All-arthroscopic AMIC® (AT-AMIC®) technique with autologous bone graft for talar osteochondral defects: clinical and radiological results

Scaffolds for Osteochondral Lesions of the Talus: Systematic Review and Meta-Analysis of the Last Ten Years Literature

Scaffolds are widely used devices for the treatment of osteochondral lesions of the talus (OCLT), aimed at enhancing mechanical stability and fostering chondrogenic differentiation. A systematic review and meta-analysis were performed to evaluate the safety, and clinical and radiological results of scaffolds for OCLT management. On 2 January 2024, a search was performed in four databases (PubMed, Embase, Web of Science, and Scopus), according to PRISMA guidelines. The risk of bias in the included studies was also evaluated. Thirty clinical studies were included in the qualitative analysis: 12 retrospective case series, 3 retrospective comparative studies, 9 prospective case series, 1 prospective comparative study, and 1 Randomized Controlled Trial (RCT). Natural scaffolds, such as bilayer collagen (COLL)I/III and hyaluronic scaffolds, were the most employed. Only minor adverse events were observed, even if more serious complications were shown, especially after medial malleolar osteotomy. An overall clinical and radiological improvement was observed after a mean of 36.3 months of follow-up. Patient age and Body Mass Index (BMI), lesion size, and location were correlated with the clinical outcomes, while meta-analysis revealed significant improvement in clinical scores with hyaluronic scaffolds compared to microfracture alone. This study highlights the safety and positive clinical outcomes associated with the use of scaffolds for OCLT. In the few available comparative studies, scaffolds have also demonstrated superior clinical outcomes compared to microfractures alone. Nevertheless, the analysis has shown the limitations of the current literature, characterized by an overall low quality and scarcity of RCTs.

The efficacy of autologous matrix-induced chondrogenesis (AMIC) for osteochondral lesions of the talus in the mid-long term: a systematic review and meta-analysis

PURPOSE

The objective of this study was to provide a comprehensive review of the existing literature regarding the treatment of osteochondral lesions of the talus (OLT) using autologous matrix-induced chondrogenesis (AMIC), while also discussing the mid-long term functional outcomes, complications, and surgical failure rate.

METHODS

We searched Embase, PubMed, and Web of Science for studies on OLT treated with AMIC with an average follow-up of at least 2 years. Publication information, patient data, functional scores, surgical failure rate, and complications were extracted.

RESULTS

A total of 15 studies were screened and included, with 12 case series selected for meta-analysis and 3 non-randomized controlled studies chosen for descriptive analysis. The improvements in the Visual Analog Scale (VAS), the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot, and Tegner scores at the last follow-up were (SMD = - 2.825, 95% CI - 3.343 to  - 2.306, P < 0.001), (SMD = 2.73, 95% CI 1.60 to 3.86, P < 0.001), (SMD = 0.85, 95% CI 0.5 to 1.2, P < 0.001) respectively compared to preoperative values. The surgery failure rate was 11% (95% CI 8-15%), with a total of 12 patients experiencing complications.

CONCLUSION

The use of AMIC demonstrates a positive impact on pain management, functional improvement, and mobility enhancement in patients with OLT. It is worth noting that the choice of stent for AMIC, patient age, and OLT size can influence the ultimate clinical outcomes. This study provides evidences supporting the safety and efficacy of AMIC as a viable treatment option in real-world medical practice.

Regeneration: AT-AMIC Technique: Limits and Indication

Osteochondral lesion of the talus (OLT) is a commune cause of chronic ankle pain. Symptomatic lesions require surgical treatment. Currently, lesions with diameter less than 107.4 mm2 are treated with bone marrow stimulating technique with notable success rate. However, more extensive lesions show less predictable surgical results. Autologous matrix-induced chondrogenesis has proven to provide satisfactory medium and long-term results on OLTs. In the current review, we describe an all-arthroscopic technique and the Milan-Tel Aviv lesion assessment protocol.

Significant Clinical Improvement After Arthroscopic Autologous Matrix-Induced Chondrogenesis for Osteochondral Lesions of the Talus: A 5-Year Follow-Up

PURPOSE

This study aims to evaluate the clinical outcomes of arthroscopic autologous matrix-induced chondrogenesis (A-AMIC) for osteochondral lesions of the talus (OLT) at 24 months and 60 months of follow-up. The secondary aim was to assess whether age, body mass index (BMI), and lesion surface affect outcomes.

DESIGN

Sixty-three patients (32 males, 31 females) with a median age of 37 years [interquartile range (IQR): 25-48] were included. Preoperative and postoperative (24 months and 60 months) clinical outcomes were evaluated using a Visual Analog Score (VAS) for pain during walking, the American Orthopaedic Foot and Ankle Society (AOFAS), Short-Form Survey (SF-12), the Halasi, and the University of California, Los Angeles (UCLA) scores. Patients were categorized according to age, BMI, and lesion surface (1-1.5 cm2 and over 1.5 cm2). The effect of each category was evaluated.

RESULTS

There were significant improvements in the VAS, AOFAS, SF-12, and UCLA, comparing the preoperative scores to the 60-month follow-up scores (P < 0.001). There were no significant differences in the above-mentioned outcomes between the follow-up periods. Patients older than 33 years had lower SF-12, Halasi, and UCLA scores (P = 0.005, 0.004, and <0.001, respectively). Overweight patients had lower VAS, SF-12, Halasi, and UCLA scores (P = 0.006, 0.002, 0.024, and 0.007, respectively). Lesion size was uninfluential.

CONCLUSION

A-AMIC yielded clinical improvements at a minimum follow-up of 60 months in patients with symptomatic OLTs, with clinical improvement peaking in the first 2 years, followed by a plateau period. Increased age and BMI were significantly associated with inferior outcomes.

Operative management of osteochondral lesions of the talus: 2024 recommendations of the working group 'clinical tissue regeneration' of the German Society of Orthopedics and Traumatology (DGOU)

The working group 'Clinical Tissue Regeneration' of the German Society of Orthopedics and Traumatology (DGOU) issues this paper with updating its guidelines. Literature was analyzed regarding different topics relevant to osteochondral lesions of the talus (OLT) treatment. This process concluded with a statement for each topic reflecting the best scientific evidence available with a grade of recommendation. All group members rated the statements to identify possible gaps between literature and current clinical practice. Fixation of a vital bony fragment should be considered in large fragments. In children with open physis, retrograde drilling seems to work better than in adults, but even there, the revision rate reaches 50%. The literature supports debridement with bone marrow stimulation (BMS) in lesions smaller than 1.0 cm² without bony defect. The additional use of a scaffold can be recommended in lesions larger than 1.0 cm². For other scaffolds besides AMIC®/Chondro-Gide®, there is only limited evidence. Systematic reviews report good to excellent clinical results in 87% of the patients after osteochondral transplantation (OCT), but donor site morbidity is of concern, reaching 16.9%. There is no evidence of any additional benefit from autologous chondrocyte implantation (ACI). Minced cartilage lacks any supporting data. Metallic resurfacing of OLT can only be recommended as a second-line treatment. A medial malleolar osteotomy has a minor effect on the clinical outcome compared to the many other factors influencing the clinical result.

Mid-term results of autologous matrix-induced chondrogenesis surgery with or without scaffolds for arthroscopic treatment of deep talus osteochondral lesions: A comparative study

OBJECTIVES

This study aims to investigate the effectiveness of arthroscopic autologous matrix-induced chondrogenesis (AMIC) procedure with or without polyglycolic acid-hyaluronic acid (PGA-HA)-based cell-free scaffold (CFS) in Bristol Stage 4 and Stage 5 osteochondral lesion of the talus (OLT) ranging between 1.5 and 3 cm2 .

PATIENTS AND METHODS

Between March 2018 and March 2021, a total of 47 patients with OLTs (29 males, 18 females; mean age: 22.8±2.3 years; range, 18 to 65 years) were retrospectively analyzed. The patients were divided into two groups based on the procedures applied. Patients in the first group (Group 1, n=23) underwent the AMIC procedure alone (curettage, microfracture, and grafting), while patients in the second group (Group 2, n=24) underwent AMIC procedure with PGA-HA-based CFS. The localization of the lesions was evaluated. All OLTs were diagnosed with preoperative radiography and magnetic resonance imaging (MRI). During the preoperative period, lesion stages were evaluated based on the Bristol staging system, and the postoperative results were evaluated based on the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) scoring system.

