Operative Techniques in Sports Medicine
Volume 18, Issue 1 , Pages 53-59, March 2010

Treatment of Talar Osteochondral Lesions in Athletes: Approaches for Treatment

  • James S. Davitt, MD

      Affiliations

    • Orthopedic and Facture Clinic, Portland, OR
    • Corresponding Author InformationAddress reprint requests to James S. Davitt, MD, Orthopedic and Facture Clinic, 11782 Barnes Rd, Suite 300, Portland, OR
    • ,
  • David L. Rothberg, MD

      Affiliations

    • Department of Orthopaedics, University of Utah, Salt Lake City, Utah

Article Outline

Surface injuries to the talus are relatively common in athletes and may occur as a result of acute injury but are often evaluated in a subacute or chronic setting. The purpose of this manuscript is to outline the key elements to understanding osteochondral lesions of the talus and identify methods of evaluation and treatment for these injuries. Specific methods of treatment are discussed and outcomes emphasized. Concurrent deformities and ligament instability patterns are reviewed.

Keywords: ankle, defect, osteochondral, talus

 

Konig,1 in 1888, first coined the term osteochondritis dissecans (OCD) in reference to loose bodies, felt not to be caused by trauma, tumor or known disease, discovered in the hip and knee. In 1922, Kappis2 published reports of OCD in the ankle and Rendu,3 in 1932, was the first to specifically describe talar OCD when he reported on a case of an intra-articular fracture of the talus. In 1959, Berndt and Hardy4 described the OCD as representing a transchondral fracture, now known more commonly as an osteochondral lesion of the talus (OLT), and ascribed it to a traumatic origin.4

The etiology of the OLT has been the topic of much debate. Konig felt that OLT was caused by inflammation-induced spontaneous necrosis that caused loosening of a joint fragment. Since that time, the lesion has been ascribed to many etiologic factors, including ischemic necrosis, inherited factors, repetitive microtrauma, and single-event macrotrauma.5 Osteochondral lesions of the talus are likely caused by a combination of these factors, with trauma being fundamental in their development. Athletes are at an enhanced risk to develop these lesions because of the repetitive and traumatic nature of their activities.

Of all osteochondral lesions, 4% are found in the talus and they represent 0.09% of all talus fractures.6 OLTs are generally accepted as being bilateral in 10% of cases, and medial lesion are more common than lateral. Berndt and Hardy4 described medial lesions as being caused by inversion, plantar flexion, and lateral rotation of the tibia, whereas lateral lesions were caused by inversion and strong dorsiflexion. Canale and Belding7 found that medial lesions were deeper, cup-shaped, and less likely to be displaced, whereas lateral lesions were usually shallow, wafer-shaped, and likely to be displaced.

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Diagnosis 

Symptoms and Examination 

Talar lesions may be diagnosed acutely but are most often identified some time after an injury, particularly to the lateral ligamentous complex. Patients often will present with a history of deep aching pain laterally after an ankle sprain. Symptoms are aggravated by weight bearing and may include catching, clicking, locking, and feelings of instability. Pain may be medial or lateral, and effusion may be present on examination with evidence of instability or decreased range of motion. One study conducted in Sheffield, England, showed that in athletes with ankle osteochondral injuries, 93% had exertional ankle pain and 75% had an effusion. Most athletes studied were soccer and rugby players.8

It is critical to evaluate each patient for lower extremity alignment, joint stability, and to identify features of the foot that may affect treatment. For example, patients with a cavovarus foot alignment and lateral ankle instability, in addition to an osteochondral lesion will require a more extensive reconstruction if surgery is warranted. An important principal is to achieve proper alignment to support talar healing but to do so demands the identification of concomitant problems. Each extremity should be assessed for ankle and subtalar range of motion, medial and lateral ankle ligamentous stability, generalized joint flexibility, and foot shape. Careful palpation of the tibiotalar joint often indicates the location of the lesion. After the physical examination characteristics are clear, imaging can be helpful to determine the magnitude of the problem and the course of action.

Imaging 

Although an OLT is often a delayed diagnosis, 70% of medial and more than 90% of lateral lesions are associated with an acute traumatic event.9, 10, 11, 12 Plain films may not show lesions initially or they may be overlooked in the acute traumatic setting. In the subset of patients suspected to have a talus lesion after ankle fracture, some are advocating the use of routine arthroscopy with fixation of ankle fractures, and thus advanced imaging may be warranted.13, 14 Computed tomography (CT) and CT arthrography show the outline of subchondral bone and cartilage, but may not show nondisplaced fractures or subchondral edema. Anderson et al showed that CT was able to find only 4 of 14 lesions not found on plain films, whereas magnetic resonance imaging (MRI) showed all 14 and as such MRI remains the gold standard in preoperative imaging.15 Appropriate coil size and technique of MRI performance is important to optimize information from advanced imaging. It is valuable for orthopedists to communicate with musculoskeletal radiologists about patients suspected to have an OLT before imaging to ensure that an optimal study is achieved.

