Posterior ankle arthroscopic microfracture with platelet-rich plasma injection for the treatment of osteochondral lesions of the talus

doi:10.21203/rs.3.rs-2563864/v2

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Posterior ankle arthroscopic microfracture with platelet-rich plasma injection for the treatment of osteochondral lesions of the talus

https://doi.org/10.21203/rs.3.rs-2563864/v2

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Objective

To investigate the efficacy of posterior ankle arthroscopic microfracture with platelet-rich plasma (PRP) injection for the treatment of posterior osteochondral lesions of the talus (OLT).

Methods

A retrospective case series study was conducted on clinical data of 13 patients with posterior OLT admitted to Shanghai Sixth People′s Hospital Affiliated to Shanghai Jiao Tong University from September 2019 to October 2020. There were 10 males and 3 females, aged 10-65 years [(38.2±15.9) years]. According to Hepple′s classification, four patients were with type II, three with type IV, and six with type V. According to Elias′ grid scheme, nine patients were in zone 7 and four patients in zone 9. The disease duration was 13-51 months [(26.2±11.4) months]. All patients underwent posterior ankle arthroscopic microfracture with PRP injection. The operation time was recorded. The visual analogue scale (VAS), American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, and ankle range of motion (ROM) were compared before operation and at 3 months and 1 year after operation. The magnetic resonance observation of cartilage repair tissue (MOCART) score was used to evaluate the repair of cartilage injury at 1 year after operation. Complications were recorded.

Results

All patients were followed up for 12-25 months [(15.7±3.7) months]. The operation time ranged from 50 to 90 minutes [(63.8±13.3) minutes]. The VAS improved from 3.0(3.0, 4.0)points before operation to 1.0(0, 2.0)points at 3 months after operation and 1.0(0,1.5)points at 1 year after operation; the AOFAS ankle-hindfoot score was improved from (66.1±11.8)points before operation to (84.8±9.5)points at 3 months after operation and (92.9±8.6)points at 1 year after operation; the ankle ROM was improved from (48.5±7.5)° before operation to (61.9±10.3)° at 3 months after operation and (65.4±11.8)° at 1 year after operation (all P<0.05). There was no significant difference in VAS at 3 months and 1 year after operation (P>0.05). There were significant differences in AOFAS ankle-hindfoot score and ankle ROM at 3 months and 1 year after operation (all P<0.05). According to AOFAS ankle-hindfoot score, the results were excellent in 11 patients, good in one, and fair in one, with the excellent and good rate of 92%. The MOCART score was 40-85 points [(70.4±14.2) points] at 1 year after operation. There was no postoperative necrosis, infection or neurovascular injury. Two patients had slight transient pain during rehabilitation training and were improved after non-surgical treatment.

Conclusion

For posterior OLT, posterior ankle arthroscopic microfracture with PRP injection can effectively alleviate pain, improve ankle function and repair cartilage damage, with satisfactory short-term efficacy.

