Bridging Conservative Management With Injectable Orthobiologic Therapies: Proceedings of the International Consensus Meetings on Cartilage Repair of the Ankle

BackgroundThe management of osteochondral lesions of the talus (OLT) is challenging, with 2 main options being conservative and surgical management. Orthobiologic therapies come to bridge the gap between these 2 options; however, inconsistencies in indication, composition, and heterogeneous evidence limit clinical decision-making. To address these challenges, 3 International Congress Meetings on Cartilage Repair of the Ankle were convened in Pittsburgh, USA (2017), Dublin, Ireland (2019), and New York, USA (2025) to establish agreement on the role of conservative management and injectable orthobiologic strategies in the treatment of OLT.MethodsSeventy-five multidisciplinary experts from over 25 countries and 1 territory participated in a structured Delphi-based consensus process. Blinded surveys, structured questionnaires, and in-person discussions were used to develop and refine statements, supported by literature review and graded evidence (A1-E). Consensus strength was defined as consensus (51%-74%), strong consensus (75%-99%), or unanimous (100%)ResultsIn total, 29 consensus statements were achieved across the 3 meetings. Strong agreement was reached regarding indications and expected outcomes of conservative management, including the role of immobilization and appropriate timing for surgical intervention. Orthobiologic injections, including platelet-rich plasma, concentrated bone marrow aspirate, and hyaluronic acid, were considered appropriate in select patients with persistent symptoms, although no superiority was demonstrated among formulations, preparation methods, or injection strategies. When used as adjuncts to surgical procedures, orthobiologics may improve radiological outcomes, with limited evidence for improvement in clinical outcomes. Technical considerations, including preferred harvest sites and a lack of standardized preparation protocols, were identified, along with key principles for patient counselingConclusionThese international consensus statements establish a standardized framework for the conservative management and use of injectable orthobiologic therapies in OLT. By clarifying indications, technical considerations, and current limitations, this work aims to improve consistency in clinical practice, guide treatment decision-making, and inform future research.

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Journal
Foot & Ankle Specialist
Published
2026-07-24
DOI
https://doi.org/10.1177/19386400261456925
Primary Topic
Foot and Ankle Surgery
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article
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article

Bridging Conservative Management With Injectable Orthobiologic Therapies: Proceedings of the International Consensus Meetings on Cartilage Repair of the Ankle

Stefan Nehrer, Rohan A. Phadke, Peter N. Mittwede, John G. Kennedy et al.
Foot & Ankle Specialist
Foot and Ankle Surgery
article

Bridging Conservative Management With Injectable Orthobiologic Therapies: Proceedings of the International Consensus Meetings on Cartilage Repair of the Ankle

Stefan Nehrer, Rohan A. Phadke, Peter N. Mittwede, John G. Kennedy, Thomas Oscar Clanton, Guillaume Robert, Christian J. A. van Bergen, David O. Osei-Hwedieh, Gregory C. Berlet, Simon Görtz, Kamran S. Hamid, Monika Volesky, G McCollum, Chayanin Angthong, Sameh A. Labib, Niek C. van Dijk, Niall A. Smyth, Christopher D. Murawski, Charles Patrick Hannon, Martin Sullivan, Benjamin B. Rothrauff, Carol L. Andrews, Richard D. Ferkel, Dominic S. Carreira, Jari Dahmen, Alberto Marangon, Adam Popchak, Tanawat Vaseenon, Gian Luigi Canata, Kaj T. A. Lambers, Schon Lc, Mallory Ehlers, Eric Giza, David B. Thordarson, Helene Simpson, Pieter D’Hooghe, Malcolm E. Dombrowski, Tuan Rs, Jeffrey S. Ling, Raluca Nicolescu, Stephen R. Kearns, R Buda, Marcelo P. Prado, Raymond C. Walls, Hélder Pereira, László Hangody, M Takao, Adam W. Mitchell, Siu Wah Kong, Amgad M. Haleem, Jochen Paul, Keun Bae Lee, Mikel L. Reilingh, Hajo Thermann, Carolyn M. Sofka, Paloma Gauthier, Martin O'Malley, MaCalus V. Hogan, Jorge Batista, Lorraine AT Boakye, Hak Jun Kim, Jay Hertel, Cristian Ortiz, Pietro Spennacchio, Mark Glazebrook, Eric Ferkel, Francesca Vannini, Eoghan T. Hurley, Philipp Niemeyer, Steven M. Raikin, Christopher J. Pearce, Jin Woo Lee, Alexander Tham, Arianna L. Gianakos, Beat Hintermann, Kirk McCullough, Samuel B. Adams, Paulo N. F. Ferrao, Christoph Becher, Daniel Haverkamp, Yasuhito Tanaka, James D. F. Calder, Kenneth J. Hunt, Onno L. Baur, Umile Giuseppe Longo, Mohamed Gomaa, James W. Stone, Christopher W. DiGiovanni, Jared Rubin, Gino M. M. J. Kerkhoffs, James J. Butler, Martin Wiewiorski, Victor Valderrabano, Markus Walther, James A. Nunley, Stephen Bayer, Sebastian Krebsbach, Pim A. D van Dijk, Xiangyang Xu, Jon Karlsson
article en

