Autologous Osteochondral Transplantation for Osteochondral Lesions of the Talus: Does Previous Bone Marrow Stimulation Negatively Affect Clinical Outcome?

Autologous osteoperiosteal transplantation is effective in the treatment of single cystic osteochondral lesions of the talus and the prognostic impact of age should be emphasized

PURPOSE

To investigate the clinical efficacy and prognostic factors associated with autologous osteoperiosteal transplantation for the treatment of single cystic osteochondral lesions of the talus (OLT).

METHODS

The clinical data of patients with single cystic OLT undergoing autologous osteoperiosteal transplantation at the Department of Foot and Ankle Surgery of our hospital between 2018 and 2022, including complete follow-up, were retrospectively analyzed. Imaging data from each patient were imported into Mimics software to measure the surface area, volume and depth of the lesions. Then, the talus nine-compartment partitioning method was used to partition the injury site. Preoperative and final follow-up assessments were performed using the American Orthopaedic Foot and Ankle Society (AOFAS) score, visual analogue scale (VAS) for pain and 36-item Short-Form Health Survey (SF-36) to evaluate treatment efficacy and analyze prognostic factors.

RESULTS

Of the 31 patients with single cystic OLT with a complete set of follow-up data, there were 17 males and 14 females, with a mean age of 43.3 ± 13.6 years, a mean follow-up time of 30.1 ± 14.0 months and a mean illness duration of 30.4 ± 20.0 months. The postoperative final follow-up AOFAS score was 90.7 ± 5.5; this represented significant improvement when compared to the preoperative score of 57.0 ± 8.5 (P < 0.001). The final postoperative follow-up VAS score was 18.5 ± 8.3; this was significantly better than the preoperative score of 57.8 ± 8.7 (P < 0.001). The physical component summary (PCS) score and mental component summary (MCS) score on the SF-36 scale showed significant improvement at the final postoperative follow-up when compared to preoperative scores (p < 0.001). No other complications were observed during follow-up, such as wound infection or pain at the donor site. One of the patients showed less improvement, which may be related to premature weight-bearing or re-sprained ankle after surgery. There was no significant correlation between the duration of illness, gender and the location, depth, surface area and volume of the OLT and the postoperative scores. However, patient age showed a significant negative correlation with the postoperative SF-36 PCS and MCS scores.

CONCLUSION

Autologous osteoperiosteal transplantation for single cystic OLT demonstrated good clinical efficacy with a low incidence of complications. Furthermore, age represents an important factor influencing prognosis.

LEVEL OF EVIDENCE

Level II.

Presurgical and Postsurgical MRI Evaluation of Osteochondral Lesions of the Foot and Ankle: A Primer

The gold standard diagnostic imaging tool for ankle OCLs is magnetic resonance imaging, which allows precise evaluation of the articular cartilage and assessment of the surrounding soft tissue structures. Post-operative morphologic MRI assessment via MOCART scores provide semi-quantitative analysis of the repair tissue, but mixed evidence exists regarding its association with post-operative outcomes. Post-operative biochemical MRIs allow assessment of the collagen network of the articular cartilage via T2-mapping and T2∗ mapping, and assessment of the articular glycosaminoglycan content via delayed gadolinium-enhanced MRI of cartilage (dGEMRIC), T1rho mapping and sodium imaging.

Particulated juvenile cartilage allograft for the treatment of osteochondral lesions of the talus is associated with a high complication rate and a high failure rate at short-term follow-up: A systematic review

PURPOSE

The purpose of this systematic review was to evaluate the clinical and radiological outcomes together with the complication rates and failure rates at short-term follow-up following particulated juvenile cartilage allograft (PJCA) for the management of osteochondral lesions of the talus (OLT).

METHODS

During October 2023, the PubMed, Embase and Cochrane library databases were systematically reviewed to identify clinical studies examining outcomes following PJCA for the management of OLTs. Data regarding study characteristics, patient demographics, lesion characteristics, subjective clinical outcomes, radiological outcomes, complications and failures were extracted and analysed.

RESULTS

Twelve studies were included. In total, 241 patients underwent PJCA for the treatment of OLT at a weighted mean follow-up of 29.0 ± 24.9 months. The weighted mean lesion size was 138.3 ± 59.6 mm2 . Prior surgical intervention was recorded in seven studies, the most common of which was microfracture (65.9%). The weighted mean American Orthopaedic Foot and Ankle Society score improved from a preoperative score of 58.5 ± 3.2 to a postoperative score of 83.9 ± 5.3. The weighted mean postoperative magnetic resonance observation of cartilage repair tissue (MOCART) score was 48.2 ± 3.3. The complication rate was 25.2%, the most common of which was allograft hypertrophy (13.2%). Thirty failures (12.4%) were observed at a weighted mean time of 9.8 ± 9.6 months following the index procedure.

CONCLUSION

This systematic review demonstrated a moderate improvement in subjective clinical outcomes following PJCA for the treatment of OLT at short term follow-up. However, postoperative MOCART scores were reported as poor. In addition, a high complication rate (25.2%) and a high failure rate (12.4%) at short-term follow-up was observed, calling into question the efficacy of PJCA for the treatment of large OLTs. In light of the available evidence, PJCA for the treatment of large OLTs cannot be currently recommended.

LEVEL OF EVIDENCE

Level IV.

Presurgical and Postsurgical MRI Evaluation of Osteochondral Lesions of the Foot and Ankle: A Primer

The gold standard diagnostic imaging tool for ankle OCLs is magnetic resonance imaging, which allows precise evaluation of the articular cartilage and assessment of the surrounding soft tissue structures. Post-operative morphologic MRI assessment via MOCART scores provide semi-quantitative analysis of the repair tissue, but mixed evidence exists regarding its association with post-operative outcomes. Post-operative biochemical MRIs allow assessment of the collagen network of the articular cartilage via T2-mapping and T2∗ mapping, and assessment of the articular glycosaminoglycan content via delayed gadolinium-enhanced MRI of cartilage (dGEMRIC), T1rho mapping and sodium imaging.

