Exclusion criterion
No.
Combination of diagnoses
14
Follow-up <6 months
14
Therapy inadequately described
8
<18 years old
17
Single case report
33
Double publication
17
No well-defined outcome
37
<10 patients
37
Combination of therapies
25
Total no. of excluded studies
202
10.3.2 Population Characteristics
In the 52 eligible studies, the total number of included patients with an OCL of the talus was 1,361. Average age was 31 years (18–75), and 63 % were male and 37 % female. The right ankle was involved in 57 % and the left in 43 %. Lesions were medial in 62 %, lateral in 36 %, central in 1 %, and medial and lateral in 1 %. A history of ankle trauma was reported in 86 % of cases. There was a primary defect in 84 %. For about half of the patients, the Berndt and Harty stage was mentioned. In 13 % it considered a Berndt and Harty stage 1 lesion, in 22 % a stage 2 lesion, in 40 % a stage 3 lesion, and in 25 % a stage 4 lesion. For evaluation of the result of therapy, the AOFAS Ankle/Hindfoot scale was most used [28] (Table 10.2).
Table 10.2
Scoring systems used for treatment of talar osteochondral lesions in the included studies. Some studies used more than one scoring system
Scoring system | No. of studies |
|---|---|
AOFAS Ankle/Hindfoot scale | 16 |
Scoring system developed by the authors | 18 |
Hannover score | 5 |
Patient satisfaction score | 5 |
Criteria proposed by Berndt and Harty | 5 |
Visual analog scale | 3 |
Martin score | 3 |
Alexander and Lichtman | 3 |
Ogilvie-Harris score | 2 |
MODEMS | 2 |
Karlsson scoring scale | 2 |
Tegner score | 1 |
Evaluation proposed by Loomer | 1 |
Mazur score | 1 |
Freiburg ankle score | 1 |
SANE | 1 |
According to Thompson and Loomer | 1 |
McCullough score | 1 |
10.3.3 Treatment Strategies
10.3.3.1 Nonoperative Treatment: Rest
This may be rest and/or restriction of (sporting) activities with or without treatment of nonsteroidal anti-inflammatory drugs (NSAIDs). The aim is to unload the damaged cartilage so edema can resolve and necrosis is prevented. Another objective could be healing of a (partly) detached fragment to the surrounding bone. Eighty-six patients, divided over three studies, were treated with rest for OCD [6, 49, 55]. The rationale to choose nonoperative treatment was not always clearly described. Stage of the lesion was not described. Two studies date back from 1953 [49] and 1975 [6]. At the time these studies were published, surgical treatment of talar OCL wasn’t as common as it is today. The duration of symptoms prior to institution of nonoperative treatment was either unreported or ranged from subacute to acute (<6 weeks) to chronic (>6 weeks). In the most recent study, patients were given the choice between operative and nonoperative treatment and chose nonoperative treatment [55]. Conservative treatment consisted of weightbearing as tolerated. In 39 of 86 patients (45 %), conservative treatment reported to be successful (range 20–54 %).
10.3.3.2 Nonoperative Treatment: Cast
Unloading the damaged cartilage is the aim of cast treatment. Duration of cast immobilization is between 3 weeks and 4 months. Four studies reported the results of this treatment [6, 9, 26, 45], and they date back at least two decades. In most cases, it involved a Berndt and Harty stage II or III lesion. In 44 of the 83 patients (53 %), the treatment was reported to be successful (range 29–69 %).
10.3.3.3 Excision
This involves excision of the partially detached fragment, without treating the defect that is left. Four studies reported the results of excision [14, 27, 41, 45]. In two studies excision was performed for superficial cartilaginous lesions, with mainly intact underlying subchondral bone. It could also involve a loose intra-articular fragment. In one study the lesions showed bony necrosis underneath. In 32 of 59 patients, the result was reported to be successful (54 %). Success rates varied from 30 to 88 %.
10.3.3.4 Excision and Curettage
After excision of the loose body, the surrounding necrotic subchondral tissue is curetted using either an open or arthroscopic technique. Most patients had a Berndt and Harty stage III or IV lesion, although also stage II lesions occurred. Thirteen studies, a total of 259 patients, reported the results of OCD treatment by excision and curettage [6, 9, 14, 20, 26, 27, 36, 37, 39, 42, 43, 46, 48]. In 199 of 259 patients, a successful result was reported (77 %). The success rate varied from 56 to 94 %.
