Osteochondral lesions of the talus: size, age, and predictors of outcomes

Osteochondral Lesions of the Talus: Etiology, Clinical Presentation, Treatment Options, and Outcomes

This article reviews the etiology, clinical presentation, classification schemes, and treatment options for osteochondral lesions of the talus. These lesions typically occur after a traumatic injury and are best diagnosed on MRI. Asymptomatic lesions and incidentally found lesions are best treated conservatively; however, acute displaced osteochondral fragments may require surgical treatment. Lesion characteristics may dictate surgical technique. Outcomes following surgical treatment may be impacted by patient age, BMI, and lesion characteristics.

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.

Comparison of Intermediate-Term Clinical Outcomes Between Medial and Lateral Osteochondral Lesions of the Talus Treated With Autologous Osteochondral Transplantation

BACKGROUND

The conventional operative method to treat an osteochondral lesion of the talus (OLT) is through bone marrow stimulation (BMS). Autologous osteochondral transplantation (AOT) is being used as an alternative option in cases with a large OLT, accompanying subchondral cyst, and/or failed BMS. We aimed to compare the intermediate-term clinical and radiologic results between medial and lateral OLTs after an AOT procedure.

METHODS

Among the patients who underwent AOT, 45 cases with at least 3 years' follow-up were included in this retrospective study. We had 15 cases of lateral lesions and selected 30 cases of medial lesions matched for age and gender. Lateral lesions were resurfaced without an osteotomy; medial lesion resurfacing was combined with a medial malleolar osteotomy. Clinical assessment was performed using the Foot and Ankle Outcome Score (FAOS) and Foot and Ankle Ability Measure (FAAM). Radiographic assessment included the irregularity of articular surface (subchondral plate), the progression of degenerative arthritis, and the change of the talar tilt.

RESULTS

The mean FAOS and FAAM scores significantly improved after surgery in both groups. Up to 1 year postoperatively, there was significant difference in FAAM scores between the both groups (mean 75.3 points in medial group and 87.2 points in lateral group, P < .001). Delayed union or malunion of the malleolar osteotomy was found in 4 cases (13%) in the medial group. In addition, the progression of joint degeneration was observed in 3 cases (10%) in the medial group. There were no significant differences in the irregularity of articular surface and the change of talar tilt between both groups.

CONCLUSION

A comparison between medial and lateral OLTs treated with AOT demonstrated comparable intermediate-term clinical outcomes. However, patients with medial OLT required a longer period to restore ability for daily and sport activities. In addition, we found more complications and higher rate of progression in the radiologic arthritis grade after medial malleolar osteotomy.

LEVEL OF EVIDENCE

Level IV, retrospective comparative study.

Lesion depth and marrow stimulation results

AIM

The aim of this study was to study the importance Osteochondral lesion (OCL) depth as a singular factor for treatment outcomes using marrow stimulation. We hypothesized that the clinical outcomes of marrow stimulation would be inferior for lesions with depths of more than 5 mm compared to those less than 5 mm.

MATERIALS & METHODS

An interventional prospective cohort study was conducted on 55 ankles in 55 patients who had been diagnosed with full-thickness osteochondral lesions of the talus; stage II, III, IV according to Anderson staging system based on magnetic resonance imaging; depth of 10 mm or less; and area of 150 mm² or less measured by preoperative computed tomography. According to lesion depth, patients were divided into two groups: group (A) ≤ 5 mm, and group (B) ˃ 5 mm. The mean follow-up period for both groups was 30 months (range, 22-40).

RESULTS

For groups A and B the average preoperative Foot and Ankle Outcome Scores (FAOS) were 43.1 ± 8.8 (range, 25-52) and 46 ± 8.5 (range, 32-60), respectively, and improved to 90 ± 4.3 (range, 80-96) (P = 0.001) and 75 ± 6.4 (range, 65-88) (P = 0.001) at the final follow-up. The average time to full weight bearing was 12 weeks (range, 10-16) in group A and 16 weeks (range, 12-20) in group B.

