Faculty Bibliography

BACKGROUND:The evidence supporting best practice guidelines in the field of cartilage repair of the ankle are based on both low quality and low levels of evidence. Therefore, an international consensus group of experts was convened to collaboratively advance toward consensus opinions based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article is to report the consensus statements on Post-treatment Follow-up, Imaging and Outcome Scores developed at the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. METHODS:Seventy-five international experts in cartilage repair of the ankle representing 25 countries and 1 territory were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within 11 working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed on in unanimous fashion within the working groups. A final vote was then held, and the strength of consensus was characterized as follows: consensus, 51% to 74%; strong consensus, 75% to 99%; unanimous, 100%. RESULTS:A total of 12 statements on Post-treatment Follow-up, Imaging, and Outcome Scores reached consensus during the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. All 12 statements reached strong consensus (greater than 75% agreement). CONCLUSIONS:This international consensus derived from leaders in the field will assist clinicians with post-treatment follow-up, imaging, and outcome scores after management of a cartilage injury of the ankle in the general population. Moreover, healing, rehabilitation, and final outcomes can be optimized for the individual patient.

BACKGROUND:Extracellular matrix cartilage allografts (EMCAs) and particulate cartilage allografts (PCAs) are relatively new biologics that may improve the quality of cartilage regeneration after bone marrow stimulation. The increasing popularity of these novel biologics in the treatment of osteochondral lesions (OCLs) of the knee and ankle joints prompts a systematic evaluation of their efficacies. PURPOSE/OBJECTIVE:The purpose of this systematic review was to clarify the effectiveness of EMCAs and PCAs on cartilage regeneration. STUDY DESIGN/METHODS:Systematic review; Level of evidence, IV. METHODS:Two reviewers searched MEDLINE and Embase in February 2016 based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Predetermined variables from each study were extracted and analyzed. RESULTS:For EMCAs, 1 in vitro study and 2 clinical studies for OCLs of the ankle joint were found. For PCAs, 3 in vitro studies, 5 clinical studies for OCLs of the knee joint, and 5 clinical studies for OCLs of the ankle joint were found. For all studies, in vitro chondrogenesis and clinical outcomes favored EMCAs and PCAs. However, the highest level of evidence was IV, and the methodological quality of evidence was indicated to be poor. CONCLUSION/CONCLUSIONS:Both EMCAs and PCAs have yielded favorable outcomes in both in vitro and clinical studies. However, the available studies were of limited data with significant confounding factors. Therefore, it is unclear whether the effectiveness of these novel biologics is any greater than that of bone marrow stimulation alone in the repair of knee and ankle cartilage.

Surgical procedures for managing chronic lateral ankle instability include anatomic direct repair, anatomic reconstruction with an autograft or allograft, and arthroscopic repair. Open direct repair is commonly used for patients with sufficient ligament quality. Reconstruction incorporating either an autograft or an allograft is another promising option in the short term, although the longevity of this procedure remains unclear. Use of an allograft avoids donor site morbidity, but it comes with inherent risks. Arthroscopic repair of chronic lateral ankle instability can provide good to excellent short- and long-term clinical outcomes, but the evidence supporting this technique is limited. Deterioration of the ankle joint after surgery is also a concern. Studies are needed on not only treating ligament insufficiency but also on reducing the risk of ankle joint deterioration.

