Concentrated Bone Marrow Aspirate May Decrease Postoperative Cyst Occurrence Rate in Autologous Osteochondral Transplantation for Osteochondral Lesions of the Talus

Efficacy of platelet-rich plasma use as an adjunctive treatment in autologous osteochondral transplantation for patients with osteochondral lesions of the talus accompanied by chronic lateral ankle instability

BACKGROUND

Autologous osteochondral transplantation (AOT) combined with biological agents is an advanced technique for treating osteochondral lesions. Therefore, this study aimed to explore the effect of combining platelet-rich plasma (PRP) treatment with AOT on postoperative functional and magnetic resonance imaging (MRI) outcomes in patients with osteochondral lesions of the talus (OLTs) accompanied by chronic lateral ankle instability (CLAI).

METHODS

This retrospective study had a minimum follow-up period of 1 year. Thiry-nine patients with CLAI who underwent AOT between 2019 and 2023 were included in this study. Of these, 21 and 18 received AOT combined with PRP treatment (AOT + PRP group) and AOT alone (AOT-alone group), respectively. Preoperative and postoperative follow-up assessments were performed using the visual analog scale (VAS), American Orthopedic Foot and Ankle Society (AOFAS), and foot and ankle ability measure-sport scale (FAAM-sport scale). The final follow-up MRI was evaluated using the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) 2.0 ankle scoring system.

RESULTS

Both groups showed a significant reduction in VAS scores and significant improvements in AOFAS and FAAM-sport scale scores at the final follow-up compared with the preoperative values. No significant differences were observed in the final follow-up VAS, AOFAS, FAAM-sport scale, and MOCART 2.0 ankle scores between the groups. However, significant between-group differences were found at postoperative months 1 (P < 0.001) and 3 (P = 0.031) for VAS scores and at postoperative month 3 for FAAM-sport scale scores (P = 0.005). The AOT + PRP group showed significantly better final follow-up scores for the "surface of the repair tissue" on the MOCART 2.0 ankle score system than the AOT-alone group (P = 0.029).

CONCLUSIONS

PRP did not result in significantly superior outcomes when used as an adjunct to AOT compared to AOT alone in the setting of concomitant OLTs and CLAI.

Operative Treatment of Nonprimary Osteochondral Lesions of the Talus: A Systematic Review

Background

Nonprimary osteochondral lesions of the talus (OLT) pose a significant challenge in orthopaedics, with no definitive consensus on optimal surgical treatment.

Purpose

To consolidate the most recent evidence on operative treatments for nonprimary OLT by assessing patient-reported outcomes (PROs), postoperative complications, and clinical failures.

Study Design

Systematic review; Level of evidence, 4.

Methods

This review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 and PRISMA in Exercise, Rehabilitation, Sport medicine and Sports science guidelines. Searches were conducted in PubMed, Embase, and Cochrane Library databases through June 2023. Eligible studies evaluated operative outcomes in skeletally mature patients with nonprimary OLT after failed previous surgeries. Primary outcomes included clinical and functional PROs. Secondary outcomes included postoperative complications and clinical failures. Quantitative analyses involved weighted means, mean differences, minimal clinically important differences, success rates (95% binomial proportion confidence interval), and a pre-to-postoperative meta-analysis.

Results

Out of 3992 identified records, 50 studies involving 806 ankles from 794 patients were included. All operative treatments significantly improved PROs (P < .05), except osteochondral allograft transplantation (OCA) for American Orthopaedic Foot and Ankle Society and pain (visual analog scale/numeric rating scale [VAS/NRS]) scores and HemiCAP for pain (VAS/NRS) scores. Autologous chondrocyte implantation (ACI) and osteochondral autologous transplantation (OAT) demonstrated the greatest PRO success rates, exceeding 80%. Postoperative complications occurred in 4% of cases, most frequently with HemiCAP. Clinical failures affected 22% of cases, particularly with autologous matrix-induced chondrogenesis, OAT, OCA, and HemiCAP.

Conclusion

Our systematic review demonstrated that ACI and OAT are promising treatments for nonprimary OLT, with ACI showing fewer clinical failures than OAT. Conversely, OCA and HemiCAP exhibited lower effectiveness and higher clinical failure rates, suggesting a need for reassessment.

Evidence-Based Clinical Practice Guidelines on Regenerative Medicine Treatment for Chronic Pain: A Consensus Report from a Multispecialty Working Group

Purpose

Injectable biologics have not only been described and developed to treat dermal wounds, cardiovascular disease, and cancer, but have also been reported to treat chronic pain conditions. Despite emerging evidence supporting regenerative medicine therapy for pain, many aspects remain controversial.

