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

BackgroundThere 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.ObjectivesThe 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 & methodsA 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.ResultsFollowing 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.ConclusionsDespite 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.     

Treatment principles for osteochondral lesions in foot and ankle

Osteochondral lesion of the talus (OLT) is a broad term used to describe an injury or abnormality of the talar articular cartilage and adjacent bone. A variety of terms have been used to refer to this clinical entity, including osteochondritis dissecans (OCD), osteochondral fracture and osteochondral defect. Whether OLT is a precursor to more generalised arthrosis of the ankle remains unclear, but the condition is often symptomatic enough to warrant treatment. In more than one third of cases, conservative treatment is unsuccessful, and surgery is indicated. There is a wide variety of treatment strategies for osteochondral defects of the ankle, with new techniques that have substantially increased over the last decade. The common treatment strategies of symptomatic osteochondral lesions include nonsurgical treatment, with rest, cast immobilisation and use of nonsteroidal anti-inflammatory drugs (NSAIDs). Surgical options are lesion excision, excision and curettage, excision combined with curettage and microfracturing, filling the defect with autogenous cancellous bone graft, antegrade (transmalleolar) drilling, retrograde drilling, fixation and techniques such as osteochondral transplantation [osteochondral autograft transfer system (OATS)] and autologous chondrocyte implantation (ACI). Furthermore, smaller lesions are symptomatic and when left untreated, OCDs can progress; current treatment strategies have not solved this problem. The target of these treatment strategies is to relieve symptoms and improve function. Publications on the efficacy of these treatment strategies vary. In most cases, several treatment options are viable, and the choice of treatment is based on defect type and size and preferences of the treating clinician.     

Transtalar retrograde drilling of medial osteochondral lesions of the talar dome

Osteochondral lesions of the medial talar dome can cause prolonged ankle disability. Chronic symptomatic lesionshave traditionally been debrided with transarticular approaches using arthrotomy, malleolar osteotomy, or arthroscopy. All of these techniques require removal of cartilage to access the underlying bone. The use of arthroscopy combined with percutaneous retrograde transtalar drilling through the sinus tarsi allows healing of the bone lesion and sparing of intact articular cartilage. Short-term results have shown high patient satisfaction.     

Surgical management of large talar osteochondral defects using autologous chondrocyte implantation

Background

Talar osteochondral lesions (OLT) occur frequently in ankle sprains and fractures. We hypothesize that matrix-induced autologous chondrocyte implantation (MACI) will have a low reoperation rate and high patient satisfaction rate in treating OLT less than 2.5 cm².

A 2-staged method for treatment of deep osteochondral lesions of the knee joint

We performed a 2-staged arthroscopic-assisted surgical procedure to treat a patient with a large osteochondral lesion of the knee joint. The osteochondral lesion was too comminuted to reattach; in addition, the underlying bony defect was too deep. In the first stage, autogenous cortical bone was used for grafting the bony defect along with screw fixation. The second stage consisted of screw removal and transplantation of autogenous osteochondral graft overlying the chondral defect. The osteochondral grafts were taken from the non–weight bearing areas of the same knee.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 9 (November-December), 2001: E35     

A comparison of surgical exposures for posterolateral osteochondral lesions of the talar dome

Background

Perpendicular access to the posterolateral talar dome for the management of osteochondral defects is difficult. We examined exposure available from each of four surgical approaches.

Osteochondral lesions of the talar dome associated with trauma

Purpose: The purpose of this study was to clarify the differences in the causes of osteochondral lesions (OCL) of the ankle based on the presence of distal fibular fractures and lateral instability of the ankle. Type of Study: Case series. Methods: We evaluated 92 cases of distal fibular fractures and 86 cases of lateral instability of the ankle, including 36 feet with subacute lateral instability of the ankle and 50 feet with chronic lateral instability of the ankle. In diagnosing OCL, we used a combination of magnetic resonance imaging to evaluate the subchondral conditions and ankle arthroscopy to evaluate the chondral conditions. Results: Of a total of 92 distal fibular fractures, 65 cases (70.7%) had OCL at the time of osteosynthesis and 27 did not (29.3%). Among the latter group, 2 developed OCL about 1 year after surgery. Of a total of 86 cases of lateral instability of the ankle, 35 (40.7%) had OCL. Among the subacute cases, 7 of 36 (19.4%) had OCL, versus 28 of 50 cases (56.0%) with chronic lateral instability of the ankle. Conclusions: Our study suggests that recurrent ankle sprains with remaining lateral instability and distal fibular fractures could be one of the causes of OCL of the ankle.     

