Description of patient (type of occupation, indication of age, intensity of sport):
40-year-old women, teacher, badminton player.
History and previous treatment:
Multiple sprains over the last two years. Ankle has felt uncomfortable when running over that period. No treatment received so far. Now significant sprain 2 months ago and feeling of instability.
Mild pain anteromedial ankle. Recurrent giving way.
On examination she has pes planus with hindfoot valgus and forefoot abduction. She has pain over ATFL and has a grade 3 anterior draw test showing significant instability. She has some recognisable tenderness over the anterior medial joint line. She has a severe hallux valgus deformity. She has good range of motion of her ankle joint as well as the midfoot joints and first MTPJ. She has no pain over the peroneal tendons, all tendons are five out of five power.
There is an osteochondral lesion occupying the mid-portion of the medial aspect of the talardome, with the transverse diameter measuring 6.3 mm and the AP diameter measuring 8.6mm. No subchondral cystic changes seen adjacent to the osteochondral lesion.
40 year old woman. Ankle Instability and Medial Talar Dome Lesion
Question(s) to this case:
Is she a candidate for Removal of Cartilage, debridement and microfracture with ATFL Brostrom? Or is the lesion amenable to debridement, microfracture and fixation of the lesion with headless screws through a medial maleolar osteotomy?
This patient has a lax ankle ( +++ ADT) and on CT an OCD with the typical aspect of an old Osteochondritis Dissecans which originates from adolence and has been "silent" for some 20 years. Possibly it has become symptomatic due to the supination trauma(s). This OCD then presents with deep ankle pain. Patient does not have deep ankle pain but anteromedial ankle pain. Anteromedial ankle pain with recognisable tenderness on palpation means anteromedial impingement due to synovitis or spurs (the sagital CT shows anterior talar spur)
In case of doubt my advice is to make an MRI. In case there is no bone marrow oedema then don`t treat the OCD. In case of bone marrow oedema then debridement (remove the fragment) and bone marrow stimulation. This can be done by anterior aproach.
Obviously the patient also needs a Brostrom repair (anatomic reconstruction) of the ATFL and CFL