Open mosaicplasty in osteochondral lesions of the talus: a prospective study

Return to sport after surgery for osteochondral lesions of the talar dome. Results of a multicenter prospective study on 58 patients

INTRODUCTION

Osteochondral lesions of the talar dome (OLTD) are most often found in patients for whom the return to sports activities is the main issue. Two types of surgery have been distinguished at present, bone marrow stimulation techniques and mosaicplasty techniques. The size of the lesion indicating the need for bone marrow stimulation as the required surgical procedure has recently been decreased (<1cm). The main objective of this study was therefore to evaluate the return to sport after OLTD surgery. Our hypothesis is that surgery of osteochondral lesions of the talar dome allows the resumption of sports activities in the majority of cases.

MATERIAL AND METHODS

This multicenter prospective study was conducted across 10 French centers specializing in foot and ankle surgery. All patients aged 18 to 65 with symptomatic OLTD resistant to thorough medical treatment for at least 6 months, justifying surgery, were included from June 2018 to September 2019. In addition to the usual demographic data, the practice of sport and level (professional, competitive, leisure) were systematically investigated preoperatively. A common protocol for surgical management and postoperative follow-up had previously been established according to the arthrographic stage of the lesion. The most recent recommendations based on size, but also depth, were taken into account. The primary endpoint was return to sport.

RESULTS

A final functional evaluation with the AOFAS (American Orthopedic Foot & Ankle Society) score was performed at a minimum of 12 months. Of 58 sports patients, 70.6% returned to sport (41/58) with an average delay of 4.3 months. A high AOFAS functional score (p=0.02) and a stage 1 lesion (p=0.006) were the only preoperative criteria significantly associated with a return to sport. No other factor was predictive of a return to sport.

CONCLUSION

Our prospective study shows that 70.6% of sports patients returned to sport after OLTD surgery according to a surgical protocol and standardized follow-up.

LEVEL OF EVIDENCE

II.

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 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.

Prognostic factors for the management of chondral defects of the knee and ankle joint: a systematic review

Purpose

Different surgical techniques to manage cartilage defects are available, including microfracture (MFx), autologous chondrocyte implantation (ACI), osteoarticular auto- or allograft transplantation (OAT), autologous matrix-induced chondrogenesis (AMIC). This study investigated the patient-related prognostic factors on the clinical outcomes of surgically treated knee and ankle cartilage defects.

Methods

This study followed the PRISMA statement. In May 2022, the following databases were accessed: PubMed, Google Scholar, Embase, and Scopus. All the studies investigating the outcomes of surgical management for knee and/or talus chondral defects were accessed. Only studies performing mesenchymal stem cells transplantation, OAT, MFx, ACI, and AMIC were considered. A multiple linear model regression analysis through the Pearson Product–Moment Correlation Coefficient was used.

Results

Data from 184 articles (8905 procedures) were retrieved. Female sex showed a positive moderate association with visual analogue scale at last follow-up (P = 0.02). Patient age had a negative association with the American Orthopaedic Foot and Ankle Score (P = 0.04) and Lysholm Knee Scoring Scale (P = 0.03). BMI was strongly associated with graft hypertrophy (P = 0.01). Greater values of VAS at baseline negatively correlate with lower values of Tegner Activity Scale at last follow-up (P < 0.0001).

Conclusion

The clinical outcomes were mostly related to the patients’ performance status prior surgery. A greater BMI was associated with greater rate of hypertrophy. Female sex and older age evidenced fair influence, while symptom duration prior to the surgical intervention and cartilage defect size evidenced no association with the surgical outcome. Lesion size and symptom duration did not evidence any association with the surgical outcome.

The Effectiveness of Osteochondral Autograft Transfer in the Management of Osteochondral Lesions of the Talus: A Systematic Review and Meta-Analysis

Osteochondral lesions of the talus (OLT) are common following ankle trauma. Operative treatment is often required, with osteochondral autografting frequently performed for large or cystic lesions, or following failed primary surgery. The aim of this systematic review was to evaluate the current evidence for osteochondral autograft transfer system (OATS) in the management of OLT. A systematic search of the PubMed, EMBASE, Scopus, and Cochrane Library databases was performed based on the Preferred Reporting Items for Systematic Reviews (PRISMA) guidelines. Study quality was assessed using the modified Coleman Methodology Score (CMS). Meta-analysis was carried out using RevMan, version 5.4 (The Cochrane Collaboration, 2020). A total of 23 studies were included. The mean modified CMS was 48.1±7.47. Fourteen studies reported preoperative and postoperative Visual Analog Scale (VAS) and American Orthopaedic Foot & Ankle Score (AOFAS). The aggregate mean preoperative and postoperative VAS score across 14 studies was 6.47±1.35 and 1.98±1.18, respectively. Meta-analysis of seven studies on 210 patients found that OATS resulted in a significant reduction in VAS score compared to baseline (Mean Difference {MD} -4.22, 95% Confidence Interval {CI} -4.54 to -3.90, P < 0.0001). The aggregate mean preoperative and postoperative AOFAS scores across 14 studies were 56.41±8.52 and 87.14±4.8, respectively. Based on eight studies on 224 patients, OATS resulted in a significant improvement in AOFAS score compared to baseline (MD 29.70, 95% CI 25.68 to 33.73, P = < 0.0001). Donor site pain occurred in 9% of cases. Current evidence from low-quality studies suggests that OATS is a safe and effective treatment option for OLT, though it is associated with a risk of donor site morbidity.