Comparison of Intermediate-Term Clinical Outcomes Between Medial and Lateral Osteochondral Lesions of the Talus Treated With Autologous Osteochondral Transplantation

BACKGROUND

The conventional operative method to treat an osteochondral lesion of the talus (OLT) is through bone marrow stimulation (BMS). Autologous osteochondral transplantation (AOT) is being used as an alternative option in cases with a large OLT, accompanying subchondral cyst, and/or failed BMS. We aimed to compare the intermediate-term clinical and radiologic results between medial and lateral OLTs after an AOT procedure.

METHODS

Among the patients who underwent AOT, 45 cases with at least 3 years' follow-up were included in this retrospective study. We had 15 cases of lateral lesions and selected 30 cases of medial lesions matched for age and gender. Lateral lesions were resurfaced without an osteotomy; medial lesion resurfacing was combined with a medial malleolar osteotomy. Clinical assessment was performed using the Foot and Ankle Outcome Score (FAOS) and Foot and Ankle Ability Measure (FAAM). Radiographic assessment included the irregularity of articular surface (subchondral plate), the progression of degenerative arthritis, and the change of the talar tilt.

RESULTS

The mean FAOS and FAAM scores significantly improved after surgery in both groups. Up to 1 year postoperatively, there was significant difference in FAAM scores between the both groups (mean 75.3 points in medial group and 87.2 points in lateral group, P < .001). Delayed union or malunion of the malleolar osteotomy was found in 4 cases (13%) in the medial group. In addition, the progression of joint degeneration was observed in 3 cases (10%) in the medial group. There were no significant differences in the irregularity of articular surface and the change of talar tilt between both groups.

CONCLUSION

A comparison between medial and lateral OLTs treated with AOT demonstrated comparable intermediate-term clinical outcomes. However, patients with medial OLT required a longer period to restore ability for daily and sport activities. In addition, we found more complications and higher rate of progression in the radiologic arthritis grade after medial malleolar osteotomy.

LEVEL OF EVIDENCE

Level IV, retrospective comparative study.

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.

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.

Allograft Versus Autograft Osteochondral Transplant for Chondral Defects of the Talus: Systematic Review and Meta-analysis

BACKGROUND

It is unclear whether the results of osteochondral transplant using autografts or allografts for talar osteochondral defect are equivalent.

PURPOSE

A systematic review of the literature was conducted to compare allografts and autografts in terms of patient-reported outcome measures (PROMs), MRI findings, and complications.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

This study was conducted according to the PRISMA guidelines. The literature search was conducted in February 2021. All studies investigating the outcomes of allograft and/or autograft osteochondral transplant as management for osteochondral defects of the talus were accessed. The outcomes of interest were visual analog scale (VAS) score for pain, American Orthopaedic Foot and Ankle Society (AOFAS) score, and Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score. Data concerning the rates of failure and revision surgery were also collected. Continuous data were analyzed using the mean difference (MD), whereas binary data were evaluated with the odds ratio (OR) effect measure.

RESULTS

Data from 40 studies (1174 procedures) with a mean follow-up of 46.5 ± 25 months were retrieved. There was comparability concerning the length of follow-up, male to female ratio, mean age, body mass index, defect size, VAS score, and AOFAS score (P > .1) between the groups at baseline. At the last follow-up, the MOCART (MD, 10.5; P = .04) and AOFAS (MD, 4.8; P = .04) scores were better in the autograft group. The VAS score was similar between the 2 groups (P = .4). At the last follow-up, autografts demonstrated lower rate of revision surgery (OR, 7.2; P < .0001) and failure (OR, 5.1; P < .0001).

CONCLUSION

Based on the main findings of the present systematic review, talar osteochondral transplant using allografts was associated with higher rates of failure and revision compared with autografts at midterm follow-up.

Clinical and MRI Donor-Site Outcomes After Autograft Harvesting From the Medial Trochlea for Talar Osteochondral Lesions: Minimum 5-Year Clinical Follow-up

Background

Autologous osteochondral transplantation (AOT) is a treatment option for large or cystic osteochondral lesions of the talus (OLTs), with promising clinical results. However, donor-site morbidity (DSM) has always been a concern with this procedure.

Purpose

To investigate the clinical and radiological outcomes of autograft harvesting from the medial trochlea for OLTs.

Study Design

Case series; Level of evidence, 4.

Methods

A total of 46 consecutive patients were included after AOT procedures for OLTs, with donor autografts (single or double plugs) harvested from the medial trochlea of the ipsilateral knee. Lysholm scores were collected postoperatively at 12-month intervals to assess clinical outcomes. Postoperative magnetic resonance imaging (MRI) was used to assess the donor site using the MOCART (magnetic resonance observation of cartilage repair tissue) score. DSM was evaluated at 12-month intervals. Statistical analysis was performed to compare patients treated with single-plug and double-plug AOT procedures and establish whether there was any correlation between MOCART and Lysholm scores.

Results

The mean follow-up period was 98.3 months (range, 67-144 months). The Lysholm scores for all patients were 92.5 ± 6.1 and 99.9 ± 0.2 at the 12-month and final follow-ups, respectively. MRI of the donor sites was taken at an average of 93.8 ± 20.5 (range, 61-141) months postoperatively, and the mean MOCART score was 76.2 ± 4.9. The overall incidence of DSM in this study was 4.3% at 12 months, postoperatively, which decreased to 0% at the 24-month follow-up. There was no significant difference in either the Lysholm score (P = .16) or the MOCART score (P = .83) between the single-plug and double-plug groups at the final follow-up. There were no significant correlations between MOCART and Lysholm scores and patient age, number of grafts, or body mass index.

