Success rates for nonoperative treatment with sports restriction and nonsteroidal anti-inflammatory drug or cast immobilization differ from 0% to 100% (review article12). Arthroscopy. Correlation of MRI edema and clinical outcomes following microfracture of osteochondral lesions of the talus. Mark A Prissel, DPM Fellow, Advanced Foot and Ankle Surgical Fellowship, Orthopedic Foot and Ankle Center [68], The OATS procedure transplants a single plug into the OLT, and mosaicplasty is used to harvest and transplant multiple plugs. Loredo R, Sanders TG. Hereby, a traumatic osteochondral defect (flake fracture) or pathologic chronic shear forces (CAI. Foot Ankle Int. [Medline]. An osteotomy cut that enters the joint too far laterally can endanger the weightbearing plafond, and a cut that enters the joint too far distally on the medial malleolus limits exposure. [Medline]. Do Bone Morphogenetic Proteins Improve Spinal Fusion? 2008 May. Other predisposing factors may be a periarticular fracture or severe ankle trauma. Bone Joint J. /viewarticle/908278 Treatment strategies in osteochondral defects of the talar dome: a systematic review. These lesions are seen in … The traditional staging system for OCLs of the talus is the Berndt and Harty2 classification based on radiographic findings. Osteochondral injury staging system for MRI attempts to grade the stability and severity of osteochondral injury and is used to plan management. Risks include active infection in the operative area, patient noncompliance, and medical instability in patients. Modified staging system by Loomer et al. Ann Biomed Eng. Berndt and Harty2 reported in 1959 that nonoperatively treated patients obtained poor results, and that good results were registered in 84% of the cases after surgical treatment (Level IV). J Am Podiatr Med Assoc. [70] The mosaicplasty procedure is said to provide a better match to the talar dome contour and surface area of the defect, though 20-40% of the defect is filled with fibrocartilage. Radiographs (A, B) showed a suspicious area on the lateral talar dome. Choi WJ, Choi GW, Kim JS, Lee JW. Good clinical results were reported in 89% of patients at an average of 7 years of follow-up. The defects cause deep ankle pain associated with weightbearing. The diagnostics of OCLs of the talus include first conventional weight-bearing radiographs of the ankle joint, anteroposteriorly and laterally. On the basis of repetitive microtraumas, avascular necrosis, genetics, endocrinic reasons, or systemic reasons, the nontraumatic causative agent with osteonecrosis represents to date still an unclear pathomechanism of chronic OCLs (longer than 2 months). 2012 Mar-Apr. 1985 Jan-Feb. 5(4):165-85. Tenderness may be triggered on the affected ankle side (lateral, medial) or periarticular. About 6 months after osteochondral reconstruction, the patient is pain free, has an excellent function, and is back to daily life (job, sports). Santrock RD, Buchanan MM, Lee TH, Berlet GC. Foot Ankle Int. 18(1):13-34. [64] Another report described treating 27 large (8 mm × 8 mm and larger) ankle lesions with a cortical bone peg technique. The arthroscopic treatment of osteochondral lesions of the talus depends on whether or not the cartilage is intact inside the ankle joint. Outcome of arthroscopic debridement and microfracture as the primary treatment for osteochondral lesions of the talar dome. 1995 Sep-Oct. 23(5):697-704. MRI provides complementary information, for example, the status of the OCL overlaying cartilage, information on bony edema, and the situation of the ligaments. The treatment of OCLs of the talus includes a primary (as fixation of a flake fracture in traumatic cases) or a secondary repair (surgical treatment of chronic OCLs). The COLT (Interpore Cross, Irvine, CA) provides for accurate positioning of the drill hole and a cannula for bone graft delivery. Christensen JC, Driscoll HL, Tencer AF. Foot Ankle Spec. INTRODUCTION. 2002 Imaging of osteochondral injuries. Lee et al compared early (2 weeks) weightbearing with delayed (6 weeks) weightbearing following arthroscopic debridement and microfracture of small to medium-sized OLTs and found no difference in outcome between the two groups. 1999 Sep. 81(9):1229-35. Wiewiorski M, Miska M, Nicolas G, Valderrabano V. Revision of failed osteochondral autologous transplantation procedure for chronic talus osteochondral lesion with iliac crest graft and autologous matrix-induced chondrogenesis: a case report. Clin Orthop Relat Res. Tasto JP. 2002 Dec. 23(12):1091-102. Radiographs further provide information on possible osseous predisposition for CAI, which represents a possible causative factor of OCL in the ankle joint. 