title: Low Level of Evidence and Methodologic Quality of Clinical Outcome Studies on Cartilage Repair of the Ankle.
abstract: OBJECTIVE
  To examine the level of evidence and methodologic quality of studies reporting surgical treatments for osteochondral lesions of the ankle.
  
  
  METHODS
  A search was performed using the PubMed/Medline, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Cochrane databases for all studies in which the primary objective was to report the outcome after surgical treatment of osteochondral lesions of the ankle. Studies reporting outcomes of microfracture, bone marrow stimulation, autologous osteochondral transplantation, osteochondral allograft transplantation, and autologous chondrocyte implantation were the focus of this analysis because they are most commonly reported in the literature. Two independent investigators scored each study from 0 to 100 based on 10 criteria from the modified Coleman Methodology Score (CMS) and assigned a level of evidence using the criteria established by the Journal of Bone and Joint Surgery. Data were collected on the study type, year of publication, number of surgical procedures, mean follow-up, preoperative and postoperative American Orthopaedic Foot & Ankle Society score, measures used to assess outcome, geography, institution type, and conflict of interest.
  
  
  RESULTS
  Eighty-three studies reporting the results of 2,382 patients who underwent 2,425 surgical procedures for osteochondral lesions of the ankle met the inclusion criteria. Ninety percent of studies were of Level IV evidence. The mean CMS for all scored studies was 53.6 of 100, and 5 areas were identified as methodologically weak: study size, type of study, description of postoperative rehabilitation, procedure for assessing outcome, and description of the selection process. There was no significant difference between the CMS and the type of surgical technique (P = .1411). A statistically significant patient-weighted correlation was found between the CMS and the level of evidence (r = -0.28, P = .0072). There was no statistically significant patient-weighted correlation found between the CMS and the institution type (r = 0.05, P = .6480) or financial conflict of interest (r = -0.16, P = .1256).
  
  
  CONCLUSIONS
  Most studies assessing the clinical outcomes of cartilage repair of the ankle are of a low level of evidence and of poor methodologic quality.
  
  
  METHODS
  Level IV, systematic review of Level I through IV studies.
authors.affiliation: Hospital for Special Surgery, New York, New York, U.S.A.
authors.forename: John M
authors.initials: JM
authors.lastname: Pinski
authors.affiliation: Hospital for Special Surgery, New York, New York, U.S.A.
authors.forename: Lorraine A
authors.initials: LA
authors.lastname: Boakye
authors.affiliation: Hospital for Special Surgery, New York, New York, U.S.A.
authors.forename: Christopher D
authors.initials: CD
authors.lastname: Murawski
authors.affiliation: Hospital for Special Surgery, New York, New York, U.S.A.
authors.forename: Charles P
authors.initials: CP
authors.lastname: Hannon
authors.affiliation: Hospital for Special Surgery, New York, New York, U.S.A.
authors.forename: Keir A
authors.initials: KA
authors.lastname: Ross
authors.affiliation: Hospital for Special Surgery, New York, New York, U.S.A.. Electronic address: murawskic@hss.edu.
authors.forename: John G
authors.initials: JG
authors.lastname: Kennedy
mesh_terms: D000843:Ankle Joint / Q000601:surgery*; D035843:Biomedical Research / Q000592:standards; D016025:Bone Transplantation; D002356:Cartilage / Q000637:transplantation*; D019902:Chondrocytes / Q000637:transplantation*; D019317:Evidence-Based Medicine; D006801:Humans; D019637:Orthopedic Procedures / Q000379:methods*; D017063:Outcome Assessment, Health Care / Q000592:standards*; D012107:Research Design / Q000592:standards; D014182:Transplantation, Autologous; D014184:Transplantation, Homologous