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TALAR OSTEOCHONDRAL LESIONS

Osteochondral lesions (OCL) can occur in any joint but are most common and most problematic on the talus (the bottom bone in the ankle joint).  An OCL involves both the bone (osteo) and the overlying cartilage (chondral).  This problem can occasionally be an acute osteochondral fracture which if caught early enough can be fixed.   Other cases involve softening of the cartilage or development of a loose cartilage flap often with swelling or cysts in the bone beneath.  This is different than arthritis, another cartilage problem, as an OCL only involves one side of the joint.  You can imagine this like a small "pot hole" in the talus.  Managing symptoms with rest, antiinflammatories, bracing and physiotherapy can help settle things down and sometimes no further intervention is needed especially for smaller more stable lesions.  If the problems persist however, injections or surgery may have a role. 

ARTHROSCOPIC MICROFRACTURE 

The gold standard treatment for OCL of the talus involves an ankle arthroscopy to clean out any scar tissue or inflammatory tissue in the ankle and to assess the cartilage.  The OCL is then identified and any loose cartilage is removed until only stable (secure) cartilage  remains.  The bone beneath is then punctured with several holes to stimulate healing.  A scar like "fibrocartilage" then fills over the defect over time which helps limit the swelling in the bone beneath and helps relieve pain with good to excellent results in 80% of people.  

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ARTHROSCOPIC BONE GRAFTING +/- CARTILAGE AUGMENTATION 

Some osteochondral lesions and too large in size either width or depth for simply micro fracture treatment.  For OCL in this category, Osteocartilage Autograft Surgery may be required, or an arthroscopic cartilage augmentation with or without bone grafting may be an option for you.  For wider lesions that aren't overly deep, Dr. Roberts may offer you cartilage augmentation with Micronised Cartilage Allograft (BioCartilage).  Studies have shown that this augmentation has outcomes similar or better than microfracture in certain types of OCL.  Long term data on how MCA performs is not yet available.  If the OCL has significant cysts under the cartilage defect, this area must be addressed.  Dr. Roberts also offers arthroscopic bone grafting procedure where bone is taken from elsewhere in your body (often just below you knee), and placed into the defect in your ankle.  This area is then usually sealed with MCA cartilage augmentation followed by a biologic glue sealant.  Dr. Roberts will  review the details of your OCL with you to determine the best treatment option for you.  

OSTEOCHONDRAL AUTOGRAFT TRANSPLANT (OATS) 

Some osteochondral lesions are too large in size either width or depth for arthroscopic treatment or have already failed arthroscopic treatment.  These patients may be a candidate for Osteochondral Autograft (OATS) .  An OATS procedure relies on bone healing which is quite reliable.  The challenge with cartilage surgery is that cartilage by definition, cannot heal or regrow.  In an OATS surgery, a plug of bone (with healthy cartilage already on it) is taken from an area in your knee (where you won't miss it!) and is placed in your ankle at the OCL.  This is often an open procedure, rather than arthroscopic, where at times, the ankle must be opened by making a cut in the tibia to be able to access the area (medial malleolar osteotomy).  This bone cut (osteotomy) is than fixed back into place with screws and/or a plate.  

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In an OATS procedure, a plug of bone and cartilage is taken from the outside border of you knee (shown here) for placement at your ankle OCL. 

OCL POST OP INSTRUCTIONS

FOLLOW UP:

  • First appointment: approximately 2 weeks from surgery, usually at the Burnaby Hospital Fracture Clinic.

  • Prior to your surgery, you should have received dates for your 6 week and 3 months follow up visits. 

  • You will typically arrange a follow up one year from surgery as well for final xrays. 

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EXPECTED RECOVERY TIMELINE:

  • Swelling and pain is normal and expected in the first two weeks.  Rest, elevation and pain medication are important to help manage this. 

  • If your pain is severe and you aren't managing with the instructions and pain medication provided, call or go to the Burnaby Emergency Department.

  • Ideally by 3 months following surgery, you are walking not necessarily far, or fast but able to get back to your normal day to day in a more normal shoe.

  • Swelling is normal and not a concern and can last for up to 6-12 months.  Some swelling doesn't always resolve fully.

  • If all is healing well, you can progress your walking and other physical activity as your symptoms allow. 

  • You will not know full recovery (pain, swelling, strength) until 9-12 months following surgery.  

 

DRESSING:

  • You will go home from surgery with a splint on your foot and ankle.  This can remain as is until your first 2 week appointment. After this appointment, once your wound has healed adequately, you will be placed in a post operative boot.

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WOUND:

  • Your wound(s) are closed with sutures or staples, some of which will need to be removed.  

  • Do not get the dressing or wound wet for the first 2 weeks.  To ensure this, a bag should be placed over the let to avoid anything getting wet.  

  • The dressing/splint should remain on until your first appointment.  Do not remove this.  It will be changed at the first 2 week appointment

  • Sutures are removed typically at the 2 week mark. Its not uncommon given the high risk of wound troubles with ankle replacement, to have them removed at 3 weeks.  

  • After your sutures are removed, you can shower 2-3 days later and allow clean water to run over the wounds.  Pat this dry and reapply a dressing if it is your preference. It is not required.  The steristrip tapes on your wound can get wet.  Just pat them dry. 

  • Steristrips should stay on for about 10-14 days usually.  If they fall off prior to this, they do not need to be reapplied.  If they are still on after 14 days, ensure you please remove them yourself. 

  • Do not immerse the wound in a bath, hot tub or pool until the scar is fully healed with no scabs.  This is often 4 weeks. 

  • No lotions or creams should be used until the wound is fully healed, often 4-6 weeks. 

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WEIGHTBEARING 

  • You may not put any weight on your foot until 6-10 weeks from surgery.

  • At 6-10 weeks from surgery (depending on how your bone healing is progressing), you can begin walking in the boot as able and then gradually, transition to a shoe as able.  Keep in mind some people still have too much swelling at this point to be able to get into the shoes they want just yet.

 

PHYSIOTHERAPY:

  • At the 2-3 week mark, if you feel able, you may begin physiotherapy.  Prior to this due to swelling, wounds and dressings, possibly therapy will be limited.  ​

  • Dr. Roberts will provide you a custom physiotherapy prescription to help guide your therapist in your recovery. 

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DRIVING:

  • You are not able to drive if you are still taking Opioid (Narcotic) pain medication

  • Left foot surgery: beginning at least 2 weeks post op, once you are able to comfortably remove the sandal/boot while driving.  Contact your insurance for further recommendations.

  • Right foot surgery:  You can drive once you are walking fully in a shoe.

  • Try practicing in a parking lot first to ensure your reaction/strength/motion is adequate 

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FLYING:

  • If possible, you should consider avoiding long haul flights for the first 4-6 weeks from surgery.

  • If you must fly before this there is an increased risk of blood clot.  Try to keep moving on the flight, stay hydrated, avoid alcohol, consider compression socks.  Discuss with Dr. Roberts if you require a blood thinner to keep your risk as low as possible. 

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WORK:

  • You should arrange to be off of work for the first 2 weeks after surgery to allow for rest and recovery.

  • If you are working from home or can get to work safely and work in a flexible seated job, you could return to work after the first week if you so choose, provided you are off opiod (narcotic) pain medication.  You will need to elevate the foot and allow for more breaks. More commonly, most patients take 6 weeks off work. 

  • Any work should be sedentary for the first 8-12 weeks.

  • Typically a return to more physical duties can begin gradually at the 12 week mark from surgery. 

  • You may discuss your return to work plan with Dr. Roberts if you still have questions.

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