Surgical treatment of osteochondritis dissecans of the talus: a systematic review

Regeneration: Bone-Marrow Stimulation of the Talus-Limits and Goals

Bone Marrow Stimulation of osteochondral lesions of the talus has been shown to be a successful way to treat cartilage injuries. Newer data suggest that Bone Marrow Stimulation is best reserved for osteochondral lesions of the talus Sizes Less Than 107.4 mm2 in area. Additionally, newer smaller and deeper techniques to perform bone marrow stimulation have resulted in less subchondral bone damage, less cancellous compaction, and superior bone marrow access with multiple trabecular access channels. Biologic adjuvants such as platelet-rich plasma (PRP), hyaluronic acid (HA), and bone marrow aspirate concentrate (BMAC) may lead to better functional outcomes when used concomitant to bone marrow stimulation.

Ankle Instability: Facts and Myths to Protect Your Cartilage Repairing

The majority of patients with an osteochondral lesion of the talus (OLT) report a history of trauma. Therefore, it is important to assess for concomitant ankle instability when dealing with patients with a symptomatic OLT. The History; Alignment; Ligaments; Others "(HALO)" approach can be a helpful tool in the evaluation of patients with an OLT. If conservative treatment fails, surgery may be indicated. Although there is a lack of comparative studies investigating the effect of stabilization procedures on cartilage repair, we believe that addressing instability is a key factor in improving patient outcome.

Retrograde Drilling, Ossoscopy, and Autologous Bone Grafting: An Alternative Technique for Treatment of Osteochondral Lesion of the Talus Stage 2 and 3 in Adults

BACKGROUND

Symptomatic osteochondral lesions of the talus (OLTs) often require surgical intervention. There are various surgical methods. A generally valid, stage-dependent therapeutic algorithm does not exist. The aim of our study is to show long- term results of an alternative technique that combines retrograde drilling, debridement performed under arthroscopic visualization, and autologous bone grafting.

METHODS

The surgical technique was performed in 24 patients with medial or lateral OLTs, and the data were analyzed retrospectively. In our technique, the affected subchondral bone was overdrilled retrogradely and resected under arthroscopic visualization (ossoscopy) without violating the cartilage. The resulting defect was filled with autologous bone from the medial tibia metaphysis. Outcome parameters were the numeric rating scale (NRS), the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, and range of motion (ROM). The Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score was assessed and a possible correlation with the clinical outcome scores was calculated. Data concerning complication rates were also collected.

RESULTS

The mean surface size of the OLTs was 0.9 ± 0.3 cm2. The mean follow-up was 89 months. The AOFAS score improved significantly from 57.7 points preoperatively to 88.8 points at the final follow-up (P < .0001). The pain value measured by the NRS decreased significantly from 8 to a pain level of 2. ROM improved in 37.5% of the patients for dorsiflexion and 29.2% for plantarflexion. There were no significant correlations between the MOCART score and the AOFAS score or the pain value on NRS.

CONCLUSION

Retrograde drilling, ossoscopy, and autologous bone grafting for OLTs is a promising technique with good long-term results. The patients' satisfaction rate, especially in OLT stages 2 and 3, was excellent.

LEVEL OF EVIDENCE

Level IV, case series.

Analysis of factors affecting the prognosis of osteochondral lesions of the talus

PURPOSE

This study aims to analyze the correlation between the prognosis of osteochondral lesions of the talus and patient age, gender, duration of illness, and injury location, surface area, depth, and volume.

METHODS

A retrospective analysis of 44 patients who underwent talus osteochondral transplantation in the Department of Foot and Ankle Surgery of our hospital between January 2017 and December 2020 was performed. The clinical medical records of the patients were collected, and the location of the osteochondral lesion of the talus was determined according to the nine-division method. The surface area, depth, and volume of the osteochondral lesion of the talus were measured using mimics software in all patients. The visual analog scale (VAS), the American Orthopedic Foot and Ankle Society (AOFAS), and the SF-36 quality of life questionnaire scores were evaluated before surgery and at the last follow-up, and correlation analysis was performed.

