Adolescent osteochondral lesion of the talus

Foot Ankle Clin N Am 7 (2002) 651 – 667

Adolescent osteochondral lesion of the talus Ankle arthroscopy in pediatric patients Ross A. Benthien, MD, MPH a, Raymond J. Sullivan, MD a,b,*, Michael S. Aronow, MD a a

Department of Orthopaedic Surgery, University of Connecticut Health Center, 10 Talcott Notch, MC 4037, Farmington, CT 06034-4037, USA b Orthopaedic Associates of Hartford, 85 Seymour Street, Hartford, CT 06106, USA

Traumatic osteochondral lesions of the talus result from inversion trauma to the ankle. Many of these injuries respond fully to conservative care, whereas others result in persistent symptoms that limit activities and eventually require surgery. In many cases, these lesions are misdiagnosed initially as ankle sprains or other soft-tissue injuries. It is not uncommon for osteochondral lesions to be diagnosed late as the source of chronic pain and instability about the ankle. These injuries, and the often prolonged limitation of sports activities, can be especially distressing to adolescent athletes and their families. Arthroscopic debridement and drilling of osteochondral lesions of the talus is a widely accepted and efficacious option for patients with persistent symptoms. Favorable results are reported by many authors [1 –13]. The advantages of arthroscopic treatment include less soft-tissue dissection, decreased postoperative pain, and the virtual elimination of osteotomy to access the lesion. In these studies, few if any adolescent patients are included and, in a review of the literature, no article has addressed the treatment of these lesions exclusively in adolescents. The authors present a review of this topic and their experience treating nine adolescent patients.

Historical review The traditional operative approach for treating osteochondral lesions of the talus was through an ankle arthrotomy, often with osteotomy. Arthroscopic treatment has become the standard over the past two decades after early reports * Corresponding author. Orthopaedic Associates of Hartford, 85 Seymour Street, Suite 607, Hartford, CT 06106, USA E-mail address: [email protected] (R.J. Sullivan). 1083-7515/02/$ – see front matter D 2002, Elsevier Science (USA). All rights reserved. PII: S 1 0 8 3 - 7 5 1 5 ( 0 2 ) 0 0 0 5 3 - 0

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of ankle arthroscopy were published from Europe, Asia, and North America in the late 1970s and early 1980s [14,15]. In 1986, three groups reported the first results from arthroscopic debridement of osteochondral lesions [9,10,16]. The latest treatment strategies use cartilage transplantation for treatment of osteochondral lesions [3,17 – 21].

Demographics Osteochondral fractures of the talus account for approximately 0.1% of all fractures and only 1% of talus fractures, but this incidence may be much higher and on the increase, likely as a result of improved imaging capabilities [22]. These injuries usually occur in active adults during the third decade, but ages range from adolescents to the elderly. Historically, nearly 70% of these injuries occurred in men, but a number of recent reports show a more equal incidence among men and women, likely the result of increased recreational pursuits by women [3,5,9,23]. Osteochondral injuries to the talus represent 4% of all cases of osteochondral lesions, with the knee the most common site.

Classification Radiographic The Berndt and Harty [24] classification system, based on radiographic findings, is used most commonly. Type I lesions are compressions or indentations of the articular surface without fragmentation and represent 7% of all lesions. Type II lesions have an osteochondral fragment that is attached to the surrounding joint surface and therefore is nondisplaced. These represent 25% of lesions. In type III lesions, the fragment is completely detached but nondisplaced. These make up 40% of lesions. Type IV lesions are displaced and represent 28% of lesions [24,25]. Computed tomography Ferkel and Sgaglione [26] developed a CT classification for these injuries. In type I lesions, a subchondral cyst with an intact articular surface is seen. In type IIA lesions, the cyst communicates with the joint at the talar dome. In type IIB, the lesion communicates with the joint with an overlying, nondisplaced fragment. Type III lesions are characterized by lucency around a nondisplaced fragment and in type IV lesions the fragment is displaced. Magnetic resonance imaging Classification by MRI parallels the radiographic system. Type I lesions are not seen on plain radiographs, whereas the MRI shows marrow edema consistent

