Arthroscopic Microfracture for Osteochondral Lesions of the Talus: Functional Outcomes at a Mean of 6.7 Years in 165 Consecutive Ankles

Return to Sports Activity After Microfracture for Osteochondral Lesion of the Talus in Skeletally Immature Children

BACKGROUND

Osteochondral lesions of the talus (OLTs) are among the common sports-related injuries. However, there are few reports on the return to sports after OLT surgery in skeletally immature children. This study was performed to evaluate the return to sports after microfracture for OLTs in skeletally immature children.

METHODS

This study involved 17 ankles of 16 patients (mean age, 13.2 years; range, 10-16 years) with open tibial epiphyses on magnetic resonance imaging (MRI) who underwent microfracture for OLTs <10 mm in diameter and confirmation of lesion instability under arthroscopy. Nine of 17 ankles had additional lateral ankle ligament stabilization. All patients were participating in some form of sports. The Japanese Society for Surgery of the Foot (JSSF) score, Ankle Activity Score (AAS), return to sports rate, lesion size, grade of subchondral bone marrow edema, and Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score on MRI were evaluated after microfracture. The mean postoperative follow-up period was 53.5 months.

RESULTS

The mean JSSF score significantly improved from 76.1 points preoperatively to 94.9 points at the final follow-up (P < .01). The mean AAS showed no change from preoperative state to final follow-up. The return to sports rate was 100%. The lesion size significantly decreased from 76.3 to 56.7 mm2 in area (P = .02) and from 283.2 to 185.6 mm3 in volume (P = .05). The bone marrow edema grade decreased in 8 of 17 ankles. The total MOCART score showed a significant improvement from 6 months to 1 year postoperatively (P = .05).

CONCLUSION

All skeletally immature children who underwent microfracture for OLTs in this study were able to return to sports activity and showed improvements in clinical scores and MRI parameters. Microfracture may be considered an effective first-line treatment for OLTs <10 mm in diameter in skeletally immature athletes.

LEVEL OF EVIDENCE

Level IV, retrospective case-control study.

Understanding Osteochondritis Dissecans: A Narrative Review of the Disease Commonly Affecting Children and Adolescents

BACKGROUND

Osteochondritis dissecans (OCD) is a joint disorder predominantly affecting the knee, elbow, and ankle of children and adolescents. This comprehensive review delves into the epidemiology, etiology, clinical manifestations, diagnostic approaches, and treatment of OCD.

RESULTS

The most common cause of OCD is repetitive microtrauma, typically associated with sports activities, alongside other significant factors such as genetic predisposition, ischemia, and obesity. In early stages or when lesions are small, OCD often presents as non-specific, vaguely localized pain during physical activity. As the condition progresses, patients may experience an escalation in symptoms, including increased stiffness and occasional swelling, either during or following activity. These symptom patterns are crucial for early recognition and timely intervention. Diagnosis in most cases is based on radiographic imaging and magnetic resonance imaging. Nonsurgical treatment of OCD in young patients with open growth plates and mild symptoms involves activity restriction, immobilization methods, and muscle strengthening exercises, with a return to sports only after symptoms are fully resolved and at least six months have passed. Surgical treatment of OCD includes subchondral drilling in mild cases. Unstable lesions involve methods like restoring the joint surface, stabilizing fractures, and enhancing blood flow, using techniques such as screws, anchors, and pins, along with the removal of fibrous tissue and creation of vascular channels. The specifics of OCD treatment largely depend on the affected site.

CONCLUSIONS

This synthesis of current research and clinical practices provides a nuanced understanding of OCD, guiding future research directions and enhancing therapeutic strategies.

Comparison of Arthroscopic Microfracture for Osteochondral Lesions of the Talus With and Without Small and Shallow Subchondral Cysts

BACKGROUND

Whether arthroscopic microfracture is effective in treating cystic osteochondral lesions of the talus (OLTs) remains controversial. In this study, outcome parameters in patients with small and shallow subchondral cysts are compared to patients without cysts with the hypothesis that equivalent outcomes may be found after primary microfracture treatment.

METHODS

From 2018 to 2021, all 50 OLTs treated with arthroscopic microfracture in the authors' hospital were retrospectively reviewed for eligibility. Single unilateral symptomatic lesions were included and divided into the cyst and noncyst groups, whereas kissing lesions and arthritic lesions were excluded. Numeric rating scale (NRS) scores, American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scores, Tegner activity level scores, Foot and Ankle Ability Measure (FAAM) scores, and magnetic resonance (MR) imaging results were used to describe outcomes.

RESULTS

A total of 35 patients were included, 16 in the cyst group and 19 in the noncyst group. The patient characteristics were similar between the 2 groups (P > .05). In the cyst group the average cysts depth was 5.0 ± 1.3 mm. After a mean follow-up duration of 36.2 ± 10.2 months, no significant differences were found between the 2 groups in NRS, AOFAS, FAAM, or Tegner score improvement (P > .05). Three patients (19%) in the cyst group had no NRS score improvement.

