ORIGINAL ARTICLE
Arthroscopic Retrograde Drilling in Juvenile Osteochondritis Dissecans of the Talus Julio J. Masquijo, MD,* Andres Ferreyra, MD,w and Eduardo Baroni, MDw
BACKGROUND
Background: Juvenile osteochondritis dissecans of the talus is rare, and the literature provides little data to guide treatment. The purpose of the present study was to evaluate our clinical and radiographic results with arthroscopic retrograde drilling in patients who were refractory to conservative care. Methods: We retrospectively evaluated all patients with juvenile osteochondritis dissecans of the talus who underwent surgery for the treatment of stable lesions that failed conservative treatment. Medical records were reviewed for symptoms and demographic information. Preoperative and latest postoperative radiographs were used to determine degree of healing. AOFAS Ankle/ Hindfoot scale and visual analog scale for pain were used to evaluate clinical outcomes. Results: We identified 6 patients (6 ankles). The mean age was 13 years, and the mean duration of follow-up was 37 months (range, 16 to 69 mo). All of them had progressed toward healing and were asymptomatic, but only 3 out of 6 had a complete radiographic healing at last follow-up. The average AOFAS Ankle/Hindfoot score improved from 69 points (55 to 75, IQR = 10) preoperatively to 98 points (90 to 100, IQR = 7) (P < 0.0027). Visual analog scale improved from 6.2 (4 to 8, IQR = 3) to 0.3 (0 to 2, IQR = 1) (P < 0.002). All patients expressed satisfaction with operative results. Conclusions: Arthroscopic retrograde drilling seems to be effective for symptoms relief, although 50% of the cases have had persistent lesions on radiographs. A longer follow-up is necessary to assess joint function in those cases with partial radiographic healing. Level of Evidence: Level IV—therapeutic.
Juvenile osteochondritis dissecans (JOCD) is an idiopathic disorder primarily affecting subchondral bone in skeletally immature patients that results in destabilization of the affected subchondral bone and its overlying articular cartilage.1,2 The talus has been reported to be the third most frequent anatomic site affected after the knee and the elbow.3 While JOCD of the knee often respond well to nonoperative management,4 juvenile osteochondritis dissecans of the talus (JOCDT) has a high failure rate with conservative treatment.5 Because of the relative rarity of this pathology, the literature provides little data to guide treatment in this scenario. Different forms of surgical treatment have been suggested in the adult literature, including arthroscopic drilling of the lesion, reduction and fixation of the fragment, excision of the fragment with curettage of the bed, and osteochondral transplantation (OATS).6 Although good outcomes with arthroscopic drilling have been well documented in the pediatric knee,7–10 the literature scarcely mentioned drilling as a treatment option for JOCDT.11 The purpose of the present study was to evaluate our clinical and radiographic results with arthroscopic retrograde drilling in a group of patients who were refractory to conservative care.
Key Words: talus, osteochondritis dissecans, drilling, children, adolescents
After obtaining institutional review board approval, a retrospective chart review was done on all patients who had undergone ankle arthroscopy with concomitant drilling during the years 2006 and 2012. Inclusion criteria included those patients with intact articular cartilage by diagnostic arthroscopy. Children who had closed growth plates at the time of surgery, those who had OCD lesions with partial or full detachment of the articular cartilage, or those with missing data were excluded.
(J Pediatr Orthop 2015;00:000–000)
From the *Department of Pediatric Orthopaedics, Sanatorio Allende, Co´rdoba; and wServicio de Ortopedia Infantil, Hospital de Pediatrı´ a Prof Dr J. P. Garrahan, Buenos Aires, Argentina. The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. The authors declare no conflicts of interest. Reprints: Julio Javier Masquijo, MD, Department of Pediatric Orthopaedics, Sanatorio Allende, Co´rdoba, Argentina. H. Irigoyen 384, Nueva Co´rdoba. CP5009. E-mail: [email protected]. Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
J Pediatr Orthop
Volume 00, Number 00, ’’ 2015
METHODS Patient Selection
Surgical Technique Indications for arthroscopic retrograde drilling included symptomatic Berndt and Harty stage I and II that were refractory to conservative care (with intact articular cartilage confirmed by arthroscopy). Surgery was performed under general anesthesia using a thigh tourniquet. Atraumatic distraction was performed using a foot strap. During all procedures, a 2.5 mm, 30-degree arthroscope www.pedorthopaedics.com |
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
1
Masquijo et al
was used through 3 portals (anteromedial, anterolateral, and posterolateral). Diagnostic arthroscopy was performed to confirm intact articular cartilage. If a loose flap was found intraoperatively, retrograde drilling was not performed, with debridement and antegrade microfracturing of the lesion performed instead. The arthroscopy equipment was then removed from the joint and the C-arm fluoroscopy machine was positioned. For medial and lateral lesions drilling was performed through the sinus tarsi. A 1.6 mm Kirschner wire was inserted toward the center of the lesion just beneath the articular cartilage. Parallel Kirschner wires were placed into different positions within the lesion. It is important to check the direction of the guidewire under AP and lateral fluoroscopic views for reaching the lesion accurately. After drilling, a tourniquet was released, the arthroscopic portals were closed with subcuticular sutures, and a bulky dressing was then applied. All of the patients immediately began a series of active motion exercises of the ankle after surgery. Physical therapy was performed from the second week after surgery. Full weight-bearing was permitted 6 weeks postoperatively, and sporting activities after 3 to 4 months.
