Osteochondral lesion of the talus: prognostic factors affecting the clinical outcome after arthroscopic marrow stimulation technique

Skeletal Features of Talus in Hepple V Lesion

The present study was to determine the characteristics of the ankle skeletal structure in patients with talus Hepple V type. We conducted a retrospective study on the skeletal structure of the talus in 110 patients with Hepple V osteochondral lesions of the talus and in control participants. The radiographic measurements taken include the following: in the coronal plane - depth of talus frontal curvature, length of the lateral and medial malleolus; in the sagittal plane - radius and height of talus, angle of tibial lateral surface, tibiotalar sector, and vertical neck angle. The osteochondral lesion of the talus showed a significantly larger mean radius (mean ± SD, 21.4 ± 2.5 mm; p < .001) and height (mean ± SD, 26.0 ± 2.7 mm; p < .005). It also demonstrated a longer mean medial malleolus length (mean ± SD, 15.7 ± 2.4 mm; p < .005), a larger mean vertical neck angle (mean ± SD, 86.2 ± 5.4°; p < .050), and a greater mean tibial lateral surface angle (mean ± SD, 80.0 ± 4.5°; p < .001). And there was a greater mean frontal curvature depth (mean ± SD, 3.9 ± 0.6 mm; p < .005). Overall, this study found that patients with Hepple V osteochondral lesions of the talus had a larger vertical neck angle and tibial lateral surface angle, a longer talus radius and medial malleolus length, a higher talus height, and a deeper frontal curvature depth. STUDY DESIGNS: Retrospective Case-Control Study.

Ankle Instability: Facts and Myths to Protect Your Cartilage Repairing

The majority of patients with an osteochondral lesion of the talus (OLT) report a history of trauma. Therefore, it is important to assess for concomitant ankle instability when dealing with patients with a symptomatic OLT. The History; Alignment; Ligaments; Others "(HALO)" approach can be a helpful tool in the evaluation of patients with an OLT. If conservative treatment fails, surgery may be indicated. Although there is a lack of comparative studies investigating the effect of stabilization procedures on cartilage repair, we believe that addressing instability is a key factor in improving patient outcome.

Participation in Sports or Recreational Activities After Osteochondral Allograft Transplantation of the Talus

BACKGROUND

Fresh osteochondral allograft (OCA) transplantation is a viable treatment option for osteochondral defects of the talus. However, sufficient data are not available on patients' participation in sports or recreational activities after the procedure.

PURPOSE

To assess whether patients undergoing OCA transplantation of the talus participated in sports or recreational activities postoperatively.

STUDY DESIGN

Case series; level of evidence, 4.

METHODS

A total of 36 ankles in 34 patients underwent OCA transplantation of the talus. At a mean follow-up of 9.2 years, information on participation in sports or recreational activities pre- and postoperatively was obtained, as well as postoperative pain, function, and satisfaction.

RESULTS

The mean age at the time of surgery was 36.1 years (range, 20.5-57.7 years), and 50% of patients were men. The mean graft size was 3.6 cm2 (range, 1-7.2 cm2) or 41.1% of the talar dome. Before the injury, 63.9% of patients (23/36 ankles) reported being highly competitive athletes or well trained and frequently sporting; 36.1% of patients (13/36 ankles) reported sometimes sporting or were nonsporting. Also, 66.7% of patients (24/36 ankles) were able to participate in sports or recreational activities after OCA transplantation and 50% (18/36 ankles) were still participating in sports or recreational activities at the latest follow-up. In a subset of well-trained or highly competitive athletes, 73.9% (17/23 ankles) were able to return to sports or recreational activities at any point after OCA transplantation, and 65.2% (15/23 ankles) were still participating at the latest follow-up. Further surgery occurred in 16.7% of patients (6/36 ankles). Graft survivorship was 94.3% at 5 years and 85.3% at 10 years. There was a significant improvement in the mean Olerud-Molander Ankle Scores, and the mean Foot and Ankle Ability Measure scores were high postoperatively. Moreover, 79.4% of patients (27/34 ankles) were either satisfied or extremely satisfied with the allograft surgery.

CONCLUSION

Fresh OCA transplantation is a reasonable surgical option for osteochondral defects of the talus for young, active patients who have failed previous operative management or have massive defects.

Long-Term Patient Outcomes for Treatment of Difficult Osteochondral Lesions of the Talus with Particulated Juvenile Allograft Cartilage Implantation ± Calcaneal Autograft: A Cohort Study

BACKGROUND

Osteochondral lesions of the talus (OCLT) are common injuries that can be difficult to treat. To date, long-term patient reported outcome measures (PROMs) of patients with particulated juvenile allograft cartilage implantation with or without calcaneal autograft have not been compared.

METHODS

Thirteen patients with difficult to treat OCLTs underwent arthroscopic-assisted implantation of particulated juvenile allograft cartilage (DeNovo NT®) with or without autogenous calcaneal bone grafting by a single surgeon. Calcaneal bone graft use was determined by lesion size > 150 mm2 and/or deeper than 5 mm. Patients were evaluated using physical examination, patient interviews, and PROMs.

RESULTS

When comparing patients in regards to calcaneal bone graft implantation, no difference in age, BMI, pre-operative PROMs, or follow-up was noted, however, calcaneal bone graft patients did have a significantly larger lesion size (188.5 ± 50.9 vs. 118.7 ± 29.4 mm2 respectively; p value = 0.027). VAS and FAAM ADL scores during final follow-up improvement did not significantly differ between cohorts. The FAAM Sports score improved significantly more for the DeNovo alone group compared to the bone graft cohort (p value = 0.032). The AOFAS score improvement did not differ between cohorts (p value = 0.944), however, the SF-36 PCS improved significantly more for the DeNovo alone group compared to the bone graft cohort (p value = 0.038). No intraoperative/perioperative complications were observed with calcaneal bone grafting.

CONCLUSION

While patients followed over the course of ~ 8 years after implantation of particulated juvenile allograft cartilage (DeNovo NT®) with/without autogenous calcaneal bone graft had positive post-operative PROMs, patients without calcaneal bone graft had significantly greater improvement in functional outcome scores. Whether these differences are due to graft incorporation or larger lesion size is unclear.

