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The role of bone marrow edema on osteochondral lesions of the talus
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The role of bone marrow edema on osteochondral lesions of the talus Riccardo D’Ambrosi, M.D.a,b,* , Camilla Maccario, M.D.a,b , Chiara Ursino, M.D.c , Nicola Serra, Ph.D.d, Federico Giuseppe Usuelli, M.D.b a
Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Milan, Italy Istituto Ortopedico Galeazzi, U.O. C.A.S.C.O. — Piede e Caviglia, Milan, Italy Università Vita-Salute San Raffaele, Milan, Italy d Seconda Università degli Studi di Napoli, Naples, Italy b c
A R T I C L E I N F O
A B S T R A C T
Article history: Received 7 October 2016 Received in revised form 13 January 2017 Accepted 7 February 2017 Available online xxx
Background: To assess the functional and radiological outcomes after arthroscopic talus autologous matrix-induced chondrogenesis (AT-AMIC1) in 2 groups: patients with and without bone marrow edema (BME). Methods: Thirty-seven patients of which 24 without edema (GNE) and 13 with edema (GE) were evaluated. All patients were treated with AT-AMIC1 repair for symptomatic osteochondral talar lesion. Clinical and radiological parameters were evaluated with VAS score for pain, AOFAS and SF-12 at T0 (preoperatively), T1 (6 months), T2 (12 months), T3 (24 months) and MRI and CT-scan at T0, T1, T2 and T3. Results: No patients were lost to the final follow-up. In both groups we found a significant difference for clinical and radiological parameters with ANOVA for repeated measures through four time points (p < 0.001). In GNE, AOFAS improved significantly at each follow-up (p < 0.05); while CT and MRI showed a significant reduction in lesion size between T1 and T2 and T2 and T3 (p < 0.05). In GE, AOFAS improved significantly between T0 and T1 and T2 and T3 (p < 0.05); lesion size, measured with CT, decreased between T1 and T2 (p < 0.05), while with MRI the lesion showed a reduction at each follow-up (p < 0.05). Lesion size was significantly higher both in MRI and CT in GE compared to GNE (p < 0.05). In GNE no patients presented edema at T3, while in GE only 23.08% of the patients presented edema at T3. Conclusions: The study revealed that osteochondral lesions of the talus were characterized by bigger size both in MRI and CT in patients with edema. We conclude that AT-AMIC1 can be considered a safe and reliable procedure that allows effective healing, regardless of edema and more than half of patients did not present edema six months after surgery. © 2017 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Keywords: Osteochondral talar lesions Autologous matrix-induced chondrogenesis Bone marrow edema Ankle arthroscopy
1. Introduction Bone marrow edema (BME) is a unique imaging characteristic of osteochondral lesion of the talus (OCLTs) identified on MRI surrounding the lesion [1,2]. The clinical and anatomopathological significance of BME is not yet clear, in fact BME identify a wide number of clinical entities, which are all characterized by the same magnetic resonance imaging (MRI) pattern and often by pain as their main symptom, but show significant differences in terms of histopathologic pictures, causal mechanisms and prognosis [3]. Radiologically BME is characterized as an area of different signal on MRI of the bone, showing an intermediate or low signal intensity
* Corresponding author at: Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Milan, Italy/Istituto Ortopedico Galeazzi, U.O. C.A.S. C.O. — Piede e Caviglia, Milan, Italy. E-mail address: [email protected] (R. D’Ambrosi).
on T1 weighted images and a high signal intensity on fatsuppressed, T2 weighted, and short tau inversion recovery sequences in comparison with the normal bone marrow [3]. Moreover BME is often associated with an increased local uptake of the tracer on the bone scan. The real meaning of BME from the histopathological point of view is still unclear. The altered signal pattern observed on MRI is probably related to a replacement of normal fatty bone marrow by a more water-rich material [4]. However, it is still unclear how the development and resolution of edema correlate with its intensity and extent of involvement within the talus in particular in surgical procedure [5,6]. Independent prognostic factors such as age, size of the lesion, high body mass index, history of trauma and presence of osteophytes have been shown by some authors to negatively affect the outcome of OCLT repair [6–11]; however, there is currently no general consensus on the prediction of therapeutic success among the various OCLT treatment possibilities, although
http://dx.doi.org/10.1016/j.fas.2017.02.010 1268-7731/© 2017 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: R. D’Ambrosi, et al., The role of bone marrow edema on osteochondral lesions of the talus, Foot Ankle Surg (2017), http://dx.doi.org/10.1016/j.fas.2017.02.010
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absence of edema is considered to be an advantage in the healing of these lesions [10,12,13]. Cuttica reported that patients with low edema intensity showed significantly better outcomes after microfracture and drilling [12]. The purpose of our study was to assess and evaluate healing and the functional outcome after ATAMIC1 (arthroscopic talus autologous matrix-induced chondrogenesis) in 2 groups: patients with and without BME.
measurements were made using the standard tools of the institution’s Picture Archiving and Communication System (PACS). The reading of all MRI and CT-scans was blinded and was performed by two orthopaedic surgeons not involved in the surgical procedure.
2. Material & methods
The statistical analysis was performed by Matlab statistical toolbox version 2008 (MathWorks, Natick, MA, USA) for Windows at 32 bit, on a sample of 37 patients, 40.54% females and 59.46% males, with ages at operation into range 14–61, with mean around 34 years old and standard deviation (SD) around 12 years old multi-comparison tests were performed with ANOVA test for repeated measures into groups (Total group, GNE group, GE group) and the Bonferroni correction of p-value was used in pairwise comparison into groups, ANOVA one way was used to test the difference between the means of GNE group and GE group, and Student’s t-test was used to test the difference between the means into group and evaluation significant trend. Finally univariate linear correlation analysis was performed and Pearson’s linear correlation coefficient R were evaluated and the correspondent pvalues were computed with T-Student test, under null hypothesis of Pearson’s linear correlation coefficient R = 0. All statistical tests with p-value < 0.05 were considered as significant and all results were expressed as mean standard deviation (SD). For simplicity we denoted with T0 = pre-operation control point, T1 = six months post-operation, T2 = six months post-operation and T3 = twenty four months post-operation.
