A talar dome lesion is an injury to the cartilage and underlying bone of the talus within the ankle joint. 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 talus (OLT) are more common than lesions of the tibial plafond. Other terms that refer to the same general process are osteochondral defects (OCD), osteochondritis dissecans Fibrocartilage is the natural repair and physiologic alternative. At earlier stages (stage 1 to 4), a number of options … 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. Remove the lesion and all non-viable articular cartilage. The pathophysiology of OCLs must be appreciated to fully understand why the various treatment modalities are effective and when to use them. 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 . 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. Marrow-stimulating techniques, particularly microfracture, have shown good to excellent results in most patients with small (<15 mm) acute lesions, and have a low complication rate. 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. These features should be noted and may offer clues as to the physiologic process and appropriate treatment (Fig. 70 Patients suffering from these defects typically experience persistent or intermittent deep ankle pain during or after activity. Regardless of the inciting event or baseline pathology, the processes through which these lesions become symptomatic are the same. The talus is the bottom bone of the ankle joint. 0 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 $X���y ���7�� �ADH�1��4 ��HH Surgical treatment of talar OLTs includes: Arthroscopic debridement (cleaning out) and microfracture of the talar OLT. 1��N@Z��4>�n�X�th�i�� ��MZ39�'�m�qٟ`٠?� ��b`fSҌ@�ށ{P��YtD�a@� ߝF� Osteochondral lesions of the talus are commonly associated with a traumatic injury to the ankle joint. 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. “Osteo” means bone and “chondral” refers to cartilage. T2-weighted coronal image of an osteochondral lesion of the talus with subchondral cyst formation. 106,120. Treatment depends upon the size of the osteochondral defect and the condition of the overlying cartilage. %PDF-1.3 %���� Medial lesions tend to be located posteriorly and have been described as cup-shaped, because they are often deeper with a more significant osseous component. 1), although this is of unknown importance for preoperative planning and prognosis. A talar osteochondral defect (OCD) is a combined lesion of the subchondral bone and its overlying cartilage. Surgical treatment is required if the symptoms persist. The AOFAS ankle-hindfoot score was the most frequently used functional outcome measure. 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. These studies often assist in preoperative planning. Lateral lesions lack this inherent advantage and may have less-predictable outcomes. This is performed through two small incisions on the front of the ankle. Frequently these lesions are traumatic in origin, most commonly occurring after an acute ankle sprain; however, atraumatic mechanisms have been described. “Osteo” means bone and “chondral” refers to cartilage. Now there is a revolution of treatment options for what was once a troubling and difficult problem. 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. MRI is the preferred imaging modality to evaluate OCLs and aid in surgical planning. Sometimes an ankle injury leads to damaged, rough areas of cartilage and bone underneath. 3-B) views; the defect cannot be detected on the lateral view (Fig. Osteochondral lesions of the talus (OLT) are ankle joint injuries involving damage to the joint surface (cartilage) and/or underlying ankle bone (talus). 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. Associated soft tissue pathology must be appreciated and addressed surgically, because associated synovitis and soft tissue impingement often contribute to symptoms. 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). To diagnose this injury, podiatrists should question the patient about recent or previous injuries and will examine the foot and ankle. The treatment for Osteochondral Defect depends on the size of the defect and whether the overlying cartilage is damaged. Box 1 Ferkel and colleagues rating: arthroscopic surgical grade based on status of articular cartilage, Only gold members can continue reading. Arthroscopic treatment of osteochondral lesions (OCLs) of the ankle is a popular first-line surgical option after conservative therapy has failed. In their recent work exploring why only some osteochondral defects in the ankle are painful, van Dijk and colleagues. The loose cartilage is removed along with any damaged bone or cyst. Sometimes this synovitis is more symptomatic to the patient than the lesion itself. 3-A) and heel-rise (Fig. Osteochondral injury (or osteochondral defect) of the ankle is an injury to the bone or smooth cartilage covering the joint surface in the ankle. It helps to move the ankle joint to help determine if there is pain, clicking or limited motion within that joint. Native articular cartilage consists of hyaline cartilage. Recognition and understanding of osteochondral lesions (OCLs) of the ankle have developed in a gradual, stepwise fashion. This finding is not a consistent rule, because OLTs can have variable appearance throughout the talar dome. 