Autologous bone graft and periosteal patch for large and recurrent talar osteochondral defect: A prospective study

Abstract

Background

Osteochondral injuries of the talus (OLT) are common as a variety of mechanisms causes them. Asymptomatic presentation with an underlying damaged bone and the overlapping symptoms with a simple sprain make OLT a potentially career-ending injury. The best surgical intervention aims to alleviate pain and improve long-term outcomes as well. These outcomes can be measured by 3 major clinical measurements: Visual analogue Score (VAS), American Orthopedic Foot and Ankle Society (AOFAS), and Foot and Ankle Disability Index (FADI), in addition to achieving the lowest complication rate possible. In this prospective study, we aim to evaluate the functional outcome of the treatment of large and recurrent OLT by osteoperiosteal patch.

Methods

Thirty patients with large (>1.5 cm²) or recurrent OLTs were prospectively treated using an osteoperiosteal graft. The procedure involved medial malleolar osteotomy, curettage of the lesion, followed by autologous cancellous bone grafting from the distal tibia, and periosteal transfer to cover the defect.

Results

VAS pain scores significantly decreased from a preoperative mean of 7.07 to 0.43 at the last follow-up. FADI scores significantly increased from 53.77 preoperatively to 93.8 at the last follow-up, indicating improved functional abilities. AOFAS scores also significantly increased from 40.6 preoperatively to 95.13 at the last follow-up, reflecting improvements in overall clinical status. The complication rate was low, with a few cases of superficial infection, DVT, and pain at the screw site, but no major complications related to the donor site.

Conclusion

The osteoperiosteal graft technique is a safe and effective method for treating large and recurrent OLTs. This single-stage procedure offers significant improvements in pain, functional abilities, and overall clinical status, with results that align with other similar studies, while also avoiding donor site complications and disease transmission risks.

1. Introduction

Osteochondral injuries in the foot are a clinically significant but variably reported entity, with the talus being the most affected tarsal bone. These injuries occur when a force is transmitted from the articular surface of one bone, across the joint, and into the adjacent cartilage, often resulting in damage to the underlying bone even if the cartilage remains superficially intact.¹ While commonly caused by direct trauma, osteochondral lesions of the talus (OLT) can also arise from non-traumatic etiologies, including repetitive microtrauma, congenital predispositions, or systemic factors such as endocrine imbalances and avascular necrosis.² Despite their relatively frequent occurrence, particularly in acute ankle sprains or fractures, OLT often goes undiagnosed due to their nonspecific presentation, which may include persistent deep ankle pain and swelling, sometimes mimicking or coinciding with an ankle sprain.^3,4

OLT predominantly affects young, active individuals, including athletes and workers with physically demanding jobs, where prolonged or severe symptoms can significantly impair quality of life and functional abilities.⁵ In severe cases, the condition can be career-ending for professional athletes. Notably, treatment strategies aim to restore joint function and alleviate pain, aiming to achieve durable outcomes that preserve or enhance the joint's structural integrity and biomechanical properties. The talus' unique anatomy and biomechanics contribute to the complexity of OLT management. Over 60 % of the talar surface is covered with articular cartilage, which, despite its thinness, supports high compressive forces during weight-bearing activitie. Additionally, the talus relies on an intricate blood supply from the posterior tibial, dorsalis pedis, and peroneal arteries, making it susceptible to avascular necrosis following injury.^{6, 7, 8}

Mechanical loading on the talar cartilage is considerable; during walking, it is subjected to forces approximately four times body weight, and even higher loads during running. This high biomechanical demand means that small cartilage or subchondral bone defects can significantly increase local stresses, leading to progressive joint damage if left untreated.^9,10 Furthermore, the thinness of the talar cartilage, coupled with its reliance on congruent joint surfaces for force distribution, makes it particularly vulnerable to increased loading stresses resulting from malalignment or trauma. Various surgical techniques have been developed to manage OLT, reflecting the diversity in lesion characteristics and patient needs.^3,11 These approaches fall broadly into three categories: Debridement and Microfracture which involves removing loose osteochondral fragments and stimulating fibrocartilage formation through techniques such as subchondral drilling or curettage. Preservation of the native hyaline cartilage is prioritized when possible, as this is crucial for long-term joint function, and Cartilage Replacement Techniques such as autologous osteochondral transplantation (OATS), autologous chondrocyte implantation (ACI), and matrix-induced autologous chondrocyte implantation (MACI) involve replacing the defect with hyaline cartilage.¹² Autologous transfer of bone and periosteum has demonstrated success in animal models and is increasingly being explored in human clinical settings.^5,6 The aim of this study was to evaluate the functional outcome of treatment of large and recurrent OLT by osteoperiosteal patch in a prospective clinical study.

