Journal of Orthopaedics and Traumatology

Osteoperiosteal versus osteochondral for autologous transplantation in treatment of

large cystic osteochondral lesions of the talus
--Manuscript Draft--

Manuscript Number: JOOT-D-24-00410

Full Title: Osteoperiosteal versus osteochondral for autologous transplantation in treatment of

large cystic osteochondral lesions of the talus

Article Type: Original article

Abstract: Abstract
Background Osteochondral lesions of the talus (OLTs) with a large subchondral cyst
have been shown to have inferior clinical outcomes after reparative techniques.
Replacement techniques such as autologous osteoperiosteal transplantation (AOPT)
and autologous osteochondral transplantation (AOCT) are indicated for large
lesions. The aim of the study was to compare the short-term clinical and radiographic
outcomes between patients undergoing AOPT and those undergoing AOCT for large
cystic OLTs.
Methods Patients who underwent AOPT or AOCT for medial large cystic
OLTs between May 2019 and June 2023 were retrospectively evaluated. According to
their characteristics, a 1:1 propensity‐score matching was performed and 65 pairs of
patients with age ranged from 18 to 60 years old were recruited. Clinical outcomes
were compared between both groups with American Orthopedic Foot and Ankle
Society (AOFAS) ankle-hindfoot score and Visual Analogue Scale (VAS). Ankle Activity
Score (AAS), time to return to sports activity (RTA), rate of return to sports level,
complications, and subjective evaluation were also collected. The integrity of
subchondral bone and the quality of repaired cartilage were evaluated using the
magnetic resonance observation of cartilage repair tissue (MOCART) score 12 months
postoperatively. Second-look arthroscopy was performed 12 months postoperatively,
and the cartilage repair was assessed with the criteria of the International Cartilage
Repair Society (ICRS).
Results The within-group comparison showed significant improvement in pain
severity and function in both groups post-treatment compared with pre-treatment.
Between groups analysis, however, showed no significant statistical difference
between both groups in all
variables containing clinical and radiographic outcomes, except in donor-
site morbidity of the AOPT group which showed better outcome compared to
the AOCT group.
Conclusions In treatment of large cystic OLTs, for patients with chondral lesion of
patellofemoral joint that are unsuitable for AOCT, AOPT may be a safe and effective
choice, with lower donor-site morbidity of the normal knee joint.
Keywords osteochondral lesion; talus; osteoperiosteal; transplantation

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1 Osteoperiosteal versus osteochondral for autologous transplantation in treatment

1 2 of large cystic osteochondral lesions of the talus

2
3
4
3 Abstract
5
6 4 Background Osteochondral lesions of the talus (OLTs) with a large subchondral cyst
7
8 5 have been shown to have inferior clinical outcomes after reparative techniques. Re-
9
10
11 6 placement techniques such as autologous osteoperiosteal transplantation (AOPT) and
12
13 7 autologous osteochondral transplantation (AOCT) are indicated for large lesions. The
14
15
16 8 aim of the study was to compare the short-term clinical and radiographic outcomes
17
18 9 between patients undergoing AOPT and those undergoing AOCT for large cystic OLTs.
19
20
21
10 Methods Patients who underwent AOPT or AOCT for medial large cystic OLTs
22
23 11 between May 2019 and June 2023 were retrospectively evaluated. According to their
24
25 12 characteristics, a 1:1 propensity‐score matching was performed and 65 pairs of patients
26
27
28 13 with age ranged from 18 to 60 years old were recruited. Clinical outcomes were
29
30 14 compared between both groups with American Orthopedic Foot and Ankle Society
31
32
33 15 (AOFAS) ankle-hindfoot score and Visual Analogue Scale (VAS). Ankle Activity Score
34
35 16 (AAS), time to return to sports activity (RTA), rate of return to sports level,
36
37
38 17 complications, and subjective evaluation were also collected. The integrity of subchon-
39
40 18 dral bone and the quality of repaired cartilage were evaluated using the magnetic reso-
41
42
19 nance observation of cartilage repair tissue (MOCART) score 12 months
43
44
45 20 postoperatively. Second-look arthroscopy was performed 12 months postoperatively,
46
47 21 and the cartilage repair was assessed with the criteria of the International Cartilage
48
49
50 22 Repair Society (ICRS).
51
52 23 Results The within-group comparison showed significant improvement in pain severity
53
54
55 24 and function in both groups post-treatment compared with pre-treatment. Between
56
57 25 groups analysis, however, showed no significant statistical difference between both
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59
60
26 groups in all variables containing clinical and radiographic outcomes, except in donor-
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 27 site morbidity of the AOPT group which showed better outcome compared to the