CONCLUSION

OLTs with small and shallow subchondral cysts can be treated with arthroscopic microfracture and achieve similar outcomes as noncystic lesions. A few cystic lesions may not respond to microfracture treatment.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Large variation in postoperative rehabilitation protocols following operative treatment of osteochondral lesions of the talus: A systematic review and meta-analysis on >200 studies

PURPOSE

A treatment-specific rehabilitation protocol and well-defined return-to-play criteria guide clinical decision-making on return to normal function, activity, sports and performance after surgical treatment for osteochondral lesion of the talus (OLT). The optimal rehabilitation protocols in the current literature remain unclear. The purpose of this study was to explore the existing literature on rehabilitation protocols from the early postoperative phase to return to sport onwards after different types of surgical treatment of OLTs.

METHODS

PubMed, Embase, CDSR, DARE and Central were searched systematically from inception to February 2023 according to the PRISMA 2020 guidelines. All clinical studies with a description of postoperative rehabilitation criteria after surgical treatment of OLTs were included. The primary outcome of this study is the extent of reportage for each rehabilitation parameter expressed in percentage. The secondary outcome is the reported median time for each parameter in rehabilitation protocols for all different treatment modalities (type of surgery). The median time, expressed as number of weeks, for each parameter was compared between different types of surgery.

RESULTS

A total of 227 articles were included reporting on 255 different rehabilitation protocols from seven different types of surgery. Weight-bearing instructions were reported in 84%-100% and the use of a cast or walker was prescribed in 27%-100%. Range of motion exercises were described in 54%-100% whereas physical therapy was advised in 21%-67% of the protocols. Any advice on return to sport was described in 0%-67% protocols. A nonparametric analysis of variance showed significant differences between the different surgical treatment modalities for the following parameters between the treatment groups: time to full weight-bearing (p < 0.0003) and return to high impact level of sports (p < 0.0003). Subjective or objective criteria for progression during rehabilitation were reported in only 24% of the studies.

CONCLUSION

An in-depth exploration of the current literature showed substantial variation in postoperative rehabilitation guidelines with an associated underreporting of the most important rehabilitation parameters in postoperative protocols after surgical treatment of OLTs. Furthermore, nearly all rehabilitation protocols were constructed according to a time-based approach. Only one out of four reported either objective or subjective criteria.

LEVEL OF EVIDENCE

Level IV, systematic review.

Ankle bone morphology affects the size of non-trauma related osteochondral lesions of the talus in skeletally immature children

BACKGROUND

This study aimed to elucidate the relationship between ankle morphology and the size of non-trauma related osteochondral lesions of the talus (OLT), because approximately half the OLT found in children is of unknown origin.

METHODS

34 ankles in 30 skeletally immature children with OLTs who underwent preoperative magnetic resonance imaging (MRI) were evaluated. Parameters measured included area of the OLT, tibial axis-medial malleolus angle (TMM), malleolar width (MalW), and talar surface angle (TSA; defined as the angle between the line perpendicular to the mid-diaphysis of the tibia and the talar joint surface; medial inclination, positive). The ankles were divided into two groups: the trauma group had a history of injury and the idiopathic group had no history of injury. The correlation between lesion area and MRI parameters were evaluated in each group.

RESULTS

Thirteen ankles in 13 patients comprised the trauma group, while 21 ankles in 17 patients were in the idiopathic group. Of the 17 patients in the idiopathic group, four had bilateral OLT. In the trauma group, MalW was significantly correlated with the area (r = 0.827, P = 0.0001). In the idiopathic group, TMM and MalW were significantly correlated with the area (r = 0.608, P = 0.003 and r = 0.566, P = 0.008). TSA was positively correlated with area in the idiopathic group (r = 0.516, P = 0.017), but negatively correlated with area in the trauma group (r = -0.609, P = 0.027). The other parameters showed no significant correlation.

CONCLUSIONS

The size of non-trauma related OLTs may have been affected by an ankle morphology showing poor bone conformity, such as an open medial malleolus and inclined talar joint surface. In addition, the evaluation of the contralateral ankle joint may be crucial when patients with OLT have no specific history of trauma.

Microfracture surgery combined with platelet-rich plasma injection in treating osteochondral lesions of talus: A system review and update meta analysis

BACKGROUND

To systematically evaluate the efficacy of arthroscopic microfracture surgery combined with platelet-rich plasma (PRP) injection in treating osteochondral lesions of talus (OLT).

METHOD

A computer-based search of the PubMed, EMbase, Cochrane Library was developed. The search time was dated in December 2022. Randomized controlled trials and prospective case control studies comparing the treatment of OLT with microfracture surgery combined with PRP injection and microfracture surgery alone were included. The quality of the literatures were evaluated. Meta analysis was completed using the data of postoperative pain and function scores of the ankle joint reported in the literature.

