Current Concepts: Treatment of Osteochondral Ankle Defects
Section snippets
Etiology
Traumatic insult is more widely accepted as the etiology of OLTs, although not without controversy. It is likely that trauma and ischemia are both involved in the pathology. Because not all patients report a history of ankle injury, a subdivision can be made in the etiology of nontraumatic and traumatic defects.
The nontraumatic etiology concerns idiopathic osteochondral defects. In these defects, ischemia, subsequent necrosis, and possibly genetics are etiologic factors. Osteochondral defects
Mechanism of injury
When the talus twists inside its boxlike housing during an ankle sprain, the cartilage lining can be damaged. It may lead to a bruise and subsequent softening of the cartilage or worse: a crack in the cartilage or delamination. Separation of the cartilage can occur in the upper layer as a result of shearing forces. Alternatively, separation may occur in the subchondral bone, giving rise to a subchondral lesion. Fragments can break off and float loose in the ankle joint or they can remain
Clinical presentation
A differentiation has to be made between the acute and the chronic situation. In the acute situation, symptoms of osteochondral ankle defects compare with those of acute ankle injuries. They include lateral or medial ankle pain, swelling, and limited range of motion. In patients who have an isolated ligamentous ankle injury, these symptoms usually resolve after functional treatment within 2 to 3 weeks. If symptoms do not resolve after 3 to 6 weeks, an (osteo)chondral defect of the talus should
Diagnosis
After careful history taking and physical examination of the ankle, routine radiographs of the ankle are taken, consisting of weight bearing anteroposterior, mortise, and lateral views of both ankles.
The radiographs may show an area of detached bone surrounded by radiolucency (Fig. 2). Initially, the damage may be too small to be visualized on routine radiography. By repeating the imaging studies in a later stage, the abnormality sometimes becomes apparent.
A heelrise view with the ankle in a
Operative treatment options
There are widely published surgical techniques for treatment of symptomatic osteochondral lesions. Generally, these techniques are based on one of the following three principles [25], [26], [27], [28], [29], [30], [31], [32]:
- 1.
Debridement and bone marrow stimulation, potentially in combination with loose body removal (microfracture, abrasion arthroplasty, or drilling)
- 2.
Securing a lesion to the talar dome (retrograde drilling, bone grafting, or internal fixation)
- 3.
Stimulating the development of
Curettage and drilling or microfracturing
After debridement, multiple connections with the subchondral bone are created. They can be accomplished by drilling or microfracturing. The objective is to partially destroy the calcified zone that is most often present and to create multiple openings into the subchondral bone. Intraosseous blood vessels are disrupted, and the release of growth factors leads to the formation of a fibrin clot. The formation of local new blood vessels is stimulated, marrow cells are introduced in the
Single block transplants
Single block transplants involve grafting a plug from the lesser–weight bearing femoral condyle into the osteochondral defect on the talar dome. Single plug grafts result in reduced ingrowth of the fibrocartilage, although donor site morbidity may be greater because of harvesting a single, larger plug [46], [48]. Similar to what is practiced in knees, the use of multiple smaller grafts (ie, mosaicplasty) is preferred, which provides a better match to the talar dome contour and surface area of
Autologous chondrocyte implantation
ACI is defined as implantation of in vitro cultured autologous chondrocytes using a periosteal tissue cover after expansion of isolated chondrocytes. In 1965, Smith was the first person to isolate and grow chondrocytes in culture [56a]. ACI was popularized by Brittberg and colleagues [57] whose original article in the New England Journal of Medicine described the early results of treatment of osteochondral lesions in the knee. At 2-year follow-up, good or excellent outcomes were reported in 14
Discussion
The choice of treatment for osteochondral ankle defects depends on symptomatology, duration of complaints, size of the defect, and whether it concerns a primary or secondary OLT. None of the current grading systems is sufficient to direct the choice of treatment [63].
Pure cartilage lesions, asymptomatic lesions, and low-symptomatic lesions are treated conservatively with rest, ice, temporarily reduced weight bearing, and in case of giving way, an orthosis. Consideration for surgical treatment
Summary
An OLT often causes pain, recurrent synovitis, and obstruction from loose bodies. It is a possible precursor of ankle osteoarthritis due to altered joint mechanics and recurrent synovitis. Current diagnostic strategies usually include MRI or CT. Recent research has shown that MRI and CT have the same diagnostic accuracy in the diagnosis of an OLT. For preoperative planning, a CT scan gives more precise information.
Arthroscopic procedures like debridement and drilling, by nature of their
Acknowledgments
Peter de Leeuw is gratefully acknowledged for recording the images in Fig. 5A through 5D.
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