SLR - June 2023 - Taylor Fillar, DPM PGY-1
Title: Surgical Management of Focal Chondral Defects of the Talus: A Bayesian Network Meta-analysisReference: Migliorini F, Maffulli N, Schenker H, Eschweiler J, Driessen A, Knobe M, Tingart M, Baroncini A. Surgical Management of Focal Chondral Defects of the Talus: A Bayesian Network Meta-analysis. Am J Sports Med. 2022 Aug;50(10):2853-2859.
Level of Evidence: Level IV
Scientific Literature Review
Reviewed By: Taylor Fillar, DPM PGY-1
Residency Program: Ascension St. John Hospital, Detroit, MI
Podiatric Relevance: There are a multitude of treatment options for focal osteochondral lesions of the talus. Podiatrists will find themselves in the position of having to advise patients on surgical options of single stage or multiple stage procedures. Furthermore, patients will request insight on time to return to sports or baseline activities of daily living depending on the operation of choice. The authors of this study proposed to determine which is the optimal surgical treatment, stating no prior consensus has been reached. A Bayesian network meta-analysis was conducted with the aim of comparing surgical strategies for the management of chondral defects of the talus, specifically focusing on a midterm follow-up. The present article compared the efficacy of a variety of focal osteochondral lesion procedures in terms of clinical scores and complications.
Methods: This level IV Bayesian network meta-analysis of all clinical trials comparing two or more surgical interventions for treatment of chondral defects of the talus. Inclusion criteria were studies that focused on AMIC, OAT, microfracture, MACT, and mosaicplasty. Data regarding patient characteristics at baseline were collected including age, BMI, sex, defect size, and number of procedures. The following outcomes of interest were analyzed: visual analog scale (VAS) score, American Orthopaedic Foot and Ankle Society (AOFAS) score, rate of failure, and rate of revision surgery. Failure was defined as recurrence of pain, catching symptoms, graft hypertrophy, and partially or completely displaced delamination demonstrated on MRI or arthroscopic examination.
Results: 521 procedures from 13 articles were analyzed. The ANOVA revealed no difference between the treatment groups in regards to mean age, BMI, sex, defect size, VAS scores, and AOFAS scores. The overall mean VAS score was 7.4 and the mean AOFAS score was 47.0 (P > 0.1). AMIC demonstrated the highest AOFAS score and lowest VAS score. In addition, AMIC exhibited the lowest rates of failure and revision. Lastly, the test for overall inconsistency was not significant.
Conclusions: The presented study indicates that at approximately 4 years of follow-up, the AMIC procedure for management of focal osteochondral lesions of the talus produced the best outcome. Through the Bayesian network meta-analysis, it was found that patients with the highest rate of complications were those who underwent OAT with allograft. The authors concluded that patients undergoing microfracture procedure demonstrated the lowest values of patient-reported outcome measures. The information presented in the study will act as a resource for my future patients who have an active osteochondral lesion diagnosis and for those who are postoperative and requesting further insight into their prior treatment. The most beneficial aspect of this study is the conclusion that allografts performed worse than autografts for treatment of osteochondral transplant. Additionally, discussing the study’s findings of long term return to baseline functionality will be an important piece of advice I will offer in my future patient encounters.