Arthroscopic Drilling For The Treatment of Osteochondral Lesions of The Talus
Arthroscopic Drilling For The Treatment of Osteochondral Lesions of The Talus
Arthroscopic Drilling For The Treatment of Osteochondral Lesions of The Talus
TABLE I
PATIENT DEMOGRAPHICS AND RESULTS
years). Ten patients (ten ankles) had a clear history of large unstable fragment, the fragment was reduced and
trauma, and seven patients (eight ankles) did not. Of fixed with bone pegs in an open operation. Seventeen
the patients who had a history of trauma, nine had an patients (the study group) were managed with arthro-
inversion injury; three (Cases 1, 13, and 14) of the nine scopic drilling; twenty-eight, with excision of the frag-
had been injured during sports activity. The remain- ment; and twenty-seven, with reduction and fixation.
ing patient (Case 8) was seen a long time after the injury, Continuity of the cartilaginous surface and stability of
and she did not remember the details. the osteochondral fragment, confirmed by arthroscopic
The preoperative symptom of the condition was probing, were regarded as essential indications for ar-
usually pain in the ankle joint during or after exercise. throscopic drilling.
In addition, mild swelling was observed in many pa-
tients. The site of the lesion was medial in all ankles. Operative Procedure
According to the radiographic classification system of After induction of spinal or general anesthesia, the
Berndt and Harty4, all of the lesions were stage II. Pre- patient is placed in the supine position with the cal-
operative computed tomography scans were made to caneal region slightly protruding from the end of the
obtain information about the osseous lesion in fourteen operating table to allow free plantar flexion and dorsi-
ankles, and magnetic resonance imaging was performed flexion of the ankle. Although there are reports7,11 of
to evaluate the condition of the bone surrounding the skeletal traction being used to widen the joint space, we
lesion in thirteen ankles. do not use that technique because the joint space is
The seventeen patients were among a group of relatively wide in patients who have this disease, most
seventy-two patients with an osteochondral lesion of of whom are young, and because the lesions are so small
the talus for whom we considered operative treatment that skilled manual manipulation is needed for drilling.
with one of three operative procedures: excision of the A medial portal adjacent to the anterior tibial tendon
osteochondral fragment and curettage, reduction and is used, and a 2.7-millimeter-diameter arthroscope is in-
fixation of the osteochondral fragment with bone pegs, serted. As the lesions are frequently located in the me-
and arthroscopic drilling. As the stability of the lesion dial aspect of the talar dome, they are examined with
cannot be determined on the basis of plain radiographs the ankle joint in plantar flexion. If the junction between
alone, arthroscopic viewing and probing are essential. the lesion and the normal area cannot be determined
Diagnostic arthroscopy was first performed in all pa- with arthroscopic viewing alone, probing of the carti-
tients; when intact cartilage over the lesion and a stable laginous surface is helpful because the cartilaginous sur-
fragment were detected with probing, arthroscopic drill- face of the lesion is often softened; when this is the case,
ing was carried out. When a small unstable fragment the tip of the probe dips into the cartilage in the region
was detected arthroscopically, excision of the fragment of the lesion. In addition, the cartilaginous surface is
and curettage was performed. In patients who had a observed with regard to its continuity and signs of de-
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.
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.
ered to have a good result. A patient who had a decrease clinical results tended to be better for younger patients
in symptoms but still had some disabling pain was con- (Fig. 2). Ten of the eleven ankles in patients who were
sidered to have a fair result. The result was considered less than twenty years old had a good result.
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 con-
trast, 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 thir-
teen ankles that were in patients who were less than
thirty years old at the time of the operation, twelve had
FIG. 4-A
a good result. In contrast, only one of the five ankles that
Figs. 4-A, 4-B, and 4-C: Case 7, a ten-year-old girl.
were in patients who were fifty years old or more had Fig. 4-A: Plain radiograph, made at the initial examination, show-
a good result; the other four had a fair result. Thus, the ing irregularity on the medial side of the talar dome (arrow).