Methods

The American Society of Pain and Neuroscience (ASPN) identified the educational need for an evidence-based guideline on regenerative medicine therapy for chronic pain. The executive board nominated experts spanning multiple specialties including anesthesiology, physical medicine and rehabilitation, and sports medicine based on expertise, publications, research, and clinical practice. A steering committee selected preliminary questions, which were reviewed and refined. Evidence was appraised using the United States Preventive Services Task Force (USPSTF) criteria for evidence level and degree of recommendation. Using a modified Delphi approach, consensus points were distributed to all collaborators and each collaborator voted on each point. If collaborators provided a decision of "disagree" or "abstain", they were invited to provide a rationale in a non-blinded fashion to the committee chair, who incorporated the respective comments and distributed revised versions to the committee until consensus was achieved.

Results

Sixteen questions were selected for guideline development. Questions that were addressed included type of injectable biologics and mechanism, evidence in treating chronic pain indications (eg, tendinopathy, muscular pathology, osteoarthritis, intervertebral disc disease, neuropathic pain), role in surgical augmentation, dosing, comparative efficacy between injectable biologics, peri-procedural practices to optimize therapeutic response and quality of injectate, federal regulations, and complications with mitigating strategies.

Conclusion

In well-selected individuals with certain chronic pain indications, use of injectable biologics may provide superior analgesia, functionality, and/or quality of life compared to conventional medical management or placebo. Future high-quality randomized clinical trials are warranted with implementation of minimum reporting standards, standardization of preparation protocols, investigation of dose-response associations, and comparative analysis between different injectable biologics.

Outcomes Following the Use of Extracellular Matrix Cartilage Allograft for the Management of Osteochondral Lesions of the Talus: A Systematic Review

Extracellular matrix cartilage allograft (EMCA) is a novel biological strategy utilized to augment the repair of osteochondral lesions of the talus (OLTs). However, there is no consensus on the precise role and outcomes following its use in the treatment of OLTs. The purpose of this systematic review was to evaluate the clinical and radiological outcomes following the use of EMCA for the treatment of OLT. During July 2023, the PubMed, Embase, and Cochrane Library databases were systematically reviewed to identify clinical studies examining outcomes following EMCA for the management of OLTs. In total, 162 patients (162 ankles) across five studies received EMCA as part of their surgical procedure at a weighted mean follow-up time of 23.8±4.2 months. Across all five studies, there were improvements in subjective clinical outcomes following the use of EMCA, regardless of the clinical scoring tool utilized. Two studies demonstrated superior postoperative magnetic resonance observation of cartilage repair tissue (MOCART) scores in the EMCA cohort compared to the bone marrow stimulation (BMS) cohort alone. In the EMCA-BMS cohort, there were seven complications (9%) and three failures (4.1%). In the autologous osteochondral transplantation (AOT) cohort, there were 10 complications (38.5%), zero failures, and six secondary surgical procedures (23.1%). In the EMCA alone cohort, there were zero complications and three failures (4.3%), all of which underwent an unspecified revision procedure. This current systematic review demonstrated improvements in both clinical and radiological outcomes following the use of EMCA for the treatment of OLTs. Further prospective comparative studies with longer follow-up times are warranted to determine the precise role of EMCA in the management of OLT.

Improved Results From Medium- and Long-Term Outcomes of Autogenous Osteoperiosteal Grafting for Large Cystic Lesions of the Talus

PURPOSE

To investigate the medium and long-term follow-up outcomes of large cystic medial osteochondral lesions of the talus (OLTs) treated with autologous tibial osteoperiosteal grafts from the medial tibia and to explore the risk factors influencing the treatment outcomes.

METHODS

The retrospective study included 75 patients with large cystic medial OLTs who underwent autologous osteoperiosteal cylinder graft taken from the medial tibia between January 2004 and August 2018. They were assessed preoperatively and postoperatively using a visual analog scale, the Orthopedic Foot & Ankle Society Ankle-Hindfoot Scale (AOFAS), and short-form 36-item Short Form Health Survey score. Magnetic resonance observation of cartilage repair tissue, second-look arthroscopy, and biopsy were used to evaluate the grafting areas.

RESULTS

After a follow-up period of 6.3 years, the virtual analog scale score decreased to 1.47 ± 1.32, and the AOFAS and 36-item Short Form Health Survey scores increased to 82.78 ± 11.65 and 83.26 ± 8.49, respectively, all of which showed significant improvement over preoperative scores (P < .001), and the average magnetic resonance observation of cartilage repair tissue score was 82.6 ± 8.4 (56.0-91.6). Eight patients underwent a second-look arthroscopic examination and were rated by the International Cartilage Repair Society scale; of them, 2 patients were rated grade Ⅰ, 4 were rated grade Ⅱ, and 2 were rated grade Ⅲ. Three patients underwent grafting area biopsy during the second-look arthroscopy, and the results showed that the grafting areas were rich in chondrocytes. Large OLTs (≥200 mm2) and obesity (body mass index ≥25) were responsible for the poor improvement of AOFAS score, according to multivariate Cox regression analysis.

CONCLUSIONS

Autologous osteoperiosteal grafting was an effective treatment for large cystic medial OLTs, with effective cartilage regeneration in the grafted areas in the medium and long term. However, the large OLTs and obesity may reduce the treatment outcomes.

