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

Effects of Losartan and Fisetin on Microfracture-Mediated Cartilage Repair of Ankle Cartilage in a Rabbit Model

BACKGROUND

Microfracture is one surgical treatment strategy for osteochondral lesions of the talus (OLTs) but results in fibrocartilage repair tissue, which has inferior mechanical properties to native hyaline cartilage. Biological regulation of microfracture has been suggested to improve the quality of cartilage repair in patients.

PURPOSE

To determine if administration of losartan, fisetin, or losartan and fisetin combined can enhance microfracture-mediated cartilage repair of OLTs in a rabbit model.

STUDY DESIGN

Controlled laboratory study.

METHODS

Four-month-old female rabbits were divided into the following groups (8 rabbits per group): microfracture only (microfracture), microfracture plus losartan (losartan), microfracture plus fisetin (fisetin), and microfracture plus losartan and fisetin (losartan+fisetin). A 2.7-mm osteochondral defect and 4 microfracture holes were created in the talar dome cartilage. The rabbits were administered losartan (10 mg/kg/day), fisetin (20 mg/kg/day), or losartan and fisetin orally until euthanized 12 weeks after surgery. Gross evaluation, micro-computed tomography, histology, and immunohistochemistry evaluations of the osteochondral defects were performed as well as quantitative polymerase chain reaction of capsule tissue and enzyme-linked immunosorbent assay of serum.

RESULTS

The losartan and fisetin groups had increased International Cartilage Regeneration & Joint Preservation Society macroscopic scores with improved cartilage repair and enhanced subchondral bone healing compared with the microfracture group. However, the losartan+fisetin group did not show a synergistic effect. O'Driscoll histology scores were higher in the losartan and fisetin groups compared with the microfracture group, while the losartan+fisetin group had a lower score than the losartan, fisetin, and microfracture groups. Collagen type 2 staining revealed organized chondrocytes in the losartan and fisetin groups, but the losartan+fisetin group did not show improvement when compared with other groups. Fisetin treatment decreased catalase and transforming growth factor-β1-activated kinase 1 expression in capsular tissue.

CONCLUSION

Concomitant microfracture and biological regulation, using oral administration of either losartan or fisetin, may improve cartilage healing of OLTs; however, losartan and fisetin combined in the current drug administration regimen does not appear to provide synergistic effects.

CLINICAL RELEVANCE

Oral intake of losartan or fisetin may result in beneficial effects on microfracture-mediated cartilage repair of OLTs.

Effect of Weight-Bearing and Mobilization After Treatment With Microfracture in Osteochondral Lesions of the Talus in Rabbits

BACKGROUND

 The aim of this study is to comparatively evaluate the effect of early weight bearing on recovery after treatment with the microfracture (MF) method in a rabbit model of osteochondral lesions (OCLs) of the talus.

MATERIALS AND METHODS

The study was carried out on 24 tali of 12 white rabbits. Experimental animals were divided into two groups. Rabbits whose weight-bearing and mobility were not limited after MF surgery were called Group 1, and rabbits with limited mobility were called Group 2. After 28 days of postoperative follow-up, tissue samples obtained from the tali were evaluated macroscopically according to the International Society for Cartilage Research Repair Evaluation scoring system 1 (ICRS-1) and microscopically according to the ICRS-2 scoring system.

RESULTS

The mean ICRS-1 score was 87.5 ± 12.5 in Group 1 and 40.2 ± 7.8 in Group 2. The intergroup comparison of ICRS-1 scores showed that the ICRS-1 scores were significantly higher in Group 1 (p = 0.01). The mean ICRS-2 score was 74.3 ± 1.9 in Group 1 and 35.2 ± 1.9 in Group 2. The comparison of ICRS-2 scores between the groups showed that the ICRS-2 scores were significantly higher in group 1 (p = 0.01).

CONCLUSION

Early weight-bearing and mobility have a more favorable effect on cartilage healing after treatment of OCL of the talus with MF surgery.

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.

Comparative analysis of short-term efficacy between robot-assisted retrograde drilling and arthroscopic microfracture for osteochondral lesions of the talus

Objective

To investigate the short-term clinical efficacy of robot-assisted retrograde drilling and arthroscopic microfracture for osteochondral lesions of the talus (OCLT).

