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Return to Play After Bipolar Patellofemoral Osteochondral Allograft Transplantation for a Professional Basketball Player

A Case Report

Marom, Niv MD1; Wang, Dean MD2; Patel, Snehal PT, MPT, SCS3; Williams, Riley J. III MD1

doi: 10.2106/JBJS.CC.18.00291
Case Reports
Free
Disclosures

Case: Extensive and multiple symptomatic chondral lesions in the knee of a professional athlete presents unique challenges when considering optimal management. We present the case of a professional National Basketball Association player with symptomatic and extensive patellofemoral chondral lesions, who failed 24 months of nonoperative management and was treated surgically with bipolar patellofemoral osteochondral allograft transplantation (OCA) consisting of 3 large grafts to the patella, medial trochlea, and lateral trochlea. The player was able to return to his preinjury level of play 10 months postoperatively and remains asymptomatic at same level of play 3 years after surgery. Postoperative magnetic resonance imaging at 16 months demonstrated good restoration of the articular architecture of the patellofemoral joint.

Conclusions: Bipolar OCA treatment for extensive chondral patellofemoral injury may be considered in high-level, high-demand athletes who wish to return to play professionally.

1Sports Medicine and Shoulder Surgery Division, Hospital for Special Surgery, New York, New York

2Department of Orthopaedic Surgery, UC Irvine Health, Orange, California

3Sports Rehabilitation Center, Hospital for Special Surgery, New York, New York

E-mail address for N. Marom: maromn@hss.edu; niv.marom@gmail.com

Investigation performed at Hospital for Special Surgery, New York, New York

Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/A827).

Management of symptomatic articular cartilage lesions of the knee, particularly if multiple and extensive, presents many challenges in a professional athlete. These challenges are further magnified in professional basketball where the high joint reactive forces associated with cutting, accelerating and decelerating, jumping, and pivoting put tremendous loads on the articular surfaces of the knee. We present the surgical treatment of extensive bipolar patellofemoral chondral erosion using osteochondral allograft transplantation (OCA) in a professional National Basketball Association (NBA) basketball player, who was able to return to his preinjury level of play after surgery.

The patient was informed that data concerning the case would be submitted for publication, and he provided consent.

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Case Report

A 26-year-old healthy professional basketball player presented with complaints of chronic, activity-related, anterior right knee pain. The player reported the onset of symptoms over 24 months before presentation to the clinic. The pain substantially limited his ability to position himself on the court with knee flexion, push-off, and jump. Moreover, the player reported constant swelling, which inhibited his ability to move explosively. Based on previous imaging and surgical procedures that included 3 arthroscopic debridements, he was diagnosed with severe cartilage degeneration of both the patella and femoral trochlea. Failed nonoperative treatment strategies used in this player included rest, physical therapy, viscosupplementation, oral nonsteroidal anti-inflammatory drug, corticosteroid injections, platelet-rich plasma injections, and bone marrow aspirate injections. Team records indicated that the patient had undergone over 50 knee aspirations over the previous 2 seasons for the purpose of relieving knee swelling and pain. Physical examination revealed neutral alignment, normal gait, and full range of motion. There was a 2+ knee effusion present. The lateral and medial facets of the patella were tender to palpation and there was subpatellar crepitus. The knee was otherwise stable with no signs of instability in all planes.

Magnetic resonance imaging (MRI) of the knee demonstrated full-thickness articular cartilage loss of the lateral and medial facets of the patella with underlying extensive bone edema. There was also corresponding cartilage loss on the anterior aspect of the lateral and medial femoral trochlea across the sulcus (Fig. 1). Both menisci were intact and both tibiofemoral compartments had diffuse mild chondromalacia.

Fig. 1

Fig. 1

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Surgical Treatment

As all nonoperative means of treating this athlete had been exhausted, the decision was made to proceed with the implantation of bipolar OCA allograft plugs. One dowel graft was placed in the patella and 2 dowel grafts were placed in the femoral trochlea. The surgery was performed based on the dowel technique described by Williams et al1. A single large femoral hemicondylar fresh osteochondral specimen was used as the donor source for all implanted grafts. The patella and trochlea were exposed by a lateral parapatellar arthrotomy. The affected areas were inspected and the lesions were sized in anticipation of OCA. The trochlea was resurfaced using two 22-mm diameter cylindrical dowel grafts with graft depth of 6 to 7 mm. The patellar lesion was resurfaced using a single 25-mm diameter cylindrical dowel graft with graft depth of 6 to 7 mm. The grafts were soaked in a bone marrow aspirate concentrate for 10 minutes before implantation. All grafts were manually press fitted into position or gently impacted into place to achieve fixation (Fig. 2).

