Dalhosie University Halifax Nova Scotia Mark Glazebrook MSc., PhD, MD, FRCS(C), Dip Sports Med Associate Professor Dalhousie University Queen Elizabeth II health sciences Center Halifax, Nova Scotia Panel: 21-Year-Old College Junior Soccer Player with Painful Ankle has Medial Talar OCL, 1.3 cm Diameter Panel Moderator: Alistair Younger, MD Pro: The Initial Treatment Should Always Be Debridement with Marrow Stimulation (6 minutes) Glazebrook MD PhD MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH
Mark Glazebrook Disclosure Statement Mark Glazebrook has received something of value in the past 1 year ( ≥ $500.00) or served as a Journal review er from a commercial company or institution related directly or indirectly to the subject of this presentation, as noted below. a = research/institutional support, b = misc. non-income support, c = royalties, d = stock/options, e = consultant/employee f = Journal review er NAME: DISCLOSURE: COMPANY/SOURCE: 1. Glazebrook e Stryker Wright Inc. 2. Glazebrook a,e Ferring Inc. 3. Glazebrook a,e Cartiva Inc 4. Glazebrook ae Smith & Nephew 5. Glazebrook f Foot & Ankle International 6. Glazebrook f JBJS(A) 7. Glazebrook f The Bone & Joint Journal 8. Glazebrook f CORR 9. Glazebrook Past BOD Member AOFAS 10. Glazebrook President Elect/BOD Canadian Orthopedics Association (COA) MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH
Mark Glazebrook Disclosure Statement Mark Glazebrook has received something of value in the past 1 year ( ≥ $500.00) or served as a Journal review er from a commercial company or institution related directly or indirectly to the subject of this presentation, as noted below. a = research/institutional support, b = misc. non-income support, c = royalties, d = stock/options, e = consultant/employee f = Journal review er NAME: DISCLOSURE: COMPANY/SOURCE: 1. Glazebrook e Stryker Wright Inc. 2. Glazebrook a,e Ferring Inc. 3. Glazebrook a,e Cartiva Inc 4. Glazebrook ae Smith & Nephew 5. Glazebrook f Foot & Ankle International 6. Glazebrook f JBJS(A) 7. Glazebrook f The Bone & Joint Journal 8. Glazebrook f CORR 9. Glazebrook Past BOD Member AOFAS 10. Glazebrook President Elect/BOD Canadian Orthopedics Association (COA) MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH
Osteochondral Lesions Definition and Terminology: Osteochondritis Dissecans OCD (1887) Inflammatory process of bone cartilage Osteochodral Fracture (1959 Berndt & Harty) Primary Traumatic etiology Osteochondrosis Dissecans (1981) Repeated trauma or spontaneous or focal avascular osteonecrosis Octeochondral Lesions (OCL) Currently Used All encompassing MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH
Osteochondral Lesions Clinical: History •Persistent pain localized •Acute: •Pain swelling •Ecchymosis •Decreased range of motion •Chronic: •Dull ache •Stiffness •Crepitation •Tenderness •Mechanical clicking •Recurrent swelling •Locking or Instability…….. MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH
Osteochondral Lesions Clinical: Physical • Swelling and ecchymosis • Localized Tenderness with palpation •Posterior dorsiflexion •Anterior plantarflexion • Range of motion: •stiffness •crepitus •clicking or locking. MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH
Osteochondral Lesions Clinical: Diagnostic Imaging (Verhagen et al. 2005) Plain radiographs sensitivity - 0.70 specificity - 0.94 CT sensitivity - 0.81 specificity - 0.99 MR sensitivity - 0.96 specificity - 0.99 Arthroscopy sensitivity - 1.0 specificity - 0.97 CT SPEC Scan?????? MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH
Osteochondral Lesions Clinical: Diagnostic Imaging (Verhagen et al. 2005) Plain radiographs sensitivity - 0.70 specificity - 0.94 CT sensitivity - 0.81 specificity - 0.99 MR sensitivity - 0.96 specificity - 0.99 Arthroscopy sensitivity - 1.0 specificity - 0.97 CT SPEC Scan?????? MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH
Osteochondral Lesions Classifications: 1. Radiographic &/or Intra-op staging Berndt and Harty 1959 2. CT scan classification Ferkel and Scranton 1993 3. MRI classification Hepple et al 1999 4. Arthroscopic grading system Pritsch 1986 MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH
