Arthroscopic treatment of osteochondral defects of the talus: outcomes at eight to twenty years of follow-up

Osteochondritis dissecans of the capitellum in adolescents

Osteochondritis dissecans (OCD) is a disorder of articular cartilage and subchondral bone. In the elbow, an OCD is localized most commonly at the humeral capitellum. Teenagers engaged in sports that involve repetitive stress on the elbow are at risk. A high index of suspicion is warranted to prevent delay in the diagnosis. Plain radiographs may disclose the lesion but computed tomography and magnetic resonance imaging are more accurate in the detection of OCD. To determine the best treatment option it is important to differentiate between stable and unstable OCD lesions. Stable lesions can be initially treated nonoperatively with elbow rest or activity modification and physical therapy. Unstable lesions and stable lesions not responding to conservative therapy require a surgical approach. Arthroscopic debridement and microfracturing has become the standard initial procedure for treatment of capitellar OCD. Numerous other surgical options have been reported, including internal fixation of large fragments and osteochondral autograft transfer. The aim of this article is to provide a current concepts review of the etiology, clinical presentation, diagnosis, treatment, and outcomes of elbow OCD.

Arthroscopic Bone Marrow Stimulation and Concentrated Bone Marrow Aspirate for Osteochondral Lesions of the Talus: A Case-Control Study of Functional and Magnetic Resonance Observation of Cartilage Repair Tissue Outcomes

PURPOSE

This study compares retrospective functional and magnetic resonance imaging (MRI) outcomes after arthroscopic bone marrow stimulation (BMS) with and without concentrated bone marrow aspirate (cBMA) as a biological adjunct to the surgical treatment of osteochondral lesions (OCLs) of the talus.

METHODS

Twenty-two patients who underwent arthroscopic BMS with cBMA (cBMA/BMS group) for an osteochondral lesion (OCL) of the talus and 12 patients who underwent arthroscopic BMS (BMS alone) for an OCL of the talus were retrospectively reviewed. The Foot and Ankle Outcome Score (FAOS) pain subscale and Short Form 12 general health questionnaire physical component summary score (SF-12 PCS) provided patient-reported outcome scores pre- and postoperatively. MRI scans were assessed postoperatively using the magnetic resonance observation of cartilage repair tissue (MOCART) score. All patients had postoperative MRI performed at the 2-year postoperative visit, and quantitative T2 mapping relaxation time values were assessed in a subset of the cBMA/BMS group.

RESULTS

The mean FAOS and SF-12 PCS scores improved significantly pre- to post-operatively (P < .01) at a mean follow-up of 48.3 months (range, 34 to 82 months) for the cBMA/BMS group and 77.3 months (range, 46 to 100 months) for the BMS-alone group. The MOCART score in the cBMA/BMS group was significantly higher than that in the BMS-alone group (P = .023). Superficial and deep T2 relaxation values in cBMA/BMS patients were higher in repair tissue compared with measurements in adjacent native articular cartilage (P = .030 and P < .001, respectively).

CONCLUSIONS

BMS is an effective treatment strategy for treatment of OCLs of the talus and results in good medium-term functional outcomes. Arthroscopic BMS with cBMA also results in similar functional outcomes and improved border repair tissue integration, with less evidence of fissuring and fibrillation on MRI.

Low Level of Evidence and Methodologic Quality of Clinical Outcome Studies on Cartilage Repair of the Ankle

PURPOSE

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.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I through IV studies.

Return to sports after arthroscopic debridement and bone marrow stimulation of osteochondral talar defects: a 5- to 24-year follow-up study

PURPOSE

Osteochondral defects (OCD) often have a severe impact on the quality of life due to deep ankle pain during and after weight bearing, which prevents young patients from leading an active life. Arthroscopic debridement and bone marrow stimulation are currently the gold standard treatment. The purpose of this study was to evaluate the number of patients that resume and maintain sports to their pre-injury activity level after arthroscopic debridement and bone marrow stimulation.

METHODS

This retrospective study evaluated patients treated with arthroscopic debridement and bone marrow stimulation between 1989 and 2008. All patients who were participating in sports before injury were included. The Ankle Activity Scale (AAS) was used to determine activity levels during specific time points (before injury, before operation, after operation and at the time of final follow-up).

RESULTS

Ninety-three patients were included. Fifty-seven (76%) patients continued participating in sports at final follow-up. The median AAS before injury of 8 (range 3-10) significantly decreased to 4 (range 2-10) at final follow-up.

