Autologous matrix-induced chondrogenesis aided reconstruction of a large focal osteochondral lesion of the talus

Atelocollagen-Induced Chondrogenesis Versus Microfracture Alone for Osteochondral Lesions of the Talus: Surgical Technique and a 1-Year Clinical Outcome Study

Osteochondral lesions of the talus (OLTs) are a common cause of post-traumatic ankle pain and disability. Atelocollagen-induced chondrogenesis (ACIC) aims to encourage the development of hyaline cartilage, which is biomechanically superior to fibrocartilage. This single-center, retrospective database study assessed patients who underwent arthroscopic microfracture with or without atelocollagen scaffold augmentation for OLT. Between 2010 and 2019, 87 patients underwent microfracture only and 31 patients underwent ACIC. Propensity score matching was used to match the ACIC group in a 1:2 ratio to a corresponding microfracture-only group using logistic regression. American Orthopaedic Foot & Ankle Society (AOFAS) scores, 100-mm Visual Analog Scale (VAS), Short Form-36 (SF-36), and satisfaction were assessed at preoperative, 3-, 6-, and 12-month intervals. There were no differences in baseline characteristics between groups after matching (P > .05). Both groups had similar improvements to VAS, AOFAS, and SF-36 scores up to 12 months (P > .05). Both groups had significant 1-year improvements to physical functioning, physical limitations in usual role activities, pain, and social functioning domains, but the ACIC group additionally had significant improvements to general health, vitality, and mental health. Patients in the ACIC group were also more satisfied than the microfracture group at all time points. Patients with OLTs who underwent ACIC reported superior satisfaction and improvements to quality of life, although clinical outcomes were similar to those who underwent microfracture alone at 1 year.Level of Evidence: Level III: Cohort study.

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.

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.

The Role of Magnetic Resonance Imaging in Autologous Matrix-Induced Chondrogenesis for Osteochondral Lesions of the Talus: Analyzing MOCART 1 and 2.0

OBJECTIVE

To determine the role of magnetic resonance imaging (MRI) MOCART (Magnetic Resonance Observation of Cartilage Repair Tissue) 1 and 2.0 scores in the assessment of postoperative outcome after autologous matrix-induced chondrogenesis (AMIC) for the treatment of osteochondral lesions of the talus (OLTs). It was hypothesized that preoperative patient factors or OLT morphology are associated with postoperative MOCART scores; yet postoperative clinical outcome is not.

STUDY DESIGN

Cohort study; Level of evidence, 4. This study evaluated isolated AMIC that were implanted on the talus of 35 patients for the treatment of symptomatic OLT. Tegner and AOFAS (American Orthopaedic Foot and Ankle Society) scores were obtained at an average follow-up of 4.5 ± 1.8 years and postoperative MRI scored according to the MOCART 1 and 2.0.

RESULTS

OLT size showed significant correlation with postoperative MRI scores (MOCART 1: P = 0.006; MOCART 2.0: P = 0.004). Bone grafting was significantly associated with a MOCART 1 subscale (signal intensity of repair tissue; P = 0.038). Age and defect size showed significant correlations with MOCART 2.0 subscales (P < 0.05). Patients with shorter follow-up had a significantly higher MOCART 1 score and a trend toward better MOCART 2.0 scores than patients with longer follow-up (64.7 vs. 52.9 months, P = 0.02; 69.4 vs. 60.6 months, P = 0.058). No MOCART score was associated with postoperative patient-reported outcomes (n.s.).

CONCLUSION

Osteochondral lesion size is associated with postoperative MOCART scores in patients treated with AMIC for OLTs, with decreasing MOCART scores over time. Yet clinical outcome does not correlate with any MOCART score. Thus, MOCART assessment seems to have no significant role in the postoperative treatment of asymptomatic patients that underwent AMIC for OLTs.

Early to medium term outcomes of osteochondral lesions of the talus treated by autologous matrix induced chondrogenesis (AMIC)

BACKGROUND

The primary aim of the study is to evaluate the functional outcome following AMIC procedure in patients with osteochondral injury of the talus. The secondary aim is to evaluate if size of the lesion and patient's age influence outcome.

MATERIALS AND METHODS

This is a retrospective study of 25 patients who underwent AMIC procedure of the talus treated by a single surgeon. Functional outcomes were evaluated using pre and post operative AOFAS and VAS scores.

RESULTS

The mean lesion size was 1.74 cms with 88% of lesions in the study more than 1.4 cms. There was a significant improvement in AOFAS score with mean improvement of 49.40 (p < 0.05) and VAS score of 5.36 (p < 0.05). We could not find any correlation between either age or lesion size with functional outcome for AMIC procedure.

CONCLUSION

AMIC procedure seems to be a reliable treatment method for larger diameter osteochondral lesions of the talus up to 2.5 cms in diameter.

Arthroscopic microfracture with atelocollagen augmentation for osteochondral lesion of the talus: a multicenter randomized controlled trial

BACKGROUND

We aimed to evaluate whether arthroscopic microfracture with atelocollagen augmentation could improve the clinical outcomes and quality of regenerated cartilage in patients with osteochondral lesion of the talus (OLT). We hypothesized that the clinical outcomes and quality of the regenerated cartilage would be superior in patients undergoing arthroscopic microfracture with atelocollagen augmentation compared to those undergoing arthroscopic microfracture alone.

