Scaffolds Based Therapy for Osteochondral Lesion of Talus

Category: Ankle, Arthroscopy, Basic Sciences/Biologics Introduction/Purpose: Numerous surgical treatment strategies for osteochondral lesions of the talus (OLT) have been proposed, but ideal treatment has yet to be established. Scaffold based-therapy for OLT is quickly becoming more popular as a new approach for reparative treatment. The purpose of this study was to systematically review published literature reporting clinical outcome of scaffold based-therapy for OLT and establish whether sufficient evidence exists to support use of scaffolds for OLT. Methods: A systematic search of the MEDLINE and EMBASE databases was performed in June 2016 based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Included studies were evaluated with regard to the level of evidence (LOE), quality of evidence (QOE), variable reporting outcome data and clinical outcomes. Modified Coleman Methodology Score (MCMS) was used to evaluate the QOE. Results: Twenty-five studies with 678 ankles were included; 96% were either LOE 3 or 4, and all studies were of poor or fair QOE. There were 6 different scaffold repair techniques, including one-step and two-step procedures. The categories of general demographics (93%) and patient-reported outcome data (84%) were well reported. The study design and imaging data were less reported with 72% and 78% respectively. Clinical variables (50%) and patient history (30%) were the least reported in studies. Clinical outcomes were evaluated using a number of different scoring systems. The weighted mean AOFAS score improved from 60.5 ± 6.3 preoperatively to 86.9 ± 8.4 at a weighted mean 41.3 month follow-up. Six studies reported that weighted mean 71.6% of patients returned to sport activity at previous level. Conclusion: This systematic review demonstrated that there is a lack of supporting data to justify current scaffold based therapy for treatment of OLT, although a lot of available commercial scaffolds for OLT exist. Further well-designed studies are necessary to determine the effectiveness of scaffold based therapy for OLT, especially compared with the available traditional treatments

Concentrated Bone Marrow Aspirate May Decrease Postoperative Cystic Occurrence Rate in Autologous Osteochondral Transplantation for Osteochondral Lesions of the Talus

Category: Ankle Introduction/Purpose: Autologous Osteochondral Transplantation (AOT) provides excellent clinical outcomes for osteochondral lesions of the talus (OLT), however, there is concern regarding the presence of cysts at the bone interface. The presence of subchondral bone cysts has been previously shown to be correlated with graft failure, and high rates of postoperative subchondral cysts formation of up to 75% at short-term follow-up have been reported. Concentrated bone marrow aspirate (CBMA) may have the potential to improve integration between the graft and native articular cartilage and bone, and may reduce interface cyst production. The purpose of this study was to clarify the efficacy of CBMA in AOT as compared with AOT alone, regarding the presence of postoperative cyst formation, postoperative functional outcomes and magnetic resonance imaging (MRI) outcomes. Methods: Patients who underwent AOT between 2004 and 2008 were retrospectively assessed at a minimum of 5-year follow-up. Twenty-eight patients were treated with AOT and CBMA (AOT/CBMA group) and 26 patients were treated with AOT alone (AOT alone group). Clinical outcomes were evaluated using the Foot and Ankle Outcome Scores (FAOS) and Short-Form 12 (SF-12) preoperatively and at final follow-up. Postoperative MRI was evaluated with the modified Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) scoring system. Cystic formation was evaluated on postoperative MRI, and cyst diameter and cyst location were assessed. Results: Fifty-four of 59 eligible patients were included. Of those, 28 patients were treated with AOT and CBMA and 26 patients were treated with AOT alone. The mean FAOS and SF-12 significantly improved in both AOT/CBMA and AOT alone groups, but there were no statistical differences between groups in FAOS (80.6 vs 75.4, p = 0.217) and SF-12 (71.1 vs 69.2, p = 0.694) at final follow-up. Additionally, there was no difference in the mean MOCART Score (80.4 vs 84.3, p = 0.484). However, AOT/CBMA did result in a statistically lower rate of cyst formation (46.4% vs 76.9%, p = 0.022) (Table 1). No statistical differences were found between groups in cyst location and cyst diameter (table 1). Conclusion: CBMA reduced the postoperative cystic occurrence rate in patients treated with AOT, although CBMA did not result in significant differences in functional outcomes nor MOCART score in patients who underwent AOT

