A Comparison of Outcomes of Particulated Juvenile Articular Cartilage and Bone Marrow Aspirate Concentrate for Articular Cartilage Lesions of the Talus

Suitability of Minced Cartilage From Osteochondral Lesions of the Talus for Immediate Autograft Reimplantation

Background

Particulated autograft cartilage implantation is a surgical technique that has been previously described for the repair of osteochondral lesions of the talus (OLT). It uses cartilage fragments harvested from the OLT that are minced into 1-2-mm3 fragments and then immediately reimplanted back into the chondral defect and sealed with fibrin glue during a single-stage surgery. The purpose of this study was to characterize the suitability of these minced cartilage fragments as immediate autograft for the treatment of OLTs.

Methods

Thirty-one patients undergoing primary arthroscopic surgery for their OLT consented to have their loose or damaged cartilage fragments removed and analyzed in the laboratory. Harvested specimens were minced into 1- to 2-mm3 fragments and cell count, cell density, and cell viability were determined. In addition, physical characteristics of the OLT lesion were recorded intraoperatively and analyzed including size, location, Outerbridge chondromalacia grade of the surrounding cartilage, density of underlying bone, and whether the surgeon thought the OLT was primarily hyaline or fibrocartilage.

Results

An average of 419 000 cells was able to be obtained from the harvested OLT fragments. The cells were 71.2% viable after mincing. Specimens from younger patients and from lesions with worse chondromalacia adjacent to the OLT had significantly higher cell numbers. Those from lateral lesions and with worse neighboring chondromalacia had a significantly higher cell density. None of the remaining physical OLT characteristics studied seemed to significantly affect cell number or viability.

Conclusion

A large number of viable cells are available for immediate autografting by removing the loose or damaged cartilage from an OLT and mincing it into 1- to 2-mm3 fragments. These can be reimplanted into the chondral defect in a single-stage surgery. Future clinical studies are needed to determine if the addition of these live autologous cells either alone or in conjunction with other techniques significantly improves the quality of the repair tissue and clinical outcomes.

Level of Evidence

Level IV, case series.

Outcomes of Particulated Juvenile Articular Cartilage and Association With Defect Fill in Patients With Full-Thickness Patellar Chondral Lesions

Background

Cartilage restoration procedures for patellar cartilage defects have produced inconsistent results, and optimal management remains controversial. Particulated juvenile articular cartilage (PJAC) allograft tissue is an increasingly utilized treatment option for chondral defects, with previous studies demonstrating favorable short-term outcomes for patellar chondral defects.

Purpose

To identify whether there is an association between defect fill on magnetic resonance imaging (MRI) with functional outcomes in patients with full-thickness patellar cartilage lesions treated with PJAC.

Study Design

Case series; Level of evidence, 4.

Methods

A retrospective review of prospectively collected data was conducted on patients treated with PJAC for a full-thickness symptomatic patellar cartilage lesion between March 2014 and August 2019. MRI was performed for all patients at 6, 12, and 24 months postoperatively. Patient-reported outcome measures (PROMs) were obtained preoperatively and at 1, 2, and >2 years postoperatively. Clinical outcome scores-including the International Knee Documentation Committee (IKDC) score, the Kujala, the Knee injury and Osteoarthritis Outcome Score-Physical Function Short Form (KOOS-PS), the Knee Injury and Osteoarthritis Outcome Score-Quality of Life (KOOS-QoL), and the Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS)-were analyzed and evaluated for a relationship with tissue fill on MRI.

Results

A total of 70 knees in 65 patients (mean age, 26.6 ± 8.1 years) were identified, of which 68 knees (97%) underwent a concomitant patellar stabilization or offloading procedure. Significant improvements were observed on all postoperative PROM scores at the 1-, 2-, and >2-year follow-up except for the Pedi-FABS, which showed no significant difference from baseline. From baseline to the 2-year follow-up, the KOOS-QoL improved from 24.7 to 62.1, the IKDC improved from 41.1 to 73.5, the KOOS-PS improved from 35.6 to 15, and the Kujala improved from 52 to 86.3. Imaging demonstrated no difference in the rate of cartilage defect fill between the 3-month (66%), 6-month (72%), 1-year (74%), and ≥2-year (69%) follow-ups. No association was observed between PROM scores and the percent fill of cartilage defect on MRI at the 1- and 2-year follow-up.

