Osteochondral Lesions of the Talus and Autologous Matrix-Induced Chondrogenesis: Is Age a Negative Predictor Outcome?

The efficacy of autologous matrix-induced chondrogenesis (AMIC) for osteochondral lesions of the talus in the mid-long term: a systematic review and meta-analysis

PURPOSE

The objective of this study was to provide a comprehensive review of the existing literature regarding the treatment of osteochondral lesions of the talus (OLT) using autologous matrix-induced chondrogenesis (AMIC), while also discussing the mid-long term functional outcomes, complications, and surgical failure rate.

METHODS

We searched Embase, PubMed, and Web of Science for studies on OLT treated with AMIC with an average follow-up of at least 2 years. Publication information, patient data, functional scores, surgical failure rate, and complications were extracted.

RESULTS

A total of 15 studies were screened and included, with 12 case series selected for meta-analysis and 3 non-randomized controlled studies chosen for descriptive analysis. The improvements in the Visual Analog Scale (VAS), the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot, and Tegner scores at the last follow-up were (SMD = - 2.825, 95% CI - 3.343 to  - 2.306, P < 0.001), (SMD = 2.73, 95% CI 1.60 to 3.86, P < 0.001), (SMD = 0.85, 95% CI 0.5 to 1.2, P < 0.001) respectively compared to preoperative values. The surgery failure rate was 11% (95% CI 8-15%), with a total of 12 patients experiencing complications.

CONCLUSION

The use of AMIC demonstrates a positive impact on pain management, functional improvement, and mobility enhancement in patients with OLT. It is worth noting that the choice of stent for AMIC, patient age, and OLT size can influence the ultimate clinical outcomes. This study provides evidences supporting the safety and efficacy of AMIC as a viable treatment option in real-world medical practice.

Regeneration: AT-AMIC Technique: Limits and Indication

Osteochondral lesion of the talus (OLT) is a commune cause of chronic ankle pain. Symptomatic lesions require surgical treatment. Currently, lesions with diameter less than 107.4 mm2 are treated with bone marrow stimulating technique with notable success rate. However, more extensive lesions show less predictable surgical results. Autologous matrix-induced chondrogenesis has proven to provide satisfactory medium and long-term results on OLTs. In the current review, we describe an all-arthroscopic technique and the Milan-Tel Aviv lesion assessment protocol.

Significant Clinical Improvement After Arthroscopic Autologous Matrix-Induced Chondrogenesis for Osteochondral Lesions of the Talus: A 5-Year Follow-Up

PURPOSE

This study aims to evaluate the clinical outcomes of arthroscopic autologous matrix-induced chondrogenesis (A-AMIC) for osteochondral lesions of the talus (OLT) at 24 months and 60 months of follow-up. The secondary aim was to assess whether age, body mass index (BMI), and lesion surface affect outcomes.

DESIGN

Sixty-three patients (32 males, 31 females) with a median age of 37 years [interquartile range (IQR): 25-48] were included. Preoperative and postoperative (24 months and 60 months) clinical outcomes were evaluated using a Visual Analog Score (VAS) for pain during walking, the American Orthopaedic Foot and Ankle Society (AOFAS), Short-Form Survey (SF-12), the Halasi, and the University of California, Los Angeles (UCLA) scores. Patients were categorized according to age, BMI, and lesion surface (1-1.5 cm2 and over 1.5 cm2). The effect of each category was evaluated.

RESULTS

There were significant improvements in the VAS, AOFAS, SF-12, and UCLA, comparing the preoperative scores to the 60-month follow-up scores (P < 0.001). There were no significant differences in the above-mentioned outcomes between the follow-up periods. Patients older than 33 years had lower SF-12, Halasi, and UCLA scores (P = 0.005, 0.004, and <0.001, respectively). Overweight patients had lower VAS, SF-12, Halasi, and UCLA scores (P = 0.006, 0.002, 0.024, and 0.007, respectively). Lesion size was uninfluential.

CONCLUSION

A-AMIC yielded clinical improvements at a minimum follow-up of 60 months in patients with symptomatic OLTs, with clinical improvement peaking in the first 2 years, followed by a plateau period. Increased age and BMI were significantly associated with inferior outcomes.

Clinical Applicability of Autologous Chondrocyte Implantation for the Treatment of Osteochondral Defects: A Meta-analysis

PURPOSE

Osteoarthritis and other joint disorders are the leading cause of disability in the elderly and the treatment of joint lesions is challenging. Autologous chondrocyte implantation (ACI) has been reported with variable effects for the treatment of osteochondral and other joint lesions. In this study, we performed a meta-analysis of the recent literature to determine the clinical applicability of ACI for osteochondral defects.

METHODS

A meta-analysis was performed on the recent literature showing the effects of ACI on osteochondral defects. The PUBMED, ScienceDirect and Google Scholar databases were used to identify eligible studies from Jan 2010 to Sep 2022. Both fixed and random models of meta-analysis were applied with all reported scoring systems to quantify the effectiveness of ACI on osteochondral defects.

RESULTS

The pool data of 965 patients as a case series after ACI from a fixed model showed a significant improvement in the osteochondral defects (odds ratio = 8.75, 95%CI = 7.127 to 10.743, p = 0.000). These results were further verified by a random model of meta-analysis. The data also showed a substantial heterogeneity among the studies used in the meta-analysis (Q-value = 160.41, I-squared = 87.53, p = 0.000). Furthermore, this meta-analysis also compared different ACI procedures with different scoring systems but the overall outcome remains the same as ACI was found to be useful for the healing of the osteochondral defects.

CONCLUSION

This meta-analysis of 965 case series revealed that the ACI markedly improved the damage osteochondral defects scores but the optimal treatment is still controversial, therefore further studies are needed to validate these findings in a clinical setting.

The Frequency and Severity of Complications in Surgical Treatment of Osteochondral Lesions of the Talus: A Systematic Review and Meta-Analysis of 6,962 Lesions

OBJECTIVE

The primary aim was to determine and compare the complication rate of different surgical treatment options for osteochondral lesions of the talus (OLTs). The secondary aim was to analyze and compare the severity and types of complications.

