Localisation of Osteochondral Lesions of the Talar Dome: MRI

Volume 03 / Issue 01 / March 2015
boa.ac.uk
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JTO Peer-Reviewed Articles
Localisation of Osteochondral
Lesions of the Talar Dome: MRI
Compared With Clinical Findings
- Can The Site Of The Pain
Predict The Site Of The Lesion?
Mark Davies
Osteochondral lesions (OCL) of the talar dome are defects of
the cartilaginous surface and underlying bone1. The lesions
range from a small defect in the talar articular surface, to
lesions associated with a subchondral cyst, or a large detached
osteochondral fragment2. Berndt and Harty3 proposed that
such lesions are resultant on an intra-articular fracture, although
others have suggested a possible genetic predisposition1,4.
of poor scientific quality with
anecdotal reporting of the sites
of tenderness.
Other pathologies frequently
coexist with OCL, and this can
lead to confusion in diagnosis.
The purpose of this study was
to investigate the relationship
between the site of perceived
pain, physical findings on
examination and the location
of the OCL on MRI scanning.
Materials and Methods
Recently Computerised
Tomography (CT) and Magnetic
Resonance Imaging (MRI) have
led to more accurate imaging
of these lesions, which in turn
has led to new classifications.
The new classifications record
subchondral cysts9 and acute
bone marrow oedema.10
Berndt and Harty described lesions
as being antero-lateral or posteromedial, whilst MRI scanning
localised 43% to the lateral and
57% to the medial sides of the talus.
Lesions in the middle of the talus are
rare, but have been reported1,12.
Mark Davies
Acutely OCL’s occur in 6.5% of
all ankle sprains5,13. Chronically
they are found in 20.5% of ankle
sprains and 57% of cases of ankle
disability14. OCL’s are one of the
most important causes of residual
pain after ankle sprain15. The
clinical diagnosis is regarded as
difficult10, and delay in establishing
the diagnosis is common3.
The pain associated with OCL’s
has been noted to be generalised
and non-specific8, similar to
the symptoms of osteoarthritis.
Localised tenderness is frequently
lacking3,5,15, although localised
tenderness has been described,
usually postero-medially or
antero-laterally in accordance
with the site of the lesions3,5,8.
Nevertheless, these studies are
Patients identified as having
chronic talar dome OCL’s on
MRI were asked to indicate the
point of maximal pain in their
ankle and a removable skin
marker was positioned at this
site. Chronic OCL was defined
as the presence of pain for more
than three months. The position
was independently measured
and the skin marker was then
removed. The patient was then
examined to elicit the point of
maximal tenderness in the ankle
joint. The position was again
marked and measured. The
examiner was blinded to the first
location and the measurements
were taken blindly, the instrument
readout was not visible whilst
measurements were being made.
The measurer and the examiner
were both blind to the MRI
findings, to eliminate bias.
An adapted technique of
anthropometrics was used to
obtain orthogonal dimensions of
>>
Volume 03 / Issue 01 / March 2015
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JTO Peer-Reviewed Articles
Figure 1: Digital callipers positioned to take the measurements
the locations16,17,18. A frame with a
moveable 90o angle bracket was
constructed to use as a reference
point for the measures. This
base was level and marked with
parallel lines for reference. Digital
callipers were then positioned to
take the measurements (Figure 1).
For the best comparison of
the measurements with MRI, a
standard position was used. The
subject placed their foot in the
frame in the same position as their
foot was in for the MRI (Figure 1).
Figure 2: Measurements taken in
the 3 axes
Measurements
were made using
digital callipers
held at 90
degrees to the
axis measured,
using the bracket
to ensure that the
calliper was in the
correct position.
Trial measures
were taken to
test for reliability
and repeatability.
Measures were
then taken in
three axes,
moving the 90
degree angle
bracket into the
correct position to
measure from the
landmarks below
(Figure 2).
X (medial to lateral) - from the medial
malleolus in a lateral direction
Y (caudal to cranial) - from the
plantar surface in a superior direction
Z (posterior to anterior) - from the
Achilles tendon insertion in an
anterior direction
The MRI scan and reports were
then reviewed for each patient.
Digital measures were replicated
from the same landmarks above,
to the centre of the lesion.
Reference lines were added
between each view and between
the slices of each view (Figure
3). Measures were taken from
these reference lines on separate
occasions to test reliability and
repeatability. The orientation of
the foot in each view was set with
reference lines through each slice,
using equivalent landmarks used
in the direct measurements.
Coronal View – a line parallel to
the orientation of the leg (Figure 3)
Axial View – a line parallel to
the anatomical axis of the foot,
through the second ray (Figure 4)
of the ankle joint, was taken as the
equivalent (Figure 4). Axial views
were disregarded if the plane of the
image did not correspond to the
plane of the foot, such as occurs in
a very plantar flexed foot position at
the time of MRI (Figure 4). The “Z”
(posterior to anterior) measure taken
in this view thus represented the
hypotenuse not the direct measure.
Figure 3: MRI of ankle in the coronal
plane showing reference line; a line
parallel to the orientation of the leg and
measurements taken from this line
Sagittal View – a line parallel to
the plantar surface of the foot
If the image did not show the
landmark sufficiently well due
to the size of area shown or the
number of slices taken, we used
equivalent points that were found
to be representative. This occurred
mostly in the axial view, if there
were insufficient slices for the
second ray to be visualised. A line
through the centre of the Achilles
tendon to the lateral border of the
tibialis anterior tendon, at the level
Analysis of the data was carried
out to test for correlations
between measures made of the
lesion as identified by the subject,
the examiner and the measures
from the MRI in all three axes.
