Influence of the Medial Malleolus Osteotomy on the Clinical Outcome of M-BMS + I/III Collagen Scaffold in Medial Talar Osteochondral Lesion (German Cartilage Register/Knorpelregister DGOU)

Effects of Preoperative Abnormality of Posterior Tibial Tendon on the Surgical Outcomes of Medial Osteochondral Lesion of the Talus

BACKGROUND

Although surgical treatment for osteochondral lesion of the talus (OLT) can obtain good clinical outcomes, the rate of return to sports is variable. It is reported that medial OLT unrelated to trauma has abnormal structures in the medial aspect, which may induce the medial OLT due to the medial instability. The posterior tibial tendon (PTT) plays an important role in the stabilization of the foot, and high mechanical stress may be added to the PTT to compensate for medial instability in medial OLT. We investigated whether abnormal PTT findings on preoperative magnetic resonance imaging (MRI) in patients with OLT affect clinical outcomes after surgery.  Methods: Eighty-one ankles in 74 patients who were treated surgically for OLT were included in this study (41 men and 33 women; mean age, 26.0 years). Abnormalities of the PTT were evaluated using preoperative MRI. The Japanese Society for Surgery of the Foot (JSSF) scale, arch height, and ankle activity score (AAS) on standing plain radiogram were compared between patients with and those without preoperative PTT abnormalities.

RESULTS

Twenty-five ankles (30.9%) had PTT abnormalities on preoperative MRI. All patients with preoperative PTT abnormalities were medial OLT. There were no significant differences in the preoperative JSSF scale in the procedures for OLT. The postoperative JSSF scale and arch height were significantly lower in patients with preoperative PTT abnormalities than those without them. AAS in patients with preoperative abnormalities significantly decreased at the final follow-up.  Conclusion: PTT abnormalities on preoperative MRI may affect clinical outcomes even in preoperative asymptomatic patients in the medial OLT unrelated to trauma.

Operative management of osteochondral lesions of the talus: 2024 recommendations of the working group 'clinical tissue regeneration' of the German Society of Orthopedics and Traumatology (DGOU)

The working group 'Clinical Tissue Regeneration' of the German Society of Orthopedics and Traumatology (DGOU) issues this paper with updating its guidelines. Literature was analyzed regarding different topics relevant to osteochondral lesions of the talus (OLT) treatment. This process concluded with a statement for each topic reflecting the best scientific evidence available with a grade of recommendation. All group members rated the statements to identify possible gaps between literature and current clinical practice. Fixation of a vital bony fragment should be considered in large fragments. In children with open physis, retrograde drilling seems to work better than in adults, but even there, the revision rate reaches 50%. The literature supports debridement with bone marrow stimulation (BMS) in lesions smaller than 1.0 cm² without bony defect. The additional use of a scaffold can be recommended in lesions larger than 1.0 cm². For other scaffolds besides AMIC®/Chondro-Gide®, there is only limited evidence. Systematic reviews report good to excellent clinical results in 87% of the patients after osteochondral transplantation (OCT), but donor site morbidity is of concern, reaching 16.9%. There is no evidence of any additional benefit from autologous chondrocyte implantation (ACI). Minced cartilage lacks any supporting data. Metallic resurfacing of OLT can only be recommended as a second-line treatment. A medial malleolar osteotomy has a minor effect on the clinical outcome compared to the many other factors influencing the clinical result.

Postoperative Management of Osteochondral Lesions of the Ankle: A Survey Among German-Speaking Foot and Ankle Surgeons

OBJECTIVE

To assess the current treatment of osteochondral lesions of the ankle (OCLA) by German-speaking foot and ankle surgeons, focusing on the management of postoperative care and rehabilitation.

DESIGN

A questionnaire was created by a panel of 4 experienced foot and ankle surgeons on behalf of the "Clinical Tissue Regeneration" (CTR) working group of the German Society of Orthopaedics and Trauma Surgery (DGOU), and distributed electronically to members of the CTR, participants of the German Cartilage Registry (Knorpelregister DGOU©), and members of 6 German-speaking orthopedics or sports medicine societies. Results were classified depending on the consensus within the answers (agreement ≥75% "strong tendency," 50%-74% "tendency," 25%-49% "weak tendency," <25% "no tendency").

