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Review Article| Volume 26, ISSUE 1, P121-136, March 2021

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Osteochondral Lesions of the Talus

An Individualized Treatment Paradigm from the Amsterdam Perspective
  • Quinten G.H. Rikken
    Affiliations
    Department of Orthopaedic Surgery, Amsterdam Movement Sciences, Amsterdam UMC, Location AMC, University of Amsterdam, Meibergdreef 9, Amsterdam 1105 AZ, The Netherlands

    Academic Center for Evidence Based Sports Medicine (ACES), Amsterdam, The Netherland

    Amsterdam Collaboration for Health and Safety in Sports (ACHSS), AMC/VUmc IOC Research Center, Amsterdam, The Netherlands
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  • Gino M.M.J. Kerkhoffs
    Correspondence
    Corresponding author. Department of Orthopaedic Surgery, Amsterdam Movement Sciences, Amsterdam UMC, Location AMC, University of Amsterdam, Meibergdreef 9, Amsterdam 1105 AZ, The Netherlands.
    Affiliations
    Department of Orthopaedic Surgery, Amsterdam Movement Sciences, Amsterdam UMC, Location AMC, University of Amsterdam, Meibergdreef 9, Amsterdam 1105 AZ, The Netherlands

    Academic Center for Evidence Based Sports Medicine (ACES), Amsterdam, The Netherland

    Amsterdam Collaboration for Health and Safety in Sports (ACHSS), AMC/VUmc IOC Research Center, Amsterdam, The Netherlands
    Search for articles by this author
Open AccessPublished:December 10, 2020DOI:https://doi.org/10.1016/j.fcl.2020.10.002

      Keywords

      Key points

      • Patients with osteochondral lesions of the talus (OLTs) typically present 6 months to 12 months after an initial trauma with deep ankle pain provoked during or after weight-bearing activities.
      • Physical examination and imaging (computed tomography or magnetic resonance imaging) are paramount in the diagnosis of an OLT.
      • The lesion size and morphology, surgeon and patient preferences, and individual patient aspects guide treatment options for individual patients.
      • Conservative treatment is the primary treatment of all OLTs, regardless if surgery is needed.
      • Optimal surgical management depends on primary or secondary nature of the lesion, size, morphology, fixability, and presence of a fragment.

      Introduction

      Osteochondral lesions of the talus (OLTs) are characterized by damage to the articular cartilage of the talus and its underlying subchondral bone. Up to 75% of OLTs occur after traumatic injuries, such as ankle sprains and ankle fractures.
      • Hintermann B.
      • Boss A.
      • Schäfer D.
      Arthroscopic findings in patients with chronic ankle instability.
      • Hintermann B.
      • Regazzoni P.
      • Lampert C.
      • et al.
      Arthroscopic findings in acute fractures of the ankle.
      • Kerkhoffs G.M.M.J.
      • Kennedy J.G.
      • Calder J.D.F.
      • et al.
      There is no simple lateral ankle sprain.
      Advancements in imaging and arthroscopy have provided clinicians with novel insights into optimal treatment indications and has drastically advanced the number of surgical treatments available, as well as improved existing treatment paradigms.
      • Dahmen J.
      • Lambers K.T.A.
      • Reilingh M.L.
      • et al.
      No superior treatment for primary osteochondral defects of the talus.
      • Kerkhoffs G.
      • Altink J.
      • Stufkens S.
      • et al.
      Talar OsteoPeriostic grafting from the Iliac Crest (TOPIC) for large medial talar osteochondral defects: operative technique.
      • Kerkhoffs G.M.M.J.
      • Reilingh M.L.
      • Gerards R.M.
      • et al.
      Lift, drill, fill and fix (LDFF): a new arthroscopic treatment for talar osteochondral defects.
      • van Bergen C.J.
      • Gerards R.M.
      • Opdam K.T.
      • et al.
      Diagnosing, planning and evaluating osteochondral ankle defects with imaging modalities.
      To date, however, no superior treatment of OLT exists.
      • Dahmen J.
      • Lambers K.T.A.
      • Reilingh M.L.
      • et al.
      No superior treatment for primary osteochondral defects of the talus.
      ,
      • Lambers K.T.A.
      • Dahmen J.
      • Reilingh M.L.
      • et al.
      No superior surgical treatment for secondary osteochondral defects of the talus.
      Therefore, an individualized treatment algorithm, guided by patient and lesion characteristics, is the preferred treatment option for OLT management. This current concepts review provides an overview of the available evidence for the diagnosis and treatment of OLTs, current and emerging, and provides evidence-based treatment guidelines from the Amsterdam perspective.

      Etiology

      The exact etiology of an osteochondral lesion currently is unknown. The injury mechanism leading to cartilage damage preceding diagnosis is the occurrence of an ankle sprain, where the talus impacts on the distal tibial plafond, thereby creating microfractures (cracks) in the cartilage and subchondral bone plate (Fig. 1).
      • Kerkhoffs G.M.M.J.
      • Karlsson J.
      Osteochondral lesions of the talus.
      ,
      • van Dijk C.N.
      • Reilingh M.L.
      • Zengerink M.
      • et al.
      Osteochondral defects in the ankle: Why painful?.
      During weight-bearing, synovial fluid infiltrates these microfractures due to increased pressure, which induces osteonecrosis.
      • van Dijk C.N.
      • Reilingh M.L.
      • Zengerink M.
      • et al.
      Osteochondral defects in the ankle: Why painful?.
      ,
      • Van der Vis H.M.
      • Aspenberg P.
      • Marti R.K.
      • et al.
      Fluid pressure causes bone resorption in a rabbit model of prosthetic loosening.
      This causes lesion expansion with, in some cases, the formation of cysts, and leads to pain.
      • Van der Vis H.M.
      • Aspenberg P.
      • Marti R.K.
      • et al.
      Fluid pressure causes bone resorption in a rabbit model of prosthetic loosening.
      These changes alter the ankle joint congruency and biomechanical loading, which can accelerate ankle degeneration further.
      • Blom R.P.
      • Mol D.
      • van Ruijven L.J.
      • et al.
      A single axial impact load causes articular damage that is not visible with micro-computed tomography: an ex vivo study on caprine tibiotalar joints.
      Juvenile OLT (ie, osteochondritis dissecans) similarly often presents after trauma but seems present from early childhood without being symptomatic.
      • Reilingh M.L.
      • Kerkhoffs G.M.M.J.
      • Telkamp C.J.A.
      • et al.
      Treatment of osteochondral defects of the talus in children.
      It is hypothesized that, from a morphologic point of view, these specific fragment type lesions are embedded onto the talar dome and held in place by fibrous tissue (Fig. 2). Trauma can destabilize this fibrotic connection and initiate a symptomatic process, although it is also possible that these specific morphologic lesions can be considered an accidental finding when a patient presents with complaints nonspecific for an osteochondral lesion in the ankle.
      Figure thumbnail gr1
      Fig. 1The formation of a traumatic OLT. (A) The talus has an impact on the tibia in an ankle sprain, for example, (B) Microfractures occur in the talus. (C) Hydrostatic loading during weight-bearing forms an OLT.
      Figure thumbnail gr2
      Fig. 2Illustration of 2 morphologically different OLTs. (1A) Coronal and (1B) sagittal views of a fragment type lesion amenable for fixation OLT. (2A) Coronal and (2B) sagittal views of a cystic OLT.

