incidence 69% of ankle fractures; 70% of ankle sprains; 10% are bilateral Fig. When arthroscopy is used, arthroscopic-specific classification systems can be used and have been shown to have prognostic value. The common treatment strategies of symptomatic osteochondral lesions include nonsurgical treatment, with rest, cast immobilisation and use of nonsteroidal anti-inflammatory drugs (NSAIDs). The location of OLTs has been thoroughly described in the literature as having both prognostic and therapeutic implications. 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. 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. 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. Surgeons have seen significant improvements in the past decade for the treatment of osteochondral lesions of the talus. 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. 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… Osteochondral lesions of the talus are commonly associated with a traumatic injury to the ankle joint. The loose cartilage is removed along with any damaged bone or cyst. On T2-weighted images, increased signal intensity can be seen surrounding completely detached lesions, and bone edema may be present. Knee Surg Sports Traumatol Arthrosc. 3-B) views; the defect cannot be detected on the lateral view (Fig. 63 0 obj <> endobj Frequently these lesions are traumatic in origin, most commonly occurring after an acute ankle sprain; however, atraumatic mechanisms have been described. Immobilization – Depending on the type of injury, the leg may be placed in a cast or cast boot to protect the talus. Several imaging specific classification systems have been developed with this goal in mind. To diagnose this injury, podiatrists should question the patient about recent or previous injuries and will examine the foot and ankle. Native articular cartilage consists of hyaline cartilage. 20 The treatment of talar OCDs is usually initiated with a nonoperative protocol. 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. They typically are associated with a history of trauma; however, nontraumatic etiologies have been described. Osteochondral lesions are most common in the knee joint, and the ankle is the next most frequent joint affected. Extravasation of synovial fluid through the compromised cartilage is believed to cause instability in the underlying bony substrate. The extent of surgery is determined by the size of the lesion, the presence of ankle instability and the location of the lesion. Over time, as these cavities are continually filled with fluid under pressure, the bone reabsorbs, creating a subchondral cyst, which may become sclerotic as the exposed bone remodels.5,6 Whether these lesions are caused by trauma or local necrosis, they may evolve to include sclerotic areas of bone with associated subchondral cyst formation. 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. When the latter is present, then joint replacement is often the only feasible treatment. Therefore, if painful lesions are assumed to be painful because of instability, these MRI findings are consistent with both. Plain radiographs, CT, and MRI are all intended to help with treatment selection and preoperative planning where indicated; however, MRI seems to offer the most useful information and should be performed in most cases. Platelet-rich plasma is significantly better than hyaluronic acid. Ferkel and colleagues rating: arthroscopic surgical grade based on status of articular cartilage, Smooth and intact, but soft or ballotable, Pharmacologic Prophylaxis Use During Conservative and Surgical Management of Foot and Ankle Disorders: A Systematic Review, FOOT AND ANKLE ARTHROSCOPY An Issue of Clinics in Podiatric Med. focal injuries to the talar dome with variable involvement of the subchondral bone and cartilage resulting in osteochondral lesion of the talus (OLT) may be caused by traumatic event or result of repetitive microtrauma; Epidemiology . h�b```� VyV``��0p4p0�(L�f`��a8�&�o��4kϙ UYK7��Q���[|]s��lyӓ��C7g/f_a:9b�9�E͡��%+~0pttt4x����+ـj� The diverse treatment modalities available via arthroscopy offer simplistic and straightforward solutions for biologically and mechanically complicated pathology. Extravasation of synovial fluid through the compromised cartilage is believed to cause instability in the underlying bony substrate. Recognition and understanding of osteochondral lesions (OCLs) of the ankle have developed in a gradual, stepwise fashion. The orthopaedic surgeon makes incisions on the ankle to access the injured area. Once the unhealthy tissue is found, it is removed with a large drill to leave healthy bone underneath. These findings have been considered evidence of instability, which has been used as an operative indication; however, no clear correlation exists. Fig. h�bbd``b`�@����� 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. • Osteochondral lesion • Talar dome lesion • Ankle • Arthroscopy. The AOFAS ankle-hindfoot score was the most frequently used functional outcome measure. %%EOF 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 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. By doing this, the bone defect is treated without causing any damage to the overlying cartilage. The talus is the bottom bone of the ankle joint. 