RESULTS

Of 44 patients, 30 were followed up with a mean period of 24.33 ± 12.19 months. There were 18 men and 12 women, with an average age of 40.73 ± 10.57 years and an average disease duration of 28.30 ± 21.25 months. The VAS, AOFAS, and SF-36 scores of all patients at the last follow-up were significantly better than those before surgery. The degree of post-operative symptom improvement was not correlated with age, sex, duration of illness, and injury location, surface area, depth, and volume.

CONCLUSION

The prognosis of osteochondral lesion of the talus is not related to patient age, gender, duration of disease, or injury location, surface area, depth, and volume.

Paediatric ankle cartilage lesions: Proceedings of the International Consensus Meeting on Cartilage Repair of the Ankle

BACKGROUND

The evidence supporting best practice guidelines in the field of cartilage repair of the ankle are based on both low quality and low levels of evidence. Therefore, an international consensus group of experts was convened to collaboratively advance toward consensus opinions based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article is to report the consensus statements on "Pediatric Ankle Cartilage Lesions" developed at the 2019 International Consensus Meeting on Cartilage Repair of the Ankle.

METHODS

Forty-three international experts in cartilage repair of the ankle representing 20 countries convened to participate in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within four working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed upon in unanimous fashion within the working groups. A final vote was then held, and the strength of consensus was characterised as follows: consensus: 51-74%; strong consensus: 75-99%; unanimous: 100%.

RESULTS

A total of 12 statements on paediatric ankle cartilage lesions reached consensus during the 2019 International Consensus Meeting on Cartilage Repair of the Ankle. Five achieved unanimous support, and seven reached strong consensus (>75% agreement). All statements reached at least 84% agreement.

CONCLUSIONS

This international consensus derived from leaders in the field will assist clinicians with the management of paediatric ankle cartilage lesions.

Osteochondral Lesions of the Talus: A Review on Talus Osteochondral Injuries, Including Osteochondritis Dissecans

This is a review on talus osteochondritis dissecans and talus osteochondral lesions. A majority of the osteochondral lesions are associated with trauma while the cause of pure osteochondritis dissecans is still much discussed with a possible cause being repetitive microtraumas associated with vascular disturbances causing subchondral bone necrosis and disability. Symptomatic nondisplaced osteochondral lesions can often be treated conservatively in children and adolescents while such treatment is less successful in adults. Surgical treatment is indicated when there is an unstable cartilage fragment. There are a large number of different operative technique options with no number one technique to be recommended. Most techniques have been presented in level II to IV studies with a low number of patients with short follow ups and few randomized comparisons exist. The actual situation in treating osteochondral lesions in the ankle is presented and discussed.

Scranton Type V Osteochondral Defects of Talus: Does one-stage Arthroscopic Debridement, Microfracture and Plasma Rich in Growth Factor cause the Healing of Cyst and Cessation of Progression to Osteoarthritis?

Introduction:

The study was conducted to evaluate the efficacy of arthroscopic debridement, microfracture and plasma rich in growth factor (PRGF) injection in the management of type V (Scranton) osteochondral lesions of talus and its role in healing the subchondral cyst and cessation of progression of ankle osteoarthritis.

Material and Methods:

This is a prospective case series conducted on patients who were diagnosed with type V osteochondral lesions of talus. All the cases were treated with arthroscopic debridement, microfracture, and PRGF injections. The patients were evaluated for the healing of subchondral cysts and progression of osteoarthritis with radiography (plain radiographs and computerised tomography Scan). Also, the patients’ outcome was evaluated with Quadruple Visual Analogue Scale, Ankle Range of Motion, Foot and Ankle Disability Index, Foot and Ankle Outcome Instrument and a Satisfaction Questionnaire.

