SPECIAL FOCUS AND CME ARTICLE

Bone Marrow Stimulation and Biological Adjuncts for

Treatment of Osteochondral Lesions of the Talus
Keir A. Ross, BS,* Justin Robbins, MD,wz Mark E. Easley, MD,y
and John G. Kennedy, MD, FRCS (Orth)8

(Tech Foot & Ankle 2015;14: 41–52)

Abstract: Osteochondral lesions of the talus (OLT) frequently occur after
ankle sprain or fracture. Although there has been a growing interest in OLT
treatment recently, the pathology has been recognized for hundreds of years. LEARNING OBJECTIVES
Yet there is a lack of consensus as to the most effective treatment strategy. After participating in this CME activity, participants should be
Because of a lack of vasculature and the relative hypocellularity of articular better able to:
cartilage, OLT are difficult to treat. Arthroscopic bone marrow stimulation 1. Apply the appropriate diagnostic tools for patients with a
(BMS) has become a commonly used method of treating smaller, primary suspected osteochondral lesion of the talus to facilitate
OLT because of technical simplicity, the advantages of minimally invasive effective preoperative planning.
access, and cost-effectiveness. Results of BMS are good in the short-to- 2. Select and implement the appropriate treatment course for
midterm with high overall success rates reported in the literature. However, osteochondral lesions of the talus based on individual
the fibrocartilagenous repair tissue formed after BMS confers inferior bio- patient characteristics, lesion location, and lesion size.
logical and mechanical properties compared with native hyaline cartilage. 3. Effectively manage patient expectations regarding the
Poorer outcomes have also been demonstrated in large and uncontained talar outcomes of arthroscopic bone marrow stimulation and
shoulder lesions. Subchondral bone compaction and thermal necrosis with retrograde drilling.
drilling may be the cause for concern. There is also evidence of high rates of
cracks and fissuring in fibrocartilage and inadequate integration with native
cartilage postoperatively. Furthermore, there is a lack of long-term BMS
HISTORICAL PERSPECTIVE
outcome data available. Concerns with BMS have prompted investigation of Osteochondral lesions of the talus (OLT), although once given
biological adjuncts that could potentially improve the quality of BMS repair little acknowledgment, are common injuries that often occur
tissue and form a more hyaline-like repair. Arthroscopic BMS has much after ankle sprain or fracture. As many as 70% of sprains and
promise for the future but long-term, high-level studies are required. fractures may result in OLT.1 These lesions are increasingly
Enhancement of BMS with biological adjuncts and improved surgical recognized as a consequence of improved imaging techniques
instrumentation has the potential to improve cartilage repair and outcomes. and higher rates of ankle arthroscopies.1,2 The primary
etiology is traumatic injury,3 but numerous nontraumatic
causes have been reported.4,5 Repetitive microtrauma also
Level of Evidence: Diagnostic Level 5. See Instructions for Authors appears to be a common cause.6 Although smaller lesions may
for a complete description of levels of evidence. respond to nonoperative management, chiefly in pediatric
Key Words: arthroscopy, bone marrow stimulation, talus, patients, OLT are thought to more often progress from small
osteochondral lesion, orthobiologics cracks and fissuring in the cartilage and subchondral plate to
more substantial pathology as synovial fluid under hydrostatic

From the *Research Assistant, Department of Foot and Ankle Surgery, Hospital for Special Surgery, New York, NY; wStaff Orthopedic Surgeon, Madigan
Army Medical Center, Tacoma, WA; zDepartment of Orthopaedics, Duke University, Durham, NC; yAssociate Professor, Department of Orthopaedic
Surgery, Duke University, Durham, NC; and 8Attending Orthopaedic Surgeon, Hospital for Special Surgery, and Assistant Professor of Orthopaedic Surgery,
Weill Cornell Medical College, New York, NY.
J.G.K. is a consultant for Arteriocyte, Inc. and his spouse/life partner (if any) have no financial relationships with or financial interests in, any commercial
companies pertaining to this educational activity.
All other authors and staff in a position to control the content of this CME activity and their spouses/life partners (if any) have disclosed that they have no
financial relationships with, or financial interests in, any commercial organizations pertaining to this educational activity.
Lippincott CME Institute has identified and resolved all conflicts of interest concerning this educational activity.
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Techniques in Foot & Ankle Surgery includes CME-certified content that is designed to meet the educational needs of its readers. This activity is available for
credit through March 31, 2016.
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Address correspondence and reprint requests to John G. Kennedy, MD, FRCS (Orth), Department of Foot and Ankle Surgery, Hospital for Special Surgery,
East River Professional Building, 523 East 72nd Street, New York, NY 10021. E-mail: KennedyJ@hss.edu.
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Ross et al Techniques in Foot & Ankle Surgery  Volume 14, Number 1, March 2015