Sesamoidectomy for the Hallux Sesamoid Disorders

Category: Midfoot/Forefoot Introduction/Purpose: Studies have shown that sesamoidectomy provides good clinical outcomes and quick return to sporting activities, however, there is concern regarding the complications following resection of one or both sesamoid bones. The purpose of the current systematic review was to evaluate the current evidence on sesamoidectomy for the treatment of the hallux sesamoid disorders. Methods: A systematic search of MEDLINE, EMBASE and Cochrane Library databases was performed based on the PRISMA guidelines. Included studies were evaluated with regard to level of evidence (LOE) and quality of evidence (QOE) using the Coleman Methodology Score. Reporting outcome data, clinical outcomes, and percentage of patients who returned to sport at previous level were also evaluated. Results: Ten studies with total 196 feet were included. The weighted mean age was 36.6 ± 11.0 with a mean follow-up of 45.1 ± 19.3 months. The mean Visual Analogue Scale score improved from a mean score of 6.5 ± 0.3 to 1.2 ± 0.5. The mean postoperative AOFAS score was 92.7 ± 2.7. Six studies demonstrated that 94.4% of patients returned to sport, with 90.0% returning to previous level, at a mean of 11.8 ± 1.8 weeks. The mean hallux valgus angle increased from 13.1 ± 2.1 preoperatively to 14.8 ± 3.7 postoperatively (p=0.470), and the mean intermetatarsal angle increased from 8.7 ± 0.8 to 9.7 ± 0.8 (p=0.180) following medial sesamoidectomy. The overall complication rate was 22.5%, and further surgeries were required in 3.0%(Table). Conclusion: The current systematic review demonstrated that sesamoidectomy for the hallux sesamoids disorders yields good clinical outcomes and a high rate of return to sports activity in the short-term. It is important to note however the high complications rate after sesamoidectomy, with a 22.5% complication rate in the short-term follow-up

Arthroscopic Repair of Lateral Ankle Ligament for Chronic Lateral Ankle Instability

Category: Ankle Introduction/Purpose: There has a been recent increase in the use of the arthroscopic approach to lateral ankle ligament repair for chronic lateral ankle instability. However, the clinical outcomes of this technique are still unclear. The purpose of this systematic review was to evaluate the current studies on arthroscopic lateral ankle ligament repair for chronic lateral ankle instability. Our hypothesis was that arthroscopic lateral ligament repair would result in excellent outcomes with a low complication rate. Methods: A systematic search of MEDLINE, EMBASE and Cochrane Library databases, based on the PRISMA guidelines, was performed during August 2017 by 2 independent reviewers. Included studies were evaluated with regard to level of evidence (LOE) and quality of evidence (QOE) using the Coleman Methodology Score. Variable reporting outcome data, clinical outcomes, and percentage of patients who returned to sport at previous level were also evaluated. Results: Twelve studies for a total of 421 ankles were included; 92% of studies were LOE III or IV and the QOE in all studies was of poor or fair quality. The weighted mean preoperative AOFAS score improved from 59.6 to 95.0 at a mean follow-up of 14.8 months in 8 studies. Five studies utilized Karlsson-Peterson scores with mean postoperative score of 88.5 at a mean follow-up of 21.2 months. Three comparative studies were reported. The comparative studies showed similar clinical outcomes between arthroscopic and open procedures. The overall complication rate was 13.4% in the included studies. . Only 2 studies reported patients returning to sport and demonstrated that 100% of patients returned to sport at pre-injury level. Conclusion: The current systematic review demonstrated that arthroscopic lateral ankle ligament repair yields favorable clinical outcomes in the short-term. However, there is no clinical evidence to support the advantages of the arthroscopic procedure over the open procedure, and there is no long-term data currently available for the arthroscopic procedure. There was a relatively high complication rate associated with the arthroscopic procedures, with a 13.4% complication rate, although recent comparative studies demonstrated similar complication rates for both open and arthroscopic techniques