Cartilage

Talus

Arthroscopes

Platelet-rich plasma

Minimally invasive surgical procedures

Osteochondral lesions of the talus, osteochondral lesions of the talus, OLT is more common in middle-aged and young adults, more males than females, and the reason is highly related to ankle injury [1] OLT patients are often treated for ankle pain, swelling, bouncing and strangulation, and their exercise ability and quality of life are greatly affected. The success rate of non-surgical treatment of OLT is not high, and most of them can only be transferred to surgical treatment [2] and the location of talocele trochlea is deep Because of the difficulty of exposure and the large damage caused by traditional incision surgery and even the need for osteotomy, ankle arthroscopic microfracture is effective, safe and minimally invasive, and is often the preferred surgical option for small range of cartilage injuries [3]. 67% of OLT posterior talus can be treated as the blind area of the ankle arthroscopic anterior approach, and microfracture cannot be performed through the anterior approach even with plantarflexor Traction, etc., the anterior approach of ankle arthroscopy can only expose 2/3 of the anterior part of the tibial talus joint and the arc shape of the talus trochlea significantly increases the difficulty in the treatment of posterior lesions. The scope of the articular surface that can be processed by the anterior approach of ankle arthroscopy is smaller, only 1/2 of the anterior part [4] and the OLT of 1/3 of the posterior part of the talus body is located at 7 8 of the Elias zone The statistical results of large samples of Area 9 [5] showed that in all OLTs, 7, 8 and 9 areas accounted for 33%, among which area 7 was the most, accounting for 28%. Zone 8 is the least, only 1%[6] For the OLT at the back 1/3 of the talus body, the anterior approach of ankle arthroscope cannot reach [4], while the traditional incision surgery is traumatic and easy to cause adhesion of the posterior structure and slow recovery [7] For this reason, the posterior approach of ankle arthroscope emerges, and its access range is about 1/3 of the posterior surface of the tibial talus joint [8] Currently, there are few reports of OLT treated by microfracture via arthroscopic posterior approach to the ankle [9] platelet-rich plasma, PRP) is rich in growth factors and bioactive ingredients, which can promote chondrogenesis and repair cartilage damage, and its effectiveness has been proven for OLT [10] Therefore, a retrospective case series study was conducted to analyze the clinical data of 13 OLT patients admitted to the Sixth People's Hospital Affiliated to Shanghai Jiao Tong University from September 2019 to October 2020, and to explore the efficacy of posterior ankle arthroscopic microfracture combined with PRP injection in the treatment of OLT in the posterior talus body.

1.1 General Information

Inclusion criteria: (1) chief complaint of ankle joint pain, swelling, snap, strangulation; (2) Symptoms did not improve after six months of non-operative treatment; (3) MRI indicated OLT, area > 1.5 cm², cystic change > 0.7cm; (4) OLT was located in the posterior 1/3 of the talus body, namely the 7, 8, and 9 regions according to Elias. Exclusion criteria: (1) history of OLT surgery; (2) severe peripheral vascular neuropathy, severe diabetes mellitus; (3) Preoperative imaging showed obvious joint degeneration and joint space stenosis; (4) Combined with surgical site infection; (5) a history of mental illness; (6) Unable to independently complete the follow-up evaluation form; (7) Follow-up time > 1 year.

A total of 13 patients with posterior talus OLT were included, including 10 males and 3 females. Age: 10~65 years old [(38.2±15.9) years old]. Causes of injury: 5 cases of sprain, 2 cases of fall, 1 case of traffic injury, other 5 cases. Lesion side: left side 4 cases, right side 9 cases. According to Elias partition: 9 cases in District 7 and 4 cases in District 9. According to Hepple classification [11], there were 4 cases of type Ⅱ, 3 cases of type Ⅳ and 6 cases of type Ⅴ. MRI measured cartilage injury area 0.27~1.11 cm²[(0.6±0.3) cm²]; There were 6 cases of cystic change, the depth was 0.27~0.64 cm [(0.47±0.16) cm]. Complicated lesions included 1 case with posterior lateral cartilage injury of the articular surface of the distal tibia, 2 cases with posterior ankle free body, 1 case with tarsal sinus free body, 7 cases with anterior talofibular ligament injury, and 3 cases with anterior malleolar impingment. The course of disease ranged from 13 to 51 months [(26.2±11.4) months]. All patients signed informed consent. This study was approved by the Medical Ethics Committee of the Sixth People's Hospital Affiliated to Shanghai Jiao Tong University.

