Morphological evaluation post-retrograde drilling using second look arthroscopy showed no worsening of overlying cartilage at 1-year follow-up. In 90 percent of patients, grafts survive at least 10 years. 2006;88:303–308. 2003 Jun;8(2):233-42, viii-ix. They reported favorable outcomes with 86% of patients having no pain or only mild pain, no advancement of MRI staging in 84% of patients, and no significant ankle arthritis at final follow-up, though many patients reported minor discomfort on activities of daily living and sporting activities. Although outcomes of most of these techniques are promising, it is hard to recommend one procedure over another due to lack of comparative analyses. OATS uses bone-cartilage cylinder grafts from a non-weight bearing portion of another joint and transplants these on the site of the defect. Osteochondral lesions of the talus are injuries to the cartilage in the bone inside the ankle joint. FIGURE 71-1 Osteochondral lesion of the talus. Osteochondral lesions are caused by trauma, osteochondritis dissecans (OCD), or osteonecrosis.  The reported incidence of complication rate varies from 0 to 14% with superficial peroneal neuropathy and portal site pain cited as the most common complications. The etiology of osteochondral lesions of the talus is frequently attributed to ankle trauma but these lesions can also stem from alcohol abuse, chronic steroid use, endocrine abnormalities or genetics.  In case of clinically suspected lesion with negative radiographs, advanced imaging options such as CT and MRI are useful. Osteochondral lesions (OCLs) are focal articular injuries of the subchondral bone and the cartilage with a multifaceted cause (trauma, ligament instability, ischemic necrosis, malalignment, endocrine diseases, and others). Despite the advantages, the reported failure rate is 40% with lesions of area >125 mm2 and male sex associated with significantly higher risk of clinical failure. MRI is the most sensitive imaging for OLT with a sensitivity of 96%. Operative treatment of osteochondral lesions of the talus. Systematic review of treatment strategies for osteochondral defects of the talar dome. There are numerous reasons that make the talar cartilage and the subchondral bone prone to vascular insufficiency. Background: The incidence of osteochondral lesions (OCLs) in association with displaced ankle fractures has only been examined in two previous studies. The knee and the ankle joint are the most commonly involved joints for OCLs in the lower extremity. in their study of 22 patients with successful initial non-operative treatment of OLT reported only minimal symptoms, a low failure rate, and no significant progression of ankle arthritis at a minimum follow-up of 10 years, though a substantial number of patients (>1/3rd) reported a decrease in sporting activity. Because MRI may overdiagnose or overestimate the … , Operative treatment is indicated for OLT that have remained symptomatic even after a conservative trial for 3–6 months.  A recent systematic review on the role of PJCAT in OLT involving 10 studies and 132 patients showed good postoperative functional outcomes, however, the regenerated cartilage was heterogeneous in nature with relatively unaltered subchondral area which is in contrast to the belief that PJCAT would restore the area of defect to near normal cartilage. J Bone Joint Surg Am. in 1986. They highlighted the heterogeneity of the data and suggested the need for high-quality prospective randomized studies using validated outcome measures for clarity regarding the effective modalities of treatment for OLT.. Patient age for all such options is a significant restrictive factor since transplanted cells and marrow cells tend to lose regenerative potential … Radiographs showed a suspicious area on the lateral talar dome.  This technique is effective in treating large cystic lesions even up to 6 cm2 with favorable outcomes reported. Surgical treatment of transchondral talar-dome fractures (osteochondritis dissecans). Osteochondral autograft transplantation is used to address small to medium defects (1–4 cm 2), often with associated bone loss. This option is useful for large OLT with extensive subchondral cysts. There was a significantly lower cost for return to play in athletes after OAT versus microfracture at 1 year ($11,428 vs $16,953, respectively), 3 years ($12,856 vs $38,000, respectively), and 10 years ($32,141 vs $60,799, respectively). They are most commonly associated with ankle trauma and wh… found PRP as an adjunct to arthroscopic microfracture for the treatment of OLT resulted in improved functional score status at an average follow-up of 16.2 months. An osteochondral lesion of the talus is often a difficult problem to treat. Classification of operative techniques for OLT. This is a relatively newer technique that employs transfer of particulated juvenile cartilage pieces with their native extracellular matrix harvested from deceased donors aged from newborns to 13 years. Actual surgical treatments for osteochondral lesions and early knee osteoarthritis seem to be promising. Surgical treatment is indicated after a failed conservative trial, larger lesion and can be broadly split into cartilage repair, replacement, and regenerative strategies. First, the talar cartilage is relatively thinner with a thickness of 0.7–1.2 mm compared to that of other joints of the lower extremity. The diagnosis of cartilage damage (osteochondral lesion, also known as talar dome) is often done with x-rays and/or an MRI. | described the natural history of OLT in 43 patients who opted for conservative treatment with a minimum follow-up of 2 years. Retrograde drilling and fixation scored 88 and 89%, respectively. 