Arthroscopic autologous iliac crest cancellous bone grafting for Hepple stage V osteochondral lesions of the talus: a retrospective case series

BACKGROUND: Evidence regarding arthroscopic autologous iliac crest cancellous bone grafting for Hepple stage V osteochondral lesions of the talus (OLTs) remains limited. This study assessed short-term clinical outcomes, postoperative imaging findings, and perioperative characteristics of this technique. METHODS: This retrospective case series included 23 patients undergoing arthroscopic autologous iliac crest cancellous bone grafting between March 2020 and July 2024. Preoperative magnetic resonance imaging (MRI) and computed tomography (CT) demonstrated subchondral cystic changes in all lesions, which were classified as Hepple stage V OLTs. The primary outcome was the European Foot and Ankle Society (EFAS) score at final follow-up. Secondary outcomes included the Visual Analogue Scale (VAS) pain score during walking, the American Orthopaedic Foot & Ankle Society (AOFAS) score, Karlsson Ankle Functional Score (KAFS), 36-Item Short Form Health Survey (SF-36) pain domain score, Tegner score and ankle range of motion (ROM). Postoperative radiographs and available CT scans were reviewed to assess graft position and subchondral healing; MRI findings were also evaluated when available. Operative time, concomitant lateral ligament repair, and complications were documented. Paired comparisons were performed using the paired t-test or Wilcoxon signed-rank test, as appropriate after assessment of normality. Median operative time was 75.0 min (Q1-Q3, 67.5-86.0), and five patients underwent concomitant lateral ligament repair. The median EFAS score improved from 9.0 (Q1-Q3, 8.0-10.0) preoperatively to 19.0 (Q1-Q3, 18.0-20.0) at final follow-up (P < 0.001). All other clinical outcome measures also improved significantly (all P < 0.001). Radiographs obtained in all 23 patients demonstrated maintained graft position. Among the 17 patients who underwent postoperative CT, structural graft incorporation was observed in all cases. MRI was obtained in eight selected patients and demonstrated no graft displacement. No major complications were observed. One patient experienced transient mild donor-site pain that resolved with conservative treatment, whereas another had delayed recovery with mild residual ankle pain. CONCLUSIONS: Arthroscopic autologous iliac crest cancellous bone grafting was associated with improvements in pain, function, and activity in patients with Hepple stage V OLTs at short-term follow-up. Postoperative CT demonstrated graft incorporation in all patients who underwent CT assessment. These preliminary findings support the feasibility of this technique for appropriately selected cystic lesions, although larger comparative studies with longer follow-up are warranted.