Background/Objectives: Large osteochondral lesions of the talus (OLT) pose a major challenge because their size and depth often exceed the indications for bone marrow stimulation, and durable biological repair remains difficult to achieve. However, evidence for autologous osteochondral transplantation (AOT) in extensive talar defects is still limited. Methods: In this retrospective cohort, 40 consecutive patients ≥ 14 years with ICRS grade III–IV lesions of the talar dome were treated with AOT at a tertiary referral center. One to three overlapping cylindrical osteochondral grafts (mean diameter 0.9 cm) were harvested from non-weight-bearing regions of the ipsilateral patellofemoral groove using a water-cooled diamond trephine system and implanted press-fit into the talar dome. Donor sites were refilled with autologous iliac crest bone cylinders and hydroxyapatite substitute. Pain (Numeric Rating Scale, NRS) and function (AOFAS Ankle–Hindfoot Score) were recorded preoperatively and at 3, 6, 9, and 12 months, and changes over time were analyzed using generalized estimating equations. Results: Mean defect size was 137.4 ± 31.9 mm2, and 82.5% of lesions were ICRS grade III. NRS pain improved from 5.69 ± 2.52 preoperatively to 0.53 ± 0.98 at 12 months (p < 0.001). AOFAS score increased from 63.79 ± 2.55 to 97.36 ± 2.49 (p < 0.001). Age and graft location significantly influenced postoperative pain, whereas graft size and sex did not. No infections, graft failures, conversions to arthrodesis or arthroplasty, or clinically relevant donor-site symptoms occurred. Conclusions: Multi-plug AOT using a diamond trephine system provides substantial and durable pain relief and functional improvement in patients with large OLT, with low complication and donor-site morbidity rates. These findings support AOT as a joint-preserving option for extensive talar defects and justify further prospective, comparative studies with long-term follow-up.

The clinical outcomes of open-wedge high-tibial osteotomy (HTO) combined with bone marrow stimulation techniques (BMSTs) (microfracture [MF], subchondral drilling [SD], microdrilling [MD] and abrasion arthroplasty[AA]) in patients with knee osteoarthritis are unclear. The aim of this systematic review was to present an up-to-date summary of the clinical outcomes associated with HTO combined with BMST in patients with knee osteoarthritis. A systematic database search on PubMed, Embase, Web of Science, and CINAHL was performed from inception up to 3 March 2024 in accordance with the PRISMA guideline. A narrative synthesis was undertaken to complement the quantitative analysis done. A total of 11 studies involving 516 patients were included. Six studies reported HTO with MF, one reported HTO with SD, two reported HTO with MD, one reported HTO with AA, and one reported HTO with chondral resurfacing. The average mean follow-up period was 33 months (range 12-120). Overall, most of the studies reported an improvement in cartilage regeneration and clinical scores above the minimal clinically important difference. While HTO with BMST shows good clinical outcomes and postoperative cartilage regeneration, the reported outcomes are highly heterogeneous. More comparative studies are needed to establish whether HTO with BMST should be recommended over isolated HTO in practice.

PurposeSurgical intervention for massive rotator cuff tear (MRCT) has been found to result in positive outcomes; however, a high retear rate has frequently been reported. The present study employed a chronic MRCT model to assess the impact of microdrilling, a bone marrow stimulation (BMS) technique and extracorporeal shockwave therapy (ESWT) on rotator cuff healing. We hypothesized that BMS would result in superior healing than ESWT, reflected by a more normal tendon‐to‐bone junction histomorphology.MethodsA chronic rotator cuff tear model was created in the supraspinatus and infraspinatus tendons of 30 Sprague–Dawley rats. Four weeks later, the tendons were repaired using the transosseous technique. The animals were randomly assigned to three groups. In Group I, the intervention consisted exclusively of tendon repair. In Group II, ESWT was administered at various time points in conjunction with the repair process. In Group III, microdrilling was performed prior to the initiation of repairs. The animals were euthanized at 4 and 8 weeks post‐repair. Repaired tendons, specifically the tendon‐to‐bone junction, were evaluated histomorphologically using the Bonar score and immunohistochemically for CD34, bone morphogenetic protein‐2 (BMP‐2), bone morphogenetic protein‐7 (BMP‐7) and transforming growth factor‐β1 (TGF‐β1).ResultsA lower Bonar scale score in Group III more closely resembled normal tissue with respect to tenocyte morphology, extracellular matrix composition and vascularity, although statistical significance was limited to vascularity and extracellular matrix composition. By contrast, Group II showed a significant time‐dependent deterioration in tenocyte morphology. Group III exhibited elevated BMP‐2 and BMP‐7 expression levels, and an increase in CD34 at the tendon‐to‐bone junction was observed in Group II; however, these did not reach statistical significance. TGF‐β1 expression remained comparable among all groups.ConclusionsBoth biological augmentation with BMS and ESWT demonstrated beneficial effects on tendon‐to‐bone healing in a rat model of chronic MRCT; however, these effects were not statistically significant. Although increased BMP‐2, BMP‐7 and CD34 expressions were noted in Group III, significant improvements were noted in vascularity according to the Bonar scale score, along with early enhancements in ground substance and overall histological structure. The deterioration of tenocyte morphology in the ESWT group highlights the need for optimized energy parameters.Level of EvidenceN/A.