This is a retro-prospective study of 37 arthroscopic cartilage reconstructions for OCLTs performed between January 2012 and September 2014 in one center specialized in foot and ankle surgery. The inclusion criteria for the case series were: osteochondral lesion of the talus Types III and IV according to Berndt and Harty’s classification [14], skeletal maturity and ability to give informed consent. Exclusion criteria were: concomitant surgical procedures, previous surgical treatment of the affected ankle, arthritis of the ankle joint, kissing lesions, haemophilia, rheumatoid arthritis, severe metabolic disorders, autoimmune disease, ongoing chemotherapy, radiation treatment or immunosuppression, pregnancy or lactation. Patients satisfying the inclusion and exclusion criteria were divided into two groups: patients with bone marrow edema (GE) on T1 weighted images and a high signal intensity on fatsuppressed, T2 weighted, and with a difference greater than 40 mm2 between the pre-operative CT-scan and the pre-operative MRI and patients without edema and with a value less than 40 mm2 between pre-operative MRI and CT were assigned to the non-edema group (GNE). All subjects gave their written informed consent to participate in the study, which was approved by the Institutional Review Board. The surgical procedures were all performed by the senior author. All surgical interventions were performed using the ATAMIC1 technique previously described [15,16]. Briefly, surgery was characterized by two arthroscopic phases. First, after having achieved an adequate exposure through the use of a HintermannTM spreader (Integra LifeSciences, Plainsboro, NJ) that allowed for sufficient joint distraction, the lesion was debrided and prepared to receive the regenerative treatment. Cancellous bone was harvested from the ipsilateral calcaneus with an accessory lateral approach on the calcaneus wall. The cancellous bone was introduced using the same cannula and impacted into the bony defect until complete fill was achieved. The second surgical step was performed in a dry condition, during which Chondro-Gide1 (Geistlich Surgery, Wolhusen, Switzerland), a porcine collagen type I/III matrix, was placed and fixed with synthetic fibrin glue (Tisseel1, Baxter, Baxter, USA) along the lesion edges. The HintermannTM spreader was then removed and matrix stability within a normal ankle range of motion was verified. All clinical assessments were performed by a clinician who was blinded to the type of surgery. Each patient was evaluated preoperatively (T0), as well as at 6 (T1), 12 (T2), and 24 (T3) months. The evaluation included clinical and quality of life parameters. Clinical evaluation consisted of subjective global pain assessment by the VAS pain score, while the intensity of pain, walking capacity, and activities of daily life were assessed by the AOFAS score and SF-12 in its Physical (PCS) and Mental component score (MCS) [17–19]. MRI and CT-scan evaluations were also performed at T0, T1, T2, and T3. The area of the lesions was defined and measured for each patient on the MRI and CT-scan according to Choi et al. [7] using coronal length (horizontal extension measured from the coronal image), sagittal length (horizontal extension measured from the sagittal image), depth (vertical extension measured from the sagittal image) and area (calculated with the ellipse formula as coronal length sagittal length 0.79). All imaging
3. Statistical analysis
4. Results Of 42 patients screened for eligibility, 37 satisfied the inclusion and exclusion criteria and were enrolled in the study. Of the 5 excluded patients, 3 had already been subjected to interventions to the affected ankle, 2 patients had severe post-traumatic osteoarthritis of the ankle. Each patient, in both groups was evaluated clinically and radiologically at T0, T1, T2, and T3. Patients satisfying the inclusion and exclusion criteria were divided into two groups. The sample of 37 patients was composed of 15 (40.54%) females and 22 (59.46%) males with ages at operation into range 14–61, with mean around 34 years old (SD 12). The GNE was composed of 24 patients, of which 10 (41.67%) were females and 14 (58.33%) males, mean age at surgery was 31 years old (range: 16–55, SD 10). The GE was composed of 13 patients, of which 5 (38.46%) were females and 8 (61.54%) males, mean age at surgery was 38 years old (range: 14–61, SD 15). In GNE 8 lesions were centromedial, 7 posteromedial, 5 centrolateral, 2 anteromedial, 1 posterolateral and 1 centrocentral. In GE lesions were divided as follows: 8 centromedial, 3 centrolateral and 2 posteromedial. No patients were lost to the final follow-up of 24 months. 4.1. Clinical evaluation In both groups we found a significant difference for AOFAS, VAS, PCS and MCS with ANOVA for repeated measures through four time points (p < 0.001). In particular in the GNE, AOFAS improved significantly at each follow-up (T0 vs T1: p = 0.0016; T1 vs T2: p = 0.0021, T2 vs T3: p = 0.0168), VAS improved significantly between T0 and T1 (p < 0.0001) and between T1 and T2 (p = 0.0039), while PCS and MCS improved significantly only between T0 and T1 (p < 0.0001). In GE we noted a significant improvement for AOFAS only between T0 and T1 (p = 0.0017) and between T2 and T3 (p = 0.0092), VAS improved significantly between T0 and T1 (p = 0.0035) and
Please cite this article in press as: R. D’Ambrosi, et al., The role of bone marrow edema on osteochondral lesions of the talus, Foot Ankle Surg (2017), http://dx.doi.org/10.1016/j.fas.2017.02.010
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Table 1 Clinical parameter scores for all the patients, GNE and GE respectively at T0,T1, T2 and T3. Multi-comparison tests were performed with ANOVA test for repeated measures into groups and the Bonferroni correction of p-value was used in pairwise comparison into groups between two consecutive control points. The measures were indicated as mean SD. Total group Parameters
T0
T1
T2
T3
p-Value
AOFAS
51.97 15.28
73.30 15.57
83.62 13.57
89.32 10.16
VAS
7.89 1.33
4.46 2.40
3.00 1.89
1.84 1.44
PCS
30.88 5.44
44.64 8.81
49.19 7.07
51.19 6.38
MCS
42.50 4.59
52.91 5.23
51.60 5.17
53.86 6.00
<0.001 (ANOVA test*) T0 vs T1:<0.0001 (B* ) T1 vs T2: 0.0005 (B* ) T2 vs T3: 0.0001 (B* ) <0.001 (ANOVA test*) T0 vs T1:<0.0001 (B* ) T1 vs T2: 0.095 (B) T2 vs T3: 0.0145 (B* ) <0.001 (ANOVA test*) T0 vs T1:<0.0001 (B* ) T1 vs T2: 0.0911 (B) T2 vs T3: 0.256 (B) <0.001 (ANOVA test*) T0 vs T1:<0.0001 (B* ) T1 vs T2: 1.00 (B) T2 vs T3: 0.252 (B)
Group 1: GNE AOFAS
52.46 15.49
72.42 16.11
84.87 14.37
89.96 9.62
VAS
7.92 1.35
4.50 2.31
2.50 1.80
2.00 1.44
PCS
31.34 4.94
43.45 8.39
49.95 7.68
52.77 5.34
MCS
42.91 4.46
53.89 5.10
51.78 4.95
54.07 6.20
Group 2: GE AOFAS
51.08 14.91
74.92 14.37
81.31 11.56
88.15 11.0
VAS
7.85 1.29
4.38 2.56
3.92 1.68
1.54 1.39
PCS
30.03 6.16
46.82 9.15
47.77 8.30
48.29 7.09
MCS
41.75 4.72
51.10 4.97
51.25 5.54
53.48 5.59
<0.001 (ANOVA test*) T0 vs T1: 0.0016 (B*) T1 vs T2: 0.0021 (B*) T2 vs T3: 0.0168 (B* ) <0.001 (ANOVA test*) T0 vs T1:<0.0001 (B* ) T1 vs T2: 0.0039 (B*) T2 vs T3: 1.00 (B) <0.001 (ANOVA test*) T0 vs T1:<0.0001 (B* ) T1 vs T2: 0.0789 (B) T2 vs T3: 0.247 (B) <0.001 (ANOVA test*) T0 vs T1:<0.0001 (B* ) T1 vs T2: 0.519 (B) T2 vs T3: 0.665 (B) <0.001 (ANOVA test*) T0 vs T1: 0.0017 (B*) T1 vs T2: 0.585 (B) T2 vs T3: 0.0092 (B*) <0.001 (ANOVA test*) T0 vs T1: 0.0035 (B* ) T1 vs T2: 1.00 (B) T2 vs T3: 0.0022 (B*) <0.001 (ANOVA test*) T0 vs T1: 0.0005 (B*) T1 vs T2: 1.00 (B) T2 vs T3: 1.00 (B) <0.001 (ANOVA test*) T0 vs T1: 0.0020 (B* ) T1 vs T2: 1.00 (B) T2 vs T3:<0.0001 (B*)
B = Bonferroni p-value corrected; VAS = visual analogue scale for pain; AOFAS = American Orthopaedic Foot & Ankle Society Ankle and Hindfoot scores; MCS = mental component score; PCS = physical component score. * Significant test.