LEVEL OF EVIDENCE

III, retrospective cohort study.

Subchondral bone cysts remodel after correction of varus deformity in ankle arthritis

BACKGROUND

Subchondral bone cysts (SBCs) of the talus are frequently observed in ankle osteoarthritis (OA). It is unclear whether the cysts need direct treatment after correction of the varus deformity in ankle OA. The purpose of this study is to investigate the incidence of SBCs and the change after supramalleolar osteotomy (SMOT).

METHODS

Thirty-one patients treated by SMOT were retrospectively reviewed, and 11 ankles had cysts preoperatively. After SMOT without management of the cysts, the evolution of cysts was evaluated on weightbearing computerized tomography (WBCT). The American Orthopaedic Foot and Ankle Society (AOFAS) clinical ankle-hindfoot scale and a visual analog scale (VAS) were compared.

RESULTS

At baseline, the average cyst volume was 65.86 ± 60.53 mm3. The number and volume of cysts were reduced dramatically (P＜.05), and the cysts vanished in 6 ankles after the SMOT. The VAS and AOFAS scores improved significantly after SMOT (P＜.001), there was no significant difference between ankles with cysts and without cysts.

CONCLUSIONS

The SMOT alone without direct treatment of the SBCs led to a decrease in the number and volume of SBCs in varus ankle OA.

LEVEL OF EVIDENCE

Level IV, case series.

Juvenile Osteochondral Lesions of the Talus: Current Concepts Review and an Update on the Literature

Osteochondral lesions of the talus (OLTs) are lesions that occur before the physis closes and are frequently associated with acute ankle trauma. These lesions are often difficult to diagnose due to swelling and inflammation that are present after the initial injury. A growing body of literature has assessed the effects of OLTs in the adult population. However, the literature examining these lesions in the juvenile population is sparse. The purpose of this review is to provide a thorough understanding of OLTs, with a specific focus on the juvenile population. We evaluate the recent literature regarding the outcomes of various surgical treatment; modalities in the pediatric patient. While the outcomes after surgical treatment of pediatric OLTs are generally favorable, the paucity of investigation in this demographic is alarming. Further research is needed to better inform practitioners and families regarding these outcomes, as treatment plans are highly dependent on the individual patient in question.

Gender Differences May Exist in the Presentation, Mechanism of Injury and Outcomes Following Bone Marrow Stimulation for Osteochondral Lesions of the Talus

Bone marrow stimulation (BMS) is indicated for patients who have symptomatic osteochondral lesions of the talus (OLT). Despite differences in ankle biomechanics and cartilage morphology between men and women, there is scant evidence examining whether these differences affect surgical outcomes. The purpose of this study was to compare the outcomes in men and women following BMS for OLTs. A retrospective analysis comparing female and male patients treated with BMS for OLT between 2007 and 2015 was performed. Clinical outcomes were evaluated using the Foot and Ankle Outcome Scores (FAOS) and Short-Form 12 (SF-12). Magnetic resonance imaging at final follow-up was evaluated with the modified magnetic resonance observation of cartilage repair tissue score. Thirty-one females and 38 males were included. In female patients, the mean FAOS pain score improved from 60 ± 16 preoperatively to 84 ± 8.9 at 1- to 2-year follow-up (p < .01), and then decreased to 80±13 at final follow-up at 3-4 years. In male patients, the mean FAOS pain score improved from 65±17 preoperatively to 83±9.2 at 1-2 year follow-up (p < .01), and then decreased to 76±14.6 at final follow-up at 3-4 years. Lateral lesions were more common in male patients. Medial lesions were more common in female patients. The outcomes following BMS in both female and male patients were good with no significant differences at short-term follow-up. FAOS scores in male patients were more likely to decrease after 1 to 2 years postsurgery, implying a possibly faster decline than in female patients.

Autologous Costal Cartilage Grafting for a Large Osteochondral Lesion of the Femoral Head: A 1-Year Single-Arm Study with 2 Additional Years of Follow-up

BACKGROUND

There is currently no ideal treatment for osteochondral lesions of the femoral head (OLFH) in young patients.

METHODS

We performed a 1-year single-arm study and 2 additional years of follow-up of patients with a large (defined as >3 cm 2 ) OLFH treated with insertion of autologous costal cartilage graft (ACCG) to restore femoral head congruity after lesion debridement. Twenty patients ≤40 years old who had substantial hip pain and/or dysfunction after nonoperative treatment were enrolled at a single center. The primary outcome was the change in Harris hip score (HHS) from baseline to 12 months postoperatively. Secondary outcomes included the EuroQol visual analogue scale (EQ VAS), hip joint space width, subchondral integrity on computed tomography scanning, repair tissue status evaluated with the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score, and evaluation of cartilage biochemistry by delayed gadolinium-enhanced magnetic resonance imaging of cartilage (dGEMRIC) and T2 mapping.

RESULTS

All 20 enrolled patients (31.02 ± 7.19 years old, 8 female and 12 male) completed the initial study and the 2 years of additional follow-up. The HHS improved from 61.89 ± 6.47 at baseline to 89.23 ± 2.62 at 12 months and 94.79 ± 2.72 at 36 months. The EQ VAS increased by 17.00 ± 8.77 at 12 months and by 21.70 ± 7.99 at 36 months (p < 0.001 for both). Complete integration of the ACCG with the bone was observed by 12 months in all 20 patients. The median MOCART score was 85 (interquartile range [IQR], 75 to 95) at 12 months and 75 (IQR, 65 to 85) at the last follow-up (range, 24 to 38 months). The ACCG demonstrated magnetic resonance properties very similar to hyaline cartilage; the median ratio between the relaxation times of the ACCG and recipient cartilage was 0.95 (IQR, 0.90 to 0.99) at 12 months and 0.97 (IQR, 0.92 to 1.00) at the last follow-up.

CONCLUSIONS

ACCG is a feasible method for improving hip function and quality of life for at least 3 years in young patients who were unsatisfied with nonoperative treatment of an OLFH. Promising long-term outcomes may be possible because of the good integration between the recipient femoral head and the implanted ACCG.

