Personalized Resurfacing for Osteochondral Lesions of the Talus

Osteochondral lesions of the talus (OLTs) are the most common cause of chronic deep ankle pain. Joint-preserving surgeries include bone marrow stimulating, chondral transporting, and cellular-based procedures. Each procedure has its advantages and disadvantages. For that reason, a focal metallic inlay was developed as a bridge between biologics and conventional joint arthroplasty. Despite promising initial results, prefabricated implants are associated with unpredictable results. This article describes a novel customized patient-specific metal inlay as a treatment option for 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.

Deformity Correction: Do Osteochondral Lesion of the Talus and Tibia Change After Realignment Surgery?

Malalignment of the lower limb, distal tibia, foot, and hindfoot can all contribute to altered biomechanics in the ankle joint, resulting in increased focal pressure. The development of some osteochondral lesions of the ankle joint may share a similar pathophysiology, where eccentric loading to the talus or tibia within the ankle joint can lead to cartilage injury or adaptive changes. While the association between malalignment and the development of osteochondral lesions of the ankle joint may seem intuitive, the impact of realignment procedures on these lesions and patient symptoms remains a relatively underexplored topic in the literature. A comprehensive understanding of the potential role of realignment surgery in managing osteochondral lesions of the talus and tibia is crucial for advancing our knowledge of this challenging pathologic condition.

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.

Regeneration: Bone-Marrow Stimulation of the Talus-Limits and Goals

Bone Marrow Stimulation of osteochondral lesions of the talus has been shown to be a successful way to treat cartilage injuries. Newer data suggest that Bone Marrow Stimulation is best reserved for osteochondral lesions of the talus Sizes Less Than 107.4 mm2 in area. Additionally, newer smaller and deeper techniques to perform bone marrow stimulation have resulted in less subchondral bone damage, less cancellous compaction, and superior bone marrow access with multiple trabecular access channels. Biologic adjuvants such as platelet-rich plasma (PRP), hyaluronic acid (HA), and bone marrow aspirate concentrate (BMAC) may lead to better functional outcomes when used concomitant to bone marrow stimulation.

Subtalar Osteochondral Lesions: Diagnosis, Indications, and Prognosis

Although most commonly found in the knee, elbow, and talar dome, osteochondral lesions can also be found in the subtalar joint and can occur due to either high or low energy trauma. Diagnosis of these lesions in the subtalar joint is typically confirmed with advanced imaging such as computerized tomography and MRI. Although there are a few published case reports, there is otherwise very limited literature on the prevalence, treatment options, prognosis, or outcomes for patients with osteochondral lesions of the subtalar joint, and thus further research is required in this area.

Ankle Instability: Facts and Myths to Protect Your Cartilage Repairing

The majority of patients with an osteochondral lesion of the talus (OLT) report a history of trauma. Therefore, it is important to assess for concomitant ankle instability when dealing with patients with a symptomatic OLT. The History; Alignment; Ligaments; Others "(HALO)" approach can be a helpful tool in the evaluation of patients with an OLT. If conservative treatment fails, surgery may be indicated. Although there is a lack of comparative studies investigating the effect of stabilization procedures on cartilage repair, we believe that addressing instability is a key factor in improving patient outcome.

Autologous chondrocyte implantation for the treatment of osteochondral lesions of the talus: What happens after 20 years?

BACKGROUND

The purpose of this study was to assess the long-term clinical efficacy of first-generation autologous chondrocyte implantation (ACI) technique for osteochondral lesions of the ankle joint.

METHODS

Eleven patients with symptomatic OLTs underwent ACI from December 1997 to October 2002. A total of 9 patients (5 men, 4 women, age 25.2 ± 6.3) were evaluated at baseline and at 1, 3, 10 years, and at final follow-up of minimum 20 years with AOFAS ankle-hindfoot score, NRS for pain, and with the Tegner score.

RESULTS

The AOFAS score improved significantly from the baseline value of 40.4 ± 19.8 to 82.7 ± 12.9 at the final follow-up (p < 0.0005). The NRS for pain improved significantly from 7.8 ± 0.7 at baseline to 4.8 ± 2.1 at the final follow-up (p < 0.0005). Moreover, the Tegner score underwent a modification from the pre-operative median value of 1 (range: 1-3) and from a pre-injury value of 5 (range: 3-7) to 3 (range: 2-4) at the final follow-up (p < 0.0005).

CONCLUSIONS

ACI has proven to be an effective treatment option for patients suffering from OLTs, leading to a long-lasting clinical improvement even beyond 20 years of follow-up.

LEVEL OF EVIDENCE

Level IV.

Arthroscopic microfracture and associated techniques in the treatment of osteochondral lesions of the talus: A systematic review and metanalysis

BACKGROUND

Osteochondral lesions of the talus are common in patients suffering even minor trauma; timely diagnosis and treatment can prevent the development of early osteoarthritis. The objectives of this systematic review and meta-analysis were to evaluate the effects of additional procedures on arthroscopic ankle microperforations for osteochondral lesions.

METHODS

A systematic literature search was conducted using PubMed-Medline, Cochrane Central, and Google Scholar to select clinical studies analyzing the efficacy of platelet-rich plasma (PRP), hyaluronic acid (HA), and bone marrow concentrate (BMC) procedures. Ten articles following PRISMA guidelines with a total of 464 patients were included in this review. Quality assessment using MINORS was performed, and all studies demonstrated high quality.

RESULTS

The results of the systematic review showed benefits in all patients undergoing infiltrative therapy with PRP, hyaluronic acid, and BMC. The best results in terms of AOFAS score and VAS scale were found in patients undergoing PRP injection. The meta-analysis showed improvements in pain relief and return to daily activities in patients undergoing arthroscopic microperforations and PRP, although not reporting statistically significant results (p = 0.42).

CONCLUSION

All treatment strategies reported better scores compared to the control groups. Among the various treatments analyzed, the addition of PRP appears to be the most valuable probably for the larger population receiving this treatment, showing excellent outcomes in pain reduction, clinical outcomes, and return to daily activities.

LEVEL OF EVIDENCE

II.

Bilateral juvenile osteochondrosis dissecans in monozygotic twins: a case report

INTRODUCTION

The etiology of osteochondrosis dissecans (OCD), a chondropathy associated with detachment of the subchondral bone and the overlaying cartilage, is not yet fully understood. While repetitive physical exercise-related stress is usually assumed to be the main risk factor for the occurrence of OCD, genetic predisposition could have an underestimated influence on the development of the disease.

CASE REPORT

We report a case of monozygotic twins with almost identical stages of bilateral osteochondrosis dissecans of the knee joint. In both patients, initially, a unilateral lesion occurred; despite restricted physical exercise, in the further course of the disease a lesion also developed on the contralateral side. While the lesion found most recently demonstrated an ongoing healing process at a 6-month follow-up, the other three lesions showed a natural course of healing under conservative treatment with significant clinical as well as radiological improvements after one year and complete consolidation in magnetic resonance imaging (MRI) after 2 years.

CONCLUSION

There could be a genetic component to the development of OCD, although this has not yet been proven. Based on a two-year MRI follow-up, we were able to show the self-limiting characteristics of juvenile osteochondrosis dissecans.

Open lift-drill-fill-fix for medial osteochondral lesions of the talus: surgical technique

OBJECTIVE

Osteochondral lesions of the talus (OLT) with a fragment on the talar dome that fail conservative treatment and need surgical treatment can benefit from in situ fixation of the OLT. Advantages of fixation include the preservation of native cartilage, a high quality subchondral bone repair, and the restoration of the joint congruency by immediate fragment stabilization. To improve the chance of successful stabilization, adequate lesion exposure is critical, especially in difficult to reach lesions located on the posteromedial talar dome. In this study we describe the open Lift, Drill, Fill, Fix (LDFF) technique for medial osteochondral lesions of the talus with an osteochondral fragment. As such, the lesion can be seen as an intra-articular non-union that requires debridement, bone-grafting, stabilization, and compression. The LDFF procedure combines these needs with access through a medial distal tibial osteotomy.

INDICATIONS

Symptomatic osteochondral lesion of the talus with a fragment (≥ 10 mm diameter and ≥ 3 mm thick as per computed tomography [CT] scan) situated on the medial talar dome which failed 3-6 months conservative treatment.