Allograft Versus Autograft Osteochondral Transplant for Chondral Defects of the Talus: Systematic Review and Meta-analysis

BACKGROUND

It is unclear whether the results of osteochondral transplant using autografts or allografts for talar osteochondral defect are equivalent.

PURPOSE

A systematic review of the literature was conducted to compare allografts and autografts in terms of patient-reported outcome measures (PROMs), MRI findings, and complications.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

This study was conducted according to the PRISMA guidelines. The literature search was conducted in February 2021. All studies investigating the outcomes of allograft and/or autograft osteochondral transplant as management for osteochondral defects of the talus were accessed. The outcomes of interest were visual analog scale (VAS) score for pain, American Orthopaedic Foot and Ankle Society (AOFAS) score, and Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score. Data concerning the rates of failure and revision surgery were also collected. Continuous data were analyzed using the mean difference (MD), whereas binary data were evaluated with the odds ratio (OR) effect measure.

RESULTS

Data from 40 studies (1174 procedures) with a mean follow-up of 46.5 ± 25 months were retrieved. There was comparability concerning the length of follow-up, male to female ratio, mean age, body mass index, defect size, VAS score, and AOFAS score (P > .1) between the groups at baseline. At the last follow-up, the MOCART (MD, 10.5; P = .04) and AOFAS (MD, 4.8; P = .04) scores were better in the autograft group. The VAS score was similar between the 2 groups (P = .4). At the last follow-up, autografts demonstrated lower rate of revision surgery (OR, 7.2; P < .0001) and failure (OR, 5.1; P < .0001).

CONCLUSION

Based on the main findings of the present systematic review, talar osteochondral transplant using allografts was associated with higher rates of failure and revision compared with autografts at midterm follow-up.

Osteochondral Lesions of the Ankle Treated with Bone Marrow Concentrate with Hyaluronan and Fibrin: A Single-Centre Study

Osteochondral defects of the ankle (OCD) are being increasingly identified as a clinically significant consequence of injury to the ankle, with the potential to lead to osteoarthritis if left untreated. The aim of this retrospective cohort study was to evaluate a single-stage treatment of OCD, based on bone marrow aspirate (BMA) centrifuged to produce bone marrow concentrate (BMC). In a dual syringe, the concentrate was mixed with thrombin in one syringe, whereas hyaluronan and fibrinogen were mixed in a second syringe. The two mixtures were then injected and combined into the prepared defect. Clinical outcome and quality of life scores (MOXFQ and EQ-5D) were collected at baseline and yearly thereafter. Multilevel models were used to analyse the pattern of scores over time. Ninety-four patients were treated between 2015 and 2020. The means of each of the three components of the MOXFQ significantly improved between baseline and 1 year (p < 0.001 for each component), with no further change from year 1 to year 3. The EQ-5D index also improved significantly from baseline to 1 year, with no evidence for further change. Our results strongly indicate that this BMC treatment is safe for, and well tolerated by, patients with OCD of the ankle as both primary treatment and those who have failed primary treatment. This technique provides a safe, efficacious alternative to currently employed cartilage repair techniques, with favourable outcomes and a low complication rate at 36 months.

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

INTRODUCTION

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

HYPOTHESIS

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

PATIENTS AND METHODS

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

RESULTS

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

DISCUSSION

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

LEVEL OF EVIDENCE

IV; retrospective study.

Safety of malleolar osteotomies in surgery for osteochondral lesions of the talus

The talus is a central bone in the hindfoot that is difficult to access surgically. Performing a medial or lateral malleolar osteotomy in the management of an osteochondral lesion of the talus (OLT) is a feared procedure amongst surgeons and their patients. The objective of this study was to assess the complications inherent to malleolar osteotomies in the treatment of OLTs.

HYPOTHESIS

The use of a standardized protocol concerning the technical performance and osteosynthesis of malleolar osteotomies results in fewer postoperative complications than a non-standardized protocol.

MATERIALS AND METHOD

This is a comparative study comprising a prospective multicenter non-randomized series with a standardized protocol for performing malleolar osteotomies, and a multicenter retrospective series without a standardized protocol. We included all patients aged 16 to 65 years with symptomatic OLTs, resistant to more than 6-months of well-conducted medical treatment, for whom surgery was considered. The minimum follow-up was 1 year for the prospective study, and 5 years for the retrospective study. A total of 86 and 97 patients were included in the prospective and retrospective studies, respectively. Of these 183 patients, 86 patients (33 prospective and 53 retrospective) underwent medial or lateral malleolar osteotomies as part of their surgery for OLT. Complications specific to the osteotomy procedures such as scar tissue, surgical site infection, non-union, articular malunion, neurological lesions or surgical revision, were investigated.