Classification 

Multiple modality-based classification schemes have been proposed beginning with Berndt and Hardy's scheme based on plain radiographs: stage I, small area of subchondral bone compression; stage II, osteochondral fragment partially detached; stage III, osteochondral fragment completely detached but not displaced; stage IV, osteochondral fragment completely detached and displaced.3 Scranton and McDermott16 added a 5th stage to the Berndt and Hardy classification system to describe patients in whom the cartilage cap is intact with a lesion involving a subchondral cyst within the talar dome. Raikin17 proposed a 6th stage in which large lesions (volumes of >3 cm3) were present. Ferkel and Sgaglione described a Berndt and Hardy equivalent scheme based upon CT: stage I, cystic lesion within dome of talus, with intact roof on all views; stage IIA, cystic lesion within communication to talar dome surface; stage IIB open articular surface lesion with overlying nondisplaced fragment; stage III, nondisplaced lesion with lucency; stage IV, displaced fragment.18 Anderson et al described an MRI scheme: stage I, subchondral trabecular compression with bone marrow edema, plain films negative; stage IIA, subchondral cysts; stage IIB, incomplete separation of fragment; stage III, unattached, nondisplaced fragment, with synovial fluid around fragment; stage IV, displaced fragment.15 More recently Cheng et al19 described an intraoperative arthroscopic classification scheme based on the appearance of articular cartilage: grade A, smooth, intact, but soft or ballotable; grade B, rough surface; grade C, fibrillation and fissures; grade D, flap present or bone exposed; grade E, loose, nondisplaced fragment; grade F displaced fragments.

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Treatment Options 

Conservative Treatment 

Most authors recommend a period of immobilization for acute nondisplaced talar osteochondral lesions or for stage I or II chronic lesions.20, 21 This is followed by physical therapy with subsequent radiographs to document healing. However, high failure rates are observed when associated with nonoperative treatment, and variable progression to chronic lesions is observed.4

Operative Treatment 

Arthroscopy With Debridement, Drilling, or Microfracture 

Arthroscopy for evaluation and treatment of the osteochondral lesion has proven to be an invaluable tool. Arthroscopic setup varies, but important points to consider before patient positioning are the location of portal sites, and the ability to maneuver and access all areas of the ankle. Standard ankle arthroscopy requires anteromedial and anterolateral portals. The addition of the posterolateral portal is important for not only inflow in smaller (2.7 mm) cannulas, but more importantly to be able to visualize and treat lesions in the posterior portion of the ankle. The ability to look from the back and debride from either anterior portal is critical for both posteromedial and posterolateral lesions. Posteromedial and posterolateral portals can be made from the prone position, but specialized equipment or some form of traction may be necessary.22

The anteromedial portal is placed first just medial to the anterior tibialis tendon penetrating just the skin with the knife and then bluntly dissecting to the joint with a mosquito clamp (Fig. 1). The blunt trocar and small joint arthroscope are introduced and inflow established. The posterolateral portal is created next in a similar manner, with the incision just lateral to the Achilles and slightly distal to the joint. A spinal needle helps with localization. Finally the anterolateral portal is established through an incision just lateral to the peroneus tertius tendon. Great care should be exercised, as the superficial peroneal nerve branches are very close. The nerve can often be palpated and marked before surgery by plantar flexing the ankle and 4th toe. A standard diagnostic examination is performed in the manner described by Ferkel.23 The lesion is visualized and synovitis debrided as necessary.

If the cartilage is intact on probing, retrograde drilling and/or bone grafting can be carried out24 (Fig. 2). This is more often the case with a postero-medial lesion. An intra-articular drill guide is used with a small incision in the sinus tarsi to direct a K-wire (usually 1.6 mm) into the lesion, taking care not to violate the cartilage. Fluoroscopy in the lateral plane is helpful. Multiple passes are made with the pin to stimulate bleeding and promote healing. If there is a cystic component, the K-wire can be overreamed with a 3.2 or 4.5 mm cannulated drill bit to facilitate curettage and bone grafting of the lesion.

If the lesion is acute and there is adequate bone on the lesion to support fixation, reduction and internal fixation should be performed. This is more likely with an anterolateral or posterolateral lesion. The fragment is often flipped 180° (Fig. 3). The decision is then made whether to attempt arthroscopic fixation or to proceed with a lateral arthrotomy for direct fixation.