LEVEL OF EVIDENCE

Level IV, case series.

Reporting of Morphology, Location, and Size in the Treatment of Osteochondral Lesions of the Talus in 11,785 Patients: A Systematic Review and Meta-Analysis

OBJECTIVE

Uniformity of reporting is a requisite to be able to compare results of clinical studies on the treatment of osteochondral lesions of the talus (OLT). The primary aim of this study was to evaluate the frequency and quality of reporting of size, morphology, and location of OLTs.

DESIGN

A literature search was performed from 1996 to 2023 to identify clinical studies on surgical treatment of OLTs. Screening was performed by 2 reviewers, who subsequently graded the quality using the methodological index for non-randomized studies (MINORS). The primary outcome was the frequency and qualitative assessment of reporting of size, morphology, and location.

RESULTS

Of 3,074 articles, 262 articles were included. This comprised a total of 11,785 patients. Size was reported in 248 (95%) of the articles and was described with a measure for surface area in 83%, however, in 56%, definition of measurement is unknown. Intraclass coefficient (ICC) value for the reliability of size measurement was 0.94 for computed tomography (CT) scan and 0.87 for MRI scan. Morphology was reported in 172 (66%) of the articles and using a classification system in 23% of the studies. Location was reported in 220 (84%) of the studies.

CONCLUSION

No consensus was found on the reporting of morphology, with non-validated classification systems and different terminologies used. For location, reporting in 9 zones is underreported. Size was well reported and measurements are more reliable for CT compared with MRI. As these prognostic factors guide clinical decision-making, we advocate the development of a standardized and validated OLT classification to reach uniform reporting in literature.

LEVEL OF EVIDENCE

Level III, systematic review.

Limited evidence in support of bone marrow aspirate concentrate as an additive to the bone marrow stimulation for osteochondral lesions of the talus: a systematic review and meta-analysis

PURPOSE

Bone marrow aspirate concentrate can be used as an additive to surgical treatment of osteochondral lesions of the talus. This systematic literature review aims to study the effect of the additional use of bone marrow aspirate concentrate on top of a surgical treatment for osteochondral lesions of the talus on clinical outcomes compared to surgical treatment alone.

METHODS

An online literature search was conducted using PubMed (Medline), Embase (Ovid), and the Cochrane library for all studies comparing a surgical intervention with bone marrow aspirate concentrate, with a surgical intervention without bone marrow aspirate concentrate. The methodological quality was rated according to the methodological index for non-randomised studies checklist. The primary outcome measure were clinical outcomes. Secondary outcome measures consisted of revision rate, complication rate, radiographic outcome measures and histological analyses. Subgroups were created based on type of surgical intervention used in the studies. If multiple articles were included in a subgroup, a linear random-effects model was used to compare the bone marrow aspirate concentrate-augmented group with the control group.

RESULTS

Out of 1006 studies found, eight studies with a total of 718 patients were included. The methodological quality, assessed according to the methodological index for non-randomised studies checklist, was weak. A significantly better functional outcome measures (p < 0.05) was found in the subgroup treated with bone marrow stimulation + bone marrow aspirate concentrate compared to the group treated with bone marrow stimulation alone, based on three non-blinded studies. No significant differences regarding clinical outcomes were found in the subgroups comparing matrix-induced autologous chondrocyte implantation with matrix-induced bone marrow aspirate concentrate, osteochondral autologous transplantation alone with osteochondral autologous transplantation + bone marrow aspirate concentrate and autologous matrix-induced chondrogenesis plus peripheral blood concentrate vs. matrix-associated stem cell transplantation bone marrow aspirate concentrate.

CONCLUSION

There is insufficient evidence to support a positive effect on clinical outcomes of bone marrow aspirate concentrate as an additive to surgical treatment of osteochondral lesions of the talus. However, based on the safety reports and initial results, sufficiently powered, patient- and researcher-blinded, prospective randomised controlled trials are justified and recommended. Until then, we advise not to implement a therapy (addition of bone marrow aspirate concentrate) without clinical evidence that justifies the additional costs involved.

LEVEL OF EVIDENCE

Level III.

Talar OsteoPeriostic Grafting from the Iliac Crest (TOPIC): Two-Year Prospective Results of a Novel Press-Fit Surgical Technique for Large, Complex Osteochondral Lesions of the Medial Talus

BACKGROUND

Press-fit Talar OsteoPeriostic grafting from the Iliac Crest (TOPIC) is a novel technique for the treatment of large osteochondral lesions of the talus. The purpose of the present study was to prospectively evaluate the 2-year clinical outcomes for patients with medial osteochondral lesions of the talus that were treated with the TOPIC procedure.

