Donor-site morbidity after osteochondral autologous transplantation for lesions of the talus

Improved Results From Medium- and Long-Term Outcomes of Autogenous Osteoperiosteal Grafting for Large Cystic Lesions of the Talus

PURPOSE

To investigate the medium and long-term follow-up outcomes of large cystic medial osteochondral lesions of the talus (OLTs) treated with autologous tibial osteoperiosteal grafts from the medial tibia and to explore the risk factors influencing the treatment outcomes.

METHODS

The retrospective study included 75 patients with large cystic medial OLTs who underwent autologous osteoperiosteal cylinder graft taken from the medial tibia between January 2004 and August 2018. They were assessed preoperatively and postoperatively using a visual analog scale, the Orthopedic Foot & Ankle Society Ankle-Hindfoot Scale (AOFAS), and short-form 36-item Short Form Health Survey score. Magnetic resonance observation of cartilage repair tissue, second-look arthroscopy, and biopsy were used to evaluate the grafting areas.

RESULTS

After a follow-up period of 6.3 years, the virtual analog scale score decreased to 1.47 ± 1.32, and the AOFAS and 36-item Short Form Health Survey scores increased to 82.78 ± 11.65 and 83.26 ± 8.49, respectively, all of which showed significant improvement over preoperative scores (P < .001), and the average magnetic resonance observation of cartilage repair tissue score was 82.6 ± 8.4 (56.0-91.6). Eight patients underwent a second-look arthroscopic examination and were rated by the International Cartilage Repair Society scale; of them, 2 patients were rated grade Ⅰ, 4 were rated grade Ⅱ, and 2 were rated grade Ⅲ. Three patients underwent grafting area biopsy during the second-look arthroscopy, and the results showed that the grafting areas were rich in chondrocytes. Large OLTs (≥200 mm2) and obesity (body mass index ≥25) were responsible for the poor improvement of AOFAS score, according to multivariate Cox regression analysis.

CONCLUSIONS

Autologous osteoperiosteal grafting was an effective treatment for large cystic medial OLTs, with effective cartilage regeneration in the grafted areas in the medium and long term. However, the large OLTs and obesity may reduce the treatment outcomes.

LEVEL OF EVIDENCE

Level IV, case series.

Surface morphology of osteochondral grafts harvested from femoral condyles with free-hand technique: a cadaveric study

PURPOSE

The purpose of this cadaver study was to examine the surface morphology of the osteochondral grafts harvested from the femoral condyles using the free-hand graft harvesting technique.

MATERIALS AND METHODS

One hundred osteochondral grafts were harvested with 6.5 mm chisels at ten different donor sites using the free-hand technique in five paired knee specimens (Mean age: 56.4 years). The cartilage and subchondral bone surface angles were measured through multiplanar reconstruction computerized tomography examination. The cartilage thickness was measured with a MicroScribe G2X digitizer with an accuracy of 0.02 mm. An acceptable congruity could be obtained when these plugs were transferred to a perpendicular socket (articular step-off of less than 1 mm and 0.5 mm) was evaluated.

RESULTS

Four plugs were damaged or broken during harvesting due to technical difficulties; thus remaining 96 plugs were analyzed. The cartilage thickness varied between 1.36 mm and 3.26 mm across the donor sites. The cartilage was the thinnest in the medial intercondylar notch and thickest in the lateral supracondylar notch. Twenty of ninety-six plugs (20.8%) had unacceptable cartilage surface inclination according to the > 0.5 mm protrusion criteria. Of these plugs, 14 were harvested from the lateral intercondylar notch, whereas five of 96 plugs (5.2%) had unacceptable cartilage surface inclination according to the > 1 mm protrusion criteria. Of these plugs, all were harvested from the lateral intercondylar notch.

CONCLUSIONS

High rates of unacceptable plugs (up to 100%) might be harvested from the lateral intercondylar notch. In large chondral lesions that require multiple plugs, lateral and medial supracondylar ridges were the best donor sites for perpendicular plug harvesting, whereas lateral intercondylar notch should be avoided.

Talar OsteoPeriostic Grafting from the Iliac Crest (TOPIC): Two-Year Prospective Results of a Novel Press-Fit Surgical Technique for Large, Complex Osteochondral Lesions of the Medial Talus

BACKGROUND

Press-fit Talar OsteoPeriostic grafting from the Iliac Crest (TOPIC) is a novel technique for the treatment of large osteochondral lesions of the talus. The purpose of the present study was to prospectively evaluate the 2-year clinical outcomes for patients with medial osteochondral lesions of the talus that were treated with the TOPIC procedure.

METHODS

Forty-three patients were prospectively assessed before and 24 months after the TOPIC procedure. All procedures were performed through a medial distal tibial osteotomy. Clinical assessment preoperatively and at 24 months of follow-up included determination of the Numeric Rating Scale (NRS) scores for pain during walking (primary outcome), at rest, during running, and during stair-climbing. The Foot and Ankle Outcome Score (FAOS) and the Mental Component Summary (MCS) score and Physical Component Summary (PCS) score of the Short Form-36 (SF-36) were also assessed. A computed tomography (CT) scan was performed 12 weeks postoperatively to assess union of the distal tibial osteotomy site and at 1 and 2 years postoperatively to assess consolidation of the graft as well as cyst development in the graft.

RESULTS

All enrolled patients were available for follow-up. The median NRS score for pain during walking improved from 7 points preoperatively to 2 points at 2 years postoperatively (p < 0.001). All other NRS scores for pain improved significantly. All FAOS subscale scores improved significantly, including those for pain (from 53 to 75), symptoms (from 50 to 61), activities of daily living (from 68 to 88), sports (from 30 to 55), and quality of life (from 19 to 38). The SF-36 PCS score improved from 43 to 48 (p < 0.001), and the MCS score changed from 28 to 26 (p > 0.05). There was a 100% rate of union of the osteotomy site at the distal tibia and 100% of the grafts showed consolidation at 1 and 2 years postoperatively.

CONCLUSIONS

The TOPIC procedure for large osteochondral lesions of the medial talar dome is an effective technique that resulted in significant improvement exceeding the minimal clinically important difference in pain scores (primary outcome) as well as in other outcomes, with 100% consolidation of the grafts.

LEVEL OF EVIDENCE

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

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.

Autologous Osteoperiosteal Transplantation for the Treatment of Large Cystic Talar Osteochondral Lesions

OBJECTIVE

The effectiveness of autologous osteoperiosteal transplantation (AOPT) for the treatment of large cystic talar osteochondral lesions (OCLs) should be further evaluated, and the postoperative cartilage coverage is questionable. The purpose of this retrospective observational study was to investigate the clinical outcomes of AOPT for the treatment of large cystic talar OCLs and to report second-look arthroscopic results.

METHODS

From June 1, 2017, to June 1, 2021, all talar OCLs at our center were reviewed. Painful cystic lesions treated with AOPT were included in the study. The American Orthopaedic Foot and Ankle Society (AOFAS; 0-100 points) ankle-hindfoot score, Foot Function Index (FFI; 0-100 points), visual analog scale (VAS; 0-10 points) score, and Tegner score (0-10 points) were used to describe pain and functional outcomes. Furthermore, complications, patient-reported satisfaction degrees, imaging results (including computed tomography and magnetic resonance), and second-look arthroscopic evaluation data were also collected for analysis.

RESULTS

A total of 29 cases were eligible for the study, and 26 responded to the latest follow-up request, with a mean follow-up duration of 30.2 (range, 12-57) months. The AOFAS score improved from 69.2 ± 10.9 preoperatively to 80.9 ± 10.0 at the latest follow-up (p = 0.000). The FFI score improved from 30.4 ± 18.4 preoperatively to 16.3 ± 14.0 at the latest follow-up (p = 0.000). The VAS pain score improved from 4.0 ± 2.1 preoperatively to 2.5 ± 2.0 at the latest follow-up (p = 0.001). No donor site morbidity was found. The mean postoperative MOCART score was 57.7 ± 9.5. Second-look arthroscopy showed a fibrillated cartilage-like surface at the lesion site in most cases, while two cases exhibited a nearly normal surface.

