Osteochondral autografts for osteochondritis dissecans of the talus

No difference between 5 and 6 weeks of non-weight bearing after osteochondral grafts for medial osteochondral defects of the talus with medial malleolar osteotomy

PURPOSE

The present study aimed to compare the clinical outcomes and safety at a 1-year follow-up after 5 or 6 weeks of non-weight bearing after a Talar OsteoPeriostic grafting from the Iliac Crest (TOPIC) for a medial osteochondral lesion of the talus (OLT).

METHODS

A retrospective comparative case-control analysis of prospectively followed patients who underwent a TOPIC procedure with medial malleolus osteotomy was performed. Patients were matched in two groups with either 5 or 6 weeks of non-weight bearing. Clinical outcomes were evaluated using the Numeric Rating Scale (NRS) during walking, rest, running, and stairclimbing. Additionally, the Foot and Ankle Outcome Score (FAOS) and American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score were assessed. Moreover, radiology and complications were assessed.

RESULTS

Eleven patients were included in the 5-week non-weight bearing group and 22 in the 6-week non-weight bearing group. No significant differences were found in any of the baseline variables. The NRS during walking in the 5-week group improved by 3.5 points and 4 points for the 6-week group (p = 0.58 at 1-year post-operatively). In addition, all other NRS scores, FAOS subscales and the AOFAS scores improved (all n.s. at 1 year follow-up). No significant differences in radiological (osteotomy union and cyst presence in the graft) were found. Moreover, no significant differences were found in terms of complications and reoperations.

CONCLUSION

No statistical significant differences were found in terms of clinical, radiological and safety outcomes between 5 or 6 weeks of non-weight bearing following a TOPIC for a medial OLT.

LEVEL OF EVIDENCE

Level III, Therapeutic.

Arthroscopic debridement and microfracture for bilateral osteochondral lesions on the lateral process of the talus involving the subtalar joint: A case report

RATIONALE

Osteochondral lesions on the lateral process of the talus involving the subtalar joint are rare; the optimal surgical treatment remains to be clarified as there are few reports. Additionally, bilateral cases are extremely rare. Therefore, the clinical outcomes of the surgical treatment for bilateral osteochondral lesions on the lateral process of the talus involving the subtalar joint have not been fully elucidated.

PATIENT CONCERNS

A 16-year-old boy who played soccer presented to our hospital with bilateral hindfoot pain. The symptoms persisted even after 3 months of conservative treatment. The patient and family requested surgical treatment to relieve the symptoms.

DIAGNOSES

The patient was diagnosed with bilateral osteochondral lesions on the lateral process of the talus, involving the subtalar joint based on computed tomography and magnetic resonance imaging findings.

INTERVENTIONS

Arthroscopic debridement and microfracture were performed bilaterally.

OUTCOMES

Postoperative computed tomography and magnetic resonance imaging of both feet revealed remodeling of the subchondral bone. The patient returned to play at the pre-injury level with no pain.

LESSONS

This report describes a case of bilateral osteochondral lesions on the lateral process of the talus, involving the subtalar joint. Arthroscopic debridement and microfracture were effective in relieving symptoms and the subchondral bone remodeling. To the best of our knowledge, this is the first report of arthroscopic treatment of osteochondral lesions of the lateral process of the talus involving the subtalar joint.

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

INTRODUCTION

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

II.

Prognostic factors for the management of chondral defects of the knee and ankle joint: a systematic review

Purpose

Different surgical techniques to manage cartilage defects are available, including microfracture (MFx), autologous chondrocyte implantation (ACI), osteoarticular auto- or allograft transplantation (OAT), autologous matrix-induced chondrogenesis (AMIC). This study investigated the patient-related prognostic factors on the clinical outcomes of surgically treated knee and ankle cartilage defects.

Methods

This study followed the PRISMA statement. In May 2022, the following databases were accessed: PubMed, Google Scholar, Embase, and Scopus. All the studies investigating the outcomes of surgical management for knee and/or talus chondral defects were accessed. Only studies performing mesenchymal stem cells transplantation, OAT, MFx, ACI, and AMIC were considered. A multiple linear model regression analysis through the Pearson Product–Moment Correlation Coefficient was used.

Results

Data from 184 articles (8905 procedures) were retrieved. Female sex showed a positive moderate association with visual analogue scale at last follow-up (P = 0.02). Patient age had a negative association with the American Orthopaedic Foot and Ankle Score (P = 0.04) and Lysholm Knee Scoring Scale (P = 0.03). BMI was strongly associated with graft hypertrophy (P = 0.01). Greater values of VAS at baseline negatively correlate with lower values of Tegner Activity Scale at last follow-up (P < 0.0001).

Conclusion

The clinical outcomes were mostly related to the patients’ performance status prior surgery. A greater BMI was associated with greater rate of hypertrophy. Female sex and older age evidenced fair influence, while symptom duration prior to the surgical intervention and cartilage defect size evidenced no association with the surgical outcome. Lesion size and symptom duration did not evidence any association with the surgical outcome.

Allograft Versus Autograft Osteochondral Transplant for Chondral Defects of the Talus: Systematic Review and Meta-analysis

BACKGROUND

It is unclear whether the results of osteochondral transplant using autografts or allografts for talar osteochondral defect are equivalent.

PURPOSE

A systematic review of the literature was conducted to compare allografts and autografts in terms of patient-reported outcome measures (PROMs), MRI findings, and complications.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

This study was conducted according to the PRISMA guidelines. The literature search was conducted in February 2021. All studies investigating the outcomes of allograft and/or autograft osteochondral transplant as management for osteochondral defects of the talus were accessed. The outcomes of interest were visual analog scale (VAS) score for pain, American Orthopaedic Foot and Ankle Society (AOFAS) score, and Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score. Data concerning the rates of failure and revision surgery were also collected. Continuous data were analyzed using the mean difference (MD), whereas binary data were evaluated with the odds ratio (OR) effect measure.

RESULTS

Data from 40 studies (1174 procedures) with a mean follow-up of 46.5 ± 25 months were retrieved. There was comparability concerning the length of follow-up, male to female ratio, mean age, body mass index, defect size, VAS score, and AOFAS score (P > .1) between the groups at baseline. At the last follow-up, the MOCART (MD, 10.5; P = .04) and AOFAS (MD, 4.8; P = .04) scores were better in the autograft group. The VAS score was similar between the 2 groups (P = .4). At the last follow-up, autografts demonstrated lower rate of revision surgery (OR, 7.2; P < .0001) and failure (OR, 5.1; P < .0001).

CONCLUSION

Based on the main findings of the present systematic review, talar osteochondral transplant using allografts was associated with higher rates of failure and revision compared with autografts at midterm follow-up.

Clinical and MRI Donor-Site Outcomes After Autograft Harvesting From the Medial Trochlea for Talar Osteochondral Lesions: Minimum 5-Year Clinical Follow-up

Background:

Autologous osteochondral transplantation (AOT) is a treatment option for large or cystic osteochondral lesions of the talus (OLTs), with promising clinical results. However, donor-site morbidity (DSM) has always been a concern with this procedure.

Purpose:

To investigate the clinical and radiological outcomes of autograft harvesting from the medial trochlea for OLTs.

Study Design:

Case series; Level of evidence, 4.

Methods:

A total of 46 consecutive patients were included after AOT procedures for OLTs, with donor autografts (single or double plugs) harvested from the medial trochlea of the ipsilateral knee. Lysholm scores were collected postoperatively at 12-month intervals to assess clinical outcomes. Postoperative magnetic resonance imaging (MRI) was used to assess the donor site using the MOCART (magnetic resonance observation of cartilage repair tissue) score. DSM was evaluated at 12-month intervals. Statistical analysis was performed to compare patients treated with single-plug and double-plug AOT procedures and establish whether there was any correlation between MOCART and Lysholm scores.

Results:

The mean follow-up period was 98.3 months (range, 67-144 months). The Lysholm scores for all patients were 92.5 ± 6.1 and 99.9 ± 0.2 at the 12-month and final follow-ups, respectively. MRI of the donor sites was taken at an average of 93.8 ± 20.5 (range, 61-141) months postoperatively, and the mean MOCART score was 76.2 ± 4.9. The overall incidence of DSM in this study was 4.3% at 12 months, postoperatively, which decreased to 0% at the 24-month follow-up. There was no significant difference in either the Lysholm score (P = .16) or the MOCART score (P = .83) between the single-plug and double-plug groups at the final follow-up. There were no significant correlations between MOCART and Lysholm scores and patient age, number of grafts, or body mass index.

Conclusion:

According to the study findings, the DSM of donor autografts harvested from the medial trochlea was low, and the number (single or double) of grafts did not affect the functional outcome.