METHODS

Forty-three patients were prospectively assessed before and 24 months after the TOPIC procedure. All procedures were performed through a medial distal tibial osteotomy. Clinical assessment preoperatively and at 24 months of follow-up included determination of the Numeric Rating Scale (NRS) scores for pain during walking (primary outcome), at rest, during running, and during stair-climbing. The Foot and Ankle Outcome Score (FAOS) and the Mental Component Summary (MCS) score and Physical Component Summary (PCS) score of the Short Form-36 (SF-36) were also assessed. A computed tomography (CT) scan was performed 12 weeks postoperatively to assess union of the distal tibial osteotomy site and at 1 and 2 years postoperatively to assess consolidation of the graft as well as cyst development in the graft.

RESULTS

All enrolled patients were available for follow-up. The median NRS score for pain during walking improved from 7 points preoperatively to 2 points at 2 years postoperatively (p < 0.001). All other NRS scores for pain improved significantly. All FAOS subscale scores improved significantly, including those for pain (from 53 to 75), symptoms (from 50 to 61), activities of daily living (from 68 to 88), sports (from 30 to 55), and quality of life (from 19 to 38). The SF-36 PCS score improved from 43 to 48 (p < 0.001), and the MCS score changed from 28 to 26 (p > 0.05). There was a 100% rate of union of the osteotomy site at the distal tibia and 100% of the grafts showed consolidation at 1 and 2 years postoperatively.

CONCLUSIONS

The TOPIC procedure for large osteochondral lesions of the medial talar dome is an effective technique that resulted in significant improvement exceeding the minimal clinically important difference in pain scores (primary outcome) as well as in other outcomes, with 100% consolidation of the grafts.

LEVEL OF EVIDENCE

Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

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.

Retrograde Autologous Talar Osteocancellous Bone Grafting for the Treatment of Osteochondral Lesions of the Talus: A Technical Note

Osteochondral lesions of the talus (OLT) are common injuries in young athletes. Various kinds of surgical procedures are available for orthopaedic surgeons, but which surgical technique is the best remains controversial. Many surgical procedures require malleolar osteotomy to obtain appropriate surgical exposure to the OLT because of the anatomic characteristics of the ankle joint. However, malleolar osteotomy is invasive and has a potential risk of complications, such as tibial chondral damage and pseudoarthrosis. This article aims to introduce a novel surgical procedure for the treatment of OLTs: retrograde autologous talar osteocancellous bone grafting without the need for osteotomy and harvesting a graft from anywhere other than the talus. First, an arthroscopic evaluation is performed to verify the location, size, and cartilage quality of the OLT as well as concomitant lesions. After confirming the position of the guide pin using a guide device arthroscopically, a talar osteocancellous bone plug is harvested using a coring reamer. The OLT of the harvested talar bone plug is removed, and under arthroscopy, the talar osteocancellous bone plug is retrogradely inserted into the talar bone tunnel. To stabilize the implanted bone plug, one or two bioabsorbable pins are inserted from the lateral wall of the talus while applying counterforce to the articular surface of the bone plug. The present surgical technique can minimally invasively address the OLT without the need for malleolar osteotomy and harvesting a graft from the knee joint or iliac bone.

Advances in Cartilage Repair

Osteochondral lesions of the ankle joint are typically associated with a traumatic etiology and present with ankle pain and swelling. Conservative management yields unsatisfactory results because of the poor healing capacity of the articular cartilage. Smaller lesions (<100 mm² or <10 mm) can be treated with less invasive procedures such as arthroscopic debridement, anterograde drilling, scaffold-based therapies, and augmentation with biological adjuvants. For patients with large lesions (>100 mm² or >10 mm), cystic lesions, uncontained lesions, or patients who have failed prior bone marrow stimulation, management with autologous osteochondral transplantation is indicated.

Bone Marrow Aspirate Concentrate Improves Outcomes in Adults With Osteochondral Dissecans of the Talus and Achilles Rupture

PURPOSE

The objective of this systematic literature review was to investigate the effects of the clinical application of bone marrow aspirate (BMA) and/or bone marrow aspirate concentrate (BMAC) in tendon and cartilage injuries in the foot and ankle.

METHODS

A search of the Embase, MEDLINE/PubMed, CINAHL, and Cochrane databases was performed in January 2021. The risk of bias of the studies was assessed using the tool "A Cochrane Risk of Bias Assessment Tool for Non-Randomized Studies." The outcomes analyzed included pain reduction and functional improvement with the use of BMA/BMAC in patients with tendon and cartilage injuries in the foot and ankle.

RESULTS

Eleven studies met the inclusion criteria for analysis, involving a total of 527 subjects with osteochondral lesions (OCLs) of the talus, cartilage lesions of the talus, and acute Achilles tendon rupture. BMAC was applied alone in 4 studies, and in 7 studies, it was compared with other techniques such as matrix-induced autologous chondrocyte implantation, particulate juvenile articular cartilage, or microfracture. Interventions demonstrated improved function and reduced foot and ankle pain and showed no serious adverse effects.

