Osteochondral Lesions of the Talus Treatment & Management
- Author: Christopher F Hyer, DPM, FACFAS; Chief Editor: Anthony E Johnson, MD more...
Conservative treatment of osteochondral lesions of the talus (OLTs) should be attempted first, whenever possible. After a period of immobilization followed by physical therapy, patients with continued symptoms should be evaluated with magnetic resonance imaging (MRI) and other imaging studies to assess the condition of the articular cartilage and stability, and to detect any intra-articular bodies.
Symptoms of intra-articular derangement are indications for operative intervention. Such symptoms include effusion, catching or locking of the ankle, instability preceded by pain, and ankle pain relieved with diagnostic lidocaine.
Surgery to treat OLTs is contraindicated when the risks outweigh the perceived benefits. Risks include active infection in the operative area, patient noncompliance, and medical instability in patients. Relative contraindications include degenerative changes of the ankle involving more than an isolated OLT.
Future controversies will likely revolve around minimizing operative morbidity and costs. Early reports with allografts have shown some subsidence and resorption, necessitating ankle arthrodesis. If this trend continues, the use of allografts will likely fall from favor.
Thus far, autologous osteochondral grafting seems to be the most reproducible and stable grafting technique. As this procedure gains favor, more reported complications at the knee donor site may evolve. A study suggested that when failure of grafting occurs, using a metal resurfacing inlay implant for revision surgery of moderately sized lesions may be considered; however, this technique has not been validated by additional studies, and the long-term results are unknown.
The autologous chondrocyte transplantation (ACT) procedure is based on actual repair of deficits of articular cartilage. Additional histologic and long-term clinical data are needed to determine the success or failure rate of this therapy. Currently, this technology is fairly cost-prohibitive, with the expense of cell culture and two surgical procedures. Future possibilities may include the use of adhesive patches instead of the periosteal flap, as well as the addition of growth factors.
In conjunction with marrow-stimulation techniques, biologic adjuncts (ie, mesenchymal stem cells, platelet-rich plasma, bone marrow aspirate concentrate) may play a role in the management of OLTs. Limited research is available regarding this, and the practicality of this technique and its long-term efficacy remain unknown.[48, 49, 50]
Conservative management of OLTs should be attempted before surgical management is embarked on. (See the images below.) Symptomatic patients with negative findings on plain radiographs should undergo an initial period of immobilization, followed by physical therapy. Studies have shown that a trial of conservative therapy does not adversely affect surgery performed after conservative therapy has failed.[17, 19] One study demonstrated that nonoperative conservative treatment can sometimes result in healing of higher-stage lesions. Patients whose plain images indicate OLTs and those who remain symptomatic after 6 weeks should undergo additional evaluation with MRI.
Surgical treatment depends on a variety of factors, including patient characteristics (eg, activity level, age, degenerative changes) and lesions (eg, location, size, chronicity). Generaly, however, surgical treatment adheres to one of the following three principles:
Loose-body removal with or without stimulation of fibrocartilage growth (microfracture, curettage, abrasion, or transarticular drilling) 
Securing OLTs to the talar dome through retrograde drilling, bone grafting, or internal fixation
Stimulating the development of hyaline cartilage through osteochondral autografts (osteochondral autograft transfer system [OATS], mosaicplasty), allografts (particulated juvenile cartilage), or cell culture (Carticel; Genzyme Biosurgery, Cambridge, MA)
Radiographic imaging is essential to assess alignment and grade the OLT. A marked distortion of normal mechanical alignment must be corrected at the same operative setting as the surgery to address the OLT. Grading the OLT allows for proper prognostication and influences whether the lesion can be approached with an antegrade or retrograde technique.
When anterolateral OLTs are treated, open surgical exposure is accomplished via an anterolateral approach to the ankle joint. Plantarflexion aids in exposing the lesion; however, this approach requires caution to avoid damaging the branches of the superficial peroneal nerve.
The open approach is also challenging when posteromedial OLTs are treated. An osteotomy cut that enters the joint too far laterally can endanger the weight-bearing plafond, and a cut that enters the joint too far distally on the medial malleolus limits exposure. Screw holes must be predrilled before osteotomy. In addition, care must be taken to avoid injury to the allograft nerve and vein, anterior tibial tendon, posterior tibial tendon, flexor digitorum longus (FDL), posterior tibial artery, and tibial nerve.