Results:

Five male patients underwent arthroscopic debridement, microfracture and PRGF injection for type V osteochondral lesion of talus. The mean age of patients was 27.4 years (19-47 years). All the patients gave history of minor twisting injury. Subchondral cyst healing was achieved in all patients by six months post-surgery. However, four out of five patients had developed early osteoarthritic changes of the ankle by their last follow-up [mean follow-up 29 months (ranged 15-36 months)]. Despite arthritic changes, all the patients reported ‘Good’ to ‘Excellent’ results on satisfaction questionnaire and Foot and Ankle Disability Index and could perform their day to day activities including sports.

Conclusion:

Arthroscopic debridement, microfracture, and PRGF causes healing of the subchondral cyst but does not cause cessation of progression to osteoarthritis of ankle in type V osteochondral defects of talus. However, despite progress to osteoarthritis, patient satisfaction post-procedure is good to excellent at short-term follow-up.

Arthroscopic Implantation of a Cartilage Matrix for an Osteochondral Defect of the Talus: A Case Report

Advances have been made in the treatment for osteochondral defects of the talus, but these injuries continue to be a challenge for foot and ankle surgeons. We present an arthroscopically assisted technique that uses an allogenic cartilage graft in treating an osteochondral lesion of the medial dome of the talus. A brief discussion on current surgical options for osteochondral defects of the talus is also provided.

Tissue Bioengineering in the Treatment of Osteochondritis Dissecans of the Talus in Children With Open Physis: Preliminary Results

BACKGROUND

Juvenile osteochondritis dissecans of the talus (JOCDT) is a focal idiopathic lesion primarily of the subchondral bone leading to subsequent cartilaginous damage. The majority of the papers dealing with JOCDT reported heterogeneous case studies of patients treated with different cartilage repair techniques. The purpose of this paper is to retrospectively review both clinical and radiologic results among 7 patients affected by JOCDT treated with arthroscopic bone marrow aspirate concentrate (BMAC) transplantation with the 1-step technique.

METHODS

Both standard anterior-posterior and lateral radiographs and a 1.5 T magnetic resonance imaging of the affected ankle were preoperatively performed in all the patients. The American Orthopaedic Foot and Ankle Society (AOFAS) score and the visual analogue scale were administered to the patients preoperatively and at the final follow-up.

RESULTS

Patients were followed up to an average of 48.1±18.4 months. According to the Berndt and Harty classification, 6 lesions were found to be in stage III and 1 lesion in stage IV. The average preoperative AOFAS score was 58.8±7.6 points. At the mean follow-up of 48.1 months the average AOFAS score improved to 95.7±5.4 points (P<0.05). Visual analogue scale improved from 6.3 preoperatively to 0.4 at final follow-up (P<0.05). Complete radiographic healing, in terms of complete bony filling, was observed in 3 of 7 cases. The magnetic resonance imaging analysis showed a complete filling of the osteochondral defect in 4 patients, whereas in 1 patient a hypotrofic tissue was observed.

CONCLUSIONS

BMAC transplantation is able to provide good to excellent results in the treatment of JOCDT. The 43% of our patients showed a complete radiographic healing, but all the patients were satisfied with the procedure. Because of the rareness of the lesion, further studies involving more patients and with a longer follow-up are required, to establish the advantage of performing a regenerative procedure like the BMAC transplantation in a pediatric population.

LEVEL OF EVIDENCE

Level IV.

Management of Osteochondral Lesions of the Talar Dome

Osteochondral lesion of the talus (OLT) is a common condition associated with ankle injury that brings challenges in the diagnosis and treatment. Symptoms related to this condition are nonspecific including pain, swelling, stiffness, and mechanical symptoms of locking and catching. While the natural history of the OLTs is not well understood, surgical treatment is often required especially in chronic cases and acute cases with displaced articular fragments. Arthroscopic treatment of the OLTs aims to restore ankle joint function and pain relief by the removal of the chondral or osteochondral fragment, debridement and stabilization of cartilage rim and subchondral bone, and stimulate healing of the bone and damaged cartilage. In patients with a large lesion or after a failure of previous bone marrow stimulation, biologic restoration techniques including the use of particulate juvenile cartilage techniques, autogenous chondrocyte implantation, and osteochondral autograft or allograft transplantation may have role. This article summarizes the contemporary concepts in the clinical evaluation and treatment of OLTs with particular emphasis on surgical strategies.

