The document describes a case study and technique using BioCartilage to treat a large osteochondral defect of the talus. The key points are: 1) A 24-year old male presented with ankle pain and imaging revealed a 1.2cm x 1.6cm osteochondral defect of the talus. 2) The defect was excised and microdrilled. BioCartilage, a micronized hyaline cartilage allograft, mixed with blood or PRP was used to fill the defect. 3) BioCartilage offers advantages over other techniques like autografts in eliminating donor site morbidity and over ACI in being a single-stage procedure without wait time.

1. BioCartilage to Treat Osteochondral Defects of the Talus: Case Report and Technique
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Jennifer Gerres, DPM ; Kelly Bumpus, DPM ; Mark Hardy, DPM FACFAS
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Residents, Cleveland Clinic/Healthspan; Director, Foot & Ankle Surgery, Healthspan Physicians Group
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Abstract
The talus is the 2nd most common site for ostechondral defect in the
lower extremity. Surgical options for lesions greater than 1cm2 include
OATS procedure, mosaicplasty, fresh osteochondral allografts, and
autologous chondrocyte implantation. These procedures can be costly,
with a large technical learning curve, and with significant donor morbidity.
We present a case and technique for Arthrex BioCartilage®, a micronized
hyaline cartilage, to relieve symptoms and improve function with the goal
of hyaline cartilage growth.
Introduction
2
Technique
Discussion
With the patient in the supine position, a 6cm longitudinal incision centered over the medial malleolus is made and carried to the
periosteum. The medial malleolar osteotomy is performed according to surgeon’s preference. We prefer an oblqiue osteotomy.
Once the osteochondral defect is visualized, it is excised using a #64 beaver blade (Figures 6 & 7). Care is taken to keep the walls
of the lesion vertical as to keep the BioCartilage® (Arthrex, Inc. Naples, FL) in place (Figure 8). The remaining sclerotic tissue is
curretted and the subhcondral bone is microdrilled 5mm deep (Figure 10). Meanwhile, the BioCartilage®, a micronized hyaline
cartilage allograft, is prepared (Figure 15). First, the allograft in powdered form is carefully poured into the provided mixing/
delivery syringe. An equivalent amount of autologous blood or platelet-rich plasma (PRP) is added to the syringe (Figure 16). This
is usually a 1:1 ratio, but can be adjusted to the surgeon’s preferred consistency (Figure 17). The allograft and autologous blood/
PRP is mixed within the syringe until homogenous. The mixture can be applied directly to the defect with the use of delivery needle
or, in our case, by Freer elevator (Figure 11). Once the deficit is completely filled (Figure 12), it is smoothed using a Freer elevator
or moistened cotton tip applicator. Fibrin is employed over the entire filled deficit to act as a glue to secure the mixture in place.
After application of fibrin, the lesion and ankle are not manipulated for 5 minutes as to allow the fibrin to set (Figure 13). Two
4.0mm screws secure the osteotomy and a buttress plate can be applied to avoid shear stress across the screws (Figure 14). The
patient remains non-weightbearing, first in a posterior splint and then in a pneumatic compression boot, for 6 to 8 weeks. At 4
weeks, the patient can begin gentle ROM exercises of the ankle joint.
There are several considerations when considering the appropriate
procedure for an osteochondral defect. This is dependent upon the
size of the lesion, its characteristics, and surgeon preferences. We
will focus on some common alternatives for lesions larger than 1cm2
in the absence of generalized osteoarthritic changes.
Figure 15
Figure 16
Figure 17
Of patients with osteochondral defects 85% present after a traumatic injury
to the ankle with complaint of prolonged pain, swelling, catching, stiffness,
or instability. Pathology ranges from a contusion of the articular cartilage
and subchondral bone to a fracture involving the cartilage or cartilage and
underlying subchondral bone.1 The mechanisms of injury are compaction,
shearing or avulsion.
Conservative therapy consists of rest, cast immobilization, and use of NSAIDs
for 6 weeks followed by progressive weight bearing and physical therapy. If
this fails, surgical options are lesion excision with or without curettage and
microfracturing, autogenous cancellous bone graft, transmalleolar antegrade
drilling, retrograde drilling.1,2,3 Restoring articular cartilage can be achieved
by osteochondral autograft or allograft transplantation: OATS procedure,
mosaicplasty, fresh osteochondral allografts, and autograft chondrocyte
implantation.2,3 The target is to relieve symptoms and improve function with
a higher percentage of hyaline cartilage retention or growth.4,5
There are specific advantages to the Arthrex BioCartilage® when
compared to autologous implantation, such as mosaicplasty and
OATS, as well as fresh juvenile osteochondral implantation. OATS
and mosaicplasty use one or more cylindrical osteochondral grafts
from the less weight bearing periphery of the ipsilateral knee or
talus, and these grafts are then transplanted into the prepared defect
site upon the talus.3 In regards to autograft, there are the obvious
immunological and cost advantages to any autograft; however, one
must always remember donor site morbidity. Our technique eliminates
donor site morbidity. Autologous chondrocyte implantation involves
placing cultured chondrocytes under a periosteal patch that covers the
lesion. This technique involves a staged procedure 6-8 weeks apart4
in an attempt to regenerate tissue with a high percentage of hyalinelike cartilage. The BioCartilage® technique avoids wait time as well as
the necessity for a second, invasive procedure. Lastly, fresh juvenile
osteochondral allografts demonstrate promising early results, but
are costly and limited by accessibility. Furthermore, the shelf life of
BioCartilage® is 5 years at room temperature, compared to 1 month
with fresh allograft. One disadvantage to the BioCartilage® technique
is the use of non-juvenile donor graft for a juvenile graft contains a
higher cell density than mature articular cartilage.
In conclusion, Arthrex BioCartilage® is a safe, excellent and promising
alternative for the treatment of large osteochondral defects of the
talus.
Figure 6
Figure 7
Figure 8
Figure 2
Figure 1
Figure 3
Case Study
A twenty-four-year-old male presented to our clinic with the complaint
of right ankle pain of four months duration. He reported no recent
injury; however, ten years prior the patient fractured his right ankle in
a four-wheeler accident and required a period of non-weightbearing
and casting. This healed without complication. Currently, the patient
complained that his right ankle joint felt stiff and unstable with
occasional locking. He had worn an ankle brace without improvement.
Upon musculoskeletal examination, the patient had pain to the medial
gutter, with inversion, and with passive range of motion of the right
ankle. Radiographs revealed an osteochondral defect of the medial
talar dome (Figures 1 & 2). An MRI demonstrated a 1.2cm x 1.6cm
x 0.8cm unstable osteochondral fracture of the central medial talar
dome (Figures 3, 4, & 5).
References
Figure 9: Excised OCD
Figure 4
Figure 5
Figure 10
Figure 11
Figure 12
Figure 13
Figure 14
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