Osteochondritis Dissecans and Chondromalacia of the Talus in Male College Soccer Player

Stanley Octavius, Shawn D. Felton, Alyssa Romasco, Jason C. CraddockFlorida Gulf Coast University, Department of Rehabilitation Sciences, Fort Myers, FL USA

Abstract

Introduction

Case Report

Rehabilitation and Results

Conclusions and Recommendations

ReferencesBadekas, T., Takvorian, M., & Souras, N. (2013). Treatment principles for osteochondral lesions in foot and ankle. International Orthopaedics, 37(9), 1697–1706. http://doi.org/10.1007/s00264-013-2076-1Cha, S. D., Kim, H. S., Chung, S. T., Yoo, J. H., Park, J. H., Kim, J. H., & Hyung, J. W. (2012). Intra-articular Lesions in Chronic Lateral Ankle Instability: Comparison of Arthroscopy with Magnetic Resonance Imaging Findings. Clinics in Orthopedic Surgery, 4(4), 293–299. http://doi.org/10.4055/cios.2012.4.4.293Gianakos, A. L., Yasui, Y., Hannon, C. P., & Kennedy, J. G. (2017). Current management of talar osteochondral lesions. World Journal of Orthopedics, 8(1), 12–20. http://doi.org/10.5312/wjo.v8.i1.12Looze, C. A., Capo, J., Ryan, M. K., Begly, J. P., Chapman, C., Swanson, D., Strauss, E. J. (2017). Evaluation and Management of Osteochondral Lesions of the Talus. Cartilage, 8(1), 19–30. http://doi.org/10.1177/1947603516670708Osti, L., Del Buono, A., & Maffulli, N. (2016). Arthroscopic debridement of the ankle for mild to moderate osteoarthritis: a midterm follow-up study in former professional soccer players. Journal of Orthopaedic Surgery and Research, 11, 37. http://doi.org/10.1186/s13018-016-0368-zPrado, M. P., Kennedy, J. G., Raduan, F., & Nery, C. (2016). Diagnosis and treatment of osteochondral lesions of the ankle: current concepts. Revista Brasileira de Ortopedia, 51(5), 489–500. http://doi.org/10.1016/j.rboe.2016.08.007Rungprai, C., Tennant, J. N., Gentry, R. D., & Phisitkul, P. (2017). Management of Osteochondral Lesions of the Talar Dome. The Open Orthopaedics Journal, 11, 743–761. http://doi.org/10.2174/1874325001711010743Van Dijk, C. N., Reilingh, M. L., Zengerink, M., & van Bergen, C. J. A. (2010). Osteochondral defects in the ankle: why painful? Knee Surgery, Sports Traumatology, Arthroscopy, 18(5), 570–580. http://doi.org/10.1007/s00167-010-1064-xVan Eekeren, I. C. M., van Bergen, C. J. A., Sierevelt, I. N., Reilingh, M. L., & van Dijk, C. N. (2016). Return to sports afterarthroscopic debridement and bone marrow stimulation of osteochondral talar defects: a 5- to 24-year follow-up study. Knee Surgery, Sports Traumatology, Arthroscopy, 24, 1311–1315. http://doi.org/10.1007/s00167-016-3992-6Zengerink, M., Struijs, P. A. A., Tol, J. L., & van Dijk, C. N. (2010). Treatment of osteochondral lesions of the talus: a systematic review. Knee Surgery, Sports Traumatology, Arthroscopy, 18(2), 238–246. http://doi.org/10.1007/s00167-009-0942-6

There is currently a wide range of procedures to manage OCD and chondromalacia of the talus. Non-operative treatment is the primary recommendation for individual with this injury. However, the slow healing property of the articular cartilage in the ankle often impedes the healing process (Rungprai, 2017). Due to the prevalence of ankle injuries and the slow natural healing process, operative treatment still remains the most effective approach to manage osteochondral lesions. In Clinical and functional outcomes following arthroscopic management of anterior impingement, grade III-IV cartilage lesions, there was no consensus on the specific postoperative rehabilitation and time to return to activity (Gianakos et al., 2017). However, this procedure is safe, effective, and cost-efficient. Other interventions such as microfracture, drilling and bone marrow stimulation have obtained favorable rating as well.