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with trabecular compression. Type II is incomplete fragmentation with attachment to the surrounding joint surface. Type IIA lesions are characterized by subchondral cyst formation. Like the other systems, type III lesions are unattached but nondisplaced and type IV are displaced [27]. Arthroscopic Arthroscopy allows for direct inspection and palpation of articular cartilage and the findings form the basis for grading system. Grade I changes are represented by intact, firm, and shiny articular cartilage; grade II has intact, but softened cartilage; and grade III lesions have fraying of the cartilage [10]. Most importantly, poor correlation has been noted between the condition of the cartilage at the time of arthroscopy and the preoperative radiographic staging. The arthroscopic staging system has been expanded to include fragmentation and displacement of the osteochondral fragments [28].

Location and mechanism Most osteochondral lesions of the talus are the result of trauma, with virtually all lateral lesions having a traumatic etiology [6,14,23]. In comparison, only 60% to 80% of medial lesions have a clear history of trauma [14,23,29]. The remainder is likely atraumatic in etiology, and the term ‘‘osteochondritis dissecans’’ is reserved for these spontaneous lesions. In a series that included both medial and lateral lesions, 87% had a related history of trauma, whereas in a recent study detailing the arthroscopic drilling of 18 medial lesions, only ten (56%) had a clear history of trauma [5,25]. Osteochondral lesions of the talus can occur throughout the dome but most commonly in the middle or anterior third laterally and in the posterior third medially. Lateral lesions usually are shallow or wafer-like and are displaced more frequently. Medial lesions tend to be deeper or cup-shaped and nondisplaced. A recent meta-analysis of over 600 cases reported in the literature demonstrated that 56% of the lesions were medial and 44% lateral, with a small number centrally located [23]. The most commonly described mechanism of injury is forceful ankle inversion with impaction of the talus on the tibial plafond or lateral malleolus. Berndt and Harty [24], using cadavera, experimentally reproduced lateral lesions with forced inversion with maximum ankle dorsiflexion. The osteochondral surface of the talus was damaged with impaction on the lateral malleolus. Similarly, medial lesions were reproduced with inversion of the plantar-flexed ankle and impaction of the dome on the tibia. Osteochondral lesions do not occur in isolation and often are associated with other injuries about the ankle. Sorrento and Mlodzienski [30] showed that 38% of 50 supination-external rotation (SER) type IV ankle fractures had dome lesions of the talus, further emphasizing the role of inversion trauma. Similarly, as many as 6.5% of patients with ankle sprains and 23% of patients requiring lateral ligament

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reconstruction have a chondral injury to the talus [31,32]. Lundeen [33] arthroscopically treated 15 adolescents for ankle symptoms, all but one with a history of trauma. Four osteochondral lesions of the talus were noted, in addition to ‘‘chondromalacia’’ and ‘‘subchondral erosions.’’ The most common findings were anterior impingement lesions, synovitis, and adhesive capsulitis. Bilateral lesions have been noted in 10% to 25% of cases, often without a history of trauma, suggesting an underlying susceptibility in some patients. The term ‘‘osteochondritis dissecans’’ is reserved for these lesions, and the treatment of nontraumatic lesions can differ from traumatic lesions. The etiology of these lesions is not clear, but possibilities include ossification defects, vascular anomolies, emboli, and endocrine abnormalities. Clinical presentation Patients present acutely after an inversion injury to the ankle, or more commonly in a delayed fashion with persistent symptoms. Symptoms include pain at the ankle, usually isolated to the side of the lesion. Other symptoms include instability, recurrent effusion, locking, or clicking. In acute injuries, inspection of the ankle demonstrates obvious signs of trauma, such as swelling and ecchymosis. Palpation of the lesion usually elicits pain. Dorsiflexion and plantarflexion of ankle facilitates examination of medial and lateral injuries, respectively. Eliciting crepitus with range of motion may represent an osteochondral lesion. These patients often present long after an ankle injury with persistent symptoms. Delays prior to definitive diagnosis and treatment are often lengthy [10,12,25]. Radiographs may be misinterpreted and a diagnosis of ankle sprain or instability is erroneously given. Osteochondral lesions should be suspected in any patient with a history of ankle trauma that results in persistent symptoms.

