Endoscopic debridement for non-insertional Achilles tendinopathy with and without platelet-rich plasma.

BACKGROUND: When non-operative management fails to improve symptoms in patients with non-insertional Achilles tendinopathy, surgery may be required. Various open and endoscopic techniques have been proposed, and platelet-rich plasma (PRP) injections have been proposed as an adjunct to aid tendon healing. METHODS: Thirty-six patients with mid-portion Achilles tendinopathy were randomized to undergo endoscopic debridement alone (n = 19) or in combination with intraoperative PRP application (n = 17). Clinical outcome measures included the Visual Analogue Scale for pain, function, and satisfaction and the Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire. Patients were followed-up at 6 weeks, 3 months, 6 months, and 12 months after surgery. An MRI examination at 3 and 12 months was used to assess signal alterations within the tendon. RESULTS: Both groups showed significant clinical improvement (p < 0.05) after surgery, with no difference between the 2 groups. Tendon diameter increased at 3 months and decreased at 12 months. The tendinopathy area increased at 3 months and decreased at 12 months below baseline level in both groups. There was no significant difference between the groups regarding the MRI parameters. Nodular thickening and MRI-detected signal alteration persisted after surgery, with no association between imaging and clinical outcome. Five minor complications were reported: 2 in the PRP group and 3 in the control group. CONCLUSION: Endoscopic debridement of the Achilles tendon improved clinical outcomes in patients with mid-portion tendinopathy. The addition of PRP did not improve outcomes compared to debridement alone. MRI parameters showed no association with clinical outcomes.

Paediatric ankle cartilage lesions: Proceedings of the International Consensus Meeting on Cartilage Repair of the Ankle.

BACKGROUND: The evidence supporting best practice guidelines in the field of cartilage repair of the ankle are based on both low quality and low levels of evidence. Therefore, an international consensus group of experts was convened to collaboratively advance toward consensus opinions based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article is to report the consensus statements on "Pediatric Ankle Cartilage Lesions" developed at the 2019 International Consensus Meeting on Cartilage Repair of the Ankle. METHODS: Forty-three international experts in cartilage repair of the ankle representing 20 countries convened to participate in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within four working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed upon in unanimous fashion within the working groups. A final vote was then held, and the strength of consensus was characterised as follows: consensus: 51-74%; strong consensus: 75-99%; unanimous: 100%. RESULTS: A total of 12 statements on paediatric ankle cartilage lesions reached consensus during the 2019 International Consensus Meeting on Cartilage Repair of the Ankle. Five achieved unanimous support, and seven reached strong consensus (>75% agreement). All statements reached at least 84% agreement. CONCLUSIONS: This international consensus derived from leaders in the field will assist clinicians with the management of paediatric ankle cartilage lesions.

Terminology for osteochondral lesions of the ankle: proceedings of the International Consensus Meeting on Cartilage Repair of the Ankle.

BACKGROUND: The evidence supporting best practice guidelines in the field of cartilage repair of the ankle is based on both low quality and low levels of evidence. Therefore, an international consensus group of experts was convened to collaboratively advance toward consensus opinions based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article is to report the consensus statements on "terminology for osteochondral lesions of the ankle" developed at the 2019 International Consensus Meeting on Cartilage Repair of the Ankle. METHODS: Forty-three international experts in cartilage repair of the ankle representing 20 countries were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within four working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed, and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed on in unanimous fashion within the working groups. A final vote was then held, and the strength of consensus was characterised as follows: consensus, 51%-74%; strong consensus, 75%-99%; unanimous, 100%. RESULTS: A total of 11 statements on terminology and classification reached consensus during the 2019 International Consensus Meeting on Cartilage Repair of the Ankle. Definitions are provided for osseous, chondral and osteochondral lesions, as well as bone marrow stimulation and injury chronicity, among others. An osteochondral lesion of the talus can be abbreviated as OLT. CONCLUSIONS: This international consensus derived from leaders in the field will assist clinicians with the appropriate terminology for osteochondral lesions of the ankle.

Osteochondral Lesions of the Tibial Plafond and Ankle Instability With Ankle Cartilage Lesions: Proceedings of the International Consensus Meeting on Cartilage Repair of the Ankle.

