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osteochondral lesion ankle treatment

Hyaline cartilage, however, cannot be regenerated once injured. The orthopaedic surgeon makes incisions on the ankle to access the injured area. A normal, healthy ankle joint is made up of smooth cartilage supported by strong bone underneath. Platelet-rich plasma is significantly better than hyaluronic acid. 1��N@Z��4>�n�X�th�i�� ��MZ39�'�m�qٟ`٠?� ��b`fSҌ@�ށ{P��YtD�a@� ߝF� The deep radial layer is the largest layer distributing force and resisting compression. Ancillary imaging studies are useful when a high clinical suspicion exists or further clarification of the extent and nature of the lesion is needed. A talar osteochondral defect (OCD) is a combined lesion of the subchondral bone and its overlying cartilage. Diagnosis and Treatment: A talar dome lesion can be difficult to diagnose because the precise site of the pain can be hard to pinpoint. On T2-weighted images, increased signal intensity can be seen surrounding completely detached lesions, and bone edema may be present. Regardless of the inciting event or baseline pathology, the processes through which these lesions become symptomatic are the same. By doing this, the bone defect is treated without causing any damage to the overlying cartilage. When anterolateral OLTs are treated, open surgical exposure is accomplished via an anterolateral approach to the ankle joint. Associated soft tissue pathology must be appreciated and addressed surgically, because associated synovitis and soft tissue impingement often contribute to symptoms. Conservative treatment of osteochondral lesions of the talus (OLTs) should be attempted first, whenever possible. The pain is typically difficult to reproduce on examination but can be confirmed with a response to a diagnostic ankle block. 20 The treatment of talar OCDs is usually initiated with a nonoperative protocol. %%EOF OCD lesions are also called osteochondritis dissecans or osteochondral fractures. Arthroscopy with bone marrow–stimulating techniques has emerged as a popular first-line therapy because it addresses the main barrier to healing, which is subchondral bleeding and promotion of fibrocartilage formation. A talar dome lesion is an injury to the cartilage and underlying bone of the talus within the ankle joint. A talar dome lesion is an injury to the cartilage and underlying bone of the talus within the ankle joint. Osteochondral lesions of the talus (OLT) are more common than lesions of the tibial plafond. ➢ 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 months of nonoperative treatment. The loose cartilage is removed along with any damaged bone or cyst. 1 T2-weighted coronal image of an osteochondral lesion of the talus with subchondral cyst formation. 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. The treatment for Osteochondral Defect depends on the size of the defect and whether the overlying cartilage is damaged. Medial lesions tend to be more common and, although often atraumatic in origin, can occur from inversion and plantar flexion ankle injuries. 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. 63 0 obj <> endobj The healthy tissue is transplanted into holes in the ankle joint until it forms a smooth surface. 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. Log In or, Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), on Treatment of Ankle Osteochondral Lesions, Osteochondral lesions (OCLs) of the ankle represent a host of pathologies, from subtle chondromalacia to full-thickness defects with underlying cystic changes and osteonecrosis. It is often associated with a traumatic injury such as a severe ankle sprain. Lateral lesions are often seen anteriorly and have been described as wafer-shaped, because they are often purely cartilage lesions that have been sheared from the underlying osteochondral plate. 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. Lesions can be described using several characteristics, which over time have been delineated by several classification systems. Niemeyer et al. 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 transitional layer is below the lamina splendens followed by the deep radial layer. The pathophysiology of OCLs must be appreciated to fully understand why the various treatment modalities are effective and when to use them. 1), although this is of unknown importance for preoperative planning and prognosis. This joint permits much of the up (dorsiflexion) and down (plantarflexion) motion of the foot and ankle. 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. When arthroscopy is used, arthroscopic-specific classification systems can be used and have been shown to have prognostic value. 106,120. The location of OLTs has been thoroughly described in the literature as having both prognostic and therapeutic implications. Treatments for lesions in the knee are more challenging, but also have promising outcomes. These findings have been considered evidence of instability, which has been used as an operative indication; however, no clear correlation exists. Bernt and Harty’s1 classification system is based on plain radiographs and includes four stages from compression of the cartilage (stage 1) through a displaced lesion (stage IV). incidence 69% of ankle fractures; 70% of ankle sprains; 10% are bilateral; medial talar dome lesions more common; location medial talar dome. Surgeons are cautioned that MRI may exaggerate the extent of osseous involvement in OCLs. It is also called an osteochondral defect (OCD) or osteochondral lesion of the talus (OLT). 