An apex proximal chevron bone cut provides excellent visualization, and Cohen et al had no nonunions or malunions when using a chevron medial malleolar osteotomy in 19 patients.[11, 52]
Posteromedial OLTs have also been treated by using a combined anterior and posterior arthrotomy exposure. This approach allows access to 80% of the talar dome while it avoids the medial malleolar osteotomy in most cases.
Arthroscopic treatment of OLTs can be accomplished by using wide-angle 2.7-mm arthroscopes, which provide more maneuverability than traditional 4- and 5-mm arthroscopes. Noninvasive joint distraction techniques enable easier visualization of the entire talar dome.[54, 55, 56, 57]
Treatment of completely detached lesions
For a completely detached lesion believed to be inappropriate for internal fixation, removal of the loose body and debridement of the bony bed are indicated. The base of the bed should be debrided back to bleeding bone, and the edges should be trimmed back to viable cartilage. Instruments available for use in this procedure include blunt-tipped probes, pituitary graspers, gouges, Kirschner wires (K-wires), awls, full-radius shavers, ring curettes, and high-speed burrs.
Studies have shown that excision and nonoperative treatment yield poor results and that excision, curettage, and drilling provide the best outcome.
Treatment of intact lesions
Drilling of the subchondral bone creates channels to enable revascularization of the fragment. Drilling can be accomplished by using existing arthroscopic portals, a curved meniscus-repair needle guide, and transmalleolar drill holes.[35, 58]
Sinus tarsi approaches to posteromedial lesions, also known as retrograde drilling or transtalar drilling, do not disrupt the articular surface. Retrograde drilling can facilitate bone grafting, which is ideal for large subchondral cystic lesions with intact articular cartilage. The COLT (Interpore Cross, Irvine, CA) provides for accurate positioning of the drill hole and a cannula for bone graft delivery. Studies have shown good clinical and radiographic results with transarticular/transmalleolar drilling and retrograde/transtalar drilling.[59, 60]
The use of traditional bone screws passed in an antegrade fashion is discouraged because irreparable damage to the intact articular cartilage results. Screw fixation typically is used for anterolateral lesions only because of the difficulty in gaining good exposure for posteromedial lesions. K-wires can be inserted retrograde through a nonarticular portion of the talus. Bioabsorbable pins can be advanced immediately below the articular surface, then cut off at the skin.
The authors have reported successful fixation after autogenous osteochondral grafting of an osteochondritis dissecans of the knee. Another report described treating 27 large (8 mm × 8 mm and larger) ankle lesions with a cortical bone peg technique. The pegs, which were 2-3 mm wide and 15-20 mm long, were harvested from the distal tibia and passed through the articular surface. They reported good clinical results in 89% of their patients at an average of 7 years of follow-up.
Another study, with an 11-year mean follow-up, reported 9 cases of fresh osteochondral allografting. Of nine grafts, six remained in situ, and three patients required ankle arthrodesis because of resorption and fragmentation of the graft. These authors discourage the use of allografting in OLTs. A high rate of complications has been reported in patients who underwent tibiotalar osteochondral allografting.
Autologous osteochondral grafting
Autologous osteochondral grafting techniques, including the OATS procedure and mosaicplasty, involve grafting a plug from the femoral trochlea or condyle into the OLT on the talar dome.
The OATS procedure transplants a single plug into the OLT, and mosaicplasty is used to harvest and transplant multiple plugs. Single-plug grafts result in reduced ingrowth of the fibrocartilage, though donor-site morbidity may be greater because of the need to harvest a single larger plug. The mosaicplasty procedure is said to provide a better match to the talar dome contour and surface area of the defect, though 20-40% of the defect is filled with fibrocartilage.
Several groups have reported good results with both procedures. Eleven patients who underwent mosaicplasty had good-to-excellent results at 24 months. The lesions averaged 18 mm × 10 mm, and there were no adverse effects on the knee. Another study reported that 94% of 36 patients undergoing mosaicplasty had good-to-excellent results, with follow-up ranging from 2-7 years. Previous surgical procedures had failed in 29 of the patients.