RESULTS

The mean follow-up was 36.2±5.6 months. In the early period, the three-month functional scores were comparable between the groups. While a significant increase was observed in the American Orthopaedic Foot and Ankle Society (AOFAS) scores from the mean preoperative of 62.71±4.44 points to the postoperative of 86.00±6.58 points in Group 1, a significant increase in the AOFAS score was observed from 65.28±7.91 points to 95.42±4.41 points in Group 2 at 12-month follow-up (p=0.016, p=0.011, respectively). The functional scores tended to progress after 12 months. Radiologically, a complete defect filling was observed in a mean of 10.5±2.7 months. No graft hypertrophy was recorded in any patients. The AOFAS and MOCART scores in Group 2 were found to be statistically significantly higher than that in Group 1 (p=0.034 for AOFAS 1/AOFAS 2 and p=0.006 for MOCART 1/MOCART 2). Overall, there was a positive, but weak, significant correlation between the final AOFAS scores and MOCART scores (r=0.347, p<0.001).

CONCLUSION

Arthroscopic AMIC procedure in deep OLTs between 1.5 cm2 and 3 cm2 can yield a statistically significant improvement both clinically and radiologically; however, the use of a PGA-HA-based CFS in addition to this procedure can improve the clinical and radiological recovery.

Epidemiology and Trends in Cartilage Surgery of the Foot and Ankle in Germany: An Analysis of National Healthcare Billing and Reporting Data from 2006 to 2020

Background and objectives: Cartilage surgery constitutes a standard intervention in foot and ankle procedures. Currently, there is a lack of epidemiological data on its frequency, age distribution, and surgical options for cartilage surgery. This study aimed to investigate the current landscape of cartilage surgery in Germany and identify the most common procedures from an epidemiological standpoint. Materials and methods: Medical billing and reporting data from the Federal Statistical Office of Germany, encompassing the period 2006-2020, was examined, including all foot and ankle cartilage surgical procedures (summarized under OPS codes 5-812 and 5-801). The dataset incorporated information on the affected joint, patient age and sex, and surgery type. Each surgical procedure was categorized as "debridement", "regeneration" or "refixation". Linear and nonlinear regression analyses were employed, with a statistical significance threshold of 0.05. Results: From the total of 136,501 procedures conducted during the study period, the most frequently performed interventions were microfracture (58,252) and chondroplasty (56,135), and thus, debridement procedures were in the leading position. The use of acellular membranes was the most used regenerative technique (n = 11,414). At the ankle joint, interventions were mostly arthroscopic and in men, while foot cartilage surgeries were preferably performed via open surgery and mostly in women. Age distribution analysis revealed two primary peaks: the first in the 20-25-year-old group (ankle and foot) and the second in the 45-50-year-old group (ankle) and 55-60-year-old group (foot). Refixation and regenerative procedures were more frequent among younger individuals, while debriding procedures were more frequent among older individuals. Regenerative procedures, particularly in the ankle, significantly increased over time. Conclusions: Cartilage surgery of the foot and ankle was common, with two primary age groups predominantly affected. Notably, recent years have witnessed a considerable rise in cartilage regenerative procedures.

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.

Ankle Sprains in Athletes: Current Epidemiological, Clinical and Imaging Trends

Purpose

Ankle injuries are frequent sports injuries. Despite optimizing treatment strategies during recent years, the percentage of chronification following an ankle sprain remains high. The purpose of this review article is, to highlight current epidemiological, clinical and novel advanced cross-sectional imaging trends that may help to evaluate ankle sprain injuries.

Methods

Systematic PubMed literature research. Identification and review of studies (i) analyzing and describing ankle sprain and (ii) focusing on advanced cross-sectional imaging techniques at the ankle.

Results

The ankle is one of the most frequently injured body parts in sports. During the COVID-19 pandemic, there was a change in sporting behavior and sports injuries. Ankle sprains account for about 16-40% of the sports-related injuries. Novel cross-sectional imaging techniques, including Compressed Sensing MRI, 3D MRI, ankle MRI with traction or plantarflexion-supination, quantitative MRI, CT-like MRI, CT arthrography, weight-bearing cone beam CT, dual-energy CT, photon-counting CT, and projection-based metal artifact reduction CT may be introduced for detection and evaluation of specific pathologies after ankle injury. While simple ankle sprains are generally treated conservatively, unstable syndesmotic injuries may undergo stabilization using suture-button-fixation. Minced cartilage implantation is a novel cartilage repair technique for osteochondral defects at the ankle.

Conclusion

Applications and advantages of different cross-sectional imaging techniques at the ankle are highlighted. In a personalized approach, optimal imaging techniques may be chosen that best detect and delineate structural ankle injuries in athletes.

Typical Complications After Cartilage Repair of the Ankle Using Autologous Matrix-Induced Chondrogenesis (AMIC)

Background:

Autologous matrix-induced chondrogenesis (AMIC) for the treatment of osteochondral lesions of the talus (OLT) results in favorable clinical outcomes, yet high reoperation rates. The aim of this study was to report and analyze typical complications and their risk factors after AMIC for OLT.

Methods:

A total of 127 consecutive patients with 130 AMIC procedures for OLT were retrospectively assessed. All AMIC procedures were performed in an open fashion with 106 (81.5%) cases requiring a malleolar osteotomy (OT) to access the OLT. Seventy-one patients (54.6%) underwent subsequent surgery. These cases were evaluated at a mean follow-up of 3.1 years (±2.5) for complications reviewing postoperative imaging and intraoperative findings during revision surgery. Six patients (8.5%) were lost to follow-up. Regression model analysis was conducted to identify factors that were associated with AMIC-related complications.

Results:

Among the 65 (50%) patients who required revision surgery, 18 patients (28%) demonstrated AMIC-related complications with deep fissuring (83%) and thinning (17%) of the AMIC graft. Conversely, 47 patients (72%) underwent subsequent surgery due to AMIC-unrelated reasons including isolated removal of symptomatic hardware (n = 17) and surgery addressing concomitant pathologies with (n = 25) and without hardware removal (n = 5). Previous prior cartilage repair surgery was significantly associated with AMIC graft-associated complications in patients undergoing revision surgery ( P = .0023). Among age, body mass index, defect size, smoking, and bone grafting, smoking was the only factor showing statistical significance with an odds ratio of 3.7 (95% CI 1.24, 10.9; P = .019) to undergo revision surgery due to graft-related complications, when adjusted for previous cartilage repair surgery.

Conclusion:

The majority of revision surgeries after AMIC for OLT are unrelated to the performed AMIC graft but frequently address symptomatic hardware and concomitant pathologies. Both smoking and previous cartilage repair surgery seem to significantly increase the risk of undergoing revision surgery due to AMIC-related complications.

Level of evidence:

Level IV, case series.

Collagen Scaffold Application in Arthroscopic Reconstruction of Osteochondral Lesions of the Talus With Autologous Cancellous Bone Grafts

Background

Single-step all-arthroscopic techniques have gained popularity recently in the treatment of osteochondral lesions of the talus (OLT). Concomitant subchondral bone defects led surgeons to add autologous bone grafting to the surgical procedures. Collagen scaffolds have been used widely for stabilization of the reconstruction and regeneration of the articular surface.

Purpose

To compare single-step all-arthroscopic treatment of OLT consisting of debridement, microfracture, autologous bone grafting, and application of fibrin sealant in 2 patient groups: with versus without collagen scaffold.

Study Design

Cohort study; Level of evidence, 3.

Methods

Included were 94 patients who underwent single-step all-arthroscopic treatment for OLT. Autologous bone grafting was applied to 48 patients (BG group), while autologous bone grafting plus collagen scaffold was applied to 46 patients (BG+S group). A fibrin sealant was applied to both groups. Clinical outcomes were assessed with the American Orthopaedic Foot & Ankle Society (AOFAS) score and the visual analog scale (VAS) for pain. Radiological outcomes were evaluated with the magnetic resonance observation of cartilage repair tissue score. The mean follow-up time was 69.3 ± 20.7 months.

Results

Patients in both groups showed statistically significant improvement in pre- to postoperative AOFAS and VAS scores (P < .001 for all), with no difference between groups in AOFAS and VAS score improvement. Complete healing with or without hypertrophy was achieved in 42 patients in the BG group (87.5%) and 38 patients in the BG+S group (82.6%).

Conclusion

The treatment of bone lesions in OLT may be the ultimate goal to obtain successful outcomes, in which case using a collagen scaffold besides grafting may not affect clinical and radiological outcomes.

Autologous matrix induced chondrogenesis plus peripheral blood concentrate (AMIC+PBC) in chondral lesions at the ankle as part of a complex surgical approach - 5-year follow-up

BACKGROUND

The aim of the study was to assess 5-year-follow-up (5FU) after Autologous Matrix Induced Chondrogenesis plus Peripheral Blood Concentrate (AMIC+PBC) in chondral lesions at the ankle as part of a complex surgical approach.