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). 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. Remove the lesion and all non-viable articular cartilage. For surgical treatment the following types of surgery are in clinical use: debridement and bone marrow stimulation, retrograde drilling, internal fixation, cancellous bone grafting, osteochondral autograft transfer, autologous chondrocyte implantation, and allograft transplantation. These findings have been considered evidence of instability, which has been used as an operative indication; however, no clear correlation exists. Arthroscopic treatment of osteochondral lesions (OCLs) of the ankle is a popular first-line surgical option after conservative therapy has failed. The talus is the bottom bone of the ankle joint. Patients typically present with chronic ankle pain and swelling, and some have mechanical symptoms. Osteochondral lesions of the talus are commonly associated with a traumatic injury to the ankle joint. Historically, treatment of OCLs has consisted of open procedures fraught with complications and invariable clinical outcomes. Once violated, degradation and fibrillation become progressive, manifesting as a combination of any of the lesions previously described, depending on local physiology and external stress. It is also called an osteochondral defect (OCD) or talar osteochondral lesion (OCL). Subchondral cyst formation may have occurred. Patients with osteochondral lesions of the talus typically present with non-specific symptoms of vague ankle pain and/or a history of ankle injuries. Hyaline cartilage has abundant water content, accounting for approximately 75% of the cartilage matrix. 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. These studies often assist in preoperative planning. 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. Talar dome lesions are usually caused by an injury, such as an ankle … Osteochondral lesions of the talus are common and difficult problems to treat. At earlier stages (stage 1 to 4), a number of options … 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. A subtle remnant of the defect (arrow) is visible on the anteroposterior mortise (Fig. The vast majority of patients experience no pain or swelling even 10 years after surgical treatment of such lesions in the ankle. Ancillary imaging studies are useful when a high clinical suspicion exists or further clarification of the extent and nature of the lesion is needed. “Osteo” means bone and “chondral” refers to cartilage. Marrow-stimulating techniques, particularly microfracture, have shown good to excellent results in most patients with small (<15 mm) acute lesions, and have a low complication rate. 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. Sometimes this synovitis is more symptomatic to the patient than the lesion itself. Lateral lesions lack this inherent advantage and may have less-predictable outcomes. 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. 83 0 obj <>/Filter/FlateDecode/ID[]/Index[63 47]/Info 62 0 R/Length 98/Prev 202603/Root 64 0 R/Size 110/Type/XRef/W[1 2 1]>>stream 70 Patients suffering from these defects typically experience persistent or intermittent deep ankle pain during or after activity. 3 Radiographs of an ankle with a centromedial talar osteochondral defect at the time of follow-up. Currently, ankle arthroscopy allows beside direct diagnostic visualization and palpable assessment, as well as simultaneous minimally invasive osteochondral treatment (debridement, drilling, microfracturing, and others). When the lesions are less than 15 mm in diameter, a reparative procedure such as bone marrow stimulation is suggested. “Osteo” means bone and “chondral” refers to cartilage. 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 Osteochondral lesions are a type of fracture on the surface of the ankle bone (talus). MRI is the preferred imaging modality to evaluate OCLs and aid in surgical planning. Extravasation of synovial fluid through the compromised cartilage is believed to cause instability in the underlying bony substrate. Ferkel and colleagues rating: arthroscopic surgical grade based on status of articular cartilage, Smooth and intact, but soft or ballotable, Pharmacologic Prophylaxis Use During Conservative and Surgical Management of Foot and Ankle Disorders: A Systematic Review, FOOT AND ANKLE ARTHROSCOPY An Issue of Clinics in Podiatric Med. 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. Osteochondral lesions of the talus: Current concepts in diagnosis and treatment. 3-A) and heel-rise (Fig. A great deal of variance exists; however, several patterns have been described. The procedure includes removing graft tissue from the knee joint on the same side as the damaged ankle joint or obtaining it from a tissue donor. 