Osteochondral Lesions of the Talus Workup

  • Author: Christopher F Hyer, DPM, FACFAS; Chief Editor: Jason H Calhoun, MD, FACS   more...
 
Updated: Feb 17, 2012
 

Imaging Studies

  • Patients with an acute ankle injury with hemarthrosis or substantial tenderness first undergo weightbearing plain radiography (anteroposterior, lateral, and mortise views).
    • Radiographs in varying degrees of plantarflexion and dorsiflexion may help in diagnosing posteromedial and anterolateral lesions, respectively.[21]
    • Plain radiographs of the opposite ankle should be obtained because of a 10-25% incidence of a contralateral lesion.[22]
  • MRI can be used to identify occult injuries of the subchondral bone and cartilage that may not be detected with routine radiographs.[20, 23]
    • Classic MRI findings include areas of low signal intensity on T1-weighted images, which suggests sclerosis of the bed of the talus and indicates a chronic lesion.[24, 25]
    • T2-weighted images reveal a rim that represents instability of the osteochondral fragment.[24, 26]
    • Posttreatment MRI depicts a reduction or disappearance of the low signal intensity on T1-weighted images and the rim on T2-weighted images.
Next

Diagnostic Procedures

  • In 1995, Cheng et al developed a comprehensive arthroscopic classification system (see Staging, below).[27]
Previous
Next

Staging

Osteochondral lesions of the talus ( OLTs) should be staged. MRI is used to evaluate the quality of the overlying cartilage and to assess the stability of the lesion.[28]

Several staging systems have been developed on the basis of the first system that Berndt and Harty proposed in 1959.[3] See the image below.

Berndt and Harty staging system for osteochondral Berndt and Harty staging system for osteochondral lesions of the talus, with grades 1-4.

In 1996, Ferkel modified this classic system and developed another system, based on CT.[29] See the images below.

Osteochondral lesions of the talus. ClassificationOsteochondral lesions of the talus. Classification system based on CT. Osteochondral lesions of the talus. Modified stagiOsteochondral lesions of the talus. Modified staging system by Loomer et al.

Ferkel's system corresponds to the stages in the Berndt and Harty classification but also considers fragment separation, the presence of subchondral cysts, and the extent of osteonecrosis.

  • MRI is sensitive in detecting bone signal changes. In 1999, Hepple et al devised the following staging system[30] :
    • Stage 1 - Articular cartilage damage only
    • Stage 2 - Cartilage injury with underlying fracture
      • Stage 2a - Cartilage injury with underlying fracture and edema
      • Stage 2b - Cartilage injury with underlying fracture but no edema
    • Stage 3 - Detached (rim signal) but not displaced fragment
    • Stage 4 - Displaced fragment
    • Stage 5 - Subchondral cyst formation
  • Cheng et al developed the following arthroscopic staging system[27] :
    • Stage A - Smooth, intact, but soft or ballotable; stable
    • Stage B - Rough surface; stable
    • Stage C - Fibrillation/fissuring; stable
    • Stage D - Flap present or bone exposed; unstable
    • Stage E - Loose, undisplaced fragment; unstable
    • Stage F - Displaced fragment; unstable
Previous
Proceed to Treatment & Management
 
 
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 and American Podiatric Medical Association

Disclosure: Wright Medical Technology Consulting fee Consulting; Wright Medical Technology Royalty Consulting; Orthopaedic Research and Education Foundation Grant/research funds Co-Investigator; DJO Global Consulting fee Consulting

Coauthor(s)

Gregory C Berlet, MD, FRCS(C)  Clinical Assistant Professor of Orthopedics, Chief of Foot and Ankle Surgery, Department of Orthopedic Surgery, Ohio State University College of Medicine and Public Health

Gregory C Berlet, MD, FRCS(C) 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, and Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

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

Disclosure: Nothing to disclose.

Specialty Editor Board

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, Florida Medical Association, and German Society of Neurology

Disclosure: Nothing to disclose.

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

Disclosure: Medscape Salary Employment

Shepard R Hurwitz, MD  Executive Director, American Board of Orthopaedic Surgery

Shepard R Hurwitz, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association for the Advancement of Science, American College of Rheumatology, American College of Sports Medicine, American College of Surgeons, American Diabetes Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Association for the Advancement of Automotive Medicine, Eastern Orthopaedic Association, Orthopaedic Research Society, Orthopaedic Trauma Association, and Southern Orthopaedic Association

Disclosure: Nothing to disclose.

Dinesh Patel, MD, FACS  Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital

Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Jason H Calhoun, MD, FACS  Frank J Kloenne Chair in Orthopedic Surgery, Professor and Chair, Department of Orthopedics, The Ohio State University Medical Center

Jason H Calhoun, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Diabetes Association, American Medical Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Missouri State Medical Association, Musculoskeletal Infection Society, Southern Medical Association, Southern Orthopaedic Association, Texas Medical Association, and Texas Orthopaedic Association

Disclosure: Nothing to disclose.

Additional Contributors

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.