Surgical management of osteochondral lesions of the first metatarsal head: A systematic review

BackgroundTreating osteochondral lesions of the first metatarsal head can help reducing pain and preventing end-stage arthritic cartilage degeneration and hallux rigidus. Several surgical techniques have been described, but no clear indications are reported. This systematic review aims to offer an overview of the current surgical treatments for focal osteochondral lesions of the first metatarsal head.MethodsThe selected articles were examined to extract data about population, surgical technique, and clinical outcomes.ResultsEleven articles were included. Mean age at surgery was 38,2 years. Osteochondral autograft was the most used technique. After surgery, an improvement was achieved in AOFAS, VAS, and hallux dorsiflexion but not in plantarflexion.ConclusionThere is limited evidence and knowledge regarding the surgical management of the first metatarsal head osteochondral lesions. Various surgical techniques have been proposed, drawn from other districts. Good clinical results have been reported. Further high-level comparative studies are necessary to design an evidence-based treatment algorithm.     

Arthroscopic treatment of ankle osteochondral lesions

Arthroscopic treatment of osteochondral lesions (OCLs) of the ankle is a popular first-line surgical option after conservative therapy has failed. MRI is the preferred imaging modality to evaluate OCLs and aid in surgical planning. Associated soft tissue pathology must be appreciated and addressed surgically, because associated synovitis and soft tissue impingement often contribute to symptoms. The diverse treatment modalities available via arthroscopy offer simplistic and straightforward solutions for biologically and mechanically complicated pathology. Marrow-stimulating techniques, particularly microfracture, have shown good to excellent results in most patients with small (<15 mm) acute lesions, and have a low complication rate.     

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.     

Management of recurrent multiple osteochondral lesions of the talus (OCLT) in a young active patient

Management of recurrent osteochondral lesion of talus in a young active male is a challenging problem. We present one such case of recurrent talar osteochondral lesions treated by Autologous Matrix Induced Chondrogenesis (AMIC). Patient had a good functional outcome at short-term follow up. We also describe the technique and review the literature regarding this novel technique.     

The influence of limited postoperative weight-bearing on the outcome of drilling in osteochondritis dissecans tali

Introduction This prospective study was performed to assess the influence of limited weight-bearing on the outcome of osteochondral drilling in the treatment of an osteochondritis dissecans tali.Materials and methods Of a total of 85 patients, 68 (80%; 37 male, 31 female, average age 28 years) were followed up after open or arthroscopic drilling between July 1990 and March 2000. The total outcome of 6 weeks limited postoperative weight-bearing (n=26) was compared with the outcome of 12 weeks limited weight-bearing (n=42). The average follow-up time was 4.8 years after surgery.Results A significant increase (p<0.01) in the HSS and AOFAS scores was found for the entire study group ranging from HSS: 82 points; AOFAS: 68 points before surgery to HSS: 94 points; AOFAS: 90 points at the time of assessment. The duration of limited weight-bearing did not significantly influence the outcome of surgery. Through osteochondral drilling, the average AOFAS score increased 20 points (73/93) and the HSS score 12 points (84/96) in the 6-week group and the AOFAS score 23 points (65/88) and the HSS score 12 points (80/92) in the 12-week group. The total outcome between the two postoperative treatment regimens showed no significant difference.Conclusion Osteochondral drilling is an adequate therapy for osteochondritis dissecans tali. The postoperative duration of limited weight-bearing does not significantly influence the surgical outcome.     

