Retrograde Drilling for Osteochondral Lesion of the Talus in Juvenile Patients

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

RATIONALE

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

PATIENT CONCERNS

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

DIAGNOSES

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

INTERVENTIONS

Arthroscopic debridement and microfracture were performed bilaterally.

OUTCOMES

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

LESSONS

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

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.

Synthetic bone grafting with preserved cartilage flap via a medial malleolus osteotomy approach to treat osteochondral lesion of the talus: technical note and preliminary clinical results

PURPOSE

Although various surgical procedures are available for osteochondral lesion of the talus (OLT), there is still no consensus on its best treatment. The purposes of this study were to describe a new surgical technique to treat OLT and to analyze its preliminary clinical results.

METHODS

Eight patients were enrolled in this retrospective study between March 2019 and May 2022 in the Second Affiliated Hospital of Chongqing Medical University. All patients were treated by synthetic bone grafting with preserved cartilage flap via a medial malleolus osteotomy approach. The patients' characteristics, operative time, and estimated blood loss were evaluated. Intraoperative photos, preoperative and postoperative X-ray and MRI imaging were recorded. The American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score and visual analog scale (VAS) score were also recorded before surgery and at each follow-up.

RESULTS

At six months after the operation, all patients showed bone ingrowth and remodeling according to X-ray and MRI. No obvious defects or ladder was found on the cartilage surface of all patients according to MRI. The AOFAS score improved from 61.63 ± 8.85 (range, 49-74) to 91.13 ± 4.49 (range, 83-97) (p < 0.001) and VAS score improved from 5.50 ± 1.60 (range, 4-8) before surgery to 1.88 ± 0.83 (range, 1-3) (p < 0.001) at latest follow-up. In all eight patients, no wound infection, skin necrosis, or delayed healing of osteotomy was found.

CONCLUSION

We proposed a simple and effective technique that restored the shape of the cartilage surface by preserving the cartilage flap and restoring the natural congruency of the subchondral bone by synthetic bone grafting. We found satisfying clinical outcomes in short-term follow-up. Our new technique might be a new surgical option for the treatment of OLT and its effectiveness should be further evaluated.

Development of osteophytes and joint space narrowing is associated with cartilage degeneration of the osteochondral fragment in the osteochondral lesion of the talus

BACKGROUND

During surgery for osteochondral lesions of the talus (OLT), preservation or excision of the osteochondral fragment is chosen based on the cartilage condition which influences the indication and clinical outcomes of surgical treatments. However, it is difficult to predict arthroscopic and histological findings of the cartilage on osteochondral fragments by radiographic evaluation. We focused on osteoarthritis (OA) changes on plain radiographs to predict the cartilage condition of the OLT. This study aimed to evaluate whether OA changes, including osteophyte and joint space narrowing, could predict arthroscopic and histological findings of the cartilage in OLT.

METHODS

Seventy ankles with OLT were included in this study. Osteophytes and joint space narrowing were scored on plain radiographs. Lesion sizes were measured on computed tomography images. The cartilage surfaces of fragments were arthroscopically assessed using the International Cartilage Repair Society (ICRS) grade. Biopsy specimens from 32 ankles were histologically analyzed using the Mankin score. The relationships between OA scores, lesion size, ICRS grades, and Mankin score were analyzed.

RESULTS

OA changes were frequently observed with increasing ICRS grades, especially in the medial tibiotalar joint. OA scores in patients with ICRS grade 1 were significantly lower than those in ICRS grades 2,3, and 4. The lesion sizes in patients with ICRS grade 3 and 4 were significantly smaller than those in patients with ICRS grade 1 and 2. Histological analysis showed increasing Mankin scores as the ICRS grade worsened. A mild correlation existed between the OA and Mankin scores (rs = 0.494).

CONCLUSIONS

OA changes, such as osteophyte formation and joint space narrowing, are associated with arthroscopic findings of the articular surface and cartilage degeneration in osteochondral fragment in OLT. Articular cartilage conditions can be predicted by OA changes on plain radiographs, which is useful for choosing the appropriate treatment for patients with OLT.

