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

Comparison of autologous matrix-induced chondrogenesis and mosaicplasty in the treatment of osteochondral defects of the talus

Objective

This study aimed to compare the medium- to long-term results of mosaicplasty and autologous matrix-induced chondrogenesis (AMIC) in treating osteochondral defects of the talus (OCD).

Methods

Fifty patients treated for talus OCD were evaluated between 2010 and 2020. Patients were divided into 2 groups: patients who underwent mosaicplasty (Group I) and those who underwent AMIC (Group II). The OCD was graded according to the Berndt-Hardy and Hepple classification systems. The size of the OCD area, the number of osteochondral plugs, and the size of the collagen matrix were determined from the surgical data. The effects of patients aged below and above 45, defect areas smaller or larger than 1.5 cm2 , and gender on functional outcomes were analyzed in both groups. Range of motion (ROM), The American Orthopaedic Foot & Ankle Society score (AOFAS), the Freiburg ankle Index score (FAI), the Tegner activity scale, and the visual analog scale (VAS) were used for the functional evaluations.

Results

Group I included 28 patients, and group II included 22 patients. The mean age was 41.6 years; the mean follow-up period was 69.9 months. In the final examination of the patients, both methods could provide significant improvement in all functional scores (P < .001). Although it was not statistically significant, group II had better functional values. The size of the defect area independently negatively affected the preoperative AOFAS (P=.001 and P=.011, respectively) and FAI (P=.001 and P=.008, respectively) scores. Besides that, age and gender did not affect the results (P > .05).

Conclusion

Both methods can provide successful results; however, the AMIC method can achieve better results than mosaicplasty in similarly sized defects without causing additional morbidity.

Operative management of osteochondral lesions of the talus: 2024 recommendations of the working group 'clinical tissue regeneration' of the German Society of Orthopedics and Traumatology (DGOU)

The working group 'Clinical Tissue Regeneration' of the German Society of Orthopedics and Traumatology (DGOU) issues this paper with updating its guidelines. Literature was analyzed regarding different topics relevant to osteochondral lesions of the talus (OLT) treatment. This process concluded with a statement for each topic reflecting the best scientific evidence available with a grade of recommendation. All group members rated the statements to identify possible gaps between literature and current clinical practice. Fixation of a vital bony fragment should be considered in large fragments. In children with open physis, retrograde drilling seems to work better than in adults, but even there, the revision rate reaches 50%. The literature supports debridement with bone marrow stimulation (BMS) in lesions smaller than 1.0 cm² without bony defect. The additional use of a scaffold can be recommended in lesions larger than 1.0 cm². For other scaffolds besides AMIC®/Chondro-Gide®, there is only limited evidence. Systematic reviews report good to excellent clinical results in 87% of the patients after osteochondral transplantation (OCT), but donor site morbidity is of concern, reaching 16.9%. There is no evidence of any additional benefit from autologous chondrocyte implantation (ACI). Minced cartilage lacks any supporting data. Metallic resurfacing of OLT can only be recommended as a second-line treatment. A medial malleolar osteotomy has a minor effect on the clinical outcome compared to the many other factors influencing the clinical result.

Freiberg`s disease of lesser metatarsals treated with bone grafting and autologous matrix induced chondrogenesis (AMIC) membrane - A series of 10 cases

BACKGROUND

Freiberg's infraction is osteonecrosis of lesser metatarsal heads most commonly affecting adolescent females. They usually present with pain and swelling of the forefoot. MRI is useful investigation in the early diagnosis. It is a self-limiting disease and the main stay of treatment is non operative. Surgery is indicated in failed conservative management which include open debridement, cheilectomy, micro fracture, osteotomies and excision arthroplasty with varying success.

METHODS

A retrospective analysis of ten patients with Freiberg`s disease of the lesser metatarsals treated with open debridement, microfracture, bone grafting and application of AMIC (Autologous Matrix induced Chondroplasty) membrane was carried out. The patients were followed up to five years and the outcome measures were scored using Manchester-Oxford Foot Questionnaire (MOxFQ) and EQVAS best health scores.

RESULTS

The mean age was 42.7 years and follow-up time was 36.4 months. The most common site was second metatarsal, eight (80%) followed by third metatarsal, two (20%). The mean base line MOxFQ was 72.5 (95% CI- 45 ± 100) which improved to 42.5 (95%CI- 2.5 ± 82.5) at one year. The mean baseline VAS improved from 26.4(10.2 ± 42.6) to 30.3 (95%CI- 2.1 ± 58.5) at one year. The mean MOxFQ and VAS at the end of 36 months was 31.4(95%CI-6.6 ± 57.2) and47.3(4.3 ± 80.3) respectively.

CONCLUSIONS

Open debridement of the Freiberg`s disease combined with microfracture of the defect, bone grafting and application of AMIC membrane shows reliable functional and radiological outcomes at short term follow up.

