Osteochondritis Dissecans Tali A Review and Case Presentation Seregelyi T. Dr. Solyom A. Dr. Ivanescu A. Prof. Dr. Bataga T.

Osteochondritis Dissecans Tali “os-tee-o-kon-DRY-tis DIS-uh-kanz” Osteo = Bone, Chondros = Cartilage, Dissecare = to Dissect, reject It is an Aquired disease and The ankle being the 3rd Most Common Site for Osteochondral lesions. Males are more prone to the disease with a Male-Female Ratio of 2:1, with most patients between 15-30 Years Of Age. OCD is considered a rare disease with an incidence of 15-30 per 100.000 per year. And it has to be noted that young patience have a chance of recovery with Immobilization & Rest of up to 50% of cases.

What is Osteochondritis Dissecans ? “Dissecating Osteochondral Lesion Of The Talus” (Assenmacher et al) or “Transchondral Talar Dome Fracture” (Kocher et al) ? OD is a defect of an articular surface leading in later stages to the complete demarcation and dislocation of a piece of cartilage and subchondral bone. There are many different definitions and many synonyms used for this phenomenon. Most of them do not help to answer this question and are the reason for confusion and misuse. The name Franz König coined in 1886, is a misnomer by itself. Back then he thought that the loose cartilage fragments in the joints were a result of inflammatory processes. But even HE noticed that some cases had no evidence of inflammation. So why the “–itis”, right? And would “-osis” be correct? Well, osteochondrosis referres to the bone growth centers, which are not involved in this disease. Assenmacher et al and Kocher et al made some suggestions that I personally find more fitting and unambiguous: “Dissecating Osteochondral Lesion of the Talus” Or: “Transchondral Talar Dome Fracture” [click]

Repetitive Minor Trauma Vascularity Disturbances Etiology ? Repetitive Minor Trauma Vascularity Disturbances Osteochondral Lesion The etiology remains unknown. But most patients diagnosed with OLT have a history of trauma in the joint. It seems to be a multifactorial cause of repetitive microtrauma, which might lead to changes in the vascularity of the subchondral bone. Recently an additional genetic predisposition is discussed. [click]

External Antero-Lateral Talar Dome Lesion History of Trauma (sprain or strain) Wafer-shaped More Aggressive (/surgical) Treatment recommended There are 2 areas where the disease occurs on the Talar Bone: External & Internal [click] The external (also: antero-lateral) part, which more often has a history of trauma and should be treated more aggressively.

Internal Medial Talar Dome Associated with Chronic Overload (eg. cavus foot) Cup-shaped More Frequent Often Asymptomatic And the internal (also: medial) articular cartilage is usually associated with lesions due to chronic overload. It is more frequent than the external one and is asymptomatic in many cases. [click]

Signs & Symptoms -> Unspecific Gradual onset of Chr. Activity-Related Pain Intermittent Edema Decreased ROM Joint locking Instability Popping sounds Limping Signs & Symptoms are unspecific. Similar to a strain or sprain of the ankle. Typically patients complain of activity-related pain with a gradual onset that might have persisted for 1-2 years. It did not respond to medication or physical therapy. [click]

MRI (gold standard, classification) Diagnosis Anamnesis Xray CT (sections) Scintigraphy (for screening) MRI (gold standard, classification) +/- Arthroscopy (in discussion now) If the signs & symptoms suggest an Osteochondral lesion of the talus (OLT), we perform an Xray. [click] Very often the Xray remains inconclusive and the defect is not diagnosed. Some suggest Scintigraphy as a screening tool for patients with negative plain radiographs, but persistent complaints. If scintigraphy turns out positive, a MRI will be performed. Magnetic Resonance Imaging is the gold standard for diagnosis and classification.

Classification Berndt & Harty Ferkel Loomer CT There are a few classification and staging systems used today. But I would like to introduce to you the one that is used the most. It is the classification system designed by Berndt & Harty in 1959. [click]

Berndt & Harty stage 1 Stage 2 In stage 1 the articular surface is fringed. In stage 2 the talus is partially fractured. [click]

Berndt & Harty Stage 3 Stage 4 In stage 3 we can see a complete fracture. The bone is chipped, but remains in place. And in the last stage the cartilage and subchondral bone break-off and dislocate within the ankle joint. This fragments are also referred to as “Joint Mice”. [click]

Case Presentation 32 year-old male Chronic ankle pain for 2 years - Gradual onset - Progressive evolution - Activity-related - Edema & Limping on examination Dx by Xray & MRI (Berndt & Harty Stage III, medial) In the final part of my presentation, I would like to show you a case of the orthopedics department here in targu mures. A 32 year old male was admitted for persistent chronic ankle pain for the past 2 years. It got worse over time, hurt more with activity and was not alleviated by medication nor physical therapy. On physical examination we could only observe an edema and the limping gait of the patient. On this slide you can see, that the xray was already pointing towards an Osteochondral fracture. [click]

After Xray, also an MRI was performed which detected a stage 3 medial lesion in the supero-medial margin of the patient’s talus. [click]

Tx: Mosaicplasty ipsilateral mosaicplasty-type autologous osteochondral grafting We treated the patient with an Osteochondral graft from a non-weight-bearing portion of his own femoral condyle. [click]

A longitudinal incision was made directly over the medial malleolus A longitudinal incision was made directly over the medial malleolus. The incision was then carried down through the subcutaneous tissue using sharp and blunt dissection. The medial malleolus is predrilled with Arthrex cannulated Trim-It Drill Bit into the tibial plafond. A V-shaped osteotomy was performed. We pulled down the medial malleolus to expose the talus. [click]

The talar lesion is prepared with the appropriate size cannulated Headed Reamer. After matching the defected cartilage site to the donor site the Arthrex OATS 10mm donor harvester was used. We drove the harvester into the donor cartilage of the low-weight bearing articular surface of the femoral condyle. [click]

The tube and the raft were then withdrawn and press fit into the prepared defect. It was made sure that there would be no protrusion. [click]

Intra-operative fluoroscopic view showing the two 4 Intra-operative fluoroscopic view showing the two 4.5mm cannulated screw fixation of medial malleolus after graft implantation The medial malleolus is replaced back to its anatomical position. The osteotomy was secured with a screw for spongious bone and the wound was closed. Here we see a fluoroscopic check of the screw fixation. After the operation the ankle was immobilized, painkillers were prescribed and physical therapy with passive range of motion exercises advised. The patient came in this week for post-operative evaluation: … [click]

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