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Osteochondral Lesions of the Tallus

ANATOMY & FUNCTION

The ankle is a joint which is formed by the tibia and fibula (bones above the ankle in the foreleg) and the talus (below the ankle joint). The ankle joint allows for the upwards (dorsiflexion) and downwards (plantarflexion) motion. The end of the shin bone (tibia) forms the inner bony prominence of the ankle called the medial malleolus. The outer bony prominence is called the lateral malleolus and is formed by the small outer bone in the foreleg called the fibula.

Figure 1: Lateral (Side) View of RightFoot

Osteochondritis dissecans is an injury to the talus bone of the ankle joint. Because the ankle joint is so small, the amount of force that goes across the joint, with each step, has been estimated to be approximately 5-10 times a person's body weight. As a result of this tremendous force that occurs in the ankle joint, relatively small injuries to the articular surface of the talus often result in chronically painful injuries.

Osteochondritis dissecans is the result of the isolated loss of blood flow to a portion of the talus bone. Usually this occurs in conjunction with a history of trauma. It is sometimes also known as an osteochondral fracture of the talus, chip fracture of the articular (joint) surface or a chondral fracture of the talus.

The development of osteochondritis may be very slow. Initially, a person may sustain a twisting injury to the ankle. As the ankle is injured, the talus bone twists within the space between the tibia and fibula. As this twisting occurs, the ligaments around the ankle may be stretched (ie ankle sprain). Unfortunately, in some people, as the twisting injury occurs, not only are the ankle ligaments stretched, but the talus bone strikes the tibia or fibula. When this occurs, some type of injury to the talus, tibia, or fibula happens. Typically, the majority of the damage occurs to the talus at the articular surface.

The articular surface should be a freely movable system. Without a blood supply, the potential for healing damage to the articular cartilage is minimal. Therefore, when this tissue is damaged, it may slowly deteriorate with the passage of time. As the articular surface deteriorates, the surface changes from a nice smooth frictionless surface to a rough cobblestone like surface. This rough degenerative surface is a form of arthritis.

When the ankle is twisted, and the talus impacts the tibia or fibula, the talar articular surface may be merely bruised, or a more serious injury may occur. If the twisting injury results in a shearing force to the talus as it impacts the tibia or fibula, then a chip fracture may occur. This "chip fracture" may either be complete, or incomplete, and it may be detached (loose body), partially detached, or non-displaced.

To further confuse things, the bone injury may not become visible on x-ray for several months.

STAGES

Stage 1: This is the most minor abnormality. Typically, there has been an injury to the articular surface of the talus. Although an injury has occurred to the articular surface, no significant disruption of the bone has taken place.

Stage 2: As the injury increase, a hairline crack begins to appear in the talus, just beneath the articular surface. The crack (or fracture line) is incomplete. This means that it does not completely extend from one side of the injury to the otherside.

Stage 3: The incomplete fracture line has now progressed to completely separate the fragment. However, the fragment remains in its place on the surface of the talus.

Stage 4: Now the fragment has broken loose and changed position so that it is no longer in the defect on the talus.

TREATMENT

The treatment depends on the age of the patient, the circumstances of the injury, and the type of bone damage. A simple bone contusion (bruise) would be treated differently then a detached bone fragment. The treatment options may vary from simply being on crutches to being casted to having surgery. The surgical procedures used to treat osteochondritis dissecans may involve removing the fragment, attempting to reattach the fragment, drilling the underlying bone to promote blood flow, or some combination of these procedures. Obviously, the exact treatment and procedure needs to be individualized to the patient, the type of bone injury, and the location of the bone injury.

ACHILLES TENDON INJURY

ANATOMY

The Achilles tendon is the tendon that connects the calf muscle (gastrocnemius) to the heel bone (calcaneus). This is the tendon that is just below the skin at the back of the ankle. As with most tendon injuries, this tendon may be injured.

Figure 1: Posterior View of Normal Achilles' Tendon as it goes from gastrocnemius muscle to the calcaneus.

FUNCTION

When the gastrocnemius muscle (in the calf) contracts (shortens), the tendon which is attached from the muscle to the heel bone (calcaneus) moves. As the muscle shortens, the tendon moves to point the foot downwards. This is the action that allows a person to stand on one's toes, to run, to jump, to walk normally, and to go up and down stairs.

