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10
Maartje Zengerink and C. Niek van Dijk
10.1 Introduction
Take-Home Points
• Recommended treatment for asymptom- Treatment strategies for osteochondral lesions
atic/low symptomatic lesions is conser- (OCL) of the ankle vary widely. Moreover, they
vative. have substantially increased over the past two
• Recommended treatment for symptomatic decades, due to technical progress. In the case of
lesions ≤15 mm is excision, curettage, a patient with a symptomatic OCL, it can be a
and BMS. challenge for the surgeon to choose from this
• For symptomatic lesions ≥15 mm, con- wide pallet of treatment strategies. Publications
sider fixation (for posttraumatic cases are numerous, but often involve only one tech-
and juveniles), or bone marrow stimula- nique and therefore lack comparison. Stages of
tion, or OATS. OCL vary between the studies, as do patient char-
• For large talar cystic lesions, consider acteristics, surgical experience, and follow-up.
antegrade or retrograde drilling with or Pooling the data of these studies can provide new
without a bone transplant or OATS. information useful in decision making.
• For secondary lesions, consider OATS The various nonsurgical and surgical tech-
or ACI. niques for treatment of symptomatic OCL include
rest or cast immobilization, excision of the lesion,
excision and curettage, excision combined with
curettage and drilling/microfracturing (i.e., bone
marrow stimulation – BMS), placement of an
autogenous (cancellous) bone graft, antegrade
(transmalleolar) drilling (TMD), retrograde drill-
ing, fixation and newer techniques like osteo-
M. Zengerink, MD, PhD (*) chondral transplantation (osteochondral autograft
Department of Orthopaedic Surgery,
Orthopaedic Research Centre Amsterdam,
transfer system – OATS), and autologous chon-
Academic Medical Center, University of Amsterdam, drocyte implantation (ACI). The last two tech-
Amsterdam, The Netherlands niques focus at replacement and regeneration of
e-mail: m.zengerink@amc.uva.nl hyaline cartilage, respectively.
C.N. van Dijk, MD, PhD Publications on the effectiveness of these
Department of Orthopaedic Surgery treatment strategies vary. The goal of these treat-
and Traumatology, Academic Medical Center,
University of Amsterdam, Amsterdam,
ment strategies is always to diminish symptoms
The Netherlands like pain and swelling and to improve function.
e-mail: c.n.vandijk@amc.uva.nl In most cases of OCL of the talus, several treat-
ment options are viable. The choice of treatment review. Agreement was needed for inclusion. In
is based on the type and size of the lesion and on case of disagreement, the opinion of a third inde-
preferences of the treating clinician [12, 13]. pendent investigator was decisive. The manu-
A meta-analysis provides information that is not scripts were blinded to the author and institute to
available from these separate publications. It prevent investigator bias. Included were all RCTs
summarizes the effectiveness of different treat- or quasi-experimental research that evaluated the
ment strategies to result in a more accurate out- effectiveness of treatment strategies for osteo-
come. A statistical reanalysis on basis of source chondral lesions of the talus. This included case
data makes the outcome more reliable. series. Studies were included if treatment for OCL
For talar OCL, three systematic reviews were of the talus was properly described and the out-
undertaken in the past [56, 62, 69], of which the come was well defined. Published studies describ-
second was an update of the first. The last review ing the results of the following treatment strategies
involved new data but also followed a different were included: nonoperative treatment – rest,
research protocol. The most important difference nonoperative treatment – cast, excision of the
was that only a series of ten patients and more fragment, excision and curettage, excision and
were included, instead of “extended case series” curettage and drilling/microfracturing, placement
of two patients and more. Another important dif- of a cancellous bone graft, antegrade (transmalle-
ference was that it involved a quality assessment olar) drilling, OATS, ACI, retrograde drilling, and
of the included studies. We will discuss the last fixation of the lesion.
review, published in 2010, since it includes the Exclusion criteria for studies and/or patients
newer techniques like OATS and ACI [69]. Based were the evaluation of a combination of diagnoses
on the results of this review, we will provide a without separately describing the results for talar
guideline concerning the best treatment for the OCL, follow-up less than 6 months, inadequately
different stages of OCL of the ankle. described therapy, age under 18 years, studies in
which less than ten patients were included (exclud-
ing single case reports), the lesser extensive of a
10.2 Materials and Methods double publication, studies with no well-defined
outcome, and if there was a combination of thera-
10.2.1 Data Sources pies described and results were not described per
therapy. In case of double publications, only the
Electronic databases MEDLINE, EMBASE, most elaborate publication was selected.
