Abstract
Background
To investigate autologous cartilage–bone graft survivorship and outcomes among young patients with symptomatic osteochondritis dissecans lesion of the talus a long-term follow-up study is warranted.
Methods
Nineteen patients who underwent a mosaicplasty operation of the talus were included. Follow-up assessment included a clinical follow-up visit with patient outcomes, and radiograph and magnetic resonance imaging evaluations.
Results
All mosaicplasty transfers were incorporated, 89 % of patients felt satisfied or neutral about the surgery, 53 % of patients retained the same osteoarthritis grade, and range of movement in the ankles was nearly the same. Patients were well-off in terms of pain and activities in daily living.
Conclusions
Mosaicplasty reconstruction seems to result in pain relief and improved subjective satisfaction and function. The results support the use of this treatment for symptomatic patients with large osteochondral defects of the talus after failed nonoperative management or other operative treatment.
Levels of Evidence
IV
1
Introduction
Cartilage surfaces act as a natural sliding surface at the joints and allow for soft and painless movement. In osteochondritis dissecans (OCD), an osteochondral body is detached from the load-bearing surface of the joint, resulting in damage to the articular surface. OCD is a disease of poorly understood etiology that causes damage to the cartilage of the joints, usually in the form of focal lesion . König in 1887 was the first to use the term OCD . It may start to manifest spontaneously or after trivial injuries to the joint . Osteochondral damage causes pain and often joint locking. If left untreated, OCD of the lower limb in most cases leads to joint degeneration and secondary osteoarthritis (OA) . The talus is the second most often place affected by the disease in the lower limb .
OCD diagnosed in adolescents can usually be treated conservatively by lessening the weight off the limb, provided that the OCD body is nondisplaced, and the cartilage surface is intact . In adults, options for surgical treatment include reattachment, microfracturing, mosaicplasty, bone marrow stimulation, and cartilage culture technology ,,,,, .
In mosaicplasty, autologous cartilage–bone grafts of the model of a cylinder are used to reconstruct the damaged area of the articular surface. Improvement of the damaged osteochondral area of the articular surface after mosaicplasty has been evaluated clinically through various functional ability questionnaires, imaging studies, second-look arthroscopies, and histological studies of tissue fragments . Currently, there is no consensus on which management is the optimal treatment for talus OCD. The body of knowledge concerning outcome after mosaicplasty for osteochondral lesion of the talus is scarce, and the cohorts are small and heterogeneous. More information about potential complications, reoperations, and patient-reported outcomes with control groups is needed.
The purpose of the long-term follow-up study was to investigate autologous cartilage–bone graft survivorship and patient satisfaction among a sample of young patients with symptomatic OCD lesion of the talus and radiological OA of different grades.
2
Material and methods
The Ethics Committee of the Helsinki and Uusimaa Hospital District, Helsinki, Finland, approved the study protocol (HUS/3365/2017).
2.1
Study subjects
This study included patients older than 16 years who underwent a mosaicplasty operation for symptomatic osteochondral (OCD) lesion of the talus between 2005 and 2018. Patients with pure traumatic talar chondral lesion without a bony defect were excluded. Twenty-one consecutive patients were eligible for inclusion.
The patients were invited to participate via an invitation letter containing a description of the research and an informed consent paper. Informed consent was obtained from all participants. Two declined to participate, leaving 19 patients for further analysis.
Four patients had previous talus operations (one microfracturing, one drilling of OCD body, and two OCD reattachments). The mean (standard deviation, SD) follow-up time from the onset of symptoms and mosaicplasty procedure was 34 (25) months.
One patient filled in the questionnaire and agreed to participate in radiological investigations but did not attend the clinical examination. One had bilateral OCD.
Before the surgery, half of the patients presented with pain during exercise without any type of previous injury. The rest had a mild trauma history with sustained walking pain.
2.2
Surgical technique
The surgeries were performed in a standardized manner by six different orthopedic surgeons without a tourniquet. Osteochondral lesion in the medial side of the talar dome was approached through vertical sagittal plane medial malleolar osteotomy with a short proximal transverse osteotomy line (17 cases) ( Fig. 1 ). Lateral lesion was approached through oblique sagittal plane lateral malleolar osteotomy (one case, Fig. 2 ) or without osteotomy (one case). Autologous cartilage–bone graft cylinders of 6, 8, or 10 mm were harvested with a COR Cartilage Repair System (COR®, DePuy Synthes Mitek Sports Medicine, Medos International Sàrl, Le Locle, Switzerland) from the ipsilateral lateral femur trochlea. The receiving site was drilled with the same size cannulated drill. The length of the cylinders was 8–12 mm. Medial malleolar osteotomy was fixed with two or three horizontal 4–6.5 mm cancellous screws whose canals were drilled before completing the osteotomy with an osteotome. Lateral malleolar osteotomy was fixed with a 6-hole, 3.5 mm, non-locking fibular plate.