2020 Jul 28;8(7):2325967120937798. doi: 10.1177/2325967120937798.  Kreulen et al. The aim of this study was to summarize all eligible studies to compare the effectiveness of treatment strategies for osteochondral defects (OCD) of the talus.  Either fixation or excision is recommended for acutely displaced lesions while conservative treatment is the initial treatment indicated for all acute undisplaced lesions and other symptomatic OLT presenting late. The skeleton … Osteochondral lesions of the talus (OLTs) continue to be a challenge for the treating surgeon, especially when lesions are refractory to marrow stimulation techniques. -, Alexander AH, Lichtman DM. Clipboard, Search History, and several other advanced features are temporarily unavailable. 2020 Aug 21;26:e921823. … There are a number of treatment options. ISSN (Print): AwaitedISSN (Online): 2582-7332, © 2020 Published by Scientific Scholar on behalf of Journal of Arthroscopic Surgery and Sports Medicine, Department of Arthroscopy & Foot and Ankle, Ganga Medical Centre and Hospital Pvt. , Most OLT are secondary to trauma, with up to 50% of ankle sprains resulting in some grade of cartilage injury. This may cause complications of the donor site and the ankle. Clinical Outcomes of Osteochondral Lesions of the Talus With Large Subchondral Cysts Treated With Osteotomy and Autologous Chondral Grafts: Minimum 2-Year Follow-up and Second-Look Evaluation. Thus, treatment should be individualized to every patient, with adequate counseling regarding the outcomes and associated complications of that technique. By the mosaicplasly technique, osteochondral grafts are transplanted from areas of little weight bearing at the outer limits of the trochlca to the focal lesion in the same knee. 1,2 Researchers have reported an occurrence of up to an astounding 73 percent in ankle fracture cases … J ISAKOS. -, Baums MH, Heidrich G, Schultz W, et al. However, due to great diversity in the articles and variability in treatment results, no definitive conclusions can be drawn. These repetitive injuries may result in microtrauma in an already vulnerable bone with sparse vascularity causing OLT.  Ferkel et al. Fifteen patients underwent mosaic osteochondral transplantation to treat a talar osteochondral defect lesion, with 11 patients available for follow-up. , This is a second-generation technique that employs a collagen matrix instead of a periosteal sleeve to secure the chondrocytes.  Toale et al. Orthopade. INTRODUCTION. Osteochondral lesions of the talus (OLT) are those that affect the chondral and subchondral areas of the talus. Berndt and Harty classification is the staging system that is widely employed for describing OLT on plain radiographs. Current treatment options include minced bone and cartilage paste, 1 mosaicplasty, 2 allogeneic osteochondral transplantation, 3-5 combined bone and chondrocyte transplantation, the so-called sandwich technique, and synthetic osteochondral implants. studied the factors influencing the results of ACI in OLT and concluded that size >137 mm2 and age <26 years to be significantly associated with better MOCART (modified magnetic resonance observation of cartilage repair tissue) scores while patients sex, depth of the lesion, and presence or absence of accompanied procedure did not affect the results of ACI in OLT. BMJ Case Rep. 2020 Jul 8;13(7):e234595. Series shows the case of a 25-years-old man, a sports and physically active patient, with chronic ankle pain, a lateral talus osteochondral lesion (OCL), and chronic ankle instability. Limited, Coimbatore, Tamil Nadu, Department of Orthopedics and Spine surgery. 1999;15:197–202. Scranton Type V Osteochondral Defects of Talus: Does one-stage Arthroscopic Debridement, Microfracture and Plasma Rich in Growth Factor cause the Healing of Cyst and Cessation of Progression to Osteoarthritis? This joint permits much of the up (dorsiflexion) and down (plantarflexion) motion of the foot and ankle. Arthroscopy. Choi et al. , Microfracture is a technique of perforating the subchondral bone to allow the progenitor cells from the bone marrow to infiltrate into the lesion [Figure 2]. Among the OLT, up to 94% of the lateral lesions are said to be secondary to trauma while only 62% of medial lesions are post-traumatic. IN) to treat patellar lesion. Because of the relatively high cost of ACI and the knee morbidity seen in OATS, we conclude that BMS is the treatment of choice for primary osteochondral talar lesions. The mean lesion size for microfracture was 3.4 cm 2, which is larger than the indicated size for this procedure. Introduction. Cystic lesions require curettage and penetration of the calcified wall of the cyst. OCD lesions are also called osteochondritis dissecans or osteochondral fractures. Yang and Lee revealed incomplete healing and inferior quality of cartilage in 36% (9/25) ankles in a second look arthroscopy analysis of arthroscopic microfracture at a mean follow-up of 3.6 years. [17,18] Arthroscopy remains the gold standard as it allows direct visualization, probing of the lesion to assess the stability of the overlying cartilage and also accurately assess the extent of the lesion. Table 3 below presents the base-case deterministic results when using an OCA graft price of £3892.50 (€4174) based on costs in Spain.  