RESULTS

Five randomized controlled trials with a total of 198 patients were included. Compared with microfracture surgery alone, meta-analysis showed that the postoperative visual analogue scale (VAS) score for ankle pain was significantly lower (P < 0.001), and the American Orthopaedic Foot and Ankle Society score (AOFAS) was significantly better ( P < 0.001) in the group of microfracture surgery combined with PRP injection. The change of VAS and AOFAS was also significantly better in the group of microfracture surgery combined with PRP injection (P < 0.001).

CONCLUSION

Arthroscopic microfracture surgery combined with PRP injection in treating OLT can significantly reduce pain and improve ankle function. More long-term follow-up, high-quality studies are needed.

LEVEL OF EVIDENCE

II.

Hyaluronic scaffold transplantation with bone marrow concentrate for the treatment of osteochondral lesions of the talus: durable results up to a minimum of 10 years

PURPOSE

The aim of this study was to evaluate the long-term clinical results of the transplantation of a hyaluronic acid membrane augmented with bone marrow aspirate concentrate (BMAC) in an one-step technique for the treatment of patients affected by osteochondral lesions of the talus (OLT).

METHODS

A total of 101 patients (64 men, 37 women, age 32.9 ± 10.9) were evaluated for a minimum of 10 years of follow-up (151.5 ± 18.4 months) The mean lesion size was 2.2 ± 1.4 cm2, the lesion had a post-traumatic origin in 73 patients, 15 patients previously had an ankle fracture, 22 patients had ankle osteoarthritis. All patients were clinically evaluated at baseline and at 2, 5, and a minimum of 10 years after treatment using the AOFAS score, the NRS for pain, and the Tegner score. A survival analysis was performed to check the survival to failure up to the last follow-up.

RESULTS

The AOFAS score significantly improved from baseline (59.6 ± 13.9) to the final follow-up (82.3 ± 14.2) (p < 0.0005). A significant reduction in the AOFAS score was found from 2 to 10 years (p < 0.0005). The NRS for pain changed from 7.0 ± 1.3 at baseline to 3.9 ± 2.7 at the final follow-up (p < 0.0005). A significant worsening was documented between 5 years and the final follow-up (p < 0.0005). The Tegner score improved from the preoperative value of 2.0 (range 1-7) to 3.0 (range 1-7) at the final follow-up (p < 0.0005), although it remained lower as compared to the preinjury level of 4.0 (range 1-9) (p < 0.0005). Better results were documented in male and younger patients with smaller lesions, without the previous surgery, and without the previous ankle fractures or osteoarthritis. At the final follow-up, 85 patients considered their general health status "satisfactory" and 84 patients reported feeling "better" than the preoperative condition. Five patients were considered failures and underwent prosthetic ankle replacement or repeated the same surgery.

CONCLUSION

This one-step technique showed to be an effective procedure for the treatment of OLT, providing a low failure rate and offering durable clinical improvements up to a minimum of 10 years of follow-up. However, this technique demonstrated a small yet significant decrease over the years in terms of pain and function and poor results in terms of sports activity level.

LEVEL OF EVIDENCE

Level IV.

The Efficacy of Platelet-Rich Plasma Augmentation in Microfracture Surgery Osteochondral Lesions of the Talus: A Systematic Review and Meta-Analysis

The appropriate surgical management of osteochondral lesions of the talus (OLT) remains a challenge for foot and ankle surgeons. Currently, microfracture (MF) is the first-line operative treatment for small osteochondral lesions. However, the fibrous cartilage regenerated after MF is mechanically inferior to hyaline cartilage regeneration and is susceptible to deterioration over time. Thus, this meta-analysis aimed to elucidate the efficacy of platelet-rich plasma (PRP) augmentation compared with MF only or other adjuvant supplementations combined with the PRP + MF group (others) for the management of OLT. We searched the PubMed, Embase, Web of Science, and Cochrane Library databases for studies that compared the clinical outcomes of patients who underwent MF only and those who underwent PRP or other adjuvant materials such as hyaluronic acid or BST-CarGel. After the screening, four randomized controlled trials and one quasi-randomized controlled trial were included in this review. We used the following tools for clinical evaluation: the American Orthopedic Foot and Ankle Society (AOFAS) score, Ankle-Hindfoot Scale score, Visual Analog Scale (VAS) score for pain, and the Foot and Ankle Ability Measure (FAAM) score. The standardized mean difference (SMD) was used to analyze the differences in outcomes between groups. Patients in the PRP + MF group had superior final VAS and AOFAS scores to the MF only group. (both p < 0.01) However, no significant improvements between baseline and final follow-up were noted in either score. In addition, there was no remarkable difference in the overall FAAM pain measures between the two groups. The PRP + MF and others groups revealed no significant effect differences in the clinical scores. The results of this analysis suggest that PRP + MF would be more favorable and effective than MF only or additional adjuvant supplementation.

