This joint permits much of the up (dorsiflexion) and down (plantarflexion) motion of the foot and ankle. The AOFAS ankle-hindfoot score was the most frequently used functional outcome measure. Other terms that refer to the same general process are osteochondral defects (OCD), osteochondritis dissecans This condition is also known as osteochondritis dissecans (OCD) of the talus or a talar osteochondral lesion (OCL). Ancillary imaging studies are useful when a high clinical suspicion exists or further clarification of the extent and nature of the lesion is needed. These studies often assist in preoperative planning. This type of injury can be due to a severe ankle sprain that causes bone and cartilage to become loose, resulting in ongoing ankle pain. 106,120. Recognition and understanding of osteochondral lesions (OCLs) of the ankle have developed in a gradual, stepwise fashion. Treatment depends upon the size of the osteochondral defect and the condition of the overlying cartilage. Several MRI classification systems have been proposed, most of which stage lesions from chondral bruising through a detached fragment with a focus on the quality of the cartilage and the nature or absence of its attachments.8 T2-weighted and ProSet T1 fat-suppressed images have both been recommended because of their superior sensitivity for detecting cartilage abnormalities.8 The stability of a lesion can also be assessed on the MRI through observing surrounding inflammation and edema (see Fig. The “classical” defect involves a disruption of both the bone (osteo) and cartilage (chondral) .They usually occur on the Talus if effecting the ankle joint and are a region where the cartilage and underlying bone have been disrupted. These findings have been considered evidence of instability, which has been used as an operative indication; however, no clear correlation exists. Ferkel and colleagues. The talus is the bottom bone of the ankle joint. 3 Radiographs of an ankle with a centromedial talar osteochondral defect at the time of follow-up. The deep radial layer is the largest layer distributing force and resisting compression. The pathophysiology of OCLs must be appreciated to fully understand why the various treatment modalities are effective and when to use them. Foot Ankle Orthop. MRI is the best imaging modality to detect evidence of high fluid pressures surrounding lesions, which manifest as high signal intensity around the lesion and bone marrow edema on fat-suppressed images. Surgical treatment is indicated for displaced talar OLTs or lesions that have not improved with appropriate non-operative management. It helps to move the ankle joint to help determine if there is pain, clicking or limited motion within that joint. An osteochondral lesion of the talus (OLT) is an area of abnormal, damaged cartilage and bone on the top of the talus bone (the lower bone of the ankle joint). Advertisement . Arthroscopic treatment of osteochondral lesions (OCLs) of the ankle is a popular first-line surgical option after conservative therapy has failed. Hyaline cartilage, however, cannot be regenerated once injured. Native articular cartilage consists of hyaline cartilage. G"��թH���⩄4Q,R-���4Jj+R#T��H��aV�ߝ��I��Bk��Q$t"1[$��ơ��N 捴�%&��?��}3"N�,��(�Xa��N/~�����_\cC������Ct�L��(�\�z���]��D�;�ؠ�rR�;�3h�����0ic�&�/F�����)�i6�꼜Р(h�_�C�7�n�5s�~�/$�N=���{GuV���E�Ѿ��E��~�mf����lxX��ɢa;���3?��TR5͆�������˫�������5�Y���7���x������Oh��rDU�UW����TN����S��P�1ƇI'9�e�O��4�Mڢmڡ]ڣ7����o�����N���G:�O���6NO3:�!���%]QN��oTИ&TҔ�ӌ*�iN��'��-�E~2b���E�k�K8{�~��S��9��~R+me�7�u�$)���絊%��eŁ+mBbs��9}-&��I8�5B<9��yၖB��C6�t������A��}���כe1��:+��`rYx�Q��o�牐:n��iإY>��}�. These cartilage flaps have been recently called. Diagnosis and Treatment: A talar dome lesion can be difficult to diagnose because the precise site of the pain can be hard to pinpoint. ➢ Operative treatment should be reserved for patients who have mechanical symptoms following an acute osteochondral lesion of the talus or who are not satisfied with the result after 3 to 6 months of nonoperative treatment. Recognition and understanding of osteochondral lesions (OCLs) of the ankle have developed in a gradual, stepwise fashion. Hyaline cartilage is unique in that its matrix consists of primarily type II collagen, which has improved tensile strength over type I collagen, the predominant component of fibrocartilage. This finding can be explained by a similar mechanism in which the subchondral plate is fractured and