Posterior arthroscopic treatment of ankle osteochondral lesions: technical note

Osteochondral lesions of the ankle are lesions that involve the cartilage and the subchondral bone of the talus. The aim of this study is to describe the clinical results of a consecutive case series of posterior osteochondral lesions of the talus treated with debridement and bone marrow stimulation by means of posterior ankle arthroscopy. We hypothesise that posterior ankle arthroscopy is an effective and safe procedure to treat lesions less than 10–15 mm in size and 5 mm in depth located in zones 7, 8 and 9 of the Raikin and Elias grid. We prospectively analysed the outcomes of 36 patients who underwent posterior endoscopic treatment of osteochondral lesions of the talus. The American Orthopaedic Foot and Ankle Society (AOFAS) clinical rating system and the Foot and Ankle Ability Measure were used and patient satisfaction was evaluated. Visual Analogue Scale (VAS) was complementarily used with these measures to evaluate the clinical behaviour of the patients. The average AOFAS score improved from 42.3 preoperatively to 89.29 postoperatively. All patients were satisfied with the surgical outcome and would choose this surgical treatment again. Three minor and transitory postoperative complications (5.55%) were observed: one patient with pain on the portals, one ecchymosis and one hypoesthesia of the heel. The average score on VAS improved from 7.75 preoperatively to 1.54 postoperatively, with an average improvement of 6.21 points. 75% of patients were able to resume their ‘preinjury’ physical activity level. The posterior arthroscopic approach with bone marrow stimulation is technically simple and is a safe and effective procedure to treat posterior talar osteochondral lesions. It has few complications, thus reducing time to return to sports and/or work activity.Level of evidenceIV, case series.

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Impact of Early Weightbearing After Ankle Arthroscopy and Bone Marrow Stimulation for Osteochondral Lesions of the Talus

Orthopaedic Journal of Sports Medicine ◽

10.1177/23259671211029883 ◽

2021 ◽

Vol 9 (9) ◽

pp. 232596712110298

Author(s):

Richard M. Danilkowicz ◽

Nathan L. Grimm ◽

Gloria X. Zhang ◽

Thomas A. Lefebvre ◽

Brian Lau ◽

...

Keyword(s):

Bone Marrow ◽

Statistical Significance ◽

Osteochondral Lesion ◽

Ankle Arthroscopy ◽

Categorical Variables ◽

Cartilage Defects ◽

Osteochondral Lesions ◽

Bone Marrow Stimulation ◽

Gold Standard Method ◽

Marrow Stimulation

Background: Osteochondral lesion of the talus (OLT) may be caused by osteochondritis dissecans, osteochondral fractures, avascular necrosis, or focal arthritic changes. For certain focal cartilage defects, bone marrow stimulation (BMS) has been a widely used technique to restore a fibrocartilage substitute overlying the defect. There are various postoperative weightbearing protocols for this procedure, with no single gold standard method. Purpose: To retrospectively review the outcomes of patients undergoing ankle arthroscopy with concomitant BMS to determine outcomes based on postoperative weightbearing status. Study Design: Cohort study; Level of evidence, 3. Methods: We retrospectively reviewed the records of patients who underwent ankle arthroscopy with BMS for OLTs between 2015 and 2018. Patients were placed into 2 cohorts based on postoperative immobilization status: the nonweightbearing (NWB) group and the weightbearing-as-tolerated (WBAT) group. Patient characteristics obtained included age, sex, comorbidities, and etiology of talar pathology. Outcomes included the pain visual analog scale (VAS), range of motion (ROM), complications, time to first weightbearing, and the method and length of immobilization. Patients who were lost to follow-up before 30 days were excluded. The chi-square test was used to compare categorical variables between cohorts, and the t test was used for continuous variables. Results: A total of 69 patients met the inclusion criteria for this study, 18 in the WBAT group and 51 in the NWB group. The mean lesion size was 9.48 × 9.21 mm (range, 3-15 mm × 2-20 mm) for the NWB group and 9.36 × 9.72 mm (range, 5-14 mm × 6-20 mm) for the WBAT group ( P > .05). The VAS scores improved from 4.40 to 0.67 for the WBAT group and from 6.33 to 2.55 for the NWB group, with the difference in final values reaching statistical significance ( P = .0002). Postoperative ROM was not significantly different between the groups. There were 4 repeat operations within the NWB cohort. Conclusion: The surgical management of OLTs can be challenging, and the postoperative weightbearing protocol can be an extra obstacle for the patient to navigate. We found no difference in pain, ROM, or complications when allowing immediate, full WBAT.

