Role of arthroscopic microfracture for cystic type osteochondral lesions of the talus with radiographic enhanced MRI support

Outcomes Following Repeat Ankle Arthroscopy and Microfracture for Osteochondral Lesions of the Talus

BACKGROUND

The management of symptomatic osteochondral lesions of the talus (OLTs) previously treated with arthroscopy is controversial. Minimal data exist on the role for repeat arthroscopy. Here, we describe our experience with repeat arthroscopy and microfracture for symptomatic OLTs.

METHODS

Our database was queried over an 8-year period to identify patients undergoing repeat arthroscopy and microfracture as treatment for symptomatic OLTs. Phone surveys were conducted to assess residual pain, patient satisfaction, and need for subsequent surgery. We compared patient outcomes based on the size of their OLT (small lesions ≤150 mm2, large >150 mm2) and the presence or absence of subchondral cysts.

RESULTS

We identified 14 patients who underwent repeat arthroscopy and microfracture for symptomatic OLTs. Patients reported reasonable satisfaction (7.6 ± 3.5 out of 10) but moderate residual pain (4.7 ± 3.4 out of 10) at midterm follow-up (5.1 ± 2.9 years). In total, 21% (3/14) of patients had undergone subsequent surgery. Patients with small (n = 5) and large OLTs (n = 9) had similar postoperative pain scores (4.2 ± 4.1 vs 4.9 ± 3.2) and postoperative satisfaction levels (6.4 ± 4.9 vs 8.3 ± 2.5).

CONCLUSION

At midterm follow-up, repeat arthroscopy for symptomatic OLTs demonstrated reasonable satisfaction but moderate residual pain. Lesion size or presence of subchondral cysts did not affect outcome, but our sample size was likely too small to detect statistically significant differences. These data show that repeat ankle arthroscopy can be performed safely with modest outcomes, and we hope that this report aids in managing patient expectations.Level of Evidence: Level IV Case Series.

Comparison of Arthroscopic Microfracture for Osteochondral Lesions of the Talus With and Without Small and Shallow Subchondral Cysts

BACKGROUND

Whether arthroscopic microfracture is effective in treating cystic osteochondral lesions of the talus (OLTs) remains controversial. In this study, outcome parameters in patients with small and shallow subchondral cysts are compared to patients without cysts with the hypothesis that equivalent outcomes may be found after primary microfracture treatment.

METHODS

From 2018 to 2021, all 50 OLTs treated with arthroscopic microfracture in the authors' hospital were retrospectively reviewed for eligibility. Single unilateral symptomatic lesions were included and divided into the cyst and noncyst groups, whereas kissing lesions and arthritic lesions were excluded. Numeric rating scale (NRS) scores, American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scores, Tegner activity level scores, Foot and Ankle Ability Measure (FAAM) scores, and magnetic resonance (MR) imaging results were used to describe outcomes.

RESULTS

A total of 35 patients were included, 16 in the cyst group and 19 in the noncyst group. The patient characteristics were similar between the 2 groups (P > .05). In the cyst group the average cysts depth was 5.0 ± 1.3 mm. After a mean follow-up duration of 36.2 ± 10.2 months, no significant differences were found between the 2 groups in NRS, AOFAS, FAAM, or Tegner score improvement (P > .05). Three patients (19%) in the cyst group had no NRS score improvement.

CONCLUSION

OLTs with small and shallow subchondral cysts can be treated with arthroscopic microfracture and achieve similar outcomes as noncystic lesions. A few cystic lesions may not respond to microfracture treatment.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Concomitant Subchondral Bone Cysts Negatively Affect Clinical Outcomes Following Arthroscopic Bone Marrow Stimulation for Osteochondral Lesions of the Talus

PURPOSE

To study the effects of concomitant subchondral bone cysts (SBCs) on prognosis after arthroscopic bone marrow stimulation (BMS) for osteochondral lesions of the talus (OLTs) less than 100 mm2 and to further assess the correlation between cystic OLT area, depth, or volume and postoperative outcomes.

METHODS

We retrospectively analyzed consecutive patients with OLTs (<100 mm2) who received BMS between April 2017 and May 2020 with a minimum follow-up of 24 months. Lesion area, depth, and volume were collected on preoperative magnetic resonance imaging. Visual analog scale (VAS), American Orthopedic Foot and Ankle Society, Karlsson-Peterson, Tegner, Foot and Ankle Ability Measure (FAAM)-Activities of Daily Life and Sports scores were assessed before surgery and at the latest follow-up. Additionally, a general linear model (GLM) and a Pearson correlation analysis (PCA) were performed to investigate the effects of concomitant cysts on postoperative results.

RESULTS

Eighty-two patients with a mean follow-up of 39.22 ± 12.53 months were divided into non-cyst (n = 45; 39.91 ± 13.03 months) and cyst (n = 37; 38.37 ± 12.02 months) groups. There was no significant difference in the OLT area between the non-cyst and cyst groups (46.98 ± 19.95 mm2 vs 56.08 ± 22.92 mm2; P = .093), but the cyst group showed significantly greater depth (6.06 ± 1.99 mm vs 3.96 ± 1.44 mm; P = .000) and volume (248.26 ± 156.81 mm3 vs 134.58 ± 89.68 mm3; P = .002). The non-cyst group showed significantly more improvement in VAS pain, Karlsson-Peterson, Tegner, and FAAM scores than the cyst group (P < .05). The GLM indicated that SBCs negatively affected VAS pain and Tegner scores (P < .05). For OLTs with cysts, the PCA showed that an area of 90.91 mm2, depth of 7.56 mm, and volume of 428.13 mm3 were potential cutoff values associated with poor outcomes.