BACKGROUND: An international consensus group of experts was convened to collaboratively advance toward consensus opinions based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article is to present the consensus statements on osteochondral lesions of the tibial plafond (OLTP) and on ankle instability with ankle cartilage lesions developed at the 2019 International Consensus Meeting on Cartilage Repair of the Ankle. METHODS: Forty-three experts in cartilage repair of the ankle were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within 4 working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed on in unanimous fashion within the working groups. A final vote was then held. RESULTS: A total of 11 statements on OLTP reached consensus. Four achieved unanimous support and 7 reached strong consensus (greater than 75% agreement). A total of 8 statements on ankle instability with ankle cartilage lesions reached consensus during the 2019 International Consensus Meeting on Cartilage Repair of the Ankle. One achieved unanimous support, and seven reached strong consensus (greater than 75% agreement). CONCLUSION: These consensus statements may assist clinicians in the management of these difficult clinical pathologies. LEVEL OF EVIDENCE: Level V, mechanism-based reasoning.

[Achilles tendon rupture-Part 2: treatment and rehabilitation]. / Achillessehnenruptur ­ Teil 2: Therapie und Nachbehandlung.

Achilles tendon ruptures can be treated conservatively with a therapeutic shoe or an orthosis. Prospective randomized trials show comparable results to surgical treatment, with the right indications, correct performance and reasonable patient compliance. The target groups for conservative treatment are inactive patients and patients with substantial general risk factors. Surgical treatment of the Achilles tendon has changed over the decades. The direct open suture technique was replaced by minimally invasive procedures with percutaneous sutures. Chronic ruptures and/or defect situations that if untreated would lead to unstable healing, can be treated by an open reconstructive or minimally invasive procedure. Reconstructive techniques include turn-down flaps and aponeurotic reconstructive repair as well as a free tendon transfer using the flexor hallucis longus tendon or hamstrings. The gold standard for follow-up treatment is an early functional treatment.

Autologous matrix-induced chondrogenesis for the treatment of osteochondral lesions of the talus: A systematic review.

This study was performed to determine whether Autologous Matrix-Induced Chondrogenesis (AMIC) is an effective and safe treatment option for patients with symptomatic Osteochondral defects of the Talus (OCTs) and to identify factors that influence the clinical outcome. A systematic review of the literature was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Three reviewers independently conducted the literature search using the MEDLINE/PubMed database and the Cochrane Database of Systematic Reviews. The databases were queried using the terms "autologous" AND "matrix" AND "induced" AND "chondrogenesis." Thirteen studies were eligible for review. All studies that compared the preoperative and postoperative mean values of different clinical/functional scores showed significant clinical improvement. The final postoperative mean Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score ranged from 50.9 to 74.5. The included studies indicated that age and body mass index may have a detrimental impact on the postoperative outcome. A higher re-intervention rate is expected with the open technique, mainly because of hardware removal after malleolar osteotomy. This data analysis demonstrated that both arthroscopic and open AMIC procedures are effective and safe for the treatment of OCTs. Level IV, systematic review of therapeutic studies.

Arthroscopic microfracture vs. arthroscopic autologous matrix-induced chondrogenesis for the treatment of articular cartilage defects of the talus.

PURPOSE: Microfracture is an established method to treat osteochondral defects of the talus. The value of the addition of an acellular matrix is still under debate. This study compared the results of arthroscopic microfracture vs. arthroscopic autologous matrix-induced chondrogenesis using a collagen I/III matrix (AMIC) in the management of articular cartilage defects of the talus. METHODS: Patients with a minimum follow-up of 5 years after arthroscopic management for an articular cartilage defect of the talus with either microfracture alone or an additional acellular matrix were matched according to age, sex and BMI. The Hannover Scoring System for the ankle (HSS) and a Visual analog scale (VAS) for pain, function and satisfaction were used to evaluate the clinical outcome. Postoperative MRI was used to assess cartilage repair tissue based on the degree of defect repair and filling of the defect, integration to border zone, surface of the repair tissue, structure of the repair tissue, and subchondral bone alterations. RESULTS: Thirty-two patients (16 microfracture, 16 AMIC) were included. No significant between-group differences were observed in demographic data and preoperative score values. Both groups showed statistically significant improvement when comparing the pre- and postoperative score values. No statistically significant differences were identified between the median values of the groups with the HSS (microfracture: 82 (range 71-96) points; AMIC 88 (range 40-98) points). Accordingly, no significant differences were observed for the VAS pain (microfracture: 0.95 (range 0-3.8); AMIC: 1.0 (range 0-8.5)), VAS function (microfracture: 8.4 (range 3.5-10); AMIC: 9.0 (range 1.5-10)) and VAS satisfaction (microfracture: 8.9 (range 2.8-10); AMIC: 9.45 (range 1.5-10)). MRI showed regeneration of tissue in the treated area without differences between the two groups. CONCLUSION: Good clinical results were observed for arthroscopic microfracture with or without an additional acellular collagen I/III matrix in the treatment for articular cartilage defects of the talus. It appears that for defects as treated in this study, it is not worthwhile adding the collagen I/III matrix to the microfractures. LEVEL OF EVIDENCE: III.

