Particulate Juvenile Articular Cartilage Transfer for Talar Osteochondral Lesions

Abstract

Osteochondral lesions of the talus present a challenge to the foot and ankle surgeon with regards to treatment. Although most bone marrow stimulation (BMS) procedures have relatively good outcomes, those patients who do not improve or present with large lesions (>1.5 cm2) are candidates for a range of more involved procedures. All of these treatments focus on improving pain and function by restoring cartilage at the lesion site. Treatment options are generally classified as either BMS or restorative. Histologic studies have found that BMS leads to infill by fibrocartilage that has physical properties inferior to that of native hyaline cartilage. The goal of restorative treatments is to create hyaline or hyaline-like cartilage. This category includes a variety of techniques each with their own advantages and disadvantages. This paper focuses specifically on one of these techniques, particulate juvenile articular cartilage transfer. A brief overview of BMS and restorative treatment options is provided. A detailed description of the surgical technique for particulate juvenile articular cartilage transfer and a review of published clinical results are discussed. Level of Evidence: Level V—expert opinion. See Instructions for Authors for a complete description of levels of evidence.

Open Treatment of Osteochondral Lesions of the Talus With Bone Grafting and Particulated Juvenile Cartilage Allografting

“…7,8,11 PJCA is a potentially superior therapeutic alternative to these transplantation techniques as it is a more cost-effective single-stage surgery that does not require an expensive culturing phase, does not require graft contouring, does not cause donor site morbidity, and does not elicit an allogenic immune response. [2][3][4][5] The other major benefit of PJCA is derived from the biochemical and cellular superiority of juvenile chondrocytes. Juvenile chondrocytes have a more robust cellular activity, a greater volume of extracellular matrix protein synthesis, an increased rate of matrix synthesis, and an upregulation of growth promoting signaling pathways leading to increased cartilage growth, expansion, and integration with the surrounding host tissues.…”

“…Both these studies reported significant function and pain improvements when cystic OLTs deeper than 5 mm were treated with PJCA and concomitant bone grafting. 3,11 Heida et al 11 concluded that for large OLTs, PJCA that is supplemented with autologous bone grafts, when indicated, resulted in a 40% to 50% improvement in ankle pain and disability within 3.5 years. Similarly, our results using PJCA with bone grafting also suggest treating the pathology of the underlying bony lesion to provide a scaffold for the regeneration of stable subchondral bone is equally as important as repairing the damaged cartilage.…”

“…It is a single-stage procedure that does not require graft contouring, has no donorsite morbidity, does not elicit an allogenic immune response, and has been shown to have superior biochemical properties leading to improved integration with the surrounding host tissue. [2][3][4][5] Despite PJCA having several theoretical benefits and promising early clinical results in moderate sized lesions (100-150 mm 2 ), there has been controversy over its clinical effectiveness in the treatment of large cystic OLTs. While some authors have published successful results when using PJCA to treat large lesions, 1,6 several others have shown an increased rate of failure in lesions with an area greater than 125 mm 2 .…”

“…7,9 Meanwhile, in examples where PJCA was successfully used to treat large cystic OLTs, PJCA with concomitant bone grafting was provided for lesions deeper than 5 mm. 3,10,11 We believe these variable results reported when PJCA is used to treat large OLTs may be related to the inconsistency in how the subchondral bone is treated prior to the placement of the PJCA rather than a failure of the allograft itself. 6,7 Despite the importance of treating the subchondral bone when managing large cystic OLTs, there is surprisingly little literature discussing the value of replacing the subchondral bone in order to provide viability to this technique.…”

“…It is a single-stage procedure that does not require graft contouring, has no donor-site morbidity, does not elicit an allogenic immune response, and has been shown to have superior biochemical properties leading to improved integration with the surrounding host tissue. 2-5…”