DESIGN

A literature search was performed in MEDLINE (PubMed), EMBASE (Ovid), and the Cochrane Library. Methodological quality was assessed using the Methodological Index for Non-Randomized Studies (MINORS). Primary outcome was the complication rate per surgical treatment option. Secondary outcomes included the severity (using the Modified Clavien-Dindo-Sink Complication Classification System for Orthopedic Surgery) and types of complications. The primary outcome, the severity, and the sub-analyses were analyzed using a random effects model. A moderator test for subgroup-analysis was used to determine differences. The types of complications were presented as rates.

RESULTS

In all, 178 articles from the literature search were included for analysis, comprising 6,962 OLTs with a pooled mean age of 35.5 years and follow-up of 46.3 months. Methodological quality was fair. The overall complication rate was 5% (4%-6%; treatment group effect, P = 0.0015). Analysis resulted in rates from 3% (2%-4%) for matrix-assisted bone marrow stimulation to 15% (5%-35%) for metal implants. Nerve injury was the most observed complication.

CONCLUSIONS

In 1 out of 20 patients treated surgically for an OLT, a complication occurs. Metal implants have a significantly higher complication rate compared with other treatment modalities. No life-threatening complications were reported.

Prognostic factors for the management of chondral defects of the knee and ankle joint: a systematic review

Purpose

Different surgical techniques to manage cartilage defects are available, including microfracture (MFx), autologous chondrocyte implantation (ACI), osteoarticular auto- or allograft transplantation (OAT), autologous matrix-induced chondrogenesis (AMIC). This study investigated the patient-related prognostic factors on the clinical outcomes of surgically treated knee and ankle cartilage defects.

Methods

This study followed the PRISMA statement. In May 2022, the following databases were accessed: PubMed, Google Scholar, Embase, and Scopus. All the studies investigating the outcomes of surgical management for knee and/or talus chondral defects were accessed. Only studies performing mesenchymal stem cells transplantation, OAT, MFx, ACI, and AMIC were considered. A multiple linear model regression analysis through the Pearson Product–Moment Correlation Coefficient was used.

Results

Data from 184 articles (8905 procedures) were retrieved. Female sex showed a positive moderate association with visual analogue scale at last follow-up (P = 0.02). Patient age had a negative association with the American Orthopaedic Foot and Ankle Score (P = 0.04) and Lysholm Knee Scoring Scale (P = 0.03). BMI was strongly associated with graft hypertrophy (P = 0.01). Greater values of VAS at baseline negatively correlate with lower values of Tegner Activity Scale at last follow-up (P < 0.0001).

Conclusion

The clinical outcomes were mostly related to the patients’ performance status prior surgery. A greater BMI was associated with greater rate of hypertrophy. Female sex and older age evidenced fair influence, while symptom duration prior to the surgical intervention and cartilage defect size evidenced no association with the surgical outcome. Lesion size and symptom duration did not evidence any association with the surgical outcome.

Autologous Matrix-Induced Chondrogenesis (AMIC) for Osteochondral Defects of the Talus: A Systematic Review

Autologous matrix-induced chondrogenesis (AMIC) has been advocated for the management of talar osteochondral lesions (OCLs). This systematic review, which was conducted according to the PRISMA 2020 guidelines, investigated the clinical and imaging efficacy and safety of the AMIC technique in the management of OCLs of the talus. Only studies investigating AMIC for talar chondral defects that were published in peer-reviewed journals were considered. In September 2022, the following databases were accessed: PubMed, Web of Science, Google Scholar, and Embase. Data on the visual analogue scale (VAS), American Orthopaedic Foot and Ankle Score (AOFAS), Tegner activity scale, and Foot Function Index (FFI) were retrieved. To evaluate the morphological MRI findings, data obtained from the magnetic resonance observation of cartilage repair tissue (MOCART) scores were evaluated. Data on hypertrophy, failures, and revision surgeries were also collected. Data from 778 patients (39% women, 61% men) were collected. The mean length of the follow-up was 37.4 ± 16.1 months. The mean age of the patients was 36.4 ± 5.1 years, and the mean BMI was 26.1 ± 1.6 kg/m2. The mean defect size was 2.1 ± 1.9 cm2. Following the AMIC technique, patients demonstrated an improved VAS (p < 0.001), AOFAS (p < 0.001), and FFI (p = 0.02) score. The MOCART score also improved from the baseline (p = 0.03). No difference was observed in the Tegner score (p = 0.08). No graft delamination and hypertrophy were reported in 353 patients. 7.8% (44 of 564) of patients required revision surgeries, and 6.2% (32 of 515) of patients were considered failures. The AMIC technique could be effective in improving symptoms and the function of chondral defects of the talus.

Surgical Management of Focal Chondral Defects of the Talus: A Bayesian Network Meta-analysis

BACKGROUND

No consensus has been reached regarding the optimal surgical treatment for focal chondral defects of the talus.

PURPOSE

A Bayesian network meta-analysis was conducted to compare the clinical scores and complications of mosaicplasty, osteochondral auto- and allograft transplant, microfracture, matrix-assisted autologous chondrocyte transplant, and autologous matrix-induced chondrogenesis (AMIC) for chondral defects of the talus at midterm follow-up.

STUDY DESIGN

Bayesian network meta-analysis; Level of evidence, 4.

METHODS

This Bayesian network meta-analysis followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) extension statement for reporting of systematic reviews incorporating network meta-analyses of health care interventions. PubMed, Embase, Google Scholar, and Scopus databases were accessed in February 2021. All clinical trials comparing 2 or more surgical interventions for the management of chondral defects of the talus were accessed. The outcomes of interest were visual analog scale (VAS) score, American Orthopaedic Foot and Ankle Society (AOFAS) score, rate of failure, and rate of revision surgery. The network meta-analysis were performed through the routine for Bayesian hierarchical random-effects model analysis. The log odds ratio (LOR) effect measure was used for dichotomous variables, and the standardized mean difference (SMD) was used for continuous variables.

RESULTS

Data from 13 articles (521 procedures) were retrieved. The median length of the follow-up was 47.8 months (range, 31.7-66.8 months). Analysis of variance revealed no difference between the treatment groups at baseline in terms of age, sex, body mass index, AOFAS score, VAS score, and mean number of defects. AMIC demonstrated the greatest AOFAS score (SMD, 11.27) and lowest VAS score (SMD, -2.26) as well as the lowest rates of failure (LOR, 0.94) and revision (LOR, 0.94). The test for overall inconsistency was not significant.

CONCLUSION

At approximately 4 years of follow-up, the AMIC procedure for management of focal chondral defects of the talus produced the best outcome.

