Association Between MRI-Based Cartilage Repair Morphology and Clinical Outcomes After Osteochondral Autograft Transfer of the Talus

Abstract

Background:

Osteochondral lesions of the talus (OLT) represent a challenging ankle pathology that may lead to persistent pain, functional impairment, and progressive joint degeneration. Open transmalleolar osteochondral autograft transfer (OAT) is a well-established treatment option for selected lesions; however, the relationship between postoperative magnetic resonance imaging (MRI)–based cartilage repair morphology and clinical outcomes remains incompletely understood.

Methods:

A retrospective review was performed of 17 patients who underwent open transmalleolar OAT for symptomatic OLT between May 2021 and March 2025, with a mean follow-up of 20.8 months (range, 6-34 months). Clinical outcomes were assessed using the visual analogue scale (VAS) and the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score. Postoperative cartilage repair morphology was evaluated using MRI and graded according to the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART 2.0) scoring system. MRI examinations were independently reviewed by 2 blinded musculoskeletal radiologists, and the mean MOCART 2.0 score was used for final analysis. Associations between clinical and radiologic parameters were analyzed using Spearman rank correlation.

Results:

Significant postoperative clinical improvement was observed. Mean VAS scores decreased from 6.6 ± 1.5 preoperatively to 1.7 ± 1.3 at final follow-up (P < .001), whereas mean AOFAS scores increased from 58.4 ± 8.0 to 88.3 ± 9.3 (P < .001). Postoperative MRI demonstrated a mean MOCART 2.0 score of 70.4 ± 9.7, indicating satisfactory structural cartilage repair. Interobserver reliability for MOCART 2.0 scoring was excellent (ICC = 0.92). No significant correlations were identified between MOCART 2.0 scores and clinical outcome measures or patient-related variables.

Conclusion:

Open transmalleolar OAT provides significant clinical improvement in carefully selected patients with OLT. However, postoperative MRI-based cartilage repair morphology assessed by MOCART 2.0 does not appear to directly correlate with clinical outcomes, suggesting that structural repair and patient-reported recovery may represent distinct dimensions of treatment response.

Level of Evidence:

Level IV, retrospective review.

Keywords

ankle AOFAS MOCART 2.0 osteochondral autograft transfer osteochondral lesion of the talus

Introduction

Osteochondral lesions of the talus (OLT) constitute a complex ankle pathology involving concomitant damage to the articular cartilage and underlying subchondral bone, and typically manifest with chronic ankle pain, recurrent joint effusion, mechanical symptoms, and functional impairment, resulting in reduced weight-bearing tolerance and diminished health-related quality of life.^1-3 In the absence of appropriate treatment, progressive osteochondral degeneration may advance and lead to ankle osteoarthritis accompanied by clinically relevant functional impairment.^4-6 Given the limited intrinsic reparative capacity of hyaline cartilage and the pivotal biomechanical function of the talar dome in axial load transmission, restoration of the osteochondral unit constitutes a fundamental therapeutic objective.^7,8 Accordingly, surgical intervention is commonly indicated in symptomatic patients despite adequate conservative management, aiming to achieve pain relief, functional restoration, and durable preservation of ankle joint integrity.⁹

Several surgical treatment modalities have been described for OLT, including bone marrow stimulation techniques (microfracture or drilling), fixation of osteochondral fragments when feasible, osteochondral autograft transfer, and cell- or scaffold-based cartilage repair strategies, with procedural selection primarily determined by lesion size, containment, cystic characteristics, and anatomical location.^10-12 Among these options, osteochondral autograft transfer (OAT) can be performed using either arthroscopic or open transmalleolar approaches; however, the optimal surgical approach remains controversial and is largely influenced by lesion characteristics. Although arthroscopic techniques have gained popularity because of reduced soft tissue morbidity and faster early recovery, they may be suboptimal for large, deep, cystic, or posteriorly located lesions, in which achieving perpendicular graft insertion and precise articular surface congruity can be technically challenging and not consistently reproducible across all clinical settings.¹³