Conclusion

According to the study findings, the DSM of donor autografts harvested from the medial trochlea was low, and the number (single or double) of grafts did not affect the functional outcome.

Arthroscopic debridement of osteochondral lesions of the talus: A systematic review

BACKGROUND

Arthroscopic debridement (AD) for the osteochondral lesions of the talar dome (OLT) was widely documented in the nineties with satisfactory results. However, in modern treatment algorithms, its role is not described. The present systematic review aims to evaluate the current evidence on the clinical outcomes of AD in the management of OLT.

METHODS

Two independent reviewers searched PubMed, EMBASE, Scopus, and Virtual Health Library databases evaluating the clinical outcomes of AD of OLT with a minimum 6-month follow-up. The following terms "talus", "chondral", "cartilage", "injury", "lesion", "delamination", "damage", "excision", "curettage", "debridement", "chondrectomy", "chondroplasty", were used alone and in combination with Boolean operators AND and OR. Studies in which surgical technique was not described, an additional procedure was performed after debridement, and/or outcomes were not reported separately when more than one technique was implemented were excluded. The modified Coleman methodology score (mCMS) was used to evaluate the methodological quality of the included studies. A narrative analysis was conducted. Publication bias was assessed using the ROBIS tool.

RESULTS

AD showed satisfactory short and medium-term outcomes for the primary treatment of OLT irrespectively of size and depth. However, the heterogeneity of the included studies and the level of available evidence hinders its recommendation.

CONCLUSIONS

There is a paucity of evidence evaluating AD alone for OLT treatment in the last two decades. Bone-marrow stimulation techniques remain the first-line surgical strategy for OLT treatment without proven superiority. Adopting AD for OLT treatment instead of MF could represent a paradigm breakthrough in clinical practice given its many potential advantages while preserving the subchondral plate.

Evidence-based Treatment of Failed Primary Osteochondral Lesions of the Talus: A Systematic Review on Clinical Outcomes of Bone Marrow Stimulation

OBJECTIVE

The purpose of this study is to systematically review the literature and to evaluate the outcomes following bone marrow stimulation (BMS) for nonprimary osteochondral lesions of the talus (OLT).

DESIGN

A literature search was performed to identify studies published using PubMed (MEDLINE), EMBASE, CDSR, DARE, and CENTRAL. The review was performed according to the PRISMA guidelines. Two authors separately and independently screened the search results and conducted the quality assessment using the Methodological Index for Non-Randomized Studies (MINORS). Studies were pooled on clinical, sports, work, and imaging outcomes, as well as revision rates and complications. The primary outcome was clinical success rate.

RESULTS

Five studies with 70 patients were included in whom nonprimary OLTs were treated with secondary BMS. The pooled clinical success rate was 61% (95% confidence interval [CI], 50-72). The rate of return to any level of sport was 83% (95% CI, 70-91), while the return to pre-injury level of sport was 55% (95% CI, 34-74). The rate of return to work was 92% (95% CI, 78-97), and the complication rate was assessed to be 10% (95% CI, 4-22). Imaging outcomes were heterogeneous in outcome assessment, though a depressed subchondral bone plate was observed in 91% of the patients. The revision rate was 27% (95% CI, 18-40).

CONCLUSIONS

The overall success rate of arthroscopic BMS for nonprimary osteochondral lesions of the talus was 61%, including a revision rate of 27%. Return to sports, work, and complication outcomes yielded fair to good results.

The MOCART (Magnetic Resonance Observation of Cartilage Repair Tissue) 2.0 Knee Score and Atlas

OBJECTIVE

Since the first introduction of the MOCART (Magnetic Resonance Observation of Cartilage Repair Tissue) score, significant progress has been made with regard to surgical treatment options for cartilage defects, as well as magnetic resonance imaging (MRI) of such defects. Thus, the aim of this study was to introduce the MOCART 2.0 knee score - an incremental update on the original MOCART score - that incorporates this progression.

MATERIALS AND METHODS

The volume of cartilage defect filling is now assessed in 25% increments, with hypertrophic filling of up to 150% receiving the same scoring as complete repair. Integration now assesses only the integration to neighboring native cartilage, and the severity of surface irregularities is assessed in reference to cartilage repair length rather than depth. The signal intensity of the repair tissue differentiates normal signal, minor abnormal, or severely abnormal signal alterations. The assessment of the variables "subchondral lamina," "adhesions," and "synovitis" was removed and the points were reallocated to the new variable "bony defect or bony overgrowth." The variable "subchondral bone" was renamed to "subchondral changes" and assesses minor and severe edema-like marrow signal, as well as subchondral cysts or osteonecrosis-like signal. Overall, a MOCART 2.0 knee score ranging from 0 to 100 points may be reached. Four independent readers (two expert readers and two radiology residents with limited experience) assessed the 3 T MRI examinations of 24 patients, who had undergone cartilage repair of a femoral cartilage defect using the new MOCART 2.0 knee score. One of the expert readers and both inexperienced readers performed two readings, separated by a four-week interval. For the inexperienced readers, the first reading was based on the evaluation sheet only. For the second reading, a newly introduced atlas was used as an additional reference. Intrarater and interrater reliability was assessed using intraclass correlation coefficients (ICCs) and weighted kappa statistics. ICCs were interpreted according to Koo and Li; weighted kappa statistics were interpreted according to the criteria of Landis and Koch.

