Foot Ankle Clin N Am

8 (2003) 739 – 749

Cartilage repair of the talus

Dirk B. Schäfer, MD
Orthopaedic Clinic of the University of Basel, Spitalstr. 21, CH-4031 Basel, Switzerland

In 1994, a paper by Brittberg et al [1] brought cartilage repair to the attention of

orthopedic surgeons. They showed, in a limited number of patients, that the transfer
of enzymatically-isolated chondrocytes into an intra-articular chamber that is
formed by an autologous periosteal flap and the subchondral bone resulted in a
repair tissue, that was stable and able to tolerate physiologic load. In contrast to this
cellular approach, in 1986 Laprell and Petersen started to transplant intact
osteochondral autologous cylinders from the posterior femoral condyles into large
anterior knee defects [2]. The same techniques were subsequently introduced for
the treatment of cartilage lesions of the ankle joint [3].
Compared with the knee, the ankle joint is different in many regards. The
thickness of adult articular talar cartilage averages 0.89 mm [4], whereas knee joint
cartilage ranges from 3 mm to 6 mm in thickness [5]. Biomechanical properties of
ankle joint cartilage are superior compared with the hip joint. Whereas the tensile
stiffness of the middle layer cartilage of the ankle increases with age from 20 to
80 years, there is a dramatic eightfold decrease in the same period for cartilage of
the hip [6]. Blood supply to the talus is limited by the area that is covered by
cartilage, which is approximately 60%, and the lack of any muscular insertion [7].
Ankle joint biomechanics are at least as complex as knee joint kinematics [8,9].
Whereas a cartilage lesion of the medial femoral condyle in association with a varus
knee can be approached by a cartilage repair technique and a high tibial valgisation
osteotomy, a cartilage lesion of the medial talar dome usually is not combined with
any other corrective osteotomy. The relevant pathomechanic is not clearly
understood. These factors underscore that an ankle joint is completely different
from the knee or hip joint. This article summarizes current knowledge of cartilage
repair of the ankle.

Etiology and pathogenesis

Joint cartilage lesions are commonly classified as partial thickness, full
thickness, or osteochondral [10]. Chondral lesions result from an acute injury

E-mail address: dschaefer@uhbs.ch

1083-7515/03/$ – see front matter D 2003 Elsevier Inc. All rights reserved.
doi:10.1016/S1083-7515(03)00143-8
740 D.B. Schäfer / Foot Ankle Clin N Am 8 (2003) 739–749

or are associated with chronic instability. Taga et al [11] examined nine freshly
injured ankle joints and found cartilage lesions in 89%. The incidence rate for
chondral lesions in 22 chronically unstable ankle joints was 95%. We investi-
gated cartilage damage of the ankle joint by arthroscopy in 148 patients who had
chronic ankle instability [12]. Partial thickness lesions of the talar cartilage were
found in 51% and full thickness lesions were found in 3%. It was concluded that
chronic instability of the ankle joint is frequently associated with a cartilage
lesion. Both studies demonstrated that most of these lesions are only superficial
and do not violate the subchondral bone. Therefore, a nontraumatic cause for pure
chondral lesions of ankle joint cartilage has not gained popularity.
Osteochondral lesions are different. An osteochondral lesion violates the sub-
chondral bone and allows access of bone marrow stromal cells. This results in a
completely different healing potential than a lesion that is limited to the chondral
layer. Proposed mechanisms for osteochondral lesions are trauma, impaired
perfusion, genetic predisposition, and endogenous factors. Proposed metabolic
diseases that are associated with osteochondrosis dissecans are hypo- and hyper-
parathyroidism and alterations of the lipid metabolism [13]. In dogs, factors that
were associated with an increased risk for osteochondrosis dissecans included high
dietary calcium, playing with other dogs, and drinking well water [14]. Foals that
were fed a low copper diet developed osteochondrosis dissecans [15]. A genetic
predisposition for osteochondrosis dissecans is possible. Stougaard [16] described
a family who had increased incidence of this disease and it has been observed
in twins.
A primary impairment of perfusion is a rare cause for an osteochondral lesion of
the talus. An avascular necrosis of the talus was described in association with lupus
erythematosus, alcohol abuse, or corticosteroid medication [17]. The lesion is
usually extensive and diffuse and the cartilage is initially intact. Subchondral
collapse leads to secondary rupture of the chondral layer.
There is general agreement that most osteochondrosis is a sequela of trauma.
Most patients who have an osteochondral lesion of the talus remember a trauma
associated with onset of symptoms [18 –21]. According to Bruns and Behrens
[22], a supination injury results in excessive shear forces on the lateral talar
shoulder and excessive compressive forces on the medial talar shoulder. Acute
compressive forces are completely transmitted onto the subchondral bone.
Micromotion in this damaged area exceeds orderly repair and remodeling of
damaged bone. The repair is fibrous, instead of bony, and initiates separation of
the osteochondral fragment.
Some degree of instability would be the logic consequence of this proposed
etiology. In contrast, instability usually is not reported in association with cartilage
repair of the ankle. We specifically investigated instability of the ankle joint and
found that a 25% prevalence of lateral instability was associated with type III and
IV talar lesions [23]. We consider instability a major factor that could even hinder
the natural healing of on osteochondral lesion. Whether correction of the instability
alone can be sufficient for the healing of an osteochondral talar lesion or improve
the outcome of more conservative forms of treatment (drilling) is speculative.
 D.B. Schäfer / Foot Ankle Clin N Am 8 (2003) 739–749 741

