Randomized Controlled Clinical Trial, Level 1.

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Several surgical techniques have been described for the treatment of talar chondral lesions. Among them, microfracture is well established. Autologous matrix-induced chondrogenesis (AMIC), using microfracture and biomaterials, has shown promising results for the treatment of knee osteochondral lesions and has been proposed for the ankle as an open technique. We describe an all-arthroscopic AMIC technique. The benefits of an all-arthroscopic procedure include smaller incisions with less soft-tissue dissection, better visualization of the joint, and a quicker recovery compared with open surgery. The use of matrix to support cartilage regeneration promotes good-quality cartilage tissue with satisfactory long-term outcomes. Our all-arthroscopic AMIC technique uses a type Ietype III porcine collagen matrix (Chondro-Gide; Geistlich Pharma, Wolhusen, Switzerland) and is characterized by 2 different arthroscopic surgical phases. First, adequate exposure is achieved through use of a Hintermann spreader (Integra LifeSciences, Plainsboro, NJ) with sufficient joint distraction and wet lesion preparation. The second surgical step is performed dry, involving matrix placement and fixation. The all-arthroscopic AMIC technique for the treatment of osteochondral lesions of the talus allows a very precise reconstruction in the case of cartilage defects and avoids the need for a more invasive operation associated with higher morbidity and a longer surgical time.

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Purpose: the aim of this study is to report the clinical and imaging results recorded by a series of patients in whom osteochondral lesions of the talus (oLts) were repaired using the autologous collagen-induced chondrogenesis (ACiC) technique with a completely arthroscopic approach. Methods: nine patients (mean age 37.4±10 years) affected by oLts (lesion size 2.1±0.9 cm 2 ) were treated with the ACiC technique. the patients were evaluated clinically both preoperatively and at 12 months after surgery using the American orthopaedic Foot and Ankle society Ankle-Hindfoot scale (AoFAs) and a visual analog scale (VAs). For morphological evaluation, the magnetic resonance observation of cartilage repair tissue (MoCARt) score was used. Results: the AoFAs score improved from 51.4±11.6 preoperatively to 71.8±20.6 postoperatively, while the VAs value decreased from 6.9±1.8 to 3.2±1.9. the mean MoCARt score was 51.7±16.6 at 12 months of follow-up; these scores did not directly correlate with the clinical results. Conclusion: use of the ACiC technique for arthroscopic repair of oLts allowed satisfactory clinical results to be obtained in most of the patients as soon as one year after surgery, with no major complications or delayed revision surgery. ACiC is a valid and lowinvasive surgical technique for the treatment of chondral and osteochondral defects of the talus. Level of evidence: therapeutic case series, level iV.

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Objectives:Achilles tendinopathy commonly occurs in both active and inactive persons. It consists in the development of pain and inflammation in the early phases, with progression to the development of fibrotic tissue and degeneration of tendon matrix. Current conservative treatment approaches do not provide sustained satisfactory results, particularly in active patients, although platelet rich plasma (PRP) injection have shown to be effective in many cases. The therapeutic effect of adipose-derived mesenchymal stem cells (ASCs), either expanded or used directly within the stromal vascular fraction (SVF), have demonstrated to possess significant anti-inflammatory and immunomodulatory effects, mediated by the release of active factors, and thus potentially useful in the treatment of tendinopathy.Methods:Patients affected by non-insertional Achilles tendinopathy (range 18-55 y/o) were prospectively enrolled in this controlled study, and randomly assigned either to single PRP injection group (GPSIII kit, Biomet, USA) (n=28 tendons) or single adipose tissue SVF (FastKit, Corios, Italy) (n=28 tendons) injection group. All patients were assessed clinically pre-operatively and at 15, 30, 60, 120 and 180 days from treatment, using VAS Pain, VISA-A, AOFAS and SF-36 forms. Patients also underwent to US and MRI before treatment and then at 4 and 6 month-follow-ups. An aliquot of SVF of each patient was analyzed in vitro for mesenchymal stem cells (MSC) content, viability, proliferation rate, differentiation potential and immunomodulatory ability. Sample size of the study was calculated with a power analysis based on VISA-A score. All the results are expressed as mean ± standard deviation. A Wilcoxon test for paired data was performed to compare variables before and after surgery.Results:Population background data and pre-operative scores were similar in the two groups (p>0.05). At final follow up both patients group showed significantly improvements in all the scores in comparison to baseline (p<0.05). In SVF patients these improvements were faster, with significantly better scores with respect to pre-injection level already starting 15 days after treatment. Indeed at this time point a significant difference between groups in term of VAS, AOFAS and VISA-A score was observed (p<0.05), with better results in the SVF group. After 6 months MR and ultrasounds showed an improvement of clinical signs in both groups, without relevant differences. No side effects were observed in neither groups. In vitro analysis showed a modest content of MSCs in the SVF samples; however these cells were able to efficiently proliferate and differentiate, and to exert good immunomodulatory effect in an in vitro inflammatory model.Conclusion:Both PRP and SVF are safe and effective treatments for Achilles tendinopathy. However, SVF allowed to obtain faster results, thus allowing to consider this treatment particularly suitable for patients requiring to come back to physical activities sooner.

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