RESULTS

No specific complication was found to be associated to the malleolar osteotomy. No surgical revision was directly linked to the osteotomy procedure. No significant difference was found between the two series.

DISCUSSION

There was no evidence of morbidity related specifically to medial or lateral malleolar osteotomies. A standardized protocol, subject to rigorous technical implementation, does not improve results after malleolar osteotomy. The fear associated with this malleolar osteotomy procedure seems unfounded.

LEVEL OF EVIDENCE

IV.

Osteochondral Lesions of the Talus: A Review on Talus Osteochondral Injuries, Including Osteochondritis Dissecans

This is a review on talus osteochondritis dissecans and talus osteochondral lesions. A majority of the osteochondral lesions are associated with trauma while the cause of pure osteochondritis dissecans is still much discussed with a possible cause being repetitive microtraumas associated with vascular disturbances causing subchondral bone necrosis and disability. Symptomatic nondisplaced osteochondral lesions can often be treated conservatively in children and adolescents while such treatment is less successful in adults. Surgical treatment is indicated when there is an unstable cartilage fragment. There are a large number of different operative technique options with no number one technique to be recommended. Most techniques have been presented in level II to IV studies with a low number of patients with short follow ups and few randomized comparisons exist. The actual situation in treating osteochondral lesions in the ankle is presented and discussed.

Osteochondral Injury of the Talus Treated With Cell-Free Hyaluronic Acid-Based Scaffold (Hyalofast®) - A Reliable Solution

Background: Osteochondral injuries commonly occur in load-bearing joints, mainly caused by traumatic incidents that can lead to detachment of the cartilage fragment either partial or complete.

Objective: This study aims to review the long-term outcome of osteochondral injury of the talus treated with a cell-free hyaluronic acid-based scaffold (Hyalofast®, Anika Therapeutics Inc., Bedford, Massachusetts, USA).

Method: This study evaluated the data of seven patients who underwent medial malleolus osteotomy, microfracture, and cell-free hyaluronic acid-based scaffold (HYALOFAST®) insertion between 2015 to 2018. All patients had an osteochondral lesion (OCL) grade III and IV of the talus based on Dipaola classification due to trauma. They were followed up for at least two years and assessed by the short form 36 health survey questionnaire (SF36) for both physical functioning and mental health, American Orthopaedic Foot and Ankle Society (AOFAS) scoring system, and visual analog scale (VAS).

Result: All patients were satisfied in terms of physical function, mental health, and pain after one month of surgery (p-value<0.05). There was also an improvement in AOFAS hindfoot and VAS scores from preoperative to postoperative. No complications were noted in the surgical site or bone union.

Conclusion: Medial malleolus osteotomy, cell-free hyaluronic acid-based scaffold (HYALOFAST®) grafting, and microfracture are considered relatively easy techniques that are a good choice for patients with sizeable cartilage deficiency and provide a good functional outcome.

Osteochondritis Dissecans: Current Understanding of Epidemiology, Etiology, Management, and Outcomes

➤

Osteochondritis dissecans occurs most frequently in the active pediatric and young adult populations, commonly affecting the knee, elbow, or ankle, and may lead to premature osteoarthritis.

➤

While generally considered an idiopathic phenomenon, various etiopathogenetic theories are being investigated, including local ischemia, aberrant endochondral ossification of the secondary subarticular physis, repetitive microtrauma, and genetic predisposition.

➤

Diagnosis is based on the history, physical examination, radiography, and advanced imaging, with elbow ultrasonography and novel magnetic resonance imaging protocols potentially enabling early detection and in-depth staging.

➤

Treatment largely depends on skeletal maturity and lesion stability, defined by the presence or absence of articular cartilage fracture and subchondral bone separation, as determined by imaging and arthroscopy, and is typically nonoperative for stable lesions in skeletally immature patients and operative for those who have had failure of conservative management or have unstable lesions.

➤

Clinical practice guidelines have been limited by a paucity of high-level evidence, but a multicenter effort is ongoing to develop accurate and reliable classification systems and multimodal decision-making algorithms with prognostic value.

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

BACKGROUND

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

OBJECTIVES

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

STUDY DESIGN & METHODS

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

RESULTS

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

CONCLUSIONS

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

Endoscopic Treatment of Symptomatic Foot and Ankle Bone Cyst with 3D Printing Application

Objective

To study the efficacy of arthroscopy for treating symptomatic bone cysts of the foot and ankle through the follow-up of patients and to further explore the application value of 3D printing technology in this treatment.

Methods

Twenty-one patients with symptomatic bone cysts in the foot and ankle who underwent arthroscopic surgery in our Center from March 2010 to December 2018 were enrolled, including 11 in the experimental group and 10 in the control group. For the control group, C-arm fluoroscopy was used intraoperatively to confirm the positioning of the cysts; for the experimental group, a 3D model of the lesion tissue and the 3D-printed individualized guides were prepared to assist the positioning of the cysts. Debridement of the lesion tissues was conducted under an arthroscope. Regular follow-ups were conducted. The time of establishing arthroscopic approaches and the times of intraoperative fluoroscopy between the two groups were compared. Significance was determined as P < 0.05.

