The Journal of Bone and Joint Surgery 81:1229-35 (1999)
© 1999 The Journal of Bone and Joint Surgery, Inc.
Arthroscopic Drilling for the Treatment of Osteochondral Lesions of the Talus*
TSUKASA KUMAI, M.D., PH.D. ,
YOSHINORI TAKAKURA, M.D., PH.D.,
ICHIRO HIGASHIYAMA, M.D. and
SUSUMU TAMAI, M.D., PH.D., NARA, JAPAN
Investigation performed at Nara Medical University, Nara
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Abstract
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Background: An osteochondral lesion of the talus is a relatively rare disorder of the ankle. While a number of treatment options have been reported, it appears to be difficult to manage all lesions with a single approach. We evaluated the indications for and the results of arthroscopic drilling for the treatment of an osteochondral lesion of the talus.
Methods: Eighteen ankles (seventeen patients) with a symptomatic osteochondral lesion of the talus were examined. The ages of the patients ranged from ten to seventy-eight years (mean, 28.0 years) at the time of the operation, and the patients were followed postoperatively for two to 9.5 years (mean, 4.6 years). After the continuity of the cartilage overlying the lesion and the stability of the lesion had been confirmed, arthroscopic drilling was performed with use of a Kirschner wire that was 1.0 to 1.2 millimeters in diameter. A cast was not applied postoperatively, and full weight-bearing was allowed six weeks after the procedure.
Results: The clinical result was good for thirteen ankles and fair for five; all ankles had improvement. Twelve of the thirteen ankles that were in patients who were less than thirty years old had a good result. In contrast, only one of the five ankles in patients who were fifty years old or more had a good result. Thus, the clinical results tended to be better for younger patients. Improvement was seen radiographically in fifteen ankles. However, the three ankles in patients who were more than sixty years old were found to have no improvement on radiographic examination. Analysis of the group of patients who had a history of trauma revealed that the mean interval between the injury and the operation was 6.3 months for the three ankles that had a good radiographic result and 11.3 months for the six that had a fair result. Thus, the radiographic results tended to be better when the interval between the injury and the operation was shorter.
Conclusions: Arthroscopic drilling for the treatment of medial osteochondral lesions of the talus does not require osteotomy of the medial malleolus or postoperative immobilization; thus, the procedure is less invasive than other types of operative treatment for the condition and it allows early resumption of daily activities and sports. On the basis of the results in this study, we believe that the procedure is effective and useful in young patients, especially those who have not yet had closure of the epiphyseal plate. A specific indication for the procedure is an early lesion with only mild osteosclerosis of the surrounding talar bone, continuity of the cartilaginous surface, and stability of the osteochondral fragment.
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Introduction
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An osteochondral lesion of the talus appears to be a relatively rare disorder and, although many patients have a history of trauma, the etiology remains largely unknown1,4,15. The principles of treatment of this condition have been well established since the description by Berndt and Harty4 in 1959, and a number of treatment methods have been reported1-4,6,8-10,12-14,16. Berndt and Harty classified the lesions into four stages. Stage I indicates a small area of compression of subchondral bone; stage II, a partially detached osteochondral fragment; stage III, a completely detached osteochondral fragment that remains in the talar crater; and stage IV, a displaced osteochondral fragment. Treatment is most commonly based on this radiographic classification system. Subsequent studies4,6,14 have supported this approach, which involves a trial of nonoperative treatment for stage-I and II and medial stage-III lesions and operative treatment for lateral stage-III lesions and stage-IV lesions. We have evaluated the treatment of osteochondral lesions of the talus in many patients, and currently we do not believe that a single approach can be applied to all lesions; instead, an appropriate treatment must be selected from the various alternatives for each patient. Of these alternatives, arthroscopic drilling is simple, is less invasive than other types of operative treatment, and necessitates a short duration of hospitalization; thus, it is considered to be highly advantageous, especially for students and athletes. In this study, we evaluated the specific indications for and the results of this procedure.
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Materials and Methods
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Seventeen (six male and eleven female) patients with eighteen affected ankles were evaluated (Table I). Their ages ranged from ten to seventy-eight years (mean, 28.0 years) at the time of the operation, and they were followed postoperatively for two to 9.5 years (mean, 4.6 years). Ten patients (ten ankles) had a clear history of trauma, and seven patients (eight ankles) did not. Of the patients who had a history of trauma, nine had an inversion injury; three (Cases 1, 13, and 14) of the nine had been injured during sports activity. The remaining patient (Case 8) was seen a long time after the injury, and she did not remember the details.