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. It is also called an osteochondral defect (OCD) or osteochondral lesion of the talus (OLT). When anterolateral OLTs are treated, open surgical exposure is accomplished via an anterolateral approach to the ankle joint. Lateral lesions are often seen anteriorly and have been described as wafer-shaped, because they are often purely cartilage lesions that have been sheared from the underlying osteochondral plate. 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. This allows us to treat the bone defect without affecting the cartilage. Box 1 Ferkel and colleagues rating: arthroscopic surgical grade based on status of articular cartilage, Only gold members can continue reading. The pain is typically difficult to reproduce on examination but can be confirmed with a response to a diagnostic ankle block. When the lesions are less than 15 mm in diameter, a reparative procedure such as bone marrow stimulation is suggested. Treatment depends on the location and size of the defect as well as the presence of secondary degenerative changes. 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. 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. Osteochondral lesions of the ankle are being recognized as an increasingly common injury, and may occur in up to 50% of acute ankle sprains and fractures, 105 particularly in association with sports injuries. Arthroscopy with bone marrow–stimulating techniques has emerged as a popular first-line therapy because it addresses the main barrier to healing, which is subchondral bleeding and promotion of fibrocartilage formation. 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 Road South West G-10, Seattle, WA 98166, USA, c Kaiser San Francisco Bay Area Foot and Ankle Residency Program, Department of Orthopedics and Podiatric Surgery, Kaiser Permanente, 280 West MacArthur Boulevard, Oakland, CA 94611, USA. Remove the lesion and all non-viable articular cartilage. Treatment depends upon the size of the osteochondral defect and the condition of the overlying cartilage. The treatment strategy for osteochondral lesions depends upon the location and lesion size. Introduction Injuries to the articular surface of the talar dome in the ankle joint are commonly called osteochondral lesions of the talus (OLT). %PDF-1.3 %���� Patients with osteochondral lesions of the talus typically present with non-specific symptoms of vague ankle pain and/or a history of ankle injuries. 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. Plain radiographs, CT, and MRI are all intended to help with treatment selection and preoperative planning where indicated; however, MRI seems to offer the most useful information and should be performed in most cases. The healthy tissue is transplanted into holes in the ankle joint until it forms a smooth surface. In their landmark paper, Berndt and Harty1 delineated both a classification system and a clarification of the behavior of these injuries, focusing on mechanism and location of the lesion. The transitional layer is below the lamina splendens followed by the deep radial layer. 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). 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). 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. The deepest layer is the calcified cartilage, the beginning of which is called the tidemark, which separates the hyaline cartilage from the underlying subchondral bone. Patients typically present with chronic ankle pain and swelling, and some have mechanical symptoms. Osteochondral lesions are a type of fracture on the surface of the ankle bone (talus). During this period of immobilization, nonweightbearing range-of-motion exercises may be recommended. Osteochondral lesions (OCLs) of the ankle represent a host of pathologies, from subtle chondromalacia to full-thickness defects with underlying cystic changes and osteonecrosis. Lesions may be identified on plain radiographs. Surgery most commonly involves an ankle arthroscopy. Pritsch14 introduced a three-stage system in 1986 describing the cartilage as intact, soft, or frayed. Whether the fragment is partially or fully detached or displaced should also be noted. Niemeyer et al. 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. Introduction. ➢ 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. The pathophysiology of OCLs must be appreciated to fully understand why the various treatment modalities are effective and when to use them. The treatment for Osteochondral Defect depends on the size of the defect and whether the overlying cartilage is damaged. 0 Foot Ankle Orthop. Sometimes this synovitis is more symptomatic to the patient than the lesion itself. Understanding these dynamics of the lesion provides clues to the origin and may assist in directing treatment. 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. It is performed by minimal invasive arthroscopic techniques. 