Effects of Early Weightbearing on Microfracture Treatment of Osteochondral Lesions of Talus with Subchondral Bone Defects

All-inside arthroscopic procedures for chronic lateral ankle instability: evidence-based clinical practice guidelines

BACKGROUND

All-inside arthroscopic procedures are now frequently employed to manage chronic lateral ankle instability (CLAI) with satisfactory functional outcomes. Currently, no evidence-based guidelines exist for all-inside arthroscopic procedures for CLAI. Many surgical decisions remain uncertain and challenging.

SOURCES OF DATA

Published scientific literature in PubMed, MEDLINE, Web of Science, EMBASE, and Cochrane databases.

AREAS OF AGREEMENT

All-inside arthroscopic repair and reconstruction procedures are reliable treatments for CLAI.

AREAS OF CONTROVERSY

The all-inside arthroscopic procedures for CLAI present significant challenges, particularly in the following aspects.

GROWING POINTS

Given the lack of guidelines for the all-inside arthroscopic procedures for CLAI, this evidence-based clinical practice guideline provides 11 recommendations to address the controversy.

AREAS TIMELY FOR DEVELOPING RESEARCH

In patients with CLAI undergoing all-inside arthroscopic procedures, comparative studies are urgently needed to establish the optimal timing for weight-bearing, as well as return to work and sports.

The Antigravity Treadmill as a Postoperative and Injury Rehabilitation Tool: Reduction in Contact Forces and Muscle Activity With Reduced Weight Running

OBJECTIVE

To investigate the effects of reduced weight running on the antigravity (AG) treadmill on maintenance of normal muscle activation and reduction of plantar forces in healthy subjects.

DESIGN

Descriptive laboratory study.

SETTING

Clinical sports medicine center.

PARTICIPANTS

Twenty healthy subjects (10 male and 10 female) aged 18 to 29 years.

INDEPENDENT VARIABLES

Subjects running at 6.5 miles per hour on a standard treadmill and on the AG treadmill at 100%, 90%, 80%, 70%, 60%, and 50% of bodyweight levels.

MAIN OUTCOME MEASURES

Dynamic plantar loading data were recorded using pressure insoles. Surface electromyography electrodes with imbedded accelerometers were used to estimate timing and magnitude of muscle activity, stride length, and cadence.

RESULTS

There was a significant, sequential reduction in peak pressure, maximum force, and force time integral (FTI) with decreasing bodyweight. A 50% bodyweight reduction resulted in a 51% reduction in maximum force and a 59% reduction in FTI in the heel, as compared with 19% to 28% at the metatarsal heads. There was reduced contact area in the heel and midfoot at and below 70% BW. Lower limb muscle activity decreases with reduced bodyweight while maintain normal muscle recruitment timing.

CONCLUSIONS

The AG treadmill provides a reduction in loading forces while maintaining normal muscle recruitment patterns. Decreased BW running preferentially unloads the hindfoot. The AG treadmill can be an effective rehabilitation tool following foot or ankle injury and may prove superior to other limited weight-bearing methods.

Comparison of arthroscopic debridement and microfracture in the treatment of osteochondral lesion of talus

Objective

This study was performed to compare the clinical effect of arthroscopic debridement vs. arthroscopic microfracture in the treatment of osteochondral lesions of the talus.

Methods

We retrospectively reviewed patients with osteochondral lesion of talus who were admitted to our hospital from April 2020 to April 2021. The patients were divided into Group A (arthroscopic debridement group, n = 39) and Group B (arthroscopic microfracture group, n = 42), and the intraoperative details in the two groups were analyzed. The American Orthopaedic Foot and Ankle Society (AOFAS) score and visual analogue scale (VAS) score were compared between the two groups before surgery and at the last follow-up.

Results

The postoperative AOFAS score (Group A, 40.9-82.26; Group B, 38.12-87.38), VAS score (Group A, 6.44-3.92; Group B, 6.38-2.05) significantly improved in both groups, but the improvement was significantly greater in Group B than in Group A (P < 0.05). Among all patients, the AOFAS and VAS scores of men aged ≤30 years and patients with a low body mass index (BMI) improved more significantly (P < 0.05).