LEVEL OF EVIDENCE

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

Healing Predictors of Conservative Treatment for Juvenile Osteochondritis Dissecans of the Talus

OBJECTIVE

To investigate the healing response of juvenile osteochondritis dissecans (JOCD) of the talus after conservative treatment, identify healing predictors, and develop a predictive model for healing.

DESIGN

Retrospective study.

SETTING

Clinics at a tertiary-level pediatric medical center.

PATIENTS

Fifty-five patients (55 ankles) who presented with JOCD.

INTERVENTIONS

Patients were managed with cast immobilization followed by activity restriction.

MAIN OUTCOME MEASURES

The primary outcome measure of progressive lesion reossification was determined from the latest radiograph, after at least 6 months of nonoperative treatment. Final clinical evaluation was performed by a questionnaire and complementary telephone interview. Multivariate logistic regression was used to determine the influence of age, sex, lesion size, classification, location, duration of symptoms, containment lesion, and the occurrence of cyst-like lesions on healing potential.

RESULTS

After nonoperative treatment, 18 (33%) of 55 lesions had failed to progress toward healing. An older age (P = 0.034) and a completely detached but undisplaced (grade III) lesion (P < 0.001) at the time of diagnosis were predictive for the failure of conservative treatment. A multivariate logistic regression best predictor model that included age and grade resulted in the best predicted healing and yielded an area under the curve of 0.920 (P < 0.001).

CONCLUSION

In two-thirds of skeletally immature patients, conservative treatment resulted in the progressive healing of JOCD of the talus. For older patients with grade III lesions showing a lower healing probability, surgical treatment should be considered.

Radiographic and Clinical Outcomes After Arthroscopic Microfracture for Osteochondral Lesions of the Talus: 5-Year Results in 355 Consecutive Ankles

Background:

Arthroscopic microfracture for osteochondral lesion of the talus (OLT) has shown good functional outcomes in the short and long term.

Purpose:

To investigate 5-year radiographic and clinical outcomes after arthroscopic microfracture in treatment of OLT and the effectiveness of adjunct therapies including platelet-rich plasma (PRP) and hyaluronic acid (HA).

Study Design:

Cohort study; Level of evidence, 2.

Methods:

We prospectively enrolled 432 patients who underwent arthroscopic microfracture for OLT from May 1, 2011, to May 31, 2015. Magnetic resonance imaging (MRI) and weightbearing radiographs were performed annually after the initial surgery. The MOCART (magnetic resonance observation of cartilage repair tissue) score was used to evaluate the structure of the repaired cartilage on MRI, and patient-reported outcomes (American Orthopaedic Foot and Ankle Society ankle-hindfoot scale [AOFAS] and the Foot and Ankle Outcome Score) were collected annually. The primary outcome measure was 5-year AOFAS score. We recorded baseline characteristics including age, body mass index (BMI), and lesion size, and other potentially related factors including number of PRP/HA injection and change in BMI from baseline.

Results:

Included were 355 patients, all with minimum 5-year follow-up data. The overall reoperation rate was 9.0% (32 of 355). According to multivariable analysis, 5-year AOFAS scores were associated with number of PRP injections (correlation coefficient, 3.12 [95% CI, 2.36 to 3.89]; P < .001), BMI at baseline (correlation coefficient, -0.222 [95% CI, -0.363 to -0.082]; P = .002), and mean BMI change from baseline (correlation coefficient, -1.15 [95% CI, -1.32 to -0.98]; P < .001). When comparing number of PRP injections (0, 1-2, or ≥3), we found that patients who had serial PRP injection (≥3 with at least a 3-month interval between injections) had diminished functional and radiographic deterioration over time.

Conclusion:

Arthroscopic microfracture improved patient-reported and structural outcomes for patients with OLT at 5 years after surgery. Serial PRP injections and reduction in BMI from baseline were able to slow radiographic and functional deterioration. Future trials regarding the combination of microfracture and PRP in treatment of OLT should focus on the efficacy of longer term, intra-articular, serial injections of PRP instead of single injections.

A prospective, single-center study following operative treatment for osteochondral lesions of the talus

BACKGROUND

(1) To evaluate patient-reported outcomes and revision surgeries after various operative interventions for osteochondral lesions of the talus (OLT) in a prospective single center series over 10 years, and (2) to identify predicting factors related to subjective ankle status and quality of life pre- and postoperatively.

METHODS

Ninety-nine patients underwent operative treatment due to primary or recurrent OLT, with an average follow up 3.5 (1.8) years. Treatment outcome was followed clinically (FAOS, EQ-5D, Tegner activity scale) and by pursuing any serious adverse events or graft failures.

RESULTS

There were 80 responding patients (81%) for the study. The mean lesion size was 2.0 (1.1) cm². All FAOS values increased from preoperative to final follow-up values (Symptoms 60-68, Pain 58-69, ADL 71-80, Sport 36-54, QoL 30-45). EQ-5D increased from 0.49 to 0.62, while Tegner activity scale change from 3.2 to 3.4. There were 19 (24%) serious adverse events recorded; 13 (16%) of them were graft-related. Graft survival rates were 100% at 1 year, 94% (males)/93% (females) at 2 years, and 77% (males)/47% (females) at 5 years. Female gender, higher BMI, and higher Kellgren-Lawrence ankle OA score were negative predictors for preoperative patient-reported ankle joint status. The foremost improvement after operative intervention was observed in patients with large osteochondral lesions without postoperative adverse events.

CONCLUSION

Various operative interventions for OLT significantly improved patients' ankle status and quality of life. High graft survival rates were demonstrated over first two years, but notable decline was confirmed thereafter, especially in female patients.

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.

Results of the osteochondral autologous transplantation for treatment of osteochondral lesions of the talus with harvesting from the ipsilateral talar articular facets

PURPOSE

There are few studies on the clinical outcomes of osteochondral autologous transplantation (OAT) harvesting from local talar non-weight-bearing articular facets for the treatment of osteochondral lesions of the talus (OLTs). The purpose of this study was to review the short- to midterm outcomes of our patients who were treated with OAT harvesting from ipsilateral talar articular facets for OLTs.