Osteochondral Lesions of the Talus: The Questions We Would Like Answered

Osteochondral lesions of the talus is common pathology that foot and ankle surgeons evaluate and treat. There is a variety of treatment modalities at the surgeon's disposal to repair these lesions, which include both open and arthroscopic surgical techniques. Although both open and arthroscopic techniques have a good success rate, there are still many debates and questions that surround this pathology. The goal of this article is to discuss some of the common questions that we ask ourselves and other surgeons.

Osteochondral lesions of the talar dome

Ankle pain and/or instability is a frequent, non-specific reason for consultation, and may reveal an osteochondral lesion of the talar dome (OLTD). There are 2 types of OLTD: (1) posteromedial, usually idiopathic, wide and deep, featuring isolated pain with severe functional impact; (2) anterolateral, often implicating trauma and associated in 30% of cases with lateral ligament involvement, in a clinical presentation associating pain and instability. The aim of the present study was to review the issue of OLTD, with 5 questions: HOW TO ESTABLISH THE DIAGNOSIS, WITH WHAT WORK-UP?: There are no specific clinical signs. A diagnosis of OLTD should be considered in all cases of painful and/or unstable ankle and especially in case of history of sprain. The clinical work-up screens systematically for laxity or associated hindfoot malalignment. CT-arthrography is the gold-standard, enabling morphologic analysis of OLTD. WHAT CLASSIFICATIONS SHOULD BE USED?: CT-arthrography determines length, depth and any cartilage dissection, classifying OLTD in 3 grades. Grade 1 is a lesion<10mm in length and<5mm in depth. Grade 2 is>10mm in length and/or>5mm in depth with intact cartilage around the lesion. Grade 3 is the same as grade 2 but with overlying cartilage dissection. WHAT ARE THE CURRENT TREATMENT INDICATIONS?: After failure of 6 months' well-conducted medical treatment (sports rest, analgesics, physiotherapy), surgical options in France today comprise microfracture in grade 1 OLTD, raising the fragment, freshening the floor of the lesion and fixing the fragment (known as "lift, drill, fill, fix" (LDFF)) in grade 2, and mosaicplasty in grade 3. WHAT ARE THE PROSPECTS FOR FUTURE TREATMENTS AND THEIR ROLES?: Treatments are progressing and improving. Ideal treatment should restore hyaline cartilage to prevent secondary osteoarthritis. Matrix and cell culture techniques need to be validated. WHAT RESULTS CAN BE EXPECTED AND WHAT SHOULD PATIENTS BE TOLD?: Management according to grade secures AOFAS scores≥80/100 in 80% of cases, whatever the grade. Return to sport is feasible in 80% of case, at a mean 6 months. Progression is satisfactory after treatment adapted to the lesion. LEVEL OF EVIDENCE: V, expert opinion.

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.

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.

Short-term outcomes following dehydrated micronized allogenic cartilage versus isolated microfracture for treatment of medial talar osteochondral lesions

BACKGROUND

Osteochondral lesions of the talus (OLTs) have been traditionally treated with bone marrow stimulation techniques such as microfracture. However, conventional microfracture results in a biomechanically weaker repair tissue of predominantly type I collagen. Acellular micronized cartilage matrix (MCM) serves as a bioactive scaffold to restore hyaline cartilage. The purpose was to compare short-term outcomes after microfracture with and without augmentation with MCM for medial-sided OLTs.

METHODS

A retrospective review was performed between 2010-2019 for medial-sided OLTs undergoing treatment with either microfracture augmented with MCM or isolated microfracture. The MCM was hydrated with either bone marrow aspirate concentrate (BMAC) or platelet-rich plasma (PRP). Outcomes included visual analogue scale (VAS) pain scores, Foot and Ankle Activity Measure (FAAM) scores, return-to-daily activities, and return-to-sport.

RESULTS

48 patients (14 MCM with PRP, 6 MCM with BMAC; 28 isolated microfracture) with average age 35.5 years (range: 13.8-67.2 years) and mean follow-up 4.0 ± 3.4 years (range,.13-10.7) were included. There was no difference in average lesion size between MCM and microfracture groups (64.0 ± 49.4 mm² versus 57.3 ± 44.2 mm², P = .63) and a trend toward larger lesion size for BMAC compared to PRP (106.5 ± 59.2 versus 45.9 ± 32.1 mm², P = .056). There was no difference in time to return-to-activity (83.5 ± 18.8 versus 87.3 ± 49.1 days) or return-to-sports (151.9 ± 62.2 versus 165 ± 99.2 days) with MCM versus isolated microfracture. However, the MCM group had a significantly greater improvement in VAS pain score at final follow-up (4.9 ± 2.2 versus 2.7 ± 2.6, P = .0032) and significantly higher post-operative FAAM-Activities of Daily Living subscale scores (97.2 ± 8.2 versus 79.7 ± 32.8, P = .033).

