Current Concepts in the Diagnosis and Treatment of

AJSM PreView, published on June 26, 2009 as doi:10.1177/0363546509336336
Clinical Sports Medicine Update
Current Concepts in the Diagnosis
and Treatment of Osteochondral Lesions
of the Ankle
Padhraig F. O’Loughlin, MD, Benton E. Heyworth,* MD, and
John G. Kennedy, MD, FRCS (Orth)
From the Hospital for Special Surgery, New York, New York
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 systems 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
lesion. In 1922, Kappis58 described a similar presentation
within the talus, as did Phemister92 in 1924. Rendu98 was the
first to describe articular fractures of the talus in 1932.
Many synonyms for OCLs of the ankle have been used,
such as osteocartilaginous bodies, joint mice, intra-articular fragmentary fractures, transchondral fractures, and
osteochondral defects, with the acronym OCD being used
interchangeably to refer to osteochondral defect or osteochondritis dissecans. We prefer to use the broader term
osteochondral lesion to define a lesion of any origin that
involves the articular surface and/or subchondral region
of the talus or tibial plafond, thus affecting cartilage, bone,
or both. The acronym OCD is reserved for osteochondritis
dissecans lesions, which represent a specific subset of
OCLs. Despite being first recognized several centuries ago,
both the causes and preferred treatment strategy for OCLs
remain the subject of frequent debate.
This review seeks to elucidate and compare theories
regarding origins within a historical background, detail
current diagnostic strategies, and provide a systematic
approach to management of OCLs within the ankle joint.
DEFINITIONS AND HISTORY
Approximately 1 in 10 000 people per day suffers an ankle
injury.59 In athletes, this number can be as high as 5.23
ankle injuries per 10 000 athlete-exposures, and higher still
during active competition (9.35 per 10 000 athleteexposures).85 In a recent systematic review of ankle injuries,
Fong et al38 identified ankle injuries as being the most common type of injury in 24 of 70 sports, with ankle sprain being
the most frequent. Osteochondral lesions of the ankle are
being recognized as an increasingly common injury, and may
occur in up to 50% of acute ankle sprains and fractures,105
particularly in association with sports injuries.106,120
Recognition and understanding of osteochondral lesions
(OCLs) of the ankle have developed in a gradual, stepwise
fashion. In 1737, Monro79 described removal of a loose body
from the ankle, which was believed to be of traumatic origin.
Franz Konig66 first coined the term “osteochondritis dissecans” in 1888, in reference to loose bodies found in the knee
joint that he believed to be fragments from an avascular bone
*Address correspondence to John G. Kennedy, MD, FRCS (Orth),
Hospital for Special Surgery, 535 East 70th St, New York, NY 10021
(e-mail: kennedyj@hss.edu).
No potential conflict of interest declared.
ETIOLOGY
Proposed causes of ankle OCLs have included local avascular necrosis,66 systemic vasculopathies, acute trauma,13,82
chronic microtrauma,37 endocrine or metabolic factors,93
The American Journal of Sports Medicine, Vol. XX, No. X
DOI: 10.1177/0363546509336336
© 2009 American Orthopaedic Society for Sports Medicine
1
2 O’Loughlin et al
degenerative joint disease,117 joint malalignment,47 and
genetic predisposition.80 Konig66 hypothesized that vascular occlusion of subchondral bone leads to a process of local
inflammation and development of a subchondral cyst.
Although such a sequence may be specific to osteochondritis dissecans, the most widely accepted cause of OCLs of
the ankle is trauma, usually in the form of ankle sprains.
In a seminal study, Berndt and Harty13 reproduced the
mechanism of injury for both lateral and medial talar
dome OCLs. It was proposed that lateral injuries occur in
inversion and dorsiflexion of the ankle, while posteromedial injuries are the result of ankle plantar flexion and
inversion. Flick and Gould37 studied more than 500
patients with OCLs and found that 98% of lateral dome
lesions and 70% of medial dome lesions were associated
with a history of trauma.
In several series, however, a significant percentage of
patients with OCLs reported no trauma, lending support
for the role of genetic, metabolic, or endocrine causes.93,99,100
Mubarak and Carroll80 described an autosomal dominant
inheritance pattern in some osteochondritis dissecans
patients characterized by endocrine dysfunction and collagen and epiphyseal abnormalities. Other authors have
cited a high incidence of familial inheritance or populations of patients with OCLs in multiple joints.18,44 Trias
et al121 noted significant rates of hypothyroidism in 1
series of OCL patients. Although most patients with OCLs
have a history of trauma, in some instances analysis of
laboratory values related to endocrine and metabolic bone
disorders, such as serum vitamin D, calcium, phosphorus,
and parathyroid hormone, may be indicated, particularly
in patients with bilateral or polyarticular disease or those
with a family history of the condition.
CLASSIFICATION
In 1959, Berndt and Hardy13 established a 4-stage classification system of ankle OCLs based on the severity of the
lesion on plain radiographs (Figure 1). This was based on
a thorough review of the literature pertaining to “transchondral fractures of the talus” from 1856 through 1956
combined with their own data from reproduction of
transchondral fractures in 15 cadaveric specimens. Their
classification was subsequently modified by Loomer et al72
in 1993 to include a fifth subtype of radiolucent, cystic
lesions, as seen on CT scans. The principal advantage of the
Berndt and Hardy system is its widespread use and simplicity. However, in 1 prospective study of 92 patients,72
50% of OCLs were not detected on plain radiographs.
