Milva Battaglia

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.

Validity of T2 mapping in characterization of the regeneration tissue by bone marrow derived cell transplantation in osteochondral lesions of the ankle.

OBJECTIVE Bone marrow derived cell transplantation (BMDCT) has been recently suggested as a possible surgical technique to repair osteochondral lesions. To date, no qualitative MRI studies have evaluated its efficacy. The aim of our study is to investigate the validity of MRI T2-mapping sequence in characterizing the reparative tissue obtained and its ability to correlate with clinical results. METHODS AND MATERIALS 20 patients with an osteochondral lesion of the talus underwent BMDCT and were evaluated at 2 years follow up using MRI T2-mapping sequence. 20 healthy volunteers were recruited as controls. MRI images were acquired using a protocol suggested by the International Cartilage Repair Society, MOCART scoring system and T2 mapping. Results were then correlated with AOFAS clinical score. RESULTS AOFAS score increased from 66.8±14.5 pre-operatively to 91.2±8.3 (p<0.0005) at 2 years follow-up. T2-relaxation time value of 35-45 ms was derived from healthy ankles evaluation and assumed as normal hyaline cartilage value and used as a control. Regenerated tissue with a T2-relaxation time value comparable to hyaline cartilage was found in all the cases treated, covering a mean of 78% of the repaired lesion area. A high clinical score was related directly to isointense signal in DPFSE fat sat (p=0.05), and percentage of regenerated hyaline cartilage (p=0.05), inversely to the percentage of regenerated fibrocartilage. Lesions depth negatively related to the integrity of the repaired tissues surface (tau=-0.523, p=0.007), and to the percentage of regenerated hyaline cartilage (rho=-0.546, p=0.013). CONCLUSIONS Because of its ability to detect cartilages quality and to correlate to the clinical score, MRI T2-mapping sequence integrated with Mocart score represent a valid, non-invasive technique for qualitative cartilage assessment after regenerative surgical procedures.

Efficacy of Ultrasound-guided Intra-articular Injections of Platelet-rich Plasma Versus Hyaluronic Acid for Hip Osteoarthritis

Intra-articular injections of platelet-rich plasma (PRP) and hyaluronic acid (HA) represent efficacious medical treatments for osteoarthritis (OA), although no comparative study on long-term efficacy in hip OA exists. The goals of the current study were to compare the clinical efficacy of PRP vs HA at 12 months of follow-up in patients with hip OA and evaluate the influence of the type of infiltration and patient age, sex, body mass index, and degree of OA on temporal clinical evolution. One hundred patients with chronic unilateral symptomatic hip OA were consecutively enrolled and randomly assigned to 1 of 2 groups: group A received PRP and group B received HA administered via intra-articular ultrasound-guided injections. Patients were evaluated at baseline and after 1, 3, 6, and 12 months using the Harris Hip Score (HHS) and visual analog scale (VAS). An overall improvement was detected in both groups between 1- and 3-month follow-up. Despite a slightly progressive worsening between 6- and 12-month follow-up, the final clinical scores remained higher compared with baseline (P<.0005), with no significant differences between PRP and HA. Regarding clinical temporal evolution, multivariate analysis showed that HHS was not influenced by the type of infiltration, patient age, sex, body mass index, or degree of OA, whereas a significant association was detected between OA grade IV and VAS evolution (P<.0005). Intra-articular injections of PRP are efficacious in terms of functional improvement and pain reduction but are not superior to HA in patients with symptomatic hip OA at 12-month follow-up.

One Step Treatment of Juvenile Osteochondritis Dissecans in the Knee: Clinical Results and T2 Mapping Characterization

Osteochondritis dissecans (OCD) is an increasingly common cause of knee pain and dysfunction among skeletally immature and young adult patients. An ideal treatment strategy with an optimal surgical technique to repair the osteochondral lesions in these patients is still controversial. The goal of this study is to evaluate and report the clinical and MRI findings for the treatment of OCD in the pediatric knee with bone marrow-derived cell transplantation by using a one-step surgical technique.

Validity of preoperative ultrasound-guided aspiration in the revision of hip prosthesis.

Preoperative diagnosis of septic loosening hip prosthesis is often challenging. Culture test on joint samples obtained during revision surgery is the diagnostic gold standard while the role of preoperative hip aspiration is still controversial. The aims of this prospective randomized study were to compare the sensitivity, specificity and accuracy of preoperative ultrasound-guided and fluoroscopic-guided aspiration, and to identify associated laboratory parameters or scintigraphy that could help in predicting septic loosing hip prosthesis. Sixty patients affected by persistent pain after hip prosthesis randomly received fluoroscopic-guided or ultrasound-guided hip aspiration before revision surgery. The results of culture tests of joint fluid presurgically and at surgery were compared. In addition, associated blood inflammatory markers and scintigraphy were evaluated. Ultrasound-guided aspiration showed a better sensitivity (69% vs. 27%), specificity (94% vs. 75%) and accuracy (83% vs. 40%) than fluoroscopic-guided aspiration. The combination of ultrasound-guided aspiration and C-reactive protein represents the best model to predict septic loosening hip prosthesis preoperatively.