Fig. 2

Fig. 2

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Postoperative Management

The patient was remained touchdown weight-bearing in a hinged knee brace for 1 week. Progression to full weight-bearing ensued during postoperative week 2 and was advanced to tolerance. During this initial period, the athlete was permitted to perform active-assisted range of motion exercises, quadriceps sets, straight leg raises, and patellar mobilization. Immediate full range of motion was permitted with the use of a continuous passive motion device. A hinged knee brace was used for 2 weeks and then discontinued due to restored quadriceps control and strength. A supervised physical therapy program was undertaken and described in detail in Table I. At 6 months, a running program utilizing the principles of progressive loading was initiated, starting with running on the AlterG treadmill and progressing to regular treadmill running. At 7 months, on-court drills and simulated play were initiated along with continued progressive loading to allow for full return to play. Mild knee effusion with no significant knee pain was present postoperatively and subsided approximately 8 weeks postoperatively. At 10 months postoperatively, he returned to play with no major complaints or problems. A 16-month postoperative MRI demonstrated excellent fill of the cartilage defects and restoration of the articular architecture of the patellofemoral joint with good osseous incorporation of the patellar and trochlear OCAs (Fig. 3). At latest follow-up (3 years), he continues to play basketball in the NBA at a high level while averaging 30 minutes per game.

Table I - Detailed Rehabilitation Program*
Phase ROM Strength Soft Tissue
Phase I (Week 0-6)
  1. Immediate ROM after surgery

  2. Emphasize full knee extension immediately

  3. AROM/AAROM exercises (pain free ROM)

  4. LE stretching

  5. (Hip, hamstring, gastrocnemius/soleus)

  1. Quadriceps re-education

  2. Leg press (60°→0° arc, progressing to 90°→0° arc)

  3. Initiate core stabilization program

  4. Ankle PREs

  5. Multiangle quadriceps isometrics

  6. Short crank bike →upright bike

  7. Multiplanar gluteus/core/hip strengthening

  8. Aquatic therapy when incisions are healed—week 6

  9. Plank progression

  10. Initiate step-ups at week 4

  1. Quadriceps, hamstring, gastrocnemius/soleus soft tissue release

  2. Mobilization to superior patellar pouch and infrapatellar soft tissue structures to provide proper patellar mobility

Phase II (Week 6-12)
  1. Gradual increase of ROM to full ROM

  2. Maintain full passive knee extension

  3. Continue patellar mobilization as needed

  4. Continue with LE stretching

  1. Progress stationary bike time—gradually increase time to 2 (20 min) sessions per day

  2. Progress to elliptical—week 10

  3. Underwater TM/AlterG gait training if gait pattern continues to be abnormal

  4. Continue with EMS as needed

  5. Progress to eccentric leg press (2 up/1 down)—week 6

  6. Chair squats—week 6

  7. Continued step-up progression

  8. Front lunges → traveling lunges—week 8

  9. TRX squats—week 8

  10. Progressive gluteus/hip strengthening

  11. Progress balance/proprioception

  12. Core progression

  13. Initiate TM walking program

  1. Initiate foam rolling program

  2. IASTM quads, hamstrings, adductor, ITB

Phase III (Week 12-20) Full ROM without limitations
  1. Continued progression of Phase I/II exercises

  2. Progress with interval biking for endurance

  3. Advanced proprioception training (perturbations)

  4. Begin agility training

  5. Stairmaster

  6. Continue with core progression

  7. Initiate sport-specific basketball activities

Continued IASTM quads, hamstrings, adductor, ITB
Phase IV (Week 20+)
  1. LE stretching

  2. Hip flexor, hip hugger, hamstring, gastrocnemius/soleus

  1. Glute activation warmup

  2. Goblet squats (DL/SL)—eccentric control

  3. Front/back squats—eccentric control

  4. Advanced multiplanar hip strengthening

  5. Deadlift (Trap Bar)

  6. SL RDL

  7. Kinetic linking drills (half kneeling, standing, SLS, power)

  8. Interval biking/rowing

  9. Assault bike high-intensity interval training

  10. Running progression

  11. AlterG running progression (initiated at week 22)

  12. Progress to interval TM running program (be cautious of overloading knee)

  13. Plyometric program

  14. Progress with agility and balance drills

  15. Progress with sport specific programs

  1. Foam rolling

  2. Quads, glutes, adductor, TFL/ITB, gastrocnemius/soleus

*
AAROM = active assistive range of motion, AROM = active range of motion, DL = double leg, EMS = electrical muscle stimulation, IASTM = instrument assisted soft tissue manipulation, ITB = iliotibial band, LE = lower extremity, PRE = progressive resistance exercise, RDL = Romanian dead lift, ROM = range of motion, SL = single leg, SLS = single leg stance, TFL = tensor fascia lata, TM = treadmill, and TRX = total body resistance exercise.

