The use of fibrin matrix-mixed gel-type autologous chondrocyte implantation in the treatment for osteochondral lesions of the talus

No difference between 5 and 6 weeks of non-weight bearing after osteochondral grafts for medial osteochondral defects of the talus with medial malleolar osteotomy

PURPOSE

The present study aimed to compare the clinical outcomes and safety at a 1-year follow-up after 5 or 6 weeks of non-weight bearing after a Talar OsteoPeriostic grafting from the Iliac Crest (TOPIC) for a medial osteochondral lesion of the talus (OLT).

METHODS

A retrospective comparative case-control analysis of prospectively followed patients who underwent a TOPIC procedure with medial malleolus osteotomy was performed. Patients were matched in two groups with either 5 or 6 weeks of non-weight bearing. Clinical outcomes were evaluated using the Numeric Rating Scale (NRS) during walking, rest, running, and stairclimbing. Additionally, the Foot and Ankle Outcome Score (FAOS) and American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score were assessed. Moreover, radiology and complications were assessed.

RESULTS

Eleven patients were included in the 5-week non-weight bearing group and 22 in the 6-week non-weight bearing group. No significant differences were found in any of the baseline variables. The NRS during walking in the 5-week group improved by 3.5 points and 4 points for the 6-week group (p = 0.58 at 1-year post-operatively). In addition, all other NRS scores, FAOS subscales and the AOFAS scores improved (all n.s. at 1 year follow-up). No significant differences in radiological (osteotomy union and cyst presence in the graft) were found. Moreover, no significant differences were found in terms of complications and reoperations.

CONCLUSION

No statistical significant differences were found in terms of clinical, radiological and safety outcomes between 5 or 6 weeks of non-weight bearing following a TOPIC for a medial OLT.

LEVEL OF EVIDENCE

Level III, Therapeutic.

Outcomes following gel-based autologous chondrocyte implantation for articular cartilage defects of the knee

BACKGROUND

Gel-based autologous chondrocyte implantation (GACI) enables a simpler and more effective delivery of chondrocytes with reproducible three-dimensional structural restoration of the articular cartilage surface. There is limited documentation of medium-term outcomes. This study assessed safety and effectiveness of GACI for treatment of cartilage defects of the knee.

METHODS

This multicentric retrospective study was conducted across eight hospitals in India. Patients who had undergone GACI (CARTIGROW®) between 2008 and 2014 for the treatment of focal articular cartilage defects of the knee (mean defect size 4.5 ± 5.8 cm2) in limbs with normal alignment were analyzed. Primary outcomes were changes in Lysholm Knee Scoring Scale score, and Knee Outcome Sports Activity Scale (SAS).

RESULTS

A total of 107 patients (110 knee joints) with mean age 31.0 ± 10.5 years were included. The mean follow-up was 9.8 ± 1.5 years (range 7.85-13.43). Majority had osteochondritis dissecans (n = 51; 46.4%). The mean Lysholm Knee Scoring Scale score (81.23 ± 13.21 vs. 51.32 ± 17.89; p < 0.0001) and SAS score (80.93 ± 8.26 vs. 28.11 ± 12.28; p < 0.0001) improved significantly at follow-up as compared to pre-operative. Magnetic Resonance Observation of Cartilage Repair Tissue score in 39 patients at minimum 2 years follow-up was 84.5 ± 4.3. Among 30 patients who were playing sports before treatment, 17 patients (56.7%) could return to the same or higher level of sports post-transplantation. No major intra-operative or post-operative complications were noted. Four patients warranted revision surgery.

CONCLUSION

GACI is an effective treatment option for large focal articular cartilage defects of the knee with a low complication rate and revision rate and significant improvement in functional scores.

Second-Look Arthroscopy Shows Inferior Cartilage after Bone Marrow Stimulation Compared with Other Operative Techniques for Osteochondral Lesions of the Talus: A Systematic Review and Meta-Analysis

OBJECTIVE

To compare cartilage quality after different surgical interventions for osteochondral lesions of the talus (OLT), evaluated by second-look arthroscopy. Secondary aims were to report concomitant diagnoses, and to correlate cartilage quality with clinical and radiological outcomes. This review hypothesizes that the cartilage repair after bone marrow stimulation (BMS) is inferior to the other available treatment options.

METHODS

PROSPERO ID: CRD42022311489. Studies were retrieved through PubMed, EMBASE (Ovid), and Cochrane Library. Studies were included if they reported cartilage quality after second-look investigation after surgical treatment of OLT. The primary outcome measure was the cartilage quality success and failure rates (%) per surgical intervention group. Correlations between the cartilage quality and clinical or radiological outcomes were calculated.

RESULTS

Twenty-nine studies were included, comprising 586 ankles that had undergone second-look arthroscopy on average 16 months after initial surgery. The success rate for BMS was 57% (95% confidence interval [CI] = 48%-65%), for fixation (FIX) 86% (95% CI = 70%-94%), for osteo(chondral) transplantation (OCT) 91% (95% CI = 80%-96%), for cartilage implementation techniques (CITs) 80% (95% CI = 69%-88%), and for retrograde drilling 100% (95% CI = 66%-100%). The success rate of BMS was significantly lower than FIX, OCT, and CIT (P < 0.01). There were no significant differences between other treatment groups. A moderate positive significant correlation between the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score and the International Cartilage Repair Society score (ICRS) was found (ρ = 0.51, P < 0.001).