CONCLUSIONS

The concomitant SBCs negatively affected the prognosis of OLTs after BMS. For OLTs with cysts, an area of 90.91 mm2, depth of 7.56 mm, and volume of 428.13 mm3 were the potential cutoff values associated with poor outcomes after BMS.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

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

OBJECTIVE

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

DESIGN

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

RESULTS

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

CONCLUSIONS

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

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

Background:

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

Purpose:

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

Study Design:

Cohort study; Level of evidence, 2.

Methods:

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

Results:

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

Conclusion:

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

High resolution flat-panel CT arthrography vs. MR arthrography of artificially created osteochondral defects in ex vivo upper ankle joints

PURPOSE

High resolution flat-panel computed tomography arthrography (FPCT-A) and magnetic resonance arthrography (MR-A) are well suited to evaluate osteochondral lesions. The current study compares the performance of FPCT-A versus MR-A in an experimental setting.

METHODS

Fourteen cadaveric ankles were prepared with artificial osteochondral defects of various sizes in four separate talar locations. After intra-articular contrast injection, FPCT-A and 3-T MR-A were acquired. Each defect was then filled with synthetic pallets. The resulting cast was used as reference. Two independent radiologists measured the dimensions of all defects with FPCT-A and MR-A. Intra-class correlation coefficients (ICC) were calculated. Data were compared using t-tests and Bland-Altman plots.

RESULTS

The correlation for FPCT-A and cast was higher compared to MR-A and cast (ICC 0.876 vs. 0.799 for surface [length x width]; ICC 0.887 vs. 0.866 for depth, p<0.001). Mean differences between FPCT-A and cast measurements were -1.1 mm for length (p<0.001), -0.7 mm for width (p<0.001) and -0.4 mm for depth (p = 0.023). By MR-A, there were no significant differences for length and width compared to cast (p>0.05). Depth measurements were significantly smaller by MR-A (mean difference -1.1 mm, p<0.001). There was no bias between the different modalities.

CONCLUSIONS

Ex vivo FPCT-A and MR-A both deliver high diagnostic accuracy for the evaluation of osteochondral defects. FPCT-A was slightly more accurate than MR-A, which was most significant when measuring lesion depth.

Comparison of Arthroscopic Treatment Methods in Talar Osteochondral Lesions: A Multicenter, Prospective, Randomized Clinical Trial

BACKGROUND

The aim of the present study was to contribute new and updated information to the literature by comparing the clinical and radiologic results of arthroscopic microfracture, platelet-rich plasma (PRP) after arthroscopic microfracture, and BST-Cargel scaffold application after arthroscopic microfracture in the treatment of talar osteochondral lesions.

METHODS

Sixty-two talar osteochondral lesion patients (31 women and 31 men) who underwent ankle arthroscopy in two different centers were randomized into three groups. The first group consisted of patients who underwent only arthroscopic microfracture (MF) (n = 22); the second group consisted of patients who underwent the PRP procedure after arthroscopic MF (PRP; n = 19); and the third group consisted of patients who underwent the BST-Cargel procedure after arthroscopic MF was (BST-Cargel; n = 21). The talar osteochondral lesions in the three groups were classified according to magnetic resonance and arthroscopic images. American Orthopedic Foot and Ankle Society, Foot and Ankle Ability Measurement (overall pain, 15-minute walking, running function), and visual analog scale scores were evaluated preoperatively and postoperatively, and postoperative return time to sports activities was performed.

RESULTS

Compared to the preoperative score, postoperative American Orthopedic Foot and Ankle Society score increased 48.80 ± 9.60 in the BST-Cargel group, whereas there was an increase of 46.68 ± 3.65 in the PRP group and 29.63 ± 3.69 in the MF group, which were statistically significant (P < .05).There was a statistically significant postoperative change in the visual analog scale scores of the patients in all three groups compared to the preoperative scores (P < .05). At the end of the follow-up, the Foot and Ankle Ability Measurement overall pain, 15-minute walking, and running function results of all three groups increased significantly postoperatively compared to the preoperative values (P < .005).

CONCLUSIONS

BST-Cargel application with microfracture is a method that can be applied easily and safely with arthroscopy to lesions larger than 1.5 cm2 regardless of the size of the cartilage defect, and it has been found to be superior to the other two methods in terms of pain, functional score, radiologic recovery, and return to sports activities.

Clinical outcomes after arthroscopic microfracture for osteochondral lesions of the talus are better in patients with decreased postoperative subchondral bone marrow edema

PURPOSE

Magnetic resonance imaging (MRI) findings of subchondral bone marrow edema (SBME) in osteochondral lesions of the talus (OLT) after arthroscopic microfracture are associated with poor clinical outcomes. However, the relationship between SBME volume change and clinical outcomes has not been analyzed. It was hypothesized that clinical outcomes correlated with SBME volume change and extent of cartilage regeneration in patients with OLT.

