Marrow Stimulation Techniques Research Articles

Limited medial osteochondral lesions of the talus associated with chronic ankle instability do not impact the results of endoscopic modified Brostr\xf6m ligament repair

BackgroundThe arthroscopic modified Broström procedure, with repair of the anterior talofibular ligament and extensor retinaculum, produces good functional outcomes in patients with chronic lateral ankle instability (CLAI). CLAI can be associated with osteochondral lesions of the talus (OLTs). It remains unclear whether associated limited OLTs affect clinical outcomes in such patients.MethodsThis retrospective cohort study included 92 CLAI patients with and without OLTs undergoing an all-inside arthroscopic modified Broström procedure from June 2016 to May 2019. The patients were divided into non-lesion group (n = 32) and lesion group (n = 60) according to whether CLAI was associated or not with OLTs. All the osteochondral lesions less than 15 mm in diameter were managed with bone marrow stimulation techniques (arthroscopic microfracture) at the time of the arthroscopic modified Broström procedure. The Visual Analogue Scale (VAS) scores, American Orthopedic Foot and Ankle Society (AOFAS) scores, Karlsson Ankle Function Score (KAFS), Anterior Talar Translation (ATT), Active Joint Position Sense (AJPS), and the rate of return to sports were compared in both groups.ResultsIncrease in all the functional scores (VAS, AOFAS, KAFS, ATT, and AJPS) in both groups was, respectively, recorded 1 year and 2 years after surgery. At the 1-year and 2-year follow-up, there was no significant difference in the VAS, AOFAS, KAFS, ATT, and AJPS scores between the non-lesion and lesion groups.ConclusionIn patients with CLAI who underwent an arthroscopic modified Broström procedure, the presence of limited OLTs (less than 15 mm in diameter), which required arthroscopic microfracture, did not exert any influence on outcome.Level of EvidenceLevel III, a retrospective comparative study.

Magnetic Resonance Imaging Assessment of Cartilage Appearance Following Marrow Stimulation of Osteochondritis Dissecans of the Humeral Capitellum

Osteochondritis dissecans (OCD) of the capitellum is often treated by marrow stimulation techniques with good long-term outcomes. Magnetic resonance imaging (MRI) can be used to characterize the healing of cartilage repair tissue. However, no formal system exists for assessment of cartilage healing after marrow stimulation in capitellar OCD. The aims of this study were to describe the postoperative MRI appearance of capitellar repair cartilage after debridement and marrow stimulation for capitellar OCD and assess differences between symptomatic and asymptomatic patients. This was a retrospective study of patients with capitellar OCD who underwent arthroscopic debridement and marrow stimulation and had a postoperative MRI to assess healing. The classification system developed by Marlovits and colleagues (Magnetic Resonance Observation of Cartilage Repair Tissue) was used to quantitatively profile the cartilage repair tissue in comparison to adjacent "normal" cartilage. Study participants completed an online survey to correlate outcomes with cartilage appearance. Eleven patients who underwent MRI for routine evaluation (asymptomatic), and 18 who underwent MRI for symptoms were identified. Overall, 59% of defects were completely filled, and in 83%, the cartilage surface had ulcerations or fibrillations. The cartilage variables were similar between symptomatic and asymptomatic patients. Capitellar subchondral bone edema was observed on the MRI of every patient who underwent a reoperation and was present in only 62% of those who did not. Clinical scores did not correlate with MRI cartilage findings, but the small sample size limited conclusions regarding clinical outcomes related to postoperative cartilage features seen on MRI. This detailed assessment of cartilage appearance by MRI after marrow stimulation for capitellar OCD demonstrated that incomplete cartilage fill was common in both symptomatic and asymptomatic patients. Those requiring a second surgery were more likely to demonstrate subchondral bone edema. Diagnostic IV.