Focal cartilage lesions of the knee joint frequently cause chronic symptoms and therefore require early treatment. Concomitant pathologies such as malalignment, ligamentous instability, or meniscal deficiency have a decisive impact on the outcome of cartilage regenerative procedures and must therefore be addressed concomitantly. Small chondral defects up to approximately 2cm2 are commonly treated primarily by bone marrow stimulation (BMS), preferably using microdrilling techniques. For defects of approximately 1-4cm2, matrix-augmented bone marrow stimulation (m-BMS) is considered the standard of care, providing superior mid-term outcomes. Larger defects exceeding approximately 2cm2 are preferentially treated with matrix-associated autologous chondrocyte transplantation (m-ACT), which has demonstrated stable long-term results. Osteochondral lesions require a combined treatment approach addressing both cartilage and subchondral bone. Overall, treatment follows a clearly defined stepwise concept based on epidemiological factors, defect morphology, concomitant pathologies, and structured rehabilitation.

Anterior cruciate ligament (ACL) injuries are among the most common sports-related knee injuries, affecting athletes across varying levels of competition. ACL repair procedures have become a popular treatment option to repair these lesions. There is a need for comprehensive analysis of recent studies among a growing body of literature to better understand return to sport (RTS), return to previous level (RPL), and timing of return to sport following these procedures. A systematic review was performed using the 2020 Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. A literature search of PubMed, Embase, Scopus, SportsDISCUS databases was performed on October 11, 2024. Two independent reviewers screened 2098 articles. The inclusion criteria were: studies from 2000 to present, minimum of 12 month follow up, level of evidence 1-4, English language, and reported outcomes after ACL repair procedures with RTS data. Data were stratified by ACL repair technique for subgroup analysis. RTS, RPL, and RTS timing were reported as ranges to reflect study variability. The 16 studies included 614 athletes with RTS rates ranging from 36% to 100%. Seven studies report RPL encompassing 342 athletes with RPL rates ranging from 60% to 81%. The average time for athletes to return to sport ranged from 5.9 months to 11.9 months. ACL repair with bone marrow stimulation achieved RTS rates ranging from 78-92%. Primary repair techniques demonstrated RTS rates from 67-100%, while primary repair with internal brace techniques demonstrated RTS rates ranging from 36-100%. RTS rates following the BEAR technique were only reported in one study and reported a return to sport rate at 88%. The majority of patients undergoing ACL repair return to sport with a majority also returning to pre-injury levels between 4-11.9 months post-surgery. ACL repair techniques are a viable treatment option in the correct patient population.

Background: Monocytosis (monocyte count &gt;0.8–1.0 x 10⁹/L) signals chronic inflammation or infection. Helicobacter pylori (H. pylori), a widespread gastric pathogen causing chronic gastritis, has been linked to systemic inflammatory responses, including hematologic changes. Objective: This review examines clinical and pathophysiological evidence linking H. pylori infection to monocytosis, focusing on mechanisms and clinical implications. Key Findings: Clinical Association: Numerous studies show H. pylori-infected individuals have elevated monocyte counts. Eradication therapy reduces these counts, suggesting a causal relationship. Pathophysiology: H. pylori induces chronic gastric inflammation and systemic cytokine release (IL-6, TNF-α, IL-1β), along with bacterial products (HP-NAP, urease), stimulating bone marrow monocyte production and systemic low-grade inflammation. Clinical Relevance: Monocytosis in H. pylori is often mild (≤2.0 x 10⁹/L) and reversible after eradication. It may aid diagnosis in endemic regions, especially in patients with dyspepsia or unexplained inflammation, after ruling out other causes. Systemic Impact: This link illustrates H. pylori's broader inflammatory role beyond gastritis. It may contribute to conditions like immune thrombocytopenia (ITP) or metabolic syndrome. Conclusions: Monocytosis is a recognized hematologic feature of H. pylori infection, driven by immune activation and bone marrow stimulation. Though non-specific, it highlights the systemic effects of H. pylori. In high-prevalence areas, clinicians should consider H. pylori in cases of unexplained monocytosis. Post-eradication monocyte normalization may serve as a biomarker of inflammation resolution. Further studies should explore monocyte subsets and their utility in clinical practice.

