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HAMIC and Medial malleolar osteotomy for Osteochondral defect of talus, using Chondrotissue by Biofuse

    Overview

    Learn the HAMIC and Medial malleolar osteotomy for Osteochondral defect of talus, using Chondrotissue by Biofuse surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the HAMIC and Medial malleolar osteotomy for Osteochondral defect of talus, using Chondrotissue by Biofuse surgical procedure.
    The ankle is the third most common joint(after the knee and elbow) to be effected by osteochondritis dissecans , its incidence being approximately 0.09%, and most commonly presenting during the second decade of life. Several studies have shown that the majority of such lesions are located in the centro-medial and centro-lateral zones. Medial lesions tended to be deeper and are associated with subchondral changes. The deeper, sometimes cystic nature of the medial talar lesions could be interpreted as lending support the theory that a pathophysiology other than trauma may contribute to the development of these lesions.
    The limited capacity of talar osteochondral lesions to heal is multifactorial. 60% of the talus is covered by cartilage, which itself has poor intrinsic regenerative capacity due to its avascularity. Cartilage relies on nutrition from synovial fluid and from the subchondral bone. The talus also has a poor blood supply which leads to a further diminished ability for talar cartilage to heal after injury. The blood supply to the talus comes from a complex anastomotic network between the peroneal, posterior tibial, and anterior tibial arterial angiosomes. This complex network from multiple vessels results in certain “watershed areas”, with poor blood supply that sit on the margins of such areas, where this limited overlap in the vessels.
    A cadeveric study by Lomax et al 2014, showed relatively poor perfusion in the posteromedial, posterolateral, and mid-medial sections of subchondral bone. Shepherd et al |(1999) found a thickness of 0.7 to 1.2 mm in the ankle compared to 1.5 to 2.6 mm in the knee, which may reduce the ability of the local cartilage to resist shear and impact loads.
    Arthroscopic cartilage repair strategies include bone marrow stimulation by intra-articular drilling, known as microfracture, and also retrograde drilling. Bone marrow stimulation is often used as the first line of treatment after failure of nonoperative measures. The cells and growth factors arising from the bone marrow stimulate repair, leading to the formation of fibrocartilage within the defect. Fibrocartilage is composed primarily of type I collagen rather than the type II collagen which is predominant in the hyaline cartilage that lines synovial joints. Though Type I collagen is biomechanically and structurally inferior to natural hyaline cartilage the technique produces reliable clinical improvement with reduction of pain and increase in function in 65% to 90% of cases.
    There are a variety of relevant prognostic indicators associated with bone marrow stimulation, including patient age, lesion chronicity, size, location and containment, and presence of subchondral cysts or associated joint degeneration. OLT size shows an inverse relationship with outcome after microfracture. Chuckpaiwong et al reviewed 105 arthroscopically treated osteochondral lesions of the ankle and lesion size was strongly correlated with successful outcome. No treatment failures were reported when lesions had an average diameter less than 15 mm, whilst only 3% of patients had a successful outcome with a lesion 15 mm or larger. A further study by Choi et al reported similar findings, with lesions under 15 mm2 based on MRI imaging achieving successful clinical outcomes, and poor results in the over 15mm.
    Microfracture therefore remains the gold standard for lesions measuring less than 15mm2. though even when of this size talar shoulder lesions, cystic lesions and those with associated degenerative changes on tibial and talar surfaces are associated with poorer outcomes.
    The limitations of arthroscopic bone marrow stimulation techniques in treating larger lesions, and as revision for failed treatment has lead to the adoption of other surgical techniques.
    Cartilage regeneration strategies include autologous chondrocyte implantation (ACI), matrix-induced autologous chondrocyte implantation (MACI). These techniques are usually considered after unsuccessful arthroscopic bone marrow stimulation treatment or may be used to treat larger lesions that are thought unlikely to respond to arthroscopic treatment.
    ACI and MACI are 2-stage procedures in which hyaline cartilage is harvested from the anterior talus or the non loading portion of the knee as a the first stage. The cartilage is cultured to expand the chondrocytes population, before the chondrocytes are re-implanted into the osteochondral lesion and kept in place either by sewing a periosteal patch over the defect or using a collagen matrix. The aim being to regenerate new hyaline cartilage that can incorporate and fill the chondral lesion.
    Unlike the ACI(autologous chondrocyte implantation) and MACI(matrix-induced autologous chondrocyte implantation) procedures, which require cartilage harvest during the first procedure and then a second procedure to implant the cells, the HAMIC procedure is a one stage technique. Giannini et al compared 56 patients receiving ACI to 25 patients treated with 1-step AMIC. Their group found no difference in the improvement in outcome scores and reported similar findings on MRI and second-look arthroscopy. Autologous Matrix Induced Chondrogenesis (AMIC) is a technique that utilises a porcine collagen membrane in association with bone marrow stimulation techniques to treat osteochondral lesions.
    The HAMIC is a technique that uses polyglycolic acid (PGA) and hyaluronin scaffold(Chondrotissue®️) to treat osteochondral lesions. This scaffold is actually a membrane which is impregnated with freeze dried high concentration hyaluronic acid. The membrane provides immediate coverage of the osteochondral defect as well as mechanical stability over the surface of the lesion. It is porous and acts as a substrate for stem cells and growth factors produced from bone marrow stimulation to grow into and onto. The addition of hyaluronic acid stimulates chondrogenesis from stem cells and results in type II collagen. The membrane is fully absorbed within 4 months.
    Readers will also find of interest the following OrthOracle techniques:
    Stem cell harvest and transplant for knee osteochondral defect (Synergy Medical technologies)
    Osteochondral grafting of the talus (OATS procedure)

