Approach Considerations
Conservative treatment of osteochondral lesions of the talus (OLTs) should be attempted first, whenever possible. After a period of immobilization followed by physical therapy, patients with continued symptoms should be evaluated with magnetic resonance imaging (MRI) and other imaging studies to assess the condition of the articular cartilage and stability, as well as to detect any intra-articular bodies. [35]
Symptoms of intra-articular derangement are indications for operative intervention. Such symptoms include effusion, catching or locking of the ankle, instability preceded by pain, and ankle pain relieved with diagnostic local anesthetic injection.
Surgery to treat OLTs is contraindicated when the risks outweigh the perceived benefits. Risks include active infection in the operative area, patient noncompliance, and medical instability in patients. Relative contraindications include degenerative changes of the ankle involving more than an isolated OLT.
Future controversies will likely revolve around minimizing operative morbidity and costs. Early reports with allografts showed some subsidence and resorption, necessitating ankle arthrodesis. If this trend continues, the use of allografts may fall from favor.
Thus far, autologous osteochondral grafting seems to be the most reproducible and stable grafting technique. As this procedure gains favor, more reported complications at the knee donor site may evolve. A study suggested that when failure of grafting occurs, using a metal resurfacing inlay implant for revision surgery of moderate-sized lesions may be considered; however, additional data are needed for validation of this technique, and the long-term results are unknown. [45]
Autologous chondrocyte transplantation (ACT; also referred to as autologous chondrocyte implantation [ACI]) is based on actual repair of deficits of articular cartilage. Additional histologic and long-term clinical data are needed to determine the success or failure rate of this therapy. This technology is fairly cost-prohibitive, with the expense of cell culture and two surgical procedures. Future possibilities may include the use of adhesive patches instead of the periosteal flap, as well as the addition of growth factors. [28]
In conjunction with marrow-stimulation techniques, [46, 47] restorative tissue (juvenile particulated allograft cartilage, allograft extracellular matrix) biologic adjuncts (ie, mesenchymal stem cells, platelet-rich plasma [PRP], bone marrow aspirate concentrate [BMAC] [48, 49] ) may play a role in the management of OLTs. There remains a need for further research in this area to determine practicality and long-term efficacy. [50, 51, 52, 53, 54] A systematic review (11 studies; N = 527) by Bachir et al cited good clinical results with BMAC. [48]
In July 2018, a supplemental issue of Foot and Ankle International was published that dealt extensively with newer concepts related to management of OLTs, in conjunction with a review of existing literature and recommendations for future research. [55] This material would serve as a useful introduction for surgeons desiring to follow future research efforts.
Medical Therapy
Conservative management of OLTs should be attempted before surgical management is embarked on. (See the images below.)
Osteochondral lesions of the talus. Illustration of percutaneous transmalleolar drilling.
Symptomatic patients with negative findings on plain radiographs should undergo an initial period of immobilization, followed by physical therapy. Studies have shown that a trial of conservative therapy does not adversely affect surgery performed after conservative therapy has failed. [15, 17] One study demonstrated that nonoperative conservative treatment can sometimes result in healing of higher-stage lesions. [12] Patients whose plain images indicate OLTs and those who remain symptomatic after 6 weeks should undergo additional evaluation with MRI.
Surgical Therapy
Surgical treatment depends on a variety of factors, including patient characteristics (eg, activity level, age, degenerative changes) and lesions (eg, location, size, chronicity). Generaly, however, surgical treatment adheres to one of the following three principles:
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Removing loose bodies, with or without stimulation of fibrocartilage growth (microfracture, curettage, abrasion, or transarticular drilling) [56]
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Securing OLTs to the talar dome through retrograde drilling, bone grafting, or internal fixation
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Stimulating the development of hyaline cartilage through osteochondral autografts (osteochondral autograft transfer system [OATS], mosaicplasty), allografts (particulated juvenile cartilage), or cell culture (eg, Carticel; Genzyme Biosurgery, Cambridge, MA)
Preparation for surgery
Radiographic imaging is essential for assessing alignment and grading the OLT. A marked distortion of normal mechanical alignment must be corrected in the same operative setting as the surgical procedure performed to address the OLT. Grading the OLT allows for proper prognostication and influences whether the lesion can be approached with an antegrade or a retrograde technique.
