Enhancing precision in osteochondral lesions of the talus measurements and improving agreement in surgical decision-making using weight-bearing computed tomography and distance mapping

PURPOSE

Weight-bearing computed tomography (WBCT) enables the creation of a three-dimensional (3D) model that represents the ankle morphology in a standing position. Distance mapping (DM) is a complementary feature that uses color coding to represent the relative intraarticular distance and can be used to outline intraarticular defects. Consequently, DM offers a novel approach to delineating osteochondral lesions of the talus (OLT), allowing for the quantification of its surface, volume and depth. The reliability of DM for OLT measurements has yet to be thoroughly evaluated. This study primarily aims to determine the reliability of DM in measuring the surface, depth and volume of OLT. A secondary objective is to ascertain whether measurements obtained through DM, when integrated with a predefined treatment algorithm, can facilitate consensus among surgeons regarding the optimal surgical intervention.

METHODS

This cohort comprised 36 patients with 40 OLTs evaluated using WBCT and DM. Two raters used DM to determine the lesion boundary (LB) and lesion fundus (LF) and calculate the lesion depth, surface and volume. The raters were asked to choose between bone marrow stimulation, autologous matrix-induced chondrogenesis and osteochondral transposition based on the measurement. Inter-rater and intra-rater agreement was measured.

RESULTS

Interclass correlation of the lesion's depth surface produced an excellent inter-rater and intra-rater agreement of 0.90-0.94 p < 0.001. Cohen's κ agreement analysis of the preferable preoperative plan produced a κ = 0.834, p < 0.001, indicating a near-perfect agreement.

CONCLUSION

WBCT-based 3D modules and DM can be used to measure the lesion's surface, depth and volume with excellent inter-rater and inter-rater agreement; using this measurement and a predetermined treatment algorithm, a near-perfect inter-rater agreement for the preoperative planning was reached. WBCT in conjunction with AI capabilities could help determine the type of surgery needed preoperatively, evaluate the hindfoot alignment and assess if additional surgeries are needed.

LEVEL OF EVIDENCE

Level III.

Analysis of preoperative and postoperative depression and anxiety in patients with osteochondral lesions of the talus

Purpose

This study aims to investigate the psychological status of patients with Hepple V osteochondral lesions of the talus (OLT) and evaluate the effect of autologous osteoperiosteal transplantation (AOPT) on their psychological well-being.

Methods

Fifty patients with Hepple V OLT who underwent AOPT at the Comprehensive Foot and Ankle Surgery Ward of Xi'an Honghui Hospital from November 2021 to May 2023 were included in this study. The patients were divided into two groups based on the presence or absence of preoperative symptoms of anxiety/depression. Group A comprised patients with preoperative symptoms, while Group B included patients without such symptoms. Preoperative and final follow-up assessments included the Hospital Anxiety and Depression Scale for evaluating anxiety and depression, the visual analogue scale for pain assessment, and the American Orthopaedic Foot and Ankle Society scores for assessing ankle and hindfoot function.

Results

Among the 50 Hepple V OLT patients who obtained complete follow-up, twenty-four had preoperative symptoms of anxiety/depression, with an incidence rate of up to 48%. Patients in Groups A and B showed significant improvement in all evaluation indexes after AOPT compared to the preoperative period, but the overall prognosis of Group A was poorer than that of Group B.

Conclusion

AOPT can effectively improve patients' pain, functional activities, and psychological status, and there is a significant correlation between patients' preoperative psychological status and prognosis.

Republication of "Osteochondral Lesions of the Talus: Current Concepts in Diagnosis and Treatment"

Osteochondral lesions of the talus (OLTs) are a difficult pathologic entity to treat. They require a strong plan. Lesion size, location, chronicity, and characteristics such as displacement and the presence of subchondral cysts help dictate the appropriate treatment required to achieve a satisfactory result. In general, operative treatment is reserved for patients with displaced OLTs or for patients who have failed nonoperative treatment for 3 to 6 months. Operative treatments can be broken down into cartilage repair, replacement, and regenerative strategies. There are many promising treatment options, and research is needed to elucidate which are superior to minimize the morbidity from OLTs.

