Aims. To explore the efficacy of extracorporeal shockwave therapy (ESWT) in the treatment of osteochondral defect (OCD), and its effects on the levels of transforming growth factor (TGF)-β, bone morphogenetic protein (BMP)-2, -3, -4, -5, and -7 in terms of cartilage and bone regeneration. Methods. The OCD lesion was created on the trochlear groove of left articular cartilage of femur per rat (40 rats in total). The experimental groups were Sham, OCD, and ESWT (0.25 mJ/mm. 2. , 800 impulses, 4 Hz). The animals were euthanized at 2, 4, 8, and 12 weeks post-treatment, and histopathological analysis, micro-CT scanning, and immunohistochemical staining were performed for the specimens. Results. In the histopathological analysis, the macro-morphological grading scale showed a significant increase, while the histological score and cartilage repair scale of ESWT exhibited a significant decrease compared to OCD at the 8- and 12-week timepoints. At the 12-week follow-up, ESWT exhibited a significant improvement in the volume of damaged bone compared to OCD. Furthermore, immunohistochemistry analysis revealed a significant decrease in type I collagen and a significant increase in type II collagen within the newly formed hyaline cartilage following ESWT, compared to OCD. Finally, SRY-box transcription factor 9 (SOX9), aggrecan, and TGF-β, BMP-2, -3, -4, -5, and -7 were significantly higher in ESWT than in OCD at 12 weeks. Conclusion. ESWT promoted the effect of TGF-β/BMPs, thereby modulating the production of extracellular matrix proteins and transcription factor involved in the regeneration of articular cartilage and subchondral bone in an OCD rat model. Cite this article: Bone Joint Res 2024;13(7):342–352

Aims

This scoping review aims to identify patient-related factors associated with a poorer outcome following total ankle arthroplasty (TAA).

Abstract. Introduction. Symptomatic osteochondritis dissecans (OCD) and traumatic osteochondral fractures (OCF) are treated with fixation with either metal or bioabsorbable device. We performed a comparative review of patients with OCD and traumatic OCF stabilised with Bio-Compression screws which are headless absorbable compression screws. Our aim was to determine whether there was a difference in outcomes between presentations. Methods. Retrospective single-centre cohort study of all patients with OCD and OCF treated with Bio-Compression screw between July 2017 and September 2022. All patients followed up until discharge with satisfactory clinical outcome. Primary outcome was return to theatre for ongoing pain or mechanical symptoms. Secondary outcome was evidence of fixation failure on follow-up MRI scan. Results. 20 patients included; 8 OCF and 12 OCD. Average age 21 (OCF), 24 (OCD). The most common location was patella (58%) in OCF or the medial femoral condyle (75%) in OCD. Traumatic defects were smaller (2.6cm2 vs 3.3cm2) although this was not statistically significant (p=0.28). In the OCF group one patient went on to have further surgery. There were no re-operations in the OCD group. Both groups had good outcomes and similar times to discharge. There was no evidence of fixation failure of Bio-Compression screws on MRI scans. Conclusions. Within the limits of this relatively small cohort there is no significant difference between outcomes for OCD or traumatic OCF fixation with Bio-Compression screws. Both groups demonstrate good outcomes irrespective of the location or the aetiology of the fragment

This study aimed to evaluate the clinical outcomes of paediatric patients who underwent a retrograde drilling treatment for their osteochondritis dissecans (OCD) of the talus. The secondary purpose was to identify factors that are predictive of a failure of the treatment. A retrospective study was done. All patients treated for talar OCD between 2014 and 2017 were reviewed to extract clinical and demographic information (age, sex, BMI, OCD size and stability, number of drilling, etc). Inclusion criteria were: (1) talar OCD treated with retrograde drilling, (2) less than 18 years, (3) at least one available follow up (4) stable lesion. Exclusion criteria was another type of treatment for a the talar OCD. Additionally, all pre-operative and post-operative medical imaging was reviewed. Outcome was classified based on the last follow-up appointment in two ways, first a score was attributed following the Berndt and Harty treatment outcome grading and second according to the necessity of a second surgery which was the failure group. Chi-square and Mann-Whitney tests were used to compared the success and failure group. Seventeen patients (16 girls and 1 boy, average age: 14.8±2.1 years) were included in our study group. The mean follow up duration was 11.5 (±12) months. Among this population, 4/17 (24%) had a failure of the treatment because they required a second surgery. The treatment result grading according to Berndt and Harty outcome scale identified good results in 8/17 (47%) patients, fair results in 4/17(24%) patients and poor results in 5/17 (29%) patients. The comparisons for various patient variables taken from the medical charts between patients who had a success of the treatment and those who failed did not find any significant differences. At a mean follow-up duration of 11.5 months, 76% of patients in this study had a successful outcome after talar OCD retrograde drilling. No statistically significant difference was identified between the success and failure group. Talar OCD in a paediatric population is uncommon, and this study reviewed the outcome of retrograde drilling with the largest sample size of the literature. Retrograde drilling achieved a successful outcome in 76% of the cases and represents a good option for the treatment of stable talar OCD

