709571

research-article2017
FAIXXX10.1177/1071100717709571Foot & Ankle InternationalAhmad and Maltenfort

Article
Foot & Ankle International

Arthroscopic Treatment of Osteochondral

18
The Author(s) 2017
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DOI: 10.1177/1071100717709571
https://doi.org/10.1177/1071100717709571

Cartilage Matrix journals.sagepub.com/home/fai

Jamal Ahmad, MD1, and Mitchell Maltenfort, PhD2

Abstract
Background: This prospective study evaluated the intermediate-term outcomes of operatively treating primary
osteochondral lesions of the talus (OLT) of 1.5 cm2 or smaller with arthroscopic excision, microfracture, and allograft
cartilage extracellular matrix (ECM).
Methods: Between 2012 and 2015, 30 consecutive patients received allograft cartilage ECM at their microfractured OLT
of 1.5 cm2 or smaller after failing nonoperative treatment. Preoperative and postoperative function and pain were graded
using the Foot and Ankle Ability Measure (FAAM) and a visual analog scale (VAS), respectively. Postoperative imaging was
assessed for osteochondral healing and degenerative changes. This included computed tomography (CT) at 6 months from
surgery. Data regarding postoperative complications were recorded. All 30 patients that received allograft cartilage ECM
for their OLT were evaluated for final follow-up at a mean of 20.2 months.
Results: Mean FAAM increased from 51.4 preoperatively to 89.3 of 100 at final follow-up. Mean VAS decreased from
8.1 preoperatively to 1.7 of 10 at final follow-up. These differences between preoperative and postoperative function and
pain were statistically significant (P < .05). At 6 months from surgery, 2 patients (6.7%) received CT scans that revealed
incomplete chondral formation at their OLT. At 19 months after surgery, a separate patient (3.3%) developed ankle
arthritic changes.
Conclusion: Treating OLTs with allograft cartilage ECM has not been previously reported. Using allograft cartilage ECM
resulted in a high rate of improvement in ankle function and pain in patients with OLTs. These findings are important as
allograft cartilage ECM could be of significant benefit for patients with OLTs.
Level of Evidence: Level III, prospective comparative series.

Keywords: arthroscopy, osteochondral, lesion, talar dome, allograft, extracellular, matrix

Introduction matters worse, the talus is known to have a precarious

Osteochondral lesions of the talar dome (OLT) are defined
as localized defects in the articular cartilage that are deep
enough to penetrate the underlying subchondral bone.6,35
Most of these OLTs have a traumatic etiology where a por-
tion of the talar dome cartilage can be damaged during rota-
tional ankle injuries, such as a ligamentous sprain or
fracture.2,4,11 With such ankle trauma, the talus can tilt
underneath and compress against the distal tibial plafond
with enough force to injure and/or fracture that section of
the talar dome cartilage. Other OLTs have a less traumatic
origin and are likely caused by repetitive shear stresses
upon the talar domes cartilage.44 Regardless of etiology,
the healing potential for OLTs is limited because of several
factors. By definition, OLTs involve articular cartilage,
which is composed of avascular hyaline cartilage. Because
of its lack of blood supply, the ability of articular cartilage
to heal itself at any joint can be inadequate.43 To make
intraosseous blood supply within its body and dome
between anastomoses of the arteries of the tarsal canal,
sinus, and sling.30 This unique aspect of talar anatomy may
confer a further detrimental effect upon OLT healing.41
OLTs can manifest with varying degrees of displacement
and size, which ultimately affect their treatment options.
While incomplete and/or nondisplaced OLTs have the
potential to heal through nonoperative means, those OLTs
1
Orthopaedic Foot and Ankle Surgery, NorthShore Orthopaedic
Institute, NorthShore University Health System, Lincolnshire, IL, USA
2
Biostatistician, Childrens Hospital of Philadelphia, Department of
Biomedical Health Informatics, Philadelphia, PA, USA
Corresponding Author:
Jamal Ahmad, MD, Orthopaedic Foot and Ankle Surgery, NorthShore
Orthopaedic Institute, NorthShore University Health System,
920 Milwaukee Avenue, 1st Floor, Lincolnshire, IL 60069, USA.
Email: Jahmad@northshore.org
2 Foot & Ankle International 0(0)
that are complete and/or displaced have a worse prognosis
and often require some type of operative repair based on
their size.39,42 Currently, the accepted operative treatment
for OLTs less than or equal to 1.5 cm2 is an arthroscopic
excision and curettage of the OLT with microfracture of the
underlying subchondral bone.22,37
However, this treatment is not without potential short-
comings. Its ability to improve ankle pain and function is
highly variable. Success rates from OLT excision and
microfracture are 85% on average, but are reported as low
as 46% by some authors.46 It is important to recognize that
OLT excision and curettage leaves a cartilaginous defect at
the talar dome.3 Upon microfracture of subchondral bone at
that site, that void is filled with a clot that contains bone
marrowderived growth factors and pluripotent mesenchy-
mal stem cells.27,31 In time, many of these stem cells differ-
entiate into fibroblasts and chondrocytes to fill that
cartilaginous void at the talar dome with fibrocartilage.32,38
However, this fibrocartilage that replaces the OLT is quite
different from normal talar articular cartilage. In contrast to
articular hyaline cartilage that contains type II collagen,26
this fibrocartilage consists primarily of type I collagen.24
This difference confers decreased stiffness and resilience
upon such fibrocartilage than talar articular cartilage.29
With worse wear properties, the fibrocartilage that forms at
the OLT is at higher risk for degradation where the OLT can
recur than if the OLT was replaced with cartilage that is
closer or identical to hyaline articular cartilage.34
To overcome such potential problems, the use of
allograft cartilage extracellular matrix (ECM) has been
explored as adjuvant treatment during arthroscopy. This
matrix contains type II collagen, proteoglycans, and carti-
laginous growth factors that are present in normal hyaline
articular cartilage.23 When the ECM is applied to the OLTs
microfracture site, it can fill that cartilaginous defect,
which may serve as an allograft cartilage scaffold (ACS)
for growth factors from talar marrow to interact with and
facilitate healing of the cartilage. The goal of using this
ECM after microfracture would be so the OLT is more
likely replaced with cartilage that is closer to hyaline talar
articular cartilage than fibrocartilage. While investigations
with human subjects that show this are lacking, allograft
cartilage ECM has shown promise in some animal studies
where its use resulted in hyaline cartilage formation at iat-
rogenic osteochondral defects.8,17
To date, no authors have examined clinical outcomes
from treating OLTs with allograft cartilage ECM in human
subjects. Excision and microfracture has limited success
and several shortcomings for treating OLTs, which includes
those that are 1.5 cm2 or smaller. The additional use of
allograft cartilage ECM after OLT microfracture may result
in higher rates of improving ankle function and pain from
OLT of 1.5 cm2 or smaller that heal through that scaffold.
Table 1. Inclusion and Exclusion Criteria for Enrollment
Within This Study.
Study Criteria
Inclusion
Patients with a primary osteochondral lesion of the talus
(OLT) of 1.5 cm2 or smaller that fail recent nonoperative
treatment, which include a minimum of 4 weeks of NWB
immobilization.
Exclusion
Patients with a primary OLT of 1.5 cm2 or smaller that have
improved symptoms from recent nonoperative treatment.
Patients with a primary OLT of greater than 1.5 cm2.
Patients with a recurrent OLT of any size.
The purpose of this study was to prospectively evaluate the
intermediate-term clinical and radiographic outcomes of
using allograft cartilage ECM as an adjuvant when
arthroscopically treating OLTs of 1.5 cm2 or smaller in a
single surgeons patient population. We hypothesized that
this method of treatment would provide high rates of return
to function, pain relief, and osteochondral healing.
Methods
This research was conducted in a prospective manner
between May 2012 and June 2015 in a single surgeons
(J.A.) practice at a single institution. The primary inclusion
criteria for study enrollment were those patients with a pri-
mary OLT of less than or equal to 1.5 cm2 who had no prior
operative treatment for it (Table 1). Patients with OLTs who
were recurrent from prior surgeries such as microfracture
that failed were excluded from this study. Patients with
OLTs larger than 1.5 cm2 were also excluded from this
investigation. Such recurrent and larger OLTs are often not
amenable to an arthroscopic excision and microfracture
(Table 1).9,45 Rather, those patients often require an osteo-
chondral autograft or allograft through an open operative
approach with or without a malleolar osteotomy and were
excluded from this research.1
At the time of study enrollment, all patients had received
either computed tomography (CT) or magnetic resonance
imaging (MRI) to confirm the presence of an OLT. Particular
attention was paid to the size, depth, and location of the
OLT at the talar dome. Using a previously reported grid
classification scheme, the OLTs location was described to
occupy one of 9 portions of the talar dome: (1) anterome-
dial; (2) anterocentral; (3) anterolateral; (4) centromedial;
(5) central direct; (6) centrolateral; (7) posteromedial; (8)
posterocentral; and (9) posterolateral.14 As a routine prac-
tice, the primary author obtains an MRI to confirm the pres-
ence of an OLT in patients with equivocal symptoms if this
study is lacking. If patients presented to the primary author
for care of their OLT from another physician and had
Ahmad and Maltenfort 3

already received prior ankle MRI or CT, they did not receive Table 2. Preoperative Demographics for This Study Population.