CONCLUSION

It is shown that 76% of the patients were able to return to sports at long-term follow-up after arthroscopic debridement and bone marrow stimulation of talar OCDs. The activity level decreased at long-term follow-up and never reached the level of that before injury. The data of our study can be of importance to inform future patients on expectations after debridement and bone marrow stimulation of a talar OCD.

LEVEL OF EVIDENCE

Retrospective case series, Level IV.

Computed tomography analysis of osteochondral defects of the talus after arthroscopic debridement and microfracture

PURPOSE

The primary surgical treatment of osteochondral defects (OCD) of the talus is arthroscopic debridement and microfracture. Healing of the subchondral bone is important because it affects cartilage repair and thus plays a role in pathogenesis of osteoarthritis. The purpose of this study was to evaluate the dimensional changes and bony healing of talar OCDs after arthroscopic debridement and microfracture.

METHODS

Fifty-eight patients with a talar OCD were treated with arthroscopic debridement and microfracture. Computed tomography (CT) scans were obtained at baseline, 2 weeks postoperatively, and 1 year postoperatively. Three-dimensional changes and bony healing were analysed on CT scans. Additionally, clinical outcome was measured with the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score and numeric rating scales (NRS) for pain.

RESULTS

Average OCD size increased significantly (p < 0.001) in all directions from 8.6 (SD 3.6) × 6.3 (SD 2.6) × 4.8 (SD 2.3) mm (anterior-posterior × medial-lateral × depth) preoperatively to 11.3 (SD 3.4) × 7.9 (SD 2.8) × 5.8 (SD 2.3) mm 2 weeks postoperatively. At 1-year follow-up, average defect size was 8.3 (SD 4.2) × 5.7 (SD 3.0) × 3.6 (SD 2.4) mm. Only average defect depth decreased significantly (p < 0.001) from preoperative to 1 year postoperative. Fourteen of the 58 OCDs were well healed. No significant differences in the AOFAS and NRS-pain were found between the well and poorly healed OCDs.

CONCLUSION

Arthroscopic debridement and microfracture of a talar OCD leads to an increased defect size on the direct postoperative CT scan but restores at 1-year follow-up. Only fourteen of the 58 OCDs were filled up completely, but no differences were found between the clinical outcomes and defect healing at 1-year follow-up.

LEVEL OF EVIDENCE

IV.

Diagnosing, planning and evaluating osteochondral ankle defects with imaging modalities

This current concepts review outlines the role of different imaging modalities in the diagnosis, preoperative planning, and follow-up of osteochondral ankle defects. An osteochondral ankle defect involves the articular cartilage and subchondral bone (usually of the talus) and is mostly caused by an ankle supination trauma. Conventional radiographs are useful as an initial imaging tool in the diagnostic process, but have only moderate sensitivity for the detection of osteochondral defects. Computed tomography (CT) and magnetic resonance imaging (MRI) are more accurate imaging modalities. Recently, ultrasonography and single photon emission CT have been described for the evaluation of osteochondral talar defects. CT is the most valuable modality for assessing the exact location and size of bony lesions. Cartilage and subchondral bone damage can be visualized using MRI, but the defect size tends to be overestimated due to bone edema. CT with the ankle in full plantar flexion has been shown a reliable tool for preoperative planning of the surgical approach. Postoperative imaging is useful for objective assessment of repair tissue or degenerative changes of the ankle joint. Plain radiography, CT and MRI have been used in outcome studies, and different scoring systems are available.

Biomimetic biphasic scaffolds for osteochondral defect repair

The osteochondral defects caused by vigorous trauma or physical disease are difficult to be managed. Tissue engineering provides a possible option to regenerate the damaged osteochondral tissues. For osteochondral reconstruction, one intact scaffold should be considered to support the regeneration of both cartilage and subchondral bone. Therefore, the biphasic scaffolds with the mimic structures of osteochondral tissues have been developed to close this chasm. A variety of biomimetic bilayer scaffolds fabricated from natural or synthetic polymers, or the ones loading with growth factors, cells, or both of them make great progresses in osteochondral defect repair. In this review, the preparation and in vitro and/or in vivo verification of bioinspired biphasic scaffolds are summarized and discussed, as well as the prospect is predicted.

