Ronny Lopes1, Teodor Negru1, Alexandre Hardy2, Hasan Basri Sezer2

1Health Atlantic, Chirurgie Du Sport, Saint Herblain, France
2Clinique Du Sport Paris, Chirurgie Du Sport, Paris, France

Keywords: Ankle arthroscopy, distal tibial, osteochondral autograft, osteochondral lesion, plafond, 3D fluoroscopy.


Graft failures of the tibial plafond are very rare. This article presents the technique of precise antegrade osteochondral auto-grafting under three-dimensional (3D) fluoroscopy. A 20-year-old athletic patient with a recurrent osteochondral lesion of the tibial plafond on a first osteochondral autograft after two years of follow-up was admitted. The revision osteochondral autograft was performed under real-time perioperative arthroscopic and 3D fluoroscopic control for greater precision. Surgery was followed by six weeks of non-weight-bearing in a walking boot. At one-year follow-up, the patient was effusion and pain free and returned to his previous activity level completely. Revision osteochondral autografting under arthroscopic and 3D fluoroscopic control seems to be an effective therapeutic option.


Osteochondral lesions of the tibial plafond are extremely rare and their true incidence is difficult to estimate.[1-3] Most osteochondral lesions of the ankle involve the talar dome. Involvement of the tibial plafond is rare.[1] Surgical management of these lesions is technically difficult due to limited access either with open surgery or arthroscopy.[2] To the best of our knowledge, there are no published cases in the literature describing a second anterograde osteochondral autograft application in the tibial plafond.[4] The present case study includes bilateral, symmetric defects which have only been reported once in the literature.[5] This report includes revision surgery of one side, the non-symptomatic side was followed by observation.

Similar to other osteochondral lesions of the talus, there are numerous possible etiologies of, particularly traumatic, vascular, necrotic or metabolic origin. The bilateral and perfectly symmetric location of these defects suggest a genetic origin which has also been described in talar lesions.[6-11] Baldassarri et al.[12] identified a history of trauma in 55% of cases, while 25% of the cases in the series by Cuttica et al.[1] were considered to be idiopathic.

Ross et al.[13] identified distribution of osteochondral lesions of the tibial plafond as 3% in zones 3 and 9, and up to 19 and 23% in zones 1 and 4. Elias et al.[14] found the same distribution in an magnetic resonance imaging (MRI) analysis of 38 lesions, with medial lesions in 38%, central lesions in 32%, and lateral lesions in 30%.

Numerous treatments reported in the literature for the treatment of these lesions are summarized in Table I which includes seven case reports,[15-21] one technical report,[22] and nine clinical series.[1-3,12,13,23-26]

Kissing lesions first described by Canosa,[15] also reported in other series,[1,16] are two-sided osteochondral injuries which is a different entity which requires a different treatment strategy. In this study, the osteochondral lesion was tibial sided and the talar dome was preserved.

This report is an original case of revision surgery of the tibial plafond using a second osteochondral autograft following anterograde osteochondral autograft failure in a young athlete. Surgery was performed under arthroscopic and 3D fluoroscopic control to obtain the best graft positioning.

Case Report

A 20-year-old male patient presented with pain and swelling of the left ankle. Initial imaging results showed a bilateral osteochondral lesion of the tibial plafond that was only symptomatic in the left ankle. Initial medical management that included non-weightbearing, discontinuation of sports, physical therapy, cortisone, and platelet-rich plasma injections was unsuccessful. The lesion of the left ankle measuring 1 cm2 and 6 mm in depth was treated surgically. An osteochondral autograft harvested from the lateral trochlea was applied to the tibial osteochondral lesion in an anterograde fashion under arthroscopic control. One-year clinical, radiological, and computed tomography (CT) follow-up was satisfactory (Figure 1) and the patient returned to sports (football) at the same level of play. At 24 months of follow-up, the patient presented with recurrence of initial exercise-induced pain and joint swelling symptoms. Imaging tests (X-ray, arthrogram, computed tomography and scintigraphy) identified a new osteochondral lesion of 6 mm in diameter originating at the margin of the anterolateral side of the primary graft (Figures 2-4).

A revision osteochondral surgery was planned due to the patient’s young age and high activity level besides the size and type of lesion. In the presence of a subchondral cyst to fill the defect, to perfectly restore the subchondral bone and the cartilage a revision osteochondral autograft was considered.

Under general anesthesia, the patient was placed in the supine position with the feet extending beyond the operating table. Ankle was placed in the neutral position and contralateral lower limb was lowered. A thigh tourniquet was applied. Prophylactic antibiotics were administered. Standard anteromedial and anterolateral portals were used. The chondral defect was identified, explored arthroscopically and measured to be 6 mm in diameter (Figure 5).