As postoperative evaluation increasingly incorporates structural assessment of cartilage repair following surgical treatment of OLT, magnetic resonance imaging (MRI) has assumed an important role in outcome analysis. MRI-based scoring systems, including the MOCART and its updated version, MOCART 2.0, provide standardized and reproducible assessment of repair tissue morphology. However, the extent to which these morphologic MRI parameters translate into clinically meaningful improvements in pain relief, function, and overall recovery remains uncertain. Reported associations between postoperative MRI findings and clinical outcome measures have been variable, limiting the interpretability and prognostic value of cartilage repair morphology in talar osteochondral reconstruction. Given the increasing reliance on postoperative MRI in clinical practice, further clarification of this relationship remains clinically relevant.^14,15

The present study aimed to investigate the association between postoperative cartilage repair morphology on MRI, as quantified by the MOCART 2.0 scoring system, and clinical outcome measures following transmalleolar OAT transfer for OLT.

Methods

We conducted a retrospective review of 17 patients who underwent transmalleolar OAT for symptomatic OLT, at a single institution, between May 2021 and March 2025. Eligible patients had symptomatic talar osteochondral defects confirmed by ankle radiographs (Figure 1A) and/or MRI (Figure 1, B and C) and a minimum postoperative follow-up of 6 months. Exclusion criteria were previous surgery on the affected ankle, advanced ankle osteoarthritis, inflammatory or rheumatologic disease, ankle instability requiring concomitant ligament reconstruction, active infection, incomplete clinical or radiologic records, or follow-up shorter than 6 months. All surgical procedures were performed by a single orthopaedic surgeon using a standardized surgical technique. Patient data were retrospectively obtained from archived hospital records and radiologic examinations stored within the hospital’s Picture Archiving and Communication System (PACS). Demographic variables, including age, sex, body mass index (BMI), symptom duration, lesion localization, operated side, and follow-up duration, were recorded for all patients. All participants were thoroughly informed about the study and provided written informed consent for the use of their clinical data. The study was conducted in accordance with the principles of the Declaration of Helsinki and received approval from the local institutional ethics committee.

Figure 1.

Preoperative and postoperative imaging of a talar osteochondral lesion treated with transmalleolar osteochondral autograft transfer. (A) Preoperative ankle radiograph demonstrating an osteochondral defect of the medial talar dome. (B) Preoperative coronal MRI demonstrating involvement of the subchondral bone in an osteochondral lesion of the medial talar dome (circled). (C) Preoperative sagittal MRI showing the depth and extent of the talar osteochondral defect (circled), highlighting subchondral bone involvement. (D) Postoperative ankle radiograph demonstrating stable medial malleolar osteotomy fixation with satisfactory graft integration after transmalleolar osteochondral autograft transfer. MRI, magnetic resonance imaging.

Surgical Procedure

All surgical procedures were performed under spinal anesthesia with the patient in the supine position and a pneumatic thigh tourniquet applied. A standard transmalleolar surgical approach was used in all cases. Depending on the location of the osteochondral lesion, either a medial or lateral malleolar osteotomy was performed to obtain adequate exposure of the talar dome and allow perpendicular access to the osteochondral defect (Figure 2A). Following exposure, unstable cartilage and necrotic subchondral bone were debrided until a stable, well-contained defect with vertical margins was obtained (Figure 2B). The size of the osteochondral defect was assessed intraoperatively by referencing the diameter of the osteochondral harvesting system. The recipient site was prepared to a depth of approximately 10 mm, corresponding to the length of the osteochondral plugs, until healthy, bleeding subchondral bone was encountered to ensure stable press-fit fixation.

Figure 2.

Intraoperative steps of transmalleolar osteochondral autograft transfer. (A) Exposure of the medial talar dome following medial malleolar osteotomy, revealing the osteochondral defect. (B) Debridement of unstable cartilage and necrotic subchondral bone to create a stable, well-contained recipient site with vertical margins. (C) Harvested cylindrical osteochondral autograft obtained from a non–weight-bearing region of the ipsilateral knee. (D) Press-fit implantation of the osteochondral autograft plug(s) into the prepared recipient site of the talar dome, restoring articular surface congruity.

