic causes, deficit of ossification centers and endocrine disorders; the latter, tibial spine impingement, discoid meniscus, and biomechanical alterations, together with injuries and overuse. The resultant subchondral bone ischemia and/or fracturing appears to determine the onset and progression of OCD. LEVEL OF EVIDENCE: Systematic review of level II-IV studies, level IV.

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Joint surface incongruence resulting from osteochondritis dissecans (OCD) alters the articular physiologic congruence, increasing the contact stress on adjacent joint surfaces and accelerating wear and the cascade of joint degeneration. Accordingly, the restoration of articular surface integrity is of major importance, especially in young adults where, in lesions left untreated or following simple fragment excision, early osteoarthritis can be anticipated. Therefore, the treatment algorithm in unstable knee OCD of the young adult foresees surgical options to restore the articular surface. Several procedures have been proposed, including refixation of the detached fragment bone marrow stimulation, osteochondral autograft implantation, fresh osteochondral allograft transplantation, and cell-based or cell-free regenerative techniques. The aim of this review was to summarize the evidence for these surgical strategies, reporting their results and limitations. The overall evidence documents positive results for each of the assorted surgical procedures applied to treat unstable OCD, thus indicating support for their selected use to treat osteochondral defects paying particular attention to their specific indications for the lesion characteristics. The fixation of a good quality fragment should be pursued as a first option, while unfixable small lesions may benefit from autografts. For large lesions, available cell-based or cell-free osteochondral scaffold are a feasible solution but with limitation in terms of regenerated tissue quality. In this light, fresh allografts may offer articular surface restoration with viable physiologic osteochondral tissue providing a predictably successful outcome, and therefore they may currently represent the most suitable option to treat unstable irreparable OCD lesion in young adults. LEVEL OF EVIDENCE: V.

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BACKGROUND: Osteochondral allograft (OCA) transplantation has become a standard therapy for cartilage restoration in young patients. PURPOSE: To determine the efficacy of fresh OCA transplantation for focal cartilage lesions in patients aged ≥40 years compared with a group of patients aged ≤39 years. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A database was used to identify patients who underwent fresh OCA transplantation in the knee in a single-surgeon practice over a 10-year period and who completed baseline patient-reported outcome (PRO) questionnaires, including the International Knee Documentation Committee (IKDC); Knee injury and Osteoarthritis Outcome Score (KOOS) subscales of Pain, Symptoms, Activities of Daily Living, Quality of Life (QOL), and Sports & Recreation; and Veterans RAND 12-Item Health Survey (VR-12). Patients who completed the same PRO measures at a minimum 12-month follow-up were categorized into 2 groups based on age at surgery and were observed longitudinally. Mixed-model regression was used to predict longitudinal growth curves for each PRO score while controlling for confounding patient and surgical variables. RESULTS: The study group consisted of 38 patients with a mean age of 52.32 years (range, 40-69 years) and mean final follow-up of 44.47 ± 24.32 months. The control group consisted of 42 patients with a mean age of 27.19 years (range, 15-39 years) and mean final follow-up of 33.75 ± 19.53 months. A statistically significant improvement from baseline to final follow-up was seen for the IKDC score and all 5 KOOS subscores in both the study and the control groups (P < .01 in 10 of 12 comparisons and P < .05 for the other 2 comparisons). Maximum improvements were seen in the KOOS QOL and Sports & Recreation subscores for both groups. There was no statistically significant difference between groups in the change from baseline to final follow-up or in differences at any time point in model-based longitudinal projections for any PRO score through 5 years. CONCLUSION: There was a significant improvement of outcomes for both groups, with no statistically significant difference between groups over longitudinal follow-up. The efficacy of fresh OCA transplantation in adults aged ≥40 years with a focal chondral lesion and without osteoarthritis is similar to that of younger adults, and benefits are greatest for the KOOS QOL and Sports & Recreation subscales, which reflect functional outcomes.

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CONTEXT: We present the current spectrum of postoperative management practices for patients receiving distal femur osteochondral allograft (OCA) transplants. EVIDENCE ACQUISITION: The Joint Restoration Foundation database was examined in cooperation with the Metrics of Osteochondral Allografts study group to identify 121 surgeons who had performed at least 1 OCA transplant in the past year; 63% of surgeons responded. STUDY DESIGN: Clinical survey. LEVEL OF EVIDENCE: Level 3. RESULTS: Postoperative weightbearing restrictions ranged from immediate nonweightbearing with full weightbearing by 12 weeks to immediate weightbearing as tolerated. Most surgeons who performed fewer (<10) OCA transplants per year followed the most restrictive protocol, while surgeons who performed more (>20) OCA transplants per year followed the least restrictive protocol. One-third of surgeons with the most restrictive protocol were more likely to change their protocol to be less restrictive over time, while none of those with the least restrictive protocol changed their protocol over time. Fifty-five percent of surgeons permitted return to full activity at 26 weeks, while 27% of surgeons lifted restrictions at 16 weeks. CONCLUSION: Characterization of the spectrum of postoperative management practices after OCA transplantation provides a foundation for future investigations regarding patient outcomes and associated cost to establish best practice guidelines. Fundamentally, surgeons with more experience with this procedure tended to be more aggressive with their postoperative rehabilitation guidelines. Most commonly, rehabilitation provided for some degree of limited weightbearing; however, the spectrum also included immediate full weightbearing practices.