METHODS

64 patients who underwent arthroscopic microfracture for OLT were followed up for more than 2 years. SBME volume change was measured by comparing preoperative and 2-year follow-up MRI. Clinical outcomes were assessed using the visual analogue scale (VAS) and the American orthopedic foot and ankle society ankle-hindfoot scale (AOFAS) at the 2-year and final follow-up. To compare clinical outcomes, patients were categorized into two groups: decreased SBME (DSBME) group (cases without SBME on either MRI or with a decreased SBME volume between the MRIs) and increased SBME (ISBME) group (cases with new SBME on postoperative MRI or with an increased SBME volume between the MRIs). Additionally, the effects of age, sex, body mass index, symptom duration, OLT size, OLT location, containment/uncontainment, preoperative subchondral cysts, pre- and postoperative SBME volumes, and MRI observation of cartilage repair tissue score on clinical outcomes were analyzed.

RESULTS

The DSBME group included 45 patients, whereas the ISBME group included 19. The mean age was 40.1 ± 17.2 years, and mean follow-up period was 35.7 ± 18.3 months. Preoperative SBME volume was significantly higher in the DSBME group, while the ISBME group had higher volumes at the final follow-up. In both groups, the VAS and AOFAS scores significantly improved at the final follow-up (p < 0.001, < 0.001). The VAS scores were significantly lower in the DSBME group at the 2-year and final follow-up (p = 0.004, 0.011), while the AOFAS scores were significantly higher (p = 0.019, 0.028). Other factors including cartilage regeneration did not affect clinical outcomes.

CONCLUSION

SBME volume change correlated with clinical outcomes after arthroscopic microfracture for OLT. Clinical outcomes were worse in patients with new postoperative SBME and increased postoperative SBME volume. In patients with an unsatisfactory clinical course that show decreased SBME via postoperative MRI, an extended follow-up in a conservative manner could be considered.

LEVEL OF EVIDENCE

Level III.

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.

One step treatment of talus osteochondral lesions with microfracture and cell free hyaluronic acid based scaffold combination

Objective

The aim of this study was to assess the effectiveness of microfracture and cell free hyaluronic acid (HA) based scaffold combination in the treatment of talus osteochondral defects (OCD).

Methods

This study retrospectively evaluated the clinical results of the 20 patients (14 males and 6 females, mean age at the time of surgery: 32.9 years (range: 16–52 years)) who were treated with MFx and cell-free HA-based scaffold combination for talus OCD smaller than 1.5 cm² and deeper than 7 mm. Results were evaluated with AOFAS and VAS scores. Also, patients' satisfaction was questioned.

Results

Patients were evaluated after an average follow-up of 20.3 months. Intraoperative measurements showed that mean depth of the lesions were 10.4 ± 1.9 mm after debridement. The mean preoperative AOFAS score was 57.45 ± 9.37, which increased to 92.45 ± 8.4 postoperatively (p < 0.05). VAS score was improved from 7.05 ± 2.45 to 1.65 ± 2.20 postoperatively (p < 0.05).

Conclusion

MFx and cell-free HA-based scaffold combination appear to be a safe and efficient technique that provide good clinical outcomes for lesions deeper than 7 mm.

Level of evidence

Level IV, Therapeutic Study.

High reported rate of return to play following bone marrow stimulation for osteochondral lesions of the talus

PURPOSE

The purpose of this study is to systematically review the literature and to evaluate the reported rehabilitation protocols, return to play guidelines and subsequent rates and timing of return to play following bone marrow stimulation (BMS) for osteochondral lesions of the talus (OLT).

METHODS

MEDLINE, EMBASE and the Cochrane Library were searched according to the PRISMA guidelines in September 2017. The rate and timing of return to play was assessed. The rehabilitation protocols were recorded, including time to start range of motion, partial weight-bearing and complete weight-bearing.

RESULTS

Fifty-seven studies with 3072 ankles were included, with a mean age of 36.9 years (range 23-56.8 years), and a mean follow-up of 46.0 months (range 1.5-141 months). The mean rate of return to play was 86.8% (range 60-100%), and the mean time to return to play was 4.5 months (range 3.5-5.9 months). There was large variability in the reported rehabilitation protocols. Range of motion exercises were most often allowed to begin in the first week (46.2%), and second week postoperatively (23.1%). The most commonly reported time to start partial weight-bearing was the first week (38.8%), and the most frequently reported time of commencing full weight-bearing was 6 weeks (28.8%). Surgeons most often allowed return to play at 4 months (37.5%).

CONCLUSIONS

There is a high rate of return following BMS for OLT with 86.8% and the mean time to return to play was 4.5 months. There is also a significant deficiency in reported rehabilitation protocols, and poor quality reporting in return to play criteria. Early weightbearing and early postoperative range of motion exercises appear to be advantageous in accelerated return to sports.

LEVEL OF EVIDENCE

Level IV.

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.

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.

Management of Posttraumatic Ankle Arthritis: Literature Review

PURPOSE OF REVIEW

Trauma is the principle cause of osteoarthritis in the ankle, which is associated with significant morbidity. This review highlights the current literature for the purpose of bringing the reader up-to-date on the management of posttraumatic ankle arthritis, describing treatment efficacy, indications, contraindications, and complications.