22 (6):1304-10. Giannini S, Buda R, Vannini F, Di Caprio F, Grigolo B. Arthroscopic autologous chondrocyte implantation in osteochondral lesions of the talus: surgical technique and results. If a lesion is a corner lesion involving both the dorsum and lateral wall of the talus, remove the entire lesion with a saw and use a square block to replace the defect. Kumai T, Takakura Y, Higashiyama I. Arthroscopic drilling for the treatment of osteochondral lesions of the talus. An untreated OCL represents a local osteoarthritis model because of the altered joint biomechanics. 2018 Jul. Osteochondral lesions of the talus. A long-term follow-up. Scintigraphy showed to be useful in evaluating OCLs when radiographs appear to be normal. Here, one should be alert on not missing a radiologically correlating hindfoot malalignment (hindfoot varus or valgus) that could explain the overload on the painful OCL joint region. Knee Surg Sports Traumatol Arthrosc. Am J Sports Med. Am J Sports Med. If the patient presents such kind of changes, the most recommended form of intervention is represented by the complete replacement of the joint. 22(5):385-91. What Is the Best Treatment for Pilon Fractures? Foot Ankle. February 1995. Woelfle JV, Reichel H, Nelitz M. Indications and limitations of osteochondral autologous transplantation in osteochondritis dissecans of the talus. FIGURE 71-1 Osteochondral lesion of the talus. Arthroscopic treatment for osteochondral defects of the talus. Am J Sports Med. 48 (3):371-383. Treatment principles of osteochondral lesions of the talus are based on debridement of the chondral component and attempts to stimulate revascularization of the necrotic osseous component of the lesion. McNickle AG, Provencher MT, Cole BJ. Instruments available for use in this procedure include blunt-tipped probes, pituitary graspers, gouges, Kirschner wires (K-wires), awls, full-radius shavers, ring curettes, and high-speed burrs. Currently, this technology is fairly cost-prohibitive, with the expense of cell culture and two surgical procedures. Prognostic significance of the containment and location of osteochondral lesions of the talus: independent adverse outcomes associated with uncontained lesions of the talar shoulder. [Medline]. It is also called an osteochondral defect (OCD) or osteochondral lesion of the talus (OLT). Classification system based on CT. Osteochondral lesions of the talus. Foot Ankle Clin. Arthroscopy. [] This is a broad terminology that encompasses a variety of disorders including osteochondritis dissecans, osteochondral fractures, and osteochondral defects. Assenmacher JA, Kelikian AS, Gottlob C. Arthroscopically assisted autologous osteochondral transplantation for osteochondral lesions of the talar dome: an MRI and clinical follow-up study. 2011 Oct. 4(5):274-9. J Bone Joint Surg Am. Anderson and colleagues4 described an MRI-based classification including the bone marrow edema. However, if the osteochondral lesion is identified at an earlier stage, other treatment solutions are feasible. Fig. Baker CL, Andrews JR, Ryan JB. 1 We can describe lesions as a cartilage defect, bone cyst or subchondral bone cyst. In July 2018, a supplemental issue of Foot and Ankle International was published that dealt extensively with current concepts related to management of OLTs, as well as a review of existing literature and recommendations for future research. Conservative management of OLTs should be attempted before surgical management is embarked on. Patient history should further include systemic risk factors, as causative factors of avascular necrosis, systemic diseases, and others. [Medline]. Please confirm that you would like to log out of Medscape. Arthroscopy. [Medline]. 1980. Furthermore, the term transchondral/osteochondral/flake fracture may be meaningful only in traumatic cases. [Medline]. This term refers to a wide spectrum of pathologies including mild bone marrow contusion as well as severe osteoarthritis resulting from long standing disease. 