• LecturehallOsteochondral Lesions of the Talus
  • Lecture Transcript
  • TAPE STARTS – [00:00]

    Male Speaker: He's Dr. Nicholas Bevilacqua who practiced at North Jersey Orthopaedic Specialists in Teaneck, New Jersey. And Dr. Bevilacqua, I've known for many years. He's an excellent speaker, has a lot of experience, and we've asked him to talk about talar dome lesions. After he is finished, you may enjoy the rest of the evening. So, thank you and thank all my speakers.

    Dr. Nicholas Bevilacqua: Alright. Thank you very much. I think you guys all deserve extra CME credits for sticking it out this long, so I appreciate it. I'll try to stay on time here so you guys can enjoy the Friday night. So osteochondral lesions of the talus, nothing to disclose for this talk. So, before we dive into the specifics of these specific lesions, I just want to take a step backwards and just think about the patient that comes in the office. They had what was diagnosed "as just an ankle sprain" and they think, a couple days, maybe a week or two, they're back to their normal activities. And they come in and they say, "look, it was just a sprain, but my ankle still hurts."

    So, it's important when you evaluate these and we're going to go over the workup to just come up with the differential diagnosis of some of the common injuries that may occur from what we may perceive or the patient perceives as just a simple ankle sprain, and we'll talk about ankle impingement, ankle instability, peroneal tendon pathology. And obviously, pay most attention to the osteochondral lesions of the talus. So, it's about 10% to 40% of these patients will develop symptoms in chronic ankle instability after a severe ankle sprain. So, this is not, unfortunately, too unfamiliar with our weekend warrior patients. So, we'll talk about the importance of history and physical exam.


    We'll go over diagnostic imaging, x-rays, MRIs, CAT scans and some diagnostic injection. So just like anything else, don't discount the importance of the history and physical. You can learn a lot from just talking to the patient, listening to their complaints. They may complain of specific localized pain or it might be vague. They may have some snapping, some clicking, some grinding. And just by listening to them, when does it hurt? What makes it better? Sometimes the ankle feels weak. It's going to give out. They can't walk on uneven ground. You can start to develop some differentials in your mind. So, symptoms consistent with ankle instability, oftentimes, patients have difficulty walking on uneven ground or they feel like I'm just afraid. I feel like my ankle's just going to give out on me.

    May not be in pain but oftentimes, they have the reinjury that initiates another pain cycle. Osteochondral lesions of the talus symptoms, it might be a little bit more vague, so they might just complain of like just a deep ankle pain or an ache. Sometimes they can't specifically localize it. Sometimes some stiffness, clicking, locking, but most often, it's just a pain. Peroneal tendons, they'll complain maybe pain with certain movements. Walking on uneven ground, maybe some snapping, clicking. It might be those tendons subluxing or dislocating out of position. So clinical exam, first, just think, inspect, palpate, manipulate, so you just want to try to localize where their pain is. Palpate the ankle joint as an anteromedial, anterolaterally. You can press along those peroneal tendons. Try to determine that area of maximum tenderness. Evaluate range of motion, muscle strength.

    And what's nice is that we have presumably an unaffected foot on the opposite side. So, you always want to compare it to the contralateral ankle. So, compare the range of motion. Is there any crepitus? Is there an abrupt stop? Is it pain with dorsiflexion or plantar flexion?


    Evaluate the muscle strength and compare it. Very useful, single like heel raise and single like hop, how's their propulsion compared to the opposite side? You can do the Molloy's test which is evaluating for anterolateral impingement. You palpate wherein you palpate anterolaterally your dorsiflexion if that exacerbates the pain. That'll become part of your differential stress maneuvers, anterior drawer, external rotational stress test. And again, compare it to the opposite side. So diagnostic imaging when they complain in the office, ideally, you're going to start with radiographs, typical three views, AP mortise lateral ankle.

    You're going to just look, rule out any subtle fractures. Maybe some avulsion fractures, osteophytes, some spurring, periarticular spurring. You can consider stress radiographs. I mean oftentimes, for this, I'm not going to torture the patient and do a stress radiograph. Usually, it's just more clinical and I'll compare it, but if you do stress radiographs, it's really not so much the number, the absolute number that you get. It's oftentimes comparing to the opposite side. So, you can do an anterior drawer, so that's going to show you if there's any insufficiency in the anterior talofib ligament. And you can do talar tilt which'll determine if there's a calcaneofibular ligament tear.