      Clinical presentation

      Patients typically present 6 months to 12 months after an initial trauma (ankle fracture or sprain), with deep ankle pain provoked during or after load-bearing activities. Additional symptoms may include, but may not be limited to, stiffness, a locking or catching sensation (which can indicate a displaced fragment or pseudoimpingement due to the displaced cartilaginous flap), swelling (especially after activities), and reduced range of motion (ROM).
      • Reilingh M.
      • van Bergen C.
      • van Dijk C.
      Diagnosis and treatment of osteochondral defects of the ankle.
      The recognizable deep ankle pain can be provoked by forcefully palpating the talar dome with the ankle in full plantar flexion (Fig. 3). It must be stated, however, that the sensitivity of this test is unknown and if lesions are located far posteriorly, this test can be false negative due to the inability to palpate the lesion.
      • Van Bergen C.J.A.
      • Tuijthof G.J.M.
      • Maas M.
      • et al.
      Arthroscopic accessibility of the talus quantified by computed tomography simulation.
      Thorough physical examination and (hetero)anamnesis are paramount for diagnosis and can aid in deciding further examinations. Further (imaging) examinations of the ankle are justified if clinical suspicion for an OLT is present.
      Figure thumbnail gr3
      Fig. 3An example of forced palpation of the medial talus. This can reproduce the recognizable deep ankle pain. Notice that with plantar flexion a larger portion of the talus can be reached.

      Imaging

      Advancements in imaging have improved the diagnostic accuracy drastically over time. Radiographs are useful only for assessing ankle alignment because its diagnostic accuracy for OLTs is low (Table 1).
      • Verhagen R.A.W.
      • Maas M.
      • Dijkgraaf M.G.W.
      • et al.
      Prospective study on diagnostic strategies in osteochondral lesions of the talus. Is MRI superior to helical CT?.
      Currently, computed tomography (CT) scans and magnetic resonance imaging (MRI) are the common diagnostic tools, with high sensitivity and specificity (see Table 1).
      • van Bergen C.J.
      • Gerards R.M.
      • Opdam K.T.
      • et al.
      Diagnosing, planning and evaluating osteochondral ankle defects with imaging modalities.
      ,
      • Verhagen R.A.W.
      • Maas M.
      • Dijkgraaf M.G.W.
      • et al.
      Prospective study on diagnostic strategies in osteochondral lesions of the talus. Is MRI superior to helical CT?.
      CT is preferred to assess the bony morphology and size of OLTs and to assess the subchondral bone layer.
      • van Bergen C.J.
      • Gerards R.M.
      • Opdam K.T.
      • et al.
      Diagnosing, planning and evaluating osteochondral ankle defects with imaging modalities.
      Additionally, supplementary CT scans with the ankle in maximum plantar flexion can determine arthroscopic accessibility during preoperative planning.
      • Van Bergen C.J.A.
      • Tuijthof G.J.M.
      • Maas M.
      • et al.
      Arthroscopic accessibility of the talus quantified by computed tomography simulation.
      MRI is used to asses ankle cartilage, detect bone marrow edema, or diagnose concomitant soft tissue injuries of the ankle. Preferably, lesion size is determined with CT, because MRI can overestimate the lesion size when bone edema is present.
      • Yasui Y.
      • Hannon C.P.
      • Fraser E.J.
      • et al.
      Lesion size measured on MRI does not accurately reflect arthroscopic measurement in talar osteochondral lesions.
      Table 1Sensitivity and specificity of imaging modalities for osteochondral lesions of the talus according to Verhagen and colleagues
      • Verhagen R.A.W.
      • Maas M.
      • Dijkgraaf M.G.W.
      • et al.
      Prospective study on diagnostic strategies in osteochondral lesions of the talus. Is MRI superior to helical CT?.
      Data from Verhagen RAW, Maas M, Dijkgraaf MGW, et al. Prospective study on diagnostic strategies in osteochondral lesions of the talus. Is MRI superior to helical CT? J Bone Joint Surg Br. 2005;87(1):41-46.
      ModalitySensitivitySpecificity
      Standard radiograph0.590.91
      Mortise view radiograph0.700.94
      CT0.810.99
      MRI0.960.89
      Radiologists should report the lesion morphology, which includes the presence of loose bodies, cysts (complexes) with or without a bony roof, sclerotic aspects, kissing lesions, fragment type lesion, signs of previous microfracturing, and containment type. Lesion size should be reported in 3 planes (anterior-posterior, medial-lateral, and depth).

      Treatment

      It is paramount that an evidence-based personalized treatment approach is applied to patients with an OLT. A personalized approach incorporates all patient and lesion characteristics to determine the optimal treatment of an individual patient. This approach is depicted in Fig. 4 and includes patient factors (age, body mass index [BMI], preoperative level of activities, and patient preference), lesion factors (primary or nonprimary [ie, failed previous surgical treatment], lesion size, and morphology) and other pathologies in the ankle (hindfoot alignment, ankle stability, and concomitant injuries). This multilevel algorithm starts with conservative therapy. If patients fail a period of conservative therapy, a further selection for surgical treatment can be made. First, a differentiation between primary and failed primary (secondary) lesions is made and ankle alignment is considered. Second, the lesion size is incorporated, which grossly determines the level of invasiveness of the procedure (in accordance with patient and surgeon preferences). After considering lesions size, the lesion morphology (fixable fragment, [multiple] cysts, focal or diffuse lesions, and location on the talus) is taken into account, combined with the overall treatment goal of a patient, thus allowing for a tailor-made approach.
      Figure thumbnail gr4
      Fig. 4Flowchart for surgical management of symptomatic OLTs after failed conservative treatment.

