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Osteochondral Defect Talus

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Other Names

  • Osteochondritis Dessicans
  • Osteochondral Defect of the Ankle
  • Osteochondral lesions of the talus (OLTs)
  • Osteochondral fractures

Background

  • This page refers to osteochondral defects (OCD) of the Ankle Joint

History

  • First recognized by Konig in 1888[1]
  • The term Osteochondritis Dessicans applied by Kappis in 1922[2]

Epidemiology

  • Ankle is the 3rd most common joint affected by OCD (need citation)
    • Knee and elbow are more common
  • Incidence is approximately 0.09%[3]
    • Most commonly affects individuals in 2nd decade of life
  • In patients with chronic, unexplained ankle pain, one study found the incidence of OCD was 81%[4]

Pathophysiology

  • General
    • See: Osteochondral Defect (Main)
    • Definition: combined lesion of subchondral bone and overlying cartilage[5]
    • In the foot and ankle, most commonly occur on the talar dome
    • Defect is bilateral in about 10% of cases[6]
  • Talus
    • Vulnerable to OCD due 60% of surface being articular cartilage with poor regenerative capacity and talaus has poor blood flow
    • Most are localized on the anterolateral or posteromedial talar dome[7]
    • Lateral: usually shallow oval shaped and are caused by a shear mechanism
    • Medial: usually deep, and cup-shaped, indicating a mechanism of torsional impaction and axial loading
  • Asymptomatic
    • Some osteochondral defects remain asymptomatic and inert
    • It is not fully why
  • Management is challenging
    • Lesions have limited healing potential due to the poor regenerative capacity of articular cartilage, poor blood supply of the talus
    • There are no consensus guidelines on appropriate treatment
  • Osteochondritis dissecans
    • Focal, idiopathic lesion of the subchondral bone with risk for instability and disruption of the adjacent articular cartilage[8]

Etiology

  • General
    • Etiology and pathogenesis are not fully understood[9]
    • Dysfunction of the subchondral bone is thought to be vascular in nature
    • Osteonecrosis of the subchondral bone contributing to damage to the overlying cartilage
  • Single traumatic insult
    • Widely accepted as the most important etiology factor
    • Talus: described in 93-98% for lateral defects, 61-70% for medial defects[10]
  • Atraumatic or repetitive microtrauma
    • Ischemia, subsequent necrosis and genetics are thought to play a role in atraumatic cases[11]
  • Idiopathic

Mechanism

  • Traumatic
    • In ankle sprains, the talus twists inside a boxlike housing which can damage the cartilage lining the talus
    • Separation can occur at the cartilage or in the subchondral bone
    • Fragments may remain partially attached and stable or break off and float loosely in the joint
    • They can heal and remain asymptomatic or progress to deep pain on weight bearing with subchondral bone cyst formation
  • Cadaveric studies
    • Berndt and Harty reproduced lateral defects by strongly inverting a dorsiflexed ankle leading to compression of the lateral talus against the fibula[12]
    • They also reproduced medial lesions by plantarflexing the ankle in combination with slight anterior displacement of the talus on the tibia, inversion and internal rotation of the talus on the tibia

Associated Conditions

Risk Factors

  • Unknown

Differential Diagnosis

Clinical Features

  • History (Acute)
    • In acute setting, often presents like a lateral ankle sprain and the OCD is missed
    • At this time, patients have pain over the ATFL, trouble weight bearing and swelling
    • Subacutely, pain, swelling, limited range of motion and trouble weight bearing often persist
    • In displaced lesions, patients can report locking or catching
    • In 24% of cases the patient denies an association with acute or repetitive trauma[17]
  • History (Chronic)
    • Chronic lesions present as deep ankle pain during or after activity[18]
    • Range of motion is often normal, pain is not reproducible
    • Swelling is absent
  • Physical Exam: Physical Exam Ankle
    • Effusion may or may not be present
    • Tenderness to palpation over lesion
    • Decreased range of motion, pain with dorsiflexion and plantarflexion
  • Special Tests

Evaluation

Osteochondral lesion is seen on the lateral talus

Radiographs

  • Standard Radiographs Ankle
    • Fire line imaging
    • Often normal, especially in acute injuries with nondisplaced lesions
    • Sensitivity is low for OCD[19]
    • Can not assess articular cartilage or characterize lesion
  • Potential findings
    • Displacement
    • Osteonecrosis
    • Cystic changes

