Arthroscopic-controlled navigation for retrograde drilling of osteochondral lesions of the talus

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

Background

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

Methods

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

Results

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

Conclusions

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

Trial registration

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

Nontraumatic avascular necrosis of the femoral head : Arthroscopic and navigation-supported core decompression

OBJECTIVE

The aim is to address core decompression and pathologies of the femoral head, treating them during the same procedure. Furthermore, radiation exposure will be reduced.

INDICATIONS

Femoral head necrosis ARCO (Association Research Circulation Osseous) stages I-III.

CONTRAINDICATIONS

Progressive femoral head necrosis as ARCO stages IIIC-IV.

SURGICAL TECHNIQUE

Arthroscopically navigated core decompression of the femoral head using an established optoelectronic system with fluoro-free software module. First, hip joint arthroscopy was performed and further pathologies were treated. Second, core decompression was navigated by a navigation pointer and drill sleeve to reach the correct target point. After visualization, the procedure is repeated 3-5 times.

POSTOPERATIVE MANAGEMENT

Limited weight bearing of the operated leg (20 kg) for 10-14 days. Active or passive continuous motion machine for 4 weeks. Adjuvant postoperative indomethacin therapy for 10 days to reduce pain and bone marrow edema.

RESULTS

From May 2018 to January 2019, 7 patients (male = 4; 40 ± 9 years) underwent arthroscopically navigated core decompression with 2 (29%) and 5 (71%) patients being classified as ARCO II and III, respectively. Preoperatively, all patients reported load-dependent pain. In all cases, we could identify synovitis, which results in soft tissue release and synovectomy. Furthermore, 4 of 7 patients had an additional labrum lesion, which is addressed by refixation or shrinking.

DISCUSSION

Compared to the conventional technique, this fluoro-free navigation procedure allows more precise drilling. Moreover, additional pathologies, as found in all our cases, could be simultaneously addressed. The intraoperative radiation exposure for the patient and surgical team could also be reduced. Although arthroscopically assisted core decompression requires more preparation time, there are advantages over conventional surgery.

Combined Therapy with Shock Wave and Retrograde Bone Marrow-Derived Cell Transplantation for Osteochondral Lesions of the Talus

Multiple treatment strategies have been developed for osteochondral lesions (OCLs) of the talus. The purpose of this retrospective study was to assess retrograde autologous bone marrow cell (BMC) transplantation via core drilling (CD) combined with focused extracorporeal shock wave treatment (ESWT) in undisplaced OCL of the talus. A total of 69 patients with unilateral osteochondral lesions of the talus (Hepple grade I-III) were divided into two groups: 41 patients received combined therapy of ESWT and BMC transplantation (group A), while 28 were administered BMC transplantation alone (group B). The patients were followed up clinically and radiographically for a minimum of 2 years. Mean follow-up was 4.1 ± 2.8 years. AOFAS scores increased more significantly while pain intensity levels decreased in group A after treatment, compared with group B values (P < 0.001). In MRI follow-up, a more remarkable improvement of OCLs of the talus was observed in group A compared with group B (P = 0.040). Therefore, the combined technique reported here is a highly effective therapeutic option in OCLs of the talus with intact cartilage. It promotes patient recovery with pain control, and improves clinical outcome for more than 2 years after surgery.

Arthroscopic Retrograde Drilling in Juvenile Osteochondritis Dissecans of the Talus

BACKGROUND

Juvenile osteochondritis dissecans of the talus is rare, and the literature provides little data to guide treatment. The purpose of the present study was to evaluate our clinical and radiographic results with arthroscopic retrograde drilling in patients who were refractory to conservative care.

METHODS

We retrospectively evaluated all patients with juvenile osteochondritis dissecans of the talus who underwent surgery for the treatment of stable lesions that failed conservative treatment. Medical records were reviewed for symptoms and demographic information. Preoperative and latest postoperative radiographs were used to determine degree of healing. AOFAS Ankle/Hindfoot scale and visual analog scale for pain were used to evaluate clinical outcomes.

RESULTS

We identified 6 patients (6 ankles). The mean age was 13 years, and the mean duration of follow-up was 37 months (range, 16 to 69 mo). All of them had progressed toward healing and were asymptomatic, but only 3 out of 6 had a complete radiographic healing at last follow-up. The average AOFAS Ankle/Hindfoot score improved from 69 points (55 to 75, IQR=10) preoperatively to 98 points (90 to 100, IQR=7) (P<0.0027). Visual analog scale improved from 6.2 (4 to 8, IQR=3) to 0.3 (0 to 2, IQR=1) (P<0.002). All patients expressed satisfaction with operative results.