Operative details
Surgical exposure
When anterolateral OLTs are treated, open surgical exposure is accomplished via an anterolateral approach to the ankle joint. Plantarflexion aids in exposing the lesion; however, this approach requires caution to avoid damaging the branches of the superficial peroneal nerve.
The open approach is also challenging when posteromedial OLTs are treated. An osteotomy cut that enters the joint too far laterally can endanger the weightbearing plafond, and a cut that enters the joint too far distally on the medial malleolus limits exposure. Screw holes must be predrilled before osteotomy. In addition, care must be taken to avoid injury to the allograft nerve and vein, anterior tibial tendon, posterior tibial tendon, flexor digitorum longus (FDL), posterior tibial artery, and tibial nerve.
An apex proximal chevron bone cut provides excellent visualization; Cohen et al had no nonunions or malunions when using a chevron medial malleolar osteotomy in 19 patients. [9, 57]
Posteromedial OLTs have also been treated by using a combined anterior and posterior arthrotomy exposure. This approach allows access to 80% of the talar dome while it avoids the medial malleolar osteotomy in most cases. [58]
Arthroscopic treatment of OLTs can be accomplished by using wide-angle 2.7-mm arthroscopes, which provide more maneuverability than the older 4- and 5-mm arthroscopes. Noninvasive joint distraction techniques enable easier visualization of the entire talar dome. [59, 60, 61, 62]
Treatment of completely detached lesions
For a completely detached lesion believed to be inappropriate for internal fixation, removal of the loose body and debridement of the bony bed are indicated. The base of the bed should be debrided back to bleeding bone, and the edges should be trimmed back to viable cartilage. Instruments available for use in this procedure include blunt-tipped probes, pituitary graspers, gouges, Kirschner wires (K-wires), awls, full-radius shavers, ring curettes, and high-speed burrs.
Studies have shown that excision and nonoperative treatment yield poor results and that excision, curettage, and drilling provide the best outcomes. [20] Although high-level evidence has been lacking, long-term follow-up of microfracture has been associated with good results. [63] In a study (N = 81) comparing arthroscopic microfracture (n = 42) with arthroscopic debridement (n = 39) for treatment of OLTs, Zhang et al found the former to be superior to the latter for improving ankle function, especially in relatively young men with a relatively low body mass index (BMI). [64]
Treatment of intact lesions
Drilling of the subchondral bone creates channels to enable revascularization of the fragment. Drilling can be accomplished by using existing arthroscopic portals, a curved meniscus-repair needle guide, and transmalleolar drill holes. [34, 65]
Sinus tarsi approaches to posteromedial lesions, also known as retrograde drilling or transtalar drilling, do not disrupt the articular surface. Retrograde drilling can facilitate bone grafting, which is ideal for large subchondral cystic lesions with intact articular cartilage. The COLT (Interpore Cross, Irvine, CA) provides for accurate positioning of the drill hole and a cannula for bone graft delivery. Studies have shown good clinical and radiographic results with transarticular/transmalleolar drilling and retrograde/transtalar drilling. [66, 67]
Internal fixation
The use of traditional bone screws passed in an antegrade fashion is discouraged because it results in irreparable damage to the intact articular cartilage. Screw fixation typically is used for anterolateral lesions only because of the difficulty in gaining good exposure for posteromedial lesions. K-wires can be inserted in a retrograde manner through a nonarticular portion of the talus. Bioabsorbable pins can be advanced immediately below the articular surface, then cut off at the skin.
Bone grafting
The authors have reported successful fixation after autogenous osteochondral grafting of an osteochondritis dissecans (OCD) of the knee. [68] Another report described treating 27 large (8 × 8 mm and larger) ankle lesions with a cortical bone peg technique. [69] The pegs, which were 2-3 mm wide and 15-20 mm long, were harvested from the distal tibia and passed through the articular surface. Good clinical results were reported in 89% of patients at an average of 7 years of follow-up.
The contemporary consensus is that lesions with a depth of more than 5 mm should be bone-grafted.
Another study, with an 11-year mean follow-up, reported nine cases of fresh osteochondral allografting. [70] Of nine grafts, six remained in situ, and three patients required ankle arthrodesis because of resorption and fragmentation of the graft. These authors discouraged the use of allografting in OLTs. A high rate of complications has been reported in patients who underwent tibiotalar osteochondral allografting. [71]
However, a systematic review assessing clinical outcomes of fresh osteochondral allografting for OLTs by Pereira et al (12 studies; N = 191; average age, 37.5 y; average follow-up, 56.8 mo) reported significant improvements in American Orthopaedic Foot and Ankle Society (AOFAS) ankle/hindfoot scores in six studies and significant decreases in visual analogue scale (VAS) pain scores in five studies. [72] The aggregate graft survival rate was 86.6%, and 21.6% of patients required minor subsequent procedures.