Osteochondral lesions of the talus (OLTs) are common ankle injuries, even small OLTs (≤100 mm2) cause pain, swelling, and reduced mobility if untreated, yet an optimal treatment standard remains elusive. This study aimed to compare the midterm outcomes of arthroscopic debridement (AD) and bone marrow stimulation (BMS) techniques for small-sized OLTs and to determine possible association between lesion size and clinical efficacy. Patients with small-sized OLTs who received AD or BMS were retrospectively analyzed, with a minimum follow-up of 36 months. A 1:1 propensity score matching was performed, and 32 pairs of patients were matched. Clinical outcomes were assessed using the visual analog scale (VAS), the Karlsson Score, Foot Ankle Outcome Score (FAOS), and the ankle activity score (AAS) scores. In addition, a general linear model analysis was performed between patient demographics and Karlsson scores in 2 groups separately to detect potential risk factors. Finally, 28 patients in the AD group and 30 patients in the BMS group completed the follow-up and were enrolled with a mean follow-up period of 67.63 ± 17.01 months. No preoperative demographic differences were found between the 2 groups (all P > .050). Both AD and BMS groups showed significant improvements in all clinical scores postoperatively. No significant intergroup differences were found in all postoperative scores except FAOS ADL (P = .030). Correlation analysis showed a strong correlation between lesion area and the postoperative Karlsson score in the AD group (r = -0.673, P < .001), with lesions greater than 61.13 mm2 associated with worse outcomes. Arthroscopic debridement and bone marrow stimulation showed similar improvements in clinical scores for small osteochondral lesions of the talus (<60 mm2). For larger lesions (>60 mm2), AD outcomes were worse; given the single-center, retrospective design and modest sample size, this data-derived cutoff is exploratory and requires external validation.

New Perspectives on Ankle Cartilage Pathology and Treatment.

Platelet-rich plasma (PRP) has emerged as a promising orthobiologic treatment for osteochondral lesions of the talus (OLTs), yet its clinical efficacy and mechanistic rationale remain under investigation. A comprehensive literature search identified 6,537 records. After screening and full-text review, 35 studies were included: 8 clinical studies in humans and 27 preclinical studies in animal or in vitro models. Data were extracted on study design, PRP application method, outcomes, and key findings. In human studies, PRP was most frequently evaluated as an adjunct to bone marrow stimulation in OLT treatment. Among 5 studies assessing this approach, 4 reported statistically significant improvements in pain and function compared with bone marrow stimulation alone. Two additional studies examined PRP with other surgical interventions, while 3 assessed PRP as a stand-alone injectable therapy. Although results varied, PRP generally demonstrated favorable outcomes in function, pain, and imaging, with no major complications reported. In preclinical studies, PRP enhanced cartilage repair in histologic, imaging, and biomechanical outcomes. Of 27 studies, 27 evaluated histologic and cellular responses, 14 examined imaging and macroscopic healing, and 7 assessed biomechanical or functional measures. PRP consistently promoted hyaline-like tissue formation, increased anabolic signaling, and improved cartilage integration and mechanical properties. Synergistic effects were observed when PRP was combined with stem cells or biomaterials. PRP demonstrates promising clinical and biological potential in the treatment of OLTs. It appears most effective when used as an adjunct to reparative surgery and may enhance cartilage regeneration through anti-inflammatory and proanabolic mechanisms. However, variability in PRP preparation and limited high-quality comparative trials highlight the need for standardized protocols and further research to optimize its application. Level III. See Instructions for Authors for a complete description of levels of evidence.

