SLR - October 2020 - Katie J. Backstrand
Reference: Haraguchi, N., Shiratsuchi, T., Ota, K., Ozeki, T., Gibu, M., & Niki, H. (2020). Fixation of the Osteochondral Talar Fragment Yields Good Results Regardless of Lesion Size or Chronicity. Knee Surgery, Sports Traumatology, Arthroscopy, 28(1), 291-297.Scientific Literature Review
Reviewed By: Katie J. Backstrand, DPM
Residency Program: Northwest Medical Center – Margate, FL
Podiatric Relevance: Osteochondral lesions of the talus (OLT) are often symptomatic enough to warrant treatment and in many cases, surgery is indicated when conservative treatment is unsuccessful. However, treatment of osteochondral talar lesions remains one of the most controversial issues in the treatment of ankle disorders, and evidence to support one type of intervention over another is insufficient. Although arthroscopic microfracture is regarded as the gold standard for providing bone-marrow stimulation, concern over the use of microfracture as first-line treatment has been raised, with some studies showing progression of osteoarthritis, declining outcomes scores, persisting pain and inability to return to prior activity levels. The goal of this study was to assess the clinical outcomes of fixation of the fragment when the talar dome cartilage is deemed healthy in efforts to preserve native cartilage.
Methods: A level IV study was performed on 45 ankles in 44 patients. In all cases, cortical bone pegs were used and osteochondral fragments were partially or completely detached (Berndt and Harty stages 2 or 3). Not all fragments were displaced. For medial lesions, a medial malleolar osteotomy was performed to expose the medial aspect of the body of the talus. For two of the lateral lesions, an osteotomy at the anterolateral corner of the tibia and at the distal end of the fibula were performed. For another two of the lateral lesions, the anterior talofibular ligament was excised to expose the lateral aspect of the talus. For the remaining two lateral lesions, the accessory anteroinferior tibiofibular ligament was resected to expose the lesion and the ankle was in full plantar flexion. All osteochondral fragments were reduced and fixed with bone pegs and, if present, bone cysts were filled with cancellous bone from the osteotomy site. For all 45 ankles, postoperative outcomes were determined by pre and postoperative Japanese Society for Surgery of the Foot (JSSF) ankle/hindfoot scores. The location of the lesions were determined according to the nine zone talar dome articular surface grid configuration, and the lesion size was measured on CTA images. Postoperative outcomes were assessed radiographically. Postoperative JSSF scores were analyzed in relation to lesion location, measured lesion area, presence of subchondral cyst, trauma, and radiographic outcomes.
Results: The mean JSSF scores improved significantly from 63.5 points preoperatively, to 93.0 postoperatively with treatment failure only occurring in one ankle. Correlation between lesion areas and postoperative JSSF scores were weak. Correlation between the time of the trauma to the time of fixation surgery and postoperative JSSF scores were also weak. Radiographic outcomes were good for 28 ankles, fair for 10 and poor for seven.
Conclusions: Although malleolar osteotomy is often required for fixation of OCLs of the talus, regardless of the lesion size and chronicity, fixation yields promising short-term outcomes. Significant clinical improvement was obtained and radiographic improvement was achieved. Through this study’s findings, a movement toward a treatment strategy that avoids unnecessary sacrifice of native cartilage and provides sustainable repair of talar OCLs appears to be appropriate.