    So oftentimes, MRI especially in a patient that has a normal x-ray, there's pain. There's tenderness. There's maybe question about peroneal tendon issue. Maybe some questionable if there is like a subtle osteochondral lesion that's not visible on x-ray. So, procedure of choice usually after radiographs for these patients that just are not getting better. CT scan, obviously, it's better for bony pathology looking at the cortical surfaces. You can look for any loose bodies. You can look for collisions and any subtle fractures that maybe just – you're not picking up on x-ray.


    And if you have ultrasound in the office, this is a nice dynamic exam that's low cost and if you have it in the office, easily available. So diagnostic injections, I use a lot of these in the office. This is helpful to differentiate especially like lateral ankle, hindfoot pain. You can inject the ankle joint. The symptoms go away. You're pretty confident it's ankle pathology. Sometimes the subtalar joint, you can have subtalar insufficiency. You can inject the sinus tarsi region. I mean, there is a little debate, is there a little bit of communication between the joints? It's not 100% but it definitely helps steer you in the right direction.

    Maybe there's posterior ankle joint impingement or astride going, and you can actually give a good diagnostic injection. If the symptoms go away, then you're confident in your diagnosis and potential surgical management moving forward. So now, you've done the adequate workup clinically, physical exam. You've done x-rays. You've done MRI or a CAT scan. Now you have the diagnosis, so now what? So, I'm just going to take some time just talking about the common pathologies that we'll see in the symptomatic ankle after a bad sprain or even like a simple fracture that was treated conservatively.

    So, we'll go over ankle synovitis, impingement, instability and osteochondral lesions of the talus, and oftentimes, I mention this because I know we're going to talk in more detail about lesions of the talus. But oftentimes, these conditions can coexist. So, you have a chronic ankle instability with that osteochondral lesion, so you can't just narrow your focus on the lesion. You still have to address the underlying instability. So, when we talk about management of the ankle especially surgically, you just want to give a brief introduction in arthroscopy because a lot of these conditions whether it's arthroscopy providing more of a diagnostic or that direct eyeball view inside the joint to uncover many – any intra articular pathology whether it's loose bodies or osteochondral lesions that maybe just aren't visible on MRI or CAT scan.


    And I think as the – our experience is increasing and the instrumentation becomes more specialized to foot and ankle. I think the indications are ever expanding. And we can use it for soft tissue impingement, bony impingement. Obviously, it's an important treatment for osteochondral lesions. And typically, for most of the pathology is going to be anterior ankle where you just have the simple anteromedial, anterolateral portals where we can address multiple conditions. So, even if we're going directly towards an osteochondral lesion and we'll talk about that, you still want to start out with like this inventory of the joints.

    You want to do this joint inspection. And oftentimes, there's chronic conditions so most of these osteochondral lesions are going to be chronic in nature so there's going to be some synovitis. There's going to be some soft tissue impingement. So, synovitis, you get inflammation, hypertrophy. The synovial linings are usually, it's after an ankle sprain or some trauma. And they'll have localized tenderness on that. Oftentimes, it's like that anterior aspect of the ankle joint.

    And you can just see some arthroscopic pictures. You get that hemorrhagic synovitis that you want to be real aggressive. Use that arthroscopic shaver and you can even use the radiofrequency one just to adequately debride away that synovitic tissue, and that provides very good symptomatic relief for the patient. So, ankle impingement, soft tissue impingement, very common. Very common cause of just that lingering pain after an ankle sprain or an ankle injury. Often, anterolateral aspect of the ankle has been described, the Bassett's ligament which is the inferior fibers of the anterior inferior tib fib ligament which rubs that lateral shoulder of the talus.


    So, you can see here in this picture. So, right in there. So, you can see the camera. Really, the position of it hasn't moved but on that top picture, you can't even see the fibula so here, you can see the fibula after it was debrided away. So, these fibers right there are going to irritate that anterolateral shoulder of the talus so you can aggressively debride that away. And that'll give a good symptomatic relief. So, this'll be all in conjunction whether you're going to do a lateral ankle ligament repair after this or you're going to address osteochondral lesion of the talus.

