Systematic review of bone marrow stimulation for osteochondral lesion of talus - evaluation for level and quality of clinical studies

Inter- and Intra-Observer Variability of the AMADEUS Tool for Osteochondral Lesions of the Talus

BACKGROUND

Managing osteochondral cartilage defects (OCDs) of the talus is a common daily challenge in orthopaedics as they predispose patients to further cartilage damage and progression to osteoarthritis. Therefore, the implementation of a reliable tool to quantify the amount of cartilage damage that is present is of the essence.

METHODS

We retrospectively identified 15 adult patients diagnosed with uncontained OCDs of the talus measuring <150 mm2, which were treated arthroscopically with bone marrow stimulation. Five independent assessors evaluated the pre-operative MRI scans with the AMADEUS scoring system (i.e., MR-based pre-operative assessment system) and the intra-/inter-observer variability was then calculated by means of the intraclass correlation coefficients (ICC) and Kappa (κ) statistics, respectively. In addition, the correlation between the mean AMADEUS scores and pre-operative self-reported outcomes as measured by the Manchester-Oxford foot questionnaire (MOxFQ) was assessed.

RESULTS

The mean ICC and the κ statistic were 0.82 (95% CI [0.71, 0.94]) and 0.42 (95% CI [0.25, 0.59]). The Pearson correlation coefficient was found to be r = -0.618 (p = 0.014).

CONCLUSIONS

The AMADEUS tool, which was originally designed to quantify knee osteochondral defect severity prior to cartilage repair surgery, demonstrated good reliability and moderate inter-observer variability for small OCDs of the talar shoulder. Given the strong negative correlation between the AMADEUS tool and pre-operative clinical scores, this tool could be implemented in clinical practise to reliably quantify the extent of the osteochondral defects of the talus.

Cartilage Injuries: Basic Science Update

The last several decades have brought about substantial development in our understanding of the biomolecular pathways associated with chondral disease and progression to arthritis. Within domains relevant to foot and ankle, genetic modification of stem cells, augmentation of bone marrow stimulation techniques, and improvement on existing scaffolds for delivery of orthobiologic agents hold promise in improving treatment of chondral injuries. This review summarizes novel developments in the understanding of the molecular pathways underlying chondral damage and some of the recent advancements within related therapeutics.

Microfracture surgery combined with platelet-rich plasma injection in treating osteochondral lesions of talus: A system review and update meta analysis

BACKGROUND

To systematically evaluate the efficacy of arthroscopic microfracture surgery combined with platelet-rich plasma (PRP) injection in treating osteochondral lesions of talus (OLT).

METHOD

A computer-based search of the PubMed, EMbase, Cochrane Library was developed. The search time was dated in December 2022. Randomized controlled trials and prospective case control studies comparing the treatment of OLT with microfracture surgery combined with PRP injection and microfracture surgery alone were included. The quality of the literatures were evaluated. Meta analysis was completed using the data of postoperative pain and function scores of the ankle joint reported in the literature.

RESULTS

Five randomized controlled trials with a total of 198 patients were included. Compared with microfracture surgery alone, meta-analysis showed that the postoperative visual analogue scale (VAS) score for ankle pain was significantly lower (P < 0.001), and the American Orthopaedic Foot and Ankle Society score (AOFAS) was significantly better ( P < 0.001) in the group of microfracture surgery combined with PRP injection. The change of VAS and AOFAS was also significantly better in the group of microfracture surgery combined with PRP injection (P < 0.001).

CONCLUSION

Arthroscopic microfracture surgery combined with PRP injection in treating OLT can significantly reduce pain and improve ankle function. More long-term follow-up, high-quality studies are needed.

LEVEL OF EVIDENCE

II.

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.

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

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

High-Density Autologous Chondrocyte Implantation as Treatment for Ankle Osteochondral Defects

PURPOSE

Two-year follow-up to assess efficacy and safety of high-density autologous chondrocyte implantation (HD-ACI) in patients with cartilage lesions in the ankle.

