Conservative Treatment for Juvenile Osteochondritis Dissecans of the Talus

Hui Taek Kim; Kunbo Park; Chang Hyo Seo; Tae Young Ahn; In Hee Kim

doi:10.4055/jkoa.2017.52.4.310

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Kim, Park, Seo, Ahn, and Kim: Conservative Treatment for Juvenile Osteochondritis Dissecans of the Talus

Original Article

J Korean Orthop Assoc 2017;52(4):310-318.

Published online: 1 December 2017

DOI: https://doi.org/10.4055/jkoa.2017.52.4.310

Conservative Treatment for Juvenile Osteochondritis Dissecans of the Talus

Hui Taek Kim, M.D., Kunbo Park, M.D.^*, Chang Hyo Seo, M.D., Tae Young Ahn, M.D., In Hee Kim, M.D.

Department of Orthopaedic Surgery, Pusan National University Hospital, Korea

^*Department of Orthopaedic Surgery, Inje University Haeundae Paik Hospital, Busan, Korea

Correspondence to: Hui Taek Kim, M.D. Department of Orthopaedic Surgery, Pusan National University Hospital, 179 Gudeok-ro, Seo-gu, Busan 49241, Korea TEL: +82-51-240-7248 FAX: +82-51-247-8395 E-mail: kimht@pusan.ac.kr

Received 9 September 2016 Revised 9 January 2017 Accepted 27 February 2017

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

We compared the results between conservative and surgical treatment methods in a group of children and adolescents with osteochondritis dissecans of the talus.

Materials and Methods

A total of 24 patients (31 ankles), who were younger than 18 years old, were included in this study. Group 1 consisted of 14 ankles (mean age at the time of treatment was 13.0 years) treated conservatively. Group 2 consisted 17 ankles (mean age at the time of treatment was 15.1 years) treated surgically. According to the Berndt and Harty classification, there were 6 ankles in class I, 4 in class II, 3 in class III, and 1 in class IV in group 1; 1 ankle in class I, 9 in class II, and 7 in class III in group 2. In group 1, there were 13 medial lesions and 1 lateral lesion; and in group 2, there were 14 medial lesions and 3 lateral lesions. The mean follow-up period was 31.9 months for group 1 and 28.9 months for group 2. Clinical and radiologic results were analyzed using the American Orthopaedic Foot and Ankle Society (AOFAS) score and the classification by Higuera et al.

Results

The mean AOFAS clinical score was 91.4 in group 1 and 87.5 in group 2. According to the classification by Higuera et al., regarding clinical results, there were 6 excellent, 7 good, and 1 fair in group 1, and 5 excellent, 2 good, and 10 fair in group 2. As for radiological results, there were 13 good and 1 fair in group 1, and 10 good and 7 fair in group 2. There was no statistical difference between the two groups.

Conclusion

Conservative treatment provided satisfactory results for osteochondritis dissecans of the talus in children and adolescents.

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Keywords: talus, osteochondritis dissecans

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Figure 1

Schematic drawings of four stages of osteochondritis dissecans of the talus in the radiographs (classified by Berndt and Harty): Stage I is compression of the affected subchondral bone, stage II is partially attached avulsion of the transchondral bone, stage III is completely detached but not displaced, and stage IV is displaced fragment.

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Figure 2

(A) Initial anteroposterior (AP) radiograph of the right ankle in a 12-year-old boy (case 3 in the group 1) showed osteochondritis dissecans of the talus located in the lateral side. He did not have any traumatic history in the affected side, but had ankle pain for several months; he was finally treated with a cast at another hospital. He was classified in accordance with the Berndt and Harty classification¹⁵⁾ as stage II. In serial T2-weighted fat suppression coronal (B) and sagittal (C) magnetic resonance imagings (MRIs), which were taken at the time of his first visit to another hospital, the overlying chondral surface of the talus was intact and continuous with the healthy part (stage II according to the classification by Dipaola et al.¹⁶⁾). (B, C) The fragment was not separated from the talus contraindicating the ostechondral fracture of the talus. During the follow-up period, he experienced aggravated pain. He was then transferred to hospital and treated conservatively. (D) AP radiograph showed that the bony fragment was slightly displaced (Berndt and Harty's stage IV). A short leg cast was applied for 4 weeks and then a brace was applied for 2 months. T1-weighted coronal (E) and sagittal (F) MRIs, which were taken 4 months after conservative treatment (9 months after initial diagnosis at another hospital), showed an enlarged lesion, but with decreased pain (stage II according to the classification by Dipaloa et al.¹⁶⁾). (G) The last follow-up radiograph of the right ankle taken 4 years after the initial treatment showed a decreased gap in the lesion. His clinical result (by Higuera et al.¹⁸⁾) was good.

