|Ahead of print publication
Current treatment concepts for osteochondral lesions of the talus
Chen-Chie Wang1, Kai-Chiang Yang2, Ing-Ho Chen3
1 Department of Orthopedic Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei; Department of Orthopedics, School of Medicine, Tzu Chi University, Hualien, Taiwan
2 School of Dental Technology, College of Oral Medicine, Taipei Medical University, Taipei, Taiwan
3 Department of Orthopedics, School of Medicine, Tzu Chi University; Department of Orthopedics, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
|Date of Submission||07-May-2020|
|Date of Acceptance||13-Jun-2020|
|Date of Web Publication||05-Oct-2020|
Department of Orthopedics, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, 707, Section 3, Chung-Yang Road, Hualien
Source of Support: None, Conflict of Interest: None
Osteochondral lesions of the talus (OLT) are a well-known cause of ankle joint pain and can sometimes lead to instability. These lesions are not only confined to articular hyaline cartilage, they can also affect the subchondral bone at the weight-bearing aspect of the talar dome. Nonoperative treatment is the preferred option for small lesions, however surgical intervention is recommended for large lesions or those for which conservative treatment has failed. Microfracture, abrasion arthroplasty and multiple drilling are all classified as bone marrow stimulation procedures; they are used to try to recruit precursor cells for cartilage regeneration and are especially suitable for small OLT lesions. For large lesions, osteochondral autografting and allografting are better options to reconstruct the articular defect, as they have better contours and mechanical strength. When there is limited subchondral bone involvement in large lesions, cell-based therapies such as autogenous chondrocyte implantation, potentially combined with a biomaterial matrix, are a promising option and acceptable functional outcomes have been reported. To provide evidence-based recommendations for clinicians, this article evaluates the currently available treatment strategies for OLT and their evolution over the past few decades.
Keywords: Microfracture, Osteochondral lesion, Talus
| Introduction|| |
Osteochondral lesion of the talus (OLT) is an injury involving the articular cartilage and subchondral bone. Kappis first described OLT in 1922 and named it osteochondritis dissecans . Traumatic injuries such as an ankle sprain were frequently combined with OLT and patients often have chronic ankle instability with repetitive sprains. However, 24% of patients cannot recall any cause of the injury . Unlike ankle ligament injuries, the pain is deeper, with intermittent ankle swelling and a limited range of motion in the ankle despite a period of conservative treatment. Previously, the terms of osteochondritis dissecans or osteochondral defect have been used to describe this clinical observation. Nowadays, however, OLT is used since the lesion is not only due to traumatic events, but also cystic lesions or other pathological factors. In daily practice, six imaging characteristics are used to describe OLT lesions [Figure 1]. (1) There are several different types of lesion, including chondral, osteochondral, subchondral, and cystic. (2) Lesions can then subsequently be subclassified as nondisplaced or displaced and (3) stable or unstable using De Smet's criteria . (4) Location is also a very important category which can be subdivided into anterior, central and posterior in the sagittal plane, and combined with medial, central and lateral in the coronal plane, formulated as a tic-tac-toe scheme . (5) Whether the lesion is contained or uncontained is a useful descriptive feature, especially during surgery. (6) Finally, lesion size is crucial for the treatment choice, as if the lesion diameter is larger than 15 mm, it should be considered a large lesion and the grafting technique can have favorable outcomes. Although the descriptive characteristics of OLT lesions can help with choosing the treatment strategy, they cannot forecast the therapeutic result. Most patients who suffer from ankle pain correlated to OLTs can be treated nonoperatively. Surgical intervention is often reserved for those patients for which conservative treatment fails. At present, there are several surgical procedures available for managing symptomatic OLTs. For smaller lesions, marrow stimulation is a possible treatment modality, including multiple drilling, microfracture, and abrasion arthroplasty. However, a pitfall of this method is that the newly regenerative tissue is fibrocartilage, which possesses less mechanical strength than hyaline cartilage and is easily degraded and damaged over a short period of time ,. When considering the treatment of large OLT lesions, osteochondral autografts or allografts are favorable choices for restoration of the whole articular surface of the talus. Mosaicplasty or Mega-OAT is used in accordance with the lesion size. Autologous chondrocyte implantation (ACI) has been described in recent decades and has the potential to regenerate the hyaline cartilage. However, this results in fibrocartilage and hyaline cartilage tissues being interspersed, and there is a need for two surgical procedures, and there is less mechanical strength, which are all concerning disadvantages of this method . This review paper evaluates the current treatment strategies and recent advances for the treatment of OLT.
