Authors' objectives:

The purpose of the present report is to assess the efficacy of the osteochondral transplant for the treatment of ankle bone-cartilage lesions.

Authors' results and conclusions: Most evidence for osteochondral autografts comes from retrospective case series trials and there are no controlled trials comparing the results of this technique with other conventional treatments. While the patients inclusion criteria are not well defined in the literature, the age limit usually proposed for this type of grafting is 50 because joint cartilage quality decreases after this age. Some studies such as the one proposed by Schottle et al in 2001 conclude that OATS renders promising results for osteochondral defects of the talar dome, even for previously operated osteochondral defects. But, although the results of retrospective case series using OATS are promising, the follow-up periods are short and there are no well-designed prospective trials with longer follow-ups to prove the durability of the repair as well as the efficacy of the procedure in preventing degenerative arthritis. Regarding mosaicplasty, Jakob et al. (2002) concluded that the autologous transplant is a valid option for the treatment of osteochondral defects, but the method is limited by the size of the defect and the number of grafts needed from the donor site. Once again, the retrospective study lacks a control group or comparison and does not include long-term assessment of results. In a more recent publication, Bentley et al. (2003) compared the autologous chondrocytes implantation (ACI) and mosaicplasty in a total of 100 patients randomized to one of the two treatments. The follow-up was 19 months long average. The trial showed excellent or good results in 88% of the patients after ACI, compared with 69% of mosaicplasty. An arthroscopy performed at one year showed excellent or good repairs in 82% of the cases after ACI and only 34% after mosaicplasty. The authors concluded that results for ACI are comparable to those obtained from other trials, but the use of mosaicplasty should be questioned. Hangody reported several trials with mosaicplasty, concluding that autologous osteochondral mosaicplasty is a valid alternative for the treatment of small to middle size focal chondral or osteochondral defects of the joint surfaces bearing weight. In 2004 Kolker et al carried out a retrospective revision of 13 patients who had received autologous bone grafting of the talus due to symptomatic osteochondral defects of the talar dome. The patients mean age was 38.4 years. Six patients (46%) failed medical treatment and needed surgery. Of the other 7, the functional results were obtained at an average of 51.9 months after surgery. The overall satisfaction rate of the patients was 46.2%, concluding that the autologous grafting technique should be used with extreme caution when considered as the primary treatment for advanced osteochondral defects of the ankle. The main international health sponsors do not cover osteochondral grafting for they consider it an experimental procedure or at research stage, or they cover it in very specific cases using strict inclusion criteria.

Authors' recommendations: There is still not enough evidence available on the efficacy of mosaicplasty or the OATS procedure for the treatment of talus cartilage joint lesions. There is very little published about the assessment of the osteochondral grafting viability. There is not enough evidence determining whether the tissues coming from places that do not carry weight could absorb the stress of weight bearing areas, neither the degree of donor site morbidity. Patient inclusion criteria are not well settled in the literature, and there is no uniform consensus on the procedure's indication. The main international health sponsors do not cover osteochondral grafting for they consider it an experimental procedure or at research stage or they cover it in very specific cases using strict inclusion criteria. The Obligatory Medical Program (PMO, from the Spanish abbreviation), does not explicitly include in the list of services which must be covered by our health system. Although there is not enough evidence to support the treatment and most health sponsors surveyed do not cover it, the following cases can be considered as potential candidates for this treatment: - Under 50 years of age with poor response to conventional treatments and any of the following: - Advance stages of osteochondritis dissecans of the talus (Berndt and Harty stages III 7 and IV 11), who have failed adequate medical treatment. - Small chondral defects (equal or smaller than 1 cm2), focal articular cartilage defects with define sharp edges, surrounded by apparently normal hyaline cartilage. - As rescue procedure after failure of other therapeutic alternatives and for patients with symptoms of years of evolution. Only well designed prospective clinical trials with long follow-ups could determine the efficacy of these procedures to relieve the symptoms caused by osteochondral lesions, improve joint function and achieve the final objective, which is the prevention of secondary arthrosis.

Authors' methods: Overview

Project Status: Completed

URL for project: http://www.iecs.org.ar/

Year Published: 2006

English language abstract: An English language summary is available

Publication Type: Not Assigned

Country: Argentina

Organisation Name: Institute for Clinical Effectiveness and Health Policy

Contact Address: Dr. Emilio Ravignani 2024, Buenos Aires - Argentina, C1414 CABA

Contact Name: info@iecs.org.ar

Contact Email: info@iecs.org.ar

Copyright: Institute for Clinical Effectiveness and Health Policy (IECS)