Intermediate Results of Large Cystic Medial Osteochondral Lesions of the Talus Treated With Osteoperiosteal Cylinder Autografts From the Medial Tibia

PURPOSE

To investigate the clinical and radiologic outcomes of an autologous osteoperiosteal cylinder graft from the medial tibia for the treatment of large cystic medial osteochondral lesions (OCLs) of the talus.

METHODS

The study included 15 patients with large cystic medial OCLs. All underwent medial malleolus osteotomy and excision and curettage of the defect site, followed by transplantation with an autologous osteoperiosteal cylinder graft from the medial tibia. They were evaluated preoperatively and after a minimum of 24 months (mean, 44.8 months; range, 24 to 72 months) postoperatively by a visual analog scale, the American Orthopaedic Foot & Ankle Society ankle-hindfoot scale, the Ogilvie-Harris scale, and magnetic resonance imaging of the ankle.

RESULTS

The mean visual analog scale score decreased from 5.40 ± 1.06 points to 1.00 ± 1.00 points (P < .001), and the mean American Orthopaedic Foot & Ankle Society score increased from 49.00 ± 8.96 points to 89.00 ± 4.17 points (P < .001). The mean Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score was 64.00 ± 5.07 points. According to the Ogilvie-Harris scale, 7 cases were rated as excellent, 5 as good, 3 as fair, and 0 as poor. No complications were observed.

CONCLUSIONS

An autologous osteoperiosteal cylinder graft from the medial tibia is effective for treating large cystic medial OCLs of the talus and has a low rate of complications.

LEVEL OF EVIDENCE

Level IV, case series.

Trends in Ankle Arthroscopy and Its Use in the Management of Pathologic Conditions of the Lateral Ankle in the United States: A National Database Study

PURPOSE

This study aimed to investigate current trends in ankle arthroscopy across time, sex, age, and region of the United States as well as the use of ankle arthroscopy in the management of lateral ankle instability.

METHODS

Patients who underwent ankle arthroscopy and those who underwent ankle arthroscopy and lateral ankle ligament repair or peroneal retinacular repair from 2007 through 2011 were identified using the PearlDiver national database. These searches yielded volumes of unique patients, sex and age distribution, and regional volumes of patients. Χ-square linear-by-linear association analysis was used for comparisons, with P < .05 considered significant.

RESULTS

We identified 15,366 ankle arthroscopy procedures in the database from 2007 to 2011. Over the 5-year study period, there was a significant increase in the overall number of ankle arthroscopies being performed, from 2,814 in 2007 to 3,314 in 2011 (P < .0001). Female patients had ankle arthroscopy more frequently than did male patients (P = .027). The majority of patients who had ankle arthroscopy were between the ages of 30 and 49 years. The use of ankle arthroscopy during lateral ligament repair procedures increased from 37.2% in 2007 to 43.7% in 2011 (P < .0001). The incidence of combined ankle arthroscopy and peroneal tendon retinacular repair increased 50%, from 2.8/100 ankle arthroscopies in 2007 to 4.2/100 ankle arthroscopies in 2011 (P < .0001).

CONCLUSIONS

The incidence of ankle arthroscopy increased significantly from 2007 to 2011, outpacing shoulder, knee, and elbow arthroscopy. Ankle arthroscopy was performed more frequently in female patients and most commonly in patients younger than 50 years. The use of ankle arthroscopy in the surgical management of lateral ankle instability also increased significantly. The incidence of concomitant ankle arthroscopy and lateral ligament repair increased significantly, as did the incidence of concomitant ankle arthroscopy and repair of peroneal tendon subluxation.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

The relationship between the lesion-to-ankle articular length ratio and clinical outcomes after bone marrow stimulation for small osteochondral lesions of the talus

PURPOSE

The purpose of this study was to determine the relationship between the defect-to-ankle articular length ratio and clinical outcomes after arthroscopic bone marrow stimulation.

METHODS

Seventeen male and 24 female patients (mean age 36.0 years, height 160.7 cm, weight 62.5 kg, body mass index 24.0) with an osteochondral lesion of the talus were treated with arthroscopic bone marrow stimulation and assessed using the Japanese Society for Surgery of the Foot (JSSF) ankle-hindfoot scale, Berndt and Harty scales and clinical outcome criteria. The lengths of the tibial and talar articular surfaces were defined from the anterior tip to posterior tip of the articular cartilage on sagittal magnetic resonance imaging scans. The size of the defect area was defined and determined for each patient on magnetic resonance images using coronal length, sagittal length, and area. The relationship between clinical outcome and sagittal tibia ratio (sagittal length of defect/length of tibia articular cartilage) and sagittal talus ratio (sagittal length of defect/length of talus articular cartilage) were assessed.