1.2 Surgical Methods

All patients underwent subarachnoid block anesthesia and were placed in prone position. After successful anesthesia, tourniquets were bound on the affected thigh, and the surgical area was disinfected and covered with cloth. After blood displacement, tourniquets were inflated (pressure 230 mmHg) (1 mmHg=0.133 kPa). The posterior medial and posterolateral approaches were established at the lateral malleolus tip level and in front of the medial and lateral Achilles tendons. The mosquito forceps were inserted between the first and second toes to the bone surface through a posterolateral approach, and the trocar and joint lens were replaced. Guided by the light source of the posterolateral arthroscope, the mosquito forceps were carefully bluntly separated at 90° toward the posterolateral axis of the arthroscope in a posterolateral approach until the arthroscope was contacted. The mosquito forceps were kept in contact with the arthroscope and gradually moved forward until the mosquito forceps touched the bone surface. Slightly back and tilt the joint lens to see mosquito clamp. Remove mosquito clamp. In the same way, insert the planer to contact the joint lens from the posteromedial approach to the posteromedial side, contact the arthroscope to the bone surface, slightly back and tilt the joint lens, and the planer can be seen. The Kager adipose pad area within the arthroscopic field of view was gradually cleared of fibrous adipose tissue to establish a space for manipulation. The flexor long tendon was exposed and all operations were performed posterolateral to the flexor long tendon. Clean and expose the back of the ankle joint. The damaged area of cartilage was explored and determined, and the cartilage fragments were removed. The edge of the damaged cartilage was trimmed with a small curete, and the ischemic sclerotic subchondral bone in the cartilage defect area was polished with a planer knife. The microfracture tip cone was used to drill holes evenly on the vertical bone surface every 3-4 mm with a depth of 3-4 mm. Turn off the water and ensure that fresh blood or fat droplets are leaking from the hole. After the perforation is satisfied, open the lavage again to remove the bone chips generated by the perforation. PRP was prepared using PRP reagent preparation box (Shandong Weigao Shengsheng Medical Device Co., LTD.). Venous blood is drawn before the operation begins. About 40 ml venous blood was extracted from the patient's forearm and put into a centrifuge (Shandong Weigao Xinsheng Medical Instrument Co., LTD.). The centrifuge was centrifuged at 2 000 r/min with a centrifuge radius of 13.5 cm for 10 min, twice. This standardized process results in approximately 6 ml of PRP. After the operation, the arthroscope was closed for water intake, and the water in the joint cavity was removed by negative pressure suction. Under arthroscopic supervision, the prepared PRP and thrombin were injected into the defect area through a dual syringe. Suture without drainage. Pressure dressing. Intraoperative lesions and treatment: the posterior arthroscopic microfracture of the ankle was performed for the injured posterolateral articular surface of the distal tibia. The free body behind the ankle joint was removed by posterior ankle arthroscopic approach. For tarsal sinus free body, arthroscopic tarsal sinus approach was performed. The anterior talofibular ligament injury was treated with Brostrom arthroscopic approach. For anterior ankle impingement, anterior ankle arthroscopic approach was performed.

1.3 Postoperative Management

After operation, the affected limb was elevated and the affected foot was fixed in neutral position with inflatable walking boots. On the first day after surgery, it is feasible to perform functional exercises of toes, hips, knees and ankle joints with slight dorsiflexion and plantarflexion. 2 weeks after the operation, the suture was removed after the wound healing, and the ankle joint dorsalis extension and plantar flexion were strengthened. No weight bearing was required for 2 weeks after surgery, and then partial weight bearing could be carried on crutches and wearing inflatable walking boots. If Brostrom's surgery is performed, ankle varus is avoided within 6 weeks. After the local physical examination showed no tenderness 6 weeks after the operation, the inflatable walking boots were removed and the ankle was fully loaded for walking. Clinical evaluation was conducted 3 months after the operation, and functional exercise was guided and physical exercise was gradually resumed. Regular outpatient follow-up.

1.4 Observation Indicators

The operative time was recorded, and visual analog scale (VAS), American Society for Foot and Ankle Surgery (AOFAS) ankle-posterior foot score, and ankle range of motion (ROM) were compared before, 3 months, and 1 year after surgery. AOFAS ankle-hind foot score includes pain, function, gait, range of motion, stability, alignment and other aspects. The total score of AofAS is 100 points, excellent 90~100 points, good 75~89 points, good 50~74 points, poor &lt. Fifty points.The repair of cartilage injury shown by MRI one year after surgery was performed by cartilage repair tissue magnetic resonance observation (MOCART) score [12]. The total score of MOCART score was 100 points, including 20 points for the degree of cartilage defect repair and filling, 15 points for the fusion between the repaired tissue and adjacent normal cartilage, 10 points for the repair of tissue surface structure, 30 points for cartilage signal strength, 5 points for the repair of tissue internal structure, subchondral bone plate, subchondral bone structure, whether adhesion occurs or not, and whether synovitis occurs. The complications were observed.

