All Rights Reserved. Foot and Ankle International, May 2001; 22(5): 380-384. One would perform an arthroscopy of the joint and identify the lesion. As always, it is essential to check for ligament laxity and tendon injury, and address both of these issues at the time of surgery if they are problematic. A 501(c)(3) non-profit organization, Osteochondral Lesions/Osteochondritis Dessicans, Translation is unavailable for Internet Explorer. [] Although majority may be associated with trauma, some may develop insidiously. After surgery, weight should be kept off the affected knee or ankle for four to six weeks. the lateral osteochondral defect. If damage is extensive, then a bone graft can be inserted to replace the cartilage. debridement of lesion to create stable cartilage rim, subchondral bone exposed. An osteochondral defect can occur acutely or develop as a result of several chronic conditions including (a) separation of the osteochondral fragment caused by an acute traumatic injury or as the end result of an unstable fragment in osteochondritis dissecans (OCD), (b) acute osteochondral … This type of treatment is best in large lesions with a major defect of over 1 cm with extensive depth. A talar osteochondral lesion (OLT) can develop after ankle sprains or ankle trauma. Treatment and prognosis. The prevailing thinking is that magnetic resonance imaging (MRI) is better in cases of pure cartilage damage or for superficial lesions while computerized tomography (CT) is better for cystic lesions and lesions that involve both cartilage and bone injury. Non-operative treatment can be successful for non-displaced talar OLTs, especially if the condition is recognized and treated early, and the lesion is relatively small. Immobilization – Depending on the type of injury, the leg may be placed in a cast or cast boot to protect the talus. If the damage is small, the surgeon may drill into the bone, which causes a small amount of bleeding and encourages healing. Our preferred technique is to use a 0.62 K-wire and drill lesions in the posterior medial region that cannot be reached with a chondral pic through a medial incision approach. In the knee, such cartilage damage can occur between the femur (thigh bone) and the tibia (shin bone). This is very simple to perform and one would make several drill holes into the lesion to allow for bleeding and fibrocartilage formation. © 2020 HMP. Although the treatment of osteochondral lesions of the talus has evolved and improved, there is a need to understand the full spectrum of treatments and be well-versed in all forms of treatment in order to have a complete bag of tools necessary to treat these complicated occurrences. There are three types of common lesion formation. It can be challenging to diagnose an osteochondral lesion at the time of injury. 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. Although wearing a brace or cast may ease the discomfort of an osteochondral lesion, they are usually not enough to remedy the problem permanently, except in children, who can respond well … OCD usually causes pain … Lesion size, location, chronicity, and characteristics such as displacement and the presence of subchondral cysts help dictate the appropriate treatment … At earlier stages (stage 1 to 4), a number of options … Osteochondral lesions of the talus (OLT) are those that affect the chondral and subchondral areas of the talus. The second most common type is an injury to the superficial cartilage surface with a crush cartilage injury or shear tear of the cartilage surface. It occurs when a small segment of bone begins to crack and separate from its surrounding region due to a lack of blood supply. The most common location of osteochondral lesions in patients with ankle trauma is on the anterolateral or pos- With an MRI, the ligament structures, tendons and cartilage of the ankle can be examined and analyzed. In this type of lesion, the pain is from the constant compression of the cyst with activity but there is no overlying damage to the cartilage and bone. We try to avoid drilling of these lesions as the superficial cartilage and bone are intact and stable. The vast majority of patients experience no pain or swelling even 10 years after surgical treatment of such lesions in the ankle. This type of injury is fairly rare. In general, our guideline for a cutoff for drilling options is a lesion less than 1 cm in diameter and a lesion less than 0.5 cm in depth. This is the most common type of injury that will require care. Osteochondral defects generally linger or get worse unless they’re treated. In some cases, both an MRI and CT are needed to diagnose an osteochondral lesion. However, in most cases with larger lesions, the surgeon should completely excise the lesion and use osteochondral grafting. The diagnosis of cartilage damage (osteochondral lesion, also known as talar dome) is often done with x-rays and/or an MRI. The common treatment strategies of symptomatic osteochondral lesions include nonsurgical treatment, with rest, cast immobilisation and use of nonsteroidal anti-inflammatory drugs (NSAIDs). Nonoperative treatment for acute, nondisplaced osteochondral lesions of the talus and cystic lesions has been associated with successful clinical results in about 50% of cases 5, 24, 25. Foot and Ankle International, May 2001; 22(5): 380-384. If an osteochondral lesion has occurred, however, everyday activities that put pressure on the joint, may lead to pain and swelling, although the joint usually is fine when at rest. 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. This may be followed with gradual progression of weightbearing and physical therapy. There is no cure as such, but the condition can be treated by a variety of means depending on the size and location of the lesion as well as the age of the patient and the degree of symptoms. Cartilage is a connective tissue that covers the bones between joints. FIGURE 71-1 Osteochondral lesion of the talus. 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. An osteochondral lesion is an injury or small fracture of the cartilage surface of the talus. The first is injury to the cartilage surface with an actual loss of part of the chondral surface and underlying subchondral bone. However, the majority of osteochondral lesions do not show themselves at the initial time of injury. An osteochondral lesion may also be known as an osteochondral defect. There is a great deal of debate as to which adjunct testing is best for diagnosing an osteochondral lesion. 