Moreover, the system is largely based on lesions with a
traumatic origin, and does not differentiate or incorporate
the spectrum of de novo lesions. As newer imaging technologies have emerged, a variety of additional classification
systems have been proposed (Table 1).5,27,53,72,114 Taranow
et al114 used MRI to describe the condition of both the cartilage and subchondral bone by employing the classic
4-stage grading to the bony component while describing the
cartilage to be either viable and intact (grade A) or nonviable (grade B). The MRI-based system by Hepple et al53 is
The American Journal of Sports Medicine
Figure 1. Berndt and Harty classification system.
based on the original Berndt and Harty classification, but
uncouples traumatic, cystic, and idiopathic etiologies of
OCLs. Mintz et al77 established a correlation between MRI
and arthroscopic findings. Because of the large degree of
signal change that can arise secondary to edema after even
mild ankle injuries, some authors30 believe MRI may overdiagnose or overestimate the extent of OCLs, and they urge
caution in the use of these classification systems.
Alternative classification systems using arthroscopic
findings have emerged as well. Pritsch et al95 graded talar
OCLs based on cartilage quality, as seen on arthroscopic
visualization. Cheng et al (unpublished data, 1995) used
arthroscopy to describe the condition of the talar cartilage,
ranging from smooth, soft, and ballottable cartilage (stage
A) to increasingly rough and fibrillated or fissured cartilage to a more unstable lesion culminating in a loose, displaced fragment (stage F). The disadvantage of an
arthroscopic classification system is that it focuses on the
cartilage insult and is unable to consider the underlying
bony component of the lesion.
DIAGNOSIS
Clinical Presentation
Osteochondral lesions of the ankle are being recognized as
an increasingly common injury that may occur in up to
50% of acute ankle sprains and fractures.105 Advances in
imaging techniques and an increasing number of ankle
arthroscopies being performed each year, in conjunction
with participation in sporting activities among all ages, are
expected to contribute to a rise in frequency of this injury.
The average age of patients with an OCL is 20 to 30 years,
with a male preponderance of 70%, and bilaterality being
reported in 10% of cases.22
Osteochondral Lesions of the Ankle 3
Vol. X, No. X, XXXX
TABLE 1
Published Classification Systems for Osteochondral Lesions of the Talus
Berndt and
Harty13 (1959)
Plain radiographs
Pritsch et al95
(1986)
Dipaola et al27
(1991)
Cheng et al,a
(1995)
Ferkel and
Sgaglione34
(1994)
Taranow et al114
(1999)
Hepple et al53
(1999)
Mintz et al77
(2003)
Arthroscopy
MRI
Arthroscopy
CT
MRI
MRI
MRI
1: Articular cartilage damage
only
2a: Cartilage
injury with
underlying
fracture and
surrounding
bony edema
2b: Stage 2a
without surrounding bony
edema
3: Detached but
undisplaced
fragment
4: Detached and
displaced
fragment
5: Subchondral
cyst formation
0: Normal
1: Hyperintense
but morphologically
intact cartilage surface
2: Fibrillation
or fissures not
extending to
bone
3: Flap present
or bone
exposed
4: Loose undisplaced fragment
5: Displaced
fragment
I: Compressed I: Intact overly- I: Thickening of
II: Chip avulsed ing cartilage
artcular cartibut attached II: Soft overlylage and lowIII: Detached
ing cartilage
signal
chip but
III: Frayed
changes on
undisplaced
overlying carintermediate/
IV: Detached
tilage
spin-density
and displaced
images
chip
II: Articular
Modification by
cartilage
Loomer et al72
breached with
(1993):
low-signal rim
Radiolucent
behind fraglesion
ment indicatacknowledged
ing fibrous
attachment
III: Articular
cartilage
breached,
high-signal
changes
behind fragment indicating synovial
fluid between
fragment and
underlying
subchondral
bone
IV: Loose body
A: Smooth,
I: Cystic lesion 1: Subchondral
intact but soft within dome
compression/
or ballottable
of talus, intact bone bruise
B: Rough
roof on all
appearing as
surface
views
high signal on
C: Fibrillation/ IIA: Cystic
T2-weighted
fissuring
lesion with
images
D: Flap present
communica2: Subchondral
or bone
tion to talar
cysts that are
exposed
dome surface
not seen
E: Loose, undis- IIB: Open artic- acutely (arise
placed fragular surface
from stage 1)
ment
lesion with
3: Partially sepF: Displaced
overlying non- arated or
fragment
displaced
detached fragfragment
ments in situ
III: Undisplaced 4: Displaced
lesion with
fragments
lucency
IV: Displaced
fragment
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
pain after a traumatic event, other patients present with
chronic ankle pain.103 Associated swelling, stiffness, and
weakness about the ankle are also common. Symptoms are
typically exacerbated by prolonged weightbearing or highimpact activities such as running or jumping sports.
