Fixation of the osteochondral talar fragment yields good results regardless of lesion size or chronicity

Fixation of Osteochondral Lesions of the Talus: Indications, Techniques, Outcomes, and Pearls from the Amsterdam Perspective

The treatment of osteochondral lesions of the talus (OLT) remains a topic of debate as no superior treatment has yet been identified. The current consensus is that it is crucial to incorporate lesion and patient characteristics into the treatment algorithm. One such lesion type is the OLT with a fragment, which may benefit from in situ fixation. Fixation preserves the native hyaline cartilage and offers a direct stabilization of the fragment with high-quality subchondral bone repair. This current concepts review describes the evidence-based clinical work-up, indications, surgical techniques, outcomes, and clinical pearls for fixation techniques of OLT from the Amsterdam perspective.

Arthroscopic Fixation Using Bioabsorbable Pins With Bone Grafting via a Medial Malleolus Approach to Treat Osteochondral Lesion of the Talus

Fixation of the osteochondral fragment has the advantage to restore the naturally congruent morphology of the talar dome with native hyaline cartilage in the treatment of the osteochondral lesion of the talus (OLT). Surgical treatment of medial talar osteochondral lesions is commonly done through a medial malleolar osteotomy. However, a medial malleolar osteotomy is an invasive procedure and gives negative impacts on clinical outcomes. Fixation for the posteromedial lesion of the OLT without the medial malleolar osteotomy may provide good clinical outcomes. We showed arthroscopic fixation for medial OLT without the medial malleolar osteotomy. Curettage and bone grafting between the fragment and its bed were performed, and then 2-mm bone tunnel in the medial malleolus was created. Bioabsorbable pins were inserted through the tunnel to fix the osteochondral fragment. Three cases (mean age 18.6 years) were treated using this technique for medial OLT and followed at 16 months (range, 12-24 months). The Japanese Society for Surgery of the Foot scale improved from 73.3 ± 1.2 points before surgery to 95.7 ± 7.5 points at the final follow-up. Bone union of the osteochondral fragment was confirmed on magnetic resonance imaging (MRI). Arthroscopic fixation for medial OLT is less invasive and yields good clinical outcomes.Levels of Evidence: Level V.

Development of osteophytes and joint space narrowing is associated with cartilage degeneration of the osteochondral fragment in the osteochondral lesion of the talus

BACKGROUND

During surgery for osteochondral lesions of the talus (OLT), preservation or excision of the osteochondral fragment is chosen based on the cartilage condition which influences the indication and clinical outcomes of surgical treatments. However, it is difficult to predict arthroscopic and histological findings of the cartilage on osteochondral fragments by radiographic evaluation. We focused on osteoarthritis (OA) changes on plain radiographs to predict the cartilage condition of the OLT. This study aimed to evaluate whether OA changes, including osteophyte and joint space narrowing, could predict arthroscopic and histological findings of the cartilage in OLT.

METHODS

Seventy ankles with OLT were included in this study. Osteophytes and joint space narrowing were scored on plain radiographs. Lesion sizes were measured on computed tomography images. The cartilage surfaces of fragments were arthroscopically assessed using the International Cartilage Repair Society (ICRS) grade. Biopsy specimens from 32 ankles were histologically analyzed using the Mankin score. The relationships between OA scores, lesion size, ICRS grades, and Mankin score were analyzed.

RESULTS

OA changes were frequently observed with increasing ICRS grades, especially in the medial tibiotalar joint. OA scores in patients with ICRS grade 1 were significantly lower than those in ICRS grades 2,3, and 4. The lesion sizes in patients with ICRS grade 3 and 4 were significantly smaller than those in patients with ICRS grade 1 and 2. Histological analysis showed increasing Mankin scores as the ICRS grade worsened. A mild correlation existed between the OA and Mankin scores (rs = 0.494).

CONCLUSIONS

OA changes, such as osteophyte formation and joint space narrowing, are associated with arthroscopic findings of the articular surface and cartilage degeneration in osteochondral fragment in OLT. Articular cartilage conditions can be predicted by OA changes on plain radiographs, which is useful for choosing the appropriate treatment for patients with OLT.

