Arthroscopic-assisted fluoroscopic navigation for retrograde drilling of a talar osteochondral lesion

Regeneration of Osteochondral Lesion of the Talus with Retrograde Drilling Technique: An In Vitro Pilot Study

Background: Retrograde Drilling (RD) is a surgical technique employed for osteochondral lesions of the talus (OCLTs) to reach the subchondral bone lesion from behind, thus preserving cartilage integrity. The aim of the present pilot study was to set up an in vitro model of OCLTs to evaluate the regenerative potential of biological approaches that could be associated with the RD technique. Methods: For this purpose, an OCLT was created in human osteochondral specimens, to try to mimic the RD technique, and to compare the regenerative potential of two biological treatments. For this purpose, three groups of treatments were performed in vitro: (1) no treatment (empty defect); (2) autologous bone graft (ABG); (3) hyaluronic membrane enriched with autologous bone marrow cells. Tissue viability; production of Collagen I and II, Vascular Endothelial Growth Factor, and Aggrecan; and histological and microCT evaluations were performed after 30 days of culture in normal culture conditions. Results: It was observed that Group 3 showed the highest viability, and Group 2 showed the highest protein production. From a histological and microtomographic point of view, it was possible to appreciate the structure of the morcellized bone with which the defect of Group 2 was filled, while it was not yet possible to observe the deposition of mineralized tissue in Group 3. Conclusions: To conclude, this pilot study shows the feasibility of an alternative in vitro model to evaluate and compare the regenerative potential of two biological scaffolds, trying to mimic the RD technique as much as possible. The tissues remained vital for up to 4 weeks and both ABG and hyaluronic acid-based scaffolds stimulated the release of proteins linked to regenerative processes in comparison to the empty defect group.

Evidence-Based Update on the Surgical Technique and Clinical Outcomes of Retrograde Drilling: A Systematic Review

BACKGROUND

Retrograde drilling is an established surgical technique to treat osteochondral lesions of the talus (OLT). It involves non-trans-articular drilling to induce subchondral bone revascularization and bone formation without damaging the overlying articular cartilage. The present study aimed to elucidate the heterogeneity of clinical studies on retrograde drilling for OLT.

DESIGN

A systematic search of the MEDLINE, Web of Science, EMBASE, and Cochrane Library databases for studies published between January 1996 and August 27, 2022, was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines by two independent reviewers. The included studies were evaluated for their level of evidence (LoE) and quality of evidence (QoE) using the Modified Coleman Methodology Score. Variables reporting surgical and clinical outcomes and complications were evaluated.

RESULTS

Eleven studies with 207 ankles were included (mean follow-up period = 31.1 months). The mean LoE was 3.8 (LoE 3: two studies, LoE 4: nine studies), and the mean QoE was 50.8 (fair: three studies, poor: eight studies). Ten studies used the American Orthopedic Foot and Ankle Society (AOFAS) score, which improved from 57.9 preoperatively to 86.1 postoperatively. The period and protocol of conservative treatment, lesion character, surgical technique, and postoperative protocol were inconsistent or underreported.

CONCLUSIONS

This systematic review revealed that low LoE and poor QoE, coupled with heterogeneity among the included studies, impede definitive conclusions regarding the effectiveness of this technique. Consequently, well-designed clinical trials are essential to develop standardized clinical guidelines for using retrograde drilling in OLT.

Retrograde Drilling and Bone Graft for Hepple Stage V Subchondral Bone Lesion of Talus Using 3D Image-Based Navigation-Assisted Endoscopic Technique

BACKGROUND

Retrograde drilling remains technically challenging, because of the difficulty of identifying the accurate location of cysts during surgery. This study's aim was to evaluate the 3-dimensional (3D) image-based surgical navigation-assisted endoscopic retrograde drilling technique for subchondral bone lesions of the talus.

METHODS

From March 2017 to June 2020, a total of 21 cases with Hepple stage V subchondral bone lesions of the talus were treated with 3D image-based surgical navigation-assisted endoscopic retrograde drilling and bone graft technique. Arthroscopic views were categorized per Pritsch classifications. The correlation between the drilled tunnel with preoperative cystic lesions were assessed under postoperative computer tomographic (CT) scans. The American Orthopaedic Foot & Ankle Society (AOFAS) scores, visual analog scale (VAS) scores, and Foot and Ankle Ability Measure (FAAM) sports scales were evaluated at the preoperative and final consultation. All complications were recorded.

RESULTS

On postoperative CT scans, in 20 cases (95.2%), the drilled tunnel was judged to have been in the center of previous cysts. Only 9 cases (42.9%) showed intact normal cartilage (grade 0, group A); 12 cases (57.1%) had intact, but soft, cartilage (grade I, group B). The median follow-up time was 24 (24, 30) months, and at final follow-up, there were no significant differences between the mean AOFAS and VAS scores in both groups (89.0 ± 6.4 vs 88.3 ± 7.0 and 1 vs 0.5) or postoperative FAAM sports scales (28.2 ± 2.2 vs 26.6 ± 4.9, P = .363). Two patients had revision surgery in group B.