Methods

This study was divided into two groups: experimental group: robot-assisted retrograde drilling group; control group: arthroscopic microfracture group. A total of 6 OCLT patients who were treated with robot navigation-assisted retrograde drilling and 10 OCLT patients who were treated with arthroscopic microfracture between October 2020 and October 2021 were retrospectively analyzed. There were 11 males and five females, with a mean age of 36 years. The patients were followed up for 6-12 months to compare the changes in the OCLT lesion area by magnetic resonance imaging (MRI), visual analogue scale/score (VAS) and American Orthopedic Foot and Ankle Society score (AOFAS) before and after surgery.

Results

All 16 patients were followed up for an average of 8 months, and no complications such as joint infection, nerve injury, or active bleeding occurred during the follow-up period. Only one patient suffered discomfort involving transient postoperative pain in the operative area, but did not experience long-term numbness or chronic pain. Postoperative MRI revealed that none of the patients had severe signs of osteonecrosis, osteolysis or cystic changes of the talus, with lesion areas smaller than those before surgery. The difference was statistically significant (P < 0.01). The patients in the experimental group showed a more significant improvement in the last 3 months than in the first 3 months of the follow-up period. At the last follow-up, the VAS score was 3 points in the experimental group and 2.2 points in the control group, and the AOFAS score was 88.6 points in the experimental group and 88 points in the control group, all of which were significantly higher than those before operation, and the differences were statistically significant, but there was no statistically significant difference between the groups.

Conclusion

Both robot navigation-assisted retrograde drilling and arthroscopic microfracture for bone marrow stimulation (BMS) to treat OCLT in all patients obtained satisfactory effects in the short term. In addition, the follow-up revealed that with excellent efficacy and few complications, robot navigation-assisted retrograde drilling was safe and minimally invasive, and greatly reduced operative time. Consequently, robot navigation-assisted retrograde drilling for BMS was a safe and effective procedure for the treatment of OCLT.

Participation in Sports or Recreational Activities After Osteochondral Allograft Transplantation of the Talus

BACKGROUND

Fresh osteochondral allograft (OCA) transplantation is a viable treatment option for osteochondral defects of the talus. However, sufficient data are not available on patients' participation in sports or recreational activities after the procedure.

PURPOSE

To assess whether patients undergoing OCA transplantation of the talus participated in sports or recreational activities postoperatively.

STUDY DESIGN

Case series; level of evidence, 4.

METHODS

A total of 36 ankles in 34 patients underwent OCA transplantation of the talus. At a mean follow-up of 9.2 years, information on participation in sports or recreational activities pre- and postoperatively was obtained, as well as postoperative pain, function, and satisfaction.

RESULTS

The mean age at the time of surgery was 36.1 years (range, 20.5-57.7 years), and 50% of patients were men. The mean graft size was 3.6 cm2 (range, 1-7.2 cm2) or 41.1% of the talar dome. Before the injury, 63.9% of patients (23/36 ankles) reported being highly competitive athletes or well trained and frequently sporting; 36.1% of patients (13/36 ankles) reported sometimes sporting or were nonsporting. Also, 66.7% of patients (24/36 ankles) were able to participate in sports or recreational activities after OCA transplantation and 50% (18/36 ankles) were still participating in sports or recreational activities at the latest follow-up. In a subset of well-trained or highly competitive athletes, 73.9% (17/23 ankles) were able to return to sports or recreational activities at any point after OCA transplantation, and 65.2% (15/23 ankles) were still participating at the latest follow-up. Further surgery occurred in 16.7% of patients (6/36 ankles). Graft survivorship was 94.3% at 5 years and 85.3% at 10 years. There was a significant improvement in the mean Olerud-Molander Ankle Scores, and the mean Foot and Ankle Ability Measure scores were high postoperatively. Moreover, 79.4% of patients (27/34 ankles) were either satisfied or extremely satisfied with the allograft surgery.

CONCLUSION

Fresh OCA transplantation is a reasonable surgical option for osteochondral defects of the talus for young, active patients who have failed previous operative management or have massive defects.

