Dr. Ferkel has really instructed us a lot on what we should be using for the osteochondral lesions of the talus. We talked about it a little bit yesterday, the big sort of debate is what are we going to put into the defect, and are we going to be able to continue to do this arthroscopic? So Rick, your wisdom, please. Okay. So is there a solution? We're going to talk primarily on chronic osteochondral lesions, and I'm going to—this is a very important slide—the factors that influence our choice. Number one is the size. I also put in yellow, yeah, sorry, subchondral cysts. Those are the two things I look at first, and then I look at the location, then I look at the containment and everything else. Now this—we kept referencing this paper for a while, and it's still a very important paper. If you look at the results in 120 ankles that had microfracture, 80 percent failed if the defect was greater than or equal to 150 millimeters squared. That was size was calculated on MRI, and we can talk about that a little later. But that noticed to us that when we see lesions that are bigger, we really have to think about a different way to handle these problems. In Laura Raponi spent some time with me and with John Kennedy, we looked at a number of studies, and we found that really the data suggested that the bone marrow stimulation was best reserved for osteochondral lesions less than 107.4 millimeters squared in area or 10.2 millimeters in diameter. So those are the numbers that we've been using a lot. Those are the numbers that I use when I try to decide if I'm going to do a marrow stimulation or if I'm going to do some type of cartilage transplant procedure. In treatment options, I've added a couple of new things. I'll try to mention them briefly under this slide. But there's a whole bunch of options that we can talk about. We don't have enough time today, but a number of different things. I want to call your attention again to the fact if you're going to do microfracture, you have to use some type of thin type of pick. The same with a drill. I don't do much microfracture anymore. I think because of the subchondral damage, I've gone to more thin wire drilling, and some of that came from this original study in 2011 from Chen that showed drilling six millimeters produced better fill and quality cartilage in a two millimeter. Now you get this crimson dufet effect where you get the bleeding, but the problem is, as we all know, this leads to a fibrocartilages covering. We also know from a study that we did and other people have done, when we looked back in 2008, we published this in the Sports Journal, we had 17 patients that five years earlier we had done the same evaluation, and 17 of those patients had 35% of the results deteriorate one grade. So of the first 50 patients in this group with almost six year follow-up, 17 patients deteriorated one grade, and that was the first study that tipped us off to the fact that results were deteriorating with microfracture. What else can we do to improve microfracture? Well, you can use bone marrow aspirate concentrate. In this nice article, in this nice study by Lisa Fortier, she showed that the microfracture results were superior when they had bone marrow aspirate than without bone marrow aspirate in horses. Also John Kennedy, his group, she looked at bone marrow aspirate concentrate with marrow stimulation, and they found that group one did better than group two. They had improved border repair and better tissue integration. Now this lift, drill, fill, and fix technique, papyrized by Kirchhoff, I think it avoids removing the cartilage at all, you lift it up and then you bone graft it, and then you put it back down, he had a very small group, there are very few patients that I've seen that I've been able to do this technique in, but this is out there and for the right patient you should consider it. Now what about indications for cartilage replacement? Well, any failure of previous marrow stimulating technique, the lesions I've already talked about size-wise, that are uncontained, and if they have a large underlying cyst, such as this one, you know that's not going to do well with marrow stimulation. So here are some of the treatment options for cartilage replacement. I'm going to first talk about this topic technique, it's a little newer technique that Kirchhoff and his group have done. It's a Taylor osteoperiosteografting from the iliac crest, they take a bone graft and they match the curvature of the Taylor dome and they replace it in through an open incision, so it's not arthroscopic, but it is a technique that's out there. Of course John Kennedy and others, Pierce-Granton, showed very good results with Oates, Pierce added the BMAC on 72 patients and they had significantly improved scores in both the FAOS and the FS-12. Now in athletic population, they also showed that on 36 patients, 21 of the professionals and almost six-year follow-up, 91% of their professionals were competing, 87% of the amateurs returned, but they did have donor site pain in 11% of the patients and postoperative cysts in a third. Now allografts are certainly something that's very viable for very large defects and if you look at this, Klikian from Chicago showed in 38 patients with good follow-up for 38 months that they had survival of almost 90%, so this is something that's available as well. Now another thing I've been doing for the last 20 years, originally with ACI and now with matrix-induced MACI for large defects and this is our indications that we started doing these about 22 years ago actually, these were in our original group, all patients had failed previous surgery. We published several papers, the last one in 2014, we were able to get 91% follow-up with 70 months, we found that excellent, 8 and 15 were good, we were able to arthroscope and get a second look in almost all those patients. Now this was a patient that had more of a MACI situation, 37-year-old roller derby competitor, we have a lot of those in California. She had had an open reduction of fixation, she failed the scope and had continued pain with a large cyst. You can see that area there. So we did an open myomial osteotomy, we pre-drilled this with a hook plate in her case, we excised the cyst, then we bone graft the cyst after drilling the bed and then we put a sandwich technique which Dr. Peterson taught me with two membranes, MACI membranes and then reattach it. Now Lenz fairly recently reported on 15 patients using the MACI technique with 13-year follow-up and he had good results as you can see there. But interesting in what we found in ACI and he found also that the MoCART scores do not correlate well with what the clinical studies show. You need to be aware of that when you're trying to evaluate how the patients are doing post-operatively. Now particularly at Juvenile Carriage we have a series of those that we've done using the donors under the age of 13. This is an allograft tissue obviously. These are put in like this, these little menses pieces. You first excise the lesion and then under a dry circumstance you then insert them and then you insert fiber and glue and cover it. Now Karnofsky looked at in 2018, 15 patients half with and half without, half with microfracture and half with the BMAC in this and they show no significant clinical differences. But what they didn't really highlight well was that the Oscondor lesions were significantly larger for the ones that they did the Juvenile Cartilage. So I think even though both showed very good results, I think that the larger lesions did better because they had Juvenile Cartilage. Now we looked at our first 14 and 31-month follow-up and we had 71% that were medial and we had significant improvement in all the scores shown here. More recently, Micronized Cartilage has become more popular. It's an allograft cartilage extracellular matrix and again Lisa Fortier looked at this in horses, microfracture versus the Micronized Cartilage in PRP and again showed that the Micronized Cartilage did better than the microfracture alone with the PRP. Now the problem is there's not a lot of results in Micronized Cartilage. Life-life, however, is five years. It is particularly cheaper than some of the other things I've talked about. More recently, last year, Mark Dracos compared microfracture to the Micronized Cartilage in BMAC and he found that the MOCART scores were higher, they had better infill, better integration and better signal change and a lower rate of revision. We are currently looking at our study. We have over 47 patients. Because of COVID, we've been unable to call them in until this year. We're just starting to call them in now and we've had a number of patients where we had cysts that we bone grafted them prior to doing the Micronized Cartilage. So hopefully next year we'll have those results to report. So overall, we're still working on the key technique to find the solution. We don't have it yet. It must be done arthroscopically and I think in the future we'll continue to improve our treatment of oscillatory lesions but we have a long way to go. Thanks a lot.

osteochondral lesions

treatment options

subchondral cysts

microfracture

cartilage transplant