Discussion
Various operative techniques for the treatment of FIG. 4-C
osteochondral lesions of the talus have been reported, Plain radiograph made one year after arthroscopic drilling. Heal-
and the results of each type of treatment have been rel- ing is complete.
bone. We also carry out open reduction and fixation of of the medial malleolus or of the dome of the talus.
large unstable osteochondral fragments, which allows There have been recent reports on the use of retro-
direct observation of the condition of the lesion and grade transtalar drilling that does not injure normal car-
the talar bone as well as the most accurate morpholog- tilage8. Recently, we also have been using retrograde
ical repair of the articular surface. However, when the transtalar drilling, but we have managed only a small
lesion is located on the posteromedial side, osteotomy number of patients and the duration of postoperative
of the medial malleolus may be required to expose follow-up is short. This procedure may become more
the lesion. Moreover, immobilization in a cast and non- popular in the near future.
weight-bearing are needed for approximately five and In the present study, the clinical and radiographic
ten weeks, respectively, and some bone atrophy is in- results tended to be better for patients who had a history
evitable10,12,13. Removal of the internal fixation is also of trauma. This may be due to the fact that, when there
necessary after bone union. In contrast, arthroscopic is no history of trauma, there is a long duration of symp-
drilling does not require osteotomy of the medial mal- toms with a resultant poor situation for remodeling be-
leolus or postoperative immobilization in a cast, so the cause of the sclerotic changes surrounding the lesion.
procedure is less invasive and allows early resumption Patients who did have a history of trauma but a longer
of daily activities and sports2,8,10,13-16. period between the injury and the operation also had
The consistency of the results of this procedure must less radiographic improvement. Many patients who
still be evaluated, but fairly good results can be obtained were managed long after the injury had sclerotic talar
if the patients are selected carefully. We performed this bone surrounding the lesion; this sclerosis is represented
procedure in patients in whom the continuity of the as an osteosclerotic image on radiographs and as a rel-
cartilaginous surface and the stability of the lesion had atively wide low-intensity area on T1-weighted mag-
been confirmed arthroscopically. Angermann and Jen- netic resonance images. Therefore, such patients may
sen2 believed that, if the overlying articular cartilage have extensive avascularity in the region of the lesion.
appears intact, then drilling into the lesion through the Destruction of the sclerotic bone must be ensured at the
cartilage is adequate treatment. However, on the basis time of the operation to induce reestablishment of the
of the results of the present study, this procedure ap- blood flow. The effects of drilling from above the osteo-
pears to be ineffective in middle-aged and older individ- chondral fragment alone may be limited in such patients.
uals who have a reduced ability to regenerate bone. Our results suggest that arthroscopic drilling, which
Particularly, when a patient has a subchondral bone is less invasive than other operative treatments and
cyst, filling in of bone is unlikely to be induced by, and can be performed with short hospitalization, should be
no radiographic improvement is expected from, drilling considered first for young patients who have an osteo-
from the articular surface alone, even if the continuity chondral lesion of the talus. A specific indication for this
of the cartilaginous surface is maintained. Although procedure is an early osteochondral lesion with only
no patient who had a subchondral cyst was included in mild osteosclerosis of the surrounding talar bone, conti-
this series, we previously performed drilling in an el- nuity of the cartilaginous surface, and stability of the
derly woman who had intact cartilage overlying a sub- osteochondral fragment.
chondral cyst. Filling in of bone was not observed after In conclusion, arthroscopic drilling for patients who
the operation, and the patient did not have a good result. are less than thirty years old has a major advantage
In contrast, this procedure is markedly effective and compared with the traditional osteotomy of the medial
useful in young patients, especially those who have not malleolus, as it allows early mobilization and return to
yet had closure of the epiphyseal plate5. With modern the preinjury status. An early stable osteochondral le-
techniques (arthroscopy and fluoroscopy), we can drill sion in a young patient should be considered an absolute
into the bone without crossing normal cartilage, either indication for the procedure.
References
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