Alberto Ruffilli

One-Step Repair in Talar Osteochondral Lesions 4-Year Clinical Results and T2-Mapping Capability in Outcome Prediction

Background: A recent one-step arthroscopic technique based on bone marrow–derived cell transplantation has achieved good results in repairing osteochondral lesions of the talus (OLTs), overcoming some of the drawbacks of older techniques. Purpose: To report the results after 4 years of a series of patients who underwent a one-step repair of osteochondral lesions of the talar dome, as well as the capability of magnetic resonance imaging (MRI) using a T2-mapping sequence to predict the clinical outcome. Study Design: Case series; Level of evidence, 4. Methods: Forty-nine patients (age [mean ± SD], 28.08 ± 9.51 y) underwent a one-step repair of OLTs. Patients were evaluated clinically by American Orthopaedic Foot and Ankle Society (AOFAS) scores and radiographs and underwent MRI preoperatively and during postoperative follow-ups at predetermined times. In all patients, the cells were harvested from the iliac crest, concentrated, and loaded on a scaffold that was implanted arthroscopically. Results: The overall AOFAS score (mean ± SD) improved from 63.73 ± 14.13 preoperatively to 82.19 ± 17.04 at 48 ± 6.1 months (P < .0005), with best results at the 24-month follow-up. A significant decrease in the clinical score was observed between 24 and 36 months postoperatively (P = .001) and between 24 and 48 months (P < .005). The T2-mapping analysis showed regenerated tissue with T2 values of 35 to 45 milliseconds, similar to hyaline cartilage, in a mean of 78% ± 16% of the repaired lesion area. The time between the occurrence of trauma and surgery was found to negatively affect the clinical outcome at the latest follow-up; patient’s age and lesion size influenced the early clinical results but did not affect the outcome at final follow-up. The stability of clinical results over time and the percentage of tissue with values similar to hyaline cartilage evidenced by MRI T2 mapping showed a tendency to correlate at the last follow-up (r = 0.497, P = .06). Conclusion: One-step repair of OLTs had good clinical results that were durable over time, even though there was a slight decrease in AOFAS score at the latest follow-up. The quality of the regenerated tissue detected by MRI T2 mapping directly correlated with the clinical results.

Surgical Treatment of Osteochondral Lesions of the Talus by Open-Field Autologuous Chondrocyte Implantation A 10-Year Follow-up Clinical and Magnetic Resonance Imaging T2-Mapping Evaluation

