Osteochondral lesions and JOCD

 

Stage IIITalus MRIMM osteot

 

Definitions

 

Juvenile Osteochondritis Dissecans (JOCD)

- abnormality of osteochondral bone in young patients

- combination of repetitive trauma and vascular insult

- often medial

 

Osteochondral fracture / lesion

- damage to osteochondral bone after trauma

- usually lateral

 

Osteochondral defect

- loss of bone and cartilage from talus

- may be secondary to trauma

- may be from displacement of loose OCD

 

Epidemiology

 

Martijn et al KSSTA 2021

- systematic review of OC lesions after ankle fracture

- 45% incidence of OC lesions, 43% on talus

 

Dahmen et al Cartilage 2022

- systematic review of OC lesions after syndesmotic injury

- 21% incidence of OC lesions, 95% talar dome

 

History

 

History of ankle injury with development of chronic symptoms

- activity-related pain, stiffness & swelling

- may have symptoms of loose body / locking

 

Symptoms of lateral ligament instability

 

Examination

 

Tenderness around ankle joint

Pain with dorsiflexion / eversion

Decreased ROM, especially dorsiflexion

Effusion

 

Test for ligament instability

 

DDx

 

Chronic ligament instability

Lateral gutter soft tissue impingement

Calcaneal fracture

Lateral process fracture of the talus

Tarsal coalition

Sinus tarsi syndrome

 

Location

 

1.  Anterolateral / ? traumatic

2.  Posteromedial / ? atraumatic

 

van Diepen et al Cartilage 2021

- systematic review of 2000 OC lesions of the talus

- 9 grid system

- 28% posteromedial

- 31% centromedial

 

Talus OCL

 

Berndt & Harty Xray Classification

 

Stage I    - subchondral compression fracture

Stage II   - partially detached osteochondral fragment

Stage III -  completely detached fragment, non displaced

Stage IV  - completely detached and displaced fragment

 

Xray

 

OCDTalus OCD Medial

Stage II medial osteochondral fragments

 

Talus OCD Medial Type IVAnkle OCD MedialStage III

Stage III medial osteochondral fragments

 

Talus OCD Anterolateral FragmentTalus OCD Anterolateral 2

Stage IV anterolateral osteochondral fragment

 

MRI 

 

Stable lesion (Stage I) - cartilage intact, no synovial fluid under lesion

 

Unstable lesions (Stage II or III) - cartilage breach, synovial fluid under lesion

 

Displaced lesion with resultant osteochondral defect

 

Talus OCD Type 2Talus OCD

Stable lesion with intact cartilage and no synovial fluid under lesion

 

Talus MRIMRI OCD

 

Talus OCD Anterolateral MRI0001Talus OCD Anterolateral MRI0002

Stage III completely detached but not displaced

 

Talus OCD

 

CT

 

Talus OCDTalus CT

Stage III

 

OCD CTOCD CT

Stage III

 

OC defectOC defect

Stage IV displaced fragment with osteochondral defect

 

Management

 

Management Algorithm

 

Stable lesion (Stage 1)

- if cartilage intact, initial non operative care

- drill in situ +/- screw fixation if no healing with non operative care

 

Unstable in situ lesion (Stage 2/3)

- large lesion: screw fixation

- small lesion: remove + microfracture / cartilage restoration

 

Displaced fragment with osteochondral lesion (Stage IV)

- ORIF if possible (i.e fragment is large and replaceable)

- remove + microfracture / cartilage restoration

 

Non Operative Management

 

Indications

 

Juvenile Osteochondritis Dissecans (JOCD) in adolescent with open growth plates

Stable lesion - intact cartilage

 

Technique

 

Touch weight bear 6 weeks

No sport 6 months

 

Results

 

Perumal et al J Pediatr Orthop 2007

- 31 patients with JOCD and open growth plates

- mean age of 12

- 6 months non operative management: 16% healed

- 12 months non operative management: 42% surgery for pain, 46% asymptomatic with visible lesions

 

Kim et al Clin J Sports Med 2022

- 55 JOCD treated with nonoperative management

- 77% healed

- increased risk nonunion with older age and completely detached lesions

 

Operative Management

 

Options

 

Drill

Screw fixation

Remove + marrow stimulation / cartilage restoration

 

Drilling

 

Indication

 

Stable lesion with intact cartilage

 

Options

 

Antegrade

- through cartilage surface of talar dome

- may have to go through medial malleolus for posteromedial lesions

 

Retroarticular

- transtalar

- uses image / arthroscopy / navigation

 

Screw fixation

 

screw OCDOCD screw

 

Indications

 

Large fragment in situ

 

Technique

 

Lift, drill, fill, fix (LDFF)

- partially displace

- debride base +/- microfracture

- consider bone graft

- secure with headless compression screws

 

Arthroscopy Approaches

 

Arthroscopy techniques medial transmalleolar screw fixation PDF

 

Anterolateral / anteromedial

- anterior 50 - 60% lesions

 

Posterolateral / posteromedial

- prone

- posterior lesions

 

Ankle OCD ArthroscopyAnkle OCD Percutaneous Drilling 1Ankle OCD Percutaneous Drilling 2

Anterolateral osteochondral lesion accessible via plantarflexing the ankle

 

Open approaches

 

Vumedi open approaches to talus OCL

 

Lateral lesion

- more anterior lesions accessible with anterolateral approach

- ± Anterior plafond osteotomy ± Chaput anterolateral osteotomy if large

 

Medial lesion

- often more posterior

- may require medial malleolar osteotomy

 

Medial Malleolar osteotomy

 

Predrill for screws

Arthrotomy / image guidance

Posterior homan to protect tibialis posterior

Initial osteotomy with saw / complete with osteotome

 

Surgical technique PDF medial malleolar osteotomy

 

Vumedi surgical technique medial malleolar osteotomy video

 

MM osteotMM osteotMM osteotomy

 

Results

 

Haraguchi et al KSSTA 2020

- ORIF of 44 talus lesions

- treatment failure in 1 patient

 

OCD screwOCD fixation

CT assessment of bony healing post ORIF with screws

 

Excision + microfracture / cartilage restoration

 

www.boneschool.com/osteochondraldefecttalus

 

 

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