Difetti osteocondrali dell`astragalo: trattamento chirurgico e

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17
Osteochondral defects of the talus: surgical treatment
and rehabilitation
B.van Ooij,L.Kaas,M.L.Reilingh,C.N.van Dijk
Orthopaedic Research Centre Amsterdam,Department of Orthopaedic Surgery,Academic Medical Centre,Amsterdam,The Netherlands
DOI 10.1007/s10261-010-0052-5
ABSTRACT Difetti osteocondrali dell’astragalo: trattamento chirurgico
e riabilitazione
Un difetto osteocondrale sintomatico dell’astragalo è una lesione a carico
della cartilagine talare e dell’osso subcondrale, causa di dolore profondo a
carico dell’articolazione tibio-tarsica e/o di limitazione dell’articolarità,
rigidità, sensazione di blocco e gonfiore. La visualizzazione di questo tipo
di lesione non è sempre possibile utilizzando la radiologia tradizionale, ma
sono spesso necessari per riconoscerla esami di secondo livello come TAC o
RMN. Il trattamento iniziale è conservativo. Le possibilità di trattamento
chirurgico includono il “debridement” (artroscopico), il “curettage”, la stimolazione midollare, la fissazione del frammento, trapianti ossei, autotrapianti cartilaginei, impianto di condrociti autologhi o HemiCAP.
Questo articolo di revisione fornisce una visione d’insieme delle attuali tecniche chirurgiche nel trattamento delle lesioni osteocondrali dell’astragalo,
con particolare attenzione alla riabilitazione post-operatoria.
Classification
The most frequently used classification was introduced by Berndt
and Harty in 1959, based on
anatomic studies in cadaver limbs
demonstrating the etiological
mechanism of transchondral fractures of the lateral talar dome [7].
The Berndt and Harty classification divides OCD in four stages:
stage I is a small compression fracture, stage II an incomplete avulsion of a osteochondral fragment,
stage III a complete fragment
Surgical approach
The preferred approach for most
OCDs is by means of anterior
arthroscopy [10]. If a posterior
OCD cannot be reached by means
of an anterior approach (in the
fully plantar flexed position) a
two-portal hindfoot approach can
be performed (Fig. 2) [11]. As a
rule, OCDs in the anterior half or
in the anterior part of the posterior half of the talus can be
Diagnosis
An osteochondral defect (OCD)
of the talus is a lesion of the talar cartilage and subchondral
bone. It is mostly caused by a
(single or multiple) traumatic
event, leading to partial or complete detachment of the fragment
[1]. An OCD can either heal and
remain asymptomatic or
progress to deep ankle pain on
weight-bearing, with or without
subchondral bone cysts formation. The deep ankle pain is most
probably caused by high fluid
pressure during activity, resulting
in stimulation of the subchondral bone nerves underneath the
cartilage defect [2]. Other possible symptoms are: limited
range of motion, stiffness, locking and swelling. In this article,
we provide an overview of the
(surgical) treatment options,
with special emphasis on postoperative rehabilitation and return to sports.
Plain radiographs should be the
initial investigation of a suspected OCD of the talus, after careful
history taking and physical examination of the ankle. These
consist of weight-bearing anteroposterior (mortise) and lateral
views of both ankles. If the radiographs do not reveal any pathology or show no area of radiolucency, the OCD sometimes may
become apparent in a later stage.
A posteromedial or posterolateral defect may be revealed by a
heelrise mortise view with the ankle in plantar flexion. The combination of medical history, physical examination and radiography
has a sensitivity and specificity of
respectively 59% and 91% [4].
Additional imaging consists of
magnetic resonance imaging
(MRI) or computed tomography
(CT), which have a similar accuracy (Fig. 1) [4]. A CT-scan is especially useful in preoperative
planning, as it can define the exact location and size of the lesion
[5,6].
A differentiation has to be made
between the acute and chronic
situation [3]. In the acute situation, symptoms of an OCD of
the talus are often unrecognized
since the swelling and pain from
the lateral ligament lesion prevail. In patients with an isolated
ligamentous ankle injury these
symptoms usually resolve after
functional treatment within two
to three weeks. If symptoms
have not resolved within 4-6
weeks, an OCD must be suspected.
