- Email: [email protected]
Cartilage Allograft Techniques and Materials
C a r tila ge A l l o g r af t Tec h n i q u e s an d M a t e r i a l s James M. Cottom,
DPM*,
Jared M. Maker,
DPM
KEYWORDS Cartilage Osteochondral lesion Talus Bone marrow stimulation Allograft KEY POINTS Hyaline cartilage lacks a vascular supply having the inability to mount an inflammatory response to injury. Allograft cartilage extracellular matrix provides a scaffold for marrow elements to interact with entering the site of injury after bone marrow stimulation. Chondrocyte density within juvenile cartilage is significantly increased compared with adult cartilage.
INTRODUCTION
Hyaline cartilage consists of 95% extracellular matrix (ECM) and 5% chondrocytes. One component of the ECM is collagen consisting of types II, V, VI, IX, X, XI, XII, and XIV; type II collagen is the most abundant.1 Glycoproteins (proteoglycans) are another component of the ECM. Glycoproteins carry a negative charge in effect attracting water, with water making up 70% to 80% of the wet weight of hyaline cartilage. This attraction of water allows cartilage to resist compressive forces.2 The role of the 5% of chondrocytes present is vital for the proper function of articular cartilage, being that they produce the ECM.1 Hyaline cartilage is structured into 4 zones consisting of the superficial, transitional, radial, and calcified cartilage zones.3 Chondrocytes lack a vascular supply, relying on nutrients to be supplied from the synovial fluid.4 Because hyaline cartilage is avascular, injury does not result in damage to blood vessels. Therefore, the inflammatory and repair phases of injury are absent, a scaffold consisting of a fibrin clot is not produced, and undifferentiated cells are not brought to the site of injury. The small number of chondrocytes present does not allow an adequate response to the injury, and the cartilage surface is not repaired.5
Disclosures: None. Coastal Orthopedics and Sports Medicine, 6015 Pointe West Boulevard, Bradenton, FL 34209, USA * Corresponding author. E-mail address: [email protected] Clin Podiatr Med Surg 32 (2015) 93–98 http://dx.doi.org/10.1016/j.cpm.2014.09.012 podiatric.theclinics.com 0891-8422/15/$ – see front matter Ó 2015 Elsevier Inc. All rights reserved.
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BONE MARROW STIMULATION TECHNIQUES
Bone marrow stimulation (BMS) allows mesenchymal stem cells to enter the site of injury and differentiate to produce reparative cartilage.1 With time, the cells within the reparative cartilage take the appearance of fibroblasts, with tightly packed type 1 collagen making up the matrix. This fibrocartilage is weaker than hyaline cartilage.6 Although fibrocartilage is weaker than hyaline cartilage, various systematic reviews have revealed good to excellent outcomes in more than 80% of patients with osteochondral lesions of the talar dome (OLTs) using this technique.7–10 Building on the technique of BMS is the adjunct use of an allograft cartilage ECM (ACEM). An ACEM preparation has become available as BioCartilage (Arthrex, Inc, Naples, FL).11 ACEM contains type 2 collagen and proteoglycans, as well as growth factors found in articular cartilage, acting as a scaffold for marrow elements entering the site of injury to interact with after BMS.11 A study looking at the interaction of adult stem cells and native articular cartilage ECM revealed a significant amount of type 2 collagen produced.12 Another study looking at baboons revealed hyaline-like cartilage at 9 weeks using a cartilage scaffold.4,13 Clinical trials have yet to be published regarding the outcome using ACEM. This procedure can be performed using an open or an arthroscopic technique (Fig. 1). When dealing with OLTs, the senior author typically uses an arthroscopic technique. After adequate debridement of the OLT, BMS is performed. The remaining
Fig. 1. (A) After adequate debridement of hyaline cartilage bone marrow stimulation is performed. (B) An abdominal insufflator is placed through one of the portals to dry the area before placement of the allograft cartilage extracellular matrix. (C) Allograft cartilage extracellular matrix (ACEM) is placed into the defect after marrow stimulation and drying of the area. (D) ACEM is made level with the surrounding cartilage followed by placement of fibrin glue.