2. Methods

2.1. Study design and patient recruitment

This prospective clinical study was conducted on 30 patients with osteochondral lesions of the talus (OLT), recruited from two medical institutions. Inclusion criteria were patients with large (≥1.5 cm²) or recurrent OLTs who had not responded to at least six months of conservative treatment. Exclusion criteria included septic arthritis, rheumatological diseases, diffuse arthritic changes, neuropathic lesions, or angular deformities to avoid confounding factors. The follow-up period ranged from 6 to 18 months (mean: 11.07 months, SD: ±3.78).

2.2. Preoperative assessment

All patients underwent a comprehensive preoperative evaluation to establish the severity of their condition and determine a baseline for measuring surgical outcomes. This evaluation included clinical and radiologic assessments.

2.3. Clinical evaluation

The clinical assessment consisted of a detailed patient history, physical examination, and functional scoring.

History: Patient-reported symptoms, including pain duration, specific location, and associated symptoms (e.g., catching, locking, giving way of the ankle), were documented. Previous trauma and prior treatments were also noted.

Physical Examination: Examination included assessment of focal swelling, tenderness, and range of motion (ROM) compared to the unaffected side. Anterior drawer tests evaluated ankle stability, and lower limb angular deformities were assessed.

2.3.1. Functional scoring

American Orthopaedic Foot and Ankle Society (AOFAS) ankle/hindfoot score: Scores ranged from 0 to 100, with clinical outcomes categorized as excellent (90–100), good (80–89), fair (70–79), or poor (<70).¹³

Foot and Ankle Disability Index (FADI): This subjective score assessed functional limitations using a 22-item module, scored as a percentage of 104 points.¹⁴

2.4. Radiological evaluation

X-rays: Standard anteroposterior (AP), lateral, and mortise weight-bearing views classified lesions using the Berndt and Harty system and assessed degenerative arthritis.

CT Scans: Axial, sagittal, and coronal reconstructions classified lesions per the Ferkel classification and evaluated defect characteristics.¹⁵

MRI: Non-contrast axial, sagittal, and coronal reconstructions classified lesions using the Hepple system.¹⁶

2.5. Incision and osteotomy

A medial malleolar osteotomy was performed in 29 patients. An incision was made along the posteromedial tibial border, curving anteriorly at the medial malleolus. After exposing the joint line, the posterior tibial tendon (PTT) was retracted, and an oblique osteotomy was performed using a microsagittal saw guided by K-wires. Cold irrigation minimized osseous heat necrosis. Fluoroscopy ensured accurate osteotomy alignment, and care was taken to avoid injuring the talar dome. Fig. 1.

Fig. 1.

A) osteotomy of the medial malleolus using a saw. (B) The medial malleolus fragment is reflected and held in place by a wire to expose the lesion.

2.6. Bone grafting and harvesting and transfer of periosteal patch

The lesion was debrided to healthy, bleeding bone while ensuring that the stable cartilage edges were preserved. A cortical window was carefully created, and cancellous bone was packed into the defect to promote osseointegration and structural support.

A periosteal graft was harvested from the proximal tibia using a meticulous technique to ensure the integrity of the cambium layer, which contains mesenchymal progenitor cells essential for cartilage regeneration. A longitudinal incision was made over the donor site, and the periosteum was carefully elevated using a periosteal elevator, ensuring that the cambium layer was not disrupted. The harvested periosteal patch was trimmed to match the defect dimensions. The periosteal patch was then transferred to the osteochondral defect with the cambium layer facing the defect to maximize chondrogenic potential. The graft was carefully positioned and sutured in place using 6-0 Vicryl sutures, which were anchored to the surrounding stable cartilage but without passing through it to avoid compromising the intact chondral surface. Additional fixation with fibrin glue was applied to enhance graft stability and adherence to the defect site. Fig. 2.

Fig. 2.

OLT after debridement and periosteal transfer.

2.7. Postoperative care

Ankles were splinted for two weeks postoperatively, and sutures were removed between 15 and 20 days. A removable walking boot was applied, allowing passive ROM exercises. Immediate postoperative weight-bearing status was non-weight-bearing. Full weight-bearing was permitted after 6–8 weeks, based on radiographic evidence of osteotomy healing.

2.8. Statistical analysis

Data analysis was performed using SPSS (version 15.0). Numerical data were described using mean ± standard deviation (SD) and range. Categorical variables were expressed as frequencies and percentages. Repeated measures ANOVA and paired t-tests compared numerical variables, while Chi-square or exact tests were used for categorical data. A p-value <0.05 was considered statistically significant.