RESULTS

The overall intrarater (ICC = 0.88, P < 0.001) as well as the interrater (ICC = 0.84, P < 0.001) reliability of the expert readers was almost perfect. Based on the evaluation sheet of the MOCART 2.0 knee score, the overall interrater reliability of the inexperienced readers was poor (ICC = 0.34, P < 0.019) and improved to moderate (ICC = 0.59, P = 0.001) with the use of the atlas.

CONCLUSIONS

The MOCART 2.0 knee score was updated to account for changes in the past decade and demonstrates almost perfect interrater and intrarater reliability in expert readers. In inexperienced readers, use of the atlas may improve interrater reliability and, thus, increase the comparability of results across studies.

Accessibility and Thickness of Medial and Lateral Talar Body Cartilage for Treatment of Ankle and Foot Osteochondral Lesions

BACKGROUND

The purposes of this study were to determine (1) if cartilage thicknesses on the talar dome and medial/lateral surfaces of the talus were similar, (2) whether there was sufficient donor cartilage surface area on the medial and lateral talar surfaces to repair talar dome cartilage injuries of the talus, and (3) whether the cartilage surface could be increased following anterior talofibular ligament (ATFL) and sectioning of the tibionavicular and tibiospring portion of the anterior deltoid.

METHODS

Medial and lateral approaches were utilized in 8 cadaveric ankles to identify the accessible medial, lateral, and talar dome cartilage surfaces in 3 conditions: (1) intact, (2) ATFL release, and (3) superficial anterior deltoid ligament release. The talus was explanted, and the cartilage areas were digitized with a coordinate measuring machine. Cartilage thickness was quantified using a laser scanner.

RESULTS

The mean cartilage thickness was 1.0 ± 0.1 mm in all areas tested. In intact ankles, the medial side of the talus showed a larger total area of available cartilage than the lateral side (152 mm² vs 133 mm²). ATFL release increased the available cartilage area on the medial and lateral sides to 167 mm² and 194 mm², respectively. However, only the lateral talar surface had sufficient circular graft donor cartilage available for autologous osteochondral transplantation (AOT) procedures of the talus. After ATFL and deltoid sectioning, there was an increase in available graft donor cartilage available for AOT procedures.

CONCLUSION

The thickness of the medial and lateral talar cartilage surfaces is very similar to that of the talar dome cartilage surface, which provides evidence that the medial and lateral surfaces may serve as acceptable AOT donor cartilage. The surface area available for AOT donor site grafting was sufficient in the intact state; however, sectioning the ATFL and superficial anterior deltoid ligament increased the overall lateral talar surface area available for circular grafting for an AOT procedure that requires a larger graft. These results support the idea that lateral surfaces of the talus may be used as donor cartilage for an AOT procedure since donor and recipient sites are similar in cartilage thickness, and there is sufficient cartilage surface area available for common lesion sizes in the foot and ankle.

CLINICAL RELEVANCE

This anatomical study investigates the feasibility of talar osteochondral autografts from the medial or lateral talar surfaces exposed with standard approaches. It confirms the similar cartilage thickness of the talar dome and the ability to access up to an 8- to 10-mm donor graft from the lateral side of the talus after ligament release. This knowledge may allow better operative planning for use of these surfaces for osteochondral lesions within the foot and ankle, particularly in certain circumstances of a revision microfracture.

Comparison of Functional and Radiographic Outcomes of Talar Osteochondral Lesions Repaired With Micronized Allogenic Cartilage Extracellular Matrix and Bone Marrow Aspirate Concentrate vs Microfracture

BACKGROUND

Microfracture (MF) has been used historically to treat osteochondral lesions of the talus (OLTs), with favorable outcomes reported in approximately 80% to 85% of cases. However, MF repairs have been shown to degrade over time at long-term follow-up, suggesting that further study into optimal OLT treatment is warranted. The use of adjuvant extracellular matrix with bone marrow aspirate concentrate (ECM-BMAC) has not been extensively evaluated in the literature. We present a comparison of patient-reported and radiographic outcomes following ECM-BMAC repair vs traditional MF.

METHODS

Patients who underwent MF (n = 67) or ECM-BMAC (n = 62) treatment for an OLT were identified and their charts were retrospectively reviewed. Postoperative magnetic resonance imaging (MRI) was evaluated and patient-reported outcome scores, either Foot and Ankle Outcome Scores (FAOS) or Patient-Reported Measurement Information System (PROMIS) scores, were collected. MRIs were scored by a radiologist, fellowship trained in musculoskeletal radiology, using the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) system. Radiographic and clinical outcomes were compared between groups.

RESULTS

On average, patients treated with ECM-BMAC demonstrated a higher total MOCART score compared to the MF group (73 ± SD 11.5 vs 54.0 ± 24.1; P = .0015). ECM-BMAC patients also had significantly better scores for the Infill, Integration, and Signal MOCART subcategories. Last, patients treated with ECM-BMAC had a lower rate of revision compared to those treated with MF (4.8% vs 20.9%; P = .007). FAOS scores were compared between groups, with no significant differences observed.

CONCLUSION

When comparing outcomes between patients treated for an OLT with ECM-BMAC vs traditional MF, we observed superior MRI results for ECM-BMAC patients. The rate of revision surgery was higher for MF patients, although patient-reported outcomes were similar between groups. The use of ECM-BMAC as an adjuvant therapy in the treatment of OLTs may result in improved reparative tissue when compared to MF.

LEVEL OF EVIDENCE

Level III, comparative series.

Autologous osteochondral transplantation for osteochondral lesions of the talus: high rate of return to play in the athletic population

PURPOSE

(1) To determine the rate of return to play following autologous osteochondral transplantation (AOT) for osteochondral lesions of the talus (OLT) and (2) report subsequent rehabilitation protocols.