|Figure 1: MRI examination revealed an Anderson IIB lesion over left medial talar dome (arrow). (a) AP view of the lesion. (b) lateral view of the lesion|
Click here to view
| Classification|| |
Previously, the most widely used classification system for OLT lesions was introduced by Berndt and Harty [Table 1] . The assessment of the lesion is based on its appearance on plain radiographs and is divided into four stages. Anderson established a magnetic resonance imaging (MRI)-based classification system which was modified from Berndt and Harty's system and this has become the most popular classification system in recent times [Table 2] . Anderson added stage IIa representing a cystic lesion. Hepple also used MRI to evaluate the staging and assigned cyst lesions as stage V . Arthroscopic classification was believed to be the most accurate method for evaluating OLT since direct visualization was possible with a probe during surgery. Pritsch was the first to describe an arthroscopic classification system based on the condition of the chondral injury . Ferkel further modified this classification system to include cystic lesions and displaced osteochondral lesions [Table 3] . Despite the possible existence of good inter- and intra-observer reliability in all of these classification systems, MRI classification is still the best image modality for helping in clinical decision-making. The correlation between the description of a lesion from arthroscopic findings and image reporting is directly proportional. MRI examination can coincide with the arthroscopic grading up to 81%–83% ,.
| Conservative Treatment|| |
For nondisplaced or minimally displaced OLTs, most studies recommend treatment with conservative management ,,,,. Displaced OLTs with acute pain and limited ankle range of motion should be considered for treatment with surgical intervention. Loose body removal and fragment fixation internally are both reasonable options. Conservative treatment includes casting immobilization, a walking boot used with non-weightbearing protection, physical therapy, bone stimulation, and even a bisphosphonate prescription. Several retrospective studies have shown good results with conservative treatment for non-displaced OLTs ,,. One meta-analysis reported a 45% success rate using conservative treatment . Nonetheless, patients who receive nonoperative management seldom recover to their previous level of sports activity. Furthermore, early ankle osteoarthritic changes were reported in patients who were treated nonoperatively ,. The current general consensus is that surgical intervention should be performed when conservative treatment fails and there is persistent symptomatic OLT.
Bone marrow stimulation method
To date, many surgical options for OLT have been described, including multiple drilling, microfracture, abrasion arthroplasty, autogenous osteochondral grafting, allograft talus transplantation and ACI . Multiple drilling, microfracture, and abrasion arthroplasty are all bone marrow stimulation methods and have an optimal functional outcome. The purpose of bone marrow stimulation methods is to penetrate the subchondral bone, which leads to the release of bone marrow precursor cells and growth factors. The healthy bone marrow precursor cells and related cytokines may contribute to articular cartilage regeneration for the OLT lesions. Initially, these techniques were developed to treat OLT lesions for all grades and sizes. However, at present, bone marrow stimulation is generally only performed for lesions smaller than 150 mm 2 or 15 mm in diameter, and has favorable outcomes for early to mid-term follow-up ,. Arthroscopic debridement is performed before the marrow is stimulated and all the unstable osteochondral fragments should be removed until a healthy cartilage rim is observed. In cases where the articular cartilage is intact and only the subchondral area was involved, retrograde drilling may be indicated . Thermal injury is a danger during multiple drilling and abrasion arthroplasty as the nearby cartilage and subchondral bone may be damaged and its healing potential will thus be decreased. Microfracture should be a better technique as there is no risk of thermal damage during subchondral bone picking [Figure 2]. However, like other bone marrow stimulating techniques, the newly regenerated cartilage is fibrocartilage or fibrous tissue. The major component of fibrocartilage is Type I collagen . Fibrocartilage has been demonstrated to have reduced resilience, lower stiffness, and early wear properties compared with hyaline cartilage . That being said, numerous retrospective studies have reported optimal results for bone marrow stimulation techniques for treating OLTs ,,,,,. The size of the lesions treated using this technique were very varied and ranged from 0.25 to 4 cm 2, while the treatment results ranged from 39% to 96%. A study by Chuckpaiwong et al. reported on 105 patients who received arthroscopic microfracture treatment. They defined the operational treatment as successful if the functional results fitted 3 of the 4 following criteria: (1) >50% improvement in the visual analog scale (VAS) score during exercise, (2) >50% improvement in the VAS score for pain in daily activity, (3) an American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score improvement of >30 points, and (4) a Roles and Maudsley score of 1 or 2. They reported the a cut off size of 15 mm in diameter for successful arthroscopic microfracture treatment, as 73 lesions out of the 105 ankles treated had a successful outcome and all of the 32 unsuccessful lesions had a diameter larger than 15 mm except one . Choi designed a study based on the lesion size in a two-dimensional plane. A total of 120 OLT lesions underwent microfracture treatment and they found that lesions smaller than 150 mm 2 were more likely to achieve a favorable outcome . Based on the results of these two studies, most surgeons only perform bone marrow stimulation techniques for lesions <150 mm 2 or 15 mm in diameter. However, a meta-analysis study recently reported that a more-suitable lesion cut off size for the bone marrow stimulation technique should be <10.2 mm in diameter or 107.4 mm 2 . Furthermore, in a recent study, it was demonstrated that South Eastern Chinese individuals have a smaller talus than Caucasian individuals . The average central trochlea tali width is only 20.3 mm in Asian people. As a consequence, a lesion 15 mm in diameter or 150 mm 2 in area would extend over half the width of the talar trochlea, which is a relatively large lesion and may lead to poor surgical outcomes . Based on anatomic proportionality, 100 mm 2 or 10 mm in diameter should be considered as the lesion cut-off size for bone marrow stimulation in Asian populations.
