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FOOT & ANKLE INTERNATIONALCopyright  2010 by the American Orthopaedic Foot & Ankle SocietyDOI: 10.3113/FAI.2010.0090 Current Concept Review: Osteochondral Lesions of the Talus
Patrick J. McGahan, MD and Stephen J. Pinney, MD, FRCS(C) INTRODUCTION
source of ankle morbidity.19 Many OLTs can be treated non-operatively. For patients in whom surgery is indicated, a Osteochondral lesion of the talus (OLT) is a broad term number of procedures has been described (Table 3). Often, used to describe an injury or abnormality of the talar artic- the initial option is marrow stimulation which attempts ular cartilage and adjacent bone. Historically, a variety of to a fill the defect with fibrocartilage generated from terms have been used to refer to this clinical entity including a local healing response.3,32 This procedure encompasses osteochondritis dissecans, osteochondral fracture, and osteo- several techniques including abrasion chondroplasty, curet- chondral defect. Currently, six characteristics are used to tage, microfracture, and antegrade or retrograde drilling of categorize a particular lesion (Table 2). An OLT can be the subchondral bone. Implantation of osteochondral auto- described as chondral (cartilage only), chondral-subchondral graft or allograft using single or multiple cylinders of artic- (cartilage and bone), subchondral (intact overlying cartilage), ular cartilage and subchondral bone are techniques that utilize or cystic. Lesions can then be subdivided as stable or unstable intact hyaline cartilage to treat OLTs. Autologous chondro- and non-displaced or displaced. The stability of a lesion can cyte implantation (ACI) repairs OLTs with “hyaline-like” be assessed directly with arthroscopy or indirectly with MRI cartilage produced by a patient’s own chondrocytes harvestedfrom intact articular cartilage and amplified in number by serial culture in vitro.3 In addition to these reparative tech- A lesion can also be categorized by its location on niques, procedures such as lateral ligament reconstruction the articular surface of the talus as medial, lateral, or and hindfoot osteotomy or arthrodesis may also be included central with added subdivisions into anterior, central, or during surgery to address concomitant problems with the posterior as advocated by some authors.82 An additional stability or alignment of the affected joint. The goal of this description of identifying whether the lesion is contained Current Concepts Review is to critically evaluate the avail- or uncontained (shoulder) may also be included. Finally, able literature on the treatment of osteochondral lesions of although no accepted definition of lesion size exists, OLTs the talus and to provide evidence-based recommendations can generally be considered as either small or large based on regarding the management of these lesions.
their cross-sectional area or greatest diameter (area greaterthan or less than 1.5 cm2 or diameter greater than or less than15 mm). Although these characteristics provide a scheme to ETIOLOGY
classify OLTs and to select a therapeutic modality, they donot reliably predict the outcome of treatment.
Although trauma is implicated in many cases, it does not While the exact incidence of symptomatic OLTs is account for the etiology of every lesion. The etiology of unknown, they are quite prevalent and are a significant OLTs has been debated since Konig recognized them in1888.54 In 1922, Kappis applied the term osteochondritis No benefits in any form have been received or will be received from a commercial dissecans to lesions he found in the ankle.51 Wagoner and party related directly or indirectly to the subject of this article.
Cohn implicated trauma as the causative agent in 41 of 64 OLTs in 1931.105 However, in the remaining 23 cases, no clear cause could be identified. Although Rendu84 in 1932 was the first to report that the lesions represent a fracture of the talus, it was not until many years later that Berndt San Francisco General Hospital2550 23rd St., Building 9, 2nd Floor and Harty proposed an anatomic rationale for an association between OLTs and intra-articular trauma.16 Using a cadaveric biomechanical model, they demonstrated that axial loading For information on pricings and availability of reprints, call 410-494-4994, x232.
Foot & Ankle International/Vol. 31, No. 1/January 2010 OSTEOCHONDRAL LESIONS OF THE TALUS Table 1: Level of Evidence and Grades of
Table 3: OLT Surgical Treatment Options
Level of Evidence
Level I: High-quality prospective randomized
Level II: Prospective comparative study
Level III: Retrospective case control study
Level IV: Case series
Level V: Expert opinion
Grades of Recommendation (given to various
treatment options based on Level of Evidence D. Autologous Chondrocyte Implantation (ACI or — Grade A: Treatment options are supported by strong
E. Concomitant Procedures (i.e. lateral ligament evidence (consistent with Level I or II studies) — Grade B: Treatment options are supported by fair
evidence (consistent with Level III or IV studies) — Grade C: Treatment options are supported by either
of the ankle with the foot in a position of inversion and conflicting or poor quality evidence (Level IV dorsiflexion could produce a lateral talar lesion. Similarly, they showed that loading the ankle with the foot in a — Grade I: When insufficient evidence exists to make
position of inversion and plantarflexion while simultaneously externally rotating the tibia resulted in a medial talar lesion.
