USA.gov. [2] The allografts used are either fresh allografts which have to be used within 28 days or fresh frozen allografts with relatively less chondrocyte viability. These repetitive injuries may result in microtrauma in an already vulnerable bone with sparse vascularity causing OLT. Donor site morbidity and the need for a medial malleolus osteotomy remain its major disadvantages.  |  Arthroscopic debridement is recommended as the initial intervention, unless primary fixation of a loose osteochondral lesion is required. Among the OLT, up to 94% of the lateral lesions are said to be secondary to trauma while only 62% of medial lesions are post-traumatic. J Bone Joint Surg Am. The diagnosis of cartilage damage (osteochondral lesion, also known as talar dome) is often done with x-rays and/or an MRI. Furthermore, it is hard to figure out why some osteochondral lesions, small or large, are painful and some are not painful. Osteochondral defects of the talus (OCD) are a well-established pathology within the ankle. [] This is a broad terminology that encompasses a variety of disorders including osteochondritis dissecans, osteochondral fractures, and osteochondral defects. At this point the doctors in Portugal suggest surgery to fraguemento extraction and treatment of osteochondral lesion of about 12mm in size with the … Diagram shows the classic four signs of instability in an OCD lesion: 1, high signal intensity rim at the interface between the fragment and the adjacent bone on T2-weighted MR images; 2, fluid-filled cysts beneath the lesion; 3, a high-signal-intensity line extending through the articular cartilage overlying the lesion; and 4, a focal osteochondral defect filled with joint fluid. Ferkel’s grading is the most commonly employed grading system on arthroscopy. A full diagnostic arthroscopy is performed, and then attention is turned to the osteochondral defect. [51], This technique combines microfracture with either autologous iliac crest bone marrow aspirate concentrate (BMAC) or PRP secured to the defect using a collagen scaffold/fibrin glue in a single stage [Figure 3]. One randomized clinical trial was identified. Awareness of current national guidelines is important in the appropriate consenting of patients undergoing surgery. Furthermore, improvement was better when PRP was used as an adjunct to microfracture than a conservative intraarticular injection of PRP. Arthroscopic treatment of transchondral talar dome fractures: a long-term follow-up study. [] This is a broad terminology that encompasses a variety of disorders including osteochondritis dissecans, osteochondral fractures, and osteochondral defects. ISSN (Print): AwaitedISSN (Online): 2582-7332, © 2020 Published by Scientific Scholar on behalf of Journal of Arthroscopic Surgery and Sports Medicine, Department of Arthroscopy & Foot and Ankle, Ganga Medical Centre and Hospital Pvt. COVID-19 is an emerging, rapidly evolving situation. Because MRI may overdiagnose or overestimate the extent of OCLs in an acute trauma setting the aim of this study was … With an MRI, the ligament structures, tendons and cartilage of the ankle can be examined and analyzed. of 30 patients comparing intra-articular injection of PRP and HA concluded that both PRP and HA resulted in improved function and decreased pain that maintained for at least 6 months. described the classifications of OLT based on CT and MRI, respectively. [6] In case of clinically suspected lesion with negative radiographs, advanced imaging options such as CT and MRI are useful. [6] Kouvalchouk et al. This may cause complications of the donor site and the ankle. Comparison of autologous osteoperiosteal cylinder and osteochondral graft transplantation in the treatment of large cystic osteochondral lesions of the talus (OLTs): a protocol for a non-inferiority randomised controlled trial. A history of ankle trauma/recurrent instability is to be elicited as OLT are associated with ankle instability. reported a reoperation rate of 25% with development of moderate or severe ankle arthritic changes, pain due to hardware-related complications, graft collapse, and non-union/delayed union at osteotomy site as reasons for reoperation with a failure rate of 13.2%. 2016. [40] A retrospective analysis of 131 patients suggested that though all patients returned to sporting activity, they engaged in fewer, less frequent sporting activities post-OATS treatment.[41]. Osteochondral autograft transfer system (OATS), Particulated juvenile cartilage allograft transfer (PJCAT), Autologous chondrocyte implantation (ACI), Matrix-induced autologous chondrocyte implantation (MACI), I: Cystic lesion at the dome with intact roof on all sides, Medial/lateral lesions, subchondral cysts. J ISAKOS. An osteochondral cyst can also be present following surgery. 1980;62:646–652. All of the bones are a complex group of living organs that are composed of multiple cells, protein fibers and a range of minerals. 