Conclusion

The arthroscopic microfracture for the treatment of osteochondral lesion of talus is superior to joint debridement in terms of improving ankle function, especially in relatively young men with a relatively low BMI.

When is the optimum time for the initiation of early rehabilitative exercise on the postoperative functional recovery of peri-ankle fractures? A network meta-analysis

Objective

The purpose of this study was to explore the safe and most effective initiation time for the functional recovery of patients with peri-ankle fractures after surgery.

Method

We searched electronic databases, including the Cochrane Library, Embase, PubMed and the reference lists of relevant articles published from inception to October 30, 2021. Two researchers independently performed literature screening and data extraction and evaluated the quality of the included literature using the Newcastle–Ottawa Scale. Network meta-analysis, including consistency testing, publication bias, and graphical plotting, was performed using Stata (v16.0).

Results

A total of 25 articles involving 1756 patients were included in this study. The results of the meta-analysis showed that functional exercise within 2 days after surgery may result in lower VAS scores compared to other techniques (P < 0.05). Functional exercise within 12 months may lead to higher AOFAS scores than that of other techniques (P < 0.05). The total postoperative complication rate, including deep vein thrombosis, showed no statistically significant differences between any two interventions (P > 0.05). The results of the surface under the cumulative ranking (SUCRA) showed that functional exercise within two days postoperatively may have the lowest VAS scores (SUCRA = 82.8%), functional exercise within 1 week postoperatively may have the lowest deep vein thrombosis rate (SUCRA = 66.8%), functional exercise within 10 days postoperatively may have the fewest total postoperative complication rate (SUCRA = 73.3%) and functional exercise within 12 months postoperatively may contribute to the highest AOFAS scores (SUCRA = 85.5%).

Conclusion

The results of this study suggest that initiation of rehabilitation within two days after surgery may be the best time to reduce postoperative pain; rehabilitation interventions within 10 days after surgery may be the optimal time for reducing the total postoperative complication rate, including deep vein thrombosis; and continued functional exercise within 12 months after surgery may steadily and ideally improve the function of the ankle joint.

Systematic Review Registration: doi: 10.37766/inplasy2021.12.0030, identifier: INPLASY2021120030

Outcomes of Single-Stage Versus Staged Treatment of Osteochondral Lesions in Patients With Chronic Lateral Ankle Instability: A Prospective Randomized Study

Background:

There is controversy about whether treatment of chronic lateral ankle instability (CLAI) with osteochondral lesions of the talus (OLT) can be performed concurrently.

Purpose:

To investigate the midterm results of arthroscopic treatment of CLAI combined with OLT in different surgical settings. It was hypothesized that the outcomes of treating both injuries at the same time would not be inferior to those of staged surgery.

Study Design:

Randomized controlled trial; Level of evidence, 1.

Methods:

Included were 103 patients with both CLAI and OLT who underwent arthroscopic microfracture surgery and an open, modified Broström-Gould procedure for ligament repair from January 2015 to December 2016. The patients were assigned randomly to a staged group (51 patients) and a single-stage group (52 patients). The staged group underwent arthroscopic debridement of the OLT and microfracture, then rehabilitation for 4 to 6 months before undergoing modified Broström-Gould ligament repair. The single-stage group underwent both procedures simultaneously. Clinical evaluations were performed on the day before surgery and at 12-month, 24-month, and final follow-up periods using the Karlsson-Peterson score, American Orthopaedic Foot & Ankle Society (AOFAS) score, and pain visual analog scale. The Karlsson-Peterson score at 24 months postoperatively was considered the primary outcome. The predefined noninferiority margin for the primary outcome was −5 points.

