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Matrix-associated stem cell transplantation (MAST) in chondral defects of the ankle is safe and effective
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Abstracts / Foot and Ankle Surgery 23(S1) (2017) 1–28
collagenase with the most commonly used high-dose single injection and to controls. Methods: Forty-five (N = 45) rabbits were randomly divided into three groups (A, B and Control). Animals in Group A (n = 18) underwent three serial low-dose (0.1 mg) injections of bacterial type I collagenase in both Achilles tendons, separated by a two-week interval. Animals in Group B (n = 18) underwent bilateral single high dose injections (0.3 mg). Rabbits in Control Group (n = 9) were injected with three consecutive doses of saline solution. Animals were euthanized after 10, 12 and 16 weeks. Histological findings, using the Bonar tendinopathy score, and biomechanical properties were compared between the groups and inside each the group, in the different time-points of euthanasia. P-values <0.05 were considered significant. Results: After 16 weeks, the Bonar score was significantly increased for both Groups A (11.8 ± 2.28) and B (5.6 ± 2.51), when compared to controls (2 ± 0.76). Group A has also differed from Group B (p < 0.001). Regarding biomechanical findings, groups differed in cross-sectional area of the Achilles tendon (p = 0.003), Young’s modulus (p = 0.024), Yield stress (p = 0.020) and ultimate tensile strength (p = 0.022), with the worst results in animals from Group A. Conclusions: The animal model of Achilles tendinopathy induced by three consecutive injections of 0.1 mg collagenase demonstrated worse histological and biomechanical properties after 16 weeks, demonstrating a more progressive and long lasting tendinopathic findings, reproducing better the disease in humans. http://dx.doi.org/10.1016/j.fas.2017.07.1093 50 IFFAS S10 05 Therapeutic potential of mesenchymal stem cells to treat Achilles tendon injuries M.H. Costa Vieira ∗ , A.C.M.B.A. Silva, R.J. Oliveira, W.S. Fernandes, R. Antoniolli Silva Federal University of Mato Grosso do Sul, Brazil Rupture of the Achilles tendon diminishes quality of life. The gold-standard therapy is a surgical suture, but this presents complications, including wound formation and inflammation. These complications spurred evaluation of the therapeutic potential of mesenchymal stem cells (MSCs) from adipose tissue. New Zealand rabbits were divided into 6 groups (three treatments with two time points each) evaluated at either 14 or 28 days after surgery: cross section of the Achilles tendon (CSAT); CSAT + Suture; and CSAT + MSC. A comparison between all groups at both time points showed a statistically significant increase in capillaries and in the structural organization of collagen in the healed tendon in the CSAT + Suture and CSAT + MSC groups at the 14-day assessment. Comparison between the two time points within the same group showed a statistically significant decrease in the inflammatory process and an increase in the structural organization of collagen in the CSAT and CSAT + MSC groups. A study of the genomic integrity of the cells suggested a linear correlation between an increase of injuries and culture time. Thus, MSC transplantation is a good alternative for treatment of Achilles tendon ruptures because it may be conducted without surgery and tendon suture and, therefore, has no risk of adverse effects resulting from the surgical wound or inflammation caused by non absorbable sutures. Furthermore, this alternative treatment exhibits a better capacity for wound healing and maintaining the original tendon architecture, depending on the