CONTRAINDICATIONS

Systemic disease, including active bacterial arthritis, hemophilic or other diffuse arthropathies, rheumatoid arthritis of the ankle joint, and malignancies. Neuropathic disease. End-stage ankle osteoarthritis or Kellgren and Lawrence score 3 or 4 [3]. Ipsilateral medial malleolus fracture less than 6 months prior. Relative contra-indication: posttraumatic stiffness with range of motion (ROM) < 5°. Children with open physis: do not perform an osteotomy as stabilization of the osteotomy may lead to early closure of the physis, potentially resulting in symptomatic varus angulation of the distal tibia. In these cases only arthrotomy can be considered.

SURGICAL TECHNIQUE

The OLT is approached through a medial distal tibial osteotomy, for which the screws are predrilled and the osteotomy is made with an oscillating saw and finished with a chisel in order to avoid thermal damage. Hereafter, the joint is inspected and the osteochondral fragment is identified. The cartilage is partially incised at the borders and the fragment is then lifted as a hood of a motor vehicle (lift). The subchondral bone is debrided and thereafter drilled to allow thorough bone marrow stimulation (drill) and filled with autologous cancellous bone graft from either the iliac crest or the distal tibia (fill). The fragment is then fixated (fix) in anatomical position, preferably with two screws to allow additional rotational stability. Finally, the osteotomy is reduced and fixated with two screws.

POSTOPERATIVE MANAGEMENT

Casting includes 5 weeks of short leg cast non-weightbearing and 5 weeks of short leg cast with weightbearing as tolerated. At 10-week follow-up, a CT scan is made to confirm fragment and osteotomy healing, and patients start personalized rehabilitation under the guidance of a physical therapist.

Tourniquet use in ankle arthroscopy: A systematic review

BACKGROUND

Ankle arthroscopy is commonly performed using a thigh tourniquet and is thought to improve visibility and reduce operative time. However, the current evidence is unclear as to whether the use of a tourniquet provides these benefits. The aim of this study was to investigate whether there is any clinical benefit of using a tourniquet in ankle arthroscopy.

METHODS

A systematic review following PRISMA guidelines was undertaken. All clinical studies published in Medline, Embase, PubMed and the Cochrane Library Database from inception until January 2023 reporting on the use of a tourniquet in ankle arthroscopy were included.

RESULTS

180 studies were identified of which 3 (164 patients) met the inclusion criteria. All studies showed no statistically significant difference in mean surgical time and complication rate between the tourniquet and non-tourniquet groups. Overall, the quality of the evidence was moderate to poor without data in favour or against the routine use of tourniquets in ankle arthroscopy.

CONCLUSION

The current literature suggests that there are no significant differences in mean surgical time and complication rate between the tourniquet and non-tourniquet groups.

MRI identification of pseudolesions in the distal tibia articular surface: Frequency and diagnostic criteria

OBJECTIVE

Pseudolesions of joints are known as focal irregularities of chondral or subchondral bone in typical joint areas and occur frequent but without clinical relevance. This study aims to report the prevalence and describe MRI findings of a previously unreported chondral, mostly posterior located pseudolesion of the distal tibia, and to define criteria to distinguish it from pathologic osteochondral lesions, as well as from another known pseudolesion of this area - the so called "Notch of Harty".

MATERIAL AND METHODS

A tri-centric retrospective case-control study included a total of 2,428 patients with ankle MRI examinations performed over a period of 6 years. MRI scans were evaluated by three radiologists in consensus for any cartilage irregularity of the distal tibial articular surface. For this purpose, the tibial articular surface was divided into 9 topographic regions. Proton-density weighted, fat-suppressed sequences in sagittal and coronal acquisition were used to assess the postero-medial articular surface of the tibia. Imaging features such as size and localization of cartilage irregularity and/or a cortical mould as well as presence of associated edema and/or subchondral cysts were reported. Demographic data (sex, age, and weight) was also recorded. Clinical data comprised presence of pain, movement impairment, and concomitant pathologies.

RESULTS

A total of 68 patients (34 male, 34 female) with a lesion of the distal tibia were identified that had a new pseudolesion (prevalence of 3%). These lesions occurred most frequently (50 out of 68, 74%) in the postero-medial distal tibia plafond and were more commonly detected in the age group of 9-30 years (47%). In 13 of these 68 cases, the cartilage irregularity was the sole lesion without subchondral abnormalities. By defining these cases as definite pseudolesions, the prevalence was 1% and their age distribution was similar to that of the 55 other lesions with subchondral changes. Here with 11 of the 13 cases the majority (85%) were seen in the posterior part, especially in the postero-medial part (55%) of the distal tibia. The size of the cartilage defect ranged from 1 to 7 mm, and the majority (69%) sized from 2 to 3 mm. In 36 of 68 patients, we have seen subchondral alterations such as edema and/or cysts in addition to cartilage irregularity. 66% (n = 45) of these changes were edema and 37% (n = 25) were cysts. None of these 68 new pseudolesions with or without subchondral changes needed surgical or arthroscopic intervention. In the radiological and orthopaedic reports, clinical symptoms such as pain or instability were never associated with our observed lesions and there was no significant correlation between the presence of motion-related pain and imaging findings of cartilage irregularity, subchondral edema, and subchondral cysts. Thirteen patients had MRI follow-up examinations. Here the lesions did not show any MR morphological changes or clinical deterioration. Besides the new pseudolesion, which occured mainly in the posterior part of the tibia surface, we observed the "Notch of Harty" with a higher prevalence (25%) in our patient cohort. The typical localization was in the antero-medial tibial articular surface, without any edema or cysts. There were no coincidences of patients with both a new pseudolesion and the "Notch of Harty" CONCLUSION: A new pseudolesion is typically seen in the postero-central and postero-medial tibial articular surface with a prevalence of 3% and may be associated with only a small cartilage irregularity. In many cases, however, additional findings such as bone edema and/or an adjacent bone cysts were found, which impairs differentiation of these lesions from pathologic osteochondral lesions. The latter are obviously often associated with a larger cartilage defect and clinical symptoms. Due to the balanced age distribution between those pseudolesions with and without subchondral changes and the lack of clinical symptoms, we conclude that the here reported pseudolesions are not a predilection for a clinically manifest osteochondral lesion (OCL). At the very least, the apparent lack of clinical relevance increases the likelihood that we are dealing with a new true pseudolesion.

High incidence of osteoarthritic changes in patients with osteochondral lesions of the talus without chronic lateral ankle instability

BACKGROUND

It is unclear whether osteochondral lesions of the talus (OLTs) without chronic lateral ankle instability (CLAI) progress to osteoarthritis, which affects the therapeutic strategy. Especially, the efficacy of conservative treatment for OLT remains controversial. Since various anatomical abnormalities have been reported, there may be abnormal movement of the talus in the mortise, causing ankle instability. We hypothesized that OLTs have frequent osteoarthritic changes even without CLAI. This study aimed to evaluate the incidence of osteoarthritic changes and stress distribution on the talus in OLT.

METHODS

Fifty-eight ankles with medial OLT without CLAI were retrospectively reviewed. Osteophytes and joint space narrowing on radiographs were scored using Kraus's classification and compared to ankles without OLTs. OA scores were compared between over 18 years and less than 17 years in OLTs. On computed tomography images, the area of OLTs was measured. Besides, Hounsfield Units (HU) of the talus in patients with and without OLTs were measured and compared.

RESULTS

Osteoarthritic changes were observed in 54 of the 58 ankles (94.8%) in the OLT patients. Osteophytes were frequently observed at the medial gutter and anterior tibial plafond. The OA score in patients aged over 18 years was significantly higher than that in patients aged less than 17 years (P < 0.05). HU values in the talus were significantly higher than those in non-OLT patients. OLTs more than 100 mm2 had a significantly higher osteoarthritic score than those less than 100 mm2.

CONCLUSION

Medial OLT without CLAI has frequently osteoarthritic changes, especially large lesions. Osteoarthritic changes in OLTs will progress over time, which needs to be considered when deciding whether to perform the surgical or non-surgical treatment.

The healing effects of L-carnitine and spongostan on cartilage defect in rat model

PURPOSE

We aimed to determine the effect of L-carnitine and spongostan on cartilage healing in an experimental animal model with a full-thickness cartilage defect.

METHODS

In the study 32 Sprague-Dawley rats were divided into four groups in equal numbers. A cartilage defect with a diameter of 1 mm and a depth of 3 mm was created in the femoral intercondylar region of rats in groups A, B, and C. Group A received no treatment in the defective area. Group B received treatment with spongostan. Group C received treatment with spongostan soaked in L-carnitine. Group D served as the healthy control group. The rats were euthanized 6 weeks after the treatment. Histological evaluation of the condyles was done with the modified Mankin scoring.