Transmalleolar OAT was subsequently performed using a commercially available osteochondral harvesting and implantation system (Arthrex). Osteochondral plugs of appropriate diameter and length were harvested from a non–weight-bearing area of the ipsilateral knee to match the prepared recipient site (Figure 2C). One or 2 plugs, depending on defect size and geometry, were transplanted into the talar defect in a press-fit manner (Figure 2D). Particular attention was paid to restoring articular surface congruity and avoiding step-off formation. Following graft implantation, the malleolar osteotomy was anatomically reduced and stabilized. In patients who were undergoing lateral malleolar osteotomy, fixation was achieved using a plate-and-screw construct, whereas medial malleolar osteotomies were stabilized with headless cannulated screws. Final stability of both the osteochondral grafts and the osteotomy fixation was confirmed intraoperatively under fluoroscopic guidance. The wound was thoroughly irrigated and closed in layers in a standard fashion.

Postoperative Period

Postoperatively, all patients followed a standardized rehabilitation and follow-up protocol. The operated ankle was immobilized in a short leg splint to facilitate soft tissue healing and protection of the malleolar osteotomy site. All patients were discharged on the first postoperative day. Passive and active-assisted ankle range-of-motion exercises were initiated at the third postoperative week following splint removal and wound healing. Partial weight-bearing with crutches was initiated at the fourth postoperative week, and full weight-bearing was permitted after the sixth postoperative week based on clinical tolerance and radiographic evidence of osteotomy union. After achieving full weight-bearing, strengthening exercises, proprioceptive training, and progressive functional rehabilitation were introduced in a stepwise manner. High-impact activities, running, and sports participation were restricted for a minimum of 3 months postoperatively. Follow-up assessments were conducted at 3 and 6 weeks postoperatively to evaluate wound healing and osteotomy stability, followed by evaluations at 3, 6, and 12 months, and subsequently at 6-month intervals.

Outcome Assessment

Clinical outcomes were assessed using the visual analogue scale (VAS) and the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score. These assessments were recorded preoperatively and at the final follow-up visit. Radiologic evaluation of cartilage repair tissue was performed using postoperative MRI. Postoperative MRI evaluations were based on the most recent follow-up visit of each patient rather than a standardized imaging time point, reflecting routine clinical practice in this retrospective cohort. In addition, follow-up ankle radiographs obtained at 6 months were used to assess malleolar osteotomy union and graft integration (Figure 1D). Cartilage repair quality was assessed according to the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART 2.0) scoring system (Figure 3). All MRI examinations were independently reviewed by 2 experienced musculoskeletal radiologists, both of whom were blinded to the clinical outcomes and each other’s assessments. For each patient, the mean MOCART 2.0 score obtained from the 2 independent evaluations was used for the final radiologic analysis. Interobserver reliability for MOCART 2.0 scoring was assessed to determine the consistency between the 2 observers. In addition, postoperative complications were recorded for all patients, including superficial wound infection, transient postoperative ankle swelling, and transient sensory disturbances.

Figure 3.

Postoperative MOCART 2.0 assessment after osteochondral autograft transfer of the talus. (A) Coronal proton density–weighted fat-suppressed image demonstrating complete defect filling and complete graft integration with the adjacent cartilage and subchondral bone. (B) Sagittal fat-suppressed (STIR) image demonstrating preserved surface congruity of the repair tissue with minimal residual bone marrow edema. (C) Sagittal T1-weighted image demonstrating subchondral bone remodeling without significant bony defect, overgrowth, or subchondral cysts. Based on the postoperative 24-month MRI evaluation, the MOCART 2.0 ankle score for this patient was 90 points, indicating excellent osteochondral repair tissue quality. MOCART, Magnetic Resonance Observation of Cartilage Repair Tissue scoring system.