Suture Button versus Syndesmotic Screw for Syndesmotic Injuries

Category: Trauma Introduction/Purpose: Syndesmotic injuries are a common athletic injury and involved in approximately 13% of ankle fractures. Screw fixation (SS) has been the most common fixation treatment for syndesmotic injury, however syndesmosis malreduction has been reported to occur up to more than 50% in syndesmotic screw fixation. Recently, suture-button fixation (SB) technique has been developed to restore anatomic function of the syndesmosis, with potential advantages of allowing physiological movement of syndesmosis, anatomic healing, avoidance of implant removal and earlier rehabilitation. However, optimal surgical treatment is still controversial to date. The purpose of this study was to compare the clinical outcomes of SB and SS fixation techniques for syndesmotic injuries with a meta-analysis of the clinical studies comparing SB and SS fixation for syndesmosis injuries. Methods: The literature search was performed according to the PRISMA guidelines to identify cohort studies comparing SB and SS fixation for syndesmosis injuries. The level of evidence (LOE) was assessed based on the criteria by the Oxford-Centre for Evidence Based Medicine. Statistical analysis was performed using RevMan, and a p-value of < 0.05 was considered to be statistically significant. Results: Ten clinical studies were identified comparing 222 patients with SB to 235 patients with SS fixation. Patients treated with SB had a higher postoperative AOFAS score at a mean of 17.2 months (90.9 vs 87.3, p = 0.002). SB resulted in a lower rate of implant failure (0.0% vs 27.1%, p < 0.0001), implant removal failure (4.0% vs 37.5%, p < 0.0001), and joint malreduction (0.8% vs 10.7%, p = 0.009). However, there was no significant difference in the rate of other complications with SB (4.2% vs 8.6%, p = 0.21). Conclusion: SB fixation results in improved functional outcomes, lower rates of implant failure, and joint malreduction. Based on the findings of this meta-analysis SB appears to be favorable to SS for treating syndesmotic injuries

The Presence and Degree of Bone Marrow Edema Influence on Midterm Clinical Outcome Following Microfracture for Osteochondral Lesions of the Talus

Category: Ankle Introduction/Purpose: Subchondral bone marrow edema (BME) has been associated with articular cartilage loss, with the potential to be a negative prognostic indicator for clinical outcome following microfracture. However, no single study has investigated the influence of BME on clinical outcome following microfracture for osteochondral lesions of the talus (OLT) at mid-term follow-up. The purpose of this study was to clarify the influence of postoperative subchondral BME on the clinical outcome in patients treated with microfracture for OLT at both short- and mid-term. Methods: Patients who underwent microfracture between 2008 and 2013 were assessed at 2- and 4-year postoperative follow-up. BME was evaluated using magnetic resonance imaging (MRI), and the presence of subchondral BME was determined with fat-suppressed T2-weighted sequences. BME was graded on a 0-3 scale based on the relation to total talar volume as follows: 0, no BME; 1, 50% of talar volume; 3, >50% of talar vome. Clinical outcomes were evaluated using the Foot and Ankle Outcome Scores (FAOS). The influence of postoperative subchondral BME on the clinical outcomes were evaluated as following; 1) the FAOS between the BME and the no BME groups were compared at 2 and 4 years post surgery, 2) the FAOS based on the BME grades were compared at each time point, and 3) correlation between the FAOS and BME grade was evaluated at each time point. Results: Forty-three (83%) of 52 eligible patients were included. No significant differences were found in FAOS between BME and no BME groups at 2-year follow-up (p=0.109), but there was a significant difference at 4-year follow-up (p = 0.041). A significant difference was found among BME grades at 4-year follow-up (p=0.035) (Table 1). A post hoc analysis showed significant differences between grade 0 and 2, 0 and 3, and 1 and 3 (p=0.041, 0.037 and 0.048, respectively). In addition, at 4-years follow-up, a significant correlation was noted between FAOS and BME grade (r= -0.453, p = 0.003) (Table 1), but not at 2-years (r = -0.212, p = 0.178). Seventy-four percent of patients still had subchondral BME at 4-year follow-up after microfracture for OLT. Conclusion: Patients with the presence of subchondral BME at mid-term follow-up after microfracture for OLT had worse clinical outcomes than those without subchondral BME. In addition, the degree of subchondral BME at mid-term follow-up was correlated with clinical outcome. However, in the short-term follow-up, there were no significant differences in clinical outcomes based on both the presence and degree of BME. The current study suggests that BME at short-term follow-up is a normal physiologic reaction. However, BME at mid-term following microfracture for OLT may be pathological, and is related to poorer clinical outcomes