In another study, plugs were harvested from the ipsilateral medial or lateral articular facet of the talus in 12 patients. Significant improvement in American Orthopaedic Foot and Ankle Society (AOFAS) scores was reported, and no structural failures occurred in the graft or donor site.
A modified mosaicplasty technique has also been proposed for management of severe OLTs. Leumann et al discussed using autologous bony periosteum–covered plugs harvested from the iliac crest for management of lesions greater than 1.5 cm2.
Autologous chondrocyte transplantation
Two reports described good early results with ACT. Koulalis et al reported the results of ACT in 8 patients, with an average follow-up of 17.6 months. Patients first underwent diagnostic arthroscopy, cartilage biopsy, chondrocyte extraction, and culture. An average of 2.5 weeks later, arthrotomy, malleolar osteotomy, bone debridement, and chondrocyte transplantation were performed. Patients were kept on nonweightbearing status for 6-7 weeks. Routine arthroscopic examination performed 6 months after the transplant showed cartilagelike tissue completely covering the OLTs. (Histologic examination of one biopsy sample did not show hyaline cartilage.)
Giannini et al reported similar results 24 months post transplant, showing that hyaline cartilage can be transplanted in the ankle joint and that good function can be expected.
ACT has been performed more often in the knee. Results of the first 100 patients undergoing this procedure in a multicenter 5-year study found that 79% showed improvement at 5 years. Compared with a control group undergoing different procedures, such as drilling or abrasionplasty, patients undergoing the transplant procedure had better functional outcomes.
Particulated juvenile cartilage allograft
This technique uses particulated juvenile cartilage allograft from donors younger than age 13 years. It is proposed that immature chondrocytes have an increased propensity to regenerate hyalinelike cartilage and have greater metabolic activity. Limited studies are available using this technique, with only relatively short-term follow-up.[76, 77, 78]
Early results for small to moderate-sized lesions demonstrated good outcomes at short-term follow-up.[76, 77] Coetzee et al identified that for lesions with a diameter of 15 mm or larger, only 56% of patients reported good-to-excellent results on the AOFAS Ankle-Hindfoot Scale at 16-month follow-up.
Treatment of coexisting OLT and ligamentous instability
Acute ankle ligament injuries with a large, unstable fragment typically first undergo surgical repair of the talar lesion. The ligament is allowed to heal postoperatively.
Treatment decisions for treating chronic OLTs with chronic ankle instability are less clear. Postoperatively, OLTs require early motion, which is not appropriate for reconstructed ligaments. Options include first repairing the OLT and then repairing the ligamentous injury at another time, or repairing the two injuries simultaneously and postponing early ankle motion until the ligament has healed. Thermal capsular shrinkage may also be a possible treatment solution.
A postoperative rehabilitation program should be tailored to each patient's individual circumstances and goals by a licensed physical therapist. With the goal of attaining full ankle range of motion, physical rehabilitation includes active and passive range-of-motion exercises and a home program, edema control, and strength and proprioceptive training.
Rehabilitation can generally begin after healing is demonstrated, which may occur after 6-7 weeks of nonweightbearing status if drilling or internal fixation was performed. Lee et al compared early (2 weeks) versus delayed (6 weeks) weightbearing following arthroscopic debridement and microfracture of small to medium-sized OLTs and found no difference in outcome between the two groups.
Operative treatment of OLTs has inherent risks. Open exposure entails use of a medial malleolar osteotomy or anterior plafond bone block to gain exposure of the tibiotalar joint. The medial malleolar osteotomy typically heals well with low incidence of nonunion, but care must be taken to place the osteotomy correctly and protect the adjacent tendons and neurovascular structures.
With second-look arthroscopy, Kim et al identified that postoperative pain (Visual Analog Scale) and function (AOFAS Ankle-Hindfoot Scale) scores were significantly worse when the tibial plafond at the malleolar osteotomy site was uneven. An anterior tibial bone-block access window is associated with a lower risk of malunion but may limit access to posterior lesions.
Arthroscopic intervention is associated with less surgical morbidity and joint stiffness, decreased rehabilitation time, and an increased functional outcome.