METHODS

A systematic review of the PubMed, Embase, and The Cochrane Library databases was performed according to the PRISMA guidelines based on specific eligibility criteria. Return to play data was meta-analysed and subsequent rehabilitation protocols were summarised. Level of evidence and quality of evidence (Zaman's criteria) were also evaluated.

RESULTS

Nine studies that totalled 205 ankles were included for review. The mean follow-up was 44.4 ± 25.0 (range 16-84) months. The mean OLT size was 135.4 ± 56.4 mm². The mean time to return to play was 5.8 ± 2.6 months. The mean rate of return to play was 86.3% (range 50-95.2%), with 81.8% of athletes returning to pre-injury status. Based on the fixed-effect model, the rate of return to play was 84.07%. Significant correlation was found between increase age and decrease rate of return to play (R² = 0.362, p = 0.00056). There was no correlation between OLT sizes and rate of return to play (R² = 0.140, p = 0.023). The most common time to ankle motion post-surgery was immediately and the most common time to full weight-bearing was 12 weeks.

CONCLUSIONS

This systematic review indicated a high rate of return to play following AOT in the athletic population. Size of OLT was not found to be a predictor of return to play, whereas advancing age was a predictor. Rehabilitation protocols were largely inconsistent and were primarily based on individual surgeon protocols. However, the included studies were of low level and quality of evidence.

LEVEL OF EVIDENCE

Level IV.

Endoscopic Treatment of Symptomatic Foot and Ankle Bone Cyst with 3D Printing Application

Objective

To study the efficacy of arthroscopy for treating symptomatic bone cysts of the foot and ankle through the follow-up of patients and to further explore the application value of 3D printing technology in this treatment.

Methods

Twenty-one patients with symptomatic bone cysts in the foot and ankle who underwent arthroscopic surgery in our Center from March 2010 to December 2018 were enrolled, including 11 in the experimental group and 10 in the control group. For the control group, C-arm fluoroscopy was used intraoperatively to confirm the positioning of the cysts; for the experimental group, a 3D model of the lesion tissue and the 3D-printed individualized guides were prepared to assist the positioning of the cysts. Debridement of the lesion tissues was conducted under an arthroscope. Regular follow-ups were conducted. The time of establishing arthroscopic approaches and the times of intraoperative fluoroscopy between the two groups were compared. Significance was determined as P < 0.05.

Results

The postoperative pathology of the patients confirmed the diagnosis. No significant perioperative complications were observed in either group, and no recurrence of bone cysts was seen at the last follow-up. The VAS scores and AOFAS scores of the two groups at the last follow-up were significantly improved compared with the preoperative data, but there was no statistical difference between the two groups. All surgeries were performed by the same senior surgeon. The time taken to establish the arthroscopic approaches between the two groups was statistically significant (P < 0.001), and the times of intraoperative fluoroscopy required to establish the approach were also statistically significant (P < 0.001). The intraoperative bleeding between the two groups was statistically significant (P < 0.01). There was 1 case in each group whose postoperative CT showed insufficient bone grafting, but no increase in cavity volume was observed during the follow-up.

Conclusion

With the assistance of the 3D printing technology for treating symptomatic bone cysts of the ankle and foot, the surgeon can design the operation preoperatively and perform the rehearsal, which would make it easier to establish the arthroscopic approach, better understand the anatomy, and make the operation smoother. This trial is registered with http://www.clinicaltrials.govNCT03152916.

Access to the talar dome surface with different surgical approaches

BACKGROUND

Access to the talar dome for the treatment of osteochondral lesions (OCLs) can be achieved via several different approaches to the ankle joint. The recent description of an anatomical nine-grid scheme of the talus has proven useful to localise OCLs but no studies have demonstrated which approaches are indicated to access each of these zones. The aim of this study is to demonstrate the access afforded to each zone by each approach.

METHODS

Four standard soft tissue ankle approaches were performed simultaneously in ten fresh-frozen cadavers (anterolateral - AL, anteromedial - AM, posterolateral - PL, posteromedial - PM). The area of the talus, which was accessible with an instrument perpendicular to the surface was documented for each of the approaches. Using ImageJ software the surface area exposed with each approach was calculated. The talar dome was then divided using a nine-grid scheme and exposure to each zone was documented.

RESULTS

The AL, AM, PL and PM approaches allow for exposure of 24%, 25%, 5%, 7% of the talar dome respectively. The AL gives access to zones 3 (completely) and 2, 5, 6 (partially); the AM to zones 1 (completely) and 2, 4, 5 (partially); the PL to zones 9 and 8 (partially); and the PM to zones 7 and 8 (partially).

CONCLUSIONS

A large area of the talar dome cannot be easily accessed with the use of standard soft tissue approaches (39%). Minimal or no access is achieved for grid zones 4-6 and 8. In those instances careful preoperative planning is necessary and extended exposure can be achieved with the use of osteotomies, section of the ATFL or through modified approaches.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Therapeutic case series, Level IV.

Knee-to-Talus Donor-Site Morbidity Following Autologous Osteochondral Transplantation: A Meta-Analysis with Best-case and Worst-case Analysis

BACKGROUND

Despite the promising clinical results of autologous osteochondral transplantation in the treatment of osteochondral lesions of the talus, the occurrence of knee donor-site morbidity remains a concern. However, the proportion of patients experiencing donor-site morbidity is not well established because of important variations in estimates drawn by heterogeneous studies with loss to followup, often made at short-term (< 1 year). Therefore, both a meta-analysis of studies that assumed no patients lost to followup had donor-site morbidity and assumed all patients lost to followup had donor-site morbidity may help to estimate the true risk of donor-site morbidity.