CONCLUSION

The transplantation of osteoperiosteal cylinder autografts taken from the iliac crest for the treatment of large cystic talar OCLs yielded acceptable clinical results. Good integration of the bony part was observed, but cartilage regeneration remained uncertain.

Clinical and MRI Donor-Site Outcomes After Autograft Harvesting From the Medial Trochlea for Talar Osteochondral Lesions: Minimum 5-Year Clinical Follow-up

Background:

Autologous osteochondral transplantation (AOT) is a treatment option for large or cystic osteochondral lesions of the talus (OLTs), with promising clinical results. However, donor-site morbidity (DSM) has always been a concern with this procedure.

Purpose:

To investigate the clinical and radiological outcomes of autograft harvesting from the medial trochlea for OLTs.

Study Design:

Case series; Level of evidence, 4.

Methods:

A total of 46 consecutive patients were included after AOT procedures for OLTs, with donor autografts (single or double plugs) harvested from the medial trochlea of the ipsilateral knee. Lysholm scores were collected postoperatively at 12-month intervals to assess clinical outcomes. Postoperative magnetic resonance imaging (MRI) was used to assess the donor site using the MOCART (magnetic resonance observation of cartilage repair tissue) score. DSM was evaluated at 12-month intervals. Statistical analysis was performed to compare patients treated with single-plug and double-plug AOT procedures and establish whether there was any correlation between MOCART and Lysholm scores.

Results:

The mean follow-up period was 98.3 months (range, 67-144 months). The Lysholm scores for all patients were 92.5 ± 6.1 and 99.9 ± 0.2 at the 12-month and final follow-ups, respectively. MRI of the donor sites was taken at an average of 93.8 ± 20.5 (range, 61-141) months postoperatively, and the mean MOCART score was 76.2 ± 4.9. The overall incidence of DSM in this study was 4.3% at 12 months, postoperatively, which decreased to 0% at the 24-month follow-up. There was no significant difference in either the Lysholm score (P = .16) or the MOCART score (P = .83) between the single-plug and double-plug groups at the final follow-up. There were no significant correlations between MOCART and Lysholm scores and patient age, number of grafts, or body mass index.

Conclusion:

According to the study findings, the DSM of donor autografts harvested from the medial trochlea was low, and the number (single or double) of grafts did not affect the functional outcome.

Autologous osteochondral transplantation for focal femoral condyle defects: Comparison of mosaicplasty by arthrotomy vs. arthroscopy

BACKGROUND

While many studies have reported the outcomes of open mosaicplasty, data on arthroscopic mosaicplasty are scarce. Only two cadaver studies have compared arthrotomy and arthroscopy. Moreover, the patello-femoral joint, which is the main donor site, has never been assessed using a specific functional score. The objective of this in vivo study was to compare arthrotomy and arthroscopy for mosaicplasty using both a global functional knee score and a specific score of the patello-femoral joint.

HYPOTHESIS

The arthroscopic technique results in better functional patello-femoral outcomes.

MATERIAL AND METHODS

We retrospectively compared two groups of 17 patients who underwent mosaicplasty for focal condylar cartilage defects, at our department between 2009 and 2019. Functional outcomes were assessed using the Kujala score and the Lysholm score, at least 1 year after surgery. The return to sports was assessed using the Tegner score.

RESULTS

Mean follow-up was 67.4±15.9 months in the arthrotomy group and 45.2±35.1 months in the arthroscopy group (p<0.01). Cartilage defect size was similar in the two groups (arthrotomy: 1.21±0.91cm²; arthroscopy: 0.92±1.23cm²; p=0.052). The mean Kujala score was 85±21.3 in the arthrotomy group and 91.9±13.7 in the arthroscopy group (p=0.064). The mean Lysholm score was 83.9±19.8 with arthrotomy and 89.5±14.9 with arthroscopy (p=0.1). The Kujala score was greater than 95 in 4 (26%) arthrotomy patients and 13 (81%) arthroscopy patients (p=0.003). The Lysholm score was higher than 95 in 4 (26%) arthrotomy patients and 12 (75%) arthroscopy patients (p=0.012). No patient underwent surgical revision for autograft failure.

DISCUSSION

This is the first clinical study comparing arthrotomy and arthroscopy for mosaicplasty. Clinical outcomes were good with both techniques. The proportion of patients with excellent Lysholm and Kujala functional scores was significantly higher in the arthroscopy group than in the arthrotomy group. This result may be ascribable to decreased donor-site morbidity obtained with arthroscopy.

LEVEL OF EVIDENCE

IV, retrospective observational comparative study.

Outcomes of Bone Marrow Stimulation for Secondary Osteochondral Lesions of the Talus Equal Outcomes for Primary Lesions

OBJECTIVE

To compare clinical, sports, work, and radiological outcomes between primary and secondary osteochondral lesions of the talus (OLTs; <15 mm) treated with arthroscopic bone marrow stimulation (BMS).

DESIGN

Secondary OLTs were matched to primary OLTs in a 1:2 ratio to assess the primary outcome measure-the Numeric Rating Scale (NRS) during activities. Secondary outcomes included the pre- and 1-year postoperative NRS at rest, American Orthopaedic Foot and Ankle Society score, Foot and Ankle Outcome Score subscales, and the EQ-5D general health questionnaire. The rates and time to return to work and sports were collected. Radiological examinations were performed preoperatively and at final follow-up using computed tomography (CT).

RESULTS

After matching, 22 and 12 patients with small (<15 mm) OLTs were included in the primary and secondary groups, respectively. The NRS during activities was not different between primary cases (median: 2, interquartile range [IQR]: 1-4.5) and secondary cases (median: 3, IQR: 1-4), P = 0.5. Both groups showed a significant difference between all pre- and postoperative clinical outcome scores, but no significant difference between BMS groups postoperatively. The return to sport rate was 90% for primary cases and 83% for secondary cases (P = 0.6). All patients returned to work. Lesion filling on CT was complete (67% to 100%) in 59% of primary cases and 67% of secondary cases (P = 0.6).

CONCLUSION

No differences in outcomes were observed between arthroscopic bone marrow stimulation in primary and secondary OLTs at 1-year follow-up. Repeat BMS may therefore be a viable treatment option for failed OLTs in the short term.

Long-term outcome for repair of osteochondral lesions of the talus by osteochondral autograft: A series of 56 Mosaicplasties®

INTRODUCTION

The present study analyzed results in 56 osteochondral Mosaicplasty® autografts for osteochondral lesion of the talus (OLT) at more than 5 years' follow-up.

HYPOTHESIS

Mosaicplasty® shows long-term efficacy and low morbidity in the treatment of OLT.

PATIENTS AND METHODS

A multicenter retrospective study included patients treated by Mosaicplasty® with more than 5 years' follow-up. Preoperative data were collected from medical files, and all patients were reassessed. AOFAS scores and FAOS were calculated at last follow-up. Imaging comprised standard radiographs and MRI or CT arthrography of the ankle.

RESULTS

Fifty-six patients were included, with a mean age of 34 years (range, 18-60 years). Seventeen involved work accidents. Mean follow-up was 8.5 years (range, 5-20 years). Mean AOFAS score at follow-up was 80.6±19.4 and mean FAOS 77.8±21.5. Work accident, preoperative osteoarthritis and untreated laxity correlated significantly with poorer results. At last follow-up, 22 patients (39%) showed signs of osteoarthritis. There was no morbidity implicating the malleolar osteotomy. There were 11 cases (20%) of persistent patellar syndrome at the donor site.