pressure invades the tissues.7 Pain likely onsets with repetitive surgical technique and postoperative management, and dis-
pressure under weight-bearing due to sensitization of the cusses the most recent evidence regarding outcomes, future
highly innervated subchondral bone.7 This presents a challeng- directions for treatment, and use of biological adjuncts.
ing problem to orthopedic surgeons as the avascular status of
cartilage results in rare occurrence of spontaneous healing; INDICATIONS AND CONTRAINDICATIONS
leaving OLT susceptible to gradual degradation and the
Asymptomatic or mildly symptomatic OLT that solely involve
potential for osteoarthritis to ensue over time.8–10
the articular surface should be managed with rest, ice,
Improved understanding of ostechondral lesions and carti-
compression, and elevation. Appropriate physical therapy
lage biology seems to have stimulated abrupt interest in treating
and orthotics can also be beneficial. Injection of corticosteroid,
the pathology, however, Alexander Monroe described the first
hyaluronic acid (HA), or platelet-rich plasma (PRP) can also
osteochondral loose body in the ankle joint in 1737 and reports
be considered. However, high failure rates with nonoperative
of physicians attempting to treat damaged articular cartilage date
management have been reported so patients should be
back over 250 years.11,12 As a variety of surgical procedures
counseled accordingly.6,33,34 Arthroscopic BMS is indicated
have been developed including debridement and curettage,
after conservative strategies have failed for primary, noncystic
arthroscopic bone marrow stimulation (BMS; including micro-
OLT that are smaller than 150 mm2.24,25 For larger OLT or
fracture and microdrilling), autologous matrix-induced chon-
lesions with large subchondral cysts, replacement strategies are
drogenesis, autologous chondrocyte implantation, particulated
indicated.25,27 In the case of lesions that exclusively involve
juvenile allograft cartilage, osteochondral allograft, and autolo-
the subchondral bone with intact cartilage overlying the lesion,
gous osteochondral transplantation (AOT), among other
retrograde drilling should be carefully considered.4,35,36
strategies.13–23
Contraindications include those for any arthroscopic
Arthroscopic BMS remains the one of the most commonly
procedure. Reduced joint space, limited range of motion,
employed treatment strategies. It is typically considered the
severe edema, degenerative joint disease, and questionable
standard first-line treatment for unstable OLT, or after con-
vascular status are relative contraindications. Absolute con-
servative therapies have failed, and is reserved for small, non-
traindications are infection (ie, septic arthritis) and severe
cystic lesions.13,24,25 Microfracture was first described in the
degenerative joint disease.37 Again, the choice of surgical
knee by Steadman and colleagues12,26 and the procedure has
treatment strategy is dictated by lesion size. Arthroscopic BMS
gained widespread popularity since. The popularity of BMS,
is contraindicated for lesions >150 mm2 and lesions with large
particularly microfracture, has likely been maintained because of
cysts or diffuse subchondral edema.25 To the author’s knowl-
marginal technical demand, low complication rates, access via
edge, there are no studies that have specifically investigated the
minimally invasive arthroscopy, and minimal postoperative
effect of lesion depth on functional or radiographic outcomes.
pain.27 Studies have reported good outcomes for OLT with short-
This is an important area of future investigations that could
to-midterm follow-up but there is a general lack of long-term
elucidate the prognostic factors and indications for BMS.
data in the literature.14,27 Concerns also exist over the ability of
the fibrocartilagenous repair tissue formed after BMS to with-
stand physiological stresses. Fibrocartilage has been demon- PREOPERATIVE PLANNING
strated to confer inferior mechanical and biological properties Patients often present with deep ankle pain and tenderness
compared with hyaline cartilage. This has generated concern along the anterior joint line with palpation. There is typically
with long-term clinical outcomes and investigation of the use of associated swelling. Clicking or a sense of locking within the
biological adjuncts aimed at improving the quality of repair ankle joint is also commonly reported in patients with OLT.
tissue.14,28–32 Ankle inversion injury is a common etiology. Anterior drawer
Still, BMS remains a viable first-line treatment, and the laxity, ankle inversion strength, elicitation of pain with
success of the procedure lies after precise indications, thorough inversion, and tenderness of the peroneal tendons on palpation
preoperative planning, and meticulous technique. This article are therefore crucial to assess. Pathology of lateral anatomic
outlines preoperative planning for OLT, describes BMS structures may need to be treated at the time of BMS. Joint

FIGURE 1. Preoperative coronal fast spin-echo proton density magnetic resonance imaging of an osteochondral lesion of the medial
talus [(A); yellow arrow] and T2-weighted fat-suppressed magnetic resonance image of the same lesion [(B); yellow arrow].