CONCLUSIONS

Evidence indicates that BMAC provides good clinical results, with improved function and reduced pain in adults with OCL and cartilage lesions of the talus and acute Achilles tendon rupture.

LEVEL OF EVIDENCE

Level IV, systematic review of level II to IV studies.

Augmenting Osteochondral Autograft Transplantation and Bone Marrow Aspirate Concentrate with Particulate Cartilage Extracellular Matrix Is Associated With Improved Outcomes

BACKGROUND

Osteochondral autograft transplant (OAT) is often used to treat large osteochondral lesions of the talus and is generally associated with good outcomes. The addition of adjuncts such as cartilage extracellular matrix with bone marrow aspirate concentrate (ECM-BMAC) may further improve the OAT procedure but have not been thoroughly studied. We hypothesized that the placement of ECM-BMAC around the OAT graft would improve radiographic and patient-reported outcomes following OAT.

METHODS

Patients who received OAT, with ECM-BMAC or BMAC alone, were screened and their charts were reviewed. For patients who did receive ECM-BMAC, the mixture was spread around the edges of the OAT plug and into any surrounding areas of cartilage damage. Survey and radiographic data were collected. Average follow-up in both groups was over 2 years. Magnetic resonance imaging scans were scored using the Magnetic Resonance Observation of Cartilage Tissue (MOCART) system. Outcomes were compared statistically between groups.

RESULTS

Patients treated with ECM-BMAC (n = 34) demonstrated significantly greater improvement of scores in the FAOS categories Symptoms (17 vs -3; P = .02) and Sports Activities (40 vs 7; P = .02), and the MOCART category Subchondral Lamina (P = .008) compared to those treated with BMAC alone (n = 30). They also experienced significantly lower rates of postoperative cysts (53% vs 18%, P = .04) and edema (94% vs 59%, P = .02).

CONCLUSION

The addition of ECM-BMAC to OAT was associated with improved imaging and clinical outcomes compared to OAT with BMAC alone.

Clinical Observation of MRI Image in Floating Needle Therapy for Cervical Spondylosis of Cervical Type

In order to solve the problem of cervical spondylosis in the early stage of various cervical spondylosis, effective treatment can prevent the deterioration of the disease. This paper presents the results of a clinical trial examining magnetic resonance imaging in the treatment of cervical spondylosis with flotation therapy and selected 68 patients with cervical spondylosis. According to research commodity, using a rigorous randomized controlled trial, 34 cases were divided into a control group (acupuncture group). The needles were kept for 30 minutes once a day. The treatment group (acupuncture combined with floating acupuncture group) was treated with acupuncture on the 1st, 3rd, and 5th days and floating acupuncture on the 2nd, 4th, and 6th days, respectively. Both groups were treated for 6 consecutive days and rested for 1 day. After 2 weeks of treatment, the simplified McGill Pain Scale (MPQ), visual analogue scale (VAS), and neck pain scale (NPQ) were observed and recorded to compare the curative effects. Finally, Excel software is used to manage the data, and SPSS21.0 is used for statistical analysis. Measurements of gender, age, disease, VAS, simple MPQ, and NPQ of the two groups were compared in the two groups, P > 0.05, which was not significant and comparable. After treatment, VAS, simple MPQ, and NPQ of the two groups were compared in and between groups, the total P < 0.05, with the mean data. Topics. Acupuncture combined with float needle and acupuncture therapy can improve the pain and breathing of cervical spondylosis and improve the quality of life of patients, but acupuncture combined with needle float is more pronounced than acupuncture groups.

Outcomes of Autologous Osteochondral Transplantation With and Without Extracellular Matrix Cartilage Allograft Augmentation for Osteochondral Lesions of the Talus

BACKGROUND

Autologous osteochondral transplantation (AOT) using a cylindrical graft in the treatment of osteochondral lesions of the talus (OLTs) is typically indicated for patients with larger lesions. However, with lesions that are irregular in shape, the AOT graft may not completely replace the lesion. For these lesions, we utilize extracellular matrix cartilage allograft (EMCA) augmentation in AOT to act as a physiologic grout at the host-graft interface.

PURPOSE

To determine if the combination of EMCA with concentrated bone marrow aspirate (CBMA) would improve integration of the host-graft interface and subsequently reduce postoperative cyst formation after AOT. It was also hypothesized that EMCA in conjunction with CBMA would demonstrate improved MOCART (magnetic resonance observation of cartilage repair tissue) scores and functional outcome scores at a minimum 2 years after surgery.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A retrospective analysis was performed comparing patients treated with AOT/CBMA alone and AOT with CBMA/EMCA. Clinical outcomes were evaluated with the Foot and Ankle Outcome Score. Magnetic resonance imaging appearance was evaluated with the use of the MOCART (magnetic resonance observation of cartilage repair tissue) score. Cyst formation was also evaluated on postoperative magnetic resonance imaging.

