Osteochondral Lesions of the Talus and Autologous Matrix-Induced Chondrogenesis: Is Age a Negative Predictor Outcome?

Purpose To assess and evaluate healing and functional outcomes after arthroscopic talus autologous matrix-induced chondrogenesis (AT-AMIC) in 2 age groups: patients older than 33 years versus patients 33 years or younger. Methods A total of 31 patients, of whom 17 were 33 years or younger (G 1 ) and 14 older than 33 years (G 2 ), were evaluated. All patients were treated with AT-AMIC repair for osteochondral talar lesion. Magnetic resonance imaging (MRI) and computed tomography (CT)-scan evaluations, as well as clinical evaluations measured by the visual analog scale (VAS) score for pain, American Orthopaedic Foot and Ankle Society Ankle and Hindfoot score (AOFAS), and Short Form-12, were performed preoperatively (T 0 ) and at 6 (T 1 ), 12 (T 2 ), and 24 (T 3 ) months postoperatively. Results G 1 consisted of 17 patients (mean age: 25 years, standard deviation: ±5), whereas G 2 consisted of 14 patients (mean age: 47 years, standard deviation: ±9). In both groups, we found a significant difference for clinical and radiological parameters with the analysis of variance for repeated measures through 4 time points ( P 1 , AOFAS improved significantly between T 0 and T 1 ( P = .025) and T 1 and T 2 ( P = .011); CT showed a significant decrease between T 1 and T 2 ( P = .003) and T 2 and T 3 ( P 2 , AOFAS improved between T 0 and T 1 ( P = .011) and T 2 and T 3 ( P = .018); CT decreased between T 1 and T 2 ( P = .025), whereas MRI showed a reduction between T 1 and T 2 ( P = .029) and T 2 and T 3 ( P = .006). AOFAS in G 1 was significantly higher at T 0 ( P = .017), T 2 ( P = .036), and T 3 ( P = .039) compared with G 2 . A negative linear correlation between AOFAS and VAS at T 1 ( R = −0.756), T 2 ( R = −0.637), and T 3 ( R = −0.728) was found in G 1 , whereas in G 2 , AOFAS was negatively correlated with VAS at T 1 ( R = −0.702). Conclusions The study revealed that osteochondral lesions of the talus were characterized by similar sizes and features, both in young and old patients. We conclude that AT-AMIC can be considered a safe and reliable procedure that allows effective healing, regardless of age, with a significant clinical improvement; in particular, clinical results are related to starting conditions of the ankle. Level of Evidence Level IV, therapeutic case series

Sport and physical activities in total ankle replacement: Mobile- and fix-bearing

Background: The number of total ankle replacements (TARs) is rapidly increasing in consequence of the availability of new designs allowing to save the range of motion and to preserve against adjacent joints degeneration. This study aimed to compare participation in sports 12 months after TAR with either mobile-bearing or fix-bearing prosthesis. Materials and Methods: One hundred and seventeen primary TARs were performed (77 Hintegra, 40 Zimmer Trabecular Metal Total Ankle). We retrospectively assessed pain and function using the visual analogue scale (VAS) pain scale, American Orthopedic Foot and Ankle Society (AOFAS), Short-Form Health Survey (SF-12 divided into Mental (MCS) and Physical (PCS) score) obtained preoperatively, 6 and 12 months postoperatively. Activity levels were determined using the Halasi ankle activity scale and the University of California at Los Angeles (UCLA) score obtained preoperatively and 12 months after the surgery. Radiographic examination included plain radiographs with full weight-bearing taken preoperatively and 12 months postoperatively. Results: All patients showed a significant improvement for AOFAS, VAS, and SF-12 scores (P Conclusions: At 1 year, both fixed and mobile bearing present significant improvements in functional and recreational scores, with neither prove superior

The role of bone marrow edema on autologous matrix induced chondrogenesis for the treatment of osteochondral lesions of the talus