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Long-term Outcomes of Microfracture for Treatment of Osteochondral Lesions of the Talus

Foot & Ankle Orthopaedics ◽

10.1177/2473011420s00176 ◽

2020 ◽

Vol 5 (4) ◽

pp. 2473011420S0017

Author(s):

Daniel Corr ◽

Jared Raikin ◽

Joseph T. O’Neil ◽

Steven M. Raikin

Keyword(s):

Bone Marrow ◽

Osteochondral Lesions ◽

Treatment Technique ◽

Foot And Ankle ◽

Bone Marrow Stimulation ◽

Time Of Surgery ◽

Patient Demographics ◽

Marrow Stimulation

Category: Ankle; Arthroscopy Introduction/Purpose: Bone marrow stimulation procedures, specifically microfracture, have become a common treatment technique for osteochondral lesions of the talus (OLT). Such procedures have been shown to be effective among a variety of patient populations at postoperative time points up to about 5 years (references?). While microfracture has been shown to be effective in short- to medium-term follow-up, there is a paucity of literature demonstrating the long-term efficacy of this procedure. Recently, the development of additional treatment techniques has been explored, with deterioration of the resultant fibrocartilage being a particular concern with microfracture. The purpose of this study is to determine the long-term effectiveness of microfracture bone marrow stimulation for treatment of OLTs in patients at least 10 years removed from surgery. Methods: A retrospective review of patients undergoing microfracture of an OLT with a single fellowship-trained orthopaedic foot and ankle surgeon at least 10 years prior was performed. Patients meeting the inclusion criteria were contacted to complete the Foot & Ankle Ability Measure (FAAM) Activities of Daily Living (ADL) and Sports subscales, visual analog scale (VAS) for pain, as well as surveyed regarding their satisfaction with the outcome of the procedure using a 5-point Likert scale. In addition to medical chart review, patients were asked directly over the phone about any subsequent foot and ankle procedures needed, any injections necessary, and whether they wore an ankle brace/orthotic in the time following the procedure. Patient demographics including sex, age at time of surgery, laterality of surgery, and surgical history following their index procedure were reviewed. Descriptive statistics were calculated for patient demographics and survey responses to assess functional outcomes. Results: Forty-two patients were contacted and completed postoperative surveys. Average patient age at the time of the procedure was 38.6 years, and 24 patients (57%) were male. On average, FAAM-ADL score was 86.57 (+-20.85), Sports score was 72.31 (+-30.48), and VAS pain score was 19.52 (scale of 0-100). Patients reported being satisfied with the outcome of the procedure in 35 of 42 cases (83.3%). Five patients (11.9%) had other foot/ankle procedures since their microfracture, with 3 directly addressing the talus in some fashion. Three patients (7.1%) received injection(s) in their ankle in the follow-up period, and 9 patients (21.4%) reported wearing a brace since the time of surgery with 6 patients (14.3%) reporting it as a direct relation to their OLT and surgery. Conclusion: This study demonstrates that microfracture is an effective functional treatment for OLT in the long term, and addresses the valid questions posed about the ability for the procedure to produce durable fibrocartilage. Patients report average functional and pain assessment scores at the 10-year postoperative mark consistent with a generally successful and effective treatment.

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Results of Arthroscopic Talar Osteochondral Lesions with Bone Marrow Stimulation and BST-CarGel

Foot & Ankle Orthopaedics ◽

10.1177/2473011419s00163 ◽

2019 ◽

Vol 4 (4) ◽

pp. 2473011419S0016

Author(s):

Jagwinder Dhaliwal ◽

Andrew Wines

Keyword(s):

