Bedside needle arthroscopy of the ankle under local anesthesia has been proposed for intra-articular delivery of injectable agents. Accuracy and tolerability of this approach in the clinical ...setting-including patients with end-stage ankle pathology and/or a history of prior surgery-is not known.
To assess clinical accuracy and tolerability of bedside needle arthroscopy as a delivery system for injectable agents into the tibiotalar joint.
This was a prospective study that included adult patients who were scheduled for an injection with hyaluronic acid to the tibiotalar joint. In our center, these injections are used as a last resort prior to extensive surgery. The primary outcome was injection accuracy, which was defined as injecting through the arthroscopic cannula with intra-articular positioning confirmed by a clear arthroscopic view of the joint space. Secondary outcome measures included a patient-reported numeric rating scale (NRS, 0-10) of pain during the procedure and willingness of patients to return for the same procedure. NRS of ankle pain at rest and during walking was collected at baseline and at 2-wk follow-up. Complications were monitored from inclusion up to a 2-wk control visit.
We performed 24 inspection-injections. Eleven (46%) participants were male, and mean age was 46.8 ± 14.5 years. Osteoarthritis was the indication for injection in 20 (83%) cases, of which 8 (33%) patients suffered from osteoarthritis Kellgren-Lawrence grade IV, and 10 (42%) patients from Kellgren-Lawrence grade III. An osteochondral defect was the indication for injection in 4 (17%) cases. A history of ankle surgery was present in 14 (58%) participants and a history of multiple ankle surgeries in 11 (46%) participants. It was possible to confirm accuracy in 21 (88%) procedures. The 3 (12%) participants where needle arthroscopy did not reach a clear view of the joint space all suffered from Kellgren-Lawrence grade IV osteoarthritis. Pain during the procedure was reported with a median of 1 interquartile ranges (IQR): 0-2. Willingness to return was 100%. Pain in rest decreased from a median NRS of 4 (IQR: 2-7) at baseline to a median of 3 (IQR: 1-5) at follow-up (
< 0.01). Pain during walking decreased from a median NRS of 8 (IQR: 6-9) to a median of 7 (IQR: 4-8) (
< 0.01). Infections or other complications were not encountered.
Clinical accuracy and tolerability of bedside needle arthroscopy of the ankle as a delivery system for injectable agents are excellent. Accuracy was 100% in patients without total ventral joint obliteration.
Purpose
The primary purpose of the present study was to assess the patient-reported outcomes, complications, and reoperation rate of patient who underwent surgical treatment for symptomatic ...osteochondral lesions of the talonavicular joint (TNJ).
Methods
Patients undergoing surgical treatment for symptomatic osteochondral lesions of the TNJ with a minimum of 12-month follow-up were included. Outcomes included clinical patient-reported outcome measures (PROMs), return to sports and work outcomes, and postoperative complications or reoperations. Medical records were screened by 2 independent reviewers. Patients were contacted by phone and underwent an in-depth interview. Additionally, operative techniques for both arthroscopic and open surgical approaches for treating TNJ osteochondral lesions were described.
Design
Retrospective Case Series (Level IV) and Surgical Technique.
Results
A total of 7 patients were included with a final follow-up time of 25.4 (SD: 15.2) months follow-up. PROMs were considered satisfactory for 5 out of 7 patients, 6 out of 7 patients returned to any level of sports at a mean of 3.7 (SD: 4.2) months, and 5 out of 6 patients returned to preinjury level of sports at a mean of 14 (SD: 7.5) months. All patients returned to work at an average of 5.4 (SD: 3.6) weeks. No complications or reoperations after index surgery were reported.
Conclusion
Surgical treatment of TNJ osteochondral lesions is a feasible procedure that may offer successful clinical, sport, and work outcomes in the majority of patients. Both open and arthroscopic surgical treatments are available and can be considered in a patient-specific treatment plan.
Uniformity of reporting is a requisite to be able to compare results of clinical studies on the treatment of osteochondral lesions of the talus (OLT). The primary aim of this study was to evaluate ...the frequency and quality of reporting of size, morphology, and location of OLTs.
