Original article
Arthroscopic treatment of talus osteochondral lesions: Study of 73 cases
Tratamiento artroscópico de las lesiones osteocondrales de astrágalo: estudio de 73 casos
M. Mellado-Romero
, B. Bravo-Giménez, C.M. Martín López, J.M. Cano-Egea, J. Vilà y Rico, C. Resines Érasun
Corresponding author
Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario Doce de Octubre, Madrid, Spain
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(A) Range of flexion: 135° and (B) flexion contracture: 20°.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "A.M. Martín-Fuentes, D. Cecilia-López, C. Resines-Erasun" "autores" => array:3 [ 0 => array:2 [ "nombre" => "A.M." "apellidos" => "Martín-Fuentes" ] 1 => array:2 [ "nombre" => "D." "apellidos" => "Cecilia-López" ] 2 => array:2 [ "nombre" => "C." 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Mellado-Romero, B. Bravo-Giménez, C.M. Martín López, J.M. Cano-Egea, J. Vilà y Rico, C. Resines Érasun" "autores" => array:6 [ 0 => array:4 [ "nombre" => "M." "apellidos" => "Mellado-Romero" "email" => array:1 [ 0 => "melli1984@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "B." "apellidos" => "Bravo-Giménez" ] 2 => array:2 [ "nombre" => "C.M." "apellidos" => "Martín López" ] 3 => array:2 [ "nombre" => "J.M." "apellidos" => "Cano-Egea" ] 4 => array:2 [ "nombre" => "J." "apellidos" => "Vilà y Rico" ] 5 => array:2 [ "nombre" => "C." "apellidos" => "Resines Érasun" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario Doce de Octubre, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Tratamiento artroscópico de las lesiones osteocondrales de astrágalo: estudio de 73 casos" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 658 "Ancho" => 1000 "Tamanyo" => 94228 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Grade II osteochondral lesion. The MRI scan shows the lesion in an anterolateral angle with subchondral bone edema and integrity of the articular surface.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Talus (or astragalus) osteochondral lesions are rare, affecting 0.041% of the population.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Most lesions are located laterally and are associated with a history of trauma; however, only 60–80% of medial lesions are attributed to traumatic causes. Lesions in the lateral dome are caused by dorsiflexion associated to inversion, whilst medial lesions are caused by plantar flexion, inversion and external rotation.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">These lesions often go unnoticed initially and most of them evolve toward chronic ankle pain. Diagnosis should be based on symptoms and imaging tests. Some lesions can be detected by simple radiography, but most cases require a computed tomography (CT) scan to be performed. This technique offers the most accurate diagnosis and the best definition of the dimensions of the lesion. A magnetic resonance imaging (MRI) test may also be required. Although this test overestimates the area involved due to its ability to detect associated bone edema, it is very useful to identify associated lesions<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The astragalus has limited reparative capacity because much of its surface is covered by articular cartilage, which limits vascular contribution.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Pain does not come from the cartilage lesion; it is most likely caused by increased fluid pressure during walking, which stimulates the richly innervated subchondral bone. Preventing future degeneration depends on various factors, including the repair of the defect and a correct alignment of the ankle joint.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">If we consider that we only obtain 45–50% of satisfactory results in patients undergoing conservative treatment, it follows that in many cases we shall have to resort to surgical treatment.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> This can be performed through open techniques or arthroscopic techniques.</p><p id="par0030" class="elsevierStylePara elsevierViewall">We can distinguish 2 approaches to treatment: on the one hand through osteochondral stimulation techniques, and on the other through chondral repair techniques. Osteochondral stimulation techniques include debridement and curettage with or without perforations. Repair techniques include autologous osteochondral transplantation, certain substitutive synthetic implants (TruFit<span class="elsevierStyleSup">®</span> Angle, OBI) and autologous chondrocyte culture. The choice of technique to be employed should take into account the grade, size and depth of the lesion, as well as the age and functional demands of the patient.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Objective</span><p id="par0035" class="elsevierStylePara elsevierViewall">The objective of our study is to evaluate the functional and clinical results using the AOFAS (American Orthopaedic Foot and Ankle Society) midfoot scale,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> as well as the complications of the different arthroscopic techniques used in the treatment of osteochondral talus lesions.</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Arthroscopic techniques</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Osteochondral stimulation</span><p id="par0040" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1.