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Purpose To compare the effect of arthroscopic microfracture surgery alone or in combination with platelet rich plasma (PRP) on functional outcomes in osteochondral lesions of the talus. Methods A total of 35 patients were included in the study. Control subjects ( n  = 16) received treatment with microfracture surgery alone, while the remaining patients (PRP group, n  = 19) were also given PRP. After an average follow-up of 16.2 months (range 12–24 months), patients were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) scoring system, Foot and Ankle Ability Measure (FAAM), and the visual analogue scale (VAS) for pain. Results At baseline, AOFAS and FAAM scores were similar in the two groups, whereas pain scores (VAS) were higher in those who were assigned to combined treatment. Despite the latter finding, the combined treatment with PRP resulted in better outcomes in terms of functional scores [AOFAS, 89.2 ± 3.9 vs. 71.0 ± 10.2, ( p  = 0.001); FAAM overall pain domain, 1.0 (1.0–2.0) vs. 2.5 (1.0–4.0), ( p  = 0.04); FAAM 15-min walking domain, 1.0 (1.0–2.0) vs. 2.0 (1.0–4.0) ( p  = 0.001)]; and pain-related scores [VAS, 2.2 ± 0.8 vs. 3.8 ± 1.2, ( p  = 0.001)] as compared to arthroscopic microfracture surgery alone. Conclusions PRP as an adjunct to arthroscopic microfracture surgery for the treatment of osteochondral lesions of the talus resulted in improved functional score status in the medium-term. Further studies to determine the long-term efficacy of this approach were warranted. Level of evidence II.

Purpose The purpose of the present study was to assess the overall clinical success rate of non-operative management for osteochondral lesions of the talus (OLT). Methods A literature search was conducted in the PubMed (MEDLINE), COCHRANE and EMBASE (Ovid) databases. Clinical success rates per separate study were calculated at the latest moment of follow-up and were defined as successful when a good or excellent clinical result at follow-up was reported in a qualitative manner or when a post-operative American Orthopaedic Foot and Ankle Society (AOFAS) score at or above 80 was reached. When clinical outcomes were based on other clinical scoring systems, outcomes reported as good or excellent were considered as clinical success. Studies methodologically eligible for a simplified pooling method were combined to calculate an overall pooled clinical success rate. Radiological changes over the course of conservative treatment were assessed either considering local OLT changes and/or overall ankle joint changes. Results Thirty articles were included, including an overall of 868 patients. The median follow-up of the included studies was 37 months (range: 3–288 months). A simplified pooling method was possible among 16 studies and yielded an overall pooled clinical success rate of 45% (95% CI 40–50%). As assessed with plain radiographs, progression of ankle joint osteoarthritis was observed in of 9% (95% CI 6–14%) of the patients. As assessed through a Computed Tomography (CT) scan, focal OLT deterioration was observed in 11% (95% CI 7–18%) of the patients. As assessed with a Magnetic Resonance Imaging (MRI) scan, focal OLT deterioration was observed in 12% (95% CI 6–24%) of the patients. An unchanged lesion was detected on plain radiographs in 53% (48/91; CI 43–63%), 76% (99/131; 95% CI 68–82%) on a CT scan and on MRI in 84% (42/50; 95% CI 71–92%) of the patients. Conclusion The current literature on non-operative management of OLTs is scarce and heterogeneous on indication and type of treatment. Promising clinical results are presented but need to interpreted with caution due to the heterogeneity in indication, duration and type of treatment. Further studies need to focus on specific types on conservative management, indications and its results. Level of evidence Systematic review, Level IV.

Purpose The purpose of this study was to compare the clinical and magnetic resonance imaging (MRI) outcomes of arthroscopic microfracture surgery alone or in combination with hyaluronic acid (HA) injection in the treatment of osteochondral lesions of the talus. Methods Thirty-five patients with osteochondral lesions of the talus who underwent arthroscopic microfracture were included and followed up for at least 9 months post-operatively. The patients were randomly divided into non-injection group ( n  = 17) who received treatment with microfracture surgery alone and injection group ( n  = 18) who also accepted intra-articular injection of HA post-operatively. Quantitative MRI was used to evaluate the cartilage repair after surgery. American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hind foot Scale scores and Visual Analogue Scale (VAS) scores were used to evaluate clinical outcomes. Results After operation, the MRI outcomes showed that the thickness index was higher (0.8 ± 0.1 vs. 0.7 ± 0.1) and the T2 index was lower (1.2 ± 0.1 vs. 1.4 ± 0.1) in the injection group than in the non-injection group ( P  < 0.01). As for the volumes of subchondral bone marrow oedema, there are no significant differences between groups (n.s.). Compared with the non-injection group, the AOFAS score and the VAS score yielded a higher level of improvement in injection group at final follow-up post-operatively ( P  < 0.05). Conclusions Arthroscopic microfracture is a safe and effective procedure for osteochondral lesions of the talus. Intra-articular HA injection as an adjunct to arthroscopic microfracture might offer better functional recovery than microfracture alone. Level of evidence II.

