Foot Ankle Clin N Am

8 (2003) 243 – 257

Arthroscopic debridement and drilling of

osteochondral lesions of the talus
Christopher J. Barnes, MDa, Richard D. Ferkel, MDa,b,*
a
Southern California Orthopedic Institute, 6815 Noble Avenue, Van Nuys, CA 91405, USA
b
University of California at Los Angeles, Los Angeles, California, USA

In 1856, Alexander Monro [1] first described osteochondral loose bodies in the
ankle joint. In 1922, Kappis [2] was the first to apply the term ‘‘osteochondritis
dissecans’’ to lesions in the ankle. This term remained in use until 1959, when
Berndt and Harty [3] coined the term ‘‘transchondral fracture of the talus’’ to de-
scribe the lesion. Several other terms have been used to describe these lesions,
including ‘‘osteochondral fracture,’’ ‘‘talar dome fracture,’’ and ‘‘flake fracture.’’
The most common designation, ‘‘osteochondritis dissecans,’’ implies an inflam-
matory lesion, which has little relevance to the actual pathophysiology of this
condition. Thus, we prefer the term ‘‘osteochondral lesion of the talus’’ (OLT) to
describe this problem.
OLTs are rare lesions, although their incidence is probably underestimated
because they may not be clinically significant or may be misdiagnosed as other
ankle pathology. Identification of these lesions by radiograph may be difficult, as
well. OLT reportedly represents 4% of all cases of osteochondritis dissecans [4].
Most series on OLTs reported that these lesions occur bilaterally in approximately
10% of cases; the average age of those affected is between 20 and 30 years. There
seems to be a slight male predominance in most series.

Cause
The precise cause of OLT has never been conclusively proved and remains
controversial. Evidence that supports a nontraumatic causation, such as id-
iopathic osteonecrosis, is supported by the fact that lower extremity trauma is

* Corresponding author. Southern California Orthopedic Institute, 6815 Noble Avenue, Van Nuys,
CA 91405.
E-mail address: [email protected] (R.D. Ferkel).

1083-7515/03/$ – see front matter D 2003 Elsevier Inc. All rights reserved.
doi:10.1016/S1083-7515(03)00016-0
244 C.J. Barnes, R.D. Ferkel / Foot Ankle Clin N Am 8 (2003) 243–257

not documented in all cases, despite the fact that such a history is common
among the general population; also, these lesions affect both ankles in a small
percentage of patients. In addition, OLTs have been associated in the litera-
ture with alcohol and steroid use, emboli, endocrine abnormalities, and heredi-
tary situations.
Despite its limitations, the trauma theory remains the most popular and plausible
explanation for the formation of OLTs. This theory suggests that a distinct episode
of macrotrauma or repetitive microtrauma in a person with a predisposition to talar
dome ischemia leads to an osteonecrotic process. Subchondral fracture and
collapse may then occur, followed by alteration of joint biomechanics with in-
creased joint pressures. Synovial fluid may be forced into the subchondral fracture
site, which prevents healing of the lesion and increases the likelihood of avascular
necrosis and detachment of the fragment.
Support for the traumatic theory of OLT formation was provided by Flick and
Gould [5]. These investigators reviewed the literature and found that, in reports
on more than 500 patients who had OLTs, 98% of lateral dome lesions and 70%
of medial dome lesions were associated with a history of trauma. Several smaller
series subsequently confirmed that most, but not all, OLTs are associated with a
history of trauma; such a history is more commonly elicited in patients with
lateral lesions.