In a review that included 582 patients with OLTs, a historyof ankle trauma was reported in 76% of patients.102 In thisstudy 56% of the OLTs were located medially and 44% were Table 2: OLT Characteristics
located laterally. Trauma was implicated in 94% of the laterallesions and 62% of the medial lesions.
The etiology of OLTs in patients without a history of trauma remains unknown. Repetitive microtrauma, vascular B. Chondral/Subchondral (cartilage and underlying abnormalities resulting in avascular necrosis, and congenital factors have been speculated to play a role.20 In an attempt C. Subchondral (intact overlying cartilage) to elucidate the etiology of non-traumatic OLTs, several studies have investigated the morphology of talar articular cartilage.7,67 One study revealed that the thickest articular cartilage is located at the medial and lateral shoulders of the talus where OLTs have been observed to occur mostcommonly. The authors conjectured that this phenomena may represent an adaptive response to areas of greatest mechan- ical stress.67 In a biomechanical analysis, tibial cartilage was found to be significantly stiffer than talar cartilage, and the authors postulated that this mechanical disparity may A. Medial (anterior, central, or posterior) contribute to the development of OLTs due to repetitive B. Lateral (anterior, central, or posterior) C. Central (anterior, central, or posterior) In their investigation to characterize the distribution of talar dome lesions, Raikin and colleagues82 developed a novel anatomic grid that divides the talar dome into nine equal zones. They analyzed 424 MRI examinations of patients with an OLT using this grid and determined that the A. Small (area <1.5 cm2 or greatest diameter majority of lesions were medial (62%) while the remaining lesions were lateral (34%). In the sagittal plane, most lesions B. Large (area >1.5 cm2 or greatest diameter were central (80%) with the remainder either anterior (6%) or posterior (14%). Overall, the medial-central zone wasthe most frequent location of an OLT (53%) followed Foot & Ankle International/Vol. 31, No. 1/January 2010 by lateral-central zone (26%). The authors also noted that of patients undergoing arthroscopy for anterolateral soft- medial lesions were significantly larger and deeper than tissue impingement, 46% had an OLT, and the authors lateral lesions, which is consistent with observations from observed that the presence of these lesions was predic- earlier studies.5,21,85 The results of their study challenged tive of a poor outcome.103 The reported incidence of OLT the common perception that the majority of OLTs are located in patients undergoing surgery for lateral ankle instability either posterior-medial or anterior-lateral. Also, their findings ranges from 17% to 63%.23,26,53,74,94 Choi23 identified that that medial lesions were wider and deeper than lateral lesions the presence of a chondral lesion was a poor prognostic appear consistent with the mechanism originally proposed indicator for lateral ligament reconstruction. However, in by Berndt and Harty. In their anatomic study, Berndt and separate studies Okuda74 and Komenda53 reported equiv- Harty proposed that lateral lesions are caused by shear alent results after lateral ligament reconstruction in the between the talus and fibula which causes shallow, displaced, presence or absence of chondral lesions. These contradic- “wafer-shaped” lesions on the lateral dome of the talus, tory findings underscore the difficulty of effectively distin- while medial lesions result from torsion and impaction of guishing between an OLT that is symptomatic and one the tibia on the talus which results in deeper, “cup-shaped” that is an incidental finding in the setting of concomitant In summary, although OLTs are prevalent, their clinical CLINICAL PRESENTATION
significance and their true incidence remain uncertain. AnOLT may be undiagnosed in the setting of a traumatic event Symptomatic OLTs typically present with pain, stiffness, (ankle sprain or fracture) when advanced imaging studies catching, and swelling of the ankle. While patients often are not obtained. In addition, they may be over-diagnosed as report a history of trauma, recurrent sprains, or chronic a symptomatic lesion when they are actually an incidental instability, in 24% of cases the patient denies an association finding in the presence of concomitant ankle pathology.
