Comparison of Early Versus Delayed Weight-bearing Outcomes after Microfracture for Small to Midsized Osteochondral Lesions of the Talus

SLR - July 2013 - Jill Peotter

Reference: Dong-Hyun Lee, Keun-Bae Lee, Sung-Taek Jung, Jong-Keun Seon, Myung-Sun Kim and II-Hoon Sung. American Journal of Sports Medicine. 2012. 40:2023-8.

 

Scientific Literature Review

Reviewed by: Jill Peotter, DPM

Residency Program: Southern Arizona VA Health Care System

Podiatric Relevance: Osteochondral defects are a common injury to the talus, in which non-surgical treatment is often unsuccessful. Many surgical options are available including debridement, subchondral drilling, microfracture, grafting and chondrocyte implantation. Microfracture is commonly used as a first-line surgical treatment due to its simplicity and limited invasiveness. The standard postoperative protocol for microfracture includes non-weight-bearing for a minimum of six-to-eight weeks. There have been a few reports with postoperative early weight-bearing, but no comparative results of delayed versus early weight-bearing postoperatively. This study compares clinical effects of early and delayed weight-bearing in patients with osteochondral defects of the talus treated by arthroscopic microfracture.
 

Methods: A total of 99 patients (101 ankles) received arthroscopic microfracture for treatment of an osteochondral defect of the talus between January 2005 and December 2008. Inclusion criteria were the following: symptomatic osteochondral defect, single focal lesion, lesions measuring less than two centimeters squared, patient age greater or equal to 18 and less than 60 years, failed conservative treatment, and no previous surgical intervention. This criteria excluded 18 patients (20 ankles). Enrolled patients were randomized into two groups for postoperative care for this prospective study. The first group consisted of 41 patients for delayed weight-bearing (DWB) in which postoperative protocol consisted of one week non-weight-bearing in a posterior splint. ROM and strengthening exercises were implemented the second week. Patients were kept non-weight-bearing in the posterior splint for six weeks total, followed by two weeks of partial weight-bearing. At eight weeks postoperative, the splint was removed. The second group consisted of 40 patients for early weight-bearing (EWB), in which the postoperative protocol consisted of one week non-weight-bearing in a posterior splint followed by partial weight-bearing in a CAM boot which was transitioned to full weight-bearing as tolerated. The patients began ROM and strengthening exercises the second postoperative week. The CAM boot was removed at eight weeks. In both groups, athletic activities were avoided for at least four months. Patients were followed postoperatively and scores were obtained at three, six and 12 months. Patients were followed for a mean of 37 months (range 24-76).

Results: In the DWB group, 88 percent of patients had good to excellent outcomes according to AOFAS scoring; 21 excellent (51 percent), 15 good (37 percent) and five fair (12 percent). This was an average score improvement from 64.9 to 89.5. In the EWB group, 90 percent had good to excellent outcomes according to AOFAS scoring; 20 excellent (50 percent), 16 good (40 percent) and four fair (10 percent). This was an average score improvement from 66.5 to 89.3. DWB VAS improved from 7.3 to 1.9, while EWB VAS improved from 7.4 to 1.8. There was no statistical significant difference between the groups when evaluating the AOFAS and VAS scores at six months, 12 months or thereafter. Both groups AAS improved from three to six. All patients returned to their pre-injury activities except for four (9.7 percent) in the DWB group and three (7.5 percent) in the EWB group. There was no correlation with sex, age, BMI, symptom duration, or lesion size and outcome.
 

Conclusions:  The results of this study suggests that early or delayed weight-bearing following arthroscopic microfracture of a small to midsized osteochondral defect of the talus produced good results. There were similar outcomes according to AOFAS, VAS and AAS in this study. Early weight-bearing consisting of one week non-weight-bearing in a posterior splint followed by weight-bearing as tolerated in a CAM boot for a total of eight weeks may be recommended as a reasonable postoperative protocol following arthroscopic microfracture.