Osteochondral to 50% of OLTs are missed on plain

Osteochondral lesions of the talus
(OLT), also commonly known as osteochondral defects (OCD) of the talus, is a
lesion involving the bone’s cartilage and subchondral bone that may break off
partially or completely from the talus.1 Articular cartilage is a
tissue with poor reparative capability that surrounds the talus.2 After the elbow and knee, the
talus is the third-most common area where OLTs may occur.3 These lesions may transpire
on the medial or lateral side of the talus.4 Osteochondral lesions of the
talus occur more frequently with traumatic injuries1,3,5,6 , accompanying up to 70-85%
of ankle sprains and fractures.3,5 They could follow a single
traumatic injury, or after multiple traumatic injuries.3,6 However, non-traumatic etiology
may lead to OLT as well including but not limited to, “congenital factors,
ligamentous laxity, spontaneous necrosis, endocrine abnormalities, steroid use,
and embolic disease.”5 Osteochondral lesions of the
talus are more common in the male population, as well as the age range of 20-30
years.4

Osteochondral
lesions of the talus may present as deep ankle pain that may or may not persist
after an ankle sprain.1,6,7 The pain can be exaggerated
during weight bearing activities, including daily life, work, and recreational
activities.1,7 The patient may experience
the sensation of their ankle giving way, catching, locking, and clicking.1,7 On a physical examination,
swelling, medial or lateral tenderness, lack of range of motion (ROM), and
instability may be present.1,7 The main complaints patients
have include pain and their overall decrease of function.8

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Osteochondral
lesions of the talus can be easily overlooked, especially when accompanied by
concurrent injury including ankle sprains.4,9 There are no specific
physical examination tools that may indicate to a clinician that a OLT may be
present.10 Additionally, diagnosis can
be delayed because plain radiographs appear normal.7,9 Gianakos et al. report that
“up to 50% of OLTs are missed on plain radiographs”.10 Osteochondral lesions of the
talus are more commonly diagnosed later when conservative treatment fails, and pain
and other symptoms persist.1,3Additional imaging is needed
including, magnetic resonance imaging (MRI), computed tomography (CT) scans,
and bone scans to accurately diagnose OLT.1,4 Bone scans can rule out occult
fractures,1 while CT scans are used to
locate the region of the lesion, and MRIs detect actual cartilage damage.1,4

            There
are numerous treatment options for OLT, however research is still being
performed to find the ideal treatment option.3 The most common treatment
options include conservative, or surgical intervention.3–5,8 Conservative treatment usually
involves, immobilization or bracing, weight bearing precautions, activity
modifications, non-steroidal anti-inflammatory medications (NSAIDs),
corticosteroid injections, and physical therapy.3,5,8,11 Conservative treatment
results are variable.8 Savage Elliot et al. found
that in conservative treatment, there was good to excellent results in only 54%
of their patients diagnosed with cystic OLTs.4 Badekus et al report a 45%
success rate for conservative treatment3 while Hannon et al. reports a
study finding 49.1% success rate with conservative treatment.5 Symptoms may resolve from
conservative treatment for the short term, however OLTs can reoccur due to the
insufficient healing of the lesion.5

Where conservative
treatment failed a surgical intervention would then be recommended.3 A surgical intervention is an
invasive approach to promote healing and resurfacing of the articular cartilage.
The choice of which surgical intervention to use depends on the size of the
lesion, and if there is a cyst present.5 Smaller lesions are defined
as lesions that are smaller or equal to 15 mm in size, where larger lesions are
defined as greater than 15 mm in size.1 The preferred treatment
options for small lesion OLTs include subchondral drilling and microfracture.1,4–6,8,12 Drilling and microfracture
stimulates the subchondral bone to promote chondral healing through an
inflammatory response to micro trauma.8,12 Ventura et al. explains the advantages
to these surgical interventions stating that they “minimize invasiveness,
decrease operating time, and allow a faster rehabilitation period and an
earlier return to work”.11 When using these surgical
techniques, studies account for good short term results, yet the long term
results are unknown.6

Pain and decreased
function are commonly the patient’s main complaints with OCL and reasons for
why patients seek out surgical intervention.8 The goal of surgical
intervention is to decrease that pain and get their patient to return to
function or activity.3,5 Return to activity can be
defined as decease in pain with movement and return to previous recreational
activities.4 Standardized outcome tools
can measure return to activity and pain ratings following a surgical
intervention.6,7,11–13 The optimal outcome tool to
use following an ankle or foot intervention is unknown.14 Outcome tools that are seen
in research are, but not limited to, the American Orthopedic Foot and Ankle
Society (AOFAS) ankle-hind foot scale, the visual analog scale (VAS), ankle
activity scale (AAS), Karlsson Peterson score, Tegner activity level, and the
Sefton articular stability scale.6,7,11–13 The AOFAS ankle-hind foot
scale has 4 categories including pain, function and alignment.14 The scale is out of 100 and a
score greater than or equal to 90 points is considered excellent, 80-89 is
considered good, 70-79 is considered fair, and a score of less than or equal to
69 is considered poor.12 SooHoo et al performed a
study looking at the responsiveness of the AOFAS scale following foot and ankle
surgery, and it was found that this outcome tool has an acceptable responsiveness
to clinical change.14 To measure the responsiveness
of this outcome tool, they studied its effect size, which equaled 1.12.14 The VAS is a scale that
allows a patient to quantify how much pain they are experiencing on a scale
from 0-10.12 The AAS is a 10-point scale
that is used to assess a patients activity level, which was developed by the
Tegner scoring system.12 The AOFAS ankle-hind foot
scale and the VAS were the two more commonly seen tools in the literature.6,7,11–13

The purpose of
this research was to determine if return to activity was achievable following a
surgical intervention for a small OCL of the talus. The patient who inspired
this research was diagnosed with this pathology and expressed concern about
returning to his recreational activities. This required research to locate
possible surgical interventions that may relate to our patient, and to
determine whether or not these interventions would allow return to activity.
Therefore this research focused on outcomes of surgical interventions for OCL
of the talus.