Current management of talar osteochondral lesions

Preoperative and Postoperative Imaging and Outcome Scores for Osteochondral Lesion Repair of the Ankle

Cartilage lesions to the ankle joint are common and can result in pain and functional limitations. Surgical treatment aims to restore the damaged cartilage's integrity and quality. However, the current evidence for establishing best practices in ankle cartilage repair is characterized by limited quality and a low level of evidence. One of the contributing factors is the lack of standardized preoperative and postoperative assessment methods to evaluate treatment effectiveness and visualize repaired cartilage. This review article seeks to examine the importance of preoperative imaging, classification systems, patient-reported outcome measures, and radiological evaluation techniques for cartilage repair surgeries.

Medial cystic osteochondral lesions of the talus exhibited lower sports levels, higher cyst-presence rate, and inferior radiological outcomes compared with lateral lesions following arthroscopic bone marrow stimulation

PURPOSE

To compare the patient-reported outcomes and radiological outcomes of the patients with medial- and lateral-cystic osteochondral lesions of the talus (OLTs) following bone marrow stimulation (BMS).

METHODS

Patients with cystic OLTs who underwent BMS between January 2016 and February 2021 were retrospectively analyzed, and the minimum follow-up time was more than 24 months. Patients were paired in a 1:1 ratio (medial-: lateral-cystic OLT; MC-OLT: LC-OLT) based on the OLT area within 30mm2, follow-up within 1 year, age within 5 years, and ligament surgery (Yes/No). The Visual analog scale, Foot and Ankle Ability Measure (FAAM)-Activities of Daily Life and Sports scores were assessed preoperatively and postoperatively. The magnetic resonance observation of cartilage repair tissue (MOCART) scores, and presence of cysts after BMS were also evaluated. Additionally, the receiver operating characteristic curve was performed.

RESULTS

The matched patients were divided into the MC-OLT(n=31, 43.35±12.32 months) and LC-OLT groups (n=31, 43.32±14.88 months, P=.986). Thirty patients of each group achieved a power of 80% and an α = 0.05 in this study. The MC-OLT group showed significantly less improvement in FAAM-ADL and sports scores (P = .034, P <0.001, respectively), lower MOCART scores (80.80±11.91 vs. 86.00±8.50, P = .010), and higher presence-rate of cyst after BMS (45.16% vs. 16.12%, P = .013). Regarding FAAM sports scores, the LC-OLT group had significantly more patients exceeding the MCID (80.64% vs. 51.61%, P = .031). Furthermore, an OLT depth of 7.23mm (sensitivity: 78.6%; specificity: 70.6%) might serve as a cut-off value for predicting the presence of cysts in medial-cystic OLTs following BMS.

CONCLUSION

Medial cystic OLTs exhibited markedly lower sports levels, higher cyst-presence rate, and inferior radiological outcomes following BMS than lateral counterparts. Additionally, an OLT depth of 7.23mm could be the cut-off value for predicting the presence of cysts regarding medial-cystic OLTs after BMS.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Improvement in Clinical and Radiographic Outcomes After Isolated Realignment Surgery in Patients With Large Cystic Osteochondral Lesion of the Talar Shoulder and Concurrent Malalignment

Background

Malalignment has been suggested as a predisposing factor for the development of osteochondral lesions of the talus (OLTs).

Purpose

To evaluate the clinical and radiographic outcomes of realignment surgery in patients with a large cystic OLT of the talar shoulder and concurrent malalignment of the foot and ankle.

Study Design

Case series; Level of evidence, 4.

Methods

The authors reviewed consecutive patients with large cystic OLTs (diameter, >10 mm) of the talar shoulder and concurrent malalignment of the foot and ankle who underwent realignment surgery between September 2013 and April 2021. The type of realignment procedure was determined based on patient symptoms and findings on plain radiographs and weightbearing computed tomography. Clinical improvement was assessed using pre- and postoperative Foot Function Index (FFI) scores and the visual analog scale (VAS) for pain. The OLT location was categorized according to Raikin zone, and the OLT area and volume were measured and compared pre- and postoperatively. The comparative analysis was performed using the Wilcoxon signed-rank test.

Results

In total, 27 ankles in 27 patients (mean age, 34.4 ± 11.9 years) were included in the analysis. There were 25 patients with a medial lesion (zone 4 [n = 19], zone 7 [n = 5], and zone 1 [n = 1]), and 2 patients with a lateral lesion (zone 6). Despite OLT location, patients' symptoms varied; 15 (55.6%) patients reported both medial- and lateral-sided pain, 10 (37%) reported lateral-sided pain, and 2 (7%) reported medial-sided pain. Supramalleolar osteotomy was performed in 18 patients, while foot and hindfoot correction without supramalleolar osteotomy was performed in 9 patients. Postoperatively, both the median FFI (from 44.4 [interquartile range (IQR), 35.7-52.2] to 9.1 [IQR, 5.2-13.9]) and median VAS pain score (from 6 [IQR, 5-6] to 1 [IQR, 1-2]) improved significantly (P < .0001 for both), and the median lesion size (from 25.8 mm2 [IQR, 19.3-45.2 mm2] to 13.8 mm2 [IQR, 6.8-26.5 mm2]) and median volume (from 2226.8 mm3 [IQR, 1311-3104 mm3] to 1326.5 mm3 [IQR, 714-2100 mm3]) decreased significantly (P < .0001 for both). During the mean follow-up of 4.1 ± 2.1 years, no subsequent surgery for OLT was necessary.

Conclusion

The results suggest that realignment procedures can improve the symptoms and radiographic profile of OLTs in patients with large cystic OLTs of the talar shoulder and malalignment of the foot and ankle.

Development of osteophytes and joint space narrowing is associated with cartilage degeneration of the osteochondral fragment in the osteochondral lesion of the talus

BACKGROUND

During surgery for osteochondral lesions of the talus (OLT), preservation or excision of the osteochondral fragment is chosen based on the cartilage condition which influences the indication and clinical outcomes of surgical treatments. However, it is difficult to predict arthroscopic and histological findings of the cartilage on osteochondral fragments by radiographic evaluation. We focused on osteoarthritis (OA) changes on plain radiographs to predict the cartilage condition of the OLT. This study aimed to evaluate whether OA changes, including osteophyte and joint space narrowing, could predict arthroscopic and histological findings of the cartilage in OLT.

METHODS

Seventy ankles with OLT were included in this study. Osteophytes and joint space narrowing were scored on plain radiographs. Lesion sizes were measured on computed tomography images. The cartilage surfaces of fragments were arthroscopically assessed using the International Cartilage Repair Society (ICRS) grade. Biopsy specimens from 32 ankles were histologically analyzed using the Mankin score. The relationships between OA scores, lesion size, ICRS grades, and Mankin score were analyzed.

RESULTS

OA changes were frequently observed with increasing ICRS grades, especially in the medial tibiotalar joint. OA scores in patients with ICRS grade 1 were significantly lower than those in ICRS grades 2,3, and 4. The lesion sizes in patients with ICRS grade 3 and 4 were significantly smaller than those in patients with ICRS grade 1 and 2. Histological analysis showed increasing Mankin scores as the ICRS grade worsened. A mild correlation existed between the OA and Mankin scores (rs = 0.494).