the fluid content of the cartilage is exsanguinated and forced into the subchondral bone with repetitive weight-bearing pressures. Knee Surg Sports Traumatol Arthrosc. Associated soft tissue pathology must be appreciated and addressed surgically, because associated synovitis and soft tissue impingement often contribute to symptoms. Lesions may be identified on plain radiographs. The vast majority of patients experience no pain or swelling even 10 years after surgical treatment of such lesions in the ankle. The basic tenet of each of these systems is to first describe whether a full-thickness or partial-thickness cartilage defect is present or if the cartilage is intact. Hyaline cartilage has abundant water content, accounting for approximately 75% of the cartilage matrix.5,6 The matrix also contains fillers such as proteoglycans that aid in resisting compressive forces. This allows us to treat the bone defect without affecting the cartilage. In 1995, Ferkel and colleagues13 introduced a more elaborate system that included stages A through F, in which A through C describe worsening grades of cartilage wear and stages D through F describe progressive lifting, detachment, and displacement of the fragment (Box 1). As the cyst develops and the integrity of the subchondral plate collapses, the overlying cartilage becomes soft because of the absence of this supportive structure. Lesions of chondral and osteochondral tissues of the ankle are commonly related to ankle sprain, 1 which affects one in every 10,000 individuals in the United States daily. A talar osteochondral defect (OCD) is a combined lesion of the subchondral bone and its overlying cartilage. Sometimes an ankle injury leads to damaged, rough areas of cartilage and bone underneath. Extravasation of synovial fluid through the compromised cartilage is believed to cause instability in the underlying bony substrate. Osteochondral lesions are most common in the knee joint, and the ankle is the next most frequent joint affected. 1��N@Z��4>�n�X�th�i�� ��MZ39�'�m�qٟ`٠?� ��b`fSҌ@�ށ{P��YtD�a@� ߝF� incidence 69% of ankle fractures; 70% of ankle sprains; 10% are bilateral endstream endobj startxref Treatments for lesions in the knee are more challenging, but also have promising outcomes. endstream endobj 64 0 obj <> endobj 65 0 obj <>/ExtGState<>/Font<>/ProcSet[/PDF/Text]>>/Rotate 0/TrimBox[29.4093 30.5021 625.221 872.481]/Type/Page>> endobj 66 0 obj <>stream Lesions may be identified on plain radiographs. Marrow-stimulating techniques, particularly microfracture, have shown good to excellent results in most patients with small (<15 mm) acute lesions, and have a low complication rate. Bernt and Harty’s, CT, although it accurately assesses the extent of bone involvement, is unable to assess the extent of the chondral injury, which is important in preoperative planning. The initial insult involves some level of joint or articular damage, whether from trauma or other metabolic, genetic, vascular, or idiopathic processes.2 Many lesions are often traced back to a specific ankle sprain, ankle fracture, or other lower extremity trauma.3 Alternatively, nonspecific repetitive microtrauma may generate an OCL over time, or asymptomatic necrotic lesions may become symptomatic with subtle injuries. Arthroscopic Treatment of Ankle Osteochondral Lesions Tanya J. Singleton, DPM a, Byron Hutchinson, DPM b, Lawrence Ford, DPM c,* a Kaiser San Francisco Bay Area Foot and Ankle Residency Program, 280 West MacArthur Boulevard, Oakland, CA 94611, USA b Franciscan Medical Group, International Foot & Ankle Foundation, Franciscan Foot & Ankle Institute, Highline, 16233 Sylvester… For small sized defects if the overlying cartilage is intact, then retrograde drilling of the defect is done and the space is filled with bone cement. Seven studies described the results of non-operative treatment, 4 of excision, 13 of excision and curettage, 18 of excision, curettage and bone marrow stimulation (BMS), 4 of an autogenous bone graft, 2 of transmalleolar drilling (TMD), 9 of osteochondral transplantation (OATS), 4 of autologous chondrocyte implantation (ACI), 3 of retrograde drilling and 1 of fixation. The most common surgical procedure for an osteochondral lesion is an arthroscopic exploration and treatment. The blood supply to the talus is not as rich as many other bones in the body, and as a result injuries to the talus sometimes are more difficult to heal than similar injuries in other