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. [42,43] These grafts can then be employed for bulk transfer after size matching using CT scan. The diagnosis of cartilage damage (osteochondral lesion, also known as talar dome) is often done with x-rays and/or an MRI. One randomized clinical trial was identified. 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. [5] In 1959, Berndt and Harty were the first to describe the pathogenesis of osteochondral lesions post-trauma. However, if we cannot get insurance approval for this material due to cost (about $7,000), we will use the aforementioned BioCartilage product instead. A review was performed of 30 athletes with 31 OLTs that were refractory to marrow stimulation or … doi: 10.1136/bcr-2020-234595. Osteochondral defects of the talus (OCD) are a well-established pathology within the ankle. Operative techniques can be broadly classified as cartilage repair, regeneration, and replacement techniques [Table 2]. of 30 patients comparing intra-articular injection of PRP and HA concluded that both PRP and HA resulted in improved function and decreased pain that maintained for at least 6 months. 1 Department of Orthopaedic Surgery, Academic Medical Centre, University of Amsterdam, P.O. 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. [12] Second, arterial supply to the talar dome and the overlying cartilage is by a retrograde vascular network that comes from the talar neck with additional watershed areas showing poor perfusion in the posteromedial, posterolateral, and mid-medial segments of the subchondral bone. Osteochondral lesions of the talus (OLTs) continue to be a challenge for the treating surgeon, especially when lesions are refractory to marrow stimulation techniques. -. concluded OATS to be an effective treatment strategy even for large OLT with MOCART scoring showing good structural integrity of the graft at mean follow-up of 24.8 months and good functional outcomes irrespective of a prior microfracture or concomitant procedure. OLT encompass a wide variety of disorders that are both difficult to diagnose and also to treat with varying functional outcomes. 2013 Apr;6(2):141-4. doi: 10.1177/1938640013479934. 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/. -, Alexander AH, Lichtman DM. [2], 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]. 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. Therapeutic arthroscopy with microfracture leads to fibrocartilaginous repair and is an effective treatment of osteochondral lesions of the talus. The proportion of the patient population treated successfully was noted, and percentages were calculated. BMJ Case Rep. 2020 Jul 8;13(7):e234595. OATS uses bone-cartilage cylinder grafts from a non-weight bearing portion of another joint and transplants these on the site of the defect. Treating osteochondral lesions of the talus can pose challenges and delayed diagnosis due to late presentation after an ankle sprain. 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. Much of this bone is covered with cartilage. Arthroscopic surgery is sometimes referred to as “keyhole surgery” as it is performed through very small incisions. Introduction. Knee Surg Sports Traumatol Arthrosc. The first description of osteocartilaginous loose bodies in the ankle, attributed to trauma, was given by Monro in 1738. Osteochondral lesions are caused by trauma, osteochondritis dissecans (OCD), or osteonecrosis. 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. This consists of particles of live cartilage that enable the surgeon to truly lay down the best quality cartilage. Anders et al. [8,9] There have been numerous changes to the terminology of these lesions since the first description, however, the term “osteochondral lesions of the talus” (OLT) is generally preferred. Fibrocartilage is predominantly made of Type I collagen which is structurally and biomechanically inferior to hyaline cartilage. Background: The incidence of osteochondral lesions (OCLs) in association with displaced ankle fractures has only been examined in two previous studies. Guney et al. Arthroscopy. [23] 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. 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. J Bone Joint Surg Am. [16] Ferkel et al. [4] 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. 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. Finally, the treatment of such lesions is comprehensive … There is limited understanding of cartilage damage and its repair. Commonly, multiple cylinders have to … Thus, treatment should be individualized to every patient, with adequate counseling regarding the outcomes and associated complications of that technique. 6-8 These treatment methods … and Hepple et al. This is an US FDA approved allograft technique and was first made available in 2007 by DeNovo NT, Natural Tissue Graft (Zimmer, Inc., Warsaw. 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 An osteochondral lesion of the talus is often a difficult problem to treat. This is often referred to as a chip inside your ankle joint. 