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Current Concepts in the Diagnosis and Treatment of Osteochondral Lesions of the Ankle
Padhraig F. O'Loughlin, Benton E. Heyworth and John G. Kennedy
Am J Sports Med 2010 38: 392 originally published online June 26, 2009
DOI: 10.1177/0363546509336336
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Clinical Sports Medicine Update
Osteochondral lesions of the ankle are a more common source of ankle pain than previously recognized. Although the exact
pathophysiology of the condition has not been clearly established, it is likely that a variety of etiological factors play a role, with
trauma, typically from ankle sprains, being the most common. Technological advancements in ankle arthroscopy and radiologic
imaging, most importantly magnetic resonance imaging, have improved diagnostic capabilities for detecting osteochondral
lesions of the ankle. Moreover, these technologies have allowed for the development of more sophisticated classification sys-
tems that may, in due course, direct specific future treatment strategies. Nonoperative treatment yields best results when
employed in select pediatric and adolescent patients with osteochondritis dissecans. However, operative treatment, which is
dependent on the size and site of the lesion, as well as the presence or absence of cartilage damage, is frequently warranted in
both children and adults with osteochondral lesions. Arthroscopic microdrilling, micropicking, and open procedures, such as
osteochondral autograft transfer system and matrix-induced autologous chondrocyte implantation, are frequently employed. The
purpose of this article is to review the history, etiology, and classification systems for osteochondral lesions of the ankle, as well
as to describe current approaches to diagnosis and management.
Keywords: osteochondral defects; osteochondral lesions; osteochondritis dissecans; foot and ankle surgery; arthroscopy
392
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Vol. 38, No. 2, 2010 Osteochondral Lesions of the Ankle 393
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394 O’Loughlin et al The American Journal of Sports Medicine
TABLE 1
Published Classification Systems for Osteochondral Lesions of the Talus
Ferkel and
Berndt and Pritsch et al95 Dipaola et al27 Cheng et al,a Sgaglione34 Taranow et al114 Hepple et al53 Mintz et al77
Harty13 (1959) (1986) (1991) (1995) (1994) (1999) (1999) (2003)
Plain radio-
graphs Arthroscopy MRI Arthroscopy CT MRI MRI MRI
I: Compressed I: Intact overly- I: Thickening of A: Smooth, I: Cystic lesion 1: Subchondral 1: Articular car- 0: Normal
II: Chip avulsed ing cartilage artcular carti- intact but soft within dome compression/ tilage damage 1: Hyperintense
but attached II: Soft overly- lage and low- or ballottable of talus, intact bone bruise only but morpho-
III: Detached ing cartilage signal B: Rough roof on all appearing as 2a: Cartilage logically
chip but III: Frayed changes on surface views high signal on injury with intact carti-
undisplaced overlying car- intermediate/ C: Fibrillation/ IIA: Cystic T2-weighted underlying lage surface
IV: Detached tilage spin-density fissuring lesion with images fracture and 2: Fibrillation
and displaced images D: Flap present communica- 2: Subchondral surrounding or fissures not
chip II: Articular or bone tion to talar cysts that are bony edema extending to
Modification by cartilage exposed dome surface not seen 2b: Stage 2a bone
Loomer et al72 breached with E: Loose, undis- IIB: Open artic- acutely (arise without sur- 3: Flap present
(1993): low-signal rim placed frag- ular surface from stage 1) rounding bony or bone
Radiolucent behind frag- ment lesion with 3: Partially sep- edema exposed
lesion ment indicat- F: Displaced overlying non- arated or 3: Detached but 4: Loose undis-
acknowledged ing fibrous fragment displaced detached frag- undisplaced placed frag-
attachment fragment ments in situ fragment ment
III: Articular III: Undisplaced 4: Displaced 4: Detached and 5: Displaced
cartilage lesion with fragments displaced fragment
breached, lucency fragment
high-signal IV: Displaced 5: Subchondral
changes fragment cyst formation
behind frag-
ment indicat-
ing synovial
fluid between
fragment and
underlying
subchondral
bone
IV: Loose body
a
Cheng MS, Ferkel RD, Applegate GR. Osteochondral lesions of the talus: A radiologic and surgical comparison. Presented at the Annual
Meeting of the Academy of Orthopaedic Surgeons, New Orleans, LA, February 16-21, 1995.