      Conservative Treatment

      Conservative management is the primary intervention for all OLTs, regardless of lesion and patient characteristics. It is possible symptoms can improve without the need of a surgical intervention.
      • Dombrowski M.E.
      • Yasui Y.
      • Murawski C.D.
      • et al.
      Conservative management and biological treatment strategies: proceedings of the international consensus meeting on cartilage repair of the ankle.
      Conservative treatment is not restricted to a single modality and often consists of a combination of interventions. Restriction of weight-bearing and physical or work activities is the primary intervention of conservative treatment and aims at decreasing symptoms. By unloading the ankle joint, less synovial fluid is forced into the developing OLT. This limits further damage to the cartilage and subcartilaginous structures, which reduces pain and synovial swelling. Patients who are overweight (BMI >25) are advised to lose weight in order to decrease ankle load. Orthopedic insoles can help with proper load distribution of the ankle joint and improve ROM, thereby aiming at decreasing contact pressure on the OLT. Physiotherapy focusses on strength and balance exercises to reduce symptoms. Hyaluronic acid injections and platelet-rich plasma (PRP) can also be considered. Partial or full (cast) immobilization up to 6 weeks can be used to decrease load bearing. Conservative treatment has the goal of achieving full return to daily activities and sports with slight to moderate pain, noting high-impact sports should be avoided.
      • Dombrowski M.E.
      • Yasui Y.
      • Murawski C.D.
      • et al.
      Conservative management and biological treatment strategies: proceedings of the international consensus meeting on cartilage repair of the ankle.
      When patients are restricted to return to high-impact sports or still experience deep ankle pain 3 months to 6 months after the start of conservative therapy, surgical treatment can be considered.
      Clinical outcomes for conservative therapy can differ. Seo and colleagues
      • Seo S.G.
      • Kim J.S.
      • Seo D.-K.
      • et al.
      Osteochondral lesions of the talus Few patients require surgery.
      recently published a retrospectively evaluated cohort of 142 symptomatic patients and reported the clinical and radiologic outcomes at mean follow-up of 5.7 years. Patients were not immobilized or restricted in activities in this study. Mean lesion width, length, and depth measured 6.9 mm, 9.4 mm, and 5.4 mm, respectively. The visual analog scale (VAS) decreased significantly, from 3.8 to 0.9, whereas the American Orthopaedic Foot & Ankle Society (AOFAS) score improved slightly (from 86 to 91). Of the 83 patients who underwent CT scan at final follow-up, lesion size did not change in 69 (83.2%), 5 (6%) decreased, and 9 (10.8%) increased but were significantly deeper pretreatment compared with the other groups. No progression of ankle osteoarthritis (OA) was found on radiographs at final follow-up. Similarly, Klammer and colleagues
      • Klammer G.
      • Maquieira G.J.
      • Spahn S.
      • et al.
      Natural history of nonoperatively treated osteochondral lesions of the talus.
      reported the natural history of a retrospective case series with 48 untreated patients (50 ankles) with a minimum follow-up of 2 years. Average mediolateral and anteroposterior diameter and depth at initial MRI were 9.6 mm, 15.8 mm, and 8.3 mm, respectively. No significant size changes were found at mean follow-up of 52 months. At initial visit, 13 (61.9%) of 21 available patients showed no signs of OA. At mean 50 months follow-up of all cases, radiographic evaluation found grade 1 OA and grade 2 OA (according to van Dijk and colleagues
      • van Dijk C.N.
      • Verhagen R.A.W.
      • Tol J.L.
      Arthroscopy for problems after ankle fracture.
      ) in 27% of cases each. At final follow-up, however, 24% and 62% of cases reported no pain (VAS 0) and mild pain (VAS 1–3), respectively. These results point to the need for a strong consideration of conservative therapy with new OLT patients. Up to 55% of OLTs, however, fail conservative management.
      • Zengerink M.
      • Struijs P.A.A.
      • Tol J.L.C.
      • et al.
      Treatment of osteochondral lesions of the talus: a systematic review.
      Reilingh and colleagues
      • Reilingh M.L.
      • Kerkhoffs G.M.M.J.
      • Telkamp C.J.A.
      • et al.
      Treatment of osteochondral defects of the talus in children.
      published a retrospective case series of 37 children with a symptomatic OLT. In this study, conservative therapy consisted of restriction of sports and physical activities, physiotherapy, taping, or casting; 92% of children initially treated with conservative therapy for at least 6 months underwent surgery, even though children are considered the best candidates for conservative therapy.
      • Rothrauff B.B.
      • Murawski C.D.
      • Angthong C.
      • et al.
      Scaffold-based therapies: proceedings of the international consensus meeting on cartilage repair of the ankle.