Imaging Radiographs The appropriate initial radiographic evaluation is standing anteroposterior, mortise, and lateral views of the ankle. An additional mortise view in plantarflexion or dorsiflexion can delineate better posterior-medial and anterior-lateral lesions, respectively (Fig. 1). Many lesions are undiagnosed by plain radiographs. These may be too small or not involve subchondral bone and therefore are not visible. In other cases, a lesion is present but not diagnosed by clinicians. Anderson et al [27] diagnosed osteochondral lesions of the talus in 14 of 30 patients with a history of ankle trauma and chronic symptoms whose initial films were read as negative. A bone scan was positive for all but one patient, and MRI demonstrated the lesion in all patients. Subsequent review of the plain radiographs showed the lesion in five

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Fig. 1. Anteroposterior radiograph of a type IV lesion, anterolateral lesion. This is an inversion injury sustained in a basketball game. This lesion was arthroscopically drilled and was symptom free at latest follow-up (case 1).

patients. In one study of 16 patients, seven (43%) had a lesion that was missed on initial radiograph but noted on retrospective review by an orthopedic surgeon [14]. Computed tomography CT provides much more detail than plain radiographs and can be used to improve the staging of lesions, demonstrate subchondral cysts, and assess fragment healing after treatment. Zinman et al [34] used CT to evaluate 37 lesions in 32 patients and showed that plain radiographs failed to show 34% of the lesions and that CT demonstrated fragment healing more often than plain radiographs. Magnetic resonance imaging MRI offers the ability to image cartilage lesions and the surrounding bone and soft tissues. Standard sagittal and coronal images usually show a low-intensity geographic region in the talar dome on T1-weighted images and a high-intensity signal rim between the talar bed and the osteochondral fragment on T2-weighted images. The region of high-intensity noted between the osteochondral fragment and the underlying talar dome represents either granulation tissue or synovial

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Fig. 2. (A and B) Coronal and saggital MR images of a type III medial lesion. This lesion had an insidious onset and was arthroscopically drilled through the medial malleolus. This patient required a repeat debridement and was symptom free at latest follow-up (case 6).

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fluid. Findings on MRI, especially the high intensity signal rim on T2, may be useful in assessing fragment stability [35,36]. Hepple and associates [37] have shown that MRI can be useful in imaging lesions not visible on plain radiographs (Fig. 2). MRI shows good correlation with arthroscopic findings. In one study, 11 of 12 osteochondral lesions were properly staged by preoperative MRI and the results correlated more closely with findings at arthroscopy than plain radiographs [38]. In another similar study, 13 of 14 patients treated with arthroscopy were properly staged by MRI [39]. MRI also can be used to assess the healing of lesions after arthroscopy. Investigators used MRI to assess lesion healing in 22 ankles and showed the lowintensity signal seen on T1 was reduced in 68.2%. In the 15 (88%) of 17 patients with good results, the signal size was reduced and remained unchanged in the five patients with fair results. Similarly, on T2 images, the signal rim disappeared in 13 of 15 patients with good results but remained in all with fair results [35].