RESULTS

The mean lesion length was 11 mm (range 6-14 mm), lesion size was 67 mm(2) (range 19-134 mm(2)), sagittal tibia ratio was 0.42 (range 0.21-0.75), and sagittal talus ratio was 0.32 (range 0.16-0.58). The mean JSSF scale improved from 74 (range 18-90) to 89 (range 67-100) postoperatively. Lesion area was not associated with the JSSF scale (r = -0.10, P = 0.52). Talus articular length (r = 0.64, P < 0.0001) and tibia articular length (r = 0.64, P < 0.0001) were correlated with patient height. The sagittal talus ratio and sagittal tibia ratio were not associated with the JSSF scale (r = -0.10, P = 0.55; r = -0.02, P = 0.90).

CONCLUSION

Arthroscopic bone marrow stimulation provides good clinical outcomes in small osteochondral lesions of the talus (<15 mm). For small lesions, the lesion size is not a prognostic factor.

LEVEL OF EVIDENCE

IV: Retrospective Case Series.

Anterior ankle arthroscopy: indications, pitfalls, and complications

Anterior ankle arthroscopy is a useful, minimally invasive technique for diagnosing and treating ankle conditions. Arthroscopic treatment offers the benefit of decreased surgical morbidity, less postoperative pain, and earlier return to activities. Indications for anterior ankle arthroscopy continue to expand, including ankle instability, impingement, management of osteochondritis dissecans, synovectomy, and loose body removal. Anterior ankle arthroscopy has its own set of inherent risks and complications. Surgeons can decrease the risk of complications through mastery of ankle anatomy and biomechanics, and by careful preoperative planning and meticulous surgical technique.

Outcomes of talar dome osteochondral defect repair using osteocartilaginous autografts: 37 cases of Mosaicplasty®

BACKGROUND

The indications of osteochondral autograft implantation using the Mosaicplasty(®) technique were only recently extended to osteochondral lesions of the talus (OLT), a site for which no medium- or long-term outcome data are available. Our objective here was to evaluate medium-term outcomes in case-series of patients who underwent Mosaicplasty(®) for OLT repair.

HYPOTHESIS

Mosaicplasty(®) provides good medium-term outcomes with low morbidity when used for OLT repair.

PATIENTS ET METHODS

We retrospectively reviewed cases of Mosaicplasty(®) for OLT repair, performed in combination with malleolar osteotomy on the side of the OLT, at either of two centres, between 1997 and 2013. Pre-operative clinical data were collected from the medical records and all patients were re-evaluated. We studied 37 patients with a mean age of 33 years.

RESULTS

Mean follow-up at re-evaluation was 76 months. Mean AOFAS score at re-evaluation was 83 (range, 9-100). A work-related cause to the OLT was associated with significantly poorer outcomes (P=0.01). AOFAS values were significantly better in patients whose OLT size was 0.5 to 1cm(2). The Ogilvie-Harris score at last follow-up was good or excellent in 78% of patients. No patient experienced morbidity related to the malleolar osteotomy. Persistent patellar syndrome was noted in 6 patients.

DISCUSSION

In our case-series, Mosaicplasty(®) for OLT repair provided good medium-term outcomes in 78% of patients. Nevertheless, the donor-site morbidity should be borne in mind. Mosaicplasty(®) deserves to be viewed as a reference standard method for OLT repair.

LEVEL OF EVIDENCE

IV, retrospective study.

Functional and MRI outcomes after arthroscopic microfracture for treatment of osteochondral lesions of the distal tibial plafond

BACKGROUND

Osteochondral lesions of the distal tibial plafond are uncommon compared with talar lesions. The objective of this study was to assess functional and magnetic resonance imaging (MRI) outcomes following microfracture for tibial osteochondral lesions.

METHODS

Thirty-one tibial osteochondral lesions in thirty-one ankles underwent arthroscopic microfracture. The Foot and Ankle Outcome Score (FAOS) and Short Form-12 (SF-12) general health questionnaire were used to obtain patient-reported functional outcome scores preoperatively and postoperatively. MRI scans were assessed postoperatively with use of the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score for twenty-three ankles.