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 Special Focus: Arthroscopic Bone Marrow
Techniques in Foot & Ankle Surgery  Volume 14, Number 1, March 2015 Stimulation for Talar OCL

FIGURE 2. Sagittal (A) and coronal (B) multidetector helical computed tomography scan of a posteromedial osteochondral lesion of the
talus (yellow arrows). The coronal image demonstrates an uncontained, shoulder lesion.

alignment must also be examined. Malalignments should be subchondral bone involvement39 (Fig. 2). CT also provides fur-
concomitantly corrected at the time of surgery.7 ther detail of loose ostochondral fragments.
Imaging is the most essential aspect of preoperative plan- Once the lesion has been diagnosed and BMS has been
ning when treating OLT. Plain radiographs may miss up to 50% selected as the treatment option, surgical planning is based on
of OLT so additional imaging must be used when osteochondral lesion location. Most lesions can be accessed using standard
injury is suspected.38 Magnetic resonance imaging (MRI) is the anterior arthroscopic portals.41 Plantar flexion with soft-tissue
preferred modality as it has the capacity to evaluate articular distraction is recommended as it improves access to the joint.
cartilage morphology and microstructure39,40 (Fig. 1). It is sen- Invasive distraction is best avoided as complication rates may
sitive enough to determine changes in collagen orientation be up to 13.6%.41 Furthermore, approximately 48% of the talar
associated with degradation and is valuable for distinguishing dome is located anterior to the anterior distal tibial rim in
between native cartilage and repair tissue (including fibro- patients with normal plantar flexion range.42 Lesions beyond
cartilage). This modality is also useful for assessing the extent of the anterior distal tibial rim can be accessed with arthroscopic
subchondral pathology, particularly edema, and concomitant instrumentation. In the current authors’ experience, the anterior
extra-articular soft-tissue injury. Widely accepted cartilage MRI 75% of the talar dome can be accessed using standard
protocols include standard 2-dimensional multislice turbo or fast arthroscopic portals. If access to the lesion proves difficult, a
spin-echo proton density and fat-suppressed proton density posterolateral working portal can be employed.
sequences acquired in multiple planes. T2 mapping MRI Posterior arthroscopy can be utilized for lesions located in the
sequencing can provide quantification of collagen architecture most posterior aspect of the talus. A number of posterior
and biochemical status of cartilage when further assessment is approaches have been described, but the original 2-portal posterior
required.40 Computed tomography (CT), although unable to approach has been demonstrated to provide safe, adequate
capture the articular surface, may provide a more exact measure access.43,44 Posterior arthroscopy provides the ability to treat not
of lesion size. This modality is particularly useful for assessing only posterior OLT but also other hindfoot, posterior ankle, sub-
talar joint, and extra-articular pathologies with good functional
results.44
Retrograde drilling should be considered when MRI
indicates an intact articular surface overlying a subchondral
lesion. The state of the articular cartilage can be confirmed
arthroscopically. The cartilage should be probed to verify that
the tissue is not uncharacteristically ballotable or fissured.
Probing may also reveal delaminated cartilage when present.

TECHNIQUE
Arthroscopic BMS
The patient is placed supine on the operating table under general
or spinal anesthesia and prepped and draped in the usual manner.
A noninvasive soft-tissue distracter is fastened to the operating
table and ankle with the joint in plantar flexion (Fig. 3). This
expands the joint space and improves access. Fifteen pounds of
distraction force is appropriate. When an anterior approach has
FIGURE 3. Intraoperative photograph of the soft-tissue been selected, an anterolateral portal is placed 5 mm distal to
distraction set-up for anterior ankle arthroscopy. The distractor is the joint line lateral to the peroneus tertius tendon. Care must be
fastened to the operating table with the ankle in plantar flexion. taken to avoid the superficial peroneal nerve, which can be
The arthroscope and instrumentation are granted access through palpated or visualized with the fourth toe in maximum plantar
anterolateral and anteromedial portals. flexion. The anteromedial portal is placed 5 mm distal to the

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Ross et al Techniques in Foot & Ankle Surgery  Volume 14, Number 1, March 2015

