Osteochondral lesions of the talar dome in the athlete: what evidence leads to which treatment

Abstract

Osteochondral lesions of the talar dome (OLT) are common injuries that involve cartilage and subchondral bone. These injuries appear in up to 42% of professional soccer players on magnetic resonance imaging (MRI). Typically, patients are 20 35-yearold male athletes experiencing chronic ankle pain, decreased range of motion, and joint effusion, especially during or after sports activities, and compromised quality of life. The low regeneration potential of chondrocytes and the recent findings revealing subchondral bone architecture's role in cartilage homeostasis, repair durability, and overall clinical outcomes make OLT treatment a challenging topic in orthopedics. The aim of this narrative review was to outline a surgical treatment algorithm for OLT management in the athlete. Debridement and bone marrow stimulation techniques remain the first-line treatment of OLT with satisfactory short- to long-term outcomes, a high return to sports (RTS) rate, and a rapid RTS, with improved results when augmented with PRP. Still, considering the controversy of its potential disadvantages, debridement should be limited to the International Cartilage Repair Society (ICRS) grade I-II injuries regardless of its size and with or without additional bone marrow stimulation (BMS)in ICRS III < 1.0 cm2 injuries. In the presence of larger lesions and subchondral plate and bone involvement, the benefits and disadvantages of osteochondral autologous transplantation system (OATS)/mosaicplasty and scaffold-based techniques should be considered for a tailored treatment approach either as a primary procedure or as an off-season procedure for better cartilage tissue quality, functional outcomes, and potentially increasing the player's professional career length. Osteochondral lesions of the talar dome (OLT) are common injuries that involve cartilage and subchondral bone. These injuries appear in up to 42% of professional soccer players on magnetic resonance imaging (MRI). Typically, patients are 20 35-yearold male athletes experiencing chronic ankle pain, decreased range of motion, and joint effusion, especially during or after sports activities, and compromised quality of life. The low regeneration potential of chondrocytes and the recent findings revealing subchondral bone architecture's role in cartilage homeostasis, repair durability, and overall clinical outcomes make OLT treatment a challenging topic in orthopedics. The aim of this narrative review was to outline a surgical treatment algorithm for OLT management in the athlete. Debridement and bone marrow stimulation techniques remain the first-line treatment of OLT with satisfactory short- to long-term outcomes, a high return to sports (RTS) rate, and a rapid RTS, with improved results when augmented with PRP. Still, considering the controversy of its potential disadvantages, debridement should be limited to the International Cartilage Repair Society (ICRS) grade I-II injuries regardless of its size and with or without additional bone marrow stimulation (BMS)in ICRS III < 1.0 cm2 injuries. In the presence of larger lesions and subchondral plate and bone involvement, the benefits and disadvantages of osteochondral autologous transplantation system (OATS)/mosaicplasty and scaffold-based techniques should be considered for a tailored treatment approach either as a primary procedure or as an off-season procedure for better cartilage tissue quality, functional outcomes, and potentially increasing the player's professional career length. Osteochondral lesions of the talar dome (OLT) are common injuries that involve the cartilage and subchondral bone. These injuries appear in up to 42% of professional soccer players on magnetic resonance imaging (MRI) (Figs. 1 and 2).1Bezuglov E. Khaitin V. Lazarev A. et al.Asymptomatic foot and ankle abnormalities in elite professional soccer players.Orthop J Sports Med. 2021; 9 (Published 2021 Jan 29)2325967120979994https://doi.org/10.1177/2325967120979994Crossref PubMed Scopus (3) Google Scholar, 2Brulc U. Drobnič M. Kolar M. Stražar K. A prospective, single-center study following operative treatment for osteochondral lesions of the talus [published online ahead of print, 2021 Aug 26].Foot Ankle Surg. 2021; S1268-7731 (00179-X)https://doi.org/10.1016/j.fas.2021.08.008Crossref Google Scholar, 3Badekas T. Takvorian M. Souras N. 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Arthroscopic microfracture vs arthroscopic autologous matrix-induced chondrogenesis for the treatment of articular cartilage defects of the talus.Knee Surg Sports Traumatol Arthrosc. 2019; 27: 2731-2736https://doi.org/10.1007/s00167-018-5278-7Crossref PubMed Scopus (30) Google Scholar, 20Shimozono Y. Coale M. Yasui Y. O'Halloran A. Deyer T.W. Kennedy J.G. Subchondral bone degradation after microfracture for osteochondral lesions of the talus: an MRI analysis.Am J Sports Med. 2018; 46: 642-648https://doi.org/10.1177/0363546517739606Crossref PubMed Scopus (45) Google Scholar, 21Vannini F. Costa G.G. Caravelli S. Pagliazzi G. Mosca M. Treatment of osteochondral lesions of the talus in athletes: what is the evidence?.Joints. 