CENTRAL, and DARE (January 1966–
December 2006) were screened. As main key-
words “Therapy; Treat*; Talus; Talar; Ankle; 10.2.3 Data Extraction
Cartilage*; Osteochondritis Dissecans; Chondral;
Osteochondral; and Transchondral” were used. Successful treatment was defined as an excellent
The search strategy for MEDLINE was (therapy or or good result at follow-up. This had to be defined
treat$) and (talar or talus or ankle) and (cartilag$ by an accepted scoring system, like the AOFAS
or osteochondritis dissecans or talar or chondral or Ankle/Hindfoot scale [28] and the Hannover scor-
osteochondral or transchondral). No language limi- ing system [59]. If success rate was not labeled by
tations were imposed. Reference lists of the selected the author, but the results were well described,
studies were searched for additional articles. they were fitted into the widely accepted score of
Thompson and Loomer [61]. The proportion of
the patient population with successful treatment
10.2.2 Study Selection, Inclusion, was noted and percentages were calculated. For
and Exclusion Criteria each treatment strategy, study size weighted suc-
cess rates were calculated. The primary outcomes
The published studies were independently were the effects of treatment on symptoms, mea-
assessed for inclusion by two investigators. sured by scoring systems concerning the ankle
Specifically developed forms were used for the (mainly the AOFAS Ankle/Hindfoot scale).
10 Meta-analysis on Therapy 85
Table 10.2 Scoring systems used for treatment of talar II or III lesion. In 44 of the 83 patients (53 %), the
osteochondral lesions in the included studies. Some stud-
treatment was reported to be successful (range
ies used more than one scoring system
29–69 %).
No. of
Scoring system studies
10.3.3.3 Excision
AOFAS Ankle/Hindfoot scale 16
Scoring system developed by the authors 18
This involves excision of the partially detached
Hannover score 5 fragment, without treating the defect that is left.
Patient satisfaction score 5 Four studies reported the results of excision [14,
Criteria proposed by Berndt and Harty 5 27, 41, 45]. In two studies excision was per-
Visual analog scale 3 formed for superficial cartilaginous lesions, with
Martin score 3 mainly intact underlying subchondral bone. It
Alexander and Lichtman 3 could also involve a loose intra-articular frag-
Ogilvie-Harris score 2 ment. In one study the lesions showed bony
MODEMS 2 necrosis underneath. In 32 of 59 patients, the
Karlsson scoring scale 2 result was reported to be successful (54 %).
Tegner score 1 Success rates varied from 30 to 88 %.
Evaluation proposed by Loomer 1
Mazur score 1 10.3.3.4 Excision and Curettage
Freiburg ankle score 1
After excision of the loose body, the surrounding
SANE 1
necrotic subchondral tissue is curetted using
According to Thompson and Loomer 1
either an open or arthroscopic technique. Most
McCullough score 1
patients had a Berndt and Harty stage III or IV
lesion, although also stage II lesions occurred.
divided over three studies, were treated with rest Thirteen studies, a total of 259 patients, reported
for OCD [6, 49, 55]. The rationale to choose non- the results of OCD treatment by excision and
operative treatment was not always clearly curettage [6, 9, 14, 20, 26, 27, 36, 37, 39, 42, 43,
described. Stage of the lesion was not described. 46, 48]. In 199 of 259 patients, a successful result
Two studies date back from 1953 [49] and 1975 was reported (77 %). The success rate varied
[6]. At the time these studies were published, sur- from 56 to 94 %.
