Marrow Stimulation Techniques Research Articles

Knee Cartilage Injuries in Football Players: Clinical Outcomes and Return to Sport After Surgical Treatment: A Systematic Review of the Literature.

To systematically review the literature and analyze clinical outcomes and return-to-sport after surgical management of cartilage injuries in football players. A systematic literature review was performed in August 2023 on PubMed, WebOfScience, and Cochrane Library to collect studies on surgical strategies for cartilage lesions in football players. Methodological quality and risk of bias were assessed with the modified Coleman Methodology score and RoB2 and RoBANS2 tools. Fifteen studies on 409 football players (86% men, 14% women) were included: nine prospective and two retrospective case series, one randomized controlled trial, one prospective comparative study, one case report, and one survey. Bone marrow stimulation (BMS) techniques were the most documented. The lesion size influenced the treatment choice: debridement was used for small lesions (1.1 cm2), BMS, osteochondral autograft transplantation (OAT), matrix-assisted autologous chondrocytes transplantation (MACT), and scaffold-augmented BMS for small/mid-size lesions (2.2-3.0 cm2), and autologous chondrocytes implantation (ACI) for larger lesions (5.8 cm2). The surgical options yielded different results in terms of clinical outcome and return-to-sport, with fastest recovery for debridement and scaffold-augmented BMS. The current evidence is limited with large methodological quality variation (modified Coleman Methodology score 43.5/100) and a high risk of bias. Decision-making in cartilage injuries seems to privilege early return-to-sport, making debridement and microfractures the most used techniques. The lesion size influences the treatment choice. However, the current evidence is limited. Further studies are needed to confirm these findings and establish a case-based approach to treat cartilage injuries in football players based on the specific patient and lesion characteristics and the treatments' potential in terms of both return-to-sport and long-term results. Systematic review, level IV.

Micro CT Analysis and 3D Modelling of Fluid Permeability of Talar Subchondral Bone After Marrow Stimulation Techniques Demonstrates Superiority of Nanofracture Over Microfracture and Fine Wire Drilling

Introduction/Purpose: The aim was to compare different bone marrow stimulation techniques and consequent fluid permeability of subchondral bone by assessing flow of radiopaque contrast agent using μCT image analysis and 3D modelling. Methods: Donated human tali specimens (n=12) were prepared by creating separate matched 10mm diameter chondral defects in each. Each defect underwent one of three surgical techniques: fine wire drilling, nanofracture or microfracture, addition of radiopaque contrast agent and imaged using a clinical μCT scanner. Using Slicer 3D software each μCT scan was segmented for bone and contrast agent regions in each surgical site of each sample. Each site was resolved into a cylinder and the ratio of segmented pixels of contrast agent against bone calculated. Results: μCT analysis indicated that 8/12 nanofracture regions demonstrated enhanced flow of contrast to at least the depth of the fracture site, with some additional lateral flow also observed. 8/12 microfracture regions demonstrated flow of contrast agent localised to the fracture site and preferential flow laterally. Only 1/12 samples with fine wire drilling demonstrated any fluid flow. In 11/12 samples that showed no permeation of contrast agent, a residual layer of contrast agent on the chondral surface was seen. Segmentation of each sample site showed a significant increase (n=12, p< 0.05) in fluid flow of the contrast agent in the nanofracture sites (11%) compared to microfracture (5%) and fine wire drilling (2%). Conclusion: Nanofracture showed significantly improved fluid permeability throughout the surrounding trabecular structure, when compared to microfracture and fine wire drilling. Microfracture allowed some fluid flow, but only confined to the immediate area around the fracture site, while fine wire drilling allows very little fluid flow at all. This study suggests that nanofracture should perhaps be the preferred mode of subchondral bone preparation for osteochondral lesions of the talus. Quantitative measurement of contrast permeability into talar subchondral bone by technique Nanofracture showed significantly improved fluid permeability throughout the surrounding trabecular structure, when compared to microfracture and fine wire drilling

Treatment of knee cartilage lesions in 2024: From hyaluronic acid to regenerative medicine.

Intact articular cartilage plays a vital role in joint homeostasis. Local cartilage repairs, where defects in the cartilage matrix are filled in and sealed to congruity, are therefore important treatments to restore a joint equilibrium. The base for all cartilage repairs is the cells; either chondrocytes or chondrogeneic cells from bone, synovia and fat tissue. The surgical options include bone marrow stimulation techniques alone or augmented with scaffolds, chondrogeneic cell implantations and osteochondral auto- or allografts. The current trend is to choose one-stage procedures being easier to use from a regulatory point of view. This narrative review provides an overview of the current nonoperative and surgical options available for the repair of various cartilage lesions. Level IV.

