Español
Foot + Ankle Problems + Treatments

Ankle Cartilage (Osteochondral) Defect

Osteochondral defects of the ankle have been described with several names, including osteochondral lesions, osteochondral fractures, dome fractures, and osteochondritis dessicans. Osteochondral defects typically occur at the bottom bone of the ankle joint, named the talus. They typically result from previous ankle trauma, such as a sprain or ankle fracture.

You can also book an appointment by calling Dr. Carreira’s office at 404-355-0743. Learn more at www.peachtreeorthopedics.com.

The talus has limited capacity to repair itself, and patients with chronic pain should be evaluated for these focal areas of cartilage and/or bone loss. X-rays may show injuries at the talar dome, but are limited insofar as bone damage also must be present to detect these injuries radiographically. Magnetic resonance imaging provides more detailed information regarding cartilage injury and other pathologies around the ankle joint.

CT-Scans of Osteochondral Defect of the Talus

Nonsurgical Treatment for Osteochondral Defects

Generally, nonsurgical treatment involves an initial period of no weight bearing with cast immobilization, followed by progressive weight bearing and mobilization to full ambulation by 12 to 16 weeks. A meta-analysis of 14 studies with a total of 201 patients followed for approximately two years showed only a 45% success rate of nonsurgical treatment of grade I, grade II, and medial grade III talar osteochondral lesions.

Surgical Treatment for Osteochondral Defects

Osteochondral grafts used for replacement of both and cartilage defects in the ankle.

Osteochondral grafts used for replacement of both and cartilage defects in the ankle.

Surgical management is reserved for unstable fragments or for failure of nonsurgical treatment. The first line of surgical treatment is performed with ankle arthroscopy and consists of the microfracture technique or drilling, in which multiple holes spaced 2-3 mm apart are placed into the cartilage defect to stimulate cartilage healing.

Results of microfracture or drilling have been encouraging compared with those of nonsurgical treatment. In a review of 16 studies with a total of 165 patients, Tol et al found these bone marrow stimulating techniques to have had “good-to-excellent” results in 88% of patients with grade III and higher lesions.

As a second and more invasive line of treatment, osteochondral grafting may be performed to reconstruct the talar dome, also leading to high success rates with pain relief and functional improvement.

Internal fixation of osteochondral lesions may be done using a variety of methods, including screws, Kirschner wires, and bioabsorbable devices. If sufficient healthy bone forms part of the osteochondral defect, fixating the osteochondral lesion may lead to significant healing.

Postsurgical Recovery for Osteochondral Defects

Following ankle surgery for osteochondral defects, patients typically are instructed to remain nonweight-bearing for 6 weeks. Ankle range-of-motion is begun at the time of suture removal, typically at two weeks. Patients are placed into CAM boots and are instructed to perform range of motion exercises at least 3 times per day.

International Consensus Meeting on Cartilage Repair of the Ankle

In November 2017, Dr. Carreira attended the International Consensus Meeting on Cartilage Repair of the Ankle. Organized by the Department of Orthopaedic Surgery at the University of Pittsburgh, this invite-only gathering aimed to foster consensus on key areas within the field of ankle repair.

What follows below is a recap of the questions, answers, and votes that Dr. Carreira and his colleagues on the History, Physical Examination, Imaging and Arthroscopy Section considered, assembled and submitted.

Nonoperative Treatments of Cartilage Injuries of the Ankle

1. What is the optimal protocol for conservative management (e.g., brace, cast, boot, PT, etc.) of a cartilage lesion of the ankle?

Answer: The optimal protocol for conservative management of an acute nondisplaced osteochondral lesion of the ankle is immobilization for 4-6 weeks with touchdown weight bearing.

Non-steroidal anti-inflammatory drugs (NSAIDs) can be prescribed in cases of significant pain and swelling unless otherwise medically contraindicated.

In cases with a significant bony component to an osteochondral injury, there is no use for a bone stimulator.

Voting Results: Strong Consensus

2. How can patients be counseled with regards to goals for function after conservative management and how long should they be followed clinically?

Answer: The goal of conservative management should be full return to function with the possibility of some pain with sporting activities. However, patients should be advised to participate in low-impact activities.

The duration of treatment for conservative management is highly individualized, but in general, may result in clinical improvement over the course of 3-6 months.

If the patient does not demonstrate clinical improvement after 3 months, an MRI should be ordered to re-evaluate the lesion.

Overall, the lesion(s) is unlikely to heal and may increase in size; patients should understand the signs and symptoms of progression (swelling, increased pain, mechanical symptoms).

Patients should be followed clinically every 6 months.

Vote: Consensus

3. Can the injection of a biological product (e.g., cBMA, HA, PRP, adipose, etc.) be considered as a conservative management strategy for a cartilage lesion of the ankle? If so, when?