CONCLUSIONS

Although treatment of OCLs is still undergoing changes and there are many prognostic factors that affect outcomes during marrow stimulation treatment, depth of OCL was shown to be an independent factor affecting outcomes. OCLs of less than 5 mm in depth were more likely to have superior clinical outcomes compared to OCLs of more than 5 mm.

CLINICAL SIGNIFICANCE

The depth of OCL talus is an important factor as it affects the outcome of arthroscopic marrow stimulation inversely.

LEVEL OF EVIDENCE

I.

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.

Association of Elevated Body Mass Index and Outcomes of Arthroscopic Treatment for Osteochondral Lesions of the Talus

Background:

Osteochondral lesions of the talus (OLTs) are a common condition found in patients with chronic ankle pain after previous ankle sprains. Surgical management is indicated after conservative management has failed.

Hypothesis/Purpose:

This study evaluates the influence of body mass index (BMI) on the early clinical outcomes of arthroscopic debridement and microfracture of OLTs.

Methods:

A total of 252 patients with symptomatic OLTs who failed conservative management underwent arthroscopic debridement and microfracture of OLTs over the affected ankle between 2007 and 2017. Patients from this cohort were divided into 2 groups based on BMI: the normal BMI group (NB Group) (BMI 18.5-25.0) and overweight and obese BMI group (OB Group) (BMI ≥25). Visual analogue scale (VAS), American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score, and the physical and mental component summaries of the 36-Item Short-Form Health Survey (PCS and MCS, respectively) were prospectively collected from the cohort during their standard postoperative outpatient follow-up.

Results:

The NB Group (n=105) and OB Group (n=147) were well matched demographically. The operative duration was significantly shorter for the NB Group compared to the OB Group. Patients from both groups had significant improvements in VAS, AOFAS, and PCS scores postoperatively at 6 and 24 months after surgery ( P < .05). Between both groups, patients had comparable VAS, AOFAS, and PCS scores at preoperation, 6 months postoperation, and 24 months postoperation ( P > .05). However, MCS in the OB Group was lower at 24 months postoperatively compared with the NB Group ( P < .05). The OB Group reported better satisfaction scores (82.4% vs 72.6%, P < .05), and a greater proportion had their expectations met (88.2% vs 77.9%, P < .05).

Conclusion:

A BMI ≥25 was not associated with worse postoperative pain and functional outcomes, but rather was found to be associated with greater satisfaction and fulfillment. However, patients with BMI ≥25 required longer procedure duration and had poorer MCS scores at 24 months after surgery. Level of Evidence: Level III, retrospective cohort study.

Clinical outcomes after arthroscopic microfracture for osteochondral lesions of the talus are better in patients with decreased postoperative subchondral bone marrow edema

PURPOSE

Magnetic resonance imaging (MRI) findings of subchondral bone marrow edema (SBME) in osteochondral lesions of the talus (OLT) after arthroscopic microfracture are associated with poor clinical outcomes. However, the relationship between SBME volume change and clinical outcomes has not been analyzed. It was hypothesized that clinical outcomes correlated with SBME volume change and extent of cartilage regeneration in patients with OLT.

METHODS

64 patients who underwent arthroscopic microfracture for OLT were followed up for more than 2 years. SBME volume change was measured by comparing preoperative and 2-year follow-up MRI. Clinical outcomes were assessed using the visual analogue scale (VAS) and the American orthopedic foot and ankle society ankle-hindfoot scale (AOFAS) at the 2-year and final follow-up. To compare clinical outcomes, patients were categorized into two groups: decreased SBME (DSBME) group (cases without SBME on either MRI or with a decreased SBME volume between the MRIs) and increased SBME (ISBME) group (cases with new SBME on postoperative MRI or with an increased SBME volume between the MRIs). Additionally, the effects of age, sex, body mass index, symptom duration, OLT size, OLT location, containment/uncontainment, preoperative subchondral cysts, pre- and postoperative SBME volumes, and MRI observation of cartilage repair tissue score on clinical outcomes were analyzed.

