Management of symptomatic osteochondral defects of the knee remains challenging because of the limited inherent vascularity and healing potential of articular cartilage. Osteochondral allograft (OCA) transplantation has yielded satisfactory results in appropriate patients; however, the effect of OCA transplantation on athletes seeking to return to sport (RTS) remains largely unknown.
Purpose:
To systematically review the literature to better understand outcomes after OCA, focusing on RTS rate and timing, and the incidence of postoperative complications.
Study Design:
Systematic review; Level of evidence, 4.
Methods:
Studies included in the PubMed, EMBASE, and Cochrane Library databases from inception to August 2024 that reported on athletes participating at the recreational, high school, collegiate, and professional levels undergoing OCA transplantation for osteochondral defects in the knee were identified. Inclusion criteria included studies reporting on patients identified as athletes undergoing OCA transplantation with reported origin, lesion characteristics (size and location), RTS rate and timing, complications, reoperations, and patient-reported outcomes.
Results:
A total of 14 studies, consisting of 471 athletes undergoing OCA transplantation with a weighted mean follow-up of 51.1 months, were identified. The weighted mean patient age was 31.4 years (range, 15-69 years), with 61% of patients being male. Lesion origin was reported in 49% (230/471) of patients, with osteochondritis dissecans (OCD) reported in 44% (100/230). The medial femoral condyle was the most common defect location (44%; 68/153). Lesion size ranged from 1 to 13.94 cm2. Sixteen percent (75/471) of patients were classified as competitive athletes, with basketball (n = 21) being the most common sport. RTS was reported in 72% (338/468) of patients, with 84% (231/275) returning at an equal or higher level of play at a weighted mean of 11.1 months (range, 6-26 months) after OCA. Complications were reported in 12% (41/351) of patients, with graft failure accounting for 54% (22/41) of complications in 6% (22/351) of patients.
Conclusion:
For athletes undergoing OCA transplantation to the knee, OCD was the most commonly reported cause, with the medial femoral condyle most frequently affected. Successful RTS was reported in 72% of patients at a mean of 11.1 months, with graft failure representing the most common complication in 6%.
AichrothP.Osteochondritis dissecans of the knee. A clinical survey. J Bone Joint Surg Br. 1971;53(3):440-447.
2.
AlfordJWColeBJ.Cartilage restoration, part 1: basic science, historical perspective, patient evaluation, and treatment options. Am J Sports Med. 2005;33(2):295-306.
3.
AlfordJWColeBJ.Cartilage restoration, part 2: techniques, outcomes, and future directions. Am J Sports Med. 2005;33(3):443-460.
4.
AllahabadiSQuigleyRFrazierLJoyceKColeBJ.Outcomes and return to sport after knee osteochondral allograft transplant in professional athletes. Orthop J Sports Med. 2024;12(2):23259671241226738.
5.
AndrioloLCrawfordDCRealeD, et al. Osteochondritis dissecans of the knee: etiology and pathogenetic mechanisms. A systematic review. Cartilage. 2020;11(3):273-290.
6.
BalazsGCWangDBurgeAJSinatroALWongACWilliamsRJIII. Return to play among elite basketball players after osteochondral allograft transplantation of full-thickness cartilage lesions. Orthop J Sports Med. 2018;6(7):2325967118786941.
7.
BauerKL.Osteochondral injuries of the knee in pediatric patients. J Knee Surg. 2018;31(5):382-391.
8.
BennettCHNadarajahVMooreMC, et al. Cartiform implantation for focal cartilage defects in the knee: a 2-year clinical and magnetic resonance imaging follow-up study. J Orthop. 2021;24:135-144.
9.
CahillBR.Osteochondritis dissecans of the knee: treatment of juvenile and adult forms. J Am Acad Orthop Surg. 1995;3(4):237-247.
10.
CampbellABPinedaMHarrisJDFlaniganDC.Return to sport after articular cartilage repair in athletes’ knees: a systematic review. Arthroscopy. 2016;32(4):651-668.e651.
11.
CavendishPAEverhartJSPetersNJSommerfeldtMFFlaniganDC.Osteochondral allograft transplantation for knee cartilage and osteochondral defects: a review of indications, technique, rehabilitation, and outcomes. JBJS Rev. 2019;7(6):e7.
12.
ChauMMTompkinsMA.Osteochondritis dissecans of the knee in young athletes. Clin Sports Med. 2022;41(4):579-594.
13.
ColadonatoCPerezARSonnierJH, et al. Evaluating return to sports after surgical treatment of unstable osteochondritis dissecans of the knee: a systematic review. Orthop J Sports Med. 2024;12(8):23259671241258489.
14.
CookJLRucinskiKCreceliusCRMaRStannardJP.Return to sport after large single-surface, multisurface, or bipolar osteochondral allograft transplantation in the knee using shell grafts. Orthop J Sports Med. 2021;9(1):2325967120967928.
15.