an updated MRI from the primary author unless their earlier
Preoperative Demographics Study Population
studies are over 4 months old.
Before operative treatment was offered to all potential Male/female 17:13
study patients with a primary OLT of 1.5 cm2 or less, they Age, y, M (range) 40.7 (15-62)
would have had failed appropriate nonoperative manage- Right/left 12:18
ment, which included a 4-week trial of nonweightbearing Workers Compensation: No 9:21
(NWB) immobilization to their involved ankle in either a Preoperative FAAM, M (range) 51.4/100 (31-82.1)
controlled ankle motion (CAM) boot or short leg cast Preoperative VAS of pain, M (range) 8.1/10 (5-10)
(SLC). Whether performed by the primary author or a dif- OLT location
ferent physician before coming to the primary author for Anteromedial 3
Anterocentral 1
care, this trial of NWB immobilization was given to all
Anterolateral 6
study patients to minimize confounding factors between
Centromedial 9
them. This protocol was done to ensure that all such patients
Central direct 2
had an attempt at nonoperative management before they
Centrolateral 2
received operative treatment. If patients with an OLT of 1.5 Posteromedial 7
cm2 or smaller improved with nonoperative modalities, they Posterocentral 0
did not receive surgery and were excluded from this study. Posterolateral 0
From 42 patients who presented with an OLT of 1.5 cm2
or less between May 2012 and June 2015, 37 failed nonop- Abbreviations: FAAM, Foot and Ankle Ability Measure; M, mean; OLT,
erative treatment from the primary author to qualify for osteochondral lesion of the talus; VAS, visual analog scale.
inclusion in this study. Of those 37 patients, 30 agreed to
enroll in this clinical trial during that period. Those 7
Operative Technique
patients who did not participate in this research had similar
demographics and preoperative scores to the 30 study All study patients had treatment on an outpatient basis.
patients. Patients were supine with the affected leg hanging depend-
Seventeen (56.7%) and 13 (43.3%) patients were male ently without traction under general anesthesia with regional
and female, respectively. Age of patients at the time of sur- block augmentation with a calf tourniquet.
gery ranged from 15 to 62 years, with a mean age of 40.7 All study patients received an ankle arthroscopy through
years. The left and right ankles were affected in 18 (60%) standard anterolateral and anteromedial portals.15 A syno-
and 12 (40%) patients, respectively. All patients described vectomy was performed to fully visualize the articular car-
rotational or twisting injuries to their ankle that caused their tilage. The OLT was excised thoroughly with curettes,
OLT. Eight (26.7%) and 9 (30%) patients reported their graspers, and shavers to vertical margins of stable, adjacent
ankle injury due to sports or an event at work with an open normal articular cartilage. The defect was measured intra-
Workers Compensation (WC) claim respectively (Table 2). operatively to confirm its dimensions as 1.5 cm2 or smaller.
Time from date of causative ankle injury to diagnosis of The subchondral plate was microfractured with an awl to
their OLT on MRI or CT ranged from 2 to 10 months. create multiple holes approximately 3 to 4 mm apart to a
Specifically, 26 and 4 study patients received a preoperative depth of 6 to 10 mm. Adequate microfracture was con-
MRI and CT, respectively, to determine the presence, size, firmed when fat droplets and/or blood emerged from the
and location of their OLT. Patients presented for final clini- holes in talar subchondral bone.