Osteochondral Lesions of the Subtalar Joint: Clinical Outcomes in 11 Patients

OBJECTIVE

The purpose of this retrospective case series was to evaluate clinical outcomes following both conservative treatment and arthroscopic bone marrow stimulation (BMS) for the management of symptomatic subtalar osteochondral lesions (OCLs).

DESIGN

All symptomatic subtalar OCLs with a minimum of 12 months follow-up having undergone either a conservative management or arthroscopic procedure were included. Patient-reported outcomes were collected via questionnaires consisting of the Foot and Ankle Outcome Score (FAOS), Numeric Rating Scale (NRS) of pain in rest, during walking, during stair climbing, and during running. In addition, return to sports data, return to work data, reoperations, and complications were collected and assessed. In total, 11 patients across 2 academic institutions were included (3 males, 8 females). The median age was 43 years (interquartile range [IQR]: 32-53).

RESULTS

All patients underwent conservative treatment first; in addition, 9 patients underwent subtalar arthroscopic debridement with or without BMS. The median follow-up time was 15 months (IQR: 14-100). In the surgically treated group, the median NRS scores were 2 (IQR: 1-3) during rest, 3 (IQR: 2-4) during walking, 4 (IQR: 4-5) during stair climbing, 5 (IQR: 4-5) during running and the median FAOS score at final follow-up was 74 (IQR: 65-83). In the conservatively treated patients, the median NRS scores were all 0 (IQR: 0-0) and the median FAOS scores were 90 (IQR: 85-94). In the group of surgical treated patients, 4 were able to return to the same level of sports, 2 returned to a lower level of sports. Both conservatively treated patients returned to the sport and the same level of prior participation. All patients except one in the surgical group returned to work.

CONCLUSIONS

This retrospective case series demonstrated that a high number of patients converted to surgery after initial conservative treatment. In addition, debridement and BMS show good clinical outcomes for the management of symptomatic subtalar OCLs at short-term follow-up. No complications nor secondary surgical procedures were noted in the surgically treated group. The high rate of failure of conservative treatment suggests that surgical intervention for symptomatic subtalar OCLs can be the primary treatment strategy; however, further research is warranted in light of the small number of patients.

Second-Look Arthroscopy Shows Inferior Cartilage after Bone Marrow Stimulation Compared with Other Operative Techniques for Osteochondral Lesions of the Talus: A Systematic Review and Meta-Analysis

OBJECTIVE

To compare cartilage quality after different surgical interventions for osteochondral lesions of the talus (OLT), evaluated by second-look arthroscopy. Secondary aims were to report concomitant diagnoses, and to correlate cartilage quality with clinical and radiological outcomes. This review hypothesizes that the cartilage repair after bone marrow stimulation (BMS) is inferior to the other available treatment options.

METHODS

PROSPERO ID: CRD42022311489. Studies were retrieved through PubMed, EMBASE (Ovid), and Cochrane Library. Studies were included if they reported cartilage quality after second-look investigation after surgical treatment of OLT. The primary outcome measure was the cartilage quality success and failure rates (%) per surgical intervention group. Correlations between the cartilage quality and clinical or radiological outcomes were calculated.

RESULTS

Twenty-nine studies were included, comprising 586 ankles that had undergone second-look arthroscopy on average 16 months after initial surgery. The success rate for BMS was 57% (95% confidence interval [CI] = 48%-65%), for fixation (FIX) 86% (95% CI = 70%-94%), for osteo(chondral) transplantation (OCT) 91% (95% CI = 80%-96%), for cartilage implementation techniques (CITs) 80% (95% CI = 69%-88%), and for retrograde drilling 100% (95% CI = 66%-100%). The success rate of BMS was significantly lower than FIX, OCT, and CIT (P < 0.01). There were no significant differences between other treatment groups. A moderate positive significant correlation between the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score and the International Cartilage Repair Society score (ICRS) was found (ρ = 0.51, P < 0.001).

CONCLUSIONS

Successful restoration of cartilage quality was found in the majority of surgically treated OLTs. However, BMS yields inferior cartilage quality compared with FIX, OCT, and CIT. Study Design. Systematic review and meta-analysis. Level of evidence. Level IV, systematic review and meta-analysis.

