Large Osteochondral Lesions Of The Talus Research Articles

AUTOLOGOUS OSTEOCHONDRAL TRANSPLANTATION FOR LARGE OSTEOCHONDRAL LESIONS OF THE TALUS IS A VIABLE OPTION IN AN ATHLETIC POPULATION

Autologous osteochondral transplantation (AOT) is an effective treatment for large Osteochondral Lesions of the Talus (OLT), however little is reported on an athletic population, who are likely to place higher demands on the reconstruction. The aim is to report the outcomes of large OLT (>150mm2) within an athletic population. The study population was limited to professional or amateur athletes (Tegner score >6) with an OLT of size 150mm2 or greater. The surgical intervention was AOT with a donor site from the lateral femoral condyle. Clinical outcomes at a minimum of 24 months included Return to Sport, VAS and FAOS Scores. In addition, graft incorporation was evaluated by MRI using MOCART scores at 12 months post-surgery. 38 athletes including 11 professional athletes were assessed. Mean follow-up was 46 months. Mean lesion size was 249mm2. 33 patients returned to sport at their previous level and one did not return to sport (mean return to play 8.2 months). Visual analogue scores improved from 4.53 pre-operatively to 0.63 post-operatively (p=0.002). FAOS Scores improved significantly in all domains (p< 0.001). Two patients developed knee donor site pain, and both had three osteochondral plugs harvested. Univariant analysis demonstrated no association between pre-operative patient or lesion characteristics and ability to return to sport. However, there was a strong correlation between MOCART scores and ability to return to sport (AUC=0.89). Our study suggests that AOT is a viable option in the management of large osteochondral talar defects in an athletic population, with favourable return to sport levels, patient satisfaction, and FAOS/VAS scores. The ability to return to sport is predicated upon good graft incorporation and further research is required to optimise this technique. Our data also suggests that patients should be aware of the increased risk of developing knee donor site pain when three osteochondral plugs are harvested.

Improved Results From Medium- and Long-Term Outcomes of Autogenous Osteoperiosteal Grafting for Large Cystic Lesions of the Talus

To investigate the medium and long-term follow-up outcomes of large cystic medial osteochondral lesions of the talus (OLTs) treated with autologous tibial osteoperiosteal grafts from the medial tibia and to explore the risk factors influencing the treatment outcomes. The retrospective study included 75 patients with large cystic medial OLTs who underwent autologous osteoperiosteal cylinder graft taken from the medial tibia between January 2004 and August 2018. They were assessed preoperatively and postoperatively using a visual analog scale, the Orthopedic Foot & Ankle Society Ankle-Hindfoot Scale (AOFAS), and short-form 36-item Short Form Health Survey score. Magnetic resonance observation of cartilage repair tissue, second-look arthroscopy, and biopsy were used to evaluate the grafting areas. After a follow-up period of 6.3 years, the virtual analog scale score decreased to 1.47 ± 1.32, and the AOFAS and 36-item Short Form Health Survey scores increased to 82.78 ± 11.65 and 83.26 ± 8.49, respectively, all of which showed significant improvement over preoperative scores (P < .001), and the average magnetic resonance observation of cartilage repair tissue score was 82.6 ± 8.4 (56.0-91.6). Eight patients underwent a second-look arthroscopic examination and were rated by the International Cartilage Repair Society scale; of them, 2 patients were rated grade Ⅰ, 4 were rated grade Ⅱ, and 2 were rated grade Ⅲ. Three patients underwent grafting area biopsy during the second-look arthroscopy, and the results showed that the grafting areas were rich in chondrocytes. Large OLTs (≥200 mm2) and obesity (body mass index ≥25) were responsible for the poor improvement of AOFAS score, according to multivariate Cox regression analysis. Autologous osteoperiosteal grafting was an effective treatment for large cystic medial OLTs, with effective cartilage regeneration in the grafted areas in the medium and long term. However, the large OLTs and obesity may reduce the treatment outcomes. Level IV, case series.

