A 2-staged method for treatment of deep osteochondral lesions of the knee joint

We performed a 2-staged arthroscopic-assisted surgical procedure to treat a patient with a large osteochondral lesion of the knee joint. The osteochondral lesion was too comminuted to reattach; in addition, the underlying bony defect was too deep. In the first stage, autogenous cortical bone was used for grafting the bony defect along with screw fixation. The second stage consisted of screw removal and transplantation of autogenous osteochondral graft overlying the chondral defect. The osteochondral grafts were taken from the non–weight bearing areas of the same knee.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 9 (November-December), 2001: E35     

Treatment strategies for osteochondral lesions of the talus: A review of the recent evidence

BackgroundThere has been no consensus regarding the treatment of osteochondral lesions of the talus, there has been many attempts to formulate a treatment pathway, with multiple proposed modalities and adjuncts used.ObjectivesThe aim of this paper was to investigate the evidence published in the recent history, identify the relevant papers, review and summarize the findings, to help clarify the available operative treatment options and their respective efficacies based on the level of evidence provided.Study design & methodsA literature search through electronic databases MEDLINE and EMBASE was done, these databases were screened for publications and papers form June 2004 to June 2019. Key words were utilised in the search ‘talus, talar, tibia, cartilage, osteochondral, ankle, osteochondritis dissecans, articular cartilage’. Studies on adults aged 18–60 years were included. Exclusion criteria were studies with less than 10 patients, or no clear outcome was recorded. Papers were reviewed by the authors and data extracted as per a pre-defined proforma.ResultsFollowing screening, 28 published articles were included and reviewed. Of these publications 5 were level I, 7 level II, 4 level III and 12 level IV. The total number of patients was 1061 patients. Treatment modalities included arthroscopic microfracture, drilling, hyaluronic acid injection, platelet rich plasma, osteochondral autologous transplantation (OAT), vascularised free bone graft among others. The most common functional measures used to assess efficacy were the Visual analogue scale (VAS) and the American Orthopaedic Foot and Ankle (AOFAS) score. Follow up ranged from 26 weeks upto 4 years.ConclusionsDespite the abundance of treatment options, high level evidence (level I) remains limited and does not conclude a definitive treatment modality as superior to others. Further research, in the form highly organised randomised clinical trials, is needed to help improve the efficacy and develop new treatment modalities in the future.     

Surgical repair of osteochondral lesions of the talus using biologic inlay osteochondral reconstruction: Clinical outcomes after treatment using a medial malleolar osteotomy approach compared to an arthroscopically-assisted approach

BackgroundSurgical treatment of osteochondral lesions of the talus affecting the medial aspect of the talar dome is typically performed using medial malleolar osteotomy to optimize access. This study compares clinical outcomes of lesions repaired using biologic inlay osteochondral reconstruction in patients who did or did not undergo medial malleolar osteotomy, depending on defect dimensions.MethodsPatients treated for osteochonral lesions of the talus through a medial mallolar approach or arthroscopically-assisted approach were prospectively followed. Assessment tools consisted of the visual analogue scale (VAS) and the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot score (AOFAS). The magnetic resonance observation of cartilage repair tissue (MOCART) score was used postoperatively.ResultsData for 24 patients (mean age 34 years, mean follow-up 22 months) was analyzed. Mean preoperative/final AOFAS and VAS in those who underwent osteotomy were 57.7/81.2 and 5.7/1.9 (p < 0.001), respectively. In those who underwent arthroscopically-assisted reconstruction, mean preoperative/final AOFAS and VAS were 54.4/84.0 and 7.6/2.0 (p < 0.001), respectively. There was no difference in mean MOCART score (p = 0.662) for those treated with osteotomy (67.3) compared to those without (70.8).ConclusionsOsteochondral lesions of the talar dome can be treated successfully by biological inlay osteochondral reconstruction technique without medial malleolar osteotomy, with good to excellent clinical outcomes expected. MRI demonstrates good integration of the graft into surrounding tissue.     

