Bipolar fresh osteochondral allograft for the treatment of end-stage osteoarthritis: comprehensive multi-joint evidence supported by long-term experience

Bipolar fresh osteochondral allograft (BFOA) has emerged as a biologically based alternative for joint resurfacing in the treatment of end-stage osteoarthritis, particularly in young and active patients for whom traditional interventions such as arthrodesis or prosthetic replacement may be suboptimal. This review synthesizes recent clinical evidence on the application of BFOA across multiple anatomical sites, namely the shoulder, knee, ankle, and first metatarsophalangeal joint (1MTPJ). The technique involves transplanting viable articular cartilage with an intact subchondral bone layer to restore joint function and alleviate pain, with outcomes largely influenced by the biomechanical environment and local soft tissue conditions. In the shoulder, limited studies have demonstrated promising improvements in clinical scores. The knee, by contrast, has shown a markedly high failure rate; complications such as graft malalignment, poor fixation, and an adverse immunologic response—possibly due to the larger graft size and extensive soft tissue involvement—have contributed to suboptimal outcomes. In the ankle, many patients have reported pain relief and functional improvement. Similar encouraging results have been observed in the treatment of hallux rigidus at the 1MTPJ, where lower mechanical demands favor graft integration. While BFOA offers a promising joint-preserving strategy for end-stage osteoarthritis, its efficacy varies by joint, highlighting the need for technical precision and careful patient selection to optimize BFOA outcomes. Further research is warranted, aimed at modulating host immune responses to enhance graft durability. KEY WORDS: Bipolar fresh allograft, osteochondral allograft, ankle, hallux, knee, shoulder.