In the ankle, osteochondral lesions usually occur on the talus, which is the bone that connects the leg to the foot. Lesion size, location, chronicity, and characteristics such as displacement and the presence of subchondral cysts help dictate the appropriate treatment … Surgical options differ according to the size, depth and amount of damage associated with an osteochondral lesion. Remove the lesion and all non-viable articular cartilage. One would use a non-invasive ankle distractor to distract the joint and check the lesion. 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. For adults, such a condition usually requires surgery. However, in most cases, the MRI gives us enough information. All Rights Reserved. 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. 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. 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. The most common location of osteochondral lesions in patients with ankle trauma is on the anterolateral or pos- 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 is sutured into place this small caliber suture, omitting one area to leave access to underlying defect. Osteochondral lesions of the talus occur for several reasons. This chapter is adapted from Chao W, Freeland E, Dedini R: Osteochondral Lesions … The cartilage can be torn, crushed or damaged and, in rare cases, a cyst can form in the cartilage. A period of … For small-sized defects with intact cartilage, our treatment of choice is Retrograde … Platelet-rich plasma is significantly better than hyaluronic acid. Nonsurgical options include: Rest; Modification of activities to reduce stress; Brace, boot or cast to immobilize the affected joint; Healing of the osteochondritis dissecans lesion should be monitored by routine follow-up imaging tests. However, if the osteochondral lesion is identified at an earlier stage, other treatment solutions are feasible. Often, the problem is not diagnosed at the initial time of injury either because clinicians did not obtain radiographs or the radiographs do not show a clear lesion. [] This is a broad terminology that encompasses a variety of disorders including osteochondritis dissecans, osteochondral fractures, and osteochondral defects. If the patient presents such kind of changes, the most recommended form of intervention is represented by the complete replacement of the joint. A chondral defect refers to a focal area of damage to the articular cartilage (the cartilage that lines the end of the bones). 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. Osteochondral lesions of the talus (OLTs) are a difficult pathologic entity to treat. Within the knee, cartilage damage can happen between the thigh bone and the shinbone. It can be challenging to diagnose an osteochondral lesion at the time of injury. If this is not available, the second option is a femoral head fresh allograft. The diagnosis of cartilage damage (osteochondral lesion, also known as talar dome) is often done with x-rays and/or an MRI. 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. In some cases, both an MRI and CT are needed to diagnose an osteochondral lesion. 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. The most common cause is from a crush or injury to the surface of the bone during the abnormal motion of the ankle in a sprain. The final and most difficult type of lesion to treat is the subchondral cystic lesion with intact overlying cartilage and bone. [] This is a broad terminology that encompasses a variety of disorders including osteochondritis dissecans, osteochondral fractures, and osteochondral … When the latter is present, then joint replacement is often the only feasible treatment. Outcome of osteochondral autograft transplantation for type-V cystic osteochondral lesions of the talus. If the patient presents such kind of changes, the most recommended form of intervention is represented by the complete replacement of the joint. An osteochondral lesion may also be known as an osteochondral defect. Within the knee, cartilage damage can happen between the thigh bone and the shinbone. A chondral defect refers to a focal area of damage to the articular cartilage (the cartilage that lines the end of the bones). 109. A talar osteochondral lesion (OLT) can develop after ankle sprains or ankle trauma. This is very simple to perform and one would make several drill holes into the lesion to allow for bleeding and fibrocartilage formation. 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. The size of the lesion … Treatment options include: non-operative conservative therapy (including but not limited to modification of activity, injections, casting, or boots), various surgeries like “microfracturing” the affected bone which brings new cells to the area in hopes building new cartilage, or transplantation of cartilage/bone from a donor or different body part. Radiographs showed a suspicious area on the lateral talar dome. periosteum from tibia taken and fitted to defect. Cast immobilization: If the OLT occurs following an acute injury, initial immobilization in a cast for 4 … Treatment depends on the severity of the talar dome lesion. When there is a break, tear, separation, or disruption of the cartilage that could be referred to as an osteochondral lesion… Stage 1,2 and 3 lesions are less likely to progress to arthritis and do well with non-operative management. Employ CT scanning to check for a solid repair at the six- to eight-week point. Lesions can be stable or unstable. 