1 28 AOCT group.
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3
4
29 Conclusions In treatment of large cystic OLTs, for patients with chondral lesion of
5
6 30 patellofemoral joint that are unsuitable for AOCT, AOPT may be a safe and effective
7
8 31 choice, with lower donor-site morbidity of the normal knee joint.
9
10
11 32 Keywords osteochondral lesion; talus; osteoperiosteal; transplantation
12
13 33 Introduction
14
15
16 34 Osteochondral lesions of the talus (OLTs) has been recognized as an increasingly com-
17
18 35 mon injury, usually occurring in acute ankle sprains, chronic ligament instability, and
19
20
21
36 fractures[1-2]. OLTs contain injury of cartilage and/or subchondral bone, which may
22
23 37 causing deep chronic ankle pain, swelling, stiffness, limited mobility, and even disabil-
24
25 38 ity[3].
26
27
28 39 Several studies have reported that this lesion respond poorly to nonsurgical treatment
29
30 40 and require bone marrow stimulation or abrasion arthroplasty, with satisfied clinical
31
32
33 41 outcomes[4-5]. However, Shimozono et al found that subchondral cysts had a negative
34
35 42 impact on clinical scores after surgery[6]. Although OLTs with small cysts could be
36
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38 43 treated effectively with micro-fracture or abrasion arthroplasty, lesions with a large sub-
39
40 44 chondral cyst which diameter is larger than 10 mm may require replacement techniques
41
42
45 such as autologous osteoperiosteal transplantation (AOPT) and autologous osteochon-
43
44
45 46 dral transplantation (AOCT) [7-8].
46
47 47 In reconstruction of osteochondral defect, AOCT could provide bone and cartilage in
48
49
50 48 the form of a plug and restores the weightbearing ability of the talus[9]. AOCT has
51
52 49 shown superior clinical outcomes in treating large cystic OLTs, however, donor-site
53
54
55 50 morbidity of the normal knee is still a concerning complication. To date, according to
56
57 51 published clinical studies of patients with AOCT in treating large cystic OLTs, the per-
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59
60
52 centage of patients with donor-site morbidity ranges from 0% to 54.5% [10-11].
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 53 Recently, more and more surgeons have tried to repair large cystic OLTs with AOPT

1 54 because of low cost and the absence of donor-site morbidity in the knee[10]. In addition,
2
3
4
55 Shi et al have reported AOPT show favourable clinical outcomes and satisfactory in-
5
6 56 corporation of grafts into the adjacent tissue of this lesion[10]. To our knowledge, sel-
7
8 57 dom studies have compared clinical outcomes between AOPT and AOCT in treating
9
10
11 58 OLTs with large cysts.
12
13 59 The primary purpose of this study was to investigate and compare the short-term
14
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16 60 clinical and radiographic outcomes between patients undergoing AOPT and those
17
18 61 undergoing AOCT for large cystic OLTs. We hypothesized that both procedures offer
19
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62 satisfied results for the treatment of patients with large cystic OLTs, and occurrence of
22
23 63 donor-site morbidity of the knee in AOPT group is less than that in AOCT group.
24
25 64 Methods
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28 65 Patient selection
29
30 66 This study was conducted at the authors’ department between May 2019 and June 2023.
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33 67 The study was reviewed and approved by the ethics committee of the authors’ hospital
34
35 68 (LL2018110501). All participants with age ranged from 18 to 60 years old were asked
36
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38 69 to sign a consent form before starting this study. According to their characteristics,
39
40 70 including sex, age, BMI, lesion size, lesion location and second-look arthroscopy his-
41
42
71 tory, a 1:1 propensity‐score matching was performed.
43
44
45 72 The inclusion criteria were as follows: (1) patients diagnosed with medial large cystic
46
47 73 OLTs; (2) a lack of response to at least 3 months of nonsurgical treatment; (3) the di-
48
49
50 74 ameter of subchondral cyst was larger than 10mm.
51
52 75 The exclusion criteria were as follows: (1) obvious structural malalignment (varus or
53
54
55 76 valgus deformity of the ankle of more than 5 degrees); (2) moderate and severe osteo-
56
57 77 arthritis; (3) systemic diseases, such as rheumatoid arthritis and gouty arthritis.
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78 Surgical intervention
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 79 All patients underwent diagnostic arthroscopy to determine the diagnosis of medial