Background Ideal treatment of osteochondral lesions of the talus is still controversial. Although good clinical and histologic results have been reported for the knee, long-term results have not been reported for autologous chondrocyte implantation in the ankle. Furthermore, magnetic resonance imaging T2 mapping is becoming an increasingly used method for noninvasive assessment of repair tissue in the knee, but no experience on the ankle has been reported. Hypothesis The 10-year clinical results of autologous chondrocyte implantation in the treatment of osteochondral lesions of the talus has clinical efficacy comparable with the long-term efficacy of autologous chondrocyte implantation in the knee. A secondary hypothesis is that magnetic resonance imaging T2 mapping may provide noninvasive assessment of the repaired tissue quality in the ankle. Study Design Case series; Level of evidence, 4. Methods Between 1997 and 1999, 10 patients (age 25.8 6 6.4 years) with an osteochondral lesion of the talus were treated with autologous chondrocyte implantation. The mean size of the lesions was 3.1 cm2 (range, 2.2-4.3 cm2). All patients were evaluated clinically (American Orthopaedic Foot and Ankle Society score), radiographically, and by magnetic resonance imaging preoperatively and at established intervals up to a mean follow-up of 119 6 6.5 months. At the final follow-up, magnetic resonance imaging was graded with the Magnetic Resonance Observation of Cartilage Repair Tissue scoring system and T2-mapping evaluation in 6 cases. Results Before surgery, the mean American Orthopaedic Foot and Ankle Society score was 37.9 6 17.8 points, while at final follow-up it was 92.7 6 9.9 (P <.0005). Magnetic resonance imaging showed well-modeled restoration of the articular surface. The regenerated cartilage showed a mean T2-mapping value of 46 microseconds (range, 34-50), with no significant difference compared with that of healthy hyaline cartilage. Conclusion The results of autologous chondrocyte implantation in the ankle joint are comparable with those in the knee as demonstrated by the significant clinical improvement, hyaline cartilage repair, and the durability of the results. Integration of both T2 mapping and Magnetic Resonance Observation of Cartilage Repair scoring permitted adequate evaluation of the repair site in the ankle.BACKGROUND Ideal treatment of osteochondral lesions of the talus is still controversial. Although good clinical and histologic results have been reported for the knee, long-term results have not been reported for autologous chondrocyte implantation in the ankle. Furthermore, magnetic resonance imaging T2 mapping is becoming an increasingly used method for noninvasive assessment of repair tissue in the knee, but no experience on the ankle has been reported. HYPOTHESIS The 10-year clinical results of autologous chondrocyte implantation in the treatment of osteochondral lesions of the talus has clinical efficacy comparable with the long-term efficacy of autologous chondrocyte implantation in the knee. A secondary hypothesis is that magnetic resonance imaging T2 mapping may provide noninvasive assessment of the repaired tissue quality in the ankle. STUDY DESIGN Case series; Level of evidence, 4. METHODS Between 1997 and 1999, 10 patients (age 25.8 +/- 6.4 years) with an osteochondral lesion of the talus were treated with autologous chondrocyte implantation. The mean size of the lesions was 3.1 cm(2) (range, 2.2-4.3 cm(2)). All patients were evaluated clinically (American Orthopaedic Foot and Ankle Society score), radiographically, and by magnetic resonance imaging preoperatively and at established intervals up to a mean follow-up of 119 +/- 6.5 months. At the final follow-up, magnetic resonance imaging was graded with the Magnetic Resonance Observation of Cartilage Repair Tissue scoring system and T2-mapping evaluation in 6 cases. RESULTS Before surgery, the mean American Orthopaedic Foot and Ankle Society score was 37.9 +/- 17.8 points, while at final follow-up it was 92.7 +/- 9.9 (P < .0005). Magnetic resonance imaging showed well-modeled restoration of the articular surface. The regenerated cartilage showed a mean T2-mapping value of 46 microseconds (range, 34-50), with no significant difference compared with that of healthy hyaline cartilage. CONCLUSION The results of autologous chondrocyte implantation in the ankle joint are comparable with those in the knee as demonstrated by the significant clinical improvement, hyaline cartilage repair, and the durability of the results. Integration of both T2 mapping and Magnetic Resonance Observation of Cartilage Repair scoring permitted adequate evaluation of the repair site in the ankle.

Bipolar Fresh Osteochondral Allograft of the Ankle

Background: Severe post-traumatic ankle arthritis poses a reconstructive challenge in the young and active patient. Bipolar fresh osteochondral allograft (BFOA) may represent an intriguing alternative to arthrodesis and prosthetic replacement. The aim of this study was to describe a lateral trans-malleolar technique for BFOA, and to evaluate the results in a case series. Materials and Methods: From 2004 to 2006, 32 patients, mean age of 36.8 ± 8.4 years, affected by ankle arthritis underwent BFOA with a mean followup of 31.2 months. The graft was prepared by specifically designed jigs, including the talus and the tibia with the medial malleolus. The host surfaces were prepared by the same jigs through a lateral approach. The graft was placed and fixed with twist-off screws. Patients were evaluated clinically and radiographically at 2, 4, and 6 month after operation, and at a minimum 24 months followup. A biopsy of the grafted areas was obtained from 7 patients at 1-year followup for histological and immunohistochemical examination. Results: Preoperative AOFAS score was 33.1 ± 10.9 and postoperatively 69.5 ± 19.4 (p < 0.0005). Six failures occurred. Cartilage harvests showed hyaline-like histology with a normal collagen component but low proteoglycan presence and a disorganized structure. Samples were positive for MMP-1, MMP-13 and Capsase-3. Conclusion: The use of BFOA represents an intriguing alternative to arthrodesis or arthroplasty. We believe precise allograft sizing, stable fitting and fixation and delayed weightbearing were key factors for a successful outcome. Further research regarding the immunological behavior of transplanted cartilage is needed. Level of Evidence: IV, Retrospective Case Series