If the cartilage surface is not intact or the lesion is chronic and displaced, most authors recommend debridement of the lesion to a stable rim of cartilage, and then microfracture or drilling of the subchondral bone to facilitate fibrocartilage growth (Fig. 4). There are small joint microfracture awls available to facilitate access to a variety of lesions in the ankle. An intra-articular drill guide works well to facilitate passage of a 1.6-mm K-wire into the joint through a separate portal, or more commonly through the malleolus. When approached through the medial malleolus for a posteromedial lesion, the guide is placed through the anteromedial portal and the lesion visualized through either lateral portal. The K-wire is introduced just barely into the joint and multiple even-spaced holes can be drilled into the talus through 1 or 2 holes in the malleolus by flexing and extending the ankle. The holes are spaced 3-5 mm apart and drilled to a depth of 10 mm. Drilling should be carried out as perpendicular to the articular surface as possible. Bleeding bone should be observed after the joint pressure has been reduced.

Postoperative care includes a brief period of immobilization for wound healing, followed by early motion but no weightbearing for 4-8 weeks, depending on lesion size. In general, most authors advocate arthroscopy with debridement and drilling/microfracture for smaller (<1.5 cm2) lesions, shallower lesions, younger patients, or as a primary surgery. Typical success rates are between 75% and 85%.20, 23, 25 Larger, deeper lesions or those with a significant cystic component do less well with this technique and may require more extensive surgery.

Osteochondral Grafts 

Osteochondral grafting has shown good promise in the treatment of OLTs that have failed initial arthroscopic drilling or have a significant cystic component that would preclude the likelihood of acceptable fibrocartilage growth.16, 26, 27, 28, 29 Osteochondral grafting involves transplanting a bone and cartilage plug either as a single large graft or multiple smaller ones, that is, mosaicplasty. The typical donor site is the nonarticular surface of the lateral femoral condyle or femoral trochlea, although harvesting of smaller plugs from the anterior talus is possible.26 There are also commercially available allograft plugs. Although autograft harvest from the ipsilateral knee can be done with relative ease arthroscopically or through a small lateral arthrotomy, the downside of violating the articular surface of a normal joint exists.30, 31 Also, the number and size of the grafts is limited. Allograft plugs avoid donor site morbidity but may have limited chondrocyte viability. When using allograft tali there is no limit to the number available, and whole allograft tali exist from which donor plugs can be harvested to more closely match patient anatomy.

The approach to osteochondral grafting is based on the location of the lesion. Arthroscopy is typically carried out first to assess the lesion and carry out other necessary debridement. For posteromedial lesions, a medial malleolar osteotomy may be necessary, whereas anteromedial lesions usually require only an arthrotomy (Fig. 5). Anterolateral lesions and even many centrolateral and posterolateral lesions can be accessed by an anterolateral arthrotomy plus or minus sectioning of the anterior talofibular ligament (ATFL). Visualization of posterior lesions may be aided by releasing the talofibular ligament, allowing for anterior subluxation of the talus.

Medial Lesions 

A medial malleolar osteotomy is invaluable for providing access to the posteromedial talar dome. Various osteotomies have been described, the most common of which is an oblique osteotomy.16 A curvilinear incision is made over the medial malleolus and anteromedial ankle joint. An arthrotomy is made to allow visualization of the anteromedial corner of the ankle joint. The posterior tibialis tendon sheath is opened and retractors are placed around the posterior aspect of the tibia to protect the tendons and neurovascular bundle. The medial malleolus is predrilled for 4-mm cancellous screws. This is important as it aids in proper reduction of the malleolus later. A thin oscillating saw is used to make an oblique osteotomy entering the joint at the medial corner of the tibia. The articular cartilage and subchondral bone should be cracked with an osteotome to complete the osteotomy. The medial malleolus is hinged on the deltoid ligament and the medial talar dome is visualized. The talus can be everted to provide for perpendicular access to the OLT for osteochondral grafting. It is important not to make the osteotomy too flat, thereby making it difficult to access the OLT, too vertical, increasing the risk of nonunion, or entering the joint too medially leaving a ledge of tibia and making access difficult. The oblique osteotomy is simple to do but has a drawback of sometimes being difficult to repair anatomically. Some authors have advocated a step-cut osteotomy.32, 33 With this approach the osteotomy is still predrilled but a K-wire is used to mark a point 1-1.5 cm proximal to the ankle joint even with the axilla of the ankle joint. The posterior tibialis tendon sheath is opened and the tendon protected. An oscillating saw is used to make a horizontal cut to the K-wire parallel to the plafond, and a narrow osteotome is used to make the vertical cut to the axilla. The malleolus is reflected and the posterior tibialis tendon sheath is released from the medial malleolus. A modification of this osteotomy was proposed to improved perpendicular access.34 In this osteotomy the horizontal limb is replaced with an oblique limb angled at 45°. These step-cut osteotomies provide excellent access to the medial talus and are more stable on reduction.33