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. This allows us to treat the bone defect without affecting the cartilage. What Bunion Procedures Does A Surgeon Need To Master? ➢ 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 … Scranton PE and McDermott JE. Scranton PE and McDermott JE. 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. 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. All Rights Reserved. After the initial pain and discomfort of a strain or sprain subsides, individuals usually resume or even increase their activity level. However, in most cases with larger lesions, the surgeon should completely excise the lesion and use osteochondral grafting. Within the ankle, these lesions … 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. The goal of non-surgical treatment is to allow the injured cartilage and bone to heal. We have found equally good outcomes with the use of autograft and fresh allograft, and therefore use the fresh allograft as our primary option. The size of the lesion … During this period of immobilization, nonweightbearing range-of-motion exercises may be recommended. Use a cast to allow for healing of the lesion for six to eight weeks. With an MRI, the ligament structures, tendons and cartilage of the ankle can be examined and analyzed. Treatment and prognosis. In certain cases, an OATS allograft option is the best option. 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. “Osteo” means bone and “chondral” refers to cartilage. Diagnosing an osteochondral lesion is very difficult on a physical exam and one rarely diagnoses this without further testing. There is a great deal of debate as to whether you should use autograft, fresh allograft or graft substitutes. A talar dome lesion is an injury to the cartilage and underlying bone of the talus within the ankle joint. With medial lesions, one must osteotomize the medial malleolus to access the joint. Treatment of type V osteochondral lesions of the talus with ipsilateral knee osteochondral autografts. These can occur from an acute traumatic injury to the knee or an underlying disorder of the bone. One may use radiographs to check for a cyst formation or cartilage damage but this imaging rarely shows definitive involvement. Treatment depends on the severity of the talar dome lesion. Lesion size, location, chronicity, and characteristics such as displacement and the presence of subchondral cysts help dictate the appropriate treatment … For most kids and young teens with osteochondritis dissecans, the … 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. They require a strong plan. Operative treatment might also be necessary if patients do not respond well to conservative treatment. Arthroscopic surgery is a procedure that is frequently used as a treatment to remove the loose cartilage and bone tissue from the joint. What Orthotic Modifications Do Podiatrists Use The Most? 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. Osteochondral defects generally linger or get worse unless they’re treated. With proper procedure selection, the options for osteochondral lesion treatment are improving and have great outcomes. Treatment of type V osteochondral lesions of the talus with ipsilateral knee osteochondral autografts. 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. The newest and most complicated treatment option is the use of retrograde drilling of the lesion. Have the patient emphasize non-weightbearing for a period of four to six weeks and immediately start using a passive range of motion machine. Surgical treatment of talar OLTs includes: Arthroscopic … Informed consent must include the possible need for further surgery, graft failure/nonunion and the potential need for ankle fusion or replacement. 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. 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; … It occurs when a small segment of bone begins to crack and separate from its surrounding region due to a lack of blood supply. It is important to pack the lesion fully to avoid further cyst formation. After surgery, weight should be kept off the affected knee or ankle for four to six weeks. 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). If the fragment is unstable or loose in the joint, surgery may be necessary to remove and repair the injured area. bone graft may be placed if underlying cyst and bone loss. The diagnosis of cartilage damage (osteochondral lesion, also known as talar dome) is often done with x-rays and/or an MRI. debridement of lesion to create stable cartilage rim, subchondral bone exposed. © 2020 HMP. One can use two allograft regions that mimic the normal makeup of talar cartilage. 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. Operative Treatment . A physician will examine the joint for instability and range of motion. This is easy to identify since the region of damaged cartilage will feel soft and a probe will easily penetrate the cartilage during arthroscopic examination. In later stages of the disorder there will be swelling of the affected joint which catches and locks during movement. “Osteo” means bone and “chondral” refers to cartilage. I would recommend starting with the treatment of easy lesions prior to trying the complex and large lesions. Dr. Baravarian is the Co-Director of the Foot and Ankle Institute of Santa Monica. Typical modalities of activity modification, bracing, nonsteroidal anti-inflammatory drugs (NSAIDs), physical therapy, and protected weight-bearing in a walking boot may alleviate symptoms 26 - 28 . 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. The treatment approach is based on the size, location and degree of separation of the bone and cartilage. 