108. When the latter is present, then joint replacement is often the only feasible treatment. this is sutured … A talar dome lesion is an injury to the cartilage and underlying bone of the talus within the ankle joint. It is not a preferred option for younger patients, since failure of the knee replacement and the need for revision is more likely in younger patients. Pertinent Pearls For Performing An Arthroscopy. Over the next few years, one may be able to begin treating cartilage lesions with cartilage cell transplants through an injection and with cartilage caps. I hope the information presented is helpful for your patient care. Dr. Baravarian may be reached at bbaravarian @mednet.ucla.edu. The treatment approach is based on the size, location and degree of separation of the bone and cartilage. “Osteo” means bone and “chondral” refers to cartilage. Often, performing an injection of local anesthetic into the involved joint will reduce pain but clinicians should not rule out other problems such as loose bodies, synovitis and ligament injury. An X-ray may be ordered, but a cartilage tear is difficult to see on an X-ray, so a magnetic resonance imaging (MRI) or computed tomography (CT) scan may be required. A medial lesion was reproduced 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. Often, it is difficult to reduce pain permanently with bracing or casting. Most of the lesions requiring surgical treatment are posteromedial in location, have poor quality articular cartilage, a loose bone fragment, necrotic bone beneath the lesion, and are poor candidates for healing with internal fixation. During this period of immobilization, nonweightbearing range-of-motion exercises may be recommended. Non-surgical treatment is appropriate for certain lesions and usually involves immobilization and restricted weightbearing. The newest and most complicated treatment option is the use of retrograde drilling of the lesion. They require a strong plan. Osteochondral lesions of the talus (OLTs) are a difficult pathologic entity to treat. Treatments for lesions in the knee are more challenging, but also have promising outcomes. It occurs when a small segment of bone begins to crack and separate from its … Platelet-rich plasma is significantly better than hyaluronic acid. 109. This surgery may be performed open or arthroscopically. If the patient presents such kind of changes, the most recommended form of intervention is represented by the complete replacement of the joint. Yet a more sedentary patient with the same lesion may do well with drilling. the lateral osteochondral defect. debridement of lesion to create stable cartilage rim, subchondral bone exposed. With an inversion or eversion stress on the ankle, the talus and tibia and/or fibula will contact each other with a massive stress, resulting in a compression or shear stress on the surface of the talus and underlying injury. Causes: Talar dome lesions … Finally, there is a subchondral cyst type injury with a cyst formation deep to the cartilage surface but an intact overlying cartilage and bone surface. Each type of injury will have different treatment options and require a different type of workup. Osteochondral injury staging system for MRI attempts to grade the stability and severity of osteochondral injury and is used to plan management.. stage I. injury limited to articular cartilage; … Treat subchondral edema either through a retrograde approach from the sinus tarsi or from an intraarticular approach through the lesion site via subchondroplasty with or without a bone marrow aspirate add-on. Individuals who play sports such as soccer, football, rugby and golf may be at risk of an osteochondral lesion. Initial x-rays are taken to check the alignment of the foot and ankle, as well as look for any bone damage. We have dealt with the actual ligament injury and its repair, treatment of peroneal tendon injuries and also conservative care of ankle injuries. periosteum from tibia taken and fitted to defect. Pain often occurs with an increase in activities such as sports and is not present with rest. Osteochondral lesions of the talus (OLTs) are a difficult pathologic entity to treat. After the initial pain and discomfort of a strain or sprain subsides, individuals usually resume or even increase their activity level. Diagnosing an osteochondral lesion is very difficult on a physical exam and one rarely diagnoses this without further testing. Operative Treatment . Conservative treatment of osteochondral lesions of the talus (OLTs) should be attempted first, whenever possible. Microfractures, are often considered the first-line surgical treatment option due to the low costs and ease of the technique (34-38), while ACI is rather reserved as a salvage procedure (39-41, 45). Within the knee, cartilage damage can happen between the thigh bone and the shinbone. ➢ Operative treatment should be reserved for patients who have mechanical symptoms following an acute osteochondral lesion of the talus or who are not satisfied with the result after 3 to 6 … He is an Associate Professor at UCLA Medical Center and is the Chief of Podiatric Surgery at Santa Monica/UCLA Medical Center. Initial x-rays are taken to check the alignment of the foot and ankle, as well as look for any bone damage. Osteochondritis dissecans (OCD) is a condition that develops in joints, most often in children and adolescents. A Stable lesion means that the cartilage overlying the bone is not damaged and the lesion is not likely to be lose. Patients will note a dull ache of the joint and may also describe mild to moderate locking or clicking. The most common surgical procedure for an osteochondral lesion is an arthroscopic exploration and treatment. Treatment of Osteochondral Lesions of the Talar Dome James W. Stone MD Key Points Although osteochondral lesions can occur over any portion of the talar dome or the tibia, the talar lesions typically occur over the anterolateral or the posteromedial talar dome. It is important to understand the principles of arthroscopy and the use of a microvector guide in the treatment of osteochondral lesions. However, if the osteochondral