SLR - February 2021 - Bryan Raymond
Reference: Carlson MJ, Antkowiak TT, Larsen NJ, Applegate GR, Ferkel RD. Arthroscopic Treatment of Osteochondral Lesions of the Talus in a Pediatric Population: A Minimum Two-Year Follow-up. Am J Sports Med. 2020 Jul;48(8):1989-1998. doi: 10.1177/0363546520924800. Epub 2020 Jun 8. PMID: 32510966.Level of Evidence: 4
Scientific Literature Review
Reviewed By: Bryan Raymond, DPM
Residency Program: Presbyterian St. Lukes/Highlands – Denver, CO
Podiatric Relevance: This article discusses the functional and radiographic outcomes of children undergoing arthroscopic treatment of symptomatic chronic osteochondral lesions of the talus (OLT) which is relevant to podiatry being that this is a debilitating condition. The authors hypothesized that patients undergoing arthroscopic treatment of OLTs would demonstrate good functional and radiographic outcomes at a minimum two-year follow up. The outcomes of arthroscopic management of these injuries will help us better treat our pediatric patients as physicians.
Methods: Retrospectively reviewed electronic medical records to identify patients <18 years old who underwent arthroscopic treatment of OLT’s with marrow stimulation. Patients who met the study criteria underwent pre-operative weightbearing plain film AP, lateral, and mortise ankle imaging and MRI. The surgical procedure performed was described in detail, subchondral drilling and microfracturing was performed. Postoperatively they evaluated ankle stability, range of motion, dorsiflexion, plantarflexion. Outcome measures included the FFI, AOFAS Hindfoot Score, Tegner Activity Scale, SF-36, and a satisfaction survey. A blinded musculoskeletal radiologist graded the postoperative imaging to classify the extent of degenerative changes. Pre and postoperative MRI’s were compared and evaluated using the MOCART (magnetic resonance observation of cartilage repair tissue) scoring system and statistical analysis was performed.
Results: Final study group consisted of 22 patients with an average age of 14.4 years old. The average clinical and radiologic follow-up was eight years. All patients improved with 91 percent satisfied, 95 percent who would recommend the surgery, 81 percent would repeat surgery again. Average post-operative outcomes scores at final follow-up were VAS of two, AOFAS of 86, FFI score of 38, SF-36 of 50, Tegner activity scale decreased from seven to six postoperative, mean dorsiflexion/plantarflexion was within 2 degrees range of the non-operative limb. There were no post-op complications. There were 18 medial lesions and four lateral lesions. Fourteen lesions were small (<1 squared centimeter) while four were large (>1 squared centimeter). Twelve ankles had unstable lesions, with a mean size of 1.05 squared centimeter). All lateral lesions were unstable, two were small and two were large with an average size of the lesions 1.32 squared centimeter. Overall 94 percent of patients showed no progression or grade one progression. The mean postoperative MOCART score was 48 for medial and 50 for lateral lesions.
Conclusions: Arthroscopic treatment of symptomatic OLTs in patients aged <18 years demonstrated good functional outcomes, high satisfaction rates, and minimal ankle osteoarthritis progression despite low MOCART scores. I found that this article was well designed, had good follow-up, well non-biased radiographic assessment. There was an association with large lesion size and instability in lesions greater than 1 squared centimeter which should caution surgeons to consider alternative options for management of these lesions. I am not surprised the low MOCART score as I do not believe enough time passed during reimaging to see consolidation, I believe following the clinical and physical findings determine success.