Osteochondral Allograft and Autograft Transplant for Femoral Head Defects: A Multicenter Study

Abstract

Background:

Osteochondral allograft transplant and autograft transplant for femoral head defects have emerged as promising treatments for concomitant cartilage and subchondral bone injuries in young patients.

Purpose:

To evaluate the clinical and radiological outcomes of patients who underwent osteochondral allograft or autograft transplant for femoral head defects and identify any risk factors that may lead to conversion to total hip arthroplasty (THA).

Study Design:

Case series; Level of evidence, 4.

Methods:

All patients who underwent osteochondral allograft or autograft transplant for femoral head defects across 2 institutions were analyzed. Clinical outcomes were assessed at final follow-up with the modified Harris Hip Score (mHHS), Hip Outcome Score–Activities of Daily Living (HOS-ADL), Hip Outcome Score–Sport-Specific Subscale (HOS-SSS), and International Hip Outcome Tool (iHOT-12). Complications and reoperations were recorded. Patients were assessed radiographically preoperatively and at final follow-up for osteoarthritis using Tönnis grading.

Results:

A total of 27 patients were included in this study (19 osteochondral allograft transplant, 8 osteochondral autograft transplant). The mean follow-up for the allograft and autograft cohorts was 2.8 and 9.5 years, respectively. The mean defect size for patients who underwent allograft and autograft transplant was 2.8 × 2.1 cm and 1.6 × 1.0 cm, respectively. The mean mHHS, HOS-ADL, HOS-SSS, and iHOT-12 for the allograft cohort were 86.7, 92.8, 81.4, and 79.0, respectively, and for the autograft cohort were 87.6, 92.7, 83.1, and 82.0, respectively. No significant difference in outcomes was noted for patients who underwent femoral head allograft versus nonorthotopic femoral condyle allograft transplant. For the allograft cohort, 4 patients (21.1%) underwent conversion to THA at a mean of 1.9 years. Of the remaining 15 allograft patients, only 1 patient (6.7%) had radiographic osteoarthritis progression. None of the patients in the autograft cohort underwent conversion to THA.

Conclusion:

Osteochondral allograft and autograft transplant for femoral head defects demonstrated overall favorable clinical outcomes and rates of conversion to THA. Additionally, nonorthotopic femoral condyle allografts demonstrated similar outcomes to femoral head allografts. Both osteochondral allograft and autograft transplant should be considered for patients with focal femoral head defects.

Keywords

femoral head osteochondral defects osteochondral transplant allograft autograft mosaicplasty

The femoral head is susceptible to trauma and various disorders such as avascular necrosis, osteochondritis dissecans, and femoroacetabular impingement.^4,19 These injuries may cause damage to the articular cartilage and underlying subchondral bone resulting in debilitating pain, a diminished quality of life, and early osteoarthritis progression. Currently, a paucity of options are available to treat femoral head osteochondral defects in young patients, with total hip arthroplasty (THA) historically being used as a primary treatment option.^6,7,40 As a result, increasing interest has arisen in joint preservation techniques such as bone marrow aspirate concentrate (BMAC), microfracture, and matrix-induced autologous chondrocyte transplant.^22,29,45 However, none of these procedures restore damaged subchondral bone, and microfracture promotes formation of a fibrocartilaginous scar rather than hyaline cartilage.³⁵

A promising alternative to these approaches is osteochondral transplant, which uses osteochondral units in a single-stage procedure to repair isolated concomitant cartilage and subchondral bone defects. Although limited studies are available demonstrating the use of this technique in the hip, substantial literature demonstrates its use in the knee, showing that the technique results in favorable long-term clinical outcomes and return to high-demand activity.^3,46 However, the emergence of this procedure has yet to be met with increased graft availability, resulting in several studies exploring the use of nonorthotopic allografts for various osteochondral defects.^16,33

Osteochondral autograft transplant involves the transfer of an osteochondral unit from a nonweightbearing area of the patient’s own joint to the osteochondral defect. Autograft transplant has demonstrated promising long-term results for osteochondral defects^2,18 but may result in donor site morbidity. Although allograft transplant is used to repair large cartilage defects (≥2 cm²), autograft transplant is typically used for smaller defects (<2 cm²).^9,10

Despite widespread use of osteochondral allograft and autograft transplant in the knee,^1,8 limited clinical data are available supporting the use of such transplant for femoral head defects. Use of these techniques in the hip can be technically challenging, and our institution is one of the few that has performed both procedures. Therefore, the purpose of this study was to evaluate the clinical and radiological outcomes of patients who underwent osteochondral allograft or autograft transplant for femoral head defects and to identify any risk factors that may lead to conversion to THA.