To install the O-armTM fluoroscopic guidance system (Medtronic Inc., MN, USA), firstly the reference frame was applied to the anteromedial side of the distal tibia with two Schanz pins and with an upward inclination to facilitate access of the receiver. Proper positioning and fixation of the reference frame was verified with O-arm. The entry point and the optimal trajectory to reach the lesion which was planned preoperatively based on 3D reconstructions were determined with the help of fluoroscopic guidance system (Figure 6). From a 2-cm longitudinal anterolateral incision, 2.4 mm drill bit of the Osteochondral Autograft Transfer System (OATS) (Arthrex, Naples, FL, USA) was inserted based on O-arm (Medtronic Inc., MN, USA) recommendations.

The center of the defect (Figure 7) was drilled with a 6-mm reamer as decided by pre- and intraoperative planning. Proper placement of the guide and reamer was checked arthroscopically, as well.

An osteochondral plug of 6 mm in diameter was harvested from the donor site of the superolateral trochlea through a 2 cm incision on the previous parapatellar scar. This step had to be performed with care to obtain matched chondral plugs with the reamed tunnel. Preoperative planning revealed a plug which was presumed to have an inclination angle of 40° with the articular surface.

The graft was implanted in an antegrade fashion taking care to keep the angle of the harvested plug, in line with the receiver site to reconstruct the joint line (Figure 8). Real-time arthroscopic view (Figure 9) and 3D fluoroscopic images were used to verify the final placement of the osteochondral autograft (Figure 10).

At one-year follow-up, the patient had no signs of inflammation in the left ankle and the patient was completely pain free with a full range of motion.

The patient was informed that data concerning the case would be submitted for publication, and he provided consent.


The presented case is very rare. Cuttica et al.[1] reported one osteochondral lesion of the tibial plafond in a series of 14 to 20 osteochondral lesions of the heel. A consecutive series of 880 arthroscopies of the ankle revealed 2.6% when all indications were included,[2] while another evaluated a series of 31 chondral defects of the ankle and revealed 6.4% when talar and tibial osteochondral lesions were included.[3]

Our patient’s initial defect located at the intersection of zones 2,3,5,6 described by Cuttica et al.[1] The right and left defects were located in exactly the same place (Figure 11). The only other bilateral lesions described in the literature[5] were in a more anterior position. Ross et al.[13] identified distribution of osteochondral lesions of the tibial plafond as 3% in zones 3 and 9, and up to 19 and 23% in zones 1 and 4. Elias et al.[14] found the same distribution in an MRI analysis of 38 lesions, with medial lesions in 38%, central lesions in 32% and lateral lesions in 30%. Baldassarri et al.,[12] who found a majority of medial lesions, (55%) suggested that there was a direct relationship between these lesions and a traumatic event during inversion of the ankle.

The advantages and the quality of the harvested osteochondral graft have been reported for the tibial plafond in two articles (a total of four patients).[17,23] One case report describes poor results after osteochondral autograft implantation for a central lesion of the tibial plafond following failure of a cancellous bone graft in a 14-year-old child. However, details of the surgical intervention were not presented.[1]

In this case, the entry point and drilling trajectory were planned based on the preoperative CT; the trajectory of the osteochondral autograft was planned to be divergent to primary autograft and in the center of the new lesion which was located at the margin of the first lesion (Figure 12). The 3D O-arm navigation system was used to optimize the final orientation of the autograft. The use of this system has been well documented in traumatic foot and ankle injuries mainly in the treatment of calcaneal fractures.[27] Other uses have been reported for arthrodesis of the hind-foot,[28] ankle arthroplasties[29] and talocalcaneal coalition resection.[30] The use of this system to navigate osteochondral graft placement in distal tibia has not been described. Alignment of the autograft and receiver site subchondral bones was achieved with precision with the aid of O-Arm guidance (Figure 10).

In conclusion, this is the first case of a revision antegrade osteochondral autograft transfer to treat a recurrent lesion of the tibial plafond which emerged at the edge of the first lesion, two years after a first osteochondral autograft, under dual perioperative control with ankle arthroscopy and 3D fluoroscopic guidance.

Citation: Lopes R, Negru T, Hardy A, Sezer HB. Arthroscopic revision of osteochondral autograft in distal tibia: A case report demonstrating precision of intraoperative 3D fluoroscopy. Jt Dis Relat Surg 2022;33(1):238-244.

Conflict of Interest

The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.

Financial Disclosure

The authors received no financial support for the research and/or authorship of this article.


