Treatment of Osteochondral Lesions of the Talus

Osteochondral Lesions of the Talus: Etiology, Clinical Presentation, Treatment Options, and Outcomes

This article reviews the etiology, clinical presentation, classification schemes, and treatment options for osteochondral lesions of the talus. These lesions typically occur after a traumatic injury and are best diagnosed on MRI. Asymptomatic lesions and incidentally found lesions are best treated conservatively; however, acute displaced osteochondral fragments may require surgical treatment. Lesion characteristics may dictate surgical technique. Outcomes following surgical treatment may be impacted by patient age, BMI, and lesion characteristics.

Talus Osteochondral Defect Treatment With Biological Scaffold

Talus Osteochondral defects (OCDs) are challenging and there is no consensus in literature regarding which is the best method of treatment. New techniques coming from regenerative medicine are being considered good alternatives of treatment and are being used exponentially in orthopaedic surgery. Platelet-rich fibrin (PRF) is the second generation of platelet concentrates. It has a convenient method of acquisition and can be used to create a biological scaffold which is able to seal up cavitary lesions. In this article, the authors describe a talus OCD treated with a biological scaffold, reporting the technique details and its results clinical and radiological results. The case report objective is to portray the use of this kind of biological material, its advantages, and limitations.Level of Evidence: Level 5.

Open Treatment of Osteochondral Lesions of the Talus With Bone Grafting and Particulated Juvenile Cartilage Allografting

BACKGROUND

Large cystic osteochondral lesions of the talus (OLT) are challenging pathological conditions to treat, but particulated juvenile cartilage allografts (PJCAs) supplemented with bone grafts are a promising therapeutic option. The purpose of this project was to further elucidate the role of PJCA with concomitant bone autografts for treating large cystic OLTs with extensive subchondral bone involvement (greater than 150 mm2 in area and/or deeper than 5 mm).

METHODS

We identified 6 patients with a mean OLT area of 307.2 ± 252.4 mm2 and a mean lesion depth of 10.85 ± 6.10 mm who underwent DeNovo PJCA with bone autografting between 2013 and 2017. Postoperative outcomes were assessed with radiographs, Foot and Ankle Outcome Scores (FAOS), and visual pain scale scores.

RESULTS

At final follow-up (27.0 ± 12.59 weeks), all patients had symptomatic improvement and incorporation of the graft on radiographs. At an average of 62 ± 20.88 months postoperatively, no patients required a revision surgery. All patients contacted by phone in 2018 and 2020 reported they would do the procedure again in retrospect and reported an improvement in their symptoms relative to their preoperative state, especially with pain and in the FAOS activities of daily living subsection (91.93 ± 9.04 in 2018, 74.63 ± 26.86 in 2020).

CONCLUSION

PJCA with concomitant bone autograft is a viable treatment option for patients with large cystic OLTs.

LEVELS OF EVIDENCE

Level IV.

Bone channeling in arthroscopic rotator cuff repair: a systematic review and meta-analysis of level I studies

BACKGROUND

There is ongoing controversy regarding the effect of bone channeling in arthroscopic rotator cuff repair. Since the most recent systematic reviews in 2019, several large high-level trials have been completed. This study assessed all available level I randomized controlled trials (RCTs) that compared arthroscopic rotator cuff repair with and without bone marrow channeling.

METHODS

A systematic search of the Ovid MEDLINE, Embase, and Cochrane Library databases was conducted through mid January 2023. Two reviewers performed screening of studies meeting the eligibility criteria: English-language RCTs in patients aged ≥18 years comparing arthroscopic rotator cuff repair of full-thickness tears with and without bone marrow channeling (channeling group and control group, respectively). Functional scores, pain, healing rates, and reoperations were reviewed using pooled analysis where appropriate. The methodologic quality of included studies was assessed using the Cochrane risk-of-bias tool and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

RESULTS

A total of 6 randomized studies (N = 593) met the inclusion criteria. Pooled analysis of all 6 studies showed no significant mean difference in function (1.32; 95% confidence interval [CI], -0.63 to 3.26), as measured by the Constant-Murley score. Retear rates were also not statistically different between groups (risk ratio, 0.99; 95% CI, 0.57 to 1.71), with pooled retear rates of 19.6% (48 of 245) with channeling and 19.8% (51 of 257) without. The other outcomes of interest were only available for analysis in a subset of studies. There were no standardized mean differences in pain (0.09; 95% CI, -0.18 to 0.36), and there were similar reoperation rates (risk ratio, 1.19; 95% CI, 0.43 to 3.34) in the channeling and control groups. For the included studies, the overall quality of evidence by outcome was judged to be moderate (function, pain, and reoperations) or low (retear rates), mainly owing to risk of bias (all outcomes) and inconsistency (retear rates).

CONCLUSION

The results of this study refute the findings of prior systematic reviews that showed that channeling reduces the retear rate when combined with arthroscopic rotator cuff repair. This meta-analysis of level I evidence, including recent larger RCTs, demonstrates that bone marrow stimulation in the setting of primary arthroscopic rotator cuff repair has no significant effect on functional outcomes, healing, pain, or reoperation rates.

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.

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.

Surgical Management and Return to Activity of an Athlete with Traumatic Posterior Tibial Tendon Rupture and Associated Injuries: A Case Report

CASE

A 22-year-old athlete sustained a traumatic posterior tibial tendon (PTT) rupture with medial malleolus fracture and anterior tibial plafond chondral lesion during practice. He underwent PTT repair, ankle arthroscopy with microfracture, and medial malleolus open reduction and internal fixation with deltoid ligament repair. At 1 year postoperatively, the patient returned to activity excluding high-level competition.

CONCLUSION

Anterior tibial chondral impaction injury with an avulsion fracture of the medial malleolus and PTT tear is effectively treated with a combined arthroscopic and open approach.