METHODS

In this multicenter, randomized controlled trial, 60 patients were randomly allocated to two groups: arthroscopic microfracture with atelocollagen augmentation (group 1, n = 31) and arthroscopic microfracture alone (group 2, n = 29). Mean 100-mm visual analog scale (VAS), Hannover scoring system (HSS), and American Orthopedic Foot and Ankle Society (AOFAS) scores were assessed 2 years postoperatively and compared between the groups. The quality of the regenerated cartilage was assessed according to the Magnetic Resonance Observation of CArtilage Repair Tissue (MOCART) score based on magnetic resonance imaging.

RESULTS

Forty-six patients (22 in group 1, 23 in group 2) completed the 2-year follow-up. The quality of the regenerated cartilage assessed based on the MOCART score was significantly superior in group 1 compared to group 2 (64.49 ± 18.27 vs 53.01 ± 12.14, p = 0.018). Clinical outcomes in terms of 100-mm VAS (17.25 ± 20.31 vs 19.37 ± 18.58, p = 0.72), HSS (93.09 ± 13.64 vs 86.09 ± 13.36, p = 0.14), and AOFAS (91.23 ± 8.62 vs 86.91 ± 10.68, p = 0.09) scores were superior in group 1 compared to group 2, but the differences were not statistically significant. Both groups showed significant improvements in clinical outcomes compared with the preoperative values.

CONCLUSION

The quality of the regenerated cartilage was superior after arthroscopic microfracture with atelocollagen augmentation compared to that after microfracture alone in patients with OLT. Clinical outcomes assessed 2 years postoperatively were superior in patients who underwent arthroscopic microfracture with atelocollagen augmentation compared to those who underwent arthroscopic microfracture alone, although the differences were not statistically significant. A long-term study of the cohort is required to confirm these findings.

TRIAL REGISTRATION

ClinicalTrials.gov ( NCT02519881 ), August 11, 2015.

Autologous Matrix-Induced Chondrogenesis: A Systematic Review of the Clinical Evidence

BACKGROUND

The addition of a type I/III collagen membrane in cartilage defects treated with microfracture has been advocated for cartilage repair, termed "autologous matrix-induced chondrogenesis" (AMIC).

PURPOSE

To examine the current clinical evidence regarding AMIC for focal chondral defects.

STUDY DESIGN

Systematic review.

METHODS

A systematic review was performed by searching PubMed, ScienceDirect, and Cochrane Library databases. Inclusion criteria were clinical studies of AMIC for articular cartilage repair, written in English. Relative data were extracted and critically analyzed. PRISMA guidelines were applied, the methodological quality of the included studies was assessed by the modified Coleman Methodology Score (CMS), and aggregate data were generated.

RESULTS

Twenty-eight clinical articles were included: 12 studies (245 patients) of knee cartilage defects, 12 studies (214 patients) of ankle cartilage defects, and 4 studies (308 patients) of hip cartilage defects. The CMS demonstrated a suboptimal study design in the majority of published studies (knee, 57.8; ankle, 55.3; hip, 57.7). For the knee, 1 study reported significant clinical improvements for AMIC compared with microfracture for medium-sized cartilage defects (mean defect size 3.6 cm²) after 5 years (level of evidence, 1). No study compared AMIC with matrix-assisted autologous chondrocyte implantation (ACI) in the knee. For the ankle, no clinical trial was available comparing AMIC versus microfracture or ACI. In the hip, only one analysis (level of evidence, 3) compared AMIC with microfracture for acetabular lesions. For medium-sized acetabular defects, one study (level of evidence, 3) found no significant differences between AMIC and ACI at 5 years. Specific aspects not appropriately discussed in the currently available literature include patient-related factors, membrane fixation, and defect properties. No treatment-related adverse events were reported.

CONCLUSION

This systematic review reveals a paucity of high-quality, randomized controlled studies testing the AMIC technique versus established procedures such as microfracture or ACI. Evidence is insufficient to recommend joint-specific indications for AMIC. Additional nonbiased, high-powered, randomized controlled clinical trials will provide better clinical and structural long-term evidence, thus helping to define possible indications for this technique.

Acetabular Chondral Lesions Associated With Femoroacetabular Impingement Treated by Autologous Matrix-Induced Chondrogenesis or Microfracture: A Comparative Study at 8-Year Follow-Up

PURPOSE

The aim of this retrospective study was to investigate, at 8 years, the clinical follow-up and failure rate (revision rate/conversion to arthroplasty) of patients with hip chondral lesions associated with femoroacetabular impingement and to compare over time the treatment by microfracture (MFx) and autologous matrix-induced chondrogenesis (AMIC).

METHODS

Patients aged between 18 and 55 years, with acetabular grade III and IV chondral lesions (Outerbridge), measuring 2 to 8 cm2 operated on at least 8 years before enrollment. Exclusion criteria were rheumatoid arthritis, dysplasia, or axial deviation of the femoral head. There were no arthritic lesions, Tonnis < 2, or joint space of at least 2 mm. MFx was performed with an awl, and the Chondro-Gide membrane used for the AMIC procedure was placed without glue. Outcomes used modified Harris hip score (mHHS) at 6 months and yearly for 8 years and patient acceptable symptomatic state.

RESULTS

Among 130 patients, 109 fulfilled inclusion criteria. Fifty were treated by MFx and 59 by AMIC. The mHHS significantly improved in both groups from 46 ± 6.0 to 78 ± 8.8 for mHHS at 6-12 months, even for lesions > 4 cm2. From 2 to 8 years, mHHS in the AMIC group was better than in the MFx group (P < .005). This mHHS improvement in the AMIC group was maintained through the 8-year follow-up period, whereas it deteriorated after 1 year in the MFx group (P < .005). Eleven patients (22%) in the MFx group required total hip arthroplasty (THA); none in the AMIC group did. Patient acceptable symptomatic state analysis confirmed similar short-term improvement, but a significant (P < .007) degradation after 2-8 years in MFx patients.