Instability of the ankle joint seems to be underrepresented in the cascade of events

that lead to a chronic osteochondral talar lesion.

Treatment

Nonoperative
In a literature review that included articles that were published between 1953
and 1998, Tol et al [24] summarized reports on the conservative treatment of
osteochondrosis (OCD) of the talus. Indications for conservative treatment were
Berndt and Harty stage I and II lesions, medial stage III lesions, or lesions with
intact cartilage as assessed arthroscopically. A total of 201 lesions were separated
into two groups depending on whether aftertreatment consisted of cast immobili-
zation. Good to excellent results were found in 41% of the group which was treated
with a cast and 59% of the group which was treated with some restriction.
Shearer et al [25] treated 35 patients who had a subchondral talar cyst (type V
lesion) with the recommendation of activity as tolerated. After 38 months, 54% had
a good or excellent result. In the subgroup of patients who were younger than
20 years, only 33% were graded as good to excellent.
It seems to be increasingly difficult to recommend conservative treatment for
osteochondral talar lesions, because nonoperative treatment is good or excellent in
50% of the patients and it is not possible to define those lesions that are suitable for
the conservative option.

Operative

Stimulative treatment
Stimulative techniques have been separated into excision alone; excision com-
bined with curettage; and excision, curettage, and drilling [24]. In a meta-analysis
that was performed by Tol et al [24], operative treatment was indicated for acute
and chronic Berndt and Harty type II –IV lesions and in lesions with frayed
cartilage. Excision alone resulted in 38% good to excellent results; excision and
curettage resulted in 78% good to excellent results; and excision, curettage, and
drilling resulted in 85% good to excellent results. When excision and curettage
were subdivided into open versus arthroscopic technique, arthroscopy gave 86%
good to excellent results. Thus an arthroscopic technique, which consisted of de-
bridement of the lesion and opening of intact subchondral bone, gave the best
results. Because of the wide variety of exclusion criteria, inclusion criteria, and clas-
sification systems used, a definitive conclusion was not given by the investigators.
Stimulative procedures are now generally performed arthroscopically. The iat-
rogenic trauma is reduced and modern techniques allow access to all areas of the
ankle joint [26]. Ogilvie-Harris et al [27] showed that arthroscopic technique al-
lows treatment of OCD even after failed open surgery. Eight patients (22 – 42 years)
who had four posteromedial and four anterolateral lesions were treated by local
742 D.B. Schäfer / Foot Ankle Clin N Am 8 (2003) 739–749

