Updated: 3/6/2019

Osteochondral Lesions of the Talus

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Evidence
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Techniques
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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 the 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 fracture 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 (marrow stimulation) 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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Questions (5)
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(OBQ13.46) A 43-year-old male sustained a left ankle injury 3 years ago. Radiographs at the time were negative and his pain improved over the next two months. However, for the last six months, he has developed persistent ankle pain with intermittent swelling. He has been treating his symptoms with physical therapy and anti-inflammatory medications with little effect. Physical examination elicits pain with ankle dorsiflexion and plantarflexion, although subtalar motion is normal. Figures A and B are radiographs of the left ankle. Figure C shows the corresponding MRI. What would be the next most appropriate step for treatment? Review Topic

QID: 4681
FIGURES:
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1

Total contact cast immobilization and nonweight-bearing for 6 weeks

12%

(322/2645)

2

Ankle arthrodesis

1%

(18/2645)

3

Open autologous chondrocyte implantation

11%

(288/2645)

4

Arthroscopic marrow stimulation

69%

(1825/2645)

5

Ankle corticosteroid injection

7%

(173/2645)

L 4

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(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? Review Topic

QID: 4434
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1

Increased incidence of traumatic etiology

67%

(3290/4917)

2

Lesions are usually deeper

4%

(186/4917)

3

Better chance of spontaneous resolution

10%

(495/4917)

4

Usually more posterior

11%

(521/4917)

5

Are more common

8%

(388/4917)

L 3

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SUBMIT RESPONSE 1

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(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? Review Topic

QID: 224
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1

Continue physical therapy

1%

(38/2711)

2

Avoidance of dancing with CAM walker boot for 2 weeks

7%

(191/2711)

3

MRI of the ankle

90%

(2443/2711)

4

Ankle steroid injection

1%

(17/2711)

5

Diagnostic ankle arthroscopy

1%

(15/2711)

L 1

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SUBMIT RESPONSE 3
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