An unusual cause of external snapping hip

The external snapping hip syndrome is a condition characterized by palpable or audible snap on the lateral region of the hip occurring during movements and sometimes associated with pain. It is typical of young adults and athletes and can be favored by the abnormal sliding of the iliotibial band or of the gluteus maximus muscle over the greater trochanter. We present a case of external snapping hip syndrome occurring in a young woman secondary to a dysmorphic sickle-shaped myotendinous junction of the gluteus maximus muscle. Diagnosis was allowed by an integrated clinical and radiological approach, based on dynamic ultrasound and magnetic resonance imaging (MRI).

Autologous Chondrocyte Implantation for Talar Osteochondral Lesions: Comparison Between 5-Year Follow-Up Magnetic Resonance Imaging Findings and 7-Year Follow-Up Clinical Results

&NA; Autologous chondrocyte implantation (ACI) is an established surgical procedure that has provided satisfactory results. The aim of the present study was to correlate the clinical outcomes of a series of 20 patients treated by ACI at a 7‐year follow‐up examination with the magnetic resonance imaging (MRI) T2‐mapping 5‐year follow‐up findings. We evaluated 20 patients using the American Orthopaedic Foot and Ankle Society (AOFAS) score preoperatively and the established follow‐up protocol until 87.2 ± 14.5 months. MRI T2‐mapping sequences were acquired at the 5‐year follow‐up examination. At the MRI examination (60 ± 12 months), the mean AOFAS score improved from 58.7 ± 15.7 to 83.9 ± 18.4. At the final follow‐up examination at 87.2 ± 14.5 months, the AOFAS score was 90.9 ± 12.7 (p = .0005). Those patients who experienced an improvement between 5 and 7 years after surgery had a significant greater percentage of T2‐map value of 35 to 45 ms (hyaline cartilage) compared with those patients who did not improve (p = .038). MRI T2 mapping was shown to be a valuable tool capable of predicting reproducible clinical outcomes after ACI even 7 years after surgery. The quality of the regenerated tissue and the degree of defect filling became statistically significant to the clinical results at the final follow‐up examination. &NA; Level of Clinical Evidence: 4

Unusual supero-medial iliac fatigue stress fracture.

Fatigue stress fractures are quite common in athletes, especially in women. They typically involve the lower extremities, but they have also been described in the pelvis and sacrum. Most of the time, they are radiographically occult at the beginning, and become visible only when the callus is detected. They are suspected owing to their clinical features, and investigated using magnetic resonance imaging (MRI) and computed tomography (CT). We present a case of unusual supero-medial iliac fatigue stress fracture in a 58-year-old amateur marathon runner woman presenting with a history of 1-month’s worsening pain in the right buttock. Diagnosis was challenging. The early radiograph was normal, and the stress fracture was suspected by clinical features and MRI. Although the fracture was evident on the MRI, the findings were subtle and overlooked. The fracture was later confirmed by CT and radiograph, showing the reparative process.

Efficacy of triamcinolone acetate and methylprednisolone acetonide for intrabursal injection after ultrasound-guided percutaneous treatment in painful shoulder calcific tendonitis: a randomized controlled trial:

Background Ultrasound-guided percutaneous irrigation of calcific tendinopathy (US-PICT) with intrabursal steroid injection is an elective treatment for painful rotator cuff calcific tendinopathy. Purpose To compare the efficacy of post-US-PICT intrabursal 40 mg injection of triamcinolone acetonide (TA) versus methylprednisolone acetate (MA). Material and Methods Forty patients (22 women; mean age 48.7 ± 7.2 years) with painful shoulder calcific tendinopathy, treated with TA or MA injected intrabursally after US-PICT, were included in this randomized controlled trial. At baseline and after 1, 7, 15, 30, 45, and 180 days, patients underwent US and clinical examination, using Constant (CS) and VAS (VS) scores. Complications and analgesic use were also recorded. Results Compared to baseline, at the 45-day follow-up, TA and MA group showed a similar improvement (Δ) in CS (42 ± 10 versus 36 ± 9 points) and VS (−4.4 ± 1.3 versus −3.6 ± 1.3 points). At the 180-day follow-up, the improvement was higher in TA versus MA (ΔCS: 53 ± 7 versus 44 ± 7 points; ΔVS: −4.9 ± 1.1 versus −3.9 ± 1 points). Multivariate analysis showed a mean CS higher (P = 0.02) in TA versus MA group, while VS was similar. TA had a 5 × higher (P = 0.007) chance of reaching complete remission (CS = 100 points) than MA group. A progressive decrease in analgesic use, concomitant to a significant and similar reduction of bursitis and calcifications, was observed in both groups. No major complications occurred. Conclusion Two-needle US-PICT with intrabursal steroid injection is safe and effective. The chance of reaching better scores and, even more important for a clinical perspective, of functional recovery, is higher in patients treated with TA than MA.