|Figure 2: The osteochondral lesion was debrided and treated with microfracture technique. Microfracture was performed by chondral pick|
Click here to view
A systematic review reported that patients with OLT lesions <150 mm 2 had good to excellent functional outcomes at short-and mid-term follow-up after microfracture treatment . However, at long-term follow-up, the results were less predictable. Ferkel reported that 35% of patients (17/50) had deteriorated results at 5 years' follow-up . Nevertheless, one 8–12 years' long-term follow-up study revealed that functional outcomes were maintained over time  and the AOFAS hindfoot score still had an average 88 points (range: 64–100). However, radiographic evaluation revealed that 33% of patients had progressive osteoarthritis. The discrepancy between later osteoarthritic changes and surgical outcomes is discernible. Lee also reported a 2nd look arthroscopic finding at postoperative 12 months after microfracture treatment . According to the International Cartilage Repair Society (ICRS) score, 60% of OLT lesions healed, while only 30% of the lesions were fully integrated within the circumference of the healthy cartilage. In spite of this, 90% of patients reported good or excellent AOFAS hindfoot scores of over 80 points. Consequently, in the bone marrow stimulation method, newly regenerated fibrocartilage with less mechanical strength is still a crucial factor and is correlated with long-term outcomes. Moreover, this kind of treatment is limited in smaller lesions. Persistent pain and progressive cartilage deterioration are the most common complication.
Osteochondral autografting has been developed to treat large OLT lesions. Restoration of the articular defect with hyaline cartilage and good bony ingrowth into the surrounding recipient site are the potential advantages of this treatment modality. The autografting procedure is also used as a salvage surgery for failed bone marrow stimulation therapy. Donor sites are often harvested from the peripheral femoral condyle of the knee. Whether a cylindrical strut graft or multiple plugs (mosaicplasty) are used is dependent on the OLT lesion size. A periarticular osteotomy, such as a medial malleolar osteotomy, transfibular osteotomy, or anterolateral tibial plafond osteotomy are often carried out to help ensure there is adequate visualization of the lesion and graft fixation ,,. The incidence of delayed union or nonunion is about 0%–2% ,,,. A 6–8-week period of non-weight bearing and cast immobilization is recommended, which means it has a longer recovery time than the bone marrow stimulation method.
Several retrospective studies have reported favorable results for osteochondral autografting. Kennedy reported significant short-term improvements in mean foot and ankle outcome scores and SF-12 scores in 72 patients. A total of 42 patients recovered to the same level of sports activity as they were prior to injury . Scranton showed that cystic lesions in 45 out of 50 patients treated with autologous osteochondral grafts had good or excellent results at a mean 36 months follow-up . Hangody published a 17-year prospective study and revealed 92% good to excellent results following treatment with talar mosaicplasty . Another recent study performed a second look arthroscopy and compared it with MRI evaluation . Arthroscopic findings revealed that 9 ankles (36%) were not completely healed according to the ICRS grading system. The postoperative MOCART score was 67.8 (range, 30–95), with good functional outcomes. Interestingly, 6 patients (24%) had a mismatch finding between their second-look arthroscopic findings and their MRIs.