Schuman reviewed 22 patients who underwent arthroscopy with curettage and drilling at an average follow-up of 4.8 years, with 86% good-to-excellent results. Complications associated with arthroscopy include hyperesthesia around the portal incision and, occasionally, neuralgia of the superficial peroneal nerves, but these were minor and transient.
Some have advocated the use of allograft implants, but these grafts may become resorbed over time and fragment, necessitating ankle arthrodesis. So far, no reports have been made of allograft rejection by the host.
The osteochondral transplantation procedures have the additional risk of a second surgical site, which adds to the risk of possible complications. A 4-year follow-up of 36 mosaicplasty patients reported six patients with donor-site complaints during strenuous exercise, but this resolved after the first year. Woelfle et al determined in a study of 32 patients who underwent the OATS procedure that advanced age (>40 years) is associated with higher donor site morbidity. The OATS procedure is thought to have greater donor-site morbidity, in that larger plugs are taken than are taken with mosaicplasty.
Gautier et al evaluated 11 patients at a 24-month follow-up and found that 10 of 11 had graft incorporation and were without major complications. Subjectively, patients may report mild pain or stiffness in the knee or ankle, but this is without objective deficits. Similarly, other authors have found good graft incorporation without serious complications.[10, 28] Restoration of articular surface congruity may be very difficult, particularly in talar shoulder lesions.
Published reports of ACT are relatively few but include good results. The procedure does necessitate two operations and is difficult technically, but no complications have been reported.
Pain after operative treatment of OLTs is common for up to 1 year. MRI changes, including edema, are slow to resolve and often match the patient's report of an achy feeling in the joint. After 6 months, a persistent effusion, a catching sensation, or severe pain signifies that healing is not progressing as intended, and further investigation with computed tomography (CT) or MRI is appropriate.
In a study by Cuttica et al, follow-up MRI at a minimum of 9 months' follow-up revealed an odds ratio of 7.8 for a poor outcome when moderate or severe edema intensity was present compared with mild or no edema intensity following microfracture.
Konig F. Uber freie Korper in den gelenken. Dtsch Z Chir. 1888. 27:90-109.
Kappis M. Weitere beitrage zur traumatisch-mechanischen entstehung der "spontanen" knorpela biosungen. Dtsch Z Chir. 1922. 171:13-29.
Berndt AL, Harty M. Transchondral fractures (osteochondritis diseccans) of the talus. J Bone Joint Surg. 1959. 41A:988-1020.
Sugimoto K, Takakura Y, Tohno Y, Kumai T, Kawate K, Kadono K. Cartilage thickness of the talar dome. Arthroscopy. 2005 Apr. 21 (4):401-4. [Medline].
Bruns J, Rosenbach B, Kahrs J. [Etiopathogenetic aspects of medial osteochondrosis dissecans tali]. Sportverletz Sportschaden. 1992 Jun. 6(2):43-9. [Medline].
Athanasiou KA, Niederauer GG, Schenck RC Jr. Biomechanical topography of human ankle cartilage. Ann Biomed Eng. 1995 Sep-Oct. 23(5):697-704. [Medline].
Shepherd DE, Seedhom BB. Thickness of human articular cartilage in joints of the lower limb. Ann Rheum Dis. 1999 Jan. 58(1):27-34. [Medline].
Treppo S, Koepp H, Quan EC. Comparison of biomechanical and biochemical properties of cartilage from human knee and ankle pairs. J Orthop Res. 2000 Sep. 18(5):739-48. [Medline].
Christensen JC, Driscoll HL, Tencer AF. 1994 William J. Stickel Gold Award. Contact characteristics of the anklejoint. Part 2. The effects of talar dome cartilage defects. J Am Podiatr Med Assoc. 1994 Nov. 84(11):537-47. [Medline].
Assenmacher JA, Kelikian AS, Gottlob C. Arthroscopically assisted autologous osteochondral transplantation for osteochondral lesions of the talar dome: an MRI and clinical follow-up study. Foot Ankle Int. 2001 Jul. 22(7):544-51. [Medline].
Anderson IF, Crichton KJ, Grattan-Smith T. Osteochondral fractures of the dome of the talus. J Bone Joint Surg Am. 1989 Sep. 71(8):1143-52. [Medline].