    Indications

    INDICATIONS
    Cartilage regeneration techniques such as HAMIC procedure are indicated in patients who have osteochondral lesions over 15 mm² diameter and also in patients who have failed to improve with arthroscopic bone marrow stimulation procedures alone.
    SYMPTOMS & EXAMINATION
    Patients will often report a history of previous trauma, sometimes this may be a historical injury occurring years before the onset of symptoms. A small proportion of patients, more commonly, the medial osteochondral lesions there is no discernable history of prior trauma to the ankle. Symptoms: Patient may variably report mechanical pain at the level of the ankle joint, crepitus, locking, clicking or swelling. Patients who present with ankle instability and pain may have an associated osteochondral lesions of the talar dome.
    Examination findings are often sparse, occasionally crepitus is felt with ankle movement, but it is not unusual for the examination to be normal.
    These are often lesions that result from weight bearing and inversion injuries, so careful examination needs to be made also of the lateral ligamentous complex, which on occasion will require intercurrent reconstruction.

    IMAGING
    Plain Xrays may show larger defects easily but are far less sensitive than cross sectional imaging for most OCDs.
    MRI scans are sensitive and specific for diagnosis of osteochondral lesions of the talar dome, although they can overestimate, the size of the bony component and subchondral cyst, due to the extensive marrow oedema that can accompany these lesions.
    Hepple et al (1999) proposed a classification system based on MRI; where stage I is articular cartilage injury only; stage II is cartilage injury with bony fracture (subdivided into acute or chronic based on the presence of oedema); stage III consists of a detached, nondisplaced bony fragment; stage IV involves displaced bony fragments with uncovered subchondral bone; and stage V lesions are characterised by subchondral cystic change. Whilst Hepple V lesions are associated with poorer outcomes after arthroscopic debridement, the relationship to prognosis following scaffold treatments such as Chondrotissue is less clear.
    In those patients who might appear to have a reasonably well preserved cartilage cap on MRI, an arthrogram may differentiate the intact cap from those with a cartilage defect in whom the contrast will be seen to track underneath the lesion.
    CT scans and CT arthrogram are more accurate in defining the bony defect and the classification system by Ferkel is frequently used for these.
    Weight bearing CT scans have the advantage of imaging both ankles with lower radiation, which on occasion is of use in the juvenile population where lesions are sometimes bilateral.
    It may be helpful in some lesions to have both MRI and CT scan to optimally plan definitive surgery.
    ALTERNATIVE OPERATIVE TREATMENT.
    Operative treatment is indicated for lesions that remain symptomatic despite 3 to 6 months of nonoperative treatment or for displaced OCL’s.
    Operative treatments can be grouped into 3 main categories: cartilage repair, replacement, and regenerative strategies. Cartilage repair includes arthroscopic debridement and bone marrow stimulation techniques. regenerative strategies including HAMIC, AMIC, ACI and MACI. Cartilage replacement techniques describe autologous osteochondral transplant such as OATS and osteochondral allograft.
    Osteochondral autograft transfer(OATs). These treatments are generally for lesions greater than 1 to 1.5 cm2 that are located in the shoulder or do not have a stable cartilaginous rim. OATS techniques involve replacing osteochondral lesions of the talus with bone and hyaline cartilage, harvested from the patient’s talus or non weightbearing portion of the knee. The benefits of this procedure are that the grafts maintain their type II collagen, thus restoring a more normal cartilage surface to the defect. The disadvantages of this technique are of donor site morbidity, and technical difficulties in attaining an articular surface that is incongruous with the surrounding articular cartilage, this is especially challenging on shoulder lesions.