2016; 4 (Published 2016 Aug 18): 111-120https://doi.org/10.11138/jts/2016.4.2.111Crossref PubMed Scopus (8) Google Scholar and can be summarized in four strategical categories2,22:1.No treatment, in which incidentally found cartilage injuries are left in place without further intervention;2.Palliative, represented by cartilage debridement and irrigation, providing pain and mechanical symptoms relief;3.Reparative, profiting from intrinsic repairability of the cartilage tissue through bone marrow stimulation (BMS), including microfracture, nanofractures, drilling, and abrasion arthroplasty;4.Restorative, wherein the cartilage defect is filled or replaced, including osteochondral grafting or substitution, and scaffold and/or cell-based therapies. Despite success rates ranging from 76% to89%, there is limited evidence defining the ideal OLT surgical treatment.19Becher C. Malahias M.A. Ali M.M. Maffulli N. Thermann H. Arthroscopic microfracture vs arthroscopic autologous matrix-induced chondrogenesis for the treatment of articular cartilage defects of the talus.Knee Surg Sports Traumatol Arthrosc. 2019; 27: 2731-2736https://doi.org/10.1007/s00167-018-5278-7Crossref PubMed Scopus (30) Google Scholar,23Zengerink M. Struijs P.A. Tol J.L. van Dijk C.N. Treatment of osteochondral lesions of the talus: a systematic review.Knee Surg Sports Traumatol Arthrosc. 2010; 18: 238-246https://doi.org/10.1007/s00167-009-0942-6Crossref PubMed Scopus (408) Google Scholar However, the defect location, size, depth, and subchondral bone status are recognized as critical in the treatment decision-making and outcomes.2Brulc U. Drobnič M. Kolar M. Stražar K. A prospective, single-center study following operative treatment for osteochondral lesions of the talus [published online ahead of print, 2021 Aug 26].Foot Ankle Surg. 2021; S1268-7731 (00179-X)https://doi.org/10.1016/j.fas.2021.08.008Crossref Google Scholar,4Doğar F. Uzun E. Gürbüz K. et al.Comparison of arthroscopic treatment methods in talar osteochondral lesions: a Multicenter, Prospective, Randomized Clinical Trial.J Am Podiatr Med Assoc. 2021; 111 (Article): 5https://doi.org/10.7547/20-218Crossref Scopus (1) Google Scholar,5Eren T.K. Ataoğlu M.B. Eren A. Geylan D.E. Öner A.Y. Kanatlı U. Comparison of arthroscopic microfracture and cell-free scaffold implantation techniques in the treatment of talar osteochondral lesions.Eklem Hastalik Cerrahisi. 2019; 30: 97-105https://doi.org/10.5606/ehc.2019.64401Crossref PubMed Scopus (7) Google Scholar,19Becher C. Malahias M.A. Ali M.M. Maffulli N. Thermann H. 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Debridement alone or in combination with BMS techniques is the most common cartilage procedure performed in OLT treatment (Figs. 3 and 4).5Eren T.K. Ataoğlu M.B. Eren A. Geylan D.E. Öner A.Y. Kanatlı U. Comparison of arthroscopic microfracture and cell-free scaffold implantation techniques in the treatment of talar osteochondral lesions.Eklem Hastalik Cerrahisi. 2019; 30: 97-105https://doi.org/10.5606/ehc.2019.64401Crossref PubMed Scopus (7) Google Scholar,26Lee Y.K. Young K.W. Kim J.S. Lee H.S. Cho W.J. Kim H.N. Arthroscopic microfracture with atelocollagen augmentation for osteochondral lesion of the talus: a multicenter randomized controlled trial.BMC Musculoskelet Disord. 2020; 21 (Published 2020 Nov 3): 716https://doi.org/10.1186/s12891-020-03730-3Crossref PubMed Scopus (8) Google Scholar,27Marín Fermín T. Hovsepian J.M. D'Hooghe P. Papakostas E.T Arthroscopic debridement of osteochondral lesions of the talus: a systematic review.Foot (Edinb). 2021; 49101852https://doi.org/10.1016/j.foot.2021.101852Crossref PubMed Scopus (1) Google Scholar Debridement of a cartilage defect comprises the smoothening of the cartilage surface in the presence of fibrillation, flaps, or loose bodies and creating stable margins using a shaver or curette. Thus, improving mechanical symptoms and synovial inflammation.27Marín Fermín T. Hovsepian J.M. D'Hooghe P. Papakostas E.T Arthroscopic debridement of osteochondral lesions of the talus: a systematic review.Foot (Edinb). 2021; 49101852https://doi.org/10.1016/j.foot.2021.101852Crossref PubMed Scopus (1) Google Scholar Additionally, the defect's bed can be perforated with a wide variety of instruments to allow an influx of bone marrow, initiating a signaling cascade with the ulterior filling by fibrocartilage tissue.5Eren T.K. Ataoğlu M.B. Eren A. Geylan D.E. Öner A.Y. Kanatlı U. Comparison of arthroscopic microfracture and cell-free scaffold implantation techniques in the treatment of talar osteochondral lesions.Eklem Hastalik Cerrahisi. 2019; 30: 97-105https://doi.org/10.5606/ehc.2019.64401Crossref PubMed Scopus (7) Google Scholar,9Camurcu Y. Ucpunar H. Yapici F. et al.Clinical and magnetic resonance imaging outcomes of microfracture plus chitosan/blood implant vs Microfracture for Osteochondral Lesions of the Talus.Foot Ankle Int. 2020; 41: 1368-1375https://doi.org/10.1177/1071100720942173Crossref PubMed Scopus (4) Google Scholar,27Marín Fermín T. Hovsepian J.M. D'Hooghe P. 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