Arthroscopic Microfracture for Osteochondral Lesions of the Talus: Second-Look Arthroscopic and Magnetic Resonance Analysis of Cartilage Repair Tissue Outcomes

Autologous osteoperiosteal transplantation for cystic osteochondral lesions of the talus: Bone reconstruction is essential

PURPOSE

Autologous osteoperiosteal transplantation (AOPT) is one of the most feasible and effective techniques for cystic osteochondral lesions of the talus (OLT). However, few reports have been reported about the process of graft-host bone healing and bone articular surface reconstruction, which help us to further understand the actual situation of bone healing and modify surgical methods.

METHODS

We retrospectively evaluated 33 osteochondral lesions in 30 patients undertaking AOPT for OLT with subchondral cysts from December 2016 to October 2021. According to CT observation, we used 4 variables to describe the bony articular repair, including the integration of the articular surface, the height of the bone filling, the status of bone union, and the appearance of bone resorption or cystic change. We also analyzed the demographic data and clinical function. Descriptive statistics were used for demographic and clinical variables. Normally distributed data were presented as mean ± SD, and non-normally distributed data were presented as median (Q1, Q3). Associations between these variables and the primary clinical outcomes were examined using t-test or one-way ANOVA test for continuous variables.

RESULTS

The patients' mean age was (41.7 ± 14.0) years old and the mean follow-up time was (29.6 ± 17.8) months. The chondral lesion size was (14.3 ± 4.1) mm. The cyst depth was (10.9 ± 3.7) mm. Significant improvements were observed in functional outcomes (according to the numeric rating scale for pain when walking and the American orthopedic foot and ankle society score) between the preoperative and latest follow-up evaluations, from 4.2 ± 2.1 to 2.2 ± 2.0 (p < 0.001), and from 66.8 ± 12.9 to 83.2 ± 10.4, respectively (p < 0.001). The overall satisfaction reached 8.3 of 10 points. All patients returned to sports and their median daily steps reached 8000 steps with 27 (81.8%) patients walking over 6000 steps daily. According to CT observation, "discontinuous bony articular surface and gap > 1 mm" was found in 27 grafts (81.8%), and "below the level of the adjacent articular surface, ≤ 1 mm" in a third of the grafts. Abnormal height of bone filling affected numeric rating scale score (p = 0.049) and American Orthopedic Foot and Ankle Society score (p = 0.027). Of note, bone resorption or cystic changes appeared in up to 13 autografts (39.4%).

CONCLUSIONS

AOPT is an effective and acceptable technique for cystic OLT. Bone reconstruction is essential for large cystic OLT. How to get better bony articular reconstruction and avoid cyst recurrence should still be paid more attention.

Comparison of the medial midline and the anterolateral portal in ankle arthroscopy for the treatment of osteochondral lesions of the medial talus

PURPOSE

To compare the clinical efficacy and complication rates between the medial midline and anterolateral portals in ankle arthroscopy for treating medial osteochondral lesions of the talus (OLTs).

METHODS

We retrospectively analyzed patients with medial OLTs who underwent either a dual medial approach (via the medial midline and anteromedial portal) or a traditional approach (via the anterolateral and anteromedial portal) between June 2017 and January 2023. The degree of injury was evaluated by radiographs, computed tomography, and magnetic resonance imaging. Clinical outcomes were assessed using the visual analog scale (VAS), the American Orthopaedic Foot and Ankle Society (AOFAS) score, and the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) scoring system. The incidence of postoperative complications, including superficial peroneal nerve (SPN) injury, was evaluated in all patients.

RESULTS

There were 39 patients in total; 16 patients underwent the dual medial approach, and 23 patients underwent the traditional approach. The mean age was 39.4 ± 9.0 years, and the mean follow-up duration was 18.7 ± 6.4 months. The clinical outcomes improved significantly in both groups (*P < 0.05), but there was no significant difference between the two groups (P > 0.05). Postoperative complications were mainly SPN injury. The incidence of SPN injury was 13.0% in the traditional approach group and 0% in the dual medial approach group, with no significant difference between the two groups (P > 0.05), but a trend of reduction in SPN injury was observed in the dual medial approach group.

CONCLUSION

The dual medial approach can also treat medial OLTs well, providing clear visualization and more convenient operation and reducing the possibility of injury to the SPN compared with the traditional approach. Therefore, we consider that the MM portal would be a good alternative to the anterolateral portal in treating medial OLTs.

Preoperative and Postoperative Imaging and Outcome Scores for Osteochondral Lesion Repair of the Ankle

Cartilage lesions to the ankle joint are common and can result in pain and functional limitations. Surgical treatment aims to restore the damaged cartilage's integrity and quality. However, the current evidence for establishing best practices in ankle cartilage repair is characterized by limited quality and a low level of evidence. One of the contributing factors is the lack of standardized preoperative and postoperative assessment methods to evaluate treatment effectiveness and visualize repaired cartilage. This review article seeks to examine the importance of preoperative imaging, classification systems, patient-reported outcome measures, and radiological evaluation techniques for cartilage repair surgeries.

Improved Results From Medium- and Long-Term Outcomes of Autogenous Osteoperiosteal Grafting for Large Cystic Lesions of the Talus

PURPOSE

To investigate the medium and long-term follow-up outcomes of large cystic medial osteochondral lesions of the talus (OLTs) treated with autologous tibial osteoperiosteal grafts from the medial tibia and to explore the risk factors influencing the treatment outcomes.

METHODS

The retrospective study included 75 patients with large cystic medial OLTs who underwent autologous osteoperiosteal cylinder graft taken from the medial tibia between January 2004 and August 2018. They were assessed preoperatively and postoperatively using a visual analog scale, the Orthopedic Foot & Ankle Society Ankle-Hindfoot Scale (AOFAS), and short-form 36-item Short Form Health Survey score. Magnetic resonance observation of cartilage repair tissue, second-look arthroscopy, and biopsy were used to evaluate the grafting areas.