Evidence for operative treatment of talar osteochondral lesions: a systematic review

Purpose

Operative treatment of talar osteochondral lesions is challenging with various treatment options. The aims were (i) to compare patient populations between the different treatment options in terms of demographic data and lesion size and (ii) to correlate the outcome with demographic parameters and preoperative scores.

Methods

A systemic review was conducted according to the PRISMA guidelines. The electronic databases Pubmed (MEDLINE) and Embase were screened for reports with the following inclusion criteria: minimum 2-year follow-up after operative treatment of a talar osteochondral lesion in at least ten adult patients and published between 2000 and 2020.

Results

Forty-five papers were included. Small lesions were treated using BMS, while large lesions with ACI. There was no difference in age between the treatment groups. There was a correlation between preoperative American Orthopaedic Foot and Ankle Society (AOFAS) score and change in AOFAS score (R = −0.849, P < 0.001) as well as AOFAS score at follow-up (R = 0.421, P = 0.008). Preoperative size of the cartilage lesion correlates with preoperative AOFAS scores (R= −0.634, P = 0.001) and with change in AOFAS score (R = 0.656, P < 0.001) but not with AOFAS score at follow-up. Due to the heterogeneity of the studies, a comparison of the outcome between the different operative techniques was not possible.

Conclusion

Patient groups with bigger lesions and inferior preoperative scores did improve the most after surgery.

Level of evidence

IV.

AMIC Procedure for Treatment of Osteochondral Lesions of Talus-A Systematic Review of the Current Literature

Osteochondral lesions of talus are a common injury where surgery is indicated in case of failed non-operative treatment or displaced lesions. Many studies have been conducted on the effectiveness of the AMIC procedure. The goal of our study is to create an overview of the current literature. A systematic search adhering to the PRISMA guidelines was conducted in PubMed (MEDLINE) and EMBASE on May 27, 2020. All included studies were evaluated according to the modified Coleman Methodology Score and information on study type, patient numbers, age, follow-up period, grade, location and size of the lesion, study in- and exclusion criteria, associated surgery, surgical technique, scaffold- and fixation technique, postoperative restrictions, reoperation rates, study outcome score, rehabilitation program, and surgical complications was extracted. Ninety-six studies were identified with 18 studies being included in our analysis. The overall quality of the literature was fair with no studies being graded as excellent. Data on preoperative evaluation and surgical technique, complication and reoperation rates, postoperative management and study outcome was extracted in order to create an overview of the current literature. The literature supports the use of the AMIC procedure as an effective treatment for osteochondral lesions of talus. Great heterogeneity exists and comparative studies are missing. While the number of studies on the topic is increasing further are needed and especially with optimized design.

Preexisting and treated concomitant ankle instability does not compromise patient-reported outcomes of solitary osteochondral lesions of the talus treated with matrix-induced bone marrow stimulation in the first postoperative year: data from the German Cartilage Registry (KnorpelRegister DGOU)

PURPOSE

The purpose of this study was to compare the subjective ankle function within the first year following matrix-induced bone marrow stimulation (M-BMS) of patients with a solitary osteochondral lesion of the talus (OCLT) with and without concomitant chronic ankle instability (CAI).

METHODS

Data from the German Cartilage Registry (KnorpelRegister DGOU) for 78 patients with a solitary OCLT and a follow-up of at least 6 months were included. All patients received M-BMS for OCLT treatment. The cohort was subdivided into patients with OCLT without CAI treated with M-BMS alone (n = 40) and patients with OCLT and CAI treated with M-BMS and additional ankle stabilisation (n = 38). The Foot and Ankle Ability Measure (FAAM), the Foot and Ankle Outcome Score (FAOS), and the Numeric Rating Scale for Pain (NRS) were used to assess patient-reported outcomes (median (minimum-maximum)).

RESULTS

From preoperatively to 12 months postoperatively, patients with OCLT without CAI treated with M-BMS alone had a significant improvement of all subscales in the FAAM [activity of daily living 64.3 (10-100) to 88.1 (39-100); sports 34.4 (0-100) to 65.6 (13-94), functional activities of daily life 50 (0-90) to 80 (30-100), functional sports 30 (0-100) to 70 (5-100)] and FAOS [pain 61.1 (8-94) to 86.1 (50-100), symptoms 60.7 (18-96) to 76.8 (29-100), activities of daily living 72.1 (24-100) to 91.9 (68-100), sport/recreational activities 30.0 (0-70) to 62.5 (0-95), quality of life 31.3 (6-50) to 46.9 (19-100)]. Within the first year, patients with OCLT and CAI treated with M-BMS and ankle stabilisation also showed significant improvement in the FAAM [activity of daily living 68.8 (5-99) to 90.5 (45-100); sports 32.8 (0-87.5) to 64.1 (0-94), functional activities of daily life 62.5 (25-100) to 80 (60-90), functional sports 30 (0-100) to 67.5 (0.95)] and the FAOS [pain 66.7 (28-92) to 87.5 (47-100), symptoms 57.1 (29-96) to 78.6 (50-100), activities of daily living 80.1 (25-100) to 98.5 (59-100), sport/recreational activities 35.0 (0-100) to 70.0 (0-100), quality of life 25.0 (0-75) to 50.0 (19-94)]. The pain level decreased significantly in both groups. No significant difference was found between both groups regarding the subscales of FAAM, FAOS and the NRS 1 year postoperatively.

CONCLUSION

Improvements in subjective ankle function, daily life activities and sports activities were observed within the first year following M-BMS. Our results suggest that preexisting and treated ankle instability did not compromise subjective outcome in patients treated with M-BMS in the first postoperative year.

LEVEL OF EVIDENCE

Level IV.

Smoking Is Associated with Anterior Ankle Impingement After Isolated Autologous Matrix-Induced Chondrogenesis for Osteochondral Lesions of the Talus

OBJECTIVE

To determine potential predictive associations between patient-/lesion-specific factors, clinical outcome and anterior ankle impingement in patients that underwent isolated autologous matrix-induced chondrogenesis (AMIC) for an osteochondral lesion of the talus (OLT).

