Faculty Bibliography

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.

Background/UNASSIGNED:The incidence of coexisting osteochondral lesions (OCLs) of the tibia and talus has been negatively correlated with successful clinical outcomes, yet these lesions have not been extensively characterized. Purpose/UNASSIGNED:To determine the incidence of coexisting tibial and talar OCLs, assess the morphologic characteristics of these lesions, and evaluate whether these characteristics are predictive of outcome. Study Design/UNASSIGNED:Case series; Level of evidence, 4. Methods/UNASSIGNED:A total of 83 patients who underwent surgery for a talar OCL were evaluated for coexisting OCLs of the distal tibia with preoperative magnetic resonance images. Size, location, containment, International Cartilage Repair Society (ICRS) grade, patient age, and patient sex were analyzed for predictors of coexisting lesions or patient outcome. The talar and tibial surfaces were each divided into 9 zones, with 1 corresponding to the most anteromedial region and proceeding laterally and then posteriorly. The Foot and Ankle Outcome Score (FAOS) was evaluated pre- and postoperatively. Results/UNASSIGNED:= .043). There was no difference in OCL size or containment between kissing and nonkissing coexisting OCLs. Conclusion/UNASSIGNED:The incidence of coexisting talar and tibial OCLs may be more prevalent than what previous reports have suggested, with older patients being more likely to present with this pathology. The location of a talar OCL correlates with the incidence of a coexisting tibial OCL.

BACKGROUND:Uncontained-type osteochondral lesions of the talus (OLTs) have been shown to have inferior clinical outcomes after treatment with bone marrow stimulation. While autologous osteochondral transplantation (AOT) is indicated for larger lesions, no study has reported on the prognostic significance of the containment of OLTs treated with the AOT procedure. PURPOSE/OBJECTIVE:To clarify the effect of the containment of OLTs on clinical and radiological outcomes in patients who underwent AOT for OLTs. STUDY DESIGN/METHODS:Case control study; Level of evidence, 3. METHODS:A retrospective cohort study comparing patients with contained-type and uncontained-type OLTs was undertaken to include all patients who underwent AOT for the treatment of OLTs between 2006 and 2014. Analyses were performed by grouping the patients according to the containment type. Clinical outcomes were evaluated using the Foot and Ankle Outcome Score (FAOS) and the 12-Item Short Form Health Survey (SF-12) preoperatively and at final follow-up. Magnetic resonance imaging (MRI) at 2 years' follow-up was evaluated with the modified magnetic resonance observation of cartilage repair tissue (MOCART) score. Multivariate regression models were used to evaluate factors affecting postoperative FAOS, SF-12, and MOCART scores. RESULTS:Ninety-four patients were included: 31 patients with a contained-type OLT and 63 patients with an uncontained-type OLT. The median patient age was 34 years (interquartile range [IQR], 28-48 years) in the contained-type group and 36 years (IQR, 27-46 years) in the uncontained-type group. The median follow-up time was 45 months (IQR, 38-63 months) in the contained-type group and 52 months (IQR, 40-66 months) in the uncontained-type group. The median FAOS and SF-12 scores improved significantly after surgery in both contained-type and uncontained-type lesions ( P < .001). The median postoperative FAOS score of patients with contained-type OLTs was higher than that of patients with uncontained-type OLTs (91.7 vs 85.0, respectively; P = .009), but no significant differences were found between the contained-type and uncontained-type groups for postoperative SF-12 and MOCART scores. The multivariate regression models showed that patients with contained-type OLTs had an approximately 10-point better score on the FAOS compared with patients with uncontained-type OLTs ( P = .006). There was a nonsignificant trend for the rate of cystic occurrence in uncontained-type OLTs to be higher than that of contained-type OLTs (55.6% vs 38.7%, respectively; P = .125). CONCLUSION/CONCLUSIONS:Patients with contained-type OLTs experienced better clinical outcomes than those with uncontained-type OLTs after AOT for the treatment of OLTs. However, the AOT procedure still provided good clinical and MRI outcomes in both contained-type and uncontained-type OLTs at midterm follow-up.

INTRODUCTION/BACKGROUND:Peroneal tendon injuries are a significant cause of lateral ankle symptoms in the active population. Accurate diagnosis and prompt treatment is important for minimizing the risk of long-term sequelae associated with chronic peroneal tendinopathy. Although several studies have been published on diagnostic strategies and treatment outcomes, there is no consensus on the optimal management of peroneal tendon pathologies. PURPOSE/OBJECTIVE:The purpose of this ESSKA-AFAS consensus statement was to conduct an international and multidisciplinary agreed guideline on management of patients with peroneal tendon pathologies. METHODS:Using the Nominal Group Technique, a panel comprised of sixteen specialists spanning nine countries was convened by the ESSKA-AFAS board. In preparation for the meeting, relevant questions were identified and supported by a systematic literature search. During the meeting, the panel members gave presentations on each question, and the evidence supporting each subject was then vetted by open discussion. Statements were thereafter adjusted on the basis of the discussion and voted upon to determine consensus using a 0-10 range Likert scale. Agreement was confirmed when a mean score of at least 7.5 was reached. CONCLUSION/CONCLUSIONS:This ESSKA-AFAS consensus statement on the optimal management of peroneal tendon pathologies is the result of international and multidisciplinary agreement combined with a systematic review of the literature. LEVEL OF EVIDENCE/METHODS:V.