cal evaluation between 12 and 33 months, with a mean fol- Allograft cartilage ECM was prepared for application
low-up time of 20.2 months. according to the manufacturers (Arthrex) instructions.5
On failure of nonoperative treatment, patients with an Specifically, the allograft was mixed with an equal amount
OLT of 1.5 cm2 or less were offered enrollment in this study of platelet-rich plasma (PRP) and then placed into a syringe
to receive arthroscopic excision, microfracture, and allograft with a cannula long enough to allow for arthroscopic deliv-
cartilage ECM (BioCartilage, Arthrex, Naples, FL). At the ery. Once the microfracture site was dried via suction, the
time of scheduling surgery, patients were assessed clinically allograft cartilage ECM was delivered into that defect
and functionally. Patients were graded according to the Foot arthroscopically. The allograft was then sealed into that
and Ankle Ability Measure (FAAM) Sports scoring system location with a coating of fibrin glue (Arthrex). As the fibrin
and a visual analog scale (VAS) of pain.7,28 This study was adhered to the allograft, care was taken to ensure that the
performed with appropriate approval and consent from the ECM remained at the microfracture site by avoiding exces-
institutional review board (IRB) at our practice and its affil- sive ankle motion. The fibrin was allowed to set for 5 min-
iated hospitals. No funding was obtained from any outside utes and the ankle was gently ranged to assess the stability
source in the performance of this study. of the allograft cartilage ECM.
4 Foot & Ankle International 0(0)
After skin closure, the ankle was held in neutral, the
tourniquet was deflated, and a well-padded posterior splint
was applied to the leg.
Postoperative Protocol
After surgery, patients were prohibited from weightbearing
to their affected ankle for 6 weeks. During the first 2 weeks
of this time, patients were immobilized in the short-leg non-
weightbearing splint. By 2 weeks after surgery, skin sutures
were removed and patients were transitioned to a CAM
boot. At this time, they were also encouraged to remove the
boot to begin regular active and passive range-of-motion
(ROM) exercises to their affected ankle.
By 6 weeks after surgery, patients were allowed to
increase their activity level gradually. At 6 to 8 weeks,
patients were allowed to progressively bear weight in incre-
ments of 50% of body weight in their CAM boots every 3
weeks. At 12 weeks after surgery, patients were started in
physical therapy, weaned out of their fracture boots, and
their level of activity increased as tolerated. At 16 to 20
weeks after surgery, patients were allowed to return to any
type of athletic activity without restrictions.
Follow-up Evaluation
Patients were assessed clinically and radiographically at
regular postoperative visits. Patients were seen at 2 weeks, 6
weeks, 12 weeks, 6 months, and 1 year after surgery. Ankle
radiographs were performed at each of these visits and the
talar dome was inspected and assessed where the OLT was
excised, microfractured, and received allograft cartilage
ECM. On early postoperative radiographs, the OLT appeared
radiolucent at the talar dome where it was microfractured.
Radiographic signs of OLT healing in this study were
defined as resolution of that radiolucent area with later
radiographs, which was based on prior literature.21 Patients
also received a CT of their ankle at 6 months after surgery to
further assess healing of articular cartilage at their OLT.
Indications of OLT healing on CT were characterized by
articular congruity between the microfracture site and the
remainder of the talar dome with neither osseous nor carti-
laginous defects.12
All patients were further invited for more recent follow-
up just before the writing of this text for updated postopera-
tive functional scores, pain levels, radiographs, and patient
satisfaction scores. Preoperative and final postoperative
function was scored according to the validated FAAM. A
validated 10-point VAS assessed preoperative and final
postoperative pain. Both preoperative and final postopera-
tive radiographs were assessed for radiolucencies and con-
gruency at the talar dome. Observed postoperative
complications at the ankle, including problems with carti-
lage healing, progression to ankle degenerative joint dis-
ease (DJD), and the need for further revision surgeries,
Table 3. Postoperative Demographics for This Study
Population.
Postoperative Demographics Study Population
2
Surface area of OLT, cm , M (range) 1.1 (0.36-1.5)
Tourniquet time, min, M (range) 43.1 (28-67)
Follow-up, mo, M (range) 20.2 (12-33)
Postoperative FAAM score, M (range) 89.3/100 (56-100)
Postoperative VAS score, M (range) 1.7/10 (0-7)
Patient satisfaction (poor/fair/good/ 1:2:10:17
excellent)
Rate of chondral delayed or 2/30 (6.7%)
nonunion, n/n (%)
Abbreviations: FAAM, Foot and Ankle Ability Measure; M, mean; OLT,
osteochondral lesion of the talus; VAS, visual analog scale.
were documented. Ankle DJD was graded from 0 or absent
to 3 or severe with Gianninis classification system.18
Finally, overall patient satisfaction from surgery was graded
as excellent, good, fair, or poor.40
Data Analysis
The Statistical Package for the Social Sciences (version
11.0; SPSS, Chicago, IL) was used for the statistical analysis
of data. Analysis of variance was performed to evaluate the
significance of differences in postoperative data between the
2 groups of patients that received either an osteochondral
autograft and allograft for operative treatment. A P value of
less than .05 was defined to be statistically significant.