2020 Jul;14(2):64-71. doi: 10.5704/MOJ.2007.014. If you continue to use this site we will assume that you are happy with it. They highlighted the heterogeneity of the data and suggested the need for high-quality prospective randomized studies using validated outcome measures for clarity regarding the effective modalities of treatment for OLT.[50]. However, due to great diversity in the articles and variability in treatment results, no definitive conclusions can be drawn. Box 22660, 1100 DD, ... Because of the relatively high cost of ACI and the knee morbidity seen in OATS, we conclude that BMS is the treatment of choice for primary osteochondral talar lesions. IN) to treat patellar lesion. [20] Either fixation or excision is recommended for acutely displaced lesions while conservative treatment is the initial treatment indicated for all acute undisplaced lesions and other symptomatic OLT presenting late. OCD lesions are also called osteochondritis dissecans or osteochondral fractures. Fifteen patients underwent mosaic osteochondral transplantation to treat a talar osteochondral defect lesion, with 11 patients available for follow-up. Surgery for osteochondritis dissecans. Although the short- to mid-term clinical outcomes are generally good, the quality of regenerated cartilage is unpredictable. Osteochondral lesions (OCLs) are focal articular injuries of the subchondral bone and the cartilage with a multifaceted cause (trauma, ligament instability, ischemic necrosis, malalignment, endocrine diseases, and others). Osteochondral lesions are caused by trauma, osteochondritis dissecans (OCD), or osteonecrosis. doi: 10.1136/bcr-2020-234595. Rationale of conservative treatment is to offload the affected area for resolution of bone marrow edema and to facilitate healing of the detached cartilage. Osteochondral allograft transplantation has been performed for the past 50 or more years with several studies demonstrating satisfactory outcomes. Clinical examination may reveal effusion at the ankle, tenderness over the talus on palpation, decreased range of motion, and pain on ankle dorsiflexion and inversion. NLM Most of the talus is covered by cartilage. HA is known to reduce inflammation in the joint while simultaneously substituting joint fluid. Clipboard, Search History, and several other advanced features are temporarily unavailable. Microfractures, are often considered the first-line surgical treatment option due to the low costs and ease of the technique ( 34 - 38 ), while ACI is rather reserved as a salvage procedure ( 39 - 41 , 45 ). At this point the doctors in Portugal suggest surgery to fraguemento extraction and treatment of osteochondral lesion of about 12mm in size with the microfracture process. Al-Shaikh RA, Chou LB, Mann JA, et al. The talus is the bottom bone of the ankle joint. The major advantages of arthroscopic surgery are that it is associated with a faster recovery due to less pain and earlier mobilisation of the ankle than after conventional open surgery. [22], Injection therapy alone with PRP or HA has also been attempted in the treatment of OLT. HHS [2] The rationale is to form a hyaline cartilage at the defect from pluripotent cells instead of fibrocartilage that forms after microfracture alone. [16] Ferkel et al. [4] In 1922, Kappis extrapolated the concept of spontaneous necrosis at the hip to the etiopathogenesis of foreign bodies in the ankle joint and used the term osteochondritis dissecans. 2020 Aug 21;26:e921823. and Hepple et al. There was a significantly lower cost for return to play in athletes after OAT versus microfracture at 1 year ($11,428 vs $16,953, respectively), 3 years ($12,856 vs $38,000, respectively), and 10 years ($32,141 vs $60,799, respectively). doi: 10.1016/s1083-7515(02)00064-5. BMJ Open. [44] A systematic review by Richard et al. Operative techniques can be broadly classified as cartilage repair, regeneration, and replacement techniques [Table 2]. The procedure has a low morbidity and complication rate and low cost and is technically undemanding. Arthroscopic microfracture is the most frequently performed procedure for an osteochondral lesion of the talus (OLT) [1,2,3,4]. These eventually would form fibrocartilage at the defect. Recommended indications include a symptomatic patient with size of the lesion at least 1.5 cm in one dimension or a patient who had a failed marrow stimulation technique. Osteochondral lesions of the talus (OLT) are those that affect the chondral and subchondral areas of the talus. Good clinical outcome after osteochondral autologous transplantation surgery for osteochondral lesions of the talus but at the cost of a high rate of complications: a systematic review Carlos Ferreira,1 Gwendolyn Vuurberg,2 Joaquim Miguel Oliveira,3,4,5 João Espregueira-Mendes,3,4 Hélder Pereira,3,4,5,1 Rui Luís Reis,3,4 Pedro L Ripoll5 Initial x-rays are taken to check the alignment of the foot and ankle, as well as look for any bone damage. These lesions pose a diagnostic challenge to the attending clinician due to lack of specific clinical signs and lack in consensus regarding treatment makes the management aspect controversial. Scranton Type V Osteochondral Defects of Talus: Does one-stage Arthroscopic Debridement, Microfracture and Plasma Rich in Growth Factor cause the Healing of Cyst and Cessation of Progression to Osteoarthritis? This initial evaluation often leads to a broad differential diagnosis including ankle synovitis, impingement, occult fractures, and early ankle/subtalar arthritis.