Statistical Analysis

Statistical analyses were conducted using SPSS for Windows, version 25.0. The normality of the distribution of continuous variables was assessed using the Shapiro-Wilk test, and a P value greater than .05 was considered indicative of a normal distribution. Descriptive statistics were reported as mean ± SD for normally distributed variables and as median with minimum and maximum values for non-normally distributed variables. Categorical variables were presented as frequencies and percentages.

Paired preoperative-postoperative comparisons were performed to evaluate changes in clinical outcome measures. When normality assumptions were met, such as in the evaluation of pre- and postoperative AOFAS scores, the paired t test was used. When normality assumptions were not satisfied, as in the comparison of VAS scores, the Wilcoxon signed-rank test was applied. The relationships between continuous variables—including VAS, AOFAS, MOCART scores, BMI, and symptom duration—were assessed using the Spearman rank correlation coefficient. Categorical variables such as sex, operated side, and talar lesion localization were summarized using frequency-based descriptive statistics, and comparisons across multiple lesion localization groups were performed using the Kruskal-Wallis test because of unequal group sizes and non-normal data distribution. Because no significant differences were identified, post hoc pairwise testing with Bonferroni correction was not required. A P value <.05 was considered statistically significant.

Interobserver reliability for MOCART 2.0 scores was assessed using the intraclass correlation coefficient (ICC) based on a 2-way random effects model with absolute agreement. ICC values were interpreted according to established guidelines, with values greater than 0.75 indicating good reliability and values greater than 0.90 indicating excellent reliability.

A post hoc power analysis was performed using G Power based on the observed preoperative-postoperative changes in VAS and AOFAS scores. The analysis demonstrated that with an α of 0.05 and a sample size of 17 patients, the study achieved a statistical power greater than 0.99 for detecting the observed effect sizes.

Results

A total of 17 patients meeting the inclusion criteria were included in the study. The cohort was predominantly male (64.7%), with a mean age of 35.0 years. Lesions were most frequently located on the medial talar dome, observed in 13 patients (76.5%). The operated ankles showed a similar distribution between the right and left sides (52.9% and 47.1%, respectively). The mean follow-up duration was 20.8 months (range, 6-34 months). Demographic characteristics are summarized in Table 1.

Table 1.

Demographic Characteristics and Pre- and Postoperative Clinical and Radiologic Findings.

Variable	Value	P Value
Sex: male/female, n (%)	11 (64.7 %) / 6 (35.3 %)
Age, y, mean ± SD (range)	35.0 ± 7.7 (24-55)
Operated side, n (%)
Right	9 (52.9 %)
Left	8 (47.1 %)
BMI, mean ± SD (range)	26.9 ± 3.0 (22.6-32.4)
Symptom duration, mo, mean ± SD (range)	19.2 ± 11.0 (3-34)
Lesion localization, n (%)
Medial talar dome	13 (76.5 %)
Lateral talar dome	3 (17.6 %)
Central talar dome	1 (5.9 %)
Duration of surgery, min, mean ± SD (range)	73.9 ± 17.2 (58-115)
Follow-up duration, mo, mean ± SD (range)	20.8 ± 10.5 (6-34)
VAS, mean ± SD (range)		<.001^a
Preoperative	6.6 ± 1.5 (4-9)
Postoperative	1.7 ± 1.3 (0-4)
AOFAS score, mean ± SD (range)		<.001^b
Preoperative	58.4 ± 8.0 (40-69)
Postoperative	88.3 ± 9.3 (66-97)
Postoperative MOCART 2.0 score, mean ± SD (range)	70.4 ± 9.7 (60-90)

Abbreviations: AOFAS, American Orthopaedic Foot & Ankle Society ankle-hindfoot score; BMI, body mass index; MOCART, Magnetic Resonance Observation of Cartilage Repair Tissue; VAS, visual analogue scale.

Wilcoxon signed-rank test.

Paired t test.

