Location Distribution of 2,087 Osteochondral Lesions 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.

Anatomical factors in the development of medial-sided osteochondral lesion of the talus: a comparative analysis

PURPOSE

The aim of this study was to determine anatomical predictors for the occurrence of medial osteochondral lesions of the talus (OLT), by analyzing morphometric variables obtained from magnetic resonance imaging (MRI).

METHODS

A total of 430 ankles with 215 ankle MRIs from patients with nontraumatic OLTs on the medial side of the talar dome and an equal number of age, sex, and side-matched healthy controls were analyzed in this retrospective study. The specific MRI parameters that were measured include the anterior opening angle of the talus (AOT), the angle between the tibial axis and medial malleolus (TMM), the angle of the tibial plafond to the malleoli (PMA), the angle between the anterior and posterior talofibular ligaments (ATFL-PTFL angle), length of the trochlea tali arc (TAL), sagittal length of distal tibial articular surface (TAS), the ratio of the sagittal length of distal tibial articular surface to the length of the trochlea tali arc (TAS/TAL), and the depth of the incisura fibularis (IncDep).

RESULTS

AOT, IncDep, ATFL-PTFL angle, PMA, TMM, TAL, and TAS/TAL exhibited significant differences between the two groups. The established cut-off values were 13° (AUC 0.875) for AOT, 3.7 mm (AUC 0.565) for IncDep, 78° (AUC 0.729) for ATFL-PTFL angle, 14° (AUC 0.581) for PMA, 15° (AUC 0.907) for TMM, 34.3 mm (AUC 0.599) for TAL, and 0.81 (AUC 0.719) for TAS/TAL. Multivariate logistic regression analysis revealed Odds Ratio (OR) = 22.22 for AOT > 13°, OR = 4.23 for ATFL-PTFL angle > 78°, OR = 1.99 for PMA ≤ 14°, OR = 31.598 for TMM > 15°, OR = 3.79 for TAS/TAL ≤ 0.81.

CONCLUSION

This study highlights the significance of anatomical parameters, particularly the TMM and AOT, as key predictors of OLT.

Personalized Resurfacing for Osteochondral Lesions of the Talus

Osteochondral lesions of the talus (OLTs) are the most common cause of chronic deep ankle pain. Joint-preserving surgeries include bone marrow stimulating, chondral transporting, and cellular-based procedures. Each procedure has its advantages and disadvantages. For that reason, a focal metallic inlay was developed as a bridge between biologics and conventional joint arthroplasty. Despite promising initial results, prefabricated implants are associated with unpredictable results. This article describes a novel customized patient-specific metal inlay as a treatment option for OLTs.

Osteochondral Lesion of the Talus: Quality of Life, Lesion Site, and Lesion Size

Osteochondral lesions of the talus (OLTs) are the lesions that affect the articular cartilage and the subchondral bone of the talus. Symptoms develop between 6 and 12 months after the index trauma and are associated with degradation of quality of life. Two-thirds of the lesions (73%) are located on the medial part of the talus, 28% of the lesions are posteromedial, and 31% of the lesions are centromedial. Currently, OLT of up to 100 mm2 can behave in a more indolent condition, and above that area, the defect tends to transmit more shearing forces to adjacent cartilage and is more symptomatic.

Ankle Cartilage: Chondral and Osteochondral Lesions: A Further Dive into the Incidence, Terminology, and the Cartilage Cascade

The current concepts thoroughly highlight the ankle cartilage cascade focusing on the different stages and the different etiologic factors that can introduce a patient into the cascade. Moreover, the authors will provide the reader with a comprehensive overview of the types of lesions that may present as symptomatic, asymptomatic, and dangerous for progression into osteoarthritis, and the authors supply the reader with considerations and directions for future clinical implications and scientific endeavors.

Medial cystic osteochondral lesions of the talus exhibited lower sports levels, higher cyst-presence rate, and inferior radiological outcomes compared with lateral lesions following arthroscopic bone marrow stimulation

PURPOSE

To compare the patient-reported outcomes and radiological outcomes of the patients with medial- and lateral-cystic osteochondral lesions of the talus (OLTs) following bone marrow stimulation (BMS).