with acute or repetitive trauma.102 Physical examination Finally, their precise contribution to a patient’s disability may may demonstrate tenderness, decreased range of motion, be difficult to determine when a painful lesion is present in pain with inversion or dorsiflexion, or an effusion. The the setting of additional symptomatic ankle pathology such differential diagnosis includes synovitis, soft-tissue or bony impingement, lateral instability, and arthritis of the ankleas well as subtalar arthritis, peroneal tendinitis, and occult fracture of the foot or ankle. A subset of OLTs presents as anasymptomatic lesion discovered incidentally in the context of Anteroposterior (AP), lateral, and mortise weight-bearing the workup of concomitant ankle pathology that is the actual radiographs of the ankle should be obtained as the initial imaging study. However, after an acute injury with a non- The incidence of symptomatic OLTs is difficult to deter- displaced lesion, plain radiographs may be unrevealing.5,29, mine due to ambiguities with the diagnosis, asymptomatic 64,104 A chronic lesion with displacement, osteonecrosis, or lesions, and the presence of concomitant pathology. The cystic change may been seen as a positive, but non-specific, reported rates of OLTs in patients with acute ankle frac- finding on plain radiographs.5,104 The limitations of plain tures ranges from 17% to 79%.1,17,47,63,65,94,96 While one radiography include a low sensitivity,5,64,104 an inability to author reported a correlation of ankle fracture severity with assess the integrity of the articular cartilage, and an inability rates of osteochondral lesions,63 another author found no to quantify the extent of the lesion. In the setting of negative correlation.1 Although OLTs can be diagnosed in associ- radiographs and a high index of suspicion for intra-articular ation with acute injuries, such as when they are discov- pathology, MRI or CT should be considered to further ered during the operative repair of an ankle fracture, their diagnosis is frequently delayed until the patient presents Debate exists regarding the choice of MRI or CT as in the office with chronic symptoms. The incidence of the optimal imaging study following plain radiography to OLTs following an acute ankle sprain has been reported assess a painful ankle. A recent study compared the utility up to 6.5%.19 However, this number may underestimate of MRI, CT, and arthroscopy in the diagnosis of OLTs.104 the true incidence as many lesions remain undiagnosed or Sensitivity and specificity of MRI were 96% and 96%, asymptomatic. A study of patients undergoing arthroscopy CT values were 81% and 99%, and arthroscopy values for residual pain at an average of 7 months following an were 100% and 97%. Although these differences were not ankle sprain revealed an osteochondral lesion in 38% of statistically significant, each modality clearly demonstrated cases.97 A similar study found 57% of patients with disability its benefits and drawbacks. MRI proved very sensitive and after ankle trauma had an OLT.5 Another study evaluating specific and allows good visualization of the articular surface.
patients with chronic unexplained ankle pain reported an However, excessive bone-marrow edema can obscure the incidence of OLT of 81%.28 OLTs in the setting of concomi- extent of the lesion and in a separate study was shown to tant ankle pathology has also been investigated. In a study underestimate the lesion grade.61 While CT cannot assess Foot & Ankle International/Vol. 31, No. 1/January 2010 OSTEOCHONDRAL LESIONS OF THE TALUS the articular cartilage directly, it is more effective than Of particular interest is the correlation between the appear- MRI at evaluating the bony defect. Finally, arthroscopy ance of a lesion on imaging and arthroscopic findings. A is advantageous for its dual capability to diagnose and study by Mintz et al.68 attempted to correlate MRI and treat an OLT. However, one disadvantage is its inability arthroscopic findings. They compared the Ferkel and Cheng to characterize subchondral lesions with intact cartilage. In arthroscopic grade with a modified MRI grading system.
clinical practice, MRI is typically obtained prior to CT to In their study, MRI appearance coincided with the arthro- evaluate a patient with unexplained pain because it can scopic grade for 83% of lesions. A similar study recently detect a variety of pathologic conditions.25 Frequently, a CT reported that MRI has an accuracy of 81% when compared is obtained to characterize bony lesions more fully when with arthroscopy.61 When the MRI appearance was inconsis- the MRI findings are inconclusive or when initial plain tent with arthroscopic findings, both studies found that MRI radiographs are indicative of an osteochondral lesion.
tends to under-grade the severity of the lesion. Currently,staging systems emphasize distinguishing between an intactand disrupted articular surface, non-displaced and displaced CLASSIFICATION
lesions, stable and unstable lesions, and non-cystic or cysticlesions. These characteristics, as outlined in Table 2, form The classification system introduced by Berndt and the basis of determining the clinical significance of a partic- Harty16 in 1959 still remains the most widely used means ular lesion and currently guide the discussion regarding the of describing an OLT (Table 4). It is based on the appear- ance of the lesion on plain radiographs and includes fourstages. Since its introduction, other classifications have beenconceived based on MRI, CT, and arthroscopic findings.
TREATMENT
Several authors have revised Berndt and Harty’s originalclassification to include a fifth stage to describe cystic Most authors advocate a trial of non-operative manage- lesions.5,64,91 Ferkel and Sgaglione28 developed a CT-based ment for non-displaced OLTs in both children and adults.5,11, staging system that emphasized the bony characteristics of 21,29,39,64,66,70,79 The main contraindication to non-operative the lesion, specifically the cystic component. Anderson5 management in children and adults are acute injuries with developed an MRI-based classification system that modi- displaced osteochondral fragments.15,57 In these cases, imme- fied Berndt and Harty’s original description by designating diate operative management is warranted to either resect or a cystic lesion as Stage IIa. Similarly, Hepple46 devised reduce and internally fixate the fragment.
a MRI classification that assigned cystic OLTs as Stage 5 A wide variety of non-operative treatment options exists lesions. DiPaola27 adapted the Berndt and Harty system to with a recommended duration ranging from 3 to 6 months.
accommodate MRI findings while maintaining the original Possible options include nonweightbearing with cast immobi- four stages. Pritsch80 described an arthroscopic classifica- lization, protected weightbearing in a walking boot, bracing, tion based on the condition of the overlying cartilage, and physical therapy and non-steroidal anti-inflammatory drugs.