    NON-OPERATIVE MANAGEMENT
    Many patients will respond well to nonoperative treatment. Non operative management includes physiotherapy, which can help strengthen the limb and address any proprioceptive deficits. Activity modification, reducing the amount of high impact activity, can be useful in reducing symptoms. supportive , cushioned shoes and analgesia can also be helpful. Surgery should only be considered in those who had significantly intrusive symptoms or who have evidence of enlargement of subchondral cysts associated with the lesion.
    CONTRAINDICATIONS
    Relative contraindications include age over 60, significant comorbidities such as diabetes, peripheral vascular disease, inflammatory arthropathy, significant osteoarthritis of the joint with changes on both the tibial and talar surfaces, active infection, severe venous insufficiency or active ulceration, or avascular necrosis of the talus.

    Setup

    The procedure can be performed under a general anaesthetic or regional anaesthesia. A popliteal block is administered prior to the procedure, to assist post-operative pain management.
    The patient is positioned supine on the table. A thigh tourniquet is applied over adequate padding, and a sealed waterproof tape placed over this to prevent the cleaning prep collecting underneath the tourniquet.
    A sandbag is placed underneath the ipsilateral buttock if the foot is externally rotated. It helps if the foot is pointing vertically upwards so that the second metatarsal is pointing to the ceiling, make sure that the leg can externally rotate enough to allow access to the medial malleolus. This positioning makes it really easy to acquire an intra-operative mortise view of the ankle which helps plan the plane of the medial malleolar osteotomy.

    Operation – 1

    Sagittal MRI showing well localised talar OCD, with associated marrow oedema suggesting an active lesion, and irregular chondral cover to the defect. A relatively shallow defect.

    Anterolateral location of the defect confirmed on axial sequences.
    This image is from a lateral OCD, not the operative case illustrated.

    Less oedema visible on the coronal view, and clear disruption of the chondral surface.
    This image is from a lateral OCD, not the operative case illustrated.

    The incision is marked out over the medial malleolus curving slightly distally as it passes over the tip of the medial malleolus and extending 10 cm proximally.The longitudinal incision is placed equi-distant between the anterior border and posterior border of the tibia, which give optimal exposure to the medial malleolus and access to the protect the anterior and posterior structures.

    The skin incision is made longitudinally along the pre-planned mark over the medial malleolus; the incision is developed through the subcutaneous tissue.Care must be taken as the saphenous vein and the saphenous nerve and its anterior and posterior distal branches lie immediately below the incision. The saphenous nerve divides 3 cm above the tip of the medial malleolus.

    Once the incision is taken down to the periosteal layer of the medial malleolus the dissection is continued anteriorly and posteriorly.It is important that the saphenous nerve and vein are carefully retracted by the assistant and branches may need to be ligated or diathermied as appropriate. The dissection is continued onto the anterior border of the tibia in line with the anterior border of the medial malleolus and its junction with the plafond.

