TOPIC at 5 Years: Promising Pain Relief, Unanswered Questions About the Relationship Between Structural Changes and Symptoms

Hollander et al. report on a prospective, single-center series of 37 patients who underwent Talar OsteoPeriostic grafting from the Iliac Crest (TOPIC) for large, predominantly medial osteochondral lesions of the talus, with 33 patients included in the 5-year analysis. The median score for pain during walking on an 11-point scale improved from 7 preoperatively to 2 at 5 years of follow-up, with improvement also noted on the Foot and Ankle Outcome Score (FAOS) subscales and the American Orthopaedic Foot reproducibility across centers and learning-curve effects remain unknown. Outcome hierarchy. Pain during walking is clinically relevant, and the score exceeded the minimal clinically important difference (MCID), but the score for global health (the Short Form SF-36 Physical Component Summary) changed only modestly, and the score assessing sports participation (median score of 60 for the FAOS Sports subscale) did not normalize—important for younger, athletic patients. Radiation and hardware burden. Serial CT scans (preoperative to 5 years) result in a cumulative radiation dose, and 43% of the patients underwent screw removal. These practical concerns should factor into shared decision-making. Cysts: a consistent finding with unclear clinical meaning. The 87% cyst rate at 5 years underscores a structural change following TOPIC, but its trajectory and clinical implications remain undefined. Current meta-analytic data suggest a poor correlation of cysts with symptoms5, but late effects (progressive pain, graft fatigue, or adjacent bone changes) need longer-term surveillance and standardized cyst grading to enable pooled analyses. Clinical Takeaway For large, medial osteochondral lesions of the talus—especially non-primary or cystic lesions—TOPIC offers a joint-preserving option in expert hands, with durable midterm pain relief, reliable consolidation, and minimal patient-reported iliac crest morbidity. Surgeons should counsel patients that (1) function improves but may not fully normalize, (2) cysts on CT are common and not necessarily a failure of treatment, and (3) the evidence remains noncomparative. What’s next? Multicenter, comparative effectiveness studies (TOPIC versus fresh allograft versus ACI), with common patient-reported outcome measures, standardized CT/MRI (magnetic resonance imaging) cyst taxonomy, radiation-minimizing imaging protocols, and the time to arthrodesis or other operation as hard end points, would clarify patient selection. Cost-effectiveness modeling that incorporates imaging and reoperation for hardware removal would further inform policy and practice.