Results

The postoperative pathology of the patients confirmed the diagnosis. No significant perioperative complications were observed in either group, and no recurrence of bone cysts was seen at the last follow-up. The VAS scores and AOFAS scores of the two groups at the last follow-up were significantly improved compared with the preoperative data, but there was no statistical difference between the two groups. All surgeries were performed by the same senior surgeon. The time taken to establish the arthroscopic approaches between the two groups was statistically significant (P < 0.001), and the times of intraoperative fluoroscopy required to establish the approach were also statistically significant (P < 0.001). The intraoperative bleeding between the two groups was statistically significant (P < 0.01). There was 1 case in each group whose postoperative CT showed insufficient bone grafting, but no increase in cavity volume was observed during the follow-up.

Conclusion

With the assistance of the 3D printing technology for treating symptomatic bone cysts of the ankle and foot, the surgeon can design the operation preoperatively and perform the rehearsal, which would make it easier to establish the arthroscopic approach, better understand the anatomy, and make the operation smoother. This trial is registered with http://www.clinicaltrials.govNCT03152916.

A triplanar osteotomy technique in arthroscopy-assisted ankle mosaicplasty

PURPOSE

Osteochondral lesions of the talus are lesions that are seen particularly in the young age group and are often related to sports injuries and trauma. These lesions, which show late symptoms radiologically, can be determined in the early stages with magnetic resonance imaging. The aim of this study was to present a new osteotomy technique to reduce the complications of mosaicplasty surgery to a minimum and provide an early return to work.

METHODS

A total of 11 patients who had cartilage lesions due to osteochondritis dissecans in the medial aspect of the talus underwent mosaicplasty after a triplanar osteotomy. The dimensions of the lesion and the depth of the triplanar osteotomy were determined preoperatively. Coronal, sagittal and transverse cuts were made at the depth defined arthroscopically. Following the osteotomy, an osteochondral graft taken from the ipsilateral knee was placed in the prepared area. Osteotomy side was fixed with one or two cannulated screws following mosaicplasty.

RESULTS

With this technique, weight-bearing can be immediate in cases with no need for osteotomy in the joint surface. In cases including the joint surface, partial weight-bearing is permitted after 4 weeks and can be increased as tolerated. In the 11 cases treated with this technique, full weight-bearing was achieved at mean 5 weeks (range, 5-8 weeks). No shift (upward displacement of osteotomized fragment) or non-union was seen in any patient.

CONCLUSION

With the triplanar osteotomy technique described here, potential shift complications can be reduced to a minimum. As only the lesion region is targeted, the osteochondral surface formed by the fracture is much less.

STUDY DESIGN

Case Series; Level of Evidence, 4.

All-Arthroscopic Osteochondral Autograft Transfer Technique for Osteochondritis Dissecans of the Talus

Juvenile osteochondritis dissecans of the talus can be a challenging condition to treat in young patients. Previously described osteochondral autograft transfer techniques for medial talar lesions have been done via open approach, often requiring medial malleolus osteotomy. The purpose of this article is to present an all-arthroscopic osteochondral autograft transfer technique for a medial talar osteochondritis dissecans lesion in a skeletally immature patient.

Osteochondral autograft transfer (mosaicplasty) for treatment of patients with osteochondral lesions of talus

PURPOSE

Osteochondral lesion of talus (OLT) is one of the common causes of ankle pain. This disorder is common in young athletes after ankle injury. There are various therapeutic options. One of the options is mosaic plasticizer. The purpose of this study was to investigate the effect of mosaicplasty on improvement of symptoms of patients with osteochondral lesions of talus.

METHODS

Nineteen patients with osteochondral lesions of talus participated in this study, who were treated with mosaicplasty. Before and after treatment, pain (visual analogue scale), function (American Orthopaedic Foot and Ankle Society), range of motion and radiographic signs were evaluated.

RESULTS

The results of this study showed that mosaicplasty could significantly reduce pain, increase function and improve radiographic symptoms. The range of motion increased after treatment, which was not significant.

CONCLUSION

We can confirm the effect of mosaicplasty on the improvement of patients with osteochondral lesions of the ankle, suggesting it as a treatment option.

Knee-to-Talus Donor-Site Morbidity Following Autologous Osteochondral Transplantation: A Meta-Analysis with Best-case and Worst-case Analysis

BACKGROUND

Despite the promising clinical results of autologous osteochondral transplantation in the treatment of osteochondral lesions of the talus, the occurrence of knee donor-site morbidity remains a concern. However, the proportion of patients experiencing donor-site morbidity is not well established because of important variations in estimates drawn by heterogeneous studies with loss to followup, often made at short-term (< 1 year). Therefore, both a meta-analysis of studies that assumed no patients lost to followup had donor-site morbidity and assumed all patients lost to followup had donor-site morbidity may help to estimate the true risk of donor-site morbidity.