The efficacy of platelet-rich plasma in osseous foot and ankle pathology: a review

The purpose of this review is to develop evidence-based practices for the use of platelet-rich plasma (PRP) to treat osseous pathologies of the lower extremity. There is moderate high-quality evidence to support the efficacy of PRP as a surgical augment to microfracture in osteochondral lesions of the talus (OLT). The literature supports a conceivable positive impact on bony union and osseous healing. There is insufficient evidence to support PRP injections in the conservative management of OLT or symptomatic ankle osteoarthritis. PRP may serve as a viable treatment method in the surgical augmentation of microfracture surgery in OLT and has promise for increasing bony union following surgical operations. Further high-quality, comparative studies with longer clinical follow-up are required.

Osteochondrogenesis with Autologous Peripheral Blood Stem Cells for Osteochondral Lesions of the Talus: Report of Five Cases

Osteochondral lesions of the talus (OLTs) may progress to ankle arthritis needing ankle arthroplasty or arthrodesis. We report five cases of OLTs treated along the principles developed for chondrogenesis of the knee joint with autologous peripheral blood stem cells (PBSCs), resulting in repair and regeneration of the bone and cartilage components. Improvement in Ankle Osteoarthritis Scale (AOS) scores with minimum two years follow-up showed statistical significance (p < 0.05).

Effectiveness of Autograft and Allograft Transplants in Treating Athletic Patients With Osteochondral Lesions of the Talus

Osteochondral lesions of the talus (OLTs) represent 50% of ankle sprains and are most common in athletes who play competitive sports or are on active military duty. OLTs can cause significant physical damage if left untreated and may inflict financial burdens and mental health issues. Over the years, replacement surgeries, mainly autologous osteochondral transplantation (AOT) and osteochondral allograft transplantation (OAT), have become instrumental in treating OLTs. However, these procedures' effectiveness in returning to full fitness to resume competitive sports or active duty has not been well-established. This systematic review attempts to help this population cohort better understand OLTs and highlight the existing clinical evidence on AOT and OAT effectiveness in treating such patients. We performed a literature search between March 2022 through September 2022 following the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Of eligible studies evaluating surgical outcomes of AOT and OAT in sportspeople and active-duty military personnel, 86% of patients who received AOT returned to competitive sports or active duty compared to 61% who received OAT. Additionally, on average, patients who underwent AOT returned to full fitness in five months rather than in 16 months for those who underwent OAT. As highlighted in this review, the limited evidence indicates that AOT may lead sportspeople and active-duty military personnel to return to pre-injury levels and resume athletic activities sooner. It is challenging to assume the same for OAT, given the limited studies in athletic cohorts with OLTs. Nevertheless, AOT and OAT are crucial surgical options that can significantly benefit competitive sportspeople and military personnel in resuming their careers.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level IV-systematic review and meta-analysis.

Midterm Prospective Evaluation of Structural Allograft Transplantation for Osteochondral Lesions of the Talar Shoulder

BACKGROUND

In cases of large osteochondral lesions of the talus (OLTs), fresh structural or bulk osteochondral allograft transplantation has yielded favorable outcomes in several retrospective and few prospective case series. The purpose of this study was to prospectively evaluate patients who received fresh structural allograft transplantation of the talar shoulder.

METHODS

A prospective evaluation of patients who received a fresh structural allograft of an OLT was performed. Preoperative imaging included magnetic resonance imaging (MRI) and/or computed tomography (CT) with plain radiographs. The following patient-reported outcomes questionnaires were administered preoperatively and yearly after surgery: 36-Item Short-Form Health Survey (SF-36), visual analog scale (VAS) for pain, and the Short Musculoskeletal Functional Assessment (SMFA). Preoperative and postoperative imaging were evaluated for allograft assimilation, evidence of arthritic changes, or functional range of motion abnormalities.

RESULTS

Thirty-one patients with a mean age of 41.4 years (±14.1, range 18-69) underwent structural fresh osteochondral allograft transplantation to the talar shoulder and were included in this study. The mean follow-up was 56.2 months (±36.1, range 24-142). The majority of patients were female (n=17, 54.8%), reported some history of prior ankle trauma (n=21, 67.7%), and underwent prior ankle surgery (n=23, 74.2%). The mean lesion size on CT scan was 1879 mm³ (n = 27) compared to the mean lesion size of 3877 mm³ (n = 21) on MRI. There was a significant improvement in the mean preoperative VAS score (P < .0001), SF-36 score (P < .0005), SMFA bother index (P < .0015), and the SMFA function index (P < .0001) at final follow-up. A total of 15 (48.4%) patients underwent an additional surgery following their osteochondral allograft transplant, most commonly arthroscopic debridement or removal of hardware, performed at an average of 25.2 (±13.0) from their index procedure. There was one failure that required a total ankle replacement. The overall graft survival rate was 96.8%.