RECENT FINDINGS

Recent studies on osteoarthritis have demonstrated variability among anatomic locations regarding the mechanisms and rates of development for posttraumatic osteoarthritis, which are attributed to newly discovered biological differences intrinsic to each joint. Regarding surgical management of posttraumatic ankle arthritis, osteochondral allograft transplantation of the talus, and supramalleolar osteotomies have demonstrated promising results. Additionally, the outpatient setting was found to be appropriate for managing pain following total ankle arthroplasty, associated with low complication rates and no readmission. Management for posttraumatic ankle arthritis is generally progressive. Initial treatment entails nonpharmacologic options with surgery reserved for posttraumatic ankle arthritis refractory to conservative treatment. Patient demographics and lifestyles should be carefully considered when formulating a management strategy, as outcomes are dependent upon the satisfaction of each set of respective criteria. Ultimately, the management of posttraumatic ankle arthritis should be individualized to satisfy the needs and desires, which are specific to each patient.

No superior treatment for primary osteochondral defects of the talus

PURPOSE

The purpose of this systematic literature review is to detect the most effective treatment option for primary talar osteochondral defects in adults.

METHODS

A literature search was performed to identify studies published from January 1996 to February 2017 using PubMed (MEDLINE), EMBASE, CDSR, DARE, and CENTRAL. Two authors separately and independently screened the search results and conducted the quality assessment using the Newcastle-Ottawa Scale. Subsequently, success rates per separate study were calculated. Studies methodologically eligible for a simplified pooling method were combined.

RESULTS

Fifty-two studies with 1236 primary talar osteochondral defects were included of which forty-one studies were retrospective and eleven prospective. Two randomised controlled trials (RCTs) were identified. Heterogeneity concerning methodological nature was observed, and there was variety in reported success rates. A simplified pooling method performed for eleven retrospective case series including 317 ankles in the bone marrow stimulation group yielded a success rate of 82% [CI 78-86%]. For seven retrospective case series investigating an osteochondral autograft transfer system or an osteoperiosteal cylinder graft insertion with in total 78 included ankles the pooled success rate was calculated to be 77% [CI 66-85%].

CONCLUSIONS

For primary talar osteochondral defects, none of the treatment options showed any superiority over others.

LEVEL OF EVIDENCE

IV.

Systematic review of bone marrow stimulation for osteochondral lesion of talus - evaluation for level and quality of clinical studies

AIM

To clarify the quality of the studies indicating lesion size and/or containment as prognostic indicators of bone marrow stimulation (BMS) for osteochondral lesions of the talus (OLT).

METHODS

Two reviewers searched the PubMed/MEDLINE and EMBASE databases using specific terms on March 2015 in accordance with the Preferred Reporting Items for Systemic Reviews and Meta-Analyses guidelines. Predetermined variables were extracted for all the included studies. Level of evidence (LOE) was determined using previously published criteria by the Journal of Bone and Joint Surgery and methodological quality of evidence (MQOE) was evaluated using the Modified Coleman Methodology Score.

RESULTS

This review included 22 studies. Overall, 21 of the 22 (95.5%) included studies were level IV or level III evidences. The remaining study was a level II evidence. MQOE analysis revealed 14 of the 22 (63.6%) included studies having fair quality, 7 (31.8%) studies having poor quality and only 1 study having excellent quality.

CONCLUSION

The evidence supporting the use of lesion size and containment as prognostic indicators of BMS for OLTs has been shown to be of low quality.

Lesion Size Is a Predictor of Clinical Outcomes After Bone Marrow Stimulation for Osteochondral Lesions of the Talus: A Systematic Review

BACKGROUND

The critical lesion size treated with bone marrow stimulation (BMS) for osteochondral lesions of the talus (OLTs) has been 150 mm2 in area or 15 mm in diameter. However, recent investigations have failed to detect a significant correlation between the lesion size and clinical outcomes after BMS for OLTs.

PURPOSE

To systematically review clinical studies reporting both the lesion size and clinical outcomes after BMS for OLTs.

STUDY DESIGN

Systematic review.

METHODS

A systematic search of the MEDLINE and EMBASE databases was performed in March 2015 based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Included studies were evaluated with regard to the level of evidence (LOE), quality of evidence (QOE), lesion size, and clinical outcomes.

RESULTS

Twenty-five studies with 1868 ankles were included; 88% were either LOE 3 or 4, and 96% did not have good QOE. The mean area was 103.8 ± 10.2 mm2 in 20 studies, and the mean diameter was 10.0 ± 3.2 mm in 5 studies. The mean American Orthopaedic Foot and Ankle Society score improved from 62.4 ± 7.9 preoperatively to 83.9 ± 9.2 at a mean 54.1-month follow-up in 14 studies reporting both preoperative and postoperative scores with a mean follow-up of more than 2 years. A significant correlation was found in 3 studies, with a mean lesion area of 107.4 ± 10.4 mm2, while none was reported in 8 studies, with a mean lesion area of 85.3 ± 9.2 mm2. The lesion diameter significantly correlated with clinical outcomes in 2 studies (mean diameter, 10.2 ± 3.2 mm), whereas none was found in 2 studies (mean diameter, 8.8 ± 0.0 mm). However, the reported lesion size measurement method and evaluation method of clinical outcomes widely varied among the studies.

CONCLUSION

An assessment of the currently available data does suggest that BMS may best be reserved for OLT sizes less than 107.4 mm2 in area and/or 10.2 mm in diameter. Future development in legitimate prognostic size guidelines based on high-quality evidence that correlate with outcomes will surely provide patients with the best potential for successful long-term outcomes.

