Foot & Ankle International – September 2025 Podcast Episode Summary

Episode Title

Immediate Postoperative Weightbearing Following Arthroscopic Bone Marrow Stimulation for Talar Osteochondral Lesions: A Matched Cohort Study

Date

September 18, 2025

Host

Mark Easley (SAGE Publications, FAI editorial team)

Guest

Dr. Gino Kerkhoffs, Chair of Orthopedic Surgery & Sports Medicine, Amsterdam University Medical Centers

Overview

This episode features an in-depth discussion with Dr. Gino Kerkhoffs about his recent lead paper in Foot & Ankle International. The study investigates whether immediate postoperative weightbearing after arthroscopic bone marrow stimulation for talar osteochondral lesions (OLTs) yields different clinical or radiological outcomes compared to a more traditional delayed weightbearing approach. The episode covers surgical techniques, rehabilitation, study methodology, and broader reflections on orthopedic education and Dutch sports culture.

Key Discussion Points & Insights

1. Study Summary & Major Findings

• Study Design & Population:
  • Retrospective matched cohort study: 26 patients (13 per group, matched for clinical factors).
  • Compared immediate postoperative weightbearing with delayed weightbearing after arthroscopic bone marrow stimulation (BMS) for talar OLTs.
  • 12-month clinical and radiological follow-up.
• Findings:
  • No significant differences in pain or function between the groups.
  • Larger proportion in immediate weightbearing group exceeded the minimal clinically important difference (MCID) in pain reduction.
  • Trend toward earlier return to work and sport in the immediate group.
  • No increase in complications—immediate weightbearing appears safe and potentially beneficial, though larger trials are needed for confirmation.
  • [01:17] B: "Our main finding was that both groups showed similar improvement in pain and function over time with no statistically significant differences... Immediate weightbearing may at least be safe and potentially beneficial."

2. Technical Pearls for Bone Marrow Stimulation

• Surgical Technique Tips:
  • Start with meticulous lesion debridement—stable, vertical shoulders, removal of devitalized cartilage.
  • Favor low-impact, small-diameter picking under arthroscopic control over traditional microfracture awls to avoid subchondral damage.
• Concerns About Microfracture:
  • Recognizes long-term limitations: fibrocartilage repair is biologically and mechanically inferior to hyaline cartilage.
  • Orthobiologics are promising but require more evidence before routine adoption.
  • Large or cystic lesions may require augmentation (e.g., the TOPIC technique).
• Patient Selection: Must consider BMI, muscle strength, balance, and tailor biologic augmentation as needed.
• [03:02] B: "For optimal bone marrow stimulation: meticulous lesion prep, minimal trauma, controlled marrow stimulation through small holes, and critical patient selection..."

3. Lesion Size, Location, & Containment

• Size Matters:
  • Lesions >15 mm have poor outcomes with traditional BMS; switch to structural autografting (e.g., TOPIC method).
  • [07:01] B: "With larger lesions... these do not so well in more than 50% of cases. We stopped using BMS for these..."
• Location/Reachability:
  • Lesion location itself not strongly predictive; technical reachability is more relevant—hard-to-reach lesions risk incomplete treatment.
  • [08:51] B: "It's maybe not only the lesion location itself... but reachability that potentially influences the outcome."
• Containment:
  • Containment matters: contained lesions (intact cartilage rim) fare better with BMS; non-contained larger lesions may need grafting.
  • Postoperative containment is more relevant than preoperative.
  • [15:27] B: "Containment after surgery, rather than pre-op status, is more relevant to BMS healing."

4. Subchondral Cysts & Imaging

• Preoperative Cysts:
  • Require debridement and breaching of the sclerotic wall for healing.
• Postoperative Cysts:
  • Common but not correlated with worse clinical outcomes at 5–7 years.
  • [11:18] B: "Postoperative cyst occurrence was not correlated with clinical outcome in any of our patients."
• Imaging:
  • Prefers CT for precise measurement.
  • MRI useful for identifying associated pathology but may exaggerate size due to edema.
  • [11:18] B: "MRI... might lead you to oversize [the lesion] a bit... CT scan gives a measurable view on the defect."

5. Patient Selection, Study Design, and MCID

• Inclusion/Exclusion:
  • Excluded patients with incomplete data or concomitant procedures (ankle ligament recon, osteotomies) to isolate effect of BMS and weightbearing.
• Study Limitations:
  • Retrospective design and small sample size—statistical power is limited.
  • A true randomized controlled trial would provide stronger evidence for causality.
• MCID Use:
  • MCID highlights clinical importance, even absent statistical significance—more patients in immediate group found meaningful benefit.
  • [36:19] B: "MCID is the smallest change that patients perceive as meaningful... more found meaningful improvement in pain with immediate weightbearing."