Chronic lesions typically present as persistent deep ankle pain,
during or after activity, after a
prior history of an inversion injur y of the ankle. Reactive
swelling or stiffness may be present, but absence of swelling,
locking or catching does not rule
out an OCD. Most patients
demonstrate a normal range of
motion with absence of recognisable tenderness on palpation
and absence of swelling.
Surgical treatment
Treatment strategies for OCDs of
the ankle have substantially increased over the last decade [1].
Conservative treatment is the first
step of the treatment of a symptomatic OCD. This may consist of
non-steroidal anti-inflammatory
drugs (NSAIDs), restriction of
(sporting) activities, rest and/or
cast immobilisation. The aim of
conservative treatment strategies
is to unload the damaged cartilage, allowing decrease of edema
and prevention of necrosis. A
(partially) detached OCD fragment can also heal to the surrounding bone. The results of
non-surgical treatment strategies
vary between 20 to 69% [1].
Surgical treatment is grossly based
on one of three principles [5]:
• debridement and bone marrow
stimulation (BMS), with or
without loose body removal.
The BMS can consist of microfracturing, drilling and abrasion arthroplasty
• securing a lesion to the talar
dome with fragment fixation,
cancellous bone grafting and/or
retrograde drilling
• development or replacement of
hyaline cartilage, using osteochondral autograft transfer
(OATS), allografts or autologous chondrocyte implantation
(ACI).
Introduction
Clinical presentation
avulsion without displacement
and stage IV represents a displaced osteochondral fragment.
As CT-scans are increasingly used
in the preoperative work-up, a
CT-classification was introduced,
based on the Berndt and Harty
classification [8]. In this classification, the stage V lesion represents an OCD with a radiolucent
defect [9].
reached with an anterior
arthroscopy if plantar flexion is
unlimited. Both approaches offer
the advantages of outpatient treatment and have the advantages of
less postoperative morbidity, faster
and more functional rehabilitation and earlier return to sports
[10,12]. Alternatively, an arthrotomy with or without medial
malleolar osteotomy could be performed [13,14]. In posteriorly lateral located OCDs, sometimes a
fibular osteotomy provides the
best open exposure [15].
Excision, curettage and bone marrow
stimulation
For this procedure all unstable
cartilage is excised and underlying necrotic bone is removed. Underlying cysts are opened and
curetted. After this debridement,
multiple connections with the
subchondral bone are created
with drilling or microfracturing,
a
b
Fig.1.Sagittal CT-scan (a) and MRI-scan (b) of the ankle of a 32-year-old male patient clearly showed
the central location of the OCD of the talus
cartilage. This technique can be
unsuitable for larger defects (>1.5
cm) [17,18]. The success rate of
BMS is on average 85%, with a
range of 46 to 100% and is regarded as the best and first treatment option currently available. It
also is relatively inexpensive and
there is low morbidity [1].
Fragment fixation, cancellous bone
grafting and retrograde drilling
In case of a large loose fragment,
fixation can be performed using a
screw, pin, rod or fibrin glue. It is
mainly applied in (sub)acute cases and in adolescents and children. Few reports have been published, with success rates of 73%
and 89% [19,20]. In case of a cys-
b
c
Fig. 2. A coronal (a) and sagittal (b) CT-scan of the
ankle of a 16-year-old woman with posterior impingement and deep ankle pain showed an os trigonum (right arrow) and a lateral located OCD of the
talus. A two-portal hindfoot arthroscopy was performed to reach the os trigonum and the OCD (c)
using a K-wire, a 2 mm drill or a
microfracture awl (Fig. 3). This
partially destroys the calcified
zone that is most often present
and creates multiple openings into the subchondral bone. Interosseous blood vessels are disrupted and a fibrin clot is formed.