TYPES OF INJURIES

Achilles tendonitis is an inflammation of the tendon. It often results from a small stretch injury that causes the tendon to become swollen, painful and less flexibility than the normal tendon. Untreated, this injury may fail to heal, or progress to a chronically painful condition. Of course, in some people, the tear may progress to a complete rupture of the tendon. A ruptured (or torn) tendon may occur when the tendon has been structurally weakened by an ongoing tendonitis, or when a completely healthy tendon is subjected to a sudden, unexpected force. As a result, the tendon tears. When the tendon tears, people often report hearing a pop at the back of the ankle. If they are playing doubles in tennis, the person often thinks that his/her partner has hit them in the back of the ankle. With the injury, pain, swelling, and loss of function occur. Since the calf muscle is no longer attached to the heel bone, people find it difficult to walk normally, and have difficulty doing activities that require any type of significant push off with their toes (such as running, jumping, doing toe raises). Left untreated, the tendon often fails to heal, thereby resulting in a permanent disability

DIAGNOSIS

For a tendon rupture, the area of the rupture is often swollen, tender, bruised (ecchymotic), and may actually have a palpable gap in the tendon. X-rays, although they do not show the tendon reliably, do show the calcaneus. When doing the x-ray, the physician is checking to see if the bone to which the Achilles tendon attached (calcaneus) has been injured. In some cases, the tendon will not tear; but instead, it will literally pull a piece of calcaneal bone off of the rest of the calcaneus. Although this is repairable, the technique is different then merely sewing the two ends of a ruptured tendon together. If the tendon has not ruptured, then the patient may have sustained only a pulling injury to the tendon. This type of injury results in a stretch injury to the tendon which is called tendonitis. Although this often heals without surgery, until completely healed, the tendon is structurally weaker then normal and is at an increased risk for tearing with continued athletic activity or additional injury producing situations.

TREATMENT

The treatment options for a complete rupture of the tendon include surgery followed by casting, or casting alone. There are advantages and disadvantages to each technique and the options should be discussed with your physician. With surgery, the tendon is either reattached to the calcaneal bone (if it has been pulled off or avulsed) or the two ends are sewn together is the tendon has been torn in two. In most people, a cast is applied after surgery until healing is complete. Each patient must be considered individually. There are many reasons why a person may not be a suitable candidate for a surgical repair of the injury. These include, but are not limited to: poor circulation, presence of skin problems at the site of the injury, age, a sedentary lifestyle, other medical conditions that make the person a poor candidate for surgery (such as heart or lung problems). If the injury is treated non-operatively, then a cast is applied until healing is complete. The length of time required for healing is highly variable. Often it may take as long as six months for complete healing to occur.