Authors have also established a strong link between OCLs
and chronic ankle instability, which may also be part of the
reported symptoms.105
Physical examination findings most commonly include
ankle joint effusion and localized tenderness over 1 or
more periarticular regions, including the anterolateral and
anteromedial joint line. Examiners should assess for varus
malalignment, instability of the ankle and subtalar joints,
and perform an anterior drawer test and standard inversion maneuvers.
Radiologic Imaging Tests
Standard weightbearing radiographs of the ankle (anteroposterior, lateral, oblique) remain the preferred first-line
imaging studies for assessing patients with a suspected
OCL, in part to rule out fractures. A Canale view (pronation of the foot to 15°, x-ray beam angled 75° cephalad)19
may also be helpful to assess the subchondral surfaces.
However, because plain radiographs may miss up to 50% of
OCLs and are unable to assess the state of cartilage, we
believe that more advanced imaging technologies are
appropriate.72 Computed tomography lacks the ability to
assess cartilage, although it is useful in obtaining greater
detail about the bony injury such as specific size, shape,
and extent of displacement.34 Magnetic resonance imaging
has been shown to detect bone bruises, cartilage damage,
and other soft tissue insults,27 and correlates closely with
arthroscopic findings.34,77 T2-weighted MRI is recommended as it can offer greater sensitivity to cartilage
change, as well as allowing identification of the zonal orientation of the collagen fibrils, thus facilitating clarification of the depth of cartilage damage.73 Although MRI is
emerging as the gold standard for OCL diagnosis, clinicians should be aware that signal patterns in the talus may
overestimate the severity of the bone injury.
4 O’Loughlin et al
The American Journal of Sports Medicine
Anatomy and Location of Lesions
Talus. Articular cartilage in adults possesses neither a
blood supply nor lymphatic drainage and is relatively ineffective in responding to injury.16 Thus injuries confined to
the cartilage alone stimulate only a slight reaction in the
adjacent chondrocytes. The talus has 60% of its surface
covered in cartilage, which may increase the risk of vascular compromise.1 In contrast, involvement of the subchondral bone via penetration of the subchondral plate allows
a typical inflammatory wound-healing response. Cells
recruited from marrow elements attempt to fill the defect
but the degree of success is predicated on age, as well as
the size and location of the defect.
In 2007, Millington et al76 used a high-resolution stereophotography system to quantify the articular cartilage topography and thickness within the ankle joint.
These factors are important in the assessment of the
extent of OCLs, to determine the best mode of treatment.
The authors found that the thickest articular cartilage
occurs over the talar shoulders. The mean thickness of
both the talar (1.1 ± 018 mm) and tibial (1.16 ± 0.14 mm)
cartilage was significantly thicker than the fibular cartilage (0.85 ± 0.13 mm).
A recent study sought to evaluate the true frequency of
OCLs on the talar dome by location and morphological
characteristics.31 The authors developed a novel, 9-zone
anatomical grid system. They identified 428 OCLs in 428
ankles and found that medial talar dome lesions were both
more common and significantly larger than lateral lesions.
With regard to specific zones on the talus, centromedial
lesions were the most common (n = 227) with centrolateral
the next most frequent site (n = 110). Posteromedial and
anterolateral lesions were rarely found. A prior study by
the same group studying MRI changes over time also
reported that of 29 OCLs of the talus, 19 (66%) were
located at the medial talar dome.30
Tibial Plafond. Osteochondral lesions of the tibial plafond (Figure 2) are rare, particularly in comparison to the
incidence of OCLs of the talus. This may be due to differences in the thickness and mechanical properties of the
cartilage in these regions, as well as the rich arterial supply to the distal tibia. Distal tibial cartilage has been
shown to be stiffer than talar cartilage.6 Anterolateral
and posteromedial cartilage at the distal tibia is also
stiffer than the corresponding areas on the talar dome,
with the softest cartilage found in the posterior half of the
talus.
TREATMENT AND RESULTS
Nonoperative Treatment
Osteochondral lesions of the talus that are asymptomatic
or are discovered as incidental findings can be treated
nonoperatively. Low-grade OCLs, particularly osteochondritis dissecans lesions in the pediatric population, may
resolve completely with variable need for immobilization
or protected weightbearing. However, it is rarer to observe
spontaneous healing in adult patients.28 One series
Figure 2. Osteochondral lesion of the tibial plafond.
demonstrated good or excellent results in only 54% of
patients with chronic, cystic talar lesions treated nonoperatively.111 While rates of ankle osteoarthritis were low in
this cohort, follow-up averaged only 38 months. In a comprehensive review of treatment strategies for OCLs of the
talus, Tol et al120 noted that of a total of 201 patients from
14 studies who had nonoperative treatment, 91 (45%) were
reported to have had successful outcomes, with patients
with chronic symptoms (>6 weeks) actually having better
results (average success rate 56%) than the overall cohort.
The authors divided the nonoperatively treated patients
into 2 groups: group 1 pursued rest or restriction of sport
or activities with or without the use of nonsteroidal antiinflammatory drugs, while group 2 underwent cast immobilization for 3 weeks to 4 months. Group 1 had good or
excellent results in 59% of patients, compared with 41% of
patients in group 2. Typical indications for nonoperative
treatment in these studies were minimal symptoms;
Berndt and Harty stage I, II, and medial stage III lesions;
or lesions with intact cartilage. Shearer et al111 have noted
a poor correlation between changes in lesion size and
clinical outcome. Therefore, a reduction in the size of the
OCL that may be seen over time with conservative measures may not necessarily correlate with symptomatic
improvement, so conversion to operative treatment may be
warranted, if symptoms persist.
