SLR - November 2015 - Samantha DelRegno
Results of Surgical Management of Osteochondritis Dissecans of the Ankle in the Pediatric and Adolescent Populations
Reference: Kramer DE, Glotzbecker MP, Shore BJ, Zurakowshi D, Yen YM, Kocher MS, Micheli LJ. Results of Surgical Management of Osteochondritis Dissecans of the Ankle in the Pediatric and Adolescent Population. J Pediatr Orthop. 2015 Oct-Nov; 35(7):725-33.
Scientific Literature Review
Reviewed By: Samantha DelRegno, DPM
Residency Program: Englewood Hospital and Medical Center, Englewood, NJ
Podiatric Relevance: Osteochondirits Dissecans (OCD) can occur as an idiopathic-acquired focal defect to subchondral bone that uncommonly occurs in adolescents between the ages of 13 and 18. The talus of the ankle joint is the third most common location in the body for these lesions to be found. These lesions are frequently treated successfully with conservative care, including immobilization and activity modification, however, when conservative therapies have failed, surgery may become an option in order for these children to ambulate and perform various physical activities pain free.
Methods: This is a retrospective chart review of 109 ankles in 100 patients, who were surgically treated for OCD lesions between 2001 and 2010. This study includes adolescents under the age of 18, who have failed at least six months of conservative therapy for a painful OCD lesion or who presented on initial visit with an unstable OCD lesion. Pre-operative data includes age at surgery, sex, history of trauma, duration of symptoms, weight, height, and BMI. Most lesions were evaluated and classified by either the Berndt and Harty criteria on x-ray or via MRI. Post-operative x-rays were also reviewed in 80 patients. Patients were also asked to complete a return to sport survey and Foot and Ankle Outcome Score (FAOS) after surgery. Statistical analysis was then used to identify predictors of reoperation, Berndt and Harty clinical grade, and FAOS score. The operative technique in each patient was variable and chosen based on the size and location of the lesion. Both salvage and excisional techniques were used. Most lesions were initially visualized using the 2-portal anterior ankle arthroscopy with fluoroscopy. Under surgeon discretion for better visualization, an ankle arthrotomy was performed in a limited number of cases. Once the size, location, and stability of the lesion was determined, one of three treatments were performed. These treatments included transarticular drilling, drilling with internal fixation, and excision of lesion with microfracture/marrow stimulation. Full weightbearing was achieved by six weeks post-operatively with physical therapy being initiated at this time. Return to impact sports was at surgeon discretion, beginning at three months post-operatively.
Results: The median follow-up period for this study was 3.3 years. The ratio of females to males included in this study was 3:1 and the Berndt and Harty clinical staging included 14 stage I, 50 stage II, 16 stage III, and 3 stage IV talar dome lesions. Intra-operatively stage I lesions were primarily treated with transarticular drilling, stage II and III were mostly divided between transarticular drilling and drilling with internal fixation, while stage IV lesions were usually excised. At a mean of 1.7 years follow-up, 29 ankles underwent reoperation with “fair” results from this revisional procedure. Of the survey responders for FAOS and return to sport, 82 percent of patients were satisfied with the outcome of their procedure and six months was the median return to sport time. It was found that females with a higher BMI were found to have a worse FAOS score.
Conclusions: Being an idiopathic condition in adolescents, it is difficult to prevent OCD lesions of the talus. However, treatment options still need to be thoroughly explored for these patients. Whenever possible, conservative therapies should be your first line of treatment, however in certain situations surgery becomes a necessity. There have been few studies evaluating results of surgery for OCD of the ankle in the pediatric population. Although 29 ankles required reoperation, the FAOS score of returned surveys remained high, demonstrating that surgical intervention based on size, location, and stability of OCD lesions in the pediatric population is a plausible treatment option. It would be interesting to perform future studies comparing the success rate of non-operative management of OCD lesions of the ankle in the pediatric population versus operative management.