Osteochondral Lesions of the Talus

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

Heppple 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
    - nondisplaced fragment wiht incomplete fracture
Operative
- arthroscopy with removal of the loose fragment and 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

TAG

(OBQ12.74) 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? Topic

Review Topic

1. Increased incidence of traumatic etiology
2. Lesions are usually deeper
3. Better chance of spontaneous resolution
4. Usually more posterior
5. Are more common

PREFERRED RESPONSE ▶

DISCUSSION: 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.

Incorrect answers:
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.

Illustrations: A

REFERENCES:

1. Ferkel RD, Hommen JP. Arthroscopy of the foot and ankle. In: Coughlin MJ, Mann RA, Saltzman CL,

2. Canale ST, Belding RH. Osteochondral lesions of the talus. J Bone Joint Surg Am. 1980 Jan;62(1):97-102. PMID:7351423 (Link to Abstract)

3. 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. 1985 Jan-Feb;5(4):165-85. PMID:3830846 (Link to Abstract)

Question Authors:

David Abbasi MD, Ben Taylor MD, Michael Hughes MD, Daniel Farber MD,

Please Rate Educational Value!

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TAG

(OBQ06.213) 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? Topic

Review Topic

1. Continue physical therapy
2. Avoidance of dancing
3. MRI
4. Ankle steroid injection
5. Diagnostic ankle arthroscopy

PREFERRED RESPONSE ▶

DISCUSSION: 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%). Nonop (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.

REFERENCES:

1. 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. 2000 Feb;21(2):119-26. PMID:10694023 (Link to Abstract)

2. Barnes CJ, Ferkel RD. Arthroscopic debridement and drilling of osteochondral lesions of the talus. Foot Ankle Clin. 2003 Jun;8(2):243-57. PMID:12911239 (Link to Abstract)

Question Authors:

Patrick McCulloch MD, Derek Moore,

Please Rate Educational Value!

3.0

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Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Ferkel RD, Hommen JP. Arthroscopy of the foot and ankle. In: Coughlin MJ, Mann RA, Saltzman CL,

Undefined

Barnes CJ, Ferkel RD. Arthroscopic debridement and drilling of osteochondral lesions of the talus. Foot Ankle Clin. 2003 Jun;8(2):243-57. PMID:12911239 (Link to Abstract)
Canale ST, Belding RH. Osteochondral lesions of the talus. J Bone Joint Surg Am. 1980 Jan;62(1):97-102. PMID:7351423 (Link to Abstract)
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. 1985 Jan-Feb;5(4):165-85. PMID:3830846 (Link to Abstract)
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. 2000 Feb;21(2):119-26. PMID:10694023 (Link to Abstract)

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