Methods

After obtaining approval from the Mayo Clinic Institutional Review Board (ID No. 23-008165), we retrospectively reviewed all patients who had undergone osteochondral allograft or autograft transplant for femoral head defects by 3 fellowship-trained orthopaedic surgeons (K.J.E., R.J.S. and A.J.K.) across 2 institutions. Inclusion criteria consisted of patients with femoral head osteochondral defects who underwent either osteochondral allograft or autograft transplant due to avascular necrosis, osteochondritis dissecans, Legg-Calvé-Perthes disease, femoroacetabular impingement, chondroblastoma, or intraosseous ganglion cysts. No patients who underwent osteochondral allograft or autograft transplant were excluded. All patients had symptomatic femoral head osteochondral defects identifiable on advanced imaging such as computed tomography (CT) or magnetic resonance imaging (MRI) (Figure 1).

Patient demographics and characteristics such as age at surgery, sex, body mass index (BMI), laterality, and indication for surgery were recorded. The length and width of the osteochondral defect were measured either intraoperatively or with CT or MRI scans preoperatively. Additionally, patients were assessed radiographically preoperatively and at final postoperative visit using anteroposterior and lateral radiographs for osteoarthritis using Tönnis grading. All radiographic and MRI grading and measurements were performed by a fellowship-trained orthopaedic surgeon (K.J.E.). The type of allograft sample (femoral head, femoral condyle) used for each patient was recorded.

Postoperatively, all patients were assessed at final follow-up with the modified Harris Hip Score (mHHS), Hip Outcome Score–Activities of Daily Living (HOS-ADL), Hip Outcome Score–Sport-Specific Subscale (HOS-SSS), International Hip Outcome Tool (iHOT-12), and whether the patient was able to return to sport.³⁸ Any complications and reoperations were recorded.

Surgical Technique

All patients underwent routine surgical antibiotic prophylaxis. A surgical hip dislocation as described by Ganz et al¹² using a trochanteric osteotomy was performed with the patient in the lateral decubitus position. A complete capsule exposure was performed by capsulotomy in a Z-shape fashion. The hip was dislocated anteriorly with external rotation, and the acetabulum and labrum were then evaluated for any pathology. The damage and collapse of the femoral head were assessed and measured. A guide pin was placed in the defect and reamed to a depth of no more than 15 mm. If bleeding bone was not achieved, such as in cases of osteonecrosis, the depth of the defect was burred to bleeding bone. For allograft transplant, a fresh allograft sample was trimmed to appropriate measurements, and marrow elements were removed with either pulsatile lavage or compressed air. In 47.4% (9/19) of patients, BMAC was placed on the osseous portion of the graft for biologic healing augmentation. Then the sample was placed with press-fit fixation using finger pressure until flush with surrounding articular cartilage (Figure 2). If the defect had been burred >10 mm to bleeding bone, autograft bone from the stable trochanter was harvested and packed into the depth of the defect before placement of the allograft.

For autograft transplant, donor osteochondral plugs were extracted from the anterior-superior aspect of the femoral head (area of the cam if present) and then placed with press-fit fixation using finger pressure until flush with surrounding cartilage (Figure 3). Bone graft was then harvested from the trochanteric bed and packed into the donor site. The number and size of the plugs were determined by the magnitude of the defect. The hip was then reduced, the capsule was closed, and the trochanteric osteotomy was fixed with multiple screws. Arthrex instrumentation was used for both allograft and autograft transplant.

Postoperatively, patients were restricted to toe-touch weightbearing for 6 weeks and then progressed to full weightbearing once healing of the greater trochanter was confirmed radiographically. Radiographs were obtained at each follow-up visit to assess graft integrity and trochanteric healing.

Statistical Analysis

Data were extracted, with continuous variables being reported as mean ± standard deviation and categorical variables reported as frequencies with percentages. Univariate linear regressions were performed to test the associations between outcome scores and age, BMI, and osteochondral defect size. Univariate logistic regressions were performed to test the associations between conversion to THA and age, BMI, and osteochondral defect size. Student t tests were used to compare outcomes of patients who received femoral head osteochondral allografts versus those who received femoral condyle osteochondral allografts. Kaplan-Meier curves were used to evaluate the probability of survival after osteochondral transplant. Statistical analysis was performed using R statistical software Version 4.3.1 (R Foundation for Statistical Computing) and SPSS Version 28.0 (IBM). P < .05 was considered statistically significant.