DISCUSSION

The present results were comparable to those reported elsewhere, showing that functional results of Mosaicplasty® autograft for OLT do not deteriorate over the long term. Work accidents correlated significantly with poorer functional outcome. Any associated instability must always be treated. Malleolar osteotomy provides good exposure without additional morbidity.

LEVEL OF EVIDENCE

IV; retrospective study.

Biological reconstruction of the joint: Concepts of articular cartilage regeneration and their scientific basis

Articular cartilage injuries are common. The diagnosis of these injuries is often delayed and may lead to early osteoarthritis. Treatment depends on many factors but mainly on the stage and size of the lesion. The anatomy of articular cartilage is complex, and it is an avascular, aneural, and alymphatic structure. Recently, more emphasis is laid on its anatomy and biomechanics to understand the regeneration process of articular cartilage.

Accessibility and Thickness of Medial and Lateral Talar Body Cartilage for Treatment of Ankle and Foot Osteochondral Lesions

BACKGROUND

The purposes of this study were to determine (1) if cartilage thicknesses on the talar dome and medial/lateral surfaces of the talus were similar, (2) whether there was sufficient donor cartilage surface area on the medial and lateral talar surfaces to repair talar dome cartilage injuries of the talus, and (3) whether the cartilage surface could be increased following anterior talofibular ligament (ATFL) and sectioning of the tibionavicular and tibiospring portion of the anterior deltoid.

METHODS

Medial and lateral approaches were utilized in 8 cadaveric ankles to identify the accessible medial, lateral, and talar dome cartilage surfaces in 3 conditions: (1) intact, (2) ATFL release, and (3) superficial anterior deltoid ligament release. The talus was explanted, and the cartilage areas were digitized with a coordinate measuring machine. Cartilage thickness was quantified using a laser scanner.

RESULTS

The mean cartilage thickness was 1.0 ± 0.1 mm in all areas tested. In intact ankles, the medial side of the talus showed a larger total area of available cartilage than the lateral side (152 mm² vs 133 mm²). ATFL release increased the available cartilage area on the medial and lateral sides to 167 mm² and 194 mm², respectively. However, only the lateral talar surface had sufficient circular graft donor cartilage available for autologous osteochondral transplantation (AOT) procedures of the talus. After ATFL and deltoid sectioning, there was an increase in available graft donor cartilage available for AOT procedures.

CONCLUSION

The thickness of the medial and lateral talar cartilage surfaces is very similar to that of the talar dome cartilage surface, which provides evidence that the medial and lateral surfaces may serve as acceptable AOT donor cartilage. The surface area available for AOT donor site grafting was sufficient in the intact state; however, sectioning the ATFL and superficial anterior deltoid ligament increased the overall lateral talar surface area available for circular grafting for an AOT procedure that requires a larger graft. These results support the idea that lateral surfaces of the talus may be used as donor cartilage for an AOT procedure since donor and recipient sites are similar in cartilage thickness, and there is sufficient cartilage surface area available for common lesion sizes in the foot and ankle.

CLINICAL RELEVANCE

This anatomical study investigates the feasibility of talar osteochondral autografts from the medial or lateral talar surfaces exposed with standard approaches. It confirms the similar cartilage thickness of the talar dome and the ability to access up to an 8- to 10-mm donor graft from the lateral side of the talus after ligament release. This knowledge may allow better operative planning for use of these surfaces for osteochondral lesions within the foot and ankle, particularly in certain circumstances of a revision microfracture.

Comparison of Clinical and Radiographic Outcomes Following Arthroscopic Debridement With Extracellular Matrix Augmentation and Osteochondral Autograft Transplantation for Medium-Size Osteochondral Lesions of the Talus

BACKGROUND

Historically, microfracture has been used to treat small talar osteochondral lesions with good results, whereas osteochondral autologous transplantation (OAT) has proven effective for the treatment of larger lesions. It is not clear which method is more effective for medium-sized lesions around the critical size of 150 mm², above which microfracture outcomes tend to be poor. The purpose of this study was to determine the potential advantages of OAT augmented with a combination of extracellular matrix and bone marrow aspirate concentrate (ECM-BMAC) compared to debridement with ECM-BMAC (DEB) in the treatment of medium-sized osteochondral lesions of the talus (OLTs).

METHODS

Clinical and radiographic data were collected retrospectively for patients treated by a single fellowship-trained foot and ankle surgeon. Magnetic resonance images (MRIs) were scored using the Magnetic Resonance Observation of Cartilage Tissue (MOCART) system and were evaluated for the presence of cysts and edema. Fifty-two patients met inclusion criteria, with 25 who received an OAT procedure. Age, body mass index, lesion size, lesion location, and follow-up time were similar between groups. Average MRI follow-up times were 16.7 months for the OAT group and 20.3 months for the DEB group (P = .38).

RESULTS

Patients treated with OAT had significantly higher average total MOCART scores (69 vs 55, P = .04) and significantly lower rates of cyst (14% vs 55%, P < .01), edema (59% vs 90%, P = .04), revision surgery (0% vs 19%, P = .05), and therapeutic injection for pain (4% vs 30%, P = .02) compared to patients treated with DEB. No significant differences were detected in patient-reported outcome scores between groups.

CONCLUSION

The native hyaline cartilage introduced by OAT appears to result in higher-quality repair tissue when compared to DEB, as evidenced by OAT patients' higher MOCART scores and lower rates of cyst and edema. There was no difference in clinical outcome scores, though OAT patients did not require revision surgery or therapeutic injection for pain as frequently as DEB patients.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Autologous osteochondral transplantation for osteochondral lesions of the talus: high rate of return to play in the athletic population

PURPOSE

(1) To determine the rate of return to play following autologous osteochondral transplantation (AOT) for osteochondral lesions of the talus (OLT) and (2) report subsequent rehabilitation protocols.

METHODS

A systematic review of the PubMed, Embase, and The Cochrane Library databases was performed according to the PRISMA guidelines based on specific eligibility criteria. Return to play data was meta-analysed and subsequent rehabilitation protocols were summarised. Level of evidence and quality of evidence (Zaman's criteria) were also evaluated.

RESULTS

Nine studies that totalled 205 ankles were included for review. The mean follow-up was 44.4 ± 25.0 (range 16-84) months. The mean OLT size was 135.4 ± 56.4 mm². The mean time to return to play was 5.8 ± 2.6 months. The mean rate of return to play was 86.3% (range 50-95.2%), with 81.8% of athletes returning to pre-injury status. Based on the fixed-effect model, the rate of return to play was 84.07%. Significant correlation was found between increase age and decrease rate of return to play (R² = 0.362, p = 0.00056). There was no correlation between OLT sizes and rate of return to play (R² = 0.140, p = 0.023). The most common time to ankle motion post-surgery was immediately and the most common time to full weight-bearing was 12 weeks.

CONCLUSIONS

This systematic review indicated a high rate of return to play following AOT in the athletic population. Size of OLT was not found to be a predictor of return to play, whereas advancing age was a predictor. Rehabilitation protocols were largely inconsistent and were primarily based on individual surgeon protocols. However, the included studies were of low level and quality of evidence.

LEVEL OF EVIDENCE

Level IV.

Osteochondral Lesions of the Talus: An Individualized Treatment Paradigm from the Amsterdam Perspective

Osteochondral lesions of the talus (OLTs) are characterized by damage to the articular cartilage of the talus and its underlying subchondral bone. Up to 75% of OLTs are caused by trauma, such as an ankle sprain or fracture. Physical examination and imaging are crucial for diagnosis and characterization of an OLT. No superior treatment for OLTs exists. It is paramount that an evidence-based personalized treatment approach is applied to patients with OLTs because lesion and patient characteristics guide treatment. This current concepts review covers clinical and preclinical evidence on OLT etiology, presentation, diagnosis, and treatment, all based on the Amsterdam perspective.