The preoperative symptom of the condition was usually pain in the ankle joint during or after exercise. In addition, mild swelling was observed in many patients. The site of the lesion was medial in all ankles. According to the radiographic classification system of Berndt and Harty4, all of the lesions were stage II. Preoperative computed tomography scans were made to obtain information about the osseous lesion in fourteen ankles, and magnetic resonance imaging was performed to evaluate the condition of the bone surrounding the lesion in thirteen ankles.
The seventeen patients were among a group of seventy-two patients with an osteochondral lesion of the talus for whom we considered operative treatment with one of three operative procedures: excision of the osteochondral fragment and curettage, reduction and fixation of the osteochondral fragment with bone pegs, and arthroscopic drilling. As the stability of the lesion cannot be determined on the basis of plain radiographs alone, arthroscopic viewing and probing are essential. Diagnostic arthroscopy was first performed in all patients; when intact cartilage over the lesion and a stable fragment were detected with probing, arthroscopic drilling was carried out. When a small unstable fragment was detected arthroscopically, excision of the fragment and curettage was performed. In patients who had a large unstable fragment, the fragment was reduced and fixed with bone pegs in an open operation. Seventeen patients (the study group) were managed with arthroscopic drilling; twenty-eight, with excision of the fragment; and twenty-seven, with reduction and fixation. Continuity of the cartilaginous surface and stability of the osteochondral fragment, confirmed by arthroscopic probing, were regarded as essential indications for arthroscopic drilling.
Operative Procedure
After induction of spinal or general anesthesia, the patient is placed in the supine position with the calcaneal region slightly protruding from the end of the operating table to allow free plantar flexion and dorsiflexion of the ankle. Although there are reports7,11 of skeletal traction being used to widen the joint space, we do not use that technique because the joint space is relatively wide in patients who have this disease, most of whom are young, and because the lesions are so small that skilled manual manipulation is needed for drilling. A medial portal adjacent to the anterior tibial tendon is used, and a 2.7-millimeter-diameter arthroscope is inserted. As the lesions are frequently located in the medial aspect of the talar dome, they are examined with the ankle joint in plantar flexion. If the junction between the lesion and the normal area cannot be determined with arthroscopic viewing alone, probing of the cartilaginous surface is helpful because the cartilaginous surface of the lesion is often softened; when this is the case, the tip of the probe dips into the cartilage in the region of the lesion. In addition, the cartilaginous surface is observed with regard to its continuity and signs of degeneration, such as fibrillation. The mobility of the osteochondral fragment in relation to the bone surrounding the lesion and the extent of the lesion are assessed with a probe.
The arthroscope is immobilized, and a Kirschner wire, 1.0 to 1.2 millimeters in diameter, is inserted from about three centimeters proximal to the tip of the medial malleolus and is directed across the medial malleolus into the lesion through the intact cartilage. The size of the Kirschner wire was selected mainly on the basis of the size of the injured region. The position of the Kirschner wire is confirmed with arthroscopy, and the wire is drilled into the lesion (percutaneous transmalleolar drilling) (Fig. 1). Under arthroscopy, the Kirschner wire is withdrawn to the articular surface at the distal end of the tibia, and drilling is performed at a few other sites after slightly changing the angle of plantar flexion or dorsiflexion of the ankle joint. Drilling is continued until healthy bleeding from the bone marrow or leakage of fat droplets is confirmed. Next, the angle of insertion of the Kirschner wire is changed, and the same procedure is repeated. The drilling is performed at several sites, including areas around the lesion. The operation is completed by irrigating the articular space.
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Fig. 1 Illustration of percutaneous transmalleolar drilling. A Kirschner wire, 1.0 to 1.2 millimeters in diameter, is inserted from about three centimeters proximal to the tip of the medial malleolus and is directed across the medial malleolus into the lesion through the intact cartilage. Drilling is continued until healthy bleeding from the bone marrow or leakage of fat droplets is confirmed.
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After the operation, no cast is applied and the operative site is gently compressed by an elastic dressing. Plantar flexion and dorsiflexion of the ankle are allowed from the day after the operation, gradual partial weight-bearing with use of a crutch is initiated at five weeks, and full weight-bearing is permitted at about six weeks after the operation. Sports activities are not permitted for at least two months.
