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Breulmann F, Mehl J, Otto A, Lappen S, Siebenlist S, Rab P. [Treatment of osteochondritis dissecans]. ORTHOPADIE (HEIDELBERG, GERMANY) 2024; 53:69-82. [PMID: 38189958 DOI: 10.1007/s00132-023-04461-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/14/2023] [Indexed: 01/09/2024]
Abstract
Osteochondritis dissecans (OD) is a rare condition with an incidence of 30/100,000. It especially affects male patients aged 10-20 years old. During the staged progression the osteochondral fragments can detach from their base. These can damage the adjacent articular cartilage, which can lead to premature osteoarthritis. Most commonly affected are the knee, ankle and elbow joints. The exact pathogenesis of OD has so far not been clearly confirmed. Several risk factors that can lead to the development of OD are discussed. These include repeated microtrauma and vascularization disorders that can lead to ischemia of the subchondral bone and to a separation of the fragments close to the joint and therefore to the development of free joint bodies. For an adequate clarification patients should undergo a thorough radiological evaluation including X‑ray imaging followed by magnetic resonance imaging (MRI) to assess the integrity of the cartilage-bone formation with determination of the OD stage. The assessment is based on criteria of the International Cartilage Repair Society (ICRS). The instability of the cartilage-bone fragment increases with higher stages. Stages I and II with stable cartilage-bone interconnection can be treated conservatively. For stages III and IV, i.e., instability of the OD fragment or the presence of free fragments, surgical treatment should be performed. Primarily, refixation of a free joint body should be carried out depending on the size and vitality of the fragment. In cases of unsuccessful conservative treatment or fixation, a debridement, if necessary in combination with a bone marrow stimulating procedure, can be employed corresponding to the size of the defect. For larger cartilage defects, an osteochondral graft transplantation should be considered. Overall, OD lesions in stages I and II show a good healing tendency under conservative treatment. In cases of incipient unstable OD, refixation can also lead to good clinical and radiological results.
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Affiliation(s)
- Franziska Breulmann
- Sektion Sportorthopädie, Klinikum rechts der Isar, Technische Universität München, 81675, München, Deutschland
| | - Julian Mehl
- Sektion Sportorthopädie, Klinikum rechts der Isar, Technische Universität München, 81675, München, Deutschland
| | - Alexander Otto
- Sektion Sportorthopädie, Klinikum rechts der Isar, Technische Universität München, 81675, München, Deutschland
| | - Sebastian Lappen
- Sektion Sportorthopädie, Klinikum rechts der Isar, Technische Universität München, 81675, München, Deutschland
| | - Sebastian Siebenlist
- Sektion Sportorthopädie, Klinikum rechts der Isar, Technische Universität München, 81675, München, Deutschland.
| | - Peter Rab
- Sektion Sportorthopädie, Klinikum rechts der Isar, Technische Universität München, 81675, München, Deutschland
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Hollander JJ, Dahmen J, Emanuel KS, Stufkens SA, Kennedy JG, Kerkhoffs GM. The Frequency and Severity of Complications in Surgical Treatment of Osteochondral Lesions of the Talus: A Systematic Review and Meta-Analysis of 6,962 Lesions. Cartilage 2023; 14:180-197. [PMID: 37144397 PMCID: PMC10416205 DOI: 10.1177/19476035231154746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 01/18/2023] [Accepted: 01/18/2023] [Indexed: 05/06/2023] Open
Abstract
OBJECTIVE The primary aim was to determine and compare the complication rate of different surgical treatment options for osteochondral lesions of the talus (OLTs). The secondary aim was to analyze and compare the severity and types of complications. DESIGN A literature search was performed in MEDLINE (PubMed), EMBASE (Ovid), and the Cochrane Library. Methodological quality was assessed using the Methodological Index for Non-Randomized Studies (MINORS). Primary outcome was the complication rate per surgical treatment option. Secondary outcomes included the severity (using the Modified Clavien-Dindo-Sink Complication Classification System for Orthopedic Surgery) and types of complications. The primary outcome, the severity, and the sub-analyses were analyzed using a random effects model. A moderator test for subgroup-analysis was used to determine differences. The types of complications were presented as rates. RESULTS In all, 178 articles from the literature search were included for analysis, comprising 6,962 OLTs with a pooled mean age of 35.5 years and follow-up of 46.3 months. Methodological quality was fair. The overall complication rate was 5% (4%-6%; treatment group effect, P = 0.0015). Analysis resulted in rates from 3% (2%-4%) for matrix-assisted bone marrow stimulation to 15% (5%-35%) for metal implants. Nerve injury was the most observed complication. CONCLUSIONS In 1 out of 20 patients treated surgically for an OLT, a complication occurs. Metal implants have a significantly higher complication rate compared with other treatment modalities. No life-threatening complications were reported.
