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Osteochondral defects (OCDs) of the talus have a significant impact on the quality of life of patients. When OCDs are of small nature (up to 15 mm in diameter), and have failed conservative management, surgical intervention may be necessary. For small cystic defects the current treatment is an arthroscopic bone marrow stimulation (BMS) procedure, during which the damaged cartilage is resected and the subchondral bone is microfractured (MF), in order to disrupt intraosseous blood vessels and thereby introduce blood and bone marrow cells into the debrided lesion, forming a microfracture fibrin clot, which contains a dilute stem cell population from the underlying bone marrow. This procedure has been reported to have a 75% successful long-term outcome. Recently, the additional use of biological adjuncts has become popular, one of them being bone marrow aspirate concentrate (BMAC) from the iliac crest. BMAC consists of mesenchymal stem cells, hematopoietic stem cells and growth factors, which may therefore theoretically improve the quality of subchondral plate and cartilage repair. The current evidence for treating talar OCDs with BMS plus BMAC is limited and heterogeneous. It is unclear to what extent the treatment of talar OCDs with BMS plus BMAC is beneficial in comparison to BMS alone.
Osteochondral defects (OCDs) of the talus have a significant impact on the quality of life of patients. When OCDs are of small nature (up to 15 mm in diameter), and have failed conservative management, surgical intervention may be necessary. For small cystic defects the current treatment is an arthroscopic bone marrow stimulation (BMS) procedure, during which the damaged cartilage is resected and the subchondral bone is microfractured (MF), in order to disrupt intraosseous blood vessels and thereby introduce blood and bone marrow cells into the debrided lesion, forming a microfracture fibrin clot, which contains a dilute stem cell population from the underlying bone marrow. This procedure has been reported to have a 75% successful long-term outcome. Recently, the additional use of biological adjuncts has become popular, one of them being bone marrow aspirate concentrate (BMAC) from the iliac crest. BMAC consists of mesenchymal stem cells, hematopoietic stem cells and growth factors, which may therefore theoretically improve the quality of subchondral plate and cartilage repair. The current evidence for treating talar OCDs with BMS plus BMAC is limited and heterogeneous. It is unclear to what extent the treatment of talar OCDs with BMS plus BMAC is beneficial in comparison to BMS alone.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| BMS without BMAC | Active Comparator |
| |
| BMS with BMAC | Experimental |
|
| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| BMS + Bone Marrow Aspirate Concentrate | Biological | Both groups of patients are surgically treated with arthroscopic bone marrow stimulation (BMS). The control group will receive BMS alone but with a sham-treatment consisting of a Jamashidi (bone marrow aspiration) needle puncture of the iliac crest. The aspirated bone marrow concentrate will be collected and sent for cell characterisation but will not be inserted in the talar OCD. The intervention group will also receive arthroscopic BMS. From this group, BMAC from the iliac crest will be taken by the same needle puncture. Part of this concentrate will be sent for cell characterisation. Another part will be implanted into the talar OCD. |
| Measure | Description | Time Frame |
|---|---|---|
| Numeric Rating Scale of Pain During Weightbearing | 2 years post-operatively |
| Measure | Description | Time Frame |
|---|---|---|
| EQ5D | pre-operatively | |
| EQ5D | three months postoperatively | |
| EQ5D |
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Inclusion Criteria:
Exclusion Criteria:
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| Name | Role | Phone | Extension | |
|---|---|---|---|---|
| Jari Dahmen, MD, BSc | Contact | +31638522988 | j.dahmen@amsterdamumc.nl |
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| BMS alone | Procedure | Both groups of patients are surgically treated with arthroscopic bone marrow stimulation (BMS). The control group will receive BMS alone but with a sham-treatment consisting of a Jamashidi (bone marrow aspiration) needle puncture of the iliac crest. The aspirated bone marrow concentrate will be collected and sent for cell characterisation but will not be inserted in the talar OCD. The intervention group will also receive arthroscopic BMS. From this group, BMAC from the iliac crest will be taken by the same needle puncture. Part of this concentrate will be sent for cell characterisation. Another part will be implanted into the talar OCD. |
