A subtle remnant of the defect (arrow) is visible on the anteroposterior mortise (Fig. MRI is the best imaging modality to detect evidence of high fluid pressures surrounding lesions, which manifest as high signal intensity around the lesion and bone marrow edema on fat-suppressed images. Introduction Injuries to the articular surface of the talar dome in the ankle joint are commonly called osteochondral lesions of the talus (OLT). Cysts may form with either chondral or osteochondral lesions when the subchondral plate is compromised. 1), although this is of unknown importance for preoperative planning and prognosis. Sometimes this synovitis is more symptomatic to the patient than the lesion itself. Lesions can be described using several characteristics, which over time have been delineated by several classification systems. These cartilage flaps have been recently called. 0 Much of this bone is covered with cartilage. The talus is the bottom bone of the ankle joint. They typically are associated with a history of trauma; however, nontraumatic etiologies have been described. Seven studies described the results of non-operative treatment, 4 of excision, 13 of excision and curettage, 18 of excision, curettage and bone marrow stimulation (BMS), 4 of an autogenous bone graft, 2 of transmalleolar drilling (TMD), 9 of osteochondral transplantation (OATS), 4 of autologous chondrocyte implantation (ACI), 3 of retrograde drilling and 1 of fixation. One would use a non-invasive ankle distractor to distract the joint and check the lesion. Several imaging specific classification systems have been developed with this goal in mind. Lateral lesions lack this inherent advantage and may have less-predictable outcomes. Osteochondral lesions of the ankle are being recognized as an increasingly common injury, and may occur in up to 50% of acute ankle sprains and fractures, 105 particularly in association with sports injuries. Advertisement . These findings have been considered evidence of instability, which has been used as an operative indication; however, no clear correlation exists. Non-surgical: Osteochondral lesions of the ankle can be treated with injections of Platelet-rich plasma and hyaluronic acid, which results in a decrease in pain scores and an increase in function for at least 6 months. Knee Surg Sports Traumatol Arthrosc. Regardless of the inciting event or baseline pathology, the processes through which these lesions become symptomatic are the same. The orthopaedic surgeon makes incisions on the ankle to access the injured area. When anterolateral OLTs are treated, open surgical exposure is accomplished via an anterolateral approach to the ankle joint. Osteochondral injury (or osteochondral defect) of the ankle is an injury to the bone or smooth cartilage covering the joint surface in the ankle. Extravasation of synovial fluid through the compromised cartilage is believed to cause instability in the underlying bony substrate. 63 0 obj <> endobj Diagnosis and Treatment: A talar dome lesion can be difficult to diagnose because the precise site of the pain can be hard to pinpoint. A talar dome lesion is an injury to the cartilage and underlying bone of the talus within the ankle joint. Osteochondral lesions of the ankle are being recognized as an increasingly common injury, and may occur in up to 50% of acute ankle sprains and fractures, 105 particularly in association with sports injuries. Arthroscopic Treatment of Ankle Osteochondral Lesions, Tanya J. Singleton, DPM a, Byron Hutchinson, DPM b, Lawrence Ford, DPM c,*, a Kaiser San Francisco Bay Area Foot and Ankle Residency Program, 280 West MacArthur Boulevard, Oakland, CA 94611, USA, b Franciscan Medical Group, International Foot & Ankle Foundation, Franciscan Foot & Ankle Institute, Highline, 16233 Sylvester Road South West G-10, Seattle, WA 98166, USA, c Kaiser San Francisco Bay Area Foot and Ankle Residency Program, Department of Orthopedics and Podiatric Surgery, Kaiser Permanente, 280 West MacArthur Boulevard, Oakland, CA 94611, USA. These findings have been considered evidence of instability, which has been used as an operative indication; however, no clear correlation exists. The theory of these nuances led to the development of many of the operative treatments currently used. 2010;18: 238-46 [Google Scholar] Steele JR, Dekker TJ, Federer AE, Liles JL, Adams SB, Easley ME. This is performed through two small incisions on the front of the ankle. 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. Plantarflexion aids in … A talar osteochondral defect (OCD) is a combined lesion of the subchondral bone and its overlying cartilage. When the latter is present, then joint replacement is often the only feasible treatment. The pain is typically difficult to reproduce on examination but can be confirmed with a response to a diagnostic ankle block. 109 0 obj <>stream Osteochondral defects (OCDs) are very localised areas of joint damage which can occur in a number of different joints , not just the ankle. This gives the repaired surface the app… Arthroscopic treatment of ankle OCLs has the advantage of a minimally invasive approach, allowing for thorough evaluation of pathology and multiple treatment modalities. The common treatment strategies of symptomatic osteochondral lesions include nonsurgical treatment, with rest, cast immobilisation and use of nonsteroidal anti-inflammatory drugs (NSAIDs). Surgical treatment is indicated for displaced talar OLTs or lesions that have not improved with appropriate non-operative management. These features should be noted and may offer clues as to the physiologic process and appropriate treatment (Fig. Currently, ankle arthroscopy allows beside direct diagnostic visualization and palpable assessment, as well as simultaneous minimally invasive osteochondral treatment (debridement, drilling, microfracturing, and others). Where small defects in the subchondral plate exist, repetitive loading from normal weight-bearing activates forces the synovial fluid under high pressure into the subchondral bone, which over time creates a cyst. This allows us to treat the bone defect without affecting the cartilage. ��@By:���'pH��0012�)f`�?�� T�c 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. 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. Talar dome lesions are usually caused by an injury, such as an ankle sprain. The pathophysiology of OCLs must be appreciated to fully understand why the various treatment modalities are effective and when to use them. 3-A) and heel-rise (Fig. The pathophysiology of OCLs must be appreciated to fully understand why the various treatment modalities are effective and when to use them. 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. This joint permits much of the up (dorsiflexion) and down (plantarflexion) motion of the foot and ankle. 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 Several MRI classification systems have been proposed, most of which stage lesions from chondral bruising through a detached fragment with a focus on the quality of the cartilage and the nature or absence of its attachments. A fragment of bone may be attached to the disrupted cartilage. The location of OLTs has been thoroughly described in the literature as having both prognostic and therapeutic implications. The cartilage is nourished by the synovial fluid, but it does not have its own blood supply and is not innervated.5,6 Articular cartilage can be divided into four zones.7 The fibrillar sheet and lamina splendens make up the most superficial layer; this is the thinnest layer with the greatest ability to resist shear stress. Lateral lesions, however, are more often associated with trauma, specifically an inversion and dorsiflexion ankle injury. Associated soft tissue pathology must be appreciated and addressed surgically, because associated synovitis and soft tissue impingement often contribute to symptoms. On T2-weighted images, increased signal intensity can be seen surrounding completely detached lesions, and bone edema may be present. Conservative treatment of osteochondral lesions of the talus (OLTs) should be attempted first, whenever possible. Fig. Arthroscopic treatment of osteochondral lesions (OCLs) of the ankle is a popular first-line surgical option after conservative therapy has failed. As the cyst develops and the integrity of the subchondral plate collapses, the overlying cartilage becomes soft because of the absence of this supportive structure. It helps to move the ankle joint to help determine if there is pain, clicking or limited motion within that joint. The basic tenet of each of these systems is to first describe whether a full-thickness or partial-thickness cartilage defect is present or if the cartilage is intact. Whether the fragment is partially or fully detached or displaced should also be noted. The treatment strategy for osteochondral lesions depends upon the location and lesion size. A normal, healthy ankle joint is made up of smooth cartilage supported by strong bone underneath. 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