between T2 and T3 (p = 0.0022), while PCS increased significantly between T0 and T1 (p = 0.0005) and MCS increased between T0 and T1 (p = 0.0020) and between T2 and T3 (p < 0.0001). Clinical results are reported in Table 1.
significantly only between T1 and T2 (p = 0.005), while MRI showed a significant reduction of the lesion at each follow-up (T0 vs T1: p = 0.0075; T1 vs T2: p = 0.0070, T2 vs T3: p = 0.0013). Radiological results are reported in Table 2.
4.2. Radiological and MRI evaluation
4.3. Edema
Both CT and MRI showed a significant difference with ANOVA for repeated measures through four time points in both groups (p < 0.001). Particularly in GNE, the size of the lesion measured by CT and MRI decreased significantly between T1 and T2 (CT: p = 0.0003, MRI: p < 0.0001) and between T2 and T3 (CT and MRI: p < 0.0001). In GE the size of the lesion measured by CT improved
In the whole group we noted that the amount of patients with edema at T0 was significantly greater in respect to the patients with edema at T3 (p = 0.00098 with McNemar’s exact test). In the GNE no patients presented edema at T3, while in GE only 23.08% of the patients presented edema at T3 (p = 0.00098 with McNemar’s exact test). Results are reported in Table 3.
Please cite this article in press as: R. D’Ambrosi, et al., The role of bone marrow edema on osteochondral lesions of the talus, Foot Ankle Surg (2017), http://dx.doi.org/10.1016/j.fas.2017.02.010
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Table 2 Radiological measures obtained with MR an CT, for all the patients, GNE and GE respectively at T0,T1, T2 and T3. Multi-comparison tests were performed with ANOVA test for repeated measures into groups and Bonferroni correction of p-value was used in pairwise comparison into groups between two consecutive control points. Measures were indicated with mean SD. Total group
T0
T1
T2
T3
p-Value
CT (mm2)
121.02 52.42
111.06 45.22
91.53 37.77
80.46 34.89
MRI (mm2)
153.61 72.75
128.15 58.88
100.50 52.16
88.24 45.11
<0.001 (ANOVA test* ) T0 vs T1: 0.0507 (B) T1 vs T2: <0.0001 (B*) T2 vs T3: <0.0001 (B*) <0.001 (ANOVA test* ) T0 vs T1: 0.0003 (B* ) T1 vs T2:<0.0001 (B* ) T2 vs T3:<0.0001 (B* )
Group 1: GNE CT (mm2)
106.67 45.58
100.73 38.03
78.86 23.45
69.21 20.55
MRI (mm2)
119.55 45.27
102.75 32.81
79.16 25.20
70.71 23.43
Group 2: GE CT (mm2)
147.51 53.88
130.14 50.89
114.92 46.93
101.23 44.94
MRI (mm2)
216.49 71.99
175.04 67.01
139.90 64.64
120.60 56.24
<0.001 (ANOVA test* ) T0 vs T1: 0.828 (B) T1 vs T2: 0.0003 (B*) T2 vs T3:<0.0001 (B* ) <0.001 (ANOVA test* ) T0 vs T1: 0.0727 (B) T1 vs T2:<0.0001 (B* ) T2 vs T3:<0.0001 (B* ) <0.001 (ANOVA test* ) T0 vs T1: 0.174 (B) T1 vs T2: 0.0005 (B*) T2 vs T3: 0.0814 (B) <0.001 (ANOVA test* ) T0 vs T1: 0.0075 (B*) T1 vs T2: 0.0070 (B* ) T2 vs T3: 0.0013 (B* )
B = Bonferroni p-value corrected; CT = computer tomography; MRI = magnetic resonance. * Significant test.
4.4. Effect of edema
4.6. Trend
Between the GNE and GE groups, with regard to clinical parameters, there are no significant differences in the control points, except for VAS in T2, where VAS for GNE group was significantly lower than the corresponding value of the GE group (p = 0.0144). For radiological parameters, the measures of the GE were significantly higher in respect to the GNE at each control point both for CT and MRI (p < 0.05). Results are reported in Table 4.
From the analysis of the trend for clinical parameters we found, both for GE and GNE, a significant increasing trend for AOFAS, PCS and MCS, and a significant decreasing trend for VAS (p < 0.0001) (Figs. 1 and 2). Results are reported in Table 5. 4.7. Complications Only a single adverse effect occurred among all patients. In one case, 8 months after the first surgery, an anterior osteophyte due to hypertrophic proliferation that caused impingement and reduction in range of motion of the ankle, necessitated repeat arthroscopy which resulted in its removal and debridement.
4.5. Correlations The only statistically significant correlation was found between CT and AOFAS at T2 for the GE (R = 0.637, p = 0.019).