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

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

Operative Technique and Clinical Outcome in Endoscopic Core Decompression of Osteochondral Lesions of the Talus: A Pilot Study

BACKGROUND Revitalizing the necrotic subchondral bone and preserving the intact cartilage layer by retrograde drilling is the preferred option for treatment of undetached osteochondral lesions of the talus (OLT). We assessed the effectiveness of Endoscopic Core Decompression (ECD) in treatment of OLT. MATERIAL AND METHODS Seven patients with an undetached OLT of the medial talar dome underwent surgical treatment using an arthroscopically-guided transtalar drill meatus for core decompression of the lesion. Under endoscopic visualization the OLT was completely debrided while preserving the cartilage layer covering the defect. The drill tunnel and debrided OLT were filled using an injectable bone graft substitute. Various clinical scores, radiographic imaging, and MRI were evaluated after a mean follow-up of 24.1 months. RESULTS The American Orthopedic Foot and Ankle Society Score significantly improved from 71.0±2.4 to 90.3±5.9, and the Foot and Ankle Disability Index improved from 71.8±11.1 to 91.7±4.8. Radiographically, we observed good bone remodelling of the medial talar dome contour within 3 months. In MRI, an alteration of the bony signal of the drill tunnel and the excised OLT remained for more than 12 months. CONCLUSIONS First follow-up results for the surgical technique described in this study are highly promising for treatment of undetached stable OLT grade II or transitional stage II-III according to the Pritsch classification. Even lesions larger than 150 mm2 showed good clinical scores, with full restoration of the medial talar dome contour in radiographic imaging.

Treatment of Osteochondritis Dissecans of the Talus in Skeletally Immature Population: A Critical Analysis of the Available Evidence

Juvenile osteochondritis dissecans of the talus (JOCDT) is a subchondral bone alteration and a partially or completely detached osteochondral fragment, affecting skeletally immature patients. A review of the English literature on PubMed was conducted. Conservative treatment was applied in patients up to Berndt-Harty stage III. Surgical indications were conservative management failure and loose bodies. The most performed procedures were drilling, subchondral bone grafting, fragment fixation, or excision. High rate of clinical success were achieved, whereas radiographic results were much lower. None of the surgical options demonstrated to be superior. Future long-term qualitative studies focusing on chondral tissue restoration are needed.

LEVELS OF EVIDENCE

Therapeutic, Level IV.

The Incidence of Surgery in Osteochondritis Dissecans in Children and Adolescents

Background:

The frequency of osteochondritis dissecans (OCD), a disorder of the subchondral bone and articular cartilage, is not well described.

Purpose:

To assess the frequency of pediatric OCD lesions that progress to surgery based on sex, joint involvement, and age.

Study Design:

Descriptive epidemiology study.

Methods:

A retrospective chart review (2007-2011) was performed on OCD. Inclusion criteria included OCD of any joint and patients aged 2 to 19 years. Exclusion criteria included traumatic osteochondral fractures or coexistence of non-OCD intra-articular lesions. Differences in progression toward surgery were compared between age groups, sex, and joint location. Logistical regression analysis was performed by sex, age, and ethnicity.