RESULTS

The average age was thirty-seven years (range, fifteen to sixty-eight years), and the average lesion area was 38 mm(2) (range, 7.1 to 113 mm(2)). Twelve ankles had a kissing lesion on the opposing surface of the talus, and two ankles had a concomitant osteochondral lesion elsewhere on the talus. FAOS and SF-12 scores were significantly improved (p < 0.01) at the time of follow-up, at an average of forty-four months. The average postoperative MOCART score was 69.4 (range, 10 to 95), with a lower score in the ankles with kissing lesions (62.8) than in the ankles with an isolated lesion (73.6). Increasing age negatively impacted improvement in SF-12 (p < 0.01) and MOCART (p = 0.04) scores. Increasing lesion area was negatively correlated with MOCART scores (p = 0.04) but was not associated with FAOS or SF-12 scores. Lesion location and the presence of kissing lesions showed no association with functional or MRI outcomes.

CONCLUSIONS

Arthroscopic microfracture provided functional improvements, but the optimal treatment strategy for tibial osteochondral lesions remains unclear. The repair tissue assessed on MRI was inferior to normal hyaline cartilage. The MRI outcomes appeared to deteriorate with increasing lesion area, and both functional and MRI outcomes appeared to deteriorate with increasing age.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Osteochondral lesions of the talus: a current concepts review and evidence-based treatment paradigm

Osteochondral lesions of the talar dome are increasingly diagnosed and are a difficult pathology to treat. Conservative treatment yields best results in pediatric patients, often leaving surgical options for adult populations. There is a paucity of long-term data and comparisons of treatment options. Arthroscopic bone marrow stimulation is a common first-line treatment for smaller lesions. Despite promising short to medium term clinical results, bone marrow stimulation results in fibrocartilagenous tissue that incurs differing mechanical and biological properties compared with normal cartilage. Autologous osteochondral transplantation has demonstrated promising clinical results in the short to medium term for larger, cystic lesions and can restore the contact pressure of the joint. However, concerns remain over postoperative cyst formation and donor site morbidity. Recent developments have emphasized the usefulness of biological adjuncts such as platelet-rich plasma and concentrated bone marrow aspirate, as well as particulate juvenile cartilage, in augmenting reparative and replacement strategies in osteochondral lesion treatment. The purpose of this article is to review diagnosis and treatment of talar osteochondral lesions so that current practice guidelines can be more efficiently used given the available treatment strategies. A treatment paradigm based on current evidence is described.

LEVELS OF EVIDENCE

Therapeutic, Level V, Expert Opinion.

Treatment of osteochondral defects of the talus in children

PURPOSE

Osteochondral talar defects are infrequent in children, and little is known about the treatment and clinical outcome of these defects. The purpose of this study was to evaluate the clinical and radiographic outcomes of conservative and primary surgically treated osteochondral talar defects in skeletally immature children.

METHODS

Thirty-six (97%) of 37 eligible patients with a symptomatic primary osteochondral talar defect were evaluated after a median follow-up of 4 years (range 1-12 years). Clinical assessment included the Berndt and Harty outcome question, Ogilvie-Harris score, Visual Analog Scale pain score (at rest, during walking and during running), the American Orthopaedic Foot and Ankle Society (AOFAS) score, and the SF-36. Weight-bearing radiographs were compared with preoperative radiographs with the use of an ankle osteoarthritis classification system.

RESULTS

Ninety-two per cent of the initially conservatively treated children [mean age 13 years (SD 2)] were eventually scheduled to undergo surgery. After fixation of the fragment, seven cases (78%) reported a good Berndt and Harty outcome, and two cases (22%) a fair outcome; the median AOFAS score was 95.0 (range 77-100). After debridement and bone marrow stimulation, 13 cases (62%) reported a good Berndt and Harty outcome, three cases (14%) a fair outcome, and five cases (24%) a poor outcome; the median AOFAS score was 95.0 (range 45-100). No signs of degenerative changes were seen in both groups at follow-up.

CONCLUSIONS

Fixation and debridement and bone marrow stimulation of an osteochondral talar defect are both good surgical options after failed conservative treatment.

LEVEL OF EVIDENCE

Retrospective case series, Therapeutic, Level IV.

Osteochondral Autologous Transplantation Is Superior to Repeat Arthroscopy for the Treatment of Osteochondral Lesions of the Talus After Failed Primary Arthroscopic Treatment

BACKGROUND

Several studies have reported on the outcome of arthroscopic treatment or osteochondral autologous transplantation (OAT) for osteochondral lesions of the talus (OLT), with mixed results. None of these studies has compared the results of repeat arthroscopy and OAT after failed primary arthroscopic treatment.