METHODS

In a prospective consecutive non-controlled clinical follow-up study, all patients with chondral lesion at the ankle treated with AMIC+PBC from July 17, 2016 to May 31, 2017 were included. Size and location of the chondral lesions, the Visual-Analogue-Scale Foot and Ankle (VAS FA) and the EFAS Score before treatment and at 5FU were analysed and compared with previous 2-year-follow-up (2FU). Peripheral Blood Concentrate (PBC) was used to impregnate a collagen I/III matrix (Chondro-Gide, Wolhusen, Switzerland) that was fixed into the chondral lesion with fibrin glue.

RESULTS

One hundred and twenty-nine patients with 136 chondral lesions were included in the study. The chondral lesions were located as follows (n (%)), medial talar shoulder only, 62 (46); lateral talar shoulder only, 42 (31); medial and lateral talar shoulder, 7 (10); tibia, 18 (13). The average for lesion size was 1.8 cm², for VAS FA 45.7 and for EFAS Score 9.8. 2FU/5FU was completed in 105 (81 %)/104(81 %) patients with 112/111 previous chondral lesions. VAS FA improved to 79.8/84.2 and EFAS Score to 20.3/21.5 (2FU/5FU). No parameter significantly differed 2FU and 5FU.

CONCLUSIONS

AMIC+PBC as part of a complex surgical approach led to improved and high validated outcome scores at 2FU/5FU. 2FU and 5FU did not differ.

Prognostic factors for the management of chondral defects of the knee and ankle joint: a systematic review

Purpose

Different surgical techniques to manage cartilage defects are available, including microfracture (MFx), autologous chondrocyte implantation (ACI), osteoarticular auto- or allograft transplantation (OAT), autologous matrix-induced chondrogenesis (AMIC). This study investigated the patient-related prognostic factors on the clinical outcomes of surgically treated knee and ankle cartilage defects.

Methods

This study followed the PRISMA statement. In May 2022, the following databases were accessed: PubMed, Google Scholar, Embase, and Scopus. All the studies investigating the outcomes of surgical management for knee and/or talus chondral defects were accessed. Only studies performing mesenchymal stem cells transplantation, OAT, MFx, ACI, and AMIC were considered. A multiple linear model regression analysis through the Pearson Product–Moment Correlation Coefficient was used.

Results

Data from 184 articles (8905 procedures) were retrieved. Female sex showed a positive moderate association with visual analogue scale at last follow-up (P = 0.02). Patient age had a negative association with the American Orthopaedic Foot and Ankle Score (P = 0.04) and Lysholm Knee Scoring Scale (P = 0.03). BMI was strongly associated with graft hypertrophy (P = 0.01). Greater values of VAS at baseline negatively correlate with lower values of Tegner Activity Scale at last follow-up (P < 0.0001).

Conclusion

The clinical outcomes were mostly related to the patients’ performance status prior surgery. A greater BMI was associated with greater rate of hypertrophy. Female sex and older age evidenced fair influence, while symptom duration prior to the surgical intervention and cartilage defect size evidenced no association with the surgical outcome. Lesion size and symptom duration did not evidence any association with the surgical outcome.

Autologous Matrix-Induced Chondrogenesis (AMIC) for Osteochondral Defects of the Talus: A Systematic Review

Autologous matrix-induced chondrogenesis (AMIC) has been advocated for the management of talar osteochondral lesions (OCLs). This systematic review, which was conducted according to the PRISMA 2020 guidelines, investigated the clinical and imaging efficacy and safety of the AMIC technique in the management of OCLs of the talus. Only studies investigating AMIC for talar chondral defects that were published in peer-reviewed journals were considered. In September 2022, the following databases were accessed: PubMed, Web of Science, Google Scholar, and Embase. Data on the visual analogue scale (VAS), American Orthopaedic Foot and Ankle Score (AOFAS), Tegner activity scale, and Foot Function Index (FFI) were retrieved. To evaluate the morphological MRI findings, data obtained from the magnetic resonance observation of cartilage repair tissue (MOCART) scores were evaluated. Data on hypertrophy, failures, and revision surgeries were also collected. Data from 778 patients (39% women, 61% men) were collected. The mean length of the follow-up was 37.4 ± 16.1 months. The mean age of the patients was 36.4 ± 5.1 years, and the mean BMI was 26.1 ± 1.6 kg/m2. The mean defect size was 2.1 ± 1.9 cm2. Following the AMIC technique, patients demonstrated an improved VAS (p < 0.001), AOFAS (p < 0.001), and FFI (p = 0.02) score. The MOCART score also improved from the baseline (p = 0.03). No difference was observed in the Tegner score (p = 0.08). No graft delamination and hypertrophy were reported in 353 patients. 7.8% (44 of 564) of patients required revision surgeries, and 6.2% (32 of 515) of patients were considered failures. The AMIC technique could be effective in improving symptoms and the function of chondral defects of the talus.

Nonoperative and Operative Soft-Tissue and Cartilage Regeneration and Orthopaedic Biologics of the Foot and Ankle: An Orthoregeneration Network Foundation Review

Orthoregeneration is defined as a solution for orthopaedic conditions that harnesses the benefits of biology to improve healing, reduce pain, improve function, and optimally, provide an environment for tissue regeneration. Options include drugs, surgical intervention, scaffolds, biologics as a product of cells, and physical and electromagnetic stimuli. The goal of regenerative medicine is to enhance the healing of tissue after musculoskeletal injuries as both isolated treatment and adjunct to surgical management, using novel therapies to improve recovery and outcomes. Various orthopaedic biologics (orthobiologics) have been investigated for the treatment of pathology involving the foot and ankle (including acute traumatic injuries and fractures, tumor, infection, osteochondral lesions, arthritis, and tendinopathy) and procedures, including osteotomy or fusion. Promising and established treatment modalities include 1) bone-based therapies (such as cancellous or cortical autograft from the iliac crest, proximal tibia, and/or calcaneus, fresh-frozen or freeze-dried cortical or cancellous allograft, including demineralized bone matrix putty or powder combined with growth factors, and synthetic bone graft substitutes, such as calcium sulfate, calcium phosphate, tricalcium phosphate, bioactive glasses (often in combination with bone marrow aspirate), and polymers; proteins such as bone morphogenic proteins; and platelet-derived growth factors; 2) cartilage-based therapies such as debridement, bone marrow stimulation (such as microfracture or drilling), scaffold-based techniques (such as autologous chondrocyte implantation [ACI] and matrix-induced ACI, autologous matrix-induced chondrogenesis, matrix-associated stem cell transplantation, particulated juvenile cartilage allograft transplantation, and minced local cartilage cells mixed with fibrin and platelet rich plasma [PRP]); and 3) blood, cell-based, and injectable therapies such as PRP, platelet-poor plasma biomatrix loaded with mesenchymal stromal cells, concentrated bone marrow aspirate, hyaluronic acid, and stem or stromal cell therapy, including mesenchymal stem cell allografts, and adipose tissue-derived stem cells, and micronized adipose tissue injections. LEVEL OF EVIDENCE: Level V, expert opinion.

AMIC Procedure for Treatment of Osteochondral Lesions of Talus-A Systematic Review of the Current Literature

Osteochondral lesions of talus are a common injury where surgery is indicated in case of failed non-operative treatment or displaced lesions. Many studies have been conducted on the effectiveness of the AMIC procedure. The goal of our study is to create an overview of the current literature. A systematic search adhering to the PRISMA guidelines was conducted in PubMed (MEDLINE) and EMBASE on May 27, 2020. All included studies were evaluated according to the modified Coleman Methodology Score and information on study type, patient numbers, age, follow-up period, grade, location and size of the lesion, study in- and exclusion criteria, associated surgery, surgical technique, scaffold- and fixation technique, postoperative restrictions, reoperation rates, study outcome score, rehabilitation program, and surgical complications was extracted. Ninety-six studies were identified with 18 studies being included in our analysis. The overall quality of the literature was fair with no studies being graded as excellent. Data on preoperative evaluation and surgical technique, complication and reoperation rates, postoperative management and study outcome was extracted in order to create an overview of the current literature. The literature supports the use of the AMIC procedure as an effective treatment for osteochondral lesions of talus. Great heterogeneity exists and comparative studies are missing. While the number of studies on the topic is increasing further are needed and especially with optimized design.

Functional Outcomes of Autologous Matrix-Related Chondrogenesis to Treat Large Osteochondral Lesions of the Talus

BACKGROUND

Osteochondral lesions of the talus (OLT) treatment is widely debated when the lesion size exceeds 150 mm². The aim of this study was to assess functional outcome and satisfaction rates of the autologous matrix-related chondrogenesis (AMIC) technique and compare the outcomes for OLTs larger than 150 mm² that were classified as primary, primary with local tumor-related OLT, or revision cases.

METHODS

A total of 77 patients who were operated by AMIC were included. The average age of the population was 39.6 years. The mean body mass index (BMI) was 27.2. Smoker rate was 28.5% of the population. Forty-two patients were primary cases, 14 patients had primary with local tumor-related OLT, and 18 patients were revision cases. Overall and subgroup functional outcomes were evaluated by visual analog scale (VAS) and Foot and Ankle Disability Index (FADI) scores. Satisfaction rates were queried, and failures were recorded.

