Clinical Comparison of the Osteochondral Autograft Transfer System and Subchondral Drilling in Osteochondral Defect of the First Metatarsal Head

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2 Clinical Comparison of the Osteochondral Autograft Transfer System and Subchondral Drilling in Osteochondral Defect of the First Metatarsal Head

3 Most isolated lesions of osteochondral defect of the first metatarsal head are originated from trauma. may lead to degeneration of the first MTP joint. The first metatarsophalangeal joint mobility is important to allows a normal gait pattern and action of the windlass mechanism, and assists in balance, impact reduction and normal stance. Therefore, osteochondral defect of the first metatarsal head should be treated properly to perform the daily activities as well as many sports activities and also not to progress in hallux rigidus. Treatment option of osteochondral lesions Marrow inducing reparative procedures - subchondral drilling, curettage, microabrasion, and microfracture. Restorative procedures - osteochondral grafting, mosaicplasty, and frozen osteochondral allografts. developed to transfer articular hyaline cartilage to replace the injured area However, studies on the osteochondral autograft transfer system for treatment of osteochondral defect of the first metatarsal head have rarely been published. The aims of this study 1) to investigate the clinical outcomes and postoperative activity levels of the osteochondral autograft transfer system in treatment of osteochondral defect of the first metatarsal head, 2) to compare the outcomes thereof with those of subchondral drilling operation, 3) to identify the prognostic factors associated with the osteochondral defect of the first metatarsal head.

4 from May 2008 to June 2010 twenty-two consecutive patients (24 feet) Group A (14 feet) : subchondral drilling Group B (10 feet) : osteochondral autograft transfers defect size was calculated by ellipse formula Mean age : 38.9 years (range, years) Mean follow-up period : 25.1 months (range, months) Male : Female = 8 : 14 Evaluation of clinical outcomes Visual Analogue Scale (VAS) for pain score AOFAS hallux metatarsophalangeal-interphalangeal scale Roles and Maudsley score for patient satisfaction Tegner activity scale Activity Rating Scale (ARS) Radiologic Evaluation AP and lateral weight-bearing radiographs : assess the first MTP joint for degenerative arthritis MRI : measure the size and location of lesions : evaluate any associated lesions (e.g. subchondral cyst) before the operation Surgical Technique For the osteochondral autograft transfer, : OATS instrumentation set (Arthrex Inc., Naples, FL) was used For subchondral drilling, : a 0.9 millimeter-diameter K-wire was used for multiple drillings of subchondral bone

5 Clinical and Functional Results Group A (Subchondral drilling) Group B (OATS) Preoperative last follow up Preoperative last follow up VAS 6.9 ± ± ± ± 1.2 AOFAS* 62.9 ± ± ± ± 5.8 Preoperative AP radiograph Tegner scale* 3.4 ± ± ± ± 1.1 Activity rating scale* 8.9 ± ± ± ± 1.9 R & M score* Excellent 0 1 ( 7%) 0 4 (40%) Good 0 4 (29%) 0 5 (50%) Fair 6 (43%) 6 (43%) 4 (40%) 1 (10%) Poor 8 (57%) 3 (21%) 6 (60%) 0 *Statistically significantly differences are observed between the groups, p < Radiological asseessment Degenerative arthritis of the first MTP joint was observed in six cases in group A and one case in group B. Large defect size ( 50 mm 2 ) and the existence of subchondral cyst were significantly associated with the development of degenerative arthritis of the first MTPjoint in group A (p = 0.011, p = 0.037, respectively), but no association was found between location of the defect area and degenerative arthritis of the first metatarsophalangeal joint in group A (p = 0.133) Intraoperative photographs. Two osteochondral plugs were impacted in the defect site and the subchondral drilling was performed at the uncovered site between impacted two plugs AP radiograph at 9 months after OATS. Degenerative arthritic change was observed.