Location
In general, medial osteochondral lesions are located in the middle or posterior
third of the talar dome, whereas lateral lesions are found primarily in the middle or
anterior portion of the talus (Fig. 1). Different patterns have been reported and, on
occasion, these lesions were found in multiple sites. In most series, medial lesions
were usually deeper and cup-shaped and were usually nondisplaced. Lateral lesions
were typically shell- and wafer-shaped and were frequently displaced by the
levering effect of the distal tibia.
The different characteristics of medial and lateral OLTs can be explained, in
part, by the proposed mechanism of injury for these lesions. In a classic
experiment, Berndt and Harty [3] attempted to produce these lesions in cadavers.
Lateral talar dome lesions were produced when an inversion force was applied to
the dorsiflexed foot with the tibia internally rotated. Medial lesions were
produced by a strong inversion force to the plantarflexed foot with the tibia in
external rotation. These investigators speculated that torsional impaction was the
principal force that caused these lesions. With lateral lesions, the anterolateral
talar dome is impacted and compressed against the medial articular surface of the
fibula when the ankle is dorsiflexed and an inversion force is applied. Conversely,
with medial lesions, the plantarflexed ankle is subjected to an inversion force and
the tibia is in external rotation; the posteromedial edge of the talar dome impacts
against the posteromedial tip of the tibia. Although subsequent studies sought to
confirm or refute these findings, it is clear that no single mechanism can explain
 C.J. Barnes, R.D. Ferkel / Foot Ankle Clin N Am 8 (2003) 243–257 245

Fig. 1. Location of osteochondral lesions of the talus. Most lesions are posteromedial or anterolateral.
(From Stone JW, Guhl JF, Ferkel RD. Articular surface defects, loose bodies, and osteophytes. In:
Ferkel RD, Whipple TL, editors. Arthroscopic surgery: the foot and ankle. Philadelphia: Lippincott-
Raven; 1996, p. 146; with permission.)

each OLT, particularly on the medial side where many lesions occur without
preceding trauma.

Diagnosis
The diagnosis of OLT requires a high index of suspicion because clinical
symptoms may be mild and routine radiographs may not reveal these lesions.
Patients may report a history of trauma, such as a fall from a height; however, in
some patients no antecedent trauma is reported. Most often, patients will complain
of persistent ankle pain, particularly following an inversion injury to the lateral
ligamentous complex. Thus, OLTs should be in the differential diagnosis of any
patient with chronic pain after an ankle sprain. Frequently-reported symptoms
include pain in the ankle, which is often localized to the side of the lesion and
exacerbated by weight bearing, along with intermittent swelling. Complaints of
catching or grinding are also common, although true joint locking is uncommon.
Physical examination findings may be nonspecific and can include localized
tenderness medially or laterally, painful or limited ankle motion, swelling, or
246 C.J. Barnes, R.D. Ferkel / Foot Ankle Clin N Am 8 (2003) 243–257

evidence of instability. Many patients who have medial lesions complain only of
lateral joint pain. Although there is no obvious anatomical explanation for this, the
pain may be referred or secondary to unconscious unloading of the medial side of
the ankle.
After a careful clinical examination, three radiograph views of the ankle should
be obtained (anterior – posterior, lateral, and mortise). When a posteromedial le-
sion is suspected, a mortise view in plantar flexion may better show the lesion.
Weight-bearing radiographs are helpful to assess for malalignment. In the absence
of radiographic findings, a bone scan is a useful, inexpensive way to screen for
OLT. Magnetic resonance imaging can also identify an occult OLT as an intra-
osseous abnormality of the talus. The use of this imaging modality has the added
benefit of revealing other soft tissue abnormalities that may be mistaken for, or
coexist with, OLT.
When an osteochondral lesion is present, computed tomography is the
imaging modality of choice for further defining the location and size of the
fragment. CT scanning can be done with or without contrast, but should always
be done in the axial (transverse) and coronal planes. Reconstruction sequences
should also be done in the sagittal plane. The senior author (RDF) prefers to
obtain bilateral hindfoot CT scans to determine if bilateral lesions are present.
Contrast may be added to assist in evaluating the articular surface and in
determining healing or lesion stability.

Staging
In 1959, Berndt and Harty [3] first attempted to classify OLTs using plain
radiography. A subsequent study by Pritsch et al [6] found that an increase in the
radiographic stage of the lesion did not accurately predict arthroscopic findings of
fragmentation or loosening. These investigators stressed the use of arthroscopy to
assess the status of the articular cartilage and to determine treatment.
More recently, Ferkel and Sgaglione [7] developed a CT classification to
provide more accurate information about the OLT (Fig. 2, Box 1). This four-stage
system is based on CT scanning in two planes and expands upon the work by
Zinman and Reis [8] who found that CT scans were superior to radiographs for
diagnosis and follow-up of OLT.
The use of MRI to stage OLT has been advocated. Anderson and colleagues [9]
compared MRI with CT in 24 patients who had OLT and developed an MRI
classification system (Box 2). These investigators found that, in most cases, MRI
and CT were comparable (Fig. 3A, B). CT scans failed to reveal some stage I
lesions, however. More recently, De Smet et al [10] examined the correlation be-
tween MRI and arthroscopic findings. These investigators found that MRI
accurately predicted the presence of the OLT and the fragment stability in 13 out
of 14 patients. One patient had a false-positive diagnosis of a chondral fragment.
At our institution, Cheng et al [11] studied 80 patients who were treated for OLT
between 1985 and 1994. Preoperative imaging studies and intraoperative video-
 C.J. Barnes, R.D. Ferkel / Foot Ankle Clin N Am 8 (2003) 243–257 247

