Retrograde Percutaneous Drilling for Osteochondritis Dissecans of the Head of the Talus: Case Report and Review of the Literature

Regeneration of Osteochondral Lesion of the Talus with Retrograde Drilling Technique: An In Vitro Pilot Study

Background: Retrograde Drilling (RD) is a surgical technique employed for osteochondral lesions of the talus (OCLTs) to reach the subchondral bone lesion from behind, thus preserving cartilage integrity. The aim of the present pilot study was to set up an in vitro model of OCLTs to evaluate the regenerative potential of biological approaches that could be associated with the RD technique. Methods: For this purpose, an OCLT was created in human osteochondral specimens, to try to mimic the RD technique, and to compare the regenerative potential of two biological treatments. For this purpose, three groups of treatments were performed in vitro: (1) no treatment (empty defect); (2) autologous bone graft (ABG); (3) hyaluronic membrane enriched with autologous bone marrow cells. Tissue viability; production of Collagen I and II, Vascular Endothelial Growth Factor, and Aggrecan; and histological and microCT evaluations were performed after 30 days of culture in normal culture conditions. Results: It was observed that Group 3 showed the highest viability, and Group 2 showed the highest protein production. From a histological and microtomographic point of view, it was possible to appreciate the structure of the morcellized bone with which the defect of Group 2 was filled, while it was not yet possible to observe the deposition of mineralized tissue in Group 3. Conclusions: To conclude, this pilot study shows the feasibility of an alternative in vitro model to evaluate and compare the regenerative potential of two biological scaffolds, trying to mimic the RD technique as much as possible. The tissues remained vital for up to 4 weeks and both ABG and hyaluronic acid-based scaffolds stimulated the release of proteins linked to regenerative processes in comparison to the empty defect group.

Current Lack of Evidence on Treatment Strategies and Clinical Outcomes for Osteochondral Lesions of the Subtalar, Talonavicular, and Calcaneocuboid Joints: A Systematic Review

OBJECTIVE

In contrast to osteochondral lesion (OCL) of the ankle, OCLs in other joints of the foot, such as subtalar joint, talonavicular joint, calcaneocuboid joint, and the midfoot, are rare conditions, but they can also lead to significant morbidity. The objective of this systematic review was to summarize the clinical evidence for the treatment of OCLs of the subtalar, talonavicular, calcaneocuboid, and the other midfoot joints.

DESIGN

A systematic search of the MEDLINE, EMBASE, and Cochrane Library databases was performed in January 2021 based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines by 2 independent reviewers. Included studies were evaluated with regard to LOE (level of evidence) and QOE (quality of evidence). Variable reporting outcome data, clinical outcomes, and complications were evaluated.

RESULTS

Seventeen studies with 21 patients were included, all of which were case reports (level 5) without any case series reporting greater than 3 patients. There were 5 patients with OCL in the subtalar joint, 15 patients in the talonavicular joint, and 1 patient in the calcaneocuboid joint. Thirteen case reports (4 subtalar joint, 8 talonavicular joint, and 1 calcaneocuboid joint) reported surgical treatment. Surgical procedures mainly included debridement, bone marrow stimulation, fixation, and bone grafting, through open or arthroscopy, all of which resulted in successful outcomes. Four case reports (1 subtalar joint, 3 talonavicular joint) reported successful conservative treatment. Other 13 case reports reported successful surgery after failed conservative treatment. No complications and reoperations were reported.

CONCLUSIONS

The current systematic review revealed that there is no available evidence to ascertain clinical outcomes of both conservative and surgical treatments for cartilage lesions in the talonavicular joint, subtalar joint, and the midfoot joints, owing to the extreme paucity of literature. Both nonoperative and operative treatments can be considered, but no treatment strategies have been established.

Retroarticular drilling for osteochondritis dissecans of the talus: A systematic review

BACKGROUND

Opinions differ on the optimal treatment for stable talar osteochondritis dissecans (OCD) with intact cartilage. Some recommend conservative management, while others prefer surgical care, which includes debridement and micro-fractures, transarticular drilling through a direct or medial malleolus approach and retroarticular drilling. The rationale behind retroarticular drilling is to induce bone marrow healing without touching the intact cartilage. The goal of this systematic review is to summarize the clinical outcomes of retroarticular drilling as a standalone procedure for stable talar OCD with intact cartilage.

PATIENTS AND METHODS

A systematic review of the literature prospectively registered in the PROSPERO register was performed along the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Medline, EMBASE and Evidence-Based Medicine databases were searched from inception to December 2021 for retroarticular drilling for stable talar OCD with an intact cartilage. Two independent evaluators screened the search results, selected the articles to be included in the analysis and assessed the methodological quality of all included articles with the Newcastle-Ottawa Scale (NOS).