Results

Patient Characteristics

A total of 27 patients were included in this study (19 osteochondral allograft transplant and 8 osteochondral autograft transplant). The mean length of follow-up was 2.8 ± 2.2 years for the allograft group and 9.5 ± 2.8 years for the autograft group. Fourteen of the allograft patients (73.7%) had at least 1-year follow-up, whereas all of the autograft patients had at least 4-year follow-up. Demographics and characteristics of patients who underwent osteochondral allograft and autograft transplant are shown in Table 1. In the allograft cohort, 11 patients (57.9%; 11/19) received a femoral head allograft whereas 8 patients (42.1%; 8/19) received a femoral condyle allograft (7 lateral femoral condyle, 1 medial femoral condyle).

Table 1

Demographics and Characteristics of Patients Who Underwent Osteochondral Allograft and Allograft Transplant for Femoral Head Defects^a

	Osteochondral Allograft	Osteochondral Autograft
Patients, n	19	8
Age at surgery, y	24.1 ± 9.4	22.0 ± 7.7
Sex
Male	14 (73.7)	4 (50.0)
Female	5 (26.3)	4 (50.0)
Body mass index, kg/m²	23.1 ± 2.9	23.4 ± 3.6
Laterality
Right	15 (78.9)	6 (75.0)
Left	4 (21.5)	2 (25.0)
Indication
Avascular necrosis	8 (42.1)	5 (62.5)
Osteochondritis dissecans	5 (26.3)	3 (37.5)
Legg-Calvé-Perthes disease	3 (15.8)	0
Chondroblastoma	1 (5.3)	0
Intraosseous ganglion cyst	1 (5.3)	0
Femoroacetabular impingement	1 (5.3)	0
Allografts used
Femoral head	11 (57.9)	NA
Lateral femoral condyle	7 (36.8)	NA
Medial femoral condyle	1 (5.3)	NA
Size of defect, cm	2.8 × 2.1	1.6 × 1.0
Follow-up, y	2.8 ± 2.2	9.5 ± 2.8

Data are expressed as mean ± SD or n (%) unless otherwise noted. NA, not applicable.

Three patients in the allograft cohort (15.8%; 3/19) had previously undergone surgical management of their affected hip with either a core decompression, femoral neck fracture internal fixation, or hip arthroscopy. Two patients in the autograft cohort (25.0%; 2/8) had previously undergone surgical management of their affected hip with either a core decompression or a concomitant hip arthroscopy and core decompression. Six patients in the allograft cohort (31.6%; 6/19) and 1 patient in the autograft cohort (12.5%; 1/8) underwent concomitant osteochondral transplant and osteochondroplasty for cam or pincer lesions. One patient in the allograft cohort simultaneously underwent a valgus producing osteotomy along with allograft transplant. All patients had postoperative radiographic follow-up (Figure 4). Of the patients eligible for follow-up who did not undergo conversion to THA, 91.3% (21/23) completed postoperative outcome score questionnaires with only 2 being lost to follow-up.

Clinical Outcomes

The mean mHHS, HOS-ADL, and iHOT-12 scores at final follow-up for the allograft cohort were 86.7 ± 10.8, 92.8 ± 5.4, and 79.0 ± 19.8, respectively (Table 2). No significant difference was seen in outcomes for patients who underwent femoral head allograft versus nonorthotopic femoral condyle allograft transplant (P≥ .226) (Table 3).

Table 2

Clinical Outcomes and Radiological Findings at Final Follow-up of Patients Who Underwent Osteochondral Allograft Transplant for Femoral Head Defects (n = 19)^a

Clinical and Radiological Parameters
mHHS	86.7 ± 10.8
HOS-ADL	92.8 ± 5.4
HOS-SSS	81.4 ± 21.0
iHOT-12	79.0 ± 19.8
Return to sport	8/12 (66.7)
Revision
Conversion to total hip arthroplasty	4 (21.1)
Trochanteric osteotomy nonunion	1 (5.3)
Arthroscopic graft debridement	1 (5.3)
Preoperative Tönnis grade
Grade 0	11 (57.9)
Grade 1	6 (31.6)
Grade 2	1 (6.7)
Grade 3	1 (6.7)
Postoperative Tönnis grade
Grade 0	10 (52.6)
Grade 1	3 (15.8)
Grade 2	3 (15.8)
Grade 3	3 (15.8)

Data are expressed as mean ± SD or n (%). HOS-ADL, Hip Outcome Score–Activities of Daily Living; HOS-SSS, Hip Outcome Score–Sport-Specific Subscale; iHOT-12, International Hip Outcome Tool; mHHS, modified Harris Hip Score.