Arthroscopically Assisted Particulated Juvenile Allograft Cartilage Implantation and Bone Grafting for Treatment of Large Cystic Osteochondral Lesions of the Talus: A Case Series

Category:Ankle; Arthroscopy; Basic Sciences/Biologics; Sports; TraumaIntroduction/Purpose:Osteochondral lesions of the talus (OCLT) are common traumatic injuries and can be difficult to treat. Conventional methods consist of arthroscopic debridement and bone marrow stimulation techniques including microfracture, curettage, abrasion chondroplasty and antegrade/retrograde drilling predominantly leading to fibrocartilage formation. These methods have proved effective for small lesions; however, larger lesions with accompanying subchondral bone cysts require more invasive treatment with osteochondral allografts or autologous chondrocyte implantation. These procedures can require harvesting of osteochondral grafts from the knee or malleolar osteotomies, which have associated donor site morbidities and complications of osteotomy healing. We describe an alternative method, an all-arthroscopic technique to treat these large cystic OCLTs, and sought to determine long-term quality of life metrics for a cohort of patients.Methods:From 2010-2012, six patients with difficult to treat OCLTs underwent arthroscopic-assisted implantation of particulated juvenile allograft cartilage with viable chondrocytes (DeNovo NT) along with autogenous bone grafting from the calcaneus by a single surgeon. These lesions all had associated cystic changes requiring bone graft to fill the defect. Other inclusion criteria included at least two of the following: 1) shoulder lesions, 2) lesion size > 200 mm2, 3) failed previous microfracture treatment, or 4) age > 40 with a Body Mass Index (BMI) > 25 kg/m2. These six patients were fully evaluated using physical examination, patient interviews, and outcome score measures. Follow-up was completed at 2 years, 4 years, and between 6-9 years at their most recent visit. Pre-operative and post-operative functional outcome scores were compared with Wilcoxon Signed Ranked Test.Results:Six patients (age: 43.8 + 14.0 years, BMI: 28.4 + 6.7 kg/m2) had average lesion sizes of 188.5 + 50.9 mm2 (range: 125-260 mm2) and most recent follow-up of 8.4 + 1.2 years (range: 6.0-9.3 years). Post-operatively, average VAS pain scores decreased by 4.2 points, 95% CI [1.6-6.8]. FAAM ADL scores improved from 41.8 to 72.5, 95% CI [11.3-50.1]. SF-36 Physical Component Scores also showed significant improvement by 37.8 points, 95% CI [20.8-54.8]. FAAM Sports (p = 0.055) and AOFAS (p = 0.066) scores clinically improved from 13.3 to 39.2 and 57.7 to 86.3, respectively, and approached statistical significance. There were no intraoperative or perioperative complications with calcaneal bone grafting.Conclusion:A small cohort of patients followed over the course of ~8 years after implantation of particulated juvenile allograft cartilage (DeNovo NT) and autogenous calcaneal bone graft for cystic OCLTs had positive post-operative, self-reported functional outcomes. Patients significantly improved compared to pre-operative measures, with no complications observed. This may be an effective long-term treatment for patients with difficult to treat OCLTs.

Autologous osteochondral transplantation provides succesful recovery in patients with simultaneous medial and lateral talus osteochondral lesions.

The aim of this study was to evaluate the success of simultaneous medial and lateral autologous osteochondral transplantation (AOT) in patients with both medial and lateral osteochondral lesions of the talus (OLT) who could not be treated with bone marrow stimulation techniques or whose previous treatments failed. Five patients who underwent medial and lateral talus AOT in the same session due to simultaneous OLT on medial and lateral talar dome were included in this retrospective study. All the patients were male, and the mean age was 34.8 (range = 26 - 42) years. Double osteochondral grafts were placed separately to the medial and lateral talar dome at the same session. Location and size of the OLT, additional ligament injuries, and postoperative evaluation of the graft were evaluated through magnetic resonance images (MRIs). The criteria of Berndt and Harty, Single Assessment Numeric Evaluation (SANE), American Orthopedic Foot and Ankle Society Score (AOFAS), visual analogue scale (VAS) score, and Tegner Activity Score were assessed preoperatively and at the last follow-up. All patients had suffered an injury with inversion of the foot while daily or sports activity. Average duration of symptoms from onset to osteochondral grafting was 25.2 months. The mean follow-up time was 61 months. The radiological evaluation showed OLT with Stage 4 or 5, anterior talofibular ligament injury and deltoid ligament strain observed in all of the patients. With the numbers available, pre and post-operative comparisons showed a significant increase in patients' satisfaction rate and significant decrease in VAS scores as well as an increase in AOFAS scores with the numbers available. No complications were encountered. Simultaneous AOT for medial and lateral OLT appears to be a reliable surgical procedure with satisfactory clinical results. Level IV, Therapeutic Study.

