April 14, 2026
3 min read
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Press-fit autologous osteoperiosteal grafting
A middle-aged, active patient — the kind who alternates between running along the canals and cycling against the Dutch wind — presents with recurrent deep ankle pain.
Three years earlier, she underwent arthroscopic bone marrow stimulation for a medial osteochondral lesion of the talus, with good initial results and a successful return to pre-injury sports.
Physical examination reveals a well-functioning ankle with good range of motion and neuromuscular control. However, palpation of the medial talus reproduces her symptoms — always an honest clinical moment where the diagnosis almost introduces itself.
Gino M.M.J. Kerkhoffs
She has already undergone adequate physical therapy and an intra-articular hyaluronic acid injection, both without meaningful relief. A CT scan demonstrates a contained medial osteochondral lesion of the talus (zones 1 to 4), measuring 12 × 10 mm, with cystic changes but no clear signs of osteoarthritis.
At this point, the real problem is not just the lesion — it is the loss of participation. She can no longer engage in sports, and her pain is now interfering with work and social life.
Her question is simple, and one we hear often: “Is there still something we can do?”
In nonprimary (ie, recurrent) osteochondral lesions of the talus of borderline size (100 mm2 to 150 mm²), we enter what might best be described as the “gray zone” — or, in Amsterdam terms, somewhere between a well-marked bike lane and complete chaos.
The literature offers no clear gold standard. While bone marrow stimulation performs well in primary lesions, its results in nonprimary cases are consistently less convincing. In addition, lesion characteristics such as increased depth and cystic morphology — both present in this case — are well-established risk factors for failure of repeat bone marrow stimulation.
In these situations, more durable biological reconstruction becomes an attractive option.
Osteochondral autografting has demonstrated reliable results, but at the cost of donor-site morbidity of up to 10% at the knee. While many patients accept this trade-off, it remains a relevant consideration — especially in otherwise healthy, active individuals.
Autologous osteoperiosteal grafting from the iliac crest provides an elegant alternative. The graft combines structural bone with a cambium layer that serves as a biological scaffold for cartilage repair. It avoids intra-articular donor-site morbidity and has demonstrated favorable mid- and long-term outcomes in complex osteochondral lesions of the talus, both using the press-fit (Talar OsteoPeriostic grafting from the Iliac Crest, or TOPIC) technique and cylindrical grafting approaches.
From a broader perspective, this technique may also align well with current societal demands: providing a durable, single-stage solution that potentially reduces long-term health care utilization — a concept that resonates well beyond the OR.
For this patient, we would recommend press-fit autologous osteoperiosteal grafting from the iliac crest as the primary treatment option, aiming for a durable biological solution in a recurrent lesion with unfavorable characteristics.
Of course, this recommendation is not made in isolation. As always — and perhaps especially in these “gray zone” cases — the decision is made together with the patient, within a shared decision-making framework that also includes nonoperative management and repeat arthroscopic bone marrow stimulation as alternative options.
Because, in the end, even in a city where everyone seems to have a strong opinion, the best outcomes still come from listening carefully.
For more information:
Gino M.M.J. Kerkhoffs, MD, PhD, MFSEM/FFSEM, is chair of the department of orthopedic surgery and sports medicine at Amsterdam University Medical Centers in Amsterdam. Kerkhoffs’s email: g.m.kerkhoffs@amsterdamumc.nl.
Sources/Disclosures
Source:
Expert Submission
References:
- Aldahshan WA, et al. Foot Ankle Surg. 2023;doi:10.1016/j.fas.2022.12.010.
- Arshad Z, et al. Clin Orthop Relat Res. 2022;doi:10.1097/CORR.0000000000002134.
- Cheng X, et al. Arthroscopy. 2023;doi:10.1016/j.arthro.2023.03.029.
- Dahmen J, et al. J Bone Joint Surg Am. 2023;doi:10.2106/JBJS.22.01322.
- Dahmen J, et al. Knee Surg Sports Traumatol Arthrosc. 2018;doi:10.1007/s00167-017-4616-5.
- Hollander JJ, et al. J Bone Joint Surg Am. 2025;doi:10.2106/JBJS.24.01377.
- Kerkhoffs GMMJ, et al. Oper Orthop Traumatol. 2021;doi:10.1007/s00064-020-00673-9.
- Lambers KTA, et al. Knee Surg Sports Traumatol Arthrosc. 2018;doi:10.1007/s00167-017-4629-0.
- Li Y, et al. Arthroscopy. 2024;doi:10.1016/j.arthro.2023.09.022.
- Rikken QGH, et al. Foot Ankle Int. 2026;doi:10.1177/10711007251405240.
- Shimozono Y, et al. Clin Orthop Relat Res. 2019;doi:10.1097/CORR.0000000000000719.
Disclosures:
Kerkhoffs reports no relevant financial disclosures.
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