Osteochondral lesion of talus

 Osteochondral lesion of talus - Terms

Historically, many terms have been used.

Osteochondral dissecans (OCD)

Transchondral talar fracture

Osteochondral talar fracture

Osteochondral lesion of talus (OLT) 

Introduced in 1994


Osteochondral lesion of talus - Incidence

2011 epidemiologic study in US military

27 per 100,000 patient-years

More common than previously considered


Incidence of bilateral lesions

Approximately 10%


Medial lesion is more common than lateral lesion

Osteochondral lesion of talus - Clinical presentation

Prolonged pain

Recurrent ankle swelling

Weakness or giving way symptoms

Continued subjective instability

Mechanical symptoms

Catching

Locking

Clicking


P/Ex

Tenderness at the joint level 


In patents with chronic ankle pain, high index of suspicion is needed!!

Osteochondral lesion of talus - Etiology 

Trauma 

Widely believed as a major etiology in the pathogenesis 

Up to 76%

Single event of macro-trauma (sprains or fractures)

Repetitive micro-trauma 



Non-trauma

Metabolic abnormalities

Vasculopathy

Osteonecrosis or ischemia of talar dome

Osteochondral lesion of talus - Pathophysiology

Primary dysfunction of the subchondral bone

Localized osteonecrosis


Disease progression

Subchondral cysts

Overlying chondromalacia

Osteochondral fragments

Loose bodies


Pain

Is a result of stimulation of highly innervated subchondral bone under cartilage defect


Osteochondral lesion of talus - Imaging and Classification

Berndt and Harty (1959)

First staging system

Radiographic findings

Osteochondral lesion of talus - Imaging and Classification

MRI classification system (1989)


Surgical treatment strategy

Indication

Refractory to 3 to 6 months of non-operative treatment 


Categorized as

Cartilage-Repair Strategies 

Cartilage-Regeneration Strategies

Cartilage-Replacement Strategies



Surgical treatment strategy

Cartilage-Repair Strategies 

Bone marrow stimulation (BMS)

Retrograde drilling


Cartilage-Regeneration Strategies

Autologous chondrocyte implantation (ACI)

Matrix-induced autologous chondrocyte implantation (MACI)

Platelet-rich plasma and bone marrow-derived cell transplantation


Cartilage-Replacement Strategies

Osteochondral autograft transfer (OAT)

Osteochondral allografting 



Surgical treatment strategy

Cartilage-Repair Strategies 

Bone marrow stimulation (BMS)

Retrograde drilling


Cartilage-Regeneration Strategies

Autologous chondrocyte implantation (ACI)

Matrix-induced autologous chondrocyte implantation (MACI)

Platelet-rich plasma and bone marrow-derived cell transplantation


Cartilage-Replacement Strategies

Osteochondral autograft transfer (OAT)

Osteochondral allografting 



BMS

Microfracture

Bone marrow progenitor cells from subchondral bone

Fibrocartilage (mainly composed of type I collagen)

Structurally inferior to native hyaline cartilage (type II collagen)

Reliable clinical outcomes in reducing pain and increasing function

Arthroscopic 

Success rate ≈  85%

Relatively inexpensive

Low morbidity 


Prognostic factors

Size

Location

Containment  



BMS

Size

< 150 mm^2


Location and containment

Contained (nonshoulder) VS Uncontained (shoulder)

Uncontained lesions have worse outcome



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