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Osteochondral Autologous Transplantation Is Superior to Repeat Arthroscopy for the Treatment of
Osteochondral Lesions of the Talus After Failed Primary Arthroscopic Treatment
Hang Seob Yoon, Yoo Jung Park, Moses Lee, Woo Jin Choi and Jin Woo Lee
Am J Sports Med published online June 6, 2014
DOI: 10.1177/0363546514535186
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AJSM PreView, published on June 6, 2014 as doi:10.1177/0363546514535186
Osteochondral Autologous Transplantation
Is Superior to Repeat Arthroscopy for
the Treatment of Osteochondral Lesions
of the Talus After Failed Primary
Arthroscopic Treatment
Hang Seob Yoon,* MD, Yoo Jung Park,y MD, Moses Lee,y MD,
Woo Jin Choi,y MD, PhD, and Jin Woo Lee,yz MD, PhD
Investigation performed at Yonsei University College of Medicine, Seoul, Korea
Background: Several studies have reported on the outcome of arthroscopic treatment or osteochondral autologous transplantation (OAT) for osteochondral lesions of the talus (OLT), with mixed results. None of these studies has compared the results of
repeat arthroscopy and OAT after failed primary arthroscopic treatment.
Purpose: To compare the outcomes of OAT and repeat arthroscopy for the treatment of OLT after primary arthroscopy
Study Design: Cohort study; Level of evidence, 3.
Methods: This study included 22 patients who underwent OAT (group A) and 22 patients who underwent repeat arthroscopy
(group B) after failed treatment of OLT among 399 patients who received primary arthroscopic marrow stimulation at single institution between 2001 and 2009. All patients were evaluated clinically using the visual analog scale (VAS) for pain and American
Orthopaedic Foot and Ankle Society (AOFAS) Ankle Hindfoot Scale. The cumulative success rates were compared by use of
Kaplan-Meier life table analysis.
Results: The patients’ demographic and clinical characteristics and indications for surgery were comparable between the groups.
Both groups showed significantly improved (P \ .001) VAS and AOFAS scores 6 months after surgery. However, group B showed
significant deterioration over a mean follow-up period of 50 months. Overall, 18 of 22 (81.8%) patients in group A and 7 of 22
(31.8%) patients in group B achieved an excellent or good (80) AOFAS score (P \ .001). No patient in group A and 14 of 22
(63.6%) in group B required further revisions.
Conclusion: Osteochondral autologous transplantation was significantly superior to repeat arthroscopic treatment of OLT after
a mean follow-up period of 48 months. Therefore, repeat arthroscopy should be used judiciously for the treatment of OLT after
failed arthroscopic treatment.
Keywords: ankle; osteochondral lesion; osteochondral autologous transplantation; repeat arthroscopy
generally poor regenerative capacity and may be unable to
self-repair depending on the size of the defect, its depth
and location, and the patient’s age.13,25 When nonoperative
treatment is unsuccessful, patients with symptomatic OLT
may be treated by various surgical methods such as arthroscopic marrow stimulation techniques, osteochondral autologous transplantation (OAT), autologous chondrocyte
implantation (ACI), and frozen osteochondral allograft.9,11,14
Arthroscopic marrow stimulation techniques, including
debridement, microfracture, anterograde drilling, and retrograde drilling, have been the preferred initial surgical
option for most OTL. Long-term follow-up has revealed
good to excellent results for arthroscopic procedures in
65% to 90% of patients.2,4-6,28,34,36,38 However, several
recent studies have reported less favorable outcomes of
arthroscopic treatment in large and uncontained
An osteochondral lesion of the talus (OLT) involves the
talar articular cartilage and adjacent subchondral bone.
Articular cartilage damaged by trauma or disease has
z
Address correspondence to Jin Woo Lee, MD, PhD, Department of
Orthopaedic Surgery, Yonsei University College of Medicine, 50 Yonseiro, Seodaemun-gu, Seoul 120-752, Korea (e-mail: ljwos@yuhs.ac).
*Department of Orthopaedic Surgery, Wooridul Hospital, Seoul,
Korea.
y
Department of Orthopaedic Surgery, Yonsei University College of
Medicine, Seoul, Korea.
The authors declared that they have no conflicts of interest in the
authorship and publication of this contribution.