A literature search was performed from 1996 to 2023 to identify clinical studies on surgical treatment of OLTs. Screening was performed by 2 reviewers, who subsequently graded the quality using the methodological index for non-randomized studies (MINORS). The primary outcome was the frequency and qualitative assessment of reporting of size, morphology, and location.
Of 3,074 articles, 262 articles were included. This comprised a total of 11,785 patients. Size was reported in 248 (95%) of the articles and was described with a measure for surface area in 83%, however, in 56%, definition of measurement is unknown. Intraclass coefficient (ICC) value for the reliability of size measurement was 0.94 for computed tomography (CT) scan and 0.87 for MRI scan. Morphology was reported in 172 (66%) of the articles and using a classification system in 23% of the studies. Location was reported in 220 (84%) of the studies.
No consensus was found on the reporting of morphology, with non-validated classification systems and different terminologies used. For location, reporting in 9 zones is underreported. Size was well reported and measurements are more reliable for CT compared with MRI. As these prognostic factors guide clinical decision-making, we advocate the development of a standardized and validated OLT classification to reach uniform reporting in literature.
Level III, systematic review.
To compare cartilage quality after different surgical interventions for osteochondral lesions of the talus (OLT), evaluated by second-look arthroscopy. Secondary aims were to report concomitant ...diagnoses, and to correlate cartilage quality with clinical and radiological outcomes. This review hypothesizes that the cartilage repair after bone marrow stimulation (BMS) is inferior to the other available treatment options.
PROSPERO ID: CRD42022311489. Studies were retrieved through PubMed, EMBASE (Ovid), and Cochrane Library. Studies were included if they reported cartilage quality after second-look investigation after surgical treatment of OLT. The primary outcome measure was the cartilage quality success and failure rates (%) per surgical intervention group. Correlations between the cartilage quality and clinical or radiological outcomes were calculated.
Twenty-nine studies were included, comprising 586 ankles that had undergone second-look arthroscopy on average 16 months after initial surgery. The success rate for BMS was 57% (95% confidence interval CI = 48%-65%), for fixation (FIX) 86% (95% CI = 70%-94%), for osteo(chondral) transplantation (OCT) 91% (95% CI = 80%-96%), for cartilage implementation techniques (CITs) 80% (95% CI = 69%-88%), and for retrograde drilling 100% (95% CI = 66%-100%). The success rate of BMS was significantly lower than FIX, OCT, and CIT (
< 0.01). There were no significant differences between other treatment groups. A moderate positive significant correlation between the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score and the International Cartilage Repair Society score (ICRS) was found (ρ = 0.51,
< 0.001).
Successful restoration of cartilage quality was found in the majority of surgically treated OLTs. However, BMS yields inferior cartilage quality compared with FIX, OCT, and CIT.
Systematic review and meta-analysis.
Level IV, systematic review and meta-analysis.
The first line of treatment for osteochondral lesions of the talus (OLT) is nonoperative. To date, there is limited evidence on risk factors that may influence conversion to surgery after primary ...nonoperative treatment for symptomatic OLTs. The aim of this study was therefore to identify risk factors for conversion to surgery after initial nonoperative treatment of OLTs.
For this cohort study, patients with a primary OLT who were nonoperatively treated for at least 6 months between 1990 and 2020 were included. Univariable Cox regression analysis, resulting in hazard ratios (HRs), on the primary outcome (i.e. conversion to surgery after initial nonoperative treatment) was performed for potential risk factors. The following risk factors were analyzed: gender, age, body mass index (BMI), numeric rating scale (NRS), lesion size (depth, sagittal length, coronal length, volume, surface), lesion morphology (presence of fragments and presence of cysts), lesion location (medial/central/lateral), congruency of the ankle joint and trauma in history. Data imputation was conducted according to the multiple data principle with pooling.