|
| one-year post-operatively |
| EQ5D | two years post-operatively |
| AOFAS | American Orthopaedic Foot and Ankle Score (AOFAS) | preoperatively |
| AOFAS | American Orthopaedic Foot and Ankle Score (AOFAS) | three months postoperatively |
| AOFAS | American Orthopaedic Foot and Ankle Score (AOFAS) | one-year post-operatively |
| AOFAS | American Orthopaedic Foot and Ankle Score (AOFAS) | two years post-operatively |
| FAOS | Foot and Ankle Outcome Score | pre-operatively |
| FAOS | Foot and Ankle Outcome Score | three months |
| FAOS | Foot and Ankle Outcome Score | one-year post-operatively |
| FAOS | Foot and Ankle Outcome Score | two years post-operatively |
| NRS in rest | Numeric Rating Scale of Pain During Rest | pre-operatively |
| NRS in rest | Numeric Rating Scale of Pain During Rest | 3 months postoperatively |
| NRS in rest | Numeric Rating Scale of Pain During Rest | 1 year postoperatively |
| NRS in rest | Numeric Rating Scale of Pain During Rest | 2 years postoperatively |
| NRS during running | Numeric Rating Scale of Pain During Running | pre-operatively |
| NRS during running | Numeric Rating Scale of Pain During Running | 3 months postoperatively |
| NRS during running | Numeric Rating Scale of Pain During Running | 1 year postoperatively |
| NRS during running | Numeric Rating Scale of Pain During Running | 2 years postoperatively |
| NRS during stair-climbing | Numeric Rating Scale of Pain During Stair-Climbing | pre-operatively |
| NRS during stair-climbing | Numeric Rating Scale of Pain During Stair-Climbing | 3 months postoperatively |
| NRS during stair-climbing | Numeric Rating Scale of Pain During Stair-Climbing | 1 year postoperatively |
| NRS during stair-climbing | Numeric Rating Scale of Pain During Stair-Climbing | 2 years postoperatively |
| NRS during performing sports | Numeric Rating Scale of Pain During Sports | pre-operatively |
| NRS during performing sports | Numeric Rating Scale of Pain During Sports | 3 months post-operatively |
| NRS during performing sports | Numeric Rating Scale of Pain During Sports | 1 year post-operatively |
| NRS during performing sports | Numeric Rating Scale of Pain During Sports | 2 years post-operatively |
| NRS during weight-bearing | Numeric Rating Scale of Pain During Weightbearing | pre-operatively |
| NRS during weight-bearing | Numeric Rating Scale of Pain During Weightbearing | 3 months postoperatively |
| NRS during weight-bearing | Numeric Rating Scale of Pain During Weightbearing | 1 year post-operativley |
| FAAM | Foot and Ankle Ability Measure | pre-operatively |
| FAAM | Foot and Ankle Ability Measure | 3 months postoperatively |
| FAAM | Foot and Ankle Ability Measure | 1 year postoperatively |
| FAAM | Foot and Ankle Ability Measure | 2 years postoperatively |
| SF-12 | Short-Form 12 | pre-operatively |
| SF-12 | Short-Form 12 | 3 months postoperatively |
| SF-12 | 1 year postoperatively |
| SF-12 | Short-Form 12 | 2 years postoperatively |
| Ankle Activity Scale (AAS) | pre-operatively |
| Ankle Activity Scale (AAS) | 3 months postoperatively |
| Ankle Activity Scale (AAS) | 1 year post-operatively |
| Ankle Activity Scale (AAS) | 2 year post-operatively |
| Return to sports | post-operatively until 2 years of follow-up post-operatively |
| Return to work | post-operatively until 2 years of follow-up post-operatively |
| Radiological outcomes: CT-scan (depth, wide, length, joint space measurement) | pre-operatively |
| Radiological outcomes: CT-scan (depth, wide, length, joint space measurement) | 2 weeks postoperatively |
| Radiological outcomes: CT-scan (depth, wide, length, joint space measurement) | 1 year postoperatively |
| Radiological outcomes: CT-scan (depth, wide, length, joint space measurement) | 2 years postoperatively |
| Radiological outcomes: MRI scan (T2 relaxation times) | Pre-operatively |
| Radiological outcomes: MRI scan (T2 relaxation times) | 1 year post-operatively |
| Radiological outcomes: MRI scan (T2 relaxation times) | 2 years post-operatively |
| Cost-effectiviness | all relevant clinical costs will be scored through a patient diary | From per-operatively to post-operatively at 2 years (one period) |
| Cell-subset analysis | protein analyses will be performed by Sanquin | per-operatively |
| Demographic data | all kinds of demographic data will be assessed (age, gender, etc.) | Pre-operatively |
| Complications | all types of complications | From per-operatively to post-operatively at 2 years (one period) |
| Re-operations | re-operations will be assessed | From per-operatively to post-operatively at 2 years (one period) |