Osteochondral Lesions Of Talus Research Articles

Association between joint effusions and concomitant structural injuries (tendinitis and structural injury) on MRI in ankle trauma without fracture.

The evaluation of correlations among joint effusion, ligament injuries, tenosynovitis and osteochondral lesion of talus (OLT) in the ankle joint is important for developing a treatment plan and predicting prognosis. To evaluate correlations among tibiotalar (anterior) and talocalcaneal (posterior) joint effusion, tenosynovitis of major flexor tendons, ligaments, and OLT in a group of patients with ankle trauma. This retrospective study included 101 patients with ankle trauma who underwent magnetic resonance imaging. Two radiologists assessed the presence and amount of effusion in the tibiotalar and talocalcaneal joints from grade 0 to 2, according to the amount of capsular distension. Concomitant structural injuries were assessed in the tibialis posterior (TP), flexor digitorum longus, flexor hallucis longus, and peroneus tendons, and the anterior talofibular ligament, calcaneofibular ligament, anteroinferior tibiofibular ligament, posteroinferior tibiofibular ligament, and OLT. The proportion of anterior and posterior joint effusion according to grade was 67.3% for anterior joint effusion grade 0, 22.8% for grade 1, and 9.9% for grade 2; for posterior joint effusion, grade 0 was 74.2%, grade 1 was 22.8%, and grade 2 was 3.0%. We found statistically significant correlations between posterior joint effusion and tenosynovitis of TP (P < 0.05) and between posterior joint effusion and OLT (P < 0.05). Posterior joint effusion is correlated with TP injury and OLT; however, tendon injuries have no correlation with other structural injuries of the ankle joint in a general population with ankle trauma.

Surgical Treatment of Talus OCL: Mid- to Long-Term Clinical Outcome With Detailed Analyses of Return to Sport

Talus osteochondral lesions are a commonly underdiagnosed problem in young athletes. Talus osteochondral lesions surgical algorithm remains controversial. Current metrics suggest that conventional treatment of osteochondral lesions of the talus is promising; yet return to sport is poorly studied. Fifty-seven patients following talus osteochondral lesion surgical intervention were included in this study. About 63.1% were female with mean age 37.1 years, mean lesion size 10×12.5 mm, and mean follow-up 79.9 months postoperatively. Patients were divided into 4 groups by surgery performed: antegrade arthroscopic bone marrow stimulation, retrograde arthroscopic drilling, osteochondral autograft transfer, and allograft cartilage implantation. Outcome metrics include Visual Analog Scale for pain and function, Short Form-12, Foot and Ankle Disability Scale, Tegner, Marx activity scores, Naal Sports inventory, and patient satisfaction. Over 77% of patients were satisfied with surgical intervention. Each intervention significantly decreased pain and increased function, except retrograde drilling. All interventions trended toward decreased Tegner score; only antegrade drilling showed significant decrease. Based on Naal's sports inventory, 85.7% of surgically treated patients reported participating in sport activities, on average 3 times/week and 50.6 minutes/session. Traditionally, talus osteochondral lesions present a difficult problem that is marred by unsatisfactory nonoperative outcomes in typically active patients. As our surgical understanding has evolved, we've continued to improve on outcomes. Our patients demonstrated 77.2% overall satisfaction rate, a statistically significant improvement in pain and function, at an average follow-up of 79.9 months postoperatively, and a high rate of return to sport with little difference between surgical interventions.

Incidence of Talar Osteochondral Lesions After Acute Ankle Fracture: A Retrospective Analysis