Stability of supramalleolar osteotomies using different implants in a sawbone model.

BACKGROUND: With ankle arthritis often affecting young patients, joint-sparing treatments instead of total joint replacement should be considered. Only a few implants were specially developed for supramalleolar osteotomies (SMOT). This study was performed to analyse the stability of different implants and their appropriateness for SMOT. METHODS: Twenty-five bone models (Sawbone Europe, Malmö, Sweden) were used for biomechanical testing. SMOT were performed as a uniplanar osteotomy, leaving 5 mm of lateral bone intact with a standardized gap of 8 mm. Five different plates commonly used for SMOT were assessed. For axial stability, the constructs were tested during 100 cycles for each load (150N and 800N) at a rate of 0.5 Hz. For rotational stability, each construct was subject to 100 cycles of 5 Nm torque at a rate of 0.25 Hz, performing three runs with an axial preload of 0N, 150N, or 800N. Ultimate axial load was performed for one-half and ultimate rotational load was performed for the other half of the constructs. In addition, the stiffness of the different constructs after failure was tested. RESULTS: All constructs showed high stability and could be tested until maximum cyclic load. There was no significant difference between the five plates, neither for stiffness (axial or rotational) nor for failure load (axial or rotational). One plate indicated superiority in axial failure testing without any significant difference. CONCLUSION: All implants could be tested until maximum load. The intact hinge apparently provides enough support to compensate for lower moment of inertia of some plates. LEVEL OF EVIDENCE: Not applicable.

T2-mapping at 3 T after microfracture in the treatment of osteochondral defects of the talus at an average follow-up of 8 years.

PURPOSE: To compare repaired cartilage with native cartilage, and inter-observer reliability, using T2 mapping at 3 T for assessing cartilage repair in osteochondral defects of the talus after the microfracture technique. METHODS: We enrolled eight females and seven males undergoing arthroscopic microfracture for osteochondral defects of the talus at an average follow-up of 7.9 ± 2.2 years (range 5-13 years). Cartilage tissue was assessed using a 3-T magnetic resonance imaging unit with an 8-channel phased array foot and ankle coil (gradient strength, 50 mT/m; slew rate, 200 T/m/s). T2 maps were then calculated. Three independent boarded specialists evaluated the images, and magnetic resonance observation of cartilage repair tissue scores was used to assess the cartilage and joint status. Clinical results were assessed using the Hannover Scoring System (HSS) for the ankle and the American Orthopaedic Foot and Ankle Society (AOFAS) hind-foot score. RESULTS: No significant mean differences were found between the T2 properties of the repair tissue and those of the native reference cartilage (T2 = 38.6 ± 5.3 ms, range 30.2-55.8 ms vs. 40.3 ± 8.5 ms, range 31.4-59.8 ms, respectively; intra-class correlation coefficient = 0.94; confidence interval 0.84-0.99, P ≤ 0.001). Despite ≥50 % defect filling in all patients, subchondral bone changes were considerable. The HSS at the follow-up revealed a mean score of 87 ± 12 (range 51-97), and the AOFAS-Score was 90 ± 13 (range 59-100). CONCLUSIONS: 3 T T2 maps were similar in repaired and native cartilage with good inter-observer reliability. LEVEL OF EVIDENCE: IV.

Autologous Matrix-Induced Chondrogenesis in the Knee: A Review.

OBJECTIVE: Autologous matrix-induced chondrogenesis (AMIC) is a 1-step cartilage restoration technique that combines microfracture with the use of an exogenous scaffold. This matrix covers and mechanically stabilizes the clot. There have been an increasing number of studies performed related to the AMIC technique and an update of its use and results is warranted. DESIGN AND METHODS: Using the PubMed database, a literature search was performed using the terms "AMIC" or "Autologous Matrix Induced Chondrogenesis." A total of 19 basic science and clinical articles were identified. RESULTS: Ten studies that were published on the use of AMIC for knee chondral defects were identified and the results of 219 patients were analyzed. The improvements in Knee Injury and Osteoarthritis Outcome Score, International Knee Documentation Committee Subjective, Lysholm and Tegner scores at 2 years were comparable to the published results from autologous chondrocyte implantation (ACI) and matrix ACI techniques for cartilage repair. CONCLUSIONS: Our systematic review of the current state of the AMIC technique suggests that it is a promising 1-stage cartilage repair technique. The short-term clinical outcomes and magnetic resonance imaging results are comparable to other cell-based methods. Further studies with AMIC in randomized studies versus other repair techniques such as ACI are needed in the future.