synovectomy and debridement to bleeding bone. After 38 months, seven of eight

were graded as good to excellent. Most follow-up radiographs demonstrated an
incomplete filling of the defect, however. Joint stability was not mentioned.
Thirty-three patients who had not had previous surgery underwent the same
treatment [28]. The grade of OCD was not communicated. After 7.4 years all
were graded good to excellent, although 21% did not reach their previous level of
sport activity.
Schuman et al. [29] treated OCD defects with curettage and drilling. Thirty-
eight patients were followed for 2 to 11 years. 27 OCD defects were of traumatic
origin and 16 had undergone previous debridement or drilling. In these, a
classification was not given. Twenty-two lesions that had not undergone previous
surgery were graded as Berndt and Harty I (14), II (6), III (1), and V (1).
Aftertreatment consisted of immediate partial weight bearing and physiotherapy.
At follow-up, 86% of patients who had not been previously operated on and 75% of
the patients who underwent revision procedures were graded as good to excellent.
Fifty-five percent of 30 athletes went back to the previous level of sport. Radio-
graphs demonstrated irregularities of subchondral bone in some patients.
Kelberine and Frank [30] found similar results. Bone healing after arthroscopi-
cally-treated OCD was usually incomplete after 5 years. A difference was found
according to the location of the lesion; 67% of medial lesions had good to excellent
results and 89% of lateral lesions had good to excellent results.
Kumai et al [31] used antegrade transmalleolar drilling for talar OCD. Eighteen
patients who had a Berndt and Harty stage II lesion at the medial side of the talus
were followed for 4.6 years. Only seven patients were older than 16 years at
surgery. At follow-up, clinical results were graded as good in 13 cases and fair in
five cases. Complete osseous union or ossification was seen in only 4 of 18 patients.
Based on the current literature, it is difficult to make recommendations for a
specific therapy. If surgery is considered, one has to be aware that stimulative
techniques lead to a good to excellent result in most cases, but normal anatomy is
generally not restored. Neither hyaline articular cartilage nor a restoration of
normal subchondral bone results from stimulative techniques.
Data suggest that stimulative therapies can and should be performed arthro-
scopically, because of reduced morbidity and earlier rehabilitation. It makes sense
to preserve viable and intact cartilage, because hyaline articular cartilage cannot be
restored at the moment. Treatment of children who have type II lesions showed
better results than adults, but restoration of their subchondral bone was incomplete.
Aftertreatment is as important as the surgical procedure. Early partial weight
bearing and early motion exercises are generally recommended. The risk:benefit
ratio of these techniques is so favorable that they should represent the first line of
therapy for a symptomatic OCD of the talus.

Autologous osteochondral transfer

The transfer of autologous osteochondral tissue is an attractive concept. It is the
only technique that brings stable articular cartilage into the defect. This has to be
balanced against limited availability, donor site morbidity, and surface congruency.
 D.B. Schäfer / Foot Ankle Clin N Am 8 (2003) 739–749 743

Depending on the preference of the surgeon, one either aims at a minimum number
of transferred osteochondral cylinders to limit the number of interfaces or at gaining
a maximum of surface congruency, which requires multiple cylinders.
Hangody et al [32]. were the first investigators who reported this technique for
talar lesions. Thirty-six patients who had a stage III or IV lesion that averaged 1 cm2
were treated with a mean of three pegs (range, 1 – 6 pegs) that were 3.5 mm to
6.5 mm in diameter. After 4.2 years, range of motion was normal in all ankle joints,
94% had good to excellent results, and there was no graft instability.
Gautier et al [33] used a similar technique. Eleven patients who had a stage II
to IV lesion of at least 70 mm2 were treated with one to eight grafts. Most
lesions were located medially; only one lesion was found laterally. After a mean of
follow-up of 2 years (range, 6– 47 months) American Foot and Ankle Society
(AOFAS) hindfoot score averaged 92.1 points and the International Knee Docu-
mentation (IKDC) knee score was normal for all knees. Pain was present in three
patients, swelling was present in two patients, stiffness was present in two patients,
and decreased range of motion was measured in four ankle joints. Graft resorption
was seen in one ankle. Patients who were younger than 45 and nonsmokers had
better results.
Schöttle et al [34] reported on 39 talar type III/IV lesions that were treated with
one to three (mean 1.4) cylinders. Defect size ranged from 1 cm2 to 3 cm2; most
lesions were located medially. An osteotomy was required in 30 ankles. After a
mean follow-up of 19.6 months (range, 6 – 42 months), the Lysholm score
had improved from 62 points to 92 points. There were no complications or
grafts instability.
Assenmacher et al [35] treated eight of nine unstable talar lesions (0.19 cm2 to
0.64 cm2) with a single osteochondral graft. After a mean follow-up of 9 months
(range, 4 – 17 months), the AOFAS hindfoot score averaged 80.2 points.
Scranton and McDermott [36] reported on 10 lesions that they defined as type V.
All were characterized by a subchondral talar cyst, which was considered a
sequela of a talar cartilage injury. All defects were treated with a single osteo-
chondral cylinder from the knee. After a mean follow-up of 17 months (range,
12 –25 months), the AOFAS score had improved from 64 points to 91 points.
Although the donor site in all surgeries was the ipsi- or contralateral knee joint, a
relevant donor site morbidity was not reported later than 1 year after surgery. Long-
term results would be important to justify the use of the knee joint as a routine
harvest site.
Sammarco and Makwana [37] used an alternative source for donor tissue.
12 patients who had a type III or IV lesion that was between 30 mm2 and 100 mm2
were treated with a one of two grafts from the anterior talar cartilage. Access was
gained by a custom wedge osteotomy of the anterior tibia. After a mean follow-up
of 2 years (range, 16– 41 months), the AOFAS score had improved from 64 points
to 98 points. An age less than 40 years and absence of degenerative joint disease
was associated with an better outcome.
Taken together, the short-term results of autologous osteochondral transfer
seems to be good to excellent in most cases.
744 D.B. Schäfer / Foot Ankle Clin N Am 8 (2003) 739–749