</span><p id="par0045" class="elsevierStylePara elsevierViewall">Debridement and curettage: the location of the lesion determined the use of classical anteromedial and anterolateral portals or posterior portals. We proceeded to the removal of the fragment, as well as any devitalized fibrous or cartilaginous debris, and curettage of the lesion surface with a synoviotome or fine arthroscopic mill, producing microfractures.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2.</span><p id="par0050" class="elsevierStylePara elsevierViewall">Anterograde and retrograde perforations: the objective was to create vascular access channels to the subchondral bone with medullar elements which stimulated the formation of fibrocartilage which covered the defect.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,10</span></a> At present, it is possible to perform perforations through the usual portals or using guides which allow transmalleolar or retrograde perforations in those cases in which extensive areas of bone edema or subchondral bone cysts coexist (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></li></ul></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Osteochondral repair</span><p id="par0055" class="elsevierStylePara elsevierViewall">In cases presenting surface osteochondral defects which are less than 2<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span> in diameter (grade III–IV), we can consider covering the defect with a graft.<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">1.</span><p id="par0060" class="elsevierStylePara elsevierViewall">Mosaicplasty: this is indicated in patients younger than 50 years with osteochondral lesions under 2<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span> in diameter and over 5<span class="elsevierStyleHsp" style=""></span>mm deep. It employs osteochondral plugs from non-load areas of the ipsilateral knee (external femoral side or intercondylar notch).<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Like other authors, due to the perpendicularity required by a correct placement of the osteochondral graft and to the axis of curvature of the talus, we favor the use of 2 plugs at most.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> Moreover, it is crucial to verify an absence of friction during dorsal or plantar flexion through arthroscopy (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>).</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">2.</span><p id="par0065" class="elsevierStylePara elsevierViewall">Synthetic substitute (TruFit<span class="elsevierStyleSup">®</span> Angle, OBI). OBI plugs are an osteochondral substitute made from a biodegradable and porous material composed of polyglycolic acid (PGA) fibers, calcium sulfate and a copolymer of lactic acid coglycolide. This technique shortens the surgical time and avoids morbidity at the donor site, albeit without offering the same properties as native cartilage.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> They have recently been recalled from the market.</p></li></ul></p></span></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Material and method</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Inclusion criteria</span><p id="par0070" class="elsevierStylePara elsevierViewall">Patients diagnosed with osteochondral talus lesions by imaging techniques, refractory to conservative treatment and intervened through arthroscopic ankle surgery.</p><p id="par0075" class="elsevierStylePara elsevierViewall">We conducted a retrospective study of 73 patients diagnosed with osteochondral talus lesions, intervened using arthroscopic techniques between 2000 and 2011 at the Arthroscopy Unit of the Orthopedic Surgery and Traumatology Service of Doce de Octubre University Hospital in Madrid, Spain.</p><p id="par0080" class="elsevierStylePara elsevierViewall">We identified 84 patients with a diagnosis of osteochondral talus lesion, of which 11 had to be ruled out because they had undergone open surgery. Of the 73 subjects included in the study, 50 patients underwent stimulation techniques (group A); platelet rich plasma (PRP) was used in 4 of them as an adjuvant treatment. Of the remaining 23 patients operated with repair techniques (group B), 20 underwent mosaicplasty and 3 of them underwent repair with a synthetic substitute graft.</p><p id="par0085" class="elsevierStylePara elsevierViewall">The lesions were classified during arthroscopic surgery, according to the classification of the International Cartilage Repair Society (ICRS),<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> which divides osteochondral lesions into: grade I, compression of the subchondral trabecular bone; grade II, articular defect; grade III, intact transchondral fracture, and grade IV, displaced transchondral fracture. We found a small number of grade I lesions (5%), and more lesions of grade II (40%), grade III (25%) and grade IV (30%). Grade I, II and some grade III lesions underwent stimulation techniques, whilst repair techniques were reserved for grade III and IV lesions (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">The mean age in group A was 32.58 years (range: 19–73 years), compared to 36.50 years (range: 19–58 years) in group B. We found a larger number of males in both groups (group A: 84.62%; group B: 83.3%). Regarding location, we observed a clear predominance of medial lesions (group A: 76.08%; group B: 91.67%). In terms of laterality, this was fairly similar in both groups, with 46.15% on the left side and 53.85% on the right side in group A and 41.67% on the left side and 58.33% on the right side in group B (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). The demographic characteristics of the sample were statistically comparable. The mean follow-up period was 19.5 months, with a minimum of 11 months (range: 11–34 months).