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Foot & Ankle International
FAI June 2025 Podcast: Talar OsteoPeriostic Grafting From the Iliac Crest (TOPIC): Prospective 2-Year Outcomes for Large Lateral Osteochondral Lesions of the Talus
00:23:40
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- [00:06]
A
This is Mark Easley and I have the distinct honor of talking with Dr. Seward Stufkins, the senior author of June's lead paper in Foot and Ankle International. The paper is titled Taylor Osteoperiostic Grafting from the Iliac Crest or Topic Prospective two Year Outcomes for Large Lateral Osteochondral Lesions of the talus. Dr. Seward Stufkins is the Vice President of the Residency Training Program at the Amsterdam University Medical center in the Netherlands. He has an MD and PhD having complemented his extensive clinical training with dedicated research experiences under the guidance of Drs. Van Dyke, Steller, and Hinterman. Dr. Stufkins is a thought leader in the management of ankle trauma, deformity and arthritis and as pertains to today's discussion, sports injuries and Ankle Cartilage pathology. In addition, Dr. Stufkin serves as an International Editor for Foot and Ankle International. Dr. Saltzman and I selected this article to highlight the investigation exclusively focusing on osteoperiosteal reconstruction of large lateral tailor dome defects. Welcome to the program. Short Short, As a senior author or the senior author for the paper, would you please give the listeners a brief summary of your paper and its major findings?
- [01:26]
B
Thank you Mark, for your kind invitation and for selecting our work. It's a pleasure to talk to you about reconstruction of large Ostraconal defects in the ankle. So we have prospectively followed a series of lateral lesions that we treated with a bone transplant from the iliac crest and what we found, a two year follow up was a solid incorporation of the graft, good pain relief, significant improvement of PROMs, and no reoperations.
- [01:53]
A
Stuart, I recognize that you published the Lateral topic surgical technique in 2023 and briefly review that in this article. In discussing the study's limitations, you acknowledge that your team's experience with the topic procedure may allow for more favorable outcomes than those for surgeons less experienced with the topic procedure. For the benefit of the listeners, would you please highlight the key surgical steps to optimize outcomes for the lateral topic procedure? And specifically, with the rectangular shape that you describe, how do you best match the iliac crest curvature to the curvature of the lateral Taylor dome? How important is drilling the recipient site? And when you place the graft subchondraly, does that mean that the periosteal layer matches the adjacent native cartilage in height?
- [02:44]
B
So first of all we measure the lesion on ct and often these larger lesions consist of many smaller lesions or smaller cysts. So we aim to remove as much as needed but preferably no more. We use a Standard anderolateral approach to the ankle joint. And for the large lesions, you need to subluxate the talus ventrally. That means, more often than not, the release of the atfl A K wire spreader, such as a Hinterman spreader, comes in handy. In the beginning, I used an oscillating saw, but I found that a sharp chisel works best to cut out the defects. For the matching curvature on the iliac crests, we have found the optimal distance from the anterior superior iliac spine. This will be published shortly. The manuscript is still under preparation. Regarding drilling of the recipient site, we do not know the exact role of this part, but for me, I like to puncture through remaining sclerotic spots and maybe stimulate the talus some more to jump start the healing process. Since we have a 100% union rate of the autograft. Never change a winning team, right? The graft is placed deep enough so the bone lies adjacent to the talar bone. The periosteal layer on the iliac crest is relatively thin and therefore lies just below the native cartilage. It then hypertrophies up to the level of the native cartilage. Perfect.
- [04:05]
A
Okay, thanks. That helps a lot. In your Figure 1, you have a selection flowchart and you excluded one patient for not having a press fit, so necessitating the use of a screw fixation. Does that mean that the topic should only rely on an interference fit of the graft and that graft fixation is not necessary? In my experience, using structural osteochondral allograft for large Taylor shoulder olts, I can sometimes achieve a perfect press fit, but often add screw fixation to ensure graft stability. If satisfactory topic graft fixation was achieved with the screw, could you explain to listeners why this patient had to be excluded?
- [04:46]
B
Yeah. So the one patient excluded was actually more a hemitelus case than a typical contained osteochondral lesion case. Regarding size, we left it out of the series for homogeneity reasons mainly. And for me, screw fixation is typically not part of the top procedure. Main ingredients to ensure quick bone healing are a press fit technique, the viability of an autograph, and really have a large surface with, well, all the walls. For a press fit technique, screws tend to loosen after graft healing and then removal, which sometimes necessitate another osteotomy to gain access to the joint. And I know you have extensive experience with large allografts. And in your 2022 paper in foot and Ankle International, you also describe a 35% of screw removal. I can imagine you also add screw fixation to ensure graft stability, but maybe also partly because the allograft takes a little longer to fully incorporate.