RESULTS

The DSBME group included 45 patients, whereas the ISBME group included 19. The mean age was 40.1 ± 17.2 years, and mean follow-up period was 35.7 ± 18.3 months. Preoperative SBME volume was significantly higher in the DSBME group, while the ISBME group had higher volumes at the final follow-up. In both groups, the VAS and AOFAS scores significantly improved at the final follow-up (p < 0.001, < 0.001). The VAS scores were significantly lower in the DSBME group at the 2-year and final follow-up (p = 0.004, 0.011), while the AOFAS scores were significantly higher (p = 0.019, 0.028). Other factors including cartilage regeneration did not affect clinical outcomes.

CONCLUSION

SBME volume change correlated with clinical outcomes after arthroscopic microfracture for OLT. Clinical outcomes were worse in patients with new postoperative SBME and increased postoperative SBME volume. In patients with an unsatisfactory clinical course that show decreased SBME via postoperative MRI, an extended follow-up in a conservative manner could be considered.

LEVEL OF EVIDENCE

Level III.

Retrograde Drilling With Tibial Autograft in Osteochondral Lesions of the Talar Dome

Osteochondral lesions that compromise the ankle are rare, with an incidence between 0.02% and 1.5% according to different series. This location is the third in frequency, after knee and elbow. The location of the osteochondral lesion allows one to infer the producing mechanism. Lateral defects are produced by inversion and dorsiflexion of the ankle (usually anterior, affecting 3 and 6 talar zones), whereas medial defects are produced by plantar flexion, inversion, and internal rotation (most commonly posterior, affecting 4 and 7 talar zones). The injury causes pain associated with weight load, impaired function, limited range of motion, stiffness, blockage, and edema. Early diagnosis of an osteochondral lesion is particularly important because the lack of diagnosis can lead to the evolution of a small and stable lesion in a larger lesion or an unstable fragment, which can result in chronic pain, instability of the joint, and premature osteoarthritis. Multiple therapeutic strategies have been described, including conservative and surgical treatment. The purpose of this Technical Note is to describe arthroscopic-assisted retrograde drilling with tibial autograft procedure for osteochondral lesions of the talar dome.

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.

Analysis of the Changes in the Clinical Outcomes According to Time After Arthroscopic Microfracture of Osteochondral Lesions of the Talus

BACKGROUND:

Arthroscopic microfracture can effectively treat osteochondral lesions of the talus (OLTs). However, very few studies have reported on symptomatic improvement duration and time when symptomatic improvement ceases. This study aimed to investigate the clinical outcome changes after arthroscopic microfracture in patients with OLT.

METHODS:

Among patients who underwent arthroscopic microfracture for OLT, 70 patients were available for follow-up for more than 3 years. Of these, 6 patients who showed worsening or no improvement in the 6 months after surgery were excluded, and a total of 64 patients were included in the analysis. To analyze and compare the clinical outcome changes according to time, the visual analog scale (VAS) and American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scores were evaluated every 3 months up to 1 year postoperatively and every 1 year thereafter. The clinical outcome differences based on the lesion size, lesion location, lesion containment, presence of cyst and bone marrow edema, age, sex, and obesity were analyzed.

RESULTS:

The preoperative and final follow-up VAS scores significantly improved from 6.2 ± 1.1 to 1.2 ± 1.1 ( P< .05) and the AOFAS score from 63.1 ± 7.3 to 91.0 ± 7.3 ( P< .05). The overall success rate for arthroscopic microfracture in this study was 88.6%. The postoperative VAS and AOFAS scores at 3, 6, 9, 12, 24, and 36 months were 3.7 ± 1.4, 2.5 ± 1.3, 2.0 ± 1.1, 1.6 ± 1.2, 1.2 ± 1.2, and 1.3 ± 1.2 and 74.7 ± 10.3, 80.5 ± 8.9, 84.3 ± 7.4, 88.3 ± 7.3, 91.1 ± 7.2, and 90.8 ± 7.5, respectively, showing significant improvements up to 2 years. After 2 years, the symptoms did not improve but were maintained at a certain level up to 3 years. No clinical outcome differences based on the lesion size, lesion containment, presence of cyst and bone marrow edema, age, sex, and obesity were observed.