Continuous Low-Intensity Ultrasound Improves Cartilage Repair in Rabbit Model of Subchondral Injury.

Subchondral drilling (SD), a bone marrow stimulation technique, is used to repair cartilage lesions that lack regenerative potential. Cartilage repair outcomes upon SD are typically fibrocartilaginous in nature with inferior functionality. The lack of cues to foster the chondrogenic differentiation of egressed mesenchymal stromal cells upon SD can be attributed for the poor outcomes. Continuous low-intensity ultrasound (cLIUS) at 3.8 MHz is proposed as a treatment modality for improving cartilage repair outcomes upon marrow stimulation. Bilateral defects were created by SD on the femoral medial condyle of female New Zealand white rabbits (n = 12), and the left joint received cLIUS treatment (3.8 MHz, 3.5 Vpp, 8 min/application/day) and the contralateral right joint served as the control. On day 7 postsurgery, synovial fluid was aspirated, and the cytokine levels were assessed by Quantibody™ assay. Rabbits were euthanized at 8 weeks and outcomes were assessed macroscopically and histologically. Defect areas in the right joints exhibited boundaries, incomplete fill, irregular cartilage surfaces, loss of glycosaminoglycan (GAG), and absence of chondrocytes. In contrast, the repaired defect area in the joints that received cLIUS showed complete fill, positive staining for GAG with rounded chondrocyte morphology, COL2A1 staining, and columnar organization. Synovial fluid collected from cLIUS-treated left knee joints had lower levels of IL1, TNFα, and IFNγ when compared to untreated right knee joints, alluding to the potential of cLIUS to mitigate early inflammation. Further at 8 weeks, left knee joints (n = 12) consistently scored higher on the O'Driscoll scale, with a higher percent hyaline cartilage score. No adverse impact on bone or change in the joint space was noted. Upon a single exposure of cLIUS to TNFα-treated cells, nuclear localization of pNFκB and SOX9 was visualized by double immunofluorescence and the expression of markers associated with the NFκB pathway was assayed by quantitative real-time polymerase chain reaction. cLIUS extends its chondroprotective effects by titrating pNFκB levels, preventing its nuclear translocation, while maintaining the expression of SOX9, the collagen II transcription factor. Our combined results demonstrate that healing of chondral defects treated with marrow stimulation by SD can be accelerated by employing cLIUS regimen that possesses chondroinductive and chondroprotective properties. Impact statement Repair of cartilage represents an unsolved biomedical burden. In vitro, continuous low-intensity ultrasound (cLIUS) has been demonstrated to possess chondroinductive and chondroprotective potential. To our best knowledge, the use of cLIUS to improve cartilage repair outcomes upon marrow stimulation, in vivo, has not been reported and our work reported here fills that gap. Our results demonstrated enhanced cartilage repair outcomes under cLIUS (3.8 MHz) in a rabbit model of subchondral injury by subchondral drilling. Enhanced repair stemmed from mesenchymal stem cell differentiation in vivo and the subsequent synthesis of articular cartilage-specific matrix.

Similar Healing Rates of Arthroscopic Rotator Cuff Repair With and Without Bone Marrow Stimulation: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Background: Bone marrow stimulation (BMS) techniques such as microfracture, nanofracture, and the crimson duvet procedure expose the bone marrow of the proximal humerus to the rotator cuff tendon footprint. The effect of performing BMS on tendon healing is a subject of interest. Purpose: To compare studies on arthroscopic rotator cuff repair with BMS versus without BMS for rotator cuff tears according to healing rates and clinical and radiological outcomes. Study Design: Systematic review and meta-analysis; Level of evidence, 2. Methods: The 2020 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed in conducting a search. Studies that compared arthroscopic rotator cuff repair with and without BMS were included if they provided postoperative patient-reported outcomes and healing rates. Dichotomous outcomes were expressed as mean differences (MDs), while continuous outcomes were expressed as odds ratio. Results: Included were 5 studies (N = 499 shoulders); 4 studies had level 1 evidence, and 1 study had level 2 evidence. The healing rate of rotator cuff repair was similar between the 2 groups (ie, with and without BMS) (odds ratio, 1.58 [95% CI, 0.63 to 4.00]; P = .33). Furthermore, there were no significant differences in the postoperative Constant score (MD, 1.41 [95% CI, –0.58 to 3.39]; P = .16), American Shoulder and Elbow Surgeons score (MD, 0.77 [95% CI, –1.43 to 2.96]; P = .49), or range of motion for forward flexion (MD, 2.45 [95% CI, –0.66 to 5.57]; P = .12) and external rotation (MD, 0.81 [95% CI, –2.35 to 3.97]; P = .62) at the final follow-up between the 2 groups. Conclusion: The healing rate of rotator cuff repair was similar, regardless of whether BMS was performed or not. Additionally, there was no significant difference in postoperative patient-reported outcome scores, range of motion, and complications. Registration: CRD42023388427 (PROSPERO).

