How to Treat Cartilage Injuries in the Ankle Joint by BMDC' s Transplantation

Osteochondral lesions of the ankle joint are defects of the cartilaginous surface and underlying subchondral bone, typically affecting the talus, most frequently traumatic in origin. Osteochondral lesions are often asymptomatic and may be treated conservatively, taking care to follow the patient over time. Bigger lesions, or higher grade lesions, especially in adult patients, are usually painful and hardly respond to a conservative treatment. So(( that,)) surgical treatment is frequently indicated. Thanks to technical advancements, regenerative techniques are quickly moving from traditional periostium based autologous chondrocyte implantation (ACI) to bone marrow derived cell transplantation (BMDCT). The introduction of a biodegradable scaffold based on the benzylic ester of hyaluronic acid for cell support and proliferation represented a first advancement toward a full arthroscopic procedure and significatively decreased the morbidity of ACI procedure in the ankle joint. Still two surgeries were required. Recently, BMDCT has been proposed as a technique capable to provide a repair of the lesion by hyaline cartilage in a one step procedure. Mesenchymal stem cells have the ability to differentiate into osteoblasts and chondroblasts. The rationale of the “one-step technique” is to transplant the entire bone-marrow cellular pool instead of isolated and expanded mesenchymal stem cells. This allows cells to be processed directly in the operating room, without the need for a laboratory phase, and BMDCT to be performed in “one step”. With a dedicated kit a total amount of about 60 ml of bone marrow aspirate is harvested from the posterior iliac crest, with the patient in prone decubitus. A scaffold and the instrumentation previously used for ACI are then used for an entirely arthroscopic implantation. Autologous platelet-rich fibrin (PRF) is added in order to provide a supplement of growth factors. The results of this procedure have been confirmed by biopsies and T2 mapping MRI and are clinically encouraging at mid-term. Evolution in surgical technique, new biomaterials and more recently the use of BMDCs permitted a marked reduction in procedure morbidity and costs up to a “one step” technique able to overcome the drawbacks of previous repair techniques. The stability of the results needs to be followed long term