Commonly used classifications are summarized in [Table 1]. , The prognostic factors that determine the success of microfracture are listed in [Table 3]. The blood supply to the talus is not as rich as many other bones in the body, and as a result injuries to the talus sometimes are more difficult to heal than similar injuries in other bones. 2002;23:381–389. This is an US FDA approved allograft technique and was first made available in 2007 by DeNovo NT, Natural Tissue Graft (Zimmer, Inc., Warsaw. Autologous chondrocyte transplantation for treating cartilage defects of the talus. In both studies magnetic resonance imaging (MRI) was performed prior to open reduction and internal fixation (ORIF). Together with the newer techniques OATS and ACI, BMS was identified as an effective treatment strategy for OCD of the talus. The talus is the bottom bone of the ankle joint. Furthermore, improvement was better when PRP was used as an adjunct to microfracture than a conservative intraarticular injection of PRP. Foot Ankle Spec.  Although majority may …  As far as BMAC is concerned, varying degrees of beneficial effects have been reported in different studies when used as an adjunct to surgical procedures. Particulated nature gives mobility to the chondrocytes to escape from the minced pieces and form a hyaline cartilage like matrix in the area of the defect. -, Becher C, Thermann H. Results of microfracture in the treatment of articular cartilage defects of the talus.  This review aims to elucidate the historical aspect of the disease, etiopathogenesis, classifications, diagnosis, and treatment to assist in day-to-day clinical practice. Anders et al. Osteochondral Allograft transplantation for knee lesions after failure of cartilage repair surgery. NLM Guney et al. 2008 Mar;37(3):204, 206-11. doi: 10.1007/s00132-008-1219-3.  This is a broad terminology that encompasses a variety of disorders including osteochondritis dissecans, osteochondral fractures, and osteochondral defects.  The rationale is to form a hyaline cartilage at the defect from pluripotent cells instead of fibrocartilage that forms after microfracture alone. A history of ankle trauma/recurrent instability is to be elicited as OLT are associated with ankle instability. doi: 10.1016/s1083-7515(02)00064-5. Clinical examination may reveal effusion at the ankle, tenderness over the talus on palpation, decreased range of motion, and pain on ankle dorsiflexion and inversion. COVID-19 is an emerging, rapidly evolving situation. 1980;62:646–652. These lesions pose a diagnostic challenge to the attending clinician due to lack of specific clinical signs and lack in consensus regarding treatment makes the management aspect controversial. The key cost driver is the cost of the graft, but over the lifetime horizon, there are QALYs gained from using OCA, and there are cost savings later due to fewer people needing a TKA in the OCA arm. This consists of particles of live cartilage that enable the surgeon to truly lay down the best quality cartilage.  In 1959, Berndt and Harty were the first to describe the pathogenesis of osteochondral lesions post-trauma. [2,39] Flynn et al. reported retrograde drilling and autogenous bone grafting to be an excellent technique in their review of 41 patients of OLT with an intact overlying cartilage with good functional and radiological outcome. If you continue to use this site we will assume that you are happy with it. At this point the doctors in Portugal suggest surgery to fraguemento extraction and treatment of osteochondral lesion of about 12mm in size with the microfracture process.  The sole indication for operative treatment at presentation is an acute lesion with displacement. BMJ Open. They also proposed the radiological classification that is widely employed even to the present day. Finite Element Analysis of the Effect of Talar Osteochondral Defects of Different Depths on Ankle Joint Stability. J Bone Joint Surg Am. -. Med Sci Monit. A treatment gap exists for patients with lesions not suitable for arthroplasty or biologic repair or who have failed prior cartilage repair surgery. Once the piece has broken off, surgery is almost always necessary. Foot Ankle Int. The major advantages of arthroscopic surgery are that it is associated with a faster recovery due to less pain and earlier mobilisation of the ankle than after conventional open surgery. Good clinical outcome after osteochondral autologous transplantation surgery for osteochondral lesions of the talus but at the cost of a high rate of complications: a systematic review Carlos Ferreira,1 Gwendolyn Vuurberg,2 Joaquim Miguel Oliveira,3,4,5 João Espregueira-Mendes,3,4 Hélder Pereira,3,4,5,1 Rui Luís Reis,3,4 Pedro L Ripoll5 Epub 2014 Oct 19. Abstract: The objective of this study was to assess the outcome of osteochondral allograft (OCA) transplantation as a salvage procedure after various cartilage repair surgeries. Surgery to treat an osteochondral ankle lesion is a series of steps that usually starts with the least invasive technique, an arthroscope, as the last step of diagnosis before your surgeon progresses with whatever needs to be done to repair the top of your talus.  