Fig. 2. CT scan classification of osteochondral lesions of the talus. (From Stone JW, Guhl JF, Ferkel RD.
Articular surface defects, loose bodies, and osteophytes. In: Ferkel RD, Whipple TL, editors. Ar-
throscopic surgery: the foot and ankle. Philadelphia: Lippincott-Raven; 1996. p. 151; with permission.)

tapes were reviewed and correlated, and the aforementioned CT and MRI staging
systems were correlated with a new arthroscopic staging system (Box 3). The
results indicated that CT is the study of choice if there is a known diagnosis of OLT;
however, when clinical and radiographic findings are nondiagnostic, MRI may be
more valuable because of its ability to show soft tissue and bone lesions.

Treatment
The appropriate treatment for OLT remains controversial, because, in part, of
the uncertainty about the cause and nature of the lesion. There is no long-term

Box 1. CT Classification of OLTs

Stage I Cystic lesion within dome of talus, intact roof on all views
Stage IIA Cystic lesion with communication to talar dome surface
Stage IIB Open articular surface lesion with overlying nondis-
placed fragment
Stage III Undisplaced lesion with lucency
Stage IV Displaced fragment

From Ferkel RD, Sgaglione NA. Arthroscopic treatment of osteo-

chondral lesions of the talus: long term results. Orthop Trans 1993 –
1994;17:1011; with permission.
248 C.J. Barnes, R.D. Ferkel / Foot Ankle Clin N Am 8 (2003) 243–257

Box 2. MRI Classification of OLTs

Stage I Subchondral trabecular compression
Plain radiograph normal, positive bone scan
Marrow edema on MRI
Stage IIA Formation of subchondral cyst
Stage II Incomplete separation of fragment
Stage III Unattached, undisplaced fragment with presence of
synovial fluid around fragment
Stage IV Displaced fragment

From Anderson IF, Crichton KJ, Grattan-Smith T, et al. Osteochon-

dral fractures of the dome of the talus. J Bone Joint Surg 1989;
71A:1143; with permission.

study of the natural history of untreated OLT because patients usually are not
seen unless they are symptomatic. In addition, there are conflicting reports in the
literature regarding the success of conservative treatment. Some of this contro-
versy stems from the lack of detail regarding these lesions; ankles that are treated
conservatively are often not adequately imaged and arthroscopy is not performed.

Fig. 3. (A) MRI scan of the ankle reveals a stage III lesion of the posteromedial talus. (B) CT scan of
the same ankle also demonstrates a stage III lesion.
 C.J. Barnes, R.D. Ferkel / Foot Ankle Clin N Am 8 (2003) 243–257 249

Box 3. Surgical grade of OLT based on articular cartilage

Grade A Smooth, intact but soft or ballottable
Grade B Rough surface
Grade C Fibrillations/fissures
Grade D Flap present or bone exposed
Grade E Loose, undisplaced fragment

From Cheng MS, Ferkel RD, Applegate GR. Osteochondral lesions of

the talus: a radiologic and surgical comparison. Presented at the
Annual Meeting of the American Academy of Orthopaedic Sur-
geons. New Orleans, February 16 – 21 1995; with permission.

