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Terminology » Osteochondral lesions of the Talus (OLT) » Transchondral fracture » Osteochondral fracture » Osteochondritis dissecans » Talar dome fracture » Talar dome lesion » Flake fracture Tol, JL; Struijs, PA; Bossuyt, PM; Verhagen, RA; van Dijk, CN: Treatment strategies in osteochondral defects...

Terminology » Osteochondral lesions of the Talus (OLT) » Transchondral fracture » Osteochondral fracture » Osteochondritis dissecans » Talar dome fracture » Talar dome lesion » Flake fracture Tol, JL; Struijs, PA; Bossuyt, PM; Verhagen, RA; van Dijk, CN: Treatment strategies in osteochondral defects of the talar dome: a systematic review. Foot Ankle Int.21(2):119 – 26,2000 » Hereditary Ossification TRAUMA!!!! » Embolic Phenomenon » Abnormal Vasculature » Spontaneous Necrosis » Hormonal Factors » Malalignment 582 patients with OLTs, a history of ankle trauma was reported in 76% of patients Fractures of the Talar Dome » Mechanism of injury depends on location – Anterolateral lesions à dorsiflexion/inversion – Posteromedial lesions à plantarflexion/inversion Fallat, Lawrence M. Christensen, Jeffrey C. Hord, Jacob A. Chapter 54: Osteochondroses of the foot and ankle. McGlamry’s Comprehensive Guide to Foot and Ankle Surgery,Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013. Fractures of the Talar Dome » Mechanism of injury depends on location – Anterolateral lesions à – Posteromedial lesions à dorsiflexion/inversion plantarflexion/inversion – “DIAL a PIMP” Dorsiflexion/Inversion à AnteroLateral Plantarflexion/Inversion à Medial Posterior Fallat, Lawrence M. Christensen, Jeffrey C. Hord, Jacob A. Chapter 54: Osteochondroses of the foot and ankle. McGlamry’s Comprehensive Guide to Foot and Ankle Surgery,Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013. 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 Foot and Ankle International 2007 Osteochondral lesions of the talus: localization and morphologic data from 424 patients using a novel anatomical grid scheme. Raikin, SM; Elias, I; Zoga, AC; et al. » 428 lesions were identified on MRI good since most of the » Medial talar dome issues are lesions are not only acressible more common but arthroscopically are larger in surface area and in depth than lateral lesions Clinical Findings Chronic ankle pain History of chronic ankle sprain Recurrent » Ankle swelling » Stiffness » Weakness » Giving way Mechanical Symptoms » Catching » Clicking » Locking » 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 intreal signal Cart Probably healthy » Small area of BML indicated sclerosis of the subchondral bone with severe degeneration of the cartilage low intensity Move sclerosis Vers Dense Fractures of the Talar Dome » Classified by Berndt & Harty (1959) – Stage I lesion Small area of subchondral compression – Stage II lesion Partially detached osteochondral fragment – Stage III lesion Fully detached without displacement – Stage IV lesion Fully detached and displaced – Stage V lesion Radiolucent defect underlying the lesion Loomer R, Fisher C, Lloyd-Smith R, Sisler J, Cooney T. Osteochondral lesions of the talus. The american journal of sports medicine. 1993;21(1):13-19. Takao, M; Uchio, Y; Naito, K; Fukazawa, I; Ochi, M: Arthroscopic assessment for intraarticular disorders in residual ankle disability after sprain. Am J SportsMed.33(5):686 – 92,2005 » 28 % of Osteochondral lesions were missed on pre-op diagnosis » Chondral lesions difficult to detect Conservative Treatment » Duration of 3-6 months » Nonweightbearing » Cast Immbolization » Walking Boot » Physical Therapy » NSAIDs Tol, JL; Struijs, PA; Bossuyt, PM; Verhagen, RA; van Dijk, CN: Treatment strategies in osteochondral defects of the talar dome: a systematic review. Foot Ankle Int.21(2):119 – 26,2000 45% Success Rate with Conservative Treatment Primary Surgical Treatments Marrow-inducing reparative treatments » Abrasion arthroplasty » Microfracture » Drilling techniques 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 mugs » Fresh osteochondral allograft » Juvenile Hyaline Allograft goodfor 28days Iiii.me only is Surgical Management Primary Nongrafting Techniques Debridement Microfracture Retrograde