METHODS

Between December 2010 and November 2018, 24 patients were enrolled in this study. There were 16 males and eight females with an average age of 39.1 years and a follow-up period of 50.9 months. The clinical results were evaluated according to the American Orthopedic Foot & Ankle Society (AOFAS) ankle-hindfoot score and the visual analogue scale (VAS) score. Pre-operative plain radiographs and magnetic resonance imaging (MRI) scans, post-operative radiographs, and X-ray and computed tomography (CT) scans at the last follow-up were observed.

RESULTS

There was a significant improvement in the AOFAS score from 61.3 ± 19.0 pre-operatively to 84.9 ± 9.2 post-operatively (P < 0.001). The VAS score improved from 6.1 ± 2.3 to 2.0 ± 1.4 at the last follow-up (P < 0.001). Twenty-one patients (87.5%) were satisfied with their clinical results. By the last follow-up CT scan, there was bone cyst formation at the donor sites in three patients, at the recipient sites in five patients and at both sites in five patients. Two patients (8.3%) underwent re-operation with arthroscopic debridement because of medial gutter hypertrophic soft tissue impingement.

CONCLUSION

OAT harvesting from the ipsilateral talar articular facet showed satisfactory results. The mean post-operative VAS score and AOFAS ankle-hindfoot score improved significantly. Post-operative impingement around the osteotomy site was the main complication and reason for re-operation after the index procedure. In addition, bone cysts at the recipient and/or donor site(s) were found with a large percentage under CT. Therefore, longer follow-up is necessary to determine the long-term clinical results for this technique.

Pediatric Osteochondritis Dissecans of the Talus

OCDs of the ankle are the third most common lesion in the body and a physician should include this in the differential while evaluating the pediatric population with the history of injury and/or pain in the ankle. Pain, stiffness, and swelling are the most common presenting complaints about the pediatric and adolescent patients with an OCD. Conservative treatment options should be attempted before attempting surgical intervention. Multiple surgical procedures exist to manage the lesion based on location, size, and other factors.

Smoking Is Associated with Anterior Ankle Impingement After Isolated Autologous Matrix-Induced Chondrogenesis for Osteochondral Lesions of the Talus

OBJECTIVE

To determine potential predictive associations between patient-/lesion-specific factors, clinical outcome and anterior ankle impingement in patients that underwent isolated autologous matrix-induced chondrogenesis (AMIC) for an osteochondral lesion of the talus (OLT).

DESIGN

Thirty-five patients with a mean age of 34.7 ± 15 years who underwent isolated cartilage repair with AMIC for OLTs were evaluated at a mean follow-up of 4.5 ± 1.9 years. Patients completed AOFAS (American Orthopaedic Foot and Ankle Society) scores at final follow-up, as well as Tegner scores at final follow-up and retrospectively for preinjury and presurgery time points. Pearson correlation and multivariate regression models were used to distinguish associations between patient-/lesion-specific factors, the need for subsequent surgery due to anterior ankle impingement and patient-reported outcomes.

RESULTS

At final follow-up, AOFAS and Tegner scores averaged 92.6 ± 8.3 and 5.1 ± 1.8, respectively. Both body mass index (BMI) and duration of symptoms were independent predictors for postoperative AOFAS and Δ preinjury to postsurgery Tegner with positive smoking status showing a trend toward worse AOFAS scores, but this did not reach statistical significance (P = 0.054). Nine patients (25.7%) required subsequent surgery due to anterior ankle impingement. Smoking was the only factor that showed significant correlation with postoperative anterior ankle impingement with an odds ratio of 10.61 when adjusted for BMI and duration of symptoms (95% CI, 1.04-108.57; P = 0.047).

CONCLUSION

In particular, patients with normal BMI and chronic symptoms benefit from AMIC for the treatment of OLTs. Conversely, smoking cessation should be considered before AMIC due to the increased risk of subsequent surgery and possibly worse clinical outcome seen in active smokers.

Surgical Treatment for Osteochondral Lesions of the Talus

Osteochondral lesions of the talus (OLT) are often associated with ankle pain and dysfunction. They can occur after ankle trauma, such as sprains or fractures, but they usually present as a continued ankle pain after the initial injury has resolved. Chronic ankle ligament instability and subsequent microtrauma may lead to insidious development of an OLT. Medial-sided lesions are more common (67%) than lateral-sided lesions. For acute lesions that are nondisplaced, nonoperative management is initially performed, with a 4-6 week period of immobilization and protected weight bearing. Symptomatic improvement results in more than 50% of patients by 3 months. Acute osteochondral talus fractures, which have a bone fragment thickness greater than 3 mm with displacement will benefit from early surgical intervention. These injuries should undergo primary repair via internal fixation with bioabsorbable compression screws 3.0 mm or smaller using at least 2 points of fixation. Acute lesions that are too small for fixation can be treated with morselization and reimplantation of the cartilage fragments. If OLTs are persistently symptomatic following an appropriate course of nonoperative treatment, various reparative and restorative surgical options may be considered on the basis of diameter, surface area, depth, and location of the lesion. A small subset of symptomatic osteochondral lesions of the talus involve subchondral pathology with intact overlying articular cartilage; in these cases, retrograde drilling into the cystic lesion can be employed to induce underlying bony healing. Cancellous bone graft augmentation may be used for subchondral cysts with volume greater than 100 mm³ or with those with a depth of more than 10 mm. Debridement, curettage, and bone marrow stimulation is a reparative technique that may be considered in lesions demonstrating a diameter less than 10 mm, with surface area less than 100 mm², and a depth less than 5 mm. This technique is commonly performed arthroscopically using curettes and an arthroscopic shaver to remove surrounding unstable cartilage. A microfracture awl of 1 mm or less is used to puncture the subchondral bone with 3-4 mm of spacing between to induce punctate bleeding. Initial (<5 year) results are good to excellent in 80% of cases, with some deterioration of improvement over time. Factors contributing to poor results include surface area greater than 1.5 cm², overall osteochondral lesion depth over 7.8 mm, smoking history, age over 40, and uncontained lesions. Lesions greater than 1.29 cm², cystic lesions, and lesions that have failed prior treatment are potential candidates for osteochondral autograft transplantation. The autograft is typically harvested from the lateral femoral condyle of the ipsilateral knee with an optimal plug depth and diameter of 12-15 mm. Transplantation often involves open technique and may even require malleolar osteotomy for perpendicular access to the defect, as well as visualization of a flush, congruent graft fit. Good to excellent outcomes have been reported in up 87.4% of cases with the most common complication being donor site morbidity in up to 15% of cases. Failure rates increased significantly in lesions larger than 225 mm². Scaffold-based therapies, such as matrix-associated chondrocyte implantation, can be employed in primary or revision settings in lesions larger than 1 cm², including uncontained shoulder lesions with or without cysts. Lesions with greater than 4 mm of bone loss following debridement may require bone grafting to augment with the scaffold. This technique requires an initial procedure for chondrocyte harvest and a secondary procedure for transplantation of the scaffold. Outcomes have been good to excellent in up to 93% of cases; however, this technique requires a two-stage procedure and can be cost-prohibitive. Particulated juvenile cartilage is a restorative technique that employs cartilage allograft from juvenile donors. The cartilage is placed into the defect and secured with fibrin glue in a single-stage procedure. Studies have shown favorable outcomes in 92% of cases, with lesions between 10 and 15 mm in diameter, but increased failure rates and poorer outcomes in lesions larger than 15 mm. This may be an alternative option for contained lesions between 10 and 15 mm in diameter. Osteochondral allograft plugs are an option for larger contained lesions (>1.5 cm in diameter) and in patients with knee osteoarthritis (OA) and concern for donor site morbidity. Furthermore, bulk osteochondral allograft from a size-matched talus can also be used for even larger, unstable/uncontained shoulder lesions. An anterior approach is often employed and fixation is achieved via placement of countersunk headless compression screws. Failure of the aforementioned options associated with persistent pain or progressive OA would then lend consideration to ankle arthroplasty versus ankle arthrodesis.