Ferkel29 expanded this system to include chondromalacia and A number of retrospective studies (Level IV) have reported completely displaced osteochondral lesions.
good results with non-operative treatment and most authors At this time, it is unclear as to whether any of these clas- recommended a trial of protected weightbearing for all non- sifications possess good inter- and intraobserver reliability or displaced lesions.11,66,70,79,92 A recent meta-analysis reported can serve as a meaningful guide to clinical decision-making.
a 45% success rate with non-operative treatement.102 Despitethese findings, it is unclear whether non-operative treatmentleads to or hastens the onset of arthritis. Several authors have Table 4: Berndt and Harty Classification of OLTs (1959)
observed arthritic changes in the ankles of patients treatednon-operatively, but they could not determine if degenera- Stage 1: Focal compression of the subchondral bone tion of the joint could have been prevented with operative intervention.21,92 Despite these concerns, it is the general Stage 2: Focal compression of the subchondral bone consensus that once a symptomatic OLT has been diagnosed, with partial detachment of a fragment of cartilage the physician must confirm that non-operative management Stage 3: Focal compression of the subchondral bone has failed before considering operative interventions. The with a fully detached fragment of cartilage and bone available data from Level IV studies constitutes fair evidence still situated in place at the site of injury (Grade B recommendation) to support a trial of non-operative Stage 4: Focal compression of the subchondral bone management for all non-displaced lesions. However, based with a fully detached fragment of cartilage and bone on the available literature, no specific conclusions can be detached from the site of injury and floating in the made regarding duration of conservative treatment, method of immobilization, weightbearing status, use of NSAIDS, orthe role of physical therapy.
Foot & Ankle International/Vol. 31, No. 1/January 2010 Although good results may be obtained without surgery, include saphenous and superficial peroneal nerve injury, pain, some lesions remain symptomatic after a course of non- operative management. The indication for surgical interven- Two studies have reviewed the results of repeat marrow tion includes symptomatic lesions refractory to conservative stimulation following failure of a prior arthroscopic proce- care regardless of stage. After deciding that surgery is indi- dure. The average AOFAS score was 80.5, and the rate of cated, the physician faces a plethora of choices from which good to excellent results was 82% for these two series.87,89 to select the most appropriate procedure for treating an OLT.
In a prospective, non-randomized trial (Level II evidence), Gobbi39 reported comparable results for OLTs treated with MARROW STIMULATION
either chondroplasty, microfracture, or an osteochondralautograft at 2-year followup. The 11 patients treated with Multiple arthroscopically assisted techniques to stimulate chondroplasty had a mean AOFAS score of 82.7 while those the release of cells and cytokines from the marrow to heal an who underwent microfracture had a mean of 83.8. The mean OLT have been described in the literature. These techniques size of lesions treated with chondroplasty was 4 cm2 while include abrasion chondroplasty, curettage, antegrade and the microfractured lesions averaged 4.5 cm2.
retrograde drilling, and debridement with microfracture.
For OLTs with the overlying articular cartilage intact, These techniques have been used to treat lesions of all several Level IV studies have reported on the results of grades and sizes. They have been employed as the initial antegrade or retrograde drilling without debridement of treatment and as the secondary option following failure of the lesion.29,35,55,58,93,99 These studies reported mean post- a previous procedure. Prior to stimulating the marrow, the operative AOFAS scores between 90 and 97 without any lesion is inspected arthroscopically. Unstable cartilage flaps complications. One study reported improved arthroscopic and fragments associated with a full thickness lesion are appearance of lesions treated with retrograde compared to debrided. Once a stable rim of intact articular cartilage antegrade drilling, but there was no difference in the AOFAS is defined, a marrow stimulation technique is performed score.55 Intuitively, the avoidance of drilling through intact on the exposed lesion bed. For lesions with the overlying cartilage should improve outcomes. However, no literature articular cartilage intact, retrograde or antegrade drilling may exists to support the theoretical advantage of the retrograde be performed.55 Alternatively, subchondral lesions can be technique for drilling an OLT. To the contrary of this treated with debridement of the overlying cartilage followed assumption, two studies have reported good results with by marrow stimulation. All of these marrow stimulating debridement and marrow stimulation of lesions with intact techniques are designed to penetrate the subchondral bone to fill the debrided talar lesion with blood containing precursor OLTs associated with cysts have been treated with a variety cells and cytokines that will mediate a healing response to of procedures. Two studies have reported good to excellent form reparative fibrocartilage. This fibrocartilage has been results in 74% to 80% of patients treated for small (less than studied extensively and is composed of Type I and Type 1.5 cm2) cystic lesions with marrow stimulation alone.41,64 II collagen, whereas hyaline cartilage consists primarily Authors of other studies have recommended against the use of Type II collagen.3,32 Although fibrocartilage poses an of marrow stimulation alone in the treatment of cystic lesions advantage over exposed subchondral bone as a surface for based on the results of their studies.29,87,88 One obstacle weightbearing, it has been shown to have inferior stiffness, to the interpretation of these results is the discrepancy in resilience, and wear properties compared with normal hyaline the method of quantifying the extent of the cyst. One study measured the depth of the cyst,29 one measured the A number of retrospective studies (Level IV evidence) diameter,90 and another calculated the area by using the depth have assessed the results of marrow stimulation techniques to and diameter of the lesion as measured on an AP X-ray or treat OLTs.8,9,14,24,29 – 31,41,49,55,59,64,73,75,80,85,87 – 89,95 These studies report average postoperative AOFAS scores ranging Another obstacle to interpreting the evidence supporting from 68 to 97 and good to excellent results in 39% to 96% the use of marrow stimulation is that most of the literature of cases. The size of the lesions included in these studies evaluates the efficacy of a single technique in a heteroge- ranges from 0.25 to 4 cm2. Although each study reports vari- neous group of lesions. Due to the retrospective nature of ations in the postoperative protocol, the regimen generally these investigations, there is little adaptation in the surgical consists of early initiation of joint motion, 6 to 8 weeks technique or the postoperative rehabilitation despite a wide of limited or nonweightbearing, progression to full weight- variation in the characteristics of the lesions under review.
