Treatment of Osteochondral Lesions of the Medial Talar Dome
For osteochondral lesions of the medial talar dome, initial management should be conservative with activity modification and restricted weight-bearing for 6 weeks, but surgical intervention is indicated for lesions >1.5 cm², unstable lesions on MRI, or persistent symptoms after conservative treatment. 1, 2, 3
Initial Diagnostic Workup
- Obtain MRI without contrast as the reference standard - it has 96% sensitivity for detecting osteochondral abnormalities and 97% sensitivity for determining lesion instability 4, 1
- Plain radiographs miss 41% of osteochondral lesions, making MRI clinically essential 1
- Look for high signal lines deep to the lesion on T2-weighted images, which indicate instability and predict surgical need 4, 1
- Subchondral edema on MRI represents active bone marrow stress causing symptoms and warrants treatment 1
Treatment Algorithm Based on Lesion Characteristics
Conservative Management (First-Line for Stable, Small Lesions)
- Restrict weight-bearing and immobilize for 6 weeks minimum 2
- Add NSAIDs and activity modification 1
- This approach is only appropriate when no loose fragment is present and the lesion is <1.5 cm² 2, 3
Surgical Indications (When Conservative Treatment Fails or Contraindicated)
Proceed directly to surgery if:
- Lesion size >1.5 cm² 3
- MRI shows instability (high signal line behind fragment, adjacent cysts, or focal defects) 4, 1
- Loose fragment clearly present on imaging 2
- Persistent symptoms after 6 weeks of conservative treatment 1
Surgical Treatment Selection
For Lesions <1.5 cm² (Small, Contained Defects)
- Arthroscopic drilling or microfracture is the procedure of choice 1, 2
- These bone marrow stimulation techniques can be performed with minimal morbidity 3
- However, these techniques produce fibrocartilage rather than hyaline cartilage 5
For Lesions 1.5-2.5 cm² (Medium-Sized Defects)
- Arthroscopic debridement with curettage or abrasion of the bone bed 2
- Consider internal fixation if a large fragment is salvageable 2
- Bone grafting may be added for subchondral defects 2
For Lesions >2.5 cm² (Large Defects)
- Autologous osteochondral transplantation (mosaicplasty) from the talar non-weight-bearing area is preferred for younger patients (≤50 years) 1, 6, 7
- This provides immediate hyaline cartilage restoration in a single procedure 5, 6
- Medial malleolar osteotomy (preferably triplane technique) provides surgical access while minimizing complications 7
- Osteochondral allograft is an alternative for very large lesions (>6 cm²) where autograft donor sites are insufficient 8, 5
Specific Considerations for Medial Talar Dome Lesions
- Medial lesions are typically located posteriorly on the talar dome 2
- These often require medial malleolar osteotomy for adequate surgical exposure 7
- Triplane osteotomy technique allows earlier weight-bearing (average 8.1 weeks) with lower complication rates (4.3%) compared to traditional osteotomy 7
Postoperative Management and Return to Sport
- Weight-bearing restrictions typically last 5-12 weeks depending on procedure type 7
- 70.6% of athletes return to sport at an average of 4.3 months post-surgery 9
- High functional scores and stage 1 lesions predict successful return to sport 9
- MRI follow-up at 9 months confirms graft incorporation and stability 6
Critical Pitfalls to Avoid
- Do not dismiss persistent symptoms as "degenerative changes" - osteochondral lesions can progress to articular collapse with significantly increased morbidity 1
- Do not delay specialist referral beyond 2-3 weeks if conservative management fails 1
- Do not order MRI with contrast - it provides no additional benefit for osteochondral lesions 1
- Do not attempt bone marrow stimulation techniques for lesions >1.5 cm² - they have inadequate outcomes and fail to restore hyaline cartilage 3
- Ensure medial malleolar osteotomy heals completely before full weight-bearing to prevent nonunion 7