LEVEL OF EVIDENCE

Level Ⅳ, case series.

The role of the oblique medial osteotomy angle during osteochondral fragment fixation in patients with a posteromedial osteochondral lesion of the talus

BACKGROUND

Medial malleolar osteotomy has been widely performed for posteromedial osteochondral lesions of the talus (OLT) to expose the lesion. In osteochondral fragment fixation, bioabsorbable pins should be inserted as perpendicular as possible to obtain the rigid fixation. However, the exposure of the lesion may depend on the osteotomy angle, which affects the pin insertion angles. This study aimed to analyze the relationship between pin insertion and osteotomy angles in the medial malleolar osteotomy.

METHODS

Twenty-four ankles of 23 patients were included. The malleolar bisector angle which was calculated from radiographs and actual osteotomy angles were measured on radiographs, and the pin insertion and osteotomy angles were measured using MRI. The intersection angle was defined by the tangential line of the tibial plafond and medial malleolar articular facet, and the bisector of this angle was defined as the malleolar bisector angle. The relationship between pin insertion and osteotomy angles was analyzed.

RESULTS

There was no significant difference between the actual osteotomy (55.7° ± 6.6°) and malleolar bisector angles (57.4° ± 4.3°) on the radiograph. There was a significant correlation between pin insertion and osteotomy angles (rs = 0.601). The pin insertion angle (54.3° ± 5.9°) in the lower actual osteotomy angle than the malleolar bisector angle was smaller than those in the higher actual osteotomy angle (63.4° ± 8.2°).

CONCLUSIONS

This study showed the osteotomy angle affected pin insertion angle. The osteotomy angle should not be smaller than the malleolar bisector angle at medial malleolar osteotomy to insert pins as perpendicular as possible for fixation of posteromedial OLTs.

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

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.

Sustained clinical success at 7-year follow-up after arthroscopic Lift-Drill-Fill-Fix (LDFF) of primary osteochondral lesions of the talus

PURPOSE

To describe the long-term clinical results of arthroscopic fragment fixation for chronic primary osteochondral lesions of the talus (OLT), using the Lift-Drill-Fill-Fix (LDFF) technique.

METHODS

Eighteen patients (20 ankles) underwent fixation for a primary OLT with an osteochondral fragment using arthroscopic LDFF and were evaluated at a minimum of 5-year follow-up. Pre- and postoperative clinical assessment was prospectively performed by measuring the Numeric Rating Scale (NRS) of pain at rest, during walking and when running. Additionally, the change in Foot and Ankle Outcome Score (FAOS) and the procedure survival (i.e., no reoperation for the OLT) at final follow-up was assessed.

RESULTS

At a mean follow-up of 7 years, the median NRS during walking significantly improved from 7 (IQR 5-8) pre-operatively to 0 (IQR 0-1.5) at final follow-up (p =  < 0.001). This result was sustained from 1-year follow-up to final follow-up. The NRS during running significantly improved from 8 (IQR 6-10) to 2 (IQR 0-4.5) (p < 0.001) and the NRS in rest from 2.5 (IQR 1-3) to 0 (IQR 0-0) (p =  < 0.001). The median FAOS at final follow-up was 94 out of 100 for pain, 71 for other symptoms, 99 for activities of daily living, 80 for sport and 56 for quality of life. The FOAS remained significantly improved post-operatively on all subscales, except for the symptoms subscale. The procedure survival rate is 87% at final follow-up.

CONCLUSION

Arthroscopic LDFF for fixable chronic primary OLTs results in excellent pain reduction and improved patient-reported outcomes, with sustained results at long-term follow-up. These results indicate that surgeons may consider arthroscopic LDFF as treatment of choice for fragmentous OLT.

LEVEL OF EVIDENCE

Level IV, prospective case series.

Clinical Outcomes of Osteochondral Fragment Fixation Versus Microfracture Even for Small Osteochondral Lesions of the Talus

BACKGROUND

The bone marrow stimulation (BMS) technique is performed for osteochondral lesions of the talus (OLTs) with a lesion size of <100 mm². The lesion defect is covered with fibrocartilage, and the clinical outcomes deteriorate over time. In contrast, the osteochondral fragment fixation can restore the native articular surface. The difference in clinical outcomes between these procedures is unclear.