  1. Cuttica DJ, Smith WB, Hyer CF, Philbin TM, Berlet GC. Arthroscopic treatment of osteochondral lesions of the tibial plafond. Foot Ankle Int 2012;33:662-8.
  2. Mologne TS, Ferkel RD. Arthroscopic treatment of osteochondral lesions of the distal tibia. Foot Ankle Int 2007;28:865-72.
  3. Bauer M, Jonsson K, Lindén B. Osteochondritis dissecans of the ankle. A 20-year follow-up study. J Bone Joint Surg [Br] 1987;69:93-6.
  4. Atik OŞ. What are the expectations of an editor from a scientific article? Jt Dis Relat Surg 2020;31:597-8.
  5. Sopov V, Liberson A, Groshar D. Bilateral distal tibial osteochondral lesion: A case report. Foot Ankle Int 2001;22:901-4.
  6. Mubarak SJ, Carroll NC. Familial osteochondritis dissecans of the knee. Clin Orthop Relat Res 1979;(140):131-6.
  7. PICK MP. Familial osteochondritis dissecans. J Bone Joint Surg [Br] 1955;37-B:142-5.
  8. Hammett RB, Saxby TS. Osteochondral lesion of the talus in homozygous twins--the question of heredity. Foot Ankle Surg 2010;16:e55-6.
  9. 9 Woods K, Harris I. Osteochondritis dissecans of the talus in identical twins. J Bone Joint Surg [Br] 1995;77:331.
  10. Anderson DV, Lyne ED. Osteochondritis dissecans of the talus: Case report on two family members. J Pediatr Orthop 1984;4:356-7.
  11. Erban WK, Kolberg K. Simultaneous mirror image osteochondrosis dissecans in identical twins. Rofo 1981;135:357.
  12. Baldassarri M, Perazzo L, Ricciarelli M, Natali S, Vannini F, Buda R. Regenerative treatment of osteochondral lesions of distal tibial plafond. Eur J Orthop Surg Traumatol 2018;28:1199-207.
  13. Ross KA, Hannon CP, Deyer TW, Smyth NA, Hogan M, Do HT, et al. Functional and MRI outcomes after arthroscopic microfracture for treatment of osteochondral lesions of the distal tibial plafond. J Bone Joint Surg [Am] 2014;96:1708-15.
  14. Elias I, Raikin SM, Schweitzer ME, Besser MP, Morrison WB, Zoga AC. Osteochondral lesions of the distal tibial plafond: Localization and morphologic characteristics with an anatomical grid. Foot Ankle Int 2009;30:524-9.
  15. Canosa J. Mirror image osteochondral defects of the talus and distal tibia. Int Orthop 1994;18:395-6.
  16. 16 Pearce CJ, Lutz MJ, Mitchell A, Calder JD. Treatment of a distal tibial osteochondral lesion with a synthetic osteochondral plug: A case report. Foot Ankle Int 2009;30:900-3.
  17. Okamura K, Sugimoto K, Isomoto S, Samoto N, Yoneda A, Tsukada N, et al. Osteochondral lesion of the tibial plafond treated with a retrograde osteochondral autograft: A report of two cases. Asia Pac J Sports Med Arthrosc Rehabil Technol 2017;8:8-12.
  18. Hayashi K, Tanaka Y. Arthroscopic antegrade cancellous bone autotransplantation for osteochondral lesions of the tibial plafond. Arthrosc Tech 2019;8:e875-e881.
  19. Desai S. Surgical treatment of a tibial osteochondral defect with debridement, marrow stimulation, and micronized allograft cartilage matrix: Report of an all-arthroscopic technique. J Foot Ankle Surg 2016;55:279-82.
  20. Corso M, DeGraauw C, Hsu W. Osteochondral lesion of the distal tibial plafond in an adolescent soccer player: A case report. J Can Chiropr Assoc 2017;61:261-8.
  21. Chapman CB, Mann JA. Distal tibial osteochondral lesion treated with osteochondral allografting: A case report. Foot Ankle Int 2005;26:997-1000.
  22. Johnson NR, Skinner S, Haleem AM. All-arthroscopic treatment of dependent osteochondral lesions of the ankle: Surgical technique. J Foot Ankle Surg 2017;56:613-7.
  23. Ueblacker P, Burkart A, Imhoff AB. Retrograde cartilage transplantation on the proximal and distal tibia. Arthroscopy 2004;20:73-8.
  24. Parisien JS, Vangsness T. Operative arthroscopy of the ankle. Three years' experience. Clin Orthop Relat Res 1985;(199):46-53.
  25. Lee W, Tran S, Cooper MT, Park JS, Perumal V. Clinical outcomes of osteochondral lesions of the tibial plafond following arthroscopic microfracture. Foot Ankle Int 2019;40:1018-24.
  26. Bui-Mansfield LT, Kline M, Chew FS, Rogers LF, Lenchik L. Osteochondritis dissecans of the tibial plafond: Imaging characteristics and a review of the literature. AJR Am J Roentgenol 2000;175:1305-8.
  27. Rübberdt A, Hofbauer VR, Herbort M, Löhrer L, Ochman S, Raschke MJ. 3D navigated osteosynthesis of calcaneal fractures. Open and minimally invasive techniques. Unfallchirurg 2009;112:15-22.
  28. Richter M, Zech S. Computer Assisted Surgery (CAS) guided arthrodesis of the foot and ankle: An analysis of accuracy in 100 cases. Foot Ankle Int 2008;29:1235-42.
  29. Reb CW, Berlet GC. Experience with navigation in total ankle arthroplasty. Is it worth the cost? Foot Ankle Clin 2017;22:455-63.
  30. Aibinder WR, Young EY, Milbrandt TA. Intraoperative three-dimensional navigation for talocalcaneal coalition resection. J Foot Ankle Surg 2017;56:1091-4.