Background Distal Tibial Bone Grafting to Talar Osteochondral - - PowerPoint PPT Presentation

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Distal Tibial Bone Grafting to Talar Osteochondral Lesions: Novel Technique and Early Results

Todd Kim, MD Andrew Haskell, MD

Talar OCLs are very common Arthroscopic Bone-Marrow

Stimulation (Microfracture)

Most common surgical treatment Reliable results in small to

medium sized lesions (<10 or 15mm)

Larger, cystic lesions Microfracture doesn’t work Osteochondral transplantation is

the most common procedure

Background

BG procedures have been described with comparable

results

Saxena/Eakin AJSM 2007 Leumann et al. KSSTA 2013

Do clinical outcomes correlate to cartilage morphology

and histology?

Lee et al., AJSM 2009

What causes the pain? Unstable cartilage or osteonecrotic bone?

What about bone grafting rather than

• steochondral transplantation?

Donor site morbidity with autograft harvest Viability, availability, and cost of allograft

tissue

Complications and articular cartilage injury

with peri-articular osteotomies

Difficult to reconstruct corner lesions

Potential Limitations of Osteochondral Transplantation

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Osteotomy is generally not necessary Performed through same medial arthrotomy

incision

Reaming removes all cystic/osteonecrotic bone Stability of structural bone plug Better coverage/fit for corner lesions because it is

placed at an oblique angle

Minimal cost

Potential Advantages of Distal Tibial Bone Grafting

Minimizes need for osteotomy Advantageous for corner lesions

Oblique Placement of Bone Graft

Surgical Technique

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8 patients with minimum 6 months

f/u (average 11.5 months)

Age 15-65, average 44 All large medial talar dome OCLs

with cystic component

111mm2; depth 7.6mm All had failed nonoperative treatment

Clinical Series

AOFAS score pre-op 65.8 post-op 89.9* (6 patients)

* improved using a paired T-test (p=0.02) Mean final f/u 90, range 77-100 (8 patients)

80-90 good; 90-100 excellent Comparative outcomes Microfracture: 88 (van Bergen et al. JBJS-Am 2013) Bone grafting: 93.4 (Saxena/Eakin AJSM 2007) Autograft: 87 (Kennedy/Murawski Cartilage 2011) Allograft: 83 (Raikin JBJS-Am 2009)

Early Results

Foot Function Index 18.4 0 = no pain, best function 100 = severe pain, worst function SF-12 52 PCS, 54 MCS Scale 0-100, healthy norm 50

Early Results

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VAS Pain 6.4 0.5 (4 patients) 1.7/10 (8 patients) VAS Satisfaction 8.9/10 (8 patients) 7/8 would have surgery again, 1 maybe No complications; no re-operations All patients returned to full duty work

Early Results

Allograft talus: $6400 have to use it Autograft OATS: OATS kit $495 OR time for harvest from knee +/- cost of osteotomy fixation Particulated Juvenile Cartilage (De Novo™) : $4400 have to use it

DTBG procedure: OATS kit $495

Cost

DTBG procedure is a safe treatment for large talar

dome OCLs

Can be performed without osteotomy and with

minimal cost relative to alternative procedures

Outcomes after short-term follow-up are

comparable to outcomes of microfracture, autograft-OAT, allograft OAT, and previously described bone grafting procedures

Conclusions

Need larger numbers and longer term follow-up Prospective, randomized study Imaging (MRI) or second-look arthroscopy to assess

healing cartilage

Is there a role for adjunctive cartilage procedures with

DTBG (De Novo™- juvenile particulated allograft cartilage)?

Future Study