Table 3

Clinical Outcomes of Patients Who Underwent Osteochondral Allograft Transplant With Either a Femoral Head or Nonorthotopic Femoral Condyle Allograft^a

	Femoral Head (n = 9)	Femoral Condyle (n = 4)	P
mHHS	86.2 ± 10.3	87.8 ± 13.4	.848
HOS-ADL	91.6 ± 5.5	95.5 ± 4.7	.226
HOS-SSS	78.0 ± 24.3	89.0 ± 8.8	.257
iHOT-12	78.7 ± 23.1	79.8 ± 12.1	.914
Return to sport	4/7 (57.1)	3/4 (75.0)	>.999

The mean mHHS, HOS-ADL, and iHOT-12 scores for the autograft cohort at final follow-up were 87.6 ± 12.4, 92.7 ± 7.6, and 82.0 ± 17.8, respectively (Table 4). Age, BMI, and size of osteochondral defect were not significantly associated with postoperative outcome scores for the allograft cohort (P≥ .131), whereas a lower BMI was significantly associated with a higher HOS-ADL score for the autograft cohort (P = .025).

Table 4

Clinical Outcomes and Radiological Findings at Final Follow-up of Patients Who Underwent Osteochondral Autograft Transplant for Femoral Head Defects (n = 8)^a

Clinical and Radiological Parameters
mHHS	87.6 ± 12.4
HOS-ADL	92.7 ± 7.6
HOS-SSS	83.1 ± 10.8
iHOT-12	82.0 ± 17.8
Return to sport	5/6 (83.3)
Revision (decompression and BMAC injection)	1 (12.5)
Preoperative Tönnis grade
Grade 0	4 (50.0)
Grade 1	4 (50.0)
Grade 2	0 (0)
Grade 3	0 (0)
Postoperative Tönnis grade
Grade 0	1 (12.5)
Grade 1	2 (25.0)
Grade 2	3 (37.5)
Grade 3	2 (25.0)

Data are expressed as mean ± SD or n (%). BMAC, bone marrow aspirate concentrate; HOS-ADL, Hip Outcome Score–Activities of Daily Living; HOS-SSS, Hip Outcome Score–Sport-Specific Subscale; iHOT-12, International Hip Outcome Tool; mHHS, modified Harris Hip Score.

Activity Level

The mean HOS-SSS for the allograft group at final follow-up was 81.4 ± 21.0, and 66.7% of patients (8/12) were able to return to sport (Table 2). No significant difference in HOS-SSS was seen for patients who underwent femoral head allograft versus nonorthotopic femoral condyle allograft transplant (P = .257) (Table 3).

The mean HOS-SSS for the autograft group at final follow-up was 83.1 ± 10.8, and 83.3% of patients (5/6) were able to return to sport (Table 4). Age, BMI, and size of osteochondral defect were not significantly associated with HOS-SSS for either cohort (P≥ .379).

Radiological Findings

The mean defect size for the patients who underwent allograft transplant was 2.8 × 2.1 cm. In this group, 5 patients (26.3%; 5/19) had Tönnis grade progression from preoperative to final follow-up assessment, with 4 of these patients ultimately undergoing conversion to THA (Table 2).

The mean defect size for the patients who underwent autograft transplant was 1.6 × 1.0 cm. In this group, 7 patients (87.5%; 7/8) had Tönnis grade progression; however, none underwent conversion to THA (Table 4).

Complications and Failures

Reoperations and conversions to THA were analyzed, with failure constituting conversion to THA. The overall reoperation rate for the entire cohort was 25.9% (7/27). Four patients (21.1%; 4/19) from the allograft cohort subsequently underwent THA at a mean of 1.9 ± 0.5 years (Figure 5). Three of these patients had avascular necrosis whereas 1 patient had Legg-Calvé-Perthes disease. The mean size of their defects was 2.9 × 2.2 cm, and 1 patient required 3 osteochondral allograft plugs. Two of these patients had substance abuse disorders with either alcohol or alcohol and cocaine, whereas another patient had prednisone-dependent asthma. One patient had a previous core decompression, and 2 patients received nonorthotopic femoral condyle allografts. Three of these patients were 29 years or older. The other patient was a 13-year-old with Legg-Calvé-Perthes disease resulting in severe flattening of the femoral head. This required femoral head reduction osteotomy, fixed with 2 screws (1 screw in the femoral head and the other in femoral neck), in addition to allograft transplant. Subsequently, the graft collapsed 14 months after transplant, ultimately requiring THA. Age, BMI, and size of osteochondral defect were not significantly associated with conversion to THA (P≥ .410).