Comparison of Intermediate-Term Clinical Outcomes Between Medial and Lateral Osteochondral Lesions of the Talus Treated With Autologous Osteochondral Transplantation

BACKGROUND

The conventional operative method to treat an osteochondral lesion of the talus (OLT) is through bone marrow stimulation (BMS). Autologous osteochondral transplantation (AOT) is being used as an alternative option in cases with a large OLT, accompanying subchondral cyst, and/or failed BMS. We aimed to compare the intermediate-term clinical and radiologic results between medial and lateral OLTs after an AOT procedure.

METHODS

Among the patients who underwent AOT, 45 cases with at least 3 years' follow-up were included in this retrospective study. We had 15 cases of lateral lesions and selected 30 cases of medial lesions matched for age and gender. Lateral lesions were resurfaced without an osteotomy; medial lesion resurfacing was combined with a medial malleolar osteotomy. Clinical assessment was performed using the Foot and Ankle Outcome Score (FAOS) and Foot and Ankle Ability Measure (FAAM). Radiographic assessment included the irregularity of articular surface (subchondral plate), the progression of degenerative arthritis, and the change of the talar tilt.

RESULTS

The mean FAOS and FAAM scores significantly improved after surgery in both groups. Up to 1 year postoperatively, there was significant difference in FAAM scores between the both groups (mean 75.3 points in medial group and 87.2 points in lateral group, P < .001). Delayed union or malunion of the malleolar osteotomy was found in 4 cases (13%) in the medial group. In addition, the progression of joint degeneration was observed in 3 cases (10%) in the medial group. There were no significant differences in the irregularity of articular surface and the change of talar tilt between both groups.

CONCLUSION

A comparison between medial and lateral OLTs treated with AOT demonstrated comparable intermediate-term clinical outcomes. However, patients with medial OLT required a longer period to restore ability for daily and sport activities. In addition, we found more complications and higher rate of progression in the radiologic arthritis grade after medial malleolar osteotomy.

LEVEL OF EVIDENCE

Level IV, retrospective comparative study.

Analysis of factors affecting the prognosis of osteochondral lesions of the talus

PURPOSE

This study aims to analyze the correlation between the prognosis of osteochondral lesions of the talus and patient age, gender, duration of illness, and injury location, surface area, depth, and volume.

METHODS

A retrospective analysis of 44 patients who underwent talus osteochondral transplantation in the Department of Foot and Ankle Surgery of our hospital between January 2017 and December 2020 was performed. The clinical medical records of the patients were collected, and the location of the osteochondral lesion of the talus was determined according to the nine-division method. The surface area, depth, and volume of the osteochondral lesion of the talus were measured using mimics software in all patients. The visual analog scale (VAS), the American Orthopedic Foot and Ankle Society (AOFAS), and the SF-36 quality of life questionnaire scores were evaluated before surgery and at the last follow-up, and correlation analysis was performed.

RESULTS

Of 44 patients, 30 were followed up with a mean period of 24.33 ± 12.19 months. There were 18 men and 12 women, with an average age of 40.73 ± 10.57 years and an average disease duration of 28.30 ± 21.25 months. The VAS, AOFAS, and SF-36 scores of all patients at the last follow-up were significantly better than those before surgery. The degree of post-operative symptom improvement was not correlated with age, sex, duration of illness, and injury location, surface area, depth, and volume.

CONCLUSION

The prognosis of osteochondral lesion of the talus is not related to patient age, gender, duration of disease, or injury location, surface area, depth, and volume.

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.

Postsurgical Evaluation of the Pediatric Foot and Ankle

This article reviews situations in which surgical treatment is required in the context of different types of pathology in the foot and ankle of children, focusing on the role of imaging in surgical planning and postsurgical assessment. The types of pathology analyzed from this perspective are congenital pathology, neuromuscular disorders, osteochondral lesions, fractures and infection, ligament injuries, and tumors.We address the most common pitfalls of postsurgical imaging of the ankle and foot in children. With some exceptions, postsurgical follow-up focuses on clinical assessment, with imaging follow-up only needed in patients where complications are suspected or symptoms recur. Postoperative assessment of the foot and ankle in children and adolescents requires knowing the indications for surgery and the most common types of interventions, along with their imaging characteristics. The radiologist needs to be aware of the normal sequence of development of structures and how to select adequate imaging techniques to assess anatomy at various stages or in different postsurgical scenarios.

Outcomes of Talar Osteochondral and Transchondral Lesions Using an Algorithmic Approach Based on Size, Location, and Subchondral Plate Integrity: A 10-Year Study on 204 Lesions

The management of transchondral and osteochondral talar lesions has evolved, with microfracturing originally considered the best initial treatment. Despite talar lesions being a tri-dimensional defect, most studies use 2-dimensional parameters to grade them. We propose in this study that tri-dimensional sizing may be more appropriate in evaluation for treatment. The present study evaluated the outcomes of treatment of talar lesions performed by a single surgeon, creating and using an algorithm based on volume, location, and integrity of the subchondral plate. The lesions were classified as "small" (up to 125 mm³), "medium" (125 mm³-1500 mm³), and "large" (>1500 mm³) based upon evaluation of the preoperative magnetic resonance imagining. Location of the lesion was also noted on a 9-region grid pattern of the talar dome. These 3 parameters dictated whether a lesion required microfracturing or retrograde drilling, autogenous or allogenous bone graft, and whether an open versus an arthroscopic approach was required. Over a 10-year period, surgery was performed on 204 lesions. Overall, the average time to return to activity was 7.93 ± 5.00 (range 2-36) months. The average preoperative American Orthopaedic Foot and Ankle score was 76.44 ± 10.98 (range 52-86), and the average postoperative American Orthopaedic Foot and Ankle score was 96.12 ± 3.46 (range 81-100), p = .0001. By using the proposed algorithm, the outcome and return to activity for most patients can be better predicted, regardless of the size or location of the osteochondral lesion. The treatment algorithm implemented in the present investigation yielded overall acceptable results, with only 7 of the 204 lesions needing additional surgery.

Association of Elevated Body Mass Index and Outcomes of Arthroscopic Treatment for Osteochondral Lesions of the Talus

Background:

Osteochondral lesions of the talus (OLTs) are a common condition found in patients with chronic ankle pain after previous ankle sprains. Surgical management is indicated after conservative management has failed.