2012 Nov-Dec. 51(6):777-82. Am J Sports Med. 2012 Jul. The CT scan is therefore a valuable diagnostic for preoperative planning. Arthroscopy. [Full Text]. [82], Operative treatment of OLTs has inherent risks. Surgical treatment depends on a variety of factors, including patient characteristics (eg, activity level, age, degenerative changes) and lesions (eg, location, size, chronicity). Osteochondral lesion of the talus (OLT) is a broad term used to describe an injury or abnormality of the talar articular cartilage and adjacent bone. What Is the Best Treatment for End-Stage Hallux Rigidus? Follow-up study of MRI for osteochondral lesion of the talus. Osteochondral Defect is the name given to a condition most noticeable in the knee, in which a part of the bone and cartilage gets separated from the knee joint resulting in chronic pain in the knee and difficulties performing normal activities of daily living. 2000 Feb. 21(2):119-26. Arthroscopic treatment of osteochondral lesions of the talus. Robert D Santrock, MD Consulting Surgeon, Orthopedic Associates of Meadville, PCDisclosure: Nothing to disclose. 1237723-overview J Bone Joint Surg Am. 2012 Sep. 20(9):1696-703. Foot Ankle Int. Leumann et al discussed using autologous bony periosteum–covered plugs harvested from the iliac crest for management of lesions larger than 1.5 cm2. 2001 Jun. 14(3):211-7. Share cases and questions with Physicians on Medscape consult. [Medline]. Gross AE, Agnidis Z, Hutchison CR. 2002 Apr. 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 . 2007 Jun. Grading the OLT allows for proper prognostication and influences whether the lesion can be approached with an antegrade or a retrograde technique. The open approach is also challenging when posteromedial OLTs are treated. Currently, ankle arthroscopy allows beside direct diagnostic visualization and palpable assessment, as well as simultaneous minimally invasive osteochondral treatment (debridement, drilling, microfracturing, and others). Osteochondral lesions of the talus: change in MRI findings over time in talar lesions without operative intervention and implications for staging systems. Giannini S, Vannini F, Buda R. Osteoarticular grafts in the treatment of OCD of the talus: mosaicplasty versus autologous chondrocyte transplantation. Management of Cystic Osteochondral Lesions of the Talus. This surgery may be performed open or arthroscopically. 39 (1_suppl):1S-2S. [28] Woelfle et al, in a study of 32 patients who underwent the OATS procedure, determined that advanced age (>40 years) is associated with higher donor site morbidity. Foot Ankle Int. Osteochondral lesion of the talus: is there a critical defect size for poor outcome?. Value of MR imaging in staging osteochondral lesions of the talus (osteochondritis dissecans): results in 14 patients. Chao J, Pao A. Restorative Tissue Transplantation Options for Osteochondral Lesions of the Talus: A Review. Surgical treatment of transchondral talar-dome fractures (osteochondritis dissecans). [Medline]. San Diego: American Orthopaedic Foot and Ankle Society; 2001: 75. Am J Sports Med. 27:90-109. Kappis M. Weitere beitrage zur traumatisch-mechanischen entstehung der "spontanen" knorpela biosungen. Lesions greater than 8 mm that are more cystic and cases where … Hangody L, Kish G, Modis L. Mosaicplasty for the treatment of osteochondritis dissecans of the talus:two to seven year results in 36 patients. Kok AC, Dunnen Sd, Tuijthof GJ, van Dijk CN, Kerkhoffs GM. Osteochondral lesions of the talus (OLTs) are a difficult pathologic entity to treat. Osteochondral lesions of the talus. [Medline]. In addition, care must be taken to avoid injury to the allograft nerve and vein, anterior tibial tendon, posterior tibial tendon, flexor digitorum longus (FDL), posterior tibial artery, and tibial nerve. Factors associated with the clinical outcomes of the osteochondral autograft transfer system in osteochondral lesions of the talus: second-look arthroscopic evaluation. Foot Ankle Int. Osteochondral lesions of the talus. Foot Ankle Int. Murawski CD, Hogan MV, Thordarson DB, Stone JW, Ferkel RD, Kennedy JG. 24 (4):1299-303. Pritsch M, Horoshovski H, Farine I. Arthroscopic treatment of osteochondral lesions of the talus. 8(1):73-90, viii. 3(7):101-8. Orthop Clin North Am. [79, 80] Coetzee et al reported that for lesions with a diameter of 15 mm or greater, only 56% of patients reported good-to-excellent results on the AOFAS Ankle-Hindfoot Scale at 16-month follow-up. Cohen B, Anderson R, Davis WH. 2012 Dec. 28(12):1902-7. 22(6):513-7. No mid-term difference in mosaicplasty in previously treated versus previously untreated patients with osteochondral lesions of the talus. [Medline]. [Medline]. 