3. Results

3.1. Demographic characteristics

The mean age of the studied cases was 35.3 (±9.35 SD) with range (20–50) years, among the studied cases there were 17 (56.7 %) female and 13 (43.3 %) males, there were 8 (26.4 %) smokers, half of the cases 15 (50 %) had lesion in left side and the other half 15 (50 %) right and there were 29 (96.7 %) with medial and 1 (3.3 %) lateral. Table 1.

Table 1.

Baseline characteristics of the included patients.

Variable	Number (n = 30)		P
Age
Range.	20–50		<0.001∗
Mean ± SD.	35.3 ± 9.35
Sex	No.	%
Female	17	56.7	<0.001∗
Male	13	43.3
Smoking
No	22	73.3	<0.001∗
Yes	8	26.7
Side of the lesion
Left	15	50.0	<0.001∗
Right	15	50.0
Location of the lesion
Medial	29	96.7	<0.001∗
Lateral	1	3.3

3.2. Classification of lesion

According to the Ferkel classification, there were 1 (3.33 %) with 2A, 2 (6.7 %) with 2B, 14 (46.7 %) with 3 and 13 (43.3 %) with 4 and according to Hepple classifications, there were 16 (53.3 %) with 3, 13 (43.3 %) with 4 and 1 (3.3 %) with 5. Table 2.

Table 2.

Distribution of the studied cases according to radiographic classifications.

Variable	Number (n = 30)
Ferkel classification:	No.	%
2A	1	3.33
2B	2	6.7
3	14	46.7
4	13	43.3
Hepple classification
3	16	53.3
4	13	43.3
5′	1	3.3

3.3. Lesion size

The mean MRI Sagittal diameter was 12.43 mm (±4.49 SD) with a range (5–22 mm), the mean MRI Coronal diameter was 12.7 mm (±3.95 SD) with range (8–20 mm), the mean Intraoperative Sagittal diameter was 11.93 mm (±4.53 SD) with range (5–21 mm) and the mean Intraoperative Coronal diameter was 12 mm (±3.72 SD) with range (8–19 mm). Table 3 The mean follow-up duration of the studied cases was 11.07 months (±3.78 SD) with range (6–18 months).

Table 3.

Distribution of the studied cases according to the diameters of the lesions.

Variable	Number (n = 30)
MRI Sagittal, mm
Range.	5–22
Mean ± SD.	18.50 ± 4.49
MRI Coronal, mm
Range.	8–20
Mean ± SD.	17.5 ± 3.95
Intraoperative Sagittal, mm
Range.	5–21
Mean ± SD.	18 ± 4.53
Intraoperative Coronal, mm
Range.	8–19
Mean ± SD.	17 ± 3.72

3.4. VAS score

The preoperative VAS score of the studied cases was 7.07 (±1.46 SD) with a range of,^{5, 6, 7, 8, 9} the mean 6 months postoperative was 1.03 (±0.85 SD) with a range of (0.41–1.46) and the mean at the last follow-up was 0.43 (±0.68 SD) with range (0–2). Table 4.

Table 4.

Distribution of the cases studied according to VAS Score.

Variable	Number (n = 30)	P- Value
Preoperative
Range	5–9	<0.001∗
Mean ± SD	7.07 ± 1.46
3 months postoperative
Range.	3–5
Mean ± SD.	2.03 ± 0.85
6 months postoperative
Range.	0–2
Mean ± SD.	1.03 ± 0.85
Last follow-up
Range.	0–2
Mean ± SD.	0.43 ± 0.68

3.5. AOFAS score

The preoperative AOFAS of the studied cases was 40.6 (±11.3 SD) with range (19–55), the mean 6 months postoperative was 94.73 (±5.57 SD) with range (89–100) and the mean at last follow-up was 95.13(±3.43 SD) with range (89–100). Table 5.

Table 5.

Distribution of the studied cases according to AOFAS.

Variable	Number (n = 30)	P-Value
Preoperative
Range.	19–55	<0.001∗
Mean ± SD.	40.6 ± 11.3
3 months postoperative
Range.	75–90
Mean ± SD.	80.73 ± 2.57
6 months postoperative
Range.	89–100
Mean ± SD.	94.73 ± 3.57
Last follow-up
Range.	89–100
Mean ± SD.	95.13 ± 3.43

3.6. FADI score

Preoperatively, the mean FADI score was 53.77 ± 5.97 (range: 44–63). At 3 months postoperative, the mean score increased to 77.77 ± 3.97 (range: 70–85). By 6 months postoperative, the mean score further improved to 93.77 ± 2.97 (range: 89–99), and this level was maintained at the last follow-up (mean: 93.8 ± 2.95, range: 89–99). The analysis revealed a highly significant difference between the preoperative and postoperative periods (p1<0.001, p2<0.001), with no significant difference between 6 months and the last follow-up (p3 = 0.326). Fig. 3.