CONCLUSIONS

OA changes, such as osteophyte formation and joint space narrowing, are associated with arthroscopic findings of the articular surface and cartilage degeneration in osteochondral fragment in OLT. Articular cartilage conditions can be predicted by OA changes on plain radiographs, which is useful for choosing the appropriate treatment for patients with OLT.

LEVEL OF EVIDENCE

Level Ⅳ, case series.

Effectiveness and safety of arthroscopy combined with radial extracorporeal shockwave therapy for osteochondritis of the talus: a prospective, single-centre, randomized, double-blind study

Aims

Arthroscopic microfracture is a conventional form of treatment for patients with osteochondritis of the talus, involving an area of < 1.5 cm2. However, some patients have persistent pain and limitation of movement in the early postoperative period. No studies have investigated the combined treatment of microfracture and shortwave treatment in these patients. The aim of this prospective single-centre, randomized, double-blind, placebo-controlled trial was to compare the outcome in patients treated with arthroscopic microfracture combined with radial extracorporeal shockwave therapy (rESWT) and arthroscopic microfracture alone, in patients with ostechondritis of the talus.

Methods

Patients were randomly enrolled into two groups. At three weeks postoperatively, the rESWT group was given shockwave treatment, once every other day, for five treatments. In the control group the head of the device which delivered the treatment had no energy output. The two groups were evaluated before surgery and at six weeks and three, six and 12 months postoperatively. The primary outcome measure was the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale. Secondary outcome measures included a visual analogue scale (VAS) score for pain and the area of bone marrow oedema of the talus as identified on sagittal fat suppression sequence MRI scans.

Results

A total of 40 patients were enrolled and randomly divided into the two groups, with 20 in each. There was no statistically significant difference in the baseline characteristics of the groups. No complications, such as wound infection or neurovascular injury, were found during follow-up of 12 months. The mean AOFAS scores in the rESWT group were significantly higher than those in the control group at three, six, and 12 months postoperatively (p < 0.05). The mean VAS pain scores in the rESWT group were also significantly lower than those in the control group at these times (p < 0.05). The mean area of bone marrow oedema in the rESWT group was significantly smaller at six and 12 months than in the control group at these times (p < 0.05).

Conclusion

Local shockwave therapy was safe and effective in patients with osteochondiritis of the talus who were treated with a combination of arthroscopic surgery and rESWT. Preliminary results showed that, compared with arthroscopic microfracture alone, those treated with arthroscopic microfracture combined with rESWT had better relief of pain at three months postoperatively and improved weightbearing and motor function of the ankle.

Etiology, Classification, Diagnostics, and Conservative Management of Osteochondral Lesions of the Talus. 2023 Recommendations of the Working Group "Clinical Tissue Regeneration" of the German Society of Orthopedics and Traumatology

METHODS

Peer-reviewed literature was analyzed regarding different topics relevant to osteochondral lesions of the talus (OLTs) treatment. This process concluded with a statement for each topic reflecting the best scientific evidence available for a particular diagnostic or therapeutic concept, including the grade of recommendation. Besides the scientific evidence, all group members rated the statements to identify possible gaps between literature and current clinical practice.

CONCLUSION

In patients with minimal symptoms, OLT progression to ankle osteoarthritis is unlikely. Risk factors for progression are the depth of the lesion on MRI, subchondral cyst formation, and the extent of bone marrow edema. Conservative management is the adaptation of activities to the performance of the ankle joint. A follow-up imaging after 12 months helps not to miss any progression. It is impossible to estimate the probability of success of conservative management from initial symptoms and imaging. Cast immobilization is an option in OLTs in children, with a success rate of approximately 50%, although complete healing, estimated from imaging, is rare. In adults, improvement by conservative management ranges between 45% and 59%. Rest and restrictions for sports activities seem to be more successful than immobilization. Intra-articular injections of hyaluronic acid and platelet-rich plasma can improve pain and functional scores for more than 6 months. If 3 months of conservative management does not improve symptoms, surgery can be recommended.

Emerging role of bone scintigraphy single-photon emission computed tomography/computed tomography in foot pain management

Foot and ankle joints being weight-bearing joints are commonly subjected to wear and tear and are prone to traumatic and other pathologies. Most of these foot and ankle pathologies present with pain. The diagnosis of pathology and localization of pain generators is difficult owing to the complex anatomy of the foot and similar clinical presentation. This makes the management of foot pain clinically challenging. Conventional anatomical imaging modalities are commonly employed for evaluation of any anatomical defect; however, these modalities often fail to describe the functional significance of the anatomical lesions, especially in presence of multiple lesions which is common in ankle and foot; however, hybrid single-photon emission computed tomography/computed tomography (SPECT/CT) by virtue of its dual modalities, that is, highly sensitive functional imaging and highly specific anatomical imaging can serve as a problem-solving tool in patient management. This review attempts to describe the role of hybrid SPECT/CT in overcoming the limitation of conventional imaging and describes its potential application in the management of foot and ankle pain.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

4, case series.

Implications of obesity in patients with foot and ankle pathology

Obesity is a growing problem defined as a body mass index of greater than 30 kg/m². It is predicted that by 2030, 48.9% of adults will be classified as obese which expands surgical risk factors to a broad population while increasing healthcare costs at the same time in different socioeconomic groups. This specific population has been widely studied in multiple surgical fields and published studies have shown the implications in each of these fields. The impact of obesity on orthopedic surgical outcomes has been previously reported in several total hip and knee arthroscopy studies, with evidence indicating that obesity is strongly associated with an increased risk of post operative complications together with higher revision rates. In line with increasing interest on the impact of obesity in orthopedics, there has been a similar output of publications in the foot and ankle literature. This review article evaluates several foot and ankle pathologies, their risk factors associated with obesity and subsequent management. It provides an updated, comprehensive analysis of the effects of obesity on foot and ankle surgical outcomes, with the ultimate aim of educating both surgeons and allied health professionals about the risks, benefits, and modifiable factors of operating on obese patients.

Retrograde Autologous Talar Osteocancellous Bone Grafting for the Treatment of Osteochondral Lesions of the Talus: A Technical Note

Osteochondral lesions of the talus (OLT) are common injuries in young athletes. Various kinds of surgical procedures are available for orthopaedic surgeons, but which surgical technique is the best remains controversial. Many surgical procedures require malleolar osteotomy to obtain appropriate surgical exposure to the OLT because of the anatomic characteristics of the ankle joint. However, malleolar osteotomy is invasive and has a potential risk of complications, such as tibial chondral damage and pseudoarthrosis. This article aims to introduce a novel surgical procedure for the treatment of OLTs: retrograde autologous talar osteocancellous bone grafting without the need for osteotomy and harvesting a graft from anywhere other than the talus. First, an arthroscopic evaluation is performed to verify the location, size, and cartilage quality of the OLT as well as concomitant lesions. After confirming the position of the guide pin using a guide device arthroscopically, a talar osteocancellous bone plug is harvested using a coring reamer. The OLT of the harvested talar bone plug is removed, and under arthroscopy, the talar osteocancellous bone plug is retrogradely inserted into the talar bone tunnel. To stabilize the implanted bone plug, one or two bioabsorbable pins are inserted from the lateral wall of the talus while applying counterforce to the articular surface of the bone plug. The present surgical technique can minimally invasively address the OLT without the need for malleolar osteotomy and harvesting a graft from the knee joint or iliac bone.