The American Journal of Sports Medicine, Vol. XX, No. X
DOI: 10.1177/0363546514535186
Ó 2014 The Author(s)
1
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Yoon et al
The American Journal of Sports Medicine
defects.4,6,7 Consequently, surgeons increasingly face the
challenge of determining the most appropriate second-line
surgical treatment strategy. Data are available from randomized studies comparing arthroscopic treatment with
OAT for OLT and from more recent studies comparing
arthroscopic treatment with ACI for cartilage defects of
the knee.15,24 However, these studies have generally
excluded patients previously treated arthroscopically, thus
obscuring the relative efficacies of OAT and repeat arthroscopy in patients in whom previous arthroscopic treatment
has failed. In a review of osteochondral lesions in the
knee, osteochondral lesions for which prior microfracture
therapy failed displayed subchondral changes such as a stiff
and thickened subchondral plate, osseous overgrowth, and
the formation of subchondral cysts.27,29 In the absence of
similar studies evaluating OLT, these findings in the knee
may provide useful and compelling information for clinical
decision making in the treatment of ankle lesions because
repeat arthroscopy has been associated with worse clinical
outcomes due to these subchondral changes.27,29
Osteochondral autologous transplantation is a procedure
in which viable hyaline cartilage and its underlying subchondral bone are harvested from the ipsilateral knee and
transplanted to the site of the defect in the talus.11,14,30
This procedure has been used to treat large and cystic osteochondral lesions or after failed index surgery. Although
OAT restores normal hyaline cartilage, it does have disadvantages, including considerable donor site morbidity, the
formation of subchondral bone cysts, poor healing potential
of the cartilage interface of the graft, the need for complex
rehabilitation, and a long recovery time.30,37
No previously published study has compared the results
of repeat arthroscopic treatment and OAT after failed
arthroscopic treatment for OLT. The first aim of this study
was to compare OAT with repeat arthroscopy for the treatment of OLT after failed primary arthroscopic treatment.
The second aim was to evaluate the hypothesis that OAT
is superior to arthroscopy in cases in which other modalities have failed.
MATERIALS AND METHODS
This study included 22 patients who underwent OAT
(group A) and 22 patients who underwent repeat arthroscopy (group B) after failed treatment of OLT among 399
patients who received arthroscopic marrow stimulation at
a single center between 2001 and 2009. All patients were
informed of the potential risks, including nonunion of the
osteotomy site and donor site morbidity after OAT, and
of the benefits and possible complications of repeat
arthroscopy. Selection of repeat arthroscopy versus OAT
was made without any preference on the part of the clinician and was decided through discussion with the patient.
The patients who elected to undergo repeat arthroscopy for
failed OLT did so because they did not want to undergo
surgery as aggressive as OAT. All arthroscopic and repeat
surgical procedures were performed by the senior surgeon
(J.W.L.). Institutional review board approval was obtained,
and all patients provided informed consent.
Inclusion and Exclusion Criteria
The inclusion criteria were joint stability, absence of extensive joint degeneration (defined as radiographic changes of
grade 2 or higher according to the grading system of
Kellgren and Lawrence22), and osteochondral lesions for
which previous arthroscopic treatment had not been successful. Patients with diffuse arthritic changes of the ankle
joint on plain radiographs or diffuse fibrillated articular
cartilage on arthroscopic examination of repeat surgery
and those with axial malalignment or chronic ankle instability were excluded, as were those with OLT that had not
been previously treated arthroscopically. Forty-eight consecutive patients who failed primary arthroscopic marrow
stimulation underwent revision surgery during the study
period. Of these 48 patients, 22 underwent OAT and 26
underwent repeat arthroscopy. Of the 26 patients who
underwent repeat arthroscopy patients, 1 patient had
chronic lateral ankle instability and 3 patients exhibited
diffuse cartilage fibrillation considered as osteoarthritis
on the talus in secondary arthroscopy. These 4 patients
were excluded from this study. None of the patients were
lost to follow-up during the study periods.
All patients had previously undergone surgery on the
same ankle, 22 for arthroscopic microfracture (13 in group
A and 9 in group B) and 22 for removal of a loose osteochondral fragment and abrasion arthroplasty (9 in group A and
13 in group B).