CONCLUSION

The 3D image-based surgical navigation-assisted endoscopic retrograde drilling and bone graft technique for the subchondral bone lesions of the talus in this small case series showed encouraging results.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Validation of the registration accuracy of navigation-assisted arthroscopic débridement for elbow osteoarthritis

BACKGROUND

The identification and precise removal of bony impingement lesions during arthroscopic débridement arthroplasty for elbow osteoarthritis is technically difficult. Surgical navigation systems, combined with preoperative 3-dimensional (3D) assessment of bony impingements, can provide real-time tracking of the surgical instruments and impingement lesions. This study aims to determine the registration accuracy of the navigation system for the humerus and ulna during elbow arthroscopy.

METHODS

We tested the registration procedure using resin bone models of 3 actual patients with elbow osteoarthritis. We digitized bone surface points using navigation pointers under arthroscopy. We initially performed paired-point registration, digitizing 6 preset anatomical landmarks, and then refined the initial alignment with surface matching registration, digitizing 30 points. The registration accuracy for each trial was evaluated as the mean target registration error in each reference marker. Three observers repeated the registration procedure 5 times each with the 3 specimens (total, 45 trials). The median of the registration accuracy was evaluated in total (45 trials) as the accuracy of the registration procedure. The differences in the registration accuracy among the 3 observers (median of 15 trials) were also examined.

RESULTS

The total registration accuracies were 0.96 mm for the humerus and 0.85 mm for the ulna. No significant differences were found in the registration accuracy for the humerus and ulna among the 3 observers.

CONCLUSIONS

This arthroscopic-assisted registration procedure is sufficiently feasible and accurate for application of the navigation system to arthroscopic débridement arthroplasty in clinical settings.

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

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

Is retrograde drilling really useful for osteochondral lesion of talus with subchondral cyst?: A case report

RATIONALE

Retrograde drilling is a well accepted procedure for osteochondral lesion of the talus and subchondral cyst with intact overlying cartilage. It has good results in most reports. Compared to anterograde drilling, retrograde drilling can protect the integrity of the articular cartilage. The purpose of this study was to evaluate the suitability of using retrograde drilling for osteochondral lesion with subchondral cyst and discuss the mechanism involved in the development of subchondral cyst.

PATIENT CONCERNS

We report a 53-year-old man who had complained left ankle pain that lasted over 6 months which was exacerbated by walking.

DIAGNOSES

We diagnosed it as osteochondral lesion of the talus with subchondral cyst.

INTERVENTIONS

Plain X-ray, computed tomography, and magnetic resonance imaging (MRI) of the ankle.

OUTCOMES

He undertook retrograde drilling without debridement of cartilage. After the surgery, the pain had been subsided for 1 year, although arthritic change had progressed. However, after 5 years of retrograde drilling, he revisited our hospital due to severe ankle pain. Plain X-ray and MRI showed arthritic change of the ankle and multiple cystic formation of talus.

LESSONS

Retrograde drilling has some problem because this procedure is not theoretically correct when the development of a subchondral cyst in osteochondral lesion of the talus is considered. In addition, retrograde drilling may impair uninjured bone marrow of the talus, resulting in the development of multiple cystic formations.

Arthroscopic Retrograde Drilling in Juvenile Osteochondritis Dissecans of the Talus

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level IV-therapeutic.

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

INTRODUCTION

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

STUDY DESIGN

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Fluoro-Free navigated retrograde drilling of osteochondral lesions

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

Retrograde drilling of symptomatic osteochondral lesions (OCL) is usually controlled by fluoroscopy. Due to the limited visualization of the OCLs in the acquired images and the narrow access to the talar dome, this approach can be demanding. Several navigation procedures have been reported (2D- or 3D- fluoroscopy or intraoperative CT-based) to increase the accuracy and reduce the radiation exposure. We developed a new arthroscopic-controlled navigation procedure which is free of radiation exposure and free of a reference base rigidly fixed to the bone. We hypothesized that this procedure (Fluoro-Free) is at least as precise as the standard 2D-Fluoro navigation (2D-Fluoro). Furthermore, our first clinical experiences are described and discussed.

MATERIAL AND METHODS

Sixteen drillings per group (standard 2D-Fluoro vs. Fluoro-Free) were performed in artificial sawbones. Times for the different steps of each drilling procedure were recorded and the precision evaluated by measuring the deviation and depth of drilling.

RESULTS

The accuracy of the Fluoro-Free navigation was as precise as the standard 2D-Fluoro based navigation (axis deviation of drill tip to the target point: 1.07 ± 0.11 versus 1.14 ± 0.15 mm). Due to the simplified workflow without radiation exposure and fixation of a reference base, the Fluoro-Free procedure was significantly faster (mean procedure time per drilling: 23.7 ± 11.6 versus 165 ± 9 seconds) and easy to use. Its clinical usefulness was demonstrated during three retrograde drillings of a talar OCL in a 16-year-old patient.

CONCLUSION

The Fluoro-Free navigation procedure is a simplified approach for retrograde drilling of OCL in the talus under arthroscopic control without radiation exposure and without the need for fixation of a dynamic reference base to the bone.