Development of convolutional neural network model for diagnosing osteochondral lesions of the talus using anteroposterior ankle radiographs

Deep learning is an advanced machine learning technique that is used in several medical fields to diagnose diseases and predict therapeutic outcomes. In this study, using anteroposterior ankle radiographs, we developed a convolutional neural network (CNN) model to diagnose osteochondral lesions of the talus (OLTs) using ankle radiographs as input data. We evaluated whether a CNN model trained on anteroposterior ankle radiographs could help diagnose the presence of OLT. We retrospectively collected 379 cases (OLT cases = 133, non-OLT cases = 246) of anteroposterior ankle radiographs taken at a university hospital between January 2010 and December 2020. The OLT was diagnosed using ankle magnetic resonance images of each patient. Among the 379 cases, 70% of the included data were randomly selected as the training set, 10% as the validation set, and the remaining 20% were assigned to the test set to evaluate the model performance. To accurately classify OLT and non-OLT, we cropped the area of the ankle on anteroposterior ankle radiographs, resized the image to 224 × 224, and used it as the input data. We then used the Visual Geometry Group Network model to determine whether the input image was OLT or non-OLT. The performance of the CNN model for the area under the curve, accuracy, positive predictive value, and negative predictive value on the test data were 0.774 (95% confidence interval [CI], 0.673-0.875), 81.58% (95% CI, 0.729-0.903), 80.95% (95% CI, 0.773-0.846), and 81.82% (95% CI, 0.804-0.832), respectively. A CNN model trained on anteroposterior ankle radiographs achieved meaningful accuracy in diagnosing OLT and demonstrated that it could help diagnose OLT.

The Efficacy of Microfracture Combined with Extracorporeal Shock Wave Therapy for Treating Osteochondral Lesion of the Talus and the Quality of Regenerated Cartilage: A Retrospective Cohort Study and MRI Assessment

BACKGROUND

osteochondral lesion of the talus (OLT) is a common disease in the physically active population, and extracorporeal shock wave therapy (ESWT) is a noninvasive treatment. We hypothesized that microfracture (MF) combined with ESWT may have great potential to become a novel combination treatment of OLT.

METHODS

the OLT patients who received MF + ESWT or MF + platelet-rich plasma (PRP) injection were retrospectively included, with a minimal follow up of 2y. The daily activating VAS, exercising VAS, and American Orthopedic Foot and Ankle Society Ankle-Hindfoot Score (AOFAS) were used to assess the efficacy and functional outcome, and ankle MRI T2 mapping was used to evaluate the quality of regenerated cartilage in the OLT patients.

RESULTS

only transient synovium-stimulated complications were found during the treatment sessions; the complication rate and daily activating VAS did not have differences between groups. MF + ESWT had a higher AOFAS and a lower T2 mapping value than MF + PRP at the 2y follow up.

CONCLUSIONS

the MF + ESWT had superior efficacy for treating OLT, which resulted in better ankle function and more hyaline-like regenerated cartilage, superior to the traditional MF + PRP.

Talar Dome Osteochondral Lesions: Pre- and Postoperative Imaging

We suggest a similar approach to evaluating osteochondral lesions of the talar dome both pre- and postoperatively. This review addresses the etiology, natural history, and treatment of talar dome osteochondral lesions with an emphasis on imaging appearances. High-resolution magnetic resonance imaging, ideally combining a small field-of-view surface coil with ankle traction, optimizes visibility of most of the clinically relevant features both pre- and postoperatively.

Simultaneous Treatment of Osteochondral Lesion Does Not Affect the Mid- to Long-Term Outcomes of Ligament Repair for Acute Ankle Sprain: A Retrospective Comparative Study with a 3–11-Year Follow-up

Purpose

This study aims to evaluate the mid- to long-term outcome of concurrent arthroscopic treatment of osteochondral lesion (OCL) and open anatomical repair of lateral ankle ligaments for severe acute ankle sprain patients and compare them to the outcome of those without OCL.

Methods

A total of 166 patients with grade III acute lateral ankle ligament injuries underwent concurrent ankle arthroscopy and open anatomic ligament repair. Forty-three patients (group A) with OCL underwent arthroscopic treatment followed by open ligament repair. A total of 105 patients (group B) without OCL were followed up as the control. The evaluation parameters included sports recovery, postoperative visual analog scale (VAS) pain score, American Orthopaedic Foot and Ankle Society (AOFAS) score, Tegner score, sprain recurrence, satisfaction, and range of motion. Patients in group A were then subgroup-analyzed according to age, sex, body mass index, injury side, OCL location, and stage (Ferkel and Cheng’s staging system).

Results

The postoperative exercise level of the two groups recovered to more than 90% of the normal level (91.2% ± 11.2% in group A and 90.9% ± 13.3% in group B, n.s.). The average time of group A and group B to return to preinjury sports activity was respectively 4.4 ± 1.0 months and 4.4 ± 1.2 months with no significant difference (p = 0.716). No significant differences were found in the preoperation VAS pain score, AOFAS score, and Tegner score between the two groups. The postoperative VAS pain score in group A was significantly higher than that in group B (0.8 ± 1.7 vs. 0.3 ± 0.8, p = 0.027), but the difference was not clinically important. The postoperative VAS pain score of patients with stage D–F lesions was significantly higher than that of patients with stage B–C lesions (1.3 ± 2.1 vs. 0.3 ± 0.9, p = 0.038).

Conclusions

For the severe acute ankle sprain combined with OCL, the simultaneous arthroscopic treatment and open lateral ankle ligament repair achieved good mid- to long-term outcomes. Except that the pain was more pronounced than in the control group, there were no differences in other outcomes. Postoperative pain was positively correlated with the grade of OCL.

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

Background

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

Methods

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

Results

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

Conclusion

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

Level of Evidence

Level III, a retrospective comparative study.

Triplane osteotomy combined with talar non-weight-bearing area autologous osteochondral transplantation for osteochondral lesions of the talus

Background

Traditional medial malleolar osteotomy combined with autologous osteochondral transplantation (AOT) is mostly used in the treatment of osteochondral lesions of the talus (OLTs), but with high osteotomy and donor site complications. We hypothesis a new triplane medial malleolar osteotomy combined with AOT from non-weight-bearing area of the talus could be a promising choice for OLTs.

Methods

We reviewed all the symptomatic OLTs patients who received AOT with triplane osteotomy of the medial malleolus between September 2015 and December 2017 in our department. According to the inclusion and exclusion criteria, 23 patients (23 ankles), including 14 males and 9 females, were included in the study. The mean age was 35.6 years. The mean size of the lesion area was 141.5 mm². According Ferkel’s classification, including 5 type I, 11 typeIIa and 7 typeIIb. The visual analog scale (VAS) for pain during walking and the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score were used for the pre- and postoperative evaluations. In addition, the incorporation of the grafts was assessed by computed tomography (CT).