Conclusion

PROM scores were significantly improved at the 2-year follow-up in patients who underwent PJAC for full-thickness patellar cartilage defects. On MRI, a cartilage defect fill of >66% was achieved by 3 months in most patients. In our sample, PROM scores were not significantly associated with the defect fill percentage at the short-term follow-up.

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.

Long-Term Patient Outcomes for Treatment of Difficult Osteochondral Lesions of the Talus with Particulated Juvenile Allograft Cartilage Implantation ± Calcaneal Autograft: A Cohort Study

BACKGROUND

Osteochondral lesions of the talus (OCLT) are common injuries that can be difficult to treat. To date, long-term patient reported outcome measures (PROMs) of patients with particulated juvenile allograft cartilage implantation with or without calcaneal autograft have not been compared.

METHODS

Thirteen patients with difficult to treat OCLTs underwent arthroscopic-assisted implantation of particulated juvenile allograft cartilage (DeNovo NT®) with or without autogenous calcaneal bone grafting by a single surgeon. Calcaneal bone graft use was determined by lesion size > 150 mm2 and/or deeper than 5 mm. Patients were evaluated using physical examination, patient interviews, and PROMs.

RESULTS

When comparing patients in regards to calcaneal bone graft implantation, no difference in age, BMI, pre-operative PROMs, or follow-up was noted, however, calcaneal bone graft patients did have a significantly larger lesion size (188.5 ± 50.9 vs. 118.7 ± 29.4 mm2 respectively; p value = 0.027). VAS and FAAM ADL scores during final follow-up improvement did not significantly differ between cohorts. The FAAM Sports score improved significantly more for the DeNovo alone group compared to the bone graft cohort (p value = 0.032). The AOFAS score improvement did not differ between cohorts (p value = 0.944), however, the SF-36 PCS improved significantly more for the DeNovo alone group compared to the bone graft cohort (p value = 0.038). No intraoperative/perioperative complications were observed with calcaneal bone grafting.

CONCLUSION

While patients followed over the course of ~ 8 years after implantation of particulated juvenile allograft cartilage (DeNovo NT®) with/without autogenous calcaneal bone graft had positive post-operative PROMs, patients without calcaneal bone graft had significantly greater improvement in functional outcome scores. Whether these differences are due to graft incorporation or larger lesion size is unclear.

LEVEL OF EVIDENCE

III, retrospective cohort 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.

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.

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.

Medial oblique malleolar osteotomy for approach of medial osteochondral lesion of the talus

PURPOSE

The medial malleolar osteotomy is commonly performed to gain access to the medial talar dome for treatment of osteochondral lesions of the talus. The primary aim of this study was to assess osseous healing based on postoperative radiographs to determine consolidation, non-union and malreduction rates.

METHODS

Sixty-seven cases were reviewed where an oblique uniplanar medial malleolar osteotomy was performed to gain access to the medial talar dome for addressing an osteochondral lesion. Two, respectively three fully threaded 3.5 mm corticalis screws were used to fixate the osteotomy. Postoperative radiographs were reviewed to assess consolidation, non-union, malreduction and dislocation of the osteotomy.

RESULTS

Out of 67 patients, 66 patients had a consolidation of the osteotomy. 23.9% of the cases showed malreduction of the osteotomy. One patient suffered a non-union, which required a revision surgery. No significant difference was shown between two and three screws used for fixation in terms of malreduction and consolidation of the osteotomy. Eighty-four percent of the patients underwent hardware removal due to pain or medial impingement.

CONCLUSION

The oblique medial malleolar osteotomy is a safe and relatively simple procedure with a high consolidation rate and low revision providing excellent exposure of the talus. The moderately high malreduction rate and required hardware removal surgery by most of the patients are relevant factors which should be considered before performing this surgery.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Nanohydroxyapatite Hydrogel Can Promote the Proliferation and Migration of Chondrocytes and Better Repair Talar Articular Cartilage

