Greg Vigna, MD, JD
Board Certified Physical Medicine and Rehabilitation
Academic Physician Certified Life Care Planner
Ankle fractures and sprains are a common ‘associated problem’ related to motor vehicle accidents and falls. Despite excellent reduction and healing of fractures persistent pain may result leading to an unacceptable functional result in 20-30% of fractures related to ‘osteochondral lesions’ (OCL) occurring at the time of injury. OCL are defects at the cartilage/bone junction in the joint. ‘Osteochondral lesions’ (OCL) is the medical term for cartilage and/or bony damage in the joint. It is recognized that likely up to 50% of ankle sprains and fractures are associated with acute ‘osteochondral lesions’. Most patients will present with chronic ankle pain after an injury where bony, ligament, and other soft tissue injuries have healed with the pain exacerbated with weight bearing, running, and increased activity. MRI is the standard diagnostic test for detection of OCL with the most common locations of symptomatic lesions at the talus and the tibial plafond. The talus is the bone of the ankle that transmits the force from walking from the foot to the lower leg through the tibial plafond, which is the base of the lower leg. Studies indicate that nonoperative management of symptomatic OCL is generally poor.
The cartilage in the joint has no blood supply so there will be no healing unless a defect in the cartilage reaches the underlying bone. If the defect reaches the underlying bone in normal situations the bone will be stimulated to produce ‘fibrous’ cartilage to replace the defect. Fibrous cartilage does not afford the normal biomechanics as hyaline cartilage does and there is a decrease in shock absorption and increased friction within the joint. In situations where the joint has traumatic defects in the cartilage or in situations where there are large defects healed with the inferior fibrous cartilage there may be unacceptable pain, disability, and traumatic osteoarthritis as a result. For small OCL defects may produce little disability, however, for larger defects this fibrous cartilage more likely than not will ultimately lead to traumatic arthritis. The goal of modern treatment is to provide a method of replacing the damaged hyaline cartilage with tissue that resembles the normal hyaline cartilage rather than the inferior fibrous cartilage. By achieving this goal the normal biomechanics of the joint will be restored decreasing the risk of posttraumatic osteoarthritis and the pain and disability that results.
There are several procedures available to orthopedic foot and ankle specialist to deal with OCL. In situations where the bone is damaged adjacent to the intact cartilage there is risk that the hyaline cartilage will degrade because its nutritional supply will be compromised if the adjacent bone does not heal properly. The goal in this situation is to provide a procedure that will stimulate the healing of the bone and preserve the nutritional source to the cartilage at risk. Retrograde drilling is an attempt to stimulate bony healing at the base of the bony defect underlying the at risk ‘hyaline cartilage’. By agitating the bony defect there will be a stimulating effect on the healing of bone. Studies indicate that lesions improve in size and pain is decreased.
In situations where there is a defect in the ‘hyaline cartilage’ microfracture and microdrilling procedures are available to the orthopedic foot and ankle specialist to stimulate the bone to produce ‘fibrous’ cartilage. Outcomes indicate that these procedures are appropriate for smaller OCL and appear to improve function. In situations that involve larger OCL tissue transplantation have been showing promise with good to excellent responses in over 90% of patients. Arthroscopic appearance following this procedure have revealed normal appearing joint cartilage in successful cases.
Both surgically and nonsurgical managed symptomatic ankle joints from OCL, ankle joint injections with hyaluronic acid has demonstrated significant improvement regarding both pain and function. Hyaluronic acid benefits the joint by rejuvenating joint fluid that serves as a lubricant and stimulates the cells that produce cartilage to do so.
Case managers for clients with ongoing symptomatic ankles following fractures and sprains must be afforded the opportunity to be evaluated by an orthopedic ankle foot specialist with all the above mentioned skills to decrease pain, improve function, and potentially decrease the development of a traumatic osteoarthritis that may ultimately require a total ankle replacement or a fusion.
Life Care Planners must appreciate the significance of OCL, understand the response to treatments, and understand the findings on diagnostic studies to be able to reasonably predict the necessary care to the patient’s life expectancy. Future care may include injections with cortisone and hyaluronic acid, physical therapy, anti-inflammatory medications, physician follow up, diagnostic test, laboratory tests, and the potential for total ankle replacements and ankle fusion.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2958283/pdf/iowa0030-0119.pdf
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