Osteochondral transplantation of autologous graft for the treatment of osteochondral lesions of talus: 5- to 7-year follow-up

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1 DOI /s ANKLE Osteochondral transplantation of autologous graft for the treatment of osteochondral lesions of talus: 5- to 7-year follow-up Dimitrios Georgiannos Ilias Bisbinas Athanasios Badekas Received: 30 May 2014 / Accepted: 10 October 2014 European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2014 Abstract Purpose Bone marrow stimulation procedures (microfractures/drilling) are considered the gold standard for the primary treatment of osteochondral talar lesions. In the literature, there is lack of evidence about the appropriate treatment in cases of failure of these procedures. A technique of osteochondral autologous transplantation of talar graft was used. It was hypothesized that this is a successful method with good results and low complication rates. Additionally, a technique of anterior ankle approach with temporary removal of a bone block from the distal tibia that gives adequate access to posterior talar dome lesions is demonstrated. Methods Between 2004 and 2007, 46 patients (37 males, 9 females), with OLT for which arthroscopic treatment with curettage and drilling or microfracture had failed, underwent osteochondral transplantation with an osteochondral graft harvested from the ipsilateral talar articular facet. A medial malleolar osteotomy or a distal tibial wedge osteotomy was used to access the talar dome defect. D. Georgiannos 1st Orthopaedic Department, 424 Military General Hospital, Thessaloníki, Greece D. Georgiannos (*) Royal Bournemouth Hospital, Castle Lane East, Bournemouth BH7 7DW, UK EVI_DIM45@hotmail.com I. Bisbinas 2nd Orthopaedic Department, 424 Military General Hospital, Thessaloníki, Greece A. Badekas Department of Foot and Ankle Surgery, Metropolitan Hospital, Athens, Greece Results The median follow-up time was 5.5 years (range m). Thirty-four lesions (70.8 %) were located in the central talar dome in the coronal plane, while 26 (54.1 %) and 19 (39.5 %) lesions were located in the lateral and medial aspect of talar dome in saggital plane, respectively. The overall improvement between the preoperative and post-operative AOFAS and VAS FA score was 35 points (p < 0.001) and 39 points (p < 0.001), respectively. Clinical results were considered as good in 43 patients (93.4 %) and fair in three patients (6.5 %). All the transplanted grafts were observed to incorporate fully into the recipient bed. No complications occurred at the site of the malleolus osteotomy or tibial osteotomy and the donor site at the talus. Conclusions The midterm results suggest that the technique of osteochondral transplantation of autologous talar graft for osteochondral lesions of talus after failure of primary treatment with bone marrow stimulation can be safely and successfully used. It demonstrates excellent post-operative scores including improvement of pain and function. This procedure is combined with removal of a tibial bone block and its subsequent replacement and does not yield complications experienced with other procedures. Level of evidence Retrospective case series, Level IV. Keywords Osteochondral lesion of talus (OLT) Osteochondral talar defect (OCD) Osteochondral transplantation Autologous cartilaginous graft Surgical treatment Introduction Osteochondral lesion is a broad term used to describe an injury or abnormality of the articular cartilage and the adjacent subchondral bone [14, 26]. Management of

2 symptomatic osteochondral lesions of the talus is challenging, given the poor healing potential of articular cartilage and limited access to the ankle joint. More than one-third of the patients have no lasting improvement with the conservative treatment [37]. The treatment strategies of symptomatic osteochondral lesions include excision of the lesion, excision combined with curettage and drilling or microfracture, ante/retrograde drilling, osteochondral autograft transfer (OAT), mosaicplasty and autologous chondrocyte implantation (ACI) [8, 38]. Although bone marrow stimulation procedures (microfractures/drilling) are considered the gold standard for primary treatment [37, 38], there is lack of evidence in the literature about what is next in cases of failure. It was hypothesized that the use of OAT with local talar graft after failure of the initial treatment is a successful method with excellent results and low complication rates. Additionally, a technique of anterior ankle approach