Quality Of Life ◽

Bone Marrow ◽

Functional Outcome ◽

Osteochondral Lesions ◽

Foot And Ankle ◽

Bone Marrow Stimulation ◽

Marrow Stimulation ◽

The Mean

Category: Ankle, Trauma Introduction/Purpose: Osteochondral lesions (OCL) are described as any defect involving both the articular surface and the subchondral bone of the talus. They are commonly associated with acute ankle injuries occurring often in active population. Bone marrow stimulation with microfracture is a standard reparative treatment for OCD however decline in related functional outcome has been reported. BST-CarGel contains chitosan which binds to negatively charged cartilage surface acting as biocompatible scaffold. This allows repair tissue with significant filling volume and proper integration into the surroundings. There has been reported better quantitative and qualitative cartilage repair tissue at 12 months with BST-CarGel. We first report on clinical results of bone marrow stimulation and BST-Cargel for recalcitrant talar OCL in patients previously treated with microfracture alone in a prospective study. Methods: This prospective single surgeon series was limited to patients with symptomatic OCL who previously had arthroscopic debridement and microfracture for same lesion. The pre-operative evaluation of all patients involved clinical assessment, weight bearing plain radiographs and magnetic resonance imaging of ankle joint. Inclusion criteria were age 18-55 years, single focal OCL of talus less than 3 cm2 and previous microfracture. Exclusion criteria was evidence of ankle osteoarthritis and allergy to chitosan or known hypersensitivity to crustaceans such as shrimp, lobster, and crab. Functional outcome assessment was measured using Foot and Ankle outcome score (FAOS) and EQ5D (Health related quality of life) pre and post-operatively. We used paired Student’s t-test for statistical analysis. Values for p < 0.05 were regarded as significant. The surgical technique used have been previously described in literature for OCL of the talus treated with bone marrow stimulation and Cargel. Results: There were fourteen patients who were treated with arthroscopic BST-Cargel with BMS and followed up prospectively. There was no loss to follow-up. The mean follow-up post-operatively was 28 months. There were eight males and six females in the study group. Patient mean age at the time of operation was 42 years (21–60 years). The mean size of talar OCL treated was 2.8 cm2 . Mean FAOS score for symptoms pre-operatively was 41.7 and post-operative was 52.8 (P<0.01). Mean FAOS pain subscale pre-operatively was 45.7 and post-operatively 55.6 (P<0.01). FAOS function and daily living score pre-operatively was 41.4 and post-operatively was 55.8 (P<0.01). Mean FAOS quality of life score was 39.2 pre-operatively and post-operative score 57.2 (P<0.01). EQ5D pre-operatively was 15 and post-operatively was 8 (P<0.01). Conclusion: We noted statistically significant improvement in each subscale of The Foot and Ankle Outcome questionnaire scores post-operatively. There was also significant improvement in generic health status instrument EQ-5D. We also noted talar OCL improvement on MRI scan taken pre and post BST-CarGel treatment. Recalcitrant OCL of talus present considerable challenge with persistent pain, functional limitations and secondary osteoarthritis. BST-Cargel treatment in our clinical study improved functional outcome scores similar to previously reported hip and knee studies. It requires standard arthroscopic technique and no complications were observed in our study.

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Immediate Unrestricted Postoperative Weightbearing and Mobilization after Bone Marrow Stimulation of Large Osteochondral Lesions of the Talus

Cartilage ◽

10.1177/1947603516657639 ◽

2016 ◽

Vol 8 (1) ◽

pp. 73-79 ◽

Cited By ~ 2

Author(s):

Gregory A. Lundeen ◽

Linda J. Dunaway

Keyword(s):

Bone Marrow ◽

Case Series ◽

Lesion Size ◽

Arthroscopic Treatment ◽

Osteochondral Lesions ◽

Postoperative Rehabilitation ◽

Level Of Evidence ◽

Bone Marrow Stimulation ◽

Marrow Stimulation

Objective There remains no consensus on a postoperative protocol following arthroscopic treatment of osteochondral lesions of the talus (OLTs) and most studies report a period of immobilization and nonweightbearing. Outcomes are believed to decrease with larger size. The purpose of our study was to evaluate patients who underwent arthroscopic treatment of large (≥150 mm2) OLTs with immediate unrestricted weightbearing and mobilization postoperatively. Design Patients who underwent arthroscopic bone marrow stimulation for osteochondral defects were identified. Exclusion criteria included lesions less than 150 mm2, additional procedures other than ligament reconstruction, incongruent ankle joint, arthritis, and tibial plafond lesions. Postoperatively, all patients were placed into a soft dressing and were allowed immediate weightbearing as tolerated. Patients were considered failures if their AOFAS (American Orthopaedic Foot and Ankle Society) score was less than 80 or if they underwent osteochondral transplant. Results Thirteen patients were available for follow-up. Two patients underwent osteochondral transplant and were considered failures. Of the remaining 11, the average follow-up time after surgery was 33 months (range, 7-59 months). Average age was 37 years (range, 15-56 years), and lesion size averaged 239 mm2 (range, 150-400 mm2). Average postoperative scores included foot function index 50 (range, 23-136), visual analog scale 3 (range, 0-8), and AOFAS hindfoot 82 (range, 40-100). The group’s overall success rate was 54% (7/13). Conclusion The results of our study are higher than those previously published studies on large lesions with a more restricted postoperative rehabilitation, suggesting that unrestricted weightbearing and range of motion does not diminish patient outcomes. Level of Evidence: IV, Case series.