Subchondral Bone Degradation Following Bone Marrow Stimulation -An MRI Analysis-

Category: Ankle Introduction/Purpose: Microfracture is the most common operative procedure for the treatment of osteochondral lesions of the talus (OLT). The role of the subchondral bone (SCB)/plate (SCBP) is recognized as one of the most significant factors providing joint-loading support to the ankle. Greater attention has recently been paid to the SCBP and its effects on overlying hyaline and fibrocartilage function. However, damage to the SCB and SCBP during microfracture may irreversibly change the joint loading support of the ankle, leading to reparative cartilage degradation. The purpose of this study is to investigate the morphological change in the SCB and SCBP after microfracture for OLT by developing a novel magnetic resonance imaging (MRI) scoring system specifically for evaluating SCB and SCBP. Methods: Twenty patients who underwent microfracture for OLT and had at least a one year follow-up 3-Tesla MRI between 2008 and 2011 were selected. A SCB Health scoring system was developed to assess the condition of the SCB using 3-Tesla MRI. The SCB Health score is based on the amount of edema, subchondral cyst diameter, qualitative change in SCBP morphology and thickness change of the SCBP (Table 1). Nine of the twenty patients had two follow-up MRIs, and differences in their scores were calculated. The clinical evaluation was assessed using the Foot and Ankle Outcome Scores (FAOS) preoperatively and at final follow-up. Results: At first follow-up MRI, 65% of patients had mild or greater edema, 40% had subchondral cysts, 65% had irregularity or collapse of their SCBP and 85% had a >25% change in SCBP thickness. The overall SCB Health score of 90% of patients were abnormal. Of the nine patients who had a subsequent follow-up MRIs, the mean time between the first and second study was 22±6 months. The scores between the two time points were not statistically significant (p=0.347, p=0.559, p=0.169, p=0.347 p=0.154 for edema, subchondral cyst diameter, qualitative SCBP measurements, SCBP thickness change and overall SCB Health score, respectively). The mean FAOS score improved significantly from 55.5±16.8 preoperatively to 76.0±12.3 at final follow-up (p<0.05). Conclusion: The SCB and SCBP were not completely healed in 90% of patients at a mean 18 months follow-up following microfracture of the talus. Subsequently, morphological changes were not restored at a mean 43 months at second follow-up in a smaller subset of patients. Most previous studies have focused on the degeneration of the articular cartilage layer, and its effect on clinical outcomes. The authors of current study believe that looking at the changes in the SCB may provide additional information as to why BMS procedures fail in the long-term

Mid-term Outcomes of Autologous Osteochondral Transplantation for Osteochondral Lesions of the Talus

Category: Ankle Introduction/Purpose: Autologous osteochondral transplantation (AOT) is an established treatment for large-sized OLT, typically greater than 107mm2. Several studies have demonstrated favourable outcomes following AOT at short- and mid-term follow-up. However, the majority of the literature on AOT has short-term follow-up and little evidence exists on the mid-term and longer-term follow-up. Additionally, few studies include a large number of patients or have a high level of evidence, limiting the ability to draw broad and meaningful conclusions about the effectiveness of the AOT procedure for the treatment of OLT beyond short-term follow-up. The purpose of the current systematic review was to evaluate the clinical outcomes analysing level and quality of evidence of the AOT procedure in the treatment of OLT at mid-term and long-term follow-up. Methods: A systematic search of the MEDLINE, EMBASE and Cochrane Library databases was performed in October 2017 based on the PRISMA guidelines. Included studies were evaluated with regard to level of evidence (LOE) and quality of evidence (QOE) using the Coleman Methodology Score. Clinical outcomes, and complications were also evaluated. Results: Eleven studies, with 500 ankles were included at a mean 62.8 months follow-up. There were 3 studies of LOE III, and 8 studies of LOE IV. There were 3 studies of fair quality and 8 studies of poor quality. The weighted mean preoperative AOFAS score was 55.1 ± 6.1, and the postoperative score was 86.2 ± 4.5, with 87.4% of patients being reported as excellent or good results. In total, 54 of the 500 patients (10.8%) had complications. The most common complication was donor site morbidity with 18 patients (3.6%) at final follow-up. Thirty-one patients (6.2%) underwent reoperations, and the authors deemed a total of 5 ankles (1.0%) failures. Only 5 studies (45.5%) used MRI for follow-up evaluation. Conclusion: The current systematic review demonstrated that good clinical and functional outcomes can be expected following AOT procedure for the treatment of OLT, with a failure rate of only 1.0% at 63 months follow-up. MRI and radiographs showed restoration of articular surface as well as a minimal presence of osteoarthritis at mid-term follow-up. However, there is still lack of data from high LOE and QOE studies, and further high quality studies are necessary