A 39-year-old female patient had a low-energy sprain injury of the right ankle. The ankle joint remained symptomatic, and the patient had pain when walking and was unable to run one year before investigations. a-b Preoperative MRI illustrate type III osteochondral defect of the medial side of the talus . The size is 15x8x6mm. c-d Mosaicplasty with two osteochondral cylinders was performed through vertical sagittal plane medial malleolar osteotomy. Cancellous screws were removed later. e-f Six years after mosaicplasty MRI showed the incorporation of the osteochondral cylinders with good cortical layer and a small bone cyst. g-h Radiographs at the end of follow-up revealed K-L 1 degenerative changes in the talocrural joint . Patient was subjectively satisfied to the treatment result.
Osteochondral lesion of the lateral side of the talus was initially fixed with small biodegradable rods with arthroscopy assisted. The patient remained symptomatic, and the fragment did not heal. After three years, at the age of 19, the patient was reoperated. a-b The reconstruction was performed with two autologous cartilage-bone grafts through oblique lateral sagittal plane malleolar osteotomy. c-d Later, the lateral malleolar plate was removed. e-f Twelve years after mosaicplasty MRI showed the incorporation of the osteochondral cylinders with good cortical layer. Patient was subjectively satisfied with the treatment result.
Postoperatively, rehabilitation included an ankle brace or cast for 6 weeks, crutches, and toe-touch weight-bearing for the first 4 weeks, followed by one week of half weight-bearing, and one week of full weight-bearing. Range of motion exercises were started early by temporarily removing the cast or brace.
2.3
Radiographic and MRI evaluation
The OA Kellgren–Lawrence (K–L) grade was assessed from weight-bearing ankle radiographs at baseline, postoperative intervals, and follow-up .
OCD classification was performed from magnetic resonance imaging (MRI) according to Dipaola et al. . The severity of cartilage degeneration was determined from MRI at the end of follow-up using the International Cartilage Repair Society (ICRS) score : grade 0, normal; grade 1, nearly normal (superficial softening and/or superficial fissures and cracks); grade 2, abnormal (lesion extending to < 50 % of the cartilage depth); grade 3, severely abnormal (cartilage defect extending to > 50 % of the cartilage depth and down to the subchondral bone); and grade 4, severely abnormal (complete defect). The size of the osteochondral lesion was measured from preoperative MRI. The evaluations were performed by an experienced musculoskeletal radiologist (V.H.).
2.4
Outcome assessment
At the end of the follow-up period, European Foot and Ankle Society (EFAS) , and a validated Finnish version of the Foot and Ankle Outcome Score (FAOS) , questionnaires were sent to all patients. The EFAS questionnaire covers pain and physical function with a maximum of 24 points. The FAOS questionnaire has five subscales—pain, other symptoms, activities of daily living, sports/recreation, and quality of life—from 0 to 100, higher scores indicating better outcome. For the FAOS score, a minimal clinically important difference of 10 points was used , . A visual analog scale (VAS) from 0 to 100 mm was used to assess pain at rest and pain during movement.
2.5
Clinical evaluation
Dorsiflexion and plantar flexion range of motion of both ankle joints were measured with a goniometer by the study group physiotherapist .
A one-leg hop test was measured three times for each leg by the physiotherapist. The longest distances for the operated and non-operated limb were used .
2.6
Complications
Data on adverse surgical complications (deep wound infection, deep vein thrombosis, autologous cartilage–bone graft failure, neurological complication) and minor complications (superficial wound infection) were collected. Donor site morbidity was also documented during the clinical visit.
2.7
Statistical methods
The results are presented as number with percentage, mean with SD, or median with interquartile range. A two-tailed t -test was used. A null hypothesis was formulated—that there is no difference in the scores of the operated ankle and the healthy, non-operated ankle. The P value for significance was set at 0.05.
3
Results
Nineteen out of 21 patients (90 %) attended the late follow-up with a mean (SD) follow-up time of 124 (39) months. Altogether, 10 were females and 9 males. The mean age of the patients at time of operation was 29 (10) years and mean body mass index was 28 (6).
3.1
Patient-related outcomes
The healthy (control) ankles were asymptomatic with maximum points in patient-related outcome measures. When the operated and the control ankle were compared, there was a statistically significant difference in the mean EFAS score, VAS pain at rest, VAS pain during movement, and all subscales of the FAOS ( Table 1 ). The FAOS subscales activities of daily living and pain did not exceed the threshold for minimal important difference, indicating good outcomes.
