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A 15-year-old athlete with ankle pain
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Andrew R. Hsu
Robert B. Anderson
A 15-year-old female high school athlete with no medical comorbidities presented to our clinic with progressively worsening left ankle pain for 8 months. She had been previously diagnosed at an outside institution with a medial talar osteochondral lesion found on radiographs and MRI without a history of trauma. She was initially treated with a course of immobilization in a tall CAM boot for 6 weeks followed by physical therapy for 6 weeks. The patient’s ankle pain persisted and she was re-immobilized in a non-weight bearing short leg cast for an additional 6 weeks. After failing nonoperative management, the patient underwent a left ankle arthroscopy with medial talar osteochondral lesion debridement and microfracture at the outside institution.
The patient had minimal benefit from her prior procedure and presented to our office for a second opinion with a primary complaint of medial ankle joint swelling and pain during ambulation and activities of daily living. She was a scholarship athlete and desired to return to competition as quickly as possible.
Examination and imaging
On physical exam, the patient was 5’3” and 110 pounds (body mass index 19.5) with a normal gait, and pain and swelling along the medial ankle joint. She had a mild, flexible cavovarus foot deformity with a plantarflexed first metatarsal. She had no gross ankle ligamentous instability and had full range of motion of the tibiotalar and subtalar joints with pain at extremes of ankle motion.
Weight-bearing radiographs were obtained (Figure 1) along with MRI (Figure 2) and CT (Figure 3) of the left ankle. Imaging showed a large medial talar osteochondral lesion (OCL) measuring approximately 1.5 x 1.5 x 0.75 cm with no loose bodies. There was mild ankle varus alignment and prominent osteophytes along the anterior aspect of the distal tibia and talar neck.
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Preoperative AP (a), mortise (b) and lateral radiographs (c) of the left ankle show a large medial talar osteochondral lesion (OCL) with osteophytes along the anterior distal tibia and talar neck. The ankle has mild varus alignment and the foot has mild cavovarus deformity with a plantarflexed first ray.
Images: Anderson RB
Preoperative coronal T2-weighted fast-spin echo (a), sagittal short tau inversion recovery (STIR) (b), and axial STIR MRI images (c) demonstrate a 1.5 x 1.5 x 0.75 cm medial talar OCL with underlying and surrounding edema.
Preoperative coronal (a), sagittal (b) and axial CT cuts (c) confirm the size of the medial talar OCD and show the amount of underlying bone loss and size of the distal tibia and talar osteophytes.
Ankle arthroscopy, OCL debridement, osteophyte removal, implantation of juvenile cartilage allograft, and first metatarsal dorsiflexion osteotomy
OCLs of the talus are defects of articular cartilage and adjacent subchondral bone that are commonly associated with traumatic injury to the ankle joint or chronic overuse due to athletic activity. A thorough history is important as talar OCLs are frequently associated with a history of ankle sprains, recurrent ankle instability, and/or acute ankle fractures with an inability to fully participate in impact activities. Anterolateral talar lesions typically result from inversion and dorsiflexion injuries, while posteromedial lesions result from inversion and plantarflexion injuries. Correct and timely diagnosis can often be difficult due to delay in patient presentation, negative initial radiographs and waxing/waning symptoms due to patient self-regulation of their physical activity.
Physical exam usually reveals tenderness and swelling along the ankle joint, decreased range of motion and mechanical symptoms, such as crepitus and grinding during end-range dorsiflexion, plantarflexion, inversion and eversion. Exam findings are often non-specific, and therefore, imaging is a critical aspect of the work-up. Weight-bearing radiographs of the ankle are a key component of initial work-up to evaluate for OCLs, mechanical axis malalignment and associated intra-articular pathology, such as impinging osteophytes. Stress radiographs can be obtained if ligamentous instability is suspected. MRI can help delineate cartilage instability and the degree of associated edema, inflammation and synovitis. CT can help demonstrate any underlying cysts and the amount of bone loss present.
Intraoperative arthroscopic view from the anterolateral portal shows medial talar OCL with overlying cartilage softening and fraying (a). This is a view from the anteromedial portal of impinging anterior distal tibia and talar neck osteophytes during ankle dorsiflexion (b).
In cases of recurrent ankle pain despite previous trials of immobilization, physical therapy and surgical intervention consisting of arthroscopy with OCL debridement and microfracture, it is imperative that the physician carefully review the previous clinical history, operative report and intraoperative pictures to determine the extent and nature of the lesion.
Discussion and treatment options
Treatment of talar OCLs depends on the grade, location and size of the lesion as well as degree of symptoms and desired level of physical activity. Nonoperative management is appropriate in low-grade lesions and includes rest, reduction or alteration of physical activity, immobilization and NSAIDs. However, the relatively avascular nature of articular cartilage can limit healing after injury and increase the risk for treatment failure and the development of future ankle osteoarthritis. Nonoperative treatment has a high failure rate with less than 45% of OCLs responding successfully. Surgical intervention is often required and consists of ankle arthroscopy with OCL curettage, debridement and possible microfracture for marrow stimulation. Penetration of subchondral bone allows mesenchymal marrow stems cells access to the articular surface, which form into a clot that matured into fibrocartilage, which replaces the injured hyaline cartilage.
