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Purpose To compare the effect of arthroscopic microfracture surgery alone or in combination with platelet rich plasma (PRP) on functional outcomes in osteochondral lesions of the talus. Methods A total of 35 patients were included in the study. Control subjects ( n  = 16) received treatment with microfracture surgery alone, while the remaining patients (PRP group, n  = 19) were also given PRP. After an average follow-up of 16.2 months (range 12–24 months), patients were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) scoring system, Foot and Ankle Ability Measure (FAAM), and the visual analogue scale (VAS) for pain. Results At baseline, AOFAS and FAAM scores were similar in the two groups, whereas pain scores (VAS) were higher in those who were assigned to combined treatment. Despite the latter finding, the combined treatment with PRP resulted in better outcomes in terms of functional scores [AOFAS, 89.2 ± 3.9 vs. 71.0 ± 10.2, ( p  = 0.001); FAAM overall pain domain, 1.0 (1.0–2.0) vs. 2.5 (1.0–4.0), ( p  = 0.04); FAAM 15-min walking domain, 1.0 (1.0–2.0) vs. 2.0 (1.0–4.0) ( p  = 0.001)]; and pain-related scores [VAS, 2.2 ± 0.8 vs. 3.8 ± 1.2, ( p  = 0.001)] as compared to arthroscopic microfracture surgery alone. Conclusions PRP as an adjunct to arthroscopic microfracture surgery for the treatment of osteochondral lesions of the talus resulted in improved functional score status in the medium-term. Further studies to determine the long-term efficacy of this approach were warranted. Level of evidence II.

Purpose Although bone marrow stimulation (BMS) as a treatment for osteochondral lesions of the talus (OCLT) shows high rates of sport resumption at short-term follow-up, it is unclear whether the sports activity is still possible at longer follow-up. The purpose of this study was, therefore, to evaluate sports activity after arthroscopic BMS at long-term follow-up. Methods Sixty patients included in a previously published randomized-controlled trial were analyzed in the present study. All patients had undergone arthroscopic debridement and BMS for OCLT. Return to sports, level, and type were assessed in the first year post-operative and at final follow-up. Secondary outcome measures were assessed by standardized questionnaires with use of numeric rating scales for pain and satisfaction and the Foot and Ankle Outcome Score (FAOS). Results The mean follow-up was 6.4 years (SD ± 1.1 years). The mean level of activity measured with the AAS was 6.2 pre-injury and 3.4 post-injury. It increased to 5.2 at 1 year after surgery and was 5.8 at final follow-up. At final follow-up, 54 patients (90%) participated in 16 different sports. Thirty-three patients (53%) indicated they returned to play sport at their pre-injury level. Twenty patients (33%) were not able to obtain their pre-injury level of sport because of ankle problems and eight other patients (13%) because of other reasons. Mean NRS for pain during rest was 2.7 pre-operative, 1.1 at 1 year, and 1.0 at final follow-up. Mean NRS during activity changed from 7.9 to 3.7 to 4.4, respectively. The FAOS scores improved at 1 year follow-up, but all subscores significantly decreased at final follow-up. Conclusion At long-term follow-up (mean 6.4 years) after BMS for OCLT, 90% of patients still participate in sports activities, of whom 53% at pre-injury level. The AAS of the patients participating in sports remains similar pre-injury and post-operatively at final follow-up. A decrease over time in clinical outcomes was, however, seen when the follow-up scores at 1 year post-operatively were compared with the final follow-up. Level of evidence Level II.