arrangement of the collagen fibers, and has important therapeutic potential. http://dx.doi.org/10.1016/j.fas.2017.07.1094 51 IFFAS S11 01 Anatomic feature of deltoid ligament attachment in posteromedial osteochondral lesion of talar dome T. Nakasa ∗ , M. Sawa, Y. Ikuta, M. Yoshikawa, Y. Tsuyuguchi, N. Adachi Department of Orthopaedic Surgery, Hiroshima University, Japan Introduction: Osteochondral lesions of the talus (OLT) are recognized as being commonly associated with trauma. However, the etiology of OLT remains unclear. In the case of a medial OLT, the deep layer of the deltoid ligament is located close to the medial OLT, and this relationship between a medial OLT and deltoid ligament could be a risk factor for medial OLT. The purpose of this study is to investigate the unique anatomic feature of the deep deltoid attachment to the talus in patients with medial OLT compared with patients with non-medial OLT. Methods: Forty ankles with medial OLT and 40 ankles without medial OLT were retrospectively reviewed in this study. MRI images provided measurements for the attachment of the deep deltoid ligaments to the coronal sections. Also, the continuity of the osteochondral fragment and its bed was evaluated on MRI and arthroscopic findings in medial OLT. Results: Coronal MRI images showed that the attachment of the deep deltoid ligament to the medial OLT was broader and located more proximally than in non-medial OLT. The continuity of fibers from the insertion site of deltoid ligament to the talus to the osteochondral fragment was observed (76.7%). In the arthroscopic findings, the osteochondral fragment was obviously connected to the talus at the medial site in 85.2% of feet. Conclusions: The location of the deep deltoid ligament attachment to the medial OLT was more proximal and its fibers continued to the osteochondral fragment more than in non-medial OLT. http://dx.doi.org/10.1016/j.fas.2017.07.1095 52 IFFAS S11 02 Matrix-associated stem cell transplantation (MAST) in chondral defects of the ankle is safe and effective M. Richter ∗ , S. Zech, S.A. Meissner Department for Foot and Ankle Surgery Nuremberg and Rummelsberg, Germany Background: The aim of the study was to assess the 5-yearfollow-up of matrix-associated stem cell transplantation (MAST) in chondral defects of the ankle. Methods: In a prospective consecutive non-controlled clinical follow-up study, all patients with chondral defect that were treated with MAST from April1 2009 to September 30, 2011 were analyzed. Size and location of the chondral defects and the Visual-AnalogueScale Foot and Ankle (VAS FA) before treatment and at follow-up were analysed. Stem cell-rich blood was harvested from the
Abstracts / Foot and Ankle Surgery 23(S1) (2017) 1–28
ipsilateral pelvic bone marrow and centrifuged (10 min, 1500 RPM). The supernatant was used to impregnate a collagen I/III matrix (Chondro-Gide). The matrix was fixed into the chondral defect with fibrin glue. Results: Sixty-six patients with 69 chondral defects were included in the study. The age of the patients was 35 years on average (range, 12–64 years). VAS FA before surgery was 48.9 on average (range, 16.5–75.9). The defects were located as follows, medial talar shoulder, n = 28; lateral talar shoulder, n = 28 (medial and lateral talar shoulder, n = 3), tibia, n = 3. The defect size was 1.4 cm2 on average (range, 0.6–6 cm2 ). 60 patients (91%) completed 5-year-follow-up. No patient was converted to fusion or total ankle replacement. The VAS FA improved to an average of 78.2 (range, 60.8–100; p = 0.01). Conclusions: MAST led to improved and high validated outcome scores at 5-year-followup. No method related complications were registered. Even though a control group is missing, we conclude that MAST is an effective method mid-term for the treatment of chondral defects of the ankle. http://dx.doi.org/10.1016/j.fas.2017.07.1096 53 IFFAS S11 03 Primary versus secondary osteochondral autograft transplantation in patients with large sized OLTs K.H. Park ∗ , Y.G. Hwang, S.H. Han, J.W. Lee Department of Orthopaedic Surgery, Yonsei University College of Medicine, Seoul, South Korea Purpose: We compared clinical outcomes between patients receiving primary transplantation and patients receiving secondary transplantation after failure of prior marrow stimulation for large sized OLT and investigate prognostic factors affecting clinical failures. Methods: Between 2005 and 2014, 18 patients with large sized OLT (>50 mm2 ) underwent primary OAT as a primary surgery (primary OAT group) and 28 patients with large sized OLT underwent secondary OAT after failure of arthroscopic marrow stimulation (secondary OAT group). Clinical outcomes were assessed using VAS, AOFAS scores, FAOS and re-operation rate. Factors associated