Donor site morbidity remains a concern during autograft harvesting. Reddy et al. reported that 4 out of 11 patients had significant knee discomfort and donor site morbidity . About 37% of patients had poor postoperative outcomes and the most commonly mentioned problem was knee instability during daily activities. LaPrade and Botker also reported that two cases suffered severe donor site morbidity with hypertrophic fibrocartilage at the graft harvest sites, which led to knee pain as well as locking . In contrast, Hangody and Fuels reported donor site morbidity rates as low as 3% in a long-term follow-up study which included 831 patients treated with mosaicplasty . Kennedy recently unveiled similar low donor site morbidity after treating 72 patients . Three patients (4%) had painful donor site discomfort in the knee joint but 2 were pain free after intra-articular steroid injections. One patient needed an arthroscopic debridement for the scar tissue incarcerated in the knee joint. This study advised to fill the donor site with synthetic bone as a void filler to help with new tissue regeneration and this may have contributed to the low percentage of donor site morbidity. The limitation of osteochondral autografting is the not suitable for mega-sized talar lesion and donor site morbidity is the major concern.
Osteochondral allograft transplantation fills the defect with a size matched graft and is performed for deep and large OLT lesions [Figure 3], [Figure 4], [Figure 5]. A major advantage is that there is no donor site morbidity. The use of a single graft also reduces potential fibrocartilage ingrowth in comparison with multiple plug mosaicplasty ,. Although osteochondral autografting provides excellent outcomes, and provides numerous viable chondrocytes, allografting is more suitable for larger OLT lesions, shoulder non-contained defects and failed multiple mosaicplasties.
|Figure 3: CT examination revealed a large cyst lesion over medial talar dome (arrow). (a) AP view and (b) lateral view depicted a Raikin zone 4 lesion|
Click here to view
|Figure 4: Arthroscopic examination revealed (a) a large medial talar dome cystic lesion with diameter >1 cm (arrow) (b) a matched size allograft was fitted into the osteochondral defect (arrow) (c) talus allograft|
Click here to view
|Figure 5: Postoperative 1 year CT revealed adequate bone and cartilage integration (arrow) in (a) AP view and (b) lateral view|
Click here to view
Gross first proposed this talar osteochondral allografting technique in 2001 for 9 patients . The 12 years' follow-up revealed that the average allograft survival time was 9 years. Gortz treated 12 patients with lesions larger than 170 cm 2 by filling in the defect with fresh osteochondral allografting . The allograft survival rate was 83%. The author reported that 60% of the patients had improved function, 80% had reduced pain, and 90% were satisfied with their functional recovery. Raikin reported on 15 ankles with large-volume cystic lesions that >300 mm 3 and had a mean follow-up time of 54 months. The AOFAS scores improved an average of 45 points and 11 patients had good or excellent functional results . El-Rashidy recently published a large study on the treatment of OLT using fresh osteochondral allograft transplantation and this has shown favorable short-term outcomes .
Although one of the negative factors associated with osteochondral allografting is the potential for infection transmission, several improvements have been proposed in a previous literature review ,,. First, in comparison with osteochondral autograft, lesion size is not an important issue even if the area is >300 mm 2 . Precise size matching for the configuration of the lesion is advantageous . Furthermore, only one strut of osteochondral allograft is necessary for filling the OLT lesion, which mitigates potential fibrocartilage ingrowth and leads to higher mechanical properties . The biggest advantage of osteochondral allografts is that the interface between multiple osteochondral autograft plugs in large lesions is eliminated. This is important because poor cartilage integration between plugs can contribute to reduced durability of the osteochondral graft . Allograft availability and lower healing rate than autograft are the limitation and may be complicated with graft subsidence and disease transmission.
ACI was proposed as a treatment option in the past two decades and favorable clinical outcomes have been reported. Brittberg first developed ACI for the treatment of full-thickness chondral defects in the knee joint . ACI is a 2-stage procedure; the first step is to harvest cartilage from a non-weightbearing site on the lateral or medial femoral condyle. After the cartilage is minced into small pieces and digested by collagenase, the cell suspension is centrifuged and the cell pellet is cropped. The cell pellet is then resuspended in culture medium and cell expansion occurs for 2 weeks. Adequate amounts of chondrocytes are subsequently implanted into the chondral defect and sealed with a periosteum. Fourteen of the 16 patients with femoral condylar chondral lesions had good-to-excellent results at 2 years' follow-up . Several studies have also shown positive outcomes following its clinical usage in talar lesions ,,. Giannini reported favorable results for 8/8 patients (100%) at a mean follow-up of 26 months . The preoperative AOFAS score was 32 points and this improved to an average of 91 points postoperatively. The 2nd look arthroscopy revealed good cartilage-like tissue regeneration in the recipient site and the histological staining demonstrated adequate type II collagen expression and abundant proteoglycan secretion in the extracellular matrix. Battaglia et al. also reported a similar result as evaluated by AOFAS scores at 5 ± 1 years' follow-up . T2 mapping MRIs also showed values comparable with normal hyaline cartilage in all cases after ACI treatment.