Results

All patients had a minimum follow-up of 22 months, with an average of 37.1 months. The mean time from osteotomy to full weight-bearing activity was 8.1 ± 2.3 weeks (range, 5–12 weeks). The mean VAS score improved from 5.6 ± 0.7 preoperatively to 0.7 ± 1.0 postoperatively (P < 0.01). The AOFAS ankle-hindfoot score improved significantly in all domains (P < 0.01). Twenty-one patients returned to sport at their previous level, and 2 returned at a lower level compared with preinjury (mean return to play, 7.4 months). According to CT, the medial malleolus recovered in all patients, and the graft was incorporated well. One patient suffered from flexor hallucis longus tendon discomfort due to internal fixation screw irritation posteromedial to the ankle. The general complication rate was 4.3% (1/23).

Conclusions

These results indicate that AOT combined with medial malleolus triplane osteotomy maybe a viable option for OLTs. Patients could perform weight-bearing exercise and return to sport as early as possible, with a lower rate of complications at the osteotomy site and donor site. However, the large sample well-designed prospective comparative studies are still needed.

Medial Transmalleolar Portal Technique for Ankle Arthroscopic Headless Screw Fixation of Talar Osteochondritis Dissecans Lesions

This article describes a technique for arthroscopic fixation of an osteochondritis dissecans (OCD) lesion of the medial talar dome with headless compression screws. This technique involves creation of a medial transmalleolar portal using a guide and drill. The medial transmalleolar portal grants perpendicular access for screw fixation of OCD lesions in addition to the potential for osteochondral autograft transplantation (OAT). Advantages include access to the medial talar dome without performing a medial malleolar osteotomy. After completion of OCD fixation, an inverted osteochondral plug can be used to backfill the portal.

Osteochondritis dissecans of the talar dome in patients with tarsal coalition

OBJECTIVE

Tarsal coalition is known to cause abnormal talocrural stress, hindfoot malalignment, and ankle sprains. These can all be associated with osteochondritis dissecans (OCD) of the talar dome. We present the first detailed description of a series of talar OCDs occurring in patients with tarsal coalition, with the goal of determining whether there is an increased prevalence of OCDs among patients with tarsal coalition.

MATERIALS AND METHODS

We studied ankle MRIs in 57 patients with tarsal coalitions, excluding those with a reported inciting traumatic event. The MRIs were performed on magnetic field strengths ranging from 0.3 to 1.5 T and included axial, coronal, and sagittal T1 and T2 or PD fat-suppressed sequences. We evaluated the morphology and location of classically described OCDs in these patients, type and location of concomitant tarsal coalition, and, when available, the presence of pes planus and hindfoot valgus on weight-bearing radiographs. Chi-squared analysis was used to compare categorical variables and a Student's t test was used for parametric continuous variables. Additionally, logistic regression was used to compute the odds ratio of talar OCD associated with patient age, gender, laterality, pes planus status, hindfoot valgus status, and coalition type.

RESULTS

Eighty-nine percent of tarsal coalitions were non-osseous coalitions and the calcaneonavicular space was the most common site of abnormal tarsal connection (54.4%). In the 29 patients with tarsal coalitions and talar OCDs, OCDs commonly occurred medially (75.9%). In the sagittal plane, talar OCDs occurred centrally, with only one case sparing the central talar dome. The mean surface area of the 29 OCDs was 89.7 mm². Both osseous coalition and hindfoot valgus were associated with smaller talar OCD mean surface area (p = 0.015 and p = 0.0001, respectively). There was no association between depth and surface area of talar OCD with either coalition location or presence of pes planus (coalition location: p = 0.455 for depth and p = 0.295 for surface area; presence of pes planus: p = 0.593 for depth and p = 0.367 for surface area).

CONCLUSION

Talar OCD prevalence is higher in patients with tarsal coalition than that reported for the general population. This occurrence may relate to altered biomechanics and repetitive talocrural stress owing to altered subtalar motion, particularly given the findings of increased odds of talar OCD in older patients, as well as weak associations between OCD surface area and both non-osseous coalition and hindfoot alignment. However, we did not find any specific OCD morphologic features attributable to the precise location of the tarsal coalition.

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.

Sufficient Cartilage for Most Talar Articular Defects Can Be Harvested From the Non-Loadbearing Talus: A Cadaveric Analysis

Purpose

To assess the quantity of morselized cartilage that can be harvested from the non–load-bearing portion of the talus for immediate reimplantation.

Methods

Non–load-bearing talar cartilage was harvested from 5 cadaveric specimens using a standard arthroscopic approach. Cartilage was separated from the talus in maximum dorsiflexion at the junction of the talar head and neck, grasped, and morselized into a graft using a cartilage particulator. The volume of reclaimed cartilage was measured, and the extrapolated area of coverage was compared to average osteochondral lesions of the talus previously reported.

Results

The total yield of cartilage graft following processing that was obtained from 5 ankle joints ranged from 0.3 mL to 2.1 mL with a mean volume of 1.3 ± 0.7 mL, yielding a theoretical 13.2 ± 7.1 cm² coverage with a 1-mm monolayer. While the average size of osteochondral lesions of the talus is difficult to estimate, they may range from 0.5 cm² to 3.7 cm² according to the literature.

Conclusions

This study validated that it is possible to harvest sufficient amount of cartilage for an autologous morselized cartilage graft via a single-stage, single-site surgical and processing technique to address most talar articular cartilage defects.

Clinical Relevance

Particulated cartilage autografts have shown promise in surgical management of cartilage defects. A single-site, single-staged procedure that uses a patient’s autologous talar cartilage from the same joint has the potential to reduce morbidity associated with multiple surgical sites, multistaged procedure, or nonautologous tissue in ankle surgery.

Internal Fixation of a Lateral Inverted Osteochondral Fracture of the Talus (LIFT) Lesion Using an Innovative Surgical Approach: Inverting the Capsulo-Lateral Fibulotalocalcaneal Ligament (LFTCL)-Fibular Periosteum Complex

Osteotomy of the distal fibula or anterolateral corner of the tibia is usually required to fix a displaced osteochondral fracture of the talus that is located central to posterior area of the lateral talar dome. However, osteotomy is an invasive procedure and is associated with complications, including nonunion, persistent pain, and hardware-related problems. Lateral inverted osteochondral fracture of the talus (LIFT) lesion is an extremely rare type of displaced osteochondral lesion of the talus. We describe a case in which a LIFT lesion was fixed using an innovative surgical approach, inverting capsulo-lateral fibulotalocalcaneal ligament (LFTCL)-fibular periosteum complex, with a favorable short-term clinical outcome.

Long-term Outcomes of Microfracture for Treatment of Osteochondral Lesions of the Talus

BACKGROUND

Microfracture is the most common reparative surgery for osteochondral lesions of the talus (OLTs). While shown to be effective in short- to midterm outcomes, the fibrocartilage that microfracture produces is both biomechanically and biologically inferior to that of native hyaline cartilage and is susceptible to possible deterioration over time following repair. With orthobiologics being proposed to augment repair, there exists a clear gap in the study of long-term clinical outcomes of microfracture to determine if this added expense is necessary.

METHODS

A retrospective review of patients undergoing microfracture of an OLT with a single fellowship-trained orthopedic surgeon from 2007 to 2009 was performed. Patients meeting the inclusion criteria were contacted to complete the Foot and Ankle Ability Measure (FAAM) Activities of Daily Living (ADL) and Sports subscales and visual analog scale (VAS) for pain, as well as surveyed regarding their satisfaction with the outcome of the procedure and their likelihood to recommend the procedure to a friend with the same problem using 5-point Likert scales. Patient demographics were reviewed and included for statistical analysis.