The release of growth factors leads
to formation of new blood vessels, marrow cells are introduced
in the defect and fibrocartilaginous tissue is formed [16]. The
main advantage of this technique
is that it can be performed by
arthroscopy with relative ease and
it allows early rehabilitation of the
patient. However, fibrous cartilage is formed, which is of inferior quality compared to hyaline
a
a
B. van Ooij
tic lesion larger than 1.5 cm in
diameter, a cancellous bone grafting can be applied after debridement of the OCD [21]. The aim of
this procedure is to restore the
weight-bearing properties of the
talus. Success rates vary from 41
to 93% [1]. In case of more or
less intact cartilage with a large
subchondral cyst, or when the
OCD is hard to reach with the
anterior arthroscopy, retrograde
drilling can be performed. This
treatment is usually performed in
large cystic lesions. The aim is to
induce subchondral revascularisation and to stimulate new bone
formation [22]. The success rate
of retrograde drilling is 88% with
a range of 81 to 100%, but sizes
b
Fig. 3. A medially located OCD of the talus was diagnosed in a 28-year-old woman. An anterior
arthroscopy was performed.A microfracture awl was used (a) to create multiple openings into the subchondral bone.During loosening of the tourniquet,sufficient haemorrhage in the defect is checked (b)
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of OCDs were not described in
any of the studies [1].
Osteochondral autograft
transfer (OATS)
The aim of OATS is to restore the
articular surface with hyaline cartilage. A medial malleolar osteotomy is usually used for medial lesions. After curettage of the
unstable cartilage and underlying necrotic bone to create a
sharply defined rim, osteochondral grafts are harvested from the
ipsilateral knee (one or more
plugs of a lesser-weight-bearing
area) [9,23]. The grafts are inserted in the recipient site in the
following way: drilling (3-4 mm
deeper than the length of the
plug), conical dilatation (0.1-0.2
mm enlargement of the hole) and
delivery to the defect site. To
match the curvature of the articular surface of the talus, several
grafts (i.e. “mosaicplasty”) provide better results and may reduce donor site morbidity
[23,24]. The success rate of OATS
is 87%, with a range of 74 to
100%, but morbidity to the
donor site is seen in 12% (range
0-37%) of the patients. Because of
this percentage of knee complaints, OATS is regarded as the
second treatment of choice, after
BMS [1].
Autologous chondrocyte
implantation (ACI)
ACI is a relatively new technique,
introduced in 1994. It is performed in a focal OCD preferably
more than 1.5 cm in diameter. If
a subchondral cyst is present, autologous bone could be used to fill
up the base of the defect (i.e. the
“sandwich technique”) [25]. The
aim of ACI is to regenerate the
former OCD tissue with a high
percentage of hyaline-like cartilage. After a biopsy of healthy
(knee) cartilage, chondrocytes are
separated by filtration and cultivated in vitro. After a culture
medium period of 11-21 days, an
arthrotomy is performed. A periosteal flap from the tibia is covered over the debrided OCD and
the cultivated chondrocytes are
injected beneath the periosteal
flap. The success rate of ACI is
76% with a range of 70 to 92%
[1], but long-term results are
needed to evaluate the efficacy of
the treatment. Furthermore, possible disadvantages are: high costs,
two-stage surgery and insufficient
graft integration [26,27].
Novel metallic implantation
technique
To treat patients with a secondary
OCD of the medial talar dome a
novel 15 mm-diameter metal implant (HemiCAP®) has been developed. The set of 15 offset sizes
was designed to correspond with
the anatomy of various talar dome
curvatures. Recently, two independent groups published biomechanical cadaver studies that
provided sufficient rationale for
clinical use [28,29]. In our institution a prospective study was
started to evaluate the clinical effect of the metal implantation
technique. The procedure was
performed in 12 patients. The
AOFAS scores improved from 70
(42-75) before surgery to 86 (58100) at 1 year, and 90 (87-90) at
2 years follow-up (p < 0.05).
There were no clinical or radiographic complications (Fig. 4).
The metallic implantation technique seems to be a promising
treatment for secondary osteochondral defects of the talus, but
more patients and longer followup are necessary to draw firm
conclusions.
Rehabilitation and return
to sports
Only few trials have studied postoperative weight-bearing, immobilization and return to sports.