    And obviously, inspect the gutters for any loose bodies, chondral bodies, osteophytes and these can all be addressed at the same time. So, you can also get bony impingement, bony impingement, again arthroscopically. You can use either an arthroscopic burr or you can sneak in maybe a little osteotome in one of the portals. Usually, you'll start on the anteromedial portal. Use that anterior surface of the medial malleolus as you're guiding to resect that bony prominence. And it's nice because it allows for dynamic visualization or inspection. You can dorsiflex that ankle just to make sure there's no more impingement after you resect it.

    So, I think it's also become the procedure of choice for Os Trigonum, posterior ankle impingement. So, you can resect the Os Trigonum through a posterior arthroscopy and you can directly visualize and debride any tenosynovitis along that FHL tendon. So now, let's turn our focus to ankle instability. Most commonly, it's going to be the lateral ligament complex. We'll talk about syndesmotic instability, deltoid, and arthroscopy allows us to evaluate the stability, integrity of these ligaments, looking within the joints.

    So, you can stress the joint, use the probes to manipulate and you can treat any intra articular pathology at the same time. So, that lateral ankle instability, very, very common pain. Usually, with direct palpation, anterior tib fig ligament, they get the feeling that the ankle's giving away. It's weak. It's unstable.


    You can see here clinically, that's an obvious positive anterior dorsal in there. So, arthroscopy can be done in conjunction with an open procedure. Nowadays, you read the journals, you see more and more of these like all inside arthroscopic Brostrom repairs. Oftentimes though, you can still do a scope, address any impingement or synovitis, inspect for any intra articular lesions and then convert it open and do a direct ligament repair.

    So, there's been many, many procedures done – proposed for lateral ligament instability. Probably the most common is the anatomic repair, the Brostrom with the Gould modification. You can do non-anatomic. Problem is that you're really stiffening the ankle and the hindfoot and changing the way the joint kinematics work. And then, you can consider an anatomic repair with tendon grafts and tenodesis screws. So just one quick slide just on the Brostrom with a – this is a repair augmented with a suture tape, so this is the typical Brostrom repair where you're going to do either all suture or an anchor, just whatever your preference is.

    But the nice thing about augmenting it with this fiber tape is that it increases the strength at day zero so you can get more aggressive with range of motion and physical therapy. So, this is just an anchor, non-articulating surface of the talus. You pull that fiber tape through that capsular ligament tissue. And then, you just do your standard. This is just showing like an all suture repair of that ligament capsular complex there. And then, once you tie it down, you'll just use that fiber tape as like a safety belt over it.

    So, syndesmosis, usually, if there's pain along the syndesmosis, like that high ankle sprain, anterior inferior tib fib pain with a squeeze test, external rotation. And usually for me, if they have like that really –the single like heel raise or single like hop, it shows that traumatic difference in propulsion compared to the uninjured side.


    And you can use your arthroscopic shaver or probe, and if you can easily place it in that syndesmotic space between the tibia and the fibula which has been termed the drive-through sign, you get – I mean, you can directly see the instability and then you'll have to address that, whatever, dynamically or with screws. Deltoid ligament, same concept so this is all part of like that joint inspection. When you're going in there even if you're just going to focus on that osteochondral lesion, you just want to inspect the integrities medially, laterally, syndesmosis.

    So now, we'll get to the good stuff here, so osteochondral lesions of the talus. So, they can be acute or chronic. Acute, we'll see here, this is just a picture there. Oftentimes, acute are going to be these anterior lateral lesions. Symptoms as I mentioned before, oftentimes, they're vague. So usually, a patient comes in. If they're like three, four months after an ankle sprain or sometimes longer, and they're just still having pain. My ankle hasn't recovered. It's like one of the first things I'll think about and I want to rule out. So, the x-rays, you do x-rays. And oftentimes, there are negatives so you're not going to see any cartilage injuries on an x-ray. And that's when you all heighten your indexes, suspicion, and consider advanced imaging for it.

    So medial lesions are more common and they're more chronic in nature. They're often deeper and non-displaced whereas lateral lesions are going to be more acute in nature about 90% of the time. They're going to be the result of an acute injury. And they're going to be less shallow, wafer-shaped, and oftentimes, they're displaced. And we'll talk about just treatment of acute lesions just a little bit different than the chronic lesions. So classically, Berndt and Harty, we'll talk about their classification system, but they were the first ones to try to reproduce the mechanism of injury.