The effect of platelet-rich plasma on osteochondral defects treated with mosaicplasty

Purpose

This study investigated the efficacy of platelet-rich plasma (PRP) on articular surfaces on which the mosaicplasty technique was performed. Our hypothesis was that PRP can accelerate the osseointegration process and enhance the quality of articular integrity after the mosaicplasty procedure.

Methods

Standard defects were created in the femoral groove of both patellofemoral joints of 12 New Zealand rabbits. PRP solution was placed inside the defect before fixation of the osteochondral autografts and injected inside the involved joint after capsular closure of the tested knees. The contralateral knees served as the control sides. The animals were euthanized three or six weeks after mosaicplasty, and both limbs were assessed according to Pineda’s histological grading scale. Significance level was set at p ≤ 0.05 a priori, and the Mann–Whitney U test was used for statistical analysis.

Results

Histologic findings at the interface between the transferred autograft and the original cartilage revealed better integration of the adjacent surfaces in the mosaicplasty with PRP group three weeks after the procedure; the difference was significant (p < 0.05). However, no significant difference in the transition zone was observed between the groups six weeks after the experiment (p = 0.59).

Conclusions

Our animal model showed that adjunctive use of PRP produced a better healing response and resulted in superior histological scores after three weeks compared with the mosaicplasty-only procedure. Interpretation of our results is important in terms of rapid return to previous activity levels. Thus, application of PRP can represent a valid therapeutic option for improving the efficacy of mosaicplasty by stimulating the local healing response.     

Treatment principles for osteochondral lesions in foot and ankle

Osteochondral lesion of the talus (OLT) is a broad term used to describe an injury or abnormality of the talar articular cartilage and adjacent bone. A variety of terms have been used to refer to this clinical entity, including osteochondritis dissecans (OCD), osteochondral fracture and osteochondral defect. Whether OLT is a precursor to more generalised arthrosis of the ankle remains unclear, but the condition is often symptomatic enough to warrant treatment. In more than one third of cases, conservative treatment is unsuccessful, and surgery is indicated. There is a wide variety of treatment strategies for osteochondral defects of the ankle, with new techniques that have substantially increased over the last decade. The common treatment strategies of symptomatic osteochondral lesions include nonsurgical treatment, with rest, cast immobilisation and use of nonsteroidal anti-inflammatory drugs (NSAIDs). Surgical options are lesion excision, excision and curettage, excision combined with curettage and microfracturing, filling the defect with autogenous cancellous bone graft, antegrade (transmalleolar) drilling, retrograde drilling, fixation and techniques such as osteochondral transplantation [osteochondral autograft transfer system (OATS)] and autologous chondrocyte implantation (ACI). Furthermore, smaller lesions are symptomatic and when left untreated, OCDs can progress; current treatment strategies have not solved this problem. The target of these treatment strategies is to relieve symptoms and improve function. Publications on the efficacy of these treatment strategies vary. In most cases, several treatment options are viable, and the choice of treatment is based on defect type and size and preferences of the treating clinician.     

Fresh osteochondral allograft transplantation (FOCAT) for definitive management of a 198 square millimeter osteochondral lesion of the talus (OLT): A case report

An osteochondral lesion of the talus (OLT) is an idiopathic acquired lesion of the subchondral bone that can lead to debilitating sequelae. The causes of OLT’s are still debatable, however, most agree that the etiology is repetitive microtrauma associated with vascular impairment. OLTs are most commonly described in the medial portion of the talus, while lateral involvement is less frequent. If not properly recognized and treated, an OLT may lead to numerous secondary conditions including premature osteoarthritis and functional limitations of the ankle joint. Multiple surgical and non-surgical treatment modalities have been described with varying results. Treatments are usually guided by the patients age, onset of symptoms, severity, and the disease stage according to the Berndt and Harty classification. Recent literature recommends curettage, drilling, or microfracture techniques for lesions which are no larger than 15 mm in diameter and no deeper than 7 mm. On the other hand, for large lesions or lesions that failed from primary bone marrow stimulation, surgery should be considered for autologous chondrocyte implantation (ACI), osteochondral autograft transplantation (OATs or mosaicplasty), or osteochondral allograft transplantation [1]. This case study examines surgical treatment of an extensive OLT in a 53 year old man who suffered with continuous ankle pain for over 10 years, misdiagnosed as ankle joint arthritis.Level of clinical evidence: Level of evidence 4.     