Forty-two patients with primary OLTs were included in this study: 23 (55%) males and 19 (45%) females with a mean age of 39.1 (SD: 14.2). The median overall follow-up time was 66 months (range: 7-188). Around 23% of the patients had a conversion to surgery at the median observation time. The Kaplan-Meier analysis revealed a survival rate of 93% (95% confidence interval CI:84-100), 90% (95% CI: 81-99), and 77% (95% CI: 63-91) at 1, 2, and 5 years after the initiation of treatment, respectively. After performing the COX regression analysis, age was the sole risk factor significantly associated with conversion to surgery with an HR of 0.93 (95% CI: 0.87-0.99). The different HRs for all other risk factors were as follows: gender: 0.33 (95% CI: 0.08-1.34), BMI: 0.87 (95% CI 0.76-1.01), depth: 0.97 (95% CI: 0.79-1.18), coronal length: 1.19 (95% CI: 0.97-1.44), sagittal length: 0.98 (95% CI: 0.87-1.12), surface area: 1.17 (95% CI: 0.41-3.31), volume: 0.96 (95% CI: 0.24-3.91), presence of fragments: 4.17 (95% CI: 0.84-20.61).
For primary OLTs, 77% of the patients were successfully treated nonoperatively at a median follow-up of 66 months without the need for a surgical intervention. Survival rates of 93%, 90%, and 77% were found at 1, 2, and 5 years after the initiation of treatment, respectively. We found that a higher age at the moment of diagnosis was significantly associated with a lower likelihood of conversion to surgery with a 7% decrease of likelihood each year the patient is older at the moment of diagnosis. The findings of this study are clinically relevant as it ameliorates the quality of the shared decision-making process between the patient and the treating team as we can advise OLT patients at a higher age with tolerable symptomatology that there is a relatively lower risk of conversion to surgery.
Abstract Purpose The present study aimed to compare the clinical outcomes and safety at a 1‐year follow‐up after 5 or 6 weeks of non‐weight bearing after a Talar OsteoPeriostic grafting from the ...Iliac Crest (TOPIC) for a medial osteochondral lesion of the talus (OLT). Methods A retrospective comparative case‐control analysis of prospectively followed patients who underwent a TOPIC procedure with medial malleolus osteotomy was performed. Patients were matched in two groups with either 5 or 6 weeks of non‐weight bearing. Clinical outcomes were evaluated using the Numeric Rating Scale (NRS) during walking, rest, running, and stairclimbing. Additionally, the Foot and Ankle Outcome Score (FAOS) and American Orthopaedic Foot and Ankle Society (AOFAS) ankle‐hindfoot score were assessed. Moreover, radiology and complications were assessed. Results Eleven patients were included in the 5‐week non‐weight bearing group and 22 in the 6‐week non‐weight bearing group. No significant differences were found in any of the baseline variables. The NRS during walking in the 5‐week group improved by 3.5 points and 4 points for the 6‐week group ( p = 0.58 at 1‐year post‐operatively). In addition, all other NRS scores, FAOS subscales and the AOFAS scores improved (all n.s. at 1 year follow‐up). No significant differences in radiological (osteotomy union and cyst presence in the graft) were found. Moreover, no significant differences were found in terms of complications and reoperations. Conclusion No statistical significant differences were found in terms of clinical, radiological and safety outcomes between 5 or 6 weeks of non‐weight bearing following a TOPIC for a medial OLT. Level of Evidence Level III, Therapeutic.
Objective
The purpose of this retrospective case series was to evaluate clinical outcomes following both conservative treatment and arthroscopic bone marrow stimulation (BMS) for the management of ...symptomatic subtalar osteochondral lesions (OCLs).
Design
All symptomatic subtalar OCLs with a minimum of 12 months follow-up having undergone either a conservative management or arthroscopic procedure were included. Patient-reported outcomes were collected via questionnaires consisting of the Foot and Ankle Outcome Score (FAOS), Numeric Rating Scale (NRS) of pain in rest, during walking, during stair climbing, and during running. In addition, return to sports data, return to work data, reoperations, and complications were collected and assessed. In total, 11 patients across 2 academic institutions were included (3 males, 8 females). The median age was 43 years (interquartile range IQR: 32-53).