RESULTS

After a median follow-up of 32 months, the score improvement for primary, primary with local tumor-related, and revision group were for VAS, 5.4 ± 0.4, 5.6 ± 0.7, and 3.6 ± 0.8, and for FADI, 46.5 ± 3.8, 45.3 ±6.5, and 26.6 ± 6.7, respectively (P < .001). Intergroup comparison showed greater improvement for the primary OLT group when compared to the revision group (P < .001). The failure rates for the primary, primary with local tumor-related, and revision group were 4.8%, 11.8%, and 38.9%, respectively.

CONCLUSION

AMIC procedure provides good functional outcome and satisfactory rates in patients with primary and primary with local tumor-related OLT larger than 150 mm², but in revision cases, the AMIC success rate was not encouraging as all had advanced OLT operative interventions.

LEVEL OF EVIDENCE

Level III, therapeutic retrospective study.

Preexisting and treated concomitant ankle instability does not compromise patient-reported outcomes of solitary osteochondral lesions of the talus treated with matrix-induced bone marrow stimulation in the first postoperative year: data from the German Cartilage Registry (KnorpelRegister DGOU)

PURPOSE

The purpose of this study was to compare the subjective ankle function within the first year following matrix-induced bone marrow stimulation (M-BMS) of patients with a solitary osteochondral lesion of the talus (OCLT) with and without concomitant chronic ankle instability (CAI).

METHODS

Data from the German Cartilage Registry (KnorpelRegister DGOU) for 78 patients with a solitary OCLT and a follow-up of at least 6 months were included. All patients received M-BMS for OCLT treatment. The cohort was subdivided into patients with OCLT without CAI treated with M-BMS alone (n = 40) and patients with OCLT and CAI treated with M-BMS and additional ankle stabilisation (n = 38). The Foot and Ankle Ability Measure (FAAM), the Foot and Ankle Outcome Score (FAOS), and the Numeric Rating Scale for Pain (NRS) were used to assess patient-reported outcomes (median (minimum-maximum)).

RESULTS

From preoperatively to 12 months postoperatively, patients with OCLT without CAI treated with M-BMS alone had a significant improvement of all subscales in the FAAM [activity of daily living 64.3 (10-100) to 88.1 (39-100); sports 34.4 (0-100) to 65.6 (13-94), functional activities of daily life 50 (0-90) to 80 (30-100), functional sports 30 (0-100) to 70 (5-100)] and FAOS [pain 61.1 (8-94) to 86.1 (50-100), symptoms 60.7 (18-96) to 76.8 (29-100), activities of daily living 72.1 (24-100) to 91.9 (68-100), sport/recreational activities 30.0 (0-70) to 62.5 (0-95), quality of life 31.3 (6-50) to 46.9 (19-100)]. Within the first year, patients with OCLT and CAI treated with M-BMS and ankle stabilisation also showed significant improvement in the FAAM [activity of daily living 68.8 (5-99) to 90.5 (45-100); sports 32.8 (0-87.5) to 64.1 (0-94), functional activities of daily life 62.5 (25-100) to 80 (60-90), functional sports 30 (0-100) to 67.5 (0.95)] and the FAOS [pain 66.7 (28-92) to 87.5 (47-100), symptoms 57.1 (29-96) to 78.6 (50-100), activities of daily living 80.1 (25-100) to 98.5 (59-100), sport/recreational activities 35.0 (0-100) to 70.0 (0-100), quality of life 25.0 (0-75) to 50.0 (19-94)]. The pain level decreased significantly in both groups. No significant difference was found between both groups regarding the subscales of FAAM, FAOS and the NRS 1 year postoperatively.

CONCLUSION

Improvements in subjective ankle function, daily life activities and sports activities were observed within the first year following M-BMS. Our results suggest that preexisting and treated ankle instability did not compromise subjective outcome in patients treated with M-BMS in the first postoperative year.

LEVEL OF EVIDENCE

Level IV.

The Use of Autologous Matrix-Induced Chondrogenesis as a Surgical Treatment for Patients with the First Metatarsophalangeal Joint Osteoarthritis: Immediate and Medium-Term Results

AIM

To demonstrate the immediate and medium-term results of the surgical treatment of patients with first metatarsophalangeal (MTP) joint osteoarthritis (OA) using the autologous matrix-induced chondrogenesis (AMIC) technique and to evaluate the effectiveness.

MATERIALS AND METHODS

Preoperatively the range of motion (ROM) in the first MTP joint was determined, and the following questionnaires were used: Visual Analogue Scale (VAS) of pain, American Orthopedic Foot & Ankle Society (AOFAS) score, and Functional Foot Index (FFI). All of the patients experienced a significant restriction of the ROM in the first MTP joint. The VAS of pain median was 70, AOFAS 52, and FFI 5.8.

RESULTS

AMIC was performed in 19 patients with first MTP joint OA. All the patients experienced a significant restriction of ROM in the first MTP joint. The VAS of pain median was 70, AOFAS 52, and FFI 5.8. By the third month, VAS of pain decreased to 25, FFI to 2.2; AOFAS median increased to 77, ROM to 60°. Six months after the surgery VAS of pain decreased to 10, FFI to 1.1; AOFAS median increased to 90, ROM to 65°. After a year of observation, VAS of pain decreased to 5, FFI to 1,0; AOFAS median increased to 92.5, ROM to 71.5°.

CONCLUSION

The results showed that a first MTP joint AMIC procedure can be a fairly effective method of surgical treatment that can relieve pain and significantly improve the quality of life of patients with first MTP joint OA.

Reliability of the MOCART score: a systematic review

BACKGROUND

The present systematic review analysed the available literature to assess reliability of the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score in the evaluation of knee and ankle osteochondral lesions.

METHODS

All the studies using the MOCART score for knee and/or talus chondral defects were accessed in March 2021. A multivariate analysis was performed to assess associations between the MOCART score at last follow-up and data of patients at baseline, clinical scores and complications. A multiple linear model regression analysis was used.

RESULTS

The MOCART score evidenced no association with patient age (P = 0.6), sex (P = 0.1), body mass index (P = 0.06), defect size (P = 0.9), prior length of symptoms (P = 0.9) or visual analogue scale (P = 0.07). For chondral defects of the knee, no statistically significant association was found between the MOCART score and the International Knee Documentation Committee (P = 0.9) and with the Lysholm Knee Scoring Scales (P = 0.2), Tegner Activity Scale (P = 0.2), visual analogue scale P = 0.07), rate of failure (P = 0.2) and revision (P = 0.9). For chondral defect of the talus, no statistically significant associations were found between the MOCART score and the American Orthopedic Foot and Ankle Score (P = 0.3), Tegner Activity Scale (P = 0.4), visual analogue scale (P = 0.1), rate of failure (P = 0.1) and revision (P = 0.7).

CONCLUSION

The MOCART score demonstrated no association with patient characteristics and with the surgical outcome in patients who underwent surgical management for knee and talus chondral defects.

LEVEL OF EVIDENCE

Level IV.

Comparison of Arthroscopic Treatment Methods in Talar Osteochondral Lesions: A Multicenter, Prospective, Randomized Clinical Trial

BACKGROUND

The aim of the present study was to contribute new and updated information to the literature by comparing the clinical and radiologic results of arthroscopic microfracture, platelet-rich plasma (PRP) after arthroscopic microfracture, and BST-Cargel scaffold application after arthroscopic microfracture in the treatment of talar osteochondral lesions.

METHODS

Sixty-two talar osteochondral lesion patients (31 women and 31 men) who underwent ankle arthroscopy in two different centers were randomized into three groups. The first group consisted of patients who underwent only arthroscopic microfracture (MF) (n = 22); the second group consisted of patients who underwent the PRP procedure after arthroscopic MF (PRP; n = 19); and the third group consisted of patients who underwent the BST-Cargel procedure after arthroscopic MF was (BST-Cargel; n = 21). The talar osteochondral lesions in the three groups were classified according to magnetic resonance and arthroscopic images. American Orthopedic Foot and Ankle Society, Foot and Ankle Ability Measurement (overall pain, 15-minute walking, running function), and visual analog scale scores were evaluated preoperatively and postoperatively, and postoperative return time to sports activities was performed.

RESULTS

Compared to the preoperative score, postoperative American Orthopedic Foot and Ankle Society score increased 48.80 ± 9.60 in the BST-Cargel group, whereas there was an increase of 46.68 ± 3.65 in the PRP group and 29.63 ± 3.69 in the MF group, which were statistically significant (P < .05).There was a statistically significant postoperative change in the visual analog scale scores of the patients in all three groups compared to the preoperative scores (P < .05). At the end of the follow-up, the Foot and Ankle Ability Measurement overall pain, 15-minute walking, and running function results of all three groups increased significantly postoperatively compared to the preoperative values (P < .005).