RESULTS

A total of 26 patients were included in the AOT + CBMA/EMCA group (10 male, 16 female), and 34 patients were included in the AOT/CBMA group (17 male, 17 female). The mean Foot and Ankle Outcome Score significantly improved in both groups (P < .001) across all subscales (symptoms, pain, activities of daily living, sports activities, and quality of life), but there was no significant difference between groups at final follow-up. There was no significant difference in mean MOCART scores between the groups (P = .118). In the AOT/CBMA group, 3 patients (8.8%) complained of knee pain, and 1 (2.9%) required additional surgery (hardware removal). In the AOT + CBMA/EMCA group, 2 patients (7.7%) complained of knee pain, and 6 patients (23%) required additional surgery (3 hardware removals and 3 arthroscopic debridements of scar tissue in the ankle).

CONCLUSION

We found that while EMCA with CBMA has benefit in regeneration and repair of OLT treated with bone marrow stimulation, there appears to be little benefit of EMCA over CBMA alone as a physiologic grout at the graft-host interface in OLT treated with AOT.

Long-term outcome for repair of osteochondral lesions of the talus by osteochondral autograft: A series of 56 Mosaicplasties®

INTRODUCTION

The present study analyzed results in 56 osteochondral Mosaicplasty® autografts for osteochondral lesion of the talus (OLT) at more than 5 years' follow-up.

HYPOTHESIS

Mosaicplasty® shows long-term efficacy and low morbidity in the treatment of OLT.

PATIENTS AND METHODS

A multicenter retrospective study included patients treated by Mosaicplasty® with more than 5 years' follow-up. Preoperative data were collected from medical files, and all patients were reassessed. AOFAS scores and FAOS were calculated at last follow-up. Imaging comprised standard radiographs and MRI or CT arthrography of the ankle.

RESULTS

Fifty-six patients were included, with a mean age of 34 years (range, 18-60 years). Seventeen involved work accidents. Mean follow-up was 8.5 years (range, 5-20 years). Mean AOFAS score at follow-up was 80.6±19.4 and mean FAOS 77.8±21.5. Work accident, preoperative osteoarthritis and untreated laxity correlated significantly with poorer results. At last follow-up, 22 patients (39%) showed signs of osteoarthritis. There was no morbidity implicating the malleolar osteotomy. There were 11 cases (20%) of persistent patellar syndrome at the donor site.

DISCUSSION

The present results were comparable to those reported elsewhere, showing that functional results of Mosaicplasty® autograft for OLT do not deteriorate over the long term. Work accidents correlated significantly with poorer functional outcome. Any associated instability must always be treated. Malleolar osteotomy provides good exposure without additional morbidity.

LEVEL OF EVIDENCE

IV; retrospective study.

Osteochondral Lesions of the Tibial Plafond: A Systematic Review

Background:

There is a paucity of data regarding osteochondral lesions of the tibial plafond (OLTPs), in part because they are far less common than osteochondral lesions of the talus.

Purpose:

To evaluate the topographical characteristics of OLTPs and outcomes after surgical intervention, while analyzing the level of evidence (LOE) and quality of evidence (QOE) of the included studies.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

A systematic review of the MEDLINE, EMBASE, and Cochrane Library databases was performed in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Studies reporting clinical data for OLTPs were included. The LOE and QOE of the included studies were evaluated using a 5-level grading system and the modified Coleman Methodology Score, respectively.

Results:

Included were 20 studies with 426 OLTPs; 4 studies were LOE 2 and 16 studies were LOE 4. Overall, 86.7% of OLTPs were associated with a traumatic history and/or previous ankle sprain. OLTPs were most commonly located in the centromedial region of the tibial plafond (30.4%), with the fewest number of OLTPs found in the anteromedial region of the tibial plafond (3.9%). In 17 of the studies, a total of 46.9% of OLTPs were associated with coexisting osteochondral lesions of the talus. The most frequently used surgical technique to treat OLTPs was microfracture, which resulted in good clinical outcomes at midterm follow-up.

Conclusion:

The results of this systematic review indicated that OLTPs are frequently preceded by ankle trauma and are often associated with coexisting osteochondral lesions of the talus. Clinical outcomes after arthroscopic intervention appear to produce good results in the midterm, but the low LOE, poor QOE, marked heterogeneity, and underreporting of the data confound any recommendation based on this systematic review.

Sheep condyle model evaluation of bone marrow cell concentrate combined with a scaffold for repair of large osteochondral defects

Aims

Minimally manipulated cells, such as autologous bone marrow concentrates (BMC), have been investigated in orthopaedics as both a primary therapeutic and augmentation to existing restoration procedures. However, the efficacy of BMC in combination with tissue engineering is still unclear. In this study, we aimed to determine whether the addition of BMC to an osteochondral scaffold is safe and can improve the repair of large osteochondral defects when compared to the scaffold alone.