Adolescent elbow osteochondral lesions following prior elbow fracture pinning

Purpose:Pinning of pediatric elbow fractures has been shown to be a safe procedure with a low complication profile. This study identified patients who underwent cartilage surgery for elbow osteochondral lesions or osteochondritis dissecans who had prior ipsilateral elbow pinning.Methods:Records of patients who underwent ipsilateral cartilage surgery for osteochondritis dissecans and prior percutaneous pinning for elbow fractures were identified. Demographics were compiled and the clinical, radiographic, and surgical results were tabulated for patients with at least 1-year of follow-up from initial presentation.Results:In total, 6/52 (11.5%) pediatric patients from 2012 to 2021 who underwent isolated elbow osteochondritis dissecans surgery (mean age at surgery 13.4 ± 1.5 years) had a history of ipsilateral elbow pinning (mean age at surgery 6.9 ± 2.4 years). Of these, five had a history of a supracondylar fracture while one patient sustained a lateral condyle fracture. Overall, three of six patients had mechanical symptoms at presentation and three had abnormal radiographs. All patients underwent pre-operative magnetic resonance imaging and the five patients with an osteochondritis dissecans lesion <1cm² underwent arthroscopy and microfracture while one with a 4-cm² lesion underwent open osteochondral allograft transfer. All patients demonstrated improved motion at final follow-up and all patients were able to return to full desired activity following surgery.Conclusion:This study demonstrates that the history of elbow fracture pinning may predispose patients to future elbow chondral injuries in adolescence. Although patients appear to do well following consequent osteochondritis dissecans surgery, patients and parents may be advised of possible association of elbow pinning and elbow osteochondral lesions.Level of Evidence:III, case–control study     

Fresh osteochondral allograft transplantation (FOCAT) for definitive management of a 198 square millimeter osteochondral lesion of the talus (OLT): A case report

An osteochondral lesion of the talus (OLT) is an idiopathic acquired lesion of the subchondral bone that can lead to debilitating sequelae. The causes of OLT’s are still debatable, however, most agree that the etiology is repetitive microtrauma associated with vascular impairment. OLTs are most commonly described in the medial portion of the talus, while lateral involvement is less frequent. If not properly recognized and treated, an OLT may lead to numerous secondary conditions including premature osteoarthritis and functional limitations of the ankle joint. Multiple surgical and non-surgical treatment modalities have been described with varying results. Treatments are usually guided by the patients age, onset of symptoms, severity, and the disease stage according to the Berndt and Harty classification. Recent literature recommends curettage, drilling, or microfracture techniques for lesions which are no larger than 15 mm in diameter and no deeper than 7 mm. On the other hand, for large lesions or lesions that failed from primary bone marrow stimulation, surgery should be considered for autologous chondrocyte implantation (ACI), osteochondral autograft transplantation (OATs or mosaicplasty), or osteochondral allograft transplantation [1]. This case study examines surgical treatment of an extensive OLT in a 53 year old man who suffered with continuous ankle pain for over 10 years, misdiagnosed as ankle joint arthritis.Level of clinical evidence: Level of evidence 4.     

自体骨软骨移植修复距骨软骨或骨软骨缺损

目的探讨从同侧膝关节非负重面获取骨软骨柱,行自体移植修复距骨穹窿部局限性软骨或骨软骨缺损的临床效果。方法23例距骨穹窿部软骨病损的患者,包括创伤后软骨缺损11例,剥脱性骨软骨炎9例和局灶性骨关节炎3例。踝关节镜下明确缺损的部位、大小,行关节镜下或加用关节切开移植术,缺损区清创后钻孔,自同侧膝关节非负重区钻取骨软骨小柱,利用骨软骨自体移植系统(osteochondralautografttransfersystem,OATS)的专用器械,采取压配固定技术将移植物植入受区的孔中,行单柱或多柱镶嵌式移植修复距骨软骨缺损。结果术后随访15～30个月,平均22个月。利用标准VAS(visualanaloguescale)尺子评估踝关节疼痛程度,评分从术前平均4.9±1.2降至术后0.8±0.1(P<0.001)。测量踝关节跖屈和背伸角度,关节活动范围由术前平均44.3°±5.8°增加到术后65.6°±11.2°(P<0.001)。按Mazur等方法综合评定踝关节的状况,评分从术前平均(51.7±8.6)分提高到(92.4±6.3)分(P<0.001)。术后MR检查提示修复的关节面平滑,移植物与周围组织结合良好。结论以同侧膝关节非负重区的骨软骨移植修复距骨局限性软骨或骨软骨缺损是一种疗效明显的外科手术方法。     

Hyaline cartilage degenerates after autologous osteochondral transplantation.