Review of K.H. Pridie (1959) on “A method of resurfacing osteoarthritic knee joints”

This classic discusses the original publication “A method of resurfacing osteoarthritic knee joints” by Dr K.H. Pridie (1959), where this pioneer surgeon described a newly developed method for the treatment of osteoarthritic joint surfaces of the knee, which he named subchondral drilling. This short and concise 11-line publication appeared in the Proceedings of the Congress of the British Orthopaedic Association. It has generated 464 citations since 1959, becoming part of the hundred most-cited publications in knee research. Pridie introduced in clinical experimentation the entity of Marrow Stimulation Techniques to liberate mesenchymal stem cells from cancellous bone. He was aware that the results induced, in terms of quality of the regrown tissue, was limited and “only” fibrocartilage. His idea might have been raised from the work of numerous animal researchers who confirmed repeatedly since 1905 that cartilage needed an osseous perforation to heal. Although the past 60 years brought modifications from the technique described in the original article, the concept of marrow stimulation introduced by Pridie remains the most frequently used in cartilage repair surgery today.

The Role of Mesenchymal Stromal Cells in the Management of Knee Chondral Defects.

Mesenchymal stromal cells (MSCs) are a subset of progenitor cells that help to promote tissue healing and regeneration through the secretion of various cytokines and growth factors. Although technically pluripotent, MSCs in vivo rarely repair damaged tissue through direct differentiation and engraftment. Augmentation of traditional marrow stimulation techniques with MSCs has been theorized to improve repair tissue quality and defect fill. Clinical trials evaluating this technique are limited but have shown modest improvements compared with isolated marrow stimulation. Various scaffolds also have been utilized in combination with MSCs to treat focal chondral defects. Although the techniques described are heterogeneous, many have shown promising early clinical outcomes. Newer techniques involving 3-dimensional bioprinted scaffolds seeded with MSCs allow for the recreation of complex architecture, more closely resembling articular cartilage. These techniques are evolving and have not yet been studied in human clinical trials.

Clinical outcomes of knee joint distraction combined with marrow stimulation procedures for patients with advanced knee osteoarthritis

BackgroundKnee joint distraction (KJD) has received much attention as a joint preserving surgery, especially in young patients with advanced knee osteoarthritis (OA). MethodsThis study included 16 patients with advanced knee OA who underwent KJD combined with marrow stimulating techniques and were followed up for more than 2 years. The patients’ clinical scores, including the Japanese Orthopaedic Association (JOA) score, Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales, ROM, joint space width, and semiquantitative MRI were evaluated. The factors affecting clinical outcomes were analyzed. ResultsPostoperatively, the JOA score and the individual scores of the KOOS subscales improved significantly (JOA score: P = 0.0028, KOOS-symptoms: P = 0.0016, -pain: P = 0.0011, -ADL: P = 0.0009, -sports/recreation: P = 0.0144, and -QOL: P = 0.0034). Although the extension of the knee joint did not change throughout the follow-up period, flexion of the joint deteriorated at the time of device removal but recovered to the preoperative level at the final follow-up. Preoperative joint space width was 2.4 ± 2.0 mm and at the final follow-up, it increased to 3.3 ± 1.5 mm, showing statistically significant improvement (P = 0.034). The postoperative semiquantitative MRI score also improved significantly (from 6.0 ± 3.0 to 42.1 ± 28.7, P = 0.0001). A high BMI was associated with a poor clinical outcome. ConclusionAlthough the effect of marrow stimulating techniques for cartilage repair was not well clarified and the complication rate was high, the clinical and radiographic outcomes showed significant improvement after KJD combined with marrow stimulating techniques in patients with advanced knee OA. However, we should be careful about suggesting this procedure in obese patients.

Is Microfracture Alone Enough?