Evaluation and Management of Osteochondral Lesions of the Talus

Osteochondral lesions of the talus are common injuries that affect a wide variety of active patients. The majority of these lesions are associated with ankle sprains and fractures though several nontraumatic etiologies have also been recognized. Patients normally present with a history of prior ankle injury and/or instability. In addition to standard ankle radiographs, magnetic resonance imaging and computed tomography are used to characterize the extent of the lesion and involvement of the subchondral bone. Symptomatic nondisplaced lesions can often be treated conservatively within the pediatric population though this treatment is less successful in adults. Bone marrow stimulation techniques such as microfracture have yielded favorable results for the treatment of small (<15 mm) lesions. Osteochondral autograft can be harvested most commonly from the ipsilateral knee and carries the benefit of repairing defects with native hyaline cartilage. Osteochondral allograft transplant is reserved for large cystic lesions that lack subchondral bone integrity. Cell-based repair techniques such as autologous chondrocyte implantation and matrix-associated chondrocyte implantation have been increasingly used in an attempt to repair the lesion with hyaline cartilage though these techniques require adequate subchondral bone. Biological agents such as platelet-rich plasma and bone marrow aspirate have been more recently studied as an adjunct to operative treatment but their use remains theoretical. The present article reviews the current concepts in the evaluation and management of osteochondral lesions of the talus, with a focus on the available surgical treatment options.

Magnetic Resonance Imaging Evidence of Postoperative Cyst Formation Does Not Appear to Affect Clinical Outcomes After Autologous Osteochondral Transplantation of the Talus

PURPOSE

To identify potential cysts using magnetic resonance imaging (MRI) after autologous osteochondral transplantation (AOT) for osteochondral lesions of the talus (OLTs) as well as to determine the effect of cysts on short-term clinical outcomes.

METHODS

Eighty-nine MRI scans of 37 patients who had AOT for an OLT were evaluated. Radiographic variables examined included cyst presence, cyst location, bone edema, and cartilage integrity. Patient clinical variables recorded and examined for association with the presence of a cyst included gender, age, preoperative lesion size, size and number of osteochondral graft used, symptoms reported, and pre- and postoperative Foot and Ankle Outcome Score (FAOS) and Short Form-12 (SF-12) scores measured at final follow-up.

RESULTS

Twenty-four patients (64.8%) had MRI evidence of cystic change after AOT for an OLT at a mean MRI follow-up time of 15 months after surgery (range 2-54). Patients with presence of a cyst after surgery were older (mean age, 42.7 years) than those without cysts (mean age, 32.7 years) (P = .041), and among patients with a cyst, older patients more often had involvement of the subchondral plate (57.3 v 36.7 years) (P < .001). No other variables associated with cyst formation had statistical significance. Mean patient FAOS scores increased from 50 (±19) preoperatively to 87 (±8) postoperatively. Mean SF-12 scores increased from 52 (±18) preoperatively to 85 (±6) postoperatively. Patients not identified as having a cyst had lower SF-12 (P = .028) and FAOS (P = .032) preoperative scores and more improvement in SF-12 (P = .006) and FAOS (P = .016) scores than patients with cysts.

CONCLUSIONS

Postoperative cyst formation on MRI was found to be a common occurrence after AOT for OLT. Although increasing age was related to increased cyst prevalence, the clinical impact of cyst formation was not found to be significant at short-term follow-up. Continued long-term longitudinal follow-up of postoperative cysts is needed.

LEVEL OF EVIDENCE

Level IV, prognostic case series.

Effect of the Presence of Subchondral Cysts on Treatment Results of Autologous Osteochondral Graft Transfer in Osteochondral Lesions of the Talus

The aim of the present study was to clinically evaluate whether the presence of subchondral cysts had an effect on the treatment results of autologous osteochondral graft transfer in osteochondral lesions of the talus. Patients were enrolled in the present study according to the inclusion criteria. In the evaluation, we divided the patients into 2 groups according to presence (n = 13 patients) or absence (n = 15 patients) of a subchondral cyst. The mean age, body mass index, follow-up period, and lesion size in each group were measured and compared, and no statistically significant differences were found between the 2 groups (p > .05). The clinical assessment was performed using the American Orthopaedic Foot and Ankle Society Hindfoot scoring system, visual analog scale, and International Knee Society scoring system. No statistically significant difference was found between the pre- and postoperative scores of the 2 patient groups (p > .05). The successful results in both groups after a 2-year follow-up period have demonstrated that treatment of osteochondral lesions of the talus with osteochondral graft transfer is a safe method that can be performed independently of the presence of a subchondral cyst.

Low Level of Evidence and Methodologic Quality of Clinical Outcome Studies on Cartilage Repair of the Ankle

PURPOSE

To examine the level of evidence and methodologic quality of studies reporting surgical treatments for osteochondral lesions of the ankle.