RESULTS

A total of 60 participants returned the questionnaire. The main results are as follows: regarding the frequency of surgical procedures for OCLA, refixation of the fragment, retrograde drilling, and bone marrow stimulation with or without using a matrix were performed by at least 75% of the surgeons and was considered a strong tendency. There was a strong tendency to stabilize the ankle (76.7%) and perform corrective osteotomies (51.7%). In total, 75.5% and 75% of the surgeons performed bone marrow stimulation with and without using a matrix, respectively. Corrective osteotomy and ankle stabilization were performed in 64.5% and 65.2% cases, respectively. Most participants included published recommendations on postoperative rehabilitation and the return to sports activities in their postoperative management. The main surgical procedures were considered the most critical factor in influencing the postoperative management by 81% of the participants (strong tendency). Adjunct surgical procedures such as corrective osteotomy and stabilization of the ankle were considered important by 67.8% of the respondents (tendency).

CONCLUSIONS

The management of OCLA varies among German-speaking foot and ankle surgeons. Therefore, guidelines remain essential to standardize the management of OCLA, to achieve improved and stable results. This survey will assist clinicians and patients with rehabilitation to return to sports after treating the ankle's cartilage injury.

[The first decade of the DGOU's cartilage register-insights for clinical practice]

BACKGROUND

Registry data provide valuable epidemiological insights that help to further improve process and outcome quality in patient care. The German Cartilage Registry (KnorpelRegister DGOU) was established in 2013 as an instrument for quality assurance after surgical cartilage regenerative procedures on hip, knee and ankle joints.

DATA COLLECTION

Participation in the German Cartilage Registry is optional for hospitals and practices. Currently, more than 160 institutions in Germany, Austria and Switzerland participate in the data collection.

DATA COLLECTED AND INITIAL FINDINGS

The implementation of PROMs ("patient related outcome measurement"), as well as the recording of surgery-related influencing factors, enable a differentiated scientific analysis and represent a key quality feature of the registry. Initial analyses of the registry data have already provided clinically relevant findings for immediate patient care. For example, patients who underwent focal cartilage therapy prior to ACT show a clinically relevant, significantly worse outcome than patients who underwent primary ACT. First conclusions could also be drawn regarding the relevance of concomitant cartilage therapy. For example, in patients with focal cartilage damage of the medial knee joint compartment, registry data indicate that leg axis correction is indicated even in cases of mild deviation of the mechanical leg axis.

CONCLUSION

The data and findings obtained from the Cartilage Registry represent an important aspect of clinical care research and serve as a complement to well-designed, clinically prospective cohort studies, RCTs, and meta-analyses.

Intraosseous Ganglion Cyst of the Talus Treated With Curettage and Bone Grafting Through a Medial Malleolus Osteotomy

BACKGROUND

Intraosseous ganglion cyst (IGC) of the talus is a rare entity. There is no consensus regarding the best surgical approach to the talus. In this study, we evaluated the outcomes of curettage and bone grafting of the talus IGC via medial malleolus osteotomy.

METHODS

Seventeen patients with talus IGC who were treated between 2002 and 2020 using curettage and bone grafting through a medial malleolus osteotomy were included. The outcome measures were ankle range of motion (ROM), pain, and function. The ankle pain was evaluated by the visual analog scale (VAS). The ankle function was evaluated by the Toronto extremity salvage score (TESS) and Musculoskeletal Tumor Society (MSTS) score.

RESULTS

The study population included 10 men and 7 women with a mean age of 34.9 ± 18.8 years and a mean follow-up of 5.4 ± 3 years. The mean size of the lesion was 2.6 ± 0.8 cm. Postoperatively, mean ankle dorsiflexion and plantar flexion were 19.4 ± 5.8 degrees and 36.7 ± 5.3 degrees, respectively. The mean VAS was 0.9 ± 1.1. The mean MSTS score and TESS were 96.2 ± 3.5 and 94.5 ± 4.1, respectively. Two patients developed ankle osteoarthritis after 3 years (1 stage I and 1 stage II). One of these patients (stage II) also had recurrence after 6 months (recurrence rate: 6.7%).

CONCLUSION

Talus IGC could be adequately managed with curettage and bone grafting through a medial malleolus osteotomy. Even so, mild pain and reduced ankle ROM remain in some patients.

LEVEL OF EVIDENCE

Level IV, retrospective cohort study.