CONCLUSIONS

BST-Cargel application with microfracture is a method that can be applied easily and safely with arthroscopy to lesions larger than 1.5 cm2 regardless of the size of the cartilage defect, and it has been found to be superior to the other two methods in terms of pain, functional score, radiologic recovery, and return to sports activities.

Matrix-induced autologous chondrocyte implantation versus autologous matrix-induced chondrogenesis for chondral defects of the talus: a systematic review

INTRODUCTION

Chondral defects of the talus are common and their treatment is challenging.

SOURCE OF DATA

Recent published literatures.

AREAS OF AGREEMENT

Membrane-induced Autologous Chondrocyte Implantation (mACI) and Autologous Matrix-Induced Chondrogenesis (AMIC) have been proposed as management for chondral defects of the talus.

AREAS OF CONTROVERSY

It is debated whether AMIC provides greater outcomes compared to mACI for chondral regeneration. Several clinical studies showed controversial results, and the best treatment has not yet been clarified.

GROWING POINTS

To investigate whether AMIC provide superior outcomes than mACI at midterm follow-up.

AREAS TIMELY FOR DEVELOPING RESEARCH

AMIC exhibits similar clinical results to mACI. However, AMIC involves one single surgical procedure, no articular cartilage harvest and hence no morbidity from it, no need for chondrocyte expansion in a separate laboratory setting. For these reasons, AMIC may be preferred to mACI.

Is there clinical evidence to support autologous matrix-induced chondrogenesis (AMIC) for chondral defects in the talus? A systematic review and meta-analysis

BACKGROUND

The aim of this study is to systematically review the literature on clinical outcomes of patients who have undergone autologous matrix-induced chondrogenesis (AMIC) for treatment of osteochondral lesions of the talus (OCL) and compare the studies' outcomes.

METHODS

Pubmed and Embase were searched in January 2020 for articles concerning OCL surgery. Studies were included if they had a minimum 1-year follow-up and the primary measures were functional outcomes. The meta-analysis compared the Visual Analogic Score (VAS), the American Orthopedic Foot and Ankle Score (AOFAS), and the Foot Function Index (FFI) between baseline and follow-up of 1-2years, and 3-5years. A random effects model was used to evaluate outcome changes.

RESULTS

The search returned 15 studies, with a total of 492 patients. The VAS improved 4.45 and 4.6 points from baseline to the 1-2year and 3-5yearfollow-up, respectively (p<0.001). AOFAS improved 31.59 and 32.47 points from baseline to the 1-2year and 3-5yearfollow-up, respectively (p<0.001). The FFI showed a significant improvement of 30.93 points from baseline to year 3-5 (p<0.001). A total of 6 patients with revision surgeries have been reported within the follow up period. It was not possible to correlate clinical features like lesion size, surgical approach, and bone marrow stimulation technique to the reported outcome.

CONCLUSION

Surgical treatment of OCL via the AMIC procedure provided significant improvement in the functional outcome and pain scores when compared to the pre-operative values. Improvements were observed up to 5years post-operatively.

Osteochondral Lesions of the Talus: An Individualized Treatment Paradigm from the Amsterdam Perspective

Osteochondral lesions of the talus (OLTs) are characterized by damage to the articular cartilage of the talus and its underlying subchondral bone. Up to 75% of OLTs are caused by trauma, such as an ankle sprain or fracture. Physical examination and imaging are crucial for diagnosis and characterization of an OLT. No superior treatment for OLTs exists. It is paramount that an evidence-based personalized treatment approach is applied to patients with OLTs because lesion and patient characteristics guide treatment. This current concepts review covers clinical and preclinical evidence on OLT etiology, presentation, diagnosis, and treatment, all based on the Amsterdam perspective.

Does the Association of Microfractures for the Treatment of Osteochondral Lesions of the Talus Affect the Outcome Following Arthroscopic Treatment for Chronic Ankle Instability?

BACKGROUND

The purpose of the present study was to retrospectively compare the outcomes of patients who underwent arthroscopic thermal capsular shrinkage with those who underwent both arthroscopic thermal capsular shrinkage and arthroscopic osteochondral lesion (OCL) treatment with microfractures. Our hypothesis was that the simultaneous treatment does not negatively affect the outcome of the combined surgical procedure by influencing the postoperative rehabilitation protocol and does not significantly differ from capsular shrinkage alone in terms of subjective and objective outcomes.

METHODS

Seventy-six patients with chronic ankle instability were treated at our department from 2004 to 2012 and reviewed retrospectively. Forty-two patients underwent arthroscopic thermal-assisted capsular shrinkage (group A), and 34 patients underwent combined arthroscopic capsular shrinkage and microfractures for OCL lesions of the talus (group B). All patients underwent a four-step surgical procedure including synovectomy, debridement, capsular shrinkage, and bracing and nonweightbearing for 21 days. In patients with OCL lesions, microfractures of the OCL were associated. Clinical assessment included objective examination, the American Orthopaedic Foot and Ankle Society ankle and hindfoot scoring system, Karlsson-Peterson score, Tegner activity level, and Sefton articular stability scale.

RESULTS

The median follow-up was 6 years (range, 2-9 years). The median postoperative visual analogue scale score, American Orthopaedic Foot and Ankle Society score, and Tegner score were improved from the preoperative level for both groups (P < .001). No significant difference was found between the two groups for the subjective scores and satisfaction rate (P = not significant). Similarly, no significant difference regarding the incidence of range-of-motion restriction was reported between the two groups (P = not significant).

CONCLUSIONS

The association of microfractures for the treatment of osteochondral lesions does not affect the outcome following arthroscopic treatment for chronic ankle instability up to 6 years from surgery.

Comparison of clinically used bilayer collagen membrane and trilayer collagen prototype fixation stability in chondral defects at the talus - An experimental human specimen study

BACKGROUND

The purpose of this human specimen experimental study was to compare the fixation stability of clinically used bilayer collagen membrane with fibrin glue with trilayer collagen prototype without fibrin glue in chondral defects at the medial or lateral talar shoulder (both matrices from Geistlich Pharma AG, Wollhusen, Switzerland).

METHODS

Eleven human specimens were used. The membranes were implanted in standardized chondral defects at the medial and lateral talar shoulder randomized. All tests were performed in load-control 15 kg. Range of motion ROM of each ankle was examined individually before testing. The average ROM was 10° dorsiflexion range 0°-20° and 30° plantarflexion range 20°-45°. 1,000 testing cycles with the defined ROM were performed. Two independent investigators, blinded to membrane and fixation type, visually assessed the membrane fixation integrity for peripheral detachment, area of defect uncovered, membrane constitution and delamination.

RESULTS

The clinically used bilayer collagen membrane plus fibrin glue showed higher fixation stability than the trilayer prototype (all p < 0.05). No significant differences occurred between medial and lateral talar shoulder location (all p > 0.05).

CONCLUSIONS

The fixation stability of the trilayer collagen prototype without fibrin glue is lower than of the clinically used bilayer membrane with fibrin glue in chondral defects at the medial and lateral talar shoulder in an experimental human specimen test. Clinical use of trilayer collagen prototype without fibrin glue has to be validated by clinical testing to evaluate if the lower stability of fixation is still sufficient.

Role of Particulated Juvenile Cartilage Allograft Transplantation in Osteochondral Lesions of the Talus: A systematic review

INTRODUCTION/PURPOSE

Osteochondral lesion of the talus (OCLT) is defined as a defect on the articular surface of the talus with/without subchondral bone involvement. Several surgical techniques are described in literature to treat OCLT. Particulated Juvenile Cartilage Allograft Transplantation (PJCAT) is a new emerging technique that has the potential of restoring the native cartilage. However, available data on PJCAT in treating OCLT is confined to a small number of studies with heterogeneous population. The aim of this study is to systematically review the literature on clinical and radiological outcomes of PJCAT in treating OCLT.

METHODS

A systematic search of Medline database was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Number of patients and demographic data included age, gender and body mass index (BMI) were extracted. The level of evidence of each included study was identified. When feasible, mechanism of injury, lesion size and average follow up were recorded. The American Orthopedic Foot and Ankle Society Score (AOFAS), and Foot and Ankle Outcome Score (FAOS) were obtained to assess the functional outcomes. Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score was selected to evaluate the radiological outcomes.

RESULTS

A total of 10 studies were eligible for this review involving 132 patients. Postoperative AOFAS scores were available for 44 patients who underwent PJCAT with an average of 86.14 at 25.5 months follow up. FAOS scores have been reported in 3 studies for 81 patients. The average preoperative score was 47.35 which has been improved to 62.88 at follow up of 23.6 months. MOCART was evaluated in 42 feet after the mean follow up of 18.2 months. The repair tissue was characterized by variable features; however, certain peculiarities were observed with higher frequency including infill hypertrophy, incomplete border zone integration, deep surface disruption, structure inhomogeneity, patches of hyperintense signals, damage of subchondral lamina and subchondral bone, adhesions and absence of effusion.