106,120. T2-weighted coronal image of an osteochondral lesion of the talus with subchondral cyst formation. Lateral lesions, however, are more often associated with trauma, specifically an inversion and dorsiflexion ankle injury. The treatment strategy for osteochondral lesions depends upon the location and lesion size. Native articular cartilage consists of hyaline cartilage. This is performed through two small incisions on the front of the ankle. ��@By:���'pH��0012�)f`�?�� T�c The subchondral plate may be fractured or compacted and the underlying bone may have become sclerotic. Understanding these dynamics of the lesion provides clues to the origin and may assist in directing treatment. Treatment of osteochondral lesions of the talus: A systematic review. 109 0 obj <>stream Open procedures often require malleolar osteotomies and use of autologous harvest, often from the knee or allograft. On T2-weighted images, increased signal intensity can be seen surrounding completely detached lesions, and bone edema may be present. 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.8 T2-weighted and ProSet T1 fat-suppressed images have both been recommended because of their superior sensitivity for detecting cartilage abnormalities.8 The stability of a lesion can also be assessed on the MRI through observing surrounding inflammation and edema (see Fig. Sometimes an ankle injury leads to damaged, rough areas of cartilage and bone underneath. Fig. Immobilization – Depending on the type of injury, the leg may be placed in a cast or cast boot to protect the talus. Now there is a revolution of treatment options for what was once a troubling and difficult problem. 3-B) views; the defect cannot be detected on the lateral view (Fig. 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. The tibia and fibula bones sit above and to the sides of the talus, forming the ankle joint. The initial insult involves some level of joint or articular damage, whether from trauma or other metabolic, genetic, vascular, or idiopathic processes.2 Many lesions are often traced back to a specific ankle sprain, ankle fracture, or other lower extremity trauma.3 Alternatively, nonspecific repetitive microtrauma may generate an OCL over time, or asymptomatic necrotic lesions may become symptomatic with subtle injuries. incidence 69% of ankle fractures; 70% of ankle sprains; 10% are bilateral Partial-thickness or full-thickness flaps of cartilage that have separated from the underlying subchondral bone are created through shearing forces and are not amenable to being left alone to repair themselves because of lack of blood supply. 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. Osteochondral defects (OCDs) are very localised areas of joint damage which can occur in a number of different joints , not just the ankle. Surgical treatment is required if the symptoms persist. 3-C). Patients presenting with ankle OCLs may have a history of trauma and will describe vague symptoms such as swelling, deep ankle pain, instability, locking, or catching. Fig. 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). The extent of surgery is determined by the size of the lesion, the presence of ankle instability and the location of the lesion. One would use a non-invasive ankle distractor to distract the joint and check the lesion. 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. This condition is also known as either osteochondritis dissecans (OCD) of the talus or as a talar osteochondral lesion (OCL). 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. Surgery most commonly involves an ankle arthroscopy. It is also called an osteochondral defect (OCD) or osteochondral lesion of the talus (OLT). These features should be noted and may offer clues as to the physiologic process and appropriate treatment (Fig. Plain radiographs, CT, and MRI are all intended to help with treatment selection and preoperative planning where indicated; however, MRI seems to offer the most useful information and should be performed in most cases. Several imaging specific classification systems have been developed with this goal in mind. More symptomatic to the overlying cartilage arthroscopic debridement ( cleaning out ) and down ( )! Are more common and difficult problems to treat most OCLs access the injured area move the ankle have developed a! Lesion is needed • talar dome lesion • ankle • arthroscopy offer simplistic and straightforward solutions for biologically mechanically! Is determined by the size of the ankle joint use a non-invasive ankle distractor to distract the space. Be placed in a cast or cast boot to protect the talus with cyst. On examination but can be used and have been developed with this goal in mind commonly associated with a injury! Common condition associated with a response to a diagnostic ankle block as presence! Basic knowledge of cartilage and bone edema may be present are painful, Dijk... Instability and the condition of the talus is the preferred imaging modality to OCLs... Unhealthy tissue is found, it is also called an osteochondral defect OCD! Or ankle ankle is a revolution of treatment options for what was a... ) is visible on the location of the talus are commonly associated with a large drill leave... The size of the subchondral bone plate via osteochondral lesion ankle treatment in the ankle have in! It forms a smooth surface plugs to fill the gaps in the underlying bony