with clinical failure were evaluated using bivariate analysis and logistic regression analysis. Survival outcomes were compared using Kaplan–Meier analysis. Results: The mean follow-up time was 6.0 years (range 2.0–10.8) and the mean size of the lesion was 194.9 mm2 (range 151.7–296.3). There was no significant difference in patients’ demographics, preoperative findings, VAS, AOFAS score, FAOS, and re-operation rate. According to bivariate analysis, significant factor associated with clinical failure was not prior marrow stimulation but more than 225 mm2 of lesion size in preoperative MRI. Logistic regression analysis revealed that preoperative AOFAS score was significant predictor of clinical failure. The survival probabilities were not significantly different between primary and secondary OAT groups in Kaplan–Meier plots. Conclusion: Outcomes of secondary OAT were comparable to those of primary OAT in the large sized OLT. Therefore, we suggested that symptomatic patients with large sized OLT could be initially treated by either marrow stimulation or OAT and if failed with marrow stimulation, secondary OAT could be considered. http://dx.doi.org/10.1016/j.fas.2017.07.1097
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54 IFFAS S11 04 Magnetic resonance t1rho mapping of articular cartilage grafts after autologous osteochondral transplantation for osteochondral lesions of the talus: A longitudinal evaluation N. Haraguchi ∗ , K. Ota, T. Ozeki, N. Nishida, T. Yoshida, A. Tsutaya Tokyo Metropolitan Police Hospital, Japan Introduction: We used T1rho imaging to quantitatively monitor changes over time in the biochemical health of grafted cartilage after autologous osteochondral transplantation (AOT) for osteochondral lesions of the talus. Methods: T1rho mapping was performed 1 and 2 years postoperatively in 9 patients treated by AOT for an osteochondral lesion of the talus. T1rho maps were constructed with the use of PRIDE software. Coronal images were analyzed with ImageJ software. The mean T1rho value of full-thickness cartilage at the repair site and that of full-thickness cartilage elsewhere in the same image (control cartilage) were determined. Correlation between the T1rho ratios (grafted-to-control cartilage T1rho values) and clinical outcomes (AOFAS scale) was examined. Results: At 1 year, a significant difference existed between the mean T1rho value of the grafted cartilage (57.0 ± 7.7 ms) and that of the control cartilage (41.8 ± 4.6 ms) (p = 0.0002). At 2 years, the mean T1rho value of the grafted cartilage (49.1 ± 6.4 ms) was significantly lower than that at 1 year (p = 0.006). Moderate negative correlation was found between the T1rho ratio and the 1- and 2year AOFAS scores (r =− 0.60 and r =− 0.50, respectively). Conclusions: Although grafted cartilage appears to degenerate at the repair site during the first year after AOT, the proteoglycan content increases thereafter. The cartilage reparation process after AOT is slower than previously believed, and this has implications for the postoperative rehabilitation protocol and timing of the patient’s return to sports. http://dx.doi.org/10.1016/j.fas.2017.07.1098 55 IFFAS S11 05 Evaluation of reproducibility of the magnetic resonance observation of cartilage repair tissue (MOCART) N. Martinelli, D. Albano, T. Giacalone, A. Bianchi ∗ , G. Romeo, F. Malerba, L. Sconfienza IRCCS Galeazzi, Milan, Italy Introduction: The Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score is a scale used for monitoring cartilage repair surgeries. The aim of this study is to evaluate the applicability and reproducibility of the MOCART score for evaluation of osteochondral lesions of the talus (OLT) repaired using the autologous matrix-induced chondrogenesis (AMIC) technique. Methods: Two radiologists (R1–R2) and two orthopaedic surgeons (O1–O2) independently reviewed 26 MRI scans performed on 13 patients with OLT repaired using the AMIC technique. The MRI scans were performed at 6 and 12 months after treatment. For inter- and intra-observer agreement evaluation for each variable of the MOCART score we used Cohen’s kappa coefficient. Progression of MOCART score between 6 and 12 months evaluation was assessed using the Wilcoxon test.
