Fig. 9.1
Computed tomography (CT) scan of an osteochondral defect of the talar bone. (a) Before debridement and bone marrow stimulation. (b) After debridement and bone marrow stimulation. (c) CT is made in full plantar flexion to see if the OCD is approachable arthroscopically
Table 9.1
Phases of OCD healing after bone marrow stimulation
Phase | Time in weeks | |
|---|---|---|
1 Inflammatory phase | Formation of fibrin clot that releases growth factors and cytokines to format granulation tissue | 1–2 |
2 Remodeling phase | Mesenchymal cells proliferate and differentiate into chondrocyte-like cells producing a matrix containing type II collagen and proteoglycans. Formation of fibrocartilaginous tissue and bone | 3–8 |
Fibrocartilaginous tissue turns into hyaline-like cartilage Formation of woven bone | 8–12 | |
Mixture of fibrocartilage and hyaline cartilage Formation of bone plate and reformed tide mark with restored subchondral bone | 12–48 |
9.3 Activity Levels
Before returning to activity/sports, it is important to quantify the patient’s level of activity. This can be monitored in various ways. Tegner and Lysholm described their activity score in 1985. It was originally tested for knee ligament injuries, but for the past 17 years, it has been used for other joint evaluations as well. The development of already existing and new kinds of sports, differences between knee and ankle loading, and different injury rates provided reasons for developing an ankle-specific activity score. Halasi et al. developed an activity score designed specifically for ankle joint. It is a single-page, easy-to-survey system that contains 53 sports, 3 working activities, and 4 general activities in categories from 0 to 10. Contact team ball sports and gymnastics are at the top of the list. The score is 10 for top-level, 9 for competitive-level, and 8 for recreational-level athletes [18]. Another activity score was developed in 1972 by Roles and Maudsley [19]. This system measures activity level, pain, and range of motion (ROM), but it is not restricted to the ankle joint. A more practical activity-level score was described for patients rehabilitating from Achilles tendon ruptures [20]. This consists of four levels of activity: walking, running, noncontact sports, and contact sports. The first and most basic level of activity after an injury is to return to normal walking. The second level is to return to running, the third is to return to a noncontact sport and the highest is to return to a contact sport. This system isn’t specific for Achilles tendon ruptures and can be applied for any ankle injury and thus also to monitor the rehabilitation after surgery for talar OCDs.
9.4 Rehabilitation
This 4-level activity scheme to return to activity is applicable for determining a return to activity after the debridement and bone marrow stimulation of a talar OCD. Return to activity is divided into four levels of increasing intensity: walking, running, return to noncontact sports, and return to contact sports (Table 9.2). Each of these levels demands specific training and exercises, and each have to be mastered before the next level can be attempted [20]. The patient’s activities are systematically expanded and carefully monitored. Before progression to the next phase and increasing training components like speed, force, and endurance all end, terms should be met. The four phases are outlined as follows:
Table 9.2
Return to activity after debridement and bone marrow stimulation of an osteochondral defect
Level | Goal | Training | End terms |
|---|---|---|---|
1 | Return to normal walking | Proprioception Passive and active sagittal ROM Force | Active stability Near normal Force, 25 % L/R → Normal walking |
2 | Return to running on even ground | Force Technical skills Endurance | Force <12 % L/R Sideward movement → Easy jogging |
3 | Return to noncontact sport | Speed Force Endurance | Running even ground Sprinting Force normalized Turning/twisting Rope jumping → Noncontact sports |
4 | Return to contact sports | Speed Force Endurance | Running uneven ground Explosive force Changing direction Sports-specific movements → Contact sports |
Level 1: The first level of activity commences on the day of the operation with active and passive dorsi- and plantar flexed motions and partial weight bearing. Early mobilization will prohibit joint stiffness. The classical wound repair cascade will start on the day of the operation. Partial weight bearing provides synovial fluid to nourish chondrocytes. After 6–8 weeks, fibrocartilaginous tissue is formed and full weight bearing is allowed to further stimulate osteoblasts in the formation of bone matrix. At the end of this phase, training of proprioception is commenced to regain normal active stability.
Level 2: The next level of activity is to resume running on even round. In case active stability has not yet been achieved, further training of proprioception might be needed. The ROM should be normalized. By training of force, endurance, and technical skills, the aim is to achieve controlled sideways movement, with the lower-leg force increasing to a left/right difference of less than 12 %. After increased activity, pain and swelling should have subsided within 24 h.