Clinical Analysis and Outcome Criteria
All outcome assessments were collected by a blinded and
independent examiner who was not involved in the clinical
and surgical management of the patients. The clinical outcomes of all patients were analyzed using the visual analog
scale (VAS) for pain and the American Orthopaedic Foot
and Ankle Society (AOFAS) Ankle Hindfoot Scale.23 All
patients were evaluated before operation and were
reviewed after 6, 12, and 24 months and then yearly thereafter. The overall clinical results were categorized according to the criteria suggested by other clinical studies
using the AOFAS score (excellent, 90-100; good, 80-89;
fair, 70-79; and poor, \70).5,6,28,33 Treatment failure was
defined as persistent or recurrent symptoms, additional
surgical treatment, or an AOFAS score lower than
80.5,6,33 The time to treatment failure was the time
between the end of the primary surgical procedure and
the date of repeat intervention.
At the time of our initial examination, standard radiography and magnetic resonance imaging (MRI) were performed on all 44 patients and revealed no arthritic
changes in any patient in either group. The size of each
OLT was measured from the preoperative MRI as
described in a previous study (calculated from the coronal
and sagittal length using the ellipse formula),6 and the
lesion was classified as small (\150 mm2) or large
(150 mm2). To avoid potential bias, an independent
observer who was not involved in the care of the patients
and was blinded to the intention of this study evaluated
the MRIs.
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OLT After Failed Primary Arthroscopic Treatment
3
Figure 1. (A) Primary arthroscopic debridement and abrasion of a full-thickness articular cartilage defect in the medial dome of
the talus. (B) Repeat arthroscopy 3 years after primary treatment showed surface irregularity with fibrillation that clearly differs
from the surrounding normal articular cartilage.
Figure 2. Osteochondral autologous transplantation (OAT) via osteotomy of the medial malleolus. (A) An area of fibrocartilage that
was of poor quality, partially loose, and not fully healed after primary arthroscopic treatment in the medial dome of the talus. (B)
After the removal of fibrotic tissue, the defect was filled with an osteochondral plug 10 mm in diameter that was harvested from
the nonweightbearing zone of the lateral femoral condyle.
Surgical Technique
Repeat Arthroscopic Marrow Stimulation Procedure.
Primary and repeat arthroscopies were performed by the
senior author using identical techniques. We used only 2
anterior portals (anteromedial and anterolateral) for the
arthroscope and working instrument. Noninvasive traction
(15 pounds) was applied by use of a foot strap to provide
gentle ankle distraction. First, the joint was examined
arthroscopically by use of previous arthroscopic portals.
No filling of the defect with fibrocartilage or loosening of
the reparative fibrocartilage from the defect site was found
in any of the 22 patients, and 4 patients had total degeneration of the microfracture area (Figure 1). This was
removed with a ring-shaped or curved curette and a power
shaver with a small blade. After this preparation of the
lesion, multiple holes were made in the exposed subchondral bone plate by use of an arthroscopic awl. In areas
affected by loss of subchondral bone, abrasion arthroplasty
was performed by trimming the damaged cartilage with
a power shaver to create a smooth, stable articular surface.
Once the microfracture or abrasion arthroplasty was completed, the tourniquet was released to visualize the release
of fat droplets and blood from the microfracture holes into
the ankle. Additional arthroscopic findings included soft
tissue impingement with a fibrotic scar in 12 patients
(54.5%) and loose body in 9 patients (40.9%). We treated
these lesions with arthroscopic debridement and bone
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The American Journal of Sports Medicine
TABLE 1
Demographic and Clinical Characteristics: Osteochondral Autologous Transplantation
(Group A) Versus Repeat Arthroscopy (Group B)a
Characteristic
Group A (n = 22)
Mean age, y
Age 35 y
Male
Body mass index, kg/m2
Duration of symptoms, mo
History of trauma
Type of defect
Contained
Uncontained
Mean defect size, mm2
\150 mm2
150 mm2
Location of defect
Medial/lateral
Anterior/middle/posterior
Arthroscopic procedure
Microfracture
Abrasion arthroplasty
Group B (n = 22)
37.1
11
15
25.6
59.9
12
6 13.6
(50)
(68)
6 3.0
6 39.3
(55)
41.6
15
18
25.3
82.2
14
6 13.2
(68)
(82)
6 3.0
6 44.6
(64)
3
19
152.9
14
8
(14)
(86)
6 76.5
(64)
(36)
3
19
138.5
15
7
(14)
(86)
6 60.0
(68)
(32)
19/3 (86/14)
3/10/9 (14/45/41)
18/4 (82/18)
6/8/8 (27/36/36)
13 (59)
9 (31)
P
.234
.220
.296
.622
.104
.833
.668
.760
.750
.680
.527
.183
9 (41)
13 (59)
a
The age, body mass index, duration of symptoms, and defect size are given as the mean 6 standard deviation and compared between the
groups by use of the Mann-Whitney U test. The categorical variables are presented as the number (%) of patients and compared between the
groups using the Pearson x2 test.