    So, I remember as a student and as a resident, you're taught DIAL a PIMP, so dorsiflexion inversion creates that anterior lateral lesion. And plantar flexion inversion creates that posteromedial lesion. But really, what we've learned is that there's different mechanisms that have been proposed and there's really – there's no single mechanism that can explain each lesion. So, when we think about classification systems, I don't think you have to sit here and memorize this classification system but it just – it gives us an idea as to which ones could be treated non-operatively and which ones should go straight to surgery.

    So, Berndt and Harty, this was the classis radiographic classification stage one. Really, it's like negative x-ray so it looks normal because you just get in that subchondral compression, so that'll be more of like bone marrow edema on MRI. Stage two is that partial fragment detachment. Three would be complete detachment but it's sitting in its place. It hasn't displaced whereas four, it's shifted. So, these are just example of stage three. This was a lady, I'll show you. We treated her non-operatively. She's got this stage three complete fragment detachment but non-displaced. And then, there's that stage four where it's that result of an acute trauma, and you get that little wafer-shaped lesion that displaces off.

    So, advanced imaging, MRI and CAT scan, so which one? Sometimes both. So, usually, if there is negative x-ray, so you're suspicious of it but the x-rays are normal, I'll typically go to an MRI, so these are patients that have just this vague ankle pain. I'll do the MRI to maybe to help diagnose a unknown lesion. It's also useful to evaluate obviously, the surrounding soft tissue structures but the problem is it typically overestimates the size of the lesion. Whereas, a CAT scan is superior to an MRI if you're really getting down and dirty in terms of like what's the measurement?


    What's the surface area? What's the diameter? Just because now, you know there's a lesion there and you're thinking about surgical approaches for it. So now, with CAT scans and MRIs, there's different classification systems. The ones probably most often used, vertical, and his group, they looked at CAT scans and they found that you can have cystic lesions with an intact root. You can have a cystic lesion that communicates with the talar dome surface. So that would be stage one, stage 2B, then you can have similar to the x-ray where you can have non-displaced lesion, and then you have a displaced lesion.

    And these are just examples, so you have this cystic lesion here, but you have intact talar dome surface whereas two, you have communication now with the – it goes into the ankle joint. And then, the completely detached but non-displaced, and then four would be detached and displaced. So now, you look at MRIs or the benefit of the MRIs, it really is going to show us the extent of subchondral bone injury with the bone marrow edema which I think has probably been underappreciated, and I think it's becoming a little bit more – I think we're understanding the importance of that bone marrow edema as a source of continued pain.

    But you can have – it is very similar to the radiographic one, stage one. You have that bone marrow edema, that subchondral compression there but intact cartilage. Stage 2A would be the cyst with the intact root, and then you have incomplete separation, incomplete non-displaced and then displaced. So, I mentioned this only because in here is some examples clinically, and you can just evaluate. The nice thing about the MRI is the bone marrow edema but you can see here how extensive and sometimes you can, again, overestimate the size of the lesion.


    But it's important because when you're thinking about surgical management or even just treatment overall, I mean, typically, the stage threes and fours are primarily treated surgically. The ones and twos, you can try a non-surgical approach and then consider surgery if they fail the non-surgical treatment. So, here's the patient that I showed you before. She was a young female, high school athlete. She suffered an ankle injury. She had that acute stage three medial lesion right here, so I did an MRI just to evaluate the extent surrounding soft tissue structures just because I was concerned also laterally with any ligament damage because it was more of like that inversion type injury.

    But it was completely detached, non-displaced nor the ligament pathology so she was treated with immobilization and that osteochondral injury was able to heal successfully without any surgical intervention. So now, if we have these ones and twos that fail non-surgical treatment and then we have the threes and fours and you're starting to think surgery, we have to also be realistic with our patients and define the goals. So obviously, the goal is number – first and foremost is pain relief. You want to improve function. Limit the progression of arthritis. I mean, this is unknown. It's unknown, the natural history of these lesions and how they're going to influence any progression of arthritis in the long term.