Abstracts / Foot and Ankle Surgery 23(S1) (2017) 1–28
collagenase with the most commonly used high-dose single injection and to controls. Methods: Forty-five (N = 45) rabbits were randomly divided into three groups (A, B and Control). Animals in Group A (n = 18) underwent three serial low-dose (0.1 mg) injections of bacterial type I collagenase in both Achilles tendons, separated by a two-week interval. Animals in Group B (n = 18) underwent bilateral single high dose injections (0.3 mg). Rabbits in Control Group (n = 9) were injected with three consecutive doses of saline solution. Animals were euthanized after 10, 12 and 16 weeks. Histological findings, using the Bonar tendinopathy score, and biomechanical properties were compared between the groups and inside each the group, in the different time-points of euthanasia. P-values <0.05 were considered significant. Results: After 16 weeks, the Bonar score was significantly increased for both Groups A (11.8 ± 2.28) and B (5.6 ± 2.51), when compared to controls (2 ± 0.76). Group A has also differed from Group B (p < 0.001). Regarding biomechanical findings, groups differed in cross-sectional area of the Achilles tendon (p = 0.003), Young’s modulus (p = 0.024), Yield stress (p = 0.020) and ultimate tensile strength (p = 0.022), with the worst results in animals from Group A. Conclusions: The animal model of Achilles tendinopathy induced by three consecutive injections of 0.1 mg collagenase demonstrated worse histological and biomechanical properties after 16 weeks, demonstrating a more progressive and long lasting tendinopathic findings, reproducing better the disease in humans. http://dx.doi.org/10.1016/j.fas.2017.07.1093 50 IFFAS S10 05 Therapeutic potential of mesenchymal stem cells to treat Achilles tendon injuries M.H. Costa Vieira ∗ , A.C.M.B.A. Silva, R.J. Oliveira, W.S. Fernandes, R. Antoniolli Silva Federal University of Mato Grosso do Sul, Brazil Rupture of the Achilles tendon diminishes quality of life. The gold-standard therapy is a surgical suture, but this presents complications, including wound formation and inflammation. These complications spurred evaluation of the therapeutic potential of mesenchymal stem cells (MSCs) from adipose tissue. New Zealand rabbits were divided into 6 groups (three treatments with two time points each) evaluated at either 14 or 28 days after surgery: cross section of the Achilles tendon (CSAT); CSAT + Suture; and CSAT + MSC. A comparison between all groups at both time points showed a statistically significant increase in capillaries and in the structural organization of collagen in the healed tendon in the CSAT + Suture and CSAT + MSC groups at the 14-day assessment. Comparison between the two time points within the same group showed a statistically significant decrease in the inflammatory process and an increase in the structural organization of collagen in the CSAT and CSAT + MSC groups. A study of the genomic integrity of the cells suggested a linear correlation between an increase of injuries and culture time. Thus, MSC transplantation is a good alternative for treatment of Achilles tendon ruptures because it may be conducted without surgery and tendon suture and, therefore, has no risk of adverse effects resulting from the surgical wound or inflammation caused by non absorbable sutures. Furthermore, this alternative treatment exhibits a better capacity for wound healing and maintaining the original tendon architecture, depending on the
arrangement of the collagen fibers, and has important therapeutic potential. http://dx.doi.org/10.1016/j.fas.2017.07.1094 51 IFFAS S11 01 Anatomic feature of deltoid ligament attachment in posteromedial osteochondral lesion of talar dome T. Nakasa ∗ , M. Sawa, Y. Ikuta, M. Yoshikawa, Y. Tsuyuguchi, N. Adachi Department of Orthopaedic Surgery, Hiroshima University, Japan Introduction: Osteochondral lesions of the talus (OLT) are recognized as being commonly associated with trauma. However, the etiology of OLT remains unclear. In the case of a medial OLT, the deep layer of the deltoid ligament is located close to the medial OLT, and this relationship between a medial OLT and deltoid