Osteochondral Lesions of the Talus Aaron K. Schachter, MD, Andrew L. Chen, MD, MS, Ponnavolu D. Reddy, MD, and Nirmal C. Tejwani, MD Abstract Early accurate diagnosis of osteochon- dral lesions of the talus is important because optimal ankle joint function requires talar integrity. 1 Boyd and Knight 2 showed that the tibiotalar ar- ticulation is subjected to more load per unit area than any other joint in the body. Consequently, injury to a por- tion of the talus may lead to degen- erative changes of the articular sur- faces and subsequent loss of range of motion (ROM). 1 The talus has a lim- ited reparative capacity because a large portion of it is covered by articular cartilage, which limits the vascular supply. 3-6 Osteochondral fractures refer to le- sions affecting the articular cartilage of the talar dome and the underlying subchondral bone. 7 Originally refer- red to as “osteochondritis dissecans,” these lesions were thought to be is- chemic. 8 Subsequent studies have shown that, in most cases, these injuries are sequelae of previous trauma. 7,9-13 Moreover, the results of these studies showed that the lo- cation of the lesion could be pre- dicted, based on the mechanism of injury. Etiology and Epidemiology Fractures of the talar body account for approximately 1% of all fractures in the human body. 14 A large proportion of these are transchondral or com- pression fractures of the talar dome, which are often unrecognized be- cause frequently they are associated with other, more obvious injuries to the foot and ankle. Alexander and Lichtman 11 observed that 28% of these injuries were associated with other fractures. These coexisting fractures, approximately half of which involve the ankle malleoli, may overshadow a significant osteochondral defect of the talus. 1 Similarly, Van Buecken et al 15 reported that these injuries (ie, transchondral talar fractures) were as- sociated with 6.5% of ankle sprains. Berndt and Harty 7 found that 57% of talar dome lesions were located me- dially and 43% laterally. Others have reported a fairly equivalent distribu- tion 9 (Fig. 1). In a series of 70 patients (71 frac- tures), all lateral talar dome injuries were associated with a traumatic event, whereas only 64% of medial ta- lar dome injuries were attributed to trauma. 10 Others have corroborated these results, reporting that all later- al lesions were associated with trau- ma (Fig. 1, B and C) but only 82% of medial lesions were 11 (Fig. 1, A). Al- though trauma usually is the cause of injury, it may not be a single event but may consist of a series of repeat- ed, less intense injuries. 12 In a com- prehensive review of published stud- ies of 500 patients, Flick and Gould 13 reported that a history of trauma was present in 98% of lateral dome lesions Dr. Schachter is Resident, Department of Ortho- paedic Surgery, NYU–Hospital for Joint Dis- eases, New York, NY. Dr. Chen is in private practice, Littleton, NH. Dr. Reddy is Fellow, Department of Orthopaedic Surgery, NYU–Hos- pital for Joint Diseases. Dr. Tejwani is Associate Professor, Department of Orthopaedic Surgery, NYU–Hospital for Joint Diseases. None of the following authors or the departments with which they are affiliated has received anything of value from or owns stock in a commercial com- pany or institution related directly or indirectly to the subject of this article: Dr. Schachter, Dr. Chen, Dr. Reddy, and Dr. Tejwani. Reprint requests: Dr. Tejwani, Bellevue Hospital– NB, 21 W 37, 550 First Avenue, New York, NY 10016. Copyright 2005 by the American Academy of Orthopaedic Surgeons. Osteochondral lesions of the talus occur infrequently and usually represent late se- quelae of ankle trauma. Because of the functional significance of the talus and its limited capacity for repair, correct early diagnosis is important. Osteochondral frac- tures should be suspected in patients with chronic ankle pain, especially those with a prior ankle injury. Historically, plain radiographs have been used to stage lesions; more recently, magnetic resonance imaging and arthroscopy have been used. Non- surgical management remains the mainstay of treatment of acute, nondisplaced os- teochondral lesions. Surgical management is reserved for unstable fragments or fail- ure of nonsurgical treatment. Recent advances in osteochondral grafting have allowed reconstruction of the talar dome, leading to more predictable relief of pain and im- provement of function. J Am Acad Orthop Surg 2005;13:152-158 152 Journal of the American Academy of Orthopaedic Surgeons but in only 70% of medial dome le- sions. Persistent ankle pain in the ab- sence of any recognized trauma should heighten suspicion of a talar osteo- chondral lesion. Mechanism of Injury Berndt and Harty 7 originally described two possible