Treatment of osteochondral lesions of the talus with microfracture technique and postoperative hyaluronan injection
Doral MN, Bilge O, Batmaz G, Donmez G, Turhan E, Demirel M, Atay OA, Uzumcugil A, Atesok K, & Kaya D. Knee Surgery, Sports Traumatology, Arthroscopy. 2011 [Epub ahead of print].
Osteochondral lesions (OCL) in the ankle may be present in as many as 41 to 71% of patients after an acute ankle injury (i.e., sprain, fracture). Ankle OCL presence is widely accepted as one of the most common causes of chronic ankle pain after an ankle injury but OCL treatment and management remain a challenge. The purpose of this prospective randomized study was to investigate the clinical results of a hyaluronan injection as an adjunct to microfracture surgery in comparison to microfracture surgery only. Fifty-seven patients (mean age = 40.5 years), who were undergoing arthroscopic debridement and microfracture surgery for the treatment of their ankle OCL, were randomized to the injection or no injection group. Forty-one patients were randomized to the injection group to receive 3 hyaluronan injections (one every week) and 16 patients were in the no-injection group (no placebo was used). The injection group received their first injection 3 weeks after surgery. Functional and pain status was assessed with the Freiburg scoring system and American Orthopaedic Foot and Ankle Society ankle/hindfoot score before and 2 years after surgery. At the 2-year follow-up, significant improvements were seen in both the injection and non-injection groups compared to pre-operative measures. Additionally, the injection group had significantly better increases in pain and function than the non-injection group.
Clinically, it appears that microfracture surgery is an effective surgical means for improving patient pain and function compared to before surgery. Furthermore, it appears that the use of hyaluronan injections post-surgery improves clinical outcomes even more. Hyaluronan injections may help to restore synovial fluid viscosity in the long-term and aid in the improvement of signs and symptoms of chronic ankle pain. The authors noted that the interpretation of this data should be cautious due to the unequal sample sizes within the injection and non-injection groups. Beyond this study, it would be interesting to see if the results vary within the injection group based on presence of certain signs and symptoms (e.g., effusion) or which traumatic pathology was in the patient’s history. Within the study population, 79% of the patients with OCL had a definite history of previous ankle trauma. With the seemingly high relative risk for development of OCL post-injury, it may be interesting to find out if hyaluronan could be a successful intervention not just post-surgically, but as an early intervention to help prevent the development of an OCL or chronic ankle pain. Chronic ankle pain is often present in the athletic population following an ankle injury and as a result, OCL should be included in clinician’s list of differential diagnoses. Even if symptoms fit, oftentimes this diagnosis is missed due to sensitivity of imaging. Any advice or thoughts on the diagnosis, treatment, or management of an ankle OCL?
Written by: Nicole Cattano
Reviewed by: Jeffrey Driban
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Doral MN, Bilge O, Batmaz G, Donmez G, Turhan E, Demirel M, Atay OA, Uzumcugil A, Atesok K, & Kaya D (2011). Treatment of osteochondral lesions of the talus with microfracture technique and postoperative hyaluronan injection. Knee Surgery, Sports Traumatology, Arthroscopy PMID: 22205098
Seems it's never "just" an ankle injury. I think it would beneficial to see what the injection could do as an intervention on its own.
C. Herb-great point about it never being "just an ankle injury." Are you suggesting an injection as an intervention for ankle sprains? Or as a preventative measure for chronic ankle pain or OCLs?