Outcomes following Particulated Juvenile Allograft Cartilage for Osteochondral Lesions of the Talus: A Systematic Review

Category: Ankle; Basic Sciences/Biologics Introduction/Purpose: The purpose of this systematic review was to evaluate the clinical and radiological outcomes together with the complication rates and failure rates at short-term follow-up following Particulated Juvenile Allograft Cartilage (PJAC) for the management of osteochondral lesions of the talus (OLT). Methods: During November 2022, the PubMed, Embase and Cochrane library databases were systematically reviewed to identify clinical studies examining outcomes following PJAC for the management of OLTs. Data regarding study characteristics, patient demographics, lesion characteristics, subjective clinical outcomes, radiological outcomes, complications and failure rates were extracted and analysed. In addition, the level of evidence and quality of evidence for each individual study was also assessed. Results: Twelve studies were included. In total, 241 patients underwent PJAC for the treatment of OLT at a weighted mean follow-up of 29.0±24.9 months. The weighted mean lesion size was 138.3±59.6 mm2 and 69.4% of OLTs were located at the medial talar dome. Prior surgical intervention was recorded in 7 studies, the most common of which was microfracture (65.9%). Concentrated bone marrow aspirate was utilized in 66 patients (27.3%). The weighted mean AOFAS score improved from a pre- operative score of 58.5±3.2 to a post-operative score of 83.9±5.3. The weighted mean post-operative MOCART score was 48.2±3.3. The complication rate was 16.5%, the most common of which was graft hypertrophy (7.0%). Thirty failures (12.4%) were observed at a weighted mean time of 9.8±9.6 months following the index procedure. Conclusion: This systematic review demonstrated a moderate improvement in subjective clinical outcomes following PJAC for the treatment of OLT at short term follow-up. However, post-operative MOCART scores were reported as poor. In addition, a moderate complication rate (16.5%) and a moderate failure rate (12.4%) was observed, calling into question the efficacy of PJAC for the treatment of large OLTs. Further studies are warranted to identify the optimal role of PJAC in the management of OLTs.

Talar OsteoPeriostic Grafting from the Iliac Crest (TOPIC): Two-Year Prospective Results of a Novel Press-Fit Surgical Technique for Large, Complex Osteochondral Lesions of the Medial Talus.

Press-fit Talar OsteoPeriostic grafting from the Iliac Crest (TOPIC) is a novel technique for the treatment of large osteochondral lesions of the talus. The purpose of the present study was to prospectively evaluate the 2-year clinical outcomes for patients with medial osteochondral lesions of the talus that were treated with the TOPIC procedure. Forty-three patients were prospectively assessed before and 24 months after the TOPIC procedure. All procedures were performed through a medial distal tibial osteotomy. Clinical assessment preoperatively and at 24 months of follow-up included determination of the Numeric Rating Scale (NRS) scores for pain during walking (primary outcome), at rest, during running, and during stair-climbing. The Foot and Ankle Outcome Score (FAOS) and the Mental Component Summary (MCS) score and Physical Component Summary (PCS) score of the Short Form-36 (SF-36) were also assessed. A computed tomography (CT) scan was performed 12 weeks postoperatively to assess union of the distal tibial osteotomy site and at 1 and 2 years postoperatively to assess consolidation of the graft as well as cyst development in the graft. All enrolled patients were available for follow-up. The median NRS score for pain during walking improved from 7 points preoperatively to 2 points at 2 years postoperatively (p < 0.001). All other NRS scores for pain improved significantly. All FAOS subscale scores improved significantly, including those for pain (from 53 to 75), symptoms (from 50 to 61), activities of daily living (from 68 to 88), sports (from 30 to 55), and quality of life (from 19 to 38). The SF-36 PCS score improved from 43 to 48 (p < 0.001), and the MCS score changed from 28 to 26 (p > 0.05). There was a 100% rate of union of the osteotomy site at the distal tibia and 100% of the grafts showed consolidation at 1 and 2 years postoperatively. The TOPIC procedure for large osteochondral lesions of the medial talar dome is an effective technique that resulted in significant improvement exceeding the minimal clinically important difference in pain scores (primary outcome) as well as in other outcomes, with 100% consolidation of the grafts. Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

The partial talus replacement (PTR) – An alternative treatment for severe osteochondral lesions of the talus utilizing a custom 3D printed talar hemiarthroplasty implant: A case report and technique guide

Large osteochondral lesions of the talus can lead to severe pain and disability. Various surgical interventions have been described in published literature. Customized implants developed through additive manufacturing are increasing in popularity with favorable results within foot and ankle surgery. This case study reports a 52-year-old male who has a history of failed prior surgical interventions with severe left ankle pain associated with a large osteochondral lesion of the talus. The patient underwent resection of the diseased bone with the aid of patient specific instrumentation followed by implantation of a custom 3D printed partial talus implant to resurface the talar dome. At a final follow up of 24 months, the patient continued to experience significant improvement in functional outcomes without radiographic evidence of implant complications.