CONCLUSIONS

Augmenting microfracture with MCM hydrated with PRP or BMAC may result in beneficial changes in pain scores and activities of daily living, but similar return-to-activities and return-to-sport times compared to microfracture alone in management of medial OLT.

LEVEL OF EVIDENCE

IV.

Evidence for operative treatment of talar osteochondral lesions: a systematic review

Purpose

Operative treatment of talar osteochondral lesions is challenging with various treatment options. The aims were (i) to compare patient populations between the different treatment options in terms of demographic data and lesion size and (ii) to correlate the outcome with demographic parameters and preoperative scores.

Methods

A systemic review was conducted according to the PRISMA guidelines. The electronic databases Pubmed (MEDLINE) and Embase were screened for reports with the following inclusion criteria: minimum 2-year follow-up after operative treatment of a talar osteochondral lesion in at least ten adult patients and published between 2000 and 2020.

Results

Forty-five papers were included. Small lesions were treated using BMS, while large lesions with ACI. There was no difference in age between the treatment groups. There was a correlation between preoperative American Orthopaedic Foot and Ankle Society (AOFAS) score and change in AOFAS score (R = −0.849, P < 0.001) as well as AOFAS score at follow-up (R = 0.421, P = 0.008). Preoperative size of the cartilage lesion correlates with preoperative AOFAS scores (R= −0.634, P = 0.001) and with change in AOFAS score (R = 0.656, P < 0.001) but not with AOFAS score at follow-up. Due to the heterogeneity of the studies, a comparison of the outcome between the different operative techniques was not possible.

Conclusion

Patient groups with bigger lesions and inferior preoperative scores did improve the most after surgery.

Level of evidence

IV.

Hyaluronic acid as an adjunct to microfracture in the treatment of osteochondral lesions of the talus: a systematic review of randomized controlled trials

BACKGROUND

Osteochondral lesions of the talus (OLT) are common after ankle trauma. Studies have shown that bioactive substances, such as hyaluronic acid (HA), alone, or in combination, with surgical treatment could improve cartilage regeneration and repair, but the effect of HA on patient reported outcomes is unclear.

METHODS

Literature searches were performed across four databases (PubMed, SPORTDiscus, Scopus, and The Cochrane Library) for randomized controlled trials in which at least one treatment arm involved use of HA as an adjunct to microfracture to treat patients with OLT. Primary outcomes included the American Orthopaedic Foot and Ankle Society scores (AOFAS), and the Visual Analog Scale (VAS) for pain. The level of evidence and methodological quality were evaluated using the Modified Coleman Methodology Score (MCMS).

RESULTS

Three randomized studies were eligible for review with a total of 132 patients (35, 40, 57 patients, respectively) and follow-up ranged from 10.5 to 25 months. Utilization of HA at the time of microfracture resulted in greater improvement in AOFAS scores compared to microfracture alone. The pooled effect size was moderate (Standardized Mean Difference [SMD] 0.45, 95% Confidence Interval [CI] 0.06, 0.84; P = .02) and between-study heterogeneity was low (I-squared = 0%). Utilization of HA during microfracture also led to greater improvement in VAS-pain scores compared to microfracture alone. The pooled effect size was very large (SMD -3.86, 95% CI -4.75, - 2.97; P < .001) and heterogeneity was moderate (I-squared = 69%).

CONCLUSION

Hyaluronic acid injection as an adjunct to arthroscopic MF in OLT provides clinically important improvements in function and pain at short-term follow-up compared to MF alone. Future longer-term follow-up studies are warranted to investigate the durability of MF with HA for treatment of OLT.

A New Concept of Mosaicplasty: Autologous Osteoperiosteal Cylinder Graft Covered With Cellularized Scaffold

A concern regarding osteochondral autograft transfer for chondral defects is donor-site morbidity of the knee, the most common source of the autograft. To avoid the drawbacks of osteochondral autograft transfer, a cylindrical osteoperiosteal graft harvested from the iliac crest covered by a same-sized cylinder of hyaluronic acid-based polymer scaffold pretreated with bone marrow aspirate concentrate and transferred to the chondral defect recipient site in the exact size for restoration of the subchondral bone and the articular cartilage.

Higher preoperative range of motion is predictive of good mid-term results in the surgical management of osteochondral lesions of the talus: a prospective multicentric study

INTRODUCTION

Osteochondral lesions of the talus (OLT) are a frequent cause of pain in young patients and a new CT arthrographic classification system of OLT was recently proposed to help guide the choices of and standardize the indications for surgical treatment. The primary hypothesis was that this algorithm would result in a postoperative AOFAS score of ≥ 80/100. The secondary hypothesis was to identify the preoperative factors of successful surgery.

METHODS

This was a prospective observational multicenter study. Eighty-six patients who underwent surgery for OLT after at least 6 months of unsuccessful conservative management were included for a mean follow-up of 15 months (12-36). Forty-nine patients with stage 1 OLT underwent microperforation, 2 patients with stage 2 OLT underwent a lift, drill, fill, and fix graft procedure with screw fixation, and 35 patients with stage 3 OLT were treated with mosaicplasty.