    Posteriorly the sheath of the tibialis posteriorly tendon should be exposed and identified, and distally the superficial deltoid should be exposed.The deltoid ligament will act as the distal soft tissue hinge upon which the osteotomised medial malleolus will be reflected to allow access to the joint.

    The sheath of the tibialis posteriorly tendon is now opened longitudinally, and the tibialis posterior tendon is exposed and should be retracted posteriorly and protected.A McDonald retractor can be passed deep to the sheath to prevent iatrogenic injury to the tendon. The sheath is released distally and a small cuff of periosteum is left anteriorly to aid repair of the sheath, after the osteotomy has been fixed.

    The tibialis posterior tendon is exposed and should be retracted posteriorly and protected.
    The tendon is at risk of iatrogenic injury when the osteotomy is being made and during the folding down of the medial malleolar osteotomy on the dital deltoid flap.

    An anterior to posterior intra-articular blunt K-wire is passed through the shoulder of the ankle mortise.K wires are helpful in planning the medial malleolar osteotomy. With the ankle aligned in as a mortise view to the image intensifier a blunt wire demarcates the desired exit point of the osteotomy, a second wire passed in the same plane, proximally in the metaphysis and is used to map the proximal plane of the medial malleolar osteotomy.
    The image intensifier is then used to predetermine the entry points of transverse fixation screws which will be predrilled.

    The metaphyseal K-wire is passed, the direction of this wire will determine the plane of the osteotomy in the sagittal plane.The K wire is passed in the sagittal plane parallel to the plafond wire passing along the shoulder of the plafond all the way from anterior to posterior in this plane. Ensure that the wire does not deviate into the midline hence into the superior weight bearing aspect of the plafond, in other words, the osteotomy should not exit more centrally as it is completed posteriorly.
    I prefer a stepped osteotomy, with a relatively vertical proximal limb as opposed to an oblique osteotomy, as it provides better access to the talar dome, it is a reasonably stable osteotomy when reduced with a large cancellous surface area which aids union.

    Using a surgical marker, the osteotomy plane is plotted along the medial malleolus with a transverse line at the proximal extent of the osteotomy.The proximal margin is the diaphyseal-metaphyseal junction, which allows adequate exposure to the talus once the medial malleolus has been reflected distally, and avoids creating a stress riser in the thicker disphyseal cortical bone.

    With the marker pen, a longitudinal line is drawn from the proximal extent of the osteotomy down to the shoulder of the ankle mortise.The line passes through the K-wire which was placed under image intensification guidance during the previous step.

    The periosteum is incised and on the superior and anterior margins of the medial tibia and a small amount of Periosteum is reflected.Reflection of the periosteum like this, allows a channel of access for the saw and will allow repair of the periosteum over the osteotomy site at the end of the procedure.

    Prior to performing the osteotomy the holes for the three fixation screws are pre-drilled.The screws are arranged a triangular pattern with the distal screw passing superior to the articular surface and the two proximal screws a centimetre or so above this, The screws are passed just shy of the lateral cortex of the tibial metaphysis.

    The transfixion screws should be parallel and spaced evenly and care should be taken to avoid breaking out of the margins of the osteotomy anteriorly, posteriorly and superiorly . The spacing allows a broad compression over the osteotomy site.

    The medial malleolar osteotomy is performed using a high speed fine saw.It is important that a Homans retractor is placed anteriorly to protect the saphenous nerve and vein and posteriorly deep to the tibialis posterior tendon to protect the tendon and the neurovascular bundle. The transverse limb of the osteotomy is then performed first.

    The anterior, or sagittal limb of the osteotomy is performed along the line of the pre-inserted K wires.The osteotomy is developed, using well-controlled probing movements of the saw. It is important that the saw does not breach the articular surface distally. The saw is passed bi-cortically through the anterior then the posterior cortex. The distal part of the osteotomy, should not extend into the ankle joint, a few millimetres of subchondral bone above the ankle should be left Intact.
    Again it is important to protect the tibialis posterior and the neurovascular bundle with a Homan retractor as these are at risk as the saw passes out of the posterior cortex

    The proximal limb of the osteotomy is completed with an osteotome.

