Surgical Interventions for Talar OCL
This page represents a partial list of the diverse surgical approaches used for treatment. Inclusion on this page does not represent endorsement of any approach.
Read about cartilage repair techniques at the International Cartilage Regeneration and Joint Preservation Society
Fixation of Loose Fragments
When an OCL involves fragments separated from the talus, fixation procedures may be considered to reattach these pieces. If the fragments are in an accessible location, fixation may be performed arthroscopically. In other cases, fixation may require an open surgery. Fixation procedures may involve surgical removal of damaged portions of the affected bone underlying the lesion. Tissue removed may be replaced with small bone grafts. In some cases bone-marrow stimulating procedures (see below) may be used to stimulate revascularization. Finally, the loose fragments are reattached using pins, screws wires, or similar devices.
Source: Rikken, Q. G., & Kerkhoffs, G. M. (2021). Osteochondral lesions of the talus: an individualized treatment paradigm from the Amsterdam perspective. Foot and ankle clinics, 26(1), 121-136.
Photo Credit: Ligamentaxis, CC BY-SA 4.0
Bone Marrow Stimulation
For smaller (less than 150 mm2), cartilage lesions, the most common surgical interventions use bone marrow stimulation techniques such as microfracture. These procedures can usually be performed arthoscopically. These approaches involve creation of small holes into the bone underlying the lesion. This stimulates revascularization and the migration of cells and growth factors into the area of the lesion where they may stimulate tissue regeneration. The new cartilage will typically be fibrocartilage, which may be less durable than the hyaline cartilage that normally covers the bones at joint surfaces.
Read about microfracture at the International Cartilage Regeneration and Joint Preservation Society
Occasionally, microfracture may be augmented by means of a scaffold (such as the proprietary product BioTissue) that is placed over the site to capture cells migrating out of the microfracture channels. As of 2022, BioTissue appears to be more available in Europe than elsewhere.
Sources:
Lan, T., McCarthy, H. S., Hulme, C. H., Wright, K. T., & Makwana, N. (2021). The management of talar osteochondral lesions-Current concepts. Journal of Arthroscopy and Joint Surgery, 8(3), 231-237.
Wang, C. C., Yang, K. C., & Chen, H. (2021). Current treatment concepts for osteochondral lesions of the talus. Tzu-Chi Medical Journal, 33(3), 243-249.
Image Credit: OpenStax, CC BY 4.0
Chondrocyte-based cartilage regeneration
Chondrocyte-based regeneration procedures proliferate chondrocytes (cartilage cells) from an individual’s own tissues and re-implant these at the location of a lesion to promote the growth of replacement cartilage.
Due to the need to proliferate the chondrocytes, these approaches are performed with two separate surgeries. The first surgery typically involves arthroscopic removal of a small amount of cartilage from a non-weight bearing location. This can also allow the surgeon to directly observe the nature of the lesion.
The cartilage obtained in this procedure is processed to remove the chondrocytes, which are then grown for several weeks in the laboratory to increase the number of cells. A second surgery is then used to implant the cells at the location of the lesion.
With Autologous Chondrocyte Implantation (ACI), the cells are typically implanted at the location of the lesion with a collagen membrane glued on top of them to keep them in place.
With Matrix- Associated Chondrocyte Implantation (MACI), the cells are induced to grow in the laboratory within a 3D biodegradable matrix. This matrix is then cut to match the contours of the lesion prior to implantation.
A less-commonly used approach to implanting chondrocytes at the location of a lesion is to use particulated junvenile articular cartilage– cartilage obtained from young donor cadavers, which has greater chondrocyte density than adult cartilage and may therefore have greater regenerative potential. One advantage cited for this technique compared to ACI and MACI is that it can be performed with a single surgery rather than a two-step procedure.
Read about ACI at the International Cartilage Regeneration and Joint Preservation Society
Bibliography:
Christensen, B. B., Olesen, M. L., Hede, K. T. C., Bergholt, N. L., Foldager, C. B., & Lind, M. (2021). Particulated cartilage for chondral and osteochondral repair: a review. Cartilage, 13(1_suppl), 1047S-1057S.
Lan, T., McCarthy, H. S., Hulme, C. H., Wright, K. T., & Makwana, N. (2021). The management of talar osteochondral lesions-Current concepts. Journal of Arthroscopy and Joint Surgery, 8(3), 231-237.
Rikken, Q. G., & Kerkhoffs, G. M. (2021). Osteochondral lesions of the talus: an individualized treatment paradigm from the Amsterdam perspective. Foot and ankle clinics, 26(1), 121-136.
Wang, C. C., Yang, K. C., & Chen, H. (2021). Current treatment concepts for osteochondral lesions of the talus. Tzu-Chi Medical Journal, 33(3), 243-249.
Image Credit: Modified from: Davide moggy, CC BY-SA 4.0
Osteochondral Transplantation (Grafting)
For larger defects, and ones with substantial involvement of the bone (such as cysts), osteochondral grafts are among the most common surgical approaches. This approach involves transplantation of bone tissue with its associated hyaline cartilage to replace native tissue excised from the area of the lesion. If surgery is successful, the graft bone and the native bone will grow together (by a similar process to how bone fractures heal) and the former site of the lesion will now be covered by hyaline cartilage.
With autografts, the bone transplant is obtained from another portion of the recipient’s body; for talar grafts the most common donor site is from the femur at the knee. For larger defects, mosaicplasty may be used, in which multiple smaller plugs may be used to fill the site of the lesion.
For very large talar lesions, it is more common to use an allograft, with the transplant material coming from the talus of a cadaver. This decreases the risk of causing problems that might result from removing a large graft from the patient’s own knee.
A much less common transplant approach is to obtain the bone and cartilage material from different sources, for example using an autograft of non-cartilaginous bone from the heel in combination with particles of cartilage taken from juvenile donors.
Read about Mosaicplasty at the International Cartilage Regeneration and Joint Preservation Society
Read about Allografts at the International Cartilage Regeneration and Joint Preservation Society
Bibliography:
Lan, T., McCarthy, H. S., Hulme, C. H., Wright, K. T., & Makwana, N. (2021). The management of talar osteochondral lesions-Current concepts. Journal of Arthroscopy and Joint Surgery, 8(3), 231-237.
Rikken, Q. G., & Kerkhoffs, G. M. (2021). Osteochondral lesions of the talus: an individualized treatment paradigm from the Amsterdam perspective. Foot and ankle clinics, 26(1), 121-136.
Wang, C. C., Yang, K. C., & Chen, H. (2021). Current treatment concepts for osteochondral lesions of the talus. Tzu-Chi Medical Journal, 33(3), 243-249.
Photo Credit: Modified from: nomen49 at German Wikipedia, CC BY-SA 3.0