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A 21-year-old male reports right ankle pain after sustaining an inversion ankle injury 2 years ago. He complains of mechanical symptoms with ankle movement that continue to be symptomatic with everyday activities. During his workup, an MRI shows a 1x1 cm lateral talar osteochondral defect (OCD). When compared to medial talar OCDs, which of the following statements is true regarding lateral talar OCDs?
Increased incidence of traumatic etiology
Lesions are usually deeper
Better chance of spontaneous resolution
Usually more posterior
Are more common
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Lateral talar OCDs have an increased history of a traumatic etiology in comparision to medial talar OCDs.
Lateral talar OCDs are also usually less common, smaller and more shallow than medial talar OCDS. Lateral talar OCDs are usually anterior in comparison to medial based OCDs, and are harder to treat with conservative treatment due to a lower incidence of spontaneous healing.
Canale et el. did a retrospective study of osteochondral lesions of the talus. They found that lateral lesions were associated with a history of inversion or inversion-dorsiflexion trauma, were morphologically shallow, and were more likely to become displaced in the joint and to have persistent symptoms. Medial lesions were both traumatic and atraumatic in origin, morphologically deep, and usually less symptomatic.
Flick et al. performed a retrospective study and review of the literature of osteochondritis dissecans of the talus (transchondral fractures of the talus). A history of trauma was noted in 100% of the lateral lesions and 80% of the medial talar dome lesions. Lateral dome lesions requiring surgery were approached through the standard anterolateral incision, while medial dome lesions were approached through the anterior tibial tendon sheath with grooving of the anteromedial distal tibia articular surface allowing posteriorly placed medial lesions to be reached, without medial malleolar osteotomy.
Illustration A shows a T1 coronal MRI with a lateral talar OCD.
Answer 2- Lateral talar OCDs are usually more shallow in depth than medial talar OCDs.
Answer 3- Lateral talar OCDs are harder to treat with conservative treatment due to a lower incidence of spontaneous healing.
Answer 4- Medial talar OCDs are usually more posteriorly located than lateral talar OCDs.
Answer 5- Medial talar OCDs are more common than lateral talar OCDs.
Canale ST, Belding RH.
J Bone Joint Surg Am. 1980 Jan;62(1):97-102. PMID: 7351423 (Link to Abstract)
Flick AB, Gould N.
Foot Ankle. 1985 Jan-Feb;5(4):165-85. PMID: 3830846 (Link to Abstract)
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A 30-year-old professional ballet dancer presents with persistant ankle pain after an ankle sprain 6 months ago. Physical therapy and NSAID's have not alleviated the symptoms. Physical exam reveals some joint swelling but no ligamentous instability. Radiographs are unremarkable. What is the next appropriate step in the management of this patient?
Continue physical therapy
Avoidance of dancing with CAM walker boot for 2 weeks
MRI of the ankle
Ankle steroid injection
Diagnostic ankle arthroscopy
The vast majority of ankle sprains heal well with time, rest, therapy, and temporary immobilization. In those approximate 10% that do not improve, an osteochondral lesion of the talus and persistent instability must be considered. The question stem states that there is no ligamentous instability so the next step should be an MRI to evaluate for an osteochondral lesion of the talus (OLT). Surgery is indicated for OLTs if conservative therapy fails after 6 months.
Tol et al performed a systematic review of 32 articles and showed that excision, curettage, and drilling had the highest success rate (85%), followed by excision and curettage (78%). Nonoperative (45%) and excision only (38%) were less successful and not recommended.
The reference by Barnes and Ferkel is a review of the evaluation and treatment of OLT's.
Tol JL, Struijs PA, Bossuyt PM, Verhagen RA, van Dijk CN.
Foot Ankle Int. 2000 Feb;21(2):119-26. PMID: 10694023 (Link to Abstract)
Barnes CJ, Ferkel RD.
Foot Ankle Clin. 2003 Jun;8(2):243-57. PMID: 12911239 (Link to Abstract)
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HPI - A 17 year old male presented to sports clinic for assessment after twisting his ankle while playing soccer two days earlier. Prior to this recent episode, his ankle was completely asymptomatic.
XRays were taken, which revealed an OCD lesion of the medial talar dome. He was referred for an MRI. Images are shown.
How would you manage this patient's OCD lesion?
HPI - No history of ankle or foot trauma.
Started complaining of pain in the ankle and midfoot in 2009, which slowly progressed.
MRI shows a 8mm x 8mm lesion in the talar dome.
How would you treat the osteochondral lesion of the talus?
HPI - Right ankle sprain 9 months ago. 1 month of rest with cast
What is the most likely cause of the cysts in the talus?