Total ankle arthroplasty and tibialis posterior tendon transfer for ankle osteoarthritis and drop foot deformity.

Total ankle arthroplasty is an alternative to arthrodesis in selected patients with end-stage arthritis of the ankle. We report on the clinical features, radiographic findings, management and results in a 58-year-old man with associated ankle osteoarthritis and drop foot deformity. The patient was managed with a total ankle arthroplasty and tibialis posterior tendon transfer. Three years after the procedure, the patient was able to walk, had no pain, and had a stable joint with 5° dorsiflexion and 20° plantar flexion.

Effects of a surface matching articular resurfacing device on tibiofemoral contact pressure: results from continuous dynamic flexion-extension cycles.

INTRODUCTION: The application of a defect-size metal implant for the treatment of focal articular cartilage lesions of the femoral condyle is of potential concern resulting in cartilage damage to opposing biological structures. This in vitro study aims to determine the tibiofemoral contact pressure with a contoured articular partial femoral resurfacing device under continuous dynamic pressure loads. METHODS: Peak and area contact pressures were determined in eight fresh-frozen cadaveric specimens using a pressure-sensitive sensor placed in the medial compartment above the menisci. All knees were tested in the untreated condition and after implantation of the prosthetic device in the weight-bearing area of the medial femoral condyle. A robotic knee simulator was used to test each knee under continuous pressure load for 400 s during 40 dynamic knee bending cycles (5°-45° flexion) with body weight ground reaction force (GRF). The GRF was adjusted to the living body weight of the cadaver donor and maintained throughout all cycles. RESULTS: Comparison of the untreated condition to focal inlay resurfacing showed no statistically significant differences (P ≤ 0.05) between all testing conditions. The average maximum peak contact pressure across all 40 flexion cycles increased by 5.1% after resurfacing compared to the untreated knees. The average area contact pressure essentially stayed the same (+0.9%). CONCLUSION: The data suggest that resurfacing with the contoured articular prosthetic device does not pose any immediate deleterious effects to the opposing surfaces based on peak and area contact pressure in a continuous dynamic in vitro application. However, long-term in vivo effects remain to be evaluated.

Microfracture for chondral defects of the talus: maintenance of early results at midterm follow-up.

We determined whether the early improvement in symptoms and function after microfracture in the management of articular cartilage defects of the talus is maintained at mid term follow-up. Factors influencing outcome and postoperative magnetic resonance imaging were also evaluated. We performed data collection prospectively using the Hannover Scoring System for the ankle (HSS) and a Visual Analog Scale (VAS) for pain and function preoperatively, at 1 +/- 0.1 year (45 ankles), 2 +/- 0.4 years (45 ankles), and at an average of 5.8 +/- 2.0 years (39 ankles) postoperatively. MRI was used to assess cartilage repair tissue based on the following variables: degree of defect repair and filling of the defect, integration to border zone, surface of the repair tissue, structure of the repair tissue and subchondral bone alterations. Comparing the outcome scores of the last follow-up to the previous follow-up points, the HSS and the VAS (pain, function and satisfaction) showed no deterioration. Four ankles, however, underwent further surgery to address the chondral defect and were regarded as failures. A body mass index greater than 25 kg/m(2) and having severe post-traumatic cartilage damage appeared to be negative prognostic factors. Results for patients older than 50 years were not inferior to those in younger patients. Microfracture arthroplasty induces repair of localized articular cartilage defects of the talus maintaining the encouraging early results at mid term follow-up.

Tibiofemoral contact mechanics with a femoral resurfacing prosthesis and a non-functional meniscus.

