SLR - October 2012 - Romina Vincenti
Reference: Anders S, Lechler P, Rackl W, Grifka J, Schaumburger J. (2012). International Orthopaedics, 36, 1635-1640.
Scientific Literature Review
Reviewed by: Romina Vincenti, DPM
Residency Program: Cedars-Sinai Medical Center, Los Angeles, CA
Podiatric Relevance:
Osteochondral lesions (OCL) of the talus are usually revitalized with anterograde drilling, microfracturing, cancellous bone grafting, or osteochondral plugs depending on the condition of the cartilage. However, cartilage preservation is essential in obtaining good results. Retrograde drilling does the same as the above techniques without damaging the cartilage surface. This study was done to combine the results of retrograde drilling along with autologous cancellous bone grafting guided by fluoroscopy and arthroscopy for OCL of the talus.
Methods:
A total of 41 talar lesions were treated by fluoroscopy-guided retrograde core drilling and autologous cancellous bone grafting, including 16 males and 22 females. The average age of the participants was 33.2 years with a mean BMI of 24.8. The mean defect size of the lesions was nine mm. All lesions had undergone failed conservative treatment and were chronic with persistent pain for over six months. Follow-up of this study was 12-54 months. Intraoperatively, the lesions were graded using the Pritsch classification and were found to have 12 grade I lesions, 22 grade II lesions and seven grade III lesions. These lesions were diagnosed preoperatively by x-ray and MRI and were also followed-up with MRI. Postoperatively, the patients were partial weightbearing for six weeks, were allowed full range of motion immediately and were restricted from impact sports for six months.
Results:
Overall the AOFAS score increased approximately 33.5 points and was mainly caused by pain reduction. Lesions that were classified as grade I and II obtained better results than grade III lesions. Also, first line treatments and open distal tibial growth plates led to significantly better results. Age, gender, BMI, localization, and follow-up time all did not influence score results. The postoperative MRI showed only two patients with demarcation, however revision was declined by patients. All other patients showed intact cartilage surface including five patients with complete subchondral bone remodeling. There were no stress fractures, necrosis, joint space narrowing or impaction of the OCL zone noted.
Conclusions:
Fluoroscopy-guided retrograde core drilling and autologous cancellous bone grafting is a highly effective therapeutic option for stable mid-sized OCL of the talus with intact cartilage grades I and II after failed conservative treatment. This procedure is beneficial to grades I and II OCL of the talus due to its minimally invasive technique and cartilage preservation. However for grade III OCL of the talus with cracked cartilage surface, this procedure is not recommended.