Results:

Overall, 317 patients with a total of 334 OCD lesions were found. The majority of lesions (61.7%) were in the knee, with ankle, elbow, shoulder, and foot lesions representing 25.4%, 12.0%, 0.6%, and 0.3% of all lesions, respectively. The majority of joints needing surgery were in the knee (58.5%), with ankle and elbow lesions representing 22.9% and 18.6% of surgeries performed, respectively. The percentage of all OCD lesions progressing to surgery was 35.3%; surgical progression for knee, ankle, and elbow joints was 33.5%, 31.8%, and 55.0%, respectively. Logistic regression analysis found no statistically significant different risk of progressing to surgery for OCD of the knee, elbow, and ankle between sexes. Patients aged 12 to 19 years had a 7.4-times greater risk of progression to surgery for knee OCD lesions than 6- to 11-year-olds. Patients aged 12 to 19 years were 8.2 times more likely to progress to surgery for all OCD lesions than patients aged 6 to 11 years. Progression to surgery of ankle OCD did not significantly differ based on location. Three of 4 trochlear lesions progressed to surgery, along with 1 of 1 tibial, 1 of 3 patellar, 40.3% of lateral femoral condylar, and 28.2% of medial femoral condylar lesions.

Conclusion:

In this large cohort study of pediatric OCD patients, 35% progressed to surgery. Progression to surgery did not differ significantly between sexes with OCD of any joint. Progression to surgery for OCD of the knee, elbow, and ankle strongly correlated with patient age at the time of diagnosis.

Clinical Relevance:

The knowledge of likelihood of progression to surgery of OCD by location, sex, and age is useful in counseling patients and in planning treatment. This study confirms a worse prognosis in the nonoperative treatment of older patients with OCD.

Inflammatory Cytokines and Matrix Metalloproteinases in the Synovial Fluid After Intra-articular Ankle Fracture

BACKGROUND

Posttraumatic osteoarthritis (PTOA) can occur after intra-articular fracture despite anatomic fracture reduction. It has been hypothesized that an early inflammatory response after intra-articular injury could lead to irreversible cartilage damage that progresses to PTOA. Therefore, in addition to meticulous fracture reduction, it would be ideal to prevent this initial inflammatory response but little is known about the composition of the synovial environment after intra-articular fracture. The purpose of this work was to characterize the inflammatory cytokine and matrix metalloproteinase (MMP) composition in the synovial fluid (SF) of patients with acute intra-articular ankle fractures.

METHODS

Twenty-one patients with an intra-articular ankle fracture were included in this study. All patients had a contralateral ankle joint that was pain free, had no radiographic evidence of arthritis, and no history of trauma. The uninjured ankle served as a matched control. SF was obtained from bilateral ankles at the time of surgery which occurred at a mean of 17 days post-fracture (range 8-40). The SF was analyzed for granulocyte macrophage colony-stimulating factor (GM-CSF), interferon-gamma (IFN-γ), tumor necrosis factor alpha (TNF-α), interleukin (IL)-1β, IL-2, IL-6, IL-8, IL-10, IL-12p70, MMP-1, MMP-2, MMP-3, MMP-9, MMP-10, CTXII, sGAG, and bilirubin/biliverdin (markers of hemearthrosis) using either multiplex assay or ELISA using commercially available kits. Mean concentrations of each factor were compared between SF from fractured and control ankles, and correlation analysis was done to determine potential relationships between levels of cytokines and time from fracture and age at fracture.

RESULTS

Twelve of 18 measured factors including GM-CSF, IL-10, IL-1β, IL-6, IL-8, TNF-α, MMP-1, MMP-2, MMP-3, MMP-9, MMP-10, and bilirubin/biliverdin were found to be significantly higher in the fractured ankles. Mean concentrations of ECM degradation markers (sGAG and CTXII) were not found to be significatnly different between groups.

CONCLUSION

These data indicate that after intra-articular ankle fracture the SF exhibits a largely pro-inflammatory and extra-cellular matrix degrading environment similar to that described in idiopathic osteoarthritis. IL-6, IL-8, MMP-1, MMP-2, MMP-3, MMP-9, and MMP-10 were significantly elevated and may play a role in the development of PTOA.