QUESTIONS/PURPOSES

To evaluate the proportion of patients who developed knee donor-site morbidity after autologous osteochondral transplantation for osteochondral lesion of the talus, by (1) meta-analysis of the proportion of patients experiencing donor-site morbidity in the best-case scenario as reported, in which no patients lost to followup were assumed to have donor-site morbidity and (2) meta-analysis of the percentage of patients who had donor-site morbidity in the worst-case scenario, in which all patients lost to followup were assumed to have donor-site morbidity and (3) present the characteristics of studies associated with the reporting of donor-site morbidity.

METHODS

A systematic search of the PubMed, Embase and The Cochrane Library databases was performed from their inception to October 2017 according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The inclusion criteria were clinical studies that reported knee donor-site morbidity after autologous osteochondral transplantation for osteochondral lesion of the talus, mean followup ≥ 1 year, full-text studies published in a peer-review journal and written in English. Quality of evidence (Case Series Quality Appraisal Checklist), sample size, mean patient age, study design, mean followup time, and observed rate of knee donor-site morbidity were evaluated. Twenty-six studies with 915 ankles (904 patients) were included in the systematic review and meta-analysis. Approximately half of the included studies were of small cohort (n < 30, 12 studies), and 12 of 26 studies did not report at all on loss to followup. In the studies that reported loss to followup (14 of 26), a total of 32 patients (35 ankles) were reported lost. Random-effects models were used to estimate the risk of donor-site morbidity as between-study heterogeneity was determined to be high in both meta-analyses that assumed that no patients lost to followup experienced donor-site morbidity (I = 82.1%) and the one that assumed all patients lost to followup experienced donor-site morbidity (I = 88.7%). Multivariable metaregression was used to estimate the association between study characteristics and the observed proportion of patients who experienced of donor-site morbidity. If there was evidence of an association between a study characteristic and proportion, a subgroup analysis was performed.

RESULTS

The estimated proportion of donor-site morbidity was 6.7% (95% confidence interval [CI], 2.8-11.8), assuming that no patients lost to followup experienced donor-site morbidity and 10.8% (95% CI, 4.8-18.3) assuming that all patients lost to followup experienced donor-site morbidity after a mean followup of 43.8 ± 24.7 months (range, 15.9-120 months). There was a negative association between study sample size and proportion of donor-site morbidity (β = -0.26; 95% CI, -0.39 to -0.12; p < 0.001 assuming that no patients lost to followup experienced donor-site morbidity and β = -0.31; 95% CI, -0.48 to -0.13; p < 0.001 assuming that all patients lost to followup experienced donor-site morbidity); that is, as study size increased, the proportion of patients reported with donor-site morbidity decreased. In larger studies (n ≥ 30), the estimated percentage of donor-site morbidity was 2.8% (95% CI, 1.2%-5.0%; I = 47.6%) assuming that no patients lost to followup experienced donor-site morbidity, and 5.0% (95% CI, 2.1%-9.0%; I = 74.5%) assuming all patients lost to followup experienced donor-site morbidity. High between-study heterogeneity (differences in methodology) could not be completely explained by variability in study sample size, mean patient age, design, or mean followup time, and may be attributable to other factors such as inconsistent definitions of donor-site morbidity.

CONCLUSIONS

The estimated proportion of donor-site morbidity after autologous osteochondral transplantation for osteochondral lesion of the talus ranged from 6.7% to 10.8% in the current meta-analysis. However, subgroup analysis demonstrated that larger studies (n ≥ 30) estimated a lower donor-site morbidity risk (< 5.0%) than smaller studies (n < 30). This estimate should be interpreted in light of the fact that nearly half of the included studies did not report on loss to followup, and so their estimates of donor-site morbidity may be low. In addition, high between-study heterogeneity and the inclusion of predominantly retrospective studies with small sample sizes likely contributed to estimates that suffered from a high risk of bias, probably in favor of the surgical treatment being studied.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Matrix-induced autologous chondrocyte implantation grafting in osteochondral lesions of the talus: Evaluation of cartilage repair using T2 mapping

Osteochondral lesions of the talus may be treated with different autologous biological approaches. These include platelet-rich plasma, stem cells or MACI and ACI. MACI implants are used to cover cartilage lining defects in the ankle. A total of 18 patients were treated with MACI implants. NMR images were taken before and after the procedure. T2 mapping was used to quantify the changes in cartilage collagen after a 6 12-month postoperative period. Increase in collagen was recorded on all patients. Both open and arthroscopic procedures were performed depending on the technical difficulties encountered during the repair.

Osteochondral Allograft Transplantation for Osteochondral Lesions of the Talus: Midterm Follow-up

BACKGROUND:

Fresh osteochondral allograft (OCA) transplantation represents a biologic restoration technique as an alternative treatment option for larger osteochondral lesions of the talus (OLT). The purpose of this study was to evaluate midterm outcomes after OCA transplantation for the treatment of OLT.

METHODS:

Nineteen patients (20 ankles) received partial unipolar OCA transplant for symptomatic OLT between January 1998 and October 2014. The mean age was 34.7 years, and 53% were male. The average graft size was 3.8 cm². All patients had a minimum follow-up of 2 years. Outcomes included the American Academy of Orthopaedic Surgeons Foot and Ankle Module (AAOS-FAM), the Olerud-Molander Ankle Score (OMAS), and pain and satisfaction questionnaires. Failure of OCA was defined as conversion to arthrodesis or revision OCA transplantation.

RESULTS:

Five of 20 ankles (25%) required further surgery, of which 3 (5%) were considered OCA failures (2 arthrodesis and 1 OCA revision). The mean time to failure was 3.5 (range, 0.9 to 6.7) years. Survivorship was 88.7% at 5 years and 81.3% at 10 years. The median follow-up of the 17 patients with grafts in situ was 9.7 years. The mean OMAS improved significantly from 40 points preoperatively to 71 points postoperatively ( P < .05; range, 5 to 55). The mean postoperative AAOS-FAM core score was 81.5 ± 15 (range, 40.5 to 96.6). Fifteen of 17 patients responded to follow-up questions regarding their ankle; 14 patients reported less pain and better function, and 13 patients were satisfied with the results of the procedure.