Patients who are asymptomatic or minimally symptomatic with lesions that involve cartilage alone may be
treated nonoperatively with rest, ice, temporarily reduced
weightbearing, and, in case of ankle malalignment, an
orthosis.128 Clinicians should be aware, however, that nonoperative management has shown relatively high rates of
Vol. X, No. X, XXXX
Osteochondral Lesions of the Ankle 5
failure in the literature.28,111 Further research into which
patients may have successful outcomes with nonoperative
care is warranted.
Surgical Management
The principal aim of surgical treatment is revascularization of the bony defect.7,40,43,67,104 Because articular hyaline
cartilage is avascular and has poor regenerative capabilities, injuries that do not penetrate the subchondral plate
have no stimulus for an inflammatory reaction and healing. When the depth of a talar OCL injury extends to the
subchondral bone, marrow cells are stimulated to produce
new tissue in an attempt to fill the defect.4,87 However, this
process involves the formation of fibrous cartilage, which
lacks the favorable biomechanical properties of normal
articular hyaline cartilage. In the case of smaller lesions,
this fibrocartilage substitute may suffice, and is the basis
behind techniques such as microfracture and micropicking.
However, with larger lesions, fibrocartilage may not be
adequate to support the longevity of the joint. Therefore,
the majority of recently developed treatment approaches
are aimed at providing a method of replacing damaged
articular cartilage with tissue that more closely resembles
hyaline cartilage. These have included primarily transplantation of osteochondral autograft plugs from distant
donor sites, allograft transplantation, or harvesting and
culturing chondrocytes that are later transplanted into the
site of the osteochondral defect.
Cartilage Stabilization/Pinning
Traumatic osteochondral fragments that have not detached
from the underlying bone may be suitable for fixation.
Whenever possible, large unstable OCLs with a viable
bony component are preferentially treated with stabilization rather than debridement alone, which may precipitate
pain and degenerative changes within the joint.4,87 Although
traditional OCL fixation has involved metal implants that
require subsequent removal, more recent techniques have
utilized compression or stabilization with bioabsorbable
materials, such as polyglycolic acid (PGA) or polylactic
acid (PLLA) bioabsorbable pins, which do not require
removal. While the literature on use of these new materials in the ankle is limited, 1 small series, in which PGA/
PLLA copolymer pins were used in conjunction with debridement of the bony bed, demonstrated healing in 6 of 7 cases,
with no evidence of an inflammatory reaction in any cases.68
Retrograde Drilling
Retrograde drilling (RD) is indicated for subchondral bone
lesions over which the overlying cartilage remains intact,
with the clear advantage of protecting the integrity of the
articular cartilage, compared with anterograde drilling
(Figure 3).114 However, it is critical not only to decompress
the lesion but also to address the structural integrity of the
subchondral cyst or defect, to prevent subsequent articular
collapse. Although previous authors have described the use
of solid bone graft, given the difficulty in adequately filling
Figure 3. Fluoroscopic image of talar retrograde drilling.
the contours of the lesion, other investigators have used
surgical-grade calcium sulfate as an alternative bone-graft
substitute that can be injected in liquid form into the
defect after drilling.62 As an adjunct, a bone-marrow aspirate may be harvested from the iliac graft and its pluripotent cells isolated by centrifuge and mixed with the calcium
graft to promote more rapid healing (Deland and Young,
unpublished data, 2001). Retrograde drilling was first
described by Lee and Mercurio70 for the knee in 1981 as an
open procedure, but now is frequently performed arthroscopically in the ankle, along with fluoroscopic radiographic
imaging. Because posteromedial and posterolateral lesions
present a challenge when using a standard drill-targeting
device arthroscopically, we have also employed the use of
computer-assisted techniques to improve the accuracy of
targeting lesions. These techniques have been employed
successfully in other studies.24,60,101
Outcomes studies investigating RD have shown good
results overall.8,67,70,114,118 Kono et al67 compared transmalleolar drilling (TMD) with RD in 30 patients with unilateral
OCLs without detachment of the cartilage, and re-look
arthroscopy was performed at 1 year to assess the cartilage.
In the TMD group, 11 lesions (58%) were unchanged (grade
I) and 8 lesions (42%) had deteriorated from grade 0 to I,
compared with the RD group, in which 3 lesions (27%) had
improved from grade I to 0 and 8 (73%) were unchanged (2
grade 0 lesions, 6 grade I lesions). In another series of 16
patients with symptomatic OCLs of the medial talar dome
treated arthroscopically with percutaneous RD through
the sinus tarsi,114 mean American Orthopaedic Foot and
Ankle Society (AOFAS) scores increased from 53.9 points to
82.6 points, with no complications reported.
Microfracture/Microdrilling
Microfracture and microdrilling (Figure 4) procedures
have the same objective: to stimulate fibrocartilage development by breaching the subchondral plate with subsequent introduction of serum factors and development of
6 O’Loughlin et al
The American Journal of Sports Medicine
Figure 4. Talar OCL micropicking.