</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">Patients were not immobilized postoperatively and began active ankle flexion and extension exercises and hydrotherapy from the time of discharge. In most cases, partial load was initiated after 3 weeks in patients undergoing stimulation techniques, and after 4 weeks in those undergoing repair techniques, with a full load at 8 weeks. Patients who underwent surgery during the initial years of the study followed a slower postoperative protocol, with partial load being delayed for 6–8 weeks.</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Results</span><p id="par0100" class="elsevierStylePara elsevierViewall">Clinical assessment was performed using the AOFAS midfoot scale (maximum value of 100 points), whilst associated injuries and complications were also recorded at the same time.</p><p id="par0105" class="elsevierStylePara elsevierViewall">The statistical analysis was performed using the software package SPSS<span class="elsevierStyleSup">®</span> v.17.0 (SPSS Inc., Chicago, IL, USA). Statistical significance was set at a 95% confidence interval (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.05).</p><p id="par0110" class="elsevierStylePara elsevierViewall">In group A, the assessment of preoperative AOFAS was 48.77 points (range: 31–67 points) compared to 85.19 points (range: 60–100 points) in the postoperative AOFAS. Group B experienced an improvement in the AOFAS score from 58.08 (range: 41–75 points) to 93.60 points (range: 80–100 points). The clinical improvement observed in both groups was statistically significant (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.001). When comparing the clinical improvement obtained in each group we did not find statistically significant differences (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.4471) (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">Next, we compared the difference between the results obtained for grade III lesions undergoing stimulation (12 patients) versus those undergoing repair (6 patients). These lesions were similar regarding depth, with a mean value of 7<span class="elsevierStyleHsp" style=""></span>mm (range: 5–12<span class="elsevierStyleHsp" style=""></span>mm). Regarding extension, the range in the stimulation group was 0.7–2.5<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span> in diameter with a mean value of 1.1<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span>. In the substitution group, the range of lesions was 1.1–1.9<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span> in diameter, with a mean value of 1.5<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span>. No statistically significant differences (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.1213) in clinical improvement were appreciated in grade III lesions treated by stimulation (preoperative AOFAS: 50.33; postoperative AOFAS: 90.83) compared to those undergoing repair (preoperative AOFAS: 67; postoperative AOFAS: 96.67) (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>).</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">Lastly, we compared patients treated with osteochondral stimulation techniques who were given PRP (preoperative AOFAS: 48.59; postoperative AOFAS: 85.14) versus those who were not given PRP (preoperative AOFAS: 49.75; postoperative AOFAS: 88.50) and found no statistically significant differences, although we must take into account the limitations of the series.</p><p id="par0125" class="elsevierStylePara elsevierViewall">Associated lesions were found in 22% of patients, often after having gone unnoticed in imaging tests and being diagnosed during arthroscopy. In group A (14%) we found 2 cases of instability treated by thermal retensing, 3 lesions of the anterior talofibular ligament (ATL) treated with a <span class="elsevierStyleItalic">peroneus brevis</span> plasty in 2 cases and by arthroscopic homograft in the other, and 2 cases of impingement, 1 in the bone and 1 in soft tissue, which were treated by arthroscopic debridement and resection.</p><p id="par0130" class="elsevierStylePara elsevierViewall">In group B (39%), we observed the following associated lesions: 2 cases of instability treated by thermal retensing and 2 ATL lesions treated with arthroscopic homograft. Moreover, we also found 4 cases of bony impingement and 1 case of soft tissue impingement, all treated by arthroscopic debridement and resection. In 1 patient the MRI led to a diagnosis of peroneal tendon injury, but the arthroscopy revealed <span class="elsevierStyleItalic">peroneus cuartus</span>, which was causing a space conflict that was resolved by tendoscopic debridement.</p><p id="par0135" class="elsevierStylePara elsevierViewall">The rate of complications in our series was low (11%). We observed 4 cases of diffuse disuse osteoporosis: 3 patients in group A and 1 patient in group B. In addition, among patients undergoing chondral stimulation techniques, 2 patients continued to suffer ankle pain and another patient developed arthritis, requiring a total ankle arthroplasty. We only found 1 case of donor site morbidity, with mild pain in the knee of 1 year evolution.