Results:

At the final follow-up, 50 patients in the single-stage group and 48 patients in the staged group completed the study. The median lesion size was 0.72 cm² (interquartile range [IQR], 0.5-1.12 cm²) in the single-stage group and 0.84 cm² (IQR, 0.7-1.05 cm²) in the staged group. At 12-month follow-up, the single-stage group had a significantly higher median Karlsson-Peterson score (79 [IQR, 70-85] vs 75 [IQR 65-80] for staged; P = .024) and median AOFAS score (85 [IQR, 76-89] vs 79.5 [IQR, 70-87] for staged; P = .045). At 24-month follow-up, the median difference in the Karlsson-Peterson score for single-stage versus staged surgery was 2 points (95% CI, −2 to 5 points), and the confidence interval was greater than the predefined value.

Conclusion:

At midterm follow-up, there was no clinical difference between single-stage versus staged surgery to treat CLAI with OLT. Single-stage surgery achieved better clinical outcomes than staged surgery at short-term follow-up.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Cartilage Repair Capacity within a Single Full-Thickness Chondral Defect in a Porcine Autologous Matrix-Induced Chondrogenesis Model Is Affected by the Location within the Defect

OBJECTIVE

Large articular cartilage defects are a challenge to regenerative surgery. Biomaterial scaffolds might provide valuable support for restoration of articulating surface. The performance of a composite biomaterial scaffold was evaluated in a large porcine cartilage defect.

DESIGN

Cartilage repair capacity of a biomaterial combining recombinant human type III collagen (rhCo) and poly-(l/d)-lactide (PLA) was tested in a porcine model. A full-thickness chondral defect covering the majority of the weightbearing area was inflicted to the medial femoral condyle of the right knee. Spontaneous cartilage repair and nonoperated healthy animals served as controls. The animals were sacrificed after a 4-month follow-up. The repair tissue was evaluated with the International Cartilage Repair Society (ICRS) macroscopic score, ICRS II histological score, and with micro-computed tomography. Additionally, histopathological evaluation of lymph nodes and synovial samples were done for toxicological analyses.

RESULTS

The lateral half of the cartilage defect in the operated groups showed better filling than the medial half. The mean overall macroscopic score for the rhCo-PLA, spontaneous, and nonoperated groups were 5.96 ± 0.33, 4.63 ± 0.42, and 10.98 ± 0.35, respectively. The overall histological appearance of the specimens was predominantly hyaline cartilage in 3 of 9 samples of the rhCo-PLA group, 2 of 8 of the spontaneous group, and 9 of 9 of the nonoperated group.

CONCLUSIONS

The use of rhCo-PLA scaffold did not differ from spontaneous healing. The repair was affected by the spatial properties within the defect, as the lateral part of the defect showed better repair than the medial part, probably due to different weightbearing conditions.

Is Early or Delayed Weightbearing the Better Choice After Microfracture for Osteochondral Lesions of the Talus? A Meta-analysis and Systematic Review

Osteochondral lesions of the talus (OLT) are common injuries requiring surgery. Arthroscopic microfracture treatment is effective and acceptable. Although the concept of postoperative rehabilitation is continuously being updated, the choice between early weightbearing (EWB) versus delayed weightbearing (DWB) following microfracture is still not settled. A meta-analysis and systematic review was performed to compare the rehabilitation effect of 2 different weightbearing protocols following microfracture. Five databases were searched for relevant studies, and full-text articles comparing EWB and DWB were reviewed. Review Manager 5.3 software was used to summarize the results of the included studies. Two reviewers independently filtered the studies, assessed quality, extracted data, and estimated the risk of bias. The pain score and functional assessment of the ankle were selected as the endpoints. The mean difference was calculated as the summary statistic for continuous data. Then, visual analog scale and American Orthopedic Foot and Ankle Society scale scores were collected and pooled. Five randomized controlled trials including 283 patients were identified for this study, revealing that there was no significant difference in pain scores between EWB and DWB following microfracture 3 months, 6 months, 12 months, and 24 months postoperatively. Function assessment showed similar results. Comprehensive analysis of current evidence still suggests that EWB and DWB after microfracture of OLT produce comparable clinical outcomes in terms of pain and functional activity. Therefore, EWB is recommended to shorten the length of time before returning to work or sports after microfracture of OLT.