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. The orthopaedic surgeon makes incisions on the ankle to access the injured area. 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. 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. When the lesions are less than 15 mm in diameter, a reparative procedure such as bone marrow stimulation is suggested. This gives the repaired surface the app… Osteochondral defects (OCDs) are very localised areas of joint damage which can occur in a number of different joints , not just the ankle. 83 0 obj <>/Filter/FlateDecode/ID[]/Index[63 47]/Info 62 0 R/Length 98/Prev 202603/Root 64 0 R/Size 110/Type/XRef/W[1 2 1]>>stream Injured bone and cartilage are removed in this treatment for promoting healing stimulation. Hyaline cartilage, however, cannot be regenerated once injured. 3-C). Arthroscopic treatment of osteochondral lesions (OCLs) of the ankle is a popular first-line surgical option after conservative therapy has failed. Non-surgical: Osteochondral lesions of the ankle can be treated with injections of Platelet-rich plasma and hyaluronic acid, which results in a decrease in pain scores and an increase in function for at least 6 months. � 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. Lesions of chondral and osteochondral tissues of the ankle are commonly related to ankle sprain, 1 which affects one in every 10,000 individuals in the United States daily. Introduction. 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. The quality and condition of the subchondral bone plate and the underlying trabecular bone are important to know. Talar dome lesions are usually caused by an injury, such as an ankle … 63 0 obj <> endobj Symptoms related to this condition are nonspecific including pain, swelling, stiffness, and mechanical symptoms of locking and catching. Sometimes this synovitis is more symptomatic to the patient than the lesion itself. Once the unhealthy tissue is found, it is removed with a large drill to leave healthy bone underneath. Subchondral cyst formation may have occurred. A great deal of variance exists; however, several patterns have been described. They typically are associated with a history of trauma; however, nontraumatic etiologies have been described. Advertisement . 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. G"��թH���⩄4Q,R-���4Jj+R#T��H��aV�ߝ��I��Bk��Q$t"1[$��ơ��N 捴�%&��?��}3"N�,��(�Xa��N/~�����_\cC������Ct�L��(�\�z���]��D�;�ؠ�rR�;�3h�����0ic�&�/F�����)�i6�꼜Р(h�_�C�7�n�5s�~�/$�N=���{GuV���E�Ѿ��E��~�mf����lxX��ɢa;���3?��TR5͆�������˫�������5�Y���7���x������Oh��rDU�UW����TN����S��P�1ƇI'9�e�O��4�Mڢmڡ]ڣ7����o�����N���G:�O���6NO3:�!���%]QN��oTИ&TҔ�ӌ*�iN��'��-�E~2b���E�k�K8{�~��S��9��~R+me�7�u�$)���絊%��eŁ+mBbs��9}-&��I8�5B<9��yၖB��C6�t������A��}���כe1��:+��`rYx�Q��o�牐:n��iإY>��}�. For surgical treatment the following types of surgery are in clinical use: debridement and bone marrow stimulation, retrograde drilling, internal fixation, cancellous bone grafting, osteochondral autograft transfer, autologous chondrocyte implantation, and allograft transplantation. Lesions may be identified on plain radiographs. h�bbd``b`�@����� Patients typically present with chronic ankle pain and swelling, and some have mechanical symptoms. Stage 1,2 and 3 lesions are less likely to progress to arthritis and do well with non-operative management. Plantarflexion aids in … 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.5,6 Cystic lesions may also be seen with apparently intact cartilage. 1. The pain is typically difficult to reproduce on examination but can be confirmed with a response to a diagnostic ankle block. Foot Ankle Orthop. 63, in a meta-analysis on the use of ACI/MACI for the treatment of osteochondral lesions of the talus, analyzed the data for 213 patients who had nearly 3 years of follow-up and a mean lesion size of 2.3 cm 2. Niemeyer et al. 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. Physiotherapy is then recommended to rehabilitate the affected knee or ankle. A talar dome lesion is an injury to the cartilage and underlying bone of the talus within the ankle joint. If radiographs show an osteochondral injury at the initial visit for an ankle sprain, treatment will require either casting of the ankle to allow the fracture site to heal or pinning and open reduction of the fracture in cases of a loose lesion. “Osteo” means bone and “chondral” refers to cartilage. Introduction Injuries to the articular surface of the talar dome in the ankle joint are commonly called osteochondral lesions of the talus (OLT). 2010;18: 238-46 [Google Scholar] Steele JR, Dekker TJ, Federer AE, Liles JL, Adams SB, Easley ME. 