Today, I'll be discussing our paper entitled Balmer Stimulation and Biologics for Osteochondral Lesions of the Talus, a Systematic Review and Meta-Analysis of Clinical Comparative Studies. These are the relevant disclosures. So osteochondral lesions of the talus are a commonly occurring injury that are typically of a traumatic etiology, but also are often idiopathic. Conservative management typically yields unsatisfactory outcomes, so surgical intervention is typically warranted. There are a litany of different surgical techniques described, one of which is Balmer stimulation via microfracture. To date, there appears to be a lack of consensus regarding the role of biological augmentation of microfracture for osteochondral lesions of the talus. The purpose of this study was to clarify the effectiveness and safety of biological adjuvants as augmentation in Balmer stimulation by assessing complication rates, continuous functional outcome scores, and return-to-play data for osteochondral lesions of the talus. So a systematic review and search was conducted in the PubMed, EMBASE, and Cochrane Library databases in February 2021. The level of evidence for each study was assessed using the criteria published in the Journal of Bone and Joint Surgery. The quality of evidence was measured and assessed by the modified Coleman Methodological Score. We extracted clinical and radiological outcomes, complications, and revision rates. Fixed-effect models were employed if heterogeneity was graded as low, and random-effect models were employed if heterogeneity was graded moderate to high. We included studies that were comparative clinical studies, reported complication rates, continuous functional scores, and or return-to-play data following bone marrow stimulation versus biologics. There had to be full-text studies published in a peer-reviewed journal in English after the year of 2000. We excluded any review articles, non-comparative clinical studies, treatment arm confounded by partially-employed adjuvant treatment studies. Studies were in the treatment arm included patients with previously failed bone marrow stimulation, animal studies, and in vitro studies. So in total, after going through the exclusion and eligibility process, 13 studies were included. The level of evidence was mixed. There were five studies of level evidence 1, one study of level of evidence 2, and seven studies of level of evidence 3. There was a fair quality of evidence with a modifier-common methodological score of 65.2. The results demonstrated that favorable outcomes were found for patients who underwent bone marrow stimulation with hyaluronic acid compared to bone marrow stimulation alone. This is as reported in the fixed-effects model for the AOFAS score, which revealed a mean difference of minus 4.88, which points in favor of bone marrow stimulation and hyaluronic acid. In addition, the visual analog scale revealed a mean difference of 1.21, which also points in favor of bone marrow stimulation and hyaluronic acid. We found a lower complication rate and revision rates were found for patients who underwent bone marrow stimulation with CBMA compared to patients who had bone marrow stimulation alone. The complication rate for those who had bone marrow stimulation alone was 26.6, and the complication rate for patients who had bone marrow stimulation augmented with CBMA was 15.5, but this was not statistically significant. We found that the pooled revision rate for patients who underwent bone marrow stimulation alone was 23.4% compared to patients who underwent bone marrow stimulation with CBMA, who had a revision rate of 8.5%, and this was statistically significant. So in conclusion, we found that bone marrow stimulation with hyaluronic acid found and produced superior AOFAS-VAS pain scores compared to bone marrow stimulation alone. In addition, bone marrow stimulation that was augmented with CBMA found a reduction in revision rates, but this was not true for overall complication rates. Our study has shown that further research is required to establish the clinical superiority of various other biologics, plus or minus bone marrow stimulation versus bone marrow stimulation alone. In addition, an investigation into the superiority of biologics compared to other biologics for osteochondrolysis and atavis is also warranted.

Balmer stimulation

biologics

osteochondral lesions

clinical comparative studies

surgical techniques