Recent literature suggests the majority of osteochondral lesions occur in the ankle joint. Previous studies have suggested that varying incidences of talar osteochondral lesions (OCLT) are associated with ankle fractures. The primary aim of our study was to investigate the incidence of osteochondral lesions associated with acute ankle fractures as observed on computed tomographic (CT) imaging. We also compared the rates of talar osteochondral lesions in patients who had ankle fractures with dislocation and closed manual reduction (CMR) prior to open reduction with internal fixation, to those who did not suffer from ankle joint dislocation. Additionally, a correlation between the location of talar dome lesions with type of ankle fracture as classified by Lauge-Hansen was investigated. Preoperative CT imaging was retrospectively reviewed in 108 patients with acute ankle fractures. A CT-modified version of Berndt Hardy's classification of osteochondral lesions, as previously described by Loomer et al, was used for diagnosis of lesions in our study. The incidence of lesions was calculated across all subjects, and retrospective comparison was performed in those who did and did not undergo closed manual reduction. Supplementary data on location of lesion and its association with ankle fracture type was also recorded. We found an overall incidence of 50.9% OCLT in patients with acute ankle fractures. This number did not significantly differ from those who underwent closed manual reduction (49%). Although a majority of lesions did occur posteriorly, we saw no statistically significant information was seen between either type of fractures or OCLT locations. Careful consideration and thorough evaluation of preoperative CT imaging should be assessed by the performing surgeon, as this could guide both diagnostic and therapeutic treatments for patients with possible osteochondral lesions of the talus undergoing surgical repair of a fractured ankle.

Osteotomy combined with lateral ligament reconstruction in treating osteochondral lesion in patients with talar injury and varus ankle.

This study aimed to investigate the therapeutic effects of osteotomy combined with lateral ligament reconstruction on the osteochondral lesion of patients with talar injuries and varus ankles.Seventy five patients with talar injuries and varus ankles who received osteotomy combined with lateral ligament reconstruction for the osteochondral lesions from June 2008 to December 2014 were retrospectively reviewed. Patients were followed up for 32.4 ± 15.3 months after surgeries, and the AOFAS-AH score, VAS score and SF36 score were determined preoperatively and postoperatively. The iconographic data were compared preoperatively and postoperatively, including tibial anterior surface angle (TAS), TTS, TT, and tibial lateral surface angle (TLS) angles.After surgeries, the AOFAS-AF score increased from 43.2 ± 8.1 to 82.1 ± 5.6, the VAS score decreased from 6.9 ± 2.3 to 1.8 ± 1.5, and the SF36 score increased from 48.7 ± 9.4 to 83.5 ± 6.2. TAS increased from 83.3 ± 5.1 to 90.3 ± 6.1, TTS increased from 70.3 ± 6.1 to 82.5 ± 5.4, TT decreased from 12.9 ± 6.1 to 6.9 ± 5.7, and TLS increased from 76.5 ± 4.1 to 81.2 ± 3.3 (P < .05).Osteotomy combined with lateral ligament reconstruction is effective for the treatment of talar osteochondral lesion with varus ankle, which could relieve the arthritic symptoms induced by cartilage lesions. By correcting the force line on lower limbs and metapedes with osteotomy completely, the treatments on talar osteochondral lesion and lateral ligament reconstruction are the critical factors with better results.

Osteotomy Guides Created Through 3D Tomographic Model for Talus Osteotomies in Massive Allograft Technology Presentation for Massive Fresh Talus Allograft Transplant

The use of 3-dimensional (D) printing in the medical segment has been increasing. In cases in which osteotomies are necessary, the use of tomographic reconstruction is useful for their planning. And if we were to add the design of osteotomy guides and 3D printing, we can ensure more precise cuts. This study aims to present 3D printing for the creation of more precise osteotomy guides, in the treatment of massive talus osteochondral lesions; and proving its use in the transplant of fresh osteochondral allografts. We present the planning and the surgery performed on a patient, using this 3D printing method with specific osteotomy guides designed for the massive osteochondral defect in zones 1, 4, and 5 (Raikin) with 2570 mm3 volume and symptomatic. At 3 months and 1 year postoperation it was evaluated with a computerized axial tomography scan, objectifying a good articular reduction and congruence of the allograft without its collapse. Planning with 3D digital design, as it is the design and production of specific surgical tools for this surgery, improved surgical time, achieving the correct fit of the allograft, and allowed for a full coverage of the osteochondral defect. Level of Evidence: Diagnostic Level V according to the criteria of the Oxford Centre for Evidence-Based Medicine (CEBM). See Instructions for Authors for a complete description of levels of evidence.

Pediatric Bassett's ligament: pathology or normal anatomy?

