Osteochondral lesions of the talus (OLT) are those that affect the chondral and subchondral areas of the talus. Furthermore, juvenile cartilage has been shown to possess copious cellular activity that results in formation of abundant extracellular matrix than its adult counterpart. , Operative treatment is indicated for OLT that have remained symptomatic even after a conservative trial for 3–6 months. Commonly, multiple cylinders have to … Although it still remains a 2-staged procedure, using a collagen matrix reduces the operative time and also helps in even distribution of chondrocytes. in 1984 emphasized that these lesions should not be called as osteochondritis dissecans but be grouped under a broader term “osteochondral lesions of the talar dome.” The arthroscopic treatment of these lesions was first described by Parisien and Pritsch et al. An OCD lesion of the ankle is a specific type of injury to the bottom bone in the ankle joint. of the talus but at the cost of a hi gh rate of. Also read: Should you play sports with an OCD lesion in your knee? doi: 10.1136/bcr-2020-234595. This initial evaluation often leads to a broad differential diagnosis including ankle synovitis, impingement, occult fractures, and early ankle/subtalar arthritis..  Return to sports rate after microfracture is reported to be 76%, though most patients may not be able to achieve the pre-injury level. Bai L, Guan S, Liu S, You T, Xie X, Chen P, Zhang W. Orthop J Sports Med. They also proposed the radiological classification that is widely employed even to the present day. described the classifications of OLT based on CT and MRI, respectively. 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). The mean lesion size for microfracture was 3.4 cm 2, which is larger than the indicated size for this procedure. Knee Surg Sports Traumatol Arthrosc. In some rare cases, osteochondral lesions can occur for no apparent reason. They are most commonly … Autologous osteochondral grafting for talar cartilage defects. Choi et al. 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  All these factors make the talus prone for developing osteochondral lesions. Berndt and Harty classification is the staging system that is widely employed for describing OLT on plain radiographs. , The prognostic factors that determine the success of microfracture are listed in [Table 3]. | Awareness of current national guidelines is important in the appropriate consenting of patients undergoing surgery. An osteochondral lesion of the talus is often a difficult problem to treat. 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. For each treatment strategy, study size weighted success rates were calculated. INTRODUCTION. A history of ankle trauma/recurrent instability is to be elicited as OLT are associated with ankle instability. Chahla et al.  Weigelt et al.  Klammer et al. Arthroscopy.  A level-II randomized study conducted by Mei-Dan et al. Osteochondral allograft transplantation has been performed for the past 50 or more years with several studies demonstrating satisfactory outcomes. The tibia and fibula bones sit above and to the sides of the talus, forming the ankle joint. My question is: For a young man with 13, with the condition that the correct option and including microfracture. Prognostic factors determining success of microfracture. The cost-per-point change in functional outcome score was $200.59 for MFx, $313.84 for OAT, and $536.59 for ACI-1. 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. Introduction.  Despite these findings, microfracture still seems to be resulting in good functional outcomes. The skeleton … 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.. The mosaicplasty technique for osteochondral lesions 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.  Commonly used classifications are summarized in [Table 1]. 1980;62:646–652. USA.gov. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms. If structured rehabilitation is unsuccessful, then … 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/. , In summary, outcomes following surgery are variable and thus treatment strategy has to be tailored to every patient depending on specific factors. There are a number of treatment options.  to detect the most effective treatment for OLT concluded that none of the interventions were clinically superior over another.  Morphological evaluation post-retrograde drilling using second look arthroscopy showed no worsening of overlying cartilage at 1-year follow-up. -. This is possible due to less damage to the surrounding skin, ligaments and tendons. 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. Initial x-rays are taken to check the alignment of the foot and ankle, as well as look for any bone damage.  Provocative tests such as anterior drawer test should be performed and compared to the unaffected side to evaluate the associated instability. , Polat et al. All of the bones are a complex group of living organs that are composed of multiple cells, protein fibers and a range of minerals. 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. , This is a second-generation technique that employs a collagen matrix instead of a periosteal sleeve to secure the chondrocytes.  The sole indication for operative treatment at presentation is an acute lesion with displacement. Comparison of autologous osteoperiosteal cylinder and osteochondral graft transplantation in the treatment of large cystic osteochondral lesions of the talus (OLTs): a protocol for a non-inferiority randomised controlled trial. Autologous chondrocyte transplantation for treating cartilage defects of the talus. In this video, I discuss the types of surgery and how you might recover from those surgeries. 