Foot & Ankle International - June 2017 - 613
Usuelli et al
different surgical techniques, autologous matrix-induced
chondrogenesis (AMIC) has proven to provide satisfactory
results through medium-term follow-up in the knee, hip,
and talus.12,19,32,34,38 AMIC combines microfractures with
the application of Chondro-Gide, a porcine collagen type I/
III bilayer matrix (Geistlich Surgery, Wolhusen,
Switzerland), used to stabilize and protect the blood clot
that results from microfracturing the subchondral bone. The
AMIC technique effectively exploits the ability of the resident bone marrow progenitor cells to regenerate articular
cartilage. Independent prognostic factors, such as age, size
of the lesion, history of trauma, and presence of osteophytes, negatively affect the outcome of OLTs treatment,
whereas there is no general consensus about body mass
index (BMI) even if it is generally considered to be a disadvantage in the healing of these lesions.4,5,8,35 In fact, in overweight patients there is an alteration of normal gait; during
the gait cycle, obese individuals have been reported to take
significantly shorter steps, walk slower, have increased step
widths, and exhibit greater ankle dorsiflexion and less ankle
plantarflexion throughout the gait cycle.18,26
The purpose of our study was to assess and evaluate
healing and the functional outcome after AT-AMIC in 2
weight groups of patients: patients with BMI t25 versus
patients with BMI <25.
Methods
This was a prospective study of 37 arthroscopic osteochondral reconstructions performed between January 2012 and
June 2014 in one center specializing in foot and ankle surgery. There were 21 patients with BMI <25 (Healthy Weight
Group [HG]) and 16 patients with BMI t25 (Overweight
Group [OG]). A BMI cut-off of 25 was used with reference
to the World Health Organization's "BMI Classification" in
which people with BMI t25 are considered overweight.14
The inclusion criteria for the prospective case series of
patients were: OLTs Type III and IV according to Berndt
and Harty's classification, skeletal maturity, and ability to
give informed consent.3 Exclusion criteria were as follows:
previous surgical treatment of the affected ankle, arthritis of
the ankle joint, kissing lesions, hemophilia, rheumatoid
arthritis, diabetes, metabolic syndrome, hyperthyroidism,
hypothyroidism, autoimmune disease, ongoing chemotherapy, radiation treatment or immunosuppression, and pregnancy or lactation. Of 53 patients screened for eligibility, 37
satisfied the inclusion and exclusion criteria and were
enrolled in the study. Of the 16 excluded patients, 7 underwent previous surgery on the affected ankle, 4 patients had
severe post-traumatic osteoarthritis of the ankle, one
showed a kissing lesion, 2 had not reached skeletal maturity, 1 woman was pregnant, and 1 was hemophilic.
Each patient in both groups was evaluated clinically and
radiologically at T0, T1, T2, and T3. Patients satisfying the
613
inclusion and exclusion criteria were divided into 2 groups.
The sample of 37 patients was composed of 15 (41%)
females and 22 (59%) males. Mean age at surgery was 34
years (range 14-61, SD ±12). The HG was composed of 21
patients, of which 11 (52.38%) were female and 10 (47.62%)
male, mean age at surgery was 33 years (range: 16-55, SD
±11) and with a mean BMI of 21.90 ± 1.94 (range: 15.6-24).
The OG was composed of 16 patients, of which 4 (25%)
were female and 12 (75%) male, mean age at surgery was
34 years (range: 14-61, SD ±14) and with a mean BMI of
27.41 ± 1.98 (range: 25.2-31.8). In HG, 7 lesions were centromedial, 6 posteromedial, 4 centrolateral, 2 anteromedial,
1 posterolateral, and 1 centrocentral. In OG, lesions were
divided as follows: 9 centromedial, 4 centrolateral, and 3
posteromedial. No patients were lost to the final follow-up
of 24 months.
The surgical procedures were all performed by the senior
author. All surgical interventions were performed using the
AT-AMIC technique previously described.32,33 Briefly, surgery was characterized by 2 arthroscopic phases. First, after
having achieved an adequate exposure through the use of a
Hintermann spreader (Integra LifeSciences, Plainsboro, NJ)
that allowed for sufficient joint distraction, the lesion was
debrided and prepared to receive the regenerative treatment.
Cancellous bone was harvested from the ipsilateral calcaneus with an accessory lateral approach to the calcaneus.
The cancellous bone was introduced using the same cannula
and impacted into the bony defect until complete fill was
achieved. The second surgical step was performed in a dry
condition, during which Chondro-Gide (Geistlich Surgery),
a porcine collagen type I/III matrix, was placed and fixed
with synthetic fibrin glue (Tisseel, Baxter, Deerfield, IL)
along the lesion edges. The Hintermann spreader was then
removed, and matrix stability within a normal ankle range of
motion was verified. No surgical accessory time (ligament
reconstruction, medial calcaneal osteotomy, calcaneal
lengthening, or malleolar osteotomy) was performed in our
group of patients. Postoperative management required
movement restriction for 15 days to avoid membrane mobilization and no weight bearing for 40 days.33
All clinical assessments were performed by 2 clinicians
not involved in the surgical procedure. Each patient was evaluated preoperatively (T0), as well as at 6 (T1), 12 (T2), and 24
(T3) months. The evaluation included clinical and quality of
life parameters. Clinical evaluation consisted of subjective
global pain assessment by the VAS pain score, whereas the
intensity of pain, walking capacity, and activities of daily life
were assessed by the AOFAS score and SF-12 in its Physical
(PCS) and Mental (MCS) component.13,20,39 MRI and
CT-scan evaluations were also performed preoperatively, and
at 6, 12, and 24 months postoperatively. The location and the
area of the lesions were defined for each patient. The area
was measured according to Choi using coronal length (horizontal extension measured from the coronal image), sagittal
Table of Contents for the Digital Edition of Foot & Ankle International - June 2017
Contents
Foot & Ankle International - June 2017 - Intro
Foot & Ankle International - June 2017 - Cover1
Foot & Ankle International - June 2017 - Cover2
Foot & Ankle International - June 2017 - i
Foot & Ankle International - June 2017 - ii
Foot & Ankle International - June 2017 - Contents
Foot & Ankle International - June 2017 - iv
Foot & Ankle International - June 2017 - v
Foot & Ankle International - June 2017 - vi
Foot & Ankle International - June 2017 - vii
Foot & Ankle International - June 2017 - viii
Foot & Ankle International - June 2017 - 1A
Foot & Ankle International - June 2017 - 1B
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Foot & Ankle International - June 2017 - 2A
Foot & Ankle International - June 2017 - 2B
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Foot & Ankle International - June 2017 - 3A
Foot & Ankle International - June 2017 - 3B
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Foot & Ankle International - June 2017 - CT1
Foot & Ankle International - June 2017 - CT2
Foot & Ankle International - June 2017 - 4A
Foot & Ankle International - June 2017 - 4B
Foot & Ankle International - June 2017 - Cover3
Foot & Ankle International - June 2017 - Cover4
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