A study by Gorgun et al (N = 94) assessed single-step all-arthroscopic treatment of OLT (involving debridement, microfracture, autologous bone grafting, and application of fibrin sealant) with (n = 46) and without (n = 48) the addition of a collagen scaffold. [73] Both groups showed significant improvements from preoperative to postoperative AOFAS and VAS scores, with no significant differences between the two groups.
Autologous osteochondral grafting
Autologous osteochondral grafting techniques, including the OATS procedure and mosaicplasty, involve grafting a plug from the femoral trochlea or condyle into the OLT on the talar dome. [74]
The OATS procedure transplants a single plug into the OLT, and mosaicplasty is used to harvest and transplant multiple plugs. [75] Single-plug grafts result in reduced ingrowth of the fibrocartilage, though donor-site morbidity may be greater because of the need to harvest a single larger plug. [76] The mosaicplasty procedure is said to provide a better match to the talar dome contour and surface area of the defect, though 20-40% of the defect is filled with fibrocartilage. [25]
Several groups have reported good results with both procedures. In one study, 11 patients who underwent mosaicplasty had good-to-excellent results at 24 months. [77] The lesions averaged 18 × 10 mm, and there were no adverse effects on the knee. Another study reported that 94% of 36 patients undergoing mosaicplasty had good-to-excellent results, with follow-up ranging from 2 to 7 years. [26] Previous surgical procedures had failed in 29 of the patients.
In another study, plugs were harvested from the ipsilateral medial or lateral articular facet of the talus in 12 patients. Significant improvement in AOFAS scores was reported, and no structural failures occurred in the graft or donor site. [78]
A modified mosaicplasty technique has also been proposed for management of severe OLTs. Leumann et al discussed using autologous bony periosteum–covered plugs harvested from the iliac crest for management of lesions larger than 1.5 cm2. [79]
Autologous chondrocyte transplantation
Two reports described good early results with ACT. [80] Koulalis et al reported the results of ACT in eight patients (average follow-up, 17.6 mo). [81] Patients first underwent diagnostic arthroscopy, cartilage biopsy, chondrocyte extraction, and culture; an average of 2.5 weeks later, they underwent arthrotomy, malleolar osteotomy, bone debridement, and chondrocyte transplantation. They were kept on nonweightbearing status for 6-7 weeks. Routine arthroscopic examination performed 6 months after the transplant showed cartilagelike tissue completely covering the OLTs. (Histologic examination of one biopsy sample did not show hyaline cartilage.)
Giannini et al reported similar results 24 months post transplant, showing that hyaline cartilage can be transplanted in the ankle joint and that good function can be expected. [82]
ACT has been performed more often in the knee. Results of the first 100 patients undergoing this procedure in a multicenter 5-year study found that 79% showed improvement at 5 years. Compared with a control group undergoing different procedures, such as drilling or abrasionplasty, patients undergoing the transplant procedure had better functional outcomes. [83]
A derivative of this method is autologous matrix-induced chondrogenesis (AMIC), which may be done via either an open or an arthroscopic approach. A systematic review by Malahias et al (13 studies) found both arthroscopic and open AMIC procedures to be effective and safe for the treatment of OLTs, though a higher reintervention rate might be expected with the open technique. [84]
Particulated juvenile cartilage allograft
This technique uses particulated juvenile cartilage allograft from donors younger than age 13 years. It is proposed that immature chondrocytes have an increased propensity to regenerate hyalinelike cartilage and have greater metabolic activity. [85] Limited studies are available using this technique, with only relatively short-term follow-up. [86, 87, 88]
Early results for small to moderate-sized lesions demonstrated good outcomes at short-term follow-up. [86, 87] Coetzee et al reported that for lesions with a diameter of 15 mm or greater, only 56% of patients reported good-to-excellent results on the AOFAS Ankle-Hindfoot Scale at 16-month follow-up. [86]
Treatment of coexisting OLT and ligamentous instability
Acute ankle ligament injuries with a large, unstable fragment typically first undergo surgical repair of the talar lesion. The ligament is allowed to heal postoperatively.
