Osteochondral lesions of the talus (OLTs) are ankle joint injuries involving damage to the joint surface (cartilage) and/or underlying ankle bone (talus). A normal, healthy ankle joint is made up of smooth cartilage supported by strong bone underneath. Sometimes an ankle injury leads to damaged, rough areas of cartilage and bone underneath. Foot and ankle orthopaedic surgeons call this type of injury an OLT. Since the ankle joint moves while walking, the rough spots may cause pain, swelling, stiffness, and decreased motion. It is kind of like having a pothole in the joint surface.
Bulk allograft transplantation takes bone and cartilage from a deceased donor (cadaver) and places it into the damaged talus. This surgery is reserved for severe cases of OLT that have either failed previous surgical treatment or involve a very large part of the talus. These types of OLTs may not respond to less invasive procedures.
Treatment for OLTs depends on several factors. The size and location of an OLT is important, as are the patient's activity level and any previous treatments. Non-surgical treatment options include medications, changes in activity, and braces or casts. Surgery may remove damaged cartilage and bone so that the underlying bone is stimulated to heal. If none of these are successful, or if the lesion is too large to have a reasonable chance of success with other procedures, bulk allograft transplantation may be an option.
The surgery usually is done under a general anesthetic. A nerve block may be used to help with pain after surgery. Your foot and ankle orthopaedic surgeon will make at least one incision, usually over the front or inside of the ankle. Depending on the location of the lesion, your surgeon may need to cut the tibia or fibula bone with a saw in order to get enough access to treat the lesion.
Your surgeon will identify and remove the OLT. This is similar to a plug on a golf course green being removed to make the hole. Your surgeon then takes a plug from a cadaver talus and places it into the hole in the patient’s talus. On occasion, a plug will not be adequate to fill the hole, and instead the graft will be shaped as needed to fit the space. If the tibia or fibula was cut, it is fixed with metal screws and/or a plate. The surgeon will close the incision and place the ankle in a splint or cast. Most commonly, the patient will go home the same day as the surgery, unless there are other medical reasons to stay at the hospital.
Bulk allograft transplantation requires a substantial recovery period. In general, no pressure or weight is allowed on the operative side for six weeks or more. The patient typically is given a walker or crutches. A kneeling walker/scooter also may be an option. A transition is then made to partial weightbearing in a cast or boot. Daily activities are allowed between 3-4 months with complete recovery taking up to a year or more.
All surgeries come with possible complications, including the risks associated with anesthesia, infection, damage to nerves and blood vessels, and bleeding or blood clots.
Specific risks of this procedure include nonunion (incomplete healing of the bones) of the graft and/or the site of the bone cuts (in the ankle), pain around the surgical site or hardware, and advancement of arthritic changes in the ankle joint. The graft may initially appear to do well, but fail and collapse even several years after surgery.
Most patients have less pain and are able to do more activities after bulk allograft transplantation. These improvements have been shown to last several years and may last many more.
Patients still may experience pain with activities after this procedure. If medications, bracing, and activity modifications fail to improve symptoms, revision surgery may be considered. Ankle fusion and possibly ankle replacement may be treatment options.
Rejection of the allograft is an unusual occurrence. An allograft may fail to heal and/or break but this does not seem to be from the body rejecting the graft itself.
It is estimated that the risk of HIV transmission from allograft transplantation is less than one in a million. There is a risk of transmitting other viruses such as hepatitis, but the risk is one in several hundred thousand.
Original article by Jaymes Granata, MD
Contributors/Reviewers: Paul Peters, MD; David Porter, MD; Jeffrey Feinblatt, MD
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