1 80 large cystic OLTs after spinal anaesthesia in the supine position. Moreover, the surface
2
3
4
81 of the lesion was debrided. The centre of the defect was determined and drilled perpen-
5
6 82 dicularly with a 2-mm pin. Then, the defect was drilled with a 4.5-mm cannulated bore
7
8 83 until fat droplets from bone marrow were visualised. A harvester tube was used to create
9
10
11 84 and enlarge the bone socket. The cyst and the sclerotic wall were debrided thoroughly
12
13 85 by awls or small pins.
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16 86 AOPT group
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18 87 A harvester tube was driven deeply and perpendicularly at a location approximately 1.5
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21
88 cm above the osteotomy plane, and then the osteoperiosteal graft was harvested. Then,
22
23 89 the graft was tapped into the cystic defect with the periosteum outward without addi-
24
25 90 tional graft fixation. The graft was flush with the normal articular cartilage, and passive
26
27
28 91 motion of the ankle joint was made to confirm the stabilize of this graft. Then, the me-
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30 92 dial malleolus was reduced and fixed by cannulated screws, driven up from the tip of
31
32
33 93 the medial malleolus into the cancellous tibia bone. The anatomic reduction was con-
34
35 94 firmed by fluoroscopy[12].
36
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38 95 AOCT group
39
40 96 The osteochondral graft was harvested from the non-weight bearing portion of the me-
41
42
97 dial femoral trochlea in the ipsilateral knee, with the harvester tube driven perpendicu-
43
44
45 98 larly. Then, the osteochondral graft was tapped into the bone socket with the periosteum
46
47 99 outward without additional fixation. The graft was flush with the normal articular car-
48
49
50 100 tilage. Passive motion of the ankle joint also was made to confirm the stabilize of this
51
52 101 graft. Then, the medial malleolus was reduced. Cannulated screws was fixed from the
53
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55 102 tip of the medial malleolus into the cancellous tibia bone, and the anatomic reduction
56
57 103 was confirmed by fluoroscopy[13].
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104 Outcome measurements
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 105 Postoperative outcomes were assessed by the same investigator who did not participate

1 106 in the surgery. AOFAS score of all patients was evaluated preoperatively and at the 12
2
3
4
107 months postoperatively[14]. The VAS consists of a 10-centimeter line where the patient
5
6 108 rates their pain, ranging from 0 (indicating no pain) to 10 (representing the worst pain
7
8 109 imaginable), which was accessed preoperatively and at the 12 months follow-up[15].
9
10
11 110 AAS ≥ 3 indicated that patients was able to walk on any uneven ground, and time to
12
13 111 return to sports activity (RTA) was recorded when the patient could reach a minimum
14
15
16 112 unlimited sports level of 3 on the Ankle Activity Score (AAS)[16-17]. Returning to the
17
18 113 previous sports level was defined and recorded when the postoperative AAS was the
19
20
21
114 same to the pre-injury AAS. An overall subjective evaluation was also conducted at 12
22
23 115 month operatively. Patients were asked to grade the result of the procedure as excellent
24
25 116 (no symptoms), good (slightly annoying), fair (improved but with residual disability),
26
27
28 117 and poor (symptoms unchanged or worsened). Excellent and good meant satisfied to
29
30 118 surgery. Complications such as wound infection, donor-site morbidity and wound
31
32
33 119 numbness were evaluated and recorded in follow-up. Magnetic resonance imaging
34
35 120 (MRI) were obtained 12 months postoperatively to compare radiographic outcomes
36
37
38 121 between two groups. The integrity of subchondral bone and the quality of repaired car-
39
40 122 tilage were evaluated using the magnetic resonance observation of cartilage repair tis-
41
42
123 sue (MOCART; 0-100 points) score[18]. Second-look arthroscopy was performed 12
43
44
45 124 months postoperatively, and the cartilage repair was assessed with the criteria of the
46
47 125 International Cartilage Repair Society (ICRS) [19].
48
49
50 126 Statistical analysis
51
52 127 A sample size calculation (G Power 3.1.9.7) based on AOFAS score of previous studies
53
54
55 128 (using two-tailed α:0.05, β:0.20 (power: 80%)) was conducted, considering an effect
56
57 129 size=1.33. Then we increased about 10% of the estimated number to ensure adequate
58
59
60
130 power. It was determined that 65 participants would be required for each group.
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 131 Shapiro-Wilk and Kolmogorov-Smirnov tests were used for testing the normality of