RESULTS

After a follow-up of at least 1 year, 56 patients (65%) had an AOFAS score > 80 and the mean AOFAS score was 82 (16-100). A lower BMI (p = 0.038), a higher preoperative range of motion in the ankle (p = 0.033), higher preoperative AOFAS and FAOS scores (p = 0.001 and p = 0.011), and the presence of a preoperative bone bruise on MRI (p = 0.020) were good prognostic factors on univariate analysis. The presence of grade 1 osteoarthritis on the Van Dijk classification was predictive of a poor prognosis (p = 0.044). Multivariate analysis showed that a good preoperative range of motion (OR = 1.080 [1.020-1.150] p = 0.01) was predictive of a positive outcome, while grade 1 osteoarthritis was predictive of a poor outcome (OR = 0.147 [0.036-0.603] p = 0.008). The postoperative AOFAS decreased in six patients and 17 patients had at least one complication: six dysthesias of the superficial fibular nerve, two of the sural nerve, and nine stage 1 complex regional pain syndromes.

CONCLUSION

The new algorithm for OLT resulted in a postoperative AOFAS score of ≥ 80/100 in 65% of cases. The positive predictive factors of a successful postoperative outcome were the presence of a good preoperative range of motion and the absence of preoperative osteoarthritis.

LEVEL OF EVIDENCE

Level II.

Location Distribution of 2,087 Osteochondral Lesions of the Talus

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Is Early or Delayed Weightbearing the Better Choice After Microfracture for Osteochondral Lesions of the Talus? A Meta-analysis and Systematic Review

Osteochondral lesions of the talus (OLT) are common injuries requiring surgery. Arthroscopic microfracture treatment is effective and acceptable. Although the concept of postoperative rehabilitation is continuously being updated, the choice between early weightbearing (EWB) versus delayed weightbearing (DWB) following microfracture is still not settled. A meta-analysis and systematic review was performed to compare the rehabilitation effect of 2 different weightbearing protocols following microfracture. Five databases were searched for relevant studies, and full-text articles comparing EWB and DWB were reviewed. Review Manager 5.3 software was used to summarize the results of the included studies. Two reviewers independently filtered the studies, assessed quality, extracted data, and estimated the risk of bias. The pain score and functional assessment of the ankle were selected as the endpoints. The mean difference was calculated as the summary statistic for continuous data. Then, visual analog scale and American Orthopedic Foot and Ankle Society scale scores were collected and pooled. Five randomized controlled trials including 283 patients were identified for this study, revealing that there was no significant difference in pain scores between EWB and DWB following microfracture 3 months, 6 months, 12 months, and 24 months postoperatively. Function assessment showed similar results. Comprehensive analysis of current evidence still suggests that EWB and DWB after microfracture of OLT produce comparable clinical outcomes in terms of pain and functional activity. Therefore, EWB is recommended to shorten the length of time before returning to work or sports after microfracture of OLT.

Impact of Early Weightbearing After Ankle Arthroscopy and Bone Marrow Stimulation for Osteochondral Lesions of the Talus

BACKGROUND

Osteochondral lesion of the talus (OLT) may be caused by osteochondritis dissecans, osteochondral fractures, avascular necrosis, or focal arthritic changes. For certain focal cartilage defects, bone marrow stimulation (BMS) has been a widely used technique to restore a fibrocartilage substitute overlying the defect. There are various postoperative weightbearing protocols for this procedure, with no single gold standard method.

PURPOSE

To retrospectively review the outcomes of patients undergoing ankle arthroscopy with concomitant BMS to determine outcomes based on postoperative weightbearing status.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

We retrospectively reviewed the records of patients who underwent ankle arthroscopy with BMS for OLTs between 2015 and 2018. Patients were placed into 2 cohorts based on postoperative immobilization status: the nonweightbearing (NWB) group and the weightbearing-as-tolerated (WBAT) group. Patient characteristics obtained included age, sex, comorbidities, and etiology of talar pathology. Outcomes included the pain visual analog scale (VAS), range of motion (ROM), complications, time to first weightbearing, and the method and length of immobilization. Patients who were lost to follow-up before 30 days were excluded. The chi-square test was used to compare categorical variables between cohorts, and the t test was used for continuous variables.

RESULTS

A total of 69 patients met the inclusion criteria for this study, 18 in the WBAT group and 51 in the NWB group. The mean lesion size was 9.48 × 9.21 mm (range, 3-15 mm × 2-20 mm) for the NWB group and 9.36 × 9.72 mm (range, 5-14 mm × 6-20 mm) for the WBAT group (P > .05). The VAS scores improved from 4.40 to 0.67 for the WBAT group and from 6.33 to 2.55 for the NWB group, with the difference in final values reaching statistical significance (P = .0002). Postoperative ROM was not significantly different between the groups. There were 4 repeat operations within the NWB cohort.