RESULTS

Of 45 respondents, 3 patients required additional surgery on their ankle for the osteochondral defect, yielding a 10-year survival rate of 93.3%. Of surviving cases, 90.4% (38/42) reported being "extremely satisfied" or "satisfied" with the outcome of the procedure. The VAS score at follow-up averaged 14 out of 100 (range, 0-75), while the FAAM-ADL and FAAM-Sports scores averaged 90.29 out of 100 and 82 out of 100, respectively. Thirty-six patients (85.7%) stated that their ankle did not prevent them from participating in the sports of their choice.

CONCLUSION

The current study represents a minimum 10-year follow-up of patients undergoing isolated arthroscopic microfracture for talar osteochondral defects, with a 93.3% survival rate and 85.7% return to sport. While biological adjuvants may play a role in improving the long-term outcomes of microfracture procedures, larger and longer-term follow-up studies are required for procedures using orthobiologics before their cost can be justified for routine use.

LEVEL OF EVIDENCE

Level IV, retrospective cohort case series study.

Large variation in management of talar osteochondral lesions among foot and ankle surgeons: results from an international survey

PURPOSE

Surgeons management of osteochondral lesions of the talus (OLT) may be different to the published guidelines because not all treatment recommendations are feasible in every country. This study aimed to assess how OLT are managed worldwide by foot and ankle surgeons.

METHODS

A web-based survey was distributed to the members of 21 local and international scientific societies focused on foot and ankle or sports medicine surgery. Answers with a prevalence greater than 75% of respondents were considered a "main tendency", whereas where prevalence exceeded 50% of respondents they were considered a "tendency".

RESULTS

A total of 1804 surgeons from 79 different countries returned the survey. The responses to 19 of 28 questions (68%) regarding management and treatment of OLT achieved a main tendency (> 75%) or a tendency (> 50%). Symptoms reported to be most suspicious for OLT were pain on weight-bearing (WB) and after activity (83%), deep localization of the pain (62%), and any history of trauma (55%). 89% of surgeons routinely obtain an MRI, 72% routinely get WB radiographs, and 50% perform a CT scan. When treated surgically, OLTs are managed in isolation by only 7% of surgeons, and combined with ligament repair or reconstruction by 79%; 67% report simultaneous excision of soft-tissue or bony impingements (64%). For lesions less than 10-15 mm in diameter, bone marrow stimulation (BMS) represents the first choice of treatment for 78% of surgeons (main tendency). No other treatment was recorded as a tendency. For lesions greater than 15 mm in diameter no tendencies were recorded. The BMS represented the most preferred treatment being the first choice of treatment for 41% of surgeons. OLT depth had little influence on treatment choice: 71% of surgeons treating small lesions and 69% treating large lesions would choose the same treatment regardless of whether the lesion had a depth lesser or greater than 5 mm.

CONCLUSION

The management of OLT by foot and ankle surgeons from around the world remains extremely varied. The main clinical relevance of this study is that it provides updated information with regard to the management of OLT internationally, which could be used by surgeons worldwide in their decision-making and to inform the patient about available surgical options.

LEVEL OF EVIDENCE

Level IV.

Editorial Commentary: Osteochondral Lesions of the Talus: All, Nothing, or Something in Between

Osteochondral lesions of the talus occur with relatively frequency, often as the sequelae of benign ankle sprains, and are only surpassed by the knee and elbow as more common locations. While microfracture of the talus is the most common first-line surgical treatment performed at the time of ankle arthroscopy, marrow stimulation alone results in fibrocartilaginous repair tissue rather than true hyaline-like articular cartilage. In addition, the benefits of bone marrow stimulation for the treatment of large (>150 mm²), deep (>7 mm), or cystic lesions is limited. Autologous osteochondral transplant has emerged as one such treatment option for large lesions that may address underlying bone loss and reconstitute articular cartilage. The utility of autologous osteochondral transplant also must be interpreted with an understanding of the potential complications, including donor-site morbidity. In addition, it is important to decompress, curettage, and back fill associated cysts with bone graft. When cysts are not treated aggressively, patients may have ongoing bone marrow edema and pain.

Long-term results of osteochondral autograft transplantation of the talus with a novel groove malleolar osteotomy technique

Objectives

This study aims to evaluate the long-term results of osteochondral autograft transfer (OAT) of talar lesions performed using a modified osteotomy technique.

Patients and methods

This retrospective study included 20 consecutive patients (11 males, 9 females; mean age 33.5±11 years; range, 15 to 56 years) (21 ankles) with osteochondral lesions of the talus (OLT) treated with the OAT system between August 2002 and October 2008. We performed a modified sulcus groove osteotomy, which provides better exposure of medial and central lesions. After a minimum duration of 10 years following surgery, patients’ clinical functions were evaluated according to the American Orthopaedic Foot and Ankle Society (AOFAS) ankle- hindfoot scale and visual analog scale (VAS). The Tegner-Lysholm scoring system was used to determine the levels of knee activity.

Results

The mean follow-up period was 143.5 (range, 120 to 186) months. The mean AOFAS scores significantly improved from 60.4±7.4 (range, 48 to 70) preoperatively to 86.2±9.23 (range, 60 to 94) at the last follow-up (p≤0.05). The mean ankle VAS score significantly decreased from 6.3±0.4 (range, 5 to 7) preoperatively to 2.0±1.4 (range, 0 to 4). The mean Tegner-Lysholm score for this group was 89.7±11.7 (range, 68 to 100). Revision surgery was performed in only two patients because of impingement and arthritis. Recurrent knee pain at the donor site of the osteochondral autograft was observed in three patients (14%).

Conclusion

In the present study, good to excellent results were obtained in the treatment of OLT with OAT for a minimum follow-up duration of 10 years. This novel technique can also simplify the steep learning curve, which is challenging for surgeons.

Unstable malleolar ankle fractures: evaluation of prognostic factors and sports return

INTRODUCTION

Ankle malleolar fractures are one of the most common surgical fractures. The literature about ankle fracture sport related is reduced. Severe fractures, fractures-dislocations, syndesmosis lesions, associated osteochondral lesions, postoperative complications, as well as age are associated in several studies with worse functional results and may, therefore, also be associated with a lower rate of sports return. This study aims to retrospectively assess the return to physical activity at the level prior to injury in individuals undergoing surgical treatment of unstable malleolar ankle injuries and to identify risk factors associated with a non-return.

MATERIALS AND METHODS

We retrospectively evaluated between January 2008 and December 2017, patients with an unstable malleolar fracture of the ankle surgically treated, recreational or competitive sportsman with a minimum follow-up of one year. Demographic data, fracture classification according to AO classification, presence/absence of osteochondral lesion, presence/absence of unstable syndesmosis lesion, associated dislocation, type of surgery, postoperative complications, functional outcome evaluation with the AOFAS score and sports return.