Articular Regional Reconstruction (ARR) for Large Osteochondral Lesions of the Talus using Viable Osteochondral Allograft Combined with Autograft: Technique Description and Case Series

Category: Ankle; Sports; Trauma Introduction/Purpose: Symptomatic osteochondral lesions of the talus (OLT) are challenging to treat, and large lesions (&gt;10mm) with concomitant subchondral bony defects are particularly challenging. Standard treatments such as bone stimulation are limited and are often restricted to smaller lesions. Particulate and fragmented chondral allograft techniques face limitations with uncontained lesions. Structural allograft/autograft techniques often require removal of regions of native, uninjured bone and may encounter donor issues. Postoperatively, ensuring reliable osseous and cartilaginous healing responses can be difficult. Articular Regional Reconstruction (ARR) is a novel technique combining viable osteochondral allograft with morselized autograft bone to address large OLT lesions with bony defects, whether contained or uncontained. We describe a consecutive series of patients undergoing ARR here. Methods: Patients indicated for the ARR procedure had preoperative MRI and CT imaging identifying large (&gt;10mm), unstable osteochondral lesions with bony defects; 11 consecutive patients that had undergone ARR were identified. OLT lesions were initially inspected arthroscopically, and then converted to open debridement. Medial malleolar osteotomies were used for access when necessary. A stable bony base and viable cartilage rim was established, removing all damaged cartilage and nonstructural material from the OLT and bony defect. Talar body structure and morphology was restored using iliac crest or tibial morselized autograft bone placed in the bony defect. Viable osteochondral allograft (Cartiform) was shaped and then secured over the autograft using suture anchors placed at the lesion periphery. Patient Reported Outcome (PRO) measures included PROMIS- physical function (PROMIS-PF), PROMIS-pain interference (PROMIS-PI), and single assessment numeric evaluation (SANE). Three patients without PRO data were excluded, leaving eight patients with preoperative and postoperative PRO data for analysis. Results: The ARR patients averaged 40 years old (range 28-60) with a mean follow up of 19 months (range 10-38). The lesion surface areas averaged 1.95 cm2 (range 1.17-2.99 cm2) with a depth of 7.25mm (range 5-9mm). Four were uncontained corner lesions. Postoperative PROMIS-PF improved from 41 to 47 (p = 0.036), and PROMIS- PI improved from 60 to 53 (p = 0.093). Average SANE scores improved from 60 to 69 (p = 0.148). No complications occurred. No revision OLT surgeries were required, though three patients returned to the OR (Two for osteotomy screw removal, one for anterior impingement of opposite corner). During these 'second looks', the implanted cartilage layer was found intact. In a recent survey, all patients indicated they would undergo the procedure again. Conclusion: Articular Regional Reconstruction (ARR) is a reproducible procedure with demonstrated potential for improvement in pain and physical function among patients with symptomatic, large osteochondral lesions of the talus with bony defects, whether 'contained' or 'uncontained'. It has particular utility as an alternative to bulk structural graft salvage procedures among patients who have failed prior procedures, as 5 of the 8 patients had undergone unsuccessful prior surgical intervention for their OLT by outside providers. Further studies on ARR of the talus are necessary to elucidate the prognosis of this procedure, establish indication boundaries, and strengthen long-term outcome data.

Augmenting Osteochondral Autograft Transplantation and Bone Marrow Aspirate Concentrate with Particulate Cartilage Extracellular Matrix Is Associated With Improved Outcomes.