DESIGN

Thirty-five patients with a mean age of 34.7 ± 15 years who underwent isolated cartilage repair with AMIC for OLTs were evaluated at a mean follow-up of 4.5 ± 1.9 years. Patients completed AOFAS (American Orthopaedic Foot and Ankle Society) scores at final follow-up, as well as Tegner scores at final follow-up and retrospectively for preinjury and presurgery time points. Pearson correlation and multivariate regression models were used to distinguish associations between patient-/lesion-specific factors, the need for subsequent surgery due to anterior ankle impingement and patient-reported outcomes.

RESULTS

At final follow-up, AOFAS and Tegner scores averaged 92.6 ± 8.3 and 5.1 ± 1.8, respectively. Both body mass index (BMI) and duration of symptoms were independent predictors for postoperative AOFAS and Δ preinjury to postsurgery Tegner with positive smoking status showing a trend toward worse AOFAS scores, but this did not reach statistical significance (P = 0.054). Nine patients (25.7%) required subsequent surgery due to anterior ankle impingement. Smoking was the only factor that showed significant correlation with postoperative anterior ankle impingement with an odds ratio of 10.61 when adjusted for BMI and duration of symptoms (95% CI, 1.04-108.57; P = 0.047).

CONCLUSION

In particular, patients with normal BMI and chronic symptoms benefit from AMIC for the treatment of OLTs. Conversely, smoking cessation should be considered before AMIC due to the increased risk of subsequent surgery and possibly worse clinical outcome seen in active smokers.

Influence of the Medial Malleolus Osteotomy on the Clinical Outcome of M-BMS + I/III Collagen Scaffold in Medial Talar Osteochondral Lesion (German Cartilage Register/Knorpelregister DGOU)

OBJECTIVE

Osteochondral lesions of the talus are common injuries, with one of the leading treatment options being the M-BMS (matrix-augmented bone marrow stimulation) + I/III collagen scaffold. Osteotomy of the medial malleolus is not unusual but presents the risk of malunion or irritation by hardware. The aim of the study was to analyze data from the German Cartilage Society (Knorpelregister DGOU) to evaluate the influence of medial malleolar osteotomy on clinical results of M-BMS + I/III collagen scaffold.

DESIGN

The ankle module of the Cartilage Register includes a total of 718 patients, while 45 patients met the inclusion criteria. Patients were treated with an M-BMS + I/III collagen scaffold of the medial talus, 30 without and 15 with an osteotomy of the medial malleolus. The follow-up evaluations included FAAM (Foot and Ankle Ability Measure), FAOS (Foot and Ankle Outcome Score), and VAS (visual analogue scale).

RESULTS

Forty-five patients (22 male, 23 female) aged between 18 and 69 years (mean: 34 years) were included in this study. Between preoperative and 12 months postoperative, we noted a significant improvement in FAAM-ADL (Activity of Daily Living) (P = 0.004) as well as FAOS-Pain (P = 0.001), FAOS-Stiffness (P = 0.047), FAOS-ADL (P = 0.002), FAOS-Sport (P = 0.001), and FAOS Quality of Life (P = 0.009). There was no significant difference between patients who underwent an osteotomy or not.

CONCLUSION

The results show a significant improvement in patients' outcome scores following a M-BMS + I/III collagen scaffold. No statistical difference was noted among those undergoing medial malleolar osteotomy.

AMIC for traumatic focal osteochondral defect of the talar shoulder: a 5 years follow-up prospective cohort study

BACKGROUND

Autologous Matrix-Induced Chondrogenesis (AMIC) is addressed to osteochondral defects of the talus. However, evidence concerning the midterm efficacy and safety of AMIC are limited. This study assessed reliability and feasibility of AMIC at 60 months follow-up. We hypothesize that AMIC leads to good clinical outcome at midterm follow-up.

METHODS

Surgeries were approached with an arthrotomy via malleolar osteotomy. A resorbable porcine I/III collagen membrane (Chondro-Gide®, Geistlich Pharma AG, Wolhusen, Switzerland) was used. Patients were followed at 24 and 60 months. The primary outcome of interest was to analyse the Foot Function Index (FFI), and the subscale hindfoot of the American Orthopaedic Foot and Ankle Score (AOFAS). Complications such as failure, revision surgeries, graft delamination, and hypertrophy were also recorded. The secondary outcome of interest was to investigate the association between the clinical outcome and patient characteristics at admission.

RESULTS

Data from 19 patients were included. The mean age at admission was 47.3 ± 13.2 years, and the mean BMI 24.1 ± 4.9 kg/m². 53% (10 of 19 patients) were female. At a mean of 66.2 ± 11.6 months, the FFI decreased at 24-months follow-up of 22.5% (P = 0.003) and of further 1.3% (P = 0.8) at 60-months follow-up. AOFAS increased at 24-months follow-up of 17.2% (P = 0.003) and of further 3.4 (P = 0.2) at 60-months follow-up. There were two symptomatic recurrences within the follow-up in two patients. There was evidence of a strong positive association between FFI and AOFAS at baseline and the same scores last follow-up (P = 0.001 and P = 0.0002, respectively).

CONCLUSION

AMIC enhanced with cancellous bone graft demonstrated efficacy and feasibility for osteochondral defects of the talus at five years follow-up. The greatest improvement was evidenced within the first two years. These results suggest that clinical outcome is influenced by the preoperative status of the ankle. High quality studies involving a larger sample size are required to detect seldom complications and identify prognostic factors leading to better clinical outcome.

LEVEL OF EVIDENCE

II, prospective cohort study.

Biologic therapies for foot and ankle injuries

Introduction: The use of orthobiologics as supplemental treatment for foot and ankle pathologies have increased in the past decades. They have been used to improve the healing of bone and soft tissue injuries. There have been several studies that examined the use of biologics for knee and hip pathologies but the foot and ankle construct has unique features that must be considered.Areas covered: The biologics for foot and ankle injuries that are covered in this review are platelet-rich plasma (PRP), stem cells, growth factors, hyaluronic acid, bone grafts, bone substitutes, and scaffolds. These modalities are used in the treatment of pathologies related to tendon and soft tissue as well as cartilage.Expert opinion: The utilization of biological adjuncts for improved repair and regeneration of ankle injuries represents a promising future in our efforts to address difficult clinical problems. The application of concentrated bone marrow and PRP each represents the most widely studied and commonly used injection therapies with early clinical studies demonstrating promising results, research is also being done using other potential therapies such as stem cells and growth factors; further investigation and outcome data are still needed.