PURPOSES/OBJECTIVE:There is a lack of substantial clinical evidence endorsing the clinical outcomes of osteotomy for peroneal tendon dislocations. The aim of this study was to compare the post-operative reoperation rates following osteotomy techniques and soft tissues procedures using large database in order to investigate the efficacy of bony techniques. METHODS:Patients who underwent osteotomy and soft tissue procedures for peroneal tendon dislocations were identified and subsequently analysed using the United Healthcare Orthopedic and the Medicare datasets (PearlDiver Patient Record Database, PearlDiver Technologies Inc., Fort Wayne, IN). The investigated period was from 2005 to 2012. The annual incidence, gender distribution, and incidences of reoperation and wound dehiscence following primary operative procedures were determined in these cohorts. RESULTS:Of 6122 patients who received operative treatment for peroneal tendon dislocations, 1416 patients (23.1%) received the osteotomy technique, while 4706 (76.9%) were treated with the soft tissue techniques. The incidence of these operative procedures did not change significantly over the time periods of each database. In both databases, reoperation rates were 2.8% (40/1416) for osteotomy patients and 3.4% (158/4706) for soft tissue repair patients, with no statistical difference (2.8 vs. 3.4%. odds ratio 0.8, 95% confidence interval [CI] 0.6-1.2, [n.s.]) between them. Based on both databases, wound dehiscence occurred in 2.6% (37/1416) of the osteotomy patients and 2.3% (110/4706) of soft tissue repair patients with no statistical difference (2.6 vs. 2.3%, odds ratio 1.1, 95% CI 0.8-1.6, [n.s.]) between the groups. CONCLUSION/CONCLUSIONS:The results of this study show that osteotomy techniques were frequently performed for patients with peroneal tendon dislocations. Nevertheless, osteotomy techniques for peroneal tendon dislocations are not associated with a lower risk of reoperation. In conclusion, soft tissue procedures offer a satisfactory method of treating peroneal tendon dislocations without any additional risk of reoperation when compared to osteotomy techniques that have potentially greater complication rates. LEVEL OF EVIDENCE/METHODS:III.

BACKGROUND:Microfracture is the most common cartilage-reparative procedure for the treatment of osteochondral lesions of the talus (OLTs). Damage to the subchondral bone (SCB) during microfracture may irreversibly change the joint-loading support of the ankle, leading to reparative fibrocartilage degradation over time. PURPOSE/OBJECTIVE:To investigate the morphological change in the SCB after microfracture for OLT by developing a novel magnetic resonance imaging (MRI) scoring system specifically for evaluating the SCB. Furthermore, this study assesses the influence of the morphological changes of the SCB on clinical outcomes based on the new score. STUDY DESIGN/METHODS:Case series; Level of evidence, 4. METHODS:Forty-two patients who underwent microfracture for OLT were included. An SCB Health (SCBH) scoring system was developed according to the amount of edema, subchondral cyst diameter, and qualitative and thickness change in the SCB, with a total score of 12 indicating normal SCB. MRI was obtained postoperatively from 6 months to 1 year, 1 to 2 years, 2 to 4 years, and 4 to 6 years. The Foot and Ankle Outcome Score (FAOS) was evaluated preoperatively and at 2 years and final follow-up. RESULTS:The mean patient age was 38.4 ± 15.6 years, with a mean follow-up of 51.7 ± 22.8 months. The mean FAOS improved significantly from 57.8 ± 14.4 preoperatively to 84.3 ± 7.2 at 24 months ( P < .001) and decreased to a final mean value of 77.1 ± 12.6 ( P < .001). The mean SCBH score decreased from 8.6 ± 1.9 preoperatively to 7.1 ± 1.8 on the first follow-up MRI ( P < .001) and significantly decreased to 5.9 ± 2.3 on the fourth follow-up MRI ( P < .001). Subchondral cysts were noticeably worse at the fourth follow-up MRI than at the first and second ( P < .001, P = .006, respectively). There was a positive correlation between the final FAOS and the SCBH score on the third and fourth follow-up MRI ( r = 0.55, P < .001; r = 0.70, P < .001, respectively), but no correlation was found on the first and second follow-up. CONCLUSION/CONCLUSIONS:The SCBs following microfracture for OLT were not restored at midterm follow-up. There was a significant decrease of the overall SCBH score over time. Noticeably, subchondral cysts deteriorated over time consistently. In addition, the SCBH score at midterm follow-up was positively correlated with clinical outcomes. Lasting morphological changes in the SCB may be indicative of longer-term failure of the microfracture procedure.

Osteochondral defects or lesions of the talus represent a management challenge. Arthroscopic débridement is the treatment of choice for patients with an osteochondral lesion of the talus in whom nonsurgical treatment fails. Although surgeons have a better understanding of the risk factors for failed débridement in patients with an osteochondral lesion of the talus, the treatment of patients in whom a high risk for failed débridement exists and patients in whom débridement fails is controversial. Surgeons should understand the current adjunct therapies available for the management of osteochondral lesions of the talus, including cartilage preparations, platelet-rich plasma, bone marrow aspirate, bone graft or bone graft substitutes, and whole bone cartilage transfer (osteochondral autograft transfer); however, evidence for the use of one adjunct therapy more than another is lacking.

