Osteocartilaginous lesions of the talus in soccer players

Return to sport after surgery for osteochondral lesions of the talar dome. Results of a multicenter prospective study on 58 patients

INTRODUCTION

Osteochondral lesions of the talar dome (OLTD) are most often found in patients for whom the return to sports activities is the main issue. Two types of surgery have been distinguished at present, bone marrow stimulation techniques and mosaicplasty techniques. The size of the lesion indicating the need for bone marrow stimulation as the required surgical procedure has recently been decreased (<1cm). The main objective of this study was therefore to evaluate the return to sport after OLTD surgery. Our hypothesis is that surgery of osteochondral lesions of the talar dome allows the resumption of sports activities in the majority of cases.

MATERIAL AND METHODS

This multicenter prospective study was conducted across 10 French centers specializing in foot and ankle surgery. All patients aged 18 to 65 with symptomatic OLTD resistant to thorough medical treatment for at least 6 months, justifying surgery, were included from June 2018 to September 2019. In addition to the usual demographic data, the practice of sport and level (professional, competitive, leisure) were systematically investigated preoperatively. A common protocol for surgical management and postoperative follow-up had previously been established according to the arthrographic stage of the lesion. The most recent recommendations based on size, but also depth, were taken into account. The primary endpoint was return to sport.

RESULTS

A final functional evaluation with the AOFAS (American Orthopedic Foot & Ankle Society) score was performed at a minimum of 12 months. Of 58 sports patients, 70.6% returned to sport (41/58) with an average delay of 4.3 months. A high AOFAS functional score (p=0.02) and a stage 1 lesion (p=0.006) were the only preoperative criteria significantly associated with a return to sport. No other factor was predictive of a return to sport.

CONCLUSION

Our prospective study shows that 70.6% of sports patients returned to sport after OLTD surgery according to a surgical protocol and standardized follow-up.

LEVEL OF EVIDENCE

II.

Arthroscopic debridement of osteochondral lesions of the talus: A systematic review

BACKGROUND

Arthroscopic debridement (AD) for the osteochondral lesions of the talar dome (OLT) was widely documented in the nineties with satisfactory results. However, in modern treatment algorithms, its role is not described. The present systematic review aims to evaluate the current evidence on the clinical outcomes of AD in the management of OLT.

METHODS

Two independent reviewers searched PubMed, EMBASE, Scopus, and Virtual Health Library databases evaluating the clinical outcomes of AD of OLT with a minimum 6-month follow-up. The following terms "talus", "chondral", "cartilage", "injury", "lesion", "delamination", "damage", "excision", "curettage", "debridement", "chondrectomy", "chondroplasty", were used alone and in combination with Boolean operators AND and OR. Studies in which surgical technique was not described, an additional procedure was performed after debridement, and/or outcomes were not reported separately when more than one technique was implemented were excluded. The modified Coleman methodology score (mCMS) was used to evaluate the methodological quality of the included studies. A narrative analysis was conducted. Publication bias was assessed using the ROBIS tool.

RESULTS

AD showed satisfactory short and medium-term outcomes for the primary treatment of OLT irrespectively of size and depth. However, the heterogeneity of the included studies and the level of available evidence hinders its recommendation.

CONCLUSIONS

There is a paucity of evidence evaluating AD alone for OLT treatment in the last two decades. Bone-marrow stimulation techniques remain the first-line surgical strategy for OLT treatment without proven superiority. Adopting AD for OLT treatment instead of MF could represent a paradigm breakthrough in clinical practice given its many potential advantages while preserving the subchondral plate.

Osteochondral Lesions of the Talus: A Review on Talus Osteochondral Injuries, Including Osteochondritis Dissecans

This is a review on talus osteochondritis dissecans and talus osteochondral lesions. A majority of the osteochondral lesions are associated with trauma while the cause of pure osteochondritis dissecans is still much discussed with a possible cause being repetitive microtraumas associated with vascular disturbances causing subchondral bone necrosis and disability. Symptomatic nondisplaced osteochondral lesions can often be treated conservatively in children and adolescents while such treatment is less successful in adults. Surgical treatment is indicated when there is an unstable cartilage fragment. There are a large number of different operative technique options with no number one technique to be recommended. Most techniques have been presented in level II to IV studies with a low number of patients with short follow ups and few randomized comparisons exist. The actual situation in treating osteochondral lesions in the ankle is presented and discussed.

