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Reconstruction of Complex Osteochondral Lesions of the Talus With Cylindrical Sponge Allograft and Particulate Juvenile Cartilage Graft: Provisional Results With a Short-Term Follow-up
Scott Bleazey and Stephen A. Brigido Foot Ankle Spec published online 30 August 2012 DOI: 10.1177/1938640012457937

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Clinical Research Reconstruction of Complex Osteochondral Lesions of the Talus With Cylindrical Sponge Allograft and Particulate Juvenile Cartilage Graft
Provisional Results With a ShortTerm Follow-up
Abstract: Osteochondral lesions of the talus can be a challenging injury to treat for even the most experienced foot and ankle surgeon. Although the advances in imaging have made the diagnosis of chondral lesions more accurate, surgeons are still struggling to find ways to reliably treat advanced lesions with subchondral bone damage. This article looks at the use of allograft bone and particulate juvenile cartilage in patients with advanced subchondral bone damage and osteochondral lesions of the talus. Levels of Evidence: Therapeutic, Level IV, Case series Keywords: unstable ankle; heel; rearfoot; bone; fractures; sprains; strains; sports podiatry

Scott Bleazey, DPM, and Stephen A. Brigido, DPM, FACFAS

Introduction

Osteochondral lesion of the talus (OLT) is a painful injury that often occurs in the setting of ankle trauma or instability. While the specific etiology of the Osteochondral lesion of the talus (OLT) OLT can vary, diagnosis depends on high-quality is a painful injury that often occurs in the imaging such as plain film setting of ankle trauma or instability. radiographs and magnetic resonance imaging (MRI).1 The pain associated with the lesion can vary, though it has been The most pressing challenge for the foot described that the damage to the suband ankle surgeon has been finding the chondral plate and its insufficient ability treatment solution for the cystic OLT that for repair are the leading factors for dishas failed microfracture surgery or that comfort and disease progression.2 Jung the surgeons deems too large for microet al3 have demonstrated that microfracfracture. Several surgeons have described ture chondroplasty is a desirable firsttechniques to address large scale articular line treatment options for even the most surface voids. Autologous chondrocyte

cystic of OLTs. Although microfracture has been widely described in the orthopaedic literature, there is little debate regarding the inconsistency in outcomes.

DOI: 10.1177/1938640012457937. From the Foot and Ankle Center at Coordinated Health, Bethlehem, Pennsylvania. Address correspondence to Stephen A. Brigido, DPM, FACFAS, Foot and Ankle Center at Coordinated Health, 2775 Schoenersville Road, Bethlehem, PA 18017; e-mail: [email protected]. For reprints and permissions queries, please visit SAGEs Web site at http://www.sagepub.com/journalsPermissions.nav. Copyright 2012 The Author(s)

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implantation, and matrix-induced autologous chondrocyte implantation (MACI) have been described with reasonable results.4-6 Autologous osteochondral transplantation (OATS) has been described in great detail.7,8 Although the OATS procedure has demonstrated the benefit of reconstructing the cystic subchondral bone and cartilage surface, there have been difficulties matching the contour of the articular surface of the knee to that of the talus.9 This difficulty arises simply because of the difference in cartilage thickness of the 2 joints. Talar cartilage is less than one-half the thickness of the femoral condyles. This thickness discrepancy may create a challenge for the surgeon trying to achieve a congruent articular surface.

Figure 1. Malleolar osteotomy to expose the full thickness chondral lesion of the talus.

Figure 3. Subchondral bone after reaming. Bone is reamed at a depth of approximately 1 cm.

Figure 2. Size-matched reamer to decompress suchondral bone. Reamer matches diameter of allograft plug. Figure 4. Allograft plug compared in size with the cartilage defect. Note that the diameter of the plug closely matches the diameter of the cartilage defect.

Methods
Medical records of 7 patients (5 male and 2 female) treated with medial malleolar osteotomy and allograft reconstruction were retrospectively reviewed. The average age was 35.4 years. Mean duration of symptoms was 9.2 months. All patients completed and failed a course of conservative treatment. Conservative treatment included at least 4 weeks in a walking boot and a 1-month course of physical therapy. Four (57.1%) patients had a prior arthroscopic microfracture of the OLT with unsatisfactory results. All surgeries were performed between January 1, 2009 and October 1, 2010. Each patient was diagnosed with a full-thickness cartilage defect with cystic lesion via magnetic resonance. All 7 patients had subchondral cysts and required decompression with cancellous bone sponge. Each of the 7 patients had a history of traumatic inversion sprain or ankle fracture preceding the diagnosis of OLT.