Table 3 Percentages of patients for Total groups, GNE and GE, with higher or lower values than the cut-off, for each control point. Total group
MR–CT 40 MR–CT > 40 p-Value (McNemar’s exact test)
T0
T1
T2
T3
% patients
% patients
% patients
% patients
64.86 35.14
78.38 21.62
89.19 10.81
91.89 8.11
0.0625
GNE group MR–CT 40 MR–CT > 40 p-Value (McNemar’s exact test)
100.00 0.00
GE group MR–CT 40 MR–CT > 40 p-Value (McNemar’s exact test)
0.00 100.00
0.0625
95.83 4.17 0.50
100.00 0.00 0.50
46.15 53.85 0.0156
0.50
100.00 0.00 0.50
69.23 30.77 0.125
76.92 23.08 0.50
Please cite this article in press as: R. D’Ambrosi, et al., The role of bone marrow edema on osteochondral lesions of the talus, Foot Ankle Surg (2017), http://dx.doi.org/10.1016/j.fas.2017.02.010
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R. D’Ambrosi et al. / Foot and Ankle Surgery xxx (2016) xxx–xxx Table 4 Clinical and radiological comparison between GE and GNE, respectively at T0, T1, T2 and T3. GNE vs GE (p-value)
T0 T1 T2 T3 *
AOFAS
VAS
PCS
MCS
CT (mm2)
MRI (mm2)
0.400 0.326 0.229 0.309
0.441 0.446 0.0144* 0.184
0.249 0.140 0.220 0.0215
0.239 0.064 0.387 0.395
0.0118* 0.0307* 0.0023* 0.0034*
<0.0001* 0.00005* 0.0002* 0.0004*
5
Table 5 Linear trend analysis for clinical and radiological parameters. Linear trend (p-value) Group
AOFAS
VAS
PCS
MCS
CT
MR
Total GNE GE
<0.0001* <0.0001* <0.0001*
<0.0001* <0.0001* <0.0001*
<0.0001* <0.0001* <0.0001*
<0.0001* <0.0001* 0.0003*
<0.0001* <0.0001* 0.0001*
<0.0001* <0.0001* <0.0001*
*
Significant test.
Significant test.
5. Discussion In our sample of patients we noted a significant improvement in all clinical parameters over the time period examined. Also the lesion size reduced significantly by the 24 month follow-up, but patients with edema presented a bigger size of the lesion at each follow-up, both in CT and MRI, suggesting that edema is related with the area of the lesion, but it is important to note that only 23.08% patients in the GE presented edema at the final follow-up, suggesting that the surgical procedure acts not only on the lesion but also on bone marrow edema. The real meaning of BME from the histopathological point of view is still unclear. The altered signal pattern observed on MRI is probably related to a replacement of normal fatty bone marrow by a more water-rich material [20]. Even if this alteration was assumed to be due to a real local edema, only a few studies actually confirm this hypothesis [21], whereas in the majority of histological samples there is no edema in the examined tissues but lymphocytic infiltrates, fibrosis, increased vascularization and less mineralized bone [3]. In particular the talus is considered a common site for bone marrow edema due to the high frequency of trauma and sprains [1,2]. This condition can cause pain and reduction of normal activities of daily living as reported in the study of Tonbul in which the Author highlighted how the pain during rest and activity may not decrease before the third and sixth month of treatment [6]. Bone marrow edema related to osteochondral injury is frequent in the acute phase but may also occur later as a result of
subchondral collapse, cartilage loss, osteoarthritis, or cyst formation [22]. Carrino et al. proved that subchondral edema is an initial joint degeneration and supports a temporal relationship between bone marrow edema-like signal and the pathogenesis of subchondral cysts [23]. The prognostic significance of edema on osteochondral talar reconstruction has until recently been relatively unclear, and in literature there is only one study in contrast with our results; in fact Cuttica et al. [12] assessed post-operative healing of osteochondral lesions, evaluating the presence of postoperative edema on MRI following drilling. A total of 29 patients with 30 OCLTs were included, and the average time from arthroscopic drilling to MRI was 81.47 weeks. The intensity of edema was classified as none, mild, moderate, or severe, based on MRI findings. The author noted that patients with a moderate or severe edema intensity had inferior clinical outcomes and concluded that the presence of edema on MRI following drilling of OCLTs may be a valuable predictor of clinical outcome, with those patients with greater edema intensity having inferior clinical outcomes. Another aim of our study was to create a cut-off between MRI and CT-scan for the evaluation of edema and clinical results. MRI and CT-scans have different characteristics, complementary in the evaluation of osteochondral lesions, in fact MRI presents a high accuracy of diagnosing OCLTs with a sensitivity and specificity of 96% [24]. Mintz et al. reported a 100% specificity and a 95% sensitivity of the MRI to identify OCLTs [25]. Additionally, De Smet et al. showed that MRI is a reliable diagnostic and an accurate predictor [26]. However, due to bony edema, the true extent of the
Fig. 1. Linear trend for clinical parameters.
Please cite this article in press as: R. D’Ambrosi, et al., The role of bone marrow edema on osteochondral lesions of the talus, Foot Ankle Surg (2017), http://dx.doi.org/10.1016/j.fas.2017.02.010
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Fig. 2. Linear trend for radiological measures.
lesion can be overestimated, which may affect the treatment decision [27,28]. CT instead presented a sensitivity and specificity of 81% and 99% [24], and is considered the most effective method for evaluating the osseous anatomy, but the major limitation is related to the lack of visualizing cartilage directly. In fact, the condition of the subchondral plate plays a key role in diagnosis and treatment of the OCLTs, because pain originates in the subchondral bone and its integrity is crucial for the vitality of articular cartilage [9,29]. In this way, combining the two techniques and creating an algorithm, we aim to be more precise in the evaluation of the OCLTs that may also to be used as a predictor outcome for arthroscopic reconstruction. The limitations of this study include the relatively small number of patients that did not allow for subpopulation analysis. Another limitation is represented by the lack of MOCART assessment of the repair tissue and T2 mapping, which could have given useful information about tissue quality in the two groups. Another important limitation is the lack of sport activity assessment in our group of patients. Furthermore the correlation between lesion location and edema was not assessed. 6. Conclusions The study revealed that osteochondral lesions of the talus were characterized by bigger size both in MRI and CT in patients with edema. We conclude that AT-AMIC1 can be considered a safe and reliable procedure that allows effective healing, regardless of edema and more than half of patients did not present edema six months after surgery. Conflict of interest The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Federico Giuseppe Usuelli, MD, reports persona fees from Integra and Geistlich and grants and personal fees from Zimmer, outside the submitted work Funding The authors received no financial support for the research, authorship, and/or publication of this article. Acknowledgement None.