DESIGN

Twenty-four consecutive patients with International Cartilage repair Society (ICRS) grade 3-4 cartilage lesions of the ankle were included. Five million chondrocytes per cm² of lesion were implanted using a type I/III collagen membrane as a carrier and treatment effectiveness was assessed by evaluating pain with the visual analogue scale (VAS) and American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score at baseline, 12-month, and 24-month follow-up, together with dorsal and plantar flexion. Magnetic resonance observation for cartilage repair tissue (MOCART) score was used to evaluate cartilage healing. Histological study was possible in 5 cases.

RESULTS

Patients' median age was 31 years (range 18-55 years). Median VAS score was 8 (range 5-10) at baseline, 1.5 (range 0-8) at 12-month follow-up, and 2 (rang e0-5) at 24-month follow-up (P < 0.001). Median AOFAS score was 39.5 (range 29-48) at baseline, 90 (range 38-100) at 12-month follow-up, and 90 (range 40-100) at 24-month follow-up (P < 0.001). Complete dorsal flexion significantly increased at 12 months (16/24, 66.7%) and 24 months (17/24, 70.8%) with regard to baseline (13/24, 54.2%) (P = 0.002). MOCART at 12- and 24-month follow-ups were 73.71 ± 15.99 and 72.33 ± 16.21. Histological study confirmed that neosynthetized tissue was cartilage with hyaline extracellular matrix and numerous viable chondrocytes.

CONCLUSION

HD-ACI is a safe and effective technique to treat osteochondral lesions in the talus, providing good clinical and histological results at short- and mid-term follow-ups.

Clinical outcomes after arthroscopic microfracture for osteochondral lesions of the talus are better in patients with decreased postoperative subchondral bone marrow edema

PURPOSE

Magnetic resonance imaging (MRI) findings of subchondral bone marrow edema (SBME) in osteochondral lesions of the talus (OLT) after arthroscopic microfracture are associated with poor clinical outcomes. However, the relationship between SBME volume change and clinical outcomes has not been analyzed. It was hypothesized that clinical outcomes correlated with SBME volume change and extent of cartilage regeneration in patients with OLT.

METHODS

64 patients who underwent arthroscopic microfracture for OLT were followed up for more than 2 years. SBME volume change was measured by comparing preoperative and 2-year follow-up MRI. Clinical outcomes were assessed using the visual analogue scale (VAS) and the American orthopedic foot and ankle society ankle-hindfoot scale (AOFAS) at the 2-year and final follow-up. To compare clinical outcomes, patients were categorized into two groups: decreased SBME (DSBME) group (cases without SBME on either MRI or with a decreased SBME volume between the MRIs) and increased SBME (ISBME) group (cases with new SBME on postoperative MRI or with an increased SBME volume between the MRIs). Additionally, the effects of age, sex, body mass index, symptom duration, OLT size, OLT location, containment/uncontainment, preoperative subchondral cysts, pre- and postoperative SBME volumes, and MRI observation of cartilage repair tissue score on clinical outcomes were analyzed.

RESULTS

The DSBME group included 45 patients, whereas the ISBME group included 19. The mean age was 40.1 ± 17.2 years, and mean follow-up period was 35.7 ± 18.3 months. Preoperative SBME volume was significantly higher in the DSBME group, while the ISBME group had higher volumes at the final follow-up. In both groups, the VAS and AOFAS scores significantly improved at the final follow-up (p < 0.001, < 0.001). The VAS scores were significantly lower in the DSBME group at the 2-year and final follow-up (p = 0.004, 0.011), while the AOFAS scores were significantly higher (p = 0.019, 0.028). Other factors including cartilage regeneration did not affect clinical outcomes.

CONCLUSION

SBME volume change correlated with clinical outcomes after arthroscopic microfracture for OLT. Clinical outcomes were worse in patients with new postoperative SBME and increased postoperative SBME volume. In patients with an unsatisfactory clinical course that show decreased SBME via postoperative MRI, an extended follow-up in a conservative manner could be considered.

LEVEL OF EVIDENCE

Level III.