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Outcomes of Bone Marrow Stimulation for Secondary Osteochondral Lesions of the Talus Equal Outcomes for Primary Lesions

Cartilage ◽

10.1177/19476035211025816 ◽

2021 ◽

pp. 194760352110258

Author(s):

Quinten G. H. Rikken ◽

Jari Dahmen ◽

Mikel L. Reilingh ◽

Christiaan J. A. van Bergen ◽

Sjoerd A. S. Stufkens ◽

...

Keyword(s):

Bone Marrow ◽

Rating Scale ◽

General Health Questionnaire ◽

Return To Sport ◽

Osteochondral Lesions ◽

Foot And Ankle ◽

Bone Marrow Stimulation ◽

Marrow Stimulation ◽

Significant Difference

Objective To compare clinical, sports, work, and radiological outcomes between primary and secondary osteochondral lesions of the talus (OLTs; <15 mm) treated with arthroscopic bone marrow stimulation (BMS). Design Secondary OLTs were matched to primary OLTs in a 1:2 ratio to assess the primary outcome measure—the Numeric Rating Scale (NRS) during activities. Secondary outcomes included the pre- and 1-year postoperative NRS at rest, American Orthopaedic Foot and Ankle Society score, Foot and Ankle Outcome Score subscales, and the EQ-5D general health questionnaire. The rates and time to return to work and sports were collected. Radiological examinations were performed preoperatively and at final follow-up using computed tomography (CT). Results After matching, 22 and 12 patients with small (<15 mm) OLTs were included in the primary and secondary groups, respectively. The NRS during activities was not different between primary cases (median: 2, interquartile range [IQR]: 1-4.5) and secondary cases (median: 3, IQR: 1-4), P = 0.5. Both groups showed a significant difference between all pre- and postoperative clinical outcome scores, but no significant difference between BMS groups postoperatively. The return to sport rate was 90% for primary cases and 83% for secondary cases ( P = 0.6). All patients returned to work. Lesion filling on CT was complete (67% to 100%) in 59% of primary cases and 67% of secondary cases ( P = 0.6). Conclusion No differences in outcomes were observed between arthroscopic bone marrow stimulation in primary and secondary OLTs at 1-year follow-up. Repeat BMS may therefore be a viable treatment option for failed OLTs in the short term.

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Evidence-based Treatment of Failed Primary Osteochondral Lesions of the Talus: A Systematic Review on Clinical Outcomes of Bone Marrow Stimulation

Cartilage ◽

10.1177/1947603521996023 ◽

2021 ◽

pp. 194760352199602

Author(s):

Jari Dahmen ◽

Eoghan T. Hurley ◽

Yoshiharu Shimozono ◽

Christopher D. Murawski ◽

Sjoerd A. S. Stufkens ◽

...

Keyword(s):

