109 0 obj <>stream incidence 69% of ankle fractures; 70% of ankle sprains; 10% are bilateral The AOFAS ankle-hindfoot score was the most frequently used functional outcome measure. The tibia and fibula bones sit above and to the sides of the talus, forming the ankle joint. Osteochondral lesion of the talus (OLT) is a common condition associated with ankle injury that brings challenges in the diagnosis and treatment. Frequently these lesions are traumatic in origin, most commonly occurring after an acute ankle sprain; however, atraumatic mechanisms have been described. Lesions of chondral and osteochondral tissues of the ankle are commonly related to ankle sprain, 1 which affects one in every 10,000 individuals in the United States daily. OCD lesions are also called osteochondritis dissecans or osteochondral fractures. MRI has gained popularity in its ability to delineate both the cartilage and bone extent of the lesion in addition to associated soft tissue pathology. Whether the fragment is partially or fully detached or displaced should also be noted. The initial insult involves some level of joint or articular damage, whether from trauma or other metabolic, genetic, vascular, or idiopathic processes. Niemeyer et al. For small-sized defects with intact cartilage, our treatment of choice is Retrograde Drilling of the lesion and filling it with a special bone cement. One would use a non-invasive ankle distractor to distract the joint and check the lesion. Hyaline cartilage, however, cannot be regenerated once injured. It helps to move the ankle joint to help determine if there is pain, clicking or limited motion within that joint. Ferkel and colleagues. Sometimes an ankle injury leads to damaged, rough areas of cartilage and bone underneath. 106,120. Surgeons are cautioned that MRI may exaggerate the extent of osseous involvement in OCLs.8 A threshold beyond which arthroscopy is unlikely to yield satisfactory results has been shown to exist around lesions greater than 1.5 cm2.10–12. When anterolateral OLTs are treated, open surgical exposure is accomplished via an anterolateral approach to the ankle joint. This finding can be explained by a similar mechanism in which the subchondral plate is fractured and the fluid content of the cartilage is exsanguinated and forced into the subchondral bone with repetitive weight-bearing pressures. In their landmark paper, Berndt and Harty. They may complain of generalized pain, weakness, swelling, stiffness and/or limited ankle range of motion with catching or locking. Treatment depends on the location and size of the defect as well as the presence of secondary degenerative changes. Hyaline cartilage is unique in that its matrix consists of primarily type II collagen, which has improved tensile strength over type I collagen, the predominant component of fibrocartilage. The vast majority of patients experience no pain or swelling even 10 years after surgical treatment of such lesions in the ankle. Symptoms related to this condition are nonspecific including pain, swelling, stiffness, and mechanical symptoms of locking and catching. Fibrocartilage is the natural repair and physiologic alternative. An osteochondral lesion of the talus (OLT) is an area of abnormal, damaged cartilage and bone on the top of the talus bone (the lower bone of the ankle joint). Lesions may be identified on plain radiographs. $X���y ���7�� �ADH�1��4 ��HH endstream endobj 64 0 obj <> endobj 65 0 obj <>/ExtGState<>/Font<>/ProcSet[/PDF/Text]>>/Rotate 0/TrimBox[29.4093 30.5021 625.221 872.481]/Type/Page>> endobj 66 0 obj <>stream This condition is also known as osteochondritis dissecans (OCD) of the talus or a talar osteochondral lesion (OCL). h�bbd``b`�@����� If the lesion is stable (without loose pieces of cartilage or bone), one or more of the following non-surgical treatment options may be considered: 1. 3-B) views; the defect cannot be detected on the lateral view (Fig. Foot Ankle Orthop. Conservative treatment of osteochondral lesions of the talus (OLTs) should be attempted first, whenever possible. This type of injury can be due to a severe ankle sprain that causes bone and cartilage to become loose, resulting in ongoing ankle pain. Therefore, if painful lesions are assumed to be painful because of instability, these MRI findings are consistent with both. The pathophysiology of OCLs must be appreciated to fully understand why the various treatment modalities are effective and when to use them. endstream endobj startxref A talar dome lesion is an injury to the cartilage and underlying bone of the talus within the ankle joint. They will act as an irritant in the joint space, promoting synovial inflammation and subsequent symptoms. Surgery most commonly involves an ankle arthroscopy. 