PURPOSE

To compare the clinical outcomes of BMS and osteochondral fragment fixation for OLTs and examine the characteristics of patients with poor clinical outcomes of BMS.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

In total, 62 ankles in 59 patients with OLTs were included. BMS was performed for 26 ankles, and fixation was performed for 36 ankles. Clinical outcomes, including the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle Hindfoot Scale and bone marrow edema (BME) as identified on magnetic resonance imaging, were compared between the 2 groups. On computed tomography scans, the lesion location was compared with or without BME in each group.

RESULTS

The AOFAS scores in the fixation group (97.3 ± 4.3 points) were significantly higher than those in the BMS group (91.3 ± 7.7 points), even when the lesion size was <100 mm² (P < .05). When comparing the ankles with or without BME in each group, the AOFAS scores at the final follow-up were significantly lower for the ankles with BME (88.6 ± 7.8 points) than for those without BME (95.0 ± 6.1 points) in the BMS group (P < .05). Lesions with BME in the sagittal plane were located more centrally than those without BME in the BMS group. In the fixation group, there were no significant differences in AOFAS scores and location of the lesion in ankles with or without BME.

CONCLUSION

The clinical outcomes of osteochondral fragment fixation are superior to those of BMS in OLTs, even for lesions sized <100 mm². Fixation is recommended even for small lesions, especially for more centralized lesions in the medial and lateral sides of the talus.

Second-look arthroscopic and magnetic resonance analysis after internal fixation of osteochondral lesions of the talus

The purpose of this study was to evaluate cartilage quality after internal fixation of osteochondral lesion of the talus (OLT) using second-look arthroscopies and MRIs. Thirty-four patients underwent internal fixation of OLTs involving large bone fragments. Twenty-one of these patients underwent second-look arthroscopies and 23 patients underwent MRIs postoperatively. The arthroscopic findings were assessed using the International Cartilage Repair Society (ICRS) grading system, and the MRI findings were evaluated using the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score. Five of the patients who underwent second-look arthroscopies showed normal cartilage, 12 showed nearly normal cartilage, 3 showed abnormal cartilage, and 1 showed severely abnormal cartilage, according to the overall ICRS repair grades. All the patients who achieved bone fragment union showed normal, or nearly normal cartilage upon second-look arthroscopy. The ICRS and MOCART scores were significantly higher for the patients with bone fragment union compared to those with nonunion (ICRS scores: 10.3 ± 1.5 vs. 6.0 ± 2.0, p < 0.001, MOCART score: 88.3 ± 10.0 vs. 39.0 ± 20.4, p < 0.001). Low signal intensities of the bone fragments on preoperative T1-weighted MRIs were not associated with nonunion (Fisher's exact test, p = 0.55), and the signal intensities increased postoperatively to levels similar to the underlying talus when bone union was achieved. Second-look arthroscopy and MRI showed normal, or nearly normal, cartilage after internal fixation of OLTs when bone union was achieved. The nonunion of bone fragments resulted in inferior cartilage quality.

Osteochondral lesion of the talus: still a problem?

Osteochondral lesion of the talus (OLT) often occurs after ankle trauma or repetitive micro-traumata, whereas the actual etiology remains unclear. The most common symptoms are local pain deep in the medial or lateral ankle that increases with weight-bearing and activity, accompanied by tenderness and swelling.

Eventually, most patients with symptomatic or unstable OLT require surgery. Many reasonable operative techniques have been described, whereas most lead to similar and satisfactory results. They can be divided into cartilage repair, cartilage regeneration and cartilage replacement techniques. The OLT size and morphology in the first place but also surgeon and individual patient aspects are considered when it comes to surgery.

For high postoperative success and low recurrence rates, underlying causes, for example, ligamentous instability and hindfoot malalignment should also be addressed during surgery.

Location Distribution of 2,087 Osteochondral Lesions of the Talus

OBJECTIVE

The primary aim of this study was to evaluate the exact location distribution in patients with osteochondral lesions of the talus (OLTs) using a 9-grid scheme. The secondary aim is to match lesion location to lesion size, arthroscopic or open operation, and trauma occurrence.