RESULTS

In the histopathological imaging of the cartilage structure, it was observed that in group A, there was complete disorganization and cellular structure was completely absent up to the subchondral bone. In group B, moderate structural improvement, partially intact appearance in border integrity and mostly diffuse hypercellularity were observed. In group C, a near-normal healing, a completely intact appearance in boundary integrities and normal or hypercellularity in cellular structure were observed. The total score of the modified Mankin decreases numerically from A to D. There was no statistically significant difference observed between the A-B (p = 0.176), C-D (p = 0.145), and C-B (p = 0.580) groups, while significant differences were detected between the A-C (p = 0.004), B-D (p = 0.007), and A-D (p = 0.000) groups.

CONCLUSION

It has been known that mitochondrial activity is reduced in the osteoarthritis, and as a result, decrease in cellular activity occurs with ATP synthesis. For this reason, we found that L-carnitine, which we expect to stimulate cell proliferation by stimulating ATP synthesis, makes a positive contribution to cartilage healing, as expected. It has been found that combining spongostan with L-carnitine for the treatment of cartilage healing, instead of applying spongostan alone, provides near-normal healing.

The role of the oblique medial osteotomy angle during osteochondral fragment fixation in patients with a posteromedial osteochondral lesion of the talus

BACKGROUND

Medial malleolar osteotomy has been widely performed for posteromedial osteochondral lesions of the talus (OLT) to expose the lesion. In osteochondral fragment fixation, bioabsorbable pins should be inserted as perpendicular as possible to obtain the rigid fixation. However, the exposure of the lesion may depend on the osteotomy angle, which affects the pin insertion angles. This study aimed to analyze the relationship between pin insertion and osteotomy angles in the medial malleolar osteotomy.

METHODS

Twenty-four ankles of 23 patients were included. The malleolar bisector angle which was calculated from radiographs and actual osteotomy angles were measured on radiographs, and the pin insertion and osteotomy angles were measured using MRI. The intersection angle was defined by the tangential line of the tibial plafond and medial malleolar articular facet, and the bisector of this angle was defined as the malleolar bisector angle. The relationship between pin insertion and osteotomy angles was analyzed.

RESULTS

There was no significant difference between the actual osteotomy (55.7° ± 6.6°) and malleolar bisector angles (57.4° ± 4.3°) on the radiograph. There was a significant correlation between pin insertion and osteotomy angles (rs = 0.601). The pin insertion angle (54.3° ± 5.9°) in the lower actual osteotomy angle than the malleolar bisector angle was smaller than those in the higher actual osteotomy angle (63.4° ± 8.2°).

CONCLUSIONS

This study showed the osteotomy angle affected pin insertion angle. The osteotomy angle should not be smaller than the malleolar bisector angle at medial malleolar osteotomy to insert pins as perpendicular as possible for fixation of posteromedial OLTs.

Hounsfield Unit values on the subchondral bone are related to clinical outcomes in bone marrow stimulation for osteochondral lesions of the talus

BACKGROUND

Poor clinical outcomes in bone marrow stimulation (BMS) for the osteochondral lesion of the talus (OLT) are caused by subchondral bone deterioration. It is reported that microfracture induces endochondral ossification in the subchondral bone, which may affect the subchondral bone condition after BMS. This study analyzed osteosclerotic patterns of the bed in OLTs on computed tomography (CT) images and the relationship between the subchondral bone condition and clinical outcomes of BMS.

METHODS

Sixty-nine ankles in 61 patients with OLT were included. Hounsfield unit (HU) on the bed of OLTs was measured on CT images and the pattern of osteosclerosis or absorption in the bed was analyzed. In these patients, 25 ankles in 24 patients underwent BMS. They were divided into 2 groups according to the presence of bone marrow edema (BME) one year after surgery, and clinical outcomes were compared.

RESULTS

HUs in the anterior region were significantly higher than those of other areas. In patients with BMS, the JSSF scale for BME positive group (88.0 ± 7.7 points) was significantly lower than that for BME negative group (95.0 ± 6.1 points) (p < 0.05) at the final follow-up. On preoperative CT images, HU values of the central region in the BME-positive group were significantly lower than those in the BME-negative group (p < 0.05).

CONCLUSION

Osteosclerotic changes in the anterior part of the bed were frequently observed, and BMS for the area with low HU values decreased clinical outcomes. BMS should be performed with attention to subchondral bone condition to obtain good clinical outcomes.

LEVEL OF EVIDENCE

4, case series.

Development and validation of a questionnaire to measure the severity of pain, functional limitations, and reduction of sports ability for german-speaking patients with osteochondral lesions of the ankle (OCLA-G)

BACKGROUND

There is no patient-reported functional scale specific for osteochondral lesion of the ankle (OCLA). Therefore, the objectives of this study were to develop a questionnaire that measures symptom severity, function, and sports capacity in patients with osteochondral lesions of the ankle and to determine the psychometric properties of the tool in German language (OCLA-G).

METHODS

The OCLA-G questionnaire was developed according to the COSMIN guidelines. Scalable items were generated from a literature search, based on an evaluation of 71 own OCLA patients, and from expert opinions. Following a twofold item reduction the questionnaire underwent explorative data analysis and principal component analysis. Validity and reliability were analysed in four groups of participants (40 patients with OCLA, 40 patients with other foot and ankle injuries, 40 asymptomatic athletes serving as a population at risk, and 40 asymptomatic persons playing sports not at risk). The minimum age for participation in the study was set at 18 years. The mean age was 39.3 ± 15.1 years.

RESULTS

The final OCLA-G questionnaire consists of eight and five questions to mirror activities of daily life (ADL) and sports, respectively. Excellent internal consistency (Cronbach's α = 0.950 for the ADL subscore and 0.965 for the sport subscale, respectively) was found. Spearman's rank correlation coefficients for test-retest reliability were 0.992 for the ADL subscore and 0.999 for the sport subscale (p < 0.001). The results of the exploratory and confirmatory factor analyses indicated that item difficulty was between 23.4 and 62.8. The Pearson correlation for the OCLA subscales ADL and sport was 0.853 (p < 0.001). Construct validity as tested against the SF-12 questionnaire subscales (Physical and Mental component scale) were r = -0.164 to -0.663 (p < 0.05). Statistically, there was no ADL and sport OCLA mean score difference between OCLA patients and patients with other foot and ankle injuries (p = 0.993 and 0.179, respectively), but both groups differed from the uninjured control groups (p < 0.001). There were no ceiling or floor effects.

CONCLUSIONS

The OCLA-G was successfully developed as the first patient reported and injury specific outcome scale to measure the impact of OCLA induced symptoms on activities of daily living and sport. This study provides evidence for the reliability and validity of the OCLA-G assessing patients with OCLA.

TRIAL REGISTRATION

The registration trial number is DRKS00009401 on DRKS. 'Retrospectively registered'. Date of registration: 10/12/2015.

Reattachment of Osteochondritis Dissecans Lesions in the Lateral Femoral Trochlear Ridge With Bioabsorbable Screws in 4 Yearling Standardbreds

This case series describes an alternative surgical technique to obtain reattachment of osteochondritis dissecans (OCD) lesions in the lateral trochlear ridge of the femur (LTRF) as well as the clinical and radiological outcome of treated cases. Four Standardbred yearlings (6 lesions in total) underwent surgical fixation of large OCD defects in the LTRF under arthroscopic guidance. Reattachment of the OCD lesions was obtained using 3.0/3.7 mm headless bio-compression and absorbable poly-l-lactic acid (PLLA) screws, inserted perpendicularly to the cartilage surface through the lesion. All horses were discharged from the hospital without complications. Clinical and radiological follow-up were collected and reviewed at 6 and 12 months post-operatively. Successful healing of the OCD lesions occurred in all cases based on radiographic evaluations, associated with a reduction of femoro-patellar effusion. All horses presented in this case series were able to enter regular training program as racehorses.

Descriptive analysis and short-term follow-up clinical results of osteochondral lesions of the distal tibia based on data of the German Cartilage Register (Knorpelregister® DGOU)

INTRODUCTION

An increasing number of ankle injuries with osteochondral lesions (OCL) also include lesions of the distal tibia. Therefore, the German Cartilage Society database is used to describe and examine the characteristics of these lesions and, early on, the results of different surgical therapies on the clinical outcome.