METHODS

A search was performed using the PubMed/Medline, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Cochrane databases for all studies in which the primary objective was to report the outcome after surgical treatment of osteochondral lesions of the ankle. Studies reporting outcomes of microfracture, bone marrow stimulation, autologous osteochondral transplantation, osteochondral allograft transplantation, and autologous chondrocyte implantation were the focus of this analysis because they are most commonly reported in the literature. Two independent investigators scored each study from 0 to 100 based on 10 criteria from the modified Coleman Methodology Score (CMS) and assigned a level of evidence using the criteria established by the Journal of Bone and Joint Surgery. Data were collected on the study type, year of publication, number of surgical procedures, mean follow-up, preoperative and postoperative American Orthopaedic Foot & Ankle Society score, measures used to assess outcome, geography, institution type, and conflict of interest.

RESULTS

Eighty-three studies reporting the results of 2,382 patients who underwent 2,425 surgical procedures for osteochondral lesions of the ankle met the inclusion criteria. Ninety percent of studies were of Level IV evidence. The mean CMS for all scored studies was 53.6 of 100, and 5 areas were identified as methodologically weak: study size, type of study, description of postoperative rehabilitation, procedure for assessing outcome, and description of the selection process. There was no significant difference between the CMS and the type of surgical technique (P = .1411). A statistically significant patient-weighted correlation was found between the CMS and the level of evidence (r = -0.28, P = .0072). There was no statistically significant patient-weighted correlation found between the CMS and the institution type (r = 0.05, P = .6480) or financial conflict of interest (r = -0.16, P = .1256).

CONCLUSIONS

Most studies assessing the clinical outcomes of cartilage repair of the ankle are of a low level of evidence and of poor methodologic quality.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I through IV studies.

Comparison of Arthroscopic Microfracture for Osteochondral Lesions of the Talus With and Without Subchondral Cyst

BACKGROUND

Although various treatment modalities for an osteochondral lesion of the talus (OLT) with a subchondral cyst have been recommended previously, the primary treatment methods for such conditions have yet to be conclusively determined. Moreover, few comprehensive studies have compared the outcomes of cases where patients were treated with microfracture for OLT with and without subchondral cysts.

PURPOSE

To evaluate the clinical outcomes after arthroscopic microfractures performed as a primary treatment for OLT with a subchondral cyst.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

The study cohort consisted of 102 patients (102 ankles) who underwent arthroscopic microfracture for small to midsized OLT. The ankles were divided into a cyst group (45 ankles) and a noncyst group (57 ankles).The American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale, visual analog scale (VAS), and Ankle Activity Score (AAS) were used to compare the clinical outcomes between the groups over a mean follow-up period of 48 months.

RESULTS

The mean AOFAS ankle-hindfoot scores were 64.8 in the cyst group and 66.2 in the noncyst group preoperatively. These improved to 91.8 and 91.3, respectively, at the final follow-up. The mean VAS scores were 7.5 in the cyst group and 7.3 in the noncyst group preoperatively; these improved to 2.3 and 2.2, respectively, at the final follow-up. The mean AAS in the cyst group and the noncyst group improved from 2.7 and 2.6 preoperatively to 6.7 and 6.5 at the final follow-up, respectively. In terms of radiographic stage improvements, the cyst group showed no change in 18 ankles (40%) and showed improvements of 1 grade in 13 ankles (28.9%), 2 grades in 9 ankles (20%), 3 grades in 3 ankles (6.7%), and 4 grades in 2 ankles (4.4%). The noncyst group showed no change in 17 ankles (29.8%) and showed improvements of 1 grade in 11 ankles (19.3%), 2 grades in 11 ankles (19.3%), 3 grades in 14 ankles (24.6%), and 4 grades in 4 ankles (7.0%). No significant differences were found between the groups in terms of the AOFAS score, VAS score, AAS, or radiographic stage improvements.

CONCLUSION

OLT with and without subchondral cysts treated with arthroscopic microfracture showed similarly good clinical results. The study results suggest that microfracture could be a primary treatment strategy for treating small to midsized OLT regardless of the existence of subchondral cysts.

T2-mapping at 3 T after microfracture in the treatment of osteochondral defects of the talus at an average follow-up of 8 years

PURPOSE

To compare repaired cartilage with native cartilage, and inter-observer reliability, using T2 mapping at 3 T for assessing cartilage repair in osteochondral defects of the talus after the microfracture technique.

METHODS

We enrolled eight females and seven males undergoing arthroscopic microfracture for osteochondral defects of the talus at an average follow-up of 7.9 ± 2.2 years (range 5-13 years). Cartilage tissue was assessed using a 3-T magnetic resonance imaging unit with an 8-channel phased array foot and ankle coil (gradient strength, 50 mT/m; slew rate, 200 T/m/s). T2 maps were then calculated. Three independent boarded specialists evaluated the images, and magnetic resonance observation of cartilage repair tissue scores was used to assess the cartilage and joint status. Clinical results were assessed using the Hannover Scoring System (HSS) for the ankle and the American Orthopaedic Foot and Ankle Society (AOFAS) hind-foot score.

RESULTS

No significant mean differences were found between the T2 properties of the repair tissue and those of the native reference cartilage (T2 = 38.6 ± 5.3 ms, range 30.2-55.8 ms vs. 40.3 ± 8.5 ms, range 31.4-59.8 ms, respectively; intra-class correlation coefficient = 0.94; confidence interval 0.84-0.99, P ≤ 0.001). Despite ≥50 % defect filling in all patients, subchondral bone changes were considerable. The HSS at the follow-up revealed a mean score of 87 ± 12 (range 51-97), and the AOFAS-Score was 90 ± 13 (range 59-100).