bearing by 3 months, and a release to athletic activity by 3 to Most studies do not correlate the results with any partic- 6 months after surgery. The complication rates reported vary ular characteristics noted at the time of surgery such as and range from 0% to 14%. They include superficial and deep the diameter, depth, or location of the OLT. Without the infection, deep vein thrombosis, stiffness requiring a reoper- ability to discriminate, decisions are based on intuition ation, complex regional pain syndrome, and plantar fasci- rather than data. For example, it is the consensus that a itis. Complications associated with the arthroscopic portals smaller lesion size should correlate with better outcome; Foot & Ankle International/Vol. 31, No. 1/January 2010 OSTEOCHONDRAL LESIONS OF THE TALUS however, the evidence has not been uniformly consistent perform osteochondral autografting of the talar dome.33,69,101 with this assumption. Two studies (Level IV and II evidence) Although most of the articular surface can be exposed using reported improved results with smaller lesions,24,39 while the appropriate osteotomy, 15% of the talus comprising the two others (Level IV evidence) did not find this relationship central portion of the dome cannot be accessed perpendic- to be true.14,41 The situation is the same for lesion grade.
ularly with any osteotomy.69 Osteotomies generally neces- Several studies have reported better results with lower grade sitate 6 to 8 weeks of nonweightbearing to heal, and this lesions,24,29,79,89 while others have not observed a correlation requirement may prolong the recovery after an autograft between outcome and lesion grade.14,41,93,99 With respect to procedure beyond what is typically necessary after a marrow location, it is a common belief that lateral lesions are more stimulation procedure. Non-union and delayed union of frequently associated with trauma than medial lesions.102 As the osteotomy may occur at a rate reported between 0% a result, many anticipate a disparity in the outcome between to 2%.2,10,34,43,56,62,86,101 Two groups have recommended medial and lateral lesions due this perceived difference in that the fixation be removed between 9 to 18 months after etiology. However, this has not been demonstrated in the the osteotomy regardless of pain or evidence of hardware literature. In fact, several authors have reported no differ- ence in outcome based on the location of an OLT.29,73,88 The reported rate of morbidity after harvesting grafts from Finally, there is no data to determine if the results vary in the knee ranges from 0% to 55%. The postoperative problems the treatment of contained versus uncontained lesions after a include persistent pain, pain on heavy exertion, patellar instability, giving way, difficulty kneeling or squatting, and The consistently positive results from numerous Level the need for additional surgery.6,10,34,39,43,83 A recent study IV studies and one Level II study constitute fair evidence reported a relatively low incidence of morbidity after graft (Grade B recommendation) to support the use of marrow harvest from the knee, although the authors reported poorer stimulation in the management of OLTs either as the initial results in patients with an increased body mass index.77 procedure or as a secondary option after failed arthroscopic Osteochondral grafts have been harvested locally from the management. The consistently positive results from Level IV talus (anterior, medial, or lateral facet) without any reported studies constitute fair evidence (Grade B recommendation) to morbidity, but it has been recommended that their diameter support antegrade or retrograde drilling alone for OLTs with the overlying cartilage intact. The evidence is insufficient Several technical points warrant consideration when (Grade I recommendation) to recommend any marrow stim- obtaining an osteochondral autograft. Harvest sites should ulation technique alone for the treatment of cystic lesions of be located at nonweightbearing portions of the knee (inter- any size. Finally, there is no evidence (Grade I recommen- condylar notch or medial/lateral femoral condyle) or talus dation) to advocate for the use of one particular marrow (anterior, medial, or lateral facet) because the defect created stimulating procedure over another based on a particular by the harvest has been shown to fill with reparative fibro- cartilage and may possibly become a source of morbiditywithin the joint.44,56 The graft should be inserted flush with OSTEOCHONDRAL AUTOGRAFTS