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Discussion</span><p id="par0140" class="elsevierStylePara elsevierViewall">Following the completion of this study, we observed that both lines of treatment offered satisfactory short-term results with few complications. Therefore, the choice of one technique or the other should depend on the characteristics of the lesion: grade, size and depth, as well as the characteristics of the patient: age and functional demands. Performing an individualized approach and treatment is crucial.</p><p id="par0145" class="elsevierStylePara elsevierViewall">Adequate treatment of talus osteochondral lesions remains a subject of controversy. Most authors<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> recommend an initially conservative treatment for grade I and II lesions, and initial surgical treatment for grade III and IV lesions.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> As recommended by Zengerink et al.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> and Schuman et al.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> at our center we use conservative measures as the first treatment, despite obtaining poor results.</p><p id="par0150" class="elsevierStylePara elsevierViewall">Zengerink et al.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> and Schuman et al.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> conducted a systematic review of 52 studies of treatment strategies for osteochondral lesions and concluded that arthroscopic excision, curettage and bone marrow stimulation was the preferred treatment for primary talus osteochondral lesions. This technique offers the following advantages: low cost, scarce morbidity, rapid recovery and high success rate.</p><p id="par0155" class="elsevierStylePara elsevierViewall">In 2010, Qin-Wei et al.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> conducted a study seeking predictors of good results in arthroscopic treatment of osteochondral talus lesions through microfractures and found a strong correlation between the size of the lesion and the rate of satisfactory results. The best results were obtained in lesions smaller than 10<span class="elsevierStyleHsp" style=""></span>mm. Considering results such as this, at our center we use substitution techniques in larger lesions. Gender, age, professional sports activities and the location of the lesion were not significantly correlated with the results.</p><p id="par0160" class="elsevierStylePara elsevierViewall">Choi et al.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> conducted a cohort study in which they concluded that advanced age was not an independent risk factor for worse outcomes with arthroscopic perforations. Moreover, they found that, in older patients, traumatic history was less frequent and presented longer duration of symptoms and smaller osteochondral lesions. In our series of patients undergoing stimulation techniques, the mean age was 33.82 years, with a maximum of 73 years, since we did not consider advanced age as an exclusion criterion for stimulation techniques. However, we reserved replacement techniques for patients under 50 years.</p><p id="par0165" class="elsevierStylePara elsevierViewall">In a different line, Hangody et al.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> reported good results using arthroscopic mosaicplasty, obtaining good or excellent final ankle function on the Hanover scale in 36 of 39 patients (94%), with scarce iatrogenic damage at the donor site at the end of a follow-up period of 2 to 7 years. This technique is typically indicated for lesions smaller than 2<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span> in patients younger than 50 years. Associated difficulties include the limited surface that can be covered, thus leaving a dead space between the grafts which must be filled by fibrocartilage. There may also be surface irregularity due to the difference in thickness of the transplanted cartilage.</p><p id="par0170" class="elsevierStylePara elsevierViewall">Osteochondral substitute plugs can also be used as an alternative to osteochondral transplantation. This technique shortens the surgical time and eliminates damage at the donor site, albeit without offering the same properties as native cartilage.</p><p id="par0175" class="elsevierStylePara elsevierViewall">At present, there are studies which associate platelet-rich plasma as a coadjuvant treatment for osteochondral transplantation,<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> even employing repeated injections of hyaluronic acid or platelet-rich plasma as an isolated treatment with good results for at least 6 months.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> Due to the small number of patients in our study in whom we used platelet-rich plasma we could not extract significant conclusions.</p><p id="par0180" class="elsevierStylePara elsevierViewall">Despite not being employed at our center, autologous chondrocyte culture has been used since the 90s for lesions greater than 1<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span>. It is a costly technique which requires close collaboration with a tissue bank and which has the disadvantage of requiring surgery to be performed in 2 stages. Nevertheless, it has shown highly satisfactory results in recent years. Niemeyer et al.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> published a meta-analysis including 16 studies which concluded that, despite the promising results of the technique, further randomized and controlled trials were required to demonstrate its superiority or inferiority with respect to microperforations and transplants.