Category: Ankle, Arthroscopy, Basic Sciences/Biologics Introduction/Purpose: to assess the functional and radiological outcomes after AT-AMIC® (arthroscopic talus autologous matrix induced chondrogenesis) in 2 groups: patients with and without bone marrow edema (BME). Methods: Thirty-seven patients of which 24 without edema (GNE) and 13 with edema (GE) were evaluated. All patients were treated with AT-AMIC® repair for osteochondral talar lesion. MRI and CT-scan evaluations, as well as clinical evaluations measured by the VAS score for pain, AOFAS and SF-12 were performed preoperatively (T0) and at 6 (T1), 12 (T2), and 24 (T3) months postoperatively. Results: GNE consisted of 24 patients while GE consisted of 13 patients. In both groups we found a significant difference for clinical and radiological parameters with ANOVA for repeated measures through four time points(p<0.001). In GNE, AOFAS improved significantly at each follow-up(p<0.05); while CT and MRI showed a significant decrease between T1 and T2 and T2 and T3(p<0.05). In GE, AOFAS improved significantly between T0 and T1 and T2 and T3(p<0.05); CT decreased between T1 and T2(p<0.05), while MRI showed a reduction at each follow-up(p<0.05). Lesion size was significantly higher both in MRI and CT in GE in respect to GNE(p<0.05). In the GNE no patients presented edema at T3, while in GE only 23.08% of the patients presented edema at T3. Conclusion: The study revealed that osteochondral lesions of the talus were characterized by bigger size both in MRI and CT in patients with edema. We conclude that AT-AMIC® can be considered a safe and reliable procedure that allows effective healing, regardless of edema and more than half of patients did not present edema six months after surgery

Posterior Talar Shifting in Mobile-Bearing and Fix-Bearing Total Ankle Replacement

Category: Ankle Arthritis Introduction/Purpose: Sagittal implant malalignment after total ankle replacement (TAR) has been considered to be a possible cause for premature implant failure. In a prior study, the change of the tibiotalar ratio (T-T ratio) over time in TARs was assessed in an unconstrained, three component implant. A significant increase in the T-T ratio between 2 and 6 months after surgery (from 34.6% to 37.2%) was documented. This variation of the talar position in the sagittal plane may be due to the presence of an inlay between the tibial and the talar components. Aim: The aim of this study was to compare the translation of the talus in TARs performed with an unconstrained, three-component design (Hintegra, Newdeal, Lyon, France; Integra, Plainsboro, NJ), and those performed with a semi-constrained, two- component design (Zimmer Trabecular Total Ankle, Zimmer, Warsaw, IN). Methods: The study included 71 consecutive patients (71 ankles) who underwent TAR with the Hintegra implant and 24 consecutive patients (24 ankles) who received the Zimmer implant between May 2011 and December 2014. The most common indication for TAR was post-traumatic arthritis (80.3% and 75.0% in the Hintegra group and in the Zimmer group, respectively). Patients were assessed clinically and radiologically preoperatively (T0), at 6 months (T2) and 12 months (T3) post-surgery. There was also a radiological assessment 2 months after surgery (T1). Results: The comparison of the T-T ratio between the two groups and over time indicated an interaction between time and group, therefore the changes of the T-T ratio with time were affected by the implant type factor (p < 0.0001). The changes of the post-operative T-T ratio over time were not significant in the Zimmer group (35.7%±6.7% at T1, T2, and T3; p=1.0 for each pairwise comparison). In the Hintegra group, the T-T ratio at 2 months (34.4%±5.5%) was significantly different to the T-T ratio at 6 months (37.0% ± 5.8%; p < 0.0001). The American Orthopaedic Foot & Ankle Society (AOFAS) score significantly increased from pre-op to 6 months post-surgery in both the Hintegra group (53.3±16.0 at 6 mos; p < 0.0001) and the Zimmer group (76.8±7.0 at 6 mos; p < 0.0001). There was no statistical difference in the preoperative scores (Hintegra: 32.7 ± 12.8; Zimmer: 34.6 ± 11.9; p=0.5347). Conclusion: The significant antero-posterior translation of the talus documented only in the cohort receiving the unconstrained, three-component implant may have associated with, and produced by the presence of the mobile bearing interface between the polyethylene insert and the tibial prosthesis

Arthroscopic autologous-matrix induced chondrogenesis in association with microfractures and autologous bone graft for the treatment of osteochondral talar lesions in young patients