      Surgical Treatment

      Bone marrow stimulation

      Arthroscopic bone marrow stimulation (BMS) is the treatment used most frequently for primary OLTs.
      • Dahmen J.
      • Lambers K.T.A.
      • Reilingh M.L.
      • et al.
      No superior treatment for primary osteochondral defects of the talus.
      BMS ideally should be considered for small (<15-mm diameter), noncystic, primary, nonfixable lesions but can also be considered and the treating team do not wish to undergo a more invasive procedure.
      • Ramponi L.
      • Yasui Y.
      • Murawski C.D.
      • et al.
      Lesion size is a predictor of clinical outcomes after bone marrow stimulation for osteochondral lesions of the talus: a systematic review.
      ,
      • Hannon C.P.
      • Bayer S.
      • Murawski C.D.
      • et al.
      Debridement, curettage, and bone marrow stimulation: proceedings of the international consensus meeting on cartilage repair of the ankle.
      After débridement and curettage of the defective cartilaginous tissue to the base of the lesion, the sclerotic bone is perforated or drilled to disrupt the intraosseous blood vessels, which mitigates the formation of a fibrin clot.
      • Reilingh M.
      • van Bergen C.
      • van Dijk C.
      Diagnosis and treatment of osteochondral defects of the ankle.
      ,
      • O’Driscoll S.W.
      The healing and regeneration of articular cartilage.
      Through the release of multipotent mesenchymal stem cells, revascularization is promoted, subsequently initiating the formation of fibrocartilage rather than hyaline-like cartilage.
      • O’Driscoll S.W.
      The healing and regeneration of articular cartilage.
      Clinical outcomes after BMS can be considered successful (AOFAS score ≥80 points) in 82% of primary OLTs, according to a recent systematic review from Dahmen and colleagues.
      • Dahmen J.
      • Lambers K.T.A.
      • Reilingh M.L.
      • et al.
      No superior treatment for primary osteochondral defects of the talus.
      Toale and colleagues
      • Toale J.
      • Shimozono Y.
      • Mulvin C.
      • et al.
      Midterm outcomes of bone marrow stimulation for primary osteochondral lesions of the talus: a systematic review.
      found a weighted mean postoperative AOFAS score of 89.9 at midterm follow-up (71.9 months) in their systematic review. This review also found a low complication rate of 3.4% and a reoperation rate of 6.0%.
      When specifically considering sports outcomes, Steman and colleagues
      • Steman J.A.H.
      • Dahmen J.
      • Lambers K.T.A.
      • et al.
      Return to sports after surgical treatment of osteochondral defects of the talus: a systematic review of 2347 cases.
      reported a pooled return to sport (RTS) rate at any level and preinjury level of 88% and 79%, respectively. This review found a time to RTS after BMS that ranged from 15 weeks to 26 weeks. The weighted mean time to RTS at any level was found to be 4.5 months by a systematic review from Hurley and colleagues.
      • Hurley E.T.
      • Shimozono Y.
      • McGoldrick N.P.
      • et al.
      High reported rate of return to play following bone marrow stimulation for osteochondral lesions of the talus.
      Long-term outcomes of BMS have been reported sparsely in the literature. van Bergen and colleagues
      • van Bergen C.J.A.
      • Kox L.S.
      • Maas M.
      • et al.
      Arthroscopic treatment of osteochondral defects of the talus: outcomes at eight to twenty years of follow-up.
      published the longest follow-up cohort to date. This study included 50 patients with primary OLTs treated with BMS or débridement at a mean 141 months’ follow-up. A median AOFAS score of 88 (range: 64–100) was reported. At final follow-up, 63% and 4% of patients were found to have grade 1 OA and grade 2 OA, according to the van Dijk classification,
      • van Dijk C.N.
      • Verhagen R.A.W.
      • Tol J.L.
      Arthroscopy for problems after ankle fracture.
      respectively. Moreover, progression of OA by 1 grade was reported in 33% of patients.
      The development of OA due to the deterioration of fibrocartilage over time, altered joint biomechanics, and subchondral bone damage are concerns in the current literature and daily clinical practice. Multiple investigators have reported the occurrence of OA in their cohorts treated with BMS. In a retrospective case series, Ferkel and colleagues
      • Ferkel R.D.
      • Zanotti R.M.
      • Komenda G.A.
      • et al.
      Arthroscopic treatment of chronic osteochondral lesions of the talus: long-term results.
      reported the clinical and radiologic outcomes of 50 arthroscopically treated patients at a mean follow-up of 72 months. This study found 34% of patients developed OA or progressed by 1 or more stage of the van Dijk classification,
      • van Dijk C.N.
      • Verhagen R.A.W.
      • Tol J.L.
      Arthroscopy for problems after ankle fracture.
      most often to grade 1. From a subgroup of 17 previously studied patients 35% had deteriorating modified Weber scores. Solely those patients with a grade 2 OA or grade 3 OA showed an association with inferior clinical outcomes in this study.
      The progression of OA after BMS can be explained partly by the inferior wear characteristics of fibrocartilage compared with the native hyaline cartilage.
      • Lynn A.K.
      • Brooks R.A.
      • Bonfield W.
      • et al.
      Repair of defects in articular joints. Prospects for material-based solutions in tissue engineering.
      ,
      • Savva N.
      • Jabur M.
      • Davies M.
      • et al.
      Osteochondral lesions of the talus: results of repeat arthroscopic debridement.
      Additionally, a depressed subchondral bone plate after BMS has been proposed to be associated with poor outcomes. Reilingh and colleagues
      • Reilingh M.L.
      • Lambers K.T.A.
      • Dahmen J.
      • et al.
      The subchondral bone healing after fixation of an osteochondral talar defect is superior in comparison with microfracture.
      found a depressed subchondral bone plate in 79% of patients as assessed per 1-year follow-up CT. In a different study, this group found lesion dimensions unchanged 1-year postoperatively compared with preoperatively (except for lesion depth).
      • Reilingh M.L.
      • van Bergen C.J.A.
      • Blankevoort L.
      • et al.
      Computed tomography analysis of osteochondral defects of the talus after arthroscopic debridement and microfracture.
      Subchondral bone healing was reported to be poor in 37% of patients, indicating a limited healing capacity following BMS. Moreover, this study also reported incomplete sclerotic bone perforation or cysts to not be (fully) débrided in 13 of 58 OLTs, as assessed on 1-year postoperative CT.
      • Reilingh M.L.
      • van Bergen C.J.A.
      • Blankevoort L.
      • et al.
      Computed tomography analysis of osteochondral defects of the talus after arthroscopic debridement and microfracture.
      These findings warrant further research in BMS indication and sustainability of results in long-term follow-up studies.
      Secondary lesions (ie, failed primary surgical treatment) treated with BMS are reported less frequently in the literature than their primary counterparts.
      • Dahmen J.
      • Lambers K.T.A.
      • Reilingh M.L.
      • et al.
      No superior treatment for primary osteochondral defects of the talus.
      ,
      • Lambers K.T.A.
      • Dahmen J.
      • Reilingh M.L.
      • et al.
      No superior surgical treatment for secondary osteochondral defects of the talus.
      Repeat BMS in 12 patients reported by Savva and colleagues
      • Savva N.
      • Jabur M.
      • Davies M.
      • et al.
      Osteochondral lesions of the talus: results of repeat arthroscopic debridement.
      improved the AOFAS score from 42.4 preoperatively to 80.5 at a mean follow-up of 5.9 years. This study excluded cystic lesions as Robinson and colleagues
      • Robinson D.E.
      • Winson I.G.
      • Harries W.J.
      • et al.
      Arthroscopic treatment of osteochondral lesions of the talus.
      found poor results after repeat BMS in 50% of patients with mostly cystic lesions. A paucity in the literature is present, however, and controversy remains about the effectiveness of repeat BMS compared with the primary procedure.
      Treatment after BMS generally consists of partial weight-bearing in the first 2 weeks postoperatively.
      • Hurley E.T.
      • Shimozono Y.
      • McGoldrick N.P.
      • et al.
      High reported rate of return to play following bone marrow stimulation for osteochondral lesions of the talus.
      ROM exercises are encouraged immediately after surgery but may be limited due to postoperative swelling. Full weight-bearing generally is allowed 6 weeks postoperatively. At this point, physical therapy can be started. Initially, strength and balance exercises with the gradual building of load are encouraged. In this phase (3–4 months postoperatively), no peak axial forces are allowed. With the help of a physiotherapist, patients increase ankle load and strength toward their desired rehabilitation goal.
      A novel frontier in the ongoing development of (surgical) treatment strategies for OLTs is adjunct therapies (ie, biologicals). These therapies are administered during the end stage of the BMS procedure or as a stand-alone treatment. PRP and bone marrow aspirate concentrate (BMAC) both are autologous blood products aiming at improving the quality of cartilage and subchondral bone repair and thereby associated clinical outcomes.
      • Dombrowski M.E.
      • Yasui Y.
      • Murawski C.D.
      • et al.
      Conservative management and biological treatment strategies: proceedings of the international consensus meeting on cartilage repair of the ankle.
      Preclinical evidence exists for the delay of OA after adjunct therapy administration.
      • Delco M.L.
      • Goodale M.
      • Talts J.F.
      • et al.
      Integrin α10β1high mesenchymal stem cells mitigate the progression of osteoarthritis in an equine talar impact model.
      Although with a low number of patients, clinical studies have shown the effectiveness of these therapies. Prospective comparative studies with sufficient power and in a randomized setting are highly necessary to define the pure effectiveness of these adjunct treatment options.
      • Guney A.
      • Akar M.
      • Karaman I.
      • et al.
      Clinical outcomes of platelet rich plasma (PRP) as an adjunct to microfracture surgery in osteochondral lesions of the talus.
      ,
      • Kim Y.S.
      • Park E.H.
      • Kim Y.C.
      • et al.
      Clinical outcomes of mesenchymal stem cell injection with arthroscopic treatment in older patients with osteochondral lesions of the talus.