Results
All patients underwent conservative treatment first; in addition, 9 patients underwent subtalar arthroscopic debridement with or without BMS. The median follow-up time was 15 months (IQR: 14-100). In the surgically treated group, the median NRS scores were 2 (IQR: 1-3) during rest, 3 (IQR: 2-4) during walking, 4 (IQR: 4-5) during stair climbing, 5 (IQR: 4-5) during running and the median FAOS score at final follow-up was 74 (IQR: 65-83). In the conservatively treated patients, the median NRS scores were all 0 (IQR: 0-0) and the median FAOS scores were 90 (IQR: 85-94). In the group of surgical treated patients, 4 were able to return to the same level of sports, 2 returned to a lower level of sports. Both conservatively treated patients returned to the sport and the same level of prior participation. All patients except one in the surgical group returned to work.
Conclusions
This retrospective case series demonstrated that a high number of patients converted to surgery after initial conservative treatment. In addition, debridement and BMS show good clinical outcomes for the management of symptomatic subtalar OCLs at short-term follow-up. No complications nor secondary surgical procedures were noted in the surgically treated group. The high rate of failure of conservative treatment suggests that surgical intervention for symptomatic subtalar OCLs can be the primary treatment strategy; however, further research is warranted in light of the small number of patients.
Objective
To compare clinical, sports, work, and radiological outcomes between primary and secondary osteochondral lesions of the talus (OLTs; <15 mm) treated with arthroscopic bone marrow ...stimulation (BMS).
Design
Secondary OLTs were matched to primary OLTs in a 1:2 ratio to assess the primary outcome measure—the Numeric Rating Scale (NRS) during activities. Secondary outcomes included the pre- and 1-year postoperative NRS at rest, American Orthopaedic Foot and Ankle Society score, Foot and Ankle Outcome Score subscales, and the EQ-5D general health questionnaire. The rates and time to return to work and sports were collected. Radiological examinations were performed preoperatively and at final follow-up using computed tomography (CT).
Results
After matching, 22 and 12 patients with small (<15 mm) OLTs were included in the primary and secondary groups, respectively. The NRS during activities was not different between primary cases (median: 2, interquartile range IQR: 1-4.5) and secondary cases (median: 3, IQR: 1-4), P = 0.5. Both groups showed a significant difference between all pre- and postoperative clinical outcome scores, but no significant difference between BMS groups postoperatively. The return to sport rate was 90% for primary cases and 83% for secondary cases (P = 0.6). All patients returned to work. Lesion filling on CT was complete (67% to 100%) in 59% of primary cases and 67% of secondary cases (P = 0.6).
Conclusion
No differences in outcomes were observed between arthroscopic bone marrow stimulation in primary and secondary OLTs at 1-year follow-up. Repeat BMS may therefore be a viable treatment option for failed OLTs in the short term.
Objective
To determine and compare the incidence rate of (osteo)chondral lesions of the ankle in patients with acute and chronic isolated syndesmotic injuries.
Design
A literature search was ...conducted in the PubMed (MEDLINE) and EMBASE (Ovid) databases from 2000 to September 2021. Two authors independently screened the search results, and risk of bias was assessed using the MINORS (Methodological Index for Non-Randomized Studies) criteria. Studies on acute and chronic isolated syndesmotic injuries with pre-operative or intra-operative imaging were included. The primary outcome was the incidence rate with corresponding 95% confidence intervals (CIs) of (osteo)chondral lesions of the ankle in combined and separate groups of acute and chronic syndesmotic injuries. Secondary outcomes were anatomic distribution and mean size of the (osteo)chondral lesions.
Results
Nine articles (402 syndesmotic injuries) were included in the final analysis. Overall (osteo)chondral lesion incidence was 20.7% (95% CI: 13.7%-29.9%). This rate was 22.0% (95% CI: 17.1-27.7) and 24.1% (95% CI: 15.6-35.2) for acute and chronic syndesmotic injuries, respectively. In the combined acute and chronic syndesmotic injury group, 95.4% of the lesions were located on the talar dome and 4.5% of the lesions were located on the distal tibia. (Osteo)chondral lesion size was not reported in any of the studies.
Conclusions
This meta-analysis shows that (osteo)chondral lesions of the ankle are present in 21% of the patients with isolated syndesmotic injuries. No difference in incidence rate was found between the different syndesmotic injury types and it can be concluded that the majority of lesions are located on the talar dome.
PROSPERO Registration Number:
CRD42020176641
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