Osteochondral autograft transplant (OAT) is often used to treat large osteochondral lesions of the talus and is generally associated with good outcomes. The addition of adjuncts such as cartilage extracellular matrix with bone marrow aspirate concentrate (ECM-BMAC) may further improve the OAT procedure but have not been thoroughly studied. We hypothesized that the placement of ECM-BMAC around the OAT graft would improve radiographic and patient-reported outcomes following OAT. Patients who received OAT, with ECM-BMAC or BMAC alone, were screened and their charts were reviewed. For patients who did receive ECM-BMAC, the mixture was spread around the edges of the OAT plug and into any surrounding areas of cartilage damage. Survey and radiographic data were collected. Average follow-up in both groups was over 2 years. Magnetic resonance imaging scans were scored using the Magnetic Resonance Observation of Cartilage Tissue (MOCART) system. Outcomes were compared statistically between groups. Patients treated with ECM-BMAC (n = 34) demonstrated significantly greater improvement of scores in the FAOS categories Symptoms (17 vs -3; P = .02) and Sports Activities (40 vs 7; P = .02), and the MOCART category Subchondral Lamina (P = .008) compared to those treated with BMAC alone (n = 30). They also experienced significantly lower rates of postoperative cysts (53% vs 18%, P = .04) and edema (94% vs 59%, P = .02). The addition of ECM-BMAC to OAT was associated with improved imaging and clinical outcomes compared to OAT with BMAC alone.

Functional Outcomes of Autologous Matrix-Related Chondrogenesis to Treat Large Osteochondral Lesions of the Talus.

Osteochondral lesions of the talus (OLT) treatment is widely debated when the lesion size exceeds 150 mm2. The aim of this study was to assess functional outcome and satisfaction rates of the autologous matrix-related chondrogenesis (AMIC) technique and compare the outcomes for OLTs larger than 150 mm2 that were classified as primary, primary with local tumor-related OLT, or revision cases. A total of 77 patients who were operated by AMIC were included. The average age of the population was 39.6 years. The mean body mass index (BMI) was 27.2. Smoker rate was 28.5% of the population. Forty-two patients were primary cases, 14 patients had primary with local tumor-related OLT, and 18 patients were revision cases. Overall and subgroup functional outcomes were evaluated by visual analog scale (VAS) and Foot and Ankle Disability Index (FADI) scores. Satisfaction rates were queried, and failures were recorded. After a median follow-up of 32 months, the score improvement for primary, primary with local tumor-related, and revision group were for VAS, 5.4 ± 0.4, 5.6 ± 0.7, and 3.6 ± 0.8, and for FADI, 46.5 ± 3.8, 45.3 ±6.5, and 26.6 ± 6.7, respectively (P < .001). Intergroup comparison showed greater improvement for the primary OLT group when compared to the revision group (P < .001). The failure rates for the primary, primary with local tumor-related, and revision group were 4.8%, 11.8%, and 38.9%, respectively. AMIC procedure provides good functional outcome and satisfactory rates in patients with primary and primary with local tumor-related OLT larger than 150 mm2, but in revision cases, the AMIC success rate was not encouraging as all had advanced OLT operative interventions. Level III, therapeutic retrospective study.

Midterm Prospective Evaluation of Structural Allograft Transplantation for Osteochondral Lesions of the Talar Shoulder.

In cases of large osteochondral lesions of the talus (OLTs), fresh structural or bulk osteochondral allograft transplantation has yielded favorable outcomes in several retrospective and few prospective case series. The purpose of this study was to prospectively evaluate patients who received fresh structural allograft transplantation of the talar shoulder. A prospective evaluation of patients who received a fresh structural allograft of an OLT was performed. Preoperative imaging included magnetic resonance imaging (MRI) and/or computed tomography (CT) with plain radiographs. The following patient-reported outcomes questionnaires were administered preoperatively and yearly after surgery: 36-Item Short-Form Health Survey (SF-36), visual analog scale (VAS) for pain, and the Short Musculoskeletal Functional Assessment (SMFA). Preoperative and postoperative imaging were evaluated for allograft assimilation, evidence of arthritic changes, or functional range of motion abnormalities. Thirty-one patients with a mean age of 41.4 years (±14.1, range 18-69) underwent structural fresh osteochondral allograft transplantation to the talar shoulder and were included in this study. The mean follow-up was 56.2 months (±36.1, range 24-142). The majority of patients were female (n=17, 54.8%), reported some history of prior ankle trauma (n=21, 67.7%), and underwent prior ankle surgery (n=23, 74.2%). The mean lesion size on CT scan was 1879 mm3 (n = 27) compared to the mean lesion size of 3877 mm3 (n = 21) on MRI. There was a significant improvement in the mean preoperative VAS score (P < .0001), SF-36 score (P < .0005), SMFA bother index (P < .0015), and the SMFA function index (P < .0001) at final follow-up. A total of 15 (48.4%) patients underwent an additional surgery following their osteochondral allograft transplant, most commonly arthroscopic debridement or removal of hardware, performed at an average of 25.2 (±13.0) from their index procedure. There was one failure that required a total ankle replacement. The overall graft survival rate was 96.8%. Fresh, structural allograft transplantation resulted in significant improvement in patient-reported postoperative pain and function in patients suffering from OLTs. The graft survival rate was 96.8% at a mean of 56.2 months follow-up, with half of patients requiring a second procedure. Level IV, prospective case series.