Bone Marrow ◽

Success Rate ◽

Revision Rate ◽

Clinical Success ◽

Clinical Success Rate ◽

Rate Of Return ◽

Osteochondral Lesions ◽

Return To Sports ◽

Bone Marrow Stimulation ◽

Marrow Stimulation

ObjectiveThe purpose of this study is to systematically review the literature and to evaluate the outcomes following bone marrow stimulation (BMS) for nonprimary osteochondral lesions of the talus (OLT).DesignA literature search was performed to identify studies published using PubMed (MEDLINE), EMBASE, CDSR, DARE, and CENTRAL. The review was performed according to the PRISMA guidelines. Two authors separately and independently screened the search results and conducted the quality assessment using the Methodological Index for Non-Randomized Studies (MINORS). Studies were pooled on clinical, sports, work, and imaging outcomes, as well as revision rates and complications. The primary outcome was clinical success rate.ResultsFive studies with 70 patients were included in whom nonprimary OLTs were treated with secondary BMS. The pooled clinical success rate was 61% (95% confidence interval [CI], 50-72). The rate of return to any level of sport was 83% (95% CI, 70-91), while the return to pre-injury level of sport was 55% (95% CI, 34-74). The rate of return to work was 92% (95% CI, 78-97), and the complication rate was assessed to be 10% (95% CI, 4-22). Imaging outcomes were heterogeneous in outcome assessment, though a depressed subchondral bone plate was observed in 91% of the patients. The revision rate was 27% (95% CI, 18-40).ConclusionsThe overall success rate of arthroscopic BMS for nonprimary osteochondral lesions of the talus was 61%, including a revision rate of 27%. Return to sports, work, and complication outcomes yielded fair to good results.

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Satisfactory long-term clinical outcomes after bone marrow stimulation of osteochondral lesions of the talus

Knee Surgery Sports Traumatology Arthroscopy ◽

10.1007/s00167-021-06630-8 ◽

2021 ◽

Author(s):

Quinten G. H. Rikken ◽

Jari Dahmen ◽

Sjoerd A. S. Stufkens ◽

Gino M. M. J. Kerkhoffs

Keyword(s):

Bone Marrow ◽

Clinical Outcomes ◽

Degenerative Changes ◽

Osteochondral Lesions ◽

Ankle Osteoarthritis ◽

Bone Marrow Stimulation ◽

Marrow Stimulation ◽

The Mean

Abstract Purpose The purpose of the present study was to evaluate the clinical and radiological outcomes of arthroscopic bone marrow stimulation (BMS) for the treatment of osteochondral lesions of the talus (OLTs) at long-term follow-up. Methods A literature search was conducted from the earliest record until March 2021 to identify studies published using the PubMed, EMBASE (Ovid), and Cochrane Library databases. Clinical studies reporting on arthroscopic BMS for OLTs at a minimum of 8-year follow-up were included. The review was performed according to the PRISMA guidelines. Two authors independently conducted the article selection and conducted the quality assessment using the Methodological index for Non-randomized Studies (MINORS). The primary outcome was defined as clinical outcomes consisting of pain scores and patient-reported outcome measures. Secondary outcomes concerned the return to sport rate, reoperation rate, complication rate, and the rate of progression of degenerative changes within the tibiotalar joint as a measure of ankle osteoarthritis. Associated 95% confidence intervals (95% CI) were calculated based on the primary and secondary outcome measures. Results Six studies with a total of 323 ankles (310 patients) were included at a mean pooled follow-up of 13.0 (9.5–13.9) years. The mean MINORS score of the included studies was 7.7 out of 16 points (range 6–9), indicating a low to moderate quality. The mean postoperative pooled American Orthopaedic Foot and Ankle Society (AOFAS) score was 83.8 (95% CI 83.6–84.1). 78% (95% CI 69.5–86.8) participated in sports (at any level) at final follow-up. Return to preinjury level of sports was not reported. Reoperations were performed in 6.9% (95% CI 4.1–9.7) of ankles and complications related to the BMS procedure were observed in 2% (95% CI 0.4–3.0) of ankles. Progression of degenerative changes was observed in 28% (95% CI 22.3–33.2) of ankles. Conclusion Long-term clinical outcomes following arthroscopic BMS can be considered satisfactory even though one in three patients show progression of degenerative changes from a radiological perspective. These findings indicate that OLTs treated with BMS may be at risk of progressing towards end-stage ankle osteoarthritis over time in light of the incremental cartilage damage cascade. The findings of this study can aid clinicians and patients with the shared decision-making process when considering the long-term outcomes of BMS. Level of evidence Level IV.

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Return to Sports After Bone Marrow–Derived Cell Transplantation for Osteochondral Lesions of the Talus

Cartilage ◽

10.1177/1947603516642574 ◽

2016 ◽

Vol 8 (1) ◽

pp. 80-87 ◽

Cited By ~ 18

Author(s):

Francesca Vannini ◽

Marco Cavallo ◽

Laura Ramponi ◽

Francesco Castagnini ◽

Simone Massimi ◽

...