CONCLUSION

Fresh, structural allograft transplantation resulted in significant improvement in patient-reported postoperative pain and function in patients suffering from OLTs. The graft survival rate was 96.8% at a mean of 56.2 months follow-up, with half of patients requiring a second procedure.

LEVEL OF EVIDENCE

Level IV, prospective case series.

Is Early or Delayed Weightbearing the Better Choice After Microfracture for Osteochondral Lesions of the Talus? A Meta-analysis and Systematic Review

Osteochondral lesions of the talus (OLT) are common injuries requiring surgery. Arthroscopic microfracture treatment is effective and acceptable. Although the concept of postoperative rehabilitation is continuously being updated, the choice between early weightbearing (EWB) versus delayed weightbearing (DWB) following microfracture is still not settled. A meta-analysis and systematic review was performed to compare the rehabilitation effect of 2 different weightbearing protocols following microfracture. Five databases were searched for relevant studies, and full-text articles comparing EWB and DWB were reviewed. Review Manager 5.3 software was used to summarize the results of the included studies. Two reviewers independently filtered the studies, assessed quality, extracted data, and estimated the risk of bias. The pain score and functional assessment of the ankle were selected as the endpoints. The mean difference was calculated as the summary statistic for continuous data. Then, visual analog scale and American Orthopedic Foot and Ankle Society scale scores were collected and pooled. Five randomized controlled trials including 283 patients were identified for this study, revealing that there was no significant difference in pain scores between EWB and DWB following microfracture 3 months, 6 months, 12 months, and 24 months postoperatively. Function assessment showed similar results. Comprehensive analysis of current evidence still suggests that EWB and DWB after microfracture of OLT produce comparable clinical outcomes in terms of pain and functional activity. Therefore, EWB is recommended to shorten the length of time before returning to work or sports after microfracture of OLT.

Comparison of Functional and Radiographic Outcomes of Talar Osteochondral Lesions Repaired With Micronized Allogenic Cartilage Extracellular Matrix and Bone Marrow Aspirate Concentrate vs Microfracture

BACKGROUND

Microfracture (MF) has been used historically to treat osteochondral lesions of the talus (OLTs), with favorable outcomes reported in approximately 80% to 85% of cases. However, MF repairs have been shown to degrade over time at long-term follow-up, suggesting that further study into optimal OLT treatment is warranted. The use of adjuvant extracellular matrix with bone marrow aspirate concentrate (ECM-BMAC) has not been extensively evaluated in the literature. We present a comparison of patient-reported and radiographic outcomes following ECM-BMAC repair vs traditional MF.

METHODS

Patients who underwent MF (n = 67) or ECM-BMAC (n = 62) treatment for an OLT were identified and their charts were retrospectively reviewed. Postoperative magnetic resonance imaging (MRI) was evaluated and patient-reported outcome scores, either Foot and Ankle Outcome Scores (FAOS) or Patient-Reported Measurement Information System (PROMIS) scores, were collected. MRIs were scored by a radiologist, fellowship trained in musculoskeletal radiology, using the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) system. Radiographic and clinical outcomes were compared between groups.

RESULTS

On average, patients treated with ECM-BMAC demonstrated a higher total MOCART score compared to the MF group (73 ± SD 11.5 vs 54.0 ± 24.1; P = .0015). ECM-BMAC patients also had significantly better scores for the Infill, Integration, and Signal MOCART subcategories. Last, patients treated with ECM-BMAC had a lower rate of revision compared to those treated with MF (4.8% vs 20.9%; P = .007). FAOS scores were compared between groups, with no significant differences observed.

CONCLUSION

When comparing outcomes between patients treated for an OLT with ECM-BMAC vs traditional MF, we observed superior MRI results for ECM-BMAC patients. The rate of revision surgery was higher for MF patients, although patient-reported outcomes were similar between groups. The use of ECM-BMAC as an adjuvant therapy in the treatment of OLTs may result in improved reparative tissue when compared to MF.