Surgical Technique
Medial malleolar osteotomy is performed slightly above the level of the tibiotalar joint line (Figure 1). The surgeon may prefer to predrill and tap the 2 partially threaded screws prior to osteotomy to assure accurate replacement of the osteotomized malleolus. After retraction of the malleolus, the OLT is

clearly defined and the diameter is measured. At this time, a reamer (Bacterin International, Belgrade, MT) measuring 6, 8, or 10 mm in diameter was chosen to closely match the premeasured lesion size. The reamer is used to decompress the cystic subchondral bone (Figure 2) of the talus. The reamer is passed through the subchondral plate into the cancellous bone (Figure 3). Next, the cylindrical sponge subchondral allograft (Osteosponge SC Plug, Bacterin International, Belgrade, MT), matching the diameter of the reamed OLT is press fit into the exposed bone. The allograft is tamped to the level of the subchondral plate. Using sterile foil, a mold is

taken of the circular void created by the reamer (Figure 4). Care is taken to note the diameter and depth of the remaining defect. At this time, the juvenile particulate cartilage graft (DeNovo NT, Zimmer, Warsaw, IN) is transferred into the foil mold using a freer elevator (Figure 5). A fibrin glue preparation is used to suspend the particulate cartilage. Once the mold is prepared, the graft will consolidate much

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Figure 5. The allograft plug is press fit into the reamed subchondral bone. Care is taken to make sure the plug sits slightly depressed compared with the cartilage surface.

Figure 7. The particulate cartilage gummy bear is placed onto the surface of the allograft plug.

Figure 9. Postoperative radiograph depicting the repair of the malleolar osteotomy. Take note of the shadowing of the medial shoulder of the talus where the allograft reconstruction occurred.

Figure 8. Fully seated and repaired chondral defect.

Figure 6. The particulate juvenile cartilage in its foil mold.

like a gummy bear (Figure 6). The graft is then transferred to the OLT, placed directly on top of the reconstructed subchondral plate (Figure 7). Care is taken to avoid having the cartilage graft sit proud above the native articular surface as this can create shear and instability. Finally, a small layer of fibrin glue is used to secure the graft to the reconstructed defect. The malleolar osteotomy is replaced and repaired with screw fixation (Figure 8). The patient is placed in a multilayer compression splint or short leg cast postoperatively. The patient is kept in a short

leg cast, non-weight-bearing for 4 weeks. At 4 weeks postoperation, the patient is transferred to a removable boot but is kept non-weight-bearing. At approximately 6 weeks, the patient is transferred to weight-bearing in a boot, with physical therapy initiated. Range-of-motion exercises began at 6 weeks postoperatively at physical therapy. Serial radiographs are taken on subsequent postoperative visits to evaluate healing of the malleolar osteotomy as well as monitor the allograft implantation site (Figure 9). The patient progresses to regular shoe gear at approximately 8 weeks postoperatively.

Results
The charts of 5 male and 2 female patients were reviewed 6 months

postoperatively (Table 1). Six of the 7 patients presented with cystic OLT on the medial talus, with the remaining patient presenting with a lateral OLT. All patients were treated with medial malleolar osteotomy except the individual with the lateral OLT. Access to the lone lateral OLT was treated with fibular osteotomy and plate fixation. Lesion size was measured preoperatively and confirmed intraoperatively with depth (in mm) representing the subchondral cystic area. Each of the 7 patients tolerated the procedure well without any major perioperative complication. There were no reported deep vein thrombosis or postoperative infections. Serial radiographs were taken and none of the 7 patients experienced inflammatory responses to either the cancellous bone sponge or juvenile particulate cartilage. One patient had a postoperative MRI performed to evaluate progression of graft incorporation. This MRI revealed a satisfactory image of the graft with no resultant subchondral cystic areas and an intact subchondral plate (Figures 10 and 11). Each of the 7 patients had surgical wounds that healed without event.

