Treatment of Osteochondral Lesions of the Talus With Bone Marrow Stimulation and Chitosan–Glycerol Phosphate/Blood Implants (BST-CarGel)

Abstract

Bone marrow stimulation (BMS) techniques represent the first-line treatment for unstable osteochondral lesions of the talus or after conservative treatment failure. These techniques are intended to penetrate the subchondral bone to elicit bleeding and allow precursor cells and cytokines from bone marrow to populate the lesion. However, the fibrocartilaginous repair tissue arising after marrow stimulation confers inferior mechanical and biological properties compared with the original hyaline cartilage. The limitations of BMS can be overcome by the use of the soluble chitosanbased polymer BST-CarGel (Piramal Life Sciences, Laval, Quebec, Canada). When mixed with freshly drawn autologous whole blood and applied to a lesion surgically prepared by BMS, BST-CarGel acts as a natural bioscaffold that increases the quantity and improves the residency of the blood clot formed in the cartilage lesion, enhancing the local healing response. The use of BST-CarGel has been previously described in the knee and hip joints with successful results. We describe the arthroscopic technique for BST-CarGel application in combination with BMS techniques for the treatment of osteochondral lesions of the talus.

Early loss of subchondral bone following microfracture is counteracted by bone marrow aspirate in a translational model of osteochondral repair

“…These procedures chiefly include autologous matrix-induced chondrogenesis (AMIC)36 and commercially available enhanced marrow-stimulation products373839. However, reports of clinical outcomes for patients treated with enhanced microfracture technique for articular cartilage repair remain limited to date, and long-term outcomes are unavailable.…”

Effect of autologous adipose-derived mesenchymal stem cell therapy in the treatment of an osteochondral lesion of the ankle

“…10 Recent research has assessed the use of an injectable bio-scaffold (BST-CarGel) in association with bone marrow stimulation techniques for isolated chondral lesions with reported improvements comparable to ACI at 12 months of follow-up. 11 The ability of mesenchymal stem cells (MSCs) to differentiate along cell lines of mesodermal lineage (including osteoblasts and chondrocytes) has seen them being explored as an orthobiologic cellular therapy for tissue repair. [12][13][14] However, despite their observed multi-potency, it is now more commonly accepted that their mechanism of action is primarily due to paracrine expression of cytokines, the release of secretomes/exosomes containing both cytokines and messenger RNA for direct horizontal translational upregulation of reparative cellular processes and by direct cell to cell interaction.…”

Geles y membranas

“…Estas técnicas de estimulación de condrogénesis autóloga mediante membranas (AMIC) o geles (ACIC), asociadas a perforaciones (micro-o nanofracturas), podrían denominarse de forma general "EMO aumentada" (10,29) . La matriz de base colágena tiene la doble función de andamiaje sobre el que "anidan" las células mesenquimales y, por otro, "contener" y estabilizar el hematoma en la lesión, logrando así un ambiente biológicamente propicio para la proliferación y diferenciación celular (2,4,16,19,24,28) .…”

“…La mayor resistencia mecánica y estabilidad que los geles o membranas imprimen al coágulo, así como un mejor aislamiento del medio intraarticular que evite migración celular o de factores inflamatorios no deseados al interior de la lesión o hueso subcondral, podría interferir con el proceso reparativo y en algunos trabajos se ha relacionado este hecho con la principal causa de dolor en las LOA, dado que el cartílago en sí mismo es un tejido anervado (25) . Sin embargo, la ventaja de los geles respecto a las membranas puede ser su facilidad técnica para implantarlos por vía artroscópica (24,26) .…”

“…Vilá y Rico et al (24) , en un trabajo multicéntrico dirigido en nuestro país en 2015, describen la técnica artroscópica en tobillo, siendo una de las ventajas de esta matriz, siempre que la lesión sea bien abordable. Recomiendan la técnica para lesiones de hasta 3 cm 2 y describen su protocolo postoperatorio.…”