As a surgical option for osteochondral lesions of the talus, autologous matrix-induced chondrogenesis (AMIC®) combines bone marrow stimulation, filling of subchondral defects, and application of a collagen bilayer matrix. The purpose of the study was to analyze the cartilage at the treated defect site in two patients. Two patients underwent revision surgery (14 and 36 months after the index AMIC® procedure) for failure due to ligamentous instability. During revision, the repair cartilage was evaluated regarding its integration, presence of fissures, thinning, or firmness. Samples for histologic evaluation were taken from the centre of the treated site. The samples were examined using standard histological and immunohistochemistry techniques. During the revision arthroscopy, the regenerated cartilage was the same color but softer than the surrounding cartilage, superficially frayed, without fissures and even with the level of the original cartilage, but not completely stable on the subchondral bone. Histology revealed the presence of Safranin-O-positive fibrocartilage-like tissue. Additionally, cartilaginous-like tissue was found in the 36-month biopsy. IHC revealed a fraction of collagen type II positive cells in the fibrocartilage-like tissue as well as a collagen type II positive extracellular matrix. The cartilaginous tissue of the 36-month biopsy revealed a homogeneous collagen type II stain. The presence of collagen type II within the tissue indicates its transformation into hyaline-like cartilage at 14 months after AMIC® continuing up to 36 months. While second-look arthroscopies and histological analyses are rare, the data presented here demonstrate cartilage regeneration, with a progressive formation of a hyaline-like cartilaginous tissue in the talus after AMIC®.

Platelet-rich plasma (PRP) is a promising treatment for enhancing the outcomes of bone marrow stimulation for osteochondral lesions of the talus (OLT) and has demonstrated efficacy in alleviating symptoms due to its biological properties. However, the role of leukocyte concentration in PRP remains unclear, particularly regarding cartilage regeneration. This study aimed to compare the clinical outcomes and time to return to activity between leukocyte-poor PRP (LP-PRP) and leukocyte-rich PRP (LR-PRP) in OLT surgery. Data from 29 patients with ≥ two year follow-up were retrospectively reviewed: 18 who received LP-PRP and 11 who received LR-PRP with OLT surgery. The study assessed the timeline of return to activity and Self-Managed Foot Evaluation Questionnaire (SAFE-Q) scores preoperatively and at three months, six months, and two years postoperatively. The LP-PRP group resumed jogging and sports significantly earlier than the LR-PRP group (P = 0.03, P < 0.01). No patients in either group experienced complications. Both groups showed improved SAFE-Q scores at six months, but at two years, the LP-PRP group maintained significantly higher scores compared to their preoperative levels, whereas the LR-PRP group showed declines in some domains. LP-PRP enabled an earlier return to sports compared with LR-PRP. Additionally, LP-PRP maintained good clinical scores two years after surgery. In contrast, the LR-PRP group showed some decline from their early postoperative peak, although absolute scores remained above preoperative levels. These findings suggest that LP-PRP may be an effective adjuvant treatment for OLT surgery. III.

Osteochondral lesions of the talus (OLT) are commonly associated with ankle trauma and can lead to significant symptoms and disability. Patients typically present with deep ankle pain 6-12 months following the initial injury. OLTs can be visualized through imaging techniques such as computed tomography (CT) scans and magnetic resonance imaging (MRI). There is general agreement that non-surgical treatment should be the initial treatment. If non-surgical management does not lead to sufficient clinical improvement, various surgical treatment options are available, both through arthroscopy as well as open techniques. The choice of treatment depends on both patient and lesion characteristics. Given their less invasive nature and shorter recovery times, arthroscopic techniques may usually be considered as a first surgical option. This article describes the etiology and diagnosis of OLTs and summarizes the available evidence on the most commonly used arthroscopic treatment options, such as bone marrow stimulation (BMS), retrograde drilling, fixation and cartilage implantation techniques.

Immediate Postoperative Weightbearing Following Arthroscopic Bone Marrow Stimulation for Talar Osteochondral Lesions: A Matched Cohort Study

