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Free accessEditorialFirst published January, 2017pp. 11-11
Free accessReview articleFirst published January, 2017pp. 12-18Posttraumatic osteoarthritis (PTOA) is the most common form of osteoarthritis (OA) of the ankle joint. PTOA occurs as a result of several factors, including the poor regenerative capacity of hyaline articular cartilage as well as increased contact stresses following trauma. The purpose of this article is to review the epidemiology, pathogenesis, and potential targets for treatment of PTOA in the ankle joint. Previous reviews primarily addressed clinical approaches to ankle PTOA, while the focus of the current article will be specifically on the newly acquired knowledge of the cellular mechanisms that drive PTOA in the ankle joint and means for potential targeted therapeutics that might halt the progression of cartilage degeneration and/or improve the outcome of surgical interventions. Three experimental treatment strategies are discussed in this review: (1) increasing the anabolic potential of chondrocytes through treatment with growth factors such as bone morphogenetic protein-7; (2) limiting chondrocyte cell death either through the protection of cell membrane with poloxamer 188 or inhibiting activity of intracellular proteases, caspases, which are responsible for cell death by apoptosis; and (3) inhibiting catabolic/inflammatory responses of chondrocytes by treating them with anti-inflammatory agents such as tumor necrosis factor-α antagonists. Future studies should focus on identifying the appropriate timing for treatment and an appropriate combination of anti-inflammatory, chondro- and matrix-protective biologics to limit the progression of trauma-induced cartilage degeneration and prevent the development of PTOA in the ankle joint.
Free accessReview articleFirst published January, 2017pp. 19-30Osteochondral lesions of the talus are common injuries that affect a wide variety of active patients. The majority of these lesions are associated with ankle sprains and fractures though several nontraumatic etiologies have also been recognized. Patients normally present with a history of prior ankle injury and/or instability. In addition to standard ankle radiographs, magnetic resonance imaging and computed tomography are used to characterize the extent of the lesion and involvement of the subchondral bone. Symptomatic nondisplaced lesions can often be treated conservatively within the pediatric population though this treatment is less successful in adults. Bone marrow stimulation techniques such as microfracture have yielded favorable results for the treatment of small (<15 mm) lesions. Osteochondral autograft can be harvested most commonly from the ipsilateral knee and carries the benefit of repairing defects with native hyaline cartilage. Osteochondral allograft transplant is reserved for large cystic lesions that lack subchondral bone integrity. Cell-based repair techniques such as autologous chondrocyte implantation and matrix-associated chondrocyte implantation have been increasingly used in an attempt to repair the lesion with hyaline cartilage though these techniques require adequate subchondral bone. Biological agents such as platelet-rich plasma and bone marrow aspirate have been more recently studied as an adjunct to operative treatment but their use remains theoretical. The present article reviews the current concepts in the evaluation and management of osteochondral lesions of the talus, with a focus on the available surgical treatment options.
Free accessReview articleFirst published January, 2017pp. 31-41The incidence of osteochondral lesions, as well as osteoarthritis of the ankle joint following osteochondritis dissecans and trauma, has been reappraised in recent years. Consequently, an increasing number of surgical interventions using different cartilage repair techniques is performed in the ankle joint, which has resulted in a growing demand for repetitive and objective assessment of cartilage tissue and its repair. While morphological imaging does enable monitoring of macroscopic changes with increasing precision, it fails to provide information about the ultrastructural composition of cartilage. The significance of molecular changes in cartilage matrix composition, however, is increasingly recognized, as it is assumed that macroscopic cartilage degeneration is preceded by a loss in glycosaminoglycans and a disorganization of the collagen network. Recent advances in biochemical magnetic resonance imaging (MRI) have yielded sequences sensitive to these changes, thus providing invaluable insight into both early cartilage degeneration and maturation of repair tissue, on a molecular level. The aim of this review was to provide a comprehensive overview of these techniques, including water and collagen-sensitive T2/T2* mapping, as well as glycosaminoglycan-sensitive sequences such as delayed gadolinium-enhanced MRI of cartilage dGEMRIC, and sodium imaging, and describe their applications for the ankle joint.
Free accessReview articleFirst published January, 2017pp. 42-49Numerous basic science articles have published evidence supporting the use of biologic augmentation in the treatment of osteochondral lesions of the talus (OLT). However, a comprehensive evaluation of the clinical outcomes of those treatment modalities in OLT has yet to be published. The purpose of this review is to provide an evidence-based overview of clinical outcomes following biologic augmentation to surgical treatments for OLT.
A comprehensive literature review was performed. Two commonly used surgical techniques for the treatment of OLT—bone marrow stimulation and osteochondral autograft transfer—are first introduced. The review describes the operative indications, step-by- step operative procedure, clinical outcomes, and concerns associated with each treatment. A review of the currently published basic science and clinical evidence on biologic augmentation in the surgical treatments for OLT, including platelet-rich plasma, concentrated bone marrow aspirate, and scaffold-based therapy follows.
Biologic agents and scaffold-based therapies appear to be promising agents, capable of improving both clinical and radiological outcomes in OLT. Nevertheless, variable production methods of these biologic augmentations confound the interpretation of clinical outcomes of cases treated with these agents.
Current clinical evidence supports the use of biologic agents in OLT cases. Nonetheless, well-designed clinical trials with patient-specific, validated and objective outcome measurements are warranted to develop standardized clinical guidelines for the use of biologic augmentation for the treatment of OLT in clinical practice.
