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Surgical)Correction)of)OCD)Utilizing)OATS)Procedure)Harvested)from)
Head)of)the)Talus
A"Case"Series"Study!
Mark Mendeszoon, DPM1 Nicole Wilson, DPM2 Kimberly Avramaut, DPM3 Renee Rodriguez, DPM3 Adam
MacEvoy, DPM4
The Northern Ohio Foot and Ankle Journal 2 (9): 2
Abstract
This case series will give a general over view of Osteochondritis Dissecans of the Talus (OCD). We will discuss how OCD develops, why there is a
problem with this condition, which necessitates medical intervention, and what treatment options can be used to alleviate pain for our patients. We
will briefly discuss surgical and non-surgical treatment options with a particular focus on the osteochondral autograft transfer system (OATS) with a
new technique for graft harvesting utilized in our case series. Traditionally, OATS procedures can have high donor site morbidity and require an
orthopedic colleague to harvest graft from the knee. With this new procedure, the graft site is taken from a non-articulating surface of the talus, which
in turn decreases donor site morbidity and does not necessitate the need for an additional surgeon present for the procedure.
Key Words: Osteochondral Defect, Talus, OATS
Accepted: September 2015
Published: October 2015
This is an Open Access article distributed under the terms of the Creative Commons Attribution License. It permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited. ©The Northern Ohio Foot and Ankle Foundation Journal. (www.nofafoundation.org)
2014. All rights reserved.
Review:
Over the years there have been many terms used
OCD, transchondral fracture, osteochondral fracture, talar
throughout medical literature to describe osteochondral
dome
lesions of the talar dome. Some of these terms include
osteochondritis dissecans was not applied to the ankle
fracture,
and
flake
fracture.
The
term
joint until 1959 when Berndt Hardy coined the term
Address Correspondence to: [email protected]
1
Private Practice (Precision Orthopedics, Chardon, Ohio); Attending, University Hospitals Richmond
Medical Center Podiatric Medicine and Surgery Residency (Richmond Heights, Ohio)
osteochondral fractures12. These lesions generally develop
secondary to trauma, but not all lesions are directly linked
to a traumatic event.
OCDs are thought to be
synonymous to a chronic non-union of an osteochondral
2
Fellow, Advanced Foot & Ankle Surgery Program, University Hospitals Richmond Medical Center
Podiatric Medicine and Surgery Residency (Richmond Heights, Ohio)
3
Resident, KSUCPM/University Hospitals Richmond Medical Center Podiatric Medicine and Surgery
Residency (Richmond Heights, Ohio)
4Private
Practice (Wolf River Family Foot Care, Bartlett, TN)
fracture, which may occur when the patient experiences a
severe Grade III ankle sprain.
During a traumatic
experience, the dome of the talus is offended causing bone
bruising or bleeding under the cartilage. When this occurs
it can cause the overlying cartilage to become soft and
fracture. These talar dome fractures can occur medially,
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Volume 2, No. 9, October 2015
laterally or centrally depending on the direction the ankle
was twisted during the inciting injury.
Table 2: Ferkel and Sgaglione classification system for CT of OCD
In general, most
medial lesions are seated more posterior and tend to be
deeper and cup shaped, while most lateral lesions are
anterior and traditionally shallower and wafer shaped.
According to the literature, medial lesions tend to occur
most often (62%), followed by lateral lesions (36%), with
When osteochondral lesions are discovered promptly after
central lesions being most rare (1%).15 It should also be
acute trauma has occurred, conservative therapy is
noted that lateral lesions tend to be displaced more often
generally the first line of care.
than their medial counterparts3,5,9,10,11,12.
consists of non-weightbearing to the affected side for 6
Conservative therapy
weeks. Another conservative option preferred by some
When treating a patient for an ankle sprain, the possibility
clinicians is the use of an ankle brace with an off-loading
of an osteochondral lesion should always be in the
component such as a patella strap or calf strap. With
differential diagnosis.
