32
Original article
DOI: http://dx.doi.org/10.1590/1413-785220162401137414
All the authors declare that there is no potential conict of interest referring to this article.
Work developed at Pontifícia Universidade Católica de Campinas, Hospital e Maternidade Celso Pierro, Department of Orthopedics and Traumatology, Campinas, SP, Brazil.
Correspondence: av. Prof. Alfonso Bovero, 523, apto. 41. São Paulo, SP, Brazil. 01254-000. korbage@hotmail.com
ARTHROSCOPIC TREATMENT OF OSTEOCHONDRAL
LESIONS OF THE TALUS
Mariana Korbage de araujo
1
, Mario Sergio Paulillo de Cillo
1
, Cinthia Kelly bittar
1
, joSé luiS aMin Zabeu
1
,
Caroliny noCiti Moreira CeZar
1
1. Pontifícia Universidade Católica de Campinas, Hospital e Maternidade Celso Pierro, Department of Orthopedics and Traumatology, Campinas, SP, Brazil.
Citation:
Araujo MK, Cillo MSP, Bittar CK, Zabeu JLA, Cezar CNM.
Arthroscopic treatment of osteochondral lesions of the talus. Acta Ortop Bras. [online]. 2016;24(1):32-4. Available
from URL: http://www.scielo.br/aob.
ABSTRACT
Objective: To assess pain and function of the ankle in patients
with injuries up to 1.5 cm diameter by the American Orthopaedic
Foot and Ankle Society (AOFAS) score after arthroscopic treat
-
ment. Methods: The AOFAS scale was applied before and after
arthroscopy, as well as the degree of subjective satisfaction of
ambulatory patients. Patients with type I osteochondral injuries,
acute trauma, using plaster, presenting lesions in other joints of
the lower limbs and cognitive impairment that would prevent the
application of the satisfaction questionnaire were excluded from
the study. Statistical analysis was performed using unpaired t
test with Welch correction, Mann Whitney test, and ANOVA, with
Kruskal Wallis test and Dun test, considering p value lower than
0.05. Results: There was an increased AOFAS scores after ar
-
throscopic treatment in 52 (94.5%) patients. The mean values of
AOFAS score in 55 patients was 77.32 ± 6.67 points preoperative
and 93.10± 8.24 points postoperative, with a mean variation of
15.8 points, p<0.001. Patients with stage II, III and IV injuries
showed an increased AOFAS scores after arthroscopic treatment,
p<0.001. No difference was found between medial and lateral
injuries, p >0.05. Conclusion: Patients with stage II, III or IV oste
-
ochondral injuries of the talus of up to 1.5 cm diameter, whether
medial or lateral, showed a significant improvement after arthros
-
copic treatment. Level of Evidence III, Retrospective Study.
Keywords: Ankle. Arthroscopy. Talus. Wounds and injuries.
Article received in 07/07/2014, approved in 07/13/2015.
INTRODUCTION
Osteochondral injuries of the talus account for 1% of body
fractures which often represent late sequelae of trauma to the
ankle and evolve with loss of movement and local arthrosis,
besides a significant impact on the patient’s quality of life.
1-4
The most used classification of osteochondral injuries proposed
by Berndt and Harty
5
in 1959 is radiological. However, other
classifications using computed tomography (CT) and mag
-
netic resonance imaging (MRI) have also been proposed.
6,7
The treatment of osteochondral injuries of the talus is based
on size, location and extent of the injury. Injuries stage I can
be treated conservatively.
4,8
Stage II, III and IV injuries may be
surgically treated by arthroscopy, arthrotomy, mosaicplasty or
chondrocyte culture implant.
4
The arthroscopic technique allows precise access to the site
of injury and less tissue damage, allowing faster and functional
recovery with fewer complications inherent to arthrotomy such
as infection, neurovascular injury, osteoarthritis and improper
posterior visualization.
4,9-11
Injuries up to 1.5 cm appear to have
better results by arthroscopy than larger injuries.
9,12
The objective of this study was to assess pain and function of
the ankle after arthroscopic treatment of patients with osteo
-
chondral injuries of the talus up to 1.5 cm diameter in ambu-
latory followup.