	ANKLE FUSION An ankle fusion surgery (or arthrodesis) is commonly suggested for a degenerative (worn out, painful) ankle joint. For many years, surgeons have considered an ankle fusion to be the permanent solution for advanced degenerative arthritis of the ankle joint. An ankle fusion is quite durable. After the ankle joint is successfully fused, patients can usually walk with a near normal gait (way of moving) and without the pain of arthritis. In the majority of cases, surgeons consider the ankle fusion to be the most appropriate treatment for a degenerative ankle in a young patient. This is due to the high demands that an active adult will place on his or her ankle over time. Artificial ankle replacement may not be durable enough in a younger, high demand patient to withstand the stress. Surgeons have thought that the ankle fusion could permanently solve the problems faced by the patient with a degenerative ankle. ANATOMY How does the ankle joint work? The ankle joint is made up of three bones: the lower end of the tibia (shinbone), the fibula (the small bone of the lower leg), and the talus (the bone that fits into the socket formed by the tibia and fibula). The talus sits on top of the calcaneus (the heelbone). The talus moves mainly in one direction. It works like a hinge to allow your foot to move up and down. Ligaments on both sides of the ankle joint help hold the bones together. Many tendons cross the ankle to move the ankle and the toes. (Ligaments connect bone to bone, while tendons connect muscle to bone.) The large Achilles tendon at the back of the ankle is the most powerful tendon in the foot. It connects the calf muscles to the heel bone and gives the foot the power for walking, running, and jumping. Inside the joint, the bones are covered with a slick material called articular cartilage. Articular cartilage is the material that allows the bones to move smoothly against one another in the joints of the body. The cartilage lining is about one-quarter of an inch thick in most joints that carry body weight, such as the ankle, hip, or knee. It is soft enough to allow for shock absorption but tough enough to last a lifetime, as long as it is not injured. What does the surgeon hope to accomplish? An ankle fusion actually removes the surfaces of the ankle joint and allows the tibia to grow together, or fuse, with the talus. There are operations for many joints in the body that surgically fuse the joint to control pain. Before the development of artificial joints this was the primary operation available to treat an extremely painful joint. In some cases, fusion is still the best choice. For the ankle, a fusion is a very good operation for treating a worn-out joint. This is especially true if the patient is young and very active. An ankle fusion, if successful, is not in danger of wearing out like an artificial ankle. An ankle fusion should last the patient a lifetime. But it is also important that the other foot joints are normal. A fusion keeps the ankle joint from moving during walking and other activities, so the other foot joints will need good mobility. What happens during surgery? Several different operations have been developed to perform an ankle fusion. The basic procedure in each operation remains the same, however. The most common way that an ankle fusion is done is by making an incision through the skin to open the joint. Once the joint is opened, the surgeon uses a surgical saw to remove the articular cartilage surfaces of the ankle joint. Once the articular cartilage is removed on both sides of the joint, the body will try to heal the two surfaces together just as if it were fractured or broken. It is important when the surfaces are removed that the angles of the cut surfaces are correct. When the tibia is brought against the talus, the foot should be at a right angle to the lower leg. Once the cuts are made the bones must be held in place while they fuse. This can be done using large metal screws and metal plates if necessary. The screws are usually under the skin and are not removed unless they begin to rub and cause pain. ANKLE ARTHROSCOPY Ankle arthroscopy involves the surgical evaluation and treatment of the ankle for a variety of conditions. Arthroscopy involves the use of fiberoptic cameras and very small surgical tools, which work through much smaller incisions than traditional surgery. You may need ankle arthroscopy if you have debris in your ankle from torn cartilage or from a bone chip. Also, if there is ligament damage from a severely sprained ankle, a bone surgeon may choose to do an arthroscopy to evaluate the extent of damage and possibly to repair it. For some people, arthroscopy means a speedier recovery, less scarring, and fewer complications than open surgery. Risks Ankle arthroscopy is a relatively safe procedure with low complication rates. As with any procedure involving the introduction of instruments to a normally sterile area, infection is a risk. Bleeding from cut blood vessels may also occur. Some people may have local nerve damage from the procedure making the overlying skin numb. There are risks in using anesthesia, depending on the type that is chosen. CHRONIC ANKLE SPRAINS An ankle sprain is a stretch or tear in one or more of the ankle ligaments. Ankle ligaments are slightly elastic bands of tissue that keep the ankle bones in place. Ankles are particularly prone to sprain because of the small size of the joint and the forces exerted when walking, running and jumping, especially if the surface is uneven. Depending on the severity of the injury, an ankle sprain is classified as: Grade I The ankle is painful, but there is little ligament damage and little loss of function. Grade II There is moderate ligament damage, and the ankle joint is somewhat loose. Grade III One or more ligaments are torn, and the ankle joint is very loose or unstable. Millions of ankle injuries occur each year in the United States. Most of them are sprains. Most sprains happen when the ankle twists suddenly. The most common injuries happen when the foot rolls onto the outside of the ankle, straining the outside ligaments of the ankle joint. These are called inversion injuries. Less common are eversion injuries, which happen when the ankle rolls onto the inside of the joint, stretching the ligaments on the inner side of the ankle. Symptoms of a sprained ankle include: Ankle pain, tenderness and swelling Ankle bruising or discoloration Trouble moving the ankle Inability to put full weight on the ankle A diagnosis of a sprained ankle is based on the history of your injury and your current symptoms. To confirm the diagnosis, he or she will examine your ankle for: Swelling or deformity Inability to feel someone touching the skin Circulation Discoloration Instability Areas of tenderness Limitation in range of motion Inability to bear weight For severe ankle injuries, X-rays are needed to determine whether a bone is broken. Fractures can occur with or without a sprain and can cause similar symptoms. How long it takes to heal depends on the severity of the sprain. Grade I sprains usually take one to two weeks to heal completely. Grade II sprains can take up to six weeks. Grade III sprains can take six months or longer to heal completely. On average, count on a two- to four-week healing period for any significant sprain. To reduce your risk of spraining an ankle: Pay close attention to the surface on which you are walking, running or jumping Do stretching exercises before and after any athletic activity Do balance exercises Wear well-fitting shoes that are appropriate for your sport Avoid sharp, sudden turns and changes in direction Strengthen foot and leg muscles by running, cycling or swimming If you have had several ankle sprains, you'll need a good rehabilitation program that involves strengthening and balance exercises. You may need to wear a brace to protect your ankle as you recover. Surgery is generally not considered an option unless conservative treatment has proven to be unsuccessful. The occurrence of persistent symptoms, instability or pain after a well planned and well executed rehabilitation program is helpful in deciding which surgical alternative is most appropriate. Surgical procedures for chronic lateral ankle instability can be classified as either reconstructive or reparative. In reconstructive techniques, tendons or grafts are redirected around the ankle to replace the damaged tendons. Reparative procedures re-establish the damaged ligamentous structures. Reconstructive procedures can be classified according to the number of ligaments that need to reinforcement. Ankle using the least complicated procedure available. Many surgical options are available.

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