To compare the clinical and radiological outcomes between bone marrow stimulation (BMS) and decortication as footprint preparation techniques in patients undergoing arthroscopic rotator cuff repair (ARCR).This double-blinded randomized clinical trial recruited 120 patients aged over 45 years, at active levels, and diagnosed with chronic unilateral rotator cuff tears. Participants were 1:1 randomized to undergo ARCR using the double-row suture-bridge technique with BMS (BMS group) or with decortication (DEC group) for footprint preparation. The primary outcome was the American Shoulder and Elbow Surgeons (ASES) score (range, 0–100, with higher scores indicating better shoulder function and fewer symptoms) at 24 months. Secondary outcomes included patient-reported outcomes, physical examinations, and rotator cuff integrity (evaluated on magnetic resonance imaging using a 5-graded system).Of the 120 participants (age, 58.7 ± 8.1 years; 83 females [69.2%]) enrolled and randomized between May 2017 and November 2021, 109 (90.8%) were analyzed with the completion of follow-up visits. The ASES scores at 24 months were not statistically significantly different between the BMS and DEC groups (89.2 ± 12.2 vs. 87.8 ± 13.9; adjusted difference, 1.7 [95% CI, −3.3 to 6.7]; P = .498). The BMS group showed superior abduction muscle strength (8.7 ± 3.2 vs. 7.4 ± 3.3 kg; P = .031) and rotator cuff integrity (undesirable integrity, 33.9% vs. 54.7%; P = .029) at 24 months as compared with the DEC group; the superiority was more significant in the subgroup of participants with higher shoulder activity levels. The rates of adverse events were comparable between groups.Among patients undergoing ARCR, BMS did not result in superior patient-reported outcomes at 24 months postoperatively compared with decortication. Nevertheless, BMS was superior in improving abduction strength and rotator cuff integrity and may be preferred in patients requiring high levels of manual labor or sports activities.

Delayed Lubricin Injection Improves Cartilage Repair Tissue Quality in an In Vivo Rabbit Osteochondral Defect Model.

Objectives:Bone marrow stimulation (BMS) is a common treatment for osteochondral lesions of the talus (OLTs) with favorable outcomes reported in the literature. However, there are concerns regarding the inferiority of fibrocartilage repair tissue and the potential degradation of results over time. To address these issues, the use of micronized cartilage matrix hydrated with bone marrow aspirate concentrate (MCM-BMAC) as an adjunct to BMS has been proposed to enhance chondrogenic differentiation and promote the development of hyaline-like cartilage. Despite its potential, evidence validating this approach remains limited. This study aimed to assess the clinical and radiographic outcomes of patients who underwent arthroscopic treatment of symptomatic OLTs using MCM-BMAC and BMS at a minimum follow-up of 2 years. Methods:Patients with symptomatic OLTs treated arthroscopically with MCM-BMAC and BMS were identified for this study. Patients were included if they were skeletally mature with a symptomatic chronic OLT as the surgical indication, failed nonoperative treatment, and had a minimum follow-up of 2 years. Outcome measures included American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score, Foot and Ankle Ability Measure (FAAM), Tegner Activity Scale, 36-Item Short Form Health Survey (SF-36, v2), visual analog scale (VAS) for pain, Patient-Reported Outcomes Measurement Information System 10 global survey (PROMIS-10), and patient satisfaction survey. Weightbearing radiographs were compared with preoperative radiographs via an ankle arthritis classification system. MRIs evaluated postoperative lesion characteristics using the magnetic resonance observation of cartilage repair tissue (MOCART 2.0) score and OsteoChondral Allograft MRI Scoring System (OCAMRISS).Results:The study group consisted of 22 patients (12 male, 10 female) with a mean age of 32.2 years (range, 15 – 63), mean follow-up of 4.2 years (range, 2 – 6.8 years), and mean lesion size of 84.2 mm2. Eighteen patients (82%) were very satisfied with their results and 20 patients (91%) reported their current level of function as normal or nearly normal. There was a significant reduction in VAS pain scores (7.0 vs 1.7, p < 0.05) and an increase in AOFAS scores (70.0 vs 90.9, p < 0.05) postoperatively. The mean postoperative Tegner activity level was 5.0, FAAM activities of daily living score was 88.8, and FAAM sports score was 69.0. The mean postoperative PROMIS-10 global physical health and mental health scores were 56.0 and 58.0, respectively, indicating very good and excellent results compared to the general population. The mean SF-36,v2 physical component score was 81.6. No patients showed evidence of radiographic progression of osteoarthritis. Postoperative MRI MOCART scores showed complete cartilage volume fill in 29% of cases, complete integration in 36% of cases, and an intact repair surface in 21% of cases, with a mean score of 58.2. The mean postoperative OCAMRISS score was 6.7. MRI findings did not correlate with clinical outcomes.Conclusions:Arthroscopic treatment of symptomatic OLTs treated with MCM-BMAC and BMS demonstrated high functional outcomes and clinical satisfaction rates despite discordant MRI results.