Saxena et al. [30] published a case
series of 26 microfracture procedures and 20 bone graft proce-
Fig. 4. Anteroposterior mortise view and lateral
weight-bearing radiographs of the affected ankle at two years follow-up showing the metal
implant resurfacing the defect.There are no degenerative changes of the ankle joint,compared
to preoperatively, or implant-related complications,and the medial malleolar osteotomy has fully healed
dures of the talus. Patients were
kept non-weight-bearing for up to
6 weeks, although patients with
small lesions (<3 mm in diameter)
were allowed to partially bear
weight at 3 weeks. After microfracturing, patients returned
to activities after 15.1 ± 4.0 weeks.
After bone grafting, patients returned to activities after 19.6 ±
5.9 weeks. Both groups had similar postoperative AOFAS scores.
It was concluded that both techniques allow patients to return to
sports. Full weight-bearing and
return to sports after microfracturing in OCDs of the talus is usually allowed earlier than after other treatment options. The postoperative immobilization protocol
after surgical treatment of OCDs
could be a variable in larger studies to create an evidence-based
consensus.
Based on our experience and
based on the limited trials on
postoperative rehabilitation and
return to sports after surgical
treatment of OCDs, we adopt the
following useful guideline:
• after debridement and BMS, partial weight-bearing (eggshell) is
allowed for the first four weeks.
After these first weeks, we allow
progress to full weight-bearing in
patients with central or posterior
lesions up to 1 cm. Larger and
anterior lesions require partial
weight-bearing up to six weeks.
Postoperative active plantar flexion and dorsiflexion are encouraged. Running on even ground is
permitted after 12 weeks [5].
Full return to normal and sporting activities is usually possible
after four to six months after surgery [17]
• in a randomized study on
OCDs including OATS, eight
weeks of non weight-bearing
were used as postoperative regimen [31]. Patients with a
malleolar osteotomy have to be
kept on non weight-bearing for
6 weeks. Following this period, partial weight-bearing for
three weeks is allowed to promote integration of the graft.
Postoperative active plantar
flexion and dorsiflexion are encouraged. Comfort could be
improved using an orthosis.
Full return to sporting activities
may start at approximately six
months
• after ACI, patients are kept non
weight-bearing and placed in a
well-padded short leg cast during the first two weeks. Following this period, partial
weight-bearing and gentle ankle
range of motion is allowed. A
controlled action motion walker boot is used. This walker
boot is used till six weeks after
the operation. Weight-bearing is
advanced based on radiographic evidence of osteotomy healing. Low-impact athletic activities such as cycling
are allowed after four to six
months. Running on even
ground and aerobics can be resumed after six to eight months.
Return to high-level sports is
permitted after 12 months [5].
Furthermore, it has to be taken into account that after every surgical treatment of OCDs rehabilitation is not only directed at protected mobilization but also at
strengthening and proprioceptive
activity.
Because of the challenge to
achieve early return to sports in
“high-demand” athletic patients,
pulsed electromagnetic fields
(PEMFs) were introduced. In our
institution a trial was started to investigate the effectiveness of
PEMFs in the rehabilitation period after arthroscopic treatment of
OCDs [32]. PEMFs could possibly improve bone and cartilage
regeneration and could possibly
suppress postoperative inflammation. Because they aim at providing evidence to clearly define
sports resumption, the future results of this trial could be of great
value in creating consensus in
postoperative rehabilitation after
surgical treatment of OCDs.
Conclusions
An osteochondral defect (OCD) of
the talus is a lesion of the talar cartilage and subchondral bone and
often leads to subchondral bone
cysts, associated with deep ankle
pain on weight-bearing. Only few
trials studied postoperative
weight-bearing, immobilization
and return to sport. Full return to
sporting activities is usually possible after 4 to 6 months after debridement and microfracturing.
Secondary procedures like OATS
and ACI might require a longer
time to return to full-impact
sports, up to 1 year.
Acknowledgement
The authors want to thank Dr. J.I.
Wiegerinck, MSc, PhD fellow of
the Orthopaedic Research Centre, Amsterdam, for providing the
images in this article.
17.
18.
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