Long-term Patient-Reported Outcome Measures Following Particulated Juvenile Allograft Cartilage Implantation for Treatment of Difficult Osteochondral Lesions of the Talus

BACKGROUND

Conventional methods are not suitable for difficult to treat osteochondral lesions of the talus (OCLTs). The role of particulated juvenile allograft articular cartilage implantation is not well elucidated for long-term patient outcomes.

METHODS

Thirteen patients with difficult-to-treat OCLTs underwent arthroscopy-assisted implantation of particulated juvenile articular cartilage graft into defects from 2010 to 2012 by the same surgeon. "Difficult to treat" was defined as having at least 3 of the following features or 2 if both variables described lesion characteristics: (1) lesions size of 107 mm² or greater, (2) shoulder lesions, (3) patients who failed microfracture, (4) patient aged ≥40 years, or (5) patient body mass index (BMI) >25. Patients were evaluated using physical examination, patient interviews, and outcome score measures. Patients had follow-up at 2 years, 4 years, and between 6 and 10 years at their most recent follow-up. Differences in functional outcome scores were compared before and after surgery.

RESULTS

Patients (age: 46.5 ± 11.8 years, BMI: 28.5 ± 6.1) had, on average, most recent follow-up of 8.0 years (range 72-113 months). Average visual analog scale for pain score decreased for patients by 3.9 points (95% confidence interval [CI] 2.18-5.60), when compared to preoperative assessment. Foot and Ankle Ability Measure (FAAM) Activities of Daily Living (ADL) and Sports subscale scores also improved from 46.5 to 80.9 (95% CI 21.35-47.43), and from 18.8 to 57.9 (95% CI 21.05-57.10), respectively. Short Form-36 Health Survey physical component scores showed significant improvement by an average of 45.5 points (95% CI 32.42-58.50). American Orthopaedic Foot & Ankle Society Ankle-Hindfoot Scale scores improved from 55.2 to 80.3 (95% CI 12.459-37.741).

CONCLUSION

These results demonstrate positive patient-reported long-term outcomes for a cohort of patients with difficult OCLTs, followed over the course of 6-10 years after treatment with arthroscopy-assisted particulated juvenile articular cartilage implantation.

LEVEL OF EVIDENCE

Level II, prospective cohort study.

Demographic Predictors of Concomitant Osteochondral Lesion of the Talus in Patients With Chronic Lateral Ankle Instability

Background:

Osteochondral lesion of the talus (OLT) is commonly found as a concomitant pathologic lesion in a large proportion of patients with chronic lateral ankle instability (CLAI). This study investigated which characteristics in a patient with CLAI increase the risk for OLT.

Methods:

Three hundred sixty-four patients who underwent a modified Broström operation for their CLAI were reviewed retrospectively. The characteristics of each patient and variables associated with OLTs were investigated. Statistical analyses were performed to determine the effect of each potential predictor on the incidence of OLT, and to evaluate the associations between the patient characteristics and variables associated with OLTs.

Results:

Patients with OLTs were more frequently female (female vs male: 63.1% vs 43.9%, P = .003). In addition, the lesion sizes were larger in female patients (female vs male: 113.9 ± 24.9 mm² vs 100.7 ± 18.0 mm², P = .002), and medial lesions were more common in female patients (female vs male; 93.3% vs 81.8%, P = .036). The lesion sizes were larger in patients with a wider talar tilt angle (P < .001), and patients with a medial OLT showed a wider talar tilt angle (12.0 ± 2.0 degrees vs 10.3 ± 2.2 degrees, P = .002).

Conclusion:

In this CLAI patient cohort, we found female patients to be at greater risk for OLTs than male patients. Furthermore, CLAI female patients with concomitant OLT had on average a larger lesion size, more frequent OLT medial position, and were associated with wider talar tilt angles, suggesting that females had more intrinsic ankle instability than males.

Level of Evidence:

Level IV, retrospective case series.

Patient-reported joint status and quality of life in sports-related ankle disorders and osteoarthritis

PURPOSE

To compare self-reported joint status, quality of life, level of activity and pain management in patients scheduled for surgical treatment of seven common ankle disorders: osteoarthritis (OA), primary osteochondral lesion of talus (P-OLT), recurrent osteochondral lesion of talus (R-OLT), lateral ankle instability (INST) and anterior (ANT-IMP), posterior (POST-IMP) and combined (COMB-IMP) ankle impingements.