Treatment Cartilage healing The goal of treatment is to facilitate cartilage healing at the site of injury. Partial thickness injuries to cartilage have limited capacity for repair. Injuries that extend to the subchondral bone allow healing of the lesion with a fibrinous scar and cellular repopulation from mesenchymal stem cells located in trabecular bone. This is the basis for treating these lesions with debridement and drilling of the subchondral bone. Age has an impact on the healing of cartilage. Matrix molecules decrease in size with increasing age and chondrocytes decrease in number and synthetic function with advancing age. The effects of age on articular cartilage imply that children and possibly adolescent patients may have an increased ability to heal lesions. In a study from Sweden, children heal osteochondritis dissecans lesions of the femoral condyles with minimal degenerative changes, whereas adults suffer significant degenerative changes [40]. At the same institution, 30 cases of osteochondritis dissecans of the ankle were evaluated an average of 21 years after injury. These lesions headled in dhildren without any discernable long-term effects, and the rate of osteoarthritis in adults was significantly less than that seen with osteochondritis dissecans of the femoral condyles [41]. In a similar study from Denmark that included 13 children with a traumatic lesion and an average 24-year follow-up, all ankles had normal range of motion and no swelling. In addition, there were no cases of osteoarthritis [42]. Nonoperative Types I, II, and III can be treated initially with a trial of immobilization, usually casting for six to eight weeks. This prevents displacement and promotes

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healing. Patients can be mobilized gradually as symptoms allow. Types I and II lesions generally do well with this treatment [25]. The treatment of type III lesions is more controversial. These also may be treated with immobilization, but some investigators have noted delayed healing or persistent symptoms in type III lateral lesions and advocate early operative treatment after failed closed management [25,29]. Operative Operative treatment generally is directed towards acute type IV lesions and symptomatic types I, II, and III lesions that have failed closed management. The authors usually treat type III lesions surgically; however, most patients are seen on a delayed basis and have failed prolonged closed management. Fragments larger than 1.5 cm or those that comprise one-third or more of the articular surface should be repaired if the cartilage is viable and the attached bony fragment is large enough to hold fixation. Smaller fragments can be excised with drilling of the bed. Most lesions can be treated arthroscopically. Open treatment, with or without osteotomy, is reserved for transplant procedures, lesions requiring fixation with pegs or screws, and injuries difficult to access arthroscopically [43]. Arthroscopic procedures are performed supine with a leg holder. Joint visualization is facilitated with a noninvasive distracter using a nylon ankle strap (Fig. 3). The use of 2.7-mm 30- and 70-degree arthroscopes greatly facilitate the evaluation and treatment of lesions, especially in the posterior joint. When softtissue contracture limits access to the joint, a 1.9-mm scope and shaver can facilitate debridement. The joint is accessed through the standard anterior-medial, anterior-lateral, and posterior-lateral portals, and at this point a thorough examination of the joint is completed [44]. Soft or fibrillated cartilage is debrided and subchondral bone in drilled with a 0.062-inch K-wire.

Fig. 3. Set-up for ankle arthroscopy. Note the cannula in the anterolateral portal and the incision over the sinus tarsi to allow for retrograde drilling. Noninvasive distraction is used to improve visualization.

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Anterograde drilling allows direct visualization of the lesion and can be performed through pre-established arthroscopy portals or the medial or lateral malleolus. Some lesions, especially posterior-medial, are often difficult to reach and these may require transmalleolar drilling. In general, crossing an open physis medially in the skeletally immature should be avoided. The distal tibial physis closes from central-medial to lateral at approximately age 12 in girls and age 14 in boys and, therefore, transmalleolar drilling in the older adolescent population is less of an issue. When anterograde drilling is necessary through an open medial physis, the number of passes with the K-wire should be limited, and talus motion can be used to improve access to the lesion. When drilling lesions, an adjustable, intra-articular guide is used to mark the lesion, and the K-wire is advanced into the lesion (Fig. 4). The wire should be advanced at an angle approximately 45 degrees to the long axis of the leg to prevent sciving into the surrounding, uninvolved cartilage. Successive passes of the wire into subchondral bone, combined with plantar-flexion and dorsiflexion (to reach posterior and anterior respectively), fully address most lesions. Drawbacks include iatrogenic injury to the articular cartilage of the malleolus and, in some cases, the drilling of intact, but soft, cartilage on the dome of the talus. In retrograde drilling, the guide is placed on the lesion and a wire is passed multiple times through the sinus tarsi into the subchondral bone below the lesion. This prevents injury to articular cartilage on the malleoli and allows preservation of intact cartilage if present. Others advocate drilling the lesion with a largecaliber cannulated drill, curettage, and bone grafting. Taranow et al have reported their results at two years using this technique with favorable improvement in function as assessed by American Orthpaedic Foot and Ankle Society (AOFAS) hindfoot scores [11]. Retrograde drilling carries the theoretic risk of vascular compromise from injury to the artery of the sinus tarsi but this has not been observed. Drilling through this region does not cross a physis and growth disturbances are not expected.