CONCLUSION

PJCAT seems to be a promising modality of treatment for OLT in terms of functional outcomes. Fair attempts of defect filling can be confirmed with MRI. Nevertheless, heterogeneous picture of regenerate cartilaginous tissue and lack of repair in subchondral bone and subchondral lamina are not in favor with claims of full restoration of lost normal hyaline articular cartilage.

Autologous matrix-induced chondrogenesis for the treatment of osteochondral lesions of the talus: A systematic review

This study was performed to determine whether Autologous Matrix-Induced Chondrogenesis (AMIC) is an effective and safe treatment option for patients with symptomatic Osteochondral defects of the Talus (OCTs) and to identify factors that influence the clinical outcome. A systematic review of the literature was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Three reviewers independently conducted the literature search using the MEDLINE/PubMed database and the Cochrane Database of Systematic Reviews. The databases were queried using the terms "autologous" AND "matrix" AND "induced" AND "chondrogenesis." Thirteen studies were eligible for review. All studies that compared the preoperative and postoperative mean values of different clinical/functional scores showed significant clinical improvement. The final postoperative mean Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score ranged from 50.9 to 74.5. The included studies indicated that age and body mass index may have a detrimental impact on the postoperative outcome. A higher re-intervention rate is expected with the open technique, mainly because of hardware removal after malleolar osteotomy. This data analysis demonstrated that both arthroscopic and open AMIC procedures are effective and safe for the treatment of OCTs. Level IV, systematic review of therapeutic studies.

Concomitant ankle instability has a negative impact on the quality of life in patients with osteochondral lesions of the talus: data from the German Cartilage Registry (KnorpelRegister DGOU)

PURPOSE

The purpose of this study was to compare patients with osteochondral lesions of the talus (OCLT) with and without concomitant chronic ankle instability (CAI).

METHODS

Data from the German Cartilage Registry (KnorpelRegister DGOU) for 63 patients with a solitary OCLT were used. All patients received autologous matrix-induced chondrogenesis (AMIC) for OCLT treatment. Patients in group A received an additional ankle stabilisation, while patients in group B received AMIC alone. Both groups were compared according to demographic, lesion-related, and therapy-related factors as well as baseline clinical outcome scores at the time of surgery. The Foot and Ankle Ability Measure (FAAM), the Foot and Ankle Outcome Score (FAOS), and the Numeric Rating Scale for Pain (NRS) were used.

RESULTS

Patients in group A were older compared to group B [median 34 years (range 20-65 years) vs. 28.5 years (range 18-72 years)]; the rate of trauma-associated OCLTs was higher (89.7% vs. 38.3%); more patients in group A had a previous non-surgical treatment (74.1% vs. 41.4%); and their OCLT lesion size was smaller [median 100 mm² (range 15-600 mm²) vs. 150 mm² (range 25-448 mm²)]. Most OCLTs were located medially in the coronary plane and centrally in the sagittal plane in both groups. Patients in group A had worse scores on the FAOS quality-of-life subscale compared to patients in group B.

CONCLUSION

Patients with OCLT with concomitant CAI differ from those without concomitant CAI according to demographic and lesion-related factors. The additional presence of CAI worsens the quality of life of patients with OCLT. Patients with OCLT should be examined for concomitant CAI, so that if CAI is present, it can be integrated into the treatment concept.

LEVEL OF EVIDENCE

IV.

Comparison Matrix-Associated Stem Cell Transplantation (MAST) with Autologous Matrix Induced Chondrogenesis plus Peripheral Blood Concentrate (AMIC+PBC) in chondral lesions at the ankle-A clinical matched-patient analysis

BACKGROUND

The aim of the study was to compare Matrix-Associated Stem Cell Transplantation (MAST) with Autologous Matrix Induced Chondrogenesis plus Peripheral Blood Concentrate (AMIC+PBC) in chondral lesions at the ankle.

METHODS

In a matched-patient clinical follow-up study, patients with chondral lesion at the ankle that were treated with MAST from April 1, 2009 to July 15, 2016, and patients that were treated with AMIC+PBC from July 17, 2016 to May 31, 2017 were included and compared. Size and location of the chondral lesions and the Visual-Analogue-Scale Foot and Ankle (VAS FA) before treatment and at follow-up were analysed. Bone Marrow Aspirate Concentrate (BMAC) was used for MAST and Peripheral Blood Concentrate (PBC) for AMIC+PBC to impregnate a collagen I/III matrix (Chondro-Gide, Wollhusen, Switzerland) that was fixed into the chondral lesion with fibrin glue.

RESULTS

One hundred and twenty-nine patients with 136 chondral lesions were included in both groups. The chondral lesions were located as follows (MAST/AMIC+PBC, n (%)), medial talar shoulder only, 59 (43)/62 (46); lateral talar shoulder only, 44 (32)/42 (31); medial and lateral talar shoulder, 7 (10)/7 (10); tibia, 19 (14)/18 (13). The lesion size was 1.6/1.8cm² on average and VAS FA was 46.9/45.7 (MAST/AMIC+PBC). For MAST/AMIC+PBC groups, 107 (83%)/105 (81%) with 112/110 previous chondral lesions completed the defined 2-year-follow-up after 24.4/23.8 months on average. VAS FA improved to 82.3/79.8 (MAST/AMIC+PBC). No parameter significantly differed between MAST and AMIC+PBC groups.

CONCLUSIONS

MAST and AMIC+PBC as part of a complex surgical approach led to improved and high validated outcome scores in 2-year-follow-up. MAST and AMIC+PBC showed similar results.

[Research progress in surgical procedures for osteochondral lesions of talus]

OBJECTIVE

To summarize the research progress of surgical procedures in osteochondral lesions of the talus (OLT).

METHODS

By consulting the related literature of OLT in recent years, the advantages and disadvantages of various surgical treatment schemes were analyzed and summarized.

RESULTS

There are many surgical treatments for OLT, including bone marrow stimulation, osteochondral transplantation, autologous chondrocyte transplantation, and biologically assisted therapy. Various schemes have different indications and limitations. With the continuous development of various technologies, the effectiveness of OLT treatment will gradually improve.

CONCLUSION

There are still many difficulties and controversies in the treatment of OLT, and there is no unified treatment plan. It is suggested that individualized operation plan should be formulated according to the specific conditions of patients.

Arthroscopic microfracture vs. arthroscopic autologous matrix-induced chondrogenesis for the treatment of articular cartilage defects of the talus

PURPOSE

Microfracture is an established method to treat osteochondral defects of the talus. The value of the addition of an acellular matrix is still under debate. This study compared the results of arthroscopic microfracture vs. arthroscopic autologous matrix-induced chondrogenesis using a collagen I/III matrix (AMIC) in the management of articular cartilage defects of the talus.

METHODS

Patients with a minimum follow-up of 5 years after arthroscopic management for an articular cartilage defect of the talus with either microfracture alone or an additional acellular matrix were matched according to age, sex and BMI. The Hannover Scoring System for the ankle (HSS) and a Visual analog scale (VAS) for pain, function and satisfaction were used to evaluate the clinical outcome. Postoperative MRI was used to assess cartilage repair tissue based on the degree of defect repair and filling of the defect, integration to border zone, surface of the repair tissue, structure of the repair tissue, and subchondral bone alterations.

RESULTS

Thirty-two patients (16 microfracture, 16 AMIC) were included. No significant between-group differences were observed in demographic data and preoperative score values. Both groups showed statistically significant improvement when comparing the pre- and postoperative score values. No statistically significant differences were identified between the median values of the groups with the HSS (microfracture: 82 (range 71-96) points; AMIC 88 (range 40-98) points). Accordingly, no significant differences were observed for the VAS pain (microfracture: 0.95 (range 0-3.8); AMIC: 1.0 (range 0-8.5)), VAS function (microfracture: 8.4 (range 3.5-10); AMIC: 9.0 (range 1.5-10)) and VAS satisfaction (microfracture: 8.9 (range 2.8-10); AMIC: 9.45 (range 1.5-10)). MRI showed regeneration of tissue in the treated area without differences between the two groups.

CONCLUSION

Good clinical results were observed for arthroscopic microfracture with or without an additional acellular collagen I/III matrix in the treatment for articular cartilage defects of the talus. It appears that for defects as treated in this study, it is not worthwhile adding the collagen I/III matrix to the microfractures.

LEVEL OF EVIDENCE

III.