RESULTS

After a follow-up period of 6.3 years, the virtual analog scale score decreased to 1.47 ± 1.32, and the AOFAS and 36-item Short Form Health Survey scores increased to 82.78 ± 11.65 and 83.26 ± 8.49, respectively, all of which showed significant improvement over preoperative scores (P < .001), and the average magnetic resonance observation of cartilage repair tissue score was 82.6 ± 8.4 (56.0-91.6). Eight patients underwent a second-look arthroscopic examination and were rated by the International Cartilage Repair Society scale; of them, 2 patients were rated grade Ⅰ, 4 were rated grade Ⅱ, and 2 were rated grade Ⅲ. Three patients underwent grafting area biopsy during the second-look arthroscopy, and the results showed that the grafting areas were rich in chondrocytes. Large OLTs (≥200 mm2) and obesity (body mass index ≥25) were responsible for the poor improvement of AOFAS score, according to multivariate Cox regression analysis.

CONCLUSIONS

Autologous osteoperiosteal grafting was an effective treatment for large cystic medial OLTs, with effective cartilage regeneration in the grafted areas in the medium and long term. However, the large OLTs and obesity may reduce the treatment outcomes.

LEVEL OF EVIDENCE

Level IV, case series.

Autologous Costal Chondral/Osteochondral Transplantation and Costa-Derived Chondrocyte Implantation for Articular Cartilage Repair: Basic Science and Clinical Applications

There has been increasing application of autologous costal chondral/osteochondral transplantation (ACCT/ACOT) and costa-derived chondrocyte implantation (ACCI) for articular cartilage repair over the past three decades. This review presents the major evidence on the properties of costal cartilage and bone and their qualifications as grafts for articular cartilage repair, the major clinical applications, and the risks and strategies for costal chondral/osteochondral graft(s) harvest. First, costal cartilage has many specific properties that help restore the articular surface. Costa, which can provide abundant cartilage and cylindrical corticocancellous bone, preserves permanent chondrocyte and is the largest source of hyaline cartilage. Second, in the past three decades, autologous costal cartilage-derived grafts, including cartilage, osteochondral graft(s), and chondrocyte, have expanded their indications in trauma and orthopaedic therapy from small to large joints, from the upper to lower limbs, and from non-weight-bearing to weight-bearing joints. Third, the rate of donor-site complications of ACCT or ACOT is low, acceptable, and controllable, and some skills and accumulated experience can help reduce the risks of ACCT and ACOT. Costal cartilage-derived autografting is a promising technique and could be an ideal option for articular chondral lesions with or without subchondral cysts. More high-quality clinical studies are urgently needed to help us further understand the clinical value of such technologies.

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.

Autologous Costal Osteochondral Transplantation for Cystic Osteochondral Lesions of the Talus: Feasible and Effective

OBJECTIVE

Osteochondral lesions of the talus (OLT) is a common and clinically challenging disease. The optimal management is still under debate. The purpose of this prospective study was to investigate the feasibility and clinical outcomes of autologous costal osteochondral transplantation (ACOT) for the treatment of cystic OLT.

METHODS

From November 2021 to April 2023, five patients underwent autologous costal osteochondral transplantation (ACOT) for cystic OLT. The demographic data was described, including age, gender, lesion size and location. We prospectively evaluated their functional and imaging outcomes of the five patients for 12 months postoperatively, including numeric rating score (NRS) for pain when walking, Tegner score, American Orthopedic Foot & Ankle Society (AOFAS) score and Foot and Ankle Ability Measure (FAAM) score, and imaging results. A paired t-test was used for preoperative and postoperative comparison of the paired-design dataset.

RESULTS

The average age was 36.6 ± 11.1 years. The average diameter of chondral lesions was 14.95 ± 2.71 mm, the average diameter of subchondral cysts was 10.66 ± 1.84 mm, and their average depth was 10.40 ± 1.86 mm. At 12 months postoperatively, the clinical function indexes improved significantly, including NRS (from 5.2 ± 2.3 to 0), Tegner score (from 3.2 ± 0.4 to 5.8 ± 0.4), AOFAS score (from 72.8 ± 10.0 to 98.2 ± 4.0), and FAAM score (FAAM/ADL from 61.2 ± 24.7 to 99.3 ± 1.6; FAAM/Sports from 32.5 ± 13.73 to 96.3 ± 8.4). Their magnetic resonance observation of cartilage repair tissue (MOCART) scores reached 78.0 ± 7.6 points. ICRS scores of three patients were nearly normal (10 or 11 points). The biopsy of the surviving grafts showed plenty of hyaline cartilage matrix and scattered chondrocytes histologically. No major severe complications were reported during the 12 months follow-up.

CONCLUSION

ACOT could significantly relieve the symptoms of patients with OLT and improve their clinical function at short-term follow-up. ACOT might be a feasible and useful method for repairing OLT with subchondral cysts.

Effectiveness and safety of arthroscopy combined with radial extracorporeal shockwave therapy for osteochondritis of the talus: a prospective, single-centre, randomized, double-blind study

Aims

Arthroscopic microfracture is a conventional form of treatment for patients with osteochondritis of the talus, involving an area of < 1.5 cm2. However, some patients have persistent pain and limitation of movement in the early postoperative period. No studies have investigated the combined treatment of microfracture and shortwave treatment in these patients. The aim of this prospective single-centre, randomized, double-blind, placebo-controlled trial was to compare the outcome in patients treated with arthroscopic microfracture combined with radial extracorporeal shockwave therapy (rESWT) and arthroscopic microfracture alone, in patients with ostechondritis of the talus.

Methods

Patients were randomly enrolled into two groups. At three weeks postoperatively, the rESWT group was given shockwave treatment, once every other day, for five treatments. In the control group the head of the device which delivered the treatment had no energy output. The two groups were evaluated before surgery and at six weeks and three, six and 12 months postoperatively. The primary outcome measure was the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale. Secondary outcome measures included a visual analogue scale (VAS) score for pain and the area of bone marrow oedema of the talus as identified on sagittal fat suppression sequence MRI scans.