    Acute injuries, you differentiate, does it involve just cartilage or is it an osteochondral and is it displaced or not? So ideally, if it's displaced and it contains cartilage and bone, you can reduce it and then fixate it. Usually, absorbable pins are helpful for this. If it's just cartilage, you remove that cartilage flap and then you treat it like a chronic lesion. Usually, you debride it down. Get to good healthy subchondral bone. Debride that calcified cartilage and then whether it's microfracture or drilling, and that's what we'll talk about with these chronic lesions here. So, our goals are basically, provide a predictable repair tissue that closely resembles the native hyaline cartilage.


    And this is really our goal. I'm going to talk obviously about microfracture and the issues we have with that. So, the approach is really dictated by the patient's symptoms, the size of the lesion, the location of the lesion, whether it's contained or not, so is it a shoulder? Does it have good, stable cartilage surrounding it? That'll influence your procedure. And then, you always want to – don't ignore the tibia. So, whenever you hear osteochondral lesions of the talus, surgically, first thing often people think about is microfracture.

    So, arthroscopy with microfracture really, I think is – has been the primary treatment strategy, and I think this really came from Tow's [phonetic] research here where he did a meta-analysis, looked at 32 studies and what was interesting, it was just the surgical management of these lesions. And they looked at just excising the lesion by itself, there's about a 38% patient satisfaction. But when you excise it and debrided that base, it went up to 78%. And then, when you did drilling or microfracture, it shot up to 85%. I think this is really where the concept of microfracture in the talus was born.

    So, time and time again, it's been proven to be very effective and reliable in treating small to midsized osteochondral lesions of the talus. And there's really no difference between drilling or using the microfracture picks. So surgically, you're going there arthroscopically. Usually, you have a probe. You define the unhealthy cartilage. Use a curette. You remove all that unhealthy cartilage. You want a good rim of healthy cartilage surrounding it, and then you're going to debride the base to get the subchondral bone. You want to get that calcified cartilage out as well. And then, you're going to either drill holes or use the microfracture to pierce through that subchondral bone.


    Use a tourniquet. Oftentimes, you'll deflate it. Make sure you get some good bony bleeding there to stimulate that bone marrow which will create that fibrin plug which goes on to create that fiber cartilage, so – and that's key because you're not reproducing the hyaline cartilage. So, I talk to patients and usually, if it's a small enough lesion, you talk to him and you say, "look, we basically want to just create a scar tissue cartilage plug that's going to hopefully reduce your symptoms." And you can even combine techniques. I mean, some people talk about using microfracture on the periphery and drilling the center.

    So now, are there any limitations? Well, the Ohio Foot & Ankle Group, the Brulet [phonetic] and Christopher Hire [phonetic], so they looked at basically 100 – almost 200 patients, 189 patients that were treated with arthroscopy and microfracture. And they had good results, but it was like a linear relationship, so the results deteriorated as the size of the lesion increased, and it was a linear relationship. And they found out one centimeter was like that turning point where above one centimeter, the results were really poor. And when you compare that to that Tow study where I showed you where it was 78%, 85% success, the average size lesion was seven millimeter, so this brings up the question, is there a critical size that may result in poor outcome from microfracture?

    And Joy [phonetic] looked at 120 ankles and basically, they had an 80% failure rate with defects over 1.5-centimeter square. And conversely, they had about a 10% failure rate with lesions smaller than that. So, size does matter. And this was a systematic review looking at lesion size as a predictor of success. It was 25 studies, 1,800 patients and basically, they found bone marrow stimulation, so that's microfracture or drilling should be reserved for lesions that are basically 100-millimeter square in the surface area.


    So that's like think of lesions diameter wise, one centimeter, so again, matching what the Ohio group talked about. So, we have to think of surgical strategies for lesions greater than one centimeter because we know less than one centimeter, ideally, if they're like at seven or eight-millimeter range, they're going to do very well with arthroscopy and microfracture, so what are our options beyond microfracture? So, there's a lot of options. If you go to the exhibit halls in some of these conferences, you'll see a lot of different products but I'm just going to talk about some of the more popular ones, particulated juvenile cartilage, osteochondral autograft or allograft and also ACI which is Autologous Chondrocyte Implantation.

    So, particulated juvenile cartilage graft, so again, this is an allograft. It's living chondrocytes and you could do this either arthroscopically or through a mini-open approach and Kotzi [phonetic] – so this is probably one of the first studies looking at results. It was across five different study groups, and it was 24 ankles. And 14 of those 24 ankles had failed the previous surgery which were microfracture. And the average lesion size and this is important, average lesion size was 125 plus or minus 75. So, it's definitely in that higher risk category that Joy helped us to find. Average depth of seven millimeters and 78% of the ankles demonstrated good to excellent scores on the AOFAS scores above 80, and 92% had good to excellent results.