6 Association between Defect Size and Clinical Outcome 8 6 Last VAS Group A R 2 = (p < 0.05) Last VAS Group B R 2 = (p = 0.312) Defect size (mm 2 ) Defect size (mm 2 ) Last AOFAS Group A R 2 = (p < 0.05) Last AOFAS Group B R 2 = (p = 0.814) Defect size (mm 2 ) Defect size (mm 2 )

7 Associations Between Satisfaction of Clinical Result and Variables of Osteochondral Defect a Group A (Subchondral drilling) Group B (OATS) S b U c OR (95% CI) p S b U c OR (95% CI) p Defect size ( ) ( ) Large ( 50 mm 2 ) d Small (< 50 mm 2 ) d Location of defect ( ) ( ) Central d Peripheral d (dorsal or plantar) Existence of subchondral cyst d ( ) ( ) Considering a VAS < 4 points, AOFAS score > 80 and good or excellent Role and Maudsley score at last follow-up as a satisfactory clinical outcome a OATS, osteochondral autograft transfer system; OR, odds ratio; CI, confidence interval. b S, satisfactory clinical result. c U, unsatisfactory clinical result. d The values are given as number. Large defect size ( 50 mm2) and existence of subchondral cyst were significant predictors of unsatisfactory clinical outcomes, with an OR of (95% CI: ) and (95% 284 CI: ), respectively, compared to small defect size (< 50 mm2) and nonexistence of subchondral cyst in group A (P =.047, P =.019, respectively). These correlations were not observed in group B. No association was found between location of defect area and clinical outcome in both groups

8 Patient Characteristics and Clinical Outcome for Groups by Defect Size and Subchondral Cyst a Factor Defect size Subchondral cyst < 50mm 2 50mm 2 CR NE E CR n (%) n (%) RR p n (%) n (%) RR p Age (years) b < 37 4 (26.7) 6 (66.7) 7 (63.6) 4 (30.8) (73.3) 3 (33.3) 4 (36.4) 9 (69.2) Gender Male 5 (33.3) 4 (44.4) 5 (45.5) 3 (23.1) Female 10 (66.7) 5 (55.6) 6 (54.5) 10 (76.9) BMI b < (40) 5 (55.6) 5 (45.5) 5 (38.5) (60) 4 (44.4) 6 (54.5) 8 (61.5) D (weeks) b < 20 6 (40) 4 (44.4) 8 (72.7) 3 (23.1) 20 9 (60) 5 (55.6) 3 (27.3) 10 (76.9) a CR, Cox proportional hazards regression analysis; NE, nonexistence; E, existence; RR, relative risk; D, Duration of symptoms. b The medial values are used as a standard values for dividing the groups. According to the Cox regression analysis, there were no significant correlations between all prognostic factors and defect size or existence of subchondral cyst. (p > 0.05, respectively)

9 Kravitz et al. 24 reported that the size and location of the defect are the major factors influencing the choice of which surgical procedure to perform. Draper and Fallat 12 reported that damaged articular cartilage has a very limited potential of healing and articular defects larger than 2 to 4 millimeters in diameter rarely heal. In our study, the defect size was a significant predictor of clinical outcome in the subchondral drilling group (p = 0.047), but no association was found in the OATS group (p = 0.748). Kravitz et al. 24 reported that the primary indication for treatment with the OATSwas the presence of a large subchondral cyst in the metatarsal head. In our study, in the subchondral drilling group, the existence of subchondral cyst significantly worsened the clinical outcomes (p = 0.019). However, the clinical outcomes of the OATS group were not influenced by the presence of a subchondral cyst. The major limitations of our study : small number of cases and the relatively short duration of the follow-up period. Conclusion Follow-up MRI would have been helpful for evaluating grafted cartilage in the OATS group and The regeneration encouraging of outcomes cartilage of in this the study subchondral suggest drilling that the group. osteochondral autograft transfer system for the first metatarsal head could potentially be utilized to restore the functionality of a metatarsophalangeal joint. If the We osteochondral concluded that defect the preoperative is larger than measurement 50 mm 2 or a of subchondral initial defect cyst size exists, using the MRI osteochondral provides valuable autograft transfer prognostic system information should be considered the clinical as the outcome treatment of osteochondral of choice rather defects than subchondral of the first metatarsal drilling operation head. for the treatment of osteochondral defect of the first metatarsal head.