OCDs will behave similar to a
conservative therapy, the healing process of the lesions can
regular ankle sprain initially, presenting with the common
be assessed with serial radiographs. If there are no signs of
symptoms of pain and swelling along with painful weight
improvement or healing after 6 weeks of conservative
bearing5,11,12.
therapy, more invasive therapy may then need to be
If these symptoms continue after initial
conservative treatment, then a lesion of the talus should be
initiated.
considered. Occasionally, patients may feel a “catch” or
conservative therapy does not adversely affect surgery
“click” in the ankle with active range of motion which is a
performed after conservative therapy has failed13,14.
Of note, studies have shown that a trial of
telltale sign and can make the diagnosis easier.
The surgical treatment options for osteochondral defects
Diagnosis of these lesions begins with a good history and
of the talus is extremely varied and will depend on the size
physical examination.
and depth of the defect along with the extent of bone and
If the clinician suspects the
possibility of an OCD, advanced imaging should be
cartilage loss.
ordered. Plain film radiographs will subtly show defects
described in the literature with multiple methods of
within the talar dome.
Advanced imaging such as
performing each approach. First is the open approach
computed tomography (CT) and magnetic resonance
which includes extensive ankle arthrotomy for excision of
imaging (MRI) examination may be performed to make a
loose bodies, joint debridement, drilling, articular surface
more definitive diagnosis of OCD. As such, there are
grooving, and medial and lateral malleolar osteotomies.
multiple classification systems for plain film, CT, and MRI
The open technique results in a great deal of trauma to the
imaging of OCDs2,12 (Tables 1 and 2).
local tissues which may be associated with conditions such
Table 1: Berndt-Hardy and Anderson classification system for plain film and
MRI, respectively, of OCD
Two different approaches have been
as non-unions, increased need for rehabilitation, stiffness,
adhesions, and continued pain. Due to advancements in
surgical methods and technique, particularly arthroscopic
technique, there is no longer a need to perform an open
method. Many less invasive methods and techniques have
been discussed in the literature. Some are meant to restore
the natural cartilage of the talar dome. Others attempt to
form another type of cartilage (fibrocartilage) through
The Northern Ohio Foot & Ankle Foundation Journal, 2015!
Mendeszoon, Wilson, Avramaut, Rodriguez, MacEvoy !
Volume 2, No. 9, October 2015
!
marrow reparative techniques. Some techniques attempt
mosaicplasty, osteochondral autograft transfer system
to debride the defective fragment while others simply
(OATS)1,4,7, and autologous chondrocyte implantation
repair the fragment11,12.
(ACI).
Debridement techniques are meant to simply clean and
debride the joint. Utilizing arthroscopy, the surgeon will
enter the ankle through portals in the skin. Once inside
the ankle joint, the surgeon will distract the ankle either
with a mechanical device or with a sterile saline pump.
Micro-instrumentation is then used to find the loose body
or failed cartilage and remove it from the ankle joint.
Concomitantly, the ankle joint is flushed which on itself
has been proven to relieve pain11,12.
A disadvantage to the first two procedures
mentioned above is the need to harvest graft from a donor
site thereby increasing the risk of donor site morbidity.
Once the grafts are harvested, they are implanted into the
primary surgical (OCD) site.
The ACI is a two-step
procedure that is commonly used in the knee, however has
been used in small joints such as the ankle. First, some
cartilaginous cells are removed through arthroscopy and
sent to a laboratory to grow and mature for 4-6 weeks.
During the second step, an open arthrotomy is used to
implant the laboratory grown cartilaginous cells into the
The reparative techniques use the idea that drilling of the
deficit and cover them with a biological dressing which will
cartilage and lesion will stimulate bleeding to that area.
keep the cells in place. The choice of biological dressing is
This bleeding subsequently forms clots that help create
based on surgeon’s preference. The two commonly used
fibrocartilage.
ones are periosteum or fibrin clot to cover the cells while
This
type
of
cartilage
lacks
the
characteristics of hyaline cartilage, however it does help the
joint by protecting it from excessive loading forces. This
type of technique has been proven to be a successful
they mature1,3,4,5,7,11,12,13.
Surgical Technique
treatment when it comes to small defects in the talar dome
The patient is placed on the operating room table in the
cartilage, but is not recommended in defects larger than
supine position and a thigh tourniquet is placed.
7mm or 1.5 cm5,8,9,10,11,12.
extremity is then prepped and draped to the knee in the
Primary repair of the fracture has also been a successful
treatment.