Autologous matrix-induced chondrogenesis for the treatment of osteochondral lesions of the talus: A systematic review

This study was performed to determine whether Autologous Matrix-Induced Chondrogenesis (AMIC) is an effective and safe treatment option for patients with symptomatic Osteochondral defects of the Talus (OCTs) and to identify factors that influence the clinical outcome. A systematic review of the literature was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Three reviewers independently conducted the literature search using the MEDLINE/PubMed database and the Cochrane Database of Systematic Reviews. The databases were queried using the terms "autologous" AND "matrix" AND "induced" AND "chondrogenesis." Thirteen studies were eligible for review. All studies that compared the preoperative and postoperative mean values of different clinical/functional scores showed significant clinical improvement. The final postoperative mean Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score ranged from 50.9 to 74.5. The included studies indicated that age and body mass index may have a detrimental impact on the postoperative outcome. A higher re-intervention rate is expected with the open technique, mainly because of hardware removal after malleolar osteotomy. This data analysis demonstrated that both arthroscopic and open AMIC procedures are effective and safe for the treatment of OCTs. Level IV, systematic review of therapeutic studies.

Return to Sport After Arthroscopic Autologous Matrix-Induced Chondrogenesis for Patients With Osteochondral Lesion of the Talus

OBJECTIVE

To determine the rate of return of patients to sport after arthroscopic autologous matrix-induced chondrogenesis (AT-AMIC) for outcomes 2 years after surgery.

DESIGN

Retrospective observational cross-sectional study.

SETTING

C.A.S.C.O.-Foot and Ankle Unit, Istituto Ortopedico Galeazzi, Milan, Italy.

PATIENTS AND INTERVENTION

Twenty-six consecutive patients, 65.4% male (mean ± SD age: 33.7 ± 11.0 years), that underwent AT-AMIC procedure between 2012 and 2015 were selected retrospectively. From this population, only sporting patients at amateur's level were included. Arthroscopic autologous matrix-induced chondrogenesis was proposed in patients with pain and persistent disability.

MAIN OUTCOME MEASURES

All patients were assessed with the American Orthopaedic Foot and Ankle Score (AOFAS), physical component score of the 12-Item Short Form Health Survey (SF-12), Halasi ankle activity score, and University of California, Los Angeles (UCLA) activity scale preoperatively and at 24 months postoperatively.

RESULTS

Overall, 80.8% of the patient group returned to the same preinjury sport. The mean follow-up was 42.6 ± 10.9 months (range from 25 to 62 months). Significant differences were observed with reference to AOFAS, SF-12, Halasi, and UCLA scores at the last follow-up in patients who had undergone AT-AMIC (all, P < 0.001).

CONCLUSIONS

A high percentage of patients return to their preinjury sport after AT-AMIC surgery.

Arthroscopic Treatment of Osteochondral Lesions of the Talus in a Suspended Position With the Patient in a Prone Position

BACKGROUND

The purpose of this study was to evaluate the clinical results and the safety of arthroscopic microfracture with the ankle suspended on a shoulder-holding traction frame for simultaneous anterior and posterior ankle arthroscopy in the prone position.

METHODS

Between May 2010 and January 2016, 31 patients with posterior osteochondral lesions of the talus (OLTs) were treated with arthroscopic microfracture in a suspended position with the patient prone. Ankle distraction was achieved by suspending the affected ankle on a shoulder-holding traction frame. The 100 mm visual analog scale (VAS) and the Foot Function Index (FFI) were checked preoperatively and at final follow-up. Postoperative complications related to the suspended position were analyzed. Lower leg intramuscular compartment pressure was checked after the surgery to determine if there was any risk of compartment syndrome.

RESULTS

The mean 100-mm VAS score, and FFI improved from 62.8 ±11.3 and 48.5 ± 12.1, respectively, preoperatively to 15.8 ± 10.4 and 16.4 ± 9.2, respectively, at final follow-up (P = .025, and P = .005, respectively). The mean anterior, lateral, superficial posterior, and deep posterior compartment pressures were 7.3 ± 1.5, 8.1 ± 1.1, 5.6 ± 1.9, and 9.2 ± 2.4 mmHg, respectively. No compartment syndrome occurred.

CONCLUSION

Arthroscopic treatment of OLT in a prone position with the ankle suspended on a shoulder-holding traction frame allowed the use of simultaneous anterior and posterior portals for viewing and instrumentation without major operative complications, such as compartment syndrome.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Autologous Matrix-Induced Chondrogenesis for Osteochondral Lesions of the Talus: A Clinical and Radiological 2- to 8-Year Follow-up Study

BACKGROUND

Autologous matrix-induced chondrogenesis (AMIC) has become an interesting treatment option for osteochondral lesions of the talus (OLTs) with promising clinical short- to midterm results.

PURPOSE

To investigate the clinical and radiological outcome of the AMIC procedure for OLTs, extending the follow-up to 8 years.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Thirty-three patients (mean age, 35.1 years; body mass index, 26.8) with osteochondral lesions of the medial talar dome were retrospectively evaluated after open AMIC repair at a mean follow-up of 4.7 years (range, 2.3-8.0 years). Patients requiring additional surgical procedures were excluded. All OLTs (mean size, 0.9 cm²; range, 0.4-2.3 cm²) were approached through a medial malleolar osteotomy, and 28 patients received subchondral autologous bone grafting. Data analysis included the visual analog scale for pain, the American Orthopaedic Foot and Ankle Society score for ankle function, the Tegner score for sports activity, and the MOCART (magnetic resonance observation of cartilage repair tissue) scoring system for repair cartilage and subchondral bone evaluation.

RESULTS

Mean ± SD visual analog scale score improved significantly from 6.4 ± 1.9 preoperatively to 1.4 ± 2.0 at latest follow-up ( P < .001). The mean American Orthopaedic Foot and Ankle Society score was 93.0 ± 7.5 (range, 75-100). The Tegner score improved significantly from 3.5 ± 1.8 preoperatively to 5.2 ± 1.7 at latest follow-up ( P < .001), and 79% returned to their previous sports levels. The MOCART score averaged 60.6 ± 21.2 (range, 0-100). Complete filling of the defect was seen in 88% of cases, but 52% showed hypertrophy of the cartilage layer. All but 1 patient showed persistent subchondral bone edema. The patient's age and body mass index, the size of the osteochondral lesion, and the MOCART score did not show significant correlation with the clinical outcome. There were no cases of revision surgery for failed AMIC. Fifty-eight percent underwent reoperation, mainly for symptomatic hardware after malleolar osteotomy.