LEVEL OF EVIDENCE

Level Ⅳ, case series.

Retrograde Drilling and Bone Graft for Hepple Stage V Subchondral Bone Lesion of Talus Using 3D Image-Based Navigation-Assisted Endoscopic Technique

BACKGROUND

Retrograde drilling remains technically challenging, because of the difficulty of identifying the accurate location of cysts during surgery. This study's aim was to evaluate the 3-dimensional (3D) image-based surgical navigation-assisted endoscopic retrograde drilling technique for subchondral bone lesions of the talus.

METHODS

From March 2017 to June 2020, a total of 21 cases with Hepple stage V subchondral bone lesions of the talus were treated with 3D image-based surgical navigation-assisted endoscopic retrograde drilling and bone graft technique. Arthroscopic views were categorized per Pritsch classifications. The correlation between the drilled tunnel with preoperative cystic lesions were assessed under postoperative computer tomographic (CT) scans. The American Orthopaedic Foot & Ankle Society (AOFAS) scores, visual analog scale (VAS) scores, and Foot and Ankle Ability Measure (FAAM) sports scales were evaluated at the preoperative and final consultation. All complications were recorded.

RESULTS

On postoperative CT scans, in 20 cases (95.2%), the drilled tunnel was judged to have been in the center of previous cysts. Only 9 cases (42.9%) showed intact normal cartilage (grade 0, group A); 12 cases (57.1%) had intact, but soft, cartilage (grade I, group B). The median follow-up time was 24 (24, 30) months, and at final follow-up, there were no significant differences between the mean AOFAS and VAS scores in both groups (89.0 ± 6.4 vs 88.3 ± 7.0 and 1 vs 0.5) or postoperative FAAM sports scales (28.2 ± 2.2 vs 26.6 ± 4.9, P = .363). Two patients had revision surgery in group B.

CONCLUSION

The 3D image-based surgical navigation-assisted endoscopic retrograde drilling and bone graft technique for the subchondral bone lesions of the talus in this small case series showed encouraging results.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

A novel retrograde technique for ankle osteochodral lesions: the sub-endo-chondral regenerative treatment (secret)

PURPOSE

To describe a new surgical technique for osteochondral lesions of the ankle, using bone marrow concentrate on a scaffold and homologous bone graft positioned through a retrograde approach. Many surgical options for ankle osteochondral lesions have been described, and the ideal treatment is still debated. Bone marrow stimulating techniques are recommended for cystic lesions, with some concerns regarding the healing potential of the subchondral bone. In case of wide osteochondral defects, regenerative solutions are preferred but a massive chondral debridement is usually required. To overcome these problems, a novel technique is proposed.

METHODS

The proposed technique was performed on patients affected by osteochondral lesions of the talus, either cysts with intact cartilage or wide osteochondral defects. A preoperative magnetic resonance imaging was obtained to localize the lesion. A 6-mm tarsal tunnel was retrogradely created toward the lesion, to allow a complete sub-endo-chondral debridement preserving the healthy cartilage. A hyaluronan scaffold soaked with a previously prepared bone marrow concentrate was retrogradely positioned under the cartilage surface and the tunnel was filled with homologous bone graft. Preoperative clinical scores and postoperative x-rays were registered.

RESULTS

Four patients were treated using this technique. No intraoperative and postoperative complications occurred. Good bone remodeling was observed at 12-week postoperative x-rays.

CONCLUSIONS

This technique combines the mini-invasiveness of retrograde drilling with the regenerative properties of biological scaffold soaked with bone marrow concentrate. Despite further research being needed, it seems a new viable solution to treat both subchondral cysts and large osteochondral defects of the ankle, whose management is still controversial.

Retrograde drilling for ankle joint osteochondral lesions: a systematic review

BACKGROUND

Extensive literature exists about the treatment of ankle osteochondral lesions, but there is no specific review of retrograde drilling, despite its common application. Indications for retrograde drilling are still few and are far from clear, and some evolutions of the technique have recently occurred. The aim of this review is to provide an update on actual applications and techniques of retrograde drilling for ankle osteochondral lesions.

