64 STG OCD Talus 2024 PDF

Osteochondral Lesion of the Talus Sean T. Grambart DPM, FACFAS, D.ABFAS Assistant Dean of Clinical Affairs, College of Podiatric Medicine and Surgery Director of Research, DMU-CPMS Attending, IMMC Foot and Ankle Surgical Residency AO Fellow Dresden, Germany Past-President, American College of Foot a...

Osteochondral Lesion of the Talus Sean T. Grambart DPM, FACFAS, D.ABFAS Assistant Dean of Clinical Affairs, College of Podiatric Medicine and Surgery Director of Research, DMU-CPMS Attending, IMMC Foot and Ankle Surgical Residency AO Fellow Dresden, Germany Past-President, American College of Foot and Ankle Surgeons 1 1 Terminology Osteochondral lesions of the Talus (OLT) Transchondral fracture Osteochondral fracture Osteochondritis dissecans Talar dome fracture Talar dome lesion Flake fracture 2 TRAUMA!!!! Hereditary Ossification Embolic Phenomenon Abnormal Vasculature Spontaneous Necrosis Hormonal Factors Malalignment 582 patients with OLTs, a history of ankle trauma was reported in 76% of patients 3 Fractures of the Talar Dome Mechanism of injury depends on location Anterolateral lesions  inversion Posteromedial lesions  plantarflexion/inversion dorsiflexion/ 4 Incidence Medial lesions ▪ Middle to posterior ▪ Deeper, cup shaped ▪ More commonly develop into cystic lesions Lateral lesions ▪ Anterior to middle of the talus ▪ Shallow and wafer shaped ▪ More commonly displaced 5 428 lesions were identified on MRI "Medial talar dome lesions are not only more common but are larger in surface area and in depth than lateral lesions" 6 Clinical Findings Chronic ankle pain History of chronic ankle sprain Recurrent » Ankle swelling » Stiffness » Weakness » Giving way Mechanical Symptoms » Catching » Clicking » Locking 7 Classifications 8 Imaging 9 MRI 10 11 33 Ankle with OLTs All had MRI and CT With or Without Bone sclerosis Area of Bone Marrow Lesion 20 ankles had biopsy of the OLT 13 ankles were evaluated Large area of BML exhibited low degeneration of cartilage Small area of BML indicated sclerosis of the subchondral bone with severe degeneration of the cartilage 12 CT 13 14 Treatment 15 Conservative Treatment 45% Success Rate with Conservative Treatment 16 Duration of 3-6 months Nonweightbearing Cast Immbolization Walking Boot Physical Therapy NSAIDs Primary Surgical Treatments Marrow-inducing reparative treatments » Abrasion arthroplasty » Microfracture » Drilling techniques 17 Restorative Techniques Autologous chondrocyte implantation (ACI) Matrix/membrane ACI (MACI) Collagen-covered autologous chondrocyte implantation (CACI) Arthroscopic allograft/autograft (AAP) with platelet-rich plasma (PRP) implantation Osteochondral autograft Osteochondral autologous transfer system » OATS » Mosaicplasty Fresh osteochondral allograft Juvenile Hyaline Allograft 18 Surgical Factors Size of the lesion Foundation of the lesion Location of the lesion History of previous surgery 19 Characteristics of Lesions Location Type of lesion Chondral Chondral/Subchondral Subchondral Cystic Stability of Lesion Medial (anterior, central, or posterior) Lateral (anterior, central, or posterior) Central (anterior, central, or posterior) Containment Stable Unstable Contained Uncontained (Shoulder Lesion) Displacement of Lesion Size of Lesion Displaced Non-displaced 20 Small (area 1.5cm2 or greatest diameter > 15mm) 120 Ankles Clinical Failure Arthroscopic marrow stimulation Patients’ having osteochondral transplantation AOFAS Ankle-Hindfoot Scale score less Evaluated for prognostic factors than 80 21 120 Ankles Arthroscopic marrow stimulation Evaluated for prognostic 25% Failure Rate factors Why is 1.5cm squared important? 22 10.5% Failure 80% Failure Primary Surgical Treatments Marrow-inducing reparative treatments » Abrasion arthroplasty » Microfracture » Drilling techniques 23 Purpose of Microfracture 24 Microfracture 25 Retrograde Drilling/ Subchondralplasry 26 Restorative Techniques Autologous chondrocyte implantation (ACI) Matrix/membrane ACI (MACI) Collagen-covered autologous chondrocyte implantation (CACI) Arthroscopic allograft/autograft (AAP) with platelet-rich plasma (PRP) implantation Osteochondral autograft Osteochondral autologous transfer system » OATS » Mosaicplasty Fresh osteochondral allograft Juvenile Hyaline Allograft 27 Allograft advantages Decreased patient morbidity Shorter surgical time Tissue flexibility Resurface large lesions 28 Allograft disadvantages Risk of disease transmission Slower biologic remodeling Potential for immune response Cost and logistics 29 Indications for allografts Medial or lateral talar defects – That are 10 mm or larger – Up to and involving the entire half of the dome 30 Indications for allografts Salvage for failure of other surgeries – Such as debridement and microfracture – Failed mosaicplasty, OATS 31 Surgical approaches Medial – medial malleolar osteotomy Lateral – lateral malleolar osteotomy Anterolateral – Tillaux osteotomy Posterior – posterior malleolar osteotomy 32 Allograft preparation Create osteochondral plugs Custom fit graft 33 A medial case 45 year old Years of medial ankle pain Failed non-surgical treatments 34 A medial case - MRI 35 Medial Malleolar Osteotomy Medial malleolar osteotomy Pre-drill screws Oblique cut as possible Protect posterior tibial tendon 36 Tibialis Posterior Tendon Medial approach 37 Medial approach 38 Medial approach 39 40 Anterior approach/hemi-talus technique 41 Anterior approach 42 Talus and graft comparison Fresh allograft – not frozen 43 Graft in place 44 6 month post operative x-rays 45 Thank You! 46