METHODS

Patients with cystic OLTs who underwent BMS between January 2016 and February 2021 were retrospectively analyzed, and the minimum follow-up time was more than 24 months. Patients were paired in a 1:1 ratio (medial-: lateral-cystic OLT; MC-OLT: LC-OLT) based on the OLT area within 30mm2, follow-up within 1 year, age within 5 years, and ligament surgery (Yes/No). The Visual analog scale, Foot and Ankle Ability Measure (FAAM)-Activities of Daily Life and Sports scores were assessed preoperatively and postoperatively. The magnetic resonance observation of cartilage repair tissue (MOCART) scores, and presence of cysts after BMS were also evaluated. Additionally, the receiver operating characteristic curve was performed.

RESULTS

The matched patients were divided into the MC-OLT(n=31, 43.35±12.32 months) and LC-OLT groups (n=31, 43.32±14.88 months, P=.986). Thirty patients of each group achieved a power of 80% and an α = 0.05 in this study. The MC-OLT group showed significantly less improvement in FAAM-ADL and sports scores (P = .034, P <0.001, respectively), lower MOCART scores (80.80±11.91 vs. 86.00±8.50, P = .010), and higher presence-rate of cyst after BMS (45.16% vs. 16.12%, P = .013). Regarding FAAM sports scores, the LC-OLT group had significantly more patients exceeding the MCID (80.64% vs. 51.61%, P = .031). Furthermore, an OLT depth of 7.23mm (sensitivity: 78.6%; specificity: 70.6%) might serve as a cut-off value for predicting the presence of cysts in medial-cystic OLTs following BMS.

CONCLUSION

Medial cystic OLTs exhibited markedly lower sports levels, higher cyst-presence rate, and inferior radiological outcomes following BMS than lateral counterparts. Additionally, an OLT depth of 7.23mm could be the cut-off value for predicting the presence of cysts regarding medial-cystic OLTs after BMS.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Skeletal Features of Talus in Hepple V Lesion

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

Open lift-drill-fill-fix for medial osteochondral lesions of the talus: surgical technique

OBJECTIVE

Osteochondral lesions of the talus (OLT) with a fragment on the talar dome that fail conservative treatment and need surgical treatment can benefit from in situ fixation of the OLT. Advantages of fixation include the preservation of native cartilage, a high quality subchondral bone repair, and the restoration of the joint congruency by immediate fragment stabilization. To improve the chance of successful stabilization, adequate lesion exposure is critical, especially in difficult to reach lesions located on the posteromedial talar dome. In this study we describe the open Lift, Drill, Fill, Fix (LDFF) technique for medial osteochondral lesions of the talus with an osteochondral fragment. As such, the lesion can be seen as an intra-articular non-union that requires debridement, bone-grafting, stabilization, and compression. The LDFF procedure combines these needs with access through a medial distal tibial osteotomy.

INDICATIONS

Symptomatic osteochondral lesion of the talus with a fragment (≥ 10 mm diameter and ≥ 3 mm thick as per computed tomography [CT] scan) situated on the medial talar dome which failed 3-6 months conservative treatment.

CONTRAINDICATIONS

Systemic disease, including active bacterial arthritis, hemophilic or other diffuse arthropathies, rheumatoid arthritis of the ankle joint, and malignancies. Neuropathic disease. End-stage ankle osteoarthritis or Kellgren and Lawrence score 3 or 4 [3]. Ipsilateral medial malleolus fracture less than 6 months prior. Relative contra-indication: posttraumatic stiffness with range of motion (ROM) < 5°. Children with open physis: do not perform an osteotomy as stabilization of the osteotomy may lead to early closure of the physis, potentially resulting in symptomatic varus angulation of the distal tibia. In these cases only arthrotomy can be considered.