CONCLUSIONS

Arthroscopic retrograde drilling seems to be effective for symptoms relief, although 50% of the cases have had persistent lesions on radiographs. A longer follow-up is necessary to assess joint function in those cases with partial radiographic healing.

LEVEL OF EVIDENCE

Level IV-therapeutic.

Arthroscopically guided navigation for repair of acromioclavicular joint dislocations: a safe technique with reduced intraoperative radiation exposure

Background

Accuracy evaluation of navigated image free placement of double cortical fixation buttons for coracoclavicular tunnel position in comparison to conventional drill guide based placement.

Methods

Twenty-six patients with acute acromioclavicular joint instability were included in this non-randomized cohort study. All patients were treated with a Double- TightRope technique. In 13 cases the conventional drill guide based placement was used (group 1). In 13 patients surgery was performed as a navigated procedure with a fluoro-free optoelectronic system (group 2). The number of coracoclavicular drillings per patient (First pass accuracy; FPA (%)) was documented, the subcoracoidal position of the fixation buttons has been evaluated and graded as “intended position achieved (IPA)” or “intended position not achieved (IPnA)”.

Results

In group 1 drilling had to be repeated in four patients (30.8 %) to achieve proper placement of the subcoracoidal fixation buttons. 100 % first pass accuracy was observed in group 2 (p = 0.03). In group 1, the intended position of the subcoracoid buttons was not achieved (IPnA) in six patients (46.2 %). In group 2 all intended positions were achieved (p = 0.005).

Conclusion

Arthroscopic controlled fluoro-free navigated coracoclavicular drilling for the repair of acromioclavicular joint dislocation has higher first pass accuracy in comparison to conventional drill guide based placement. Therefore the navigation enables a precise position of the drill holes, may reduce the risk of an iatrogenic coracoid fracture and migration of fixation devices.

Trial registration

Local institutional review board No. 061-14-10032014

Osteochondritis Dissecans Involving the Trochlear Groove Treated With Retrograde Drilling: A Case Report

Osteochondritis dissecans (OCD) occurs frequently in the humeral capitellum of the upper extremity, whereas OCD involving the trochlear groove (trochlear groove OCD) is rarely reported. A standard treatment for trochlear groove OCD has therefore not been determined, although several methods have been tried.The case of a 14-year-old male gymnast with bilateral trochlear groove OCD is presented. Retrograde drilling from the lateral condyle of the humerus was applied for the OCD lesion of the left elbow, since it was larger in size than that in the right elbow and was symptomatic. Conversely, since the right lesion was small and asymptomatic, it was managed conservatively.After treatment, consolidation of the OCD lesions was observed in both elbows. However, the time to healing was shorter in the left elbow treated surgically than in the right elbow managed conservatively.In conclusion, retrograde drilling is a very simple and minimally invasive treatment. This case suggests that retrograde drilling for trochlear groove OCD may be a useful procedure that may accelerate the healing process for OCD lesions.

Image-free navigated coracoclavicular drilling for the repair of acromioclavicular joint dislocation: a cadaver study

BACKGROUND

Reconstruction of the coracoclavicular ligament functions to restore anatomic alignment of the clavicle and may improve biomechanical function and clinical outcomes. Improper placement of the coracoclavicular tunnel may inherently weaken the coracoid. The purpose of this study was to evaluate the feasibility and accuracy of navigated image-free placement of K-wires for coracoclavicular tunnel position in comparison to conventional drill guide-based placement.

MATERIALS AND METHODS

Eight human shoulder specimens were assigned for conventional technique with a coracoclavicular guide device (group CP) and the paired contralateral side for the navigated procedure (group NP) with an optoelectronic system with a fluoro-free software module. First-pass accuracy (%) and the K-wire trajectory (lateral-center orientation (LC), center-center (CC) orientation and medial-center orientation (MC) were measured.

RESULTS

In all navigated K-wires a 100 % first-pass accuracy was observed. In three of the eight (37.5 %) specimens of the drill guide-based group, drilling had to be repeated. One of them had to be repeated twice, resulting in eight versus twelve drillings for the navigated versus conventional group, respectively (p = 0.021). K-wire trajectory showed an MC orientation in most of the specimen (n = 9, group NP 4, group CP 5).