However, newly regenerated hyaline cartilage and fibrocartilage interposition, the poor rebuilding of the subchondral defect, requirement of 2-stage procedures, were the mentioned pitfalls. Since the newly regenerated fibrocartilage has poor mechanical strength and resilience, joint degeneration will progress with time. Another issue of concern is the graft hypertrophy when periosteum is used as Brittberg originally proposed. This hypertrophy may be due to the cambium layer of periosteum possessed progenitor cells, which stimulate cell overgrowth. To overcome this sequalae, a collagen I/III membrane has been used for the coverage flap. Gooding published a study comparing the effectiveness of these two types of covering membrane . The periosteum group had 20% graft hypertrophy compared with 2.9% in the collagen membrane group. Thus, collagen membranes have become the favorable covering material for sealing chondrocytes in the cartilage defect.
Matrix-associated chondrocyte implantation (MACI) is a new treatment method based on tissue engineering technology. Chondrocyte/matrix scaffold constructs have been developed for cartilage regeneration in recent decades ,. Currently available matrices are often composed of collagen or hyaluronic acid-based biodegradable materials. 3D scaffolds provide cells a biomimetic environment similar to the human body. Advantages of this method include maintenance of the cell phenotype in the matrices, even distribution of cells in the scaffold and matching size implants. Recent studies have shown promising results when using MACI for the treatment of OLTs ,,,. Magnan reported a positive result when 30 OLTs were treated with chondrocyte/collagen matrices using the MACI technique. At an average nearly 4 years' follow-up time, the mean preoperative AOFAS score was 36.9 which improved to an average of 83.9 postoperatively. Good to excellent results were observed in 28 of 30 patients . Giannini treated 46 patients with the MACI method using a hyaluronic acid matrix and the mean AOFAS score improved from 57.2 preoperative to 86.8 at 12-month follow-up. The 36-month follow-up showed a persistent result with an average score of 89.5 points. Thirty-eight out of 46 patients reported excellent or good results and only 5% reported poor results. Richter and Zech reported using bone marrow stem cells/collagen I/III matrix to treat OLT in 124 OLTs . The VAS FA score was improved from 45.2 preoperative to 84.4 postoperative with an optimal outcome. Recently, an expandable biomimetic scaffold was reported and revealed optimal hyaline cartilage regeneration both in in vitro and in vivo animal model ,. The character of higher biocompatibility of the organized scaffold maybe a better choice for tissue engineered cartilage in the future. However, ACI and MACI technique still have some drawback. Regenerated fibrous tissue, fibrocartilage, and hyaline cartilage interposition with less mechanical strength may procure the limited results. High economic cost and donor site morbidity remain potential barriers.
| Conclusion|| |
The treatment for osteochondral lesions of talus has evolved over the past few decades and a lot of new treatment options have been described. Nonoperative treatment is a good primary treatment option. Although positive results such as pain relief and functional status improvement are reported, poor healing potential of the articular hyaline cartilage is the inherent limitation. Surgical intervention, including bone marrow stimulation techniques, osteochondral autografting or allografting, and cell-based therapies all play important roles as treatment strategies in accordance with the lesion size and defect depth. However, all current surgical methods have limitations. With the increase in bionic implants found in translational medicine, tissue engineered cartilage regeneration technology such as MACI or other new biotechnology for the treatment of osteochondral lesions of talus will most likely play a promising role in its future treatment.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Kappis M. Weitere Beiträge zur traumatisch-mechanischen Entstehung der spontanen Knorpelablösungen (sogen. Osteochondritis dissecan
s). Deutsche Zeitschrift Chirurgie 1922;171:13-29.
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 2000;21:119-26.
Assenmacher JA, Kelikian AS, Gottlob C, Kodros S. Arthroscopically assisted autologous osteochondral transplantation for osteochondral lesions of the talar dome: An MRI and clinical follow-up study. Foot Ankle Int 2001;22:544-51.