The Euclidean distance between
the measures was calculated and
descriptive statistics produced for
each measure group. In addition,
the 95% confidence interval was
calculated to show the range of
measures to be expected in any
population, to show the degree of
association between them.
Results
A total of 19 patients with OCL
were recruited. The methods
and equipment used, proved to
be repeatable and reproducible
(unpublished data). Using
the frame and callipers was
repeatable and reproducible to
within 2.7mm. The tools on the
computer system for the MRI
were repeatable to within 3.4mm.
In terms of whether the lesion was
medial or lateral; the subject and
examiner agreed in 84% of cases,
the subject’s location of pain
agreed with the MRI in 58% of
cases and the examiner’s location
of tenderness agreed with the
MRI in 63% of cases.
Figure 4: MRI of ankle in the axial
plane showing reference line; a line
parallel to the anatomical axis of the
foot, through the second ray and
measurements taken from this line
Agreement with respect to the
localisation between quadrants
in two planes, i.e. antero-lateral,
postero-medial etc., the subject
Volume 03 / Issue 01 / March 2015
boa.ac.uk
Page 49
© 2015 British Orthopaedic Association
Journal of Trauma and Orthopaedics: Volume 03, Issue 01, pages 46-49
Title: Localisation of Osteochondral Lesions of the Talar Dome: MRI Compared With
Clinical Findings - Can The Site Of The Pain Predict The Site Of The Lesion?
Authors: Mark Davies
and examiner agreed in 63%
of cases, the subject’s location
of pain agreed with the MRI in
42% of cases and the examiner’s
location of tenderness agreed
with the MRI in 37% of cases.
Figures 5, 6 and 7 show these
location points as scatter
plots with Pearson correlation
coefficients. These plots in each
plane demonstrate the degree
of spread. Scatter plots of the
locations between the subject and
examiner show the best correlation
with the highest correlation in
the coronal plane (X axis, 0.87),
whilst the lowest correlation
was in the sagittal plane (Z axis,
0.38). The subjects’ localisation
of pain and the location of the
OCL on MRI were generally more
poorly correlated with the lowest
correlation also in the coronal
plane (X axis, 0.49). Correlation
between the maximum tenderness
as assessed by the examiner and
the location of the OCL on MRI
was higher in all three planes
compared to that localised by the
subject correlated with the MRI.
It was highest in the axial plane (Y
axis, 0.82) and again lowest in the
coronal plane (X axis, 0.62).
The range of Euclidean distances,
between the locations was high,
ranging from 6mm to 59mm.
The location as assessed by the
subject was, on average, 30mm
away from the location found
by the examiner. The subject
generally localised pain further
from the lesion on MRI than did
the examiner on palpation.
Discussion
Figure 6: Location points as scatter
plots with Pearson correlation
coefficients between Subject Locations
vs. MRI Locations in all 3 planes
Different authors suggest
symptoms differ between lesion
sites and that pinpoint tenderness
can be elicited1,19,20. References
to physical findings include
tenderness in the antero-lateral
corner of the tibio-talar joint for
lateral lesions and in the antero
medial corner for medial lesions8.
Fransom21 and Berlet22 found that
with the addition of plantar flexion
and dorsiflexion respectively,
antero-lateral lesions can be
palpated antero-laterally, and
postero-medial lesions may be
palpated posterior to the medial
malleolus; however neither group
provided supporting evidence for
these claims.
Verhagen, in their prospective study
on diagnostic strategies, did not
evaluate the findings on physical
examination in isolation15. Although
they specified the locations of lesions
and endeavoured to determine the
diagnostic value of clinical findings,
they did not relate them to routine
radiological examination.
Figure 5: Location points as scatter
plots with Pearson correlation
coefficients between Subject Locations
vs. Examiner Locations in all 3 planes
Figure 7: Location points as scatter
plots with Pearson correlation
coefficients between Examiner Locations
vs. MRI Locations in all 3 planes
The scale of the measures has
to be taken into account when
considering any relationship. The
dimension of an average sized talus
is approximately 50mm in both
the sagittal and coronal planes,
thus a separation between the
subject’s localisation of pain and the
examiner’s assessment of maximal
tenderness of 50mm represents the
whole width or depth of the articular
surface of the talus. Thus, a medial
lesion may present with lateral pain
and tenderness and vice versa.
The source of pain when there
is damage to articular cartilage
and subchondral bone is
unclear. Articular cartilage is not
innervated and is therefore not
the direct source of the pain23,24,25.
Associations between subarticular
bone marrow changes and
pain are strong and these are
analogous to the changes seen in
OCL, but whether this is a direct
source of pain is unclear23,24,26.
In this study, the pain experienced
by the patient and the area of
tenderness found, were as variable
to each other as to the actual site
of the lesion. We suggest that OCL
of the talar dome result in pain that
is poorly localised, with respect
to the site of the lesion, and the
area of maximum tenderness.
As a result, vaguely located ankle
pain with poor clinical localisation
would warrant MRI to exclude an
OCL. Care must be taken when
attributing an OCL on an MRI to
the subject’s pain.
Mark Davies is a Consultant
Orthopaedic Surgeon at Northern
General Hospital, Sheffield
specialising in elective and
trauma of the adult foot and ankle.
He co-ordinates the research
activity for the Sheffield Foot and
Ankle Unit.
Correspondence:
Email: mark.davies@sth.nhs.uk
References can be found online at
www.boa.ac.uk/publications/JTO
or by scanning the QR Code.
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