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Osteochondral Lesions of the Talus Aaron K. Schachter, MD, Andrew L. Chen, MD, MS, Ponnavolu D. Reddy, MD, and Nirmal C. Tejwani, MD Abstract Early accurate diagnosis of osteochondral lesions of the talus is important because optimal ankle joint function requires talar integrity. 1 Boyd and Knight 2 showed that the tibiotalar ar- ticulation is subjected to more load per unit area than any other joint in the body. Consequently, injury to a portion of the talus may lead to degen- erative changes of the articular surfaces and subsequent loss of range of motion (ROM). 1 The talus has a limited reparative capacity because a large portion of it is covered by articular cartilage, which limits the vascular supply. 3-6 Osteochondral fractures refer to lesions affecting the articular cartilage of the talar dome and the underlying subchondral bone. 7 Originally refer- red to as “osteochondritis dissecans,” these lesions were thought to be is- chemic. 8 Subsequent studies have shown that, in most cases, these injuries are sequelae of previous trauma. 7,9-13 Moreover, the results of these studies showed that the location of the lesion could be pre- dicted, based on the mechanism of injury. Etiology and Epidemiology Fractures of the talar body account for approximately 1% of all fractures in the human body. 14 A large proportion of these are transchondral or compression fractures of the talar dome, which are often unrecognized because frequently they are associated with other, more obvious injuries to the foot and ankle. Alexander and Lichtman 11 observed that 28% of these injuries were associated with other fractures. These coexisting fractures, approximately half of which involve the ankle malleoli, may overshadow a significant osteochondral defect of the talus. 1 Similarly, Van Buecken et al 15 reported that these injuries (ie, transchondral talar fractures) were associated with 6.5% of ankle sprains. Berndt and Harty 7 found that 57% of talar dome lesions were located me- dially and 43% laterally. Others have reported a fairly equivalent distribu- tion 9 (Fig. 1). In a series of 70 patients (71 fractures), all lateral talar dome injuries were associated with a traumatic event, whereas only 64% of medial talar dome injuries were attributed to trauma. 10 Others have corroborated these results, reporting that all lateral lesions were associated with trauma (Fig. 1, B and C) but only 82% of medial lesions were 11 (Fig. 1, A). Al- though trauma usually is the cause of injury, it may not be a single event but may consist of a series of repeat- ed, less intense injuries. 12 In a com- prehensive review of published studies of 500 patients, Flick and Gould 13 reported that a history of trauma was present in 98% of lateral dome lesions Dr. Schachter is Resident, Department of Ortho- paedic Surgery, NYU–Hospital for Joint Dis- eases, New York, NY. Dr. Chen is in private practice, Littleton, NH. Dr. Reddy is Fellow, Department of Orthopaedic Surgery, NYU–Hos- pital for Joint Diseases. Dr. Tejwani is Associate Professor, Department of Orthopaedic Surgery, NYU–Hospital for Joint Diseases. None of the following authors or the departments with which they are affiliated has received anything of value from or owns stock in a commercial com- pany or institution related directly or indirectly to the subject of this article: Dr. Schachter, Dr. Chen, Dr. Reddy, and Dr. Tejwani. Reprint requests: Dr. Tejwani, Bellevue Hospital– NB, 21 W 37, 550 First Avenue, New York, NY 10016. Copyright 2005 by the American Academy of Orthopaedic Surgeons. Osteochondral lesions of the talus occur infrequently and usually represent late sequelae of ankle trauma. Because of the functional significance of the talus and its limited capacity for repair, correct early diagnosis is important. Osteochondral fractures should be suspected in patients with chronic ankle pain, especially those with a prior ankle injury. Historically, plain radiographs have been used to stage lesions; more recently, magnetic resonance imaging and arthroscopy have been used. Non- surgical management remains the mainstay of treatment of acute, nondisplaced osteochondral lesions. Surgical management is reserved for unstable fragments or failure of nonsurgical