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.

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Osteochondral Lesions of the Tibial Plafond and Ankle Instability With Ankle Cartilage Lesions: Proceedings of the International Consensus Meeting on Cartilage Repair of the Ankle

BACKGROUND

An international consensus group of experts was convened to collaboratively advance toward consensus opinions based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article is to present the consensus statements on osteochondral lesions of the tibial plafond (OLTP) and on ankle instability with ankle cartilage lesions developed at the 2019 International Consensus Meeting on Cartilage Repair of the Ankle.

METHODS

Forty-three experts in cartilage repair of the ankle were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within 4 working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed on in unanimous fashion within the working groups. A final vote was then held.

RESULTS

A total of 11 statements on OLTP reached consensus. Four achieved unanimous support and 7 reached strong consensus (greater than 75% agreement). A total of 8 statements on ankle instability with ankle cartilage lesions reached consensus during the 2019 International Consensus Meeting on Cartilage Repair of the Ankle. One achieved unanimous support, and seven reached strong consensus (greater than 75% agreement).

CONCLUSION

These consensus statements may assist clinicians in the management of these difficult clinical pathologies.

LEVEL OF EVIDENCE

Level V, mechanism-based reasoning.

Understanding the Cheerleader as an Orthopaedic Patient: An Evidence-Based Review of the Literature

Cheerleading is a highly popular youth sport in the United States and has been increasingly recognized in recent years for its athleticism and competitive nature. The sport has changed dramatically since its inception. When the sport of cheerleading was first developed, its primary purpose was to entertain crowds and support other athletes. Today, cheerleaders are competitive athletes themselves. Cheerleaders, most of whom are in the pediatric age group, and their parents commonly approach orthopaedic surgeons and sports medicine physicians with questions regarding the risks associated with participation in the sport. Appropriate clinical guidance is especially important for athletes returning to the sport after an injury. However, unlike other popular sports (eg, football, basketball, and volleyball), the intricacies of cheerleading are not well-known to those outside the sport, including many health care providers. Previous studies have reported on the epidemiological patterns of injuries associated with cheerleading and how such aesthetic sports affect the body, finding that fractures and concussions are prevalent and that catastrophic injuries are more common than in most other sports. Here, we provide an evidence-based discussion of 10 pertinent topics regarding cheerleading and its risks to the musculoskeletal system. The purpose of this review is to provide a comprehensive resource for orthopaedic surgeons and sports medicine physicians who care for these athletes.

Outcomes of Bone Marrow Stimulation for Secondary Osteochondral Lesions of the Talus Equal Outcomes for Primary Lesions

OBJECTIVE

To compare clinical, sports, work, and radiological outcomes between primary and secondary osteochondral lesions of the talus (OLTs; <15 mm) treated with arthroscopic bone marrow stimulation (BMS).

DESIGN

Secondary OLTs were matched to primary OLTs in a 1:2 ratio to assess the primary outcome measure-the Numeric Rating Scale (NRS) during activities. Secondary outcomes included the pre- and 1-year postoperative NRS at rest, American Orthopaedic Foot and Ankle Society score, Foot and Ankle Outcome Score subscales, and the EQ-5D general health questionnaire. The rates and time to return to work and sports were collected. Radiological examinations were performed preoperatively and at final follow-up using computed tomography (CT).

RESULTS

After matching, 22 and 12 patients with small (<15 mm) OLTs were included in the primary and secondary groups, respectively. The NRS during activities was not different between primary cases (median: 2, interquartile range [IQR]: 1-4.5) and secondary cases (median: 3, IQR: 1-4), P = 0.5. Both groups showed a significant difference between all pre- and postoperative clinical outcome scores, but no significant difference between BMS groups postoperatively. The return to sport rate was 90% for primary cases and 83% for secondary cases (P = 0.6). All patients returned to work. Lesion filling on CT was complete (67% to 100%) in 59% of primary cases and 67% of secondary cases (P = 0.6).

CONCLUSION

No differences in outcomes were observed between arthroscopic bone marrow stimulation in primary and secondary OLTs at 1-year follow-up. Repeat BMS may therefore be a viable treatment option for failed OLTs in the short term.

