Sections

Sections Osteochondral Lesions of the Talus
Overview
Presentation
Workup
Treatment
Media Gallery
References

Workup

Radiography

Patients with an acute ankle injury with hemarthrosis or substantial tenderness first undergo weightbearing plain radiography (anteroposterior [AP], lateral, and mortise views). Radiographs in varying degrees of plantarflexion and dorsiflexion may help in diagnosing posteromedial and anterolateral lesions, respectively.^[33] Plain radiographs of the opposite ankle should be considered, especially if symptoms are apparent, because of the 10-25% incidence of a contralateral lesion.^[34]

Magnetic Resonance Imaging

Magnetic resonance imaging (MRI) can be used to identify occult injuries of the subchondral bone and cartilage that may not be detected with routine radiography.^{[35, 36]} Postoperative MRI evaluation may also be considered to assess healing after surgical management.^[37]

Classic MRI findings include areas of low signal intensity on T1-weighted images, which suggest sclerosis of the bed of the talus and indicate a chronic lesion.^{[38, 39]} T2-weighted images reveal a rim that represents instability of the osteochondral fragment.^{[38, 40]} Posttreatment MRI depicts a reduction or disappearance of the low signal intensity on T1-weighted images and the rim on T2-weighted images.

Arthroscopy

Arthroscopy may be used as the basis for staging osteochondral lesions of the talus (OLTs). In 1995, Cheng et al developed a comprehensive arthroscopic classification system (see Staging).^[41] Typically, arthroscopy is performed to confirm the diagnosis and in conjunction with treatment. Isolated diagnostic arthroscopy is rarely performed.

Staging

OLTs should be staged. MRI is used to evaluate the quality of the overlying cartilage and to assess the stability of the lesion.^[42] Several staging systems have been developed on the basis of the first system that Berndt and Harty proposed in 1959 (see the image below).^[1]

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

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In 1996, Ferkel modified this classic system and developed another system, based on computed tomography (CT) findings.^[43] (See the images below.) Ferkel's system corresponded to the stages in the Berndt and Harty classification but also considered fragment separation, the presence of subchondral cysts, and the extent of osteonecrosis.

Osteochondral lesions of the talus. Classification system based on CT.

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Osteochondral lesions of the talus. Modified staging system by Loomer et al.

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MRI is sensitive in detecting bone signal changes. In 1999, Hepple et al devised the following staging system^[44]:

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^[41]:

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

Treatment & Management

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Media Gallery

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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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)

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: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: NovaStep, Inc. Received income in an amount equal to or greater than $250 from: NovaStep, Inc.

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

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

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: DJO Global; Stryker; Tissue Tech; ZimmerBiomet, Artelon, Ossio, BBHP, Medline, Paragon28, Restor3d Serve(d) as a speaker or a member of a speakers bureau for: Tissue tech, Artelon, Ossio, Medline, DJO, Stryker Received royalty from ZimmerBiomet; Stryker; Medline; Artelon; Ossio.

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

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

Vinod K Panchbhavi, MD, FACS, FAOA, FABOS, FAAOS Professor of Orthopedic Surgery, Chief, Division of Foot and Ankle Surgery, Director, Foot and Ankle Fellowship Program, Department of Orthopedic Surgery, University of Texas Medical Branch School of Medicine

Vinod K Panchbhavi, MD, FACS, FAOA, FABOS, FAAOS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Orthopaedic Trauma Association, Texas Orthopaedic Association

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Styker.

Additional Contributors

James K DeOrio, MD Professor of Orthopedics, Director, Duke Foot and Ankle Fellowship, Duke University Medical Center, Duke University School of Medicine; Associate Professor, Mayo Clinic College of Medicine; Clinical Assistant Professor, F Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences

James K DeOrio, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Foot and Ankle Society, Association of Graduates, United States Air Force Academy, Doctors Mayo Society, Mayo Clinic Alumni Association, Society of Air Force Clinical Surgeons, Society of Military Orthopaedic Surgeons

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Exactech; Treace Medical; Additive; Mirus; Crossroads Orthopedics Serve(d) as a speaker or a member of a speakers bureau for: Exactech; Treace Medical; Additive; Mirus; WoultersKluwer; Crossroads Orthopedics Received income in an amount equal to or greater than $250 from: Exactech; Treace Medical; Additive; Mirus; WoultersKluwer; Crossroads Orthopedics.

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.

Sections Osteochondral Lesions of the Talus
Overview
Presentation
Workup
Treatment
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References

Osteochondral Lesions of the Talus Workup

Radiography

Magnetic Resonance Imaging

Arthroscopy

Staging

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