    Finally the sagittal limb of the osteotomy is completed using an osteotome.Any remaining bone bridges in the anterior and posterior cuts are gently teased apart, the osteotome should not breach the tibial plafond and as the malleolus becomes freer, the osteotome is gently worked to lever the osteotomy with some patience and care. The aim is that the articular surface will fissure in the plane of the osteotomy. This insures that the talus is not damaged and the slightly irregular breach of the plafond helps in the reduction of the osteotomy at the end of the procedure as the surfaces interdigitate.

    The medial malleolus is now carefully reflected distally ensuring that the articular surface and osteotomy has been completed.At this stage further progressive soft tissue release is often required in order to free the malleolus up sufficiently to allow it to fold down and provide adequate exposure of the dome of the talus.

    The foot is positioned hanging free over the end of a bolster with the assistant plantar flexing and everting the ankle, following the osteotomy, which allows good exposure of the osteotomy.It is important that the anterior, posterior and lateral extent of the osteochondral lesion are visible and accessible.
    If visibility is sub-optimal, a Hintermann distractor with wires placed between the tibial metaphysis and the medial talus, close to the deep deltoid insertion, will allow further distraction and improved access .

    Once adequate exposure has been achieved, the osteochondral lesion is inspected.
    The lesion is inspected visually and carefully palpated with a blunt probe, noting exposed bone, unstable cartilage and bone, irregular or soft cartilage and identifying the margins of normal articular hyaline cartilage.

    The osteochondral lesion is excised once the margins have been confidently identified.The lesion is initially circumfrentiated using a scalpel to provide a clearly demarcated base with a rim of normal articular cartilage. This is best done sequentially, piecemeal in order to avoid removing any normal articular cartilage at the margins.

    The base of the osteochondral lesion is prepared to expose a stable bleeding base, initially using a curette.The aim is to produce a healthy bleeding base and regular edges of the osteochondral lesion, forming a ‘punched out’ lesion where the edges of the defect are the same depth to the centre of the defect. This will ensure that the chondrotissue is seated At the level of the articular surface evenly throughout and does not become elevated at the circumference.

    Operation – 2

    The margins of the osteochondral lesion is prepared with a high speed burr.The burr is very effective at creating an even depth of the defect from anterior to posteriorly and medial to lateral. The burr should be irrigated to avoid thermal damage to the interface of the bone here.

    The base of the lesion is finally prepared using a fine K-wire on a wire driver with irrigation to avoid thermal injury.The K wire is drilled at least 5 mm deep to the surface in order to breach the subchondral plate. the microfracture holes should be 3 to 5 mm apart and spread evenly over the base of the lesion. alternatives to drilling are microfracture or nanofracture.

    Bone graft is harvested from the exposed tibial metaphysis.Shallower lesions may not require grafting, however deeper or cystic lesions (Hepple 5) will require bone grafting to the base of the lesion. In this case a small amount is needed which is harvested the use of a small sharp currette (1), in bigger defects I tend to use a bone trephine passed in to the metaphyseal bone.

    Cancellous bone graft is packed into the base of the lesion and impacted with a punch.Sufficient graft is placed into the defect until it is almost flush with the surrounding articular cartilage.

    Bone graft impaction into the osteochondral lesion using a punch.
    The graft is impacted until the surface is 2mm recessed below the level of the surrounding articular surface (depth of the chondrotissue).
    The aim is to provide an even base on which to lay the Chondrotissue graft so that it lies seamlessly in parallel to the surface of the rest of the articular surface, over the entire surface area of the lesion.

    A surgical marker pen is used to demarcate the articular cartilage at the margin of the lesion in order to size the chondrotissue implant.

    The margins of the osteochondral lesion can be seen clearly marked here with the surgical marker pen.

    A slightly oversized chondrotissue implant is presented to the lesion to assess size and pressed firmly to the margins, then trimmed to sizeThe chondrotissue picks up the pre-marked ink from the surgical pen.

    The chondrotissue implant is trimmed to the appropriate size.
    The ink that’s been deposited on the graft is used to trim the chondrotissue implant to the exact size of the lesion.