Fibrocartilage repair involves chronic cellular senescence in a rat model of bone marrow stimulation.

In Shoulder-Active Patients Having Arthroscopic Rotator Cuff Repair, Bone Marrow Stimulation and Decortication Did Not Differ for Patient-Reported Outcomes at 2 Years

Arthroscopic bone marrow stimulation (BMS) is widely used for treating small osteochondral lesions of the talus (OLT). Although its short-term efficacy is well-established, mid- and long-term outcomes remain ambiguous. This study evaluates the 5-year follow-up results of arthroscopic BMS with a focus on pain and functional recovery. We conducted a cohort study at a traumatology and orthopedic department on patients with OLT during 5-year follow-up period. Follow-up evaluations included magnetic resonance imaging (MRI) and computed tomography (CT) scans. Pain levels and functional outcomes were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) score and the Visual Analogue Scale (VAS) at one and five years postoperatively. The study was conducted retrospectively, follow-up time points were determined in accordance with the standard protocol adopted in the clinic. The mean AOFAS score significantly improved from 67.1 ± 9.4 preoperatively to 86.5 ± 12.5 at one year (p < 0.05) and remained consistent at five years (85.7 ± 11.2; p > 0.05). The VAS score showed a marked reduction from 6.4 ± 1.4 preoperatively to 1.6 ± 2.3 at one year (p < 0.05) and 1.9 ± 2.4 at five years (p > 0.05). CT scans confirmed a substantial decrease in lesion size postoperatively, with no significant changes between the one- and five-year evaluations. Arthroscopic BMS demonstrates sustained clinical benefits for OLT, providing significant pain relief and functional improvement over a mid-term period.Level of Evidence:4. The online version contains supplementary material available at 10.1007/s43465-025-01527-x.

Bone marrow stimulation (BMS) is the most commonly performed surgery for osteochondral lesion of the talus (OLT), but there is a risk of poor outcome when cysts recur. The indications of BMS in the presence of cystic OLT remain controversial. To investigate whether a new "jumping dot (JD) sign," manifesting as speckle-like areas of elevated signals surrounding the subchondral bone cyst (SBC) on preoperative magnetic resonance imaging (MRI) against the background of bone marrow edema (BME), could be a predictor of clinical outcome and recurrence of SBCs following BMS and to further propose a more precise indication regarding BMS surgery for cystic OLT. Cohort study; Level of evidence, 3. Patients with cystic OLTs (<150 mm2) who received BMS between November 2016 and January 2021 were retrospectively studied. Visual analog scale for pain and American Orthopaedic Foot & Ankle Society (AOFAS) scores were assessed preoperatively and at follow-up. The normal bone marrow, BME, and SBCs (including size) were quantified, and the JD sign was evaluated on the preoperative MRI. Notably, the maximal vertical diameter of the cyst was rigorously defined as the greatest distance measured from the superior to the inferior margins of the cyst in this study. The MOCART (magnetic resonance observation of cartilage repair tissue) score and the cyst recurrence were evaluated, and multivariate analysis was performed to evaluate the association of the JD sign with outcomes at the final follow-up. A total of 117 patients were divided into the JD sign group (n = 41) and no JD sign group (n = 76), and no significant difference was found for the follow-up duration (48.04 ± 14.78 months vs 48.46 ± 15.38 months; P = .89). Overall, the patients had significantly improved AOFAS scores (68.69 ± 7.46 vs 86.40 ± 10.75; P = .009) and lessened postoperative cysts (117/117 vs 43/117; P = .000). However, both uni- and multivariate analysis revealed that the JD sign was negatively associated with clinical outcomes following BMS (P < .05). Additionally, the JD sign group showed significantly higher cyst recurrence rate (75.60% vs 15.78%; P < .001) and lower MOCART score (73.04 ± 11.28 vs 80.59 ± 19.07; P = .008). When the maximal vertical diameter of the cyst was >5.4 mm, the JD sign showed excellent effectiveness in predicting the postoperative cyst recurrence (sensitivity, 81.4%; specificity, 68.9%; positive predictive value, 61.34%; and negative predictive value, 86.44%). The JD sign might be significantly associated with inferior clinical outcomes and higher SBC recurrence following BMS for cystic OLT. For those patients with the maximal vertical diameter of the cyst >5.4 mm and with JD signs, BMS may not be an appropriate option.