Figure 5. Two parallel screw malleolar fixation technique,
with evidence of displacement of osteotomy fragment.
Figure 6. Three-screw malleolar fixation technique, with
evidence of satisfactory anatomic alignment.
scar tissue at the defect site. While the efficacy of micro­
fracture in ankle OCLs is somewhat controversial,86 most
series have demonstrated that it provides symptomatic
relief.11,43,116 In the presence of a small (<6 mm), shear-type
lesion characterized primarily by chondral damage, but
minimal subchondral bone involvement, this technique
may be optimal.87 Chuckpaiwong et al23 investigated 105
cases of talar OCLs treated with microfracture, reporting
no failures of treatment with lesions smaller than 15 mm
(n = 73) regardless of location, but only 1 successful outcome in lesions greater than 15 mm (n = 32). The authors
also highlighted increasing age, higher body mass index,
history of trauma, and presence of osteophytes as factors
negatively affecting outcome.
81
area. Most areas of the talar dome can be accessed perpendicularly without the necessity for a malleolar
osteotomy.26,81 Muir et al81 demonstrated that, on average,
only 17% of the medial talar dome and 20% of the lateral
talar dome could not be accessed without an osteotomy.
After an anterolateral osteotomy, they reported an increase
of 22% in sagittal exposure, while malleolar osteotomies
provided access to the entire medial and lateral talar dome
areas with a residual central 15% of the talar dome
remaining inaccessible perpendicularly. Several wellaccepted techniques for medial malleolar osteotomy have
been described.88,119,129 Critical to all methods of osteotomy
is a precise reduction and fixation to avoid fibrous nonunion or malunion. Three-screw fixation (Figure 5) may be
beneficial to reduce translation of bony fragments that can
occur with 2-screw fixation (Figure 6).
Mosaicplasty. For treatment of larger talar lesions,
Hangody et al51 described a method for autologous grafting
using numerous cylindrical osteochondral plugs taken
Tissue Transplantation
For transplant of osteochondral constructs into the talus,
perpendicular access is generally required to the injured
Vol. X, No. X, XXXX
Figure 7. An MRI scan of talus following an osteochondral
autograft transfer system (OATS) procedure.
from the nonweightbearing segment of the medial or lateral femoral ridge of the knee and transferring them to a
talar dome defect with a surface area of no more than
4 cm2 and approximately 10 mm in diameter. The authors
recommend a mini-arthrotomy and identify OCLs in the
medial or lateral aspect of the dome (rather than the central part of the talus) and otherwise normal tibial and
talar articular surfaces as factors associated with better
results.49 Good-to-excellent results have been reported in
as high as 94% of patients in some series.9,51 In a study
with 2- to 7-year follow-up, 36 talar OCL patients were
reviewed, with excellent results in 26 patients, good in 6,
and moderate in 2, based on the Hanover scoring system.50
A second-look arthroscopy procedure was performed in 8
patients and showed normal and congruent-appearing
surfaces, with specific staining revealing type II–specific
normal articular cartilage collagen and articular cartilage
proteoglycans that were of similar quality to a control
biopsy specimen. However, other authors have emphasized
the technical challenge of reproducing a smooth articular
surface, with protrusion of plugs in an “organ pipe”
arrangement.75,89 Patient complaints such as a “catching”
sensation and late-onset postoperative pain have also been
described.84
Osteochondral Autologous Transfer System. Osteochon­
dral autologous transfer system (OATS) has been advocated for the treatment of large cystic OCLs, such as type V
lesions (Figure 7).53,72 Based on the course of a large cohort
of patients with failures after simple drilling, curetting,
debridement, or bone grafting, Scranton107 suggested that
type V lesions (as described by Hepple et al53) greater than
6 mm in diameter with articular disruption should be indicated for OATS (Table 1). After arthroscopic identification
or confirmation of a lesion greater than 6 mm in diameter
with disrupted cartilage, conversion to open surgery is
Osteochondral Lesions of the Ankle 7
pursued, with a posteromedial lesion generally requiring
a medial malleolar osteotomy.107 Some authors advocate
release of the anterior talofibular ligament, anterior
subluxation, and forced plantar flexion to achieve adequate exposure for posterolateral lesions.108 The lesion is
debrided at the edges and matched to a graft of equal size
harvested from a nonweightbearing area of the ipsilateral
knee. One series reported 90% patient satisfaction in a
retrospective review of 50 OATS cases with a lesion diameter from 8 mm to 20 mm.108 In another series with average follow-up of 16 months and an average lesion size of
12 mm × 10 mm, the mean postoperative AOFAS score
was 88, the Lysholm knee score (assessing donor-site
pain) was 97, and 89% of patients said they would have
the procedure again.3 The authors believe OATS to be an
effective salvage procedure for patients with failed previous procedures and long-standing symptoms. Studies have
suggested that viability of chondrocytes in the periphery of
the graft may be affected by the acquisition method, with
manual punches being associated with better survival of
cells than use of a power trephine system.33,97
Osteochondral Allograft Transplantation. As an alternative to OATS, osteochondral allograft transplantation may
be more suitable for very large OCLs of the talus, and has
the advantage of optimization of matching graft morphologic characteristics with the defect site, which is done
with both radiologic and direct measurements
intraoperatively.96,115 Raikin96 classified OCLs as “massive” or not viable for standard repair options when the
volume exceeds 3 cm3 and suggested that this grade may
represent a sixth stage to the Berndt and Harty classification system. Some authors prefer fresh osteochondral
allografts over fresh-frozen grafts, citing a decline in chondrocyte viability in the latter.115 In such cases, transplantation should be performed within 7 days of the death of
the donor. However, other authors report good results with
frozen allografts that were frozen for less than 14 days
before insertion.96 Typically, the defect is burred to create
an even-edged rectangular defect with a flat base that
can be packed with cancellous graft from distal tibia or
donor talus to aid subsequent graft integration. The
transplanted allograft is usually held in place by screw
fixation.
