Pediatric Osteochondral Lesions of the Talus: a Systematic Review and Treatment Algorithm

Osteochondral lesions of the talus (OLT) peak in incidence during childhood, yet there exists a paucity of research on treatment among skeletally immature populations due to their high potential for spontaneous recovery. Current guidelines on treatments are based on adult studies, which may differ in prognoses and outcomes compared to children. This paper compares outcomes across conservative and various surgical interventions for pediatric OLTs, with the synthesized evidence forming the basis of a treatment algorithm. An electronic literature search was conducted across PubMed, Embase, and MEDLINE databases for studies published prior to July 2023. The main outcomes were clinical and radiological success rates, obtained for each treatment method via simple pooling. Thirty-seven studies involving 797 lesions were included, with a mean MINORS score of 6.52 (range: 2 to 12). The clinical success rates were 51% for conservative treatment, 85% for bone marrow stimulation, 89% for retrograde drilling, 82% for fixation, and 74% for osteochondral transplantation. The radiological success rates, in the same order, were 58%, 85%, 61%, 89%, and 81%. Conservative treatments yielded lower clinical and radiological success rates than surgical interventions but warrant an initial trial in stable lesions. Surgery should be indicated for unstable lesions or failed conservative treatment. Drilling and bone marrow stimulation are effective in lower grade lesions, while fixation should be considered for loosened fragments and transplantation for large, non-salvageable lesions. Future research utilizing more robust methodology and reporting outcomes according to baseline lesion characteristics will consolidate these guidelines.