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Results
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The clinical evaluation was performed according to the criteria of Berndt and Harty4. A patient who had occasional symptoms but no disabling pain was considered to have a good result. A patient who had a decrease in symptoms but still had some disabling pain was considered to have a fair result. The result was considered to be poor if the symptoms had not decreased. The clinical result was good for thirteen ankles and fair for five; all ankles had a decrease in the symptoms (Table I). All thirteen ankles with a good result had recovered a full range of motion no later than two weeks after the operation, and the swelling around the ankle had also decreased. Pain did not recur after walking with full weight-bearing. The five ankles that were rated as fair also regained an almost full range of motion two weeks after the operation. However, four of these five ankles gradually became slightly swollen again after walking with weight-bearing was resumed. The five ankles that were rated as fair were painful after the patients walked a long distance. Two (Cases 5 and 6) of the five ankles were painful when the patients went up and down stairs, and another ankle (Case 17) was slightly painful after recreational sports. Seven patients (seven ankles) had engaged in sports as recreational activities before the operation, and all of them had resumed sports activity at the time of the evaluation.
Of the ten ankles that had a history of trauma, eight had a good result and two had a fair result. In contrast, of the eight ankles that did not have a history of trauma, five had a good result and three had a fair result. Thus, the clinical results tended to be worse for the ankles that did not have a history of trauma. Of the thirteen ankles that were in patients who were less than thirty years old at the time of the operation, twelve had a good result. In contrast, only one of the five ankles that were in patients who were fifty years old or more had a good result; the other four had a fair result. Thus, the clinical results tended to be better for younger patients (Fig. 2). Ten of the eleven ankles in patients who were less than twenty years old had a good result.
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Fig. 2 Graph showing the relationship between the age at the time of the operation and the clinical result. Twelve of the thirteen ankles that had a good result were in patients who were less than thirty years old.
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The radiographic result was considered to be good when complete osseous union or ossification was observed, fair when osseous union or ossification was incomplete but improved compared with the preoperative finding, and poor when no changes were observed. The ankles with a fair radiographic result showed some tendency toward ossification compared with the preoperative finding; mainly, the radiolucent zone distal to the osteochondral fragment tended to disappear. The radiographic result was good for four ankles, fair for eleven, and poor for three (Table I). Of the ten ankles that had a history of trauma, three, six, and one had a good, fair, and poor result, respectively. In contrast, of the eight ankles that did not have a history of trauma, one, five, and two were rated as good, fair, and poor, respectively. Radiographic results tended to be worse for patients who did not have a history of trauma. Three of the four ankles in which complete osseous union or ossification was observed were in patients who were less than twenty years old (Figs. 3, 4-A, 4-B and 4-C), and all three of the ankles in which there were no radiographic changes compared with the preoperative status were in patients who were more than sixty years old. Analysis of the group that had a history of trauma showed that the mean interval between the injury and the operation was 6.3 months for the three ankles that had a good radiographic result and 11.3 months for the six that had a fair radiographic result.
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Fig. 3 Graph showing the relationship between the age at the time of the operation and the radiographic result. Three of the four ankles that had a good result were in patients who were less than twenty years old, and all three ankles with a poor result were in patients who were more than sixty years old.
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Figs. 4-A, 4-B, and 4-C: Case 7, a ten-year-old girl.
Fig. 4-A: Plain radiograph, made at the initial examination, showing irregularity on the medial side of the talar dome (arrow).
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Fig. 4-B Arthroscopy showed that, although there was roughness of the cartilaginous surface (arrows), its continuity was preserved. Mild softening of the cartilage was detected by probing.