METHODS

The cross-sectional study design was implemented. Hospital records of 610 patients that were admitted for surgical intervention on the ankle joint over a seven year period were reviewed. Patient selection (over 18 years, no systemic musculoskeletal illnesses, only one isolated ankle pathology) resulted in 123 eligible patients for current study (OA 22, P-OLT 19, R-OLT 18, INST 15, ANT-IMP 20, POST-IMP 13, COMB-IMP 16). Foot and Ankle Outcome Score (FAOS), European quality of life in a visual analogue and in five dimensions (EQ-VAS, EQ-5D-3L), Tegner activity scale (TAS) and pain medication usage were recorded at the admission and compared across these seven groups.

RESULTS

All evaluated ankle disorders induced the following: (a) subjective joint-specific dysfunction - FAOS cumulative: 42 (OA), 50 (R-OLT), 65 (P-OLT), 65 (INST), 63 (ANT-IMP), 61 (POST-IMP), 60 (COMB-IMP); (b) decreased quality of life - EQ-5D-3L: 0.41 (OA), 0.44 (R-OLT), 0.56 (P-OLT), 0.62 (INST), 0.64 (ANT-IMP), 0.56 (POST-IMP), 0.60 (COMB-IMP) and (c) decreased activity level - TAS: 2.1 (OA), 2.7 (R-OLT), 3.7 (P-OLT), 4.0 (INST), 4.7 (ANT-IMP), 4.4 (POST-IMP), 5.1 (COMB-IMP). FAOS subscales, EQ-5D-3L and TAS were significantly lower in OA and R-OLT patients. Between 31% (POST-IMP) and 68% (OA and R-OLT) of patients required pain medication over one month prior to the assessment.

CONCLUSION

All analysed ankle disorders in patients amenable for surgical treatment induced a considerable decline in patients` perceived ankle function, quality of life and activity level. The worst subjective ankle status was reported equally by OA and R-OLT patients, while patients with the other five disorders reported comparable values.

Finite Element Analysis of the Effect of Talar Osteochondral Defects of Different Depths on Ankle Joint Stability

Background

Talus cartilage injury leads to changes in biomechanics of the ankle joint and ultimately affects ankle joint function, but which talus cartilage defects require surgery is still uncertain. This research used a finite element method to simulate the effect of different depth of talus cartilage defects on the stress and stability of the ankle joint in a certain area.

Material/Methods

A three-dimensional finite element model with different depths of osteochondral defects was created to simulate and calculate joint stress and displacement of the articular surface of the distal tibia and the proximal talus while the ankle joint was in the push-off, midstance, and heel-strike phases.

Results

The equivalent stress of the proximal talus did not change significantly at a defect depth of 1 mm, whereas the equivalent stress of the upper talus increased significantly at a defect depth of ≥3 mm or more, reaching a maximum value at a defect depth of 10 mm. The equivalent stress of the tibial cartilage and the equivalent stress and displacement in the corresponding forces in the midstance phase and heel-strike phase were significantly different from those in the normal group, but the difference in stress in each defect group was not obvious.

Conclusions

The effect of cartilage defects of the talus on biomechanics of the ankle is clear, especially in the midstance and push-off phases. When the defect reaches the subchondral bone (at a depth of 3 mm), the most obvious change in ankle joint stability occurs, and it does not increase linearly with the increase in depth of the defect.

Predictors of Osteochondral Lesions of the Talus in Patients Undergoing Broström-Gould Ankle Ligament Reconstruction

Chronic ankle instability is associated with intra-articular and extra-articular ankle pathologies, including osteochondral lesions of the talus. Patients with these lesions are at risk for treatment failure for their ankle instability. Identifying these patients is important and helps to guide operative versus nonoperative treatment. There is no literature examining which patient characteristics may be used to predict concomitant osteochondral lesions of the talus. A retrospective chart review was performed on patients (N = 192) who underwent a primary Broström-Gould lateral ankle ligament reconstruction for chronic ankle instability from 2010 to 2014. Preoperative findings, magnetic resonance imaging, and operative procedures were documented. Patients with and without a lesion were divided into 2 cohorts. Fifty-three (27.6%) patients had 1 lesion identified on preoperative magnetic resonance imaging. Forty (69.0%) of these lesions were medial, 18 (31.0%) were lateral, and 5 patients had both. Female sex was a negative predictor of a concomitant lesion (p = .013). Patients were less likely to have concomitant peroneal tendinopathy (30.2% vs 48.9%; p = .019) in the presence of a lesion. However, sports participation was a positive predictor of a concomitant lesion (p = .001). The remainder of the variables (age, body mass index, smoking, trauma, duration, contralateral instability, global laxity) did not show a significant difference. In patients who underwent lateral ankle ligament reconstruction, females were less likely to have a lesion than males. Patients with peroneal tendinopathy were less likely to have a lesion compared with patients without. Additionally, athletic participation was a positive predictor of a concomitant lesion.

Return to Sport After Arthroscopic Autologous Matrix-Induced Chondrogenesis for Patients With Osteochondral Lesion of the Talus

OBJECTIVE

To determine the rate of return of patients to sport after arthroscopic autologous matrix-induced chondrogenesis (AT-AMIC) for outcomes 2 years after surgery.

DESIGN

Retrospective observational cross-sectional study.

SETTING

C.A.S.C.O.-Foot and Ankle Unit, Istituto Ortopedico Galeazzi, Milan, Italy.

PATIENTS AND INTERVENTION

Twenty-six consecutive patients, 65.4% male (mean ± SD age: 33.7 ± 11.0 years), that underwent AT-AMIC procedure between 2012 and 2015 were selected retrospectively. From this population, only sporting patients at amateur's level were included. Arthroscopic autologous matrix-induced chondrogenesis was proposed in patients with pain and persistent disability.

MAIN OUTCOME MEASURES

All patients were assessed with the American Orthopaedic Foot and Ankle Score (AOFAS), physical component score of the 12-Item Short Form Health Survey (SF-12), Halasi ankle activity score, and University of California, Los Angeles (UCLA) activity scale preoperatively and at 24 months postoperatively.