In a recent systematic review by Tol et al [12], the average success rate of

nonoperative treatment was 45% compared with 85% for excision, curettage,
and drilling. The data in the literature, however, was not specific about the stage
of the lesions at the time of treatment. The investigators stated that, because of
the great diversity in the articles and the variability in treatment results, no de-
finitive conclusions can be drawn; further prospective, randomized, controlled
trials are necessary.
Despite the limitations of the literature, there is some consensus regarding
treatment of OLT. Berndt and Harty [3], as well as Canale and Belding [13]
advocated that stage I and II lesions should be treated conservatively, regardless
of location. These investigators concurred that stage III medial lesions should be
treated nonoperatively, whereas stage III lateral lesions and stage IV lesions are
better approached surgically. Flick and Gould [5] argued that surgical treatment
yielded superior results to conservative therapy, even for some stage II lesions.
They agreed with Alexander and Lichtman [14], however, that the delay in op-
erative treatment that results from a trial of nonoperative therapy does not affect
the results of later surgical treatment.
A recent study by Schimmer et al [15] examined the results of diagnostic and
operative arthroscopy in the treatment of 36 OLTs. These investigators found that
despite the use of preoperative MRI, arthroscopy helps to assess the extent and
stability of the OLT and to define the treatment strategy, including continued
conservative care in the case of stage I lesions. Their results supported a con-
servative approach to stage II and III medial lesions, as well.
At our institution, the senior author (RDF) advocates conservative treatment
for acute and chronic CT scan stage I and II lesions. This typically includes 6 to
12 weeks of protected weight bearing in a cast. If the patient remains symp-
tomatic after this treatment, arthroscopic evaluation is suggested. Arthroscopy is
also advocated for all symptomatic CT scan stage III and IV lesions, except in
children with open physes, in whom initial conservative treatment with casting is
recommended for stage III lesions.
250 C.J. Barnes, R.D. Ferkel / Foot Ankle Clin N Am 8 (2003) 243–257

Traditionally, surgical treatment of OLTs has consisted of excision of loose

bodies, joint debridement, and abrasion or drilling at the site of the lesion.
Initially, these procedures were done by way of open methods, but because of the
problems that are associated with an open approach, particularly malleolar
osteotomy, most cases are now performed arthroscopically. In the case of acute
traumatic lesions that are large and have a substantial amount of subchondral
bone attached to the articular cartilage, internal fixation may be the preferred
treatment option. Likewise, there are cases in which bone grafting or transplanta-
tion of autologous chondrocytes may be indicated. There are no large patient
series that have evaluated these techniques, however, so definite recommenda-

Fig. 4. Overhead view of the operative setup for ankle arthroscopy. The typical arrangement of the
anesthesiologist, surgeon, assistant, scrub nurse, and equipment is shown. (From Ferkel RD. Operating
room environment and the surgical team. In: Ferkel RD, Whipple TL, editor. Arthroscopic surgery: the
foot and ankle. Philadelphia: Lippincott-Raven; 1996. p. 82; with permission.)
 C.J. Barnes, R.D. Ferkel / Foot Ankle Clin N Am 8 (2003) 243–257 251

tions cannot be made at this time. Thus, for the purpose of this article, we focus
on arthroscopic debridement and drilling of these lesions.

Arthroscopic technique
When treating OLT arthroscopically, proper operating room setup is essential
(Fig. 4). Small-joint instrumentation and noninvasive distraction permits
adequate visualization of the ankle joint (Fig. 5A, B). Several commercially
available noninvasive ankle distractors, which consist of a strap attached to a
traction device and sterile bar, are available. Because larger arthroscopes are dif-
ficult to maneuver in the ankle joint, 2.7-mm 30° and 70° arthroscopes are useful.
A 1.9-mm 30° arthroscope is necessary in tight ankle joints. Aiming devices,
such as a Micro Vector (Smith and Nephew Endoscopy, Andover, MA) guide,
and bone grafting sets are also useful.
Arthroscopic evaluation of the ankle should begin with a 21-point examination
of the joint. Care should be taken to examine the talus and the tibial articular
surfaces because some cases of OLT have associated lesions on the tibia. The