Ankle injury, although more prevalent within the physically active population, is fairly common with the general population as well. Ankle injuries is fairly easy to treat primarily using a conservative approach by health care professionals such as athletic trainers, physical therapists and physicians. However, if an ankle injury is not properly treated early on, this can lead to more serious problems later on such as osteochondral dissicans. This injury has been reported on approximately 50% to 73% of acute ankle injuries (Looze et al., 2017). Although this condition affects a significant portion on individuals suffering from chronic ankle injuries, only a small portion of those individividuals benefit from conservation treatments. As a result, this call for more invasive treatments which sparks a lot of interest in the health care field. One the reason that makes this injury so difficult to treat is the slow healing process of the cartilage on the talocrural joint (Gianakos et al., 2017). This topic is very important in the healthcare field mainly due to the varying perspectives of the underlying cause of the pain that the affected individuals usually experienced. Many healthcare professionals believe that the pain with injury primarily comes from the lesion in the cartilage. However, others believe that the pain is most probably caused by repetitive high fluid pressure during walking, which results in stimulation of the highly innervated subchondral bone underneath the cartilage defect (Dijk et al., 2010). They come to this conclusion because during loading of walking, compressed cartilage forces its water into the micro fractured subchondral bone, leading to a localized high increased flow and pressure of fluid in the subchondral bone (Dijk et al., 2010).

In a study comparing arthroscopy with magnetic resonance imaging (MRI), abnormalities of the anterior talofibularligament were found in 100 percent of patients with intra-articular lesions. MRI is the most commonly used tool to diagnose intra-articular lesion. However, its sensitivity and inter-observer reliability are very low.

Phase 1: This phase last 6 weeks. The athlete had to use crutches to avoid putting too much stress in the area throughout the healing process. The main emphasis was on active range of motion exercises, stretching the gastrocnemius and soleus muscle group, and using modalities to control pain and inflammation.

Phase 2: During this phase, the emphasis was on strengthening and introducing the athlete to various low level functional exercises. We worked on range of regaining normal range of motion, strengthening lower extremity musculatures, and gait/functional training. Toward the end of this phase, we introduced the athlete to various endurance exercises. To facilitate the transition to weight bearing exercises, we incorporated various aquatic exercises, in addition to using an anti-gravity treadmill. This approach significantly helps to maintain the athlete cardiovascular fitness while progressively increase the amount of weight bearing force on the talus. We also incorporated many proprioceptive exercises while working on the athlete’s ball control technique. This phase last about 3 weeks.

Phase 3: The goal for this phase was to regain normal strength, pain-free range of motion, and cardiovascular fitness. A major aspect of this phase was the addition of agility and plyometric exercises. Once the athlete started to regain confidence jogging on land without pain, we then progressed him to agility and speed exercises. The athlete was able to participate in team practice with moderate intensity. These practice sessions mainly involved passing, jogging, ball control, and other technical skills. Once the athlete regained full strength and lateral hop was > 90% of the involved lower extremity, the athlete was then allowed to participate in full team practice as tolerated.

Background: This Level 4 Case report presents a 22 year-old (180.34 cm and 87.5 kg) collegiate male soccer player. The athlete has a history of lateral ankle pain which started two years prior. The mechanism of the injury involved a twisting motion of the talocrural joint with persistent exacerbation of symptoms. Athlete was referred to the team physician for further evaluations. Differential diagnosis: Chronic tearing and scarring of the anterior fibular ligament, peroneus longus and brevis tendinopathy, distal posterior tendon hypertrophic tendinopathy, interstitial fraying and mild relative inflammation involving the distal tendon sheath. Treatments: Treatments involved right ankle arthroscopy, right ankle osteochondral defect drilling, right autologous platelet concentrate grafting. The procedure also required an anteromedial arthrotomy for the fibrin scaffolding remplissage including the cartilage fragments, infiltrating over the scaffolding platelet rich plasma in liquid form. Uniqueness (Level 4 clinical case study): It is reported that osteochondritis dessicans can be present in about 50 to 73 percent of athletes with a history of ankle injuries. Treatment of osteochondral dissecans of the talus can be extremely difficulty and time extensive because of the limited healing potential of the talar articular surface and the enormous forces transmitted through the talocrural joint. It is reported that only 50 percent of those injuries can be identified using radiographs. Non-operative treatment is often times the best recommended protocol for ankle injuries, with OCD lesions however, the results are not as favorable mainly due to the poor healing properties of the articular surface of the ankle. As a result, operative treatment such as micro-fracture, drilling, and bone marrow stimulation for smaller lesions are usually required. Currently, the most effective treatment for symptomatic osteochondral lesions of the talus involved osteochondral transplantation, bone marrow stimulation, and autologous chondrocyte implantation with a success rate of 87, 85, and 76 % respectively. Conclusions: This case delineated the diagnosis and treatment of an athlete suffering from osteochondritis dissecans and chondromalacia of the talus. This case study further investigated the efficacy of multiple operative treatments, which are very common for patients with similar conditions.