Table 1
Outcome scores for the operated ankle and healthy control ankle based on the EFAS score, VAS pain at rest, VAS pain during movement, and the FAOS subscales of pain, other symptoms, activities of daily living, sports/recreation, and quality of life.
| Outcome measure | Operated ankle | Control ankle | P value |
|---|---|---|---|
| mean (SD) | mean (SD) | ||
| EFAS score (0–24) | 17.4 (5.0) | 21.9 (4.0) | 0.006 |
| VAS pain at rest (0–100) | 6.0 (6.8) | 0.9 (1.4) | 0.008 |
| VAS pain during movement (0–100) | 17.4 (25.1) | 5.0 (18.4) | 0.003 |
| FAOS score (0–100) | 84.5 (14.7) | 97.1 (8.3) | 0.002 |
| pain (0–100) | 89.0 (12.0) | 98.3 (7.0) | 0.007 |
| other symptoms (0–100) | 77.6 (21.4) | 94.4 (10.4) | 0.005 |
| activities of daily living (0–100) | 93.8 (8.4) | 98.8 (5.0) | 0.034 |
| sports/recreation (0–100) | 78.9 (28.6) | 96.3 (11.6) | 0.019 |
| quality of life (0–100) | 65.8 (28.9) | 94.1 (19.6) | 0.001 |
EFAS = European Foot and Ankle Society; FAOS = Foot and Ankle Outcome Score; SD = standard deviation; VAS = visual analog scale.
FAOS subscales: pain (9 items), other symptoms (7 items), activities of daily living (17 items), sports/recreation (5 items), and quality of life (4 items).
3.2
Subjective satisfaction
Eight patients (42 %) reported being very satisfied, 5 (26 %) satisfied, 4 (21 %) neutral (not worse or better than before surgery), 2 (11 %) unsatisfied, and none very unsatisfied with the result of the reconstructive surgery of the talus OCD.
3.3
Osteoarthritis progression
Between the preoperative assessment and final follow-up (median 10 years), the OA K–L grade did not deteriorate in 10 out of 19 patients (53 %), and in 9 patients (47 %) progression of the OA by one (7 patients) or two grades (2 patients) was noted. Final postoperative X-ray showed OA K–L grade 0 in three (16 %), grade 1 in 10 (53 %), grade 2 in three (16 %), and grade 3 in three (16 %) patients. None had K–L grade 4 ankle OA ( Table 2 ).
Table 2
Osteochondritis dissecans (OCD) lesion type and radiographic and magnetic resonance imaging (MRI) findings preoperatively and at final follow-up (n = 19).
| Patient | OCD | Preop osteoarthritis | Preop MRI | Mosaicplasty plugs | Postop OA | Postop MRI |
|---|---|---|---|---|---|---|
| Lesion type | K-L grade | OCD lesion size (mm) | number, diameter (mm) | K-L grade | ICRS grade | |
| 1 | III | 0 | 15x8x6 | 2 × 6 | 1 | 0 |
| 2 | II | 1 | 14x6x4 | 2 × 6 | 1 | 0 |
| 3 | III | 0 | 6x6x2 | 1 × 6 | 0 | 0 |
| 4 | II | 3 | 26x10x10 | 2 × 6 + 1 × 8 | 3 | 0 |
| 5 | II | 1 | 15x10x5 | 1 × 6 | 1 | 0 |
| 6 | ND | 1 | ND | 1 × 6 | 1 | 0 |
| 7 | III | 0 | 10x10x6 | 1 × 6 | 2 | 0 |
| 8 | III | 1 | 15x10x4 | 2 × 6 | 2 | 0 |
| 9 | II | 2 | 12x7x5 | 3 × 6 | 3 | 0 |
| 10 | III | 0 | 8x5x4 | 2 × 6 | 1 | 0 |
| 11 | II | 0 | 10x7x4 | 1 × 8 | 0 | 0 |
| 12 | II | 0 | 13x8x4 | 1 × 8 + 1 × 6 | 1 | 0 |
| 13 | II | 1 | 13x7x4 | 1 × 6 | 1 | 0 |
| 14 | II | 1 | 8x5x4 | 1 × 8 | 1 | 0 |
| 15 | II | 1 | 10x7x4 | 2 × 8 | 1 | 0 |
| 16 | II | 2 | 14x12x6 | 1 × 8 + 1 × 6 | 3 | III |
| 17 | III | 0 | 16x10x7 | 3 × 6 | 2 | IV |
| 18 | III | 0 | 12x8x3 | 3 × 6 | 1 | IV |
| 19 | II | 0 | 5x5x5 | 2 × 6 | 0 | IV |
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