Autori: FG Usuelli, L De Girolamo, M Grassi, C Maccario, V Guarella, U A Montrasio, M Boga
Dove AOFAS
Anno: 2014-2015
Published: Arthroscopy Techniques – June 8, 2015

Summary:
A number of treatments has been proposed and used for symptomatic talus osteochondral lesion. The traditional surgical starting option is an arthroscopic debridement with any sort of bone marrow stimulations. Literature supports it showing good results in term of pain and function at a short time follow-up, but many controversies are still open regarding medium-long term results. Furthermore these procedures are not able to produce normal cartilage. AMIC with cancellous bone graft represents a promising option between cartilage-regeneration procedures. An all arthroscopic approach can help to reduce its morbidity.

Introduction:
Daily clinical experience suggesting OCLT to be related to trauma injuries has been confirmed by literature in recent years. Talar lesions have shown to occur in up to 50% of traumatic ankle sprains, with higher rates with concomitant lateral instability (55%), distal fibular fracture (70.7%) and complete deltoid disruption (100%). 
The starting treatment consists in an arthroscopic debridement with any sort of bone marrow stimulation. Literature presents good results ( up to 80%) at least for a short follow up, but these procedures are not able to produce normal cartilage and often patients with larger lesion need further surgeries.
Autologous matrix-induced chondrogenesis ( AMIC) with bone graft is an option for refractory lesions or untreated lesions likely to be unresponsive (larger ones).
It has been previously described with an open technique.
We are proposing it with an anterior arthroscopic approach and distraction.
The purpose of this study was to collect data from patients treated with this arthroscopic technique.

Methods:
This study is a cohort case series planned to collect imaging and clinical data from patients arthroscopic-treated with AMIC and autologous bone graft.
20 consecutive subjects were recruited in a single center ( IRCCS Galeazzi).
The surgeries were all performed by the same surgeon (February 2012 – June 2013).

In our Institution all patients with the clinical suspect of painful OCLT receive an ankle WB-Xrays and an MRI. If a large OCLT is detected ( with one dimension > 1.2mm), then a CT- Scan is performed and if it confirms the size of the lesion, the patient can be recruited for AMIC and bone graft treatment. 
Inclusion criteria for this study were age (15 – 60 y.o), BMI ( < 31) and lesion size (at least one dimension > 1.2 mm on MRI and CT Scan and > 1.0 mm at the arthroscopic measurement).
Treated lesions were either uncontained (12) or contained (4), 12 medial, 4 lateral.

16 subjects (11 males, 4 females, average BMI 24.3) were retrospectively enrolled to complete follow up (AOFAS, SF-12 and VAS; MRI and CT Scan) of 6, 12, 24 and 36 months.
Average pre-op AOFAS, SF-12 and VAS were 57.78, 38.1, 8.3. 
The following scheme was used for AOFAS score: greater than 89 were assessed as excellent, 80-89 as good, 70 to 79 as fair, less than 70 as poor.

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Results:
We reported 12 excellent, 3 good results and 1 failure who required a further arthroscopic debridement ( 6 months minimum follow-up, average: 10.2).
MRI and TAC has shown no mobilization of AMIC membrane.
One patient had a failure, with had an immediate poor post-op recovery, and high ESR and CRP levels. Tests for infections or allergic reactions to suine collagen ( AMIC component) were negative. He improved after its removal.

Conclusion:
The majority of the patients reported good to excellent results for pain and function after 6 months.
MRI and CT scan show acting reparative process.
Limitations of the study include the absence of a control group, retrospective enrollment and lenght of follow-up.
However the study is ongoing and further results are expected.

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