SURGICAL TECHNIQUE

The OLT is approached through a medial distal tibial osteotomy, for which the screws are predrilled and the osteotomy is made with an oscillating saw and finished with a chisel in order to avoid thermal damage. Hereafter, the joint is inspected and the osteochondral fragment is identified. The cartilage is partially incised at the borders and the fragment is then lifted as a hood of a motor vehicle (lift). The subchondral bone is debrided and thereafter drilled to allow thorough bone marrow stimulation (drill) and filled with autologous cancellous bone graft from either the iliac crest or the distal tibia (fill). The fragment is then fixated (fix) in anatomical position, preferably with two screws to allow additional rotational stability. Finally, the osteotomy is reduced and fixated with two screws.

POSTOPERATIVE MANAGEMENT

Casting includes 5 weeks of short leg cast non-weightbearing and 5 weeks of short leg cast with weightbearing as tolerated. At 10-week follow-up, a CT scan is made to confirm fragment and osteotomy healing, and patients start personalized rehabilitation under the guidance of a physical therapist.

Evidence-Based Update on the Surgical Technique and Clinical Outcomes of Retrograde Drilling: A Systematic Review

BACKGROUND

Retrograde drilling is an established surgical technique to treat osteochondral lesions of the talus (OLT). It involves non-trans-articular drilling to induce subchondral bone revascularization and bone formation without damaging the overlying articular cartilage. The present study aimed to elucidate the heterogeneity of clinical studies on retrograde drilling for OLT.

DESIGN

A systematic search of the MEDLINE, Web of Science, EMBASE, and Cochrane Library databases for studies published between January 1996 and August 27, 2022, was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines by two independent reviewers. The included studies were evaluated for their level of evidence (LoE) and quality of evidence (QoE) using the Modified Coleman Methodology Score. Variables reporting surgical and clinical outcomes and complications were evaluated.

RESULTS

Eleven studies with 207 ankles were included (mean follow-up period = 31.1 months). The mean LoE was 3.8 (LoE 3: two studies, LoE 4: nine studies), and the mean QoE was 50.8 (fair: three studies, poor: eight studies). Ten studies used the American Orthopedic Foot and Ankle Society (AOFAS) score, which improved from 57.9 preoperatively to 86.1 postoperatively. The period and protocol of conservative treatment, lesion character, surgical technique, and postoperative protocol were inconsistent or underreported.

CONCLUSIONS

This systematic review revealed that low LoE and poor QoE, coupled with heterogeneity among the included studies, impede definitive conclusions regarding the effectiveness of this technique. Consequently, well-designed clinical trials are essential to develop standardized clinical guidelines for using retrograde drilling in OLT.

Reporting of Morphology, Location, and Size in the Treatment of Osteochondral Lesions of the Talus in 11,785 Patients: A Systematic Review and Meta-Analysis

OBJECTIVE

Uniformity of reporting is a requisite to be able to compare results of clinical studies on the treatment of osteochondral lesions of the talus (OLT). The primary aim of this study was to evaluate the frequency and quality of reporting of size, morphology, and location of OLTs.

DESIGN

A literature search was performed from 1996 to 2023 to identify clinical studies on surgical treatment of OLTs. Screening was performed by 2 reviewers, who subsequently graded the quality using the methodological index for non-randomized studies (MINORS). The primary outcome was the frequency and qualitative assessment of reporting of size, morphology, and location.

RESULTS

Of 3,074 articles, 262 articles were included. This comprised a total of 11,785 patients. Size was reported in 248 (95%) of the articles and was described with a measure for surface area in 83%, however, in 56%, definition of measurement is unknown. Intraclass coefficient (ICC) value for the reliability of size measurement was 0.94 for computed tomography (CT) scan and 0.87 for MRI scan. Morphology was reported in 172 (66%) of the articles and using a classification system in 23% of the studies. Location was reported in 220 (84%) of the studies.

CONCLUSION

No consensus was found on the reporting of morphology, with non-validated classification systems and different terminologies used. For location, reporting in 9 zones is underreported. Size was well reported and measurements are more reliable for CT compared with MRI. As these prognostic factors guide clinical decision-making, we advocate the development of a standardized and validated OLT classification to reach uniform reporting in literature.

LEVEL OF EVIDENCE

Level III, systematic review.