LEVEL OF EVIDENCE

Level III, comparative series.

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

Background:

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

Hypothesis:

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

Study Design:

Cohort study; Level of evidence, 3.

Methods:

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

Results:

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

Conclusion:

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

Midterm Results of Fresh-Frozen Osteochondral Allografting for Osteochondral Lesions of the Talus

BACKGROUND

Osteochondral lesions of the talus (OLT) are relatively common. Following the failure of conservative treatment, many operative options have yielded varied results. In this study, midterm outcomes after fresh-frozen osteochondral allograft transplantation for the treatment of OLT were evaluated.

METHODS

Twenty-five patients (12 women and 13 men) with a mean age 40.4 (range 18-70) years between 2009 and 2014 were enrolled. Of 25 ankles, 3, 13, 4, and 4 were involved with the talus at Raikin zone 3, 4, 6, and 7 as well as one coexisted with zone 4 and 6 lesion. The mean OLT area was 1.82 cm² (range, 1.1-3.0). The mean follow-up period was 5.5 years (range, 4-9.3). Outcomes evaluation included the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, visual analog scale score, and 12-item Short Form Health Survey (SF-12).

RESULT

AOFAS ankle-hindfoot score increased from 74 preoperatively to 94 at 2 years postoperatively (P < .001) and the SF-12 physical health component scores increased from 32 to 46 points (P < .001). Incorporation was inspected in all patients in the latest follow-up, and graft subsidence and radiolucency were observed in 2 and 7 cases, respectively, whereas graft collapse and revision OLT graft were not observed. Bone sclerosis was found in 6 of 25 patients.

CONCLUSION

With respect to midterm results, fresh, frozen-stored allograft transplantation might be an option in the management of symptomatic OLT.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Intra-articular Injections of Hyaluronic Acid on Osteochondral Lesions of the Talus After Failed Arthroscopic Bone Marrow Stimulation

BACKGROUND

The purpose of the study was to compare clinical and functional outcomes before and after hyaluronic acid (HA) injections in patients with osteochondral lesions of the talus who experienced a failure of their primary treatment with arthroscopic microfracture surgery.

METHODS

A total of 40 patients were included in the final study. These patients had received microfracture surgery but continued to experience postoperative pain over an average of 13.0 months (range, 0-81 months) and were available for investigation with a mean follow-up for 29.1 months (SD 14.7; range 2.6-79.6 months). All patients received intra-articular injections of HA once per week for 3 weeks. We assessed clinical and functional outcomes before and after injection using the American Orthopaedic Foot & Ankle Society (AOFAS) score, Foot and Ankle Outcome Score (FAOS), Short Form Health Survey (SF-36), the visual analog scale (VAS) for pain, and the Alexander subjective scale.

RESULTS

The AOFAS score significantly increased from 50.7 ± 13.8 to 79.9 ± 13.8 and the FAOS scores for symptom, pain, daily living, and sports were significantly higher postinjection compared to preinjection (all P < .001). Similarly, the mean VAS for pain was significantly decreased after 6 weeks following injection and continued to decrease over the follow-up period; the mean VAS was significantly lower postinjection compared to preinjection at 12 months (P < .001).

CONCLUSION

Intra-articular HA injections on average significantly improved clinical and functional scores after failed primary operative treatment. HA injections may provide an alternative to secondary operative treatment and provide better clinical outcomes than other conservative treatments.

LEVEL OF EVIDENCE

Level II, prospective observational cohort study.

Arthroscopic Treatment of Osteochondral Lesions of the Talus in a Suspended Position With the Patient in a Prone Position

BACKGROUND

The purpose of this study was to evaluate the clinical results and the safety of arthroscopic microfracture with the ankle suspended on a shoulder-holding traction frame for simultaneous anterior and posterior ankle arthroscopy in the prone position.

METHODS

Between May 2010 and January 2016, 31 patients with posterior osteochondral lesions of the talus (OLTs) were treated with arthroscopic microfracture in a suspended position with the patient prone. Ankle distraction was achieved by suspending the affected ankle on a shoulder-holding traction frame. The 100 mm visual analog scale (VAS) and the Foot Function Index (FFI) were checked preoperatively and at final follow-up. Postoperative complications related to the suspended position were analyzed. Lower leg intramuscular compartment pressure was checked after the surgery to determine if there was any risk of compartment syndrome.