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Figure 3

(A) Initial anteroposterior radiograph of the right ankle in an 11-year-old boy (case 1 in the group 1) showed osteochondritis dissecans of the talus located in the medial side. He was classified as stage III in accordance with the Berndt and Harty classification.¹⁵⁾ He had a similar lesion in the left ankle. A short leg cast was applied for 4 weeks and subsequently a brace for 2 months. T1 weighted coronal (B) and sagittal (C) magnetic resonance imagings, which were taken four years and seven months later, showed remaining lesions (stage II according to the classification by Dipaola et al.¹⁶⁾). (D) The last follow-up radiograph of the right ankle, which was taken five years and six months after the initial visit, showed the lesion healing. His clinical result (classification by Higuera et al.¹⁸⁾) was excellent; he had mild symptoms in the right ankle during running.

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Table 1

Patient Data

Variable	Sex/age at the time of Dx (initial visit)	Site	Berndt & Harty stage (x-ray)	Dipaola MRI stage (Dx interval from x-ray)	Treatment	Fellow-up period (mo)	Higuera classification (clinical/radiologic)	AOFAS score
Group 1^*
Case 1	Male/11	Rt/M	III	II (55 mo)	Cast, brace	66	Excellent/good	97
		Lt/M	III	II	Cast, brace		Excellent/good	86
Case 2	Female/9	Rt/M	I		Brace	26	Excellent/good	98
Case 3	Male/12	Rt/L	IV	II (1 day, 9 mo)	Cast, brace	48	Good/good	91
Case 4	Female/11	Rt/M	II	III (4 mo)	Cast, brace	21	Good/good	99
Case 5	Female/18	Rt/M	II	I (1 wk)	Cast, brace	29	Fair/fair	85
		Lt/M	I	I (1 wk)	Cast, brace		Good/good	90
Case 6	Female/17	Lt/M	I	II (1 day)	Cast, brace	27	Good/good	91
Case 7	Female/17	Rt/M	II	II (1 day)	Cast, brace	27	Good/good	90
Case 8	Female/10	Rt/M	I		Cast	24	Excellent/good	90
Case 9	Female/12	Rt/M	II		Cast	21	Good/good	91
		Lt/M	I		Cast		Excellent/good	91
Case 10	Male/13	Rt/M	I		Cast	30	Excellent/good	90
		Lt/M	III		Cast		Good/good	90
Group 2^†
Case 1	Male/15	Lt/M	III	II (3 days)	OATS	25	Excellent/good	94
Case 2	Male/18	Rt/M	II	III (2 days)	AD, MF, LBR	29	Fair/fair	84
		Lt/M	II		AD		Fair/fair	86
Case 3	Female/17	Rt/M	II	II (2 mo)	AD	27	Fair/good	87
Case 4	Male/18	Lt/L	III		AD	49	Fair/fair	81
Case 5	Female/12	Lt/M	II	III (5 days)	AD	30	Fair/fair	84
Case 6	Male/15	Rt/M	II	III (1 wk)	AD	26	Fair/good	87
Case 7	Male/14	Lt/L	III	III (1 wk)	AD, MF	36	Fair/fair	86
Case 8	Male/15	Lt/M	III		AD, MF	25	Excellent/good	94
Case 9	Female/10	Rt/M	II	II (4 wk)	AD, MF	29	Good/good	87
		Lt/M	I	II			Good/good	85
Case 10	Female/15	Rt/M	III	III (5 days)	AD, MF (both)	26	Excellent/good	91
		Lt/M	II	III			Fair/fair	84
Case 11	Female/15	Lt/M	III	III (3 days)	AD, MF	18	Fair/fair	86
Case 12	Male/16	Lt/ L	III	III (4 days)	AD, MF	28	Excellent/good	91
Case 13	Male/15	Lt/M	II	II (6 wk)	AD, MF	30	Excellent/good	94
Case 14	Female/16	Rt/M	II	III (5 days)	AD, MF	26	Fair/good	87