A comparison of surgical exposures for posterolateral osteochondral lesions of the talar dome

Background

Perpendicular access to the posterolateral talar dome for the management of osteochondral defects is difficult. We examined exposure available from each of four surgical approaches.

Surgical management of osteochondral lesions of the first metatarsal head: A systematic review

BackgroundTreating osteochondral lesions of the first metatarsal head can help reducing pain and preventing end-stage arthritic cartilage degeneration and hallux rigidus. Several surgical techniques have been described, but no clear indications are reported. This systematic review aims to offer an overview of the current surgical treatments for focal osteochondral lesions of the first metatarsal head.MethodsThe selected articles were examined to extract data about population, surgical technique, and clinical outcomes.ResultsEleven articles were included. Mean age at surgery was 38,2 years. Osteochondral autograft was the most used technique. After surgery, an improvement was achieved in AOFAS, VAS, and hallux dorsiflexion but not in plantarflexion.ConclusionThere is limited evidence and knowledge regarding the surgical management of the first metatarsal head osteochondral lesions. Various surgical techniques have been proposed, drawn from other districts. Good clinical results have been reported. Further high-level comparative studies are necessary to design an evidence-based treatment algorithm.     

A novel nano-composite multi-layered biomaterial for treatment of osteochondral lesions: Technique note and an early stability pilot clinical trial

Introduction

Osteochondral articular defects are a key concern in orthopaedic surgery. Current surgical techniques to repair osteochondral defects lead to poor subchondral bone regeneration and fibrocartilage formation, which is often associated with joint pain and stiffness. The objective of this pilot clinical study is to evaluate the performance and the intrinsic stability of a newly developed biomimetic osteochondral scaffold and to test the safety and the feasibility of the surgical procedure.

Methods

A gradient composite osteochondral scaffold based on type I collagen-hydroxyapatite was obtained by nucleating collagen fibrils with hydroxyapatite nanoparticles.Thirteen patients (15 defect sites) were treated with scaffold implantation from January 2007 to July 2007: four at the medial femoral condyle, two at the lateral femoral condyles, five at the patellas and four at the trochleas. The mean size of the defects was 2.8 cm² (range: 1.5-5.9 cm²).All patients were followed up prospectively. High-resolution magnetic resonance imaging (MRI) was used to determine “the early postoperative adherence rate” at 4-5 weeks and 25-26 weeks after scaffold implantation. Moreover, the magnetic resonance observation of cartilage repair tissue (MOCART) ^{[13] and [14]} score was performed on every MRI. Two second-looks were performed at 6 months; cartilage repair was assessed using the International Cartilage Repair Society (ICRS) visual scoring system and histological and immunohistochemical analysis of the two biopsies was carried out.

Results

A completely attached graft and repair tissue were found in 13 of 15 lesions (86.7%). A partial detachment was observed in two patients (13.3%). No detached grafts were found.Complete filling of the cartilage defect and congruency of the articular surface were seen in 10 lesions (66.7%) with MRI evaluation at 6 months. The complete integration of the grafted cartilage was detected in eight lesions (53.3%). Subchondral bone changes (oedema or sclerosis) were found in eight defects (53.3%). Statistical analysis showed a significant improvement in the International Knee Documentation Committee (IKDC) subjective and objective scores from preoperative to 6 months’ follow-up (p < 0.0005).Visual scoring of the repaired tissue at second-look revealed a normal repair score in one case and a near-normal repair score in the other case. Histological analysis showed the formation of subchondral bone without the presence of biomaterial. The cartilage repair tissue appeared to be engaged in an ongoing maturation process.

Conclusions

The technique is safe and MRI evaluation at short-term follow-up has demonstrated good stability of the scaffold without any other fixation device. The preliminary clinical results at short-term follow-up are encouraging. A clinical and MRI study with longer follow-up and randomised studies will be done to confirm the high potential of this novel osteochondral scaffold.     

