| Part One Effect analysis of iliac bone autografting for Hepple V osteo-chondral lesions of the talusBackground:Talar cartilage injury is a kind of disease that causes long-term and chronic pain of ankle joint.Osteochondral lesion of the talus（OLT）is an important cause of ankle pain and functional limitation[1].From the anatomic view,ankle site had approximately 1/2 to 3/5 the maximum cartilage thickness at weight-bearing areas as that of hip and knee（2.7mm vs3-6mm）[2].Thus,any abnormal alignment of the ankle would lead to local stress concentration and accelerate the degeneration of ankle cartilage[2][3].Many studies have shown that patients with repeated sprains or fractures of the ankle have a high probability of talar cartilage injury[4].In the early stages of talar cartilage injury,there are no obvious signs and the pain is diffuse and poorly localized;in the late stages,the main clinical manifestations are ankle swelling and pain（aggravated during weight-bearing walking）and joint strangulation.Currently,there is well-established consensus that conservative treatment is effective for early talar cartilage damage（Stage I and II defined by Hepple classification）,which typically imaging presents with injury of the articular cartilage alone[1].The conservative treatment is mainly by reducing physical activity,avoiding vigorous exercise,and taking appropriate rest;intraarticular injection of platelet-rich plasma（PRP）[10],extracorporeal shock wave therapy,and oral medications may also be administered[6].However,there is controversy regarding the treatment of talus cartilage injuries of stage III-V,especially Hepple V,for doctors and patients,there are great challenges in the treatment process.At present,the main surgical approaches include arthroscopic microfracture or drilling,autologous or allogeneic osteochondral transplantation,and autologous chondrocyte implantation or periosteal bone grafting[11].Although arthroscopic drilling has the advantages of minimal trauma and rapid recovery,it is only effective for lesions<15 mm[12];long-term follow-up studies show that bone cysts deteriorate after minimally invasive surgery,leading to surgical failure and poor results,making it unsuitable for larger cartilage injuries[13][14].Osteochondral grafting using autologous,allogeneic,or engineered bone grafts is becoming widely used for osteochondral injuries,especially for Hepple V OLT.Allogeneic osteochondral grafts avoid donor complications,but carry the risks of graft rejection and disease transmission.Autologous osteochondral grafts are usually taken from the osteochondral column of the ipsilateral knee,producing hyaline cartilage with excellent biomechanical properties,but potentially leading to irreversible knee damage.However,iliac bone grafts have fewer complications in the treatment of talar cartilage injuries,and the iliac periosteum has multifunctional stem cells with the ability to differentiate into chondrocytes and fibrocartilage[7][8][15].Autologous osteochondral transplantation has been viewed as an alternative choice for treating these lesions,but donor-site morbidity has limited its application.This study aimed to analyze the efficacy of iliac bone autografting for Hepple V osteochondral lesions of the talus.Methods:This retrospective study included 32 patients surgically treated for Hepple V osteochondral lesions of the talus from January 2015 to January2020.All patients underwent open surgery.Ipsilateral iliac bone grafts were taken and filled with talar cartilage injury area.The improvement of postoperative ankle pain was evaluated by Visual Analogue Scale（VAS）,and the improvement of ankle function was evaluated by the American Orthopaedic Foot&Ankle Society（AOFAS）.During the postoperative follow-up,X-ray examination of the front and side of the ankle joint and CT of the ankle joint were performed to evaluate the bone cartilage healing in the graft area.Results:Thirty-two patients（32 ankles）（100%）returned for clinical and radiologic follow-up at an average of 28（range 24–36）months postoperatively.At 3 months postoperatively and at the last follow-up,the AOFAS scores were（80.4±3.6）and（89.2±6.4）,respectively,which were significantly improved compared with the preoperative score（49.7±8.1）,indicating a statistically significant difference between the two sets of data（P<0.05）.The VAS scores were（2.1±0.9）and（1.5±0.8）,respectively,which were significantly better than the preoperative score（6.2±1.7）,and both difference has statistics significance（P<0.05）.Re-examination of the front and side of the ankle joint X-rays and CT showed that the bone healing at the osteotomy of medial malleolus and osteochondral transplantation area.All patients had no pain at the donor site.No complications occurred in 32 patients at the last follow-up.Conclusions:With iliac bone autografting for Hepple V osteochondral lesions of the talus can effectively relieve ankle joint pain and significantly improved ankle function.Level of evidence:Level III,Retrospective series.Part Two Comparing Platelet-rich Plasma Injections with Extracorporeal Shock Wave Therapy for Chronic Plantar FasciitisBackground: Plantar fasciitis is a self-limiting disease that is a common cause of adult heel pain.The 40-70 year old middle-aged and elderly are high incidence groups.[2] The main reason is that changes in biomechanics and variations in the structure of the foot lead to inflammation of the plantar fascia and degeneration of the fascia.