Free accessResearch articleFirst published January, 2017pp. 50-60The low regenerative potential of cartilage contributed to the development of different cell therapies aimed to improve the clinical outcome in young patients with Osteochondral Lesions of the Talus (OLT). This study is designed to assess the regenerative potential of autologous matrix-induced Bone Marrow Aspirate Concentrate (mBMAC) and matrix-induced Autologous Chondrocyte Implantation (mACI) evaluating, on a small number of osteochondral biopsies, the expression of some catabolic, inflammatory, and pain mediators.
Twenty-two patients with OLT were analyzed in this study; 7 were treated with mACI and 15 with mBMAC. Informed consent was obtained from all the patients. Clinical assessments were performed pre-operatively and at 12, 24, and 36 months after surgery using the American Orthopedic Foot and Ankle Society (AOFAS). Histology and immunohistochemistry were used to assess cartilage repair at 24 months. Data were analyzed using non-parametric Wilcoxon-Mann-Whitney and Spearman tests.
A remarkable improvement in AOFAS score was noticed for both treatments up to 36 months; however, patients treated with mACI reported the best AOFAS score. Various degrees of tissue remodeling were observed by histological analysis for both cell strategies. However, mBMAC treatment showed a higher expression of some fibrous and hypertrophic markers compared to mACI group. A mild positivity for nerve growth factor, as pain mediator, was noticed for both treatments.M
Our findings demonstrated the best histological and clinical results following mACI treatment since different fibrotic and hypertrophic features were evident in the mBMAC group at 24-month follow-up.
Free accessResearch articleFirst published January, 2017pp. 61-72To report on our institution’s early results from juvenile particulate cartilage allograft transplantation of the talus.
Because of the relative rarity of the procedure at the talus, it was decided to provide a comprehensive understanding of the currently available evidence via a 2-part study with (1) a systematic review of the literature and (2) a retrospective single-center cohort study of the authors’ patients, their demographics, and their early outcomes.
(1) Four studies were included with 33 ankles with a weighted mean follow-up of 14.3 months. Only 1 ankle (3.3%) was converted to a revision open osteochondral allograft with medial malleolar osteotomy at 16 months postoperative; 6 (18.2%) required nonrevision type reoperations at an average of 15 months postoperative. (2) Six patients with mean age 35.7 ± 14.4 years were evaluated from the authors’ institution at mean 13.04 ± 8.35 months’ follow-up. All reported subjective improvements in pain and motion, and functional improvements, although postoperative magnetic resonance imaging in 3 patients at time points between 3 months and 2 years postoperative demonstrate persistent subchondral edema and nonuniform chondral surface in the talus. There were no intraoperative or postoperative complications, and there have been no reoperations.
Preliminary data suggest that treatment of large, traumatic or atraumatic, symptomatic osteochondral talar defects with particulated juvenile cartilage transplantation may improve patient subjective complaints of pain and function. Systematic review of the available literature highlights the need for future prospective, larger cohort studies of its use on the talus but suggests similar potential for the technology.
Free accessResearch articleFirst published January, 2017pp. 73-79There remains no consensus on a postoperative protocol following arthroscopic treatment of osteochondral lesions of the talus (OLTs) and most studies report a period of immobilization and nonweightbearing. Outcomes are believed to decrease with larger size. The purpose of our study was to evaluate patients who underwent arthroscopic treatment of large (≥150 mm2) OLTs with immediate unrestricted weightbearing and mobilization postoperatively.
Patients who underwent arthroscopic bone marrow stimulation for osteochondral defects were identified. Exclusion criteria included lesions less than 150 mm2, additional procedures other than ligament reconstruction, incongruent ankle joint, arthritis, and tibial plafond lesions. Postoperatively, all patients were placed into a soft dressing and were allowed immediate weightbearing as tolerated. Patients were considered failures if their AOFAS (American Orthopaedic Foot and Ankle Society) score was less than 80 or if they underwent osteochondral transplant.
Thirteen patients were available for follow-up. Two patients underwent osteochondral transplant and were considered failures. Of the remaining 11, the average follow-up time after surgery was 33 months (range, 7-59 months). Average age was 37 years (range, 15-56 years), and lesion size averaged 239 mm2 (range, 150-400 mm2). Average postoperative scores included foot function index 50 (range, 23-136), visual analog scale 3 (range, 0-8), and AOFAS hindfoot 82 (range, 40-100). The group’s overall success rate was 54% (7/13).
The results of our study are higher than those previously published studies on large lesions with a more restricted postoperative rehabilitation, suggesting that unrestricted weightbearing and range of motion does not diminish patient outcomes.
IV, Case series.
Free accessResearch articleFirst published January, 2017pp. 80-87Arthroscopic “one-step” technique based on bone marrow–derived cell transplantation (BMDCT) have achieved good results in repairing osteochondral lesions of the talus (OLT), overcoming important drawbacks of older techniques. It may be particularly adequate for the treatment of athletes in order to permit a safe and stable return to sports. The aim of this study was to report the results at 48 months of a series of athletes and the factors influencing the return to sports.
Case series. A total of 140 athletes underwent a “one-step” BMDCT repair of OLT. All the patients had the cells harvested from the iliac crest, condensed and loaded on a scaffold, and then implanted. Patients were evaluated clinically by the American Orthopaedic Foot and Ankle Society (AOFAS) scores and Halasi score.
AOFAS score improved from 58.7 ± 13.5 preoperatively to 90.6 ± 8.6 (
“One-step” BMDCT repair of OLT had good clinical results that was durable over time in athletes, permitting a return to sports at preinjury level in the majority of patients. The preoperative presence of impingement and articular degeneration were the main negative prognostic factors.