METHODS

A systematic review was carried out according to the 2020 PRISMA guidelines. The PubMed and Embase databases were searched in June 2023. The search string focused on studies related to retrograde drilling in the treatment of ankle osteochondral lesions.

RESULTS

Twenty-one articles for a total of 271 ankles were included in this review. The mean length of the treated lesions was 11.4 mm. Different navigation systems were used, with fluoroscopy the most commonly used. Various adjuvants were employed after drilling, with bone graft the most commonly applied. In most cases, postoperative patient satisfaction and symptom relief were reported, and no complications occurred. Retrograde drilling was found to be suitable for the treatment of subchondral cysts with intact cartilage or small lesions. Some modifications to the original technique may allow surgical indications to be extended to more complex cases.

CONCLUSIONS

Middle-term results of retrograde drilling showed postoperative satisfaction and symptom relief with both original and modified techniques. Additional research is required to investigate the long-term results.

LEVEL OF EVIDENCE

IV.

TRIAL REGISTRATION

This systematic review was registered on PROSPERO (id number: CRD42022371128).

A Systematic Review of the Retrograde Drilling Approach for Osteochondral Lesion of the Talus: Questioning Surgical Approaches, Outcome Evaluation and Gender-Related Differences

BACKGROUND

Retrograde drilling (RD) is a minimally invasive surgical procedure mainly used for non-displaced osteochondral lesions (OCL) of the talus, dealing with subchondral necrotic sclerotic lesions or subchondral cysts without inducing iatrogenic articular cartilage injury, allowing the revascularization of the subchondral bone and new bone formation.

METHODS

This systematic review collected and analyzed the clinical studies of the last 10 years of literature, focusing not only on the clinical results but also on patients' related factors (gender, BMI, age and complications).

RESULTS

Sixteen clinical studies were retrieved, and differences in the type of study, follow-up, number and age of patients, lesion type, dimensions, grades and comparison groups were observed, making it difficult to draw conclusions. Nevertheless, lesions on which RD showed the best results were those of I-III grades and not exceeding 150 mm² in size, showing overall positive results, a good rate of patient satisfaction, improvements in clinical scores, pain reduction and return to daily activities and sports.

CONCLUSIONS

There are still few studies dealing with the issue of post-surgical complications and gender-related responses. Further clinical or preclinical studies are thus mandatory to underline the success of this technique, also in light of gender differences.

Juvenile Osteochondral Lesions of the Talus: Current Concepts Review and an Update on the Literature

Osteochondral lesions of the talus (OLTs) are lesions that occur before the physis closes and are frequently associated with acute ankle trauma. These lesions are often difficult to diagnose due to swelling and inflammation that are present after the initial injury. A growing body of literature has assessed the effects of OLTs in the adult population. However, the literature examining these lesions in the juvenile population is sparse. The purpose of this review is to provide a thorough understanding of OLTs, with a specific focus on the juvenile population. We evaluate the recent literature regarding the outcomes of various surgical treatment; modalities in the pediatric patient. While the outcomes after surgical treatment of pediatric OLTs are generally favorable, the paucity of investigation in this demographic is alarming. Further research is needed to better inform practitioners and families regarding these outcomes, as treatment plans are highly dependent on the individual patient in question.

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.

Treatment of Osteochondral Lesions of the Talus in the Skeletally Immature Population: A Systematic Review

INTRODUCTION

Skeletally immature osteochondral lesions of the talus (OLTs) are underreported and little is known about the clinical efficacy of different treatment options. The primary aim of the present study was to investigate the clinical efficacy of different conservative and surgical treatment options. The secondary aim was to assess return to sports (RTS) and radiologic outcomes for the different treatment options.

