Comparison between Osteochondral Autologous Transplantation and Dorsiflexion Closing Wedge Metatarsal Osteotomy for Operative Treatment of Late-Stage Freiberg Disease in Adult Patients

Category: Lesser Toes; Midfoot/Forefoot Introduction/Purpose: This study aimed to compare the clinical results between osteochondral autologous transplantation (OAT) and dorsiflexion closing wedge metatarsal osteotomy (DCWMO) in symptomatic adult patients with late-stage Freiberg disease. Methods: Between 2012 and 2017, patients with late-stage Freiberg disease surgically treated with OAT (12 patients) or DCWMO (15 patients) were retrospectively identified. The American Orthopaedic Foot & Ankle Society-lesser MTP- interphalangeal (AOFAS-LMI) score, visual analog scale score for subjective pain, and range of motion (ROM) were determined preoperatively and at final follow-up. Postoperative complications were also recorded. Results: The AOFAS-LMI score at final follow-up was significantly greater in the OAT group than in the DCWMO group (95.7 vs. 87.9, p<0.001), whereas plantarflexion at final follow-up was significantly lower in the DCWMO group than in the OAT group (30.0 degrees vs. 24.0 degrees, p=0.037). The DCWMO group reported more postoperative complications including postoperative joint stiffness, deformity, and pain recurrence. In the OAT group, one patient complained of mild knee pain. Conclusion: OAT seemed a better procedure for late-stage Freiberg disease compared with DCWMO in adult patients in terms of postoperative functional score and ROM, with lesser complication rates.

Long-Term Survivorship and Clinical Outcomes of Osteochondral Autologous Transplantation for Steroid-Induced Osteonecrosis of the Knee

Objective Treatments for steroid-induced osteonecrosis of the knee remains challenging, and there has not been sufficient evidence to support joint preservation surgery. This study evaluated long-term outcomes of osteochondral autologous transplantation (OAT) for steroid-induced osteonecrosis of the knee. Design This retrospective case series included patients who underwent OAT for steroid-induced osteonecrosis of the knee from 1998 to 2008. The survivorship and need for secondary surgery were evaluated, and the clinical outcome was evaluated with the International Knee Documentation Committee (IKDC) subjective score. Preoperative and final Kellgren-Lawrence (KL) grade of the femorotibial and patellofemoral joints were individually evaluated. Results Fourteen knees of 10 patients whose mean age was 32.5 (95%CI 26.4-38.6) years were included and followed for 14.0 (12.4-15.7) years. The mean lesion size of 6.9 (5.3-8.5) cm2 was repaired using 4 median (minimum 2, maximum 5) osteochondral plugs. No revision surgeries were performed for transplanted osteochondral plugs. The IKDC subjective score improved from 32.9 (24.5-41.3) to 74.2 (61.9-88.5) ( P < 0.001). Knee flexion was improved at the final follow-up, and Seiza sitting was finally possible in 9 knees in 7 patients. Although the osteoarthritic change did not progress in femorotibial joint, patellofemoral joint showed early osteoarthritic changes at the final follow-up (mean KL grade: 0.8 [0.5-1.1]). Conclusions Prosthetic joint replacement was successfully avoided for at least the first decade by OAT in young patients with steroid-induced osteonecrosis of the knee. The progression of KL grade of the patellofemoral joint is of concern.

Comparison of Osteochondral Autologous Transplantation and Dorsiflexion Closing Wedge Metatarsal Osteotomy for Late-Stage Freiberg Disease in Adults

Background: This study aimed to compare the clinical results between osteochondral autologous transplantation (OAT) and dorsiflexion closing wedge metatarsal osteotomy (DCWMO) in symptomatic adult patients with late-stage Freiberg disease. Methods: Between 2012 and 2017, patients with late-stage Freiberg disease surgically treated with OAT (12 patients) or DCWMO (15 patients) were retrospectively identified. The American Orthopaedic Foot & Ankle Society–lesser metatarsophalangeal-interphalangeal (AOFAS-LMI) score, visual analog scale score for subjective pain, and range of motion (ROM) were determined preoperatively and at final follow-up. Postoperative complications were also recorded. Results: The AOFAS-LMI score at final follow-up was significantly greater in the OAT group than in the DCWMO group (95.7 vs 87.9, P < .001), whereas plantarflexion at final follow-up was significantly lower in the DCWMO group than in the OAT group (30.0 vs 24.0 degrees, P = .037). The DCWMO group reported more postoperative complications including postoperative joint stiffness, deformity, and pain recurrence. In the OAT group, one patient complained of mild knee pain. Conclusion: OAT seemed a better procedure for late-stage Freiberg disease compared with DCWMO in adult patients in terms of postoperative functional score and ROM, with lower complication rates. Level of Evidence: Level III, retrospective comparative study.

