SLR - September 2010 - Brant L. McCartan

One-step Bone Marrow-derived Cell Transplantation in Talar Osteochondral Lesions

Reference:  Giannini, G., Buda, R., Vannini, F., Cavallo, M., Brigolo, B.  One-step Bone Marrow-derived Cell Transplantation in Talar Osteochondral Lesions.  Clinical Orthopaedics and Related Research, (Dec 2009) 467:3307-3320

Scientific Literature Reviews

Reviewed by:  Brant L. McCartan, DPM, MBA, MS
Residency Program: Beth Israel Deaconess Medical Center/Harvard Medical School

Podiatric Relevance:
Ankle sprains are common injuries seen in the podiatric practice, and osteochondral lesions are frequently associated with ankle sprains.  Although osteochondral grafting and autologous chondrocyte implantation have shown some hyaline cartilage repair, there is no current standard treatment of choice for osteochondral lesions.  Many surgeons currently employ ankle arthroscopy as part of their treatment arsenal.  This article examines bone marrow-derived cell transplantation for the treatment of osteochondral lesions, and also compares it to autologous chondrocyte implantation via ankle arthroscopy.   

Methods:
A prospective clinical study was performed on 48 patients with Type II osteochondral lesions of the talar dome (39 were located medially and 9 were located laterally).  The minimum follow-up was 24 months.  Eight patients were previously treated with microfractures, five with arthroscopic debridement, and two with autologous chondrocyte implantation unsucessfully.  AOFAS score, AP & Lateral WB standard radiographic examination and MRI were performed preoperatively and postoperatively.  23 patients received a collagen powder scaffold, and 25 received the hyaluronic acid membrane.  There was no difference between the two scaffolds in a preclinical examination as well as postoperative examination.  Bone marrow was derived from the posterior iliac crest until 60 mL was collected.  6 mL of cell concentrate was derived by adding platelet-poor plasma to the monomuclear cells obtained from the bone marrow (post centrifuge).  After ankle arthroscopy, the lesion was prepared until healthy bone was visible.  The composite paste was prepared with 1 g of powder scaffold (or a cut-out of the hyaluronic acid membrane), 2 mL bone marrow concentrate and 1 mL of platelet-rich fibrin gel.  After implantation, a layer of platelet-rich fibrin gel was spread over to hold the implant in place.  Proper postoperatve protocol was used.  Patients had 6, 12, 18 and 24 month follow-up appointments with standard radiographic examination.  Five patients underwent second-look arthroscopy to examine the degree of defect repair, graft integration and gross appearance.  Biopsy specimens were taken tangentially for histologic and immunohistologic analysis.

Results: 
Chondrogenic and osteogenic differentiation was seen from the bone marrow-derived cells.  There was no intraoperative complications, and postoperatively, there was one patient with a superficial infection of an arthroscopic portal that resolved with oral antibiotics.  Mean AOFAS scores improved from 64.4 +/- 14.5 to 91.4 +/- 7.7 at 24 months.  MRI showed newly formed tissue at the lesion site in all patients at 24 months.  Collagen Type I was seen in the middle of the specimen, and collagen Type II was seen throughout the entire thickness of the cartilage. 

Conclusions:
 The use of bone marrow-derived cells appears to be a suitable method to treat osteochondral lesions.  This treatment showed similar AOFAS scores to other techniques (OATS, Open and Arthroscopic Autologous Chondrocyte Implantation).  The one step approach, along with chondrogenic and osteogenic differentiation may make it superior to other treatments, namely the two step autologous chondrocyte implantation.   

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