CONCLUSION

The surgical management of OLTs can be challenging, and the postoperative weightbearing protocol can be an extra obstacle for the patient to navigate. We found no difference in pain, ROM, or complications when allowing immediate, full WBAT.

The management of talar osteochondral lesions - Current concepts

Osteochondral lesions of the talus (OLTs) are a common complication following trauma, involving both the articular cartilage and the underlying subchondral bone, with variable aetiologies and often presenting with non-specific symptoms. Diagnosis of OLTs requires a combination of clinical assessment and imaging and despite many different treatment options, there is no generalised consensus regarding which option is the most effective. Left untreated, OLTs risk progressing to osteoarthritis. Acute non-displaced OLTs can be treated non-operatively. However, OLTs refractory to non-surgical care for three to six months may be suitable for surgical care. In these cases, conservative treatments are often unsuccessful, particularly for larger and more severe defects and so the majority require surgical intervention. Although bone marrow stimulation techniques remain the "gold standard" for lesions <150 mm2, there still requires a need for better long term clinical data and cost-benefit analyses compared with other treatment options. Biological attempts at either regenerating or replacing the articular cartilage are however demonstrating some promising results, but each with their own advantages and disadvantages. In this review, we summarise the clinical management of OLTs and present the current concepts of different treatment regimes.

Osteochondritis Dissecans: Current Understanding of Epidemiology, Etiology, Management, and Outcomes

➤

Osteochondritis dissecans occurs most frequently in the active pediatric and young adult populations, commonly affecting the knee, elbow, or ankle, and may lead to premature osteoarthritis.

➤

While generally considered an idiopathic phenomenon, various etiopathogenetic theories are being investigated, including local ischemia, aberrant endochondral ossification of the secondary subarticular physis, repetitive microtrauma, and genetic predisposition.

➤

Diagnosis is based on the history, physical examination, radiography, and advanced imaging, with elbow ultrasonography and novel magnetic resonance imaging protocols potentially enabling early detection and in-depth staging.

➤

Treatment largely depends on skeletal maturity and lesion stability, defined by the presence or absence of articular cartilage fracture and subchondral bone separation, as determined by imaging and arthroscopy, and is typically nonoperative for stable lesions in skeletally immature patients and operative for those who have had failure of conservative management or have unstable lesions.

➤

Clinical practice guidelines have been limited by a paucity of high-level evidence, but a multicenter effort is ongoing to develop accurate and reliable classification systems and multimodal decision-making algorithms with prognostic value.

Comparison of Clinical and Radiographic Outcomes Following Arthroscopic Debridement With Extracellular Matrix Augmentation and Osteochondral Autograft Transplantation for Medium-Size Osteochondral Lesions of the Talus

BACKGROUND

Historically, microfracture has been used to treat small talar osteochondral lesions with good results, whereas osteochondral autologous transplantation (OAT) has proven effective for the treatment of larger lesions. It is not clear which method is more effective for medium-sized lesions around the critical size of 150 mm², above which microfracture outcomes tend to be poor. The purpose of this study was to determine the potential advantages of OAT augmented with a combination of extracellular matrix and bone marrow aspirate concentrate (ECM-BMAC) compared to debridement with ECM-BMAC (DEB) in the treatment of medium-sized osteochondral lesions of the talus (OLTs).

METHODS

Clinical and radiographic data were collected retrospectively for patients treated by a single fellowship-trained foot and ankle surgeon. Magnetic resonance images (MRIs) were scored using the Magnetic Resonance Observation of Cartilage Tissue (MOCART) system and were evaluated for the presence of cysts and edema. Fifty-two patients met inclusion criteria, with 25 who received an OAT procedure. Age, body mass index, lesion size, lesion location, and follow-up time were similar between groups. Average MRI follow-up times were 16.7 months for the OAT group and 20.3 months for the DEB group (P = .38).

RESULTS

Patients treated with OAT had significantly higher average total MOCART scores (69 vs 55, P = .04) and significantly lower rates of cyst (14% vs 55%, P < .01), edema (59% vs 90%, P = .04), revision surgery (0% vs 19%, P = .05), and therapeutic injection for pain (4% vs 30%, P = .02) compared to patients treated with DEB. No significant differences were detected in patient-reported outcome scores between groups.

CONCLUSION

The native hyaline cartilage introduced by OAT appears to result in higher-quality repair tissue when compared to DEB, as evidenced by OAT patients' higher MOCART scores and lower rates of cyst and edema. There was no difference in clinical outcome scores, though OAT patients did not require revision surgery or therapeutic injection for pain as frequently as DEB patients.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Bone Marrow Stimulation for Osteochondral Lesions of the Talus: Are Clinical Outcomes Maintained 10 Years Later?

BACKGROUND

Arthroscopic bone marrow stimulation (BMS) is considered the first-line treatment for osteochondral lesions of the talus (OLTs). However, the long-term stability of the clinical success of BMS remains unclear.