CotterEJFrankRMWangKC, et al. Clinical outcomes of osteochondral allograft transplantation for secondary treatment of osteochondritis dissecans of the knee in skeletally mature patients. Arthroscopy. 2018;34(4):1105-1112.
16.
CrawfordZTSchumaierAPGlogovacGGraweBM.Return to sport and sports-specific outcomes after osteochondral allograft transplantation in the knee: a systematic review of studies with at least 2 years’ mean follow-up. Arthroscopy. 2019;35(6):1880-1889.
17.
DaudASafirOAGrossAKuzykPRT. Return to paralympic rowing after partial joint transplantation: a case report. JBJS Case Connect. 2021;11(3). doi:10.2106/JBJS.CC.20.00808
18.
FavreJErhart-HledikJCBlazekKFaselBGoldGEAndriacchiTP.Anatomically standardized maps reveal distinct patterns of cartilage thickness with increasing severity of medial compartment knee osteoarthritis. J Orthop Res. 2017;35(11):2442-2451.
19.
FrankRMLeeSLevyD, et al. Osteochondral allograft transplantation of the knee: analysis of failures at 5 years. Am J Sports Med. 2017;45(4):864-874.
20.
GudasRKalesinskasRJKimtysV, et al. A prospective randomized clinical study of mosaic osteochondral autologous transplantation versus microfracture for the treatment of osteochondral defects in the knee joint in young athletes. Arthroscopy. 2005;21(9):1066-1075.
21.
HaberDBLoganCAMurphyCP, et al. Osteochondral allograft transplantation for the knee: post-operative rehabilitation. Int J Sports Phys Ther. 2019;14(3):487-499.
22.
HarrisJDWaltonDMEricksonBJ, et al. Return to sport and performance after microfracture in the knees of National Basketball Association players. Orthop J Sports Med. 2013;1(6):2325967113512759.
23.
HevesiMDenbeighJMPaggiCA, et al. Fresh osteochondral allograft transplantation in the knee: a viability and histologic analysis for optimizing graft viability and expanding existing standard processed graft resources using a living donor cartilage program. Cartilage. 2021;13(1 suppl):948s-956s.
24.
HurleyETDaveyMSJamalMSManjunathAKAlaiaMJStraussEJ.Return-to-play and rehabilitation protocols following cartilage restoration procedures of the knee: a systematic review. Cartilage. 2021;13(1 suppl):907s-914s.
25.
KarataglisDLearmonthDJA. Management of big osteochondral defects of the knee using osteochondral allografts with the MEGA-OATS technique. Knee. 2005;12(5):389-393.
26.
KocherMSTuckerRGanleyTJFlynnJM.Management of osteochondritis dissecans of the knee: current concepts review. Am J Sports Med. 2006;34(7):1181-1191.
27.
KrychAJPareekAKingAHJohnsonNRStuartMJWilliamsRJ.Return to sport after the surgical management of articular cartilage lesions in the knee: a meta-analysis. Knee Surg Sports Traumatol Arthrosc. 2017;25(10):3186-3196.
28.
KrychAJRobertsonCMWilliamsRJIII; Cartilage Study Group. Return to athletic activity after osteochondral allograft transplantation in the knee. Am J Sports Med. 2012;40(5):1053-1059.
29.
KunzeKNRamkumarPNManziJE, et al. Risk factors for failure after osteochondral allograft transplantation of the knee: a systematic review and exploratory meta-analysis. Am J Sports Med. 2023;51(5):1356-1367.
30.
LaiWCBohlenHLFacklerNPWangD.Osteochondral allografts in knee surgery: narrative review of evidence to date. Orthop Res Rev. 2022;14:263-274.
31.
LindénB.The incidence of osteochondritis dissecans in the condyles of the femur. Acta Orthop Scand. 1976;47(6):664-667.
32.
LiuJNAgarwallaAChristianDR, et al. Return to sport following high tibial osteotomy with concomitant osteochondral allograft transplantation. Am J Sports Med. 2020;48(8):1945-1952.
33.
LukJStokerAMTeixeiroE, et al. Systematic review of osteochondral allograft transplant immunology: how we can further optimize outcomes. J Knee Surg. 2021;34(1):30-38.
34.
MankinHJ.The response of articular cartilage to mechanical injury. J Bone Joint Surg Am. 1982;64(3):460-466.
35.
MarkusDHHurleyETHaskelJD, et al. High return to sport in patients over 45 years of age undergoing osteochondral allograft transplantation for isolated chondral defects in the knee. Cartilage. 2021;13(1 suppl):915S-919S.
36.
MaromNWangDPatelSWilliamsRJIII. Return to play after bipolar patellofemoral osteochondral allograft transplantation for a professional basketball player: a case report. JBJS Case Connect. 2019;9(3):e0291.
37.
McCarthyMAMeyerMAWeberAE, et al. Can competitive athletes return to high-level play after osteochondral allograft transplantation of the knee?Arthroscopy. 2017;33(9):1712-1717.