QUESTIONS/PURPOSES

To evaluate the proportion of patients who developed knee donor-site morbidity after autologous osteochondral transplantation for osteochondral lesion of the talus, by (1) meta-analysis of the proportion of patients experiencing donor-site morbidity in the best-case scenario as reported, in which no patients lost to followup were assumed to have donor-site morbidity and (2) meta-analysis of the percentage of patients who had donor-site morbidity in the worst-case scenario, in which all patients lost to followup were assumed to have donor-site morbidity and (3) present the characteristics of studies associated with the reporting of donor-site morbidity.

METHODS

A systematic search of the PubMed, Embase and The Cochrane Library databases was performed from their inception to October 2017 according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The inclusion criteria were clinical studies that reported knee donor-site morbidity after autologous osteochondral transplantation for osteochondral lesion of the talus, mean followup ≥ 1 year, full-text studies published in a peer-review journal and written in English. Quality of evidence (Case Series Quality Appraisal Checklist), sample size, mean patient age, study design, mean followup time, and observed rate of knee donor-site morbidity were evaluated. Twenty-six studies with 915 ankles (904 patients) were included in the systematic review and meta-analysis. Approximately half of the included studies were of small cohort (n < 30, 12 studies), and 12 of 26 studies did not report at all on loss to followup. In the studies that reported loss to followup (14 of 26), a total of 32 patients (35 ankles) were reported lost. Random-effects models were used to estimate the risk of donor-site morbidity as between-study heterogeneity was determined to be high in both meta-analyses that assumed that no patients lost to followup experienced donor-site morbidity (I = 82.1%) and the one that assumed all patients lost to followup experienced donor-site morbidity (I = 88.7%). Multivariable metaregression was used to estimate the association between study characteristics and the observed proportion of patients who experienced of donor-site morbidity. If there was evidence of an association between a study characteristic and proportion, a subgroup analysis was performed.

RESULTS

The estimated proportion of donor-site morbidity was 6.7% (95% confidence interval [CI], 2.8-11.8), assuming that no patients lost to followup experienced donor-site morbidity and 10.8% (95% CI, 4.8-18.3) assuming that all patients lost to followup experienced donor-site morbidity after a mean followup of 43.8 ± 24.7 months (range, 15.9-120 months). There was a negative association between study sample size and proportion of donor-site morbidity (β = -0.26; 95% CI, -0.39 to -0.12; p < 0.001 assuming that no patients lost to followup experienced donor-site morbidity and β = -0.31; 95% CI, -0.48 to -0.13; p < 0.001 assuming that all patients lost to followup experienced donor-site morbidity); that is, as study size increased, the proportion of patients reported with donor-site morbidity decreased. In larger studies (n ≥ 30), the estimated percentage of donor-site morbidity was 2.8% (95% CI, 1.2%-5.0%; I = 47.6%) assuming that no patients lost to followup experienced donor-site morbidity, and 5.0% (95% CI, 2.1%-9.0%; I = 74.5%) assuming all patients lost to followup experienced donor-site morbidity. High between-study heterogeneity (differences in methodology) could not be completely explained by variability in study sample size, mean patient age, design, or mean followup time, and may be attributable to other factors such as inconsistent definitions of donor-site morbidity.

CONCLUSIONS

The estimated proportion of donor-site morbidity after autologous osteochondral transplantation for osteochondral lesion of the talus ranged from 6.7% to 10.8% in the current meta-analysis. However, subgroup analysis demonstrated that larger studies (n ≥ 30) estimated a lower donor-site morbidity risk (< 5.0%) than smaller studies (n < 30). This estimate should be interpreted in light of the fact that nearly half of the included studies did not report on loss to followup, and so their estimates of donor-site morbidity may be low. In addition, high between-study heterogeneity and the inclusion of predominantly retrospective studies with small sample sizes likely contributed to estimates that suffered from a high risk of bias, probably in favor of the surgical treatment being studied.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Osteochondral Lesions of the Talus

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.

Biological reconstruction of large osteochondral lesions of the talar dome with a modified "sandwich" technique-Midterm results

BACKGROUND

Surgical treatment for large osteochondral lesions of the talar dome (OLTD) must restore the convexity and curvature of the talus. Here, we present midterm results and describe the modified "sandwich" reconstruction procedure. Bone defects were restored using a biological inlay consists of autologous bone chips that were mixed with bone marrow concentrate and fibrin glue and covered with a xenogeneic collagen membrane infiltrated with bone marrow concentrate and stabilized by fibrin glue.

METHODS

Ten patients who were treated using a modified "sandwich" OLTD reconstruction were assessed after an average follow-up period of 46.4 (±18) months, using the clinical American Orthopaedic Foot and Ankle Society Ankle Hindfoot Scale (AOFAS) score and radiological magnetic resonance observation of cartilage repair tissue (MOCART) score.

RESULTS

The mean AOFAS score increased significantly from 58.3 (±8.5) points to 81.8 (±15.5) points as well the mean VAS score reduced significantly from 5.58 (±0.97) to 1.83 (±0.93) points. The average MOCART score was 69.5% (±16.7%) in the final follow-up.