Patient Evaluation Evaluation of the patients consisted of review of the chart and a follow-up examination. A chart review was completed to obtain age, sex, lesion location, prior treatment, complications, and subsequent procedures. During the physical examination, the hindfoot was evaluated for swelling, range of motion, strength, and stability. The American Orthopaedic Foot and Ankle Society (AOFAS) Ankle/Hindfoot scale12 and visual analog scale (VAS) for pain13 were used to evaluate clinical outcomes. Results were obtained preoperatively using these instruments and at last follow-up visit. The 100point AOFAS scoring system combines subjective and objective data for the evaluation of clinical parameters; points are allocated as follows: pain (40 points), function (45 points), and alignment (15 points). This system considers a score of Z90 points as excellent, 80 to 89 as good, 70 to 79 as fair, and r69 as poor. A 10-point VAS was used to quantify patient-assessed pain. Furthermore, patients rated their overall satisfaction with the surgical procedure as very satisfied, satisfied, neutral, moderately unsatisfied, and very unsatisfied and were asked whether they would have the procedure again. All subjects in this series underwent standard radiography, MRI and/or CT scan, and ankle arthroscopy. All preoperative radiographs were evaluated using the Berndt and Harty14 radiographic staging system. Radiographic success of healing after this procedure was measured by the degree of healing determined by comparison between the preoperative and postoperative studies and recorded as a percentage of healing with 100% denoting a lesion that is completely healed on radiograph.8 These evaluations were performed blindly and independently to prevent examiner bias.
2 | www.pedorthopaedics.com
J Pediatr Orthop
Volume 00, Number 00, ’’ 2015
Statistical Analyses The 2 outcome variables, AOFAS and VAS, were tested for normality (Shapiro-Wilk), resulting in nonnormal distribution. Values are expressed as median, minimum to maximum, and interquartile range (IQR). Comparisons were performed before and after a test with Wilcoxon signed-rank test. A 2-tailed P-value
Arthroscopic Retrograde Drilling in Juvenile Osteochondritis Dissecans of the Talus Julio J. Masquijo, MD,* Andres Ferreyra, MD,w and Eduardo Baroni, MDw
BACKGROUND
Background: Juvenile osteochondritis dissecans of the talus is rare, and the literature provides little data to guide treatment. The purpose of the present study was to evaluate our clinical and radiographic results with arthroscopic retrograde drilling in patients who were refractory to conservative care. Methods: We retrospectively evaluated all patients with juvenile osteochondritis dissecans of the talus who underwent surgery for the treatment of stable lesions that failed conservative treatment. Medical records were reviewed for symptoms and demographic information. Preoperative and latest postoperative radiographs were used to determine degree of healing. AOFAS Ankle/ Hindfoot scale and visual analog scale for pain were used to evaluate clinical outcomes. Results: We identified 6 patients (6 ankles). The mean age was 13 years, and the mean duration of follow-up was 37 months (range, 16 to 69 mo). All of them had progressed toward healing and were asymptomatic, but only 3 out of 6 had a complete radiographic healing at last follow-up. The average AOFAS Ankle/Hindfoot score improved from 69 points (55 to 75, IQR = 10) preoperatively to 98 points (90 to 100, IQR = 7) (P < 0.0027). Visual analog scale improved from 6.2 (4 to 8, IQR = 3) to 0.3 (0 to 2, IQR = 1) (P < 0.002). All patients expressed satisfaction with operative results. Conclusions: Arthroscopic retrograde drilling seems to be effective for symptoms relief, although 50% of the cases have had persistent lesions on radiographs. A longer follow-up is necessary to assess joint function in those cases with partial radiographic healing. Level of Evidence: Level IV—therapeutic.
Juvenile osteochondritis dissecans (JOCD) is an idiopathic disorder primarily affecting subchondral bone in skeletally immature patients that results in destabilization of the affected subchondral bone and its overlying articular cartilage.1,2 The talus has been reported to be the third most frequent anatomic site affected after the knee and the elbow.3 While JOCD of the knee often respond well to nonoperative management,4 juvenile osteochondritis dissecans of the talus (JOCDT) has a high failure rate with conservative treatment.5 Because of the relative rarity of this pathology, the literature provides little data to guide treatment in this scenario. Different forms of surgical treatment have been suggested in the adult literature, including arthroscopic drilling of the lesion, reduction and fixation of the fragment, excision of the fragment with curettage of the bed, and osteochondral transplantation (OATS).6 Although good outcomes with arthroscopic drilling have been well documented in the pediatric knee,7–10 the literature scarcely mentioned drilling as a treatment option for JOCDT.11 The purpose of the present study was to evaluate our clinical and radiographic results with arthroscopic retrograde drilling in a group of patients who were refractory to conservative care.