Return to sport after surgery for osteochondral lesions of the talar dome. Results of a multicenter prospective study on 58 patients

IntroductionOsteochondral lesions of the talar dome (OLTD) are most often found in patients for whom the return to sports activities is the main issue. Two types of surgery have been distinguished at present, bone marrow stimulation techniques and mosaicplasty techniques. The size of the lesion indicating the need for bone marrow stimulation as the required surgical procedure has recently been decreased (<1cm). The main objective of this study was therefore to evaluate the return to sport after OLTD surgery. Our hypothesis is that surgery of osteochondral lesions of the talar dome allows the resumption of sports activities in the majority of cases. Material and methodsThis multicenter prospective study was conducted across 10 French centers specializing in foot and ankle surgery. All patients aged 18 to 65 with symptomatic OLTD resistant to thorough medical treatment for at least 6 months, justifying surgery, were included from June 2018 to September 2019. In addition to the usual demographic data, the practice of sport and level (professional, competitive, leisure) were systematically investigated preoperatively. A common protocol for surgical management and postoperative follow-up had previously been established according to the arthrographic stage of the lesion. The most recent recommendations based on size, but also depth, were taken into account. The primary endpoint was return to sport. ResultsA final functional evaluation with the AOFAS (American Orthopedic Foot & Ankle Society) score was performed at a minimum of 12 months. Of 58 sports patients, 70.6% returned to sport (41/58) with an average delay of 4.3 months. A high AOFAS functional score (p=0.02) and a stage 1 lesion (p=0.006) were the only preoperative criteria significantly associated with a return to sport. No other factor was predictive of a return to sport. ConclusionOur prospective study shows that 70.6% of sports patients returned to sport after OLTD surgery according to a surgical protocol and standardized follow-up. Level of evidenceII.

Microfracture Lateral to the Greater Tuberosity of the Humerus Enhances Tendon-to-Bone Healing in a Rat Rotator Cuff Model

Background: Microfracture at the rotator cuff insertion is an established surgical marrow-stimulation technique for enhancing rotator cuff healing. However, the effect of lateralized or medialized microfracture on the insertion is unknown. Purpose: To compare the biomechanical and histologic effects of microfracture at 3 different regions for rotator cuff repair in a rat model. Study Design: Controlled laboratory study. Methods: A total of 72 Sprague-Dawley rats with bilateral supraspinatus tendon insertion detachment were allocated into 4 groups with 4 different interventions: no microfracture at the humeral head as a control group (Con), traditional microfracture at the footprint area (MFA), and medialized microfracture to the footprint area (MMFA) on the articular surface of the humerus or lateralized microfracture to the footprint area at the greater tuberosity (LMFA). All underwent immediate repair. Tendon-to-bone healing was assessed by biomechanical and histologic tests 4 and 8 weeks postoperation. Results: At 4 weeks, the LMFA group showed a significantly superior failure load compared with the other groups (all P < .05). The LMFA and MFA groups showed significantly superior stiffness compared with the Con and MMFA groups (all P < .01). At 8 weeks, superior failure load and stiffness were observed in the LMFA group compared with the control group (all P < .05). Histologic examination revealed that the LMFA group had superior collagen composition and tendon-to-bone maturation at the interface at 4 and 8 weeks compared with the Con group (all P < .05). Conclusion: Lateralized microfracture at the greater tuberosity improved the histologic quality of repair tissue and biomechanical strength at the tendon-to-bone insertion after rotator cuff repair in a rat model. Clinical Relevance: Microfracture lateral to the footprint area might be a better way to enhance rotator cuff healing clinically.