the surrounding articular surface. A graft countersunk greaterthan 2 mm has been shown in animal studies to undergo Osteochondral autografts have been used to treat OLTs of cartilage necrosis and fibrous overgrowth, while a graft left all grades and sizes. The rationale for their use is that an proud demonstrates micromotion in its bed and fissuring of articular defect is replaced with hyaline cartilage attached to its hyaline cartilage.3,48 Several authors have found that up its subchondral plate to allow bony integration of the graft to one-third of the total area of an osteochondral autograft within the lesion bed. Biopsies obtained during second-look will degenerate into reparative fibrocartilage due to damaged arthroscopy provide the histological evidence confirming the cartilage at the periphery of the graft, the filling of gaps at survival of chondrocytes within the transplanted hyaline the interface of the graft and the walls of the defect, and cartilage.10,43 Osteochondral autografts have been used to chondrocyte death due to the mechanical trauma of graft treat acute and chronic defects as the initial procedure or insertion.18,50,76 These points highlight the critical impor- as a secondary salvage after a failed arthroscopic debride- tance of careful matching of the size and shape of the auto- ment. Individual or multiple autografts (mosaicplasty) are graft to the defect to minimize the amount of fibrocartilage harvested from the ipsilateral knee or talus. The decision to acquire one or several osteoarticular cylinders depends A number of retrospective studies (Level IV evidence) on the size and location of the OLT as well as the prefer- assessing the effectiveness of osteochondral autografts to ence of the surgeon. Access to the defect to permit inser- treat OLTs have been performed.2,6,10,42,56,60,86 These studies tion of the autograft perpendicular to the articular surface report average postoperative AOFAS scores ranging from often requires an arthrotomy combined with a peri-articular 80 to 90.8 and good to excellent results in 91% to 100% osteotomy.33,69,101 Medial malleolar, lateral malleolar, and of patients. The size of the lesions treated in these studies anterolateral (Chaput) osteotomies have been utilized to ranged from 0.16 to 5.0 cm2. The duration of recovery before Foot & Ankle International/Vol. 31, No. 1/January 2010 returning to full activity ranged from 3 to 12 months. The rate results of these two techniques. Lastly, there is insufficient of complications varied from 10% to 100%, which included evidence (Grade I recommendation) to support the use of failure of the graft, persistent pain, prolonged swelling or osteochondral autografting on the basis of the size, location, stiffness, prolonged time to recovery, painful hardware used grade, stability, displacement, or containment of a lesion.
to fixate the osteotomy, and problems with wound healingsuch as suture granuloma, incisional neuroma, and wound OSTEOCHONDRAL ALLOGRAFT
dehiscence.2,34,39,56 In a prospective, non-randomized trial(Level II evidence) comparing chondroplasty, microfracture, In the operative treatment of an OLT, osteochondral allo- and osteochondral autograft with 2-year followup, Gobbi39 grafts are used for lesions that are not amenable to other reported an average AOFAS score of 85 in 12 patients procedures. Structural allografts are typically employed to with grade 3 or 4 lesions treated with autograft taken reconstruct collapsed articular surfaces due to avascular from the ipsilateral knee. The average size of the lesions necrosis and to fill large (greater than 1 cm diameter and was 3.7 (range, 1.2 to 5) cm2. They did not observe any 5 mm depth) osteochondral defects where harvesting an auto- morbidity in the knee from which the graft was harvested.