RESULTS

The mean 100-mm VAS score, and FFI improved from 62.8 ±11.3 and 48.5 ± 12.1, respectively, preoperatively to 15.8 ± 10.4 and 16.4 ± 9.2, respectively, at final follow-up (P = .025, and P = .005, respectively). The mean anterior, lateral, superficial posterior, and deep posterior compartment pressures were 7.3 ± 1.5, 8.1 ± 1.1, 5.6 ± 1.9, and 9.2 ± 2.4 mmHg, respectively. No compartment syndrome occurred.

CONCLUSION

Arthroscopic treatment of OLT in a prone position with the ankle suspended on a shoulder-holding traction frame allowed the use of simultaneous anterior and posterior portals for viewing and instrumentation without major operative complications, such as compartment syndrome.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Lesion Size Measured on MRI Does Not Accurately Reflect Arthroscopic Measurement in Talar Osteochondral Lesions

Background:

Lesion size is a major determinant of treatment strategy for osteochondral lesions of the talus (OLTs). Although magnetic resonance imaging (MRI) is commonly used in the preoperative evaluation of OLTs, the reliability of the MRI measurement compared with the arthroscopic measurement is unknown.

Purpose:

To compare preoperative lesion size measured on MRI versus intraoperative lesion size measured during arthroscopy.

Study Design:

Cohort study (diagnosis); Level of evidence, 2.

Methods:

We retrospectively reviewed a consecutive series of patients treated with bone marrow stimulation for OLTs. The diameter of the lesion was measured at its widest point in 2 planes, and MRI measurements were compared with those made during arthroscopy using a custom-made graduated probe.

Results:

A total of 39 patients with 45 OLTs were analyzed. Mean ± SD area measurements on MRI were significantly greater than the equivalent arthroscopic measurements (42.2 ± 30.5 vs 28.6 ± 23.1 mm², respectively; P = .03). Compared with the arthroscopic measurement, MRI overestimated OLT size in 53.3% (24/45) of ankles and underestimated OLT size in 24.4% (11/45). The mean MRI diameter measurement was significantly greater than the arthroscopic measurement in the coronal plane (MRI diameter vs arthroscopic measurement coronal plane, 6.1 ± 2.6 vs 4.9 ± 2.3 mm, P = .03; sagittal plane, 8.0 ± 3.6 vs 6.3 ± 3.6 mm, P = .05). Further, MRI overestimated coronal diameter in 48.9% (22/45) of ankles and underestimated in 26.7% (12/45) compared with the arthroscopic measurement. Similarly, sagittal plane MRI diameter measurements overestimated lesion size in 46.7% (21/45) of ankles and underestimated lesion size in 28.9% (13/45) compared with the arthroscopic findings.

Conclusion:

In a majority of lesions, MRI overestimated OLT area and diameter compared with arthroscopy. Surgeons should be aware of the discrepancies that can exist between MRI and arthroscopic measurements, as these data are important in making treatment decisions and educating patients.

Osteochondral Allograft Transplantation for Osteochondral Lesions of the Talus: Midterm Follow-up

BACKGROUND:

Fresh osteochondral allograft (OCA) transplantation represents a biologic restoration technique as an alternative treatment option for larger osteochondral lesions of the talus (OLT). The purpose of this study was to evaluate midterm outcomes after OCA transplantation for the treatment of OLT.

METHODS:

Nineteen patients (20 ankles) received partial unipolar OCA transplant for symptomatic OLT between January 1998 and October 2014. The mean age was 34.7 years, and 53% were male. The average graft size was 3.8 cm². All patients had a minimum follow-up of 2 years. Outcomes included the American Academy of Orthopaedic Surgeons Foot and Ankle Module (AAOS-FAM), the Olerud-Molander Ankle Score (OMAS), and pain and satisfaction questionnaires. Failure of OCA was defined as conversion to arthrodesis or revision OCA transplantation.