Fig. 5. (A) An assortment of small-joint instrumentation is useful when performing ankle arthroscopy.
(B) Setup for noninvasive ankle distraction. The strap is positioned to avoid injury to the anterior
neurovascular structures and to allow access to the ankle and subtalar portals, as needed.
252 C.J. Barnes, R.D. Ferkel / Foot Ankle Clin N Am 8 (2003) 243–257

arthroscope should be placed in the anteromedial, anterolateral, and posterolateral

portals to ensure complete visualization.
Different methods have been developed for penetrating subchondral bone to
stimulate cartilage repair, including drilling through the subchondral bone,
abrading the articular surface, and creating small-diameter defects with a sharp
instrument (microfracture). At this time, the senior author (RDF) prefers a
combination of microfracture and drilling to stimulate cartilage repair for OLT.
When treating an OLT, the lesion should be palpated with a small-joint probe
and an assessment should be made about whether the chondral fragment has
enough bone to allow healing if it is reattached. If the lesion is primarily chondral
in nature, excision is recommended with subsequent curettage and transmalleolar
or transtalar drilling of the base. When drilling OLTs, multiple drill holes at 3-mm
to 5-mm intervals are placed to a depth of 10 mm to potentiate vascular access
and healing with fibrocartilage (Fig. 6).
When approaching an anterolateral lesion, it is best to have the arthroscope in
the anteromedial portal, inflow in the posterolateral portal, and instrumentation in
the anterolateral portal. If drilling directly through the anterolateral portal is
difficult, a Micro Vector guide can be inserted through the anterolateral portal and
drilling can be done from the medial portion of the talus across to the lateral talar
dome lesion. Alternatively, the arthroscope can be inserted anterolaterally and the
Micro Vector can be inserted anteromedially to approach these lesions.
Posteromedial OLTs are the most commonly seen chronic lesions. When ap-
proaching these lesions, the anteromedial portal should be placed in a more
central location than usual to avoid abutment of the arthroscope and instrumenta-
tion against the medial malleolus. The groove of Harty allows for access and
visualization of most lesions in the midportion of the talus with the arthroscope in
the anteromedial portal. If the lesion is anterior, it can be approached with the
arthroscope in the anterolateral portal to facilitate drilling (Fig. 7). When the

Fig. 6. After drilling and microfracture of an osteochondral lesion of the talus, a good bleeding bed is
seen. (From Stone JW, Guhl JF, Ferkel RD. Articular surface defects, loose bodies, and osteophytes. In:
Ferkel RD, Whipple TL, editors. Arthroscopic surgery: the foot and ankle. Philadelphia: Lippincott-
Raven; 1996. p. 167; with permission.)
 C.J. Barnes, R.D. Ferkel / Foot Ankle Clin N Am 8 (2003) 243–257 253

Fig. 7. Transmalleolar drilling of an osteochondral lesion in the anterior aspect of the talus. The
arthroscope is placed in the anterolateral portal to facilitate drilling.

lesion is more posterior, however, it is better approached with the arthroscope in

the posterolateral portal, instrumentation in the anteromedial portal, and inflow
through the anterolateral portal (Fig. 8).
Drilling of the medial talus can be done in four ways. First, a Micro Vector
guide can be used to perform transmalleolar drilling. A small incision over the
medial malleolus is made and the drill guide is inserted. A 0.045 or 0.062 K-wire
is used to create drill holes in the area that provides the best direct angle into the
lesion. Alternatively, an offset guide can be used to place multiple holes. A third
method is to flex and extend the ankle joint with the pin tip in one position to

Fig. 8. Transmalleolar drilling with the arthroscope posterolaterally. The inflow canula is typically
placed in the anterolateral portal.
254 C.J. Barnes, R.D. Ferkel / Foot Ankle Clin N Am 8 (2003) 243–257

place multiple drill holes into the lesion (Fig. 9). When using this technique, it is
important that the pin tip penetrates the medial malleolus only slightly when
moving the ankle joint to prevent scuffing of the surrounding articular cartilage.
In addition, the ankle should not be moved while the pin is inserted into the talus
because hardware damage can occur. A fourth approach to medial talar lesions
involves retrograde transtalar drilling with the aide of a drill guide (Fig. 10A).
During drilling, cool irrigation of the pin is used to prevent thermal necrosis.
Using a cannulated trephine, a bone plug can be advanced into the osteochondral
lesion (Fig. 10B, C).
Following arthroscopic debridement and drilling of an OLT, the patient is
placed in a splint for 1 week. At that time, a compression stocking and removable
posterior splint are applied and range of motion exercises are initiated. Formal
physiotherapy is started after wound healing is complete. There continues to be
debate regarding the amount of time the patient should remain nonweight bearing
following debridement and drilling. The senior author (RDF) prefers to keep
patients nonweight bearing for 4 weeks when the lesion is less than 1.5 cm in
diameter and for 8 weeks when the lesion is larger. In general, running is avoided
for at least 3 months whereas cutting and jumping exercises are not permitted for
4 to 6 months.