^* Conservative treatment;

^† Operative treatment. Dx, diagnosis; MRI, magnetic resonance imaging; AOFAS, American Orthopaedic Foot and Ankle Society; Rt, right; Lt, left; M, medial; L, lateral; OATS; osteochondral autograft transfer system; AD, arthroscopic drilling; MF, microfracturing; LBR, loose body removal.

Table 2

Arthroscopic and Radiographic Staging Systems for Characterizing Osteochondral Lesions in MRI^*

Stage	Arthroscopy	MRI	Radiograph (by Berndt and Harty¹⁵⁾)
I	Irregularity and softening of articular cartilage No definable fragment	Thickening of articular cartilage and low signal changes	Compression lesion No visible fragment
II	Articular cartilage breached, definable fragment, not displaceable	Articular cartilage breached, low signal rim behind fragment indicating fibrous attachment	Fragment attached
III	Articular cartilage breached, definable fragment, displaceable, but attached by some overlying articular cartilage	Articular cartilage breached, high signal changes behind fragment indicating synovial fluid between fragment and underlying subchondral bone	Nondisplaced fragment without attachment
IV	Loose body	Loose body	Displaced fragment

^* Classified by Dipaola et al. (Arthroscopy. 1991;7:101-4). ¹⁶⁾ MRI, magnetic resonance imaging.

Table 3

Ankle-Hindfoot Score of the American Orthopaedic Foot and Ankle Society¹⁷⁾

Parameter	Point
Pain
None	40
Mild, occasional	30
Moderate, daily	20
Severe, almost always present	0
Function (activity limitations, support requirement)
No limitations, no support	10
No limitation of daily activities, limitation of recreational activities, no support	7
Limited daily and recreational activities, cane	4
Severe limitation of daily and recreational activities, walker, crutches, wheelchair, brace	0
Maximum walking distance (blocks)
>6	5
4–6	4
1–3	2
<1	0
Walking surfaces
No difficulty on any surface	5
Some difficulty on uneven terrain, stairs, inclines, ladders	3
Severe difficulty on uneven terrain, stairs, inclines, ladders	0
Gait abnormality
None, slight	8
Obvious	4
Marked	0
Sagittal motion (flexion plus extension)
Normal or mild restriction (≥30°)	8
Moderate restriction (15°–29°)	4
Severe restriction (<15°)	0
Hindfoot motion (inversion plus eversion)
Normal or mild restriction (75%–100% normal)	6
Moderate restriction (25%–74% normal)	3
Marked restriction (<25% normal)	0
Ankle-hindfoot stability (anteroposterior, varus-valgus)
Stable	8
Definitely unstable	0
Alignment
Good, plantigrade foot, ankle-hindfoot well aligned	10
Fair, plantigrade foot, some degree of ankle-hindfoot malalignment observed, no symptoms	5
Poor, non-plantigrade foot, severe malalignment, symptoms	0

Table 4

Clinical and Radiologic Classification of Higuera et al.¹⁸⁾

Grade	Clinical	Radiologic
Excellent	No pain, complete mobility, no inflammation	Completely disappeared lesion
Good	Pain on exercise but not during routine activities, movement restricted <10°, no inflammation	Remission of the lesion but with signs of alteration of the articular surface
Fair	Pain during routine activities (relieved with analgesics), activity restricted, some degree of inflammation	Remission of the lesion but with mild pinching of the joint, presence of osteophytes
Poor	Continuous pain, require analgesics on a regular basis	Clear signs of arthrosis and no remission

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