Second-look arthroscopic and magnetic resonance analysis after internal fixation of osteochondral lesions of the talus

The purpose of this study was to evaluate cartilage quality after internal fixation of osteochondral lesion of the talus (OLT) using second-look arthroscopies and MRIs. Thirty-four patients underwent internal fixation of OLTs involving large bone fragments. Twenty-one of these patients underwent second-look arthroscopies and 23 patients underwent MRIs postoperatively. The arthroscopic findings were assessed using the International Cartilage Repair Society (ICRS) grading system, and the MRI findings were evaluated using the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score. Five of the patients who underwent second-look arthroscopies showed normal cartilage, 12 showed nearly normal cartilage, 3 showed abnormal cartilage, and 1 showed severely abnormal cartilage, according to the overall ICRS repair grades. All the patients who achieved bone fragment union showed normal, or nearly normal cartilage upon second-look arthroscopy. The ICRS and MOCART scores were significantly higher for the patients with bone fragment union compared to those with nonunion (ICRS scores: 10.3 ± 1.5 vs. 6.0 ± 2.0, p < 0.001, MOCART score: 88.3 ± 10.0 vs. 39.0 ± 20.4, p < 0.001). Low signal intensities of the bone fragments on preoperative T1-weighted MRIs were not associated with nonunion (Fisher's exact test, p = 0.55), and the signal intensities increased postoperatively to levels similar to the underlying talus when bone union was achieved. Second-look arthroscopy and MRI showed normal, or nearly normal, cartilage after internal fixation of OLTs when bone union was achieved. The nonunion of bone fragments resulted in inferior cartilage quality.

Arthroscopic evaluation after osteochondral autogenous transfer with osteotomy of medial malleolus for osteochondral lesion of the talar dome

BACKGROUND

The purpose of this study was to investigate the second-look arthroscopic evaluation after osteochondral autogenous transfer (OAT) for osteochondral lesion of the talar dome (OLT) with the criteria of the International Cartilage Repair Society (ICRS).

METHODS

Ten patients (twelve ankles) with OLT underwent OAT with osteotomy of the medial malleolus. Clinical outcomes were evaluated using the American Orthopedic Foot & Ankle Society (AOFAS) ankle-hindfoot scale. The condition of the transplanted cartilage was evaluated at the time of second-look arthroscopy using the ICRS Cartilage Repair Assessment.

RESULTS

The AOFAS ankle-hindfoot scale was significantly improved from 65.1 ± 1.9 points before surgery to 98.1 ± 2.8 points at the time of second-look arthroscopy (p < 0.01). The ICRS Cartilage Repair Assessment was 11.4 points on average (9-12 points).

CONCLUSIONS

The OAT for OLT is considered to be a useful treatment even if invasion by medial malleolus osteotomy is added.

LEVEL OF EVIDENCE

Level IV, Case series.

Long-term outcome for repair of osteochondral lesions of the talus by osteochondral autograft: A series of 56 Mosaicplasties®

INTRODUCTION

The present study analyzed results in 56 osteochondral Mosaicplasty® autografts for osteochondral lesion of the talus (OLT) at more than 5 years' follow-up.

HYPOTHESIS

Mosaicplasty® shows long-term efficacy and low morbidity in the treatment of OLT.

PATIENTS AND METHODS

A multicenter retrospective study included patients treated by Mosaicplasty® with more than 5 years' follow-up. Preoperative data were collected from medical files, and all patients were reassessed. AOFAS scores and FAOS were calculated at last follow-up. Imaging comprised standard radiographs and MRI or CT arthrography of the ankle.

RESULTS

Fifty-six patients were included, with a mean age of 34 years (range, 18-60 years). Seventeen involved work accidents. Mean follow-up was 8.5 years (range, 5-20 years). Mean AOFAS score at follow-up was 80.6±19.4 and mean FAOS 77.8±21.5. Work accident, preoperative osteoarthritis and untreated laxity correlated significantly with poorer results. At last follow-up, 22 patients (39%) showed signs of osteoarthritis. There was no morbidity implicating the malleolar osteotomy. There were 11 cases (20%) of persistent patellar syndrome at the donor site.

DISCUSSION

The present results were comparable to those reported elsewhere, showing that functional results of Mosaicplasty® autograft for OLT do not deteriorate over the long term. Work accidents correlated significantly with poorer functional outcome. Any associated instability must always be treated. Malleolar osteotomy provides good exposure without additional morbidity.

LEVEL OF EVIDENCE

IV; retrospective study.

Predicting Outcomes of Talar Osteochondritis Dissecans Lesions in Children

Background

Reports detailing the rates of radiographic healing after treatment of talar osteochondritis dissecans (TOCD) remain scarce. There is also a paucity of data characterizing treatment outcomes and the risk factors associated with poor outcomes in children with TOCD.

Purpose

To identify factors associated with healing, assess treatment outcomes, and develop a clinically useful nomogram for predicting healing of TOCD in children.

Study Design

Case-control study; Level of evidence, 3.

Methods

This was a retrospective review of all patients ≤18 years of age with TOCD from a single pediatric institution over a 12-year period. Surgical treatment was left to the discretion of the treating surgeon based on standard treatment techniques. Medical records and radiographs were reviewed for patient and clinical data, lesion characteristics, and skeletal maturity. Radiographic healing was evaluated at the 1-year follow-up, and patients with complete versus incomplete healing were compared using multivariable logistic regression models to examine the predictive value of the variables.

Results

The authors analyzed 92 lesions in 74 patients (mean age, 13.1 ± 2.7 years [range, 7.1-18.0 years]; 61% female). Of these, 58 (63%) lesions were treated surgically (drilling, debridement, microfracture, bone grafting, or loose body removal), and the rest were treated nonoperatively. Complete radiographic healing was seen in 43 (47%) lesions. In bivariate analysis, patients with complete healing were younger (P = .006), were skeletally immature (P = .013), and had a lower body mass index (BMI; P < .001) versus those with incomplete healing. In a multivariate regression model, the factors that correlated significantly with the rate of complete healing were age at diagnosis, BMI, and initial surgical treatment. The lesion dimensions were not significantly associated with the likelihood of healing. A nomogram was developed using the independent variables that correlated significantly with the likelihood of complete radiographic healing.

Conclusion

Complete radiographic healing of TOCD lesions was more likely in younger patients with a lower BMI. The effect of initial surgical treatment on potential healing rate was greater in older patients with a higher BMI.

Sufficient Cartilage for Most Talar Articular Defects Can Be Harvested From the Non-Loadbearing Talus: A Cadaveric Analysis

Purpose

To assess the quantity of morselized cartilage that can be harvested from the non–load-bearing portion of the talus for immediate reimplantation.

Methods

Non–load-bearing talar cartilage was harvested from 5 cadaveric specimens using a standard arthroscopic approach. Cartilage was separated from the talus in maximum dorsiflexion at the junction of the talar head and neck, grasped, and morselized into a graft using a cartilage particulator. The volume of reclaimed cartilage was measured, and the extrapolated area of coverage was compared to average osteochondral lesions of the talus previously reported.

Results

The total yield of cartilage graft following processing that was obtained from 5 ankle joints ranged from 0.3 mL to 2.1 mL with a mean volume of 1.3 ± 0.7 mL, yielding a theoretical 13.2 ± 7.1 cm² coverage with a 1-mm monolayer. While the average size of osteochondral lesions of the talus is difficult to estimate, they may range from 0.5 cm² to 3.7 cm² according to the literature.

Conclusions

This study validated that it is possible to harvest sufficient amount of cartilage for an autologous morselized cartilage graft via a single-stage, single-site surgical and processing technique to address most talar articular cartilage defects.

Clinical Relevance

Particulated cartilage autografts have shown promise in surgical management of cartilage defects. A single-site, single-staged procedure that uses a patient’s autologous talar cartilage from the same joint has the potential to reduce morbidity associated with multiple surgical sites, multistaged procedure, or nonautologous tissue in ankle surgery.

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.

Autologous osteochondral transplantation for osteochondral lesions of the talus: high rate of return to play in the athletic population

PURPOSE

(1) To determine the rate of return to play following autologous osteochondral transplantation (AOT) for osteochondral lesions of the talus (OLT) and (2) report subsequent rehabilitation protocols.

METHODS

A systematic review of the PubMed, Embase, and The Cochrane Library databases was performed according to the PRISMA guidelines based on specific eligibility criteria. Return to play data was meta-analysed and subsequent rehabilitation protocols were summarised. Level of evidence and quality of evidence (Zaman's criteria) were also evaluated.

RESULTS

Nine studies that totalled 205 ankles were included for review. The mean follow-up was 44.4 ± 25.0 (range 16-84) months. The mean OLT size was 135.4 ± 56.4 mm². The mean time to return to play was 5.8 ± 2.6 months. The mean rate of return to play was 86.3% (range 50-95.2%), with 81.8% of athletes returning to pre-injury status. Based on the fixed-effect model, the rate of return to play was 84.07%. Significant correlation was found between increase age and decrease rate of return to play (R² = 0.362, p = 0.00056). There was no correlation between OLT sizes and rate of return to play (R² = 0.140, p = 0.023). The most common time to ankle motion post-surgery was immediately and the most common time to full weight-bearing was 12 weeks.

CONCLUSIONS

This systematic review indicated a high rate of return to play following AOT in the athletic population. Size of OLT was not found to be a predictor of return to play, whereas advancing age was a predictor. Rehabilitation protocols were largely inconsistent and were primarily based on individual surgeon protocols. However, the included studies were of low level and quality of evidence.

LEVEL OF EVIDENCE

Level IV.

Long-term results of osteochondral autograft transplantation of the talus with a novel groove malleolar osteotomy technique

Objectives

This study aims to evaluate the long-term results of osteochondral autograft transfer (OAT) of talar lesions performed using a modified osteotomy technique.