Evidence-based Treatment of Failed Primary Osteochondral Lesions of the Talus: A Systematic Review on Clinical Outcomes of Bone Marrow Stimulation

OBJECTIVE

The purpose of this study is to systematically review the literature and to evaluate the outcomes following bone marrow stimulation (BMS) for nonprimary osteochondral lesions of the talus (OLT).

DESIGN

A literature search was performed to identify studies published using PubMed (MEDLINE), EMBASE, CDSR, DARE, and CENTRAL. The review was performed according to the PRISMA guidelines. Two authors separately and independently screened the search results and conducted the quality assessment using the Methodological Index for Non-Randomized Studies (MINORS). Studies were pooled on clinical, sports, work, and imaging outcomes, as well as revision rates and complications. The primary outcome was clinical success rate.

RESULTS

Five studies with 70 patients were included in whom nonprimary OLTs were treated with secondary BMS. The pooled clinical success rate was 61% (95% confidence interval [CI], 50-72). The rate of return to any level of sport was 83% (95% CI, 70-91), while the return to pre-injury level of sport was 55% (95% CI, 34-74). The rate of return to work was 92% (95% CI, 78-97), and the complication rate was assessed to be 10% (95% CI, 4-22). Imaging outcomes were heterogeneous in outcome assessment, though a depressed subchondral bone plate was observed in 91% of the patients. The revision rate was 27% (95% CI, 18-40).

CONCLUSIONS

The overall success rate of arthroscopic BMS for nonprimary osteochondral lesions of the talus was 61%, including a revision rate of 27%. Return to sports, work, and complication outcomes yielded fair to good results.

Osteochondral Lesions of the Talus: A Review on Talus Osteochondral Injuries, Including Osteochondritis Dissecans

This is a review on talus osteochondritis dissecans and talus osteochondral lesions. A majority of the osteochondral lesions are associated with trauma while the cause of pure osteochondritis dissecans is still much discussed with a possible cause being repetitive microtraumas associated with vascular disturbances causing subchondral bone necrosis and disability. Symptomatic nondisplaced osteochondral lesions can often be treated conservatively in children and adolescents while such treatment is less successful in adults. Surgical treatment is indicated when there is an unstable cartilage fragment. There are a large number of different operative technique options with no number one technique to be recommended. Most techniques have been presented in level II to IV studies with a low number of patients with short follow ups and few randomized comparisons exist. The actual situation in treating osteochondral lesions in the ankle is presented and discussed.

Surgical Treatment of Talus OCL: Mid- to Long-Term Clinical Outcome With Detailed Analyses of Return to Sport

Talus osteochondral lesions are a commonly underdiagnosed problem in young athletes. Talus osteochondral lesions surgical algorithm remains controversial. Current metrics suggest that conventional treatment of osteochondral lesions of the talus is promising; yet return to sport is poorly studied. Fifty-seven patients following talus osteochondral lesion surgical intervention were included in this study. About 63.1% were female with mean age 37.1 years, mean lesion size 10 × 12.5 mm, and mean follow-up 79.9 months postoperatively. Patients were divided into 4 groups by surgery performed: antegrade arthroscopic bone marrow stimulation, retrograde arthroscopic drilling, osteochondral autograft transfer, and allograft cartilage implantation. Outcome metrics include Visual Analog Scale for pain and function, Short Form-12, Foot and Ankle Disability Scale, Tegner, Marx activity scores, Naal Sports inventory, and patient satisfaction. Over 77% of patients were satisfied with surgical intervention. Each intervention significantly decreased pain and increased function, except retrograde drilling. All interventions trended toward decreased Tegner score; only antegrade drilling showed significant decrease. Based on Naal's sports inventory, 85.7% of surgically treated patients reported participating in sport activities, on average 3 times/week and 50.6 minutes/session. Traditionally, talus osteochondral lesions present a difficult problem that is marred by unsatisfactory nonoperative outcomes in typically active patients. As our surgical understanding has evolved, we've continued to improve on outcomes. Our patients demonstrated 77.2% overall satisfaction rate, a statistically significant improvement in pain and function, at an average follow-up of 79.9 months postoperatively, and a high rate of return to sport with little difference between surgical interventions.