Bone marrow stimulation for talar osteochondral lesions at long-term follow-up shows a high sports participation though a decrease in clinical outcomes over time

PURPOSE

Although bone marrow stimulation (BMS) as a treatment for osteochondral lesions of the talus (OCLT) shows high rates of sport resumption at short-term follow-up, it is unclear whether the sports activity is still possible at longer follow-up. The purpose of this study was, therefore, to evaluate sports activity after arthroscopic BMS at long-term follow-up.

METHODS

Sixty patients included in a previously published randomized-controlled trial were analyzed in the present study. All patients had undergone arthroscopic debridement and BMS for OCLT. Return to sports, level, and type were assessed in the first year post-operative and at final follow-up. Secondary outcome measures were assessed by standardized questionnaires with use of numeric rating scales for pain and satisfaction and the Foot and Ankle Outcome Score (FAOS).

RESULTS

The mean follow-up was 6.4 years (SD ± 1.1 years). The mean level of activity measured with the AAS was 6.2 pre-injury and 3.4 post-injury. It increased to 5.2 at 1 year after surgery and was 5.8 at final follow-up. At final follow-up, 54 patients (90%) participated in 16 different sports. Thirty-three patients (53%) indicated they returned to play sport at their pre-injury level. Twenty patients (33%) were not able to obtain their pre-injury level of sport because of ankle problems and eight other patients (13%) because of other reasons. Mean NRS for pain during rest was 2.7 pre-operative, 1.1 at 1 year, and 1.0 at final follow-up. Mean NRS during activity changed from 7.9 to 3.7 to 4.4, respectively. The FAOS scores improved at 1 year follow-up, but all subscores significantly decreased at final follow-up.

CONCLUSION

At long-term follow-up (mean 6.4 years) after BMS for OCLT, 90% of patients still participate in sports activities, of whom 53% at pre-injury level. The AAS of the patients participating in sports remains similar pre-injury and post-operatively at final follow-up. A decrease over time in clinical outcomes was, however, seen when the follow-up scores at 1 year post-operatively were compared with the final follow-up.

LEVEL OF EVIDENCE

Level II.

High reported rate of return to play following bone marrow stimulation for osteochondral lesions of the talus

PURPOSE

The purpose of this study is to systematically review the literature and to evaluate the reported rehabilitation protocols, return to play guidelines and subsequent rates and timing of return to play following bone marrow stimulation (BMS) for osteochondral lesions of the talus (OLT).

METHODS

MEDLINE, EMBASE and the Cochrane Library were searched according to the PRISMA guidelines in September 2017. The rate and timing of return to play was assessed. The rehabilitation protocols were recorded, including time to start range of motion, partial weight-bearing and complete weight-bearing.

RESULTS

Fifty-seven studies with 3072 ankles were included, with a mean age of 36.9 years (range 23-56.8 years), and a mean follow-up of 46.0 months (range 1.5-141 months). The mean rate of return to play was 86.8% (range 60-100%), and the mean time to return to play was 4.5 months (range 3.5-5.9 months). There was large variability in the reported rehabilitation protocols. Range of motion exercises were most often allowed to begin in the first week (46.2%), and second week postoperatively (23.1%). The most commonly reported time to start partial weight-bearing was the first week (38.8%), and the most frequently reported time of commencing full weight-bearing was 6 weeks (28.8%). Surgeons most often allowed return to play at 4 months (37.5%).

CONCLUSIONS

There is a high rate of return following BMS for OLT with 86.8% and the mean time to return to play was 4.5 months. There is also a significant deficiency in reported rehabilitation protocols, and poor quality reporting in return to play criteria. Early weightbearing and early postoperative range of motion exercises appear to be advantageous in accelerated return to sports.

LEVEL OF EVIDENCE

Level IV.

Rehabilitation and Return to Sports: Proceedings of the International Consensus Meeting on Cartilage Repair of the Ankle

BACKGROUND

The evidence supporting best practice guidelines in the field of cartilage repair of the ankle are based on both low quality and low levels of evidence. Therefore, an international consensus group of experts was convened to collaboratively advance toward consensus opinions based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article is to report the consensus statements on Rehabilitation and Return to Sports developed at the 2017 International Consensus Meeting on Cartilage Repair of the Ankle.