with temporary removal of a bone block from the distal tibia that gives adequate access to posterior talar dome lesions is demonstrated. To our knowledge, this case series has the longest follow-up and includes the largest number of patients treated with osteochondral transplantation of local talar graft for osteochondral talar defects. Materials and methods Institutional Review Board approval was obtained prior to beginning the study by the Hospital Ethic Committee. Between 2004 and 2007, an osteochondral transplantation of local talar osteochondral graft was performed for 48 symptomatic osteochondral talar lesions, in 46 patients. Inclusion criteria in this prospectively designed observational study were an age between 18 and 55 years, lack of signs of extensive joint degeneration and osteochondral lesions of stage 3, 4 and 5 according to modified classification based on MRI appearances [17], for which previous arthroscopic treatment was not successful. Exclusion criteria were infection, severe osteoarthritis, rheumatoid arthritis and metabolic diseases, hindfoot deformities with need of correction and osteochondral talar defects without previous arthroscopic treatment. The following variables were collected: patient s age and gender, mechanism of injury, duration of symptoms, location of lesion at the talar dome and size of lesion. The location of lesion was based on a nine-zone grid. The talar dome articular surface was divided into a grid of nine zones of equal surface areas in the axial plane, where the anteromedial zone was zone 1 and the posterolateral zone was zone 9 [30]. All patients were followed up at 2 weeks for wound check, at 6 and 12 weeks with radiographs and at 6 months for clinical assessment. Routine follow-up was at 1 and 5 years. All patients were clinically examined and graded by the AOFAS-hindfoot score (primary outcome measure range points) [19] and the VAS FA score (total score ranging from 0 to 100 points) [32] preoperatively and at 6 months post-operatively. Clinical results were graded according to the criteria of Berndt and Harty [5] into good (freedom from symptoms or slightly annoying but not disabling symptoms), fair (improvement but some disability persisted) and poor (symptoms unchanged or required a revision operation). Cross-bridging between the osteotomized surfaces on two orthogonal radiographs without apparent intra-articular step was considered as radiological union in optimal position. All cases were performed under general anaesthesia and ankle block with thigh tourniquet on after administration of 1.5 g cefuroxime. Far posteromedial lesions (six cases) were approached with a medial malleolar osteotomy. An L-shaped incision used as in the standard medial approach to the talus but extended posteriorly to the posterior edge of the malleolus. An oblique osteotomy was then performed while the talar articular surface was protected with an elevator. The malleolus was retracted distally as it was hinged on the deltoid ligament. All the other lesions were approached with distal tibial block osteotomy. An arthrotomy was performed through an 8-cm anteromedial or anterolateral incision as required. A wedge-shaped bone block, 10 mm wide, 20 mm deep and 30 mm in height, was made at the distal anterior tibial articular surface on the side of the osteochondral lesion (Fig. 1). The two vertical parallel saw cuts were made first and then a third oblique cut used to connect the two vertical cuts proximally in the metaphysis. The saw was driven obliquely, pointing the articular surface of distal tibia at a depth of about 2 cm. All three cuts were left incomplete for the last 2 3 mm to avoid damage of the articular surface of distal tibia with the power saw. A thin osteotome was used instead to complete the three cuts through the cartilage. The bone block was temporarily removed and left aside. The defect created at the distal tibia permitted access to the lesion from above. In one case of posterolateral lesion, access was difficult after removal of the bone block and plantarflexion of the ankle. ATFL and CFL were released and taken down from their fibular origin, allowing an anterolateral dislocation of the talar dome and access to posterolaterally located lesion. At the end, a modified Brostrom procedure was performed to restore the lateral ankle ligaments. The lesions were prepared by removing the loose cartilage flaps and debriding the articular surface up to stable rim. The lesion was drilled with the appropriate size drill (4.75, 6 or 8 mm) to a depth of 9 10 mm.