1 132 data distribution and showed that all measured variables were normally distributed. Un-
2
3
4
133 paired t-tests and chi-square were used to compare the subjects’ characteristics of the
5
6 134 two groups. A statistical package for the social sciences computer program (version 20
7
8 135 for Windows; SPSS Inc., Chicago, Illinois, USA) was used for data analysis. P<0.05
9
10
11 136 was considered significant.
12
13 137 Results
14
15
16 138 Patient Demographics
17
18 139 166 patients were assessed for eligibility, 21 patients did not meet the inclusion criteria
19
20
21
140 and 15 patients refused to join the study (Fig. 1). The study population consisted of 88
22
23 141 men and 42 women aged 18 to 60 years old with large cystic OLTs who were randomly
24
25 142 assigned to two equal groups. The two groups were comparable with no significant
26
27
28 143 difference in any of the demographic characteristics (Table 1).
29
30
31
32
33
34
35
36
37
38
39
40
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50
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52
53
54 144
55
56 145 Fig. 1 Flowchart for patients eligibility
57
58
59
TABLE 1
60 Comparisons of Clinical Characteristics between Two Groups a
61 AOPT Groups(n=65) AOCT Groups(n=65) P Value b
62
63
64
65
 Age, y, mean ± SD 40.38 ±7.42 40.76 ±7.36 0.767
Male sex (%) 43 (66.15%) 45 (69.23%) 0.851
2
1 BMI, kg/m , mean ± SD 20.68 ±1.01 20.90 ±1.02 0.221
2 Symptoms duration, mo, mean ± SD 42.09 ±6.66 41.28 ±7.17 0.503
3 History of trauma, (%) 50 (76.92%) 48 (73.85%) 0.839
4 Right talus, n (%) 35 (53.85%) 42 (64.62%) 0.284
5 Lesion size, mm, mean ± SD
6 Length 11.34 ±1.68 11.44 ±2.15 0.741
7 Width 10.19 ±1.48 10.36 ±1.57 0.540
8 Depth 9.77 ±1.34 9.83 ±1.17 0.765
9 Diameter 12.04 ±1.34 12.33 ±1.69 0.294
10 Lesion location, n (%) 0.534
11 Zone 1 16 (24.62%) 15 (23.08%)
12 Zone 4 23 (35.38%) 29 (44.62%)
13 Zone 7 26 (40.00%) 21 (32.30%)
14 2
15
a Data are reported as n (%) or mean ± SD. BMI, body mass index, kg/m .
16 b Independent t test or chi-square test. The P values shown are for intergroup comparisons. Significance was accepted for
17 P<0.05.
18 146
19
20 147 Clinical outcomes
21
22
23 148 The within-group comparison showed significant improvement in AOFAS score and
24
25 149 VAS score in both groups post-treatment compared with pre-treatment. Compared with
26
27
28 150 AOCT group, there was no significant difference in postoperative AOFAS score, VAS
29
30 151 score, AAS score, RTA, rate of return to sports level and subjective evaluation in AOPT
31
32
33
152 group. However, donor-site morbidity showed better outcome in AOPT group com-
34
35 153 pared to the AOCT group (Table 2).
36
37 TABLE 2
38 Comparisons of Clinical Outcomes between Two Groups a
39 AOPT Groups(n=65) AOCT Groups(n=65) P Value b
40
AOFAS score, mean ± SD
41
42 Preoperative 71.14 ±3.35 70.51 ±3.22 0.276
43 Postoperative 91.29 ±3.37 91.74 ±3.16 0.438
c
44 P Value (within) <0.001 <0.001
45 VAS score, mean ± SD
46 Preoperative 6.08 ±0.85 6.05 ±0.98 0.848
47 Postoperative 1.02 ±0.80 1.15 ±0.75 0.312
48 P Value (within) c <0.001 <0.001
49 AAS score, mean ± SD
50 Pre-symptom 8.34 ±1.03 8.23 ±0.92 0.547
51 Preoperative 1.26 ±0.69 1.18 ±0.62 0.537
52 Postoperative 7.58 ±0.95 7.34 ±1.01 0.157
53 RTA, mo, mean ± SD 6.35 ±0.67 6.42 ±0.68 0.605
54 Return to previous sports level, n (%) 31 (47.69%) 28 (76.92%) 0.725
55
Complication, n (%) 0.028
56
Donor-site morbidity 0 (0%) 6 (9.23%)
57
58 Rate of satisfaction, n (%) 100 (100%) 100 (100%) 1.000
59 Subjective evaluation, n (%) 0.210
60 Excellent 43 (66.15%) 35 (53.85%)
61 Good 22 (33.85%) 30 (46.15%)
62
63
64
65
 Fair 0 (0%) 0 (0%)
Poor 0 (0%) 0 (0%)
1 a Data are reported as n (%) or mean ± SD. AOFAS, American Orthopedic Foot and Ankle Society; VAS, Visual Analogue
2 Scale; AAS, Ankle Activity Score; RTA, time to return to sports activity.
3 b Independent t test or chi-square test. The P values shown are for intergroup comparisons. Significance was accepted for
4 P<0.05.
5 c Paired t test. The P values shown are for intragroup comparisons. Significance was accepted for P<0.05.
6 154
7
8
9
155 Radiographic outcomes
10
11 156 All patients underwent MRI scan at the final follow-up time node (12 months postop-
12
13 157 erative). Shown in table 3, compared with AOCT group, there was no significant dif-
14
15
16 158 ference in MOCART score, cysts on MRI, bone marrow edema and incorporation in
17
18 159 AOPT group.
19
20
21 TABLE 3
22 Comparisons of Radiologic Outcomes between Two Groups a
23 AOPT Groups(n=65) AOCT Groups(n=65) P Value b
24 MOCART score, mean ± SD 75.08 ±5.86 76.85 ±5.91 0.091
25 Cysts on MRI, (%) 0.860
26 Disappear 35 (53.85%) 37 (56.92%)
27 Decrease 30 (46.15%) 28 (43.08%)
28 Bone marrow edema, (%) 0.371
29 Yes 42 (64.62%) 36 (55.38%)
30 No 23 (35.38%) 29 (44.62%)
31 Incorporation, (%) 0.857
32 Full 26 (40.00%) 25 (38.46%)
33
Part 39 (60.00%) 40 (61.54%)
34
35 a Data are reported as n (%) or mean ± SD. MOCART, the Magnetic Resonance Observation of Cartilage Repair Tissue
36 scoring system; MRI, magnetic resonance imaging.
37 b Independent t test or chi-square test. The P values shown are for intergroup comparisons. Significance was accepted for
38 P<0.05.
39 160
40
41 161 Second-look arthroscopic outcomes
42
43
44 162 All patients were evaluated second-look arthroscopic outcomes when internal fixation
45
46 163 screws that used to fix the medial malleolus were removed 12 months postoperatively.
47
48
49 164 Shown in table 4, compared with AOCT group, there was no significant difference in
50
51 165 ICRS score and ICRS repair category in AOPT group.
52
53
TABLE 4
54
55
Comparisons of Second-look Arthroscopic Outcomes between Two Groups a
56 AOPT Groups(n=65) AOCT Groups(n=65) P Value b
57 ICRS visual score, mean ± SD 10.08 ±0.94 10.32 ±1.13 0.180
58 Initially grafted surface 4.20 ±0.62 4.37 ±0.63 0.123
59 Integration to border zone 3.52 ±0.50 3.56 ±0.50 0.727
60 Macroscopic appearance 2.37 ±0.63 2.40 ±0.60 0.671
61 ICRS repair category, (%) 0.852
62
63
64
65
 Grade I: Normal 21 (32.31%) 22 (33.85%)
Grade II: Nearly Normal 44 (67.69%) 43 (66.15%)
1 Grade III: Abnormal 0 (0%) 0 (0%)
2 Grade IV: Severely Abnormal 0 (0%) 0 (0%)
3 a Data are reported as n (%) or mean ± SD. ICRS, the International Cartilage Repair Society.
4 b Independent t test or chi-square test. The P values shown are for intergroup comparisons. Significance was accepted for
5 P<0.05.
6 166
7
8
9
167 Discussion
10
11 168 This study compared the outcomes between the AOPT and the AOCT groups as a sur-
12
13 169 gical option for large cystic OLTs prospectively, which showed no significant statistical
14
15
16 170 difference between both groups in all variables containing clinical and radiographic
17
18 171 outcomes between groups analysis, except in donor-site morbidity of the AOPT group
19
20
21 172 which showed better outcome compared to the AOCT group.
22
23 173 In the pathogenesis of lesions of the subchondral region of the OLTs, the importance of
24
25
26 174 subchondral bone has been well discussed by Deng et al[20]. They found that when
27
28 175 trauma causes the damage of cartilage and the subchondral bone plate, continuous high-
29
30
176 pressured liquid flow into the subchondral bone, which induces osteolysis and subchon-
31
32
33 177 dral cysts[20]. In addition, previous studies reported that subchondral cysts had a neg-
34
35 178 ative impact on clinical outcomes after surgery such as micro-fracture or abrasion ar-
36
37
38 179 throplasty[21]. In hence, it is necessary for patients to be taken replacement techniques
39
40 180 such as AOPT and AOCT in treatment of OLTs with a large subchondral cyst which
41
42
43 181 diameter is larger than 10 mm. We support that the subchondral bone plate could play
44
45 182 an important role in maintaining cartilage metabolism by supporting the normal ankle
46
47
48
183 pressure and blocking the brunt of the continuous high-pressured articular liquid.
49
50 184 Therefore, AOPT and AOCT would show satisfied outcomes for OLTs with large cystic
51
52 185 lesions, by reconstructing the normal subchondral bone plate.
53
54
55 186 In the present study, postoperative clinical and radiologic outcomes were well observed
56
57 187 in the both groups at approximately 12 months of follow-up. In AOPT group, the AO-
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60
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65
 188 FAS score significantly improved from a mean 71.14 to 91.29, the VAS score signifi-