RESULTS

92 patients met the inclusion criteria. The mean AOFAS score observed was 90.93 (67-100). 69.7% of patients returned without limitations in performing physical activity. 21.75% returned with limitations and 8.7% did not return to physical activity. No association was observed between age, sex, syndesmosis lesion and greater risk of not returning to physical activity. Patients with bimalleolar or trimalleolar fractures, osteochondral injury, or associated dislocation presented an increased risk of inferior functional score and non-return sporting activity.

CONCLUSIONS

Bimalleolar and trimalleolar fractures, associated presence of dislocation and osteochondral lesions are associated with worse clinical outcome and lower return onset.

Posteromedial Approach for Osteochondral Lesions of the Talus

BACKGROUND

Medial malleolar osteotomy is an established procedure for accessing the medial localized osteochondral lesions of the talus. The purpose of this study was to describe a single approach, which allows perpendicular access to the lesion without a malleolar osteotomy.

METHODS

Six patients were treated surgically for medial localized talar osteochondral lesions. Four patients had stage III and 2 patients had stage IV lesions. A single posteromedial approach was used for accessing the medial talar dome.

RESULTS

The method of treatment was mosaicplasty in 4 patients and osteochondral fragment fixation in 2 patients. One patient who was treated with a fragment fixation procedure showed screw loosening. Incorporation of the osteochondral grafts was proved by magnetic resonance imaging in all mosaicplasty cases.

CONCLUSION

A single posteromedial approach was sufficient in the posteromedial localized osteochondral lesion of the talus. As the lesion was approached by soft tissue exposure only, a malleolar osteotomy was not required. Thus, osteotomy-related complications were avoided.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Finite Element Analysis of the Effect of Talar Osteochondral Defects of Different Depths on Ankle Joint Stability

Background

Talus cartilage injury leads to changes in biomechanics of the ankle joint and ultimately affects ankle joint function, but which talus cartilage defects require surgery is still uncertain. This research used a finite element method to simulate the effect of different depth of talus cartilage defects on the stress and stability of the ankle joint in a certain area.

Material/Methods

A three-dimensional finite element model with different depths of osteochondral defects was created to simulate and calculate joint stress and displacement of the articular surface of the distal tibia and the proximal talus while the ankle joint was in the push-off, midstance, and heel-strike phases.

Results

The equivalent stress of the proximal talus did not change significantly at a defect depth of 1 mm, whereas the equivalent stress of the upper talus increased significantly at a defect depth of ≥3 mm or more, reaching a maximum value at a defect depth of 10 mm. The equivalent stress of the tibial cartilage and the equivalent stress and displacement in the corresponding forces in the midstance phase and heel-strike phase were significantly different from those in the normal group, but the difference in stress in each defect group was not obvious.

Conclusions

The effect of cartilage defects of the talus on biomechanics of the ankle is clear, especially in the midstance and push-off phases. When the defect reaches the subchondral bone (at a depth of 3 mm), the most obvious change in ankle joint stability occurs, and it does not increase linearly with the increase in depth of the defect.

Evidence on ankle injections for osteochondral lesions and osteoarthritis: a systematic review and meta-analysis

PURPOSE

To evaluate the evidence supporting safety and effectiveness of intra-articular injective treatments for ankle lesions ranging from osteochondral lesions of the talus (OLT) to osteoarthritis (OA).

METHODS

A systematic review and a meta-analysis were performed on PubMed, Embase, and Cochrane Library in March 2020. Safety was evaluated through the reported side effects and effectiveness through the scores used. The quality of the studies was assessed using the Cochrane Collaboration Risk of Bias 2.0 tool and the Downs and Black checklist. For each outcome, the quality of evidence was graded according to GRADE guidelines.

RESULTS

Twenty-four studies (21 for OA, 3 for OLT) were included on hyaluronic acid (HA), platelet-rich plasma (PRP), saline, methylprednisolone, botulinum toxin type A (BoNT-A), mesenchymal stem cells (MSCs), and prolotherapy. No severe adverse events were reported. For OLT, a comparison was possible between HA and PRP showing no significant difference. For ankle OA, a significant difference favouring HA versus saline was documented at six months (p < 0.001). The GRADE level of evidence was very low.

CONCLUSION

This meta-analysis supports the safety of intra-articular treatment for ankle OA and OLT, while only a very low evidence supports the efficacy of HA in terms of better results versus placebo for the treatment of ankle OA, and other conclusions are hindered by the scarcity of the available literature. This urges further and stronger trials to specifically investigate potential and limitations of these different injective approaches for the treatment of OLT and ankle OA.

Platelet rich plasma for treatment of osteochondral lesions of the talus: A systematic review of clinical trials

BACKGROUND

The ankle is the second most frequent site, following the knee, that requires cartilage repair. Osteochondral lesion of the talus (OLT) is common among athletes and is a result of talar cartilage detachment with or without subchondral bone fragmentation after a traumatic event. Treatment strategies for OLT can be classified as reparative or replacement interventions, with the former taking precedence. Recent studies show that the growth factors and bioactive components in platelet rich plasma (PRP) could improve cartilage regeneration. The prospect of using autologous blood to obtain a product that could enhance regeneration in damaged cartilage has been regarded as innovative, as it could circumvent the need for a replacement, and potentially join the ranks of first line reparative interventions against cartilage diseases.

METHODS

Literature searches were performed across seven search engines for randomized controlled trials using PRP to treat patients with OLT. Outcomes extracted included ankle function and pain measures. Level of evidence and methodological quality were evaluated using relevant guidelines.

RESULTS

Four studies met the eligibility criteria and were systematically appraised. Two studies scored Level 1 and 2 scored Level 2 based on the LOE assessment. MQOE evaluation revealed one study with excellent quality, and three with good quality. Overall results showed that PRP, as an adjunct to microfracture surgery, significantly improved function and reduced pain compared to microfracture surgery alone. Intra-articular PRP injection also demonstrated significantly enhanced recovery of function, and decreased pain scores compared to HA.

CONCLUSION

PRP improves joint function, and reduces pain in patients with OLT regardless of the method of implementation. In addition, inter-study comparison demonstrated that patients that received surgery along with PRP injections improved more than those that received PRP only. The studies that corroborate this conclusion have high levels of evidence with satisfactory methodological quality.

LEVEL OF EVIDENCE

Level 2, systematic review of Level 1 and 2 studies.

[Micro-fracture therapy combined with intra-articular injection of platelet-rich plasma for small sized osteochondral lesion of the talus]

OBJECTIVE

To investigate the effectiveness of micro-fracture therapy combined with intra-articular injection of platelet-rich plasma (PRP) in the treatment of small sized osteochondral lesion of the talus (OLT).

METHODS

Between September 2014 and October 2017, 43 patients with small sized OLT met the inclusive criteria were admitted and randomly divided into micro-fracture group (21 cases) and combined group (22 cases). Patients in the micro-fracture group were treated with micro-fracture therapy, and patients in the combined group were treated with micro-fracture therapy combined with intra-articular injection of PRP. There was no significant difference in gender, age, disease duration, side of OLT, injured position, lesion area, Mintz classification, and preoperative American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hind foot score and visual analogue scale (VAS) score between the two groups ( P>0.05). After treatment, MRI, VAS score, and AOFAS ankle-hind foot score were used to evaluate the recovery of OLT and the ankle function.