Methods

The ovine femoral condyle model was used. Bone marrow was aspirated, concentrated, and used intraoperatively with a collagen/hydroxyapatite scaffold to fill the osteochondral defects (n = 6). Tissue regeneration was then assessed versus the scaffold-only group (n = 6). Histological staining of cartilage with alcian blue and safranin-O, changes in chondrogenic gene expression, microCT, peripheral quantitative CT (pQCT), and force-plate gait analyses were performed. Lymph nodes and blood were analyzed for safety.

Results

The results six months postoperatively showed that there were no significant differences in bone regrowth and mineral density between BMC-treated animals and controls. A significant upregulation of messenger RNA (mRNA) for types I and II collagens in the BMC group was observed, but there were no differences in the formation of hyaline-like cartilage between the groups. A trend towards reduced sulphated glycosaminoglycans (sGAG) breakdown was detected in the BMC group but this was not statistically significant. Functional weightbearing was not affected by the inclusion of BMC.

Conclusion

Our results indicated that the addition of BMC to scaffold is safe and has some potentially beneficial effects on osteochondral-tissue regeneration, but not on the functional endpoint of orthopaedic interest.

Cite this article: Bone Joint Res 2021;10(10):677–689.

Topical Review: Bone Marrow Aspirate Concentrate and Its Clinical Use in Foot and Ankle Surgery

Bone marrow aspirate concentrate (BMAC) is now commonly used in orthopedic surgery. Animal studies showed promising results for cartilage, bone, and soft tissue healing; however, many of these outcomes have yet to be translated to human models. While there has been an increase in the use of BMAC in foot and ankle procedures, the associated clinical evidence is limited. The purpose of this review is to analyze the existing literature in order to evaluate the safety and efficacy of BMAC in foot and ankle surgery.

Comparison of Clinical and Radiographic Outcomes Following Arthroscopic Debridement With Extracellular Matrix Augmentation and Osteochondral Autograft Transplantation for Medium-Size Osteochondral Lesions of the Talus

BACKGROUND

Historically, microfracture has been used to treat small talar osteochondral lesions with good results, whereas osteochondral autologous transplantation (OAT) has proven effective for the treatment of larger lesions. It is not clear which method is more effective for medium-sized lesions around the critical size of 150 mm², above which microfracture outcomes tend to be poor. The purpose of this study was to determine the potential advantages of OAT augmented with a combination of extracellular matrix and bone marrow aspirate concentrate (ECM-BMAC) compared to debridement with ECM-BMAC (DEB) in the treatment of medium-sized osteochondral lesions of the talus (OLTs).

METHODS

Clinical and radiographic data were collected retrospectively for patients treated by a single fellowship-trained foot and ankle surgeon. Magnetic resonance images (MRIs) were scored using the Magnetic Resonance Observation of Cartilage Tissue (MOCART) system and were evaluated for the presence of cysts and edema. Fifty-two patients met inclusion criteria, with 25 who received an OAT procedure. Age, body mass index, lesion size, lesion location, and follow-up time were similar between groups. Average MRI follow-up times were 16.7 months for the OAT group and 20.3 months for the DEB group (P = .38).

RESULTS

Patients treated with OAT had significantly higher average total MOCART scores (69 vs 55, P = .04) and significantly lower rates of cyst (14% vs 55%, P < .01), edema (59% vs 90%, P = .04), revision surgery (0% vs 19%, P = .05), and therapeutic injection for pain (4% vs 30%, P = .02) compared to patients treated with DEB. No significant differences were detected in patient-reported outcome scores between groups.

CONCLUSION

The native hyaline cartilage introduced by OAT appears to result in higher-quality repair tissue when compared to DEB, as evidenced by OAT patients' higher MOCART scores and lower rates of cyst and edema. There was no difference in clinical outcome scores, though OAT patients did not require revision surgery or therapeutic injection for pain as frequently as DEB patients.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Treatment strategies for osteochondral lesions of the talus: A review of the recent evidence

BACKGROUND

There has been no consensus regarding the treatment of osteochondral lesions of the talus, there has been many attempts to formulate a treatment pathway, with multiple proposed modalities and adjuncts used.

OBJECTIVES

The aim of this paper was to investigate the evidence published in the recent history, identify the relevant papers, review and summarize the findings, to help clarify the available operative treatment options and their respective efficacies based on the level of evidence provided.

STUDY DESIGN & METHODS

A literature search through electronic databases MEDLINE and EMBASE was done, these databases were screened for publications and papers form June 2004 to June 2019. Key words were utilised in the search 'talus, talar, tibia, cartilage, osteochondral, ankle, osteochondritis dissecans, articular cartilage'. Studies on adults aged 18-60 years were included. Exclusion criteria were studies with less than 10 patients, or no clear outcome was recorded. Papers were reviewed by the authors and data extracted as per a pre-defined proforma.

RESULTS

Following screening, 28 published articles were included and reviewed. Of these publications 5 were level I, 7 level II, 4 level III and 12 level IV. The total number of patients was 1061 patients. Treatment modalities included arthroscopic microfracture, drilling, hyaluronic acid injection, platelet rich plasma, osteochondral autologous transplantation (OAT), vascularised free bone graft among others. The most common functional measures used to assess efficacy were the Visual analogue scale (VAS) and the American Orthopaedic Foot and Ankle (AOFAS) score. Follow up ranged from 26 weeks upto 4 years.