1 189 cantly improved from a mean 6.08 to 1.02, the AAS score significantly improved from
2
3
4
190 a mean 1.26 to 7.58, the mean postoperative MOCART score was 75.08, and the mean
5
6 191 ICRS score was 10.08 at second-look arthroscopy. Besides, in AOCT group, the AO-
7
8 192 FAS score significantly improved from a mean 70.51 to 91.74, the VAS score signifi-
9
10
11 193 cantly improved from a mean 6.05 to 1.15, the AAS score significantly improved from
12
13 194 a mean 1.18 to 7.34, the mean postoperative MOCART score was 76.85, and the mean
14
15
16 195 ICRS score was 10.32 at second-look arthroscopy. These results have shown excellent
17
18 196 clinical and radiologic outcomes with these two techniques in treatment of OLTs with
19
20
21
197 large subchondral cysts, which is similar to previous researches[7-8, 10, 22].
22
23 198 Moreover, in this study, compared with AOCT group, there was no significant statistical
24
25 199 difference in postoperative AOFAS score, VAS score, RTA, rate of return to previous
26
27
28 200 sports level, rate of satisfaction, MOCART score and ICRS score in AOCT group. We
29
30 201 believe that both two techniques are simple, safe and effective surgical procedures for
31
32
33 202 the treatment of large cystic OLTs, by providing effective graft replacement and joint
34
35 203 pressure support. However, AOPT showed better outcome in donor-site morbidity com-
36
37
38 204 pared to the AOCT group. The graft in AOCT group was harvested from the non-weight
39
40 205 bearing portion of the medial femoral trochlea in the ipsilateral knee, patients with do-
41
42
206 nor-site morbidity would feel symptomatic and painful when climbing stairs. We sup-
43
44
45 207 port that friction of patella and femoral trochlea during knee flexion may increase do-
46
47 208 nor-site morbidity of the ipsilateral knee. In addition, graft harvesting can cause release
48
49
50 209 of intra-articular proinflammatory cytokines that can induce pain postoperatively, lead-
51
52 210 ing to symptomatic of the knee, which has become a concerning shortcoming with
53
54
55 211 AOCT[23].
56
57 212 Various studies reported clinical outcomes of AOPT for the treatment of large cystic
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59
60
213 medial OLTs, and grafts were harvested from the ipsilateral anterior superior iliac
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 214 spine[10, 22, 24-28]. However, in our study the autografts in AOPT group were taken