    In lesions, 10 millimeters are larger and then those smaller than 15 millimeters, so that 10 – so that one to 1.5 was 92 success rate. And they did have one partial graft delamination at 16 months so one failure there. And a subsequent study following this. So, here's just a clinical example. So, this was a patient of mine, so it was an anterolateral lesion. It was a chronic lesion. And he had also ligament instabilities, so I was going to open it anyway.


    And basically, you can see here, I'm going to enlarge that sight. So, you treat this initially similar to like microfracture. You're going to define the borders of the unhealthy cartilage. You're going to curette that. In this case, you're going to get down to that subchondral bone, but you want to be careful. You don't want to do aggressive microfracture or drilling because you don't want too much bleeding because that can dilute and dislodge these chondrocytes. And then, you're going to use fibrin glue.

    So, the glue helps keep those particles in place, but it also acts as a matrix, and it forms this little cartilage plug, so you put the fibrin glue in the defect. You put the chondrocytes and then another layer of fibrin glue. You let that sit. It forms a nice stable plug. So, Saltzman [phonetic] looked at particulated juvenile articulate cartilage for lesions, and it was a two-part study. One part was systematic review, second part was a retrospective case series just because he didn't have any patients in his own retrospective center. It was just six patients. But in this systematic review, four studies, 33 ankles, one conversion to a bulk allograft, and in his own group, six patients all reported improvement in pain and motion and functional improvements.

    However, the MRI postop in three patients demonstrated persistent subchondral edema and non-uniform chondral surface of the talus, so I think this is a good strategy for those larger lesions but certainly, not the final answer. So, here's an example. One of my patients, 35-year-old male, deep aching ankle pain, weak, unstable ankle, so he had a previous RAF [phonetic] of an osteochondral lesion, so he had a displaced lesion that was fixated with absorbable pins. And basically, what I did was a lateral ligament repair, and then I addressed this one.


    So, you can do it arthroscopically, but I did medial malleolar osteotomy, got good visualization and used the particulated juvenile chondrocytes there. So now, what happens if we have a deeper lesion or maybe it involves a – it's more extensive or involves a shoulder. It's uncontained. So, now we can consider an osteochondral allograft transplantation whether it's an allograft or an autograft. So, this is indicated for larger cystic lesions and oftentimes, these failed microfracture and you can do core grafting that will go over. That's a little picture for that, or you can do like a – if it's pretty extensive, you can do an M block bone graft.

    So, Scratin [phonetic] found 90% good to excellent results in 50 cases with a follow-up of 36 months. Similarly, Hangurty [phonetic] reported good to excellent results in 94%. The problem is these studies look at – these are actually looking at autografts. So, these are grafts taken from the knee, and the problem is that they got donor site morbidity up to even 40%. So now, you're taking a patient that has a painful ankle and you're giving them a painful knee, so then you think about alright, what's the advantage now of an allograft?

    Well, that obviates that knees for that second surgery so it's a one stage procedure. But now, yeah, the question is concerns over cost, disease transmission and even availability because these are fresh talus grafts. Here's an example of a 44-year-old female, severe ankle pain, MRI, one by 0.8-centimeter medial lesion with full thickness cartilage defects, subchondral bone marrow edema and also a cystic lesion. And she also had previous arthroscopy with microfracture two years prior, so when you think in surgical approach, the size of the lesion, the fact of the cystic lesion involved, repeat microfracture is probably doomed for failure.


    So, in this situation, medial malleolar osteotomy and this was an allograft, so it was a fresh frozen osteochondral plug. And here's an example, so you do that. Medial malleolar osteotomy, interoperative fluoroscopy, you can use a guide wire just to help guide the location of the osteotomy. It dramatically increases the visibility of the lesion. And then, you have instrumentation here. You size it out, so you're going to probe it to find the borders of it and then you're going to match it. And you're going to get – you're going to excise a plug and then you're going to use your fresh talus allograft to get a matching plug.