lesion is identified at an earlier stage, other treatment solutions are feasible. Actual surgical treatments for osteochondral lesions and early knee osteoarthritis seem to be promising. After removing all non-viable cartilage, the surgeon should fenestrate the subchondral bone with either a K-wire or a chondral pick. If the patient presents such kind of changes, the most recommended form of intervention is represented by the complete replacement of the joint. The treatment of an osteochondral lesion is based on the stability of the lesion. In certain cases, we will try drilling as a first-line treatment option in a more sedentary patient and give complete information to the patient about the possible need for further treatment. Usually, an osteochondral lesion occurs when there is an injury to the joint, especially if there is an ankle sprain or if the knee is badly twisted. There is also a problem with mild sclerosis of the walls of the cyst that one must treat. 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Younger patients, particularly … In cases of osteochondral lesion, the patient will begin to experience swelling and pain in the ankle with this increased activity. 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. With medial lesions, one must osteotomize the medial malleolus to access the joint. bone graft may be placed if underlying cyst and bone loss. Continued. Treatment depends on the severity of the talar dome lesion. These can occur from an acute traumatic injury to the knee or an underlying disorder of the bone. 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. A patient with an osteochondral lesion will often feel a dull ache in the joint and may also experience a mild locking or clicking of their knee or ankle joint. We have found equally good outcomes with the use of autograft and fresh allograft, and therefore use the fresh allograft as our primary option. Operative treatment might also be necessary if … At earlier stages (stage 1 to 4), a number of options exist including: osteochondral … In order to treat the problem properly, one must diagnose the cause, the amount of injury and the residual problem present. If the lesion is stable (without loose pieces of cartilage or bone), one or more of the following nonsurgical … Employ CT scanning to check for a solid repair at the six- to eight-week point. Treatment depends upon the size of the osteochondral defect and the condition of the overlying cartilage. Furthermore, the location of the lesion will also dictate treatment options. In the ankle, osteochondral lesions usually occur on the talus, which is the bone that connects the leg to the foot. Osteochondral fracture of the lateral femoral condyle is a rare injury of the knee joint, which mostly occurs in adolescence 1.In adolescence, the cartilage‐bone interface is the weakest transitional area in the knee joint, and there is no obvious boundary between calcified and uncalcified cartilage 2.The biomechanical strength of immature osteochondral junction was lower … Although the cause of such lesions is unknown, they may involve a genetic predisposition to such a condition. Osteochondritis dissecans (OCD or OD) is a joint disorder primarily of the subchondral bone in which cracks form in the articular cartilage and the underlying subchondral bone. Scranton PE, Jr., Frey CC, Feder KS. Treatment. Treatment of type V osteochondral lesions of the talus with ipsilateral knee osteochondral autografts. Surgical options differ according to the size, depth and amount of damage associated with an osteochondral lesion. For adults, such a condition usually requires surgery. 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. bone graft may be placed if underlying cyst and bone loss. Scranton PE and McDermott JE. Once the diagnosis has been confirmed, treatment may be surgical or non-surgical, depending on the nature of the OLT, presence of other injuries and patient characteristics. Cast immobilization: If the OLT occurs following an acute injury, initial immobilization in a cast for 4 … This allows us to treat the bone defect without affecting the cartilage. Many scans may miss the damage caused by the lesion, which is also masked by the sprain or trauma that caused the injury. They require a strong plan. One would use a non-invasive ankle distractor to distract the joint and check the lesion. By Jeffrey E. McAlister, DPM, FACFAS, and Eric So, DPM, AACFAS |. Then you fill the region with either allograft or autograft. This chapter is adapted from Chao W, Freeland E, Dedini R: Osteochondral Lesions … The diagnosis of cartilage damage (osteochondral lesion, also known as talar dome) is often done with x-rays and/or an MRI. Repetitive trauma has also been associated with the development of such lesions. For stable lesions, non-operative management is usually the first step including: Scranton PE and McDermott JE. Nonsurgical Treatment Approaches. Most commonly, a surgeon will perform an arthroscopic exploration and treatment. Treatment is split up into three grades, depending on how severe the injury is: Grade 1: This treatment doesn’t require any invasive procedures. An osteochondral defect refers to a focal area of damage that involves both the cartilage and a piece of underlying bone. Within the knee, cartilage damage can happen between the thigh bone and the shinbone. The treatment for Osteochondral Defect depends on the size of the defect and whether the overlying cartilage is damaged. Lesion size, location, chronicity, and characteristics such as displacement and the presence of subchondral cysts help dictate the appropriate treatment … If the MRI shows a cystic lesion and we are concerned about the overlying cartilage and bone seal, and if there is a small fracture in the overlying subchondral bone region, we will often get a CT scan after the MRI. If the lesion is stable (without loose pieces of cartilage or bone), one or more of the following nonsurgical treatment options may be considered: Immobilization. If the fragment is unstable or loose in the joint, surgery may be necessary to remove and repair the injured area. 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. We prefer the use of autograft and often harvest the material from either the calcaneus or distal tibia. 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