CONCLUSIONS

Image-free navigated coracoclavicular drilling for the repair of acromioclavicular joint dislocation has higher first-pass accuracy in comparison to conventional drill guide-based placement and, therefore, may enable a precise anatomic position of the drill holes and reduce the risk of an iatrogenic coracoid fracture.

[Occult fractures of extremities in adults and children. Exemplified by foot and ankle injuries]

BACKGROUND

Occult fractures in children and adults cannot by definition be diagnosed by conventional radiographs. These injuries are usually recognized as bone marrow edema by magnetic resonance imaging (MRI). There are no randomized controlled trials or prospective cohort studies concerning the correct management of occult fractures and, therefore, no evidence-based treatment guidelines can be drafted.

OBJECTIVES

This article summarizes the current diagnostic and treatment concepts for occult fractures under special consideration of foot and ankle injuries.

METHODS

A selective search of the current literature was performed and also taking own experience into consideration.

RESULTS AND CONCLUSION

The clinical prognosis of occult fractures is generally good and there is no evidence that these lesions need specific treatment. Besides forensic applications and problems pursuant to insurance law, MRI examination is only indicated when conventional radiographs are unremarkable, pain persists for an unusually long period of time and when a relevant therapeutic consequence can be expected from the MRI results. Classical pitfalls are combinations of occult fractures with potentially unstable ligamentous injuries and patients with disordered pain perception as in cases of diabetic polyneuropathy, as the common therapeutic concept of weight bearing according to pain is not suitable for these patients and can lead to severe complications.

The role of demineralized allograft subchondral bone in the treatment of talar cystic OCD lesions that have failed microfracture

Cystic talar shoulder defects are particularly challenging osteochondral lesions. A retrospective chart review was performed on 13 adults that previously failed microfracture, presented with medial cystic osteochondral lesions of the talus, and were treated with malleolar osteotomy and subchondral allograft reconstruction. The aim of the study was to evaluate the effect of a medial malleolar osteotomy and allograft subchondral bone plug on pain and function. We hypothesized that following surgery, pain and function would significantly improve. Compared with preoperative measures, pain (first step in the morning, during walking, at the end of the day) and function (descending the stairs, ascending the stairs, and ambulating up to 4 blocks) improved postoperatively at 6 and 12 months (P ≤ .001). During each activity, pain improved postoperatively from 6 to 12 months (P ≤ .006). Postoperatively, from 6 to 12 months, the level of disability improved while descending the stairs (P = .004), and the level of disability experienced while ascending the stairs and ambulating up to 4 blocks was maintained (P ≥ .02). Multiple regression analyses identified body mass index as a predictor of preoperative function (R(2) = .34, P = .04). No variables were identified as significant predictors of postoperative pain or function. With all osteotomies healing, no graft rejection, and a single deep venous thrombosis, allograft subchondral plugs appear to successfully treat osteochondral lesions of the talus with improvements in pain and function as well as an acceptable complication rate.

LEVEL OF EVIDENCE

Therapeutic, Level IV: Retrospective Case Series.

Role of Demineralized Allograft Subchondral Bone in the Treatment of Shoulder Lesions of the Talus: Clinical Results With Two-Year Follow-Up

Cystic osteochondral lesions of the talus present a considerable challenge for foot and ankle surgeons. The purpose of the present study was to evaluate the effect of a medial malleolar osteotomy and implantation of demineralized allograft subchondral bone on pain and function 2 years after surgery. For inclusion, patients demonstrated radiographic evidence of a medial cystic full-thickness osteochondral defect of the talus and previously failed microfracture (N = 12). We hypothesized that improvements in pain and disability would be maintained across time. Compared with the preoperative values, 2 years after surgery, pain and disability had significantly reduced (p < .001). Significant reductions had occurred in postoperative pain from 6 months to 1 year (p = .001) and from 6 months to 2 years (p = .005). Similarly, significant reductions had occurred in postoperative disability from 6 months to 1 year (p = .008) and from 6 months to 2 years (p = .03). The reductions in postoperative pain and disability were maintained from 1 year to 2 years (p ≥ .79). Multiple regression analyses identified depression as a predictor of 2-year postoperative pain (R(2) = 0.36, p = .04). No variables were identified as significant predictors of postoperative disability at 2 years. Other than 1 previously reported peroneal deep venous thrombosis, no additional complications occurred. With successful graft incorporation, no inflammatory response, and no additional complications, the allograft subchondral plug appears to successfully treat osteochondral lesions of the talus and maintain improvements in pain and disability at intermediate follow-up.