Physician preferences in diagnostics and treatment of juvenile osteochondritis dissecans are diverse across the knee, ankle and elbow: an ESSKA survey

PURPOSE

To investigate the current preferences regarding the work-up and treatment choices of juvenile osteochondritis dissecans (JOCD) of the knee, ankle and elbow among orthopaedic surgeons.

METHODS

An international survey was set up for all European Society of Sports Traumatology, Knee Surgery and Arthroscopy (ESSKA) members, which assessed various questions on diagnosis and treatment of JOCD of different joints. Respondents answered questions for one or more joints, based on their expertise. Proportions of answers were calculated and compared between joints. Consensus was defined as more than 75% agreement on an item; disagreement was defined as less than 25% agreement.

RESULTS

Fifty physicians responded to the survey, of whom forty-two filled out the questions on the knee, fourteen on the ankle and nine on the elbow. Plain radiography and MRI were the most used imaging modalities for the assessment and follow-up of JOCD in the knee and ankle, but not for the elbow. MRI was also the preferred method to assess the stability of a lesion in the knee and ankle. There was universal agreement on activity and/or sports restriction as the non-operative treatment of choice for JOCD. Size, stability and physeal closure were the most important prognostic factors in determining the operative technique for the elbow. For the knee, these factors were size and stability and for the ankle, these were size and location.

CONCLUSION

Activity and/or sports restriction was the non-operative treatment of choice. Furthermore, plain radiography and MRI were the preferred imaging modalities for the knee and ankle, but not for the elbow. For determining the operative technique, physicians agreed that the size of the lesion is an important prognostic factor in all joints. These findings help us understand how juvenile osteochondritis dissecans is treated in current practice and may provide opportunities for improvement.

LEVEL OF EVIDENCE

Level V.

Characteristics and Clinical Outcomes After Osteochondral Allograft Transplantation for Treating Articular Cartilage Defects: Systematic Review and Single-Arm Meta-analysis of Studies From 2001 to 2020

Background

Osteochondral allograft transplantation (OCA) treats symptomatic focal cartilage defects with satisfactory clinical results.

Purpose

To comprehensively analyze the characteristics and clinical outcomes of OCA for treating articular cartilage defects.

Study Design

Systematic review; Level of evidence, 4.

Methods

We searched Embase, PubMed, Cochrane Database, and Web of Science for studies published between January 1, 2001, and December 31, 2020, on OCA for treating articular cartilage defects. Publication information, patient data, osteochondral allograft storage details, and clinical outcomes were extracted to conduct a comprehensive summative analysis.

Results

In total, 105 studies involving 5952 patients were included. The annual reported number of patients treated with OCA increased from 69 in 2001 to 1065 in 2020, peaking at 1504 cases in 2018. Most studies (90.1%) were performed in the United States. The mean age at surgery was 34.2 years, and 60.8% of patients were male and had a mean body mass index of 26.7 kg/m2. The mean lesion area was 5.05 cm2, the mean follow-up duration was 54.39 months, the mean graft size was 6.85 cm2, and the number of grafts per patient was 54.7. The failure rate after OCA was 18.8%, and 83.1% of patients reported satisfactory results. Allograft survival rates at 2, 5, 10, 15, 20, and 25 years were 94%, 87.9%, 80%, 73%, 55%, and 59.4%, respectively. OCA was mainly performed on the knee (88.9%). The most common diagnosis in the knee was osteochondritis dissecans (37.9%), and the most common defect location was the medial femoral condyle (52%). The most common concomitant procedures were high tibial osteotomy (28.4%) and meniscal allograft transplantation (24.7%). After OCA failure, 54.7% of patients underwent revision with primary total knee arthroplasty.

Conclusion

The annual reported number of patients who underwent OCA showed a significant upward trend, especially from 2016 to 2020. Patients receiving OCA were predominantly young male adults with a high body mass index. OCA was more established for knee cartilage than an injury at other sites, and its best indication was osteochondritis dissecans. This analysis demonstrated satisfactory long-term postoperative outcomes.

