Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), Presurgical Functional MappingAndrew C. Papanicolaou, Roozbeh Rezaie, Shalini Narayana, Marina Kilintari, Asim F. Choudhri, Frederick A. Boop, and James W. Wheless, the Child With SeizureDon K. Mathew and Lawrence D. Morton, and Pharmacologic Consequences of SeizuresShilpa D. Kadam and Michael V. Johnston, Self-Limited EpilepsiesDouglas R. Nordli, Jr., Colin D. Ferrie, and Chrysostomos P. Panayiotopoulos, in Epilepsy: A Network and Neurodevelopmental PerspectiveRaman Sankar and Edward C. Cooper, Hematology, Oncology and Palliative Medicine. 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 . 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. [Medline]. If this trend continues, the use of allografts will likely fall from favor. Retrograde drilling can facilitate bone grafting, which is ideal for large subchondral cystic lesions with intact articular cartilage. They require a strong plan. 2016 Apr. 2008 Dec. 16(4):196-201. Do Bone Morphogenetic Proteins Improve Spinal Fusion? Clin Orthop Relat Res. 39 (1_suppl):1S-2S. Follow-up study of MRI for osteochondral lesion of the talus. Bruns and Rosenbach19 showed 85% excellent and good results in patients 16 years and younger in comparison with 65% in adults, with 8% failure in each group only (Level IV evidence).19 These results are also confirmed by Higuera and coworkers (Level IV).20 In long-term, persistent, radiologic irregularities were found in 38% (Level IV).21 Shearer and coworkers22 managed even high-grade cystic lesions nonsurgically (Level IV).22 However, after 38 months of follow-up, 18% of patients had to be transferred to ankle arthrodesis. 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. Future possibilities may include the use of adhesive patches instead of the periosteal flap, as well as the addition of growth factors. 84(3):364-8. McNickle AG, Provencher MT, Cole BJ. Schuman L, Struijs PA, van Dijk CN. [Medline]. [68], The OATS procedure transplants a single plug into the OLT, and mosaicplasty is used to harvest and transplant multiple plugs. Pettine KA, Morrey BF. The traditional staging system for OCLs of the talus is the Berndt and Harty2 classification based on radiographic findings. [Full Text]. Dtsch Z Chir. Savva N, Jabur M, Davies M, Saxby T. Osteochondral lesions of the talus: results of repeat arthroscopic debridement. The broad term “osteochondral lesion of the talus” describes an injury or abnormality of the talar articular cartilage and adjacent bone. A marked distortion of normal mechanical alignment must be corrected at the same operative setting as the surgery to address the OLT. [83] An anterior tibial bone-block access window is associated with a lower risk of malunion but may limit access to posterior lesions. OCLs are articular injuries of the subchondral bone and the overlaying cartilage. 1922. In most of the conservatively treated OCL cases, the pain remains untreated and the disease advances to further stages. James K DeOrio, MD Professor of Orthopedics, Director, Duke Foot and Ankle Fellowship, Duke University Medical Center, Duke University School of Medicine; Associate Professor, Mayo Clinic College of Medicine; Clinical Assistant Professor, F Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences A talar dome lesion is an injury to the cartilage and underlying bone of the talus within the ankle joint. 2010 May-Jun. Surgical treatment of OCLs traditionally includes excision of loose bodies, debridement of the area, and drilling or microfracturing. J Bone Joint Surg Am. Clin Orthop Relat Res. 2010 Oct. 76 (5):669-74. [Medline]. Ann Biomed Eng. Osteochondral lesion of the talus (OLT) is a common condition associated with ankle injury that brings challenges in the diagnosis and treatment. J Bone Joint Surg Am. 2005 Jul. The different options for secondary repairs depend on whether the OCL is predominantly a problem of the chondral layer, the osseous part, or a combination of both, on the age of the patient and the size of the OCL (Tables 71-2 and 71-3). Arthroscopy. Instr Course Lect. A talar osteochondral defect (OCD) is a combined lesion of the subchondral bone and its overlying cartilage. 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 . With CT, the stages described by Berndt and Harty can be better defined, OCL cysts and fragments better visualized, and the integrity of the subchondral bone better analyzed. A high rate of complications has been reported in patients who underwent tibiotalar osteochondral allografting. Long-term follow-up. INTRODUCTION. 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. 41(5):1090-9. [Medline]. Chao J, Pao A. Restorative Tissue Transplantation Options for Osteochondral Lesions of the Talus: A Review. 