Patients and methods

This retrospective study included 20 consecutive patients (11 males, 9 females; mean age 33.5±11 years; range, 15 to 56 years) (21 ankles) with osteochondral lesions of the talus (OLT) treated with the OAT system between August 2002 and October 2008. We performed a modified sulcus groove osteotomy, which provides better exposure of medial and central lesions. After a minimum duration of 10 years following surgery, patients’ clinical functions were evaluated according to the American Orthopaedic Foot and Ankle Society (AOFAS) ankle- hindfoot scale and visual analog scale (VAS). The Tegner-Lysholm scoring system was used to determine the levels of knee activity.

Results

The mean follow-up period was 143.5 (range, 120 to 186) months. The mean AOFAS scores significantly improved from 60.4±7.4 (range, 48 to 70) preoperatively to 86.2±9.23 (range, 60 to 94) at the last follow-up (p≤0.05). The mean ankle VAS score significantly decreased from 6.3±0.4 (range, 5 to 7) preoperatively to 2.0±1.4 (range, 0 to 4). The mean Tegner-Lysholm score for this group was 89.7±11.7 (range, 68 to 100). Revision surgery was performed in only two patients because of impingement and arthritis. Recurrent knee pain at the donor site of the osteochondral autograft was observed in three patients (14%).

Conclusion

In the present study, good to excellent results were obtained in the treatment of OLT with OAT for a minimum follow-up duration of 10 years. This novel technique can also simplify the steep learning curve, which is challenging for surgeons.

Matrix-Induced Autologous Chondrocyte Implantation (MACI) Grafting for Osteochondral Lesions of the Talus

BACKGROUND

Matrix-induced autologous chondrocyte implantation (MACI) is an established treatment method for larger joints and has shown promising results in the ankle as well. We present a series of patients after ankle MACI with long-term follow-up of clinical and radiological outcomes.

METHODS

We present the follow-up of 15 patients who underwent MACI grafting from August 2003 to February 2006. The mean follow-up was 12.9 years. Clinical evaluations were conducted using the American Orthopaedic Foot & Ankle Society (AOFAS), Foot and Ankle Activity Measurement (FAAM), and visual analog scale (VAS) scoring systems and the magnetic resonance observation of cartilage repair tissue (MOCART) scoring system for radiological evaluation.

RESULTS

The mean size of the talar osteochondral defects was 204 mm². We found a significant improvement in mean AOFAS score from 60 preoperatively to a mean of 84 at 12 years postoperatively. The 12-year FAAM score for Activities of Daily Living was 89% (range, 62%-99%). The mean 12-year MOCART score was 65 points (range, 30-100 points) with significant agreement between assessors (P < .001). However, the MOCART scores did not correlate with the FAAM scores (P = .86).

CONCLUSION

Considering our long-term follow-up, we believe MACI is a reliable treatment method for talar osteochondral defects providing lasting pain relief and satisfying clinical results. However, with an equivalent outcome, but at higher costs, and the requirement for 2 operative procedures, the results do not seem to be superior to other established methods. The clinical utility of the MOCART score requires further scrutiny since we were not able to show any correlation between the score and clinical outcome.

LEVEL OF EVIDENCE

Level IV, case series.

Return to Sports After Surgical Treatment of Osteochondral Defects of the Talus: A Systematic Review of 2347 Cases

BACKGROUND

Osteochondral defects (OCDs) of the talus are found subsequent to ankle sprains and ankle fractures. With many surgical treatment strategies available, there is no clear evidence on return-to-sport (RTS) times and rates.

PURPOSE

To summarize RTS times and rates for talar OCDs treated by different surgical techniques.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

The literature from January 1996 to November 2018 was screened, and identified studies were divided into 7 different surgical treatment groups. The RTS rate, with and without associated levels of activity, and the mean time to RTS were calculated per study. When methodologically possible, a simplified pooling method was used to combine studies within 1 treatment group. Study bias was assessed using the MINORS (Methodological Index for Non-Randomized Studies) scoring system.

RESULTS

A total of 61 studies including 2347 talar OCDs were included. The methodological quality of the studies was poor. There were 10 retrospective case series (RCSs) that investigated bone marrow stimulation in 339 patients, with a pooled mean rate of RTS at any level of 88% (95% CI, 84%-91%); 2 RCSs investigating internal fixation in 47 patients found a pooled RTS rate of 97% (95% CI, 85%-99%), 5 RCSs in which autograft transplantation was performed in 194 patients found a pooled RTS rate of 90% (95% CI, 86%-94%), and 3 prospective case series on autologous chondrocyte implantation in 39 patients found a pooled RTS rate of 87% (95% CI, 73%-94%). The rate of return to preinjury level of sports was 79% (95% CI, 70%-85%) for 120 patients after bone marrow stimulation, 72% (95% CI, 60%-83%) for 67 patients after autograft transplantation, and 69% (95% CI, 54%-81%) for 39 patients after autologous chondrocyte implantation. The mean time to RTS ranged from 13 to 26 weeks, although no pooling was possible for this outcome measure.

CONCLUSION

Different surgical treatment options for talar OCDs allow for adequate RTS times and rates. RTS rates decreased when considering patients' return to preinjury levels versus return at any level.

Surgical repair of osteochondral lesions of the talus using biologic inlay osteochondral reconstruction: Clinical outcomes after treatment using a medial malleolar osteotomy approach compared to an arthroscopically-assisted approach

BACKGROUND

Surgical treatment of osteochondral lesions of the talus affecting the medial aspect of the talar dome is typically performed using medial malleolar osteotomy to optimize access. This study compares clinical outcomes of lesions repaired using biologic inlay osteochondral reconstruction in patients who did or did not undergo medial malleolar osteotomy, depending on defect dimensions.

METHODS

Patients treated for osteochonral lesions of the talus through a medial mallolar approach or arthroscopically-assisted approach were prospectively followed. Assessment tools consisted of the visual analogue scale (VAS) and the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot score (AOFAS). The magnetic resonance observation of cartilage repair tissue (MOCART) score was used postoperatively.

RESULTS

Data for 24 patients (mean age 34years, mean follow-up 22 months) was analyzed. Mean preoperative/final AOFAS and VAS in those who underwent osteotomy were 57.7/81.2 and 5.7/1.9 (p<0.001), respectively. In those who underwent arthroscopically-assisted reconstruction, mean preoperative/final AOFAS and VAS were 54.4/84.0 and 7.6/2.0 (p<0.001), respectively. There was no difference in mean MOCART score (p=0.662) for those treated with osteotomy (67.3) compared to those without (70.8).

CONCLUSIONS

Osteochondral lesions of the talar dome can be treated successfully by biological inlay osteochondral reconstruction technique without medial malleolar osteotomy, with good to excellent clinical outcomes expected. MRI demonstrates good integration of the graft into surrounding tissue.

Knee-to-Talus Donor-Site Morbidity Following Autologous Osteochondral Transplantation: A Meta-Analysis with Best-case and Worst-case Analysis

BACKGROUND

Despite the promising clinical results of autologous osteochondral transplantation in the treatment of osteochondral lesions of the talus, the occurrence of knee donor-site morbidity remains a concern. However, the proportion of patients experiencing donor-site morbidity is not well established because of important variations in estimates drawn by heterogeneous studies with loss to followup, often made at short-term (< 1 year). Therefore, both a meta-analysis of studies that assumed no patients lost to followup had donor-site morbidity and assumed all patients lost to followup had donor-site morbidity may help to estimate the true risk of donor-site morbidity.

QUESTIONS/PURPOSES

To evaluate the proportion of patients who developed knee donor-site morbidity after autologous osteochondral transplantation for osteochondral lesion of the talus, by (1) meta-analysis of the proportion of patients experiencing donor-site morbidity in the best-case scenario as reported, in which no patients lost to followup were assumed to have donor-site morbidity and (2) meta-analysis of the percentage of patients who had donor-site morbidity in the worst-case scenario, in which all patients lost to followup were assumed to have donor-site morbidity and (3) present the characteristics of studies associated with the reporting of donor-site morbidity.

METHODS

A systematic search of the PubMed, Embase and The Cochrane Library databases was performed from their inception to October 2017 according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The inclusion criteria were clinical studies that reported knee donor-site morbidity after autologous osteochondral transplantation for osteochondral lesion of the talus, mean followup ≥ 1 year, full-text studies published in a peer-review journal and written in English. Quality of evidence (Case Series Quality Appraisal Checklist), sample size, mean patient age, study design, mean followup time, and observed rate of knee donor-site morbidity were evaluated. Twenty-six studies with 915 ankles (904 patients) were included in the systematic review and meta-analysis. Approximately half of the included studies were of small cohort (n < 30, 12 studies), and 12 of 26 studies did not report at all on loss to followup. In the studies that reported loss to followup (14 of 26), a total of 32 patients (35 ankles) were reported lost. Random-effects models were used to estimate the risk of donor-site morbidity as between-study heterogeneity was determined to be high in both meta-analyses that assumed that no patients lost to followup experienced donor-site morbidity (I = 82.1%) and the one that assumed all patients lost to followup experienced donor-site morbidity (I = 88.7%). Multivariable metaregression was used to estimate the association between study characteristics and the observed proportion of patients who experienced of donor-site morbidity. If there was evidence of an association between a study characteristic and proportion, a subgroup analysis was performed.

