UCSF Health Remote Second Opinion

Dr. Daniel Thuillier, MD — Foot and Ankle Surgery, UCSF Health

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Imaging Interpretation

• Large osteochondral lesion along the central medial shoulder of the talus, that is cystic and with surrounding bone marrow edema within the talus
  → Big damaged area on the inner ankle bone with fluid-filled pockets and inflammation in surrounding bone
• Lesion of this size will alter the kinematics and force distribution of the cartilage
  → The damage is big enough to change how the joint moves and bears weight
• Joint fluid is likely irritating the underlying bone
  → Fluid leaking through damaged cartilage is causing bone pain

Treatment Recommendation

• Lesions over a centimeter with cystic bone changes generally do not do well with simple arthroscopy, debridement and bone marrow stimulation — would not recommend that
  → The damage is too severe for a simple "clean up" surgery to work
• Recommends talar allograft (could be multiple plugs or bulk allograft) as the best surgical option
  → Another donor bone transplant is the best fix — contradicts other doctors
• Pain may continue up to a year from surgery as grafts of this size can take a long time to fully incorporate
  → Recovery could be slow; the graft takes time to fuse with existing bone

Non-Invasive Options

• Injections (Supartz, steroid, PRP), ankle bracing, oral anti-inflammatories are all reasonable
  → These can reduce pain and inflammation but won't heal the defect long-term
• No further tests or specialists needed — CT, MRI and history provide a complete picture
  → All the imaging needed has been done

Cleveland Clinic Remote Second Opinion

Dr. Sagar Chawla, MD, MPH — Foot and Ankle Surgery, Cleveland Clinic

Imaging Summary

• Large area of the talus with disease — cartilage loss about 15mm x 10mm on MRI
  → Significant missing cartilage, roughly the size of a fingernail
• Cystic bone degeneration underlying the cartilage measuring 15mm x 12mm x 10mm on CT
  → Bone damage with fluid pockets underneath the cartilage loss

Treatment Recommendations

• First: Optimize non-operative management — physical therapy, steroid injection, and possibly HA injections (already doing this)
  → Continue current conservative treatment to manage symptoms
• For surgery: Recommends arthroscopy debridement of the ankle joint, bone grafting of the area of cystic degeneration, and implantation of biocartilage extracellular matrix overlying the bone graft
  → Clean up the joint, fill the bone holes, and apply a cartilage-promoting scaffold on top
• This option is optimal for re-establishing bone lost in the area — even if future surgery is needed, advantageous
  → Restoring bone now makes any future surgery easier
• If future surgery needed: next step would be a fresh-frozen semi-talus, then total ankle joint replacement
  → Escalation path: partial bone replacement → full ankle replacement
• Ankle joint fusion is not optimal for someone young with good range of motion
  → Fusing the ankle (eliminating movement) should be avoided if possible

Dr. Choung Third Opinion

Third opinion from Dr. Danny Choung, DPM at San Rafael Podiatry.

MRI Findings

• Inflammatory signal to the cartilage and bony area of the prior surgical site of the talar dome
• The cartilage portion of the graft has worn down in some areas, probably more than 50% of the original graft
• The underlying bone seems to be generally holding up
• Cysts seen on CT are confirmed to be small — most of the signal is from reactive bony inflammation versus fluid-filled cysts

Recommended Approach

• HA (hyaluronic acid) injection as a non-surgical option — some studies show beneficial effects when coupled with microfracture surgery, but that type of surgery is less likely to help in a recurrent condition
• Avoid high-impact activities — the safest option to decrease bony inflammation, often leads to gradual decrease of pain
• May continue exercising but avoid running/jumping activities

Against Repeat Allograft

• Further surgery to rebuild the cartilage will not be of much benefit, and can lead to stiffness of the ankle
• Evidence for surgical treatment of recurrent lesions is not strong

If Symptoms Worsen in the Future

• If cartilage further breaks down or symptoms worsen, another grafting procedure using autograft from the knee (patient's own cartilage) would serve best
• Would require another medial malleolar osteotomy, which may lead to some joint stiffness and localized arthritis because a repeat osteotomy can damage cartilage along the cut line
• Has patients with similar sized osteochondral lesions doing relatively well with non-surgical management

Subchondralplasty Update

• Subchondralplasty is indicated for larger cysts — the MRI confirms the cysts are small, so this is not currently indicated

CT Scan Review

Dr. Choung reviews the CT scan and explains the current state of the ankle:

• Anatomy: The medial gutter (inside portion) of the left ankle is where the cartilage injury and surgery occurred. The lateral gutter (outside) is healthy for comparison
• Osteotomy site: The medial malleolus was cut to access the joint during surgery (can't reach from the front). Two screws were placed. Some irregularity visible at this bone cut
• Bone spurs: Small spurs have developed at the front of the joint, possibly from the osteotomy healing or imperfect cartilage graft match with the tibia
• Graft incorporation: The cartilage graft incorporated well overall and has blood supply, but because it's a donor graft, it's not perfect — the bone has some mechanical inferiority
• Pressure mismatch: Hard to get a perfect anatomical match from a donor. Even a small mismatch causes uneven pressure distribution, which damages the cartilage receiving excess pressure
• Cysts: Multiple small cysts have developed throughout the graft from this pressure damage. Visible throughout various portions of the graft
• Cartilage surface: The front part of the graft's bony border is still intact. The back portion shows discontinuity — areas where cysts have broken through to the cartilage surface
• Bone wearing: The bone substance that supports the cartilage has worn down since surgery 14-15 years ago
• Possible pain sources: Could be any combination of: cartilage wearing, cysts, or bone spurs — difficult to determine which is the primary cause
• Recommended imaging: An MRI with metal suppression would be helpful to fully evaluate the cartilage (CT can't assess cartilage directly)

MRI Scans

MRI imaging of the left ankle.

Dr. Collman Second Opinion

Second opinion from podiatrist Dr. David Collman, comparing perspectives with Dr. Gentile's assessment.

Points of Agreement

• Eventually the ankle will need more surgery
• The ankle graft will not heal on its own; the holes in the graft are permanent
• Avoid physical activity involving the ankle — no basketball, no running

Different Perspectives

• Activity restriction timeline: Avoid basketball and running for about 1 year to observe the joint (Dr. Gentile left it open as "let pain guide you")
• Against repeat allograft surgery while young: Significantly less knowledge of outcomes after a 2nd allograft. If it goes poorly: more pain, more surgery, ankle immobility. Higher likelihood the graft doesn't attach or has other problems compared to the first time
• Recommended arthroscopy instead: Insert a thin scope into the ankle along with a scraping tool to "clean up" sharp bones and possibly stimulate cartilage growth in areas where it's missing
• Arthroscopy has limited downside — 2 weeks in a boot — and could extend the life of the current graft rather than jumping to major surgery
• Arthroscopy also allows observation of the joint at 10x zoom for better decision-making on next steps
• Ordered standing X-rays: Weight-bearing X-rays to observe the ankle joint under load
• X-ray results: The follow-up x-rays show good preservation of ankle joint space

Dr. Gentile Consultation

Follow-up discussion on left ankle CT scan with Dr. Michael Gentile, DPM (Foot and Ankle Surgery).

History

• Pain is worse when standing stationary
  → Standing still hurts more than walking or moving
• Pain started to increase when he increased basketball playing
  → More sports activity triggered more pain
• Denies any redness, warmth, or swelling
  → No visible signs of inflammation

Physical Exam

• DP and PT 2/3. CFT immediate
  → Good blood flow to the foot; pulses feel normal
• Very mild edema about the left ankle, not associated with erythema, ecchymosis, or warmth
  → Slight swelling, but no redness, bruising, or heat
• SILT. Paresthesias absent. Gross neurologic deficits absent
  → Sensation intact, no tingling/numbness, nerves working fine
• Palpable soft tissue crepitus in the anterior medial aspect of the ankle
  → Can feel a crackling/grinding sensation on the inner front of the ankle
• No significant pain with ankle plantarflexion and palpation of the talar dome
  → Pointing toes down and pressing on the ankle bone doesn't hurt much
• Tender at the anterior joint line with palpation at the end of dorsiflexion
  → Pain when pressing the front of the joint while foot is flexed upward

CT Review

• Fairly good incorporation of the medial shoulder talar allograft
  → The donor bone graft has mostly fused well
• Slight lucency on the most inferior aspect
  → Small gap/dark line visible at the bottom of the graft
• Mismatch in height with the graft sitting slightly proud (not universal)
  → The graft sticks up slightly higher than surrounding bone in some spots
• Significant cystic changes within the graft without obvious collapse
  → Fluid-filled pockets inside the graft, but it hasn't caved in
• Medial malleoli osteotomy healed with anatomic alignment and stable hardware
  → The bone that was cut to access the ankle has healed perfectly; screws are solid
• No significant arthritic changes adjacent to the osteotomy
  → No arthritis forming around where the bone was cut
• Mild anterior tibial and dorsal talar neck spurring, consistent with activities and possibly early arthritis
  → Small bone spurs forming at the front of the ankle, common with sports but could signal early arthritis