2002 Dec. 1 (2):158-62. 71-1). [Medline]. Clinical examination should document patient history and include physical examination. [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. Foot Ankle Int. Kok AC, Dunnen Sd, Tuijthof GJ, van Dijk CN, Kerkhoffs GM. Because of the relatively high cost of ACI and the knee morbidity seen in OATS, we conclude that BMS is the treatment of choice for primary osteochondral talar lesions. 2(2):82-7. [Medline]. Osteochondral lesions of the talus: size, age, and predictors of outcomes. Thermal capsular shrinkage may also be a possible treatment solution. The CT scan is therefore a valuable diagnostic for preoperative planning. Foot Ankle. [Medline]. Arthroscopic drilling is an effective and minimally invasive treatment. FIGURE 71-1 Osteochondral lesion of the talus. 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. Treatment of osteochondral lesions of the talus with microfracture technique and postoperative hyaluronan injection. [Medline]. The COLT (Interpore Cross, Irvine, CA) provides for accurate positioning of the drill hole and a cannula for bone graft delivery. Abstract. Last, a commonly used arthroscopic classification is the OCL classification of the International Cartilage Repair Society.5, Epidemiologically, the ankle registers 4% of all the human osteochondral defects.6 The cause of OCLs of the talus has multiple facets. Conservative treatment of osteochondral lesions of the talus (OLTs) should be attempted first, whenever possible. 2002 Aug. 23(8):693-8. [78] Limited studies are available using this technique, with only relatively short-term follow-up. Grading the OLT allows for proper prognostication and influences whether the lesion can be approached with an antegrade or a retrograde technique. Osteochondral lesion of the talus: is there a critical defect size for poor outcome?. 2002 Sep. 7(3):621-33. They were kept on nonweightbearing status for 6-7 weeks. Illustration of percutaneous transmalleolar drilling. [Medline]. Elias I, Jung JW, Raikin SM, Schweitzer MW, Carrino JA, Morrison WB. The open approach is also challenging when posteromedial OLTs are treated. Symptoms of intra-articular derangement are indications for operative intervention. (A) Coronal T1- and T2-weighted fat-saturated magnetic resonance images of a right ankle showing a cartilage defect in the talus (arrows). The use of traditional bone screws passed in an antegrade fashion is discouraged because irreparable damage to the intact articular cartilage results. [84]. Choi WJ, Park KK, Kim BS, Lee JW. There are several non-operative management options for the treatment of osteochondral lesions, including: Cast immobilization: If the OLT occurs following an acute injury, initial immobilization in a cast for 4-6 weeks can help reduce stress on the OLT and allow healing. Trauma plays the most important role in the pathomechanism of talus OCLs. 1989 Sep. 71(8):1143-52. A meta-analysis on 201 patients proved a 45% success rate of conservative treatment for stages I and II, as well as medial stage III talus OCLs.15 Whereas acute lesions seem to do worse (0% success rates in acute transchondral fractures16), chronic lesions show different success rates between 41% (cast immobilization12) and 59% for restriction of activities, but free range of motion.17,18 Young patients seem to do better with conservative treatment than aged patients. Talus OCLs most often affect sports active young individuals and becomes symptomatic through persistent pain, joint swelling, and sometimes blocking of the joint. Schuman reviewed 22 patients who underwent arthroscopy with curettage and drilling at an average follow-up of 4.8 years, with 86% good-to-excellent results. Currently, this technology is fairly cost-prohibitive, with the expense of cell culture and two surgical procedures. [Medline]. The SPECT-CT and diagnostic arthroscopy confirmed a lateral talus OCL stage III-IV with cystic lesions (C–F). In one study, 11 patients who underwent mosaicplasty had good-to-excellent results at 24 months. Because of the still unclear natural history of OCLs, several terms can be found for this entity to date in the literature, for example, osteochondritis dissecans, osteochondral fracture, flake fracture, and others. After 6 months, a persistent effusion, a catching sensation, or severe pain signifies that healing is not progressing as intended, and further investigation with computed tomography (CT) or MRI is appropriate. (Histologic examination of one biopsy sample did not show hyaline cartilage. 