RESULTS

The estimated proportion of donor-site morbidity was 6.7% (95% confidence interval [CI], 2.8-11.8), assuming that no patients lost to followup experienced donor-site morbidity and 10.8% (95% CI, 4.8-18.3) assuming that all patients lost to followup experienced donor-site morbidity after a mean followup of 43.8 ± 24.7 months (range, 15.9-120 months). There was a negative association between study sample size and proportion of donor-site morbidity (β = -0.26; 95% CI, -0.39 to -0.12; p < 0.001 assuming that no patients lost to followup experienced donor-site morbidity and β = -0.31; 95% CI, -0.48 to -0.13; p < 0.001 assuming that all patients lost to followup experienced donor-site morbidity); that is, as study size increased, the proportion of patients reported with donor-site morbidity decreased. In larger studies (n ≥ 30), the estimated percentage of donor-site morbidity was 2.8% (95% CI, 1.2%-5.0%; I = 47.6%) assuming that no patients lost to followup experienced donor-site morbidity, and 5.0% (95% CI, 2.1%-9.0%; I = 74.5%) assuming all patients lost to followup experienced donor-site morbidity. High between-study heterogeneity (differences in methodology) could not be completely explained by variability in study sample size, mean patient age, design, or mean followup time, and may be attributable to other factors such as inconsistent definitions of donor-site morbidity.

CONCLUSIONS

The estimated proportion of donor-site morbidity after autologous osteochondral transplantation for osteochondral lesion of the talus ranged from 6.7% to 10.8% in the current meta-analysis. However, subgroup analysis demonstrated that larger studies (n ≥ 30) estimated a lower donor-site morbidity risk (< 5.0%) than smaller studies (n < 30). This estimate should be interpreted in light of the fact that nearly half of the included studies did not report on loss to followup, and so their estimates of donor-site morbidity may be low. In addition, high between-study heterogeneity and the inclusion of predominantly retrospective studies with small sample sizes likely contributed to estimates that suffered from a high risk of bias, probably in favor of the surgical treatment being studied.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Primary Versus Secondary Osteochondral Autograft Transplantation for the Treatment of Large Osteochondral Lesions of the Talus

BACKGROUND

Recent studies have reported promising clinical results after osteochondral autograft transplantation (OAT) for the treatment of large osteochondral lesions of the talus (OLT). However, no study has yet compared clinical outcomes between primary and secondary OAT for large OLT.

PURPOSE

To compare clinical outcomes among patients with large OLT who receive primary OAT versus those who receive secondary OAT after failure of marrow stimulation and to identify factors associated with clinical failure.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

From 2005 to 2014, 46 patients with large OLT (≥150 mm²) underwent OAT: 18 underwent OAT as initial surgical management (primary OAT group), and 28 patients underwent secondary OAT after failure of previous arthroscopic marrow stimulation (secondary OAT group). In both groups, OAT procedures included arthroscopic inspection and debridement of concomitant soft tissue injuries. Clinical outcomes were assessed using pain visual analog scale (VAS), the Roles and Maudsley score, Foot and Ankle Outcome Scores (FAOS), and revisional surgery rates. Factors associated with clinical failures were evaluated using bivariate and logistic regression analyses. Survival outcomes were compared using Kaplan-Meier analysis.

RESULTS

Mean follow-up time was 6 years (range, 2-10.8 years). Mean lesion size was 194.9 mm² (range, 151.7-296.3 mm²). There were no significant differences between groups in patient demographics and preoperative findings. Postoperative pain VAS, Roles and Maudsley score, FAOS, and revisional surgery rates were not significantly different at last follow-up. Prior marrow stimulation was not significantly associated with clinical failure on bivariate analysis. Lesion size greater than 225 mm² on preoperative magnetic resonance imaging was significantly associated with clinical failure. Survival probabilities from Kaplan-Meier plots were not significantly different between the primary and secondary OAT groups ( P = .947).

CONCLUSION

Clinical outcomes of patients with large OLT treated with secondary OAT after failed marrow stimulation were found to be comparable with those who were treated with primary OAT. These results may be helpful to orthopaedic surgeons deciding appropriate surgical options for patients with large OLT.

No superior treatment for primary osteochondral defects of the talus

PURPOSE

The purpose of this systematic literature review is to detect the most effective treatment option for primary talar osteochondral defects in adults.

METHODS

A literature search was performed to identify studies published from January 1996 to February 2017 using PubMed (MEDLINE), EMBASE, CDSR, DARE, and CENTRAL. Two authors separately and independently screened the search results and conducted the quality assessment using the Newcastle-Ottawa Scale. Subsequently, success rates per separate study were calculated. Studies methodologically eligible for a simplified pooling method were combined.

RESULTS

Fifty-two studies with 1236 primary talar osteochondral defects were included of which forty-one studies were retrospective and eleven prospective. Two randomised controlled trials (RCTs) were identified. Heterogeneity concerning methodological nature was observed, and there was variety in reported success rates. A simplified pooling method performed for eleven retrospective case series including 317 ankles in the bone marrow stimulation group yielded a success rate of 82% [CI 78-86%]. For seven retrospective case series investigating an osteochondral autograft transfer system or an osteoperiosteal cylinder graft insertion with in total 78 included ankles the pooled success rate was calculated to be 77% [CI 66-85%].

CONCLUSIONS

For primary talar osteochondral defects, none of the treatment options showed any superiority over others.

LEVEL OF EVIDENCE

IV.

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.

Restorative Tissue Transplantation Options for Osteochondral Lesions of the Talus: A Review

Symptomatic osteochondral lesions of the talus remain a challenging problem due to inability for cartilage lesions to heal. Numerous treatment options exist, including nonoperative management, marrow stimulating techniques, and autograft-allograft. Arthroscopic marrow stimulation forms fibrocartilage that has been shown to be biomechanically weaker than hyaline cartilage. Restorative tissue transplantation options are being used more for larger and cystic lesions. Newer biologics and particulated juvenile cartilage are currently under investigation for possible clinical efficacy. This article provides an evidenced-based summary of available literature on the use of biologics for treatment of osteochondral lesions of the talus.

Evaluation and Management of Osteochondral Lesions of the Talus

Osteochondral lesions of the talus are common injuries that affect a wide variety of active patients. The majority of these lesions are associated with ankle sprains and fractures though several nontraumatic etiologies have also been recognized. Patients normally present with a history of prior ankle injury and/or instability. In addition to standard ankle radiographs, magnetic resonance imaging and computed tomography are used to characterize the extent of the lesion and involvement of the subchondral bone. Symptomatic nondisplaced lesions can often be treated conservatively within the pediatric population though this treatment is less successful in adults. Bone marrow stimulation techniques such as microfracture have yielded favorable results for the treatment of small (<15 mm) lesions. Osteochondral autograft can be harvested most commonly from the ipsilateral knee and carries the benefit of repairing defects with native hyaline cartilage. Osteochondral allograft transplant is reserved for large cystic lesions that lack subchondral bone integrity. Cell-based repair techniques such as autologous chondrocyte implantation and matrix-associated chondrocyte implantation have been increasingly used in an attempt to repair the lesion with hyaline cartilage though these techniques require adequate subchondral bone. Biological agents such as platelet-rich plasma and bone marrow aspirate have been more recently studied as an adjunct to operative treatment but their use remains theoretical. The present article reviews the current concepts in the evaluation and management of osteochondral lesions of the talus, with a focus on the available surgical treatment options.

Knee donor-site morbidity after mosaicplasty - a systematic review

BACKGROUND

Mosaicplasty has been associated with good short- to long-term results. Nevertheless, the osteochondral harvesting is restricted to the donor-site area available and it may lead to significant donor-site morbidity.

PURPOSE

Provide an overview of donor-site morbidity associated with harvesting of osteochondral plugs from the knee joint in mosaicplasty procedure.

METHODS

Comprehensive search using Pubmed, Cochrane Library, SPORTDiscus and CINAHL databases was carried out through 10th October of 2016. As inclusion criteria, all English-language studies that assessed the knee donor-site morbidity after mosaicplasty were accepted. The outcomes were the description and rate of knee donor-site morbidity, sample's and cartilage defect's characterization and mosaicplasty-related features. Correlation between mosaicplasty features and rate of morbidity was performed. The methodological and reporting quality were assessed according to Coleman's methodology score.

RESULTS

Twenty-one studies were included, comprising a total of 1726 patients, with 1473 and 268 knee and ankle cartilage defects were included. The defect size ranged from 0.85 cm2 to 4.9 cm2 and most commonly 3 or less plugs (averaging 2.9 to 9.4 mm) were used. Donor-site for osteochondral harvesting included margins of the femoral trochlea (condyles), intercondylar notch, patellofemoral joint and upper tibio-fibular joint. Mean donor-site morbidity was 5.9 % and 19.6 % for knee and ankle mosaicplasty procedures, respectively. Concerning knee-to-knee mosaicplasty procedures, the most common donor-site morbidity complaints were patellofemoral disturbances (22 %) and crepitation (31 %), and in knee-to-ankle procedures there was a clear tendency for pain or instability during daily living or sports activities (44 %), followed by patellofemoral disturbances, knee stiffness and persistent pain (13 % each). There was no significant correlation between rate of donor-site morbidity and size of the defect, number and size of the plugs (p > 0.05).