Microfracture may not be appropriate for talar OCLs larger than 1.5 cm in any dimension. Larger lesions and those unresponsive to microfracture may require an osteochondral allograft, autograft, autologous chondrocyte implantation (ACI) or matrix-induced autologous chondrocyte implantation (MACI). Allograft transfers can be associated with graft subsidence and resorption and autograft transfer can have donor site morbidity and morphological mismatch. ACI restores hyaline cartilage but requires two operative procedures and a possible malleolar osteotomy for lesion exposure and access. Since 2007, particulated juvenile articular cartilage (DeNovo NT; Zimmer; Warsaw, Ind.) has emerged as a viable alternative treatment for OCLs refractory to initial surgical intervention.
This intraoperative view shows the anteromedial portal extended to create an open medial arthrotomy and expose distal tibia and talar neck osteophytes (a). View of medial talar OCL after osteophyte excision (b). OCL elevation using a freer (c) and view of OCL cartilage and bony defect measuring 1.7 x 2.5 x 0.8 cm after unstable fragment removal (d). Insertion of 2-3 drops of fibrin glue (e) followed by placement of one package of DeNovo NT particulated juvenile cartilage (Zimmer; Warsaw, Ind.) by hand through a small-joint arthroscopy cannula (f). Final view of OCL with implanted DeNovo NT in place and dried fibrin glue (5 minutes) on top of cartilage (g) is seen here.
Use of juvenile allograft chondrocytes can help reproduce hyaline cartilage in a single-stage procedure with low complications and morbidity. Cartilage allografts are prepackaged and contain young donor chondrocytes with high metabolic activity, cellular density and proteoglycan content. Current indications include young patients (<50 years) with symptomatic, isolated talar OCLs that have failed previous nonoperative management and surgical microfracture. Large OCLs >1 cm2 are also a relative indication as these lesions tend to have a higher failure rate when treated with microfracture alone. Contraindications for use include necrotic bone, diffuse osteoarthritis, autoimmune disease, morbid obesity and active infection. Potential complications include joint effusion and inflammation, failure of graft incorporation and graft delamination. Therefore, the risks, benefits and alternatives of this procedure and any other OCL treatment must be discussed thoroughly with patients and families in order to properly set goals and expectations.
Postoperative AP (a) and lateral radiographs (b) of the left foot show first metatarsal dorsiflexion osteotomy secured with bicortical 4.0 mm partially threaded DARCO screw (Wright Medical Technology Inc; Memphis, Tenn.). Postoperative lateral radiograph of the left ankle shows removal of impinging distal tibia and talar neck osteophytes (c).
Regardless of surgical option chosen, all treatment plans must be tailored to the individual patient based on their history, exam, and functional demands. All patients must be counseled appropriately about the risks and benefits of nonoperative and operative treatment and the associated opportunity costs of not being able to participate in athletics. In the present case, the patient was a scholarship high school athlete desiring return to competitive athletics as soon as possible. The addition of a supramalleolar valgus-producing osteotomy was discussed with the patient and her family as a treatment to realign her mild varus ankle alignment. However, given the patient’s goals and the additional morbidity of an ankle realignment osteotomy, this option was not chosen.
Management
Our patient underwent surgical intervention consisting of left ankle arthroscopy, OCL debridement, osteophyte removal, implantation of Denovo NT juvenile cartilage allograft and first metatarsal dorsiflexion osteotomy without complications. A diagnostic arthroscopy was first performed to visualize the size, shape and stability of the talar OCL along with the degree of anterior osteophyte impingement (Figure 4). An extensive synovectomy was performed and the anteromedial portal was extended 2.5 cm to visualize and remove the anterior osteophytes (Figure 5). The medial talar OCL was freed from its unstable bony base and excised, leaving a cartilage and bony defect measuring 1.7 x 2.5 x 0.8 cm. Underlying bone was debrided to bleeding surfaces and cartilage edges were stabilized.
After copious irrigation, fibrin glue was placed into the bony bed followed by DeNovo NT particulated juvenile cartilage. One package of DeNovo NT was used to cover the defect and implanted using a small-joint arthroscopy cannula followed by additional fibrin glue on top. After the cartilage implant was dry (5 minutes), the ankle joint was taken through a range of motion and the arthotomy was closed in layers. An incision was then made over the first metatarsal. A long oblique dorsiflexion closing wedge osteotomy was created and secured with a bicortical 4-mm partially threaded DARCO screw (Wright Medical Technology Inc.; Memphis, Tenn.) using fluoroscopy (Figure 6). We believed that our patient’s cavovarus foot posture was a contributing factor in the development of her medial talar OCD, and that correcting her alignment was important in her overall management. The incision was closed and the patient was made non-weight bearing (NWB) in a splint for 2 weeks.
Sutures were removed at 2 weeks followed by placement in a NWB short leg cast for 2 weeks. At 4-week follow-up, the patient was advanced to a tall CAM boot NWB with the initiation of active and passive range of motion exercises to reduce scar formation for 2 weeks. She was progressed out of her tall CAM boot from weeks 6 to 10 into a regular shoe and is currently 12 weeks out from surgery, transitioning back to athletic activity without any pain or other symptoms.
References:
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For more information:
Andrew R. Hsu, MD, and Robert B. Anderson, MD, are from the OrthoCarolina Foot & Ankle Institute, Charlotte, North Carolina. They can be reached at 2001 Vail Ave., Suite 200B, Charlotte, NC 28207. Hsu’s email: andyhsu1@gmail.com. Anderson’s email: robert.anderson@orthocarolina.com.
Disclosures: Hsu has no relevant financial disclosures. Anderson receives royalties from Arthrex Inc., DJ Orthopaedics and Wright Medical Technology Inc.; is a paid consultant for Amniox, Wright Medical Technology Inc. and Arthrex Inc.; and receives research support from Wright Medical Technology Inc.