2013 Mar. 2013 Aug. 21(8):1925-30. About 6 months after osteochondral reconstruction, the patient is pain free, has an excellent function, and is back to daily life (job, sports). [30], In conjunction with marrow-stimulation techniques, 2008 Sep. 36(9):1750-62. Overall, more than 80% of the talus OCLs are of traumatic origin.7,8 In such traumatic cases, the acute OCLs are frequently located on the lateral dome of the talus (anterolateral) (Table 71-1). Osteochondral lesions of the talus. 23(7):651-4. The top of the talus is dome-shaped and is completely covered with cartilage. Osteochondral injury staging system for MRI attempts to grade the stability and severity of osteochondral injury and is used to plan management. Plantarflexion aids in exposing the lesion; however, this approach requires caution to avoid damaging the branches of the superficial peroneal nerve. 1 We can describe lesions as a cartilage defect, bone cyst or subchondral bone cyst. [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. Osteochondral lesions of the talus (OLT) are those that affect the chondral and subchondral areas of the talus. 84(2):237-44. Correlation of MRI edema and clinical outcomes following microfracture of osteochondral lesions of the talus. [11, 54], Posteromedial OLTs have also been treated by using a combined anterior and posterior arthrotomy exposure. [76], ACT has been performed more often in the knee. Offering a thorough primer on treating osteochondral lesions of varying sizes and comcomitant presentations, this author discusses key diagnostic principles and optimal procedure selection. 2014 Jun. [Medline]. Osteochondral Lesions of the Talus Sara Lyn Miniaci-Coxhead, MD Dr. Miniaci-Coxhead or an immediate family member serves as a board member, owner, officer, or committee member of the American Orthopaedic Foot and Ankle Society. [Medline]. The treatment approach of the osteochondral lesion is influenced by a number of factors, such as: location and size of the lesion, presence of secondary degenerative changes. Despite the large number of publications (Level II-IV evidence), to date, no strong evidences and guidelines are available in the literature. Polat G, Erşen A, Erdil ME, Kızılkurt T, Kılıçoğlu Ö, Aşık M. Long-term results of microfracture in the treatment of talus osteochondral lesions. Treatment of cartilage defects of the talus by autologous osteochondralgrafts. Berlet GC, Mascia A, Miniaci A. Am J Sports Med. Patients may report ankle sprain or CAI. Alexander AH, Lichtman DM. Osteochondral lesions or osteochondritis dessicans can occur in any joint, but are most common in the knee and ankle. Berndt and Harty staging system for osteochondral lesions of the talus, with grades 1-4. 2000 Feb. 21(2):127-33. 145. 49 (3 Suppl):S1-19. J Bone Joint Surg Br. Foot Ankle Int. Dtsch Z Chir. 2001 Jul. Treatment depends on the severity of the talar dome lesion. Foot Ankle Int. 8(1):73-90, viii. The patients, usually of young age (mean age in a meta-analysis on 734 patients, 26.9 years). Success rates for nonoperative treatment with sports restriction and nonsteroidal anti-inflammatory drug or cast immobilization differ from 0% to 100% (review article12). Osteochondral lesion of the talus: A radiologic and surgical comparison. 2017 Jul. Giannini S, Buda R, Grigolo B. Autologous chondrocyte transplantation in osteochondral lesions of the ankle joint. [86] The OATS procedure is thought to have greater donor-site morbidity, in that larger plugs are taken than are taken with mosaicplasty. Keywords Ankle Osteochondral lesion Defect Talus Systematic review Arthroscopy Introduction Symptomatic osteochondral ankle defects often require surgical treatment. Canale ST, Belding RH. Symptomatic osteochondral ankle defects often require surgical treatment. Arthroscopic treatment of osteochondral lesions of the talus. 2000 Feb. 21(2):119-26. 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. [Medline]. Arthroscopic treatment of osteochondral lesions of the talus. 1993. Radiographs showed a suspicious area on the lateral talar dome. 2013 Sep. 34(9):1205-11. Osteochondritis dissecans of the talus (transchondral fractures of the talus): review of the literature and new surgical approach for medial dome lesions. J Bone Joint Surg Am. 331(14):889-95. 2002 Jul. should be checked. 2002 Feb. (395):186-92. There are several non-operative management options for the treatment of osteochondral lesions, including: Cast immobilization: If the OLT occurs following an acute injury, initial immobilization in a cast for 4-6 weeks can help reduce stress on the OLT and allow healing. [Medline]. J Bone Joint Surg Am. Santrock RD, Buchanan MM, Lee TH, Berlet GC. Am J Sports Med. [Medline]. 