Advances in Cartilage Repair

Poor adherence rates to the minimum information for studies evaluating biologics in orthopaedics (MIBO) guidelines for clinical studies on platelet-rich plasma for osteochondral lesions of the talus: A systematic review

INTRODUCTION

The Minimum Information for Studies Evaluating Biologics in Orthopaedics (MIBO) guidelines were developed in 2017 in order to establish a standardized approach for reporting key characteristics in platelet rich plasma (PRP)-based studies. However, the adherence to the guidelines from authors publishing data on studies related to the use of PPR in the management of osteochondral lesions of the talus (OLTs) has not yet been determined. The purpose of this study was to analyze how well clinical trials on PRP interventions for OLTs adhered to the MIBO guidelines.

METHODS

PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were used to perform a systematic review of the PubMed, Embase and Cochrane Library databases. Inclusion criteria clinical studies that assessed PRP interventions for OLTs. The original 23 MIBO checklist items were separated and modified into a 46-point checklist. Adherence was determined by calculating the total percentage of checklist items that each article adequately and clearly reported from the 46-point checklist.

RESULTS

A total of 9 studies (356 patients) with a weighted mean age of 42.1 ± 6.1 years were included in this study. The weighted mean follow-up was 32.2 ± 8.7 months. Overall, only 42.8 % ± 5.2 % of the 46-point MIBO checklist items were reported per article with no articles displaying adherence rates of 100 %. No articles had adherence rates ≥ 50 %, 6 (66.7 %) had adherence rates between 40.0 % and 49.9 % and 3 (33.3 %) had adherence rates less than 39.9 %. There was no difference in mean adherence rates between studies published prior to publication of the MIBO guidelines in May 2017 (41.7 %) and after publication of the MIBO guidelines in May 2017 (44.0 %) (p = 0.6473). There was variation in adherence rates between categories with the "Postoperative Care" category having the highest adherence rate (83.3 %) while the "Activation" category and the "Whole Blood Processing" had the lowest adherence rates (5.6 %).

CONCLUSION

This systematic review demonstrated that clinical studies evaluating outcomes following the use of PRP in the setting of OLTs poorly adhered to MIBO guidelines. None of the included studies had adherence rates ≥ 50 % and only 1 of the 12 MIBO categories had adherence rates ≥ 80 %. Interestingly, there was no difference in the mean adherence rates in studies conducted before and after publication of the MIBO guidelines in May 2017. This study underscores the need for superior reporting of critical data related to PRP in studies evaluating outcomes in patients with OLTs augmented with PRP.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Limited evidence to support demineralized bone matrix in foot and ankle surgical procedures: A systematic review

BACKGROUND

Demineralized bone matrix (DBM) is a commonly utilized allogenic bone graft substitute to promote osseous union. However, little is known regarding outcomes following DBM utilization in foot and ankle surgical procedures.

AIM

To evaluate the clinical and radiographic outcomes following DBM as a biological adjunct in foot and ankle surgical procedures.

METHODS

During May 2023, the PubMed, EMBASE and Cochrane library databases were systematically reviewed to identify clinical studies examining outcomes following DBM for the management of various foot and ankle pathologies. Data regarding study characteristics, patient demographics, subjective clinical outcomes, radiological outcomes, complications, and failure rates were extracted and analyzed. In addition, the level of evidence (LOE) and quality of evidence (QOE) for each individual study was also assessed. Thirteen studies were included in this review.

RESULTS

In total, 363 patients (397 ankles and feet) received DBM as part of their surgical procedure at a weighted mean follow-up time of 20.8 ± 9.2 months. The most common procedure performed was ankle arthrodesis in 94 patients (25.9%). Other procedures performed included hindfoot fusion, 1st metatarsophalangeal joint arthrodesis, 5th metatarsal intramedullary screw fixation, hallux valgus correction, osteochondral lesion of the talus repair and unicameral talar cyst resection. The osseous union rate in the ankle and hindfoot arthrodesis cohort, base of the 5th metatarsal cohort, and calcaneal fracture cohort was 85.6%, 100%, and 100%, respectively. The weighted mean visual analog scale in the osteochondral lesions of the talus cohort improved from a pre-operative score of 7.6 ± 0.1 to a post-operative score of 0.4 ± 0.1. The overall complication rate was 27.2%, the most common of which was non-union (8.8%). There were 43 failures (10.8%) all of which warranted a further surgical procedure.

CONCLUSION

This current systematic review demonstrated that the utilization of DBM in foot and ankle surgical procedures led to satisfactory osseous union rates with favorable wound complication rates. Excellent outcomes were observed in patients undergoing fracture fixation augmented with DBM, with mixed evidence supporting the routine use of DBM in fusion procedures of the ankle and hindfoot. However, the low LOE together with the low QOE and significant heterogeneity between the included studies reinforces the need for randomized control trials to be conducted to identify the optimal role of DBM in the setting of foot and ankle surgical procedures.