Category: Ankle, Ankle Arthritis, Arthroscopy, Basic Sciences/Biologics Introduction/Purpose: The purpose is to evaluate the clinical and radiological outcomes of patients younger than 20 years, treated with the arthroscopic-talus autogolous matrix-induced chondrogenesis (AT-AMIC®) technique and autologous bone graft for osteochondral lesion of the talus (OLT) at a follow-up of 24 months. Methods: 13 patients under 20 years (range 13.2 – 19.85) underwent the AT-AMIC® procedure and autologous bone graft for OLTs. Patients were evaluated pre-operatively (T0) and at 6 (T1), 12 (T2) and 24 (T3) months postoperatively, using the AOFAS score, the VAS and the SF-12 respectively in its Mental (MCS) and Physical component (PCS). Radiological assessment included CT-scan, MRI and intraoperative measurement of the lesion. A multivariate statistical analysis was performed. Results: Mean size lesion measured during surgery was 1.1102 cm3 ± 0.518 cm3. We found a significant difference in clinical and radiological parameters with ANOVA for repeated measures (p<0.001). All clinical scores significantly improved (p<0.05) from T0 to T3. Lesion area significantly reduced from 120.12 ± 29.58 mm2 pre-operatively to 75.78 ± 15.00 mm2 (p<0.05) at final follow- up as assessed by CT, and from 133.32 ± 32.42 mm2 to 83.45 ± 15.54 mm2 (p<0.05) as assessed by MRI. Moreover we noted an important correlation between intra-operative size measurement of the lesion and BMI (p=0.0114). Conclusion: The technique can be considered safe and effective, reporting early good results in young patients. Moreover we demonstrated a significant correlation between BMI and lesion size and a significant impact of OLTs on quality of life

Total ankle replacement through a lateral approach: surgical tips

Purpose: Recently, the Zimmer Trabecular Metal Total Ankle Replacement (Zimmer TM TAR) was developed to be used through a lateral transfibular approach. The purpose of this paper is to describe the surgical technique and early outcomes of the TAR via the lateral approach using the Zimmer TM TARs. Methods: Sixty-seven patients underwent primary TAR using the Zimmer TM TAR between May 2013 and May 2015. Patients were clinically evaluated preoperatively and postoperatively at six and twelve months and annually using the American Orthopaedic Foot & Ankle Society (AOFAS) ankle and hindfoot scores, visual analogue scale (VAS) pain score, and the Short Form Health Survey (SF-12) questionnaire. The minimum follow-up was 12 months. Results: The mean AOFAS hindfoot score increased from 32.8 preoperatively to 85.0 at the latest follow-up (p-value < 0.001). The mean VAS pain score decreased from 8.0 to 2.0 at the latest follow-up (p-value < 0.001). The Physical and Mental Health Composite Scale scores (PCS and MCS) of the SF-12 passed from a mean value of 30.2 preoperatively to 43.1 (p-value < 0.001) and from a mean value of 44.6 to 53.5 at the latest follow-up (p-value < 0.001), respectively. Conclusions: We present our surgical tips and the early results of this prosthetic design which are encouraging. They could be useful as an adjunct to the manufacturer’s surgical technique guidance for surgeons who utilize these implants

Decreasing Postoperative Narcotic Utilization with the Use of Concentrated Bone Marrow Aspirate in First Metatarsophalangeal Joint Interposition Arthroplasty

Category: Midfoot/Forefoot Introduction/Purpose: Interposition arthroplasty is an interim procedure for the treatment of first metatarsophalangeal osteoarthritis demonstrating excellent survivorship. The procedure is commonly performed at our institution and successful long-term results have been described. Furthermore, we have utilized concentrated, autologous, bone marrow aspirate (BMAC) to augment and accelerate patient recovery, decrease postoperative pain, reduce postoperative narcotic requirement, and improve tissue healing for a variety of ankle and foot pathology. The purpose of this study was to compare the early outcomes of interpositional arthroplasty with patients receiving BMAC augmentation versus controls and to evaluate postoperative analgesia and narcotic requirements. Methods: After IRB approval, patients undergoing interposition arthroplasty for hallux rigidus at our institution from 2009-2014 were identified. All cases were performed using autograft capsular interposition by a single surgeon. 18 BMAC cases with complete records were identified. These were matched to controls in a 1:1 manner by age, gender, and laterality. A retrospective analysis of prospectively collected data was performed. Demographics, clinical range of motion, complications, VAS scoring, FAAM, FFI, AOFAS scores were recorded and analyzed. Postoperative analgesia requirements, narcotic usage, and prescription data were collected. Follow-up was conducted at 2,6,12,24, & 52 weeks postoperatively. Time experiencing pain and time to achieve maximum functional satisfaction were recorded. Results: 89% (32/36) of patients undergoing interposition arthroplasty were female, average age 58 years (range, 39-74). The average number of weeks experiencing pain, narcotic utilization, and time to achieve functional satisfaction was statistically lower in the BMAC group, 11 weeks (range, 6-24) versus controls, 27.4 weeks (range, 6-52), (p=0.001). The number of post-operative days of pain requiring narcotic analgesia was significantly lower in patients receiving BMAC 4.2 days (range, 1-14) compared to controls averaging 13.8 days (range, 2-48) (p=0.02). Both groups demonstrated improvements in pre- and postoperative VAS scores, increase in motion, SF-36, FAAM, FFI, and AOFAS scores at 52 week follow up. There were no failures and there was one superficial infection requiring oral antibiotics. Conclusion: This study confirms that patients undergoing interpositional arthroplasty demonstrate excellent clinical improvements in short-term follow-up with few complications. Moreover, augmentation of this procedure with BMAC results in a significant decrease in narcotic utilization and recovery time post-operatively. BMAC may be a useful adjunct in diminishing postoperative narcotics we prescribe to our patients