10.3.3.5 Excision, Curettage, and BMS
Bone marrow stimulation involves creating multiple connections with the subchondral bone. It follows excision and curettage. The connections to the subchondral bone can be accomplished by drilling or microfracturing. The aim is to partially destroy the calcified zone that is most often present and to create multiple openings into the subchondral bone. Intra-osseous blood vessels are disrupted, and the release of growth factors leads to the formation of a fibrin clot. The formation of local new blood vessels is stimulated, bone marrow cells are introduced in the OCL, and fibrocartilaginous tissue is formed. Most patients had a Berndt and Harty stage III or IV lesion, but stage I and II lesions also occurred. Lesions were usually not larger than 1.5 cm in diameter. A total of 18 studies, including 388 patients, described the results of BMS [1, 3, 5, 7, 11, 16, 17, 20–22, 25, 38, 40, 41, 52, 57, 60, 63]. In 329 of 386 patients, treatment was reported to be successful (85 %). The success rate varied from 46 to 100 %.
10.3.3.6 Excision, Curettage, and Autogenous Bone Graft
In this technique, the defect that remains after excision and curettage is filled with autogenous cancellous bone. The objective is to restore the weightbearing properties of the talus. Indications for treatment were large, often medial lesions, exceeding 1.5 cm in diameter. Four publications reported the results of this technique, for 74 patients [8, 16, 29, 31]. In 45 of 74 patients, the result was successful (61 %). Success rates varied from 41 to 93 %.
10.3.3.7 Antegrade (Transmalleolar) Drilling
An OCL that is hard to reach because of its location on the talar dome can be drilled through the malleolus. A K-wire is inserted about 3 cm proximal to the tip of the medial malleolus and directed across the medial malleolus into the lesion through the intact cartilage. Two publications described the results of this technique, for 41 patients [30, 48]. In 26 patients, the result was reported to be successful (63 %, range 32–100 %).
10.3.3.8 Osteochondral Transplantation/OATS® (Arthrex)
These are the alternative to allografts for the treatment of OCL. Two related procedures have been developed: mosaicplasty and osteochondral autograft transfer system. Both are reconstructive bone grafting techniques that use one or more cylindrical osteochondral grafts from the less weightbearing periphery of the ipsilateral knee. The transplants are then placed into the prepared defect site on the talus. The objective is to reproduce the mechanical, structural, and biochemical properties of the original hyaline articular cartilage which has become damaged. It is performed either by an open approach or by an arthroscopic procedure. Indications involve large, often medial lesions, sometimes with a cyst underneath. Sometimes it is used as a secondary treatment, after failed primary (surgical) treatment. Nine studies described the results of 243 patients treated with OATS [2, 18, 20, 23, 32, 35, 51, 53, 54]. Good/excellent results were obtained in 212 patients (87 %). Success rates varied from 74 to 100 %. Morbidity of the donor knee joint was seen in 12 % of patients (0–37 %). Three studies did not discuss the possibility of postoperative knee pain [23, 32, 51].
10.3.3.9 Autologous Chondrocyte Implantation/ACI
The aim of ACI is to regenerate tissue with a high percentage of hyaline-like cartilage. First, a region of healthy articular cartilage is arthroscopically identified and a biopsy is taken. The tissue is minced and enzymatically digested. Chondrocytes are separated by filtration, and the isolated chondrocytes are cultivated in culture medium for 11–21 days. In a second stage, an arthrotomy is performed, and the chondral lesion is excised up to the healthy surrounding cartilage. A periosteal flap is removed from the tibia and sutured to the surrounding rim of normal cartilage. The cultured chondrocytes are then injected beneath the periosteal flap. Lesions larger than 1 cm2, in the absence of generalized osteoarthritic changes, are suitable for this technique. Four studies, describing 59 patients, were included [4, 19, 44, 68]. In 45 of 59 patients (76 %), a successful result was reported. The success rate varied from 70 to 92 %.