3 Fig. 1 A wedge-shaped bone block was removed from the anterior distal tibia (a) to visualize the talar dome lesion (b) and allow for the osteochondral transplantation The osteochondral graft was harvested from the anterior aspect of the ipsilateral talar articular facet, just right at the articular cartilage margin both anteriorly and laterally or medially. The donor site was not back filled at all. A donor harvester device was used (Single Use OAT System, Arthrex, Naples, FL, Italy), and the graft was inserted and gently tamped into the recipient site until it was slightly proud to the surrounding cartilage edges (Fig. 2). At the end, all the distal tibial bone blocks and the osteotomized medial malleoli were repositioned and fixed with two absorbable pins and two screws, respectively. The post-operative rehabilitation protocol included no weight-bearing mobilization in a cast for 6 weeks, partial weight-bearing mobilization in a walking boot and physiotherapies for the next 4 weeks and then full weight-bearing mobilization. Statistical analysis Analysis of variance was performed with the Wilcoxon signed-rank test, and statistical significance was defined at the 5 % (p < 0.05) level. Results Forty-six patients with 48 osteochondral talar lesions were treated with osteochondral graft harvested from the ipsilateral anterior talar articular facet. Preoperative data are shown in Table 1. The age was 36.2 years (SD 8.1 years). The sex ratio between males and females was 4.1:1 (37 males, 9 females). Twenty-six patients had suffered a previous sport-related injury with inversion of the foot. Thirteen patients had experienced an injury while working, and seven patients could not recall any significant injury prior to the onset of symptoms. Average duration of symptoms from onset to first surgical intervention was 12 months (range 6 22 months) and from first operation to osteochondral grafting was 16 (range 12 43) months. Locations of lesions are shown in Table 2. Thirty-four lesions (70.8 %) were located in the central talar dome in the coronal plane, while 26 (54.1 %) and 19 (39.5 %) lesions were located in the lateral and medial aspect of talar dome in saggital plane, respectively. In terms of the individual zones, 21 (43.7 %) lesions were located in zone 6 (laterally and centrally), and 11 (22.9 %) lesions were located in zone 4 (medially and centrally) (Table 3).

4 Fig. 2 Osteochondral donor site at the anterior talar facet (small arrow) and recipient site at the central-medial talar dome (long arrow). Note that the graft inserted slightly proud to the surrounding cartilage edges Table 1 Preoperative data Data No. of patients 46 No. of lesions 48 Age 36 (range 19 53) Gender (m/f ratio) 4.1:1 (37 m/9 f) Mechanism of injury Sport injury 26 Injury at work 13 No. of injuries 7 Classification (MRI based) Stage 3 18 Stage 4 24 Stage 5 6 Lesions were classified according to modified classification based on MRI appearance before the original surgery (Fig. 3a) [37]. Eighteen lesions were classified as stage 3 (detached but undisplaced fragment), 24 lesions were classified as stage 4 (detached but displaced fragment) and six lesions as stage 5 (lesions with subchondral cyst formation). The graft sizes ranged from 4.75 to 8 mm in diameter: eight grafts of 4.75 mm, 18 grafts of 6 mm and 22 N grafts of 8 mm. All of the 4.75-mm grafts were used for lesions of the lateral third of the talar dome. Thirteen out of 18 (72.2 %) 6-mm grafts were used also for lateral talar defects. Sixteen out of 22 (72.7 %) 8-mm grafts were used for grafting medial talar defects. The preoperative AOFAS score was 55 (SD 4.2), and the post-operative score was 90 (SD 5.8). The median VAS FA score was 52 (SD 6.6) preoperatively and 91 (SD 8.2) post-operatively. Clinical results were considered as good in 43 patients (93.4 %) and fair in three patients (6.5 %). By radiographic examination, the transplanted grafts were observed to incorporate fully into the recipient bed in all cases. All osteotomy sites healed without problems (Fig. 4). No decreased joint space or significant osteoarthritic changes were showed at the last follow-up radiographs. Three cases of superficial wound infection were treated uneventfully with oral antibiotics. One patient was complaining of numbness at the distribution area of superficial peroneal nerve, but the sensation came back to normal at 1 year post-operatively. Two patients continued to complain of occasional ache over the anteromedial aspect of their ankle, although they did not decrease their daily living or sport activities. Five patients underwent surgery subsequently to the index procedure. Three had arthroscopy and excision of impinging osteophytes from the lateral malleolus 8 10 months following surgery, and two had arthroscopy with debridement of the anterior tibial marginal osteophytes at the site where the tibial bone block had been removed 12 months following surgery. In all cases, the articular cartilage of the grafted lesion appeared to be normal, in continuity with the surrounding normal cartilage. The articular cartilage on the tibial