Baker CL, Andrews JR, Ryan JB. Arthroscopic treatment of transchondral talar dome fractures. Arthroscopy. 1986. 2(2):82-7. [Medline].
Parisien JS. Arthroscopic treatment of osteochondral lesions of the talus. Am J Sports Med. 1986 May-Jun. 14(3):211-7. [Medline].
Pettine KA, Morrey BF. Osteochondral fractures of the talus. A long-term follow-up. J Bone Joint Surg Br. 1987 Jan. 69(1):89-92. [Medline].
Van Buecken K, Barrack RL, Alexander AH. Arthroscopic treatment of transchondral talar dome fractures. Am J Sports Med. 1989 May-Jun. 17(3):350-5; discussion 355-6. [Medline].
Pritsch M, Horoshovski H, Farine I. Arthroscopic treatment of osteochondral lesions of the talus. J Bone Joint Surg Am. 1986 Jul. 68(6):862-5. [Medline].
Alexander AH, Lichtman DM. Surgical treatment of transchondral talar-dome fractures (osteochondritis dissecans). Long-term follow-up. J Bone Joint Surg Am. 1980. 62(4):646-52. [Medline].
Canale ST, Belding RH. Osteochondral lesions of the talus. J Bone Joint Surg Am. 1980 Jan. 62(1):97-102. [Medline].
Flick AB, Gould N. Osteochondritis dissecans of the talus (transchondral fractures of the talus): review of the literature and new surgical approach for medial dome lesions. Foot Ankle. 1985 Jan-Feb. 5(4):165-85. [Medline].
Woods K, Harris I. Osteochondritis dissecans of the talus in identical twins. J Bone Joint Surg Br. 1995 Mar. 77(2):331. [Medline].
[Guideline] Thomas JL, Christensen JC, Kravitz SR, Mendicino RW, Schuberth JM, Vanore JV, et al. The diagnosis and treatment of heel pain: a clinical practice guideline-revision 2010. J Foot Ankle Surg. 2010 May-Jun. 49 (3 Suppl):S1-19. [Medline].
Tol JL, Struijs PA, Bossuyt PM, Verhagen RA, van Dijk CN. Treatment strategies in osteochondral defects of the talar dome: a systematic review. Foot Ankle Int. 2000 Feb. 21(2):119-26. [Medline].
Shearer C, Loomer R, Clement D. Nonoperatively managed stage 5 osteochondral talar lesions. Foot Ankle Int. 2002 Jul. 23(7):651-4. [Medline].
Donnenwerth MP, Roukis TS. Outcome of arthroscopic debridement and microfracture as the primary treatment for osteochondral lesions of the talar dome. Arthroscopy. 2012 Dec. 28(12):1902-7. [Medline].
Choi WJ, Choi GW, Kim JS, Lee JW. Prognostic significance of the containment and location of osteochondral lesions of the talus: independent adverse outcomes associated with uncontained lesions of the talar shoulder. Am J Sports Med. 2013 Jan. 41(1):126-33. [Medline].
Choi WJ, Park KK, Kim BS, Lee JW. Osteochondral lesion of the talus: is there a critical defect size for poor outcome?. Am J Sports Med. 2009 Oct. 37(10):1974-80. [Medline].
Al-Shaikh RA, Chou LB, Mann JA. Autologous osteochondral grafting for talar cartilage defects. Foot Ankle Int. 2002 May. 23(5):381-9. [Medline].
Hangody L, Kish G, Modis L. Mosaicplasty for the treatment of osteochondritis dissecans of the talus:two to seven year results in 36 patients. Foot Ankle Int. 2001 Jul. 22(7):552-8. [Medline].
Brittberg M, Lindahl A, Nilsson A. Treatment of deep cartilage defects in the knee with autologous chondrocyte transplantation. N Engl J Med. 1994. 331(14):889-95. [Medline].
Giannini S, Vannini F, Buda R. Osteoarticular grafts in the treatment of OCD of the talus: mosaicplasty versus autologous chondrocyte transplantation. Foot Ankle Clin. 2002 Sep. 7(3):621-33. [Medline].
