SLR-February2014-Brian Kissel
Reference: Treatment of Osteochondral Defects of the Talus with a Metal Resurfacing Inlay Implant after Failed Previous Surgery: A Prospective Study. C. J. A. van Bergen; I. C. M. van Eekeren; M. L. Reilingh; I. N. Sierevelt; C. N. van Dijk. Bone Joint J, December 2013 95-B:1650-1655.
Scientific Literature Review
Reviewed By: Brian G. Kissel, DPM
Residency Program: Detroit Medical Center
Podiatric Relevance: Osteochondral defects (OCDs) of the talus can be painful and debilitating conditions for patients. Many patients first undergo conservative routes of therapy such as immobilization, physical therapy, and injections. The literature shows this to be beneficial in a fair number of cases. However, some patients do not heal and progress with pain on weight bearing, swelling, instability, decreased range of motion, and synovitis. The authors of this article attempted to evaluate the effectiveness of a metallic implant for OCDs of the medial talar dome after failed previous surgeries that were too large for arthroscopic debridement and bone marrow stimulation, but small enough for sufficient coverage by the implant.
Methods: This study included 20 patients with OCDs of the medial talar dome that had continued pain for more than a year after a previous surgical treatment measuring between 12mm and 20mm on CT scans. Eight of the patients had one previous procedure, nine of them had two and three of the patients had three prior operations. These procedures included arthroscopic or open debridement and bone marrow stimulation in all cases, cancellous bonegrafting in four cases, osteochondral screw fixation in one case, and five patients received additional hyaluronic acid injections. Of note, diabetic patients were excluded due to association with increased risk of infection as well as softer and more permeable talar cartilage. The implants were all placed by the senior author using the same technique. Outcome measurements were done using the NRS (numeric rating scale) of pain, the AOFAS, and FAOS, and Short-Form 36. Patients were followed up at two and six weeks, three and six months, and annually post-operatively with the mean duration of three years (2 to 5 years).
Results: The results of this study showed an improvement in NRS pain at rest, walking, stair climbing, and running with significant difference noted at all post-operative time points with walking. The media in AOFAS improved from 62 pre-operatively to 75 at six months, 87 at one year and 87 at final follow-up. This showed statistical significant differences at one year and at the final follow-up when compared with the pre-operative score. The FAOS improved significantly as well, while the SF-36 improved but did not show statistical significance. Seven additional surgeries were performed on six of the patients, five of which per removal of the medial malleolar screws. Twelve of the patients played sports prior to the onset of their symptoms and while only three were able to play pre-operatively, 11 of those 12 returned to sports post-operatively. Also of the 20 patients, 18 indicated they would undergo the procedure again and recommend it to their family members.
Conclusions: The authors concluded that for a limited group of people with a medial talar dome lesion a metallic implant is a promising treatment option after failed previous surgery. The study shows that younger and more active patients with focal talar defects can be successfully treated with the metallic implant allowing the patient to avoid an ankle arthrodesis or replacement procedure even after a history of prior surgeries. This is a promising conclusion especially when 18 of the 20 patients in the study stated they would undergo the procedure again and/or recommend it to friends or family. This is another option that should be considered when encountering such a patient with the right sized talar dome lesion.