treatment. Recent advances in osteochondral grafting have allowed reconstruction of the talar dome, leading to more predictable relief of pain and im- provement of function. J Am Acad Orthop Surg 2005;13:152-158 152 Journal of the American Academy of Orthopaedic Surgeons but in only 70% of medial dome lesions. Persistent ankle pain in the ab- sence of any recognized trauma should heighten suspicion of a talar osteochondral lesion. Mechanism of Injury Berndt and Harty 7 originally described two possible mechanisms for osteochondral fractures of the talus. Com- pressive injury to an ankle positioned in dorsiflexion and inversion (eg, a direct tibiotalar impact) may crush the subchondral bone of the lateral talar dome, with or without overlying cartilage damage. Alternatively, subject- ing the plantarflexed ankle to impact forces of inversion and external rota- tion can produce osteochondral injuries to the medial talar surface. O’Farrell and Costello 16 also suggested that the medial talar osteochondral lesion is caused by a combination of inversion with plantar flexion. Other mechanisms thought to account for lesions in other locations 17 include impaction of the dome against the lateral malleolus, re- sulting in lateral dome lesions, or against the posterior tibial lip, result- ing in medial defects. 7,18 Classification In 1959, Berndt and Harty 7 proposed a staging system based on radiographic findings: stage I, small area of subchondral bone compression; stage II, osteochondral fragment par- tially detached; stage III, osteochondral fragment completely detached but not displaced; stage IV, osteochondral fragment completely detached and displaced. Other grading systems based on more recent radio- logic techniques also have been described. For example, Anderson et al 19 and Ferkel et al 20 used magnetic resonance imaging (MRI) to classify talar osteochondral injury. With interest in and use of ankle arthroscopy increasing, some have questioned the accuracy of classification based solely on plain tomography. Pritsch et al 21 graded lesions according to articular injury visualized during ankle arthroscopy, ranging from grade I (intact appearance) to grade III (frayed appearance). The authors found that radiographic and arthroscopic findings correlated poor- ly. Fifty percent of lesions classified as stage IV according to the Berndt and Harty system were found to be intact viewed through the arthroscope. However, direct visualization of an intact articular surface does not permit the underlying bone to be examined; thus, the extent of a bony lesion may be underestimated. Pritsch et al 21 em- phasized that treatment protocols should be based on the integrity of the articular cartilage and that plain radiographs may not necessarily show the critical elements of talar osteochondral injury. This concept under- scores that MRI and ankle arthroscopy have the potential to play important roles in the evaluation of these injuries. Clinical Evaluation The first step in assessing ankle pain should be a meticulous clinical evaluation to differentiate among the many potential diagnoses, including ligamentous injury, fractures of the fib- ula, and fractures of the tibial plafond. In patients with acute injury, the ankle and foot may be swollen and pain- ful, limiting the specificity of the ex- amination. Nonetheless, the ankle and foot should be palpated to identify any discrete locations of tenderness. A careful neurovascular assessment is also essential. ROM of the injured ankle and hindfoot should be compared with ROM in the contralateral lower extremity. Testing for instability should be performed, including an anterior drawer test with the ankle in both plantar flexion and dorsiflexion. The ankle also should be subjected to inversion and eversion stress testing. Although ankle sprains are more common than osteochondral injuries of the talus, talar osteochondral injury should be included in the differ- ential diagnosis of chronic ankle pain. The index of suspicion for talar osteochondral injury should be high in the Figure 1 Plain radiographs of posttraumatic osteochondral injuries (arrows). A, Mortise view of a medial injury. B, Anteroposterior view of a lateral lesion of the talus. C, Oblique view of a lateral lesion of the talus. Aaron