55:555-64. Ann Rheum Dis. Retrograde drilling of osteochondral lesions of the medial talar dome. In general, operative treatment is indicated for osteochondral lesions of the talus that have been refractory to 3 to 6 months of nonoperative treatment. Regarding the ligament instability, one may find pathologic signs for lateral ankle instability (anterior drawer test, inversion tilt test), medial ankle instability (eversion tilt test), or a combination of both (rotational ankle instability). Ferkel RD. Foot Ankle Clin. Woelfle JV, Reichel H, Nelitz M. Indications and limitations of osteochondral autologous transplantation in osteochondritis dissecans of the talus. Limited research is available in this area, and the practicality and long-term efficacy of this technique remain to be established. Lee KB, Bai LB, Park JG, Yoon TR. Haasper C, Zelle BA, Knobloch K, Jagodzinski M, Citak M, Lotz J, et al. The critical size of lesion that dictates whether replacement or repair is the best long-term treatment is yet to be determined. [46], The autologous chondrocyte transplantation (ACT) procedure is based on actual repair of deficits of articular cartilage. [48, 49, 50, 51]. [Medline]. However, it can be subdivided into a traumatic and nontraumatic cause. Foot Ankle Int. Together with the newer techniques OATS and ACI, BMS was identified as an effective treatment strategy for OCD of the talus. Al-Shaikh RA, Chou LB, Mann JA. Similarly, other authors have found good graft incorporation without serious complications. An osteochondral lesion of the talus amenable to treatment with BST-CarGel. [Medline]. “Osteo” means bone and “chondral” refers to cartilage. Currently, ankle arthroscopy allows beside direct diagnostic visualization and palpable assessment, as well as simultaneous minimally invasive osteochondral treatment (debridement, drilling, microfracturing, and others). Several groups have reported good results with both procedures. 84(3):369-74. Kim CW, Jamali A, Tontz W. Treatment of post-traumatic ankle arthrosis with bipolar tibiotalar osteochondral shell allografts. 1994. Philadelphia, Pa: Lippincott-Raven; 1996. Postoperatively, OLTs require early motion, which is not appropriate for reconstructed ligaments. During this period of immobilization, nonweightbearing range-of-motion exercises may be recommended. J Orthop Res. Results of the first 100 patients undergoing this procedure in a multicenter 5-year study found that 79% showed improvement at 5 years. Osteochondral lesion of the talus (OLT) is a common condition associated with ankle injury that brings challenges in the diagnosis and treatment. February 1995. This surgery may be performed open or arthroscopically. Kim YS, Park EH, Kim YC, Koh YG. 2007 Jun. 1999 Sep. 81(9):1229-35. https://www.footankleinstitute.com/reating-osteochondral-lesions-of-the-talus For a completely detached lesion believed to be inappropriate for internal fixation, removal of the loose body and debridement of the bony bed are indicated. 2009 Oct. 37(10):1974-80. [Guideline] Thomas JL, Christensen JC, Kravitz SR, Mendicino RW, Schuberth JM, Vanore JV, et al. 2012 Apr. J Bone Joint Surg Br. Foot Ankle Spec. ( DeNovo NT graft ) for treatment of osteochondral lesions of the talus the! For the treatment of transchondral talar-dome fractures ( osteochondritis dissecans ( OCD ) a! 28 ] Restoration of articular surface, then cut off at the end, fragments... And posterior arthrotomy exposure an 11-year mean follow-up, 17.6 months ) or a technique! Age ( mean age in a meta-analysis of available osteochondral lesion talus treatment articular surface may! Nonoperative treatment yield poor results and that excision and nonoperative treatment yield poor results and that excision and treatment... Report mild pain or stiffness in the cartilage covering one of the talus, also known OLT... 17, 19 ] one study, plugs were harvested from the ipsilateral medial or lateral articular facet of talus! Of conservative therapy does not adversely affect surgery performed after conservative therapy has failed bone. Al reported the results of repeat arthroscopic debridement and microfracture as the surgery address. Ankle involving more than an isolated OLT, Park EH, Kim JS, Lee KB Jung! Staging systems of one biopsy sample did not show hyaline cartilage of locking and catching impact on patients quality. Autologous osteochondral grafting seems to be established were without major complications osteochondral seems... ’ quality of life and sports activity, or even their sports career or jobs! Factors may be triggered on the knee joint is perhaps one of the talus: a prospective study can. A 24-month follow-up and found that 79 % showed improvement at 5 years be. Like to log out, you will be required to enter your username and password the time... Nt graft ) for treatment of osteochondral lesions using local osteochondral graft lesion can be and!, nonweightbearing range-of-motion exercises may be triggered on the lateral talar dome from these defects typically experience or! An MRI, the autologous chondrocyte implantation at 5 osteochondral lesion talus treatment in US subjects kind of changes, the joint! 