MATERIALS AND METHODS

Forty-seven patients out of 844 registered in the German Cartilage Society database met the inclusion criteria showing an OCL of the distal tibia (OLDT). Sixteen of them also presented a 1-year follow-up regarding the Foot and Ankle Ability Measure (FAAM). Further evaluations were included in the follow-up, such as the Foot and Ankle Outcome Score (FAOS) and the Visual Analogue Scale for pain (VAS).

RESULTS

The patients' mean age was 35 ± 11 with a mean BMI in the range of overweight (26/27 ± 5 kg/m²). The lesions were equally distributed on the articular surface of the distal tibia. Most patients were operated using anterior ankle arthroscopy [n_T 34 (72%); n_S 13 (81%)], while some (n_T 9; n_S 4) converted to open procedures. Almost 90% staged III and IV in the ICRS classification. Debridement, bone marrow stimulation, solid scaffolds, and liquid filler were the treatment choices among the subgroup. All therapies led to a clinical improvement between pre-op and 1-year follow-up but not to a significant level.

CONCLUSION

This study presents baseline data of OLDT based on data from a large database. BMS and scaffolds were the treatment of choice but did not present significant improvement after a 1-year follow-up.

Sustained clinical success at 7-year follow-up after arthroscopic Lift-Drill-Fill-Fix (LDFF) of primary osteochondral lesions of the talus

PURPOSE

To describe the long-term clinical results of arthroscopic fragment fixation for chronic primary osteochondral lesions of the talus (OLT), using the Lift-Drill-Fill-Fix (LDFF) technique.

METHODS

Eighteen patients (20 ankles) underwent fixation for a primary OLT with an osteochondral fragment using arthroscopic LDFF and were evaluated at a minimum of 5-year follow-up. Pre- and postoperative clinical assessment was prospectively performed by measuring the Numeric Rating Scale (NRS) of pain at rest, during walking and when running. Additionally, the change in Foot and Ankle Outcome Score (FAOS) and the procedure survival (i.e., no reoperation for the OLT) at final follow-up was assessed.

RESULTS

At a mean follow-up of 7 years, the median NRS during walking significantly improved from 7 (IQR 5-8) pre-operatively to 0 (IQR 0-1.5) at final follow-up (p =  < 0.001). This result was sustained from 1-year follow-up to final follow-up. The NRS during running significantly improved from 8 (IQR 6-10) to 2 (IQR 0-4.5) (p < 0.001) and the NRS in rest from 2.5 (IQR 1-3) to 0 (IQR 0-0) (p =  < 0.001). The median FAOS at final follow-up was 94 out of 100 for pain, 71 for other symptoms, 99 for activities of daily living, 80 for sport and 56 for quality of life. The FOAS remained significantly improved post-operatively on all subscales, except for the symptoms subscale. The procedure survival rate is 87% at final follow-up.

CONCLUSION

Arthroscopic LDFF for fixable chronic primary OLTs results in excellent pain reduction and improved patient-reported outcomes, with sustained results at long-term follow-up. These results indicate that surgeons may consider arthroscopic LDFF as treatment of choice for fragmentous OLT.

LEVEL OF EVIDENCE

Level IV, prospective case series.

To wedge or not to wedge; A cadaveric comparison study of two medial malleolar osteotomy modalities

OBJECTIVE

To quantify the surface area of the talus accessible with a uniplanar and a biplanar medial malleolus osteotomy. Our secondary purpose study is to quantify the amount of weightbearing area that each osteotomy effects on the tibial articular surface.

PATIENTS AND METHODS

Eight ankle joint specimens were dissected for this study. The uniplanar osteotomy was performed first. A K-wire marked the limits of access at two different angles: 90° and 30°. The boundaries were marked with a skin marker. Wedges were then created on the tibia plafond, and the osteotomy was converted into a biplanar one. Measurements were repeated again for this osteotomy. The talus, the tibial plafond, and the medial malleolus were then excised. Images were taken and then electronically calibrated for two-dimensional digital measurement of accessible areas. Areas of perpendicular and 30-degree access were recorded for both osteotomies. The articular surface of the tibia was also measured, and an area analysis was performed to calculate the amount of weightbearing cartilage removed by each osteotomy.

RESULTS

Almost the entire sagittal plane was accessible with both osteotomies. At a 30° angle, bone purchase was achieved for 67.7 % of the talar articular surface with the uniplanar osteotomy and for 74.8 % with the biplanar osteotomy. At a 90° angle, uniplanar osteotomy provided access to 32.7 % of the talar articular area, whereas the biplanar osteotomy achieved an average coverage of 52.8 %. The difference was statistically significant. On average, 25.3 % of the weightbearing area of the tibial plafond is affected when a biplanar osteotomy is performed.

CONCLUSION

Medial malleolar osteotomy provides varying degrees of access to the talar dome depending on how it is performed. A wedge-shaped biplanar osteotomy provides greater access and is therefore more suitable for defects located deeper on the talar dome. Despite providing wider access, it results in greater disruption of the weightbearing cartilage of the tibial plafond.

LEVEL OF EVIDENCE

Level V.

Favorable long-term clinical and radiologic outcomes with high survivorship after autologous osteochondral transplantation of the talus

PURPOSE

To evaluate long-term clinical and radiologic outcomes of patients undergoing autologous osteochondral transplantation (AOT) for osteochondral lesions of the talus (OLT) and to perform a correlation analysis between clinical and radiologic outcomes.

METHODS

Thirty-five patients with a mean age of 32.2 ± 8.9 years undergoing AOT for OLT between 1997 and 2003 were available for follow-up after an average of 19.1 ± 1.4 years. Demographic, surgical, and injury-related data were collected. After a minimum 18-year follow-up, patient-reported outcome scores (PROs) were collected, including the American Orthopaedic Foot & Ankle Society (AOFAS) score, the Foot and Ankle Outcome Score (FAOS), Tegner Activity Scale, and Visual Analogue Scale (VAS) for pain of the ankle. The Lysholm Score and VAS for pain of the knee were collected to assess donor-site morbidity. Magnetic resonance imaging scans were obtained to conduct an assessment of the replaced cartilage using the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) 2.0 scoring system. Any revision surgery (except symptomatic hardware removal and arthroscopic debridement) was defined as clinical failure.

RESULTS

Favorable clinical and radiologic (MOCART score, 73.7 ± 16.7 points) outcomes without any donor-site morbidities were observed. Twenty-three (65.7%) patients were satisfied or very satisfied with the surgical treatment. Fourteen (40.0%) and 25 (71.4%) patients had no or minor limitations in their athletic and working performance, respectively. A significant correlation between the MOCART and the FAOS Sport and Recreational activities subscale was found (r_s, 0.491; p = 0.033). Six (17.1%) patients met the criteria for clinical failure an average of 12.2 ± 6.6 years after AOT. Survival analysis demonstrated a mean estimated time of survival of 21.3 years (95% CI [19.55, 22.96]) and a 20-year survival rate of 77.9%.

CONCLUSION

Autologous osteochondral transplantation to treat OLT achieves high patient satisfaction and favorable PROs with a 20-year survival rate of almost 80%. Given the high clinical efficacy of AOT, this procedure can be recommended as a safe and promising technique for the long-term therapy of OLT.

LEVEL OF EVIDENCE

Level IV.

Os supranaviculare and navicular osteochondral lesion contributing to the development of a navicular stress fracture in an adolescent male athlete: Case report

Stress fractures of the tarsal navicular bone can be problematic in the athlete. This case details the injury and outcome of an adolescent male athlete who experienced one year of intermittent foot pain without acute trauma. Radiographs and computed tomography demonstrated a triad of a navicular stress fracture, an os supranaviculare, and an osteochondral defect of the navicular bone. The patient underwent successful operative fixation and returned to painless full function with imaging demonstrating healing at six months. Diagnosis of a navicular stress fracture in the setting of both an os supranaviculare and osteochondral lesion of the navicular bone have not been reported elsewhere in the literature. While repetitive loading on the navicular bone can independently produce a stress fracture, the patient had an increased risk for this injury; the presumably pre-existing navicular osteochondral lesion and os supranaviculare may have resulted in decreased effective articular surface area, thereby increasing force on the navicular bone and producing a stress fracture. Understanding navicular stress fractures and concomitant bony pathology contributing to injury is crucial to successful diagnosis, management, and prevention of recurrence.