Outcomes Following Repeat Ankle Arthroscopy and Microfracture for Osteochondral Lesions of the Talus.

The management of symptomatic osteochondral lesions of the talus (OLTs) previously treated with arthroscopy is controversial. Minimal data exist on the role for repeat arthroscopy. Here, we describe our experience with repeat arthroscopy and microfracture for symptomatic OLTs. Our database was queried over an 8-year period to identify patients undergoing repeat arthroscopy and microfracture as treatment for symptomatic OLTs. Phone surveys were conducted to assess residual pain, patient satisfaction, and need for subsequent surgery. We compared patient outcomes based on the size of their OLT (small lesions ≤150 mm2, large >150 mm2) and the presence or absence of subchondral cysts. We identified 14 patients who underwent repeat arthroscopy and microfracture for symptomatic OLTs. Patients reported reasonable satisfaction (7.6 ± 3.5 out of 10) but moderate residual pain (4.7 ± 3.4 out of 10) at midterm follow-up (5.1 ± 2.9 years). In total, 21% (3/14) of patients had undergone subsequent surgery. Patients with small (n = 5) and large OLTs (n = 9) had similar postoperative pain scores (4.2 ± 4.1 vs 4.9 ± 3.2) and postoperative satisfaction levels (6.4 ± 4.9 vs 8.3 ± 2.5). At midterm follow-up, repeat arthroscopy for symptomatic OLTs demonstrated reasonable satisfaction but moderate residual pain. Lesion size or presence of subchondral cysts did not affect outcome, but our sample size was likely too small to detect statistically significant differences. These data show that repeat ankle arthroscopy can be performed safely with modest outcomes, and we hope that this report aids in managing patient expectations.Level of Evidence: Level IV Case Series.

Autologous Osteochondral Transplantation for Large Osteochondral Lesions of the Talus Is a Viable Option in an Athletic Population

Background: Autologous osteochondral transplantation (AOT) has been shown to be a viable treatment option for large osteochondral lesions of the talus. However, there are limited data regarding the management of large lesions in an athletic population, notably with regard to return to sport. Our investigation focused on assessing both qualitative and quantitative outcomes in the high-demand athlete with large (>150 mm2) lesions. Hypothesis: AOT is a viable option in athletes with large osteochondral lesions and can allow them to return to sport at their preinjury level. Study Design: Case series; Level of evidence, 4. Methods: The study population was limited to professional and amateur athletes (Tegner score, >6) with a talar osteochondral lesion size of 150 mm2 or greater. The surgical intervention was AOT with a donor site from the lateral femoral condyle. Clinical outcomes at a minimum of 24 months included return to sport, visual analog scale (VAS) for pain score, and Foot and Ankle Outcome Score (FAOS). In addition, graft incorporation was evaluated by magnetic resonance imaging (MRI) using MOCART (magnetic resonance observation of cartilage repair tissue) scores at 12 months after surgery. Results: A total of 38 athletes, including 11 professional athletes, were assessed. The mean follow-up was 45 months. The mean lesion size was 249 mm2. Thirty-three patients returned to sport at their previous level, 4 returned at a lower level compared with preinjury, and 1 did not return to sport (mean return to play, 8.2 months). The VAS improved from 4.53 preoperatively to 0.63 postoperatively (P = .002). FAOSs improved significantly in all domains (P < .001). Two patients developed knee donor site pain, and both had 3 osteochondral plugs harvested. Univariant analysis demonstrated no association between preoperative patient or lesion characteristics and ability to return to sport. However, there was a strong correlation between MOCART scores and ability to return to sport. The area under receiver operating characteristic of the MOCART score and return to play was 0.891 (P = .005), with a MOCART score of 52.50 representing a sensitivity of 0.85 and specificity of 0.80 in determining ability to return to one’s previous level of activity. Conclusion: Our study suggests that AOT is a viable option in the management of large osteochondral talar defects in an athletic population, with favorable return to sport level, patient satisfaction, and FAOS/VAS scores. The ability to return to sport is predicated upon good graft incorporation, and further research is required to optimize this technique. Our data also suggest that patients should be aware of the increased risk of developing knee donor site pain when 3 osteochondral plugs are harvested.