Statistically significant postoperative improvements were observed in the evaluated clinical outcome measures. The mean VAS score significantly decreased from 6.6 ± 1.5 preoperatively to 1.7 ± 1.3 at the final follow-up, corresponding to a mean improvement of 4.9 points (95% CI, 4.0-5.9; P < .001). Similarly, the mean AOFAS score improved from a preoperative value of 58.4 ± 8.0 to 88.3 ± 9.3 postoperatively, with a mean increase of 29.9 points (95% CI, 25.7-34.0; P < .001). Postoperative MRI assessment demonstrated a mean MOCART 2.0 score of 70.4 ± 9.7, reflecting satisfactory structural cartilage repair (Table 1). Interobserver reliability analysis showed excellent agreement between the 2 radiologists for MOCART 2.0 scoring (ICC = 0.92; 95% CI, 0.86-0.96).

Spearman rank correlation analysis was performed to evaluate associations between clinical and radiologic parameters. No significant correlation was observed between preoperative VAS and AOFAS scores (ρ = −0.18, P = .48), nor between postoperative VAS and AOFAS scores (ρ = −0.43, P = .09). In addition, a weak negative correlation was noted between postoperative VAS scores and MOCART 2.0 scores; however, this association did not reach statistical significance (ρ = −0.37, P = .14). Postoperative AOFAS and MOCART 2.0 scores were likewise not significantly correlated (ρ = 0.23, P = .37). Symptom duration showed no association with either postoperative AOFAS scores (ρ = −0.16, P = .54) or MOCART 2.0 scores (ρ = 0.06, P = .81). BMI demonstrated a moderate negative trend toward lower postoperative AOFAS scores (ρ = −0.47, P = .06), although this did not reach statistical significance. No significant relationship was identified between BMI and postoperative MOCART 2.0 scores (ρ = −0.22, P = .39) (Table 2).

Table 2.

Correlation Analysis Between Clinical and Radiologic Parameters.

Variable	Correlation Coefficient (ρ)	P Value	Interpretation
Preop. VAS vs preop. AOFAS	−0.18	.48	No statistically significant correlation
Postop. VAS vs postop. AOFAS	−0.43	.09	Moderate negative trend; not statistically significant
Postop. VAS vs postop. MOCART	−0.37	.14	No statistically significant correlation
Postop. AOFAS vs postop. MOCART	0.23	.37	No statistically significant correlation
Symptom duration vs postop. AOFAS	−0.16	.54	No statistically significant correlation
Symptom duration vs postop. MOCART	0.06	.81	No statistically significant correlation
BMI vs postop. AOFAS	−0.47	.06	Moderate negative trend; near-significant
BMI vs postop. MOCART	−0.22	.39	No statistically significant correlation

Abbreviations: AOFAS, American Orthopaedic Foot & Ankle Society; BMI, body mass index; MOCART, Magnetic Resonance Observation of Cartilage Repair Tissue; VAS, visual analogue scale.

No major complications were observed during the follow-up period. One patient developed a superficial wound infection, which was managed with oral antibiotic therapy and resolved within 4 weeks. One patient experienced transient sensory disturbance localized to the dorsomedial aspect of the foot, which resolved spontaneously within 8 weeks. In addition, transient postoperative ankle swelling was observed in 2 patients, with complete spontaneous resolution within 6 weeks.

Discussion

In the present study, patients with OLT treated with transmalleolar OAT demonstrated significant postoperative clinical improvement, and pain reduction as reflected by decreased VAS scores and increased AOFAS scores. Radiologic evaluation revealed satisfactory cartilage repair on postoperative MRI, with acceptable MOCART 2.0 scores. However, despite favorable clinical and structural outcomes, MRI-based cartilage repair scores were not significantly associated with either demographic variables or clinical outcome measures.