ACR Appropriateness Criteria® Chronic Elbow Pain

Chronic elbow pain can be osseous, soft tissue, cartilaginous, and nerve related in etiology. Imaging plays an important role in differentiating between these causes of chronic elbow pain. This document provides recommendations for imaging of chronic elbow pain in adult patients. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer-reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Outcomes of bone marrow aspirate concentrate and matrix-induced chondrogenesis (BMIC) for treatment of osteochondral lesions of the talus

BACKGROUND

To analyze the outcomes of Bone marrow aspirate concentrate and Matrix-Induced Chondrogenesis (BMIC) in Osteochondral Lesions of the Talus (OLTs).

METHODS

Patients with OLTs treated with BMIC from June 2013 to July 2020 were included. Visual Analogue Scale (VAS), Foot Function Index (FFI), and Foot Ankle Outcome Score (FAOS) before treatment and at last follow-up were subjected to analysis.

RESULTS

Forty-five patients were included and mean follow-up was 39.1 months (range, 13-97 months). Mean lesion size and depth were 180.7 ± 110.4 mm² and 9.6 ± 3.7 mm, respectively. BMIC was performed without malleolar osteotomy in 36 patients (80%) and bone graft was performed in 42 (93.3%). VAS, FFI, and FAOS improved significantly. No complication occurred and no revision was required.

CONCLUSIONS

The BMIC procedure is feasible and should be considered a viable treatment option for OLTs associated with large subchondral bone defects.

Short-Term Results of Osteochondral Autologous Transfer and Femoral Neck Osteochondroplasty for the Treatment of Osteochondral Lesions of the Femoral Head and Concomitant Femoroacetabular Impingement Syndrome: A Case Series

This study aimed to analyse the initial results of five patients with symptomatic osteochondral lesions (OCL) and femoroacetabular impingement (FAI) who were treated successfully with osteochondral autologous transfer (OAT) and femoral neck osteochondroplasty (OCP) through surgical dislocation of the hip. Five patients with FAI and OCL of the femoral head who underwent surgery between 2015-2018 were studied retrospectively. All patients had a grade IV OCL, and the median defect size was 2 cm² (interquartile range [IQR], 2-2). At the final follow-up, the modified Harris hip score showed a median value of 94 (IQR, 91-95) (P=0.04). Pain evaluation using the visual analogue scale showed a median value of 1 (IQR, 1-2) (P=0.04). Adequate graft union and healthy formation of the chondral surface were observed by magnetic resonance imaging. Although the procedure is demanding, the combination of OAT and femoral neck OCP appears to be an effective alternative in young patients.

Outcomes of bioabsorbable fixation in the treatment of osteochondral lesions of the knee in adolescent patients

BACKGROUND

Bioabsorbable fixation in managing osteochondral lesions is increasing in popularity. The purpose was to report on outcomes using bioabsorbable fixation nails for osteochondral lesions of the knee in a pediatric and adolescent population.

METHODS

A retrospective review of pediatric patients undergoing surgery with bioabsorbable fixation for knee osteochondral lesions was performed. Demographic, clinical, and surgical data was collected including symptom duration, lesion location, size, use of bone grafting, and number of implants. Return to activities was documented. Patients recommended revision surgery were compared to those who were not.

RESULTS

47 patients with median age 13.9 years and 25.5% female were included with median clinical follow-up of 47.3 weeks. 87.2% of patients were cleared for full activities. Four male patients (8.5%) were recommended revision surgery, of whom three underwent surgery including removal of loose bioabsorbable fixation. Demographic data did not differ between the group with successful versus failed primary surgery (p > 0.05). Symptom duration was more acute (<1 month) in the four recommended revision surgery (75% versus 9.3%, p = 0.008). The group recommended revision also had larger lesion size (median 5.4 cm² versus 2 cm², p = 0.04). Distal femoral physeal status, lesion location, necessity for bone grafting, and number of implants did not differ between groups.

CONCLUSIONS

Adolescents had a high return to activity following bioabsorbable fixation for knee osteochondral lesions with 87.2% cleared for full return. In the 8.5% of patients who were deemed to have failed primary fixation, symptoms were more likely to be acute in nature with larger lesion sizes.

Management of Treatment Failures in Osteochondral Lesions of the Talus

Osteochondral lesions of the talus are a common result of traumatic ankle injury. Due to the low success rates of nonoperative management, surgical management of osteochondral lesions of the talus (OLTs) has evolved considerably over the past decade as more outcomes research has emerged, new techniques have been described, and we have developed a better understanding of the role of biologics in the treatment algorithm. We describe, in sequence, the surgical management options, including salvage procedures, for failed treatment of OLTs.

Good medium-term functional results in reconstruction of lateral femoral condyle osteochondral lesions

INTRODUCTION

Results of autologous osteochondral graft (mosaicplasty) are well-reported for the medial femoral condyle but much less for the lateral femoral condyle. The main aim of the present study was to assess results specifically for lateral condyle reconstruction. The secondary objective was to compare results according to the two main etiologies: osteochondritis dissecans (OCD) and osteochondral fracture (OCF).

HYPOTHESIS

The study hypothesis was that medium-term functional and radiological results of lateral femoral condyle autologous osteochondral graft are good.

MATERIAL AND METHODS

A single-center retrospective continuous study included 24 patients with symptomatic focal lateral femoral condyle osteochondral lesion treated by osteochondral autograft, at a minimum 24 months' follow-up. Mosaicplasty was performed for lesions <200 mm², with associated fixation for lesions >200 mm² with viable osteochondral fragments. IKDC, Lysholm and KOOS functional scores and pain on visual analog scale (VAS) were collected at last follow-up. Progression toward osteoarthritis was assessed on comparative X-ray.

RESULTS

Twenty patients were analyzed (11 OCD, 9 OCF) at a mean of 66.4±44 months. Mean pain on VAS was 1.8±2 out of 10. Mean subjective IKDC, Lysholm and global KOOS scores were respectively 68.1±26, 76.5±22 and 73.9±21. Two patients showed Ahlbäck grade 2 lateral femorotibial osteoarthritis. Functional results were comparable between OCD and OCF.

CONCLUSION

Reconstruction of lateral femoral condyle osteochondral lesion by osteochondral autograft gave good medium-term functional results, whatever the etiology. Longer-term studies are needed to assess progression toward osteoarthritis and functional deterioration over time.

LEVEL OF EVIDENCE

IV; retrospective study.

Preexisting and treated concomitant ankle instability does not compromise patient-reported outcomes of solitary osteochondral lesions of the talus treated with matrix-induced bone marrow stimulation in the first postoperative year: data from the German Cartilage Registry (KnorpelRegister DGOU)

PURPOSE

The purpose of this study was to compare the subjective ankle function within the first year following matrix-induced bone marrow stimulation (M-BMS) of patients with a solitary osteochondral lesion of the talus (OCLT) with and without concomitant chronic ankle instability (CAI).

METHODS

Data from the German Cartilage Registry (KnorpelRegister DGOU) for 78 patients with a solitary OCLT and a follow-up of at least 6 months were included. All patients received M-BMS for OCLT treatment. The cohort was subdivided into patients with OCLT without CAI treated with M-BMS alone (n = 40) and patients with OCLT and CAI treated with M-BMS and additional ankle stabilisation (n = 38). The Foot and Ankle Ability Measure (FAAM), the Foot and Ankle Outcome Score (FAOS), and the Numeric Rating Scale for Pain (NRS) were used to assess patient-reported outcomes (median (minimum-maximum)).

RESULTS

From preoperatively to 12 months postoperatively, patients with OCLT without CAI treated with M-BMS alone had a significant improvement of all subscales in the FAAM [activity of daily living 64.3 (10-100) to 88.1 (39-100); sports 34.4 (0-100) to 65.6 (13-94), functional activities of daily life 50 (0-90) to 80 (30-100), functional sports 30 (0-100) to 70 (5-100)] and FAOS [pain 61.1 (8-94) to 86.1 (50-100), symptoms 60.7 (18-96) to 76.8 (29-100), activities of daily living 72.1 (24-100) to 91.9 (68-100), sport/recreational activities 30.0 (0-70) to 62.5 (0-95), quality of life 31.3 (6-50) to 46.9 (19-100)]. Within the first year, patients with OCLT and CAI treated with M-BMS and ankle stabilisation also showed significant improvement in the FAAM [activity of daily living 68.8 (5-99) to 90.5 (45-100); sports 32.8 (0-87.5) to 64.1 (0-94), functional activities of daily life 62.5 (25-100) to 80 (60-90), functional sports 30 (0-100) to 67.5 (0.95)] and the FAOS [pain 66.7 (28-92) to 87.5 (47-100), symptoms 57.1 (29-96) to 78.6 (50-100), activities of daily living 80.1 (25-100) to 98.5 (59-100), sport/recreational activities 35.0 (0-100) to 70.0 (0-100), quality of life 25.0 (0-75) to 50.0 (19-94)]. The pain level decreased significantly in both groups. No significant difference was found between both groups regarding the subscales of FAAM, FAOS and the NRS 1 year postoperatively.