Long-term results of osteochondral autograft transplantation of the talus with a novel groove malleolar osteotomy technique

Objectives

This study aims to evaluate the long-term results of osteochondral autograft transfer (OAT) of talar lesions performed using a modified osteotomy technique.

Patients and methods

This retrospective study included 20 consecutive patients (11 males, 9 females; mean age 33.5±11 years; range, 15 to 56 years) (21 ankles) with osteochondral lesions of the talus (OLT) treated with the OAT system between August 2002 and October 2008. We performed a modified sulcus groove osteotomy, which provides better exposure of medial and central lesions. After a minimum duration of 10 years following surgery, patients’ clinical functions were evaluated according to the American Orthopaedic Foot and Ankle Society (AOFAS) ankle- hindfoot scale and visual analog scale (VAS). The Tegner-Lysholm scoring system was used to determine the levels of knee activity.

Results

The mean follow-up period was 143.5 (range, 120 to 186) months. The mean AOFAS scores significantly improved from 60.4±7.4 (range, 48 to 70) preoperatively to 86.2±9.23 (range, 60 to 94) at the last follow-up (p≤0.05). The mean ankle VAS score significantly decreased from 6.3±0.4 (range, 5 to 7) preoperatively to 2.0±1.4 (range, 0 to 4). The mean Tegner-Lysholm score for this group was 89.7±11.7 (range, 68 to 100). Revision surgery was performed in only two patients because of impingement and arthritis. Recurrent knee pain at the donor site of the osteochondral autograft was observed in three patients (14%).

Conclusion

In the present study, good to excellent results were obtained in the treatment of OLT with OAT for a minimum follow-up duration of 10 years. This novel technique can also simplify the steep learning curve, which is challenging for surgeons.

Systematic Postoperative Assessment of a Minimally-Invasive Sheep Model for the Treatment of Osteochondral Defects

To assess the clinical course of a sheep stifle joint model for osteochondral (OC) defects, medial femoral condyles (MFC) were exposed without patella luxation using medial parapatellar skin (3–4 cm) and deep incisions (2–3 cm). Two defects (7 mm diameter; 10 mm depth; OC punch) were left empty or refilled with osteochondral autologous transplantation cylinders (OATS) and explanted after six weeks. Incision-to-suture time, anesthesia time, and postoperative wound or impairment scores were compared to those in sham-operated animals. Implant performance was assessed by X-ray, micro-computed tomography, histology, and immunohistology (collagens 1, 2; aggrecan). There were no surgery-related infections or patellar luxations. Operation, anesthesia, and time to complete stand were short (0.5, 1.4, and 1.5 h, respectively). The wound trauma score was low (0.4 of maximally 4; day 7). Empty-defect and OATS animals reached an impairment score of 0 significantly later than sham animals (7.4 and 4.0 days, respectively, versus 1.5 days). Empty defects showed incomplete healing and dedifferentiation/heterotopic differentiation; OATS-filled defects displayed advanced bone healing with remaining cartilage gaps and orthotopic expression of bone and cartilage markers. Minimally-invasive, medial parapatellar surgery of OC defects on the sheep MFC allows rapid and low-trauma recovery and appears well-suited for implant testing.

Osteochondral Defects of the Talus: How to Treat Without an Osteotomy

Surgical management of osteochondral lesions of the talus without an osteotomy depends on the size, location, and chronicity of the lesion. Bone marrow stimulation techniques, such as microfracture, can be performed arthroscopically and have consistently good outcomes in lesions less than 1 cm in diameter. For lesions not amenable to bone marrow stimulation, one-stage techniques, such as allograft cartilage extracellular matrix and allograft juvenile hyaline cartilage, may be used. Arthroscopy may be used in many cases to address these lesions; however, an arthrotomy may be required to use osteochondral autograft and allograft transplantation techniques.

Biomimetic polyvinyl alcohol/type II collagen hydrogels for cartilage tissue engineering

Type II collagen (Col-II) is one of the important organic components of the cartilage extracellular matrix (ECM). Such natural material is known for its good biocompatibility, but it could not provide a good supporting environment for seed cells due to its rapid degradation and poor strength. In the present work, different contents of Col-II were incorporated into porous polyvinyl alcohol (PVA) to fabricate porous PVA/Col-II composite hydrogels for cartilage tissue engineering. The results illustrate that, after incorporation of Col-II, the elasticity modulus of the composite hydrogels firstly increases, and then decreases (under moisture state). The elasticity modulus of PVA/Col-II (at the ratio of 1:1) hydrogels reaches 11 ± 1.7 KPa, about two-fold higher than pure PVA hydrogels (4.9 ± 0.6 KPa). Meanwhile, all hydrogels exhibit relatively high water content (> 95%) and porosity (> 75%). The degradation analysis indicates that Col-II incorporation induce a high degradation ratio of the composite hydrogels. Cell culture results show PVA/Col-II hydrogels have no negative effects on cells viability and proliferation. The PVA/Col-II hydrogels may possess a potential application in the field of articular cartilage tissue engineering and regeneration.

Donor Site Evaluation After Osteochondral Autograft Transplantation for Capitellar Osteochondritis Dissecans

BACKGROUND

Osteochondral autograft transplantation (OAT) for capitellar osteochondritis dissecans (OCD) requires harvesting of tissue from the asymptomatic knee joint. However, donor site morbidity (DSM) in such cases remains unclear.

PURPOSE

To evaluate DSM and postoperative radiographic findings in patients undergoing OAT for advanced capitellar OCD.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Eighty-six juvenile athletes underwent OAT for advanced capitellar OCD. The 2000 International Knee Documentation Committee subjective score, rate of return to sports, and symptoms in the donor knee were assessed at a mean follow-up of 86 months (range, 28-185 months). Additionally, 49 of the 86 patients were assessed by radiographic and magnetic resonance imaging (MRI) findings of the knee donor site. DSM was defined according to the usual criterion (persistent symptoms for >1 year or the need for subsequent intervention) and a stricter criterion (the presence of any symptoms, such as effusion, patellofemoral complaints, crepitation, unspecified disturbance, stiffness, pain/instability during activities, and osteoarthritic change). The stricter criterion was also used to allocate patients into a DSM group and a no-DSM group.

RESULTS

Two and 11 patients were determined to have DSM according to the usual and stricter criteria, respectively. All patients returned to the competitive level of their sports. The mean International Knee Documentation Committee score was 99.0. MRI findings showed abnormal signal intensity in 17 patients (35%) and hypertrophic changes in 11 patients (22%) at the donor harvest sites. The MOCART (magnetic resonance observation of cartilage repair tissue) score was higher in the no-DSM group (mean, 68.2) than in the DSM group (mean, 52.9) (P = .027).

CONCLUSION

OAT for juvenile athletes with advanced capitellar OCD provided good clinical outcomes. The DSM rate was relatively low (2.3%) with the usual criterion but high (12.8%) with the stricter criterion. MRI showed an abnormal signal intensity and hypertrophy in some cases.

Knee-to-Talus Donor-Site Morbidity Following Autologous Osteochondral Transplantation: A Meta-Analysis with Best-case and Worst-case Analysis

BACKGROUND

Despite the promising clinical results of autologous osteochondral transplantation in the treatment of osteochondral lesions of the talus, the occurrence of knee donor-site morbidity remains a concern. However, the proportion of patients experiencing donor-site morbidity is not well established because of important variations in estimates drawn by heterogeneous studies with loss to followup, often made at short-term (< 1 year). Therefore, both a meta-analysis of studies that assumed no patients lost to followup had donor-site morbidity and assumed all patients lost to followup had donor-site morbidity may help to estimate the true risk of donor-site morbidity.