Age-Related Outcome of Mobile-Bearing Total Ankle Replacement

The aim of this study was to investigate clinical and radiographic outcomes in patients 50 years and younger vs patients older than 50 years undergoing total ankle replacement. Seventy consecutive patients who underwent primary total ankle replacement were included in this retrospective study. Patients were assessed clinically and radiographically. There was a statistically significant difference between the 2 groups for the American Orthopaedic Foot & Ankle Society score at final follow-up. The younger group had significantly greater improvement compared with the older group. Total ankle arthroplasty is an effective treatment for young, active patients with symptomatic end-stage ankle arthritis. [Orthopedics. 2017; 40(3):e567-e573.]

Sports and physical activity after osteochondral talar reconstruction with arthroscopic autologous matrix-induced chondrogenesis

Category: Sports Introduction/Purpose: Osteochondral talar lesions (OLTs) are common entities in active patients who practice sports. Degenerative changes and development of osteoarthritis can occur in up to 50% of non-treated patients, due to poor chondral tissue healing abilities. In recent years, autologous matrix-induced chondrogenesis (AMIC) repair has been introduced for OLTs with satisfactory results through medium-term follow-up. The aim of the study was to evaluate the return to sport and physical activities in patients underwent arthroscopic autologous matrix-induced chondrogenesis (AT-AMIC) 2 years after surgery. Methods: This is an observational cross-sectional study. Informed consent was obtained from all participants, and procedures were conducted according to the Declaration of Helsinki. Twenty-seven consecutive patients, 62.9% (17) male (mean ± SD age: 33.7±11.2 years), that underwent AT-AMIC were included in the study. All patients were assessed with the American Orthopaedic Foot & Ankle Score (AOFAS), physical component score of the 12-Item Short Form Health Survey (PCS-SF-12), HALASI ankle activity score and University of California, Los Angeles (UCLA) activity scale preoperatively and at 24 months after surgery. Results: Overall, 81.48% of the patient group returned to the same preinjury sport. Mean follow-up was 42.7 ±11.1 months. A significant interaction with time (from pre-operative to the final follow-up) for the clinical parameters UCLA, Halasi, AOFAS and SF-12 was found, P<0.001). In addition, there were significant differences between preoperative versus last follow-up (all, P <0.001), Conclusion: A high percentage of patients return to their sport activity after osteochondral talar reconstruction with AT-AMIC technique; furthermore AT-AMIC improve quality of life in young and active patients, allowing return to sport

Bone-Block Arthrodesis Procedure in Failures of First Metatarsophalangeal Joint Replacement

Category: Midfoot/Forefoot Introduction/Purpose: The treatment of the failure of the first metatarsophalangeal joint (MTP1) prosthesis can be complex. There is no consensus regarding treatments options. The main issue is the available bone stock.The aim of the study was to report on clinical and radiographic results for MTP1 arthrodesis with autologous bone graft (bone-block fusion) as a revision procedure of a previous MTP1 implant failure. Methods: We enrolled 12 patients who underwent MTP1 prosthesis failures and retrospectively collected data. All the patient underwent removal of the prosthetic implant and simultaneous MTp1 arthrodesis with autologous bone graft, harvested from the ipsilateral calcaneus (minimum follow-up of 24 months). The minimum time period elapsed between the surgical procedure of prosthetic implant and the revision surgery has been 18 months. Patients were evaluated preoperatively with a weight-bearing radiograph of the foot and CT-scan and at 24 months after surgery with Foot Ankle Disability Index (FADI). Results: The reasons for implant-failures were: 8 mobilization and 4 malalignment. The average defect filled with bone-block was 12.2 mm. The fusion was performed with a plate and locking-screws. We had 3 cases of asymptomatic nonunion at the falangeal side of the fusion, none on the other side. Mean average rate of consolidation in other patients was 10 weeks. All patients returned to common activities’ of daily living. Average FADI was foun1d to be 84.6 at final follow-up. Conclusion: The management of this pathology is still controversial. Bone-block MTP1 arthrodesis The main limitation of the study is the small sample. seems to be a viable option