As an important load-bearing part of the body, joints are prone to articular cartilage degradation during exercise, resulting in joint pain, swelling, and deformity, which has an adverse impact on patients’ life quality and social medical security. Therefore, this study aims to test an effective biopolymer scaffold in promoting the growth of chondrocytes in talus. Hydrogel (Gel)-nanohydroxyapatite (nHA) was invented as a new type of biopolymer scaffold for osteoarthritis treatment in this research. To detect the effects of Gel-nHA on guidance, cartilage matrix secretion, mineralization, proliferation, and migration of chondrocyte, we cultured chondrocytes to study the biological properties of nHA. It was found that Gel could guide chondrocytes to permeate and migrate, so it could be used as acellular matrix scaffolds for chondrocyte regeneration. In addition, nHA could stimulate chondrocytes to secrete cartilage matrix, such as type II collagen and mucopolysaccharide (GAGs). At the same time, nHA help to induce chondrocyte mineralization and stimulate the secretion of type X collagen, so as to better maintain the integrity of bone cartilage interface. In Gel-nHA, chondrocyte viability could be better maintained, and the proliferation and migration of chondrocytes could be better promoted, so as to better repair the articular cartilage of talus. Therefore, the Gel-nHA scaffold is expected to become an effective method for repairing talus cartilage in the future.

Cartilage Injuries and Posttraumatic Osteoarthritis in the Wrist: A Review

OBJECTIVE

Focal cartilage injuries, and posttraumatic osteoarthritis (OA) in the wrist are likely common and a cause of wrist pain. To estimate the incidence of cartilage lesions and to understand the pathomechanisms leading to wrist cartilage injuries and OA, a literature review on the subject was performed combined with a presentation of one of the authors' own experience.

DESIGN

This study includes a literature review of the topic. As a comparison to the review findings, the observations of one of the authors' consecutive 48 wrist arthroscopies, were assessed. PubMed, Scholar, and Cochrane databases were searched using the keywords "cartilage injury AND wrist AND treatment" and "wrist AND cartilage AND chondral AND osteochondral AND degenerative OA."

:RESULT

A total of 11 articles, including 9 concerning chondral and osteochondral repair and treatment and 2 regarding posttraumatic OA, were retrieved. The cartilage repair treatments used in these articles were drilling, osteochondral autograft, juvenile articular cartilage allograft, and chondrocyte implantation. One article displayed concomitant cartilage injuries in displaced distal radius fractures in 32% of the patients. The review of our findings from a 1-year cohort of wrist arthroscopies showed 17% cartilage injuries.

CONCLUSION

There is a lack of knowledge in current literature on cartilage injuries and treatment, as well as posttraumatic OA in the wrist. Cartilage injuries appear to be common, being found in 17% to 32% of all wrist arthroscopies after trauma, but no guidelines regarding conservative or surgical treatment can be recommended at the moment. Larger prospective comparative studies are needed.

Particulated Cartilage for Chondral and Osteochondral Repair: A Review

INTRODUCTION

Injuries to articular cartilage have a poor spontaneous repair potential and no gold standard treatment exist. Particulated cartilage, both auto- and allograft, is a promising new treatment method that circumvents the high cost of scaffold- and cell-based treatments.

MATERIALS AND METHODS

A comprehensive database search on particulated cartilage was performed.

RESULTS

Fourteen animal studies have found particulated cartilage to be an effective treatment for cartilage injuries. Many studies suggest that juvenile cartilage has increased regenerative potential compared to adult cartilage. Sixteen clinical studies on 4 different treatment methods have been published. (1) CAIS, particulated autologous cartilage in a scaffold, (2) Denovo NT, juvenile human allograft cartilage embedded in fibrin glue, (3) autologous cartilage chips-with and without concomitant bone grafting, and (4) augmented autologous cartilage chips.

CONCLUSION

Implantation of allogeneic and autologous particulated cartilage provides a low cost and effective treatment alternative to microfracture and autologous chondrocyte implantation. The methods are promising, but large randomized controlled studies are needed.

Articular Cartilage Fragmentation Improves Chondrocyte Migration by Upregulating Membrane Type 1 Matrix Metalloprotease

OBJECTIVE

This study was undertaken to elucidate the mechanism of improved chondrocyte migration after juvenile articular cartilage fragmentation.

DESIGN

In vitro organ culture with rabbit cartilage fragments and cell culture with rabbit chondrocytes were performed. In part A, minced juvenile cartilage fragments (~0.5 × 0.5 × 0.5 mm) from rabbits, planted in gelatin sponge and fibrin glue, were cultured for 2, 4, or 6 weeks in vitro and compared with the cartilage chunks (~4 × 4 × 1 mm) and membrane type 1 matrix metalloprotease (MT1-MMP) inhibitor groups. Chondrocyte outgrowth was evaluated on histology and confocal laser scanning microscopy. MT1-MMP expression was compared between the cartilage fragment group and the cartilage chunks group. In part B, articular chondrocytes were harvested from juvenile rabbits, MT1-MMP was transfected into the cells, and cell migration was evaluated using the Transwell and wound healing tests.