CONCLUSION

AMIC for osteochondral talar lesions led to significant pain reduction, recovery of ankle function, and successful return to sport. The MOCART score did not correlate with the good clinical results; the interpretation of postoperative imaging remains therefore challenging.

Matrix-associated stem cell transplantation (MAST) in chondral lesions at the ankle as part of a complex surgical approach- 5-year-follow-up in 100 patients

BACKGROUND

The aim of the study was to assess the 5-year-follow-up after matrix-associated stem cell transplantation (MAST) in chondral lesions at the ankle as part of a complex surgical approach.

METHODS

In a prospective consecutive non-controlled clinical follow-up study, all patients with chondral lesion at the ankle that were treated with MAST from April 1, 2009 to May 31, 2012 were included. Size and location of the chondral lesions, method-associated problems and the Visual-Analogue-Scale Foot and Ankle (VAS FA) before treatment and at follow-up were analysed. Stem cell-rich blood was harvested from the ipsilateral pelvic bone marrow and centrifuged (10min, 1500RPM). The supernatant was used to impregnate a collagen I/III matrix (Chondro-Gide) that was fixed into the chondral lesion with fibrin glue.

RESULTS

One hundred and twenty patients with 124 chondral lesions were included in the study. Age at the time of surgery was 35 years on average (range, 12-65 years), 74 (62%) were male. VAS FA before surgery was 45.2 on average (range, 16.4-73.5). Lesions were located at medial talar shoulder, n=55; lateral talar shoulder, n=58 (medial and lateral, n=4); tibia, n=11. Lesion size was 1.7cm² on average (range, .8-6cm²). One hundred patients (83%) completed 5-year-follow-up after. VAS FA improved to 84.4 (range, 54.1-100; t-test, p<0.01).

CONCLUSIONS

MAST as part of a complex surgical approach led to improved and high validated outcome scores in the mid-term-follow-up. No method related complications were registered. Even though a control group is missing, we conclude that MAST as part of a complex surgical approach is an effective method for the treatment of chondral lesions of the ankle for at least five years.

Autologous Matrix-Induced Chondrogenesis: A Systematic Review of the Clinical Evidence

BACKGROUND

The addition of a type I/III collagen membrane in cartilage defects treated with microfracture has been advocated for cartilage repair, termed "autologous matrix-induced chondrogenesis" (AMIC).

PURPOSE

To examine the current clinical evidence regarding AMIC for focal chondral defects.

STUDY DESIGN

Systematic review.

METHODS

A systematic review was performed by searching PubMed, ScienceDirect, and Cochrane Library databases. Inclusion criteria were clinical studies of AMIC for articular cartilage repair, written in English. Relative data were extracted and critically analyzed. PRISMA guidelines were applied, the methodological quality of the included studies was assessed by the modified Coleman Methodology Score (CMS), and aggregate data were generated.

RESULTS

Twenty-eight clinical articles were included: 12 studies (245 patients) of knee cartilage defects, 12 studies (214 patients) of ankle cartilage defects, and 4 studies (308 patients) of hip cartilage defects. The CMS demonstrated a suboptimal study design in the majority of published studies (knee, 57.8; ankle, 55.3; hip, 57.7). For the knee, 1 study reported significant clinical improvements for AMIC compared with microfracture for medium-sized cartilage defects (mean defect size 3.6 cm²) after 5 years (level of evidence, 1). No study compared AMIC with matrix-assisted autologous chondrocyte implantation (ACI) in the knee. For the ankle, no clinical trial was available comparing AMIC versus microfracture or ACI. In the hip, only one analysis (level of evidence, 3) compared AMIC with microfracture for acetabular lesions. For medium-sized acetabular defects, one study (level of evidence, 3) found no significant differences between AMIC and ACI at 5 years. Specific aspects not appropriately discussed in the currently available literature include patient-related factors, membrane fixation, and defect properties. No treatment-related adverse events were reported.

CONCLUSION

This systematic review reveals a paucity of high-quality, randomized controlled studies testing the AMIC technique versus established procedures such as microfracture or ACI. Evidence is insufficient to recommend joint-specific indications for AMIC. Additional nonbiased, high-powered, randomized controlled clinical trials will provide better clinical and structural long-term evidence, thus helping to define possible indications for this technique.

Relationship between symptomatic osteochondral lesions of the talus and quality of life, body mass index, age, size and anatomic location

INTRODUCTION

The aim of the study was to assess the relationship between symptomatic osteochondral lesions of the talus (OLTs) and age, body mass index (BMI), quality of life (QOL), size and anatomic location.

METHODS

Fifty-two patients with chronic OLTs were analyzed including BMI, Visual Analogue Scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS), Short-Form Health Survey (SF-12 divided into Mental (MCS) and Physical (PCS) score) and the 12-Item General Health Questionnaire (GHQ-12). Every patient underwent magnetic resonance imaging (MRI) and computed tomography (CT) examinations. We carried out a sub-analysis by dividing the talus into 6 areas, 3 vertical (medial, central and lateral group) and 3 horizontal (anterior, middle and posterior group).

RESULTS

There were 31 (60%) male and 21 (40%) female patients. Mean MCS and PCS resulted respectively 43.9 and 35.2. OLTs were located as follows: medial 20 (38.50%); central 13 (24.0%); and lateral 19 (36.50%); anterior 24 (46.15%); middle 16 (30.77%); and posterior 12 (23.08%). No significant differences were found among different groups with the exception of the anterior and posterior group for MCS (p=0.021). In the central group we identified a negative correlation (R=-0.672) between aging and AOFAS and a positive correlation between BMI and lesion size. We found a positive correlation between CT and MRI in each group.

CONCLUSIONS

OLTs impact patients' quality of life particularly in the physical component. Additionally, in patients with central lesions we found a positive linear correlation between lesion size and BMI and a worsening of the ankle with increasing age.

The role of biologic in foot and ankle trauma-a review of the literature

PURPOSE OF REVIEW

The use of biologics in orthopedics is becoming increasingly popular as an adjuvant in healing musculoskeletal injuries. Though many biologics involved in the management of foot and ankle injuries are used based on physician preference, reports of improved outcomes when combined with standard operative treatment has led to further clinical interest especially in foot and ankle trauma.