Wiewiorski M, Miska M, Nicolas G, Valderrabano V. Revision of Failed Osteochondral Autologous Transplantation Procedure for Chronic Talus Osteochondral Lesion With Iliac Crest Graft and Autologous Matrix-Induced Chondrogenesis: A Case Report. Foot Ankle Spec. 2012 Jan 31. [Medline].
Niemeyer P, Salzmann G, Schmal H, Mayr H, Südkamp NP. Autologous chondrocyte implantation for the treatment of chondral and osteochondral defects of the talus: a meta-analysis of available evidence. Knee Surg Sports Traumatol Arthrosc. 2012 Sep. 20(9):1696-703. [Medline].
Murawski CD, Kennedy JG. Operative treatment of osteochondral lesions of the talus. J Bone Joint Surg Am. 2013 Jun 5. 95(11):1045-54. [Medline].
Stroud CC, Marks RM. Imaging of osteochondral lesions of the talus. Foot Ankle Clin. 2000 Mar. 5(1):119-33. [Medline].
Stone JW. Osteochondral Lesions of the Talar Dome. J Am Acad Orthop Surg. 1996 Mar. 4(2):63-73. [Medline].
Loredo R, Sanders TG. Imaging of osteochondral injuries. Clin Sports Med. 2001 Apr. 20(2):249-78. [Medline].
Elias I, Jung JW, Raikin SM, Schweitzer MW, Carrino JA, Morrison WB. Osteochondral lesions of the talus: change in MRI findings over time in talar lesions without operative intervention and implications for staging systems. Foot Ankle Int. 2006 Mar. 27(3):157-66. [Medline].
Cuttica DJ, Shockley JA, Hyer CF, Berlet GC. Correlation of MRI edema and clinical outcomes following microfracture of osteochondral lesions of the talus. Foot Ankle Spec. 2011 Oct. 4(5):274-9. [Medline].
Higashiyama I, Kumai T, Takakura Y. Follow-up study of MRI for osteochondral lesion of the talus. Foot Ankle Int. 2000 Feb. 21(2):127-33. [Medline].
Mesgarzadeh M, Sapega AA, Bonakdarpour A, et al. Osteochondritis dissecans: analysis of mechanical stability with radiography, scintigraphy, and MR imaging. Radiology. 1987 Dec. 165(3):775-80. [Medline].
De Smet AA, Fisher DR, Burnstein MI. Value of MR imaging in staging osteochondral lesions of the talus (osteochondritis dissecans): results in 14 patients. AJR Am J Roentgenol. 1990 Mar. 154(3):555-8. [Medline].
Cheng MS, Ferkel RD, Applegate GR. Osteochondral lesion of the talus: A radiologic and surgical comparison. Paper presented at: Annual Meeting of the Academy of Orthopaedic Surgeons, New Orleans, La. February, 1995.
Lee KB, Bai LB, Park JG, Yoon TR. A comparison of arthroscopic and MRI findings in staging of osteochondral lesions of the talus. Knee Surg Sports Traumatol Arthrosc. 2008 Sep 9. [Medline].
Ferkel RD. Articular surface defects, loose bodies, and osteophytes. Arthroscopic Surgery: The Foot and Ankle. Philadelphia, Pa: Lippincott-Raven; 1996. 145.
Hepple S, Winson IG, Glew D. Osteochondral lesions of the talus: a revised classification. Foot Ankle Int. 1999 Dec. 20(12):789-93. [Medline].
van Bergen CJ, van Eekeren IC, Reilingh ML, Sierevelt IN, van Dijk CN. Treatment of osteochondral defects of the talus with a metal resurfacing inlay implant after failed previous surgery: a prospective study. Bone Joint J. 2013 Dec. 95-B(12):1650-5. [Medline].
Kok AC, Dunnen Sd, Tuijthof GJ, van Dijk CN, Kerkhoffs GM. Is technique performance a prognostic factor in bone marrow stimulation of the talus?. J Foot Ankle Surg. 2012 Nov-Dec. 51(6):777-82. [Medline].
Kim YS, Park EH, Kim YC, Koh YG. Clinical outcomes of mesenchymal stem cell injection with arthroscopic treatment in older patients with osteochondral lesions of the talus. Am J Sports Med. 2013 May. 41(5):1090-9. [Medline].