Cartilage Allograft Techniques and Materials
portion of the procedure is performed dry. Drying of the area is done using an abdominal insufflator through one of the portals as well as cottonoids to further dry the defect. During the drying process the ACEM is prepared on the back table by mixing the product with platelet-rich plasma drawn from the patient. Once the defect is adequately dried, the ACEM is carefully injected through a canula, effectively placed within the void and made level with the surrounding healthy cartilage using a freer elevator. Fibrin glue is then injected over the ACEM and allowed to dry, holding the scaffold in place. PARTICULATED JUVENILE ARTICULAR CARTILAGE
Particulated juvenile articular cartilage, available as DeNovo Natural Tissue graft (Zimmer, Warsaw, IN, USA) is an allograft obtained from donors younger than 13 years old. The chondrocyte density within juvenile articular cartilage is significantly increased (10 times) compared with mature articular cartilage.14 When comparing juvenile chondrocytes with adult chondrocytes in vitro, Adkisson and colleagues15 found that proteoglycans within the new cartilage produced by juvenile chondrocytes to be significantly higher (100-fold). Along with this, gene expression for types II and IX collagen was found to be significantly higher as well in juvenile chondrocytes compared with adult chondrocytes. A clinical study by Coetzee and colleagues16 found the average American Orthopedic foot and ankle society (AOFAS) score to be 85 18 with 80 or more considered a good/excellent outcome with this technique. This procedure can be performed using an open or arthroscopic technique. With arthroscopic transplantation for OLTs of the talus, the cartilage defect is adequately debrided. Again, the defect is dried thoroughly as described previously. One package of DeNovo Natural Tissue graft can treat a 2.5 cm2 of lesion surface area.17 The fluid within the package is aspirated and the juvenile cartilage is loaded into a small cannula. A 10-gauge angiocatheter can be used for this purpose to deliver the juvenile cartilage.18 Once the area is dried, an initial layer of fibrin glue is placed. After this the juvenile cartilage is delivered to the area and evenly distributed using a freer elevator. A second layer of fibrin glue is then applied over the area and allowed to dry. Fresh Allograft Transplantation
Fresh allograft transplantation addresses both the deficient hyaline cartilage as well as the underlying osseous structure.19,20 With respect to OLT, Berlet and colleagues21 discuss the use of a press-fit technique for contained lesions, and bulk allograft transplantation for uncontained as well as large structural lesions. With the press-fit technique, an allograft plug was harvested using an appropriate instrumentation system. The allograft plug is placed within the talus with no fixation needed.21 Larger defects can be excised completely with the fresh allograft measured to fit within the portion removed. Fixation is achieved with bioabsorbable pins or countersunk screws.22 Fresh allograft transplantation is a reasonable option with studies showing improvements in function using this technique.21,23,24 DISCUSSION
Osteochondritis dissecans of the talus is commonly seen by the foot and ankle surgeon, primarily occurring after a traumatic event.8,25–27 These lesions can be painful, often incapacitating, and affecting mainly young and middle-aged adults.28–31 Approximately one half of acute ankle sprains that occur have cartilage injury as a result.32,33 When looking at acute ankle fractures, a study by Leontaritis and
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colleagues found that 73% had chondral damage.34 Nonoperative therapy of osteochondritis dissecans has shown to have a 49.1% success rate in a recent systematic review by Zengerink and colleagues.7 Along with osteochondritis dissecans of the talus, this pathology has also been documented in relationship to the first metatarsophalangeal joint.35–37 With respect to osteochondritis dissecans of the talus, when conservative therapy fails, operative intervention is often performed to alleviate pain and restore function. Various allograft techniques are available for the repair of damaged articular cartilage. SUMMARY