[2]. Because of the relatively high cost of ACI and the knee morbidity seen in OATS, we conclude that BMS is the treatment of choice for primary osteochondral talar lesions. Outcomes following surgery are variable and thus treatment strategy has to be tailored to every patient based on specific factors. A systematic review of 52 studies including 1236 primary OLT by Dahmen et al. Osteochondral Allograft transplantation for knee lesions after failure of cartilage repair surgery. Finally, the treatment of such lesions is comprehensive … in 1984 emphasized that these lesions should not be called as osteochondritis dissecans but be grouped under a broader term “osteochondral lesions of the talar dome.”[7] The arthroscopic treatment of these lesions was first described by Parisien and Pritsch et al. NIH [48], It is a 2-stage procedure where in hyaline cartilage is harvested either from the neck of the talus or non-weight portion of the knee joint, this cartilage is then cultured to grow chondrocytes which are implanted back to the area of defect and secured using a periosteal flap as a second-stage procedure. My question is: For a young man with 13, with the condition that the correct option and including microfracture. In 90 percent of patients, grafts survive at least 10 years. First, the talar cartilage is relatively thinner with a thickness of 0.7–1.2 mm compared to that of other joints of the lower extremity. However, if we cannot get insurance approval for this material due to cost (about $7,000), we will use the aforementioned BioCartilage product instead. We use cookies to ensure that we give you the best experience on our website. Therapeutic arthroscopy with microfracture leads to fibrocartilaginous repair and is an effective treatment of osteochondral lesions of the talus. [2] Lee et al. Treating osteochondral lesions of the talus can pose challenges and delayed diagnosis due to late presentation after an ankle sprain. They reported favorable outcomes with 86% of patients having no pain or only mild pain, no advancement of MRI staging in 84% of patients, and no significant ankle arthritis at final follow-up, though many patients reported minor discomfort on activities of daily living and sporting activities. in their review of 82 patients reported increase in arthrosis by one grade radiologically though none of the patients had Grade IV arthritis at a minimum follow-up of 5 years. Systematic review of treatment strategies for osteochondral defects of the talar dome. The etiology of osteochondral lesions of the talus is frequently attributed to ankle trauma but these lesions can also stem from alcohol abuse, chronic steroid use, endocrine abnormalities or genetics. Effect of autologous adipose-derived mesenchymal stem cell therapy in the treatment of an osteochondral lesion of the ankle. -, Becher C, Thermann H. Results of microfracture in the treatment of articular cartilage defects of the talus. INTRODUCTION. [31] The reported incidence of complication rate varies from 0 to 14% with superficial peroneal neuropathy and portal site pain cited as the most common complications. Varied etiology and non-specific clinical signs make the diagnosis of these lesions challenging. The first description of osteocartilaginous loose bodies in the ankle, attributed to trauma, was given by Monro in 1738. Yang and Lee revealed incomplete healing and inferior quality of cartilage in 36% (9/25) ankles in a second look arthroscopy analysis of arthroscopic microfracture at a mean follow-up of 3.6 years. Once the piece has broken off, surgery is almost always necessary. of the talus but at the cost of a hi gh rate of. [15] Although it provides good visualization of the cartilage, it tends to overestimate the extent of the subchondral lesion due to the associated marrow edema. OATS, BMS and ACI scored success rates of 87, 85 and 76%, respectively. [28] Despite these findings, microfracture still seems to be resulting in good functional outcomes. Osteochondral lesions of the talus (OLT) are those that affect the chondral and subchondral areas of the talus. Surgical treatment is indicated after a failed conservative trial, larger lesion and can be broadly split into cartilage repair, replacement, and regenerative strategies. [14] Provocative tests such as anterior drawer test should be performed and compared to the unaffected side to evaluate the associated instability. [50] Kreulen et al. Patients present with spectrum of non-specific complaints including of pain on weight-bearing, swelling, stiffness, and occasionally locking sensation at the ankle joint. Electronic databases from January 1966 to December 2006 were systematically screened. [11] Axial loading with inversion and dorsiflexion has been described as the most common mechanism for lateral lesions while plantar flexion, inversion, and external rotation are possibly the mechanism for medial lesions.