METHODS

Seventy-five international experts in cartilage repair of the ankle representing 25 countries and 1 territory were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within 11 working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed upon in unanimous fashion within the working groups. A final vote was then held, and the strength of consensus was characterized as follows: consensus, 51% to 74%; strong consensus, 75% to 99%; unanimous, 100%.

RESULTS

A total of 9 statements on rehabilitation and return to sports reached consensus during the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. All 9 statements reached strong consensus, with at least 86% agreement.

CONCLUSIONS

The rehabilitation process for an ankle cartilage injury requires a multidisciplinary and comprehensive approach. This international consensus derived from leaders in the field will assist clinicians with rehabilitation and return to sports after treatment of a cartilage injury of the ankle.

Surgical outcome of posterior ankle impingement syndrome with concomitant ankle disorders treated simultaneously in patient engaged in athletic activity

BACKGROUND

It is unclear whether simultaneous surgery for posterior ankle impingement syndrome (PAIS) and concomitant ankle disorders, such as anterior ankle impingement syndrome (AAIS), lateral ankle instability (LAI), and osteochondral lesion of the talus (OLT), allows for early return to athletic activity.

METHODS

Ninety-seven patients who engaged in athletic activity (mean age 27 [range 18-43] years) and were treated by a hindfoot endoscopic approach for PAIS alone or simultaneously for PAIS and concomitant ankle disorders were included in this study. The patients were divided into four groups: PAIS alone (group A, n = 61), PAIS with AAIS (group B, n = 8), PAIS with LAI with or without AAIS (group C, n = 20), and PAIS with OLT with or without AAIS/LAI (group D, n = 8). In all patients, the concomitant ankle disorder was treated simultaneously by arthroscopic debridement for AAIS, bone marrow stimulation or autologous cancellous bone transplantation for OLT, and anterior talofibular ligament repair or reconstruction for LAI. American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale scores before and 2 years after surgery and times from surgery to resuming training and athletic activity were compared between the groups.

RESULTS

Mean AOFAS score improved significantly after surgery in all groups (groups A and C, P < .0001; groups B and D: P < .05). The time taken to return to training was significantly longer in group D than in groups A, B, and C (all P < .01) as was the time taken to return to athletic activity in groups C and D when compared with group A (P < .01); however, there were no significant differences in this regard between groups B and C.

CONCLUSION

Concomitant surgery for AAIS and LAI with PAIS did not delay the postoperative start of training, however, concomitant surgery for LAI and OLT delayed the return to athletic activity when compared with PAIS surgery alone.

STUDY DESIGN

Clinical Retrospective Comparative Study.

Osteochondral lesions of the talus in the athlete: up to date review

PURPOSE OF REVIEW

Osteochondral lesions of the talus (OLT) are common injuries in athletes. The purpose of this study is to comprehensively review the clinical results and return to sport capacity in athletes following treatment for OLT.

RECENT FINDINGS

Reparative procedures, such as bone marrow stimulation, and replacement procedures, such as autologous osteochondral transplantation, provide good clinical outcomes in short- and mid-term follow-up in the athlete. Recently, biological augmentation and scaffold-based therapies have been shown to improve clinical and radiological outcomes in OLT in both the general population and athletes. Most studies are of a low level of evidence. Studies analyzing the return to sport capability in athletes are further lacking. High-level evidence and well-designed clinical trials are required to establish the most effective treatment protocol.

Operative Treatment for Osteochondral Lesions of the Talus: Biologics and Scaffold-Based Therapy

OBJECTIVE

Numerous basic science articles have published evidence supporting the use of biologic augmentation in the treatment of osteochondral lesions of the talus (OLT). However, a comprehensive evaluation of the clinical outcomes of those treatment modalities in OLT has yet to be published. The purpose of this review is to provide an evidence-based overview of clinical outcomes following biologic augmentation to surgical treatments for OLT.

DESIGN

A comprehensive literature review was performed. Two commonly used surgical techniques for the treatment of OLT-bone marrow stimulation and osteochondral autograft transfer-are first introduced. The review describes the operative indications, step-by- step operative procedure, clinical outcomes, and concerns associated with each treatment. A review of the currently published basic science and clinical evidence on biologic augmentation in the surgical treatments for OLT, including platelet-rich plasma, concentrated bone marrow aspirate, and scaffold-based therapy follows.