</p><p id="par0185" class="elsevierStylePara elsevierViewall">The study conducted at our center has limitations, as it was a retrospective study with a mean follow-up period shorter than 2 years. Satisfactory results were obtained in both treatment groups.</p><p id="par0190" class="elsevierStylePara elsevierViewall">Our therapeutic algorithm for the treatment of osteochondral lesions was the following: osteochondral stimulation techniques for grade I–II–III lesions and replacement techniques for grade III–IV lesions, taking into account the characteristics of both patients and lesions, as well as the experience and preference of the surgeon. We opted for treating grade III lesions through repair techniques when the size of the lesion was less than 2<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span> and the depth was greater than 5<span class="elsevierStyleHsp" style=""></span>mm, in patients younger than 50 years. Likewise, we can say that there were no statistically significant differences in clinical improvement observed with one technique over the other, in the same way that Gobbi et al.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> found no statistically significant differences in their prospective randomized study (level of evidence I) comparing chondroplasty, microfractures and osteochondral allografts.</p><p id="par0195" class="elsevierStylePara elsevierViewall">We were able to achieve both diagnosis and treatment of associated injuries, often not diagnosed by CT or MRI scans. When we analyzed the scientific evidence published in the literature, we found a level of evidence B regarding the role of arthroscopic techniques in the treatment of osteochondral talus lesions.<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24,25</span></a> Further long-term, prospective, randomized studies with more cases would be required in order to evaluate the possible superiority of chondral stimulation versus chondral substitution techniques or vice versa.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conclusions</span><p id="par0200" class="elsevierStylePara elsevierViewall">We consider arthroscopic ankle surgery as an excellent technique for the accurate staging of osteochondral talus lesions, which are occasionally difficult to differentiate through imaging techniques.</p><p id="par0205" class="elsevierStylePara elsevierViewall">Both lines of treatment offered satisfactory results with few complications. The choice of one technique or another should depend on the characteristics of the lesion: grade, size and depth, as well as the characteristics of the patient: age and functional demands.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Level of evidence</span><p id="par0210" class="elsevierStylePara elsevierViewall">Level of evidence <span class="elsevierStyleSmallCaps">iv</span>.</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Ethical responsibilities</span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Protection of people and animals</span><p id="par0215" class="elsevierStylePara elsevierViewall">The authors declare that this investigation did not require experiments on humans or animals.</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Confidentiality of data</span><p id="par0220" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their workplace on the publication of patient data and that all patients included in the study received sufficient information and gave their written informed consent to participate in the study.</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Right to privacy and informed consent</span><p id="par0225" class="elsevierStylePara elsevierViewall">The authors declare having obtained written informed consent from patients and/or subjects referred to in the work. This document is held by the corresponding author.</p></span></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Financing</span><p id="par0230" class="elsevierStylePara elsevierViewall">This study employed no sources of financing.</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Conflict of interests</span><p id="par0235" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:15 [ 0 => array:2 [ "identificador" => "xres231463" "titulo" => array:5 [ 0 => "Abstract" 1 => "Background and aim" 2 => "Material and method" 3 => "Results" 4 => "Conclusions" ] ] 1 => array:2 [ "identificador" => "xpalclavsec217967" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres231464" "titulo" => array:5 [ 0 => "Resumen" 1 => "Introducción y objetivo" 2 => "Material y método" 3 => "Resultados" 4 => "Conclusiones" ] ] 3 => array:2 [ "identificador" => "xpalclavsec217968" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Objective" "secciones" => array:1 [ 0 => array:3 [ "identificador" => "sec0015" "titulo" => "Arthroscopic techniques" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Osteochondral stimulation" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Osteochondral repair" ] ] ] ] ] 6 => array:3 [ "identificador" => "sec0030" "titulo" => "Material and method" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "Inclusion criteria" ] ] ] 7 => array:2 [ "identificador" => "sec0040" "titulo" => "Results" ] 8 => array:2 [ "identificador" => "sec0045" "titulo" => "Discussion" ] 9 => array:2 [ "identificador" => "sec0050" "titulo" => "Conclusions" ] 10 => array:2 [ "identificador" => "sec0055" "titulo" => "Level of