Although most patients with OCLs complain of ankle imaging studies for assessing patients with a suspected
pain after a traumatic event, other patients present with OCL, in part to rule out fractures. A Canale view (prona-
chronic ankle pain.103 Associated swelling, stiffness, and tion of the foot to 15°, x-ray beam angled 75° cephalad)19
weakness about the ankle are also common. Symptoms are may also be helpful to assess the subchondral surfaces.
typically exacerbated by prolonged weightbearing or high- However, because plain radiographs may miss up to 50% of
impact activities such as running or jumping sports. OCLs and are unable to assess the state of cartilage, we
Authors have also established a strong link between OCLs believe that more advanced imaging technologies are
and chronic ankle instability, which may also be part of the appropriate.72 Computed tomography lacks the ability to
reported symptoms.105 assess cartilage, although it is useful in obtaining greater
Physical examination findings most commonly include detail about the bony injury such as specific size, shape,
ankle joint effusion and localized tenderness over 1 or and extent of displacement.34 Magnetic resonance imaging
more periarticular regions, including the anterolateral and has been shown to detect bone bruises, cartilage damage,
anteromedial joint line. Examiners should assess for varus and other soft tissue insults,27 and correlates closely with
malalignment, instability of the ankle and subtalar joints, arthroscopic findings.34,77 T2-weighted MRI is recom-
and perform an anterior drawer test and standard inver- mended as it can offer greater sensitivity to cartilage
sion maneuvers. change, as well as allowing identification of the zonal ori-
entation of the collagen fibrils, thus facilitating clarifica-
Radiologic Imaging Tests tion of the depth of cartilage damage.73 Although MRI is
emerging as the gold standard for OCL diagnosis, clini-
Standard weightbearing radiographs of the ankle (antero- cians should be aware that signal patterns in the talus may
posterior, lateral, oblique) remain the preferred first-line overestimate the severity of the bone injury.
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Vol. 38, No. 2, 2010 Osteochondral Lesions of the Ankle 395
Surgical Management
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Vol. 38, No. 2, 2010 Osteochondral Lesions of the Ankle 397
Figure 5. Two parallel screw malleolar fixation technique, Figure 6. Three-screw malleolar fixation technique, with
with evidence of displacement of osteotomy fragment. evidence of satisfactory anatomic alignment.
81
scar tissue at the defect site. While the efficacy of micro area. Most areas of the talar dome can be accessed per-
fracture in ankle OCLs is somewhat controversial,86 most pendicularly without the necessity for a malleolar
series have demonstrated that it provides symptomatic osteotomy.26,81 Muir et al81 demonstrated that, on average,
relief.11,43,116 In the presence of a small (<6 mm), shear-type only 17% of the medial talar dome and 20% of the lateral
lesion characterized primarily by chondral damage, but talar dome could not be accessed without an osteotomy.
minimal subchondral bone involvement, this technique After an anterolateral osteotomy, they reported an increase
may be optimal.87 Chuckpaiwong et al23 investigated 105 of 22% in sagittal exposure, while malleolar osteotomies
cases of talar OCLs treated with microfracture, reporting provided access to the entire medial and lateral talar dome
no failures of treatment with lesions smaller than 15 mm areas with a residual central 15% of the talar dome
(n = 73) regardless of location, but only 1 successful out- remaining inaccessible perpendicularly. Several well-
come in lesions greater than 15 mm (n = 32). The authors accepted techniques for medial malleolar osteotomy have
also highlighted increasing age, higher body mass index, been described.88,119,129 Critical to all methods of osteotomy
history of trauma, and presence of osteophytes as factors is a precise reduction and fixation to avoid fibrous non-
negatively affecting outcome. union or malunion. Three-screw fixation (Figure 5) may be
beneficial to reduce translation of bony fragments that can
Tissue Transplantation occur with 2-screw fixation (Figure 6).