Background. Structural and functional outcome of bone graft with first or second generation autologous chondrocyte implantation (ACI) in osteochondral defects has not been reported. Methods. Seventeen patients (mean age of 27±7 years, range 17–40), twelve with osteochondritis dissecans (OD) (ICRS Grade 3 and 4) and five with isolated osteochondral defect (OCD) (ICRS Grade 4) were treated with a combined implantation of a unicortical autologous bone graft with ACI (the Osplug technique). Functional outcome was assessed with Lysholm scores. The repair site was evaluated with the Oswestry Arthroscopy Score (OAS), MOCART score and ICRS II histology score. Formation of subchondral lamina and lateral integration of the bone grafts were evaluated from MRI scans. Results. The mean defect size was 4.5±2.6SD cm. 2. (range 1–9) and depth was 11.3±5SD mm (range 5–18). The pre-operative Lysholm score improved from 45 (IQR 24, range 16–79) to 77 (IQR 28, range 41–100) at 1 year (p-value 0.001) and 70 (IQR 35, range 33–91) at 5 years (p-value 0.009). The mean OAS of the repair site was 6.2 (range 0–9) at a mean of 1.3 years. The mean MOCART score was 61 ± 22SD (range 20–85) at 2.6 ± 1.8SD years. Histology demonstrated generally good integration of the repair cartilage with the underlying bone. Poor lateral integration of the bone graft on the MRI scan and a low OAS were significantly associated with a poor Lysholm score and failure. Conclusion. Osplug technique shows significant improvement of functional outcome for up to 5 years in patients with a high grade OD or OCD. This is the first report describing association of bone graft integration with functional outcome after such a procedure. It also demonstrates histological evidence of integration of the repair cartilage with the underlying bone graft. Level of Evidence. III

To determine if there are osteochondritis dissecans (OCD) lesions of the knee that are so unstable on MRI that they are incapable of healing without operative intervention. A secondary objective was to determine the ability of orthopaedic residents to accurately grade OCD lesions according to the Kijowski criteria of stable and unstable. A retrospective review was performed of patients who had femoral condyle OCD lesions from 2009-present. Only patients with open growth plates and serial MRIs were included. Each MRI was classified according to the Kijowski classification by a junior orthopaedic surgery resident as well as an MSK trained radiologist. A weighted kappa value was used to assess the inter-rater agreement. The final analysis included 16 patients (17 knees) with 49 MRI's. The weighted kappa agreement between reviewers for overall lesion stability was moderate (0.570 [95% CI 0.237–0.757]). The initial MRI lesion was graded as stable in 59% (10/17) of the knees. Two of these 10 knees became unstable during the study period, however, both stabilised again on subsequent MRIs, one with surgery and the other without surgery. The initial MRI was graded as unstable in 41% (7/17) of the knees. Two of the seven knees (29%) later demonstrated MRI evidence of lesion stability without surgical intervention. The most important finding in this study was the ability of unstable OCD lesions on MRI to heal without operative intervention. The ability of an orthopaedic surgery resident to grade these lesions on MRI was moderate