Hyaline cartilage is avascular in nature, relying on surrounding synovial fluid for its nutrient supply. Lacking an inflammatory response, hyaline cartilage is unable to be repaired itself after injury. BMS technique allows reparative cartilage to be produced, taking the form of fibrocartilage. Fibrocartilage is weaker than hyaline cartilage. Various cartilage allograft materials are available for reparative techniques. The cartilage allograft materials discussed herein include fresh allograft transplantation, ACEM, and particulated juvenile articular cartilage. REFERENCES
1. Alford JW, Cole BJ. Cartilage restoration part 1: basic science, historical perspective, patient evaluation, and treatment options. Am J Sports Med 2005; 33(2):295–306. 2. Gomoll AH, Minas T. The quality of healing: articular cartilage. Wound Repair Regen 2014;22(S1):30–8. 3. Buckwalter JA, Mankin HJ, Grodzinsky AJ. Articular cartilage and osteoarthritis. Instr Course Lect 2005;54:465–80. 4. Triche R, Mandelbaum BR. Overview of cartilage biology and new trends in cartilage stimulation. Foot Ankle Clin 2013;18(1):1–12. 5. Mankin HJ. The response of articular cartilage to mechanical injury. J Bone Joint Surg Am 1982;64(3):460–6. 6. Buckwalter JA, Mow VC, Ratcliffe A. Restoration of injured or degenerated articular cartilage. J Am Acad Orthop Surg 1994;2:192–201. 7. Zengerink M, Struijs PA, Tol JL, et al. Treatment of osteochondral lesions of the talus: a systematic review. Knee Surg Sports Traumatol Arthrosc 2010;18(2): 238–46. 8. Tol JL, Struijs PA, Bossuyt PM, et al. Treatment strategies in osteochondral defects of the talar dome: a systematic review. Foot Ankle Int 2000;21(2):119–26. 9. Glazebrook MA, Ganapathy V, Bridge MA, et al. Evidence-based indications for ankle arthroscopy. Arthroscopy 2009;25(12):1478–90. 10. Donnenwerth MP, Roukis TS. Outcome of arthroscopic debridement and microfracture as the primary treatment of osteochondral lesions of the talar dome. Arthroscopy 2012;28(12):1902–7. 11. BioCartilage: Micronized Cartilage Matrix. Naples (FL): Arthrex; 2014. 12. Cheng NC, Estes BT, Awad HA, et al. Chondrogenic differentiation of adiposederived adult stem cells by a porous scaffold derived from native articular cartilage extracellular matrix. Tissue Eng Part A 2009;15(2):231–41. 13. Temple TH. Cartilage matrix for talus OCD in AOFAS Summer Meeting. San Diego (CA), June 20–23, 2012. 14. Giza E, Howell S. Allograft juvenile articular cartilage transplantation for treatment of talus osteochondral defects. Foot Ankle Spec 2013;6(2):141–4.
Cartilage Allograft Techniques and Materials
15. Adkisson HD, Martin JA, Amendola RL. The potential of human allogenic juvenile chondrocytes for restoration of articular cartilage. Am J Sports Med 2010;38(7): 1324–33. 16. Coetzee JC, Giza E, Schon LC, et al. Treatment of osteochondral lesions of the talus with particulated juvenile cartilage. Foot Ankle Int 2013;34(9):1205–11. 17. DeNovo Natural Tissue. Natural tissue graft: arthroscopic-assisted surgical technique for ankle cartilage repair. Warsaw (IN): Zimmer; 2007. 18. Cerrato R. Particulated juvenile articular cartilage allograft transplantation for osteochondral lesions of the talus. Foot Ankle Clin 2013;18(1):79–87. 19. Bugbee WD. Fresh osteochondral allografts. J Knee Surg 2002;15(3):191–5. 20. McCulloch PC, Kang RW, Sobhy MH, et al. Prospective evaluation of prolonged fresh osteochondral allograft transplantation of the femoral condyle: minimum 2-year follow-up. Am J Sports Med 2007;35(3):411–20. 21. Berlet GC, Hyer CF, Philbin TM, et al. Does fresh osteochondral allograft transplantation of talar osteochondral defects improve function? Clin Orthop Relat Res 2011;469(8):2356–66. 22. McCollum GA, Myerson MS, Jonck J. Managing the cystic osteochondral defect allograft or autograft. Foot Ankle Clin 2013;18(1):113–33. 23. Haene R, Qamirani E, Story RA, et al. Intermediate outcomes of fresh talar osteochondral allografts for treatment of large osteochondral lesions of the talus. J Bone Joint Surg Am 2012;94(12):1105–10. 