ligament could be a risk factor for medial OLT. The purpose of this study is to investigate the unique anatomic feature of the deep deltoid attachment to the talus in patients with medial OLT compared with patients with non-medial OLT. Methods: Forty ankles with medial OLT and 40 ankles without medial OLT were retrospectively reviewed in this study. MRI images provided measurements for the attachment of the deep deltoid ligaments to the coronal sections. Also, the continuity of the osteochondral fragment and its bed was evaluated on MRI and arthroscopic findings in medial OLT. Results: Coronal MRI images showed that the attachment of the deep deltoid ligament to the medial OLT was broader and located more proximally than in non-medial OLT. The continuity of fibers from the insertion site of deltoid ligament to the talus to the osteochondral fragment was observed (76.7%). In the arthroscopic findings, the osteochondral fragment was obviously connected to the talus at the medial site in 85.2% of feet. Conclusions: The location of the deep deltoid ligament attachment to the medial OLT was more proximal and its fibers continued to the osteochondral fragment more than in non-medial OLT. http://dx.doi.org/10.1016/j.fas.2017.07.1095 52 IFFAS S11 02 Matrix-associated stem cell transplantation (MAST) in chondral defects of the ankle is safe and effective M. Richter ∗ , S. Zech, S.A. Meissner Department for Foot and Ankle Surgery Nuremberg and Rummelsberg, Germany Background: The aim of the study was to assess the 5-yearfollow-up of matrix-associated stem cell transplantation (MAST) in chondral defects of the ankle. Methods: In a prospective consecutive non-controlled clinical follow-up study, all patients with chondral defect that were treated with MAST from April1 2009 to September 30, 2011 were analyzed. Size and location of the chondral defects and the Visual-AnalogueScale Foot and Ankle (VAS FA) before treatment and at follow-up were analysed. Stem cell-rich blood was harvested from the
Abstracts / Foot and Ankle Surgery 23(S1) (2017) 1–28
ipsilateral pelvic bone marrow and centrifuged (10 min, 1500 RPM). The supernatant was used to impregnate a collagen I/III matrix (Chondro-Gide). The matrix was fixed into the chondral defect with fibrin glue. Results: Sixty-six patients with 69 chondral defects were included in the study. The age of the patients was 35 years on average (range, 12–64 years). VAS FA before surgery was 48.9 on average (range, 16.5–75.9). The defects were located as follows, medial talar shoulder, n = 28; lateral talar shoulder, n = 28 (medial and lateral talar shoulder, n = 3), tibia, n = 3. The defect size was 1.4 cm2 on average (range, 0.6–6 cm2 ). 60 patients (91%) completed 5-year-follow-up. No patient was converted to fusion or total ankle replacement. The VAS FA improved to an average of 78.2 (range, 60.8–100; p = 0.01). Conclusions: MAST led to improved and high validated outcome scores at 5-year-followup. No method related complications were registered. Even though a control group is missing, we conclude that MAST is an effective method mid-term for the treatment of chondral defects of the ankle. http://dx.doi.org/10.1016/j.fas.2017.07.1096 53 IFFAS S11 03 Primary versus secondary osteochondral autograft transplantation in patients with large sized OLTs K.H. Park ∗ , Y.G. Hwang, S.H. Han, J.W. Lee Department of Orthopaedic Surgery, Yonsei University College of Medicine, Seoul, South Korea Purpose: We compared clinical outcomes between patients receiving primary transplantation and patients receiving secondary transplantation after failure of prior marrow stimulation for large sized OLT and investigate prognostic factors affecting clinical failures. Methods: Between 2005 and 2014, 18 patients with large sized OLT (>50 mm2 ) underwent primary OAT as a primary surgery (primary OAT group) and 28 patients with large sized OLT underwent secondary OAT after failure of arthroscopic marrow stimulation (secondary OAT group). Clinical outcomes were assessed using VAS, AOFAS scores, FAOS and re-operation rate. Factors associated with clinical failure were evaluated using bivariate analysis and