Keyword(s):

Bone Marrow ◽

Cell Transplantation ◽

Case Series ◽

Clinical Results ◽

Osteochondral Lesions ◽

Return To Sports ◽

One Step ◽

American Orthopaedic ◽

Return To Activity

Objective Arthroscopic “one-step” technique based on bone marrow–derived cell transplantation (BMDCT) have achieved good results in repairing osteochondral lesions of the talus (OLT), overcoming important drawbacks of older techniques. It may be particularly adequate for the treatment of athletes in order to permit a safe and stable return to sports. The aim of this study was to report the results at 48 months of a series of athletes and the factors influencing the return to sports. Design Case series. A total of 140 athletes underwent a “one-step” BMDCT repair of OLT. All the patients had the cells harvested from the iliac crest, condensed and loaded on a scaffold, and then implanted. Patients were evaluated clinically by the American Orthopaedic Foot and Ankle Society (AOFAS) scores and Halasi score. Results AOFAS score improved from 58.7 ± 13.5 preoperatively to 90.6 ± 8.6 ( P < 0.005) at 24 months, and to 90.9 ± 10.7 at 48 months. Halasi score was 6.88 ± 1.8 preinjury, 4.08 ± 1.7 preoperatively, and 5.56 ± 2.0 at final follow-up. At the final follow-up, all the patients (beside 1 failure and 3 lost) were able to return to activity and 72.8% were able to resume sports at preinjury level. Conclusions “One-step” BMDCT repair of OLT had good clinical results that was durable over time in athletes, permitting a return to sports at preinjury level in the majority of patients. The preoperative presence of impingement and articular degeneration were the main negative prognostic factors.

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Effect of subchondral bone sclerosis in repair tissue after bone marrow stimulation for osteochondral talar lesions

Foot & Ankle Orthopaedics ◽

10.1177/2473011418s00525 ◽

2018 ◽

Vol 3 (3) ◽

pp. 2473011418S0052

Author(s):

Ichiro Yoshimura ◽

Tomonobu Hagio ◽

Kazuki Kanazawa ◽

Masahiro Suzuki ◽

Takuaki Yamamoto

Keyword(s):

Bone Marrow ◽

Subchondral Bone ◽

Cartilage Tissue ◽

Osteochondral Lesions ◽

Lesion Length ◽

Bone Marrow Stimulation ◽

Repair Tissue ◽

Marrow Stimulation ◽

Bone Sclerosis ◽

The Relationship

Category: Arthroscopy Introduction/Purpose: The arthroscopic bone marrow stimulation (ABMS) technique is the first-line procedure for the treatment of osteochondral lesions of the talus (OLT). Recently, T2 mapping was used to evaluate repair cartilage tissue, but the prognostic factors for T2 values after ABMS have never been clarified. Some patients have OLT with sclerotic changes in the subchondral bone, and several articles have suggested that the subchondral bone condition affects the condition of the articular cartilage. Furthermore, subchondral bone sclerosis (SBC) was found to be associated with an inferior outcome after ABMS.The purpose of this study was to investigate the relationship between subchondral bone sclerotic changes and repair tissue T2 values on MRI after ABMS. Methods: Twenty ankles in 20 patients treated with ABMS for OLT were evaluated. The patients included 7 males and 13 females (age, 30.52±21.44 years, lesion length 10.4±3.0mm, lesion area 55.7±26.5mm2). Repair tissue was assessed using a 3T MRI unit, and T2 maps were calculated at the one-year post-ABMS follow up. The patients were divided into two groups; with SBC and without SBC on pre-ABMS CT images. We investigated the relationship between T2 values and SBC. Clinical results were measured using the Japanese Society for Surgery of the Foot (JSSF) Ankle-Hindfoot Scale. Results: No significant mean differences were found in T2 values or JSSF scores between the with SBC and without SBC groups post-ABMS (T2 values; 48.2±3.3ms vs. 50.1±2.9ms, P=0.7 / JSSF scale score; 89.4±5.8 points vs. 93.3±8.2 points, P=0.25). Lesion length was correlated with the T2 values of repair tissue (Length; r=0.3 P=0.01). Age and BMI were not significantly correlated with T2 values of the repair tissue. Conclusion: The presence of SBC prior to ABMS did not affect the T2 values of repair tissue after ABMS. However, we believe that lesion size affected the condition of the repair tissue.

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