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Osteochondral Lesions of the Talus Managed via Particulated Juvenile Articular Cartilage

March 01, 2019

Contributors: J Preston Van Buren, DO; Jeffrey L. Wake, ATC, BS; Kevin D Martin, DO; Kevin D Martin, DO

Osteochondral lesions of the talus (OLTs) are common injuries. Chondral injuries occur in approximately 50% of patients with an ankle sprain and 73% of patients with an ankle fracture. These lesions involve damage to the articular cartilage and the surrounding subchondral bone, causing decreased range of motion, activity limitations, and deep ankle pain. A variety of systems are available for the classification of OLTs, including the Berndt and Harty classification, the Ferkel and Sgaglione CT Staging System, the Hepple MRI Staging System, and the Arthroscopic Staging System. An anatomic grid scheme was developed by Raikin et al to easily map OLTs using MRI. Typically, management is nonsurgical, consisting of non-weight-bearing and immobilization, for patients with a stage I or stage II lesion and is surgical for patients with a stage III or stage IV lesion that does not improve with nonsurgical management. Surgical treatment options vary; however, management of OLTs via juvenile articular cartilage allograft has been increasing, resulting in good outcomes. This video demonstrates the management of an OLT via arthroscopic juvenile allograft cartilage, which results in improved function and decreased pain secondary to the development of articular cartilage at the defect site. The patient is prepared and draped in the supine position to expose the appropriate lower extremity. A tourniquet is applied to the ipsilateral thigh to limit blood flow to the surgical site. A limb positioner is used to distract the ipsilateral ankle, allowing the surgeon to use both hands for the procedure. A 5-mm anteromedial portal is established using the nick-and-spread technique. A blunt trocar is introduced into the ankle joint via the anteromedial portal. The ankle should be kept in dorsiflexion to prevent cartilage injury. Traction is provided via the limb positioner. An anterolateral portal is made under direct visualization. Diagnostic arthroscopy is performed to identify loose bodies and cartilage lesions. Foreign bodies should be removed. A 90° curette is used to clear the osteochondral lesion with sharp margins down to the subchondral bone. The margins should be 90° to the plane of the talar cartilage. After the lesion is clear, it is measured. A Frazier tip is used to suction saline out of the joint. Cotton tipped applicators are used to completely dry the surface of the lesion. One-third of the tip of a 1-mL syringe is cut off, and the proximal portion will be used as a modified port to introduce the juvenile cells into the joint. A 16-g angiocatheter is used to introduce fibrin glue into the joint, applying a thin layer to the surface of the subchondral bone. The juvenile cells that have had the fluid drained off are introduced into the syringe using a small freer elevator. The plunger of the syringe can be used to further introduce the juvenile cells into the lesion. The freer elevator is used to smooth the cells over the lesion. The cells do not need to be more than one layer thick. A thin layer of fibrin glue is applied over the cells using a new angiocatheter. The ankle is taken through dorsiflexion/plantar flexion to ensure proper placement of the cells. Postoperatively, patients are instructed to remain non-weight-bearing in a boot for 6 weeks and remain 25% weight-bearing from postoperative weeks 6 through 12, with full weight-bearing allowed after postoperative week 12. Physical therapy, which includes range of motion exercises, bicycling, nonimpact cardio, and pool therapy, is initiated 7 weeks postoperatively. OLTs may be debilitating injuries in patients with an ankle sprain. Treatment options for the management of these lesions depend on classification and patient progression. Surgical management of OLTs varies. Juvenile allograft cartilage is advantageous because it is a single-stage procedure that allows for the repair of large cartilage defects and preserves subchondral bone. Most studies on juvenile cartilage focus on its use for the management of patellar lesions; however, a 2017 study by Saltzman et al. demonstrated promising outcomes in 33 patients with an OLT. Conversely, Dekkar et al. reported a 40% failure rate associated with the use of juvenile allograft to manage OLTs, with failure defined as no improvement or worse symptoms postoperatively. The risks associated with the management of OLTs via arthroscopic juvenile allograft cartilage include the typical risks associated with arthroscopy about the ankle, including nerve irritation and infection, joint effusion, joint inflammation, graft hypertrophy, and graft delamination. Graft-mediated disease transmission also may occur. Joint stiffness may occur in patients who do not perform diligent range of motion exercises postoperatively.

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