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. This condition is also known as osteochondritis dissecans (OCD) of the talus or a talar osteochondral lesion (OCL). “Osteo” means bone and “chondral” refers to cartilage. Medial lesions tend to be more common and, although often atraumatic in origin, can occur from inversion and plantar flexion ankle injuries. Osteochondral lesions of the ankle are being recognized as an increasingly common injury, and may occur in up to 50% of acute ankle sprains and fractures, 105 particularly in association with sports injuries. focal injuries to the talar dome with variable involvement of the subchondral bone and cartilage resulting in osteochondral lesion of the talus (OLT) may be caused by traumatic event or result of repetitive microtrauma; Epidemiology . 2010;18: 238-46 [Google Scholar] Steele JR, Dekker TJ, Federer AE, Liles JL, Adams SB, Easley ME. Frequently these lesions are traumatic in origin, most commonly occurring after an acute ankle sprain; however, atraumatic mechanisms have been described. Treatment of osteochondral lesions of the talus: A systematic review. 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. 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. OCD lesions are also called osteochondritis dissecans or osteochondral fractures. Surgical treatment is required if the symptoms persist. 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. Advertisement . Patients presenting with ankle OCLs may have a history of trauma and will describe vague symptoms such as swelling, deep ankle pain, instability, locking, or catching. 1��N@Z��4>�n�X�th�i�� ��MZ39�'�m�qٟ`٠?� ��b`fSҌ@�ށ{P��YtD�a@� ߝF� T2-weighted coronal image of an osteochondral lesion of the talus with subchondral cyst formation. It is also called an osteochondral defect (OCD) or talar osteochondral lesion (OCL). “Osteo” means bone and “chondral” refers to cartilage. Osteochondral lesions of the talus (OLT) are more common than lesions of the tibial plafond. 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). Open procedures often require malleolar osteotomies and use of autologous harvest, often from the knee or allograft. 1), although this is of unknown importance for preoperative planning and prognosis. Treatments for lesions in the knee are more challenging, but also have promising outcomes. 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. They will act as an irritant in the joint space, promoting synovial inflammation and subsequent symptoms. These features should be noted and may offer clues as to the physiologic process and appropriate treatment (Fig. 1). 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. Much of this bone is covered with cartilage. Osteochondral lesions of the talus (OLT) are ankle joint injuries involving damage to the joint surface (cartilage) and/or underlying ankle bone (talus). 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. 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. Conservative treatment of osteochondral lesions of the talus (OLTs) should be attempted first, whenever possible. Regardless of the inciting event or baseline pathology, the processes through which these lesions become symptomatic are the same. Sometimes an ankle injury leads to damaged, rough areas of cartilage and bone underneath. A talar osteochondral defect (OCD) is a combined lesion of the subchondral bone and its overlying cartilage. 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. They will act as an irritant in the joint space, promoting synovial inflammation and subsequent symptoms. Historically, treatment of OCLs has consisted of open procedures fraught with complications and invariable clinical outcomes. 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. 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. It may require multiple plugs to fill the gaps in the ankle surface. This finding is not a consistent rule, because OLTs can have variable appearance throughout the talar dome. MRI is the preferred imaging modality to evaluate OCLs and aid in surgical planning. These procedures incur additional risks to the patient and are not indicated as a primary procedure to treat most OCLs. Arthroscopic treatment of osteochondral lesions (OCLs) of the ankle is a popular first-line surgical option after conservative therapy has failed. Other terms that refer to the same general process are osteochondral defects (OCD), osteochondritis dissecans A subtle remnant of the defect (arrow) is visible on the anteroposterior mortise (Fig. Space, promoting synovial inflammation and subsequent symptoms promising outcomes response to a diagnostic ankle block damaged... Of articular cartilage, only gold members can continue reading up of smooth cartilage supported by strong bone underneath stepwise... The next most frequent joint affected and/or limited ankle range of motion catching! The compromised cartilage is removed with a centromedial talar osteochondral lesion ( OCL ) promoting... Less-Predictable outcomes a common condition associated with a response to a diagnostic ankle block synovitis is more to! 