Results
The OLT was located at the centromedial, posteromedial,
anterolateral, anteromedial, centrolateral, central-direct,
and anterocentral talar dome in 9, 7, 6, 3, 2, 2, and 1 patients,
respectively. At surgery, no study patients were found to
have discrepancies between preoperative imaging and
arthroscopic findings to prevent them from receiving
arthroscopic excision, microfracture, and allograft cartilage
ECM for their OLT. The intraoperative size of the OLT
ranged from 0.36 to 1.5 cm2, with a mean size of 1.1 cm2
measured arthroscopically. The tourniquet time from the
skin incision to closure was between 28 and 67 minutes,
with a mean of 43.1 minutes.
The mean FAAM score increased from 51.4 of 100 pre-
operatively to 89.3 of 100 at the time of final follow-up (P
< .05). The mean VAS pain score decreased from 8.1 of 10
preoperatively to 1.7 of 10 at final follow-up (P < .05).
Patient satisfaction at final follow-up was poor, fair, good,
and excellent in 1 (3.3%), 2 (6.7%), 10 (33.3%), and 17
(56.7%) patients, respectively (Table 3).
Patients postoperative imaging included a CT scan at 6
months from surgery and ankle radiographs at latest follow-
up. At 6 months from surgery, 28 of 30 patients (93.3%)
Ahmad and Maltenfort 5
achieved full osteochondral healing on CT imaging.
Restoration of the talar dome was visible on CT with articu-
lar congruity between the microfracture site and the remain-
der of the dome with neither osseous nor cartilaginous
defects. At their final visit, these 28 patients showed no
radiographic signs of healing problems with their OLT.
Radiographic healing was determined by resolution of radio-
lucencies within the talar dome at its microfracture site.
Short- and longer-term complications were noted in 4
(13.3%) patients. No patients developed intraoperative
problems. No patients developed postoperative wound
complications or nerve injuries. One patient (3.3%) devel-
oped a symptomatic infrapopliteal deep vein thrombosis
(DVT) at 2 weeks after surgery. Two patients (6.7%) devel-
oped delayed or incomplete chondral healing at their OLT,
which was discovered on CT at 6 months after surgery. One
of these patients was asymptomatic and required no active
treatment at that time. She ultimately achieved full osteo-
chondral healing of her OLT by 12 months after surgery,
which was seen on a CT performed at that time. At her latest
follow-up of 30 months from surgery, this individual
remained without ankle symptoms or radiographic signs of
OLT healing problems. The other patient was symptomatic
and required an osteochondral autograft transplant (OATS)
from his ipsilateral superolateral distal femoral condyle to
achieve full talar chondral healing. One patient (3.3%)
developed painful Giannini Stage 2 degenerative changes at
her medial ankle joint by 19 months from her surgery due to
a centromedial 1.5-cm2 OLT. This patient opted for nonop-
erative treatment of her ankle arthritis with functional brac-
ing, which provided partial relief of symptoms at her latest
follow-up of 22 months from her ankle arthroscopy.
Discussion
Treatment of talar OLTs remains a challenge. The tradi-
tional operative treatment for OLTs less than or equal to 1.5
cm2 is an arthroscopic excision and curettage of the OLT
with microfracture of the underlying subchondral bone.37
Although this procedure can be successful at improving
ankle symptoms, it is not without potential problems. An
important consideration about OLT excision and curettage
is that a cartilaginous void remains at the talar dome.3 One
method of replacing this cartilage is with osteochondral
grafts through an open ankle arthrotomy and malleolar
osteotomy, as needed. One type of graft is an osteochondral
autograft plug(s) from the patients own distal femoral
condyle.25,36 Schottle et al published one of the earliest
reports on treating OLTs with osteochondral autograft.36
While they acknowledge a learning curve to this proce-
dure, they reported high rates of cartilage healing with low
rates of complications. More recently, Kim et al retrospec-
tively treated 52 patients with OLTs and obtained 95%
healing of cartilage with single or multiple osteochondral
autograft plugs.25 However, harvesting osteochondral auto-
graft from the distal femur has potential problems that
include the risk of donor-site complications and inferior
cartilaginous properties with involvement of the knee
joint.16,33 An alternative to using such autografts can be
with fresh talar osteochondral allograft. The advantages of
using talar allograft over distal femoral autograft are the
avoidance of a knee incision and sacrifice of cartilage there
and replacing the OLT with talar cartilage. Gross et al pub-
lished one of the earliest reports on treating OLTs with
fresh osteochondral talar allograft.20 Among 9 patients that
received talar allograft, only 6 (66.7%) achieved graft heal-
ing while the other 3 experienced graft fragmentation.