RESULTS:

Five of 20 ankles (25%) required further surgery, of which 3 (5%) were considered OCA failures (2 arthrodesis and 1 OCA revision). The mean time to failure was 3.5 (range, 0.9 to 6.7) years. Survivorship was 88.7% at 5 years and 81.3% at 10 years. The median follow-up of the 17 patients with grafts in situ was 9.7 years. The mean OMAS improved significantly from 40 points preoperatively to 71 points postoperatively ( P < .05; range, 5 to 55). The mean postoperative AAOS-FAM core score was 81.5 ± 15 (range, 40.5 to 96.6). Fifteen of 17 patients responded to follow-up questions regarding their ankle; 14 patients reported less pain and better function, and 13 patients were satisfied with the results of the procedure.

CONCLUSION:

Our study of midterm results after OCA transplantations showed that this procedure was a reasonable treatment option for large OLT.

LEVEL OF EVIDENCE:

Level IV, case series.

Analysis of the Changes in the Clinical Outcomes According to Time After Arthroscopic Microfracture of Osteochondral Lesions of the Talus

BACKGROUND:

Arthroscopic microfracture can effectively treat osteochondral lesions of the talus (OLTs). However, very few studies have reported on symptomatic improvement duration and time when symptomatic improvement ceases. This study aimed to investigate the clinical outcome changes after arthroscopic microfracture in patients with OLT.

METHODS:

Among patients who underwent arthroscopic microfracture for OLT, 70 patients were available for follow-up for more than 3 years. Of these, 6 patients who showed worsening or no improvement in the 6 months after surgery were excluded, and a total of 64 patients were included in the analysis. To analyze and compare the clinical outcome changes according to time, the visual analog scale (VAS) and American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scores were evaluated every 3 months up to 1 year postoperatively and every 1 year thereafter. The clinical outcome differences based on the lesion size, lesion location, lesion containment, presence of cyst and bone marrow edema, age, sex, and obesity were analyzed.

RESULTS:

The preoperative and final follow-up VAS scores significantly improved from 6.2 ± 1.1 to 1.2 ± 1.1 ( P< .05) and the AOFAS score from 63.1 ± 7.3 to 91.0 ± 7.3 ( P< .05). The overall success rate for arthroscopic microfracture in this study was 88.6%. The postoperative VAS and AOFAS scores at 3, 6, 9, 12, 24, and 36 months were 3.7 ± 1.4, 2.5 ± 1.3, 2.0 ± 1.1, 1.6 ± 1.2, 1.2 ± 1.2, and 1.3 ± 1.2 and 74.7 ± 10.3, 80.5 ± 8.9, 84.3 ± 7.4, 88.3 ± 7.3, 91.1 ± 7.2, and 90.8 ± 7.5, respectively, showing significant improvements up to 2 years. After 2 years, the symptoms did not improve but were maintained at a certain level up to 3 years. No clinical outcome differences based on the lesion size, lesion containment, presence of cyst and bone marrow edema, age, sex, and obesity were observed.

CONCLUSION:

Symptomatic improvement early after arthroscopic microfracture for OLT was observed continuously for up to 2 years postoperatively. Symptom improvement was maintained without worsening for up to 3 years after surgery. Determining the final outcome of microfracture at least after 2 years would be reasonable.

LEVEL OF EVIDENCE:

Level IV, case series.

Efficacy of Particulated Juvenile Cartilage Allograft Transplantation for Osteochondral Lesions of the Talus

BACKGROUND

Particulated juvenile cartilage allograft transplantation (PJCAT) is a novel treatment option for osteochondral lesions of the talus (OLTs). It is typically employed as a salvage procedure after initial debridement and microfracture has failed as it is theorized to deliver viable hyaline cartilage. We hypothesized that PJCAT would be a safe and effective treatment option for OLTs.

METHODS

This is a retrospective case-control study of patients who underwent PJCAT for the treatment of OLTs at a single academic institution. Failure of the procedure was defined as no change or worsening of symptoms and/or the need for a subsequent cartilage restoration procedure. Variables recorded included preoperative magnetic resonance imaging (MRI) area and volume, intraoperative size, etiology, lesion location, sex, age, body mass index (BMI), history of prior surgery, American Orthopaedic Foot & Ankle Society score, and foot and ankle outcome score. Fifteen patients completed a minimum of 12 months of follow-up (mean, 34.6 months).