24. El-Rashidy H, Villacis D, Omar I, et al. Fresh osteochondral allograft for the treatment of cartilage defects of the talus: a retrospective review. J Bone Joint Surg Am 2011;93(17):1634–40. 25. Hannon CP, Smyth NA, Murawski CD, et al. Osteochondral lesions of the talus. Bone Joint J 2014;96B(2):164–71. 26. 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 1985;5:165–85. 27. O’Loughlin PF, Heyworth BE, Kennedy JG. Current concepts in the diagnosis and treatment of osteochondral lesions of the ankle. Am J Sports Med 2010;38: 292–404. 28. Lin JS, Andersen LB, Juliano PJ. Effectiveness of composite bone graft substitute plugs in the treatment of chondral and osteochondral lesions of the talus. J Foot Ankle Surg 2010;49(3):224–31. 29. Tontz WL, Bugbee WD, Brage ME. Use of allografts in the management of ankle arthritis. Foot Ankle Clin 2003;8(2):361–73. 30. Becher C, Thermann H. Results of microfracture in the treatment of articular cartilage defects of the talus. Foot Ankle Int 2005;26(8):583–9. 31. Shea MP, Manoli A 2nd. Osteochondral lesions of the talar dome. Foot Ankle Int 1993;14(1):48–55. 32. Murawski CD, Kennedy JG. Current concepts review: operative treatment of osteochondral lesions of the talus. J Bone Joint Surg Am 2013;95:1045–54. 33. Saxena A, Eakin C. Articular talar injuries in athletes: results of microfracture and autogenous bone graft. Am J Sports Med 2007;35(10):1680–7. 34. Leontaritis N, Hinojosa L, Panchbhavi VK. Arthroscopically detected intraarticular lesions associated with acute ankle fractures. J Bone Joint Surg Am 2009;91(2):333–9. 35. Kim YS, Park EH, Lee HJ, et al. Clinical comparison of the osteochondral autograft transfer system and subchondral drilling in osteochondral defects of the first metatarsal head. Am J Sports Med 2012;40(8):1824–33.
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36. Bojanic I, Smoljanovic T, Ozren K. Osteochondritis dissecans of the first metatarsophalangeal joint: arthroscopy and microfracture technique. J Foot Ankle Surg 2011;50(5):623–5. 37. Vancil D, Mozena J. Osteochondritis dissecans of the first metatarsophalangeal joint. J Am Podiatr Med Assoc 1986;76(11):645–7.
DPM*,
Jared M. Maker,
DPM
KEYWORDS Cartilage Osteochondral lesion Talus Bone marrow stimulation Allograft KEY POINTS Hyaline cartilage lacks a vascular supply having the inability to mount an inflammatory response to injury. Allograft cartilage extracellular matrix provides a scaffold for marrow elements to interact with entering the site of injury after bone marrow stimulation. Chondrocyte density within juvenile cartilage is significantly increased compared with adult cartilage.
INTRODUCTION
Hyaline cartilage consists of 95% extracellular matrix (ECM) and 5% chondrocytes. One component of the ECM is collagen consisting of types II, V, VI, IX, X, XI, XII, and XIV; type II collagen is the most abundant.1 Glycoproteins (proteoglycans) are another component of the ECM. Glycoproteins carry a negative charge in effect attracting water, with water making up 70% to 80% of the wet weight of hyaline cartilage. This attraction of water allows cartilage to resist compressive forces.2 The role of the 5% of chondrocytes present is vital for the proper function of articular cartilage, being that they produce the ECM.1 Hyaline cartilage is structured into 4 zones consisting of the superficial, transitional, radial, and calcified cartilage zones.3 Chondrocytes lack a vascular supply, relying on nutrients to be supplied from the synovial fluid.4 Because hyaline cartilage is avascular, injury does not result in damage to blood vessels. Therefore, the inflammatory and repair phases of injury are absent, a scaffold consisting of a fibrin clot is not produced, and undifferentiated cells are not brought to the site of injury. The small number of chondrocytes present does not allow an adequate response to the injury, and the cartilage surface is not repaired.5
Disclosures: None. Coastal Orthopedics and Sports Medicine, 6015 Pointe West Boulevard, Bradenton, FL 34209, USA * Corresponding author. E-mail address: [email protected] Clin Podiatr Med Surg 32 (2015) 93–98 http://dx.doi.org/10.1016/j.cpm.2014.09.012 podiatric.theclinics.com 0891-8422/15/$ – see front matter Ó 2015 Elsevier Inc. All rights reserved.