OBJECTIVES: Autologous osteochondral grafting is a well-established clinical procedure to treat focal cartilage defects in patients, although basic research on this topic remains sparse. The aim of the current study was to evaluate (1) histological changes of transplanted hyaline cartilage of osteochondral grafts and (2) the tissue that connects the transplanted cartilage with the adjacent cartilage in a sheep model. METHOD: Both knee joints of four sheep were opened surgically and osteochondral grafts were harvested and simultaneously transplanted to the contralateral femoral condyle. The animals were sacrificed after three months and the received knee joints were evaluated histologically. RESULTS: Histological evaluation showed a complete ingrowth of the osseous part of the osteochondral grafts. A healing or ingrowth at the level of the cartilage could not be observed. Histological evaluation of the transplanted grafts according to Mankin revealed significantly more and more severe signs of degeneration than the adjacent cartilage, such as cloning of chondrocytes and irregularities of the articular surface. CONCLUSION: We found no connecting tissue between the transplanted and the adjacent cartilage and histological signs of degeneration of the transplanted hyaline cartilage. In the light of these findings, long-term results of autologous osteochondral grafts in human beings have to be followed critically.     

Langzeitergebnisse nach klebung von osteochondralen fragmenten bei osteochondrosis dissecans

Zusammenfassung Anhand von Ergebnissen einer Langzeitnachuntersuchung von operativ behandelten Patienten mit Osteochondrosis dissecaus des Knie- und Sprunggelenks wird die Problematik des früher verwendeten Zyanoakrylatklebers zur Refixation von osteochondralen Fragmenten dargestellt. Bei Osteochondrosis dissecans tali (n = 38) war die einzige erneute Dissekatlokkerung bei der Patientin zu verzeichnen, bei der Zyanoakrylatkleber verwendet worden war. Das Nachuntersuchungsergebnis bei 97 Patienten mit Osteochondrosis dis secans genus durchschnittlich 10 Jahre postoperativ zeigt, daß das Langzeitergebnis vom Knorpelzustand und insbesondere vom operativen Vorgehen und vom Alter des Patienten zum Zeitpunkt der Operation abhängig ist. Je besser der Knorpel erhalten ist, desto besser ist das Resultat bzw. desto geringer ist das AusmaB der Arthrose. Schwer resorbierbarer Kleber (Akrylatkleber) führte regelmäßig zur Ausbildung einer Arthrose. Die zusammenfassende Beurteilung nach dem Schema von Arcq ergab in 59,6% ein sehr gutes und in 18,3% ein gutes Langzeitergebnis; 56% der Kniegelenke wiesen keine gonarthrotischen Veränderungen auf. Aus diesen Ergebnissen kann gefolgert werden, daß leicht resorbierbarer Kleber wie der Fibrinkleber eine gute Refixation von osteochondralen Fragmenten unter den Bedingungen der Frühmobilisation ermöglicht, Schwer-resorbierbarer Kleber wie Zyanoakrylat dagegen aufgrund seines Barriereeffekts die biologische Einheilung erheblich stört und eine Reintegration der Fragmente stört.