CONCLUSION:

Our study of midterm results after OCA transplantations showed that this procedure was a reasonable treatment option for large OLT.

LEVEL OF EVIDENCE:

Level IV, case series.

Good clinical and functional outcomes at mid-term following autologous osteochondral transplantation for osteochondral lesions of the talus

PURPOSE

Autologous osteochondral transplantation is an established treatment for large-sized osteochondral lesions of the talus (OLT) with excellent short term outcomes. However, few studies assess the outcomes of autologous osteochondral transplantation at mid-term follow-up. The purpose of the current systematic review was to evaluate the clinical outcomes of the autologous osteochondral transplantation procedure in the treatment of OLT at mid-term and long-term follow-up.

METHODS

A systematic search of the MEDLINE, EMBASE and Cochrane Library databases was performed in October 2017 based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Included studies were evaluated with regard to level of evidence (LOE) and quality of evidence (QOE) using the Coleman Methodology Score. Clinical outcomes, and complications were also evaluated.

RESULTS

Eleven studies, with 500 ankles were included at a mean 62.8 months follow-up. Seven studies used the American Orthopaedic Foot and Ankle Society (AOFAS) score. The weighted mean preoperative AOFAS score was 55.1 ± 6.1, and the postoperative score was 86.2 ± 4.5, with 87.4% of patients (132 of 151) being reported as excellent or good results. In total, 53 of the 500 patients (10.6%) had complications. The most common complication was donor site morbidity with 18 patients (3.6%) at final follow-up. Thirty-one patients (6.2%) underwent reoperations, and 5 ankles (1.0%) were regarded as failed autologous osteochondral transplantation.

CONCLUSION

The current systematic review demonstrated that good clinical and functional outcomes can be expected following autologous osteochondral transplantation for the treatment of OLT, with a low failure rate. The results from this study show patients can be reasonably counselled to expect good clinical outcomes in the mid-term. MRI and radiographs showed restoration of articular surface as well as a minimal presence of osteoarthritis at mid-term follow-up. However, as low level and quality of evidence and the variability of the data may confound the data, further well-designed studies are necessary to determine the effectiveness of autologous osteochondral transplantation in the treatment for OLT.

LEVEL OF EVIDENCE

IV.

Effect of the Containment Type on Clinical Outcomes in Osteochondral Lesions of the Talus Treated With Autologous Osteochondral Transplantation

BACKGROUND

Uncontained-type osteochondral lesions of the talus (OLTs) have been shown to have inferior clinical outcomes after treatment with bone marrow stimulation. While autologous osteochondral transplantation (AOT) is indicated for larger lesions, no study has reported on the prognostic significance of the containment of OLTs treated with the AOT procedure.

PURPOSE

To clarify the effect of the containment of OLTs on clinical and radiological outcomes in patients who underwent AOT for OLTs.

STUDY DESIGN

Case control study; Level of evidence, 3.

METHODS

A retrospective cohort study comparing patients with contained-type and uncontained-type OLTs was undertaken to include all patients who underwent AOT for the treatment of OLTs between 2006 and 2014. Analyses were performed by grouping the patients according to the containment type. Clinical outcomes were evaluated using the Foot and Ankle Outcome Score (FAOS) and the 12-Item Short Form Health Survey (SF-12) preoperatively and at final follow-up. Magnetic resonance imaging (MRI) at 2 years' follow-up was evaluated with the modified magnetic resonance observation of cartilage repair tissue (MOCART) score. Multivariate regression models were used to evaluate factors affecting postoperative FAOS, SF-12, and MOCART scores.

RESULTS

Ninety-four patients were included: 31 patients with a contained-type OLT and 63 patients with an uncontained-type OLT. The median patient age was 34 years (interquartile range [IQR], 28-48 years) in the contained-type group and 36 years (IQR, 27-46 years) in the uncontained-type group. The median follow-up time was 45 months (IQR, 38-63 months) in the contained-type group and 52 months (IQR, 40-66 months) in the uncontained-type group. The median FAOS and SF-12 scores improved significantly after surgery in both contained-type and uncontained-type lesions ( P < .001). The median postoperative FAOS score of patients with contained-type OLTs was higher than that of patients with uncontained-type OLTs (91.7 vs 85.0, respectively; P = .009), but no significant differences were found between the contained-type and uncontained-type groups for postoperative SF-12 and MOCART scores. The multivariate regression models showed that patients with contained-type OLTs had an approximately 10-point better score on the FAOS compared with patients with uncontained-type OLTs ( P = .006). There was a nonsignificant trend for the rate of cystic occurrence in uncontained-type OLTs to be higher than that of contained-type OLTs (55.6% vs 38.7%, respectively; P = .125).

CONCLUSION

Patients with contained-type OLTs experienced better clinical outcomes than those with uncontained-type OLTs after AOT for the treatment of OLTs. However, the AOT procedure still provided good clinical and MRI outcomes in both contained-type and uncontained-type OLTs at midterm follow-up.

Osteochondral Autograft: Proceedings of the International Consensus Meeting on Cartilage Repair of the Ankle

BACKGROUND

Treatment guidelines for cartilage lesions of the talus have been 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 on key topics regarding cartilage lesions of the talus. The purpose of this consensus article is to explain the process and delineate the consensus statements derived from this consensus meeting on the use of "osteochondral autograft" for osteochondral lesions of the talus.

METHODS

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

RESULTS

A total of 14 statements on osteochondral autograft reached consensus during the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. Two achieved unanimous support, 11 reached strong consensus (greater than 75% agreement), and 1 achieved consensus. All statements reached at least 67% agreement.