Mosaicplasty. For treatment of larger talar lesions,
For transplant of osteochondral constructs into the talus, Hangody et al51 described a method for autologous grafting
perpendicular access is generally required to the injured using numerous cylindrical osteochondral plugs taken
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398 O’Loughlin et al The American Journal of Sports Medicine
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Vol. 38, No. 2, 2010 Osteochondral Lesions of the Ankle 399
Autologous Chondrocyte Implantation/Transplantation arthroscopic treatment methods used for talar OCLs
(ACI/ACT). Autologous chondrocyte transplantation is an (excision, curettage, and abrasion arthroplasty) were also
alternative to osteochondral grafting techniques.74 The effective for those of the distal tibia, based on average
technique, as described by Giannini et al,41 involves har- AOFAS ankle-hindfoot score improvement from 52 preop-
vesting a small amount of cartilage arthroscopically from eratively to 87 postoperatively and good or excellent
the knee ipsilateral to the ankle injury for chondrocyte results in 14 of 17 patients at medium-term follow-up.
cultures, which are grown in vitro for approximately 30 Ueblacker et al123 reported on a new technique for retro-
days. The OCL is debrided and filled with autologous can- grade osteochondral autograft transplantation for treat-
cellous bone harvested from the ipsilateral distal tibial ment of OCLs of the proximal and distal tibia. Their series
metaphysis. Periosteum is acquired from the ipsilateral involved 5 patients, 2 of whom had painful chondral lesions
proximal tibial metaphysis to cover the transplant area of the distal anterocentral and posteromedial tibia. All
and is fixed with resorbable sutures. Before the flap is fully patients were satisfied with the surgery. Follow-up arthros-
sutured down, the chondrocytes are transplanted in liquid copy showed the osteochondral cylinders well integrated
media through the remaining unsutured area, which is and flush with the articular surface.
then sutured and sealed with fibrin glue. Malleolar osteot- One case report described a female patient with bilateral
omy is fixed with 1 or more screws. At 1 year, the screws distal tibial OCLs after several months of intensive mili-
are removed, and at that time an ankle arthroscopy is per- tary training.112 One month after cessation of active train-
formed to assess the graft site. The authors reported on 8 ing and nonoperative therapy, the severity of pain decreased
patients treated with ACT, with average preoperative to considerably and the patient remained asymptomatic in
postoperative AOFAS scores improving from 32.1 points to her daily activities at 3 years. A second case report
91 points at 2 years.41 Baums et al10 reported on 12 simi- described osteochondral allografting of a distal tibial OCL,
larly treated patients, 11 of whom had good-to-excellent with 2-year follow-up radiographs demonstrating satisfac-
results after 63 months of follow-up, with an average pre- tory incorporation of the graft without collapse and with
operative AOFAS score of 43.5 increasing to 88.4 postop- preservation of joint space.21
eratively. One recent study suggests that decreased
postoperative pain may be an advantage of ACI, compared Adjunctive Treatments/Future Directions
with other techniques.43 Gobbi et al43 compared surgical
outcomes in 33 similarly sized talar OCLs treated with Viscosupplementation Therapy
chondroplasty (11 cases), microfracture (10 cases), and
OATS (12 cases). Although no significant difference was Despite a dearth of convincing outcomes data to support
detected between the groups, with reference to AOFAS or their use, the popularity of intra-articular hyaluronic acid
single-assessment numeric evaluation scores, the numeric (HA) derivative injections, also known as viscosupplemen-
pain intensity was significantly greater at 24 hours post- tation therapy, continues to grow for arthritis and other
operatively with OATS than with the other 2 techniques. conditions in a variety of joints. Pleimann et al94 were
