Abstract
Introduction: Revitalizing of the necrotic subchondral bone is the therapeutic paradigm in OCL/OD of the talus. Bone-marrow stimulation includes K-wire drilling or open debridement and cancellous bone grafting. Our results presented here are based on retrograde core-drilling and autologous cancellous bone-grafting of the talar dome guided by fluoroscopy and arthroscopy. Performed as a minimal-invasive technique, no additional harvesting site for bone-grafting is necessary.
Methods: 38 patients (16 female, 25 male) with 41 symptomatic focal osteochondral lesions (ICRS I–III°) of the talus (3 bilateral) were treated by fluoroscopicguided retrograde coredrilling and autologous cancellous bone-grafting from the drilling cylinder. The results were evaluated retrospectively by use of the Ogilvie-Harris-Score (OHS), subjective clinical ratings on a visual analogue scale (VAS (0–10 max.)) and MRI. The patient’s mean age was 33.2 (±15.4) years. 27 patients (66%) reported a trauma history (sprain, compression). Most defects were located in the medial talus (36/41), 4 were lateral and 1 central. 34 cases were primary interventions. In 14 cases the growth plate of the distal tibial epiphysis was detectable.
Results: The follow-up was 7–54 months with a mean of 29 (±13) months. The arthroscopic findings according to ICRS classified 12/41 as I°, 22/41 as II° and 7/41 as III° lesions. Preoperatively there were 11 poor, 25 fair, 4 good and 1 excellent ratings in the OHS-score turning into 1/9/13/18 postoperatively. There were 75.6% (31/41) overall good/excellent results. Good or excellent results were predominantly seen in grade I with 91.6% (11/12) and in grade II with 77.3% (17/22), whereas grade III showed success only in 42.8% (3/7). Open growth plates resulted good or excellent results in 85.7% (12/14 cases). First-line treatments showed a markedly better outcome of 82.3% (28/34) of good/ excellent results compared to 42.8% (3/7) of second-line treatments. Gender or trauma history did not influence the score results. Pain intensity on a VAS significantly reduced from 7.5 (±1.5) to 3.7 (±2.6). The subjective functional status on the VAS revealed a remarkable increase from 4.6 (±2.3) to 8.2 (±2.0), (p< 0.01). In MRI controls two patients showed a progression into demarcation (IV°) associated with a fair or poor score result.
Conclusion: Our results indicate that fluoroscopic-guided retrograde core-drilling and autologous cancellous bone grafting is an appropriate operative option for talar OCL in minor grades I + II. Performed as a minimal-invasive technique, the subchondral necrosectomy and combined bone-grafting provide extended revitalization properties for OCL healing. Tending to success rates of only 42% in lesions III°, this technique can not generally be recommended here.
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