Level 3: The third level of activity is a return to noncontact sports. Training focuses on speed and endurance. Running or sprinting on even ground shouldn’t be problematic. At the end of this phase, rope jumping, turning, or twisting should be possible. Some pain may occur after intensifying activity but should be absent after 24 hours.
Level 4: This, the highest level of activity phase, is defined as a return to contact sports. Final training for gaining muscle strength, improving speed and endurance should make it possible to run on uneven ground, generating explosive force in sprinting, twisting, and turning and/or other sports-specific movements.
9.4.1 Level 1 (Walking)
In the literature, returning to normal weight bearing after debridement and bone marrow stimulation varies directly from post surgery to 8 weeks after surgery [10, 21–25]. Ogilvie-Harris et al. [25] allowed immediate full weight bearing according to comfort, whereas Chuckpaiwong et al. [27] splinted their patients for 1–2 weeks, after which they commenced ROM exercises and full weight bearing in walking boots. Barnes and Ferkel et al. [26] prefer to keep patients non-weight bearing for 4 weeks when the lesion is less than 1.5 cm in diameter and for 8 weeks when the lesion is larger. Saxena and Eakin [10] prevented weight bearing using a below-knee cast boot for up to 6 weeks, although patients with small lesions (<3 mm in diameter) were allowed to partially bear weight after 3 weeks. All patients were allowed passive ROM exercises at 3 weeks and at 6 weeks, active ROM exercises were allowed. In the study of Guo et al. [22], patients were allowed to advance to full weight bearing 8 weeks after surgery, while Lee et al. [23] had a non-weight-bearing period of 6–8 weeks and partial weight bearing after 8 weeks [23]. Seijas et al. [24] reported weight bearing after an average of 8 weeks (4–14 weeks).
Lee et al. [30] compared early versus delayed weight bearing. Early weight bearing was defined as partial weight bearing in the first 2 weeks followed by full weight bearing as soon as tolerated. In the delayed group, all patients were kept non-weight bearing for 6 weeks. Lee et al. showed no significant difference between the two groups.
9.4.2 Level 2 (Running)
Impact activities, such as running, were first allowed at 12 weeks by the following authors: Saxena and Eakin [10], Seijas et al. [24], and Ogilvie-Harris and Sarrosa [31]. No other studies mentioned return to running [21–23]. It is also the present senior author’s practice to allow running on even ground after 12 weeks.
9.4.3 Level 3 (Noncontact Sports)
Chuckpaiwong et al. [21] allowed patients to return to sports after 4–6 months, depending on muscle strength. Guo et al. [22] allowed sports after 6 months. In the study of Lee et al. [23], the ankle activity score by Halasi et al. significantly improved from 3 [1–5] to 6 [3–8] and showed that 63 % of their patients were returned to their pre-injury sporting level. Ogilvie-Harris and Sarrosa [25] reported in their study that 79 % of patients were able to return to unrestricted sports, 18 % were able to play but at a lower level, and 3 % were unable to return to any sports.
9.4.4 Level 4 (Contact Sports)
Saxena and Eakin [10] reported a significantly faster return to activity after treatment with microfracturing in high-injury-prone patients, such as soccer and basketball players, when compared with patients treated with bone grafting (15.1 ± 4.0 weeks vs 19.6 ± 5.9 weeks). Arthroscopically treated patients had a faster return to activity, compared with patients treated with an arthrotomy (15.8 ± 4.8 weeks vs 17.5 ± 5.5 weeks), but the difference was not statistically significant. Seijas et al. [24] reported a return to competition soccer within an average of 20 weeks. In our clinic, a full return to sports activities is usually possible 4–6 months after surgery [7, 27].
9.4.5 Influencing Factors
9.4.5.1 Age
Animal studies show that cartilage proteoglycans from immature animals are larger compared to those of mature animals. It is likely that OCDs in young individuals heal more effectively than in mature and elderly individuals [31]. This was supported by two studies, where younger patients with talar ODs had a better functional and clinical outcome after debridement and bone marrow stimulation. Kumai et al. reported a clinical good result (12 out of 13 ankles) in patients under the age of 30 after bone marrow stimulation, but in patients of 50 years and older, only 1 out of 5 patients managed the same results. Chuckpaiwong et al. also showed significant improvements in the outcome of surgical treatment when the patient is younger, has a lower BMI, and has a shorter duration of symptoms [32, 21]. However, other clinical studies failed to show that older age is an independent predictor for clinical failure after arthroscopic treatment [29, 33, 34].