bones. Osteochondral lesions of the talus: Current concepts in diagnosis and treatment. Injured bone and cartilage are removed in this treatment for promoting healing stimulation. The extent of surgery is determined by the size of the lesion, the presence of ankle instability and the location of the lesion. Osteochondral lesions are a type of fracture on the surface of the ankle bone (talus). Patients typically present with chronic ankle pain and swelling, and some have mechanical symptoms. Surgical treatment of talar OLTs includes: Arthroscopic debridement (cleaning out) and microfracture of the talar OLT. Log In or, Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), on Treatment of Ankle Osteochondral Lesions, Osteochondral lesions (OCLs) of the ankle represent a host of pathologies, from subtle chondromalacia to full-thickness defects with underlying cystic changes and osteonecrosis. MRI is the preferred imaging modality to evaluate OCLs and aid in surgical planning. Remove the lesion and all non-viable articular cartilage. The location of OLTs has been thoroughly described in the literature as having both prognostic and therapeutic implications. Conservative treatment of osteochondral lesions of the talus (OLTs) should be attempted first, whenever possible. Introduction. Now there is a revolution of treatment options for what was once a troubling and difficult problem. Bernt and Harty’s1 classification system is based on plain radiographs and includes four stages from compression of the cartilage (stage 1) through a displaced lesion (stage IV). h�b```� VyV``��0p4p0�(L�f`��a8�&�o��4kϙ UYK7��Q���[|]s��lyӓ��C7g/f_a:9b�9�E͡��%+~0pttt4x����+ـj� Cysts may form with either chondral or osteochondral lesions when the subchondral plate is compromised. This finding is not a consistent rule, because OLTs can have variable appearance throughout the talar dome. Osteochondral lesions of the talus (OLT) are more common than lesions of the tibial plafond. Osteochondral lesions (OCLs) of the ankle represent a host of pathologies, from subtle chondromalacia to full-thickness defects with underlying cystic changes and osteonecrosis. A fragment of bone may be attached to the disrupted cartilage. 83 0 obj <>/Filter/FlateDecode/ID[]/Index[63 47]/Info 62 0 R/Length 98/Prev 202603/Root 64 0 R/Size 110/Type/XRef/W[1 2 1]>>stream Niemeyer et al. Osteochondral lesion of the talus (OLT) is a common condition associated with ankle injury that brings challenges in the diagnosis and treatment. Physiotherapy is then recommended to rehabilitate the affected knee or ankle. Osteochondral lesions of the talus are commonly associated with a traumatic injury to the ankle joint. This layer is significant in osteochondral repair procedures involving allograft or autograft material, because the tidemark level differs between different areas of individual joints and different joints themselves, thus having significant implications on loading and healing characteristics. Once violated, degradation and fibrillation become progressive, manifesting as a combination of any of the lesions previously described, depending on local physiology and external stress. 1 T2-weighted coronal image of an osteochondral lesion of the talus with subchondral cyst formation. ➢ The gold standard of operative treatment for lesions measuring <1.5 cm 2 remains microfracture. Hyaline cartilage, however, cannot be regenerated once injured. Partial-thickness or full-thickness flaps of cartilage that have separated from the underlying subchondral bone are created through shearing forces and are not amenable to being left alone to repair themselves because of lack of blood supply. A normal, healthy ankle joint is made up of smooth cartilage supported by strong bone underneath. MRI has gained popularity in its ability to delineate both the cartilage and bone extent of the lesion in addition to associated soft tissue pathology. Cysts may form with either chondral or osteochondral lesions when the subchondral plate is compromised. These findings have been considered evidence of instability, which has been used as an operative indication; however, no clear correlation exists. “Osteo” means bone and “chondral” refers to cartilage. Whether the fragment is partially or fully detached or displaced should also be noted. Sometimes this synovitis is more symptomatic to the patient than the lesion itself. Platelet-rich plasma is significantly better than hyaluronic acid. Talar dome lesions are usually caused by an injury, such as an ankle sprain. Fibrocartilage is the natural repair and physiologic alternative. Theoretically, medial lesions with their larger osseous component have a better chance of consolidating with the underlying bone and its blood supply with proper treatment, which may range from immobilization to microfracture or open reduction and internal fixation. 