A critical review of the literature on arthroscopic autologous matrix-induced chondrogenesis and matrix-assisted autologous chondrocyte transplantation for acetabular chondral defects

Background/Aims

Significant acetabular chondral defects are a common clinical finding during hip arthroscopy, for which the current surgical management approach may be falling short. Autologous matrix-induced chondrogenesis and matrix-assisted autologous chondrocyte transplantation are two novel cell-regenerative therapies that offer a way to repair acetabular chondral defects.

Methods

A literature search of Cochrane, CINAHL, AMED and Medline (2007–2017) databases revealed seven relevant articles, but only four involved a hip arthroscopic approach.

Results

All included studies demonstrated some significant improvements in patient-reported outcomes for autologous matrix-induced chondrogenesis and matrix-assisted autologous chondrocyte transplantation. There appears to be a practical advantage in terms of cost and convenience for using one-step autologous matrix-induced chondrogenesis. However, over-reliance on one particular research team and use of small-scale retrospective studies constitutes low-level, non-generalisable evidence.

Conclusions

The literature does not convincingly support either of these new applications over and above any other currently available treatments. Further research is needed and should involve different centres, longer follow-ups and place a higher emphasis on methodological rigour in order to maximise the trustworthiness of results.

Autologous Matrix-Induced Chondrogenesis for Osteochondral Lesions of the Talus: A Clinical and Radiological 2- to 8-Year Follow-up Study

BACKGROUND

Autologous matrix-induced chondrogenesis (AMIC) has become an interesting treatment option for osteochondral lesions of the talus (OLTs) with promising clinical short- to midterm results.

PURPOSE

To investigate the clinical and radiological outcome of the AMIC procedure for OLTs, extending the follow-up to 8 years.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Thirty-three patients (mean age, 35.1 years; body mass index, 26.8) with osteochondral lesions of the medial talar dome were retrospectively evaluated after open AMIC repair at a mean follow-up of 4.7 years (range, 2.3-8.0 years). Patients requiring additional surgical procedures were excluded. All OLTs (mean size, 0.9 cm²; range, 0.4-2.3 cm²) were approached through a medial malleolar osteotomy, and 28 patients received subchondral autologous bone grafting. Data analysis included the visual analog scale for pain, the American Orthopaedic Foot and Ankle Society score for ankle function, the Tegner score for sports activity, and the MOCART (magnetic resonance observation of cartilage repair tissue) scoring system for repair cartilage and subchondral bone evaluation.

RESULTS

Mean ± SD visual analog scale score improved significantly from 6.4 ± 1.9 preoperatively to 1.4 ± 2.0 at latest follow-up ( P < .001). The mean American Orthopaedic Foot and Ankle Society score was 93.0 ± 7.5 (range, 75-100). The Tegner score improved significantly from 3.5 ± 1.8 preoperatively to 5.2 ± 1.7 at latest follow-up ( P < .001), and 79% returned to their previous sports levels. The MOCART score averaged 60.6 ± 21.2 (range, 0-100). Complete filling of the defect was seen in 88% of cases, but 52% showed hypertrophy of the cartilage layer. All but 1 patient showed persistent subchondral bone edema. The patient's age and body mass index, the size of the osteochondral lesion, and the MOCART score did not show significant correlation with the clinical outcome. There were no cases of revision surgery for failed AMIC. Fifty-eight percent underwent reoperation, mainly for symptomatic hardware after malleolar osteotomy.

CONCLUSION

AMIC for osteochondral talar lesions led to significant pain reduction, recovery of ankle function, and successful return to sport. The MOCART score did not correlate with the good clinical results; the interpretation of postoperative imaging remains therefore challenging.

Analysis of the Changes in the Clinical Outcomes According to Time After Arthroscopic Microfracture of Osteochondral Lesions of the Talus

BACKGROUND:

Arthroscopic microfracture can effectively treat osteochondral lesions of the talus (OLTs). However, very few studies have reported on symptomatic improvement duration and time when symptomatic improvement ceases. This study aimed to investigate the clinical outcome changes after arthroscopic microfracture in patients with OLT.

METHODS:

Among patients who underwent arthroscopic microfracture for OLT, 70 patients were available for follow-up for more than 3 years. Of these, 6 patients who showed worsening or no improvement in the 6 months after surgery were excluded, and a total of 64 patients were included in the analysis. To analyze and compare the clinical outcome changes according to time, the visual analog scale (VAS) and American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scores were evaluated every 3 months up to 1 year postoperatively and every 1 year thereafter. The clinical outcome differences based on the lesion size, lesion location, lesion containment, presence of cyst and bone marrow edema, age, sex, and obesity were analyzed.

RESULTS:

The preoperative and final follow-up VAS scores significantly improved from 6.2 ± 1.1 to 1.2 ± 1.1 ( P< .05) and the AOFAS score from 63.1 ± 7.3 to 91.0 ± 7.3 ( P< .05). The overall success rate for arthroscopic microfracture in this study was 88.6%. The postoperative VAS and AOFAS scores at 3, 6, 9, 12, 24, and 36 months were 3.7 ± 1.4, 2.5 ± 1.3, 2.0 ± 1.1, 1.6 ± 1.2, 1.2 ± 1.2, and 1.3 ± 1.2 and 74.7 ± 10.3, 80.5 ± 8.9, 84.3 ± 7.4, 88.3 ± 7.3, 91.1 ± 7.2, and 90.8 ± 7.5, respectively, showing significant improvements up to 2 years. After 2 years, the symptoms did not improve but were maintained at a certain level up to 3 years. No clinical outcome differences based on the lesion size, lesion containment, presence of cyst and bone marrow edema, age, sex, and obesity were observed.

CONCLUSION:

Symptomatic improvement early after arthroscopic microfracture for OLT was observed continuously for up to 2 years postoperatively. Symptom improvement was maintained without worsening for up to 3 years after surgery. Determining the final outcome of microfracture at least after 2 years would be reasonable.

LEVEL OF EVIDENCE:

Level IV, case series.

All-arthroscopic AMIC® (AT-AMIC) for the treatment of talar osteochondral defects: A short follow-up case series

INTRODUCTION

Various procedures have been used to treat osteochondral lesions of the talus. Among the new alternatives to treat these lesions, Autologous Matrix-Induced Chondrogenesis (AMIC^®) has proven to provide satisfactory results through medium-term follow-up. The aim of this study is to report early post-operative clinical results of patients submitted to the AT-AMIC^® technique and autologous bone graft, when necessary, for OLT's at a eight-month minimum follow-up.

METHODS

This is case series of 17 consecutive patients that were submitted to AT-AMIC^®, between January of 2016 and April of 2017. Nine men and eight women, between 15 and 67 years were diagnosed with OLTs with the typical history of deep ankle pain and corresponding magnetic resonance imaging injury. Surgery was proposed only after failure of conservative treatment of at least 3 months. Patients answered the AOFAS score preoperatively and at the last follow-up, ranging from 8 to 20 months.

RESULTS

Average size of OLTs were 1.16cm², with Raikin 4 location being the most common (71%). Calcaneal osteotomy was the most common associated procedure, with 18%. Average follow-up was 10.8 months. Average AOFAS before surgery was 46.4, increasing to 89.5 at the last follow-up. This difference was statistically significant with a p-value of <0.001. No complications were observed and no changes in the post-operative protocol were needed.

CONCLUSION

AT-AMIC^® is a reliable and reproducible method of treatment for OLTs, reaching high clinical postoperative scores, with a very low rate of complications. Further comparative study is needed to prove its efficacy.

Successful treatment of infected wound dehiscence after minimally invasive locking-plate osteosynthesis of tibial pilon and calcaneal fractures by plate preservation, surgical debridement and antibiotics

OBJECTIVE

The aim is to present a case series that illustrates possible benefits from combining minimally invasive plate osteosynthesis (MIPO), plastic surgery and antibiotic therapy, in order to treat and eradicate infection in patients with tibial pilon or calcaneal fractures.

METHODS

Eleven consecutive patients with dehiscence of the surgical wound in outcomes MIPO using a Locking Compression Plate (LCP) for tibial pilon, or calcaneus fractures. The patients had developed a documented infection of the surgical wound. All patients were treated and followed-up by the multidisciplinary team with the orthopedic surgeon, the plastic surgeon and the infectious disease physician. All patients were followed by the plastic surgeon to treat the wound dehiscence, as well as by the orthopedic surgeon until fracture consolidation. The duration of the antibiotic therapy was from 4 to 6 months. After 6 weeks, the intravenous treatment was replaced by oral administration. The follow-up intervals were 15 days, 40 days, and 3 months.

RESULTS

The average time of wound closure was 109±60 days. The antibiotics used were chosen according to the antibiogram. The antibiotic therapy had a duration of 4-6 months, and after 6 weeks, the therapy switched to oral administration. At the 3-month follow-up, all patients had excellent outcomes and had returned to their normal activity of daily living.