A prospective case control study analysed clinical and radiographic results in patients operated on with the periosteum autologous chondrocyte implantation (ACI) due to cartilage lesions on the femoral condyles over 10 years ago. 31 out of the 45 patients (3 failures, 9 non-responders, 2 others) were available for a continuous clinical (Lyshom/Tegner, IKDC, KOOS) and radiographic (Kellgren-Lawrence) follow-up at 0, 2, 5, and 10 years after the ACI procedure. The patients were sub-grouped into focal cartilage lesions (FL) – 10, osteochondritis dissecans (OCD) – 12, and cartilage lesions with simultaneous ACL reconstruction (ACL) – 9 subgroups. Lysholm, Tegner, and IKCD subjective scores revealed stable results over the period from 2 to 10 years with a significant improvement toward the pre-operative levels, but the patients had not reached their pre-injury Tegner levels. KOOS profile at 10 years was: Pain 78.6, Symptoms 78.1, Activities of daily living 82.5, Sports 56.9, and Quality of life 55.1. A 10-year IKDC knee examination classified operated knees as: 14 normal, 10 nearly normal, 5 abnormal and 2 severely abnormal. Kellgren-Lawrence scores of 2 and above were found in 10 patients (FL 5, OCD 0, and ACL 5). Seven patients in the group required an arthroscopic re-intervention (3 ACI related, 4 ACI unrelated). ACI provided safe and stable performance of operated knees over ten years. High incidence of knee osteoarthritis in FL and ACL subgroups, and low incidence in OCD patients indicate that best long performance is expected in localised low-impact cartilage lesions of young patients

Osteochondritis Dissecans (OCD) is a condition for which the aetiology remains unknown. It affects subchondral bone and secondarily its overlying cartilage and is mostly found in the knee. It can occur in adults, but is generally identified when growth remains, when it is referred to as juvenile OCD. As the condition progresses, the affected subchondral bone separates from adjacent healthy bone, and can lead to demarcation and separation of its associated articular cartilage. Any symptoms which arise relate to the stage of the disease. Early disease without separation of the lesion results in pain. Separation of the lesion leads to mechanical symptoms and swelling and, in advanced cases, the formation of loose bodies. Early identification of OCD is essential as untreated OCD can lead to the premature degeneration of the joint, whereas appropriate treatment can halt the disease process and lead to healing. Establishing the stability of the lesion is a key part of providing the correct treatment. Stable lesions, particularly in juvenile patients, have greater propensity to heal with non-surgical treatment, whereas unstable or displaced lesions usually require surgical management. This article discusses the aetiology, clinical presentation and prognosis of OCD in the knee. It presents an algorithm for treatment, which aims to promote healing of native hyaline cartilage and to ensure joint congruity. Take home message: Although there is no clear consensus as to the best treatment of OCD, every attempt should be made to retain the osteochondral fragment when possible as, with a careful surgical technique, there is potential for healing even in chronic lesions. Cite this article: Bone Joint J 2016;98-B:723–9

Purpose. To assess the reliability of a biomimetic osteochondral scaffold Maioregen (Finceramica Faenza SpA, Faenza, Italt) as a salvage and joint-preserving procedure in the treatment of late stages of osteonecrosis of the knee. Methods. Nine active patients aged under 65 year presenting with clinical and radiological signs of SPONK were treated with a biomimetic osteochondral scaffold. All patients were clinically evaluated preoperatively and yearly with a minimum follow-up of 2 years. Subjective IKDC and Lysholm Knee Scale were used to assess clinical outcome. Pre-operative and post-operative pain was quantified with VAS scale. Activity level were evaluated pre-operatively and at follow-up according to Tegner Activity Scale. Results. Subjective IKDC (35 ± 14.5 to 75.7 ± 20) and Lysholm Knee Scale (49.7 ± 17.9 to 86.6 ± 12.7) significantly improved from pre-operative evaluation (p < .01). VAS decreased from a mean pre-operative value of 6.3 ± 2.5 to 1.6 ± 2.7 at 2 years follow-up. Tegner Activity Scale doesn't show significant differences between pre-operative values and those obtained at two-year follow up. Two of nine patients returned to be symptomatic after 18 months from the implants and progressed to condylar collapse, despite the joint-preserving treatment, and underwent a total knee arthroplasty. Conclusions. Biomimetic scaffold can be a valid option in surgical treatment of SPONK in young active patients. Use of this surgical technique, originally developed for OCD, gives good clinical results at a mid-term follow up also in treatment of osteonecrosis and could postpone or even spare joint replacement procedures

Cartilage defects of the hip cause significant pain and may lead to arthritic changes that necessitate hip replacement. We propose the use of fresh osteochondral allografts as an option for the treatment of such defects in young patients. Here we present the results of fresh osteochondral allografts for cartilage defects in 17 patients in a prospective study. The underlying diagnoses for the cartilage defects were osteochondritis dissecans in eight and avascular necrosis in six. Two had Legg-Calve-Perthes and one a femoral head fracture. Pre-operatively, an MRI was used to determine the size of the cartilage defect and the femoral head diameter. All patients underwent surgical hip dislocation with a trochanteric slide osteotomy for placement of the allograft. The mean age at surgery was 25.9 years (17 to 44) and mean follow-up was 41.6 months (3 to 74). The mean Harris hip score was significantly better after surgery (p < 0.01) and 13 patients had fair to good outcomes. One patient required a repeat allograft, one patient underwent hip replacement and two patients are awaiting hip replacement. Fresh osteochondral allograft is a reasonable treatment option for hip cartilage defects in young patients.