gical treatment of talar OCL wasn’t as common
as it is today. The duration of symptoms prior to 10.3.3.5 Excision, Curettage, and BMS
institution of nonoperative treatment was either Bone marrow stimulation involves creating mul-
unreported or ranged from subacute to acute (<6 tiple connections with the subchondral bone. It
weeks) to chronic (>6 weeks). In the most recent follows excision and curettage. The connections
study, patients were given the choice between to the subchondral bone can be accomplished by
operative and nonoperative treatment and chose drilling or microfracturing. The aim is to par-
nonoperative treatment [55]. Conservative treat- tially destroy the calcified zone that is most often
ment consisted of weightbearing as tolerated. In present and to create multiple openings into the
39 of 86 patients (45 %), conservative treatment subchondral bone. Intra-osseous blood vessels
reported to be successful (range 20–54 %). are disrupted, and the release of growth factors
leads to the formation of a fibrin clot. The forma-
10.3.3.2 Nonoperative Treatment: Cast tion of local new blood vessels is stimulated,
Unloading the damaged cartilage is the aim of bone marrow cells are introduced in the OCL,
cast treatment. Duration of cast immobilization is and fibrocartilaginous tissue is formed. Most
between 3 weeks and 4 months. Four studies patients had a Berndt and Harty stage III or IV
reported the results of this treatment [6, 9, 26, lesion, but stage I and II lesions also occurred.
45], and they date back at least two decades. In Lesions were usually not larger than 1.5 cm in
most cases, it involved a Berndt and Harty stage diameter. A total of 18 studies, including 388
10 Meta-analysis on Therapy 87
Table 10.4 Success percentages (patients with a good/excellent result at follow-up after treatment of an osteochondral
talar lesion) of a previous review by Verhagen et al. [66] compared to the current review
Verhagen et al., studies published up to Current review, studies published up to
Treatment strategy 2000 (%) 2006 (%)
Nonoperative treatment – rest 45 45
Nonoperative treatment – cast – 53
Excision 38 54
Excision and curettage 76 77
Excision, curettage, and BMS 86 85
Autogenous bone graft 85 61
TMD – 63
OATS 94 87
ACI – 76
Retrograde drilling 81 88
Fixation 73 89
Total 76
and curettage, excision and curettage and BMS, The results of nonoperative treatment were
and OATS. The number of patients in other cate- poor compared to operative treatment. In spite of
gories, mainly retrograde drilling, fixation, and this, and especially in acute cases, nonoperative
transmalleolar drilling, was too limited for a reli- treatment should always be the first treatment to
able interpretation of the results. Therefore, no be considered.
definitive conclusions could be drawn. Today, most publications on treatment of OCL
Recommendations concerning these techniques of the talus involve arthroscopic excision, curet-
must be judged accordingly. Some techniques do tage and bone marrow stimulation, and ACI and
not apply to all Berndt and Harty OCL stages or OATS. They scored success percentages of 85 %,
are only suitable in the acute phase (<6 weeks). 76 %, and 87 %, respectively. ACI is a relatively
Retrograde drilling is usually reserved for large expensive technique, and OATS gives morbidity
OCL with intact overlying cartilage, as confirmed from knee complaints in a relevant number of
by arthroscopy. It is the treatment of choice when patients – up to 36 % [2, 18, 34, 47]. Therefore,
there is a large subchondral cyst with overlying we recommend arthroscopic excision, curettage,
healthy cartilage. The studies concerning retro- and BMS to be the first treatment of choice for
grade drilling did not describe size of the lesions primary OCL. It is relatively inexpensive, and
[30, 50, 58]. Fixation is indicated for large there is low morbidity, a quick recovery, and a
fragments that can be reattached. It is applied high success rate.
especially in (sub)acute cases and in adolescents The results of the last review differ slightly
and children. Transmalleolar drilling is performed from the results described in the previous review
when a defect is hard to reach because of its loca- of Verhagen and co-workers [66]. Results of both
tion on the talar surface. A disadvantage is that reviews are listed in Table 10.4. The success per-
healthy tibial cartilage is damaged. The reported centage for BMS has changed very little.
results do not support the use of this technique Verhagen included 21 studies and 227 patients;
[30, 48]. Besides, most talar lesions can be reached this review included 18 studies and 388 patients.