QUESTIONS/PURPOSES

To evaluate the proportion of patients who developed knee donor-site morbidity after autologous osteochondral transplantation for osteochondral lesion of the talus, by (1) meta-analysis of the proportion of patients experiencing donor-site morbidity in the best-case scenario as reported, in which no patients lost to followup were assumed to have donor-site morbidity and (2) meta-analysis of the percentage of patients who had donor-site morbidity in the worst-case scenario, in which all patients lost to followup were assumed to have donor-site morbidity and (3) present the characteristics of studies associated with the reporting of donor-site morbidity.

METHODS

A systematic search of the PubMed, Embase and The Cochrane Library databases was performed from their inception to October 2017 according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The inclusion criteria were clinical studies that reported knee donor-site morbidity after autologous osteochondral transplantation for osteochondral lesion of the talus, mean followup ≥ 1 year, full-text studies published in a peer-review journal and written in English. Quality of evidence (Case Series Quality Appraisal Checklist), sample size, mean patient age, study design, mean followup time, and observed rate of knee donor-site morbidity were evaluated. Twenty-six studies with 915 ankles (904 patients) were included in the systematic review and meta-analysis. Approximately half of the included studies were of small cohort (n < 30, 12 studies), and 12 of 26 studies did not report at all on loss to followup. In the studies that reported loss to followup (14 of 26), a total of 32 patients (35 ankles) were reported lost. Random-effects models were used to estimate the risk of donor-site morbidity as between-study heterogeneity was determined to be high in both meta-analyses that assumed that no patients lost to followup experienced donor-site morbidity (I = 82.1%) and the one that assumed all patients lost to followup experienced donor-site morbidity (I = 88.7%). Multivariable metaregression was used to estimate the association between study characteristics and the observed proportion of patients who experienced of donor-site morbidity. If there was evidence of an association between a study characteristic and proportion, a subgroup analysis was performed.

RESULTS

The estimated proportion of donor-site morbidity was 6.7% (95% confidence interval [CI], 2.8-11.8), assuming that no patients lost to followup experienced donor-site morbidity and 10.8% (95% CI, 4.8-18.3) assuming that all patients lost to followup experienced donor-site morbidity after a mean followup of 43.8 ± 24.7 months (range, 15.9-120 months). There was a negative association between study sample size and proportion of donor-site morbidity (β = -0.26; 95% CI, -0.39 to -0.12; p < 0.001 assuming that no patients lost to followup experienced donor-site morbidity and β = -0.31; 95% CI, -0.48 to -0.13; p < 0.001 assuming that all patients lost to followup experienced donor-site morbidity); that is, as study size increased, the proportion of patients reported with donor-site morbidity decreased. In larger studies (n ≥ 30), the estimated percentage of donor-site morbidity was 2.8% (95% CI, 1.2%-5.0%; I = 47.6%) assuming that no patients lost to followup experienced donor-site morbidity, and 5.0% (95% CI, 2.1%-9.0%; I = 74.5%) assuming all patients lost to followup experienced donor-site morbidity. High between-study heterogeneity (differences in methodology) could not be completely explained by variability in study sample size, mean patient age, design, or mean followup time, and may be attributable to other factors such as inconsistent definitions of donor-site morbidity.

CONCLUSIONS

The estimated proportion of donor-site morbidity after autologous osteochondral transplantation for osteochondral lesion of the talus ranged from 6.7% to 10.8% in the current meta-analysis. However, subgroup analysis demonstrated that larger studies (n ≥ 30) estimated a lower donor-site morbidity risk (< 5.0%) than smaller studies (n < 30). This estimate should be interpreted in light of the fact that nearly half of the included studies did not report on loss to followup, and so their estimates of donor-site morbidity may be low. In addition, high between-study heterogeneity and the inclusion of predominantly retrospective studies with small sample sizes likely contributed to estimates that suffered from a high risk of bias, probably in favor of the surgical treatment being studied.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

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.

Analysis of Defect Size and Ratio to Condylar Size With Respect to Outcomes After Isolated Osteochondral Allograft Transplantation

BACKGROUND

Osteochondral allograft transplantation (OCA) is a successful knee joint preservation technique; however, the effects of defect size and defect size:condyle ratio (DSCR) are poorly understood.

PURPOSE

To quantify clinical outcomes of isolated OCA of the knee based on defect size and DSCR.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data from patients who underwent OCA of the knee without major concomitant procedures by a single surgeon were analyzed at a minimum follow-up of 2 years. Osteochondral defect size was measured intraoperatively, and femoral condyle size was measured with preoperative imaging. Patient-reported outcomes, reoperations, and survival rates were analyzed per defect size and DSCR, comparing males and females and patients <40 and ≥40 years old.

RESULTS

Sixty-eight patients were included, of whom 57% were male (mean ± SD: age, 34.5 ± 10.3 years; follow-up, 5.2 ± 2.6 years). Mean osteochondral defect size and DSCR were 3.48 ± 1.72 cm² and 0.2 ± 0.1, respectively. Defect size was larger among males as compared with females (3.97 ± 1.71 cm² vs 2.81 ± 1.16 cm², P = .005), while DSCRs were not significantly different between sexes ( P = .609). The cohort as a whole demonstrated improvements in the following scores: Lysholm, International Knee Documentation Committee, Knee injury and Osteoarthritis Outcome Score, Western Ontario and McMaster Universities Osteoarthritis Index, and 12-Item Short Form Health Survey Physical ( P < .05). There were 27 reoperations (39.7%) at a mean of 2.5 ± 1.92 years and 8 failures (11.8%) at a mean of 2.62 ± 1.3 years. Mean DCSR was higher among patients with graft failure (0.26 ± 0.20 vs 0.19 ± 0.07, P = .049). After stratification by age, failures among patients ≥40 years old were associated with a larger defect size (mean 5.37 ± 3.50 cm² vs 3.22 ± 1.32 cm², P = .03) and higher DSCR (mean 0.30 ± 0.25 vs 0.19 ± 0.06, P = .05) when compared with nonfailures. Failures among patients <40 years old were not significantly associated with defect size or DSCR ( P > .05) as compared with nonfailures.

CONCLUSION

Patients undergoing isolated OCA transplantation demonstrated significant clinical improvements and a graft survival of 88.2% at 5.2 years. Failures overall were associated with a larger DSCR, and failures among patients ≥40 years old with a larger DSCR and larger defect size. Increasing defect size among males was positively correlated with some improved outcomes, although this was not maintained in analysis of the DSCR, suggesting similar prognosis after OCA regardless of sex.

CLINICAL RELEVANCE

Failed osteochondral allografts are associated with larger defect sizes and defect:condyle ratios in this study, providing additional information to surgeons for appropriate patient consultation.

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.

Good clinical and functional outcomes at mid-term following autologous osteochondral transplantation for osteochondral lesions of the talus

PURPOSE

Autologous osteochondral transplantation is an established treatment for large-sized osteochondral lesions of the talus (OLT) with excellent short term outcomes. However, few studies assess the outcomes of autologous osteochondral transplantation at mid-term follow-up. The purpose of the current systematic review was to evaluate the clinical outcomes of the autologous osteochondral transplantation procedure in the treatment of OLT at mid-term and long-term follow-up.

METHODS

A systematic search of the MEDLINE, EMBASE and Cochrane Library databases was performed in October 2017 based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Included studies were evaluated with regard to level of evidence (LOE) and quality of evidence (QOE) using the Coleman Methodology Score. Clinical outcomes, and complications were also evaluated.