In the current literature, OAT for OLT has consistently been associated with substantial pain relief and functional improvement. In a long-term series using an open transmalleolar exposure, Toker et al¹⁶ reported an increase in AOFAS scores from 60.4 to 86.2 at a mean follow-up of 143.5 months, accompanied by a reduction in VAS from 6.3 to 2.0. Similarly, Scranton et al¹⁷ showed favorable early outcomes in patients, reporting an average 27-point improvement in the AOFAS score following OAT. However, clinical improvement has not been uniformly high across all studies. Imhoff et al¹⁸ demonstrated more moderate long-term functional recovery, with AOFAS scores increasing from 50 to 78 and VAS decreasing from 7.8 to 1.5, particularly when the procedure was performed as a secondary intervention. Likewise, Gautier et al¹⁹ reported heterogeneous mid-term functional outcomes after transmalleolar OAT, noting that patients with large or complex lesions and those with a history of prior surgery were less likely to achieve high postoperative AOFAS scores. These observations underscore the influence of lesion characteristics and patient selection on postoperative outcomes, rather than the surgical technique itself. Furthermore, a systematic review and meta-analysis by Feeney²⁰ demonstrated consistent overall clinical improvement, with pooled mean VAS scores decreasing from 6.47 ± 1.35 to 1.98 ± 1.18 and pooled mean AOFAS scores improving from 56.41 ± 8.52 to 87.14 ± 4.8 at final follow-up. In the present study, the mean improvement in VAS score was 4.9 points, and this improvement was not only statistically significant but also exceeded the minimal clinically important difference (MCID), indicating a clinically meaningful improvement from the patient perspective.²¹

Postoperative cartilage repair morphology assessed by MRI using the MOCART score has shown variable results after osteochondral reconstruction of the talus. Flynn et al²² reported high postoperative MOCART scores (mean 85.8) at short-term follow-up, suggesting satisfactory early graft incorporation. At the other end of the follow-up spectrum, Keszég et al²³ reported relatively lower MOCART 2.0 scores (mean 50.8) at a mean follow-up of nearly 14 years in competitive athletes, indicating that structural MRI scores may decline over time, particularly under high functional demands. However, long-term radiologic deterioration is not universal, as Winkler et al²⁴ demonstrated favorable MOCART 2.0 scores (73.7 ± 16.7) at an average 19-year follow-up, suggesting that acceptable structural cartilage morphology may be maintained over time. In our study, similarly satisfactory MOCART 2.0 scores (70.4 ± 9.7) were observed at short- to mid-term follow-up. Whether these radiologic findings remain stable or evolve over longer periods warrants further investigation through longitudinal MRI assessments.

When the available literature and clinical experience are considered together, it becomes clear that no single surgical technique is universally optimal for all OLT. Although arthroscopic techniques have gained popularity owing to their minimally invasive nature, the role of arthroscopic OAT remains a subject of ongoing debate. Kim et al²⁵ reported favorable outcomes following OAT, demonstrating an improvement in AOFAS scores from 67.4 ± 4.9 to 82.6 ± 7.8 with concomitant pain reduction. However, multiple studies have highlighted the technical limitations of arthroscopic OATS, particularly in large, deep, cystic, or posteriorly located lesions, where achieving perpendicular graft placement and optimal surface congruity can be challenging. Hangody and Füles²⁶ emphasized that transmalleolar techniques allow more reliable graft positioning, an observation further supported by the systematic review of Zengerink et al,²⁷ which concluded that although arthroscopic OATS is promising, its applicability is constrained by technical demands and strict patient selection. In addition, Yoon et al²⁸ reported superior outcomes with OAT compared with repeat arthroscopy in patients with failed prior arthroscopic treatment, underscoring the role of transmalleolar techniques, particularly in revision settings. Accordingly, surgical decision making should be individualized, with transmalleolar OAT representing a safe and effective option for lesions that are less amenable to arthroscopic treatment.