METHODS

A systematic review was performed in the databases PubMed, EMBASE, and Cochrane. Search terms consisted of "talus" and "osteochondral lesion." Two independent reviewers evaluated search results and conducted the quality assessment using the Methodological Index for Non-Randomized Studies (MINORS). Primary outcome measure was OLT location in the 9 zone-grid. Secondary outcome measures were OLT size in 9-zones, preoperative radiological modality use, demographic lesion size variables as well as open or arthroscopic treatment.

RESULTS

Fifty-one articles with 2,087 OLTs were included. Heterogeneity concerning methodological nature was observed and methodological quality was low. The posteromedial (28%) and centromedial (31%) zones combined as one location was the location with the highest incidence of OLTs with a rate of 59%. Individual OLT size was reported for only 153 lesions (7%). Preoperative combination of X-ray and magnetic resonance imaging (MRI), and/or computed tomography (CT) was reported in 20 studies (43%). Trauma was reported in 78% of patients. Furthermore, 67% was treated arthroscopically and 76% received primary OLT treatment.

CONCLUSION

The majority of OLTs are located in the posteromedial and centromedial zone, while the largest OLTs were reported in the centrocentral zone. Further research is required to identify the prognostic impact of location occurrence on the outcomes following OLT treatment.

Internal Fixation of a Lateral Inverted Osteochondral Fracture of the Talus (LIFT) Lesion Using an Innovative Surgical Approach: Inverting the Capsulo-Lateral Fibulotalocalcaneal Ligament (LFTCL)-Fibular Periosteum Complex

Osteotomy of the distal fibula or anterolateral corner of the tibia is usually required to fix a displaced osteochondral fracture of the talus that is located central to posterior area of the lateral talar dome. However, osteotomy is an invasive procedure and is associated with complications, including nonunion, persistent pain, and hardware-related problems. Lateral inverted osteochondral fracture of the talus (LIFT) lesion is an extremely rare type of displaced osteochondral lesion of the talus. We describe a case in which a LIFT lesion was fixed using an innovative surgical approach, inverting capsulo-lateral fibulotalocalcaneal ligament (LFTCL)-fibular periosteum complex, with a favorable short-term clinical outcome.

Histopathological and Radiographic Features of Osteolysis After Fixation of Osteochondral Fragments Using Poly-L-Lactic Acid Pins for Osteochondral Lesions of the Talus

BACKGROUND

Fixation of osteochondral fragments is a potential option for treating an osteochondral lesion of the talus (OLT) involving large lesions in the remaining articular cartilage surface. Bioabsorbable devices, especially those made of poly-L-lactic acid (PLLA), can be used for the fixation of an OLT. Postoperative osteolysis surrounding the PLLA pins is occasionally observed; however, the significance of osteolysis remains unknown.

PURPOSE

To elucidate the association between osteolysis surrounding the PLLA pins, histopathological findings in subchondral bone, and preoperative Hounsfield unit (HU) values at the pin fixation site.

STUDY DESIGN

Case Series; Level of evidence, 4.

METHODS

This retrospective analysis included 20 patients with OLT (11 men and 9 women; mean age, 20.9 years; 1 bilateral case). Tissue from the osteochondral fragment was collected intraoperatively using a bone biopsy needle for histological evaluation. The fragment was fixed through the biopsy hole using a PLLA pin. Osteolysis surrounding the PLLA pin was assessed at 1 year postoperatively using magnetic resonance imaging (MRI). Histopathological scores were assigned based on trabecular bone loss, empty lacunae, inflammatory granulation tissue, cartilage-like tissue, and the presence of osteoclasts. The HU values around the pin insertion site, detected on the postoperative MRI scans, were measured using the region of interest based on the preoperative coronal and sagittal computed tomography (CT) images.

RESULTS

Osteolysis was observed postoperatively in 9 ankles (42.9%). Histopathological evaluation revealed that the osteolysis group had a significantly higher pathological score than the nonosteolysis group (10.2 vs 6.3; P < .001). Lower HU values were identified in the osteolysis group on preoperative coronal and sagittal CT images (P < .05). The histopathological score negatively correlated with preoperative HU values (Pearson r = -0.46; P = .037).