PURPOSE/OBJECTIVE:Bone marrow concentrate (BMC) and platelet-rich plasma (PRP) are used extensively in regenerative medicine. The aim of this study was to determine differences in the cellular composition and cytokine concentrations of BMC and PRP and to compare two commercial BMC systems in the same patient cohort. METHODS:Patients (29) undergoing orthopaedic surgery were enrolled. Bone marrow aspirate (BMA) was processed to generate BMC from two commercial systems (BMC-A and BMC-B). Blood was obtained to make PRP utilizing the same system as BMC-A. Bone marrow-derived samples were cultured to measure colony-forming units, and flow cytometry was performed to assess mesenchymal stem cell (MSC) markers. Cellular concentrations were assessed for all samples. Catabolic cytokines and growth factors important for cartilage repair were measured using multiplex ELISA. RESULTS:Colony-forming units were increased in both BMCs compared to BMA (p < 0.0001). Surface markers were consistent with MSCs. Platelet counts were not significantly different between BMC-A and PRP, but there were differences in leucocyte concentrations. TGF-β1 and PDGF were not different between BMC-A and PRP. IL-1ra concentrations were greater (p = 0.0018) in BMC-A samples (13,432 pg/mL) than in PRP (588 pg/mL). The IL-1ra/IL-1β ratio in all BMC samples was above the value reported to inhibit IL-1β. CONCLUSIONS:The bioactive factors examined in this study have differing clinical effects on musculoskeletal tissue. Differences in the cellular and cytokine composition between PRP and BMC and between BMC systems should be taken into consideration by the clinician when choosing a biologic for therapeutic application. LEVEL OF EVIDENCE/METHODS:Clinical, Level II.

AIM/OBJECTIVE:To clarify the quality of the studies indicating lesion size and/or containment as prognostic indicators of bone marrow stimulation (BMS) for osteochondral lesions of the talus (OLT). METHODS:Two reviewers searched the PubMed/MEDLINE and EMBASE databases using specific terms on March 2015 in accordance with the Preferred Reporting Items for Systemic Reviews and Meta-Analyses guidelines. Predetermined variables were extracted for all the included studies. Level of evidence (LOE) was determined using previously published criteria by the Journal of Bone and Joint Surgery and methodological quality of evidence (MQOE) was evaluated using the Modified Coleman Methodology Score. RESULTS:This review included 22 studies. Overall, 21 of the 22 (95.5%) included studies were level IV or level III evidences. The remaining study was a level II evidence. MQOE analysis revealed 14 of the 22 (63.6%) included studies having fair quality, 7 (31.8%) studies having poor quality and only 1 study having excellent quality. CONCLUSION/CONCLUSIONS:The evidence supporting the use of lesion size and containment as prognostic indicators of BMS for OLTs has been shown to be of low quality.

AIM/OBJECTIVE:To clarify the effectiveness of scaffold-based therapy for osteochondral lesions of the talus (OLT). METHODS:A systematic search of MEDLINE and EMBASE databases was performed during August 2016 and updated in January 2017. Included studies were evaluated with regard to the level of evidence (LOE) and quality of evidence (QOE) using the Modified Coleman Methodology Score. Variable reporting outcome data, clinical outcomes, and the percentage of patients who returned to sport at previous level were also evaluated. RESULTS:Twenty-eight studies for a total of 897 ankles were included; 96% were either LOE III or IV. Studies were designated as either of poor or fair quality. There were 30 treatment groups reporting six different scaffold repair techniques: 13 matrix-induced autologous chondrocyte transplantation (MACT), nine bone marrow derived cell transplantation (BMDCT), four autologous matrix-induced chondrogeneis (AMIC), and four studies of other techniques. The categories of general demographics (93%) and patient-reported outcome data (85%) were well reported. Study design (73%), imaging data (73%), clinical variables (49%), and patient history (30%) were also included. The weighted mean American Orthopaedic Foot and Ankle Society (AOFAS) score at final follow-up was: 86.7 in MACT, 88.2 in BMDCT, and 82.3 in AMIC. Eight studies reported that a weighted mean of 68.3% of patients returned to a previous level of sport activity. CONCLUSION/CONCLUSIONS:Scaffold-based therapy for OLT may produce favorable clinical outcomes, but low LOE, poor QOE, and variability of the data have confounded the effectiveness of this treatment.