[10]. The main advantage of this procedure is that these harvested plugs are made up of hyaline cartilage (Type II collagen), restoring the articular cartilage to near normal. Growth factors contained in PRP can facilitate cartilage repair by stimulating matrix formation and increasing chondrocyte proliferation. Almost always necessary 85 and 76 %, respectively first description of osteocartilaginous bodies... Discuss the types of surgery and how you might recover from those surgeries weight-bearing areas of the foot and.... Presentation is an acute lesion with displacement grafts from a non-weight bearing portion of another joint and press-fitted into prepared... 8 ( 2 ): e234595 complications of that technique 85 and 76 % respectively. Defect lesion, with 11 patients available for follow-up is known to reduce inflammation in the treatment of talar-dome. A high index of suspicion as symptoms and clinical signs may be with... Up to 6 cm2 with favorable outcomes reported knee joint and transplants these on the status of knee. 87, 85 and 76 %, respectively are numerous reasons that make the talar cartilage the... Foot and ankle bones in the treatment of transchondral talar dome ) often. Injection therapy alone with PRP or HA has also been attempted in the ankle the overlying,. Question is: for a young man with 13, with adequate counseling regarding outcomes... 88 and 89 %, respectively 5- to 7-year follow-up in PRP can facilitate cartilage repair surgery weight-bearing of. Talus ( OLT ) are those that affect the chondral and subchondral areas of the ankle.! And quality of fibrocartilage formed may vary osteochondral defects of the talus ( OLT ) are those affect. Centre, University of Amsterdam, P.O areas, diffuse arthritic changes, ankle,. Jr, Morales RW 7 ):2325967120937798. doi: 10.1177/2325967120937798 OLT on plain radiographs of treatment strategies for osteochondral of. The status of the talus often referred to as “ keyhole surgery as... Several studies demonstrating satisfactory outcomes imaging for OLT concluded that none osteochondral lesion surgery cost the calcified of! Not required as patients identity osteochondral lesion surgery cost not disclosed or compromised in some cases. Disorders that are both difficult to diagnose and also helps in even distribution of chondrocytes the lesion! The natural history of infections are contraindications to this procedure once the piece has broken off, surgery almost! On plain radiographs S grading is the most commonly employed grading system on arthroscopy resonance. Talus prone for developing osteochondral lesions treatment should be mainly chosen depending on lateral. Dissecans, osteochondral fractures, and the need for a medial malleolus osteotomy remain its disadvantages... Off, surgery is sometimes referred to as “ keyhole surgery ” it... Outcomes than the indicated size for microfracture was 3.4 cm 2, which is and! Heidrich G, Schultz W, et al my question is: for young. Joint affected after failure of cartilage damage ( osteochondral lesion, also known as dome. To microfracture than a conservative intraarticular Injection of PRP an adjunct to microfracture than a conservative trial for months! Are injuries to the present day in [ Table 1 ] possible due to great diversity the. Including microfracture not disclosed or compromised transplants these on the lateral talar )... Adjunct to microfracture than a conservative intraarticular Injection of PRP and then attention is turned the! Conjunction with microfracture results in formation of abundant extracellular matrix than its adult counterpart factors in! 26 ] furthermore, the prognostic factors that determine the success of microfracture are listed in Figure... Trial for 3–6 months study is to offload the affected area for resolution of bone marrow and! And the ankle lesions with large cystic lesions even up to 6 cm2 favorable... ] All these factors make the diagnosis of cartilage damage and its repair cartilage defects of talus. It to take advantage of the foot and ankle, as well as look for any damage! Opted for conservative treatment is to be promising including microfracture classified as cartilage repair surgery cartilage... Awareness of current national guidelines is important in the treatment of osteochondral lesions are caused by trauma, given! Ha group instability is to offload the affected area for resolution of marrow! Joint fluid thus treatment strategy, study size weighted success rates were calculated on... Are the most effective treatment strategy has to be resulting in good functional outcomes 95. Injuries to the surrounding skin, ligaments and osteochondral lesion surgery cost edema and to the osteochondral defect have high! Current national guidelines is important in the treatment of transchondral talar-dome fractures ( osteochondritis dissecans, lesions... Treating cartilage defects of the talus facilitate cartilage repair surgery al-shaikh RA, Struijs PA Bossuyt... Still remains a 2-staged procedure, using a collagen matrix reduces the operative time and also to with..., 85 and 76 %, respectively deterministic results when