Ankle > Osteochondral Lesion of the Talus > Treatments

   Arthroscopic Surgery

Treatment introduction

Your physician can use an arthroscope - a tiny camera with about a three to five millimeter diameter - to take a look at the top of your talus in the ankle joint. Using small incisions, microsurgery instruments can be used to repair damaged bone and cartilage in your ankle after an osteochondral lesion. Surgery is more commonly prescribed for adult patients. Arthroscopy is sometimes useful as a diagnostic tool when MRI (magnetic resonance imaging) is inconclusive. Your physician may be able to make the final diagnosis and surgically repair your talus within a few hours. The surgery for an osteochondral ankle lesion typically is a step-by-step procedure, which moves from the final diagnosis through various surgical steps depending on the extent of damage in your talus. Small lesions may only need to have the cartilage smoothed over, whereas large lesions may require a surgeon to make a larger incision and remove loose chips of bone and cartilage.

Preparing for Surgery

If you and your physician have decided on arthroscopic surgery to repair your osteochondral lesion, the decisions you make and the actions you take before your surgery can be every bit as important as the procedure itself in ensuring a healthy recovery.

   Prior to your return home from the hospital, make sure that you have received any equipment you will need when you get home. This may include crutches or household items to make movement around the house easier. You should receive prescriptions for these from your doctor before you go home from the hospital.

   Any physical problems or changes in your overall health, such as a fever or infection, should be reported to your surgeon, and you should notify your surgeon of any new medications you are taking.

   Learn the potential risks and benefits of the surgery, and ask your surgeon any questions that will help you better understand the procedure. It can also help to talk to someone else who has undergone the same surgery.

   If possible, practice walking with your crutches so you are ready to use them after surgery.

   Getting a second opinion from another qualified surgeon is often advisable, particularly in rare or unique cases.

   Make sure the orthopedist performing the surgery is board-certified or eligible, which can be determined by calling the American Board of Orthopaedic Surgery at 919-929-7103.

RELATED TOPICS

   What to ask the doctor

Day of Surgery

At most medical centers, you will go to "patient admissions" to check in for your operation. There may be separate check-in areas for ambulatory outpatients (patients go home the same day after surgery) and for overnight inpatient surgery, so be sure to ask your doctor or one of his assistants about this. After you have checked in to the hospital, you will go to a holding area where the final preparations are made. The mandatory paperwork is completed, and your ankle may be shaved, though this is not always necessary. You will be asked to change into a hospital gown and, if applicable, remove your watch, glasses, dentures, and jewelry. You will have the opportunity to speak with your orthopedic surgeon or one of his assistants and meet the anesthesiologist or nurse anesthetist (a nurse who has done graduate training to provide anesthesia under the supervision of an anesthesiologist). An IV (intravenous) line may be inserted into your arm at this time. You will then walk or ride on a stretcher to the operating room. Most patients are not sedated until they go into the operating room. Here are some important steps to remember for the day of your surgery:

   You will probably be told not to eat or drink anything after midnight on the night before your surgery. This will reduce the risk of vomiting while you are under general anesthesia.

   Since you will most likely be able to go home within a few hours of surgery, arrange for someone to drive you home when you are released.

   Wear a loose pair of shorts, sweatpants, or other clothing that will fit comfortably over your short leg cast or splint when you leave the hospital.

   Take it easy. Keeping a good frame of mind can help ease any nerves or anxiety about undergoing surgery. Distractions such as reading, watching television, chatting with visitors, or talking on the telephone can also help.

RELATED TOPICS

   ABC’s of anesthesia

Surgery Procedure

Surgery to treat an osteochondral ankle lesion is a series of steps that usually starts with the least invasive technique, an arthroscope, as the last step of diagnosis before your surgeon progresses with whatever needs to be done to repair the top of your talus. Small osteochondral lesions may only require the first few steps, whereas large lesions usually require more complex procedures. Spinal anesthesia typically is given to numb you from the waist down and you usually are sedated so you sleep through the procedure. Surgery can last up to two hours.

   Your surgeon inserts an arthroscope through a quarter-inch incision and views the cartilage lesions on your talus. One or two additional small incisions, or "portals," will be made to allow the insertion of instruments into the ankle.

   Fluid is injected into the ankle joint through one of these portals, which allows the surgeon to view, through the arthroscope, the extent of the cartilage damage.

   Usually, the first step is debridement. Your surgeon cleans up rough edges of frayed or damaged cartilage to smooth the cartilage surface.

   Curettage, which is the removal of any dead or fractured bone from the lesion, is performed if bone has been chipped underneath your talar cartilage. Any loose pieces of bone and cartilage are removed.

   Depending on how stable the bone fragments are and how large the cartilage lesion is, the next surgical option is to drill the fractured area with an instrument called a K-wire.

   Drilling encourages blood flow and growth of fibrocartilage, which is the type of cartilage your body regrows in response to damage. You normally have a coating of hyaline cartilage on top of your talus, which cannot regrow. Fibrocartilage is not as proficient or as ideal as hyaline cartilage because it is not as strong, nor does it absorb shock as well, during movements. But fibrocartilage usually is sufficient to relieve pain and enable normal movement in your ankle.

   In rare cases, open surgery can be the final step if your osteochondral lesion is large or in a position where the arthroscope cannot properly visualize the lesion. Debridement, curettage, and drilling are similarly performed.

