No superior surgical treatment for secondary osteochondral defects of the talus

Abstract

Purpose The purpose of this systematic review was to identify the most effective surgical treatment for talar osteochondral defects after failed primary surgery.Methods A literature search was conducted to find studies published from January 1996 till July 2016 using PubMed (MEDLINE), EMBASE, CDSR, DARE and CENTRAL. Two authors screened the search results separately and conducted quality assessment independently using the Newcastle–Ottawa scale. Weighted success rates were calculated. Studies eligible for pooling were combined.ResultsTwenty-one studies with a total of 299 patients with 301 talar OCDs that failed primary surgery were investigated. Eight studies were retrospective case series, twelve were prospective case series and there was one randomized controlled trial. Calculated success percentages varied widely and ranged from 17 to 100%. Because of the low level of evidence and the scarce number of patients, no methodologically proper meta-analysis could be performed. A simplified pooling method resulted in a calculated mean success rate of 90% [CI 82–95%] for the osteochondral autograft transfer procedure, 65% [CI 46–81%] for mosaicplasty and 55% [CI 40–70%] for the osteochondral allograft transfer procedure. There was no significant difference between classic autologous chondrocyte implantation (success rate of 59% [CI 39–77%]) and matrix-associated chondrocyte implantation (success rate of 73% [CI 56–85%]).Conclusions Multiple surgical treatments are used for talar OCDs after primary surgical failure. More invasive methods are administered in comparison with primary treatment. No methodologically proper meta-analysis could be performed because of the low level of evidence and the limited number of patients. It is therefore inappropriate to draw firm conclusions from the collected results. Besides an expected difference in outcome between the autograft transfer procedure and the more extensive procedures of mosaicplasty and the use of an allograft, neither a clear nor a significant difference between treatment options could be demonstrated. The need for sufficiently powered prospective investigations in a randomized comparative clinical setting remains high. This present systematic review can be used in order to inform patients about expected outcome of the different treatment methods used after failed primary surgery.Level of evidenceIV.

Talar OsteoPeriostic grafting from the Iliac Crest (TOPIC) for large medial talar osteochondral defects

“…In a recent review, we described that there are several options that appear to be safe and provide good results in prospective case series, with up to 90% success of OATS techniques for larger talar osteochondral defects after failed prior surgical treatment [30]. In these OATS results, there were several harvesting sites described for the plugs.…”

“…For fixable defects, arthroscopic and open internal fixation procedures are amenable options and have proven to be effective for pediatric and adult patient populations [28,29,31,45,46]. In case of large defects or in case of failure of firstline surgical treatment, more extensive and invasive surgery can be considered a necessary step in the management process [30]. The more common treatment strategies currently include osteochondral allograft procedures, osteochondral autograft transfer system (OATS) procedures, and classic and matrix-associated chondrocyte implantation (ACI, MACI) [20,21,32,39,55,56].…”

Feasibility Study to Determine if Microfracture Surgery Using Water Jet Drilling Is Potentially Safe for Talar Chondral Defects in a Caprine Model

“…4 Pain reduction, functional improvement, and patient satisfaction are described to be 61% to 86% in both primary and secondary OCDT. 5,6 However, limited research is available on whether improvement of the surgical technique is possible. 7 The current technique mainly involves hammering microfracture awls or drilling K-wires.…”

Metal Resurfacing Inlay Implant for Osteochondral Talar Defects After Failed Previous Surgery: A Midterm Prospective Follow-up Study

“…Despite good to excellent long-term results of primary surgical treatment of OCDs (up to 76%) by treatment such as debridement and bone marrow stimulation, not all patients experience relief of symptoms. 11,20,30,32,37 Secondary treatment options (with reported success percentages >90%), often required in larger lesions (>15 mm diameter), consist of tissue transplant techniques such as osteochondral autograft transfer system (OATS), 3,7 bone graft, 9 autologous chondrocyte implantation (ACI), 3,19 and matrix-induced autologous chondrocyte implantation (MACI). 13,27,32,36,37 However, such options require a donor site, and a surgeon may not want to damage a fully healthy joint to potentially save another.…”