RESULTS

The failure rate of PJCAT in this series was 40% (6/15). Preoperative MRI area and intraoperative OLT size along with male sex were predictive of failure ( P < .05). Age, BMI, etiology, technique (open vs arthroscopic), history of prior surgery, and location of lesion were not predictors of failure in this limited series ( P > .05). Patients with lesions greater than 125 mm² area had a significant increased risk of clinical failure ( P < .05). Functional outcome scores were significantly better at final follow-up in the patients who had undergone successful treatment vs those who did not.

CONCLUSION

These findings demonstrate the association of preoperative MRI lesion area, intraoperative lesion size, and male sex as risk factors for failure of PJCAT setting of an already difficult to treat pathology.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Prospective Evaluation of Structural Allograft Transplantation for Osteochondral Lesions of the Talar Shoulder

BACKGROUND

Structural or bulk osteochondral allograft transplantation for shoulder talar osteochondral lesions as a salvage procedure has demonstrated efficacy in several retrospective reviews. The purpose of this study was to evaluate prospectively patients who received fresh structural allograft transplantation to the talus.

METHODS

Prospective evaluation of a consecutive series of patients who underwent fresh structural allograft transplantation for an osteochondral lesion of the talus (OLT) was performed. Preoperative magnetic resonance imaging (MRI) and/or computed tomography (CT) and plain radiographs were obtained on all patients. The following patient-reported outcomes questionnaires were administered preoperatively and yearly after surgery: 100-mm visual analog scale (VAS) pain scale, American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot Scale, Short Form 36 (SF-36), and the Short Musculoskeletal Functional Assessment (SMFA). Preoperative and postoperative radiographs were assessed for allograft incorporation and subsequent arthritis. Fourteen patients with an average age of 40 years (range, 18-69) and a mean follow-up of 55 months (range, 24-97) underwent structural fresh osteochondral allograft transplantation to the talar shoulder.

RESULTS

The average size of the OLT was 2269 mm³ (range, 813-8366) based on CT imaging and 5797 mm³ (range, 1136-12 489) based on MRI imaging. There was significant ( P < .05) improvement in the VAS pain, AOFAS scale, SF-36, and SMFA scores. Five (36%) of the patients required additional surgery for pain and stiffness. Two patients had cartilage delamination and were considered treatment failures. Therefore, the success rate was 86% (12/14).

CONCLUSION

Significant improvement in pain and function was achieved with structural allograft transplantation for large OLTs at midterm follow-up. This was a safe and effective treatment option in this small series for large OLTs.

LEVEL OF EVIDENCE

Level IV, prospective case series.

Immediate Unrestricted Postoperative Weightbearing and Mobilization after Bone Marrow Stimulation of Large Osteochondral Lesions of the Talus

OBJECTIVE

There remains no consensus on a postoperative protocol following arthroscopic treatment of osteochondral lesions of the talus (OLTs) and most studies report a period of immobilization and nonweightbearing. Outcomes are believed to decrease with larger size. The purpose of our study was to evaluate patients who underwent arthroscopic treatment of large (≥150 mm²) OLTs with immediate unrestricted weightbearing and mobilization postoperatively.

DESIGN

Patients who underwent arthroscopic bone marrow stimulation for osteochondral defects were identified. Exclusion criteria included lesions less than 150 mm², additional procedures other than ligament reconstruction, incongruent ankle joint, arthritis, and tibial plafond lesions. Postoperatively, all patients were placed into a soft dressing and were allowed immediate weightbearing as tolerated. Patients were considered failures if their AOFAS (American Orthopaedic Foot and Ankle Society) score was less than 80 or if they underwent osteochondral transplant.

RESULTS

Thirteen patients were available for follow-up. Two patients underwent osteochondral transplant and were considered failures. Of the remaining 11, the average follow-up time after surgery was 33 months (range, 7-59 months). Average age was 37 years (range, 15-56 years), and lesion size averaged 239 mm² (range, 150-400 mm²). Average postoperative scores included foot function index 50 (range, 23-136), visual analog scale 3 (range, 0-8), and AOFAS hindfoot 82 (range, 40-100). The group's overall success rate was 54% (7/13).

CONCLUSION

The results of our study are higher than those previously published studies on large lesions with a more restricted postoperative rehabilitation, suggesting that unrestricted weightbearing and range of motion does not diminish patient outcomes.

LEVEL OF EVIDENCE

IV, Case series.