Paper #118 Autologous osteochondral grafting for cartilage defects of the talar dome

Abstract

We present a follow-up study including a standardized outcome analysis of both the recipient and donor sites to help further develop our understanding of both the management and prognosis of osteochondral defects of the talus treated with the use of autologous osteochondral grafting. The cases of twenty-one patients surgically treated with open talar autologous osteochondral grafting for symptomatic focal cartilage defects of the talar dome between 1998 and 2000 were retrospectively reviewed. The mean age of men and women was 31.3 and 33.7 years, respectively, with a mean time to follow-up of 20.5 months. The talar lesions were preoperatively evaluated using plain radiographs, computerized tomography (CT), magnetic resonance imaging (MRI), and arthroscopy. The surgical management for all patients consisted of open debridement of the talar dome defect approached using either an oblique medial malleolar osteotomy for the medial talar dome lesion or a soft tissue takedown of the syndesmotic ligaments via an anterolateral approach for the lateral talar dome lesion. The donor osteochondral cylindrical grafts were then harvested using an open arthrotomy from the nonweightbearing trochlear border of the ipsilateral knee and consequently press-fitted into the respective sized recipient talar site to fill the defect. The medial malleolar osteotomy site was then rigidly internally fixed using two screws for the medial lesion or a modified Brostrom repair was performed to reconstruct the lateral ligaments for the lateral talar lesion. The postoperative regimen included an eight week course of nonweightbearing in a short leg cast with early range of motion of the knee followed by a foot and ankle and knee rehabilitation program. The mean size of the talar dome defects was 10mm x 15mm (range 70mm2 to 350mm2). Functional outcome results were prospectively obtained, for both the ankle and the knee, using the MODEMS AAOS Foot and Ankle Follow-up questionnaire, the AOFAS (American Orthopedic Foot and Ankle Society) ankle-hindfoot scale and Hannover scores for the ankle, and the International Knee Documentation Committee (IKDC) subjective knee evaluation form (a modification of the MODEMS Knee follow-up questionnaire), the IKDC objective knee examination form, and the Hospital for Special Surgery (HSS) score for the knee. The mean AOFAS ankle-hindfoot score was 60.6 (range 42 to 72) preoperatively, 83.5 (range 60 to 100) at twelve months postoperatively (in nineteen patients), and 89 (range 65 to 100) at final follow-up. The Hannover ankle assessment revealed a mean score of 93.3 (range 73 to 104) at final follow-up, and the mean score for the MODEMS AAOS Foot and Ankle Follow-up questionnaire was 93.2 (range 77.5 to 100). Regarding donor site pathology, the IKDC subjective knee evaluation form revealed a mean score of 87.4 (range 61.4 to 100) at final follow-up. Using the IKDC objective evaluation form, the mean postoperative score for the knee was grade A (normal) in 14 (67%) and grade B (nearly normal) in seven (33%). Using the HSS score, the mean score was 95.3 (range 85 to 100). There was 90.5% overall patient satisfaction. Additionally, there was a statistically significant association between the presence of a bipolar ankle lesion (with a focal cartilage defect of the distal tibial plafond opposite the corresponding talar lesion) and less than excellent outcome results (p < 0.05). We believe that the technique of autologous osteochondral grafting presented is valuable and should be considered an option for the patient with a symptomatic focal osteochondral defect of the talus.