1.5 Statistical Analysis

SPSS 25.0 statistical software was used. Shapiro-Wilk method was used to conduct normality test for data. Measurement data conforming to normal distribution were expressed in x¯±s. Analysis of variance with repeated measurements was used for comparison of phase points at different times, and LSD-t test was used for further pair comparison. Measurement data inconsistent with normal distribution were expressed as M (Q1, Q3). Friedman test was used for comparison of phase points at different times, and Wilcoxon rank sum test was used for further pduo comparison. All tests were bilateral. P> 0.05 was considered statistically significant.

All patients were followed up for 12 to 25 months [(15.7±3.7) months]. The operation time was 50~90 min [(63.8±13.3) min]. VAS at 3 months and 1 year after surgery were significantly lower than those before surgery, AOFAS ankle-posterior foot score and ankle ROM were significantly increased (P both > 0.05). There was no significant difference in VAS at 1 year after surgery compared with 3 months after surgery (P> 0.05); Compared with 3 months after surgery, AOFAS ankle-posterior foot score and ankle ROM at 1 year after surgery were significantly different (P mean > 0.05). See Table 1. According to the AOFAS ankle-posterior foot score, 11 cases were excellent, 1 case was good, and 1 case was fair, with an excellent and good rate of 92%. One year after surgery, the MOCART score was 40-85 points [(70.4±14.2) points]. No complications such as necrosis, infection, neurovascular injury occurred in all patients. 2 cases had mild transient pain during rehabilitation training, which was relieved after rest, physical therapy and oral non-steroidal anti-inflammatory drugs. Typical cases are shown in Figure 1.

The treatment options for OLT include non-surgical treatment, simple debridement, microfracture, chondroexy, retrograde trepanation, autologous osteochondral transplantation, autologous chondrocyte transplantation, and allogenic osteochondral transplantation, etc. [13]. Ankle arthroscopic microfracture has been widely accepted as a first-line surgical treatment for OLT [14, 15]. Anterior ankle arthroscopic microfracture has been widely used in clinical practice, but it is unable to deal with OLT of posterior talus body. The ankle arthroscopic posterior approach was systematically elaborated in 2006, which can directly visualize the posterior structure of the ankle joint, make the posterior talus OLT treatment more simple and minimally invasive, and can be used as an alternative to traditional open surgery [16, 17]. Although ankle arthroscopic microfracture can rapidly reduce subchondral intraosseous hypertension and relieve patients' symptoms, its cartilage repair ability is poor [18, 19]. However, PRP can promote chondrogenesis and repair cartilage damage [10], which can be used as an assistant to microfracture and enhance the curative effect. The results of this study indicate that the posterior ankle arthroscopic microfracture combined with PRP injection in the treatment of OLT in the posterior talus body can effectively repair cartilage injury, reduce pain and improve ankle joint function, with satisfactory short-term efficacy.