Results

A total of 40 patients were enrolled and randomly divided into the two groups, with 20 in each. There was no statistically significant difference in the baseline characteristics of the groups. No complications, such as wound infection or neurovascular injury, were found during follow-up of 12 months. The mean AOFAS scores in the rESWT group were significantly higher than those in the control group at three, six, and 12 months postoperatively (p < 0.05). The mean VAS pain scores in the rESWT group were also significantly lower than those in the control group at these times (p < 0.05). The mean area of bone marrow oedema in the rESWT group was significantly smaller at six and 12 months than in the control group at these times (p < 0.05).

Conclusion

Local shockwave therapy was safe and effective in patients with osteochondiritis of the talus who were treated with a combination of arthroscopic surgery and rESWT. Preliminary results showed that, compared with arthroscopic microfracture alone, those treated with arthroscopic microfracture combined with rESWT had better relief of pain at three months postoperatively and improved weightbearing and motor function of the ankle.

Validation of the Foot and Ankle Outcome Score (FAOS) for Osteochondral Lesions of the Ankle

BACKGROUND

The purpose of this study was to validate the Foot and Ankle Outcome Score (FAOS) for osteochondral lesions of the talus (OLTs). We hypothesize that the FAOS will meet all 4 psychometric criteria for validity in this patient population.

METHODS

From 2008 to 2014, a total of 208 patients with OLTs were included in the construct validity portion of the study. All patients completed FAOS and 12-Item Short-Form Health Survey (SF-12) scores. Twenty additional patients were prospectively recruited and were asked to complete questionnaires to determine the relevance of each of the FAOS questions as it related to their OLT. Forty-four patients completed the FAOS 1 month after the first FAOS to assess reliability via Spearman correlation coefficient. Responsiveness of the FAOS was assessed with 54 patients who had both preoperative and postoperative FAOS scores via Student paired t test with significance determined as P < .05. In total, 229 unique patients were included in this study.

RESULTS

Statistically significant associations were found between all FAOS and SF-12 subscales (P < .01). The FAOS symptoms subscale demonstrated the lowest correlation with the SF-12 physical health domains. No floor or ceiling effects were identified. Weak correlations were calculated between the 5 FAOS subscales and the SF-12 mental component summary score. All FAOS domains met the threshold for acceptable content validity (score > 2.0). All FAOS subscales demonstrated acceptable test-retest reliability, with ICC values ranging from 0.81 (ADL) to 0.92 (Pain).

CONCLUSION

This study demonstrates the acceptable yet moderate construct and content validity, reliability, and responsiveness of the FAOS for patients with OLTs of the ankle joint. We endorse the use of the FAOS in evaluating ankle OLTs in both the research and clinical setting and consider it a useful patient-reported, self-administered instrument following surgical intervention.

LEVEL OF EVIDENCE

Level IV, retrospective case study.

The Frequency and Severity of Complications in Surgical Treatment of Osteochondral Lesions of the Talus: A Systematic Review and Meta-Analysis of 6,962 Lesions

OBJECTIVE

The primary aim was to determine and compare the complication rate of different surgical treatment options for osteochondral lesions of the talus (OLTs). The secondary aim was to analyze and compare the severity and types of complications.

DESIGN

A literature search was performed in MEDLINE (PubMed), EMBASE (Ovid), and the Cochrane Library. Methodological quality was assessed using the Methodological Index for Non-Randomized Studies (MINORS). Primary outcome was the complication rate per surgical treatment option. Secondary outcomes included the severity (using the Modified Clavien-Dindo-Sink Complication Classification System for Orthopedic Surgery) and types of complications. The primary outcome, the severity, and the sub-analyses were analyzed using a random effects model. A moderator test for subgroup-analysis was used to determine differences. The types of complications were presented as rates.

RESULTS

In all, 178 articles from the literature search were included for analysis, comprising 6,962 OLTs with a pooled mean age of 35.5 years and follow-up of 46.3 months. Methodological quality was fair. The overall complication rate was 5% (4%-6%; treatment group effect, P = 0.0015). Analysis resulted in rates from 3% (2%-4%) for matrix-assisted bone marrow stimulation to 15% (5%-35%) for metal implants. Nerve injury was the most observed complication.

CONCLUSIONS

In 1 out of 20 patients treated surgically for an OLT, a complication occurs. Metal implants have a significantly higher complication rate compared with other treatment modalities. No life-threatening complications were reported.

Ankle Sprains in Athletes: Current Epidemiological, Clinical and Imaging Trends

Purpose

Ankle injuries are frequent sports injuries. Despite optimizing treatment strategies during recent years, the percentage of chronification following an ankle sprain remains high. The purpose of this review article is, to highlight current epidemiological, clinical and novel advanced cross-sectional imaging trends that may help to evaluate ankle sprain injuries.

Methods

Systematic PubMed literature research. Identification and review of studies (i) analyzing and describing ankle sprain and (ii) focusing on advanced cross-sectional imaging techniques at the ankle.

Results

The ankle is one of the most frequently injured body parts in sports. During the COVID-19 pandemic, there was a change in sporting behavior and sports injuries. Ankle sprains account for about 16-40% of the sports-related injuries. Novel cross-sectional imaging techniques, including Compressed Sensing MRI, 3D MRI, ankle MRI with traction or plantarflexion-supination, quantitative MRI, CT-like MRI, CT arthrography, weight-bearing cone beam CT, dual-energy CT, photon-counting CT, and projection-based metal artifact reduction CT may be introduced for detection and evaluation of specific pathologies after ankle injury. While simple ankle sprains are generally treated conservatively, unstable syndesmotic injuries may undergo stabilization using suture-button-fixation. Minced cartilage implantation is a novel cartilage repair technique for osteochondral defects at the ankle.