CONCLUSIONS

Osteochondral harvesting in mosaicplasty often results in considerable donor-site morbidity. The donor-site morbidity for knee-to-ankle (16.9 %) was greater than knee-to-knee (5.9 %) mosaicplasty procedures, without any significant correlation between rate of donor-site morbidity and size of the defect, number and size of the plugs. Lack or imcomplete of donor-site morbidity reporting within the mosaicplasty studies is a concern that should be addressed in future studies.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I-IV studies.

Osteochondral Autograft Transfer Combined With Cancellous Allografts for Large Cystic Osteochondral Defect of the Talus

BACKGROUND

Large cystic osteochondral defects of the talus can be challenging to treat. This retrospective control study looked at the use of osteochondral autograft transfer combined with cancellous allograft in patients with advanced cartilage and subchondral bone damage of the talus.

METHODS

Thirteen patients were treated with large cystic osteochondral defect of the talus between February 2010 and July 2013. All of these cystic osteochondral defects were larger than 15 mm in diameter. The subchondral defects were filled with cancellous allograft and the center of the lesions were sealed with an osteochondral cylinder autograft that was harvested from the ipsilateral medial femoral condyle. The visual analog scale (VAS) score for pain during daily activities, American Orthopaedic Foot & Ankle Society Ankle and Hindfoot (AOFAS-AH) scores and subjective satisfaction survey rating were obtained. Plain radiographs and magnetic resonance imaging of the ankle were obtained before and after surgery. In 5 cases, arthroscopy was performed 12 months postoperatively, and the cartilage repair was assessed with the criteria of the International Cartilage Repair Society. Twelve patients were available for follow-up at a mean of 25.4 months (range, 18 to 48 months).

RESULTS

Average postoperative AOFAS-AH score 12 months after surgery was 88±7 compared with 64±10 preoperatively. The mean VAS score decreased from 6±1 preoperatively to 1±1 at the latest follow-up. Seven patients rated their result as excellent, 5 as good and none as fair. The radiolucent area of the cysts disappeared on the plain radiographs in all cases. The mean International Cartilage Repair Society arthroscopic score from follow-up arthroscopy was 9±1 points.

CONCLUSIONS

The use of osteochondral autograft transfer combined with cancellous allograft was an effective option for the treatment of large cystic talar osteochondral lesions.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Magnetic Resonance Imaging Evidence of Postoperative Cyst Formation Does Not Appear to Affect Clinical Outcomes After Autologous Osteochondral Transplantation of the Talus

PURPOSE

To identify potential cysts using magnetic resonance imaging (MRI) after autologous osteochondral transplantation (AOT) for osteochondral lesions of the talus (OLTs) as well as to determine the effect of cysts on short-term clinical outcomes.

METHODS

Eighty-nine MRI scans of 37 patients who had AOT for an OLT were evaluated. Radiographic variables examined included cyst presence, cyst location, bone edema, and cartilage integrity. Patient clinical variables recorded and examined for association with the presence of a cyst included gender, age, preoperative lesion size, size and number of osteochondral graft used, symptoms reported, and pre- and postoperative Foot and Ankle Outcome Score (FAOS) and Short Form-12 (SF-12) scores measured at final follow-up.

RESULTS

Twenty-four patients (64.8%) had MRI evidence of cystic change after AOT for an OLT at a mean MRI follow-up time of 15 months after surgery (range 2-54). Patients with presence of a cyst after surgery were older (mean age, 42.7 years) than those without cysts (mean age, 32.7 years) (P = .041), and among patients with a cyst, older patients more often had involvement of the subchondral plate (57.3 v 36.7 years) (P < .001). No other variables associated with cyst formation had statistical significance. Mean patient FAOS scores increased from 50 (±19) preoperatively to 87 (±8) postoperatively. Mean SF-12 scores increased from 52 (±18) preoperatively to 85 (±6) postoperatively. Patients not identified as having a cyst had lower SF-12 (P = .028) and FAOS (P = .032) preoperative scores and more improvement in SF-12 (P = .006) and FAOS (P = .016) scores than patients with cysts.

CONCLUSIONS

Postoperative cyst formation on MRI was found to be a common occurrence after AOT for OLT. Although increasing age was related to increased cyst prevalence, the clinical impact of cyst formation was not found to be significant at short-term follow-up. Continued long-term longitudinal follow-up of postoperative cysts is needed.

LEVEL OF EVIDENCE

Level IV, prognostic case series.

Low Level of Evidence and Methodologic Quality of Clinical Outcome Studies on Cartilage Repair of the Ankle

PURPOSE

To examine the level of evidence and methodologic quality of studies reporting surgical treatments for osteochondral lesions of the ankle.

METHODS

A search was performed using the PubMed/Medline, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Cochrane databases for all studies in which the primary objective was to report the outcome after surgical treatment of osteochondral lesions of the ankle. Studies reporting outcomes of microfracture, bone marrow stimulation, autologous osteochondral transplantation, osteochondral allograft transplantation, and autologous chondrocyte implantation were the focus of this analysis because they are most commonly reported in the literature. Two independent investigators scored each study from 0 to 100 based on 10 criteria from the modified Coleman Methodology Score (CMS) and assigned a level of evidence using the criteria established by the Journal of Bone and Joint Surgery. Data were collected on the study type, year of publication, number of surgical procedures, mean follow-up, preoperative and postoperative American Orthopaedic Foot & Ankle Society score, measures used to assess outcome, geography, institution type, and conflict of interest.

RESULTS

Eighty-three studies reporting the results of 2,382 patients who underwent 2,425 surgical procedures for osteochondral lesions of the ankle met the inclusion criteria. Ninety percent of studies were of Level IV evidence. The mean CMS for all scored studies was 53.6 of 100, and 5 areas were identified as methodologically weak: study size, type of study, description of postoperative rehabilitation, procedure for assessing outcome, and description of the selection process. There was no significant difference between the CMS and the type of surgical technique (P = .1411). A statistically significant patient-weighted correlation was found between the CMS and the level of evidence (r = -0.28, P = .0072). There was no statistically significant patient-weighted correlation found between the CMS and the institution type (r = 0.05, P = .6480) or financial conflict of interest (r = -0.16, P = .1256).

CONCLUSIONS

Most studies assessing the clinical outcomes of cartilage repair of the ankle are of a low level of evidence and of poor methodologic quality.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I through IV studies.

Topographic variations in biomechanical and biochemical properties in the ankle joint: an in vitro bovine study evaluating native and engineered cartilage

PURPOSE

The purposes of this study were to identify differences in the biomechanical and biochemical properties among the articulating surfaces of the ankle joint and to evaluate the functional and biological properties of engineered neocartilage generated using chondrocytes from different locations in the ankle joint.

METHODS

The properties of the different topographies within the ankle joint (tibial plafond, talar dome, and distal fibula) were evaluated in 28 specimens using 7 bovine ankles; the femoral condyle was used as a control. Chondrocytes from the same locations were used to form 28 neocartilage constructs by tissue engineering using an additional 7 bovine ankles. The functional properties of neocartilage were compared with native tissue values.

RESULTS

Articular cartilage from the tibial plafond, distal fibula, talar dome, and femoral condyle exhibited Young modulus values of 4.8 ± 0.5 MPa, 3.9 ± 0.1 MPa, 1.7 ± 0.2 MPa, and 4.0 ± 0.5 MPa, respectively. The compressive properties of the corresponding tissues were 370 ± 22 kPa, 242 ± 18 kPa, 255 ± 26 kPa, and 274 ± 18 kPa, respectively. The tibial plafond exhibited 3-fold higher tensile properties and 2-fold higher compressive and shear moduli compared with its articulating talar dome; the same disparity was observed in neocartilage. Similar trends were detected in biochemical data for both native and engineered tissues.

CONCLUSIONS

The cartilage properties of the various topographic locations within the ankle are significantly different. In particular, the opposing articulating surfaces of the ankle have significantly different biomechanical and biochemical properties. The disparity between tibial plafond and talar dome cartilage and chondrocytes warrants further evaluation in clinical studies to evaluate their exact role in the pathogenesis of ankle lesions.

CLINICAL RELEVANCE

Therapeutic modalities for cartilage lesions need to consider the exact topographic source of the cells or cartilage grafts used. Furthermore, the capacity of generating neocartilage implants from location-specific chondrocytes of the ankle joint may be used in the future as a tool for the treatment of chondral lesions.

Osteochondritis dissecans of the ankle in children and adolescents: demographics and epidemiology

BACKGROUND

Osteochondritis dissecans (OCD) of the ankle is a disorder of the talar or distal tibial subchondral bone and articular cartilage whose incidence in children is not clearly known.

PURPOSE

To assess the demographics and epidemiology of OCD of the ankle in children.

STUDY DESIGN

Descriptive epidemiologic study.

METHODS

A retrospective chart review of an integrated health system was conducted on patients with ankle OCD aged 2 to 19 years from 2007 to 2011, with >1 million patients in this cohort. Lesion location, laterality, and all patient demographics were recorded. Ankle OCD incidence was determined for the group as a whole and by both sex and age group (divided into age groups of 2-5, 6-11, and 12-19 years). The risk for ankle OCD for age group, sex, and ethnicity was assessed using multivariate logistic regression models.