CLINICAL RELEVANCE

In addition to anatomic fracture reduction, these data lend credence to reducing acute intra-articular inflammation through the development of antagonists to these pro-inflammatory and degrading mediators. Likewise, intra-articular lavage might reduce this inflammatory burden.

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.

Prospective clinical trial of patients who underwent ankle arthroscopy with articular diseases to match clinical and radiological scores with intra-articular cytokines

OBJECTIVE

There is still a lack of reliable data on cytokine concentrations in the ankle and their value for prognosis.

METHODS

In a prospective clinical trial, lavage fluids were collected from 49 patients with an arthroscopy of the ankle. The fluids were investigated by ELISA for cytokine levels. Clinical scores (FFI, AOFAS) were evaluated both pre-operatively and then again 12 months after surgery (n = 43, 88%). Radiological changes were noted with the Kellgren-Lawrence-Score (KLS) and the Ankle Osteoarthritis Scoring System (AOSS). Based on the difference between the pre- and postoperative clinical scores, two groups were defined according to whether they had benefited from the surgical therapy (Δ score ≥ 10) or not (Δ score < 10).

RESULTS

The average clinical scores had improved to a statistically significant extent in the one-year follow-up (p < 0.01). BMP-2 (p = 0.02), IGF-1 (p = 0.04), BMP-7 (p = 0.01) and aggrecan (p = 0.04) showed significant correlations with pre-operative clinical and radiological scores (p = 0.02, p = 0.01, p = 0.01, p = 0.01). Furthermore, BMP-2 (p = 0.01), IGF-1/TPC (p = 0.03) and aggrecan (p = 0.01) correlated with scores after one year (p = 0.02, p = 0.01). High aggrecan concentrations were associated with a low clinical and a high radiological score at both time points, both indicating progress of cartilage degeneration in contrast to BMP-2 or IGF-1. Furthermore, MMP-13 concentrations were significantly higher in the non-benefit group (p = 0.02).

CONCLUSION

BMP-2, IGF-1, aggrecan and MMP-13 seem to be involved in the degenerative process of cartilage in the ankle joint. Additionally, high synovial MMP-13 concentrations indicate a worse clinical outcome.

Treatment of juvenile osteochondritis dissecans of the talus: current concepts review

Juvenile osteochondritis dissecans of the talus (JODT) affects the subchondral bone primarily and, in a skeletally immature population, articular cartilage secondarily. It probably consists of aseptic bone necrosis whose spontaneous healing is impaired by microtraumas, resulting in an osteochondral injury and, in some cases, in osteoarthritis. In many cases the clinical presentation is asymptomatic. Mild chronic pain is frequent, sometimes accompanied by swelling, stiffness or locking. Few data are currently available on this topic and, moreover, most existing data were obtained from mixed groups and populations; it is therefore difficult to outline a scheme for the treatment of JODT. However, the most suitable treatment in the first stages of the disease is conservative. The presence of a loose body is an indication for surgical fixation, drilling or regenerative procedures, depending on the presence/extent of subchondral bone sclerosis and the surgeon's experience. Drilling has been shown to promote the healing of lesions with minimal surgical trauma. Microfractures, since they induce fibrocartilage repair, are to be considered only for small injuries. Mosaicplasty and osteochondral autograft transplantation may cause donor site morbidity and are techniques little reported in JODT. Regenerative techniques and fresh allografts give good results in osteochondral lesions, but further studies are required to describe the results that can be obtained in JODT alone.

Association between intraarticular cytokine levels and clinical parameters of osteochondritis dissecans in the ankle

Background

Reliable data about in vivo regulation of cytokines in osteochondritis dissecans (OCD) of the ankle are still missing. Disease-specific regulation patterns were hypothesized.