RESULTS

The histology and confocal microscopy results revealed that cell accumulation occurred at the edge of cartilage fragments, and outgrowth was better in the cartilage fragment group than those in the cartilage chunks group. Similar results were observed for MT1-MMP expression. After MT1-MMP inhibition, cells did not accumulate at the edge of the cartilage fragments, and chondrocyte outgrowth did not occur. Furthermore, overexpression of MT1-MMP enhanced the migration of articular chondrocytes.

CONCLUSIONS

Juvenile articular cartilage fragmentation improved chondrocyte migration by upregulating MT1-MMP.

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.

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.

Arthroscopic Treatment of Osteochondral Lesions of the Talus Utilizing Juvenile Particulated Cartilage Allograft: A Case Series

The treatment options for osteochondral lesions of the ankle are scarce, and newer modalities are becoming available. We describe a minimally invasive arthroscopic approach with implantation of juvenile particulated allograft to facilitate the growth of true hyaline cartilage in patients with osteochondral lesions of the talus. The purpose of this study was to subjectively review clinical outcomes using the validated Foot and Ankle Outcomes Score in patients who underwent this technique. Our technique was performed on 82 consecutive patients with average follow-up of 24 (range 9 to 86) months. We found that 28 (88%) of 32 patients who responded to the questionnaire had good or excellent results for activities of daily living; 26 (82%) of 32 patients had at least a good result for both pain and symptoms; and 25 (78%) of 32 had at least a fair result for functional sports and quality of life.

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

INTRODUCTION/PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Outcomes and Predictors of Postoperative Pain Improvement Following Particulated Juvenile Cartilage Allograft Transplant for Osteochondral Lesions of the Talus

BACKGROUND

Particulated juvenile cartilage allograft transfer (PJCAT) is an emerging treatment option for management of osteochondral lesions of the talus (OCLTs). This series reports on outcomes and identifies predictors for success following PJCAT for isolated OCLTs.

METHODS

We reviewed 33 consecutive patients who underwent PJCAT by a single surgeon from 2013 to 2017. Preoperative demographic factors (age, body mass index [BMI], tobacco use, behavioral health comorbidity, and ankle pain visual analog score [VAS]) and OCLT morphologic data were collected. Outcomes included postoperative improvements in VAS and American Orthopaedic Foot & Ankle Society (AOFAS) score and clinical success/failure. Results of 7 second-look arthroscopies and complications are provided. Categorical data are reported as frequencies, and statistical means with P values are reported for continuous variables. We had a mean 3.5 years of follow-up.

RESULTS

Improvement in ankle pain VAS following isolated PJCAT was 51% (P < .001). For the first 16 consecutive patients in whom complete AOFAS scores were available, 40% (P < .001) improvement occurred. Presence of 1 or more behavioral health diagnoses was a risk factor for decreased pain relief, while moderate to severe preoperative pain (VAS >5.9) predicted improved postoperative pain relief. Age, BMI, tobacco use, and OCLT morphology did not affect outcomes.

CONCLUSION

For treatment of large, high-stage OCLTs, PJCAT resulted in 40% to 50% improvement in ankle pain and disability within 3.5 years. The results may be better in patients with moderate to severe preoperative pain but worse in those with preexisting behavioral health diagnoses.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Particulated juvenile articular cartilage allograft transplantation for osteochondral lesions of the knee and ankle

Introduction: Osteochondral lesions have been challenging to treat due to the limited regenerative capacity of native hyaline cartilage. Although surgical options are available, a newer technique, Particulated Juvenile Cartilage Allograft Transplantation (PJCAT) has shown promise for lesions of the knee and ankle. Short-term studies have been encouraging of its use, but there is still limited evidence of its long-term durability.Areas covered: This review will summarize the surgical options currently available for osteochondral lesions, outline the indications and contraindications of PJCAT, present the basic science and clinical evidence of the procedure, and describe the surgical approaches of this technique.Expert opinion: PJCAT is a promising method to treat osteochondral lesions. However, continued research is needed to document the efficacy of this technique and potential superiority over other techniques. Benefits include ease of application, potential for arthroscopic or minimally invasive delivery, no need for perpendicular access, no donor site morbidity, and delivery of viable chondrocytes in hyaline cartilage.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Orthobiologics

Use of orthobiologics in sports medicine and musculoskeletal surgery has gained significant interest. However, many of the commercially available and advertised products are lacking in clinical evidence. Widespread use of products before fully understanding their true indications may result in unknown adverse outcomes and may also lead to increased health care costs. As more products become available, it is important to remain judicial in use and to practice evidence-based medicine. Likewise, it is important to continue advances in research in hopes to improve surgical outcomes. This article reviews clinical evidence behind common orthobiologics in the treatment of foot and ankle pathology.

