SLR - June 2013 - Satwinder Kaur Gosal
Reference: van Bergen CJ, Kox LS, Maas M, Sierevelt IN, Kerkhoff GM, van Dijk CN; Arthroscopic Treatment of Osteochondral Defects of the Talus: Outcomes at Eight to Twenty Years of Follow-up. The Journal of Bone & Joint Surgery. 2013 Mar;95(6):519-525.Scientific Literature Review
Reviewed by: Satwinder Kaur Gosal, DPM
Residency Program: Massachusetts General Hospital, Boston, MA
Podiatric Relevance: Osteochondral defects of the talar dome, often diagnosed and treated in podiatric practice, commonly occur in young active adults. Symptoms include ankle pain, during or after physical activity, and swelling, stiffness or locking. Early surgical intervention by arthroscopic debridement and bone marrow stimulation is considered the gold standard of treatment.
Methods: Approved by a local Medical Ethic Committee, 105 patients who had undergone arthroscopic treatment of talar dome osteochondral defects from 1988 to 2000 were identified. Fifty patients, 30 male and 20 female, with mean age of 32 years at the time of surgery, were eventually included. Defect size was determined by CT (first choice), and if unavailable, by MR or radiographic imaging. Chart review and interview data included injury mechanism, duration of symptoms prior to surgery, postoperative rehabilitation, postoperative pain, and ankle stiffness, swelling, and function. Clinical outcomes were measured from subjective questionnaires including Ogilvie-Harris scoring, Berndt and Harty outcome question, American Orthopeadic Foot & Ankle Society (AOFAS) ankle-hindfoot score, Short Form-36 (SF-36), and by resumption to work and sports. Weight bearing x-rays were obtained postoperatively and at the final follow-up visit, for staging and grading of osteoarthritis. X-rays were read by a blinded independent musculoskeletal radiologist, and then graded in blinded fashion by two orthopaedic surgeons according to a modified Berndt and Harty classification system. Univariate logistic regression analysis was performed, based on defect size, location, & classification, patient age & body mass index, traumatic etiology, and duration of symptoms.
Results: Fifty percent of defects were located on the centromedial aspect of the talar dome. Seven defects were classified as Berndt and Harty stage I, one as stage II, six as stage III, two as stage IV, twenty-nine as stage V, and five could not be classified. Ogilvie-Harris Score was excellent in 10 patients (20 percent), good in 29 (58 percent), fair in 11 (22 percent), and poor in none (0 percent). According to the Berndt and Harty outcome questions, 37 patients responded as good, 10 as fair, and 3 as poor. The median AOFAS score was 88. The SF-36 score ranged from a mean of 71 for vitality to 91 for emotional component role. Ninety-four percent of the patients resumed work postoperatively and eighty-eight resumed playing sports. Radiographic osteoarthritis was noted as grade 0 on 16 (33 percent), grade I on 30 (63 percent), grade II on 2 (4 percent), and grade III on none. Thirty-two (67 percent) showed no progression and 16 (33 percent) showed progression by one grade. Progression of osteoarthritis occurred in 47 percent of non-cystic defects and 32 percent of cystic defects. None of the prognostic factors were found to be significantly associated with the Ogilvie-Harris score of osteoarthritis progression.
Conclusion: This study was conducted primarily to evaluate the long-term outcome of arthroscopic debridement and bone marrow stimulation of talar dome osteochondral defects and secondarily to identify prognostic factors affecting long-term results. Surgical treatment initial success rates were maintained over time, but no predictive outcome factors could be identified.