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%. Awareness of current national guidelines is important in the appropriate consenting of patients undergoing surgery. 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. There are only a few recent studies that have reported the outcomes following non-operative management. Autologous chondrocyte transplantation for treating cartilage defects of the talus. Actual surgical treatments for osteochondral lesions and early knee osteoarthritis seem to be promising. Surgical treatment of transchondral talar-dome fractures (osteochondritis dissecans). Electronic databases from January 1966 to December 2006 were systematically screened. Furthermore, improvement was better when PRP was used as an adjunct to microfracture than a conservative intraarticular injection of PRP. FIGURE 71-1 Osteochondral lesion of the talus. 2016 Dec;24(12):3722-3729. doi: 10.1007/s00167-014-3389-3. All of the bones are a complex group of living organs that are composed of multiple cells, protein fibers and a range of minerals. 2003 Jun;8(2):233-42, viii-ix. 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). 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. Plain radiography is the initial investigation of choice in a clinically suspected case of OLT. [53], In summary, outcomes following surgery are variable and thus treatment strategy has to be tailored to every patient depending on specific factors. 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.[50]. [1] This is a broad terminology that encompasses a variety of disorders including osteochondritis dissecans, osteochondral fractures, and osteochondral defects. Systematic review of treatment strategies for osteochondral defects of the talar dome. transplantation surgery fo r osteochondral lesions. Ferkel’s grading is the most commonly employed grading system on arthroscopy. 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. [6] Kouvalchouk et al. [14] Provocative tests such as anterior drawer test should be performed and compared to the unaffected side to evaluate the associated instability. J ISAKOS. Foot Ankle Int. doi: 10.2106/JBJS.E.00033.  |  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. [15] Although it provides good visualization of the cartilage, it tends to overestimate the extent of the subchondral lesion due to the associated marrow edema. 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. Radiographs showed a suspicious area on the lateral talar dome. 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. This joint permits much of the up (dorsiflexion) and down (plantarflexion) motion of the foot and ankle. OCD lesions are also called osteochondritis dissecans or osteochondral fractures. In this video, I discuss the types of surgery and how you might recover from those surgeries. If you continue to use this site we will assume that you are happy with it. A systematic review of 52 studies including 1236 primary OLT by Dahmen et al. doi: 10.12659/MSM.921823. There are numerous reasons that make the talar cartilage and the subchondral bone prone to vascular insufficiency. 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. 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. These authors evaluate the effectiveness of procedures such as microfracture and arthroscopy, and recent innovations such as … Retrograde drilling and fixation scored 88 and 89%, respectively. Osteochondral lesions of the talus are injuries to the cartilage in the bone inside the ankle joint. Osteochondral allograft transplantation has been performed for the past 50 or more years with several studies demonstrating satisfactory outcomes. 2008 Mar;37(3):204, 206-11. doi: 10.1007/s00132-008-1219-3. Patients present with spectrum of non-specific complaints including of pain on weight-bearing, swelling, stiffness, and occasionally locking sensation at the ankle joint. [2] Lee et al. Une lésion localisée ou diffuse est ainsi retrouvée chez deux tiers des patients en cas d’exploration arthroscopique d’un genou douloureux.1–4 Les faibles capacités de cicatrisation du cartilage au-delà d’une certaine taille sont expliquées par sa nature avasculaire et les facultés très limitées de régénération des chondrocytes.5–7 Les lésions cartilagineuses sont des facteurs de risque d’arthrose post-traumatique.8,9 De nombreuses technique… Cystic lesions require curettage and penetration of the calcified wall of the cyst. complications: a systematic review. 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. 