MATERIALS AND METHODS
This study was approved by the Medical Ethics Committee
of Hospital Municipal Mário Gatti, Campinas, SP, Brazil, under
CAAE number 30256814.0.0000.54530. A Free and Informed
Consent form was signed by all participants.
The study included skeletally mature patients undergoing ar
-
throscopy of the talus from November 1997 to August 2010,
presenting osteochondral injuries of the talus up to 1.5 cm
diameter. Injuries were classified radiologically according to
Berndt and Harty
5
and their location as anterolateral, anterome-
dial, posteromedial and posterolateral. Computed tomography
(CT) and magnetic resonance imaging (MRI) were also used
to assist the classification and evaluation of the integrity of the
lateral ankle ligaments.
Arthroscopic treatment was performed by excision, debridement
Acta Ortop Bras. 2016;24(1):32-4
33
and perforation
4,7,9,13,14
and the patient was instructed not to per-
form physical efforts in the first 30 days and return to sports
practice 12 weeks after the surgery.
The scale of the American Orthopaedic Foot and Ankle Society
(AOFAS)
15
was applied preoperatively and at outpatient follow-up.
The location and the stage of the injuries were considered.
Subjective satisfaction questionnaire were also applied one
year after the procedure, considering the following responses:
Very satisfied; satisfied; regular or dissatisfied. The researchers
who applied the AOFAS scale and satisfaction questionnaire
did not participate at the arthroscopy procedures.
Patients with osteochondral injuries type I, patients with acute
trauma, using plaster, injuries in other joints of the lower lim
-
bs and cognitive alterations that did not allow application of
the satisfaction questionnaire were excluded from the study. In
cases with complications and those requiring more than one
arthroscopy, only the first evaluation procedure was considered.
Statistical analysis was performed using the t test and ANOVA
analysis of variance and unpaired values with Kruskal-Wallis
and Dun test, considering as significant p<0.05.
RESULTS
Sixty five patients were analyzed and 10 were excluded. Among
the 55 patients included, 34 (61.8%) were men and 21 (38.2%)
were women. The age of patients at the time of surgery ranged
from 17 to 57 years old, mean 36.89 ± 9.15 years old.
We identified 30 (54.5%) injuries on the right side, 24 (43.6%)
on the left side and one (1.9%) bilateral injury.
Among the 34 medial injuries, 11 (32.3%) were ranked as stage II, 20
(58.8%) as stage III, three (8.8%) as stage IV. Among the 21 lateral
injuries, 10 (47.6%) were stage II, 10 (47.6%) were stage III and one
(4.8%) stage IV. Central injuries were not found.
The postoperative follow-up of these patients ranged from 10
to 48 months, 20.23 ± 8.6 months, on average.
Table 1 shows the distribution of mean AOFAS scores at pre
and postoperative periods according to the stage of the injury.
No difference was observed between medial and lateral injuries,
p> 0.05, nor between anterior and posterior injuries, p> 0.05. Ta
-
ble 2 shows the distribution of average AOFAS scores in the pre
and postoperative periods according to the location of the injury.
Subjective assessment of postoperative patients revealed 51
(92.7%) of satisfactory cases. Table 3 shows the distribution
of mean AOFAS scores according to the subjective degree of
patient’s satisfaction.
In this study, 42 (76.4%) patients were older than 30 years at the
time of surgery, with an average of pre- or postoperative values
by AOFAS scale not different from patients younger than 30
years, p> 0.05. Similarly, men showed no significant difference
from women in the AOFAS assessment, p>0.05.
Table 1. Distribution of mean AOFAS scores according to the stage
of the injury.
Stage of the injury
(n)
Preoperative
AOFAS
mean ± sd
Postoperative
AOFAS
mean ± sd
Difference p
II (22 ) 79.09 ± 7.71 95.19 ± 6.17 16.1 <0.001
III (30 ) 76.66 ± 6.0 91.16 ± 9.23 14.5 <0.001
IV (4) 73.0 ± 2.0 96.75 ± 6.5 23.7 =0.003
Total (55) 77.32 ± 6.67 93.10 ± 8.24 15.8 <0.001
Table 2. Distribution of mean AOFAS scores according to the location
of the injury.
