2025 AOFAS Annual Meeting-Symposium 5A: The Talus is So Frustrating

Video Transcription

Video Summary

This comprehensive discussion addressed the challenging management of osteochondral lesions of the talus (OLT) as of 2025, focusing on the evolving role of microfracture and alternatives. Dr. Tommy Haytmanik reviewed microfracture outcomes, noting 10-year data showing approximately 78% good-to-excellent results but highlighting limitations: lesion location, size, cyst presence, and involvement of the subchondral plate affect success. He emphasized nuanced patient evaluation, associated instability, and the importance of bone grafting for cystic lesions. Newer adjuncts like extracellular matrix combined with bone marrow aspirate concentrate (BMAC) may enhance repair tissue quality, though evidence remains mixed.<br /><br />Dr. Mark Dracos critiqued microfracture, underscoring that it stimulates fibrocartilage formation rather than hyaline cartilage, resulting in poorer biomechanical properties and frequent degradation. He distinguished reparative strategies (microfracture, scaffolds, BMAC) from replacement approaches like osteochondral autografts (OATS). OATS shows higher-quality repair tissue, better functional scores, and lower revision rates, especially for larger or revision lesions. The subchondral plate’s integrity was stressed as critical but difficult to restore with reparative methods. Dr. Dracos presented case examples illustrating outcomes and challenges.<br /><br />Dr. Rob Rizzi discussed salvage procedures, including medial malleolar osteotomy for allograft implantation, the use of fresh versus frozen grafts, and the incorporation of patient-specific instrumentation. Structural allografts can restore bone and cartilage in large defects or shoulder lesions, potentially delaying or avoiding arthrodesis or ankle replacement. Failures occur but outcomes are generally favorable long-term.<br /><br />Panel discussion covered technical nuances like handling uncontained lesions, use of biological adjuncts, weight-bearing protocols, insurance challenges for OATS, and comparison of implant materials. The importance of patient selection, lesion size (around 10-15 mm cutoff), and avoiding overtreatment was underlined. Overall, improved diagnostic precision, biologic augmentation, and surgical techniques are advancing treatment but no single gold standard exists; individualized multimodal approaches best address OLT complexity.

Keywords

osteochondral lesions of the talus

OLT management

microfracture outcomes

bone marrow aspirate concentrate

extracellular matrix adjuncts

fibrocartilage vs hyaline cartilage

osteochondral autografts (OATS)

subchondral plate integrity

medial malleolar osteotomy

structural allografts

patient-specific instrumentation

weight-bearing protocols

lesion size criteria

biologic augmentation

individualized multimodal treatment