plafond had also healed without articular surface defects. Regarding the donor area, there was development of a chondral-like tissue that filled the defect. The median follow-up time was 5.5 years (range m). Discussion The most important finding of the present study was the fact that the transplantation of autologous osteochondral talar graft can be used for treatment of osteochondral talar defects after failure of the initial treatment with drilling or microfractures. This technique was proved safe with good clinical results, low complication rate and demonstrated excellent post-operative scores including improvement of pain and function. A large variety of treatment strategies exist for osteochondral lesions of talar dome: conservative [6], excision of fragment [37], excision and curettage with or without drilling [2, 6, 33], excision and curettage with microfractures

5 Table 2 Location of lesions Zone/location No. of lesions per zone % 1. AM 2. AC 3. AL CM 5. CC 6. CL PM 8. PC 9. PL Coronal plane Saggital plane Anterior third % Medial third Central third Posterior third Central third % Posterior third % 39.6 % 6.2 % 54.2 % Table 3 Graft size used in each zone Graft size 4.75 mm (no. 8) Graft size 6 mm (no. 18) Graft size 8 mm (no. 22) Fig. 3 MRI of the right ankle demonstrates an osteochondral defect of the talar dome before (a) and 6 months after (b) treatment with debridement and microfractures Fig. 4 Anteroposterior (a) and lateral (b) post-operative radiographs of the ankle revealed good incorporation of the osteochondral graft (arrow) and healing of the distal tibial wedge block

6 [4, 10, 37] and cancellous bone grafting [7, 20]. Arthroscopic debridement combined with curettage and drilling is widely recognized as the gold standard treatment for smaller lesions. Satisfactory results with this technique have been reported to be as high as % [2, 32]. But even this technique resulted in fibrocartilaginous tissue filling the defect [24], and it has shown suboptimal results for larger lesions, cystic lesions and lesion requiring revision surgery (Fig. 3b) [4, 33]. This has led to development of surgical techniques aimed at restoring the superior biomechanical properties of hyaline cartilage including osteochondral transplantation (OATS) [1, 34, 35] or mosaicplasty [13, 14, 26], osteochondral allograft [9, 15] and ACI [3, 21]. With transplantation, intact normal articular cartilage harvested from the knee was implanted into the defect. The graft provided a fully formed articular cartilage matrix that has the potential to provide viable chondrocytes that can maintain the matrix [26]. However, the procedure involved the morbidity associated with disturbing an otherwise normal knee to obtain the graft which was described in the literature up to % [11, 25, 31, 36]. Also, the size and shape of the graft are limited by the amount of cartilage that can reasonably be harvested from a healthy knee. In addition, there is scant evidence to support the assumption that cartilage from the knee can withstand the tremendous forces sustained by the talar dome. The hyaline cartilage of the knee is different from that on the talus and may not be as sturdy as that of the talus [28]. By harvesting the graft from the anterior part of medial or lateral talar facet, which is a low weight-bearing area [22], the risks of the procedure were reduced. Since the graft size is relatively small, the integrity of the anterior dome is maintained. The maximum diameter of the grafts should not exceed 6 8 mm. For the reconstruction of larger osteochondral lesions, grafts should be taken from the ipsilateral knee [22]. There was no evidence of collapse of the talus at the donor site either in our study or in the literature. Due to the shape, size and anatomy of the ankle joint, access to the posterior third of talar dome was quite challenging. A malleolar osteotomy became a popular procedure to gain access to posterior third of talar dome [8, 14, 26]. V-shaped osteotomies seemed to be disadvantageous because they offered an inferior view of the ankle joint and prevented a perpendicular setting of the fixation screw to the level of the osteotomy [7]. Using the oblique osteotomy [27], no problems or any complications such as non-union or incongruity of the articular surface with subsequent osteoarthritis were encountered. Second look arthroscopy revealed that the cartilage of the grafted lesion appeared to be normal, in continuity with the surrounding normal cartilage. The tibial articular cartilage on the tibial plafond had also healed without articular surface defects, and regarding the donor area, there was development of a chondral-like tissue that filled the defect. The findings of this study are in agreement with those of other studies stating good gliding articular surfaces, histologically proven survival of the transplanted hyaline cartilage and fibrocartilage covering the donor sites after control arthroscopies [11]. A periphery of chondrocytes around each plug dies after mosaicplasty harvest. It is estimated that 24 % of the chondrocytes implanted from the graft harvester