Answer: The injection of a biological product in the form of concentrated bone marrow aspirate or platelet-rich plasma can be considered as a conservative management strategy for a cartilage lesion of the ankle if there is no improvement in symptoms after 4-6 weeks.

Vote: Consensus

4. For how long can conservative management be attempted before surgery is recommended?

Answer: The length of conservative management can be based upon symptom progression/regression, as well as size and displacement of the lesion.

In general, conservative treatment can be attempted for 3 months before surgery is recommended, with the following exceptions:

An acute, displaced osteochondral fragment can be fixed immediately.

Large lesions with edema and/or ligamentous instability should be treated at 6-8 weeks if there is no response to conservative treatment.

In general, conservative management may not be prolonged to 6 months, with the following exceptions:

  • A demonstrable improvement in symptoms
  • Unresolved/uncontrolled medical co-morbidities

Vote: Strong Consensus

Debridement, Curettage, and Bone Marrow Stimulation

1. In what cases/lesion types can debridement and curettage without bone marrow stimulation be considered for the surgical treatment of cartilage pathology of the ankle?

Answer: Debridement and curettage without bone marrow stimulation can be considered for the following cases/lesion types:

  • Partial thickness chondral lesions
  • Acute lesions (e.g., found during arthroscopy after ankle fracture; professional athlete in season and looking to return to competition; etc.)
  • Incidental lesion found during arthroscopy
  • Lesion caused by other disease (e.g., gouty arthritis, PVNS, etc.)

Vote: Strong Consensus

2. In what cases/lesion types can bone marrow stimulation be considered for the surgical treatment of cartilage pathology of the ankle?

Answer: Bone marrow stimulation can be considered for the surgical treatment of full thickness chondral or osteochondral lesions that have failed conservative treatment.

Vote: Strong Consensus

3. What are the ideal lesion size guidelines (diameter, depth, etc.) for the use of bone marrow stimulation in the primary surgical treatment of an osteochondral lesion of the talus?

Answer: The ideal size guidelines for use of bone marrow stimulation are lesions <10 mm in diameter, <100 mm2 in area, and <5 mm in depth. Bone marrow stimulation is less likely to succeed when used as a sole treatment in a lesion 15 mm in diameter or greater.

Vote: Strong Consensus

4. What local prognostic factors should be considered when utilizing bone marrow stimulation for the surgical treatment of cartilage pathology of the ankle?

Answer: The following prognostic factors should be considered when utilizing bone marrow stimulation for surgical treatment of cartilage pathology of the ankle:

  • Lesion size
  • Lesion location
  • Presence of a cyst(s)
  • Uncontained lesion
  • Bone marrow edema
  • Joint alignment
  • Ankle stability
  • Previous cartilage repair procedure

Vote: Strong Consensus

5. How can the lesion site (base and edge) be prepared prior to bone marrow stimulation?

Answer: The lesion site can be prepared prior to bone marrow stimulation by debriding all loose or fibrillated cartilage until there is a stable rim of articular cartilage. Stable edges should be vertical and 90 degrees to the subchondral bone. The calcified cartilage layer of bone should be removed, but care should be taken not to destroy the framework of the underlying subchondral bone.

Vote: Strong Consensus

6. How can damaged cartilage be differentiated from healthy cartilage intra-operatively and how much should be removed?

Answer: All unstable cartilage can be removed from the defect site. Articular cartilage that is stable, but appears abnormal/damaged, can be left in situ, as stability is more important than visual appearance and slightly damaged but stable cartilage is superior to fibrocartilage.

The following methods may be used to differentiate damage cartilage from healthy cartilage intra-operatively:

  • Probing articular cartilage to assess how soft or ballotable it is;
  • Probing articular cartilage to see if it can be delaminated off of subchondral bone.

Vote: Strong Consensus

7. Can an awl or drill be utilized for bone marrow stimulation of the ankle, and what size should be used?

Answer: The use of an awl or a low speed drill of 2 mm or less in size is recommended.

Vote: Strong Consensus

8. To what depth can the awl/drill holes be made in the ankle?

Answer: The awl/drill holes can be made to a depth that results in subchondral bone bleeding or presence of fat droplets.

Vote: Strong Consensus

9. What distance should be maintained between the awl/drill holes in the ankle?

Answer: The distance between the awl apertures should be 3 – 5 mm.

Vote: Strong Consensus

10. To what depth can a lesion be debrided before bone grafting is required in the ankle?

Answer: A lesion can be debrided to a depth of 5 mm before bone grafting is required.

Vote: Strong Consensus

12. Can biological augmentation of a bone marrow stimulation procedure be considered?

Answer: Some form of biological augmentation may be beneficial in lesions treated with bone marrow stimulation in the ankle.