CONCLUSIONS

Successful restoration of cartilage quality was found in the majority of surgically treated OLTs. However, BMS yields inferior cartilage quality compared with FIX, OCT, and CIT. Study Design. Systematic review and meta-analysis. Level of evidence. Level IV, systematic review and meta-analysis.

Clinical Applicability of Autologous Chondrocyte Implantation for the Treatment of Osteochondral Defects: A Meta-analysis

PURPOSE

Osteoarthritis and other joint disorders are the leading cause of disability in the elderly and the treatment of joint lesions is challenging. Autologous chondrocyte implantation (ACI) has been reported with variable effects for the treatment of osteochondral and other joint lesions. In this study, we performed a meta-analysis of the recent literature to determine the clinical applicability of ACI for osteochondral defects.

METHODS

A meta-analysis was performed on the recent literature showing the effects of ACI on osteochondral defects. The PUBMED, ScienceDirect and Google Scholar databases were used to identify eligible studies from Jan 2010 to Sep 2022. Both fixed and random models of meta-analysis were applied with all reported scoring systems to quantify the effectiveness of ACI on osteochondral defects.

RESULTS

The pool data of 965 patients as a case series after ACI from a fixed model showed a significant improvement in the osteochondral defects (odds ratio = 8.75, 95%CI = 7.127 to 10.743, p = 0.000). These results were further verified by a random model of meta-analysis. The data also showed a substantial heterogeneity among the studies used in the meta-analysis (Q-value = 160.41, I-squared = 87.53, p = 0.000). Furthermore, this meta-analysis also compared different ACI procedures with different scoring systems but the overall outcome remains the same as ACI was found to be useful for the healing of the osteochondral defects.

CONCLUSION

This meta-analysis of 965 case series revealed that the ACI markedly improved the damage osteochondral defects scores but the optimal treatment is still controversial, therefore further studies are needed to validate these findings in a clinical setting.

Gel-Based Autologous Chondrocyte Implantation (GACI) in the Chondral Defects of the Knee: An Observational Study

Introduction

Gel-based autologous chondrocyte implantation (GACI) is known to have superior results when compared to conventional autologous chondrocyte implantation (ACI) in terms of delivery of chondrocytes to the articular cartilage surface with reproducible three-dimensional structural restoration. This study aims to evaluate the short-term outcomes of gel-based autologous chondrocyte implantation (GACI) for the treatment of large focal articular cartilage defects of the knee.

Methods

This was a prospective observational study among 25 patients who underwent GACI. Primary outcome measures included Lysholm Knee Scoring Scale and IKDC score and secondary outcome measures included MRI assessment of cartilage repair using MOCART.

Results

Mean age of the population was 39.8 ± 7.5 years. The study found a highly significant improvement in both Lysholm knee score (pre-op: 45.1 to post-op: 72.4) and IKDC score (pre-op: 36.7 to post-op: 78.5) (p < 0.001) at the final follow-up of 24 months, even with the mean defect size being 4.5 ± 5.8 cm2. Postoperative MRI showed a mean MOCART score improvement from 39.4 to 67.4 at the final follow-up. No major complications were observed.

Conclusion

GACI is an effective and safe treatment option for large focal articular cartilage defects around the knee, with significant improvement in functional scores and low revision rates at medium-term follow-up.

The Frequency and Severity of Complications in Surgical Treatment of Osteochondral Lesions of the Talus: A Systematic Review and Meta-Analysis of 6,962 Lesions

OBJECTIVE

The primary aim was to determine and compare the complication rate of different surgical treatment options for osteochondral lesions of the talus (OLTs). The secondary aim was to analyze and compare the severity and types of complications.

DESIGN

A literature search was performed in MEDLINE (PubMed), EMBASE (Ovid), and the Cochrane Library. Methodological quality was assessed using the Methodological Index for Non-Randomized Studies (MINORS). Primary outcome was the complication rate per surgical treatment option. Secondary outcomes included the severity (using the Modified Clavien-Dindo-Sink Complication Classification System for Orthopedic Surgery) and types of complications. The primary outcome, the severity, and the sub-analyses were analyzed using a random effects model. A moderator test for subgroup-analysis was used to determine differences. The types of complications were presented as rates.

RESULTS

In all, 178 articles from the literature search were included for analysis, comprising 6,962 OLTs with a pooled mean age of 35.5 years and follow-up of 46.3 months. Methodological quality was fair. The overall complication rate was 5% (4%-6%; treatment group effect, P = 0.0015). Analysis resulted in rates from 3% (2%-4%) for matrix-assisted bone marrow stimulation to 15% (5%-35%) for metal implants. Nerve injury was the most observed complication.

CONCLUSIONS

In 1 out of 20 patients treated surgically for an OLT, a complication occurs. Metal implants have a significantly higher complication rate compared with other treatment modalities. No life-threatening complications were reported.

Efficacy and safety of autologous chondrocyte implantation for osteochondral defects of the talus: a systematic review and meta-analysis

INTRODUCTION

Studies have reported various effects of autologous chondrocyte implantation (ACI) on osteochondral defects of the talus. Therefore, to assess the effectiveness of ACI for osteochondral defects of the talus, we used the meta-analytic approach.

MATERIALS AND METHODS

Electronic databases PubMed, Embase, and the Cochrane Library were systematically searched to identify eligible studies from their inception until November 2020. The random-effects model was used to calculate the incidence of success rate and American Orthopaedic Foot and Ankle Society (AOFAS) score for patients after ACI treatment. Subgroup analyses were also conducted based on age, technique, indication, size, and follow-up duration.