Several points require further investigation:

The indication for autologous osteochondral transfer has not been defined. The
size of the defect, the symptoms, and the specific stage that require an osteochon-
dral transfer are not known. The reported lower limit of a defect size that is
considered appropriate for an osteochondral transfer is in the range of 0.5 cm2, but
some investigators indicated it for lesions that were 30 mm2 in size. Most
procedures were performed for type III and IV lesions, although type II lesions
that were labeled as new type V (subchondral cyst) were treated.
Studies that compare the transfer of a single versus multiple cylinders are
missing. In a cadaver model, four smaller grafts performed better than two larger
grafts with regard to total contact area and mean contact pressure [38]. This
suggests that more, smaller grafts would allow a better restoration of a standard
defect. Healing could not be evaluated.
The surgical approach to medial talar lesions often requires a medial malleolar
osteotomy. Although this did not result in a specific reported morbidity in those
studies, it results in a cartilage fracture at the medial ankle. Fissures and cracks of
articular cartilage do not normally heal and the long-term outcome of that technique
is not known.
Postoperative rehabilitation seems to be balanced between early functional
aftertreatment and complete immobilization of the joint for healing of the grafts.
Proponents of a functional concept [33] allowed partial weight bearing with early
physiotherapy right from surgery. Restrictive regimes [39] proposed weight
bearing only 10 weeks postoperatively and used a cast for 4 weeks. It will be
necessary to define the type of motion and load bearing that is best for cartilage
repair of the ankle joint; so far, early functional aftertreatment has been considered
a cornerstone in joint surgery [40].
There is a discrepancy between postulated cause and specific treatment: Most
investigators agree that a traumatic event initiates an osteochondral lesion. This
results either in a medial or lateral edge loading of the talus and progressive
destruction of the osteochondral tissue. Consequently, instability should be a
common clinical finding in patients who have an osteochondral lesion, but is
generally not reported; once, malalignment was found. Sammarco and Makwana
[37] mentioned two cases of flat feet that underwent osteochondral transfer, in
which correction was performed. In contrast, it is taught that cartilage repair should
only be performed if malalignment and instability are addressed [41]. In our own
experience, instability or malalignment are commonly associated with osteochon-
dral lesions of the talar cartilage [23]. Sixteen patients (average age, 38.5 years)
who had a grade III or IV type lesion underwent osteochondral transfer of a mean of
2.8 grafts (range, 1– 6 grafts). Defects were located laterally (11), medially (4), and
centrally (1). Mosaicplasty was performed as a primary procedure in eight patients
and after failed previous surgery in six patients. All joints underwent arthroscopic
evaluation of joint stability and ligament insufficiency [12]. Four joints demon-
strated a lateral instability. Concomitant malalignment included one varus mal-
alignment of the tibia, one hindfoot varus, and one hindfoot valgus. Consequently,
cartilage repair included ligament stabilization and corrective osteotomies. These
 D.B. Schäfer / Foot Ankle Clin N Am 8 (2003) 739–749 745

data suggest that instability and malalignment are underreported in cases of ankle
joint cartilage lesions; this probably reflects the difficulty to detect and grade these
entities. In the presence of an osteochondral lesion, a minor degree of instability
may be sufficient to represent a contributing factor to the cartilage defect. A painful
ankle under load — a key symptom of an osteochondral talar lesion — may reduce
the incidence of recurrent ankle sprains, which usually leads to the diagnosis of
instability. We still do not have a standard with which to grade ankle joint
instability. Medial and rotatory instability have gained more attention only recently
[9], which adds more complexity to ankle joint instability, and, probably, associated
cartilage damage.
As is usual in modern orthopedic surgery, a technique is available that gives
encouraging short- and mid-term results, before the disease is understood.