Interrelations Between the Too-Long Anterior Calcaneal Process, Hind and Mid-tarsal Bone Volumes, Angles and Osteochondral Lesion of the Dome of the Talus: Analysis by Software Slicer of 69 CT Scan of Feet

Introduction

Although the association between Too-Long Anterior Calcaneal Process (TLACP) and osteochondral lesion of the dome of the talus (OCL) has been hypothesized, no study has investigated the interrelations between TLACP, hind and mid-tarsal volumes and angles and the development of OCL. The main goals of this work are: (1) to measure the volume of the calcaneum, talus, navicular and cuboid in subjects with and without TLACP; (2) to evaluate the angular relationships between talus, calcaneum and navicular in subjects with and without TLACP; (3) to assess whether TLACP has an effect on the volume of OCL.

Methods

This is a retrospective study of 69 CT scans of 54 consecutive children aged 11-15 years who had undergone a CT scan due to symptomatology suggestive of TLACP. The 3D Slicer software allowed to calculate the volume of the talus, calcaneum, navicular, cuboid, TLACP and OCL (in cm3). The PACS system was used to perform the angular measurements (in degrees) between talus, calcaneum and navicular in the frontal, axial and sagittal plane.

Results

Amid the 69 CT scans, 49 were found to have pathologies related to TLACP (71%, TLACP Group) and 20/69 were normal (29%, Control Group). The mean hind and mid-tarsal bone volumes of the TLACP group were comparable to those of the control group. There were 40 (81.6%) OCLs detected exclusively in pathological feet (TLACP group); 32 lesions were medial (80%), and 8 lesions were lateral (20%). According to Ferkel and Sgaglione CT Staging System, there were 22 (55%) stage 1 lesions, 5 (12.5%) stage 2A, 3 (7.5%) stage 2B and 10 (25%) stage three lesions. Only the angle between the talus and calcaneum in the frontal plane was significantly lower in pathological feet with respect to the control group (p < 0.001). In pathological feet, the talus was supinated, and the calcaneus pronated.

Conclusions

TLACP tend to stiffen the foot, modifying its biomechanics and leading to supination of the talus and pronation of the calcaneum. This induces an overpressure at the medial side of the talus where we observed a greater frequency of medial OCL with larger volume than lateral OCL.

Level of Evidence

III.

Talar Dome Osteochondral Lesions: Pre- and Postoperative Imaging

We suggest a similar approach to evaluating osteochondral lesions of the talar dome both pre- and postoperatively. This review addresses the etiology, natural history, and treatment of talar dome osteochondral lesions with an emphasis on imaging appearances. High-resolution magnetic resonance imaging, ideally combining a small field-of-view surface coil with ankle traction, optimizes visibility of most of the clinically relevant features both pre- and postoperatively.

15% of Talar Osteochondral Lesions Are Present Bilaterally While Only 1 in 3 Bilateral Lesions Are Bilaterally Symptomatic

BACKGROUND

The primary aim of the present study was to determine the prevalence of osteochondral lesions of the contralateral talus in patients with computed tomography (CT)-confirmed osteochondral lesions of the talus (OLT). The secondary aims were to determine if the contralateral lesions were symptomatic and to describe the demographic characteristics and radiographic presentation of patients with bilateral OLT.

METHODS

To identify patients with bilateral OLT, we utilized a cross-sectional database of consecutive patients with a CT-proven OLT who had undergone bilateral CT scanning at our hospital between January 1989 and June 2021. The primary outcome was the prevalence of bilateral OLT. Patients with bilateral OLT were grouped into a unilaterally symptomatic group and a bilaterally symptomatic group. Patient and lesion characteristics were compared between these groups as well as between the symptomatic and asymptomatic ankles in the unilaterally symptomatic group. Radiographic examination included lesion volume, location, and morphology.

RESULTS

Of 1,062 patients with OLT, 161 (15%) had bilateral OLT. Of the patients with bilateral OLT, 53 (33%) were bilaterally symptomatic. Patients who were bilaterally symptomatic were younger (p = 0.03) and more likely to present with a non-traumatic etiology (p < 0.01) in comparison with those who were unilaterally symptomatic. No differences were observed between the unilaterally and bilaterally symptomatic groups in terms of lesion morphology, volume, or location. In the unilaterally symptomatic group, lesion volume was significantly larger in symptomatic ankles in comparison with the contralateral, asymptomatic ankles (p < 0.01), but no significant differences were observed in terms of lesion morphology or location.