Osteochondral Autologous Transplantation for Treating Patellar High-Grade Chondral Defects: A Systematic Review

Background: Patellar cartilage defects account for 34.6% of defects found during routine arthroscopy. These defects pose a challenge in orthopaedic surgery because they have been associated with worse outcomes after surgical repair compared with other chondral lesions within the knee. Purpose: To systematically review the literature for evidence on results of osteochondral autologous transplantation (OAT) for the management of isolated patellar cartilage high-grade defects (International Cartilage Repair Society [ICRS] grade 3-4). Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review of the literature was performed to find studies that addressed outcomes regarding OAT to treat patellar high-grade cartilage defects (ICRS grade 3-4). Studies addressing patient-reported outcomes, return to sports, or magnetic resonance imaging (MRI) at follow-up after isolated OAT procedures for patellar cartilage defects were included. Results: A total of 5 studies were included in this review. We were not able to perform a meta-analysis as no studies had available data. A total of 102 patients who received an isolated OAT for a patellar chondral defect were included in these 5 studies. All patients showed significant improvement at final follow-up based on the following patient-reported outcome scores: Lysholm, International Knee Documentation Committee, Kujala, Tegner, and 36-Item Short Form Health Survey. We found that 4 studies used MRI during the first postoperative year to assess osteochondral plug integration and positioning. The results demonstrated that most plugs were integrated and correctly positioned when evaluated at follow-up, conducted on average after 12 months. Whether patients were able to return to sports was queried in 2 of the included studies, revealing that patients could return to their previous level in most cases (Tegner score, 5-9 at 2 years after surgery). Conclusion: Results indicate that OAT is a safe and reliable technique to treat patellar high-grade osteochondral defects, allowing for significant improvement in patient-reported outcomes and return to sports.

Osteochondral Autologous Transplantation Versus Dorsal Closing Wedge Metatarsal Osteotomy for the Treatment of Freiberg Infraction in Athletes: A Randomized Controlled Study With 3-Year Follow-up

Background: Dorsiflexion closing wedge metatarsal osteotomy (DCWMO) has been considered the traditional treatment of Freiberg disease. Several case reports presented osteochondral autologous transplantation (OAT) as an alternative treatment. Purpose/Hypothesis: The purpose was to compare the results of DCWMO versus OAT for the treatment of Freiberg infraction in an athletic population. It was hypothesized that OAT was superior to DCWMO regarding functional outcomes, pain, and the time that the athletes returned to training and to previous sport level. Study Design: Randomized controlled trial; Level of evidence, 2. Methods: Between 2008 and 2013, 27 consecutive patients with Freiberg disease were randomly assigned to either the DCWMO group (14 patients) or the OAT group (13 patients). The primary outcomes collected were as follows: postoperative complications, range of motion of the metatarsophalangeal joint, length of the metatarsal, function of the foot (measured with the American Orthopaedic Foot and Ankle Society–lesser metatarsophalangeal-interphalangeal [AOFAS-LMI] score), and pain (assessed with the visual analog scale–foot and ankle score). Results: Mean follow-up was 46 months (range, 36-60 months). The mean ± SD AOFAS-LMI score in the DCWMO group was 63.4 ± 14.4 preoperatively, 81.8 ± 6.6 at 1 year postoperatively, and 84.4 ± 5.6 at 3 years postoperatively, while in the OAT group, it was 62.8 ± 14, 89.9 ± 7.1, and 92 ± 6.9, respectively ( P < .001). The differences in the AOFAS-LMI scores favoring the OAT group at 1 and 3 years reached statistical but not clinical significance. The mean visual analog scale–foot and ankle score was improved significantly from 48.1 ± 11.5 to 91.8 ± 9.5 in the DCWMO group and from 49.9 ± 10.9 to 95.4 ± 4.4 in the OAT group. There was a shortening of the metatarsals by a mean 1.9 ± 0.5 mm in the DCWMO group, as opposed to a metatarsal lengthening of 0.2 ± 0.1 mm in the OAT group. In the OAT group, patients were able to start training at 6 ± 1 weeks ( P < .001) and return to full sport action at 10 ± 2.5 weeks ( P < .05), while in the DCWMO group, the time was 8 ± 1.5 and 13 ± 2.5 weeks, respectively. Conclusion: The authors concluded that OAT is equal to DCWMO. Acceptable clinical results were reported, as well as very low morbidity and early return to sport activities. That makes the OAT procedure a safe, effective, and optimal treatment for an athletic population experiencing Freiberg infraction.