Elias I, Zoga AC, Morrison WB, Besser MP, Schweitzer ME, Raikin SM. Osteochondral lesions of the talus: Localization and morphologic data from 424 patients using a novel anatomical grid scheme. Foot Ankle Int 2007;28:154-61.
Alford JW, Cole BJ. Cartilage restoration, part 1: Basic science, historical perspective, patient evaluation, and treatment options. Am J Sports Med 2005;33:295-306.
Furukawa T, Eyre DR, Koide S, Glimcher MJ. Biochemical studies on repair cartilage resurfacing experimental defects in the rabbit knee. J Bone Joint Surg Am 1980;62:79-89.
Giannini S, Buda R, Ruffilli A, Cavallo M, Pagliazzi G, Bulzamini MC, et al. Arthroscopic autologous chondrocyte implantation in the ankle joint. Knee Surg Sports Traumatol Arthrosc 2014;22:1311-9.
Berndt AL, Harty M. Transchondral fractures (osteochondritis dissecans) of the talus. J Bone Joint Surg Am 1959;41-A: 988-1020.
Anderson IF, Crichton KJ, Grattan-Smith T, Cooper RA, Brazier D. Osteochondral fractures of the dome of the talus. J Bone Joint Surg Am 1989;71:1143-52.
Hepple S, Winson IG, Glew D. Osteochondral lesions of the talus: A revised classification. Foot Ankle Int 1999;20:789-93.
Pritsch M, Horoshovski H, Farine I. Arthroscopic treatment of osteochondral lesions of the talus. J Bone Joint Surg Am 1986;68:862-5.
Ferkel RD, Zanotti RM, Komenda GA, Sgaglione NA, Cheng MS, Applegate GR, et al. Arthroscopic treatment of chronic osteochondral lesions of the talus: Long-term results. Am J Sports Med 2008;36:1750-62.
Lee KB, Bai LB, Park JG, Yoon TR. A comparison of arthroscopic and MRI findings in staging of osteochondral lesions of the talus. Knee Surg Sports Traumatol Arthrosc 2008;16:1047-51.
Mintz DN, Tashjian GS, Connell DA, Deland JT, O'Malley M, Potter HG. Osteochondral lesions of the talus: A new magnetic resonance grading system with arthroscopic correlation. Arthroscopy 2003;19:353-9.
Canale ST, Belding RH. Osteochondral lesions of the talus. J Bone Joint Surg Am 1980;62:97-102.
Bauer M, Jonsson K, Lindén B. Osteochondritis dissecans of the ankle. A 20-year follow-up study. J Bone Joint Surg Br 1987;69:93-6.
Pettine KA, Morrey BF. Osteochondral fractures of the talus. A long-term follow-up. J Bone Joint Surg Br 1987;69:89-92.
Loomer R, Fisher C, Lloyd-Smith R, Sisler J, Cooney T. Osteochondral lesions of the talus. Am J Sports Med 1993;21:13-9.
McCullough CJ, Venugopal V. Osteochondritis dissecans of the talus: The natural history. Clin Orthop Relat Res 1979;144:264-8.
Shearer C, Loomer R, Clement D. Nonoperatively managed stage 5 osteochondral talar lesions. Foot Ankle Int 2002;23:651-4.
Murawski CD, Kennedy JG. Operative treatment of osteochondral lesions of the talus. J Bone Joint Surg Am 2013;95:1045-54.
Chuckpaiwong B, Berkson EM, Theodore GH. Microfracture for osteochondral lesions of the ankle: Outcome analysis and outcome predictors of 105 cases. Arthroscopy 2008;24:106-12.
Bae DK, Yoon KH, Song SJ. Cartilage healing after microfracture in osteoarthritic knees. Arthroscopy 2006;22:367-74.
Kono M, Takao M, Naito K, Uchio Y, Ochi M. Retrograde drilling for osteochondral lesions of the talar dome. Am J Sports Med 2006;34:1450-6.
Nehrer S, Spector M, Minas T. Histologic analysis of tissue after failed cartilage repair procedures. Clin Orthop Relat Res 1999;365:149-62.
Schuman L, Struijs PA, van Dijk CN. Arthroscopic treatment for osteochondral defects of the talus. Results at follow-up at 2 to 11 years. J Bone Joint Surg Br 2002;84:364-8.
Saxena A, Eakin C. Articular talar injuries in athletes: Results of microfracture and autogenous bone graft. Am J Sports Med 2007;35:1680-7.