CONCLUSIONS

MFx and AMIC techniques led to marked clinical short-term improvement in patients with chondral defects resulting from femoroacetabular impingement in the first 2 years. However, AMIC gave significantly better results as measured by mHHS, which were maintained after 8 years, the results of MFx in the hip deteriorated over time with 22% of patients undergoing conversion to THA. No patient in the AMIC group was converted to THA; the results of AMIC appeared stable over time and independent of lesion size.

LEVEL OF EVIDENCE

III, retrospective patient group study.

Beneficial clinical effects but limited tissue quality following osteochondral repair with a cell-free multilayered nano-composite scaffold in the talus

BACKGROUND

The treatment of larger osteochondral lesions of the talus remains an operative challenge. In addition to micro fracturing and osteochondral transplantation one promising strategy could be the operative repair with a cell-free multilayered nano-composite scaffold with the potential to regenerate bone and cartilage in one treatment.

METHODS

In this prospective case series four consecutive patients who suffered from a single osteochondral lesion (≥1.5cm²) on the medial talus were enrolled. The repair potential of the implant was assessed using MRI based biochemical, compositional MR sequences (T2 mapping) as well as semi-quantitative morphological analyses (MOCART score) at 18 months follow-up after the surgery. The clinical outcome was determined at 6-, 12-, 18-, and 24 months follow-up by using the Ankle Disability Index and the AOFAS score.

RESULTS

At 18 months after the surgery, the clinical outcome was significantly improved compared to the preoperative baseline. Global T2 relaxation times of the repair tissue were significantly increased compared to the healthy control cartilage.

CONCLUSIONS

Osteochondral repair with a cell-free, biomimetic scaffold provides good clinical, short-term results. However, biochemical MR imaging provides strong evidence for limited repair tissue quality at 18 months after the implantation.

LEVEL OF EVIDENCE

IV.

Sports Activity After Reconstruction of Osteochondral Lesions of the Talus With Autologous Spongiosa Grafts and Autologous Matrix-Induced Chondrogenesis

BACKGROUND

For the treatment of osteochondral lesions of the talus (OCLTs), autologous matrix-induced chondrogenesis (AMIC) is a safe 1-step procedure with good clinical and radiological results. However, data regarding postoperative sports activity after AMIC are limited.

PURPOSE

To identify significant factors influencing the rate of postoperative sports and recreational activities.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

The sports and recreational activities of 60 patients (mean age, 34.9 ± 11.5 years) undergoing the AMIC procedure were retrospectively analyzed at a mean of 46.9 ± 17.8 months (range, 24.5-87.0 months) postoperatively. The visual analog scale (VAS) for pain score, Tegner activity scale score, activity rating scale (ARS) score, and satisfaction with surgery outcomes were assessed.

RESULTS

Corrective calcaneal osteotomy was performed in 38 of 60 (63.3%) patients. Ligament repair was performed in 41 of 60 (68.3%) patients. The mean VAS score improved significantly from 6.9 ± 1.6 points (range, 5-10 points) preoperatively to 2.3 ± 1.9 points (range, 0-6 points) at latest follow-up (P < .001). No significant change in the mean Tegner activity scale score (3.3 ± 2.0 preoperatively to 3.4 ± 2.2 postoperatively; P = .526) and the mean ARS score (2.6 ± 4.3 preoperatively to 2.3 ± 3.4 postoperatively; P = .874) was noted. The percentage of patients involved in sports activity before the onset of symptoms became significantly lower at the time of surgery (from 95.0% to 53.3%; P < .001); no significant difference was noted postoperatively (from 53.3% to 58.3%; P = .663). No significant difference of the weekly sports frequency and the duration of sports activity was found postoperatively.

CONCLUSION

Patients undergoing AMIC repair of an OCLT participate at a similar low postoperative sports and recreational activity level compared with the preoperative level.

Arthroscopic Treatment of Chondral and Osteochondral Defects in the Ankle Using the Autologous Matrix-Induced Chondrogenesis Technique

One of the greatest challenges nowadays facing orthopaedic surgeons around the world is the problem of articular cartilage defects and their treatment. The autologous matrix-induced chondrogenesis technique is based on 2 elements-drilling into bones and matrix application. The purpose of this article is to present the surgical technique of arthroscopic treatment of chondral or osteochondral defects in the ankle using the autologous matrix-induced chondrogenesis technique.

Clinical outcome and T2 assessment following autologous matrix-induced chondrogenesis in osteochondral lesions of the talus

PURPOSE

Scientific evidence for the treatment of osteochondral lesions (OCLs) of the talus is limited. The aim of this study was an evaluation of the clinical outcome after a one-step autologous subchondral cancellous bone graft and autologous matrix-induced chondrogenesis (AMIC) in medial OCLs of the talus and the assessment of the repair tissue (RT).

METHODS

Seventeen patients (eight women, nine men; mean age, 38.8 ± 15.7 years) with an OCL of the medial talus underwent surgery. Clinical and radiological assessment was performed after a mean follow-up of 39.5 ± 18.4 months, including established scoring systems (American Orthopaedic Foot and Ankle Society [AOFAS] Score, Foot Function Index [FFI], visual analogue scale [VAS]), evaluation of Magnetic Resonance Observation of Cartilage Repair Tissue scoring system (MOCART Score) and T2 mapping.