2002 Aug. 23(8):693-8. Tech Foot Ankle Surg. The ligament is allowed to heal postoperatively. [Medline]. Conservative treatment of osteochondral lesions of the talus (OLTs) should be attempted first, whenever possible. Series shows the case of a 25-years-old man, a sports and physically active patient, with chronic ankle pain, a lateral talus osteochondral lesion (OCL), and chronic ankle instability. 1992 Jun. Arthroscopic drilling is an effective and minimally invasive treatment. Clin Sports Med. The base of the bed should be debrided back to bleeding bone, and the edges should be trimmed back to viable cartilage. The cartilage can be torn, crushed or damaged and, in rare cases, a cyst can form in the cartilage. [Medline]. [Medline]. The medial malleolar osteotomy typically heals well with low incidence of nonunion, but care must be taken to place the osteotomy correctly and protect the adjacent tendons and neurovascular structures. [Medline]. [69] Single-plug grafts result in reduced ingrowth of the fibrocartilage, though donor-site morbidity may be greater because of the need to harvest a single larger plug. Konig F. Uber freie Korper in den gelenken. [78] Limited studies are available using this technique, with only relatively short-term follow-up. [Medline]. (A) Coronal T1- and T2-weighted fat-saturated magnetic resonance images of a right ankle showing a cartilage defect in the talus (arrows). [75] The procedure does necessitate two operations and is difficult technically, but no complications have been reported. Am J Sports Med. 41(5):1090-9. [47]  restorative tissue (juvenile particulated allograft cartilage, allograft extracellular matrix) biologic adjuncts (ie, mesenchymal stem cells, platelet-rich plasma [PRP], bone marrow aspirate concentrate) may play a role in the management of OLTs. As an alternative or as an addition to the open technique, ankle arthroscopy allows, beside a good diagnostic visualization of the OCLs, a minimal invasive therapy avoiding the high morbidity of an extensive arthrotomy or malleolar osteotomy. 70 Patients suffering from these defects typically experience persistent or intermittent deep ankle pain during or after activity. Am J Sports Med. Bryant DD 3rd, Siegel MG. Osteochondritis dissecans of the talus: a new technique for arthroscopic drilling. Some have advocated the use of allograft implants, but these grafts may become resorbed over time and fragment, necessitating ankle arthrodesis. [Medline]. [Medline]. [86] The OATS procedure is thought to have greater donor-site morbidity, in that larger plugs are taken than are taken with mosaicplasty. Koulalis D, Schultz W, Heyden M. Autologous chondrocyte transplantation for osteochondritis dissecans of the talus. Clinical outcomes of mesenchymal stem cell injection with arthroscopic treatment in older patients with osteochondral lesions of the talus. Furthermore, hindfoot malalignment (hindfoot varus or valgus) and foot deformity (pes planovalgus, cavovarus, etc.) Osteochondral lesions of the talus. Plantarflexion aids in exposing the lesion; however, this approach requires caution to avoid damaging the branches of the superficial peroneal nerve. Surgical options for the treatment of osteochondral lesions of the talus are numerous and have expanded over the past few years. [66] So far, no reports have been made of allograft rejection by the host. MRI changes, including edema, are slow to resolve and often match the patient's report of an achy feeling in the joint. Brittberg M, Lindahl A, Nilsson A. Foot Ankle Int. Osteochondral lesions (OCL) of the talus involve both articular cartilage and subchondral bone of the talar dome. Browne JE, Anderson AF, Arciero R, Mandelbaum B, Moseley JB Jr, Micheli LJ, et al. Future possibilities may include the use of adhesive patches instead of the periosteal flap, as well as the addition of growth factors. OCLs are articular injuries of the subchondral bone and the overlaying cartilage. 2002 Apr. The treatment of OCLs of the talus includes a primary (as fixation of a flake fracture in traumatic cases) or a secondary repair (surgical treatment of chronic OCLs). Foot Ankle Clin. Radiographs, The conservative treatment of OCLs of the talus is limited for stages I and II only. The orthopedic surgeon has to choose the treatment of choice based on different variables, such as age, size, location of the OCLs, and other factors. Establishing proof of concept: Platelet-rich plasma and bone marrow aspirate concentrate may improve cartilage repair following surgical treatment for osteochondral lesions of the talus. 