RESULTS

For the final meta-analysis, we selected 23 case series studies with a total of 458 patients with osteochondral defects of the talus. Overall, after ACI for patients with osteochondral defects of the talus, we noted that the incidence of success rate was 89% (95% confidence interval (95% CI) 85%-92%; P < 0.001). Moreover, after ACI for patients with osteochondral defects of the talus, the AOFAS score was 86.33 (95% CI 83.33-89.33; P < 0.001). Subgroup analysis showed that the AOFAS score after ACI is significantly different when stratified by the mean age of the patients (P = 0.006).

CONCLUSIONS

This study revealed that the use of ACI could provide a relatively high success rate and improve the AOFAS score for patients with osteochondral defects of the talus, which should be recommended in clinical practice.

Medial oblique malleolar osteotomy for approach of medial osteochondral lesion of the talus

PURPOSE

The medial malleolar osteotomy is commonly performed to gain access to the medial talar dome for treatment of osteochondral lesions of the talus. The primary aim of this study was to assess osseous healing based on postoperative radiographs to determine consolidation, non-union and malreduction rates.

METHODS

Sixty-seven cases were reviewed where an oblique uniplanar medial malleolar osteotomy was performed to gain access to the medial talar dome for addressing an osteochondral lesion. Two, respectively three fully threaded 3.5 mm corticalis screws were used to fixate the osteotomy. Postoperative radiographs were reviewed to assess consolidation, non-union, malreduction and dislocation of the osteotomy.

RESULTS

Out of 67 patients, 66 patients had a consolidation of the osteotomy. 23.9% of the cases showed malreduction of the osteotomy. One patient suffered a non-union, which required a revision surgery. No significant difference was shown between two and three screws used for fixation in terms of malreduction and consolidation of the osteotomy. Eighty-four percent of the patients underwent hardware removal due to pain or medial impingement.

CONCLUSION

The oblique medial malleolar osteotomy is a safe and relatively simple procedure with a high consolidation rate and low revision providing excellent exposure of the talus. The moderately high malreduction rate and required hardware removal surgery by most of the patients are relevant factors which should be considered before performing this surgery.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Correlation of Postoperative Imaging With MRI and Clinical Outcome After Cartilage Repair of the Ankle: A Systematic Review and Meta-analysis

Background:

Magnetic resonance imaging (MRI) is commonly used for evaluation of ankle cartilage repair, yet its association with clinical outcome is controversial. This study analyzes the correlation between MRI and clinical outcome after cartilage repair of the talus including bone marrow stimulation, cell-based techniques, as well as restoration with allo- or autografting.

Methods:

A systematic search was performed in MEDLINE, Embase, and Cochrane Collaboration. Articles were screened for correlation of MRI and clinical outcome. Guidelines of Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) were used. Chi-square test and regression analysis were performed to identify variables that determine correlation between clinical and radiologic outcome.

Results:

Of 2687 articles, a total of 43 studies (total 1212 cases) were included with a mean Coleman score of 57 (range, 33-70). Overall, 93% were case series, and 5% were retrospective and 2% prospective cohort studies. Associations between clinical outcome and ≥1 imaging variable were found in 21 studies (49%). Of 24 studies (56%) using the composite magnetic resonance observation of cartilage repair tissue (MOCART) score, 7 (29%) reported a correlation of the composite score with clinical outcome. Defect fill was associated with clinical outcome in 5 studies (12%), and 5 studies (50%) reported a correlation of T2 mapping and clinical outcome. Advanced age, shorter follow-up, and larger study size were associated with established correlation between clinical and radiographic outcome (P = .021, P = .028, and P = .033).

Conclusion:

Interpreting MRI in prediction of clinical outcome in ankle cartilage repair remains challenging; however, it seems to hold some value in reflecting clinical outcome in patients with advanced age and/or at a shorter follow-up. Yet, further research is warranted to optimize postoperative MRI protocols and assessments allowing for a more comprehensive repair tissue evaluation, which eventually reflect clinical outcome in patients after cartilage repair of the ankle.

Level of Evidence: Level III, systematic review and meta-analysis.

Arthroscopic evaluation after osteochondral autogenous transfer with osteotomy of medial malleolus for osteochondral lesion of the talar dome

BACKGROUND

The purpose of this study was to investigate the second-look arthroscopic evaluation after osteochondral autogenous transfer (OAT) for osteochondral lesion of the talar dome (OLT) with the criteria of the International Cartilage Repair Society (ICRS).

METHODS

Ten patients (twelve ankles) with OLT underwent OAT with osteotomy of the medial malleolus. Clinical outcomes were evaluated using the American Orthopedic Foot & Ankle Society (AOFAS) ankle-hindfoot scale. The condition of the transplanted cartilage was evaluated at the time of second-look arthroscopy using the ICRS Cartilage Repair Assessment.

RESULTS

The AOFAS ankle-hindfoot scale was significantly improved from 65.1 ± 1.9 points before surgery to 98.1 ± 2.8 points at the time of second-look arthroscopy (p < 0.01). The ICRS Cartilage Repair Assessment was 11.4 points on average (9-12 points).

CONCLUSIONS

The OAT for OLT is considered to be a useful treatment even if invasion by medial malleolus osteotomy is added.

LEVEL OF EVIDENCE

Level IV, Case series.