CONCLUSIONS

The presented modified "sandwich" technique permanently recreates the convexity and curvature in large osteochondral lesions of the talar dome with a single step surgical procedure.

Restorative Tissue Transplantation Options for Osteochondral Lesions of the Talus: A Review

Symptomatic osteochondral lesions of the talus remain a challenging problem due to inability for cartilage lesions to heal. Numerous treatment options exist, including nonoperative management, marrow stimulating techniques, and autograft-allograft. Arthroscopic marrow stimulation forms fibrocartilage that has been shown to be biomechanically weaker than hyaline cartilage. Restorative tissue transplantation options are being used more for larger and cystic lesions. Newer biologics and particulated juvenile cartilage are currently under investigation for possible clinical efficacy. This article provides an evidenced-based summary of available literature on the use of biologics for treatment of osteochondral lesions of the talus.

Diagnosis and treatment of osteochondral lesions of the ankle: current concepts

We conducted a wide-ranging review of the literature regarding osteochondral lesions of the ankle, with the aim of presenting the current concepts, treatment options, trends and future perspectives relating to this topic.

Medium-term outcomes of mosaicplasty versus arthroscopic microfracture with or without platelet-rich plasma in the treatment of osteochondral lesions of the talus

PURPOSE

This study aimed to compare medium-term functional effects of three different treatment modalities in patients with osteochondral lesions of the talus (OLT).

METHODS

Fifty-four patients undergoing arthroscopic surgery for osteochondral lesion of the talus were included in this study. Patients were assigned to one of the three treatment groups: microfracture surgery (n = 19), microfracture surgery plus platelet-rich plasma (PRP) (n = 22), and mosaicplasty (n = 13). Function was assessed using the American Orthopedic Foot and Ankle Society (AOFAS) scoring system and VAS scores for pain, before and after surgery. In addition, the Foot and Ankle Ability Measure (FAAM) tests for pain and 15-min walking were done at follow-up visits.

RESULTS

The median duration of follow-up was 42 months (range 12-84 months). All groups showed significant improvements in AOFAS and VAS pain scores at the last follow-up visit, when compared to baseline. The groups did not differ with regard to change in baseline AOFAS score; however, improvement in VAS pain scores was significantly better in the mosaicplasty group when compared to the microfracture group (change from baseline, -5.8 ± 1.0 vs. -3.2 ± 2.9, p = 0.018).

CONCLUSIONS

All the three treatment modalities resulted in good medium-term functional results. However, mosaicplasty procedure seems to be a promising option and it might be preferred particularly in patients where pain control is important.

LEVEL OF EVIDENCE

II.

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.

Medial Malleolar Osteotomy and Osteochondral Autograft Transfer for Osteochondritis Dissecans of the Distal Tibial Plafond

The literature on the surgical treatment of osteochondritis dissecans of the distal tibial plafond is significantly limited. The purpose of this case study is to present a novel surgical technique to repair osteochondritis dissecans of the distal medial tibial plafond. A retrospective chart and radiographic review of a 15-year-old male was performed with a 24-month follow-up along with a review of the literature. A right angled medial malleolar osteotomy provides adequate exposure, width, and depth of the medial distal tibial plafond allowing for the successful transfer of osteochondral autograft plugs.

LEVELS OF EVIDENCE

Therapeutic, Level IV: Case report.

Outcomes of talar dome osteochondral defect repair using osteocartilaginous autografts: 37 cases of Mosaicplasty®

BACKGROUND

The indications of osteochondral autograft implantation using the Mosaicplasty(®) technique were only recently extended to osteochondral lesions of the talus (OLT), a site for which no medium- or long-term outcome data are available. Our objective here was to evaluate medium-term outcomes in case-series of patients who underwent Mosaicplasty(®) for OLT repair.

HYPOTHESIS

Mosaicplasty(®) provides good medium-term outcomes with low morbidity when used for OLT repair.

PATIENTS ET METHODS

We retrospectively reviewed cases of Mosaicplasty(®) for OLT repair, performed in combination with malleolar osteotomy on the side of the OLT, at either of two centres, between 1997 and 2013. Pre-operative clinical data were collected from the medical records and all patients were re-evaluated. We studied 37 patients with a mean age of 33 years.

RESULTS

Mean follow-up at re-evaluation was 76 months. Mean AOFAS score at re-evaluation was 83 (range, 9-100). A work-related cause to the OLT was associated with significantly poorer outcomes (P=0.01). AOFAS values were significantly better in patients whose OLT size was 0.5 to 1cm(2). The Ogilvie-Harris score at last follow-up was good or excellent in 78% of patients. No patient experienced morbidity related to the malleolar osteotomy. Persistent patellar syndrome was noted in 6 patients.

DISCUSSION

In our case-series, Mosaicplasty(®) for OLT repair provided good medium-term outcomes in 78% of patients. Nevertheless, the donor-site morbidity should be borne in mind. Mosaicplasty(®) deserves to be viewed as a reference standard method for OLT repair.

