Comparison of Functional and Radiographic Outcomes of Talar Osteochondral Lesions Repaired With Micronized Allogenic Cartilage Extracellular Matrix and Bone Marrow Aspirate Concentrate vs Microfracture

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

II.

Bone Marrow Aspirate Concentrate Improves Outcomes in Adults With Osteochondral Dissecans of the Talus and Achilles Rupture

PURPOSE

The objective of this systematic literature review was to investigate the effects of the clinical application of bone marrow aspirate (BMA) and/or bone marrow aspirate concentrate (BMAC) in tendon and cartilage injuries in the foot and ankle.

METHODS

A search of the Embase, MEDLINE/PubMed, CINAHL, and Cochrane databases was performed in January 2021. The risk of bias of the studies was assessed using the tool "A Cochrane Risk of Bias Assessment Tool for Non-Randomized Studies." The outcomes analyzed included pain reduction and functional improvement with the use of BMA/BMAC in patients with tendon and cartilage injuries in the foot and ankle.

RESULTS

Eleven studies met the inclusion criteria for analysis, involving a total of 527 subjects with osteochondral lesions (OCLs) of the talus, cartilage lesions of the talus, and acute Achilles tendon rupture. BMAC was applied alone in 4 studies, and in 7 studies, it was compared with other techniques such as matrix-induced autologous chondrocyte implantation, particulate juvenile articular cartilage, or microfracture. Interventions demonstrated improved function and reduced foot and ankle pain and showed no serious adverse effects.

CONCLUSIONS

Evidence indicates that BMAC provides good clinical results, with improved function and reduced pain in adults with OCL and cartilage lesions of the talus and acute Achilles tendon rupture.

LEVEL OF EVIDENCE

Level IV, systematic review of level II to IV studies.

Autologous Costal Cartilage Grafting for a Large Osteochondral Lesion of the Femoral Head: A 1-Year Single-Arm Study with 2 Additional Years of Follow-up

BACKGROUND

There is currently no ideal treatment for osteochondral lesions of the femoral head (OLFH) in young patients.

METHODS

We performed a 1-year single-arm study and 2 additional years of follow-up of patients with a large (defined as >3 cm 2 ) OLFH treated with insertion of autologous costal cartilage graft (ACCG) to restore femoral head congruity after lesion debridement. Twenty patients ≤40 years old who had substantial hip pain and/or dysfunction after nonoperative treatment were enrolled at a single center. The primary outcome was the change in Harris hip score (HHS) from baseline to 12 months postoperatively. Secondary outcomes included the EuroQol visual analogue scale (EQ VAS), hip joint space width, subchondral integrity on computed tomography scanning, repair tissue status evaluated with the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score, and evaluation of cartilage biochemistry by delayed gadolinium-enhanced magnetic resonance imaging of cartilage (dGEMRIC) and T2 mapping.

RESULTS

All 20 enrolled patients (31.02 ± 7.19 years old, 8 female and 12 male) completed the initial study and the 2 years of additional follow-up. The HHS improved from 61.89 ± 6.47 at baseline to 89.23 ± 2.62 at 12 months and 94.79 ± 2.72 at 36 months. The EQ VAS increased by 17.00 ± 8.77 at 12 months and by 21.70 ± 7.99 at 36 months (p < 0.001 for both). Complete integration of the ACCG with the bone was observed by 12 months in all 20 patients. The median MOCART score was 85 (interquartile range [IQR], 75 to 95) at 12 months and 75 (IQR, 65 to 85) at the last follow-up (range, 24 to 38 months). The ACCG demonstrated magnetic resonance properties very similar to hyaline cartilage; the median ratio between the relaxation times of the ACCG and recipient cartilage was 0.95 (IQR, 0.90 to 0.99) at 12 months and 0.97 (IQR, 0.92 to 1.00) at the last follow-up.

CONCLUSIONS

ACCG is a feasible method for improving hip function and quality of life for at least 3 years in young patients who were unsatisfied with nonoperative treatment of an OLFH. Promising long-term outcomes may be possible because of the good integration between the recipient femoral head and the implanted ACCG.

LEVEL OF EVIDENCE

Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Limited evidence of adjuvant biologics with bone marrow stimulation for the treatment of osteochondral lesion of the talus: a systematic review

PURPOSE

To evaluate the complication rates, continuous functional outcome scores, and return to play data following bone marrow stimulation (BMS) versus biologics ± BMS for the treatment of osteochondral lesion of the talus (OLT).

METHODS

A systematic review was performed. The PubMed and Embase databases were searched using specific search terms and eligibility criteria according to the PRISMA guidelines. The level of evidence was assessed using published criteria by The Journal of Bone & Joint Surgery, and the quality of evidence using the Modified Coleman Methodology Score. Continuous variables were presented as mean ± standard deviation and categorical variables as frequencies (percentages).

