Osteoperiosteal versus osteochondral for autologous transplantation in the treatment of large cystic osteochondral lesions of the talus

Liu et al. Journal of Orthopaedics and Traumatology (2025) 26:8 https://doi.org/10.1186/s10195-025-00818-1 ORIGINAL ARTICLE Journal of Orthopaedics and Traumatology Open Access Osteoperiosteal versus osteochondral for autologous transplantation in the treatment of large cystic osteochondral lesions of the talus Lequan Liu1*, Jiangtao Jin1, Jinping Pan1, Huikang Guo1, Sen Li1, Jisheng Li1 and Zheng Zhang1 Abstract Background Osteochondral lesions of the talus (OLTs) with a large subchondral cyst have been shown to have inferior clinical outcomes after reparative techniques. Replacement techniques such as autologous osteoperiosteal transplantation (AOPT) and autologous osteochondral transplantation (AOCT) are indicated for large lesions. The aim of the study was to compare the short-term clinical and radiographic outcomes between patients undergoing AOPT and those undergoing AOCT for large cystic OLTs. Methods Patients who underwent AOPT or AOCT for medial large cystic OLTs between May 2019 and June 2023 were retrospectively evaluated. According to their characteristics, 1:1 propensity‐score matching was performed, and 65 pairs of patients with ages ranging from 18 to 60 years old were recruited. Clinical outcomes were compared between both groups with the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score and Visual Analogue Scale (VAS). The Ankle Activity Score (AAS), time to return to sports activity (RTA), rate of return to sports level, complications, and results of a subjective evaluation were also collected. The integrity of subchondral bone and the quality of repaired cartilage were evaluated using the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score 12 months postoperatively. Second-look arthroscopy was performed 12 months postoperatively, and the cartilage repair was assessed with the criteria of the International Cartilage Repair Society (ICRS). Results The within-group comparison showed significant improvements in pain severity and function in both groups post-treatment compared with pre-treatment. Between-group analysis, however, showed no significant statistical difference between groups in any of the variables for clinical and radiographic outcomes, except for donor-site morbidity of the AOPT group, which showed a better outcome compared to the AOCT group. Conclusions In the treatment of large cystic OLTs, for patients with a chondral lesion of the patellofemoral joint that is unsuitable for AOCT, AOPT may be a safe and effective choice, with lower donor-site morbidity of the normal knee joint. Keywords Osteochondral lesion, Talus, Osteoperiosteal, Transplantation *Correspondence: Lequan Liu 1 Arthroplasty Dept, Jincheng General Hospital, 1st Kangping Road, Beishidian Area, Jincheng 048006, Shanxi, People’s Republic of China Introduction Osteochondral lesion of the talus (OLT) has been recognized as an increasingly common injury that usually occurs in acute ankle sprains, chronic ligament instability, and fractures [1, 2]. An OLT is an injury to cartilage and/or subchondral bone that may cause deep chronic ankle pain, swelling, stiffness, limited mobility, and even disability [3]. © The Author(s) 2025. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. Liu et al. Journal of Orthopaedics and Traumatology (2025) 26:8 Several studies have reported that this lesion responds poorly to nonsurgical treatment and requires bone marrow stimulation or abrasion arthroplasty, with satisfactory clinical outcomes [4, 5]. However, Shimozono et al. found that subchondral cysts had a negative impact on clinical scores after surgery [6]. Although OLTs with small cysts could be treated effectively with microfracture or abrasion arthroplasty, lesions with a large subchondral cyst (with a diameter larger than 10 mm) may require replacement techniques such as autologous osteoperiosteal transplantation (AOPT) and autologous osteochondral transplantation (AOCT) [7, 8]. In the reconstruction of osteochondral defects, AOCT can provide bone and cartilage in the form of a plug and restore the weight-bearing ability of the talus [9]. AOCT has shown superior clinical outcomes when used to treat large cystic OLTs; however, donor-site morbidity of the normal knee is still a concerning complication. To date, according to published clinical studies of patients who received AOCT to treat large cystic OLTs, the percentage of patients with donor-site morbidity ranges from 0 to 54.5% [10, 11]. Recently, more and more surgeons have tried to repair large cystic OLTs with AOPT because of its low cost and the absence of donor-site morbidity in the knee [10]. In addition, Shi et al. have reported that AOPT shows favourable clinical outcomes and permits satisfactory incorporation of grafts into the tissue adjacent to this lesion [10]. However, to our knowledge, few studies have compared the clinical outcomes of AOPT and AOCT when they are used to treat OLTs with large cysts. The primary purpose of this study was to investigate and compare the short-term clinical and radiographic outcomes of patients undergoing AOPT with those of patients undergoing AOCT for large cystic OLTs. We hypothesized that both procedures offered satisfactory results for the treatment of patients with large cystic OLTs and that donor-site morbidity of the knee occurred less frequently in the AOPT group than in the AOCT group. Page 2 of 8 The inclusion criteria were as follows: (1) patients diagnosed with medial large cystic OLTs; (2) a lack of response to at least 3 months of nonsurgical treatment; (3) the diameter of the subchondral cyst was larger than 10 mm. The exclusion criteria were as follows: (1) obvious structural malalignment (varus or valgus deformity of the ankle of more than 5°); (2) moderate and severe osteoarthritis; (3) systemic diseases, such as rheumatoid arthritis and gouty arthritis. Surgical intervention All patients underwent diagnostic arthroscopy to diagnose a medial large cystic OLT after spinal anesthesia in the supine position. Moreover, the surface of the lesion was debrided. The centre of the defect was determined and drilled perpendicularly with a 2-mm (...truncated)