Stage of the injury
(n)
Preoperative
AOFAS
mean ± sd
Postoperative
AOFAS
mean ± sd
Difference p
Posteromedial (28) 77.62 ± 6.86 93.25 ± 9.06 15.5 <0.001
Anterolateral (17) 76.76 ± 7.62 93.80 ± 6.80 17.1 <0.001
Anteromedial (6) 78.0 ± 5.44 91.51 ± 6.77 13.5 0.002
Posterolateral (4) 74.75 ± 0.95 89.75 ± 11.95 15.0 0.04
Medial total (34) 77.91 ± 6.57 93.14 ± 8.58 15.5 <0.001
Lateral total (21) 76.38 ± 6.87 93.04 ± 7.87 16.6 <0.001
Anterior total (23) 77.08 ± 7.01 93.03 ± 6.77 17.4 <0.001
Posterior total (32) 77.50 ± 6.51 93.03 ± 9.26 14.1 <0.001
Table 3. Distribution of mean AOFAS scores according to patient’s
degree of satisfaction.
Degree of satisfaction
(n)
Preoperative
AOFAS
mean ± sd
Postoperative
AOFAS
mean ± sd
p
Very satisfied (19) 81.25 ± 5.42 99.84 ± 0.68 <0.001
Satisfied (22) 71.41 ± 5.78 91.25 ± 6.19 <0.001
Not satisfied (4) 72.25 ± 9.81 76.00 ± 10.48 0.3119
DISCUSSION
This is a cohort retrospective non controlled study which eva-
luated pain and ankle function before and after treatment of
osteochondral injuries of the talus up to 1.5 cm diameter by
arthroscopic technique.
Osteochondral injuries of the talus were more frequent in men,
located mostly on the right side, at the medial portion with pre
-
dominance of posteromedial injuries, which was also found in
other studies.
9,10,16,17
The low prevalence of stage IV injuries is
also in accordance with other studies.
9
This study demonstrated a significant improvement of pain and
ankle function after treatment of osteochondral injuries of the
talus by arthroscopy, assessed by the AOFAS scale. Tol et al.
18
found 88% good and excellent results in patients with stage III
injuries or more advanced injuries who underwent arthroscopy
under the same conditions as the present study. Chuckpaiwong
et al.
12
found 100% success in injuries smaller than 1.5 cm
diameter, although another study
9
associated better results to
injuries smaller than 1 cm. Guo et al.
9
also found significant
improvement, with an average score of 90.16 ± 9.96 posto
-
peratively as compared to 70.81 ± 6.96 preoperatively by the
AOFAS scale.
The improvement of pain and ankle function was significant
in both the medial injuries as the lateral ones. Twenty three
(67.6%) injuries of the 34 medial injuries were stage III or IV.
Eleven injuries (52.3%) of the 21 lateral injuries were stage III
or IV without significant difference, p> 0.05. Schimmer et al.
17
found better results with medial injuries, but only 26.3% of them
were stage III or IV. Guo et al.
9
found no differences between
medial or lateral injuries, and all lateral injuries and 86% medial
injuries were stage III or IV.
Acta Ortop Bras. 2016;24(1):32-4
34
The subjective degree of patient satisfaction was not significant
for stage IV injuries. Guo et al.,
9
using a visual scale, found good
correlation between AOFAS score and patient’s visual scale. Ogil
-
vie-Haris and Sarrosa
14
observed improvement of pain, swelling,
stiffness, limping and physical activity after arthroscopy.
CONCLUSION
Treatment of osteochondral injuries of the talus up to 1.5 cm
diameter by arthroscopy and injury resection with drilling and
debridement improves pain and function of the ankle, regard
-
less of the stage of the injury and its medial or lateral location.
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AUTHORS’ CONTRIBUTIONS: This manuscript is a non-controlled, retrospective cohort study. All authors contributed equaly to the study. MSPC
(0000000207582547*) and CKB (000000021997572*) performed most surgeries; MKA (0000000340595342*), CNMC (000000210612081*) and
JLAZ (0000000296810125*) mostly contributed to the writing. Every author followed-up the patients and contributed for the collection of clinical
data.*ORCID Identifier (Open Researcher and Contributor ID).
Acta Ortop Bras. 2016;24(1):32-4