38.
MithoeferKHamblyKDella VillaSSilversHMandelbaumBR.Return to sports participation after articular cartilage repair in the knee: scientific evidence. Am J Sports Med. 2009;37(suppl 1):167s-176s.
39.
MithoeferKWilliamsRJIIIWarrenRFWickiewiczTLMarxRG.High-impact athletics after knee articular cartilage repair: a prospective evaluation of the microfracture technique. Am J Sports Med. 2006;34(9):1413-1418.
40.
MontalvoAMSchneiderDKWebsterKE, et al. Anterior cruciate ligament injury risk in sport: a systematic review and meta-analysis of injury incidence by sex and sport classification. J Athl Train. 2019;54(5):472-482.
41.
MooreMVargasLHaniduI, et al. Immune hypersensitivity is associated with higher graft failure rate after osteochondral allograft transplantation of the knee. Arthrosc Sports Med Rehabil. 2024;6(3):100933.
42.
NambuTGasserBSchneiderEBandiWPerrenSM.Deformation of the distal femur: a contribution towards the pathogenesis of osteochondrosis dissecans in the knee joint. J Biomech. 1991;24(6):421-433.
43.
NielsenESMcCauleyJCPulidoPABugbeeWD.Return to sport and recreational activity after osteochondral allograft transplantation in the knee. Am J Sports Med. 2017;45(7):1608-1614.
44.
NissenCWAlbrightJCAndersonCN, et al. Descriptive epidemiology from the Research in Osteochondritis Dissecans of the Knee (ROCK) prospective cohort. Am J Sports Med. 2022;50(1):118-127.
45.
ObedianRSGrelsamerRP.Osteochondritis dissecans of the distal femur and patella. Clin Sports Med. 1997;16(1):157-174.
46.
PageMJMcKenzieJEBossuytPM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71.
47.
PelletierJPRaynauldJPBerthiaumeMJ, et al. Risk factors associated with the loss of cartilage volume on weight-bearing areas in knee osteoarthritis patients assessed by quantitative magnetic resonance imaging: a longitudinal study. Arthritis Res Ther. 2007;9(4):R74.
48.
PriceMJTucaMNguyenJ, et al. Juvenile osteochondritis dissecans of the trochlea: a cohort study of 34 trochlear lesions associated with sporting activities that load the patellofemoral joint. J Pediatr Orthop. 2020;40(3):103-109.
RobertiDiSarsisaTFioreMCocoV, et al. Fresh osteochondral allograft transplantation in osteochondritis dissecans in the knee joint. Life (Basel). 2021;11(11):1205.
51.
RobinsonPGWilliamsonTMurrayIRAl-HouraniKWhiteTO.Sporting participation following the operative management of chondral defects of the knee at mid-term follow up: a systematic review and meta-analysis. J Exp Orthop. 2020;7(1):76.
52.
SadrKNPulidoPAMcCauleyJCBugbeeWD.Osteochondral allograft transplantation in patients with osteochondritis dissecans of the knee. Am J Sports Med. 2016;44(11):2870-2875.
53.
SchallmoMSSinghSKBarthKA, et al. A cross-sport comparison of performance-based outcomes of professional athletes following primary microfracture of the knee. Knee. 2018;25(4):692-698.
54.
ScilliaAJAuneKTAndrachukJS, et al. Return to play after chondroplasty of the knee in National Football League athletes. Am J Sports Med. 2015;43(3):663-668.
55.
SkelleyNWKurtenbachCKimberKPiattBNoonanB.Return-to-sport review for current cartilage treatments. J Knee Surg. 2021;34(1):39-46.
56.
SlatteryCAKweonCYHagenMSGeeAOWilliamsonRV.Comparison of medial and lateral posterior femoral condyle articular cartilage wear patterns. Knee. 2018;25(6):1165-1170.
57.
SlimKNiniEForestierD, et al. Methodological index for non-randomized studies (MINORS): development and validation of a new instrument. ANZ J Surg. 2003;73(9):712-716.
58.
StannardJPCookJL.Prospective assessment of outcomes after primary unipolar, multisurface, and bipolar osteochondral allograft transplantations in the knee: a comparison of 2 preservation methods. Am J Sports Med. 2020;48(6):1356-1364.
59.
TrianaJDeClouetteBMontgomerySRJr, et al. Increased kinesiophobia leads to lower return to sport rate and clinical outcomes following osteochondral allograft transplantation of the knee. Knee Surg Sports Traumatol Arthrosc. 2024;32(2):490-498.
60.
TrianaJLiZIRaoNKingeryMTStraussEJ.Return to play after knee articular cartilage restoration: surgical options, rehabilitation protocols, and performance outcomes. Curr Rev Musculoskelet Med. 2023;16(12):575-586.
61.
VivekananthaPSritharanPHemstockRJohnsonJde SaD. High rates of return to sport following management of osteochondritis dissecans of the femoral trochlea: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2024;32(2):389-404.
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