Fig. 3.

Distribution of the studied cases according to FADI.

3.7. Complications

Complications were observed in a minority of patients. Superficial infections occurred in 3 cases (10 %), while non-union of the medial malleolus osteotomy was not reported in any case (0 %). Deep vein thrombosis (DVT) was noted in 2 patients (6.7 %), and 1 patient (3.3 %) reported pain at the screw site. Overall, the complication rates were low, with no major adverse events, highlighting the relative safety of the procedure.

3.8. Post operative imaging

3.8.1. X-ray

Postoperative X-rays are requested immediately after surgery. On the 45th day, follow-up X-rays (AP, lateral and mortise views) were ordered. On the 90th day, follow-up X-rays were ordered. Then X-ray is done every three months to evaluate degenerative changes in joint and healing of osteotomy but is less useful for the assessment of OCD repair tissue. We found that after three months there is healing of osteotomy and no degenerative changes in the joint. Fig. 4.

Fig. 4.

Postoperative X-ray findings taken six weeks post-surgery, divided into three views: A (Anteroposterior), which assesses the frontal alignment between the tibia and talus along with the healing status of the osteotomy; B (Lateral), providing a side perspective to evaluate the contour of the talar dome and check for any displacements or complications; and C (Mortise), offering a focused view to examine the relationship between the tibia, fibula, and talus, crucial for identifying joint effusion and early signs of osteoarthritis.

3.8.2. CT

Three months following surgery, CT was ordered to assess the completeness thickness and level of a subchondral plate (flush, depressed, or proud), as well as bone volume filling of the defect and post-operative loose particles. However, to our knowledge, a post-operative grading system based on CT is unavailable. We discovered that after three months, there is satisfactory bone volume filling of the defect and no post-operative loose particles.

3.8.3. MRI

MRI was not performed in most patients due to concerns regarding artifact interference from the metallic implant used for osteotomy fixation, However, MRI was done for three patients after the removal of the screws, it shows persistent bone marrow edema and joint effusion. Fig. 5.

Fig. 5.

MRI After Removal of Screws: (A) and (B) Coronal Cuts, (C) and (D) Sagittal Cuts Showing Bone Marrow Edema of One of the Included Cases, with an edema size measuring approximately 12 mm × 8 mm in the coronal plane and 14 mm × 7 mm in the sagittal plane.

4. Discussion

Talus OCLs are common and are becoming more widely recognized thanks to advances in cartilage-sensitive imaging. It is estimated that up to 50 % of acute ankle sprains and fractures result in osteochondral damage. Approximately 23,000 lateral ankle sprains occur everyday in the United States, making talus OCL therapy more critical than previously considered.¹⁷ In this study, we aim to evaluate advantages and disadvantages of management of osteochondral lesion of talus with osteo-periosteal bone graft. Our results show a great improvement in the 3 clinical measurements, starting with the AOFAS scores, which improved from 40.6 preoperatively to 95.13 at the last follow-up. This emphasizes the substantial enhancement in the postoperative functional outcomes. These results are consistent with Nikolopoulos et al., 2019 who found that the mean AOFAS score increased from 40.3 preoperatively to a 1-year postoperative mean score of 95, with no further change at the 2-year postoperative landmark.¹⁸

Alsafty, 2018 even had a better preoperative AOFAS mean starting at 71.4 and ended with 93.2 after he performed autologous osteochondral transplantation for OCD talus on 12 patients.¹⁹ Usuelli et al., 2018 concluded their study with a mean AOFAS of 57.1 initially and 71.5 at 6 months postoperative.²⁰ A 2013 study by Walther and Martin showed a similar trend, in which 42 patients with of OCD larger than 2 cm² were treated with scaffold-based reconstruction. AOFAS score increased from 47.3 points to 88.3 points at a minimum 2-month follow-up.²¹ Our data showed a significant change when it comes to FADI scores, it increased significantly from 53.77 to 93.8 in the last follow-up visit respectively. Other studies such as Nikolopoulos et al., 2019 agree with our findings, as they discovered that the mean FADI score increased from 53.3 preoperatively to a 1-year postoperative mean score of 93.2 and a 2-year postoperative mean score of 93.3.¹⁸ Baumfeld et al. (2018) treated patients with talar osteochondral defects utilizing an all-arthroscopic method that included autologous matrix-induced chondrogenesis and the microfracture technique. The study found that the AOFAS score improved dramatically from 46.4 to 89.5 during the 8–20 month follow-up period. This shows a major improvement in function after the described treatment.²² Yontar et al., 2022 found that the mean preoperative FADI score was 36.9, which increased to 78.5 postoperatively.²³