PURPOSE

To investigate the long-term clinical outcomes among patients who underwent BMS for OLT and to identify prognostic factors for the need for revision surgery.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A retrospective analysis was performed on 202 ankles (189 patients) that were treated with BMS for OLT and had a minimum follow-up of 10 years. The visual analog scale for pain, American Orthopaedic Foot & Ankle Society ankle-hindfoot score, and the Foot and Ankle Outcome Score (FAOS) were assessed by repeated measures analysis of variance. Prognostic factors associated with revision surgery were evaluated with Cox proportional hazard regression models and log-rank tests.

RESULTS

The mean lesion size was 105.32 mm² (range, 19.75-322.79); 42 ankles (20.8%) had large lesions (≥150 mm²). The mean visual analog scale for pain improved from 7.11 ± 1.73 (mean ± SD) preoperatively to 1.44 ± 1.52, 1.46 ± 1.57, and 1.99 ± 1.67 at 1, 3 to 6, and ≥10 years, respectively, after BMS (P < .001). The mean ankle-hindfoot score also improved, from 58.22 ± 13.57 preoperatively to 86.88 ± 10.61, 86.17 ± 10.23, and 82.76 ± 11.65 at 1, 3 to 6, and ≥10 years after BMS (P < .001). The FAOS at the final follow-up was 82.97 ± 13.95 for pain, 81.81 ± 14.64 for symptoms, 83.49 ± 11.04 for activities of daily living, 79.34 ± 11.61 for sports, and 78.71 ± 12.42 for quality of life. Twelve ankles underwent revision surgery after a mean 53.5 months. Significant prognostic factors associated with revision surgery were the size of the lesion (preoperative magnetic resonance imaging measurement ≥150 mm²; P = .014) and obesity (body mass index ≥25; P = .009).

CONCLUSION

BMS for OLT yields satisfactory clinical outcomes at a mean follow-up of 13.9 years. The success of the surgery may depend on the lesion size and body mass index of the patient.

Recent Developed Strategies for Enhancing Chondrogenic Differentiation of MSC: Impact on MSC-Based Therapy for Cartilage Regeneration

Articular cartilage is susceptible to damage, but its self-repair is hindered by its avascular nature. Traditional treatment methods are not able to achieve satisfactory repair effects, and the development of tissue engineering techniques has shed new light on cartilage regeneration. Mesenchymal stem cells (MSCs) are one of the most commonly used seed cells in cartilage tissue engineering. However, MSCs tend to lose their multipotency, and the composition and structure of cartilage-like tissues formed by MSCs are far from those of native cartilage. Thus, there is an urgent need to develop strategies that promote MSC chondrogenic differentiation to give rise to durable and phenotypically correct regenerated cartilage. This review provides an overview of recent advances in enhancement strategies for MSC chondrogenic differentiation, including optimization of bioactive factors, culture conditions, cell type selection, coculture, gene editing, scaffolds, and physical stimulation. This review will aid the further understanding of the MSC chondrogenic differentiation process and enable improvement of MSC-based cartilage tissue engineering.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Level II.

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.

Characteristics of Osteochondral Lesions of the Talus in Different Age Groups

We analyzed the characteristics of 112 consecutive patients who were operatively treated for osteochondral lesions of the talus from August 2014 to April 2019 in our hospital. The patients were divided into three age groups: young-adult (<40 years), middle-age (40-60 years) and old-age (>60 years). The basic clinical features, localization and size of the lesions, Hepple stage, and surgical procedures were compared among groups. Several significant differences were found on the characteristics of osteochondral lesions of the talus among age groups. There were more female patients in the old-age group (p<0.01), and old patients had a longer duration of symptoms (p<0.05). The OLTs in middle- and old-age patients were mostly located in the medial part of the talus with larger depth (p<0.01). Hepple stage 5, the cystic type, was very common in the old-age group (p<0.01). With regard to surgical procedures, more osteochondral autograft transplantations were applied in the old-age group (p<0.01). Female and deep medial talar subchondral cyst is the typical characteristics of patients over 60 years old. Age is an important factor that must be considered when choosing surgery procedure for patients with osteochondral lesions of the talus.

Arthroscopic Treatment of Osteochondral Lesions of the Talus With Microfracture and Platelet-Rich Plasma-Infused Micronized Cartilage Allograft

Osteochondral lesions of the talus (OLTs) are difficult to treat. Arthroscopic microfracture augmented with micronized cartilage (BioCartilage; Arthrex, Naples, FL) and platelet-rich plasma is emerging as a treatment for moderate-sized, well-contained full-thickness OLTs. This treatment may provide superior histologic results and is less technically demanding and yields less morbidity than an open osteochondral allograft or autograft transfer. This technique guide presents the senior author's preferred strategy for treatment of a moderate-sized OLT with arthroscopic microfracture and placement of micronized cartilage and platelet-rich plasma.