The top of the talus (ankle bone) is dome-shaped and is completely covered with cartilage. A talar dome lesion is an injury to the cartilage and underlying bone of the talus within the ankle joint. While symptoms may take months to develop, a talar dome lesion can cause pain, swelling, and more. This is why if you suspect some type of pain or injury to the ankle, it is important to have it diagnosed quickly. The place to start is with the skilled and experienced orthopedic specialists at OCC – Advanced Orthopedic & Sports Medicine Specialists in Denver, Parker, or Aurora, Colorado. Left untreated, a talar dome lesion can lead to long-term damage to the bone.
OVERVIEW
The talus is the uppermost bone in the foot that together with the tibia (shinbone) make up the ankle joint. The top of the talus is completely covered with cartilage—a tough, rubbery tissue that enables the ankle to move smoothly. When the ankle joint is injured, the cartilage may become torn or fractured and there is also injury to the underlying bone, causing a talar dome lesion. A talar dome lesion is also called an osteochondral defect (OCD), osteochondral lesion of the talus (OLT) or talar osteochondral lesion (OCL). “Osteo” means bone and “chondral” refers to cartilage. Osteochondral lesions can occur in any joint but are most common in the knee and ankle. Talar dome lesions account for 4% of all osteochondral lesions in the body. However, they have been found in more than 40% of patients after operative treatment of ankle fractures. About 85% of talar dome lesions are caused by a traumatic ankle injury.
ABOUT THE ANKLE
The ankle is the joint that connects the foot to the lower leg. Healthcare providers sometimes refer to it as the tibiotalar joint or the talocrural joint. The ankle moves in two directions: plantar flexion—down, away from the body, and dorsiflexion—up, toward the body. The ankles are made of bones, cartilage, ligaments, muscles, nerves, and blood vessels. Ankles are synovial joints. They’re made of a cavity in one bone that another bone fits into. Slippery cartilage covers the ends of the bones. A synovial membrane—a fluid-filled sac that lubricates and protects the joint—lines the space between the bones. This helps the joints move with as little friction as possible. The three bones that make up the ankle joint are the tibia (shinbone), fibula (calf bone), and talus. The talus sits between the tibia and fibula and the calcaneus (heel bone) below it. Even though it’s a small bone, the talus plays a big role in the ability to stand and move. It functions to support the weight of the leg, allow the foot to move up and down, maintain balance by moving the back of the foot side-to-side, stabilize the arch, and support ligaments in the ankle, heel, and foot.
WHAT IS TALAR DOME LESION?
If the ankle is injured through fracture or sprain, the talus and the tibia can collide against one another. When the tibia and talus collide, damage can occur to the cartilage of the talus resulting in a talar dome lesion. These lesions to the talar dome vary in severity from bruising of the cartilage to an actual fracture of the talar dome. In most cases, talar dome lesions form after another ankle injury, like a sprain, when the cartilage doesn’t heal correctly. When cartilage doesn’t heal correctly, it can soften and break off, and this in turn can cause debris to build up in the ankle joint, leading to further irritation. Talar dome lesions most commonly occur in two areas of the talus:
- The inside and top part of the lower bone of the ankle (the medial talar dome)
- The outside and top part of the lower bone of the ankle (the anterolateral talar dome)
CAUSES
The most common cause of talar dome lesions occurs in patients who experience a traumatic injury to the ankle. This could be an ankle sprain from weight-bearing forces or a traumatic landing with an ankle twist. They occur with ankle sprains resulting from falling off a ladder or falling off a bike. They can happen from the trauma of an automobile accident. They can also occur in individuals who wear inappropriate footwear or have poor foot biomechanics that put them at risk. Up to 42% of soccer players have been shown to have talar dome lesions. Other sports that put an athlete at risk are football, rugby, golf, basketball, running and track and field, gymnastics, and dancing such as ballet. Repeated trauma to the ankle over time can also cause talar dome lesions to gradually develop.
SYMPTOMS
It is unlikely that one experiences symptoms right away, as talar dome lesions can take months to develop. Common symptoms include:
- Deep ankle pain
- Ankle pain on waking
- Ankle joint swelling
- Stiffness
- Tenderness to touch
- Clicking, catching, or locking
- Bruising
- Pain going up and down stairs and hills
- Any activity that requires placing weight on the ankle can be painful enough to cause a limp
NON-SURGICAL TREATMENTS
Non-operative treatment can be successful for non-displaced talar dome lesions, especially if the condition is recognized and treated early, and the lesion is relatively small. If the lesion is stable (without loose pieces of cartilage or bone) one or more of the following non-surgical treatment options may be considered:
- Immobilization: depending on the type of injury the leg may be placed in a cast or cast boot to protect the talus
- Crutches
- Oral medications: non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen may help reduce pain and inflammation
- Protective braces: (ex. Ankle Lacer) to decrease stress
- Physical therapy: working on strengthening the muscles around the ankle, range of motion of the ankle, and balancing
WHEN IS SURGERY INDICATED?
If conservative treatments are unsuccessful, surgery may be required to remove the loose bone and cartilage fragments within the joint and establish an environment for healing. A variety of surgical techniques is available to accomplish this. The type of surgery that is most effective depends on the size, location, and severity of the lesion. Most commonly, a surgeon will perform an arthroscopic exploration and treatment. Treatments may include:
- Removing injured cartilage and bone
- Fixing the injured fragment in place with pins or screws
- Microfracture or drilling of the lesion (to create channels for blood and bone marrow to help heal)
- Bone grafting the bone cyst below the cartilage
Arthroscopic debridement (cleaning out) and microfracture of the talar OLT are the standard operative treatments and lead to good or excellent results in 75-80% of patients with typical talar dome lesions. There are other options for those with a very large talar dome lesion or for those whom the above procedures don’t help.
GETTING THE RIGHT DIAGNOSIS. GETTING THE RIGHT DOCTOR.
It is not uncommon for a patient to present sometime after an ankle injury, frustrated because the ankle continues to ache, swell, or catch. This can be because a talar bone lesion has been missed. A talar dome lesion can be difficult to diagnose because the precise site of the pain can be hard to pinpoint. To diagnose this injury, the foot and ankle surgeon will question the patient about recent or previous injury and will examine the foot and ankle, moving the ankle joint to help determine if there is pain, clicking, or limited motion within that joint. Sometimes the surgeon will inject the joint with an anesthetic (pain-relieving medication) to see if the pain goes away for a while, indicating that the pain is coming from inside the joint. X-rays are taken, and often an MRI or other advanced imaging tests are ordered to further evaluate the lesion and extent of the injury. At Advanced Orthopedics in Denver, Parker, or Aurora, Colorado, their surgeons have had years of experience diagnosing and treating talar dome lesions. Their skilled specialists keep up with the latest, evolving developments in surgical techniques and technology and apply this knowledge to the benefit of their patients. Expertise is essential, but so is a caring specialist who treats you with concern and respect. You’ll find it all at Advanced Orthopedics.