CONCLUSION

Intraoperative biopsy of the OLT allowed for histopathological evaluation of the same site as that of the PLLA pin fixation. Our findings suggest that preoperative subchondral trabecular deterioration is associated with the incidence of postoperative osteolysis surrounding the PLLA pin. Additionally, low preoperative HU values in subchondral bone under OLT may serve as a predictor of osteolysis surrounding the PLLA pin.

[Osteochondral lesions of the talus : Individualized approach based on established and innovative reconstruction techniques]

Osteochondral lesions (OCL) of the talus are defined as chondral damage with subchondral involvement. The traumatic etiology is important; in particular, sprains and fractures can lead to lesions of the articular surface and the subchondral plate. As a result, unstable lesions and subchondral cysts can trigger substantial persistent pain and functional impairments. A primary conservative treatment can be considered and is especially recommended in children and adolescents; however, return to previous sports activity and level is often not achieved. The principles of reconstructive surgical management include internal fixation of osteochondral fragments, bone marrow stimulation, autologous membrane-augmented chondrogenesis ± bone grafting, osteochondral transfer, retrograde techniques ± bone grafting, (matrix-associated) autologous chondrocyte implantation and autologous osteoperiosteal graft from the iliac crest. Additional surgical procedures for ankle stabilization and deformity correction should be considered if necessary.

Osteochondral Lesions of the Talus: An Individualized Treatment Paradigm from the Amsterdam Perspective

Osteochondral lesions of the talus (OLTs) are characterized by damage to the articular cartilage of the talus and its underlying subchondral bone. Up to 75% of OLTs are caused by trauma, such as an ankle sprain or fracture. Physical examination and imaging are crucial for diagnosis and characterization of an OLT. No superior treatment for OLTs exists. It is paramount that an evidence-based personalized treatment approach is applied to patients with OLTs because lesion and patient characteristics guide treatment. This current concepts review covers clinical and preclinical evidence on OLT etiology, presentation, diagnosis, and treatment, all based on the Amsterdam perspective.

Internal Fixation of Osteochondral Lesion of the Talus Involving a Large Bone Fragment

BACKGROUND

Internal fixation of an osteochondral lesion of the talus (OLT) can restore the congruency of the talus and maintain the subchondral bone and innate hyaline cartilage. However, OLT that is indicated for fixation is rarely encountered; hence, not many studies report on the results after the procedure.

PURPOSE

To evaluate the clinical and radiological outcomes after internal fixation of chronic OLT involving a large bone fragment of at least 10 mm in diameter and 3 mm in depth on computed tomography (CT).

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

We retrospectively reviewed the data of 26 patients with OLT treated with internal fixation between August 2014 and April 2018. Of the patients, 15 were male and 11 were female, with a mean age of 16 years (range, 11-29 years). The primary radiological outcome measurement was bone union assessed on the 6-month postoperative CT scan. Clinical outcomes were assessed at a mean of 27.7 months postoperatively.

RESULTS

Twenty patients (77%) achieved bone union on postoperative CT scan. The mean 100-mm visual analog scale (VAS) improved from 30.5 ± 8.5 preoperatively to 13.4 ± 9.7 postoperatively (P < .001). The mean Foot Function Index (FFI) improved from 30.5 ± 6.7 preoperatively to 13.7 ± 9.8 postoperatively (P < .001). A malleolar osteotomy was not necessary to approach the lesion in 88% of patients. A bone fragment with an irregular margin and low density on the preoperative CT scan was significantly associated with nonunion (odds ratio: 7.67, 95% confidence interval: 2.67 to 22.02, P = .008). The difference in clinical outcomes between patients with skeletally immature ankles and those with skeletally mature ankles was not statistically significant. Patient age did not correlate with postoperative 100-mm VAS (Pearson correlation coefficient, r = -0.07, P = 0.72) or the postoperative FFI (Pearson correlation coefficient, r = -0.05, P = .80).

CONCLUSION

Internal fixation of an OLT involving a large bone fragment resulted in satisfactory clinical and radiologic outcomes. We found that patients with skeletally immature and mature ankles attained healing at comparable rates after the internal fixation of OLT.