RESULTS

Preoperative pain (7.8 ± 2.1) significantly improved to an average of 3.2 ± 2.4 postoperatively. AOFAS Score averaged 82.6 ± 13.4, MOCART Score 52.7 ± 15.9. Mean T2 relaxation time of the RT was 41.6 ± 6.3 ms and showed no significant differences to the surrounding cartilage (mean, 38.8 ± 8.5; p = 0.58). MOCART Score significantly correlated with the AOFAS Score (rho = 0.574, p = 0.040). T2 relaxation time of the RT significantly correlated with the MOCART Score (rho = 0.593, p = 0.033).

CONCLUSIONS

The one-step autologous subchondral cancellous bone grafting and AMIC leads to a significant reduction in postoperative pain and satisfying postoperative functional outcome in mid-term follow-up. Magnetic resonance imaging (MRI) assessment demonstrated a good quality of regenerative tissue similar to the MRI ultrastructure of the surrounding cartilage.

All-Arthroscopic Autologous Matrix-Induced Chondrogenesis for the Treatment of Osteochondral Lesions of the Talus

Several surgical techniques have been described for the treatment of talar chondral lesions. Among them, microfracture is well established. Autologous matrix-induced chondrogenesis (AMIC), using microfracture and biomaterials, has shown promising results for the treatment of knee osteochondral lesions and has been proposed for the ankle as an open technique. We describe an all-arthroscopic AMIC technique. The benefits of an all-arthroscopic procedure include smaller incisions with less soft-tissue dissection, better visualization of the joint, and a quicker recovery compared with open surgery. The use of matrix to support cartilage regeneration promotes good-quality cartilage tissue with satisfactory long-term outcomes. Our all-arthroscopic AMIC technique uses a type I-type III porcine collagen matrix (Chondro-Gide; Geistlich Pharma, Wolhusen, Switzerland) and is characterized by 2 different arthroscopic surgical phases. First, adequate exposure is achieved through use of a Hintermann spreader (Integra LifeSciences, Plainsboro, NJ) with sufficient joint distraction and wet lesion preparation. The second surgical step is performed dry, involving matrix placement and fixation. The all-arthroscopic AMIC technique for the treatment of osteochondral lesions of the talus allows a very precise reconstruction in the case of cartilage defects and avoids the need for a more invasive operation associated with higher morbidity and a longer surgical time.

In vivo animal study and clinical outcomes of autologous atelocollagen-induced chondrogenesis for osteochondral lesion treatment

Background

Collagen acts as a scaffold for healing damaged cartilage. This study evaluated the results of an in vivo animal study and provides short-term clinical results on a mixture of atelocollagen and fibrin glue-enhanced microfracture techniques in patients with osteochondral lesions (OCL) of the talus.

Methods

This paper contains animal in vivo data and clinical outcomes on the effectiveness of atelocollagen. An in vivo animal study was conducted with full-thickness cartilage defects created in the femoral condyle of 12 rabbits equally divided into 4 groups evaluated at 2, 4, 8, and 12 weeks. Four chondral lesions were created according to one procedure on each rabbit with each lesion treated as follows: (1) microfracture, (2) microfracture and the lesion covered with atelocollagen, (3) microfracture and the lesion covered with mixture of atelocollagen and fibrin glue, and (4) microfracture and the lesion covered with fibrin glue. In the clinical evaluation, 17 patients were treated with a combination of microfracture and atelocollagen injection for symptomatic full-thickness OCL of the talus. They were evaluated by the American Orthopedic Foot and Ankle Society Ankle-Hindfoot Score (AOFAS), Hannover Ankle Score System (HSS), visual analog scale (VAS), and magnetic resonance imaging (MRI) at baseline and at 12-months follow-up. Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score of the post-op status was compared with the MOCART score and a modified Anderson’s score of the pre-op status.

Results

In the animal study, subchondral bone and cartilage were generated completely in groups 2 and 3 microscopically. Hyaline-like cartilage was found in the repair tissue. In the clinical evaluation, mean AOFAS improved from 62 to 88, mean HSS improved from 62 to 87, and mean VAS score improved from 64 to 18, respectively (p <0.001). Fifteen patients (89 %) reported good or excellent satisfaction. We defined the improvement of most of the subchondral bone edema and bone cyst as well as a chondral lesion by radiologic evaluation.

Conclusions

Rapid regeneration of cartilage was demonstrated in the in vivo animal study, and patients showed significant clinical improvement. Atelocollagen-enhanced microfracture enabled a reasonable treatment of cartilage defects.

Current Concepts in Hip Preservation Surgery: Part I

Context:

An evolution in conceptual understanding, coupled with technical innovations, has enabled hip preservation surgeons to address complex pathomorphologies about the hip joint to reduce pain, optimize function, and potentially increase the longevity of the native hip joint. Technical aspects of hip preservation surgeries are diverse and range from isolated arthroscopic or open procedures to hybrid procedures that combine the advantages of arthroscopy with open surgical dislocation, pelvic and/or proximal femoral osteotomy, and biologic treatments for cartilage restoration.

Evidence Acquisition:

PubMed and CINAHL databases were searched to identify relevant scientific and review articles from January 1920 to January 2015 using the search terms hip preservation, labrum, surgical dislocation, femoroacetabular impingement, peri-acetabular osteotomy, and rotational osteotomy. Reference lists of included articles were reviewed to locate additional references of interest.

Study Design:

Clinical review.

Level of Evidence:

Level 4.

Results:

Thoughtful individualized surgical procedures are available to optimize the femoroacetabular joint in the presence of hip dysfunction.

Conclusion:

A comprehensive understanding of the relationship between femoral and pelvic orientation, morphology, and the development of intra-articular abnormalities is necessary to formulate a patient-specific approach to treatment with potential for a successful long-term result.