Conclusion

Applications and advantages of different cross-sectional imaging techniques at the ankle are highlighted. In a personalized approach, optimal imaging techniques may be chosen that best detect and delineate structural ankle injuries in athletes.

Retrograde Autologous Talar Osteocancellous Bone Grafting for the Treatment of Osteochondral Lesions of the Talus: A Technical Note

Osteochondral lesions of the talus (OLT) are common injuries in young athletes. Various kinds of surgical procedures are available for orthopaedic surgeons, but which surgical technique is the best remains controversial. Many surgical procedures require malleolar osteotomy to obtain appropriate surgical exposure to the OLT because of the anatomic characteristics of the ankle joint. However, malleolar osteotomy is invasive and has a potential risk of complications, such as tibial chondral damage and pseudoarthrosis. This article aims to introduce a novel surgical procedure for the treatment of OLTs: retrograde autologous talar osteocancellous bone grafting without the need for osteotomy and harvesting a graft from anywhere other than the talus. First, an arthroscopic evaluation is performed to verify the location, size, and cartilage quality of the OLT as well as concomitant lesions. After confirming the position of the guide pin using a guide device arthroscopically, a talar osteocancellous bone plug is harvested using a coring reamer. The OLT of the harvested talar bone plug is removed, and under arthroscopy, the talar osteocancellous bone plug is retrogradely inserted into the talar bone tunnel. To stabilize the implanted bone plug, one or two bioabsorbable pins are inserted from the lateral wall of the talus while applying counterforce to the articular surface of the bone plug. The present surgical technique can minimally invasively address the OLT without the need for malleolar osteotomy and harvesting a graft from the knee joint or iliac bone.

Comparison of arthroscopic debridement and microfracture in the treatment of osteochondral lesion of talus

Objective

This study was performed to compare the clinical effect of arthroscopic debridement vs. arthroscopic microfracture in the treatment of osteochondral lesions of the talus.

Methods

We retrospectively reviewed patients with osteochondral lesion of talus who were admitted to our hospital from April 2020 to April 2021. The patients were divided into Group A (arthroscopic debridement group, n = 39) and Group B (arthroscopic microfracture group, n = 42), and the intraoperative details in the two groups were analyzed. The American Orthopaedic Foot and Ankle Society (AOFAS) score and visual analogue scale (VAS) score were compared between the two groups before surgery and at the last follow-up.

Results

The postoperative AOFAS score (Group A, 40.9-82.26; Group B, 38.12-87.38), VAS score (Group A, 6.44-3.92; Group B, 6.38-2.05) significantly improved in both groups, but the improvement was significantly greater in Group B than in Group A (P < 0.05). Among all patients, the AOFAS and VAS scores of men aged ≤30 years and patients with a low body mass index (BMI) improved more significantly (P < 0.05).

Conclusion

The arthroscopic microfracture for the treatment of osteochondral lesion of talus is superior to joint debridement in terms of improving ankle function, especially in relatively young men with a relatively low BMI.

Collagen Scaffold Application in Arthroscopic Reconstruction of Osteochondral Lesions of the Talus With Autologous Cancellous Bone Grafts

Background

Single-step all-arthroscopic techniques have gained popularity recently in the treatment of osteochondral lesions of the talus (OLT). Concomitant subchondral bone defects led surgeons to add autologous bone grafting to the surgical procedures. Collagen scaffolds have been used widely for stabilization of the reconstruction and regeneration of the articular surface.

Purpose

To compare single-step all-arthroscopic treatment of OLT consisting of debridement, microfracture, autologous bone grafting, and application of fibrin sealant in 2 patient groups: with versus without collagen scaffold.

Study Design

Cohort study; Level of evidence, 3.

Methods

Included were 94 patients who underwent single-step all-arthroscopic treatment for OLT. Autologous bone grafting was applied to 48 patients (BG group), while autologous bone grafting plus collagen scaffold was applied to 46 patients (BG+S group). A fibrin sealant was applied to both groups. Clinical outcomes were assessed with the American Orthopaedic Foot & Ankle Society (AOFAS) score and the visual analog scale (VAS) for pain. Radiological outcomes were evaluated with the magnetic resonance observation of cartilage repair tissue score. The mean follow-up time was 69.3 ± 20.7 months.

Results

Patients in both groups showed statistically significant improvement in pre- to postoperative AOFAS and VAS scores (P < .001 for all), with no difference between groups in AOFAS and VAS score improvement. Complete healing with or without hypertrophy was achieved in 42 patients in the BG group (87.5%) and 38 patients in the BG+S group (82.6%).

Conclusion

The treatment of bone lesions in OLT may be the ultimate goal to obtain successful outcomes, in which case using a collagen scaffold besides grafting may not affect clinical and radiological outcomes.

Radiographic and Clinical Outcomes After Arthroscopic Microfracture for Osteochondral Lesions of the Talus: 5-Year Results in 355 Consecutive Ankles

Background:

Arthroscopic microfracture for osteochondral lesion of the talus (OLT) has shown good functional outcomes in the short and long term.

Purpose:

To investigate 5-year radiographic and clinical outcomes after arthroscopic microfracture in treatment of OLT and the effectiveness of adjunct therapies including platelet-rich plasma (PRP) and hyaluronic acid (HA).

Study Design:

Cohort study; Level of evidence, 2.

Methods:

We prospectively enrolled 432 patients who underwent arthroscopic microfracture for OLT from May 1, 2011, to May 31, 2015. Magnetic resonance imaging (MRI) and weightbearing radiographs were performed annually after the initial surgery. The MOCART (magnetic resonance observation of cartilage repair tissue) score was used to evaluate the structure of the repaired cartilage on MRI, and patient-reported outcomes (American Orthopaedic Foot and Ankle Society ankle-hindfoot scale [AOFAS] and the Foot and Ankle Outcome Score) were collected annually. The primary outcome measure was 5-year AOFAS score. We recorded baseline characteristics including age, body mass index (BMI), and lesion size, and other potentially related factors including number of PRP/HA injection and change in BMI from baseline.