MRI

  • Imaging modality of choice
    • 96% sensitive, 96% specific[19]
    • Staged by Happle Classification
    • Good visualization of articular surface
  • Potential findings
    • Edema of the bone, cartilage
  • Considerations
    • May over estimate the size of the lesion

CT

  • Not routinely ordered
    • 81% sensitive, 99% specific[19]
  • Benefits
    • May better characterize the subchondral bone, cysts

Arthroscopy

  • Diagnostic gold standard
    • Most patients will have advanced imaging prior to intervention
    • 100% sensitive, 97% specific[19]

Classification

Berndt and Harty Classification

  • Radiographic classification using plain films[20]
    • I. Subchondral Compression
    • II. Partially detached osteochondral fragment
    • III. Completely detached fragment without displacement
    • IV. Detached and displaced fragment

Ferkel and Sgaglione CT Staging System

  • Based on CT[21]
    • I. Intact roof/cartilage with underlying cystic lesion
    • IIA. Cystic lesion with communication to surface
    • IIB. Open surface lesion with overlying fragment
    • III. Nondisplaced fragment with lucency beneath
    • IV. Displaced fragment

Hepple MRI Staging System

  • Based on MRI findings[22]
    • I. Articular Cartilage injury only
    • IIA. Acute cartilage injury with bony fracture
    • IIB. Chronic cartilage injury with bony fracture
    • III. Detached, nondisplaced bony fragment
    • IV. Displaced fragment, uncovered subchondral bone
    • V. Subchondral cyst present

Arthroscopic Classification

  • A. Smooth and intact but soft
  • B. Rough surface
  • C. Fibrillation/fissures
  • D. Flap present or bone exposed
  • E. Loose, nondisplaced fragment
  • F. Displaced fragment

Management

Nonoperative

  • Indications
    • Asymptomatic lesions found incidentally
    • Acute, symptomatic lesions that are nondisplaced (Grade B recommendation)
  • Immobilization
  • Weight bearing (WB)
    • Strategies vary widely and there is no clear consensus
    • Consider non-WB, protected WB or full WB in immobilization
  • Physical Therapy
  • NSAIDS

Operative

  • Indications
    • Symptomatic lesions which have failed 3-6 months of nonoperative treatment
    • Displaced OCD, acute or chronic
  • Technique
    • Cartilage repair
    • Cartilage replacement
    • Regenerative strategies

Rehab and Return to Play

Rehabilitation

  • Needs to be updated

Return to Play/ Work

  • Needs to be updated

Complications and Prognosis

Prognosis

  • Nonoperative treatment
    • Effective in about 45-50% of cases[23][24][25]
    • May increase risk of OA, currently unknown[26]
  • Overall return to sport systematic review[27]
    • Mean time to RTS ranged from 13 to 26 weeks
    • Bone marrow stimulation (339 patients) had a RTS level of 88%
    • Internal fixation (49 patients) found a pooled RTS rate of 97%
    • Autograft transplantation (194 patients) found a pooled RTS rate of 90%
    • Autologous chondrocyte implantation (39 patients) found a pooled RTS rate of 87%
  • Return to pre-injury level of sports[27]
    • Bone marrow stimulation 79%
    • Autograft transplantation 72%
    • Autologous chondrocyte implantation 69%

Complications

  • Ankle Osteoarthritis
  • Inability to return to sport
  • Graft failure
  • Persistent pain
    • Some patients due not achieve pain relief regardless of treatment