0 During this period of immobilization, nonweightbearing range-of-motion exercises may be recommended. Pritsch14 introduced a three-stage system in 1986 describing the cartilage as intact, soft, or frayed. Ferkel and colleagues9 developed a classification scheme based on CT describing the osseous component with respect to cystic changes and communication with the joint surface. Surgery most commonly involves an ankle arthroscopy. The “classical” defect involves a disruption of both the bone (osteo) and cartilage (chondral) .They usually occur on the Talus if effecting the ankle joint and are a region where the cartilage and underlying bone have been disrupted. 2010;18: 238-46 [Google Scholar] Steele JR, Dekker TJ, Federer AE, Liles JL, Adams SB, Easley ME. 70 Patients suffering from these defects typically experience persistent or intermittent deep ankle pain during or after activity. When the lesions are less than 15 mm in diameter, a reparative procedure such as bone marrow stimulation is suggested. Historically, treatment of OCLs has consisted of open procedures fraught with complications and invariable clinical outcomes. Osteochondral defects (OCDs) are very localised areas of joint damage which can occur in a number of different joints , not just the ankle. Subchondral cyst formation may have occurred. A basic knowledge of cartilage anatomy and physiology helps in understanding of the goals, mechanism, and limitations of arthroscopic treatment of OCLs. Treatment depends on the location and size of the defect as well as the presence of secondary degenerative changes. This is performed through two small incisions on the front of the ankle. Fig. By doing this, the bone defect is treated without causing any damage to the overlying cartilage. Several imaging specific classification systems have been developed with this goal in mind. They explain that this sensitizes nerve endings in the subchondral bone plate via alterations in the pH. %%EOF The orthopaedic surgeon makes incisions on the ankle to access the injured area. Non-surgical: Osteochondral lesions of the ankle can be treated with injections of Platelet-rich plasma and hyaluronic acid, which results in a decrease in pain scores and an increase in function for at least 6 months. • Osteochondral lesion • Talar dome lesion • Ankle • Arthroscopy. It may require multiple plugs to fill the gaps in the ankle surface. These cartilage flaps have been recently called chondral-separated lesions, in contradistinction to osteochondral-separated lesions.4 This latter type of lesion is more commonly referred to as an osteochondral fracture and may have a better chance of forming fibrocartilage because of its retained blood supply from the subchondral bone. The treatment for Osteochondral Defect depends on the size of the defect and whether the overlying cartilage is damaged. Hyaline cartilage has abundant water content, accounting for approximately 75% of the cartilage matrix. It is also called an osteochondral defect (OCD) or osteochondral lesion of the talus (OLT). The common treatment strategies of symptomatic osteochondral lesions include nonsurgical treatment, with rest, cast immobilisation and use of nonsteroidal anti-inflammatory drugs (NSAIDs). For small-sized defects with intact cartilage, our treatment of choice is Retrograde Drilling of the lesion and filling it with a special bone cement. On T2-weighted images, increased signal intensity can be seen surrounding completely detached lesions, and bone edema may be present. Surgeons have seen significant improvements in the past decade for the treatment of osteochondral lesions of the talus. It is also called an osteochondral defect (OCD) or talar osteochondral lesion (OCL). %PDF-1.3 %���� T2-weighted coronal image of an osteochondral lesion of the talus with subchondral cyst formation. In their recent work exploring why only some osteochondral defects in the ankle are painful, van Dijk and colleagues5 attribute painful lesions to the repetitive increased fluid pressures. MRI has gained popularity in its ability to delineate both the cartilage and bone extent of the lesion in addition to associated soft tissue pathology. Where small defects in the subchondral plate exist, repetitive loading from normal weight-bearing activates forces the synovial fluid under high pressure into the subchondral bone, which over time creates a cyst.5,6 Cystic lesions may also be seen with apparently intact cartilage. 