Background Skeletally immature osteochondral lesions of the talus (OLTs) have a significant impact on the health status and quality of life of pediatric patients and the involved family. the current literature showed success in 4 out of 10 patients but it is currently unknown which type of non-operative management showed better clinical- and radiological outcomes. The aim of this study is to compare immobilization and supervised rehabilitation with a ‘skillful’’ neglect in the treatment for skeletally immature patients with an OLT. The hypothesis is that a period of immobilization and supervised rehabilitation will lead to better clinical and radiological outcomes compared to ‘’skillful’’ neglect. Methods Multicenter, prospective, comparative study. Skeletally immature children with an OLT will be assigned to the intervention or control group after a shared decision-making process. Patients in the intervention group will undergo a 4-week period of immobilization with normal casting and non-weightbearing, which is followed by 4 weeks of immobilization with a removable cast and weight bearing boot. Afterwards, they will receive a protocolled period of rehabilitation under supervision of a physical therapist. The control group will have a ‘skillful’’ neglect treatment. The main study outcome is the difference between the two groups on the Oxford Ankle and Foot Questionnaire for Children (OxAFQ-C). Secondary study outcomes are radiologic changes in terms of morphology and lesion size. Numeric Rating Scale (NRS) during weight bearing and quality of life measured with a Pediatrics Quality of Life (Peds-QL) and EuroQol-5 Dimension youth (EQ-5D-y). Discussion This protocol reports on the study design of the CARE Study and it aims to setup a study for evaluating different types of non-operative management in pediatric patients suffering an OLT. This study will compare clinical and radiological outcomes between two different non-operative strategies for treating OLTs in the skeletally immature population. Based on the results of this study, an evidence-based treatment protocol for non-operative management for pediatric OLTs can be provided. Trial registration This study is registered in the International Clinical Trial Registry Platform (ICTRP) with trial number NLOMON54282, date of registration 05192023.

Purpose The purpose of this study was to compare the clinical and magnetic resonance imaging (MRI) outcomes of arthroscopic microfracture surgery alone or in combination with hyaluronic acid (HA) injection in the treatment of osteochondral lesions of the talus. Methods Thirty-five patients with osteochondral lesions of the talus who underwent arthroscopic microfracture were included and followed up for at least 9 months post-operatively. The patients were randomly divided into non-injection group ( n  = 17) who received treatment with microfracture surgery alone and injection group ( n  = 18) who also accepted intra-articular injection of HA post-operatively. Quantitative MRI was used to evaluate the cartilage repair after surgery. American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hind foot Scale scores and Visual Analogue Scale (VAS) scores were used to evaluate clinical outcomes. Results After operation, the MRI outcomes showed that the thickness index was higher (0.8 ± 0.1 vs. 0.7 ± 0.1) and the T2 index was lower (1.2 ± 0.1 vs. 1.4 ± 0.1) in the injection group than in the non-injection group ( P  < 0.01). As for the volumes of subchondral bone marrow oedema, there are no significant differences between groups (n.s.). Compared with the non-injection group, the AOFAS score and the VAS score yielded a higher level of improvement in injection group at final follow-up post-operatively ( P  < 0.05). Conclusions Arthroscopic microfracture is a safe and effective procedure for osteochondral lesions of the talus. Intra-articular HA injection as an adjunct to arthroscopic microfracture might offer better functional recovery than microfracture alone. Level of evidence II.

Purpose The aim of this study is to report the outcomes of the treatment of talar osteochondral lesions with arthroscopic microfracture technique and postoperative intra-articular hyaluronan injection. Method Fifty-seven patients (29 men, 28 women) with osteochondral lesions of the talus were included in this prospective randomized clinical study between the years 2003 and 2009. The patients were treated with arthroscopic debridement and microfracture technique. Randomly selected 41 patients were injected intra-articular hyaluronan (injection group). The remaining 16 patients did not receive postoperative injection (non-injection group). Assessment of the pain and functional outcomes was performed using the Freiburg and AOFAS ankle/hindfoot scoring systems. Results In the injection group, the mean postoperative Freiburg functional and pain scores were significantly higher compared to preoperative functional and pain scores ( P  < 0.001). Similarly, for the patients in non-injection group, the mean postoperative Freiburg functional and pain scores were significantly higher compared to preoperative functional and pain scores ( P  < 0.001). The AOFAS functional and pain scores of the patients in the injection group were significantly higher ( P  < 0.001) postoperatively compared to preoperative scores. Scoring the patients in the non-injection group according to AOFAS system also revealed significantly higher ( P  < 0.001) postoperative functional and pain scores over preoperative scores. The increase in the postoperative scores was found to be significantly higher in the injection group compared to non-injection group in both Freiburg and AOFAS systems ( P  < 0.001). Conclusion Treatment of osteochondral lesions of the talus using microfracture technique significantly improved functional and pain scores postoperatively. Additional treatment with intra-articular hyaluronan injection as an adjunct to microfracture technique may offer better clinical outcomes over microfracture technique alone. Level of evidence Randomized, controlled trial, Level I.