Methods

28 patients with a mean age of 30.7 ± 14.8 years undergoing an arthroscopy of the ankle because of OCD were prospectively included in a clinical trial. Lavage fluids were analyzed by ELISA for levels of aggrecan, BMP-2, BMP-7, IGF-1, IGF-1R, bFGF, endoglin, MMP-13, and IL-1β. Additionally, clinical parameters and scores (FFI, CFSS, AOFAS) were evaluated and supplemented by the Kellgren Lawrence Score (KLS) for conventional X-rays and the Ankle Osteoarthritis Scoring System (AOSS) for MRI.

Results

Grading of OCD lesions statistically significant increased with age and was higher in case of previously performed operations (p < 0.03). A worse clinical function reflected by low AOFAS and CFSS scores or high FFI was associated with high grading of cartilage damage or OCD (p < 0.03). Similarly, high radiological scores (KLS and AOSS) indicating progress of OA positively correlated with grading of cartilage damage and OCD. The concordance between the MRI and arthroscopic classification was overall moderate (κ = 0.52). Biochemically, only IGF/IGF-1R levels were consistently negatively associated with OCD grading, ICRS score, FFI and KLS (p < 0.05). Correlation data is supported by post hoc statistics.

Conclusions

Radiological and clinical parameters in association with synovial IGF-1/IGF-1R levels indicated an increasing joint degeneration with rising OCD stage.

Trial registration

German Clinical Trials Register DRKS00000365, 11/03/2008.

Early intra-articular complement activation in ankle fractures

Cytokine regulation possibly influences long term outcome following ankle fractures, but little is known about synovial fracture biochemistry. Eight patients with an ankle dislocation fracture were included in a prospective case series and matched with patients suffering from grade 2 osteochondritis dissecans (OCD) of the ankle. All fractures needed external fixation during which joint effusions were collected. Fluid analysis was done by ELISA measuring aggrecan, bFGF, IL-1β, IGF-1, and the complement components C3a, C5a, and C5b-9. The time periods between occurrence of fracture and collection of effusion were only significantly associated with synovial aggrecan and C5b-9 levels (P < 0.001). Furthermore, synovial expressions of both proteins correlated with each other (P < 0.001). Although IL-1β expression was relatively low, intra-articular levels correlated with C5a (P < 0.01) and serological C-reactive protein concentrations 2 days after surgery (P < 0.05). Joint effusions were initially dominated by neutrophils, but the portion of monocytes constantly increased reaching 50% at day 6 after fracture (P < 0.02). Whereas aggrecan and IL-1β concentrations were not different in fracture and OCD patients, bFGF, IGF-1, and all complement components were significantly higher concentrated in ankle joints with fractures (P < 0.01). Complement activation and inflammatory cell infiltration characterize the joint biology following acute ankle fractures.

Clinical results after different operative treatment methods of radial head and neck fractures: a systematic review and meta-analysis of clinical outcome

INTRODUCTION

There is no consensus on optimal treatment strategy for Mason type II-IV fractures. Most recommendations are based upon experts' opinion.

METHODS

An OVID-based literature search were performed to identify studies on surgical treatment of radial head and neck fracture. Specific focus was placed on extracting data describing clinical efficacy and outcome by using the Mason classification and including elbow function scores. A total of 841 clinical studies were identified describing in total the clinical follow-up of 1264 patients.

RESULTS

For type II radial head and neck fractures the significant best treatment option seems to be ORIF with an overall success rate of 98% by using screws or biodegradable (polylactide) pins. ORIF with a success rate of 92% shows the best results in the treatment of type III fractures and seem to be better than resection and implantation of a prosthesis. For this fracture type the ORIF with screws (96%), biodegradable (polylactide) pins (88%) and plates (83%) showed the best results. In the treatment of type IV fractures similar results could be found with a tendency of the best results after ORIF followed by resection and implantation of a prosthesis. If a prosthesis was implanted, the primary implantation seems to be associated with a better outcome after type III (87%) and IV (82%) fractures compared to the results after a secondary implantation.

DISCUSSION

Recommendations for surgical treatment of radial head and neck fractures according to the Mason classification can now be given with the best available evidence.

LEVEL OF EVIDENCE

IV.