RESULTS

Eleven studies, with 500 ankles were included at a mean 62.8 months follow-up. Seven studies used the American Orthopaedic Foot and Ankle Society (AOFAS) score. The weighted mean preoperative AOFAS score was 55.1 ± 6.1, and the postoperative score was 86.2 ± 4.5, with 87.4% of patients (132 of 151) being reported as excellent or good results. In total, 53 of the 500 patients (10.6%) had complications. The most common complication was donor site morbidity with 18 patients (3.6%) at final follow-up. Thirty-one patients (6.2%) underwent reoperations, and 5 ankles (1.0%) were regarded as failed autologous osteochondral transplantation.

CONCLUSION

The current systematic review demonstrated that good clinical and functional outcomes can be expected following autologous osteochondral transplantation for the treatment of OLT, with a low failure rate. The results from this study show patients can be reasonably counselled to expect good clinical outcomes in the mid-term. MRI and radiographs showed restoration of articular surface as well as a minimal presence of osteoarthritis at mid-term follow-up. However, as low level and quality of evidence and the variability of the data may confound the data, further well-designed studies are necessary to determine the effectiveness of autologous osteochondral transplantation in the treatment for OLT.

LEVEL OF EVIDENCE

IV.

Particulated Autograft Cartilage Implantation for the Treatment of Osteochondral Lesions of the Talus: A Novel Technique

Osteochondral lesions of the talus often occur following ankle sprains and fractures. Operative intervention is typically required because of the diminished intrinsic repair capability of talar articular cartilage. Several techniques have evolved that emphasize replacing the defect with cartilage that closely mimics the biological properties of hyaline articular cartilage. The goals of operative treatment are resolution of symptoms, physiologic healing, and restoration of function while eliminating the need for further intervention. This article describes a novel, single-step technique for the treatment of osteochondral lesions of the talus with the use of particulated autograft cartilage implantation.

LEVELS OF EVIDENCE

Level V.

Osteochondral Autograft: Proceedings of the International Consensus Meeting on Cartilage Repair of the Ankle

BACKGROUND

Treatment guidelines for cartilage lesions of the talus have been based on both low quality and low levels of evidence. Therefore, an international consensus group of experts was convened to collaboratively advance toward consensus opinions on key topics regarding cartilage lesions of the talus. The purpose of this consensus article is to explain the process and delineate the consensus statements derived from this consensus meeting on the use of "osteochondral autograft" for osteochondral lesions of the talus.

METHODS

Seventy-five international experts in cartilage repair of the ankle representing 25 countries and 1 territory were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within 11 working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed upon in unanimous fashion within the working groups. A final vote was then held, and the strength of consensus was characterized as follows: consensus, 51% to 74%; strong consensus, 75% to 99%; and unanimous, 100%.

RESULTS

A total of 14 statements on osteochondral autograft reached consensus during the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. Two achieved unanimous support, 11 reached strong consensus (greater than 75% agreement), and 1 achieved consensus. All statements reached at least 67% agreement.

CONCLUSIONS

This international consensus derived from leaders in the field will assist clinicians with osteochondral autograft as a treatment strategy for osteochondral lesions of the talus.

Topographic Analysis of 2 Alternative Donor Sites of the Ipsilateral Elbow in the Treatment of Capitellar Osteochondritis Dissecans

PURPOSE

To find the best topographic subchondral bone match between the capitellum and 2 proposed alternative donor sites of the ipsilateral elbow for capitellar osteochondral autologous transplantation: the non-articulating part of the radial head and the lateral olecranon tip.

METHODS

In our retrospective database, 20 patients with an unremarkable computed tomography scan of the elbow despite clinical suspicion were identified for analysis. Included were patients aged 11 to 20 years with intact osseous structures and a computed tomography slice thickness of 1.25 mm or less. Three-dimensional polygon models were created using a standard predefined threshold, after which 4 articular surface lesions on the capitellum were created: central 40°, central 60°, lateral 40°, and lateral 60°. In addition, 3 donor locations on the non-articulating part of the radial head (diameter, 5 mm) and the lateral olecranon tip (diameter, 3.5 mm) were created. For each of 24 donor-recipient combinations, the donor graft surface was virtually placed on the recipient surface to quantify the mean distance between surfaces.

RESULTS

The group of 20 patients consisted of 16 male and 4 female patients with a mean age of 15.9 years (range, 12-18 years). For a central 40° lesion, the mean distance across all 6 donor-recipient combinations ranged from 0.085 ± 0.023 to 0.118 ± 0.036 mm; for a central 60° lesion, the mean distance ranged from 0.075 ± 0.018 to 0.117 ± 0.062 mm; for a lateral 40° lesion, the mean distance ranged from 0.087 ± 0.030 to 0.182 ± 0.226 mm; and for a lateral 60° lesion, the mean distance ranged from 0.084 ± 0.048 to 0.115 ± 0.045 mm. There were no differences in topographic matching between donor-recipient combinations.

CONCLUSIONS

The findings of this study show a less than 0.2-mm difference in the topographic subchondral bone match between 4 common lesion locations on the capitellum and 2 alternative donor sites of the ipsilateral elbow for capitellar osteochondral autologous transplantation: the non-articulating part of the radial head and the lateral olecranon tip.

CLINICAL RELEVANCE

These findings suggest that the non-articulating part of the radial head and the lateral olecranon tip may potentially be used as a donor source when treating capitellar osteochondritis dissecans.

Outcome of autologous bone grafting with preservation of articular cartilage to treat osteochondral lesions of the talus with large associated subchondral cysts

Aims

The aim of this study was to evaluate antegrade autologous bone grafting with the preservation of articular cartilage in the treatment of symptomatic osteochondral lesions of the talus with subchondral cysts.

Patients and Methods

The study involved seven men and five women; their mean age was 35.9 years (14 to 70). All lesions included full-thickness articular cartilage extending through subchondral bone and were associated with subchondral cysts. Medial lesions were exposed through an oblique medial malleolar osteotomy, and one lateral lesion was exposed by expanding an anterolateral arthroscopic portal. After refreshing the subchondral cyst, it was grafted with autologous cancellous bone from the distal tibial metaphysis. The fragments of cartilage were fixed with 5-0 nylon sutures to the surrounding cartilage. Function was assessed at a mean follow-up of 25.3 months (15 to 50), using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot outcome score. The radiological outcome was assessed using MRI and CT scans.

Results

The mean AOFAS score improved from 65.7 (47 to 81) preoperatively to 92 (90 to 100) at final follow-up, with 100% patient satisfaction. The radiolucent area of the cysts almost disappeared on plain radiographs in all patients immediately after surgery, and there were no recurrences at the most recent follow-up. The medial malleolar screws were removed in seven patients, although none had symptoms. At this time, further arthroscopy was undertaken, when it was found that the mean International Cartilage Repair Society (ICRS) arthroscopic score represented near-normal cartilage.

Conclusion

Autologous bone grafting with fixation of chondral fragments preserves the original cartilage in the short term, and could be considered in the treatment for adult patients with symptomatic osteochondral defect and subchondral cysts. Cite this article: Bone Joint J 2018;100-B:590-5.

T1ρ mapping of articular cartilage grafts after autologous osteochondral transplantation for osteochondral lesions of the talus: A longitudinal evaluation

BACKGROUND

Clinical results of autologous osteochondral transplantation (AOT) for treatment of osteochondral lesions of the talus have been mixed. T1ρ imaging can be used to noninvasively detect early cartilage degeneration.

PURPOSE OR HYPOTHESIS

To quantitatively assess, by means of T1ρ imaging, changes over time in the biochemical health of grafted cartilage after AOT for osteochondral lesions of the talus.

STUDY TYPE

Retrosepctive case series.

POPULATION

The study group comprised nine patients who underwent AOT for an osteochondral lesion of the talus and in whom T1ρ mapping was performed 1 and 2 years postoperatively.