TABLE 2
Type of Intra-Articular Lesions in Both Groupsa
Group A (n = 22) Group B (n = 22) Pb
Subchondral cyst
Tibial chondral lesion
Soft tissue impingement
Ossicle
Loose body
13
1
12
4
9
(59)
(5)
(55)
(18)
(41)
14(64)
3 (14)
14 (64)
0 (0)
10 (45)
.760
.300
.544
.038
.764
a
Values are expressed as n (%).
Mann-Whitney U test.
b
marrow stimulation. After surgery, the patients were
restricted to partial weightbearing for 4 weeks and were
prescribed physical therapy for range of motion and
strengthening. No impact activities were allowed for a minimum of 12 weeks.
Osteochondral Autologous Transplantation. After
arthroscopic inspection and debridement of the ankle joint,
the lesion was approached through a small longitudinal
incision in the joint capsule. Remnants of residual fibrotic
tissue were removed from the subchondral bone of the
defect. The osteochondral grafts (6 and 8 mm) were harvested from the nonweightbearing zone of the lateral femoral condyle using a special chisel (OATS; Arthrex, Naples,
Florida, USA). The recipient lesions were debrided and
prepared for the grafts. The donor cylinders were
implanted by use of a press-fit technique (Figure 2). A
mean of 2.1 osteochondral plugs (range, 1-3 plugs) were
used in each patient. In patients with medial OLT, osteotomy of the medial malleolus was necessary for appropriate
exposure of the talus lesion. For osteotomy of the medial
ankle, 4 drill holes were made and oblique osteotomy was
performed at the transition between the pilon and the
medial malleolar joint surface. After OAT, the medial
ankle was fixed with four 4.0-mm screws. Postoperatively,
passive exercise of the ankle with limited range of motion
and active isometric training were initiated immediately.
Toe-touch ambulation with crutches was permitted, and
physical therapy was prescribed. Gradual progression
from partial to full weightbearing activity was allowed
beginning 6 weeks after surgery after follow-up radiographs confirmed good incorporation of the osteochondral
graft.16,26
Statistical Analysis
The clinical data were compared using the nonparametric
Wilcoxon signed rank test for paired samples (preoperative
and postoperative scores). Differences between groups
were analyzed using the Mann-Whitney U test for continuous variables and the chi-square test or Fisher’s exact
test (used when the expected frequency count in a cell
was \5), as appropriate, for categorical variables. Bivariate analysis was performed using Spearman’s correlation
coefficient for correlations between preoperative variables
(age, sex, body mass index [BMI], symptom duration,
time interval between the procedures, type of defect, and
defect size) and all final clinical outcomes. The estimated
probabilities of clinical failure were calculated using the
Kaplan-Meier method.21 A P value less than .05 was considered indicative of significance. The data were analyzed
using the Statistical Package for Social Sciences (v 18.0;
SPSS Inc, Chicago, Illinois, USA).
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OLT After Failed Primary Arthroscopic Treatment
TABLE 3
Comparison of Clinical Outcomes Between the
Osteochondral Autograft Transplantation
(Group A) and Repeat Arthroscopic Treatment (Group B)a
TABLE 4
Correlations Between Preoperative
Variables and Clinical Outcome
Group A (n = 22)
Group A
(n = 22)
VAS score, mean 6 SD
Preoperative
6 months
12 months
24 months
Last follow-up
AOFAS score, mean 6 SD
Preoperative
6 months
12 months
24 months
Last follow-up
Clinical outcome
at last follow-up, No. (%)1-3,b
Excellent
Good
Fair
Poor
Group B
(n = 22)
P
6.14
2.95
2.45
1.95
1.91
6
6
6
6
6
1.32
1.09
1.14
0.89
1.54
5.86
3.18
2.68
3.41
5.27
6
6
6
6
6
1.55
.708
1.05
.508
0.84
.324
1.22 \.001
1.72 \.001
50.40
82.81
86.22
85.90
85.27
6
6
6
6
6
7.66
6.58
5.56
4.15
5.75
50.41
83.73
79.77
71.77
69.64
6
6
6
6
6
11.40 .144
2.65
.056
4.09 \.001
10.00 \.001
10.59 \.001
\.001
6 (27.3)
12 (54.5)
4 (18.2)
0
0
7 (31.8)
5 (22.7)
10 (45.5)
a
Boldface type indicates statistical significance (P \ .05).