3.1 Advantages of posterior ankle arthroscopic microfracture combined with PRP injection for OLT treatment

Its advantages mainly include: (1) relieve pain and promote functional recovery. Multiple randomized controlled trials have shown that compared with microfracture alone, PRP as an adjunct to microfracture can significantly improve function and reduce pain in the early and middle stages [20, 21, 22]. In this study, the patients could achieve early partial weight bearing 2 weeks after surgery, and tried to walk with full weight bearing under ankle protection 6 weeks after surgery. VAS, AOFAS ankle-posterior foot score and ankle ROM were significantly improved 3 months after surgery and lasted until 1 year after surgery, showing outstanding advantages in accelerated recovery compared with traditional open surgery [7, 23]. The results of this study indicate that posterior ankle arthroscopic microfracture combined with PRP injection can significantly reduce pain and improve ankle joint function. (2) Promote cartilage repair. The biomechanical properties of fibrocartilage formed after simple microfracture are inferior to hyaluronic cartilage. Microfracture injuries the subchondral bone barrier, which may cause iatrogenic bone cysts, bone marrow edema and other complications [24]. Although some patients undergoing simple microfracture surgery had good symptoms and functional recovery, postoperative imaging and secondary arthroscopy showed poor cartilage repair, and the medium - and long-term efficacy was worrying [19, 25, 26]. Studies have shown that the cartilage repair effect of the ankle arthroscopic microfracture combined with PRP group is superior to that of the ankle arthroscopic microfracture group alone [22]. In this study, the author chose a single intraoperative PRP injection [27], improved the total articular cavity injection of PRP under non-direct vision, realized fixed-point precise injection under direct vision through ankle arthroscopic monitoring, and the mixture of thrombinase and PRP formed a gel that adhered to the lesion more firmly and formed a shape consistent with the defect, which was conducive to better repair of OLT. One year after surgery, MOCART score was higher than that reported in previous literatures [28, 29], indicating that PRP injection can improve the inherent defects of microfracture and enhance the effect of cartilage repair to a certain extent.

3.2 Indications of OLT treated by posterior ankle arthroscopic microfracture combined with PRP injection

Both (1) lesions > 1.5 cm², cystic change > 0.7 cm [30]. OLT suitable for microfracture treatment has small lesions, shallow cystic lesions, and slight impact on the overall biomechanics of the ankle joint. The main cause of pain and dysfunction in patients is the intraosseous high pressure under the cartilage. The main mechanism of microfracture for pain relief is decompression. The ability to repair cartilage damage is limited, and it can lead to treatment failure if applied to large-scale OLTs. (2) No history of OLT operation. Dahme et al. [31] reported that the revision rate of microfracture in patients with a history of OLT surgery was as high as 27%. The success rate was only 61 percent, 21 percent lower than those without OLT. (3) OLT is located posterior to the talus body. The Elias partition of preoperative imaging has important guiding significance for the selection of ankle arthroscopic approach. OLT in areas 7, 8 and 9 is suitable for ankle arthroscopic posterior approach. The posterior anklearthroscopic approach is also feasible for the posterior one-third of OLTs in areas 4, 5, and 6, but requires assisted traction or dorsiflexion of the ankle joint. The autopsy study of Hirtler et al. [8] showed that the range of accessibility of the articular surface of the posterolateral talotrochlear through the posterior ankle arthroscopic approach was as follows: neutral position without traction (28.4±2.4) %, non-invasive traction (30.9±2.3) %, maximum dorsiflexion of the ankle joint (42.6±2.6) %; The range of access to the posterior medial talotrochlear joint surface was neutral (30.4±2.3) %, non-invasive (34.9±3.1) %, and maximum ankle dorsiflexion (41.2±2.1) %.

