OCD Talus and OATS: Gregory C Berlet MD, FRCS(C), FAOA Orthopedic - - PowerPoint PPT Presentation

OCD Talus and OATS:

Gregory C Berlet MD, FRCS(C), FAOA Orthopedic Foot and Ankle Center

Disclosures

• Consultant/Speaker Bureau/Royalties/

Stock: Wright Medical, Stryker, ZimmerBiomet, DJO, Plasmology4, Amniox Medical, United Orthopedic Group, Paragon 28, CrossRoads, Ossio

OCD Talus: My Approach

Dictated by :

• Symptoms of the patient
• Mechanism of injury
• Size of the lesion
• Containment of the lesion
• Previous treatment of the lesion
• Corresponding damage to the tibia

ISCRA

• International Society on Cartilage

Repair of the Ankle (ISCRA)

• Focus groups develop consensus with

the larger group participating in voting at the in person meeting

Consensus Meeting of ISCRA November 2017

Our Patient

• 21 year old athlete with a large OCD
• With no history of injury, mechanical

alignment challenges we must consider this as an osteochondrosis

• Focal alteration in subchondral bone

with subsequent cartilage compromise

• Issues: Size (large), Bone compromise

OCD Talus: My Approach

Dictated by :

• Symptoms of the patient
• Size of the lesion
• Containment of the lesion
• Previous treatment of the lesion
• Corresponding damage to the tibia

Outcomes: Microfracture OLT

Tol JL et al. 2000 –Meta-analysis 32 studies; 1966-1998 –Success of OLT surgeries:

• Excision, curettage, drilling: 85%
• Excision, curettage: 78%
• Excision alone: 38%

Tol … van Dijk: : FAI 21(2), 2000

Results: OFAC

• Retrospective review of 189 patients
• Arthroscopy + Microfracture
• MRI used to determine size
• Review of clinical outcomes ( 37 mo avg)

Cuttica, Berlet et al: FAI 32(11), 2011

Results: OFAC

• Direct correlation
• f size to outcome
• Linear relationship
• f size of lesion to
• utcome
• MRI changes may

persist longer than expected

Cuttica, Berlet et al: FAI 32(11), 2011

Results: OFAC vs Tol

• Average lesion size in Tol

= 7 mm

• OFAC results deteriorated

after > 1 cm

• Maybe size does matter
• Strategy has to be size

dependent

• CRITICAL SIZE DEFECT

Critical Defect Size

Choi et al:

• 120 ankles with talus microfracture
• Failure defined as:

– Repeat surgery – AOFAS < 80 ( fair or poor result )

• Defect size > 150 mm2 ( 7 mm )

– 80% failure rate ( p < .001)

Choi et al. AJSM 37(10) Oct 2009

OATS: Indications

• Primary cystic lesions

> 1cm

• Revision primary

procedures with a lesion size >1 cm

• Our patient = 1.3 cm

ISCRA 2017

Theoretically address both bone and cartilage injury

Osteochondral Plug Transfer

cartilage bone

OATS: Technique

• A depth of 12-15 mm is the optimal

depth to drill the lesion and optimal length of the graft to harvest

• Congruency of the implanted graft is

essential and care should be taken during surgery to achieve an articular surface as closely as possible to the native talus

ISCRA 2017

ICRS 2009

Hangody:

– 1178 mosaicplasty over 10.5 years Talar Mosaicplasty: – Best outcomes of all indications – >90 % good to excellent – Addresses bone defect and cartilage

8th Annual Congress of International Cartilage Research Society 2009

Plug Osteochondral Transfer

Imhoff et al:

• Level 4 clinical series

– 32 patients – avg f/u 84 months – AOFAS, Tegner and VAS

• Results: improvement of all parameters
• Partial incongruity = poorer result
• Primary better than revision cases

Imhoff et al, AJSM 39(7), 2011

OATS: Auto vs Allograft

• Cylindrical osteochondral allograft

plugs are preferred to autograft:

• Contained lesions greater than 1.5 cm
• Knee osteoarthritis
• History of knee infection
• Patients expressing concern about donor

site morbidity of the knee ISCRA 2017

OATS: Source of Graft

• Allograft plugs should be sourced from

the talus, as well as matched for size and side for reasons related to cartilage thickness, morphology and congruency

• There is an absence of clinical evidence to

recommend in favor of or against the use

• f decellularized osteochondral allograft

plugs

ISCRA 2017

Graft Survival: Fresh Wins

• Fresh osteochondral grafts have shown

viable chondrocytes >17 yrs

• Sig decrease in viable chondrocytes by

day 28 ( 70% viability remains )

• “ fresh osteochondral allografts should

not be used if older than 28 days, preferable to use grafts not older than 21 days”

Williams et al: JBJS 85A, 2003

ISCRA 2017

Best Option for This Patient: OATS

• Size Matters

– Patients lesion is 1.3 cm

• ISCRA guidelines applied:
• Autograft from knee (<1.5 cm)
• 2 plugs intersecting
• Plugs are flush
• Biologic augmentation should be

considered

THANK YOU