Evaluation and Management of Osteochondral Lesions of the Talus

Abstract

Osteochondral lesions of the talus are common injuries that affect a wide variety of active patients. The majority of these lesions are associated with ankle sprains and fractures though several nontraumatic etiologies have also been recognized. Patients normally present with a history of prior ankle injury and/or instability. In addition to standard ankle radiographs, magnetic resonance imaging and computed tomography are used to characterize the extent of the lesion and involvement of the subchondral bone. Symptomatic nondisplaced lesions can often be treated conservatively within the pediatric population though this treatment is less successful in adults. Bone marrow stimulation techniques such as microfracture have yielded favorable results for the treatment of small (<15 mm) lesions. Osteochondral autograft can be harvested most commonly from the ipsilateral knee and carries the benefit of repairing defects with native hyaline cartilage. Osteochondral allograft transplant is reserved for large cystic lesions that lack subchondral bone integrity. Cell-based repair techniques such as autologous chondrocyte implantation and matrix-associated chondrocyte implantation have been increasingly used in an attempt to repair the lesion with hyaline cartilage though these techniques require adequate subchondral bone. Biological agents such as platelet-rich plasma and bone marrow aspirate have been more recently studied as an adjunct to operative treatment but their use remains theoretical. The present article reviews the current concepts in the evaluation and management of osteochondral lesions of the talus, with a focus on the available surgical treatment options.

Keywords: ankle; autologous chondrocyte; cartilage repair; grafts; joint involved; microfracture; procedures; repair; talus.

Figure 1.

Berndt and Harty’s original classification of osteochondral lesions of the talus.

Figure 2.

(A) Arthroscopic view of talar dome lesion after curettage. (B) The same lesion after bone marrow stimulation with microfracture.

Figure 3.

Intraoperative photographs of a failed debridement and microfracture for a large talar dome lesion. (A) A size-matched cadaveric talus is secured within a transplant vice. (B) After medial malleolar osteotomy the lesion is circumscribed and sized for allograft. (C) The larger allograft plug is placed first and the remaining lesion is circumscribed for second plug using the “snowman” technique. (D) The talus is prepared for the second plug. (E) Both plugs have been press-fit into the defect. (F) The cadaveric talus after donation of both osteochondral plugs.

Figure 4.

(A) Arthroscopic view of talar dome osteochondral lesion after curettage. (B) Placement of particulated juvenile cartilage into defect. (C) The transplanted cartilage layer is coated in fibrin glue and adhered to bed of defect.