Comparison of Clinical and Radiographic Outcomes Following Arthroscopic Debridement With Extracellular Matrix Augmentation and Osteochondral Autograft Transplantation for Medium-Size Osteochondral Lesions of the Talus

Background: Historically, microfracture has been used to treat small talar osteochondral lesions with good results, whereas osteochondral autologous transplantation (OAT) has proven effective for the treatment of larger lesions. It is not clear which method is more effective for medium-sized lesions around the critical size of 150 mm2, above which microfracture outcomes tend to be poor. The purpose of this study was to determine the potential advantages of OAT augmented with a combination of extracellular matrix and bone marrow aspirate concentrate (ECM-BMAC) compared to debridement with ECM-BMAC (DEB) in the treatment of medium-sized osteochondral lesions of the talus (OLTs). Methods: Clinical and radiographic data were collected retrospectively for patients treated by a single fellowship-trained foot and ankle surgeon. Magnetic resonance images (MRIs) were scored using the Magnetic Resonance Observation of Cartilage Tissue (MOCART) system and were evaluated for the presence of cysts and edema. Fifty-two patients met inclusion criteria, with 25 who received an OAT procedure. Age, body mass index, lesion size, lesion location, and follow-up time were similar between groups. Average MRI follow-up times were 16.7 months for the OAT group and 20.3 months for the DEB group ( P = .38). Results: Patients treated with OAT had significantly higher average total MOCART scores (69 vs 55, P = .04) and significantly lower rates of cyst (14% vs 55%, P < .01), edema (59% vs 90%, P = .04), revision surgery (0% vs 19%, P = .05), and therapeutic injection for pain (4% vs 30%, P = .02) compared to patients treated with DEB. No significant differences were detected in patient-reported outcome scores between groups. Conclusion: The native hyaline cartilage introduced by OAT appears to result in higher-quality repair tissue when compared to DEB, as evidenced by OAT patients’ higher MOCART scores and lower rates of cyst and edema. There was no difference in clinical outcome scores, though OAT patients did not require revision surgery or therapeutic injection for pain as frequently as DEB patients. Level of Evidence: Level III, retrospective comparative study.

Comparison of Microfracture with Extracellular Matrix Augmentation and Osteochondral Autograft Transplantation for the Treatment of Medium-Size Osteochondral Lesions of the Talus

Category: Ankle; Arthroscopy; Basic Sciences/Biologics Introduction/Purpose: Historically, microfracture has been used to treat small talar osteochondral lesions (OLTs) with good results, while osteochondral autologous transplantation (OAT) has proven superior for the treatment of larger lesions. It is not clear which method is more effective for medium-sized lesions, around the critical size of 150 mm2 above which microfracture outcomes tend to be poor. While OAT carries the risk of co-morbidity at the knee and often requires a malleolar osteotomy, it is thought to result in superior repair tissue compared to microfracture by introducing native hyaline cartilage to the ankle. Microfracture, in contrast, results in the formation of structurally inferior fibrocartilage. The purpose of this study was to determine the relative benefits of OAT and microfracture in the treatment of medium-sized OLTs. Methods:: Patients treated for an OLT with OAT or microfracture by a single surgeon fellowship-trained in foot and ankle orthopedics between 2015 and 2018 were screened. Both OAT and microfracture techniques were augmented with a mixture of extracellular matrix and bone marrow aspirate concentrate (ECM-BMAC) for every case included in this study. Patients treated without ECM-BMAC were excluded. Only patients with a lesion size between 80 and 165 mm2 were included. Minimum follow-up was 12 months. Clinical outcomes were collected in the form of FAOS or PROMIS scores, depending on departmental standards at the time of treatment. MRIs were collected for radiographic analysis of cartilage repair tissue. MRIs were scored using the MOCART system by a fellowship trained radiologist and were also evaluated for the presence of cysts and edema. Patient charts were reviewed to determine rates of revision surgery and therapeutic injection for pain. Results:: 52 patients were identified who fit inclusion criteria. 27 of these patients received microfracture and 25 received OAT. The average lesion size for all patients was 117.5 mm2. Patients treated with OAT had significantly higher average total MOCART scores (69 vs. 55, p = 0.04) and significantly lower rates of cyst (14% vs. 55%, p <0.01), edema (59% vs. 90%, p = 0.04), revision surgery (0% vs. 19%, p = 0.05), and therapeutic injection for pain (4% vs. 30%, p = 0.03) compared to patients treated with microfracture. No significant differences were detected in patient reported outcome scores between groups for either FAOS or PROMIS. Age, BMI, lesion size, lesion location, and follow-up time were statistically indistinguishable between groups. Conclusion:: In treating OLTs, the native hyaline cartilage introduced by OAT appears to result in higher quality repair tissue when compared to microfracture, as evidenced by OAT patients’ higher MOCART scores and lower rates of cyst and edema. This advantage was also reflected in the fact that OAT patients required revision surgery and therapeutic injection for pain less frequently than did microfracture patients. OAT may offer benefits over MF that outweigh its greater risk of comorbidity when addressing medium-sized OLTs. [Table: see text]

Performance of Biopsy Needle With Therapeutic Injection System to Prevent Bleeding Complications

Renal disease is epidemic in the United States with approximately 8 × 106 people having chronic kidney disease. Renal biopsies are widely used to provide essential diagnostic information to physicians. However, the risk of bleeding complications possibly leading to life-threatening situations results in the contra-indication of biopsy in certain patient populations. Safer renal biopsies will allow more accurate diagnosis and better management of this epidemic health problem. We report the preclinical testing of a novel biopsy device called the therapeutic injection system (TIS). The device introduces a third stage to the standard two-stage side-cut percutaneous biopsy process. The third stage is designed to reduce bleeding complications by injecting a hemostatic plug at the time of biopsy. Laboratory evaluation and preliminary in vivo animal testing using an anticoagulated porcine model of the TIS and Bard Monopty® (Bard Medical, Covington, GA) control device were performed. The hemostatic material Gelfoam® (Pfizer, Brussels, Belgium) was selected as the active material comprising the hemostatic plugs. The performance of two composite plugs, one composed of polyvinyl alcohol (PVA) combined in 2:1 and 12:1 ratios with the hemostatic material, and one plug composed of 100% hemostatic material were tested. Stroke sequence and hemostatic plug deployment were verified by sequential firing of the TIS biopsy needle into clear gelatin and ex vivo bovine kidney specimens. In vivo trials with porcine specimens revealed a significant reduction in blood loss (8.1 ± 3.9 ml, control versus 1.9 ± 1.6 ml, 12:1 PVA/hemostatic, TIS, α = 0.01, n = 6). The 100% hemostatic plug showed a substantial and immediate reduction in blood loss (9.2 ml, control versus 0.0 ml, TIS, n = 1). The prototype device was shown to work repeatedly and reliably in laboratory trials. Initial results show promise in this approach to control post biopsy bleeding. This solution maintains the simplicity and directness of the percutaneous approach, while not significantly changing the standard percutaneous biopsy procedure.