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Introduction
  • Osteochondral lesions of the talus may be caused by
    • trauma
    • repetitive microtrauma with no history of trauma
      • bilateral in 10% of cases
  • Locations include
    • medial talar dome
      • usually no history of trauma
      • more common
      • more posterior
      • larger and deeper than lateral lesions
    • lateral talar dome 
      • usually have a traumatic history 
      • more superficial and smaller
      • more central or anterior
      • lower incidence of spontaneous healing
      • more often displaced and symptomatic
Classification
 
Berndt and Harty Radiographic Classification  
Stage 1  • Small area of subchondral compression
Stage 2  • Partial fragment detachment. 
Stage 3  • Complete fragment detachment but not displaced. 
Stage 4  • Displaced fragment. 
 
Ferkel and Sgaglione CT Staging System
Stage 1  • Cystic lesion within dome of talus with an intact roof on all view
Stage 2a  • Cystic lesion communication to talar dome surface
Stage 2b  • Open articular surface lesion with overlying nondisplaced fragment.
Stage 3  •  Nondisplaced lesion with lucency
Stage 4  • Displaced fragment
 
Hepple  MRI Staging System
Stage 1  • Articular cartilage edema
Stage 2a  • Cartilage injury with underlying facture and surrounding bony edema
Stage 2b  • Stage 2a without surrounding bone edema
Stage 3  • Detached but nondisplaced fragment
Stage 4  • Displaced fragment
Stage 5  • Subchondral cyst formation
 
Presentation
  • Symptoms
    • pain, swelling, and mechanical symptoms such as catching or locking
  • Physical exam
    • effusion
Imaging
  • Radiographs  
    • may be normal
    • may see subtle lucency or bone fragmentation
  • CT
    • helpful in evaluating lesions seen on radiographs
  • MRI
    • indicated in ankle sprains that do not heal with time 
Treatment
  • Nonoperative
    • short leg cast and non weight bearing for 6 weeks
      • indications
        • acute injury
        • nondisplaced fragment with incomplete fracture
  • Operative
    • arthroscopy with removal of the loose fragment and microfracture or antegrade drilling of the base  
      • indications
        • chronic fractures  
        • size < 1 cm
        • displaced smaller fragment with minimal bone on the osteochondral fragment (poor healing potential)
    • retrograde drilling and or bone grafting  
      • indications
        • size > 1 cm with intact cartilage cap
    • ORIF vs. osteochondral grafting
      • indications
        • size > 0.5 cm and displaced
      • rehabilitation
        • emphasize peroneal strengthening, range of motion, and proprioceptive training 
 

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