94
Cottom & Maker
BONE MARROW STIMULATION TECHNIQUES
Bone marrow stimulation (BMS) allows mesenchymal stem cells to enter the site of injury and differentiate to produce reparative cartilage.1 With time, the cells within the reparative cartilage take the appearance of fibroblasts, with tightly packed type 1 collagen making up the matrix. This fibrocartilage is weaker than hyaline cartilage.6 Although fibrocartilage is weaker than hyaline cartilage, various systematic reviews have revealed good to excellent outcomes in more than 80% of patients with osteochondral lesions of the talar dome (OLTs) using this technique.7–10 Building on the technique of BMS is the adjunct use of an allograft cartilage ECM (ACEM). An ACEM preparation has become available as BioCartilage (Arthrex, Inc, Naples, FL).11 ACEM contains type 2 collagen and proteoglycans, as well as growth factors found in articular cartilage, acting as a scaffold for marrow elements entering the site of injury to interact with after BMS.11 A study looking at the interaction of adult stem cells and native articular cartilage ECM revealed a significant amount of type 2 collagen produced.12 Another study looking at baboons revealed hyaline-like cartilage at 9 weeks using a cartilage scaffold.4,13 Clinical trials have yet to be published regarding the outcome using ACEM. This procedure can be performed using an open or an arthroscopic technique (Fig. 1). When dealing with OLTs, the senior author typically uses an arthroscopic technique. After adequate debridement of the OLT, BMS is performed. The remaining
Fig. 1. (A) After adequate debridement of hyaline cartilage bone marrow stimulation is performed. (B) An abdominal insufflator is placed through one of the portals to dry the area before placement of the allograft cartilage extracellular matrix. (C) Allograft cartilage extracellular matrix (ACEM) is placed into the defect after marrow stimulation and drying of the area. (D) ACEM is made level with the surrounding cartilage followed by placement of fibrin glue.
Cartilage Allograft Techniques and Materials
portion of the procedure is performed dry. Drying of the area is done using an abdominal insufflator through one of the portals as well as cottonoids to further dry the defect. During the drying process the ACEM is prepared on the back table by mixing the product with platelet-rich plasma drawn from the patient. Once the defect is adequately dried, the ACEM is carefully injected through a canula, effectively placed within the void and made level with the surrounding healthy cartilage using a freer elevator. Fibrin glue is then injected over the ACEM and allowed to dry, holding the scaffold in place. PARTICULATED JUVENILE ARTICULAR CARTILAGE
Particulated juvenile articular cartilage, available as DeNovo Natural Tissue graft (Zimmer, Warsaw, IN, USA) is an allograft obtained from donors younger than 13 years old. The chondrocyte density within juvenile articular cartilage is significantly increased (10 times) compared with mature articular cartilage.14 When comparing juvenile chondrocytes with adult chondrocytes in vitro, Adkisson and colleagues15 found that proteoglycans within the new cartilage produced by juvenile chondrocytes to be significantly higher (100-fold). Along with this, gene expression for types II and IX collagen was found to be significantly higher as well in juvenile chondrocytes compared with adult chondrocytes. A clinical study by Coetzee and colleagues16 found the average American Orthopedic foot and ankle society (AOFAS) score to be 85 18 with 80 or more considered a good/excellent outcome with this technique. This procedure can be performed using an open or arthroscopic technique. With arthroscopic transplantation for OLTs of the talus, the cartilage defect is adequately debrided. Again, the defect is dried thoroughly as described previously. One package of DeNovo Natural Tissue graft can treat a 2.5 cm2 of lesion surface area.17 The fluid within the package is aspirated and the juvenile cartilage is loaded into a small cannula. A 10-gauge angiocatheter can be used for this purpose to deliver the juvenile cartilage.18 Once the area is dried, an initial layer of fibrin glue is placed. After this the juvenile cartilage is delivered to the area and evenly distributed using a freer elevator. A second layer of fibrin glue is then applied over the area and allowed to dry. Fresh Allograft Transplantation