METHODS

An electronic literature search was carried out in the databases PubMed, EMBASE, Cochrane, CDSR, CENTRAL, and DARE from January 1996 to September 2021 to identify suitable studies for this review. The authors separately screened the articles for eligibility and conducted the quality assessment using the Methodological Index for Non-Randomized Studies (MINORS). Clinical success rates were calculated per separate study and pooled per treatment strategy. Radiologic outcomes and sports outcomes for the different treatment strategies were assessed.

RESULTS

Twenty studies with a total of 381 lesions were included. The mean MINORS score of the included study was 7.6 (range: 5 to 9). The pooled success rate was 44% [95% confidence interval (CI): 37%-51%] in the conservative group (n=192), 77% (95% CI: 68%-85%) in the bone marrow stimulation (BMS) group (n=97), 95% (95% CI: 78%-99%) in the retrograde drilling (RD) group (n=22), 79% (95% CI: 61%-91%) in the fixation group (n=33) and 67% (95% CI: 35%-88%) in the osteo(chondral) autograft group (n=9). RTS rates were reported in 2 treatment groups: BMS showed an RTS rate of 86% (95% CI: 42%-100%) without specified levels and an RTS rate to preinjury level of 43% (95% CI: 10%-82%). RD showed an RTS rate of 100% (95% CI: 63%-100%) without specified levels, an RTS rate to preinjury level was not given. RTS times were not given for any treatment option. The radiologic success according to magnetic resonance imaging were 29% (95% CI: 16%-47%) (n=31) in the conservative group, 81% (95% CI: 65%-92%) (n=37) in the BMS group, 41% (95% CI: 18%-67%) (n=19) in the RD group, 87% (95% CI: 65%-97%) (n=19) in the fixation group, and were not reported in the osteo(chondral) transplantation group. Radiologic success rates based on computed tomography scans were 62% (95% CI: 32%-86%) (n=13) in the conservative group, 30% (95% CI: 7%-65%) (n=10) in the BMS group, 57% (95% CI: 25%-84%) (n=7) in the RD group, and were not reported for the fixation and the osteo(chondral) transplantation groups.

CONCLUSIONS

This study showed that for skeletally immature patients presenting with symptomatic OLTs, conservative treatment is clinically successful in 4 out of 10 children, whereas the different surgical treatment options were found to be successful in 7 to 10 out of 10 children. Specifically, fixation was clinically successful in 8 out of 10 patients and showed radiologically successful outcomes in 9 out of 10 patients, and would therefore be the primary preferred surgical treatment modality. The treatment provided should be tailor-made, considering lesion characteristics and patient and parent preferences.

LEVEL OF EVIDENCE

Level IV-systematic review and meta-analysis.

Osteochondral lesions of the talar dome: an up-to-date approach to multimodality imaging and surgical techniques

Osteochondral lesions (OCLs) of the talar dome consist of a multifactorial pathology of the articular cartilage and subchondral bone and can result in persistent ankle pain and osteoarthritis (OA). Along with a physical examination and clinical history, an imaging evaluation plays a pivotal role in the diagnosis of these lesions and is fundamental for making treatment decisions and determining prognosis by providing information regarding the size, location, and cartilage and subchondral bone statuses as well as associated lesions and degenerative changes. Multiple surgical techniques for OCLs of the talar dome have been developed in recent decades, including cartilage repair, regeneration, and replacement strategies, and radiologists should be acquainted with their specific expected and abnormal postoperative imaging findings to better monitor the results and predict poor outcomes. The present article proposes a thorough review of the ankle joint anatomy and biomechanics, physiopathology, diagnosis, and treatment of OCLs of the talar dome, highlighting the radiological approach and imaging findings in both pre- and postoperative scenarios.

Matrix-associated autologous chondrocyte implantation with autologous bone grafting of osteochondral lesions of the talus in adolescents: patient-reported outcomes with a median follow-up of 6 years

BACKGROUND

This study presents patient-reported outcome measures after combined matrix-associated autologous chondrocyte implantation and autologous bone grafting in high-stage osteochondral lesions of the talus in adolescents.