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The role of bone marrow edema on osteochondral lesions of the talus Riccardo D’Ambrosi, M.D.a,b,* , Camilla Maccario, M.D.a,b , Chiara Ursino, M.D.c , Nicola Serra, Ph.D.d, Federico Giuseppe Usuelli, M.D.b a
Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Milan, Italy Istituto Ortopedico Galeazzi, U.O. C.A.S.C.O. — Piede e Caviglia, Milan, Italy Università Vita-Salute San Raffaele, Milan, Italy d Seconda Università degli Studi di Napoli, Naples, Italy b c
A R T I C L E I N F O
A B S T R A C T
Article history: Received 7 October 2016 Received in revised form 13 January 2017 Accepted 7 February 2017 Available online xxx
Background: To assess the functional and radiological outcomes after arthroscopic talus autologous matrix-induced chondrogenesis (AT-AMIC1) in 2 groups: patients with and without bone marrow edema (BME). Methods: Thirty-seven patients of which 24 without edema (GNE) and 13 with edema (GE) were evaluated. All patients were treated with AT-AMIC1 repair for symptomatic osteochondral talar lesion. Clinical and radiological parameters were evaluated with VAS score for pain, AOFAS and SF-12 at T0 (preoperatively), T1 (6 months), T2 (12 months), T3 (24 months) and MRI and CT-scan at T0, T1, T2 and T3. Results: No patients were lost to the final follow-up. In both groups we found a significant difference for clinical and radiological parameters with ANOVA for repeated measures through four time points (p < 0.001). In GNE, AOFAS improved significantly at each follow-up (p < 0.05); while CT and MRI showed a significant reduction in lesion size between T1 and T2 and T2 and T3 (p < 0.05). In GE, AOFAS improved significantly between T0 and T1 and T2 and T3 (p < 0.05); lesion size, measured with CT, decreased between T1 and T2 (p < 0.05), while with MRI the lesion showed a reduction at each follow-up (p < 0.05). Lesion size was significantly higher both in MRI and CT in GE compared to GNE (p < 0.05). In GNE no patients presented edema at T3, while in GE only 23.08% of the patients presented edema at T3. Conclusions: The study revealed that osteochondral lesions of the talus were characterized by bigger size both in MRI and CT in patients with edema. We conclude that AT-AMIC1 can be considered a safe and reliable procedure that allows effective healing, regardless of edema and more than half of patients did not present edema six months after surgery. © 2017 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Keywords: Osteochondral talar lesions Autologous matrix-induced chondrogenesis Bone marrow edema Ankle arthroscopy
1. Introduction Bone marrow edema (BME) is a unique imaging characteristic of osteochondral lesion of the talus (OCLTs) identified on MRI surrounding the lesion [1,2]. The clinical and anatomopathological significance of BME is not yet clear, in fact BME identify a wide number of clinical entities, which are all characterized by the same magnetic resonance imaging (MRI) pattern and often by pain as their main symptom, but show significant differences in terms of histopathologic pictures, causal mechanisms and prognosis [3]. Radiologically BME is characterized as an area of different signal on MRI of the bone, showing an intermediate or low signal intensity
* Corresponding author at: Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Milan, Italy/Istituto Ortopedico Galeazzi, U.O. C.A.S. C.O. — Piede e Caviglia, Milan, Italy. E-mail address: [email protected] (R. D’Ambrosi).
on T1 weighted images and a high signal intensity on fatsuppressed, T2 weighted, and short tau inversion recovery sequences in comparison with the normal bone marrow [3]. Moreover BME is often associated with an increased local uptake of the tracer on the bone scan. The real meaning of BME from the histopathological point of view is still unclear. The altered signal pattern observed on MRI is probably related to a replacement of normal fatty bone marrow by a more water-rich material [4]. However, it is still unclear how the development and resolution of edema correlate with its intensity and extent of involvement within the talus in particular in surgical procedure [5,6]. Independent prognostic factors such as age, size of the lesion, high body mass index, history of trauma and presence of osteophytes have been shown by some authors to negatively affect the outcome of OCLT repair [6–11]; however, there is currently no general consensus on the prediction of therapeutic success among the various OCLT treatment possibilities, although
http://dx.doi.org/10.1016/j.fas.2017.02.010 1268-7731/© 2017 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: R. D’Ambrosi, et al., The role of bone marrow edema on osteochondral lesions of the talus, Foot Ankle Surg (2017), http://dx.doi.org/10.1016/j.fas.2017.02.010
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absence of edema is considered to be an advantage in the healing of these lesions [10,12,13]. Cuttica reported that patients with low edema intensity showed significantly better outcomes after microfracture and drilling [12]. The purpose of our study was to assess and evaluate healing and the functional outcome after ATAMIC1 (arthroscopic talus autologous matrix-induced chondrogenesis) in 2 groups: patients with and without BME.
measurements were made using the standard tools of the institution’s Picture Archiving and Communication System (PACS). The reading of all MRI and CT-scans was blinded and was performed by two orthopaedic surgeons not involved in the surgical procedure.
2. Material & methods
The statistical analysis was performed by Matlab statistical toolbox version 2008 (MathWorks, Natick, MA, USA) for Windows at 32 bit, on a sample of 37 patients, 40.54% females and 59.46% males, with ages at operation into range 14–61, with mean around 34 years old and standard deviation (SD) around 12 years old multi-comparison tests were performed with ANOVA test for repeated measures into groups (Total group, GNE group, GE group) and the Bonferroni correction of p-value was used in pairwise comparison into groups, ANOVA one way was used to test the difference between the means of GNE group and GE group, and Student’s t-test was used to test the difference between the means into group and evaluation significant trend. Finally univariate linear correlation analysis was performed and Pearson’s linear correlation coefficient R were evaluated and the correspondent pvalues were computed with T-Student test, under null hypothesis of Pearson’s linear correlation coefficient R = 0. All statistical tests with p-value < 0.05 were considered as significant and all results were expressed as mean standard deviation (SD). For simplicity we denoted with T0 = pre-operation control point, T1 = six months post-operation, T2 = six months post-operation and T3 = twenty four months post-operation.