Single-step ultra-purified alginate gel implantation in patients with knee chondral defects.

Implantation of ultra-purified alginate (UPAL) gel is safe and effective in animal osteochondral defect models. This study aimed to examine the applicability of UPAL gel implantation to acellular therapy in humans with cartilage injury. A total of 12 patients (12 knees) with symptomatic, post-traumatic, full-thickness cartilage lesions (1.0 to 4.0 cm2) were included in this study. UPAL gel was implanted into chondral defects after performing bone marrow stimulation technique, and assessed for up to three years postoperatively. The primary outcomes were the feasibility and safety of the procedure. The secondary outcomes were self-assessed clinical scores, arthroscopic scores, tissue biopsies, and MRI-based estimations. No obvious adverse events related to UPAL gel implantation were observed. Self-assessed clinical scores, including pain, symptoms, activities of daily living, sports activity, and quality of life, were improved significantly at three years after surgery. Defect filling was confirmed using second-look arthroscopy at 72 weeks. Significantly improved MRI scores were observed from 12 to 144 weeks postoperatively. Histological examination of biopsy specimens obtained at 72 weeks after implantation revealed an extracellular matrix rich in glycosaminoglycan and type II collagen in the reparative tissue. Histological assessment yielded a mean overall International Cartilage Regeneration & Joint Preservation Society II score of 69.1 points (SD 10.4; 50 to 80). This study provides evidence supporting the safety of acellular UPAL gel implantation in facilitating cartilage repair. Despite being a single-arm study, it demonstrated the efficacy of UPAL gel implantation, suggesting it is an easy-to-use, one-step method of cartilage tissue repair circumventing the need to harvest donor cells.

Current Concepts in Clinical Treatment of Osteochondral Lesions of the Talus

Osteochondral lesions of the talus (OLTs) are common reason for the deep ankle pain and seriously affect patient’s sports and the daily life. Managements of the OLTs including conservative treatment, cartilage repair surgery, cartilage replacement surgery and cartilage regeneration surgery. For asymptomatic, serendipitous, or acute OLTs with no displaced fragments, conservative treating is suitable to execute, including mainly including affected ankle immobilization with or without physical therapy, bone stimulation, or drugs used. For small OLTs, cartilage repair strategy like bone marrow stimulation technique (BMS) was recommended, and microfracture is the most commonly used surgical procedure. For larger OLTs, both cartilage replacement and cartilage regeneration could be considered including. Although there are many treatment options, each treatment option may have certain limitations and may not be applicable. With the continuous development of science and technology, the development of biological adjuvants and tissue engineering technology has been accelerated and promoted. The combined application of surgery and biological adjuvants and tissue engineering technology has gradually become a hot spot in clinical research. This work briefly introduced present strategies and advance in treatment of OLTs and discussed the potential application problems aiming to provide reference for the future treatment selection and research of OLTs.

Local Intraoperative Marrow-Derived Augmentation for Primary Rotator Cuff Repair: An Updated Systematic Review and Meta-analysis of Studies From 2010 to 2022

Recurrent tears of the rotator cuff pose a substantial problem despite advances in repair technique. Biologic augmentation via marrow stimulation or vented anchors may strengthen the suture-tendon junction and improve healing rates of native tissue, thereby enhancing outcomes of primary surgical repair. To provide a focused systematic review and meta-analysis of local, intraoperative marrow-derived augmentation techniques in clinical primary rotator cuff repair. Systematic review; Level of evidence, 4. A systematic review of PubMed, Embase, and Cochrane was conducted following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A total of 2131 studies from 2010 to 2022, focused on either marrow stimulation or vented anchors, were isolated and classified as either preclinical or clinical. Meta-analysis was performed for comparative marrow stimulation and vented anchor studies. Heterogeneity was tested through calculation of I 2. A total of 13 clinical studies were included in the review. All 9 comparative studies included in the meta-analysis demonstrated high methodologic quality or a low risk of bias. The pooled retear rate across all 9 clinical studies for patients undergoing marrow stimulation was 11%. For the 5 studies in the meta-analysis, the pooled retear rates were 15% for marrow stimulation and 30% for controls. Meta-analysis demonstrated a significant difference in the overall retear rate that favored marrow stimulation (odds ratio [OR], 0.41; 95% CI, 0.25-0.66; P = .0003; I 2 = 0%). Similarly, meta-analysis of the Constant score at final follow-up demonstrated a statistically significant difference between the 2 groups that favored a higher Constant score in the marrow stimulation group (mean difference, 2.84; 95% CI, 1.02-4.66; P = .002; I 2 = 29%). Vented anchors demonstrated improved ossification and bone density at the anchor site, but no difference in outcomes or retear. Pooled retear rates were 22.5% for vented anchors and 27.8% for controls. Current evidence demonstrates that marrow-stimulation techniques may have a positive impact on healing and retear rate, while vented anchors have a muted impact relative to nonvented anchors. Although available evidence is limited and more research is needed, findings to date suggest that marrow stimulation techniques may be an inexpensive, straightforward technique to consider in qualifying patients to prevent rotator cuff retears.