were dead. It seems safer and simpler to insert one larger harvested graft [18]. There will be dead space between the cylindrical grafts which may ultimately be filled with fibrocartilage. It is best to limit this dead space as much as possible [11]. The use of a single osteochondral plug minimizes fibrocartilage ingrowth [12], a prominent feature of the mosaicplasty technique. In mosaicplasty, % of the defect is replaced with fibrocartilage [1]. Also, one graft should produce a more congruent surface and recreating the 3-D surface of the talus is difficult with several plugs [1]. Many authors had described OLT as occurring most commonly in the anterolateral and posteromedial talar dome [5, 6, 10]. With the routine use of diagnostic MRI scan, this historical supposition was challenged [16, 30]. Using a nine-zone grid of the surface of the talar dome, the authors determined that the most common location for the osteochondral defects of the talus was in the centromedial (zone 4) and centrolateral (zone 6) regions (53 vs. 23 %, respectively) [30]. They also demonstrated that medial lesions were significantly larger and deeper compared with lateral lesions. Osteochondral lesions at the central talar dome in the saggital plane (zones 2, 5, 8) are exceedingly uncommon, and lesions in the anterior dome in the coronal plane (zones 1, 2, 3) are relatively uncommon [30]. However, the results of this study are similar to the distribution reported in a recent study [29], where OLT located in the centrolateral talar dome were almost twice as common as those located in the centromedial dome (43.7 vs %, respectively). With regard to lesion morphology, this study parallels the previous studies demonstrated that medial lesions are larger than lateral ones. The bigger grafts (8 mm) were used mainly for medial defects, and the smaller (4.75 mm) grafts were used exclusively for lateral defects. The removal of a portion of the anterior tibial plafond was first utilized to access lesions of talar dome in The anteromedial articular surface of the tibia overlying the talar lesion was grooved with a narrow gouge. The area of distal tibial articular surface removed was 4 5 mm wide by 6 8 mm deep and was not replaced [10]. But this technique was impractical for far posterior talar lesions since the amount of bone needed to be removed was significant and would decrease the tibial load-bearing capacity of tibial plafond if not replaced [34]. A new technique with temporary removal of a bone block from the distal tibia and reinsertion and fixation

7 after the end of osteochondral transplantation has been described. Either a five-sided bone block with a rectangular basis of the articular surface [34] or a four-sided bone pyramid with a triangular basis [22, 23] could be temporarily removed and reinserted. We preferred the removal of a five-sided bone block which gives better observation and access to posterior talar dome. The defect was visualized from above, and the removal of the bone block allowed for perpendicular placement of osteochondral grafts to the defect area. No complications were encountered with this technique. After second look arthroscopy, the articular cartilage of the tibial plafond was congruent and healed without articular surface defects. The overall improvement in the AOFAS score in our study was 35 points and in VAS FA score was 39 points. This is in agreement with the improvement reported in studies using similar techniques [22, 34]. The Wilcoxon signed-rank test revealed significant difference between the preoperative and post-operative values in both the AOFAS and the VAS FA scores (p < 0.001). The good results of this study (93.4 %) were superior to good results (87 %) obtained in 243 patients treated with osteochondral transplantation from nine studies included in a recent systematic review [38]. There are several limitations present in the study. There was no control group, but its strength was increased as it was a prospectively organized study. Also, our results do compare well with the success rate for OATS published in the literature. Follow-up was the longer so far reported, but long term follow-up will be necessary to determine whether the results deteriorate with time. The relatively small number of patients precluded drawing statistically significant conclusions although this study included the largest number of patients with osteochondral lesions of talus treated with local talar graft transplantation in the literature. After all, the midterm results of this study suggest that 1. Osteochondral transplantation of local talar graft can be safely and successfully used for treatment of osteochondral talar defects of stage 3 5 after failure of the initial treatment with drilling or microfractures. 2. Graft harvest from the anterior part of medial/lateral talar facet reduces the morbidity associated with graft harvesting from the knee. 3. The temporary removal of a bone block from the distal tibia through an anterior approach gives adequate access even to posterior talar dome lesions. 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