1 215 from the medial tibia instead of the iliac crest, which is similar to Chen et al. Autografts
2
3
4
216 harvesting from tibia could reduce surgical incisions, which could reduce the risk of
5
6 217 wound infection and sciatic nerve injury.
7
8 218 Cao et al [29]found that the periosteal bone column of a patient had grown well, but
9
10
11 219 several small low‐density areas appeared on the surface of the bone column, which
12
13 220 showed a relatively minor improvement in terms of their postoperative evaluation indi-
14
15
16 221 cators. These findings may be related to the patient's premature weight‐bearing or re‐
17
18 222 sprained ankle following surgery[26]. However, in our study, all patients in both groups
19
20
21
223 were immobilized in a short leg cast and non-weight bearing on the affected limb for 6
22
23 224 weeks after surgery, and partial weight bearing were allowed 7 to 8 weeks after surgery.
24
25 225 At 8 weeks after surgery, full weight bearing was allowed, after healing of the osteot-
26
27
28 226 omy is confirmed by X-ray. In hence, all patients in both two groups selected satisfied
29
30 227 to surgery in overall subjective evaluation because of scientific postoperative rehabili-
31
32
33 228 tation in our study.
34
35 229 It is important to consider the limitations of this study. The duration of follow-up period
36
37
38 230 in this study was limited to a specific timeframe, and the long-term effects of AOPT
39
40 231 versus AOCT therapy were not evaluated. Future studies with longer follow-up periods
41
42
232 are needed to provide more comprehensive insights into the comparative effects of these
43
44
45 233 two treatment approaches. While our study demonstrated significant positive outcomes
46
47 234 of AOPT, several questions remain unanswered, presenting avenues for future research.
48
49
50 235 Firstly, the long-term effects of AOPT versus AOCT on clinical outcomes, need to be
51
52 236 explored. Lastly, exploring the biomechanical and histological outcomes of AOPT ver-
53
54
55 237 sus AOCT in treatment of large cystic OLTs. Future research endeavors addressing
56
57 238 these unanswered questions will contribute to a deeper understanding of the therapeutic
58
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239 potential of AOPT and further optimize its application in clinical practice.
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 240 Conclusion