Only 2 small series involving the use of an osteochondral
allograft exist in the literature. Raikin96 reported on 6
cases, 5 of which involved the medial talar dome and 1, the
lateral talar dome. Five of the 6 OCLs were of traumatic
origin. Two patients had fresh allograft transplantation,
and 4 had fresh-frozen talus allografts, with all approaches
except for 1 involving a malleolar osteotomy. Mean AOFAS
ankle scores improved from 42 preoperatively to 86 postoperatively, which included 1 patient who went on to have an
ankle arthrodesis for persistent pain. All patients stated
they would have the procedure performed on the contralateral side if necessary. Gross et al46 reported on 9 cases of
talar OCLs treated with fresh osteochondral allograft
transplantation, 6 of which remained in situ at a mean
follow-up of 11 years. The remaining 3 patients required
ankle arthrodeses, secondary to resorption and fragmentation of the graft.
8 O’Loughlin et al
Autologous Chondrocyte Implantation/Transplantation
(ACI/ACT). Autologous chondrocyte transplantation is an
alternative to osteochondral grafting techniques.74 The
technique, as described by Giannini et al,41 involves harvesting a small amount of cartilage arthroscopically from
the knee ipsilateral to the ankle injury for chondrocyte
cultures, which are grown in vitro for approximately 30
days. The OCL is debrided and filled with autologous cancellous bone harvested from the ipsilateral distal tibial
metaphysis. Periosteum is acquired from the ipsilateral
proximal tibial metaphysis to cover the transplant area
and is fixed with resorbable sutures. Before the flap is fully
sutured down, the chondrocytes are transplanted in liquid
media through the remaining unsutured area, which is
then sutured and sealed with fibrin glue. Malleolar osteotomy is fixed with 1 or more screws. At 1 year, the screws
are removed, and at that time an ankle arthroscopy is performed to assess the graft site. The authors reported on 8
patients treated with ACT, with average preoperative to
postoperative AOFAS scores improving from 32.1 points to
91 points at 2 years.41 Baums et al10 reported on 12 similarly treated patients, 11 of whom had good-to-excellent
results after 63 months of follow-up, with an average preoperative AOFAS score of 43.5 increasing to 88.4 postoperatively. One recent study suggests that decreased
postoperative pain may be an advantage of ACI, compared
with other techniques.43 Gobbi et al43 compared surgical
outcomes in 33 similarly sized talar OCLs treated with
chondroplasty (11 cases), microfracture (10 cases), and
OATS (12 cases). Although no significant difference was
detected between the groups, with reference to AOFAS or
single-assessment numeric evaluation scores, the numeric
pain intensity was significantly greater at 24 hours postoperatively with OATS than with the other 2 techniques.
Disadvantages of ACI include the cost of culturing hyaline
cells, the need for 2 surgical procedures, and the durability
of the graft.
Most recently, Giannini et al42 have reported on the
results of ACI incorporating the use of a hyaluronan-based
3-dimensional scaffold (Hyalograft C, Fidia Advanced
Biopolymers, Abana Terme, Italy) for symptomatic posttraumatic osteochondral talar dome lesions in 46 patients.
It involved a 3-step process with initial cartilage harvest
from the detached osteochondral fragment, chondrocyte
culture on the Hyalograft C scaffold, and subsequent
arthroscopic implantation of the 3-dimensional scaffold.
They reported excellent clinical and histologic results, with
an increase in AOFAS scores from 57.2 to 86.8. Hyalinelike cartilage regeneration was identified histologically in
samples obtained at second-look arthroscopy in 3 patients
at an average of 18 months after surgery.
Treatment of Tibial Plafond Lesions
Because of the rarity of tibial plafond OCLs, there are few
reports in the literature related to treatment recommendations. In the largest series involving distal tibial OCLs,
Mologne and Ferkel78 retrospectively reviewed 880 consecutive ankle arthroscopies, 23 (2.6%) of which involved
treatment of tibial plafond OCLs. They concluded that
The American Journal of Sports Medicine
arthroscopic treatment methods used for talar OCLs
(excision, curettage, and abrasion arthroplasty) were also
effective for those of the distal tibia, based on average
AOFAS ankle-hindfoot score improvement from 52 preoperatively to 87 postoperatively and good or excellent
results in 14 of 17 patients at medium-term follow-up.