Fresh allograft transplantation addresses both the deficient hyaline cartilage as well as the underlying osseous structure.19,20 With respect to OLT, Berlet and colleagues21 discuss the use of a press-fit technique for contained lesions, and bulk allograft transplantation for uncontained as well as large structural lesions. With the press-fit technique, an allograft plug was harvested using an appropriate instrumentation system. The allograft plug is placed within the talus with no fixation needed.21 Larger defects can be excised completely with the fresh allograft measured to fit within the portion removed. Fixation is achieved with bioabsorbable pins or countersunk screws.22 Fresh allograft transplantation is a reasonable option with studies showing improvements in function using this technique.21,23,24 DISCUSSION
Osteochondritis dissecans of the talus is commonly seen by the foot and ankle surgeon, primarily occurring after a traumatic event.8,25–27 These lesions can be painful, often incapacitating, and affecting mainly young and middle-aged adults.28–31 Approximately one half of acute ankle sprains that occur have cartilage injury as a result.32,33 When looking at acute ankle fractures, a study by Leontaritis and
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colleagues found that 73% had chondral damage.34 Nonoperative therapy of osteochondritis dissecans has shown to have a 49.1% success rate in a recent systematic review by Zengerink and colleagues.7 Along with osteochondritis dissecans of the talus, this pathology has also been documented in relationship to the first metatarsophalangeal joint.35–37 With respect to osteochondritis dissecans of the talus, when conservative therapy fails, operative intervention is often performed to alleviate pain and restore function. Various allograft techniques are available for the repair of damaged articular cartilage. SUMMARY
Hyaline cartilage is avascular in nature, relying on surrounding synovial fluid for its nutrient supply. Lacking an inflammatory response, hyaline cartilage is unable to be repaired itself after injury. BMS technique allows reparative cartilage to be produced, taking the form of fibrocartilage. Fibrocartilage is weaker than hyaline cartilage. Various cartilage allograft materials are available for reparative techniques. The cartilage allograft materials discussed herein include fresh allograft transplantation, ACEM, and particulated juvenile articular cartilage. REFERENCES
1. Alford JW, Cole BJ. Cartilage restoration part 1: basic science, historical perspective, patient evaluation, and treatment options. Am J Sports Med 2005; 33(2):295–306. 2. Gomoll AH, Minas T. The quality of healing: articular cartilage. Wound Repair Regen 2014;22(S1):30–8. 3. Buckwalter JA, Mankin HJ, Grodzinsky AJ. Articular cartilage and osteoarthritis. Instr Course Lect 2005;54:465–80. 4. Triche R, Mandelbaum BR. Overview of cartilage biology and new trends in cartilage stimulation. Foot Ankle Clin 2013;18(1):1–12. 5. Mankin HJ. The response of articular cartilage to mechanical injury. J Bone Joint Surg Am 1982;64(3):460–6. 6. Buckwalter JA, Mow VC, Ratcliffe A. Restoration of injured or degenerated articular cartilage. J Am Acad Orthop Surg 1994;2:192–201. 7. Zengerink M, Struijs PA, Tol JL, et al. Treatment of osteochondral lesions of the talus: a systematic review. Knee Surg Sports Traumatol Arthrosc 2010;18(2): 238–46. 8. Tol JL, Struijs PA, Bossuyt PM, et al. Treatment strategies in osteochondral defects of the talar dome: a systematic review. Foot Ankle Int 2000;21(2):119–26. 9. Glazebrook MA, Ganapathy V, Bridge MA, et al. Evidence-based indications for ankle arthroscopy. Arthroscopy 2009;25(12):1478–90. 10. Donnenwerth MP, Roukis TS. Outcome of arthroscopic debridement and microfracture as the primary treatment of osteochondral lesions of the talar dome. Arthroscopy 2012;28(12):1902–7. 11. BioCartilage: Micronized Cartilage Matrix. Naples (FL): Arthrex; 2014. 12. Cheng NC, Estes BT, Awad HA, et al. Chondrogenic differentiation of adiposederived adult stem cells by a porous scaffold derived from native articular cartilage extracellular matrix. Tissue Eng Part A 2009;15(2):231–41. 13. Temple TH. Cartilage matrix for talus OCD in AOFAS Summer Meeting. San Diego (CA), June 20–23, 2012. 14. Giza E, Howell S. Allograft juvenile articular cartilage transplantation for treatment of talus osteochondral defects. Foot Ankle Spec 2013;6(2):141–4.