Cell therapy for cartilage repair

Regenerative medicine, using cells as therapeutic agents for the repair or regeneration of tissues and organs, offers great hope for the future of medicine. Cell therapy for treating defects in articular cartilage has been an exemplar of translating this technology to the clinic, but it is not without its challenges. These include applying regulations, which were designed for pharmaceutical agents, to living cells. In addition, using autologous cells as the therapeutic agent brings additional costs and logistical challenges compared with using allogeneic cells. The main cell types used in treating chondral or osteochondral defects in joints to date are chondrocytes and mesenchymal stromal cells derived from various sources such as bone marrow, adipose tissue or umbilical cord. This review discusses some of their biology and pre-clinical studies before describing the most pertinent clinical trials in this area.

AMIC for traumatic focal osteochondral defect of the talar shoulder: a 5 years follow-up prospective cohort study

BACKGROUND

Autologous Matrix-Induced Chondrogenesis (AMIC) is addressed to osteochondral defects of the talus. However, evidence concerning the midterm efficacy and safety of AMIC are limited. This study assessed reliability and feasibility of AMIC at 60 months follow-up. We hypothesize that AMIC leads to good clinical outcome at midterm follow-up.

METHODS

Surgeries were approached with an arthrotomy via malleolar osteotomy. A resorbable porcine I/III collagen membrane (Chondro-Gide®, Geistlich Pharma AG, Wolhusen, Switzerland) was used. Patients were followed at 24 and 60 months. The primary outcome of interest was to analyse the Foot Function Index (FFI), and the subscale hindfoot of the American Orthopaedic Foot and Ankle Score (AOFAS). Complications such as failure, revision surgeries, graft delamination, and hypertrophy were also recorded. The secondary outcome of interest was to investigate the association between the clinical outcome and patient characteristics at admission.

RESULTS

Data from 19 patients were included. The mean age at admission was 47.3 ± 13.2 years, and the mean BMI 24.1 ± 4.9 kg/m². 53% (10 of 19 patients) were female. At a mean of 66.2 ± 11.6 months, the FFI decreased at 24-months follow-up of 22.5% (P = 0.003) and of further 1.3% (P = 0.8) at 60-months follow-up. AOFAS increased at 24-months follow-up of 17.2% (P = 0.003) and of further 3.4 (P = 0.2) at 60-months follow-up. There were two symptomatic recurrences within the follow-up in two patients. There was evidence of a strong positive association between FFI and AOFAS at baseline and the same scores last follow-up (P = 0.001 and P = 0.0002, respectively).

CONCLUSION

AMIC enhanced with cancellous bone graft demonstrated efficacy and feasibility for osteochondral defects of the talus at five years follow-up. The greatest improvement was evidenced within the first two years. These results suggest that clinical outcome is influenced by the preoperative status of the ankle. High quality studies involving a larger sample size are required to detect seldom complications and identify prognostic factors leading to better clinical outcome.

LEVEL OF EVIDENCE

II, prospective cohort study.

Outcomes of arthroscopic bone graft transplantation for Hepple stage V osteochondral lesions of the talus

Background

Based on MRI imaging findings, osteochondral lesions of the talus (OLT) can be classified into five stages, in which stage V represents OLT with subchondral cyst formation. The aim of this study was to evaluate the outcomes of patients undergoing arthroscopic transplantation of calcaneus bone graft for Hepple stage V OLT.

Methods

This retrospective study included 24 patients with Hepple stage V OLT (15 men and 9 women), with an average age of 39.8±12.9 years old. The mean follow-up period was 18.9±11.8 months. At this follow-up, all patients were clinically evaluated using the American Orthopedic Foot and Ankle Society (AOFAS) score, the Karlsson Ankle Function Score (KAFS), the Tegner score, and the visual analogue scale (VAS). Furthermore, 14 patients underwent MRI imaging examinations, and the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) 2.0 score was assessed.

Results

The AOFAS score, KAFS, Tegner activity score, and VAS pain score (preoperative: 62.2, 60.4, 2.1, and 6.2, respectively; postoperative: 92.8, 88.5, 4.2, and 1.6, respectively) improved significantly (P=0.0001). The MRI-based MOCART score of the articular cartilage repair tissue after surgery was 68±14.8.

Conclusions

Arthroscopic transplantation of calcaneus bone graft for Hepple stage V OLT could obtain satisfying clinical and radiological outcomes in the short-term.

Autologous Matrix Induced Chondrogenesis (AMIC) Compared to Microfractures for Chondral Defects of the Talar Shoulder: A Five-Year Follow-Up Prospective Cohort Study

Introduction: Many procedures are available to manage cartilage defects of the talus, including microfracturing (MFx) and Autologous Matrix Induced Chondrogenesis (AMIC). Whether AMIC or MFx are equivalent for borderline sized defects of the talar shoulder is unclear. Thus, the present study compared the efficacy of primary isolated AMIC versus MFx for borderline sized focal unipolar chondral defects of the talar shoulder at midterm follow-up. Methods: Patients undergoing primary isolated AMIC or MFx for focal unipolar borderline sized chondral defects of the talar shoulder were recruited prospectively. For those patients who underwent AMIC, a type I/III collagen resorbable membrane was used. The outcomes of interest were: Visual Analogic Scale (VAS), Tegner Activity Scale, American Orthopedic Foot and Ankle Score (AOFAS). The Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) was assessed by a blinded radiologist, who had not been involved in the clinical management of the patients. Data concerning complication rate and additional procedures were also collected. Results: The mean follow-up was 43.5 months. The mean age of the 70 patients at operation was 32.0 years, with a mean defect size of 2.7 cm². The mean length of hospitalization was shorter in the MFx cohort (p = 0.01). No difference was found between the two cohorts in terms of length of prior surgery symptoms and follow-up, mean age and BMI, sex and side, and defect size. At a mean follow-up of 43.5 months, the AOFAS (p = 0.03), VAS (p = 0.003), and Tegner (p = 0.01) scores were greater in the AMIC group. No difference was found in the MOCART score (p = 0.08). The AMIC group evidenced lower rates of reoperation (p = 0.008) and failure (p = 0.003). Conclusion: At midterm follow-up, AMIC provides better results compared to MFx.