Analysis of congruence for talar dome geometry among tali of different sizes

Traumatic injury and idiopathic avascular necrosis of the talus bone can result in osteochondral lesions of the talus leading to pain, motion loss, and disability. Treatment with osteochondral allografting currently requires the donor talus to be size matched to the recipient talus to ensure precise fits. Eliminating or reducing the need for size matching would lessen costs and the delay between diagnosis and treatment. 3D models of 12 tali of varying sizes were used to analyze curvatures and profiles of select areas on the talar dome. The allograft procedure was mimicked to compare the results between using 20mm and 30mm osteochondral allografts with, and without, donor size matching. The observed curvatures and profiles on the talar dome were found to be consistent between tali of different sizes. Size matching was not required to have acceptable levels of deviation between donor and recipient tali when using 20mm length segments. Deviations without size matching were found to be very similar to the deviations with size matching with only 14.8% of the fits without size matching having larger deviations (although less than 1.5mm) than those with size matching. Using the 30mm segments, there was a significant difference between the small female tali and the largest male tali. Thus, donor size matching is not necessary when treating large osteochondral lesions of the talus with an osteochondral allograft taken from the central 20mm of the donor talar dome, and only sex matching may be necessary for 30mm grafts.

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.

Osteochondral Allograft Transplantation Surgery for Osteochondral Lesions of the Talus in Athletes

Osteochondral lesions of the talus (OLTs) continue to be a challenge for the treating surgeon, especially when lesions are refractory to marrow stimulation techniques. The purpose of this study is to evaluate the outcomes of lesions treated with osteochondral allograft transplantation. A review was performed of 30 athletes with 31 OLTs that were refractory to marrow stimulation or predicted to be refractory based on size and location of the lesion. Results were evaluated in terms of occupational outcomes and numeric pain scales. Lesions treated had a mean area of 1.37 (range 0.36 to 3.3) cm2. Overall excellent outcomes were achieved in 11 (35%) ankles. Nineteen (61%) ankles achieved good or excellent occupational outcomes, and 12 (39%) ankles demonstrated poor occupational outcomes and the patients were unable to continue their previous active occupations. Patients were found to have a mean pain scale score of 3 (range 0 to 7) of 10 at a mean of 21 (range 10 to 24) months after operative management. Osteochondral allograft transplantation is an option for the treatment of selected athletes with large OLTs, as well as lesions that are refractory to marrow stimulation techniques. The results of this study may help active young patients and their surgeons to better understand outcomes and options in their shared decision-making process.

Comparative Outcomes for the Treatment of Articular Cartilage Lesions in the Ankle With a DeNovo NT Natural Tissue Graft: Open Versus Arthroscopic Treatment.