Patient: Athlete was a 22 year-old (180.34 cm and 87.5 kg) collegiate male soccer player. Athlete has a history of lateral ankle pain which started two years ago.

Mechanism of injury: The mechanism of injury involved a twisting motion of the talocrural joint with persistent exacerbation of symptoms. The athlete has also sustained multiple lateral ankle injuries, but returned to play without being fully recovered. Over time, the injury progressively worsen and affected the athlete’s gait. This would ultimately increase the force load and its dissipation at the talocrural joint.

Clinical Examination: One of the major difficulties clinicians are facing in treating osteochondral lesions, an abnormality of the talararticular cartilage and adjacent bone, is finding great treatment strategy. Currently, there are many interventions that are very promising. However, it is important to note that in more than one third of patients with the condition, conservative treatment is not successful. As a result, clinicians rely on a variety of surgical options. Some of the most common ones are bone marrow stimulation (BMS), osteochondral autograph transfer system (OATS), excision and curettage. Most of the studies conducted in the past mainly focus in those three categories. These three major areas of interest also contained the most significant number of participants. However, when compared to other treatment strategies, these particular interventions do not necessary yield the most successful outcomes. In order to further evaluate the best treatment of osteochondral lesion (OCL) of the talus, Djik and colleague conducted a systematic review to compare different treatment strategies in terms of their effectiveness in treating OCL. The treatment strategies that were analyzed in the review were the following: Non-operative with rest, non-operative with cast, excision, excision and curettage, excision/curettage and BMS, autogenous bone graft, TMD, OATS, and lastly ACI. Overall, the results reveal that OATS, BMS and ACI scored success rates of 87, 85 and 76%, respectively. Retrograde drilling and fixation scored 88 and 89%, respectively. Although retrograde drilling and fixation do have a higher success rate, it is important to note that there has not being many studies conducted in those two categories. Because of these major limitations, OATS, BMS and ACI remains the most effective treatment strategies for OCL of the talus.

Radiographic Findings: : Long and short axis fat and water-weighted images were performed. The findings reveal osseous edema which involves the talus for which acute contusion or acute on chronic contusion is favored. Chronic osteochondral defect involves the central talar dome measuring approximately 1.75x 1.25 cm. Regions of chronic contusion also involve the distal fibula and medial malleolus.

Anatomy:Talocrural joint: Is a uniaxial, modified synovial joint formed by the articulation of the trochlea (dome) and sides of the talus with the rectangular cavity formed by the distal end of the tibia and both malleoli. The talocrural joint is often referred as the mortise. The structure of the mortise must be sufficiently stable to accept the forces that pass between the leg and foot. Although variable, approximately 90% to 95% of the compressive forces pass through the talus and tibia; the remaining 5% to 10% pass through the lateral region of the talus and the fibula. The talocrural joint is lined with about 3 mm of articular cartilage, which can be compressed to by 30% to 40% in response to physiological loads. This load absorption mechanism protects the subchondral bone from damaging stress. The talocrural joint possesses one degree of freedom. Motion occurs around an axis of rotation that passes through the body of the talus and through the tips of both malleoli.

Purpose

An osteochondral defect (OD) of the talus is a lesion involving the talar articular cartilage and its subchondral bone. It is mostly caused by a single or multiple traumatic events, but idiopathic OD of the ankle might occur (Dijk et al., 2010). The defect initially may consist only of cartilage damage caused by shearing stresses, with the subchondral bone intact, but a bone contusion following high-impact force also can cause a defect. This Case report analyzedtheanatomical structure of the talocrural joint to understand how it affects function when an osteochondral lesion is present. Overall, the The aim of this paper is to provide a comprehensive summary of the rehabilitation and management of a case involving osteochondral lesions of the talus.