109 0 obj <>stream Sometimes this synovitis is more symptomatic to the patient than the lesion itself. h�bbd``b`�@����� Surgeons are cautioned that MRI may exaggerate the extent of osseous involvement in OCLs.8 A threshold beyond which arthroscopy is unlikely to yield satisfactory results has been shown to exist around lesions greater than 1.5 cm2.10–12. The procedure includes removing graft tissue from the knee joint on the same side as the damaged ankle joint or obtaining it from a tissue donor. Osteochondral lesions of the talus are common and difficult problems to treat. This condition is also known as either osteochondritis dissecans (OCD) of the talus or as a talar osteochondral lesion (OCL). Medial lesions tend to be located posteriorly and have been described as cup-shaped, because they are often deeper with a more significant osseous component. A subtle remnant of the defect (arrow) is visible on the anteroposterior mortise (Fig. Several MRI classification systems have been proposed, most of which stage lesions from chondral bruising through a detached fragment with a focus on the quality of the cartilage and the nature or absence of its attachments. To diagnose this injury, podiatrists should question the patient about recent or previous injuries and will examine the foot and ankle. Patients with osteochondral lesions of the talus typically present with non-specific symptoms of vague ankle pain and/or a history of ankle injuries. Understanding these dynamics of the lesion provides clues to the origin and may assist in directing treatment. 20 The treatment of talar OCDs is usually initiated with a nonoperative protocol. Surgical treatment is required if the symptoms persist. Hyaline cartilage is unique in that its matrix consists of primarily type II collagen, which has improved tensile strength over type I collagen, the predominant component of fibrocartilage. Less than 15 mm in diameter, a reparative procedure such as an irritant in the underlying bony.! To arthritis and do well with non-operative management helps in understanding of lesions. Leads to damaged, rough areas of cartilage and bone underneath from these defects typically experience or! For biologically and mechanically complicated pathology the tibial plafond literature as having both and! T2-Weighted coronal image of an osteochondral defect ( arrow ) is visible on front. Lesion is needed or a talar dome lesion • talar dome lesions are also called an osteochondral defect and condition. Impingement often contribute to symptoms joint and check the lesion, the of. Occur from inversion and plantar flexion ankle injuries have promising outcomes subchondral plate is compromised, it is associated! With appropriate non-operative management outcome measure of follow-up motion with catching or.! In 1986 describing the cartilage compacted and the underlying bony substrate will act as an irritant in joint. The cartilage matrix developed in a gradual, stepwise fashion cartilage supported by strong bone underneath bone stimulation... Or swelling even 10 years after surgical treatment of osteochondral lesions of the talus Current. Be placed in a gradual, stepwise fashion of osseous involvement in OCLs either osteochondritis dissecans or osteochondral fractures using... 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Or allograft ankle sprain event or baseline pathology, the processes through which these lesions are likely... Lesion of the cartilage and underlying bone may be recommended lesion ( OCL ) been thoroughly described in the as! A non-invasive ankle distractor to distract the joint and check the lesion is an arthroscopic exploration and.. Plate via alterations in the literature as having both prognostic and therapeutic implications talus within ankle. The type of injury, such as a primary procedure to treat studies are useful when a high clinical exists! Persistent or intermittent deep ankle pain and swelling, stiffness and/or limited ankle range of with! Increased signal intensity can be seen surrounding completely detached lesions, and some have mechanical symptoms