Drilling/Subchondroplas ty restorative Grafting Techniques Autografts Allografts Characteristics of Lesions Type of lesion maynot SeeChandra Chondral but Chondral/Subchondral Subchondral will Cystic Wjj Stability of Lesion Stable Unstable BE Fondral Toscopical Medial (anterior, central, or posterior) Lateral (anterior, central, or posterior) Central (anterior, central, or posterior) Containment Contained Uncontained (Shoulder Lesion) involvesDorsal and Sutter Displacement of Lesion Displaced Non-displaced Location Size of LesionDetermines success Small (area 1.5cm2 or greatest diameter > 15mm) Surgical Factors 15 of Emilioruas fail » Size of the lesion » Foundation of the lesion contained » Location of the lesion » History of previous surgery 1 1 Am J Sports Med October 2009 37:1974-1980 Osteochondral Lesion of the Talus: Is There a Critical Defect Size for Poor Outcome? Woo Jin Choi, Kwan Kyu Park, Bom Soo Kim et al » 120 Ankles primary » Arthroscopic marrow stimulation » Evaluated for prognostic factors procedure Clinical Failure Patients’ having osteochondral transplantation surg site AOFAS Ankle-Hindfoot Scale score less than 80 Woo Jin Choi, Kwan Kyu Park, Bom Soo Kim et al Osteochondral Lesion of the Talus: Is There a Critical Defect Size for Poor Outcome? Am J Sports Med October 2009 37:1974-1980 » 120 Ankles » Arthroscopic marrow greater than 80 stimulation T.EE » Evaluated for prognostic factors 25% Failure Rate Y Why is 1.5cm squared important? had a 25 rate rail 10.5% Failure 80% Failure Primary Surgical Treatments Marrow-inducing reparative treatments » Abrasion arthroplasty » Microfracture » Drilling techniques Purpose of Microfracture make holes in Mostget down Past Subchoudual Plate iiciikrattiiaisiodsi.in iaiitsiiiag Blood has stem cell undiff mesenchymal stem a will result in fibro Cart Purpose » Clinical and radiographic outcomes of arthroscopic debridement and microfracture for osteochondral lesions of the talus Methods » 82 patients » Mean defect size was 1.7 ± 0.7 cm2 » Arthroscopic debridement and microfracture for osteochondral lesions » Minimum 5-year follow-up Knee Surg Sports Traumatol Arthrosc (2016) 24:1299–1303 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 Allograft advantages Decreased patient morbidity Shorter surgical time Tissue flexibility Resurface large lesions allograft postop Allograft disadvantages looks transparent Risk of disease but transmission rare possible Slower biologic remodeling Potential for immune response Cost and logistics sincegetsreabsorbe Sinie not the recipient good forincreasing Bloodflow to then incorp autograft w lookgoodPos op Allograft harvest Good relationship with tissue bank Allograft procurement within 24 hours of death Transplantation with 21 days Extensive donor screening (requires 2 weeks of time) Indications for allografts Medial or lateral talar defects – That are 10 mm or larger – Up to and involving the entire half of the dome Indications for allografts Salvage for failure of other surgeries – Such as debridement and microfracture – Failed mosaicplasty, OATS Contraindications Significant peripheral vascular disease Noncompliance Significant pre-morbid medical conditions Advanced neuropathy Active infections Preoperative considerations Evaluate lower extremity for deformities Angulation of tibial plafond in any direction in relationship to axis of tibia > 10 degrees may require corrective osteotomy Most correct the Devormities First Preoperative planning must correct forefoot rearfootbff.gg Lateral ankle ligament laxity ◆ Test for with anterior drawer and talar tilt ◆ Reconstruct or repair lateral ankle ligaments before or during grafting Surgical approaches Medial – medial malleolar osteotomy Lateral – lateral malleolar osteotomy Anterolateral – Tillaux osteotomy Posterior – posterior malleolar osteotomy must be careful Allograft preparation Create osteochondral plugs linear graft Custom fit graft Mosaic Post-Op Protocol Weight bear restriction depends on graft Pt will never size – Hemi-talus no weight for 3 months be running – Smaller lesions no weight for 6 weeks againyou Early motion once wound healed Just are Formal physical therapy at 6 weeks preventing a fusion Full activity allowed by 6 months