      Fixation techniques

      When OLT fragments are fixable, acute primary cases and chronic cases can be considered for fixation.
      • Reilingh M.L.
      • Murawski C.D.
      • DiGiovanni C.W.
      • et al.
      Fixation techniques: proceedings of the international consensus meeting on cartilage repair of the ankle.
      According to experts, an osteochondral fragment diameter of at least 10 mm and depth of 3 mm is a minimum threshold for a technically feasible fixation.
      • Reilingh M.L.
      • Murawski C.D.
      • DiGiovanni C.W.
      • et al.
      Fixation techniques: proceedings of the international consensus meeting on cartilage repair of the ankle.
      For acutely displaced lesions and the skeletally immature, fixation should be considered first. Acute symptomatic but stable lesions and chronic lesions first should be treated conservatively. Contraindications for fixation are ankle OA (grade ≥2), advanced osteoporosis, or septic arthritis.
      • Lambers K.T.A.
      • Dahmen J.
      • Reilingh M.L.
      • et al.
      Arthroscopic lift, drill, fill and fix (LDFF) is an effective treatment option for primary talar osteochondral defects.
      The advantages of fixation over other surgical treatments are the ability to restore the congruency of the talus and the preservation of hyaline cartilage and subchondral bone.
      • Kerkhoffs G.M.M.J.
      • Reilingh M.L.
      • Gerards R.M.
      • et al.
      Lift, drill, fill and fix (LDFF): a new arthroscopic treatment for talar osteochondral defects.
      ,
      • Reilingh M.L.
      • Lambers K.T.A.
      • Dahmen J.
      • et al.
      The subchondral bone healing after fixation of an osteochondral talar defect is superior in comparison with microfracture.
      ,
      • Reilingh M.L.
      • Murawski C.D.
      • DiGiovanni C.W.
      • et al.
      Fixation techniques: proceedings of the international consensus meeting on cartilage repair of the ankle.
      Additionally, if fixation fails, BMS still can be considered as a follow-up intervention. OLT fixation can be performed arthroscopically in case the lesion can be reached through an anterior or posterior approach and in case the fragment can be fixed perpendicular to the articular cartilaginous talar dome. Open OLT fixation can be considered if lesions are not fixable through arthroscopy or in cases of surgeon preference.
      Open fixation of an OLT starts with an arthrotomy to visualize the lesion. Depending on the lesion location, a medial malleolar osteotomy is performed to reach the lesion and to obtain working space.
      • Kumai T.
      • Takakura Y.
      • Kitada C.
      • et al.
      Fixation of osteochondral lesions of the talus using cortical bone pegs.
      • Schuh A.
      • Salminen S.
      • Zeiler G.
      • et al.
      Ergebnisse der refixation der osteochondrosis dissecans des talus mit kirschnerdrähten.
      • Nakasa T.
      • Ikuta Y.
      • Tsuyuguchi Y.
      • et al.
      MRI tracking of the effect of bioabsorbable pins on bone marrow edema after fixation of the osteochondral fragment in the talus.
      Hereafter, the osteochondral fragment is removed and the underlying site and/or cyst curetted or drilled. Bone grafts are collected from the distal tibia or other non–weight-bearing areas of the joint. These bone plugs are used to fill the excavated site, after which the fragment is reduced and fixated. Different techniques have been described for filling and fixating OLTs, such as the use of bone pegs or cancellous bone grafts and screw fixation or the use of Kirschner wires.
      • Kerkhoffs G.M.M.J.
      • Reilingh M.L.
      • Gerards R.M.
      • et al.
      Lift, drill, fill and fix (LDFF): a new arthroscopic treatment for talar osteochondral defects.
      ,
      • Kumai T.
      • Takakura Y.
      • Kitada C.
      • et al.
      Fixation of osteochondral lesions of the talus using cortical bone pegs.
      ,
      • Schuh A.
      • Salminen S.
      • Zeiler G.
      • et al.
      Ergebnisse der refixation der osteochondrosis dissecans des talus mit kirschnerdrähten.
      ,
      • Nakasa T.
      • Adachi N.
      • Kato T.
      • et al.
      Appearance of subchondral bone in computed tomography is related to cartilage damage in osteochondral lesions of the talar dome.
      ,
      • Haraguchi N.
      • Shiratsuchi T.
      • Ota K.
      • et al.
      Fixation of the osteochondral talar fragment yields good results regardless of lesion size or chronicity.
      Outcomes for open fixation of OLTs have been reported in multiple studies. At a mean follow-up of 7 years, good Berndt and Harty scores were found for 24 (89%) out of 27 patients by Kumai and colleagues.
      • Kumai T.
      • Takakura Y.
      • Kitada C.
      • et al.
      Fixation of osteochondral lesions of the talus using cortical bone pegs.
      In a retrospective study of 20 patients treated with open internal fixation, Schuh and colleagues
      • Schuh A.
      • Salminen S.
      • Zeiler G.
      • et al.
      Ergebnisse der refixation der osteochondrosis dissecans des talus mit kirschnerdrähten.
      found excellent and good results according to the Ogilvie-Harris score in 80% and 20% of patients, respectively. Haraguchi and colleagues
      • Haraguchi N.
      • Shiratsuchi T.
      • Ota K.
      • et al.
      Fixation of the osteochondral talar fragment yields good results regardless of lesion size or chronicity.
      found a mean Japanese Society for Surgery of the Foot (JSSF) ankle/hindfoot score of 93 out of 100 points at 2 years postoperatively for 44 patients. This study found no correlation between the JSSF score and lesion size or chronicity, meaning that chronic lesions, therefore, are amenable for fixation from an evidence-based perspective. An excellent mean postoperative AOFAS score of 98.5 and VAS score of 0 (meaning no pain) was reported in 83% of patients at 1-year follow-up using bioabsorbable pins by Nakasa and colleagues.
      • Nakasa T.
      • Ikuta Y.
      • Tsuyuguchi Y.
      • et al.
      MRI tracking of the effect of bioabsorbable pins on bone marrow edema after fixation of the osteochondral fragment in the talus.
      The aforementioned study found osteolytic changes in approximately 28% of implants, which was correlated to a shallower insertion angle. This could pose a risk for treatment failure at long-term follow-up and is inherent to fixation procedures. Surgeons, therefore, should carefully insert the fixation screw perpendicular to the osteochondral fragment at a 90° angle to minimize this risk. Disadvantages of the open procedure are need of a longer immobilization period and nonunion or delayed union after an osteotomy.