This decline aligns with the findings of Yontar et al., 2022 in their study on 77 patients operated by Autologous Matrix-Induced Chondrogenesis (AMIC) for large OCD lesion of talus and found that the mean preoperative VAS for pain was 7.21 and the mean postoperative VAS was 2.21.²³ IIn a research by Bai et al. (2020), 19 patients with OLTs who had autologous chondral grafting and malleolar osteotomy experienced a significant decrease in pain as indicated by the VAS scale. The mean VAS score reduced dramatically from 4.68 preoperatively to 0.47 a year after surgery. The VAS values after one and two years were similar, demonstrating a prolonged reduction in pain..²⁴

Weigelt et al., 2019 in their similar study treated 33 patients with OLTs with Autologous Matrix-Induced Chondrogenesis. The study found that the mean VAS score significantly improved from 6.4 preoperatively to 1.4 at the latest follow-up (average of 4.7 years of follow-up).²⁵ It's worth noting that our VAS mean difference is the largest among all these similar studies. This large mean difference can be attributed to the surgical approach's overall lower rate of complications, as we found fewer cases of superficial infection, DVT (deep vein thrombosis) and pain at the screw site, even avoiding pain at the donor's site as shown in Yontar et al., 2022.²³ The surgical technique itself is highlighted for its advantages over other open approaches, as it is a single-stage procedure, reducing the need for multiple surgeries, which contrasts with other two-stage approaches such as Autologous Chondrocyte Implantation (ACI). Furthermore, the use of an autograft eliminates the risk of disease transmission associated with allograft, which was observed in Shimozono et al., 2018²⁶

4.1. Strengths

This study has several strengths including its prospective clinical design, which allows for reliable data collection, and its focus on a specific patient population with large or recurrent OLTs. The use of standardized outcome measures, such as VAS, AOFAS, and FADI scores, provides objective data on patient progress. Furthermore, the study used comprehensive imaging modalities, such as plain radiographs, CT scans, and MRI, which allowed for thorough evaluation and classification of the lesions. Finally, its focus on large lesions and their treatment makes this study valuable given that this is an understudied area of research.

4.2. Limitations

We acknowledge that there is no validated scoring system for OCLs of the talus, but it also notes the AOFAS is commonly used in literature, and we further acknowledge that AOFAS, while widely used, may not be the most efficient reporting tool.

4.3. Recommendations

We recommend future research to include a wider range of lesion sizes to assess the suitability of different treatment modalities for varying degrees of OLTs. The need for longer follow-up studies is essential to evaluate the durability of fibrocartilage that develops after osteoperiosteal patch procedures. Furthermore, we suggest comparing outcomes of patients treated with the osteoperiosteal patch to those whose OLTs were covered by hyaline cartilage, to determine the most effective treatment. Finally, long-term monitoring is needed to detect disease progression after healing.

5. Conclusion

Autologous bone graft and periosteal transfer are an effective treatment for large and recurrent OLTs, demonstrating significant improvements in patient-reported outcomes and low complication rates. Patients experienced a substantial reduction in pain, with the mean VAS score decreasing from 7.07 preoperatively to 0.43 at the last follow-up. Both the AOFAS and FADI scores showed significant improvement, increasing from 40.6 to 95.13 and 53.77 to 93.8, respectively.

CRediT authorship contribution statement

Ali M. Safaan: Conceptualization, and design of the study, Methodology, Investigation, and, Data curation, Formal analysis, Writing – original draft, Writing – review & editing. Y.A. Radwan: Conceptualization, and design of the study, Writing – review & editing, Supervision. Ahmed Khedr: Methodology, Investigation, and, Data curation, Formal analysis, Writing – original draft, Writing – review & editing. Ali M. Reda Mansour: Methodology, Investigation, and, Data curation, All authors have read and approved the final manuscript.

Guardian/patient consent

All patients provided informed consent before they participated in this study. The consent process adhered to the ethical guidelines set forth by the Faculty of Medicine, Cairo University and applicable international standards.

Ethical statement

The study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki and approved by the Ethics Committees of Al Kasr Al-Ainy Hospital, Assuit University, and Alzohoor Hospital. Ethical considerations included ensuring patient confidentiality and obtaining informed consent for participation and data collection.

Funding statement

No funding was received for this study.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.