RESULTS

Biologic agents and scaffold-based therapies appear to be promising agents, capable of improving both clinical and radiological outcomes in OLT. Nevertheless, variable production methods of these biologic augmentations confound the interpretation of clinical outcomes of cases treated with these agents.

CONCLUSIONS

Current clinical evidence supports the use of biologic agents in OLT cases. Nonetheless, well-designed clinical trials with patient-specific, validated and objective outcome measurements are warranted to develop standardized clinical guidelines for the use of biologic augmentation for the treatment of OLT in clinical practice.

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.

Mosaicplasty for osteochondral lesions of the talus: a report of two cases

Two women (24 and 27 years old) noted pain in the affected ankle of several years' duration. Radiography and magnetic resonance imaging revealed osteochondral lesions of the talus in both patients. The lesion sites measured 1.3 × 1.0 × 0.4 cm (0.52 cm(3)) and 2.0 × 1.9 × 0.5 cm (1.9 cm(3)). Each patient received a medial malleolar osteotomy with mosaicplasty. Donor plugs were obtained from the ipsilateral knee in both patients. Surgery was performed successfully in both patients without complications. At 2-year follow-up, both patients had recovered good ankle function, with no donor site morbidity. American Orthopedic Foot and Ankle Society ankle/hindfoot scores improved in the affected ankles from 16 to 84 in case 1 and from 43 to 87 in case 2. Mosaicplasty is effective in treating stage III or IV osteochondral lesions of the talus and results in good-to-excellent recovery of function.

Microfracture for osteochondral lesions of the talus: a systematic review of reporting of outcome data

BACKGROUND

Microfracture is recognized as a primary treatment strategy for osteochondral lesions of the talus up to 15 mm in size. The ability of fibrocartilage to withstand the mechanical loading of the joint over time is unknown.

PURPOSE

The purpose of this study was to systematically review studies of microfracture for OLT and descriptively analyze the outcome data reported to determine whether it is consistent from one study to another and able to be pooled for systematic review.

METHODS

A systematic electronic search was performed using the MEDLINE and EMBASE databases. Studies that were published between January 1966 and June 2011 were included in the review. Only studies that reported data specifically on microfracture for treatment of osteochondral lesions of the talus and written in English were included in this review.

RESULTS

Twenty-four studies were included in this systematic review. The categories of general demographics and study design were generally well reported (each over 80% of studies). Patient history and patient-reported outcome data were reported less (55%-66%). Clinical variables (48%) and imaging data (39%) were the least reported in studies.

CONCLUSION

There were gross inconsistencies and an underreporting of data between studies such that pooling was deemed impossible. A concerted effort must be made by investigators to ensure that there is adequate reporting of data in studies of microfracture treatment for OLT. A set of guidelines to assist surgeons in reporting data may be useful for future research.

Rehabilitation and return-to-sports activity after debridement and bone marrow stimulation of osteochondral talar defects

An osteochondral defect (OD) is a lesion involving the articular cartilage and the underlying subchondral bone. ODs of the talus can severely impact on the quality of life of patients, who are usually young and athletic. The primary treatment for ODs that are too small for fixation, consists of arthroscopic debridement and bone marrow stimulation. This article delineates levels of activity, determines times for return to activity and reviews the factors that affect rehabilitation after arthroscopic debridement and bone marrow stimulation of a talar OD. Articles for review were obtained from a search of the MEDLINE database up to January 2012 using the search headings 'osteochondral defects', 'bone marrow stimulation', 'sports/activity', 'rehabilitation', various other related factors and 'talus'. English-, Dutch- and German-language studies were evaluated.The review revealed that there is no consensus in the existing literature about rehabilitation times or return-to-sports activity times, after treatment with bone marrow stimulation of ODs in the talus. Furthermore, scant research has been conducted on these issues. The literature also showed that potential factors that aid rehabilitation could include youth, lower body mass index, smaller OD size, mobilization and treatment with growth factors, platelet-rich plasma, biphosphonates, hyaluronic acid and pulse electromagnetic fields. However, most studies have been conducted in vitro or on animals. We propose a scheme, whereby return-to-sports activity is divided into four phases of increasing intensity: walking, jogging, return to non-contact sports (running without swerving) and return to contact sports (running with swerving and collision). We also recommend that research, conducted on actual sportsmen, of recovery times after treatment of talar ODs is warranted.