RECENT FINDINGS

The most recent studies have shown benefits for biologic use in patients predisposed to poor bone and soft tissue healing. Biologics have shown benefit in treating soft tissue injuries such as Achilles ruptures as well as the complications of trauma such as non-unions and osteoarthritis. Biologics have shown some benefit in improving functional and pain scores, as well as reducing time to heal in foot and ankle traumatic injuries, with particular success shown with patients that have risk factors for poor healing. As the use of biologics continues to increase, there is a need for high-level studies to confirm early findings of lower level reports.

The role of bone marrow edema on osteochondral lesions of the talus

BACKGROUND

To assess the functional and radiological outcomes after arthroscopic talus autologous matrix-induced chondrogenesis (AT-AMIC^®) in 2 groups: patients with and without bone marrow edema (BME).

METHODS

Thirty-seven patients of which 24 without edema (GNE) and 13 with edema (GE) were evaluated. All patients were treated with AT-AMIC^® repair for symptomatic osteochondral talar lesion. Clinical and radiological parameters were evaluated with VAS score for pain, AOFAS and SF-12 at T₀ (preoperatively), T₁ (6 months), T₂ (12 months), T₃ (24 months) and MRI and CT-scan at T₀, T₁, T₂ and T₃.

RESULTS

No patients were lost to the final follow-up. In both groups we found a significant difference for clinical and radiological parameters with ANOVA for repeated measures through four time points (p<0.001). In GNE, AOFAS improved significantly at each follow-up (p<0.05); while CT and MRI showed a significant reduction in lesion size between T₁ and T₂ and T₂ and T₃ (p<0.05). In GE, AOFAS improved significantly between T₀ and T₁ and T₂ and T₃ (p<0.05); lesion size, measured with CT, decreased between T₁ and T₂ (p<0.05), while with MRI the lesion showed a reduction at each follow-up (p<0.05). Lesion size was significantly higher both in MRI and CT in GE compared to GNE (p<0.05). In GNE no patients presented edema at T_3, while in GE only 23.08% of the patients presented edema at T_3. CONCLUSIONS: The study revealed that osteochondral lesions of the talus were characterized by bigger size both in MRI and CT in patients with edema. We conclude that AT-AMIC^® can be considered a safe and reliable procedure that allows effective healing, regardless of edema and more than half of patients did not present edema six months after surgery.

Bactibilia in diseases of the biliary tract and pancreatic gland in patients older than 80 years: a STROBE-retrospective cohort study in a teaching hospital in Italy

Bile is a lipid-rich sterile solution produced in the liver that can be infected resulting in bactibilia. A higher incidence of postoperative infectious complications has been seen in patients with bactibilia. Recently, gram-negative bacteria have been linked to a tumor-associated inflammatory status. This study is a retrospective cohort study of 39 patients, who are over 80 years of age only (53.85% males and 46.15% females), hospitalized with diseases of the biliopancreatic system in one teaching hospital in Italy from January 2011 to December 2012 with a follow-up of 5 years. The most common biliary diseases after surgery were pancreatic head cancer (p < 0.0001) and gallbladder cancer (p = 0.0051), while the most common bacteria in the bile were E. coli (p = 0.0180) and Pseudomonas spp. (p < 0.0001). Uni- and multivariate linear correlation analysis revealed that patients with pancreatic head cancer had low survival times compared to patients with other diseases. Moreover, the bacterium type was a positive predictor of survival time compared to other variables. Our data confirm E. coli as a pathogen in patients with gallbladder and pancreatic cancer. Although the influence of bactibilia in developing surgical complications is limited, we consider that its composition is crucial to properly address the antibiotic treatment in biliary tract infections, especially in the elderly.

Autologous Microfractured and Purified Adipose Tissue for Arthroscopic Management of Osteochondral Lesions of the Talus

In recent years, regenerative techniques have been increasingly studied and used to treat osteochondral lesions of the talus. In particular, several studies have focused their attention on mesenchymal stem cells derived from adipose tissue. Adipose-derived stem cells (ADSCs) exhibit morphological characteristics and properties similar to other mesenchymal cells, and are able to differentiate into several cellular lines. Moreover, these cells are also widely available in the subcutaneous tissue, representing 10 - 30% of the normal body weight, with a concentration of 5,000 cells per gram of tissue. In the presented technique, the first step involves harvesting ADSCs from the abdomen and a process of microfracture and purification; next, the surgical procedure is performed entirely arthroscopically, with less soft tissue dissection, better joint visualization, and a faster recovery compared with standard open procedures. Arthroscopy is characterized by a first phase in which the lesion is identified, isolated, and prepared with microperforations; the second step, performed dry, involves injection of adipose tissue at the level of the lesion. Between January 2016 and September 2016, four patients underwent arthroscopic treatment of osteochondral lesion of the talus with microfractured and purified adipose tissue. All patients reported clinical improvement six months after surgery with no reported complications. Functional scores at the latest follow-up are encouraging and confirm that the technique provides reliable pain relief and improvements in patients with osteochondral lesion of the talus.

No superior treatment for primary osteochondral defects of the talus

PURPOSE

The purpose of this systematic literature review is to detect the most effective treatment option for primary talar osteochondral defects in adults.

METHODS

A literature search was performed to identify studies published from January 1996 to February 2017 using PubMed (MEDLINE), EMBASE, CDSR, DARE, and CENTRAL. Two authors separately and independently screened the search results and conducted the quality assessment using the Newcastle-Ottawa Scale. Subsequently, success rates per separate study were calculated. Studies methodologically eligible for a simplified pooling method were combined.

RESULTS

Fifty-two studies with 1236 primary talar osteochondral defects were included of which forty-one studies were retrospective and eleven prospective. Two randomised controlled trials (RCTs) were identified. Heterogeneity concerning methodological nature was observed, and there was variety in reported success rates. A simplified pooling method performed for eleven retrospective case series including 317 ankles in the bone marrow stimulation group yielded a success rate of 82% [CI 78-86%]. For seven retrospective case series investigating an osteochondral autograft transfer system or an osteoperiosteal cylinder graft insertion with in total 78 included ankles the pooled success rate was calculated to be 77% [CI 66-85%].

CONCLUSIONS

For primary talar osteochondral defects, none of the treatment options showed any superiority over others.

LEVEL OF EVIDENCE

IV.