- [05:51]
A
Yeah, it's good. I like it. You're turning the tables on me and asking me a question. That's wonderful. It may. I. I don't. I don't know because I don't use a lot of autographed. I do have some experience with cylindrical graphs and even in some graphs that try to incorporate that curvature on the lateral femoral condyle. But I don't have the experience you do in comparing autograph to allograph because for the last. Gosh, for the last 15, 20 years I've used this allograft fresh allograph, tailless. So I don't know if I have a good comparison, but very good question and thank you. Good. So I keep me on my toes. I like that. So Serge, you cite two references of clinical experience with osteoperiosteal grafting, one by Leuman et al and the other from Lee et al. As well as two references from o' Driscoll's group suggesting the cartilage regeneration potential of periosteum. In your team's experience, what is the true articular cartilage regenerative potential of periosteum and is it even important in this procedure? Have you had experience with second look arthroscopy or even biopsies to determine if indeed the periosteum exhibits characteristics of articular cartilage or simply serves a similar function to articular cartilage Mark, to be honest,
- [07:07]
B
we just don't know. On MRI there are sequences that give qualitative information such as this T1Rho mapping and Degeneric and they show good cordage, a good quality cartilage. But second look arthroscopies also look good. The tissue that lies over the iliac crest graft looks eyeline. But you know, after bone marrow stimulation you sometimes also see beautiful cartilage regeneration doesn't always have the appearance of fibrocartilage. So obtaining biopsies well from a transplant that looks beautiful. In a happy pain free patients. I would not be able to convince my patient then it's not possible where I live to do that secretly.
- [07:53]
A
Fair enough. Okay, so I like it. It sounds like the results are quite good. And you also have vast experience with medial defects. So there's a whole complement of articles and research that you've done. So sounds like it's a very reproducible procedure and I know that Bat Hinterman had talked about it even earlier. So you trained with them. So I love the experience and I'm learning more. Maybe I need to learn come directly and do a fellowship with you so I can learn how to do this procedure as well. But you also you reference she et al as comparison of autologous osteoperiosteal and osteochondral transplantation of large medial cystic osteochondral lesions of the talus. Would you please summarize their findings just briefly and provide the listeners with why you and your team favor the topic procedure over osteochondral transplantation. And quite frankly you've explained some of it. But just tell us why you favor this. Just some simple points and just compliment more what you've already said about the advantages of the topic procedure.
- [08:59]
B
Yeah, so first of all let's be straight. The osteochondral transplantation has really good results so why change it? The group of XI published their comparative study in the Journal of sports medicine in 22 and compared the clinical outcomes at a minimum of two year follow up and both groups showed significant clinical improvements. So no significant difference in final functional scores. The osteoperiosteal group had fewer donor side complications. So even though the osteochondral transplantation comes from the non weight bearing zone femoral condyle, 13% had persisting knee pain. MRI scores were comparable suggesting good cartilage repair quality in both. Therefore, we think that our topic procedure can be used for even larger lesions than those treated with cylindrical harvest methods. It's easier than a mosaic plasti. The osteochondral transplants really have excellent outcomes, but unfortunately more donor side morbidity than the bone transplants from the iliac crest. I think that would be one of the main reasons that we changed and now stick to our topic procedure.
- [10:08]
A
Perfect. Thank you and thanks for summarizing that. And I'm sorry to Dr. Shi if I said his name wrong. It could be sure, but I do the best I can and I'm trying with your name too but Seward, I think I'm close. So you are in Amsterdam. If I were to visit Amsterdam, I would not want to miss the Van Gogh Museum or the Heineken Brewery experience. Those are some things I want to do. But maybe perhaps we save the red light district for another time. But what else do you recommend to our listeners should they consider visiting Amsterdam anytime soon?
- [10:39]
B
I like this in between question when visiting our beautiful city rich in history Art and culture. You should go on a canal boat tour so the city is even more beautiful, maybe most beautiful from the water, especially at sunset or in the evening. And when you do visit the Van Gogh here at the Museum Square, don't miss the Reichmuseum with Dutch masters such as Rembrandt and Vermeer. And when the weather is nice, visit the Vondelpark. Maybe even go cycling there if you. If you dare. Well, there's so much to see and do. Let me take this opportunity. We're proud to host the International Congress on Carcass Repair of the ankle in April 27th. Wouldn't that be good opportunity to visit the red light? I mean to visit Amsterdam.