Fig. 4. Intraarticular drill guide. Marker (A) is placed at the site of lesion and the K-wire is advanced through the sheath (B) allowing controlled, accurate drilling of osteochondral lesions.

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Complications from ankle arthroscopy should be expected in approximately 10% of cases. Neurologic injury to the superficial peroneal, saphenous, or sural nerve accounts for 50% of the complications. Other complications include superficial and deep infection, ligament injuries, adhesions, instrument failure, and fractures [8,43].

Treatment outcomes Over 100 articles have been published concerning treatment of Osteochondral Defect (OCD) of the talus. A comprehensive review of treatment strategies demonstrated that nonoperative treatment generally yields inferior results. Overall, only 45% of patients had good or excellent results. Activity limitation without immobilization yielded 59% good or excellent results compared with 41% in those treated with immobilization only. Surgical treatment generally provides significantly improved results. Simple excision of chondral fragments results in 38% good or excellent results, but excision with curettage and excision with curettage and drilling results in 78% and 85% good or excellent results respectively [23]. These results include open and arthroscopic treatment. This meta-analysis excluded patients under 18 years of age, and the applicability to the adolescent population is unknown. Open surgical procedures produce good results in adolescents. Berndt and Harty [24] operatively treated nine lesions in eight children with eight good results and one poor result. Flick and Gould [14] treated three of four pediatric patients conservatively and all had poor results and came to surgery. In one patient, the initial treatment was surgical. All had excellent results at latest follow-up. Arthroscopic treatment with debridement and drilling has been used increasingly since the mid-1980s [2– 13]. In general, the number of good and excellent results in these series approaches 80%. In most cases, the followup has been limited and the long term results after treatment is unknown. In a series of 18 ankles treated with arthroscopic transmalleolar drilling of medial lesions, Kumai and associates treated 11 ankles in ten adolescent patients, with ten good and one fair result at an average follow-up of more than four years. Adolescent patients and those with a history of trauma had the most improvement [5]. In addition, arthroscopy may also be useful in the revision of failed open procedures [45].

Postoperative care Postoperative care varies widely, mainly in the degree and duration of immobilization. Some surgeons apply only compressive dressings and allow immediate weight bearing [4,7,10]. Others allow early range of motion with four to six weeks of non-weight bearing [2,5,11]. Others believe that a more prolonged period of immobilization is required [12].

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Clinical series Materials and methods Between March 1998 and June 2000, nine adolescents were evaluated at the authors’ institution and treated with arthroscopic surgery for an osteochondral lesion of the talus (Table 1). Five were males and the average age was 14.8 years (range, 11– 17). The average duration of symptoms was 11.9 months, including two patients seen and treated acutely for type IV lesions. If these patients were excluded, the average duration of symptoms, prior to treatment, was 15.3 months. The most common complaints were pain with walking or sports activities, instability, and limitation of sports activities. Six patients attributed their injury and the onset of symptoms to sports activities, four in basketball and one each in soccer and football. In three others, the injury was not sports related. Five reported an acute twisting event, three had an insidious onset, and in one patient the onset was not recorded. All patients were evaluated with standard radiographs. In addition, all patients had a preoperative MRI, except one, who had an acute type IV lesion and lateral ligamentous disruption and was evaluated by CT. All patients were followed clinically and were evaluated for pain, return to sports, and functional limitations. Clinical grading was performed as described by Berndt and Harty [24] (Fig. 5). Operative procedure The authors’ operative procedure follows the one described earlier and here a few key points are emphasized. A tourniquet and a noninvasive distracter are used. The authors routinely use anterior-medial and anterior-lateral portals with posterior-lateral portal used to improve access to posterior lesions. A complete examination of the joint is performed [44]. Lesions are debrided with motorized shavers and drilled with 0.062 K-wires. All drilling is performed with an intra-

