Osteochondral Lesions of Talus

The natural history of osteochondral lesions of the talus appears to be fairly benign, especially as it relates to the risk of the development of arthritis.

• Treatment is thus most appropriately based on the patient's symptoms, a very relevant fact given that many osteochondral lesions are incidental findings.

There are a host of classifications for osteochondral lesions, although no 1 classification is used universally, as the classifications generally do not influence treatment nor do they predict prognosis.

Nonoperative treatment is limited in terms of options; often activity modification is a central aspect. A boot or cast may be considered, and even a period of non-weight bearing in certain settings may be warranted.

There are a variety of surgical treatment options; the size and location of the lesion will often steer the surgeon toward one treatment vs. another. Given the relatively mild morbidity associated with marrow stimulation, it is often used as the 1st-line treatment, while more invasive treatments are often reserved for the revision setting.

Osteochondral lesions of the talus (OLT) represent a continuum of disease that is likely not 1 single pathology but a grouping of similar pathologies.

The historical term for this grouping of pathologies, osteochondritis dissecans (OCD), emphasized a localized vascular deficiency within the talus as the principle pathology with the symptoms being secondary to loss of adequate chondral support &/or cyst formation within the talus. Traumatic chondral defects, on the other hand, are often related to shear.

Traditionally, lateral defects were more likely to be traumatic in nature, while medial and posteromedial defects were more likely a true OCD.

While treatment of these lesions has advanced considerably over the years, the underlying pathogenesis of the OCD (i.e., nontraumatic) lesions remains unclear.

Certainly, establishing the natural history of any pathology is critical to understanding if and when intervention is warranted.

There is surprisingly little evidence that speaks to the natural history of OLTs.

Some surgeons theorize that asymptomatic OLTs may lead to ankle osteoarthritis if left untreated. However, there is simply very little evidence to back up this statement. What little evidence that does exist suggests that the natural history of OLTs is relatively benign.

Given this fact, treatment for OLTs should be based chiefly on symptoms referable to the lesion. Further, it appears that the asymptomatic OLT can be summarily ignored.

There are no fewer than 4 classification schemes depending on various imaging modalities.