More recently, El-Rashidy et al performed an osteochon-
dral talar transplant in a larger patient population with
OLTs.13 Among the 38 patients in this retrospective study,
34 patients (89.5%) achieved graft healing with significant
improvement in pain and function. Although either osteo-
chondral autograft or allograft can replace the cartilage
defect at the talar dome following excision and curettage of
an OLT, both grafts cannot be done purely arthroscopically.
Both materials can only be applied to the talus with an
open ankle arthrotomy with or without malleolar osteot-
omy, which is more morbid than arthroscopic surgery.
In recent years, some authors have explored the use of
particulated juvenile allograft cartilage to treat OLTs after
arthroscopic excision and curettage. The most studied type
of this material is DeNovo Natural Tissue (NT) graft
(Zimmer, Warsaw, IN), which is allograft cartilage from
donors under the age of 13 years. Often, this graft can be
applied to the talar domes cartilaginous defect arthroscopi-
cally without need for open ankle arthrotomy with or with-
out malleolar osteotomy.19 Coetzee et al published the
earliest report on treating OLTs with particulated juvenile
allograft cartilage in 23 patients.10 Although mean function
and pain improved significantly from this method, 1 patient
developed cartilage graft delamination at 16 months after
surgery. An important consideration with this procedure is
that the OLT is not microfractured, so bone marrowderived
growth factors and pluripotent mesenchymal stem cells
from the talus are not involved with cartilage healing from
this allograft.
Microfracture of subchondral bone at an OLT theoreti-
cally enables recruitment of growth factors and stem cells at
the talar domes cartilaginous defect.27,31 Such stem cells
can differentiate into chondrocytes and fill that cartilagi-
nous void with fibrocartilage.32,38 However, this fibrocarti-
lage that replaces the OLT has less stiffness, resilience, and
ultimately survivorship than talar articular cartilage.29,45
Our research was novel as it was the first to prospec-
tively examine outcomes from utilizing allograft cartilage
ECM for managing OLTs at 1.5 cm2 or smaller. The use of
this material had several advantages over other means of
treating OLTs. It could be applied to the cartilaginous void
6 Foot & Ankle International 0(0)
at the talar dome after the OLT was excised and microfrac-
tured. It did not require an open ankle arthrotomy and/or
malleolar osteotomy. This allograft also benefited from
talar growth factors and stem cells that were produced dur-
ing microfracture of the OLT. At final follow-up, our
patients had a large and significant improvement in func-
tional and pain scores. Operative times had a wide range,
which is explained by the additional steps needed to apply
allograft cartilage ECM to the OLTs microfracture site.
However, the extra time that was required to use this bioma-
terial did not have a negative impact on patients or their
outcomes. In fact, the primary author became more efficient
in arthroscopic use of allograft cartilage ECM with an
increasing number of these procedures over time. Ultimately,
the use of this type of allograft to treat OLTs resulted in a
high rate of return to function, pain relief, and chondral
healing.