FIELD STRENGTH/SEQUENCE

3 Tesla. T1ρ-weighted turbo field echo.

ASSESSMENT

The mean T1ρ value of full-thickness cartilage at the repair site and that of full-thickness cartilage elsewhere in the same image (far-field cartilage) were determined. Clinical assessment was based on the American Orthopaedic Foot & Ankle Society (AOFAS) scale. Correlation between the T1ρ ratios (grafted-to-far-field cartilage T1ρ values) and clinical outcomes was examined.

STATISTICAL TESTS

Mixed effects model. Pearson correlation analysis.

RESULTS

At 1 year, a significant difference existed between the mean T1ρ value of the grafted cartilage (57.0 ± 7.7 ms) and that of the far-field cartilage (41.8 ± 4.6 ms) (P < 0.001). At 2 years, the mean T1ρ value of the grafted cartilage (49.1 ± 6.4 ms) was significantly lower than that at 1 year (P = 0.011). Moderate negative correlation was found between the 1-year T1ρ ratio and 1-year AOFAS score (r = -0.60) and between the 2-year T1ρ ratio and 2-year AOFAS score (r = -0.50).

DATA CONCLUSION

Our observation of substantial restoration of the proteoglycan content of the grafted cartilage approximately 2 years after AOT for osteochondral lesions of the talus indicates that the content changes gradually and that the cartilage reparation process is slower than previously believed.

LEVEL OF EVIDENCE

3 Technical Efficacy: Stage 3 J. MAGN. RESON. IMAGING 2018;48:398-403.

Matrix-associated stem cell transplantation (MAST) in chondral defects of the ankle is safe and effective - 2-year-followup in 130 patients

BACKGROUND

The aim of the study was to assess the 2-year-follow-up of matrix-associated stem cell transplantation (MAST) in chondral defects of the ankle.

METHODS

In a prospective consecutive non-controlled clinical follow-up study, all patients with chondral defect that were treated with MAST from October 1, 2011 to July 31, 2013 were analyzed. Size and location of the chondral defects, method-associated problems and the Visual Analogue Scale Foot and Ankle (VAS FA) before treatment and at follow-up were analyzed. 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). The matrix was fixed into the chondral defect with fibrin glue.

RESULTS

One hundred and forty-four patients with 150 chondral defects were included in the study. The age of the patients was 35 years on average (range, 12-68 years), 85 (59%) were male. The VAS FA before surgery was 48.5 on average (range, 16.5-78.8). The defects were located as follows, medial talar shoulder, n=62; lateral talar shoulder, n=66 (medial and lateral talar shoulder, n=6), tibia, n=22. The defect size was 1.6cm² on average (range, .6-6cm²). 130 patients (90%) completed 2-year-follow-up. The VAS FA improved to an average of 87.5 (range, 62.1-100; t-test (comparison with preoperative scores), p=.01).

CONCLUSIONS

MAST led to improved and high validated outcome scores. No method related complications were registered. Even though a control group is missing, we conclude that MAST is a safe and effective method for the treatment of chondral defects of the ankle.

Current concepts in treatment of early knee osteoarthritis and osteochondral lesions; the role of biological augmentations

Early knee osteoarthritis and chondral lesions are a common cause of disability in younger patients. Surgical options, such as microfractures, ACI and OAT, provide good, but not fully satisfying, outcomes. Recent advance in biological knowledge introduced two different methodological approaches of delivering growth factors and stem cells into the articular environment. Platelet-Rich Plasma and Mesenchimal Stem Cells are supposed to change the way to approach early knee osteoarthritis and chondral lesions, though their indications and limits are yet to be determined.

Current concepts in treatment of early knee osteoarthritis and osteochondral lesions; the role of biological augmentations

Early knee osteoarthritis and chondral lesions are a common cause of disability in younger patients. Surgical options, such as microfractures, ACI and OAT, provide good, but not fully satisfying, outcomes. Recent advance in biological knowledge introduced two different methodological approaches of delivering growth factors and stem cells into the articular environment. Platelet-Rich Plasma and Mesenchimal Stem Cells are supposed to change the way to approach early knee osteoarthritis and chondral lesions, though their indications and limits are yet to be determined.

Clinical Outcomes of Donor Sites After Osteochondral Graft Harvest From Healthy Knees

Background:

The use of autologous osteochondral grafts has become popular in the treatment of small, isolated, well-contained articular cartilage defects. However, donor site morbidity is a problem, and few reports are available of donor site morbidity after mosaicplasty.

Purpose:

To examine the clinical outcomes of donor sites after osteochondral grafts from healthy knees.

Study Design:

Case series; Level of evidence, 4.

Methods:

Between September 1997 and September 2011, there were 40 patients (40 knees; 32 men, 8 women; 31 right knees, 9 left knees) with asymptomatic osteochondral graft donor sites used for autologous transfer; all had a follow-up period of >2 years. The mean patient age at surgery was 21.0 years (range, 12-58 years). The recipient sites included the elbow (n = 28), contralateral knee (n = 5), and ankle (n = 7). The mean diameter of the grafted plugs was 7.5 mm (range, 4.5-9 mm), and the mean number of grafted plugs was 2.2 (range, 1-3). At a mean follow-up of 43.1 months (range, 24-177 months), knee symptoms, return to sport, ability to sit straight in Japanese style, and radiological changes of the patellofemoral joint were evaluated. Whether operative age, follow-up period, and diameter or number of the grafted plugs were risk factors was analyzed statistically. Significance was defined as P < .05.

Results:

Thirty-four patients had no knee symptoms, and 4 patients had occasional mild knee pain. Two patients underwent reoperation for arthrofibrosis and not for cartilage defect. Twenty-seven patients had complete return to sports, and 32 patients could sit straight; donor site morbidity was not the cause of failure to return to sports or inability to sit straight. The radiological changes became worse in 3 patients, and the risk factor for degenerative change was older operative age.

Conclusion:

When osteochondral plugs were obtained from healthy knees, 34 patients (85%) were asymptomatic at follow-up. No donor site defects required surgical intervention due to persistent symptoms.

Osteochondral Allograft Transplantation for Treatment of Focal Patellar Osteochondral Lesion

Patellar osteochondral lesions are common and particularly disabling injuries that can affect young and highly active patients. If enough functional impairment, ranging from difficulty climbing stairs to pain with squatting, is present, surgical treatment may be warranted. For the treatment of these lesions, various techniques have been described, including autologous osteochondral transplantation, as well as microfracture surgery. However, these are not without disadvantages. Although morbidity is noted in cases of autologous osteochondral transplantation, uncertain and possibly unsustainable results are associated with the microfracture procedure. Therefore, we present an alternative surgical treatment option for this pathology. The objective of this Technical Note is to describe our preferred approach for an osteochondral allograft transplant procedure to treat a focal patellar osteochondral lesion.

Restorative Tissue Transplantation Options for Osteochondral Lesions of the Talus: A Review

Symptomatic osteochondral lesions of the talus remain a challenging problem due to inability for cartilage lesions to heal. Numerous treatment options exist, including nonoperative management, marrow stimulating techniques, and autograft-allograft. Arthroscopic marrow stimulation forms fibrocartilage that has been shown to be biomechanically weaker than hyaline cartilage. Restorative tissue transplantation options are being used more for larger and cystic lesions. Newer biologics and particulated juvenile cartilage are currently under investigation for possible clinical efficacy. This article provides an evidenced-based summary of available literature on the use of biologics for treatment of osteochondral lesions of the talus.

Editorial Commentary: Robbing Peter to Pay Paul? Is Osteochondral Autograft Transplantation of the Elbow Capitellum Worth the Price?

Osteochondritis dissecans (OCD) of the elbow capitellum is a common disorder that causes pain and functional limitation in the athletic adolescent elbow. Many surgical options have been proposed over the years, but none has stood the test of time. A recent well-written systematic review highlights the treatment options and recognizes a growing trend toward osteochondral allograft transplantation as the ideal solution. Unfortunately, the study also underscores the paucity of evidence on which we base our treatment decisions for OCD of the elbow in the young athlete. Although the potential benefits of osteochondral grafting are encouraging, consideration of associated risks such as donor site morbidity is essential.