AOFAS, American Orthopaedic Foot and Ankle Society Ankle
Hindfoot Scale; SD, standard deviation; VAS, visual analog scale.
b
Clinical results at final follow-up were graded according to the
AOFAS scores (excellent; 90-100, good; 80-89, fair; 70-79, and
poor; \70).
5
Age
Male sex
Body mass index
Duration of symptoms
Time interval between
the procedures
Type of defect
(uncontained)
Defect size
Spearman
Correlation
Coefficient
Group B (n = 22)
P
Spearman
Correlation
Coefficient
P
–0.325
0.224
0.086
0.091
0.131
.140
.159
.702
.425
.641
0.085
0.329
–0.085
0.525
–0.223
.706
.621
.708
.411
.317
–0.082
.095
–0.052
.059
0.417
.053
–0.462
.030
RESULTS
Baseline Characteristics
The 2 groups did not differ significantly in age, gender
ratio, BMI, duration of symptoms, defect size, or primary
arthroscopic procedure (all P . .05) (Table 1). The mean
duration of follow-up was 48 months overall, 45 months
(range, 24-101 months) in group A and 50 months (range,
24-116 months) in group B.
Comparison of the primary arthroscopic data showed
that the groups were similar with respect to the types, sizes,
and grades of their lesions. Overall, the cartilage defects of
patients in this study were predominantly large (mean total
defect size, 152.9 mm2 in group A and 138.5 mm2 in group
B) and full thickness (Ferkel and Cheng10 staging system,
grades D-F) and were located mainly on the medial talar
dome. The groups had similar proportions of associated
intra-articular lesions, including subchondral cysts, tibial
chondral lesions, soft tissue impingement, ossicles, and
loose bodies (P . .05) (Table 2).
Clinical Outcomes
Figure 3. Kaplan-Meier survival curve showing the cumulative rate of clinical failure in patients treated with osteochondral autologous transplantation (OAT) versus repeat
arthroscopy. Patients treated with repeat arthroscopy showed
significantly greater clinical failure (defined as persistent pain
or recurrent symptoms, additional surgical treatment, or
AOFAS score \80) than did those treated with OAT (P \ .001)
Both groups demonstrated significant clinical improvement
(P \ .05) after 1 year, and comparison of the clinical outcome
criteria5,6,28,33 showed that the AOFAS scores were excellent
or good (80) in 19 of 22 (86.4%) patients in group A versus
12 of 22 (54.5%) in group B (P = .021). Group B showed significant deterioration at the 1-year follow-up assessment but
had still achieved significant clinical improvement relative to
the patients’ preoperative evaluations (P \ .001). As of the
last follow-up, 18 of 22 (81.8%) patients in group A but only
7 of 22 (31.8%) in group B maintained excellent or good
results (P \ .001) (Table 3). The pattern of lower postoperative AOFAS scores in the patients treated with repeat
arthroscopy persisted, and the cumulative clinical failure
rate was significantly higher in the patients treated with
repeat arthroscopy compared with those treated with OAT
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(P \ .001) (Figure 3). Similar trends were also observed for
the VAS score.
In group A, 4 patients reported continued ankle pain and
swelling even after appropriate rehabilitation and were not
completely satisfied with the statuses of their ankles. Therefore, we performed second-look arthroscopy in each of these
patients at a mean of 21.4 months (range, 14-36 months)
after their index operations. The second-look arthroscopies
revealed fibrillation of the graft surface and soft tissue
between the grafts on probing relative to the surrounding
cartilage, which required debridement. Six months after
debridement and chondroplasty, these patients were painfree and began engaging in sports activities. In group B,
14 of 15 patients with failure underwent revision OAT.
The single patient who experienced clinical failure but
refused to undergo more aggressive surgery was managed
with nonsurgical measures, including rest, immobilization,
anti-inflammatory medication, and physical therapy.