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BACKGROUND: Articular cartilage lacks the ability for intrinsic repair after acute injury, and focal articular cartilage lesions cause significant morbidity worldwide. Arthroscopic debridement (chondroplasty) represents the majority of cartilage procedures of the knee; however, limited data exist regarding outcomes after chondroplasty performed in isolation of concurrent procedures or not as a primary treatment for osteoarthritis (OA). HYPOTHESIS: Arthroscopic mechanical chondroplasty is beneficial for patients with a focal cartilage lesion of the knee in the absence of meniscal pathology or OA. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Potential participants were identified by querying billing data from a 3-year period in a single-surgeon practice, and eligible patients were verified to meet inclusion criteria through electronic medical record review. OA was quantified through Kellgren-Lawrence (KL) scoring. Subjective patient-reported outcome (PRO) scores, including International Knee Documentation Committee (IKDC), Knee injury and Osteoarthritis Outcome Score (KOOS), Western Ontario and McMaster Universities Arthritis Index (WOMAC), Tegner, Lysholm, and Veterans RAND 12-Item Health Survey (VR-12), were collected preoperatively and at follow-up intervals. International Cartilage Repair Society (ICRS) grade and lesion size were determined at arthroscopy. Linear regression was used to determine the effect of baseline score on final follow-up score. Correlated regression equations were used to assess the relationship of covariates and change in PRO scores. RESULTS: Fifty-three of 86 (62%) eligible participants completed postoperative questionnaires at an average of 31.5 months (range, 11.5-57 months). The mean patient age was 37.3 ± 9.7 years and mean body mass index (BMI) was 27.7 ± 5.6 kg/m2; 33 (62%) participants were women. The mean treated lesion size was 3.3 ± 1.9 cm2, of these, 36 (68%) were ICRS grade 2 or 3, and 42 (79%) patients had a KL score of 0 to -2. On average, the cohort demonstrated significant improvement from baseline for almost all PRO scores. Regression analysis of change in score versus baseline indicated participants with lower preoperative scores gained more benefit from chondroplasty. Correlated regression equations showed KL score >0 and male sex had a consistent positive effect on change in PRO scores, high ICRS grade had a consistent negative effect, and lesion size, age, and obesity had no effect. Eight patients (15%) required further surgical intervention within the follow-up period. CONCLUSION: The clinical efficacy of chondroplasty for repair of focal cartilage defects of the knee has not been studied in isolation from concurrent orthopaedic procedures. Our data show that arthroscopic mechanical chondroplasty is beneficial to patients, and response to surgical intervention is correlated with baseline PRO scores, sex, ICRS grade, and KL score.