The Effect of Containment Type on Clinical Outcome in Osteochondral Lesions of the Talus Treated with Autologous Osteochondral Transplantation

Category: Ankle Introduction/Purpose: Operative management for osteochondral lesions of the talus (OLT) can be broadly divided into reparative techniques, including bone marrow stimulation (BMS), and replacement techniques, including autologous osteochondral transplantation (AOT). Predictors of outcome of BMS have been established as lesion size, containment of the lesion, and previous surgery. Predictors of outcome of AOT or allograft transplantation have been established as body mass index and the requirement for greater than 2 grafts. However, containment of the lesions has not been assessed as a predictor of outcome in patients undergoing AOT to date. Therefore, the purpose of the current study is to clarify the effect of the containment of OLT on clinical and radiological outcomes in patients who underwent AOT procedure for the treatment of OLT. Methods: A retrospective cohort study comparing patients with contained type and uncontained type OLT was undertaken, to include all patients who underwent AOT procedure for the treatment of OLT between 2006 and 2014. Analyses were performed by grouping the patients according to the containment type, location, and both the type of containment and location. Clinical outcomes were evaluated using the Foot and Ankle Outcome Scores (FAOS) and Short-Form 12 (SF-12) preoperatively and at the final follow-up. Magnetic resonance imaging (MRI) at 2 years follow-up was evaluated with modified magnetic resonance observation of cartilage repair tissue (MOCART) score. Comparisons between groups were made with the Man-Whitney U test for continuous variables and the?2 or Fisher exact test for categorical variables. Multivariate regression models were used to evaluate factors affecting postoperative FAOS, SF-12 and MOCART scores. A value of p < 0.05 was considered statistically significant. Results: Ninety-four patients were included, with 31 with a contained type OLT and 63 with an uncontained type OLT. The median follow-up time were 45 months in contained type and 52 months in uncontained type. The mean FAOS and SF-12 improved significantly after surgery in both contained and uncontained lesions (p<0.001). The mean postoperative FAOS in contained type was higher than uncontained type (89.5 vs 80.2, p=0.009), but no significant differences were found between uncontained and contained type in postoperative SF-12 and MOCART score. The multivariate regression models showed that patients with contained type OLT had approximately 10 points better scores in FAOS compared to uncontained type (p=0.006) (Table 1). Patients who had previous microfracture performed worse postoperative FAOS than those who did not (p =0.004). Conclusion: Patients with contained type OLT experienced better clinical outcomes than those with uncontained type OLT following AOT procedure for the treatment of OLT. However, the AOT procedure still provided good clinical and MRI outcomes in both contained type and uncontained type OLT at the mid-term follow-up

Midterm Outcomes of Bone Marrow Stimulation for Primary Osteochondral Lesions of the Talus: A Systematic Review

Background: Bone marrow stimulation (BMS) is a common surgical intervention in the treatment of small osteochondral lesions of the talus (OLTs). Evidence has shown good clinical outcomes after BMS in the short term, but several studies have shown less favorable results at midterm and long-term follow-up because of fibrocartilaginous repair tissue degeneration. Purpose: To evaluate the clinical and radiological outcomes of BMS in the treatment of primary OLTs at midterm and long-term follow-up and to investigate reported data in these studies. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic search of the MEDLINE, Embase, and Cochrane Library databases was performed in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Clinical and radiological outcomes as well as reported data were evaluated. Results: A total of 15 studies comprising 853 patients (858 ankles) were included at a weighted mean follow-up time of 71.9 months. There were 9 studies that used the American Orthopaedic Foot & Ankle Society (AOFAS) score, with a weighted mean postoperative score of 89.9. There were 3 studies that measured postoperative magnetic resonance imaging results in the midterm using the MOCART (magnetic resonance observation of cartilage repair tissue) scoring system and showed 48% of patients with complete filling, 74% with complete integration, and 76% with surface damage. There was a complication rate of 3.4% and a reoperation rate of 6.0% after BMS in the midterm. Conclusion: This systematic review found good clinical outcomes after BMS at midterm follow-up for primary OLTs. Radiological outcomes showed repair tissue surface damage in the majority of patients, which may be a harbinger for long-term problems. Data were variable, and numerous data were underreported. Further high-quality studies, a validated outcome scoring system, and further radiological reports at midterm follow-up are required to accurately assess the success of BMS in the midterm