Bassett's ligament is an accessory fascicle of the anterior inferior tibiofibular ligament. The prevalence, normal thickness and clinical implications of a thickened ligament have not been described in the pediatric radiology literature. The purpose of this study was to determine the prevalence and thickness of Bassett's ligament in pediatric patients with magnetic resonance imaging (MRI) findings of lateral talar osteochondral lesions, medial talar osteochondral lesions and posterior ankle impingement, to compare these measurements with normal MRIs, and to compare the reproducibility of these measurements. This is a retrospective study of pediatric ankle MRIs with four cohorts containing 21 patients each. All MRIs were retrospectively reviewed by a pediatric musculoskeletal radiologist and a pediatric radiology fellow. The prevalence of Bassett's ligament and its axial thickness were obtained for each cohort with repeat measurements for intra-observer and interobserver variability. Average thickness and standard deviation of Bassett's ligament were calculated. The prevalence of Bassett's ligament and its thickness in each cohort were (mean±standard deviation): lateral osteochondral lesions, 71% (15/21), 1.9±0.5mm; medial osteochondral lesions, 52% (11/21), 1.4±0.2mm; posterior impingement, 52% (11/21), 1.3±0.2mm; and normal ankle examinations, 71% (15/21), 1.5±0.4mm. The thickness of Bassett's ligament was increased in the lateral talar osteochondral lesion group when compared to normal (P=0.02), while thickness in the medial osteochondral lesion and posterior impingement groups was not significant when compared to normal. The repeat measurements showed no significant difference in intra-observer and interobserver variability. Bassett's ligament is a normal structure in children. Thickening of Bassett's ligament is seen with lateral osteochondral lesions and may be an indirect sign of anterolateral tibiotalar capsule injury.

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

Historically, microfracture has been used to treat small talar osteochondral lesions with good results, whereas osteochondral autologous transplantation (OAT) has proven effective for the treatment of larger lesions. It is not clear which method is more effective for medium-sized lesions around the critical size of 150 mm2, above which microfracture outcomes tend to be poor. The purpose of this study was to determine the potential advantages of OAT augmented with a combination of extracellular matrix and bone marrow aspirate concentrate (ECM-BMAC) compared to debridement with ECM-BMAC (DEB) in the treatment of medium-sized osteochondral lesions of the talus (OLTs). Clinical and radiographic data were collected retrospectively for patients treated by a single fellowship-trained foot and ankle surgeon. Magnetic resonance images (MRIs) were scored using the Magnetic Resonance Observation of Cartilage Tissue (MOCART) system and were evaluated for the presence of cysts and edema. Fifty-two patients met inclusion criteria, with 25 who received an OAT procedure. Age, body mass index, lesion size, lesion location, and follow-up time were similar between groups. Average MRI follow-up times were 16.7 months for the OAT group and 20.3 months for the DEB group (P = .38). Patients treated with OAT had significantly higher average total MOCART scores (69 vs 55, P = .04) and significantly lower rates of cyst (14% vs 55%, P < .01), edema (59% vs 90%, P = .04), revision surgery (0% vs 19%, P = .05), and therapeutic injection for pain (4% vs 30%, P = .02) compared to patients treated with DEB. No significant differences were detected in patient-reported outcome scores between groups. The native hyaline cartilage introduced by OAT appears to result in higher-quality repair tissue when compared to DEB, as evidenced by OAT patients' higher MOCART scores and lower rates of cyst and edema. There was no difference in clinical outcome scores, though OAT patients did not require revision surgery or therapeutic injection for pain as frequently as DEB patients. Level III, retrospective comparative study.

Comparison of Functional and Radiographic Outcomes of Talar Osteochondral Lesions Repaired With Micronized Allogenic Cartilage Extracellular Matrix and Bone Marrow Aspirate Concentrate vs Microfracture.