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BACKGROUND: Autologous cartilage tissue implants, including the NeoCart implant, are intended to repair focal articular cartilage lesions. Short-term results from United States Food and Drug Administration (FDA) phase I and phase II clinical trials indicated that the NeoCart implant was safe when surgically applied as a cell-based therapy and efficacious compared with microfracture. HYPOTHESIS: Quantitative magnetic resonance imaging (MRI) analysis would reveal NeoCart tissue maturation through to 60-month follow-up. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Patients with symptomatic full-thickness cartilage lesions of the distal femoral condyle were treated with NeoCart in FDA clinical trials. Safety and efficacy were evaluated prospectively by MRI and clinical patient-reported outcomes (PROs) through to 60-month follow-up. Qualitative MRI metrics were quantified according to modified MOCART (magnetic resonance observation of cartilage repair tissue) criteria, with an independent evaluation of repair tissue signal intensity. Subjective PROs and objective range of motion (ROM) were obtained at baseline and through to 60 months. RESULTS: Twenty-nine patients treated with NeoCart were observed over a mean of 52.0 ± 15.5 months (median, 60 months). MOCART analyses indicated significant improvement ( P < .001) in cartilage quality from 3 to 24 months, with stabilization from 24 to 60 months. Signal intensity of the repair tissue evolved from hyperintense at early follow-up to isointense after 6 months and to hypointense after 24 months. The temporal progression toward hypointense T2 signals at later time points observed here indicated a further reorganization of the repair tissue toward a dense tissue that was less similar to the surrounding native tissue. However, 80% of patients showed evidence of subchondral bone changes on MRI at all time points; 4 patients (14%) showed no improvement of MRI criteria. Compared with baseline values, significant improvement ( P < .001) was seen in PROs (mean [±SD] baseline to mean [±SD] final follow-up), including the International Knee Documentation Committee score (47.9 ± 17.4 to 75.5 ± 22.1), physical component summary of the Short Form-36 (40.5 ± 7.2 to 51.4 ± 8.1), and all 5 domains of the Knee injury and Osteoarthritis Outcome Score (Pain: 64.8 ± 12.1 to 86.1 ± 17.3; Activities of Daily Living: 75.5 ± 14.8 to 91.6 ± 13.8; Quality of Life: 28.6 ± 15.5 to 69.4 ± 28.0; Symptoms: 65.8 ± 13.8 to 86.6 ± 13.4; Sports and Recreation: 41.4 ± 24.3 to 72.4 ± 28.8). Significant ( P < .0001) decreases from baseline scores for the visual analog scale for pain (34.6 ± 22.5) were seen by 6 months and sustained at final follow-up (14.3 ± 18.4). ROM significantly ( P < .0001) improved from baseline (131.5° ± 7.9°) to final follow-up (140.7° ± 6.3°). CONCLUSION: Longitudinal MRI analysis demonstrated that NeoCart-based repair tissue is durable and evolves over time. For a majority of patients, this progression trended from an initial hyperintense signal to a hypointense signal at later follow-ups. Changes in radiographic measures over time corresponded with improvement in clinical measures, with maximum benefits experienced at 24-month follow-up. Similarly, clinical efficacy for the total cohort, determined by clinical outcome scores, reached a maximum at 24 months without decline to 60 months. Results from safety and exploratory clinical trials indicate that NeoCart is a safe and effective treatment for articular cartilage lesions through to 5-year follow-up. Registration: NCT00548119 ( ClinicalTrials.gov identifier).

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BACKGROUND: Conduct a prospective randomized study to compare clinical outcomes of anterior cruciate ligament (ACL) reconstruction using quadrupled hamstring tendon (HT) allograft or doubled tibialis anterior (TA) allograft. Limited level 1 data exist comparing outcomes of different soft tissue allograft constructs for ACL reconstruction. We hypothesized no difference would exist in the patient reported outcomes (PRO), arthrometric testing, or rate of re-rupture between the two constructs. METHODS: Ninety eight subjects undergoing primary ACL reconstruction were randomized to HT (n=47) or TA (n=51) allograft. Subjects completed validated (PRO) measures pre-operatively, and six months and two years post-operatively. Arthrometric testing was performed at six months to assess integrity of the reconstruction. RESULTS: Fifty-eight percent of subjects (57/98) completed a two-year follow up. Allograft re-tear rates were similar between groups (6.2% HT vs. 4.0% TA, respectively, p=1.0). The relative risk of re-tear in the HT group was 1.5 compared to the TA group (p=0.7). The TA group improved significantly more on the physical portion of the VR-12 (p=0.046) and Lysholm score (p=0.014) compared to the HT group. There was no difference in the change from baseline for the other PRO scores at two years. CONCLUSIONS: Our data indicate no difference in graft failure rate and similar improvement from baseline in most PRO scores between treatment groups after two years. Based on these findings, TA allograft appears to provide a reliable and satisfactory option for patients who elect to undergo allograft ACL reconstruction.

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The authors present a case of a previously healthy 36-year-old man with a 3-day history of spontaneous complete right lower extremity foot drop. He noticed the symptoms immediately when he attempted to stand after waking from sleep. The patient had no history of similar symptoms, recent trauma, or peripheral nerve disease. Physical examination showed a slap foot gait, complete numbness of the lateral leg and dorsal foot, and 0/5 strength with ankle and great toe dorsiflexion and ankle eversion. Serum laboratory studies showed normal values. Nerve conduction studies confirmed increased latency and decreased amplitude of the right peroneal nerve at the knee, whereas electromyography showed denervation of the tibialis anterior and extensor digitorum brevis. Anteroposterior and lateral radiographs showed a normal right knee with the exception of a posterior fibular neck exostosis. Physical therapy, an ankle-foot orthosis, and a 5-day course of oral prednisone burst (50 mg) were prescribed. After 1 month of therapy without resolution, the patient underwent surgical release of the common peroneal nerve and excision of the bony prominence. Twelve days postoperatively, the patient had no sensory improvements but had improved findings on motor examination. Three months postoperatively, the patient had near-normal sensation to light touch in the superficial and deep peroneal nerves, with 5/5 strength and a normal gait. The patient returned to all activity without limitations. The authors present this unique case describing a fibro-osseous source of common peroneal compressive neuropathy and review the literature for spontaneous peroneal entrapment, highlighting the importance of prompt diagnosis and treatment.

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