Table 1 Preoperative data Case M/F Side Age Mechanism

Activity

Pre-op MRI

Location Type Procedure

1 2 3 4 5 6 7 8 9

Basketball None Basketball Basketball Football None Soccer None Basketball

Yes Yes No/CT Yes Yes Yes Yes Yes Yes

AL PM PM PM AL AC/M PL PM AL

M F M M M M F F F

L L L R R L R R L

15 11 14 17 17 15 14 13 17

Twisting Not specified Twisting Twisting Twisting Insidious Insidious Insidious Twisting

IV III IV III III III III II IV

Debride/drill Debride/drill Debride/drill-MM Debride/drill-MM Debride/drill Debride/drill-MM Debride/drill Debride/retro-drill Debride/drill

AL, anterolateral; PM, posteromedial; MM, transmedial malleolus drilling; M, male; F, female; R, right; L, left; PL, posterolateral; AC/M, anterocentral/medial.

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Fig. 5. (A) Arthroscopic photo of a type IV lesion that occurred during a basketball game. (B) The bed of the displaced osteochondral fragment. (C) The displaced fragment appeared nonviable, and drilling of the lesion was elected. At latest follow-up, the patient was symptom free with a clinically good result (case 9).

articular guide (Arthrex, Naples, FL). The authors have used retrograde drilling through the sinus tarsi, with fluoroscopic imaging, for intact medial lesions. Postoperative management Patients are maintained non-weight bearing for six weeks. At two weeks, the splint and sutures are removed and the patient is placed in a range-of-motion walking boot. This is removed two to three times daily for ankle dorsiflexion and

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Fig. 5 (continued).

plantarflexion exercises. Ankle inversion and eversion is prohibited. At six weeks, full weight-bearing in the boot is allowed and physical therapy is initiated for strengthening and range of motion. Between 6 and 10 weeks, the patient is transitioned to a stirrup ankle brace with progressive advancement of weightbearing activities. Results Patients were evaluated in the office for an average of 12 months (range 2 to 27) postoperatively (Table 2). One was lost to follow-up at two months. Six of seven patients involved in sports were able to return to competition. Seven of nine were pain free at latest follow-up and eight of nine had no limitations of Table 2 Clinical outcomes Case

Follow-up (months)

Return to sports

Pain free

Activity restriction

Repeat arthroscopy

Clinical rating*

1 2 3 4 5 6 7 8 9

5 27 19 2 25 15 3 9 5

Yes No Yes Not specified Yes Not specified Yes Yes Yes

Yes No Yes Yes No Yes Yes Yes Yes

No Yes No No No No No No No

No Yes No No Yes Yes No No No

Good Poor/poor Good Good Poor/fair Poor/good Good Good Good

* Rating system from: Berndt AL, Harty M. Transchondral fractures (osteochondritis dissecans) of the talus. J Bone Joint Surg 1959;41A(6):988 – 1020.