genous graft of adequate size to restore the anatomy of the Two patients experienced persistent pain and stiffness in talus would be difficult. Allografts provide intact hyaline the ankle requiring arthroscopic debridement for anterior cartilage to repair the articular surface, typically require a impingement. Only one of the patient’s symptoms resolved malleolar osteotomy for insertion, and necessitate graft fixa- tion with either impaction or small caliber screws.4,40,81,100 The studies that support the use of osteochondral auto- Typically, an allograft is obtained in bulk from a tissue bank grafts used standardized protocols for treatment and did and shaped intraoperatively to fit the defect. Fresh allografts not consistently correlate their results with specific char- should be harvested within 24 hours of the donor’s death acteristics of the lesion. Only one study evaluated the use and implanted within 1 week to ensure maximal chondrocyte of osteochondral autografts to treat cystic lesions, and the viability.100 In cases where fresh tissue cannot be obtained, authors reported good results.90 Several studies have demon- fresh-frozen allografts may be used instead as there is no strated better results treating smaller sized lesions.2,10,39 In clear evidence at this time that fresh allografts provide supe- three separate studies comparing the use of solitary versus rior results to fresh-frozen grafts.81 Postoperatively, patients multiple (mosaicplasty) osteochondral grafting, two reported must be kept nonweightbearing for 6 to 8 weeks to allow better results with solitary grafts10,39 while the third found the concomitant osteotomy required for insertion to heal. In no difference between the two methods.2 However, the inter- cases where very large allografts are used, the patients are pretation of these results are confounded by the size of kept protected weightbearing for up to a year to allow graft the lesion because most solitary grafts are performed on incorporation. The advantages of using allografts include the smaller lesions whereas mosaicplasty is utilized for larger elimination of morbidity from harvesting an autograft, the lesions. The results of grafting based on the location of the plentiful intraoperative availability of tissue for graft, and lesion have not been extensively investigated. Only one study the use of hyaline cartilage to resurface defects of any size reported improved outcomes with medial compared to lateral or shape. Potential drawbacks include failure of the graft to lesions.2 With respect to lesion grade, one author reported no heal to the surrounding bone, the risk of disease transmis- correlation between outcome and the severity of the lesion.2 sion, immunogenicity, and the long time interval necessary No data exists comparing the use of osteochondral autograft for graft incorporation. Additional complications pertaining for contained versus uncontained lesions. Finally, while there to the use of an osteotomy and arthrotomy are also potential appears to be a general consensus that the outcomes after autografting deteriorate in an older patient population,10,34 Two retrospective studies (Level IV evidence) have little data exists in the literature to support this claim.
assessed the efficacy of osteochondral allografts to treat The consistently positive results from several Level IV OLTs.40,81 One study reviewed nine patients who had failed studies and one limited Level II study constitute fair evidence previous arthroscopic management and were treated subse- (Grade B recommendation) to support the use of osteochon- quently with an osteochondral allograft.40 At an average dral autografting as a primary or as a secondary procedure to 12-years followup, six patients were satisfied with the func- treat OLTs. However, when choosing an osteochondral auto- tion of their ankle. Of the three patients who failed treatment, graft for treatment of an OLT, the surgeon must appreciate all of their allografts developed avascular necrosis neces- the potentially extended recovery time compared to a marrow sitating an ankle fusion. No complications were reported stimulation procedure. There is insufficient evidence (Grade I related to the procedure. In another study, six patients with recommendation) in the literature to support the use of osteo- an average lesion size of 4.38 cm3 were treated with an chondral autograft in the treatment of cystic lesions. Simi- allograft.81 At an average followup of nearly 2 years, the larly, there is insufficient evidence (Grade I recommendation) average AOFAS score was 86. Five patients continued to to recommend solitary versus multiple autografts for an OLT function well with an intact graft, while the sixth patient as the available literature does not differentiate between the underwent ankle arthrodesis due to pain.
Foot & Ankle International/Vol. 31, No. 1/January 2010 OSTEOCHONDRAL LESIONS OF THE TALUS These two Level IV studies do not provide sufficient prolonged knee symptoms at 12 months in 0% to 70% evidence (Grade I recommendation) to support the use of of patients undergoing this procedure.71,106 Alternatively, osteochondral allograft for an OLT of any size, location, the harvest can be performed from the anterior talus with grade, stability, displacement, or containment.
little reported morbidity.13 A recent study reported a 20%incidence of graft hypertrophy seen during second-look AUTOLOGOUS CHONDROCYTE IMPLANTATION
arthroscopy, the clinical significance of which is unknown.71In addition, a recent review of all adverse events following Autologous Chondrocyte Implantation (ACI) has been ACI (all joints included), found an overall graft complication investigated as a means of repairing OLTs of various grades rate of 3.8% with graft failure, delamination, or hypertrophy and sizes. It has been used as the initial and secondary option being the three most common events observed.107 for acute or chronic lesions. ACI requires two surgical proce- Like studies investigating other techniques for treating dures and the use of cell culture. The first procedure harvests OLTs, the literature evaluating the efficacy of ACI used hyaline cartilage from the patient’s talus or femoral condyle.
standardized treatment protocols that did not vary according The chondrocytes are then isolated from the harvested tissue to the specific characteristics of the lesion. Also, the majority and cultured in the laboratory for approximately 3 weeks of papers did not correlate the results of treatment with to amplify the number of chondrocytes. The second proce- the specific characteristics of the lesions. Several authors dure re-implants the chondrocytes into the debrided bed of reported good results with the “sandwich procedure” to treat the osteochondral lesion, through a malleolar osteotomy if cystic lesions with a depth greater than 5 mm.38,71 One study necessary.13 A periosteal patch from the distal tibia seals the found no correlation between the outcome and the size or chondrocytes in the defect.12,13 Over time, the re-implanted location of the lesion.38 However, this study observed that chondrocytes fill the defect with new hyaline cartilage. Anal- outcomes were affected predominantly by the age of the ysis of biopsies from defects treated with ACI has shown the patient and this relationship may have masked the detection novel tissue to be “hyaline-like” and composed of approx- of additional corrrelations.38 None of these studies reported imately 42% hyaline cartilage.3,38 This “hyaline-like” carti- the results comparing the use of ACI in contained versus lage reportedly has biomechanical properties similar to native cartilage that may make it more durable than fibrocartilage Based on these limited number of Level IV studies, there is insufficient evidence (Grade I recommendation) to Recently, a report in the literature has described an arthro- support the use of ACI to treat OLTs as a primary or as scopic technique that obviates the need for an osteotomy.