Hypothesis/Purpose:

This study evaluates the influence of body mass index (BMI) on the early clinical outcomes of arthroscopic debridement and microfracture of OLTs.

Methods:

A total of 252 patients with symptomatic OLTs who failed conservative management underwent arthroscopic debridement and microfracture of OLTs over the affected ankle between 2007 and 2017. Patients from this cohort were divided into 2 groups based on BMI: the normal BMI group (NB Group) (BMI 18.5-25.0) and overweight and obese BMI group (OB Group) (BMI ≥25). Visual analogue scale (VAS), American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score, and the physical and mental component summaries of the 36-Item Short-Form Health Survey (PCS and MCS, respectively) were prospectively collected from the cohort during their standard postoperative outpatient follow-up.

Results:

The NB Group (n=105) and OB Group (n=147) were well matched demographically. The operative duration was significantly shorter for the NB Group compared to the OB Group. Patients from both groups had significant improvements in VAS, AOFAS, and PCS scores postoperatively at 6 and 24 months after surgery ( P < .05). Between both groups, patients had comparable VAS, AOFAS, and PCS scores at preoperation, 6 months postoperation, and 24 months postoperation ( P > .05). However, MCS in the OB Group was lower at 24 months postoperatively compared with the NB Group ( P < .05). The OB Group reported better satisfaction scores (82.4% vs 72.6%, P < .05), and a greater proportion had their expectations met (88.2% vs 77.9%, P < .05).

Conclusion:

A BMI ≥25 was not associated with worse postoperative pain and functional outcomes, but rather was found to be associated with greater satisfaction and fulfillment. However, patients with BMI ≥25 required longer procedure duration and had poorer MCS scores at 24 months after surgery. Level of Evidence: Level III, retrospective cohort study.

Comparison of Autologous Osteoperiosteal and Osteochondral Transplantation for the Treatment of Large, Medial Cystic Osteochondral Lesions of the Talus

BACKGROUND

Autologous osteoperiosteal transplantation (AOPT) using graft harvested from the iliac crest is used to treat large cystic osteochondral lesions of the talus (OLTs). However, no studies have compared clinical and radiologic outcomes between AOPT and autologous osteochondral transplantation (AOCT) using graft harvested from the nonweightbearing zone of the femoral condyle of the ipsilateral knee in patients with large cystic OLTs.

PURPOSE

To compare clinical and radiologic outcomes between patients undergoing AOPT and those undergoing AOCT for large cystic OLTs.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Between March 2015 and March 2018, patients who underwent AOCT and AOPT to treat medial large cystic OLTs (>10 mm) were retrospectively evaluated. For comparability, the 2 groups were matched 1:1 based on their characteristics, including sex, age, body mass index, side of injury, follow-up period, and the preoperative cyst volume. After propensity score matching, 23 patients were enrolled in each group for the analysis. Clinical outcomes were assessed using the visual analog scale (VAS), the American Orthopaedic Foot & Ankle Society (AOFAS) score, and the Tegner score. Donor-site morbidity was recorded according to the symptoms, including pain, stiffness, swelling, and discomfort. In addition, the Lysholm score was used to assess the most common knee donor-site morbidity. Radiologic outcomes were evaluated using the magnetic resonance observation of cartilage repair tissue (MOCART) score, and the International Cartilage Regeneration & Joint Preservation Society (ICRS) score was obtained during second-look surgery.

RESULTS

The mean follow-up period was about 48 months. There were no significant differences in patient characteristics and lesion volumes between groups. Postoperative ankle pain VAS score, AOFAS score, and Tegner score were not significantly different between groups at final follow-up. Total donor-site morbidity (P = .004) and discomfort morbidity (P = .009) were significantly lower in the AOPT group than in the AOCT group. However, the Lysholm score showed no significant difference between the donor knee and the opposite knee (P = .503) in the AOCT group. The MOCART and ICRS scores were not significantly different between groups.

CONCLUSION

Clinical and radiologic outcomes of patients who underwent AOPT from the iliac crest were found to be comparable with those of patients who underwent AOCT from the ipsilateral knee for the treatment of medial large cystic OLTs. These results may be helpful for orthopaedic surgeons to decide appropriate treatments for patients with large cystic OLTs.

Higher preoperative range of motion is predictive of good mid-term results in the surgical management of osteochondral lesions of the talus: a prospective multicentric study

INTRODUCTION

Osteochondral lesions of the talus (OLT) are a frequent cause of pain in young patients and a new CT arthrographic classification system of OLT was recently proposed to help guide the choices of and standardize the indications for surgical treatment. The primary hypothesis was that this algorithm would result in a postoperative AOFAS score of ≥ 80/100. The secondary hypothesis was to identify the preoperative factors of successful surgery.

METHODS

This was a prospective observational multicenter study. Eighty-six patients who underwent surgery for OLT after at least 6 months of unsuccessful conservative management were included for a mean follow-up of 15 months (12-36). Forty-nine patients with stage 1 OLT underwent microperforation, 2 patients with stage 2 OLT underwent a lift, drill, fill, and fix graft procedure with screw fixation, and 35 patients with stage 3 OLT were treated with mosaicplasty.

RESULTS

After a follow-up of at least 1 year, 56 patients (65%) had an AOFAS score > 80 and the mean AOFAS score was 82 (16-100). A lower BMI (p = 0.038), a higher preoperative range of motion in the ankle (p = 0.033), higher preoperative AOFAS and FAOS scores (p = 0.001 and p = 0.011), and the presence of a preoperative bone bruise on MRI (p = 0.020) were good prognostic factors on univariate analysis. The presence of grade 1 osteoarthritis on the Van Dijk classification was predictive of a poor prognosis (p = 0.044). Multivariate analysis showed that a good preoperative range of motion (OR = 1.080 [1.020-1.150] p = 0.01) was predictive of a positive outcome, while grade 1 osteoarthritis was predictive of a poor outcome (OR = 0.147 [0.036-0.603] p = 0.008). The postoperative AOFAS decreased in six patients and 17 patients had at least one complication: six dysthesias of the superficial fibular nerve, two of the sural nerve, and nine stage 1 complex regional pain syndromes.