This is a retro-prospective study of 37 arthroscopic cartilage reconstructions for OCLTs performed between January 2012 and September 2014 in one center specialized in foot and ankle surgery. The inclusion criteria for the case series were: osteochondral lesion of the talus Types III and IV according to Berndt and Harty’s classification [14], skeletal maturity and ability to give informed consent. Exclusion criteria were: concomitant surgical procedures, previous surgical treatment of the affected ankle, arthritis of the ankle joint, kissing lesions, haemophilia, rheumatoid arthritis, severe metabolic disorders, autoimmune disease, ongoing chemotherapy, radiation treatment or immunosuppression, pregnancy or lactation. Patients satisfying the inclusion and exclusion criteria were divided into two groups: patients with bone marrow edema (GE) on T1 weighted images and a high signal intensity on fatsuppressed, T2 weighted, and with a difference greater than 40 mm2 between the pre-operative CT-scan and the pre-operative MRI and patients without edema and with a value less than 40 mm2 between pre-operative MRI and CT were assigned to the non-edema group (GNE). All subjects gave their written informed consent to participate in the study, which was approved by the Institutional Review Board. The surgical procedures were all performed by the senior author. All surgical interventions were performed using the ATAMIC1 technique previously described [15,16]. Briefly, surgery was characterized by two arthroscopic phases. First, after having achieved an adequate exposure through the use of a HintermannTM spreader (Integra LifeSciences, Plainsboro, NJ) that allowed for sufficient joint distraction, the lesion was debrided and prepared to receive the regenerative treatment. Cancellous bone was harvested from the ipsilateral calcaneus with an accessory lateral approach on the calcaneus wall. The cancellous bone was introduced using the same cannula and impacted into the bony defect until complete fill was achieved. The second surgical step was performed in a dry condition, during which Chondro-Gide1 (Geistlich Surgery, Wolhusen, Switzerland), a porcine collagen type I/III matrix, was placed and fixed with synthetic fibrin glue (Tisseel1, Baxter, Baxter, USA) along the lesion edges. The HintermannTM spreader was then removed and matrix stability within a normal ankle range of motion was verified. All clinical assessments were performed by a clinician who was blinded to the type of surgery. Each patient was evaluated preoperatively (T0), as well as at 6 (T1), 12 (T2), and 24 (T3) months. The evaluation included clinical and quality of life parameters. Clinical evaluation consisted of subjective global pain assessment by the VAS pain score, while the intensity of pain, walking capacity, and activities of daily life were assessed by the AOFAS score and SF-12 in its Physical (PCS) and Mental component score (MCS) [17–19]. MRI and CT-scan evaluations were also performed at T0, T1, T2, and T3. The area of the lesions was defined and measured for each patient on the MRI and CT-scan according to Choi et al. [7] using coronal length (horizontal extension measured from the coronal image), sagittal length (horizontal extension measured from the sagittal image), depth (vertical extension measured from the sagittal image) and area (calculated with the ellipse formula as coronal length sagittal length 0.79). All imaging
3. Statistical analysis
4. Results Of 42 patients screened for eligibility, 37 satisfied the inclusion and exclusion criteria and were enrolled in the study. Of the 5 excluded patients, 3 had already been subjected to interventions to the affected ankle, 2 patients had severe post-traumatic osteoarthritis of the ankle. Each patient, in both groups was evaluated clinically and radiologically at T0, T1, T2, and T3. Patients satisfying the inclusion and exclusion criteria were divided into two groups. The sample of 37 patients was composed of 15 (40.54%) females and 22 (59.46%) males with ages at operation into range 14–61, with mean around 34 years old (SD 12). The GNE was composed of 24 patients, of which 10 (41.67%) were females and 14 (58.33%) males, mean age at surgery was 31 years old (range: 16–55, SD 10). The GE was composed of 13 patients, of which 5 (38.46%) were females and 8 (61.54%) males, mean age at surgery was 38 years old (range: 14–61, SD 15). In GNE 8 lesions were centromedial, 7 posteromedial, 5 centrolateral, 2 anteromedial, 1 posterolateral and 1 centrocentral. In GE lesions were divided as follows: 8 centromedial, 3 centrolateral and 2 posteromedial. No patients were lost to the final follow-up of 24 months. 4.1. Clinical evaluation In both groups we found a significant difference for AOFAS, VAS, PCS and MCS with ANOVA for repeated measures through four time points (p < 0.001). In particular in the GNE, AOFAS improved significantly at each follow-up (T0 vs T1: p = 0.0016; T1 vs T2: p = 0.0021, T2 vs T3: p = 0.0168), VAS improved significantly between T0 and T1 (p < 0.0001) and between T1 and T2 (p = 0.0039), while PCS and MCS improved significantly only between T0 and T1 (p < 0.0001). In GE we noted a significant improvement for AOFAS only between T0 and T1 (p = 0.0017) and between T2 and T3 (p = 0.0092), VAS improved significantly between T0 and T1 (p = 0.0035) and
Please cite this article in press as: R. D’Ambrosi, et al., The role of bone marrow edema on osteochondral lesions of the talus, Foot Ankle Surg (2017), http://dx.doi.org/10.1016/j.fas.2017.02.010
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Table 1 Clinical parameter scores for all the patients, GNE and GE respectively at T0,T1, T2 and T3. Multi-comparison tests were performed with ANOVA test for repeated measures into groups and the Bonferroni correction of p-value was used in pairwise comparison into groups between two consecutive control points. The measures were indicated as mean SD. Total group Parameters
T0
T1
T2
T3
p-Value
AOFAS
51.97 15.28
73.30 15.57
83.62 13.57
89.32 10.16
VAS
7.89 1.33
4.46 2.40
3.00 1.89
1.84 1.44
PCS
30.88 5.44
44.64 8.81
49.19 7.07
51.19 6.38
MCS
42.50 4.59
52.91 5.23
51.60 5.17
53.86 6.00
<0.001 (ANOVA test*) T0 vs T1:<0.0001 (B* ) T1 vs T2: 0.0005 (B* ) T2 vs T3: 0.0001 (B* ) <0.001 (ANOVA test*) T0 vs T1:<0.0001 (B* ) T1 vs T2: 0.095 (B) T2 vs T3: 0.0145 (B* ) <0.001 (ANOVA test*) T0 vs T1:<0.0001 (B* ) T1 vs T2: 0.0911 (B) T2 vs T3: 0.256 (B) <0.001 (ANOVA test*) T0 vs T1:<0.0001 (B* ) T1 vs T2: 1.00 (B) T2 vs T3: 0.252 (B)
Group 1: GNE AOFAS
52.46 15.49
72.42 16.11
84.87 14.37
89.96 9.62
VAS
7.92 1.35
4.50 2.31
2.50 1.80
2.00 1.44
PCS
31.34 4.94
43.45 8.39
49.95 7.68
52.77 5.34
MCS
42.91 4.46
53.89 5.10
51.78 4.95
54.07 6.20
Group 2: GE AOFAS
51.08 14.91
74.92 14.37
81.31 11.56
88.15 11.0
VAS
7.85 1.29
4.38 2.56
3.92 1.68
1.54 1.39
PCS
30.03 6.16
46.82 9.15
47.77 8.30
48.29 7.09
MCS
41.75 4.72
51.10 4.97
51.25 5.54
53.48 5.59
<0.001 (ANOVA test*) T0 vs T1: 0.0016 (B*) T1 vs T2: 0.0021 (B*) T2 vs T3: 0.0168 (B* ) <0.001 (ANOVA test*) T0 vs T1:<0.0001 (B* ) T1 vs T2: 0.0039 (B*) T2 vs T3: 1.00 (B) <0.001 (ANOVA test*) T0 vs T1:<0.0001 (B* ) T1 vs T2: 0.0789 (B) T2 vs T3: 0.247 (B) <0.001 (ANOVA test*) T0 vs T1:<0.0001 (B* ) T1 vs T2: 0.519 (B) T2 vs T3: 0.665 (B) <0.001 (ANOVA test*) T0 vs T1: 0.0017 (B*) T1 vs T2: 0.585 (B) T2 vs T3: 0.0092 (B*) <0.001 (ANOVA test*) T0 vs T1: 0.0035 (B* ) T1 vs T2: 1.00 (B) T2 vs T3: 0.0022 (B*) <0.001 (ANOVA test*) T0 vs T1: 0.0005 (B*) T1 vs T2: 1.00 (B) T2 vs T3: 1.00 (B) <0.001 (ANOVA test*) T0 vs T1: 0.0020 (B* ) T1 vs T2: 1.00 (B) T2 vs T3:<0.0001 (B*)
B = Bonferroni p-value corrected; VAS = visual analogue scale for pain; AOFAS = American Orthopaedic Foot & Ankle Society Ankle and Hindfoot scores; MCS = mental component score; PCS = physical component score. * Significant test.