Some fixation methods available include
screws, pins, or nails. These can either be permanent or
can be absorbable in nature. It is important to remember
that with primary fixation of these fractures, acute
fractures respond much better to primary repair than
chronic injuries8,10,12.
Lastly, there are different techniques which attempt to
restore the articular surface of the joint to a “pre-injury”
condition.
When utilizing these techniques the joint
surface is resurfaced with hyaline cartilage. The hyaline
cartilage is much more suitable for the joint environment
and will be more durable than other forms of cartilage.
Much larger defects can be repaired with this technique
than others.
Different forms of this procedure are
The
usual sterile manner. Next, portals for an ankle scope are
created medial to the anterior tibialis tendon and lateral to
the extensor digitorum longus. At this time, visualization
is obtained of the osteochondral defect as well as any
inflammation of the ankle joint and surrounding
structures.
The inflammatory tissues are removed
arthroscopically as best as possible.
Attention is then directed toward the medial malleolus and
tarsal tunnel region where a large curvilinear incision is
made. Dissection is carried down to the medial malleolus
using full thickness skin flaps while taking care to protect
neurovascular structures.
Before creating the medial
malleolar osteotomy, two 4.0 cannulated screws are
inserted fully into the medial malleolus (Image 1A). They
are then backed out approximately 80% of the way. This
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Volume 2, No. 9, October 2015
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is done in order to help achieve proper alignment of the
The plug of cartilage is then transferred into the talar dome
osteotomy site after repair of the lesion. The osteotomy is
lesion utilizing the MiTek® Transfer System (Image 3).
then created at a 45-degree angle using a sagittal saw taking
Once inserted fully and properly into the lesion, the new
care not to advance into the talar dome (Image 1B). This
plug is noted to sit flush with the rest of the talar dome.
can be ascertained by using an osteotome to cut through
All instrumentation is removed and the ankle joint is
the lateral cortex of the medial malleolus. The ankle joint
placed in the full range of motion to ensure there is no
and lesion are then visualized after the medial malleolus is
step off or deficit noted. The medial malleolar osteotomy
freed of soft tissue attachments and reflected.
is then fixated using the previously placed 4.0 screws. The
surgical sites are then copiously irrigated and all incisions
closed appropriately. Of important surgical note, one of
the subjects did not receive a medial malleolar osteotomy
as the osteochondral lesion was easily visualized with
distraction of the ankle joint.
Image 1: A) Insertion of two 4.0 cannulated screws prior to osteotomy cut. B) Screws
are backed out then the osteotomy cut is made at a 45-degree angle.!
Once the osteochondral lesion is visualized, the flapping
cartilaginous defect is freed from the talar dome. The
lesion’s diameter and depth are then measured to assure
appropriate sizing of the instrumentation and graft. The
MiTek® Core System is used for harvesting of the plug to
fill the defect. In order to harvest this plug, dissection is
continued onto the plantar medial aspect of the talus. The
graft is then harvested from the non-articulating surface of
Image 3: Insertion of the graft into the talar dome lesion.
Case Report
the talus (Image 2). The void left in the talus is filled with
Four patients’ cases were reviewed in this study. All four
demineralized bone matrix (DBM) bone putty.
subjects initially presented with complaints of ankle pain
with ambulation and a sensation of the ankle “giving out.”
Two of the patients had a history of a traumatic event.
One was an acute traumatic event occurring 3 months
prior to initial visit. The other was an incidence occurring
2 years prior with a surgical ankle arthroscopy procedure
being performed prior to initial visit.
On physical exam of the subjects, all were noted to have
an antalgic gait. There was pain on palpation of the ankle
joint and along the soft tissue structures surrounding the
Image 2: Harvesting of the graft from the non-articulating surface of the
ankle joint including the posterior tibial tendon, lateral
talus using the Mitek core system.
collateral ligaments, and/or Achilles tendon insertion.
The Northern Ohio Foot & Ankle Foundation Journal, 2015!
Mendeszoon, Wilson, Avramaut, Rodriguez, MacEvoy !
Volume 2, No. 9, October 2015
!
