Debridement, Curettage, Microfracture, and Fixation Techniques for Osteochondral Lesions of the Talus

Abstract

Category: Ankle Introduction/Purpose: Osteochondral lesions of the talus (OLTs) are a challenging clinical pathology for orthopaedic surgeons. To date, the treatment guidelines for these lesions have been 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 on key topics regarding cartilage lesions of the talus. Debridement, curettage, microfracture, and fixation techniques are surgical modalities to treat the lesion and were discussed as one portion of the first International Consensus Meeting on Cartilage Repair of the Ankle. The purpose of this abstract is to explain the process and delineate the consensus statements derived from this consensus meeting on debridement, curettage, microfracture, and fixation techniques for osteochondral lesions of the talus. Methods: 75 national and international experts in cartilage repair of the ankle, representing 25 countries and all six continents, were convened and participated in a process based on the Delphi method of achieving consensus. Experts were assigned to groups separated by topics, including debridement, curettage, microfracture, and fixation techniques. Questions and statements were drafted within the groups and a comprehensive literature review was performed and, where possible, used to confirm or dispute the recommendations made. In addition, the available evidence for each statement was graded. Once the statements achieved majority vote within the groups, a vote to the overall group was undertaken. The statements were then further edited on the basis of the discussion and votes within the entirety of the consensus group. A final vote then occurred, and the strength of consensus was characterized as follows: consensus: 51 - 74%; strong consensus: 75 - 99%; unanimous: 100%. Results: 29 statements addressing debridement, curettage, microfracture, and fixation techniques reached some degree of consensus. In the case of microfracture, 94% (strong consensus) agreed that the ideal size guidelines are lesions <10 mm in diameter, <100 mm2 in area, and <5 mm in depth. In addition, 92% (strong consensus) voted that lesion size, location, presence of cyst(s), containment of lesion, joint alignment, bone marrow edema, ankle stability, and previous cartilage repair procedures are all important local prognostic factors for microfracture. For fixation, 90% of participants (strong consensus) voted that a stable displaced OLT fragment or a nondisplaced OLT fragment should be fixed as soon as possible in order to maximize healing potential and minimize intra-articular damage. Conclusion: There is a lack of evidence-based guidelines available to direct treatment for clinicians when managing osteochondral lesions of the ankle. This international consensus derived from leaders in the field will assist clinicians with a combination of expert- and evidence-based guidelines to consider in the treatment of a cartilage lesion of the talus using debridement, curettage, microfracture, and fixation techniques.