Background Chronic lateral ankle instability (CLAI) often arises from inadequately managed injuries to the lateral collateral ligaments, potentially leading to osteochondral lesions of the talus (OLT) and subsequent osteoarthritis. Hepple Stage V OLT, characterized by subchondral cysts, presents a significant therapeutic challenge. This study aimed to evaluate the efficacy of arthroscopic anterior talofibular ligament (ATFL) repair combined with retrograde drilling and allograft bone grafting in patients with CLAI and Hepple Stage V OLT with an intact talar articular surface. Methods This retrospective, small-sample exploratory study included 12 patients (ten men; median age: 35 years) who underwent arthroscopic treatment (between January 2020 and December 2022) for chronic lateral ankle instability with subchondral cysts, specifically Hepple Stage V OLT cases with an intact talar articular surface, after failing non-surgical interventions. The ATFL was repaired using the all-inside Internal Brace (IB) augmentation with the arthroscopic modified Broström operation. Treatment for OLT involved simultaneous retrograde drilling and allograft bone grafting. The median follow-up duration was 24 months (range: 20–35 months). The improvement of postoperative ankle pain was assessed using the Visual Analogue Scale (VAS), and the improvement of ankle function was evaluated using the American Orthopedic Foot ༆ Ankle Society (AOFAS) score and Foot༆Ankle Outcome Score (FAOS). Radiographic assessments were conducted at a minimum of 12 months postoperatively. Results All 12 patients (12 ankles; 100%) returned for clinical and radiological follow-up at an average of 24 months (20–35 months) postoperatively. Subjective improvement was reported after arthroscopic surgery. The median AOFAS score demonstrated a substantial improvement from 67 preoperatively (range: 58–70) to 94 at the final follow-up (range: 90–98), with P  < 0.05. Similarly, The FAOS score improved from 65 preoperatively (range: 58–75) to 91 at the final follow-up (range: 89–97), with P  < 0.05. Radiographic follow-up results indicated satisfactory healing of the ATFL and favorable bone ingrowth post-subchondral cyst bone grafting. Conclusion Arthroscopic ATFL repair combined with retrograde drilling and allograft bone grafting yields favorable clinical and radiographic outcomes in patients with CLAI and Hepple Stage V OLT. This integrated approach addresses both ligament instability and subchondral cyst pathology, potentially delaying the progression of osteoarthritis.

Purpose Surgeons management of osteochondral lesions of the talus (OLT) may be different to the published guidelines because not all treatment recommendations are feasible in every country. This study aimed to assess how OLT are managed worldwide by foot and ankle surgeons. Methods A web-based survey was distributed to the members of 21 local and international scientific societies focused on foot and ankle or sports medicine surgery. Answers with a prevalence greater than 75% of respondents were considered a “main tendency”, whereas where prevalence exceeded 50% of respondents they were considered a “tendency”. Results A total of 1804 surgeons from 79 different countries returned the survey. The responses to 19 of 28 questions (68%) regarding management and treatment of OLT achieved a main tendency (> 75%) or a tendency (> 50%). Symptoms reported to be most suspicious for OLT were pain on weight-bearing (WB) and after activity (83%), deep localization of the pain (62%), and any history of trauma (55%). 89% of surgeons routinely obtain an MRI, 72% routinely get WB radiographs, and 50% perform a CT scan. When treated surgically, OLTs are managed in isolation by only 7% of surgeons, and combined with ligament repair or reconstruction by 79%; 67% report simultaneous excision of soft-tissue or bony impingements (64%). For lesions less than 10–15 mm in diameter, bone marrow stimulation (BMS) represents the first choice of treatment for 78% of surgeons (main tendency). No other treatment was recorded as a tendency. For lesions greater than 15 mm in diameter no tendencies were recorded. The BMS represented the most preferred treatment being the first choice of treatment for 41% of surgeons. OLT depth had little influence on treatment choice: 71% of surgeons treating small lesions and 69% treating large lesions would choose the same treatment regardless of whether the lesion had a depth lesser or greater than 5 mm. Conclusion The management of OLT by foot and ankle surgeons from around the world remains extremely varied. The main clinical relevance of this study is that it provides updated information with regard to the management of OLT internationally, which could be used by surgeons worldwide in their decision-making and to inform the patient about available surgical options. Level of evidence Level IV.