See Also

References

  1. ↑ Konig, F: Ueber freie Korper in den Gelenken. Deutsch Z Chir, 27:90 – 109, 1888.
  2. ↑ Kappis, M: Weitere Beitrage zur traumatisch-mechanischen Entstehung der “spontanen” Knorpelablosungen. Deutsch Z Chir, 171:13 – 29, 1922.
  3. ↑ Bauer M, Jonsson K, Linden B. Osteochondritis dissecans of the ankle: a 20-year follow-up study. J Bone Joint Surg Br. 1987;69(1):93-96.
  4. ↑ Ferkel, R; Sgaglione, N; DelPizzo, W; et al.: Arthroscopic treatment of osteochondral lesions of the talus: Long-term results. Orthop Trans, 14:172 – 173, 1990.
  5. ↑ Reilingh ML, van Bergen CJ, van Dijk CN. Diagnosis and treatment of osteochondral defects of the ankle. South Afr Orthop J. 2009;8:44-50.
  6. ↑ Hermanson, Evan, and Richard D. Ferkel. "Bilateral osteochondral lesions of the talus." Foot & ankle international 30.8 (2009): 723-727.
  7. ↑ Zengerink M, Struijs PA, Tol JL, van Dijk CN (2009) Treatment of osteochondral lesions of the talus: a systematic review. Knee Surg Sports Traumatol Arthrosc.
  8. ↑ Edmonds EW, Shea KG. Osteochondritis dissecans: editorial comment. Clin Orthop Relat Res. 2013;471(4):1105-1106.
  9. ↑ McCoy AM, Toth F, Dolvik NI, et al., Articular osteochondrosis: a comparison of naturally-occurring human and animal disease. Osteoarthritis Cartilage. 2013;21(11): 1638-1647
  10. ↑ Verhagen, Ronald AW, et al. "Systematic review of treatment strategies for osteochondral defects of the talar dome." Foot and ankle clinics 8.2 (2003): 233-242.
  11. ↑ Schachter, Aaron K., et al. "Osteochondral lesions of the talus." JAAOS-Journal of the American Academy of Orthopaedic Surgeons 13.3 (2005): 152-158.
  12. ↑ HARTY, MICHAEL. "Transchondral fractures (osteochondritis dissecans) of the talus." (1959).
  13. ↑ Bosien, WR; Staples, OS; Russell, SW: Residual disability following acute ankle sprains. J Bone Joint Surg Am. 37-A(6):1237 – 43, 1955.
  14. ↑ Saxena A, Eakin C. Articular talar injuries in athletes: results of microfracture and autogenous bone graft. Am J Sports Med. 2007;35(10):1680-1687.
  15. ↑ Leontaritis N, Hinojosa L, Panchbhavi VK. Arthroscopically detected intra-articular lesions associated with acute ankle fractures. J Bone Joint Surg Am. 2009;91(2): 333-339.
  16. ↑ 16.0 16.1 McGahan, Patrick J., and Stephen J. Pinney. "Current concept review: osteochondral lesions of the talus." Foot & ankle international 31.1 (2010): 90-101.
  17. ↑ Tol, JL; Struijs, PA; Bossuyt, PM; Verhagen, RA; van Dijk, CN: Treatment strategies in osteochondral defects of the talar dome: a systematic review. Foot Ankle Int. 21(2):119 – 26, 2000.
  18. ↑ Ferkel, Richard D., et al. "Arthroscopic treatment of chronic osteochondral lesions of the talus: long-term results." The American journal of sports medicine 36.9 (2008): 1750-1762.
  19. ↑ 19.0 19.1 19.2 19.3 Verhagen RA, Maas M, Dijkgraaf MG, Tol JL, Krips R, van Dijk CN. Prospective study on diagnostic strategies in osteochondral lesions of the talus: is MRI superior to helical CT? J Bone Joint Surg Br. 2005;87(1):41-46.
  20. ↑ Berndt AL, Harty M. Transchondral fractures (osteochondritis dissecans) of the talus. J Bone Joint Surg Am. 1959;41A: 988-1020.
  21. ↑ Ferkel RD, Zanotti RM, Komenda GA, et al. Arthroscopic treatment of chronic osteochondral lesions of the talus: longterm results. Am J Sports Med. 2008;36(9):1750-1762.
  22. ↑ Hepple S, Winson IG, Glew D. Osteochondral lesions of the talus: a revised classification. Foot Ankle Int. 1999;20(12): 789-793.
  23. ↑ Canale ST, Belding RH. Osteochondral lesions of the talus. J Bone Joint Surg Am. 1980;62(1):97-102.
  24. ↑ McCullough CJ, Venugopal V. Osteochondritis dissecans of the talus: the natural history. Clin Orthop Relat Res. 1979;144: 264-268.
  25. ↑ Tol, JL; Struijs, PA; Bossuyt, PM; Verhagen, RA; van Dijk, CN: Treatment strategies in osteochondral defects of the talar dome: a systematic review. Foot Ankle Int. 21(2):119 – 26, 2000.
  26. ↑ Shearer, C; Loomer, R; Clement, D: Nonoperatively managed stage 5 osteochondral talar lesions. Foot Ankle Int. 23(7):651 – 4, 2002.
  27. ↑ 27.0 27.1 Steman, Jason AH, et al. "Return to sports after surgical treatment of osteochondral defects of the talus: a systematic review of 2347 cases." Orthopaedic journal of sports medicine 7.10 (2019): 2325967119876238.
Created by:
John Kiel on 26 June 2019 19:41:04
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Last edited:
3 October 2022 23:51:18
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