    The Chondrotissue continues to be presented to the lesion and finely trimmed until a perfect fit is achieved. The level of the graft should be equal throughout the leson and should not be elevated at the sides. If the graft does not sit evenly throughout the margins of the lesion can be excavated a little further before the graft is re-applied.

    The chondrotissue graft is soaked in a small amount of saline or serum.soaking the chondrotissue improves the handling properties of the implant, making it more pliant and allows it to be seated within the lesion more easily.

    The graft can be seen seated evenly within the osteochondral lesion flush with the surrounding articular cartilage.

    Fixation of the chondrotissue graft is achieved with fibrinogen glue (tisseel) which is infiltrated evenly around the margins of the lesion.The graft may also be sutured or fixed with fine PDS pins, We prefer fibrinogen glue as this does not leave a potentially abrasive foreign body around the lesion and graft. exposure of the lateral aspect of the lesion is often poor making suturing challenging.
    Wait at least three minutes for the fibrinogen glue to set the joint is then gently washed out prior to fixation of the osteotomy.

    The medial malleolus is reduced and a depth gauge or a K wire can be used to align the pre-drilled screw holes before fixation.The depth gauge is then used to measure the length of the screws and should be measured just shy of the lateral cortex of the tibia. Care should be taken to ensure that the osteotomy is reduced at the level of the plafond, the anterior joint can be directly visualised anteriorly, and that the tibialis posterior tendon is not entrapped in the osteotomy site when it is reduced.

    Partially threaded 4 mm cannulated screws are passed through the pre-drilled holes.I tend to pass all three screws partially in and then sequentially tighten these to provide a good even compression across the osteotomy site.
    Screw passage should be checked on the image intensifier to ensure correct alignment and adequate clearance from the joint.

    Once fixation has been achieved the osteotomies site should be carefully inspected to ensure this has been reduced both visually and on the image intensifier.

    The sheath of the tibialis posterior tendon is repaired.the sheath is sutured to a cuff of posterior tibial periosteom and the reflected periosteum over the osteotomy site is sutured with an absorbable suture.

    The wound is then closed in layers, starting with the deep fascia using an absorbable suture.

    The skin is closed with an interrupted non absorbable monofilament suture.

    The wounds are dressed with a sterile dry dressing.

    A below knee back slab is applied with the ankle in a plantigrade position.The ankle is held in position until the plaster slab has set.

    Post Operative

    High elevation for five days.
    Regular analgesia
    Popliteal block
    Mobilise non-weight-bearing six weeks
    Thromboembolic prophylaxis

    A check x-ray is performed at 6 weeks to assess union of the malleolar osteotomy.
    If union is achieved, the plaster is removed, patients are allowed to weight bear. Often a pneumatic boot is helpful in allowing the patient to remain active whilst managing swelling and inflammation during this transition period
    At six weeks the patient should see the physiotherapist, working on range of movement and gentle closed chain exercises.
    I advise that running / impact activity should be avoided for a minimum of 6 months.