In our cohort, postoperative MOCART 2.0 scores were not significantly associated with clinical outcomes or patient-related factors, including postoperative AOFAS, symptom duration, or BMI. This lack of correlation reflects the well-recognized structure-symptom dissociation in ankle osteochondral repair, where MRI-based morphologic findings and patient-reported pain and function often represent distinct constructs. Although MOCART primarily assesses structural repair features, clinical scores are influenced by multiple factors such as pain processing, synovitis, impingement, and functional adaptation. One possible explanation for this dissociation is that pain in osteochondral lesions may primarily originate from subchondral bone pathology rather than the cartilage layer itself. In this context, stabilization and restoration of the subchondral bone may play a more critical role in symptom relief than the morphologic appearance of the cartilage repair tissue. In addition, the absence of a statistically significant association could be partly attributable to the relatively small sample size. With only 17 patients included, the present study may not have been adequately powered to detect modest or moderate correlations between MOCART 2.0 scores and clinical outcome measures. In such small cohorts, only very strong associations are likely to reach statistical significance, and clinically relevant but weaker relationships may remain undetected, raising the possibility of a type II error. Therefore, the absence of a statistically significant correlation in this study does not necessarily preclude the existence of a true relationship between structural cartilage repair and clinical recovery. Our findings are consistent with previous studies evaluating the relationship between MOCART and clinical outcomes in OLT. Usuelli et al²⁹ and Casari et al³⁰ reported no significant correlation between MOCART scores and AOFAS or VAS despite clinical improvement, and similar observations have been described following arthroscopic microfracture. At the evidence-synthesis level, systematic reviews have likewise demonstrated no meaningful association between MOCART and commonly used clinical outcome measures.^31,32 Collectively, these data support the interpretation of MOCART as a useful tool for structural assessment, rather than a direct surrogate for functional or symptomatic recovery.

This study has several limitations, including its retrospective design, the relatively small sample size, and the absence of a control or comparison group. Moreover, the correlation analyses involving multiple clinical and radiologic variables were conducted as exploratory analyses without formal adjustment for multiple testing, and the results should be interpreted accordingly. Another limitation relates to the use of the AOFAS score for functional assessment. Although widely used in foot and ankle research, the AOFAS score is not a formally validated patient-reported outcome measure and may not fully reflect the patient perspective on functional recovery, and thus functional outcomes based on this scale should be interpreted cautiously. In addition, postoperative MRI timing was not standardized across patients, which may have influenced the assessment of cartilage repair morphology. Despite these limitations, the study has several methodological strengths. All procedures were performed by a single experienced surgeon using a standardized transmalleolar OAT technique, ensuring procedural consistency and minimizing technical variability. Pain outcomes were assessed using the validated visual analog scale (VAS), and radiologic evaluation was conducted with the MOCART 2.0 system by 2 independent blinded radiologists, demonstrating excellent interobserver reliability (ICC = 0.92).

Conclusion

Transmalleolar OAT represents a reliable and effective treatment option for carefully selected OLT, particularly those that are large, deep, cystic, posteriorly located, or revision cases, where arthroscopic techniques may be technically limited. In the present study, significant clinical improvement was achieved; however, MRI-based cartilage repair quality assessed by MOCART 2.0 did not demonstrate a direct correlation with clinical outcomes, highlighting that structural repair and patient-reported recovery may reflect distinct dimensions of treatment response. Future studies should aim to further clarify this relationship through prospective, comparative designs, larger multicenter cohorts, and extended follow-up, with consideration of longitudinal MRI evaluation where feasible to better capture the temporal evolution of cartilage repair.

Supplemental Material

sj-pdf-1-fao-10.1177_24730114261445398 – Supplemental material for Association Between MRI-Based Cartilage Repair Morphology and Clinical Outcomes After Osteochondral Autograft Transfer of the Talus

Supplemental material, sj-pdf-1-fao-10.1177_24730114261445398 for Association Between MRI-Based Cartilage Repair Morphology and Clinical Outcomes After Osteochondral Autograft Transfer of the Talus by İbrahim Halil Rizvanoglu in Foot & Ankle Orthopaedics

Footnotes

ORCID iD

İbrahim Halil Rizvanoglu, MD,

Ethical Considerations

This study was approved by the ethics committee of the Sanko University of Medical Sciences under the code 89528399-000-11. All procedures were performed in accordance with the ethical principles of the Declaration of Helsinki.

Consent for Publication

Consent for publication was obtained from each participant in this study.

Funding

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

Declaration of Conflicting Interests

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Disclosure forms for all authors are available online.

Data Availability Statement

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

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