Typical Complications After Cartilage Repair of the Ankle Using Autologous Matrix-Induced Chondrogenesis (AMIC)

Background:

Autologous matrix-induced chondrogenesis (AMIC) for the treatment of osteochondral lesions of the talus (OLT) results in favorable clinical outcomes, yet high reoperation rates. The aim of this study was to report and analyze typical complications and their risk factors after AMIC for OLT.

Methods:

A total of 127 consecutive patients with 130 AMIC procedures for OLT were retrospectively assessed. All AMIC procedures were performed in an open fashion with 106 (81.5%) cases requiring a malleolar osteotomy (OT) to access the OLT. Seventy-one patients (54.6%) underwent subsequent surgery. These cases were evaluated at a mean follow-up of 3.1 years (±2.5) for complications reviewing postoperative imaging and intraoperative findings during revision surgery. Six patients (8.5%) were lost to follow-up. Regression model analysis was conducted to identify factors that were associated with AMIC-related complications.

Results:

Among the 65 (50%) patients who required revision surgery, 18 patients (28%) demonstrated AMIC-related complications with deep fissuring (83%) and thinning (17%) of the AMIC graft. Conversely, 47 patients (72%) underwent subsequent surgery due to AMIC-unrelated reasons including isolated removal of symptomatic hardware (n = 17) and surgery addressing concomitant pathologies with (n = 25) and without hardware removal (n = 5). Previous prior cartilage repair surgery was significantly associated with AMIC graft-associated complications in patients undergoing revision surgery ( P = .0023). Among age, body mass index, defect size, smoking, and bone grafting, smoking was the only factor showing statistical significance with an odds ratio of 3.7 (95% CI 1.24, 10.9; P = .019) to undergo revision surgery due to graft-related complications, when adjusted for previous cartilage repair surgery.

Conclusion:

The majority of revision surgeries after AMIC for OLT are unrelated to the performed AMIC graft but frequently address symptomatic hardware and concomitant pathologies. Both smoking and previous cartilage repair surgery seem to significantly increase the risk of undergoing revision surgery due to AMIC-related complications.

Level of evidence:

Level IV, case series.

Autologous matrix induced chondrogenesis (AMIC) as revision procedure for failed AMIC in recurrent symptomatic osteochondral defects of the talus

Autologous matrix induced chondrogenesis (AMIC) is a bone marrow stimulating technique used for the surgical management of chondral defects of the talus. The present study evaluated the clinical outcomes and imaging of AMIC as revision procedure for failed AMIC surgery for osteochondral defects of the talus. Forty-eight patients with symptomatic osteochondral defects who received a revision AMIC were evaluated after a minimum of two years follow-up. Patients with previous procedures rather than AMIC, those who required additional surgical procedures (e.g. ligament repair or deformity correction), or those who had evidence of kissing, bilateral, or multiple lesions were excluded. Outcome parameters included the Visual Analogic Scale (VAS), Tegner Activity Scale, the American Orthopedic Foot and Ankle Score (AOFAS), and the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score. All patients were followed by an assessor who was not involved in the clinical management. 27 patients were enrolled in the present study. The mean age of the patient was 34.9 ± 3.1 years, and the mean BMI 27.2 ± 5.1 kg/m². The mean defect surface area was 2.8 ± 1.9 cm². The mean follow-up was 44.3 ± 21.4 months. The mean hospital length of stay was 4.4 ± 1.4 days. At final follow-up, the mean VAS score was 4.1 ± 3.1, the mean Tegner 3.5 ± 1.6, the mean AOFAS 58.8 ± 20.6. The preoperative MOCART score was 22.1 ± 13.7 points, the postoperative MOCART score was 42.3 ± 27.9 points (+ 20.2%; P = 0.04), respectively. 30% (8 of 27 patients) experienced persistent pain and underwent a further chondral procedure. Concluding, AMIC could be a viable option as revision procedure for failed AMIC in recurrent symptomatic osteochondral defects of the talus. The PROMs indicated that patients were moderately satisfied with the procedure, and the MOCART score demonstrated a significant improvement from baseline to the last follow-up. A deeper understanding in prognostic factors and patient selection is critical to prevent failures.

The management of talar osteochondral lesions - Current concepts

Osteochondral lesions of the talus (OLTs) are a common complication following trauma, involving both the articular cartilage and the underlying subchondral bone, with variable aetiologies and often presenting with non-specific symptoms. Diagnosis of OLTs requires a combination of clinical assessment and imaging and despite many different treatment options, there is no generalised consensus regarding which option is the most effective. Left untreated, OLTs risk progressing to osteoarthritis. Acute non-displaced OLTs can be treated non-operatively. However, OLTs refractory to non-surgical care for three to six months may be suitable for surgical care. In these cases, conservative treatments are often unsuccessful, particularly for larger and more severe defects and so the majority require surgical intervention. Although bone marrow stimulation techniques remain the "gold standard" for lesions <150 mm2, there still requires a need for better long term clinical data and cost-benefit analyses compared with other treatment options. Biological attempts at either regenerating or replacing the articular cartilage are however demonstrating some promising results, but each with their own advantages and disadvantages. In this review, we summarise the clinical management of OLTs and present the current concepts of different treatment regimes.