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. 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. In order to protect the soft tissues, one should drill through the medial malleolus with the use of a microvector guide. If the damage is small, the surgeon may drill into the bone, which causes a small amount of bleeding and encourages healing. These can occur from an acute traumatic injury to the knee or an underlying disorder of the bone. Arthroscopic treatment of the OLTs aims to restore ankle joint function and pain relief by the removal of the chondral or osteochondral fragment, debridement and stabilization of cartilage rim and … Although the cause of such lesions is unknown, they may involve a genetic predisposition to such a condition. Over a period of time, ankle pain will resolve and the patient will begin to increase his or her level of activity. The treatment for Osteochondral Defect depends on the size of the defect and whether the overlying cartilage is damaged. How To Diagnose And Treat Osteochondral Lesions Of The Talus, How To Assess And Treat Ligamentous Laxity Syndromes In The Foot And Ankle, Pertinent Pearls In Evaluating And Treating Chronic Ankle Instability, Current Best Practices In The Treatment Of Plantar Plate Tears. Each type of injury will have different treatment options and require a different type of workup. Immobilization – Depending on the type of injury, the leg may be placed in a cast or cast boot to protect the talus. Furthermore, the location of the lesion will also dictate treatment options. An osteochondral defect refers to a focal area of damage that involves both the cartilage and a piece of underlying bone. Surgical treatment is indicated for displaced talar OLTs or lesions that have not improved with appropriate non-operative management. The type of surgery that is most effective depends on the size, location and severity of the lesion. Nonsurgical Treatment Approaches. 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. However, the majority of osteochondral lesions do not show themselves at the initial time of injury. Treatment depends upon the size of the osteochondral defect and the condition of the overlying cartilage. This may be followed with gradual progression of weightbearing and physical therapy. the lateral osteochondral defect. The damaged cartilage is cleaned out and removed. 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 … This is the most common type of injury that will require care. However, if the osteochondral lesion is identified at an earlier stage, other treatment solutions are feasible. Peroneal Tendon Dysfunction: Why Peroneal Tendon Tears Should Be Treated Like Posterior Tibial Tendon Tears. Choose a doctor and schedule an appointment. The first is injury to the cartilage surface with an actual loss of part of the chondral surface and underlying subchondral bone. the lateral osteochondral defect. If the fragment is unstable or loose in the joint, surgery may be necessary to remove and repair the injured area. After removing all non-viable cartilage, the surgeon should fenestrate the subchondral bone with either a K-wire or a chondral pick. Cartilage is a connective tissue that covers the bones between joints. Treatment. If the lesion is stable (without loose pieces of cartilage or bone), one or more of the following nonsurgical … Then you fill the region with either allograft or autograft. 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 to non-surgical treatment. They require a strong plan. 1. Nonsurgical Treatment Approaches. In order to treat the problem properly, one must diagnose the cause, the amount of injury and the residual problem present. A second point to consider is the level of activity the patient would like to return to. For related articles, check out the archives at www.podiatrytoday.com. [] Although majority may be associated with trauma, some may develop insidiously. Osteochondral lesions or osteochondritis dessicans can occur in any joint, but are most common in the knee and ankle. Conservative care of osteochondral lesions is difficult. 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 … It is important to understand the principles of arthroscopy and the use of a microvector guide in the treatment of osteochondral lesions. After performing this procedure, one should emphasize non-weightbearing for six to eight weeks and again use a CT scan to check healing. 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. An osteochondral defect refers to a focal area of damage that involves both the cartilage and a piece of underlying bone. It occurs when a small segment of bone begins to crack and separate from its … In our hands, we will get an MRI as our primary diagnostic test as it gives us information on the ligament, tendon and synovial regions as well as the osteochondral lesion. We have dealt with the actual ligament injury and its repair, treatment of peroneal tendon injuries and also conservative care of ankle injuries. Treatment depends on the location and size of the defect as well as the presence of secondary degenerative changes. Treatment depends on the severity of the talar dome lesion. - Operative Treatment: - Arthroscopy of the Ankle: - osteochondral lesions of the talus can be debrided, and loose bodies and small osteochondral fragments can be removed; - use of non-invasive or invasive distraction improves access to joint and allows adequate debridement and curettage of bed; He is an Associate Professor at UCLA Medical Center and is the Chief of Podiatric Surgery at Santa Monica/UCLA Medical Center. When the latter is present, then joint replacement is often the only feasible treatment. 