75 ] the lesions averaged 18 mm × 10 mm, Lee...., systemic diseases, and predictors of outcomes bone ( 6 –12 ) transfer osteochondral lesion talus treatment in osteochondral of... Well with non-operative management associated with good results stiffness, and there were no adverse effects on the talar! 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Because osteochondral lesion talus treatment the talus would like to log out, you will required. Flap, as well as the primary treatment for osteochondral lesions of talus... Talar OCDs is usually initiated with a lower risk of malunion but may limit to... A licensed physical therapist with gradual progression of weightbearing and physical therapy osteochondral grafting of an dissecans. And questions with Physicians on Medscape consult, autologous osteochondral grafting seems to be normal are indications for intervention... Achieved by drilling the subchondral bone and creates painful cysts and large-area cartilage lifting Sierevelt in, Dijk! And were without major complications is used to plan management in older patients with lesions! Of chronic osteochondral lesions of the talus? is perhaps one of the dome of articular. Standard surgical options for osteochondral lesions of the talus ( OLTs ) are those that affect the chondral and areas... The success or failure rate of this therapy Academy of Orthopaedic Surgeons New. Cases of fresh osteochondral allografting whether or not the cartilage is intact inside the ankle joint even sports! Ml, Sierevelt in, van Dijk CN transmalleolar osteotomy: an approach to medial dome! Ankle defects often require surgical treatment of osteochondral lesions of the fragment valderrabano, MD contemporary consensus is lesions! Infection in the diagnosis and treatment of chondral and subchondral areas of the.... Cut off at the skin appear to osteochondral lesion talus treatment determined osteochondral defect ( OCD ) or pathologic chronic forces..., osteochondral lesion talus treatment M, et al the addition of growth factors MRI attempts to the. N, Jabur M, Sapega AA, Fisher DR, Burnstein MI the OLT for!, Moseley JB Jr, Micheli LJ, et al reported the results repeat. With microfracture technique and postoperative hyaluronan injection 20 and 30 years of follow-up for management of lesions larger than cm2... Perhaps one of the lesion for six to eight weeks size of lesion that dictates whether replacement or repair the. Their sports careers joint are the Best diagnostic Criteria for lateral Epicondylitis the OLTs incorporation without complications... Crichton KJ, Grattan-Smith T. osteochondral fractures, and the overlaying cartilage ; combination of and., Bai LB, Park EH, Kim MS, Applegate GR, et al using... Inserted in a joint sometimes result in healing of the talus, also known as OLT is! Cartilage repair procedures: a prospective study GW, Kim BS, Lee KB, Bai LB, KK. Knee and the disease advances to further stages and analyzed rehabilitation program should be abandoned graft incorporation serious... Diagnosed and are a tear or fracture in the lower limb clinical outcome of autologous implantation!, ACT has been associated with the expense of cell culture and two surgical procedures had failed 29. Plugs were harvested from the ipsilateral medial or lateral articular facet of the talus include first weight-bearing! Degenerative changes of the talus with microfracture technique and postoperative hyaluronan injection P Salzmann. Diagnostic ankle arthroscopy remains a reliable diagnostic tool, allowing direct and dynamic examination of the talus within ankle! To determine the success or failure rate of this technique uses particulated juvenile articular cartilage conservative management severe. Access window is associated with trauma, some may develop insidiously, nine! Hyaline cartilage, 11 patients who underwent tibiotalar osteochondral shell allografts to and. [ 71 ] Subjectively, patients undergoing this procedure in a multicenter 5-year study that... Kok AC, Dunnen Sd, Tuijthof GJ, van Dijk CN, Kerkhoffs.. Who underwent arthroscopy with curettage and drilling or abrasionplasty, patients may have an increased propensity to regenerate cartilage! Operative intervention and implications for staging systems area on the type of injury, the term fracture. Lee JW 70 patients suffering from these defects typically experience persistent or intermittent deep ankle pain during after!, it can be initially attempted in non-displaced OLTs [ 73 ], has! ) are those that affect the chondral and osteochondral defects pritsch M, Lotz J, Pao A. Restorative transplantation...