Sustained five-year benefit of autologous matrix-induced chondrogenesis for femoral acetabular impingement-induced chondral lesions compared with microfracture treatment

The repair of chondral lesions associated with femoroacetabular impingement requires specific treatment in addition to that of the impingement. In this single-centre retrospective analysis of a consecutive series of patients we compared treatment with microfracture (MFx) with a technique of enhanced microfracture autologous matrix-induced chondrogenesis (AMIC).

Acetabular grade III and IV chondral lesions measuring between 2 cm2 and 8 cm2 in 147 patients were treated by MFx in 77 and AMIC in 70. The outcome was assessed using the modified Harris hip score at six months and one, two, three, four and five years post-operatively. The outcome in both groups was significantly improved at six months and one year post-operatively. During the subsequent four years the outcome in the MFx group slowly deteriorated, whereas that in the AMIC group remained stable. Six patients in the MFx group subsequently required total hip arthroplasty, compared with none in the AMIC group

We conclude that the short-term clinical outcome improves in patients with acetabular chondral damage following both MFx and AMIC. However, the AMIC group had better and more durable improvement, particularly in patients with large (≥ 4 cm2) lesions.

Cite this article: Bone Joint J 2015; 97-B:628–35.

Reconstruction of focal cartilage defects in the talus with miniarthrotomy and collagen matrix

SURGICAL PRINCIPAL AND OBJECTIVE

Treatment of focal cartilage defects (traumatic or osteochondrosis dissecans) of the talus using a collagen matrix. The goal is to stabilize the superclot formed after microfracturing to accommodate cartilage repair. The procedure can be carried out via miniarthrotomy, without medial malleolus osteotomy.

INDICATIONS

International Cartilage Repair Society (ICRS) grade III and IV focal cartilage defects of the talus > 1.5 cm(2).

CONTRAINDICATIONS

Generalized osteoarthritis, inflammatory joint disease, gout, neuroarthropathy.

SURGICAL TECHNIQUE

Miniarthrotomy to open the ankle joint. Debridement of unstable cartilage and necrotic bone, curettage of cysts. Filling of the bone defects with autologous cancellous bone. Sealing of reconstructed bone with fibrin glue and attachment of a collagen matrix shaped to precisely fit the defect.

POSTOPERATIVE REGIMEN

Immobilization for 48 h. Partial weight bearing of 10 kg for 6 weeks, with continuous passive motion. Increasing weight bearing from 7 weeks onwards.

RESULTS

Follow-up of at least 30 months in 14 patients showed improvement in the Score of the American Orthopedic Foot and Ankle Society (AOFAS) from 50 to 89 points, with equal mobility on both sides of the upper ankle joint.

Osteochondral lesions of the ankle joint in professional soccer players: treatment with autologous matrix-induced chondrogenesis

Acute and recurrent ankle sprains and other trauma to the ankle joint are common injuries in soccer and can be accompanied by or result in osteochondral lesions of the ankle joint, majorly of the talus. Conservative treatment frequently fails. Several operative treatment techniques exist; however, the choice of the right procedure is difficult due to lack of literature with a high level of evidence. We present our treatment method for acute and chronic ankle osteochondral lesions with cystic formation approached by a new surgical technique combining bone plasty and a collagen matrix (autologous matrix-induced chondrogenesis).

LEVELS OF EVIDENCE

Therapeutic, Level IV: Case series.

Characterization of the collagen component of cartilage repair tissue of the talus with quantitative MRI: comparison of T2 relaxation time measurements with a diffusion-weighted double-echo steady-state sequence (dwDESS)

OBJECTIVES

The purpose of this study was to characterize the collagen component of repair tissue (RT) of the talus after autologous matrix-induced chondrogenesis (AMIC) using quantitative T2 and diffusion-weighted imaging.

METHODS

Mean T2 values and diffusion coefficients of AMIC-RT and normal cartilage of the talus of 25 patients with posttraumatic osteochondral lesions and AMIC repair were compared in a cross-sectional design using partially spoiled steady-state free precession (pSSFP) for T2 quantification, and diffusion-weighted double-echo steady-state (dwDESS) for diffusion measurement. RT and cartilage were graded with modified Noyes and MOCART scores on morphological sequences. An association between follow-up interval and quantitative MRI measures was assessed using multivariate regression, after stratifying the cohort according to time interval between surgery and MRI.

RESULTS

Mean T2 of the AMIC-RT and cartilage were 43.1 ms and 39.1 ms, respectively (p = 0.26). Mean diffusivity of the RT (1.76 μm(2)/ms) was significantly higher compared to normal cartilage (1.46 μm(2)/ms) (p = 0.0092). No correlation was found between morphological and quantitative parameters. RT diffusivity was lowest in the subgroup with follow-up >28 months (p = 0.027).

CONCLUSIONS

Compared to T2-mapping, dwDESS demonstrated greater sensitivity in detecting differences in the collagen matrix between AMIC-RT and cartilage. Decreased diffusivity in patients with longer follow-up times may indicate an increased matrix organization of RT.

KEY POINTS

• MRI is used to assess morphology of the repair tissue during follow-up. • Quantitative MRI allows an estimation of biochemical properties of the repair tissue. • Differences between repair tissue and cartilage were more significant with dwDESS than T2 mapping.

Autologous Matrix-Induced Chondrogenesis in the Knee: A Review

OBJECTIVE

Autologous matrix-induced chondrogenesis (AMIC) is a 1-step cartilage restoration technique that combines microfracture with the use of an exogenous scaffold. This matrix covers and mechanically stabilizes the clot. There have been an increasing number of studies performed related to the AMIC technique and an update of its use and results is warranted.