10.3.3.10 Retrograde Drilling
In case of a primary OCL with more or less intact cartilage with a large subchondral cyst, or in case a defect is hard to reach via the usual anterolateral and anteromedial portals, retrograde drilling is suitable. For medial lesions, arthroscopic drilling can take place through the sinus tarsi. For lateral lesions, the cyst is approached from anteromedial. Revascularisation is induced in the subchondral bone, and subsequently the formation of new bone is stimulated. A cancellous graft may be placed to fill the gap. Three publications, comprising 42 patients, were included [30, 50, 58]. It mainly involved medial lesions. Size of the lesions was not described. Postoperatively immediate range-of-motion exercises were commenced in all studies. After 2 [50], 4 [30], or 6 [58] weeks postoperatively, partial weightbearing was started. In 37 of 42 patients, this treatment was reported to be successful (88 %, range 81–100 %).
10.3.3.11 Fixation
Large loose fragments can be secured to the underlying bone using either a screw, pin, rod, or fibrin glue. One publication, for a total of 27 patients, met our inclusion criteria [33]. In this study, stage II–IV lesions were elevated, the bed was curetted and drilled, and after alignment of the fragment, it was reattached with at least two bone pegs from the distal tibia. Results were reported to be successful in 24 patients (89 %).
Results are summarized in Table 10.3.
Table 10.3
Results per treatment strategy
Treatment strategy | No. of studies | No. of patients | No. of patients good/excellent result | Success percentage (%) | Range (%) |
|---|---|---|---|---|---|
Nonoperative, rest | 3 | 86 | 39 | 45 | 20–54 |
Nonoperative, cast | 4 | 83 | 44 | 53 | 29–69 |
Excision | 4 | 59 | 32 | 54 | 30–88 |
Excision and curettage | 13 | 259 | 199 | 77 | 56–94 |
Excision, curettage, and BMS | 18 | 388 | 329 | 85 | 46–100 |
Autogenous bone graft | 4 | 74 | 45 | 61 | 41–93 |
TMD | 2 | 41 | 26 | 63 | 32–100 |
OATS | 9 | 243 | 212 | 87 | 74–100 |
ACI | 4 | 59 | 45 | 76 | 70–92 |
Retrograde drilling | 3 | 42 | 37 | 88 | 81–100 |
Fixation, bone pegs | 1 | 27 | 24 | 89 | – |
Total | 65 | 1,361 | 1,032 | 76 | 20–100 |
10.3.4 Quality Assessment of Included Studies
On “study design,” together 52 studies scored a total of 28 stars, out of a possible 104. On “selection,” 48 out of 52 possible stars were scored. On “outcome,” 34 out of 104 stars were scored.
10.4 Discussion
The most important finding of the review we discuss was that bone marrow stimulation (BMS), osteochondral transplantation (OATS) and autologous chondrocyte implantation (ACI) could be identified as the three most effective treatment options.
The review summarizes 65 study groups in 52 studies which describe treatment strategies for osteochondral talar lesions. There was a great diversity in trials concerning patient characteristics, staging of the defect, duration of follow-up, and outcome measures. A relatively large number of studies were dedicated to treatment by excision and curettage, excision and curettage and BMS, and OATS. The number of patients in other categories, mainly retrograde drilling, fixation, and transmalleolar drilling, was too limited for a reliable interpretation of the results. Therefore, no definitive conclusions could be drawn. Recommendations concerning these techniques must be judged accordingly. Some techniques do not apply to all Berndt and Harty OCL stages or are only suitable in the acute phase (<6 weeks). Retrograde drilling is usually reserved for large OCL with intact overlying cartilage, as confirmed by arthroscopy. It is the treatment of choice when there is a large subchondral cyst with overlying healthy cartilage. The studies concerning retrograde drilling did not describe size of the lesions [30, 50, 58]. Fixation is indicated for large fragments that can be reattached. It is applied especially in (sub)acute cases and in adolescents and children. Transmalleolar drilling is performed when a defect is hard to reach because of its location on the talar surface. A disadvantage is that healthy tibial cartilage is damaged. The reported results do not support the use of this technique [30, 48]. Besides, most talar lesions can be reached by means of the standard anterior or posterior arthroscopic approach, using intermittent distraction and a 90° microfracture probe [64, 65, 70].
Related posts:
Preoperative Planning for Osteochondral Defects
Rehabilitation After Replacement Procedures (i.e., OATS, Allograft)
Diagnosis of Chondral Injury After Supination Trauma
Rehabilitation After Bone Marrow Stimulation
Arthroscopy After Ankle Fracture
Diagnosis of Osteochondral Defects of the Talus by Computerized Tomography (CT) and Single-Photon Emission Computed Tomography (SPECT-CT)
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