The technique of microfracture (MFX) was first performed 40 years ago and served for many years as the main procedure for repairing cartilage defects. There is a need to improve microfractures because the regenerated cartilage differs from the original histological aspect; it is less hyaline and more fibrocartilaginous. In addition, and more importantly, the benefits do not persist and the long-term results are unsatisfactory. Adjunctive treatments include platelet-rich plasma (PRP), cell-free-based scaffolds, adipose-derived mesenchymal stem cells (ADSCs), and bone marrow aspirate concentrate (BMAC). The aim of this review was to provide an overview and a perspective of the available data regarding MFX and the principal adjunctive treatments from recent years and also to challenge the traditional MFX procedure. We found that cell-free scaffolds, platelet-rich plasma, and bone marrow aspirate concentrate, although they are relatively novel therapies, showed great potential and maintained their clinical benefits for longer periods of time compared to microfracture alone. As for chitosan-based therapy and adipose-derived mesenchymal stem cells, we were not able to form a definitive conclusion. We believe that the available data show promising results, and future research should be done on each topic discussed. Moreover, investigators involved in bone marrow stimulation techniques should focus on conducting prospective comparative studies, performing second-look arthroscopy, and rely on a single enhancement procedure that can be adequately compared with MFX alone.

Short-term outcomes following dehydrated micronized allogenic cartilage versus isolated microfracture for treatment of medial talar osteochondral lesions

BackgroundOsteochondral lesions of the talus (OLTs) have been traditionally treated with bone marrow stimulation techniques such as microfracture. However, conventional microfracture results in a biomechanically weaker repair tissue of predominantly type I collagen. Acellular micronized cartilage matrix (MCM) serves as a bioactive scaffold to restore hyaline cartilage. The purpose was to compare short-term outcomes after microfracture with and without augmentation with MCM for medial-sided OLTs. MethodsA retrospective review was performed between 2010–2019 for medial-sided OLTs undergoing treatment with either microfracture augmented with MCM or isolated microfracture. The MCM was hydrated with either bone marrow aspirate concentrate (BMAC) or platelet-rich plasma (PRP). Outcomes included visual analogue scale (VAS) pain scores, Foot and Ankle Activity Measure (FAAM) scores, return-to-daily activities, and return-to-sport. Results48 patients (14 MCM with PRP, 6 MCM with BMAC; 28 isolated microfracture) with average age 35.5 years (range: 13.8–67.2 years) and mean follow-up 4.0 ± 3.4 years (range,.13–10.7) were included. There was no difference in average lesion size between MCM and microfracture groups (64.0 ± 49.4 mm2 versus 57.3 ± 44.2 mm2, P = .63) and a trend toward larger lesion size for BMAC compared to PRP (106.5 ± 59.2 versus 45.9 ± 32.1 mm2, P = .056). There was no difference in time to return-to-activity (83.5 ± 18.8 versus 87.3 ± 49.1 days) or return-to-sports (151.9 ± 62.2 versus 165 ± 99.2 days) with MCM versus isolated microfracture. However, the MCM group had a significantly greater improvement in VAS pain score at final follow-up (4.9 ± 2.2 versus 2.7 ± 2.6, P = .0032) and significantly higher post-operative FAAM-Activities of Daily Living subscale scores (97.2 ± 8.2 versus 79.7 ± 32.8, P = .033). ConclusionsAugmenting microfracture with MCM hydrated with PRP or BMAC may result in beneficial changes in pain scores and activities of daily living, but similar return-to-activities and return-to-sport times compared to microfracture alone in management of medial OLT. Level of evidenceIV.

Reconstruction of Large Osteochondral Lesions in the Knee: Focus on Fixation Techniques.

Large (>3 cm2), focal osteochondral lesions (OCL) may result in poor functional outcomes and early secondary osteoarthritis of the knee. The surgical management of these OCL remains challenging. The treatment strategy must be tailored to various aspects, including lesion-specific (e.g., size, location, chronicity), joint-specific (e.g., instability, limb alignment, meniscal status), and patient-specific factors (e.g., age, activity level, comorbidities). Simple chondroplasty and bone marrow stimulation (BMS) techniques should be reserved for smaller lesions, as they only realize midterm clinical benefits, related to inferior wear characteristics of the induced fibrocartilage (type I collagen). Therefore, much attention has been focused on surgical restoration with hyaline cartilage (type II collagen), based on chondrocyte transplantation and matrix-assisted autologous chondrocyte implantation (MACI). Limited graft availability, staged procedures (MACI), and high treatment costs are limitations of these techniques. However, acute traumatic OCL of the femoral condyles and patellofemoral joint may also be suitable for preservation by surgical fixation. Early detection of the fragment facilitates primary repair with internal fixation. The surgical repair of the articular surface may offer promising clinical and cost-effective benefits as a first-line therapy but remains under-investigated and potentially under-utilized. As a unique characteristic, the fixation technique allows the anatomic restoration of the hyaline articular surface with native cartilage and the repair of the subchondral bone. In this manuscript, we present a case series of large OCL around the knee that were preserved by surgical fixation. Furthermore, various implants and techniques reported for this procedure are reviewed.