CONCLUSION

The new algorithm for OLT resulted in a postoperative AOFAS score of ≥ 80/100 in 65% of cases. The positive predictive factors of a successful postoperative outcome were the presence of a good preoperative range of motion and the absence of preoperative osteoarthritis.

LEVEL OF EVIDENCE

Level II.

Effect analysis of iliac bone autografting for Hepple V osteochondral lesions of the talus

Background

Talar cartilage injury is a kind of disease that causes long-term and chronic pain of ankle joint. Autologous osteochondral transplantation has been viewed as an alternative choice for treating these lesions, but donor-site morbidity has limited its application. This study aimed to analyze the efficacy of iliac bone autografting for Hepple V osteochondral lesions of the talus.

Methods

This retrospective study included 32 patients surgically treated for Hepple V osteochondral lesions of the talus from January 2015 to January 2020. All patients underwent open surgery. Ipsilateral iliac bone grafts were taken and filled with talar cartilage injury area. The improvement of postoperative ankle pain was evaluated by Visual Analogue Scale (VAS), and the improvement of ankle function was evaluated by the American Orthopaedic Foot & Ankle Society (AOFAS). During the postoperative follow-up, X-ray examination of the front and side of the ankle joint and CT of the ankle joint were performed to evaluate the bone cartilage healing in the graft area.

Results

Thirty-two patients (32 ankles) (100%) returned for clinical and radiologic follow-up at an average of 28 (range 24–36) months postoperatively. At 3 months postoperatively and at the last follow-up, the AOFAS scores were (80.4 ± 3.6) and (89.2 ± 6.4), respectively, which were significantly improved compared with the preoperative score (49.7 ± 8.1), and the difference was statistically significant (P < 0.05). The VAS scores were (2.1 ± 0.9) and (1.5 ± 0.8), respectively, which were significantly better than the preoperative score (6.2 ± 1.7), and the difference was statistically significant (P < 0.05). Re-examination of the front and side of the ankle joint X-rays and CT showed that the bone healing at the osteotomy of medial malleolus and osteochondral transplantation area. All patients had no pain at the donor site. No complications occurred in 32 patients at the last follow-up.

Conclusions

With iliac bone autografting for Hepple V osteochondral lesions of the talus can effectively relieve ankle joint pain and significantly improved ankle function.

Level of evidence

Level III, Retrospective series.

Sufficient Cartilage for Most Talar Articular Defects Can Be Harvested From the Non-Loadbearing Talus: A Cadaveric Analysis

Purpose

To assess the quantity of morselized cartilage that can be harvested from the non–load-bearing portion of the talus for immediate reimplantation.

Methods

Non–load-bearing talar cartilage was harvested from 5 cadaveric specimens using a standard arthroscopic approach. Cartilage was separated from the talus in maximum dorsiflexion at the junction of the talar head and neck, grasped, and morselized into a graft using a cartilage particulator. The volume of reclaimed cartilage was measured, and the extrapolated area of coverage was compared to average osteochondral lesions of the talus previously reported.

Results

The total yield of cartilage graft following processing that was obtained from 5 ankle joints ranged from 0.3 mL to 2.1 mL with a mean volume of 1.3 ± 0.7 mL, yielding a theoretical 13.2 ± 7.1 cm² coverage with a 1-mm monolayer. While the average size of osteochondral lesions of the talus is difficult to estimate, they may range from 0.5 cm² to 3.7 cm² according to the literature.

Conclusions

This study validated that it is possible to harvest sufficient amount of cartilage for an autologous morselized cartilage graft via a single-stage, single-site surgical and processing technique to address most talar articular cartilage defects.

Clinical Relevance

Particulated cartilage autografts have shown promise in surgical management of cartilage defects. A single-site, single-staged procedure that uses a patient’s autologous talar cartilage from the same joint has the potential to reduce morbidity associated with multiple surgical sites, multistaged procedure, or nonautologous tissue in ankle surgery.

Editorial Commentary: Drill and Fill: Bone Marrow Stimulation Plus Allograft Matrix May Optimize the Treatment of Osteochondral Lesions of the Talus

Osteochondral lesions of the talus remain a challenging pathologic entity facing orthopaedic foot and ankle surgeons. Although multiple treatment options exist, there is limited evidence supporting one technique over another. The ultimate goal of surgical intervention is to achieve lesion infill with tissue properties that best mimic those of hyaline articular cartilage. Restoring the anatomic surface of the talus may provide long-term clinical success and improve function. Augmentation of bone marrow stimulation with extracellular matrix cartilage allograft aims to achieve this goal.

Long-term Natural Course of the Osteochondral Lesion of the Talus in a Child: A Case Report

Recent reports have described midterm natural courses of osteochondral lesion of the talus (OLT) and lack of progression of ankle osteoarthritis (OA) in adult patients. The relationship between the OLT managed with nonoperative treatment and development of OA in children remains unknown. We report the long-term course of medial OLT in a 12-year-old female who was treated nonoperatively for 10 years. Radiographically, no osteoarthritic changes were observed at the first examination. She initially returned to her basketball club after nonoperative treatment. Although daily activities were not restricted, limitation of recreational activities began to appear at 4 years of follow-up. Subsequently, plain radiographs revealed bone absorption around the osteochondral fragment and osteophyte formation at the medial gutter, then ankle OA was advanced at the final follow-up.

Operative treatments for osteochondral lesions of the talus in adults: A systematic review and meta-analysis

PURPOSE

This systematic review aimed to identify the available evidence regarding the comparative effectiveness and safety of various operative treatments in adult patients with osteochondral lesions of the talus (OLT).