      • Colin F.
      • Gaudot F.
      • Odri G.
      • et al.
      Supramalleolar osteotomy: techniques, indications and outcomes in a series of 83 cases.
      ,
      • Krähenbühl N.
      • Zwicky L.
      • Bolliger L.
      • et al.
      Mid- to long-term results of supramalleolar osteotomy.
      These disadvantages prompted the recent development of arthroscopic fixation techniques.
      • Kerkhoffs G.M.M.J.
      • Reilingh M.L.
      • Gerards R.M.
      • et al.
      Lift, drill, fill and fix (LDFF): a new arthroscopic treatment for talar osteochondral defects.
      ,
      • Kim H.N.
      • Kim G.L.
      • Park J.Y.
      • et al.
      Fixation of a posteromedial osteochondral lesion of the talus using a three-portal posterior arthroscopic technique.
      Arthroscopic fixation is a technically demanding procedure. Determining the fixation angle is difficult under the scope but is considered a crucial step and as such should be reserved for advanced arthroscopists.
      • Nakasa T.
      • Ikuta Y.
      • Tsuyuguchi Y.
      • et al.
      MRI tracking of the effect of bioabsorbable pins on bone marrow edema after fixation of the osteochondral fragment in the talus.
      The lift, drill, fill, and fix (LDFF) procedure is a novel arthroscopic fixation technique (which can also be performed open) developed by Kerkhoffs and colleagues.
      • Kerkhoffs G.M.M.J.
      • Reilingh M.L.
      • Gerards R.M.
      • et al.
      Lift, drill, fill and fix (LDFF): a new arthroscopic treatment for talar osteochondral defects.
      The procedure combines the advantages of fixation with marrow stimulation for increased healing potential and consolidation of the fragment.
      • Kerkhoffs G.M.M.J.
      • Reilingh M.L.
      • Gerards R.M.
      • et al.
      Lift, drill, fill and fix (LDFF): a new arthroscopic treatment for talar osteochondral defects.
      ,
      • Lambers K.T.A.
      • Dahmen J.
      • Reilingh M.L.
      • et al.
      Arthroscopic lift, drill, fill and fix (LDFF) is an effective treatment option for primary talar osteochondral defects.
      Visualization and working space can be created through standard anteromedial and anterolateral portals, or posterior portals if the lesion is located far posteriorly.
      • Kerkhoffs G.M.M.J.
      • Reilingh M.L.
      • Gerards R.M.
      • et al.
      Lift, drill, fill and fix (LDFF): a new arthroscopic treatment for talar osteochondral defects.
      ,
      • Van Bergen C.J.A.
      • Tuijthof G.J.M.
      • Maas M.
      • et al.
      Arthroscopic accessibility of the talus quantified by computed tomography simulation.
      ,
      • Kim H.N.
      • Kim G.L.
      • Park J.Y.
      • et al.
      Fixation of a posteromedial osteochondral lesion of the talus using a three-portal posterior arthroscopic technique.
      First, an osteochondral bone flap is created, which should stay attached posteriorly. By means of a chisel, the flap is lifted and functions like a lever through its posterior attachment (lift), a crucial step, as depicted in Fig. 5. Second, the lesion site is débrided and perforated through the sclerotic bone to promote revascularization (drill). In the following step, cancellous bone grafts are harvested from non–weight-bearing areas of the distal tibia and used to pack the lesion site (fill). Similarly to the hood of a car, the osteochondral flap is relocated to its original position with an adequate compression fixated through using a biocortical screw (fix).
      • Kerkhoffs G.M.M.J.
      • Reilingh M.L.
      • Gerards R.M.
      • et al.
      Lift, drill, fill and fix (LDFF): a new arthroscopic treatment for talar osteochondral defects.
      Rehabilitation after the arthroscopic and open LDFF procedures consists first of a short-leg non-weightbearing cast for 4 and 6 weeks, respectively.
      • Kerkhoffs G.M.M.J.
      • Reilingh M.L.
      • Gerards R.M.
      • et al.
      Lift, drill, fill and fix (LDFF): a new arthroscopic treatment for talar osteochondral defects.
      ,
      • Lambers K.T.A.
      • Dahmen J.
      • Reilingh M.L.
      • et al.
      Arthroscopic lift, drill, fill and fix (LDFF) is an effective treatment option for primary talar osteochondral defects.
      This then is changed for a walking cast with full weight-bearing allowed. The walking cast can be removed after a period up to 4 weeks for arthroscopically treated cases and 6 weeks for open LDFF cases. Physical therapy can be started at this point, focusing on a return to full weight-bearing in approximately 2 weeks.
      Figure thumbnail gr5
      Fig. 5Arthroscopic view during the LDFF procedure. (A) Lesion in situ. (B) With the posterior margin of the flap still attached, the lesion is lifted (lift). (C) Perforating of sclerotic subchondral bone with a chisel (drill), (D) filling of the lesion with cancellous autograft (fill), and (E) fixation of the lesion while applying axial pressure for flap stabilization (fix).
      The arthroscopic LDFF procedure has shown promising outcomes. Lambers and colleagues
      • Lambers K.T.A.
      • Dahmen J.
      • Reilingh M.L.
      • et al.
      Arthroscopic lift, drill, fill and fix (LDFF) is an effective treatment option for primary talar osteochondral defects.
      published a prospective cohort of 27 ankles and found a postoperative numeric rating scale during running of 2.9 compared with the preoperative numeric rating scale of 7.8 at mean follow-up of 27 months after LDFF fixation, indicating a significant decrease in pain. Fragment fusion was complete on CT scans in 92% of cases at 1-year follow-up, indicating a successful integration of the subchondral bone layer and preservation of hyaline cartilage. Reilingh and colleagues
      • Reilingh M.L.
      • Lambers K.T.A.
      • Dahmen J.
      • et al.
      The subchondral bone healing after fixation of an osteochondral talar defect is superior in comparison with microfracture.
      found that the subchondral bone plate was depressed in 28% of LDFF patients on 1-year follow-up CT compared with 79% found in patients treated with BMS. The restoration of the subchondral bone plate and preservation of hyaline cartilage in fixation has been hypothesized to delay the onset or progression of OA compared with marrow stimulation.
      • Lambers K.T.A.
      • Dahmen J.
      • Reilingh M.L.
      • et al.
      Arthroscopic lift, drill, fill and fix (LDFF) is an effective treatment option for primary talar osteochondral defects.
      Midterm to long-term outcomes for fixation techniques, however, are needed to evaluate these premises and to determine the optimal fixation procedure.