Background:The treatment of osteochondral lesions of the talus (OLTs) with a juvenile cartilage allograft is a relatively new procedure. Although other treatment options exist for large OLTs, the potential advantage of a particulated juvenile allograft is the ability to perform the procedure arthroscopically or through a minimal approach. No previous studies have looked at the results of an arthroscopic approach, nor have any compared an arthroscopic technique with an open approach.Purpose:To compare the outcomes of an arthroscopic transfer technique with the previously published open technique.Study Design:Cohort study; Level of evidence, 3.Methods:A total of 34 patients (mean age, 33 years) underwent treatment of talar cartilage lesions with a DeNovo NT Natural Tissue Graft. Of these treatments, 20 were performed arthroscopically and 14 were performed with open arthrotomy. There was no statistically significant difference between the groups with respect to age, lesion width, lesion depth, lesion length, or operative time. The mean lesion area was 107 mm2. The scores from 6 different validated outcome measures were recorded for patients in each group preoperatively and subsequently at 6 months, 1 year, 18 months, and 2 years.Results:Comparing outcome scores at each time point to baseline, there were no statistically significant postoperative differences found between open and arthroscopic approaches with regard to the visual analog scale (VAS) for pain (P = .09), American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale (P = .17), Foot and Ankle Ability Measure (FAAM)–sports subscale (P = .73), Short Form–12 (SF-12) physical health summary (P = .85), SF-12 mental health summary (P = .91), or FAAM–activities of daily living subscale (P = .76).Conclusion:The treatment of talar articular cartilage lesions with a DeNovo NT Natural Tissue Graft demonstrated no significant differences in outcome at 2 years regardless of whether the graft was inserted with an arthroscopic or open technique.Clinical Relevance:Our analysis demonstrated no significant difference between an arthroscopic versus open approach at any time point for the first 2 years after implantation of a juvenile particulated cartilage allograft for large OLTs. With that said, both groups demonstrated improvement from baseline. These findings indicate that surgeons with different levels of comfort utilizing arthroscopic techniques can offer this treatment modality to their patients without altering their planned surgical approach. In addition, this will be particularly helpful in counseling patients for surgery when the extent of the defect will be evaluated intraoperatively. Patients can be counseled that they will likely have the same incisions regardless of whether they require debridement, microfracture, or implantation of a particulated allograft.

Osteochondral Allograft Transplantation for Osteochondral Lesions of the Talus: Midterm Follow-up.

Fresh osteochondral allograft (OCA) transplantation represents a biologic restoration technique as an alternative treatment option for larger osteochondral lesions of the talus (OLT). The purpose of this study was to evaluate midterm outcomes after OCA transplantation for the treatment of OLT. Nineteen patients (20 ankles) received partial unipolar OCA transplant for symptomatic OLT between January 1998 and October 2014. The mean age was 34.7 years, and 53% were male. The average graft size was 3.8 cm2. All patients had a minimum follow-up of 2 years. Outcomes included the American Academy of Orthopaedic Surgeons Foot and Ankle Module (AAOS-FAM), the Olerud-Molander Ankle Score (OMAS), and pain and satisfaction questionnaires. Failure of OCA was defined as conversion to arthrodesis or revision OCA transplantation. Five of 20 ankles (25%) required further surgery, of which 3 (5%) were considered OCA failures (2 arthrodesis and 1 OCA revision). The mean time to failure was 3.5 (range, 0.9 to 6.7) years. Survivorship was 88.7% at 5 years and 81.3% at 10 years. The median follow-up of the 17 patients with grafts in situ was 9.7 years. The mean OMAS improved significantly from 40 points preoperatively to 71 points postoperatively ( P < .05; range, 5 to 55). The mean postoperative AAOS-FAM core score was 81.5 ± 15 (range, 40.5 to 96.6). Fifteen of 17 patients responded to follow-up questions regarding their ankle; 14 patients reported less pain and better function, and 13 patients were satisfied with the results of the procedure. Our study of midterm results after OCA transplantations showed that this procedure was a reasonable treatment option for large OLT. Level IV, case series.

MRI Tracking of the Effect of Bioabsorbable Pins on Bone Marrow Edema After Fixation of the Osteochondral Fragment in the Talus.

Large osteochondral lesions of the talus (OLT) with good articular cartilage can be fixed by using bioabsorbable pins. These pins have various advantages but they can have adverse effects such as foreign body inflammation. This negative impact of pins on subchondral bone can be seen as bone marrow edema (BME) on magnetic resonance imaging (MRI). The purpose of this study was to investigate the course of change in BME on MRI, including osteolytic change around pins in OLT treated with pin fixation. This study comprised 13 ankles in 12 patients, who underwent surgeries to fix an OLT using poly-l-lactide acid pins. MRIs were taken at preoperative, 3, 6, and 12 months after surgery. The area of BME was measured at each time point, and osteolytic change around pins was evaluated. Moreover, pin insertion angle was measured. BME significantly decreased from preoperative to 6 and 12 months. At 1 year, 28.1% of pins exhibited osteolytic change around them. Pin insertion angle was significantly lower in those with osteolytic change than those with no osteolytic change. At 3 and 6 months and 1 year postoperatively, BME with osteolytic change was significantly greater than those patients with no osteolytic change. The American Orthopaedic Foot & Ankle Society score significantly improved from preoperative (76.6±3.4 points) to 1 year after surgery (98.5±3.8 points). A shallow pin insertion angle was associated with osteolytic change around pins and persistence of BME on MRI, although excellent results were obtained at 1 year after surgery. Level III, retrospective comparative series.