K. Schachter, MD, et al Vol 13, No 3, May/June 2005 153 setting of ankle pain without any recognized trauma or with persistent ankle pain after an acute injury has re- solved. Radiographic Evaluation Plain Radiography Standard radiographic views of the ankle should be obtained, including anteroposterior, lateral, and mortise, with weight bearing if possible. Canale and Kelly 10 proposed that the talar profile may be visualized better with an ankle radiograph made with 15° of foot pronation and with the tube an- gled 75° cephalad. Nonstandard pro- jections that allow further elucidation of the talar profile include the mortise view of the ankle in plantar flexion to visualize posteromedial lesions and stress views to detect ligamentous laxity. DeLee 22 suggested that radiography cannot identify cartilaginous defects or grade I (nondisplaced) lesions. The inability of plain radiography to visualize nonosseous struc- tures limits its usefulness. 10 Computed Tomography Computed tomography (CT) allows the integrity of the subchondral bone to be assessed in multiple planes, and CT is often invaluable in preoperative planning 10,23 (Fig. 2). However, CT is limited in its ability to visualize cer- tain osteochondral lesions, especially cartilaginous or nondisplaced (grade I) lesions. In comparing the use of CT and MRI to evaluate possible osteochondral talar defects identified by bone scintigraphy, Anderson et al 19 reported that, although CT and MRI were 90% concordant in identifying lesions visible by plain radiography, CT was capable of identifying only 4 of 14 lesions that were not evident on plain radiographs (stage I), whereas MRI demonstrated all 14. Bone Scintigraphy Anderson et al 19 examined the role of bone scintigraphy in the evaluation of patients with posttraumatic ankle disability, reporting a 57% incidence of osteochondral defects of the talar dome, despite normal appearance on radiography. The authors found bone scintigraphy to be useful in evaluating ankle injuries when radiographs appear to be normal but suggested that a positive bone scan be followed up with MRI. Urman et al 24 found that when bone scans showed abnormal uptake in the talar dome on at least one view, the scan was 94% sen- sitive and 96% specific for osteochondral injury. Magnetic Resonance Imaging MRI allows multiplanar evaluation and offers the advantage of vi- sualizing the surface of articular cartilage and subchondral bone as well as edema and other features of the surrounding soft tissue (Fig. 3). MRI also allows early subchondral damage (stage I lesions) to be detect- ed. 25,26 In one study, 19 MRI allowed grade I osteochondral lesions to be identified correctly in all 14 patients who had had abnormal results on bone scintigraphy. MRI findings also have been found to correlate closely with visual findings during arthroscopy. 20 Radiographic Protocol Stone 27 proposed a radiographic protocol for evaluating osteochondral lesions of the talus. Plain radiography Figure 2 Computed tomography scans of a medial talar osteochondral lesion. A, Coronal view demonstrating extent of the lesion. B, Axial view showing the medial malleolar lesion (arrow). Figure 3 MRI scans of an ankle. A, Sagittal T2-weighted scan demonstrating an anterior talar dome lesion. B, Coronal T1-weighted scan demonstrating a medial talar dome defect. Osteochondral Lesions of the Talus 154 Journal of the American Academy of Orthopaedic Surgeons should be used for initial evaluation of patients presenting with acute ankle injury with hemarthrosis or with significant tenderness at the bony landmarks of the ankle. Any osteochondral lesion identified should then be evaluated with CT to deter- mine the size, shape, location, and de- gree of displacement. Persistence of pain despite normal appearance on plain radiographs warrants further investigation, such as MRI or bone scintigraphy. The MRI scans should be scrutinized for associated injuries (eg, ligamentous disruption) that may be responsible for, or contribute to, persistent ankle pain. Treatment Nonsurgical Generally, nonsurgical treatment in- volves an initial period of no weight bearing with cast immobilization, followed by progressive weight bearing and mobilization to full ambulation by 12 to 16 weeks. 