Treatment Options Discussed

• Option 1: Conservative management — Continue activity-based symptom monitoring. If pain worsens and affects daily life, consider bracing, cortisone injections, and oral pain medication
  → Wait and see; manage pain with supports and medication if needed
• Option 2: Repeat allograft surgery — Patient is leaning toward this option. Previous graft lasted 12 years. Likely can access without re-cutting the bone (osteotomy), but that option remains available if needed
  → Do another donor bone transplant; might not need to cut through the ankle bone this time

Recommendations

• If considering surgery soon, hold off on cortisone injections
  → Cortisone can interfere with surgery/healing
• Consider an AFO to load share/divert weightbearing stress away from the area
  → Wear an ankle brace to reduce pressure on the damaged area
• Change activities to lower-impact options to reduce mechanical stress
  → Avoid high-impact sports like basketball for now
• Surgery would need to wait for donor graft matching
  → Need to find a matching donor bone, which takes time

CT Scan Review

Dr. Gentile reviews the CT scan and explains the current state of the graft:

• Graft location: The original cut where the block of bone was removed and the donor bone placed is visible on the scan
• Graft incorporation: The donor bone incorporated well into the surrounding normal bone
• Cystic changes: Over time, the cartilage over the graft has likely thinned and broken down, allowing joint fluid to seep in and form cysts (like "Swiss cheese" or geodes)
• Pain source: When fluid pushes into these cysts, it creates pressure inside the bone which can cause pain. Additionally, if the cartilage surface has worn away, you may be rubbing on raw bone
• Graft alignment: Part of the graft may have healed sitting slightly high ("proud"), which means it hasn't been able to wear evenly over time — this happens more often than expected
• Graft size: The graft covers almost a third of the side of the talar bone — it's a sizable area
• Unknown factors: Can't determine from CT how much of the original smooth cartilage surface on the graft has survived vs. worn away
• Treatment approach: Depends on how much the symptoms bother you — can be approached conservatively or surgically

CT Scans

CT imaging of the left ankle. Compared with CTs from 9/27/2012 at Cayuga Medical Center.

CT Scan Findings

Bones

• 15 mm area of sclerosis of medial talar dome with several subchondral cysts measuring up to 4 mm
  → There's a ~15mm dense/hardened spot on the inner ankle bone with small fluid-filled pockets underneath
• Consistent with incorporation of allograft with subsequent degenerative changes
  → The donor bone graft has fused in, but there's some wear and tear happening
• Linear lucency at presumed inferior margin of graft
  → There's a thin dark line at the bottom edge of the graft (could be a gap or incomplete fusion)
• Post-operative changes of ORIF of medial distal tibia with two screws; no residual fracture plane visualized
  → The two screws from surgery are visible; the bone they fixed has healed completely
• Normal mineralization without acute fracture or dislocation
  → Bone density looks healthy, no new breaks or joints out of place
• No change in area of sclerosis and irregularity in caudal talus along neck and body
  → The rough/dense areas on the lower talus bone haven't changed since 2012
• Mild tibiotalar joint space narrowing and osteophyte formation
  → Early arthritis: the ankle joint gap is slightly smaller and small bone spurs are forming

Soft Tissues

Subcutaneous tissues and muscles are normal.
→ The skin, fat, and muscles around the ankle look healthy

Other

No significant joint effusion. No calcified intra-articular bodies.
→ No swelling/fluid buildup in the joint, no loose bone chips floating around

Return of Pain

Observed the return of dull ankle pain when standing for more than 1.5 hours in a day, or doing physical activity for more than 30 minutes.

Diagnosis + Procedure

Diagnosed with an osteochondral lesion of the talus. The damaged bone and cartilage fragment needed to be removed, and the resulting defect would be filled with a talar osteochondral allograft (donor bone and cartilage transplant). Additionally, the ATFL (anterior talofibular ligament)—the ligament that prevents the ankle from rolling outward—would be tightened to restore stability.

CT Scans

CT imaging of the left ankle.

Arthrogram

Pain During Standing

When standing for extended time, dull pain increases.

First CT Scans

Initial CT imaging of the left ankle to assess the injury.