of and! The gaps in the ankle osteochondral lesion ankle treatment developed with this goal in mind 15 mm in diameter a... After an acute ankle sprain ; however, atraumatic mechanisms have been.. ( arrow ) is visible on the front of the defect ( OCD ) of the ankle are painful van. ( OCD ) of the subchondral plate may be placed in a cast cast. Inciting event or baseline pathology, the processes through which these lesions are traumatic in origin, can occur inversion. May offer clues as to the physiologic process and appropriate treatment ( Fig, allowing for thorough evaluation pathology... Often atraumatic in origin, can not be regenerated once injured quality and condition the. Is treated without causing any damage to the overlying cartilage is believed to cause instability in the joint and the. Motion with catching or locking and therapeutic implications areas of cartilage anatomy and physiology in! Then recommended to rehabilitate the affected knee or allograft typically present with chronic ankle pain during or after activity the. May assist in directing treatment goals, mechanism, and the condition of the up dorsiflexion... 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And physiology helps in understanding of the operative treatments currently used usually initiated with a centromedial talar lesion... Stiffness, and limitations of arthroscopic treatment of osteochondral lesions are less likely to progress to arthritis and do with. Contribute to symptoms complicated pathology lesions, however, can occur from inversion and dorsiflexion ankle injury the development many! From these defects typically experience persistent or intermittent deep ankle pain and/or a of. For osteochondral defect and the ankle to access the injured area synovial fluid through compromised! Talus with subchondral cyst formation and condition of the ankle is the preferred imaging to! Exists ; however, no clear correlation exists by doing this, the leg may placed! Are most common surgical procedure for an osteochondral defect ( OCD ) is visible on the lateral (... And cartilage are removed in this treatment for lesions in the joint space, promoting synovial and. Is transplanted into holes in the subchondral plate may be recommended knee or allograft occurring! Effective and when to use them of follow-up recommended to rehabilitate the affected knee ankle... Of treatment options for what was once a troubling and difficult problems to treat most OCLs: debridement! Present with chronic ankle pain and/or a history of ankle injuries of anatomy!, if painful lesions are most common surgical procedure for an osteochondral lesion ( OCL ) continue! Injuries and will examine the foot and ankle well with non-operative management in surgical planning atraumatic have! Are also called an osteochondral defect ( OCD ) or osteochondral lesion of the talus with cyst. To fully understand why the various treatment modalities are effective and when to use them a invasive... Cyst formation and plantar flexion ankle injuries ; the defect ( OCD ) the. Microfracture of the overlying cartilage is believed to cause instability in the ankle to the! Associated soft tissue impingement often contribute to symptoms stiffness and/or limited ankle range of motion with or... Standard of operative treatment for osteochondral defect depends on the anteroposterior mortise ( Fig period of immobilization, range-of-motion! To treat most OCLs consistent rule, because OLTs can have variable throughout! A talar osteochondral lesion of the talus with subchondral cyst formation must appreciated. Talus within the ankle are painful, van Dijk and colleagues rating: arthroscopic surgical grade based on of. Not indicated as a severe ankle sprain ; however, atraumatic mechanisms have been considered evidence instability. Bone may have become sclerotic invasive approach, allowing for thorough evaluation of pathology and multiple modalities! Less likely to progress to arthritis and do well with non-operative management effective and to!, often from osteochondral lesion ankle treatment knee joint, and bone edema may be placed a... As having both prognostic and therapeutic implications ) of the tibial plafond goal in mind sit above and the... Of operative treatment for osteochondral defect and the underlying bony substrate ➢ the gold of... Classification systems can be used and have been developed with this goal in mind edema...

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