Biochemical, biomechanical and histological properties of osteoarthritic porcine knee cartilage: implications for osteochondral transplantation

Introduction Cartilage lesions of the knee joint are frequently observed during arthroscopy and when surgical intervention is required, osteochondral autograft procedures are an established method of treatment. Frequently lesions are located on the medial femoral condyle (MFC), and typical donor locations for osteochondral grafts include the medial and lateral patellar groove. This technique provides good results, even when the quality of cartilage transplanted from an osteoarthritic joint is doubtful. This study characterizes biological, biomechanical and histological properties of cartilage explants from the patellar groove harvested from osteoarthritic joints. Materials and methods Cylindrical cartilage explants were harvested from the arthritic areas of the MFC as well as normal appearing regions of the medial and lateral patellar groove from porcine joints revealing various grades of osteoarthritis. Matrix synthesis rates were determined, and explants were investigated by mechanical testing and histology. Results Articular cartilage obtained from the typical donor areas of the medial and lateral patellar groove provided constant enhanced material properties, matrix synthesis rates and histological appearance compared to samples from the arthritic lesions of the MFC, even in joints with end-stage osteoarthritis of the MFC. No significant difference was found between patellar groove cartilage samples harvested from joints with different stages of osteoarthritis. Conclusion Our findings demonstrate that healthy appearing cartilage from the patellar groove does not undergo significant alterations in material properties due to the arthritic milieu present in osteoarthritic joints. Accordingly these locations provide a source of functional tissue for transplant procedures even in joints with end-stage osteoarthritis.     

Arthroscopic debridement of osteochondral lesions of the talus: A systematic review

BackgroundArthroscopic debridement (AD) for the osteochondral lesions of the talar dome (OLT) was widely documented in the nineties with satisfactory results. However, in modern treatment algorithms, its role is not described. The present systematic review aims to evaluate the current evidence on the clinical outcomes of AD in the management of OLT.MethodsTwo independent reviewers searched PubMed, EMBASE, Scopus, and Virtual Health Library databases evaluating the clinical outcomes of AD of OLT with a minimum 6-month follow-up. The following terms "talus", "chondral", "cartilage", "injury", "lesion", "delamination", "damage", "excision", "curettage", "debridement", "chondrectomy", "chondroplasty", were used alone and in combination with Boolean operators AND and OR. Studies in which surgical technique was not described, an additional procedure was performed after debridement, and/or outcomes were not reported separately when more than one technique was implemented were excluded. The modified Coleman methodology score (mCMS) was used to evaluate the methodological quality of the included studies. A narrative analysis was conducted. Publication bias was assessed using the ROBIS tool.ResultsAD showed satisfactory short and medium-term outcomes for the primary treatment of OLT irrespectively of size and depth. However, the heterogeneity of the included studies and the level of available evidence hinders its recommendation.ConclusionsThere is a paucity of evidence evaluating AD alone for OLT treatment in the last two decades. Bone-marrow stimulation techniques remain the first-line surgical strategy for OLT treatment without proven superiority. Adopting AD for OLT treatment instead of MF could represent a paradigm breakthrough in clinical practice given its many potential advantages while preserving the subchondral plate.     

Establishing proof of concept: Platelet-rich plasma and bone marrow aspirate concentrate may improve cartilage repair following surgical treatment for osteochondral lesions of the talus

Osteochondral lesions of the talus are common injuries in the athletic patient. They present a challenging clinical problem as cartilage has a poor potential for healing. Current surgical treatments consist of reparative (microfracture) or replacement (autologous osteochondral graft) strategies and demonstrate good clinical outcomes at the short and medium term follow-up. Radiological findings and second-look arthroscopy however, indicate possible poor cartilage repair with evidence of fibrous infill and fissuring of the regenerative tissue following microfracture. Longer-term follow-up echoes these findings as it demonstrates a decline in clinical outcome. The nature of the cartilage repair that occurs for an osteochondral graft to become integrated with the native surround tissue is also of concern. Studies have shown evidence of poor cartilage integration, with chondrocyte death at the periphery of the graft, possibly causing cyst formation due to synovial fluid ingress. Biological adjuncts, in the form of platelet-rich plasma (PRP) and bone marrow aspirate concentrate (BMAC), have been investigated with regard to their potential in improving cartilage repair in both in vitro and in vitro settings. The in vitro literature indicates that these biological adjuncts may increase chondrocyte proliferation as well as synthetic capability, while limiting the catabolic effects of an inflammatory joint environment. These findings have been extrapolated to in vitro animal models, with results showing that both PRP and BMAC improve cartilage repair. The basic science literature therefore establishes the proof of concept that biological adjuncts may improve cartilage repair when used in conjunction with reparative and replacement treatment strategies for osteochondral lesions of the talus.     