2020 Jul 28;8(7):2325967120937798. doi: 10.1177/2325967120937798. Foot Ankle Spec. Finite Element Analysis of the Effect of Talar Osteochondral Defects of Different Depths on Ankle Joint Stability. The skeletal system is made up of all the joints and bones in the body. Effect of autologous adipose-derived mesenchymal stem cell therapy in the treatment of an osteochondral lesion of the ankle. Osteochondral lesions of the talus (OLT) are those that affect the chondral and subchondral areas of the talus. [10], Most OLT are secondary to trauma, with up to 50% of ankle sprains resulting in some grade of cartilage injury. At this point the doctors in Portugal suggest surgery to fraguemento extraction and treatment of osteochondral lesion of about 12mm in size with the … 2013 Jun 5;95(11):1045-54. doi: 10.2106/JBJS.L.00773. Surgical treatment is indicated after a failed conservative trial, larger lesion and can be broadly split into cartilage repair, replacement, and regenerative strategies. Osteochondral Lesion Anatomy. Because MRI may overdiagnose or overestimate the … Osteochondral lesions of the talus (OLT) are those that affect the chondral and subchondral areas of the talus. 1980;62:646–652. [29] Return to sports rate after microfracture is reported to be 76%, though most patients may not be able to achieve the pre-injury level. Clinicians should have a high index of suspicion as symptoms and clinical signs may be non-specific. eCollection 2020 Jul. [13] All these factors make the talus prone for developing osteochondral lesions. 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. -, Becher C, Thermann H. Results of microfracture in the treatment of articular cartilage defects of the talus. Fifteen patients underwent mosaic osteochondral transplantation to treat a talar osteochondral defect lesion, with 11 patients available for follow-up. National Center for Biotechnology Information, Unable to load your collection due to an error, Unable to load your delegates due to an error. [3] 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). After a longer follow-up, some patients showed that the beneficial results were not maintained, indicating the deterioration of the … 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. [51], This technique combines microfracture with either autologous iliac crest bone marrow aspirate concentrate (BMAC) or PRP secured to the defect using a collagen scaffold/fibrin glue in a single stage [Figure 3]. 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. High-impact activities, such as running and jumping, should be avoided until 6 to 12 months after surgery. Both non-operative and operative modalities have been described for the treatment of OLT. Berndt and Harty classification is the staging system that is widely employed for describing OLT on plain radiographs. An OCD lesion of the ankle is a specific type of injury to the bottom bone in the ankle joint. 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. Operative treatment of osteochondral lesions of the talus. Fifty-two studies described the results of 65 treatment groups of treatment strategies for OCD of the talus. [44] A systematic review by Richard et al. [21] Weigelt et al. Background: The incidence of osteochondral lesions (OCLs) in association with displaced ankle fractures has only been examined in two previous studies. My question is: For a young man with 13, with the condition that the correct option and including microfracture. 32 … [54] to detect the most effective treatment for OLT concluded that none of the interventions were clinically superior over another. 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. Importance Osteochondral autologous transplantation surgery (OATS) is one of many treatment modalities for osteochondral lesions of the talus (OLT). 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). of the talus but at the cost of a hi gh rate of. Osteochondral autograft transfer system (OATS), Particulated juvenile cartilage allograft transfer (PJCAT), Autologous chondrocyte implantation (ACI), Matrix-induced autologous chondrocyte implantation (MACI), I: Cystic lesion at the dome with intact roof on all sides, Medial/lateral lesions, subchondral cysts. [11] 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.[10]. 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. Also read: Should you play sports with an OCD lesion in your knee? Recovery and surgery for an OCD lesion of the knee. Osteochondral lesions are most common in the knee joint, and the ankle is the next most frequent joint affected. This may cause complications of the donor site and the ankle. [3] This review aims to elucidate the historical aspect of the disease, etiopathogenesis, classifications, diagnosis, and treatment to assist in day-to-day clinical practice. Outcome. This option is useful for large OLT with extensive subchondral cysts. [2] This technique is effective in treating large cystic lesions even up to 6 cm2 with favorable outcomes reported. This site needs JavaScript to work properly. [25,32-36], In OLT with subchondral cysts and intact overlying cartilage, retrograde drilling is a better modality that penetrates the necrosed subchondral bone without disturbing the overlying cartilage. IN) to treat patellar lesion. [19] Commonly used classifications are summarized in [Table 1]. NIH Although outcomes of most of these techniques are promising, it is hard to recommend one procedure over another due to lack of comparative analyses. 2020 Aug 21;26:e921823. 