We attempted to identify factors associated with the
final results in both groups but found no associations
between several preoperative variables and clinical outcomes as of the last follow-up evaluation in group A (Table
4). In group B, poorer clinical outcomes were associated
with patients who had larger defect (r = –0.462, P =
.030). In group A, the rate of clinical failure was higher
in patients with large defects (25.0%, 2/8) than in those
with small defects (14.3%, 2/14). However, this difference
did not reach statistical significance (P = .393). In group
B, clinical failure occurred within 50 months in 8 of 15
patients (53.3%) with small defects versus in all (100%,
7/7) of the patients with large defects (P \ .001).
In group A, 4 of 22 (18%) patients and 2 of 22 (9%)
patients reported mild knee pain and crepitation, respectively. These complaints resolved successfully within 3
months of nonoperative treatment. One patient developed
a superficial wound infection, which had resolved after
oral antibiotic therapy. In group B, there were no intraoperative or perioperative complications, including wound
infection and neural injury.
DISCUSSION
A number of promising surgical interventions for OLT
have been established in recent years. These can be either
reparative, as are marrow stimulation techniques, or
restorative, for which OAT and ACI have become wellestablished techniques.11,37 The clinical results and outcomes of reparative and restorative techniques have been
carefully investigated, and various predictors and factors
influencing the success rates of these techniques have
been established. Several authorities advocate the preferential use of arthroscopic treatment in patients with
OLT, claiming good clinical results equal to those of cartilage replantation techniques such as OAT and ACI.7,14,33
In our study, 88% of 399 patients who underwent primary
arthroscopic marrow stimulation did not require revision
surgery. Our results are consistent with those reported
by Choi et al,6 who found that 8 of 120 ankles (6.7%)
required revision surgery after arthroscopic marrow
stimulation, with good to excellent results in 81.6% ankles
at the average 35.6 months follow-up. Lee et al,28 in a study
of 20 ankles treated with arthroscopic treatment, reported
that overall 90% of ankles achieved good to excellent
results. Therefore, arthroscopic marrow stimulation is currently the primary technique used to treat symptomatic
OLT.
Arthroscopic treatment has been reported to provide
effective improvement in ankle function when used to treat
small OLT, but favorable long-term results have been less
predictable for large OLT.1,12 In cases in which primary
arthroscopic treatment fails, the decision of which subsequent technique to choose has become increasingly difficult, as such patients may be unlikely to have good
clinical outcomes irrespective of the surgical technique
used. In the last 10 to 15 years, there have been many
attempts to identify the most appropriate method for treating lesions in which primary arthroscopy has failed. The
techniques examined have included repeat arthroscopy,
open reconstructive procedures including OAT, ACI, and
structural osteochondral allograft.16,20,26,32,37 Kreuz
et al26 used OAT to treat recurrent OLT after failed primary arthroscopic treatment and achieved good clinical
results. Savva et al32 reported that repeat arthroscopic
debridement is an acceptable option for treatment of small
to medium-sized OLT for which primary debridement
failed. However, there have been no studies comparing
OAT and repeat arthroscopy, and only level 4 studies for
each technique are available in the literature.16,17,31,32,39
The present study is, to our knowledge, the first to compare OAT with repeat arthroscopy for treatment of OLT in
which prior arthroscopic treatment failed. We have shown
that both OAT and repeat arthroscopy give encouraging
clinical results for the first year of follow-up but that
OAT is significantly superior to repeat arthroscopy after
follow-up for a mean of 4 years.
The size of the OLT influences the choice and results of
its treatment. Arthroscopic marrow stimulation procedures
have been proposed as an easy, rapid, and inexpensive way
to restore cartilage injuries, but these procedures may
restore cartilage defects by inducing the formation of fibrocartilage. For smaller lesions, this substitution of fibrocartilage may suffice; however, for larger lesions, fibrocartilage
may not be adequate for longevity of the joint.6,7,14 In contrast, several studies have suggested that the results of
OAT remain more durable over the long term, especially
in large OLT, because of the ability of OAT to provide
mechanically stable hyaline cartilage.9,11,14,16,18 When
size-dependent repair is discussed in the literature, OAT
is generally recommended for larger cartilage defects.9,14
Hangody et al19 reported the treatment of 36 patients
with osteochondral defects larger than 10 mm using OAT
and achieved excellent results in 34 patients (94%) after
a mean follow-up period of 4.2 years. The cited reports are
in agreement with our finding. In our study, the size of
the osteochondral lesions was comparable between the
groups. One of the notable features of the present study is
that we analyzed the clinical outcomes relative to the preoperative variables and were thus able to show that the size of
the cartilage defect was the strongest predictor of poor
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OLT After Failed Primary Arthroscopic Treatment
clinical outcome in group B but did not affect the clinical
results in group A. Among patients with larger osteochondral defects (150 mm2), only 2 of 8 (25.0%) in group A versus all (100%, 7/7) in group B exhibited clinical failure. The
higher failure rate of repeat arthroscopy for treatment of
large osteochondral defects could account in part for the
major difference in clinical outcomes between the OAT
group and the repeat arthroscopy group.