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Discussion
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Various operative techniques for the treatment of osteochondral lesions of the talus have been reported, and the results of each type of treatment have been relatively satisfactory9,10,12-14,16. We have encountered more than 100 osteochondral lesions of the talus. The size and stability of the lesion, the continuity of the cartilaginous surface, and the condition of the talar bone surrounding the lesion have varied among patients, and it appears to be inappropriate to treat all lesions with a single approach. In fact, we choose among three options—excision of the osteochondral fragment, reduction and fixation of the osteochondral fragment, and arthroscopic drilling—according to the condition of the individual lesion, and we have obtained relatively good results with each procedure. For this reason, careful selection of the type of treatment is important, and various imaging modalities must be used effectively to evaluate the condition of the lesion accurately13,15-17. Computed tomography scans and magnetic resonance imaging are particularly useful for assessing the features of the lesion. Magnetic resonance imaging also provides information about the condition of the talar bone surrounding the lesion17. As a discrepancy between the radiographic staging system of Berndt and Harty4 and the arthroscopic appearance has been reported16, direct arthroscopic viewing and probing are also important for selection of the best treatment method. We perform excision of the osteochondral fragment and curettage in patients in whom the osteochondral fragment is small and completely detached from the talar bone. We also carry out open reduction and fixation of large unstable osteochondral fragments, which allows direct observation of the condition of the lesion and the talar bone as well as the most accurate morphological repair of the articular surface. However, when the lesion is located on the posteromedial side, osteotomy of the medial malleolus may be required to expose the lesion. Moreover, immobilization in a cast and non-weight-bearing are needed for approximately five and ten weeks, respectively, and some bone atrophy is inevitable10,12,13. Removal of the internal fixation is also necessary after bone union. In contrast, arthroscopic drilling does not require osteotomy of the medial malleolus or postoperative immobilization in a cast, so the procedure is less invasive and allows early resumption of daily activities and sports2,8,10,13-16.
The consistency of the results of this procedure must still be evaluated, but fairly good results can be obtained if the patients are selected carefully. We performed this procedure in patients in whom the continuity of the cartilaginous surface and the stability of the lesion had been confirmed arthroscopically. Angermann and Jensen2 believed that, if the overlying articular cartilage appears intact, then drilling into the lesion through the cartilage is adequate treatment. However, on the basis of the results of the present study, this procedure appears to be ineffective in middle-aged and older individuals who have a reduced ability to regenerate bone. Particularly, when a patient has a subchondral bone cyst, filling in of bone is unlikely to be induced by, and no radiographic improvement is expected from, drilling from the articular surface alone, even if the continuity of the cartilaginous surface is maintained. Although no patient who had a subchondral cyst was included in this series, we previously performed drilling in an elderly woman who had intact cartilage overlying a subchondral cyst. Filling in of bone was not observed after the operation, and the patient did not have a good result. In contrast, this procedure is markedly effective and useful in young patients, especially those who have not yet had closure of the epiphyseal plate5. With modern techniques (arthroscopy and fluoroscopy), we can drill into the bone without crossing normal cartilage, either of the medial malleolus or of the dome of the talus. There have been recent reports on the use of retrograde transtalar drilling that does not injure normal cartilage8. Recently, we also have been using retrograde transtalar drilling, but we have managed only a small number of patients and the duration of postoperative follow-up is short. This procedure may become more popular in the near future.
In the present study, the clinical and radiographic results tended to be better for patients who had a history of trauma. This may be due to the fact that, when there is no history of trauma, there is a long duration of symptoms with a resultant poor situation for remodeling because of the sclerotic changes surrounding the lesion. Patients who did have a history of trauma but a longer period between the injury and the operation also had less radiographic improvement. Many patients who were managed long after the injury had sclerotic talar bone surrounding the lesion; this sclerosis is represented as an osteosclerotic image on radiographs and as a relatively wide low-intensity area on T1-weighted magnetic resonance images. Therefore, such patients may have extensive avascularity in the region of the lesion. Destruction of the sclerotic bone must be ensured at the time of the operation to induce reestablishment of the blood flow. The effects of drilling from above the osteochondral fragment alone may be limited in such patients.
Our results suggest that arthroscopic drilling, which is less invasive than other operative treatments and can be performed with short hospitalization, should be considered first for young patients who have an osteochondral lesion of the talus. A specific indication for this procedure is an early osteochondral lesion with only mild osteosclerosis of the surrounding talar bone, continuity of the cartilaginous surface, and stability of the osteochondral fragment.
In conclusion, arthroscopic drilling for patients who are less than thirty years old has a major advantage compared with the traditional osteotomy of the medial malleolus, as it allows early mobilization and return to the preinjury status. An early stable osteochondral lesion in a young patient should be considered an absolute indication for the procedure.
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Footnotes
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*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.
Department of Orthopaedic Surgery, Nara Medical University, 840 Shijyo-cho, Kashihara, Nara 634-8522, Japan.
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Abstract
Introduction