Although majority may be associated with trauma, some may develop insidiously. INTRODUCTION. , In summary, outcomes following surgery are variable and thus treatment strategy has to be tailored to every patient depending on specific factors. of the talus but at the cost of a hi gh rate of. transplantation surgery fo r osteochondral lesions. | Much of this bone is covered with cartilage. 2020 Feb 9;10(2):e033850. doi: 10.1136/bcr-2020-234595. Box 22660, 1100 DD, ... Because of the relatively high cost of ACI and the knee morbidity seen in OATS, we conclude that BMS is the treatment of choice for primary osteochondral talar lesions. Clinicians should have a high index of suspicion as symptoms and clinical signs may be non-specific. Therapeutic arthroscopy with microfracture leads to fibrocartilaginous repair and is an effective treatment of osteochondral lesions of the talus. Osteochondral allograft reconstruction (OCA) is highly cost-effective [30, 31] but the procedure is limited by the scarcity of fresh grafts and in some countries use is restricted by law [11, 46]. Electronic databases from January 1966 to December 2006 were systematically screened.  Although majority may be associated with trauma, some may develop insidiously. Patient’s consent not required as patients identity is not disclosed or compromised. A full diagnostic arthroscopy is performed, and then attention is turned to the osteochondral defect. If structured rehabilitation is unsuccessful, then … doi: 10.12659/MSM.921823. Les lésions du cartilage articulaire du genou sont fréquentes. reported a reoperation rate of 25% with development of moderate or severe ankle arthritic changes, pain due to hardware-related complications, graft collapse, and non-union/delayed union at osteotomy site as reasons for reoperation with a failure rate of 13.2%. Lesions with large cystic areas, diffuse arthritic changes, ankle malalignment, and prior history of infections are contraindications to this procedure. The skeletal system is made up of all the joints and bones in the body. The cost-per-point change in functional outcome score was $200.59 for MFx, $313.84 for OAT, and $536.59 for ACI-1.  Due to high rates of reoperation and failure, it is necessary to opt for other less morbid techniques initially, keeping this technique of osteochondral allografting as a bail out procedure in failed cases.  Axial loading with inversion and dorsiflexion has been described as the most common mechanism for lateral lesions while plantar flexion, inversion, and external rotation are possibly the mechanism for medial lesions.. This tissue is mechanically inferior, but the results of the procedure in the short term are generally good with smaller lesion (<1.5 cm 2) [16, 22]. Outcome. For each treatment strategy, study size weighted success rates were calculated. There is also the possibility to associate the treatment with growth factors. The main advantage of this procedure is that these harvested plugs are made up of hyaline cartilage (Type II collagen), restoring the articular cartilage to near normal.  Conservative treatment mainly consists of rest, avoiding sporting activities, cast immobilization with or without NSAIDs, and intraarticular injection of platelet-rich plasma (PRP) and hyaluronic acid (HA).  Weigelt et al.  Klammer et al. After a longer follow-up, some patients showed that the beneficial results were not maintained, indicating the deterioration of the …  Useful algorithm describing the indication for each procedure is outlined in [Figure 1]. High-impact activities, such as running and jumping, should be avoided until 6 to 12 months after surgery. Outcomes following surgery are variable and thus treatment strategy has to be tailored to every patient based on specific factors. Long-term follow-up. in their review of 82 patients reported increase in arthrosis by one grade radiologically though none of the patients had Grade IV arthritis at a minimum follow-up of 5 years. reported good pain relief and function in a prospective study of 10 patients with a long follow-up of 13 years and concluded that MACI should be considered for osteochondral lesions that fail initial microfracture treatment. Background: The incidence of osteochondral lesions (OCLs) in association with displaced ankle fractures has only been examined in two previous studies. [Diagnosis and treatment of osteochondral lesions of the talus]. Bai L, Guan S, Liu S, You T, Xie X, Chen P, Zhang W. Orthop J Sports Med. , It is a 2-stage procedure where in hyaline cartilage is harvested either from the neck of the talus or non-weight portion of the knee joint, this cartilage is then cultured to grow chondrocytes which are implanted back to the area of defect and secured using a periosteal flap as a second-stage procedure. One randomized clinical trial was identified.  This is a broad terminology that encompasses a variety of disorders including osteochondritis dissecans, osteochondral fractures, and osteochondral defects. , Injection therapy alone with PRP or HA has also been attempted in the treatment of OLT. and Hepple et al. Get the latest public health information from CDC: https://www.coronavirus.gov, Get the latest research information from NIH: https://www.nih.gov/coronavirus, Find NCBI SARS-CoV-2 literature, sequence, and clinical content: https://www.ncbi.nlm.nih.gov/sars-cov-2/. 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