Microfracture (MF) has been used historically to treat osteochondral lesions of the talus (OLTs), with favorable outcomes reported in approximately 80% to 85% of cases. However, MF repairs have been shown to degrade over time at long-term follow-up, suggesting that further study into optimal OLT treatment is warranted. The use of adjuvant extracellular matrix with bone marrow aspirate concentrate (ECM-BMAC) has not been extensively evaluated in the literature. We present a comparison of patient-reported and radiographic outcomes following ECM-BMAC repair vs traditional MF. Patients who underwent MF (n = 67) or ECM-BMAC (n = 62) treatment for an OLT were identified and their charts were retrospectively reviewed. Postoperative magnetic resonance imaging (MRI) was evaluated and patient-reported outcome scores, either Foot and Ankle Outcome Scores (FAOS) or Patient-Reported Measurement Information System (PROMIS) scores, were collected. MRIs were scored by a radiologist, fellowship trained in musculoskeletal radiology, using the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) system. Radiographic and clinical outcomes were compared between groups. On average, patients treated with ECM-BMAC demonstrated a higher total MOCART score compared to the MF group (73 ± SD 11.5 vs 54.0 ± 24.1; P = .0015). ECM-BMAC patients also had significantly better scores for the Infill, Integration, and Signal MOCART subcategories. Last, patients treated with ECM-BMAC had a lower rate of revision compared to those treated with MF (4.8% vs 20.9%; P = .007). FAOS scores were compared between groups, with no significant differences observed. When comparing outcomes between patients treated for an OLT with ECM-BMAC vs traditional MF, we observed superior MRI results for ECM-BMAC patients. The rate of revision surgery was higher for MF patients, although patient-reported outcomes were similar between groups. The use of ECM-BMAC as an adjuvant therapy in the treatment of OLTs may result in improved reparative tissue when compared to MF. Level III, comparative series.

Diagnosis and Treatment of Persistent Problems After Ankle Sprains: Surgical Management of Osteochondral Lesions of the Talus

Ankle sprains are common injuries that can lead to persistent disability and pain for many patients. Such symptoms are often a result of damage to the articular cartilage of the talar dome and the subchondral bone, an injury broadly classified as an osteochondral lesion of the talus. Lesions indicated for surgery can be treated with a range of methods. These generally fall into the categories of reparative treatment, which is suitable for smaller lesions and can typically be performed arthroscopically, or replacement strategies, which can provide superior outcomes for large lesions but often require an open approach. In recent years, many treatment options have incorporated stem cells and other biologics that seek to improve healing. We will provide an overview of indications for the treatment of talar osteochondral lesions and current treatment strategies before discussing our favored technique, outcomes, and potential complications.

Osteochondral Lesions of the Talus: A Review on Talus Osteochondral Injuries, Including Osteochondritis Dissecans.

This is a review on talus osteochondritis dissecans and talus osteochondral lesions. A majority of the osteochondral lesions are associated with trauma while the cause of pure osteochondritis dissecans is still much discussed with a possible cause being repetitive microtraumas associated with vascular disturbances causing subchondral bone necrosis and disability. Symptomatic nondisplaced osteochondral lesions can often be treated conservatively in children and adolescents while such treatment is less successful in adults. Surgical treatment is indicated when there is an unstable cartilage fragment. There are a large number of different operative technique options with no number one technique to be recommended. Most techniques have been presented in level II to IV studies with a low number of patients with short follow ups and few randomized comparisons exist. The actual situation in treating osteochondral lesions in the ankle is presented and discussed.

The Application of All-arthroscopic Technique to Deep Osteochondral Lesions in the Talus With Scaffold and Autograft Bone Taken From the Tibial Plafond

Osteochondral lesions in the talus are frequently seen disorders that can cause chronic ankle pain. Surgical treatment is determined by the size and location of the lesion. The microfracture procedure and additional application of scaffold technique have gained popularity for the treatment of small osteochondral defects. However, these techniques may be insufficient and have poor outcomes in deep lesions. Therefore, several different invasive surgical techniques that require the malleolar osteotomy have been described. Problems associated with the invasive surgical intervention may be seen such as reduction loss in the osteotomy site, delayed union or nonunion, permanent pain, and/or swelling. We describe a new all-arthroscopic technique for the treatment of deep talus osteochondral lesions using an autologous bone graft taken from the tibial plafond region together with a chitosan-based noncellular scaffold.