1 241 In treatment of large cystic OLTs, for patients with chondral lesion of patellofemoral
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242 joint that are unsuitable for AOCT, AOPT may be a safe and effective choice, with
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6 243 lower donor-site morbidity of the normal knee joint.
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8 244 Declarations
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11 245 Ethics approval and consent to participate
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13 246 All methods of this study were carried out in accordance with relevant guidelines and
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16 247 regulations, which were approved by our Hospital. Written informed consent was
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18 248 obtained from all subjects.
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249 Consent for publication
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23 250 Not applicable.
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25 251 Availability of data and materials
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28 252 Not applicable.
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30 253 Competing interests
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33 254 The authors declare no competing interests.
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35 255 Funding
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38 256 Not applicable.
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40 257 Authors' contributions
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258 LL, JJ, and JP designed and supervised this study. LL and HG wrote this manuscript.
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45 259 SL and JL participated in the exercise instruction, follow-up and outcomes
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47 260 measurements. All authors were involved in the data collection, statistics analysis. LL
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50 261 and ZZ were involved in the revision of this manuscript. All authors read and approved
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52 262 the final manuscript.
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55 263 Acknowledgements
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57 264 We are grateful to all patients who participated in this study.
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265 References
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Table1 Click here to access/download;Table;TABLE 1.docx

TABLE 1
Comparisons of Clinical Characteristics between Two Groups a
AOPT Groups(n=65) AOCT Groups(n=65) P Value b
Age, y, mean ± SD 40.38 ±7.42 40.76 ±7.36 0.767
Male sex (%) 43 (66.15%) 45 (69.23%) 0.851
BMI, kg/m2, mean ± SD 20.68 ±1.01 20.90 ±1.02 0.221
Symptoms duration, mo, mean ± SD 42.09 ±6.66 41.28 ±7.17 0.503
History of trauma, (%) 50 (76.92%) 48 (73.85%) 0.839
Right talus, n (%) 35 (53.85%) 42 (64.62%) 0.284
Lesion size, mm, mean ± SD
Length 11.34 ±1.68 11.44 ±2.15 0.741
Width 10.19 ±1.48 10.36 ±1.57 0.540
Depth 9.77 ±1.34 9.83 ±1.17 0.765
Diameter 12.04 ±1.34 12.33 ±1.69 0.294
Lesion location, n (%) 0.534
Zone 1 16 (24.62%) 15 (23.08%)
Zone 4 23 (35.38%) 29 (44.62%)
Zone 7 26 (40.00%) 21 (32.30%)
a Data are reported as n (%) or mean ± SD. BMI, body mass index, kg/m2.
b Independent t test or chi-square test. The P values shown are for intergroup comparisons. Significance was
accepted for P<0.05.
Table2 Click here to access/download;Table;TABLE 2.docx

