ADVERTISEMENT
Exploring Treatment Options For Osteochondral Lesions
In a discussion of osteochondral lesions of the talus at the ACFAS Annual Scientific Conference, several panelists delved into treatments including microfracture, osteochondral autograft transplantation and mesenchymal stem cells.
Why do some osteochondral lesions hurt and some do not? Glenn Weinraub, DPM, FACFAS, notes the etiology is not easily understood as most research on osteochondral lesions focuses on treatment rather than causes.
Lloyd and colleagues noted that 1 mm of lateral talar shift caused a 40 percent loss of tibiotalar contact surface area, concluding that 1 mm of shift is the indication for surgical fixation.1 Dr. Weinraub noted the authors saw a large variance in the talar contact surface area depending on the ankle joint morphology. Dürr and coworkers found that stress-induced bone resorption may be an etiology for subchondral bone cysts in patients with osteoarthrosis.2
Elias and coworkers established nine zones for localizing and characterizing osteochondral talar lesions. Thomas Harris, MD, says the researchers note the lesions most often arise in zone 4 at the medial talar dome with the next highest occurrence in zone 6 at the lateral talar dome.3
Dr. Weinraub says the pain in osteochondritis dissecans is probably caused by the repetitive high fluid pressure and a decrease to pH that sensitizes the highly innervated subchondral bone.
In planning surgery for osteochondral lesions of the talus, Jonathan Sharpe, DPM, FACFAS, says the level of evidence is low and there are not enough Level I studies. He also notes a paucity of information on non-operative therapies like casts or bracing.
Dr. Sharpe emphasizes attempting conservative care initially for osteochondral lesions. Osteochondral lesions of the talus with minimal symptoms did not worsen over time when physicians used non-operative treatment, according to a retrospective review of 41 ankles in 48 patients.4
As far as imaging goes, Dr. Sharpe cites modalities such as stress radiographs, diagnostic blocks and advanced imaging. Specifically, single-photon emission computed tomography-computed tomography (SPECT-CT) can reveal additional diagnostic information affecting the treatment of osteochondral lesions of the talus, according to a study by Leumann and colleagues.5 Dr. Sharpe says the study authors found that treatment changed in 48 percent of patients with SPECT-CT alone and 52 percent with SPECT-CT and magnetic resonance imaging (MRI) combined. However, Dr. Sharpe says there is no strong evidence to support a gold standard in imaging for osteochondral lesions of the talus.
What The Research On Microfracture Indicates
Microfracture can be a primary option for treating osteochondral lesions of the talus, according to Dr. Harris.
A study by van Bergen and colleagues found that the initial effects of arthroscopic debridement and bone marrow stimulation for osteochondral defects of the talus were preserved in 50 patients for a mean follow-up of 12 years, notes Dr. Harris.6 After receiving arthroscopic microfracture for osteochondral lesions of the talus, 18 of 22 patients in a study by Kuni and coworkers had no pain or mild pain at the two year follow-up, notes Dr. Harris.7 In a study of 30 patients, Becher and Thermann found good results with microfracture for osteochondral defects and degenerative chondral defects.8
However, Dr. Harris notes lesion size can be an important consideration for microfracture. In a study of 10 cadavers, Schäfer and colleagues found arthroscopy-based assessment of the size of an osteochondral lesion in the ankle joint can lead to over- and underestimating of the defect’s size.9 Dr. Harris says the difference between the area of the defects and the measurement of three independent investigators in the study averaged 52 percent, 49 percent and 49 percent respectively.
Although arthroscopic debridement and drilling can be successful for osteochondral lesions of the talus, there may be inferior functional outcomes with these modalities when it comes to treating lesions that are larger than 1.5 cm2 and lesions that are uncontained, according to Cuttica and coworkers.10 A study by Chuckpaiwong and coworkers focused on 105 patients with osteochondral lesions of the ankle who had ankle arthroscopy with microfracture. Dr. Harris says the authors had “excellent” results with microfracture in lesions smaller than 15 mm, regardless of location.11
What factors besides size can predict a negative outcome for microfracture? Dr. Harris says in a study of 50 patients, Yoshimura and patients found inferior outcomes with arthroscopic bone stimulation in older patients, deep lesions and medial lesions in the medial malleolus.12
What Are The Best Grafts For Open And Minimally Invasive Procedures?
Whether you are performing open or minimally invasive surgeries, there are allograft and autograft options for osteochondral lesions of the talus, according to the panelists.
Stephen Brigido, DPM, FACFAS, cites a study by Scranton and McDermott indicating “significant improvement” in 10 patients after the treatment of large cystic talar lesions with a cored osteochondral graft taken from the ipsilateral knee.13 In a review of 13 patients, Brigido and colleagues found that demineralized allograft subchondral bone plugs improved pain and function in patients with osteochondral lesions of the talus.14
What about allografts for larger lesions? Dr. Brigido and Amber Shane, DPM, FACFAS, cite a study by Raikin concerning 15 patients with osteochondral lesions of the talus who had osteochondral autograft transplantation (OATS).15 The mean volume of the lesions in the study was 6,059 mm3 and the study authors found the treatment effective in larger volume cystic lesions.