MATERIALS AND METHODS

The PubMed, Embase, ISI Web of Knowledge, and the Cochrane Controlled Trial Register of Controlled Trials were searched from their inception date to September 2019. Two reviewers selected the randomized controlled trials (RCTs) and non-RCTs assessing the comparative effectiveness and safety of various operative treatments for OLT. The meta-analysis was performed using Revman 5.3.

RESULTS

Eight studies (1 RCT and 7 non-RCTs) with 375 patients were included in this review. The difference in the American Orthopaedic Foot and Ankle Society (AOFAS) score between the cartilage repair and replacement was not significant. The cartilage regeneration with or without cartilage repair had significant superiority in improving the AOFAS score compared with the cartilage repair. The difference in the magnetic resonance observation of cartilage repair tissue score between the cartilage repair and replacement and between cartilage repair and cartilage repair plus regeneration was significant.

CONCLUSIONS

Cartilage regeneration and cartilage repair plus regeneration had significant superiority in improving the ankle function and radiological evaluation of OLT, although the trials included did not have high-level evidence. Moreover, which treatment between the 2 was safer could not be addressed in this review as most of the trials did not report the safety outcome. Further studies are needed to define the best surgical option for treating OLT.

Histopathological and Radiographic Features of Osteolysis After Fixation of Osteochondral Fragments Using Poly-L-Lactic Acid Pins for Osteochondral Lesions of the Talus

BACKGROUND

Fixation of osteochondral fragments is a potential option for treating an osteochondral lesion of the talus (OLT) involving large lesions in the remaining articular cartilage surface. Bioabsorbable devices, especially those made of poly-L-lactic acid (PLLA), can be used for the fixation of an OLT. Postoperative osteolysis surrounding the PLLA pins is occasionally observed; however, the significance of osteolysis remains unknown.

PURPOSE

To elucidate the association between osteolysis surrounding the PLLA pins, histopathological findings in subchondral bone, and preoperative Hounsfield unit (HU) values at the pin fixation site.

STUDY DESIGN

Case Series; Level of evidence, 4.

METHODS

This retrospective analysis included 20 patients with OLT (11 men and 9 women; mean age, 20.9 years; 1 bilateral case). Tissue from the osteochondral fragment was collected intraoperatively using a bone biopsy needle for histological evaluation. The fragment was fixed through the biopsy hole using a PLLA pin. Osteolysis surrounding the PLLA pin was assessed at 1 year postoperatively using magnetic resonance imaging (MRI). Histopathological scores were assigned based on trabecular bone loss, empty lacunae, inflammatory granulation tissue, cartilage-like tissue, and the presence of osteoclasts. The HU values around the pin insertion site, detected on the postoperative MRI scans, were measured using the region of interest based on the preoperative coronal and sagittal computed tomography (CT) images.

RESULTS

Osteolysis was observed postoperatively in 9 ankles (42.9%). Histopathological evaluation revealed that the osteolysis group had a significantly higher pathological score than the nonosteolysis group (10.2 vs 6.3; P < .001). Lower HU values were identified in the osteolysis group on preoperative coronal and sagittal CT images (P < .05). The histopathological score negatively correlated with preoperative HU values (Pearson r = -0.46; P = .037).

CONCLUSION

Intraoperative biopsy of the OLT allowed for histopathological evaluation of the same site as that of the PLLA pin fixation. Our findings suggest that preoperative subchondral trabecular deterioration is associated with the incidence of postoperative osteolysis surrounding the PLLA pin. Additionally, low preoperative HU values in subchondral bone under OLT may serve as a predictor of osteolysis surrounding the PLLA pin.

Osteochondral Lesions of the Distal Tibial Plafond: A Systematic Review of Lesion Locations and Treatment Outcomes

BACKGROUND

Osteochondral lesions of the tibial plafond (OLTPs) remain less common than osteochondral lesions of the talus (OLTs), but recognition of the condition has increased.

PURPOSE

To systematically evaluate the literature on lesion locations and treatment outcomes of OLTPs, whether in isolation or in combination with OLTs.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A search was performed using the PubMed, Embase, and CINAHL databases for studies on lesion locations or with imaging or treatment outcomes of OLTPs. Case reports and reports based on expert opinion were excluded. Lesion locations as well as outcome measure results were aggregated. The Methodological Index for Non-randomized Studies score was used to assess methodological quality when applicable.

RESULTS

Included in this review were 10 articles, all published in 2000 or later. Most studies were evidence level 4, and the mean Methodological Index for Non-randomized Studies score was 8.6 (range, 8-10). Overall, 174 confirmed OLTP cases were identified, and the mean patient age was 38.8 years. Of the 157 lesions with confirmed locations, the most common was central-medial (32/157; 20.4%). Of 6 studies on treatment outcomes, all but 1 evaluated bone marrow stimulation techniques. Microfracture of small lesions (<150 mm2) was the most common treatment utilized. Imaging and functional outcomes appeared favorable after treatment. The data did not support differences in outcomes between isolated OLTPs and OLTPs with coexisting OLTs.

CONCLUSION

Osteochondral lesions of the distal tibia most commonly occurred at the central-medial tibial plafond. Microfracture of small lesions was the most common treatment utilized, and clinical and magnetic resonance imaging results were favorable, although data were heterogeneous. Areas for future research include the following: the effect of patient factors and additional pathologies on outcomes; larger or deeper lesion treatment; more direct comparisons of outcomes between kissing or coexisting lesions and isolated lesions; and head-to-head comparison of treatments, such as microfracture, bone marrow-derived cell transplantation, and osteochondral autografts/allografts.

Bone Marrow Stimulation for Osteochondral Lesions of the Talus: Are Clinical Outcomes Maintained 10 Years Later?

BACKGROUND

Arthroscopic bone marrow stimulation (BMS) is considered the first-line treatment for osteochondral lesions of the talus (OLTs). However, the long-term stability of the clinical success of BMS remains unclear.