Allograft Salvage Procedure in Multiple-Revision Anterior Cruciate Ligament Reconstruction

Background: Multiple-revision anterior cruciate ligament (ACL) reconstructions represent a surgical challenge due to the presence of previous tunnels, hardware, injuries to the secondary stabilizers, and difficulties in retrieving autologous tendons. An anatomic ACL reconstruction may therefore result in a demanding surgery, thus requiring 2 stages. Purpose: To analyze the efficacy of an over-the-top ACL reconstruction technique plus extra-articular plasty using Achilles or tibialis posterior tendon allograft in restoring knee stability in patients with at least 2 failed previous ACL reconstructions, as well as to evaluate the factors able to affect the final outcome. Study Design: Case series; Level of evidence, 4. Methods: From 2002 to 2008, 24 male athletes with a mean age of 30.8 years underwent surgery. Twenty patients had undergone 2, whereas 4 patients had undergone 3 previous reconstructions. The International Knee Documentation Committee (IKDC) score and KT-2000 arthrometric evaluation were used to measure outcomes at a mean follow-up period of 3.3 years (range, 2-7). Results: The mean ± SD IKDC subjective score at follow-up was 81.3 ± 14.0. The IKDC objective score was an A or B in 20 patients (83%). Arthrometer side-to-side difference averaged 3.1 ± 1.1 mm. Range of motion was normal or nearly normal in 23 patients and abnormal in 1. Of the 20 good results, 17 patients resumed sports activity at the preinjury level. Conclusion: A 2-stage revision is an accepted option in cases of excessive tunnel enlargement and bone loss, especially on the femoral side, to achieve anatomic reconstruction. Nonanatomic over-the-top ACL reconstruction and lateral extra-articular plasty technique allow one to overcome difficult anatomic situations on the femoral side, permitting a 1-step surgery. The overall results obtained in this series are comparable with those of other ACL revision series. The higher rate of mild instability observed in our series may not be attributable to the surgical technique but rather to the chronic instability suffered by these knees before last revision.

Arthroscopic Treatment of Ankle Anterior Bony Impingement The Long-term Clinical Outcome

Background: Arthroscopic treatment of anterior ankle bony impingement provides good results, with a tendency to decrease over time. The purpose of this study was to analyze the factors affecting long-term results. Methods: Eighty consecutive patients with a mean age of 37.3 years were treated between 2000 and 2004. Impingement lesions were identified according to Scranton-McDermott classification. Preoperative ankle osteoarthritis was documented by van Dijk scale upon the x-rays. Bone spurs were analyzed and classified according to location and size. The associated chondral lesions were classified following the International Cartilage Repair Society (ICRS) criteria. Patient data, foot morphology, and previous traumas were recorded. Patients were evaluated after a mean of 104.6 months follow-up with the American Orthopaedic Foot and Ankle Society (AOFAS) scale. The influence of different factors on outcomes was statistically analyzed. Results: The mean preoperative AOFAS score was 50.9, while at follow-up it was 70.7 (P < .05). The different grades of Scranton-McDermott impingement classification did not affect the results, but the different grades of van Dijk scale significantly affected the result but not the preoperative stage. Tibial localized spurs had better outcome at follow-up. The grade of the chondral lesions significantly affected the outcome. Other factors negatively affecting the results were age, cavus foot morphology, and history of previous ankle fracture. Conclusion: Arthroscopic treatment provides overall good results, but the long-term presence of associated conditions such as chondral lesions, advanced age, and previous trauma are relevant as prognostic factors. Based on these results, a new classification for bony impingement syndrome system is proposed. Level of Evidence: Level IV, case series.

