SLR - November 2014 - Clark Johnson
Osteochondral Autologous Transplantation Is Superior to Repeat Arthroscopy for the Treatment of Osteochondral Lesions of the Talus After Failed Primary Arthroscopic Treatment
Reference: Han Seob Yoon, Yoo Jung Park, Moses Lee, Woo Jin Choi, Jin Woo Lee. Osteochondral Autologous Transplantation Is Superior to Repeat Arthroscopy for the Treatment of Osteochondral Lesions of the Talus After Failed Primary Arthroscopic Treatment. Am J Sports Med. 2014; 42(8):1896-1903
Scientific Literature Review
Reviewed By: Clark Johnson, DPM
Residency Program: North Colorado Podiatric Medicine and Surgery Residency, Greeley, CO
Podiatric Relevance: Osteochondral lesions of the talus (OLT), which consist of traumatic damage to the talar articular cartilage and underlying subchondral bone, have traditionally been treated with arthroscopic marrow stimulation techniques. These include debridement, microfracture, anterograde drilling and retrograde drilling. These techniques have demonstrated successful long-term outcomes, when appropriate patient selection based on lesion characteristics (surface area and lesion depth) has occurred. Unfortunately, no prior studies have been conducted to directly compare treatment methods for those patients who have failed initial treatment with marrow stimulation techniques. This is a level III prospective cohort study with the primary goal to compare osteochondral autologous transplantation (OAT) with repeat arthroscopy for the treatment of OLT after failed primary arthroscopic treatment. The secondary goal was to determine if OAT was superior to arthroscopy in cases in which other treatment methods have previously failed.
Methods: Forty-eight patients were selected from among 399 patients who received arthroscopic marrow stimulation between 2001 and 2009. Inclusion criteria were joint stability, absence of extensive joint degeneration and osteochondral lesions for which previous arthroscopic treatment had not been successful. Exclusion criteria were diffuse arthritic changes of the ankle joint on plain radiography, diffuse fibrillated articular cartilage on arthroscopic evaluation, axial malalignment or chronic ankle instability. All patients were informed of the risks inherent with each surgery, and then were allowed to select their preferred method of treatment: repeat arthroscopy with marrow stimulation or OAT. IRB approval and informed consent were obtained. Twenty-two patients elected to undergo OAT (Group A) and 26 elected to undergo repeat arthroscopy (Group B). Of the 26 Group B patients, one demonstrated chronic lateral ankle instability, and three exhibited diffuse cartilage fibrillation on repeat arthroscopic evaluation and these four patients were therefore excluded from the study. This left 22 patients in Group A (OAT) and 22 patients in group B (repeat arthroscopy). None of the remaining patients were lost to follow-up during the study period. Outcome assessments were based on visual analog scale (VAS) for pain, and the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle Hindfoot Scale. Patients were evaluated preoperatively, and then reviewed at 6, 12 and 24 months, and then annually.
Results: The two groups were similar with respect to the types, sizes, and grades of lesions. Both groups demonstrated significant clinical improvement after one year; however Group B patients were not able to maintain this clinical improvement. Seven of 22 patients in Group B, and 18 of 22 patients in Group A maintained excellent or good AOFAS scores at the final follow—up. Poorer clinical outcomes were associated with larger defects in Group B, but this trend was not seen in Group A. Fourteen of 15 patients with failure in Group B eventually underwent revision OAT.
Conclusions: Primary arthroscopic marrow stimulation has been demonstrated to be a valid and successful treatment method for OLT. Lesion size has been shown to be a prime determinant of success with primary arthroscopic marrow stimulation. Smaller lesions tend to resolve more readily, and with greater long-term durability, with marrow stimulation; however, larger lesions tend to achieve the best and most long-lasting relief with OAT. In those patients who fail to achieve clinical success with primary arthroscopic marrow stimulation, OAT is the preferred method of revision treatment when compared with repeat arthroscopic marrow stimulation.