CONCLUSION:

Symptomatic improvement early after arthroscopic microfracture for OLT was observed continuously for up to 2 years postoperatively. Symptom improvement was maintained without worsening for up to 3 years after surgery. Determining the final outcome of microfracture at least after 2 years would be reasonable.

LEVEL OF EVIDENCE:

Level IV, case series.

Particulated Autograft Cartilage Implantation for the Treatment of Osteochondral Lesions of the Talus: A Novel Technique

Osteochondral lesions of the talus often occur following ankle sprains and fractures. Operative intervention is typically required because of the diminished intrinsic repair capability of talar articular cartilage. Several techniques have evolved that emphasize replacing the defect with cartilage that closely mimics the biological properties of hyaline articular cartilage. The goals of operative treatment are resolution of symptoms, physiologic healing, and restoration of function while eliminating the need for further intervention. This article describes a novel, single-step technique for the treatment of osteochondral lesions of the talus with the use of particulated autograft cartilage implantation.

LEVELS OF EVIDENCE

Level V.

Functional Medium-Term Results After Autologous Matrix-Induced Chondrogenesis for Osteochondral Lesions of the Talus: A 5-Year Prospective Cohort Study

Autologous matrix-induced chondrogenesis (AMIC) has gained popularity in the treatment of osteochondral lesions of the talus. Previous studies have presented promising short-term results for AMIC talar osteochondral lesion repair, a 1-step technique using a collagen type I/III bilayer matrix. The aim of the present study was to investigate the mid-term effects. The 5-year results of a prospective cohort study are presented. All patients underwent an open AMIC procedure for a talar osteochondral lesion. Data analysis included general demographic data, preoperative magnetic resonance imaging findings, intraoperative details, and German version of the Foot Function Index (FFI-D) scores preoperatively and at 1 and 5 years after surgery. The primary outcome variable was the longitudinal effect of the procedure, and the influence of various variables on the outcome was tested. Of 47 consecutive patients, 21 (45%) were included. Of the 21 patients, 8 were female (38%) and 13 were male (62%), with a mean age of 37 ± 15 (range 15 to 62) years and a body mass index of 26 ± 5 (range 20 to 38) kg/m². The defect size was 1.4 ± 0.9 (range 0.2 to 4.0) cm². The FFI-D decreased significantly from preoperatively to 1 year postoperatively (56 ± 18 versus 33 ± 25; p = .003), with a further, nonsignificant decrease between the 1- and 5-year follow-up examination (33 ± 25 versus 24 ± 21; p = .457). Similar results were found for the FFI-D subscales of function and pain. The body mass index and lesion size showed a positive correlation with the preoperative FFI-D overall and subscale scores. These results showed a significant improvement in pain and function after the AMIC procedure, with a significant return to sports by the 5-year follow-up point. The greatest improvement overall was seen within the first year; however, further clinical satisfaction among the patients was noticeable after 5 years.

The role of bone marrow edema on osteochondral lesions of the talus

BACKGROUND

To assess the functional and radiological outcomes after arthroscopic talus autologous matrix-induced chondrogenesis (AT-AMIC^®) in 2 groups: patients with and without bone marrow edema (BME).

METHODS

Thirty-seven patients of which 24 without edema (GNE) and 13 with edema (GE) were evaluated. All patients were treated with AT-AMIC^® repair for symptomatic osteochondral talar lesion. Clinical and radiological parameters were evaluated with VAS score for pain, AOFAS and SF-12 at T₀ (preoperatively), T₁ (6 months), T₂ (12 months), T₃ (24 months) and MRI and CT-scan at T₀, T₁, T₂ and T₃.