Purpose This study aims to analyze the correlation between the prognosis of osteochondral lesions of the talus and patient age, gender, duration of illness, and injury location, surface area, depth, and volume. Methods A retrospective analysis of 44 patients who underwent talus osteochondral transplantation in the Department of Foot and Ankle Surgery of our hospital between January 2017 and December 2020 was performed. The clinical medical records of the patients were collected, and the location of the osteochondral lesion of the talus was determined according to the nine-division method. The surface area, depth, and volume of the osteochondral lesion of the talus were measured using mimics software in all patients. The visual analog scale (VAS), the American Orthopedic Foot and Ankle Society (AOFAS), and the SF-36 quality of life questionnaire scores were evaluated before surgery and at the last follow-up, and correlation analysis was performed. Results Of 44 patients, 30 were followed up with a mean period of 24.33 ± 12.19 months. There were 18 men and 12 women, with an average age of 40.73 ± 10.57 years and an average disease duration of 28.30 ± 21.25 months. The VAS, AOFAS, and SF-36 scores of all patients at the last follow-up were significantly better than those before surgery. The degree of post-operative symptom improvement was not correlated with age, sex, duration of illness, and injury location, surface area, depth, and volume. Conclusion The prognosis of osteochondral lesion of the talus is not related to patient age, gender, duration of disease, or injury location, surface area, depth, and volume.

Background Osteochondral talar defects usually affect athletic patients. The primary surgical treatment consists of arthroscopic debridement and microfracturing. Although this is mostly successful, early sport resumption is difficult to achieve, and it can take up to one year to obtain clinical improvement. Pulsed electromagnetic fields (PEMFs) may be effective for talar defects after arthroscopic treatment by promoting tissue healing, suppressing inflammation, and relieving pain. We hypothesize that PEMF-treatment compared to sham-treatment after arthroscopy will lead to earlier resumption of sports, and aim at 25% increase in patients that resume sports. Methods/Design A prospective, double-blind, randomized, placebo-controlled trial (RCT) will be conducted in five centers throughout the Netherlands and Belgium. 68 patients will be randomized to either active PEMF-treatment or sham-treatment for 60 days, four hours daily. They will be followed-up for one year. The combined primary outcome measures are (a) the percentage of patients that resume and maintain sports, and (b) the time to resumption of sports, defined by the Ankle Activity Score. Secondary outcome measures include resumption of work, subjective and objective scoring systems (American Orthopaedic Foot and Ankle Society – Ankle-Hindfoot Scale, Foot Ankle Outcome Score, Numeric Rating Scales of pain and satisfaction, EuroQol-5D), and computed tomography. Time to resumption of sports will be analyzed using Kaplan-Meier curves and log-rank tests. Discussion This trial will provide level-1 evidence on the effectiveness of PEMFs in the management of osteochondral ankle lesions after arthroscopy. Trial registration Netherlands Trial Register (NTR1636)

Purpose Surgeons management of osteochondral lesions of the talus (OLT) may be different to the published guidelines because not all treatment recommendations are feasible in every country. This study aimed to assess how OLT are managed worldwide by foot and ankle surgeons. Methods A web-based survey was distributed to the members of 21 local and international scientific societies focused on foot and ankle or sports medicine surgery. Answers with a prevalence greater than 75% of respondents were considered a “main tendency”, whereas where prevalence exceeded 50% of respondents they were considered a “tendency”. Results A total of 1804 surgeons from 79 different countries returned the survey. The responses to 19 of 28 questions (68%) regarding management and treatment of OLT achieved a main tendency (> 75%) or a tendency (> 50%). Symptoms reported to be most suspicious for OLT were pain on weight-bearing (WB) and after activity (83%), deep localization of the pain (62%), and any history of trauma (55%). 89% of surgeons routinely obtain an MRI, 72% routinely get WB radiographs, and 50% perform a CT scan. When treated surgically, OLTs are managed in isolation by only 7% of surgeons, and combined with ligament repair or reconstruction by 79%; 67% report simultaneous excision of soft-tissue or bony impingements (64%). For lesions less than 10–15 mm in diameter, bone marrow stimulation (BMS) represents the first choice of treatment for 78% of surgeons (main tendency). No other treatment was recorded as a tendency. For lesions greater than 15 mm in diameter no tendencies were recorded. The BMS represented the most preferred treatment being the first choice of treatment for 41% of surgeons. OLT depth had little influence on treatment choice: 71% of surgeons treating small lesions and 69% treating large lesions would choose the same treatment regardless of whether the lesion had a depth lesser or greater than 5 mm. Conclusion The management of OLT by foot and ankle surgeons from around the world remains extremely varied. The main clinical relevance of this study is that it provides updated information with regard to the management of OLT internationally, which could be used by surgeons worldwide in their decision-making and to inform the patient about available surgical options. Level of evidence Level IV.