CONCLUSIONS

3 T T2 maps were similar in repaired and native cartilage with good inter-observer reliability.

LEVEL OF EVIDENCE

IV.

Clinical outcomes of platelet rich plasma (PRP) as an adjunct to microfracture surgery in osteochondral lesions of the talus

PURPOSE

To compare the effect of arthroscopic microfracture surgery alone or in combination with platelet rich plasma (PRP) on functional outcomes in osteochondral lesions of the talus.

METHODS

A total of 35 patients were included in the study. Control subjects (n = 16) received treatment with microfracture surgery alone, while the remaining patients (PRP group, n = 19) were also given PRP. After an average follow-up of 16.2 months (range 12-24 months), patients were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) scoring system, Foot and Ankle Ability Measure (FAAM), and the visual analogue scale (VAS) for pain.

RESULTS

At baseline, AOFAS and FAAM scores were similar in the two groups, whereas pain scores (VAS) were higher in those who were assigned to combined treatment. Despite the latter finding, the combined treatment with PRP resulted in better outcomes in terms of functional scores [AOFAS, 89.2 ± 3.9 vs. 71.0 ± 10.2, (p = 0.001); FAAM overall pain domain, 1.0 (1.0-2.0) vs. 2.5 (1.0-4.0), (p = 0.04); FAAM 15-min walking domain, 1.0 (1.0-2.0) vs. 2.0 (1.0-4.0) (p = 0.001)]; and pain-related scores [VAS, 2.2 ± 0.8 vs. 3.8 ± 1.2, (p = 0.001)] as compared to arthroscopic microfracture surgery alone.

CONCLUSIONS

PRP as an adjunct to arthroscopic microfracture surgery for the treatment of osteochondral lesions of the talus resulted in improved functional score status in the medium-term. Further studies to determine the long-term efficacy of this approach were warranted.

LEVEL OF EVIDENCE

II.

Anatomic Reconstruction With a Semitendinosus Allograft for Chronic Lateral Ankle Instability

BACKGROUND

The modified Broström procedure has been successful for most patients with chronic lateral ankle instability (CLAI); however, a subset of patients has had unsatisfactory outcomes. For those at risk of failure, anatomic reconstruction of the lateral ankle ligaments using a semitendinosus allograft to augment the modified Broström procedure is available.

PURPOSE

To report the results of anatomic reconstruction of the lateral ankle with a semitendinosus allograft for the treatment of CLAI.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

This is a retrospective review of a single surgeon's experience from 2003 to 2011 in performing anatomic lateral ankle ligament reconstruction with a semitendinosus allograft for the treatment of CLAI. Of 38 patients (40 ankles), 31 (33 ankles; 82% of patients) returned for final follow-up and constituted the study group. Preoperatively, all patients completed the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Score (AHS) and a visual analog scale (VAS) for pain and underwent plain and stress talar tilt radiographs. At the most recent follow-up, patients were evaluated by an independent surgeon and completed the postoperative AHS, Foot-Function Index (FFI), VAS for pain, Tegner activity score, and a satisfaction survey. Patients were evaluated with plain and stress talar tilt and anterior drawer radiographs.

RESULTS

At a mean follow-up of 38 ± 30 months (range, 24-107 months), 100% of patients were completely satisfied with the procedure. AHS values significantly improved from a mean of 60.3 ± 14.4 to 87.5 ± 9.3 (P < .0001). VAS pain scores significantly decreased from 7.3 ± 1.3 to 1.9 ± 1.8 (P < .0001). Twenty-two of 31 patients (71%) either returned to or were 1 level below their previous preoperative or preinjury Tegner activity level. No patients developed arthritic changes beyond grade I on plain radiographs. On stress radiographs, the mean talar tilt decreased from 14.3° ± 5.4° to 3.1° ± 2.4°. The mean postoperative anterior tibiotalar translation was 1.8 ± 1.1 mm, with no patients having greater than 5 mm of translation.

CONCLUSION

Anatomic lateral ankle ligament reconstruction with a semitendinosus allograft for the treatment of CLAI leads to high patient satisfaction, decreased pain, a stable ankle without arthritic changes, and significantly improved function.

Microfracture for osteochondral lesions of the talus: a systematic review of reporting of outcome data

BACKGROUND

Microfracture is recognized as a primary treatment strategy for osteochondral lesions of the talus up to 15 mm in size. The ability of fibrocartilage to withstand the mechanical loading of the joint over time is unknown.

PURPOSE

The purpose of this study was to systematically review studies of microfracture for OLT and descriptively analyze the outcome data reported to determine whether it is consistent from one study to another and able to be pooled for systematic review.

METHODS

A systematic electronic search was performed using the MEDLINE and EMBASE databases. Studies that were published between January 1966 and June 2011 were included in the review. Only studies that reported data specifically on microfracture for treatment of osteochondral lesions of the talus and written in English were included in this review.

RESULTS

Twenty-four studies were included in this systematic review. The categories of general demographics and study design were generally well reported (each over 80% of studies). Patient history and patient-reported outcome data were reported less (55%-66%). Clinical variables (48%) and imaging data (39%) were the least reported in studies.

CONCLUSION

There were gross inconsistencies and an underreporting of data between studies such that pooling was deemed impossible. A concerted effort must be made by investigators to ensure that there is adequate reporting of data in studies of microfracture treatment for OLT. A set of guidelines to assist surgeons in reporting data may be useful for future research.