mechanisms for osteo- chondral fractures of the talus. Com- pressive injury to an ankle positioned in dorsiflexion and inversion (eg, a di- rect tibiotalar impact) may crush the subchondral bone of the lateral talar dome, with or without overlying car- tilage damage. Alternatively, subject- ing the plantarflexed ankle to impact forces of inversion and external rota- tion can produce osteochondral inju- ries to the medial talar surface. O’Farrell and Costello 16 also suggested that the medial talar osteochondral lesion is caused by a combination of inversion with plantar flexion. Other mechanisms thought to account for lesions in other locations 17 include impaction of the dome against the lateral malleolus, re- sulting in lateral dome lesions, or against the posterior tibial lip, result- ing in medial defects. 7,18 Classification In 1959, Berndt and Harty 7 proposed a staging system based on radio- graphic findings: stage I, small area of subchondral bone compression; stage II, osteochondral fragment par- tially detached; stage III, osteochon- dral fragment completely detached but not displaced; stage IV, osteo- chondral fragment completely de- tached and displaced. Other grading systems based on more recent radio- logic techniques also have been de- scribed. For example, Anderson et al 19 and Ferkel et al 20 used magnetic resonance imaging (MRI) to classify talar osteochondral injury. With interest in and use of ankle arthroscopy increasing, some have questioned the accuracy of classifica- tion based solely on plain tomogra- phy. Pritsch et al 21 graded lesions ac- cording to articular injury visualized during ankle arthroscopy, ranging from grade I (intact appearance) to grade III (frayed appearance). The au- thors found that radiographic and ar- throscopic findings correlated poor- ly. Fifty percent of lesions classified as stage IV according to the Berndt and Harty system were found to be intact viewed through the arthroscope. However, direct visualization of an in- tact articular surface does not permit the underlying bone to be examined; thus, the extent of a bony lesion may be underestimated. Pritsch et al 21 em- phasized that treatment protocols should be based on the integrity of the articular cartilage and that plain radiographs may not necessarily show the critical elements of talar osteochon- dral injury. This concept under- scores that MRI and ankle arthroscopy have the potential to play important roles in the evaluation of these injuries. Clinical Evaluation The first step in assessing ankle pain should be a meticulous clinical eval- uation to differentiate among the many potential diagnoses, including liga- mentous injury, fractures of the fib- ula, and fractures of the tibial plafond. In patients with acute injury, the an- kle and foot may be swollen and pain- ful, limiting the specificity of the ex- amination. Nonetheless, the ankle and foot should be palpated to identify any discrete locations of tenderness. A careful neurovascular assessment is also essential. ROM of the injured an- kle and hindfoot should be compared with ROM in the contralateral lower extremity. Testing for instability should be performed, including an anterior drawer test with the ankle in both plantar flexion and dorsiflexion. The ankle also should be subjected to inversion and eversion stress testing. Although ankle sprains are more common than osteochondral injuries of the talus, talar osteochondral inju- ry should be included in the differ- ential diagnosis of chronic ankle pain. The index of suspicion for talar osteo- chondral injury should be high in the Figure 1 Plain radiographs of posttraumatic osteochondral injuries (arrows). A, Mortise view of a medial injury. B, Anteroposterior view of a lateral lesion of the talus. C, Oblique view of a lateral lesion of the talus. Aaron K. Schachter, MD, et al Vol 13, No 3, May/June 2005 153 setting of ankle pain without any rec- ognized trauma or with persistent an- kle pain after an acute injury has re- solved. Radiographic Evaluation Plain Radiography Standard radiographic views of the ankle should be obtained, including anteroposterior, lateral, and mortise, with weight bearing if possible. Canale and Kelly 10 proposed that the talar pro- file may be visualized better with an ankle radiograph made with 15° of foot pronation and with the tube an- gled 75° cephalad. Nonstandard pro- jections that allow further elucidation of the talar profile include the mor- tise view of the ankle in plantar flex- ion to visualize posteromedial lesions and stress views to detect ligamen- tous laxity. DeLee 22 suggested that ra- diography cannot identify cartilagi- nous defects or grade I (nondisplaced) lesions. The inability of plain radiog- raphy to visualize nonosseous struc- tures limits its usefulness. 