CONCLUSIONS

Despite the abundance of treatment options, high level evidence (level I) remains limited and does not conclude a definitive treatment modality as superior to others. Further research, in the form highly organised randomised clinical trials, is needed to help improve the efficacy and develop new treatment modalities in the future.

Emerging Biological Treatment Methods for Ankle Joint and Soft Tissue Conditions: Clinical Applications as Alternative or Adjuvant

In the past 2 decades, there has been a rapid expansion of clinical studies investigating the safety and efficacy of biological treatment methods for a wide range of diseases. These biological treatment methods increasingly are used in clinical practice based on limited available evidence. This article provides an overview of evidence on biological treatment methods for foot and ankle pathologies, including ankle osteoarthritis, osteochondral lesions of the talus, and Achilles tendinopathy.

Current management strategies for osteochondral lesions of the talus

The management of symptomatic osteochondral lesions of the talus (OLTs) can be challenging. The number of ways of treating these lesions has increased considerably during the last decade, with published studies often providing conflicting, low-level evidence. This paper aims to present an up-to-date concise overview of the best evidence for the surgical treatment of OLTs. Management options are reviewed based on the size of the lesion and include bone marrow stimulation, bone grafting options, drilling techniques, biological preparations, and resurfacing. Although many of these techniques have shown promising results, there remains little high level evidence, and further large scale prospective studies and systematic reviews will be required to identify the optimal form of treatment for these lesions. Cite this article: Bone Joint J 2021;103-B(2):207-212.

Cyst formation in the subchondral bone following cartilage repair

Subchondral bone cysts represent an early postoperative sign associated with many articular cartilage repair procedures. They may be defined as an abnormal cavity within the subchondral bone in close proximity of a treated cartilage defect with a possible communication to the joint cavity in the absence of osteoarthritis. Two synergistic mechanisms of subchondral cyst formation, the theory of internal upregulation of local proinflammatory factors, and the external hydraulic theory, are proposed to explain their occurrence. This review describes subchondral bone cysts in the context of articular cartilage repair to improve investigations of these pathological changes. It summarizes their epidemiology in both preclinical and clinical settings with a focus on individual cartilage repair procedures, examines an algorithm for subchondral bone analysis, elaborates on the underlying mechanism of subchondral cyst formation, and condenses the clinical implications and perspectives on subchondral bone cyst formation in cartilage repair.

Decreased Graft Thickness Is Associated With Subchondral Cyst Formation After Osteochondral Allograft Transplantation in the Knee

BACKGROUND

Subchondral changes, specifically cyst formation, are a known finding after osteochondral allograft (OCA) transplantation.

PURPOSE/HYPOTHESIS

The purpose was to determine potential predictive associations between preoperative patient characteristics or OCA morphology and postoperative OCA appearance as assessed by the osteochondral allograft magnetic resonance imaging scoring system (OCAMRISS) at 6-month follow-up. It was hypothesized that preoperative patient factors or OCA morphology is associated with postoperative OCAMRISS scores.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

This study evaluated 74 OCAs that were implanted in the femoral condyles of 63 patients for the treatment of symptomatic osteochondral defects in the knee. Postoperative magnetic resonance imaging was obtained at a mean ± SD follow-up of 5.5 ± 1.0 months. A musculoskeletal radiologist scored all grafts according to the OCAMRISS. Point biserial correlation, Mann-Whitney U test, Fisher exact test, and chi-square test were used to distinguish associations between OCAMRISS subscales and age, sex, smoker status, body mass index, previous surgery, concomitant surgery, bone marrow augmentation, graft location, graft size, and bony graft thickness.

RESULTS

OCA bony thickness showed significant correlation with cystic changes at the graft-host junction (P = .019). Grafts with cystic formation were significantly thinner than grafts without cystic changes (P = .008). The odds ratio for grafts with <5-mm bony thickness demonstrating cystic changes was 4.9 (95% CI, 1.5-16.1; P = .009). Bony graft thickness was not associated with graft integration, but 40% of grafts with a bony thickness >9 mm presented with a residual osseous cleft, as opposed to 11.3% of thinner grafts (P = .1). The augmentation with bone marrow aspirate did not affect osseous graft integration or subchondral cystic formation (P = .375 and P = .458, respectively).

CONCLUSION

Osteochondral allograft thickness is associated with subchondral cyst formation at short-term follow-up. Thin grafts demonstrate a substantially increased risk of developing subchondral cysts at the graft-host junction after OCA transplantation. Conversely, thicker grafts may negatively affect osseous graft integration. Hence, surgeons should be aware of the potential pitfalls of transplanting thin or thick grafts regarding cystic formation and delay of osseous integration after cartilage resurfacing.