Background This study systematically compares the efficacy of different adjunctive therapies in enhancing microfracture (MF) treatment for osteochondral lesions of the talus (OLT) through a network meta-analysis, aiming to identify the optimal adjunctive therapy for microfracture. Methods A systematic search of PubMed, Embase, Web of Science, Cochrane, and Scopus databases was conducted for relevant literature until October 1, 2024. Two researchers independently screened, extracted data, and assessed quality. The review process was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Results A total of six randomized controlled trials were included, comprising 295 OLT patients and involving four adjunctive therapies: MF combined with platelet-rich plasma (MF_PRP), hyaluronic acid (MF_HA), collagen scaffold (MF_CS), and pulsed electromagnetic fields (MF_PEMF). The results of the network meta-analysis indicated that while HA is the most commonly used adjunctive therapy, PRP-assisted MF demonstrated the best improvement in AOFAS and VAS scores for OLT. The surface under the cumulative ranking curve (SUCRA) predictions also revealed that PRP has the greatest potential among the four adjunctive therapies, followed by HA. Conversely, MF_PEMF showed the least effectiveness in improving AOFAS and VAS scores. Additionally, only one study reported complications associated with MF_PEMF and MF, with no statistically significant differences between the two. Conclusion Among the MF adjunctive therapies validated by RCTs, HA is the most widely used; however, PRP-assisted MF provides the best outcomes for OLT patients, suggesting that its application should be emphasized in clinical practice. PROSPERO Registration No: CRD42024546984. Clinical trial details Not applicable.

Smoking is known to negatively affect the outcomes of orthopedic procedures, but its impact on arthroscopic microfracture for osteochondral lesions of the talus (OLT) remains unclear. We aimed to compare clinical outcomes and the status of repaired cartilage following arthroscopic microfracture for small to medium-sized OLT in smokers versus nonsmokers. We enrolled 239 patients (250 ankles), dividing them into smoker (56 patients, 59 ankles) and nonsmoker groups (183 patients, 191 ankles). The primary outcome measure was the FAOS (Foot and Ankle Outcome Score). The AOFAS (American Orthopaedic Foot & Ankle Society) ankle-hindfoot scale, SF-36 PCS (Short Form-36 Physical Component Summary) score, and VAS (Visual Analog Scale) for pain were included as secondary outcomes. Preoperative magnetic resonance imaging (MRI) assessed lesion size, location, and subchondral cyst presence. Postoperative cartilage repair status was evaluated using the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score on 3.0-T MRI. The mean OLT sizes were 74.4 mm2 in smokers and 69.9 mm2 in nonsmokers on preoperative MRI. The mean age was 35.9 years in smoker group and 38.8 years in nonsmoker group (p = 0.157). The overall mean follow-up duration was 83.6 months (range, 24-217), with no significant intergroup difference (p = 0.582). There was no significant difference in primary and secondary clinical outcome variables between the two groups at the final follow-up (p > 0.05). In terms of postoperative MRI, 75 ankles (18 smokers, 57 nonsmokers) assessed repaired cartilage status and the mean total MOCART score was significantly lower in smokers (65.0, range 30.0-85.0) compared with nonsmokers (73.7, range 40.0-95.0; p = 0.027). Particularly, the smoker group had significantly lower MOCART scores for surface for repair tissue and signal intensity of the repair tissue variables, respectively (p = 0.019, p = 0.008). Although smoker group showed worse status of repaired cartilage on postoperative MRI, the smoker group reported comparable clinical outcomes to those of the nonsmoker group following arthroscopic microfracture for small to medium-sized OLT over a mean follow-up of 7 years. However, caution should be taken in interpreting our conclusion and further larger studies are needed for robust conclusions.

Background Skeletally immature osteochondral lesions of the talus (OLTs) have a significant impact on the health status and quality of life of pediatric patients and the involved family. the current literature showed success in 4 out of 10 patients but it is currently unknown which type of non-operative management showed better clinical- and radiological outcomes. The aim of this study is to compare immobilization and supervised rehabilitation with a ‘skillful’’ neglect in the treatment for skeletally immature patients with an OLT. The hypothesis is that a period of immobilization and supervised rehabilitation will lead to better clinical and radiological outcomes compared to ‘’skillful’’ neglect. Methods Multicenter, prospective, comparative study. Skeletally immature children with an OLT will be assigned to the intervention or control group after a shared decision-making process. Patients in the intervention group will undergo a 4-week period of immobilization with normal casting and non-weightbearing, which is followed by 4 weeks of immobilization with a removable cast and weight bearing boot. Afterwards, they will receive a protocolled period of rehabilitation under supervision of a physical therapist. The control group will have a ‘skillful’’ neglect treatment. The main study outcome is the difference between the two groups on the Oxford Ankle and Foot Questionnaire for Children (OxAFQ-C). Secondary study outcomes are radiologic changes in terms of morphology and lesion size. Numeric Rating Scale (NRS) during weight bearing and quality of life measured with a Pediatrics Quality of Life (Peds-QL) and EuroQol-5 Dimension youth (EQ-5D-y). Discussion This protocol reports on the study design of the CARE Study and it aims to setup a study for evaluating different types of non-operative management in pediatric patients suffering an OLT. This study will compare clinical and radiological outcomes between two different non-operative strategies for treating OLTs in the skeletally immature population. Based on the results of this study, an evidence-based treatment protocol for non-operative management for pediatric OLTs can be provided. Trial registration This study is registered in the International Clinical Trial Registry Platform (ICTRP) with trial number NLOMON54282, date of registration 05192023.