DESIGN AND METHODS

Using the PubMed database, a literature search was performed using the terms "AMIC" or "Autologous Matrix Induced Chondrogenesis." A total of 19 basic science and clinical articles were identified.

RESULTS

Ten studies that were published on the use of AMIC for knee chondral defects were identified and the results of 219 patients were analyzed. The improvements in Knee Injury and Osteoarthritis Outcome Score, International Knee Documentation Committee Subjective, Lysholm and Tegner scores at 2 years were comparable to the published results from autologous chondrocyte implantation (ACI) and matrix ACI techniques for cartilage repair.

CONCLUSIONS

Our systematic review of the current state of the AMIC technique suggests that it is a promising 1-stage cartilage repair technique. The short-term clinical outcomes and magnetic resonance imaging results are comparable to other cell-based methods. Further studies with AMIC in randomized studies versus other repair techniques such as ACI are needed in the future.

Autologous collagen-induced chondrogenesis technique (ACIC) for the treatment of chondral lesions of the talus

PURPOSE

Autologous collagen-induced chondrogenesis technique (ACIC) combines microfractures with the use of an injectable atelocollagen matrix that allows performing the whole cartilage repair treatment arthroscopically. The aim of this study was to evaluate the in vitro cytocompatibility of this biomaterial using human bone marrow mesenchymal stem cells and human chondrocytes. Moreover, the preliminary data of five patients affected by chondral lesion of the talus treated with the ACIC technique are shown.

METHODS

Human bone marrow mesenchymal stem cells and human chondrocytes were seeded on solid and pre-solid atelocollagen scaffolds. Cell-scaffold constructs were cultured for 7 days and then prepared for histological analyses. Arthroscopic ACIC was performed in five patients affected by chondral lesions of the talus; they were clinically evaluated with AOFAS, VAS and Tegner score before and then after 6 months from surgery.

RESULTS

In vitro results showed that both bone marrow mesenchymal stem cells and chondrocytes were able to efficiently colonize the whole construct, from the surface to the core, only when seeded on the pre-solid atelocollagen scaffold, but not on its solid form. No adverse events were observed in the patients treated with the ACIC technique; a significant improvement in VAS pain scale and in AOFAS score was found at 6 months follow up.

CONCLUSION

Injectable atelocollagen can be considered a feasible scaffold for cartilage repair treatment, in particular if used in its pre-solid form. ACIC leads to good clinical results in the treatment for chondral lesions of the talus even if longer follow-up and a higher number of patients are necessary to confirm these data.

LEVEL OF EVIDENCE

IV.

Osteochondral lesions of the talus: aspects of current management

Osteochondral lesions (OCLs) occur in up to 70% of sprains and fractures involving the ankle. Atraumatic aetiologies have also been described. Techniques such as microfracture, and replacement strategies such as autologous osteochondral transplantation, or autologous chondrocyte implantation are the major forms of surgical treatment. Current literature suggests that microfracture is indicated for lesions up to 15 mm in diameter, with replacement strategies indicated for larger or cystic lesions. Short- and medium-term results have been reported, where concerns over potential deterioration of fibrocartilage leads to a need for long-term evaluation. Biological augmentation may also be used in the treatment of OCLs, as they potentially enhance the biological environment for a natural healing response. Further research is required to establish the critical size of defect, beyond which replacement strategies should be used, as well as the most appropriate use of biological augmentation. This paper reviews the current evidence for surgical management and use of biological adjuncts for treatment of osteochondral lesions of the talus.

[Osteochondritis dissecans of the talus. Diagnosis and treatment]

Osteochondritis dissecans of the talus (ODT) describes a special entity of osteochondral lesions of the talus (OLT) which has to be distinguished from acute traumatic lesions. Its exact etiology still remains uncertain with multiple predispositioning factors being discussed. Following the knee and elbow, the ankle joint with 4% is the third most affected joint. Early stages can often be treated conservatively. In case of an advanced stage or failure of conservative treatment, a variety of operative techniques are available, which can be used based on the patient and the stage.

Chondral and osteochondral reconstruction of local ankle degeneration

Local cartilage or osteochondral degeneration of the ankle are common, painful posttraumatic conditions in young, sport-active patients. Conservative treatment of the acute initial stage of local cartilage or osteochondral damage might be indicated, but commonly fails in the presence of local or asymmetric osteoarthritic disease. Many surgical treatment methods are available for the orthopedic surgeon, which show satisfactory short-term to mid-term results. However, the scientific evidence for these procedures is weak. This article discusses the commonly used methods for cartilage and osteochondral repair and new upcoming methods, plus the role of concomitant disorders of the ankle joint.

Delayed gadolinium-enhanced MRI of cartilage of the ankle joint: results after autologous matrix-induced chondrogenesis (AMIC)-aided reconstruction of osteochondral lesions of the talus

AIM

To assess cartilage quality using delayed gadolinium-enhanced magnetic resonance imaging after repair of osteochondral lesions of the talus using autologous matrix-induced chondrogenesis (AMIC).

MATERIALS AND METHODS

A three-dimensional (3D) spoiled gradient-echo (SGE) sequence at 3 T was used to obtain quantitative T1 relaxation times before and after Gd-DTPA2 (Magnevist, 0.2 mM/kg bod weight) administration to assess 23 cases of AMIC-aided repair of osteochondral lesions of the talus. Delta relaxation rates (ΔR1) for reference cartilage (RC) and repair tissue (RT), and the relative delta relaxation rate (rΔR1) were calculated. The morphological appearance of the cartilage RT was graded on sagittal dual-echo steady-state (DESS) views according to the "magnetic resonance observation of cartilage repair tissue" (MOCART) protocol. The study was approved by the institutional review board and written consent from each patient was obtained.