RESULTS

A total of 85 patients fit the inclusion criteria, and 71.8% of lesions found were in the medial talus, 56.5% of lesions were right sided, and none were bilateral. No ankle OCD lesions were found in 2- to 5-year-olds. The incidence of ankle OCD in patients aged 6 to 19 years was 4.6 per 100,000 overall and 3.2 and 6.0 per 100,000 for male and female patients, respectively. Patients aged 12 to 19 years represented the vast majority of those with OCD, with an incidence of 6.8 per 100,000 compared with 1.1 per 100,000 in those 6 to 11 years of age. In those aged 6 to 11 and 12 to 19 years, female patients had a respective incidence of 1.5 and 8.9 per 100,000, whereas male patients had a respective incidence of 0.7 and 4.8 per 100,000. The overall female/male ratio of ankle OCD was 1.6:1. Multivariate logistic regression analysis revealed a 6.9 times increased risk for ankle OCD in patients aged 12 to 19 years compared with those aged 6 to 11 years (95% CI, 3.8-12.5; P < .0001), and female patients had a 1.5 times greater risk for ankle OCD than male patients (95% CI, 1.0-2.3; P = .06). On the basis of race and ethnicity, non-Hispanic whites had the highest relative risk for disease and African Americans the lowest risk.

CONCLUSION

In this population-based cohort study of pediatric ankle OCD, female patients had a greater incidence of OCD and a 1.5 times greater risk for ankle OCD compared with male patients. Teenagers had nearly 7 times the risk for ankle OCD compared with children 6 to 11 years of age.

Bony periosteum-covered iliac crest plug transplantation for severe osteochondral lesions of the talus: a modified mosaicplasty procedure

PURPOSE

This study reports first evidence of a modified procedure for osteochondral autologous transplantation where bony periosteum-covered plugs are harvested at the iliac crest and transplanted into the talar osteochondral lesion.

METHODS

Thirteen out of 14 patients, average age 39.6 (SD 14.4) years, were followed clinically and radiographically for a median of 25 (24-28) months (minimal follow-up, 24 months).

RESULTS

For these 13 patients, the American Orthopaedic Foot and Ankle Society hindfoot score increased from 47 (SD 11) points pre-operatively, to 81 (SD 14) points postoperatively (p < 0.0001). The average pain score decreased from 6.6 (SD 1.3) points pre-operatively, to 1.4 (SD 1.9) points postoperatively (p < 0.0001). Seven patients returned to sports activity. Radiographically good plug osteointegration was observed in nine out of 11 ankles. Follow-up arthroscopy showed fibrous cartilage in four ankles, periosteum hypertrophy in five ankles, and partial or total missing of coverage of the bone in three ankles. Three revision surgeries had to be performed.

CONCLUSIONS

This modified mosaicplasty might be recommended for severe and recurrent osteochondral lesions of the talus and may lead to restoration of the subchondral bone stock, formation of fibro-cartilage, and stable joint function.

LEVEL OF EVIDENCE

IV.

An anterior ankle arthroscopic technique for retrograde osteochondral autograft transplantation of posteromedial and central talar dome cartilage defects

PURPOSE

The purpose of this study was to present an arthroscopic technique for the treatment for posteromedial and central cartilage defects of the talus using anterior arthroscopic portals and without performing a medial malleolar osteotomy.

METHODS

Nine fresh cadavers were dissected. Autografts were implanted under arthroscopy using a retrograde osteochondral transplantation system, and their position was estimated using specific angular calibrators and later confirmed by software analysis of two photographs of the disarticulated ankle joint.

RESULTS

In eight cases, the congruence between the surrounding articular cartilage and the cartilage of the graft was high, with differences measuring <1 mm. There were no iatrogenic cartilage lesions of the tibial plafond and no fractures of the talus. All the autografts remained stable during full range of motion cycles of the ankle joint. One failure was reported.

CONCLUSION

This cadaveric study showed that the retrograde osteochondral autograft transplantation technique in the talus is feasible. It can be used to restore the posteromedial and central talar articular surfaces using conventional ankle arthroscopic instrumentation and anterior arthroscopic portals without resorting to a medial malleolar osteotomy. Further clinical and biomechanical studies are required to prove the efficacy of this technique and its reproducibility in routine clinical practice.

Technique: Osteochondral Grafting of Capitate Chondrosis in PRC

Background Proximal row carpectomy (PRC) is a useful treatment option for wrist arthritis, but the operation is contraindicated when there is arthritis of the capitate head. We describe a technique that involves resurfacing of a capitate that has focal chondrosis, using an osteochondral graft harvested from the resected carpal bones. Materials and Methods PRC patients who had a focal area of capitate chondrosis underwent osteochondral grafting of the capitate. Pre- and postoperative pain level, employment status, motion, grip strength, and Modified Mayo Wrist Scores (MMWS) were assessed. Postoperative Disability of the Arm, Shoulder, and Hand (DASH) scores were also calculated. Description of Technique The articular surface of the capitate is assessed for need for grafting. The proximal row is resected with the lunate removed intact. The arthritic area is prepared. The graft is taken from the lunate and placed in the prepared site of the capitate. Results Eight patients (average age of 53 years) were followed for 18 months. Pain: Preoperatively, moderate to severe in 7 patients; postoperatively, mild to no pain in 7 patients. Motion: Preoperative, 84° (74% of the contralateral side); postoperative 75° (66%). Grip Strength: Preoperative, 29 kg (62%); postoperative, 34 kg (71%). Mayo Wrist Score: Preoperative, 51 (poor); postoperative, 68 (fair). Average postoperative DASH score was 19.5. Follow-up radiographs showed that 75% of patients had mild to no degeneration. Conclusions Osteochondral grafting in PRC offers satisfactory results in terms of pain relief, return to work, motion, and grip strength. Level of Evidence Therapeutic IV, Case series.

A systematic review on the reporting of outcome data in studies on autologous osteochondral transplantation for the treatment of osteochondral lesions of the talus

PURPOSE

The purpose of this study was to systematically review studies on autologous osteochondral transplantation (AOT) for osteochondral lesions (OCLs) of the talus and descriptively analyze the outcome data reported to determine whether it is consistent from one study to another and able to be pooled for systematic review.

METHODS

A systematic electronic search was performed using the MEDLINE and EMBASE databases. Studies that were published between January 1966 and June 2011 were included in the review. Only studies that reported data specifically on AOT for treatment of OCLs of the talus and written in English were included in this review. A predefined data sheet with 36 variables was created, and it was determined whether or not each of those variables were reported or not reported. The 36 variables were then grouped into 6 categories, and the categorical means were reported.

RESULTS

A total of 20 studies were included in this systematic review. The categories of general demographics and study design were generally well reported (each more than 80% of studies). Patient-reported outcomes and clinical variables were reported less in 73% and 67% of studies, respectively. The least-reported categories were patient history (45%) and imaging data (49%).

CONCLUSIONS

Inconsistencies and an underreporting of data were apparent between studies, such that pooling was deemed not possible. An effort must be made by investigators to ensure that there is adequate reporting of data in studies of AOT treatment for OCLs of the talus.

Managing the cystic osteochondral defect: allograft or autograft

Osteochondral lesions of the talus are generally benign, and many heal or are not symptomatic. A subset of these defects progress to large cystic lesions, which have a less favorable prognosis. The treatment options are joint preservation or sacrifice. Joint salvage entails marrow stimulation techniques or hyaline cartilage replacement with allograft or autograft. When lesions reach greater than 3 cm(2) or Raikin class IV or become uncontained on the shoulders of the talus, autografting techniques become more challenging. Osteochondral allografting may be a better surgical option, often achievable without a malleolar osteotomy for exposure.

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

In this article, our research on osteochondral lesions of the talus (OLTs) is summarized, the orthopedic literature is reviewed, and the direction of future research and treatment trends are discussed. Our research has explored the role of lesion size, significance of marrow edema, relationship of patient age, importance of lesion containment, and role of a stable cartilage lesion cap in the prognosis and outcomes of these lesions. We have identified smaller sized lesions, younger patients and contained lesions as independent predictors of success for the operative treatment of OLTs. Our data should facilitate the development of a more comprehensive treatment algorithm to more accurately predict success in operative management of these lesions.

The use of fibrin matrix-mixed gel-type autologous chondrocyte implantation in the treatment for osteochondral lesions of the talus

PURPOSE

This study assessed the clinical results and second-look arthroscopy after fibrin matrix-mixed gel-type autologous chondrocyte implantation to treat osteochondral lesions of the talus.

METHODS

Chondrocytes were harvested from the cuboid surface of the calcaneus in 38 patients and cultured, and gel-type autologous chondrocyte implantation was performed with or without medial malleolar osteotomy. Preoperative American orthopedic foot and ankle society ankle-hind foot scores, visual analogue score, Hannover scoring system and subjective satisfaction were investigated, and the comparison of arthroscopic results (36/38, 94.7 %) and MRI investigation of chondral recovery was performed. Direct tenderness and relationship to the active daily life of the donor site was evaluated.

RESULTS

The preoperative mean ankle-hind foot scores (71 ± 14) and Hannover scoring system (65 ± 10) had increased to 91 ± 12 and 93 ± 14, respectively, at 24-month follow-up (p < 0.0001), and the preoperative visual analogue score of 58 mm had decreased to 21 mm (p < 0.0001). Regarding subjective satisfaction, 34 cases (89.5 %) reported excellent, good or fair. Chondral regeneration was analysed by second-look arthroscopy and MRI. Complications included one non-union and two delayed-unions of the osteotomy sites, and 9 ankles (9/31, 29.0 %) sustained damaged medial malleolar cartilage due to osteotomy. Marked symptoms at the biopsy site did not adversely affect the patient's active daily life.