Second-Look Needle Arthroscopy After Prior Surgical Treatment for Cartilage Lesions of the Ankle: The Amsterdam and New York City Perspectives

OBJECTIVE

The purpose of this prospective study was to evaluate the quality of the reparative cartilage during second-look needle arthroscopy following talar osteoperiostic grafting from the iliac crest (TOPIC) or autologous osteochondral transplantation (AOT) procedure for the management of large osteochondral lesions (OCLs) of the talus.

DESIGN

Prospective case series.

METHODS

Patients who underwent second-look needle arthroscopy following either TOPIC or AOT procedure were prospectively recruited when they needed a second look. The primary outcome was the assessment of the quality of the reparative cartilage via second-look needle arthroscopy scored by the International Cartilage Repair Society (ICRS) score. The secondary outcomes were the number and nature of needle arthroscopy interventions and complications associated with these interventions.

RESULTS

Five patients underwent second-look needle arthroscopy following TOPIC procedure and 11 patients underwent second-look in-office needle arthroscopy following AOT. The mean ICRS in the TOPIC cohort was 9.4 ± 1.0 at a mean time of 24.4 months following the index procedure. The mean ICRS in the AOT cohort was 10.6 ± 1.3 at a mean time of 58.8 months following the index procedure. No complications were observed in either cohort.

CONCLUSION

This study demonstrated that TOPIC and AOT lead to adequate-looking quality reparative cartilage at short-term to mid-term follow-ups. However, further studies with larger patient cohorts and longer follow-ups are warranted. Furthermore, second-look needle arthroscopy is a safe and viable minimally invasive procedure that can effectively evaluate the quality of reparative cartilage following surgical intervention for OCLs of the talus.

Assessment of the Monocyte Subpopulations and M1/M2 Macrophage Ratio in Concentrated Bone Marrow Aspirate

OBJECTIVE

The purpose of this study was to determine the M1/M2 macrophage ratio in concentrated bone marrow aspirate (cBMA) in patients undergoing surgical intervention augmented with cBMA for osteochondral lesions of the talus (OLTs).

DESIGN

Samples of peripheral blood (PB), bone marrow aspirate (BMA), and cBMA were collected during the procedure. The samples were analyzed by automated cell counting and multicolor fluorescence-activated cell sorting with specific antibodies recognizing monocytes (CD14+ CD16+) and the M1 (CD86+) and M2 (CD163+CD206+) populations within that monocyte population. Cytokine concentrations within the samples were evaluated with enzyme-linked immunosorbent assay (ELISA). The composition of cBMA was compared between 2 commercially available BMA concentration systems.

RESULTS

Thirty-eight patients with a mean age of 43.2 ± 10.1 years old undergoing a surgical procedure for the treatment of OLTs involving the use of cBMA were included. cBMA had a mean fold increase of 4.7 for all white blood cells, 6.1 for monocytes, 7.9 for lymphocytes, 2.4 for neutrophils, and 9.6 for platelets when compared to BMA. The mean M1/M2 ratio for PB, BMA, and cBMA was 15.2 ± 12.0, 20.8 ± 13.3, and 22.1 ± 16.0, respectively. There was a statistically significant higher concentration of interleukin-1 receptor antagonist (IL-1Ra) in the cBMA sample (8243.3 ± 14,837.4 pg/mL) compared to both BMA (3143.0 ± 2218.5 pg/mL) and PB (1847.5 ± 1520.4 pg/mL) samples. The IL-1Ra/IL-1β ratio for PB, BMA, and cBMA was 790.6 ± 581.9, 764.7 ± 675.2, and 235.7 ± 192.1, respectively. There was no difference in the cBMA M1/M2 ratio (19.0 ± 11.1 vs 24.0 ± 18.3) between the Magellan (Isto Biologics, Hopkinton, Massachusetts) and Angel systems (Arthrex Inc, Naples, Florida).

CONCLUSION

This prospective study found that the M1/M2 ratio in cBMA was 22.1 ± 16.0, with significant patient to patient variation observed. Overall, there was no statistically significant difference in the M1/M2 ratio across PB, BMA, and cBMA samples. This is the first study to characterize the macrophage subpopulation within cBMA, which may have significant clinical implications in future studies.

Visualized trends and bibliometric analysis in ankle cartilage repair from 2004 to 2024

Ankle cartilage injuries are a common sports-related condition that significantly impairs patients' daily activities and imposes substantial economic burdens on both families and society. Effective cartilage repair strategies are crucial to addressing this pathological condition. Current conservative treatments include muscle strengthening, use of ankle braces, physical therapy, and the administration of NSAIDs. In cases of severe injury, surgical interventions such as osteophyte resection and cartilage transplantation may be necessary. However, the inherent regenerative capacity of articular cartilage is limited, and conventional treatments are insufficient to promote cartilage regeneration and repair. Consequently, innovative therapies such as stem cell therapy, exosome therapy, and cartilage regeneration scaffolds are prioritized for future development. In recent years, significant progress has been made in ankle cartilage repair. While bibliometric studies on cartilage repair exist, specific analyses focused on ankle cartilage repair are lacking. This study aims to address this gap by conducting a bibliometric analysis of 131 articles published over the past two decades, highlighting development trajectories, research hotspots, and evolutionary trends through knowledge mapping. Our findings indicate growing global interest, with the United States leading in international collaboration, funding, publication output, and citation frequency. Foot & Ankle International emerges as the leading journal for publication and dissemination in this field, with Kerkhoffs GMMJ identified as the most influential author. Notable hotspot keywords include "osteochondral lesions" and "platelet-rich plasma." By highlighting critical research hotspots and collaboration patterns, this study not only enriches the existing literature on ankle cartilage repair but also serves as a foundational resource for clinicians and researchers aiming to develop innovative strategies for improving patient outcomes. Furthermore, our findings underscore the necessity of interdisciplinary collaboration in advancing the understanding and treatment of ankle cartilage injuries. Ultimately, the visual characterization of these trends provides valuable insights into the field's evolutionary trajectory, offering guidelines for future research directions and encouraging further exploration of this promising area.