Results:

Included were 355 patients, all with minimum 5-year follow-up data. The overall reoperation rate was 9.0% (32 of 355). According to multivariable analysis, 5-year AOFAS scores were associated with number of PRP injections (correlation coefficient, 3.12 [95% CI, 2.36 to 3.89]; P < .001), BMI at baseline (correlation coefficient, -0.222 [95% CI, -0.363 to -0.082]; P = .002), and mean BMI change from baseline (correlation coefficient, -1.15 [95% CI, -1.32 to -0.98]; P < .001). When comparing number of PRP injections (0, 1-2, or ≥3), we found that patients who had serial PRP injection (≥3 with at least a 3-month interval between injections) had diminished functional and radiographic deterioration over time.

Conclusion:

Arthroscopic microfracture improved patient-reported and structural outcomes for patients with OLT at 5 years after surgery. Serial PRP injections and reduction in BMI from baseline were able to slow radiographic and functional deterioration. Future trials regarding the combination of microfracture and PRP in treatment of OLT should focus on the efficacy of longer term, intra-articular, serial injections of PRP instead of single injections.

Avascular Necrosis of the Talus Following Subchondroplasty: A Case Report and Review of Literature

CASE

Avascular necrosis (AVN) of the talus in a 45-year-old female following subchondroplasty with calcium phosphate bone filler for treatment of anterolateral and posteromedial talar dome bone marrow lesions (BMLs). The patient subsequently presented as consultation, 18 months postoperatively, with AVN of the talus. After failing conservative management, the patient underwent a total ankle arthroplasty at 46 months after subchondroplasty with resolution of pain.

CONCLUSION

There are few studies that have reported on the safety of subchondroplasty of the talus. Given the tenuous blood supply to the talar body and poor patient outcomes associated with AVN, caution should be taken before extrapolating the generally positive results of subchondroplasty in the knee.

LEVEL OF EVIDENCE

Level IV.

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

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

Correlation of Postoperative Imaging With MRI and Clinical Outcome After Cartilage Repair of the Ankle: A Systematic Review and Meta-analysis

Background

Magnetic resonance imaging (MRI) is commonly used for evaluation of ankle cartilage repair, yet its association with clinical outcome is controversial. This study analyzes the correlation between MRI and clinical outcome after cartilage repair of the talus including bone marrow stimulation, cell-based techniques, as well as restoration with allo- or autografting.

Methods

A systematic search was performed in MEDLINE, Embase, and Cochrane Collaboration. Articles were screened for correlation of MRI and clinical outcome. Guidelines of Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) were used. Chi-square test and regression analysis were performed to identify variables that determine correlation between clinical and radiologic outcome.

Results

Of 2687 articles, a total of 43 studies (total 1212 cases) were included with a mean Coleman score of 57 (range, 33-70). Overall, 93% were case series, and 5% were retrospective and 2% prospective cohort studies. Associations between clinical outcome and ≥1 imaging variable were found in 21 studies (49%). Of 24 studies (56%) using the composite magnetic resonance observation of cartilage repair tissue (MOCART) score, 7 (29%) reported a correlation of the composite score with clinical outcome. Defect fill was associated with clinical outcome in 5 studies (12%), and 5 studies (50%) reported a correlation of T2 mapping and clinical outcome. Advanced age, shorter follow-up, and larger study size were associated with established correlation between clinical and radiographic outcome (P = .021, P = .028, and P = .033).

Conclusion

Interpreting MRI in prediction of clinical outcome in ankle cartilage repair remains challenging; however, it seems to hold some value in reflecting clinical outcome in patients with advanced age and/or at a shorter follow-up. Yet, further research is warranted to optimize postoperative MRI protocols and assessments allowing for a more comprehensive repair tissue evaluation, which eventually reflect clinical outcome in patients after cartilage repair of the ankle.Level of Evidence: Level III, systematic review and meta-analysis.

A New Concept of Mosaicplasty: Autologous Osteoperiosteal Cylinder Graft Covered With Cellularized Scaffold

A concern regarding osteochondral autograft transfer for chondral defects is donor-site morbidity of the knee, the most common source of the autograft. To avoid the drawbacks of osteochondral autograft transfer, a cylindrical osteoperiosteal graft harvested from the iliac crest covered by a same-sized cylinder of hyaluronic acid-based polymer scaffold pretreated with bone marrow aspirate concentrate and transferred to the chondral defect recipient site in the exact size for restoration of the subchondral bone and the articular cartilage.

Osteochondral Lesions of the Ankle Treated with Bone Marrow Concentrate with Hyaluronan and Fibrin: A Single-Centre Study

Osteochondral defects of the ankle (OCD) are being increasingly identified as a clinically significant consequence of injury to the ankle, with the potential to lead to osteoarthritis if left untreated. The aim of this retrospective cohort study was to evaluate a single-stage treatment of OCD, based on bone marrow aspirate (BMA) centrifuged to produce bone marrow concentrate (BMC). In a dual syringe, the concentrate was mixed with thrombin in one syringe, whereas hyaluronan and fibrinogen were mixed in a second syringe. The two mixtures were then injected and combined into the prepared defect. Clinical outcome and quality of life scores (MOXFQ and EQ-5D) were collected at baseline and yearly thereafter. Multilevel models were used to analyse the pattern of scores over time. Ninety-four patients were treated between 2015 and 2020. The means of each of the three components of the MOXFQ significantly improved between baseline and 1 year (p < 0.001 for each component), with no further change from year 1 to year 3. The EQ-5D index also improved significantly from baseline to 1 year, with no evidence for further change. Our results strongly indicate that this BMC treatment is safe for, and well tolerated by, patients with OCD of the ankle as both primary treatment and those who have failed primary treatment. This technique provides a safe, efficacious alternative to currently employed cartilage repair techniques, with favourable outcomes and a low complication rate at 36 months.