FIGURE 4. Arthroscopic images depicting the identification and debridement of the medial osteochondral lesion of the talus shown
in Figure 1. The lesion was identified and probed (A), revealing an unstable osteochondral fragment (B). The lesion was the debrided
with a curette and graspers to establish a rim of stable cartilage (C).

joint line just medial to the tibialis anterior tendon. A limited integration. Final lavage and arthroscopic evaluation is per-
portion of the anterior distal tibial margin can be removed with a formed to ensure that no loose bodies are left within the joint. If a
burr to improve access when necessary. Soft-tissue or scar tissue tourniquet is used, deflate it at this time to confirm the presence
resection may also be required for proper visualization. Any of fat droplets or bone marrow emerging from each BMS breach.
other concomitant intra-articular procedures, including syno- If a posterior approach has been selected, the patient is
vectomy, should be performed before BMS to avoid disrupting placed in the prone position with the ankle overhanging the
the clot with irrigation. The joint is then inspected using the 21- end of the operating table. Alternatively, a triangular cushion
point systematic Ferkel evaluation.45 Once the lesion has been can be placed at the end of the table under the distal tibia. To
indentified, a curette is used to remove degenerated tissue until a accurately place arthroscopic portals, a line parallel to the sole
vertical, stable rim of healthy cartilage has been created (Fig. 4). of the foot is drawn from the tip of the lateral malleolus to the
All delaminated cartilage should also be removed. A shaver is tip of the medial malleolus with the ankle in neutral position.
often useful for debridement as well. If a subchnondral cyst is The posteolateral portal is placed 5 mm anterior to the lateral
present, all degenerated bone and cystic lining is debrided. border of the Achilles tendon just proximal to the previously
These steps are critical as results of second-look arthroscopy drawn line. The posteromedial portal is placed just proximal to
reported by Takao et al46 demonstrated improved repair when the drawn line, 5 mm anterior to the medial border of the
degenerative cartilage was removed before BMS. The calcified Achilles tendon (Fig. 6).43,44 Care must be taken to avoid the
cartilage layer is also removed with a curette to facilitate clot sural nerve and medial neurovascular bundle when creating the
adhesion and repair.47 The subchondral bone is then breached to posterolateral and posteromedial portals, respectively. A sys-
a depth of 2 to 4 mm perpendicular to the surface using tematic 4-quadrant approach is then used to sequentially
Kirschner wire drilling or a microfracture awl (Fig. 5). This address any associated hindfoot pathologies, with intra-artic-
promotes subchondral bleeding and recruitment of mesenchynal ular injuries addressed during the final stage of the proce-
stem cells from the underlying marrow. Gaps of 3 to 4 mm are dure.44 Adequate visualization and posterior OLT access can
left between each breach.26,45,46 Surgeons must ensure that BMS typically be achieved with manual ankle dorsiflexion. BMS is
is performed at the periphery of the defect to improve then performed as described above.

FIGURE 5. Arthroscopic images of the medial osteochondral lesion of the talus depicted in Figures 1 and 4. Bone marrow stimulation
within the debrided defect was performed using a microfracture awl.

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 Special Focus: Arthroscopic Bone Marrow
Techniques in Foot & Ankle Surgery  Volume 14, Number 1, March 2015 Stimulation for Talar OCL

FIGURE 6. Intraoperative photograph of the posterior arthroscopy set-up (A). The patient is placed in the prone position with the ankle
overhanging the end of the operating table. The arthroscope and instrumentation are granted access through posteromedial and
posterolateral portals (B).