References

  1. Konig F. Uber freie Korper in den gelenken. Dtsch Z Chir. 1888;27:90-109.

  2. Kappis M. Weitere beitrage zur traumatisch-mechanischen entstehung der "spontanen" knorpela biosungen. Dtsch Z Chir. 1922;171:13-29.

  3. Berndt AL, Harty M. Transchondral fractures (osteochondritis diseccans) of the talus. J Bone Joint Surg. 1959;41A:988-1020.

  4. 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].

  5. 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. Jul 2001;22(7):544-51. [Medline].

  6. Anderson IF, Crichton KJ, Grattan-Smith T. Osteochondral fractures of the dome of the talus. J Bone Joint Surg Am. Sep 1989;71(8):1143-52. [Medline].

  7. Baker CL, Andrews JR, Ryan JB. Arthroscopic treatment of transchondral talar dome fractures. Arthroscopy. 1986;2(2):82-7. [Medline].

  8. Parisien JS. Arthroscopic treatment of osteochondral lesions of the talus. Am J Sports Med. May-Jun 1986;14(3):211-7. [Medline].

  9. Pettine KA, Morrey BF. Osteochondral fractures of the talus. A long-term follow-up. J Bone Joint Surg Br. Jan 1987;69(1):89-92. [Medline].

  10. Van Buecken K, Barrack RL, Alexander AH. Arthroscopic treatment of transchondral talar dome fractures. Am J Sports Med. May-Jun 1989;17(3):350-5; discussion 355-6. [Medline].

  11. Pritsch M, Horoshovski H, Farine I. Arthroscopic treatment of osteochondral lesions of the talus. J Bone Joint Surg Am. Jul 1986;68(6):862-5. [Medline].

  12. Canale ST, Belding RH. Osteochondral lesions of the talus. J Bone Joint Surg Am. Jan 1980;62(1):97-102. [Medline].

  13. 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. Jan-Feb 1985;5(4):165-85. [Medline].

  14. Woods K, Harris I. Osteochondritis dissecans of the talus in identical twins. J Bone Joint Surg Br. Mar 1995;77(2):331. [Medline].

  15. Bruns J, Rosenbach B, Kahrs J. [Etiopathogenetic aspects of medial osteochondrosis dissecans tali]. Sportverletz Sportschaden. Jun 1992;6(2):43-9. [Medline].

  16. Athanasiou KA, Niederauer GG, Schenck RC Jr. Biomechanical topography of human ankle cartilage. Ann Biomed Eng. Sep-Oct 1995;23(5):697-704. [Medline].

  17. Shepherd DE, Seedhom BB. Thickness of human articular cartilage in joints of the lower limb. Ann Rheum Dis. Jan 1999;58(1):27-34. [Medline].

  18. Treppo S, Koepp H, Quan EC. Comparison of biomechanical and biochemical properties of cartilage from human knee and ankle pairs. J Orthop Res. Sep 2000;18(5):739-48. [Medline].

  19. 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. Nov 1994;84(11):537-47. [Medline].

  20. Loredo R, Sanders TG. Imaging of osteochondral injuries. Clin Sports Med. Apr 2001;20(2):249-78. [Medline].

  21. Stroud CC, Marks RM. Imaging of osteochondral lesions of the talus. Foot Ankle Clin. Mar 2000;5(1):119-33. [Medline].

  22. Stone JW. Osteochondral Lesions of the Talar Dome. J Am Acad Orthop Surg. Mar 1996;4(2):63-73. [Medline].

  23. 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. Mar 2006;27(3):157-66. [Medline].

  24. Higashiyama I, Kumai T, Takakura Y. Follow-up study of MRI for osteochondral lesion of the talus. Foot Ankle Int. Feb 2000;21(2):127-33. [Medline].

  25. Mesgarzadeh M, Sapega AA, Bonakdarpour A, et al. Osteochondritis dissecans: analysis of mechanical stability with radiography, scintigraphy, and MR imaging. Radiology. Dec 1987;165(3):775-80. [Medline].

  26. 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. Mar 1990;154(3):555-8. [Medline].

  27. 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.

  28. 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. Sep 9 2008;[Medline].

  29. Ferkel RD. Articular surface defects, loose bodies, and osteophytes. In: Arthroscopic Surgery: The Foot and Ankle. Philadelphia, Pa: Lippincott-Raven; 1996:145.

  30. Hepple S, Winson IG, Glew D. Osteochondral lesions of the talus: a revised classification. Foot Ankle Int. Dec 1999;20(12):789-93. [Medline].

  31. 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. Dec 29 2011;[Medline].

  32. 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.

  33. 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.

  34. 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. Sep 2008;36(9):1750-62. [Medline].

  35. 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. May 2008;36(5):873-80. [Medline].

  36. Savva N, Jabur M, Davies M, Saxby T. Osteochondral lesions of the talus: results of repeat arthroscopic debridement. Foot Ankle Int. Jun 2007;28(6):669-73. [Medline].

  37. Tasto JP. Arthroscopy of the subtalar joint and arthroscopic subtalar arthrodesis. Instr Course Lect. 2006;55:555-64. [Medline].

  38. 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. Feb 2000;21(2):119-26. [Medline].