1 Berndt and Harty 7 found that, after acute osteochondral injury, nonsurgical treatment with immobilization nearly always resulted in healing. Many authors have suggested that the decision to operate should depend on the grade of the lesion. Berndt and Harty grade I and II lesions should be managed non- surgically for up to 1 year to allow for resolution before resorting to surgery. 9,11,15,27-29 Nevertheless, a meta- analysis of 14 studies with a total of 201 patients showed only a 45% success rate of nonsurgical treatment of grade I, grade II, and medial grade III talar osteochondral lesions (not all injury types were specified). 30 Non- surgical treatment of chronic lesions had a success rate of 56%. 30 Shelton and Pedowitz 29 reported just 25% sat- isfactory results for nonsurgical treatment of grade II and III lesions. Surgical Failure of nonsurgical management or the presence of advanced grade III or IV lesions often necessi- tates surgical intervention. Excision, Drilling, and Curettage Excision may be done with either open or arthroscopic techniques. Ex- cision of the subchondral fragment and curettage of the lesion’s surface is done to remove debris, fibrous tissue, or devitalized cartilage. This procedure has been recommended in the treatment of chronic lesions and lesions with necrotic material. 22 Vascu- lar access channels are then created in the underlying subchondral bone using an awl, drill, or arthroscopic shaver. This allows marrow elements to migrate into the site of injury and produce fibrocartilage to cover the lesion. 1,27,30,31 Generally, arthroscopic excision and drilling can be done as outpatient procedures. They are associated with fa- cilitated rehabilitation, a quick return to normal function, and minimal wound-healing complications. 27 Trans- articular drilling may be indicated in the treatment of a symptomatic osseous lesion underlying an intact cartilaginous surface. 27 However, exposure can be limited by the topography of the joint as well as by the diffi- culty in reaching posterior lesions through standard anterior portals. Transarticular drilling is also user de- pendent and requires specialized equipment and arthroscopic instru- ments. Results of excision and drilling have been encouraging compared with those of nonsurgical treatment. In a review of 16 studies with a total of 165 patients, Tol et al 30 found excision, curettage, and drilling to have had good to excellent results in 88% of patients with grade III and higher lesions. However, simple excision and curettage without drilling (9 studies, 111 patients) had a success rate of 78%, whereas excision alone (5 studies, 63 patients) had a success rate of 38%. 30 The success rate of excision alone has been shown to be lower than that of nonsurgical treatment (45%). 32 Internal Fixation Internal fixation of osteochondral lesions may be done using a variety ofmethods,includingscrews,Kirsch- ner wires, and bioabsorbable devic- es. 33,34 DeLee 22 proposed that internal fixation is indicated when the injury occurs acutely and the fracture is larger than one third the size of the re- spective dome. Stone 27 suggested that the lesion should be at least 7.5 mm in diameter and that the patient be young for surgical fixation. The surgical approach is determined by the location of the lesion. Lesions on the lateral aspect of the talar dome may be approached using either an anterolateral or posterolateral approach; anteromedial lesions may be accessed through an anteromedial approach. Posteromedial lesions may require osteotomy of the medial malleolus for adequate exposure. Tochigi et al 35 suggested using an anterolateral tibial osteotomy to allow access to centrolat- eral talar lesions. Excision of loose fragments with débridement and curettage of the lesions should be performed before internal fixation of the osteochondral fragment. 