Description of patient (type of occupation, indication of age, intensity of sport):
A 49-year-old nurse (male) and an active runner until 2 years ago.
History and previous treatment:
Two years ago, sudden pain deep in right ankle while running. After a few weeks also during ADL and while descending stairs. Running stop was advised, which diminished the complaints and pain. He walks okay, short walks are possible, long bicycle rides cause some tension and swelling.
Current complaints:
There is more of an annoying feeling than actual pain
Physical examination:
Little swelling of ankle joint, minimal Achilles tendon shortening, normal subtalar ROM, normal ankle ROM, no signs of impingement, no localized pain on palpation.
Radiology:
X-ray:
Posteromedial osteochondral lesion of the talus. No general joint space narrowing. Only limited degenerative changes of the ankle joint. Intact subtalar joint. Beginning of degeneration of processus anterior of calcaneus.
Additional investigation (CT/MRI):
[Picture 1, 2 + 3]
CT: Extensive lesions posteromedial in talar dome. Depression of articular surface with calcified material loose in joint space. Two subcortical cysts.
[Picture 4]
MRI: Medial osteochondral lesion of the talus, with central piece of bone. Increased cyst formation compared to images of 2011, but diminished bone oedema. Total lesion size unchanged. Slight increase in degenerative changes of the ankle with limited cartilage damage of anterior distal tibia.
Images:
Case summary:
Medial osteochondral lesion of the talus with considerable size multilocular cyst and limited secondary degenerative changes.
Question(s) to this case:
Is surgery warranted, given the limited complaints in activities of daily living?
Is curettage still an option or should we go for ankle osteotomy and open mosaic-plasty? (OATS)
Expert:
The sagittal CT shows the size of lesion which is probably 16-18 mm correct? It also shows the cyst underneath. Finally it shows the osteophytes anterior and posterior as sign of long-lasting existence of the OCD. It has been asymptomatic for years.
Since he is low symptomatic consider conservative with heel/shoe adaptation(more valgus pressure), make a standing X-ray to see if there is medial joint space narrowing. In combination with slight varus heel consider lateralising calcaneal osteotomy. Debridement from anterior arthroscopy is possible (in case no varus alignment and no medial joint space narrowing) but prognosis is moderate due to size of lesion.