Cite this article: Bone Joint J 2014;96-B(11 Supple A):11–16.

Background. Lateral ligament injuries of the ankle are common. They account for up to 50% of all sporting injuries. Recovery times vary, leading to time away from sport and training for the professional athlete. Predicting this time is important for the treating surgeon, the athlete and the rehabilitation team. This can be difficult as associated ankle injuries occurring at the time of the trauma may alter recovery and rehabilitation. Aim. To compare the time to return to training and sports of isolated lateral ligament injuries with more complex injuries of the ankle treated surgically and to evaluate if lateral ligament repair is safe and effective in the professional athlete. Study design: Case series; level of evidence 4. Methods. A consecutive series of professional sportsmen and women were treated operatively for radiologically and clinically confirmed grade III lateral ligament injury between 2005 and 2009. The patients were split into two groups; isolated lateral ligament injuries and those with other associated injuries. The end points studied were the time to return to training in weeks and the time to return to play in weeks. Results. There were 26 ankles in 26 patients. 16 were isolated injuries (Group A) and 10 had associated injuries (Group B). The associated injuries included, osteochondral defects (OCD) (3), deltoid ligament injury (5), syndesmotic injury (1) and deltoid ligament injury combined with an OCD (1). The mean time to return to training in group A was 61.3 days (range 55–110) and in group B was 99.5 days (63–152). The mean time to return to play in Group A was 78.2 days (range 63–127) and group B 116.7 days (82–178). The time to return to training and play was significantly shorter for the isolated lateral ligament injury group, (p=0.0003) and (p=0.0004) respectively. The only complications were two minor wound infections that responded to oral antibiotics. No patient returned for recurrent instability and all returned to their pre-injury level of play. Conclusion. Lateral ligament repair was a successful and safe procedure leading to return to pre-injury level of play for all the athletes. Time to return to training and play was significantly shorter if there were no associated injuries to the ankle. NO DISCLOSURES

The management of failed autologous chondrocyte implantation (ACI) and matrix-assisted autologous chondrocyte implantation (MACI) for the treatment of symptomatic osteochondral defects in the knee represents a major challenge. Patients are young, active and usually unsuitable for prosthetic replacement. This study reports the results in patients who underwent revision cartilage transplantation of their original ACI/MACI graft for clinical or graft-related failure. We assessed 22 patients (12 men and 10 women) with a mean age of 37.4 years (18 to 48) at a mean of 5.4 years (1.3 to 10.9). The mean period between primary and revision grafting was 46.1 months (7 to 89). The mean defect size was 446.6 mm² (150 to 875) and they were located on 11 medial and two lateral femoral condyles, eight patellae and one trochlea.

The mean modified Cincinnati knee score improved from 40.5 (16 to 77) pre-operatively to 64.9 (8 to 94) at their most recent review (p < 0.001). The visual analogue pain score improved from 6.1 (3 to 9) to 4.7 (0 to 10) (p = 0.042). A total of 14 patients (63%) reported an ‘excellent’ (n = 6) or ‘good’ (n = 8) clinical outcome, 5 ‘fair’ and one ‘poor’ outcome. Two patients underwent patellofemoral joint replacement. This study demonstrates that revision cartilage transplantation after primary ACI and MACI can yield acceptable functional results and continue to preserve the joint.

Cite this article: Bone Joint J 2014;96-B:54–8.