Fig. 3

Fig. 3

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Discussion

Articular cartilage lesions of the knee have shown increased frequency in high level athletes, with patellofemoral defects being the most common (37%)2. Although cartilage lesions may be seen in asymptomatic athletes, many of these injuries are symptomatic and can lead to persistent pain and swelling and also play a role in the development of early onset osteoarthritis2-4.

The presented case combines unique aspects of the challenging management of cartilage injuries in professional athletes. First and foremost, treating professional athletes requires understanding their distinctive features, which include greater functional and biomechanical demands, pressure to return to play within a short time frame, and a multidisciplinary involvement in the treatment plan by athletic trainers, physical therapists, coaches, and management staff. All these features should be taken to consideration when tailoring an optimal treatment plan. Additionally, the characteristics of the cartilage lesions treated in this case are unconventional. It has been shown that treating patellofemoral cartilage lesions, especially large and advanced lesions, has unpredictable outcomes with either cartilage restoration technique chosen5,6 and many surgeons are hesitant to treat these lesions surgically. Moreover, the bipolar and extensive nature of the lesions as well as the fact that professional basketball involves high stresses and strains on the patella make it even a greater challenge.

Among the numerous surgical treatments that can be considered after exhaustion of conservative management, OCA transplantation has been shown to provide excellent functional outcomes for the treatment of large cartilage lesions and those involving the subchondral bone7-10. Unlike other cartilage restoration techniques, OCA transplantation is able to restore the articular surface architecture with viable, mature, structurally stable articular cartilage in patients with large osteochondral defects in a single-step procedure without inducing donor site morbidity11-13. When treating professional athletes, return to activity and sports are usually the primary goal and several studies in recent years reported on high rate of return to sport activities after OCA procedures14-16. Krych et al.14 reported on 38 athletes treated at our institution at an average 2.5 years of follow-up and found that 88% returned to sport in a limited fashion, while 79% returned to preinjury levels of sport after an average of 9.6 months following surgery. Nielsen et al.15 showed 75.2% of return to sport and recreational activities in athletic patients at a mean follow-up of 6 years, with survivorship rates of 91% at 5 years and 89% at 10 years.

When considering bipolar cartilage lesions of the knee, which may reflect a higher burden of osteoarthritic disease, poorer results with lower survivorship rates and higher reoperation rates are reported17-20. Meric et al.21 showed survivorship rates of 64% at 5 years and 39% at 10 years for OCA of bipolar osteochondral lesions in an older population of patients (mean, 40 years old). However, patients with surviving allografts reported improved subjective clinical outcomes postoperatively, suggesting that this procedure can still be beneficial in some patients with bipolar disease.

We chose to use in this case 3 nonorthotopic OCAs, all harvested from one large femoral hemicondylar allograft. Previous studies performed at our institution suggested that condyle-specific and anteroposterior matching may not be necessary and provides comparable outcomes to matching grafts in OCA knee surgeries22,23. This allows for better and faster graft availability, use of fresher grafts, and lower procedure costs, especially in scenarios where multiple OCAs are planned to be used and/or chondral lesions are in locations, which are less available as allograft.

Proper postsurgery rehabilitation program is particularly important for achieving better outcomes in these challenging cases. An early goal of regaining full joint range of motion and specifically extension, as well as manipulations for decreasing the edema and swelling, allows for proper quadriceps activation and smooth transition to the more strenuous rehabilitation phases. Additional important principle in the rehabilitation program in this case was improving core and hip stability and strength, which can potentially decrease the forces in the knee joint and specifically the patellofemoral compartment. Kinetic linking principles were also used throughout the rehabilitation process starting early in the unloaded supine position and progressing to single-leg power movements using the entire kinetic chain. These principles teach the athlete how to distribute force not only using the knee, but the entire kinetic chain.

To conclude, although there are currently no studies specifically evaluating the treatment of extensive cartilage loss in the high-level athlete, this particular case demonstrates that surgical treatment of extensive patellofemoral chondromalacia with OCA resulted in a successful outcome and may be considered in high-level, high-demand athletes who wish to return to play professionally.

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References

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