Arthroscopic Drilling for the Treatment of Osteochondral Lesions of the Talus
Abstract & Commentary
Synopsis: Preservation of the partially attached osteochondral fragment is beneficial and transmalleolar drilling of the stage II osteochondral lesions of the medial talar dome, using an arthroscopic technique, is less invasive than the open transmalleolar approach.
Source: Kumai T, et al. Arthroscopic drilling for the treatment of osteochondral lesions of the talus. J Bone Joint Surg Am 1999;81:1229-1235.
Osteochondral lesions of the talar dome are often a source of persistent pain after a sprain injury of the ankle in the athlete. Controversy exists with regard to the treatment of stage II lesions as defined by the Berndt and Hardy classification.1 A stage II lesion has an osteochondral fragment that is only partially detached from the talar dome. More severe stage III and IV lesions with complete detachment of the fragment can be treated with debridement of the detached fragment and drilling or curettage of its base; however, particularly with medial lesions, most authors feel that with stage II lesions it is better to preserve the articular cartilage, if possible.
In this study, Kumai and colleagues treated 18 ankles in 17 patients with transmalleolar drilling of a stage II osteochondral lesion of the medial talar dome. The patients’ mean age was 28 years. They were followed for a minimum of two years and in all 18 cases the symptoms improved and for 13 ankles the results were considered good and for five they were considered to be fair. Most important, all patients younger than 30 years of age had a good result. In most cases, an improvement in the appearance of the lesion radiographically could be demonstrated as well, particularly again in the younger patients. Those treated within about six months of the injury seemed to do better than those whose treatment was delayed for up to a year. Kumai et al conclude that preservation of the partially attached osteochondral fragment is beneficial and that transmalleolar drilling of these stage II osteochondral lesions of the medial talar dome, using an arthroscopic technique, is less invasive than the open transmalleolar approach, allowing the patients to resume daily activities and sports much earlier. Kumai et al found the procedure to be effective and useful in young patients, especially those who had not yet undergone closure of the epiphyseal plate. Kumai et al feel that preservation of the partially attached osteochondral fragment is beneficial in these patients.
Comment by James D. Heckman, MD
Controversy exists about the treatment of medial stage II talar dome lesions. It is frustrating at the time of arthroscopy to find a partially attached, large medial osteochondral lesion, particularly in a young person, because removing the lesion and osteotomizing the medial malleolus to drill the defect seems so destructive when one is trying to restore a fibrocartilaginous healing response. One other alternative would be prolonged cast immobilization. Canale and Belding2 have recommended that 6-8 weeks of cast immobilization may lead to resolution of symptoms in many of these patients. Another surgical approach has recently been described by Ferkel and others3 in which a retrograde transtalar approach is used to drill the osseous bed of the osteochondral defect from below, leaving the articular cartilage intact.
The technique reported in this paper is simple and straightforward and seems to have produced good results, particularly in young patients. A 1 or 1.2 mm Kirschner wire is drilled across the medial malleolus and into the osteochondral defect of the medial dome of the talus. By dorsiflexing and plantar flexing the ankle, different parts of the lesion can be drilled in this fashion. While there is some risk of breaking off the Kirschner wire and the drilling obviously does at least minor damage to the articular surface of the opposing tibial axillary surface, the clinical results in this relatively small group of patients seems to confirm its effectiveness. Mature osteochondral lesions such as these will be persistently symptomatic unless treated in some fashion, and this technique seems to provide a viable and effective solution.
References
1. Berndt AL, Hardy M. Transchondral fractures (osteochondritis dissecans) of the talus. J Bone Joint Surg Am 1959;41:988-1020.
2. Canale ST, Belding RH. Osteochondral lesions of the talus. J Bone Joint Surg Am 1980;62:97-102.
3. Ferkel RD. Osteochondral lesions of the talus. In: Whipple TL, ed. Arthroscopic Surgery: The Foot and Ankle. Philadelphia, Pa.: Lippincott-Raven; 1996:145-170.
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