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Table 1. Demographics Patient 1 2 3 4 5 6 7 Age (Years) 27 46 53 37 23 28 34 Gender Male Female Male Female Male Male Male Location Medial talus Medial talus Medial talus Medial talus Medial talus Lateral talus Medial talus Size of Osteochondral Lesion of the Talus (mm) 7 11 7 11 11 10 3 13 13 7 7 9 9 5 4 9 9 5 4 6 4

The parameters found in the activity scale (Figure 13) assessed the ability of the patient to ambulate down stairs, ambulate up stairs, and ambulate up to 4 city blocks. This scale was also visual in nature, with a value of 0 being unable to perform and 10 being able to perform without pain. Again, each of the 7 patients demonstrated clinically significant improvements in each of the 3 parameters. Patients demonstrated the greatest clinical benefit walking up to 4 blocks and ambulating down stairs. All 7 patients reported that they would do the surgery again looking back on the procedure at the 6-month postoperative milestone.

Figure 10. Pre-Operative MRI of ankle demonstrating medial talar OLT.

Figure 11. Six-month postoperative magnetic resonance image showing the process of subchondral bone incorporation and formation of articular surface. It is important to note that the authors feel this process is incomplete at 6 months.

Conclusion
There is little debate that microfracture chondroplasty is the preferred choice for initial treatment of OLT.10-13 When microfracture fails to provide relief, there is great debate as to the benefits of surgical techniques such as MACI and OATS. Although there is supporting literature of both techniques, each demonstrates limitations when treating cystic lesions. MACI does little to address the need for repairing the damaged subchondral plate. The failure to address subchondral bone deficit, in the authors opinion, makes it challenging for a uniform articular surface repair to occur. This is also a multiple step procedure that increases cost and potential risk to the patient. The OATS is a single-stage procedure that has more supporting literature. While the OATS procedure does address the issue of subchondral bone damage, the difference in articular cartilage thickness between the knee and talus also creates a challenge for the surgeon in trying to prepare a uniform and smooth articular surface. Donor site morbidity has also been discussed and is a concern especially when dealing with the high-level athlete. Emerging technologies such as cancellous bone sponge and particulate cartilage graft, in combination, may be a solution to treat not only the articular surface defect but also the underlying subchondral bone damage in severe lesions. Mirzayan,14 in 2006, described several

Each of the patients responded to a pain scale and an activity scale reported at the preoperative baseline and at 6 months postoperation. The pain and activity scales used were consistent across the patient population and were issued by the same clinical nurse. The parameters included in the pain scale were the pain during the first step in the morning, pain during basic walking, and pain at the end of the day. The pain scale was visual analogue in nature, with a value of 0 being no pain and 10 being

pain preventing ambulation (Figure 12). All patients demonstrated clinically significant improvements to each of the 3 parameters, with the greatest clinical improvements during the first step in the morning and pain at the end of the day.

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Figure 12. Pain scale.

and short-term follow-up, the authors feel the data warrants conceptual discussion. The authors believe that a larger study, with multiple-year followup and postoperative advanced imaging may give surgeons a better understanding of the role of cancellous bone sponge and particulate cartilage in challenging OLTs.

References
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2.
0 = no pain and 10 = pain preventing ambulation.

3.

Figure 13. Activity scale.

5.

6.
0 = unable to perform and 10 = able to perform without pain.

requirements deemed necessary for structural repair. Using these requirements as a guide, the authors believe that this cancellous bone sponge has several benefits for repair. First, the sponge allograft has a significant porosity present. This can potentially allow for cell migration to occur through the scaffold. Second, this material has the ability to mold itself to the surrounding talar bone. The unique sponge characteristic allows the surgeon to use the cylinder shaped graft in voids that are not necessarily perfect matches. Finally, this tissue can enhance the repair, by allowing the particulate chondrocytes to bind to the host tissue.

Cellular binding occurs via the use of juvenile particulate chondrocytes. These chondrocytes are minimally manipulated, viable hyaline cartilage cells. In 2004, Feder et al15 described the age effect of biologic activity of isolated chondrocytes. These data supported the use of using hyaline chondrocytes from donors up to 13 years of age. Pediatric chondrocytes demonstrated better biologic response in healing and 10 times the cell density compared with that of adult chondrocytes. The treatment of challenging talar osteochondral lesions has evolved significantly over the past several years. Although these data have a small sample

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