PURPOSE/OBJECTIVE:The purpose of this systematic review was to evaluate the current studies on arthroscopic lateral ankle ligament repair for chronic lateral ankle instability. METHODS:A systematic search of MEDLINE, EMBASE, and Cochrane Library databases was performed during August 2017. 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:Eight studies for a total of 269 ankles were included; 87.5% of studies were LOE III or IV, and the QOE in all studies was of poor or fair quality. Preoperative American Orthopaedic Foot and Ankle Society (AOFAS) scores ranged from 41.2 to 69.9, and postoperative AOFAS scores ranged from 90.2 to 98. All studies using AOFAS score showed an increase in postoperative outcome score of 22.8 to 54.2 at a mean follow-up of 17.1 months. Five studies used Karlsson-Peterson scores with mean postoperative score of 88.5 (range, 76.2-93.6) at a mean follow-up of 21.2 months. The comparative studies showed similar clinical outcomes between arthroscopic and open procedures. The overall complication rate was 11.6% in the included studies. The overall rate of return to sport was 100%. CONCLUSIONS: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 are no long-term data currently available for the arthroscopic procedure. There was a relatively high complication rate (11.5%) associated with the arthroscopic procedures, although recent comparative studies demonstrated similar complication rates for both open and arthroscopic techniques. LEVEL OF EVIDENCE/METHODS:Level IV, systematic review of Level I, III, and IV studies.

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.

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.

Introduction Autologous osteochondral transplantation (AOT) is a treatment for osteochondral lesions with known concerns, including histological degradation of the graft and poor cartilage integration. Platelet-rich plasma (PRP) and hyaluronic acid (HA) have been described has having the potential to improve results. The aim of this study was to evaluate the effect of PRP and HA on AOT in a rabbit model. Methods Thirty-six rabbits underwent bilateral knee AOT treated with either the biological adjunct (PRP, n = 12; HA, n = 12; PRP + HA, n = 12) or saline (control). PRP and HA were administered as an intra-articular injection. The rabbits were euthanized at 3, 6, or 12 weeks postoperatively. The graft sections were assessed using the modified International Cartilage Repair Society (ICRS) scoring system. The results from the PRP alone group is from previously published data. Results The mean modified ICRS histological score for the PRP-treated group was higher than its control ( P = 0.002). The mean modified ICRS histological score for the HA-treated group showed no difference compared with its control ( P = 0.142). The mean modified ICRS histological score for the PRP + HA-treated group was higher than its control ( P = 0.006). There was no difference between the mean modified ICRS scores of the PRP- and the PRP + HA-treated grafts ( P = 0.445). Conclusion PRP may decrease graft degradation and improve chondral integration in an animal model. In this model, the addition of HA was not synergistic for the parameters assessed.

PURPOSE/OBJECTIVE:The purpose of this systematic review is to evaluate the effects of adipose derived mesenchymal stem cells (ADSCs) in the treatment of osteoarthritis (OA) in the clinical setting. METHODS:A literature search was performed in the MEDLINE, EMBASE, and The Cochrane Library Database up to January 2017 for inclusion and exclusion criteria. Criteria for inclusion were clinical studies demonstrating the effects of ADSCs on OA, and written in English. The following variables were analyzed: donor site, volume of adipose tissue, preparation of ADSCs, clinical outcomes, and complication rate. RESULTS:Sixteen studies (knee: 14 studies, multiple joints: 1 study, ankle: 1 study) were included in this systematic review. All of the studies prepared ADSCs in the form of the stromal vascular fraction (SVF). Inconsistencies between studies were found with regards to reported clinical variability, donor sites of SVF, and reported clinical outcomes. Nine studies used either platelet-rich plasma (PRP) (7/16) or fibrin (4/16) or both PRP and Fibrin (1/16), as an adjunct at time of SVF injection. All of the studies reported an improvement in clinical outcomes with the use of SVF. Five studies reported a 90% satisfaction rate, and no study reported any complications with liposuction. Five studies reported on complications, with a 5% incidence of swelling and pain. CONCLUSIONS:This systematic review demonstrated that ADSCs are currently used in the form of SVF. While SVF may produce favorable clinical outcomes with minimal risk of side effects on osteoarthritis, the variability in the data and the use of biological adjuvants have confounded the effectiveness of ADSCs. This study will help surgeons understand the limitations in the literature on ADSCs. LEVEL OF EVIDENCE/METHODS:Level IV, systematic review of level IV studies.