RESULTS

All incisions healed by first intention, and no complications such as venous thrombosis and ankle joint infection occurred. All patients were followed up 12-18 months after operation, with an average of 15.6 months. The VAS scores and the AOFAS ankle-hind foot scores were significantly improved at 6 and 12 months after operation in the two groups ( P<0.05), and the scores at 12 months were significantly improved when compared with postoperative scores at 6 months ( P<0.05). Compared with the micro-fracture group, the VAS score and the AOFAS ankle-hind foot score were significantly improved in the combined group at 6 and 12 months after operation ( P<0.05). MRI showed that OLT was well filled in both groups at 12 months after operation.

CONCLUSION

Compared with micro- fracture therapy, micro-fracture therapy combined with intra-articular injection of PRP can effectively reduce pain, improve ankle function, and has a good effectiveness in the treatment of small sized OLT.

Arthroscopic Microfracture for Osteochondral Lesions of the Talus: Functional Outcomes at a Mean of 6.7 Years in 165 Consecutive Ankles

BACKGROUND

Arthroscopic microfracture for osteochondral lesions of the talus (OLT) has shown good functional outcomes. However, some studies have reported that functional outcomes deteriorate over time after surgery.

PURPOSE

To use various functional scoring systems to evaluate functional outcomes in a large sample of patients with OLT treated by arthroscopic microfracture.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

The study cohort consisted of 165 ankles (156 patients) that underwent arthroscopic microfracture for small to mid-sized OLT. The mean lesion size was 73 mm² (range, 17-146 mm²), and the mean follow-up period was 6.7 years (range, 2.0-13.6 years). The Foot and Ankle Outcome Score (FAOS), American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scale, visual analog scale (VAS) for pain, and 36-Item Short Form Health Survey (SF-36) were used to compare the functional outcomes between the preoperative and final follow-up assessments.

RESULTS

The mean FAOS significantly improved in regard to all subscores (P < .001). The AOFAS ankle-hindfoot scale showed an improvement from 71.0 points (range, 47.0-84.0) preoperatively to 89.5 points (range, 63.0-100) at the final follow-up (P < .001). The VAS score showed an improvement from 6.2 points (range, 4.0-9.0) preoperatively to 1.7 points (range, 0-6.0) at the final follow-up (P < .001). The mean SF-36 score improved from 62.4 points (range, 27.4-76.6) preoperatively to 76.2 points (range, 42.1-98.0) at the final follow-up (P < .001). Among 165 ankles, 22 ankles (13.3%) underwent repeat arthroscopic surgery for evaluation of repaired cartilage status.

CONCLUSION

Arthroscopic microfracture showed good functional outcomes and improved quality of life with maintenance of satisfactory outcomes at a mean follow-up of 6.7 years. Therefore, arthroscopic microfracture seems to be reliable as a first-line treatment for OLT at an intermediate-term follow-up.

Clinical Results of Bioabsorbable Pin Fixation Relative to the Bone Condition for Osteochondral Lesion of the Talus

BACKGROUND

Fixation of an osteochondral lesion of the talus (OLT) can restore the natural congruency of the joint surface with hyaline cartilage. In this procedure, the bone condition of the osteochondral fragment is important for stabilizing the lesion, and it may affect clinical outcomes. The aim of this study was to explore the influence of the fragment's bone condition on clinical outcomes.

METHODS

Eighteen ankles in 17 patients with a mean age of 20.1 years, which had undergone fixation of an OLT using bioabsorbable pins, were included. Based on the fragment's bone condition on preoperative computed tomography scans, ankles were divided into 3 groups: normal, segmentation, and absorption. The American Orthopaedic Foot & Ankle Society (AOFAS) scale and magnetic resonance imaging (MRI) findings were evaluated both pre- and postoperatively. Second-look arthroscopic findings were evaluated in 15 ankles and were compared with biopsy specimens from the initial surgery.

RESULTS

The AOFAS scale significantly improved at the final follow-up in all groups with no significant differences among the 3 groups. MRI at 1 year showed good bone incorporation and a congruent cartilage surface in all groups, but the bone marrow lesion in the absorption group was significantly larger than that in the other groups. In second-look arthroscopy, all ankles showed stable and near-normal cartilage. There was no significant correlation between arthroscopic and histological findings.

CONCLUSION

We found that fixation can be considered when there is a good cartilage surface on a large OLT, even if bone absorption in the fragment exists.

LEVEL OF EVIDENCE

Level III, comparative study.

Return to Sport After Arthroscopic Autologous Matrix-Induced Chondrogenesis for Patients With Osteochondral Lesion of the Talus

OBJECTIVE

To determine the rate of return of patients to sport after arthroscopic autologous matrix-induced chondrogenesis (AT-AMIC) for outcomes 2 years after surgery.

DESIGN

Retrospective observational cross-sectional study.

SETTING

C.A.S.C.O.-Foot and Ankle Unit, Istituto Ortopedico Galeazzi, Milan, Italy.

PATIENTS AND INTERVENTION

Twenty-six consecutive patients, 65.4% male (mean ± SD age: 33.7 ± 11.0 years), that underwent AT-AMIC procedure between 2012 and 2015 were selected retrospectively. From this population, only sporting patients at amateur's level were included. Arthroscopic autologous matrix-induced chondrogenesis was proposed in patients with pain and persistent disability.

MAIN OUTCOME MEASURES

All patients were assessed with the American Orthopaedic Foot and Ankle Score (AOFAS), physical component score of the 12-Item Short Form Health Survey (SF-12), Halasi ankle activity score, and University of California, Los Angeles (UCLA) activity scale preoperatively and at 24 months postoperatively.

RESULTS

Overall, 80.8% of the patient group returned to the same preinjury sport. The mean follow-up was 42.6 ± 10.9 months (range from 25 to 62 months). Significant differences were observed with reference to AOFAS, SF-12, Halasi, and UCLA scores at the last follow-up in patients who had undergone AT-AMIC (all, P < 0.001).

CONCLUSIONS

A high percentage of patients return to their preinjury sport after AT-AMIC surgery.

[Research progress in surgical procedures for osteochondral lesions of talus]

Objective

To summarize the research progress of surgical procedures in osteochondral lesions of the talus (OLT).

Methods

By consulting the related literature of OLT in recent years, the advantages and disadvantages of various surgical treatment schemes were analyzed and summarized.

Results

There are many surgical treatments for OLT, including bone marrow stimulation, osteochondral transplantation, autologous chondrocyte transplantation, and biologically assisted therapy. Various schemes have different indications and limitations. With the continuous development of various technologies, the effectiveness of OLT treatment will gradually improve.

Conclusion

There are still many difficulties and controversies in the treatment of OLT, and there is no unified treatment plan. It is suggested that individualized operation plan should be formulated according to the specific conditions of patients.

Large Osteochondral Lesions of the Talus Treated With Autologous Bone Graft and Periosteum Transfer

Background:

The treatment of large osteochondral lesions of the talus (OLTs) is challenging due to the poor intrinsic reparative capability of the damaged articular cartilage. Autologous transfer of bone and periosteum has been used successfully in the treatment of large defects in animals, and therefore it was believed that this technique might show similar results in humans. The purpose of this study was to assess the outcome of an innovative technique for autologous transplantation of cancellous tibial graft with periosteal transfer in large OLTs.