距骨骨软骨损伤的诊断及关节镜治疗

目的 总结、分析距骨骨软骨损伤的症状、体征、影像学特点、关节镜下治疗方法及手术效果.方法 2000年至2005年共收治34例距骨骨软骨损伤患者,对其临床资料包括症状、体征、X线片、MRI表现、关节镜手术方法等进行回顾性分析,术后随访根据主观和客观评分判断疗效.术前美国足踝外科后足评分平均(71±8)分,术前主观疼痛程度评分(7.5±1.3)分.结果 34例患者MRI均有骨软骨损伤征象,其中21例通过X线片检查发现距骨骨软骨损伤.距骨骨软骨损伤的主要症状为负重疼痛以及运动后加重,MRI诊断准确率较X线片高(χ2=16.07,P＜0.001).31例患者获得随访,平均随访时间为28个月.术后美国足踝外科后足评分(91±9)分,显著高于术前(t=9.147,P＜0.001);术后主观疼痛程度评分(2.4±2.3)分,显著低于术前(t=10.853,P＜0.001);临床疗效优良率为87.1%.结论 MRI检查能够提高诊断的正确率,关节镜微创手术治疗距骨骨软骨损伤效果良好.     

Cartilage repair techniques of the talus: An update

Symptomatic chondral or osteochondral defects of the talus reduce the quality of life of many patients. Although their pathomechanism is well understood, it is well known that different aetiologic factors play a role in their origin. Additionally, it is well recognised that the talar articular cartilage strongly differs from that in the knee. Despite this fact, many recommendations for the management of talar cartilage defects are based on approaches that were developed for the knee. Conservative treatment seems to work best in paediatric and adolescent patients with osteochondritis dissecans. However, depending on the size of the lesions, surgical approaches are necessary to treat many of these defects. Bone marrow stimulation techniques may achieve good results in small lesions. Large lesions may be treated by open procedures such as osteochondral autograft transfer or allograft transplantation. Autologous chondrocyte transplantation, as a restorative procedure, is well investigated in the knee and has been applied in the talus with increasing popularity and promising results but the evidence to date is poor. The goals of the current article are to summarise the different options for treating chondral and osteochondral defects of the talus and review the available literature.     

Mosaicplasty for the treatment of femoral head defect after incorrect resorbable screw insertion

Articular cartilage lesions and osteochondral defects remain a difficult problem for the patient and physician. A variety of procedures and treatments have been proposed to lessen symptoms and restore the articular surface. The knee joint has been the focus of the vast majority of these cartilage restoration procedures. Osteochondral defects of the proximal femur are significantly less common, and their management remains poorly defined. This article reports the case of a young man with a deep osteochondral defect of the femoral head caused by penetrated resorbable screw after internal fixation of a displaced large single fragment of the posterior acetabular rim and subsequent treatment using mosaicplasty.     

No mid-term difference in mosaicplasty in previously treated versus previously untreated patients with osteochondral lesions of the talus