Partial ACL Tears: Anatomic Reconstruction Versus Nonanatomic Augmentation Surgery

Treatment of partial anterior cruciate ligament (ACL) tears requires ACL remnant preservation. The goal of this study was to compare the outcome of anatomic reconstruction of the torn bundle with nonanatomic augmentation using the over-the-top femoral route. Fifty-two athletes (mean age, 23.3 years) with partial ACL lesions underwent anatomic reconstruction (n=26) or nonanatomic augmentation (n=26). Intraoperative damage of the healthy bundle that required a standard ACL reconstruction occurred in 2 patients in the anatomic reconstruction group. International Knee Documentation Committee (IKDC) score, Tegner score, and arthrometer evaluation were used pre-operatively and at follow-up for up to 5 years postoperatively. One failure occurred in the anatomic reconstruction group. Mean IKDC subjective score at follow-up was 88.2 ± 5.7 in the anatomic reconstruction group and 90.2 ± 4.7 in the nonanatomic augmentation group. According to the IKDC objective score at final follow-up, 96% of knees in the nonanatomic augmentation group were normal vs 87.5% in the anatomic reconstruction group. No significative differences were observed between the 2 groups at final follow-up. Anteromedial bundle reconstruction showed significantly lower IKDC subjective and objective scores and higher residual instability values as evaluated with the arthrometer compared with posterolateral bundle reconstruction (P=.017). The surgical treatment of ACL partial tears is demanding. Adapted portals, perfect control of the tunnel drilling process, and intercondylar space management are required in anatomic reconstruction. The nonanatomic augmentation technique is simpler, providing excellent durable results over time with a lower complication rate. Anteromedial bundle reconstruction is associated with a poorer outcome, especially when performed with anatomic reconstruction.

Saphenous nerve injury during hamstring tendons harvest: Does the incision matter? A systematic review

PurposeInfrapatellar branch of saphenous nerve injury is a common complication following hamstring graft harvest during anterior cruciate ligament reconstruction. The direction of skin incision performed at proximal tibial metaphysis may affect the rate of iatrogenic nerve damage. Aim of the present systematic review was to evaluate evidence that would substantiate the adoption of one incision over another for hamstring graft harvesting.MethodsThe available literature was systematically screened searching studies dealing with iatrogenic injury to the saphenous nerve after anterior cruciate ligament reconstruction using hamstring tendons. A search was performed using the keywords “Saphenous” and “Infrapatellar branch” in combination with “Anterior cruciate ligament”, “arthroscopy” and “hamstrings”, supplying no limits regard the publication year. Coleman methodological score was performed in all the retained articles.ResultsFive articles matched the inclusion criteria. There were two randomized controlled trials, one prospective comparative study and two retrospective comparative series. Poor methodological quality was found overall. A vertical incision was found to significantly affect the presence of hypoesthesia and the extent of the area of sensory loss in three articles; no difference was registered in one, and a trend towards a lower rate of iatrogenic nerve damage using an oblique incision was found in the remaining one, without any statistical significance.ConclusionAlthough the low methodological quality of the analysed studies does not permit to draw definitive conclusions, the anatomical course of the nerve along with the results obtained in the available studies seems to suggest lower rate of neurological impairment adopting an oblique incision. This kind of incision may therefore be preferred in the routine clinical practice.Level of evidence Systematic review, Level II.