10 1.Baltzer AW, Arnold JP. Bone-cartilage transplantation from the ipsilateral knee for chondral lesions of the talus. Arthroscopy. Feb 2005;21(2): Barnes CJ, Ferkel RD. Arthroscopic debridement and drilling of osteochondral lesions of the talus. Foot Ankle Clin. Jun 2003;8(2): Berndt AL, Harty M. Transchondral fractures (osteochondritis dissecans) of the talus. J Bone Joint Surg Am. Jun 2004;86-A(6): Bonney G, Macnab I. Hallux valgus and hallux rigidus; a critical survey of operative results. J Bone Joint Surg Br. Aug 1952;34-B(3): Brewster M. Does total joint replacement or arthrodesis of the first metatarsophalangeal joint yield better functional results? A systematic review of the literature. J Foot Ankle Surg. Nov-Dec;49(6): Brittberg M, Winalski CS. Evaluation of cartilage injuries and repair. J Bone Joint Surg Am. 2003;85-A Suppl 2: Campbell CJ, Ranawat CS. Osteochondritis dissecans: the question of etiology. J Trauma. Mar 1966;6(2): Chen FS, Frenkel SR, Di Cesare PE. Repair of articular cartilage defects: part I. Basic Science of cartilage healing. Am J Orthop (Belle Mead NJ). Jan 1999;28(1): Choi WJ, Park KK, Kim BS, Lee JW. Osteochondral lesion of the talus: is there a critical defect size for poor outcome? Am J Sports Med. Oct 2009;37(10): Daniilidis K, Martinelli N, Marinozzi A, et al. Recreational sport activity after total replacement of the first metatarsophalangeal joint: a prospective study. Int Orthop. Oct;34(7): Dipaola JD, Nelson DW, Colville MR. Characterizing osteochondral lesions by magnetic resonance imaging. Arthroscopy. 1991;7(1): Draper SD, Fallat LM. Autogenous bone grafting for the treatment of talar dome lesions. J Foot Ankle Surg. Jan-Feb 2000;39(1): Ferkel RD, Zanotti RM, Komenda GA, et al. Arthroscopic treatment of chronic osteochondral lesions of the talus: long-term results. Am J Sports Med. Sep 2008;36(9): Flick AB, Gould N. Osteochondritis dissecans of the talus (transchondral fractures of the talus): review of the literature and new surgical approach for medial dome lesions. Foot Ankle. Jan-Feb 1985;5(4): Gautier E, Kolker D, Jakob RP. Treatment of cartilage defects of the talus by autologous osteochondral grafts. J Bone Joint Surg Br. Mar 2002;84(2): Giannini S, Buda R, Grigolo B, Vannini F. Autologous chondrocyte transplantation in osteochondral lesions of the ankle joint. Foot Ankle Int. Jun 2001;22(6): Giannini S, Vannini F. Operative treatment of osteochondral lesions of the talar dome: current concepts review. Foot Ankle Int. Mar 2004;25(3): Gross AE, Agnidis Z, Hutchison CR. Osteochondral defects of the talus treated with fresh osteochondral allograft transplantation. Foot Ankle Int. May 2001;22(5): Hangody L, Kish G, Modis L, et al. Mosaicplasty for the treatment of osteochondritis dissecans of the talus: two to seven year results in 36 patients. Foot Ankle Int. Jul 2001;22(7): Hayes DW, Jr., Averett RK. Articular cartilage transplantation. Current and future limitations and solutions. Clin Podiatr Med Surg. Jan 2001;18(1): Hopson M, Stone P, Paden M. First metatarsal head osteoarticular transfer system for salvage of a failed hemicap-implant: a case report. J