LEVEL OF EVIDENCE

IV, retrospective study.

Outcomes are favorable after arthroscopic treatment of osteochondritis dissecans of the talus

Arthroscopic treatment of osteochondritis dissecans (OCD) of the talus has resulted in outcomes as good as, or better than, those after arthrotomy. We noted a lack of prospective studies investigating the outcomes of arthroscopic treatment. As such, we conducted a prospective study investigating the functional outcomes, pain scores, patient satisfaction, and expectation scores of patients undergoing arthroscopic treatment of OCD of the talus, hypothesizing that these patients would have good outcomes and satisfaction. A total of 61 patients underwent arthroscopic chondroplasty, removal of loose bodies, and microfracture for OCD of the talus and completed ≥1 year of follow-up. We evaluated patients pre- and postoperatively at 6 and 12 months using the Ankle-Hindfoot score, visual analog scale for pain, and Medical Outcomes Study short-form 36 questionnaires. We also evaluated the patients' expectations and satisfaction. The mean Ankle-Hindfoot score improved significantly from 53.0 ± 14.3 points preoperatively to 77.8 ± 19.1 at 6 months and 83.1 ± 18.3 at 12 months after arthroscopic treatment (p < .001). The overall scores at the final follow-up visit were excellent for 30 (49%), good for 6 (10%), fair for 18 (30%), and poor for 7 (11%). The patients also experienced significant improvement in the visual analog scale score and physical component score of the short-form 36 questionnaire (p < .001). Of the 61 patients, 67% had their expectations fulfilled and 74% were satisfied with their surgery at 12 months of follow-up. Arthroscopic treatment of OCD of the talus continues to be a successful procedure to alleviate pain and loss of function. It is also associated with improvements to quality of life and good patient satisfaction.

Outcomes Following Microfracture in Grade 3 and 4 Articular Cartilage Lesions of the Ankle

BACKGROUND

The purpose of this study was to document outcomes following microfracture of articular cartilage lesions of the ankle. Our hypothesis was that patients who underwent ankle microfracture would have good to excellent outcomes.

METHODS

This study was institutional review board approved. Patients older than 18 years who underwent ankle microfracture surgery for Outerbridge grade 3 or 4 articular cartilage lesions, by a single surgeon, were included. Detailed intraoperative findings were documented at surgery. Patients completed a questionnaire with Foot and Ankle Disability Index (FADI), Lysholm, Tegner, and patient satisfaction with outcome. All data were collected prospectively and stored in a data registry and retrospectively reviewed. Forty patients (21 males, 19 females, mean age = 42 years [range, 19-65 years]) were included in this study. Thirteen (33%) had previous ankle surgery. Follow-up was obtained for 94% of patients (n = 34). Mean follow-up time was 26 months (range, 12-48 months).

RESULTS

Mean talar defect size was 70 mm² (range, 4-300 mm²). Mean tibia defect size was 31 mm² (range, 8-54 mm²). Four patients (10.5%) required subsequent surgery following microfracture surgery. Mean time to second surgery was 17 months (range, 4-32 months). Mean Lysholm score was 74 (range, 31-96). Mean FADI Activities of Daily Living (ADL) was 81 (range, 33-99), FADI Sport was 62 (range, 13-100), and FADI total score was 77 (range, 28-98). Median Tegner was 4 (range, 0-10). Median patient satisfaction was 8 (range, 3-10). Patients who had previous ankle surgery had significantly lower outcome scores versus patients who did not have previous ankle surgery for FADI ADL (70 vs 81, P = .029) and FADI Total (51 vs 77, P = .028). Days from injury to surgery were correlated with age at surgery (r = .323, P = .042) and negatively correlated with FADI ADL (r = -.431, P = .014), FADI Sport (r = -.490, P = .004), FADI Total (r = -.429, P = .014), and Tegner (r = -.402, P = .023).

CONCLUSION

Patients who underwent microfracture for grade 3 or 4 ankle articular cartilage lesions had high patient satisfaction. Patients who had previous ankle surgery had lower postoperative ankle function; however, patient satisfaction remained high. This study supports microfracture for treatment of grade 3 and 4 ankle articular cartilage lesions.

LEVEL OF EVIDENCE

Level IV, case series.

Osteochondral transplantation for the treatment of osteochondral defects at the talus with the Diamond twin system(®) and graft harvesting from the posterior femoral condyles

BACKGROUND

The aim of this study is to analyze clinical results after osteochondral cylinder transplantation for osteochondral defects at the medial or lateral talar dome using the Diamond twin system (Karl Storz). We hypothesize that grafts harvesting from the posterior femoral condyles are associated with less donor site morbidity than reported by previous studies.