Marked differences in local bone remodelling in response to different marrow stimulation techniques in a large animal.

Marrow stimulation, including subchondral drilling and microfracture, is the most commonly performed cartilage repair strategy, whereby the subchondral bone plate is perforated to release marrow-derived cells into a cartilage defect to initiate repair. Novel scaffolds and therapeutics are being designed to enhance and extend the positive short-term outcomes of this marrow stimulation. However, the translation of these newer treatments is hindered by bony abnormalities, including bone resorption, intralesional osteophytes, and bone cysts, that can arise after marrow stimulation. In this study, three different marrow stimulation approaches – microfracture, subchondral drilling and needle-puncture – were evaluated in a translationally relevant large-animal model, the Yucatan minipig. The objective of the study was to determine which method of marrow access (malleted awl, drilled Kirschner wire or spring-loaded needle) best preserved the underlying subchondral bone. Fluorochrome labels were injected at the time of surgery and 2 weeks post-surgery to capture bone remodelling over the first 4 weeks. Comprehensive outcome measures included cartilage indentation testing, histological grading, microcomputed tomography and fluorochrome imaging. Findings indicated that needle-puncture devices best preserved the underlying subchondral bone relative to other marrow access approaches. This may relate to the degree of bony compaction occurring with marrow access, as the Kirschner wire approach, which consolidated bone the most, induced the most significant bone damage with marrow stimulation. This study provided basic scientific evidence in support of updated marrow stimulation techniques for preclinical and clinical practice.

Cartilage repair procedures for early osteoarthritis

Commonly used cartilage repair procedures have been established for focal cartilage lesions; however, degenerative lesions with accompanying changes of other intraarticular structures are much more common in clinical practice. This stage, in which classic radiological signs of osteoarthritis are absent, is called early osteoarthritis and is characterized by impaired joint homeostasis with biomechanical and biochemical changes that can have anegative effect on regenerative cartilage therapy procedures. Cartilage repair procedures are indicated for symptomatic focal early osteoarthritis, defined as cartilage degeneration ICRS gradesI or II around afocal cartilage defect ICRS gradesIII or IV. In more advanced osteoarthritis with significant narrowing of the joint space, cartilage repair procedures are generally contraindicated. The most studied cartilage repair procedure for early osteoarthritis is autologous chondrocyte implantation, which has shown acceptable results in case series, although higher failure rates are to be expected compared to focal, traumatic cartilage lesions. The use of bone marrow-stimulating techniques seems to be limited in early osteoarthritis and should only be used in cases of lesion < 2 cm2 and very little surrounding cartilage degeneration. Concomitant surgical procedures, especially unloading osteotomies, are very important.

Osteochondral Lesions of the Distal Tibial Plafond: A Systematic Review of Lesion Locations and Treatment Outcomes.

Background:Osteochondral lesions of the tibial plafond (OLTPs) remain less common than osteochondral lesions of the talus (OLTs), but recognition of the condition has increased.Purpose:To systematically evaluate the literature on lesion locations and treatment outcomes of OLTPs, whether in isolation or in combination with OLTs.Study Design:Systematic review; Level of evidence, 4.Methods:A search was performed using the PubMed, Embase, and CINAHL databases for studies on lesion locations or with imaging or treatment outcomes of OLTPs. Case reports and reports based on expert opinion were excluded. Lesion locations as well as outcome measure results were aggregated. The Methodological Index for Non-randomized Studies score was used to assess methodological quality when applicable.Results:Included in this review were 10 articles, all published in 2000 or later. Most studies were evidence level 4, and the mean Methodological Index for Non-randomized Studies score was 8.6 (range, 8-10). Overall, 174 confirmed OLTP cases were identified, and the mean patient age was 38.8 years. Of the 157 lesions with confirmed locations, the most common was central-medial (32/157; 20.4%). Of 6 studies on treatment outcomes, all but 1 evaluated bone marrow stimulation techniques. Microfracture of small lesions (<150 mm2) was the most common treatment utilized. Imaging and functional outcomes appeared favorable after treatment. The data did not support differences in outcomes between isolated OLTPs and OLTPs with coexisting OLTs.Conclusion:Osteochondral lesions of the distal tibia most commonly occurred at the central-medial tibial plafond. Microfracture of small lesions was the most common treatment utilized, and clinical and magnetic resonance imaging results were favorable, although data were heterogeneous. Areas for future research include the following: the effect of patient factors and additional pathologies on outcomes; larger or deeper lesion treatment; more direct comparisons of outcomes between kissing or coexisting lesions and isolated lesions; and head-to-head comparison of treatments, such as microfracture, bone marrow–derived cell transplantation, and osteochondral autografts/allografts.