Autologous chondrocyte implantation

Autologous chondrocyte implantation is a cell-based method for cartilage
repair. Chondrocytes are harvested from an intact area, enzymatically isolated,
and expanded. Prepared chondrocytes are reinjected in a chamber, which is formed
by the chondral defect, the subchondral bone, and a periosteal flap on top [42].
After successful treatment of knee joint lesions with follow-up times over 10 years,
this technique was recently used for cartilage lesions of the ankle joint [43].
Four reports include a total of 40 patients. Giannini et al [3] treated eight patients
aged 18 to 38 years with ACI for osteochondrosis dissecans of the talus. No patient
had previous surgery. Seven patients were treated with autologous chondrocyte
implantation (ACI) alone; the other patient had filling of a deep osteochondral
defect with cancellous bone before the ACI. Defect size averaged 3.3 cm2.
Aftertreatment consisted of continuous passive motion; weight bearing was
allowed after 3 months. After 26 months, the average AOFAS score [44] had
improved from 32.1 points to 91 points (range, 54 –100 points). Biopsies from five
joints stained positive for collagen type II and proteoglycans.
Koulalis et al [45] reported on eight patients aged 22 to 42 years who had an
average defect size of about 1 cm2 that resulted from osteochondrosis dissecans.
Three patients had previously undergone surgery. Their technique consisted
of filling of the subchondral defect with autologous cancellous bone and imme-
diate ACI. Weight bearing was allowed after 6 to 7 weeks. Follow-up time was
18 months. Five patients were graded as excellent and three were graded as good. A
single histology after 6 months showed fibrocartilage. Arthroscopically, two repair
areas were 1 mm deeper than the surrounding cartilage.
Peterson [46] presented results of his first 14 patients (age, 18 –42 years). All
had had at least one failed previous surgery. Defect size averaged 1.7 cm2
(range, 0.3 cm2 to 3.5 cm2). Surgery consisted of ACI alone in 10 patients and
an additional ligament repair in four patients. Postoperatively, partial weight
bearing was allowed for 6 to 8 weeks. After 33 months, six patients were graded
as excellent, five patients were graded as good, and three patients were graded
as poor or fair.
746 D.B. Schäfer / Foot Ankle Clin N Am 8 (2003) 739–749

Ferkel [41] presented preliminary results of 10 patients (average age 36 years)

after 3 to 32 months. Detailed results were not available. Second-look arthros-
copy showed good-looking, but soft, cartilage in three patients.
Based on the limited number of treatments it is difficult to define indications for
ACI of the talus, although that was proposed by Ferkel [41] and Behrens and Bruns
[47]. These recommendations limit the procedure to adults up to 55 years of age
who should have a focal unipolar, contained defect of a relevant size with
unsuccessful previous surgery. Contraindications include be kissing lesions,
degenerative changes, and uncorrected malalignment of instability. Evidence for
these limitations does not exist and it is not clear whether experience gained from
the treatment at the knee joint can be extrapolated to the ankle.
Twenty-three out of 30 patients, for whom data were available, required a
medial or lateral osteotomy. Current available data allow no conclusion about
which specific type and size of defect require an ACI for repair of an osteochondral
lesion of the talus.

Allografts
Experience with osteochondral allografts for talar cartilage defects is limited.
Gross et al [48] reported on nine patients who were treated with a single graft.
Defects were of type IV, at least 1 cm in diameter, and 5 mm deep. Age averaged
38 years (range, 22 – 47 years). After 11 years, six grafts were in situ, two of
which were partially resorbed. Three joints underwent fusion as a result of
graft resorption.
Kim et al [49] transplanted bipolar grafts for traumatic ankle arthrosis in seven
patients. After 6 years, four were rated good to excellent, two failed to unite, one
had malalignment; two patients underwent secondary ankle fusion.
With improvements in total ankle arthroplasty and the introduction of newer
techniques, such as autologous chondrocyte transplantation, the indication for
allografts will probably decrease further. The complication rate is high and salvage
procedure is fusion.

Summary
The cause of a typical osteochondral lesion of the talus is traumatic; if
symptomatic, several options exist. Because nonoperative treatment results in no
more than 50% good to excellent results, the following types of surgery are in
clinical use: (1) debridement and drilling, (2) osteochondral transfer, and (3) auto-
logous chondrocyte transplantation. Reported good to excellent results are at least
80% in the short term. Currently available data allow no recommendation of a
specific therapy for a specific lesion. Advocates of drilling and debridement accept
that the repair tissue is fibrocartilage; osteochondral transfer includes a donor side
morbidity. We are still at the beginning of cartilage repair; it will take time before a
certain type of lesion can be treated with the best modality because that requires
comparative randomized prospective studies with a long follow-up.
 D.B. Schäfer / Foot Ankle Clin N Am 8 (2003) 739–749 747

All modern cartilage repair techniques, that were initially investigated at

the knee joint, are now in use for ankle osteochondral lesions. Reported short-
term success rates are greater than 80%. Further improvements will depend
on the understanding of the pathogenesis and the role of contributing factors
(eg, instability).

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