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treatment to surgical procedures for patients with OCL of
the talus.
Albano et al1 analyzed the MOCART score and found a
low intra- and interobserver reproducibility for most categories of the score in patients who underwent AMIC repair of
the talus. Our results do not confirm these findings. We
found a significant agreement between the 2 assessors of our
data. To the best of our knowledge, no study has determined
whether clinical and radiological outcomes significantly
correlate for this type of surgery. This is important given
both are employed for diagnostic and/or prognostic purposes. In this regard, our results show that there is no correlation at all. Logically, the utility of a scoring matrix
encompassing the patient experience regarding mobility and
pain (ie, FAAM scoring) is highly relevant; thus, the purpose
of the MOCART score in clinical settings has to be questioned and is subject to further research and refinement.
There are limitations of our study. The study group was
relatively small, and 5 patients were lost to follow-up.
Importantly, we know that 3 of these patients had moderate
to bad outcomes. Since we were not able to obtain scores in
these patients, the data presented should be interpreted with
care, and the group mean scores, along with the proportion
of individuals who would opt to have the surgery again,
would certainly be lower if all patients had been evaluated
at this point postoperatively. The lowest FAAM score of our
15 patients was 62 points. Also, if the 5 patients who could
not be included each had a FAAM score of 60 points after
12 years of follow-up, our theoretical mean FAAM score
(ADL) would have been 78 ± 16 points. Although, this can
still be interpreted as a good overall result, we could also
assume that the number of patients who would not opt to
have the same surgery again might be increased to between
6 and 8 out of 20. Regarding the assessment of the lesion
size, the graft area was measured from the graft template
used intraoperatively with a disposable surgical ruler.
Simple geometric shapes (eg, circle and square) were used
with standard geometric formulae. Complex shapes were
calculated as best fit. This technique has limited accuracy
when expressing measurements in terms of square millimeters and is intended to convey a useful relative sense of size
for comparison between patients. While the strength of this
study lies in the long follow-up and the additional radiologic analyses, we lack a control group with which to compare outcomes, which would have been helpful to directly
compare outcomes between MACI and a less costly intervention, such as a microfracture procedure.

Conclusion
In conclusion, MACI grafting was a reliable and safe treatment option for talar dome lesions and led to a high rate of

Foot & Ankle International 41(9)
satisfactory results in long-term effectiveness. However,
considering the resource intensity, costs, and requirement
for a 2-staged procedure that does not appear to be more
effective than less intensive options (eg, microfracture), we
refrain from recommending the MACI procedure as a superior treatment option for osteochondral lesions of the talar
dome. The MOCART classification represents a good system for radiological evaluation with high interassessor
agreement; however, the poor association between
MOCART and the clinical outcome challenges the utility of
the score in the clinical setting.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this article. ICMJE forms for all authors are available online.

Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.

ORCID iD
Christopher G. Lenz, MD,
7902

https://orcid.org/0000-0001-5949-

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https://www.orcid.org/0000-0001-5949-7902 https://www.orcid.org/0000-0001-5949-7902

Foot & Ankle International - September 2020

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