    You want to try to match the location on the cadaver bone and basically, you're going to just gently tap that in, so these don't require fixation. It should be a nice press fit with the cartilage level with the surrounding cartilage. So, another example, this is an osteochondral allograft transplantation, so this is with a patient that failed previous surgeries, so they have a large cystic lesion, previous ankle arthrotomy with excision of the osteochondral lesion. And they actually had that particulated juvenile chondrocytes one year prior.

    And they were continuing to complain of pain. You can see the MRI and the CAT scan in this case, it shows the extensive nature of it, the depth, the surrounding bone marrow edema, the cystic lesion. But it was well-contained. You can see that CAT scan on multiple views. I was confident that there was a good rim, so I went in there thinking like a core graft. If the shoulder was involved, you have that fresh talus there that you can certainly take out the whole shoulder. But the only thing is that it requires fixation.

    I'll show a quick case on that. And you put that plug in, so that's treating the bone and the cartilage, so you're aggressively debriding that cystic lesion and you're matching the depth with your graft.


    So, here's a lady with a large cystic shoulder lesion so the difference is now, this isn't contained, so this is a large lesion, 1.5 by 0.85 with subchondral cyst and she had previous ankle injuries. No prior surgery but it did involve the shoulder, so if we think about those cylindrical grafts, my concern was that there was nothing – no good cartilage and bone keeping it in place, so you have to do more of a M block bone graft. And you take out the affected bone and cartilage and you use that as a template with that cadaver bone.

    And there's definitely fiddle factor where you start out a little bit bigger and then you gently just shave the graft until it fits nice and you just fixate that. In this case, I just used some headless screws. So, in this lady, and this was performed in November 2014, and I had the opportunity to go in there about three years later. Just arthroscopically, she was just complaining of joint impingement. And you can see here, arthroscopically, you did get good incorporation of that plug. I mean, there's definitely some fabulation that was just debrided, but it did – the graft incorporated nicely and her symptoms in terms of the lesion, she did well.

    So, the last thing, I know I'm over time and I promise I will be done. Just give me 30 seconds, so ACI. So, ACI, what's interesting about this is that you're basically taking a cartilage graft from the patient's knee and you're culturing it. And basically, you're getting thousands of viable chondrocytes from the patient's – is their own donor. So, Steve Quach [phonetic] who's actually a partner in my practice that I've had the privilege of working with for the last 10 years, so when he was a fellow, he wrote up this paper, Autologous Chondrocyte Implantation of the Ankle, two to 10-year results. And it was basically 29 patients treated with ACI. You can see the size of these lesions, 1.8 by 1.1, so large lesions. Many had failed prior microfracture.


    And 86%, interestingly enough, had a second look arthroscopy for like removal of hardware. And he found firmness in the articular cartilage, appeared on the second look arthroscopy, and it actually got better over time. So, they found improvement in all parameters of all the scoring systems that they used. So, there were complications because not to get too technical but when you do this procedure, you have to – you send it to the lab. It comes back. It takes like three or four weeks. It's expensive. Oftentimes, insurances don't cover for them. We actually had a case where we did – he did the first surgery to take the graft from the knee and insurance actually didn't cover the processing, the culturing of the chondrocytes.

    So, it was like a waste of procedure, so definitely, insurance and cost issues within. But really, when you put this on, initially described with a periosteal graft to cover it, and that results in graft hypertrophy, so there were some issues with failure afterwards and I think the future, they're looking at different grafts to use to hold those cells in place. So, in summary, just to go back through all the slides we talked about, so don't discount the importance of history and physical exam. You can learn a lot from your patients.

    Put your hands on them, manipulate it, stress it, palpate and always consider other injuries. Oftentimes, they're – nothing occurs in isolation. If there's chronic ankle instability, address that along with addressing the lesion. And when you're thinking about the surgical approach specifically for these lesions, microfracture or arthroscopy with microfracture I think still is pretty much the gold standard for smaller lesions, less than one centimeter. And lesions one to two, that's where you'd think about maybe like that particulated juvenile cartilage. If there's underlying cyst, you do like a sandwich procedure where you put the bone graft and then the chondrocytes over that.


    And then, for lesions greater than 1.5, that's where you start thinking about these osteochondral grafts. And I think the future is probably headed towards regenerative cells that can form the tissue we wanted to form without compromising the subchondral bone. Alright. Thank you so much for your time and patience. Any questions?

    TAPE ENDS [00:38:21]