RESULTS

The AMIC cases had a mean T1 relaxation time of 1.194 s (SD 0.207 s) in RC and 1.470 s (SD 0.384 s) in RT before contrast medium administration. The contrast-enhanced T1 relaxation time decreased to 0.480 s (SD 0.114 s) in RC and 0.411 s (SD 0.096 s) in RT. There was a significant difference (p > 0.05) between the ΔR1 in RC (1.372 × 10(-3)/s, range 0.526-3.201 × 10(-3)/s, SD 0.666 × 10(-3)/s) and RT (1.856 × 10(-3)/s, range 0.93-3.336 × 10(-3)/s, SD 0.609 × 10(-3)/s). The mean rΔR1 was 1.49, SD 0.45). The mean MOCART score at follow-up was 62.6 points (range 30-95, SD 15.3).

CONCLUSION

The results of the present study suggest that repair cartilage resulting from AMIC-aided repair of osteochondral lesions of the talus has a significantly lower glycosaminoglycan (GAG) content than normal hyaline cartilage, but can be regarded as having hyaline-like properties.

Autologous matrix-induced chondrogenesis in osteochondral lesions of the talus

Recurrent ankle sprains and other trauma as well as ankle malalignment can lead to chronic osteochondral lesions of the talus. Conservative treatment frequently fails. Several operative treatment techniques exist; however, the choice of the right procedure is difficult. This article presents a new surgical technique suitable for treatment osteochondral lesions that combines bone plasty and a collagen matrix.

Scaffolds for cartilage repair of the ankle joint: The impact on surgical practice

BACKGROUND

Ideal management of osteochondral lesions in the ankle joint is still theme of debate. Scaffold-based repair is emerging as a new approach for regenerative treatment.

METHODS

Articles published in PubMed from 2000 to January 2012 addressing cartilage scaffold-based treatment were identified, including levels I-IV evidence clinical trials with measures of functional, clinical or imaging outcome.

RESULTS

The analysis showed a progressively increasing number of articles from 2000. The number of selected papers was 19:15 focusing on two-step and 4 on one-step procedures; no randomized studies, 3 comparative studies, 11 case series and 5 case reports were identified.

CONCLUSIONS

Regenerative surgical approach with scaffold-based procedures is emerging as a potential therapeutic option for the treatment of chondral lesions of the ankle. One step treatments simplify the procedure and the results reported are very close to the previous techniques. However, well-designed studies are lacking, and randomized long-term trials are necessary to confirm the potential of these techniques.

LEVEL OF EVIDENCE

Review - IV.

Reconstruction of osteochondral lesions of the talus with autologous spongiosa grafts and autologous matrix-induced chondrogenesis

BACKGROUND

Osteochondral lesions (OCLs) of the talus are a common entity in sports orthopaedics. There are several operative techniques with a good outcome on follow-up examinations. However, limitations such as sacrificing healthy cartilage (osteochondral autograft transfer system [OATS], mosaicplasty), multiple-stage operative procedures (matrix-induced autologous chondrocyte transplantation [MACI], autologous chondrocyte implantation [ACI]), high costs (ACI, allograft), and limited availability (allograft) do remain and reflect potential drawbacks of the currently used techniques.

PURPOSE

To describe a novel operative technique for the treatment of OCLs of the talus in the form of an economically efficient, 1-step procedure combining OCL debridement, spongiosaplasty, and sealing of the OCL area with a collagen matrix.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Twenty-six patients underwent surgery receiving a modified autologous matrix-induced chondrogenesis (AMIC)-aided repair of OCLs of the talus consisting of debridement, autologous grafting, and sealing of the defect with a collagen scaffold. Ligament repair was performed in 17 of 26 cases. A corrective calcaneal osteotomy was performed in 16 of 26 cases. Clinical and radiological assessment was performed before and a minimum of 24 months after surgery (mean, 31 months; range, 24-54 months). Clinical examination included the American Orthopaedic Foot and Ankle Society (AOFAS) ankle score and the visual analog scale (VAS) for pain. Radiological imaging included single-photon emission computed tomography-computed tomography (SPECT-CT) and magnetic resonance imaging (MRI). The magnetic resonance observation of cartilage repair tissue (MOCART) score was applied, and sport activity was documented.

RESULTS

The AOFAS ankle score improved significantly from a mean of 60 points preoperatively (range, 17-79 points) to 89 points (range, 61-100 points) postoperatively (P < .01). The preoperative pain score averaged 5 (range, 2-8), improving to an average of 1.6 (range, 0-7) postoperatively (P < .01). The MOCART score for cartilage repair tissue on postoperative MRI averaged 62 points (range, 20-95 points). Complete filling of the defect at the level of the surrounding cartilage was found in 35%, and complete filling with a hypertrophic cartilage layer was found in 50% of the patients. Normal signal intensity of the repair tissue compared with the adjacent native cartilage was seen in 15%, with nearly normal activity in 69%. Nineteen patients (73%) participated in sports before the onset of symptoms compared with 3 (12%) at the time of surgery. The number increased to 16 patients (62%) at postoperative follow-up.

CONCLUSION

The modified AMIC procedure is safe for the treatment of OCLs in the ankle with overall good clinical and MRI results.