Foot Ankle Surg. Jul-Aug 2009;48(4): Imhoff AB, Ottl GM, Burkart A, Traub S. [Autologous osteochondral transplantation on various joints]. Orthopade. Jan 1999;28(1): Kelberine F, Frank A. Arthroscopic treatment of osteochondral lesions of the talar dome: a retrospective study of 48 cases. Arthroscopy. Jan-Feb 1999;15(1): Kravitz AB. Osteochondral autogenous transplantation for an osteochondral defect of the first metatarsal head: a case report. J Foot Ankle Surg. Mar-Apr 2005;44(2): Kumai T, Takakura Y, Higashiyama I, Tamai S. Arthroscopic drilling for the treatment of osteochondral lesions of the talus. J Bone Joint Surg Am. Sep 1999;81(9): Lee KB, Bai LB, Yoon TR, Jung ST, Seon JK. Second-look arthroscopic findings and clinical outcomes after microfracture for osteochondral lesions of the talus. Am J Sports Med. Nov 2009;37 Suppl 1:63S-70S. 27.Loomer R, Fisher C, Lloyd-Smith R, Sisler J, Cooney T. Osteochondral lesions of the talus. Am J Sports Med. Jan-Feb 1993;21(1): Marx RG, Stump TJ, Jones EC, Wickiewicz TL, Warren RF. Development and evaluation of an activity rating scale for disorders of the knee. Am J Sports Med. Mar-Apr 2001;29(2): Mendicino RW, Hallivis RM, Cirlincione AS, Catanzariti AR, Krause N. Osteochondral autogenous transplantation for osteochondritis dissecans of the ankle joint. J Foot Ankle Surg. Sep-Oct 2000;39(5): Mithoefer K, Hambly K, Della Villa S, Silvers H, Mandelbaum BR. Return to sports participation after articular cartilage repair in the knee: scientific evidence. Am J Sports Med. Nov 2009;37 Suppl 1:167S-176S. 31.Paul J, Sagstetter A, Kriner M, Imhoff AB, Spang J, Hinterwimmer S. Donor-site morbidity after osteochondral autologous transplantation for lesions of the talus. J Bone Joint Surg Am. Jul 2009;91(7): Paul J, Sagstetter M, Lammle L, et al. Sports Activity After Osteochondral Transplantation of the Talus. Am J Sports Med. Jan Reddy S, Pedowitz DI, Parekh SG, Sennett BJ, Okereke E. The morbidity associated with osteochondral harvest from asymptomatic knees for the treatment of osteochondral lesions of the talus. Am J Sports Med. Jan 2007;35(1): Schenck RC, Jr., Goodnight JM. Osteochondritis dissecans. J Bone Joint Surg Am. Mar 1996;78(3): Scranton PE, Jr., McDermott JE. Treatment of type V osteochondral lesions of the talus with ipsilateral knee osteochondral autografts. Foot Ankle Int. May 2001;22(5): Street CC, Shereff MJ. Traumatic osteochondral defect of the first metatarsal head: a case report. Am J Orthop (Belle Mead NJ). Oct 1999;28(10): Tegner Y, Lysholm J. Rating systems in the evaluation of knee ligament injuries. Clin Orthop Relat Res. Sep 1985(198): Title CI, Zaret D, Means KR, Jr., Vogtman J, Miller SD. First metatarsal head OATS technique: an approach to cartilage damage. Foot Ankle Int. Nov 2006;27(11): Valderrabano V, Leumann A, Rasch H, Egelhof T, Hintermann B, Pagenstert G. Knee-to-ankle mosaicplasty for the treatment of osteochondral lesions of the ankle joint. Am J Sports Med. Nov 2009;37 Suppl 1:105S-111S. 40.Zelent ME, Neese DJ. Osteochondral autograft transfer of the first metatarsal head: a case report. J Foot Ankle Surg. Sep-Oct 2005;44(5):