Outcomes Following Autologous Osteochondral Transplantation for Osteochondral Lesions of the Talus at 10-Year Follow-Up: A Retrospective Review

OBJECTIVE

The purpose of this study was to evaluate outcomes following autologous osteochondral transplantation (AOT) for the treatment of osteochondral lesions of the talus (OLT) at a minimum of 10-year follow-up.

DESIGN

Retrospective chart review identified patients who underwent AOT for the treatment of OLT. Pre-operative magnetic resonance imaging (MRI) scans were obtained in all patients. Clinical outcomes assessed included: pre- and post-operative foot and ankle outcome score (FAOS), visual analog scale (VAS), patient satisfaction, complications, failures and secondary surgical procedures.

RESULTS

Thirty-nine patients with a mean lesion size was 122.3 ± 64.1 mm2 and mean follow-up time of 138.9 ± 16.9 months were included. The mean FAOS scores improved from a preoperative score of 51.9 ± 16.0 to 75.3 ± 21.9 (P < 0.001). Increasing lesion size was variable associated with inferior FAOS scores (R2 = 0.2228). There was statistically significant higher mean T2 relaxation values at the superficial layer at the site of the AOT graft (42.9 ± 5.2 ms) compared to the superficial layer of the adjacent native cartilage (35.8 ± 3.8 ms) (P < 0.001). Seventeen complications (43.6%) were observed, the most common of which was anterior ankle impingement (25.6%). There were 2 failures (5.1%), both of which had a history of prior bone marrow stimulation via microfracture and post-operative cysts identified on MRI.

CONCLUSION

This retrospective review found that AOT for the treatment of large OLTs produced a 94.9% survival rate at a minimum of 10-year follow-up. Increasing lesion size was associated with inferior clinical outcomes. The findings of this study indicates that AOT is a viable long-term surgical strategy for the treatment of large OLTs.

Lesion Size Location Dependency on Maximum Pressure in Osteochondral Defects: Experiments and Finite-Element Analysis

Background

Osteochondral defects (OCDs) in the knee joint have significant clinical implications, particularly regarding contact pressures and pressure distribution. Understanding how these factors are influenced by defect size and location is crucial for developing effective therapeutic strategies.

Purpose/Hypothesis

The purpose of this study was to investigate the impact of defect size and location on contact pressures and pressure distribution in the knee joint. It was hypothesized that an increase in defect size would result in elevated contact pressures and alterations in pressure distribution, with specific variations related to defect location.

Study Design

Descriptive laboratory study.

Methods

The study utilized 6 cadaveric knees, including the patella and fibula, subjected to controlled compressive loading for measuring contact pressures. Simultaneously, computed tomography-based models were created for finite-element analysis (FEA) to investigate the impact of varying defect sizes and locations on contact pressures and pressure distribution in the knee joint, excluding the patellofemoral joint. The study employed analysis of variance to assess contact pressure and defect size association. Comparison between medial and lateral femoral condyles at full extension and 30° flexion angle was performed, followed by post hoc testing. Fisher exact test analyzed peak pressure point location and defect size, categorizing them into medial and lateral.

Results

An increase in defect size corresponded with heightened contact pressures on both medial and lateral femoral condyles at full extension (P = .013 for medial and P = .024 for lateral). However, this correlation did not yield significant differences at 30° of flexion (P = .674 for medial and P = .333 for lateral). During mechanical testing, the highest pressures occurred near 5 mm defect dimensions. FEAs showed a significant increase in pressure and circumferential-edge stress with 7-mm defects. Peak contact pressure points shifted laterally with more significant defects.

Conclusion

Our study demonstrated the impact of defect size, location, and alignment on knee joint contact pressures. Intervening promptly with defects exceeding 3 mm is crucial, as significant stress levels manifest beyond this threshold. Significant increases in contact pressures were noted with larger defect sizes, particularly between 3 and 10 mm at full extension. Peak pressure points shifted with defect size increments, and alignment variations showed minimal stress variation at 30° compared with 0°. FEA validated increasing contact pressures up to 7 mm defect size, beyond which pressures stabilized or slightly decreased. A concentrated pressure distribution on the medial side was observed. These findings inform our understanding of the biomechanical implications of OCDs.

Clinical Relevance

In the field of sports medicine, this research offers valuable insights to clinicians and researchers, elucidating key factors influencing knee joint health and the potential consequences of OCDs.

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

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

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.