Treatment of Osteochondral Talar Lesion with Mesenchymal Cells on Collagen Scaffold

Treatment of Osteochondral Talar Lesion with Mesenchymal Cells on Collagen Scaffold

Primary Autologous Osteochondral Transfer Shows Superior Long-Term Outcome and Survival Rate Compared With Bone Marrow Stimulation for Large Cystic Osteochondral Lesion of Talus

To compare the results of bone marrow stimulation (BMS) versus autologous osteochondral transfer (AOT) as primary surgical option for large cystic osteochondral lesion of talus (OLT) and to further distinguish factors associated with clinical failures and overall survival. We retrospectively analyzed patients with symptomatic large cystic OLT (>300 mm3) who underwent either primary BMS or AOT between January 2001 and January 2016 with a minimum follow-up of 36 months. Lesion surface area and volume were measured on magnetic resonance imaging. Clinical outcomes were assessed using pain visual analog scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) score, and Foot and Ankle Outcome Score (FAOS). Survival outcomes and factors associated with clinical failures were evaluated using Kaplan-Meier analysis and Cox regression analyses, respectively. Fifty of the total 853 patients had large cystic OLTs. Thirty-two patients underwent primary BMS, and 18 patients underwent primary AOT. Mean follow-up period was 118 months, and average lesion surface area and volume were 152.8 mm2 and 850.7 mm3, respectively. The primary AOT group showed significantly superior improvements in clinical outcomes compared with the BMS group at last follow-up (P= .001). Fourteen patients in the primary BMS group and 2 patients in the primary AOT group experienced clinical failure. Kaplan-Meier analysis showed a superior survival rate of primary AOT (P= .042). Syndesmosis widening (hazard ratio 12.361; P= .004) and large lesion surface area (hazard ratio 1.011; P= .014) were significant relative risks of clinical failure in the primary BMS group. However, lesion volume showed no significant relationship with clinical failure. Long-term results of primary AOT showed superior clinical improvements and survival rate in treating large cystic OLT. Risk factors for failure in the primary BMS group were large lesion surface area and syndesmosis widening. Retrospective comparative study LEVEL OF EVIDENCE: III.

Large variation in management of talar osteochondral lesions among foot and ankle surgeons: results from an international survey.

Surgeons management of osteochondral lesions of the talus (OLT) may be different to the published guidelines because not all treatment recommendations are feasible in every country. This study aimed to assess how OLT are managed worldwide by foot and ankle surgeons. A web-based survey was distributed to the members of 21 local and international scientific societies focused on foot and ankle or sports medicine surgery. Answers with a prevalence greater than 75% of respondents were considered a "main tendency", whereas where prevalence exceeded 50% of respondents they were considered a "tendency". A total of 1804 surgeons from 79 different countries returned the survey. The responses to 19 of 28 questions (68%) regarding management and treatment of OLT achieved a main tendency (> 75%) or a tendency (> 50%). Symptoms reported to be most suspicious for OLT were pain on weight-bearing (WB) and after activity (83%), deep localization of the pain (62%), and any history of trauma (55%). 89% of surgeons routinely obtain an MRI, 72% routinely get WB radiographs, and 50% perform a CT scan. When treated surgically, OLTs are managed in isolation by only 7% of surgeons, and combined with ligament repair or reconstruction by 79%; 67% report simultaneous excision of soft-tissue or bony impingements (64%). For lesions less than 10-15mm in diameter, bone marrow stimulation (BMS) represents the first choice of treatment for 78% of surgeons (main tendency). No other treatment was recorded as a tendency. For lesions greater than 15mm in diameter no tendencies were recorded. The BMS represented the most preferred treatment being the first choice of treatment for 41% of surgeons. OLT depth had little influence on treatment choice: 71% of surgeons treating small lesions and 69% treating large lesions would choose the same treatment regardless of whether the lesion had a depth lesser or greater than 5mm. The management of OLT by foot and ankle surgeons from around the world remains extremely varied. The main clinical relevance of this study is that it provides updated information with regard to the management of OLT internationally, which could be used by surgeons worldwide in their decision-making and to inform the patient about available surgical options. Level IV.

