SLR - January 2016 - Sam Bazrafshan
Reference: Guney A, Yurdakul E, Karaman I, Bilal O, Kafadar IH, Oner M. Medium-Term Outcomes of Mosaicplasty Versus Arthroscopic Microfracture With or Without Platelet-Rich Plasma in the Treatment of Osteochondral Lesions of the Talus. Knee Surg Sports Traumatol Arthrosc. 2015 Oct 22.Scientific Literature Review
Reviewed By: Sam Bazrafshan, DPM
Residency Program: Bethesda Health Inc.
Podiatric Relevance: Osteochondral lesions of the talus (OLT) can occur in up to 6.5 percent of all patients that sustain ankle sprains. Literature has shown that the regeneration of viable cartilage is a difficult process, particularly hyaline cartilage. Early diagnosis and treatment is vital in preventing the early onset of osteoarthritis, which carries its own burden on patient functionality. This article provides physicians with other treatment modalities, in conjunction with our typical first choice surgical procedures, such as microfracture and mosaicplasty. The aim of this study was to compare clinical and functional outcomes of three different treatments in patients with OLT, including microfracture, microfracture with PRP and mosaicplasty.
Methods: Fifty-four patients with diagnosis of OLT were divided into three treatment categories, including microfracture (n=19), microfracture with PRP (n=22) and mosaicplasty (n=13). All lesions were identified with arthroscopy and categorized using the Hepple classification. Mosaicplasty was done via a medial malleolus osteotomy and criteria included patients with high physical activity, Stage 3 or higher, and lesion size of greater than 15mm. Follow up ranged from 12-84 months and averaged 42 months. Post-operative protocol included splint immobilization with the ankle fixed at 90 degrees for one day, followed by mobilization of the ankle with crutches. Patients were to remain non-weight bearing for three weeks, with partial loading allowed for the next three weeks and full weight bearing permitted at week six. The mosaicplasty group was allowed partial weight bearing once there was radiographic union of the osteotomy on day 45, and full loading was allowed after eight weeks.
Results: Patient and lesion characteristics were not significantly different between study groups. Mosaicplasty group had significantly shorter duration of follow-up visits when compared to the microfracture group. All three groups had significant improvements on AOFAS scores when compared to baselines but there was no difference between each group at last follow up visit. VAS scores of the mosaicplasty group were significantly improved when compared to the microfracture group; however, all three groups had significant reduction of VAS scores when compared to baseline scores. Among the microfracture group, five patients needed a repeat surgery for worsening pain.
Conclusions: Based on this study, mosaicplasty was shown to be superior to microfracture with or without PRP on the basis of pain control. However, there was no difference on AOFAS scores or FAAM scores, which demonstrate that microfracture should still be considered as an initial surgical treatment modality for OLT. Previous literature shows that patients show significant improvements with microfracture even after 11 year follow up. It is important to note, that although, bone marrow stimulation shows promising functional results, mosaicplasty and autologous chondrocyte transplantation provides regeneration of tissue that is histologically similar to native hyaline cartilage. Microfracture provides the formation of a weaker fibrocartilaginous tissue. The study did not observe significant differences in patients treated with additional PRP application; however, other recent studies have shown functional improvement alongside microfracturing.