Large variation in management of talar osteochondral lesions among foot and ankle surgeons: results from an international survey

PURPOSE

Surgeons management of osteochondral lesions of the talus (OLT) may be different to the published guidelines because not all treatment recommendations are feasible in every country. This study aimed to assess how OLT are managed worldwide by foot and ankle surgeons.

METHODS

A web-based survey was distributed to the members of 21 local and international scientific societies focused on foot and ankle or sports medicine surgery. Answers with a prevalence greater than 75% of respondents were considered a "main tendency", whereas where prevalence exceeded 50% of respondents they were considered a "tendency".

RESULTS

A total of 1804 surgeons from 79 different countries returned the survey. The responses to 19 of 28 questions (68%) regarding management and treatment of OLT achieved a main tendency (> 75%) or a tendency (> 50%). Symptoms reported to be most suspicious for OLT were pain on weight-bearing (WB) and after activity (83%), deep localization of the pain (62%), and any history of trauma (55%). 89% of surgeons routinely obtain an MRI, 72% routinely get WB radiographs, and 50% perform a CT scan. When treated surgically, OLTs are managed in isolation by only 7% of surgeons, and combined with ligament repair or reconstruction by 79%; 67% report simultaneous excision of soft-tissue or bony impingements (64%). For lesions less than 10-15 mm in diameter, bone marrow stimulation (BMS) represents the first choice of treatment for 78% of surgeons (main tendency). No other treatment was recorded as a tendency. For lesions greater than 15 mm in diameter no tendencies were recorded. The BMS represented the most preferred treatment being the first choice of treatment for 41% of surgeons. OLT depth had little influence on treatment choice: 71% of surgeons treating small lesions and 69% treating large lesions would choose the same treatment regardless of whether the lesion had a depth lesser or greater than 5 mm.

CONCLUSION

The management of OLT by foot and ankle surgeons from around the world remains extremely varied. The main clinical relevance of this study is that it provides updated information with regard to the management of OLT internationally, which could be used by surgeons worldwide in their decision-making and to inform the patient about available surgical options.

LEVEL OF EVIDENCE

Level IV.

Return to Sports After Surgical Treatment of Osteochondral Defects of the Talus: A Systematic Review of 2347 Cases

BACKGROUND

Osteochondral defects (OCDs) of the talus are found subsequent to ankle sprains and ankle fractures. With many surgical treatment strategies available, there is no clear evidence on return-to-sport (RTS) times and rates.

PURPOSE

To summarize RTS times and rates for talar OCDs treated by different surgical techniques.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

The literature from January 1996 to November 2018 was screened, and identified studies were divided into 7 different surgical treatment groups. The RTS rate, with and without associated levels of activity, and the mean time to RTS were calculated per study. When methodologically possible, a simplified pooling method was used to combine studies within 1 treatment group. Study bias was assessed using the MINORS (Methodological Index for Non-Randomized Studies) scoring system.

RESULTS

A total of 61 studies including 2347 talar OCDs were included. The methodological quality of the studies was poor. There were 10 retrospective case series (RCSs) that investigated bone marrow stimulation in 339 patients, with a pooled mean rate of RTS at any level of 88% (95% CI, 84%-91%); 2 RCSs investigating internal fixation in 47 patients found a pooled RTS rate of 97% (95% CI, 85%-99%), 5 RCSs in which autograft transplantation was performed in 194 patients found a pooled RTS rate of 90% (95% CI, 86%-94%), and 3 prospective case series on autologous chondrocyte implantation in 39 patients found a pooled RTS rate of 87% (95% CI, 73%-94%). The rate of return to preinjury level of sports was 79% (95% CI, 70%-85%) for 120 patients after bone marrow stimulation, 72% (95% CI, 60%-83%) for 67 patients after autograft transplantation, and 69% (95% CI, 54%-81%) for 39 patients after autologous chondrocyte implantation. The mean time to RTS ranged from 13 to 26 weeks, although no pooling was possible for this outcome measure.

CONCLUSION

Different surgical treatment options for talar OCDs allow for adequate RTS times and rates. RTS rates decreased when considering patients' return to preinjury levels versus return at any level.