SLR - February 2022 - Monte J. Schmalhaus
Reference: Johnson MA, Park K, Talwar D, Maguire KJ, Lawrence JTR. Predicting Outcomes of Talar Osteochondritis Dissecans Lesions in Children. Orthop J Sports Med. 2021 Nov 15;9(11):23259671211051769. doi: 10.1177/23259671211051769. PMID: 34805420; PMCID: PMC8597075.Level of Evidence: Case-control study; Level of evidence, 3.
Scientific Literature Review
Reviewed By: Monte J. Schmalhaus, DPM
Residency Program: Kaiser San Francisco Bay Area Foot & Ankle Residency Program – Oakland, CA
Podiatric Relevance: The talus is the third most common location of osteochondral (OCD) lesions in the body and is thought to heal at a slower rate compared to other joints. Symptomatic lesions can cause disability and be a source of persistent ankle pain. In adults, OCDs of the talus are often related to trauma but can also be present from incompletely healed adolescent lesions. Most of the literature has combined adult and pediatric cohorts, with a paucity of literature in the isolated pediatric population. The purpose of this study was to identify factors associated with complete radiographic healing and assess treatment outcomes in pediatric patients with OCDs.
Methods: This is a retrospective study that analyzed 92 OCD lesions of the talus in 74 patients aged 18 and younger, that were treated over a 12-year period. Based on the Berndt and Harty Criteria, 23 lesions were stage-1, 29 were stage-2, 26 were stage-3, and 14 were stage-4. Patients were either treated non-operatively or operatively regardless of stage and depending on physician discretion. About two thirds of lesions were treated surgically. Surgical treatments consisted of drilling (39 percent), debridement and microfracture (36 percent), debridement with or without loose body removal (10 percent), or grafting (5 percent). Radiographs were evaluated at one-year follow up. Healing was defined as reossification of the lesion with consistency in radiodensity on radiographs. Bivariate and multivariate models were then used to compare significant variables in patients who showed complete radiographic healing compared to those who did not.
Results: Complete radiographic healing at one-year follow-up was observed in 54 percent of all patients. Bivariate analysis showed that patients in both treatment groups who healed completely were younger, had a lower BMI, and were found to have open physis. Multivariate model showed that patients who were treated surgically showed a significant positive correlation for radiographic healing. There were no significant differences in radiographic healing based off patient sex, Berndt and Harty stage, lesion size, or lesion location. At one-year follow up, over 90 percent of lesions that demonstrated complete healing had good or fair outcome compared to 67 percent in the lesions that showed incomplete healing.
Conclusions: Overall, this study found that children with OCDs treated both operatively and non-operatively, greater radiographic healing was observed in those with lower BMI and younger age. In addition, multivariate analysis showed initial treatment with surgery was positively associated with radiographic healing at one year. Interestingly there was no differences associated with lesion size or location. Limitations of this study include relatively short follow-up, lack of categorization of treatment based on Berndt and Harty clinical staging, and a large variation in surgical treatments. Despite these limitations, this article identified factors associated with radiographic healing and outcomes of OCDs in children. This study highlights the importance of including OCDs as a differential in children who present with ankle pain as early detection and treatment of OCDs may lead to reduction of pain and improved patient outcomes.