Fluoroscope-assisted arthroscopic retroarticular drilling for osteochondral lesions of talus with bone grafting – Clinical outcome analysis and review of literature

Objectives: Early stages of osteochondral lesions with or without cystic changes are amenable to revitalization and cartilage restoration. In these cases, we assess the outcome using our standard technique and by eliminating the need for malleolar osteotomy. Materials and Methods: Seven cases of osteochondral lesion of talus were treated with retroarticular drilling under arthroscopy and fluoroscopy assistance. These cases were followed up for a minimum of 6 months (mean 20 ± 12.53 months). The functional outcome was assessed using American Orthopedic Foot and Ankle Score (AOFAS) hindfoot score. Results: The AOFAS increased from 49.28 (±6.7) points to 85 (±9.12) points and was noted to be statistically significant (P &lt; 0.001). 2/7 ankles were lateral sided lesion and had a history of trauma. 6/7 cases had an intact intraoperative cartilage status, whereas one case had Grade C (fissures and fibrillation). However, the location of lesion or the grade of lesion did not influence the results. Conclusion: This treatment modality seems to be a feasible option for early lesions and can be considered before alternative cartilage replacement treatment strategies are employed.

Autologous Osteochondral Transplantation for Osteochondral Lesions of the Talus: Does Gender Impact Outcomes?

Category:Ankle; ArthroscopyIntroduction/Purpose:Autologous osteochondral transplantation (AOT) is commonly used in the treatment of osteochondral lesions (OCL) of the talus. There is limited data comparing gender differences in the incidence, presentation, and outcomes following AOT. The purpose of this study is to compare these differences between male and female patients.Methods:Eighty-five consecutive patients who underwent AOT were retrospectively reviewed. Patients were divided into two groups based on gender. Demographic data and OCL defect characteristic data were recorded. Functional outcomes were assessed pre- and post-operatively using the Foot and Ankle Outcome Score (FAOS). The Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score was used to assess cartilage incorporation. The mean clinical follow-up was 47.2 months, with mean MRI follow-up of 24.8 months.Results:Fifty-five (65%) males and 30 (35%) females were included. OCL defect size was significantly larger in men (112.8mm2) when compared with women (88.7mm2) (p<0.0001). Male patients had a significantly longer duration of symptoms (p<0.001) and OCLs were more likely traumatic in nature (p=0.0006) when compared with female patients. Mean FAOS improved pre- to postoperatively from 50 to 81(P < .001) with a statistically significant increase in men (p<0.0001). The mean MOCART score was 82.1 and 86.7 in male and female patients, respectively (p<0.0001). Lesion size was negatively correlated with MOCART score (r = -0.36,P = .004). No differences were found in knee donor site morbidity, complication rate, or revision surgery.Conclusion:Our study demonstrates that male patients typically present with talar OCLs that are larger in size, traumatic in nature, and with longer symptom duration when compared with female patients. In addition, male patients had greater improvement in FAOS scores following AOT. Therefore, understanding these differences may influence the management and treatment of talar OCLs in male and female patients.

Pain Scores and Return to Activities/Sport Following Dehydrated Micronized Allogenic Cartilage and Isolated Microfracture for Treatment of Talar Osteochondral Lesions

