Additional mesenchymal stem cell injection improves the outcomes of marrow stimulation combined with supramalleolar osteotomy in varus ankle osteoarthritis: short-term clinical results with second-look arthroscopic evaluation

Yong Sang Kim, Moses Lee, Yong Gon Koh, Yong Sang Kim, Moses Lee, Yong Gon Koh

Abstract

Background: Supramalleolar osteotomy (SMO) is reported to be an effective treatment for varus ankle osteoarthritis by redistributing the load line within the ankle joint. Mesenchymal stem cells (MSCs) have been proposed as a new treatment option for osteoarthritis on the basis of their cartilage regeneration ability. The purpose of this study was to compare the clinical, radiological, and second-look arthroscopic outcomes between MSC injection with marrow stimulation and marrow stimulation alone in patients with varus ankle osteoarthritis who have undergone SMO.

Methods: In this retrospective study, 62 patients (64 ankles) with varus ankle osteoarthritis underwent second-look arthroscopy at a mean of 12.8 months after arthroscopic marrow stimulation combined with SMO; 33 ankles were subjected to marrow stimulation alone (group I), and 31 were subjected to marrow stimulation with MSC injection (group II). Clinical outcome measures included a visual analog scale (VAS) for pain and the American Orthopaedic Foot and Ankle Society (AOFAS) score. Radiological outcome variables included the tibial-ankle surface (TAS), talar tilt (TT), and tibial-lateral surface (TLS) angles. In second-look arthroscopy, cartilage regeneration was evaluated using the International Cartilage Repair Society (ICRS) grade.

Results: The mean VAS score improved significantly from 7.2 ± 1.0 to 4.7 ± 1.4 in group I and from 7.3 ± 0.8 to 3.7 ± 1.5 in group II at the final follow-up (P < 0.001 for both groups). The mean AOFAS score also improved significantly from 61.7 ± 5.8 to 80.9 ± 6.7 in group I and from 60.6 ± 6.1 to 85.2 ± 5.1 in group II at the final follow-up (P < 0.001 for both groups). There were significant differences in the mean VAS and AOFAS scores between groups at the final follow-up (P = 0.002 and 0.010, respectively). At second-look arthroscopy, there were significant differences in ICRS grades between groups(P = 0.015 for medial aspect of the talar dome, P = 0.044 for medial aspect of the tibial plafond, and P = 0.005 for articular surface of the medial malleolus). ICRS grades were significantly correlated with clinical outcomes in both groups (all P < 0.05). Mean TAS, TT, and TLS angles improved significantly after SMO in both groups but were not significantly correlated with clinical outcomes or ICRS grade (all n.s.).

Conclusions: The clinical and second-look arthroscopic outcomes of MSC injection with marrow stimulation were better compared to those of marrow stimulation alone in patients with varus ankle osteoarthritis who have undergone SMO. Furthermore, the ICRS grade is significantly correlated with clinical outcome.

Keywords: Marrow stimulation; Mesenchymal stem cell; Supramalleolar osteotomy; Varus ankle osteoarthritis.

Figures

Fig. 1
Fig. 1
Flow diagram of patient involvement in the study
Fig. 2
Fig. 2
a–d Arthroscopic views of left ankle in a 54-year-old male patient who underwent marrow stimulation alone combined with supramalleolar osteotomy. e–h Arthroscopic views of the left ankle in a 52-year-old female patient who underwent mesenchymal stem cell injection and marrow stimulation combined with supramalleolar osteotomy. a, e Intraoperative arthroscopic findings showing a cartilage lesion with osteoarthritic change in the medial gutter area. b, f Arthroscopic views showing the perforation of the subchondral bone with a microfracture awl after the debridement of all unstable and damaged cartilage in the lesion. c, g Adequate bone bleeding at microfracture holes was confirmed after the tourniquet was released. d Second-look arthroscopy showing poor cartilage regeneration at the microfractured site (International Cartilage Repair Society [ICRS] grade IV). g Arthroscopic view after mesenchymal stem cell injection. h Second-look arthroscopy showing nearly normal coverage of the cartilage lesion (ICRS grade II)
Fig. 3
Fig. 3
Weightbearing ankle radiographs showing the radiographic parameters used to measure alignment in ankles with varus ankle osteoarthritis. a Anteroposterior view showing measurement of the tibial-ankle surface angle (TAS) and the talar tilt (TT). b Lateral view showing measurement of the tibial-lateral surface angle (TLS)

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