logistic regression analysis. Survival outcomes were compared using Kaplan–Meier analysis. Results: The mean follow-up time was 6.0 years (range 2.0–10.8) and the mean size of the lesion was 194.9 mm2 (range 151.7–296.3). There was no significant difference in patients’ demographics, preoperative findings, VAS, AOFAS score, FAOS, and re-operation rate. According to bivariate analysis, significant factor associated with clinical failure was not prior marrow stimulation but more than 225 mm2 of lesion size in preoperative MRI. Logistic regression analysis revealed that preoperative AOFAS score was significant predictor of clinical failure. The survival probabilities were not significantly different between primary and secondary OAT groups in Kaplan–Meier plots. Conclusion: Outcomes of secondary OAT were comparable to those of primary OAT in the large sized OLT. Therefore, we suggested that symptomatic patients with large sized OLT could be initially treated by either marrow stimulation or OAT and if failed with marrow stimulation, secondary OAT could be considered. http://dx.doi.org/10.1016/j.fas.2017.07.1097
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54 IFFAS S11 04 Magnetic resonance t1rho mapping of articular cartilage grafts after autologous osteochondral transplantation for osteochondral lesions of the talus: A longitudinal evaluation N. Haraguchi ∗ , K. Ota, T. Ozeki, N. Nishida, T. Yoshida, A. Tsutaya Tokyo Metropolitan Police Hospital, Japan Introduction: We used T1rho imaging to quantitatively monitor changes over time in the biochemical health of grafted cartilage after autologous osteochondral transplantation (AOT) for osteochondral lesions of the talus. Methods: T1rho mapping was performed 1 and 2 years postoperatively in 9 patients treated by AOT for an osteochondral lesion of the talus. T1rho maps were constructed with the use of PRIDE software. Coronal images were analyzed with ImageJ software. The mean T1rho value of full-thickness cartilage at the repair site and that of full-thickness cartilage elsewhere in the same image (control cartilage) were determined. Correlation between the T1rho ratios (grafted-to-control cartilage T1rho values) and clinical outcomes (AOFAS scale) was examined. Results: At 1 year, a significant difference existed between the mean T1rho value of the grafted cartilage (57.0 ± 7.7 ms) and that of the control cartilage (41.8 ± 4.6 ms) (p = 0.0002). At 2 years, the mean T1rho value of the grafted cartilage (49.1 ± 6.4 ms) was significantly lower than that at 1 year (p = 0.006). Moderate negative correlation was found between the T1rho ratio and the 1- and 2year AOFAS scores (r =− 0.60 and r =− 0.50, respectively). Conclusions: Although grafted cartilage appears to degenerate at the repair site during the first year after AOT, the proteoglycan content increases thereafter. The cartilage reparation process after AOT is slower than previously believed, and this has implications for the postoperative rehabilitation protocol and timing of the patient’s return to sports. http://dx.doi.org/10.1016/j.fas.2017.07.1098 55 IFFAS S11 05 Evaluation of reproducibility of the magnetic resonance observation of cartilage repair tissue (MOCART) N. Martinelli, D. Albano, T. Giacalone, A. Bianchi ∗ , G. Romeo, F. Malerba, L. Sconfienza IRCCS Galeazzi, Milan, Italy Introduction: The Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score is a scale used for monitoring cartilage repair surgeries. The aim of this study is to evaluate the applicability and reproducibility of the MOCART score for evaluation of osteochondral lesions of the talus (OLT) repaired using the autologous matrix-induced chondrogenesis (AMIC) technique. Methods: Two radiologists (R1–R2) and two orthopaedic surgeons (O1–O2) independently reviewed 26 MRI scans performed on 13 patients with OLT repaired using the AMIC technique. The MRI scans were performed at 6 and 12 months after treatment. For inter- and intra-observer agreement evaluation for each variable of the MOCART score we used Cohen’s kappa coefficient. Progression of MOCART score between 6 and 12 months evaluation was assessed using the Wilcoxon test.