Disadvantages of ACI include the cost of culturing hyaline among the first authors to report on the use of HA injec-
cells, the need for 2 surgical procedures, and the durability tions as an adjunct in the nonoperative treatment of
of the graft. ankle arthritis in 2002. Salk et al102 recently performed
Most recently, Giannini et al42 have reported on the a controlled trial in which 22 patients were randomized to
results of ACI incorporating the use of a hyaluronan-based receive either 5 weekly intra-articular injections of
3-dimensional scaffold (Hyalograft C, Fidia Advanced Hyalgan (sodium hyaluronate) or saline placebo injections
Biopolymers, Abana Terme, Italy) for symptomatic post- for ankle osteoarthritis, demonstrating significantly better
traumatic osteochondral talar dome lesions in 46 patients. improvement in the HA treatment group. Tytherleigh-
It involved a 3-step process with initial cartilage harvest Strong et al122 reported increased markers of articular
from the detached osteochondral fragment, chondrocyte cartilage survival and function in a sheep model, in which
culture on the Hyalograft C scaffold, and subsequent viscosupplementation therapy was used as an adjunct to
arthroscopic implantation of the 3-dimensional scaffold. osteochondral grafting of the knee. Other studies have sup-
They reported excellent clinical and histologic results, with ported these findings as well. Most recently, Cohen et al25
an increase in AOFAS scores from 57.2 to 86.8. Hyaline- conducted a double-blind randomized controlled study
like cartilage regeneration was identified histologically in examining the safety and efficacy of intra-articular sodium
samples obtained at second-look arthroscopy in 3 patients hyaluronate in the treatment of pain associated with ankle
at an average of 18 months after surgery. osteoarthritis. Thirty consecutive patients were enrolled,
and those treated demonstrated a significantly greater
Treatment of Tibial Plafond Lesions improvement from baseline on the Ankle Osteoarthritis
Scale at 3 months than did the control group. The authors
Because of the rarity of tibial plafond OCLs, there are few concluded that sodium hyaluronate may be a safe and
reports in the literature related to treatment recommenda- effective option for pain associated with ankle osteoarthri-
tions. In the largest series involving distal tibial OCLs, tis but advocated the need for larger studies.
Mologne and Ferkel78 retrospectively reviewed 880 con- Because of the presumed benefits of HA derivatives on
secutive ankle arthroscopies, 23 (2.6%) of which involved synovial fluid and chondrocyte function, the senior author
treatment of tibial plafond OCLs. They concluded that of this review (J.G.K.) routinely uses viscosupplementation
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400 O’Loughlin et al The American Journal of Sports Medicine
as adjunctive treatment with all methods of surgical treat- that they may be harvested with relative ease by means of
ment of ankle OCLs. We are involved in a clinical trial that a bone-marrow aspirate and a small number of pluripotent
aims to establish how HA may help in maintaining the cells can be isolated, grown in vitro if necessary, and then
integrity of cartilage transplants in patients undergoing introduced into osteochondral defects. They have the capa-
the OATS procedure. It is known that the peripheral rim bility to differentiate into articular cartilage and induce the
of the graft suffers chondral cell death and that the graft formation of subchondral bone. Recently, MSCs have been
itself may also have reduced chondral viability after trans- used with success in hybrid scaffolds to repair osteochon-
plant due to integrative problems as well as the impact dral defects in animal models.48,55,65 Although still in the
forces involved in graft placement.91,127 The authors hypoth- early stages of application, this unique approach may have
esize that HA will act in these cases, as it does in degen- great potential in treatment of human cartilage defects.