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. Surgery for osteochondritis dissecans. Importance Osteochondral autologous transplantation surgery (OATS) is one of many treatment modalities for osteochondral lesions of the talus (OLT). J Bone Joint Surg Am. A full diagnostic arthroscopy is performed, and then attention is turned to the osteochondral defect. NLM 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. © Copyright 2020 – Journal of Arthroscopic Surgery and Sports Medicine – All rights reserved.Published by Scientific Scholar on behalf of Indian Arthroscopy Society. Osteochondral lesions of the talus are injuries to the cartilage in the bone inside the ankle joint. Patient’s consent not required as patients identity is not disclosed or compromised. Arthroscopic microfracture is the most frequently performed procedure for an osteochondral lesion of the talus (OLT) [1,2,3,4]. 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%. 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. A systematic review of 52 studies including 1236 primary OLT by Dahmen et al. Foot Ankle Spec.  This is a broad terminology that encompasses a variety of disorders including osteochondritis dissecans, osteochondral fractures, and osteochondral defects.  In case of clinically suspected lesion with negative radiographs, advanced imaging options such as CT and MRI are useful.  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. doi: 10.12659/MSM.921823. Both non-operative and operative modalities have been described for the treatment of OLT. Clinicians should have a high index of suspicion as symptoms and clinical signs may be non-specific. Table 3 below presents the base-case deterministic results when using an OCA graft price of £3892.50 (€4174) based on costs in Spain. INTRODUCTION. 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. OLT encompass a wide variety of disorders that are both difficult to diagnose and also to treat with varying functional outcomes. However, if we cannot get insurance approval for this material due to cost (about $7,000), we will use the aforementioned BioCartilage product instead.  Although majority may be associated with trauma, some may develop insidiously. Hence, MRI is the investigation of choice in a clinically suspected lesion with negative radiographs while CT remains the preferred investigation for pre-operative planning with a positive plain radiograph as it better demonstrates the subchondral area of the lesion. Fifteen patients underwent mosaic osteochondral transplantation to treat a talar osteochondral defect lesion, with 11 patients available for follow-up.  This is a broad terminology that encompasses a variety of disorders including osteochondritis dissecans, osteochondral fractures, and osteochondral defects. 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. Classification of operative techniques for OLT. in 1986. This is often referred to as a chip inside your ankle joint. Osteochondral lesions of the talus (OLT) are those that affect the chondral and subchondral areas of the talus. Seven studies described the results of non-operative treatment, 4 of excision, 13 of excision and curettage, 18 of excision, curettage and bone marrow stimulation (BMS), 4 of an autogenous bone graft, 2 of transmalleolar drilling (TMD), 9 of osteochondral transplantation (OATS), 4 of autologous chondrocyte implantation (ACI), 3 of retrograde drilling and 1 of fixation. HHS Osteochondral lesions are caused by trauma, osteochondritis dissecans (OCD), or osteonecrosis. Surgical treatment is indicated after a failed conservative trial, larger lesion and can be broadly split into cartilage repair, replacement, and regenerative strategies. 1,2 Researchers have reported an occurrence of up to an astounding 73 percent in ankle fracture cases … This joint permits much of the up (dorsiflexion) and down (plantarflexion) motion of the foot and ankle. Methods: The study included 28 patients (17 males, 11 females; mean age 30.3 years; range 22-55 years) who had osteochondral lesions of the talus and were treated by arthroscopic surgery. Osteochondral defects of the talus (OCD) are a well-established pathology within the ankle. An osteochondral cyst can also be present following surgery. Clipboard, Search History, and several other advanced features are temporarily unavailable.  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.. Because MRI may overdiagnose or overestimate the extent of OCLs in an acute trauma setting the aim of this study was … 2020 Feb 9;10(2):e033850.  Although majority may … 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. , 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. 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. NIH  A systematic review of level 1 and 2 studies by Yausep et al. One randomized clinical trial was identified. Microfractures, are often considered the first-line surgical treatment option due to the low costs and ease of the technique ( 34 - 38 ), while ACI is rather reserved as a salvage procedure ( 39 - 41 , 45 ). of the talus but at the cost of a hi gh rate of. Rationale of conservative treatment is to offload the affected area for resolution of bone marrow edema and to facilitate healing of the detached cartilage. [Diagnosis and treatment of osteochondral lesions of the talus]. The procedure has a low morbidity and complication rate and low cost and is technically undemanding. Al-Shaikh RA, Chou LB, Mann JA, et al. Arthroscopic debridement is recommended as the initial intervention, unless primary fixation of a loose osteochondral lesion is required. Furthermore, improvement was better when PRP was used as an adjunct to microfracture than a conservative intraarticular injection of PRP. Osteochondral lesions of the talus (OLT) are those that affect the chondral and subchondral areas of the talus.  