CONCLUSIONS

In patients presenting with symptomatic OLT, the prevalence of bilateral OLT was 15%, and 1 in 3 patients with bilateral OLT were symptomatic on both sides. Larger lesion volume was associated with the presence of symptoms in patients with bilateral OLT. For patients with bilateral OLT, the treating team should be aware that younger patients and patients without a history of trauma are at a higher risk for having bilateral symptoms.

LEVEL OF EVIDENCE

Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Incidence of (Osteo)Chondral Lesions of the Ankle in Isolated Syndesmotic Injuries: A Systematic Review and Meta-Analysis

OBJECTIVE

To determine and compare the incidence rate of (osteo)chondral lesions of the ankle in patients with acute and chronic isolated syndesmotic injuries.

DESIGN

A literature search was conducted in the PubMed (MEDLINE) and EMBASE (Ovid) databases from 2000 to September 2021. Two authors independently screened the search results, and risk of bias was assessed using the MINORS (Methodological Index for Non-Randomized Studies) criteria. Studies on acute and chronic isolated syndesmotic injuries with pre-operative or intra-operative imaging were included. The primary outcome was the incidence rate with corresponding 95% confidence intervals (CIs) of (osteo)chondral lesions of the ankle in combined and separate groups of acute and chronic syndesmotic injuries. Secondary outcomes were anatomic distribution and mean size of the (osteo)chondral lesions.

RESULTS

Nine articles (402 syndesmotic injuries) were included in the final analysis. Overall (osteo)chondral lesion incidence was 20.7% (95% CI: 13.7%-29.9%). This rate was 22.0% (95% CI: 17.1-27.7) and 24.1% (95% CI: 15.6-35.2) for acute and chronic syndesmotic injuries, respectively. In the combined acute and chronic syndesmotic injury group, 95.4% of the lesions were located on the talar dome and 4.5% of the lesions were located on the distal tibia. (Osteo)chondral lesion size was not reported in any of the studies.

CONCLUSIONS

This meta-analysis shows that (osteo)chondral lesions of the ankle are present in 21% of the patients with isolated syndesmotic injuries. No difference in incidence rate was found between the different syndesmotic injury types and it can be concluded that the majority of lesions are located on the talar dome.

PROSPERO REGISTRATION NUMBER

CRD42020176641.

Osteochondral lesion of the talus: still a problem?

Osteochondral lesion of the talus (OLT) often occurs after ankle trauma or repetitive micro-traumata, whereas the actual etiology remains unclear. The most common symptoms are local pain deep in the medial or lateral ankle that increases with weight-bearing and activity, accompanied by tenderness and swelling.

Eventually, most patients with symptomatic or unstable OLT require surgery. Many reasonable operative techniques have been described, whereas most lead to similar and satisfactory results. They can be divided into cartilage repair, cartilage regeneration and cartilage replacement techniques. The OLT size and morphology in the first place but also surgeon and individual patient aspects are considered when it comes to surgery.

For high postoperative success and low recurrence rates, underlying causes, for example, ligamentous instability and hindfoot malalignment should also be addressed during surgery.

The effect of talus osteochondral defects of different area size on ankle joint stability: a finite element analysis

BACKGROUND

Osteochondral lesion of the talus (OLT) is one of the most common ankle injuries, which will lead to biomechanical changes in the ankle joint and ultimately affect ankle function. Finite element analysis (FEA) is used to clarify the effect of talus osteochondral defects on the stability of the ankle joint at different depths. However, no research has been conducted on talus osteochondral defect areas that require prompt intervention. In this research, FEA was used to simulate the effect of the area size of talus osteochondral defect on the stress and stability of the ankle joint under a specific depth defect.

METHODS

Different area sizes (normal, 2 mm* 2 mm, 4 mm* 4 mm, 6 mm* 6 mm, 8 mm* 8 mm, 10 mm* 10 mm, and 12 mm* 12 mm) of the three-dimensional finite element model of osteochondral defects were established. The model was used to simulate and calculate joint stress and displacement of the articular surface of the distal tibia and the proximal talus when the ankle joint was in the heel-strike, midstance, and push-off phases.