evidence" ] 11 => array:3 [ "identificador" => "sec0060" "titulo" => "Ethical responsibilities" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0065" "titulo" => "Protection of people and animals" ] 1 => array:2 [ "identificador" => "sec0070" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0075" "titulo" => "Right to privacy and informed consent" ] ] ] 12 => array:2 [ "identificador" => "sec0080" "titulo" => "Financing" ] 13 => array:2 [ "identificador" => "sec0085" "titulo" => "Conflict of interests" ] 14 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-02-04" "fechaAceptado" => "2013-03-21" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec217967" "palabras" => array:4 [ 0 => "Talus" 1 => "Osteochondral lesions" 2 => "Arthroscopy" 3 => "Chondral repair" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec217968" "palabras" => array:4 [ 0 => "Astrágalo" 1 => "Lesiones osteocondrales" 2 => "Artroscopia" 3 => "Reparación condral" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Background and aim</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The aim of our study is to analyze the different techniques used in arthroscopic treatment of talus osteochondral lesions.</p> <span class="elsevierStyleSectionTitle" id="sect0015">Material and method</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We retrospectively analyzed 73 patients who underwent surgery between 2000 and 2011. Patients were divided in two groups: group A (51 patients), those treated with osteochondral stimulation techniques, and group B (32 patients), that were treated by repair techniques. The mean age was 32.58 (19–73) years in group A and 36.50 (19–58) in group B. It is identified male predominance and medial lesions in both groups.</p> <span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Were evaluated according to the AOFAS ankle scoring scale, it is observed a statistically significant clinical improvement (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.001). Preoperative values were 48.77 (31–67) in group A and 58.08 (41–75) in group B. After surgery scores amounted to 85.19 (60–100) in group A and 93.60 (80–100) in group B.</p> <span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Ankle arthroscopy is an excellent technique for the accurate staging of osteochondral lesions, and diagnosis and treatment of associated injuries. The arthroscopic treatment of lesions grade <span class="elsevierStyleSmallCaps">i</span>, <span class="elsevierStyleSmallCaps">ii</span> and sometimes <span class="elsevierStyleSmallCaps">iii</span>, by stimulation techniques and chondral lesions grade <span class="elsevierStyleSmallCaps">iii</span> and <span class="elsevierStyleSmallCaps">iv</span> by replacement techniques, gives good results with few complications.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0035">Introducción y objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">El objetivo de nuestro estudio es analizar las distintas técnicas artroscópicas empleadas en el tratamiento de las lesiones osteocondrales de astrágalo.</p> <span class="elsevierStyleSectionTitle" id="sect0040">Material y método</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Realizamos un estudio retrospectivo de 73 casos, intervenidos entre los años 2000 y 2011. Los pacientes se dividieron en 2 grupos: grupo A (51 pacientes), aquellos tratados mediante técnicas de estimulación osteocondral; grupo B (32 pacientes), tratados mediante técnicas de reparación. La edad media fue de 32,58 años (19-73) en el grupo A, y 36,50 años (19-58) en el grupo B. Se identifica predominio del sexo masculino y de lesiones mediales en ambos grupos.</p> <span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se evaluaron los resultados siguiendo la escala de la AOFAS de retropié, observando una mejoría clínica estadísticamente significativa (p<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0,001). Los valores preoperatorios fueron 48,77 (31-67) en el grupo A, y 58,08 (41-75) en el grupo B. Después de la intervención quirúrgica las puntuaciones ascendieron a 85,19 (60-100) en el grupo A, y 93,60 (80-100) en el grupo B.</p> <span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La cirugía artroscópica es la técnica de elección en el tratamiento de las lesiones osteocondrales de tobillo, permite una correcta estadificación y tratamiento de las lesiones asociadas. El tratamiento artroscópico de las lesiones grado <span class="elsevierStyleSmallCaps">i</span>, <span class="elsevierStyleSmallCaps">ii</span>y, en ocasiones <span class="elsevierStyleSmallCaps">iii</span> mediante técnicas de estimulación condral, y de lesiones grado <span class="elsevierStyleSmallCaps">iii</span> y <span class="elsevierStyleSmallCaps">iv</span> mediante técnicas de reparación ofrece buenos resultados con escasas complicaciones (11%).</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Mellado-Romero M., et al. Tratamiento artroscópico de las lesiones osteocondrales de astrágalo: estudio de 73 casos. Rev Esp Cir Ortop Traumatol. 2013;<span class="elsevierStyleBold">57</span>:224–30.</p>" ] ] "multimedia" => array:8 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 597 "Ancho" => 800 "Tamanyo" => 46408 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Grade IV osteochondral lesion of the talus in an anteromedial angle. Plain radiography is the first imaging test to be considered in the diagnosis of osteochondral lesions.