Arthroscopic Minced Cartilage Implantation for Chondral Lesions at the Talus: A Technical Note

In the past few years, autologous chondrocyte implantation has been shown to be the most suitable cartilage reconstructive technique with the best tissue quality. Although this method is part of the standard surgical repertoire in the knee joint, it has so far not been an established method in the ankle because there are no prospective randomized controlled studies to prove a significant advantage over alternative methods of cartilage repair. The methods most frequently used in this context (e.g., marrow stimulation techniques) can, however, at most generate hyaline-like and thus biomechanically inferior regenerates. Minced cartilage implantation, on the other hand, is a relatively simple and cost-effective 1-step procedure with promising biological potential and—at least in the knee joint—satisfactory clinical results. We present an arthroscopic surgical technique by which the surgeon can apply autologous chondrocytes in a 1-step procedure (AutoCart; Arthrex, Munich, Germany) to treat articular cartilage defects in the ankle joint.

Proposal of a new CT arthrographic classification system of osteochondral lesions of the talus

BackgroundSurgical treatment of osteochondral lesions of the talus (OLT) is warranted if medical treatments fail, achieving good results in around 85% of cases. Numerous classification systems, based on all possible imaging modalities (radiography, MRI, CT scan, scintigraphy, and CT arthrography), have been proposed to guide surgical treatments, but none has proven to be superior. A recent study demonstrated the prognostic value of CT arthrography by accurately describing the subchondral bone plate. A systematic review of the literature has brought new criteria to predict good outcome following bone marrow stimulation surgical techniques: lesions should measure less than 1 centimeter in size and 5 millimeters in depth. Based on these data, we are proposing a new simple, 3-stage CT arthrographic classification system of OLT. Materials and methodsAfter a brief overview of the classification, 60 CT-arthrographies of ankles with OLT were organized according to this new CT arthrographic classification system by four surgeons (two juniors and two seniors). Two imaging assessments were performed one month apart. Statistical analysis was performed using the Fleiss’ kappa coefficient to determine the inter- and intraobserver agreement. ResultsAn excellent inter- and intraobserver agreement was found with overall Fleiss’ kappa coefficients of 0.897 and 0.847, respectively. ConclusionThe results of our study showed an excellent inter- and intraobserver agreement for this new CT arthrographic classification system of OLT. The principal advantage of this new classification system, based on the latest data in the literature, is its ability to easily distinguish lesions that are more amenable to bone marrow stimulation techniques. Level of evidenceII.

Acellular Cartilage Repair Technique Based on Ultrapurified Alginate Gel Implantation for Advanced Capitellar Osteochondritis Dissecans.