Treatment decisions for treating chronic OLTs with chronic ankle instability are less clear. Postoperatively, OLTs require early motion, which is not appropriate for reconstructed ligaments. Options include first repairing the OLT and then repairing the ligamentous injury at another time, or else repairing the two injuries simultaneously and postponing early ankle motion until the ligament has healed. Thermal capsular shrinkage may also be a possible treatment solution. [68]
Postoperative Care
A postoperative rehabilitation program should be tailored to each patient's individual circumstances and goals by a licensed physical therapist. With the goal of attaining full ankle range of motion (ROM), physical rehabilitation includes active and passive ROM exercises and a home program, edema control, and strength and proprioceptive training.
Rehabilitation can generally begin after healing is demonstrated, which may occur after 6-7 weeks of nonweightbearing status if drilling or internal fixation was performed. Lee et al compared early (2 wk) weightbearing with delayed (6 wk) weightbearing following arthroscopic debridement and microfracture of small to medium-sized OLTs and found no difference in outcome between the two groups. [89]
Complications
Operative treatment of OLTs has inherent risks. Open exposure entails use of a medial malleolar osteotomy or anterior plafond bone block to gain exposure of the tibiotalar joint. The medial malleolar osteotomy typically heals well with a low incidence of nonunion, but care must be taken to place the osteotomy correctly and protect the adjacent tendons and neurovascular structures. [57]
With second-look arthroscopy, Kim et al found that postoperative pain (visual analogue scale [VAS]) and function (AOFAS Ankle-Hindfoot Scale) scores were significantly worse when the tibial plafond at the malleolar osteotomy site was uneven. [90] An anterior tibial bone-block access window is associated with a lower risk of malunion but may limit access to posterior lesions. [78]
Arthroscopic intervention is associated with less surgical morbidity and joint stiffness, decreased rehabilitation time, and an increased functional outcome. [91]
Schuman reviewed 22 patients who underwent arthroscopy with curettage and drilling at an average follow-up of 4.8 years, with 86% good-to-excellent results. [92] Complications associated with arthroscopy include hyperesthesia around the portal incision and, occasionally, neuralgia of the superficial peroneal nerves, but these were minor and transient.
Some have advocated the use of allograft implants, but these grafts may become resorbed over time and fragment, necessitating ankle arthrodesis. [70] So far, no reports have been made of allograft rejection by the host.
The osteochondral transplantation procedures carry the additional risk of a second surgical site, which adds to the risk of possible complications. A 4-year follow-up of 36 mosaicplasty patients reported six patients with donor-site complaints during strenuous exercise, but this resolved after the first year. [26] Woelfle et al, in a study of 32 patients who underwent the OATS procedure, determined that advanced age (>40 years) is associated with higher donor-site morbidity. [93] The OATS procedure is thought to have greater donor-site morbidity, in that larger plugs are taken than are taken with mosaicplasty.
Gautier et al evaluated 11 patients at a 24-month follow-up and found that 10 of 11 had graft incorporation and were without major complications. [77] Subjectively, patients may report mild pain or stiffness in the knee or ankle, but this is without objective deficits. Similarly, other authors have found good graft incorporation without serious complications. [8, 26] Restoration of articular surface congruity may be very difficult, particularly in talar shoulder lesions.
Published reports of ACT have been relatively few but have included good results. [81] The procedure does necessitate two operations and is difficult technically, but no complications have been reported.
Long-Term Monitoring
Pain after operative treatment of OLTs is common for up to 1 year. MRI changes, including edema, are slow to resolve and often match the patient's report of an achy feeling in the joint. After 6 months, a persistent effusion, a catching sensation, or severe pain signifies that healing is not progressing as intended, and further investigation with computed tomography (CT) or MRI is appropriate.
In a study by Cuttica et al, follow-up MRI at a minimum of 9 months' follow-up revealed an odds ratio of 7.8 for a poor outcome when moderate or severe edema intensity was present as compared with mild or no edema intensity following microfracture. [37]
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Berndt and Harty staging system for osteochondral lesions of the talus, with grades 1-4.
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Osteochondral lesions of the talus. Modified staging system by Loomer et al.
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Osteochondral lesions of the talus. Classification system based on CT.
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Osteochondral lesions of the talus.
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Osteochondral lesions of the talus. Illustration of percutaneous transmalleolar drilling.
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Osteochondral lesions of the talus. Cannulated drill placed over a guidewire.