- [11:26]
A
All right, good. All right, well, we'll. We'll write. We'll write those notes down. And we look forward to seeing you. Thank you for the invitation. So short. Preoperatively, you and your co investigators evaluate the lateral osteochondral defects and reconstruction with ct. Preoperatively, you carefully assess the lesion dimensions and morphology. And you even mentioned that you look for cysts and address those too. And deciding and optimal graft harvest from the iliac crest. Was the preoperative CT essential or did you rely more on the intraoperative clinical measurements of recipient site after debriding the olt?
- [12:06]
B
So there are basically two steps. The CT is essential in the pre op planning and in deciding which treatment is suitable. And regarding morphology, you know, we try to fix fragmentous lesions whenever possible. So that's a really crucial step. Regarding the graft size, after the broadening osteocondal defect, we measure the recipient site again and harvest the graft accordingly. So the harvest is based on intra op caliper measurements and not on the pre op CT measurements.
- [12:38]
A
Great. Yeah, I was curious about that. When I do my osteochondral reconstructions with the allograft, the Taylor allograft, I do the same with the caliber. It's one of those things where for me I have to measure. Measure twice and cut once. I only get one chance. So I have a caliber and a little ruler. So thank you for sharing that. Then at three months and at one year and then again at two years, you and the team carefully evaluated the topic reconstructions with CT looking for graft incorporation and potential cyst formation. As is reported in other studies, you noted that all graphs incorporated but observe cysts in nearly all of the patients. You and your colleagues discuss that cysts are to be expected with this procedure and bear no correlation with clinical outcomes. To me, cysts have a negative connotation and may even prompt further intervention. So with that said, do you recommend that I treat the patient and the patient's symptoms and try to avoid treating the scans and what I see on the CT after the surgery?
- [13:46]
B
Yeah, Mark. So here we are on a slippery slope. And of course, in case cysts reoccur, we follow the patient. Also, when they're asymptomatic and when they become symptomatic, we treat according to our protocol. But first of all, many cysts that reoccur are very small and stable over time. We meticulously look at all the scans of these prospective series, and therefore, maybe we report more than that is relevant. We report everything we see, and I think that's part of the high percentages. But if the scan looks good and the patient is happy, we consider it a success. If the scan looks not so good but the patient is still happy, is it a success or a failure of the treatment? But here's the dilemma, and another question for you. Do you think there is consensus about success or failure of a treatment that aims to fill the defect when we also know that there are asymptomatic lesions out there?
- [14:44]
A
Yeah, I think that's a great question. I don't know the answer either. And I thought it was important that you said that you look for cysts preoperatively. So I wonder, too, do preoperative cysts lead to persistent cysts? And we do our best to try to fill those or address those as well. Maybe that particular patient has a greater predilection to having cysts formation. I don't know. But I agree with you that I see cysts with the allograft Taylor Allograft reconstructions. I do, and I look to see if they're progressive or if they're stable. So I think that's important. And then I treat the patients according to their symptoms. It's much like total ankle replacement.
- [15:24]
B
Right.
- [15:24]
A
We try to do our best and at times we have some cyst formation, but if they're not progressive, I'm not going to intervene. But if it's progressive, I may need to act. So I think that's very, very fair and a good answer. So, all right, we'll just transgress just a little bit. Seward. This past week, the Dutch football soccer championship was decided and PSV Eindhoven took the title. I trust that you're an Ajax Amsterdam fan and my understanding that Ajax Amsterdam had every opportunity to be the champion, but suffered A late season collapse. And you are the one to keep the topic graphs from collapsing. So what can you do to help Ajax regain the championship next season?
- [16:09]
B
That's funny. We're going to talk soccer now. I think you want to add an extra 20 minutes to this podcast, Mark. So I'm always surprised by your knowledge about soccer and I vividly remember one of your presentations several years ago in Milan where your presentation consists of asking the audience to rate Italian soccer players, showing their heads and asking for for applause. That was really funny. So, about Ajax. The previous season was a disaster. So the 2324 season was a disaster. We even have been on a historically low position in the rankings, followed by chaos at the management level, at a weak transfer window and a lack of clear playing style. And there you have the perfect storm. You might even consider the second place this season a miracle. I think they read really well actually. For next season to compare with a topic procedure, I would advise to go look for a solid foundation, reconnect with your identity in a historical context. You know, this year ike celebrates his 125th birthday. You could say celebrate innovation, but with respect for the past. Just like autografting.