Lateral Lesions 

Anterolateral lesions are best approached through a lateral arthrotomy. The incision should be placed in such a way as to be able to be extended proximally if a lateral malleolar osteotomy is necessary. The superficial peroneal nerve must be identified and protected. The extensor retinaculum is divided, the extensor tendons retracted medially, and the arthrotomy is created. For many anterolateral lesions, this will be adequate. As the lesion becomes more posteriorly positioned, additional exposure is required. The ATFL can be divided to allow the talus to subluxate forward. If that is still not enough, an oblique osteotomy of the distal fibula can be performed. This is done at a 45° angle to the long axis of the bone. The syndesmostic ligaments are divided and the fibula is turned down allowing exposure to the posterolateral talar dome. The calcaneofibular ligament can usually be left alone. The osteotomy is repaired with a plate and screws, as well as a syndesmosis screw. The ligaments are also repaired. The fibular osteotomy and ATFL release provide the most access to the lateral talar dome.35

An alternative to a fibular osteotomy to gain access to the posterolateral or centrolateral talus is an osteotomy of the anterolateral tibia.36 This avoids the possible nonunion risk associated with fibular osteotomies. After a similar anterolateral approach, a 2-step osteotomy of the tubercle of Chaput is performed with an oscillating saw and completed with an osteotome. The authors stress the importance of maintaining at least a 1-cm articular fragment and predrilling for accurate reduction. The syndesmotic ligaments are preserved and the fragment is hinged on the anterior-inferior tibiofibular ligament. Plantarflexion aids in visualization as it does in all lateral approaches. The fragment is repaired with a lag screw that was predrilled before making the osteotomy.

Finally, a so-called channel osteotomy of the tibia has been proposed. This osteotomy is either quadrangular shaped or pyramidal.26, 37 The osteotomy is performed after an anterolateral approach to the ankle and involves a channel section of the distal tibia that is cut and removed to gain perpendicular access to the osteochondral lesion. K-wires are used to ensure that the planned cut will be posterior enough for complete access to the involved talar dome. The bone block is completely removed from the field and then repaired using absorbable pins or screws, which were predrilled before making the osteotomy.

Osteochondral Grafting 

After the lesion has been exposed through arthrotomy alone or in conjunction with an osteotomy, it is sharply debrided to stable edges and measured. It is simplest if the lesion is completely covered by a single osteochondral plug, as this minimizes donor site morbidity and maximizes the area that is covered by articular cartilage. When multiple plugs are required, the small gaps between the rounded edges must fill in with fibrocartilage. If a single plug is required, the center of the recipient site is identified and the plug size determined. Multiple commercial systems are available for removal of the recipient bone and the harvest of donor graft. The talus can be much denser than the femur and the commercial harvesters may not remove the recipient plug cleanly. In that case, an anterior cruciate ligament (ACL) guide pin can be drilled into the center of the lesion, taking care to be perpendicular to the articular surface. The lesion is reamed down to an appropriate depth, usually 15 mm, using the ACL reamers. A donor plug is then harvested to match the size and provide a press fit. It is critical that the donor-harvesting instrument is the proper size (usually 1 mm larger than the recipient) or the press fit will not be obtainable. The depth is also important to match. If the graft is too proud, further impaction will damage the cartilage surface or cause increased force in that area. If the graft is countersunk, the cartilage cannot bear load. Beveling the boney end of the plug aids in positioning. If the lesion is located along the medial corner, harvesting from the femoral trochlea can provide a better articular contour than from the lateral femoral condyle.16

Postoperative care usually consists of a below-the-knee non-weightbearing cast for 4 weeks followed by a removable cast boot until the osteotomy is healed. Range of motion exercises are then instituted and partial weightbearing and strengthening is begun at 6 weeks after surgery.

Autologous Chondrocyte Transplantation 

Like osteochondral grafting, autologous chondrocyte transplantation was initially described in the knee.38 Multiple studies have described the appearance of hyaline-like cartilage on follow-up pathological examinations.38, 39, 40, 41 However, there does exist some controversy regarding the quality of the cartilage at the repair site.42 This procedure is more costly than those described previously as it requires a separate procedure to harvest two to three 3-mm cartilage cylinders from the knee or ankle. This cartilage is then cultured in a laboratory and 30 days later a sufficient new chondrocytes are then ready for transplantation. The procedure has the advantage of being able to provide coverage for larger lesions. Theoretically, there is also no fibrocartilage infill between plugs as the surface is continuous with the native cartilage.