---

Long-term results after refixation of osteochondral fragments in cases of osteochondritis dissecans at the talar dome and femoral condyles. The use of cyanaocrylateand fibrin glue

Long-term results after surgical treatment of osteochondritis dissecans of the talar dome and joint knee are dependent on the stage of cartilage damage, the age at operation and on the surgical technique. In cases of osteochondritis dissecans of the talar dome the only loosening of a refixed osteochondral fragment was seen after glueing with acrylate. Using the classification of Arcq in 59.6% an excellent and in 18.3% a good result was observed in cases of osteochondritis dissecans at the femoral condyles. In regard to the development of osteoarthritis in 56% no signs of osteoarthritis were visible. Worst results were obtained in knee joints in which acrylate glue was used for refixation of the osteochondral fragments. In conclusion we recommend the use of fibrin glue for refixation of osteochondral fragments in cases of osteochondritis dissecans even when early mobilisation follows the operation. Because of the long-lasting resorption and barrier effect to ingrowing tissue the use of cyanoacrylate should be avoided.

     

The anterior approach for the treatment of posterior osteochondral lesions of the talus: comparison of different surgical techniques

Introduction: Most of all osteochondral talar lesions are located in the middle and posterior area of the talar surface. Malleolar osteotomy is often used to access the defect but may be associated with malunion or secondary osteoarthritis. We present an alternative approach to the talus with temporary removal and replacement of a tibial bone block and compare it with other anterior approaches described in the literature. Patients and methods: Thirteen patients (5 males, 8 females) with an average age of 27.2 years and an osteochondral talar lesion were included in our study. All patients were previously operated on the same ankle. Ten lesions were caused by a sports injury. The average follow up was 45 months. The patients were evaluated before and after surgery using the ankle and hindfood score (AOFAS). For the analyses baseline clinical data were compared with follow up data using the Wilcoxon test. Results: The overall improvement between the preoperative and postoperative AOFAS scores was an average of 34.9 points (P=0.0002). No complications occurred at the site of the tibial bone block and the donor site at the talus. There were no patients with recurrence or an ankle osteoarthrosis in the follow up period. Conclusion: The removal of a tibial bone block and its subsequent replacement is a useful technique to access osteochondral talar lesions for osteochondral transplantation for which arthroscopic interventions have failed. The results are comparable to other anterior approaches described in the literature.An erratum to this article can be found at     

Arthroscopic debridement of osteochondral lesions of the talus: A systematic review

BackgroundArthroscopic debridement (AD) for the osteochondral lesions of the talar dome (OLT) was widely documented in the nineties with satisfactory results. However, in modern treatment algorithms, its role is not described. The present systematic review aims to evaluate the current evidence on the clinical outcomes of AD in the management of OLT.MethodsTwo independent reviewers searched PubMed, EMBASE, Scopus, and Virtual Health Library databases evaluating the clinical outcomes of AD of OLT with a minimum 6-month follow-up. The following terms "talus", "chondral", "cartilage", "injury", "lesion", "delamination", "damage", "excision", "curettage", "debridement", "chondrectomy", "chondroplasty", were used alone and in combination with Boolean operators AND and OR. Studies in which surgical technique was not described, an additional procedure was performed after debridement, and/or outcomes were not reported separately when more than one technique was implemented were excluded. The modified Coleman methodology score (mCMS) was used to evaluate the methodological quality of the included studies. A narrative analysis was conducted. Publication bias was assessed using the ROBIS tool.ResultsAD showed satisfactory short and medium-term outcomes for the primary treatment of OLT irrespectively of size and depth. However, the heterogeneity of the included studies and the level of available evidence hinders its recommendation.ConclusionsThere is a paucity of evidence evaluating AD alone for OLT treatment in the last two decades. Bone-marrow stimulation techniques remain the first-line surgical strategy for OLT treatment without proven superiority. Adopting AD for OLT treatment instead of MF could represent a paradigm breakthrough in clinical practice given its many potential advantages while preserving the subchondral plate.     

Techniques of chondral and osteochondral repair in the knee

Summary Spontaneous repair of chondral lesions is incomplete and of poor quality. Currently, the repair of cartilage with loss of substance can only be envisaged if it is located in a weightbearing zone in young subjects with a well aligned and stable knee. Four techniques are currently used and satisfying: microfractures, osteochondral grafts, and grafts of chondrocytes. Fresh allografts are also reported, though they are difficult to employ in Europe.