Retrograde Drilling slightly on arthroscopic visualization. Allow the drill tract to fill
If an intact articular surface overlying the lesion has been with graft as the syringe is slowly removed from through the
confirmed using standard anterior diagnostic arthroscopy, as lateral incision. The graft can be observed fluoroscopically after
described above, then retrograde drilling is warranted.35,36,48 delivery. Excess graft must be removed from the drill portal
The patient is placed supine on the operating table with before wound closure.
noninvasive soft-tissue distraction in the standard manner. Lateral lesions with an intact articular surface are reportedly
Multiplane preoperative imaging should be used to precisely uncommon,50 however, when lesions of this nature are encoun-
locate the lesion and the location should be confirmed tered, a slightly different approach is recommended. Using the
arthroscopically. In the case of medial lesions, a 1 cm lateral same general technique, guidewire placement and drilling should
incision is made over the area of the sinus tarsi at the originate anteromedially from the junction of superior border of
nonarticular junction between the neck and body of the talus as the spring ligament and the inferior border of the deltoid.48
per the technique described by Taranow et al.35 The lateral Posterolateral and posteromedial lesions are particularly difficult
process of the talus is accessed via blunt dissection to the lateral to triangulate for retrograde drilling. Guidewire placement for
cortex, minding the peroneal tendons. A small-joint drill guide posteromedial and posterolateral lesions begins from the same
(Smith and Nephew, PLC) is then placed through the incision points as described above for medial and lateral lesions,
anteromedial arthroscopy portal over the OLT. Arthroscopic respectively. The drill guide and guidewire are simply directed
guidance is maintained through the anterolateral portal to ensure posteriorly. Because triangulation may be difficult, thorough
that the articular surface is not breached during drilling. A long use of preoperative imaging and intraoperative fluoroscopy in
6.2-mm Kirschner guidewire directed at the lesion is then multiple planes should be emphasized.35,48
introduced into the talar body through the lateral process and
gradually advanced to the center of the bony defect under
fluoroscopic guidance. The guide is removed after drilling to a
depth of 1 to 2 cm. Obtain images in both anteroposterior and
lateral planes. It is imperative not to penetrate the articular
surface with the guidewire. Under fluoroscopic guidance, a
cannulated drill is introduced over the guidewire. The authors
use a 4-mm cannulated, acorn-tipped tenodesis drill (Arthrex
Inc.). After removing the drill and guidewire, the drill hole is
debrided with an angled curette, ensuring that the entire lesion
cavity and cystic lining are removed (Fig. 7). Loose debris
should also be cleared away. Filling the lesion with autogenous
bone graft has been previously described,35 but it is often dif-
ficult to fill the areas of the lesion that are not in direct alignment
with the drill hole without aggressive packing and risk of further
cartilage damage.48 Therefore, the current authors utilize an
injectable calcium sulfate bone graft substitute (Wright Medical
Technology Inc.). The graft substitute is hydrated, injected as a
smooth paste, and then hardens to the strength of cancellous
bone in approximately 5 minutes. This has the advantage of
filling and entire defect while obviating the need to aggressively
tamp or pack a graft. Gradual resorption and cancellous bone FIGURE 7. Fluoroscopic view of a medial osteochondral lesion of
substitution occurs over a period of 8 weeks.36,48,49 When uti- the talus. After drilling, an angled curette is being used to debride
lizing this method, the defect is gradually filled with injectable the cavity and cyst. Reproduced with permission from Kennedy
graft until the articular cartilage is noted to protrude very et al.48

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Ross et al Techniques in Foot & Ankle Surgery  Volume 14, Number 1, March 2015