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Affiliation(s)
- Julian J. Hollander
- Department of Orthopaedic Surgery and Sports Medicine, Amsterdam Movement Sciences, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
- Academic Center for Evidence Based Sports Medicine, Amsterdam UMC, Amsterdam, The Netherlands
- Amsterdam Collaboration for Health and Safety in Sports, International Olympic Committee Research Center, Amsterdam UMC, Amsterdam, The Netherlands
| | - Jari Dahmen
- Department of Orthopaedic Surgery and Sports Medicine, Amsterdam Movement Sciences, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
- Academic Center for Evidence Based Sports Medicine, Amsterdam UMC, Amsterdam, The Netherlands
- Amsterdam Collaboration for Health and Safety in Sports, International Olympic Committee Research Center, Amsterdam UMC, Amsterdam, The Netherlands
| | - Kaj S. Emanuel
- Department of Orthopaedic Surgery and Sports Medicine, Amsterdam Movement Sciences, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
- Academic Center for Evidence Based Sports Medicine, Amsterdam UMC, Amsterdam, The Netherlands
- Amsterdam Collaboration for Health and Safety in Sports, International Olympic Committee Research Center, Amsterdam UMC, Amsterdam, The Netherlands
- Department of Orthopedic Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Sjoerd A.S. Stufkens
- Department of Orthopaedic Surgery and Sports Medicine, Amsterdam Movement Sciences, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
- Academic Center for Evidence Based Sports Medicine, Amsterdam UMC, Amsterdam, The Netherlands
- Amsterdam Collaboration for Health and Safety in Sports, International Olympic Committee Research Center, Amsterdam UMC, Amsterdam, The Netherlands
| | - John G. Kennedy
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
| | - Gino M.M.J. Kerkhoffs
- Department of Orthopaedic Surgery and Sports Medicine, Amsterdam Movement Sciences, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
- Academic Center for Evidence Based Sports Medicine, Amsterdam UMC, Amsterdam, The Netherlands
- Amsterdam Collaboration for Health and Safety in Sports, International Olympic Committee Research Center, Amsterdam UMC, Amsterdam, The Netherlands
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Arthroscopic defect size measurement in osteochondral lesions of the talus underestimates the exact defect size and size measurement with arthro-MRI (MR-A) and high-resolution flat-panel CT-arthro imaging (FPCT-A). Knee Surg Sports Traumatol Arthrosc 2023; 31:716-723. [PMID: 36441219 DOI: 10.1007/s00167-022-07241-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 11/15/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE The size of osteochondral lesions of the talus (OLTs) is highly relevant for their treatment. In addition to intraoperative measurement of defect size, preoperative planning by means of magnetic resonance imaging (MRI) or computed tomography (CT) is crucial. METHODS Four defects of different sizes and depths were created on the talar joint surface in 14 cadaver feet. All defects were evaluated, both arthroscopically and via arthrotomy with a probe. Arthro-MRI (MR-A) and high-resolution flat-panel CT arthro scans (FPCT-A) were acquired. Length, width, and depth were measured for every defect and the defect volume was calculated. To determine the exact defect size, each talar defect was filled with plastic pellets to form a cast and the casts were scanned using FPCT to create a 3D multiplanar reconstruction data set. Finally, the surgically measured values were compared with the radiological values and the exact defect size. RESULTS Overall, the surgically measured values (both arthroscopic and open) underestimated the exact defect size (p < 0.05). Arthroscopically determined defect length and width showed the largest deviation (p < 0.05) and underestimated the size in comparison with MR-A and FPCT-A. The FPCT-A measurements demonstrated higher correlation with both the arthroscopic and open surgical measurements than did the MR-A measurements (p < 0.05). CONCLUSION The exact defect size is underestimated on intraoperative measurement, in both arthroscopic and open approaches. Arthroscopic defect size measurement underestimates defect size in comparison with MR-A and FPCT-A. FPCT-A was shown to be a reliable imaging technique that allows free image reconstruction in every plane and could be considered as the new reference standard for preoperative evaluation of defect size in OLT.
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