TABLE 2
Comparisons of Clinical Outcomes between Two Groups a
AOPT Groups(n=65) AOCT Groups(n=65) P Value b
AOFAS score, mean ± SD
Preoperative 71.14 ±3.35 70.51 ±3.22 0.276
Postoperative 91.29 ±3.37 91.74 ±3.16 0.438
P Value (within) c <0.001 <0.001
VAS score, mean ± SD
Preoperative 6.08 ±0.85 6.05 ±0.98 0.848
Postoperative 1.02 ±0.80 1.15 ±0.75 0.312
P Value (within) c <0.001 <0.001
AAS score, mean ± SD
Pre-symptom 8.34 ±1.03 8.23 ±0.92 0.547
Preoperative 1.26 ±0.69 1.18 ±0.62 0.537
Postoperative 7.58 ±0.95 7.34 ±1.01 0.157
RTA, mo, mean ± SD 6.35 ±0.67 6.42 ±0.68 0.605
Return to previous sports level, n (%) 31 (47.69%) 28 (76.92%) 0.725
Complication, n (%) 0.028
Donor-site morbidity 0 (0%) 6 (9.23%)
Rate of satisfaction, n (%) 100 (100%) 100 (100%) 1.000
Subjective evaluation, n (%) 0.210
Excellent 43 (66.15%) 35 (53.85%)
Good 22 (33.85%) 30 (46.15%)
Fair 0 (0%) 0 (0%)
Poor 0 (0%) 0 (0%)
a Data are reported as n (%) or mean ± SD. AOFAS, American Orthopedic Foot and Ankle Society; VAS,
Visual Analogue Scale; AAS, Ankle Activity Score; RTA, time to return to sports activity.
b Independent t test or chi-square test. The P values shown are for intergroup comparisons. Significance was
accepted for P<0.05.
c Paired t test. The P values shown are for intragroup comparisons. Significance was accepted for P<0.05.
Table3 Click here to access/download;Table;TABLE 3.docx

TABLE 3
Comparisons of Radiologic Outcomes between Two Groups a
AOPT Groups(n=65) AOCT Groups(n=65) P Value b
MOCART score, mean ± SD 75.08 ±5.86 76.85 ±5.91 0.091
Cysts on MRI, (%) 0.860
Disappear 35 (53.85%) 37 (56.92%)
Decrease 30 (46.15%) 28 (43.08%)
Bone marrow edema, (%) 0.371
Yes 42 (64.62%) 36 (55.38%)
No 23 (35.38%) 29 (44.62%)
Incorporation, (%) 0.857
Full 26 (40.00%) 25 (38.46%)
Part 39 (60.00%) 40 (61.54%)
a Data are reported as n (%) or mean ± SD. MOCART, the Magnetic Resonance Observation of Cartilage
Repair Tissue scoring system; MRI, magnetic resonance imaging.
b Independent t test or chi-square test. The P values shown are for intergroup comparisons. Significance was
accepted for P<0.05.
Table4 Click here to access/download;Table;TABLE 4.docx

TABLE 4
Comparisons of Second-look Arthroscopic Outcomes between Two Groups a
AOPT Groups(n=65) AOCT Groups(n=65) P Value b
ICRS visual score, mean ± SD 10.08 ±0.94 10.32 ±1.13 0.180
Initially grafted surface 4.20 ±0.62 4.37 ±0.63 0.123
Integration to border zone 3.52 ±0.50 3.56 ±0.50 0.727
Macroscopic appearance 2.37 ±0.63 2.40 ±0.60 0.671
ICRS repair category, (%) 0.852
Grade I: Normal 21 (32.31%) 22 (33.85%)
Grade II: Nearly Normal 44 (67.69%) 43 (66.15%)
Grade III: Abnormal 0 (0%) 0 (0%)
Grade IV: Severely Abnormal 0 (0%) 0 (0%)
a Data are reported as n (%) or mean ± SD. ICRS, the International Cartilage Repair Society.
b Independent t test or chi-square test. The P values shown are for intergroup comparisons. Significance was
accepted for P<0.05.
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