SLR - May 2023 - Milad Adloo
Title: Advances in Cartilage RepairReference: Azam MT, Butler JJ, Duenes ML, McAllister TW, Walls RC, Gianakos AL, Kennedy JG. Advances in Cartilage Repair. Orthop Clin North Am. 2023 Apr;54(2):227-236. doi: 10.1016/j.ocl.2022.11.007. Epub 2023 Jan 31. PMID: 36894294.
Level of Evidence: Level III systematic review
Scientific Literature Review
Reviewed By: Milad Adloo
Residency Program: NYU Langone Hospital – Brooklyn
Podiatric Relevance: Many podiatrists encounter osteochondral lesions (OCL) of the ankle joint in their patient populations. While MRI is the gold standard for diagnosis, treatment options have varying degree of success rates depending on lesion size and use of biological adjuncts. The authors review the most recent clinical evidence for various treatment modalities for talar OCLs.
Methods: A review of recent literature was performed for reparative, regenerative, and replacement techniques for talar OCLs. The utilization of biological supplementation including platelet-rich plasma (PRP), concentrated bone marrow aspirate (CBMA), and hyaluronic acid (HA) were analyzed and the results summarized.
Results: Reparative technique of bone marrow stimulation (BMS) may not be suitable in patients with an OCL greater than 10mm in diameter. The hyaline-like material that is formed after BMS is less resilient, less durable, and inferior compared to native cartilage. There is also concern of the integrity of the subchondral plate after BMS. Regenerative techniques include autologous chondrocyte implantation (ACI), matrix-induced autologous chondrocyte implantation (MACI), and autologous matrix-induced chondrogenesis (AMIC) which are often utilized after failed microfracture. ACI and MACI have similar outcomes, with limitations being 2 procedures and cost. The primary replacement technique investigated was autologous osteochondral transplantation (AOT). The authors report this is their preferred method of treatment and offers advantages over reparative and regenerative techniques. BMS and PRP has been shown to promote chondrocyte synthesis and collagen deposition. Of note is that there is significant variability between patients and preparation techniques. CBMA is a useful adjunct to BMS with the addition of mesenchymal stem cells and growth factors promote hyaline-like repair and increased collagen deposition. It was also shown that CBMA reduces postoperative subchondral cysts following AOT. Clinical data report improvements in pain scores and radiological outcomes when HA is used in conjunction with BMS and CBMA.
Conclusions: OCLs of the ankle smaller than 10mm can be managed with less invasive procedures such as arthroscopic debridement, anterograde drilling, and augmentation with biological adjuvants. Large lesions or a failed BMS procedure warrant a replacement procedure such as AOT. The precise indication for each biological adjuvant evaluated has yet to be determined. The authors largely describe future developments for treatment not necessarily focusing on the biological aspects, but rather shifting technique to an in-office nano-arthroscopy model which the senior author is a consultant for. Future studies should focus on the precise mechanism of action and indication for each biologic, which has yet to be determined.