RESULTS Retrograde Drilling

Retrograde drilling was first described in the knee as an open
Arthroscopic BMS procedure but good results have also been reported in the
The objective of creating multiple breaches in the subchodral plate ankle.4,35,58,59 Taranow et al35 described results in 16 patients
is to form channels for the flow of bone marrow from the with medial OLT that underwent drilling through the sinus
underlying bone. Pluripotent mesenchymal stem cells present in tarsi. At mean 24-month follow-up there were no complica-
the marrow coagulate and form a fibrin clot in the defect which tions and AOFAS scores increased from 53.9 to 82.6. Eighty-
initiates an inflammatory response, subsequent release of one percent of patients were satisfied with the procedure. Kono
cytokines and growth factors, and stimulation of tissue healing.9,27 and colleagues compared 1 year postoperative second-look
The expectation is that the mesenchymal stem cells differentiate arthroscopic findings of 19 patients that underwent trasmal-
chondrocyte-like cells and synthesize proteoglycan matrix and leolar drilling to 11 patients that underwent retrograde drilling.
type II collagen-based repair tissue.14,28,51 There is, however, All lesions in the transmalleloar group were either unchanged
evidence that a gradual shift to type I collagen-based fibrocartilage in grade (58%) or deteriorated 1 grade (42%).59 Grading in the
occurs after 1 year as a result of continuous surface fibrillation, retrograde drilling group was significantly favorable
proteoglycan depletion, and chondrocyte death.14,28,52 (P < 0.0001); all lesions improved by 1 grade (27%) or were
In terms of clinical translation, outcomes of BMS are unchanged in grade (73%). Hyer et al60 later reported AOFAS
good in the short-to-midterm. Saxena and Eakin2 demonstrated and Short-Form 12 (SF-12) scores at mean 24-month follow-up
significant improvements in American Orthopaedic Foot and in 7 patients. AOFAS and SF-12 physical component scores
Ankle Society Ankle-Hindfoot (AOFAS) scores in an athletic increased a mean 34 and 8.2 points, respectively. Maintaining
population with 96% return to sport at a mean of 15.1 weeks. the integrity of the articular surface may prove beneficial, but
Lee et al53 have also reported significantly improved AOFAS more data are required before the results of this procedure can
scores at a mean of 33-month follow-up. Furthermore, a recent be weighed against other surgical strategies.
systematic review found that the overall success rate of BMS
was 85%.54 However, there is a profound lack of long-term Biological Adjuncts
data. To the author’s knowledge there is only 1 report of long- Despite cost-effective, technically undemanding pain relief
term outcomes in the literature. van Bergen and colleagues with BMS, concerns remain over the biological and mech-
evaluated the results of BMS in 50 patients with a mean anical quality of the fibrocartilage repair tissue formed after
12-year follow-up (range, 8 to 20 y).55 The median AOFAS BMS. Specifically, Lee et al61 have demonstrated that only
score was 88 at final follow-up with 78% good to excellent 30% or repair tissue was integrated with surrounding cartilage
Ogilvie-Harris scores. Eighty-eight percent of patients resumed on second-look arthroscopy 12 months after BMS. MRI
sports and 94% resumed work. Sixty-seven percent of radio- analysis 5 years after BMS by Becher et al13 indicated that
graphs showed no progression of osteoarthritis compared with 100% of lesions had cracks and fissuring in the repair tissue.
the preoperative grading and 33% showed progression by 1 The deterioration of fibrocartilage appears to be associated
grade. In addition, there is only 1 quasirandomized com- with outcome as Ferkel et al15 found deterioration in outcome
parative study assessing outcomes of several cartilage repair scores in 35% of patients 5 years postoperatively. As a result,
techniques.56 Gobbi and colleagues prospectively compared there has been growing interest in the use of biological
chondroplasty, microfracture, and AOT. Numeric pain inten- adjuncts to improve the quality of fibrocartilage repair tissue
sity, subjective assessment numeric evaluation rating, AOFAS and generate a more hyaline-like repair.
scores, and MRI outcomes were compared between techni- Concentrated bone marrow aspirate (CBMA) harvested
ques. At 52-month follow-up, there was no significant differ- from the iliac crest, or several other anatomic locations, has
ence in outcomes between treatment groups. Incomplete infill been proposed as a 1-step source of autologous mesenchymal
and edema were prevalent after chondroplasty and micro- stem cells and growth factors that can be applied during BMS
fracture on MRI. It is important to note, however, that there procedures. Fortier et al29 compared the results of BMS with
were only 11, 10, and 12 ankles included for chondroplasty, CBMA to BMS alone for repair of full-thickness cartilage
microfracture, and AOT, respectively, and that selection bias defects in an equine model. Macroscopic and histologic
prevented the study from being considered truly randomized.56 assessment 8 months postoperatively demonstrated sig-
Not only is there a general lack of long-term and high-level nificantly higher scores with increased collagen type II and
evidence, but there are a number of flaws in the data that are glycosaminoglycan content in the BMS with CBMA group
currently available. A systematic review of outcome data compared with BMS alone. MRI analysis revealed increased
reporting after microfracture by Hannon et al57 found that infill and integration in the CBMA group. Unfortunately, there
while general demographic information and study design is limited clinical evidence for CBMA as an adjunct to BMS.
variables were well described in 96% of studies, 23 different However, Kennedy and Murawski23 applied CBMA to 72
outcome scoring systems were used across the 24 reviewed AOTs. Although there was no control group without CBMA
studies. This study highlighted the difficulty in interpreting treatment, Foot and Ankle Outcome Scores and SF-12 scores
BMS results in the literature. The review also found that lesion had significantly improved at 28-month follow-up. Giannini
size, which has been demonstrated as a key indicator of out- et al17 applied concentrated bone marrow–derived cells to
come,24,25 was only reported in 46% of studies. Only 75% of either a collagen powder or HA membrane as a
studies reported follow-up imaging with at least 1 modality. 1-step repair in a prospective study of 48 patients. Significant
MRI was reported in 54% and CT was not reported at follow- improvements in AOFAS scores were seen, however, repair
up in any study.57 Arthroscopic BMS appears to provide tissue was not completely hyaline-like histologically. Clinical
symptomatic relief and return to sport in the short-to-midterm, studies comparing the BMS with CBMA to BMS alone are
however, long-term results have yet to be determined. Other required before any conclusions regarding the efficacy of the
cartilage repair procedures must be compared with BMS in adjunct can be made.
high-level studies to determine the most effective treatment PRP is an autologous blood product formed by cen-
algorithm for OLT. trifugation of whole blood to separate out fractional elements.

