Emerging Advances In Ankle Cartilage Repair

Author(s): 
Rotem Ben-Ad, DPM, and Bob Baravarian, DPM

   In their study comparing patients treated with either microfracture alone or with a combination of arthroscopic marrow stimulation treatment and stem cell therapy, Kim and colleagues found significantly more favorable results in patients who had a stem cell supplemented procedure.9 This was especially true for lesions that were larger than 109 mm² or those with subchondral cysts present.

   In our practice at the University Foot and Ankle Institute, we have found success in enhancing other treatment modalities with stem cell therapy. For example, one can introduce bone marrow aspirate following a simple microfracture procedure or even add bone marrow aspirate to stimulate subchondral bone formation when retrograde drilling is required.

   One may combine stem cell therapy with the aforementioned DeNovo graft, amnion membrane application or platelet rich plasma. Addition of an amnion membrane creates a solid scaffold onto which the stem cells can proliferate.10 Amnion membrane’s regenerative and anti-inflammatory properties are ideal for use in supporting the repair process of a talar lesion. Platelet rich plasma (PRP) contributes many growth factors to the area to again augment the healing process. One can even use PRP and bone marrow aspirate prior to casting during conservative treatment to increase the probability of cartilage restoration.

In Conclusion

Although there are many facets to the treatment of osteochondral lesions of the ankle and talus, the main factors to consider are the size of the lesion, the depth of the lesion and the desired activity level of the patient. With advancements in orthobiologic and regenerative therapies, the treatment of these lesions is being more customized to the needs of the individual patient.

   In the future, cartilage replacement may be as simple as an injection or spray but for now, the stem cell options are helping us address lesions previously doomed to treatment failure.

   Dr. Ben-Ad is a Fellow at University Foot and Ankle Institute in Los Angeles.

   Dr. Baravarian is an Assistant Clinical Professor at the UCLA School of Medicine. He is the Chief of Podiatric Foot and Ankle Surgery at the Santa Monica UCLA Medical Center and Orthopedic Hospital, and is the Director of the University Foot and Ankle Institute in Los Angeles.

References
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7. Kruse DL, Ng A, Paden M, Stone PA. Arthroscopic DeNovo® NT juvenile allograft cartilage implantation in the talus: A case presentation. J Foot Ankle Surg. 2012; 51(2):218-221.
8. Coetzee JC, Giza E, Schon LC, et al. Treatment of osteochondral lesions of the talus with particulated juvenile cartilage. Foot Ankle Int. 2013; ebup ahead of print.
9. Kim YS, Park EH, Kim YC, Koh YG. Clinical outcomes of mesenchymal stem cell injection with arthroscopic treatment in older patients with osteochondral lesions of the talus. Am J Sports Med. 2013; 41(5):1090-9.
10. Niknejad H, Peirovi H, Jorjani M, et al. Properties of the amnion membrane for potential use in tissue engineering. Eur Cell Materials. 2008; 15:88-99.

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