Talar OsteoPeriostic grafting from the Iliac Crest (TOPIC) for large medial talar osteochondral defects : Operative technique

Objective

Provision of a natural scaffold, good quality cells, and growth factors in order to facilitate the replacement of the complete osteochondral unit with matching talar curvature for large medial primary and secondary osteochondral defects of the talus.

Indications

Symptomatic primary and secondary medial osteochondral defects of the talus not responding to conservative treatment; anterior–posterior or medial–lateral diameter >10 mm on computed tomography (CT); closed distal tibial physis in young patients.

Contraindications

Tibiotalar osteoarthritis grade III; multiple osteochondral defects on the medial, central, and lateral talar dome; malignancy; active infectious ankle joint pathology.

Surgical technique

A medial distal tibial osteotomy is performed, after which the osteochondral defect is excised in toto from the talar dome. The recipient site is microdrilled in order to disrupt subchondral bone vessels. Then, the autograft is harvested from the ipsilateral iliac crest with an oscillating saw, after which the graft is adjusted to an exact fitting shape to match the extracted osteochondral defect and the talar morphology as well as curvature. The graft is implanted with a press-fit technique after which the osteotomy is reduced with two 3.5 mm lag screws and the incision layers are closed. In cases of a large osteotomy, an additional third tubular buttress plate is added, or a third screw at the apex of the osteotomy.

Postoperative management

Non-weight bearing cast for 6 weeks, followed by another 6 weeks with a walking boot. After 12 weeks, a CT scan is performed to assess consolidation of the osteotomy and the inserted autograft. The patient is referred to a physiotherapist.

Results

Ten cases underwent the TOPIC procedure, and at 1 year follow-up all clinical scores improved. Radiological outcomes showed consolidation of all osteotomies and all inserted grafts showed consolidation. Complications included one spina iliaca anterior avulsion and one hypaesthesia of the saphenous nerve; in two patients the fixation screws of the medial malleolar osteotomy were removed.

Open reconstruction with autologous spongiosa grafts and matrix-induced chondrogenesis for osteochondral lesions of the talus can be performed without medial malleolar osteotomy

PURPOSE

To evaluate complication rates and postoperative outcomes in patients with osteochondral lesions of the talus who underwent an autologous matrix-induced chondrogenesis (AMIC) procedure with autologous spongiosa grafting without malleolar osteotomy.

METHODS

A total of 23 patients with a mean age of 35.6 ± 13.9 years were included in this study. The mean follow-up was 33.5 ± 10.4 months (range 24-52.9 months). The clinical outcomes were evaluated using the visual analog scale (VAS) and the Foot Function Index (FFI). Postoperatively, lesion healing was assessed using the magnetic resonance observation of cartilage repair tissue (MOCART) protocol.

RESULTS

There were no intraoperative or perioperative complications. In one patient, arthroscopic arthrolysis was performed due to painful arthrofibrosis. The mean VAS significantly decreased from 7.6 ± 1.1 (range 4.2-9.3) to 1.4 ± 2.2 (range 0-7.4) (P < 0.001). The mean FFI significantly improved from 46.8 ± 14.3 (range 24.3-80.8) to 15.9 ± 11.4 (range 10.0-51.7) (P < 0.001). The mean MOCART score at 1-year follow-up was 74.1 ± 12.4 (range 50-95). Both preoperative and postoperative pains were significantly higher for smokers when compared to non-smokers.

CONCLUSIONS

The results of the present study study indicate that AMIC procedure can be performed through the anterolateral and anteromedial arthrotomy without malleolar osteotomy. Thus, the possible complications associated with malleolar osteotomy can be avoided. The AMIC procedure without a malleolar osteotomy can be considered a safe and reliable procedure in patients with osteochondral lesions localized anterior to the midline in the sagittal plane.

LEVEL OF EVIDENCE

Therapeutic case series, Level IV.

Scaffold-Based Therapies: Proceedings of the International Consensus Meeting on Cartilage Repair of the Ankle

BACKGROUND

The evidence supporting best practice guidelines in the field of cartilage repair of the ankle are based on both low quality and low levels of evidence. Therefore, an international consensus group of experts was convened to collaboratively advance toward consensus opinions based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article is to report the consensus statements on "Scaffold-Based Therapies" developed at the 2017 International Consensus Meeting on Cartilage Repair of the Ankle.

METHODS

Seventy-five international experts in cartilage repair of the ankle representing 25 countries and 1 territory were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within 11 working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed upon in unanimous fashion within the working groups. A final vote was then held, and the strength of consensus was characterized as follows: consensus, 51% to 74%; strong consensus, 75% to 99%; unanimous, 100%.

RESULTS

A total of 9 statements on scaffold-based therapies reached consensus during the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. One achieved unanimous support, 8 reached strong consensus (greater than 75% agreement), and 1 was removed because of redundancy in the information provided. All statements reached at least 80% agreement.