10 Computed Tomography Computed tomography (CT) allows the integrity of the subchondral bone to be assessed in multiple planes, and CT is often invaluable in preoperative planning 10,23 (Fig. 2). However, CT is limited in its ability to visualize cer- tain osteochondral lesions, especially cartilaginous or nondisplaced (grade I) lesions. In comparing the use of CT and MRI to evaluate possible osteo- chondral talar defects identified by bone scintigraphy, Anderson et al 19 re- ported that, although CT and MRI were 90% concordant in identifying lesions visible by plain radiography, CT was capable of identifying only 4 of 14 le- sions that were not evident on plain radiographs (stage I), whereas MRI demonstrated all 14. Bone Scintigraphy Anderson et al 19 examined the role of bone scintigraphy in the evaluation of patients with posttraumatic ankle disability, reporting a 57% incidence of osteochondral defects of the talar dome, despite normal appearance on radiography. The authors found bone scintigraphy to be useful in evaluat- ing ankle injuries when radiographs appear to be normal but suggested that a positive bone scan be followed up with MRI. Urman et al 24 found that when bone scans showed abnor- mal uptake in the talar dome on at least one view, the scan was 94% sen- sitive and 96% specific for osteochon- dral injury. Magnetic Resonance Imaging MRI allows multiplanar evalua- tion and offers the advantage of vi- sualizing the surface of articular car- tilage and subchondral bone as well as edema and other features of the surrounding soft tissue (Fig. 3). MRI also allows early subchondral dam- age (stage I lesions) to be detect- ed. 25,26 In one study, 19 MRI allowed grade I osteochondral lesions to be identified correctly in all 14 patients who had had abnormal results on bone scintigraphy. MRI findings also have been found to correlate closely with visual findings during arthros- copy. 20 Radiographic Protocol Stone 27 proposed a radiographic protocol for evaluating osteochondral lesions of the talus. Plain radiography Figure 2 Computed tomography scans of a medial talar osteochondral lesion. A, Coronal view demonstrating extent of the lesion. B, Axial view showing the medial malleolar lesion (arrow). Figure 3 MRI scans of an ankle. A, Sagittal T2-weighted scan demonstrating an anterior talar dome lesion. B, Coronal T1-weighted scan demonstrating a medial talar dome defect. Osteochondral Lesions of the Talus 154 Journal of the American Academy of Orthopaedic Surgeons should be used for initial evaluation of patients presenting with acute an- kle injury with hemarthrosis or with significant tenderness at the bony landmarks of the ankle. Any osteo- chondral lesion identified should then be evaluated with CT to deter- mine the size, shape, location, and de- gree of displacement. Persistence of pain despite normal appearance on plain radiographs warrants further investigation, such as MRI or bone scintigraphy. The MRI scans should be scrutinized for associated injuries (eg, ligamentous disruption) that may be responsible for, or contribute to, persistent ankle pain. Treatment Nonsurgical Generally, nonsurgical treatment in- volves an initial period of no weight bearing with cast immobilization, fol- lowed by progressive weight bearing and mobilization to full ambulation by 12 to 16 weeks. 1 Berndt and Harty 7 found that, after acute osteochondral injury, nonsurgical treatment with im- mobilization nearly always resulted in healing. Many authors have sug- gested that the decision to operate should depend on the grade of the le- sion. Berndt and Harty grade I and II lesions should be managed non- surgically for up to 1 year to allow for resolution before resorting to surgery. 9,11,15,27-29 Nevertheless, a meta- analysis of 14 studies with a total of 201 patients showed only a 45% suc- cess rate of nonsurgical treatment of grade I, grade II, and medial grade III talar osteochondral lesions (not all injury types were specified). 30 Non- surgical treatment of chronic lesions had a success rate of 56%. 30 Shelton and Pedowitz 29 reported just 25% sat- isfactory results for nonsurgical treat- ment of grade II and III lesions. Surgical Failure of nonsurgical manage- ment or the presence of advanced grade III or IV lesions often necessi- tates surgical intervention. Excision, Drilling, and Curettage Excision may be done with either open or arthroscopic techniques. Ex- cision of the subchondral fragment and curettage of the lesion’s surface is done to remove debris, fibrous tis- sue, or devitalized cartilage. This pro- cedure has been recommended in the treatment of chronic lesions and le- sions with necrotic material. 