Category:SportsIntroduction/Purpose:Osteochondral lesions of the talus (OLT) are common injuries, however management remains challenging. Lesion size remains a common determinant of treatment and microfracture remains common for smaller lesions. Microfracture provides access to mesenchymal stem cells within the subchondral bone. Dehydrated micronized allogenic cartilage (DMAC) (BioCartilage, Arthrex, Naples, FL) utilizes a single stage attempt to augment microfracture with a scaffold over the defect to improve hyaline cartilage restoration. DMAC requires hydration with plasma rich protein (PRP) or bone marrow aspirate concentrate (BMAC). Currently, there is limited literature on pain scores and return-to-activities and satisfactory return- to-sport following DMAC treatments. The purpose of this study is to report pain scores, percent and time return-to -activities, percent and time to satisfactory return-to-sport following microfracture + DMAC and isolated microfracture.Methods:We reviewed a series of 65 cases (37 female and 28 male; mean age 34.6 (SD 14.1); mean BMI 27.3 (SD 6.2)) between 2010 and 2019 in which surgical treatment for OLT consisted of microfracture + DMAC, or isolated microfracture. Surgical procedure was determined by treating surgeon. Demographic, visual analog scale (VAS) pain scores (0-10), return-to-activities, and satisfactory-return-to-sport were collected preoperatively and postoperatively at 3-months, 6-months, and 1 year. Return-to- activities was defined as any engagement in desired activities, whereas satisfactory-return-to-sport was determined by patient- report. T-tests were used to determine between group differences.Results:Sixty-five cases (DMAC 25; isolated-microfracture: 40) demonstrated mean pain score at 3-months for DMAC and isolated-microfracture of 0.8 and 2.0, respectively, (p=0.04). There were no significant differences in remaining pain scores. By 1- year, 100% of DMAC and 87.5% of isolated-microfracture returned-to-activities, p=0.09. Of those that returned-to-activities there was no difference in time-to-return-to-activities between groups 82.9 days vs 82.4 days. By 1-year, patients that return-to-sport demonstrated a patient-reported satisfactory-level-of-return of 52.0% in DMAC and 37.5% in isolated-microfracture. Of those that returned satisfactorily-to-sport, the time-to-satisfactory-return-to-sport was similar (mean 139.5 and 135.7 days, p=0.66). A subgroup analysis of microfracture + DMAC group determined that PRP (n=16) had less pain at 3 months than BMAC (n=9), mean 0.8 vs 2.0, respectively; p=0.03, with no other differences noted (p>0.05).Conclusion:The use of microfracture + DMAC may improve early post-operative pain scores and improve ability to return to a patient-reported satisfactory level of sport by 1-year. Isolated microfracture and DMAC augmentation had similar rates and times to return-to-activities, and pain levels after 6-months post-operatively. The use of PRP to supplement DMAC improved early post- operative pain scores compared to BMAC which may be related to donor-site morbidity. Otherwise PRP and BMAC supplementation of DMAC had similar subsequent pain scores, and rate and time to return to activities. Augmentation of microfracture with DMAC for OLTs may improve outcomes compared to microfracture alone.

Comparison of Microfracture with Extracellular Matrix Augmentation and Osteochondral Autograft Transplantation for the Treatment of Medium-Size Osteochondral Lesions of the Talus

Category:Ankle; Arthroscopy; Basic Sciences/BiologicsIntroduction/Purpose:Historically, microfracture has been used to treat small talar osteochondral lesions (OLTs) with good results, while osteochondral autologous transplantation (OAT) has proven superior for the treatment of larger lesions. It is not clear which method is more effective for medium-sized lesions, around the critical size of 150 mm2 above which microfracture outcomes tend to be poor. While OAT carries the risk of co-morbidity at the knee and often requires a malleolar osteotomy, it is thought to result in superior repair tissue compared to microfracture by introducing native hyaline cartilage to the ankle.Microfracture, in contrast, results in the formation of structurally inferior fibrocartilage. The purpose of this study was to determine the relative benefits of OAT and microfracture in the treatment of medium-sized OLTs.Methods::Patients treated for an OLT with OAT or microfracture by a single surgeon fellowship-trained in foot and ankle orthopedics between 2015 and 2018 were screened. Both OAT and microfracture techniques were augmented with a mixture of extracellular matrix and bone marrow aspirate concentrate (ECM-BMAC) for every case included in this study. Patients treated without ECM-BMAC were excluded. Only patients with a lesion size between 80 and 165 mm2 were included. Minimum follow-up was 12 months. Clinical outcomes were collected in the form of FAOS or PROMIS scores, depending on departmental standards at the time of treatment. MRIs were collected for radiographic analysis of cartilage repair tissue. MRIs were scored using the MOCART system by a fellowship trained radiologist and were also evaluated for the presence of cysts and edema. Patient charts were reviewed to determine rates of revision surgery and therapeutic injection for pain.Results::52 patients were identified who fit inclusion criteria. 27 of these patients received microfracture and 25 received OAT. The average lesion size for all patients was 117.5 mm2. Patients treated with OAT had significantly higher average total MOCART scores (69 vs. 55, p = 0.04) and significantly lower rates of cyst (14% vs. 55%, p <0.01), edema (59% vs. 90%, p = 0.04), revision surgery (0% vs. 19%, p = 0.05), and therapeutic injection for pain (4% vs. 30%, p = 0.03) compared to patients treated with microfracture. No significant differences were detected in patient reported outcome scores between groups for either FAOS or PROMIS. Age, BMI, lesion size, lesion location, and follow-up time were statistically indistinguishable between groups.Conclusion::In treating OLTs, the native hyaline cartilage introduced by OAT appears to result in higher quality repair tissue when compared to microfracture, as evidenced by OAT patients’ higher MOCART scores and lower rates of cyst and edema. This advantage was also reflected in the fact that OAT patients required revision surgery and therapeutic injection for pain less frequently than did microfracture patients. OAT may offer benefits over MF that outweigh its greater risk of comorbidity when addressing medium-sized OLTs.