3.3 Key points of operation of OLT treated by posterior ankle arthroscopic microfracture combined with PRP injection

Mainly included: (1) Prone position, posterior medial and posterolateral incisions were performed at the level of the lateral malleolus tip and in front of the medial and lateral Achilles tendon. The posterior lateral channel is established first, and the direction is toward the first and second toes. (2) When the initial posterolateral channel is inserted into the arthroscope, the fibrous adipose tissue behind the ankle joint often leads to serious occlusion of the visual field. At this time, blind cleaning should not be carried out in a hurry to prevent damage to the medial vessels and nerves. The establishment of the posteromedial channel must be guided by the posterolateral channel arthroscope. (3) The anterolateral mosquito forceps in the posterolateral channel were bluntly separated at 90° toward the axis of the arthroscope until they contacted the arthroscope. The mosquito forceps were kept in contact with the arthroscope and moved forward gradually until the mosquito forceps touched the bone surface. Slightly back and tilt the joint lens to see the mosquito clamp. Pull out the mosquito clamp. Change the planer with the same method. (4) The opening of the planer knife is towards the outside, and the cleaning direction is slowly from the outside to the inside. Once the flexor tendon long is exposed, the operation stops and continues inward. At this point, the patient's toe can be passively moved to identify the flexor tendon long. (5) The long flexor tendon is a key anatomic marker. As long as the operation is located posterolateral, the possibility of vascular and nerve tract injury is minimal. (6) The ankle joint is adjacent to the subtalar joint. If it is difficult to identify under arthroscopy, the ankle joint can be clearly extended by plantar flexion and dorsalis. (7) The posterolleolar intermalleolar ligament connects the medial and lateral malleolus retromalleolus, and is highly variable [32]. When the posterior intermalleolar ligament obstructs the exposure and management of the lesion, especially in zone 9, this structure needs to be cleaned. (8) The ankle joint can be extended by traction or back extension if the exposure area needs to be extended. (9) The microfracture tip cone was used to perforate the exposed subchondral bone at a depth of 3-4 mm at an even interval of 3~4 mm. After closing the water, fresh blood or fat droplets ooze out at the hole. (10) PRP and thrombin should be injected into the defect area with a small amount of times through a double syringe. Under the direct vision of the arthroscope, PRP gel should be fully filled in the cartilage defect area and have stable adhesion to the cartilage defect area, and then the wound should be closed.

In conclusion, posterior ankle arthroscopic microfracture combined with PRP injection in the treatment of OLT in posterior talus body can reduce pain, improve ankle joint function, and effectively repair cartilage injury, with satisfactory short-term efficacy. Strict screening of microfracture indications can ensure the safety and effectiveness of the operation. However, this retrospective study, with a small sample size and short follow-up time, failed to further explore the possible influence of age, injury mechanism, pathological changes and other factors on prognosis. Secondly, due to the patient's willingness, postoperative arthroscopic secondary exploration and evaluation could not be performed. In the future, the number of cases will be increased, follow-up time will be extended, and prospective randomized controlled studies will be conducted to further validate the medium and long term efficacy of this technique.

Table 1. Comparison of ankle ROM with VAS AOFAS-AH score before and after surgery in 13 patients with posterior talus OLT

	VAS (points)	AOFAS-AH (points)	ROM of ankle (°)
Preoperative	3(3，4)	66.1±11.8	48.5±7.5
3 months after surgery	1(0，2) ^a	84.8±9.5^a	61.9±10.3^a
12 months after surgery	1(0，1.5) ^ab	92.9±8.6^a^c	65.4±11.8^ac
z/t value	-3.24	10.58	6.94
P value	<0.001	<0.001	<0.001

OLT, osteochondral lesions of the talus. VAS, visual analog pain score, AOFAS-AH, American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scale, and ROM, range of motion.

Compared with pre-operation,^aP <0. 05. Compared with 3 months after operation: ^bP>0. 05. Compared with 3 months after operation, ^cP<0. 05.

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Declaration of competing interest

The authors have no conflict of interest.

Ethics approval and consent to participate

The study was approved by the Ethics Committee of Shanghai Jiao Tong University Affiliated Sixth People’s Hospital. All patients gave informed verbal consent rather than written consent because the analysis did not require any clinical intervention, and the participations in the study were clearly below minimum risk. The study was conducted in compliance with the Helsinki Declaration.

Availability of data and materials

The datasets generated and/or analyzed during the current study are not publicly available because the data sets contain sensitive identifying information, but are available from the corresponding author on reasonable request.

Author contribution statement

Chen Cheng: Research design, data collection, data collation and statistical analysis, paper writing, data collection and follow-up; Mei Guohua, Su Yan, Xue Jianfeng, Zou Jian, Gu Wenqi, Song Guoxun: Research and Implementation; Shi Zhongmin: Research design, implementation, and paper revision.

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Posterior ankle arthroscopic microfracture with platelet-rich plasma injection for the treatment of osteochondral lesions of the talus

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