PURPOSE

To compare the outcomes of OAT and repeat arthroscopy for the treatment of OLT after primary arthroscopy

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

This study included 22 patients who underwent OAT (group A) and 22 patients who underwent repeat arthroscopy (group B) after failed treatment of OLT among 399 patients who received primary arthroscopic marrow stimulation at single institution between 2001 and 2009. All patients were evaluated clinically using the visual analog scale (VAS) for pain and American Orthopaedic Foot and Ankle Society (AOFAS) Ankle Hindfoot Scale. The cumulative success rates were compared by use of Kaplan-Meier life table analysis.

RESULTS

The patients' demographic and clinical characteristics and indications for surgery were comparable between the groups. Both groups showed significantly improved (P < .001) VAS and AOFAS scores 6 months after surgery. However, group B showed significant deterioration over a mean follow-up period of 50 months. Overall, 18 of 22 (81.8%) patients in group A and 7 of 22 (31.8%) patients in group B achieved an excellent or good (≥80) AOFAS score (P < .001). No patient in group A and 14 of 22 (63.6%) in group B required further revisions.

CONCLUSION

Osteochondral autologous transplantation was significantly superior to repeat arthroscopic treatment of OLT after a mean follow-up period of 48 months. Therefore, repeat arthroscopy should be used judiciously for the treatment of OLT after failed arthroscopic treatment.

Pathogenesis of post-traumatic OA with a view to intervention

Post-traumatic osteoarthritis (PTOA) subsequent to joint injury accounts for over 12% of the overall disease burden of OA, and higher in the most at-risk ankle and knee joints. Evidence suggests that the pathogenesis of PTOA may be related to inflammatory processes and alterations to the articular cartilage, menisci, muscle and subchondral bone that are initiated in the acute post-injury phase. Imaging of these early changes, as well as a number of biochemical markers, demonstrates the potential for use as predictors of future disease, and may help stratify patients on the likelihood of their developing clinical disease. This will be important in guiding future interventions, which will likely target elements of the inflammatory response within the joint, molecular abnormalities related to cartilage matrix degradation, chondrocyte function and subchondral bone remodelling. Until significant improvements are made, however, in identifying patients most at risk for developing PTOA--and therefore those who are candidates for therapy--primary prevention programmes will remain the most effective current management tools.

Osteochondral lesions of the talus: aspects of current management

Osteochondral lesions (OCLs) occur in up to 70% of sprains and fractures involving the ankle. Atraumatic aetiologies have also been described. Techniques such as microfracture, and replacement strategies such as autologous osteochondral transplantation, or autologous chondrocyte implantation are the major forms of surgical treatment. Current literature suggests that microfracture is indicated for lesions up to 15 mm in diameter, with replacement strategies indicated for larger or cystic lesions. Short- and medium-term results have been reported, where concerns over potential deterioration of fibrocartilage leads to a need for long-term evaluation. Biological augmentation may also be used in the treatment of OCLs, as they potentially enhance the biological environment for a natural healing response. Further research is required to establish the critical size of defect, beyond which replacement strategies should be used, as well as the most appropriate use of biological augmentation. This paper reviews the current evidence for surgical management and use of biological adjuncts for treatment of osteochondral lesions of the talus.

Arthroscopic Treatment of Osteochondral Talar Defects

Introduction

Arthroscopic debridement and bone marrow stimulation (i.e., drilling or microfracturing) is considered the primary surgical treatment of osteochondral defects of the talus.

Step 1 Position the Patient

For anterior ankle arthroscopy, position the patient supine; for posterior arthroscopy, position the patient prone.

Step 2 Arthroscopic Approach

For anterior ankle arthroscopy, place the portals medial to the tibialis anterior tendon and lateral to the peroneus tertius tendon at the level of the ankle joint; for posterior arthroscopy, place the portals lateral and medial to the Achilles tendon just above the level of the tip of the lateral malleolus.

Step 3 Debridement and Bone Marrow Stimulation

Fully debride the osteochondral defect and create multiple microfractures in the bottom of the defect.

Step 4 Closure and Postoperative Care

Prescribe partial weight-bearing for six weeks.

Results

A systematic review of the literature identified eighteen studies on bone marrow stimulation that included a total of 388 patients³. The study weighted success rate was 85% (range, 46% to 100%).

What to Watch For

IndicationsContraindicationsPitfalls & Challenges.