Primary Versus Secondary Osteochondral Autograft Transplantation for the Treatment of Large Osteochondral Lesions of the Talus

Background: Recent studies have reported promising clinical results after osteochondral autograft transplantation (OAT) for the treatment of large osteochondral lesions of the talus (OLT). However, no study has yet compared clinical outcomes between primary and secondary OAT for large OLT. Purpose: To compare clinical outcomes among patients with large OLT who receive primary OAT versus those who receive secondary OAT after failure of marrow stimulation and to identify factors associated with clinical failure. Study Design: Cohort study; Level of evidence, 3. Methods: From 2005 to 2014, 46 patients with large OLT (≥150 mm²) underwent OAT: 18 underwent OAT as initial surgical management (primary OAT group), and 28 patients underwent secondary OAT after failure of previous arthroscopic marrow stimulation (secondary OAT group). In both groups, OAT procedures included arthroscopic inspection and debridement of concomitant soft tissue injuries. Clinical outcomes were assessed using pain visual analog scale (VAS), the Roles and Maudsley score, Foot and Ankle Outcome Scores (FAOS), and revisional surgery rates. Factors associated with clinical failures were evaluated using bivariate and logistic regression analyses. Survival outcomes were compared using Kaplan-Meier analysis. Results: Mean follow-up time was 6 years (range, 2-10.8 years). Mean lesion size was 194.9 mm² (range, 151.7-296.3 mm²). There were no significant differences between groups in patient demographics and preoperative findings. Postoperative pain VAS, Roles and Maudsley score, FAOS, and revisional surgery rates were not significantly different at last follow-up. Prior marrow stimulation was not significantly associated with clinical failure on bivariate analysis. Lesion size greater than 225 mm² on preoperative magnetic resonance imaging was significantly associated with clinical failure. Survival probabilities from Kaplan-Meier plots were not significantly different between the primary and secondary OAT groups (P =.947). Conclusion: Clinical outcomes of patients with large OLT treated with secondary OAT after failed marrow stimulation were found to be comparable with those who were treated with primary OAT. These results may be helpful to orthopaedic surgeons deciding appropriate surgical options for patients with large OLT.