Osteochondral autograft transplantation also shows some long-term success. Gross and coworkers, in a study of nine patients with osteocartilaginous lesions of the talus between 1980 and 1996, noted six of the grafts remained in situ as of 2001 and the mean survival rate is 11 years.16
However, there can be failure with the use of allografts. Dr. Brigido cites a study by Jeng and colleagues of 29 patients who had osteochondral total ankle allograft transplants. The authors noted 14 transplants needed revision in the form of another ankle transplant, prosthetic total ankle arthroplasty or bone block arthrodesis while six other transplants were radiographic failures because of problems with the allografts or loss of joint space.17
Bugbee and colleagues, in a study of 88 ankles in 84 patients, found that fresh bipolar ankle osteochondral allograft transplantation was effective for tibiotalar arthritis with a high patient satisfaction rate although Dr. Shane says the researchers acknowledged a 29 percent reoperation rate.18
Can Emerging Modalities Have An Impact?
Among the innovative treatments on the horizon for osteochondral lesions of the talus are marrow-derived cells and mesenchymal stem cells, according to Troy Watson, MD.
Vannini and coworkers focused on 140 athletes who had bone marrow-derived cell transplantation for osteochondral lesions of the talus. Dr. Watson says the authors related that most patients were able to return to sports at pre-injury levels.19
Kim and colleagues studied mesenchymal stem cells in a study of 65 patients over age 50 with osteochondral lesions of the talus.20 Dr. Watson says in comparison with arthroscopic marrow stimulation treatment alone, mesenchymal stem cells were effective, particularly for lesions larger than 109 mm2 or in the presence of a subchondral cyst.
References
1. Lloyd J, Elsayed S, Hariharan K, Tanaka H. Revisiting the concept of talar shift in ankle fractures. Foot Ankle Int. 2006;27(10):793-6.
2. Dürr HD, Martin H, Pellengahr C, et al. The cause of subchondral bone cysts in osteoarthrosis: a finite element analysis. Acta Orthop Scand. 2004;75(5):554-8.
3. Elias I, Zoga AC, Morrison WB, et al. Osteochondral lesions of the talus: localization and morphologic data from 424 patients using a novel anatomical grid scheme. Foot Ankle Int. 2007;28(2):154-61.
4. Klammer G, Maquieira GJ, Spahn S, et al. Natural history of nonoperatively treated osteochondral lesions of the talus. Foot Ankle Int. 2015;36(1):24-31.
5. Leumann A, Valderrabano V, Plaass C, et al. A novel imaging method for osteochondral lesions of the talus--comparison of SPECT-CT with MRI. Am J Sports Med. 2011;39(5):1095-101.
6. Van Bergen CJ, Kox LS, Maas M, et al. Arthroscopic treatment of osteochondral defects of the talus: outcomes at eight to twenty years of follow-up. J Bone Joint Surg Am. 2013;95(6):519-25.
7. Kuni B, Schmitt H, Chloridis D, Ludwig K. Clinical and MRI results after microfracture of osteochondral lesions of the talus. Arch Orthop Trauma Surg. 2012;132(12):1765-71.
8. Becher C, Thermann H. Results of microfracture in the treatment of articular cartilage defects of the talus. Foot Ankle Int. 2005;26(8):583-9.
9. Schäfer D, Boss A, Hintermann B. Accuracy of arthroscopic assessment of anterior ankle cartilage lesions. Foot Ankle Int. 2003;24(4):317-20.
10. Cuttica DJ, Smith WB, Hyer CF, et al. Osteochondral lesions of the talus: predictors of clinical outcome. Foot Ankle Int. 2011;32(11):1045-51.
11. Chuckpaiwong B, Berkson EM, Theodore GH. Microfracture for osteochondral lesions of the ankle: outcome analysis and outcome predictors of 105 cases. Arthroscopy. 2008;24(1):106-12.
12. Yoshimura I, Kanazawa K, Takeyama A, et al. Arthroscopic bone marrow stimulation techniques for osteochondral lesions of the talus: prognostic factors for small lesions. Am J Sports Med. 2013;41(3):528-34.
13. Scranton PE Jr, McDermott JE. Treatment of type V osteochondral lesions of the talus with ipsilateral knee osteochondral autografts. Foot Ankle Int. 2001;22(5):380-4.
14. Brigido SA, Protzman NM, Galli MM, Bleazey ST. The role of demineralized allograft subchondral bone in the treatment of talar cystic OCD lesions that have failed microfracture. Foot Ankle Spec. 2014;7(5):377-86.
15. Raikin SM. Fresh osteochondral allografts for large-volume cystic osteochondral defects of the talus. J Bone Joint Surg Am. 2009;91(12):2818-26.
16. Gross AE, Agnidis Z, Hutchison CR. Osteochondral defects of the talus treated with fresh osteochondral allograft transplantation. Foot Ankle Int. 2001;22(5):385-91.
17. Jeng CL, Kadakia A, White KL, Myerson MS. Fresh osteochondral total ankle allograft transplantation for the treatment of ankle arthritis. Foot Ankle Int. 2008;29(6):554-60.
18. Bugbee WD, Khanna G, Cavallo M, et al. Bipolar fresh osteochondral allografting of the tibiotalar joint. J Bone Joint Surg Am. 2013;95(5):426-32.
19. Vannini F, Cavallo M, Ramponi L, et al. Return to sports after bone marrow-derived cell transplantation for osteochondral lesions of the talus. Cartilage. 2017;8(1):80-87.
20. Kim YS, Park EH, Kim YC, Koh YG. Clinical outcomes of mesenchymal stem cell injection with arthroscopic treatment in older patients with osteochondral lesions of the talus. Am J Sports Med. 2013;41(5):1090-9.