PURPOSE

To investigate the long-term clinical outcomes among patients who underwent BMS for OLT and to identify prognostic factors for the need for revision surgery.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A retrospective analysis was performed on 202 ankles (189 patients) that were treated with BMS for OLT and had a minimum follow-up of 10 years. The visual analog scale for pain, American Orthopaedic Foot & Ankle Society ankle-hindfoot score, and the Foot and Ankle Outcome Score (FAOS) were assessed by repeated measures analysis of variance. Prognostic factors associated with revision surgery were evaluated with Cox proportional hazard regression models and log-rank tests.

RESULTS

The mean lesion size was 105.32 mm² (range, 19.75-322.79); 42 ankles (20.8%) had large lesions (≥150 mm²). The mean visual analog scale for pain improved from 7.11 ± 1.73 (mean ± SD) preoperatively to 1.44 ± 1.52, 1.46 ± 1.57, and 1.99 ± 1.67 at 1, 3 to 6, and ≥10 years, respectively, after BMS (P < .001). The mean ankle-hindfoot score also improved, from 58.22 ± 13.57 preoperatively to 86.88 ± 10.61, 86.17 ± 10.23, and 82.76 ± 11.65 at 1, 3 to 6, and ≥10 years after BMS (P < .001). The FAOS at the final follow-up was 82.97 ± 13.95 for pain, 81.81 ± 14.64 for symptoms, 83.49 ± 11.04 for activities of daily living, 79.34 ± 11.61 for sports, and 78.71 ± 12.42 for quality of life. Twelve ankles underwent revision surgery after a mean 53.5 months. Significant prognostic factors associated with revision surgery were the size of the lesion (preoperative magnetic resonance imaging measurement ≥150 mm²; P = .014) and obesity (body mass index ≥25; P = .009).

CONCLUSION

BMS for OLT yields satisfactory clinical outcomes at a mean follow-up of 13.9 years. The success of the surgery may depend on the lesion size and body mass index of the patient.

Limitations of accessibility of the talar dome with different open surgical approaches

PURPOSE

The aim of this study is to systematically review the current, relevant literature and provide a thorough understanding of the various open surgical approaches utilized to gain access to the talar dome for treatment of osteochondral lesions. Realizing the limits of access from soft tissue exposures and osteotomies, with and without external distraction, will help surgeons to select the appropriate approach for each individual clinical situation.

METHODS

A literature search was performed using three major medical databases: PubMed (MEDLINE), Scopus, and Embase. The Quality Appraisal for Cadaveric Studies (QUACS) scale was used to assess the methodological quality of each included study.

RESULTS

Of 3108 reviewed articles, nine cadaveric studies (113 limbs from 83 cadavers) evaluating the accessibility of the talar dome were included in the final analysis. Most of these (7/9 studies) investigated talar dome access in the context of treating osteochondral lesions of the talus (OLTs) requiring perpendicular visualization of the involved region. Five surgical approaches (anteromedial; AM, anterolateral; AL, posteromedial; PM, posterolateral; PL, and direct posterior via an Achilles tendon splitting; DP), four types of osteotomy (anterolateral tibial, medial malleolar, distal fibular, and plafondplasty), and two methods of distraction (Hintermann retractor and external fixator) were used among the included studies. The most commonly used methods quantified talar access in the sagittal plane (6/9 studies, 66.7%). The greatest exposure of the talar dome can be achieved perpendicularly by performing an additional malleolar osteotomy (90.9% for lateral, and 100% for medial). The methodological quality of all included studies was determined to be satisfactory.

CONCLUSION

Gaining perpendicular access to the central portion of the talar dome, measured in the sagittal plane, has clear limitations via soft tissue approaches either medially or laterally from the anterior or posterior aspects of the ankle. It is possible to access a greater talar dome area in a non-perpendicular fashion, especially from the posterior soft tissue approach. Various types of osteotomies can provide greater accessibility to the talar dome. This systematic review can help surgeons to select the appropriate approach for treatment of OLTs in each individual patient preoperatively.

LEVEL OF EVIDENCE

Level IV.

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.

Internal Fixation of Osteochondral Lesion of the Talus Involving a Large Bone Fragment

BACKGROUND

Internal fixation of an osteochondral lesion of the talus (OLT) can restore the congruency of the talus and maintain the subchondral bone and innate hyaline cartilage. However, OLT that is indicated for fixation is rarely encountered; hence, not many studies report on the results after the procedure.

PURPOSE

To evaluate the clinical and radiological outcomes after internal fixation of chronic OLT involving a large bone fragment of at least 10 mm in diameter and 3 mm in depth on computed tomography (CT).

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

We retrospectively reviewed the data of 26 patients with OLT treated with internal fixation between August 2014 and April 2018. Of the patients, 15 were male and 11 were female, with a mean age of 16 years (range, 11-29 years). The primary radiological outcome measurement was bone union assessed on the 6-month postoperative CT scan. Clinical outcomes were assessed at a mean of 27.7 months postoperatively.

RESULTS

Twenty patients (77%) achieved bone union on postoperative CT scan. The mean 100-mm visual analog scale (VAS) improved from 30.5 ± 8.5 preoperatively to 13.4 ± 9.7 postoperatively (P < .001). The mean Foot Function Index (FFI) improved from 30.5 ± 6.7 preoperatively to 13.7 ± 9.8 postoperatively (P < .001). A malleolar osteotomy was not necessary to approach the lesion in 88% of patients. A bone fragment with an irregular margin and low density on the preoperative CT scan was significantly associated with nonunion (odds ratio: 7.67, 95% confidence interval: 2.67 to 22.02, P = .008). The difference in clinical outcomes between patients with skeletally immature ankles and those with skeletally mature ankles was not statistically significant. Patient age did not correlate with postoperative 100-mm VAS (Pearson correlation coefficient, r = -0.07, P = 0.72) or the postoperative FFI (Pearson correlation coefficient, r = -0.05, P = .80).

CONCLUSION

Internal fixation of an OLT involving a large bone fragment resulted in satisfactory clinical and radiologic outcomes. We found that patients with skeletally immature and mature ankles attained healing at comparable rates after the internal fixation of OLT.