CONCLUSIONS

This international consensus derived from leaders in the field will assist clinicians with osteochondral autograft as a treatment strategy for osteochondral lesions of the talus.

Primary Versus Secondary Osteochondral Autograft Transplantation for the Treatment of Large Osteochondral Lesions of the Talus

BACKGROUND

Recent studies have reported promising clinical results after osteochondral autograft transplantation (OAT) for the treatment of large osteochondral lesions of the talus (OLT). However, no study has yet compared clinical outcomes between primary and secondary OAT for large OLT.

PURPOSE

To compare clinical outcomes among patients with large OLT who receive primary OAT versus those who receive secondary OAT after failure of marrow stimulation and to identify factors associated with clinical failure.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

From 2005 to 2014, 46 patients with large OLT (≥150 mm²) underwent OAT: 18 underwent OAT as initial surgical management (primary OAT group), and 28 patients underwent secondary OAT after failure of previous arthroscopic marrow stimulation (secondary OAT group). In both groups, OAT procedures included arthroscopic inspection and debridement of concomitant soft tissue injuries. Clinical outcomes were assessed using pain visual analog scale (VAS), the Roles and Maudsley score, Foot and Ankle Outcome Scores (FAOS), and revisional surgery rates. Factors associated with clinical failures were evaluated using bivariate and logistic regression analyses. Survival outcomes were compared using Kaplan-Meier analysis.

RESULTS

Mean follow-up time was 6 years (range, 2-10.8 years). Mean lesion size was 194.9 mm² (range, 151.7-296.3 mm²). There were no significant differences between groups in patient demographics and preoperative findings. Postoperative pain VAS, Roles and Maudsley score, FAOS, and revisional surgery rates were not significantly different at last follow-up. Prior marrow stimulation was not significantly associated with clinical failure on bivariate analysis. Lesion size greater than 225 mm² on preoperative magnetic resonance imaging was significantly associated with clinical failure. Survival probabilities from Kaplan-Meier plots were not significantly different between the primary and secondary OAT groups ( P = .947).

CONCLUSION

Clinical outcomes of patients with large OLT treated with secondary OAT after failed marrow stimulation were found to be comparable with those who were treated with primary OAT. These results may be helpful to orthopaedic surgeons deciding appropriate surgical options for patients with large OLT.

Comparison of Juvenile Allogenous Articular Cartilage and Bone Marrow Aspirate Concentrate Versus Microfracture With and Without Bone Marrow Aspirate Concentrate in Arthroscopic Treatment of Talar Osteochondral Lesions

BACKGROUND

The purpose of this study was to compare the functional and radiographic outcomes of patients who received juvenile allogenic chondrocyte implantation with autologous bone marrow aspirate (JACI-BMAC) for treatment of talar osteochondral lesions with those of patients who underwent microfracture (MF).

METHODS

A total of 30 patients who underwent MF and 20 who received DeNovo NT for JACI-BMAC treatment between 2006 and 2014 were included. Additionally, 17 MF patients received supplemental BMAC treatment. Retrospective chart review was performed and functional outcomes were assessed pre- and postoperatively using the Foot and Ankle Outcome Score and Visual Analog pain scale. Postoperative magnetic resonance images were reviewed and evaluated using a modified Magnetic Resonance Observation of Cartilage Tissue (MOCART) score. Average follow-up for functional outcomes was 30.9 months (range, 12-79 months). Radiographically, average follow-up was 28.1 months (range, 12-97 months).

RESULTS

Both the MF and JACI-BMAC showed significant pre- to postoperative improvements in all Foot and Ankle Outcome Score subscales. Visual Analog Scale scores also showed improvement in both groups, but only reached a level of statistical significance ( P < .05) in the MF group. There were no significant differences in patient reported outcomes between groups. Average osteochondral lesion diameter was significantly larger in JACI-BMAC patients compared to MF patients, but size difference had no significant impact on outcomes. Both groups produced reparative tissue that exhibited a fibrocartilage composition. The JACI-BMAC group had more patients with hypertrophy exhibited on magnetic resonance imaging (MRI) than the MF group ( P = .009).

CONCLUSION

JACI-BMAC and MF resulted in improved functional outcomes. However, while the majority of patients improved, functional outcomes and quality of repair tissue were still not normal. Based on our results, lesions repaired with DeNovo NT allograft still appeared fibrocartilaginous on MRI and did not result in significant functional gains as compared to MF.

LEVEL OF EVIDENCE

Level III, comparative series.

Restorative Tissue Transplantation Options for Osteochondral Lesions of the Talus: A Review

Symptomatic osteochondral lesions of the talus remain a challenging problem due to inability for cartilage lesions to heal. Numerous treatment options exist, including nonoperative management, marrow stimulating techniques, and autograft-allograft. Arthroscopic marrow stimulation forms fibrocartilage that has been shown to be biomechanically weaker than hyaline cartilage. Restorative tissue transplantation options are being used more for larger and cystic lesions. Newer biologics and particulated juvenile cartilage are currently under investigation for possible clinical efficacy. This article provides an evidenced-based summary of available literature on the use of biologics for treatment of osteochondral lesions of the talus.

Platelet-Rich Plasma and Concentrated Bone Marrow Aspirate in Surgical Treatment for Osteochondral Lesions of the Talus

Platelet-rich plasma (PRP) and concentrated bone marrow aspirate (CBMA) have the potential to improve the quality of cartilage repair in osteochondral lesions of the talus (OLT). In this review, we describe the basic science and clinical evidence that has been published on the topic of PRP and CBMA on 2 commonly used surgical techniques for the treatment of OLT: bone marrow stimulation and osteochondral autograft transfer.