between T2 and T3 (p = 0.0022), while PCS increased significantly between T0 and T1 (p = 0.0005) and MCS increased between T0 and T1 (p = 0.0020) and between T2 and T3 (p < 0.0001). Clinical results are reported in Table 1.
significantly only between T1 and T2 (p = 0.005), while MRI showed a significant reduction of the lesion at each follow-up (T0 vs T1: p = 0.0075; T1 vs T2: p = 0.0070, T2 vs T3: p = 0.0013). Radiological results are reported in Table 2.
4.2. Radiological and MRI evaluation
4.3. Edema
Both CT and MRI showed a significant difference with ANOVA for repeated measures through four time points in both groups (p < 0.001). Particularly in GNE, the size of the lesion measured by CT and MRI decreased significantly between T1 and T2 (CT: p = 0.0003, MRI: p < 0.0001) and between T2 and T3 (CT and MRI: p < 0.0001). In GE the size of the lesion measured by CT improved
In the whole group we noted that the amount of patients with edema at T0 was significantly greater in respect to the patients with edema at T3 (p = 0.00098 with McNemar’s exact test). In the GNE no patients presented edema at T3, while in GE only 23.08% of the patients presented edema at T3 (p = 0.00098 with McNemar’s exact test). Results are reported in Table 3.
Please cite this article in press as: R. D’Ambrosi, et al., The role of bone marrow edema on osteochondral lesions of the talus, Foot Ankle Surg (2017), http://dx.doi.org/10.1016/j.fas.2017.02.010
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Table 2 Radiological measures obtained with MR an CT, for all the patients, GNE and GE respectively at T0,T1, T2 and T3. Multi-comparison tests were performed with ANOVA test for repeated measures into groups and Bonferroni correction of p-value was used in pairwise comparison into groups between two consecutive control points. Measures were indicated with mean SD. Total group
T0
T1
T2
T3
p-Value
CT (mm2)
121.02 52.42
111.06 45.22
91.53 37.77
80.46 34.89
MRI (mm2)
153.61 72.75
128.15 58.88
100.50 52.16
88.24 45.11
<0.001 (ANOVA test* ) T0 vs T1: 0.0507 (B) T1 vs T2: <0.0001 (B*) T2 vs T3: <0.0001 (B*) <0.001 (ANOVA test* ) T0 vs T1: 0.0003 (B* ) T1 vs T2:<0.0001 (B* ) T2 vs T3:<0.0001 (B* )
Group 1: GNE CT (mm2)
106.67 45.58
100.73 38.03
78.86 23.45
69.21 20.55
MRI (mm2)
119.55 45.27
102.75 32.81
79.16 25.20
70.71 23.43
Group 2: GE CT (mm2)
147.51 53.88
130.14 50.89
114.92 46.93
101.23 44.94
MRI (mm2)
216.49 71.99
175.04 67.01
139.90 64.64
120.60 56.24
<0.001 (ANOVA test* ) T0 vs T1: 0.828 (B) T1 vs T2: 0.0003 (B*) T2 vs T3:<0.0001 (B* ) <0.001 (ANOVA test* ) T0 vs T1: 0.0727 (B) T1 vs T2:<0.0001 (B* ) T2 vs T3:<0.0001 (B* ) <0.001 (ANOVA test* ) T0 vs T1: 0.174 (B) T1 vs T2: 0.0005 (B*) T2 vs T3: 0.0814 (B) <0.001 (ANOVA test* ) T0 vs T1: 0.0075 (B*) T1 vs T2: 0.0070 (B* ) T2 vs T3: 0.0013 (B* )
B = Bonferroni p-value corrected; CT = computer tomography; MRI = magnetic resonance. * Significant test.
4.4. Effect of edema
4.6. Trend
Between the GNE and GE groups, with regard to clinical parameters, there are no significant differences in the control points, except for VAS in T2, where VAS for GNE group was significantly lower than the corresponding value of the GE group (p = 0.0144). For radiological parameters, the measures of the GE were significantly higher in respect to the GNE at each control point both for CT and MRI (p < 0.05). Results are reported in Table 4.
From the analysis of the trend for clinical parameters we found, both for GE and GNE, a significant increasing trend for AOFAS, PCS and MCS, and a significant decreasing trend for VAS (p < 0.0001) (Figs. 1 and 2). Results are reported in Table 5. 4.7. Complications Only a single adverse effect occurred among all patients. In one case, 8 months after the first surgery, an anterior osteophyte due to hypertrophic proliferation that caused impingement and reduction in range of motion of the ankle, necessitated repeat arthroscopy which resulted in its removal and debridement.
4.5. Correlations The only statistically significant correlation was found between CT and AOFAS at T2 for the GE (R = 0.637, p = 0.019).