Outcome of arthroscopic debridement and microfracture as the primary treatment for osteochondral lesions of the talar dome

PURPOSE

The purpose of this systematic review was to determine patient outcomes after arthroscopic debridement and microfracture for osteochondral lesions (OCLs) of the talar dome.

METHODS

Infotrieve-PubMed/MEDLINE and Google Scholar were systematically searched for the following terms: microfracture AND ankle OR talus. In addition, we hand-searched common American and European orthopaedic and podiatric surgical journals for relevant manuscripts. Articles considered for inclusion were published in peer-reviewed journals, used the American Orthopaedic Foot & Ankle Society hindfoot scoring system for outcome measurement, and involved arthroscopic debridement and microfracture for OCL of the talar dome.

RESULTS

We identified 29 potentially relevant publications, of which 7 met our inclusion criteria. A total of 295 patients (299 ankles) were included in this study. The weighted mean postoperative American Orthopaedic Foot & Ankle Society hindfoot score was 86.8 points, translating to good to excellent outcomes in 80.2% of patients.

CONCLUSIONS

Many techniques exist for the treatment of OCLs of the talar dome. Good to excellent results can be consistently reached in greater than 80% of patients with arthroscopic debridement and microfracture. However, additional prospective trials should be undertaken to determine differences in outcome between techniques, size and location of the OCL, and other patient quality factors, such as cost and time to return to work.

LEVEL OF EVIDENCE

Level IV, systematic review of Level II, III, and IV studies.

Reconstruction of complex osteochondral lesions of the talus with cylindrical sponge allograft and particulate juvenile cartilage graft: provisional results with a short-term follow-up

Osteochondral lesions of the talus can be a challenging injury to treat for even the most experienced foot and ankle surgeon. Although the advances in imaging have made the diagnosis of chondral lesions more accurate, surgeons are still struggling to find ways to reliably treat advanced lesions with subchondral bone damage. This article looks at the use of allograft bone and particulate juvenile cartilage in patients with advanced subchondral bone damage and osteochondral lesions of the talus.

Is technique performance a prognostic factor in bone marrow stimulation of the talus?

Although results of bone marrow stimulation in osteochondral defects of the talus (OCLT) have been satisfactory, the technique performance has not yet been subjected to review as a prognostic factor. The aim of this systematic review is to determine whether variation within technique influences outcome of bone marrow stimulation for OCLT. Electronic databases were searched for articles on OCLT treated with bone marrow stimulation techniques, providing a technique description. Six articles on microfracture were included (198 patients). Lesion size averaged 0.9 cm (2) to 4.5 cm (2), and follow-up varied from 2 to 6 years. Key elements were removal of unstable cartilage, hole depth variation between 2 and 4 mm until bleeding or fat droplets occurred, and a distance between the created holes of 3 to 4 mm. The success rate (excellent/good results by any clinical outcome score) was 81%. There is a vast similarity in the technique with similar outcomes as in previous general reviews; therefore variation in technique as currently described in the literature does not seem to influence the outcome of bone marrow stimulation for OCLT. Whether the instruments used or the hole depth and geometry influence clinical outcome remains to be determined. Microfracture is safe and effective for OCLTs smaller than 15 mm. However, in this review, only 81% of patients obtained satisfactory results. Larger clinical trials are needed with clearly defined patient groups, technique descriptions, and reproducible outcome measures to provide insight in the specific indications and the preferred technique of bone marrow stimulation.

Treatment of osteochondral lesions of the talus with microfracture technique and postoperative hyaluronan injection

PURPOSE

The aim of this study is to report the outcomes of the treatment of talar osteochondral lesions with arthroscopic microfracture technique and postoperative intra-articular hyaluronan injection.

METHOD

Fifty-seven patients (29 men, 28 women) with osteochondral lesions of the talus were included in this prospective randomized clinical study between the years 2003 and 2009. The patients were treated with arthroscopic debridement and microfracture technique. Randomly selected 41 patients were injected intra-articular hyaluronan (injection group). The remaining 16 patients did not receive postoperative injection (non-injection group). Assessment of the pain and functional outcomes was performed using the Freiburg and AOFAS ankle/hindfoot scoring systems.

RESULTS

In the injection group, the mean postoperative Freiburg functional and pain scores were significantly higher compared to preoperative functional and pain scores (P < 0.001). Similarly, for the patients in non-injection group, the mean postoperative Freiburg functional and pain scores were significantly higher compared to preoperative functional and pain scores (P < 0.001). The AOFAS functional and pain scores of the patients in the injection group were significantly higher (P < 0.001) postoperatively compared to preoperative scores. Scoring the patients in the non-injection group according to AOFAS system also revealed significantly higher (P < 0.001) postoperative functional and pain scores over preoperative scores. The increase in the postoperative scores was found to be significantly higher in the injection group compared to non-injection group in both Freiburg and AOFAS systems (P < 0.001).

CONCLUSION

Treatment of osteochondral lesions of the talus using microfracture technique significantly improved functional and pain scores postoperatively. Additional treatment with intra-articular hyaluronan injection as an adjunct to microfracture technique may offer better clinical outcomes over microfracture technique alone.

LEVEL OF EVIDENCE

Randomized, controlled trial, Level I.