Purpose Although bone marrow stimulation (BMS) as a treatment for osteochondral lesions of the talus (OCLT) shows high rates of sport resumption at short-term follow-up, it is unclear whether the sports activity is still possible at longer follow-up. The purpose of this study was, therefore, to evaluate sports activity after arthroscopic BMS at long-term follow-up. Methods Sixty patients included in a previously published randomized-controlled trial were analyzed in the present study. All patients had undergone arthroscopic debridement and BMS for OCLT. Return to sports, level, and type were assessed in the first year post-operative and at final follow-up. Secondary outcome measures were assessed by standardized questionnaires with use of numeric rating scales for pain and satisfaction and the Foot and Ankle Outcome Score (FAOS). Results The mean follow-up was 6.4 years (SD ± 1.1 years). The mean level of activity measured with the AAS was 6.2 pre-injury and 3.4 post-injury. It increased to 5.2 at 1 year after surgery and was 5.8 at final follow-up. At final follow-up, 54 patients (90%) participated in 16 different sports. Thirty-three patients (53%) indicated they returned to play sport at their pre-injury level. Twenty patients (33%) were not able to obtain their pre-injury level of sport because of ankle problems and eight other patients (13%) because of other reasons. Mean NRS for pain during rest was 2.7 pre-operative, 1.1 at 1 year, and 1.0 at final follow-up. Mean NRS during activity changed from 7.9 to 3.7 to 4.4, respectively. The FAOS scores improved at 1 year follow-up, but all subscores significantly decreased at final follow-up. Conclusion At long-term follow-up (mean 6.4 years) after BMS for OCLT, 90% of patients still participate in sports activities, of whom 53% at pre-injury level. The AAS of the patients participating in sports remains similar pre-injury and post-operatively at final follow-up. A decrease over time in clinical outcomes was, however, seen when the follow-up scores at 1 year post-operatively were compared with the final follow-up. Level of evidence Level II.

Background We aimed to evaluate whether arthroscopic microfracture with atelocollagen augmentation could improve the clinical outcomes and quality of regenerated cartilage in patients with osteochondral lesion of the talus (OLT). We hypothesized that the clinical outcomes and quality of the regenerated cartilage would be superior in patients undergoing arthroscopic microfracture with atelocollagen augmentation compared to those undergoing arthroscopic microfracture alone. Methods In this multicenter, randomized controlled trial, 60 patients were randomly allocated to two groups: arthroscopic microfracture with atelocollagen augmentation (group 1, n  = 31) and arthroscopic microfracture alone (group 2, n  = 29). Mean 100-mm visual analog scale (VAS), Hannover scoring system (HSS), and American Orthopedic Foot and Ankle Society (AOFAS) scores were assessed 2 years postoperatively and compared between the groups. The quality of the regenerated cartilage was assessed according to the Magnetic Resonance Observation of CArtilage Repair Tissue (MOCART) score based on magnetic resonance imaging. Results Forty-six patients (22 in group 1, 23 in group 2) completed the 2-year follow-up. The quality of the regenerated cartilage assessed based on the MOCART score was significantly superior in group 1 compared to group 2 (64.49 ± 18.27 vs 53.01 ± 12.14, p  = 0.018). Clinical outcomes in terms of 100-mm VAS (17.25 ± 20.31 vs 19.37 ± 18.58, p  = 0.72), HSS (93.09 ± 13.64 vs 86.09 ± 13.36, p  = 0.14), and AOFAS (91.23 ± 8.62 vs 86.91 ± 10.68, p  = 0.09) scores were superior in group 1 compared to group 2, but the differences were not statistically significant. Both groups showed significant improvements in clinical outcomes compared with the preoperative values. Conclusion The quality of the regenerated cartilage was superior after arthroscopic microfracture with atelocollagen augmentation compared to that after microfracture alone in patients with OLT. Clinical outcomes assessed 2 years postoperatively were superior in patients who underwent arthroscopic microfracture with atelocollagen augmentation compared to those who underwent arthroscopic microfracture alone, although the differences were not statistically significant. A long-term study of the cohort is required to confirm these findings. Trial registration ClinicalTrials.gov ( NCT02519881 ), August 11, 2015.