Autologous Chondrocyte Transplantation for OCD of the Talus
Abstract & Commentary
Synopsis: This retrospective, nonrandomized study of 8 patients with OCD of the talus (2 lateral, 4 medial, 3 central) treated with autologous chondrocyte transplantation found symptomatic improvement evidenced by pain-free motion, with improved but persistent osteochondral abnormalities on MRI and arthroscopy.
Source: Koulalis D, et al. Clin Orthop. 2002;395:186-192.
This paper describes the application of tissue engineering principles to osteochondritis dissecans (OCD) of the talus similar to the currently popular treatment of OCD of the knee. Koulalis and colleagues treated 8 patients with persistent pain and swelling about the ankle after the diagnosis and conservative treatment (minimum 12 months) of a talar OCD lesion. Four of 8 patients underwent an index procedure of lesion debridement either arthroscopically (3) or open (4). The OCD lesions seen were as follows: 4 medial, 2 central, and 2 lateral. All patients underwent arthroscopic debridement with articular cartilage biopsy for chondrocyte cultivation (Codon GmbH, Teltow, Berlin, Germany).
At an average of 2.5 weeks, the cultivated chondrocytes were reimplanted under a sewn periosteal flap. Defect sites were grafted, if necessary, with tibial cancellous graft at the time of cell reimplantation. Five of 8 patients required a malleolar osteotomy, while 3 implantations were performed through an arthrotomy alone. Patients were treated with postoperative continuous passive motion and protected weight bearing for 6-7 weeks postoperatively. All patients underwent MRI scanning at 3, 6, and 12 months postimplantation with follow-up averaging 17.6 months. MRI results showed only 1 patient with articular coverage by 6 months, and 5 of 8 patients had articular coverage at 1 year. Arthroscopic evaluation at 6 months in 3 patients revealed cartilage-like tissue in the defect with continuity of the articular surface in 2 of 3 patients. Of those 3 patients, a biopsy taken revealed only evidence of fibrocartilage and type I collagen. All patients were noted to have pain-free range of motion. Complications included dorsiflexion loss of 10° in 3 of 8 patients.
Comment by Robert C. Schenck, Jr., MD
Articular injuries about any joint continue to be a perplexing issue. With the advancement of tissue engineering techniques, and specifically chondrocyte implantation techniques pioneered by Brittberg and colleagues, articular repair is becoming a reality.1 Certainly, OCD is a specific injury where autologous chondrocyte implantation (ACI, Carticel®, Genzyme, Boston, Mass) is being actively applied in the knee and ankle/talus. Autologous chondrocyte implantation or transplantation requires tissue engineering principles and a 2-staged procedure with the second procedure requiring an arthrotomy.
All OCD lesions are not created equal, and the location, joint involved, and degree of bone loss certainly play a factor in the treatment option selected.2 In this paper reviewed, Koulalis et al selected adult OCD lesions, which in my experience require more aggressive treatment than simple drilling. Specifically in regards to talar OCD lesions, the need for osteotomy is commonplace in my experience, and in this study, one half of patients required an osteotomy. Lastly, Koulalis et al note themselves that even at 12 months follow-up, chondrocyte transplantation did not create normal articular cartilage, but improvement in symptoms. Articular regeneration will require tissue engineering principles, and as Koulalis et al outlined, this is just the beginning.
Dr. Schenck, Deputy Chairman, Department of Orthopaedics, University of Texas Health Science Center, San Antonio, is Associate Editor of Sports Medicine Reports.
References
1. Brittberg M, et al. N Engl J Med. 1994;331:889-895.
2. Schenck RC, Goodnight JM. J Bone Joint Surg. 1996; 78-A:439-456.
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