22 Vascu- lar access channels are then created in the underlying subchondral bone using an awl, drill, or arthroscopic shaver. This allows marrow elements to migrate into the site of injury and produce fibrocartilage to cover the le- sion. 1,27,30,31 Generally, arthroscopic excision and drilling can be done as outpatient pro- cedures. They are associated with fa- cilitated rehabilitation, a quick return to normal function, and minimal wound-healing complications. 27 Trans- articular drilling may be indicated in the treatment of a symptomatic os- seous lesion underlying an intact car- tilaginous surface. 27 However, expo- sure can be limited by the topography of the joint as well as by the diffi- culty in reaching posterior lesions through standard anterior portals. Transarticular drilling is also user de- pendent and requires specialized equipment and arthroscopic instru- ments. Results of excision and drilling have been encouraging compared with those of nonsurgical treatment. In a review of 16 studies with a total of 165 patients, Tol et al 30 found excision, curettage, and drilling to have had good to excellent results in 88% of pa- tients with grade III and higher lesions. However, simple excision and curet- tage without drilling (9 studies, 111 patients) had a success rate of 78%, whereas excision alone (5 studies, 63 patients) had a success rate of 38%. 30 The success rate of excision alone has been shown to be lower than that of nonsurgical treatment (45%). 32 Internal Fixation Internal fixation of osteochondral lesions may be done using a variety ofmethods,includingscrews,Kirsch- ner wires, and bioabsorbable devic- es. 33,34 DeLee 22 proposed that internal fixation is indicated when the injury occurs acutely and the fracture is larg- er than one third the size of the re- spective dome. Stone 27 suggested that the lesion should be at least 7.5 mm in diameter and that the patient be young for surgical fixation. The surgical approach is determined by the location of the lesion. Lesions on the lateral aspect of the talar dome may be approached using either an anterolateral or posterolateral approach; anteromedial lesions may be accessed through an anteromedial approach. Posteromedial lesions may require os- teotomy of the medial malleolus for adequate exposure. Tochigi et al 35 sug- gested using an anterolateral tibial os- teotomy to allow access to centrolat- eral talar lesions. Excision of loose fragments with débridement and curet- tage of the lesions should be performed before internal fixation of the osteo- chondral fragment. 22 Current Trends Osteochondral Allograft Fresh-frozen osteochondral al- lografts have been used to repair os- teochondral lesions of the talus. Gross et al 36 reported retrospectively on a series of nine patients in whom they had implanted talar osteochondral al- lografts to avoid the donor-site mor- bidity associated with autograft har- vest. Only four of the patients had an identifiable previous trauma to the af- fected ankle. One of the procedures was performed for a traumatic open fracture with talar osteochondral de- ficiency. The authors’ indications for performing the procedure included a lesion with a diameter of at least 1 cm and a depth of at least 5 mm as well as inability to perform primary repair of the fragment. Aaron K. Schachter, MD, et al Vol 13, No 3, May/June 2005 155 Following open débridement of the lesion to a bleeding host bed, prefashioned fresh-frozen cadaveric osteochondral allografts were trans- planted using one or two minifrag- ment cancellous screws for graft fixation. Postoperative management included cast immobilization for 2 weeks, with subsequent ROM exer- cises and a patellar tendon–bearing brace for 1 year. At a mean follow-up of 11 years, six of the nine grafts remained intact. The three failures resulted from fragmentation and resorption of the allograft. Osteochondral Autograft Osteochondral autografts use car- tilage and subchondral bone harvest- ed from host non–weight-bearing ar- ticular surfaces. Both the knee and the talus itself have been used as donor sites. 37-42 Assenmacher et al 43 reported on arthroscopically assisted autograft transplantation in nine patients with talar dome lesions. The lesions were graded using both MRI and arthros- copy. Unstable lesions were identified by radiographic evidence of grade III or IV injury or by the arthroscopic vi- sualization of a loose fragment. Pa- tients considered to have unstable le- sions underwent autograft of the talar osteochondral defect with a plug har- vested from the ipsilateral distal fe- mur. The lesions were débrided be- fore the grafts were placed. After adequate débridement, grafting was performed through an arthrotomy. The prefashioned graft was inserted into a reamed recipient site and packed into place. Postoperatively, patients remained non–weight bear- ing for 7 