Ueblacker et al123 reported on a new technique for retrograde osteochondral autograft transplantation for treatment of OCLs of the proximal and distal tibia. Their series
involved 5 patients, 2 of whom had painful chondral lesions
of the distal anterocentral and posteromedial tibia. All
patients were satisfied with the surgery. Follow-up arthroscopy showed the osteochondral cylinders well integrated
and flush with the articular surface.
One case report described a female patient with bilateral
distal tibial OCLs after several months of intensive military training.112 One month after cessation of active training and nonoperative therapy, the severity of pain decreased
considerably and the patient remained asymptomatic in
her daily activities at 3 years. A second case report
described osteochondral allografting of a distal tibial OCL,
with 2-year follow-up radiographs demonstrating satisfactory incorporation of the graft without collapse and with
preservation of joint space.21
Adjunctive Treatments/Future Directions
Viscosupplementation Therapy
Despite a dearth of convincing outcomes data to support
their use, the popularity of intra-articular hyaluronic acid
(HA) derivative injections, also known as viscosupplementation therapy, continues to grow for arthritis and other
conditions in a variety of joints. Pleimann et al94 were
among the first authors to report on the use of HA injections as an adjunct in the nonoperative treatment of
ankle arthritis in 2002. Salk et al102 recently performed
a controlled trial in which 22 patients were randomized to
receive either 5 weekly intra-articular injections of
Hyalgan (sodium hyaluronate) or saline placebo injections
for ankle osteoarthritis, demonstrating significantly better
improvement in the HA treatment group. TytherleighStrong et al122 reported increased markers of articular
cartilage survival and function in a sheep model, in which
viscosupplementation therapy was used as an adjunct to
osteochondral grafting of the knee. Other studies have supported these findings as well. Most recently, Cohen et al25
conducted a double-blind randomized controlled study
examining the safety and efficacy of intra-articular sodium
hyaluronate in the treatment of pain associated with ankle
osteoarthritis. Thirty consecutive patients were enrolled,
and those treated demonstrated a significantly greater
improvement from baseline on the Ankle Osteoarthritis
Scale at 3 months than did the control group. The authors
concluded that sodium hyaluronate may be a safe and
effective option for pain associated with ankle osteoarthritis but advocated the need for larger studies.
Because of the presumed benefits of HA derivatives on
synovial fluid and chondrocyte function, the senior author
of this review (J.G.K.) routinely uses viscosupplementation
Osteochondral Lesions of the Ankle 9
Vol. X, No. X, XXXX
as adjunctive treatment with all methods of surgical treatment of ankle OCLs. We are involved in a clinical trial that
aims to establish how HA may help in maintaining the
integrity of cartilage transplants in patients undergoing
the OATS procedure. It is known that the peripheral rim
of the graft suffers chondral cell death and that the graft
itself may also have reduced chondral viability after transplant due to integrative problems as well as the impact
forces involved in graft placement.91,127 The authors hypothesize that HA will act in these cases, as it does in degenerative joint disease, to preserve existing cartilage and
produce a more robust graft. However, it must be emphasized that ongoing clinical trials are needed to confirm the
efficacy of this treatment. Hyaluronic acid may be an
adjunct to improve outcomes in compromised cartilage in
the future, but at this time, it is not standard practice to
employ it in this fashion.
Electrical/Electromagnetic Stimulation
Although the efficacy of electric and electromagnetic stimulation on bone repair and healing of cartilage defects is
controversial, studies have suggested an upregulation of
known molecular healing factors, such as transforming
growth factor–beta (TGF-β) and various bone morphogenetic proteins (BMPs, which are members of the TGF-β
superfamily), as well as osteoclasts.2,14,20,71,126 One proposed
mechanism is that pulsed electromagnetic fields stimulate
chondrocyte proliferation by means of a nitrous oxide pathway.36 A recent study investigating bone formation and
graft stabilization in a sheep model of osteochondral
autograft treatment suggested that pulsed electromagnetic
field treatment leads to improved results.12 Based on a
growing body of evidence, the use of electric and electromagnetic stimulation may play an increasing role in the
future treatment of ankle OCLs.
Ultrasound Stimulation
Ultrasound is a propagating pressure wave that transfers
mechanical energy into tissues.130 Low-intensity ultrasound has been studied as a modality with properties that
can enhance bone52,64 and cartilage healing.29,90 In a
recently studied rabbit model with bilateral knee OCLs,
the effects of low-intensity pulsed ultrasound in repairing
osteochondral injuries was compared with the untreated
contralateral side, revealing significantly higher scores in
gross appearance grades, histologic grades, and proteoglycan quantity on the treated side.56 More evidence is needed
to assess the role of low-intensity pulsed ultrasound in the
acceleration of repair of osteochondral injuries.
Mesenchymal Stem Cells
Mesenchymal stem cells (MSCs) from bone marrow have
been cultured in vitro and induced to form cartilage before
implantation into the chondral defects in rabbits.124 Bone
marrow has been aspirated from the iliac crests in a caprine
model and chondrogenesis of the MSCs induced.17
Mesenchymal stem cells represent a valuable adjunct in
that they may be harvested with relative ease by means of
a bone-marrow aspirate and a small number of pluripotent
cells can be isolated, grown in vitro if necessary, and then
introduced into osteochondral defects. They have the capability to differentiate into articular cartilage and induce the
formation of subchondral bone. Recently, MSCs have been
used with success in hybrid scaffolds to repair osteochondral defects in animal models.48,55,65 Although still in the
early stages of application, this unique approach may have
great potential in treatment of human cartilage defects.