Survivorship of Bipolar Fresh Total Osteochondral Ankle Allograft

Background: Severe posttraumatic ankle arthritis poses a reconstructive challenge in the young and active patient. Bipolar fresh total osteochondral allograft (BFTOA) may represent an intriguing alternative to arthrodesis and prosthetic replacement. The purpose of this article was to evaluate the outcomes of BFTOA performed through an anterior approach to the ankle and to investigate the parameters influencing the results. Methods: A total of 26 patients (18 males and 8 females with a mean age of 34.9 ± 7.7 years) underwent BFTOA. The allograft was prepared with the help of specifically designed jigs and the surgery was performed using a direct anterior approach. Patients were evaluated clinically and radiographically at 2, 4, 6, and 12 months after the operation, and at a mean 40.9 ± 14.1 months of follow-up. Radiographic evaluation included the measurement of allograft size matching and alignment. Results: The AOFAS score improved from 26.6 ± 6 preoperatively to 77.8 ± 8.7 after a mean follow-up of 40.9 ± 14.1 months (P < .0005). Six failures occurred. Joint degeneration was classified as 2 in 12 and as 3 in 14 patients. A statistically significant correlation between low degrees of distal tibial slope and better clinical outcomes was observed (P = .049). Conclusion: BFTOA appears to be a viable option to arthrodesis or arthroplasty. Precise allograft sizing, stable fitting, and fixation and delayed weight-bearing were key factors for a successful outcome. In this series the correct alignment of the tibial graft, in terms of slope, was found to play a crucial role in the allograft survivorship. Level of Evidence: Level IV, case series.

Conversion of painful ankle arthrodesis to bipolar fresh osteochondral allograft: case report.

Ankle arthrodesis has been used successfully for endstage arthritis of the ankle for more than a century and has remained the gold standard for end-stage posttraumatic arthritis against which other surgical options for ankle arthritis are compared for clinical and functional benefits.2,12,14 Nevertheless, degenerative changes in the adjacent joints following an ankle arthrodesis have been reported and may lead to additional fusion surgery over time.9,10 When performing an arthrodesis, variations from the ideal positions of fixation (90 degrees or up to 10 degrees of dorsiflexion in case of midtarsal joint arthritis, 5 to 10 degrees valgus, and 5 degrees to 10 degrees of external rotation),3 could be labeled as malpositions and may be a cause of pain or cause flexion or extension deformities of the knee leading to gait disturbances.13 Ankle arthroplasty is considered to be a salvage option for those patients who are not satisfied with an ankle arthrodesis which has been shown to be capable, in selected cases, to give the patient a satisfactory restoration of function.6

Temperature-Controlled Continuous Cold Flow Device after Total Knee Arthroplasty: A Randomized Controlled Trial Study

Abstract Total knee arthroplasty (TKA) is a widely accepted and successful procedure for end‐stage arthritis. Nevertheless, fast‐track may be compromised by many factors, such as pain, edema, and blood loss. Cryotherapy has been advocated as a safe and effective strategy to improve the postoperative results, acting on pain, edema, and blood loss. This study is a prospective randomized controlled study, involving 50 patients after primary TKA. A power analysis was performed preoperatively. Twenty‐four patients were addressed to a postoperative treatment with a continuous cold flow device (Hilotherm, Hilotherm GmbH, Germany). Twenty‐six patients represented the control group, treated with crushed ice packs. All the patients shared the same analgesic strategy and the same rehabilitation protocol. Pain, analgesic consumption, active knee range of motion, drain output, transfusion requirement, and total blood loss were evaluated at different follow‐ups (postoperative first, third, and seventh days). The two groups were homogenous for preoperative and intraoperative features. The groups showed no statistically significant differences in all the evaluated parameters. A modest reduction of knee volume was evident after 7 days from surgery (trend). No differences in blood loss were noticed. Continuous cold flow device in the acute postoperative setting after TKA did not show superiority in reducing edema, pain, and blood loss, compared with traditional icing regimen. Thus, due to the costs, it should be reserved to selected cases.