9.4.5.2 Body Mass Index
9.4.5.3 Defect Size
An animal study has demonstrated that larger defects are less likely to recover completely [35]. Chuckpaiwong et al. [21] reported good to excellent results in 100 % of patients with lesions <15 mm in diameter (n = 73). However, they found a poor outcome in all but one of the 32 patients with lesions exciding 15 mm in diameter. The effect of the size of the lesion on the clinical outcome was further assessed by Choi et al. [36]. Of the 25 patients with lesions >15 mm in diameter, 80 % had a poor outcome. Clinically, the larger the defect size, the less likely a functional outcome for patients after debridement and bone marrow stimulation of the talus [21, 22]. It is concluded that the cutoff point is approximately 15 mm [36].
9.4.5.4 Hyaluronic Acid
Hyaluronic acid (HA) is widely used as a nonsurgical treatment option for ankle and knee osteoarthritis [37, 38], but it is also used in the treatment of talar OCD [39]. Intra-articular injection of HA reduces pain and inflammation and at the same time supplements the endogenous joint fluid. Some studies suggested that HA treatments facilitate a biological activation based on the lasting benefits of HA treatment long after the presence of HA after injection [40].
9.4.5.5 Mobilization
Immobilization has a great influence on the ankle joint. One week of ankle immobilization resulted in a loss in plantar flexion strength, balance, and walking gait in asymptomatic volunteers [41]. In animal studies, mobilization leads to thicker and stiffer cartilage with a greater concentration of endogenous proteoglycan [42–46]. In our clinic, we promote active dorsi- and plantar flexed movements, without weight bearing, direct post operatively.
9.4.5.6 Platelet-Rich Plasma
In vitro data shows a higher rate of proteoglycan synthesis and accumulation as well as collagen synthesis with treatment of platelet-rich plasma (PRP) [47]. PRP treatment also enhances mesenchymal stem cell (MSC) proliferation [48]. In animal studies, PRP treatment leads to more neochondrogenesis and glycosaminoglycans in OCDs after 4 weeks and to more hyaline tissue after 12 weeks. Although there is no literature on the use of PRP as an adjunct to surgical treatment, Mei-Dan et al. [39] recently performed a prospective clinical trial comparing PRP with hyaluronic acid (HA) injection for the treatment of osteochondral lesions of the talus. There was a significantly better clinical improvement after PRP treatment than after HA injection.
9.4.5.7 Insulin-Like Growth Factor
9.4.5.8 Bone Morphogenic Proteins
Bone morphogenic protein-7 (BMP-7) has been investigated for its capacity to regenerate articular cartilage and currently appears to be the gold standard growth factor for cartilage repair. In animal studies, BMP-7 appears effective in regeneration of osteochondral or focal chondral defects [55].
9.4.5.9 Platelet-Derived Growth Factor
Evidence to support the use of platelet-derived growth factor (PDGF) is extrapolated from its role in wound healing and stimulation of matrix synthesis in growth plate chondrocytes [52]. In an animal study, rats were injected into the knee and no adverse effects were noted in the cartilage or synovial membrane [56]. Presently, the most commonly used form of PDGF is as a component of platelet-rich plasma (PRP).
9.4.5.10 Transforming Growth Factor-b1
9.4.5.11 Pulse Electromagnetic Fields
In vitro studies show improved bone development, increased chondrocyte proliferation, and increased proteoglycan synthesis with downregulation of IL-1 and stimulation of TGF-b and IGF-1 after treatment with PEMFs [60–67]. In an animal study, PEMFs stimulated osteoblast activity during the healing process of an OD [68]. Clinically, PEMF treatment improves the functional recovery of patients after arthroscopic treatment of chondral lesions in the knee and reduces the use of nonsteroidal anti-inflammatory drugs [69]. A double-blind, randomized controlled trial started in 2008 that will provide information about the efficiency of treatment with PEMF in patients with an OD in the talus [59].
Related posts:
Conservative Treatment of Talar Osteochondritis Dissecans (OCD)
Lift, Drill, Fill and Fix (LDFF): A Cartilage Preservation Technique in Osteochondral Talar Defects
Osteochondral Ankle Injuries in Footballers
Management of Cystic Osteochondral Lesions of the Talus
Mosaicplasty of Osteochondral Lesions of the Ankle
Arthroscopic Debridement of Osteochondral Lesions of the Talus
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