RESULTS

Twelve studies, on 99 patients were included in the final analysis. Methodological quality was poor for all the included studies. High heterogeneity prevented any pooling or meta-analysis, but favorable clinical results were reported according to excellent post-intervention scores on the American Orthopedic Foot and Anke Score (AOFAS), ranging from 88.9 to 100. There was also significant improvement in pain as measured by the Visual Analog Scale (VAS), ranging between 2.3 and 5.9.

DISCUSSION

Favorable results seem to be achieved with retroarticular drilling without grafting for stable talar OCD with intact cartilage, but more powered comparative studies between surgical options and conservative management are needed to establish the gold standard treatment.

LEVEL OF EVIDENCE

IV.

A Systematic Review of the Retrograde Drilling Approach for Osteochondral Lesion of the Talus: Questioning Surgical Approaches, Outcome Evaluation and Gender-Related Differences

BACKGROUND

Retrograde drilling (RD) is a minimally invasive surgical procedure mainly used for non-displaced osteochondral lesions (OCL) of the talus, dealing with subchondral necrotic sclerotic lesions or subchondral cysts without inducing iatrogenic articular cartilage injury, allowing the revascularization of the subchondral bone and new bone formation.

METHODS

This systematic review collected and analyzed the clinical studies of the last 10 years of literature, focusing not only on the clinical results but also on patients' related factors (gender, BMI, age and complications).

RESULTS

Sixteen clinical studies were retrieved, and differences in the type of study, follow-up, number and age of patients, lesion type, dimensions, grades and comparison groups were observed, making it difficult to draw conclusions. Nevertheless, lesions on which RD showed the best results were those of I-III grades and not exceeding 150 mm² in size, showing overall positive results, a good rate of patient satisfaction, improvements in clinical scores, pain reduction and return to daily activities and sports.

CONCLUSIONS

There are still few studies dealing with the issue of post-surgical complications and gender-related responses. Further clinical or preclinical studies are thus mandatory to underline the success of this technique, also in light of gender differences.

Retrograde Drilling, Ossoscopy, and Autologous Bone Grafting: An Alternative Technique for Treatment of Osteochondral Lesion of the Talus Stage 2 and 3 in Adults

BACKGROUND

Symptomatic osteochondral lesions of the talus (OLTs) often require surgical intervention. There are various surgical methods. A generally valid, stage-dependent therapeutic algorithm does not exist. The aim of our study is to show long- term results of an alternative technique that combines retrograde drilling, debridement performed under arthroscopic visualization, and autologous bone grafting.

METHODS

The surgical technique was performed in 24 patients with medial or lateral OLTs, and the data were analyzed retrospectively. In our technique, the affected subchondral bone was overdrilled retrogradely and resected under arthroscopic visualization (ossoscopy) without violating the cartilage. The resulting defect was filled with autologous bone from the medial tibia metaphysis. Outcome parameters were the numeric rating scale (NRS), the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, and range of motion (ROM). The Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score was assessed and a possible correlation with the clinical outcome scores was calculated. Data concerning complication rates were also collected.

RESULTS

The mean surface size of the OLTs was 0.9 ± 0.3 cm2. The mean follow-up was 89 months. The AOFAS score improved significantly from 57.7 points preoperatively to 88.8 points at the final follow-up (P < .0001). The pain value measured by the NRS decreased significantly from 8 to a pain level of 2. ROM improved in 37.5% of the patients for dorsiflexion and 29.2% for plantarflexion. There were no significant correlations between the MOCART score and the AOFAS score or the pain value on NRS.

CONCLUSION

Retrograde drilling, ossoscopy, and autologous bone grafting for OLTs is a promising technique with good long-term results. The patients' satisfaction rate, especially in OLT stages 2 and 3, was excellent.

LEVEL OF EVIDENCE

Level IV, case series.

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.

Arthroscopic Debridement and Microfracture of Osteochondral Lesion of the Talar Head

Osteochondral lesions of the talar head can be classified into 4 types according to their location. A type 1 lesion is located at the anterior part of the talar head. Surgical debridement and microfracture are indicated for symptomatic type 1 lesions if conservative treatment fails to relieve the pain. The purpose of this technical note was to describe the details of arthroscopic debridement and microfracture of the symptomatic type 1 osteochondral lesion of the talar head and the kissing lesion at the navicular bone. The procedure is performed through the standard portals of talonavicular arthroscopy and has the advantages of minimally invasive surgery of better cosmetic results and less surgical trauma.