METHODS

A total of 12 adolescent patients (13 ankles) received matrix-associated autologous chondrocyte implantation and autologous bone grafting for a solitary osteochondral lesion of the talus at a single centre. The Foot and Ankle Outcome Score and Foot and Ankle Ability Measure were defined as outcome measures (median follow-up 80 months [range 22-107 months]). Pre- and postoperative ankle radiographs were evaluated according to the van Dijk ankle osteoarthritis scale.

RESULTS

The study population consisted of four male and nine female cases (mean age at the time of surgery, 17.7 ± 2.1 years). Eight lesions were classified as traumatic and five as idiopathic. Twelve lesions were located medial vs one lateral in the coronal plane and all central in the sagittal plane. The median lesion size and depth were 1.3 cm2 (range 0.9-3.2 cm2) and 5 mm (range 5-9 mm), respectively. There were no perioperative complications in any of the cases. In 9 cases patient-reported outcome measures were available. The results of the Foot and Ankle Outcome Score subscales were symptoms, 70 ± 14; pain, 83 ± 10; activities of daily living, 89 ± 12; sports/recreational activities, 66 ± 26; and quality of life, 51 ± 17. The mean overall Foot and Ankle Outcome Score was 78 ± 13. The results of the Foot and Ankle Ability Measure subscales were activities of daily living, 81 ± 20; function/activities of daily living, 84 ± 13; sports, 65 ± 29; and function/sports, 73 ± 27. According to the function overall subscale of the Foot and Ankle Ability Measure, in two cases, the patients assessed the ankle function as normal, in three as nearly normal, and in three as abnormal (missing data, n = 1). Preoperative van Dijk scale: stage 0 in five cases and stage I in eight cases; postoperative van Dijk scale: stage 0 in four cases, stage I in 9 cases CONCLUSIONS: Patient-reported outcome measures following matrix-associated autologous chondrocyte implantation and autologous bone grafting for high-stage osteochondral lesions of the talus in adolescents show heterogeneous results. Long-term limitations mainly affect sports and recreational activities. Osteochondral lesions of the talus are associated with osteoarthritis, even preoperatively. However, we did not find significant osteoarthritis progression after matrix-associated autologous chondrocyte implantation and autologous bone grafting in the long term.

Re-operation rate after surgical treatment of osteochondral lesions of the talus in paediatric and adolescent patients

BACKGROUND

The aim of this study is to analyse the re-operation rate after surgical treatment of osteochondral lesions of the talus (OCLTs) in children and adolescents.

METHODS

Between 2009 and 2019, 27 consecutive patients with a solitary OCLT (10 male, 17 female; mean age 16.9 ± 2.2 years; 8 idiopathic vs. 19 traumatic) received primary operative treatment (arthroscopy + bone marrow stimulation [BMS], n = 8; arthroscopy + retrograde drilling, n = 8; autologous chondrocyte implantation [ACI]/autologous bone grafting, n = 9; arthroscopy + BMS + retrograde drilling; n = 1; flake fixation, n = 1). Seventeen OCLTs were located at the medial and ten at the lateral talus. 'Re-operation' as the outcome measure was evaluated after a median follow-up of 42 months (range 6-117 months). Patients were further subdivided into groups A (re-operation, n = 7) and B (no re-operation, n = 20). Groups A and B were compared with respect to epidemiological, lesion- and therapy-related variables.

RESULTS

Seven of 27 patients needed a re-operation (re-operation rate 25.9% after a median interval of 31 months [range 13-61 months]). The following operative techniques were initially used in these seven patients: arthroscopy + BMS n = 2, arthroscopy + retrograde drilling n = 4, ACI + autologous bone grafting n = 1. A comparison of group A with group B revealed different OCLT characteristics between both groups. The intraoperative findings according to the International Cartilage Repair Society (ICRS) classification revealed significantly more advanced cartilage damage in group B than in group A (p = 0.001).

CONCLUSIONS

We detected a re-operation rate of 25.9% after primary surgical OCLT treatment. Patients with re-operation had significantly lower ICRS classification stages compared to patients without re-operation.