Table 3 Percentages of patients for Total groups, GNE and GE, with higher or lower values than the cut-off, for each control point. Total group
MR–CT 40 MR–CT > 40 p-Value (McNemar’s exact test)
T0
T1
T2
T3
% patients
% patients
% patients
% patients
64.86 35.14
78.38 21.62
89.19 10.81
91.89 8.11
0.0625
GNE group MR–CT 40 MR–CT > 40 p-Value (McNemar’s exact test)
100.00 0.00
GE group MR–CT 40 MR–CT > 40 p-Value (McNemar’s exact test)
0.00 100.00
0.0625
95.83 4.17 0.50
100.00 0.00 0.50
46.15 53.85 0.0156
0.50
100.00 0.00 0.50
69.23 30.77 0.125
76.92 23.08 0.50
Please cite this article in press as: R. D’Ambrosi, et al., The role of bone marrow edema on osteochondral lesions of the talus, Foot Ankle Surg (2017), http://dx.doi.org/10.1016/j.fas.2017.02.010
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R. D’Ambrosi et al. / Foot and Ankle Surgery xxx (2016) xxx–xxx Table 4 Clinical and radiological comparison between GE and GNE, respectively at T0, T1, T2 and T3. GNE vs GE (p-value)
T0 T1 T2 T3 *
AOFAS
VAS
PCS
MCS
CT (mm2)
MRI (mm2)
0.400 0.326 0.229 0.309
0.441 0.446 0.0144* 0.184
0.249 0.140 0.220 0.0215
0.239 0.064 0.387 0.395
0.0118* 0.0307* 0.0023* 0.0034*
<0.0001* 0.00005* 0.0002* 0.0004*
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Table 5 Linear trend analysis for clinical and radiological parameters. Linear trend (p-value) Group
AOFAS
VAS
PCS
MCS
CT
MR
Total GNE GE
<0.0001* <0.0001* <0.0001*
<0.0001* <0.0001* <0.0001*
<0.0001* <0.0001* <0.0001*
<0.0001* <0.0001* 0.0003*
<0.0001* <0.0001* 0.0001*
<0.0001* <0.0001* <0.0001*
*
Significant test.
Significant test.
5. Discussion In our sample of patients we noted a significant improvement in all clinical parameters over the time period examined. Also the lesion size reduced significantly by the 24 month follow-up, but patients with edema presented a bigger size of the lesion at each follow-up, both in CT and MRI, suggesting that edema is related with the area of the lesion, but it is important to note that only 23.08% patients in the GE presented edema at the final follow-up, suggesting that the surgical procedure acts not only on the lesion but also on bone marrow edema. The real meaning of BME from the histopathological point of view is still unclear. The altered signal pattern observed on MRI is probably related to a replacement of normal fatty bone marrow by a more water-rich material [20]. Even if this alteration was assumed to be due to a real local edema, only a few studies actually confirm this hypothesis [21], whereas in the majority of histological samples there is no edema in the examined tissues but lymphocytic infiltrates, fibrosis, increased vascularization and less mineralized bone [3]. In particular the talus is considered a common site for bone marrow edema due to the high frequency of trauma and sprains [1,2]. This condition can cause pain and reduction of normal activities of daily living as reported in the study of Tonbul in which the Author highlighted how the pain during rest and activity may not decrease before the third and sixth month of treatment [6]. Bone marrow edema related to osteochondral injury is frequent in the acute phase but may also occur later as a result of
subchondral collapse, cartilage loss, osteoarthritis, or cyst formation [22]. Carrino et al. proved that subchondral edema is an initial joint degeneration and supports a temporal relationship between bone marrow edema-like signal and the pathogenesis of subchondral cysts [23]. The prognostic significance of edema on osteochondral talar reconstruction has until recently been relatively unclear, and in literature there is only one study in contrast with our results; in fact Cuttica et al. [12] assessed post-operative healing of osteochondral lesions, evaluating the presence of postoperative edema on MRI following drilling. A total of 29 patients with 30 OCLTs were included, and the average time from arthroscopic drilling to MRI was 81.47 weeks. The intensity of edema was classified as none, mild, moderate, or severe, based on MRI findings. The author noted that patients with a moderate or severe edema intensity had inferior clinical outcomes and concluded that the presence of edema on MRI following drilling of OCLTs may be a valuable predictor of clinical outcome, with those patients with greater edema intensity having inferior clinical outcomes. Another aim of our study was to create a cut-off between MRI and CT-scan for the evaluation of edema and clinical results. MRI and CT-scans have different characteristics, complementary in the evaluation of osteochondral lesions, in fact MRI presents a high accuracy of diagnosing OCLTs with a sensitivity and specificity of 96% [24]. Mintz et al. reported a 100% specificity and a 95% sensitivity of the MRI to identify OCLTs [25]. Additionally, De Smet et al. showed that MRI is a reliable diagnostic and an accurate predictor [26]. However, due to bony edema, the true extent of the
Fig. 1. Linear trend for clinical parameters.
Please cite this article in press as: R. D’Ambrosi, et al., The role of bone marrow edema on osteochondral lesions of the talus, Foot Ankle Surg (2017), http://dx.doi.org/10.1016/j.fas.2017.02.010
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R. D’Ambrosi et al. / Foot and Ankle Surgery xxx (2016) xxx–xxx
Fig. 2. Linear trend for radiological measures.
lesion can be overestimated, which may affect the treatment decision [27,28]. CT instead presented a sensitivity and specificity of 81% and 99% [24], and is considered the most effective method for evaluating the osseous anatomy, but the major limitation is related to the lack of visualizing cartilage directly. In fact, the condition of the subchondral plate plays a key role in diagnosis and treatment of the OCLTs, because pain originates in the subchondral bone and its integrity is crucial for the vitality of articular cartilage [9,29]. In this way, combining the two techniques and creating an algorithm, we aim to be more precise in the evaluation of the OCLTs that may also to be used as a predictor outcome for arthroscopic reconstruction. The limitations of this study include the relatively small number of patients that did not allow for subpopulation analysis. Another limitation is represented by the lack of MOCART assessment of the repair tissue and T2 mapping, which could have given useful information about tissue quality in the two groups. Another important limitation is the lack of sport activity assessment in our group of patients. Furthermore the correlation between lesion location and edema was not assessed. 6. Conclusions The study revealed that osteochondral lesions of the talus were characterized by bigger size both in MRI and CT in patients with edema. We conclude that AT-AMIC1 can be considered a safe and reliable procedure that allows effective healing, regardless of edema and more than half of patients did not present edema six months after surgery. Conflict of interest The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Federico Giuseppe Usuelli, MD, reports persona fees from Integra and Geistlich and grants and personal fees from Zimmer, outside the submitted work Funding The authors received no financial support for the research, authorship, and/or publication of this article. Acknowledgement None.
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Please cite this article in press as: R. D’Ambrosi, et al., The role of bone marrow edema on osteochondral lesions of the talus, Foot Ankle Surg (2017), http://dx.doi.org/10.1016/j.fas.2017.02.010