Arthroscopic Management of Osteochondral Lesion of Plantar Medial Talar Head

Osteochondral lesions of the talar head can be classified into 4 types: type 1 is located at the anterior part of the talar head, type 2 is at the plantar side of the talar head, type 3 is at the plantar lateral side of the talar head, and type 4 is at the plantar medial aspect of the talar head. The purpose of this Technical Note is to describe the details of arthroscopic management of an osteochondral lesion of the plantar medial talar head. It includes arthroscopic synovectomy of the medial recess of the anterior subtalar joint, debridement, and microfracture of the osteochondral lesion.

Osteochondritis Dissecans of the Capitellum: A Case Report of Successful Arthroscopic Treatment

Introduction. Osteochondritis dissecans (OCD) of the capitellum is a localized disorder of the subchondral bone, in a region with limited healing capacity. Although its aetiology is still unknown, it has been associated with repetitive microtrauma. The natural history of this disease involves the evolution for degenerative joint disease in approximately half of the patients, with early identification and treatment being critical to optimizing the outcome. Case Presentation. We present a rare case in our practice, illustrating a capitellar OCD in a fifteen-year-old White male without an identified cause of repetitive microtrauma. Conclusion. In this case prompt diagnosis and arthroscopic-assisted treatment led to a successful result.

Osteochondral alteration in a child treated with levetiracetam: a rare case of juvenile osteochondritis dissecans of the talar head

Levetiracetam is a relatively novel antiepileptic drug used for the treatment of partial and generalized seizures in adult and children. Several animal studies describe a possible drug adverse effect on skeletal growth and metabolism. We present a case report of a 10-year-old female child who underwent a prolonged 7-year treatment with levetiracetam for sporadic secondary convulsions secondary to enterovirus encephalitis at the age of 15 months. This patient developed an osteochondritis dissecans lesion (OCD) of the talar head well treated conservatively. Only a few cases have been described of this rare type of OCD. We hypothesize a possible association between levetiracetam therapy and OCD development, suggesting the importance of long-term control of bone growth in levetiracetam-treated pediatric populations.

Is retrograde drilling really useful for osteochondral lesion of talus with subchondral cyst?: A case report

RATIONALE

Retrograde drilling is a well accepted procedure for osteochondral lesion of the talus and subchondral cyst with intact overlying cartilage. It has good results in most reports. Compared to anterograde drilling, retrograde drilling can protect the integrity of the articular cartilage. The purpose of this study was to evaluate the suitability of using retrograde drilling for osteochondral lesion with subchondral cyst and discuss the mechanism involved in the development of subchondral cyst.

PATIENT CONCERNS

We report a 53-year-old man who had complained left ankle pain that lasted over 6 months which was exacerbated by walking.

DIAGNOSES

We diagnosed it as osteochondral lesion of the talus with subchondral cyst.

INTERVENTIONS

Plain X-ray, computed tomography, and magnetic resonance imaging (MRI) of the ankle.

OUTCOMES

He undertook retrograde drilling without debridement of cartilage. After the surgery, the pain had been subsided for 1 year, although arthritic change had progressed. However, after 5 years of retrograde drilling, he revisited our hospital due to severe ankle pain. Plain X-ray and MRI showed arthritic change of the ankle and multiple cystic formation of talus.

LESSONS

Retrograde drilling has some problem because this procedure is not theoretically correct when the development of a subchondral cyst in osteochondral lesion of the talus is considered. In addition, retrograde drilling may impair uninjured bone marrow of the talus, resulting in the development of multiple cystic formations.

Treatment of osteochondral lesions of the talus in athletes: what is the evidence?

PURPOSE

ankle injuries make up 15% of all sports injuries and osteochondral lesions of the talus (OLTs) are an increasingly frequent problem in active patients. There exist no widely shared guidelines on OLT treatment in the athletic population. The aim of this paper is to review all the existing literature evidence on the surgical treatment of OLTs in athletes, in order to determine the current state of the art in this specific population, underlining both the limits and the potential of the strategies used.

METHODS

a systematic review of the literature was performed focusing on the different types of surgical treatment used for OLTs in athletes. The screening process and analysis were performed separately by two independent researchers. The inclusion criteria for relevant articles were: clinical reports of any level of evidence, written in English, with no time limitation, or clinical reports describing the treatment of OLTs in the athletic population.

RESULTS

with the consensus of the two observers, relevant data were then extracted and collected in a single database to be analyzed for the purposes of the present manuscript. At the end of the process, 16 papers met the selection criteria. These papers report a total of 642 athletic patients with OCTs.

CONCLUSIONS

the ideal treatment for cartilage lesions in athletes is a controversial topic, due to the need for an early return to sports, especially in elite players; this need leads to extensive use of microfractures in this population, despite the poor quality of repair associated with this technique. None of the surgical strategies described in this paper seems to be superior to the others.

LEVEL OF EVIDENCE

systematic review of level IV studies, level IV.