weeks, with ROM exercises begun 10 days postoperatively. There were no complications or revision surgery, and results were good or ex- cellent as assessed with the American Orthopaedic Foot and Ankle Soci- ety (AOFAS) ankle-hindfoot score. Follow-up MRI demonstrated that the grafts were incorporated in all subjects at 9 months postoperatively. Scranton and McDermott 44 reported on osteochondral autograft replace- ment of stage IV talar lesions in 10 pa- tients. The distal femur was used as a donor site; average increase in the AOFAS ankle-hindfoot score was 27 points. Mendicino et al 38 corroborated these results; they reported a high level of patient satisfaction, excellent return to function, and no donor site com- plaints with the use of distal femoral osteochondral autografts to treat stage III and IV lesions. The anterior talar dome also has been used as a donor site for osteo- chondral autograft of the talus. Lee 39 reported no postoperative complica- tions and cited advantages of the ta- lar dome donor site that include elim- ination of a second surgical site, decreased intraoperative time, and a close match in shape of the graft to the native recipient site. Mosaicplasty autograft also has been described, with reconstruction of the osteochondral defect using multiple, small-diameter plug au- tografts as opposed to one large, pre- fashioned graft. Hangody and col- leagues 41,42 reported on the outcomes of talar mosaicplasty, with the medi- al or lateral femoral condyle as the do- nor site. In 36 patients, multiple grafts of 4.5 × 3.5 mm were harvested to re- constitute the talar defects, which av- eraged 1 cm in diameter (Fig. 4). Us- ing the Hanover scoring system, ankle function was judged to be good or excellent in 34 of the 36 patients (94%) at follow-up of 2 to 7 years. 42 All patients returned to full activity. Functional performance of osteo- chondral grafts has been evaluated. Histologic analysis by Giannini et al 40 showed that, unlike drilled le- sions, which heal with fibrocarti- lage, 41,45 osteochondral autografts heal with type II collagen at the re- cipient site. Type II collagen is char- acteristic of hyaline cartilage. Gian- nini et al 40 reported an increase in the AOFAS ankle-hindfoot score from an average of 32 preoperatively to 91 postoperatively in eight patients. Summary Because talar integrity is important for ankle function and because artic- ular repair is difficult, osteochondral lesions may result in functional im- pairment and, later, chronic ankle pain and functional debilitation. Os- teochondral injury should be sus- pected in cases of recalcitrant ankle pain once more common causes, such as ligamentous injury, are ruled out. Although occasionally the etiol- ogy of such lesions is unidentifiable, the majority arise as late sequelae of ankle trauma. Lateral lesions are thought to be secondary to com- bined forceful dorsiflexion and ever- sion of the ankle, whereas medial in- juries may result from combined ankle inversion and plantar flexion. If an osteochondral talar defect is suspected but plain radiographs fail to reveal the lesion, MRI may be use- ful for identifying early, nondis- placed lesions. Early (grade I or II) lesions may be amenable to nonsurgical treatment; more severe (grade III or IV) lesions or those for which nonsurgical man- agement has failed may necessitate surgical intervention. Subchondral drilling is done for stable lesions to encourage fibrocartilage growth, and osteochondral grafts may be used to restore the talar articular surface for unstable or larger defects. To date, functional outcomes reported for os- Figure 4 Mosaicplasty. Intraoperative pho- tograph showing osteochondral autografts (arrows) at the site of a talar dome defect. Osteochondral Lesions of the Talus 156 Journal of the American Academy of Orthopaedic Surgeons teochondral grafting of the talus gen- erally have been favorable. Recent re- search has suggested that healing of such grafts may occur with a predom- inance of type II collagen, but further investigation is necessary to deter- mine whether these weight-bearing surfaces are biomechanically similar to hyaline cartilage. References 1. Saunders R: Fractures and fracture dis- locations of the talus, in Mann RA, Coughlin MJ (eds): Surgery of the Foot and Ankle, ed 7. St. Louis, MO: Mosby, 1991, vol 2, pp 1465-1518. 2. Boyd HS, Knight RA: Fractures of the astralgus. South Med J 1942;35:160-167. 3. Kleiger B: Injuries of the talus and its joints. Clin Orthop 1976;121:243-262. 4. Mulfinger GL, Trueta J: The blood sup- ply of the talus. J Bone Joint Surg Br 1970; 52:160-167. 5. Haliburton RA, Sullivan CR, Kelly PJ, Peterson LFA: The extra-osseous and intra-osseus blood supply of the talus. 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