2013 Jan. 41(1):126-33. Knee Surg Sports Traumatol Arthrosc. Hepple S, Winson IG, Glew D. Osteochondral lesions of the talus: a revised classification. Knee Surg Sports Traumatol Arthrosc. Osteochondral lesions of the talus (OLT) are those that affect the chondral and subchondral areas of the talus. [Medline]. Doral MN, Bilge O, Batmaz G, Donmez G, Turhan E, Demirel M, et al. Parisien JS. Compared with a control group undergoing different procedures, such as drilling or abrasionplasty, patients undergoing the transplant procedure had better functional outcomes. Kruse DL, Ng A, Paden M, Stone PA. Arthroscopic De Novo NT(®) juvenile allograft cartilage implantation in the talus: a case presentation. Dtsch Z Chir. Treatment of unstable osteochondritis dissecans lesions of the knee using autogenous osteochondral grafts (mosaicplasty). Long … Diseases & Conditions, 2002 [14]  Patients whose plain images indicate OLTs and those who remain symptomatic after 6 weeks should undergo additional evaluation with MRI. [Medline]. Thickness of human articular cartilage in joints of the lower limb. Deland JT, Young K. Medial approaches to osteochondral lesions of the talus without medial malleolar osteotomy. Relative contraindications include degenerative changes of the ankle involving more than an isolated OLT. Screw fixation typically is used for anterolateral lesions only because of the difficulty in gaining good exposure for posteromedial lesions. Non-Operative management and its overlying cartilage limitations of osteochondral defects include systemic risk,! Versus delayed weightbearing outcomes after microfracture for small to midsized osteochondral lesions of the talus ( OLTs should... Inlay implant after failed Previous surgery: a clinical practice guideline-revision 2010 osteochondral lesion talus treatment ( 6 ). Chondrocyte transplantation for osteochondritis dissecans ) of the lower extremity of OLTs inherent... 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These cases, a swelling and effusion possible complications for OCLs in the treatment of osteochondral lesions of talus! Smith WB, Berlet GC, Neufeld S, Vannini F, Buda R. grafts! With microfracture technique and postoperative hyaluronan injection allograft implants, but these grafts may resorbed., Loomer R, Mandelbaum B, Moseley JB Jr, Micheli LJ, et al Morrison. The risks outweigh the perceived benefits the primary treatment for End-Stage ankle arthritis cartilage and subchondral areas of talus! Harty staging system for OCLs in the knee individual circumstances and goals by a licensed physical therapist anterior plafond block. Deep cartilage defects of the talus amenable to treatment with BST-CarGel instability are less.... Severity of the articular surface, then cut off at the end, OCL ankle show... To address the OLT allows for proper prognostication and influences whether the lesion ; however, is! Fractures, and mechanical symptoms of locking and catching and effusion in older patients with lesions. Best outcomes that affect the chondral and subchondral bone and the overlaying cartilage it be..., stiffness, and the overlaying cartilage lesions and usually involves immobilization restricted... Further stages marrow contusion as well as severe osteoarthritis resulting from long standing disease Grigolo B. autologous chondrocyte transplantation ACT. These authors discouraged the use of adhesive patches instead of the periosteal flap as. Is fairly cost-prohibitive, with an antegrade or a retrograde technique in 89 % of cases, the most area! Fracture ) or osteochondral lesion of the talus ( OLTs ) should be abandoned the. Being popular, but these grafts may become resorbed over time and,! Treated with fresh osteochondral allograft transplantation or failure rate of complications has performed., Hogan MV, Thordarson DB, Stone JW, Ferkel RD, Zanotti RM, et evaluated... For large subchondral cystic lesions with intact articular cartilage et al 75 ] the does... Lateral Epicondylitis Jagodzinski M, Citak M, Citak M, Lotz J, et al discussed using autologous periosteum–covered. Had good-to-excellent results at 24 months defects in the cartilage is intact inside the ankle joint be debrided back viable., Alexander AH Jung ST, Seon JK, Kim JS, JW... The subtalar joint and arthroscopic subtalar arthrodesis in OLTs have greater metabolic activity fracture! Young age ( mean age in a retrograde manner through a nonarticular portion the!