Our results from using allograft cartilage ECM to man-
age OLTs of 1.5 cm2 or smaller invite some comparisons to
prior literature where similar OLTs were treated with
arthroscopic excision and microfracture. Zengerink et al
performed a meta-analysis on patients that received
arthroscopic excision and microfracture for OLTs of 1.5
cm2 or smaller.46 Among 18 studies with a total of 388
patients, 329 individuals reported good or excellent scores
at their latest follow-up. Based solely on these clinical
scores, Zengerink et al reported the mean success rate of
arthroscopic excision and microfracture as 85% (329/388)
in treating OLTs of 1.5 cm2 or smaller. It is critical to realize
that this 85% value is an average from multiple studies,
where some individual investigators reported success rates
as low as 46% with excision and microfracture for OLTs of
1.5 cm2 or less. It is also important to recognize that this
reported rate of 85% success is purely clinical and does not
account for osteochondral healing on radiographs or other
imaging modalities. Many of these 18 studies that Zengerink
et al reviewed did not perform postoperative CT or MRI to
assess OLT resolution, as opposed to the protocol of this
investigation. If osteochondral healing on radiographs, CT,
and/or MRI is also used to determine the success rate of
excision and microfracture, this procedure may likely have
a lower success rate for OLTs of 1.5 cm2 or less than what
Zengerink et al calculated.
The degree of success achieved in this study are better
than what Zengerink et al reported from their meta-analysis
of patients that received OLT excision and microfracture
without using a biomaterial such as allograft cartilage ECM.
When success is defined as clinical and/or radiographic
healing of the OLT, the success rate from using allograft
cartilage ECM is 96.7% where 29 of 30 patients achieved
this by their final follow-up. This includes the 1 patient that
achieved healing of her OLT, but then developed medial
ankle arthritis over 18 months after surgery. When success
is defined as patient satisfaction, the success rate with
employing allograft cartilage ECM is 90% where 27 of 30
patients rated their satisfaction as good or excellent. With
such high rates of osteochondral healing, the authors feel
that the apparent added benefit of utilizing allograft carti-
lage ECM for OLTs outweighs whatever additional costs or
operative time may occur with its use. We believe the high
degree of clinical improvement, osteochondral healing, and
patient satisfaction that we achieved with allograft cartilage
ECM is likely due to our patients OLT healing with more
hyaline articular cartilage than fibrocartilage. Certainly,
patients will have greater short-term and long-term benefit
should their OLT heal with articular rather than fibrocarti-
lage, where the former has better wear properties than the
latter.29,34 However, we acknowledge that this study cannot
directly validate these statements. Rather, future investiga-
tions that specifically focus on these matters may be needed
to confirm or dispute the benefits that we observed in using
allograft cartilage ECM for treating OLTs.
We acknowledge the limitations of this study. The pri-
mary shortcoming of this study was the lack of a control
population of patients who received arthroscopic operative
treatment of their OLT with excision and microfracture, but
without using allograft cartilage ECM. Without a cohort, it
can be argued that improvements in function and pain seen
in this study would not have been significantly different
than if patients did not receive this allograft. Although
patients who received allograft cartilage ECM for their OLT
likely healed with cartilage that more closely resembles
articular cartilage than fibrocartilage, it remains uncertain if
this yields a significant difference in clinical outcomes
between the two. Before this study, the primary author did
not routinely use allograft cartilage ECM during arthroscopic
excision and microfracture of patients with OLTs of 1.5 cm2
or smaller. These patients would not be a good control pop-
ulation for this study because they would have been enrolled
retrospectively instead of prospectively. Furthermore, those
patients were treated at an earlier time in the primary
authors practice, which may be a confounding factor with
evolution in operative techniques. We acknowledge the
benefit of having a control population for this type of study
and are currently devising a randomized, prospective con-
trolled trial that compares operative treatment of patients
with OLTs of 1.5 cm2 or smaller with and without allograft
cartilage ECM.
Other limitations of this study involve its enrollment and
duration. We acknowledge that our study population was
limited in size. A larger number of patients may be needed
to confirm our results. In addition, it can be argued that our
patient population requires longer follow-up than the
medium term to fully assess their final clinical and radio-
graphic outcomes. In time, the cartilage that forms from
allograft cartilage ECM at the OLT may wear down.
Although this cartilage is likely closer to articular cartilage
than fibrocartilage, it remains to be seen if this would resorb
Ahmad and Maltenfort 7
in the long term because of the allogenicity of the ECM
applied to the OLT.
Conclusion
Outcomes from treating OLTs with allograft cartilage ECM
had not been previously reported in the orthopaedic litera-
ture. After an OLT was excised and microfractured, deposi-
tion of this allograft acted as a bio-scaffold at the
microfracture site to promote cartilage healing. This study
showed that using allograft cartilage ECM resulted in a high
rate of improving ankle function and pain relief in patients
with OLTs at or smaller than 1.5 cm2 at intermediate-term
follow-up. Studies with a larger patient population and lon-
ger follow-up may be needed to confirm these findings.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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