  39. Bryant DD 3rd, Siegel MG. Osteochondritis dissecans of the talus: a new technique for arthroscopic drilling. Arthroscopy. 1993;9(2):238-41. [Medline].

  40. Kumai T, Takakura Y, Higashiyama I. Arthroscopic drilling for the treatment of osteochondral lesions of the talus. J Bone Joint Surg Am. Sep 1999;81(9):1229-35. [Medline].

  41. Taranow WS, Bisignani GA, Towers JD. Retrograde drilling of osteochondral lesions of the medial talar dome. Foot Ankle Int. Aug 1999;20(8):474-80. [Medline].

  42. Berlet GC, Mascia A, Miniaci A. Treatment of unstable osteochondritis dissecans lesions of the knee using autogenous osteochondral grafts (mosaicplasty). Arthroscopy. Apr 1999;15(3):312-6. [Medline].

  43. 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. Apr 2002;84(3):369-74. [Medline].

  44. Gross AE, Agnidis Z, Hutchison CR. Osteochondral defects of the talus treated with fresh osteochondral allograft transplantation. Foot Ankle Int. May 2001;22(5):385-91. [Medline].

  45. Kim CW, Jamali A, Tontz W. Treatment of post-traumatic ankle arthrosis with bipolar tibiotalar osteochondral shell allografts. Foot Ankle Int. Dec 2002;23(12):1091-102. [Medline].

  46. [Best Evidence] 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. Oct 2006;22(10):1085-92. [Medline].

  47. 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. May 2008;128(5):499-504. [Medline].

  48. Al-Shaikh RA, Chou LB, Mann JA. Autologous osteochondral grafting for talar cartilage defects. Foot Ankle Int. May 2002;23(5):381-9. [Medline].

  49. Gautier E, Kolker D, Jakob RP. Treatment of cartilage defects of the talus by autologous osteochondralgrafts. J Bone Joint Surg Br. Mar 2002;84(2):237-44. [Medline].

  50. 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. Jul 2001;22(7):552-8. [Medline].

  51. Sammarco GJ, Makwana NK. Treatment of talar osteochondral lesions using local osteochondral graft. Foot Ankle Int. Aug 2002;23(8):693-8. [Medline].

  52. 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. Oct 30 2011;[Medline].

  53. Koulalis D, Schultz W, Heyden M. Autologous chondrocyte transplantation for osteochondritis dissecans of the talus. Clin Orthop. Feb 2002;(395):186-92. [Medline].

  54. Giannini S, Buda R, Grigolo B. Autologous chondrocyte transplantation in osteochondral lesions of the ankle joint. Foot Ankle Int. Jun 2001;22(6):513-7. [Medline].

  55. 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.

  56. Santrock RD, Buchanan MM, Lee TH, Berlet GC. Osteochondral lesions of the talus. Foot Ankle Clin. Mar 2003;8(1):73-90, viii. [Medline].

  57. 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. Apr 2002;84(3):364-8. [Medline].

  58. Shearer C, Loomer R, Clement D. Nonoperatively managed stage 5 osteochondral talar lesions. Foot Ankle Int. Jul 2002;23(7):651-4. [Medline].

  59. 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].

  60. Giannini S, Vannini F, Buda R. Osteoarticular grafts in the treatment of OCD of the talus: mosaicplasty versus autologous chondrocyte transplantation. Foot Ankle Clin. Sep 2002;7(3):621-33. [Medline].

  61. 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. Jan 31 2012;[Medline].

  62. Agung M, Ochi M, Adachi N, Uchio Y, Takao M, Kawasaki K. Osteochondritis dissecans of the talus treated by the transplantation of tissue-engineered cartilage. Arthroscopy. Dec 2004;20(10):1075-80. [Medline].

  63. Giannini S, Buda R, Faldini C, Vannini F, Bevoni R, Grandi G. Surgical treatment of osteochondral lesions of the talus in young active patients. J Bone Joint Surg Am. 2005;87 Suppl 2:28-41. [Medline].

  64. Raikin SM, Elias I, Zoga AC, Morrison WB, Besser MP, Schweitzer ME. Osteochondral lesions of the talus: localization and morphologic data from 424 patients using a novel anatomical grid scheme. Foot Ankle Int. Feb 2007;28(2):154-61. [Medline].

  65. Rodriguez EG, Hall JP, Smith RL, Rachoy JP, Szmyd T. Treatment of osteochondral lesions of the talus with cryopreserved talar allograft and ankle distraction with external fixation. Surg Technol Int. 2006;15:282-8. [Medline].

  66. Scranton PE Jr, Frey CC, Feder KS. Outcome of osteochondral autograft transplantation for type-V cystic osteochondral lesions of the talus. J Bone Joint Surg Br. May 2006;88(5):614-9. [Medline].

  67. Tanaka Y, Omokawa S, Fujii T, Kumai T, Sugimoto K, Takakura Y. Vascularized bone graft from the medial calcaneus for treatment of large osteochondral lesions of the medial talus. Foot Ankle Int. Dec 2006;27(12):1143-7. [Medline].

 
Previous
Next
 
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.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.