- [17:25]
A
Man, that is good. That is a great answer. All right, well, thank you for sharing. All right, Seward, back to the topic at hand. You acknowledged that lateral osteochondral lesions of the talus are less common than medial ones and mentioned that according to the literature, traditionally outcomes of surgical management for lateral osteochondral lesions of the talus are not as favorable as they are for medial OLTs. You and your colleagues identified 10 patients with large OLTs, lateral OLTs and and report satisfactory outcomes at two years with a topic procedure. One patient was lost to follow up and two others needed to be excluded, leaving seven for the investigation. Are the two year outcomes of your lateral topic procedures similar to your results with the same procedure for large medial olts? And are your results favorable compared to other surgical treatments methods for OLTs?
- [18:17]
B
Yes, I think they're all quite comparable, but also have to acknowledge that this is a very small series, so a real comparison with other techniques maybe cannot be made at this moment. The first results are promising, similar to the results of medial alts. In 2023, we published on 43 patients with medial lesions and reported a reduction of pain from NRS 7 to 2. And for the lateral lesions, the NRS pain reduced from 6 to 1. The main difference of course, is access to the lesion. The medial lesion requires an osteotomy while the Lateral lesions involve HFL release and repair. The only thing we can do is closely follow both and try to provide larger studies with longer follow up periods in the future. And we're also very curious about survival.
- [19:11]
A
Perfect. Thank you. And Seward, you and your colleagues were comprehensive in your clinical assessment employing a numeric rating scale, the foot and ankle outcome score, the AOFAs ankle hindfoot score, and the mental and physical component summaries of the SF36. Your focus was on pain during walking before and after the topic procedure. Do you have experience allowing your topic patients to return to high impact activities in sport or do you recommend limiting the reconstructions to lower impact activities?
- [19:44]
B
Yeah, that's a great question. So pain relief during everyday activities is the main focus. There are patients that return to high impact activities in sports and we try to give them no restrictions, just follow them and see how it affects their long term results. So far we see no clinical worsening with patients playing sports. Maybe there's a trend towards more cyst formation radiologically in the high impact subgroup, but we have to gather more data to know that for sure. Great.
- [20:18]
A
Thank you. Yeah. And more information needed. I always hesitate a bit to let my allograft patients, structural allograft patients, go back to high activities, but they always surprise me, so we have more to learn. Seward, the surgical approach for this procedure, you've mentioned it requires release and repair of the lateral ankle ligaments. You mentioned that in cases of gross chronic instability and non viable ligamentous structures, you augment the repair with an internal brace. Although your study is limited to only seven patients, have you and your colleagues identified any difference in outcomes between patients with and without preoperative lateral ankle instability?
- [20:57]
B
So my threshold for augmenting the repair is relatively low in atopic patients. And this is probably due to the fact that I think that instability plays a role in the etiology in the medial lesions. For me, there is a component of a repetitive overload that might cause some acute lesions to develop into chronic lesions. Like in other joint repetitive overload plays a role and that just might be the reason that some lesions heal and some become chronic. For the lateral lesions, it might just be that it's not the repetitive overload, but the instability is one of the relevant aspects. Also, for the smaller lesions that require bms, I just look for the instability. And for the topic patients, when you go as far as a large bone transplant, then you might as well reassure yourself and your patient that a persisting instability is not going to ruin your results.
- [21:55]
A
Great. Thank you very much. So I have one more simple question for you. What should we call where you live? Is it Holland or is it the Netherlands? What should we call it?
- [22:07]
B
There's another great, great question of a different level. So the the term Holland and the Netherlands are often used interchangeably, but they're not the same. So official country name is Kingdom of the Netherlands and is composed of 12 provinces, including north and South Holland. So these two provinces have historically been the most influential and that's why the name Holland became widely used abroad.
- [22:42]
A
Great. Thank you very much. And Seward, excellent work. As our podcast comes to its conclusion, is there anything else you would like to share with the listeners?
- [22:51]
B
Well, I think that your questions were excellent, Mark, and we covered a lot, even soccer and history. And it was just an honor being on your podcast.
- [23:01]
A
Well, thank you. It's an honor to have you on the podcast. So thank you. And thank you for taking time away from your conference, your orthopedic conference right now. So I'd like to thank Dr. Stufkins for sharing his insights and his and his co authors FAI publication Taylor Osteoperiostic Grafting from the Iliac Crestor topic the Prospective two Year Outcomes for Large Lateral Osteochondral Lesions of the Talus. And I would like to thank everyone for participating in this month's FAI podcast. This is Mark Easley and I look forward to next month's podcast.