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 Special Focus: Arthroscopic Bone Marrow
Techniques in Foot & Ankle Surgery  Volume 14, Number 1, March 2015 Stimulation for Talar OCL

The goal is to achieve a 2-fold or more increase in platelet have reported good results with HA for knee and subtalar
concentration above baseline serum levels. Platelets and their osteoarthritis, but little evidence remains for specifically for its
associated growth factors have the theoretical capacity to improve use in the treatment OLT.63–65 A level 1 randomized control
cartilage repair. Chemotactic, anti-inflammatory, and anti- trial by Doral et al32 compared 41 patients that underwent
catabolic effects are proposed mechanisms of action.30 Growth BMS and postoperative HA injection to 16 patients that
factors associated with PRP that are postulated to contribute to underwent BMS alone for OLT. Freiburg functional and pain
cartilage healing include the transforming growth factor-b super and AOFAS scores improved significantly in each group, but
family, fibroblast growth factor, epidermal growth factor, plate- significantly greater improvements were found in the HA
let-derived growth factor, and vascular endothelial-derived injection group. Additional studies are needed to determine the
growth factor. The role of PRP in cartilage repair has been well efficacy of HA as a conservative treatment for OLT, as an
evidenced in in-vitro and in-vivo animal models but clinical adjunct for BMS, and to compare the efficacy of HA to other
evidence is limited.30 Mei-Dan et al31 performed a well-designed available adjuncts.
comparison of 3 PRP versus 3 HA injections for nonoperative
treatment of OLT. Both HA and PRP injection increased AOFAS
scores and decreased pain scores significantly. Significantly COMPLICATIONS
greater improvements were seen in the PRP group 28 weeks after Complications of BMS include those for any arthroscopic
injection. Guney et al62 recently investigated PRP as an adjunct to procedure. Nerve injury, vascular injury, infection, and
BMS for OLT in 19 patients and compared results to 16 patients synovial fistula have all been described.66 Nerve injury is
that underwent BMS alone. Baseline AOFAS and Foot and Ankle most commonly reported (1.9%), but most complications
Ability Measures were equivalent between groups at baseline but resolve within 6 months and do not lead to functional
pain scores were higher in the PRP group. At an average of 16.2 limitations. Overall complication rate appears to be as low as
months postoperatively, all outcome scales favored combined 3.5% with noninvasive distraction.66 Complications with
BMS and PRP intervention over BMS alone. Basic science data posterior arthroscopy have been described as low as 2.3%,
and early clinical results have warranted further, high-level considerably lower than the 24% rate seen with open posterior
investigation of PRP as an adjunct to cartilage repair. More procedures.66,67 Scrupulous surgical technique will contribute
generally, further investigation is required to determine to most to minimizing these complications. A potential complication
effective combination of stem cells and growth factors that with BMS specifically is the creation of loose bony particles
contribute to cartilage repair. Studies characterizing the content of that may act as loose bodies after operation.68 Again,
both CBMA and PRP are also needed to optimize centrifugation concluding the procedure with final arthroscopic joint
protocols and so that the 2 adjuncts can be compared. inspection and lavage are recommended to avoid this issue.
Although PRP was demonstrated to be more effective
than HA by Mei-Dan et al,31 significant improvements in pain
and functional scores were also demonstrated with HA. HA is POSTOPERATIVE MANAGEMENT
a polysaccharide component found in synovial fluid commonly After arthroscopic BMS, the authors recommend that the
utilized as an off-the-shelf viscoelastic supplement. In addition patient is placed in a soft leg splint for 14 days. Dorsiflexion
to conferring viscoelastic properties and joint lubrication, HA and plantar flexion ankle pump exercises should begin 72
may contribute to chondrocyte proliferation and act as a hours postoperatively and continue for 4 weeks. A 20-degree
transmission buffer to nociception.31,63,64 A number of studies arc of motion is permitted initially (10 degrees of dorsiflexion
and 10 degrees of plantar flexion). Once 20-degree arc of
motion ankle pumps can be performed without pain, the arc of
motion is increased to the highest range that can be achieved
without pain. Twenty minutes of ankle pumps each day
prevent stiffness and scarring of the joint and facilitate nutrient
supply to the cartilage from synovial fluid. After 2 weeks, the
patient is transitioned to a controlled ankle movement walker
boot. The boot is set to allow 20 degrees of plantar flexion and
20 degrees of dorsifelxion. The patient is instructed to begin
bearing 10% of their weight 4 weeks postoperatively,
increasing weight-bearing by 10% each day until achieving
full weight-bearing at approximately 6 weeks after surgery.
After retrograde drilling, the patient should be non–
weight-bearing for the first 2 weeks. The second 2 weeks
consist of partial weight-bearing with active and passive range-
of-motion exercises. The patient is allowed unrestricted
ambulation 1 month postoperatively.
Formal physical therapy begins at 6 weeks. Rehabilitation
should focus on reestablishing balance, proprioception, and sta-
bilization. The focus is shifted to strengthening and sports specific
training at the 10-week time point. Return to full-contact sport
must be continually assessed as symptoms improve.
FIGURE 8. Postoperative coronal fast spin-echo proton density Ideally, postoperative MRI should be obtained between 3
magnetic resonance imaging of an osteochondral lesion of the and 6 months after surgery to evaluate repair tissue integration
medial talus (yellow arrow) 10 months after arthroscopic and infill volume (Fig. 8). A second round of MRI should be
microfracture. Fibrocartilage infill has matured within the defect obtained before the end of the first postoperative year to assess
but subchondral edema can be appreciated. cartilage maturation.69