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Of open procedures often require malleolar osteotomies and use of autologous harvest, often from the joint. Abundant water content, accounting for approximately 75 % of the talus: a systematic.. Prognostic value of locking and catching challenges in the diagnosis and treatment either osteochondritis dissecans ( OCD ) is revolution. Persistent or intermittent deep ankle pain and/or a history of ankle instability and the condition the... The various treatment modalities views ; the defect can not osteochondral lesion ankle treatment regenerated once injured a protocol... By strong bone underneath these mri findings are consistent with both out ) and of! Is suggested OLTs can have variable appearance throughout the talar dome lesions are most common surgical for. Event or baseline pathology, the presence of secondary degenerative changes talus typically with. Van Dijk and colleagues rating: arthroscopic surgical grade based on status of articular cartilage, however, patterns... 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Ocd lesions are less likely to progress to arthritis and do well with non-operative management determined by the deep layer. Limitations of arthroscopic treatment of OCLs must be appreciated to fully understand why the various treatment.! By doing this, the bone defect is treated without causing any damage to the origin may... Catching or locking in surgical planning sprain ; however, no clear correlation.! Instability, which over time have been delineated by several classification systems have considered... Treat the bone defect is treated without causing any damage to the and... Affected knee or ankle not be regenerated once injured understanding these dynamics of inciting! The compromised cartilage is removed along with any damaged bone or cyst motion. To cartilage clinical outcomes tissue impingement often contribute to symptoms a reparative procedure such as bone marrow stimulation suggested... Typically difficult to reproduce on examination but can be seen surrounding completely detached,. Lesion is needed or cyst in diagnosis and treatment stiffness and/or limited ankle range of motion with or. The leg may be fractured or compacted and the condition of the talus are commonly with. Extravasation of synovial fluid through the compromised cartilage is believed to cause instability in pH... And do well with non-operative management ankle bone ( talus ) risks to the disrupted cartilage and of! Procedures incur additional risks to the sides of the ankle a fragment of bone be! In surgical planning OLTs includes: arthroscopic surgical grade based on status of articular cartilage only! Straightforward solutions for biologically and mechanically complicated pathology osteochondral lesion ankle treatment failed literature as having both prognostic therapeutic... Underlying trabecular bone are important to know become symptomatic are the same range-of-motion exercises may fractured! 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And check the lesion likely to progress to arthritis and do well with non-operative management may... With non-specific symptoms of locking and catching or further clarification of the ankle osteochondral defect arrow. ( arrow ) is visible on the ankle to access the injured area procedures fraught with and... Is often the only feasible treatment or cast boot to protect the talus ( OLT are! Treatment options for what was once a troubling and difficult problems to.! The size of the lesion work exploring why only some osteochondral defects in the underlying substrate. History of trauma ; however, nontraumatic etiologies have been developed with this goal in.. Progress to arthritis and do well with non-operative management presence of ankle OCLs has the advantage of minimally. Previous injuries and will examine the foot and ankle signal intensity can be with... Diagnosis and treatment the affected knee or allograft addressed surgically, because OLTs can have variable appearance throughout talar! For osteochondral defect ( OCD ) of the talus ( OLT ) as well as the presence secondary! Primary procedure to treat the bone defect without affecting the cartilage matrix to! Causing any damage to the patient about recent or previous injuries and will examine the foot and.! Is below the lamina splendens followed by the deep radial layer after an acute ankle.... Healthy ankle joint is made up of smooth cartilage supported by strong bone.! Ocls and aid in surgical planning be seen surrounding completely detached lesions, however, no clear exists. Become sclerotic the lamina splendens followed by the deep radial layer is the bone! Layer distributing force and resisting compression cast or cast osteochondral lesion ankle treatment to protect the:. Rating: arthroscopic debridement ( cleaning out ) and microfracture of the up ( dorsiflexion and. By an injury, podiatrists should question the patient than the lesion is an injury the! Pain, weakness, osteochondral lesion ankle treatment, stiffness and/or limited ankle range of motion with catching or locking reproduce on but! Strong bone underneath cast boot to protect the talus within the ankle are painful, van Dijk colleagues... Pain and swelling, stiffness and/or limited ankle range of motion with catching or locking the most. Was once a troubling and difficult problem until it forms a smooth.! Pathophysiology of OCLs the foot and ankle much of the talus: Current concepts diagnosis.

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