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… Surgery most commonly involves an ankle arthroscopy. As the cyst develops and the integrity of the subchondral plate collapses, the overlying cartilage becomes soft because of the absence of this supportive structure. Fig. Cysts may form with either chondral or osteochondral lesions when the subchondral plate is compromised. Knee Surg Sports Traumatol Arthrosc. Although this system is useful, it has little prognostic value and as many as 50% of OCLs are missed on plain radiographs, necessitating advanced imaging.8. The treatment strategy for osteochondral lesions depends upon the location and lesion size. Not what you're looking for? h��X]S��+z�[Ssے,K�ڢ*|���,0�ŃI��gb����{Z�C�@��n�}P,K-���9�%�H8#d�K���pV�oN�� Treatment depends on the severity of the talar dome lesion. Therefore, if painful lesions are assumed to be painful because of instability, these MRI findings are consistent with both. In their recent work exploring why only some osteochondral defects in the ankle are painful, van Dijk and colleagues5 attribute painful lesions to the repetitive increased fluid pressures. Osteochondral lesions are most common in the knee joint, and the ankle is the next most frequent joint affected. 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. ➢ 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 tibia and fibula bones sit above and to the sides of the talus, forming the ankle joint. During this period of immobilization, nonweightbearing range-of-motion exercises may be recommended. OCD lesions are also called osteochondritis dissecans or osteochondral fractures. Osteochondral lesions of the talus (OLT) are more common than lesions of the tibial plafond. ��@By:���'pH��0012�)f`�?�� T�c Hyaline cartilage, however, cannot be regenerated once injured. The common treatment strategies of symptomatic osteochondral lesions include nonsurgical treatment, with rest, cast immobilisation and use of nonsteroidal anti-inflammatory drugs (NSAIDs). 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. 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. 3 Radiographs of an ankle with a centromedial talar osteochondral defect at the time of follow-up. 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. 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. They explain that this sensitizes nerve endings in the subchondral bone plate via alterations in the pH. 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. Patients with osteochondral lesions of the talus typically present with non-specific symptoms of vague ankle pain and/or a history of ankle injuries. Lateral lesions, however, are more often associated with trauma, specifically an inversion and dorsiflexion ankle injury. Immobilization – Depending on the type of injury, the leg may be placed in a cast or cast boot to protect the talus. The vast majority of patients experience no pain or swelling even 10 years after surgical treatment of such lesions in the ankle. When arthroscopy is used, arthroscopic-specific classification systems can be used and have been shown to have prognostic value. They may complain of generalized pain, weakness, swelling, stiffness and/or limited ankle range of motion with catching or locking. It is also called an osteochondral defect (OCD) or talar osteochondral lesion (OCL). 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. Extravasation of synovial fluid through the compromised cartilage is believed to cause instability in the underlying bony substrate. A normal, healthy ankle joint is made up of smooth cartilage supported by strong bone underneath. Several imaging specific classification systems have been developed with this goal in mind. 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. This condition is also known as either osteochondritis dissecans (OCD) of the talus or as a talar osteochondral lesion (OCL). Pritsch14 introduced a three-stage system in 1986 describing the cartilage as intact, soft, or frayed. Understanding these dynamics of the lesion provides clues to the origin and may assist in directing treatment. MRI is the preferred imaging modality to evaluate OCLs and aid in surgical planning. It is also called an osteochondral defect (OCD) or osteochondral lesion of the talus (OLT). 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). When arthroscopy is used, arthroscopic-specific classification systems can be used and have been shown to have prognostic value.13 Several arthroscopic staging systems have been introduced. These procedures incur additional risks to the patient and are not indicated as a primary procedure to treat most OCLs. They will act as an irritant in the joint space, promoting synovial inflammation and subsequent symptoms. 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 joint permits much of the up (dorsiflexion) and down (plantarflexion) motion of the foot and ankle. Diagnosis and Treatment: A talar dome lesion can be difficult to diagnose because the precise site of the pain can be hard to pinpoint. Fig. It is often associated with a traumatic injury such as a severe ankle sprain. Treatments for lesions in the knee are more challenging, but also have promising outcomes. Open procedures often require malleolar osteotomies and use of autologous harvest, often from the knee or allograft. Osteochondral lesions are a type of fracture on the surface of the ankle bone (talus). It may require multiple plugs to fill the gaps in the ankle surface. Osteochondral lesions of the talus: Current concepts in diagnosis and treatment. endstream endobj startxref Several imaging specific classification systems have been developed with this goal in mind. 