   Incisions usually are closed with stitches and your ankle is put into a splint to immobilize it. You are then taken to the recovery room.

Recovery Room

After arthroscopic surgery for an osteochondral ankle lesion, you will be transported to the recovery room where you will be closely observed for one to two hours while the immediate effects of anesthesia wear off. Your ankle will be immobilized in a splint or cast when you wake up and your ankle will be elevated. After surgery, you usually experience some pain. Adequate pain medications will be prescribed for you. You will either be given an IV patient-controlled analgesia (PCA) device, a device that delivers pain medications in safe amounts when you push a button, or prescribed oral, IV, or intramuscular pain medications when you ask for them. Your surgeon will prescribe crutches and you are usually instructed to keep all weight off your ankle for at least six weeks. Your temperature, blood pressure, and heartbeat will be monitored by a nurse who, with the help of the doctor, will determine when you can prepare to go home. You will normally be able to leave the hospital or clinic within three to four hours after surgery. Make sure to have someone available to drive you home, as you will be unable to drive a car.

Home recovery

After undergoing surgery to repair an osteochondral lesion of the talus, physicians generally recommend that you avoid bearing weight until your ankle has healed. Crutches are usually prescribed for about six weeks, and you should rest as much as possible with your ankle elevated above your heart level. This helps blood drain away from your ankle and controls swelling. For two or three days after surgery, most patients are instructed to stay off their feet and rest. You may be able to get around more after about three days, but you should continue to elevate your ankle as much as possible and use your crutches to keep weight off your ankle. You may need to use pain medication prescribed by your physician for one or two days after surgery. Pain usually decreases within a few days. Household tasks that require you to be on your feet may be difficult. It can be helpful to have someone around the house who can help with any physical chores. Patients commonly return to their physician’s office within 10 to 14 days to have the post-surgery ankle splint replaced by a short leg cast. You typically are instructed to keep the cast dry. Either wrap a plastic garbage bag around the cast while showering or bathe with your leg out of the tub.

While wearing a cast, you probably will have to use crutches for six to eight weeks. Typically, you will return to your physician for check-up visits every few weeks. Depending on the extent of surgery, your cast will be removed and your ankle will be put into a removable cam walker. A cam walker is a type of boot splint made of nylon straps that secure around your lower leg and foot to hold your ankle in place. There is usually an adjustable ankle hinge that can be set to allow some limited ankle motion. Patients generally are instructed to remove their cam walker for a brief period to perform simple range of motion exercises. Prop your leg up on a stool or pillow so your ankle is off the floor. Physicians generally recommend moving your ankle up, down, and side-to-side. Start with slow movements and do not move your ankle too far in any direction. In general, you should continue using your crutches and wearing your cast or cam walker as instructed by your doctor until symptoms resolve. You typically begin partial weight bearing in a brace or cam walker before going back to normal shoe wear. Your physician may suggest physical therapy that can be done at home, or refer you to a physical therapist after about six weeks. However, many patients can strengthen their ankles without formal physical therapy. Your physician generally evaluates your ankle after six weeks and determines whether regular cardiovascular exercise and everyday weight bearing can sufficiently strengthen your ankle. Massage and heat therapy also may be used to soothe muscle pain. However, massaging an injured ankle can disrupt the healing process. Your physician will decide when it is safe to begin ankle massage. A balanced diet, vitamin supplements, proper hydration, and exercise may help you recuperate and get you back on your feet again. You may be able to perform workouts with your upper body that can give you a cardiovascular workout while you are seated.

RELATED TOPICS

   Recovery-proof your home

   When to call the doctor after surgery

Rehabilitation

The recovery period after an osteochondral lesion usually lasts six months to a year. Typically, you progress from range-of-motion exercises to light cardiovascular exercise and then strengthening exercises. If you experience episodes of minor swelling or pain while exercising, have your physician examine your ankle. Formal physical therapy is prescribed for patients who do not make good progress strengthening their ankles on their own. Physical therapy usually involves learning and performing ankle stretching and foot and lower leg strengthening exercises.

Prevention

To prevent reinjury after an osteochondral lesion, you should make sure you have equal strength in both the injured and uninjured ankles. A strong and flexible ankle may be more able to withstand any abnormal positions and strain that occur during sports and activities. Before you engage in sports and activities that involve twisting and jumping, physicians generally recommend that you focus on building up your cardiovascular fitness. Begin slowly, and avoid overusing your ankle. Physicians often recommend a cross-training approach that alternates your workouts each day between impact activities like jogging, and low impact activities like swimming or cycling. The amount of weight training you may need to strengthen your ankle and prevent reinjury varies greatly depending on your age and the size of the osteochondral lesion. Older patients may need to undergo a specific leg and ankle strengthening program under the supervision of a physical therapist. Younger patients are more likely to regain full ankle strength after range of motion exercises and standard cardiovascular fitness training. It is particularly important to maintain strength in your peroneal muscles, located on the outside of your lower leg around your small lower leg bone (fibula). The peroneals help keep your ankle from turning inward, which can damage the cartilage on top of your foot bone. Though the recovery period may be lengthy, most patients can safely return to sports and activities within nine months to a year of an osteochondral lesion. Once your ankle lesion heals and you have equal strength in both ankles, the cartilage typically is stable, especially in younger patients, and reinjury is rare. A small amount of pain is normal during activities. If you feel so much pain in your ankle to warrant taking a painkiller before an activity, visit your physician for a checkup.