Savva N, Jabur M, Davies M, Saxby T. Osteochondral lesions of the talus: Results of repeat arthroscopic debridement. Foot Ankle Int 2007;28:669-73.
Hunt SA, Sherman O. Arthroscopic treatment of osteochondral lesions of the talus with correlation of outcome scoring systems. Arthroscopy 2003;19:360-7.
Parisien JS. Arthroscopic treatment of osteochondral lesions of the talus. Am J Sports Med 1986;14:211-7.
Choi WJ, Park KK, Kim BS, Lee JW. Osteochondral lesion of the talus: Is there a critical defect size for poor outcome? Am J Sports Med 2009;37:1974-80.
Ramponi L, Yasui Y, Murawski CD, Ferkel RD, DiGiovanni CW, Kerkhoffs GM, et al. Lesion Size Is a Predictor of Clinical Outcomes After Bone Marrow Stimulation for Osteochondral Lesions of the Talus: A Systematic Review. Am J Sports Med 2017;45:1698-705.
Kuo CC, Lu HL, Leardini A, Lu TW, Kuo MY, Hsu HC. Three-dimensional computer graphics-based ankle morphometry with computerized tomography for total ankle replacement design and positioning. Clin Anat 2014;27:659-68.
Bisicchia S, Rosso F, Amendola A. Osteochondral allograft of the talus. Iowa Orthop J 2014;34:30-7.
Donnenwerth MP, Roukis TS. Outcome of arthroscopic debridement and microfracture as the primary treatment for osteochondral lesions of the talar dome. Arthroscopy 2012;28:1902-7.
van Bergen CJ, Kox LS, Maas M, Sierevelt IN, Kerkhoffs GM, van Dijk CN. Arthroscopic treatment of osteochondral defects of the talus: Outcomes at eight to twenty years of follow-up. J Bone Joint Surg Am 2013;95:519-25.
Lee KB, Bai LB, Yoon TR, Jung ST, Seon JK. Second-look arthroscopic findings and clinical outcomes after microfracture for osteochondral lesions of the talus. Am J Sports Med 2009;37 Suppl 1:63S-70S.
Garras DN, Santangelo JA, Wang DW, Easley ME. A quantitative comparison of surgical approaches for posterolateral osteochondral lesions of the talus. Foot Ankle Int 2008;29:415-20.
Muir D, Saltzman CL, Tochigi Y, Amendola N. Talar dome access for osteochondral lesions. Am J Sports Med 2006;34:1457-63.
Thordarson DB, Kaku SK. Results of step-cut medial malleolar osteotomy. Foot Ankle Int 2006;27:1020-3.
Gautier E, Kolker D, Jakob RP. Treatment of cartilage defects of the talus by autologous osteochondral grafts. J Bone Joint Surg Br 2002;84:237-44.
Hangody L, Kish G, Módis L, Szerb I, Gáspár L, Diószegi Z, et al. Mosaicplasty for the treatment of osteochondritis dissecans of the talus: Two to seven year results in 36 patients. Foot Ankle Int 2001;22:552-8.
Kreuz PC, Steinwachs M, Erggelet C, Lahm A, Henle P, Niemeyer P. Mosaicplasty with autogenous talar autograft for osteochondral lesions of the talus after failed primary arthroscopic management: A prospective study with a 4-year follow-up. Am J Sports Med 2006;34:55-63.
Sammarco GJ, Makwana NK. Treatment of talar osteochondral lesions using local osteochondral graft. Foot Ankle Int 2002;23:693-8.
Kennedy JG, Murawski CD. The treatment of osteochondral lesions of the talus with autologous osteochondral transplantation and bone marrow aspirate concentrate: Surgical technique. Cartilage 2011;2:327-36.
Scranton PE Jr., Frey CC, Feder KS. Outcome of osteochondral autograft transplantation for type-V cystic osteochondral lesions of the talus. J Bone Joint Surg Br 2006;88:614-9.
Hangody L, Dobos J, Baló E, Pánics G, Hangody LR, Berkes I. Clinical experiences with autologous osteochondral mosaicplasty in an athletic population: A 17-year prospective multicenter study. Am J Sports Med 2010;38:1125-33.
Yang HY, Lee KB. Arthroscopic microfracture for osteochondral lesions of the talus: Second-look arthroscopic and magnetic resonance analysis of cartilage repair tissue outcomes. J Bone Joint Surg Am 2020;102:10-20.
Reddy S, Pedowitz DI, Parekh SG, Sennett BJ, Okereke E. The morbidity associated with osteochondral harvest from asymptomatic knees for the treatment of osteochondral lesions of the talus. Am J Sports Med 2007;35:80-5.