Deol PP, Cuttica DJ, Smith WB, Berlet GC. Osteochondral lesions of the talus: size, age, and predictors of outcomes. Foot Ankle Clin. 2013 Mar. 18(1):13-34. [Medline].
Smyth NA, Murawski CD, Haleem AM, Hannon CP, Savage-Elliott I, Kennedy JG. Establishing proof of concept: Platelet-rich plasma and bone marrow aspirate concentrate may improve cartilage repair following surgical treatment for osteochondral lesions of the talus. World J Orthop. 2012 Jul 18. 3(7):101-8. [Medline]. [Full Text].
Doral MN, Bilge O, Batmaz G, Donmez G, Turhan E, Demirel M, et al. Treatment of osteochondral lesions of the talus with microfracture technique and postoperative hyaluronan injection. Knee Surg Sports Traumatol Arthrosc. 2011 Dec 29. [Medline].
Cohen B, Anderson R, Davis WH. Chevron-type transmalleolar osteotomy: an approach to medial talar dome lesions. Techniques in Foot and Ankle Surgery. 2002/12. 1(2):158-62.
Deland JT, Young K. Medial approaches to osteochondral lesions of the talus without medial malleolar osteotomy. San Diego: American Orthopaedic Foot and Ankle Society; 2001: 75.
Ferkel RD, Zanotti RM, Komenda GA, Sgaglione NA, Cheng MS, Applegate GR, et al. Arthroscopic treatment of chronic osteochondral lesions of the talus: long-term results. Am J Sports Med. 2008 Sep. 36(9):1750-62. [Medline].
Giannini S, Buda R, Vannini F, Di Caprio F, Grigolo B. Arthroscopic autologous chondrocyte implantation in osteochondral lesions of the talus: surgical technique and results. Am J Sports Med. 2008 May. 36(5):873-80. [Medline].
Savva N, Jabur M, Davies M, Saxby T. Osteochondral lesions of the talus: results of repeat arthroscopic debridement. Foot Ankle Int. 2007 Jun. 28(6):669-73. [Medline].
Tasto JP. Arthroscopy of the subtalar joint and arthroscopic subtalar arthrodesis. Instr Course Lect. 2006. 55:555-64. [Medline].
Bryant DD 3rd, Siegel MG. Osteochondritis dissecans of the talus: a new technique for arthroscopic drilling. Arthroscopy. 1993. 9(2):238-41. [Medline].
Kumai T, Takakura Y, Higashiyama I. Arthroscopic drilling for the treatment of osteochondral lesions of the talus. J Bone Joint Surg Am. 1999 Sep. 81(9):1229-35. [Medline].
Taranow WS, Bisignani GA, Towers JD. Retrograde drilling of osteochondral lesions of the medial talar dome. Foot Ankle Int. 1999 Aug. 20(8):474-80. [Medline].
Berlet GC, Mascia A, Miniaci A. Treatment of unstable osteochondritis dissecans lesions of the knee using autogenous osteochondral grafts (mosaicplasty). Arthroscopy. 1999 Apr. 15(3):312-6. [Medline].
Kumai T, Takakura Y, Kitada C, Tanaka Y, Hayashi K. Fixation of osteochondral lesions of the talus using cortical bone pegs. J Bone Joint Surg Br. 2002 Apr. 84(3):369-74. [Medline].
Gross AE, Agnidis Z, Hutchison CR. Osteochondral defects of the talus treated with fresh osteochondral allograft transplantation. Foot Ankle Int. 2001 May. 22(5):385-91. [Medline].
Kim CW, Jamali A, Tontz W. Treatment of post-traumatic ankle arthrosis with bipolar tibiotalar osteochondral shell allografts. Foot Ankle Int. 2002 Dec. 23(12):1091-102. [Medline].
Gobbi A, Francisco RA, Lubowitz JH, Allegra F, Canata G. Osteochondral lesions of the talus: randomized controlled trial comparing chondroplasty, microfracture, and osteochondral autograft transplantation. Arthroscopy. 2006 Oct. 22(10):1085-92. [Medline].
Haasper C, Zelle BA, Knobloch K, Jagodzinski M, Citak M, Lotz J, et al. No mid-term difference in mosaicplasty in previously treated versus previously untreated patients with osteochondral lesions of the talus. Arch Orthop Trauma Surg. 2008 May. 128(5):499-504. [Medline].