[3,4,5] However,sedentary,long-term standing,exercise overload,and obesity（BMI>30Kg/m2）are common predisposing factors.[6,7] The clinical manifestations of PF are mainly pain and discomfort in the heel,usually with tenderness at the center of the plantar.It is characterized by severe pain and swelling in the heel when the patient takes the first step in the morning or stays still for a long time.The symptoms are alleviated as the activity increases,but as the walking distance or standing time increases,the pain symptoms worsen.[3]PF can be treated by numerous methods,the main methods include conservative and surgical treatment.But there is no cure.The conservative treatment involves reduced or no weight bearing,nonsteroidal anti-inflammatory drugs（NSAIDs）,stretching the gastrocnemius and soleus muscles and the plantar fascia,orthopedic insoles,corticosteroids,extracorporeal shock wave therapy（ESWT）,platelet-rich plasma（PRP）injections,are mainly aimed to reduce inflammation.[8,9] while continued problems may require surgical intervention,however,it is reported that only 10% of patients undergo surgery.[10] The surgical treatment includes soft tissue release,plantar nerve release,calcaneus osteotomy and calcaneus spur resection.[11,12] However,the surgery trauma is large,the price is high,and the postoperative effect is general,so the surgical treatment is not worthy of clinical promotion.Although there are so many treatments for the PF,but there is currently no gold standard.The mechanism by which NSAIDs treat PF is to produce anti-inflammatory and analgesic effects by inhibiting cyclooxygenase（COX）and preventing the synthesis of prostaglandins（PGs）.However,long-term use of large amounts of NSAIDs can cause adverse effects such as gastric mucosal damage,gastric bleeding,and even gastric perforation.[13] There are many types of insoles for the treatment of plantar fasciitis.The function of the insole is to reduce the pressure of the heel by providing shock absorbing cushion,while providing support for the medial arch to reduce the pressure on the plantar fascia.The fascia of the fascia and the calcaneus at the stop point of the calcaneus can be evenly distributed.However,this method lacks long-term follow-up or the sample size is small,and further research is needed.[14] Corticosteroid injections are usually reserved for resistant PF after a conservative,non-invasive intervention failure.The potent anti-inflammatory effects of corticosteroids accelerate the process of pain relief.However,its use has also described complications such as application site infection,heel fat pad atrophy and plantar fascia rupture.Corticosteroid injections are often reserved for resistant PF after failure of conservative noninvasive interventions.The potent anti-inflammatory effect of corticosteroids may hasten the process of pain relief.[15,16,17]At present,the literature reports that ESWT and PRP have achieved good results in the treatment of PF.ESWT can cause changes in substance P after acting on bone and muscle tissue.Substance P is a neuropeptide distributed in the nerve fibers.It is related to pain transmission.ESWT can release substance P in a short time and reduce its concentration in nerve fibers,thus relieving pain.[18] Platelet-pich plasma（PRP）is a plasma containing high concentrations of platelets obtained by centrifugation of autologous whole blood.PRP has been proved to contain various growth factors such as vascular endothelial growth factor（VEGF）,insulin-like growth factor（IGF）,transforming growth factor-β1（TGF β1）,epidermal growth factor（EGF）,and transforming growth factor-β2,（TGF-β2）,and platelet-derived growth factor（PDGF）,etc.These growth factors play an important role in tissue repair and regeneration [19,20].Although the fullness of literature of studies focused on the conservative treatment of PF,there are no paper comparing the long-term efficacy and the clinical outcome of the ESWT and PRP.The purpose of this prospective study was to compare the curative effect following platelet-rich plasma（PRP）injections with extracorporeal shock wave therapy（ESWT）,in the patients with chronic plantar fasciitis.Method: 100 patients with plantar fasciitis were randomly divided into 2 groups（group A and group B）,50 patients in each group.Patients were treated with autologous PRP injection in group A and with dolorclast radial ESWT in group B.Outcomes were assessed prior to the therapy and at 3,6,12,and 24 months following the therapy,which included American Orthopaedic Foot and Ankle Society（AOFAS）scores,visual analog scale（VAS）pain scores,subjective satisfaction score and MRI studies were obtained in all cases to confirm the diagnosis of plantar fasciitis.Result: No severe complications were recorded in the A and B groups.And in the treatment of plantar fasciitis have achieved good results.There was no significant difference in AOFAS scores between the two groups at 3 months after treatment.The AOFAS scores at 3,6,12,and 24 months after treatment in group A were 91,85,84,and 80.The AOFAS scores in group B were 89,85,83,and 79,respectively.Both groups of patients had significant improvement compared with before treatment（P<0.01）.Conclusion: The observations in this study indicate that PRP and ESWT are safe and feasible options for the treatment of chronic plantar fasciitis.But the long-term effect is not particularly satisfying. |
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