Paper 52: Pre- and Post-operative Patient Management by an Integrated Care Team Reduces Postoperative Failure Rates Following Osteochondral Allograft Transplantation in the Knee

Abstract

Objectives: To assess the effects of an integrated care team including a health behavior psychologist on postoperative adherence and associated outcomes for patients undergoing osteochondral and/or meniscus allograft transplantation in the knee. Methods: With IRB approval and documented informed consent, patients were prospectively enrolled into a registry dedicated to following outcomes after OCA and meniscus allograft transplantation surgery between January of 2016 and April of 2021. Patients undergoing primary osteochondral and/or meniscus allograft transplantation to address symptomatic full-thickness cartilage loss and/or meniscus deficiency were included. Patient adherence rates and outcomes were compared based on two cohorts: patients that did not see a behavioral health psychologist preoperatively, and patients that met preoperatively identify potential barriers to adherence, set expectations for postoperative protocols, and identify a plan to moderate risk factors to non-adherence. Patients in both cohorts met preoperatively with the rest of the integrated care team specializing in joint preservation. Data were collected preoperatively, and at all follow-up visits at 3 months, 6 months, and yearly post-operatively. Visual analog scale (VAS) pain scores, International Knee Documentation Committee scores, PROMIS Global Health, and PROMIS Pain interference scores were collected. Treatment failure was defined as any reoperation to revise any of the osteochondral and/or meniscus allografts (revision) or for conversion to arthroplasty in the affected knee. Functional survival (success) was defined as patient- reported pain and function scores improved from pre-operative levels without need for revision or arthroplasty. Patients were categorized as nonadherent when documented evidence of a break from the physical therapy protocol was recounted to a member of the healthcare team by the patient or their physical therapy provider. Data were included for analyses when applicable registry data were available for at least one year following surgery. Chi-square or Fisher’s exact tests were used to analyze differences in proportions, while unpaired t-Tests, one-way analysis of variance tests, or rank sum tests were used to assess significant differences in variables with continuous data. Significance was set a priori at p < 0.05. Results: For patients in the study (n=213), 23.4% were documented to be nonadherent. Of those who were nonadherent, 4 (8.0%) were in the Health Psych cohort versus 46 (92.0%) who were not. Patients in the No Health Psych cohort were significantly more likely to be nonadherent to postoperative rehabilitation protocols (p = .023, OR = 3.4). Tobacco use (p<.001, OR = 7.9), higher preoperative PROMIS Pain Interference score (p<.001), lower preoperative PROMIS Mental Health score (p<.001), older age (p<.001) and higher BMI (p<.001) were also significantly associated with nonadherence. 81.6% of adherent patients had successful outcomes (mean final follow-up 46.7 months, range 12-75), while 40% of nonadherent patients required revision or total knee arthroplasty during the study period, such that nonadherent patients were 3x more likely (p = .004) to experience treatment failure. In this cohort of patients, male sex (p<.001, OR = 3.4) and bipolar OCA transplantation surgeries (p<.001, OR = 5.0) were also significantly associated with increased risk for treatment failure. Conclusions: Preoperative education and postoperative support for patients provided by an integrated care team including a health psychologist can significantly improve adherence and outcomes following osteochondral and meniscal allograft transplantation in the knee.