a secondary option. Similarly, there is insufficient evidence The chondrocytes are cultured in a biologic matrix that (Grade I recommendation) to guide the use of this technique serves both as a delivery system for the cells as well as based on the size, location, grade, stability, displacement, or a scaffold for repair negating the need for a periosteal patch.36,38 Early results with this so-called matrix-associatedchondrocyte implantation (MACI) have been promising.13,22 AUTOGENOUS BONE GRAFT
However, the safety and long-term efficacy of these newbiologic scaffolds have not been firmly established. When Although most cystic OLTs are treated with one of the depth of the lesion is greater than 5 mm, cancellous the aforementioned techniques, autogenous cancellous bone bone grafting has been recommended.12,13,36,38,71 This tech- grafting alone to pack a defect has been evaluated in two nique is referred to as the “sandwich technique,” consisting retrospective studies (Level IV evidence).52,88 While one of cancellous bone graft covered by a “sandwich” of two study reported an average postoperative AOFAS score of 93, periosteal patches with the autologous chondrocytes inserted the other noted good to excellent results in only 46% of patients with 6 of 13 patients requiring re-operation. Based A number of retrospective studies (Level IV evidence) on the limited data from these two Level IV studies, there assessing the effectiveness of ACI in the management is insufficient evidence (Grade I recommendation) to support of OLTs have been performed.12,36 – 38,71,106 These studies the use of autogenous bone grafting alone to treat a cystic report average postoperative AOFAS scores ranging from 88.4 to 90.5 with good to excellent results in 82% to 92% Recently, there have been two case series on the use of of patients. The sizes of the lesions range from 0.5 to vascularized bone grafts to treat cystic lesions with intact 6.25 cm2. The time to return to full activity ranges from overlying cartilage.45,98 Cancellous bone grafts, osteochon- 8 to12 months, and the authors required a strict adherence dral allografts, and osteochondral autografts are susceptible to a multi-phase rehabilitation program beginning with non- to necrosis, collapse, and failure due to the discrete patterns weightbearing and the use of continuous passive motion.71 of perfusion to the talar dome. Vascularized bone grafts offer The rates of complication were low in these reviews and a potential means of avoiding these complications because included only a superficial infection and donor site morbidity they are implanted with their own blood supply. One study of the knee. Tissue harvest from the knee can result in included two cases in which a vascularized iliac crest bone Foot & Ankle International/Vol. 31, No. 1/January 2010 graft was used to replace subchondral bone with intact over- typically performed with cylindrical plugs of bone and lying cartilage after the curettage of benign tumors.45 At 10- cartilage most commonly harvested from the ipsilateral and 4.5-years followup respectively, both grafts had survived, knee or talus. This technique offers the advantage of and the patients reported pain-free function. Another study replacing the lost cartilage with real hyaline cartilage.
reported the use of a vascularized calcaneus graft to treat However, disadvantages include a prolonged recovery large cystic osteochondral lesions on the medial side of the time compared to marrow stimulation, the potential for talus with intact overlying cartilage.98 Four patients were donor site morbidity, and difficulty matching the graft treated with an average lesion size of 4.31 cm2. At an average follow-up of 34 months, all grafts had survived without 8. Autologous Chondrocyte Implantation (ACI) offers the evidence of osteonecrosis and the average AOFAS score was theoretical advantage of replacing the cartilage defect 83. Although the results from these two level IV studies are with the patient’s own cartilage cells. However, to promising, there is insufficient evidence (Grade I recommen- date there is insufficient evidence to fully assess the dation) to support the use of a vascularized bone graft to treat REFERENCES
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Nº 170, quarta-feira, 3 de setembro de 2008Art. 1o Autorizar o funcionamento do curso de Adminis- PORTARIA No- 620, DE 2 DE SETEMBRO DE 2008 Por maioria de votos, NEGAR provimento ao recurso. Ven-tração, bacharelado, com 160 (cento e sessenta) vagas totais anuais,cido o Conselheiro Moisés Giacomelli Nunes da Silva (Relator) quenos turnos diurno e noturno, a ser ministrado pela Faculdade

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Report of drugs magnesium Sulphate Misoprostol ACKNOWLEDGMENTS We are grateful to the Dr.Yasin, Hargeisa Hospital, Berbera Hospital, Burco Hospital, and Adna Aden Hospital as a whole in Somaliland region for their cooperation, time and provision of information individually and in focus group that helped the survey team get a better understanding of the medical report in We wis

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