Childhood Cartilage ECM Enhances the Chondrogenesis of Endogenous Cells and Subchondral Bone Repair of the Unidirectional Collagen-dECM Scaffolds in Combination with Microfracture

Despite the formation of mechanically inferior fibrocartilage, microfracture (MF) still remains the gold standard to repair the articular cartilage defects in clinical settings. To date, although many tissue-engineering scaffolds have been developed to enhance the MF outcome, the clinical outcomes remain inconsistent. Decellularized extracellular matrix (dECM) is among the most promising scaffold for cartilage repair due to its inheritance of the natural cartilage components. However, the impact of dECM from different developmental stages on cellular chondrogenesis and therapeutic effect remains elusive, as the development of native cartilage involves the distinct temporal dependency of the ECM components and various growth factors. Herein, we hypothesized that the immature cartilage dECM at various developmental stages was inherently different, and would consequently impact the chondrogenic potential BMSCs. In this study, we fabricated three different unidirectional collagen-dECM scaffolds sourced from neonatal, childhood, and adolescent rabbit cartilage tissues, and identified the age-dependent biological variations, including DNA, cartilage-specific proteins, and growth factors; along with the mechanical and degradation differences. Consequently, the different local cellular microenvironments provided by these scaffolds led to the distinctive cell morphology, circularity, proliferation, chondrogenic genes expression, and chondrogenesis of BMSCs in vitro, and the different gross morphology, cartilage-specific protein production, and subchondral bone repair when in combination with microfracture in vivo. Together, this work highlights the immature cartilage dECM at different developmental stages that would result in the diversified effects to BMSCs, and childhood cartilage would be considered the optimal dECM source for the further development of dECM-based tissue engineering scaffolds in articular cartilage repair.

Location Distribution of 2,087 Osteochondral Lesions of the Talus

OBJECTIVE

The primary aim of this study was to evaluate the exact location distribution in patients with osteochondral lesions of the talus (OLTs) using a 9-grid scheme. The secondary aim is to match lesion location to lesion size, arthroscopic or open operation, and trauma occurrence.

METHODS

A systematic review was performed in the databases PubMed, EMBASE, and Cochrane. Search terms consisted of "talus" and "osteochondral lesion." Two independent reviewers evaluated search results and conducted the quality assessment using the Methodological Index for Non-Randomized Studies (MINORS). Primary outcome measure was OLT location in the 9 zone-grid. Secondary outcome measures were OLT size in 9-zones, preoperative radiological modality use, demographic lesion size variables as well as open or arthroscopic treatment.

RESULTS

Fifty-one articles with 2,087 OLTs were included. Heterogeneity concerning methodological nature was observed and methodological quality was low. The posteromedial (28%) and centromedial (31%) zones combined as one location was the location with the highest incidence of OLTs with a rate of 59%. Individual OLT size was reported for only 153 lesions (7%). Preoperative combination of X-ray and magnetic resonance imaging (MRI), and/or computed tomography (CT) was reported in 20 studies (43%). Trauma was reported in 78% of patients. Furthermore, 67% was treated arthroscopically and 76% received primary OLT treatment.

CONCLUSION

The majority of OLTs are located in the posteromedial and centromedial zone, while the largest OLTs were reported in the centrocentral zone. Further research is required to identify the prognostic impact of location occurrence on the outcomes following OLT treatment.

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.

Long-term Patient-Reported Outcome Measures Following Particulated Juvenile Allograft Cartilage Implantation for Treatment of Difficult Osteochondral Lesions of the Talus

BACKGROUND

Conventional methods are not suitable for difficult to treat osteochondral lesions of the talus (OCLTs). The role of particulated juvenile allograft articular cartilage implantation is not well elucidated for long-term patient outcomes.

METHODS

Thirteen patients with difficult-to-treat OCLTs underwent arthroscopy-assisted implantation of particulated juvenile articular cartilage graft into defects from 2010 to 2012 by the same surgeon. "Difficult to treat" was defined as having at least 3 of the following features or 2 if both variables described lesion characteristics: (1) lesions size of 107 mm² or greater, (2) shoulder lesions, (3) patients who failed microfracture, (4) patient aged ≥40 years, or (5) patient body mass index (BMI) >25. Patients were evaluated using physical examination, patient interviews, and outcome score measures. Patients had follow-up at 2 years, 4 years, and between 6 and 10 years at their most recent follow-up. Differences in functional outcome scores were compared before and after surgery.

RESULTS

Patients (age: 46.5 ± 11.8 years, BMI: 28.5 ± 6.1) had, on average, most recent follow-up of 8.0 years (range 72-113 months). Average visual analog scale for pain score decreased for patients by 3.9 points (95% confidence interval [CI] 2.18-5.60), when compared to preoperative assessment. Foot and Ankle Ability Measure (FAAM) Activities of Daily Living (ADL) and Sports subscale scores also improved from 46.5 to 80.9 (95% CI 21.35-47.43), and from 18.8 to 57.9 (95% CI 21.05-57.10), respectively. Short Form-36 Health Survey physical component scores showed significant improvement by an average of 45.5 points (95% CI 32.42-58.50). American Orthopaedic Foot & Ankle Society Ankle-Hindfoot Scale scores improved from 55.2 to 80.3 (95% CI 12.459-37.741).

CONCLUSION

These results demonstrate positive patient-reported long-term outcomes for a cohort of patients with difficult OCLTs, followed over the course of 6-10 years after treatment with arthroscopy-assisted particulated juvenile articular cartilage implantation.

LEVEL OF EVIDENCE

Level II, prospective cohort study.

Arthroscopic one-step matrix-assisted bone marrow stimulation for the treatment of osteochondral defects of the talus

OBJECTIVE

All arthroscopic one-step treatment of osteochondral defects of the talus with matrix-assisted bone marrow stimulation with a cell-free hyaluronic acid 3D matrix.