One patient (5.3%; 1/19) from the allograft cohort underwent revision surgery for a nonunion trochanteric osteotomy at 0.7 years. This patient was 35 years old at the time of surgery and had an alcohol substance abuse disorder. Postoperatively at 6 months, 1 patient (5.3%; 1/19) from the allograft cohort underwent arthroscopic graft debridement. One patient (12.5%; 1/8) from the autograft cohort underwent core decompression and BMAC treatment 5 months postoperatively. One patient in the allograft cohort (5.3%; 1/8) and 3 patients in the autograft cohort (37.5%; 3/8) subsequently underwent hardware removal; however, this was not considered a complication.

Discussion

In this study, we investigated the clinical outcomes of patients who underwent osteochondral allograft or autograft transplant for femoral head osteochondral defects. We found that these procedures demonstrated favorable clinical outcomes as a majority of patients returned to sport and had a HOS-ADL ≥90, mHHS ≥85, iHOT-12 ≥80, and HOS-SSS ≥80. Both allograft and autograft transplant were successful in delaying progression of osteoarthritis and conversion to THA. Notably, a minority of allograft patients demonstrated Tönnis grade progression, whereas outcomes were comparable between those who received femoral head and femoral condyle allografts. Additionally, no autograft patients underwent conversion to THA at final follow-up. Thus, osteochondral allograft and autograft transplant should be considered for adolescents and young adults with focal concomitant cartilage and subchondral bone femoral head defects.

Although the literature is limited, the published studies have shown favorable clinical outcomes after osteochondral allograft transplant for hip defects.^23,31,34,36 Mei and colleagues³¹ recently published the largest osteochondral allograft cohort for femoral head lesions in the literature, comprising 22 patients, with a mean follow-up of 5.7 years. The authors reported a significant improvement in mHHS (P < .001), with 72.7% (16/22) of patients having a mHHS ≥70 at final postoperative follow-up. Additionally, osteoarthritis progression occurred in only 18.2% of patients whereas graft survivorship was 78.5% at 5 years.³¹ Khanna et al²³ demonstrated significant improvements in pre- to postoperative Harris Hip Scores (P < .01) in 17 patients, with 76.5% (13/17) of the patients having scores ≥70 and only 3 patients (17.6%) undergoing subsequent THA. Similarly, our study demonstrated favorable clinical outcomes with a mean HOS-ADL of 92.8 and mHHS of 86.7 at a mean 2.8 years postoperatively.

In contrast to literature on the hip, a substantial number of studies have demonstrated success of osteochondral allograft transplant in the knee. For example, Sadr et al⁴¹ followed 135 patients (149 knees) who underwent osteochondral allograft transplant with a median follow-up of 6.3 years and found that 95% of patients were satisfied with the outcome of their procedure with only 8% undergoing treatment failure. Similarly, Gilat and colleagues¹³ demonstrated 5- and 10-year survival rates of 86.2% and 81.8%, respectively, with 58.9% of patients achieving significant clinical benefit for the International Knee Documentation Committee score at a mean final follow-up of 7.7 years. Although osteochondral allograft transplant has been shown to result in favorable clinical outcomes in both the hip and the knee, it is substantially more challenging to obtain surgical exposure of the hip.

Our cohort also included patients who received nonorthotopic femoral condyle grafts for osteochondral allograft transplant. A recent study found that a local curvature mismatch between donor and host may have a negative effect on midterm clinical outcomes in patients undergoing knee osteochondral allograft transplant.¹⁶ However, Mologne et al³³ found lateral femoral condyles to be acceptable graft options for medial femoral condyle osteochondral defects. In our cohort, the clinical outcomes of the patients who received femoral condyle and femoral head allografts were notably similar. This is important because most tissue banks do not procure femoral heads for transplant and the majority of knee osteochondral defects occur within the medial condyle, resulting in underused lateral femoral condyles. Our results demonstrate that nonorthotopic osteochondral allograft transplant may be a suitable option for femoral head defects.