Cartilage Allograft Techniques and Materials
15. Adkisson HD, Martin JA, Amendola RL. The potential of human allogenic juvenile chondrocytes for restoration of articular cartilage. Am J Sports Med 2010;38(7): 1324–33. 16. Coetzee JC, Giza E, Schon LC, et al. Treatment of osteochondral lesions of the talus with particulated juvenile cartilage. Foot Ankle Int 2013;34(9):1205–11. 17. DeNovo Natural Tissue. Natural tissue graft: arthroscopic-assisted surgical technique for ankle cartilage repair. Warsaw (IN): Zimmer; 2007. 18. Cerrato R. Particulated juvenile articular cartilage allograft transplantation for osteochondral lesions of the talus. Foot Ankle Clin 2013;18(1):79–87. 19. Bugbee WD. Fresh osteochondral allografts. J Knee Surg 2002;15(3):191–5. 20. McCulloch PC, Kang RW, Sobhy MH, et al. Prospective evaluation of prolonged fresh osteochondral allograft transplantation of the femoral condyle: minimum 2-year follow-up. Am J Sports Med 2007;35(3):411–20. 21. Berlet GC, Hyer CF, Philbin TM, et al. Does fresh osteochondral allograft transplantation of talar osteochondral defects improve function? Clin Orthop Relat Res 2011;469(8):2356–66. 22. McCollum GA, Myerson MS, Jonck J. Managing the cystic osteochondral defect allograft or autograft. Foot Ankle Clin 2013;18(1):113–33. 23. Haene R, Qamirani E, Story RA, et al. Intermediate outcomes of fresh talar osteochondral allografts for treatment of large osteochondral lesions of the talus. J Bone Joint Surg Am 2012;94(12):1105–10. 24. El-Rashidy H, Villacis D, Omar I, et al. Fresh osteochondral allograft for the treatment of cartilage defects of the talus: a retrospective review. J Bone Joint Surg Am 2011;93(17):1634–40. 25. Hannon CP, Smyth NA, Murawski CD, et al. Osteochondral lesions of the talus. Bone Joint J 2014;96B(2):164–71. 26. 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 1985;5:165–85. 27. O’Loughlin PF, Heyworth BE, Kennedy JG. Current concepts in the diagnosis and treatment of osteochondral lesions of the ankle. Am J Sports Med 2010;38: 292–404. 28. Lin JS, Andersen LB, Juliano PJ. Effectiveness of composite bone graft substitute plugs in the treatment of chondral and osteochondral lesions of the talus. J Foot Ankle Surg 2010;49(3):224–31. 29. Tontz WL, Bugbee WD, Brage ME. Use of allografts in the management of ankle arthritis. Foot Ankle Clin 2003;8(2):361–73. 30. Becher C, Thermann H. Results of microfracture in the treatment of articular cartilage defects of the talus. Foot Ankle Int 2005;26(8):583–9. 31. Shea MP, Manoli A 2nd. Osteochondral lesions of the talar dome. Foot Ankle Int 1993;14(1):48–55. 32. Murawski CD, Kennedy JG. Current concepts review: operative treatment of osteochondral lesions of the talus. J Bone Joint Surg Am 2013;95:1045–54. 33. Saxena A, Eakin C. Articular talar injuries in athletes: results of microfracture and autogenous bone graft. Am J Sports Med 2007;35(10):1680–7. 34. Leontaritis N, Hinojosa L, Panchbhavi VK. Arthroscopically detected intraarticular lesions associated with acute ankle fractures. J Bone Joint Surg Am 2009;91(2):333–9. 35. Kim YS, Park EH, Lee HJ, et al. Clinical comparison of the osteochondral autograft transfer system and subchondral drilling in osteochondral defects of the first metatarsal head. Am J Sports Med 2012;40(8):1824–33.
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36. Bojanic I, Smoljanovic T, Ozren K. Osteochondritis dissecans of the first metatarsophalangeal joint: arthroscopy and microfracture technique. J Foot Ankle Surg 2011;50(5):623–5. 37. Vancil D, Mozena J. Osteochondritis dissecans of the first metatarsophalangeal joint. J Am Podiatr Med Assoc 1986;76(11):645–7.