Pain with passive dorsiflexion and plantarflexion of the
patient opted out of formal physical therapy and
ankle joint was present (Table 3).
performed home therapy due to financial issues. By 8-10
months, all patients were pain free. On physical exam, the
Table 3: Physical exam findings per patient prior to procedure
subjects’ ankle joint ranges of motion were all within
normal limits and without pain or crepitus.
The
surrounding soft tissue structures of the ankle joint were
found to be non-painful. Serial radiographs of the patients
were obtained during follow up appointments.
patients
who
had
a
medial
malleolar
The
osteotomy
Subjects also underwent imaging procedures prior to
demonstrated good healing of the osteotomy site with
surgical procedure. Upon radiographic examination, no
stable hardware. There was no morbidity noted at the
acute fractures were seen.
All subjects had an MRI
donor site and appropriate incorporation of the graft into
performed which demonstrated a talar dome lesion with
the talar defect was noted. One patient complained of
talar microfractures.
Also noted on MRI studies was
some moderate thigh pain and cramping 10 months post
injury or inflammation to the lateral collateral ligaments,
op that was diagnosed as myositis and successfully treated
posterior tibial tendon, and/or ankle joint capsule. After
with flexeril.
review of physical exam findings and MRI readings, all
four patients were deemed appropriate candidates for an
OATS procedure.
The utilization of the OATS procedure is a great way to
Post-operatively, all patients were placed in a posterior
splint in the operating room.
At the first follow up
appointment approximately 5-7 days post-op, the patients
were then placed non-weight bearing in a below knee cast
for anywhere from 3-6 weeks.
Discussion
Patients were then
transitioned from a below knee cast and placed in a
removable walking boot. Protected weight bearing was
allowed beginning at approximately 5-6 weeks. At this
time, formal physical therapy was initiated.
At
approximately 3 months post-op patients were fully
transitioned into normal shoe gear with either over the
counter or custom orthotics.
Outcome
The four patients were followed for approximately 1-year
post operatively. During the first 3 months post op the
repair an osteochondral defect of the talus.
With the
technique discussed in this paper, harvesting of the graft
for correction from the patient’s own body helps to ensure
the success of the procedure.
Even though one can
harvest a plug of bone and cartilage from a cadaver, we
believe that success is enhanced when utilizing an
autograft. Grafts can be obtained from other areas of the
body, including the knee. However, in the authors’
experience harvesting the graft from the non-articular
surface of the talus is reasoned to have a decreased donor
site morbidity based on patient outcome. Another benefit
of utilizing graft from the talus is that another surgical
incision does not need to be made to harvest the graft.
The initial incision needs to only be minimally lengthened
to be able to access the non-articulating surface of the
talus.
only complaints were of some minimal swelling, pain or
When conservative therapy for osteochondral defects fail,
stiffness. These complaints resolved within 3-4 months
surgical intervention may then be utilized for correction.
and with the help of therapy. It should be noted that one
There are many different techniques for surgical correction
The Northern Ohio Foot & Ankle Foundation Journal, 2015!
Volume 2, No. 9, October 2015
of a talar dome lesion, but the procedure studied in this
paper has shown positive post-operative results with
minimal complications.
The subjects studied were
followed for a one-year period and all reported good
outcomes with pain free range of motion of the ankle joint
and pain free ambulation. The patients were able to return
to activities previously performed prior to the initial injury
and surgery. With proper surgical technique and patient
compliance, the OATS procedure is very useful and
demonstrates encouraging results in successfully treating
osteochondritis dissecans.
Conclusion
The OATS procedure is a very useful surgical intervention
to treat patients with osteochondral lesions of the talus.
Initial surgical techniques include harvesting graft from the
knee. This technique has a fairly high morbidity of the
donor site and also requires an orthopedic surgeon for
harvesting of the graft. The technique outlined in this case
series helps make the OATS procedure more useful for the
podiatric surgeon. Not only does this technique allow for
decreased donor site morbidity, it eliminates the need to
have an orthopedic colleague assist with the case for
retrieval of the graft from the knee. It is the opinion of
the authors that not only do these improvements of the
procedure decrease time and cost by not needing to
employ the efforts of a second surgeon, but they will also
result in a more satisfactory patient outcome.
_____________________________________________
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