Background:One of the most important limitations of osteochondral autograft transplant is the adverse effect on donor sites in the knee. Ultrapurified alginate (UPAL) gel is a novel biomaterial that enhances hyaline-like cartilage repair for articular defects. To avoid the need for knee cartilage autografting when treating osteochondritis dissecans (OCD) of the capitellum, we developed a surgical procedure involving a bone marrow stimulation technique (BMST) augmented by implantation of UPAL gel.Hypothesis:BMST augmented by UPAL gel implantation improves the cartilage repair capacity and provides satisfactory clinical outcomes in OCD of the capitellum.Study Design:Case series; Level of evidence, 4.Methods:A total of 5 athletes with advanced capitellar OCD in the dominant elbow underwent BMST augmented by implantation of UPAL gel. The osteochondral defects were filled with UPAL gel after BMST. At a mean follow-up of 97 weeks, all patients were evaluated clinically and radiographically.Results:At final follow-up, all 5 patients had returned to competitive-level sports, and 4 patients were free from elbow pain. The mean Timmerman-Andrews score significantly improved from 100 to 194 points. Radiographically, all patients exhibited graft incorporation and a normal contour of the subchondral cortex. Magnetic resonance imaging showed that the preoperative heterogeneity of the lesion had disappeared, and the signal intensity had returned to normal. Arthroscopic examinations consistently exhibited improvement in the International Cartilage Regeneration and Joint Preservation Society (ICRS) grade of lesions from 3 or 4 to 1 or 2 in 4 patients at 85 weeks postoperatively. Histologic analysis of biopsy specimens revealed an average total ICRS Visual Assessment Scale II histologic score of 1060.Conclusion:The acellular cartilage repair technique using UPAL gel for advanced capitellar OCD provided satisfactory clinical and radiographic results. The present results suggest that this novel technique is a useful, minimally invasive approach for treating cartilaginous lesions in athletes.

Next-Generation Marrow Stimulation Technology for Cartilage Repair: Basic Science to Clinical Application.

Given the relatively high prevalence of full-thickness articular cartilage lesions, including in patients who are <40 years of age, and an inability to detect some of these lesions until the time of arthroscopy, there is value in performing a single-stage cartilage procedure such as marrow stimulation (MS). While the positive outcomes of first-generation MS (namely microfracture) have been observed to drop off after 24 months in several studies, improvements have been seen when compared with preoperative conditions for lesions that are 2 to 3 cm2 in size, and MS is considered to be a procedure with technical simplicity, fairly short surgical times, and relatively low morbidity. A recent study showed that autologous chondrocyte implantation (ACI) and osteochondral allograft (OCA) transplantation remain viable treatment options for chondral defects of the knee in the setting of failed MS. Basic science principles that have been elucidated in recent years include (1) the creation of vertical walls during defect preparation, (2) an increased depth of subchondral penetration, (3) a smaller awl diameter, and (4) an increased number of subchondral perforations, which are all thought to help resolve issues of access to the mesenchymal stromal cells (MSCs) and the subchondral bone structure/overgrowth issues. Pioneering and evolving basic science and clinical studies have led to next-generation clinical applications, such as a hyaluronic acid-based scaffold (ongoing randomized controlled trial [RCT]), an atelocollagen-based gel (as described in a recently published RCT), a micronized allogeneic cartilage scaffold (as described in a recently completed prospective cohort study), and a biosynthetic hydrogel that is composed of polyethylene glycol (PEG) diacrylate and denatured fibrinogen (as described in an ongoing prospective study). This review summarizes important points for defect preparation and the recent advances in MS techniques and identifies specific scaffolding augmentation strategies (e.g., mesenchymal augmentation and scaffold stimulation [MASS]) that have the capacity to advance cartilage regeneration in light of recent laboratory and clinical studies.

Athletic Performance in the National Basketball Association After Arthroscopic Debridement of Osteochondral Lesions of the Talus.

Background:Use of marrow-stimulating techniques to treat osteochondral lesions of the talus (OLTs) in National Basketball Association (NBA) players is controversial.Hypothesis:NBA players will be able to return to preinjury playing status after treatment of OLTs by arthroscopic debridement alone without marrow-stimulating techniques.Study Design:Cohort study; Level of evidence, 3.Methods:Between the 2000 and 2015 seasons, 10 NBA players were treated with arthroscopic debridement of an OLT. The following performance outcomes were compared pre- and postoperatively: seasons played, games played, games started, minutes per game, points per game, field goals, 3-point shots, rebounds, assists, double doubles, triple doubles, steals, blocks, turnovers, personal fouls, assists per turnovers, steals per turnovers, NBA rating, scoring efficiency, and shooting efficiency. In addition, the players were compared with a matched control group using mixed effects regression and Fisher least significant difference modeling.Results:All 10 players returned to play in the NBA after arthroscopic debridement without microfracture or drilling of an OLT. When compared with preoperative performance, postoperative mean points scored, assists made, and steals made increased by 2.86 (P = .042), 0.61 (P = .049), and 0.15 (P = .027), respectively. Only field goal percentage decreased postoperatively when compared with matched controls; however, this normalized by the end of the second season after surgery. There was no statistically significant change in any of the other performance factors when compared with matched controls. All patients returned to basketball during the same season (n = 1) or the following season (n = 9) if the operation was performed off-season. The mean length of career after surgery was 4.1 years, with 5 players still playing in the league at the time of this study.Conclusion:After arthroscopic debridement of an OLT without drilling or microfracture, there was a high rate of return to the NBA, with improved points scored, assists, and steals made after surgery when compared with preoperative performance. There was no statistically significant change in any performance factors when compared with uninjured matched controls. Lesion size did not affect player career length. These data should be used to manage patients’ and teams’ expectations regarding players’ ability to return to elite levels of athletic performance after surgery of an OLT.