Histological and Inflammatory Cytokine Analysis of Osteochondral Lesions of the Talus After Failed Microfracture: Comparison With Fresh Allograft Controls

Background:

The most common first-line treatment of osteochondral lesions of the talus (OLTs) is microfracture. Although many patients do well with this procedure, a number fail and require reoperation. The mechanism of failure of microfracture is unknown, and to our knowledge there has been no research characterizing failed microfracture regarding histological and inflammatory makeup of these lesions that may contribute to failure.

Purpose:

To characterize the structural and biochemical makeup of failed microfracture lesions.

Study Design:

Case series; Level of evidence, 4.

Methods:

Specimens from 8 consecutive patients with symptomatic OLTs after microfracture who later underwent fresh osteochondral allograft transplantation were analyzed. For each patient, the failed microfracture specimen and a portion of the fresh allograft replacement tissue were collected. The allograft served as a control. Histology of the failed microfracture and the allograft replacement was scored using the Osteoarthritis Research Society International (OARSI) system. Surface roughness was also compared. In addition, tissue culture supernatants were analyzed for 16 secreted cytokines and matrix metalloproteinases (MMPs) responsible for inflammation, pain, cartilage damage, and chondrocyte death.

Results:

The OARSI grade, stage, and total score as well as surface smoothness were significantly worse in the failed microfracture sample, indicating better cartilage and bone morphology for the allografts compared with the failed microfracture lesions. Analyzed cytokines and MMPs were significantly elevated in the microfracture tissue culture supernatants when compared with fresh osteochondral tissue supernatants.

Conclusion:

These data demonstrate a significantly rougher cartilage surface, cartilage and subchondral bone histology that more closely resembles osteoarthritis, and elevated inflammatory cytokines and MMPs responsible for pain, inflammation, cartilage damage, and chondrocyte death when compared with fresh osteochondral allografts used as controls.

Surgical Treatment of Osteochondral Lesions of the Tibial Plafond: A Systematic Review and Meta-Analysis

BACKGROUND

The literature on osteochondral lesions of the tibial plafond (OLTPs) is sparse. The aim of this study was therefore to provide an overview of clinical and radiological outcomes following treatment of OLTPs.

METHODS

We performed a systematic search of the MEDLINE, Embase, and Cochrane library databases. The review was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines and included all original articles on treatment outcomes for OLTPs. The methodological quality of the articles was assessed using the Methodological Index for Non-Randomized Studies (MINORS). Baseline patient and lesion characteristics were pooled and weighted according to the number of lesions per study. The primary outcome was any clinical or patient-reported outcome measure pooled by treatment method when separable data were available. Secondary outcomes were complications, reoperation rates, radiological outcomes, and sport outcomes.

RESULTS

The search yielded 2,079 articles, of which 10 studies (1 prospective case series, 1 retrospective comparative study, and 8 retrospective case series) with a total of 175 patients were included. The overall methodological quality of the studies was low. All patients were treated surgically; 96% of the lesions were primary cases (i.e., first-time surgery) and 58% were solitary tibial lesions (i.e., no opposing talar lesion). Arthroscopic bone marrow stimulation was the most frequently used treatment strategy (51%), followed by cartilage transplantation (17%), chondrogenesis-inducing techniques (11%), osteochondral transplantation (3%), retrograde drilling (3%), and mixed (i.e., inseparable) treatments (15%). The clinical outcomes of the different surgical therapies were considered to be moderate to good. The pooled postoperative AOFAS (American Orthopaedic Foot & Ankle Society) score for bone marrow stimulation and osteochondral transplantation was 54.8 (95% confidence interval [CI], 49.5 to 85.0) (n = 14) and 85.3 (95% CI, 56 to 100) (n = 3), respectively. Overall, complications and reoperations were rarely reported. The pooled complication and reoperation rates could only be calculated for bone marrow stimulation and were 5% and 7%, respectively.