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activities. Fifty-six percent of the lesions involved the medial dome and 44% involved the lateral dome. All anterior-lateral lesions were preceded by a discreet traumatic episode, compared with 50% of the posterior-medial lesions. Three patients (33%) required reoperation. Case 2 required arthroscopic debridement of an anterior-lateral impingement lesion and further scar debridement and redrilling of a posterior-medial osteochondral lesion 12 and 19 months after the index procedure, respectively. The patient is currently pain-free with walking but has pain with aggressive weight bearing. The clinical outcome was rated as poor and the patient’s prognosis is guarded. The authors’ plan is osteochondral transplantation from the ipsilateral knee if the clinical situation deteriorates. Case 5 required an arthroscopic synovectomy, open debridement of the flexor hallucis longus tendon, and open excision of a symptomatic os trigonum 25 months after the index procedure. Final clinical grade was good. Case 6 had repeat arthroscopy for an anterolateral impingement lesion 14 months after the initial drilling procedure with a final clinical grade of good. There were no perioperative complications. Discussion This series reports the results of the arthroscopic treatment of osteochondral lesions of the talus exclusively in adolescent patients. The relief of pain and rate of return to activities and sports compares favorably with results reported in adults. The authors’ patients were split evenly by gender, and the location of the lesions and their relationship to trauma paralleled the rates reported in the studies of adults. The authors observed excellent pain relief and return to function in all but one patient. These results reflect early follow-up and further clinical observation is required to assess the permanence of the authors’ outcomes. The authors’ experience underscores the continued difficulty in securing an early diagnosis of these injuries. If the three patients with acute type IV lesions are excluded, the remaining patients were referred to the authors’ institution for evaluation and treatment an average of 18 months after initial injury or onset of symptoms. These patients had failed maximal conservative treatment with immobilization, limited weight bearing, and anti-inflammatory medications. This being the case, most came to surgery within two months of referral. Preoperatively, the authors believe MRI is an important adjunct for injury assessment and is obtained routinely on all patients. These studies are superior for staging lesions, evaluating the ankle for coexistent injuries, and planning the arthroscopic procedure. The authors believe that their operative techniques give good access to all lesions with a minimum of complications. Postoperatively, the authors keep patients non-weight bearing for at least six weeks. The authors believe this helps to protect the fibrocartilage repair of the lesion. Early range of motion at two weeks helps to prevent joint stiffness and maximizes cartilage nutrition. All but one of the injuries treated in this series were type III or IV. Many patients were referrals to a regional academic center and this population likely represents a select group that has failed conservative treatment and may derive greater benefit

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from arthroscopic debridement and drilling than the background population. There are certainly many other types I, II, and III lesions treated at the authors’ institution and in the community that heal without identifiable dysfunction. The cases in this series may result from more significant initial injuries or progression of types I and II injuries that have failed conservative management. Whatever the natural history of these more advanced lesions, in the authors’ series and in others, they are more likely to require surgical intervention for failed conservative therapy [10,12]. Studies with extremely long-term follow-up of osteochondritis dissecans lesions in children, treated conservatively, emphasize the good and excellent functional outcomes and the virtual absence of osteoarthritic changes. One criticism is that studies with such extensive long-term follow-up evaluate patients when participation in aggressive weight-bearing activities may be on the decline, possibly bolstering overall satisfaction. Whereas these observations can be seen as evidence for nonoperative and supportive treatment, all of the authors’ patients were significantly limited in activities, especially sports. Many adolescents are deeply committed to their sports activities and often participate year-round. It seems reasonable to offer early treatment to facilitate sports participation, even if the long-term prognosis of nonoperative treatment may be quite good. In addition, the authors know that the operative treatment of these lesions in adults offers improved outcomes and this experience may, with caution, be transferable to the adolescent population. Most thought-provoking would be the acute treatment of the more severe types III and IV lesions in the pediatric population, especially in athletes. Three patients (cases 1, 3, and 9) who sustained type IV lesions all had surgery within two months; at an average of nine months’ follow-up, all are pain free, without activity limitation, and back to sports participation. Whereas type IV lesions generally require early intervention, similar results may be generalized to lateral, or even medial, type III lesions.

Summary Osteochondral lesions of the talus can be difficult to diagnose and can result in a significant functional limitation in young, active patients. New imaging modalities have improved the diagnosis and staging of these lesions. In general, nonoperative treatment results in poorer outcomes compared with operative treatment, and arthroscopic treatment has results similar to open treatment. Although the literature is limited, the treatment of adolescents results in outcomes similar to the adult population.

References [1] Amendola A, Petrik J, Webster-Bogaert S. Ankle arthroscopy: outcome in 79 consecutive patients. Arthroscopy 1996;12(5):565 – 73.

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