Platelet-Rich Plasma
At the site of any injury involving bone, a clot will form
that consists of red blood cells, white blood cells, and platelets in a fibrin matrix. In bone healing, the alpha granules
within the platelets are a valuable reservoir of exogenous
factors.39 These factors include platelet-derived growth factor, insulin-like growth factor, and TGF-β, which along
with a number of other factors play a critical role in bone
healing.57 Platelet-rich plasma has recently been studied
in conjunction with autologous chondrocyte transfer, showing promise both as a scaffold in which to help hold ACI
cells and as a reservoir of growth-stimulating factors.15,83
Computer-Aided Navigation and
Robot-Assisted Surgery
As computer navigation techniques become more sophisticated and more user-friendly, their integration into orthopaedic procedures increases (Figure 8). Computer navigation
is particularly attractive for OCLs given the importance of
precise localization and the potential for minimally invasive procedures.60,61 Robot-assisted surgery may also be
ultimately favored over conventional orthopaedic techniques in the treatment of OCLs because of the optimization of accuracy and precision in the preparation of bone
surfaces, and the potential for more reliable and reproducible outcomes with regard to spatial accuracy. How rapidly
these technologies advance in foot and ankle surgery, and
orthopaedic surgery as a whole, remains to be seen.
Tissue Engineering
Tissue engineering can be defined as the application of
biological, chemical, and engineering principles to the
repair, restoration, or regeneration of living tissue by
using biomaterials, cells, and factors alone or in combination.69 There are 3 common tissue engineering approaches
used to address osteochondral injuries113: extraction of
the appropriate cells from the patient, in vitro culture,
followed by transplantation back into the body defect that
requires regeneration; placement of biologic factors, such
as molecules or growth factors, into body defects; and use
of 3-dimensional porous materials (eg, titanium, tantalum) to stimulate the ingrowth of new tissue. A combination of these 3 approaches may also be used, such that
there are osteoinductive, osteoconductive, and osteogenic
elements, thus providing an optimal environment for
bone growth.63
10 O’Loughlin et al
The American Journal of Sports Medicine
polymer scaffolds, with the resultant implant placed in fullthickness OCLs in 80 rabbits. Significant enhancement of
the quality of the repair tissue with more hyaline-appearing
cartilage and a smoother surface was observed in both
BMP-7 and Shh gene–treated animals versus controls.
CONCLUSION
Figure 8. Computer–aided orthopaedic surgery.
The repair of OCLs requires a tissue engineering
approach that aims to mimic the physiologic properties
and structure of 2 different tissues (cartilage and bone)
using a scaffold-cell construct.113 Hoque et al54 have developed 2 such scaffolds, the first of which is composed of
fibrin and polycaprolactone (PCL), and the second of which
is composed of PCL and PCL–tricalcium phosphate.
However, clinical efficacy has yet to be established.
Growth Factors. Growth factors are cytokines that are
critical for optimal healing. Several growth factors have
been shown to improve cartilage healing in vivo. Bone morphogenetic protein–2 appears to be intimately involved
with the growth and differentiation of MSCs to chondroblasts and osteoblasts.125 Sellers et al109,110 used recombinant human BMP-2 for the treatment of full-thickness
defects of articular cartilage in rabbits, and found an accelerated formation of new subchondral bone and an improved
histologic appearance of the overlying articular surface.
However, the direct application of growth factors is controversial, as the method of delivery and ability to maintain
appropriate endogenous levels remains challenging.
Gene Therapy. Gene therapy involves the modification of
cellular genetic information, and its application to the
treatment of cartilage lesions involves transferring specific
genes that code for certain growth factors into chondrocytes
or progenitor cells. Vectors may be viral or nonviral, with
viral vectors appearing to be a more efficient prospect.32
Delivery may be executed either in vivo or in vitro. In vitro
delivery offers greater safety and control, although it represents a greater technical challenge. Because of the theoretical risk of insertional mutagenesis by the viral vectors
integrating into the genome of the cells, safety remains a
concerning obstacle to nonexperimental use at this stage.
By using tissue engineering to incorporate growth factors
(osteoinductive), tissue scaffolds (osteoconductive), and gene
therapy (osteogenic), Grande et al45 have successfully influenced the cartilage repair environment in the treatment of
OCLs in a rabbit model. Periosteal stem cells with known
osteoinductive potency were transduced with either BMP-7
or sonic hedgehog (Shh) gene. The cells were subsequently
cultured and expanded and then seeded into bioresorbable
Osteochondral lesions of the ankle are being recognized
with increasing frequency, in part because of heightened
understanding and awareness, and in part because of
improved MRI and arthroscopic technology. As a result,
treatment strategies and techniques continue to be rapidly
developed and improved upon. However, outcomes research
remains sparse on this subject; despite a number of emerging future directions that hold promise in the treatment of
OCLs, more evidence is necessary before they can be
treated with consistent efficacy and safety.
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