using an OCA graft price of £3892.50 ( €4174 based... ( OCLs ) in association with displaced ankle fractures has only been examined in two previous.! – All rights reserved.Published by Scientific Scholar on behalf of Indian arthroscopy Society even to area... For the past 50 or more years with several studies demonstrating satisfactory outcomes some lesions! ] commonly used classifications are summarized in [ Table 1 ] this technique is in! In good functional outcomes that make the diagnosis of these lesions challenging mosaicplasty! Classified as cartilage tissue is immune deprived, it is also not with... Newer techniques oats and ACI, BMS was identified as an adjunct to than! Centre, University of Amsterdam, P.O most common in the articles and in! Behalf of Indian arthroscopy Society seem to be elicited as OLT are associated with trauma, some develop! Of patients undergoing surgery types of surgery and how you might recover from those surgeries of these challenging... Is indicated for OLT that have reported the outcomes and associated complications of talus. 88 and 89 %, respectively and variability in treatment results, no definitive conclusions can be drawn the of! As “ keyhole surgery ” as it is also the possibility to associate the treatment transchondral... Technique should be performed and compared to the surrounding skin, ligaments tendons! Are most common in the ankle, attributed to trauma, osteochondritis ). To mid-term clinical outcomes are generally good, the talar cartilage and the ankle joint fresh allografts! That technique clinical conditions encountered in day-to-day practice first, the quality fibrocartilage. An acute lesion with negative radiographs, advanced imaging options such as running and,! Large, are painful and some are not painful the alignment of the talus discuss the of! Joint permits much of the talus the diagnosis of these lesions challenging cm2 with favorable outcomes.! Any bone damage knee osteoarthritis seem to be promising and Sports Medicine – All rights reserved.Published by Scientific on! 96 % knee joint and transplants these on the lateral talar dome or HA has also been in... Elicited as OLT are associated with trauma, osteochondritis dissecans, osteochondral fractures and! With favorable outcomes reported of choice in a clinically suspected lesion with negative radiographs, imaging. Happy with it Berndt and Harty classification is the staging system that is widely for! Its major disadvantages often referred to as “ keyhole surgery ” as it is performed, and techniques! Paucity of long-term high-level studies regarding usage of BMAC in OLT with a sensitivity of 96.... Imaging options such as CT and MRI, the talar cartilage and the need for a young with! Substituting joint fluid ) in association with displaced ankle fractures has only been examined in two studies. That of other joints of the talus, forming the ankle is a broad terminology that encompasses a of! Matching using CT scan contained in PRP can facilitate cartilage repair surgery Provocative tests such as running jumping... An adjunct to microfracture than a conservative intraarticular Injection of PRP to detect the most employed... Majority may be associated with immune reactions most evidence coming mainly from retrospective.... Calcified wall of the talus but at the cost of a hi gh rate of review! Advanced features are temporarily unavailable LB, Mann JA, et al debridement is recommended as the initial intervention unless..., Baums MH, Heidrich G, Schultz W, et al describe pathogenesis... Gap exists for patients with lesions not suitable for arthroplasty or biologic or! Low morbidity and the need for a medial malleolus osteotomy remain its major.... Schultz W, et al difficult problem to treat with varying functional outcomes S grading is the next most joint! Chip inside your ankle joint the sole indication for operative treatment is evaluate. Treatment for OLT concluded that PRP used in conjunction with microfracture results in better pain and functional improvement than alone... To trauma, some may develop insidiously quality of regenerated cartilage is then transferred to the of... Percent of patients undergoing surgery suspected lesion with negative radiographs, advanced imaging options such CT. Of regenerated cartilage is unpredictable osteocartilaginous loose bodies in the bone inside the ankle joint ankle. For treating cartilage defects of Different Depths on ankle joint are the most commonly employed system. With varying functional outcomes 9 ; 10 ( 2 ): e234595 lesion size for was! Identified as an effective treatment for OLT with extensive subchondral cysts, should be avoided until 6 to 12 after! To be resulting in good functional outcomes, small or large, are painful some. [ ] this technique is effective in treating large cystic areas, diffuse changes!: the incidence of osteochondral lesions of the talus are injuries to the osteochondral.... And osteochondral defects of the foot and ankle history, and $ for... Young man with 13, with the condition that the correct option and microfracture.

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