Fig. 9. (A) Flexion and extension of the ankle allows multiple drill holes to be made in the talus with
limited holes through the tibia. (B) Initial drill hole made in the talus. (C) Plantarflexion allows the
same pin to drill a hole more posterolaterally in the talus. (D) Dorsiflexion allows the same pin to drill
a hole more anteriolaterally in the talus. (From Stone JW, Guhl JF, Ferkel RD. Articular surface
defects, loose bodies, and osteophytes. In: Ferkel RD, Whipple TL, editors. Arthroscopic surgery: the
foot and ankle. Philadelphia: Lippincott-Raven; 1996. p. 165; with permission.)
 C.J. Barnes, R.D. Ferkel / Foot Ankle Clin N Am 8 (2003) 243–257 255

Fig. 10. (A) Transtalar drilling of an osteochondral lesion of the medial dome of the talus begins with
the insertion of a K-wire through the sinus tarsi with the aid of a drill guide. (B) A cannulated trephine
is used to core bone out of the lateral aspect of the talus into the area of the lesion. (C) Using a plunger,
the bone plug is advanced into the area of the lesion. (From Stone JW, Guhl JF, Ferkel RD. Articular
surface defects, loose bodies, and osteophytes. In: Ferkel RD, Whipple TL, editors. Arthroscopic
surgery: the foot and ankle. Philadelphia: Lippincott-Raven; 1996. p. 166; with permission.)
256 C.J. Barnes, R.D. Ferkel / Foot Ankle Clin N Am 8 (2003) 243–257

Table 1
Comparison of arthroscopic treatment results
F/U Average Good or excellent
Study Cases (months) age (years) Trauma (%) results (%)
Van Buecken et al [16] 15 26 23 93 87
Ferkel et al [17] 50 71 32 74 72
Kumai et al [18] 18 55 28 59 72
Ogilvie-Harris & Sarrosa [19] 33 88 33 85 100
Schuman et al [20]a 22 51 33 77 86
a
Results are for patients undergoing primary surgery only

Treatment results
The results of arthroscopic treatment of OLT by several investigators are
summarized in Table 1. The senior author’s clinical experience at our institution
with 50 patients has been reviewed. Sixty-six percent of the lesions involved the
medial dome of the talus, 27% involved the lateral dome, and 7% were central
lesions. Acute lateral lesions were either excised and drilled or underwent
internal fixation. Medial lesions were either drilled or excised and then drilled.
Overall results were good to excellent in 72% of cases, as graded by three dif-
ferent methods. Outcome in this group was not significantly affected by a delay
in diagnosis.

Summary
Diagnosis of OLTs requires a high index of suspicion because these lesions are
rare and the symptoms can be falsely attributed to acute or chronic ankle sprains.
When no abnormality is present on plain radiographs, a bone scan or MRI can
reliably identify the presence of an OLT. CT scanning can provide even better
detail of the location and size of the fragment and help stage these lesions and
guide treatment. Arthroscopic staging is believed to be the best method to de-
termine treatment.
In a patient without an obvious loose body, initial nonoperative treatment
is warranted. When nonoperative therapy fails or when a high stage lesion is
present, operative options should be explored. Arthroscopic techniques provide
results that are equal to or better than management by arthrotomy and have the
advantages of lower morbidity and quicker overall rehabilitation time. In most
cases, arthroscopic treatment involves loose body removal and debridement and
drilling of the underlying bone or drilling alone for intact lesions. Although it
is unknown whether such treatment can reduce the incidence of late arthrosis
in a patient who has an OLT, a recent study suggested that healing occurs and
the MRI appearance of the talar dome normalizes in many patients postoper-
atively [21].
 C.J. Barnes, R.D. Ferkel / Foot Ankle Clin N Am 8 (2003) 243–257 257

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