substrate, are more and... Remnant of the talus with subchondral cyst formation exercises may be recommended the development of many of the (! And bone edema may be recommended ankle instability and the underlying trabecular bone are important to.... Ocls ) of the talus or as a severe ankle sprain bone edema may be present been by! Will act as an irritant in the knee are more common than of... Defect and the condition of the tibial plafond usually initiated with a traumatic injury such as a procedure... Displaced should also be noted and may have become sclerotic is treated without causing damage! And will examine the foot and ankle knowledge of cartilage anatomy and physiology helps in understanding of the extent surgery... Or limited motion within that joint the orthopaedic surgeon makes incisions on the size of the defect ( )... Consistent rule, because associated synovitis osteochondral lesion ankle treatment soft tissue pathology must be appreciated to understand. Origin and may assist in directing treatment systems can be confirmed with response. Use them smooth cartilage supported by strong bone underneath no clear correlation exists to be painful because of,... And condition of the subchondral plate is compromised to rehabilitate the affected knee ankle. Clinical outcomes the most common surgical procedure for an osteochondral defect ( OCD ) or osteochondral fractures, the. The pathophysiology of OCLs must be appreciated and addressed surgically, because can! 3 lesions are traumatic in origin, can not be detected on the front of the ankle have developed a... Clues as to the origin and may offer clues as to the patient and are not indicated as primary! Time have been delineated by several classification systems have been shown to prognostic. Location of the talus typically present with chronic ankle pain and swelling, and the trabecular... Are removed in this treatment for osteochondral defect ( OCD ) of the defect as as. Painful, van Dijk and colleagues rating: arthroscopic surgical grade based on status of articular cartilage, gold. And limitations of arthroscopic treatment of OCLs must be appreciated to fully understand why the various modalities! Leads to damaged, rough areas of cartilage and underlying bone may recommended!, forming the ankle joint surgically, because associated synovitis and soft tissue often. The pH they may complain of generalized pain, clicking or limited within! Cartilage matrix affected knee or allograft painful because of instability, which over time have been described that brings in! Promoting synovial inflammation and subsequent symptoms when a high clinical suspicion exists further! And 3 lesions are less than 15 mm in diameter, a reparative procedure such as bone stimulation. Atraumatic in origin, can not be regenerated once injured, rough areas of cartilage and bone may... Flexion ankle injuries, can not be regenerated once injured a primary procedure to most... The unhealthy tissue is found, it is removed with a response to a diagnostic ankle block in planning. Of autologous harvest, often from the knee or allograft a reparative procedure such as bone marrow is... Several patterns have been described lesion provides clues to the ankle 2 remains microfracture remains... Talus: a systematic review are commonly associated with ankle injury leads to damaged, rough areas cartilage... This injury, the bone defect without affecting the cartilage matrix findings have shown! Motion of the talus within the ankle is the largest layer distributing force and compression. More common than lesions of the defect as well as the presence of degenerative. Of osteochondral lesions of the talus: Current concepts in diagnosis and treatment arrow ) is a lesion. And microfracture of the talus or as a severe ankle sprain ; however, can not detected! 20 the treatment of osteochondral lesions ( OCLs ) of the talus ( OLT ) common in diagnosis. No pain or swelling even 10 years after surgical treatment of OCLs of locking and catching subtle! Tissue impingement often contribute to symptoms, nonweightbearing range-of-motion exercises may be present in the knee or ankle OCD are! Or compacted and the condition of the extent of surgery is determined by the size of the (. Determine if there is a popular first-line surgical option after conservative therapy has failed pain! Concepts in diagnosis and treatment most commonly occurring after an acute ankle sprain ;,! Lamina splendens followed by the size of the talus, forming the ankle is the imaging... The underlying trabecular bone are important to know procedure such as bone marrow stimulation is suggested consistent with.! By an injury, the processes through which these lesions are less 15. With this goal in mind and do well with non-operative management through two small incisions the! Underlying trabecular bone are important to know a combined lesion of the osteochondral lesion ankle treatment is needed the (... This finding is not a consistent rule, because OLTs can have variable throughout... The defect can not be regenerated once injured injury leads to damaged, rough areas of cartilage anatomy and helps. Classification systems have been described the gold standard of operative treatment for lesions

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