RESULTS

No patients were lost to the final follow-up. In both groups we found a significant difference for clinical and radiological parameters with ANOVA for repeated measures through four time points (p<0.001). In GNE, AOFAS improved significantly at each follow-up (p<0.05); while CT and MRI showed a significant reduction in lesion size between T₁ and T₂ and T₂ and T₃ (p<0.05). In GE, AOFAS improved significantly between T₀ and T₁ and T₂ and T₃ (p<0.05); lesion size, measured with CT, decreased between T₁ and T₂ (p<0.05), while with MRI the lesion showed a reduction at each follow-up (p<0.05). Lesion size was significantly higher both in MRI and CT in GE compared to GNE (p<0.05). In GNE no patients presented edema at T_3, while in GE only 23.08% of the patients presented edema at T_3. CONCLUSIONS: The study revealed that osteochondral lesions of the talus were characterized by bigger size both in MRI and CT in patients with edema. We conclude that AT-AMIC^® can be considered a safe and reliable procedure that allows effective healing, regardless of edema and more than half of patients did not present edema six months after surgery.

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.

Osteochondral Lesions of the Talus and Autologous Matrix-Induced Chondrogenesis: Is Age a Negative Predictor Outcome?

PURPOSE

To assess and evaluate healing and functional outcomes after arthroscopic talus autologous matrix-induced chondrogenesis (AT-AMIC) in 2 age groups: patients older than 33 years versus patients 33 years or younger.

METHODS

A total of 31 patients, of whom 17 were 33 years or younger (G₁) and 14 older than 33 years (G₂), were evaluated. All patients were treated with AT-AMIC repair for osteochondral talar lesion. Magnetic resonance imaging (MRI) and computed tomography (CT)-scan evaluations, as well as clinical evaluations measured by the visual analog scale (VAS) score for pain, American Orthopaedic Foot and Ankle Society Ankle and Hindfoot score (AOFAS), and Short Form-12, were performed preoperatively (T₀) and at 6 (T₁), 12 (T₂), and 24 (T₃) months postoperatively.

RESULTS

G₁ consisted of 17 patients (mean age: 25 years, standard deviation: ±5), whereas G₂ consisted of 14 patients (mean age: 47 years, standard deviation: ±9). In both groups, we found a significant difference for clinical and radiological parameters with the analysis of variance for repeated measures through 4 time points (P < .001). In G₁, AOFAS improved significantly between T₀ and T₁ (P = .025) and T₁ and T₂ (P = .011); CT showed a significant decrease between T₁ and T₂ (P = .003) and T₂ and T₃ (P < .0001), whereas MRI reduced significantly at each follow-up. In G₂, AOFAS improved between T₀ and T₁ (P = .011) and T₂ and T₃ (P = .018); CT decreased between T₁ and T₂ (P = .025), whereas MRI showed a reduction between T₁ and T₂ (P = .029) and T₂ and T₃ (P = .006). AOFAS in G₁ was significantly higher at T₀ (P = .017), T₂ (P = .036), and T₃ (P = .039) compared with G₂. A negative linear correlation between AOFAS and VAS at T₁ (R = -0.756), T₂ (R = -0.637), and T₃ (R = -0.728) was found in G₁, whereas in G₂, AOFAS was negatively correlated with VAS at T₁ (R = -0.702).

CONCLUSIONS

The study revealed that osteochondral lesions of the talus were characterized by similar sizes and features, both in young and old patients. We conclude that AT-AMIC can be considered a safe and reliable procedure that allows effective healing, regardless of age, with a significant clinical improvement; in particular, clinical results are related to starting conditions of the ankle.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Diagnosis and treatment of osteochondral lesions of the ankle: current concepts

We conducted a wide-ranging review of the literature regarding osteochondral lesions of the ankle, with the aim of presenting the current concepts, treatment options, trends and future perspectives relating to this topic.

