SLR - August 2018 - Heather H. Schaefbauer

Primary Versus Secondary Osteochondral Autograft Transplantation for the Treatment of Large Osteochondral Lesions of the Talus

Reference: Park KH, Hwang Y, Han SH, Park YJ, Shim DW, Choi WJ, Lee JW. Primary Versus Secondary Osteochondral Autograft Transplantation for the Treatment of Large Osteochondral Lesions of the Talus. Am J Sports Med. 2018 May;46(6): 1389–1396.

Scientific Literature Review

Reviewed By: Heather H. Schaefbauer, DPM
Residency Program: HealthPartners Institute/Regions Hospital, St. Paul, MN

Podiatric Relevance: Osteochondral lesions of the talus (OLT) are commonly encountered in clinical practice today and often cause a significant amount of pain and disability. Nonoperative treatment measures, such as cast immobilization or rest, can be successful; however, there are still a large proportion of patients who fail nonoperative measures and require one of the numerous options for surgical intervention, such as microfracture or osteochondral autograft transplantation (OAT). Arthroscopic microfracture is the most common primary surgical intervention, but recent studies have shown less favorable outcomes when used for the treatment of large OLTs. This article compares clinical results after primary versus secondary OAT for large OLT.

Methods: A total of 46 patients between 2005 and 2014 with large (>150 mm2), symptomatic OLTs who underwent surgical intervention were included in the study. Group 1 included 18 patients who received primary OAT, and group 2 included 28 patients who underwent secondary OAT. All surgeries were performed by one surgeon with a minimum follow-up of two years. Patients included in the study were those with a large OLT (>150 mm2), stable ankle joint and those undergoing either primary OAT or secondary OAT after failed microfracture. Clinical outcomes were assessed utilizing the pain visual analog scale (VAS), the Roles and Maudsley score and the Foot and Ankle Outcome Score (FAOS).

Results: There was a statistically significant improvement (P < .001) in overall VAS pain scores from 6.2 +/- 1.3 preoperatively to 1.9 +/- 1.1 at last follow-up. No significant difference in VAS pain score was found between the primary and secondary OAT groups. There were 11 revisional surgeries performed during the study period, which did not show statistical significance between the two groups. Clinical failure occurred in 11 of 46 ankles (23.9 percent). Prior microfracture in the secondary OAT group did not correlate with increased likelihood of clinical failure. There were no serious complications, such as deep infection, nonunion or nerve injury, reported.

Conclusions: The results of the study demonstrate favorable outcomes for both primary and secondary OAT for the treatment of large OLTs. The study noted that prior microfracture did not affect the survival of OAT and that revisional surgery rates between the two groups were not significantly different. The authors concluded that secondary OAT after failed microfracture had comparable clinical outcomes with primary OAT for the treatment of large OLT. Lastly, the authors conclude that this study should serve as a useful tool for surgeons to better predict surgical outcomes and choose the best procedure for patients with large, symptomatic OLTs. 

Educational Opportunities