CONCLUSIONS

Surgical interventions for OLTPs appear to yield moderate to good clinical outcomes. Bone marrow stimulation resulted in a moderate AOFAS score. Complications and reintervention rates were found to be low. The current evidence in the literature is limited because of the underreporting of clinical, radiological, and sport data and the heterogenous outcome scores reported.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

[Osteochondral lesions of the talus : Individualized approach based on established and innovative reconstruction techniques]

Osteochondral lesions (OCL) of the talus are defined as chondral damage with subchondral involvement. The traumatic etiology is important; in particular, sprains and fractures can lead to lesions of the articular surface and the subchondral plate. As a result, unstable lesions and subchondral cysts can trigger substantial persistent pain and functional impairments. A primary conservative treatment can be considered and is especially recommended in children and adolescents; however, return to previous sports activity and level is often not achieved. The principles of reconstructive surgical management include internal fixation of osteochondral fragments, bone marrow stimulation, autologous membrane-augmented chondrogenesis ± bone grafting, osteochondral transfer, retrograde techniques ± bone grafting, (matrix-associated) autologous chondrocyte implantation and autologous osteoperiosteal graft from the iliac crest. Additional surgical procedures for ankle stabilization and deformity correction should be considered if necessary.

Osteochondral Lesions of the Talus: An Individualized Treatment Paradigm from the Amsterdam Perspective

Osteochondral lesions of the talus (OLTs) are characterized by damage to the articular cartilage of the talus and its underlying subchondral bone. Up to 75% of OLTs are caused by trauma, such as an ankle sprain or fracture. Physical examination and imaging are crucial for diagnosis and characterization of an OLT. No superior treatment for OLTs exists. It is paramount that an evidence-based personalized treatment approach is applied to patients with OLTs because lesion and patient characteristics guide treatment. This current concepts review covers clinical and preclinical evidence on OLT etiology, presentation, diagnosis, and treatment, all based on the Amsterdam perspective.

Electromagnetic navigation reduces radiation exposure for retrograde drilling in osteochondrosis dissecans of the talus

Background

Retrograde drilling in osteochondrosis dissecans (OCD) is a widely used surgical intervention. A radiation-free electromagnetic navigation system (ENS)-based method was compared with the standard freehand fluoroscopic (SFF) method regarding clinical applicability.

Methods

We performed a clinical cohort study at a department of Orthopaedics in a Level 1 children’s hospital with 40 patients (20 SFF and 20 ENS). Retrograde drilling of the talar dome was used in patients with unstable medial OCD (MRI stage 2 according to Hepple’s revised classification; stage 2 according to the International Cartilage Repair Society). The outcome measurements were: (a) Intraoperative fluoroscopy exposure and length of surgery and (b) Postoperative serial follow-up MRIs every 6 months.

Results

22 female and 18 male patients aged 13.8 ± 1.6 years (range: 11–17 years) were included. Using the ENS technique, length of surgery was significantly reduced to 20.2 ± 6.4 min compared to 36.1 ± 11.8 min (p < 0.01) for the SFF technique. The average x-ray radiation time for the SFF technique was 23.5 ± 13.5 sec and 1.9 ± 1.7 sec for the ENS technique (p < 0.01). Radiation exposure was significantly reduced from 44.6 ± 19.7 mSv (SFF technique) to 5.6 ± 2.8 mSv (ENS technique) (p < 0.01). Intraoperative perforation of cartilage occurred once in the SFF group. Correct placement of the drilling channel was verified in all patients on follow-up MRI after six months and a timely healing was seen after two years.

Conclusions

The ENS method provides for a significant reduction in length of surgery and radiation exposure. ENS was without intraoperative cartilage perforation. The clinical and radiological follow-up parameters are comparable for SFF- and ENS-guided retrograde drilling.

Trial registration

WF – 085/20, 05/2020 “retrospectively registered” https://www.aerztekammer-hamburg.org/ethik_kommission.html.

Six out of ten patients with sinus tarsi syndrome returned to pre-injury type of sport after subtalar arthroscopy

PURPOSE

The purpose of this study was to determine multiple return to sport rates, long-term clinical outcomes and safety for subtalar arthroscopy for sinus tarsi syndrome.