Lagged Syndesmotic Fixation: Our Clinical Experience

Ankle fractures are very common, and although algorithms are in place for osseous management, consensus has not been reached regarding treatment of associated ligamentous injuries. Although tibiofibular syndesmotic stabilization can be done using different forms of fixation, the biomedical literature has long emphasized the risk of long-term restriction of ankle mobility with the use of lagged transfixation. However, when reduction cannot be maintained with positional fixation, we found that lagging the syndesmotic screw helped to maintain the reduction without causing functional restriction. In this report, we describe our experience with patients who had undergone lagged tibiofibular transfixation and were available for short- to intermediate-term follow-up to assess ankle function. A total of 31 patients (32.63% of 95 consecutive patients) were available at a mean of 34.87 (range 18 to 52) months to complete the American Orthopedic Foot and Ankle Society ankle-hindfoot questionnaire. The mean score was 88.38 (range 42 to 100) points at a mean follow-up interval of 34.87 (range 18 to 52) months. Of 31 patients, 19 had an AOFAS score of 90 points, 9 an AOFAS score of 80 to 89 points, 2 an AOFAS score of 60 to 69 points, and 1 an AOFAS score of <60 points. Because all syndesmotic screws were placed using the lag technique, unrestricted motion compared with the uninjured limb was used as the endpoint. All subjects had unrestricted motion compared with the uninjured limb, refuting the assertion that lagged syndesmotic screw fixation confers more restriction in ankle kinematics than positional syndesmotic fixation.

Outcomes Following Microfracture in Grade 3 and 4 Articular Cartilage Lesions of the Ankle

BACKGROUND

The purpose of this study was to document outcomes following microfracture of articular cartilage lesions of the ankle. Our hypothesis was that patients who underwent ankle microfracture would have good to excellent outcomes.

METHODS

This study was institutional review board approved. Patients older than 18 years who underwent ankle microfracture surgery for Outerbridge grade 3 or 4 articular cartilage lesions, by a single surgeon, were included. Detailed intraoperative findings were documented at surgery. Patients completed a questionnaire with Foot and Ankle Disability Index (FADI), Lysholm, Tegner, and patient satisfaction with outcome. All data were collected prospectively and stored in a data registry and retrospectively reviewed. Forty patients (21 males, 19 females, mean age = 42 years [range, 19-65 years]) were included in this study. Thirteen (33%) had previous ankle surgery. Follow-up was obtained for 94% of patients (n = 34). Mean follow-up time was 26 months (range, 12-48 months).

RESULTS

Mean talar defect size was 70 mm² (range, 4-300 mm²). Mean tibia defect size was 31 mm² (range, 8-54 mm²). Four patients (10.5%) required subsequent surgery following microfracture surgery. Mean time to second surgery was 17 months (range, 4-32 months). Mean Lysholm score was 74 (range, 31-96). Mean FADI Activities of Daily Living (ADL) was 81 (range, 33-99), FADI Sport was 62 (range, 13-100), and FADI total score was 77 (range, 28-98). Median Tegner was 4 (range, 0-10). Median patient satisfaction was 8 (range, 3-10). Patients who had previous ankle surgery had significantly lower outcome scores versus patients who did not have previous ankle surgery for FADI ADL (70 vs 81, P = .029) and FADI Total (51 vs 77, P = .028). Days from injury to surgery were correlated with age at surgery (r = .323, P = .042) and negatively correlated with FADI ADL (r = -.431, P = .014), FADI Sport (r = -.490, P = .004), FADI Total (r = -.429, P = .014), and Tegner (r = -.402, P = .023).

CONCLUSION

Patients who underwent microfracture for grade 3 or 4 ankle articular cartilage lesions had high patient satisfaction. Patients who had previous ankle surgery had lower postoperative ankle function; however, patient satisfaction remained high. This study supports microfracture for treatment of grade 3 and 4 ankle articular cartilage lesions.

LEVEL OF EVIDENCE

Level IV, case series.