CONCLUSIONS

This international consensus derived from leaders in the field will assist clinicians with applying scaffold-based therapies as a treatment strategy for osteochondral lesions of the talus.

LEVEL OF EVIDENCE

Level V, expert opinion.

No superior treatment for primary osteochondral defects of the talus

PURPOSE

The purpose of this systematic literature review is to detect the most effective treatment option for primary talar osteochondral defects in adults.

METHODS

A literature search was performed to identify studies published from January 1996 to February 2017 using PubMed (MEDLINE), EMBASE, CDSR, DARE, and CENTRAL. Two authors separately and independently screened the search results and conducted the quality assessment using the Newcastle-Ottawa Scale. Subsequently, success rates per separate study were calculated. Studies methodologically eligible for a simplified pooling method were combined.

RESULTS

Fifty-two studies with 1236 primary talar osteochondral defects were included of which forty-one studies were retrospective and eleven prospective. Two randomised controlled trials (RCTs) were identified. Heterogeneity concerning methodological nature was observed, and there was variety in reported success rates. A simplified pooling method performed for eleven retrospective case series including 317 ankles in the bone marrow stimulation group yielded a success rate of 82% [CI 78-86%]. For seven retrospective case series investigating an osteochondral autograft transfer system or an osteoperiosteal cylinder graft insertion with in total 78 included ankles the pooled success rate was calculated to be 77% [CI 66-85%].

CONCLUSIONS

For primary talar osteochondral defects, none of the treatment options showed any superiority over others.

LEVEL OF EVIDENCE

IV.

No superior surgical treatment for secondary osteochondral defects of the talus

PURPOSE

The purpose of this systematic review was to identify the most effective surgical treatment for talar osteochondral defects after failed primary surgery.

METHODS

A literature search was conducted to find studies published from January 1996 till July 2016 using PubMed (MEDLINE), EMBASE, CDSR, DARE and CENTRAL. Two authors screened the search results separately and conducted quality assessment independently using the Newcastle-Ottawa scale. Weighted success rates were calculated. Studies eligible for pooling were combined.

RESULTS

Twenty-one studies with a total of 299 patients with 301 talar OCDs that failed primary surgery were investigated. Eight studies were retrospective case series, twelve were prospective case series and there was one randomized controlled trial. Calculated success percentages varied widely and ranged from 17 to 100%. Because of the low level of evidence and the scarce number of patients, no methodologically proper meta-analysis could be performed. A simplified pooling method resulted in a calculated mean success rate of 90% [CI 82-95%] for the osteochondral autograft transfer procedure, 65% [CI 46-81%] for mosaicplasty and 55% [CI 40-70%] for the osteochondral allograft transfer procedure. There was no significant difference between classic autologous chondrocyte implantation (success rate of 59% [CI 39-77%]) and matrix-associated chondrocyte implantation (success rate of 73% [CI 56-85%]).

CONCLUSIONS

Multiple surgical treatments are used for talar OCDs after primary surgical failure. More invasive methods are administered in comparison with primary treatment. No methodologically proper meta-analysis could be performed because of the low level of evidence and the limited number of patients. It is therefore inappropriate to draw firm conclusions from the collected results. Besides an expected difference in outcome between the autograft transfer procedure and the more extensive procedures of mosaicplasty and the use of an allograft, neither a clear nor a significant difference between treatment options could be demonstrated. The need for sufficiently powered prospective investigations in a randomized comparative clinical setting remains high. This present systematic review can be used in order to inform patients about expected outcome of the different treatment methods used after failed primary surgery.

LEVEL OF EVIDENCE

IV.

Biological reconstruction of large osteochondral lesions of the talar dome with a modified "sandwich" technique-Midterm results

BACKGROUND

Surgical treatment for large osteochondral lesions of the talar dome (OLTD) must restore the convexity and curvature of the talus. Here, we present midterm results and describe the modified "sandwich" reconstruction procedure. Bone defects were restored using a biological inlay consists of autologous bone chips that were mixed with bone marrow concentrate and fibrin glue and covered with a xenogeneic collagen membrane infiltrated with bone marrow concentrate and stabilized by fibrin glue.

METHODS

Ten patients who were treated using a modified "sandwich" OLTD reconstruction were assessed after an average follow-up period of 46.4 (±18) months, using the clinical American Orthopaedic Foot and Ankle Society Ankle Hindfoot Scale (AOFAS) score and radiological magnetic resonance observation of cartilage repair tissue (MOCART) score.

RESULTS

The mean AOFAS score increased significantly from 58.3 (±8.5) points to 81.8 (±15.5) points as well the mean VAS score reduced significantly from 5.58 (±0.97) to 1.83 (±0.93) points. The average MOCART score was 69.5% (±16.7%) in the final follow-up.

CONCLUSIONS

The presented modified "sandwich" technique permanently recreates the convexity and curvature in large osteochondral lesions of the talar dome with a single step surgical procedure.

Scaffolds based therapy for osteochondral lesions of the talus: A systematic review

AIM

To clarify the effectiveness of scaffold-based therapy for osteochondral lesions of the talus (OLT).

METHODS

A systematic search of MEDLINE and EMBASE databases was performed during August 2016 and updated in January 2017. Included studies were evaluated with regard to the level of evidence (LOE) and quality of evidence (QOE) using the Modified Coleman Methodology Score. Variable reporting outcome data, clinical outcomes, and the percentage of patients who returned to sport at previous level were also evaluated.