A novel retrograde technique for ankle osteochodral lesions: the sub-endo-chondral regenerative treatment (secret).

To describe a new surgical technique for osteochondral lesions of the ankle, using bone marrow concentrate on a scaffold and homologous bone graft positioned through a retrograde approach. Many surgical options for ankle osteochondral lesions have been described, and the ideal treatment is still debated. Bone marrow stimulating techniques are recommended for cystic lesions, with some concerns regarding the healing potential of the subchondral bone. In case of wide osteochondral defects, regenerative solutions are preferred but a massive chondral debridement is usually required. To overcome these problems, a novel technique is proposed. The proposed technique was performed on patients affected by osteochondral lesions of the talus, either cysts with intact cartilage or wide osteochondral defects. A preoperative magnetic resonance imaging was obtained to localize the lesion. A 6-mm tarsal tunnel was retrogradely created toward the lesion, to allow a complete sub-endo-chondral debridement preserving the healthy cartilage. A hyaluronan scaffold soaked with a previously prepared bone marrow concentrate was retrogradely positioned under the cartilage surface and the tunnel was filled with homologous bone graft. Preoperative clinical scores and postoperative x-rays were registered. Four patients were treated using this technique. No intraoperative and postoperative complications occurred. Good bone remodeling was observed at 12-week postoperative x-rays. This technique combines the mini-invasiveness of retrograde drilling with the regenerative properties of biological scaffold soaked with bone marrow concentrate. Despite further research being needed, it seems a new viable solution to treat both subchondral cysts and large osteochondral defects of the ankle, whose management is still controversial.

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.

Clinical Outcomes of Osteochondral Fragment Fixation Versus Microfracture Even for Small Osteochondral Lesions of the Talus

Background: The bone marrow stimulation (BMS) technique is performed for osteochondral lesions of the talus (OLTs) with a lesion size of <100 mm2. The lesion defect is covered with fibrocartilage, and the clinical outcomes deteriorate over time. In contrast, the osteochondral fragment fixation can restore the native articular surface. The difference in clinical outcomes between these procedures is unclear. Purpose: To compare the clinical outcomes of BMS and osteochondral fragment fixation for OLTs and examine the characteristics of patients with poor clinical outcomes of BMS. Study Design: Cohort study; Level of evidence, 3. Methods: In total, 62 ankles in 59 patients with OLTs were included. BMS was performed for 26 ankles, and fixation was performed for 36 ankles. Clinical outcomes, including the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle Hindfoot Scale and bone marrow edema (BME) as identified on magnetic resonance imaging, were compared between the 2 groups. On computed tomography scans, the lesion location was compared with or without BME in each group. Results: The AOFAS scores in the fixation group (97.3 ± 4.3 points) were significantly higher than those in the BMS group (91.3 ± 7.7 points), even when the lesion size was <100 mm2 (P < .05). When comparing the ankles with or without BME in each group, the AOFAS scores at the final follow-up were significantly lower for the ankles with BME (88.6 ± 7.8 points) than for those without BME (95.0 ± 6.1 points) in the BMS group (P < .05). Lesions with BME in the sagittal plane were located more centrally than those without BME in the BMS group. In the fixation group, there were no significant differences in AOFAS scores and location of the lesion in ankles with or without BME. Conclusion: The clinical outcomes of osteochondral fragment fixation are superior to those of BMS in OLTs, even for lesions sized <100 mm2. Fixation is recommended even for small lesions, especially for more centralized lesions in the medial and lateral sides of the talus.

