Speaker: Follow an algorithm to treat osteochondritis dissecans of the talus
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WAIKOLOA, Hawaii — According to a presenter, surgeons should determine lesion size, consider biologic assistance, and weigh the costs and risks when treating patients with osteochondritis dissecans of the talus.
“[Osteochondritis dissecans] OCD, these are hard to treat. All the literature across the board you are going to see is 72% [and] 85% [success rates], and so the ones that fail can be frustrating,” Eric Giza, MD, said in his presentation at Orthopedics Today Hawaii. “Over time, I’ve taken it to the point where I kind of have an algorithm, so I can at least try to minimize any of those bad outcomes.”
Commonly, when patients present with OCD of the talus, they will describe a deep ache in the ankle — similar to a tooth ache, Giza said. Once the diagnosis has been made, the first step of the algorithm is to determine the size of the lesion. For the purpose of his talk, Giza was most concerned with medium-sized lesions of 100 mm2 to 150 mm2.
According to Giza, fewer than 50% of OCD cases can be identified on an X-ray. Regular CT scans can be misleading, and MRI of the talus can be useful in identifying some cartilage delamination or bone edema; however, 3D CT scans with morphometric analysis are the most accurate for determining lesion size, he said.
While many surgeons may immediately defer to microfracture, recently published literature has shown poor long-term functional outcomes for medium-sized lesions treated with microfracture, Giza said.
“So, for the last 15 years, the pursuit has been: Can we get some type of biologic adjunct to our fixation and get better results?” he said.
Research on juvenile allografting at 2 to 4 years has been promising, Giza said. However, it is a costly option that is hard to get approved by insurance. In Australia, research on matrix-induced autologous chondrocyte implantation has shown promising outcomes up to 13 years; however, it is only approved for use in the knee in the United States.
Micronized cartilage scaffolding is a single-stage, low cost and low risk option to enhance microfracture and, according to Giza, it is the preferred arthroscopic approach for OCD of the talus in 2022.
In the future, surgeons can take scaffolding to the next level by utilizing an acute cartilage autograft taken from the patient’s delaminated cartilage with live chondrocytes and mixing that with the cartilage scaffold, Giza said. There has already been literature published on early outcomes and technique, he added.
“In summary, I think scaffolding does enhance your microfracture and your treatment of [OCD of the talus], but your future is to look for the single-stage, low cost [and] low risk type of treatment,” Giza said. “Again, we base these on size. The majority that you are going to see are in this medium range, and I think this works well for my practice.”
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Giza E. Talus OCD treatment algorithm - Autograft/allograft. Presented at: Orthopedics Today Hawaii. Jan. 9-13, 2022; Waikoloa, Hawaii.
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