RESULTS

Overall, 80.8% of the patient group returned to the same preinjury sport. The mean follow-up was 42.6 ± 10.9 months (range from 25 to 62 months). Significant differences were observed with reference to AOFAS, SF-12, Halasi, and UCLA scores at the last follow-up in patients who had undergone AT-AMIC (all, P < 0.001).

CONCLUSIONS

A high percentage of patients return to their preinjury sport after AT-AMIC surgery.

Osteochondral Allograft Transplantation Surgery for Osteochondral Lesions of the Talus in Athletes

Osteochondral lesions of the talus (OLTs) continue to be a challenge for the treating surgeon, especially when lesions are refractory to marrow stimulation techniques. The purpose of this study is to evaluate the outcomes of lesions treated with osteochondral allograft transplantation. A review was performed of 30 athletes with 31 OLTs that were refractory to marrow stimulation or predicted to be refractory based on size and location of the lesion. Results were evaluated in terms of occupational outcomes and numeric pain scales. Lesions treated had a mean area of 1.37 (range 0.36 to 3.3) cm². Overall excellent outcomes were achieved in 11 (35%) ankles. Nineteen (61%) ankles achieved good or excellent occupational outcomes, and 12 (39%) ankles demonstrated poor occupational outcomes and the patients were unable to continue their previous active occupations. Patients were found to have a mean pain scale score of 3 (range 0 to 7) of 10 at a mean of 21 (range 10 to 24) months after operative management. Osteochondral allograft transplantation is an option for the treatment of selected athletes with large OLTs, as well as lesions that are refractory to marrow stimulation techniques. The results of this study may help active young patients and their surgeons to better understand outcomes and options in their shared decision-making process.

[Biomechanical study on repair and reconstruction of talar lesion by three-dimensional printed talar components]

Objective

To explore the feasibility of the repair and reconstruction of large talar lesions with three-dimensional (3D) printed talar components by biomechanical test.

Methods

Six cadaveric ankle specimens were used in this study and taken CT scan and reconstruction. Then, 3D printed talar component and osteotomy guide plate were designed and made. After the specimen was fixed on an Instron mechanical testing machine, a vertical pressure of 1 500 N was applied to the ankle when it was in different positions (neutral, 10° of dorsiflexion, and 14° of plantar flexion). The pressure-bearing area and pressure were measured and calculated. Then osteotomy on specimen was performed and 3D printed talar components were implanted. And the biomechanical test was performed again to compare the changes in pressure-bearing area and pressure.

Results

Before the talar component implantation, the pressure-bearing area of the talus varied with the ankle position in the following order: 10° of dorsiflexion > neutral position > 14° of plantar flexion, showing significant differences between positions ( P<0.05). The pressure exerted on the talus varied in the following order: 10° of dorsiflexion < neutral position < 14° of plantar flexion, showing significant differences between positions ( P<0.05). The pressure-bearing area and pressure were not significantly different between before and after talar component implantations in the same position ( P>0.05). The pressure on the 3D printed talar component was not significantly different from the overall pressure on the talus ( P>0.05).

Conclusion

Application of the 3D printed talar component can achieve precise repair and reconstruction of the large talar lesion. The pressure on the repaired site don't change after operation, indicating the clinical feasibility of this approach.

Effect of the Containment Type on Clinical Outcomes in Osteochondral Lesions of the Talus Treated With Autologous Osteochondral Transplantation

BACKGROUND

Uncontained-type osteochondral lesions of the talus (OLTs) have been shown to have inferior clinical outcomes after treatment with bone marrow stimulation. While autologous osteochondral transplantation (AOT) is indicated for larger lesions, no study has reported on the prognostic significance of the containment of OLTs treated with the AOT procedure.

PURPOSE

To clarify the effect of the containment of OLTs on clinical and radiological outcomes in patients who underwent AOT for OLTs.

STUDY DESIGN

Case control study; Level of evidence, 3.

METHODS

A retrospective cohort study comparing patients with contained-type and uncontained-type OLTs was undertaken to include all patients who underwent AOT for the treatment of OLTs between 2006 and 2014. Analyses were performed by grouping the patients according to the containment type. Clinical outcomes were evaluated using the Foot and Ankle Outcome Score (FAOS) and the 12-Item Short Form Health Survey (SF-12) preoperatively and at final follow-up. Magnetic resonance imaging (MRI) at 2 years' follow-up was evaluated with the modified magnetic resonance observation of cartilage repair tissue (MOCART) score. Multivariate regression models were used to evaluate factors affecting postoperative FAOS, SF-12, and MOCART scores.

RESULTS

Ninety-four patients were included: 31 patients with a contained-type OLT and 63 patients with an uncontained-type OLT. The median patient age was 34 years (interquartile range [IQR], 28-48 years) in the contained-type group and 36 years (IQR, 27-46 years) in the uncontained-type group. The median follow-up time was 45 months (IQR, 38-63 months) in the contained-type group and 52 months (IQR, 40-66 months) in the uncontained-type group. The median FAOS and SF-12 scores improved significantly after surgery in both contained-type and uncontained-type lesions ( P < .001). The median postoperative FAOS score of patients with contained-type OLTs was higher than that of patients with uncontained-type OLTs (91.7 vs 85.0, respectively; P = .009), but no significant differences were found between the contained-type and uncontained-type groups for postoperative SF-12 and MOCART scores. The multivariate regression models showed that patients with contained-type OLTs had an approximately 10-point better score on the FAOS compared with patients with uncontained-type OLTs ( P = .006). There was a nonsignificant trend for the rate of cystic occurrence in uncontained-type OLTs to be higher than that of contained-type OLTs (55.6% vs 38.7%, respectively; P = .125).

CONCLUSION

Patients with contained-type OLTs experienced better clinical outcomes than those with uncontained-type OLTs after AOT for the treatment of OLTs. However, the AOT procedure still provided good clinical and MRI outcomes in both contained-type and uncontained-type OLTs at midterm follow-up.