6. Rehabilitation Protocol & Elite Athletes

• Weightbearing & PT Timeline:
  • Immediate weightbearing as tolerated; crutches used for 1–2 weeks as needed.
  • Start range-of-motion (ROM) exercises right after surgery.
  • Physical therapy begins within first week post-op, focusing on ROM, muscle strength, gait, and functional milestones rather than fixed timelines.
  • High-impact activity only once strength, balance, and pain-free dorsiflexion achieved.
  • [30:52] B: "Not about pushing full weightbearing immediately, but removing restrictions and allowing patients to self-regulate based on their symptoms."
• Tailoring for Athletes:
  • Same surgical principles apply, but elite athletes receive even more individualized progression and intense monitoring.
  • [33:36] B: "We apply the same science, but the environment allows us a different pace."

7. Outcomes Over Time & Duration of Symptoms

• 12 vs. 24 Month Outcomes:
  • No marked differences expected at 2 years compared to 1 year; gains stable over time for most patients.
• Symptom Duration:
  • Longer symptoms pre-op lead to harder, slower recovery—possible pain sensitization, deconditioning, psychological barriers.
  • [27:25] B: "Longer symptoms before treatment, recovery is slower after, even if structural result seems good."

8. Broader Perspectives — Dutch Water Management, Cycling Culture, Sports

• Water Management:
  • The "Room for the River" concept widens riverbeds/creates safe flood zones—living with water, not just fighting it.
  • [13:46] B: "Room for the river... creates space for water by widening riverbeds... it's a smart way to live with water."
• Amsterdam Bike Culture:
  • Old, scruffy bikes are practical—less likely to be stolen, better in harsh weather.
  • [21:01] B: "In Amsterdam, bikes are about practicality... the worse it looks, the more likely it's still there when you return."
• Dutch Women's Field Hockey:
  • Remarkably successful due to structured youth programs, high competitiveness, and strong team culture.
  • [29:09] B: "It's a performance culture—starts young, structured, supportive... clear pathway from grassroots to world class."

9. Training the Next Generation

• Early exposure in medical school, hands-on research, and active involvement drive interest in orthopedics among young people.
• Regular meetings and mentoring keep students engaged and passionate about the specialty.
• [37:47] B: "From early on, we invite them to join the team... The youngest researchers organize meetings, present, and are inspired to contribute."

Notable Quotes & Timestamps

On Study Results and Safety

• [01:17] Dr. Kerkhoffs: "Immediate weightbearing may at least be safe and potentially beneficial alternative to delayed protocols."

On Technical Pearls

• [03:02] Dr. Kerkhoffs: "...minimal trauma to the subchondral plate, controlled marrow stimulation, ideally through small holes, and critical patient selection..."

On Lesion Size

• [07:01] Dr. Kerkhoffs: "With larger lesions... these do not so well in more than 50% of cases. We stopped using BMS for these..."

On Cysts

• [11:18] Dr. Kerkhoffs: "Postoperative presence of these cysts was not correlated with clinical outcomes in any of these patients."

On Rehabilitation

• [30:52] Dr. Kerkhoffs: "Immediate weightbearing as tolerated from day one... allowing patients to self regulate based on symptoms and function."

On Elite Athlete Approach

• [33:36] Dr. Kerkhoffs: "...apply the same science, but the environment allows us a different pace."

On Training the Next Generation

• [37:47] Dr. Kerkhoffs: "...we expose students to orthopedics in the first year... invite them to join the team, present, and contribute."

On Dutch Resilience

• [13:46] Dr. Kerkhoffs: "It's a relatively smart way to live with the water and not just fight it."

Important Timestamps

| Segment | Topic | |-----------------|----------------------------------------------| | 01:17 | Summary of study design & findings | | 03:02 | Surgical tips for BMS | | 07:01 | Dealing with larger lesions | | 08:51 | Lesion location and outcomes | | 11:18 | Subchondral cysts and imaging | | 15:27 | Lesion containment | | 17:49 | Inclusion/exclusion criteria | | 19:08 | Study design limitations and RCT discussion | | 22:41 | 3- & 6-month recovery data points | | 24:21 | 2-year versus 1-year outcomes | | 27:25 | Duration of symptoms impact | | 30:52 | Rehabilitation details | | 33:36 | Protocol for elite athletes | | 36:19 | MCID explanation | | 37:47 | Training/mentoring young doctors |

Tone and Style

The conversation is scholarly but accessible, engaging listeners with both high-level technical discussion and practical tips. Dr. Kerkhoffs combines evidence-based recommendations with a pragmatic, patient-centered approach. Personal anecdotes about Dutch culture and orthopedic training add warmth and depth.

Conclusion

Immediate postoperative weightbearing following arthroscopic bone marrow stimulation for talar OLTs is at least as safe and effective as delayed protocols, possibly enabling faster return to work and sport, with no increased risk of adverse outcomes. Individualization—guided by lesion characteristics, patient goals, and practical reachability—remains key. Despite study limitations, these findings can inform clinicians and open the door to more permissive, patient-friendly rehabilitation protocols.

Dr. Kerkhoffs’s broader reflections highlight the value of early, hands-on orthopedic education, resiliency—both in the Dutch landscape and sports—and the collaborative nature of high-functioning orthopedic teams.

For further details and a deeper dive, consult the full episode or the original FAI publication.