OCD Talus: Classification (Most recognized) TABLE 1: BERNDT AND HARTY CLASSIFICATION STAGE DESCRIPTION I Small subchondral compression II Incomplete fragment avulsion III Complete fragment detachment undisplaced IV Complete fragment detachment displaced MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH
Osteochondral Lesions - Etiology Traumatic Etiology: - Lateral OCLs Inversion, dorsiflexion & internal rotation impaction fibula. -Medial OCLs Inversion and plantar flexion impaction of the posteromedial talar dome on tibia Incidence of OCL in acute ankle injury ~ 70% Coltart WD 1952, Bosien WR et al. 1955, Hintermann B et al. 200 and Leontaritis et al. 2009. MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH
Osteochondral Lesions - Etiology Cystic Etiology ( Van Dijk 2010) : Atraumatic or traumatic etiology OCD lesions are increasingly associated with subchondral cysts. -Progression of simple non painful OCD’s to cystic painful OCD’s is dependant on microfractured subchondral bone. -These subchondral defects allows fluid to be compressed from cartilage into the subchondral bone leading to a localized high pressure -resultant local osteolysis causing a painful subchondral cyst. The pain in osteochondral defects: Intermittent local rise in intraosseous fluid pressure with occurs on every step, and sensitizes From Van DIjk 2010 the highly innervated subchondral bone. MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH
Osteochondral Lesions: Location - Anterolateral Common - Posteromedial Common - Central Uncommon - Posterolateral Uncommon Difficult to access with standard anterior ankle arthroscopy MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH
Surgical approach for Posteromedial OCL?? Anterior Posterior Combined Anterior & Posterior Approach Malleolar Osteotomy Trans tibial or Trans talar approach MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH
Surgical approach for OCL 12:00 1:00 MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH
Surgical approach for OCL Level 1 Evidence……………….. Anterior Arthroscopy 12:00 1:00 MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH
Surgical approach for OCL Level 1 Evidence……………….. 12:00 1:00 Posterior Arthroscopy MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH
Surgical approach for OCL Combined Approach (Knee Flexed) or Combined Approach (Knee Flexed) Flip Patient or Flip Patient 12:00 1:00 Recommend Dr. Ferkel’s Technique MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH
Surgical approach for OCL Combined Approach (Knee Flexed) or Combined Approach (Knee Flexed) Flip Patient or Flip Patient Level 1 Evidence……………….. Anterior Arthroscopy 12:00 1:00 Posterior Arthroscopy MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH
TREATMENT OF OCL MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH
Treatment of OCL Most published sources recommend non-operative treatment Stage I and II lesions It is generally agreed that operative intervention is recommended in Stage IV lesions and Stage I & II lesions with ongoing clinical symptoms Controversy exists for large stage III lesions and lesions in the skeletally immature patient. MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH
Characteristics of an OCL require immediate OR Rx? • Limited Level 1 Evidence on Immediate Rx: • Type or Size Very Large & Cystic • Location Not a time sensitive Issue • Presence of Fragment Flipped Fragment or Loose Catching MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH
Clinical Outcomes of OCL Treatment MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH
Evidence-Based Indications for Ankle Arth Mark A. Glazebrook, Venkat Ganapathy, Michael A. Bridge, James W . Stone, Jean-Pascal Allard Arthroscopy: The Journal of Arthroscopic and Related Surgery December 2009 (Vol. 25, Issue 12, Pages 1478-1490) Purpose : Review the literature available for the current generally accepted indications for ankle arthroscopy. Describe Level of Evidence (LOE) available to support generally accepted indications for ankle arthroscopy. Provide a Grade of Recommendation for Treatment based on LOE available. MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH
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