CONCLUSIONS

Fibrin matrix-mixed gel-type autologous chondrocyte implantation using the cuboid surface of the calcaneus as a donor can be used for treating osteochondral lesions of the talus.

Factors associated with the clinical outcomes of the osteochondral autograft transfer system in osteochondral lesions of the talus: second-look arthroscopic evaluation

BACKGROUND

Identifying factors associated with the clinical outcomes of the osteochondral autograft transfer system would be helpful for treating patients with an osteochondral lesion of the talus.

PURPOSE

To investigate the clinical and second-look arthroscopic results of the osteochondral autograft transfer system and to identify the prognostic factors associated with this procedure.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

The authors retrospectively evaluated 52 ankles that underwent osteochondral autograft transfer for a medial osteochondral lesion of the talus. Second-look arthroscopies were performed at a mean of 13.1 months postoperatively. Clinical outcomes were evaluated according to a visual analog scale (VAS) for pain, American Orthopaedic Foot and Ankle Society (AOFAS) score, and the Tegner activity scale. Statistical analyses were performed to identify various prognostic factors associated with the clinical outcomes.

RESULTS

The mean VAS, AOFAS, and Tegner activity scale scores were all significantly improved from 6.9 ± 0.9 to 3.3 ± 1.4 (VAS), from 67.4 ± 4.9 to 82.6 ± 7.8 (AOFAS), and from 3.0 ± 0.8 to 3.9 ± 0.9 (Tegner; P < .05). Regarding overall patient satisfaction with the operation, 49 (95%) patients reported good to excellent results. Prognostic factors including the patient's age, sex, body mass index, duration of symptoms, defect size and depth, location of osteochondral lesion of the talus, and the existence of a subchondral cyst did not significantly influence clinical outcomes (P > .05), except for body mass index on the Tegner activity scale score (P = .021). Significant differences were observed among clinical outcomes for second-look arthroscopy according to the presence of soft tissue impingement and uncovered areas around the graft (P < .05). The VAS and AOFAS score at the last follow-up were significantly worse when the articular surface of the tibial plafond at the malleolar osteotomy site was uneven (P = .031 and .012, respectively).

CONCLUSION

This study showed that the articular surface of the tibial plafond at the malleolar osteotomy site, soft tissue impingement, and uncovered areas around the graft were important factors affecting the clinical outcomes, as observed through second-look arthroscopy. Therefore, surgeons should restore the articular surface accurately after the osteotomy, and more caution should be taken to avoid soft tissue impingement and uncovered areas around the graft when performing osteochondral autograft transfer.

Open mosaicplasty in osteochondral lesions of the talus: a prospective study

Osteochondral lesions of the talus present with symptoms of pain and painful motion, affecting the quality of the patient's daily life. We evaluated the 2-year short-term outcomes of patients whose large osteochondral lesions of the talus were treated with medial malleolar osteotomy and a mosaic graft harvested from the knee on the same side. A total of 32 patients who had cartilage lesions due to osteochondritis dissecans in the medial aspect of the talus underwent mosaicplasty after medial malleolar osteotomy. The patients were followed up for a mean period of 16.8 (range 12 to 24) months. The staging and treatment plan of the osteochondral lesions of the talus were made according to the Bristol classification. The follow-up protocol for the patients included direct radiography and magnetic resonance imaging. The American Orthopaedic Foot and Ankle Society scoring system was used to assess the patients during the pre- and postoperative periods. Of the 32 patients, 3 (9.4%) were female and 29 (90.6%) male, with a mean age of 27.5 (range 20 to 47) years. The mean preoperative American Orthopaedic Foot and Ankle Society score was 59.12 ± 7.72 but had increased to 87.94 ± 3.55 during the postoperative 2 years. The increase in American Orthopaedic Foot and Ankle Society score was statistically significant (p < .05). We have concluded that open mosaicplasty is a reliable and effective method for the treatment of osteochondral lesions with subchondral cyst formation in the talus, exceeding 1.5 cm in diameter.

Intermediate outcomes of fresh talar osteochondral allografts for treatment of large osteochondral lesions of the talus

BACKGROUND

Large osteochondral defects of the talus present a treatment challenge. Fresh osteochondral allograft transplantation can be used for large lesions without the donor-site morbidity associated with other procedures such as autologous chondrocyte implantation or osteochondral autograft transfer. The goal of this study was to prospectively evaluate the intermediate outcomes of fresh osteochondral allografting for osteochondral lesions of the talus with use of validated outcome measures.

METHODS

Sixteen patients (seventeen ankles) received a fresh osteochondral allograft, and all sixteen were available for follow-up. Data were prospectively collected with use of the Ankle Osteoarthritis Scale (AOS), Short Form-36 (SF-36), and American Academy of Orthopaedic Surgeons (AAOS) Foot and Ankle Module outcome measures. Postoperative American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot scale scores were also collected. All sixteen patients underwent radiographic and computed tomographic (CT) analyses preoperatively, and fifteen patients had these studies postoperatively.

RESULTS

The average duration of follow-up was 4.1 years. The latest follow-up CT evaluation identified failure of graft incorporation in two of sixteen ankles. Osteolysis, subchondral cysts, and degenerative changes were found in five, eight, and seven ankles, respectively. Five ankles were considered failures, and two required a reoperation because of ongoing symptoms. The AOS Disability and the AAOS Foot and Ankle Core Scale scores significantly improved, but there was no significant change in the AOS Pain, AAOS Foot and Ankle Shoe Comfort Scale, or SF-36 scores. Overall, ten patients had a good or excellent result; however, persistent symptoms remained in six of these patients. Only four were symptom-free.

CONCLUSION

The use of a fresh osteochondral allograft is a reasonable option for the treatment of large talar osteochondral lesions. The high reoperation rate (two of seventeen) and failure rate (five of seventeen) must be taken into consideration when one is choosing this procedure for the management of these lesions.

Synthetic osteochondral grafting of ankle osteochondral lesions

BACKGROUND

The treatment of osteochondral lesions, especially those with a cystic component or those that have failed the standard arthroscopic procedures can be challenging. Synthetic grafts have several potential advantages over other second line treatments including the fact that only one operation is required and no other joint is violated.

METHOD

We report the results of the first series of synthetic grafts used in the treatment of osteochondral lesions of the ankle with a minimum of one year follow up.

RESULTS

There was significant improvement in the American Orthopaedic Foot & Ankle Society (AOFAS) Hindfoot and Ankle Osteoarthritis Scale (AOS) scores and all patients were satisfied with the results of surgery. Magnetic Resonance Imaging (MRI) scans at one year have demonstrated resolution of the bony cysts and surrounding bone marrow oedema but, worryingly, continued to show high signal on the T2 weighted images within the plugs themselves. Qualitative T2 mapping has suggested a fibrous rather than hyaline appearance of the cartilage portions of the plugs.

CONCLUSIONS

The clinical results have been encouraging but more patients and longer follow up are required before firm conclusions can be drawn.

Osteochondral lesions of the talus: effect of defect size and plantarflexion angle on ankle joint stresses

BACKGROUND

Osteochondral lesions of the talus (OLTs) are a common cause of ankle pain and disability. Current clinical guidelines favor autogenous or allogenic osteochondral grafting procedures for lesions larger than 10 mm in diameter because of increased failure rates in these larger lesions with arthroscopic debridement, curettage, and microfracture. There are currently no biomechanical data nor level I clinical data supporting this size threshold.

PURPOSE

The purpose of this study was to determine the effect of OLT defect size on stress concentration, rim stress, and location of peak stress and whether a threshold defect size exists.

STUDY DESIGN

Descriptive laboratory study.

METHODS

Progressively larger medial OLTs were created (6, 8, 10, and 12 mm) in 8 fresh-frozen cadaveric ankle joints. With a calibrated Tekscan pressure sensor in the tibiotalar joint, an axial load of 686 N was applied, and pressure was recorded in neutral and 15° of plantar flexion with each defect size. Peak stress, contact area, peak and average rim stresses, and location of peak stress were determined.

RESULTS

The distance between peak stress and defect rim was significantly decreased with increasing defect size for lesions of 10 mm and larger. Total tibiotalar contact area was significantly decreased with increasing defect size and with ankle plantar flexion. While peak joint stress and peak rim stress were not affected by defect size or plantar flexion, average rim stress was significantly increased by plantar flexion.

CONCLUSION

Reduction in contact area and shift in the location of peak stress with increasing defect size may contribute to articular cartilage degeneration, pain, and defect enlargement in patients with OLTs. There appears to be a threshold of 10 mm after which the distance between the rim of the defect and the peak stress decreases; however, there is no change in peak stress magnitude with increasing defect size.

CLINICAL RELEVANCE

The location of peak stress in the ankle joint becomes closer to the rim of the defect in OLTs at a threshold of 10 mm and greater in diameter. These data may have implications toward OLT size thresholds for surgical decision making in symptomatic lesions (ie, primary osteochondral transplantation procedure vs curettage and debridement). The ultimate goal is to determine whether there is a threshold defect size for primary osteoarticular graft techniques.

