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Osteochondral Lesions of the Talus Treatment & Management

  • Author: Christopher F Hyer, DPM, FACFAS; Chief Editor: Anthony E Johnson, MD  more...
 
Updated: Apr 12, 2016
 

Approach Considerations

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.[36]

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.[46]

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.[30]

In conjunction with marrow-stimulation techniques,[47] 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]

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Medical Therapy

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.[14]  Patients whose plain images indicate OLTs and those who remain symptomatic after 6 weeks should undergo additional evaluation with MRI.

Osteochondral lesions of the talus. Illustration o Osteochondral lesions of the talus. Illustration of percutaneous transmalleolar drilling.
Osteochondral lesions of the talus. Cannulated dri Osteochondral lesions of the talus. Cannulated drill placed over a guidewire.
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Surgical Therapy

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) [51]
  • 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)

Procedural details

Preoperative assesment

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.

Surgical exposure

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.[53]

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.[22]

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]

Internal fixation

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.

Bone grafting

The authors have reported successful fixation after autogenous osteochondral grafting of an osteochondritis dissecans of the knee.[61] Another report described treating 27 large (8 mm × 8 mm and larger) ankle lesions with a cortical bone peg technique.[62] 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.[63] 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.[64]

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.[65]

The OATS procedure transplants a single plug into the OLT, and mosaicplasty is used to harvest and transplant multiple plugs.[66] 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.[67] 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.[27]

Several groups have reported good results with both procedures. Eleven patients who underwent mosaicplasty had good-to-excellent results at 24 months.[68] 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.[28] 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.[69]

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.[70]

Autologous chondrocyte transplantation

Two reports described good early results with ACT.[71] Koulalis et al reported the results of ACT in 8 patients, with an average follow-up of 17.6 months.[72] 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.[73]

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.[74]

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.[75] 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.[76]

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.[61]

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Postoperative Care

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.[79]

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Complications

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.[52]

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.[80] An anterior tibial bone-block access window is associated with a lower risk of malunion but may limit access to posterior lesions.[69]

Arthroscopic intervention is associated with less surgical morbidity and joint stiffness, decreased rehabilitation time, and an increased functional outcome.[81]

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.[82] 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.[63] 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.[28] 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.[83] 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.[68] 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.[72] The procedure does necessitate two operations and is difficult technically, but no complications have been reported.

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Long-Term Monitoring

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.[38]

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Contributor Information and Disclosures
Author

Christopher F Hyer, DPM, FACFAS Foot and Ankle Surgeon, Director, Advanced Foot and Ankle Surgery Fellowship, Orthopedic Foot and Ankle Center

Christopher F Hyer, DPM, FACFAS is a member of the following medical societies: American College of Foot and Ankle Surgeons, American Podiatric Medical Association

Disclosure: Received consulting fee from Wright Medical Technology for consulting; Received royalty from Wright Medical Technology for consulting; Received consulting fee from Amniox for consulting; Received consulting fee from Stryker for none; Received consulting fee from Biomet for none.

Coauthor(s)

Gregory C Berlet, MD, FRCSC Partner, Orthopedic Foot and Ankle Center

Gregory C Berlet, MD, FRCSC is a member of the following medical societies: American Medical Association, American Orthopaedic Foot and Ankle Society, Canadian Medical Association, Canadian Orthopaedic Association, College of Physicians and Surgeons of Ontario, Ontario Medical Association, Royal College of Physicians and Surgeons of Canada

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Wright Medical Technology; DJO Global; Stryker; Tissue Tech; ZimmerBiomet<br/>Serve(d) as a speaker or a member of a speakers bureau for: Wright Medical Technology; Tissue Tech<br/>Received research grant from: DJO Global<br/>Received research funds from zimmer; Received royalty from SAGE, Wright Medical, Bledsoe Brace, and Stryker; Received stock or stock options from Bledsoe, Tissue Tech, and Wright Medical Technology; .

Robert D Santrock, MD Consulting Surgeon, Orthopedic Associates of Meadville, PC

Disclosure: Nothing to disclose.

Mark A Prissel, DPM Fellow, Advanced Foot and Ankle Surgical Fellowship, Orthopedic Foot and Ankle Center

Mark A Prissel, DPM is a member of the following medical societies: American College of Foot and Ankle Surgeons, American Podiatric Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Anthony E Johnson, MD Chairman, Department of Orthopaedic Surgery, San Antonio Military Medical Center; Research Director, US Army–Baylor University Doctor of Science Program (Orthopaedic Physician Assistant); Custodian, Military Orthopaedic Trauma Registry; Associate Professor, Department of Surgery, Baylor College of Medicine; Associate Professor, The Norman M Rich Department of Surgery, Uniformed Services University of the Health Sciences

Anthony E Johnson, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Healthcare Executives, American College of Sports Medicine, American Orthopaedic Association, Arthroscopy Association of North America, Association of Bone and Joint Surgeons, International Military Sports Council, San Antonio Community Action Committee, San Antonio Orthopedic Society, Society of Military Orthopaedic Surgeons, Special Operations Medical Association

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Society of Military Orthopaedic Surgeons; American Academy of Orthopaedic Surgeons<br/>Received research grant from: Congressionally Directed Medical Research Program<br/>Received income in an amount equal to or greater than $250 from: Nexus Medical Consulting.

Additional Contributors

James K DeOrio, MD Associate Professor of Orthopedic Surgery, Duke University School of Medicine

James K DeOrio, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Foot and Ankle Society

Disclosure: Received royalty from Merete for other; Received royalty from SBi for other; Received royalty from BioPro for other; Received honoraria from Acumed, LLC for speaking and teaching; Received honoraria from Wright Medical Technology, Inc for speaking and teaching; Received honoraria from SBI for speaking and teaching; Received honoraria from Integra for speaking and teaching; Received honoraria from Datatrace Publishing for speaking and teaching; Received honoraria from Exactech, Inc for speaking a.

Acknowledgements

Thomas H. Lee, MD (Assistant Professor of Orthopedic Surgery, Ohio State University College of Medicine; Consulting Surgeon, Orthopedic Foot and Ankle Center) is gratefully acknowledged for contributions made to this article.

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Berndt and Harty staging system for osteochondral lesions of the talus, with grades 1-4.
Osteochondral lesions of the talus. Modified staging system by Loomer et al.
Osteochondral lesions of the talus. Classification system based on CT.
Osteochondral lesions of the talus.
Osteochondral lesions of the talus. Illustration of percutaneous transmalleolar drilling.
Osteochondral lesions of the talus. Cannulated drill placed over a guidewire.
 
 
 
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