INDICATIONS

Symptomatic osteochondral defects of the talus (1-2 cm², ICRS III-IV).

CONTRAINDICATIONS

Large non-shouldered osteochondral defects (2 cm²) of the talus, arthritis, kissing lesions of the distal tibia, metabolic arthropathies, non-reconstructable defects, hindfoot malalignment, chronic inflammatory systemic disorders.

SURGICAL TECHNIQUE

Arthroscopic examination of the ankle joint and visualization of the osteochondral defect of the talus to confirm the indication via standard portals. First, debridement of the osteochondral defect with arthroscopic curette or shaver, removal of loose fragments, resection of the sclerotic bone via shaver and measurement of the defect size. Second, multiple perforation of the subchondral plate to recruit mesenchymal stem cells from the underlying bone marrow by an microfracturing awl to stimulate the differentiation of fibrocartilaginous repair tissue in the defect zone. Then, the cell-free hyaluronic acid 3D matrix is placed into the defect via arthroscopic forceps and modulated by a probe to avoid detachment of the matrix by ankle joint movement.

POSTOPERATIVE MANAGEMENT

Postoperative management includes movement restrictions for pro- and supination but free passive dorsal extension and plantar flexion. No weight-bearing is allowed for 6 weeks.

RESULTS

Twenty-three patients (male: 11/women: 12) with a mean age of 33 years (range: 18-56) and a minimum follow-up of 24 months were included in this retrospective two-center study. The mean values for Foot and Ankle Outcome Score (FAOS) were 79 (range 33-93), for Tegner score 3 (range: 1-5) and the Visual analog scale (VAS) pain 1 (range: 0-3) and VAS function 2 (range: 0-5). At follow-up, MRI was available in 17 of 23 patients. MRI results showed a mean Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score of 81 (range: 65-90). Complications were not observed during the follow-up period.

Comparison of Clinical and Radiographic Outcomes Following Arthroscopic Debridement With Extracellular Matrix Augmentation and Osteochondral Autograft Transplantation for Medium-Size Osteochondral Lesions of the Talus

BACKGROUND

Historically, microfracture has been used to treat small talar osteochondral lesions with good results, whereas osteochondral autologous transplantation (OAT) has proven effective for the treatment of larger lesions. It is not clear which method is more effective for medium-sized lesions around the critical size of 150 mm², above which microfracture outcomes tend to be poor. The purpose of this study was to determine the potential advantages of OAT augmented with a combination of extracellular matrix and bone marrow aspirate concentrate (ECM-BMAC) compared to debridement with ECM-BMAC (DEB) in the treatment of medium-sized osteochondral lesions of the talus (OLTs).

METHODS

Clinical and radiographic data were collected retrospectively for patients treated by a single fellowship-trained foot and ankle surgeon. Magnetic resonance images (MRIs) were scored using the Magnetic Resonance Observation of Cartilage Tissue (MOCART) system and were evaluated for the presence of cysts and edema. Fifty-two patients met inclusion criteria, with 25 who received an OAT procedure. Age, body mass index, lesion size, lesion location, and follow-up time were similar between groups. Average MRI follow-up times were 16.7 months for the OAT group and 20.3 months for the DEB group (P = .38).

RESULTS

Patients treated with OAT had significantly higher average total MOCART scores (69 vs 55, P = .04) and significantly lower rates of cyst (14% vs 55%, P < .01), edema (59% vs 90%, P = .04), revision surgery (0% vs 19%, P = .05), and therapeutic injection for pain (4% vs 30%, P = .02) compared to patients treated with DEB. No significant differences were detected in patient-reported outcome scores between groups.

CONCLUSION

The native hyaline cartilage introduced by OAT appears to result in higher-quality repair tissue when compared to DEB, as evidenced by OAT patients' higher MOCART scores and lower rates of cyst and edema. There was no difference in clinical outcome scores, though OAT patients did not require revision surgery or therapeutic injection for pain as frequently as DEB patients.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Arthroscopic International Cartilage Repair Society Classification System Has Only Moderate Reliability in a Porcine Cartilage Repair Model

BACKGROUND

The International Cartilage Repair Society (ICRS) score was designed for arthroscopic use to evaluate the quality of cartilage repair.

PURPOSE

To evaluate the reliability of the ICRS scoring system using an animal cartilage repair model.

STUDY DESIGN

Controlled laboratory study.

METHODS

A chondral defect with an area of 1.5 cm² was made in the medial femoral condyle of 18 domestic pigs. Five weeks later, 9 pigs were treated using a novel recombinant human type III collagen/polylactide scaffold, and 9 were left to heal spontaneously. After 4 months, the pigs were sacrificed, then 3 arthroscopic surgeons evaluated the medial femoral condyles via video-recorded simulated arthroscopy using the ICRS scoring system. The surgeons repeated the evaluation twice within a 9-month period using their recorded arthroscopy.

RESULTS

The porcine cartilage repair model produced cartilage repair tissue of poor to good quality. The mean ICRS total scores for all observations were 6.6 (SD, 2.6) in arthroscopy, 5.9 (SD, 2.7) in the first reevaluation, and 6.2 (SD, 2.8) in the second reevaluation. The interrater reliability with the intraclass correlation coefficient (ICC) for the ICRS total scores (ICC, 0.46-0.60) and for each individual subscore (ICC, 0.26-0.71) showed poor to moderate reliability. The intrarater reliability with the ICC also showed poor to moderate reliability for ICRS total scores (ICC, 0.52-0.59) and for each individual subscore (ICC, 0.29-0.58). A modified Bland-Altman plot for the initial arthroscopy and for the 2 reevaluations showed an evident disagreement among the observers.

CONCLUSION

In an animal cartilage repair model, the ICRS scoring system seems to have poor to moderate reliability.

CLINICAL RELEVANCE

Arthroscopic assessment of cartilage repair using the ICRS scoring method has limited reliability. We need more objective methods with acceptable reliability to evaluate cartilage repair outcomes.