RESULTS

When OLT occurred, the contact pressure of the articular surface, the equivalent stress of the proximal talus, the tibial cartilage, and the talus cartilage did not change significantly with an increase in the size of the osteochondral defect area when the heel-strike phase was below 6 mm * 6 mm. Gradual increases started at 6 mm * 6 mm in the midstance and push-off phases. Maximum changes were reached when the defect area size was 12 mm * 12 mm. The same patterns were observed in the talus displacement.

CONCLUSIONS

The effect of the defect area of the ankle talus cartilage on the ankle biomechanics is evident in the midstance and push-off phases. When the size of the defect reaches 6 mm * 6 mm, the most apparent change in the stability of the ankle joint occurs, and the effect does not increase linearly with the increase in the size of the defect.

Correlation between EFAS- and MOCART score and clinical outcome after AMIC®-procedure for osteochondral lesion of the talus

INTRODUCTION

Even though an increased interest in the use of the EFAS Score (European Foot and Ankle Society) has been observed, no data comparing it with radiological findings has been presented in the literature. Accordingly, the aim of this study is to investigate how the post-operative integration of the AMIC^® (autologous matrix-induced chondrogenesis)-membrane for osteochondral lesion of the talus using the MOCART (Magnetic Resonance Observation of Cartilage Repair Tissue) - Score is related to the clinical satisfaction of the patients.

MATERIAL AND METHODS

A group of 24 patients aged between 17 and 63 (with a mean age of 35.7) were included at least 1 year post-operatively. They had all undergone an AMIC^®-procedure of the talus. MRI findings using the MOCART Score were correlated to the EFAS Score at the same time point.

RESULTS

Our main results showed no correlation between the MOCART-Score and the EFAS-Score (R = - 0.08). There was also no correlation between the MOCART-Score, the FFI-Score (Foot and Function Index) (R = 0.2) and the MOXFQ-Score (Manchester-Oxford Foot Questionnaire) (R = 0.12). There was no correlation between components of the MOCART-Score with the EFAS-Score (R between - 0.32 and 0.23).

CONCLUSION

Our results question whether the MRI (a standard part of AMIC^®-procedure-of-the-ankle post-operative follow-up) is still the most appropriate tool for post-operative control. They also offer a starting point for future discussion regarding the need for post-operative MRI and the use of other radiological diagnostics in relation to clinical satisfaction.

One in Three Patients With Chronic Lateral Ankle Instability Has a Cartilage Lesion

BACKGROUND

Chronic lateral ankle instability (CLAI) is associated with the presence or development of intra-articular pathologies such as chondral or osteochondral lesions, or (O)CLs. Currently, the incidence of (O)CLs in patients with CLAI is unknown.

PURPOSE

To determine the incidence of (O)CLs in patients with CLAI.

STUDY DESIGN

Systematic review and meta-analysis; Level of evidence, 4.

METHODS

A literature search was conducted in the PubMed (MEDLINE), Embase (Ovid), and Cochrane databases for articles published from January 2000 until December 2020. Two authors independently screened the search results and conducted the quality assessment using the methodological index for non-randomized studies (MINORS) criteria. Clinical studies were included that reported findings on the presence of ankle (O)CLs based on pre- or intraoperative diagnostic measures in patients with CLAI (>6 months of symptoms). Patient and lesion characteristics were pooled using a simplified method. Lesion characteristics included localization and chondral and osteochondral involvement. The primary outcome was the incidence of (O)CLs in ankles with CLAI. A random-effects model with 95% CIs was used to analyze the primary outcome. The distribution of (O)CLs in the ankle joint was reported according to talar or tibial involvement, with medial and lateral divisions for talar involvement.

RESULTS

Twelve studies were included with 2145 patients and 2170 ankles with CLAI. The pooled incidence of (O)CLs in ankles with CLAI was 32.2% (95% CI, 22.7%-41.7%). Among all lesions, 43% were chondral and 57% were osteochondral. Among all (O)CLs, 85% were located on the talus and 17% on the distal tibia. Of the talar (O)CLs, 68% were located medially and 32% laterally.