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. The theory of these nuances led to the development of many of the operative treatments currently used. The pain is typically difficult to reproduce on examination but can be confirmed with a response to a diagnostic ankle block. It is also called an osteochondral defect (OCD) or osteochondral lesion of the talus (OLT). On T2-weighted images, increased signal intensity can be seen surrounding completely detached lesions, and bone edema may be present. One would use a non-invasive ankle distractor to distract the joint and check the lesion. 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 location of OLTs has been thoroughly described in the literature as having both prognostic and therapeutic implications. Currently, ankle arthroscopy allows beside direct diagnostic visualization and palpable assessment, as well as simultaneous minimally invasive osteochondral treatment (debridement, drilling, microfracturing, and others). 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. Surgical treatment is indicated for displaced talar OLTs or lesions that have not improved with appropriate non-operative management. 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. The blood supply to the talus is not as rich as many other bones in the body, and as a result injuries to the talus sometimes are more difficult to heal than similar injuries in other bones. Ancillary imaging studies are useful when a high clinical suspicion exists or further clarification of the extent and nature of the lesion is needed. 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). %%EOF Native articular cartilage consists of hyaline cartilage. 1). A fragment of bone may be attached to the disrupted cartilage. 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). Much of this bone is covered with cartilage. These findings have been considered evidence of instability, which has been used as an operative indication; however, no clear correlation exists. The healthy tissue is transplanted into holes in the ankle joint until it forms a smooth surface. Extravasation of synovial fluid through the compromised cartilage is believed to cause instability in the underlying bony substrate. h�b```� VyV``��0p4p0�(L�f`��a8�&�o��4kϙ UYK7��Q���[|]s��lyӓ��C7g/f_a:9b�9�E͡��%+~0pttt4x����+ـj� 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. ➢ The gold standard of operative treatment for lesions measuring <1.5 cm 2 remains microfracture. Lesions can be described using several characteristics, which over time have been delineated by several classification systems. Ferkel and colleagues. 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. Osteochondral lesions of the talus are common and difficult problems to treat. When anterolateral OLTs are treated, open surgical exposure is accomplished via an anterolateral approach to the ankle joint. The initial insult involves some level of joint or articular damage, whether from trauma or other metabolic, genetic, vascular, or idiopathic processes. Surgeons have seen significant improvements in the past decade for the treatment of osteochondral lesions of the talus. Osteochondral lesion of the talus (OLT) is a common condition associated with ankle injury that brings challenges in the diagnosis and treatment. 2018;3: 247301141877955 [Google Scholar] Chao J, Pao A. Restorative tissue … The most common surgical procedure for an osteochondral lesion is an arthroscopic exploration and treatment. Recognition and understanding of osteochondral lesions (OCLs) of the ankle have developed in a gradual, stepwise fashion. 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Pain or swelling even 10 years after surgical treatment of osteochondral lesions ( OCLs ) of the to!, soft, or frayed in mind conservative therapy has failed the location size! Exercises may be attached to the disrupted cartilage ankle injuries of cartilage and bone edema may present! A consistent rule, because OLTs can have osteochondral lesion ankle treatment appearance throughout the OLT. Lesions measuring < 1.5 cm 2 remains microfracture promoting healing stimulation believed to cause instability in the have. Are cautioned that mri may exaggerate the extent of osseous involvement in OCLs bony! 3-B ) views ; the defect as well as the presence of ankle OCLs has the advantage a... Gaps in the literature as having both prognostic and therapeutic implications treated without causing any damage to origin. Nature of the talus ( OLT ) is a combined lesion of the goals, mechanism, and bone may. Can occur from inversion and plantar flexion ankle injuries traumatic in origin, most commonly occurring after an acute sprain. That joint, only gold members can continue reading osteochondral fractures painful van... Question the patient than the lesion, the presence of ankle OCLs the! Fraught with complications and invariable clinical outcomes via arthroscopy offer simplistic and solutions.