Microfacture vs. Drilling of Articular Cartilage Defects: A Systematic Review

Microfracture (MFx) is one of the most common techniques used for the treatment of articular cartilage defects, though recently there has been a trend toward the use of drilling rather than MFx for the treatment of these defects. The purpose of this study was to perform a systematic review of basic science studies to determine the effect of microfracture versus drilling for articular cartilage repair. A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify basic science studies comparing outcomes of MFx versus drilling. The search phrase used was microfracture AND (drilling OR micro drilling). Inclusion criteria were basic science studies that directly compared the effect of MFx versus drilling on the subchondral bone, bone marrow stimulation, and cartilage regeneration. Six studies met the inclusion criteria and were included in this systematic review. Four studies were performed in rabbits and two in humans. All of the included studies investigated cartilage repair in the knee joint. In four studies, 4x4 mm2 cartilage defects were created in mature rabbit knees. Microfracture produced fractured and compacted bone and led to increased osteocyte necrosis as compared to drilling. Deep drilling (6 mm) was superior to both shallow drilling (2 mm) and MFx in terms of increased subchondral hematoma with greater access to marrow stroma, improved cartilage repair, and increased mineralized bone. However, the overall quality of cartilage repair tissue was poor regardless of marrow stimulation technique. Two studies that investigated repair tissue after MFx and/or drilling in human patients with osteoarthritis and cartilage defects found that cartilage repair tissue did not achieve the quality of normal hyaline articular cartilage. Based on the available basic science literature, deep drilling of cartilage defects in the knee joint results in improved biological features compared to MFx, including less damage to the subchondral bone and greater access to marrow stroma. Regardless of marrow stimulation technique, the overall quality of cartilage regeneration was poor and did not achieve the characteristics of native hyaline cartilage.

Is there clinical evidence to support autologous matrix-induced chondrogenesis (AMIC) for chondral defects in the talus? A systematic review and meta-analysis

BackgroundThe aim of this study is to systematically review the literature on clinical outcomes of patients who have undergone autologous matrix-induced chondrogenesis (AMIC) for treatment of osteochondral lesions of the talus (OCL) and compare the studies’ outcomes. MethodsPubmed and Embase were searched in January 2020 for articles concerning OCL surgery. Studies were included if they had a minimum 1-year follow-up and the primary measures were functional outcomes. The meta-analysis compared the Visual Analogic Score (VAS), the American Orthopedic Foot and Ankle Score (AOFAS), and the Foot Function Index (FFI) between baseline and follow-up of 1−2years, and 3−5years. A random effects model was used to evaluate outcome changes. ResultsThe search returned 15 studies, with a total of 492 patients. The VAS improved 4.45 and 4.6 points from baseline to the 1−2year and 3−5yearfollow-up, respectively (p<0.001). AOFAS improved 31.59 and 32.47 points from baseline to the 1−2year and 3−5yearfollow-up, respectively (p<0.001). The FFI showed a significant improvement of 30.93 points from baseline to year 3−5 (p<0.001). A total of 6 patients with revision surgeries have been reported within the follow up period. It was not possible to correlate clinical features like lesion size, surgical approach, and bone marrow stimulation technique to the reported outcome. ConclusionSurgical treatment of OCL via the AMIC procedure provided significant improvement in the functional outcome and pain scores when compared to the pre-operative values. Improvements were observed up to 5years post-operatively.