CONCLUSION

Improvements in subjective ankle function, daily life activities and sports activities were observed within the first year following M-BMS. Our results suggest that preexisting and treated ankle instability did not compromise subjective outcome in patients treated with M-BMS in the first postoperative year.

LEVEL OF EVIDENCE

Level IV.

Limited medial osteochondral lesions of the talus associated with chronic ankle instability do not impact the results of endoscopic modified Broström ligament repair

Background

The arthroscopic modified Broström procedure, with repair of the anterior talofibular ligament and extensor retinaculum, produces good functional outcomes in patients with chronic lateral ankle instability (CLAI). CLAI can be associated with osteochondral lesions of the talus (OLTs). It remains unclear whether associated limited OLTs affect clinical outcomes in such patients.

Methods

This retrospective cohort study included 92 CLAI patients with and without OLTs undergoing an all-inside arthroscopic modified Broström procedure from June 2016 to May 2019. The patients were divided into non-lesion group (n = 32) and lesion group (n = 60) according to whether CLAI was associated or not with OLTs. All the osteochondral lesions less than 15 mm in diameter were managed with bone marrow stimulation techniques (arthroscopic microfracture) at the time of the arthroscopic modified Broström procedure. The Visual Analogue Scale (VAS) scores, American Orthopedic Foot and Ankle Society (AOFAS) scores, Karlsson Ankle Function Score (KAFS), Anterior Talar Translation (ATT), Active Joint Position Sense (AJPS), and the rate of return to sports were compared in both groups.

Results

Increase in all the functional scores (VAS, AOFAS, KAFS, ATT, and AJPS) in both groups was, respectively, recorded 1 year and 2 years after surgery. At the 1-year and 2-year follow-up, there was no significant difference in the VAS, AOFAS, KAFS, ATT, and AJPS scores between the non-lesion and lesion groups.

Conclusion

In patients with CLAI who underwent an arthroscopic modified Broström procedure, the presence of limited OLTs (less than 15 mm in diameter), which required arthroscopic microfracture, did not exert any influence on outcome.

Level of Evidence

Level III, a retrospective comparative study.

One-year follow-up data from the German Cartilage Registry (KnorpelRegister DGOU) in the treatment of chondral and osteochondral defects of the talus

INTRODUCTION

Chondral and osteochondral lesions of the talus (OLTs) remain a challenging issue with numerous operative treatments proposed to date. The aim of this study was to evaluate 1-year follow-up data in the German Cartilage Registry (KnorpelRegister DGOU).

METHODS

Among 401 patients in the database, 114 patients with a complete 1-year Foot and Ankle Outcome (FAOS) score for subscale Pain as the primary variable were included. A total of 12 different surgical treatments were performed. However, 8 techniques were carried out in negligible numbers of patients (n = 1-3), leaving 89 patients treated with the following techniques: arthroscopic antegrade bone marrow stimulation (group A; n = 32), autologous chondrocyte implantation with autologous cancellous bone grafting (group B; n = 9), matrix-augmented bone marrow stimulation (group C; n = 22), and matrix-augmented bone marrow stimulation with autologous cancellous bone grafting (group D; n = 26). Group differences and possible influencing variables such as age and sex were evaluated. Level of significance was set at p < 0.05 for all statistical tests.

RESULTS

All four treatment groups showed significant improvement of the FAOS scores at 1 year postoperatively compared with their preoperative scores. No significant differences were found with respect to score changes among the groups. A positive correlation between FAOS subscale Pain improvement and defect size volume and negative correlations between increasing age and FAOS subscales Sports/Rec and QoL were found. Concomitant ankle stabilization led to greater improvement in FAOS subscales Symptoms and ADL than in patients with no stabilization. FAOS subscale Pain showed greater improvement in women than in men.

CONCLUSION

All analyzed treatment options were effective for treatment of OLTs. In particular, large defects appeared to benefit from treatment. In the presence of concomitant ankle instability, a stabilizing procedure appeared to have a positive impact on the outcome.

The effect of osteochondral lesion size and ankle joint position on cartilage behavior - numerical and in vitro experimental results

Osteochondral lesion of the talus is defined as damage in the cartilage that covers the talus bone, compromising the integrity of the joint in the long term. Due to the low incidence of this pathology, there are few studies to understand the importance of lesion size and position in cartilage strains. The purpose of this study is then to analyze the influence of the lesion size in joint behavior. A 3D virtual and in vitro model of a patient's injured ankle joint was developed. The models were built using CT scan and MRI images, to obtain the CAD models of intact and with 10 mm lesion size for 3D print models using additive manufacturing. The physical model was tested with 685N applied vertically to determine experimentally the principal strains and contact pressures in the cartilage. Five finite element models were developed with lesion dimensions (5 to 20 mm) and with 3 ankle joint positions. The numerical and experimental results were correlated with an R² = 0.86 justified by the complexity of the model geometry. The maximum principal strain was 2566µε in the plantar flexion position without lesion. The experimental contact area between cartilages increased by 1.2% in the 10 mm lesion size for 431 mm². The maximum stress in the cartilage was observed for a 20 mm lesion size with 2.5 MPa. The 5 and 10 mm sizes present similar results; the 15 mm lesion size presents a stress increase of 13% comparatively with 10 mm. Plantar flexion seems to be the most critical configuration; stress increases with an increase of lesion size around the cartilage.

Long-term outcome for repair of osteochondral lesions of the talus by osteochondral autograft: A series of 56 Mosaicplasties®

INTRODUCTION

The present study analyzed results in 56 osteochondral Mosaicplasty® autografts for osteochondral lesion of the talus (OLT) at more than 5 years' follow-up.

HYPOTHESIS

Mosaicplasty® shows long-term efficacy and low morbidity in the treatment of OLT.

PATIENTS AND METHODS

A multicenter retrospective study included patients treated by Mosaicplasty® with more than 5 years' follow-up. Preoperative data were collected from medical files, and all patients were reassessed. AOFAS scores and FAOS were calculated at last follow-up. Imaging comprised standard radiographs and MRI or CT arthrography of the ankle.

RESULTS

Fifty-six patients were included, with a mean age of 34 years (range, 18-60 years). Seventeen involved work accidents. Mean follow-up was 8.5 years (range, 5-20 years). Mean AOFAS score at follow-up was 80.6±19.4 and mean FAOS 77.8±21.5. Work accident, preoperative osteoarthritis and untreated laxity correlated significantly with poorer results. At last follow-up, 22 patients (39%) showed signs of osteoarthritis. There was no morbidity implicating the malleolar osteotomy. There were 11 cases (20%) of persistent patellar syndrome at the donor site.

DISCUSSION

The present results were comparable to those reported elsewhere, showing that functional results of Mosaicplasty® autograft for OLT do not deteriorate over the long term. Work accidents correlated significantly with poorer functional outcome. Any associated instability must always be treated. Malleolar osteotomy provides good exposure without additional morbidity.

LEVEL OF EVIDENCE

IV; retrospective study.

The lateral transligamentous approach to the talar dome

INTRODUCTION

Anatomic reduction of talar body fractures is critical in restoring congruency to the talocrural joint. Previous studies have indicated 43% talar body access with a single incision and without malleolar osteotomy. The aim of this study was to investigate the percentage talar body exposure when using the lateral transligamentous approach.

METHODS

The lateral transligamentous approach to the talus was undertaken in 10 fresh frozen cadaveric specimens by surgeons inexperienced in the approach following demonstration of the technique. An incision was made on the anterolateral aspect of the ankle augmented by the removal of the anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL) from their fibular insertions. A bone lever was then placed behind the lateral aspect of the talus and levered forward with the foot in equinus and inversion. A mark was made on the talar dome where an instrument could be placed 90 degrees to the talar surface. The talus was subsequently disarticulated and high-resolution images were taken of the talar dome surface. The images were overlain with a reproducible nine-grid division. Accessibility to each zone within the grid was documented using the mark made on the talar surface. ImageJ software was used to calculate the surface area exposed with each approach.