    Recommended Reading

    Eugenio Boux et al Clin Orthop Relat Res 2012 reported the results of “A cell free scaffold-based cartilage repair provides improved function and Hyaline-like repair at one year” using the Hamic procedure in the knees of 52 patients the scaffold was inserted arthroscopically, with significant improvement in patients functional scores
    They produced a follow up study in 2014 published in the open journal of orthopaedics, although there appears to be sustained improvement in patients functional scores, and MRI scans showing good coverage of the lesion. although it is not clear how may patients were lost to follow up.
    Gigante’s group published a series of 9 patients titled “single stage cartilage repair in the knee with microfracture covered with a resorbable polymer based matrix and autologous bone marrow” in the Knee Dec 2013. Patients reported significant improvement in pain and functional scores. MRI scans that showed filling of the defect. 5 patients consented to re arthroscopy the findings were of one normal appearing joint, three nearly normal and one abnormal. The biopsied lesions showed hyaline like cartilage. They concluded that the procedure was effective in treating pain and producing hyaline like cartilage.
    Ulanay Kanath reported a retrospective series of 40 patients in Arthroscopy in 2017 titled “Single step arthroscopic repair with cell free polymer based scaffold in osteochondral lesions of the talus: Clinical and radiological results”. The procedure was performed arthroscopically, 84.4% of patients reported good or excellent results. Interestingly there was no correlation between the MRI based scoring system (MOCART) and the AOFAS scores, however there was correlation with the defect filling and functional scores. They reported this was a simple safe and effective treatment for osteochondral lesions of the talar dome.
    They produced a follow up study in 2014 published in the open journal of orthopaedics, although there appears to be sustained improvement in patients functional scores, and MRI scans showing good coverage of the lesion. although it is not clear how may patients were lost to follow up.
    Gigante’s group published a series of 9 patients titled “single stage cartilage repair in the knee with microfracture covered with a resorbable polymer based matrix and autologous bone marrow” in the Knee Dec 2013. Patients reported significant improvement in pain and functional scores. MRI scans that showed filling of the defect. 5 patients consented to re arthroscopy the findings were of one normal appearing joint, three nearly normal and one abnormal. The biopsied lesions showed hyaline like cartilage. They concluded that the procedure was effective in treating pain and producing hyaline like cartilage.
    Ulanay Kanath reported a retrospective series of 40 patients in Arthroscopy in 2017 titled “Single step arthroscopic repair with cell free polymer based scaffold in osteochondral lesions of the talus: Clinical and radiological results”. The procedure was performed arthroscopically, 84.4% of patients reported good or excellent results. Interestingly there was no correlation between the MRI based scoring system (MOCART) and the AOFAS scores, however there was correlation with the defect filling and functional scores. They reported this was a simple safe and effective treatment for osteochondral lesions of the talar dome.
    Glasbrenner et al published in Orthop J Sports Med 2020 a study titled “Matrix-augmented bone marrow stimulation with a polyglycolic acid membrane with hyaluronan vs microfracture in local cartilage defects of thefemoral condyles: A multicentre randomized controlled trial” showed improvement in pain, functional scores and defect filling on MRI scan following chondrotissue repair at 54 weeks and 108 weeks but failed to show a difference between this and microfracture in the knee.

    Becher reported a small series of 5 patients with 21 months follow up osteochondral lesions of the retropatellar articular surface with chondrotissue with 2 excellent, 2 good and 1 fair outcome, positive MRI findings and defect filling in Arch Orthop Trauma surg 2015.
    Walther, Richter et al published in Foot and ankle surgery 2020 “Is there clinical evidence to support autologous matrix-induced chondrogenesis (AMIC) for chondral lesions of the talus? A systematic review and meta-analysis”
    They included 12 studies with 323 patients, reported significant improvements in patients pain and functional scores. They found that only 1% of patients required further surgery. There were no reported adverse effects related to AMIC in any of the studies. The resolution of pain and improved function seem to be maintained over time as there seemed to be no reports of deterioration in the 5 year studies. No significant difference in outcomes were seen between groups who underwent the procedure arthroscopically or via a medial malleolar osteotomy. They advocate use of AMIC in lesions over 1cm as a one stage procedure.

    Becher reported a small series of 5 patients with 21 months follow up osteochondral lesions of the retropatellar articular surface with chondrotissue with 2 excellent, 2 good and 1 fair outcome, positive MRI findings and defect filling in Arch Orthop Trauma surg 2015.
    Walther, Richter et al published in Foot and ankle surgery 2020 “Is there clinical evidence to support autologous matrix-induced chondrogenesis (AMIC) for chondral lesions of the talus? A systematic review and meta-analysis”
    They included 12 studies with 323 patients, reported significant improvements in patients pain and functional scores. They found that only 1% of patients required further surgery. There were no reported adverse effects related to AMIC in any of the studies. The resolution of pain and improved function seem to be maintained over time as there seemed to be no reports of deterioration in the 5 year studies. No significant difference in outcomes were seen between groups who underwent the procedure arthroscopically or via a medial malleolar osteotomy. They advocate use of AMIC in lesions over 1cm as a one stage procedure.

    Reference

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