RESULTS

BMS versus BMS + hyaluronic acid (HA): no complications in either treatment arm were reported. The mean American Orthopaedic Foot and Ankle Society score was 43.5 to 67.3 points and 44.0 to 72.4 points, respectively. The mean 10 mm Visual Analogue Scale pain score was 7.7 to 3.8 points and 7.5 to 2.5 points, respectively. BMS versus BMS + concentrated bone marrow aspirate (CBMA): the pooled overall complication rate was 17/64 (26.6%) versus 11/71 (15.5%), respectively (non-significant). The pool revision rate was 15/64 (23.4%) versus 6/71 (8.5%), respectively (p = 0.016). There has been a notable poor reporting of complication rates for the use of ADSC and PRP as adjuvant biological therapies to BMS for the treatment of OLT.

CONCLUSION

There was an overall limited comparative clinical evidence of adjuvant biologics with BMS versus BMS alone for the treatment of OLT. BMS + HA and BMS + CBMA can provide superior outcomes, albeit the currently limited evidence. Further studies are warranted to establish the true clinical superiority of the various biologics ± BMS versus BMS alone. These studies must also compare the various biologics against one another to determine, if any, the optimal biologic for OLT. Clinicians should counsel patients accordingly on these findings as required.

LEVEL OF EVIDENCE

Level III.

Radiographic and Clinical Outcomes After Arthroscopic Microfracture for Osteochondral Lesions of the Talus: 5-Year Results in 355 Consecutive Ankles

Background:

Arthroscopic microfracture for osteochondral lesion of the talus (OLT) has shown good functional outcomes in the short and long term.

Purpose:

To investigate 5-year radiographic and clinical outcomes after arthroscopic microfracture in treatment of OLT and the effectiveness of adjunct therapies including platelet-rich plasma (PRP) and hyaluronic acid (HA).

Study Design:

Cohort study; Level of evidence, 2.

Methods:

We prospectively enrolled 432 patients who underwent arthroscopic microfracture for OLT from May 1, 2011, to May 31, 2015. Magnetic resonance imaging (MRI) and weightbearing radiographs were performed annually after the initial surgery. The MOCART (magnetic resonance observation of cartilage repair tissue) score was used to evaluate the structure of the repaired cartilage on MRI, and patient-reported outcomes (American Orthopaedic Foot and Ankle Society ankle-hindfoot scale [AOFAS] and the Foot and Ankle Outcome Score) were collected annually. The primary outcome measure was 5-year AOFAS score. We recorded baseline characteristics including age, body mass index (BMI), and lesion size, and other potentially related factors including number of PRP/HA injection and change in BMI from baseline.

Results:

Included were 355 patients, all with minimum 5-year follow-up data. The overall reoperation rate was 9.0% (32 of 355). According to multivariable analysis, 5-year AOFAS scores were associated with number of PRP injections (correlation coefficient, 3.12 [95% CI, 2.36 to 3.89]; P < .001), BMI at baseline (correlation coefficient, -0.222 [95% CI, -0.363 to -0.082]; P = .002), and mean BMI change from baseline (correlation coefficient, -1.15 [95% CI, -1.32 to -0.98]; P < .001). When comparing number of PRP injections (0, 1-2, or ≥3), we found that patients who had serial PRP injection (≥3 with at least a 3-month interval between injections) had diminished functional and radiographic deterioration over time.

Conclusion:

Arthroscopic microfracture improved patient-reported and structural outcomes for patients with OLT at 5 years after surgery. Serial PRP injections and reduction in BMI from baseline were able to slow radiographic and functional deterioration. Future trials regarding the combination of microfracture and PRP in treatment of OLT should focus on the efficacy of longer term, intra-articular, serial injections of PRP instead of single injections.

Augmenting Osteochondral Autograft Transplantation and Bone Marrow Aspirate Concentrate with Particulate Cartilage Extracellular Matrix Is Associated With Improved Outcomes

BACKGROUND

Osteochondral autograft transplant (OAT) is often used to treat large osteochondral lesions of the talus and is generally associated with good outcomes. The addition of adjuncts such as cartilage extracellular matrix with bone marrow aspirate concentrate (ECM-BMAC) may further improve the OAT procedure but have not been thoroughly studied. We hypothesized that the placement of ECM-BMAC around the OAT graft would improve radiographic and patient-reported outcomes following OAT.

METHODS

Patients who received OAT, with ECM-BMAC or BMAC alone, were screened and their charts were reviewed. For patients who did receive ECM-BMAC, the mixture was spread around the edges of the OAT plug and into any surrounding areas of cartilage damage. Survey and radiographic data were collected. Average follow-up in both groups was over 2 years. Magnetic resonance imaging scans were scored using the Magnetic Resonance Observation of Cartilage Tissue (MOCART) system. Outcomes were compared statistically between groups.