BACKGROUND: Increased contact stress with a femoral resurfacing prosthesis implanted in the medial femoral condyle and a non-functional meniscus is of concern for potential deleterious effects on tibiofemoral contact mechanics. METHODS: Peak contact pressures were determined in seven fresh frozen human cadaveric specimens using a pressure sensitive sensor placed in the medial compartment above the menisci. A knee simulator was used to test each knee in static stance positions (5 degrees/15 degrees/30 degrees/45 degrees) and through 10 dynamic knee flexion cycles (5-45 degrees) with single body weight ground reaction force which was adjusted to the living body weight of the cadaver donor. All specimens were tested in three different conditions: untreated knee (A); flush implantation of a 20mm resurfacing prosthesis (HemiCAP) in the weight bearing area of the medial femoral condyle (B); complete radial tear at the posterior horn of the medial meniscus with the femoral resurfacing device in place (C). FINDINGS: On average, flush device implantation resulted in no statistically significant differences when compared to the untreated normal knee. The meniscal tear resulted in a significant increase of the mean maximum peak contact pressures by 63%, 57%, and 57% (all P< or =0.05) at 15 degrees , 30 degrees and 45 degrees static stance positions and 78% (P< or =0.05) through the dynamic knee flexion cycle. No significant different maximum peak contact pressures were observed at 5 degrees stance position. INTERPRETATION: Although the condition of a meniscal tear without the resurfacing device could not be compared, possible effects of reduced meniscal tissue and biomechanical integrity of the meniscus must be considered in an in vivo application.

Endoscopic treatment of chronic mid-portion Achilles tendinopathy: novel technique with short-term results.

In this prospective study, we present the short-term clinical results of a novel endoscopic surgical technique for patients suffering from chronic painful mid-portion Achilles tendinopathy. Eight consecutive patients (seven men and one woman, mean age 52 years) diagnosed with chronic painful mid-portion Achilles tendinopathy were included in this study and were treated with endoscopic debridement of the ventral neovascularized area, the peritendineum and the Achilles tendon. Patients recorded the function of the Achilles tendon and the severity of Achilles tendon pain during tendon loading activity, pre and postoperatively in a visual analogue scale. Patient global satisfaction was also assessed in a similar manner. Patients were followed-up for 6 months. All patients experienced immediate postoperative pain relief. In terms of Achilles tendon pain, the median visual analogue score (VAS) increased from 40 (10-60) (preoperatively) to 97.5 (85-100) (last follow-up examination). In terms of Achilles tendon function, the median VAS increased from 22.5 (0-30) (preoperatively) to 90 (80-95) (last follow-up examination). In terms of global satisfaction, the median VAS in the last follow-up examination was 85 (70-95). No postoperative complications were recorded. In conclusion, the short-term clinical results were satisfactory.

Delayed diagnosis of a pseudoaneurysm with recurrent hemarthrosis of the knee joint.

This is a case report of recurrent hemarthrosis of the knee joint over 3 months. The patient, a 47-year-old male had three arthroscopic procedures with multiple joint punctures over a 3-month-period prior to our initial consultation. The first procedure (arthroscopic synovectomy) was done for suspected infection following a series of hyaluronic acid injections. Recurrent hemarthrosis developed subsequent to this. Upon further evaluation, a pseudoaneurysm of the superior middle genicular artery was detected and successfully treated with selective angiographic embolization.

Effects of a contoured articular prosthetic device on tibiofemoral peak contact pressure: a biomechanical study.

Many middle-aged patients are affected by localized cartilage defects that are neither appropriate for primary, nor repeat biological repair methods, nor for conventional arthroplasty. This in vitro study aims to determine the peak contact pressure in the tibiofemoral joint with a partial femoral resurfacing device (HemiCAP, Arthrosurface Inc., Franklin, MA, USA). Peak contact pressure was determined in eight fresh-frozen cadaveric specimens using a Tekscan sensor placed in the medial compartment above the menisci. A closed loop robotic knee simulator was used to test each knee in static stance positions (5 degrees /15 degrees /30 degrees /45 degrees ) with body weight ground reaction force (GRF), 30 degrees flexion with twice the body weight (2tBW) GRF and dynamic knee-bending cycles with body weight GRF. The ground reaction force was adjusted to the living body weight of the cadaver donor and maintained throughout all cycles. Each specimen was tested under four different conditions: Untreated, flush HemiCAP implantation, 1-mm proud implantation and 20-mm defect. A paired sampled t test to compare means (significance, P < or = 0.05) was used for statistical analysis. On average, no statistically significant differences were found in any testing condition comparing the normal knee with flush device implantation. With the 1-mm proud implant, statistically significant increase of peak contact pressures of 217% (5 degrees stance), 99% (dynamic knee bending) and 90% (30 degrees stance with 2tBW) compared to the untreated condition was seen. No significant increase of peak contact pressure was evaluated with the 20-mm defect. The data suggests that resurfacing with the HemiCAP does not lead to increased peak contact pressure with flush implantation. However, elevated implantation results in increased peak contact pressure and might be biomechanically disadvantageous in an in vivo application.