Methods:

Forty-one patients (22 females, 19 males), with a mean age of 34.9 years (range, 18-72 years), with a large OLT (>200 mm²) were treated with autologous bone graft and periosteum transfer. OLTs averaging 310 mm² were identified on a preoperative computed tomography scan. The procedure consisted of malleolar osteotomy, curettage of sclerotic bone, autologous bone graft from the proximal tibia, and transfixion of periosteum over the graft. Outcome measures, including the pain visual analog scale (VAS), ankle range of motion (ROM), American Orthopaedic Foot & Ankle Society (AOFAS) score, and Foot & Ankle Disability Index (FADI), were compared between preoperative and 1 and 2 years following surgery.

Results:

There were significant improvements in VAS pain score from 7.7 before surgery to 1.1 at 1 year after surgery and 0.4 at 2 years or more after surgery. The AOFAS and FADI scores were also significantly improved from 40.3 and 53.3 preoperatively to 95 and 93.2 postoperatively at 1 year and 95 and 93.2 at 2 or more years postoperatively, respectively. Postoperative complications included 2 patients who required removal of medial malleolar osteotomy tension bands due to symptomatic hardware. There were no nonunions or malunions of the osteotomies and no donor site complications.

Conclusion:

Autologous bone graft and periosteum transfer was an effective treatment for large OLTs leading to significant decreases in pain and improvement in functional scores at more than 2 years after surgery.

Level of Evidence:

Level IV, retrospective case series.

Microfracture provides better clinical results than debridement in the treatment of acute talar osteochondral lesions using arthroscopic assisted fixation of acute ankle fractures

PURPOSE

Ankle arthroscopy is a useful tool for detection and treatment of accompanying intraarticular pathologies in acute ankle fractures. The purpose of this study was to compare the treatment results of talus osteochondral lesions (OLT) with debridement and microfracture in arthroscopy assisted surgery of acute ankle fractures.

METHODS

Eleven consecutive patients who were treated with arthroscopic acute debridement and 14 consecutive patients who were treated with arthroscopic acute microfracture in the treatment of ankle fracture were included in the study. All patients were controlled clinically and radiologically in the postoperative period. Ankle pain was evaluated with the visual analog score (VAS), ankle functions were assessed with American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale (AOFAS), and osteoarthritic changes were analyzed with Van Dijk score.

RESULTS

There was no significant difference between the groups in terms of age, gender, injury side and trauma mechanism (n.s). Mean time to surgery, fracture healing duration, first weight-bearing and full weight-bearing, follow-up period and Van Dijk score were all similar in both groups (n.s). The AOFAS score and VAS activity score were statistically significantly better in the microfracture group (p = 0.044 and p = 0.001).

CONCLUSIONS

The clinical relevance of the present study is to define the acute treatment of the first osteochondral damage that occurred simultaneously with ankle fracture, to improve postoperative functional outcomes and to prevent post-traumatic osteoarthritis. Both debridement and microfracture yield good functional outcomes in the second year of the treatment. Microfracture ensures significantly more successful clinical results than debridement.

LEVEL OF EVIDENCE

Level III.

Diagnosis: History, Physical Examination, Imaging, and Arthroscopy: Proceedings of the International Consensus Meeting on Cartilage Repair of the Ankle

BACKGROUND

The evidence supporting best practice guidelines in the field of cartilage repair of the ankle are based on both low quality and low levels of evidence. Therefore, an international consensus group of experts was convened to collaboratively advance toward consensus opinions based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article is to report the consensus statements on "Diagnosis: History, Physical Examination, Imaging, and Arthroscopy" developed at the 2017 International Consensus Meeting on Cartilage Repair of the Ankle.

METHODS

Seventy-five international experts in cartilage repair of the ankle representing 25 countries and 1 territory were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within 11 working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed upon in unanimous fashion within the working groups. A final vote was then held, and the strength of consensus was characterized as follows: consensus: 51 - 74%; strong consensus: 75 - 99%; unanimous: 100%.

RESULTS

A total of 12 statements on the diagnosis of cartilage injuries of the ankle reached consensus during the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. Two achieved unanimous support and 10 reached strong consensus (greater than 75% agreement). All statements reached at least 86% agreement.

CONCLUSIONS

This international consensus derived from leaders in the field will assist clinicians in the diagnosis of cartilage injuries of the ankle.

Primary Versus Secondary Osteochondral Autograft Transplantation for the Treatment of Large Osteochondral Lesions of the Talus

BACKGROUND

Recent studies have reported promising clinical results after osteochondral autograft transplantation (OAT) for the treatment of large osteochondral lesions of the talus (OLT). However, no study has yet compared clinical outcomes between primary and secondary OAT for large OLT.

PURPOSE

To compare clinical outcomes among patients with large OLT who receive primary OAT versus those who receive secondary OAT after failure of marrow stimulation and to identify factors associated with clinical failure.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

From 2005 to 2014, 46 patients with large OLT (≥150 mm²) underwent OAT: 18 underwent OAT as initial surgical management (primary OAT group), and 28 patients underwent secondary OAT after failure of previous arthroscopic marrow stimulation (secondary OAT group). In both groups, OAT procedures included arthroscopic inspection and debridement of concomitant soft tissue injuries. Clinical outcomes were assessed using pain visual analog scale (VAS), the Roles and Maudsley score, Foot and Ankle Outcome Scores (FAOS), and revisional surgery rates. Factors associated with clinical failures were evaluated using bivariate and logistic regression analyses. Survival outcomes were compared using Kaplan-Meier analysis.

RESULTS

Mean follow-up time was 6 years (range, 2-10.8 years). Mean lesion size was 194.9 mm² (range, 151.7-296.3 mm²). There were no significant differences between groups in patient demographics and preoperative findings. Postoperative pain VAS, Roles and Maudsley score, FAOS, and revisional surgery rates were not significantly different at last follow-up. Prior marrow stimulation was not significantly associated with clinical failure on bivariate analysis. Lesion size greater than 225 mm² on preoperative magnetic resonance imaging was significantly associated with clinical failure. Survival probabilities from Kaplan-Meier plots were not significantly different between the primary and secondary OAT groups ( P = .947).

CONCLUSION

Clinical outcomes of patients with large OLT treated with secondary OAT after failed marrow stimulation were found to be comparable with those who were treated with primary OAT. These results may be helpful to orthopaedic surgeons deciding appropriate surgical options for patients with large OLT.

Osteochondral lesion of the distal tibial plafond in an adolescent soccer player: a case report

INTRODUCTION

Osteochondral lesions of the tibial plafond account for approximately 2.6% of osteochondral lesions in the ankle. There are few cases describing this lesion in the literature, with little information on mechanism of injury, history/physical findings or recommendations for management.

CASE PRESENTATION

A 17-year-old male competitive soccer player presented with a 6-7 month history of medial ankle pain after an inversion sprain. He presented with locking and giving way of the ankle with weight-bearing and pushing off the foot to the contralateral side. Radiographs were negative for fracture or osteochondral involvement. Magnetic resonance imaging revealed an osteochondral lesion of the tibial plafond with no injury to the talar dome.

SUMMARY

This case discusses the clinical presentation, imaging findings, management and outcomes of this osteochondral lesion of the distal tibial plafond.