Innovative Tissue-Engineered Strategies for Osteochondral Defect Repair and Regeneration: Current Progress and Challenges

Clinical treatments for the repair of osteochondral defects (OCD) are merely palliative, not completely curative, and thus enormously unfulfilled challenges. With the in-depth studies of biology, medicine, materials, and engineering technology, the conception of OCD repair and regeneration should be renewed. During the past decades, many innovative tissue-engineered approaches for repairing and regenerating damaged osteochondral units have been widely explored. Various scaffold-free and scaffold-based strategies, such as monophasic, biphasic, and currently fabricated multiphasic and gradient architectures have been proposed and evaluated. Meanwhile, progenitor cells and tissue-specific cells have also been intensively investigated in vivo as well as ex vivo. Concerning bioactive factors and drugs, they have been combined with scaffolds and/or living cells, and even released in a spatiotemporally controlled manner. Although tremendous progress has been achieved, further research and development (R&D) is needed to convert preclinical outcomes into clinical applications. Here, the osteochondral unit structure, its defect classifications, and diagnosis are summarized. Commonly used clinical reparative techniques, tissue-engineered strategies, emerging 3D-bioprinting technologies, and the status of their clinical applications are discussed. Existing challenges to translation are also discussed and potential solutions for future R&D directions are proposed.

Clinical and Magnetic Resonance Imaging Outcomes of Microfracture Plus Chitosan/Blood Implant vs Microfracture for Osteochondral Lesions of the Talus

BACKGROUND

The aim of this study was to compare the clinical and magnetic resonance imaging (MRI) outcomes of arthroscopic microfracture (MF) plus chitosan-glycerol phosphate/blood implant and MF alone for the treatment of the osteochondral lesions of the talus (OCLTs).

METHODS

Patients who underwent either MF plus chitosan (group 1, n = 32) or MF alone (group 2, n = 31) between 2015 and 2019 in 2 separate time periods were retrospectively analyzed. Visual analog scale (VAS) score and American Orthopaedic Foot & Ankle Society (AOFAS) score were used for clinical evaluation. The magnetic resonance observation of cartilage repair tissue (MOCART) system was used for MRI evaluation. The mean follow-up time was 32 ± 13 months (range, 12-61 months).

RESULTS

Postoperatively, we detected significant improvements in both groups in terms of VAS and AOFAS scores. However, we observed no statistically significant difference between groups in terms of clinical scores, except the mean VAS function score, which was significantly higher in group 1 (P = .022). According to MOCART scale, complete repair with the filling of the chondral defect and intactness of the surface of the repair tissue were more common in group 1. However, these parameters did not significantly differ between groups (P = .257 and .242, respectively).

CONCLUSION

Arthroscopic MF plus chitosan glycerol phosphate/blood implant did not result in better clinical and MRI outcomes compared with MF alone in the treatment of OCLTs.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Clinical Outcomes of Osteochondral Lesions of the Talus With Large Subchondral Cysts Treated With Osteotomy and Autologous Chondral Grafts: Minimum 2-Year Follow-up and Second-Look Evaluation

Background:

Osteochondral lesions of the talus (OLTs) with large subchondral cysts are challenging to treat.

Purpose:

To determine the safety and efficacy of autologous chondral grafting and malleolus osteotomy for treating OLTs associated with large subchondral cysts.

Study Design:

Case series; Level of evidence, 4.

Methods:

A total of 19 patients underwent autologous chondral grafting and malleolus osteotomy. We obtained the visual analog scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot, and magnetic resonance observation of cartilage repair tissue (MOCART) scores at 1 and 2 years postoperatively. The International Cartilage Repair Society (ICRS) score was collected 2 years postoperatively during second-look arthroscopic surgery.

Results:

In all patients, the osteotomy site healed without nonunion or malunion. Only 1 patient developed joint space narrowing. No donor site complications occurred. The mean AOFAS score significantly improved at 1 year (from 72.8 ± 4.8 preoperatively to 93.7 ± 4.6; t = –13.708; P < .0001). The 1- and 2-year AOFAS scores were similar (t = –0.755; P = .455), indicating stable improvement. The mean VAS score significantly decreased at 1 year (from 4.68 ± 0.67 preoperatively to 0.47 ± 0.69; t = 18.974; P < .0001). The 1- and 2-year VAS scores were similar (t = –0.705; P = .455), as were the 1- and 2-year MOCART scores (64.2 ± 7.5 vs 67.4 ± 7.3, respectively; t = –1.312; P = .198). The ICRS scores were as follows: 7 points (abnormal) in 1 (5.2%) patient, 8 to 11 points (nearly normal) in 9 (47.4%) patients, and 12 points (normal) in 9 (47.4%) patients.

Conclusion:

Osteotomy combined with autologous osteochondral transplantation provided good functional outcomes in patients with OLTs and large subchondral cysts. Second-look arthroscopic surgery showed healthy cartilage healing.

Characteristics of Osteochondral Lesions of the Talus in Different Age Groups

We analyzed the characteristics of 112 consecutive patients who were operatively treated for osteochondral lesions of the talus from August 2014 to April 2019 in our hospital. The patients were divided into three age groups: young-adult (<40 years), middle-age (40-60 years) and old-age (>60 years). The basic clinical features, localization and size of the lesions, Hepple stage, and surgical procedures were compared among groups. Several significant differences were found on the characteristics of osteochondral lesions of the talus among age groups. There were more female patients in the old-age group (p<0.01), and old patients had a longer duration of symptoms (p<0.05). The OLTs in middle- and old-age patients were mostly located in the medial part of the talus with larger depth (p<0.01). Hepple stage 5, the cystic type, was very common in the old-age group (p<0.01). With regard to surgical procedures, more osteochondral autograft transplantations were applied in the old-age group (p<0.01). Female and deep medial talar subchondral cyst is the typical characteristics of patients over 60 years old. Age is an important factor that must be considered when choosing surgery procedure for patients with osteochondral lesions of the talus.

Long-term Prognosis After Successful Nonoperative Treatment of Osteochondral Lesions of the Talus: An Observational 14-Year Follow-up Study

Background:

Little is known about the long-term prognosis of osteochondral lesions of the talus (OLTs) after nonoperative treatment.