Lateral ligament reconstruction with autogenous partial peroneus longus tendon for chronic lateral ankle instability

To assess the effectiveness of lateral ligament reconstruction with autogenous partial peroneus longus tendon for chronic lateral ankle instability. Between September 2014 and November 2018, 32 patients (32 sides) with chronic lateral ankle instability were treated with lateral ankle ligament reconstruction by using autogenous anterior half of the peroneus longus tendon. There were 25 males and 7 females, with an average age of 28.5 years (range, 20-51 years). The disease duration was 6-41 months (mean, 8.9 months). The preoperative Karlsson-Peterson ankle score was 53.7±9.7. The talar tilt angle was (14.9±3.7)°, and the anterior talar translation was (8.2±2.8) mm. Six patients combined with osteochondral lesion of talus and 4 patients combined with bony impingement. All incisions healed by first intention postoperatively. All patients were followed up 12-53 months (mean, 22.7 months). At last follow-up, the Karlsson-Peterson ankle score was 85.2±9.6; the talar tilt angle was (4.3±1.4)°; the anterior talar translation was (3.5±1.1) mm. There were significant differences in all indexes between pre- and post-operation ( P<0.05). Seventeen patients were very satisfied with the results, 10 patients were satisfied, 4 patients were normal, and 1 patient was unsatisfied. After operation, the ankle sprain occurred in 7 cases, the tenderness around the compression screws at calcaneus in 5 cases, the anterolateral pain of ankle joint over 6 months in 4 cases. No patient had discomfort around the reciepient sites. At last follow-up, the ultrasonography examination showed that there was no significant difference in the density and diameter between bilateral peroneus longus tendons in 12 cases. For chronic lateral ankle instability, the lateral ankle ligament reconstruction with the autogenous partial peroneus longus tendon is a safe and effective surgical option.

Bone marrow stimulation for talar osteochondral lesions at long-term follow-up shows a high sports participation though a decrease in clinical outcomes over time

PurposeAlthough bone marrow stimulation (BMS) as a treatment for osteochondral lesions of the talus (OCLT) shows high rates of sport resumption at short-term follow-up, it is unclear whether the sports activity is still possible at longer follow-up. The purpose of this study was, therefore, to evaluate sports activity after arthroscopic BMS at long-term follow-up.MethodsSixty patients included in a previously published randomized-controlled trial were analyzed in the present study. All patients had undergone arthroscopic debridement and BMS for OCLT. Return to sports, level, and type were assessed in the first year post-operative and at final follow-up. Secondary outcome measures were assessed by standardized questionnaires with use of numeric rating scales for pain and satisfaction and the Foot and Ankle Outcome Score (FAOS).ResultsThe mean follow-up was 6.4 years (SD ± 1.1 years). The mean level of activity measured with the AAS was 6.2 pre-injury and 3.4 post-injury. It increased to 5.2 at 1 year after surgery and was 5.8 at final follow-up. At final follow-up, 54 patients (90%) participated in 16 different sports. Thirty-three patients (53%) indicated they returned to play sport at their pre-injury level. Twenty patients (33%) were not able to obtain their pre-injury level of sport because of ankle problems and eight other patients (13%) because of other reasons. Mean NRS for pain during rest was 2.7 pre-operative, 1.1 at 1 year, and 1.0 at final follow-up. Mean NRS during activity changed from 7.9 to 3.7 to 4.4, respectively. The FAOS scores improved at 1 year follow-up, but all subscores significantly decreased at final follow-up.ConclusionAt long-term follow-up (mean 6.4 years) after BMS for OCLT, 90% of patients still participate in sports activities, of whom 53% at pre-injury level. The AAS of the patients participating in sports remains similar pre-injury and post-operatively at final follow-up. A decrease over time in clinical outcomes was, however, seen when the follow-up scores at 1 year post-operatively were compared with the final follow-up.Level of evidenceLevel II.