The prognostic significance of the containment of OLT
has recently garnered renewed attention in the field of
arthroscopic marrow stimulation treatment.4,8 Intact cartilage walls provide an enclosed space in which marrow clot
can form; however, the ‘‘superclot’’ that facilitates fibrocartilage formation might not form in uncontained lesions.29
Choi et al4 found that patients with uncontained OLT
had substantially worse clinical results than those with
contained OLT after follow-up for 74 months. Although
the containment of the OLT has not been reported to affect
the clinical outcome after OAT, OAT with perpendicular
access can be used to reconstruct the articular surface of
the talar dome.9 Most of the patients in our present series
had uncontained OLT, which may have contributed to the
difference in long-term results between the 2 groups.
As our understanding of its underlying pathophysiological process has increased, osteoarthritis has come to be
considered a disease of the entire osteochondral unit rather
than being limited to the articular cartilage.3 In a review of
osteochondral lesions in the knee, osteochondral lesions for
which microfracture therapy failed resembled chronic
chondral lesions and displayed subchondral changes such
as a stiff and thickened subchondral plate, osseous overgrowth, and the formation of subchondral cysts.27,29 In
the absence of similar studies evaluating arthroscopic
treatment of the talus, these previous studies of the knee
indicate that changes of the osteochondral unit may provide useful insight into the limitations of repeat arthroscopic treatment.27,29 The alteration to the osteochondral
unit can be theorized to be responsible for the worse outcomes after repeat arthroscopy versus OAT because the
latter replaces the cartilage lesions with an intact and integrated bone–hyaline cartilage unit loaded with viable cells.
Osteochondral autologous transplantation has become
an accepted surgical procedure for the treatment of OTL
of large size9 and those associated with expansive subchondral cysts.35 However, clinical outcomes and success rates
of OAT as a revision technique after failure of marrow
stimulation in the same location remain controversial.
Imhoff et al20 found that patients in whom OAT was the
second surgical procedure after arthroscopic drilling for
a talar defect had worse clinical outcomes than did those
in whom OAT was the first surgical procedure. In contrast,
Haasper et al16 reported equally favorable outcomes in
patients undergoing secondary OAT relative to patients
undergoing primary OAT after follow-up for a median of
24 months. Kreuz et al26 described good clinical outcomes
after a mean follow-up period of 49 months in their 35
patients treated with OAT after failed primary arthroscopic management. Despite the general baseline severity
of the lesions treated with OAT in the present study,
81.8% of the patients had excellent or good AOFAS scores
7
(80 points) after follow-up for a mean of 45 months.
Although our study did not examine primary OAT and
therefore cannot determine whether the results of revision
OAT after failed arthroscopic microfracture are better or
worse, it does demonstrate that OAT is an effective option
for the treatment of symptomatic OLT in which arthroscopic treatment has failed.
The limitations of our study include its retrospective
nonrandomized nature, although we did use data gathered
preoperatively. We also examined a relatively small number of patients, which limits our statistical power. Furthermore, it remains questionable whether the AOFAS score is
the best evaluation to assess the clinical outcome for the
treatment of OLT. However, given that no previously published study has compared the results of repeat arthroscopic treatment with those of OAT for the treatment of
OLT for which primary arthroscopic treatment has failed,
we believe that our data may aid orthopaedic surgeons in
the selection of the most appropriate revision technique
in such cases.
Arthroscopic treatment plays an important role in the
treatment of OLT. However, the management of OLT in
which arthroscopic treatment has failed is challenging
given the poor potential of these lesions for healing. In
our study, OAT showed significant superiority over repeat
arthroscopic treatment of OLT in the ankle after follow-up
for a mean of 48 months. Therefore, repeat arthroscopy
should be used judiciously for the treatment of OLT in
which arthroscopic treatment has failed.
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