RESULTS

Twenty-eight studies for a total of 897 ankles were included; 96% were either LOE III or IV. Studies were designated as either of poor or fair quality. There were 30 treatment groups reporting six different scaffold repair techniques: 13 matrix-induced autologous chondrocyte transplantation (MACT), nine bone marrow derived cell transplantation (BMDCT), four autologous matrix-induced chondrogeneis (AMIC), and four studies of other techniques. The categories of general demographics (93%) and patient-reported outcome data (85%) were well reported. Study design (73%), imaging data (73%), clinical variables (49%), and patient history (30%) were also included. The weighted mean American Orthopaedic Foot and Ankle Society (AOFAS) score at final follow-up was: 86.7 in MACT, 88.2 in BMDCT, and 82.3 in AMIC. Eight studies reported that a weighted mean of 68.3% of patients returned to a previous level of sport activity.

CONCLUSION

Scaffold-based therapy for OLT may produce favorable clinical outcomes, but low LOE, poor QOE, and variability of the data have confounded the effectiveness of this treatment.

Osteochondral Autograft and Allograft Transplantation in the Talus

Large, symptomatic, focal chondral, and osteochondral lesions of the ankle are treated with osteochondral autograft/allograft transplantation (OAT) procedure, a reconstructive bone grafting technique that uses one or more cylindrical osteochondral grafts from an area of low impact or allograft source and transplants them into the prepared defect site on the talus. This technique allows defects to be filled with mature, hyaline articular cartilage. Acute or chronic chondral or osteochondral lesions can be debilitating; provided here is a review of osteochondral autograft or allograft transplantation. OAT shows a trend toward greater longevity and durability and improved outcomes in high-demand patients.

Novel curved surface preparation technique for knee resurfacing

Conventional tools are incapable of preparing the curved articular surface geometry required during cartilage repair procedures. A novel curved surface preparation technique was proposed and tested to provide an accurate low-cost solution. Three shapes of samples, with flat, 30 mm radius and 60 mm radius surfaces, were manufactured from foam bone substitute for testing. Registering guides and cutting guides were designed and 3-D printed to fit onto the foam samples. A rotational cutting tool with an adapter was used to prepare the surfaces following the guidance slots in the cutting guides. The accuracies of the positions and shapes of the prepared cavities were measured using a digital calliper, and the surface depth accuracy was measured using a 3-D scanner. The mean shape and position errors were both approximately ± 0.5 mm and the mean surface depth error ranged from 0 to 0.3 mm, range - 0.3 to + 0.45 mm 95% CI. This study showed that the technique was able to prepare a curved surface accurately; with some modification it can be used to prepare the knee surface for cartilage repair.

Treatment of osteochondral lesions of the talus with autologous collagen-induced chondrogenesis: clinical and magnetic resonance evaluation at one-year follow-up

PURPOSE

the aim of this study is to report the clinical and imaging results recorded by a series of patients in whom osteochondral lesions of the talus (OLTs) were repaired using the autologous collagen-induced chondrogenesis (ACIC) technique with a completely arthroscopic approach.

METHODS

nine patients (mean age 37.4±10 years) affected by OLTs (lesion size 2.1±0.9 cm(2)) were treated with the ACIC technique. The patients were evaluated clinically both preoperatively and at 12 months after surgery using the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale (AOFAS) and a visual analog scale (VAS). For morphological evaluation, the magnetic resonance observation of cartilage repair tissue (MOCART) score was used.

RESULTS

the AOFAS score improved from 51.4±11.6 preoperatively to 71.8±20.6 postoperatively, while the VAS value decreased from 6.9±1.8 to 3.2±1.9. The mean MOCART score was 51.7±16.6 at 12 months of follow-up; these scores did not directly correlate with the clinical results.

CONCLUSION

use of the ACIC technique for arthroscopic repair of OLTs allowed satisfactory clinical results to be obtained in most of the patients as soon as one year after surgery, with no major complications or delayed revision surgery. ACIC is a valid and low-invasive surgical technique for the treatment of chondral and osteochondral defects of the talus.

LEVEL OF EVIDENCE

therapeutic case series, level IV.

Diagnosis and treatment of osteochondral lesions of the ankle: current concepts

We conducted a wide-ranging review of the literature regarding osteochondral lesions of the ankle, with the aim of presenting the current concepts, treatment options, trends and future perspectives relating to this topic.

Medial malleolar osteotomy for the treatment of talar osteochondral lesions: anatomical and morbidity considerations

PURPOSE

Osteochondral lesions of the talus are often located posteromedially requiring open surgery to facilitate solid and complete osteochondral reconstruction. The aim of the study was to identify the optimal anatomical site for medial malleolar osteotomy based on the criteria of minimal cartilage damage (Study I) and to report on the morbidity in patients receiving osteotomy performed at the previously identified site (Study II).

METHODS

For Study I, cartilage coverage of the tibiofibular ankle joint facet was measured in 40 cadaveric ankles (20 cadaver specimens). In Study II, we assessed clinical (VAS pain score, AOFAS score, range of motion) and radiological outcome measures (SPECT-CT) in 17 patients (mean age, 36.8 ± 10.8 years) undergoing medial malleolar osteotomy.