Osteochondral Allograft Transplantation of the Knee: Analysis of Failures at 5 Years

BACKGROUND

Osteochondral allograft transplantation (OAT) is being performed with increasing frequency, and the need for reoperations is not uncommon.

PURPOSE

To quantify survival for OAT and report findings at reoperations.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A review of prospectively collected data of 224 consecutive patients who underwent OAT by a single surgeon with a minimum follow-up of 2 years was conducted. The reoperation rate, timing of reoperation, procedure performed, and findings at surgery were reviewed. Failure was defined by revision OAT, conversion to knee arthroplasty, or gross appearance of graft failure at second-look arthroscopic surgery.

RESULTS

A total of 180 patients (mean [±SD] age, 32.7 ± 10.4 years; 52% male) who underwent OAT with a mean follow-up of 5.0 ± 2.7 years met the inclusion criteria (80% follow-up). Of these, 172 patients (96%) underwent a mean of 2.5 ± 1.7 prior surgical procedures on the ipsilateral knee before OAT. Forty-eight percent of OAT procedures were isolated, while 52% were performed with concomitant procedures including meniscus allograft transplantation (MAT) in 65 (36%). Sixty-six patients (37%) underwent a reoperation at a mean of 2.5 ± 2.5 years, with 32% (21/66) undergoing additional reoperations (range, 1-3). Arthroscopic debridement was performed in 91% of patients with initial reoperations, with 83% showing evidence of an intact graft; of these, 9 ultimately progressed to failure at a mean of 4.1 ± 1.9 years. A total of 24 patients (13%) were considered failures at a mean of 3.6 ± 2.6 years after the index OAT procedure because of revision OAT (n = 7), conversion to arthroplasty (n= 12), or appearance of a poorly incorporated allograft at arthroscopic surgery (n = 5). The number of previous surgical procedures was independently predictive of reoperations and failure; body mass index was independently predictive of failure. Excluding the failed patients, statistically and clinically significant improvements were found in the Lysholm score, International Knee Documentation Committee score, Knee injury and Osteoarthritis Outcome Score, and Short Form-12 physical component summary at final follow-up ( P < .001 for all), with inferior outcomes (albeit overall improved) in patients who underwent a reoperation.

CONCLUSION

In this series, there was a 37% reoperation rate and an 87% allograft survival rate at a mean of 5 years after OAT. The number of previous ipsilateral knee surgical procedures was predictive of reoperations and failure. Of the patients who underwent arthroscopic debridement with an intact graft at the time of arthroscopic surgery, 82% experienced significantly improved outcomes, while 18% ultimately progressed to failure. This information can be used to counsel patients on the implications of a reoperation after OAT.

Nanoreinforced Hydrogels for Tissue Engineering: Biomaterials that are Compatible with Load-Bearing and Electroactive Tissues

Given their highly porous nature and excellent water retention, hydrogel-based biomaterials can mimic critical properties of the native cellular environment. However, their potential to emulate the electromechanical milieu of native tissues or conform well with the curved topology of human organs needs to be further explored to address a broad range of physiological demands of the body. In this regard, the incorporation of nanomaterials within hydrogels has shown great promise, as a simple one-step approach, to generate multifunctional scaffolds with previously unattainable biological, mechanical, and electrical properties. Here, recent advances in the fabrication and application of nanocomposite hydrogels in tissue engineering applications are described, with specific attention toward skeletal and electroactive tissues, such as cardiac, nerve, bone, cartilage, and skeletal muscle. Additionally, some potential uses of nanoreinforced hydrogels within the emerging disciplines of cyborganics, bionics, and soft biorobotics are highlighted.

Osteochondral Allograft Transfer for Treatment of Osteochondral Lesions of the Talus: A Systematic Review

PURPOSE

The purpose of this study is to present a systematic review of the literature regarding the use of fresh bulk osteochondral allograft transfer for treatment of large osteochondral lesions of the talus (OCLT) in an effort to characterize the functional outcomes, complications, and reoperation rates.

METHODS

A search of the PubMed, CINAHL, Embase, and Cochrane Databases was performed between January 1, 1990, and March 1, 2016, and included all articles related to outcomes after fresh talar allograft transplantation for OCLT. Inclusion criteria were series (1) published in the English language, (2) using fresh talar allograft, and (3) reporting at least one outcome measure of interest including American Orthopaedic Foot and Ankle Society (AOFAS) score, pain visual analog scale (VAS) score, reoperation rate, and rate of allograft collapse. Weighted averages of outcome data were used.

RESULTS

Five studies involving 91 OCLT met the inclusion criteria. The mean age of the cohort was 39 years (range, 15 to 74), and 53% were male. Fresh talar allograft was transplanted into 71 medial, 18 lateral, and 2 central OCLT. At a mean follow-up of 45 ± 3.3 (range, 6 to 91) months, AOFAS scores improved from 48 preoperatively to 80 postoperatively. Pain VAS scores improved from 7.1 preoperatively to 2.7 postoperatively. Twenty-three of the 91 (25%) patients required at least one reoperation, for a total of 28 operations. The most common indications for reoperation were development of moderate to severe osteoarthritis (14%), pain due to hardware (9%), extensive graft collapse (3%), and delayed or nonunion of osteotomy site (1%). Ultimately 12 (13.2%) of the cases were considered failures, with 8 (8.8%) resulting in tibiotalar arthrodesis or ankle replacement.

CONCLUSIONS

Fresh bulk allograft transplantation can substantially improve functional status as well as effectively prevent or delay the eventual need for ankle arthrodesis or replacement. However, patients must be carefully selected and counseled on the morbidity of the procedure as well as the high incidence of clinical failure (13%) and need for reoperation (25%) and revision surgery (8.8%).

LEVEL OF EVIDENCE

Level IV, systematic review of Level IV studies.

Donor-site morbidity after osteochondral autologous transplantation for osteochondritis dissecans of the capitellum: a systematic review and meta-analysis

PURPOSE

To determine the rate of donor-site morbidity after osteochondral autologous transplantation (OATS) for capitellar osteochondritis dissecans.

METHODS

A literature search was performed in PubMed/MEDLINE, Embase, and Cochrane Library to identify studies up to November 6, 2016. Criteria for inclusion were OATS for capitellar osteochondritis dissecans, reported outcomes related to donor sites, ≥10 patients, ≥1 year follow-up, and written in English. Donor-site morbidity was defined as persistent symptoms (≥1 year) or cases that required subsequent intervention. Patient and harvest characteristics were described, as well as the rate of donor-site morbidity. A random effects model was used to calculate and compare weighted group proportions.

RESULTS

Eleven studies including 190 patients were included. In eight studies, grafts were harvested from the femoral condyle, in three studies, from either the 5th or 6th costal-osteochondral junction. The average number of grafts was 2 (1-5); graft diameter ranged from 2.6 to 11 mm. In the knee-to-elbow group, donor-site morbidity was reported in 10 of 128 patients (7.8%), knee pain during activity (7.0%) and locking sensations (0.8%). In the rib-to-elbow group, one of 62 cases (1.6%) was complicated, a pneumothorax. The proportion in the knee-to-elbow group was 0.04 (95% CI 0.0-0.15), and the proportion in the rib-to-elbow group was 0.01 (95% CI 0.00-0.06). There were no significant differences between both harvest techniques (n.s.).

CONCLUSIONS

Donor-site morbidity after OATS for capitellar osteochondritis dissecans was reported in a considerable group of patients.

LEVEL OF EVIDENCE

Level IV, systematic review of level IV studies.