Simultaneous surgery for chronic lateral ankle instability accompanied by only subchondral bone lesion of talus

INTRODUCTION

Osteochondral lesion of the talus (OCT) frequently accompanies chronic lateral ankle instability (CLAI). However, it remains unclear whether concomitant OCT and CLAI should be treated surgically at the same time. The purpose was to evaluate the clinical outcome of simultaneous surgery involving stabilization of CLAI and retrograde drilling for only subchondral bone lesion of the talus.

STUDY DESIGN

The study was a case series; level of evidence, 4.

MATERIALS AND METHODS

Between January 2006 and February 2010, 16 feet of 16 patients (5 men, 11 women; mean age 25 years; age range 14-49 years) with CLAI accompanied by only subchondral bone lesion of talus underwent surgical repair or reconstruction of the anterior talofibular ligament and retrograde drilling. Subchondral bone lesion of talus was diagnosed by preoperative magnetic resonance imaging (MRI) and intraoperative arthroscopic investigation. Clinical outcome was measured using the American Orthopedic Foot and Ankle Society Ankle-Hindfoot Scale (AOFAS) and a visual analog scale (VAS). Improvement in lesion area was evaluated by assessing the change between preoperative and postoperative MRI findings.

RESULTS

Preoperative to postoperative changes in all patients were as follows: mean AOFAS score improved from 73.4 points (range 62-87) to 91.2 points (range 85-100) (p < 0.001); mean VAS score improved from 55.0 points (range 40-80) to 6.5 points (range 0-20) (p < 0.001); and mean lesion area improved from 33.9 mm(2) (range 14.2-59.6) to 11.8 mm(2) (range 4.3-22.1) (p < 0.001).

CONCLUSIONS

Simultaneous surgery involving lateral ankle stabilization and retrograde drilling under arthroscopic and fluoroscopic guidance is a promising method for treating CLAI accompanied by only subchondral bone lesion of talus.

Retrograde drilling of talar osteochondritis dissecans lesions: a feasibility and accuracy analysis of a novel electromagnetic navigation method versus a standard fluoroscopic method

PURPOSE

A novel method using an electromagnetic navigation system (ENS) was developed, and its feasibility and accuracy for retrograde drilling procedures were evaluated and compared with the standard freehand fluoroscopic method in an experimental setting.

METHODS

A controlled laboratory study of 16 standard freehand fluoroscopically guided and 16 electromagnetically navigated retrograde drilling procedures was performed on 4 cadaveric human ankle joints. Four artificial cartilage lesions were consecutively set, 2 on the medial and 2 on the lateral talar dome. Drilling accuracy was measured in terms of the distance from the final position of the drill bit to the tip of the probe hook and the distance between the tip of the drill bit and the center of the cartilage lesion on the articular cartilage surface. Intraoperative fluoroscopy exposure times were documented, as were readjustments of drilling directions or complete restarts. All procedures were timed with a stopwatch.

RESULTS

Successful retrograde drilling was accomplished in 12 cases with the standard fluoroscopy-guided technique and in all 16 ENS-guided procedures. The overall mean time for the fluoroscopy-guided procedures was 660.00 ± 239.87 seconds and the overall mean time for the ENS method was 308.06 ± 54.03 seconds, providing a mean time benefit of 420.13 seconds. The mean distance from the final position of the drill bit to the tip of the probe hook was 3.25 ± 1.29 mm for the standard method and 2.19 ± 0.54 mm for the ENS method, and the mean distance between the tip of the drill bit and the center of the cartilage lesion on the articular cartilage surface was 2.50 ± 0.97 mm for the standard method and 0.88 ± 0.81 mm for the ENS method.

CONCLUSIONS

Compared with the standard fluoroscopic technique, the ENS method used in this study showed higher accuracy and a shorter procedure time and required no X-ray radiation.

CLINICAL RELEVANCE

The novel method considerably improves on the standard operating procedure in terms of safety, operation time, and radiation exposure.