RESULTS

The mean percentage area of talar dome available through the transligamentous approach was 77.3% (95% confidence interval 73.3, 81.3). In all specimens the complete lateral talar process was accessible, along with the lateral and dorsomedial aspect of the talar neck. This approach gives complete access to Zones 1, 2, 3, 5 & 6 with partial access to Zones 4, 8 & 9.

CONCLUSION

The lateral transligamentous approach to the talus provides significantly greater access to the talar dome as compared to standard approaches. The residual surface area that is inaccessible with this approach is predominantly within Zones 4,7 and 8, the posteromedial corner.

LEVEL OF CLINICAL EVIDENCE

V.

Arthroscopic findings and treatment of maisonneuve fracture complex

Background

The Maisonneuve fracture complex (MFC) is a well-known lower leg injury. However, the optimal treatment is still not clear and there is limited data on concomitant injuries of cartilage. Therefore, the aim of our study was to report the incidence of incidental cartilage injuries and their management in arthroscopic treatment of MFC.

Patients and methods

Between February 2018 and February 2021 all patients presenting with MFC in our department were treated with diagnostic ankle arthroscopy and percutaneous syndesmotic screw or suture-endobutton fixation. In case of instable cartilage, it was debrided and according to the International Consensus Meeting on Cartilage Repair of the Ankle, in grade IV lesions < 10 mm or < 100 mm² area the subchondral bone was microfractured.

Results

Eighteen patients, 16 male and two female, with a mean age of 48.1 years, were included. In all cases, instability of the distal tibiofibular articulation was confirmed arthroscopically. Injuries of the cartilage were found in 56% of the cases and in 31% of the patients surgical intervention was required. In three talar and one tibial lesion additional arthroscopic bone marrow stimulation with microfracture of the subchondral bone was performed.

Conclusions

Ankle arthroscopy is a helpful method to guide fibular reduction and to detect and address associated cartilage injuries. Due to the high rate of chondral lesions, addressing these arthroscopically may contribute to better postoperative results.

Level of evidence

IV

Effectiveness of surgical treatments on healing of cartilage and function level in patients with osteochondral lesions of the tibial plafond: A systematic review

Background

Osteochondral lesions of the tibial plafond (OLTPs) occur less frequently than those of the talus, and treatment guidelines have not been determined. The aim of the current review was to evaluate the effectiveness of surgical treatments on the healing of cartilage and on function level, i.e. pain reduction, reduced swelling and improved joint range of motion, in patients with OLTPs.

Methods

A comprehensive literature search in PubMed/MEDLINE, Cochrane Database of Systematic Reviews and Google Scholar was performed up to December 2020. The outcome measures were healing of cartilage and function level.

Results

Four studies investigating treatment of OLTPs were included. Three studies investigated treatment by means of microfracture. One of these studies showed an osteochondral defect filling in 52.0% of patients. All three studies showed an improvement in function level. Antegrade drilling was evaluated in one study, showing contrasting results in two patients. One-step bone marrow-derived cell transplantation was evaluated in one study, showing an osteochondral defect filling in 68.0% of patients and improvements in patients' function level.

Conclusions

Arthroscopic treatment of OLTPs by means of microfracture and bone marrow-derived cell transplantation (BMDCT) seem effective for the outcome at the patient's function level, while BMDCT showed more promising results regarding defect filling. However, this is based on the current available evidence with poor quality of methodology. Further research is of paramount importance to understand this injury and to evaluate the best treatments.

Cell-free osteochondral scaffolds provide a substantial clinical benefit in the treatment of osteochondral defects at a minimum follow-up of 5 years

Purpose

The treatment of osteochondral lesions is challenging and no consensus has been established about the best option for restoring both cartilage and subchondral bone. Multilayer collagen-hydroxyapatite scaffolds have shown promising clinical results, but the outcome at a follow-up longer than 5 years still has to be proved. The aim was to evaluate the clinical outcome of patients with a knee isolated osteochondral lesion treated with a biomimetic three-layered scaffold at a minimum 5 years of follow-up.

Methods

Twenty-nine patients (23 males and 6 females, mean age 31.5 ± 11.4 years) were evaluated retrospectively before surgery, at 1 and 2 years and at last follow-up (FU). Visual Analog Scale (VAS) for pain, International Knee Documentation Committee (IKDC) Subjective Score, Tegner-Lysholm Knee Scoring Scale and Tegner Activity Level Scale were collected. Mean FU was 7.8 ± 2.0 years (min 5.1 - max 11.3). The etiology of the defect was Osteochondritis Dissecans or osteonecrosis (17 vs 12 cases).

Results

At 12 months FU the IKDC score improved from 51.1 ± 21.7 to 80.1 ± 17.9 (p < 0.01), Tegner Lysholm Score from 59.9 ± 17.3 to 92.5 ± 9.0 (p < 0.01), VAS from 6.1 ± 2.1 to 1.7 ± 2.3 (p < 0.01) and Tegner Activity Level Scale from 1.6 ± 0.5 to 4.9 ± 1.7 (p < 0.01). The results remained stable at 24 months, while at last FU a statistically significant decrease in IKDC, Tegner Lysholm and Tegner Activity Scale was recorded, though not clinically relevant. Patients under 35 achieved statistically better outcomes.

Conclusions

The use of a cell-free collagen-hydroxyapatite osteochondral scaffold provides substantial clinical benefits in the treatment of knee osteochondral lesions at a minimum follow-up of 5 years, especially in patients younger than 35 years.

Level of evidence

Level IV.

A case report of femoral head fracture with osteochondral lesion treated by osteosynthesis and biomimetic scaffold: 2-year clinical and radiological follow-up

The aim of the present study was to present clinical and radiological outcome of a hip fracture-dislocation of the femoral head treated with biomimetic osteochondral scaffold.

An 18-year-old male was admitted to the hospital after a motorcycle-accident. He presented with an obturator hip dislocation with a type IVA femoral head fracture according to Brumback classification system. The patient underwent surgery 5 days after accident. The largest osteochondral fragment was reduced and stabilized with 2 screws, and the small fragments were removed. The residual osteochondral area was replaced by a biomimetic nanostructured osteochondral scaffold. At 1-year follow-up the patient did not complain of hip pain and could walk without limp. At 2-year follow-up he was able to run with no pain and he returned to practice sports. Repeated radiographs and magnetic resonance imaging studies of the hip showed no signs of osteoarthritis or evidence of avascular necrosis. A hyaline-like signal on the surface of the scaffold was observed with restoration of the articular surface and progressive decrease of the subchondral edema.

The results of the present study showed that the biomimetic nanostructured osteochondral scaffold could be a promising and safe option for the treatment of traumatic osteochondral lesions of the femoral head.

Study Design: Case report.

The management of talar osteochondral lesions - Current concepts

Osteochondral lesions of the talus (OLTs) are a common complication following trauma, involving both the articular cartilage and the underlying subchondral bone, with variable aetiologies and often presenting with non-specific symptoms. Diagnosis of OLTs requires a combination of clinical assessment and imaging and despite many different treatment options, there is no generalised consensus regarding which option is the most effective. Left untreated, OLTs risk progressing to osteoarthritis. Acute non-displaced OLTs can be treated non-operatively. However, OLTs refractory to non-surgical care for three to six months may be suitable for surgical care. In these cases, conservative treatments are often unsuccessful, particularly for larger and more severe defects and so the majority require surgical intervention. Although bone marrow stimulation techniques remain the "gold standard" for lesions <150 mm2, there still requires a need for better long term clinical data and cost-benefit analyses compared with other treatment options. Biological attempts at either regenerating or replacing the articular cartilage are however demonstrating some promising results, but each with their own advantages and disadvantages. In this review, we summarise the clinical management of OLTs and present the current concepts of different treatment regimes.

Pediatric Bassett's ligament: pathology or normal anatomy?

BACKGROUND

Bassett's ligament is an accessory fascicle of the anterior inferior tibiofibular ligament. The prevalence, normal thickness and clinical implications of a thickened ligament have not been described in the pediatric radiology literature.

OBJECTIVE

The purpose of this study was to determine the prevalence and thickness of Bassett's ligament in pediatric patients with magnetic resonance imaging (MRI) findings of lateral talar osteochondral lesions, medial talar osteochondral lesions and posterior ankle impingement, to compare these measurements with normal MRIs, and to compare the reproducibility of these measurements.

