Metal Resurfacing Inlay Implant for Osteochondral Talar Defects After Failed Previous Surgery: A Midterm Prospective Follow-up Study.

BACKGROUND: Treatment of osteochondral talar defects (OCDs) after failed previous surgery is challenging. Promising short-term results have been reported with use of a metal resurfacing inlay implant. PURPOSE: To evaluate the midterm clinical effectiveness of the metal implant for OCDs of the medial talar dome after failed previous surgery. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: We prospectively studied all patients who met the inclusion criteria and received a metal resurfacing inlay implant between 2007 and 2014. The primary outcome measure was implant survival, as measured by reoperation rate. Secondary outcome measures were numeric rating scales for pain at rest and during walking, running, and stair climbing; the Foot and Ankle Outcome Score (FAOS); the American Orthopaedic Foot and Ankle Society Ankle Hindfoot Scale; the 36-Item Short Form Health Survey (SF-36); return to work and sports; and radiographic evaluation. RESULTS: This study included 38 patients with a mean age of 39 years (SD, ±13 years) and a mean follow-up of 5.1 years (SD, ±1.5 years). Two patients (5%) underwent revision surgery by means of an ankle arthrodesis (2 and 6 years postoperatively). In 8 patients, computed tomography scanning was conducted to assess postoperative complaints. These scans showed impression of the tibial plafond (n = 4), a small tibial cyst (<2.5 mm; n = 1), and cyst formation around the implant screw (n = 4). A total of 21 reoperations were performed, including medial malleolar screw removal (n = 12), arthroscopic removal of bony anterior impingement (n = 7), and calcaneal realignment osteotomy (n = 2). All secondary outcome measures improved significantly, apart from pain at rest, the FAOS symptoms subscale, and the SF-36 mental component scale. The mean time for return to sport was 4.1 months (SD, ±3 months), and 77% of patients resumed sporting activities postoperatively. Only 1 patient did not return to work postoperatively. Radiographs at final follow-up showed cyst formation (n = 2), subchondral periprosthetic radiolucency (n = 2), and non-preexisting joint space narrowing (n = 2). CONCLUSION: This study shows that the metal implant is an effective technique when assessed at midterm follow-up for OCDs of the medial talar dome after failed previous surgery.

Effects of Pulsed Electromagnetic Fields on Return to Sports After Arthroscopic Debridement and Microfracture of Osteochondral Talar Defects: A Randomized, Double-Blind, Placebo-Controlled, Multicenter Trial.

BACKGROUND: Osteochondral defects (OCDs) of the talus usually affect athletic patients. The primary surgical treatment consists of arthroscopic debridement and microfracture. Various possibilities have been suggested to improve the recovery process after debridement and microfracture. A potential solution to obtain this goal is the application of pulsed electromagnetic fields (PEMFs), which stimulate the repair process of bone and cartilage. HYPOTHESIS: The use of PEMFs after arthroscopic debridement and microfracture of an OCD of the talus leads to earlier resumption of sports and an increased number of patients that resume sports. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: A total of 68 patients were randomized to receive either PEMFs (n = 36) or placebo (n = 32) after arthroscopic treatment of an OCD of the talus. The primary outcomes (ie, the number of patients who resumed sports and time to resumption of sports) were analyzed with Kaplan-Meier curves as well as Mann-Whitney U, chi-square, and log-rank tests. Secondary functional outcomes were assessed with questionnaires (American Orthopaedic Foot and Ankle Society ankle-hindfoot score, Foot and Ankle Outcome Score, EuroQol, and numeric rating scales for pain and satisfaction) at multiple time points up to 1-year follow-up. To assess bone repair, computed tomography scans were obtained at 2 weeks and 1 year postoperatively. RESULTS: Almost all outcome measures improved significantly in both groups. The percentage of sport resumption (PEMF, 79%; placebo, 80%; P = .95) and median time to sport resumption (PEMF, 17 weeks; placebo, 16 weeks; P = .69) did not differ significantly between the treatment groups. Likewise, there were no significant between-group differences with regard to the secondary functional outcomes and the computed tomography results. CONCLUSION: PEMF does not lead to a higher percentage of patients who resume sports or to earlier resumption of sports after arthroscopic debridement and microfracture of talar OCDs. Furthermore, no differences were found in bone repair between groups. REGISTRATION: Netherlands Trial Register NTR1636.

Fibrates as therapy for osteoarthritis and rheumatoid arthritis? A systematic review.

Fibrates are used as lipid-lowering drugs to prevent cardiovascular pathology. Fibrates are ligands of peroxisome proliferator-activated receptor α (PPARα). Besides altering lipid metabolism, PPARα ligands exert anti-inflammatory effects on various cell types. In this study, we hypothesized that PPARα agonists exert beneficial effects on osteoarthritis (OA) and rheumatoid arthritis (RA) by their local anti-inflammatory effects, but also by their systemic influences. A systematic literature search of Medline and EMBASE databases was performed up to August 2011. The main search items were osteoarthritis, rheumatoid arthritis, peroxisome proliferator-activated receptor alpha and fibrates. Inclusion criteria were in vivo or in vitro studies regarding humans or animals in which the effects of PPARα ligands were studied. Six in vivo human studies, four in vivo animal studies and seven in vitro studies were included. The in vivo human studies showed all beneficial clinical effects of PPARα ligands, but studies were small and only four were randomized. Ligands for PPARα significantly reduced pain, swelling of the joints and decreased systemic inflammatory markers. In vitro and in vivo animal studies indicate that PPARα agonists inhibit bone resorption, and reduce inflammatory and destructive responses in cartilage and synovium. PPARα agonists such as fibrates should be considered as potential therapeutic strategy for RA. There is no clinical evidence for their use in OA, although in vitro studies indicate that PPARα agonists demonstrate different joint-protective effects locally, and systemic effects on inflammation, serum lipid levels and vascular pathology. Animal studies should be performed and after confirmation of the protective effects of PPARα, large randomized controlled trials could investigate fibrates in OA and RA.

Rehabilitation and return-to-sports activity after debridement and bone marrow stimulation of osteochondral talar defects.

An osteochondral defect (OD) is a lesion involving the articular cartilage and the underlying subchondral bone. ODs of the talus can severely impact on the quality of life of patients, who are usually young and athletic. The primary treatment for ODs that are too small for fixation, consists of arthroscopic debridement and bone marrow stimulation. This article delineates levels of activity, determines times for return to activity and reviews the factors that affect rehabilitation after arthroscopic debridement and bone marrow stimulation of a talar OD. Articles for review were obtained from a search of the MEDLINE database up to January 2012 using the search headings 'osteochondral defects', 'bone marrow stimulation', 'sports/activity', 'rehabilitation', various other related factors and 'talus'. English-, Dutch- and German-language studies were evaluated.The review revealed that there is no consensus in the existing literature about rehabilitation times or return-to-sports activity times, after treatment with bone marrow stimulation of ODs in the talus. Furthermore, scant research has been conducted on these issues. The literature also showed that potential factors that aid rehabilitation could include youth, lower body mass index, smaller OD size, mobilization and treatment with growth factors, platelet-rich plasma, biphosphonates, hyaluronic acid and pulse electromagnetic fields. However, most studies have been conducted in vitro or on animals. We propose a scheme, whereby return-to-sports activity is divided into four phases of increasing intensity: walking, jogging, return to non-contact sports (running without swerving) and return to contact sports (running with swerving and collision). We also recommend that research, conducted on actual sportsmen, of recovery times after treatment of talar ODs is warranted.