Purpose:

To evaluate the clinical and radiological long-term results of initially successfully treated OLTs after a minimum follow-up of 10 years.

Study Design:

Case series; Level of evidence, 4.

Methods:

Between 1998 and 2006, 48 patients (50 ankles) with OLTs were successfully treated nonoperatively. These patients were enrolled in a retrospective long-term follow-up, for which 24 patients could not be reached or were available only by telephone. A further 2 OLTs (6%) that had been treated surgically were excluded from the analysis and documented as failures of nonoperative treatment. The final study group of 22 patients (mean age at injury, 42 years; range, 10-69 years) with 24 OLTs (mean size, 1.4 cm²; range, 0.2-3.8 cm²) underwent clinical and radiological evaluation after a mean follow-up of 14 years (range, 11-20 years). Ankle pain was evaluated with a visual analog scale (VAS), ankle function with the American Orthopaedic Foot and Ankle Society (AOFAS) score, and sports activity with the Tegner score. Progression of ankle osteoarthritis was analyzed based on plain ankle radiographs at the initial presentation and the final follow-up according to the Van Dijk classification.

Results:

At final follow-up, the 24 cases (ie, ankles) showed a median VAS score of 0 (IQR, 0.0-2.25) and a median AOFAS score of 94.0 (IQR, 85.0-100). Pain had improved in 18 cases (75%), was unchanged in 3 cases (13%), and had increased in 3 cases (13%). The median Tegner score was 4.0 (IQR, 3.0-5.0). Persistent ankle pain had led to a decrease in sports activity in 38% of cases. At the final follow-up, 11 cases (73%) showed no progression of ankle osteoarthritis and 4 cases (27%) showed progression by 1 grade.

Conclusion:

Osteochondral lesions of the talus that successfully undergo an initial nonoperative treatment period have minimal symptoms in the long term, a low failure rate, and no relevant ankle osteoarthritis progression. However, a decrease in sports activity due to sports-related ankle pain was observed in more than one-third of patients.

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.

Retrograde Drilling for Osteochondral Lesion of the Talus in Juvenile Patients

Background:

Retrograde drilling (RD) is generally used for treating osteochondral lesion of the talus (OLT) with a stable osteochondral fragment and nearly normal articular cartilage surface. Previous studies that included participants of various ages have reported good clinical results. This study aimed to clarify the clinical outcomes of RD for OLT in juvenile patients whose bone-forming ability and physical activity might affect the healing process.

Methods:

This retrospective study included 8 juvenile patients who underwent RD for OLT (5 boys and 3 girls, mean age 14.9 years, mean follow-up 2 years, 7 medial and 1 central lesion). American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score and ankle activity score were evaluated, and arthroscopic findings were graded according to the International Cartilage Research Society (ICRS) classification system. The condition of the underlying bone was assessed on preoperative computed tomographic images. The stability, incorporation, and subsidence of the osteochondral fragment, articular surface congruity, and the area of the bone marrow lesion (BML) were evaluated using magnetic resonance imaging (MRI).

Results:

AOFAS ankle-hindfoot score and ankle activity score significantly improved postoperatively. Arthroscopically, the lesions were classified as ICRS grade 0 or 1. Bone sclerosis or multiple small cysts of the underlying bone were observed in all patients. MRI demonstrated no signs of osteochondral fragment instability or subsidence, good or fair fragment incorporation, good articular surface congruity, or slight irregularity. The postoperative BML was reduced; however, these BMLs were still detectable at 1 year after surgery.

Conclusion:

Our data suggested that RD is an option for treating juvenile patients with OLT refractory to nonoperative treatment at short-term follow-up. Although bone sclerosis or multiple small cysts were identified in the underlying bone preoperatively and the BML under the osteochondral fragment remained postoperatively, clinical status such as pain and physical activity level were improved by RD.

Level of Evidence:

Level IV, retrospective case series.

Primary Versus Secondary Osteochondral Autograft Transplantation for the Treatment of Large Osteochondral Lesions of the Talus

BACKGROUND

Recent studies have reported promising clinical results after osteochondral autograft transplantation (OAT) for the treatment of large osteochondral lesions of the talus (OLT). However, no study has yet compared clinical outcomes between primary and secondary OAT for large OLT.

PURPOSE

To compare clinical outcomes among patients with large OLT who receive primary OAT versus those who receive secondary OAT after failure of marrow stimulation and to identify factors associated with clinical failure.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

From 2005 to 2014, 46 patients with large OLT (≥150 mm²) underwent OAT: 18 underwent OAT as initial surgical management (primary OAT group), and 28 patients underwent secondary OAT after failure of previous arthroscopic marrow stimulation (secondary OAT group). In both groups, OAT procedures included arthroscopic inspection and debridement of concomitant soft tissue injuries. Clinical outcomes were assessed using pain visual analog scale (VAS), the Roles and Maudsley score, Foot and Ankle Outcome Scores (FAOS), and revisional surgery rates. Factors associated with clinical failures were evaluated using bivariate and logistic regression analyses. Survival outcomes were compared using Kaplan-Meier analysis.

RESULTS

Mean follow-up time was 6 years (range, 2-10.8 years). Mean lesion size was 194.9 mm² (range, 151.7-296.3 mm²). There were no significant differences between groups in patient demographics and preoperative findings. Postoperative pain VAS, Roles and Maudsley score, FAOS, and revisional surgery rates were not significantly different at last follow-up. Prior marrow stimulation was not significantly associated with clinical failure on bivariate analysis. Lesion size greater than 225 mm² on preoperative magnetic resonance imaging was significantly associated with clinical failure. Survival probabilities from Kaplan-Meier plots were not significantly different between the primary and secondary OAT groups ( P = .947).

CONCLUSION

Clinical outcomes of patients with large OLT treated with secondary OAT after failed marrow stimulation were found to be comparable with those who were treated with primary OAT. These results may be helpful to orthopaedic surgeons deciding appropriate surgical options for patients with large OLT.