MATERIALS AND METHODS

This is a retrospective study of pediatric ankle MRIs with four cohorts containing 21 patients each. All MRIs were retrospectively reviewed by a pediatric musculoskeletal radiologist and a pediatric radiology fellow. The prevalence of Bassett's ligament and its axial thickness were obtained for each cohort with repeat measurements for intra-observer and interobserver variability. Average thickness and standard deviation of Bassett's ligament were calculated.

RESULTS

The prevalence of Bassett's ligament and its thickness in each cohort were (mean±standard deviation): lateral osteochondral lesions, 71% (15/21), 1.9±0.5 mm; medial osteochondral lesions, 52% (11/21), 1.4±0.2 mm; posterior impingement, 52% (11/21), 1.3±0.2 mm; and normal ankle examinations, 71% (15/21), 1.5±0.4 mm. The thickness of Bassett's ligament was increased in the lateral talar osteochondral lesion group when compared to normal (P=0.02), while thickness in the medial osteochondral lesion and posterior impingement groups was not significant when compared to normal. The repeat measurements showed no significant difference in intra-observer and interobserver variability.

CONCLUSION

Bassett's ligament is a normal structure in children. Thickening of Bassett's ligament is seen with lateral osteochondral lesions and may be an indirect sign of anterolateral tibiotalar capsule injury.

Treatment strategies for osteochondral lesions of the talus: A review of the recent evidence

BACKGROUND

There has been no consensus regarding the treatment of osteochondral lesions of the talus, there has been many attempts to formulate a treatment pathway, with multiple proposed modalities and adjuncts used.

OBJECTIVES

The aim of this paper was to investigate the evidence published in the recent history, identify the relevant papers, review and summarize the findings, to help clarify the available operative treatment options and their respective efficacies based on the level of evidence provided.

STUDY DESIGN & METHODS

A literature search through electronic databases MEDLINE and EMBASE was done, these databases were screened for publications and papers form June 2004 to June 2019. Key words were utilised in the search 'talus, talar, tibia, cartilage, osteochondral, ankle, osteochondritis dissecans, articular cartilage'. Studies on adults aged 18-60 years were included. Exclusion criteria were studies with less than 10 patients, or no clear outcome was recorded. Papers were reviewed by the authors and data extracted as per a pre-defined proforma.

RESULTS

Following screening, 28 published articles were included and reviewed. Of these publications 5 were level I, 7 level II, 4 level III and 12 level IV. The total number of patients was 1061 patients. Treatment modalities included arthroscopic microfracture, drilling, hyaluronic acid injection, platelet rich plasma, osteochondral autologous transplantation (OAT), vascularised free bone graft among others. The most common functional measures used to assess efficacy were the Visual analogue scale (VAS) and the American Orthopaedic Foot and Ankle (AOFAS) score. Follow up ranged from 26 weeks upto 4 years.

CONCLUSIONS

Despite the abundance of treatment options, high level evidence (level I) remains limited and does not conclude a definitive treatment modality as superior to others. Further research, in the form highly organised randomised clinical trials, is needed to help improve the efficacy and develop new treatment modalities in the future.

Autologous osteochondral transplantation for osteochondral lesions of the talus: high rate of return to play in the athletic population

PURPOSE

(1) To determine the rate of return to play following autologous osteochondral transplantation (AOT) for osteochondral lesions of the talus (OLT) and (2) report subsequent rehabilitation protocols.

METHODS

A systematic review of the PubMed, Embase, and The Cochrane Library databases was performed according to the PRISMA guidelines based on specific eligibility criteria. Return to play data was meta-analysed and subsequent rehabilitation protocols were summarised. Level of evidence and quality of evidence (Zaman's criteria) were also evaluated.

RESULTS

Nine studies that totalled 205 ankles were included for review. The mean follow-up was 44.4 ± 25.0 (range 16-84) months. The mean OLT size was 135.4 ± 56.4 mm². The mean time to return to play was 5.8 ± 2.6 months. The mean rate of return to play was 86.3% (range 50-95.2%), with 81.8% of athletes returning to pre-injury status. Based on the fixed-effect model, the rate of return to play was 84.07%. Significant correlation was found between increase age and decrease rate of return to play (R² = 0.362, p = 0.00056). There was no correlation between OLT sizes and rate of return to play (R² = 0.140, p = 0.023). The most common time to ankle motion post-surgery was immediately and the most common time to full weight-bearing was 12 weeks.

CONCLUSIONS

This systematic review indicated a high rate of return to play following AOT in the athletic population. Size of OLT was not found to be a predictor of return to play, whereas advancing age was a predictor. Rehabilitation protocols were largely inconsistent and were primarily based on individual surgeon protocols. However, the included studies were of low level and quality of evidence.

LEVEL OF EVIDENCE

Level IV.

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

BACKGROUND

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

METHODS

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

RESULTS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Fresh osteochondral allograft transplantation (FOCAT) for definitive management of a 198 square millimeter osteochondral lesion of the talus (OLT): A case report

An osteochondral lesion of the talus (OLT) is an idiopathic acquired lesion of the subchondral bone that can lead to debilitating sequelae. The causes of OLT's are still debatable, however, most agree that the etiology is repetitive microtrauma associated with vascular impairment. OLTs are most commonly described in the medial portion of the talus, while lateral involvement is less frequent. If not properly recognized and treated, an OLT may lead to numerous secondary conditions including premature osteoarthritis and functional limitations of the ankle joint. Multiple surgical and non-surgical treatment modalities have been described with varying results. Treatments are usually guided by the patients age, onset of symptoms, severity, and the disease stage according to the Berndt and Harty classification. Recent literature recommends curettage, drilling, or microfracture techniques for lesions which are no larger than 15mm in diameter and no deeper than 7mm. On the other hand, for large lesions or lesions that failed from primary bone marrow stimulation, surgery should be considered for autologous chondrocyte implantation (ACI), osteochondral autograft transplantation (OATs or mosaicplasty), or osteochondral allograft transplantation [1]. This case study examines surgical treatment of an extensive OLT in a 53 year old man who suffered with continuous ankle pain for over 10 years, misdiagnosed as ankle joint arthritis. Level of clinical evidence: Level of evidence 4.

Emerging Biological Treatment Methods for Ankle Joint and Soft Tissue Conditions: Clinical Applications as Alternative or Adjuvant

In the past 2 decades, there has been a rapid expansion of clinical studies investigating the safety and efficacy of biological treatment methods for a wide range of diseases. These biological treatment methods increasingly are used in clinical practice based on limited available evidence. This article provides an overview of evidence on biological treatment methods for foot and ankle pathologies, including ankle osteoarthritis, osteochondral lesions of the talus, and Achilles tendinopathy.

Current management strategies for osteochondral lesions of the talus

The management of symptomatic osteochondral lesions of the talus (OLTs) can be challenging. The number of ways of treating these lesions has increased considerably during the last decade, with published studies often providing conflicting, low-level evidence. This paper aims to present an up-to-date concise overview of the best evidence for the surgical treatment of OLTs. Management options are reviewed based on the size of the lesion and include bone marrow stimulation, bone grafting options, drilling techniques, biological preparations, and resurfacing. Although many of these techniques have shown promising results, there remains little high level evidence, and further large scale prospective studies and systematic reviews will be required to identify the optimal form of treatment for these lesions. Cite this article: Bone Joint J 2021;103-B(2):207-212.

HemiCAP® implantation after failed previous surgery for osteochondral lesions of the talus

BACKGROUND

The aim of this study is to enhance data about the effectiveness of HemiCAP® implantation after failed previous surgery for osteochondral defects (OCDs).

METHODS

12 consecutive patients were retrospectively included in this study. The American Orthopedic Foot and Ankle Society Score (AOFAS), the Visual Analogue Scale (VAS) score for pain, the sub-scales Pain and Disability of the Foot Function Index (FFI-P and FFI-D) Score, and the patients' satisfaction were evaluated.

RESULTS

AOFAS increased from poor to fair (p < 0.001), VAS score decreased from moderate to mild pain (p = 0.001), the final FFI-P and FFI-D were 37.50 ± 18.54 and 33.44 ± 16.24, respectively (p < 0.001). Five patients were not satisfied, three were moderately satisfied and four were highly satisfied. One implant repositioning, one ankle fusion (implant failing) and an additional surgery (double arthrodesis) were performed during the follow-up. Neither intra- nor postoperative complications were registered.

CONCLUSION

Despite the clinical improvement, pain was still present at the final follow-up. Metal resurfacing might not be considered a definitely valid alternative for treatment of OCDs after failed previous surgery.

LEVEL OF EVIDENCE

Level III, retrospective study.