Efficacy of Particulated Juvenile Cartilage Allograft Transplantation for Osteochondral Lesions of the Talus

BACKGROUND

Particulated juvenile cartilage allograft transplantation (PJCAT) is a novel treatment option for osteochondral lesions of the talus (OLTs). It is typically employed as a salvage procedure after initial debridement and microfracture has failed as it is theorized to deliver viable hyaline cartilage. We hypothesized that PJCAT would be a safe and effective treatment option for OLTs.

METHODS

This is a retrospective case-control study of patients who underwent PJCAT for the treatment of OLTs at a single academic institution. Failure of the procedure was defined as no change or worsening of symptoms and/or the need for a subsequent cartilage restoration procedure. Variables recorded included preoperative magnetic resonance imaging (MRI) area and volume, intraoperative size, etiology, lesion location, sex, age, body mass index (BMI), history of prior surgery, American Orthopaedic Foot & Ankle Society score, and foot and ankle outcome score. Fifteen patients completed a minimum of 12 months of follow-up (mean, 34.6 months).

RESULTS

The failure rate of PJCAT in this series was 40% (6/15). Preoperative MRI area and intraoperative OLT size along with male sex were predictive of failure ( P < .05). Age, BMI, etiology, technique (open vs arthroscopic), history of prior surgery, and location of lesion were not predictors of failure in this limited series ( P > .05). Patients with lesions greater than 125 mm² area had a significant increased risk of clinical failure ( P < .05). Functional outcome scores were significantly better at final follow-up in the patients who had undergone successful treatment vs those who did not.

CONCLUSION

These findings demonstrate the association of preoperative MRI lesion area, intraoperative lesion size, and male sex as risk factors for failure of PJCAT setting of an already difficult to treat pathology.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

The Use of Particulated Juvenile Allograft Cartilage in Foot and Ankle Surgery

Particulated juvenile allograft cartilage (PJAC) has significant promise and is currently supported by several studies. Potential benefits of this new technique include single-stage procedure, simplicity in the surgical technique, implantation of juvenile tissue, and a lack of donor site morbidity. This article discusses the imaging, surgical options, and postoperative management of PJAC.

Bone Marrow Aspirate Concentrate and Its Uses in the Foot and Ankle

Bone marrow aspirate has been used for the adjunctive treatment of numerous pathologic conditions in orthopedics. Viable cells are found in aspiration from many different anatomic regions of the body. Concentration of these cells has been shown to improve healing due to the increased number of certain important cells. This article discusses the mechanisms involved and reviews the literature.

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.

Bone Marrow Aspirate Concentrate-Enhanced Marrow Stimulation of Chondral Defects

Mesenchymal stem cells (MSCs) from bone marrow play a critical role in osteochondral repair. A bone marrow clot forms within the cartilage defect either as a result of marrow stimulation or during the course of the spontaneous repair of osteochondral defects. Mobilized pluripotent MSCs from the subchondral bone migrate into the defect filled with the clot, differentiate into chondrocytes and osteoblasts, and form a repair tissue over time. The additional application of a bone marrow aspirate (BMA) to the procedure of marrow stimulation is thought to enhance cartilage repair as it may provide both an additional cell population capable of chondrogenesis and a source of growth factors stimulating cartilage repair. Moreover, the BMA clot provides a three-dimensional environment, possibly further supporting chondrogenesis and protecting the subchondral bone from structural alterations. The purpose of this review is to bridge the gap in our understanding between the basic science knowledge on MSCs and BMA and the clinical and technical aspects of marrow stimulation-based cartilage repair by examining available data on the role and mechanisms of MSCs and BMA in osteochondral repair. Implications of findings from both translational and clinical studies using BMA concentrate-enhanced marrow stimulation are discussed.