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 658 "Ancho" => 1000 "Tamanyo" => 94228 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Grade II osteochondral lesion. The MRI scan shows the lesion in an anterolateral angle with subchondral bone edema and integrity of the articular surface.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 517 "Ancho" => 1300 "Tamanyo" => 94545 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Arthroscopic image of perforations, 4<span class="elsevierStyleHsp" style=""></span>mm apart from each other, until bleeding of the subchondral site which stimulates production of fibrocartilage at the defect.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 504 "Ancho" => 1300 "Tamanyo" => 79026 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Debridement of the osteochondral lesion and reconstruction of the defect with an osteochondral plug in a grade IV medial lesion.</p>" ] ] 4 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">ICRS classification \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Description \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Grade <span class="elsevierStyleSmallCaps">i</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Compression of the subchondral trabecular bone \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Grade <span class="elsevierStyleSmallCaps">ii</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Articular defect \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Grade <span class="elsevierStyleSmallCaps">iii</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Intact transchondral fracture \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Grade <span class="elsevierStyleSmallCaps">iv</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Displaced transchondral fracture \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab347192.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Classification of osteochondral lesions according to the International Cartilage Repair Society (ICRS) scale.</p>" ] ] 5 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="3" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Treatment group</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Demographic data \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Stimulation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Repair \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Age (years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">32.58 (range: 19–73) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">36.50 (range: 19–58) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Gender \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">42 males \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">19 males \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 females \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 females \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Side \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">27 right \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13 right \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">23 left \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 left \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Location of the lesion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">37 medial \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">21 medial \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13 lateral \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 lateral \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ICRS classification \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4: grade <span class="elsevierStyleSmallCaps">i</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0: grade <span class="elsevierStyleSmallCaps">i</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">29: grade <span class="elsevierStyleSmallCaps">ii</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0: grade <span class="elsevierStyleSmallCaps">ii</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12: grade <span class="elsevierStyleSmallCaps">iii</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6: grade <span class="elsevierStyleSmallCaps">iii</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5: grade <span class="elsevierStyleSmallCaps">iv</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17: grade <span class="elsevierStyleSmallCaps">iv</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab347193.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Demographic data of patients and osteochondral lesions.</p>" ] ] 6 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">SD: standard deviation. Chi-squared test. Difference in post-pre AOFAS: <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.4471.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="4" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Treatment group</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Stimulation</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Repair</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Mean \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">SD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Mean \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">SD \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Preoperative AOFAS score \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">48.77 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10.21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">58.08 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9.93 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Postoperative AOFAS score \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">85.19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12.17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">93.60 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5.89 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Difference in post-pre AOFAS scores \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">36.42 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13.20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">35.20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12.68 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab347191.