22 Current Trends Osteochondral Allograft Fresh-frozen osteochondral allografts have been used to repair osteochondral lesions of the talus. Gross et al 36 reported retrospectively on a series of nine patients in whom they had implanted talar osteochondral allografts to avoid the donor-site mor- bidity associated with autograft harvest. Only four of the patients had an identifiable previous trauma to the af- fected ankle. One of the procedures was performed for a traumatic open fracture with talar osteochondral de- ficiency. The authors’ indications for performing the procedure included a lesion with a diameter of at least 1 cm and a depth of at least 5 mm as well as inability to perform primary repair of the fragment. Aaron K. Schachter, MD, et al Vol 13, No 3, May/June 2005 155 Following open débridement of the lesion to a bleeding host bed, prefashioned fresh-frozen cadaveric osteochondral allografts were trans- planted using one or two minifrag- ment cancellous screws for graft fixation. Postoperative management included cast immobilization for 2 weeks, with subsequent ROM exercises and a patellar tendon–bearing brace for 1 year. At a mean follow-up of 11 years, six of the nine grafts remained intact. The three failures resulted from fragmentation and resorption of the allograft. Osteochondral Autograft Osteochondral autografts use cartilage and subchondral bone harvested from host non–weight-bearing articular surfaces. Both the knee and the talus itself have been used as donor sites. 37-42 Assenmacher et al 43 reported on arthroscopically assisted autograft transplantation in nine patients with talar dome lesions. The lesions were graded using both MRI and arthroscopy. Unstable lesions were identified by radiographic evidence of grade III or IV injury or by the arthroscopic visualization of a loose fragment. Pa- tients considered to have unstable lesions underwent autograft of the talar osteochondral defect with a plug harvested from the ipsilateral distal femur. The lesions were débrided before the grafts were placed. After adequate débridement, grafting was performed through an arthrotomy. The prefashioned graft was inserted into a reamed recipient site and packed into place. Postoperatively, patients remained non–weight bearing for 7 weeks, with ROM exercises begun 10 days postoperatively. There were no complications or revision surgery, and results were good or excellent as assessed with the American Orthopaedic Foot and Ankle Soci- ety (AOFAS) ankle-hindfoot score. Follow-up MRI demonstrated that the grafts were incorporated in all subjects at 9 months postoperatively. Scranton and McDermott 44 reported on osteochondral autograft replace- ment of stage IV talar lesions in 10 patients. The distal femur was used as a donor site; average increase in the AOFAS ankle-hindfoot score was 27 points. Mendicino et al 38 corroborated these results; they reported a high level of patient satisfaction, excellent return to function, and no donor site com- plaints with the use of distal femoral osteochondral autografts to treat stage III and IV lesions. The anterior talar dome also has been used as a donor site for osteochondral autograft of the talus. Lee 39 reported no postoperative complications and cited advantages of the talar dome donor site that include elim- ination of a second surgical site, decreased intraoperative time, and a close match in shape of the graft to the native recipient site. Mosaicplasty autograft also has been described, with reconstruction of the osteochondral defect using multiple, small-diameter plug autografts as opposed to one large, prefashioned graft. Hangody and col- leagues 41,42 reported on the outcomes of talar mosaicplasty, with the medial or lateral femoral condyle as the do- nor site. In 36 patients, multiple grafts of 4.5 × 3.5 mm were harvested to re- constitute the talar defects, which av- eraged 1 cm in diameter (Fig. 4). Us- ing the Hanover scoring system, ankle function was judged to be good or excellent in 34 of the 36 patients (94%) at follow-up of 2 to 7 years. 42 All patients returned to full activity. Functional performance of osteochondral grafts has been evaluated. Histologic analysis by Giannini et al 40 showed that, unlike drilled lesions, which heal with fibrocartilage, 41,45 osteochondral autografts heal with type II collagen at the recipient site. Type II collagen is char- acteristic of hyaline cartilage. Gian- nini et al 40 reported an increase in the AOFAS ankle-hindfoot score from an average of 32 preoperatively to 91 postoperatively in eight patients. Summary Because talar integrity is important for ankle function and because articular repair is difficult, osteochondral lesions may result in functional im- pairment and, later, chronic