After the chondrocytes have been cultured after the first procedure, the OLT is approached in the same way that is used to approach the talus for osteochondral grafting. The lesion is likewise debrided back to a sharp stable margin. Next, the lesion is measured with sterile tinfoil or paper, and periosteum is carefully harvested from the proximal or distal tibia. While harvesting, it is important to have cleaned the periosteum of all fat and other tissue first. The periosteum must be kept intact throughout and one should mark the outer layer. The deeper layer or cambian layer will be placed against the subchondral bone. Care should be taken not to disrupt this layer. The size of the periosteal fragment that is harvested is slightly larger than the defect to fill to provide for measurement errors. After the subchondral bone is dry, the periosteum is sutured to the surrounding cartilage with # 6-0 absorbable suture and sealed with fibrin glue, leaving an opening through which to implant the cultured chondrocytes. The water seal is tested first by gently filling the defect with saline, removing it, and repairing any leaks that exist. The chondrocytes are then injected, and the periosteum sutured and sealed with the fibrin glue.

When there are significant cystic defects, either the defect can be bone grafted at the index cartilage harvest, or a “sandwich” procedure can be performed.43 The defect is first bone-grafted and then a periosteal flap is placed with cambian side up, followed by a second periosteal flap cambian side down. The chondrocytes are injected between the periosteal layers and the flap is sealed.

Postoperative care involves continuous passive motion typically for the first 4 weeks for 6 hours a day, along with active motion exercises. Weight bearing is allowed to begin at 6 weeks progressing to full by 10-12 weeks.

Bulk Allografts 

Occasionally, the talar lesion will be quite large and deep. Methods that have been previously described may not be able to cover the whole area, including cartilage and bone. Therefore, fresh bulk allografts have been described as an alternative. Bulk allografts were first used in tumor reconstruction around joints and slowly found their way into the knee. Here large femoral condyle allografts were used to reconstruct major defects. Gross et al44 described using fresh talar allografts to reconstruct osteochondral lesions in the talus. An osteotomy was necessary and internal fixation was used. Later, the use of an anterior approach with an external fixator to distract the joint was used to obviate the need for an osteotomy.45 This technique involved resecting the diseased hemi-talar articular surface and fixing it with countersunk screws. Both techniques require precise (≤1 mm difference) talar size matching, and therefore take time to schedule. Risks of fresh allograft transfer are also worth consideration. The results were considered successful in two-thirds of the cases. The most common cause for failure was collapse of the graft.

Comorbidities 

In addition to treatment of the osteochondral lesion, limb alignment and stability need to be taken into account to optimize outcome. Most authors stress the need for appropriate preoperative examination of ligament stability and hindfoot alignment. Lateral ankle instability is typically treated with a modified Brostrom repair if local tissues are adequate. If inadequate local soft-issue is available for repair, an anatomic ligament reconstruction is usually necessary using autologous hamstring tendon or allograft tendon. Hindfoot varus, which can be subtle, is corrected with a lateralizing calcaneal osteotomy or metatarsal osteotomy. Occasionally, there can be fixed forefoot compensatory valgus that requires correction to balance the forefoot after ankle and hindfoot correction. This is usually only necessary in cases of long-standing deformity with varus malalignment through the ankle.

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Conclusions 

Talar osteochondral lesions are variable in location and personality. Particularly in an athletic population, one has to be aware that such injuries may develop and prompt treatment may allow a more rapid return to sport. Treatment options are based on size, imaging characteristics, history of prior treatment, limb alignment, and stability. Various algorithms have been proposed based on different classification systems.21, 25 In general, arthroscopy with debridement and drilling/microfracture is performed on primary lesions that do not have a significant cystic component. Osteochondral autograft is indicated when there is a cystic component (type V lesions) or as a treatment in cases that have failed arthroscopic drilling, but has limitations based on size. Larger lesions may require autologous chondrocyte transplantation or bulk allografts.

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References 

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 This manuscript was created with the support of the Beals orthopaedic Resource Center, Department of Orthopaedics and Rehabilitation, Oregon Health and Science University. No further financial support was received for the development of this manuscript.

PII: S1060-1872(10)00017-1

doi:10.1053/j.otsm.2010.02.002

Operative Techniques in Sports Medicine
Volume 18, Issue 1 , Pages 53-59, March 2010

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