SLR-January 2014- Farwa Abid-Hoffman
Reference: J. Chris Coetzee, Eric Giza, Lew C. Schon, Gregory C.Berlet, Steven Neufeld, Rebecca M. Stone and Erin L. Wilson. FAI 2013. 34(9):1205-1211.
Scientific Literature Review
Reviewed By: Farwa Abid-Hoffman, DPMResidency Program: St. John Hospital and Medical Center
Podiatric Relevance: Osteochondral lesions (OCL) of the talus are frequently present in traumatic ankle injuries such as ankle sprains, fractures, and recurrent ankle instability. As the severity of the traumatic injury increases, the incidence of OCLs consequently increases. In most cases, operative treatment includes ankle arthroscopy with debridement, microfracture, abrasion chondroplasty, curettage, and drilling. Performing these bone marrow stimulation procedures, however, do not produce normal articularhyaline cartilage, but instead produce fibrocartilage. And larger OCLs (greater than 1cm) may require secondary procedures such as osteochondral allograft/autograft chondrocyteimplantation. Juvenile articular cartilage may be used to treat these larger lesions and avoid the need for a possible malleolar osteotomy and inherent technical difficulties with osteochondral graft implantation. Juvenile articular cartilage also has the potential to reproduce hyaline cartilage making the salvage of the joint more physiologic. The purpose of this study was to assess the outcomes of pain, function, and activity level from subjects treated with particulated juvenile cartilage for symptomatic OCLs.
Methods: This study was a cohort case series that collected outcomes in patients treated with particulated juvenile cartilage between 2009-2011 with at least a 12-month post-operative visit, with average follow-up of 16.2 months. Twelve males and 11 females representing 24 ankles met the inclusion and exclusion criteria for the study with an average age at surgery of 35.0 years and an average body mass index of 28 +/- 5.8. Fourteen ankles had failed at least one prior bone marrow stimulation procedure. The average lesion size was 125 +/- 75 mm2, with average depth was 7+/- 5 mm. In addition to the juvenile chondrocyte treatment, 9 (38 percent) ankles had one concomitant procedure and nine (38 percent) had more than one concomitant procedure. The operative technique for this study included an ankle arthroscopy then cartilage repair procedure per surgeon’s preference. An arthroscopic probe was used to measure the lesion and one package of juvenile chondrocyte per 2.5cm2 of lesion size was used. Fibrin glue was used as a base of the chondrocyte implant onto the lesion, with additional fibrin applied to the fibrin-tissue construct after implantation. The postoperative patient surveys included the American Orthopaedic Foot & Ankle Society Ankle Hindfoot Scale (AOFAS),Short-Form 12v2, Health Survey (SF-12), pain intensity measured on a 100-mmvisual analog scale (VAS Pain), Foot and Ankle Ability Measure (FAAM), and a global satisfaction questionnaire.Results: Ninety-two percent of subjects with moderate-sized lesions (larger than or equal to 10 mm and smaller than 15 mm) and 56 percent of large lesions (larger than or equal to 15 mm) demonstrated good to excellent results. The average AOFAS score of subjects about one year post-operatively was comparable to other reported treatments including BMS, ACI, and matrix-induced autologous chondrocyte implantation. FAAM daily living score (ADL) and Sports subscores demonstrated good postoperative function and VAS Pain postoperative results (VAS Pain 24 ± 25) at an average follow-up of 16.2 months are in line with previously reported results. However, these are difficult to fully interpret without preoperative values for comparison.
Conclusions: Larger OCLs may be treated with juvenile articular cartilage obviating the need for secondary procedures such as osteochondral allograft/autograft chondrocyte implantation. This study showed the majority of patients treated with juvenile chondrocyte demonstrated good to excellent pain and functional outcomes after one year. However, this study has limitations including absence of a control group, limited subjects, length of follow up, and retrospective enrollment. Retrospective enrollment limits preoperative comparison of clinical and functional comparison. The results of this study however do demonstrate a trend that may indicate using juvenile chondrocyte implantation for good to excellent functional outcome for patients with larger OCLs.