Matricali GA, Dereymaeker GP, Luyten FP. Donor site morbidity after articular cartilage repair procedures: a review. Acta Orthop Belg. 2010 Oct. 76 (5):669-74. [Medline].
Gautier E, Kolker D, Jakob RP. Treatment of cartilage defects of the talus by autologous osteochondralgrafts. J Bone Joint Surg Br. 2002 Mar. 84(2):237-44. [Medline].
Sammarco GJ, Makwana NK. Treatment of talar osteochondral lesions using local osteochondral graft. Foot Ankle Int. 2002 Aug. 23(8):693-8. [Medline].
Leumann A, Valderrabano V, Wiewiorski M, Barg A, Hintermann B, Pagenstert G. Bony periosteum-covered iliac crest plug transplantation for severe osteochondral lesions of the talus: a modified mosaicplasty procedure. Knee Surg Sports Traumatol Arthrosc. 2013 Jul 13. [Medline].
Niemeyer P, Salzmann G, Schmal H, Mayr H, Südkamp NP. Autologous chondrocyte implantation for the treatment of chondral and osteochondral defects of the talus: a meta-analysis of available evidence. Knee Surg Sports Traumatol Arthrosc. 2011 Oct 30. [Medline].
Koulalis D, Schultz W, Heyden M. Autologous chondrocyte transplantation for osteochondritis dissecans of the talus. Clin Orthop. 2002 Feb. (395):186-92. [Medline].
Giannini S, Buda R, Grigolo B. Autologous chondrocyte transplantation in osteochondral lesions of the ankle joint. Foot Ankle Int. 2001 Jun. 22(6):513-7. [Medline].
Browne JE, Anderson AF, Micheli LJ. Five-year multicenter outcome of autologous chondrocyte implantation of the knee: results in the first 100 consecutive patients. J Am Acad Orthop Surg. 2002.
McNickle AG, Provencher MT, Cole BJ. Overview of existing cartilage repair technology. Sports Med Arthrosc. 2008 Dec. 16(4):196-201. [Medline].
Coetzee JC, Giza E, Schon LC, Berlet GC, Neufeld S, Stone RM, et al. Treatment of osteochondral lesions of the talus with particulated juvenile cartilage. Foot Ankle Int. 2013 Sep. 34(9):1205-11. [Medline].
Kruse DL, Ng A, Paden M, Stone PA. Arthroscopic De Novo NT(®) juvenile allograft cartilage implantation in the talus: a case presentation. J Foot Ankle Surg. 2012 Mar-Apr. 51(2):218-21. [Medline].
Hatic SO 2nd, Berlet GC. Particulated juvenile articular cartilage graft (DeNovo NT Graft) for treatment of osteochondral lesions of the talus. Foot Ankle Spec. 2010 Dec. 3(6):361-4. [Medline].
Lee DH, Lee KB, Jung ST, Seon JK, Kim MS, Sung IH. Comparison of early versus delayed weightbearing outcomes after microfracture for small to midsized osteochondral lesions of the talus. Am J Sports Med. 2012 Sep. 40(9):2023-8. [Medline].
Kim YS, Park EH, Kim YC, Koh YG, Lee JW. Factors associated with the clinical outcomes of the osteochondral autograft transfer system in osteochondral lesions of the talus: second-look arthroscopic evaluation. Am J Sports Med. 2012 Dec. 40(12):2709-19. [Medline].
Santrock RD, Buchanan MM, Lee TH, Berlet GC. Osteochondral lesions of the talus. Foot Ankle Clin. 2003 Mar. 8(1):73-90, viii. [Medline].
Schuman L, Struijs PA, van Dijk CN. Arthroscopic treatment for osteochondral defects of the talus. Results at follow-up at 2 to 11 years. J Bone Joint Surg Br. 2002 Apr. 84(3):364-8. [Medline].
Woelfle JV, Reichel H, Nelitz M. Indications and limitations of osteochondral autologous transplantation in osteochondritis dissecans of the talus. Knee Surg Sports Traumatol Arthrosc. 2013 Aug. 21(8):1925-30. [Medline].