CONCLUSION

(O)CLs were found in up to 32% of ankles with CLAI. The most common location was the talus (85%). Furthermore, most lesions were located on the medial talar dome (68%). These findings will aid physicians in the early recognition and treatment of ankle (O)CLs in the context of CLAI.

Anatomic risk factors for the occurrence of medial talar osteochondral lesions: a case-control study

OBJECTIVE

This study aimed to determine the anatomical risk factors that may play a role in the etiology of medial-sided osteochondral lesions of the talus (OLT) using morphological parameters in magnetic resonance imaging (MRI).

SUBJECTS AND METHODS

One hundred twenty-four patients with medial-sided OLT and age- and sex-matched 124 controls were included in this retrospective study. Two examiners conducted independent OLT classification and measurements of five MRI parameters: tibial axis-medial malleolus angle (TMM), the anterior opening angle of the talus (AOT), talus position (TalPos), the ratio of the distal tibial articular surface to the length of the trochlea tali arc (TAS/TAL), depth of the incisura fibularis (IncDep). Statistical analysis included intraclass correlation coefficients, independent t-tests, receiver-operating characteristic (ROC) analysis, area under the curve (AUC) calculation, and logistic regression analysis. A p-value < 0.05 was considered statistically significant.

RESULTS

TTM, AOT, TalPos, and TAL values were significantly higher and the TAS/TAL ratio was significantly lower in the case group than in the control group (p < 0.001). Cut-off and AUC values for TMM were 15.15° (AUC 0.763), AOT 13.05° (AUC 0.826), TalPos 0.75 mm (AUC 0.887), TAL 35.45 mm (AUC 0.642), and TAS/TAL ratio 0.82 (AUC 0.784), p < 0.001. Multivariate logistic regression analysis results were odds ratio (OR) = 6.1 for TMM ≥ 15.15°, OR = 8.9 for AOT ≥ 13.05°, OR = 36.1 for TalPos ≥ 0.75 mm, and OR = 6.7 for TAS/TAL ratio ≤ 0.82.

CONCLUSION

Ankle morphology might have an influence on OLT development. The talus position (TalPos) and anterior opening angle of the talus (AOT) seemed to be the strongest predisposing factors.

Safety of malleolar osteotomies in surgery for osteochondral lesions of the talus

The talus is a central bone in the hindfoot that is difficult to access surgically. Performing a medial or lateral malleolar osteotomy in the management of an osteochondral lesion of the talus (OLT) is a feared procedure amongst surgeons and their patients. The objective of this study was to assess the complications inherent to malleolar osteotomies in the treatment of OLTs.

HYPOTHESIS

The use of a standardized protocol concerning the technical performance and osteosynthesis of malleolar osteotomies results in fewer postoperative complications than a non-standardized protocol.

MATERIALS AND METHOD

This is a comparative study comprising a prospective multicenter non-randomized series with a standardized protocol for performing malleolar osteotomies, and a multicenter retrospective series without a standardized protocol. We included all patients aged 16 to 65 years with symptomatic OLTs, resistant to more than 6-months of well-conducted medical treatment, for whom surgery was considered. The minimum follow-up was 1 year for the prospective study, and 5 years for the retrospective study. A total of 86 and 97 patients were included in the prospective and retrospective studies, respectively. Of these 183 patients, 86 patients (33 prospective and 53 retrospective) underwent medial or lateral malleolar osteotomies as part of their surgery for OLT. Complications specific to the osteotomy procedures such as scar tissue, surgical site infection, non-union, articular malunion, neurological lesions or surgical revision, were investigated.

RESULTS

No specific complication was found to be associated to the malleolar osteotomy. No surgical revision was directly linked to the osteotomy procedure. No significant difference was found between the two series.

DISCUSSION

There was no evidence of morbidity related specifically to medial or lateral malleolar osteotomies. A standardized protocol, subject to rigorous technical implementation, does not improve results after malleolar osteotomy. The fear associated with this malleolar osteotomy procedure seems unfounded.

LEVEL OF EVIDENCE

IV.