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? Please enable it to take advantage of the complete set of features! The purpose of this study is to evaluate the outcomes of lesions treated with osteochondral allograft transplantation. Once the piece has broken off, surgery is almost always necessary. Together with the newer techniques OATS and ACI, BMS was identified as an effective treatment strategy for OCD of the talus. Most of the talus is covered by cartilage. If structured rehabilitation is unsuccessful, then … [52] A systematic review of level 1 and 2 studies by Yausep et al. [48], 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. 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.”[7] The arthroscopic treatment of these lesions was first described by Parisien and Pritsch et al. OATS, BMS and ACI scored success rates of 87, 85 and 76%, respectively. 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. of the talus but at the cost of a hi gh rate of. INTRODUCTION. transplantation surgery fo r osteochondral lesions. Growth factors contained in PRP can facilitate cartilage repair by stimulating matrix formation and increasing chondrocyte proliferation. An osteochondral cyst can also be present following surgery. This commonly occurs after an ankle sprain where the two bones hit against each other, causing a piece of cartilage and bone to chip off inside the ankle. 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. 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. Bai L, Guan S, Liu S, You T, Xie X, Chen P, Zhang W. Orthop J Sports Med. Limited, Coimbatore, Tamil Nadu, Department of Orthopedics and Spine surgery. 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. [27] Toale et al. [40] 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.[41]. HA is known to reduce inflammation in the joint while simultaneously substituting joint fluid. The skeleton … We use cookies to ensure that we give you the best experience on our website. They are most commonly … -, Baums MH, Heidrich G, Schultz W, et al. NLM [47] 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. The tibia and fibula bones sit above and to the sides of the talus, forming the ankle joint. The talus is the bottom bone of the ankle joint. Prognostic factors determining success of microfracture. Diagram shows the classic four signs of instability in an OCD lesion: 1, high signal intensity rim at the interface between the fragment and the adjacent bone on T2-weighted MR images; 2, fluid-filled cysts beneath the lesion; 3, a high-signal-intensity line extending through the articular cartilage overlying the lesion; and 4, a focal osteochondral defect filled with joint fluid. However, due to great diversity in the articles and variability in treatment results, no definitive conclusions can be drawn. 2016. [Diagnosis and treatment of osteochondral lesions of the talus]. 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. 2020 Jul;14(2):64-71. doi: 10.5704/MOJ.2007.014. [] This is a broad terminology that encompasses a variety of disorders including osteochondritis dissecans, osteochondral fractures, and osteochondral defects. And analyzed that of other joints of the foot and ankle, as well as look for any damage. Understanding of cartilage damage ( osteochondral lesion of the overlying cartilage at 1-year follow-up for large OLT extensive... 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Cost-Per-Point change in functional outcome score was $ 200.59 for MFx, $ 313.84 for OAT, osteochondral... Correct option and including microfracture imaging ( MRI ) was performed prior open! Prior history of ankle trauma/recurrent instability is to evaluate the associated instability 2020 Feb 9 ; 10 ( 2:233-42! Joint fluid Xie X, Chen P, Zhang W. Orthop J Sports Med should! Describing the indication for operative treatment is indicated for OLT with a minimum follow-up of 2.! [ 54 ] to detect the most commonly employed grading system on arthroscopy, should mainly! To take advantage of the Effect of autologous graft for the treatment with a sensitivity 96. 10 ( 2 ): e234595 Schultz W, et al using an OCA graft price of £3892.50 ( )... To detect the most effective treatment for OLT that have remained symptomatic even after a conservative intraarticular Injection of.... Prp used in conjunction with microfracture results in formation of abundant extracellular matrix than its adult.! 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Berndt and Harty classification is the initial investigation of choice osteochondral lesion surgery cost a clinically suspected case of clinically suspected with... © Copyright 2020 – Journal of arthroscopic surgery is sometimes referred to as “ keyhole surgery ” as is! Type of injury to the surrounding skin, ligaments and tendons [ 24 ], operative treatment at is... As patients identity is not disclosed or compromised opted for conservative treatment with a minimum follow-up of 2 years problem... And compared to the present day Table 2 ] Although majority may be non-specific Bossuyt PM, Dijk! C, Thermann H. results of 65 treatment groups of treatment strategies for OCD the. Bodies in the lower extremity 88 and 89 %, respectively grafts can then be employed for describing OLT plain...