Subchondral Drilling Independent of Drill Hole Number Improves Articular Cartilage Repair and Reduces Subchondral Bone Alterations Compared With Debridement in Adult Sheep

Background: Subchondral drilling is an established marrow stimulation technique for small cartilage defects, but whether drilling is required at all and if the drill hole density affects repair remains unclear. Hypotheses: Osteochondral repair is improved when the subchondral bone is perforated by a higher number of drill holes per unit area, and drilling is superior to defect debridement alone. Study Design: Controlled laboratory study. Methods: Rectangular full-thickness chondral defects (4 × 8 mm) were created in the trochlea of adult sheep (N = 16), debrided down to the subchondral bone plate without further treatment as controls (no treatment; n = 7) or treated with either 2 or 6 (n = 7 each) subchondral drill holes (diameter, 1.0 mm; depth, 10.0 mm). Osteochondral repair was assessed at 6 months postoperatively by standardized (semi-)quantitative macroscopic, histological, immunohistochemical, biochemical, and micro–computed tomography analyses. Results: Compared with defect debridement alone, histological overall cartilaginous repair tissue quality (P = .025) and the macroscopic aspect of the adjacent cartilage (P≤ .032) were improved after both drilling densities. Only drilling with 6 holes increased type 2 collagen content in the repair tissue compared with controls (P = .038). After debridement, bone mineral density was significantly decreased in the subchondral bone plate (P≤ .015) and the subarticular spongiosa (P≤ .041) compared with both drilling groups. Debridement also significantly increased intralesional osteophyte sectional area compared with drilling (P≤ .034). No other differences in osteochondral repair existed between subchondral drilling with 6 or 2 drill holes. Conclusion: Subchondral drilling independent of drill hole density significantly improves structural cartilage repair compared with sole defect debridement of full-thickness cartilage defects in sheep after 6 months. Subchondral drilling also leads to a better reconstitution of the subchondral bone compartment below the defects. Simultaneously, drilling reduced the formation of intralesional osteophytes caused by osseous overgrowth compared with debridement. Clinical Relevance: These results have important clinical implications, as they support subchondral drilling independent of drill hole number but discourage debridement alone for the treatment of small cartilage defects. Clinical studies are warranted to further quantify the effects of subchondral drilling in similar settings.

Promoting endogenous articular cartilage regeneration using extracellular matrix scaffolds.

Articular cartilage defects fail to heal spontaneously, typically progressing to osteoarthritis. Bone marrow stimulation techniques such as microfracture (MFX) are the current surgical standard of care; however MFX typically produces an inferior fibro-cartilaginous tissue which provides only temporary symptomatic relief. Here we implanted solubilised articular cartilage extracellular matrix (ECM) derived scaffolds into critically sized chondral defects in goats, securely anchoring these implants to the joint surface using a 3D-printed fixation device that overcame the need for sutures or glues. In vitro these ECM scaffolds were found to be inherently chondro-inductive, while in vivo they promoted superior articular cartilage regeneration compared to microfracture. In an attempt to further improve the quality of repair, we loaded these scaffolds with a known chemotactic factor, transforming growth factor (TGF)-β3. In vivo such TGF-β3 loaded scaffolds promoted superior articular cartilage regeneration. This study demonstrates that ECM derived biomaterials, either alone and particularly when combined with exogenous growth factors, can successfully treat articular cartilage defects in a clinically relevant large animal model.

Osteochondral lesions of the talar dome in the athlete: what evidence leads to which treatment

Osteochondral lesions of the talar dome in the athlete: what evidence leads to which treatment

Marrow stimulation in football (soccer) players: a narrative review

IntroductionThe prevalence of focal cartilage defects in elite athletes is estimated to be as high as 36%, and treatment in professional football players poses a complex clinical challenge. Marrow stimulation is a common treatment option for athletes with symptomatic, contained, full-thickness chondral injuries. ObjectivesTo report the current indications for and efficacy of marrow stimulation in football players. MethodsPubMed, Scopus, and Embase were searched. All levels of evidence (I-IV) pertaining to marrow stimulation in football players were analyzed and presented in a narrative review. ResultsReported return to sport rates following microfracture range from 52% to 95%, with up to 67% of athletes returning to preinjury level of performance. Clinical outcomes improve shortly after microfracture but may decline by 2 years postoperatively. Augmented marrow stimulation techniques have since been developed in an effort to improve repair quality and clinical outcomes, though supporting data is limited. ConclusionIn professional football players, marrow stimulation is a viable treatment for the repair of small (<2 cm2), isolated cartilage injuries, though deterioration of mid- to long-term outcomes may hamper its widespread use. Multiple augmentation techniques have demonstrated the potential to generate a mechanically and biologically superior repair; however, more robust, high-level studies are needed to adequately assess efficacy.