Management of Osteochondral Lesions of the Talar Dome

Osteochondral lesion of the talus (OLT) is a common condition associated with ankle injury that brings challenges in the diagnosis and treatment. Symptoms related to this condition are nonspecific including pain, swelling, stiffness, and mechanical symptoms of locking and catching. While the natural history of the OLTs is not well understood, surgical treatment is often required especially in chronic cases and acute cases with displaced articular fragments. Arthroscopic treatment of the OLTs aims to restore ankle joint function and pain relief by the removal of the chondral or osteochondral fragment, debridement and stabilization of cartilage rim and subchondral bone, and stimulate healing of the bone and damaged cartilage. In patients with a large lesion or after a failure of previous bone marrow stimulation, biologic restoration techniques including the use of particulate juvenile cartilage techniques, autogenous chondrocyte implantation, and osteochondral autograft or allograft transplantation may have role. This article summarizes the contemporary concepts in the clinical evaluation and treatment of OLTs with particular emphasis on surgical strategies.

Arthroscopic Surgical Technique for an Acute Talar Dome Osteochondral Lesion in a Professional Rugby League Player

BACKGROUND

Talar osteochondral lesions represent challenging clinical entities, particularly in high-demand athletes. Surgical treatment of large lesions often requires a 2-step procedure, or the use of osteotomy in the case of autologous osteochondral transfer, which can delay return to sport.

METHODS

A professional rugby league player underwent surgery for a complex injury to the ankle. A talar osteochondral lesion with a maximal diameter of 15 mm was treated in an arthroscopic fashion using the cartilage taken from the completely displaced osteochondral fragment. Cartilage was cut into chips and combined with bone graft product containing platelet-derived growth factor and a porous collagen scaffold. Autologous cartilage was then reimplanted arthroscopically. The patient was allowed full ankle motion from 2 weeks postoperatively, and weightbearing was commenced at 6 weeks. Follow-up imaging and functional outcomes, including return to sport, were assessed at regular intervals.

RESULTS

The patient was able to return to professional rugby league by 23 weeks postoperatively. Magnetic resonance imaging at 16 months postoperatively showed restoration of the subchondral plate and osseous infill. At final follow-up, the patient remained pain free and was playing at preinjury level.

CONCLUSION

This report describes good outcomes using a novel, 1-step cartilage repair technique to treat a large talar osteochondral lesion in a professional athlete.

LEVELS OF EVIDENCE

Level V: Expert opinion.

Patient compliance with touchdown weight bearing after microfracture treatment of talar osteochondral lesions

BACKGROUND

The aim of this study was to prospectively evaluate the compliance of our patients with a touchdown weight bearing (without supporting any weight on the affected side by only touching the plantar aspect of the foot to the ground to maintain balance to protect the affected side from mechanical loading) postoperative rehabilitation protocol after treatment of talar osteochondral lesion (TOL).

METHODS

Fourteen patients, who had been treated with arthroscopic debridement and microfracture, were followed prospectively. The patients were evaluated for weight bearing compliance with using a stationary gait analysis and feedback system at the postoperative first day, first week, third week, and sixth week.

RESULTS

The mean visual analog scale (VAS) scores of the patients at the preoperative, postoperative first day, first week, third week, and sixth weeks were 5.5, 5.9, 3.6, 0.9, and 0.4, respectively. The decrease in VAS scores were statistically significant (p < 0.0001). First postoperative day revealed a mean value of transmitted weight of 4.08% ±0.8 (one non-compliant patient). The mean value was 4.34% ±0.8 at the first postoperative week (two non-compliant patients), 6.95% ±2.3 at the third postoperative week (eight non-compliant patients), and 10.8% ±4.8 at the sixth postoperative week (11 non-compliant patients). In the analysis of data, we found a negative correlation between VAS scores and transmitted weight (Kendall's tau b = -0.445 and p = 0.0228).

CONCLUSIONS

Although patients were able to learn and adjust to the touchdown weight bearing gait protocol during the early postoperative period, most patients became non-compliant when their pain was relieved. To prevent this situation of non-compliance, patients should be warned to obey the weight bearing restrictions, and patients should be called for a follow-up at the third postoperative week.

Comparison of Outcomes for Osteochondral Lesions of the Talus With and Without Chronic Lateral Ankle Instability

BACKGROUND

Previous reports suggest that prolonged instability of the ankle may contribute to development of osteochondral lesions and eventually lead to osteoarthritis. However, no studies have directly compared osteochondral lesions in ankles with chronic lateral ankle instability (CLAI) to those without instability. This study was performed to determine characteristics and resulting clinical outcomes associated with osteochondral lesions of the talus (OLT) in patients with and without instability.

METHODS

Of 420 patients who underwent primary arthroscopic marrow stimulation for OLT, 74 patients were identified as having concomitant CLAI. After considering age, sex, body mass index, and initial trauma history for the propensity score (1:2 ratio), a total of 148 patients without CLAI were matched from the remainder of the cohort. Demographics and lesion characteristics were compared using preoperative magnetic resonance imaging (MRI) and arthroscopy. Clinical outcomes were compared using a visual analog scale (VAS), the American Orthopaedic Foot & Ankle Society (AOFAS) ankle score, and the Foot and Ankle Outcome Score (FAOS).

RESULTS

The OLT group with CLAI presented a significantly increased proportion of lateral-side OLT, large OLT (150 mm(2) or larger), and chondral lesions at the tip of the medial malleolus (P = .018, P = .024, and P < .001, respectively). VAS and AOFAS scores were comparable at the last follow-up. However, the OLT with CLAI group also exhibited a significantly increased proportion of failure (AOFAS score less than 80) and inferior outcomes in the FAOS for the sport and recreation subscale (P = .034 and P = .005, respectively).

CONCLUSIONS

Compared with osteochondral lesions in ankles without CLAI, osteochondral lesions in an unstable ankle had an increased proportion of larger lesions (150 mm(2) or larger) and additional chondral lesions at the tip of the medial malleolus and the tibia plafond. This group also displayed increased clinical failure (AOFAS score less than 80). Inferior performance in sport and recreational activities may be more likely in patients with both OLT and CLAI.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

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.