Abstract

BackgroundThe management of osteochondral lesions of the talus (OLT) is challenging, with 2 main options being conservative and surgical management. Orthobiologic therapies come to bridge the gap between these 2 options; however, inconsistencies in indication, composition, and heterogeneous evidence limit clinical decision-making. To address these challenges, 3 International Congress Meetings on Cartilage Repair of the Ankle were convened in Pittsburgh, USA (2017), Dublin, Ireland (2019), and New York, USA (2025) to establish agreement on the role of conservative management and injectable orthobiologic strategies in the treatment of OLT.MethodsSeventy-five multidisciplinary experts from over 25 countries and 1 territory participated in a structured Delphi-based consensus process. Blinded surveys, structured questionnaires, and in-person discussions were used to develop and refine statements, supported by literature review and graded evidence (A1-E). Consensus strength was defined as consensus (51%-74%), strong consensus (75%-99%), or unanimous (100%)ResultsIn total, 29 consensus statements were achieved across the 3 meetings. Strong agreement was reached regarding indications and expected outcomes of conservative management, including the role of immobilization and appropriate timing for surgical intervention. Orthobiologic injections, including platelet-rich plasma, concentrated bone marrow aspirate, and hyaluronic acid, were considered appropriate in select patients with persistent symptoms, although no superiority was demonstrated among formulations, preparation methods, or injection strategies. When used as adjuncts to surgical procedures, orthobiologics may improve radiological outcomes, with limited evidence for improvement in clinical outcomes. Technical considerations, including preferred harvest sites and a lack of standardized preparation protocols, were identified, along with key principles for patient counselingConclusionThese international consensus statements establish a standardized framework for the conservative management and use of injectable orthobiologic therapies in OLT. By clarifying indications, technical considerations, and current limitations, this work aims to improve consistency in clinical practice, guide treatment decision-making, and inform future research.

Foot & Ankle Specialist
Semmelweis University (HU), Hospital for Special Surgery (US), Cedars-Sinai Medical Center (US), Brigham and Women's Hospital (US), Dalhousie University (CA), Loyola University Medical Center (US), Universität für Weiterbildung Krems (AT), Mayo Clinic (US), Mercy Medical Center (US), Harvard University (US), Cairo University (EG), Emory University (US), University of Cape Town (ZA), Centre Hospitalier de Luxembourg (LU), University of Pittsburgh (US), Duke University (US), Yonsei University (KR), Korea University Medical Center (KR), Queen Elizabeth II Health Sciences Centre (CA), Hospital Israelita Albert Einstein (BR), Franklin Institute (US), Sahlgrenska University Hospital (SE), University Medical Center Freiburg (DE), Ruijin Hospital (CN), Clínica Alemana (CL), University Hospital Galway (IE), Amsterdam UMC Location University of Amsterdam (NL), UNSW Sydney (AU), Yale University (US), Magna Graecia University (IT), Clínica Las Condes (CL), NYU Langone Health (US), Massachusetts General Hospital (US), Nanium (Portugal) (PT), Rothman Orthopaedics (US), Kantonsspital Baselland (CH), Chonnam National University Hospital (KR), Schön Klinik München Harlaching (DE), Memorial Healthcare System (US), Kantonsspital Winterthur (CH), Cleveland Clinic Florida (US), Prince of Wales Hospital (AU), Steadman Clinic (US), Orthopedic Foot & Ankle Center (US), Nara Medical University Hospital (JP), Casa di Cura Columbus (IT), Istituto Ortopedico Rizzoli (IT), St Vincent's Clinic (AU), München Klinik Harlaching (DE), University of Pittsburgh Medical Center (US), Netcare Unitas Hospital (ZA), Campus Bio Medico University Hospital (IT), Amsterdam University Medical Centers (NL), Southern California Orthopedic Institute (US), Duke University Hospital (US), Peachtree Orthopaedic Clinic (US), Carolina Musculoskeletal Institute (US), Fortius Clinic (GB), Chiang Mai University (TH), McGill University (CA), University of Virginia (US), Nara Medical University (JP), Albany Medical Center Hospital (US), University of Pennsylvania (US), University of California, Davis (US), University of Colorado Denver (US)
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