Platelet-Rich Plasma and Adipose-Derived Mesenchymal Stem Cells in Association with Arthroscopic Microfracture of Knee Articular Cartilage Defects: A Pilot Randomized Controlled Trial.

Background This study aims to compare the effects of platelet-rich plasma (PRP) alone or in combination with adipose-derived mesenchymal stem cells (AD-MSCs) in patients affected by cartilage defects, undergoing knee arthroscopic microfracture. Methods Thirty-eight patients diagnosed with a knee monocompartmental cartilage defect (Outerbridge grade IV) on the MRI, underwent an arthroscopic procedure. After the confirmation of the lesion, they all received the same bone marrow stimulation technique (microfracture) and were randomized into two groups: the first one had additional PRP injection (group A), while the second received PRP and AD-MSC injection (group B). Knee assessment and pain score were documented with Knee Injury Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee (IKDC) score, Short-Form (SF) 12, and Visual Analogue Scale (VAS) before the treatment and at 1, 3, 6, and 12 months of follow-up postoperatively. An additional arthroscopic procedure, performed in four patients for a subsequent meniscal lesion, let us evaluate cartilage evolution by performing a macro/microscopical assessment on cartilage biopsy specimens. Results At the 12-month follow-up, both groups showed a comparable functional improvement. The scores on the IKDC form, KOOS, pain VAS, and SF-12 significantly improved from baseline (p < 0.05) to 12 months postoperatively in both treatment groups. The four second-look arthroscopies showed a complete repair of the articular defects by smooth solid cartilage layer, with a good chondrocytic population, in both groups. A thick smooth hyaline-like cartilage with a predominantly viable cell population and normal mineralization (a form closely resembling native tissue) was observed in group B. Conclusions Modern regenerative medicine techniques, such as PRP and AD-MSC, associated with traditional arthroscopic bone marrow stimulating techniques, seem to enhance cartilage restoration ability. The preliminary results of this pilot study encourage the synergic use of these regenerative modulating systems to improve the quality of the regenerated cartilage.

SUBCHONDRAL DRILLING INDEPENDENT OF DRILL HOLE NUMBER IMPROVES ARTICULAR CARTILAGE REPAIR AND REDUCES SUBCHONDRAL BONE ALTERATIONS COMPARED TO DEBRIDEMENT

Purpose: Subchondral drilling is an established marrow stimulation technique for symptomatic small articular cartilage defects, but the effect of drill hole number per unit area remains unclear. In the current study we first tested the hypothesis that osteochondral repair is improved when the subchondral bone plate is perforated with a higher number of drill holes. Second, we tested the hypothesis that subchondral drilling per se is superior to defect debridement alone.

Surgical therapy in osteoarthritis

To provide an evidence-based overview of the different surgical procedures in osteoarthritis (OA). This narrative review reports on surgical therapies (1) for severe, end stage OA and (2) of surgical options aiming to possibly reduce OA development earlier in the course of the disease. Surgical practice guidelines provide evidence-based recommendations to assist in the clinical decision-making. Total joint arthroplasty represents the only valuable, established surgical option for severe, end stage OA. For hip and knee OA, it is by far the most common surgical procedure and provides considerable pain relief, functional restoration, and improved quality of life. Surgical therapy aiming to postpone OA essentially addresses extra- or intraarticular pre-osteoarthritic deformities, defined as congenital or acquired disturbances of the joint structure that adversely affect its function. Approaches in this category include osteotomies and different cartilage repair procedures such as osteochondral autograft and allograft transfer, marrow stimulation techniques, and autologous chondrocyte implantation. However, they are not only less commonly performed than arthroplasty, but the scientific clinical evidence in favour of this type of surgery to reduce the long-term risk of developing OA is considerably reduced. Total knee and hip arthroplasty are two of the most successful procedures in all of medicine. As the progression of this insidious disease is often asymptomatic and slow, it is imperative to judge reparative procedures at their potential to reduce OA development at long-term, besides their primary clinical outcomes. Evidence-based guidelines provide a valuable tool for high-quality surgical decision making in OA.