erative joint disease, to preserve existing cartilage and
produce a more robust graft. However, it must be empha- Platelet-Rich Plasma
sized that ongoing clinical trials are needed to confirm the
efficacy of this treatment. Hyaluronic acid may be an At the site of any injury involving bone, a clot will form
adjunct to improve outcomes in compromised cartilage in that consists of red blood cells, white blood cells, and plate-
the future, but at this time, it is not standard practice to lets in a fibrin matrix. In bone healing, the alpha granules
employ it in this fashion. within the platelets are a valuable reservoir of exogenous
factors.39 These factors include platelet-derived growth fac-
Electrical/Electromagnetic Stimulation tor, insulin-like growth factor, and TGF-β, which along
with a number of other factors play a critical role in bone
Although the efficacy of electric and electromagnetic stimu- healing.57 Platelet-rich plasma has recently been studied
lation on bone repair and healing of cartilage defects is in conjunction with autologous chondrocyte transfer, show-
controversial, studies have suggested an upregulation of ing promise both as a scaffold in which to help hold ACI
known molecular healing factors, such as transforming cells and as a reservoir of growth-stimulating factors.15,83
growth factor–beta (TGF-β) and various bone morphoge-
netic proteins (BMPs, which are members of the TGF-β Computer-Aided Navigation and
superfamily), as well as osteoclasts.2,14,20,71,126 One proposed Robot-Assisted Surgery
mechanism is that pulsed electromagnetic fields stimulate
chondrocyte proliferation by means of a nitrous oxide path- As computer navigation techniques become more sophisti-
way.36 A recent study investigating bone formation and cated and more user-friendly, their integration into ortho-
graft stabilization in a sheep model of osteochondral paedic procedures increases (Figure 8). Computer navigation
autograft treatment suggested that pulsed electromagnetic is particularly attractive for OCLs given the importance of
field treatment leads to improved results.12 Based on a precise localization and the potential for minimally inva-
growing body of evidence, the use of electric and electro- sive procedures.60,61 Robot-assisted surgery may also be
magnetic stimulation may play an increasing role in the ultimately favored over conventional orthopaedic tech-
future treatment of ankle OCLs. niques in the treatment of OCLs because of the optimiza-
tion of accuracy and precision in the preparation of bone
Ultrasound Stimulation surfaces, and the potential for more reliable and reproduc-
ible outcomes with regard to spatial accuracy. How rapidly
Ultrasound is a propagating pressure wave that transfers these technologies advance in foot and ankle surgery, and
mechanical energy into tissues.130 Low-intensity ultra- orthopaedic surgery as a whole, remains to be seen.
sound has been studied as a modality with properties that
can enhance bone52,64 and cartilage healing.29,90 In a Tissue Engineering
recently studied rabbit model with bilateral knee OCLs,
the effects of low-intensity pulsed ultrasound in repairing Tissue engineering can be defined as the application of
osteochondral injuries was compared with the untreated biological, chemical, and engineering principles to the
contralateral side, revealing significantly higher scores in repair, restoration, or regeneration of living tissue by
gross appearance grades, histologic grades, and proteogly- using biomaterials, cells, and factors alone or in combina-
can quantity on the treated side.56 More evidence is needed tion.69 There are 3 common tissue engineering approaches
to assess the role of low-intensity pulsed ultrasound in the used to address osteochondral injuries113: extraction of
acceleration of repair of osteochondral injuries. the appropriate cells from the patient, in vitro culture,
followed by transplantation back into the body defect that
Mesenchymal Stem Cells requires regeneration; placement of biologic factors, such
as molecules or growth factors, into body defects; and use
Mesenchymal stem cells (MSCs) from bone marrow have of 3-dimensional porous materials (eg, titanium, tanta-
been cultured in vitro and induced to form cartilage before lum) to stimulate the ingrowth of new tissue. A combina-
implantation into the chondral defects in rabbits.124 Bone tion of these 3 approaches may also be used, such that
marrow has been aspirated from the iliac crests in a caprine there are osteoinductive, osteoconductive, and osteogenic
model and chondrogenesis of the MSCs induced.17 elements, thus providing an optimal environment for
Mesenchymal stem cells represent a valuable adjunct in bone growth.63
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Vol. 38, No. 2, 2010 Osteochondral Lesions of the Ankle 401
CONCLUSION
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402 O’Loughlin et al The American Journal of Sports Medicine
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