Screw placement for acetabular fractures: which navigation modality (2-dimensional vs. 3-dimensional) should be used? An experimental study

OBJECTIVES

Screw navigation techniques with different image guidance [2-dimensional (2D) vs. 3-dimensional (3D) fluoroscopy] were evaluated for acetabular fracture surgery.

METHODS

Two-dimensional and 3D navigation images were analyzed for visualization of different osseous corridors: supra-acetabular, anterior column, posterior column, and infra-acetabular. Forty guide wires per group were placed in synthetic pelvis with a prefabricated soft tissue envelope (10 per group) using a 2D or 3D fluoroscopic navigation procedure. Duration of the single steps for each procedure and of cumulative fluoroscopy time was measured. The accuracy of guide wire placement was evaluated visually and in 3D cone-beam scans.

RESULTS

The overall procedure time per pelvis was significantly reduced in the 3D group compared with the 2D group [mean ± standard error (SE) (minutes): 50.11 ± 1.38 vs. 63.42 ± 2.32; P < 0.0001]. A trend to reduction in image acquisition time [mean ± SE (minutes): 12.37 ± 1.34 vs. 15.43 ± 1.03; P = not significant] and significant increase in the cumulative fluoroscopy time [mean ± SE (seconds): 64 ± 9 vs. 13 ± 1.3; P < 0.0001) was measured in the 3D compared with the 2D group, caused by the 3D scan. Intra-articular misplacements were not observed in both the groups, but an increased accuracy could be achieved using the 3D image-based navigation procedure (perfect placement: 37 vs. 29; secure placement: 2 vs. 7; misplacement: 1 vs. 4).

CONCLUSIONS

Both navigation procedures securely prevent an intra-articular penetration during drilling, but the 3D image-based navigation procedure increases the overall accuracy compared with the 2D image-based navigation technique (misplacement rates of 2.5% vs. 10%). Especially, in very narrow corridors (as the infra-acetabular screw path), the use of 3D navigation should be preferred.

TREATMENT OF OSTEOCHONDRAL LESIONS OF THE TALUS BY MEANS OF THEARTHROSCOPY-ASSISTED MICROPERFORATION TECHNIQUE

OBJECTIVE

To evaluate patients affected by osteochondral fractures of the talus who were treated surgically by means of arthroscopy-assisted microperforation.

METHODS

A retrospective study was carried out on 24 patients with osteochondral lesions of the talus who underwent microperforation assisted by videoarthroscopy of the ankle. They were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) score system before and after the operation.

RESULTS

There were 19 men and 5 women, with a mean age of 35.3 years (minimum of 17 years and maximum of 54 years). The minimum follow-up was two years (maximum of 39 months). All the patients showed an improvement in AOFAS score after surgery, with an average improvement of around 22.5 points.

CONCLUSION

Videoarthroscopy-assisted microperforation is a good option for treating osteochondral lesions of the talus and provides good functional results.

Fluoro-Free navigated retrograde drilling of osteochondral lesions

PURPOSE

Retrograde drilling of osteochondral lesions (OCLs) is a recommended, but demanding operative approach for revascularization of lesions in stage 1-3 according to Berndt and Harty after failed conservative treatment. The gold standard of intraoperative driller guidance is fluoroscopic control. Limitations are a 2D visualization of a 3D procedure and sometimes limited view of the OCL in fluoroscopy, leading to increased radiation exposure. A new image-free navigation procedure was evaluated for practicability and precision in first clinical applications.

METHODS

In a period of 7 months, retrograde drillings were performed in eight patients (3x femoral condyle, 5x talus) using the new Fluoro-Free navigation procedure without rigidly fixed reference bases.

RESULTS

In total, 29 retrograde drillings were performed without any technical problem. The overall mean operating time was 82.1 ± 29.3 min (34.6 ± 6.4 min for the standard arthroscopy and 11.2 ± 1.2 min per drill). Twenty-seven of 29 drillings hit the target with a 100% first-pass accuracy. Two complications during drilling (one navigation specific and one navigation independent) were observed.

CONCLUSION

The paper describes the promising first clinical applications of a new Fluoro-Free navigation procedure for the retrograde drilling of OCLs determined by arthroscopy. The benefit of that navigated drillings with a high rate of first-pass accuracy and no need for radiation exposure in contrast to standard techniques is highlighted.