What Are Osteochondral Lesions and Options for Treatment

An osteochondral lesion is a tear or fracture in the cartilage covering one of the bones in the ankle joint, the talus, or lateral and medial malleolus. The severity of the lesion can vary, ranging from small cracks or fissures in the cartilage to complete detachment of a piece of cartilage along with a segment of the underlying bone. It commonly occurs in weight-bearing joints such as the ankle, and can result from trauma, repetitive stress, or underlying conditions such as osteoarthritis.

Who is most commonly susceptible to osteochondral lesions?

While osteochondral lesions can affect anyone, certain groups may be more susceptible. Athletes engaging in high-impact sports, individuals who are overweight and place excess stress on joints, those with a history of joint trauma, and older adults are among those who may have an increased risk. Factors such as repetitive stress, joint injuries, age-related changes, and excess body weight contribute to this susceptibility. However, it's important to remember that susceptibility can vary among individuals, and other factors like genetics and joint alignment also play a role.

What are the symptoms of an osteochondral lesion?

The cartilage can be torn, crushed or damaged and symptoms may include pain, swelling, stiffness, or it could feel like a dull ache in the joint and cause limited range of motion in the affected joint. The patient may also complain of mechanical symptoms, such as clicking and popping sounds caused by a loose fragment of cartilage and/or bone.

How do you test for osteochondral lesions?

man holding x-ray of foot and ankle

Plain x-rays can be used to help diagnose an osteochondral lesion. Areas of decreased density (i.e., darker areas) seen on the plain x-rays can be indicative of this condition, although it is not uncommon for the plain x-rays to be read as normal. The gold standard for diagnosis is an MRI of the ankle. An MRI may show that the cartilage and bone damage is displaced (out of position) or non-displaced (perfectly in position).

How do you treat osteochondral lesions?

Treatment options for osteochondral lesions depend on several factors, including the size, location, and severity of the lesion, as well as the patient's age, activity level, and overall health. Some common treatment approaches include:

Non-Surgical Treatments

For small and stable lesions, conservative approaches may be tried initially, especially if the condition is recognized and treated early. Younger patients, particularly growing children or adolescents, have a much better chance of healing an osteochondral lesion without surgery compared to adults. Non-surgical options are typically used when the lesion is small, does not cause significant symptoms, and does not interfere with joint function. There are several non-operative management options for the treatment of osteochondral lesions, including:

Cast immobilization

man sitting on couch in a cast

If the osteochondral lesion occurs following an acute injury, initial immobilization in a cast for 4-6 weeks or using a CAM walker can help reduce stress on the osteochondral lesion to allow healing. This treatment approach can be initially attempted in non-displaced osteochondral lesions.

Physical therapy

Working on strengthening the muscles around the ankle, range of motion of the ankle, and balancing (proprioception)

Protective Braces

(ex. Ankle Lacer) to decrease stress can also be utilized

Over-the-counter pain medications

Common options include acetaminophen (Tylenol) for mild to moderate pain and nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen (Advil, Motrin) and naproxen sodium (Aleve) to reduce pain and inflammation. Topical analgesics, such as creams or patches containing menthol or capsaicin, can also provide temporary relief.

Activity Modification

Activity modification to prevent prolonging the healing process

Surgical Treatments

Surgical treatment is indicated for displaced talar osteochondral lesions or lesions that have not improved with appropriate conservative, non-operative management. Surgical treatment of talar osteochondral lesions includes:

Arthroscopic Surgery

This minimally invasive procedure involves the use of a small camera and surgical instruments inserted through tiny incisions in the joint. The surgeon can then assess and repair the damaged cartilage and bone. Techniques used in arthroscopic surgery include debridement (removal of loose or damaged tissue), microfracture (creating small holes in the bone to stimulate new cartilage growth), and cartilage transplantation or autologous chondrocyte implantation, which replaces damaged cartilage with healthy cartilage from another area or using the patient's own cartilage cells.

Osteochondral Grafting

This procedure is also called Osteochondral Autologous Autograft Transfer (OATs Procedure). An OATs-type procedure is reserved for patients who have been treated by debridement and microfracture and are still not doing well, or also in cases where the lesion is large or involves a significant area of damaged cartilage and bone. An osteochondral grafting procedure may also be called a mosaicplasty. This involves transplanting a graft from a healthy donor or from a non-weight-bearing area of the patient's own joint to replace the damaged tissue. The graft can be secured in place with screws or other fixation methods. The graft is usually harvested from the patient's knee on the same leg, from an area of that joint that does not bear any load. The main disadvantage of this procedure is that the patient can develop knee problems after this procedure, the prolonged recovery time, and the increased complication rate, compared to arthroscopic debridement.

Osteochondral Allograft Transplantation

In some situations, when a large portion of the joint is affected, an osteochondral allograft transplantation may be performed. This involves using a graft from a cadaver donor to replace the damaged tissue. Osteochondral allografts (cadaver grafts) have been used to treat large talar lesions with some success. However, the larger the graft, the more likely it seems that it will collapse as a new blood supply is established into the graft after transplantation.

Autologous chondrocyte transplantation (ACI)

This procedure attempts to harvest a patient's own healthy cartilage, grow the cells in a lab, and then re-implant these cells back into the area where the cartilage was lost. Unfortunately, this approach in the ankle has not yet met with clinical success and is not currently available. Laboratory and clinical work continue in this area.

Other Medical Treatments

Any other significant medical treatments that exist may need to be addressed at the time surgery is indicated. This may include:

  • Surgery to address ankle instability, such as a Brostrom lateral ligament repair or a lateral ligament tendon reconstruction
  • Calcaneal osteotomy to address significant hindfoot alignment abnormalities such as hindfoot varus, which is treated with a lateralizing calcaneal osteotomy.

The choice of treatment depends on various factors and is determined by the orthopedic surgeon based on the individual patient's condition. Rehabilitation and physical therapy are typically recommended after any surgical intervention to restore joint function, strengthen the surrounding muscles, and promote a successful recovery.

It's important to consult with a healthcare professional, such as an orthopedic surgeon, who can evaluate the specific situation and provide appropriate diagnosis and treatment options for an osteochondral lesion.

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