Arthroscopic autologous chondrocyte implantation in osteochondral lesions of the talus: mid-term T2-mapping MRI evaluation

PURPOSE

Autologous chondrocyte implantation (ACI) in the ankle has become an established procedure to treat osteochondral lesions. However, a non-invasive method able to provide information on the nature of the repair tissue is needed. Recently, MRI T2 mapping was identified as a method capable of qualitatively characterizing articular cartilage. The aim of this study was to evaluate the mid-term results of a series of patients arthroscopically treated by ACI and investigate the nature of the repair tissue by MRI T2 mapping.

METHODS

Twenty patients, aged 35 ± 8 years, with an osteochondral lesion of the talus, underwent ACI and were evaluated at 5 ± 1 years' follow-up clinically (AOFAS score) and by the MRI T2-mapping sequence. MRI images were acquired using a protocol proposed by the International Cartilage Repair Society, evaluated by the MOCART score and completed by the T2-mapping sequence. Healthy volunteers, mean age 29 ± 6 years, were enrolled, and their T2 map values were used as a control. Their MRI results were then correlated with the clinical score.

RESULTS

The AOFAS score increased from 59 ± 16 pre-operatively to 84 ± 18 at follow-up (P < 0.0005). Patients with more than 4 years' follow-up were found to have the most satisfactory results. On the basis of the controls, healthy hyaline cartilage tissue showed a T2 map value of 35-45 ms. A mean T2 map value compatible with normal hyaline cartilage was found in all the cases treated, covering a mean percentage of 69% ± 22 of the repaired lesion area.

CONCLUSIONS

ACI was able to provide durable results that improved over time. Because of its ability to detect cartilage quality, the MRI T2-mapping sequence integrated with the Mocart score is a valid, non-invasive technique in evaluating the nature of the repair tissue in the ankle joint.

LEVEL OF EVIDENCE

Therapeutic study, Level IV.

Effectiveness of composite bone graft substitute plugs in the treatment of chondral and osteochondral lesions of the talus

A review of outcomes in 13 patients with talar dome osteochondral or chondral lesions treated with a bone graft substitute plug was undertaken in an effort to evaluate its effectiveness in comparison with other reported surgical techniques. Mean patient age was 36.4 (range 16 to 57) years. Mean follow-up was 30.1 (range 7 to 43) months. Medial malleolar osteotomy was performed in 9 (69.23%) cases. Average defect diameter was 9.8 (range 5 to 20) mm. Pain decreased significantly from 6.2 (range 3 to 9) to 4.0 (range 0 to 9) (P = .009). Postoperative American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scores averaged 67.3 (range 26 to 100). Younger age, smaller defect size, and avoidance of medial malleolar osteotomy resulted in better outcomes. Mean Short Form-36 scores for the study group fell below US norms in all categories, and 12 (92.31%) ankles demonstrated persistent lesions radiographically. Postoperative magnetic resonance imaging in 2 (15.39%) patients demonstrated enlarged lesions, and 4 (30.77%) patients underwent revision surgery that revealed abnormal cartilage around the implant site. Complications included 1 (7.69%) deep venous thrombosis, 1 (7.69%) arthrofibrosis, and 1 (7.69%) superficial neuritis. Despite some improvement in pain, comparison of functional outcome showed bone graft substitute plug implantation to be less effective overall than other operative interventions. Future investigations with more specific selection criteria are warranted to gain further insight into the efficacy of these bone graft substitute plugs.

Osteocartilaginous lesions of the talus in soccer players

OBJECTIVE

The objective of this study is to describe the results of arthroscopic debridement for talar lesions in a population of soccer players.

PATIENTS

Patients were sixteen soccer players with osteochondral talar lesions, treated surgically between 1999 and 2004.

INTERVENTIONS

All patients were diagnosed clinically. Complementary imaging studies included X-ray, scintigraphy, and magnetic resonance imaging. All patients underwent arthroscopic debridement.

MAIN OUTCOME MEASUREMENTS

At 3.56 years of follow up, patient status was assessed using a visual analog scale (VAS) and the Ogilvie-Harris scale. The mean time to return to sports at the same level as that before the start of symptoms was evaluated.

RESULTS

The Ogilvie-Harris score showed 81.75% excellent results and 18.25% good results. The VAS score was 0.26 (0-2.2). Among the total, 93.75% of patients resumed sports activities at the same level as that before surgery.

CONCLUSIONS

Arthroscopic debridement of talar osteochondral lesions in soccer players provides excellent results. We consider this option the treatment of choice in this population.

Treatment of osteochondral lesions of the talus: a systematic review

The aim of this study was to summarize all eligible studies to compare the effectiveness of treatment strategies for osteochondral defects (OCD) of the talus. Electronic databases from January 1966 to December 2006 were systematically screened. The proportion of the patient population treated successfully was noted, and percentages were calculated. For each treatment strategy, study size weighted success rates were calculated. Fifty-two studies described the results of 65 treatment groups of treatment strategies for OCD of the talus. One randomized clinical trial was identified. Seven studies described the results of non-operative treatment, 4 of excision, 13 of excision and curettage, 18 of excision, curettage and bone marrow stimulation (BMS), 4 of an autogenous bone graft, 2 of transmalleolar drilling (TMD), 9 of osteochondral transplantation (OATS), 4 of autologous chondrocyte implantation (ACI), 3 of retrograde drilling and 1 of fixation. OATS, BMS and ACI scored success rates of 87, 85 and 76%, respectively. Retrograde drilling and fixation scored 88 and 89%, respectively. Together with the newer techniques OATS and ACI, BMS was identified as an effective treatment strategy for OCD of the talus. Because of the relatively high cost of ACI and the knee morbidity seen in OATS, we conclude that BMS is the treatment of choice for primary osteochondral talar lesions. However, due to great diversity in the articles and variability in treatment results, no definitive conclusions can be drawn. Further sufficiently powered, randomized clinical trials with uniform methodology and validated outcome measures should be initiated to compare the outcome of surgical strategies for OCD of the talus.

Fresh osteochondral allografts for large-volume cystic osteochondral defects of the talus

BACKGROUND

Large-volume osteochondral lesions of the talus present a difficult dilemma for the treating physician. The purpose of this study was to evaluate the clinical outcomes of talar lesions with a volume of >3000 mm(3) treated with fresh bulk osteochondral allograft transplantation.

METHODS

Fifteen patients (mean age, 41.9 years) who had symptomatic osteochondral lesions of the talus with a mean volume of 6059 mm(3) underwent fresh matched osteochondral allograft transplantation. All patients were followed prospectively for a minimum of two years and were evaluated with use of the pain score on a visual analog scale, which ranged from 0 to 10, and the American Orthopaedic Foot and Ankle Society ankle-hindfoot score, which had a maximum of 100 points. Patient satisfaction and radiographic stability of the graft were also assessed.

RESULTS

All patients were available for follow-up at an average fifty-four months after surgery. Two ankles subsequently underwent conversion to an ankle arthrodesis at thirty-two and seventy-six months, respectively. With the scores for these patients included (at the time of arthrodesis), the mean pain score had improved from 8.5 to 3.3 and the mean American Orthopaedic Foot and Ankle Society ankle-hindfoot score had improved 45 points, from 38 to 83 points. Overall, five patients rated the result as excellent, six as good, two as fair, and two as poor.

CONCLUSIONS

Bulk fresh osteochondral allograft transplantation to the talus is a viable reconstructive option for patients with large-volume cystic lesions of the talar dome. Graft stability and viability are maintained both structurally and functionally over a mean follow-up period of 4.5 years (minimum, two years).

Knee-to-ankle mosaicplasty for the treatment of osteochondral lesions of the ankle joint

BACKGROUND

Osteochondral lesions are frequently seen in athletes after ankle injuries. At this time, osteochondral autologous transplantation (OATS, mosaicplasty) is the only surgical treatment that replaces the entire osteochondral unit in symptomatic lesions.

PURPOSE

To evaluate the clinical and radiological midterm to long-term outcome of ankles treated with knee-to-ankle mosaicplasty.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Clinical evaluation consisted of patient satisfaction, pain evaluation (visual analog scale [VAS]), American Orthopaedic Foot and Ankle Society (AOFAS) ankle score, sports activity score, range of motion, the radiological evaluation of magnetic resonance imaging (MRI), and single photon emission computed tomography-computed tomography (SPECT-CT) analysis of both the ankle and the knee joint.

RESULTS

Twelve of 21 patients (mean age, 43 years; male, 8; female, 4) were available for latest follow-up (mean, 72 months). At follow-up, patients reported a satisfaction rate of good to excellent in 92% (n = 11) and poor in 8% (n = 1). The average VAS pain score was 3.9 (preoperative, 5.9; P = .02), AOFAS ankle score significantly increased from 45.9 to 80.2 points (P < .0001), sports activity score remained significantly decreased with 1.25 (preinjury level, 2.3; P = .035), and ankle dorsiflexion was significantly reduced (P = .003). Knee pain was reported in 6 patients (50%). Radiologically, recurrent lesions were found in 10 of 10 cases (100%) and some degree of cartilage degeneration and discontinuity of the subchondral bone plate in 100%.

CONCLUSION

Indications for mosaicplasty with a plug transfer from the knee to the talus must be considered carefully, as at midterm, moderate outcome and considerable donor-site morbidity may be found.