Key Words: talus, osteochondritis dissecans, drilling, children, adolescents
After obtaining institutional review board approval, a retrospective chart review was done on all patients who had undergone ankle arthroscopy with concomitant drilling during the years 2006 and 2012. Inclusion criteria included those patients with intact articular cartilage by diagnostic arthroscopy. Children who had closed growth plates at the time of surgery, those who had OCD lesions with partial or full detachment of the articular cartilage, or those with missing data were excluded.
(J Pediatr Orthop 2015;00:000–000)
From the *Department of Pediatric Orthopaedics, Sanatorio Allende, Co´rdoba; and wServicio de Ortopedia Infantil, Hospital de Pediatrı´ a Prof Dr J. P. Garrahan, Buenos Aires, Argentina. The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. The authors declare no conflicts of interest. Reprints: Julio Javier Masquijo, MD, Department of Pediatric Orthopaedics, Sanatorio Allende, Co´rdoba, Argentina. H. Irigoyen 384, Nueva Co´rdoba. CP5009. E-mail: [email protected]. Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
J Pediatr Orthop
Volume 00, Number 00, ’’ 2015
METHODS Patient Selection
Surgical Technique Indications for arthroscopic retrograde drilling included symptomatic Berndt and Harty stage I and II that were refractory to conservative care (with intact articular cartilage confirmed by arthroscopy). Surgery was performed under general anesthesia using a thigh tourniquet. Atraumatic distraction was performed using a foot strap. During all procedures, a 2.5 mm, 30-degree arthroscope www.pedorthopaedics.com |
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
1
Masquijo et al
was used through 3 portals (anteromedial, anterolateral, and posterolateral). Diagnostic arthroscopy was performed to confirm intact articular cartilage. If a loose flap was found intraoperatively, retrograde drilling was not performed, with debridement and antegrade microfracturing of the lesion performed instead. The arthroscopy equipment was then removed from the joint and the C-arm fluoroscopy machine was positioned. For medial and lateral lesions drilling was performed through the sinus tarsi. A 1.6 mm Kirschner wire was inserted toward the center of the lesion just beneath the articular cartilage. Parallel Kirschner wires were placed into different positions within the lesion. It is important to check the direction of the guidewire under AP and lateral fluoroscopic views for reaching the lesion accurately. After drilling, a tourniquet was released, the arthroscopic portals were closed with subcuticular sutures, and a bulky dressing was then applied. All of the patients immediately began a series of active motion exercises of the ankle after surgery. Physical therapy was performed from the second week after surgery. Full weight-bearing was permitted 6 weeks postoperatively, and sporting activities after 3 to 4 months.
Patient Evaluation Evaluation of the patients consisted of review of the chart and a follow-up examination. A chart review was completed to obtain age, sex, lesion location, prior treatment, complications, and subsequent procedures. During the physical examination, the hindfoot was evaluated for swelling, range of motion, strength, and stability. The American Orthopaedic Foot and Ankle Society (AOFAS) Ankle/Hindfoot scale12 and visual analog scale (VAS) for pain13 were used to evaluate clinical outcomes. Results were obtained preoperatively using these instruments and at last follow-up visit. The 100point AOFAS scoring system combines subjective and objective data for the evaluation of clinical parameters; points are allocated as follows: pain (40 points), function (45 points), and alignment (15 points). This system considers a score of Z90 points as excellent, 80 to 89 as good, 70 to 79 as fair, and r69 as poor. A 10-point VAS was used to quantify patient-assessed pain. Furthermore, patients rated their overall satisfaction with the surgical procedure as very satisfied, satisfied, neutral, moderately unsatisfied, and very unsatisfied and were asked whether they would have the procedure again. All subjects in this series underwent standard radiography, MRI and/or CT scan, and ankle arthroscopy. All preoperative radiographs were evaluated using the Berndt and Harty14 radiographic staging system. Radiographic success of healing after this procedure was measured by the degree of healing determined by comparison between the preoperative and postoperative studies and recorded as a percentage of healing with 100% denoting a lesion that is completely healed on radiograph.8 These evaluations were performed blindly and independently to prevent examiner bias.
2 | www.pedorthopaedics.com
J Pediatr Orthop
Volume 00, Number 00, ’’ 2015
Statistical Analyses The 2 outcome variables, AOFAS and VAS, were tested for normality (Shapiro-Wilk), resulting in nonnormal distribution. Values are expressed as median, minimum to maximum, and interquartile range (IQR). Comparisons were performed before and after a test with Wilcoxon signed-rank test. A 2-tailed P-value