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Comparison between improvement on the AOFAS scale in lesions treated with repair vs substitution.</p>" ] ] 7 => array:7 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">SD: standard deviation. Chi-squared test. Difference in post-pre AOFAS: <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.213.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="4" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Treatment group</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Stimulation</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Substitution</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Mean \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">SD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Mean \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">SD \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Preoperative AOFAS score \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">50.33 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9.97 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">67 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Postoperative AOFAS score \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">90.83 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5.38 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">96.67 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.89 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Difference in post-pre AOFAS scores \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">40.50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14.24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">29.67 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8.50 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab347190.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Comparison between improvement on the AOFAS scale in grade III osteochondral lesions treated through stimulation vs substitution.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:25 [ 0 => array:3 [ "identificador" => "bib0005" 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 7 | 1 | 8 |
| 2024 October | 31 | 5 | 36 |
| 2024 September | 41 | 6 | 47 |
| 2024 August | 49 | 8 | 57 |
| 2024 July | 30 | 8 | 38 |
| 2024 June | 27 | 2 | 29 |
| 2024 May | 24 | 7 | 31 |
| 2024 April | 18 | 1 | 19 |
| 2024 March | 37 | 5 | 42 |
| 2024 February | 34 | 9 | 43 |
| 2024 January | 44 | 9 | 53 |
| 2023 December | 41 | 9 | 50 |
| 2023 November | 71 | 5 | 76 |
| 2023 October | 63 | 11 | 74 |
| 2023 September | 43 | 7 | 50 |
| 2023 August | 24 | 6 | 30 |
| 2023 July | 37 | 9 | 46 |
| 2023 June | 39 | 14 | 53 |
| 2023 May | 57 | 8 | 65 |
| 2023 April | 53 | 1 | 54 |
| 2023 March | 40 | 2 | 42 |
| 2023 February | 46 | 5 | 51 |
| 2023 January | 28 | 12 | 40 |
| 2022 December | 40 | 6 | 46 |
| 2022 November | 50 | 8 | 58 |
| 2022 October | 27 | 9 | 36 |
| 2022 September | 34 | 3 | 37 |
| 2022 August | 23 | 6 | 29 |
| 2022 July | 24 | 7 | 31 |
| 2022 June | 30 | 12 | 42 |
| 2022 May | 19 | 11 | 30 |
| 2022 April | 33 | 6 | 39 |
| 2022 March | 25 | 7 | 32 |
| 2022 February | 13 | 3 | 16 |
| 2022 January | 10 | 6 | 16 |
| 2021 December | 15 | 9 | 24 |
| 2021 November | 10 | 6 | 16 |
| 2021 October | 17 | 11 | 28 |
| 2021 September | 34 | 11 | 45 |
| 2021 August | 50 | 6 | 56 |
| 2021 July | 4 | 5 | 9 |
| 2021 June | 17 | 11 | 28 |
| 2021 May | 11 | 4 | 15 |
| 2021 April | 22 | 12 | 34 |
| 2021 March | 9 | 7 | 16 |
| 2021 February | 13 | 6 | 19 |
| 2021 January | 4 | 4 | 8 |
| 2018 February | 12 | 4 | 16 |
| 2018 January | 19 | 1 | 20 |
| 2017 December | 16 | 0 | 16 |
| 2017 November | 20 | 3 | 23 |
| 2017 October | 21 | 3 | 24 |
| 2017 September | 21 | 3 | 24 |
| 2017 August | 17 | 2 | 19 |
| 2017 July | 28 | 1 | 29 |
| 2017 June | 83 | 15 | 98 |
| 2017 May | 37 | 2 | 39 |
| 2017 April | 30 | 8 | 38 |
| 2017 March | 27 | 27 | 54 |
| 2017 February | 27 | 3 | 30 |
| 2017 January | 34 | 1 | 35 |
| 2016 December | 32 | 2 | 34 |
| 2016 November | 32 | 3 | 35 |
| 2016 October | 45 | 1 | 46 |
| 2016 September | 60 | 5 | 65 |
| 2016 August | 32 | 1 | 33 |
| 2016 July | 26 | 4 | 30 |
| 2016 June | 29 | 2 | 31 |
| 2016 May | 34 | 7 | 41 |
| 2016 April | 34 | 5 | 39 |
| 2016 March | 45 | 10 | 55 |
| 2016 February | 21 | 8 | 29 |
| 2016 January | 70 | 0 | 70 |
| 2015 December | 29 | 5 | 34 |
| 2015 November | 25 | 4 | 29 |
| 2015 October | 26 | 5 | 31 |
| 2015 September | 24 | 3 | 27 |
| 2015 August | 39 | 9 | 48 |
| 2015 July | 34 | 7 | 41 |
| 2015 June | 6 | 0 | 6 |
| 2015 May | 13 | 2 | 15 |
| 2015 April | 0 | 1 | 1 |
| 2014 September | 1 | 0 | 1 |
| 2014 August | 2 | 1 | 3 |
| 2014 July | 3 | 0 | 3 |
| 2014 June | 5 | 0 | 5 |
| 2014 May | 7 | 1 | 8 |
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