ankle pain and functional debilitation. Os- teochondral injury should be suspected in cases of recalcitrant ankle pain once more common causes, such as ligamentous injury, are ruled out. Although occasionally the etiology of such lesions is unidentifiable, the majority arise as late sequelae of ankle trauma. Lateral lesions are thought to be secondary to combined forceful dorsiflexion and eversion of the ankle, whereas medial injuries may result from combined ankle inversion and plantar flexion. If an osteochondral talar defect is suspected but plain radiographs fail to reveal the lesion, MRI may be useful for identifying early, nondisplaced lesions. Early (grade I or II) lesions may be amenable to nonsurgical treatment; more severe (grade III or IV) lesions or those for which nonsurgical management has failed may necessitate surgical intervention. Subchondral drilling is done for stable lesions to encourage fibrocartilage growth, and osteochondral grafts may be used to restore the talar articular surface for unstable or larger defects. To date, functional outcomes reported for os- Figure 4 Mosaicplasty. Intraoperative pho- tograph showing osteochondral autografts (arrows) at the site of a talar dome defect. Osteochondral Lesions of the Talus 156 Journal of the American Academy of Orthopaedic Surgeons teochondral grafting of the talus generally have been favorable. Recent re- search has suggested that healing of such grafts may occur with a predom- inance of type II collagen, but further investigation is necessary to deter- mine whether these weight-bearing surfaces are biomechanically similar to hyaline cartilage. References 1. Saunders R: Fractures and fracture dislocations of the talus, in Mann RA, Coughlin MJ (eds): Surgery of the Foot and Ankle, ed 7. St. Louis, MO: Mosby, 1991, vol 2, pp 1465-1518. 2. Boyd HS, Knight RA: Fractures of the astralgus. South Med J 1942;35:160-167. 3. Kleiger B: Injuries of the talus and its joints. Clin Orthop 1976;121:243-262. 4. Mulfinger GL, Trueta J: The blood supply of the talus. J Bone Joint Surg Br 1970; 52:160-167. 5. Haliburton RA, Sullivan CR, Kelly PJ, Peterson LFA: The extra-osseous and intra-osseus blood supply of the talus. J Bone Joint Surg Am 1958;40:1115-1120. 6. Kelly PJ, Sullivan CR: Blood supply of the talus. Clin Orthop 1963;30:37-44. 7. Berndt AL, Harty M: Transchondral fractures (osteochondritis dissecans) of the talus. J Bone Joint Surg Am 1959;41: 988-1020. 8. Konig F: Veber freie korper in der ge- henken. Dtsch Z Chir 1888;27:90-109. 9. Canale ST, Belding RH: Osteochondral lesions of the talus. J Bone Joint Surg Am 1980;62:97-102. 10. Canale ST, Kelly FB Jr: Fractures of the neck of the talus: Long-term evaluation of seventy-one cases. J Bone Joint Surg Am 1978;60:143-156. 11. Alexander AH, Lichtman DM: Surgical treatment of transchondral talar-dome fractures (osteochondritis dissecans): Long-term follow-up. J Bone Joint Surg Am 1980;62:646-652. 12. Ray RB, Coughlin EJ: Osteochondritis dissecans of the talus. J Bone Joint Surg 1947;29:697-706. 13. FlickAB, Gould N: Osteochondritis dissecans of the talus (transchondral fractures of the talus): Review of the liter- ature and a new surgical approach for medial dome lesions. Foot Ankle 1985;5: 165-185. 14. Sneppen O, Christensen SB, Krogsoe O, Lorentzen J: Fracture of the body of the talus. Acta Orthop Scand 1977;48: 317-324. 15. Van Buecken K, Barrack RL, Alexander AH, Ertl JP: Arthroscopic treatment of transchondral talar dome fractures. Am J Sports Med 1989;17:350-356. 16. O’Farrell TA, Costello BG: Osteochon- dritis dissecans of the talus: The late results of surgical treatment. J Bone Joint Surg Br 1982;64:494-497. 17. Davidson AM, Steele HD, MacKenzie DA, Penny JA: A review of twenty-one cases of transchondral fractures of the talus. J Trauma 1967;7:378-415. 18. Resnick D, Goergen TG, Niwayama G: Physical injury and diagnosis of bone disorders, in Resnick D, Niwayama G (eds): Diagnosis of Bone and Joint Disor- ders, ed 2. Philadelphia, PA: WB Saun- ders, 1988, pp 2756-3009. 19. Anderson IF, Crichton KJ, Grattan-Smith T, Cooper RA, Brazier D: Osteochondral fractures of the dome of the talus. J Bone Joint Surg Am 1989;71:1143-1152. 