RESULTS

The medial edge in the transition zone of the tibial plafond to the medial malleolus showed less than 75 % of cartilage coverage in 62.5 % of cadavers (Study I). Surgery resulted in lower pain levels (2.4 ± 2.6 compared with 6.3 ± 1.8 points; p < 0.001) and greater AOFAS scores (82.9 ± 14.1 compared with 43.5 ± 10.8 to points; p < 0.001) compared with baseline (Study II). No signs of intra-operative damage or mal- or non-union were found. Long-term morbidity was found in one patient. Implant removal was necessary in 12 of 17 patients (71 %).

CONCLUSION

Anatomically, there is an optimal location for the medial malleolar osteotomy at the medial ankle edge involving minimal cartilage damage. Clinical results using this location showed no short- or mid-term morbidity and little long-term morbidity. However, many patients required re-intervention for implant removal.

LEVEL OF EVIDENCE

IV.

Repair of osteochondral defects in the minipig model by OPF hydrogel loaded with adipose-derived mesenchymal stem cells

AIM

Critical knee osteochondral defects in seven adult minipigs were treated with oligo(polyethylene glycol)fumarate (OPF) hydrogel combined with autologous or human adipose-derived stem cells (ASCs), and evaluated after 6 months.

METHODS

Four defects were made on the peripheral part of right trochleas (n = 28), and treated with OPF scaffold alone or pre-seeded with ASCs.

RESULTS

A better quality cartilage tissue characterized by improved biomechanical properties and higher collagen type II expression was observed in the defects treated by autologous or human ASC-loaded OPF; similarly this approach induced the regeneration of more mature bone with upregulation of collagen type I expression.

CONCLUSION

This study provides the evidence that both porcine and human adipose-derived stem cells associated to OPF hydrogel allow improving osteochondral defect regeneration in a minipig model.

Low Level of Evidence and Methodologic Quality of Clinical Outcome Studies on Cartilage Repair of the Ankle

PURPOSE

To examine the level of evidence and methodologic quality of studies reporting surgical treatments for osteochondral lesions of the ankle.

METHODS

A search was performed using the PubMed/Medline, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Cochrane databases for all studies in which the primary objective was to report the outcome after surgical treatment of osteochondral lesions of the ankle. Studies reporting outcomes of microfracture, bone marrow stimulation, autologous osteochondral transplantation, osteochondral allograft transplantation, and autologous chondrocyte implantation were the focus of this analysis because they are most commonly reported in the literature. Two independent investigators scored each study from 0 to 100 based on 10 criteria from the modified Coleman Methodology Score (CMS) and assigned a level of evidence using the criteria established by the Journal of Bone and Joint Surgery. Data were collected on the study type, year of publication, number of surgical procedures, mean follow-up, preoperative and postoperative American Orthopaedic Foot & Ankle Society score, measures used to assess outcome, geography, institution type, and conflict of interest.

RESULTS

Eighty-three studies reporting the results of 2,382 patients who underwent 2,425 surgical procedures for osteochondral lesions of the ankle met the inclusion criteria. Ninety percent of studies were of Level IV evidence. The mean CMS for all scored studies was 53.6 of 100, and 5 areas were identified as methodologically weak: study size, type of study, description of postoperative rehabilitation, procedure for assessing outcome, and description of the selection process. There was no significant difference between the CMS and the type of surgical technique (P = .1411). A statistically significant patient-weighted correlation was found between the CMS and the level of evidence (r = -0.28, P = .0072). There was no statistically significant patient-weighted correlation found between the CMS and the institution type (r = 0.05, P = .6480) or financial conflict of interest (r = -0.16, P = .1256).

CONCLUSIONS

Most studies assessing the clinical outcomes of cartilage repair of the ankle are of a low level of evidence and of poor methodologic quality.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I through IV studies.

Viability of talus osteochondral defect cartilage for chondrocyte harvesting: results of 151 patients

BACKGROUND

Large talar cartilage defects can be treated with either autologous chondrocyte implantation or matrix autologous chondrocyte implantation. Both techniques depend on successful harvesting of the chondrocytes. In the past, they have come from the ipsilateral knee, which has been associated with donor site morbidity. We hypothesized that damaged cartilage from the talus can be used as a reliable source for chondrocyte cell harvesting in preparation for possible matrix-induced autologous chondrocyte implantation (MACI).

METHODS

Chondrocytes were harvested from the injured talar cartilage during ankle arthroscopy and sent to a cell laboratory, measured for initial biopsy weight, cultured for 4 to 6 weeks, and then analyzed for viability. A total of 151 patients were analyzed.

RESULTS

The average biopsy initial weight was 187.1 mg. The average number of cells was 3.13 × 10(5). The viability of the chondrocytes provided by the manufacturer averaged 92.3% (range, 33%-100%).

CONCLUSIONS

Chondrocytes harvested from the damaged talar articular cartilage were functional and proliferated with an average viability of 92%.

CLINICAL RELEVANCE

This technique may provide a useful source of chondrocytes if needed for a future cell-based regenerative procedure such as MACI while eliminating the need to harvest chondrocytes from the knee or other intact areas of cartilage on the talus.

LEVEL OF EVIDENCE

Level IV, case series.

[Malleolar osteotomy--osteotomy as approach]

Both arthroscopic and open surgical techniques may be used for treatment of osteochondral lesions of the ankle joint. Osteotomy around the ankle joint is a well established technique to extend the approach in cases where the osteochondral lesions are located more posteriorly. Medial, oblique, monoplanar malleolar osteotomy should be used in patients with lesions of the medial talus shoulder. The posterolateral ostechondral lesions are less frequent and in such cases distal fibular osteotomy is recommended. In this study the indications for different forms of osteotomy are discussed and the surgical techniques are described.