LaPrade RF, Botker JC. Donor-site morbidity after osteochondral autograft transfer procedures. Arthroscopy 2004;20:e69-73.
Hangody L, Füles P. Autologous osteochondral mosaicplasty for the treatment of full-thickness defects of weight-bearing joints: Ten years of experimental and clinical experience. J Bone Joint Surg Am 2003;85-A Suppl 2:25-32.
Kadakia AR, Espinosa N. Why allograft reconstruction for osteochondral lesion of the talus? The osteochondral autograft transfer system seemed to work quite well. Foot Ankle Clin 2013;18:89-112.
Gross AE, Agnidis Z, Hutchison CR. Osteochondral defects of the talus treated with fresh osteochondral allograft transplantation. Foot Ankle Int 2001;22:385-91.
Görtz S, De Young AJ, Bugbee WD. Fresh osteochondral allografting for osteochondral lesions of the talus. Foot Ankle Int 2010;31:283-90.
Raikin SM. Fresh osteochondral allografts for large-volume cystic osteochondral defects of the talus. J Bone Joint Surg Am 2009;91:2818-26.
El-Rashidy H, Villacis D, Omar I, Kelikian AS. Fresh osteochondral allograft for the treatment of cartilage defects of the talus: A retrospective review. J Bone Joint Surg Am 2011;93:1634-40.
Winters BS, Raikin SM. The use of allograft in joint-preserving surgery for ankle osteochondral lesions and osteoarthritis. Foot Ankle Clin 2013;18:529-42.
Ng A, Bernhard K. Osteochondral autograft and allograft transplantation in the talus. Clin Podiatr Med Surg 2017;34:461-9.
Brittberg M, Lindahl A, Nilsson A, Ohlsson C, Isaksson O, Peterson L. Treatment of deep cartilage defects in the knee with autologous chondrocyte transplantation. N Engl J Med 1994;331:889-95.
Giannini S, Buda R, Grigolo B, Vannini F. Autologous chondrocyte transplantation in osteochondral lesions of the ankle joint. Foot Ankle Int 2001;22:513-7.
Thermann H, Driessen A, Becher C. Autologous chondrocyte transplantation in the treatment of articular cartilage lesions of the talus. Orthopade 2008;37:232-9.
Battaglia M, Vannini F, Buda R, Cavallo M, Ruffilli A, Monti C, et al. Arthroscopic autologous chondrocyte implantation in osteochondral lesions of the talus: Mid-term T2-mapping MRI evaluation. Knee Surg Sports Traumatol Arthrosc 2011;19:1376-84.
Gooding CR, Bartlett W, Bentley G, Skinner JA, Carrington R, Flanagan A. A prospective, randomised study comparing two techniques of autologous chondrocyte implantation for osteochondral defects in the knee: Periosteum covered versus type I/III collagen covered. Knee 2006;13:203-10.
Wang CC, Yang KC, Lin KH, Liu HC, Lin FH. A highly organized three-dimensional alginate scaffold for cartilage tissue engineering prepared by microfluidic technology. Biomaterials 2011;32:7118-26.
Wang CC, Yang KC, Lin KH, Liu YL, Yang YT, Kuo TF, et al. Expandable scaffold improves integration of tissue-engineered cartilage: An in vivo
study in a rabbit model. Tissue Eng Part A 2016;22:873-84.
Magnan B, Samaila E, Bondi M, Vecchini E, Micheloni GM, Bartolozzi P. Three-dimensional matrix-induced autologous chondrocytes implantation for osteochondral lesions of the talus: Midterm results. Adv Orthop 2012;2012:942174.
Aurich M, Bedi HS, Smith PJ, Rolauffs B, Mückley T, Clayton J, et al. Arthroscopic treatment of osteochondral lesions of the ankle with matrix-associated chondrocyte implantation: Early clinical and magnetic resonance imaging results. Am J Sports Med 2011;39:311-9.
Valderrabano V, Miska M, Leumann A, Wiewiorski M. Reconstruction of osteochondral lesions of the talus with autologous spongiosa grafts and autologous matrix-induced chondrogenesis. Am J Sports Med 2013;41:519-27.
Richter M, Zech S. Matrix-associated stem cell transplantation (MAST) in chondral lesions at the ankle as part of a complex surgical approach- 5-year-follow-up in 100 patients. Foot Ankle Surg 2019;25:264-71.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3]