Although majority may be associated with trauma, some may develop insidiously. J ISAKOS.  A retrospective analysis of 131 patients suggested that though all patients returned to sporting activity, they engaged in fewer, less frequent sporting activities post-OATS treatment.. 2016. Background: The incidence of osteochondral lesions (OCLs) in association with displaced ankle fractures has only been examined in two previous studies. , 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]. 2016 Dec;24(12):3722-3729. doi: 10.1007/s00167-014-3389-3. Systematic review of treatment strategies for osteochondral defects of the talar dome. This is an US FDA approved allograft technique and was first made available in 2007 by DeNovo NT, Natural Tissue Graft (Zimmer, Inc., Warsaw. … [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. 2020 Jul 28;8(7):2325967120937798. doi: 10.1177/2325967120937798. Fibrocartilage is predominantly made of Type I collagen which is structurally and biomechanically inferior to hyaline cartilage. Med Sci Monit.  Toale et al. Cystic lesions require curettage and penetration of the calcified wall of the cyst.  Kreulen et al.  Kouvalchouk et al. 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.  Decision-making depends mainly on the stability of the overlying cartilage, size, and the containment of the lesion (shoulder and non-shoulder type lesion).  In 1922, Kappis extrapolated the concept of spontaneous necrosis at the hip to the etiopathogenesis of foreign bodies in the ankle joint and used the term osteochondritis dissecans. that included four studies concluded that PRP used in conjunction with microfracture results in better pain and functional improvement than microfracture alone. This consists of particles of live cartilage that enable the surgeon to truly lay down the best quality cartilage. 32 … Outcomes following surgery are variable and thus treatment strategy has to be tailored to every patient based on specific factors. 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. Long-term follow-up. Much of this bone is covered with cartilage. Verhagen RA, Struijs PA, Bossuyt PM, van Dijk CN. Plain radiography is the initial investigation of choice in a clinically suspected case of OLT.  Useful algorithm describing the indication for each procedure is outlined in [Figure 1]. Once the piece has broken off, surgery is almost always necessary. BMJ Case Rep. 2020 Jul 8;13(7):e234595. -, Alexander AH, Lichtman DM. Furthermore, PRP group had significantly better outcomes than the HA group. High-impact activities, such as running and jumping, should be avoided until 6 to 12 months after surgery. The next day did MRI scans and X-rays and there was the release of free bone fragment in the knee joint and with apparent origin in the former osteochondral lesion. Knee Surg Sports Traumatol Arthrosc. This procedure is a single-stage procedure and as it does not require a press fit or graft contouring due to its particulate nature, it can be carried out arthroscopically. 2020 Aug 21;26:e921823. Recommended indications include a symptomatic patient with size of the lesion at least 1.5 cm in one dimension or a patient who had a failed marrow stimulation technique. The talus is the bottom bone of the ankle joint. 2013 Jun 5;95(11):1045-54. doi: 10.2106/JBJS.L.00773. Electronic databases from January 1966 to December 2006 were systematically screened. | 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]. Osteochondral Lesion Anatomy. 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. Finite Element Analysis of the Effect of Talar Osteochondral Defects of Different Depths on Ankle Joint Stability. , Injection therapy alone with PRP or HA has also been attempted in the treatment of OLT. OATS, BMS and ACI scored success rates of 87, 85 and 76%, respectively.  Although it provides good visualization of the cartilage, it tends to overestimate the extent of the subchondral lesion due to the associated marrow edema. If you continue to use this site we will assume that you are happy with it. 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. transplantation surgery fo r osteochondral lesions. A treatment gap exists for patients with lesions not suitable for arthroplasty or biologic repair or who have failed prior cartilage repair surgery. 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. There is also the possibility to associate the treatment with growth factors. At this point the doctors in Portugal suggest surgery to fraguemento extraction and treatment of osteochondral lesion of about 12mm in size with the … However, due to great diversity in the articles and variability in treatment results, no definitive conclusions can be drawn. 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. These eventually would form fibrocartilage at the defect. Further sufficiently powered, randomized clinical trials with uniform methodology and validated outcome measures should be initiated to compare the outcome of surgical strategies for OCD of the talus. Although the short- to mid-term clinical outcomes are generally good, the quality of regenerated cartilage is unpredictable. After a longer follow-up, some patients showed that the beneficial results were not maintained, indicating the deterioration of the … 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. 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. This may cause complications of the donor site and the ankle. Arthroscopic treatment of transchondral talar dome fractures: a long-term follow-up study. Orthopade.  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