3D-printed Talar Components for the Reconstruction of Large Osteochondral Lesions of the Talus

Category: Ankle Introduction/Purpose: The reconstruction of large osteochondral lesions of the talus (OLTs) presents a clinical challenge. In this study, a biomechanical experiment was performed using 3D-printed talar components for the reconstruction of large talar lesions, and intra-articular stress tests were conducted before and after implantation. Methods: Eight cadaveric ankle specimens were used in this study. After the specimen was fixed on an Instron mechanical testing machine, a piece of Fuji pressure-sensitive film was inserted into the articular cavity. A vertical pressure of 1500-N was applied to the ankle when it was in different positions, i.e. neutral, 10 degrees of dorsiflexion, and 14 degrees of plantar flexion. The total pressure-bearing area and the pressure intensity (MPa) on the talus were calculated to determine their changes before and after implantation. Results: The pressure-bearing area of the talus varied with the ankle position in the following order: 10 degrees of dorsiflexion &gt; neutral position &gt; 14 degrees of plantar flexion (P&lt;0.05). The pressure intensity exerted on the talus varied in ascending order: 10 degrees of dorsiflexion &lt; neutral position &lt; 14 degrees of plantar flexion (P&lt;0.05). However, the intensity of the pressure on the graft was insignificantly different from the overall pressure intensity on the talus (P&gt;0.05). Conclusion: Treatment using a 3D-printed talar component can achieve precise reconstruction of a large OLT after the surgical removal of the talar lesion. The pressure intensity on the repaired site did not change before and after the operation, indicating the clinical feasibility of this approach.

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.

Outcomes following repeat ankle arthroscopy for osteochondral lesions of the talus (OLTs)

Category: Ankle, Arthroscopy Introduction/Purpose: Management of symptomatic osteochondral lesions of the talus (OLTs) previously treated with arthroscopy remains controversial. Many advocate for open surgical intervention, particularly in patients with larger OLTs. Minimal data, however, exists on the role for repeat ankle arthroscopy. Here, we describe our experience with repeat arthroscopy for symptomatic OLTs, hypothesizing similar pain and satisfaction scores regardless of OLT size. Methods: Our surgical database was queried to identify patients who underwent repeat arthroscopy from February, 1997 – May, 2015. From that cohort, we identified a subset of patients with a diagnosis of symptomatic OLT who were treated with arthroscopic debridement and microfracture. We then performed a retrospective chart review. Phone surveys were conducted to assess clinical outcomes including pain and satisfaction scores as well as to record any subsequent surgery reported by the patient. Using previously defined criteria for size threshold, OLTs were categorized as either small (=150 mm2) or large (&gt; 150 mm2) based on operative dimensions noted at the time of repeat surgery. Results: We identified 15 patients who underwent repeat arthroscopy for symptomatic OLTs. Patients reported reasonable satisfaction (average: 7.3, SD: 2.7) but moderate residual pain (average: 4.6, SD: 3.3) at midterm follow-up (average: 5.0 years, SD: 2.8). Further surgery after repeat arthroscopy was performed in 20% (3/15) of patients. Only 1 patient developed a postoperative complication (superficial DVT treated with observation). Small (n=6) and large OLTs (n=9) had similar postoperative pain scores (4.2 ± 3.7 versus 4.9 ± 3.2), postoperative satisfaction levels (7.5 ± 3.4 versus 7.2 ± 2.3), and reoperation rates (33% versus 22%) (P&gt;.05). Patients with larger OLTs were younger at the time of repeat arthroscopy (P=.026) with no differences in sex or BMI (P&gt;.05) between groups. Conclusion: At midterm follow-up, repeat arthroscopy for symptomatic OLTs demonstrated reasonable satisfaction but with moderate residual pain and a 20% rate of subsequent surgery. There was no statistically significant difference in postoperative pain scores, satisfaction scores, or reoperation rates between small and large OLTs. Repeat arthroscopy for symptomatic OLTs can be done safely – however, patients should be educated to have guarded optimism regarding their outcome.