Posteromedial talar OCD: which aproach?

38 / M
Office job
Very active person: ski, wrestling

Multiple falls.
Last incident 6 month ago while jumping.
Onset of pain after incident.
Underwent 2 series of physioterapy sessions.
Uses crutches whenever he stresses the ankle.

Deep ankle pain with activity.

Stable ankle
No swelling

Osteochondritis dissecans of the talus.
Pictures :
- sagital MRI section
- coronal MRI section
- sagital CT sections with ankle in dorsal flection

38 / M, office job but very active , deep ankle pain, activity - related, set in after a ski trauma 5 month ago. 2 series of physioteraphy and the use of crutches.

1. Due to the location of the lession (CT scan is made in dorsal flexion), malleolar osteotomy is the approach of choice ?
2. What would be the procedure of choice to treat the deffect ?

This is a typical case of posteromedial OCD. Treatment is by debridement and bone marrow stimulation. The aproach can best be by anterior arthroscopy. If you bring the ankle in forced plantar flexion you will see the defect. In case the ankle is stable then you only will see the most anterior part of the defect. From there you can work posterior. Only in case the ankle has limited plantarflexion then you might have difficulty in reaching the defect.
In case you want to be better informed then you can make preoperative a CT scan in plantar flexion. This also can confirm the size of the lesion: in case it is less then 15 mm in length on the sagital image then you can perform bone marrow stimulation. This plantair flexed CT will also give you a good idea of the location of the OCD during the surgery.
In my experience in 99% of these defects they can be treated in forced plantar flexion.
You can interchange the forced plantar flexion position with soft tissue distraction. For the technique of soft tissue distractor see ankleplatform