Surgical technique: Second-generation bone marrow stimulation via surgical dislocation to treat hip cartilage lesions

BACKGROUND

Compared to knees, hips have more bony constraint and soft tissue coverage. Thus, repair of focal cartilage defects in hips requires more invasive and technically complex surgeries than simple arthroscopy or arthrotomy. Autologous matrix-induced chondrogenesis (AMIC) is a second-generation bone marrow stimulation technique. Improvement in Tegner, Lysholm, International Cartilage Repair Society (ICRS), and Cincinnati scores has been reported at 1 and 2 years after AMIC in knees. AMIC is potentially useful to repair defects in hips, but it is unknown whether it relieves symptoms or results in a durable construct.

DESCRIPTION OF TECHNIQUE

A surgical hip dislocation is used to access the defect. This is débrided to stable cartilage shoulders, necrotic bone is removed, and the lesion base is drilled. Autogenous bone graft is used for lesions with bony defects to create a level surface. Fibrin gel and a collagen membrane are placed to stabilize the superclot for fibrocartilage formation.

METHODS

We treated six patients with AMIC in the hip between 2009 and 2010. We obtained Oxford Hip and UCLA Activity Scores. Repair quality was assessed on 6-month postoperative MRI using the modified magnetic resonance observation of cartilage repair tissue (MOCART) system. Minimum 1-year followup data were available for four patients (range, 1-2.5 years).

RESULTS

Postoperative Oxford Hip Scores ranged from 13 to 17, UCLA Activity Scores ranged from 5 to 10, and MOCART scores ranged from 55 to 75. No complications occurred.

CONCLUSIONS

We describe AMIC in the hip. Although these patients had pain relief and improved function, long-term followup is necessary to assess the duration of improvement, durability of repair, and potential for arthrosis.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Clinical and MRI results after microfracture of osteochondral lesions of the talus

PURPOSE

Arthroscopic microfracture (AM) of osteochondral lesions of the talus is used to induce intrinsic refilling of the defect and reduce pain. The aim of this retrospective study was to investigate the clinical state after AM and the MRI outcome.

METHODS

A total of 22 patients [10 women, 12 men, 31 years old (mean, 13-68 range)] treated for osteochondral lesions of the talus by AM were examined 2 years (median) postoperatively and pre- and postoperative MRI results compared. Swelling/effusion, articular constriction, joint pain, and range of motion restriction were documented. Clinical state was evaluated using the AOFAS hindfoot score. MRI was used to assess the size of the defect, presence of bone marrow edema, cysts and effusion, thickness of repair tissue, and integrity of the cartilage.

RESULTS

In all but six cases, the defect was located at the medial shoulder of the talus. The postoperative AOFAS score at follow-up was 87.5 points (median 36-100 points range). Seven patients were free of pain, 11 had "mild, occasional" pain, 1 "moderate daily", and 3 "severe, almost always present" pain (AOFAS). The defect volume was significantly reduced from 377 mm(3) preoperatively (median, interquartile distance: 417 mm(3)) to 249 mm(3) postoperatively (median, IQD: 336 mm(3), p = 0.019, Wilcoxon). In 7 cases, the defect was completely filled, in 11 partially and in 4 only slightly.

CONCLUSION

After AM of osteochondral lesions of the talus, 18 of 22 patients had no or mild, occasional pain at 2 years follow-up. On MRI, the lesion volume had been reduced and filling with repair tissue was found.

Reconstruction of complex osteochondral lesions of the talus with cylindrical sponge allograft and particulate juvenile cartilage graft: provisional results with a short-term follow-up

Osteochondral lesions of the talus can be a challenging injury to treat for even the most experienced foot and ankle surgeon. Although the advances in imaging have made the diagnosis of chondral lesions more accurate, surgeons are still struggling to find ways to reliably treat advanced lesions with subchondral bone damage. This article looks at the use of allograft bone and particulate juvenile cartilage in patients with advanced subchondral bone damage and osteochondral lesions of the talus.

Reconstruction of a large osteochondral lesion of the distal tibia with an iliac crest graft and autologous matrix-induced chondrogenesis (AMIC): a case report

Isolated osteochondral lesions (OCL) of the distal tibia are rare and lack clear treatment guidelines. With the case we present here, we suggest a novel surgical approach and report the successful use of autologous matrix-induced chondrogenesis-aided reconstruction for OCL of the distal tibia. A 29-year-old male patient complained about persisting pain of the left ankle joint and a restricted activity level 12 months after an ankle sprain. Imaging revealed edema of the subchondral bone and thinning of the cartilage above the osseous defect at the lateral distal tibia. The OCL was debrided followed by microfracturing of the underlying sclerotic bone. A cancellous bone plug was harvested from the iliac crest and impacted into the defect. A collagen matrix was then fixed on the defect. After 12 months, the patient was free of pain and returned to full activity. Conventional radiographs at 1 year showed successful osseous integration of the plug and a nearly anatomic shape of the tibial joint line. Delayed gadolinium-enhanced MRI of cartilage scans at 36 months showed an intact cartilage layer over the defect and glycosaminoglycan content, indicating hyaline-like cartilage repair. This case demonstrates autologous matrix-induced chondrogenesis-aided reconstruction of large osteochondral lesions of distal tibia to be a promising treatment method. Our aim was to describe the case of a patient with a large isolated osteochondral lesion of the distal tibia treated by a novel operative technique using cancellous bone from the iliac crest and a collagen I/III matrix.

Revision of failed osteochondral autologous transplantation procedure for chronic talus osteochondral lesion with iliac crest graft and autologous matrix-induced chondrogenesis: a case report

This article describes a novel technique for treatment of recurrent large osteochondral lesions of the talus using autologous matrix-induced chondrogenesis with a collagen I/III matrix.