Background Chronic lateral ankle instability (CLAI) often arises from inadequately managed injuries to the lateral collateral ligaments, potentially leading to osteochondral lesions of the talus (OLT) and subsequent osteoarthritis. Hepple Stage V OLT, characterized by subchondral cysts, presents a significant therapeutic challenge. This study aimed to evaluate the efficacy of arthroscopic anterior talofibular ligament (ATFL) repair combined with retrograde drilling and allograft bone grafting in patients with CLAI and Hepple Stage V OLT with an intact talar articular surface. Methods This retrospective, small-sample exploratory study included 12 patients (ten men; median age: 35 years) who underwent arthroscopic treatment (between January 2020 and December 2022) for chronic lateral ankle instability with subchondral cysts, specifically Hepple Stage V OLT cases with an intact talar articular surface, after failing non-surgical interventions. The ATFL was repaired using the all-inside Internal Brace (IB) augmentation with the arthroscopic modified Broström operation. Treatment for OLT involved simultaneous retrograde drilling and allograft bone grafting. The median follow-up duration was 24 months (range: 20–35 months). The improvement of postoperative ankle pain was assessed using the Visual Analogue Scale (VAS), and the improvement of ankle function was evaluated using the American Orthopedic Foot ༆ Ankle Society (AOFAS) score and Foot༆Ankle Outcome Score (FAOS). Radiographic assessments were conducted at a minimum of 12 months postoperatively. Results All 12 patients (12 ankles; 100%) returned for clinical and radiological follow-up at an average of 24 months (20–35 months) postoperatively. Subjective improvement was reported after arthroscopic surgery. The median AOFAS score demonstrated a substantial improvement from 67 preoperatively (range: 58–70) to 94 at the final follow-up (range: 90–98), with P  < 0.05. Similarly, The FAOS score improved from 65 preoperatively (range: 58–75) to 91 at the final follow-up (range: 89–97), with P  < 0.05. Radiographic follow-up results indicated satisfactory healing of the ATFL and favorable bone ingrowth post-subchondral cyst bone grafting. Conclusion Arthroscopic ATFL repair combined with retrograde drilling and allograft bone grafting yields favorable clinical and radiographic outcomes in patients with CLAI and Hepple Stage V OLT. This integrated approach addresses both ligament instability and subchondral cyst pathology, potentially delaying the progression of osteoarthritis.

Purpose (1) To determine the rate of return to play following autologous osteochondral transplantation (AOT) for osteochondral lesions of the talus (OLT) and (2) report subsequent rehabilitation protocols. Methods A systematic review of the PubMed, Embase, and The Cochrane Library databases was performed according to the PRISMA guidelines based on specific eligibility criteria. Return to play data was meta-analysed and subsequent rehabilitation protocols were summarised. Level of evidence and quality of evidence (Zaman’s criteria) were also evaluated. Results Nine studies that totalled 205 ankles were included for review. The mean follow-up was 44.4 ± 25.0 (range 16–84) months. The mean OLT size was 135.4 ± 56.4 mm 2 . The mean time to return to play was 5.8 ± 2.6 months. The mean rate of return to play was 86.3% (range 50–95.2%), with 81.8% of athletes returning to pre-injury status. Based on the fixed-effect model, the rate of return to play was 84.07%. Significant correlation was found between increase age and decrease rate of return to play ( R 2  = 0.362, p  = 0.00056). There was no correlation between OLT sizes and rate of return to play ( R 2  = 0.140, p  = 0.023). The most common time to ankle motion post-surgery was immediately and the most common time to full weight-bearing was 12 weeks. Conclusions This systematic review indicated a high rate of return to play following AOT in the athletic population. Size of OLT was not found to be a predictor of return to play, whereas advancing age was a predictor. Rehabilitation protocols were largely inconsistent and were primarily based on individual surgeon protocols. However, the included studies were of low level and quality of evidence. Level of evidence Level IV.