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 … 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. It is at this point that the patient will present for further consultation. Osteochondral Lesions of the Talus Sara Lyn Miniaci-Coxhead, MD Dr. Miniaci-Coxhead or an immediate family member serves as a board member, owner, officer, or committee member of the American Orthopaedic Foot and Ankle Society. Younger patients, particularly … Pain often occurs with an increase in activities such as sports and is not present with rest. One should physically examine the ankle to check for instability and tendon or ligament injury. Dr. Baravarian may be reached at bbaravarian @mednet.ucla.edu. 108. The treatment of an osteochondral lesion is based on the stability of the lesion. This type of injury is fairly rare. Foot and Ankle International, May 2001; 22(5): 380-384. Outcome of osteochondral autograft transplantation for type-V cystic osteochondral lesions … The affected joint may also seem to be loose. Such lesions are a tear or fracture in the cartilage covering one of the bones in a joint. The common treatment strategies of symptomatic osteochondral lesions include nonsurgical treatment, with rest, cast immobilisation and use of nonsteroidal anti-inflammatory drugs (NSAIDs). Treatment is split up into three grades, depending on how severe the injury is: Grade 1: This treatment doesn’t require any invasive procedures. Treatment depends on the location and size of the defect as well as the presence of secondary degenerative changes. Patients will note a dull ache of the joint and may also describe mild to moderate locking or clicking. Continued. 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. At earlier stages (stage 1 to 4), a number of options exist including: osteochondral … Patients may have an OLT that is present a… A talar dome lesion is an injury to the cartilage and underlying bone of the talus within the ankle joint. Cedars-Sinai has a range of comprehensive treatment options. 108. Then using a microvector guide, the surgeon would drill a tunnel from the sinus tarsi region into the cystic lesion with a guide pin. 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. An OLT is an injury to the cartilage and underlying bone of the talus within the joint, where it begins to soften and break off as a result of not healing properly. Surgical options differ according to the size, depth … Medial lesions … OCD usually causes pain … Foot and Ankle International, May 2001; 22(5): 380-384. Osteochondral lesions of the talus (OLT) are those that affect the chondral and subchondral areas of the talus. Initial x-rays are taken to check the alignment of the foot and ankle, as well as look for any bone damage. Many scans may miss the damage caused by the lesion, which is also masked by the sprain or trauma that caused the injury. Surgical treatment of OCLs traditionally includes excision of loose bodies, debridement of the area, and drilling or microfracturing. © 2020 Cedars-Sinai. Initial x-rays are taken to check the alignment of the foot and ankle, as well as look for any bone damage. Use the OATS system to remove the plug of damaged cartilage and bone to a depth of 1 cm or so, and utilize a replacement graft. Treatment of the subchondral bone will aid in pain relief even if one treats the overlying cartilage. 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. This surgery may be performed open or arthroscopically. We prefer the use of autograft and often harvest the material from either the calcaneus or distal tibia. Non-surgical treatment is appropriate for certain lesions and usually involves immobilization and restricted weightbearing. 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. Actual surgical treatments for osteochondral lesions and early knee osteoarthritis seem to be promising. Know what is Osteochondral defect, its causes, symptoms, treatment and prevention. We try to avoid drilling of these lesions as the superficial cartilage and bone are intact and stable. 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. Osteochondral lesions of the talus (OLT) are those that affect the chondral and subchondral areas of the talus. The most common surgical procedure for an osteochondral lesion is an arthroscopic exploration and treatment. Clean out the lesion with a small curette and debride the sclerotic walls. This is referred to as an osteochondral defect (OCD) or osteochondral lesion of the talus (OLT). The goal of treatment is to ease pain and get your child back to using their joint normally. Yet a more sedentary patient with the same lesion may do well with drilling. The most common location of osteochondral lesions … There is also a problem with mild sclerosis of the walls of the cyst that one must treat. Treatment. An osteochondral lesion is an injury or small fracture of the cartilage surface of the talus. this is sutured … FIGURE 71-1 Osteochondral lesion of the talus. What Are The Vascular Ramifications Of COVID-19? 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. Difficult on a physical exam and one rarely diagnoses this without further.. A problem with mild sclerosis of the talus ( OLT ) are that. Joins the foot and the patient presents such kind of changes, second! Can be inserted to replace the cartilage surface with an MRI and CT are needed to an! Informed consent must include the possible need for ankle fusion or replacement physician will examine the joint of. 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