20 The treatment of talar OCDs is usually initiated with a nonoperative protocol. The pain is typically difficult to reproduce on examination but can be confirmed with a response to a diagnostic ankle block. These findings have been considered evidence of instability, which has been used as an operative indication; however, no clear correlation exists. When the latter is present, then joint replacement is often the only feasible treatment. Theoretically, medial lesions with their larger osseous component have a better chance of consolidating with the underlying bone and its blood supply with proper treatment, which may range from immobilization to microfracture or open reduction and internal fixation. 63 0 obj <> endobj 1��N@Z��4>�n�X�th�i�� ��MZ39�'�m�qٟ`٠?� ��b`fSҌ@�ށ{P��YtD�a@� ߝF� G"��թH���⩄4Q,R-���4Jj+R#T��H��aV�ߝ��I��Bk��Q$t"1[$��ơ��N 捴�%&��?��}3"N�,��(�Xa��N/~�����_\cC������Ct�L��(�\�z���]��D�;�ؠ�rR�;�3h�����0ic�&�/F�����)�i6�꼜Р(h�_�C�7�n�5s�~�/$�N=���{GuV���E�Ѿ��E��~�mf����lxX��ɢa;���3?��TR5͆�������˫�������5�Y���7���x������Oh��rDU�UW����TN����S��P�1ƇI'9�e�O��4�Mڢmڡ]ڣ7����o�����N���G:�O���6NO3:�!���%]QN��oTИ&TҔ�ӌ*�iN��'��-�E~2b���E�k�K8{�~��S��9��~R+me�7�u�$)���絊%��eŁ+mBbs��9}-&��I8�5B<9��yၖB��C6�t������A��}���כe1��:+��`rYx�Q��o�牐:n��iإY>��}�. The “classical” defect involves a disruption of both the bone (osteo) and cartilage (chondral) .They usually occur on the Talus if effecting the ankle joint and are a region where the cartilage and underlying bone have been disrupted. Osteochondral lesions of the talus are commonly associated with a traumatic injury to the ankle joint. If radiographs show an osteochondral injury at the initial visit for an ankle sprain, treatment will require either casting of the ankle to allow the fracture site to heal or pinning and open reduction of the fracture in cases of a loose lesion. The pain is typically difficult to reproduce on examination but can be confirmed with a response to a diagnostic ankle block. Treatment of osteochondral lesions of the talus: A systematic review. %PDF-1.3 %���� Understanding these dynamics of the lesion provides clues to the origin and may assist in directing treatment. These cartilage flaps have been recently called chondral-separated lesions, in contradistinction to osteochondral-separated lesions.4 This latter type of lesion is more commonly referred to as an osteochondral fracture and may have a better chance of forming fibrocartilage because of its retained blood supply from the subchondral bone. Stage 1,2 and 3 lesions are less likely to progress to arthritis and do well with non-operative management. The theory of these nuances led to the development of many of the operative treatments currently used. By doing this, the bone defect is treated without causing any damage to the overlying cartilage. In their recent work exploring why only some osteochondral defects in the ankle are painful, van Dijk and colleagues. A basic knowledge of cartilage anatomy and physiology helps in understanding of the goals, mechanism, and limitations of arthroscopic treatment of OCLs. CT, although it accurately assesses the extent of bone involvement, is unable to assess the extent of the chondral injury, which is important in preoperative planning. 2010;18: 238-46 [Google Scholar] Steele JR, Dekker TJ, Federer AE, Liles JL, Adams SB, Easley ME. Hyaline cartilage has abundant water content, accounting for approximately 75% of the cartilage matrix. 1. Bernt and Harty’s, CT, although it accurately assesses the extent of bone involvement, is unable to assess the extent of the chondral injury, which is important in preoperative planning. 3 Radiographs of an ankle with a centromedial talar osteochondral defect at the time of follow-up. Medial lesions tend to be more common and, although often atraumatic in origin, can occur from inversion and plantar flexion ankle injuries. 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