Lesion Size May Predict Return to Play in Young Elite Athletes Undergoing Microfracture for Osteochondral Lesions of the Talus

PURPOSE

To evaluate the clinical and sports-related outcomes of arthroscopic microfracture (MFx) for osteochondral lesion of the talus (OLT) in elite athletes.

METHODS

The athletes who underwent arthroscopic MFx for OLTs at our institution between January 2011 and September 2015 with minimum 2 years of follow-up were reviewed. The Foot and Ankle Outcome Score, American Orthopaedic Foot & Ankle Society, and visual analog scale pain score, time and rate of "return-to-competition" (RTC, return to an official match for at least 1 minute after treatment), and rate of "return-to-play" (RTP, participation in at least 2 entire seasons after treatment) were used to evaluate the outcomes. We compared athletes who were able to RTP with those who were not.

RESULTS

In total, 41 patients (mean age 19.34 ± 3.76 years) were included. The mean follow-up was 54.9 ± 13.72 months. In total, 36 patients had medial lesions, and 5 patients had lateral lesions. All subscales of preoperative Foot and Ankle Outcome Score were significantly improved at the final follow-up. The mean preoperative American Orthopaedic Foot & Ankle Society score of 74.46 ± 8.10 improved to 91.62 ± 2.99 (P < .001) at the final follow-up. The mean preoperative visual analog scale pain score of 5.44 ± 1.57 improved to 2.66 ± 1.04 (P < .001). All patients achieved RTC (100%) at mean time of 5.45 ± 3.18 months, and 74.4% of patients were able to RTP. The RTP-group showed significantly smaller lesions compared to the No-RTP group (71.52 ± 43.29 vs 107.00 ± 45.28 mm², P = .009). The cut-off OLT size for predicting RTP was 84.0 mm², with a sensitivity of 90.0% and specificity of 75.9%.

CONCLUSIONS

All athletes were able to RTC at average of 5.45 months after MFx for OLTs with minimal subchondral involvement, and 74.4% were able to RTP. The only prognostic variable for RTP was lesion size, and its predictive cut-off was 84.0 mm².

LEVEL OF EVIDENCE

IV, Case series.

Athletic Performance in the National Basketball Association After Arthroscopic Debridement of Osteochondral Lesions of the Talus

Background:

Use of marrow-stimulating techniques to treat osteochondral lesions of the talus (OLTs) in National Basketball Association (NBA) players is controversial.

Hypothesis:

NBA players will be able to return to preinjury playing status after treatment of OLTs by arthroscopic debridement alone without marrow-stimulating techniques.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Between the 2000 and 2015 seasons, 10 NBA players were treated with arthroscopic debridement of an OLT. The following performance outcomes were compared pre- and postoperatively: seasons played, games played, games started, minutes per game, points per game, field goals, 3-point shots, rebounds, assists, double doubles, triple doubles, steals, blocks, turnovers, personal fouls, assists per turnovers, steals per turnovers, NBA rating, scoring efficiency, and shooting efficiency. In addition, the players were compared with a matched control group using mixed effects regression and Fisher least significant difference modeling.

Results:

All 10 players returned to play in the NBA after arthroscopic debridement without microfracture or drilling of an OLT. When compared with preoperative performance, postoperative mean points scored, assists made, and steals made increased by 2.86 (P = .042), 0.61 (P = .049), and 0.15 (P = .027), respectively. Only field goal percentage decreased postoperatively when compared with matched controls; however, this normalized by the end of the second season after surgery. There was no statistically significant change in any of the other performance factors when compared with matched controls. All patients returned to basketball during the same season (n = 1) or the following season (n = 9) if the operation was performed off-season. The mean length of career after surgery was 4.1 years, with 5 players still playing in the league at the time of this study.

Conclusion:

After arthroscopic debridement of an OLT without drilling or microfracture, there was a high rate of return to the NBA, with improved points scored, assists, and steals made after surgery when compared with preoperative performance. There was no statistically significant change in any performance factors when compared with uninjured matched controls. Lesion size did not affect player career length. These data should be used to manage patients’ and teams’ expectations regarding players’ ability to return to elite levels of athletic performance after surgery of an OLT.

Current treatment concepts for osteochondral lesions of the talus

Osteochondral lesions of the talus (OLT) are a well-known cause of ankle joint pain and can sometimes lead to instability. These lesions are not only confined to articular hyaline cartilage, they can also affect the subchondral bone at the weight-bearing aspect of the talar dome. Nonoperative treatment is the preferred option for small lesions, however surgical intervention is recommended for large lesions or those for which conservative treatment has failed. Microfracture, abrasion arthroplasty and multiple drilling are all classified as bone marrow stimulation procedures; they are used to try to recruit precursor cells for cartilage regeneration and are especially suitable for small OLT lesions. For large lesions, osteochondral autografting and allografting are better options to reconstruct the articular defect, as they have better contours and mechanical strength. When there is limited subchondral bone involvement in large lesions, cell-based therapies such as autogenous chondrocyte implantation, potentially combined with a biomaterial matrix, are a promising option and acceptable functional outcomes have been reported. To provide evidence-based recommendations for clinicians, this article evaluates the currently available treatment strategies for OLT and their evolution over the past few decades.

Arthroscopic Treatment of Osteochondral Lesions of the Talus With Microfracture and Platelet-Rich Plasma-Infused Micronized Cartilage Allograft

Osteochondral lesions of the talus (OLTs) are difficult to treat. Arthroscopic microfracture augmented with micronized cartilage (BioCartilage; Arthrex, Naples, FL) and platelet-rich plasma is emerging as a treatment for moderate-sized, well-contained full-thickness OLTs. This treatment may provide superior histologic results and is less technically demanding and yields less morbidity than an open osteochondral allograft or autograft transfer. This technique guide presents the senior author's preferred strategy for treatment of a moderate-sized OLT with arthroscopic microfracture and placement of micronized cartilage and platelet-rich plasma.