Objectives. Surgical treatment is standard for advanced osteochondritis dissecans (OCD) of the humeral capitellum. When cartilage is seen to be separated or completely detached, this fragment fixation is not usually applied. There have been reports of cases in which advanced OCD of the humeral capitellum progressed to osteoarthritis (Fig), particularly in cases which involved the lateral wall. In these cases, every attempt should be made to reconstruct the lateral wall to avoid osteoarthritis. In this study, we followed up cases with rib osteochondral autograft transplantation technique. Methods. Subjects were 20 cases who were followed up until after they started pitching. The mean age was 13.8 years old and the mean observation period was 2 years and 6 months (from 7 months to 6 year 3 months). Kocher's approach was used to give a good access to the aspect of the radiohumeral joint. The majority of cases suffered from extensive OCD of the elbow. Detached fragment was removed (Fig. 2a) and graft from 5. th. or 6. th. rib with screw fixation was performed on 12 patients and 8 received fixation with no material (Fig. 2b). Follow-up assessment included the range of motion, start time of playing catch and throwing a ball with full power, sports activity, evaluation of radiography, a subjective (including Pain, Swelling, Locking/Catching and Sport activity) and objective (Flexion contracture, Pronation/Supination and sagittal arc of motion) modified elbow rating system by Timmeman et al. We also investigated the details of the arthroscopy observations and the 2nd arthroscopy findings for 4 cases. Results. Preoperative elbow extension increased from −13.5 to −10 degrees and elbow flexion increased from 117 to 123 degrees, but no significant differences were found. All but one patient resumed baseball sporting activity. Catching was started at an average of 3.5 (2 to 5.5 months) months postoperatively and pitching the ball with full power was achieved at 6.7 months. One case was found to have degenerative changes on plain X-ray, and two cases were found to have deviated screws. The mean elbow rating system subjective score improved significantly from 63.9.5 to 89.5 points, as did the overall rating, increasing from 131.6 to 164.8 points. The 2. nd. arthroscopy observations for 4 patients showed that 2 experienced pain due to the loose body, 1 had a limitation in range of motion due to spur formation, and 1 had a screw deviation. Graft survival was observed in two out of four cases. Partial detachment was observed in two cases. Conclusion. Recovery of articular facets with hyaline cartilage were possible using this surgical technique, and in addition, the costal-costochondral grafts, comprising cortical and cancellous bone, were simultaneously transplanted en bloc. This indicates that it is adequate treatment for extensive OCD. All the patients started pitching 3 months postoperatively and returned to full baseball activities after 6 months. Even in cases with extensive OCD, with large osseous and cartilaginous deficits, the surgical technique was useful and showed favorable results

We have evaluated the clinical effectiveness of a metal resurfacing inlay implant for osteochondral defects of the medial talar dome after failed previous surgical treatment. We prospectively studied 20 consecutive patients with a mean age of 38 years (20 to 60), for a mean of three years (2 to 5) post-surgery. There was statistically significant reduction of pain in each of four situations (i.e., rest, walking, stair climbing and running; p ≤ 0.01). The median American Orthopaedic Foot and Ankle Society ankle-hindfoot score improved from 62 (interquartile range (IQR) 46 to 72) pre-operatively to 87 (IQR 75 to 95) at final follow-up (p < 0.001). The Foot and Ankle Outcome Score improved on all subscales (p ≤ 0.03). The mean Short-Form 36 physical component scale improved from 36 (23 to 50) pre-operatively to 45 (29 to 55) at final follow-up (p = 0.001); the mental component scale did not change significantly. On radiographs, progressive degenerative changes of the opposing tibial plafond were observed in two patients. One patient required additional surgery for the osteochondral defect. This study shows that a metal implant is a promising treatment for osteochondral defects of the medial talar dome after failed previous surgery.

Cite this article: Bone Joint J 2013;95-B:1650–5.

The treatment of osteochondral lesions and osteoarthritis remains an ongoing clinical challenge in orthopaedics. This review examines the current research in the fields of cartilage regeneration, osteochondral defect treatment, and biological joint resurfacing, and reports on the results of clinical and pre-clinical studies. We also report on novel treatment strategies and discuss their potential promise or pitfalls. Current focus involves the use of a scaffold providing mechanical support with the addition of chondrocytes or mesenchymal stem cells (MSCs), or the use of cell homing to differentiate the organism’s own endogenous cell sources into cartilage. This method is usually performed with scaffolds that have been coated with a chemotactic agent or with structures that support the sustained release of growth factors or other chondroinductive agents. We also discuss unique methods and designs for cell homing and scaffold production, and improvements in biological joint resurfacing. There have been a number of exciting new studies and techniques developed that aim to repair or restore osteochondral lesions and to treat larger defects or the entire articular surface. The concept of a biological total joint replacement appears to have much potential.

Cite this article: Bone Joint Res 2013;2:193–9.