METHODS

Subtalar arthroscopies performed for sinus tarsi syndrome between 2013 and 2018 were analyzed. Twenty-two patients were assessed (median age: 28 (IQR 20-40), median follow-up 60 months (IQR 42-76). All patients were active in sports prior to the injury. The primary outcome was the return to pre-injury type of sport rate. Secondary outcomes were time and rate of return to any type of sports, return to performance and to improved performance. Clinical outcomes consisted of Numerous Rating Scale of pain, Foot and Ankle Outcome Score, 36-item Short Form Survey and complications and re-operations.

RESULTS

Fifty-five percent of the patients returned to their preoperative type of sport at a median time of 23 weeks post-operatively (IQR 9.0-49), 95% of the patients returned to any type and level sport at a median time of 12 weeks post-operatively (IQR 4.0-39), 18% returned to their preoperative performance level at a median time of 25 weeks post-operatively (IQR 8.0-46) and 5% returned to improved performance postoperatively at 28 weeks postoperatively (one patient). Median NRS in rest was 1.0 (IQR 0.0-4.0), 2.0 during walking (IQR 0.0-5.3) during walking, 3.0 during running (IQR 1.0-8.0) and 2.0 during stair-climbing (IQR 0.0-4.5). The summarized FAOS score was 62 (IQR 50-90). The median SF-36 PCSS and the MCSS were 46 (IQR 41-54) and 55 (IQR 49-58), respectively. No complications and one re-do subtalar arthroscopy were reported.

CONCLUSION

Six out of ten patients with sinus tarsi syndrome returned to their pre-injury type of sport after being treated with a subtalar arthroscopy. Subtalar arthroscopy yields effective outcomes at long-term follow-up concerning patient-reported outcome measures in athletic population, with favorable return to sport level, return to sport time, clinical outcomes and safety outcome measures.

LEVEL OF EVIDENCE

IV.

Satisfactory long-term clinical outcomes after bone marrow stimulation of osteochondral lesions of the talus

PURPOSE

The purpose of the present study was to evaluate the clinical and radiological outcomes of arthroscopic bone marrow stimulation (BMS) for the treatment of osteochondral lesions of the talus (OLTs) at long-term follow-up.

METHODS

A literature search was conducted from the earliest record until March 2021 to identify studies published using the PubMed, EMBASE (Ovid), and Cochrane Library databases. Clinical studies reporting on arthroscopic BMS for OLTs at a minimum of 8-year follow-up were included. The review was performed according to the PRISMA guidelines. Two authors independently conducted the article selection and conducted the quality assessment using the Methodological index for Non-randomized Studies (MINORS). The primary outcome was defined as clinical outcomes consisting of pain scores and patient-reported outcome measures. Secondary outcomes concerned the return to sport rate, reoperation rate, complication rate, and the rate of progression of degenerative changes within the tibiotalar joint as a measure of ankle osteoarthritis. Associated 95% confidence intervals (95% CI) were calculated based on the primary and secondary outcome measures.

RESULTS

Six studies with a total of 323 ankles (310 patients) were included at a mean pooled follow-up of 13.0 (9.5-13.9) years. The mean MINORS score of the included studies was 7.7 out of 16 points (range 6-9), indicating a low to moderate quality. The mean postoperative pooled American Orthopaedic Foot and Ankle Society (AOFAS) score was 83.8 (95% CI 83.6-84.1). 78% (95% CI 69.5-86.8) participated in sports (at any level) at final follow-up. Return to preinjury level of sports was not reported. Reoperations were performed in 6.9% (95% CI 4.1-9.7) of ankles and complications related to the BMS procedure were observed in 2% (95% CI 0.4-3.0) of ankles. Progression of degenerative changes was observed in 28% (95% CI 22.3-33.2) of ankles.

CONCLUSION

Long-term clinical outcomes following arthroscopic BMS can be considered satisfactory even though one in three patients show progression of degenerative changes from a radiological perspective. These findings indicate that OLTs treated with BMS may be at risk of progressing towards end-stage ankle osteoarthritis over time in light of the incremental cartilage damage cascade. The findings of this study can aid clinicians and patients with the shared decision-making process when considering the long-term outcomes of BMS.

LEVEL OF EVIDENCE

Level IV.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Level II.