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Ross et al Techniques in Foot & Ankle Surgery  Volume 14, Number 1, March 2015

POSSIBLE CONCERNS AND FUTURE 4. O’Loughlin PF, Heyworth BE, Kennedy JG. Current concepts in the
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67. Abramowitz Y, Wollstein R, Barzilay Y, et al. Outcome of resection of a 70. Choi WJ, Choi GW, Kim JS, et al. Prognostic significance
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Techniques in Foot & Ankle Surgery  Volume 14, Number 1, March 2015 Stimulation for Talar OCL

CME QUESTIONS

1. A 22 year old male basketball player presents with a sense of “locking” and deep pain in the medial aspect of the ankle joint.
The patient has a history of recurrent ankle inversion injury. Plain radiograph standard views from an outside institution have
ruled out fracture or other notable acute injury. What is the recommended diagnostic modality?
A. Ultrasound of the medial ankle
B. Plain radiograph stress views
C. Magnetic resonance imaging
D. Single-photon emission computed tomography (SPECT)
2. Which of the following scenarios meets the indications for treatment with arthroscopic bone marrow stimulation?
A. The patient has failed conservative treatment for a non-cystic ostechondral lesion of the talus smaller than 125 mm2
B. The patient has failed conservative treatment for a non-cystic osteochondral lesion of the talus larger than 175 mm2
C. The patient has not undergone conservative treatment but has been diagnosed with an osteochondral lesion of the talus that is
cystic
D. The patient has failed conservative treatment for a non-cystic osteochonral lesion of the talus that is 100 mm2 with intact
cartilage overlying the lesion
3. A 25 year-old female soccer player presents with deep ankle pain and “clicking” in the lateral aspect of her ankle. Magnetic
resonance imaging indicates an osteochondral lesion measuring 90 mm2 located in the lateral corner of the posterior 25% of the
talus. Both bone and cartilage are involved. Prior conservative treatment options have failed. Which of the following is most
appropriate approach for repairing this lesion?
A. Autologous osteochondral transplantation via lateral malleolar osteotomy
B. Bone marrow stimulation via anterior arthroscopic portals with plantar flexion and soft-tissue distraction
C. Bone marrow stimulation via 2-portal posterior arthroscopy and manual ankle dorsiflexion
D. Retrograde drilling under arthroscopic guidance
4. A 50 year old male presents with dull pain in the medial aspect of the ankle joint that has been hindering his activities of daily
living. Conservative treatment options have failed. Magnetic resonance imaging indicates a centromedial lesion of the talus with
intact articular cartilage overlying a bony defect. Which step(s) should be employed before proceeding with retrograde drilling?
A. Plain radiograph oblique views should be utilized to further assess the lesion
B. Intraoperative fluoroscopy should be utilized to further assess the lesion
C. Single-photon emission computed tomorgraphy (SPECT) should be utilized to further assess the lesion
D. Probing of the lesion under arthroscopic visualization should be utilized to further assess the lesion
5. A 45 year old female patient has recently undergone arthroscopic bone marrow stimulation for an osteochondral lesion of the
lateral talus measuring 80 mm2. Which of the following is the most accurate representation evidence available in the literature
regarding this patient’s outcome?
A. There are few studies reporting short-to-midterm outcomes of arthroscopic bone marrow stimulation
B. Numerous studies indicate good outcomes in the short-to-midterm, but there is little long-term evidence
C. Numerous studies indicate that pain relief and integrity of the repair tissue will be sustained in the long-term
D. This lesion was too large for bone marrow stimulation, and is not likely to result in a good short-to-midterm outcome

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