by means of the standard anterior or posterior The success rate went from 86 to 85 %. For
arthroscopic approach, using intermittent distrac- OATS, the success rate changed from 94 to 87 %.
tion and a 90° microfracture probe [64, 65, 70]. Verhagen found one study with 36 patients
90 M. Zengerink and C.N. van Dijk
treated with this technique. The last review iden- Table 10.5 Recommended treatments for different types
of osteochondral lesions
tified nine eligible studies comprising 243
patients. The ACI technique was not included in Type Treatment
the previous review by Verhagen et al. The last Asymptomatic/low Conservative
symptomatic lesions
review identified four studies, comprising 59
Symptomatic lesions Excision, curettage, and
patients, describing the results of ACI, leading to ≤15 mm BMS
a success percentage of 76 %. The exclusion cri- Symptomatic lesions Consider fixationa/BMS/
teria of the last review were stricter than the pre- ≥15 mm OATS
vious review. Considering the number of patients, Large talar cystic lesion Consider antegrade/
Verhagen and co-workers excluded single case retrograde drilling ± bone
reports but included a series of two patients and transplant/OATS
Secondary lesions Consider OATS/ACI
more. To be included in the last review, each
a
study group had to involve ten patients or more. Posttraumatic cases, juveniles
This excluded the “extended case reports” and
only allowed true case series to be evaluated. The moderately concerning “outcome”: no blind
initial goal was to only include study groups of assessment was described. Often it was not clear
20 patients or more. This protocol however whether patients were scored by someone else
excluded too many studies, and the criterion was than the author. Loss to follow-up exceeded 5 %
stretched to ten patients. In comparison to Tol in many cases. Scoring low on the items described
[62], this eliminated 13 studies (and 18 treatment above leads to a higher chance of introducing
groups) and in comparison to Verhagen [66] 30 bias.
studies. The eleven treatment strategies we discuss can
The highest level of evidence is formed by be assigned to one of four treatment methods
randomized clinical trials. It would have been they are based on: (1) conservative treatment
preferable if the review included more RCTs. (i.e., nonoperative treatment with rest or cast), (2)
However, only one RCT was identified, describ- debridement with or without bone marrow stimu-
ing the results of chondroplasty (excision and lation (i.e., excision, excision and curettage, exci-
curettage), microfracturing, and osteochondral sion and curettage with BMS, excision and
transplantation [20]. Looking at the setup and curettage with autogenous bone graft and ante-
inclusion of this study, one can debate whether grade (transmalleolar) drilling), (3) replacement
this study was a truly randomized trial, as is also of the defect with cartilage (i.e., OATS and ACI),
stated by the authors of the article. No case-control and (4) securing the lesion to the talar dome (i.e.,
studies were identified. retrograde drilling and fixation).
Assessment of quality by the adjusted NOS The current treatment options, OATS, ACI,
showed that studies scored low on study design. and BMS, show similar results, although ACI
Seven out of 52 studies were prospective in scores somewhat lower. Since OATS leads to co-
design. Most case series were retrospectively morbidity in up to 36 %, and ACI has a high cost,
executed, however, and in nine studies the pro- or the best available treatment option for symptom-
retrospective nature of the study was not even atic lesions up to 15 mm is excision, curettage,
described. Twenty-one studies accounted for the and BMS. For other lesions we recommend treat-
protocol they had followed, but the majority of ment as described in Table 10.5, supported by the
studies didn’t mention a protocol or did not ISAKOS consensus [10].
describe it properly. Nearly all studies reported Recently, two other systematic reviews con-
on a representative patient group. Studies scored cerning OCL of the talus have been published
10 Meta-analysis on Therapy 91
Appendix 1: Newcastle-Ottawa
Quality Assessment Scale Every included study was separately assessed
for quality using an adjusted version of the
Adjusted for Case Series Newcastle-Ottawa Scale, as described above. It
Study Design was performed by scoring each study for study
1. Type of study design (0–2 stars), selection of patients (0–1
(a) Prospective* star), and outcome (0–2 stars). The designs that
(b) Retrospective earned a star are marked with a *. For each
(c) Other study, the total number of stars is noted in the box
(d) Not described above.
92 M. Zengerink and C.N. van Dijk
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