CONCLUSION

The patients in this study responded positively to a combination of MIPO, plastic surgery and antibiotic therapy, confirming that multidisplinary treatment in association with titanium devices are able to eradicate infection in short time.

Treatment of Osteochondral Lesions of the Talus With Cell-free Polymer-based Scaffold in Single-Step Arthroscopic Surgery

Arthroscopic techniques have recently gained popularity for the treatment of osteochondral defects of the talus. The microfracture procedure is the most commonly applied arthroscopic technique. However, it is not effective for the treatment of larger lesions. Tissue-engineered scaffolds have been used for cartilage regeneration arthroscopically, and promising results have been reported. We treated larger osteochondral lesions of the talus with polyglycolic acid-hyaluronan scaffold biomaterial (Chondrotissue, BioTissue AG, Zurich, Switzerland) in a single-step arthroscopic surgery. Traction methods and fibrin glue were avoided.

Single-Step Arthroscopic Repair With Cell-Free Polymer-Based Scaffold in Osteochondral Lesions of the Talus: Clinical and Radiological Results

PURPOSE

To report the clinical and radiological results of patients with talar osteochondral lesions who were treated by microfracture and cell-free scaffold implantation in a single-step arthroscopic surgery.

METHODS

Forty patients, treated with a single-step arthroscopic surgery, were evaluated in this single-center-based retrospective study. Patients with degenerative arthritis (n = 1), history of ankle fracture (n = 1), kissing lesions (n = 1), lower extremity deformity (n = 1), and lesions <1.5 cm² (n = 4) were excluded. Oversized (>10 mm depth) bone cysts were additionally treated with bone graft. Patients were evaluated clinically, using the American Orthopedic Foot and Ankle Society (AOFAS) hindfoot score. Radiological assessment was performed with magnetic resonance imaging, using the magnetic resonance observation of cartilage repair tissue (MOCART) score.

RESULTS

Thirty-two patients with a mean age of 38 ± 12 years were evaluated. The mean defect size was 2.5 ± 0.8 cm² and the mean defect volume was 2.4 ± 1.9 cm³. The mean preoperative AOFAS score was 52.8 ± 13.9 and increased to 87.1 ± 11.1 postoperatively at the mean follow-up of 33.8 ± 14.0 months (P = .0001). A total of 84.4% of patients had good to excellent clinical scores. Clinical scores had no significant relation with age, lesion size, depth, or body mass index. The mean MOCART score was 64.2 ± 12.0. There was no significant correlation between the total MOCART and AOFAS scores (P = .123). A significant relation was found between the defect filling (the subgroup of the MOCART score) and the clinical outcomes (P = .0001, rho = 0.731).

CONCLUSIONS

The arthroscopic scaffold implantation technique is a single-step, safe, and effective method for the treatment of talar osteochondral lesions with satisfactory clinical and radiological outcomes.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Evaluation of reproducibility of the MOCART score in patients with osteochondral lesions of the talus repaired using the autologous matrix-induced chondrogenesis technique

PURPOSE

To evaluate the applicability and reproducibility of magnetic resonance observation of cartilage repair tissue (MOCART) score for morphological evaluation of osteochondral lesions of the talus (OLT) repaired using autologous matrix-induced chondrogenesis (AMIC) technique.

METHODS

Two radiologists (R1-R2) and two orthopaedists (O1-O2) independently reviewed 26 ankle MRIs performed on 13 patients (6 females; age: 38.9 ± 15.9, 14-63) with OLT repaired using AMIC. The MRIs were performed at 6 and 12 months from surgery. For inter/intra-observer agreement evaluation for each variable of the MOCART, we used Cohen's kappa coefficient. Progression of MOCART between 6- and 12-month evaluation was assessed using the Wilcoxon test. The Spearman's correlation coefficient was used to evaluate the correlation between baseline lesion size and MOCART.

RESULTS

The inter-observer agreement between R1 and R2 ranged from poor (adhesions, k = 0.124) to almost perfect (subchondral bone, k = 0.866), between O1 and O2 from absent (effusion, k = -0.190) to poor (surface, k = 0.172), and between R1 and O1 from absent (cartilage interface, k = -0.324) to fair (signal intensity, k = 0.372). The intra-observer agreement of R1 ranged from poor (signal intensity, k = 0.031) to substantial (subchondral lamina, k = 0.677), while that of O1 from absent (subchondral bone, k = -0.061) to substantial (surface, k = 0.663). There was a significant increase of MOCART between 6- and 12-month evaluation of R1 (Z = -2.672; P = 0.008), R2 (Z = -2.721; P = 0.007) and O1 (Z = -3.034; P = 0.002). Conversely, the increase of MOCART of O2 was not significant (Z = -1.665; P = 0.096). Inverse correlation between lesion size at baseline and MOCART was significant at 12-month evaluation (-0.726; P = 0.005).

CONCLUSION

MRI has an important role in the follow-up of surgical repaired OLT, but MOCART score does not seem to be sufficiently reproducible to be applied for this purpose.

The Impact of Weight on Arthroscopic Osteochondral Talar Reconstruction

BACKGROUND

The purpose of the study was to assess the functional and radiologic outcomes after AT-AMIC (arthroscopic talus autologous matrix-induced chondrogenesis) in 2 weight groups of patients with osteochondral lesions of the talus (OLTs): patients with BMI <25 (Healthy Weight Group [HG]) and with BMI ≥25 (Overweight Group [OG]).

METHODS

Thirty-seven patients were evaluated. HG was composed of 21 patients (BMI = 21.90 ± 1.94), whereas OG consisted of 16 patients (BMI = 27.41 ± 1.98). All patients were treated with AT-AMIC repair for OLTs. Magnetic resonance imaging (MRI), computed tomography (CT), Visual Analgoue Scale (VAS) for pain, American Orthopaedic Foot & Ankle Society (AOFAS) Ankle and Hindfoot score and Short-Form Health Survey (SF-12) were administered preoperatively (T₀) and at 6 (T₁), 12 (T₂), and 24 (T₃) months postoperatively.

RESULTS

In both groups, we found a significant difference for clinical and radiologic parameters with analysis of variance for repeated measures through 4 time points ( P < .001). In HG, AOFAS increased at every follow-up ( P < .05), whereas in OG, AOFAS improved only between T₂ and T₃ ( P = .0104). In OG we found a significant difference comparing CT and MRI at each follow-up; in HG this difference was found only at T₀ ( P < .0001) and T₁ ( P = .0492). Finally, OG presented a significantly larger lesion measured with MRI at T₀ ( P = .033).

CONCLUSIONS

OLTs in overweight patients were characterized by a larger preoperative size. At final follow-up, both groups showed a significant clinical improvement. AT-AMIC can be considered a safe and reliable procedure, regardless of weight, with a significant improvement also in quality of life.

LEVEL OF EVIDENCE

Level III, comparative study.

Combining Microfractures, Autologous Bone Graft, and Autologous Matrix-Induced Chondrogenesis for the Treatment of Juvenile Osteochondral Talar Lesions

BACKGROUND

The purpose of this study was to evaluate the clinical and radiologic outcomes of patients younger than 20 years, treated with the arthroscopic-talus autologous matrix-induced chondrogenesis (AT-AMIC) technique and autologous bone graft for osteochondral lesion of the talus (OLT).

METHODS

Eleven patients under 20 years (range 13.3-20.0) underwent the AT-AMIC procedure and autologous bone graft for OLTs. Patients were evaluated preoperatively (T₀) and at 6 (T₁), 12 (T₂), and 24 (T₃) months postoperatively, using the American Orthopaedic Foot & Ankle Society Ankle and Hindfoot (AOFAS) score, the visual analog scale and the SF-12 respectively in its Mental and Physical Component Scores. Radiologic assessment included computed tomographic (CT) scan, magnetic resonance imaging (MRI) and intraoperative measurement of the lesion. A multivariate statistical analysis was performed.

RESULTS

Mean lesion size measured during surgery was 1.1 cm³ ± 0.5 cm³. We found a significant difference in clinical and radiologic parameters with analysis of variance for repeated measures ( P < .001). All clinical scores significantly improved ( P < .05) from T₀ to T₃. Lesion area significantly reduced from 119.1 ± 29.1 mm² preoperatively to 77.9 ± 15.8 mm² ( P < .05) at final follow-up as assessed by CT, and from 132.2 ± 31.3 mm² to 85.3 ± 14.5 mm² ( P < .05) as assessed by MRI. Moreover, we noted an important correlation between intraoperative size of the lesion and body mass index (BMI) ( P = .011).

CONCLUSIONS

The technique can be considered safe and effective with early good results in young patients. Moreover, we demonstrated a significant correlation between BMI and lesion size and a significant impact of OLTs on quality of life.

LEVEL OF EVIDENCE

Level IV, retrospective case series.