RESULTS

Patients treated with ECM-BMAC (n = 34) demonstrated significantly greater improvement of scores in the FAOS categories Symptoms (17 vs -3; P = .02) and Sports Activities (40 vs 7; P = .02), and the MOCART category Subchondral Lamina (P = .008) compared to those treated with BMAC alone (n = 30). They also experienced significantly lower rates of postoperative cysts (53% vs 18%, P = .04) and edema (94% vs 59%, P = .02).

CONCLUSION

The addition of ECM-BMAC to OAT was associated with improved imaging and clinical outcomes compared to OAT with BMAC alone.

Ankle Instability

Ankle sprains are a common injury among physically active populations and occur with an incidence of around 2.15 per 1000 person-years. This article discusses various surgical procedures used to treat chronic lateral ankle instability, including direct ligament repair, anatomic reconstruction, and nonanatomic reconstruction. We focus our discussion on the most common and challenging complications of ankle stabilization, both in our experience and as supported by the existing literature, including recurrent instability, superficial peroneal nerve injury, and unaddressed pathology that continues to cause symptoms and limit function. We offer possible methods to manage these conditions as well as available outcome data.

Osteochondral Lesions of the Ankle Treated with Bone Marrow Concentrate with Hyaluronan and Fibrin: A Single-Centre Study

Osteochondral defects of the ankle (OCD) are being increasingly identified as a clinically significant consequence of injury to the ankle, with the potential to lead to osteoarthritis if left untreated. The aim of this retrospective cohort study was to evaluate a single-stage treatment of OCD, based on bone marrow aspirate (BMA) centrifuged to produce bone marrow concentrate (BMC). In a dual syringe, the concentrate was mixed with thrombin in one syringe, whereas hyaluronan and fibrinogen were mixed in a second syringe. The two mixtures were then injected and combined into the prepared defect. Clinical outcome and quality of life scores (MOXFQ and EQ-5D) were collected at baseline and yearly thereafter. Multilevel models were used to analyse the pattern of scores over time. Ninety-four patients were treated between 2015 and 2020. The means of each of the three components of the MOXFQ significantly improved between baseline and 1 year (p < 0.001 for each component), with no further change from year 1 to year 3. The EQ-5D index also improved significantly from baseline to 1 year, with no evidence for further change. Our results strongly indicate that this BMC treatment is safe for, and well tolerated by, patients with OCD of the ankle as both primary treatment and those who have failed primary treatment. This technique provides a safe, efficacious alternative to currently employed cartilage repair techniques, with favourable outcomes and a low complication rate at 36 months.

Higher preoperative range of motion is predictive of good mid-term results in the surgical management of osteochondral lesions of the talus: a prospective multicentric study

INTRODUCTION

Osteochondral lesions of the talus (OLT) are a frequent cause of pain in young patients and a new CT arthrographic classification system of OLT was recently proposed to help guide the choices of and standardize the indications for surgical treatment. The primary hypothesis was that this algorithm would result in a postoperative AOFAS score of ≥ 80/100. The secondary hypothesis was to identify the preoperative factors of successful surgery.

METHODS

This was a prospective observational multicenter study. Eighty-six patients who underwent surgery for OLT after at least 6 months of unsuccessful conservative management were included for a mean follow-up of 15 months (12-36). Forty-nine patients with stage 1 OLT underwent microperforation, 2 patients with stage 2 OLT underwent a lift, drill, fill, and fix graft procedure with screw fixation, and 35 patients with stage 3 OLT were treated with mosaicplasty.

RESULTS

After a follow-up of at least 1 year, 56 patients (65%) had an AOFAS score > 80 and the mean AOFAS score was 82 (16-100). A lower BMI (p = 0.038), a higher preoperative range of motion in the ankle (p = 0.033), higher preoperative AOFAS and FAOS scores (p = 0.001 and p = 0.011), and the presence of a preoperative bone bruise on MRI (p = 0.020) were good prognostic factors on univariate analysis. The presence of grade 1 osteoarthritis on the Van Dijk classification was predictive of a poor prognosis (p = 0.044). Multivariate analysis showed that a good preoperative range of motion (OR = 1.080 [1.020-1.150] p = 0.01) was predictive of a positive outcome, while grade 1 osteoarthritis was predictive of a poor outcome (OR = 0.147 [0.036-0.603] p = 0.008). The postoperative AOFAS decreased in six patients and 17 patients had at least one complication: six dysthesias of the superficial fibular nerve, two of the sural nerve, and nine stage 1 complex regional pain syndromes.

CONCLUSION

The new algorithm for OLT resulted in a postoperative AOFAS score of ≥ 80/100 in 65% of cases. The positive predictive factors of a successful postoperative outcome were the presence of a good preoperative range of motion and the absence of preoperative osteoarthritis.

LEVEL OF EVIDENCE

Level II.