Vote: Unanimous

13. Is it necessary to perform bone marrow stimulation for saucer-type lesions of the ankle?

Answer: Bone marrow stimulation can be performed for saucer-type lesions of the ankle. When a clear bone fragment is visible, the fragment can be preserved in cases where the lesion is acute and large enough to accommodate fixation.

Vote: Strong Consensus

14. Which aspect(s) of the patient history can be documented in the setting of a known or suspected cartilage lesion of the ankle?

Answer: The following aspects of the patient history can be documented in the setting of a known or suspected cartilage lesion of the ankle: 1) ADLs/sporting activities; 2) duration of symptoms; 3) history of trauma; 4) localization of pain; 5) mechanical symptoms (e.g., locking, instability); 6) mechanism of injury; 7) previous treatment and 8) swelling

Vote: Unanimous

15. Which aspect(s) of the physical examination can be performed/documented in the setting of a known or suspected cartilage lesion of the ankle?

Answer: The following aspects of the physical examination can be performed/documented in the setting of a known or suspected cartilage lesion of the ankle:

  1. alignment;
  2. ankle range of motion;
  3. assessment of stability (e.g., anterior drawer, talar tilt);
  4. swelling; and
  5. tenderness to palpation.

Vote: Strong Consensus

16. How can the surgeon clinically discern whether a cartilage lesion of the ankle is symptomatic?

Answer: A clinical history of deep ankle pain +/- swelling, usually exacerbated with activity, is the most important aspect in discerning whether a cartilage lesion of the ankle is symptomatic.

Vote: Strong Consensus

17. Which radiographic/imaging studies can be utilized to evaluate a known or suspected cartilage lesion of the ankle?

Answer: Weight-bearing AP, lateral, and mortise radiographs can be utilized to evaluate a known or suspected cartilage lesion of the ankle. Standard CT and/or MRI sequences are sufficient to evaluate a known or suspected cartilage lesion of the ankle.

Vote: Strong Consensus

18. Which specific radiographic/imaging protocols can be utilized to evaluate a known or suspected cartilage lesion of the ankle?

Answer: Weight-bearing AP and lateral radiographs can be utilized to evaluate a known or suspected cartilage lesion of the ankle. Standard CT and MRI sequences are sufficient to evaluate a known or suspected cartilage lesion of the ankle. A CT scan with the ankle in full plantar flexion can be ordered to evaluate arthroscopic accessibility for preoperative planning.

Vote: Strong Consensus

19. Which radiographic/imaging findings can be assessed/documented in the setting of a cartilage lesion of the ankle?

Answer: The following radiographic/imaging findings can be assessed/documented in the setting of a cartilage lesion of the ankle: 1) alignment; 2) associated lesions/injuries; 3) cystic changes; 4) degenerative changes; 5) edema; 6) location; 7) loose fragments; 8) size and 9) stability of the lesion

Vote: Strong Consensus

20. How can the location of a lesion(s) be documented?

Answer: The location of a lesion can be documented using a nine-zone anatomic grid scheme (medial/central/lateral and anterior/central/posterior), as described by Elias et al (5).

Vote: Strong Consensus

21. How can lesion size be measured on imaging?

Answer: Lesion size can be estimated in three planes, including surface area and depth of the lesion. If precise measurement is required including depth, the use of CT is recommended. For daily practice, a size estimate using MRI is appropriate.

Vote: Unanimous

22. How can lesion size be measured/confirmed during surgery?

Answer: Intra-operative measurement of lesion size can be estimated via the use of a probe in order to confirm the size assessment made via imaging. However, intra-operative measurement of lesion size can be difficult and inaccurate.

Vote: Strong Consensus

23. When is diagnostic arthroscopy a helpful tool in assessing a known or suspected cartilage lesion of the ankle?

Answer: Diagnostic arthroscopy is of limited value and seldom influences treatment approach in the assessment of a known or suspected cartilage lesion of the ankle.

Vote: Strong Consensus

24. What considerations can be made when extrapolating imaging findings to expected surgical findings of a cartilage lesion of the ankle?

Answer: Magnetic resonance imaging tends to overestimate lesion size.

Vote: Strong Consensus

25. How can associated conditions (e.g., ankle instability, peroneal tendon pathology, malalignment, kissing lesions, etc.) be assessed in the setting of a cartilage lesion of the ankle?

Answer: Associated conditions can be assessed clinically with a careful history and physical examination. If indicated, additional imaging studies may include specific radiographic views, ultrasound and/or MRI. It is recommended that specific attention be given to alignment.

Vote: Strong Consensus

Photos of Ankle Cartilage (Osteochondral) Defect