In our cohort treated with osteochondral allograft transplant, 4 patients underwent subsequent THA. Two patients who underwent subsequent THA had histories of substance abuse with either alcohol or alcohol and cocaine, whereas another patient was chronically dependent on prednisone for asthma symptoms. Myers³² reported one of the earliest case series of osteochondral allograft transplant for femoral head defects and demonstrated that most outcome failures were found in patients receiving systemic steroid therapy. Therefore, our findings reinforce existing literature,^5,21,26 such that substance abuse and chronic steroid therapy should be contraindications for osteochondral allograft transplant. Increasing age has previously been shown to be a risk factor for graft failures, as 3 patients who subsequently underwent THA were older than 29 years.²⁵ The final patient to undergo THA had Legg-Calvé-Perthes disease that resulted in severe deformation of the articular surface and femoral head. Although the femoral head healed after reduction osteotomy, the allograft did not, likely resulting in osteoarthritis progression. Mei and colleagues³¹ reported on 2 patients with Legg-Calvé-Perthes disease with global cartilage damage and joint deformity that subsequently required THA. As a result, for patients with avascular necrosis, our indication for performing osteochondral transplant is a focal area of collapse with a Kerboul angle ≤200°.¹⁷

Osteochondral autograft transplant similarly demonstrated satisfactory clinical outcomes, with several studies in the literature indicating substantial improvements in Harris Hip Scores pre- to postoperatively by >25 points. Additionally, these studies reported the autograft plugs to be well incorporated with no evidence of radiographic progression to collapse at final follow-up.^14,20 Viamont-Guerra et al⁴⁴ found that mHHS improved from 56.3 preoperatively to 88.4 postoperatively in 22 patients at a mean final follow-up of 3.3 years. Interestingly, patients with lesions ≥2 cm² had less improvement in the mHHS and Western Ontario and McMaster Universities Osteoarthritis Index than patients with lesions <2 cm². Our study has the longest follow-up in the literature of patients who underwent osteochondral autograft transplant, with a mean of 9.5 years.¹¹ Although osteoarthritis progression was seen in most of these patients, none have yet to undergo THA. Notably, a majority of outcomes in the autograft cohorts were superior to the allograft cohort, which may have been due to a smaller defect size. However, a few patients showed favorable outcomes with larger lesions, suggesting that autograft transplant may be a viable alternative to allograft transplant when fresh allografts are not available.

Alternative treatment options for hip cartilage defects include microfracture, which has shown favorable short-term outcomes in the hip.^27,30,37 In the knee, this technique is limited to smaller lesions (<2 cm²), has questionable long-term outcomes, and requires intact subchondral bone.^15,24 Another treatment option is matrix-induced autologous chondrocyte transplant, which has shown favorable results for larger cartilage defects. However, it is a 2-stage procedure resulting in an increased risk of general surgical complications and, similar to microfracture, requires healthy subchondral bone.^10,39 Last, a THA can be performed; however, it has shown lower patient satisfaction, increased activity restrictions, and significantly increased complication and revision rates in young cohorts.^28,42,43 Therefore, large cartilage defects or cartilage defects with concomitant subchondral bone damage may best be treated with osteochondral transplant.

Limitations

This study is not without limitations. This is a retrospective study with a limited sample size, a heterogeneous patient population, and a lack of preoperative patient-reported outcome measures, which limited statistical analysis. However, osteochondral transplant for femoral head defects is exceedingly rare. Additionally, we present one of the largest case series in the literature and are among the few institutions that currently perform these technically challenging procedures. Only a few patients underwent postoperative MRI, which may better demonstrate subtle evidence of disease progression or joint degeneration in comparison to radiographs. However, because most patients were not symptomatic, obtaining advanced imaging on every patient was not indicated.

Conclusion

Footnotes

Submitted April 18, 2024; accepted March 7, 2025.

One or more of the authors has declared the following potential conflict of interest or source of funding: This study was funded by the AOSSM-JRF Ortho Allograft Grant. K.J.E. has received support for education from Goode Surgical and hospitality payments from Arthrex. M.H. has received support for education from Smith & Nephew, Medwest Associates, Arthrex, and Foundation Medical; honoraria from Encore Medical; and consulting fees from Vericel Corporation. R.J.S. has received royalties from Zimmer Biomet Holdings; consulting fees from Orthalign Inc, THINK Surgical, and Zimmer Biomet; and hospitality payments from Gemini Medical and Link Bio. A.J.K. had received royalties and consulting fees from Arthrex and Responsive Arthroscopy, consulting fees and honoraria from the Joint Restoration Foundation, and a grant from DJO. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

ORCID iDs

Sean C. Clark

Mario Hevesi

Aaron J. Krych

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