      Osteo(chondral) transplantation

      Autologous or allogenic osteo(chondral) transplantation (AOT) is a restorative technique that replaces the damaged bone–chondral unit. Additionally, it repairs the weight-bearing capacities of the talus.
      • Reilingh M.
      • van Bergen C.
      • van Dijk C.
      Diagnosis and treatment of osteochondral defects of the ankle.
      AOT generally is used for larger (>15 mm in diameter), (massive) cystic, primary, and secondary lesions of the talus.
      An open approach through an arthrotomy or osteotomy (for medial lesion) is needed for proper visualization. During the conventional AOT procedure, a single cylindrical graft or multiple cylinders (ie, mosaicplasty) are harvested and subsequently implanted into the fully débrided and excised lesion site. Both autografts and fresh allografts are available for transplantation.
      • Dahmen J.
      • Lambers K.T.A.
      • Reilingh M.L.
      • et al.
      No superior treatment for primary osteochondral defects of the talus.
      ,
      • Lambers K.T.A.
      • Dahmen J.
      • Reilingh M.L.
      • et al.
      No superior surgical treatment for secondary osteochondral defects of the talus.
      ,
      • Smyth N.A.
      • Murawski C.D.
      • Adams S.B.
      • et al.
      Osteochondral allograft: proceedings of the international consensus meeting on cartilage repair of the ankle.
      ,
      • Hurley E.T.
      • Murawski C.D.
      • Paul J.
      • et al.
      Osteochondral autograft: proceedings of the international consensus meeting on cartilage repair of the ankle.
      The primary donor site for autografts is the lateral femoral condyle site of the ipsilateral knee.
      • Dahmen J.
      • Lambers K.T.A.
      • Reilingh M.L.
      • et al.
      No superior treatment for primary osteochondral defects of the talus.
      ,
      • Hurley E.T.
      • Murawski C.D.
      • Paul J.
      • et al.
      Osteochondral autograft: proceedings of the international consensus meeting on cartilage repair of the ankle.
      • Paul J.
      • Sagstetter A.
      • Kriner M.
      • et al.
      Donor-site morbidity after osteochondral autologous transplantation for lesions of the talus.
      • Shimozono Y.
      • Hurley E.T.
      • Nguyen J.T.
      • et al.
      Allograft compared with autograft in osteochondral transplantation for the treatment of osteochondral lesions of the Talus.
      Allografts are the preferred option for patients with knee OA, a history of knee infections, or when the defect size exceeds the possibility of a safe sized harvesting procedure from the knee.
      • Smyth N.A.
      • Murawski C.D.
      • Adams S.B.
      • et al.
      Osteochondral allograft: proceedings of the international consensus meeting on cartilage repair of the ankle.
      Pooled success rates (AOFAS score ≥80) after autografts have been reported to be 77% for primary lesions and 90% for secondary lesions, according to 2 comprehensive systematic reviews.
      • Dahmen J.
      • Lambers K.T.A.
      • Reilingh M.L.
      • et al.
      No superior treatment for primary osteochondral defects of the talus.
      ,
      • Lambers K.T.A.
      • Dahmen J.
      • Reilingh M.L.
      • et al.
      No superior surgical treatment for secondary osteochondral defects of the talus.
      The pooled clinical success rate of allografts was found to be 55% in secondary lesions and ranged from 20% to 100% for primary lesions.
      • Dahmen J.
      • Lambers K.T.A.
      • Reilingh M.L.
      • et al.
      No superior treatment for primary osteochondral defects of the talus.
      ,
      • Lambers K.T.A.
      • Dahmen J.
      • Reilingh M.L.
      • et al.
      No superior surgical treatment for secondary osteochondral defects of the talus.
      Shimozono and colleagues
      • Shimozono Y.
      • Hurley E.T.
      • Nguyen J.T.
      • et al.
      Allograft compared with autograft in osteochondral transplantation for the treatment of osteochondral lesions of the Talus.
      reported the clinical and radiologic outcomes of a retrospective case-series of 25 autograft and 16 allograft patients at mean follow-up of 26 months and 22 months, respectively. This study found autografts to show significantly superior Foot and Ankle Outcome Scores (FAOS) and Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) scores over allografts. Additionally, they found an allograft failure rate of 25% compared with no failures for autografts. Extensive research has found the use of greater than or equal to 3 grafts, a high BMI, and uncontained lesion type associated with inferior clinical outcomes either of the ankle or the donor kee.
      • Hurley E.T.
      • Murawski C.D.
      • Paul J.
      • et al.
      Osteochondral autograft: proceedings of the international consensus meeting on cartilage repair of the ankle.
      ,
      • Paul J.
      • Sagstetter A.
      • Kriner M.
      • et al.
      Donor-site morbidity after osteochondral autologous transplantation for lesions of the talus.
      ,
      • Shimozono Y.
      • Donders J.C.E.
      • Yasui Y.
      • et al.
      Effect of the containment type on clinical outcomes in osteochondral lesions of the talus treated with autologous osteochondral transplantation.
      Even though knee function seems to be unaffected, according to Paul and colleagues,
      • Paul J.
      • Sagstetter A.
      • Kriner M.
      • et al.
      Donor-site morbidity after osteochondral autologous transplantation for lesions of the talus.
      donor-site morbidity of the knee has been found to be between 6.7% and 10.8% after AOT procedures, according to a meta-analysis by Hurley and colleagues.
      • Hurley E.T.
      • Shimozono Y.
      • McGoldrick N.P.
      • et al.
      High reported rate of return to play following bone marrow stimulation for osteochondral lesions of the talus.
      In recent years, these concerns have caused the emergence of other transplantation sites, such as the iliac crest.
      • Kerkhoffs G.
      • Altink J.
      • Stufkens S.
      • et al.
      Talar OsteoPeriostic grafting from the Iliac Crest (TOPIC) for large medial talar osteochondral defects: operative technique.
      Iliac crest transplants are hypothesized to support the regeneration of articular cartilage through the bone-periosteal membrane, which acts as a natural scaffold and possesses local growth factors as well as resemble the natural curvature of the talus.
      • Kerkhoffs G.
      • Altink J.
      • Stufkens S.
      • et al.
      Talar OsteoPeriostic grafting from the Iliac Crest (TOPIC) for large medial talar osteochondral defects: operative technique.
      ,
      • Maia F.R.
      • Carvalho M.R.
      • Oliveira J.M.
      • et al.
      Tissue engineering strategies for osteochondral repair.
      ,
      • Mendes L.F.
      • Katagiri H.
      • Tam W.L.
      • et al.
      Advancing osteochondral tissue engineering: bone morphogenetic protein, transforming growth factor, and fibroblast growth factor signaling drive ordered differentiation of periosteal cells resulting in stable cartilage and bone formation in vivo.
      Hu and colleagues
      • Hu Y.
      • Guo Q.
      • Jiao C.
      • et al.
      Treatment of large cystic medial osteochondral lesions of the talus with autologous osteoperiosteal cylinder grafts.
      treated 17 cystic OLTs with osteoperiosteal cylindrical grafts from the iliac crest with a mean postoperative AOFAS score of 90 and mean VAS of 0.9 at 33 months follow-up. At second-look arthroscopy, the mean International Cartilage Repair Society (ICRS) score was 9. A preclinical study by Sung and colleagues
      • Sung M.S.
      • Jeong C.H.
      • Lim Y.S.
      • et al.
      Periosteal autograft for articular cartilage defects in dogs: MR imaging and ultrasonography of the repair process.
      demonstrated the ability of articular cartilage repair in all subjects after periosteal grafting. Another novel procedure is the talar osteoperiosteal grafting from the iliac crest (TOPIC) technique.
      • Kerkhoffs G.
      • Altink J.
      • Stufkens S.
      • et al.
      Talar OsteoPeriostic grafting from the Iliac Crest (TOPIC) for large medial talar osteochondral defects: operative technique.
      The TOPIC procedure is an individualized treatment that can be considered for primary and secondary lesions greater than 10 mm in diameter. The TOPIC technique is ideal for lesions located at the medial and lateral edges of the talar dome (Fig. 6). Preoperatively, a CT scan is made to determine the location, size, and accessibility of the OLT and if an osteotomy is needed. In most cases, an osteotomy is performed to gain access to the joint. Hereafter, the lesion site is inspected, and the OLT excised fully until healthy bone and prepared for graft receipt by microdrilling the subchondral bone base. Drilling facilitates the introduction of marrow cells, which aid the integration of the TOPIC graft. The donor site then is measured for graft harvesting. An oversized graft (by 1 mm in all directions of the prepared donor site) is harvested from the anterior superior iliac crest. The graft then is prepared to press-fit shape, which allows the surgeon to mimic the size, depth, and curvature of the excised lesion site. This allows for minimal chondral damage during the procedure and accurate fit of the graft. Due to the press-fit preparation of the graft no additional screws are necessary for graft fixation but can be considered if deemed biomechanically appropriate. Postoperatively, patients are placed in a nonwalking cast for 6 weeks, after which they are placed in a walking boot for another 6 weeks. At 12 weeks postoperatively, a CT scan is made to asses graft incorporation and osteotomy healing. This allows aftertreatment to be individualized, if necessary. After this period physical therapy is started to assist recovery.
      Figure thumbnail gr6
      Fig. 6Preoperative and 3 months postoperative CT scans of a patient treated with the TOPIC procedure. Preoperatively a large posteromedial lesion on (1A) coronal and (1B) sagittal images. (2A, 2B) Three months postoperatively. the graft is well incorporated.
      Results of an initial 10-patient prospective cohort study found an AOFAS score improvement from 50 to 83 points at 1 year postoperatively.
      • Kerkhoffs G.
      • Altink J.
      • Stufkens S.
      • et al.
      Talar OsteoPeriostic grafting from the Iliac Crest (TOPIC) for large medial talar osteochondral defects: operative technique.
      Pain during running (VAS) was found to improve from 7.1 to 2.6 at final follow-up. All patients showed consolidation of the graft and osteotomy.