Introduction Osteochondral transplantations, albeit technically challenging, appear promising not only in knee joint lesions, but also in the treatment of talus lesions. We hypothesized that in patients suffering osteochondral lesions of the talus, favorable outcomes are obtained in patients undergoing primary mosaicplasty as compared to patients undergoing secondary mosaicplasty. Materials and methods Over a 3-year period (1998–2001), 14 patients (six male, eight female, median age 22 years) were treated with an autologous osteochondral transplantation of the talus. Eight patients were previously untreated (group I). Six patients had previous ankle procedures, such as microfracturing (group II). The median follow-up was 24 months and 100% complete at 12 months. The functional outcome was evaluated at least at 6 weeks, 12 weeks, and 1 year after surgery using pain on a visual analog scale (VAS) and sports activity was recorded at 1 year after surgery. In ten patients, magnetic resonance imaging (MRI) of the ankle was performed at 1 year after surgery (group I/II: 7/3). Results Overall ankle pain was decreased from 6.9 ± 2.1 to 4.0 ± 2.8 postoperatively. The mean knee pain for the donor knee was 2.6 ± 2.4. We found no significant difference between the primary mosaicplasty group and the secondary mosaicplasty group with regard to pain. MRI scans of ten patients showed a complete incorporation of the osteochondral cylinders at 1 year after surgery. Conclusion Favorable outcomes were obtained in patients undergoing primary mosaicplasty as compared to patients undergoing secondary mosaicplasty. We found no significant difference among patients with previous ankle surgery in contrast to those without, with a median 24-months follow-up.     

A prospective,single-center study following operative treatment for osteochondral lesions of the talus

Background(1) To evaluate patient-reported outcomes and revision surgeries after various operative interventions for osteochondral lesions of the talus (OLT) in a prospective single center series over 10 years, and (2) to identify predicting factors related to subjective ankle status and quality of life pre- and postoperatively.MethodsNinety-nine patients underwent operative treatment due to primary or recurrent OLT, with an average follow up 3.5 (1.8) years. Treatment outcome was followed clinically (FAOS, EQ-5D, Tegner activity scale) and by pursuing any serious adverse events or graft failures.ResultsThere were 80 responding patients (81%) for the study. The mean lesion size was 2.0 (1.1) cm². All FAOS values increased from preoperative to final follow-up values (Symptoms 60–68, Pain 58–69, ADL 71–80, Sport 36–54, QoL 30–45). EQ-5D increased from 0.49 to 0.62, while Tegner activity scale change from 3.2 to 3.4. There were 19 (24%) serious adverse events recorded; 13 (16%) of them were graft-related. Graft survival rates were 100% at 1 year, 94% (males)/93% (females) at 2 years, and 77% (males)/47% (females) at 5 years. Female gender, higher BMI, and higher Kellgren-Lawrence ankle OA score were negative predictors for preoperative patient-reported ankle joint status. The foremost improvement after operative intervention was observed in patients with large osteochondral lesions without postoperative adverse events.ConclusionVarious operative interventions for OLT significantly improved patients’ ankle status and quality of life. High graft survival rates were demonstrated over first two years, but notable decline was confirmed thereafter, especially in female patients.     

Vascularized osteochondral free flaps from the femoral trochlea as versatile procedure for reconstruction of osteochondral lesions of the talus

BackgroundOsteochondral lesions of the talus (OLT) are defects affecting the articular cartilage as well as the subchondral bone, on the lateral shoulder possibly associated with trauma. This study presents the results of reconstructing OLT using vascularized osteochondral flaps from the femoral trochlea.MethodsWe treated 19 patients with osteochondral talar shoulder defects, using osteochondral flaps from the medial (MFT) or lateral (LFT) femoral trochlea. Functional outcome was evaluated by clinical investigation, visual analogue scale (VAS, 0–10), American Orthopaedic Foot and Ankle Society-Ankle and Hindfoot Scale (AOFAS, 0–100) and The Foot and Ankle Disability Index (FADI, 0–104). Radiographic postoperative follow-up was done by anterior-posterior and lateral X-rays and union of the transferred osteochondral flaps was documented by CT scans.ResultsThe osteochondral flaps fused in all of the 19 cases. After a median follow-up of 45.5 months, the patients showed an average FADI of 94.9 and AOFAS-Ankle and Hindfoot Scale of 91.2. All of them were walking free and normal. Subjective median satisfaction was 1.3 in a scale from 1 to 5.ConclusionVascularized transfer of osteochondral flaps from the femoral trochlea is a reliable treatment option for symptomatic OLT of the medial and lateral talar edge.Level of clinical evidence: Therapeutic IV