20. Ferkel RD, Flannigan BD, Elkins BS: Magnetic resonance imaging of the foot and ankle: Correlation of normal anat- omy with pathologic conditions. Foot Ankle 1991;11:289-305. 21. Pritsch M, Horoshovski H, Farine I: Ar- throscopic treatment of osteochondral lesions of the talus. J Bone Joint Surg Am 1986;68:862-865. 22. DeLee JC: Fractures and dislocations of the foot, in Mann RA, Coughlin MJ (eds): Surgery of the Foot and Ankle,ed6.St. Louis, MO: Mosby, 1991, pp 1465-1518. 23. Reis ND, Zinman C, Besser MIB, et al: High-resolution computerised tomography in clinical orthopaedics. J Bone Joint Surg Br 1982;64:20-24. 24. Urman M, Ammann W, Sisler J, et al: The role of bone scintigraphy in the evaluation of talar dome fractures. J Nucl Med 1991;32:2241-2244. 25. Deutsch AL: Osteochondral injury of the talar dome, in Deutsch AL, Mink JH, Kerr R (eds): MRI of the Foot and Ankle. Philadelphia, PA: Lippincott- Raven, 1996, pp 111-134. 26. Dipaolo JD, Nelson DW, Colville MR: Characterizing osteochondral lesions by magnetic resonance imaging. Ar- throscopy 1991;7:101-104. 27. Stone JW: Osteochondral lesions of the talar dome. J Am Acad Orthop Surg 1996; 4:63-73. 28. Pettine KA, Morrey BF: Osteochondral fractures of the talus: Along-term follow- up. J Bone Joint Surg Br 1987;69:89-92. 29. Shelton ML, Pedowitz WJ: Injuries to the talar dome, subtalar joint, and mid- foot, in Jahss MH (ed): Disorders of the Foot & Ankle: Medical and Surgical Man- agement, ed 2. Philadelphia, PA: WB Saunders, 1991, vol 3, pp 2274-2292. 30. Tol JL, Struijs PAA, Bossuyt PMM, Ver- hagen RAW, van Dijk CN: Treatment strategies in osteochondral defects of the talar dome: A systematic review. Foot Ankle Int 2000;21:119-126. 31. Kumai T, Takakura Y, Higashiyama I, Tamai S: Arthroscopic drilling for the treatment of osteochondral lesions of the talus. J Bone Joint Surg Am 1999;81: 1229-1235. 32. Parisien JS, Vangsness T: Operative arthroscopy of the ankle: Three years’ ex- perience. Clin Orthop 1985;199:46-54. 33. Shea MP, Manoli A II: Osteochondral lesions of the talar dome. Foot Ankle 1993;14:48-55. 34. Mallon WJ, Wombwell JH, Nunley JA: Intra-articular talar fractures: Repair using the Herbert bone screw. Foot An- kle 1989;10:88-92. 35. Tochigi Y, Amendola A, Muir D, Saltz- man C: Surgical approach for centrolat- eral talar osteochondral lesions with an anterolateral osteotomy. Foot Ankle Int 2002;23:1038-1039. 36. Gross AE, Agnidis Z, Hutchison CR: Osteochondritis defects of the talus treated with fresh osteochondral allograft transplantation. Foot Ankle Int 2001;22:385-391. 37. Chang E, Lenczner E: Osteochondritis dissecans of the talar dome treated with an osteochondral autograft. Can J Surg 2000;43:217-221. 38. Mendicino RW, Hallivis RM, Cirlicione AS, Catanzariti AR, Krause N: Osteo- chondral autogenous transplantation for osteochondritis dissecans of the ankle joint. J Foot Ankle Surg 2000;39:343-348. 39. Lee MS: Anterior talar dome as an al- ternative donor site for osteochondral transplantation for medial talar dome lesions. Clin Podiatr Med Surg 2001;18: 545-549. 40. Giannini S, Buda R, Grigolo B, Vannini F: Autologous chondrocyte transplantation in osteochondral lesions of the ankle joint. Foot Ankle Int 2001;22:513-517. 41. Hangody L, Kish G, Kárpáti Z, Szerb I, Eberhardt R: Treatment of osteochondritis dissecans of the talus: Use of the mosaicplasty technique–a preliminary Aaron K. Schachter, MD, et al Vol 13, No 3, May/June 2005 157 report. Foot Ankle Int 1997;18:628-634. 42. Hangody L, Kish G, Módis L, et al: Mo- saicplasty for the treatment of osteochondritis dissecans of the talus: Two to seven year results in 36 patients. Foot Ankle Int 2001;22:552-558. 43. Assenmacher JA, Kelikian AS, Gottlob C, Kodros S: Arthroscopically assisted autologous osteochondral transplantation for osteochondral lesions of the talar dome: An MRI and clinical follow- up study. Foot Ankle Int 2001;22:544-587. 44. Scranton PE Jr, McDermott JE: Treat- ment of type V osteochondral lesions of the talus with ipsilateral knee osteochondral autografts. Foot Ankle Int 2001; 22:380-384. 45. Buckwalter JA, Mow VC, Ratcliffe A: Restoration of injured or degenerated articular cartilage. J Am Acad Orthop Surg 1994;2:192-201. Osteochondral Lesions of the Talus 158 Journal of the American Academy of Orthopaedic Surgeons

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