      Regenerative and retrograde treatments

      Multiple treatment modalities remain and have been used throughout the world. The cell-based techniques predominantly are used as salvage procedures. Retrograde treatments, however, are predominantly considered a primary treatment. These treatments have varying indications and results, as discussed further.
      Cartilage transplantation and chondrogenesis-inducing techniques are cell-based therapies used in larger (>15-mm diameter), cystic, and secondary lesions. Either autologous chondrocytes from non–weight-bearing areas of the ankle or blood/marrow-like products are used to resurface the OLT. In the first-generation cartilage transplantation technique, autologous chondrocyte implantation (ACI), cells are harvested and externally expanded for reimplantation. The second-generation matrix-associated chondrocyte implantation (MACI) combines a scaffold with expanded chondrocytes for reimplantation. Autologous matrix–induced chondrogenesis (AMIC) combines microfracturing with a biodegradable collagen membrane to induce chondrogenesis.
      • Usuelli F.G.
      • D’Ambrosi R.
      • Maccario C.
      • et al.
      All-arthroscopic AMIC® (AT-AMIC®) technique with autologous bone graft for talar osteochondral defects: clinical and radiological results.
      Bone marrow–derived cell transplantation (BMDCT) uses a platelet-rich fibrin and BMAC-injected scaffold. The treatment success (AOFAS score ≥80 points) rate for these treatments range from 56% to 100% in primary lesions.
      • Dahmen J.
      • Lambers K.T.A.
      • Reilingh M.L.
      • et al.
      No superior treatment for primary osteochondral defects of the talus.
      Pooled success rates from 57% to 72% have been reported for secondary lesions.
      • Dombrowski M.E.
      • Yasui Y.
      • Murawski C.D.
      • et al.
      Conservative management and biological treatment strategies: proceedings of the international consensus meeting on cartilage repair of the ankle.
      The need for 2-stage procedures with ACI and MACI is a disadvantage. These techniques and the biomaterials used, however, currently are emerging, with increasing literature published, and could prove a valuable treatment options for secondary and larger primary lesions.
      • Rothrauff B.B.
      • Murawski C.D.
      • Angthong C.
      • et al.
      Scaffold-based therapies: proceedings of the international consensus meeting on cartilage repair of the ankle.
      For defects with a good articular cartilage layer (as assessed per MRI or diagnostic arthroscopy) and a (massive) cyst, subchondroplasty or retrograde drilling can be considered.
      • Reilingh M.
      • van Bergen C.
      • van Dijk C.
      Diagnosis and treatment of osteochondral defects of the ankle.
      ,
      • Miller J.R.
      • Dunn K.W.
      Subchondroplasty of the ankle: a novel technique.
      During retrograde drilling, a nontransarticular approach under fluoroscopy allows for drilling up to the subcartilaginous cyst and its débridement. This initiates intraosseous blood vessel disruption similarly to BMS and initiates subarticular bone filling of the cyst. Retrograde drilling has been found to have a success rate between 68% and 100% in primary OLTs.
      • Dahmen J.
      • Lambers K.T.A.
      • Reilingh M.L.
      • et al.
      No superior treatment for primary osteochondral defects of the talus.
      Subchondroplasty historically has been used in subchondral bone defects of the knee and recently has been pioneered for OLT surgery.
      • Miller J.R.
      • Dunn K.W.
      Subchondroplasty of the ankle: a novel technique.
      During the procedure, calcium phosphate is injected via a retrograde approach to fill the subchondral lesion and may be combined with additional arthroscopic treatments of the OLT.
      • McWilliams G.D.
      • Yao L.
      • Simonet L.B.
      • et al.
      Subchondroplasty of the ankle and hindfoot for treatment of osteochondral lesions and stress fractures: initial imaging experience.
      Only few short-term clinical outcomes are available, and show differing results.
      • Miller J.R.
      • Dunn K.W.
      Subchondroplasty of the ankle: a novel technique.
      ,
      • McWilliams G.D.
      • Yao L.
      • Simonet L.B.
      • et al.
      Subchondroplasty of the ankle and hindfoot for treatment of osteochondral lesions and stress fractures: initial imaging experience.
      Avascular necrosis can be a serious complication after subchondroplasty.
      • Hanselman A.
      • Cody E.
      • Easley M.
      • et al.
      Iatrogenic avascular necrosis of the talus following subchondroplasty [abstract]. AOFAS Annual Meeting 2019.
      Future research will determine the efficacy and safety of this technique.

      Acknowledgments

      The authors would like to thank Jari Dahmen for his valuable contribution to this work.

      Disclosure

      No authors reported receiving funding for this study or any other conflict of interest.

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