Six-year survival of reimplanted talus after isolated total talar extrusion: a case report

Background

Open total extrusion of the talus without concomitant fracture is an extremely rare injury. We present 6-year follow-up data of a patient treated using a temporary spanning external fixator and less invasive single K-wire fixation.

Case presentation

A 55-year-old Asian man who had a totally extruded talus without fracture underwent immediate reimplantation surgery. A spanning external fixator with single antegrade K-wire fixation was applied to maintain the reimplanted talus. During 6 years of follow-up, he could walk without aids and could squat, corresponding to an American Orthopaedic Foot and Ankle Society score of 85. We found that the suspect lesion that was evident at 6 months after surgery had disappeared at 12 months postoperatively on the basis of sequential follow-up magnetic resonance imaging. There was no evidence of osteonecrosis of the dislocated talus at the final follow-up.

Conclusions

In patients with a totally extruded talus, a surgical strategy including immediate reimplantation of the talus and a temporary spanning fixator with single K-wire fixation might be useful to allow early mobilization around the ankle joint and to prevent additional damage of the foot without significant complications.

Successful treatment of infected wound dehiscence after minimally invasive locking-plate osteosynthesis of tibial pilon and calcaneal fractures by plate preservation, surgical debridement and antibiotics

OBJECTIVE

The aim is to present a case series that illustrates possible benefits from combining minimally invasive plate osteosynthesis (MIPO), plastic surgery and antibiotic therapy, in order to treat and eradicate infection in patients with tibial pilon or calcaneal fractures.

METHODS

Eleven consecutive patients with dehiscence of the surgical wound in outcomes MIPO using a Locking Compression Plate (LCP) for tibial pilon, or calcaneus fractures. The patients had developed a documented infection of the surgical wound. All patients were treated and followed-up by the multidisciplinary team with the orthopedic surgeon, the plastic surgeon and the infectious disease physician. All patients were followed by the plastic surgeon to treat the wound dehiscence, as well as by the orthopedic surgeon until fracture consolidation. The duration of the antibiotic therapy was from 4 to 6 months. After 6 weeks, the intravenous treatment was replaced by oral administration. The follow-up intervals were 15 days, 40 days, and 3 months.

RESULTS

The average time of wound closure was 109±60 days. The antibiotics used were chosen according to the antibiogram. The antibiotic therapy had a duration of 4-6 months, and after 6 weeks, the therapy switched to oral administration. At the 3-month follow-up, all patients had excellent outcomes and had returned to their normal activity of daily living.

CONCLUSION

The patients in this study responded positively to a combination of MIPO, plastic surgery and antibiotic therapy, confirming that multidisplinary treatment in association with titanium devices are able to eradicate infection in short time.

Single-Step Arthroscopic Repair With Cell-Free Polymer-Based Scaffold in Osteochondral Lesions of the Talus: Clinical and Radiological Results

PURPOSE

To report the clinical and radiological results of patients with talar osteochondral lesions who were treated by microfracture and cell-free scaffold implantation in a single-step arthroscopic surgery.

METHODS

Forty patients, treated with a single-step arthroscopic surgery, were evaluated in this single-center-based retrospective study. Patients with degenerative arthritis (n = 1), history of ankle fracture (n = 1), kissing lesions (n = 1), lower extremity deformity (n = 1), and lesions <1.5 cm² (n = 4) were excluded. Oversized (>10 mm depth) bone cysts were additionally treated with bone graft. Patients were evaluated clinically, using the American Orthopedic Foot and Ankle Society (AOFAS) hindfoot score. Radiological assessment was performed with magnetic resonance imaging, using the magnetic resonance observation of cartilage repair tissue (MOCART) score.

RESULTS

Thirty-two patients with a mean age of 38 ± 12 years were evaluated. The mean defect size was 2.5 ± 0.8 cm² and the mean defect volume was 2.4 ± 1.9 cm³. The mean preoperative AOFAS score was 52.8 ± 13.9 and increased to 87.1 ± 11.1 postoperatively at the mean follow-up of 33.8 ± 14.0 months (P = .0001). A total of 84.4% of patients had good to excellent clinical scores. Clinical scores had no significant relation with age, lesion size, depth, or body mass index. The mean MOCART score was 64.2 ± 12.0. There was no significant correlation between the total MOCART and AOFAS scores (P = .123). A significant relation was found between the defect filling (the subgroup of the MOCART score) and the clinical outcomes (P = .0001, rho = 0.731).

CONCLUSIONS

The arthroscopic scaffold implantation technique is a single-step, safe, and effective method for the treatment of talar osteochondral lesions with satisfactory clinical and radiological outcomes.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

The Impact of Weight on Arthroscopic Osteochondral Talar Reconstruction

BACKGROUND

The purpose of the study was to assess the functional and radiologic outcomes after AT-AMIC (arthroscopic talus autologous matrix-induced chondrogenesis) in 2 weight groups of patients with osteochondral lesions of the talus (OLTs): patients with BMI <25 (Healthy Weight Group [HG]) and with BMI ≥25 (Overweight Group [OG]).

METHODS

Thirty-seven patients were evaluated. HG was composed of 21 patients (BMI = 21.90 ± 1.94), whereas OG consisted of 16 patients (BMI = 27.41 ± 1.98). All patients were treated with AT-AMIC repair for OLTs. Magnetic resonance imaging (MRI), computed tomography (CT), Visual Analgoue Scale (VAS) for pain, American Orthopaedic Foot & Ankle Society (AOFAS) Ankle and Hindfoot score and Short-Form Health Survey (SF-12) were administered preoperatively (T₀) and at 6 (T₁), 12 (T₂), and 24 (T₃) months postoperatively.

RESULTS

In both groups, we found a significant difference for clinical and radiologic parameters with analysis of variance for repeated measures through 4 time points ( P < .001). In HG, AOFAS increased at every follow-up ( P < .05), whereas in OG, AOFAS improved only between T₂ and T₃ ( P = .0104). In OG we found a significant difference comparing CT and MRI at each follow-up; in HG this difference was found only at T₀ ( P < .0001) and T₁ ( P = .0492). Finally, OG presented a significantly larger lesion measured with MRI at T₀ ( P = .033).

CONCLUSIONS

OLTs in overweight patients were characterized by a larger preoperative size. At final follow-up, both groups showed a significant clinical improvement. AT-AMIC can be considered a safe and reliable procedure, regardless of weight, with a significant improvement also in quality of life.

LEVEL OF EVIDENCE

Level III, comparative study.