METHODS

We have surgically treated 20 patients with an osteochondral defect of the talus by osteochondral transplantation with the Diamond twin system via an osteotomy of the ankle. The osteochondral cylinders were harvested from the posterior aspects of the femoral condyles of the ipsilateral knee. The defects at donor site were filled with a bone substitute of tricalcium phosphate (Synthricer, Karl Storz). The mean age was 25.4 years. After a mean time of 12.6 months, the screws at the medial malleolus were removed and an arthroscopy was performed. The functional outcome was evaluated with the visual analog scale for pain at walking, running, stair climbing, quality of life at the time of implant removal and at a mean follow-up of 25.8 months. Activity was assessed with the Tegner scale. Knee function was evaluated with the Lysholm score.

RESULTS

In one case, the osteochondral cylinder did not heal and an osteochondral fragment was removed arthroscopically. In all other cases, the osteochondral cylinder was stable with surrounding cartilage. The average ICRS Cartilage Repair Assessment was 10.1 points (±1.3). All malleolar osteotomies healed radiologically. In 15 patients, a synovectomy and local debridement of the ankle were performed at second-look arthroscopy. Ankle pain at walking, running and stair climbing as measured by a visual analog scale (10-0) decreased significantly from preoperatively to the first follow-up (mean 12.6 months) and to the second follow-up (mean 25.8 months). The ankle-related quality of life increased significantly from preoperatively to postoperatively. There was no significant change in the Lysholm score. The activity measured with the Tegner activity scale increased significantly from preoperatively to the last follow-up, but only two out of nine patients continued pivoting sports.

CONCLUSIONS

Autologous osteochondral grafting with the Diamond twin system is a reliable treatment option for symptomatic osteochondral defects of the talus. After 1 year, the majority of patients had still some complaints. However, after screw removal and second-look arthroscopy, the pain and ankle-related quality of life further improved.

CLINICAL RELEVANCE

The donor site morbidity after graft harvesting from the posterior aspects of the femoral condyles is lower than previously reported.

[Malleolar osteotomy--osteotomy as approach]

Both arthroscopic and open surgical techniques may be used for treatment of osteochondral lesions of the ankle joint. Osteotomy around the ankle joint is a well established technique to extend the approach in cases where the osteochondral lesions are located more posteriorly. Medial, oblique, monoplanar malleolar osteotomy should be used in patients with lesions of the medial talus shoulder. The posterolateral ostechondral lesions are less frequent and in such cases distal fibular osteotomy is recommended. In this study the indications for different forms of osteotomy are discussed and the surgical techniques are described.

Treatment of large cystic medial osteochondral lesions of the talus with autologous osteoperiosteal cylinder grafts

PURPOSE

To investigate the clinical, radiologic, and second-look arthroscopic outcomes of autologous iliac crest osteoperiosteal cylinder graft transplantation for medial osteochondral lesions of the talus (OLTs) with large subchondral cysts.

METHODS

Between January 2008 and December 2010, 17 consecutive cases of medial OLT with a subchondral cyst larger than 10 mm in diameter received transplantation of autologous osteoperiosteal cylinder graft, which was harvested from the ipsilateral iliac crest. The visual analog scale score for pain during daily activities, American Orthopaedic Foot & Ankle Society hindfoot and ankle scores, and subjective satisfaction survey rating were obtained. Plain radiographs and magnetic resonance imaging of the ankle were obtained before and after surgery. In 13 cases second-look arthroscopy was performed 12 months postoperatively and the cartilage repair was assessed with the criteria of the International Cartilage Repair Society.

RESULTS

Sixteen patients were available for follow-up at a mean of 32.6 months (range, 24 to 48 months). The mean visual analog scale score decreased from 5.51 ± 0.83 preoperatively to 0.98 ± 0.98 at the latest follow-up, and the median American Orthopaedic Foot & Ankle Society score improved from 75 preoperatively to 90 at the latest follow-up. Seven patients resumed sporting activities. Overall, 7 patients rated the result as excellent, 8 as good, and 1 as fair. The radiolucent area of the cysts disappeared on the plain radiographs in all cases. The mean Magnetic Resonance Observation of Cartilage Repair Tissue score was 60 ± 9.4 points, whereas subchondral bone edema persisted on the postoperative magnetic resonance images in 16 cases. The mean International Cartilage Repair Society arthroscopic score for cartilage repair at second-look arthroscopy was 9 ± 1.4 points.

CONCLUSIONS

Autologous iliac crest osteoperiosteal cylinder graft transplantation with supplemental bone grafting is a simple, safe, and effective procedure for treatment of large cystic medial OLT. It can successfully fill the subchondral cyst and repair the cartilage defect.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Fixation of a posteromedial osteochondral lesion of the talus using a three-portal posterior arthroscopic technique

Fixation of a large osteochondral fragment on the posteromedial talus can be performed using medial malleolar osteotomy or an arthroscopic technique with a transmalleolar portal. However, osteotomy can be associated with some morbidity, such as longstanding pain and tenderness at the osteotomy site. Also, it requires longer immobilization. However, the transmalleolar portal damages the tibial articular cartilage, which can later cause pain. In young patients, it can injure the epiphyseal plate. We describe a posterior arthroscopic technique using 3 posterior portals that allow access to a posteromedial osteochondral lesion of the talus and fixation of the osteochondral fragment without malleolar osteotomy or transmalleolar drilling.